Women in Dentistry - Blog

By: Reefa McDoom, RRDH

(1) A successful dental practice has as much to do with the ability to adapt in mindset as it does, sound clinical outcomes.

Dentistry has evolved significantly in the past two decades and with the legalization of recreational cannabis in Canada in October of 2018, responsible dental professionals recognized that they owe it to their patient to pivot and embrace the culture of change.

After alcohol and tobacco, marijuana is the most used and abused drug in the world. Its use is illegal in most countries but that is quickly changing. Cannabis use is more prevalent than all of the other illicit drugs combined. This is a daunting thought considering that the smoking of dried cannabis sativa leaves is the most common method of use worldwide, and dental professionals understand the negative repercussions of smoking and the oral cavity.

(2) A Little History

The oldest evidence of cannabis was found in a tomb in Turpan, China dating back to 2700 BC. Cannabis has been co-evolving with humans for millennia and was used as an analgesic, a sedative, an anti-inflammatory, to treat skin rashes, cramps, earaches, and many other medical issues which our ancestors faced.

With the advent and availability of synthetic pharmaceuticals in the early 1900s, the use of cannabis in medicine declined only to see a resurgence in the 1960s. The political climate in the western world and the United States in particular seemed to encourage the recreational use of marijuana in epic proportions within the young adult population.

As with any trend among the masses came scientific interest. With that interest came research, and with that research, in 1990, the Endogenous Cannabinoid System (ECS) within the brain was recognized and described in medicine.

Cannabinoids are a class of chemicals that directly interact with the nervous system’s ECS. There are more than sixty-six cannabinoids in marijuana and THC remains in the foreground of public interest and continues to be the most researched today. Receptors and Neurotransmitters in the CNS and PNS make this interaction possible allowing the THC to bind to and activate the receptors in the ECS, thereby producing the psychoactive neurological response. The sensation of feeling ‘high’.

(3) Hemp and Marijuana: The Two Species of Cannabis Plants

Hemp is one of the first plants to be spun into usable fiber. It has been around for millennia and the clothing which our early ancestors wore was likely woven from hemp. Like bamboo, it is one of the fastest-growing plants and continues to be refined for many uses today, including the production of fabric, paper, rope, and many others. Hemp contains less than 0.3% THC (tetrahydrocannabinol) which is the chemical that produces the psychoactive effect of cannabis. It cannot produce intoxication. Hemp is therefore, grown worldwide without restriction. CBD (cannabidiol), the non-psychoactive chemical in cannabis can be extracted from both hemp and marijuana plants and is widely used in the medical world.

(4) The Two Prominent Species of Marijuana Plants

The two prominent species of marijuana plants are sativa and indica. Both strains contain THC. Sativa dominant strains steal the show because they have a higher concentration of THC which produces a stimulating, energetic, psychoactive ‘head high’. This effect is what recreational users often seek. Indica dominant strains behave differently, offering a full-body calming intoxication and a deep state of relaxation.

(5) The Four Methods of Cannabis Use

Smoking/Vaping: The traditional and most common use of marijuana is inhalation. Approximately fifty percent of the available THC in the strain is absorbed in the lungs and enters the bloodstream, reaching the brain in minutes. Smoking has the most rapid onset of the psychoactive effects which makes this method of use most popular among recreational users. The psychoactive response is largely a result of a combination of body chemistry, strain genetics, and whether the individual is a chronic or occasional user. The motor and cognitive effects can last up to 12 hours.

Ingestion: Edibles are defined as any food or drink containing cannabis. The cannabinoids (THC and CBD) are activated through heat (decarboxylated) and are fat-soluble, so olive oil and butter are commonly used as a base. The cannabinoids are absorbed through the digestive tract and are metabolized by the liver. This method has the slowest and most varied onset ranging from ninety minutes to two plus hours. Edibles produce a full-body intoxicating effect lasting up to twenty-four hours. Common edibles are gummies, cookies, butter, chocolates, and olive oil.

(6) Oral-Mucosal

Tinctures are applied under the tongue or sprayed into the mouth and are absorbed through the oral mucosal lining. Its onset is faster than edibles; its duration varies and can last for hours, and both THC, CBD, and combinations of these two oils are available. This is the preferred method of consumption for the treatment of nervous system disorders and epilepsy.

Topical: These are creams and balms which are thick oil extracts containing active cannabinoids. They are applied to and absorbed through the skin and the effects are localized. Cannabis creams are used mostly for muscle pain and dermal inflammatory conditions, like eczema.

(7) Smoking Marijuana

It is important to recognize that the primary port of entry for cannabis use is the oral cavity.

Most recreational marijuana smokers are chronic users. The common oral manifestations we may see in the dental chair are xerostomia, oral lesions like stomatitis, hyperkeratosis, candidiasis, periodontal disease, caries, staining, and gingival hyperplasia. Though limited, due to cannabis use being illegal in many countries, each of these manifestations are chronicled in relatively recent clinical research studies.

Although cannabis has no nicotine, the chemical components of dried marijuana leaves and tobacco are very similar. They both contain phenols, nitrosamines, and formaldehyde and the tar content of cannabis is approximately three times higher than tobacco.

(8) THC and CBD in Medicine

Both THC and CBD are used in medicine and their uses are growing. THC is often used as an antiemetic for patients undergoing treatments for cancer and HIV/AIDS. It is used for chronic pain due to nervous system injuries and as an antispasmodic for the treatment of Multiple Sclerosis. THC is also used to treat Alzheimer’s Disease, Parkinson’s Disease, Fibromyalgia, and Lupus amongst others.

CBD is widely used for the treatment anxiety, depression, and insomnia. It is an anti-inflammatory, and analgesic, and anticonvulsant, and an antiemetic. CBD is used extensively in medicine and many patients appreciate the medicinal effects without the psychoactive response.

(9) Pharmaceuticals

Factors which define recreational cannabis (specifically marijuana) is determined by why the individual wants to use the drug and the framework in which the user gains access to the compound. Medicinal cannabis is legal in many countries and a medical doctor must prescribe the medication. In counties and states where medical cannabis is legal, a physician may prescribe the use of cannabis in the forms which we have previously discussed or they may offer a synthetically made pharmaceutical which include CBD, THC, or both.

Nabilone (Cesamet): This is a synthetic THC analog cannabinoid capsule which can be found in the Compendium of Pharmaceuticals. It was approved in Canada 1982 and is used as an appetite stimulant and antiemetic for the prevention of nausea and vomiting associated with chemotherapy. Some potential dental concerns related to the regular use of Nabilone are aphthous stomatitis, xerostomia, dysgeusia (bad taste in the mouth), and orthostatic hypotension.

Nabiximols (Sativex): This oral (buccal) spray contains both the THC and CBD cannabinoids and was approved in Canada in 2005. It is used to treat spasticity and neuropathic pain associated with Multiple Sclerosis and it is also used, along with opioids, as an analgesic to treat the pain associated with certain cancers. Some potential dental concerns include xerostomia, ulcerations, pharyngitis, dysgeusia, glossodynia (burning of the tongue), and throat irritations.

Epidiolex: This oral medication is not available in Canada but is used successfully in other countries. It is a liquid made of pure synthetic CBD which is administered orally with a dosing syringe. It is an anticonvulsant which is used to treat drug-resistant seizures due to Dravet syndrome and Lennox-Gastaut syndrome.

There are many factors affecting the oral and general health of cannabis/marijuana users. They include the individual’s method of use, whether the user is ingesting edibles or smoking. The latter (smoking) comes with obvious health concerns. Research has shown that chronic daily users over occasional users have greater susceptibility to the negative effects and repercussions to their oral and general health. Also noteworthy, is the fact that synthetic recreational marijuana, produced illegally in labs, is more potent than government-approved vetted products. Strains like K2, Spice, and Angry Birds come with increased risk.

(10) Cannabis and Drug Interactions

The acute effects of cannabis use (the first three hours after consumption) are easily recognized. These include impaired cognitive function, increased sensations, increased anxiety, peripheral vasodilation (red eyes) hyperactivity, and tachycardia, to name a few. These manifestations in a dental patient are less than ideal, and a positive office visit with good dental outcomes would be unlikely. Legally, we cannot knowingly treat an intoxicated patient. Intoxicated, in this case, is defined as having used marijuana or any other drug within four hours prior to their dental appointment.

With the growing number of cannabis users, drug interactions become an important consideration. Some of the more clinically significant interactions may occur when cannabis is taken with other CNS depressant drugs such as sedatives, hypnotics, and alcohol. Studies have noted varying degrees of increased drowsiness with cannabis use in individuals who are taking one or combinations of benzodiazepines, barbiturates, narcotics, and some antidepressants. There is also an increased risk of bleeding when cannabis is used by individuals who routinely use blood thinners, antiplatelet drugs, ASA, and NSAIDs.

The chronic effects of cannabis use are being recognized widely today due to increased research over the past three decades. The impairment of cognitive function and memory along with decreased motivation are common effects of chronic cannabis use. Some research suggests that there is also an increased risk of mood and psychotic disorders like schizophrenia and depression.

(11) In the Dental Chair

It is impossible to attain ‘informed consent’ to proceed with a dental treatment if your patient is impaired. The acute anxiety and general state of unease which many patients suffer in anticipation of and during their dental visit is amplified with cannabis use.

Hypotension is a concern when dismissing a patient after having been reclined in a dental chair for a period of time. The patient should be advised to sit for a few minutes before getting up as syncope is an unwelcomed result of orthostatic hypotension.

As dental practitioners, we must also be cognizant of the potential adverse effects of cannabis use and the epinephrine in local anesthetics as well as the use of nitrous oxide. Recognized impairment requires the rescheduling of the appointment.

Patients should be encouraged to consider tinctures or edibles instead of smoking or vaping. Encouraging good oral hygiene and treatment recommendations (like xylitol) for their xerostomia is important for caries management, along with fluoride treatments. Increased water consumption and dietary discussions to reduce sugar intake should be introduced along with the strong recommendation to stay on track with re-care visits and caries detecting x-rays prescribed by the DDS, so they can be monitored on a timely basis.

Today, forty-four countries have legalized medicinal marijuana and eight have legalized the use of recreational. Legal or not, like it or not, our patients are using cannabis. For obvious reasons, they remain guarded when sharing information in the dental chair. An open, non-judgmental approach when engaging about cannabis use or when updating their medical history will go a long way in patient care. It is important for us to keep current with changes in the applicable cannabis laws wherever we are practicing and to become comfortable having candid, open conversations with our patients.