By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management
On November 7, Ohio residents voted by a wide margin to become the 24th state to legalize the recreational use of marijuana. While the drug is nominally illegal under federal law, the substance is becoming a fixture of more and more Americans’ lives. Some 17% of respondents to a 2023 Gallup poll said they smoke marijuana; among adults aged 18 to 34, the number was 29%.
In the past decade, a giant industry has sprung up to capitalize on this growing market. According to an August opinion piece in the Washington Post, legal U.S. marijuana sales equaled $30 billion in 2022, with the drug outselling both chocolate ($20 billion) and craft beer ($28 billion). These figures signal more than a cultural shift. They also reveal a remarkable commercial success that has engendered some less visible public health costs.
Most of today’s marijuana is a far cry from the plant consumed in the 1960s and 1970s, when the drug first gained social acceptability. Market forces, coupled with a lack of federal standards for marijuana and other cannabis merchandise, have led to a proliferation of smokable, vapable, and edible products that typically have higher and even extremely high concentrations of THC (marijuana’s psychoactive compound). As a result, some people who use these products are becoming addicted, and some others, including children and teens, are experiencing psychosis. According to data from the Substance Abuse and Mental Health Services Administration, almost 800,000 drug-related emergency department visits in 2021 involved cannabis. In Colorado, the first state to legalize recreational marijuana use, marijuana-related emergency department visits quadrupled in the early years of medical and recreational marijuana legalization.
Oral Health Implications
Even at safer levels, dental professionals should be aware that consuming marijuana and other cannabis products can have oral health effects. Research compiled by the American Dental Association (ADA) indicates that regular users have higher rates of dental caries and significantly higher rates of periodontal disease than non-users. These consumers are also more likely to experience xerostomia, a symptom also associated with smoking tobacco.
“We don’t yet know for certain if cannabis is physiologically increasing the risk of cavities,” my colleague Austin Le, DDS, MSc, told me, but there is an association between the two. Austin is an orthodontist and an assistant research scientist in the Department of Population Health, NYU Langone Health. He and his fellow investigator, Joseph J. Palamar, PhD, MPH, of NYU Grossman School of Medicine, are among the few researchers studying the oral health implications of cannabis use. His goal is not to discourage all cannabis consumption, which he acknowledges may have some positive effects. “We’re just saying, let’s be cautious,” he says. He wants the advice he and other dentists give patients to be grounded in evidence, and he can’t achieve that goal without more research.
Austin believes the association between cannabis use and caries likely results from behaviors such as the increased snacking that often accompanies marijuana use, and research supports this hypothesis. One small but interesting study comparing cannabis users and smokers in Switzerland found significantly higher decayed surface values, less frequent daily tooth brushing and dental check-ups, and much higher consumption of sugary beverages among the cannabis-using group.
Researchers are also trying to tease out whether smoking marijuana or consuming cannabis in other forms puts people at higher risk for oral and pharyngeal cancers. While tobacco use and orally inhaling smoke are strongly associated with some cancers and malignant lesions in the mouth, the research to date on oral cancer and cannabis use is inconclusive, Austin told me.
What Can Dental Professionals Do?
While we wait for additional evidence, the ADA recommends that dental health care providers ask their patients about cannabis use and advise them accordingly, a practice Austin heartily endorses. In a 2022 commentary in the Journal of the American Dental Association, he called on dental professionals to ask at least one question about drug use when taking a health history.
Austin says there are many reasons dentists may shy away from the question, especially in a private practice setting. It’s a very personal topic, and “a lot of clinicians are trying to foster a nice and minimally intrusive customer experience for their patients,” he says. Dentists may also worry that patients’ answers may obligate them to refer or treat something they regard as beyond the scope of their expertise.
Despite these limitations, he would like to see dentists ask the question routinely, especially with young people, who report the highest levels of cannabis use. “We already ask, are you taking any medications? What’s another two seconds to say, are you using any cannabis, because if you are, it might affect our treatment decisions.” As a secondary benefit, asking routinely may surface patients who need referral for substance-use disorder. “I view it as low hanging fruit with potentially great benefits that could change a lot of people’s lives,” Austin told me.
Cannabis as Medicine
Further complicating the clinical picture, a growing body of research supports the use of cannabis in managing pain, including the pain of oral cancer, which can be especially severe. This is welcome news in the dental community, which is striving to reduce opioid prescriptions. My NYU Dentistry colleague Brian Schmidt, DDS, MD, PhD, senior vice dean for research development and academic affairs, is working with researchers at the UCLA School of Dentistry to develop a non-addictive cannabis-based pain medication for oral cancer patients without the addictive properties or side effects of marijuana. This could be a boon both to prescribing clinicians and to their patients.
Because of the potential benefits of cannabis for treating oral pain and other conditions, we owe it to our patients to learn more about this increasingly popular drug and to be nuanced in how we discuss cannabis and marijuana use. This may be especially tricky with older adults, who experience high levels of oral disease. Austin and Joseph Palamar have found evidence to suggest that older adults are less forthcoming about their drug use, but available surveillance data show their cannabis use trending upward, perhaps in part because people who started using marijuana in their youth are aging into this population. Given that poor oral health is linked to diabetes and cardiovascular disease, getting a full picture of these patients’ substance use may be important to managing both their oral and overall health.
Austin’s impression is that most dentists are unprepared for a conversation that goes beyond counseling abstinence, but he is still eager to see screening questions asked regularly in the dental office. “If you don’t ask anyone, then you’re going to miss everyone,” he reasons. “If you ask everyone, you might get a few who say yes and potentially change their lives and improve their health situation in a very meaningful way.”
I couldn’t agree more. We owe it to our patients to let them know we’re open to discussing the risks and benefits of cannabis use. Kudos to Austin, Brian, and the other researchers who are helping to determine more precisely what those are.