it produces less odor than smoking. Disadvantages are that vaping produces dry mouth and fewer positive marijuana effects (Etter, 2015). A small Johns Hopkins study found that vaping marijuana increased short-term anxiety, paranoia, memory loss, and distraction over what was seen in traditional marijuana smoking (Johns Hopkins Medicine, 2018; Spindle et al., 2018). Marijuana buds and oil are often the product of choice for these devices rather than hashish or a hazardous concoction called butane honey oil. In an exploratory study (Etter, 2015), 45% of individuals who smoked and vaped marijuana reported that vaping reduced their marijuana use, 37% said it had no impact on their marijuana use, and 6% said that it increased their marijuana use. Vaping is also less expensive than traditional smoking. One in vitro study concluded that “temperature-controlled, electrically-driven vaporizers efficiently decarboxylate inactive acidic cannabinoids and reliably release their corresponding neutral, active cannabinoids. Thus, they offer a promising application mode for the safe and efficient administration of medicinal cannabis” (Lanz et al., 2016). One literature review revealed something about marijuana that is somewhat counterintuitive: It suggests that marijuana increases rather than reduces forced vital capacity (FVC) – the amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible (Ribeiro & Ind, 2016). This effect may Marijuana-induced oral pathology In general, marijuana users have poorer oral health than non- users, with higher plaque scores; higher decayed, missing, and filled (DMF) teeth scores; and less healthy gingiva (Darling & Arendorf, 1992). One of the most significant adverse effects of marijuana use is xerostomia. For this reason, chronic use of marijuana increases the risk of xerostomia-induced caries (Cho et al., 2005; Darling & Arendorf, 1993). Marijuana smoking causes changes, termed “cannabis stomatitis,” in the oral epithelium; this condition includes hyperkeratosis and leukoedema of the buccal mucosa. Acute signs and symptoms include sialostasia, xerostomia, and irritation and superficial (topical) anesthesia of the oral epithelium (Maloney, 2011). With chronic use, cannabis stomatitis presents as chronic inflammation of the oral epithelium and leukoplakia, which may progress to neoplasia. Marijuana can elicit variable parasympathetic effects, which in combination with the stress of a visit to the dentist could result in a syncopal episode. During dental treatment, patients who are active users or intoxicated can become anxious, paranoid, and dysphoric. Local anesthetic solutions containing epinephrine may seriously prolong tachycardia already induced by the marijuana (Berger & Conway, 2017; Cho et al., 2005; Jones, 2002). Table 3 summarizes the dental implications of treating marijuana users. Marijuana-related oral cancer usually occurs on the tongue and the anterior floor of the mouth (Firth, 1997; Marks et al., 2014; Zhang et al., 1999). The mechanism by which marijuana smoke acts as a carcinogen relates to the presence of benzopyrene, nitrosamines, and aromatic hydrocarbons, in twice the concentration as that found in the same amount of tobacco smoke (Tashkin, 2018). Marijuana smoke is associated with dysplastic changes within the epithelium of the buccal mucosa (immature cell forms, anucleated squamous cells, increased nuclear pleomorphism, and increased mitotic activity and abnormalities). Smoking marijuana is associated with oral premalignant lesions, including erythroplakia and leukoplakia. One study found that the association between marijuana use, and head and neck cancer was stronger among younger patients (less than 50 years old; Zhang et al., 1999). The long-term prognosis in young patients with head and neck cancer is poorer than in older patients because tumors appear more aggressive in younger patients and require more extreme treatment such as radiotherapy and surgical resection. A synergistic effect between marijuana and tobacco smoke has also been observed, suggesting that the interactions of different risk factors further increased the risk of developing oral cancer (Zhang et al., 1999). An analysis of nine studies involving 10,000 subjects concluded
be related to the anti-inflammatory effects of the plant. However, the review also cited several community- based studies, all but one of which showed a significant increase in symptoms of chronic bronchitis and use of acute care services for respiratory illness in people who frequently smoke marijuana. An analysis of survey questions and standardized spirometry data from a cross-sectional study of adults in the United States who participated in the National Health and Nutrition Examination Survey from 2007 to 2010 showed that 59.1% had used marijuana and 12.2% had used marijuana in the last month. The effect of smoking marijuana was measured as the ratio or relationship between lung function scores recorded as forced expiratory volume and FVC. The study concluded that, despite marijuana smoke being a known irritant to the airways of the lungs, cumulative lifetime marijuana use, up to 20 joint-years, is not associated with adverse changes in the above spirometric measures of lung health. However, people who smoke marijuana for more than 20 joint-years may have a significant increased risk of lung disease when compared with those who have never smoked marijuana (Kemper et al., 2015). A large study found that, in HIV-infected patients, long-term marijuana smoking seems to increase infectious pulmonary disease and chronic bronchitis (Lorenz et al., 2019). that smokers of marijuana had an elevated risk of oropharyngeal cancers but a reduced risk of tongue cancer (Dana-Farber Cancer Institute, 2016). Clearly, more research is necessary. Table 3: Dental Implications of Treating Marijuana Users • Marijuana abusers generally have poor oral and periodontal health. • Chronic smokers of marijuana have an increased risk of developing oral leukoplakia and oral cancer, oral candidiasis, and other oral infections. • Local anesthetic containing epinephrine may prolong tachycardia following an acute dose of marijuana. • Marijuana-intoxicated patients may experience acute anxiety and dysphoria during dental treatment. • Marijuana-related oral cancer usually occurs on the anterior floor of the mouth and the tongue. • Marijuana smoke is associated with dysplastic changes within the epithelium of the buccal mucosa (immature cell forms, anucleated squamous cells, increased nuclear pleomorphism, and increased mitotic activity and abnormalities). • Oral candidiasis and the intra-oral prevalence and density of candidal species are increased in marijuana smokers. • Diffuse gingival hyperplasia and concurrent alveolar bone loss has also been noted in chronic abusers of marijuana. Note . Source: Adapted from Le, A., & Palamar, J. J. (2019). Oral health implications of increased cannabis use among older adults: Another public health concern. Journal of Substance Use, 24 (1), 61-65. The relationship between the presence of oral papilloma and marijuana smoking has been hypothesized. Such a relationship could be related to suppression of the immune response by different cannabinoids (Darling & Arendorf, 1993). However, Ortiz and colleagues (2018) failed to find an association between frequent marijuana use and human papillomavirus infection. Oral candidiasis and the density and intra-oral prevalence of candidal species are increased in marijuana smokers, most likely as a result of the presence of hydrocarbons in marijuana, which act as an energy source for certain Candida species (American Dental Association [ADA], 2019; Marks et al., 2014). Additional factors, such as a compromised immune response resulting from chronic marijuana use (ADA, 2019), nutritional factors, and poor denture hygiene, should also be considered.
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