A fiery-red and painful gingivitis with associated white patches has been documented on the gingiva of marijuana smokers (Darling & Arendorf, 1993). Diffuse gingival hyperplasia and concurrent alveolar bone loss have also been noted in chronic abusers of marijuana. However, for both conditions, other etiologies were not fully considered, and therefore supporting evidence is lacking. Current knowledge on the effects of cannabinoids on periodontal health is inadequate because Marijuana-dental drug interactions Table 4 delineates the medications most commonly used in dentistry (Donaldson & Goodchild, 2012; Rosenberg, 2010). In reviewing potential drug interactions between marijuana and these particular medications, considerations are few but important. Table 4: Medications Most Commonly Used in Dentistry Analgesics and Anti-inflammatory Agents • Acetaminophen • Aspirin • Codeine • Glucocorticoids (dexamethasone, prednisone) • Hydrocodone • Ibuprofen • Oxycodone Antibiotics • Amoxicillin • Azithromycin • Cephalexin • Chlorhexidine (topical) • Clarithromycin • Clindamycin • Clotrimazole (topical) • Doxycycline • Erythromycin • Fluconazole • Metronidazole • Nystatin • Penicillin • Terconazole (topical) • Tetracycline
the frequency, amount, duration, and mode of administration of marijuana differs among individuals, rendering controlled epidemiological studies difficult to undertake. Personal risk factors, including oral hygiene, general health, age, concurrent tobacco smoking, and polypharmacy, make it difficult to identify the specific influence of cannabis abuse on susceptibility to periodontitis. narcotic-containing analgesics (i.e., codeine, hydrocodone, and oxycodone). Unfortunately, the historical and unfounded belief that patients with significant orofacial pain should be prescribed opioid-containing analgesics has added to our current opioid epidemic. Opioids are frequently prescribed for short-term orofacial pain management associated with dental procedures in emergency and clinical settings, even though they are not anti-inflammatory agents, and therefore do not target the underlying pathophysiology of orofacial pain (Aminoshariae et al., 2016; Moore & Hersch, 2013). Opioids should definitely not be prescribed in patients who may be concurrently using marijuana because both of these agents act as central nervous system (CNS) depressants and the combination could result in a deeper level of sedation than intended – up to, and including, a loss of consciousness and unresponsiveness. This would be an emergency situation. Antibiotics and antifungals Although no specific drug interactions between the most common antibiotics prescribed in dentistry and marijuana have been observed, certain antibiotics can increase the effects of specific cannabinoids, such as cannabidiol, which are metabolized through the cytochrome P450 (CYP) isoenzyme system. Erythromycin may be the classic example of a drug that acts as an inhibitor of CYP3A4. Taking erythromycin with cannabidiol can lead to increased effects of cannabidiol, because cannabidiol is also metabolized by CYP3A4. The best strategy would be to avoid this combination. If a macrolide antibiotic is indicated, prescribing azithromycin instead of erythromycin would be an excellent alternative. Azithromycin is not metabolized through the cytochrome enzyme system. The antifungal fluconazole is a strong CYP2C19 inhibitor and moderate inhibitor of CYP3A4. For this reason, concurrent administration with marijuana can lead to increased effects and side effects of cannabidiol. If an antifungal agent is needed to help treat oral candidiasis in a marijuana user, the swish and swallow approach with nystatin would be a better choice. Local and topical anesthetics No drug interaction concerns have arisen between marijuana and the local or topical anesthetics typically used in dentistry. Sedative agents Given the high incidence of dental fear in the general population, many patients who visit the dentist will inquire about the opportunity for sedation services. In most cases, the intervention will involve either oral or inhalational pharmacological modalities, each of which present specific concerns in the marijuana user. In the case of the marijuana smoker, an odor from the patient may be indicative of recent usage, even in the face of patient denial. These patients have already self-medicated with a sedative, rendering another oral or inhalational sedative unnecessary. It is more difficult to discern patients who may have recently employed marijuana in a topical or edible formulation. If the practitioner’s level of suspicion is high, but unconfirmed by the patient, the prudent practitioner may choose to avoid additional sedatives. However, in the highly fearful patient, low, conservative doses of any additional CNS depressant may be considered (i.e., nitrous oxide/oxygen inhalational sedation or oral medicines such as the benzodiazepines).
Local Anesthetics • Articaine • Bupivacaine • Lidocaine (+/- epinephrine) Topical Anesthetics • Benzocaine • Dyclonine Sedatives • Benzodiazepines • Zaleplon
• Mepivacaine (+/- levonordefrin) • Prilocaine
• Lidocaine • Tetracaine
• Zolpidem • Nitrous oxide Note . Source: Adapted from Donaldson, M., & Goodchild, J. H. (2012). Pregnancy, breast-feeding and drugs used in dentistry. Journal of the American Dental Association, 143 (8), 858-871. Analgesics and anti-inflammatory agents Acetaminophen has a synergistic effect when administered with a nonsteroidal anti-inflammatory drug (NSAID), and the combination has repeatedly shown superior analgesic efficacy compared with either drug alone (Aminoshariae et al., 2016; Moore & Hersch, 2013). This therapeutic combination also has a better side effect profile and less potential for abuse than opioids. For example, NSAIDs have been shown to be associated with a reduced incidence of postoperative nausea and vomiting of up to 30% compared with narcotics (Elia et al., 2005). Knowledge and understanding of individual maximum recommended doses cannot be overemphasized since the most effective dose for the shortest period of time will provide the greatest pain-relief balanced against patient safety concerns. There are no specific concerns in combining acetaminophen with an NSAID to ensure appropriate pain relief in patients who may be concurrently using marijuana. Although this is also true for the co-administration of glucocorticoids, the same cannot be said for
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