S4 E03: Patients Using Cannabis: A Dentist’s Guide

Wright: [00:00:00] What do you do if you have a patient in a dental chair who is obviously high? I'm Dr. ArNelle Wright.

Ioannidou: [00:00:06] And I'm Dr. Effie Ioannidou and today we are having a really great conversation about cannabis and our patients.

Announcer:: [00:00:19] From the American Dental Association, this is Dental Sound Bites. Created for dentists by dentists. Ready? Let's dive right into real talk on Dentistry's daily wins and sticky situations.

Ioannidou: [00:00:34] Before we dive into the episode, if you have enjoyed Dental Sound Bites, please help us by rating the podcast on Apple Podcasts, Spotify, or wherever you're listening.

Wright: [00:00:45] Yes, yes, please leave us a review. That's going to help us continue to support other dentists and our great profession.

Ioannidou: [00:00:53] Yeah, absolutely, ArNelle. Thank you, guys. 

Okay, let's talk about cannabis. All right. There was an ADA news story about this, right? Some years ago, that said that many dentists have had a patient that was high during a dental visit. I have never experienced this, but I'm sure many people have, right?

Wright: [00:01:12] Crazy. Yeah. It surprises me that you haven't had a patient that was high in your chair.

Ioannidou: [00:01:18] Or not that I know of.

Wright: [00:01:20] Oh. Okay. Okay. So maybe today during our conversation, you may learn some things to look for because I'm sure somebody has been high up in your chair. I'm sure.

Ioannidou: [00:01:33] That's right. That's right.

Wright: [00:01:35] And in 2023, the ADA Dentist’s Trend Report survey found that 46 percent of the 500 respondents reported seeing more patients under the influence than in the previous year. And that made us want to know, what should you do in that situation? How does it affect your treatment plan? And why are some patients coming in high?

Ioannidou: [00:01:56] And also this finding tells you that it's not that rare, right? So it's exactly what we were saying, like maybe either I'm not that observant.

Wright: [00:02:05] No, I doubt it.

Ioannidou: [00:02:06] Or I don't know the signs.

Wright: [00:02:08] Effie, do not do that to yourself. No, we know you're observant. Come on, we know you're Queen Bee. You're observant.

Ioannidou: [00:02:15] So actually, that's why we have the right guest today to help us get some answers on this topic. We have invited an expert, Dr. Barry Taylor, to join us today. So hi, Dr. Taylor. Nice meeting you. And tell us a little bit about yourself.

Taylor: [00:02:31] The introduction conversation has been great. A lot of comments I would love to make. Which all lead to why I got into this as the expert, so to say. But I'm a general dentist. I no longer practice clinically now, but I did practice clinically up until 2020 and I still have an active dental license, a general dentist.

I went to Oregon Health Science University School of Dentistry. But I think related to this, before I started dental school, I did two years of research as a research assistant. And the lab I was in, we actually were looking at the dopamine receptor. And at that time, there were two dopamine receptors. I think now they recognize four or six, I'm not sure.

But at the time, there was the D1 and the D2 receptors. I just kind of had that in my background and went to dental school, graduated from dental school. And then what happened was, about 2016, I read an article in a well respected dental magazine. It wasn't a peer review, but it was just kind of an article about what you should do if you have a patient in your chair that is high.

And in that article, it made reference to the fact that if that patient has used marijuana, like within the past seven days or something like that, you should not treat that patient. If they're a risk of infection, you shouldn't treat that patient. And I read that and having grown up in Oregon, having gone to undergraduate in Oregon, having gone to dental school in Oregon, I'm sure the first patients I treated that were under the influence that probably started in dental school. And I read that article and at that same time was when Colorado, Washington, California had already legalized it for medical reasons. Oregon was coming on board legalizing it for recreational reasons. And I just really wanted to develop a program of educating dentists, dental hygienists, dental assistants, anyone in the oral health profession, that they would feel comfortable talking to their patients about marijuana use, cannabis use, but have it come from a scientific evidence-based background.

And going back to that article that I read when I was reading something about, you know, you shouldn't treat a patient for seven days, I just, there were just some ridiculous statements.I really wanted to educate oral health professionals so that they would feel comfortable treating patients and be as comfortable talking to their patients about marijuana use and cannabis use as they are about tobacco use or alcohol use or opioid pain, you know, any of the other medications, substances, that our patients are under the influence of.

Wright: [00:04:59] I love that. Can I just chime in really quickly? I'm so glad that you said you wanted to develop an education program, because I don't know if y'all saw my face about when you said you shouldn't treat anybody, like when you read that article, I was like, because I'm like, Oh, well, more than likely, I probably have done that on a very, very regular basis. And, hopefully, you know, the authorities won't come and get me. But still, is that still a recommendation?

Taylor: [00:05:22] No, absolutely not. Absolutely not. No, not at all.

Wright: [00:05:26] Update us.

Taylor: [00:05:27] You know, when we talk about recommendations, and there's kind of two different issues because either A, and I would say it's somewhat similar to how do you treat patients who have used alcohol?

Wright: [00:05:37] Right.

Taylor: [00:05:38] You know, if it's four o'clock in the afternoon and your patient tells you that they had brunch and had a mimosa or a Bloody Mary with their friend at breakfast at 9 a.m., are you still going to treat them that afternoon? There's two things, you know, for consent and whatnot, you're going to use your professional judgment to make a judgment call as to are they coherent with me? Can I have an intelligent conversation with them? Are they answering questions? So on and so forth. 

And then the second factor is you're going to take vital signs. And I think that's, with cannabis, I always go back to the importance of taking the vital signs. And then also that gets into a discussion of the difference of asking questions. And this is where I want the doctors and hygienists and assistants, everyone to be comfortable asking the questions. You know, did you smoke it? Did you take an edible? Is it a, 3 o'clock afternoon patient and they wake and bake, so to say, and he's a 25-year-old who does that every single solitary morning, but they did that in the morning and now it's an afternoon patient? Or did they take an edible in the parking lot at noon because they want to be relaxed for the dental appointment at 1 o'clock or 2 o'clock?

Wright: [00:06:38] Yeah, I always say, how did you consume it? That’s how I ask.

Taylor: [00:06:41] That's a critical thing. That's a critical thing. Because when we smoke it, a quick onset of action of about 30 minutes, peak action at about 30 minutes to 45 minutes. And then on average, a duration of action of about two hours. You know, we're talking averages here and it affects everyone differently. But when you start talking about an edible, and all of a sudden you're talking about a range of onset of action, which could be anywhere from one hour to three hours where that peak action is for the patient is much, much more variable. It could be at two hours, it could be out at three or four hours.

And then I think really the concern with an edible is a duration of action that can be as long as six or eight hours. So asking the patient when they took it, I think almost more importantly is what form did you take that in? Did you take it as an edible or did you smoke it? Because you're going to have very much different dynamics for how it's affecting the patient.

Ioannidou: [00:07:37] But I think what you said was very right. It's how we train practitioners and staff to feel comfortable asking these questions, right? There is this kind of a, it's the stigma, the taboo of, you know, I know that's not my business. I don't want to go into this for several reasons. Like we are not trained for this. We don't, maybe we feel, you know, we don't want to touch any legal liability thing. It’s so complicated.

Wright: [00:08:03] Dr. Taylor, is cannabis use from your experience and expertise, is it increasing overall? And if so, could you just let us into a little bit more why that is?

Taylor: [00:08:15] It is. As it becomes legal in more states, and I think now we have 23 or 24 states, District Columbia, however we're going to count them, where it is legal for recreational use. You have, I think, 36, 37 states where it is legal for medicinal reasons. And you really only have, I think, three states where there is absolutely no use of marijuana or cannabis in any manner.

The other thing that's interesting when we're talking about it, is that it's not an increase in use among teenagers and whatnot. That actually hasn't increased in the manner that you would maybe, you think it would as it became legal in states. The greatest rate of increase of use of a marijuana for THC is actually in the older population over the age of 55.

Wright: [00:09:00] Huh. I can believe that actually.

Taylor: [00:09:02] Yeah. And people will sometimes say, like, Oh, well, of course, you know, those are all the hippies in the sixties. Well, actually, no, those people are actually in their seventies and eighties. It's, the reason why is, hypothetically, is that more and more people are using it for a perceived medicinal reason and not for a recreational reason.

Ioannidou: [00:09:18] Interesting.

Wright: [00:09:19] I can believe that.

Ioannidou: [00:09:19] Yeah. I'm 55 and I can tell you I'm no hippie of the 60s. I was born in 69. So these people that say the hippies of the 60s don't do simple math.

Wright: [00:09:29] I hope that, I hope it wasn't offensive for me to say I can believe that. I think I was thinking, I'm just saying it from an experience.

Ioannidou: [00:09:34] No, no, no, no. You were absolutely right.

Wright: [00:09:36] I was just going to say from an experience perspective, seeing some of my patients, like, they talk about, like, anxiety and they're just, like, medicinal users. Exactly to your point, what you said. So, like, and I feel like it's just becoming less taboo. It's almost like stigmas around, you know, mental health things. People are just being more open and talking about it on a regular basis now. So, I really love this conversation we're having.

Taylor: [00:09:58] I think the stigma is a good word. I mean, I'm talking about the scientific terms of, you know, reduced rate of safety and how people view it. But yeah, it's the stigma. That's the word that sums it all up.

Ioannidou: [00:10:08] Yeah. I mean, I really want to go back to what you said about the, if you will, the least increase that we see in the teenager, young adults, probably because, you know, I mean, I don't know about teenagers and I would, I would predict that with the vaping and everything, perhaps they use, they're combining those two, but for young adults, we always know that four years in college, if you don't experience this, then you're not considered cool. Right? So it has been in common use for ever and ever and ever for decades now, right?

Taylor: [00:10:42] Very much so. Yeah. And I think going back to kind of the original question, everything is, because this is about patient education and communication with patients, is the reason why I like to talk about that older population using it, is that when a patient is sitting in your chair and yes, statistically, the highest heavy consumers are, you know, age 20-25, 16-20, you know, the young male that is your classic. True. But having said that, you need to ask every patient, because it's your older patients can, not as likely, but they very commonly can be using it.

Wright: [00:11:11] I feel like my older patients, they just come outright and say it. Like it's no hiding it. They're like, it's on Front Street, right? Yeah. And I feel like when we have conversations about it, it make it less, it makes it less, like, weird to talk about it.

Taylor: Yeah, you're right.

Ioannidou: [00:11:25] So if I suspect that someone on my dental chair is high, what's the first thing that I need to do? And what's the right way to approach this patient?

Taylor: [00:11:34] Well, the first question is to say, you know, Hey, I noticed you have dilated eyes or, you know, I can smell cannabis on you, but if they've used an edible, you're not going to have that aroma.

The first thing I would just, I'd flat out ask them, and then I think, and I hope, every single solitary dentist, hygienist, oral health provider, well, particularly with hygienists and dentists, that we're taking their vital signs. So that's going to be the other thing. So if you haven't, you take the vital signs. You're asking them in a nice conversation manner, have you used cannabis today?

And then you want to know, going back to our earlier conversation, when did you use it and how did you use it? Hopefully we'll be honest with you. If you're suspicious, they've got dilated eyes, or they seem a little incoherent, then that's a check mark of, okay, this is, I'm not going to proceed with treatment because my professional judgment is picking up that something is off here and I need to know what is off.

But if they are honest with you and they tell you that they, I just took an edible an hour ago, that's what you need to be educated. Like, you know, I'm not too comfortable. Or, you know, maybe like, okay, like how many milligrams did you take? How often do you take it? Oh, it's the first time I've ever used cannabis. My friend suggested it to me and said I should take 10 milligrams because it will help me relax. I've never done this before. Well, no, that'd be a red flag. And I would absolutely be, like, no. You know, have someone drive you home because there is an increased risk of motor vehicle accidents. You're under the influence. I'd be very, very concerned about it.

If it's someone who says, Oh, I took five milligrams every night before I go to sleep. Um, I thought it would help me relax for the dental appointment. I took five milligrams. I take the vitals. I'd be more comfortable treating them. And I think there in the Journal of the American College of Dentists is a 2010, Dr. Peltier, well respected editor for the journal, he wrote a really good article in that issue. And it was about, it's not ethical to have a blanket statement around cannabis use. Like you can't just say like, if you have used cannabis within the past 24 hours, I will not treat you. There's not really evidence to back that up either from an ethical standpoint or from a scientific standpoint.

Wright: [00:13:38] The nature of our job is so hard. Like, we have to shift in between decisions and it's, like, case by case. As much as like, I say this all the time to mentees, as much as I'd like to have, like, blanket statements for certain things, it's like, it depends on the data that's in front of you at that time. Like, I don't know, to your point, I hope that that's, like, adding value to our listeners

Ioannidou: [00:13:59] For sure.

Taylor: [00:14:00] Well said. It's very well said. We, I think we dentists, I mean, I think all providers want those black and white statements of, this is the path to take. And we, Oh yeah. That's why we go to dental school with the professional judgment. We have to make some judgment calls.

Ioannidou: [00:14:14] Absolutely. For sure.

Wright: [00:14:15] Okay. So let's say that my patient admits that they are high. How does that affect my treatment plan? Maybe we can go into a little bit more background about cannabis and all of that, like anything that you have to add.

Taylor: [00:14:29] Yeah. So when we talk about cannabis and marijuana, we tend to use the two terms interchangeably. Cannabis really is referring more to the plant. So the cannabis plant could be very, very high concentrations of CBD and CBD is cannabinoid, which is not psychoactive and has low affinity for the CB1 and CB2 receptor, when we start talking about the endocannabinoid system. 

When we talk about marijuana, we're tending to talk about the cannabis plant, which is high in THC concentration. And so it's like, when we talk about medical use and recreational use and, going down a rabbit hole a little bit, you know, if someone is using cannabis for recreational reasons, they are probably using it with a high THC concentration. If someone is using it for medical reasons, you really need to ask like, Oh, are you using cannabis with a high CBD concentration? Cause that could have zero effect on our dentistry. Or other people are using marijuana, cannabis, with a high THC concentration and saying they're using it for medicinal reasons. Did I take us too far down a rabbit hole? That was a lot.

Ioannidou: [00:15:29] No, no, no, no.

Wright: [00:15:30] That was a lot to wrap my head around, but this was good. I feel like our listeners, they actually need this. Like even me, I was just like, okay, wait, let me just write a few things down here. Let me get some notes. You know.

Taylor: [00:15:40] The bottom line is that if someone says a blanket statement of, yes, I use marijuana or yes, you use cannabis. You, that's why I want to educate. And that's why people listen to the podcast to like, Oh, okay. So like, do you use it for the high THC concentration or do you use it for a CBD concentration? Then you ask more probing questions of, Oh, how often do you use it? And when do you use it? Do you use it as an edible or do you smoke it? So kind of two different paths, but going back to conversation with the patient.

Wright: [00:16:07] We'll be right back.

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Wright: [00:17:02] Welcome back to Dental Sound Bites. We are having a conversation with Dr. Barry Taylor about the impact of cannabis on oral health.

Ioannidou: [00:17:10] So how does cannabis specifically impact oral health? And what do we see with the chronic use of cannabis? And is there a difference between patients who smoke versus consume it as edible?

Taylor: [00:17:24] Taylor: Yeah. All, do you have a few hours? No, all great questions. I think that the quickest and easiest one to explain is that it causes dry mouth. Now we're talking about marijuana, THC. So I may have said this already. CBD has this weak affinity for the CB1 and CB2 receptor. THC has a high affinity for those receptors.

And so, it decreases salivation and it does it through a number of ways. It decreases the signaling within the cells of the salivary glands. It relaxes the muscles around the salivary glands. And it also decreases the innervation and the stimulation of the salivary glands by changing the neurotransmitters at the nerve ends and whatnot.

So, a number of different ways, all those ways, they all cause decreased salivation. I was just lecturing at the dental school today, that's why this is so familiar to me. And it's on a number of the different strains. The number one negative effect is dry mouth. So, getting dry mouth is incredibly common from using THC.

And you're going to get that whether you're smoking it or if you're using an edible. And then we all know xerostomia, of course, is going to cause caries, you know, that's a given. And so then there are a number of studies, the best one is actually out of an adolescent program in Nevada, I think it's the most extensive one, but showing a very significant increase in dental caries.

And then that kind of leads, because of that xerostomia, that leads to the second thing. That is that THC, you get the munchies, right? We all, you know, I'm sure you've heard people joking about getting the munchies when they use THCs. So that is, that's caused by, there is a hormone protein, called leptin, which is released by fat cells. And so the normal process is we eat a meal, leptin is released, leptin tells our brain that we are full. We don't eat anymore. Cannabis inhibits leptin. So the brain doesn't get that message.

And then another thing that THC does is it increases, in certain areas in the brain, it increases the release of dopamine. So now all of a sudden sweeter foods taste, you know, more sweet, salty foods, you know. So you develop this craving for unhealthy foods. There's no message in your brain saying that you're full. So this whole joke about like, Oh, you know, getting high and getting the munchies. And so these high sugary foods, soda pops and whatnot, combined with dry mouth. You have like the recipe for dental caries.

Ioannidou: [00:19:50] Absolutely. It's exactly the recipe. 

Taylor: [00:19:53] The next one is a little bit more, you don't have that same cause and effect, so to say. But when we talk about periodontal disease, so there's a great study out of New Zealand. I mispronounced the name, I think it's the Dunedin Study. But a number, three papers were published in different journals on the Dunedin Study, and this was a large general population study, meaning that they were taking a large cohort of people, and then every four to six years, doing, full health exams on them.

So this wasn't a dental study. This was a study looking at heart disease, lung, everything, just the general health of the population. But we were lucky because they were doing periodontal disease, periodontal probings and measurements in that study. So you're following this population over a number of years.

And now that study, three papers have come out of that showing that the increased prevalence of periodontal disease. And actually kind of the lighthearted thing, that you saw some headlines in popular literature was that periodontal disease was actually the only disease that showed a correlation to smoking THC cannabis.

There is no other disease that showed a correlation with increased use of THC. And then a similar study was done in the United States. It's called the NHANES study. Very similar, but the same conclusion after that study was that those people that smoked cannabis increased clinical attachment loss.

So, you know, you have two very large studies, large and showing a prevalence of periodontal disease in those people that use cannabis. And the important thing there,as well was that, that was for people that were smoking marijuana. So we don't know if there's a difference, you know, like between using edibles versus smoking it, and then it comes back to smoke. It’s smoke and smoke is bad, you know, the damage it does to the micro vessels and everything. It comes back to, you can't say so much that maybe it's the THC, the marijuana, causing the periodontal disease, but what it comes back to  is smoke,

Wright: [00:21:50] Right? So good.

Ioannidou: [00:21:51] Oh, for sure. And I'm sure it, perhaps it also goes back to the microbial profiling of these patients. But you know, it's so interesting. Yeah, for sure.

Taylor: [00:22:02] Yeah. And then the three big categories of oral health and the third one is around oral cancer. Yep.

And there are probably equal number of studies showing a positive association between THC use and oral cancer. And there are, I would say, probably even more studies showing no association between THC and oral cancer.

The one exception to that is with laryngeal cancer, positive association with that. But there is a study actually showing that there actually was a decrease in oral tongue cancer from that population that was using THC. But that's hard to study oral cancer because it, you know, I don't know, when I was in dental school, they told us oral cancer was like 3 percent of all cancers. I don't know the exact statistics, but it's a very small population that gets oral cancer. And then of that small population, you have, you know, let's say 10 percent that are using marijuana on a regular basis. So it's such a small population sample. It's hard to study that.

Wright: [00:23:03] Yeah. Well, speaking of studying, like, are there any specific guidelines or recommendations for the use of cannabis in medical or dental patients that our practitioners should be aware of?

Taylor: [00:23:16] I say this a little bit cautiously because this is just Barry Taylor speaking after reading a lot of articles and everything. I think there's something to be said for using edibles versus smoking it. Because we know the damage from smoking it. 

When you smoke it, you also have that increased airway retention. You're inhaling it. You're trying to hold it in. We know all the damage from smoke, whether it's tobacco or cannabis or anything. So I think there's something to be said for using it as an edible and not smoking it. I think a lot of it then is patient communication, you know, your patients may, your college patients or whoever, may think it's kind of funny, the increased appetite and everything. But they may not put the connection between, Oh yeah, I do get cotton mouth, dry mouth every time I use THC.

You know, that's where the education comes in. Like, Oh, yeah, you get that dry mouth. You're also eating a lot of sugary foods and your oral healthcare, you know, increased caries and whatnot. And I think it's all things in moderation, just like alcohol use or a lot of other substances. The person who's using an edible Friday nights, two or three times a month, you know, I'm not the least bit concerned about, I'm concerned about the person who is smoking cannabis on a daily basis.

And then, you know, we haven't talked at all about cannabis use disorder and there is a cause and effect there with dosage and chronic users. It's not a completely safe drug, depending on how you look at it, about 20 to 30 percent of the population will develop some degree of cannabis use disorder. The population that uses cannabis, different ways to measure it, different studies, but I think it's pretty safe to say 20 to 30 percent will develop a degree of cannabis use disorder, you know, anywhere from mild to severe. Centers for Disease Control will say that 10 percent will develop an addiction. So I think it's safe to say that probably 10 percent will develop an addiction, severe problem with it, but as high as 30 percent will develop some degree of a problem with it. And again, the other thing that's important is that we're talking about THC.

Ioannidou: [00:25:09] If we want to think about the key, the bottom line of our conversation, how would you summarize the bullet points for us, Dr. Taylor?

Taylor: [00:25:19] Right. Being comfortable to talk to your patients, finding out, are they smoking it? Are they using it as an edible?

Ioannidou: [00:25:25] That's right.

Taylor: [00:25:25] Clarifying with them, are they using products which have, you know, marijuana, high THC? So are they using it to the degree to get that euphoria, that intoxication? Or are they telling you that they use cannabis and it is just, you know, CBD gummies that they bought on Amazon. So really making sure you understand and clarify, is it CBD or THC? Because two different paths there. 

And I really think at the most basic level, the most common one, you know, is, is the dry mouth and the, and the connection between dry mouth and dental caries. And if they're smoking it, then, you know, how often? Because, it'd be the same conversation you have with a tobacco user about periodontal disease

Ioannidou: [00:26:07] And cancer.

Taylor: [00:26:08] Yeah. Very much so. Exactly.

Ioannidou: [00:26:10] I mean, this was such a useful conversation. I learned so much.

Wright: [00:26:14] So good. I'm over here still writing notes.

[00:26:17] I know

Taylor: [00:26:18] You two are great. You two are great. You two are great.

Ioannidou: [00:26:21] I'm like looking forward to having a patient who's high.

Wright: [00:26:25] Listen, you might not get any work done.

Ioannidou: [00:26:28] I'm ready to go.

Wright: [00:26:28] You might not get any work done.

Taylor: [00:26:31] You know, if it's someone who has smoked I'll, if it's someone who has smoked cannabis and you've taken the vital signs and it's been a couple hours and the vital signs are fine. There's not huge medical emergency risks with someone who has used cannabis.

Ioannidou: [00:26:46] Oh, very good point.

Announcer:: [00:26:48] On the next Dental Sound Bites.

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Ioannidou: This time we are focusing on respect. 

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Ioannidou: [00:27:07] Thank you so much, Dr. Taylor. This was meaningful. This was very educational. I'm prepared. I'm prepared. Yeah.

Taylor: [00:27:16] Yeah. Thank you both.

Wright: [00:27:16] Yes. We're so glad that you are here with us. Yeah.

Taylor: [00:27:19] Thank you for the opportunity. It's great.

Ioannidou: [00:27:20] Oh, of course. Now tell us a little bit, where can our listeners find more about you or where can they follow you online if they want to?

Taylor: [00:27:29] Yeah, I don't have any presence online. I'm the executive director for the Oregon Dental Association. Yeah. I'm the, I'm the executive director for the Oregon Dental Association. So I don't have any online presence or anything. I'm going to send you a website. It's called STEM. I think is what it's called, but it's a pretty good website for information on cannabis and it's all evidence based and whatnot.

Ioannidou: [00:27:51] We can share with our listeners so they can have at least the resources to get more educated. That's great.

Taylor: [00:27:56] It's just a good resource for that information.

Ioannidou: [00:27:59] Yeah, that's great.

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Ioannidou: [00:28:12] And don't forget that you can also rate the episode, write a review and follow us on social media.

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