Cannabis: Oral Health Effects

Cannabis is a genus of annual flowering plants found in temperate zones around the world, with a long history of use for industrial, recreational and medicinal purposes.^{1, 2} The plant Cannabis sativa acts as a mild sedative and mood enhancer for recreational users and is used for its analgesic and antiemetic properties in clinical applications.^3-5 The dried flowers or leaves of the cannabis plant can be smoked as marijuana, which is the most common form of cannabis use in the United States.⁶

The proportion of cannabis users has increased dramatically since the early 1970s. According to the 2021 National Survey on Drug Use and Health, about 49% of American adults said they had used marijuana at least once in their lifetime, and more than 18% of Americans over 12 years of age reported past-year use of marijuana.⁷ The same survey found that the percentage of individuals reporting heavy (i.e., daily or almost-daily) marijuana use rose to 4.7%.⁷  

Studies continue to demonstrate increasing cannabis use among American adults, including growing past-year cannabis use among older adults (> 65 years of age). One study reported that cannabis usage among older individuals rose from 2.4% in 2015 to 4.2% in 2018, a 75% increase.⁸ Another survey found that 15% of older adults reported having used cannabis within the past three years.⁹ Cannabis use among older individuals has also been linked with increasing cannabis-related emergency room visits,¹⁰ and a higher prevalence of cannabis use disorder was reported in a cohort of older adults with chronic pain.¹¹

Despite the increasing social and legal acceptance of cannabis over time, public health concerns remain due to the potential adverse effects associated with cannabis use, including impaired cognitive functioning, impairment in driving vehicles, blurred vision, cardiovascular effects (e.g., tachycardia), and increased risk of psychotic symptoms or development of substance use disorder.^12-15

Chemical analysis of Cannabis sativa has identified more than 500 compounds, of which over 125 are cannabinoids, a class of chemicals that directly interact with the nervous system’s endogenous cannabinoid receptors.^{5, 16-18} Tetrahydrocannabinol (THC) and cannabidiol (CBD) are two of the primary (and most well-studied) cannabinoids present in cannabis. From a neurotropic perspective, THC is considered the most important of the cannabinoids and it is the main active ingredient in marijuana, responsible for its psychoactive effects.

The concentration of THC determines a cannabis product’s potency and varies widely across and within various preparations.^{3-5, 16, 19} THC potency of cannabis products has been observed to be increasing over time.^20-22  THC typically refers to the most potent delta-9 isomer, although synthetically concentrated forms of delta-8 THC and delta-10 THC are becoming increasingly common.^{23, 24} 

The dried leaves and flowers of the cannabis plant are usually rolled into cigarettes (“joints”^{16, 22}) or placed in a water (“bong”²²) or other pipe and smoked, or its resin or oil forms (hashish and hash oil, respectively) are ingested or inhaled. When smoked, marijuana delivers average THC concentrations between 0.5% and 9.6%,^{3, 19} although cannabis products available may have considerably higher THC concentrations (often exceeding 18%).^{25, 26}

Cannabis can also be vaporized through a non-combustive heating process that releases psychoactive compounds such as THC, which are inhaled by the user. Several vaporizer models, including pen-sized and tabletop devices, are used for vaping cannabis herb, wax, or e-liquid.²⁷  Initial research has shown that cannabis vaping has become increasingly popular among adolescents,²⁸ and can also produce stronger subjective drug effects and impairment in cognitive functioning.²⁹

Another method of cannabis administration, known as “dabbing,” uses concentrated butane hash oil, which is vaporized rapidly and inhaled.³⁰  Dabbing with cannabis concentrate is a highly potent mode of administration, with THC concentrations ranging from 66.4% to 75.5%.^{16, 31} The practice of dabbing has been cited as a causal factor in a case report of acute lung injury mimicking pneumonia,³² as well as adverse events associated with the high THC concentration (e.g., incapacitation, vomiting).³³

Cannabis can also be mixed into food substances, and numerous cannabis-derived food products are available for medicinal or recreational purposes, particularly in U.S. states that have legalized recreational marijuana.³⁴ Some food products contain forms of hashish with THC concentrations ranging from 2% to 20% (edibles with much higher THC concentrations are also available in some states).^{3, 16, 19} Consuming foods containing cannabis or cannabis-derived compounds (e.g., THC) is associated with slower onset of psychoactive effects, which can be delayed by one to three hours.¹⁶ Researchers have noted that use of cannabis edibles can present public safety concerns due to persistent effects of THC within the body, which can potentially heighten risk of inadvertent overconsumption.³⁵ Additionally, in 2022, the FDA issued a Consumer Alert³⁶ that advised adults to keep cannabis edible products away from young children, due to concerns about poisoning from accidental ingestion.

Cannabidiol (CBD) is another primary cannabinoid present in the cannabis plant, but unlike THC, CBD is non-psychotropic so it does not cause a “high.” Use of CBD has been increasing in popularity for its potential benefits in providing relief from conditions such as anxiety, depression, insomnia, pain, and epilepsy.^37,38 Popular CBD forms include CBD suspended in oil, alcohol (tinctures), or a spray administered sublingually, vaporization liquid, capsules/pills, topical creams, and edibles.^{39, 40}

Although hemp (cannabis with a THC concentration of ≤ 0.3% on a dry weight basis) is no longer considered a controlled substance under the Agricultural Improvement Act of 2018, over-the-counter CBD products and dietary supplements containing or derived from cannabis are not FDA-approved. In September 2021, the CDC released a Health Advisory warning consumers that CBD product labeling may underestimate the concentration of THC by not reporting delta-8 THC concentrations, which may result in psychoactive and other adverse effects.²³

The neurological and behavioral effects of cannabis include a sense of well-being coupled with immediate cognitive and psychomotor impairment.^{4, 5, 21, 29, 41}  Frequent use has long been associated with chronic systemic health effects, including addiction^{21, 22, 42} and disruption of brain development,^{5, 42} particularly among adolescents—who are not only the most likely to try the drug but are also at a critical period for brain development.^{5, 21, 42, 43}  Cannabis use in adolescence is also associated with an unclear relationship with psychotic disorders and an exacerbation of psychotic symptoms, including schizophrenic episodes,^{21, 42, 44-48} as well as suicidal ideation and behavior.^{23, 49} Prenatal cannabis exposure has also been associated with childhood psychopathology.^{43, 50}

Immediate cardiovascular effects of cannabis include increased heart rate (tachycardia) and microcirculation disruptions that can lead to a number of serious conditions, from myocardial infarction to stroke,^51-53 and vascular occlusive diseases referred to as “cannabis arteritis.”^{5, 16, 22, 42, 54-57} In addition, there are case reports of sudden cardiac death during intoxication,^{5, 13, 42, 55} plus one study that found greater risk of increased systolic blood pressure after cannabis use.⁵⁸

Cannabis contains many of the same carcinogens as tobacco, and chronic smoking of marijuana is associated with similar respiratory pathologies as tobacco smoking,^{3-5, 13, 21, 41, 55, 59-61} although co-occurrence of tobacco and marijuana smoking complicates ascribing causality to cannabis.

The use of cannabis, particularly marijuana smoking, has been associated with poor quality of oral health,^{3, 4, 16, 22, 73} but etiology has been complicated by the number of associated factors with frequent users, including: concomitant use of tobacco, alcohol, and other drugs; poor oral hygiene practices; and infrequent visits to dentists.^{3, 4, 16, 41, 74} It may also lead to xerostomia (dry mouth), which can contribute to a number of oral health conditions (dry mouth effects also reportedly last between 1 to 6 hours after cannabis use).^{3, 5, 16, 22, 75}  Further, the main psychotropic agent, THC, is an appetite stimulant, which often leads users to consume cariogenic snack foods.^{16, 76} Regular cannabis users are known to have significantly higher incidence of caries than nonusers,^{3, 16, 54, 77, 78} particularly on normally easy-to-reach smooth surfaces.^{16, 79}  

Leukoedema is more common among cannabis users than non-users but it is unclear whether associated irritants, such as orally inhaled smoke, rather than cannabis itself, may be contributing causes.^{16, 73, 78} Smoking marijuana is associated with gingival enlargement,^{3-5, 16, 54} erythroplakia and chronic inflammation of the oral mucosa with hyperkeratosis and leukoplakia,^{3-5, 16} sometimes referred to as “cannabis stomatitis,” which can develop into malignant neoplasias.^{3, 5} It has been reported that a synergistic effect between tobacco and cannabis smoke may increase oral and neck cancer risk for people who smoke both.^{3, 61}  The risk and aggressiveness of cancers associated with cannabis appear to be higher in younger (i.e., <50 years old) users.^{3, 73}  Immunosuppressive effects of cannabis, especially in association with oral papillomavirus in smokers,^{3, 80} may contribute to these increased risks of cancer,^{3, 81} but other studies have found no association between marijuana use itself and head and neck cancers.^{46, 82, 83}

The immunosuppressive effects of cannabis may contribute as well to a higher prevalence of oral candidiasis compared to non-users.^{3, 4, 16, 42, 73}  It has been hypothesized that hydrocarbons present in cannabis provide an energy source for Candida albicans, resulting in increased presence and density of colonies.^{3, 73}  Alternatively, the generally poor oral hygiene among many cannabis smokers may promote candidiasis colonization.^{3, 4, 16, 73}  Recent research has suggested that viable microbiota may be transmitted from contaminated marijuana, which could further exacerbate a pathogenic oral environment.⁸⁴

A number of studies have suggested a direct relationship between cannabis use and periodontal disease,^{3-5, 16, 19, 85, 86} including several systematic reviews^{77, 87, 88} and a 2020 rapid evidence review.⁸⁹ Recent studies have tested the relationship between periodontitis and frequent cannabis use and adjusted for confounding factors, such as cigarette smoking, alcohol use, social status and other health issues.^{19, 87, 90} Significantly higher rates of periodontitis were observed among the frequent users compared to non-users, with significantly higher numbers of sites with high pocket depths (≥4 mm) and attachment loss.^{19, 90}  Further, periodontitis may occur at an earlier age in marijuana users than the general population with chronic periodontitis.^{19, 85, 91-94} A study of adolescents in Chile, however, found no association between regular use of cannabis and periodontal disease,⁹⁵ but it may be expected that long-term use would result in periodontal disease later in life.⁹²  In a histometric experiment, laboratory rats exposed to marijuana smoke had a significant increase in alveolar bone loss due to periodontitis,⁶⁰ despite research that has indicated that specific cannabinoids, such as the non-psychotropic CBD, may prevent bone loss.^{96, 97}

Signs and symptoms of an active (intoxicated) cannabis user may include:^{22, 54}

• Euphoria
• Hyperactivity
• Tachycardia
• Paranoia
• Delusions
• Hallucinations

A currently intoxicated (i.e., “high”) user may present several difficulties for the dental practitioner. Increased anxiety, paranoia and hyperactivity may heighten the stress experience of a dental visit.^{3, 5, 22, 41, 54}  Increased heart rate and other cardiorespiratory effects of cannabis make the use of epinephrine in local anesthetics (for procedural pain control) potentially life-threatening.^{5, 54, 89} Patients may be unwilling to self-report marijuana use or unable to answer reliably, but determination of intoxication may be possible during the routine cardiac risk assessment.²² Due to concerns such as the potential risk of administering epinephrine or products containing alcohol to a “high” patient,^{4, 5, 41, 54, 55} in addition to increased anxiety or diminished ability to provide informed consent, the dentist may consider refusing to treat a cannabis-intoxicated patient⁹⁸ or postponing non-emergency treatment for at least 24 hours.⁵⁴ Additionally, a 2023 study reported that cannabis users required more intravenous anesthetic agents (i.e., general anesthesia) than non-cannabis users during ambulatory oral surgery procedures (e.g., extraction).⁹⁹ Additionally, there may be legal implications regarding validity of informed consent with intoxicated patients, especially with irreversible procedures like extractions. Effects of acute intoxication effects are reported to subside within 2 to 3 hours.^{16, 22, 54}

The following dental findings may indicate a chronic recreational cannabis user:^{3-5, 16, 54, 100, 101}

• Xerostomia
• Leukoplakia
• Periodontitis
• Gingival enlargement/hyperplasia
• Increased decayed, missing or filled teeth
• Stomatitis
• Candidiasis
• Alveolar bone loss

If the patient appears to be a cannabis user, it may be helpful to understand whether the use is medicinal, as this may suggest relevant comorbidities.²² Verification of cannabis use may be an opportunity to discuss other health consequences and inform the patient of the importance of fluoride, good oral hygiene practices, and healthy snacking.¹⁰²

When dental health care providers suspect cannabis use, recommendations for patient care include:^{5, 16, 54}

• Completing a comprehensive oral examination and including questions about cannabis use in a thorough dental and medical history.
• Emphasizing the importance of regular dental visits and oral care.
• Encouraging healthy, nutritious snacks over sweet, cariogenic snacks.
• Considering employing preventive measures, such as topical fluorides.
• Considering treatment for xerostomia,¹⁰³ if necessary, while avoiding alcohol-containing products.
• Keeping advised of current changes in applicable laws on recreational or medicinal cannabis.

Statement on Provision of Dental Treatment for Patients with Substance Use Disorders (Trans.2005:329)

1. Dentists are urged to be aware of each patient’s substance use history, and to take this into consideration when planning treatment and prescribing medications.
2. Dentists are encouraged to be knowledgeable about substance use disorders—both active and in remission—in order to safely prescribe controlled substances and other medications to patients with these disorders.
3. Dentists should draw upon their professional judgment in advising patients who are heavy drinkers to cut back, or the users of illegal drugs to stop.
4. Dentists may want to be familiar with their community’s treatment resources for patients with substance use disorders and be able to make referrals when indicated.
5. Dentists are encouraged to seek consultation with the patient’s physician, when the patient has a history of alcoholism or other substance use disorder.
6. Dentists are urged to be current in their knowledge of pharmacology, including content related to drugs of abuse; recognition of contraindications to the delivery of epinephrine-containing local anesthetics; safe prescribing practices for patients with substance use disorders—both active and in remission—and management of patient emergencies that may result from unforeseen drug interactions.
7. Dentists are obliged to protect patient confidentiality of substances abuse treatment information, in accordance with applicable state and federal law.

The Practice of Dentistry and Cannabis (Trans. 2021: 300)

Resolved, that that the ADA encourage the development of best practices for the management of patients and their caregivers, dentists, and dental team members who are under the influence of cannabis. 

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87. Chisini LA, Cademartori MG, Francia A, et al. Is the use of cannabis associated with periodontitis? A systematic review and meta-analysis. J Periodontal Res 2019;54(4):311-17.
88. Mayol M, Andrade E, Rivoir SP, Rossy LAB, Rosing CK. Periodontal status in cannabis smokers. A systematic review. J Int Acad Periodontol 2021;23(2):150-66.
89. Keboa MT, Enriquez N, Martel M, Nicolau B, Macdonald ME. Oral health implications of cannabis smoking: a rapid evidence review. J Can Dent Assoc 2020;86:k2.
90. Thomson W, Poulton R, Broadbent JM, et al. Cannabis smoking and periodontal disease among young adults. JAMA 2008;299(5):525-31.
91. Duane B. Further evidence that periodontal bone loss increases with smoking and age. Evid Based Dent 2014;15(3):72-3.
92. Meier MH, Caspi A, Cerda M, et al. Associations between cannabis use and physical health problems in early midlife: a longitudinal comparison of persistent cannabis vs tobacco users. JAMA Psychiatry 2016.
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Professional Resources

ADA Oral Health Topics page on Xerostomia

ADA Media Relations: Half of dentists say patients are high at dental appointments (November 2022) 

Patient Resources

ADA MouthHealthy Nutrition: What You Eat Affects Your Teeth.

American Society of Addiction Medicine

Centers for Disease Control and Prevention (CDC):

• About Cannabis
• Cannabis Frequently Asked Questions

Food and Drug Administration (FDA):

• What You Need to Know (And What We’re Working to Find Out) About Products Containing Cannabis or Cannabis-derived Compounds, Including CBD

Mayo Clinic:

• Drug Addiction
• Marijuana and Depression

National Institute on Drug Abuse (NIDA):

• Drugs of Abuse (click on “Marijuana”)
• Marijuana
• Myth or Fact? “Marijuana Is Stronger These Days”
• Synthetic Cannabinoids (K2/Spice) DrugFacts

Systematically Testing the Evidence on Marijuana (STEM) [US Department of Veterans Affairs and the Center for Evidence-based Policy at Oregon Health & Science University]