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Influence of Cannabis Use on Periodontal Disease: a Scoping Review

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Influence of Cannabis Use on Periodontal Disease: a Scoping Review Influence of cannabis use on periodontal disease: a scoping review Matias Mederos1, Alejandro Francia2, Luiz Alexandre Chisini3, Guillermo Grazioli4, Ernesto Andrade5 DOI: 10.22592/ode2018n31a2 Abstract Recent publications suggest the possible association between cannabis (Cannabis sativa) and periodontitis. Objective: To analyze the possible influence of cannabis use on periodontal disease, highlighting the available evidence and identifying the associated variables in the studies. Materials and methods: We conducted a scoping review applying a structured search method in PubMed/MEDLINE, Science Direct, LILACS, SciELO including publications until May 2017. Results: In vivo studies showed greater bone loss in animals exposed to cannabis. Clinical cases show that chronic cannabis use may result in gingival enlargement (with clinical features similar to phenytoin induced enlargement) and localized severe chronic periodontitis. Most of the epidemiological studies confirmed the possible association between cannabis and periodontitis. Conclusions: The specific mechanism by which cannabis acts in the gingival tissues is unknown. Keywords: cannabis, periodontal disease. 1 Undergraduate Student, School of Dentistry, Universidad de la República. ORCID: 0000-0002-1561-2283 2 Physiology Department, School of Dentistry, Universidad de la República. ORCID: 0000-0002-7942-9189 3 Postgraduate Degree in Dentistry, Universidad Federal de Pelotas, Brazil. ORCID: 0000-0002-3695-0361 4 Department of Dental Materials, Universidad de la República. ORCID: 0000-0001-9969-3780 5 Periodontics Department, School of Dentistry, Universidad de la República. ORCID: 0000-0002-9511-3678 4 Odontoestomatología. Vol. XX - Nº 31 - Junio 2018 Introduction might reduce inflammatory processes(23). If we consider the increase in the prevalence of can- Periodontitis is one of the most common nabis use throughout the world (16% in the chronic diseases, with a high prevalence that United States, 11% in France and 9% in Uru- (1,2) varies according to each population group . guay)(24), it is essential to research the possible It affects approximately 46% of adults in the effects of cannabis on the oral cavity and peri- (1) United States of America . In turn, a recent odontal tissues in order to understand its role in global burden report showed that over 11% of the onset of periodontal disease and to develop the world’s population presents severe forms of and lead appropriate public health policies. (2) the disease . In Latin America, almost 10% of Therefore, the aim of this scoping review is to the young population is affected by periodon- analyze the possible influence of cannabis use tal disease, and approximately 35% of children on periodontal disease, surveying the available have gingivitis, with the highest prevalence (3) evidence and identifying the associated vari- rates in Colombia (77%) and Bolivia (73%) . ables in the studies. In adults, periodontitis affects up to 62.6% of individuals(4). In Uruguay, data from the First National Survey of Oral Health showed that Methodology among young people (15 to 24), the percentage of individuals with no signs of bleeding, with ab- Study design: The scoping review involves a sence of tartar and probing depth (PD) > 4mm systematic search but does not imply an anal- was close to 30%(5). Similarly, individuals aged ysis of the methodological quality of the stud- between 35 and 44 had a 16.5% prevalence of ies. This review presents a summary of the arti- moderate and 5.9% prevalence of severe peri- cles available in the literature by providing an odontal disease respectively(6). The highest prev- overview of the existing content, setting future alence was found in individuals aged between research paths and pointing to the gaps in the (25,26) 65 and 74, where 34.7% had moderate peri- literature . odontitis and 17% severe periodontitis(6). These Search strategy: We conducted a scoping results emphasize the importance of prevention review applying a structured search method and treatment in oral health programs(7). in PubMed/MEDLINE, Science Direct, LI- Periodontal disease is mainly characterized by LACS, and SciELO including publications gingival inflammation, formation of periodon- until May 2017. We used keywords and con- tal pockets and destruction of the supporting trolled terminology (MeSH terms) based on tissues (alveolar bone and periodontal ligament) questions structured according to the PICO (8). It is the result of the interaction of microbial Model: “What is the possible influence of can- biofilm (necessary etiological factor but insuf- nabis use on periodontal disease?” where we ficient in itself), a susceptible host and mod- defined: ulating factors(9). Several studies have shown Population: individuals with periodontal dis- the existence of risk factors, among them to- ease. bacco(10), diabetes(11–14), obesity/overweight(15,16) Intervention: cannabis use and genetic factors(17,18). These elements mod- Control: individuals who do not use cannabis ulate the host’s susceptibility or resistance with Result: Periodontal disease alteration each microbial challenge(9). In this way, the following search strategy was Recent publications suggest a possible associ- implemented: (periodontal disease OR peri- ation between cannabis (Cannabis sativa) and odontitis OR gingivitis OR gingival disease) periodontitis. However, the use of cannabis AND (cannabis OR marijuana). All study de- components could have positive effects as they signs on humans and animals were included. Influence of cannabis use on periodontal disease: a scoping review 5 Study selection and eligibility criteria: Four long-term cannabis consumption may lead researchers participated in the paper search to gingival enlargement with clinical features (MM, AF, LC and EA) for the review design, similar to the ones caused by phenytoin,(30) in and were advised by a librarian. The records addition to chronic localized severe periodon- were entered into EndNote (Thomson Reu- titis(29). ters, Rochester, New York, NY, USA) to elim- Epidemiological studies: four epidemiologi- inate duplicates and create a virtual library. cal studies were retrieved. Table 1 shows the The researchers read and filtered the titles and main features of the studies. The methodolog- abstracts for all records that complied with the ical design of most studies was cross-section- predefined criteria. No language or year re- al(19,20,31), and there was a prospective study striction was applied. All original papers were from a cohort of births(27). Fifty percent of the included. Letters to the editor, in vitro articles studies were population-based(19,27), while one and reviews were not included in this review. was conducted with high school students(20) Additionally, the references of each paper and another with aboriginal communities were traced in order to broaden the search. from Australia. Three of the four studies were conducted on adults(19,27,31), while only one evaluated adolescents(20). Similarly, Shariff et al. (19) included patients with diabetes and pre- Results vious periodontal treatment, while Lopez et (20) A total of 260 records were obtained from the al. were the only ones that evaluated the search, of which 65 articles remained after re- patients’ oral hygiene habits. moving duplicates. After reading titles and ab- Although cannabis exposure and the classifi- stracts, 10 articles were selected to read the full cation of periodontal disease have been cat- text. Two of these articles were excluded(27,28). egorized differently in the studies reviewed, The reasons for exclusion are presented in fig- cannabis use is linked to periodontal disease ure 1. Finally, eight articles met the inclusion (Table 2). We observed a significant associa- criteria and were included in this review (Fig- tion between cannabis use and prevalence of (21,31) ure 1). periodontitis , where cannabis users had a In vivo studies: Studies on mice evaluated the prevalence of periodontal disease 44% high- (31) influence of the inhalation of cannabis and er than that of non-users . Similarly, popu- cannabidiol (CBD) on periodontal disease lation data from the United States National measuring attachment loss and bone density. Health and Nutrition Examination Survey Increased bone loss and lower bone density showed that the recreational use of cannabis were observed in mice exposed to cannabis or was associated with advanced probing depth (19) cannabidiol, which shows that these substanc- and clinical attachment loss . Additionally, es can negatively influence periodontal tissues. a study conducted on Chilean students found Clinical cases: Two clinical cases were includ- a Necrotizing Ulcerative Gingivitis (NUG) ed in this review(29,30). These articles show that odds ratio that was 53% lower in individuals 6 Matias Mederos, Alejandro Francia, Luiz Alexandre Chisini, Guillermo Grazioli, Ernesto Andrade who had never used cannabis compared to fre- tion, followed by the clinical symptoms of quent users(20). The other associations were not xerostomy (as it has parasympatholytic prop- statistically significant(20). erties), which would enhance the pathological Influence of cannabis on periodontal dis- effect(32). We must remember that cannabis ease: Table 1 shows the impact of cannabis on components that are not cannabinoids (prod- periodontal disease according to the action of ucts of combustion) are similar to those in to- its chemical components. Authors state that bacco and can have local and systemic effects
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