The practice of dentistry is currently evolving at a fast pace. As a physician, I see major technological advancements that include pain free implants, app-based post-surgical follow-up, and the use of artificial intelligence to predict problems, all of which elevate the way dentists provide care.
It is tempting for dentists to jump on the current CBD (cannabidiol) bandwagon. CBD is very popular right now and claimed to be effective for a range of issues from pain to anxiety. Ironically, CBD is, in fact, not proven useful for any of these things in adult humans. Cannabis, meaning THC containing products derived from the cannabis plant, has been shown to address these problems. However, the complexity of administering, adjusting to, and monitoring cannabis use makes it less than ideal in the acute dental situation.
For patients undergoing simple, one-time procedures, cannabis is not a good substitute for the tried-and-true approaches to pain or anxiety relief. For patients who are contemplating major work, perhaps spanning many procedures – for example, root canals or maxillofacial reconstruction – planning ahead to initiate cannabis medication is viable and should involve consultation with and ongoing guidance from a Cannabinoid Specialist.
Below are key points about what is known about cannabis and CBD and how to effectively use them.
- What is CBD and what is cannabis? How are they related?
CBD or cannabidiol is a cannabinoid or a chemical compound derived from cannabis. It has become incredibly popular recently but largely because it is a good product to sell, not because it is a safe or effective medication.
In general, questions about CBD pre-suppose that CBD is a useful medication. It is not. There is no data in adult humans to show that CBD is useful. All studies to date, except for kids with rare genetic seizure disorders, are done in mice or cell culture and are NOT reasonably applied to humans.
THC (tetrahydrocannabinol) is another cannabinoid from cannabis. While it does cause some intoxication for which it has become famous, it is really the best researched and clearly proven compound in cannabis. There is some evidence that pure THC is not as effective as using whole cannabis that contains THC and other compounds, including CBD. This is a case where the whole appears to be more effective than the individual components. This is called the Entourage Effect and while the evidence to support it is sparse, it is intriguing.
- What is the average dose of CBD or cannabis?
Extrapolating from kids and mice, CBD has been shown to require vast doses: 10-20 mg per kilogram of body weight, equating to 700 to 1400 mg per day for the average 70 kg human. This is not available, sustainable, or affordable.
While low dose CBD may not be harmful it is not helpful either. When you get to higher doses it has been shown to interact dangerously with many conventional medications like blood thinners, heart medications, and a range of others including over-the-counter meds like Loratadine (Claritin). There are even data that show that at higher doses CBD can cause direct liver toxicity.
THC-dominant cannabis, on the other hand, has been shown to be effective for pain and for anxiety. Doses are quite low, typically 5-15mg, delivered by inhalation (vaporized flower is safest) or orally. In the acute setting vaporized flower would be most helpful as the onset is 10-15 minutes compared to 1-2 hours for oral.
- Are there regulated guidelines for dosing CBD and cannabis?
There are no dosing guidelines for CBD beyond the 10-20 mg per Kg range mentioned above. Again, there are no studies in adult humans to show that CBD is safe or effective for any condition.
Dosing guidelines for cannabis use are more readily available and scientifically justified. A great source of information on use of cannabis to treat patients is the Association of Cannabinoid Specialists. They have a dosing and treatment handbook for members. You can find them at cannaspecialists.org.
As an MD, I would argue that it is the responsibility of your cannabinoid specialist physician to know the available products and to be able to recommend the best ones as well as the actual use regimen.
- What factors influence how much CBD or cannabis you should take?
You should not take CBD at this time. There are not sufficient data to assure that it is safe or effective. In the future, we may well have data to support the use of CBD but for now it is not a medically justified product.
Cannabis dosing is not clearly affected by weight or other common factors. Low doses are safer and more effective than higher ones and less likely to lead over the long-term to misuse and addiction. Guidance on dosing for individuals and specific situations should come from consultation with a cannabinoid specialist.
- Are there any side effects to CBD or cannabis? Can you take too much?
While low dose CBD may not be harmful it is not helpful either. Nausea, poor appetite, fatigue and diarrhea are minor issues that have been reported. When you get to higher doses CBD has been shown to interact dangerously with many conventional medications like blood thinners, heart medications, and a range of others. There are even data that show that at higher doses CBD can cause direct liver toxicity.
Cannabis will always come with some degree of side effects. Primarily this includes intoxication and dry mouth. Our job is always to maximize the benefit while minimizing these side effects. This is primarily accomplished with attention to dose and timing. The dental literature does show that chronic dry mouth in cannabis recreational users can lead to recession and complications. For this reason, attention needs to be paid to both medical and recreational users of cannabis.
It is commonly said that you cannot overdose on cannabis. This is incorrect. It would be correct to say that you cannot lethally overdose on cannabis. However, death is not the only negative outcome possible. Getting too much cannabis can be a very unpleasant experience, and while non-lethal, should be avoided. Further there are no safe and proven pharmacological interventions for over-intoxication.
- Should anyone avoid CBD or cannabis?
Everyone should avoid using CBD. It has not been proven to do anything, but the risks of drug interactions and liver toxicity are real.
I would strongly urge against using either cannabis or CBD while pregnant. Whatever the unclear data we have on cannabis and pregnancy, we have none on CBD specifically and every reason to expect that it may have effects on pregnancy. We just have no idea what they might be.
Caution should be exercised when using cannabis for patients who have history of atrial fibrillation, severe congestive heart failure, or history of cardiac or cerebral vascular insufficiency.
As medical professionals, we are available to answer questions surrounding cannabis and CBD use from a medical perspective. At inhaleMD, we are dedicated to treating patients through cannabis therapeutics. Our medical practices specialize in creating effective treatment plans for people seeking relief under the guidance of caring, well-trained physicians.
Cannabis medicine is unlocking new doors to treatment of pain and anxiety, and leading to new knowledge about human physiology. The pandemic, however, is creating vast need to catch up on delayed dental care. The intersection of these two phenomena is creating opportunities for dentistry to improve delivery of patient care.
ABOUT THE AUTHOR
Jordan Tishler, MD, is a cannabis specialist, President of the Association of Cannabinoid Specialists, as well as a graduate and instructor at Harvard Medical School. He’s been instrumental in the implementation and improvement of medical cannabis regulation in many states, including Massachusetts, New Hampshire, Connecticut, New York
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