Periodontal Disease and its Unlikely Partner in Crime

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You can tell just by looking at this photograph that the radiographic evidence in this case of periodontal disease is going to be devastating. With periodontal disease this severe, how old do you think this patient is? Aside from poor oral hygiene, regular consumption of energy drinks, and poor nutrition, there is another factor that could be destroying this young 31-year-old patient’s mouth, specifically his gingiva and supporting bone structures… marijuana.

As I examined the patient I was highly concerned with the amount of radiographic bone loss and recession that was present. I first thought that this had to be a case of Localized Juvenile Periodontitis (LJP), but the devastation was throughout the patient’s entire mouth, and he was a bit too old for that. Then I considered Rapidly Progressing Periodontitis (RPP). We took a bacterial culture of his mouth prior to periodontal treatment and found that while he had a higher level of Treponema denticolea and Fusobacterium nucleatum species, he did not have the elevated levels of Bacteroides or Actinobacillus that I would expect with RPP.

My hygienist and I continued to delve ever deeper. With every new patient, we ask a very comprehensive list of questions and review their medical histories thoroughly. One of the questions on our form that is especially uncomfortable to ask is about the use of illicit drugs. This particular man was more than forthcoming when asked this question, and responded that he used marijuana on a daily basis. With the neighboring state of Colorado having legalized this drug, more and more patients are becoming comfortable discussing their recreational usage. As the use of marijuana becomes more decriminalized, and as patients are more willing to “fess up” to their use, I am beginning to see marijuana as an emerging factor in the proliferation and severity of these patients’ cases of periodontal disease.

Even the American Academy of Periodontology has made a statement recently about this connection. “At a time when the decriminalization of marijuana use is becoming more common in the United States, users should be made aware of the impact that any form of cannabis can have on the health of their gums,” says Dr. Terrence J. Griffin, president of the American Academy of Periodontology (AAP). “There are a number of risk factors that contribute to the development of periodontal disease, and this report suggests that cannabis use may be one of them.”

In this particular case, I diagnosed him with ANUG (Acute Necrotizing Ulcerative Gingivitis) due to gingival bleeding without provocation, severe pain in all quadrants, and sloughing and necrosing gingival tissues. Due to the severity of the infection, my hygienist began periodontal therapy that same day. She anesthetized his whole mouth, and began gingival debridement with chlorhexidine and scaling and root planing to remove as much calculus, infection, bacteria, and granulation tissue as possible. At his 10-day follow up appointment, his mouth was again treated in its entirety. The change in the gingival tissue health and color was pronounced, as evident in the above photo.

While there is no doubt that marijuana could have played a major role in escalating the symptoms and severity of this patient’s periodontal disease, it is also impossible to say that he wouldn’t have been in the same predicament without its influence on his health. Proper nutrition, oral hygiene, and regular dental care always are important, but even more so when your patient uses marijuana or other illicit drugs.

Be aware, this is a recently identified risk factor being associated with periodontal disease, as recently as late 2016. And while many have heard the virtues of medicinal marijuana extolled, I have to say that this patient’s case opened my eyes to another side of marijuana. If you are left wondering how a patient’s gingival health could have declined so quickly, or progressed so swiftly at a young age, start asking those difficult, awkward questions on your medical history sheets, and really listen to the answers.

Sources:

www.colgate.com/en/us/oc/oral...to.../ada-03-cannabis-linked-periodontal-disease

www.perio.org/consumer/marijuana-use

www.ada.org/en/publications/ada.../cannabis-use-associated-with-periodontal-disease