Introduction

Cannabis and cocaine use is a global problem with a range of adverse consequences for individual, family, and community health.¹ After alcohol and tobacco, cannabis and cocaine are among the most commonly used psychoactive drugs (PD) by adolescents and adults in most countries.^1-3

Argentina is no exception. A 2017 study showed that cannabis and cocaine are the most commonly used PD by the general population after tobacco and alcohol. Their use has increased exponentially over the last decade in both sexes. Young people aged between 18 and 24 have the highest use and increase rates.³

In general terms, the consequences of PD on the oral health of users vary considerably. They can affect hard and soft oral tissues, induce malignancy, and predispose patients to infection.⁴ Periodontal disease, tooth decay, and tooth loss are the most frequently described disorders usually related to more extended periods of consumption time.^4-6 The coexistence of a highly cariogenic diet and/or complex individual, family, and social risk factors affects the genesis of poor oral health.² These factors-which include frequent multiple substance use-hamper diagnosis, therapeutic approaches, and research in affected patients.^4,7

A link between cannabis use and periodontal disease has been proven.^8-11) The association between cannabis smoking and other disorders, such as caries, soft tissue lesions, and oral cancer, is inconsistent.⁹⁾ Some authors say that the mental state of cannabis smokers can delay dental treatment visits.⁹

Regarding cocaine, the frequency of periodontitis, visible plaque, gingival bleeding, and oral mucosal lesions was significantly higher in cocaine users than in non-users.^5,12) Tartar and a greater probing depth were the most frequent findings in other studies.^6,13

The vast majority of studies on oral health in PD users address men-who are generally in treatment units or rehabilitation programs-and/or lack a comparison group.^4,6,12-14

This study aims to describe and analyze the types of dental visits and diagnoses of female cannabis and/or cocaine users over four years and compare them with female non-users.

Methods

A retrospective cohort study was conducted. The women were selected from the joint hospitalization sector of the Neonatology Service of Establecimiento Asistencial Dr. Lucio Molas (EALM) of Santa Rosa, La Pampa Argentina. They were selected in the immediate postpartum period.

Female cocaine and/or cannabis users (FU): all the women who fulfilled the screening criteria and had a positive postpartum urine sample for cocaine and/or cannabis. The tests were conducted in the Neonatology Service of the EALM, between 2009 and 2013.

Females not using cocaine or cannabis (FNU): women not complying with the screening criteria and who had delivered in the same neonatal unit on the same day or week as FU. This comparison group was selected based on similar maternal age, place of origin, and social security status as the FU group. Two non-users were chosen for each user to increase the power of the study.

Results

There were no significant differences between female users (FU) and female non-users (FNU) in the selection variables; the groups were homogeneous (Table 1). The average age of both FU and FNU was 22 (FU SD: 4.78; FNU SD:4.33).

No significant differences were found in educational level (p=0.32). Incomplete secondary education was the most frequent value (Table 2).

No participant had diabetes, HIV, or an immunosuppressive disorder before pregnancy, acquired during pregnancy, or four years postpartum.

The drugs detected in FU urine were: cocaine (9 women: 31%), cannabis (10 women: 35%), cocaine and cannabis (5 women: 17%), cocaine with phencyclidine and/or benzodiazepines (5 women: 17%).

The age range of first-drug use for cocaine and/or cannabis was 11 to 29 years. The average period of consumption was 5.14 years (SD: 2.96). Ninety-three percent were multiple substance users during pregnancy, mainly using cocaine and/or cannabis with tobacco and/or alcohol. Ninety-three percent of these women reported moking during pregnancy, as did 21% of FNU (p<0.0001). Fifty-five percent of the FU had drunk alcohol during pregnancy, while none of the FNU had done so (p<0.0001).

Table 3 shows the type and frequency of dental visits in both groups in four years. There were no differences between groups in the percentage of women who attended checkups, but there was a significant difference in dental emergency visits, where FU surpassed FNU.

Figure 1 shows the percentage distribution of dental emergency visits according to the number of visits (0 to 4) and whether the patients were FU or FNU. Thirty-four percent of FU and 76% of FNU attended no emergency dental visits in four years. Patients attended up to three or four visits in the FU group, which was not the case among FNU.

Table 4 shows the comparison of dental diagnoses. FU presented a significantly higher frequency of gingivitis and periodontitis than FNU (p=0.0001).

Ten FU (62%) diagnosed with gingivitis and periodontitis had used these substances for less than seven years. The others had used cannabis and/or cocaine between 7 and 13 years.

A FU sought emergency dental care and was admitted for facial cellulitis at the onset of a dental infection. No FU were hospitalized for oral conditions.

Discussion

The women in both groups were public health users, lived close to the hospital where they gave birth, did not have social security or prepaid health insurance, and had a similar education level. This is important since various studies in the general population and PD users found worse oral conditions and greater severity of periodontal disease when the patients had a lower socioeconomic and educational level.^16-19

Table 3 shows that we found no significant differences between groups in the percentage of checkup dental visits. Differences were found in emergency visits, which were higher among FU. In addition, FU attended more emergency visits than checkup visits (the opposite of FNU). Some authors have highlighted that cocaine and cannabis users have poor adherence to health checkups.^7,20,21 This has also been described in studies on dental visits attended by PD users: they tend to seek care almost exclusively in emergencies.^2,22

The main emergency diagnosis in FU was gingivitis and periodontitis, significantly higher than in FNU. Periodontal disease is the main dental consequence of cannabis and cocaine use, although it generally entails periods of consumption longer than 7 or 13 years, longer than described in this study.^5,8-12,23 However, the vast majority of FU were also smokers, and half had consumed alcohol.

Multiple substance use characterizes most studies on cannabis and cocaine, with cannabis and tobacco being the most frequent association.^10,24 Multiple substance use associated with other coexisting severe social and family factors makes it difficult to determine the weight of each element, or of all of them, on the results presented.⁷

One limitation of the study is its retrospective nature, which prevents us from knowing the time of smoking and how much alcohol was consumed. Another limitation is that it refers exclusively to the women included in the study in the postpartum period. Therefore, their oral health may have been influenced by pregnancy-related hormonal changes, which many authors associate with poorer periodontal health.^25,26

However, this study could be helpful in public health and for professionals as there is scarce information on the oral health of female cannabis and/or cocaine users, especially considering that global consumption continues increasing. FU may be expected to require more dental care in the coming years. In fact, in 2012, a study detected that 21% of those interviewed in the dentist’s waiting room reported problematic use of some type of PD-cannabis in 16.8% of cases and cocaine in 1% of cases-exceeding the general population percentages.²⁷

Another important consideration for professional practice is the potential risk of serious interaction between some local anesthetics and cannabis. Therefore, it would be essential to include questions about PD use in the patient's records.²⁸

Finally, the number of individuals affected by periodontitis has increased substantially in the world and in Latin America in particular.²⁹ Recently, periodontitis has been associated with complications such as death, ICU admission, and the need for mechanical ventilation in COVID-19 patients.³⁰ Health managers, practitioners, and researchers must remain on the lookout for further evidence on the relationship between these increasing data and the effects of cannabis, cocaine, and multiple substance use.

Conclusions

Women who used cannabis and/or cocaine sought emergency dental care more often and had a more frequent diagnosis of gingivitis and periodontitis than non-users. Given the high percentage of multiple substance use, these differences cannot be attributed to one drug or the other. However, this study prompts public health to consider the need to address the oral health of FU in advance and to address the overall complexity of the multiple coexisting risk factors. The immediate postpartum period could be an excellent time to perform a dental checkup and provide prevention guidelines, considering these patients seek care mainly for dental emergencies.