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Abstract

Background:

Medical marijuana (MM) use is increasing, requiring health care professionals, such as dentists, to possess a working knowledge of MM. Previous studies have indicated that MM education is lacking in current health care education. The aim of this study is to understand dental practitioners’ views and expertise around MM.

Methods:

A 50-question survey was created to assess, in detail, dental and dental hygiene faculty and students’ knowledge, practice, and attitudes toward MM, and to identify possible correlations between responses. The survey was modeled after a previous survey conducted among practicing pharmacists. All faculty dentists, faculty dental hygienists, students, and residents at the Arthur A. Dugoni School of Dentistry, University of the Pacific, were invited by email to participate.

Results:

A total of 219 surveys were included in this study. The factor with the most abundant correlations was the opinion that MM is valuable for pain. This view had a positive correlation with the opinions that (1) MM may be better than nonsteroidal anti-inflammatory drugs, acetaminophen, and narcotics for pain control and risk/benefit ratios, (2) that physicians and pharmacies should dispense MM, (3) that recreational marijuana should be approved, (4) agreement with the current MM dispensing methods, (5) a preference for patients to use MM, (6) favoring MM if it were available by prescription and US Food and Drug Administration (FDA) approved, (7) preferring the use of Cannabidiol (CBD) formulations, and (8) feeling that more research and education (as well as continuing education credits) are needed.

Conclusions:

Having more information and control over both the product and access to it might lead to increased comfort for providers. This would lead to better outcomes as well as greater communication between patients and their providers.

Practical Implications:

The findings of this survey suggest more MM education and research is needed—statements with which the majority participants of this study have explicitly and strongly agreed.

Introduction

Marijuana’s medical role is widely recognized; 42 countries, 35 American states, and the District of Columbia have all legalized its usage. Almost 90% of Americans favor its legalization for medical use while support for recreational legalization has reached 57%.¹ Yet, some stigma and differences in access and cost between the two usages still exists. As more people have access to medical marijuana (MM), the role that health care professionals can and do play becomes ever more important because it is they who prescribe marijuana and help patients navigate its usage and effects.²

Furthermore, individuals are presumably more willing to discuss its usage with health care providers, including dentists.^3–6 Accordingly, this increasing public and legal acceptance and usage of MM indicates that health care professionals will continue to become ever more involved with growing numbers of patients using MM,⁷ having MM-related conditions, or asking for MM in lieu of other pain treatments. As such, their attitudes and knowledge is an area that deserve research attention. Indeed, recent work has expanded our understanding of the type of health care providers who are engaged with MM and their attitudes.⁸ It has identified a shift in their attitudes toward MM similar to that of the general public. In 1989, 41% of physicians endorsed legalization of MM, although these views were informed by their specialties⁹; for example, oncologists and hospice specialists were more in favor of legalization than specialists in other areas.¹⁰ By 2013, a study of international physicians showed that 76% supported MM.¹¹ These attitudes—and the willingness to prescribe it—are influenced by how marijuana is regarded; if medical personnel view taking marijuana as a stigmatizing event, they are less likely to prescribe it, even if they believe in its palliative benefits.¹²

This may be due to the fact that most providers have received little or no training in MM.^13,14 A study that looked at medical school training found that 66.7% of deans stated that their students were not prepared to prescribe MM. This finding was echoed by almost 90% of residents and fellows, who indicated that they lacked the knowledge to prescribe. Moreover, 85% stated that they received no education in medical school or residency, even though 78% indicated that it should be required at some point in their studies.¹⁵ Moreover, results from a recent study showed that patients are engaging with their primary care physicians around the use of Cannabidiol (CBD) but that these Primary care physican (PCPs) do not believe that they possessed inadequate knowledge and training on the subject.¹⁶ This educational gap is not limited to physicians; other health care professionals, such as pharmacists, have also declared that they need more training.¹⁷

Particularly noteworthy is the lack of attention that has been paid to the dental profession, although many individuals’ first experience, or ongoing involvement, with pain management occurs around dental care.¹⁸ Even though dentists may not be prescribing MM, their patients may be utilizing it, which will affect treatment.^5,19Accordingly, the dental field deserves particular attention given the amount of interaction that dentists have with patients including the likelihood that they will be dealing with pain management.²⁰ Yet, little is known about the degree of formalized training that dental professionals receive or their attitudes toward MM, even though are confronted with many of the same issues as other health care providers who struggle with how best to advise patients.²¹ This is a particularly critical issue as a recent survey by the American Dental Association found that 52% of dentists sampled reported having patients who were high on marijuana or other drugs and that these situations caused a change in patient care.²² Additionally, little research has been carried out on alternative treatments and the research that does exist provides conflicting results and/or indicates a great need for education in this area.^9,15 Moreover, work that focuses on dental professionals’ attitudes and knowledge toward MM is practically nonexistent.

This study seeks to help fill this gap by surveying a group of dental professionals on their views and knowledge regarding MM. The rationale behind this study is to understand the perspectives of dental professionals in order to better prepare them for patient interactions involving MM. As marijuana becomes more ubiquitous, dentists will be required to address its implications for patient care, making this an essential area of research.

Methods and Data

The study protocol (#20-02) and informed consent form were approved by the University of the Pacific Institutional Review Board. It builds on a similar survey, which was conducted among practicing pharmacists.¹⁰ The previous survey questions were tested on a focus group of pharmacy faculty and students, and revised based on their feedback for content clarity and reduced completion time. Most of those questions were used for this survey, though some additional questions were added to enhance our understanding of the specific issues that dental professionals would experience. Experts in the field of dentistry and MM were consulted to review the survey questions for relevance and completeness. To ensure the revised survey’s suitability for the target population, it was pilot tested on a small sample of dentists. This testing aimed to assess ease of understanding, appropriateness, and completion time. Participants provided feedback on the clarity of the questions, the relevance of the answer choices, and any difficulties encountered during the survey. Based on this feedback, further refinements were made to enhance the survey’s comprehensibility and relevance.

To assess reliability, we conducted a test–retest procedure with the pilot group. The participants were asked to retake the revised survey after an interval, and their responses from the initial and subsequent administrations were compared. The results indicated no significant differences, demonstrating the survey’s reliability.

The answer choices were formatted as a 7-point Likert scale. The final survey consisted of 50 questions, divided into four sections: (1) demographics, (2) knowledge of MM and interactions with patients, (3) opinions, and (4) issues related to MM research, education, and policy.

Eligibility to participate in this study was status as a faculty dentists, faculty dental hygienists, students, or residents at the Arthur A. Dugoni School of Dentistry. Accordingly, all individuals who fit the criteria were invited by email to participate in the survey, which totaled 560 students and 370 faculty. Responses were completely voluntary. The survey was not tied to any course, and the involved study personnel were known by the students to not be involved in grading of any kind for any course. As an incentive, they were informed that all participants would be entered into a raffle to win a Hydroflask water bottle. These prizes were purchased entirely by funding from grant DRES03-130. The survey was completed through Survey Monkey after informed consent was received, from November 10, 2019 to December 13, 2019. The survey was anonymous to the study personnel, unless the participants wanted to enter into the raffle, in which case they submitted their email address. However, any identifying information was removed when the data were analyzed and only the aggregate data were used. Surveys in which more than three questions were unanswered were not included in the analysis.

Statistical calculations were performed with IBM SPSS Statistics version 25. For correlations between ordinal and categorical variables, the Spearman’s rho test was used. The Spearman’s rho test was chosen instead of the Pearson’s r or t-test because individual Likert scales, rather than overall Likert scores, were used to investigate for correlations. Also, the Spearman’s rho test makes less stringent assumptions about responses being ordinal. A copy of the survey used and the full dataset can be found in the appendix of this issue.

Results

A total of 278 surveys were completed, out of the 930 people invited; however, 59 surveys were excluded for being incomplete, resulting in 219 surveys being included in this study yielding a response rate of 23.5%. Seventeen percent of participants were faculty, and the rest were students or residents. Although the majority of respondents are yet to be practicing dentists, their beliefs, experience, and knowledge are critical given that they represent future practitioners. Table 1 shows the demographic profile of the participants. The participant pool ratio of females to males is similar to that of dental schools across the United States, but compared with national and state average demographics (32–33% of dentists are female at the state and national level),²³ women are overrepresented in our sample. In terms of ethnicity, our participant ratios differed from both national²³ and California²⁴ averages, with the greatest difference being far more respondents of Asian descent. Given the large number of student respondents, the sample also skews younger than the average dentists in the United States with only 17% under 35.²³

Table 1.

Demographic Profile of Survey Respondents

Demographic profile	Study
Survey respondents	%
Gender
Male	49
Female	51
Age (years)
20–29	59
30–39	7
40–49	5
50–59	4
60+	5
Did not answer	20
Ethnic background
White	36
Black or African American	0
Asian	53
Hispanic/Latino	3
Other	8
Occupation
Dentist	16
Dental student	77
Dental resident	4
Dental hygienist	1
Other	1

Table 2.

Selected Survey Findings, Presented as Percentages (Full Dataset is Available at https://scholarlycommons.pacific.edu/esob-facdata/1/)

	Strongly disagree	Disagree or somewhat disagree	Neither agree nor disagree	Somewhat agree or agree	Strongly agree
Seeing more prescriptions for synthetic CBDs now	8	16	58	18	1
Physicians should dispense MM	3	20	36	39	3
Recreational marijuana should be approved	10	18	28	37	7
Pharmacies should dispense MM	6	18	23	48	5
Approve of the current dispensing of MM	3	25	44	26	2
Prefer patients use MM	5	23	56	15	1
Would favor MM if by prescription	1	10	28	52	9
Would prefer MM if it were FDA-approved	1	5	20	54	20
Prefer only CBD products	1	10	36	45	9
MM should be as accessible as other prescription drugs	5	37	28	25	4
States should track MM users	8	27	24	35	7
MM is valuable for pain	1	8	21	60	11
May be better than NSAIDs for pain	5	16	51	25	3
May be better than APAP for pain	3	16	52	26	2
May be better than narcotics	6	17	47	28	3
Risk–benefit profile may be better than NSIADs	3	21	60	15	1
Risk–benefit profile may be better than APAP	5	19	58	17	2
Risk–benefit profile may be better than Narcotics	3	6	43	35	7
MM is abused	1	43	33	20	3

MM, medical marijuana.

Forty percent of respondents either agreed or strongly agreed that MM is valuable for pain, and 30% somewhat agreed. However, the majority of participants indicated that they only have very little (32%) or some (33%) knowledge about major aspects of MM. Twenty-one percent stated that they have very little knowledge about MM side effects and 40% said that they had some knowledge. Only 21% of the respondents agreed partially with the statement that they knew where to find information about MM whereas 30% somewhat agreed with that statement. Fifty-one percent of respondents said that they never discuss it with their patients, and 29% said they do so in less than 10% of all incidents in which it would have been pertinent.

Similarly, 59% said that they do not monitor patients who are taking MM. Although 54% state that they do not have patients who take MM, 30% replied that they monitored its use in less than 10% of cases that were indicated. Yet, the majority of respondents stated that they think that drug interactions involving MM are moderately (28%), very (20%), or extremely (11%) important. Similarly, there is a concern with the adverse reactions to MM, with respondents stating that they are moderately (30%), very (13%), or extremely (6%) important. Table 2. provides additional information.

Some correlations were found between the respondents’ answers. For the question of whether one approves of the current method of dispensing MM, approval was inversely correlated with age (r_s = −0.204, p = 0.008). For the question of whether continuing education credit should be given for courses on MM, approval was also correlated with age (r_s = 0.141, p = 0.042).

Respondents’ knowledge about MM was a frequent correlate of responses to this survey. The more knowledgeable respondents were about MM, the more likely they were to suggest a specific dispensary when asked (r_s = 0.283, p < 0.001). Respondents’ amount of knowledge about MM also correlated with how frequently they asked patients about MM use (r_s = 0.260, p < 0.01) and monitored patients using MM (r_s = 0.313, p < 0.001), and how much they trusted their patients’ answers regarding their MM use (r_s = 0.208, p = 0.002).

Respondents reporting more knowledge about MM were also more likely to discourage their patients from using MM (r_s = 0.189, p = 0.005). They had more patients that use MM (r_s = 0.314, p < 0.001), and did so against their advice (r_s = 0.259, p < 0.001). They were more likely to change their treatment plan knowing that a patient was using MM (r_s = 0.278, p < 0.001). They were more likely to feel the risk/benefit ratio for MM is superior to narcotics (r_s = 0.260, p < 0.001). They were also more approving of legalizing recreational marijuana across the country (r_s = 0.230, p = 0.001).

Perception about MM correlates with the opinion of whether physicians should be able to dispense MM. Those that felt MM should be dispensed by physicians also were more likely to agree with the statements that MM may be valuable for pain (r_s = 0.445, p < 0.001); may be more effective against pain than Nonsteroidal anti-inflammatory drugs (NSAIDs) (r_s = 0.279, p < 0.001), Acetaminophen (APAP) (r_s = 0.312, p < 0.001), and narcotics (r_s = 0.287, p < 0.001); and may have a better risk/benefit ratio than NSAIDs (r_s = 0.271, p < 0.001), APAP (r_s = 0.274, p < 0.001), and narcotics (r_s = 0.313, p < 0.001). They were also less likely to feel that MM is abused (r_s = −0.301, p < 0.001).

Agreement with the statement that MM should be approved for recreational use correlated with agreement with the statement that physicians should be able to dispense MM (r_s = 0.445, p < 0.01). Therefore, those who felt MM should be approved for recreational use held similar views to those who felt MM should be dispensed by physicians. They also shared similar views toward the value of MM for pain, whether it is abused, and how its efficacy and side effect profile compares to that of NSAIDs, APAP, and narcotics. These respondents also feel that states should not track individuals’ marijuana use.

Similar correlations were also seen by those that feel pharmacies should dispense MM and those that prefer patients use MM. Those who would be more willing to discuss MM if only the CBD option were available had similar correlations, but differed by not perceiving the side effect profile to be better than that for NSAIDs and APAP. They did, however, feel that MM had a better side effect profile than narcotics.

The factor that had the most abundant correlations was the opinion that MM is valuable for pain. This had a positive correlation with the opinions that MM may be better than NSAIDS, APAP, and narcotics for pain control and risk/benefit ratios; that physicians and pharmacies should dispense MM; that recreational marijuana should be approved; approval of the current MM dispensing methods; preference for patients to use MM; favoring MM if it were available by prescription and FDA approved; preferring the use of CBD formulations; and that more research and education (as well as continuing education credit) are needed. The opinion that MM is valuable for pain negatively correlated with the opinion that MM is abused, and that states need to track its use.

Whether a participant was a faculty member or student/resident had little correlation with responses to MM questions. The only correlations were that faculty monitored their patients’ MM use more frequently (r_s = −0.235, p = 0.001), and were less approving of the current MM dispensing protocols (r_s = 0.229, p = 0.001).

Discussion

In this cross-sectional study, we found that the perception of MM as an effective and safe pain management tool strongly influences its favorable view among dental professionals. However, we should interpret these results cautiously given the demographics of our respondents—predominantly dental students under 35 from a state where marijuana is legalized.

Yet, our survey reveals a significant knowledge gap about MM among dental professionals. A majority report low familiarity with MM’s side effects and appropriate dosages. This gap probably limits patient discussions about MM, explaining why those with less knowledge are less likely to inquire about MM use, monitor patient use, or recommend dispensaries. Clearly, though not MM prescribers, dental professionals need to be aware of MM use among their patients due to potential impacts on treatment plans and drug interactions.

Interestingly, more informed professionals tend to discourage MM use, possibly because of more open patient dialogs. The survey also unveiled concerns about the absence of dispensary protocols and dosage options. A majority would prefer MM to undergo FDA approval or be sold in pharmacies, though it is unclear whether this stems from familiarity with these processes or the desire for more oversight.

The age of respondents influenced responses. Younger participants, generally more accepting of MM and knowledgeable about CBD, were less supportive of continuing education credits for MM, possibly due to unfamiliarity with professional education requirements or disagreement on the venue of learning.

Despite the significance of these findings, our study has limitations, including its cross-sectional nature, reliance on self-reported data, and a respondent pool largely composed of California-based dental students. Yet, it is clear that even in a state that views marijuana positively and while marijuana acceptance is rising, legal frameworks and educational practices lag behind. Our study reveals that a critical knowledge gap exists among dental professionals, even though they recognize MM’s therapeutic potential. More education and research on MM are clearly needed, a sentiment echoed by our respondents. Prior studies support this, showing that health care professionals believe in MM’s efficacy but lack adequate knowledge for patient counseling.

Clearly, greater control and information about MM could improve comfort, patient–provider communication, and health outcomes. Accordingly, new policies should be developed that provide frameworks for dental professionals to discuss MM use effectively with patients. Such changes may require government agencies like the FDA to play larger roles, particularly given the need to explore alternatives with fewer side effects for pain management.

Footnotes

Data Access Statement

The data used in this study are available at the following location: (). All relevant data can be accessed and downloaded from this website. The dataset contains the information necessary to reproduce the results and findings reported in the article. Access to the data is open and free for researchers and interested individuals who wish to validate or build upon the presented research. The authors encourage the utilization of this dataset to foster collaboration, scientific advancement, and further exploration in related fields.

Authors’ Contributions

D.S. contributed to the conception and design of the study, collected the data, wrote the original draft of the article, and participated in the review and editing process. Additionally, the D.S. contributed to the development and implementation of the methodology. A.Y. participated in the conception and design of the study and provided valuable input during the review and editing process. D.S. and A.Y. supervised the data collection process and ensured its accuracy. Y.G. contributed to the validation of the study’s findings and performed the data analysis. All authors provided critical insights and expertise during the analysis phase and reviewed the article for intellectual content. All authors have made substantial contributions to the intellectual content of the article and have actively participated in its development.

Author Disclosure Statement

The authors declare that there are no conflicts of interest regarding the publication of this article. They affirm that they have no financial or personal relationships that could inappropriately influence the content or interpretation of the findings presented herein. Furthermore, there are no affiliations, funding sources, or other circumstances that might create biases or conflicts of interest with regard to this research. The authors have followed the ethical guidelines and standards for scientific integrity and have strived to present accurate and unbiased information in this article.

Funding Information

No funding was received for this article.

Abbreviations Used

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Assessment of Knowledge,Attitudes,and Practices of Dental and Dental Hygiene Faculty and Students Toward Medical Marijuana: A Cross-Sectional Study