Content Dam Diq Online Articles 2018 04 Vaping 1

Vaping: the new gateway drug and what dental professionals can do

April 18, 2018
It may take years for the full effects of vaping on the oral cavity to be understood. In the meantime, here's what dental assistants can do to guide their patients who vape.

This article originally appeared in Dental Assisting Digest e-newsletter. Subscribe to this informative monthly ENL designed specifically for the dental assistant here.

In 2003, Apple introduced a music-selling service called iTunes, voters in California ousted Gov. Gray Davis and elected action film star Arnold Schwarzenegger, and in China, a pharmacist named Hon Lik patented the modern e-cigarette. Yes, we’ve come a long way since 2003. But as it turns out, perhaps not far enough.

Humans are funny creatures. For the most part, we’re eternal optimists when it comes to the products we use. We surmise that if a product is available for sale to the general public, and everyone uses that product, then it must be safe, right? When we find a product that we can use and enjoy, we cling to it for dear life, even if we aren’t really sure of its long-term effects.

While you might be skeptical about this, a quick trip down memory lane might be enough to convince you otherwise.

In the early 1900s, wellness enthusiasts eager to harness the healing properties of natural hot springs discovered that many of those springs contained low levels of radioactivity. Well, they countered, if a little radioactivity is good, then a lot must be even better! Soon, radium was in everything from bottled water to pendants to, yes, even toothpaste. This radiation craze went on for years and led to one of the most gruesome headlines ever published in the New York Times, “The radium water worked fine until his jaw came off.”

In the 1950s, a new drug called thalidomide was discovered in then West Germany and promoted as a treatment for morning sickness and sleeplessness. At the time, it was considered a wonder drug. Thalidomide was even sold over-the-counter in Europe for many years. Unfortunately, by the time the evidence caught up in the 1960s, it was too late for more than 10,000 infants who had been born with birth defects of their limbs, which we now recognize as characteristic of thalidomide babies.

In 1999, Merck & Co. introduced the nonsteroidal anti-inflammatory drug (NSAID) Vioxx (rofecoxib) for treatment of osteoarthritis and dysmenorrhea. Vioxx was one of a new class of NSAIDs that promised relief of pain and inflammation without the adverse gastrointestinal effects common with the use of other NSAIDs. Despite its approval by the FDA as safe and effective—and blockbuster sales—Vioxx was subsequently pulled from the market in 2004 because, as we learned, we don’t actually see all of a drug’s side effects and adverse reactions during the limited time it’s involved in clinical trials. It took nearly five years to amass conclusive evidence that Vioxx raised risks of cardiovascular events such as heart attack and stroke with long-term, high-dosage use.

So, we humans tend to stubbornly believe that the absence of evidence of harm must equal evidence of safety. We decide that new, novel products that seem safe and effective in the short term must, therefore, be so in the long term, before the jury is actually in. For the past 15 years, that’s exactly what we’ve been thinking about vaping.

“Hey, at least it’s not smoking,” insist former smokers who have used vaping to quit tobacco. To some degree, they’re correct, based on what we know about long-term use of tobacco-based cigarettes. But what if these former smokers keep on vaping, long after they’ve quit cigarettes? Well, that’s when things get interesting. There is still a lot we don’t know about vaping. As we’ve seen, we can’t conclude that something is safe just because we haven’t yet discovered the ways in which it might be unsafe. Once again, a lack of evidence isn’t evidence at all.

Vaping e-liquids are not regulated. We don’t actually know what’s in most of them. Different formulations contain all sorts of compounds, among them varying levels of metals, propylene glycol (antifreeze), and diacetyl, which can cause an irreversible condition called popcorn lung.

When it comes to vaping, it’s not that the jury is still out—the jury honestly hasn’t even convened yet. We simply don’t know what we don’t know about inhaling these substances over a sustained period of time. It could be perfectly safe. On the other hand, in 25 years, today’s vapers could very well be dealing with all sorts of respiratory issues. We just don’t know.

In science and medicine, we must go where the evidence leads us. When we don’t yet have the evidence, that means that sometimes we have to wait for it to catch up. With vaping, it’s taken 15 years to get the first large batch of peer-reviewed observational and clinical evidence.

Here’s what it’s telling us.

While a great deal of the evidence does support arguments in favor of vaping for harm reduction in older, active, long-time smokers who are trying to wean off tobacco products, it’s definitely not all strawberry, vanilla, or cotton candy flavored vape clouds.

Of the 600 pages in the most comprehensive report about vaping so far, published by The National Academies of Sciences, Engineering and Medicine, there were two undisputed conclusions.

(1) Teens whose first exposure to nicotine is vaping may be more likely to start using real tobacco. “For kids who initiate on e-cigarettes, there’s a great chance of intensive use of cigarettes,” according to Mitch Zeller, head of the FDA’s tobacco division, as quoted in the New York Times. In other words, for young people who don’t already smoke, vaping is the opposite of harm reduction; it’s a gateway to harm.

(2) E-liquids generally still deliver nicotine, and nicotine has the same effects on the body no matter what the delivery route. In terms of oral health, this means potentially compromised oral mucosa. Reduced blood flow due to nicotine’s vasoconstrictive effects mean less oxygen, fewer nutrients, and decreased regenerative capacity in the gingiva. In addition, vaping can mask symptoms of periodontal disease in patients because reduced blood flow can cause decreased symptoms, specifically bleeding. Without that telltale sign, regular oral exams and cleanings may not catch early disease without proactive monitoring of pocket depth. As ironic as it may seem, patients who smoke cigarettes, with their telltale stains and other symptoms, may stand a better chance of early diagnosis of periodontal disease than patients who vape.

So, what’s a diligent dental assistant to do when it comes to vaping and oral-systemic health risks? Discuss it with your patients, just as you discuss smoking cessation. Ask questions. Share your knowledge. Talk about other products people used thinking they were safe that were later found not to be safe. Perhaps skip the radium story, but you could emphasize how much we don’t yet know about the long-term effects of vaping.

Remember that not all patients who vape are vaping nicotine. Since vape pens are refillable and e-liquid is not regulated, patients who vape may be vaping all sorts of substances, including cannabis and illicit drugs. Make sure you and your team are extra diligent in screening for signs of periodontal disease that might not be apparent in patients who vape.

With over 30 years of experience as a pharmacist, dental educator, and author, Tom Viola, RPh, CCP, has earned a reputation as an international authority on dental pharmacology. He says that knowledge of pharmacology has never been more essential to patient care. Tom is on the faculty of 10 dental professional degree programs, and has instructed students in chemistry, anatomy and physiology, pathophysiology, pharmacology, and local anesthesia. In addition, he’s instructed hundreds of practicing dental hygienists in local anesthesia certification courses. Tom is well known for his contributions to many dental journals in the areas of pharmacology, pain management, and local anesthesia. He’s served as a contributor, chapter author, and peer reviewer for several dental pharmacology textbooks and national board exam review books. For more information, visit or contact him at [email protected]. Those planning meetings can click here.
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