Vaping and oral health: Bringing the facts to patients

Electronic smoking device usage is on the rise. Vaping is gaining popularity with younger patients who have never used nicotine products before and are now trying flavored electronic cigarettes.

I recently caught an episode of a popular sitcom in which a teenage daughter candidly admitted to her mom that she had tried a vaping pen. Her mom got very upset, and the daughter had no clue why her mom would be so put off by it. I thought to myself, “What do I know about vaping, and why is this a prime time storyline?” So I began to research, and I discovered that this is a controversial issue both nationally and worldwide. Vaping is gaining popularity, and young people are being exposed to it while not being fully aware of the consequences to their health. A recent study conducted by Monitoring the Future conducted a survey of 44,000 students last year spanning from 8th grade to 12th grade and discovered that the rate in which vaping products were used doubled in one year’s time.¹

Times are changing

“In the late 1990s and early 2000s, some states implemented comprehensive smoking bans that prohibited smoking in most workplaces and all public places, including previously exempted bars and restaurants.”² Cigarette smoking has been decreasing since laws were enacted that banned smoking in public places. Use among middle school and high school students has been steadily decreasing since 2014 due to education about the harmful effects of tobacco. This has left the consumer market wide-open for alternative uses of nicotine. Electronic devices are promoted as a less harmful alternative with fun flavors for recreational and social use.³

In 2019, the FDA took steps to restrict the sales and marketing of electronic smoking devices to minors. “Some people have suggested that use of e-cigarettes by young people might ‘protect’ them from using cigarettes further down the road. There is no evidence to support this claim. Some studies show that nonsmoking youth who use e-cigarettes are more likely to try tobacco cigarettes in the future than nonsmoking youth who do not use e-cigarettes.”⁴

Vape trends

Vapor lounges, sometimes called vapor houses, are popping up everywhere—in big cities, small towns, shopping malls, strip malls—usually centrally located in heavily trafficked areas. I passed by one vape shop next to a game store and video arcade in my local community, clearly attempting to attract young people. Consumers can purchase their favorite flavors from coffee to maple syrup all while relaxing and vaping in plush lounge chairs indoors. Electronic cigarette users report using energy drinks while vaping. Some vapor liquid contains substances such as caffeine and ginseng for an energy boost or as an alternative to non-nicotine vaping.^5,6,7

Risks of vaping

Electronic cigarette users may experience xerostomia and increased risk for tooth decay as a result of the vaporized liquid entering the mouth. Aerosols from vaping irritate the lining of the mucosa and are absorbed into the buccal mucosa and the pharyngeal tissues. According to the British Dental Journal, e-liquids from electronic cigarettes create an aerosolized cariogenic vapor delivered directly to the mucosa and hard tissues of the mouth, bonding with streptococcus mutans. That process, along with a dry environment, creates a perfect breeding ground for a biofilm matrix to bloom.⁶

Similar to tobacco cigarettes, smoke-free vaping devices have chemicals manufactured into them that cause irreversible damage to the human body. Much research is being conducted on the effects on the oral cavity; however, we must wait for long-term studies that show the vaping effects on epithelial tissue.⁸

Toxic chemicals

Oral mucosa that is exposed to chemicals will incur changes to the epithelial tissue and promote the inflammatory response in the periodontal ligament resulting in periodontal disease.^3,9 Chemicals in the aerosols found in vaping liquid or “juice” include:

• Diacetyl: chemical flavoring that is safe to ingest but unsafe when heated to a high temperature and inhaled; associated with serious lung disease
• Benzene: a volatile organic compound found in car exhaust and linked to leukemia and bone marrow disease
• Heavy metals: levels of lead, nickel, chromium, and manganese exceed safe limits for inhalation

• Nicotine: addictive stimulant and potent parasympathomimetic alkaloid^10,4,11,12  

Nontoxic chemicals

Nontoxic chemicals found in vaping liquid create palatable pleasure and increase risk for tooth decay. These include:

• Propylene glycol: food additive sweetener^13,6
  
• Glycerin: colorless, odorless, viscous liquid for sweetness^13,12
• Flavorings^13,5,7

Patient education

How many of us are comfortable broaching conversations about smokeless nicotine products with our patients? When put on the spot, can we pull out statistics, figures, and share the real truth about vaping? As uncomfortable as it may be, we need to ask our patients about their exposure to and usage of vaping as part of their health history update. Many patients believe that it is safer and less harmful than tobacco cigarettes. The truth is that long-term effects are still unknown. More research needs to be conducted according to the National Institute on Drug Abuse.¹⁴

Some patients may be vaping as a form of tobacco smoking cessation. “E-cigarettes haven’t been thoroughly evaluated in scientific studies. For now, not enough data exists on the safety of e-cigarettes, how the health effects compare to traditional cigarettes, and if they are helpful for people trying to quit smoking.”¹⁴ Inform patients that one liquid nicotine cartridge contains about 200 puffs, equivalent to the amount of nicotine in one pack of 20 cigarettes.¹⁵

I challenge hygienists to screen for vaping usage at both initial and recare appointments. Do soft tissue assessments and document mucosal changes. Utilize CAMBRA for patient education. Clinically, we are going to see an increased rate of decay in vaping patients. It is our duty as oral health-care providers to educate our patients on risk factors along with the effects of using vaping devices as an alternative to smoking cigarettes. Our younger patients are being exposed to vaping and are lured by the attractiveness of advertising. It is gaining popularity recreationally with younger patients including those who have never smoked before. It is our job to bring the facts to our patients.

References

1. National Institute on Drug Abuse. Monitoring the future 2108 survey results. https://www.drugabuse.gov/related-topics/trends-statistics/infographics/monitoring-future-2018-survey-results. Updated 2018. Accessed May 3, 2019.
2. Institute of Medicine of the National Academies. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. 2010. Washington, DC: The National Academies Press. https://doi.org/10.17226/12649.
3. Black-Rochester K. E-Cigarettes are as bad for teeth as regular cigarettes. Futurity website. https://www.futurity.org/electronic-cigarettes-teeth-gums-1299582/. Published November 17, 2016. Accessed May 1, 2019.
4. Portland State University. Cancer-causing benzene found in e-cigarette vapors operated at high power. Medical Xpress. Mar. 8, 2017.  https://medicalxpress.com/news/2017-03-cancer-causing-benzene-e-cigarette-vapors-high.html. Accessed May 14, 2019.
5. Nemeth J. Vaping risks: what vaping can do to your mouth. YouTube. https://www.youtube.com/watch?v=btzUK1-TmrA. Published January 25, 2019. Accessed April 29, 2019.
6. Umerji S. Cariogenicity of e-cigarettes. Br Dent J. 2018;224(1):4. doi:10.1038/sj.bdj.2018.12.
7. Scary new fad: caffeine vaping. Berkeley Wellness website. http://www.berkeleywellness.com/self-care/over-counter-products/article/scary-new-fad-caffeine-vaping. Published May 12, 2016. Accessed May 15, 2019.
8. Cho JH. The association between electronic-cigarette use and self-reported oral symptoms including cracked or broken teeth and tongue and/or inside-cheek pain among adolescents: a cross-sectional study. PloS One. 2017;12(7):e0180506. doi: 10.1371/journal.pone.0180506.
9. Holliday R, Stubbs C. A dental perspective on electronic cigarettes: the good, the bad and the ugly. OralHealthwebsite. https://www.oralhealthgroup.com/features/a-dental-perspective-on-electronic-cigarettes-the-good-the-bad-and-the-ugly/. Published June 15, 2015. Accessed May 1, 2019.
10. U.S. Department of Health and Human Services. Know the risks: e-cigarettes and young people. https://e-cigarettes.surgeongeneral.gov/knowtherisks.html#aerosol-exposure. Accessed May 13, 2019.
11. Mozes A. Toxic metals found in e-cigarette vapor. WebMD website. https://www.webmd.com/smoking-cessation/news/20180226/toxic-metals-found-in-e-cigarette-vapor. Published February 26, 2018.
12. The National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes. https://www.nap.edu/read/24952/chapter/8. Published 2018.
13. Froum S, Neymark A. Vaping and oral health: It’s worse than you think. Perio-Implant Advisory website. https://www.perioimplantadvisory.com/articles/2019/01/vaping-and-oral-health-it-s-worse-than-you-think.html. Published January 10, 2019. Accessed May 1, 2019.
14. Electronic cigarettes (e-cigarettes). National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes. Published June 6, 2018.  
15. How much nicotine is in JUUL? Truth Initiative website. https://truthinitiative.org/research-resources/emerging-tobacco-products/how-much-nicotine-juul. Published February 26, 2019.

Katie Leiva, RDH, is a native of the Chicagoland area. Katie has been practicing dental hygienist for 10 years with nearly 14 years’ experience working in the dental field. She has spent the majority of her career in general private practice and has worked in periodontic and pediatric settings. Katie is currently working full time in a corporate dental setting. Katie is passionate about postnatal care and speaks about the development of the oral cavity through breastfeeding. She is currently pursuing a bachelor of science in oral health promotion. Katie Leiva can be contacted at [email protected].