Vaping Hits Home
Dental practices confront the latest public health challenge
Catherine Paulhamus, MA
The campaign to decrease tobacco use is considered a great public health success. Through these efforts, the population has become increasingly aware of the dangers of smoking and chewing tobacco: cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis.1 In November 2018, the Centers for Disease Control and Prevention (CDC) announced that smoking was down to 14%, the lowest level ever recorded in adults (a 67% decline since 1965).2 However, of the 47 million adults who use tobacco products, about 9 million (19%) reported using two or more-most often cigarettes plus electronic cigarettes (e-cigarettes).2
As e-cigarettes arrived on the market, they initially seemed to offer many benefits for smoking cessation. With no noticeable smoke or odor, they were not offensive to bystanders and could be used in more locations (although there are potential health effects from secondhand fumes, as with secondhand smoke).3 E-cigarettes were promoted as less toxic than other tobacco products and therefore safer. In addition, these devices offered a variety of flavors that masked the nicotine in a technological package-cementing their appeal to the younger population.
Some health practitioners and organizations noted these benefits and began to endorse e-cigarettes as a method for current smokers to quit.4 Relative to any other tobacco delivery product, these devices are certainly safer. However, they are not harmless, and the long-term consequences are unknown.
The public health goal would be for current smokers to switch to vaping to reduce their exposure to tobacco-related diseases. However, there is no definitive evidence that vaping results in any significant reduction in smoking. Instead, a majority of adults use e-cigarettes while continuing to smoke. Even worse, people who do not smoke start with vaping, increasing their health risks considerably.5,6 At the same time, according to the Surgeon General, e-cigarette use by US youth has become epidemic. In 2018, more than 3.6 million youth, including 1 in 5 high school students and 1 in 20 middle school students, were using e-cigarettes.5
Considering the confusion around e-cigarettes, how should oral health practitioners advise patients? How harmful are these aerosols to oral health?
A Concoction of Chemicals
Risks to oral health from e-cigarettes result not only from the nicotine (as with other tobacco products), but also from the vapor components. The liquid in e-cigarettes usually includes propylene glycol, glycerin, flavorings, and water, in addition to nicotine.7 More than 60 chemical compounds have been identified in this liquid, and even more are found in the aerosol (including heavy metals such as cadmium, lead, nickel, tin, and copper).8 "These chemicals that are present may be causing a whole new set of problems that we're not aware of, and that won't become apparent for the next five or 10 years," Dr. Michael Glogauer, chief of dentistry at the University Health Network in Toronto, explained in a series of articles on "Vape Fail."9
Although long-term results are unavailable, research on oral health effects is signaling areas of concern. A survey of publications includes these findings:
• Vapor from e-cigarettes led to cell death in gum tissue after just two exposures.9
• E-cigarette fluids (with and without nicotine) triggered molecular responses in oral fibroblasts, raising concerns about their role in the pathogenesis of oral diseases.10
• Electronic nicotine product use is associated with increased risk of developing periodontal disease (even after accounting for the use of other tobacco products).11
• Daily e-cigarette use was independently associated with a 78% higher odds of poor oral health.12
• E-cigarette aerosols have similar properties as high-sucrose, gelatinous candies and acidic drinks: data suggest that this may increase the risk of cariogenic potential.13
• Three DNA-damaging compounds (formaldehyde, acrolein, and methylglyoxal) levels increased in the saliva after vaping. Compared with people who don't vape, four of the five e-cigarette users showed increased DNA damage.14
• When used orally, the breakdown products of propylene glycol include acetic acid, lactic acid, and propionaldehyde, which are all toxic to enamel and soft tissue.7
Clearing the Air
How can hygienists respond to patients regarding e-cigarettes and their risks relative to other tobacco products? The goal is for patients to be free from any form of tobacco. Therefore, some organizations recommend asking patients about e-cigarette use during every visit or medical history, especially as the symptoms of vaping may not be as noticeable as cigarette use.15
Patients may not be aware that e-cigarettes are not recommended as a cessation device in the United States. Instead, nicotine-replacement products and prescriptions, or prescription non-nicotine medications are advisable.
"The best practice is to offer advice, assistance, and resources," explained Natalie Hagel, RDH, assistant professor of comprehensive care at Tufts School of Dental Medicine, in an interview. "Do not judge-smoking comes with such a stigma, and some people who have never smoked, or don't have that addiction gene, don't understand how addictive it can be. Ask them if they are interested in quitting-you can't push someone who is not ready. If you can, work alongside their primary-care physician."15
In a recent study published by the American Dental Hygienists' Association, the authors concluded there is a need for dental hygienists to increase their understanding of e-cigarettes and comfort level in discussing their use.16 Asking about patients' tobacco use and implementing the five major steps to intervention (5 A's) can be important first steps, as other studies demonstrate that counseling in dental practices is effective.16
Clearly, dental hygienists and other oral health professionals are in a unique position to diminish the long-term damage from this latest public health concern - with access to resources, information, and twice a year, the patients themselves.
1. Smoking and tobacco use. Health effects. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/tobacco/basic_information/health_effects/index.htm. Accessed December 17, 2019.
2. Cigarette smoking among U.S. adults lowest ever recorded: 14% in 2017. Centers for Disease Control and Prevention. November 8, 2018. https://www.cdc.gov/media/releases/2018/p1108-cigarette-smoking-adults.html. Accessed December 19, 2019.
3. Electronic smoking devices and secondhand aerosol. American Nonsmokers' Rights Foundation Web site. https://no-smoke.org/electronic-smoking-devices-secondhand-aerosol/. Accessed December 19, 2019.
4. Crowe K. The road to vaping. Canadian Broadcasting Corporation Web site. December 2, 2019. https://newsinteractives.cbc.ca/longform/the-road-to-vaping. Accessed December 13, 2019.
5. Surgeon General's Advisory on E-cigarette Use Among Youth. US Department of Health and Human Services. December 18, 2018. https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf. Accessed December 16, 2019.
6. Chaffee BW. Electronic cigarettes: trends, health effects and advising patients amid uncertainty. J Calif Dent Assoc. 2019;47(2):85-92.
7. Froum S, Neymark A. Vaping and oral health: It's worse than you think. Perio-Implant Advisory Web site. January 10, 2019. https://www.perioimplantadvisory.com/clinical-tips/article/16412201/vaping-and-oral-health-its-worse-than-you-think. Accessed December 16, 2019.
8. E-cigarettes: Facts, stats and regulations. Truth Initiative Web site. November 11, 2019. https://truthinitiative.org/research-resources/emerging-tobacco-products/e-cigarettes-facts-stats-and-regulations. Accessed December 12, 2019.
9. Cuttler M. ‘It is not harmless:' Dentists voice concern over vaping. Canadian Broadcasting Corporation Web site. December 5, 2019. https://www.cbc.ca/news/health/vaping-dentistry-1.5377999. Accessed December 12, 2019.
10. Sancilio S, Gallorini M, Cataldi A, et al. Modifications in human oral fibroblast ultrastructure, collagen production, and lysosomal compartment in response to electronic cigarette fluids. J Periodontol.2017;88(7):673-680.
11. Atuegwu NC, Perez MF, Oncken C, et al. Association between regular electronic nicotine product use and self-reported periodontal disease status: Population assessment of tobacco and health survey. Int J Environ Res Public Health. 2019;16(7):1263. doi: 10.3390/ijerph16071263
12. Huilgol P, Bhatt SP, Biligowda N. Association of e-cigarette use with oral health: a population-based cross-sectional questionnaire study. J Public Health (Oxf). 2019;41(2):354-361.
13. Kim SA, Smith S, Beauchamp C. Cariogenic potential of sweet flavors in electronic-cigarette liquids. PLoS ONE. 13(9):e0203717. https://doi.org/10.1371/journal.pone.0203717.
14. E-cigarettes can damage DNA. American Chemical Society. August 20, 2018. https://www.sciencedaily.com/releases/2018/08/180820085208.htm. Accessed December 17, 2019.
15. Ragovin H. Massachusetts ban on vapes a boon for oral health. Tufts Now. December 6, 2019. https://now.tufts.edu/articles/massachusetts-ban-vapes-boon-oral-health. Accessed December 19, 2019.
16. Abadi S, Couch ET, Chaffee BW, Walsh MM. Perceptions related to use of electronic cigarettes. American Dental Hygienists' Association. May 2017. https://adha.cdeworld.com/courses/20687-perceptions-related-to-use-of-electronic-cigarettes. Accessed December 10, 2019.