No e-cigarette smoke without fire
Kimberley Lloyd-Rees uncovers another layer to the complex issue of e-cigarettes and asks: does vaping cause caries?
Discussions around vaping are becoming more prevalent in daily practice.
Patients ask: ‘Are vapes any better than cigarettes?’. Others ask: ‘I read that someone died because of vapes, is this true?’
The conversation is ongoing between colleagues about whether we should be recommending the use of e-cigarettes.
Towards the end of last year, a cluster of deaths in the US were linked to vaping-related lung illnesses. This led to international headlines. Anyone who has started to dig deeper into vaping will have realised the complexity of the subject.
For one, there are few long-term studies available. Additionally, the laws, regulations and culture around vaping are different in the UK than in America. America is where much of the negativity and warnings surrounding the use of e-cigarettes originates.
If any of your patients are using an e-cigarette, or you are talking to them about smoking cessation, they probably have concerns.
In the UK, vaping has increased as smoking has declined. The proportion of ex-smokers who use an e-cigarette as a replacement product has also grown.
Figures from ASH (Action on Smoking and Health, 2019) have indicated that 54.1% of regular vapers are ex-smokers. Nearly 40% are dual use, using an e-cigarette to reduce their cigarette use.
It is therefore no secret that smoking has a significant impact on general and oral health.
Tobacco smoking is an independent risk factor for the ‘initiation, extent and severity of periodontal disease’ (Borojevic, 2012). It can also lead to tooth loss, halitosis, stained teeth. Smoking is the main cause of mouth cancer.
Smokers who want to stop need all the support that dental care practitioners are uniquely positioned to give.
The NHS states that, although e-cigarettes aren’t ‘risk free’, they can be effective as part of a ‘stop smoking’ programme.
Vaping and caries
The negative news seen about vaping, often relates with lung-based diseases. What about dental implications?
There has been a rise in anecdotal reports featuring patients at low caries risk developing new carious legions since they started vaping.
Dental professionals doing their own reading might have seen the 2018 study that looked at the link between vaping and caries (Kim et al, 2018).
This US-based work investigated what happened when tooth surfaces were exposed to e-cigarette aerosols with ‘similar physio-chemical properties as high-sucrose, gelatinous candies and acidic drinks’.
It found that sweet-flavoured e-cigarettes interact with the teeth in a way that resembles how high-sucrose snacks and sweet, acidic drinks do. Concluding that not only do e-cigarettes negatively affect the respiratory and cardiac systems but they can also have significant implications on oral health.
Dental caries affects nearly half the world’s population (WHO, 2018).
The issue of caries – cause, prevalence and impact – is complex everywhere, including in the UK.
When discussing with our patients we need to be aware of as many factors as possible. Therefore, the correlation between socioeconomic inequalities on caries occurrence is particularly concerning, especially when it affects children, who lose the benefits of a healthy start to life that everyone deserves.
In a letter to the British Dental Journal earlier in the same year, Umeriji (2018) asked readers to consider the cariogenicity of ‘e-liquids (that) contain a mixture of various chemicals including sucrose, aqueous glycerine and artificial flavourings’. The chemicals travel to the oral cavity via vapour from the e-cigarette. The letter stated these issues were particularly relevant because ‘vaping has become especially popular with teenagers and young adults’.
As a result, however, figures from ASH appear to confirm this. Just 0.1% of 11-18-year-olds who have never smoked, vape more than once a week and not one said they vape every day (ASH, 2019b).
Again, we look over to the US to see a different picture. In January 2020, the US banned candy, mint, fruit and dessert-flavoured e-cigarettes, with the move directly linked to concerns over their growing use among high school students, who like the sweet taste.
The quality of preventive advice is key to avoiding caries. Listen, engage, inspire and motivate your patients in daily preventive practices. This includes a good diet and regular appointments. Also, correct brushing with brushes like those in the Tandex range and smoking cessation.
Vaping is still an effective method to wean a smoker off cigarettes. It is not recommended for non-smokers. Sweet flavours should be discouraged and once they are confident that they no longer need to smoke tobacco, vaping must also stop.
Vaping is a complex topic and caries is a multifactorial disease. Therefore, dental practitioners must deliver consistent messages supported with evidence. Smoking cessation plays a major role in preventive dentistry. Alongside good oral hygiene instruction and diet advice.
In order to offer the best preventive advice, it is crucial to stay abreast of new developments in the rapidly progressing evidence base surrounding e-cigarette use and safety.
Action on Smoking (ASH) (2019a). Use of e-cigarettes (vaporisers) among adults in Great Britain. ASH Smokefree GB Survey
Action on Smoking (ASH) (2019b). Use of e-cigarettes among young people in Great Britain. ASH Smokefree GB Survey
Borojevic T (2012) Smoking and periodontal disease. Mater Sociomed 24(4): 274-276
Kim SA, Smith S, Beauchamp C, Song Y, Chiang M, Giuseppetti A, Frukhtbeyn S, Shaffer I, Wilhide J, Routkevitch D, Ondov JM (2018). Cariogenic potential of sweet flavors in electronic-cigarette liquids. PloS one 13(9): e0203717
Umerji S (2018) Cariogenicity of e-cigarettes. British Dental Journal 224(1): 4
World Health Organization (2018) Oral health. Key Facts