Vaping: Periodontal Disease and Oral Cancer are Coming for Future Generations

I recently did research for a study club on the effects of vaping. The stats were interesting to say the least. Anyone in the healthcare and wellness space might find this information insightful due to the oral and systemic effects facing Millennials, Gen Z and Gen Alpha.

It could be a cause of increased diagnoses of periodontal disease and mental health disorders in our younger populations.

When I was in Dental Hygiene school, the topic of vaping or e-cigarettes was non-existent. We learned about combustible smoking products (cigarettes, cigars, marijuana joints) and the effects on the oral cavity, but not vaping. That’s because e-cigarettes didn’t enter the U.S. market until 2007, or really gain traction until 2014. Only in the last few years have studies regarding the effects of vaping on the oral cavity and oral disease been established.

What is vaping?

The term “vaping” can commonly be confused with the term vapor, like water vapor that is used during a facial or comes from water boiling in a tea kettle. That is not the case with vaping or the use of e-cigarettes. The CDC defines e-cigarettes as electronic devices that heat a liquid and produce an aerosol. An aerosol breaks down to a mix of small particles in the air, and this particular “mix” of particles contains nicotine, flavorings and other chemicals. This introduces metals and toxins into the body unlike those found in cigarettes.

Other names include: E-hookahs, mods, tank systems, vapes, ENDS (electronic nicotine delivery systems), Juul, Cig-a-likes and Squonk mods. The amount of nicotine varies between brands and delivery methods. Vaping is often marketed as the “safer” or “healthier” alternative to regular combustible smoking.

But is it? The fluid in e-cigarettes can include:

o??Propylene glycol - a synthetic liquid that absorbs water.

o??Benzene – a carcinogen (specifically increases the risk of leukemia) that can be found in glue, adhesives, cleaning products and paint strippers.

o??Formaldehyde – a carcinogen: enzymes in the body break down formaldehyde into formic acid, which further breaks down into carbon dioxide. Once inhaled, these ingredients are broken down by the cells lining the mouth, nose, throat and airways.

Who is vaping?

Here are the statistics:

o???1 in 20 Americans vape and youth e-cigarette usage?increased by 1800% in 2018 alone. (CDC, 2023)

o???In 2011 there were 7 million e-cigarette users and by 2018 that number increased to 41 million. There were 82 million vapers worldwide in 2021. Worldwide vaping sales reached $15.7 billion in 2018 and are expected to reach $40 billion by the end of 2023.

o???In 2021, 4.5% of American adults used e-cigarettes. (CDC, 2023)

o There was an increase in e-cigarette use from 8.8% to 10.2% between 2019 and 2021 among U.S. adults ages 18-29. (American Cancer Society, 2023)

o???From 2017 to 2019, the percentage of high school students that vaped within a 30-day timeframe increased among:

• 12th graders: 11% to 25%
• ?10th graders: 8% to 20%
• 8th graders: 4% to 9%

o??More than 30% of teens who start using e- cigarettes begin smoking traditional tobacco products within six months.

o??Truth Initiative data (truthinitiative.org) published information that was gathered between the summer of 2021 and the summer of 2022. It showed that 797,698 teens between 15 and 18 years old (4.6%), 356,891 (3.9%) 19- to 20-year-olds and 315,737 (1.9%) 21- to 24-year-olds tried their first e-cigarette.

https://truthinitiative.org/research-resources/emerging-tobacco-products/new-data-shows-nearly-800000-teens-vaped-first-time

Do you think there is a target audience?

Why is this an issue in Dentistry?

I have noticed a dramatic increase in how often I have the vaping conversation with patients who in high school and college. We are talking 4346, 4341 and 4342’s (dental codes specifically for the treatment of early to severe periodontal disease) in this young age range, with bleeding, inflammation and black sub-gingival calculus. Here are some studies on why this could be happening.

In March 2020, iScience published research that was completed by NYU that showed changes in the oral microbiome from the use of e-cigarettes. This study shared that the aerosol byproduct modulates the microbiome, in turn increasing risk of infection. It consisted of 119 participants (non-smoker/non-vapers, cigarette smokers and vapers.) They all had an oral exam and had salivary samples taken to test the bacteria present. Nearly 75% of tobacco smokers showed signs of periodontal disease, 43% of e-cigarette users had signs of periodontal disease and 28% non-smokers/non-vapers showed signs of periodontal disease. The e-cigarette users showed changes in the microbiome similar to that of a traditional cigarette smoker. The aerosols altered the cytokine concentration at mRNA and protein level in the presence of periodontal pathogens leading to the heightened inflammatory response. It was also observed that with aerosol contact, Porphyromonas gingivalis (our lovely friend linked to periodontal disease) increased by 65% in the oral cavity, therefore increasing inflammation in the mouth.

See the full study here https://www.cell.com/iscience/fulltext/S2589-0042(20)30068-7#relatedArticles.

Another article published by Science Advances in May 2020 which was a follow-up to the above study discussed the stress vaping puts on the oral microbiome. We know that stress on any microbiome (eye, gut and mouth) can cause permanent negative effects. The study concluded that this stress creates a pathogen rich environment, where the bacteria coat themselves in a “slime layer” when exposed to vapor. This “slime layer” makes it difficult for healthy bacteria to attach to the colony, in turn this allows the pathogenic bacteria to be opportunistic. These changes can happen within 3 to 12 months of vaping.

See the articles herehttps://www.science.org/doi/10.1126/sciadv.aaz0108 and https://www.inverse.com/mind-body/vaping-creates-a-slime-cloak-in-the-mouth-study

More studies are in the pipeline, but I can’t imagine they will have better news. If you have come across any others, please reach out to me.

Why is this a healthcare issue?

Here are the systemic effects of vaping:

o??Nausea and vomiting

o??Heightened inflammatory response

o??Reduced impulse control (side effect on adolescent brain from nicotine)

o??Respiratory disorders:

·???EVALI (e-cigarette or vaping associated lung injury)

·???Vitamin E acetate was linked to an EVALI outbreak causing 2800 hospitalizations in Feb 2020 (68 confirmed deaths). Normally when ingested, vitamin E acetate doesn’t cause harm. However, when inhaled it can interfere with normal lung functioning.

o??Mood disorders (side effect on adolescent brain from nicotine)

o??Cardiovascular damage

o According to a 2020 article published in Translational Cancer Research, even low levels of e-cigarette toxins can increase the risk of developing oral cancer.

How do we help our patients?

I started keeping track of my patients who vape. Among all of them, I didn’t see that signature smokers stain. Signs I did notice, and have been documented as possible indicators of a vaping patient, were:

o??Receding gums

o??Xerostomia

o??Tooth sensitivity

o??Caries

o??Acid erosion

o??Inflamed upper and lower anterior lingual gingiva

o??Heavy bleeding (different from traditional cigarettes)

o??Slimy layer on the dentition

o??Heavy bleeding even after gingivitis treatment

As dental professional, we now have to pivot our thoughts from what we assume a typical periodontal disease patient looks like. If the tissue looks funny on a 15-year-old, time to probe.

Health history review is key. The templates all ask about tobacco usage, but very few of the templates I have come across include e-cigarette use. It’s time to ask if the patient does ANY SORT of smoking or list e-cigarettes next to tobacco and marijuana use on the form. Why? Because more often than not, patients don’t think that vaping counts as smoking or tobacco use. This is how conversations in my chair have gone:

Me: “Has your mouth been dry lately, your tissues are quite parched and I’m noticing more inflammation than usual. Do you smoke?”

Patient: “I don’t smoke, I vape.”

I try to remember that vaping has been marketed as safer and even as a smoking cessation method. Some patients really do think it’s better, so a lecture likely won't work. Approaching underage patients’ parents has been the most challenging aspect of this, especially when high school and college students need scaling with the presence of inflammation or scaling and root planing.

So far, for me, patient education in these cases has had a great end result, but it’s slow moving. Patients (and their parents) need to be on board. Putting information up where patients can see it visibly in the operatory has been a good method for them to bring up the topic before I do: posters about periodontal disease and oral cancer screening. I’d love to know how my fellow clinicians are broaching this topic with parents.

All of this information could also mean incorporating oral cancer screening adjuncts like VELscope?, OralID??or ViziLite? into the exams of even our young patients.

So, this is my call to arms against this epidemic facing our youth. It will likely have long-term effects on their oral and systemic health that we have not yet been able to measure. Let’s have the conversation on vaping and do our part to keep the next generation healthy.