When it comes toand the potential , you probably think you’ve heard it all. New York periodontist Scott Froum, D.D.S., did too — including the possibility of in someone’s face. But then Froum started noticing a troubling trend among his patients.
Two stories stuck out to him. The first involves a young man who had quit smoking traditional tobacco products by switching to e-cigarettes, which he had been using for five years.
Believing vaping to be healthier, this patient smoked a cartridge a day, often chasing it with a sugar-laden energy drink to quench the resulting dry mouth. The combination left him with extensive tooth decay, enamel wear and, eventually, tooth loss.
Then there was the older gentleman who had also switched from traditional cigarettes to e-cigarettes. This patient had been cavity-free for 35 years, but within a year of taking up vaping, the enamel on his teeth started to erode and soften, increasing his risk of cavities.
It was this latter case that led Froum, who is also a clinical associate professor in the department of periodontics at SUNY Stony Brook School of Dental Medicine, to dig into the research on vaping’s effect on oral health.
He posted his findings in Perio-Implant Advisory, of which he is the editorial director (Warning: there are graphic images) and the response was huge. The article was picked up by other industry magazines, leading to an outpouring of emails from other dentists.
“We began seeing [the tooth decay], but didn’t realize what it was from,” Froum says. “We had been noticing it in teens that weren’t at risk and then attributing it to other things like Monster Energy-type drinks. We never realized that vaping could also be a cause.”
What the research says about how vaping harms your teeth
Anecdotal stories don’t definitively prove vaping makes your teeth rot, but they shouldn’t be dismissed outright either. Most experts agree that although e-cigarettes generally contain fewer toxins than tobacco cigarettes, that doesn’t mean they’re harmless. And after reviewing the evidence on how propylene glycol, vegetable glycerin, and nicotine — the three most common ingredients in e-cigarettes — can affect oral health, Froum thinks there’s cause for concern.
Propylene glycol, a liquid alcohol that’s often used in food processing because of its ability to mix well with flavoring ingredients, can lead to dry mouth, which (when chronic) can cause cavities and gum disease. PG also breaks down into acetic acid, lactic acid and propionaldehyde — all of which are known to deteriorate tooth enamel and soft tissues.
Research also shows that when teeth are exposed to vaping aerosol that contains a mix of vegetable glycerin and flavorings, they carry four times more bacteria than teeth that haven’t been exposed.
Although both propylene glycol and vegetable glycerin are recognized as safe for ingestion by the FDA, less is known about their health effects (or those of their byproducts, which include potential carcinogens, like formaldehyde, and heavy metals like lead, nickel and mercury) when they’re inhaled.
“These breakdown products haven’t been tested,” Froum says. “Because vaping was deemed to be innocuous and a better choice than smoking, nobody studied it… they kind of let the lesser evil go by unchecked and not researched.”
Experts also don’t know how the distribution of these chemicals changes when they’re turned into a vapor, says periodontist Richard Kao, D.D.S., Ph.D., president of the American Academy of Periodontology and clinical professor in the department of orofacial sciences at the University of California San Francisco.
There’s some evidence they may be able to travel farther into the body’s tissues and cells, just as diacetyl — a buttery-flavored chemical in foods — did when popcorn factory workers inhaled it, causing a type of lung disease known as bronchiolitis obliterans, or “popcorn lung.”
The potential effect of nicotine on gums, on the other hand, is well-known thanks to cigarette research. Although e-cigarettes generally contain less nicotine than tobacco cigarettes, there’s substantial evidence it can have the same effect: decreased blood flow and cellular turnover, which can increase your risk of gum disease and tooth loss.
And what the research doesn’t say
Given the explosion of e-cigarette use, especially among kids — it increased 78% among high school students and 49% among middle school students between 2017 and 2018, according to the CDC — the FDA asked the National Academies of Sciences, Engineering and Medicine (NASEM) to report on the potential public health consequences.
Unfortunately, when it came to oral health, NASEM researchers were unable to find any epidemiological studies examining the link between e-cigarette use and periodontal disease. And the clinical and in vitro studies that did exist only provided “limited evidence” that e-cigarette aerosol can cause cell damage in oral tissue.
The problem with trying to evaluate the public health risk of vaping at this time is that e-cigarettes are still relatively new. They were first imported into the US in 2006 but didn’t really gain traction into 2015 when. The studies that do exist are small and often done on tissue samples in a lab or only include people who have switched from traditional cigarettes to e-cigarettes — not first-time users who only use e-cigarettes.
“We know cigarettes can cause cardiovascular disease, lung disease and cancer and that they dramatically increase your chances of getting gum disease by 400%,” Kao says. “But it took something like 20 to 30 years of research to get those kinds of facts. Vaping is a new problem that’s largely associated with young adults, who don’t show up in dental offices as often, so it’s hard to say how bad the problem really is.”
Froum, too, acknowledges these limitations, but based on the available evidence and what he’s seeing in his office, says he believes “a tidal wave of oral health problems is heading our way.”
How to take control of your oral health
If you’re fond of your smile and want to keep it intact, the best thing you can do is, Kao says. But, Froum warns, “if you’re going to vape, then your oral hygiene has to be impeccable.”
Here are a few ways to minimize your risk of developing dental issues:
- Brush with fluoride toothpaste. Aim for at least twice a day, plus at least 20 minutes after vaping. When you drink something acidic, it weakens the enamel of your teeth, and brushing too soon after can remove some of that enamel. There’s no research to suggest vaping would cause the same problem, but if you want to be extra cautious, Froum says, “Wait 20 minutes before you brush your teeth.”
- Clean between your teeth. And along your gum line. Using dental floss is best, especially if you’re young, but older vapers who have more space between their teeth and gums may also get good results from oral irrigators.
- Avoid dry mouth. Carry around a bottle of water or a moisturizing mouth spray containing xylitol, which can help stimulate saliva production. “And certainly avoid sugary drinks when you’re vaping,” says Froum.
- See the dentist more often. Instead of a yearly appointment, go in “every six to four months to check for cavities and things of that nature,” Froum advises.
Oral health issues to watch for
Whether you currently vape or have recently quit, it’s important to continue monitoring your oral health between dental visits. “Vaping may not stain your teeth like smoking cigarettes does,” Kao says, “but the nicotine and some of the chemicals are still harmful carcinogens that can cause problems.”
Here are a few symptoms to look out for:
- Red, puffy, bleeding gums. “These can all be signs of periodontal disease going unchecked,” Kao says.
- Receding gums. “When you lose a lot of gum tissue, you essentially lose the protective seal for keeping the bacteria out of your body,” Kao says. This can cause faster gum recession and more bone loss.
- White spots on your teeth. “These are decalcifications that show the beginning of enamel softening,” Froum says.
- Red or white patches on your gums or the inside of your cheek. “These lesions could be something as simple as scarring,” Kao says. “But sometimes they start transforming into precancerous cells and sometimes they do become cancer cells. And the thing you should know about oral cancer is that by the time we catch it, there’s not a high success rate to treat it. So any oral cancer is a bad cancer.”
- Oral thrush. White patches on your tongue or mouth or redness inside your mouth can also be a sign of thrush, an outbreak of a type of fungus, or yeast, known as Candida. “We know that Candida is a normal part of the flora,” Kao says. “But when a person’s immune system is compromised, there’s an overgrowth.”
These problems can take longer to develop in teens and young adults with no prior history of tobacco use, but that doesn’t mean you or your loved one should wait to see a professional. “Damages can go unseen, unmonitored, and could potentially get to be quite extreme before they’re aware of what’s going on,” Kao warns.
Your dentist should be your first stop. “But if the problem advances, most dentists are very good about sending you to a periodontist,” Kao says. Just know that smokers, even those who go in for cleanings every six months, tend to respond worse to treatment and maintenance management. Their gum tissue just isn’t as resilient — and the same may be true for vapers, says Kao.
It’s just too soon to tell.