Vaping and oral health

E-cigarette ingredients raise concern for dental professionals
August 16th, 2019

Parents aren’t the only ones scrambling to get in front of the sudden popularity of e-cigarettes. Vaping is yet one more factor that dentists must consider as they strive to keep patients’ mouths healthy.

Although the e-cig industry often claims their products aren’t as harmful as traditional cigarettes, preliminary studies of side effects are raising red flags, including among the dental community, says Dr. Crystal Stinson, assistant professor in public health sciences.

Without enough long-term, evidence-based data on the risks of e-cigarettes yet, dentists can only make an educated prediction as to what awaits their patients in the long term. One look at the ingredients and it’s easy to connect the dots.

Dr. Crystal Stinson

“The flavorings and components of e-cigarettes change the oral microbiome and the pH of the saliva. Those two things can increase the risk of caries and periodontal disease,” says Stinson, a certified tobacco treatment specialist and co-principle investigator of a three-year, $1.5 million grant funded by the Cancer Prevention & Research Institute of Texas for the tobacco cessation program at the college.

While the e-cigarette industry acknowledges that nicotine is present, the general public seems unaware of how e-cigs also contain other compounds with questionable track records, she says.

“If you ask most kids what is in this, they don’t even know it’s nicotine,” she says. “Most people think it’s just water vapor.”

Details on the exact contents of e-cigarettes aren’t always easy to find, mostly because a list on product labels won’t be required by the Food and Drug Administration until 2022. For now, e-cig users are likely to only find a listing of nicotine content and flavor recipe on the side. Unfortunately, that means many vapers have no idea what they’re inhaling.

“Even for the adults, it’s not informed consent. People don’t know what it does. Maybe there’s an ingredient list in the fine print, or maybe not. But there’s not enough regulation beyond just knowing it contains nicotine. There’s no requirement that the other chemicals be listed,” says Katharine Miller Nimmons, tobacco cessation program coordinator and evaluator for the CPRIT grant. The program will help implement onsite tobacco cessation services at the Agape Clinic and North Dallas Shared Ministries, as well as at Texas A&M College of Dentistry.

Katharine Miller Nimmons

“This generation, you walk down the grocery store aisle and everything is organic, and everything’s BPA free. And we’re so concerned about the foods we want to eat being ‘clean.’ But some of these same people are taking chemicals that they have no idea what they are and inhaling them directly into their lungs and bloodstream,” Nimmons says.

Formaldehyde, which for many brings back memories of dissecting frogs in high school biology, is one ingredient often found in e-cigs. Then there’s benzene, toluene and acetoin, which are all known to cause cancer in animals, Stinson says. Anyone who is familiar with popcorn lung—an ailment suffered by popcorn factory workers who inhaled the diacetyl added for flavor in microwave popcorn—should be aware that compound can also be found in e-cigs.

Vape recipes, with a wide selection of flavorings and differing nicotine levels, are as varied as the plethora of independent shops that make and blend the products onsite, Stinson says. Shops offer personalized liquids that entice young customers with flavors like cheesecake or bubblegum or cinnamon roll.

Although tar buildup is a tell-tale sign of traditional cigarette use, dental professionals have a vape-related list to assess during regular checkups as they look for changes in the oral cavity. Other oral health issues related to e-cigs, besides an increase in cavities or periodontal disease, include enamel erosion and an increased risk of oral cancer.

“The pH of saliva is important because it buffers acid that’s produced by the bacteria that lives in your mouth. So if you’re not buffering that acid, it’s destroying your enamel,” Stinson says. “And your oral microbiome is protective against dental caries and the pathogens that cause periodontal disease. If you’re tampering with that, your risk of getting those types of dental disorders is increased.

“Some studies that are going on now are looking at changes in the epithelium, the mucosa and on the tongue and floor of the mouth, with prolonged exposure to the compounds of the e-cigarettes to see if there are any epithelial changes.”

Such changes are usually the beginnings of oral cancer. Dysplasia in the epithelium becomes invasive and turns to cancer, she says.

The vaping fallout goes beyond dental-related issues. Nicotine, a neurotoxin, can have unexpected side effects in young people with still-developing brains. Young vapers may experience ADHD, depression and anxiety, she says. Withdrawal symptoms in those who try to kick the habit are often much more severe than in adults. Fully formed brains can adapt better to nicotine.

The advent of e-cigarettes or vaping has practically wiped out any progress made in reducing tobacco product use among our youth, according to the Centers for Disease Control and Prevention.

“It has caught a lot of the school boards and educators and policymakers by surprise. It was a big thing before they had any rules like, ‘No, you can’t vape at school. No, you can’t vape on the bus,’” says Nimmons.

In 2018, 4.9 million U.S. high school and middle-school students admitted using a tobacco product in the past 30 days. That’s a staggering 1.3 million-person increase in just one year, according to a Vital Signs report published by the CDC. One in four high school students currently use tobacco products.

“The skyrocketing growth of young people’s e-cigarette use over the past year threatens to erase progress made in reducing youth tobacco use. It’s putting a new generation at risk for nicotine addiction,” says Robert R. Redfield, CDC director.

Such alarming statistics are being met with countermeasures in states across the country. In Texas, the legal age for purchasing tobacco products will increase from 18 to 21 on September 1. Earlier this summer, Texas Gov. Greg Abbott signed Senate Bill 21 into law to make it more difficult for minors to access tobacco products.

Delaware, Illinois, New York and Ohio passed similar laws this year, and 21 is already the legal age to purchase tobacco products in California, Hawaii, Maine, Massachusetts, New Jersey and Oregon. More states are heading that way with recent legislation, including Arkansas, Connecticut, Maryland, Utah, Vermont, Virginia, Washington, and the District of Columbia.

“Somebody is selling it to these kids. That’s the part that I feel everybody should be livid about, and policy should be coming out of the woodwork to stop this, but it’s not happening. One or two times and that young person could become addicted,” Stinson says. “I think there’s a lot of conversation right now about just removing the flavors. If you take the flavors away, maybe they’ll be less likely to be enticed to vape.”

— Kathleen Green Pothier