Many patients ask their dental professional if vaping is harmful to their oral health. It can often be confusing to follow the evidence and guidance on e-cigarettes.
BSP is grateful to Dr Richard Holliday, from Newcastle University School of Dental Sciences, who has prepared a brief summary of current evidence on e-cigarettes and periodontal health for dental professionals. The summary has been reviewed and contributed to by BSP Council and we hope that you find it helpful.
We have invited our Patient Forum members to review this information. Once we have their feedback, we intend to add some helpful pateint information about vaping to our website.
Dr Richard Holliday is a Senior Lecturer/ Honorary Consultant in Restorative Dentistry and Specialist in Periodontics at Newcastle University. His research interests are translational in nature, spanning fundamental research to pragmatic clinical trials and public health research. He has a particular focus on tobacco and novel nicotine products and is currently conducting a large national multi-centre randomised controlled trial on smoking cessation interventions in primary dental care (The ENHANCE-D trial).
An evidence summary on e-cigarettes and periodontal health (2023)
There have been several alarming media articles and press releases in recent months about vaping and oral health. Some have stated that vaping is as damaging, or more damaging, for oral health than smoking; that e-cigarettes cause cancer and that they should not be advised as a transition from tobacco smoking. Often no supporting evidence is provided for these claims. This evidence summary aims to provide a simple and clear overview of the current UK recommendations and the evidence base around e-cigarette use.
The Chief Medical Officer for England, Professor Sir Chris Whitty, said earlier this year "The key points about vaping (e-cigarettes) can be easily summarised. If you smoke, vaping is much safer; if you don’t smoke, don’t vape".
What are the general health effects of vaping?
Many large reviews from expert groups have reviewed the health effects of e-cigarette use. A famous US report, published in 2018 by the National Academies of Science, Engineering and Medicine (NASEM), concluded that ‘Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes. However, the absolute risks of the products cannot be unambiguously determined at this time. Long-term health effects, of particular concern for youth who become dependent on such products, are not yet clear.’1 The Office for Health Improvement and Disparities, (OHID) 2022 report completed a systematic review on the health risks of vaping and concluded that ‘vaping poses only a small fraction of the risk of smoking…. This does not mean vaping is risk-free, particularly for people who have never smoked.’2
It is particularly noteworthy that this magnitude of relative risk between vaping and smoking is not reflected in current public perceptions. In 2023, 39% of adult smokers reported that they thought that e-cigarettes were a lot more, more or equally harmful as cigarettes (the opposite of the evidence reviews and expert opinion).3 This is up from 7% in 2013.3
What is the evidence for vaping effects on periodontal health?
Tobacco smoking is well known as one of the most important risk factors for periodontal disease development and progression. It is little surprise that much attention is being focused on the potential effects of e-cigarettes on periodontal health.
Individual studies can be found to support different viewpoints on e-cigarettes e.g. showing periodontal damage or not. Looking at the evidence as a whole identifies a number of evidence reviews. The NASEM report (2018) was one of the earliest and concluded that there was evidence suggesting that ‘switching to e-cigarettes will improve periodontal disease in smokers’, although this evidence was classed as limited.1
A systematic review in 2020 concluded that switching to e-cigarettes may mitigate oral symptomatology for conventional smokers but that oral health sequelae may be associated with e-cigarette use.4 Similarly, a critical review in the Journal of Dental Research (2021) from an international author group concluded that the risk of periodontal disease associated with e-cigarette use was less than that associated with tobacco smoking, but more than that seen in non-smokers.5
The Public Health England (PHE)/OHID annual reviews specifically looked at oral health for the first time in 2022, including 28 studies in humans, 31 animal and one in cell lines.2 They found no further studies that would change the conclusions from the above reviews.
In 2022 a systematic review and network meta-analysis found that periodontal parameters were similar among non-users and e-cigarette users, while tobacco smokers presented the worst indices.6 Bleeding on probing (BOP) was reduced in both e-cigarette users and tobacco smokers. It’s important to note the included studies had several limitations as highlighted in previously published critique.7
Most recently a large longitudinal US cohort study found no associations with self-reported gum disease, precancerous oral lesions, bone loss around teeth, loose teeth or tooth removal.8 A positive association was observed with bleeding after brushing or flossing – the authors discuss that this could be a direct effect of e-cigarette use but could also be related to the observed increase in bleeding due to quitting cigarette smoking, especially given that most of the e-cigarette users were former or current cigarette users.
A research area that has been of particular interest has been the effects on the oral microbiome and the resulting potential impacts on periodontal health. A number of studies have examined this and overall they suggest that e-cigarettes have quantifiable effects on the oral microbiome and that it may push the microbiome in a dysbiotic direction.9,10,11 Conducting these human studies is challenging as often e-cigarette users are previous or current tobacco smokers which makes it hard to interpret the findings – some of these microbiological studies have measured expired air carbon monoxide and demonstrated that several of their e-cigarette user group were also likely smoking tobacco. Longitudinal studies are required to determine the clinical impacts of these changes.
What is the evidence for e-cigarettes helping smokers to quit?
A regularly updated Cochrane Systematic Review and Meta-analysis includes 78 studies and 22,052 participants and looks at several comparisons.12
When comparing e-cigarettes to traditional nicotine replacement therapies (NRT; patches and gum; our usual standard of care), it finds high certainty evidence that e-cigarettes are more effective. In absolute terms, this translates to 6/100 people quitting with NRT compared to 8-12/100 with e-cigarettes. This comparison is based upon 6 randomized controlled trials with 2378 participants. Arguably this evidence base is as strong, or stronger, than anything else we do in dentistry.
With respect to dental settings in particular, a separate Cochrane review looked at all cessation options but included only one small trial with e-cigarettes.13 In the UK there is an ongoing national trial investigating smoking cessation in dental settings, which includes e-cigarettes. The findings are due to be reported in 2025 (ENHANCE-D trial, NIHR funded).
What is the current guidance on e-cigarettes for smoking cessation?
There is comprehensive guidance for UK healthcare professionals:
- NHS websites provide useful information to users (and healthcare professionals) on using e-cigarettes to stop smoking, Vaping myths and youth vaping.
- NICE guidance includes e-cigarettes, recommending that health and social care professionals should offer advice on using nicotine-containing products on general sale, including over-the-counter NRT and nicotine-containing e-cigarettes. Items for discussion include ensuring that users use them long enough to ensure they don’t return to smoking and the importance of getting enough nicotine to overcome withdrawal symptoms. The guidance also discusses that there is not enough evidence to know the long-term harms from e-cigarette use, but that it is likely to be substantially less harmful than smoking and that smoking tobacco should be stopped completely.
- Annual expert independent evidence reviews commissioned by Public Health England (now the OHID).
- Delivering better oral health: an evidence-based toolkit for prevention. Chapter 11: Smoking and tobacco use.
- National Centre for Smoking Cessation training – vaping: a guide for healthcare professionals.
Young people and ‘disposables’
Vaping is not for children or young people. Worryingly, we have recently seen a large increase in young people using e-cigarettes and this has principally been put down to the popularity of disposable products. At the time of writing the UK government is holding a consultation on how to reduce youth vaping and ensure the law is enforced (there are already age of sale laws in place). It is likely that further restrictions on this product category will be introduced in the near future.
The bottom line
In summary, the oral health evidence supports the general public health messages and guidance on e-cigarettes. E-cigarette use is far less harmful than tobacco cigarettes, although not risk free – we will likely see oral health consequences of long-term vaping (but less than from tobacco smoking). E-cigarettes are not recommended for non-users, especially young people. For existing smokers, e-cigarettes can be an effective quit aid and dental professionals should support patients who choose to use this method of cessation.
7th December 2023
- National Academies of Sciences, Engineering, and Medicine. 2018. Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press. https://doi.org/10.17226/24952.
- McNeill A, Simonavicius E, Brose L, Taylor E, East K, Zuikova E. Nicotine vaping in England: an evidence update including health risks and perceptions 2022. A report commissioned by the Office for Health Improvement and Disparities. 2022. Available from: https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update
- Action on Smoking and Health. Use of e-cigarettes (vapes) among adults in Great Britain. 2023. Available from: https://ash.org.uk/uploads/Use-of-e-cigarettes-among-adults-in-Great-Britain-2023.pdf
- Yang I, Sandeep S, Rodriguez J. The oral health impact of electronic cigarette use: a systematic review. Crit Rev Toxicol. 2020 Feb;50(2):97-127. doi: 10.1080/10408444.2020.1713726. Epub 2020. Erratum in: Crit Rev Toxicol. 2020;1.
- Holliday R, Chaffee BW, Jakubovics NS, Kist R, Preshaw PM. Electronic Cigarettes and Oral Health. J Dent Res. 2021;100(9):906-913.
- Pesce P, Menini M, Ugo G, Bagnasco F, Dioguardi M, Troiano G. Evaluation of periodontal indices among non-smokers, tobacco, and e-cigarette smokers: a systematic review and network meta-analysis. Clin Oral Investig. 2022;26(7):4701-4714.
- Holliday R, Chaffee B, Ryan V, McColl E, Preshaw PM. Letter to the editor regarding "Impact of cigarette smoking and vaping on the outcome of full-mouth ultrasonic scaling among patients with gingival inflammation: a prospective study". Clin Oral Investig. 2020;24(1):517-518.
- Silveira ML, Everard CD, Sharma E, Lauten K, Alexandridis AA, Duffy K, Taylor EV, Tolliver EA, Blanco C, Compton WM, Kimmel HL, Iafolla T, Hyland A, Chaffee BW. Tobacco Use and Incidence of Adverse Oral Health Outcomes Among US Adults in the Population Assessment of Tobacco and Health Study. JAMA Netw Open. 2022;5(12):e2245909.
- Pushalkar S, Paul B, Li Q, Yang J, Vasconcelos R, Makwana S, González JM, Shah S, Xie C, Janal MN, et al. Electronic cigarette aerosol modulates the oral microbiome and increases risk of infection. iScience. 2020; 23(3):100884.
- Thomas SC, Xu F, Pushalkar S, Lin Z, Thakor N, Vardhan M, Flaminio Z, Khodadadi-Jamayran A, Vasconcelos R, Akapo A, Queiroz E, Bederoff M, Janal MN, Guo Y, Aguallo D, Gordon T, Corby PM, Kamer AR, Li X, Saxena D. Electronic Cigarette Use Promotes a Unique Periodontal Microbiome. mBio. 2022;13(1):e0007522.
- Ganesan SM, Dabdoub SM, Nagaraja HN, Scott ML, Pamulapati S, Berman ML, Shields PG, Wewers ME, Kumar PS. Adverse effects of electronic cigarettes on the disease-naive oral microbiome. Sci Adv. 2020;6(22):eaaz0108.
- Hartmann-Boyce J, Lindson N, Butler AR, McRobbie H, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2022;11(11):CD010216.
- Holliday R, Hong B, McColl E, Livingstone-Banks J, Preshaw PM. Interventions for tobacco cessation delivered by dental professionals. Cochrane Database Syst Rev. 2021;2(2):CD005084.