Anti-Vaping Education of Dental Patients: A Call to Action

Electronic nicotine delivery systems, commonly known as e-cigarettes and vaping, were first developed in 2003 by Chinese pharmacist Hon Lik and were introduced in the United States in 2007.¹ An e-cigarette is a device with a heating element at one end that produces an aerosol from a liquid nicotine solution, creating a vapor, which is inhaled through a mouthpiece. The liquid portion of the e-cigarette, commonly referred to as vaping juice, comes in various flavors and is composed of propylene glycol and glycerin. E-liquid is available with or without nicotine.

Many perceive the use of e-cigarettes and vaping as a safe alternative to conventional cigarettes with little or no harmful health effects. Studies of current smokers who plan to quit have reported that e-cigarettes and vaping are viewed as a safe method to stop smoking cigarettes.² Additionally, the manufacturer of a popular vaping device describes the ingredients of its devices as materials that are commonly used by the medical, beauty, and food industries, suggesting safety. On its website, the company even describes the nicotine in its product as pharmaceutical grade, which users may interpret as safe.

The use of e-cigarettes has greatly increased in the past few years among middle and high school students. According to the 2018 National Youth Tobacco Survey, 3.6 million middle and high school students are current e-cigarette users, which represents a 78% increase in high school users and a 48% increase in middle school users from 2017 to 2018.³ The increased use of e-cigarettes among teens has been attributed to the appealing design of the vaping pens, which in some cases may resemble a flash drive, and the many flavors that are available. Vaping devices can have high nicotine content. The top three reasons that middle and high school students list for vaping are: (1) friends or family members use the products, (2) the availability of flavors such as mint, candy, fruit, or chocolate, and (3) the belief that e-cigarettes are less harmful than other forms of tobacco like cigarettes.⁴

Middle and high school students are a demographic group associated with higher caries rates due to subpar oral hygiene; consumption of sugary, low pH drinks; and, often, the presence of fixed orthodontic appliances. The cariogenic and erosive potential of soft drinks is well recognized.⁵ Dental caries is a complex disease process with many etiologic factors correlated to oral hygiene, diet, pH, quantity of sugar consumed as well as the frequency of consumption.⁶ The presence of fixed orthodontic appliances in teens further puts them at greater risk of developing caries.⁷ As many as 50% of children treated with fixed appliances reportedly had at least one white spot lesion after the fixed appliances were removed.⁸ The ability of e-liquids containing propylene glycol, glycerin, and sweet flavors to cause changes in the surface of tooth enamel that promote the attachment of Streptococcus mutans, combined with poor oral hygiene and/or a high sucrose diet, can result in damage to teeth.^9,10 Combining vaping with the aforementioned risk factors associated with teens can create an oral environment with a high potential for the development of extensive dental caries.

During regular recall visits an increase in caries activity in a previously caries-free teen should raise suspicion that something has changed in the patient's oral health routine, which could be the use of e-cigarettes. Teens may be reluctant to confirm a vaping habit due to fear that their parent or guardian may learn of this activity. Because teenaged patients may not provide truthful and accurate answers to questions about their use of e-cigarettes, in order to reach as many of these patients as possible the entire dental team should communicate the potential for vaping to cause unesthetic and unhealthy changes to the teeth. This message may be communicated through in-office posters and brochures as well as a short script inserted into routine oral hygiene instructions reviewed with patients of all ages.

 During regular preventive visits dentists and hygienists have the ability to help patients improve their oral and overall health through communication regarding the damage that the use of e-cigarettes or vaping can cause. Showing patients images of the unsightly changes that e-cigarettes can produce in the dentition may greatly impact a patient's decision to stop vaping, even more so than expressing concern for their general health. All members of the dental profession must join forces with the medical profession to educate the public about the health damage vaping can cause so that patients can make informed choices.

Cynthia Jetter, DMD
Assistant Professor, Department of Community Health, Rutgers School of Dental Medicine, Newark
New Jersey; Private Practice, Voorhees, New Jersey

Jill York, DDS, MAS
Associate Professor, Department of Community Health, Assistant Dean for Extramural Clinics, Hunterdon Endowed Chair in Dental Public Health, Rutgers School of Dental Medicine, Newark, New Jersey; Clinical Assistant Professor, Rowan University School of Osteopathic Medicine, 
Stratford, New Jersey

Darlene Saggiomo, RDH
Hygienist, Extramural Clinics, Rutgers School of Dental Medicine,
Newark, New Jersey

Jason Tsai
Fourth-year Dental Student, Rutgers School of Dental Medicine,
Newark, New Jersey