E-cigs and your teeth: Should vapers be worried?

E-Cigs and Your Teeth: Should Vapers Be Worried?

Smokers have a reputation for having bad teeth. They get “nicotine stains,” people say, turning their teeth from a brilliant white into a dull yellow-brown.

Faced with comments like this, most vapers would rightly point out that nicotine in pure form is actually colourless. It seems obvious that – much like with the health risks – the problem for your teeth from smoking isn’t the nicotine, it’s the tar.

But are we actually right? Recent studies on the topic have flagged up vaping as a potential concern, and although they’re a long way from showing dental problems in real-world vapers, it is a sign that there could be issues in future.

So here’s a run-down of what we know about vaping and the teeth so far, the role of nicotine and what we can do to minimise any risk.

How Does Smoking Affect Your Teeth?

To understand the potential risks of vaping to your teeth, it makes sense to learn a bit about how smoking causes oral health issues. While there are many differences between the two – inhaling tar-laden smoke is very different from inhaling droplets of liquid – vapers and smokers are exposed to nicotine and other chemicals in a similar way.

For smokers, dental issues are more likely than they are in never-smokers or ex-smokers. For example, current smokers are four times as likely to have poor oral health compared to people who’ve never smoked, and they’re over twice as likely to have three or more oral health issues.

Smoking affects your oral health in many different ways, ranging from the yellow-brown staining and bad breath it causes through to more serious oral health issues like gum disease (technically called periodontal disease) and oral cancer. Smokers also have more tartar than non-smokers, which is a form of hardened plaque, otherwise known as calculus.

There are other effects of smoking that cause problems for your teeth, too. For instance, smoking impacts your immune system and interferes with your mouth’s ability to heal itself, both of which can exacerbate other problems caused by smoking.

 Man smoking with bad stained teeth

Smoking and Gum Disease

Gum disease is one of the most common dental issues in the UK and around the world, and smokers are around twice as likely to get it as non-smokers. It’s an infection of the gums and the bone surrounding your teeth, which over time leads to the tissue and bone breaking down and may cause tooth loss.

It’s caused by plaque, which is the name for a mixture of saliva and the bacteria in your mouth. As well as causing the gum irritation and inflammation that characterises gum disease, plaque also directly impacts your teeth, leading to tooth decay.

When you consume food containing a lot of sugar or starch, the bacteria process the carbohydrates it contains for energy. This process creates acid as a by-product. If you don’t keep your teeth clean, this acid eventually impacts your tooth’s surface and causes decay. But plaque contains a lot of different bacteria, and some of these directly irritate your gums too.

So while one of the consequences of plaque build-up is more relevant for gum disease, both lead to problems with your teeth and smokers are more likely to suffer both consequences than non-smokers. The effects smoking has on your immune system mean that if a smoker gets a gum infection resulting from plaque build-up, his or her body is less likely to be able to fight it off. In addition, when damage is done as a result of the build-up of plaque, the impact of smoking on wound healing makes it more difficult for your gums to heal themselves.

Over time, if you don’t treat gum disease, spaces can start to open up between your gums and your teeth. This problem gets worse as more of the tissues break down, and eventually can lead to your teeth becoming loose or even falling out.

Overall, smokers have twice the risk of periodontal disease compared to non-smokers, and the risk is bigger for people who smoke more and who smoke for longer. On top of this, the problem is less likely to respond well when it gets treated.

Man in the dentist with rotten teeth

Smoking and Gum Disease: Is Nicotine to Blame?

For vapers, learning about the connection between smoking and gum disease invites one question: is it the nicotine or the tar in tobacco that causes the problems? Of course, as vapers we’d be inclined to blame the smoke and tar rather than the nicotine, but would be right to?

There are several theories relating to the link between smoking and gum disease:

  • The toxins in smoke could directly damage gum tissue.
  • Smoke could change the specific microbes found in plaque or change how the immune system responds to it.
  • Nicotine causes blood vessels to constrict, and this could make the early warning signs (like bleeding from the gums) harder to spot.
  • Nicotine’s effect on blood vessels could lead to “hypoxia” – low levels of oxygen in the tissues – and this could predispose your gums to infections, as well as reducing the ability of your gums to heal themselves.

Unfortunately, it’s not really clear which explanation or combination of them is causing the problems for smokers. For vaping, though, there are clearly some potential benefits. There are far fewer toxins in vapour, so any issues caused as a result of them will be less severe in vapers than smokers.

The last two potential explanations relate directly to nicotine, but there are a couple of things worth noting.

For the idea that nicotine reduces blood flow and that causes the issues, there are some problems. Studies looking directly for the impact of this on the gums (here and here) have found either no change in blood flow or slight increases.

Although nicotine does make your blood vessels constrict, the impact smoking has on blood pressure tends to overcome this and blood flow to the gums increases overall. This is the opposite of what you’d expect if the explanation were true, and at least suggests that it isn’t the major factor at play. Vaping has less of an impact on blood pressure, though, so the result for vapers could be different.

The other idea is that the gum tissues are getting less oxygen, and this is causing the problem. Although studies have shown that the hypoxia caused by smoking parallels how nicotine acts in the body, nicotine isn’t the only thing in smoke that could have this effect. Carbon monoxide in particular is a component of smoke (but not vapour) that has exactly that effect, and hydrogen cyanide is another.

It’s not completely clear which is to blame, but since wound healing (which is a closely-related issue) is affected in smokers but not in NRT users, it’s unlikely that nicotine alone is doing all the damage or even most of it.

Unsurprisingly, a lot of the discussion of this topic conflates nicotine with smoke, and this makes it hard to work out how much of a role nicotine really has. There isn’t much evidence looking at this relating to vaping specifically, as you’d expect, but there isn’t much relating to nicotine out of smoke at all.

Bad and good teeth being scraped

The Research on Vaping and the Teeth: Cell Studies

First, there have been some studies looking specifically at how vaping affects the teeth. However, these studies have mainly taken the form of cell culture studies. These are known as “in vitro” (literally “in glass”) studies, and while they’re useful for understanding the biological mechanisms underpinning the potential health effects of vaping (and other exposures, medicines and pretty much anything), it is a limited form of evidence. Just because something affects a bunch of cells in a culture doesn’t mean it will have the same effect in a real human body.

With that in mind, the research on vaping and your teeth is summarized by a review from March 2017. The authors address evidence about gum disease, which includes cell culture studies showing that e-liquids have harmful effects on ligament cells and connective tissues in the gums. Aldehydes in e-cig vapour can have impacts on proteins and cause damage to DNA. All of these effects could theoretically lead to periodontal disease in vapers.

Nicotine also has the potential to cause problems for the teeth too, although again this is based on cell studies and evidence from people smoking tobacco. The authors argue that vaping could lead to impaired healing.

But the truth is that at the moment, we don’t have very much evidence specifically concerning vaping, and much of the above is ultimately speculation. It’s speculation based on mechanistic studies of how nicotine interacts with cells in your mouth, so it can’t be completely ignored, but the evidence we have so far can’t really say too much about what will happen to real-world vapers in practice.

Woman vaping and smiling

The Research on Vaping and the Teeth: A Study on Real Vapers

However, there is one study that looked at oral health in real-world vapers, and its results were generally positive. The research included 110 smokers who’d switched to vaping and had their oral health examined at the start of the study, after 60 days and after 120 days. The vapers were split up into those who’d smoked for less than 10 years (group 1) and those who’d smoked for longer (group 2).

At the start of the study, 85 % of group 1 had a plaque index score of 1, with just 15 of them having no plaque at all. For group 2, none of the participants had a plaque score of 0, with about three-quarters scoring 2 out of 3, and the rest of the participants split between scores of 1 and 3. By the end of the study, 92% of group 1 and 87 % of the longer-term smokers in group 2 had plaque scores of 0.

For gum bleeding, at the start of the study, 61% of group 1 participants and 65% of group 2 participants bled after being poked with a probe. By the final follow-up, 92% of group 1 and 98% of group 2 had no bleeding. The researchers also took a papillary bleeding index, which involves a probe being inserted between the gum-line and the teeth, and similar improvements were seen. At the start of the study, 66% of group 1 and 60% of group 2 participants showed no bleeding, but at the end of the study, this had increased to 98% of group 1 and 100% of group 2.

It might only be one study, but the message it sends is pretty clear: switching to vaping from smoking appears to be a positive move as far as your teeth are concerned.

(A big thanks to Mitch Clarke for pointing that study out to us in the comments!)

Research on Snus and Gums

The study looking at real-world vapers’ teeth had pretty positive results, but as the cell studies show, there is still some potential for issues over the long-term. Unfortunately, aside from that study there is little we can do but speculate. However, we do have some extra evidence we can call on.

If nicotine is responsible for the dental issues that smokers experience – or at least partially responsible for them – then we should see signs of problems in other people who use nicotine without smoking. Snus – the Swedish form of smokeless tobacco that’s essentially snuff in a mini teabag – and nicotine gums give two great sources of evidence we can use to investigate the issue in a bit more detail.

On the whole, the evidence doesn’t seem to point the finger at nicotine very much. One study looked at evidence covering 20 years from Sweden, with over 1,600 participants in total, and found that while severe gum disease was more common in smokers, snus users didn’t seem to be at increased risk at all. There is some indication that gum recession and loss of tooth attachment is more common at the location the snus is held, but on the whole the likelihood of issues is much more closely related to smoking than snus use.

Although this hasn’t been studied as much as you may think, a study in nicotine gum users provides yet more evidence that nicotine isn’t really the issue. Chewing sugar-containing gum obviously has the potential to affect your teeth even without nicotine, but a comparison between 78 people who chewed nicotine gum for 15 weeks with 79 who chewed non-nicotine gum found no difference at all on things such as plaque, gingivitis, tartar and other oral health related outcomes. Again, smoking did increase the risk of tartar and gingivitis.

Overall, while there are some plausible explanations for how nicotine could affect your oral health, the evidence really doesn’t support a link. This is good news for any vapers, snus users or long-term NRT users, but it should go without saying that avoiding smoking and looking after your teeth in general is still important for your oral health.

Snus

Dehydration and Your Teeth: Will Vaping Indirectly Affect Our Teeth?

When it comes to nicotine, the evidence we have so far suggests that there’s little to worry about, and the cell studies directly addressing vaping are hard to draw firm conclusions from without further evidence. But these aren’t the only ways that vaping could impact your teeth and oral health.

One thing most vapers know is that vaping can dehydrate you. Both PG and VG are hygroscopic, which means they suck moisture out of their immediate environment. This is why getting a dry mouth after vaping is really common. Your mouth is in near-constant contact with PG and VG and most vapers quickly get accustomed to drinking more than usual to compensate. The question is: does this constant dehydration pose a risk for your teeth?

There is an interesting paper on the potential link between mild dehydration and dental issues, and overall it stresses that there is no direct evidence of a link. However, there are many indirect pieces of evidence and suggestive findings that hint at potential problems.

This largely comes down to your saliva. By literally “washing” your teeth as it moves around the mouth, containing ions that neutralise acids from your diet, containing calcium and phosphate that can reverse the effects of acids on your teeth and containing proteins that also impact how molecules interact with your teeth, saliva appears to be an essential factor in maintaining oral health. If dehydration – from vaping or anything else – leads to reduced saliva production, this could have a knock-on effect on your teeth and make tooth decay and other issues more likely.

The paper points out that there a lot of variables to consider and this makes drawing firm conclusions difficult, but the authors write:

“The link between dehydration and dental disease is not directly proved, although there is considerable circumstantial evidence to indicate that such a link exists.”

And this is the closest we can really get to an answer to this question. However, there are some interesting anecdotes in the comments to this post on vaping and your teeth (though the article itself just speculates on the risk for gum disease).

One commenter, “Skwurl,” after a year of exclusive vaping, points out that dry mouth and cotton mouth are common, and this can lead to bad breath and seems to cause issues with tooth decay. The commenter claims to practice good oral hygiene, but of course there’s no way of knowing this, nor what his or her teeth were like before switching to vaping.

However, this isn’t the only story in the comments, and while it’s all speculative, with the evidence discussed above, it’s certainly plausible that vaping can lead to dehydration-related issues with your teeth.

Man drinking a bottle of water

Tips for Looking After Your Teeth as a Vaper

The potential for risk is far from certain, but it’s clear that there are some simple steps you can take to reduce your risk of dental health problems from vaping.

  • Stay hydrated. This is important for any vaper anyway, but given the potential risks related to dehydration, it’s particularly important for your teeth. I keep a bottle of water with me at all times, but however you do it, make sure you fight dry mouth with plenty of fluids.
  • Vape less frequently with higher-nicotine juice. One idea that originally came from Dr. Farsalinos (more broadly about reducing the risk from vaping) is that vaping less often with higher-nicotine juice is safer than vaping more with lower-nicotine juice. For your teeth, this same advice is very valid – the dehydration is related to PG and VG, so the less of it you inhale, the smaller the effect will be. Technically, if the theories about nicotine’s role in gum disease are true, increasing your intake wouldn’t be ideal, but overall it seems nicotine isn’t the important factor.
  • Pay extra attention to your teeth and keep brushing. Although some vapers may have problems, it’s obvious that most of us haven’t experienced issues. The explanation for this is likely that many vapers look after their teeth in general. Brush at least twice a day to minimise any risk and keep an eye out for potential issues. If you notice a problem, go to your dentist and get it sorted out.

The good news is this is all pretty simple, and apart from the second suggestion you’ll probably be doing everything you need to anyway. However, if you start to notice issues or you feel like your teeth are getting worse, taking steps to reduce dehydration and paying extra attention to your teeth is a good idea, in addition to seeing your dentist.

Woman brushing her teeth

Getting Some Perspective: Your Teeth or Your Lungs?

While vaping is likely to be much better for your teeth than smoking, there are still potential issues due to dehydration and even possibly to do with nicotine. However, it’s important to get a bit of perspective before you take any drastic action, especially with so little evidence to back up any concerns.

If you’re switching to a low-risk form of nicotine use, it’s unlikely to be because of your teeth. You have lungs to worry about, not to mention your heart and a lot else. The research so far mainly focuses on these more serious risks. So even if vaping does end up having some effect on your teeth or gums, it won’t change the fact that vaping is a better idea than smoking. There are other priorities.

Look after your teeth – like you should anyway – but don’t lose perspective and forget what’s really important.

Leave a comment:

4 thoughts on “E-Cigs and Your Teeth: Should Vapers Be Worried?

  1. You mentioned that there have only been studies on effects of vaping in vitro, but actually, there was a study released in Dec last year that looked at the oral health of 110 smokers after they started vaping and saw “a progressive improvement in the periodontal indexes, as well as in the general health perception.” Don’t know if you overlooked this one on PubMed, but I’ll leave the link below. Good article otherwise!
    https://www.ncbi.nlm.nih.gov/pubmed/27930577

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