FACT SHEET: Vaping (involves use of “electronic nicotine delivery systems” or “electronic cannabinoid delivery systems”, such as “electronic cigarettes” [e-cigarettes], “vape pens”, and “advanced personal vaporizers” [mods])
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
Is medical consult advised?
- No, in most cases.
- Yes, if there are signs/symptoms of respiratory compromise (e.g., cough, shortness of breath, or chest pain).
- Yes, if the patient/client indicates a desire to end his/her nicotine addiction or otherwise stop vaping.
Is the initiation of invasive dental hygiene procedures contra-indicated?**
Is medical consult advised?
- See above.
Is medical clearance required?
Is antibiotic prophylaxis required?
Is postponing treatment advised?
- No, in most cases.
- Yes, if there is significant shortness of breath or other possible vaping-associated pulmonary manifestations that may compromise safety of the invasive procedures or require urgent/emergent management. Elective oral healthcare should be postponed until the shortness of breath, or other possible serious vaping-related signs/symptoms, has been medically addressed or has abated.
Oral management implications
- The dental hygienist should incorporate questions about vaping in the medical history. Black market vape juices (whether nicotine- or cannabis-containing) are at particular risk of containing harmful adulterants and contaminants.
- The dental hygienist should inform patients/clients that vaping negatively impacts oral health. Use of e-cigarettes is also associated with initiation of smoking in previous non-smokers. Vaping (and smoking, as applicable) cessation should be encouraged (particularly if vaping is being undertaken for recreational purposes)1, and harm reduction can be achieved with vaping devices that do not contain nicotine. However, the dental hygienist should be careful not to be judgmental of patients/clients who vape (and/or smoke).
- Whether vaping is being undertaken recreationally or as part of a medically sanctioned method of smoking cessation or harm reduction (which is much less common), management of xerostomia and proactive maintenance of dental hygiene are important. This includes regular professional dental hygiene care and visits to monitor oral health.
- Plaque index is typically increased in patients/clients who vape.
- While carcinogens appear to be reduced in e-cigarettes compared to combustible cigarettes, the oral healthcare practitioner should be alert for signs/symptoms of oral cancer, particularly given the high prevalence of dual use.
- The dental hygienist should be alert for signs/symptoms of respiratory distress (e.g., shortness of breath, cough, and chest pain) in patients/clients who use e-cigarettes, with medical referral occurring as indicated.
- Xerostomia results from the moisture absorbency effects of propylene glycol (PG) or vegetable glycerin (VG, or glycerol) contained in e-liquids (i.e., vape juice). In turn, this places the patient/client who vapes at elevated risk of periodontitis, gingivitis, and viral and fungal (such as oral candidiasis) infections.
- Increased susceptibility to microbial infection results from the reduction in blood supply caused by nicotine exposure. Dry mouth is another sequela of reduced blood flow.
- Other oral manifestations linked to vaping include: gingival ulcers, gingival bleeding, gingival pain, tongue pain, inside-cheek pain, increased plaque build-up, increased dental caries2, tooth infection, and increased incidence of cracked and broken teeth3.
- Altered enamel colour and reduced luminosity have been shown to result from aerosols with various nicotine contents and flavours. Flavoured liquids cause the greatest colour change.
- Sensitive teeth have been reported by some users of e-cigarettes.
- Sore and dry throat are common complaints.
- Bruxism results from nicotine stimulation of jaw muscles.
Related signs and symptoms
- Vaping is the act of inhaling and exhaling an aerosol produced by a vaping device when a liquid (known as “e-liquid”, “e-juice”, or “vape juice”), usually flavoured, is heated. The aerosol is inhaled through the mouth and lungs and partially absorbed in the bloodstream, with the remaining aerosol being exhaled. Vape juice is typically comprised of a humectant carrier solution (usually propylene glycol and/or vegetable glycerin), chemical flavourants, and additives (most notably nicotine and/or cannabis derivatives); adulterants and contaminants may also be present. Carcinogens and toxic chemicals (e.g., formaldehyde and acetaldehyde) are present in vape juice aerosols, albeit at generally lower concentrations than are found in cigarette smoke.
- While most vaping devices are used to inhale nicotine-containing vape juices, cannabinoid-containing vape juices can also be consumed in this way.
- In Canada, federal regulation is minimal regarding the composition, quality, design, and manufacture of e-cigarettes and e-liquids. Federal regulation is mainly limited to restrictions on advertising and age for distribution4, and provincial legislation varies widely.
- In Ontario, provincial legislation5 specifies that the legal age of purchase of e-cigarettes (and their associated components, including e-juice) is 19 years of age (similar to tobacco-containing combustible cigarettes and cannabis). Under regulatory changes effective in July 2020, candy and fruit-flavoured e-liquids — generally considered to be aimed at teens — are limited to specialty adults-only vape and cannabis stores. However, other Ontario retail stores are still able to sell, in nicotine concentrations below 20 mg/mL, tobacco-, menthol-, and mint-flavoured vape products.
- Vaping is common in Ontario (and Canada), and it is increasing. Vaping among Ontario teens doubled between 2017 and 2019, from 11% to 23%. In 2017, 4.6 million Canadians aged 15 years and older acknowledged having tried an e-cigarette.
- While a consensus has emerged that e-cigarettes are safer than combustible cigarettes, it remains controversial whether e-cigarettes should be recommended as a first-line treatment to aid smoking cessation.
- Although e-cigarettes may assist with smoking cessation, there is growing evidence that recreational vaping leads to harm. Furthermore, the variety of pathologies associated with use suggests that the ability of e-cigarettes to harm the lungs isn’t limited to any one product or contaminant.6 These acute or near-term pathologies include EVALI (“e-cigarette, or vaping, product use-associated with lung injury”)7 and vaping-associated bronchiolitis (i.e., bronchiolitis obliterans or “popcorn worker’s lung”)8. Long-term, direct health risks caused by vaping are expected to take many years to become apparent.9
- Cough, shortness of breath, and chest pain are potential signs/symptoms of adverse pulmonary effects of vaping.
- Nicotine is a highly addictive chemical, and vaping with nicotine-containing solutions leads to dependence. Non-smokers aged 14 to 30 years who use e-cigarettes have a greater than three-fold increase in the initiation of cigarette smoking.
- Children and youth are particularly vulnerable to nicotine’s effects on the brain, including alterations to brain development and influences on memory and concentration.
- Vapers (and smokers) are at higher risk of serious illness and complications from coronavirus (i.e., Covid-19) infection. Both vaping and smoking cause lung tissue inflammation, increasing susceptibility to pulmonary infection.
References and sources of more detailed information
- College of Dental Hygienists of Ontario
- Rouabhia M. Impact of Electronic Cigarettes on Oral Health: A Review. J Can Dent Assoc. 2020;86:k7.
- Cho JH. The association between electronic-cigarette use and self-reported oral symptoms including cracked or broken teeth and tongue and/or inside-cheek pain among adolescents: A cross-sectional study. PLoS ONE. 2017;12(7):e0180506.
- Chaffee BW. Electronic Cigarettes: Trends, Health Effects and Advising Patients Amid Uncertainty. J Calif Dent Assoc. 2019;47(2):85-92.
- Aloosh J, Johnston J, Harvey B. Five Things to Know About … E-cigarettes. CMAJ. 2019: October 15;191:E1136. doi: 10.1503/cmaj.190552
- Standbrook MB. Vaping-Associated Lung Illnesses Highlight Risks to All Users of Electronic Cigarettes (editorial). CMAJ. 2019 December 2;191:E1319-20. doi: 10.1503/cmaj.191503
- Landman ST, Dhaliwal I, Mackenzie CA, Martinu T, Steele A, Bosma KJ. Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth. CMAJ. 2019: December 2;191:E1321-1331. doi: 10.1503/cmaj.191402
- Borrelli B, O’Connor GT. E-Cigarettes to Assist with Smoking Cessation (editorial). N Engl J Med. 2019;380:678-679.
- Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019;380:629-637.
- Drazen JM, Morrissey S, Campion EW. The Dangerous Flavors of E-Cigarettes (editorial). N Engl J Med. 2019;380:679-680.
- Hammond D, Reid JL, Rynard VL, et al. Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys. BMJ. 2019;365:I2219
- Soneji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr. 2017;171:788-797.
- Wang JB, Olgin JE, Nah G, et al. Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the Health eHeart Study. PLoS One. 2018;13(7):e0198681. Published 2018 Jul 25. doi:10.1371/journal.pone.0198681
- Centre for Advanced Dental Research and Care, Mount Sinai Hospital
- Ontario Dental Hygienists’ Association
- Government of Ontario
- Government of Canada
- BC Centre for Disease Control
- American Lung Association
https://www.medscape.com/viewarticle/925562 (Protecting Youth From e-Cigs: 5 Things to Know)
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St. Louis: Elsevier Mosby; 2013.
1 The Canadian Cancer Society, facilitated by Government of Ontario funding, offers a free, confidential Smokers’ Helpline for vapers (and smokers) in Ontario via TeleHealth Ontario at 1-866-797-0000 or 1-877-513-5333. Smokers’ Helpline Online is available at www.smokershelpline.ca.
2 Vaping alters the oral microbiome. E-cigarette aerosols containing propylene glycol or vegetable glycerin increase adhesion of Streptococcus mutans to enamel and promote biofilm formation. In addition, sucrose, sucralose, and sugar alcohol are additives to e-cigarette liquids, which are used to enhance taste and fragrance.
3 Nicotine may be a contributing factor to increased incidence of cracked and broken teeth given its adverse effects on dentin matrix synthesis and mineralization in dental pulp cells. Nicotine also enhances Streptococcus mutans biofilm formation, which in turn increases the risk of caries. In addition, xerostomia may contribute to cracked or broken teeth. Furthermore, lead solder in some electronic cigarettes is hypothesized to contribute to damaged teeth in adolescent vapers, given that environmental lead exposure is associated with increased incidence of dental caries. Direct dental trauma from the vaping device itself may also play a role in cracking and chipping of teeth.
4 Vaping products that do not contain cannabis were initially regulated federally in Canada in 2018. Cannabis extracts, such as vaping products, became legal for sale in Canada in 2019.
5 Smoke-Free Ontario Act
6 Case reports of vaping-associated lung pathology describe varied patho-physiological mechanisms, which may be from the reactions of individuals to different causative agents in e-cigarettes. Some potential causes of pulmonary injury from vaping include e-liquid
- carrier solution (e.g., propylene glycol and vegetable glycerin)
- flavourants (e.g., diacetyl; 2,3-pentanedione; and acetoin)
- additives (e.g., nicotine; tetrahydrocannabinol; cannabidiol; butane hash oil; and other oil-rich additives)
- adulterants (e.g., vitamin E acetate, a tetrahydrocannabinol adulterant)
- aerosol emissions (e.g., carbonyls from heating propylene glycol and vegetable glycerin; particulates; trace metal elements; and volatile organic compounds [VOCs])
- contaminants (e.g., bacterial endotoxins and fungal glucans).
7 EVALI is characterized by shortness of breath, cough, fever and chills, vomiting, diarrhea, headache, dizziness, chest pain, and rapid heart rate. The epidemic in the United States, with cases also occurring in Canada, has been linked to vitamin E acetate in cannabis oil. More than 1,800 persons in the USA — most younger than 35 years and 14% under the age of 18 — had been sickened as of October 2019, many of them critically. At least 37 affected persons died.
8 Vaping-associated bronchiolitis may present with intractable cough, progressive shortness of breath, and malaise. Fever, increased heart rate, and hypoxemia may then ensue.
9 Electronic cigarettes were introduced to North America in the early 2000s (and only federally regulated/legalized in Canada in 2018/2019). Knowledge regarding the long-term health consequences of using these devices is still evolving.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.