Vaping vs Smoking: Impact on Oral Health

Author: Maria Fasomytaki

Abstract

Smoking is widely recognized as one of the most harmful habits as it can cause long-term negative effects such as cancer, stroke, heart attack, lung disease and other health problems. As expected, the oral cavity has also been affected, since tobacco smoking is a major risk factor for poor oral health, increasing the risk of periodontal disease, tooth loss, oral cancer and delayed wound healing. Recently, there has been a notable rise in the use of electronic cigarettes and it has been observed that it is very popular especially among adolescents. Despite the fact that vaping has been promoted as a safer alternative, its effects on oral health must be explored. This research will compare how traditional smoking and vaping affect different aspects of oral health. Focus areas will include periodontal inflammation, changes in oral microbiome, salivary gland function, implant survival, caries and the risk of potentially premalignant oral lesions. The review will also consider the biological mechanisms and the molecular pathways in the oral epithelium associated with each practice. Although current evidence suggests that vaping may be less damaging than smoking, it is not risk-free. Understanding these differences is important for dentists, who play a key role in prevention and patient’s education. The aim of this review is to clarify what is known so far and identify areas that need further research.

Introduction

The e-cigarette was first produced in China in 2003 by a pharmacist, whose intention was to create an alternative to smoking. It was introduced into Europe and North America in 2006 (Seiler-Ramadas et al., 2020). Since then e-cigarettes have evolved into multiple generations of devices and have gained worldwide popularity, with more than 40 million users reported globally by 2019 and an industry value exceeding $19 billion annually (Holliday et al., 2021).

E-cigarettes were classified according to the U.S. Food and Drug Administration as Electronic Nicotine Delivery Systems (ENDS). ENDS are electronic devices that mimic cigarettes and offer an experience that is similar to conventional smoking (Zhang et al., 2023). These devices are battery operated, which heat nicotine oil (e-liquid) and convert it to vapor, called aerosol that is inhaled by the user. The vapor comprises propylene glycol and/or glycerol, usually with nicotine and flavoring (Almeida-da-Silva et al., 2021). Propylene glycol is a mildly sweet tasting liquid. When it is heated and aerosolized, it can break down into byproducts such as acetic acid, lactic acid and propanol. Glycerin is another colorless liquid, sweeter than table sugar.
The nebulizer of these systems mainly consists of coil and wick made from metals tin, zinc, copper, silver and other heavy metals (Zhang et al., 2023). Repeated heating and cooling cycles can lead metal elements to dissolve into the liquid, which can potentially cause toxic effects (Williams et al., 2013).

Although ENDS are frequently promoted as less harmful to health than smoking, this claim requires careful consideration. The fact that they are odorless, they don’t cause halitosis and they are free of tar, which is a substance of conventional cigarettes widely recognized as carcinogenic, has contributed to their appeal. However, their aerosols still contain a range of chemical byproducts, some of which may have toxic or carcinogenic potential. Recognizing these risks is crucial in dentistry, as the oral cavity is directly exposed to both tobacco smoke and to e-cigarette vapor.

Materials and methods

In the present research articles were searched in PubMed, Elsevier Scopus and Google Scholar databases using the keywords: vape, vaping, e-cigarettes, oral health, cigarettes, tobacco, smoking. Studies published in the last 15 years that address the oral effects of vaping  were selected, including comparisons among tobacco-users, e-cigarette users and non-smokers. Repeated articles, researches prior to 2010 and those in other languages than English were excluded.

Results

PERIODONTAL HEALTH
The periodontium consists of the gingiva and alveolar bone, both of which support the teeth and form a specialized subgingival environment. This sustains a complex microbial community that directly interact with teeth and the level of its diversity is often reflective of oral health status.  Disruption of the microbial balance can lead to pathological conditions of the periodontium, such as gingivitis and periodontitis (Thomas et al., 2022).

Gingivitis is a reversible inflammatory condition of the gingiva with no loss attachment or bone loss as a response to the bacteria that form biofilms at the gingival margin and in the sulcus.
Periodontitis is characterized by loss of periodontal attachment and consequently bone loss due to microbial- associated inflammation (Tonetti et al., 2018).

It is well established that smoking is a risk factor for both gingivitis and periodontitis.
Indeed, a systematic review of Leite et al. (2018) showed that smoking increases the risk of developing periodontitis by 85%.Tobacco smoking has been implicated in periodontal diseases through multiple pathways such as impairing immune and inflammatory responses, altering the subgingival microbial ecology, reducing oxygen supply to the tissues and weakening the healing ability of the tissues (Darby et al., 2022 and Apatzidou et al., 2022).

As far as vaping is concerned, there is not enough evidence to fully characterize its impacts on periodontal tissues (Figueredo et al., 2020). Despite the fact that, a growing number of studies, whose aim was to compare cigarette smokers with e-cigarette smokers and non-smokers, showed that while conventional cigarette smokers exhibit poorer periodontal status and higher levels of proinflammatory cytokines with e-cigarettes smokers and non-smokers, the risk of increased periodontal inflammation in e-cigarettes users compared with never-smokers cannot be dismissed (BinShabaib et al., 2019). In fact, the levels of plaque index, pocket depth, clinical attachment loss, and marginal bone loss were increased in vaping groups compared to non‐smokers (Al‐ AlQahtani et al., 2018, BinShabaib et al., 2019).
Overall, these findings suggest that vaping has detrimental effects on periodontal tissues, although to a lesser extent to conventional smoking, highlighting the need for further studies.

Regarding, how vaping affects the periodontal microbiome, studies suggest that e-cigarette use promotes a stable microbiome that is between those of the cigarette smokers and nonsmokers, while also displaying distinct characteristics that may influence oral health differently than conventional cigarette. Epithelial cell exposes to ENDS aerosols showed increased susceptibility to infection and as a result it has been noticed that E-cigarettes aerosols can modify both the salivary microbiome and host inflammatory responses (Thomas et al., 2022).
In addition, a study demonstrated that the presence of flavors in e-liquids can more strongly disrupt biofilm formation and the growth of oral bacteria, suggesting that these additives may play an important role in the composition of oral microbiome (Fatima et al., 2023).
To sum up, subgingival microbiome of vapers is a hybrid community having similarities with those of both cigarette smokers and nonsmokers.   
Definitely, the uniqueness of the e-cigarette associated periodontal microbiome highlights the need for further research into this novel microbial environment (Thomas et al., 2022).


CARIES
Researchers have found that vaping was associated with a higher risk of dental caries (Irusa et al., 2022). The combination of glycerin and flavoring agent in e-liquid pods leads to an increase in microbial adhesion and in biofilm formation.  Aerosols generated from heated e-liquid are sticky, which promotes the attachment of Streptococcus mutans (a well-known caries associated bacterium) to the enamel, contributing to demineralization and cavity formation.
Indeed, research has shown that despite the fact that glycerol cannot be metabolized by bacteria that cause tooth decay, it has the potential combined with propylene glycerol to demineralize dental enamel and increase the vulnerability to caries (Zhang et al., 2023)

AESTHETIC
Vaping can also negatively affect the appearance of the teeth. The interaction of the enamel with glycerin, nicotine and propanediol contributes to tooth discoloration. Although ENDS do not contain tar- which is a substance of cigarettes and as it is well established it stains the teeth- aerosol can still induce color changes in teeth.
Additionally, the restorations are not unaffected by this phenomenon.  Vaping has an adverse impact on the color stability of restoration materials especially of composite resins. Some studies claim that this discoloration is milder than discoloration caused by smoking, while others suggest that it is comparable to conventional cigarettes’ discoloration (Zhang et al., 2023). It seems that the extent of color change varies and may also be influenced by the flavor of the e-liquid and its nicotine concentration (Yang et al., 2020).

PREMALIGNENT LESIONS AND CANCER
ENDS vapors could have cytotoxic, genotoxic and inflammatory effects on oral tissues. Actually, the World Health Organization recognized heated propylene glycol, a common e-liquid component, as a potential carcinogen. Apart from that, carcinogenic substances, such as N’-nitrosonornicotine and thiocynates, associated with smoking have been detected in the saliva of ENDS users, reflecting biochemical similarities with conventional smoking (Zhang et al., 2023).

Despite the fact that e-cigarettes were initially designed and promoted as a healthier substitute to conventional smoking products, increasing number of evidence demonstrates that their aerosols contain a wide range of toxicants, carcinogens and organic compounds produced through thermal breakdown of solvents, even if their concentrations are generally lower than those detected in tobacco cigarettes.
Comparative studies of e-cigarette aerosol and tobacco smoke report markedly lower levels of certain toxic substances such as formaldehyde, acetaldehyde, acrolein and toluene. Nevertheless, substantial amount of other harmful agents -including toxic metals (aluminum, cadmium, chromium, copper, lead, magnesium, manganese, nickel, and zinc), a number of organic compounds including carbonyls (e.g., acrolein from glycerol/glycerine), and potentially harmful compounds such as silicate beads, tin, and flavorings as well as propylene oxide (from propylene glycol)- have been identified in e-cigarette aerosols, despite their absence in conventional cigarette smoke (Isik Andrikopoulos et al., 2019, Cichońska et al., 2024). These substances may induce epithelial alterations and initiate early stages of malignant development.
Indeed, some case reports have already documented oral cancers in long term e-cigarette users, suggesting that the carcinogenic potential goes beyond theory (Guo et al., 2022).
Elevated salivary levels of IL-1β and TGF-β in these users also reflect an environment that promotes inflammation and supports dysplastic changes and malignant transformation (Kamal et al., 2022). Additionally, PH changes associated with e-liquid exposure have been linked to elevated rates of hyperplastic candidiasis, a lesion with premalignant risk (Iacob et al., 2024).
In summary, even though the levels of toxicants in ENDS vapor are lower than those in smoke, biological reactivity and cancer case reports raise significant concerns about ENDS potential to trigger premalignant changes in the oral cavity.

SALIVARY GLAND FUNCTION AND COMPOSITION OF SALIVA
Saliva plays a vital role in maintaining oral homeostasis by buffering acids, supplying antimicrobial agents and inducing remineralization. Cichońska et al (2024) narrative review on ENDS effects describes how e-cigarette aerosols can impair salivary  function by reducing saliva’s antioxidant and antibacterial abilities, elevating markers of epithelial damage and altering concentrations of IgA and lactoferrin.
Alsenani et al (2025) assessed salivary flow rate, PH and capacity in e-cigarette users and found that vaping was correlated with lower flow rates and decreased buffering ability, which can diminish saliva’s capacity to neutralize acids and maintain microbial balance.
Additionally, research suggests that because of the hygroscopic nature of propylene glycol that is contained in e-liquid, it usually mixes with saliva, leading to dry mouth (Zhang et al., 2023).
Together these findings suggest that vaping may impair both the quantity and the quality of saliva, weakening the oral cavity’s first line of defense and contributing to greater susceptibility to caries, inflammation and mucosal damage.

IMPLANT SURVIVAL
Tobacco consumption negatively affect peri-implant health, with ENDS exhibiting comparable impacts. To be more precise, Cigarette Smokers (CS) and Vaping Smokers (VS) demonstrated significantly higher mean peri-implant plaque scores (PI), probing depths (PD)> 4mm and radiographic bone loss (RBL) compared with Non-Smokers (NS).  Differences in bleeding on probing were also significant between NS and both CS and VS. Both groups also showed elevated concentrations of proinflammatory cytokines such as TNF-a, IL-6 and IL-1βin CS and VS relative to NS, suggesting an enhanced peri-implant response that may play a key role in the progression of peri-implant tissue damage (AlQahtani et al., 2018).
Recent research has further demonstrated that ENDS use is associated with alterations in peri-implant health and in microbial biofilm. Guney et al (2024) found that e-cigarette users have increased peri-implant inflammation and a greater prevalence of pathogenic oral bacteria compared to non-smokers, indicating that vaping disrupts peri-implant homeostasis and contributes to progressive bone loss and as a result to implant failure.
These findings emphasize the importance of including both smoking and vaping in patient risk assessment.

INJURIES BY EXPLOSIONS
Another major risk for human health caused by ENDS is injuries due to e-cigarettes explosions.  Lithium batteries that are used in many ENDS devices are susceptible to thermal runaway, which is a condition that occurs when the internal battery temperature increases (it can rapidly rise to 500oC and more) (Kaltenborn et al., 2023) to the point of causing explosion or fire. According to a systematic review, in 13% of the cases the burns, which were caused by explosion, involved the face (Seitz & Kabir, 2018).Cases of injuries have been reported that include tooth fracture and dislodgment, fracture of alveolar ridge (Colaianni et al., 2016), soft palate damage and lip lacerations (Vaught et al., 2017).

NICOTIN ADDICTION
Nicotine, the primary addictive substance in both traditional cigarettes and e-cigarettes, plays a key role in cigarette dependence. ENDS manufacturers report that a single device can contain an amount of nicotine equivalent to that contained in a full pack of 20 conventional cigarettes (Almeida-da-Silva et al., 2021).
Nevertheless, an analysis of nicotine content in different samples of e-cigarettes refill liquids revealed that over half of them contained concentrations that differed greatly from what is shown on the label. The variation ranged from 66% less than the labeled concentration to 172% higher than what was indicated (Ahmed et al., 2021).
Nicotine exposure during adolescence can disrupt brain regions involved in attention, learning, mood regulation and impulse control. Since the brain continues developing until around age of 25 and synaptic connections strengthen each time a new memory is formed or a skill is learned, nicotine can interfere with proper synapse formation. 
Researches have also shown that early nicotine use may also elevate the risk of developing addictions to other drugs later in life (BinShabaib et al., 2019).

IS IT A METHOD TO QUIT SMOKING?
The evidence regarding the role of e-cigarettes in smoking reduction or cessation remains inconsistent (Ghosh et al., 2017).  Up to now, smaller clinical trials –many of which were not specifically designed to evaluate cessation- have generally failed to demonstrate clear benefits of e-cigarettes use in achieving abstinence from smoking (Orellana-Barrios et al., 2015). Although being marketed by manufacturers as a cessation aids since their introduction, ENDS devices have not received FDA approval for this purpose (Wang et al., 2021).
Findings from surveys and observational studies are similarly contradictory. Some report that e-cigarette users are more likely to quit smoking (Holliday et al., 2021),
while others indicate that e-cigarette use, and especially dual use with tobacco, may actually decrease the probability of successful cessation (Orellana-Barrios et al., 2015).

Discussion

The evidence presented demonstrates that both traditional smoking and vaping have adverse effects on oral tissues, though the extent and underlying mechanisms may differ. Although vaping may expose users to lower levels of certain carcinogenic compounds, it still poses several risks for oral health, including increased caries susceptibility, discoloration of both teeth and restorations and a higher risk of injuries caused by ENDS explosions. The review reveals that e-cigarette aerosols can alter the oral microbiome, elevating the inflammatory response and contributing this way to periodontal diseases, implant failure and to the development of oral lesions.

LIMITATIONS
While this review highlights important aspects regarding the impact of vaping on oral health, certain limitations should be acknowledged.
First of all, there is a lack of consistency in defining vaping. Across studies, the term “e-cigarette user” may refer to individuals who vape occasionally, daily, or have used e-cigarettes for periods ranging from a few weeks to several years. Many studies do not clearly specify duration and frequency, making it difficult to differentiate between short-term and chronic exposure effects (Seiler-Ramadas et al., 2020).
Furthermore, the majority of studies is cross-sectional and they involve small samples, which limits their statistical power. For example, investigations comparing traditional smokers, e-cigarette users and non-smokers have included short observational periods, complicating the effort to evaluate changes in periodontal parameters over time (BinShabaib et al., 2019 and AlQahtani et al., 2018). Follow-up cases rarely exceed six months, which undermines attempts to estimate long-term outcomes with precision (Thomas et al., 2022 and Zhang et al., 2023).
In addition, a major limitation of the review was that there is a reported absence of standards in the production and marketing of e-liquids. Differences in nicotine concentration, flavoring agents and heating coil materials lead to significant variability in the aerosol produced and, consequently, in user exposure levels (Williams et al., 2013 and Zhang et al., 2023). So, the potential risks associated with ENDS e-liquid are not completely understood, due to the novelty and diversity of these products.
Taking all the above into consideration, there is a need for additional high-quality prospective studies with standardized vaping exposure, larger populations and long-term follow ups, in order to provide more reliable, evidence- based data for a deeper assessment of the safety of ENDS.

PREVENTION
Effective control and prevention of the growing trend of e-cigarette use, especially among youths, requires a multiple approach that combines education, clinical involvement and regulatory control. Public health campaigns should emphasize that although vaping may contain fewer toxic compounds than smoking, it can adversely affect the oral cavity (Fatima et al., 2023 and Zhang et al., 2023). Raising awareness among adolescents and their parents is essential, since e-cigarettes are often marketed as a safe alternative to tobacco.
Dentists play a crucial role to this effort. They should record vaping habits in patients’ medical history, inquire about the duration and frequency of use and inform patients about the potential oral consequences. This could help identify early mucosal and periodontal changes associated with vaping (Holiday et al., 2021).
From a regulatory perspective, stronger manufacturing and labeling standards are necessary to manage the heterogeneity to e-liquid composition. To be more specific, policies requiring transparent labeling, restrictions on flavorings appealing to youth and clear warnings about oral and systematic health effects are recommended (Seitz et al., 2018). Moreover, visual evidence and images showing the severity of burns caused by ENDS explosions could serve as a tool for prevention. Seitz et al (2018) suggest that using graphic images can effectively influence attitudes and promote healthier behaviors so as to reduce or even prevent e-cigarette use.

Conclusions and recommendations

The perception among consumers that electronic nicotine delivery systems represent a safer alternative to traditional tobacco products has been a major factor contributing to the rapid growth of e-cigarette use. Public awareness and education about the potential dangers of vaping is crucial. Stronger regulatory efforts are required to prevent youth initiation and to control marketing strategies that usually target young audiences.
As the popularity of vaping continues to rise, it is essential that dentists remain well informed in order to provide their patients with accurate information derived from evidence- based data.
Further research is urgently needed, as several domains are still underexplored. For example, future studies should directly compare the biological effects of e-cigarette aerosols and those of tobacco smoke. The relation between toxicants contained in ENDS aerosols with specific DNA damage also requires better investigation. Research should also examine the effects of various flavorings on oral microbiome composition and on carcinogenic potential.
Because of the current regulatory gap surrounding ENDS products, their safety and quality standards are inconsistent, highlighting the doubts on their reliability.
Overall, the use of e-cigarettes as a safer alternative to smoking remains questionable based on existing evidence and ongoing scientific awareness is essential to protect public and oral health.

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