E-cigarettes and oral health

DOI: 10.3238/dzz-int.2019.0207-0208

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Introduction

E-cigarettes are battery-operated devices that heat up chemical solutions, which are referred to as liquids. Aerosols in different flavors are produced, many of which can contain nicotine [6]. A survey in Germany indicated a population of 1,4 % that use e-cigarettes regularly, which corresponds to approximately one million people in Germany. The main users of e-cigarettes are between the ages of 20 and 60 years [5]. The American PATH-study of 2018 indicated, that 1,7 % of participants solely smoked e-cigarettes and 1,4 % smoked cigarettes as well as e-cigarettes in their daily lives. [1]. E-cigarettes are a common and established phenomenon in the population [11]. Due to frequent use and recent development, the question is raised of what effect this has on oral health.

Statement

The process of „vaping“ produces aerosol, which contains fine particles, rather than tobacco smoke [1]. The basic ingredients include propylene glycol, glycol, nicotine and various flavors [3]. It is important to differentiate ingredients because liquids can differ greatly. Studies suggest that propylene glycol in general is harmless for children and adults, however, it can induce rhinitis, asthma, eczema and allergic reactions. Further- more, nicotine extracts from tobacco contain impurities such as cotinine, anabasine, anatabine, myosmine and heavy metals [7].

Ganapathy et al. (2017) investigated the effect of e-cigarette extract in bronchial epithelial cells (NuLi-1) and in cells of the squamous cell carcinoma of the oral cavity (UM-SCC-1). The extracts testes induced significant increases of dose-depen­dent DNA-damage in cells. It was determined that extracts from e-cigarettes caused less DNA damages than extracts from regular cigarettes. E-cigarette extracts cause a significant increase of reactive oxygen species (ROS) and lower the cellular antioxidative capacity. This resulted in a significant increase in 8-hydroxydesoxyguanosin level, which causes one of the most common mutagenic DNA lesion [6]. Munakata et al. (2018) measured a rise in concentration of IL-8 and makrophage colony-stimulating factor (GM-CSF) in bronchial epithelial cells (BEAS-2B) [9]. In healthy study participants a one-time e-cigarette use caused an increased number of endothelial progenitor cells in the blood, which is a sign for a potential vascular change, according to Antoniewicz et al. (2016). After 24 h the progenitor cell count returned to the level of the control group [4].

Furthermore, first conclusions on the impact of e-cigarettes on the oral cavity and enamel were drawn. The working group of Sancilio et al. (2016) investigated the effect of e-liquids on humane gingiva fibro­blasts (HGF). A dose-dependent reduction of 20 % of the HGF activity was determined for liquids with and without nicotine. The apoptotic percentage of HGF-cells increased just like the prevalence of the pro-apoptotic Bax protein [10]. Kim et al. (2018) examined how the use of e-cigarettes impacts healthy enamel and the oral flora. Enamel samples of extracted, cavity-free wisdom teeth were exposed to the aerosol of e-cigarettes (10 drags and 150 drags) and subsequently cultivated with S. mutans in corrugated sheets. The aerosols formed a viscous surface that significantly increased the adhesion of S. mutans on enamel surfaces. Besides facilitated bacteria adhesion, Kim et al. noted that the used flavors (such as sucralose, ethyl butyrate, triacetin, hexylacetate) and their metabolites have a significant impact on surface hardness of the enamel sample. It was found that the hardness decreased by up to 21,5 % [8]. The working group of Willershausen et al. (2014) investigated the effect of menthol as an additive: The menthol additive in the liquid causes a significant reduction of the proliferation rate of periodontal ligament cells (PDL). Due to these results the working group recommends to not use menthol as an additive in the liquid of e-cigarettes [13].

Besides the effect on the enamel, Al Qahtani et al. (2018) also determined insights on the impact on the periodontium. The percentage of prob­ing depths ≥ 4 mm was increased significantly in hookah smokers (7,0 % ± 1,1 %) and cigarette smokers- (7,8 % ± 1,2 %) or rather e-cigarette smokers (5,3 % ± 1,5 %), when compared to non-smokers (4,4 % ± 0,6 %). The plaque index also showed significantly higher values for all smoking habits. E-cigarette smokers exhibit a plaque index of 51,9 % ± 10,2 %, while it was 34,1 % ± 14,7 % in non-smokers. The concentration of cytokines in the patients’ periimplanted sulcus fluid was also examined. All smoking habits caused a significant rise of proinflammatory cytokines TNF-α, IL-1β and IL-6. The total volume of sulcus fluid also increased significantly [2].

Summary

The present findings from in-vitro and in-vivo investigations allow an initial assessment of potential consequences of the use of e-cigarettes. Currently, electronic smoking devices cannot be seen as a safe means to quit smoking due to potentially harmful effects [12]. Longterm studies are necessary for substantiated statements concerning oral health. In addition, the assessment of e-cigarettes is hampered by the usage of additives and their relevant variations in composition and effect [8, 9, 13].

References

  1. Akinkugbe AA: Cigarettes, e-cig­a­rettes, and adolescents‘ oral health: Findings from the Population Assessment of Tobacco and Health (PATH) study. JDR Clin Trans Res 2018: 2380084418806870
  2. AlQahtani MA, Alayad AS, Alshihri A, Correa FOB, Akram Z: Clinical peri-implant parameters and inflammatory cytokine profile among smokers of cigarette, e-cigarette, and waterpipe. Clin Implant Dent Relat Res 2018; 20: 1016–1021
  3. Antoniewicz L, Brynedal A, Hedman L, Lundbäck M, Bosson JA: Acute effects of electronic cigarette inhalation on the vasculature and the conducting airways. Cardiovasc Toxicol 2019. doi.org/10. 1007/s12012–019–09516-x
  4. Antoniewicz L, Bosson JA, Kuhl J et al.: Electronic cigarettes increase endo­thelial progenitor cells in the blood of healthy volunteers. Atherosclerosis 2016; 255: 179–185
  5. Eichler M, Blettner M, Singer S: The use of e-cigarettes. Dtsch Arztebl Int 2016; 113: 847–854
  6. Ganapathy V, Manyanga J, Brame L et al.: Electronic cigarette aerosols suppress cellular antioxidant defenses and induce significant oxidative DNA dam­age. PLoS ONE 2017; 12: e0177780
  7. Hajek P, Etter J-F, Benowitz N, Eis­senberg T, McRobbie H: Electronic cig­arettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction 2014; 109: 1801–1810
  8. Kim SA, Smith S, Beauchamp C et al.: Cariogenic potential of sweet flavors in electronic-cigarette liquids. PLoS ONE 2018; 13: e0203717
  9. Munakata S, Ishimori K, Kitamura N, Ishikawa S, Takanami Y, Ito S: Oxidative stress responses in human bronchial epithelial cells exposed to cigarette smoke and vapor from tobacco- and nicotine-containing products. Regul Toxicol Pharmacol 2018; 99: 122–128
  10. Sancilio S, Gallorini M, Cataldi A, Di Giacomo V: Cytotoxicity and apoptosis induction by e-cigarette fluids in human gingival fibroblasts. Clin Oral Investig 2016; 20: 477–483
  11. Schraufnagel DE, Blasi F, Drummond MB et al.: Electronic cigarettes. A position statement of the forum of international respiratory societies. Am J Respir Crit Care Med 2014; 190: 611–618
  12. Sultan AS, Jessri M, Farah CS: Elec­tronic nicotine delivery systems: Oral health implications and oral cancer risk. J Oral Pathol Med 2018 Dec 3. doi: 10.1111/jop.12810. [Epub ahead of print]
  13. Willershausen I, Wolf T, Weyer V, Sader R, Ghanaati S, Willershausen B: Influence of e-smoking liquids on human periodontal ligament fibroblasts. Head Face Med 2014; 10: 39

Translation: Yasmin Schmidt-Park

Citation: Behnke R, Lang H: E-cigarettes and oral health. Dtsch Zahnärztl Z Int 2019; 1: 207–208

DOI.org/10.3238/dzz-int.2019.0207–0208

richard Behnke

University Medicine Rostock

Polyclinic for Dental Preservation

and Periodontology

Strempelstr. 13, 18057 Rostock

Richard.Behnke@med.uni-rostock.de

(Photo: private)

Prof. Dr. Hermann lang

University Medicine Rostock

Polyclinic for Dental Preservation

and Periodontology

Strempelstr. 13, 18057 Rostock

Hermann.Lang@med.uni-rostock.de

(Photo: private)


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