Smokers are said to have bad teeth. They get "nicotine stains", people often say, that turn their white teeth into dull or yellowish.
Most vapers who encounter comments like this would rightly point out that nicotine in its pure form is actually colorless. It seems evident that, just as with health risks, nicotine is not the source of the problem for the teeth when smoking; rather, it's the tar.
But are we really right? New studies on the subject have flagged up that vaping is a potential problem, and even if the results are far from being able to be tied to dental problems in real-world vapers, it is a sign that dental-care problems could arise in the future.
Here is a short summary of what we know about vaping and how it affects the teeth, the role of nicotine, and what we can do to minimize the risk.
How does smoking affect the teeth?
To understand the potential risks to the teeth from vaping, it is reasonable to learn a little about how smoking causes oral health problems. Although there are many differences between the two – inhaling smoke containing tar is very different from inhaling drops of liquid – vapers and smokers are exposed to nicotine and other chemicals in a similar way.
Smokers have a greater risk of dental problems than those who never smoked or are former smokers. For example, active smokers have four times the risk of having poor oral health compared with people who have never smoked, and they have twice the risk of having three or more oral health problems.
Smoking affects your oral health in many ways; it can cause everything from yellow-brown staining and bad breath to more serious oral health problems such as gum disease (technically called periodontal disease) and oral cancer. Smokers also tend to have more tartar than non-smokers, which is a form of hardened plaque.
There are other effects of smoking that also cause dental problems. For example, smoking affects your immune system and disrupts the mouth’s ability to heal, both of which can worsen other problems caused by smoking.
Smoking and gum disease
Gum disease is one of the most common dental health problems in Sweden and around the world, and smokers have about twice the risk of developing it compared with non-smokers. It involves infection of the gums and the bone surrounding the teeth, which over time leads to tissue and bone breakdown and can cause tooth loss.
The disease is caused by plaque, which is the name for a mixture of saliva and bacteria in the mouth. In addition to causing irritation and inflammation in the gums that characterize gum disease, plaque also directly affects the teeth, leading to cavities.
When you consume foods that contain a lot of sugar or starch, the bacteria break down the carbohydrates in the food into glucose that is used for energy. This process creates acid as a byproduct. If you don't keep your teeth clean, this acid gradually affects the surface of the teeth and causes cavities. But plaque contains many different bacteria, and some of these are also direct causes of irritation to the gums.
Thus, while one consequence of plaque formation is more relevant to gum disease, both lead to dental health problems and smokers are at greater risk of experiencing both consequences than non-smokers. The effects of smoking on the immune system mean that if a smoker develops a gum infection caused by plaque formation, his or her body has less chance to fight it. Additionally, when damage occurs as a result of plaque formation, the effect of smoking on wound healing makes it harder for the gums to heal.
Over time, if gum disease is not treated, pockets can form between the gums and teeth. This problem worsens as more tissue breaks down, and eventually can lead to the teeth becoming loose or even falling out.
Overall, smokers have about twice the risk of periodontal disease compared with non-smokers, and the risk is greater for people who smoke heavily and for longer periods. In addition, the chances of positive outcomes when the problem is treated are smaller.
Smoking and gum disease: Is nicotine the culprit?
Among vapers examining the link between smoking and gum disease, the following question arises: is it the nicotine or the tar in tobacco that causes the problems? Of course, we as vapers would be inclined to blame the smoke and tar rather than nicotine, but would it be right to do so?
There are several theories about the connection between smoking and gum disease:
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Toxins in smoke can directly damage gum tissue.
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Smoke can alter the specific microbes found in plaque or affect how the immune system responds to it.
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Nicotine causes blood vessels to constrict, and this can make it difficult to detect early warning signs (such as bleeding from the gums).
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Nicotine's effect on blood vessels can lead to "hypoxia" – low levels of oxygen in tissues – and this can make the gums susceptible to infections as well as reduce the gums' ability to heal.
Unfortunately it is not entirely clear which explanation or combination of them is the cause of problems in smokers. For vapers this does, however, imply obvious potential benefits. There are far fewer toxins in the vapor, so any problems caused by these will be less severe in vapers than in smokers.
The two last possible explanations are directly tied to nicotine, but there are a couple of things worth noting.
When it comes to the idea that nicotine reduces blood flow and this causes problems, there are some issues. Studies that directly looked at the effect of this on the gums (here ) found either no change in blood flow or small increases. A bonus study is the here which also addresses the topic.
Even though nicotine really causes blood vessels to constrict, the effect of smoking on blood pressure is typically stronger and the blood flow to the gums increases overall. This is the opposite of what would be expected if the explanation were correct and at least suggests that this is not the most important factor in the whole. However, vaping has less effect on blood pressure, so the result may be different for vapers.
The second thought is that the gum tissues receive less oxygen, which causes the problem. Although studies have shown that hypoxia caused by smoking is parallel to how nicotine acts in the body, nicotine is not the only thing in smoke that can have this effect. Carbon monoxide in particular is a component in smoke (but not in vapor) that has exactly the same effect, and hydrogen cyanide is another.
It is not entirely clear which is the culprit, but since wound healing (a closely related problem) is affected in smokers but not in users of nicotine replacement therapy, it is unlikely that nicotine alone causes all the damage or most of the damage.
It is not surprising that much of the discussion on the topic mixes nicotine with smoke, and that makes it hard to determine how big a role nicotine really has. There is not much research looking at this specifically related to vaping, as one would expect, but there is not much research at all related to nicotine without smoke.
Research on vaping and the teeth
First, there have been some studies that specifically look at how vaping affects the teeth. These studies, however, have all taken the form of cell culture studies. These are known as "in vitro" studies (literally “in glass”) and although they are useful for understanding the biological mechanisms underlying the potential health effects of vaping (and other exposures, medications and almost everything), they are a limited form of research. Just because something affects a bunch of cells in a culture does not mean it will have the same effect in a real human body.
With this in mind, a review of the research on vaping and teeth in a March 2017 article summarises the findings. The authors look at research on gum disease, which includes cell culture studies showing that e-liquids have harmful effects on ligament cells and connective tissue in the gums. Aldehydes in the vapor from e-cigarettes can affect proteins and cause DNA damage. All of these effects could theoretically lead to periodontal disease in vapers.
Nicotine also has the potential to cause dental problems, although this too is based on cell studies and studies of people who smoke tobacco. The authors claim that vaping can lead to impaired healing.
But the truth is that we currently do not have much research that specifically looks at vaping, and much of the above is ultimately speculation. It is speculation based on mechanistic studies of how nicotine interacts with cells in the mouth, so it cannot be completely ignored, but the evidence we have so far does not really say much about what will happen to real vapers in practice.
Research on snus and gum health
So how should we respond to the current questions about vaping's potential effects on the teeth? Like the authors of the above-mentioned article, we are largely limited to speculation as well. But not entirely.
If nicotine is the cause of the dental problems that smokers experience — or at least contributes to these problems — then we should see signs of the problems in others who use nicotine without smoking. Snus — the Swedish variant of smoke-free tobacco in a tiny teabag-like pouch — and nicotine gums provide two excellent sources of research we can use to investigate the question in more detail.
Overall, the research does not seem to point to nicotine. One study reviewed 20 years of research in Sweden, with a total of over 1600 participants, and found that while serious gum disease was more common among smokers, snus users did not appear to have an increased risk. There are signs that gum recession and loss of periodontal attachment are more common where snus is used, but overall the likelihood of experiencing these problems is much more related to smoking than snus use.
Although this has not been studied as much as you might think, a study of nicotine gum users provides even more evidence that nicotine isn't really the problem. Chewing sugar-containing gum clearly has the potential to affect the teeth even without nicotine, but a comparison of 78 people who chewed nicotine gum for 15 weeks with 79 who chewed non-nicotine gum found no difference in things like plaque, gingivitis, tartar and other oral health-related conditions. Again, smoking increased the risk of tartar and gingivitis.
Overall, even though there are some credible explanations for how nicotine could affect oral health, the link is not fully supported by studies. This is good news for all vapers, snus users or long-term nicotine replacement users, but it is clearly still important for your oral health to avoid smoking and to take care of your teeth in general.
Dehydration linked to the teeth: will vaping indirectly affect our teeth?
When it comes to nicotine the evidence we have so far suggests there is nothing to worry about, and the cell studies that directly look at vaping are hard to draw conclusions from without further research. But these are not the only ways that vaping can affect the teeth and oral health.
One thing most vapers know is that vaping can dry out the mouth. Both PG and VG are hygroscopic, which means they absorb moisture from their immediate surroundings. That is why it is very common to have a dry mouth after vaping. Your mouth is constantly in contact with PG and VG and most vapers quickly get used to drinking more than usual to compensate. The question is: does this constant dehydration pose a risk to your teeth?
There is an interesting document about the potential link between mild dehydration and dental health problems, and it emphasizes overall that there is no direct evidence of a connection. However, there are many indirect proofs and findings that point to potential problems.
It basically comes down to saliva. By literally "washing" the teeth as it moves around the mouth, containing ions that neutralize acids from food, containing calcium and phosphate that can neutralize the effects of acids on the teeth, and containing proteins that also affect how molecules interact with the teeth, saliva appears to be an important factor in maintaining good oral health. If dehydration – due to vaping or anything else – leads to reduced saliva production, this could have a devastating effect on the teeth and increase the risk of tooth loss and other problems.
The document notes that there are many caveats to consider, which makes it hard to draw firm conclusions, but the authors write:
"The direct link between dehydration and dental diseases is not proven, although there are significant indications suggesting that such a link exists."
And this is the closest we can really get to an answer to this question. There are, however, some interesting reports in the comments to this post about vaping and teeth (even though the article itself only speculates about the risk of gum disease).
One commenter, "Skwurl", states, after vaping exclusively for a year, that dry mouth is common, which can lead to bad breath and seems to increase the risk of cavities. The commenter claims to be careful with good oral hygiene, but of course it is impossible to verify this, or know the condition of his/her teeth before switching to vaping.
But this is not the only story in the comments, and even if everything is just speculation, including the research discussed above, it is certainly likely that vaping can lead to dehydration-related dental problems.
Tips on how to take care of your teeth as a vaper
The risk is far from obvious, but it is clear that there are some simple steps you can follow to reduce the risk of dental problems from vaping.
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Stay hydrated. It is anyway important for all vapers, but given the potential dehydration-related risks it is particularly important for the teeth. I carry a bottle of water with me all the time, but in any case, make sure to combat dry mouth with plenty of fluids.
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Vape less often with higher-nicotine juice. An idea that originally comes from Dr. Farsalinos (largely about reducing the risk from vaping) is that vaping less often with higher-nicotine juice is safer than vaping more often with juice with lower nicotine content. For the teeth the same advice applies – dehydration is linked to PG and VG, so the less you inhale the less the effect. Technically, if the theories about nicotine's role in gum disease are true, it would not be good to increase nicotine intake, but overall it seems nicotine is not the key factor.
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Take care of your teeth in the best possible way and keep brushing. Even if some vapers may have dental problems, it is clear that most of us have not experienced any problems. The likely explanation is that many vapers in general take care of their teeth. Brush at least twice a day to minimize the risk and watch for potential problems. If you notice a problem, visit your dentist and have it treated.
The good news is that all of this is fairly simple, and aside from the second suggestion you will probably do everything you anyway need to do. But if you start to notice problems or feel that your teeth are getting worse, it is a good idea to take action to reduce dehydration and take better care of your teeth, in addition to visiting your dentist.
Get a little perspective: the teeth or the lungs?
Although vaping is likely much better for the teeth than smoking, there are still potential problems linked to dehydration and possibly even nicotine. It is, however, important to gain some perspective before taking drastic actions, especially with so little research supporting the concerns.
If you are going to switch to a low-risk variant of nicotine use, it is unlikely to be because of the teeth. You have the lungs to worry about, not to mention the heart and much else. The research so far focuses mainly on these more serious health risks. So even if vaping really did have any effect on your teeth or gums, it will not change the fact that vaping is a better idea than smoking. There are other priorities.
Take care of your teeth – as you should anyway – but don't lose perspective and don't forget what is really important.
