Nicotine - Oral Health

Are alternative nicotine products safer than smoking? Can switching to alternative products improve oral health?

• Awareness Days/Weeks/Months of Interest:
  • March 20 - World Oral Health Day
  • April (US) - Oral Cancer Awareness Month
  • April (US) - Oral, Head, and Neck Cancer Awareness Week/Month
  • November (UK) - Mouth Cancer Action Month

ENDS NVP ANDS E-Cigarettes

2023: The risk profile of electronic nicotine delivery systems, compared to traditional cigarettes, on oral disease: a review

• Relevant studies indicated that patients using ENDS have better preservation of alveolar bone height compared with traditional smokers.
• Overall, ENDS appear to be more implant-friendly than conventional tobacco cigarettes
• Many of the carcinogens present in tobacco are not present in the aerosol generated by ENDS, which makes ENDS appear to be less damaging to the oral mucosa.

2022: Electronic cigarettes: an update on products, regulation, public health approaches and oral health

• Regulatory approaches vary considerably around the world but in the UK and Europe, e-cigarettes are regulated as consumer or medicinal product, and their use is permitted. In the UK, e-cigarettes have increasingly been supported by public health institutions for smoking cessation as part of a Tobacco Harm Reduction strategy.
• The potential harms (including to oral health) from e-cigarette use are likely to be much less than from tobacco cigarettes.

2022: Electronic Cigarette Use Promotes a Unique Periodontal Microbiome

• Our results demonstrate that the e-cig user’s subgingival microbiome is a unique amalgamation of microbiota, containing similarities to those of both conventional smokers and nonsmokers. Due to many shared features with the conventional smoker’s microbiome and considering the widespread promotion of e-cigarettes as a “healthier” alternative to or replacement for conventional cigarettes, our results show that e-cigarette use may promote a healthier SGP [subgingival plaque] microbiome with respect to that of smokers but not compared to that found with never smoking in the first place.

2021: Electronic Cigarettes and Oral Health

• However, for smokers with existing oral diseases, the major benefits of quitting tobacco smoking are likely to outweigh any negative impacts from e-cigarette use, particularly over the short term. Hence, if a smoker is keen to use an e-cigarette as part of a quit attempt, we consider (according to currently available evidence) that they should not be discouraged from doing so based on oral health concerns.

2019: Influence of Electronic Cigarettes on Selected Antibacterial Properties of Saliva

• Lowering the level of IgA in saliva may lead to a weakening of the specific immune response and cause earlier development of more severe periodontitis. In our research, it was observed that the tobacco smokers’ level of salivary IgA was statistically significantly lower in comparison to the values in both the control group and the group of e-cigarette users. IgA content in the saliva of e-cigarette users was not statistically significant lower compared to the control group. This indicates that electronic cigarettes compared to traditional cigarettes have less effect on IgA concentration in saliva.

2019: A lower impact of an acute exposure to electronic cigarette aerosols than to cigarette smoke in human organotypic buccal and small airway cultures was demonstrated using systems toxicology assessment

• Overall, the study demonstrated that exposure to undiluted test mix or base EC aerosols under the testing conditions (an acute 28-min exposure), even at a deposited nicotine concentration that is 200 times greater than that found in the saliva of EC users, had no impact on morphology of buccal and small airway cultures. In contrast, following the same puff number, the already diluted 3R4F CS resulted in overt tissue damage.
• The study was funded by Philip Morris International. The MarkTen® EC devices were manufactured and provided by Altria Client Services LLC. All authors are paid employees of Philip Morris International R&D, or Altria Client Services LLC.

2019: A Comparison of Flavorless Electronic Cigarette-Generated Aerosol and Conventional Cigarette Smoke on the Planktonic Growth of Common Oral Commensal Streptococci

• A potential implication of these results is that flavorless E-liquids and their generated aerosol induce less tooth decay and periodontal disease than traditional cigarette smoke.
• A case for improving oral health (and overall health) could be made by federal health regulatory agencies for promoting the use of electronic nicotine delivery systems over the use of traditional cigarettes as a means of harm reduction.

2019: Effect of nicotine on human gingival, periodontal ligament and oral epithelial cells. A systematic review of the literature

• According to findings from in vitro studies, nicotine, at levels found in tobacco smokers, nicotine replacement therapy users and e-cigarette users, is unlikely to be cytotoxic to human gingival and periodontal cells, though saliva levels in smokeless tobacco users may be high enough to achieve cytotoxicity. There was limited and contradictory evidence for nicotine effects on cell attachment, proliferation and inflammatory mediator production.

2019: Impact of cigarette smoking and vaping on the outcome of full-mouth ultrasonic scaling among patients with gingival inflammation: a prospective study

• There are no studies that have assessed the oral soft tissue response to full-mouth ultrasonic scaling (FMUS) among cigarette-smokers (CS) (group 1), individuals vaping electronic-cigarettes (E-cigs) (group 2), and never-smokers (NS) (group 3). The aim was to assess the impact of cigarette smoking and vaping on periodontal tissues following FMUS.
• Following FMUS, gingival inflammation is worse in CS compared with individuals vaping E-cigs and NS.

2019: Clinical periodontal status and gingival crevicular fluid cytokine profile among cigarette-smokers, electronic-cigarette users and never-smokers

• Periodontal status is poorer and GCF levels of proinflammatory cytokines are higher in cigarette-smokers compared with electronic-cigarette smokers and never-smokers. However, the probability of increased periodontal inflammation and GCF proinflammatory cytokine levels in electronic-cigarette users than never-smokers cannot be annulled.

2018: Comparative study of the effects of cigarette smoke and electronic cigarettes on human gingival fibroblast proliferation, migration and apoptosis

• The damage to gingival fibroblasts was greater with conventional cigarette smoke condensate than with nicotine-rich e-vapor condensate.

2017: Comparison of Periodontal Parameters and Self-Perceived Oral Symptoms Among Cigarette Smokers, Individuals Vaping Electronic Cigarettes, and Never-Smokers

• To the authors’ knowledge, there are no studies that have compared periodontal parameters and self-perceived oral symptoms (OSs) among cigarette smokers (CSs) (group 1), individuals exclusively vaping electronic cigarettes (group 2), and never-smokers (NSs) (group 3).
• Periodontal inflammation and self-perceived OSs were poorer among CSs than among vaping individuals and NSs.

2016: Electronic Cigarette: Role in the Primary Prevention of Oral Cavity Cancer

• Cigarette smoke has been identified as the main cause of oral cavity carcinoma. ...in our in vivo study, the oral cavity cells of e-cigarette smokers showed CMN and TMN values similar to those of healthy controls, indicating the safety of e-cigarettes. The use of electronic cigarettes seems to be safe for oral cells and should be suggested as an aid to smoking cessation.

2015: Oral Health Foundation: (Formerly known as the British Dental Health Foundation)

• "Smoking is the cause of many serious oral health problems, including worsening gum disease, which is one of the most common causes of caries in UK adults. It is also responsible for the majority or mouth cancers and is the direct cause of thousands of deaths every year. Every year almost seven thousand people in the UK are diagnosed with mouth cancer, and it leads to more deaths than testicular and cervical cancer combined."
• "We need to spread the message that e-cigarettes, while not risk free, are much less harmful than smoking, as currently nearly half the population are not aware of this… The British Dental Health Foundation believe that there is a long way to go to before we get to a smoke-free lifestyle but any way which smoking numbers can be cut, and therefore lives saved, is positive and one which we will support.”

HnB THP HTP Heated Tobacco Products

2018: Assessment of enamel discoloration in vitro following exposure to cigarette smoke and emissions from novel vapor and tobacco heating products

• For the first time, diverse NGPs [next generation tobacco and nicotine products] across the risk continuum were assessed in vitro for their impact on enamel staining. CS exposure significantly increased the level of bovine enamel sample discoloration, whereas THP1.0 [tobacco heated product] or NVP [nicotine vapor product] exposure resulted in values comparable to the controls.
• This study was funded by British American Tobacco (BAT) R&D, Southampton. Experimental work was performed at BAT R&D and Intertek CRS, UK. All authors are employees of BAT, Intertek CRS or Borgwaldt KC GmbH.

Nicotine

2021: Potential Suppressive Effect of Nicotine on the Inflammatory Response in Oral Epithelial Cells: An In Vitro Study

• HSC-2 cell viability was not impaired by nicotine at the concentrations usually observed in smokers; increased expressions of IL-8 and ICAM-1 induced by P. gingivalis LPS or TNF-α were diminished by nicotine treatment. Additionally, an inhibitory effect on β-defensin production was also demonstrated. Apart from being the usually alleged harmful substance, nicotine probably exerted a suppressive effect on inflammatory factors production in HSC-2 cells.
• Acknowledgement: This research was supported by the grant from Ministry of Science and Technology of China under a contract from the International Science & Technology Cooperation Program Foundation Nr.1019 and the National Natural Science Foundation of China (Grant No. 81500859).
• Citation: An, N., Holl, J., Wang, X., Rausch, M. A., Andrukhov, O., & Rausch-Fan, X. (2021). Potential Suppressive Effect of Nicotine on the Inflammatory Response in Oral Epithelial Cells: An In Vitro Study. International Journal of Environmental Research and Public Health, 18(2), 483. https://doi.org/10.3390/ijerph18020483

Nicotine Gum

2012 Randomized controlled trial to evaluate tooth stain reduction with nicotine replacement gum during a smoking cessation program

• The results of this study confirm that chewing the tested nicotine replacement gum as recommended in a ‘real world’ active smoking cessation program produces a statistically significant change in the parameter of whitening as measured by change from baseline versus the negative control (Microtab) following 6 weeks in a smoking cessation programme. The Vita® Shade Guide (the secondary outcome measure) supported the trend of stain improvement. These results support the efficacy of the tested nicotine replacement gum in stain reduction, in arresting the progression of tooth stain and in shade lightening.
• Acknowledgement: The study was fully funded by McNeil AB who is the manufacturer of the test and control products. It was designed by McNeil AB in consultation with HW and DOM. The study was run, participants recruited, smoking cessation intervention administered and data collected by the team of research staff at the Oral Health Services Research Centre at University College Cork under the leadership of HW with consultant input from DOM. RK carried out the clinical examinations but was blinded to intervention allocation. The data were analysed by McNeil AB with input from HW and DOM. The study was externally monitored by MDS Pharma Services, UK and conducted to ICH GCP standards. The data were interpreted by HW, DOM and RK. The manuscript was drafted by HW with editorial comment from the other authors. HW decided to submit the manuscript for publication.
• Citation: Whelton H, Kingston R, O'Mullane D, Nilsson F. Randomized controlled trial to evaluate tooth stain reduction with nicotine replacement gum during a smoking cessation program. BMC Oral Health. 2012 Jun 13;12:13. doi: 10.1186/1472-6831-12-13. PMID: 22695211; PMCID: PMC3444372.

Nicotine Patch

2020 Effectiveness of nicotine patch for the control of pain, oedema, and trismus following third molar surgery: a randomized clinical trial

• The positive findings in the present study in surgeries performed under local anaesthesia are in agreement with data from systematic reviews that have reported the effectiveness of nicotine in the control of postoperative pain following surgery under general anaesthesia.
• This study establishes a new prevention and treatment modality regarding pain, oedema, and trismus in a versatile, convenient, safe, and effective form, thereby minimizing gastrointestinal and cardiovascular disorders caused by the use of anti-inflammatory drugs in third molar surgeries.
• PDF Version
• Citation: Landim FS, Laureano Filho JR, Nascimento J, do Egito Vasconcelos BC. Effectiveness of nicotine patch for the control of pain, oedema, and trismus following third molar surgery: a randomized clinical trial. Int J Oral Maxillofac Surg. 2020 Nov;49(11):1508-1517. doi: 10.1016/j.ijom.2019.08.013. Epub 2020 May 4. PMID: 32381373.
• Acknowledgements: Funding - CAPES, Ministry of Education, Brazil

2000 Nicotine Patches for Aphthous Ulcers Due to Behçet's Syndrome

• We describe a woman with Behçet's syndrome characterized by recurrent oral and genital aphthous ulcers, severe eye involvement, and the onset of arthritis at the age of 29 years. At the age of 35 several large and extremely painful buccal aphthous ulcers developed. Therapy with a nicotine patch led to a regression of all aphthous ulcers within a few days. A month later, after the patient had stopped using the nicotine patches, four aphthous ulcers developed within a week. These ulcers rapidly regressed once she resumed using the nicotine patches.
• PDF Version (Note: Need to scroll down to the correct section)
• Citation: Philippe Scheid, M.D., Abraham Bohadana, M.D., Yves Martinet, M.D., Ph.D., Université Henri Poincaré, 54500 Nancy-Vandoeuvre, France, December 14, 2000, N Engl J Med 2000; 343:1816-1817, DOI: 10.1056/NEJM200012143432418

Snus

2020: No association between moist oral snuff (snus) use and oral cancer: pooled analysis of nine prospective observational studies

• Swedish snus use does not appear to be implicated in the development of oral cancer in men.

Snus science database

• Snusforumet’s snus science database includes a collection of studies and research on snus and snus policy from a variety of sources and perspectives. The documents are in Swedish, English, and Norwegian.

Smoking, Tobacco Harm Reduction, and Oral Health Care Providers (Lack of Knowledge/Misinformation)

2022: Dental Student's Awareness and Perception toward Nicotine Replacement Therapy in Riyadh Region Saudi Arabia

• About 74.4% of participants were aware of NRT nearly 50% of students think motivating about NRT is waste of time.

2022: Knowledge and Perception of e-Cigarettes among Dental Students in Riyadh Region Saudi Arabia

• In the present study, results 80% of the participants had no clear opinion on the health effects of e-cigarette indicating lack of knowledge about use, potential merits, and demerits of e-cigarette.

2021: Nicotine-related misperceptions among faculty and students at a Midwestern dental school

• The response rate for faculty was 55.1% and that for students was 37.5%. The majority of faculty and students “agreed” or “strongly agreed” that nicotine causes cancer, birth defects, cardiovascular disease, oral inflammation, and Chronic Obstructive Pulmonary Disease.
• Dental school faculty and students linked the risks of smoking tobacco to nicotine. Based on the results of this study, we feel our institution's curriculum should consider including information specific to nicotine in addition to tobacco in general.

2017: Knowledge, attitude and practices of institution-based dentists toward nicotine replacement therapy

• Having the advantage of working in an academic environment, the postgraduate students and members of faculty lack a detailed knowledge about NRT restricting them to practice it whenever required though they report a strong positive attitude toward this pharmacotherapy. Hence, there is a strong need for implementation of tobacco control policy in India, making repeated training on tobacco cessation counseling giving importance to NRT, not only to students but also to all the faculty members of all the dental institutions of this country where tobacco-related problems are highly prevalent.

Responses to Misinformation

2022: Vaping misrepresentations

• Response to: Fairchild R, Setarehnejad A. Erosive potential of commonly available vapes: a cause for concern? Br Dent J 2021; 231: 487-491.
  • also: Bartlett D. Expert view: David Bartlett. Br Dent J 2021; 231: 700.
• "The authors incorrectly claim that nicotine causes a 'high risk of oral and whole-body health complications'. They cite a WHO poster which presents the effects of whole tobacco smoke on health, not the effect of nicotine. Nicotine has been used in the form of NRT for over 30 years, including in pregnant women, and is regarded as extremely safe, even for long-term use"