Title	Electronic Cigarettes May Have Potential to Cause Long-Term Oral Health Consequences
Clinical Question	In periodontally healthy patients, does the use of electronic cigarettes have significant long-term oral health consequences as compared to nonsmokers?
Clinical Bottom Line	For patients with periodontal health, electronic cigarette use has been shown to have an association with long-term oral health outcomes as compared to nonsmokers. This is supported by two separate systematic reviews consisting of several studies of low level evidence (i.e. case reports). These systematic reviews summarized the best evidence published to date; however, more prospective clinical studies with a longer exposure period of interest are needed to investigate adverse oral health effects.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 31843181 Ralho / 2019 8 Studies/398 Adult Patients Systematic review of non-randomized trials Key results Electronic cigarettes (e-cigs) have the potential to develop greater susceptibility to oral tissue alterations as compared to nonsmokers with hyperplastic candidiasis reported the most frequently among e-cig users. Based on the studies included, the following periodontal and peri-implant clinical and radiographic parameters are higher among electronic cigarette users than nonsmokers: plaque index, probing depth, clinical attachment loss, radiographic bone loss, and proinflammatory cytokine levels. Bleeding on probing incidence was higher in nonsmokers compared to electronic cigarette users, potentially due to the e-cig liquid which has a vasoconstrictive effect. Additional research is needed for longer follow-up times and a larger population size. 32043402 Yang / 2020 99 Studies/Adult Patients Systematic review of non-randomized trials Key results Electronic cigarette use may be accompanied by mild mouth and throat discomfort. Based on the included studies, electronic cigarettes may increase the risk for oral mucosal lesions and changes in the oral microbiome, as well as periodontal worsening in comparison to nonsmokers. Additionally, the components of electronic cigarette vapor have potential genotoxic, cytotoxic, and carcinogenic features. Studies have demonstrated the potential risk of traumatic injury from device explosions. Further research is needed to evaluate the future clinical outcomes of electronic cigarette use on oral health.
Evidence Search	("electronic nicotine delivery systems"[MeSH Terms] OR ("electronic"[All Fields] AND "nicotine"[All Fields] AND "delivery"[All Fields] AND "systems"[All Fields]) OR "electronic nicotine delivery systems"[All Fields] OR ("electronic"[All Fields] AND "cigarettes"[All Fields]) OR "electronic cigarettes"[All Fields]) AND ("oral health"[MeSH Terms] OR ("oral"[All Fields] AND "health"[All Fields]) OR "oral health"[All Fields])) AND (systematicreview[Filter])
Comments on The Evidence	Validity: The two systematic reviews provided the highest level of evidence for this given topic; however, the majority of the included studies were low to moderate levels of evidence, making them inconclusive. Neither systematic review provided quantitative data, so no meta-analysis was performed. Yang et al. 2020 conducted their review according to PRISMA guidelines and used a quality assessment tool to evaluate the evidence by two independent reviewers controlling for bias. The main limitation of this review is that the majority of the studies included oral health effects from electronic cigarette use as ancillary findings instead of the primary study design intent. Ralho et al. 2019 conducted their review using a variety of databases. The quality of the methodology of each study was evaluated using the ROBINS-I tool. Some studies included retrospective data as well as self-reported outcomes, which may have affected results. This review also details the risk of bias of the studies, with a large proportion of bias due to confounding at the preintervention stage. Perspective: These systematic reviews summarized the best evidence published to date, concluding that electronic cigarettes have the potential to have long-term oral health outcomes as compared to nonsmokers. However, more prospective clinical studies with an exposure period of interest long enough to be meaningful are needed to provide more accurate conclusions.
Applicability	“Electronic cigarette use has rapidly increased in the United States as an estimated 15% of all adults reported having used e-cigs with the majority being between 18-44 years old.” Given that e-cigs only came to market in the early 2000s, the impact of these products on oral health is only just starting to develop. This evidence shows the potential for electronic cigarettes to evoke a wide range of oral health sequalae as compared to nonsmokers. However, clinicians should be advised that further long-term research is still needed to more strongly advise their patients about the potential adverse effects of electronic cigarette use on the oral cavity.
Specialty	(Public Health) (General Dentistry) (Periodontics)
Keywords	Electronic Cigarettes, Oral Health
ID#	3482
Date of submission	11/30/2021
E-mail	sextone@livemail.uthscsa.edu
Author	Emily Sexton, DDS
Co-author(s)	Michael Lamb, DMD
Co-author(s) e-mail	lambm2@livemail.uthscsa.edu
Faculty mentor	David Lasho, DDS, MSD
Faculty mentor e-mail	lasho@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available