Trying to clear the air: e-cigarette use and periodontal disease

OPEN | VERIFIABLE CPD PAPER REVIEW Literature Review Trying to clear the air: e‑cigarette use and periodontal disease Gabby Robson,1 Xii Cin Lim,2 Iman Chaudhari,3 Joshua Hurley,*1 Saba Khalil,1 Veronica Amin1 and Luigi Nibali4 Key points Summarises the current evidence on the effect of e-ciagrette usage on periodontal health and limitations in this area of study. Educates on the possible effects of e-cigarette usage on periodontal tissues, periodontal health and periodontal treatment outcomes, and compares to conventional smoking and non-smoking. Addresses the discrepancy between public perception of e-cigarette usage and the findings of current evidence. Provides a summary of current guidelines and advice to practitioners. Abstract Introduction With record rates of e‑cigarette use in the United Kingdom, it is becoming more important that dental professionals understand the consequences of e‑cigarette use on oral health. Methods This narrative review considers the current bank of literature regarding e‑cigarette use and periodontal health and disease. Results Some studies have found that e‑cigarette users had worsened periodontal health and poorer response to periodontal treatment compared to non-smokers. However, there is mixed evidence on this topic and the current evidence base remains limited, with few high-quality studies available. Similarly, although current research suggests that e‑cigarette use is safer for the periodontium than conventional smoking, further long-term, large-cohort studies will be required to improve the evidence base. Conclusion In the meantime, the guidance from the British Society of Periodontology and Implant Dentistry is to ensure patients understand the lack of information and research available. The National Institute for Health and Care Excellence support this and note that there may be a place for e‑cigarettes as an aid to quitting smoking, supporting patients to become tobacco-free. It would, however, be sensible for dental practitioners to discourage negative health habits, including e‑cigarette use, unless to replace a potentially more dangerous habit, such as conventional smoking. Introduction The prevalence of e‑cigarette use (vaping) has increased significantly, with record rates of use reaching 9.1% in the United Kingdom (UK). 1 Given that e‑cigarettes were introduced in the early 2000s, scientific literature on this subject is limited compared to that of conventional smoking. However, there are emerging trends in the literature, Undergraduate Student, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, London UK; 2Academic Foundation Dentist, University of Bristol, UK; 3Foundation Dentist, London, UK; 4Professor of Periodontology/Honorary Consultant, Periodontology Unit, Centre for Host Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial Sciences, King’s College London, London, UK. *Correspondence to: Joshua Hurley Email address: 1 Refereed Paper. Submitted 16 January 2025 Revised 23 May 2025 Accepted 8 June 2025 https://doi.org/10.1038/s41415-025-8919-5 explored in this narrative review, which inform the current guidance that clinicians should implement in practice. Aim To educate clinicians on the current literature regarding the impacts of e-cigarette usage on periodontal health and its limitations, including current guidance provided. Methods This narrative review was developed as a follow-on from the Student British Society of Periodontology and Implant Dentistry (BSP) webinar, ‘E-cigarette vaping: a risk for periodontal health? By students, for students’, which was presented by the authors of this paper. A literature search was conducted using PubMed and Google Scholar. Search terms included combinations of ‘e-cigarette’, ‘vaping’, ‘systemic effects’, ‘periodontal health’, ‘periodontal status’, BRITISH DENTAL JOURNAL | VOLUME 239 NO. 10 | November 28 2025 © The Author(s) 2025. ‘periodontal treatment’, ‘implant outcomes’, and ‘smoking cessation’. Given the limited number of studies and systematic reviews available in this area, a narrative review approach was considered appropriate to synthesise the existing literature. To inform the ‘Practitioner guidance’ section, the latest guidelines and recommendations were sourced from the official websites of the National Institute for Health and Care Excellence (NICE), the BSP, and the Delivering Better Oral Health (DBOH) toolkit published by the Office for Health Improvement and Disparities, Department of Health and Social Care, NHS England and NHS Improvement (these are correct as of the date of manuscript submission). Characteristics of e‑cigarette users Most e‑cigarette users are current or previous smokers; usage among never-smokers has been reported to be rare.2 Use among men is more common, with 9.5% of men 16 years and older reporting e‑cigarette use daily or occasionally, 687 REVIEW compared to 7.9% of women.3 E‑cigarette use is fairly evenly distributed between ages 16–59, with a reduced rate of use in those over 60.3 Younger individuals tend to use e-cigarettes for enjoyment whereas individuals older than 45 years are more likely to use e-cigarettes to quit smoking.4 Box 1 highlights additional demographic trends and usage patterns among e-cigarette users.4,5 It is important to consider that not all e-cigarettes are created equal. They vary in nicotine levels and flavours – each with different ingredients – offered by companies to appeal to a plethora of users, leading to diverse effects across the population. E-cigarettes and systemic links Evidence on the systemic effects of e-cigarette use does not have a robust evidence base – there is a distinct lack of long-term studies on this subject. There is, however, emerging evidence that e-cigarette use has neurological, pulmonary, cardiovascular and oral and dental effects, as detailed in Figure 1.6,7,8 Daily or heavy e-cigarette users also tend to have higher rates of alcohol and cannabis use and other highrisk behaviours,9 which can influence health outcomes and are considered co-morbidities for many diseases. The lack of long-term human studies on e-cigarette use must be Box 1 Additional facts about e‑cigarette users • 40.6% of older people prefer tobacco-flavoured e‑cigarettes versus only 4.8% of younger people; 51.1% of younger people prefer fruit flavours4 • Being young and perceiving e‑cigarette use as less harmful than conventional smoking increases the chance of recent (within the last 30 days) e‑cigarette use4 • Women from white and multiracial backgrounds were more likely to have tried e‑cigarettes5 • Lowest use was among Black African and Indian men, and women from all Asian and Black African backgrounds5 • E-cigarette users are more likely to have parents with a lower socioeconomic status at birth2 addressed to better inform users, public health policies, and resource allocation. Potential mechanisms of periodontal deterioration of e- (...truncated)