Vaping: hidden risks to your gums

[Music] There is evidence that youth vaping is associated with then later take up of the cigarette smoking. We still need the evidence to clearly say that smoking leads to more periplentitis. Hello and welcome to the EFP Paratarchs podcast. My name is Dr. Anika Kroger. I'm your host for today. Our topic today is vaping smoking and oral health and we've got two wonderful guests. First of all, Professor De Né Apatsido, who is the director of the EFP accredited Postgraduate Program Paratontology and Implant Biology at our Estotal University of Thessaloniki, Greece. She is the group program chair of therapy at IEDR, an editorial board member of Sarasaintifty journals. Her research interests lives within wound healing and application of novel treatment technologies and parodontal and bone regeneration, including stem cell therapies. She has received research, prices and awards and national and international levels. Secondly, we have invited Professor Thomas Ditchick, who is a professor of oral surgery in head of the department of oral surgery at the University of Birmingham School of Dentistry. As a clinical researcher and epidemiologist with expertise in parodontology and oral surgery, he has contributed to major EFP consensus work, including the Tonya the European Workshove of Parodontology. He is research-exposed parodontal disease, its systemic interactions and clinical outcomes. Hello, dear De Né and hello, Thomas. Thank you so much for taking the time and being on the podcast with us today. Hello, this is Danai. The pleasure is online and great to be here and share this with you. Thank you. Hi, Annika. Thank you. Thanks for having me. Thank you. Perfect. We all know the massive impact smoking can have on oral health, but we also know that the incidence of vaping is very important. The incidence of vaping or the exposure of vaping in our patients has increased. So could you maybe explain the effect of smoking and vaping have on oral health and if e-sugrids are safer or are safer alternative to normal smoking? Well, it has been so. This is beyond doubt that they both have negative effects in oral health. But indeed, they impact the oral tissues in different ways. For example, in conventional cigarettes smoking the tobacco burns and it's in high temperatures. And this combustion at 600 to 800 degrees releases great smoke, acid, over six or seven thousand different chemicals, including tar, carbon monoxide and others. On the other side, the alternatives like a heated no burn tobacco and goes into lower temperatures, 350 somewhere around there. And this means that it avoids combustion while it reduces the levels of harmful substances. And lastly, the e-sugrids, that is what we know as vaping, is even lower to 100 to 250 degrees. It creates an air flow vapor as an liquid is heated by a coil. And is far less harmful than the smoke in terms of chemicals. But we really don't know the exact content of those chemicals in the vapor in the aerosol. Yeah, I agree with that. I think it's a very different story. And I think the, I mean, we have super robust evidence for smoking in oral health. I mean, this is the EFP podcast here. So I guess, you know, I'll be forgiven to focus on periode a little bit. And I was always fascinated how long it took the profession to realize what an important risk factor smoking actually is. I think we were focused on plaque and brushing so much, and it took us a while to understand that other host factors are very important. And smoking is by far the most important behavioral, special environmental risk factor we know. I'm talking about cigarettes smoking. I'm talking about you, obviously. And yeah, we have super robust evidence. You know, it did so much higher incidents of periode and ultimately tooth loss as well. I mean, I've done a lot of work on the association with tooth loss. And we have really very robust evidence from large cohorts showing, you know, those response and showing benefit of cessation. And I'm just waping. It makes an awful lot of sense that it's much less harmful, I think, based on what, that I have said, we just know that there are much fewer toxicants in what is inhaled from e cigarettes or these heated tobacco products simply because the combustion is not happening. And maybe from an happy perspective on reviewing the literature because I prepared somewhat for this here today. So looking at the happy, it is way too early, I think, to really say anything definitive in terms of what the potential harms are. The level of evidence is not great at the moment. And a lot of it, I think, has to do with the fact that simply these products haven't been around for long enough to exert a harmful effect on area, et cetera. I mean, I guess we can talk about this in a little bit more detail looking at specific endpoints. But in general, my impression is that it's early days, you know, they've not been around for too long and obviously something like periode tooth loss, even more so. There are pretty long latency periods before you can see a harmful effect on these clinical endpoints. So I think a lot of a dyspeculation at the time, but I think it's reasonable to assume that they will be far less harmful than the cigarette smoking. Well, if I may add, I almost said I fully agree with you because Tobacco Smoking has been identified as a citizen epidemic. It was never coming up on the studies on the literature and we were summing up all the patient populations trying to identify various parameters that could affect treatment outcomes. And then it was identified that smoking is one of the red factors to get diabetes and they have to be controlled. And on the other hand, this is a misconception, but that is debatable. And this is the great interest. We believe that vaping is far less harmful. So there are two scenarios. The adults start to use it to stop to quit Tobacco Smoking. On the other hand, in the families, the household family is relaxed with a smoking pan and it widely used among the youth. So from one side, the adults use it as a station to stop smoking. And on the other hand, the youth starts with it. And nobody knows if this is an intermediate step before the start to back or smoke or anything else. There is evidence that youth vaping is associated with then later take up of cigarettes smoking. You know, whether that's causal obviously is very difficult to tease out because I mean these people who vape are different from those who don't vape and they may be more likely to start smoking anyway. And that really the cause who knows on the other hand, yeah, there is robust evidence that it helps with smoking cessation and there have been projections in terms of the expected benefits that if every cigarette smokers which to e cigarettes or alternative tobacco products, the huge gains and life gains to be expected. So the same could be said for dental outcomes, although obviously we can't be sure of that, but I think it is reasonable to assume that and I cannot solve that conundrum, you know, I think that the field is divided right some argue very much in favor for promoting it as a cessation tool in the armamentarium to help smoking cessation. And there is evidence that they work better than other nicotine replacement forms or other pharmacological therapies, but yeah, your point is well taken. You know, that is the tricky part because we think they are safer than we tend to use it broadly and even parents are more relaxed about it. Yeah, tell me about it. Tell me about it. I'm sitting in a restaurant and I could see somebody taking secretly almost you know hiding behind his hands to take a puff in a closed environment. I guess then when they are also in the difficult part of like how they are advertised they are like all like all this sweet flavors and all very colorful and things like that. I guess we've run ahead a little bit with that and I know Thomas you've covered parts of this already, but would you go as far as saying that you would rather or you would try to steer a patient away from conventional combustion smoking into e cigarettes rather than remaining into a regular smoke pattern. Do you think that would be beneficial or would you say rather completely stop obviously that would be the ideal but already at the point already where you would rather have the patients vaping than smoking. Oh, absolutely. I mean, I'm convinced that it's less harmful than cigarettes smoking and so if the alternative is continued to smoke than I would say no, no, I do say that actually to patients. Yeah, of course, if you can stop smoking completely, that's fine. I'm not an expert in smoking cessation strategies, but I mean we know that it's very difficult. We know that many don't even want to stop. So that's a very short conversation sometimes, but those who want to smoke those who want to stop smoking. I mean, I certainly encourage them to look into these alternatives. I suspect that one thing is the dependence on the nicotine, of course, but then also it's this the thing that I'm going to do. you do, right? The fiddling around, you have this little thing that you put in your mouth. There's many sort of dimensions to this that I'm not a psychologist, I don't fully understand. You know, I imagine that that's easier for many people than to go call Turkey. Yeah, and I think Dene also pointed out a very particularly important aspect that you have different groups or vaping is aimed at different groups, yeah? So for one, you have those people that already smoke us that try to get away from smoking or the other group, which is particularly young people, young adults, which the advertisement is really made for, isn't it? And it seems like the UK is trying to effectively face out the legality of it for people, so they're supposed to be a band coming. So I guess that's politically also quite important to recognize that. Well, yeah, but can you imagine the response of the people and you really meet our freedom with something that has not been entirely proven? But if you break it down and you see the literature, surely, in the vapour, in the aerosol of it is cigarette, you can find harmful substances and chemicals. Okay, let's go back to the patient inside of the mouth, at the patient. What are the first early warning signs you see on the day-to-day practice that might come from smoking or vaping that might already cause damage? Receiving gums probably in worsened periodontal disease, mobility, there is this coloration even on the dorsum of the tongue, heavy coating. It can be various other things and it's like the mouth is dry from saliva and it is a different consistency and various other little things. You see people coughing easier and even with the cigarettes, because they inhale this little droplet which go directly to their lungs because of a small sensitive and can be easier injured and late healing in any oral wound. I don't know Thomas, what do you think? Yeah, I don't know. I mean, your question was about early warning signs, right? And the and the oral cavity? I'm not sure. I mean, what's an early warning sign? You know, it's an warning sign for what? Pertontitis is that a warning sign for tooth loss? You know, I'm not quite sure how to answer that. I think the lack of bleeding, if you will. So the fact that we don't see much clinical signs of gingivitis in a smoker is maybe a warning sign because I don't think that has sort of any pathological meaning it tells us it's not sort of a disease in itself. It's just a lack of a diagnostic sign if you like. I'm not sure that's helpful in sort of the communication or in the clinic as such, you know, you may notice it. It's difficult to explain that to a patient that you know, you have a problem because your arms don't bleed. And if you look in the literature because something going back to the E-sigarettes for a second, actually, there is evidence that the E-sigarettes have that same effect. So some of the studies indicate that bleeding on probing is less common than in non-users of tobacco products. Again, the evidence is not that great. If you look in detail in the studies because I think that is only meaningful if you really do sort of site level analyses and put it in relation to the pocket depth, et cetera, because bleeding on probing means something very different if it's a shallow or no pocket versus a patient with Pertontitis or a site with Pertontitis. So that's difficult to judge, but I do think that if a patient comes and you have some oral disease that is smoking associated, just as per your is the prime example for that. That may be the first adverse health effect that that patient encounters or he is confronted with. They start at smoking when they were 15, 20, they felt invincible and now all of a sudden then your chat and you can actually point out to a consequence of smoking in that first health effect. And I think that's an opportunity there to engage with them. So I think in some sense the period disease might be an early sign of your lack of adverse health effect more generally and that may be an opportunity to engage with them to make them stop. But which makes our position as clinicians even more important because we're one of the first people that would recognize these earlier warning signs and the impact it might have on oral health and also systemic health, isn't it? You mentioned about vaping, masking, bleeding in periodontal disease and ginger vitus. Is there any hypothesis behind it? Why that is the case? Are you aware of any? By several ways people believe it's just vasoconstriction because nicotine is very active at that but it's more complicated than that. There are vascular changes, there is flow change and the thelial damage, cell metabolism I mean on various molecular levels and mechanisms what we see as less bleeding or less swelling in the gums but what I want to talk is that all that we see is those dependent and sometimes in light or moderate smokers we don't see the extent or the effects that we see in heavy smokers and that makes a big difference even in the way you handle or you deal with the patient. Yeah so even reducing it will have a positive effect on you if you can't stop fully. We talked about the angle that smoking and vaping is a risk factor in all that develop periodontal disease which affect us at have on periodontal treatment or implant treatment and treatment outcomes. Could you highlight that? Yeah I mean smoking is clearly associated with implant failure so it is both in terms of early failure so actually lack of osteointegration that's not published yet but I can say that we've looked at over 100,000 implants and early failure within a year of placement so that's largely osteointegration failure. You see again a dose dependent effect of smoking. You need very large studies because implant placement is such a successful procedure right so the vast majority of implants are osteointegrate but you can see that roughly in a heavy smoker heavy current smoker you have roughly doubling of the risk of early implant failure and then it's also associated with periompland diseases very much like periodontitis. Yeah there's no question that it's not a good thing. Having said that the implant story is interesting because I've come across people occasionally say they don't treat smokers right with certain procedures and so forth and to me it's more question of consent explaining things because smokers lose more teeth so they need more implants right so you have a bit of a problem then if you say you know they're not eligible and it doesn't mean that they don't work in smokers right they they can work again it's very much dose dependent we're not trying to ban smokers from getting implants it's just that maybe you do something that's more conservative and not such aggressive therapies perhaps again you know that's something you need to obviously discuss and communicate with the patient. I feel agree with you they have to know number one they have to know what can go wrong with smoking and implant therapy and then they have to consent of course but we still need evidence to clearly say that smoking leads to more periplantitis. I mean it modifies periplant hemococytis but we still need stronger evidence and as Thomas said there is more literature coming up as time passes in terms of periodontal therapy the treatment outcomes are improved in smokers but they are certainly inferior to those of non-smokers and that makes the difference. I was presenting I was a bit disappointed in that time and I was saying smoking had a detrimental effect on the treatment outcome it's not that because you get positive response to treatment but it's inferior it's less than what you would aim for. Yeah that's a common misunderstanding I remember discussions with you know students and colleagues it's not that periotreatment doesn't work in smokers. If you think about it before we knew about smoking it's not so long ago right in the 80s early 90s you know it's just when the evidence came up I went to dental school in the early 90s when I trained and the story was periotreatment is very successful it works brilliantly in general and then 10 years later people said no it doesn't work in 20% of the population well that's not quite correct right it just works less well. And another thing we have to consider is the regenerative outcomes in smokers this is lower as well the regenerative capacity of tissues is lower and that is the interesting part because when you look into the literature the inclusion criteria always in a regenerative clinical trial is less than smokers with less than 10 cigarettes a day so the aim for the low dose smokers and to be included and go through regenerative periot surgery so that is another interesting point. Yeah I just wanted to ask was Thomas already highlighted that the general declining of treatment obviously wouldn't be correct because it increases the risk of failure increases the risk of suboptimal treatment outcomes we can't say no really because they still have a treatment need but is there like a threshold where you would classify as like a more high risk patient due to their smoking habits or vaping habits and then you would probably be more conservative in your approach do you have a set threshold in your mind for that? Well you've one smog in the 10th cigarette a day. And what does this mean? Little. I tell you why, because the smoking behavior is very so much across-object. How long they're gonna take the puff? How often? So yes, I believe that even into Michael Smog, but also in the cigarette, the device, they'll liquidate different content, or even the smoking behavior, there is largely across-objects. Yeah, that's true. On the other hand, talking about sort of misclassification or measurement and epidemiologic studies, smoking is one of the easier to measure exposures. Compare that to, I don't know, nutrition, right? So we do studies now on the Mediterranean diet and parodisease and so forth. And that's a different story. So people tend to have some idea of many cigarettes they smoke. You know, they have to go, they spend a lot of money on a pack. So in terms of their behavioral risk factors, that's, I think, one of the easier to ascertain exposures. But yeah, I take your point. There's obviously still lots of variability. I completely agree with that. There's no harder fast threshold. In plant failure or treatment failure is also obviously multifactorial, right? So then you can have good success in smokers. But if they are also diabetic and don't brush their teeth and so forth, then that's a different story. But the good news is not all of our smoking patients are doomed. A lot of those effects are reversible, aren't they? So how quickly can patients, if they do manage to stop smoking or vaping? When can they expect to see improvements and how much or how four of those damages are reversible? That's interesting. Because you see this rebound in divitis happening, let's say in the first month, from a few weeks to six weeks. And the patients start to bleed again, because the fluids are back to normal. You see the mouth getting moisturized more than it was before. And this butt breath is slowly being eliminated. So yeah, this takes from, let's say, weeks to a couple of months. They believe that immunologically, the host repairs the deficiencies in a matter of three or four or six months. But when it comes to risk of periodontitis, I don't know what Thomas has in mind, but it takes more than maybe 10 or 20 years to reverse back to a no risk as a non-smoker. Yeah, I agree. So I'm sure we've all had patients who stopped smoking and said that caused my gums to bleed to the periodontitis that they hadn't didn't know about, that was an explode, so to speak, in terms of swelling and bleeding and so forth. And for periodontitis, I think 10 years is probably reasonable for tooth loss. Tooth loss can be ascertained by self-report. So we have some data from large cohorts. I did two studies myself, one in US doctors and dentists, tens of thousands of participants. And then also in a German cohort, tens of thousands again, where you see that the risk of tooth loss is sort of indistinguishable from that of never smokers, sort of 15 to 20 years after smoking cessation. That takes a while and that may not sound that encouraging or optimistic, but actually it's an exponential decline, right? So you get big effects, big drops in the risk early on and then sort of it tapers more slowly. So there's definitely a sound evidence base to say, you will lift to see the benefits of smoking cessation if you stop now. One of the common themes we had of our podcast series here was that our responsibility as a clinician goes beyond just looking at the mouth and looking at the teeth. And Thomas Yehai noted that we're not specialists in smoking cessation. So what role should we dental professionals play in supporting the patients to quit smoking and vaping? And more specifically, how should we see their conversation with the patient? That's interesting because periodontology is changing, it's evolving and periodontology becomes more holistic, more inclusive, more systematic, prevention oriented. So we have to identify the individuals that smoke, we have to identify as clinicians, the response to treatment, let's say the healing potential. And we have to augment this. That is what makes periodontal therapy successful. So it's like a bond between the therapist and the patient. So you have to raise sympathy and respect, understanding good communication channels. And you will find resistance. There will be a lot of resistance. But that is not rejecting patients or labeling them that they are not committed or they are not motivated. So you have to understand this. And you go one step forward. But if necessary, you go one step back to endorse this relationship between the patient and the therapist. I agree. I think, especially as a periodontist, I think that has become a lot easier. There's much more awareness in the field, obviously, for the host factors. They're part of the classification now. You have to ask and assess it. That's the first thing. I think 20 years ago or 25 years or 30 years ago, lots of dentists probably didn't know whether or not their patients smoked or not. Now, it's really part of your dental history, even, if you like. And that has become a lot easier. You can also feel much more as a medic because you can share the feeling of failure, if you like. A minority of patients with attempt quitting will actually successfully quit. That's just the nature of the beast. And we're just a little factor in that story, I guess. We have a unique position in this story again, because we may be the first ones who see an actual physical consequence of smoking in a patient. And that's a periodontitis. I think it's an important role that we have there. But just so let me add on to this, that the state plays a role. There should be training dentists or dental professionals in how to approach, how to deal, how to manage, how to overcome restrictions and limitations, resistance of patients. We have to admit this at an academic environment differs hugely from a private practice, where a time is mummy. And sometimes you cannot spend the full session just by chatting, but this chatting, although it is so important and so vital to accomplish your treatment goals from a part of dental professionals, it might look like the clock is running. Yeah, I agree. But the specific approaches that one can take will probably differ very much in which system you operate, in which country you operate, in which healthcare system you operate and so forth. So I don't think there is a one size fits all. I'm not sure if you were suggesting that, but I'm not sure we should be trained in cessation per se. So from the UK, there have been some papers suggesting a brief advice thing. So ask about smoking and then you obviously have to tell them about the risk associated with it and that their periode disease, for example, may be a consequence of their smoking and then steer them in the right direction in terms of cessation if they are willing to consider quitting. I don't think that that's necessarily the dentist role or will ever be the dentist role to do that. Very much like diabetes. I mean, diabetes, you would refer them to a diabetologist. Let's say a 45 year old patient comes to me, has severe periode, that's my responsibility, then you ask for smoking diabetes. If that's a non-doubacnosed diabetic, but they look like they could be diabetic, for example, then I tell them to speak to their doctor or seek advice and maybe get an HB1 CT test or get tested for diabetes because a lot of patients have undiagnosed diabetes sometimes. So that is a similar story. I think we have a role because we see patients that are not necessarily regularly see a doctor. We're healthcare professionals, we have access to patients because for some reasons we have convinced the public that it's a good thing to go to the dentist once a year, at least, whereas they don't necessarily go and see their doctor regularly if they feel young and healthy. - We do have those running in Greece. You get a two day training, more or less. You become an ambassador and you pass the exam to the other dental professionals. Let's say in your practice or let's say in the academic environment. So the training passes on from 10 to 10 days. - And what's the training content? Does it extend to a pharmacological therapy? - No, no, no. How to start a conversation. How to ask. I really enjoy treating this like a methodological narrative. It's a recently published in period 2000 by Dr. Ram Sae. And he talks about the different stages that you go through from connection to information, to motivation, to action. So there is a scheduled approach that you could follow. - You could, I agree. We have in the UK here, the NHS stops smoking service. So you have a place where you can actually send the patient. That's important. That may not be available elsewhere, or maybe more difficult or not accessible for various reasons. Ultimately, I think it's a specialist area. And yes, we have a role. I think it's an important role. That's not to be underestimated. I mean, what do you think? I don't think it would ever go significantly beyond keeping the conversation going, perhaps, as you go through treatment with the patient. So that is the effort we have to make. So instead of stopping at the stage of a brief advice, go a little bit deeper and understand the motives and the potential of quitting smoking. Behavior management technique is an important topic. Very. Especially for periodontists. I mean, just think of all hygiene, etc. And I think it's still underrepresented in our training, I suspect, that that is still a major issue. I guess to summarize, as clinicians or weak clinicians are in a very unique position, that we see the patient on a way more regular basis and also those patients that don't present with a GP on a regular basis. So we are the first contact healthcare professional with a lot of these patients. So it puts us in a unique position having to seek at least an initial conversation with them. I'm guessing. Then obviously there's quite a disparity in which system you're working and what more support we can offer them or not. But it is important that we are the first people that have to seek that initial conversation with the patient. I guess I think maybe we can agree on that. I can agree with that. I concur. I concur. There's very good, very good. We're heading towards the end of this podcast. So before I ask you the last question, I want to thank both of you so much for taking the time and having the lovely conversation with me. I would like to give the opportunity to talk about one common misconception or a common myth you repeatedly encounter with your patient in relation to making or vaping with oral health. And you're allowed to dispute it or support it with the current literature. What is something you always wanted to let everyone know what is true, what is not true? The one thing that I've always been concerned with them vaping in this cigarette is that they're not standard or quality controls. They liquid, they're device itself, the maintenance of the device. And all of this when they come together they make this harmful habit of vaping. So one thing I would say is not that everything that is out there is used in a wise manner with the device and the liquid that you buy from any place anywhere. So that is my main concern and the misconception that we have that with this cigarette everything is the same. What we get out there is the same, not even the nicotine. The measured from the labeled nicotine very hugely. So that is my number one concern. Interesting, Thomas. A misconception or a myth you would like to deal with today. You know the absence of bleeding. Because we use bleeding as a diagnostic indicator. We use it in periolot. We use it in periimplund maintenance that made it into the latest treatment guideline that it should be monitored for periimplund health and so forth. And bleeding on probing I think is overrated as a diagnostic test. And what hasn't made it into the treatment guidelines is that I think it means something completely different in a smoker. Or it is even less valid in a smoker than in a non-smoker. So I think there is misunderstanding or misconception in the profession a little bit. Because that's a very strong effect actually. Very strong dose dependent effect but also patients may have this idea that there is no bleeding. So I am actually alright. Thank you both of you for taking the time. It was a pleasure to have you on here. Thanks for the beautiful conversation. Thank you Annika. Thanks for having me again. Thank you. I totally enjoyed it. Thank you all. Great to be with you.