Article
I would like to report a case where there seems to be strong circumstantial evidence that an electronic cigarette caused caries. Searches of PubMed and Google found very few references to a link between caries and e-cigarettes.
A 51-year-old female presented with multiple smooth surface active carious lesions. She has recently had several extractions due to caries, coincidentally on her RHS, where she tends to place the e-cigarette. The caries particularly affects the palatal aspect of UR3, incisal aspect of UR1 and the buccal cervical areas of the lower posteriors (Figure 1).
Bitewing radiographs show interproximal caries in most teeth (Figure 2). Oral hygiene is good and, on careful questioning, the patient consistently reported a diet with low sugar quantity and frequency. She takes the following medications, and has not had changes in several years: venaflaxine, dihydrocodeine, paracetamol, tramadol, omaprazole, iron tablets.
The patient reported a frequent mild dry mouth although, on examination, saliva levels appeared normal. This is almost certainly a side effect of the opioids and venaflaxine.
Clinically, the pattern of caries is typical of severe xerostomia or high sugar frequency causing caries in areas not usually affected, such as smooth surfaces at the cervical margin. Clearly, this situation has not been going on for long as most lesions are relatively small and active, which is consistent with the patient starting frequent use of an e-cigarette 9 months previously. She had previously smoked cigarettes.
The mechanism of caries is not clear to me. Clearly, the xerostomia has a significant role; the question remains as to whether the e-cigarette has increased the caries further. ‘E-liquid’ contains mainly propylene glycol and glycerine, which might be a substrate for cariogenic bacteria, but this is speculative (Figure 3). Users of e-cigarettes report a mild sensation of a dry mouth when using them. Does the e-cigarette dry the mouth and allow more caries?
Given that e-cigarettes are a relatively new phenomenon and the health affects are not known, it would seem prudent to be vigilant. Whether future research proves this speculative link with caries remains to be seen, but I would be hesitant in suggesting e-cigarettes to patients with existing xerostomia or high caries rates.