لخّصلي

Effects of Alternative Smoking (E-Cigarettes, Waterpipe, IQOS) on Oral Health

Abstract

Alternative smoking methods such as electronic cigarettes (e-cigarettes or vaping), waterpipe (shisha), and heated tobacco products (IQOS) are increasingly popular, with claims of reduced harm compared to conventional cigarettes.Heat-not-burn tobacco (IQOS), oral fibroblasts and keratinocytes: Cytotoxicity, morphological analysis, apoptosis and cellular cycle.Pocket depth, bleeding, attachment loss (OR?4.3) Intermediate; CAL higher than non-smokers, lower than conventional smokers Oral Mucosa Lesions White patches ~20%; micronuclei; pre-malignant signs Acanthosis, dysplasia, hyperparakeratosis; pre-malignant Limited data; mild potential changes Pre-malignant Risk ?Vaping is associated with xerostomia (dry mouth), decreased salivary flow, disrupted oral microbiome, and increased pathogenic bacteria such as Streptococcus.---

Introduction

Electronic cigarettes (e-cigarettes), waterpipe (shisha), and heated tobacco products (IQOS) are marketed as safer alternatives to conventional smoking.This report reviews the oral health consequences of each product, focusing on periodontal health, oral mucosal lesions, pre-malignant risks, xerostomia, microbiome changes, and cytotoxic/genotoxic effects.Micronuclei, binucleated cells Cytotoxic/genotoxic changes, OPMDs Unclear; low cytotoxicity, proliferation may pose future risk Saliva Flow & Properties ?https://doi.org/10.4103/jpbs.jpbs_1352_24

Senaratne, N. L. N. M., Chong, C. W., Yong, L. S., Yoke, L. F., & Gopinath, D. G. (2023).https://doi.org/10.18295/squmj.6.2022.043

Camoni, N., Conti, G., Esteves-Oliveira, M., Carvalho, T. S., Roccuzzo, A., Cagetti, M. G., & Campus, G. (2023).---

Oral Health Effects by Product

E-Cigarettes (Vaping)

Periodontal health: Increased gingival inflammation, mild clinical attachment loss compared to non-smokers.Cytotoxicity/Genotoxicity: In vitro studies show low cytotoxicity; increased fibroblast and keratinocyte proliferation, minor cellular cycle changes.https://doi.org/10.3389/froh.2023.1275717

Alsenani, M., Alothman, L., Alsenaidi, J., Alnowaiser, A., Aldawsari, M., & Alharbi, N. (2025).https://doi.org/10.3290/j.ohpd.a32671

Valenti, C., Gambelunghe, A., Fanasca, L., Billi, M., Cianetti, S., & Marinucci, L. (2021).Waterpipe smoking is linked to greater periodontal pocket depth, gingival inflammation, attachment loss, and epithelial dysplasia.Microbiome: Dysbiosis with increased pathogenic bacteria (Streptococcus) and decreased beneficial species.https://doi.org/10.3390/app13179654

Bibars, A. R. M. A., Obeidat, S. R., Khader, Y., Mahasneh, A. M., & Khabour, O. F. (2015).However, studies show that these products can compromise oral health, affecting the periodontium, oral mucosa, salivary flow, and the oral microbiome.Salivary effects: Reduced unstimulated salivary flow, decreased buffering capacity, increased acidity.Cytotoxicity/Genotoxicity: Increased cellular stress, abnormal nuclear morphology, early markers of potential carcinogenesis.---

Heated Tobacco Products (IQOS)

Periodontal health: Intermediate between non-smokers and conventional smokers.risk of malignancy No clear genetic mutations observed

Discussion

All alternative smoking methods expose the oral cavity to nicotine and chemical toxins.E-cigarettes show intermediate effects: less severe on gingival tissues but significant xerostomia and microbiome imbalance.Overall, none of these alternatives are fully safe; all exhibit pre-malignant and inflammatory markers in oral tissues.Electronic cigarettes, heated tobacco products, and oral health: A systematic review and meta-analysis.Oral mucosal lesions including white patches and micronuclei indicate potential pre-malignant changes.IQOS appears less cytotoxic than conventional cigarettes, but still affects periodontal tissues and cellular activity.Oral mucosa: Acanthosis, epithelial dysplasia, hyperparakeratosis.

Effects of Alternative Smoking (E‑Cigarettes, Waterpipe, IQOS) on Oral Health

Abstract

Alternative smoking methods such as electronic cigarettes (e‑cigarettes or vaping), waterpipe (shisha), and heated tobacco products (IQOS) are increasingly popular, with claims of reduced harm compared to conventional cigarettes. However, recent studies indicate significant negative effects on oral health. Vaping is associated with xerostomia (dry mouth), decreased salivary flow, disrupted oral microbiome, and increased pathogenic bacteria such as Streptococcus. Oral mucosal lesions including white patches and micronuclei indicate potential pre-malignant changes. Waterpipe smoking is linked to greater periodontal pocket depth, gingival inflammation, attachment loss, and epithelial dysplasia. IQOS appears less cytotoxic than conventional cigarettes, but still affects periodontal tissues and cellular activity. A comparative table highlights differences in oral impact among these alternatives.

Introduction

Electronic cigarettes (e‑cigarettes), waterpipe (shisha), and heated tobacco products (IQOS) are marketed as safer alternatives to conventional smoking. However, studies show that these products can compromise oral health, affecting the periodontium, oral mucosa, salivary flow, and the oral microbiome. This report reviews the oral health consequences of each product, focusing on periodontal health, oral mucosal lesions, pre-malignant risks, xerostomia, microbiome changes, and cytotoxic/genotoxic effects. A comparative table summarizes the oral impacts of each alternative.

Oral Health Effects by Product

E‑Cigarettes (Vaping)

Periodontal health: Increased gingival inflammation, mild clinical attachment loss compared to non-smokers. Less severe than conventional cigarettes.

Oral mucosa: White patches in ~20% of vapers vs 6% in non-smokers. Micronuclei, binucleated cells indicate potential pre-malignant lesions.

Salivary effects: Reduced unstimulated salivary flow, decreased buffering capacity, increased acidity. Xerostomia is common.

Microbiome: Dysbiosis with increased pathogenic bacteria (Streptococcus) and decreased beneficial species.

Cytotoxicity/Genotoxicity: Increased cellular stress, abnormal nuclear morphology, early markers of potential carcinogenesis.

References: Al Bayati et al., 2025; Alsenani et al., 2025.

Waterpipe (Shisha)

Periodontal health: Increased pocket depth, gingival bleeding, and attachment loss (OR≈4.3).

Oral mucosa: Acanthosis, epithelial dysplasia, hyperparakeratosis. White lesions and pre-malignant changes are common.

Salivary effects: Reduced salivary flow, similar to conventional smokers.

Microbiome: Increased Firmicutes (Streptococcus), decreased Proteobacteria. Dysbiosis increases risk of periodontal disease.

Cytotoxicity/Genotoxicity: High cytotoxicity and DNA damage; increased pre-malignant cellular changes.

References: Senaratne et al., 2023; Bibars et al., 2015; Grillo et al., 2023.

Heated Tobacco Products (IQOS)

Periodontal health: Intermediate between non-smokers and conventional smokers. Mild clinical attachment loss and pocket depth changes.

Oral mucosa: Limited data; potential mild changes due to nicotine exposure.

Salivary effects: Expected mild reduction in flow due to nicotine.

Microbiome: Not well studied; possible mild dysbiosis.

Cytotoxicity/Genotoxicity: In vitro studies show low cytotoxicity; increased fibroblast and keratinocyte proliferation, minor cellular cycle changes.

References: Valenti et al., 2021; Camoni et al., 2023.

Comparison Table

Indicator E‑Cigarettes (Vaping) Waterpipe (Shisha) IQOS

Periodontal Health ↑ Gingival inflammation, mild attachment loss ↑ Pocket depth, bleeding, attachment loss (OR≈4.3) Intermediate; CAL higher than non-smokers, lower than conventional smokers
Oral Mucosa Lesions White patches ~20%; micronuclei; pre-malignant signs Acanthosis, dysplasia, hyperparakeratosis; pre-malignant Limited data; mild potential changes
Pre-malignant Risk ↑ Micronuclei, binucleated cells Cytotoxic/genotoxic changes, OPMDs Unclear; low cytotoxicity, proliferation may pose future risk
Saliva Flow & Properties ↓ Flow, ↓ buffering, ↑ acidity ↓ Flow, similar to conventional smoking Mild decrease expected
Oral Microbiome Dysbiosis; ↑ Streptococcus, ↓ beneficial bacteria ↑ Firmicutes (Streptococcus), ↓ Proteobacteria; dysbiosis Not well studied; potential mild imbalance
Halitosis ↑ due to xerostomia ↑ due to smoke and chemical exposure Mild increase possible
Xerostomia Common (~1/3 users) Common Mild to moderate possible
Cytotoxicity ↑ Nuclear changes, abnormal cells High cytotoxicity; pre-malignant cells Low cytotoxicity; increased proliferation
Genotoxicity ↑ Micronuclei; potential carcinogenic risk DNA damage; ↑ risk of malignancy No clear genetic mutations observed

Discussion

All alternative smoking methods expose the oral cavity to nicotine and chemical toxins. Shisha and conventional smoking are the most harmful regarding periodontium and oral microbiome. E‑cigarettes show intermediate effects: less severe on gingival tissues but significant xerostomia and microbiome imbalance. IQOS may be less damaging than conventional cigarettes regarding gingival inflammation, but cellular and potential genotoxic effects remain a concern. Overall, none of these alternatives are fully safe; all exhibit pre-malignant and inflammatory markers in oral tissues.

Conclusion

No safe alternative: E‑cigarettes, waterpipe, and IQOS all pose oral health risks.

E‑Cigarettes: Xerostomia, dysbiosis, gingival inflammation, pre-malignant cellular changes.

Waterpipe: Similar or higher risk than conventional cigarettes; pre-malignant mucosal lesions.

IQOS: Less severe effects, but potential genotoxic and proliferative cellular changes exist.

Awareness is crucial: Reducing harm does not mean elimination of risk; ongoing monitoring and patient education are necessary.

References (APA Style)

Al Bayati, S. A. A. F., Al Sharbatti, S. S., Ibrahim, E. H., Bylappa, S. K., & Saleh, D. K. H. (2025). The impact of electronic cigarettes on oral health: Analytic cross-sectional study. Journal of Pharmacy & Bioallied Sciences, 17(Suppl 2), S1131–S1137. https://doi.org/10.4103/jpbs.jpbs_1352_24

Senaratne, N. L. N. M., Chong, C. W., Yong, L. S., Yoke, L. F., & Gopinath, D. G. (2023). Impact of waterpipe smoking on the salivary microbiome. Frontiers in Oral Health, 4, Article 1275717. https://doi.org/10.3389/froh.2023.1275717

Alsenani, M., Alothman, L., Alsenaidi, J., Alnowaiser, A., Aldawsari, M., & Alharbi, N. (2025). Correlation between e-cigarette use and salivary flow rate, pH, and buffering capacity: A cross-sectional pilot study. BDJ Open, 11, Article 1806. https://doi.org/10.1186/s12903-025-07255-w

Grillo, R., Khemiss, M., & da Silva, Y. S. (2023). Cytotoxic and genotoxic effects of waterpipe on oral health status: Systematic review and meta-analysis. Sultan Qaboos University Medical Journal, 23(1), 5–12. https://doi.org/10.18295/squmj.6.2022.043

Camoni, N., Conti, G., Esteves-Oliveira, M., Carvalho, T. S., Roccuzzo, A., Cagetti, M. G., & Campus, G. (2023). Electronic cigarettes, heated tobacco products, and oral health: A systematic review and meta-analysis. Applied Sciences, 13(17), 9654. https://doi.org/10.3390/app13179654

Bibars, A. R. M. A., Obeidat, S. R., Khader, Y., Mahasneh, A. M., & Khabour, O. F. (2015). The effect of waterpipe smoking on periodontal health. Oral Health & Preventive Dentistry, 13(2), 103–108. https://doi.org/10.3290/j.ohpd.a32671

Valenti, C., Gambelunghe, A., Fanasca, L., Billi, M., Cianetti, S., & Marinucci, L. (2021). Heat-not-burn tobacco (IQOS), oral fibroblasts and keratinocytes: Cytotoxicity, morphological analysis, apoptosis and cellular cycle. Journal of Periodontal Research, 56(5), 917–928. https://doi.org/10.1111/jre.12888