Abstract. Cigarette smoking is one of the most firmly established modifiable risk factors for periodontal disease, exerting effects through vascular, immunologic, and microbiologic pathways that accelerate attachment and bone loss while paradoxically suppressing the clinical signs of inflammation. As electronic cigarette use has expanded, attention has turned to whether these products are periodontally safer. Current evidence indicates that while e-cigarettes lack the combustion products of conventional tobacco, they are not biologically inert in the periodontium. This review summarizes the mechanisms, clinical outcomes, and practice implications of tobacco and e-cigarette use for periodontal health.
Conventional Tobacco and Periodontitis
The association between cigarette smoking and periodontitis is dose-dependent and consistently reported across epidemiologic studies, with smokers demonstrating greater prevalence, extent, and severity of periodontal destruction than non-smokers. Smoking is estimated to account for a substantial fraction of periodontitis cases in adult populations and is associated with poorer response to both non-surgical and surgical periodontal therapy, higher tooth loss, and increased risk of implant complications. Critically, smoking exerts a vasoconstrictive effect that reduces gingival bleeding on probing, which can mask disease severity and complicate clinical assessment.
Mechanisms of Injury
The deleterious periodontal effects of smoking are multifactorial. Nicotine and combustion by-products impair gingival microcirculation and reduce oxygen tension in periodontal tissues. Tobacco exposure suppresses neutrophil function and alters cytokine profiles, compromising host defense against periodontal pathogens, while simultaneously promoting a dysregulated, tissue-destructive inflammatory response. Smoking also impairs fibroblast function and wound healing, contributing to diminished regenerative and reparative capacity following therapy. Collectively, these mechanisms yield accelerated attachment and alveolar bone loss with attenuated clinical warning signs.
Electronic Cigarettes: Emerging Evidence
Systematic reviews and meta-analyses of e-cigarette use report unfavorable periodontal associations relative to non-users, including elevated markers of inflammation and oxidative stress and, in several analyses, greater clinical attachment loss. Comparative data generally position e-cigarette users between never-smokers and conventional smokers, with cigarette smokers exhibiting the poorest outcomes; however, some studies find no significant difference between e-cigarette users and non-smokers on certain destructive endpoints such as probing depth and marginal bone loss, reflecting heterogeneity and the relatively short exposure histories available for study. Importantly, nicotine-containing aerosols retain the vasoactive properties relevant to periodontal pathology, and the absence of bleeding should not be interpreted as periodontal health in these patients.
Oral Microbiome Effects
Both smoking and vaping are associated with shifts in the oral microbial community toward dysbiosis. Reported changes include enrichment of periodontal pathogens and reduced microbial diversity, with the microbiome of heavy e-cigarette users described as resembling that of cigarette smokers more than that of non-users. Such ecological shifts plausibly contribute to the initiation and progression of periodontal inflammation, though longitudinal data establishing causality remain limited.
Implications for Dental Practice
Tobacco and nicotine use histories—including e-cigarette use—should be routinely obtained and documented, and clinicians should recognize that reduced bleeding on probing in these patients may underestimate disease activity. Smoking- and vaping-cessation counseling is an evidence-based component of periodontal care and improves treatment response. Because tobacco use is also a major risk factor for oral and oropharyngeal malignancy, periodontal evaluation should be paired with oral mucosal examination; see our related review of HPV-associated oropharyngeal cancer and our discussion of periodontal disease and cardiovascular risk. A patient-oriented companion to this review is available in our guide to smoking, vaping, and your oral health.
Conclusion
Cigarette smoking remains a principal modifiable driver of periodontal disease, producing accelerated tissue destruction alongside suppressed clinical signs. Available evidence indicates that e-cigarettes, while likely less harmful than combustible tobacco, are associated with adverse periodontal and microbiologic changes and should not be regarded as periodontally safe. Cessation counseling and vigilant clinical assessment are central to managing these patients.
References
1. Leite FRM, Nascimento GG, Baake S, et al. Impact of smoking on periodontitis: systematic review and meta-analysis of dose-response. Am J Prev Med. 2018;54(6):831–841.
2. Warnakulasuriya S, Dietrich T, Bornstein MM, et al. Oral health risks of tobacco use and effects of cessation. Int Dent J. 2010;60(1):7–30.
3. Figueredo CA, Abdelhay N, Figueredo CM, et al. The impact of vaping on periodontitis: a systematic review. Clin Exp Dent Res. 2021;7(3):376–384.
4. Ibraheem WI, et al. Effects of electronic cigarettes on periodontal health: a systematic review and meta-analysis. 2024.
5. Karaaslan F, Dikilitaş A, Yiğit U. The effects of vaping electronic cigarettes on periodontitis. Aust Dent J. 2020;65(2):143–149.
This article is intended for general educational purposes and does not constitute individual medical or dental advice. For a periodontal evaluation, the team at Fridman Family Dental Care in Valencia, CA is here to help — contact us to schedule an appointment.
