S5 E05: Vaping & Oral Health

Wright: [00:00:00] Vaping and e-cigarettes have been a hot topic in the headlines for several years, causing concern about their impact on our health. I'm Dr. ArNelle Wright.  

Ioannidou: [00:00:09] And I'm Dr. Effie Ioannidou. And today we are exploring the impact of vaping on oral health. I have a story about this, but we can talk about this later. With our guests.  

Wright: [00:00:21] Oh, I'm so excited to hear your story  

Announcer: [00:00:25] From the American Dental Association, this is Dental Sound Bites. Created for dentists by dentists. Ready? Let's dive right into real talk on dentistry's daily wins and sticky situations. 

Wright: [00:00:41] Well, hello. Hello everyone. We've got a very interesting topic to discuss today, vaping and how it impacts oral health.  

Ioannidou: [00:00:50] First things first, if you want to be part of our Dental Sound Bites community. Please don't hesitate. Be a part of our community and take a moment to subscribe wherever you listen and stay updated with our new episodes. 

Wright: [00:01:05] And don't forget you can now watch every episode on the ADA's YouTube channel.  

Ioannidou: [00:01:10] Back to today's episode, our guest is very well versed in the topic. Please welcome my friend and colleague, Dr. Purnima Kumar.  

Kumar: [00:01:21] Thank you. Thank you. Thank you. So good to be here today with you guys.  

Wright: [00:01:24] Welcome. Welcome.  

Kumar: [00:01:26] I've been listening to these podcasts for a long time. It's so much fun.  

Ioannidou: [00:01:29] I know. Right. I mean, Nelle and I, we really enjoy our time on this podcast and we are so happy to have you here with us. So before we start, I know you quite well, but for our audience, tell us a little bit about yourself. Tell us how you came up with this research direction and your expertise in general in Perio and more. 

Kumar: [00:01:54] Ooh, where should we start? It's a long story. All of our stories, right? I mean, they are long and they're big and I don't think everyone wants to hear all of it, but I'll tell you very, very quickly. I tell people I'm like the sun. I rose in the East and I'm setting in the West. You know, lots of dental trainings. 

First, I started life in India, went to my, did dental training, my first patio training in India. Worked. Went to the Middle East, worked there for several years, was instrumented in setting up the first dental school there as well. Moved to England for a few months. And then I came to the United States to do my second Perio training and then my PhD along with that. I just stepped down as chair of the Council for Scientific Affairs of the ADA, I just finished my term. 

Wright: [00:02:46] Congratulations.  

Kumar: [00:02:48] Thank you. It was an absolute blast. And you know, the joy of working with the brightest minds in dentistry ever is like, Oh my God, it's fantastic. So yeah, that's a little about me. But my vaping story Effie is, is absolutely crazy. You're not going to believe this when I tell you the story. You know, the first time I heard about vape, you remember the grant that we got from the NIH, the smoking cessation grant way back when? 

Ioannidou: [00:03:16] Yeah.  

Kumar: [00:03:16] So we got an R01, which is a five-year grant from the NIH, to study the impact of smoking cessation. Right? So, I mean, think about it, talk about an uphill task, right? Getting people to quit smoking. And so we were doing that, and we were at 17 percent success rate. I am going to take that for a win. It was doing great. 

But then some of our patients came to me and they said, subjects, subjects, they came to me and they said, hey, can we use e-cigarettes to quit? And you know, this is how smart I was back in the day. I thought it was an online support tool. And I said, of course, yes, of course. I mean, go for it, right? 

That's how much I knew about electronic cigarettes. It's electronic cigarettes. And I thought it's an online tool. And, and I go back to the lab and I tell the kids the story. I'm like, Hey, this person was asking about it. And they said, you know, it's a device, right? Like, what do you mean? They're like, you put it in your mouth and you suck on it. 

And I was like, Oh, good heavens. So you're not going to smoke a cigarette, but you're going to suck on something. And they're like, yes, it's heated. So we paused the smoking cessation study because, you know, we didn't want people to quit smoking and use e-cigarettes without us knowing. So it was a confounder for our study. 

So we put it on pause and then we, I got a funding from the Food and Drug Administration, FDA, to actually study vaping. And that was the first vaping study. And I'll tell you this, you know, I did the study. We have twin daughters and they were 19 and, and freshmen in high school, in college at that time. 

And they were at Ohio State where I was. So, so I go home and I'm like, Hey, I'm paying 50 bucks, for spit, plaque samples. I'm just going to take quick measurements of, you know, their teeth and other stuff. Fifty bucks, 25 minutes in and out. Let me know if your friends are interested. Seventy-five percent of my population, of my subjects, came from my girl's, daughter's, friends' group. Four of them, I had driven to soccer practice. 

One of them looks at me and says, Mrs. Kumar, are you going to tell my mom? And I'm like, I cannot tell your mom because you've signed the consent form. But you know what? You're done. Once I collect your sample, you are done using this. I am watching you and you'll wish in the end that I actually told your mom. You're done. You're not using this anymore. 

So really that's where we started. We, our kids, our subjects were so young. So young, right? And, and it was shocking to see, I mean, with, with smokers, we're always used to seeing the 40, 50, 60-year-olds in our, that's, I mean, for decades I've studied smoking and I'm so used to that population being in my chair. 

And then I'm getting the 18, 19, 20-year-olds. And really, ever since I started doing e-cigarette research, we completely shifted our demographic. It is more young people.  

Ioannidou: [00:06:11] It's the epidemic of the, you know, teenage years for sure.  

Kumar: [00:06:15] I'm sure you've seen that, Effie, as well.  

Ioannidou: [00:06:17] And this is actually the story that I wanted to share. 

I've seen this and I, my daughter was vaping when she was, and we found out, completely accidentally. She was vaping when she was in high school for a very short period of time. The funny story is when you, at the time, when I found out four years, five years ago that she was vaping, I was not even sure what I was looking for. I didn't know how the device looks. Like, you know, when our, when we were young, we were cigarette smokers, right? Parents knew what they were looking for. They were looking for a pack of cigarettes. I was so uninformed. I had no idea. Exactly what you said, Purnima. I had no idea exactly how the device looks. And it's so tiny that it can be hidden anywhere.  

Kumar: [00:07:08] Absolutely Effie. I'm going to tell you the story, you know, really when I started and it really evolved in that, that, you know, one year period that we collected these samples, the entire spectrum of vape evolved. It looked like a cigarette. It started like a cigarette, you know? And again, I forgot to tell you this, but I'm actually the ADA spokesperson on vaping and smoking.  

Wright: [00:07:28] Yeah.  

Kumar: [00:07:29] So given that I've done a lot of these talks and, you know, talk to the media about this quite a bit. So when we first started, a vape looked, it was called a vape pen, and it looked like a cigarette. 

It even had that white and brown structure on it just to make you feel. Right? And then, Suddenly, it looked like a hand grenade. It had these little round, long things and then it had a thing sticking out of it. So it looked like these little grenades. You remember those, those lip glosses that used to come in these little round things that we all used in our mouths and lips and back then. So it looked like that. 

And then the third generation came out. Which looked like your fricking TV remote control. It looked like you were holding your TV remote to your mouth with a little, you know, if you had a TV remote, it's the same size as that, that size. And if it had a little pipe sticking out of it and you were vaping it. So it looked like literally people were sucking on their TV remote controls. Right? 

And that is the problem with studying this because vaping is, the attraction to vaping, apart from it being so cool and all of the, and we'll talk about that in a minute, but the problem with studying vaping is that you can personalize these devices. 

They're actually called egos. Like it's your ego, right? So you can do something. So it's on the go as well as it's your ego. See what a lovely play on words, right?  And it's also called a mod. It's a modifiable device, which means you can put as much of the liquid, the nicotine containing liquid or whatever, the vaporizing liquid, as much of it as you want. 

You can add anything from two drops to 20 drops. And you can crank up the voltage all the way to whatever you want. So each person can personalize the vape to how much of a hit that they need. So then how do you study this? You know, you're the vape who vaping is not the vape that I am vaping. And, and it can be completely different from someone else.  

Wright: [00:09:29] Well, we jumped right into our episode. I love that we got straight to it. I want to just kind of do some level setting really quickly and just for all of our community members out there, if you could, I know you, you talked about vaping, like you've kind of described it in so many ways, but just for like a quick definition, can you just tell everybody what exactly is vaping and what falls under this category? 

Because, this is going to sound really crazy and my ignorance is going to show, but I was always confused about if it was nicotine or not, or if you could even vape nicotine. And so I bet some other people might have that, you know, same question.  

Kumar: [00:10:09] Okay. So a vape is actually a very simple construct. A vape is so simple. I mean, the simplicity of it is really quite spectacular. It's basically a little cartridge that contains a fluid and the cartridge is, you know, there's the fluid comes out of the cartridge through a cotton. So right next to the cartridge is a cotton ball. And right next, right behind the cartridge, is a heating coil. 

So basically the fluid gets sucked into the cotton ball, gets absorbed into the cotton ball, which then gets heated, and this heated liquid now vaporizes to produce an aerosol, which is then emitted. So there's a battery, there's a heating coil, and there's a cartridge, and there's cotton. That's it. That's the entire vape construct. 

So that's, that's how this, this thing works. Then the magic is in that liquid that goes into the cartridge.  

Wright: Okay.  

Kumar: And that liquid, if you, anytime you read what is in it, I mean, and according, officially, according to what the label says, that liquid typically contains a vehicle to, you know, to hold all of these things. The vehicle can be propylene, glycol or glycerol. So glycerol is basically, we all know glycerol, right? It's what makes your ice cream fluffy. So it has that, you know, the cool whip, that's, and propylene glycol is antifreeze. So you have these two products and that is the vehicle. 

And then you have multiple flavoring agents. They can be anything, anything from bananas foster to pomegranate juice, to tobacco flavoring, to mint flavoring, to candy flavoring, to whatever. You name it, there's, last documentation I read, there are 7,764 flavors.  

Wright: Oh my gosh.  

Kumar: Right?  

Wright: [00:12:09] 8,000 flavors. That's crazy.  

Ioannidou: [00:12:12] Yes. They make it very attractive, right? 

Kumar: [00:12:14] Exactly.  

Wright: [00:12:15] Oh, yeah. Very appealing.   

Kumar: [00:12:17] Exactly. Right. When you think of something and they make it look wholesome. You can have nicotine or no nicotine in vape. Vape can be nicotine free as well as nicotine containing. However, if you look at all the studies, many studies, many reports in many, you know, very, very powerful scientific journals have shown that even, that liquid that is marketed as nicotine free tends to contain some level of nicotine. 

So, you know, the standardization of these products is not where we want it to be. So that is something that is there. And when they say it contains three milligrams of nicotine or six or 18 milligrams of nicotine or those, they are not standard as well. That is highly variable and there are a lot of batch effects and so the same e-juice that you might be buying today can be quite different from the next batch of e-liquid that you're buying. 

So all of these variabilities are happening in that.  

Ioannidou: Exactly.  

Kumar: So the, you know, there's documentation. Now it's been 10 years. So it really came to the market in 2009. In 2011, it came into mainstream. And from 2017, 2018, it really took off. It really took off in a big way. And of course, the pandemic contributed to a lot of, you know, at home using, you know, that kind of thing. 

So you couldn't monitor it as much, you know, all our studies were paused. We didn't know what the documentation was, what the demographics were. So all of these things were going on. So if you're actually looking at about 10 years' worth of exposure of people to vape. So just now beginning to collect data on what happens on the lung, the cardiovascular system, the oral cavity. And today we'll talk a little bit about the oral cavity.  

Ioannidou: [00:14:07] But what I want to ask, Purnima, is that it sounds so appealing, so attractive, 7,000 flavors. But what happens to someone that vapes, right? This is what they forget to mention. They've mentioned the flavors. So what happens? Tell us, speak a little bit about the adverse events for systemic health and oral health, right? And how different is it from smoking? Or, is it different?  

Kumar: [00:14:34] I'll tell you about my research, but let's set the stage by saying what other people are finding, right? What are these incidental findings? So there's all these studies that are coming out to show that vapers have higher caries. They have much higher caries than, than non-vapers. And for the same amount of plaque, they have a higher level of gingival inflammation. So there's more bleeding gums, there's more redness, there's more gingival inflammation for the same amount of plaque. There's also some studies that seem to suggest that vapers have a higher prevalence of periodontitis, the irreversible form of gum disease. So, there does seem to be some evidence. 

Although that, you know, it's a chronic disease. So if you only have an exposure for 10 years, how do you immediately say the chronic disease can be attributed to that? So that is a little, we need more time to actually tie it in a hundred percent to that. And that's the problem. 

That's the problem. Effie, you've been on study sections, so you know how the system works. So, the first time I submitted a grant proposal to the National Institutes of Health, three of the reviewers -- they always get reviewed by three or four people -- all three reviewers said there is no evidence to say that vaping causes periodontitis. Therefore, the significance of this grant is not very high.  

Right, and so we had to write a rebuttal to that saying, listen up you all, peridontitis, by the time you even measure one millimeter of attachment loss, it takes five years. And so we're measuring disease in increments of one millimeter, and this has been in the market for only 10 years. We don't have, so if you're going to wait 50 years. Then probably you might be able to do that. And haven't we made that mistake once already with smoking? We waited 50 years before this country would even stand up and say maybe, possibly, we think that smoking might cause lung cancer.  

Ioannidou: Yeah. Yeah.  

Kumar: So one, you cannot wait 50 years, you're not going to wait a whole generation to have disease and then say, Oh my God, maybe we need to do something about this. 

Fortunately, what we're able to do now is look for what is known as intermediate markers of harm. You know, our body responds very quickly at the molecular level. So, and, you know, if you're looking for clinical science, they take much longer to happen, but the damage process begins very, very, very early on, some 10, 15, 20 years before it can be clinically evident in chronic diseases. 

And now, since we use molecular biology, there's multiple ways of studying it. One of the simplest ways, because it's the mouth and we are very lucky to be studying the mouth. One of the simplest ways is to study the bacteria that live in our mouth. You know, everybody thinks, Oh, bacteria, who cares? We're going to brush it off. You're going to use mouthwash on it and destroy it, right? It's, it's bad for you.  

But actually, the evidence is the other way. These bacteria that are present in our mouth, we acquired them before you blew out your first birthday candle. This is it. This is it. Your microbiome was established, and you got it from your mom, mostly from your mom, a little bit from your dad, from her microbiome. And so this was established in your mouth, but before your first birthday, and this trained your immune system to establish this equilibrium, right?  

And it, it keeps your mouth healthy. It keeps your gums tight against each other. It does a lot of wonderful, positive things. So it actively participates in keeping us healthy. This thing called the microbiome, the bacteria that live in our mouth. 

The beautiful thing about bacteria is they can, one can become two in four minutes. By the time the human cell wakes up and says, Oh my God, something is going on here, let me respond to it, five generations of bacteria have passed by. There's a great, great, great, great grandchild of that one that has come in. So it responds like that, right? It's like, let's go, let's go, let's go. They have been living on earth since the earth was cooling.  

So we can use these bacteria almost like a cannary in the coal mine. We can say, Oh my gosh, what's going on. Can we measure the harm that this is causing? How are the bacteria respond? They know how to respond to harm and, and how to, and then you can look at the interaction between the bacteria and the mucosal system. And you can study these at a molecular level. So you have what is known as an intermediate marker of harm. 

And those are the things that we are measuring and we are saying, look everyone, things are not well, there's so much going on here, these, and, you know, the first sign that bacteria, that things are going to go south in your body. Remember how you get a cold before you get a cough? You get sniffles, you get cold, you get a runny nose, you get the phlegm. And then you start coughing and then you get chills and you get a fever, right?  

That first step of creating that phlegm is when bacteria start cloaking themselves in this thick cell, because they're responding to stress by covering themselves in this thick cell layer that comes out as mucus, right? 

Same thing in the mouth. As soon as these bacteria start looking at vape and get exposed to them, they go into what is known as osmotic shock and heat shock. And so they're not going to die just because you, you know, try to burn them alive. They will just cover themselves in a slime layer and sit very comfortably in that. 

Our body looks at the slime layer and says, Oh my God. And you know, this is madness. The immune system goes crazy. The inflammation goes crazy high and they're trying to push it out. So, our immune system goes completely nuts over it. Right? So now by measuring what, how much slime layer happens and how quickly the slime layer happens, and how much immune inflammation happens, and what these immune markers are, we are able to measure how quickly e-cigarettes or cigarettes can cause harm to your body. 

It's not yet measurable as clinical disease because that's going to downstream. It's going to happen a little bit later. But right now, you can actually measure how much harm is happening and quantify the harm, right? So we actually did that study and we're finding out -- okay, hold on to your seats here – this is this is so I mean, when I saw that I was, I I mean, I was so angry. I'm just gonna say it. I was angry, right? I was just angry because we compared smokers who have been smoking for five years, right? And we measured the amount of harm. So you can have like a harm index, right? We can measure how much the shifting, and we call this dysbiosis, which means how much the community is becoming more like disease like, right? 

So, so how much it's shifting. We measured the amount of dysbiosis after five years of smoking, and we found that was equal to, guess how long it takes to establish that dysbiosis in vaping? Take a number.  

Ioannidou: [00:21:37] I don't know. Six months.  

Kumar: [00:21:39] Six months. Effie, you know the data. Stop it. Yes. Six months to one year of vaping.  

Wright: [00:21:46] That's crazy.  

Kumar: [00:21:47] Isn't it? It's crazy. I'm just angry. I'm just angry at this point.  

Ioannidou: [00:21:53] But it's so valuable. This data is really valuable. And just to highlight that this is your own data, Purnima, right? This is from your study.  

Kumar: [00:22:01] Yes.  

Ioannidou: [00:22:02] And tell us a little bit about the study. This is the e-cigarette study, right?  

Kumar: [00:22:06] This is the e-cigarette study.  

Ioannidou: [00:22:07] Funded by, let's advertise you a bit.   

Kumar: [00:22:12] So we have a R01, which is a five year, multimillion dollar grant to study e-cigarettes. And this was funded by the NIH and the grant before this was funded by the Food and Drug Administration. So we have different grants that get funded by different folks. So in this grant, the way we did the study was, people who never smoke or never wait. One group, the control, the good, good people. The no, I don't mean good, good.  

Wright: [00:22:38] We know what to mean.  

Kumar: [00:22:38] The control group, right?  The healthy, healthy people. And then people who only vape. And then remember I had this group that was going to quit smoking and start vaping, so the quitters who used vape, because that was marketed as a smoking cessation tool. And then a group that was using both vape and cigarettes. There is a group like that, and they're a very large group now. So we compared all of these groups, and we said, is smoking and vaping causing the same type of change? 

And we found no smoking has its own type of change. Vaping has its own type of change. But when you quit smoking and start vaping, you don't become healthy. You become more like a vaper. And when you use both smoke cigarettes and vape, you become more like a vaper. So vaping and rock, paper, scissors, if you played rock, paper, scissors, vaping is really beats  

Ioannidou: Kills everything. 

Kumar: Yeah. It kills everything.  

Wright: Wow. 

Kumar: So then we said, okay, what happens? Because, you know, if you take anything into your mouth, like if you ate a salad today, the bacteria in your mouth are actually going to break down the salad and produce these beautiful compounds called nitrates, which open up your blood vessels and lower your blood pressure, which is why eating salad is good for your heart. 

Because the bacteria on your mouth and your gut help to break this down. So bacteria will eat anything, anything. They will chew on anything. So we said, okay, what happens when you vape? What do the bacteria do to it? The bacteria actually break down that vapor. You know, these, when you think about glycerol and glycol, they are giant carbon molecule. It is C26. Think of six, you know, 26 carbon molecules. It's a giant organic compound. What these bacteria do is they look at it and like, Oh my God, it's like a hamburger meal. And they literally break it down into all of these compounds.

Ioannidou: Hmm.  

Kumar: And they chew it up. And so they produce what are known as these active metabolites, which then have more effect on it. Right? So, this is a cycle that keeps perpetuating and perpetuating and perpetuating. And worst thing is when you actually heat that little piece of,  so everybody, when, and, Effie, this is exactly what you and I were talking about some time ago, people look at this and say, Why should this be harmful? You get passion fruit flavoring. Yeah, it is a flavor. What's wrong with that? You know what? Bananas foster banana flavored chocolate. You eat it. What's wrong with that?  

The problem is these are all generally regarded as safe for human use. So it's called grass, all of these, right? They're generally regarded as safe for human use, but as labeled. What happens is when you heat these products. Under very high pressure at these high temperatures, they break down. They produce acetaldehyde, formaldehyde, acrolein, things that, you know, are used to mummify you when you're dead.   

Wright: [00:25:25] Like that. Put a pause in that.  

Ioannidou: [00:25:28] Yes, that's a very good parallel for people to understand how toxic these things are, right?  

Kumar: [00:25:35] Effie, I was reading a study the other day, and it shocked me even more, if it's possible to shock someone, right? At some point you become numb, but I don't think so. We actually, and we threw out some data because when we looked at that liquid, you know, the vapor as it came out, we actually did what is known as a gas chromatography and tried to identify all the compounds. And we did this with colleagues at the National Institutes of Standards and Technology, NIST. 

So it is a government organization. We did a very nice study with them. And what we were finding was all this cadmium and lead and cobalt and we're like, Hmm, something wrong. There's a contaminant, something wrong, something wrong. So we didn't publish that data. We, you know, sometimes you have to sit on your data. And we didn't know. So we said, okay, you know what? Sit on it. Don't publish it. My grad student was upset, but I said, it could be just a contaminant. Maybe you ran the reaction wrong. Something happened. Let it go. 

Then studies came out from labs who've been, toxicology labs, who do this really every day. You know, that is not a contaminant. You know where that's coming from? That little metal cartridge that contains that liquid, when it gets heated, these metals are being released from the cartridge.  

Ioannidou: [00:26:49] Wow. Wow. It's really scary. It's really scary.  

Wright: [00:26:55] We'll be right back.  

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Wright: [00:27:49] Welcome back to the Dental Sound Bites podcast. We're having a conversation about the impacts of vaping on oral health with Dr. Purnima Kumar.  

Ioannidou: [00:28:00] It's fascinating the information that you are offering Purnima. And I want to ask, tell us a little bit, you have discovered all these things, right? You and others. How does this affect the practice of dentistry? Like what do we, what, how should we inform our patients? Is there anything, any indicators that the dentist could observe and look out for?  

Kumar: [00:28:25] Good, great question. So, so again, serendipity, right? Would you, the best thing about combining patient practice with research is you go to morning, you go to see your patient in the morning, you come up with a new research question. You can go back to your lab in the afternoon and start answering that. You're, all your research questions come from your patients.  I do a lot of soft tissue grafting in my practice. I do a lot of soft tissue grafts, you know, post orthodontic young, younger adults. I do a lot of it. And I'm, even though I say so myself, I'm pretty good at it. 

I'm pretty good at it. But then I started seeing this little bit, you know, I started seeing this failure, like, you know, graft exposure, flap dehiscence, you know, things going south. I was like, Hey, what's going on, what's going on. And then consistently, I started hearing from these kids, yes, I vape. And I started asking them, do you smoke? And I never asked, do you vape? So I said, do you vape? Do you vape? They said, yes.  

So then we did a wound healing study. We, we actually called people in, created two punch biopsy wounds in the roof of their mouth, five-millimeter punch biopsies, itty bitty stuff, nothing major, right? Then you expect a punch biopsy to heal within four to seven days, maximum 10 days, the wound will completely close. 

Unless you vape. In vapors, a five-millimeter wound did not close for 21 days.  

Ioannidou: Wow. Yeah.  

Kumar: Doesn't heal.  

Wright: [00:29:48] Oh my gosh.  

Kumar: [00:29:50] Right. Right. So I'm still good at what I do.  

Wright: There you go.  

Kumar: Right. No, no, I'm saying, but, but these are the things that you're finding out every day. Right. What, and so the other thing we found when we created these punch biopsies, our vapers bled a lot more and bled a lot longer. 

So there is an increased bleeding tendency in them. So we're now trying to investigate what causes the bleeding tendency, you know, where the changes are, but they bleed a lot more and they bleed a lot longer. You know, you take a punch biopsy, you think it's done and, you know, you put a pack on it, you hold the pressure. They stopped bleeding. I mean, there's nothing major, but these people continued bleeding for significant amounts of time.  

Wright: [00:30:31] Yeah. So, while you're on the topic of clinical practice for all of our listeners out there, like, what kind of language can we use to help educate our patients that do report vaping on that medical history form, you know, like any post-op complications or, like, how can we, what language can we use to educate them now that we know this information? 

Kumar: [00:30:51] Right? So I think for vapers, what can we tell our patients, right? The first thing we need to tell people and we need to stop normalizing this word called vaping. It is an aerosol.  

Wright: Uh, okay.  

Kumar: Like your Raid and your, and your ant bait and your hairspray. It's an aerosol. Let's get that very clear. Vaping brings you, you know, steam facials and tea pots and tea kettles; it's got that comforting feeling to it. It's not. We need to start telling our patients it's an aerosol and it carries with it all the harms that an aerosol can. That's number one.  

The number two that I always tell all my patients is that it, that the studies, the data we have right now suggests that it puts them at increased harm for future disease. Definitely puts them at higher harm. It also causes their plaque to be much more gummy and gunky and mucousy. So what we're noticing is that that this plaque is much harder to remove. So, increasing oral prophylaxis, you know, now you have to brush, and you have to floss, and you have to do it twice a day, and making sure that these people are on higher recall intervals with us. 

Ioannidou: Yeah.  

Kumar: You know, seeing your dentist once a year for teeth cleaning is not sufficient for these people. You have to come in more often. You have to be close. And including vaping in informed consent, like if you're, we have smoking on most of our informed consents. It's time to bring vaping into our informed consents as well. 

So these are absolutely, absolutely critical. And warning patients that they might have a higher bleeding tendency. We're waiting to validate that on a larger sample size and, you know, but I think, I'm fairly confident, that that data will come out the way we saw it before. There can be a higher bleeding tendency in the mouth. I don't know about the other organs. We haven't studied it. But in the mouth there could be.  

Also that they are at higher risk for cavities and therefore, you know, the same things that we talk about frequency of sugar intake. You know, brushing after sugar. You know, those kinds of important life messages become even more important for them because now they're double risk, right? 

They have vaping and they're eating higher sugar. So their risk for cavities and things like that is much higher. So, there's a lot that we can talk to our patients about, and I think the most important help we can provide them is frequent maintenance, recall and maintenance. 

I keep these patients on a three month recall with me. I'm like, we're not, we're not playing, we're not playing.  

Wright: [00:33:27] I was going to ask that.  

Kumar: [00:33:28] We're really not playing. You want to vape?  And especially now with the newer generation of vapes that have come out, they look very small and they can be easily, you know, mistaken for a smart, you know, a thumb drive, a memory stick. 

And the thing is they are different because they have a different nicotine chemistry. The salt, the nicotine is no longer the nicotine that you just get from the tobacco plant and you put into this. They have altered the chemistry of nicotine. Remember how I said, it takes five seconds. You need it to go hit your brain. So they've altered the chemistry of the nicotine to make it with salt, so it hits your brain faster.  

Wright: [00:34:05] Even faster than five to 15 seconds?  

Kumar: [00:34:08] Oh yeah, yeah, yeah. It's like, boom, it hits your head. So the addictive potential is higher. It's that. And because of its ease of use. So with the cigarette, something is very simple. You have to take it out. You have to light it. You smoke either the length of it. You know, it's a standard length. You smoke, whatever you do, you stub it out and you have to move on. Vape is not like that. It is, you know, you can pick it up, you can. A couple of puffs, you can put it down and you can move on. 

Now there are reports coming out, you know how you go to sleep at night and you don't even think about it, you just drink a glass of water while you're asleep and you don't even think about it? You don't even remember when you wake up that you actually drank some water. People are now vaping like that. 

It's by their bedside table. They wake up, take a couple of puffs, they go to bed. So, it's very difficult for people to self-regulate and self-document what they're doing with this.  

Ioannidou: [00:34:59] I'm thinking now, and again, my research line is not on this, but I'm thinking cigarette smoking was also easier to quantify, right? We used to say a pack a day, a pack and a half, two, whatever. How can you quantify vaping? Based on what? Based on the hits?  

Wright: [00:35:17] Maybe that's the whole idea.  

Kumar: [00:35:19] Right. Right. This is the whole, this is exactly it, Effie, and that is assuming everybody's using the same type of vaping device, right? There's, there's heterogeneity in devices. There is heterogeneity in the liquid composition. There is heterogeneity in the flavoring agent. That each brand comes with its own thing.  

You know, this time last year, actually, September 2023, I was in Australia, and I did more than 14 or 15 TV and radio interviews because Australia decided to ban vapes. They said, Oh, you want this to be a smoking cessation device? Fantastic. Get a prescription. We'll make it available to you. We want to help quit smoking, but on prescription. You don't walk into the next, you know, 7-Eleven or Speedway and buy it off the shelf. They're pulling it off the shelves. So, this year, I was now back exactly a year after I did those interviews, and I talked to them and all of that. 

It was great. People were calling me and I didn't even know. I learned about places in Australia based on the TV stations that were calling me. They’re like, this is Radio Hobart, and I'm checking on the map. Where is Hobart? You know? So, this year I went back. And exactly a year after that, I went back and I asked them, how's it going? 

I'm so proud of you guys that you actually banned it. How's it going? They said, no, we cannot regulate it. People are still buying it. They're buying it online. They just get it shipped through, you know, some store. So, it just, you can order a product from any part of the world and have it shipped to you. How do you, how do you control these things anymore?  

Ioannidou: [00:36:56] Yeah, it's, it's really hard for sure. It's really hard, but I think, and my question connects to this. I think it's really important for people to understand the consequences of vaping. I think it's a matter of education, right? And, and closing with our very interesting conversation, I would like to ask you, and I know you touched upon this, but I think it's important for us to put like a summary of, you know, this information that will be handy for all the practitioners. So how can dentists and practitioners address this? You spoke about more frequent recalls. You spoke about medical history. Bring like two, three points that we as practitioners have to remember.  

Kumar: [00:37:40] Yes. So I would say as practitioners, our duty is, again, we are life coaches. We are not just dentists, right? We are life coaches as well.  

Wright: [00:37:49] Oh, I love that so much.  

Kumar: [00:37:51] So, part of our life coaching is to take a detailed history. That's where it begins. You know, if you're vaping, I mean, again, being nonjudgmental, just take the history and say, Hey, I noticed some changes. I want to ask you, elicit the history. Do you vape? Have you ever used a vape cigarette before? Do you know what vaping is? And then having that conversation. And saying, here's the data, here are the resources. This is what happens. So, that part of education. 

And we did this beautiful thing, the ADA CE panel, we did this beautiful survey. 

It's, you know, JADA. Where we showed that when you offer smoking cessation, but this is a smoking cessation, but we said when you offer smoking cessation counseling to multiple teams, members, so the hygienist speaks to you, the assistant speaks to you, the doctor speaks to you. When it comes from multiple sources that the, you know, the compliance with that is much higher. 

So highly educating our teams, our dental teams around this and saying, I am not just the doctor alone speaking to the patient. You guys are part of this process. Let's all of us have these conversations. Let everyone talk to them and being watchful for science. Your hygienist will tell you, listen, as I polish this, this block seems to be very adherent. It's very thick. It's very gunky. It doesn't look good.  

Looking for things like clues, like, I mean, really at this point, we're searching for clues. Do you see extra dryness? And, and I just want to bring this up. I know we have a minute and last minute one information. But there are studies coming out, some from our lab, some from other labs, that smoking causes higher candidiasis. So higher fungal infections in the mouth, and it is not the classic white, curdy white patch candidiasis that we're so used to seeing the pseudomembranous form. This is more erosive. It looks like dry lips. It looks like little corners of the mouth. It looks like glossodynia. So it's very atypical candidiasis. 

So watching for those signs, like really it is like playing Sherlock Holmes in this kid's lives, right? And we do that as parents. We are constantly looking to see what, you know, what's changing in our children's lives. I think we just need to carry that into our practice. And also say at a policy level, start to think about frequent maintenance, frequent recalls. bringing them in, educating them about wound healing, regular stuff, you know, and then informed consent. We really have to change our informed consents at this point.  

Ioannidou: [00:40:17] I loved it.  

Wright: [00:40:18] I love that.  

Announcer: [00:40:20] On the next Dental Sound Bites.  

Ioannidou: [00:40:22] Happy New Year. We are taking a break for the holidays. Hope everyone has a safe and enjoyable time. And we're returning in January in 2025.  

Wright: [00:40:33] Yes. Happy new year, everybody. We are going to be back with an amazing episode. One of your favorites. We have Dr. Marco Vujicic here, and we're going to be talking about what to expect from the dental profession in 2025.  

Ioannidou: [00:40:44] It will be amazing. 

Wright: [00:40:53] Wow, this was such a good episode. I feel like I learned so much and I just sat here just taking it all in because I'm like, Ooh, how can I incorporate this? I wanna talk to my team about that, you know? So this was really, really good. I know we've talked about a lot, and as we go ahead and close the episode, we wanna just give you the opportunity to share anything else that you wanted to add that we didn't get to cover? It's just so good just learning and hearing from you. So,  

Kumar: [00:41:22] Oh, no, I mean, you guys are so thorough. I think we went through a lot of stuff. We unpacked so many things. Oh my gosh.  

Wright: [00:41:30] Yeah, we did.  

Ioannidou: [00:41:33] I think it's very important for our audience to make sure that they don't underestimate the significance of vaping. Right? 

Kumar: [00:41:43] Absolutely.  

Ioannidou: [00:41:44] Yeah.  

Kumar: [00:41:45] Absolutely. Absolutely. No p values here. Right?  

Ioannidou: [00:41:49] I know. Thank you so much. Thank you Purnima for making the time. Yeah. Thank you for making the time to be with us today. We had a blast and tell our listeners, let them know where can they find you if you want to be found.  

Wright: [00:42:04] Cause I'm going to be looking. 

Kumar: [00:42:06] I’m at the University of Michigan. I'm very, very easy to find. So, if you say Purnima Kumar, University of Michigan. Fortunately, there aren't many Purnimas in this world, you know, at least in this part of the world, that are Periodontists. So, I'm easy to find as long as you can spell my name right. I'm not Purnina. I'm not Purina. I have been called Purina. Yeah, Pranima.  

But, just saying, all jokes aside, I'm at the University of Michigan, and that's a place. But the ADA has a lot of resources on this, you know, so definitely I would direct people to that page. We have, as a spokesperson for the ADA, we have done a lot of media interviews, a lot of media talks about this. And so there's a wealth of information available on ADA. Healthy Mouth .org [MouthHealthy.org]. So, there's a lot of it and we keep it updated and try and keep it as current as possible.  

So, yes, we actually did a lot of work. As part of, you know, my role there with this Council for Scientific Affairs. We actually spent a lot of time updating a lot of these resources and we will continue to do so. So yes, healthy mouth .org [MouthHealthy.org] is a place to go.  

Wright: [00:43:21] Thank you. Well, for all of our listeners, if you know someone that would love to learn more and hear this episode, please be sure to share it with them. them. Um, we're just so glad to have you here on the episode or on the show, Dr. Kumar. Thank you so much for being here. 

Um, yeah, I'm just glad that we had you.  

Ioannidou: [00:43:42] Thank you. 

Kumar: [00:43:44] Thank you so much. This was such fun. Thank you.  

Ioannidou: [00:43:46] And don't forget, don't forget, don't forget to rate the episode, to write a review and follow us on social media. We do this right. And don't forget that we now can watch us on the ADA YouTube channel. Tune in next week for a bonus episode on this topic. 

Announcer: [00:44:05] Thank you for joining us. Dental Sound Bites is an American Dental Association podcast. You can also find this show, resources, and more on the ADA member app and online at ADA.org/podcast.