E ‐ cigarettes effect on periodontal health: a systematic review

Background: Smoking is well known risk factors that promote periodontal tissue destruction. Both smoking and periodontitis nowadays consider as a common health problem globally. As smoking habit evolution, electronic cigarettes (E-cigs) have emerged as an alternative to cigarettes. The number of E-cigs smoker or vaping users around the world are increasing. However, information about the effect of E-cigs on periodontium is very lacking lately. The study aimed to compare the effect of cigarette consumption on periodontium by clinical health parameters between all smokers’ type. Method: This review follows the PRISMA guidelines. Document search was carried out in PubMed, Ebsco Host and Scopus using the keywords or phrases: (periodontal health) AND (((((electronic cigarette) OR Vaping) OR e-cig) OR electronic nicotine delivery system) OR nicotine delivery system). A total of 137 articles were obtained after the duplicates were eliminated and five articles were considered met the eligibility criteria for systematic review. Result: This review found that E-cigs are less harmful compared to tobacco cigarettes, with comparable result between E-cigs smoker and non-smoker on some clinical periodontal health parameters for mean probing depth, clinical attachment loss, score of plaque index (PI) and papillary bleeding index (PBI) as well. In contrast, the study reveals that bleeding on probing level was higher among non-smokers than smokers. Conclusion: E-cigs are less harmful compared to tobacco cigarettes on some clinical periodontal health parameters. This result should be interpreted with caution because there is currently insufficient data to investigate the effect of E-cigs on periodontal health through clinical parameters.


INTRODUCTION
Smoking-related diseases are a well-known public health issue that affects people all over the world. [1][2][3] According to WHO data, the smoking prevalence among people aged 15 years in high income countries is expected to be 22.4% in 2020 and 20.5% in 2025 for both sexes. In the meantime, WHO projected 22.4% and 20.5% for upper middleincome countries, against the 10.7% and 9.8% for the low-income countries. The projected data show a decrease from 2020 to 2025, but WHO estimates that 10% of deaths in 2020 will be caused by smoking. 4 As a result, smoking has become one of the world's major public health issues. 2,5 Periodontal diseases are oral disease that ranks first in the 2001 world book record as a common disease that is often found in the community. 6 Periodontitis, due to its high prevalence, is known as major global oral health problem. Periodontitis can negatively affect the tooth supporting structure lead to a decreasing of periodontal support to the teeth, impairing tooth function on mastication and also facial aesthetic, being the initial source of systemic infection and of course impairing the host quality of life. [7][8][9] Study from 1990-2010 showed that severe periodontitis was the sixth highest prevalence of the disease (11.2%) with an increase in prevalence of 57.3% in 10 years. 6,10 Smoking is well known risk factors that promote periodontal tissue destruction. 11 Both smoking and periodontitis nowadays consider as a common health problem globally. 7,12 Some countries now have laws that regulate and limit tobacco use in public places. Electronic cigarettes (E-cigs) have emerged as a popular alternative to cigarettes among adolescent smokers for the first time or former smokers who prefer Ecigs to be used for smoking cessation. The effects of E-cigsor vaping on oral health, particularly periodontal tissue, are rarely reported in the literature. 3 The use of E-cigs are increasing around the world, but more research into its effect on periodontal tissue is needed. On that basis, the purpose of this systematic review was to examine the current evidence and compare the effect of Ecigs and other types of smokers on periodontal tissue health using available clinical parameters.

Data Selection
The guidelines for PRISMA (Preferred  The studies included in the systematic review were classified into four types: case control studies 13

DISCUSSION
Adolescent's general perception of E-cigs compared to conventional cigarettes is considered to be less harmful 17 and less addictive 18,19 .
Escalating use of E-cigs may be partly due to public perception about E-cigs are less harmful dan smoke cigarettes. [20][21][22][23][24] Most of former smokers' belief that by using E-cigs, they are less risky, and can be a substitute and helpful for cigarettes smoking cessation, 25,26 and this systematic review confirms that believe.
This review found that E-cigs are less harmful compared to tobacco cigarettes, with comparable result between E-cigs smoker and non-smoker on some clinical periodontal health parameters for mean probing depth, clinical attachment loss, score of plaque index (PI) and also papillary bleeding index (PBI). In contrast, the study reveals that bleeding on probing level was higher among nonsmokers than smokers. This result should be interpreted with caution because there is currently insufficient data to investigate the effect of E-cigs on periodontal health through clinical parameters.
Bleeding on probing (BoP) is one of the fundamental clinical parameter health for periodontium. BoP related to early sign of clinical inflammation on periodontium. BoP can be found in early lesion of gingivitis and can be visualized earlier than redness and swelling. 27 Three studies reported that BoP site significantly higher in NS subjects comparing to ES or CS with no differences between ES and CS. 13 should not be considered a risk-free alternative.

CONFLICT OF INTEREST
No conflict of interest and financial disclosures were reported by the authors of this paper.