Nicotine-Induced Biological Masking and Oral Health: Investigating Diagnostic Silence and Disease Progression Among Young E-Cigarette Users

Abstract

The increasing use of electronic nicotine delivery systems (ENDS) among adolescents has raised concerns about nicotine dependence and oral health. This review examines how repeated vaping and nicotine-induced physiological changes may contribute to a state of “diagnostic silence,” in which oral disease progresses without being fully recognized by the user. Chemically complex e-cigarette aerosols can generate reactive oxygen species that contribute to oxidative stress and cellular damage, while nicotine-induced vasoconstriction can reduce visible inflammatory signs such as gingival bleeding. This biological masking may contribute to a perception gap between how young users assess their oral health and their clinical condition. In one study of young e-cigarette users in Pakistan, most participants rated their dental health positively despite objective clinical evidence of dental and periodontal disease. Evidence from other populations also indicates substantial oral health concerns among e-cigarette users. Together, these findings suggest that nicotine dependence, biological masking, and limited risk awareness may allow oral deterioration to progress while reducing users’ recognition of their own risk. This highlights the importance of proactive dental assessment and communication that helps young users understand that the absence of noticeable symptoms does not necessarily indicate good oral health.