Tobacco-Free Nicotine Increases Risk of Infection and Nonunion Following Open Fixation of Mandibular Fracture

Background: The surge in electronic cigarettes and smokeless nicotine products has introduced an emerging concern. Although nicotine cessation is recommended to patients before surgery, existing guidelines are often based on evidence from combustible tobacco. No studies have evaluated how tobacco-free nicotine dependence (TFND) affects outcomes after mandibular fracture repair. The authors of the present study sought to examine whether TFND is associated with increased complications following open fixation of mandibular fracture. Methods: This was a retrospective cohort analysis of electronic medical records from multiple healthcare organizations. Patients who underwent open fixation for mandibular fracture were identified. Individuals with TFND, excluding those with cigarette or other tobacco product use, were compared to nicotine-free controls. Propensity score matching (1:1) accounted for demographics and comorbidities. Outcomes assessed within 1 year postoperatively included osteomyelitis, infected hardware, facial abscess formation, nonunion, periodontitis, dental caries, and onset of opioid use disorder. Adjusted risk ratios (RR) were calculated, with statistical significance set at P < .05. Results: Following propensity matching, each group had 2623 patients with similar characteristics. Patients with TFND had significantly higher risk of developing osteomyelitis (RR: 1.87, P < .001), infected hardware (RR: 1.46, P = .028), facial abscess formation (RR: 1.63, P = .001), nonunion (RR: 2.15, P = .001), and opioid use disorder (RR: 2.32, P = .009) compared to nicotine-free patients after mandibular fixation. Conclusions: Tobacco-free nicotine dependence significantly increases risk of infection and nonunion following mandibular fracture repair. As vaping and smokeless nicotine products become increasingly prevalent, perioperative screening and cessation counseling remain critical.