Dental Professionals

Dentists and Dental Hygienists can help people quit smoking because they are experts in oral health, are accustomed to counseling about oral preventive health, and have broad exposure to the general population. 1 

Dental Professionals

             It is well documented that tobacco use affects virtually every organ in the human body causing an overall decrease in health as well as quality of life.11,14 In addition to being linked with numerous cancers and coronary conditions, tobacco use plays a strong role in the etiology of various oral conditions, including:1,2,6  

  • Oral Cancer
  • Leukoplakia
  • Periodontitis
  • Nicotine Stomatitis
  • Teeth Staining
  • Degeneration of salivary glands
  • Delayed wound healing           

             Smoking prevalence in the U.S. has slowly declined to about 13% in 2020, although over 30.8 million American adults still smoke.16 In 2015, 68.0% of adult smokers (22.7 million) said they would like to quit, but as of 2018, only 7.5% of adult smokers (2.9 million) were able to do so annually.17 An increasingly attractive venue for tobacco cessation is in the health-care setting where providers are seen as a credible source of cessation advice and patients are sensitive to their health at the time of the visit.2,6 In addition to being knowledgeable about the hazards of smoking, health-care providers are likely to have regular contact with their patients which allows for convenient follow-up opportunities.

           Dentists are favorably situated to provide cessation assistance due to the regularity of visits.1,2 Most dental patients receive care on a biannual basis, providing a mechanism for long-term contact to assess changes in oral health.1,2,6 Dental visits differ from visits to other health-care providers in that they are usually preventive rather than problem oriented.1,10 Additionally, patients today are more concerned about cosmetic dentistry than ever before, creating an opportunity to introduce cessation strategies for cosmetic reasons.2 

             Dental offices are such a promising avenue for providing tobacco cessation that many organizations have publicly encouraged and supported the idea, including:2  

                                            

 

             Recent research suggests that behavioral interventions, when paired with an oral examination, may increase tobacco abstinence rates among both cigarette smokers and smokeless tobacco users.18 Even a single session of behavioral intervention may be enough to promote smoking cessation, though a multi-session approach shows even better rates of success.19   

 

 

Smoking cessation counseling and treatment survey results from dentists21 

Smoking cessation counseling and treatment survey results from dentists21 

 

             Despite encouragement from these national organizations, surveys suggest that only half of US dental offices offer smoking cessation counseling, treatment, or some combination of both to their patients.21 The vast majority of the time, counseling involves the dentist or both the dentist and the hygienist.21 Of those who offer counseling and or treatment, 69% stated that they would be willing to prescribe pharmacological treatments to assist patients with cessation.21 Of note, one quarter of dental professionals who reported not engaging in smoking cessation counseling and/or treatment were current or former smokers, vapers, or smokeless tobacco users themselves.21 The majority of dentists polled were unaware that most medical benefits cover both counseling and pharmacological treatment for smoking cessation.21 Other obstacles associated with dental cessation practices include:2,6,7,8,9 

  • Patient resistance 
  • Amount of time required  
  • Advice lacking enough information to be helpful
  • Concerns about effectiveness 
  • Absence of educational materials 
  • Lack of reimbursement 

             Relatively few health-care professionals are familiar with tobacco use rates among their adolescent patients— an age when tobacco use initiation is at its peak. In 2020, nearly 7% of middle school students and 25% of high school students reported currently using a tobacco product.17 As such, pediatric dentists play a vital role in the promotion of smoking cessation in youths.22 Yet, studies show very few dentists (26%) could estimate smoking prevalence within that age group, compared to 38% of pediatricians and 48% of family practitioners.7 As a consequence, fewer than 1 in 10 dentists reported “always” counseling this age group while more than 3 in 10 reported “seldom or never” counseling them.7,12 Common excuses from dentists include:1,7 

  • “Counseling is ineffective in altering behavior of adolescents”  
  • “It’s difficult to know which of my patients are truly at risk” 
  • “I don’t feel qualified to counsel patients on this matter” 

           The American Academy of Pediatric Dentists (AAPD) recommends beginning to counsel all patients about the consequences of tobacco use and second-hand smoke exposure between the ages of 6-12 years.22 When polled, parents, even those who smoked, were overwhelmingly in favor of dentists discussing tobacco use with their children.22 In instances of identified tobacco use, the AAPD recommends referring patients to primary care and/or behavioral interventions for additional recommendations and support.22 

Dental professionals can help smokers quit by: 23 

  • Consistently identifying patients who smoke,  
  • Advising them to quit, and  
  • Offering them information about cessation treatment. 

            Despite a lack of knowledge being cited as a major barrier to smoking cessation counseling and treatment, one study found that 95.2% of dentists are willing or very willing to receive training in tobacco cessation.2, 20 These studies indicate that dental professionals believe tobacco cessation should be a part of dental care, but that certain barriers (e.g. training, time, reimbursement, etc.) need to be overcome before cessation activities can be integrated into routine practice.20, 22 Experts believe a curriculum change in dental schools that includes tobacco cessation training is paramount to improving cessation behaviors in practice.1,6 Additionally, cessation advice should not be the sole responsibility of the dentist. Instead, the work-load should be distributed across all practice staff as to minimize the burden for any one person. Front office staff can maintain tobacco-related documents in patients’ charts, acting as a prompt for discussion of tobacco use, while hygienists can focus more on the actual cessation advice. Dental hygienists are best positioned to deliver brief tobacco cessation counseling for a variety of reasons including:1,6,7,13,14 

  • They have more time with patients  
  • They are keen to learn and apply new skills 
  • This type of education fits well with the other health behavior messages delivered by the hygienist (e.g. brushing and flossing, etc.) 
  • The cleaning visit is especially suitable for tobacco intervention. It is a long, scheduled visit, and provides sufficient time for feedback on tobacco’s impact on oral health 
 

Brief Intervention    

            The Clinical Practice Guidelines for Treatment of Tobacco Use and Dependence advocates the use of the ‘5 As’ of tobacco cessation intervention to be delivered by health-care practitioners.6 The 5 A’s consist of:2,5,6 

  • Ask patients routinely about their tobacco use status 
  • Advise all tobacco-using patients to quit 
  • Assess the readiness of tobacco users to quit 
  • Assist all tobacco users interested in quitting 
  • Arrange for patient follow-up care 

            One approach is based on the 5 A's model of tobacco cessation, wherein the entire burden of the intervention falls on the dental practice. The second approach uses an abbreviated model (3 A's), in which the dental practice is responsible for identifying and advising tobacco-using patients to quit, but refers proactive patients interested in quitting to a tobacco quitline for counseling. For more information on the 5 A's please click here.(link is external) 

            If dental practitioners provided cessation assistance routinely to their patients and achieved even modest success rates, the public health impact would be enormous. Researchers and clinicians must continue to work together towards universal adoption of effective tobacco cessation interventions at each clinical encounter. 

  

Did you know that the Medicaid population is significantly more likely to use tobacco than the general population? Do you want to enhance your skills at reaching and intervening with Medicaid patients who use tobacco? Maryland TCRC has an online training to teach you the strategies that can be utilized with all patients—regardless of their health insurance status. You can sign-up for this FREE self-paced online training by going to https://HABITSLabTraining.litmos.com/self-signup/ and entering the training code, "medicaid".  

 

Additional Resources:  

References: 
  1. Albert, D. A., Severson, H., Gordon, J., Ward, A., Andrews, J., & Sadowsky, D. (2005). Tobacco attitudes, practices, and behaviors: A survey of dentists participating in managed care. Nicotine & Tobacco Research, 7 (1), S9-S18 

  2. Albert, D., Ward, A., Ahluwalia, K., & Sadowsky, D. (2002). Addressing tobacco in managed care: A survey of dentists' knowledge, attitudes, and behaviors. American Journal Of Public Health, 92(6), 997-1001. 

  3. Centers for Disease Control and Prevention . ( 2002 ). Cigarette smoking among adults.  United States, 2000. MMWR Morbidity and Mortality Weekly Report, 51 , 642 – 645. 

  4. Dolan TA, McGorray SP, Grinstead-Skigen CL, Meddenburg R. Tobacco control activities in U.S. dental practices. 1997; 128:1669-1679. 

  5. Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., et al. (2008). Treating tobacco use and dependence: 2008 update—Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 

  6. Gordon, J. S., Lichtenstein, E., Severson, H. H., & Andrews, J. A. (2006). Tobacco cessation in dental settings: Research findings and future directions. Drug And Alcohol Review, 25(1), 27-37. 

  7. Gregorio, D. I. (1994). Counseling adolescents for smoking prevention: A survey of primary care physicians and dentists. American Journal Of Public Health, 84(7), 1151-1153. 

  8. Hastreiter RJ, Bakdash B, Roesch MH, Walseth J. Use of tobacco prevention and cessation strategies and techniques in the dental office. J Am Dent Assoc. 1994; 125:1475-1484. 

  9. Jones RB, Pomrehn PR, Mecklenburg RE, Lindsay EA, Manley M, Ockene JK. The COMMIT dental model: tobacco control practices and attitudes. Dental Association 1993; 124;92-104. 

  10. Manski, R. J., & Moeller, J. F. (2002). Use of dental services: An analysis of visits, procedures and providers, 1996. The Journal Of The American Dental Association, 133, 167–175. 

  11. Salive M. C., Cornoni-Huntley J., LaCroix A. Z., Ostfield A. M., Wallace R. B., Hennekens C. H. Predictors of smoking cessation and relapse in older adults. American Journal Of Public Health 1992; 82: 1268–71. 

  12. Seffrome JR, Stauffer DJ. Patient education on cigarette smoking: the dentist's role. The Journal Of American Dental Association 1976; 92:7514. 

  13. Severson, H. H., Eakin, E. G., Stevens, V. J., & Lichtenstein, E. (1990). Dental office practices for tobacco users; independent practice HMO clinics. American Journal of Public Health, 80, 1503–1505. 

  14. Tait, R. J., Hulse, G. K., Waterreus, A., Flicker, L., Lautenschlager, N. T., Jamrozik, K., & Almeida, O. P. (2007). Effectiveness of a smoking cessation intervention in older adults. Addiction, 102(1), 148-155. 

  15. Tong, E. K., Strouse, R., Hall, J., Kovac, M., & Schroeder, S. A. (2010). National survey of U.S. health professionals' smoking prevalence, cessation practices, and beliefs. Nicotine & Tobacco Research, 12(7), 724-733. 

  16. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States; 2022. Retrieved September 22, 2022 from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm  

  17. Centers for Disease Control and Prevention. Smoking Cessation: Fast Facts; 2022. Retrieved September 22, 2022 from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/smoking-cessation-fast-facts/index.html  

  18. Carr, A. B., & Ebbert, J. (2012). Interventions for tobacco cessation in the dental setting. Cochrane database of systematic reviews, (6). Retrieved September 14, 2022 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3916957/ 

  19. Holliday, R., Hong, B., McColl, E., Livingstone-Banks, J., & Preshaw, P. M. (2021). Interventions for tobacco cessation delivered by dental professionals. Cochrane Database of Systematic Reviews, (2). Retrieved September 19, 2022 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8095016/ 

  20. Bendotti, H., McGowan, K., & Lawler, S. (2021). Utilisation of a brief tobacco smoking cessation intervention tool in public dental services. Health Promotion Journal of Australia, 32, 367-377. Retrieved September 19, 2022 from: https://onlinelibrary.wiley.com/doi/abs/10.1002/hpja.448 

  21. Kumar, P., Viola, T., Frazier, K., Duong, M. L., Khajotia, S., & Urquhart, O. (2021). Smoking cessation counseling and treatment: An American Dental Association Clinical Evaluators Panel survey. The Journal of the American Dental Association, 152(10), 872-873. Retrieved September 14, 2022 from: https://www.sciencedirect.com/science/article/pii/S0002817721004414   

  22. Calvo, J. M., Renelus, R., & Tsao, M. (2021). The Pediatric Dentist's Role in the Prevention and Cessation of Tobacco Use Among Children and Adolescents. CDA Journal - August 21: Helping Dental Patients Quit Tobacco. Retrieved September 22, 2022 from: https://issuu.com/cdapublications/docs/_cda_aug_2021_journal_issuu_a/s/12909940  

  23. American Dental Association. Tobacco Use and Cessation. Retrieved September 22, 2022 from: https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/tobacco-use-and-cessation.