Dental Professionals

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.⁷ 

           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  

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             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 rates among American Dental Association Clinical Evaluators ²¹ 

Despite encouragement from these national organizations, surveys suggest that about half (49%) of US dental offices offer smoking cessation counseling, treatment, or some combination of both to their patients. Among those surveyed: ²¹

• When both counseling and treatment are used:
  • Counseling involves the dentist 90% of the time.
  • 69% stated that they would be willing to prescribe pharmacological treatments to assist patients with cessation.
• 1 in 4 dental professionals who reported not engaging in smoking cessation counseling and/or treatment were current or former smokers, vapers, or smokeless tobacco users themselves.
• The majority of dentists polled (60%) were unaware that most medical benefits cover both counseling and pharmacological treatment for smoking cessation.
  ****In Maryland, Medicaid covers all prescription and over-the-counter tobacco cessation medications.****

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 and that medicaid reimburses for over-the-counter nictoine replacement therapy? 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:  

• Centers for Disease Control and Prevention:  “Dental Professionals: Help Your Patients Quit” 
• American Dental Association: Tobacco Resources 
• American Academy of Pediatric Dentists: Policy Statement 
• American Dental Hygienists’ Association: Provider Resources & Webinar