Nick Coller considers the role of the dental therapist in smoking and tobacco cessation.
Unlike other areas of the body, some smokers do not realise that tobacco use can affect the periodontium, nor do they realise that it is part of the therapist’s remit to broach the subject. The subject can therefore be fraught to raise.
Drawing on his experience as an ex-smoker (who worked in the tobacco industry), the author aims to provide a deeper understanding of the issues surrounding the subject, to engender greater confidence when treating and communicating with patients who smoke or use tobacco. Namely:
1. What is it like to be a smoker?
2. Why is it so hard to give up?
3. What oral presentations of tobacco use should therapists look for in a smoker’s mouth?
4. What should be communicated to patients who use tobacco and how should this be done?
What is it like to be a smoker?
To examine the issue from a smoker’s perspective: Many smokers started smoking when they were young, with many thinking that they would be able to give up at any time. By the time they realised they couldn’t, it was too late. According to the 2014 American Surgeon General’s Report, ‘nearly 9 out of 10 adult smokers started before age 18, and nearly all started by age 26. Most of these young people never considered the long-term health consequences associated with tobacco use when they started smoking’.*1
There are very few smokers in the western world, if any, who do not know that smoking is bad for one’s health. They are constantly subjected to messages to this affect. Indeed, being confronted with such messages might actually trigger the need to smoke, as it causes stress.*2 About 40% of current smokers attempt to quit each year but fewer than one in 10 are successful *2. Thus, many smokers have gone through several quit attempts and ‘failed’. Each quit attempt is likely to have left them feeling deflated about their prospects of ever giving up.
Further, the modern-day smoker is increasingly a social pariah. There are fewer and fewer places to smoke in public. It is likely that the modern-day smoker has been given smoking cessation advice many times before by a number of health care professionals (and possibly been left feeling ashamed or chided). It is only natural therefore that smokers might be defensive when the subject of smoking (let alone quitting) is raised.
Why is it so hard to give up smoking?
Smoking is an addiction not a ‘nasty habit’. Addiction is defined as a psychological and physical inability to stop consuming a chemical, drug, activity, or substance, even though it is causing psychological and physical harm. Research indicates that quitting smoking could be harder than stopping using cocaine or opiates like heroin. In 2012, researchers reviewed 28 different studies of people who were trying to quit using the substance they were addicted to. They found that about 18% were able to quit drinking, and more than 40% were able to quit opiates or cocaine, but only 8% were able to quit smoking. *3
Nicotine alters the balance of the dopamine and noradrenaline in the brain. This, in turn, alters the user’s mood and concentration levels. When nicotine is inhaled, it rushes to the brain in seconds, inducing pleasure and reducing stress and anxiety. However a few minutes after the cigarette is extinguished, the nicotine level in the body starts to diminish causing withdrawal symptoms such as anxiety and irritability.*4
As well as causing a physical dependence, nicotine has a psychological effect, where the smoker links smoking to social activities or uses smoking to manage their feelings and emotions. This then contributes further to the difficulty of giving up.
What oral presentations of tobacco use should therapists be aware of?
Tobacco use, both smoking and chewing tobacco, seriously affects general and oral health.
Therapists routinely examine for lesions as part of the intra oral examination in every patient and therefore it is of particular importance that they understand what oral lesions and conditions to look for in particular when treating patients who use tobacco. Moreover, therapists tend to see patients more often than the dentist, making them on the front line of spotting oral lesions and conditions linked to smoking. Therapists should be particularly vigilant in the case of a patient that uses tobacco AND consumes alcohol, as there is a significant risk of neoplasm in the case of patients who smoke and drink. *5
The presence of any lesions and their exact size and nature should be carefully noted in the notes (with intraoral pictures where possible) and referral protocols strictly adhered to.
Therapists should be aware of the following (but non-exhaustive) list of the most pertinent and serious:
1. Intraoral lesions and mucosal conditions
2. Intraoral conditions
1. Intraoral lesions and mucosal conditions
Delivering Better Oral Health 2017 highlights: ‘the most significant effects of tobacco use on the oral cavity are oral cancers’.*6 Mouth cancer can present as a variety of abnormalities and visible changes affecting the oral mucosa, including ulceration, swelling and areas of erythema. The most common sites that oral cancers can occur are the gingivae, tongue, floor of the mouth and lip.’*7
Smokers are seven to ten times more likely to suffer from oral cancer than people who have never smoked (Warnakulasuriya, Sutherland and Scully, 2005) and in long-term regular users of smokeless tobacco this risk is more than 11 times that of a non-user (Prabhakaran and Mani, 2002).
The State of Mouth Cancer UK report 2018-19 produced by the Oral Health Foundation highlights that there are 8302 new cases of mouth cancer in the UK every year. This has increased by 49% in the last decade and by 135% compared with 20 years' ago. Approximately 2,722 British people lose their life to mouth cancer every year, with a ten-year survival rate of between 19% and 58%, depending on the location of the cancer and the stage of diagnosis.
Erythroplakia and leukoplakia
The WHO defines oral leukoplakia as ‘a predominantly white lesion of the oral mucosa that cannot be characterised as any other definable lesion’. Leukoplakia is often associated with tobacco smoking, although idiopathic forms can also occur.
The WHO defines erythroplakia as a ‘fiery red patch that cannot be characterized either clinically or pathologically as any other definable lesion’. It, too, is more commonly seen in smokers.
Both conditions carry a significant risk of being dysplastic or carcinoma.
Oral submucous fibrosis
Oral submucous fibrosis affects virtually only those from the Indian subcontinent, being linked to paan, khat and betelnut chewing. The condition causes fibrosis of the cheeks, soft palate or inner aspects of the lips. Bedi et al highlight ‘The fibrosis is often so severe that the affected area is almost white and so hard that it literally cannot be indented with the finger. Frequently the buccal fibrosis causes such severe restriction of opening that dental treatment becomes increasingly difficult and finally impossible’.*8
Smoker’s keratosis is a white/grey tile-like patch with little red nodules commonly found in a smoker’s mouth (especially the palate) often in an area that is subject to friction. The condition has no long-term consequences and will usually clear up on cessation of smoking.
Smoker’s melanosis, normally seen on the upper and lower front gingivae, is tissue pigmentation caused by melanin deposits from tobacco use. The amount of pigmentation increases with greater tobacco use, and is more common in women, occurring in 5.0 – 22% of cigarette and pipe smokers. There is no treatment for smoker’s melanosis; and the tissues typically, but not always, return to normal, after smoking cessation. *9
2. Intraoral conditions
Smoking is an important non microbial aetiological risk factor in periodontal disease. Due to its negative effect on the periodontium smoking status should be reassessed annually and recorded.*6
Studies indicate that smoking is responsible for approximately 60% of tooth loss due to periodontitis *10. It is well documented that smokers have fewer teeth, deeper pockets, more recession and periodontal bone loss than non-smokers. *11-13 Smoking also increases the prevalence of destructive forms of periodontal disease such as acute necrotizing ulcerative gingivitis.
It should also not be forgotten that periodontal treatment is compromised in those who use tobacco (something they should be warned of) because of nicotine’s vasoconstrictive effect on blood vessels and subsequent negative effects on post treatment healing.
Smoking has been shown to reduce salivary flow.*14 Reduced saliva means the oral cavity is less likely to be cleansed of oral bacteria, resulting in poorer oral hygiene. A drier mouth with poor oral hygiene has a negative effect on caries rate.
Risk to implants
Implants are negatively affected by tobacco use. Firstly, the failure rate of implant osseointegration after placement is considerably higher among smokers than non-smokers (because of smoking’s negative effect on wound healing). Secondly the risk of peri-implantitis is also greater in those who use tobacco *15. Tobacco users should be warned of these risks and discussions should again be recorded in the notes.
What should be communicated to smokers about tobacco use and how is this best approached?
Historically, the 5As approach based on the WHO Article 14 guidance in the Framework Convention on Tobacco Control.*16 has been the go-to pathway for approaching the subject of smoking with patients. These guidelines can be summarized by the 5 ‘A’s:
Ask about and record smoking status
Advise smokers of the benefit of stopping
Assess motivation to quit
Assist smokers in their quit attempt
Arrange follow up with stop smoking services
The approach is rigorous and internationally accepted. It has however some significant disadvantages:
It can take up a significant amount of time, which can especially be a disadvantage in a time pressurised first appointment
It can place the clinician in the tricky position of sounding like they are emotionally involved in the outcomes of the conversation, which in turn is likely to engender a negative response in the smoker
Any conversation about stopping smoking (let alone such a protracted one) is more likely to ‘immediately create a negative reaction in a smoker, raising anxiety levels’ *2
All of the foregoing can decrease rapport in the long term (which might actually hinder the patient from seeking advice from the clinician if and when they are considering a quit attempt).
To this end, Delivering Better Oral Health 2017 shifted focus away from the 5 As approach, highlighting that “the key priority and role of the dental team is to support people who use tobacco, engage with them and advise that their local stop smoking service provides the best chance of stopping…providing a referral to those services where appropriate’*6. Delivering Better Oral Health 2017 promotes the benefits of ‘VBA: Very Brief Advice’. This approach, is quicker than the 5As approach and puts onus on the clinician to:
1. Adjust their input based on patient responses, with only the most basic messages imparted to patients who are not interested in quitting
2. Direct patients who are engaged with the idea of quitting to services that provide them the best chance of doing so
Here then, the clinician is afforded the opportunity to ‘push on open doors,’ focussing their attention on patients for whom the subject of smoking cessation is of interest. This in turn helps create patient rapport and enables the therapist not to appear emotionally invested in the outcomes of the discussion. The VBA consists of three elements:
1. Ask - Establishing smoking status
All patients should have their smoking status assessed annually
Probe: if patient wants to stop smoking
If the patient does not want to stop simply mentioning:
If and when the patient considers smoking that there are specialist services which can help
The clinician can provide information and help were the patient to ever want to quit
2. Advise: The best way to stop smoking is a combination of medication and specialist support on the best quitting
3. Act (on patient response).
Refer and prescribe (patients are 4 times for likely to quit fully with support)*6
When discussing the subject of smoking and tobacco use with patients, therapists should remain mindful of how difficult it is to quit and how disempowering failed quit attempts feel. Therapists are however ideally placed to direct patients who are considering a quit attempt to specialist smoking cessation services where patients are 4 times more likely to quit than by will power alone.* 6. Appearing emotionally uninvolved with patient choice is key. Authentic patient communication based on individual response is more likely to be well received, (than generic stop smoking messages that have been heard before and elicit a shame or anger response of behalf of the smoker).
The VBA approach also allows the therapist to understand the wishes of those who currently do not want to quit, whilst still conveying the message that specialist services offer the best chance of quitting were the patient to ever consider this.
Akinkugbe AA, Slade GD, Divaris K, Poole C (2016) Systematic review and meta- analysis of the association between exposure to environmental tobacco smoke and periodontitis endpoints among nonsmokers. Nicotine Tob Res 18(11): 2047-2056
Akinkugbe AA, Sanders AE, Preisser JS, Cai J, Salazar CR, Beck JD (2017) Environmental tobacco smoke exposure and periodontitis prevalence among nonsmokers in the hispanic community health study/study of Latinos. Community Dent Oral Epidemiol 45(2): 168-177
Axéll T, Hedin CA (1982) Epidemiologic study of excessive oral melanin pigmentation with special reference to the influence of tobacco habits. Scand J Dent Res 90: 434-442
Bagnardi V, Blangiardo M, La Vecchia C, Corrao G (2001) A meta-analysis of alcohol drinking and cancer risk. Br J Cancer 85: 1700
Bedi R, Scully C (2014) Tropical Oral Health. Manson’s Tropical Infectious Diseases 1073-1083
Center for Disease Control and Prevention (2000) Cigarette smoking among adults – United States, 1998. MMWR Morb Mortal Wkly Rep 49(39): 881-4
Dietrich T, Walter C, Oluwagbemigun K, et al (2015) Smoking, smoking cessation, and risk of tooth loss: the EPIC-Potsdam study. J Dent Res 94(10): 1369-1375
Lambert PM, Morris HF, Ochi S (2000) The influence of smoking on three-year clinical success of osseointegrated dental implants. Ann Periodontol 5(1): 79-89
Lewis M (2018) Mouth cancer: presentation, detection and referral in primary dental care. Br Dent J 225: 833-840
Mecklenburg RE (2004) Tobacco Effects in the Mouth National Cancer Institute & Institute of Dental Research Guide for Health Professionals. Darby PA, USA: Diane Publishing
Moore RA, Aubin HJ (2012) Do placebo response rates from cessation trials inform on strength of addictions? Int J Environ Res Public Health 9(1): 192-211
Rad M, Kakoie S, Brojeni FN, Pourdamghan N (2010) Effect of long-term smoking on whole-mouth salivary flow rate and oral health. J Dent Res Dent Clin Dent Prospects 4(4): 110-114
Sutton JD, Salas Martinez ML, Gerkovich MM (2017) Environmental tobacco smoke and periodontitis in United States non- smokers, 2009 to 2012. J Periodontol 88(6): 565-574
US Department of Health and Human Services (2012) Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention
WHO (2003). WHO Framework Convention on Tobacco Control. Available at: http://www.who.int/tobacco/framework/WHO_ FCTC_ english.pdf
October 2020. P.17-19 IRISH DENTISTRY www.irishdentistry.ie