The Tobacco-Using Patient and the Dental Office

As a primary care clinician, the dentist should identify and be prepared to intervene with tobacco users. Epidemiologic data suggest that more than 70% of the 50 million smokers in the United States today have made at least one prior quit attempt, and approximately 46% try to quit each year. Most smokers make several quit attempts before they successfully kick the habit. Healthcare providers can play a vitally important role in helping their patients attempt and accomplish cessation. Brief interventions by clinicians simply advising patients to quit have been shown to have a small beneficial effect,1,2 but a somewhat more intensive intervention is more effective—about 10% of smokers are induced to abstain for at least a year.3 Currently, physicians provide most tobacco cessation interventions, although it has been demonstrated that all healthcare providers can be effective.4

The use of tobacco products, especially cigarette smoking, represents the leading cause of preventable illness and death in the developed world.5 Tobacco use increases the risk for lung and gastrointestinal cancers.6,7 Lung cancer is the most common cause of cancer deaths in the United States. Cigarette smoking is responsible for 87% of the lung cancers and accounts for 30% of all cancer deaths.6 An estimated 164,100 new cases of lung and bronchial cancer were expected to be diagnosed in 2000. Each year, more than 156,900 men and women die from lung cancer. Lung cancer mortality rates are about 23 times higher for current male smokers and 13 times higher for current female smokers compared to lifelong nonsmokers.7 Using any form of tobacco also raises the risk for esophageal cancer. The longer tobacco is used, the greater the risk, with the greatest risk among persons who combine alcohol use with tobacco use.8

Cigarette smoking is a major causative factor of congestive heart disease. Smokers can have a 2- to 4-fold increase in risk for coronary heart disease over nonsmokers. Smoking contributes to an increase in blood pressure through increased coronary vascular resistance, lower oxygen availability, enhancement of platelet aggregation, increased fibrinogen, and depression of HDL cholesterol. Studies indicate that when patients stop smoking, morbidity and mortality from cardiovascular disease decrease.9 Improvements can also be seen in patients with congestive heart failure who have already had a myocardial infarction. The increased risk for coronary heart disease decreases to that of nonsmokers over a period of 5 to 10 years following successful termination of the smoking habit.10

In addition to being associated with a number of cancers and coronary conditions, tobacco plays a role in the etiology of a number of oral conditions; it is a primary risk factor for oral cancer as well as leukoplakia, periodontitis, and delayed wound healing.11-14 Alcohol and tobacco use contribute to almost 75% of all oral cancer incidence.

Figure 1. Cigarette smoking can lead to periodontitis and the loss of alveolar bone support.

Chronic smoking can lead to increased prevalence and severity of periodontal disease, contributing to the loss of teeth and edentulism (Figure 1). Interestingly, studies have calculated that a substantial percentage of the variance of periodontitis in the population (as high as 50%) can be attributed to smoking alone.15-17 Longitudinal studies of both treated and untreated periodontitis have shown higher progression of attachment loss and bone loss in smokers than nonsmokers.18 A dose-response relationship between exposure to smoking, measured in pack years, and extent and severity of progressive periodontitis has been demonstrated as well. It is the primary reason for loss of teeth among 19- to 40-year-olds.19

Overall, smokers show less favorable response to conventional periodontal therapy than nonsmokers. The difference in response becomes particularly pronounced in more elaborate treatment procedures such as regenerative periodontal therapies (guided tissue regeneration and grafting procedures) that have been shown to be significantly less successful and predictable in smokers.20 Finally, studies have demonstrated the beneficial effects of smoking cessation on periodontal health. Progression of bone loss was decreased in patients who quit smoking versus subjects who continued to smoke throughout the observation period.21

Recently, maternal tobacco use has been related to primary caries development in their children.22 However, the link between dental caries and tobacco is not conclusive. Smokeless tobacco can contribute to increased acid attack on the enamel surface if the brand of tobacco contains high concentrations of sugar, and gingival recession often occurs in the location that the user habitually places his/her smokeless tobacco. There may, therefore, be a higher incidence of cervical or root caries in smokeless tobacco users.

Smokeless tobacco use is often mistakenly regarded as a safe alternative to cigarette smoking, particularly among teenagers. Most smokeless tobaccos contain substantial quantities of nicotine, leading to a similar pattern of addiction as seen with cigarette smoking.23 Smokeless tobacco increases the risk for oral, pharyngeal, and esophageal cancer. Repetitive use of smokeless tobacco can cause a precancerous condition in the mouth called leukoplakia.24 Occurring on the lips or inside the cheek, leukoplakia is a white, leathery-appearing patch that results in cancer diagnosis in 3% to 5% of cases. The risk of cancer of the oral soft tissues is almost 50 times greater in long-term users than nonusers. Other dangers from smokeless tobacco use include the following: gum recession that results in exposed roots and increased sensitivity to heat and cold; drifting and tooth loss from damage to gingival tissue; abrasion to tooth enamel because of high levels of sand and grit contained in smokeless tobaccos; tooth discoloration; and bad breath.25,26

Cigar smoking is seen by many as an alternative to cigarette smoking, and because of publicity campaigns, media exposure in movies and music videos, and athletes who use cigars, there is an increase in teens and young adults who smoke cigars. Occasional cigar smoking may pose serious health risks. There is increased risk for periodontal disease, which can lead to tooth and alveolar bone loss.27 Risk of lung cancer and heart disease may be the same as that of cigarette smokers. Cigar smokers also suffer from excessive tooth stain and chronic halitosis.28

Oral mucosal changes related to tobacco use are attributed to irritants such as temperature, the drying effects of smoke, tobacco toxins, carcinogens, and changes in the local immune response. These changes include the following:

•Leukoplakia, defined as a white patch or plaque on the oral mucosa that cannot be classified clinically as any other disease. Tobacco use is the primary cause of leukoplakic lesions. Tobacco users are more likely to have leukoplakia than nonusers. The frequency and length of tobacco use is directly related to the prevalence of leukoplakia.

•Snuff Dippers Pouch, which may be a form of leukoplakia. These white or red adherent lesions are tissue of various degrees of abnormal appearance, from white, translucent patches to thickened, cracked areas. Although lesions can be found at any step of a continuous process, they are categorized into 3 degrees, with degree 3 being the most serious.

Figure 2. Nicotonic stomatitis. (Source: Tobacco Effects in the Mouth: a National Cancer Institute and National Institute of Dental Research Guide for Health Professionals. NIH publication No. 94-3330.) Figure 3. Chronic hyperplastic candidiasis. (Same source as Figure 3.)
Figure 4. Leukoedema. Figure 5. Hairy tongue. (Same source as Figure 3.)
Figure 6. Tobacco stains. (Same source as Figure 3.)

•Nicotinic Stomatitis (Figure 2), which appears as a diffuse palatal keratosis with chronic inflammation of the palatal salivary glands. It does not become malignant and is reversible with cessation of tobacco use.

•Smoker's Melanosis, a melanin pigmentation stimulated by smoking that may occur in the attached gingiva of about 5% to 10% of smokers. It is more common in heavy smokers.

•Chronic Hyperplastic Candidiasis (Figure 3), an adherent red or white plaque that may be flat or slightly elevated and may incorporate erythematous areas.

•Leukoedema (Figure 4), a diffuse, grayish-white, opalescent lesion of the buccal mucosa. It is often present bilaterally. This is a benign lesion and is present more frequently in smokers.

•Hairy tongue (Figure 5), an overgrowth of the filiform papillae of the tongue that can trap plaque and tobacco residues, contributing to poor appearance and bad breath.29

Cosmetic conditions such as tobacco stains are more difficult to treat successfully in smokers and smokeless tobacco users (Figure 6). Tobacco stains can penetrate into enamel and restorative materials, creating brown to yellow darkening of teeth, discoloration of nonmetallic restorations, and dark outlines around restorative margins. Tobacco staining of removable prosthetic appliances can be a problem; patients are frequently unable to remove tenacious stains.29

TOBACCO CESSATION ACTIVITIES IN THE DENTAL OFFICE

Dentists are favorably situated to provide tobacco cessation services because more than 50% of smokers make an annual visit to the dentist.30,31 Dental patients, especially those with insurance, receive care on a regular basis. Dental treatment often necessitates frequent contact with patients over an extended period of time, providing a mechanism for long-term contact and reinforcement. In addition, the dental provider is in the unique position of being able to associate cessation advice with readily visible changes in oral status.

THE 5 A'S

The 5-step process, referred to as the 5 A's, work together to provide a comprehensive patient cessation program.32 The proper management of the patient requires an understanding of when it is appropriate to utilize the 5 A's in practice and alternatively when a patient's tobacco addiction requires referral and treatment within a more comprehensive setting. The 5 A's are (1) ask, (2) advise, (3) assess, (4) assist, and (5) arrange.

Ask: Identify and Flag Tobacco Users

Before you can address your patients' tobacco use, you must first ask if they use tobacco. You can ask the patient directly when reviewing the patient's health history, or alternatively you can ask during the oral exam. All it takes is 4 words: "Do you use tobacco?" Once you establish whether or not the patient uses tobacco, it is important to record the information in the patient's chart. This will make it easier for you to follow up when the patient returns for the next visit.

Advice: Relate Oral Health Findings and Give Direct Advice to Quit

Discussing the results of the oral exam and showing the oral effects of tobacco can be a powerful motivational tool. Use this discussion as a way to state your advice clearly to quit. Remember to advise your patients to quit at every visit.

Assess: Is Your Patient Ready to Quit?

You may think that tobacco users do not want to discuss quitting. However, research has shown that the majority of smokers would like to quit. Even if your patients are not ready to quit using tobacco now, they will appreciate your efforts and advice. By getting patients to talk about their tobacco use, you may move them closer to a decision to quit.

Assist: Help Patients to Quit Using Behavioral and Pharmacological Approaches

When patients express an interest in quitting, you will want to assist them by giving them information that they can use that will help them quit. You can provide self-help materials, make referrals to local resources, and may also want to discuss the use of pharmacotherapy, such as nicotine gum or patches.

Arrange: Provide Follow-up Contact and Encouragement

For those patients who make a commitment to quit, a call from your office on or before the patients' quit date has proven to be a key factor in patients successfully quitting. For those who are not quite ready to quit, it is important to discuss their tobacco use at every visit. Each time it is discussed, the patient may move closer to making a decision to quit.

It takes only 3 to 5 minutes to discuss tobacco with each patient, and as you develop your own style for talking to patients, you will feel more comfortable.

It is important to recognize that stopping tobacco use is a process, and there are a number of stages of quitting. Every patient you counsel will not be able to quit immediately. Do not give up, be persistent, and be supportive of patients, regardless of the stage of quitting.

MOTIVATIONAL INTERVIEWING

Figure 7. Motivational interviewing is helpful when dealing with addictive behavior.

Motivational interviewing is a technique that has been found to be helpful when dealing with addictive behaviors (Figure 7).33 The following are the key points of motivational interviewing:

(1) Express empathy. Try to understand how difficult quitting can be and how important tobacco can be in your patient's life. Imagine giving up something you really enjoy (eg, high-fat snacks, golf, or alcohol) and how hard it might be, no matter what the benefits.

(2) Develop discrepancy. Try to get the patients to discuss the advantages and disadvantages of their tobacco use. Try to point out inconsistencies in what they think is important and continued tobacco use (eg, "You have a family that you obviously care about a lot. How do you think your smoking affects them now and might affect them in the future?").

(3) Avoid argument. Try to accept the patient's point of view and don't try to convince him or her to do something he or she isn't ready to do. Don't give the patients anything to push against.

(4) Roll with resistance. Accept and acknowledge that some patients are not ready to quit (or even think about quitting). Let them know that it's okay and completely their decision to make.

(5) Support self-efficacy. Help patients to set realistic goals (eg, they may be unable to spend time with smokers or drink alcohol when they first quit, or they may benefit from additional support from friends or family). Identify the strengths and skills that they possess to attain these goals (eg, Do they have smoke-free friends? What kind of support resources do they have available?).

PHARMACOTHERAPIES FOR TOBACCO CESSATION 34

At any level of supportive care, effective pharmacotherapy generally doubles the cessation rate compared to placebo. The goal of nicotine replacement therapy is to safely replace daily nicotine intake (1 mg of nicotine absorbed per cigarette; 1 pack-per-day (ppd) smoker needs 20 mg of nicotine). Every smoker should be encouraged to use pharmacotherapies endorsed in the guideline except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations (eg, pregnant women and adolescents). The clinician should explain how these medications increase smoking cessation success and reduce withdrawal symptoms. Pharmacotherapy agents include bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch.

Nicotine Patch

The nicotine patch is available without prescription and is easy to use; apply it daily on a hairless upper body skin site. A 21-mg patch replaces a 1 ppd smoker. Use 14 mg or 7 mg for tapering or < 10 cigarettes per day or < 100 pounds. Focal rash is common; rotate the patch site daily. Taper only after successful cessation and confidence in a smoke-free lifestyle—usually 8 to 12 weeks minimum. Remove before bedtime if there is sleep disturbance.

Nicotine Gum

Do not chew like ordinary gum! It is also available without prescription. Nicotine is absorbed across buccal mucosa. Alternate chewing and "parking" between cheek and gum. Four-mg gum is most effective (2 mg absorbed)-10 pieces replace 1 ppd smoker (20 mg absorbed). Use 2-mg gum (1 mg absorbed) for lighter smokers-10 pieces replace a half-ppd smoker (10 mg absorbed). Regular prophylactic use is more effective than use when needed. Tapering the schedule is usually over 2 to 3 months. Acidic beverages (eg, coffee, tea, citrus juices, and sodas) inactivate nicotine. Therefore, do not consume these drinks during gum use.

Bupropion

Bupropion is by prescription only. It is prescribed as Zyban or Wellbutrin SR, to begin approximately 2 weeks before quit date. It is contraindicated if there is a history of seizure, alcohol dependence, or an eating disorder. Start 150 mg per day x 3 days, then 150 mg two times per day at least 8 hours apart. (Seizure risk is increased with an increased plasma level.) Never double up if a dose is missed. Treat for 7 to 12 weeks or longer until cessation is successful and there is confidence that a smoke-free lifestyle is imminent. Tapering is not required, and it is effective in both individuals with and without depression.

CONCLUSION

Tobacco use has profound oral and systemic effects. Dentists are probably the best-suited healthcare professionals to serve both as patient educators on the adverse effects of smoking on oral and systemic health and as advocates of smoking cessation. Thus, dentists must expand their preventive and therapeutic armamentarium to include smoking cessation strategies.

Treatment of tobacco users is cost-effective. Smoking cessation interventions are less costly than other routine medical interventions such as treatment of mild to moderate high blood pressure and preventive medical practices such as periodic mammography.

In summary, for smoking cessation intervention to impact a large number of tobacco users, it is essential that clinicians and healthcare delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a healthcare setting.


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Dr. Albert is an associate professor and assistant director of community health at the Columbia University School of Dental and Oral Surgery. He also holds an appointment in the Joseph Mailman School of Public Health at Columbia University. He is the principal investigator of a Robert Wood Johnson Foundation "Addressing Tobacco in Managed Care" project conducted with Aetna Dental. He is a co-investigator in the American Legacy Foundation/ Kellogg Foundation Community Voices tobacco initiative in Northern Manhattan. He is the director of the Washington-Heights/ Inwood component of the Columbia DentCare program, a community-based series of practices and approaches to healthcare delivery and prevention. He maintains a practice within the ambulatory care network in the community of Washington Heights/Inwood in Northern Manhattan. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .