Dental Clinician/Patient Communication Regarding Nicotine Use

Patients look to dental professionals for cessation assistance, but their addiction and enjoyment of tobacco far outweigh the best intentions of a caring clinician. We must be mindful that our efforts to educate do not come across as judgment or lecture. We must consider any existing oral conditions that may cause harm to the patient. For suggestions on how to approach your patients who smoke about smoking cessation options, the following websites may provide helpful information:

Preventive oral cancer screenings are an annual standard of care. Documentation of such exams should also be standard procedure in all hygiene recare protocols. Use of early detection oral cancer techniques and products may be helpful. They include: visible light fluorescent wands that excite certain atypical compounds in the tissues, toluidine blue staining, vital staining, and DNA-evaluation and saliva-based oral cancer diagnosis. Brush and scalpel biopsies are the most effective.23

Smoking will reduce both mucous and serous saliva production. With compromised salivary flow and the effects of nicotine on the body, calcium uptake to teeth via saliva may also be inhibited in both smokers and chewing tobacco users. Educating the patient about the benefits of in-office and home therapeutic doses of calcium-phosphate fluoride varnishes and toothpastes will help to protect tobacco users and abusers from new or recurrent decay. A caries assessment evaluation is now considered the standard of care by the American Dental Association and should be incorporated into dental appointment protocols for patients with substance use disorders. (Figure 7). Assessing the patient’s lifestyle and habits with regard to their risk for decay and need for therapeutic doses of calcium phosphate fluoride varnishes and toothpastes is essential. There are various sources of additional information on varnish and toothpastes protocols for review.

Figure 7. Caries Assessment Form.

Image of caries assessment form.

It is important for the clinician to have resources for patients interested in smoking cessation. Since smoking and tobacco use affects so many patients’ health worldwide, a failure to suggest smoking cessation options and opportunities may not only affect your patients’ oral health, but may affect their lifespan as well. The US Preventive Services Task Force recommends the Five A’s and Refer Model.2,14 More information on this model can be found at: USPreventiveServicesTaskForce.org

Quit lines are telephone-based tobacco cessation services. Most are accessed through a toll-free number and provide callers with services including educational materials, referral to formal cessation programs and individualized telephone counseling. They are a significant resource universally available to dental clinicians. Evidence has revealed that quit lines are convenient, effective and preferred by smokers.18

Of current smokers who visited a physician, 50.7% were advised to quit. Of current smokers who visited a dental healthcare provider, 11.8% were advised to quit. Of all smokers who reported receiving advice to quit smoking, more than 90% reported receiving the advice from a physician, whereas only 13.5% reported receiving such advice from a dental healthcare provider.9 These data indicate there is room to improve the rates at which any health care provider offers tobacco/nicotine cessation information.

Quitting smokeless tobacco may cause short-term problems, especially for those who have used heavily for many years. These temporary changes can result in nicotine withdrawal symptoms that include cravings, anger/irritability, anxiety, depression or weight gain. Tobacco cessation programs for chew users need to be carefully supported. Many times health education via photographs and the invasive nature of oral cancers surgeries are enough to motivate the user to quit. There are many resources to support smokeless tobacco cessation including the Guide to Quitting Smokeless Tobacco from the American Cancer Society. In addition, the following are suggested to assist in living a dip-free lifestyle:

  • Limited contact with other dippers, especially in the early weeks of quitting.
  • Do not buy, carry, or hold dip cans for others.
  • Do not let people dip in your home. Post a small “No Tobacco” sign by your front door.
  • Ask others to help you remain tobacco-free. Give them specific examples of things that are helpful (such as not dipping around you) and things that are not helpful (like asking you to buy chew for them).
  • Focus on what is personally gained by quitting: health, saving money, extended lifespan, quality of life, improved hygiene.13