All forms of tobacco used in the United States have oral health consequences, placing the dentist in a unique position to offer discussion about tobacco use recognition, prevention, and cessation. Cigarette smoking can lead to a variety of adverse oral effects, including gingival recession, impaired healing following periodontal therapy, oral cancer, mucosal lesions (e.g., oral leukoplakia, nicotine stomatitis), periodontal disease, and tooth staining. Use of smokeless tobacco is associated with increased risks of oral cancer and oral mucosal lesions (e.g., oral leukoplakia). Smokeless tobacco use also causes oral conditions such as gingival keratosis, tooth discoloration, halitosis, enamel erosion, gingival recession, alveolar bone damage, periodontal disease, tooth loss, and coronal or root-surface dental caries due to sugars added to the product. Second-hand smoke has been linked to periodontal disease.
1 | Learn the 5 As
Because of the oral health implications of tobacco use, dental practices may provide a uniquely effective setting for tobacco use recognition, prevention, and cessation. Health-care professionals, including dental professionals, can help smokers quit by consistently identifying patients who smoke, advising them to quit, and offering them information about cessation treatment. The U.S. Department of Health and Human Services Agency for Healthcare Research and Quality has published a five-step algorithm for health-care professionals to use when engaging patients who are dependent on nicotine called “The 5As” (Five Major Steps to Intervention. www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html).
The five steps are:
1. Ask: Identify and document tobacco use status for every patient at every visit.
2. Advise: In a clear, strong, and personalized manner, urge every tobacco user to quit.
3. Assess: Is the tobacco user willing to make a quit attempt at this time?
4. Assist: For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit.
5. Arrange: Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date.
The 2008 U.S. Public Health Service clinical practice guideline for treating tobacco use and dependence found that counseling or medication are effective when used by themselves for treating tobacco dependence; however, the combination of counseling plus medication was more effective than either method alone.
In the United States, telephone counseling is available free through a system of state-based quit lines accessible with one toll-free number (1-800-QUIT-NOW [784-8669]).
2 | Pharmacologic Interventions
According to the Centers for Disease Control and Prevention, use of cessation medications is appropriate for most adult smokers, with the exception of:
• pregnant women
• light smokers (i.e., persons who smoke fewer than 5 to 10 cigarettes daily)
• persons with specific medical contraindications (e.g., seizure disorders)
Nicotine-replacement therapy, bupropion (an atypical antidepressant), and varenicline (a selective nicotine receptor partial agonist) are first-line pharmacologic therapies recommended by the U.S. Department of Health and Human Services to assist with smoking cessation.
A 2014 summary of 12 Cochrane reviews looking at efficacy and harms of pharmacologic therapies for smoking cessation used network meta-analysis to make direct and indirect comparisons of efficacy between nicotine-replacement therapy, bupropion, and varenicline for smoking cessation. The review found higher abstinence rates with nicotine-replacement therapies (17.6%) and bupropion (19.1%), compared with placebo (10.6%). Varenicline (27.6%) or a combination of nicotine-replacement therapies (e.g., longer-acting patch plus short-acting inhaler, 31.5%) were the most effective approaches for achieving smoking cessation. The analysis found that none of the therapies was associated with an increased rate of serious adverse events.
• Cahill K, Stevens S, Lancaster T. Pharmacological treatments for smoking cessation. JAMA 2014;311(2):193-4.
• Couch ET, Chaffee BW, Gansky SA, Walsh MM. The changing tobacco landscape: What dental professionals need to know. J Am Dent Assoc 2016;147(7):561-9.
• Drugs for tobacco dependence. Med Lett Drugs Ther 2016;58(1489):27-31
• Jamal A, King BA, Neff LJ, et al. Current Cigarette Smoking Among Adults – United States, 2005-2015. MMWR Morb Mortal Wkly Rep 2016;65(44):1205-11.
• Levy JM, Abramowicz S. Medications to Assist in Tobacco Cessation for Dental Patients. Dent Clin North Am 2016;60(2):533-40.
• National Institute on Drug Abuse. Research Report Series: Tobacco/Nicotine (NIH Publication Number 16-4342). National Institutes of Health.
The following tables list prescription and non-prescription medications commonly used in dentistry today to assist patients with tobacco cessation.
NOTE: The sample prescriptions in this handbook represent a general recommendation. Clinicians are responsible to adjust the prescription dose, frequency and length of treatment based on the procedure performed, the medicine prescribed, and the patient conditions such as age, weight, metabolism, liver and renal function.
Intranasal: 0.5 mg · Inhaled: 10 mg · Gum/Lozenges: 2 mg, 4 mg Transdermal: 5 mg, 7 mg, 10 mg, 14 mg, 15 mg, 21 mg
• Smoking cessation
• Intranasal Nicotine: Squirt 1 to 2 sprays (1x 0.5 mg to 2x 0.5 mg) per nostril every hour, up to a maximum of 80 sprays per day Maximum daily dosage of 40 mg or 1/2 bottle per day Maximum duration of therapy 3 months
• Inhaled Nicotine: Inhale the content of 6 to 12 cartridges (6x 10 mg to 12x 10 mg) per day as needed up to a maximum of 16 cartridges per day Each cartridge has 10 mg of nicotine but only 4 mg are delivered Recommended duration between 6 to12 weeks
• Transdermal Nicotine:
For patients smoking more than 10 cigarettes/day
– One 21-mg patch/day x 6 weeks, then
– One 14-mg patch/day x 2 weeks, then
– One 7-mg patch/day x 2 weeks