Colorado dental practitioners' attitudes and practices regarding tobacco-use prevention activities for 8- through 12-year-old patients

BACKGROUND: Tobacco use is a leading risk factor for oral morbidities and mortalities such as oral cancers and periodontitis. This study characterizes the factors related to dentists and hygienists conducting tobacco-use prevention counseling with 8- through 12-year-old patients. METHODS: The study used a mailed survey of dentists (n = 434), orthodontists (n = 91) and hygienists (n = 160) practicing in Colorado to collect data on the practitioners' tobacco-use prevention counseling activity, demographic characteristics, barriers to counseling and attitudes toward tobacco use. The authors used multiple logistic regression to determine which variables were associated independently with a dental practitioner's counseling children. RESULTS: The response rate was 25.6 percent. Prevalence of tobacco-use prevention counseling for children was low (38 percent for dentists and 44 percent for hygienists). Among dentists, the perception of tobacco use in children as a problem, perceived effectiveness of counseling and perceived role of a dental practitioner in counseling children were associated positively with counseling. Lack of skills was associated negatively with counseling. Among hygienists, perceived role in counseling children was associated positively and lack of time was associated negatively with counseling. CONCLUSIONS: Few dental practitioners counsel 8- through 12-year-old patients about tobacco use. Factors related to counseling appear to be amenable to education of dentists, in particular, regarding the importance of the problem, the effectiveness of counseling and skill development. CLINICAL IMPLICATIONS: Preventing tobacco use among children is integral to promoting patients' oral health. Training dentists through continuing education should increase the frequency of tobacco-use prevention counseling with children by both dentists and hygienists.     

How well does the health history form identify adolescent smokers?

BACKGROUND: This study examines the accuracy of adolescents' reports of tobacco use on a health history form completed in the dental office and the relationship between these reports and cessation advice provided by dental professionals. METHODS: The authors compared reports of smoking status provided by adolescents during phone interviews with the adolescents' reports of smoking on a health history form completed during a dental visit. Adolescents aged between 14 and 17 years who were scheduled for a dental hygiene visit in a large managed care system were eligible for the study: 1162 completed the phone interview, and the study staff members audited the charts of a stratified random sample (n=280) of these. RESULTS: The health history form identified only 38.0 percent of those who reported having smoked in the previous 30 days during the phone interview and 57.4 percent of those who reported having smoked daily. Only 8.9 percent of all subjects interviewed reported that a dentist or a dental hygienist had ever talked with them about smoking. An examination of the chart audit sample indicated that advice was reported more often by adolescents who had identified themselves as smokers on the health history form (odds ratio = 2.62, 95 percent confidence interval = 1.35 to 5.10), but the reported rate of receiving advice still was low (25 percent). CONCLUSIONS: Adolescents underreport tobacco use on health history forms that ask them to specify whether they use tobacco products. Dentists and dental staff members provide advice about tobacco use to adolescents only infrequently. CLINICAL IMPLICATIONS: The wording of tobacco-use screening questions on health history forms and the conditions under which the forms are completed might affect the accuracy of the information adolescents provide.     

Preventing and detecting oral cancer. Oral health care providers' readiness to provide health behavior counseling and oral cancer examinations

BACKGROUND: The authors conducted a study to examine oral cancer prevention and early detection practice patterns in a population-based random sample of practicing oral health care professionals in New York state. METHODS: The authors surveyed a population-based, self-weighting, stratified random sample of dentists (n = 1,025) and dental hygienists (n = 1,025) in New York state. They assessed the subjects' readiness to offer tobacco-use cessation and alcohol-abuse counseling and oral cancer examinations. RESULTS: The effective response rates were 55 and 66 percent for dentists and dental hygienists, respectively. In terms of readiness to perform oral cancer examinations for patients aged 40 years and older, the large majority (82 percent of dentists and 72 percent of dental hygienists) were in the maintenance stage of behavior, indicating that oral cancer examinations were a routine part of their practice. In terms of readiness to offer tobacco-use cessation counseling, only 12 percent of dentists and 21 percent of dental hygienists were in the maintenance stage, and only 2 percent of dentists and 4 percent of dental hygienists were in the maintenance stage of offering alcohol-abuse counseling. CONCLUSIONS: Oral cancer examinations seem to have been adopted as a standard of practice by most oral health care providers in New York state, but cancer prevention services, such as counseling regarding cessation of tobacco use and alcohol abuse, are lacking. CLINICAL IMPLICATIONS: Oral health care providers should be trained in oral cancer prevention services such as tobacco-use cessation and alcohol-abuse counseling and encouraged to include these services, along with continued provision of oral cancer examinations, as a standard aspect of care.     

WHO framework convention on tobacco control and its relevance to the dental professions in South Africa.

One in nine deaths in South Africa is related to tobacco use. Recognition of the need for global partnership to curb the tobacco epidemic has led to the WHO member states' adoption of the first global public health treaty--the framework convention for tobacco control (FCTC). Relevant to the dental profession, within the FCTC's guiding principle of the need to protect all persons from the initiation, maintenance or increase of tobacco use are articles 12 and 14. These challenge parties to take action to train health workers and to secure treatment for tobacco dependence. Preventing initiation of tobacco use by youths is as fundamental to the prevention of periodontal disease and oro-pharyngeal cancer as providing fluoride and dental sealants for the prevention of dental caries. Tobacco control, whether in private practice or in public service, must be viewed within the context of an ethical obligation for primary prevention. There are science-based clinical guidelines for implementing tobacco prevention and tobacco cessation. Dentists who implement an effective cessation programme in their practices can expect to achieve quit rates of 10-15% each year. However, this primary prevention effort can be no better than the knowledge, skills and values of the practitioners providing the service. The FCTC may change the environment that dentistry is practised in globally. The relevant stakeholders in the dental profession should therefore assume stewardship by providing support for the training of dental professionals in tobacco counselling and advocate for the adequate reimbursement of practitioners providing such services.     

Dental students' attitudes toward smoking cessation guidelines

Dentists can be effective in helping their patients achieve smoking cessation. To plan a didactic program, we explored the smoking cessation attitudes and practices of dental students and identified barriers to service provision in the dental setting. We assessed 244 fourth-year dental students at New York University College of Dentistry through a self-report survey. The instrument included a twenty-nine-item measure assessing attitudes towards tobacco-use counseling and adherence to National Cancer Institute tobacco cessation guidelines. The survey also assessed demographics, tobacco use history, and level of preparation to provide services. Generally, students endorsed tobacco prevention practices, but perceived barriers to service provision. Students provided counseling inconsistently, with 69 percent asking about smoking, 58 percent advising cessation, 24 percent offering assistance, and 22 percent providing followup on a routine basis. Those who provided more counseling were more likely to have undergone formal training in smoking cessation, did not feel time was a barrier to counseling, and had more favorable beliefs about dentists' role in promoting smoking cessation. Study findings indicate great receptivity among students as well as a critical need and opportunity to include comprehensive cessation counseling training in the dental curriculum.     

Diabetes and oral health promotion: a survey of disease prevention behaviors

BACKGROUND: Diabetes is a chronic metabolic disease known to affect oral disease progression. The authors surveyed health behaviors essential for preventing dental and periodontal diseases and maintaining oral health is a population of adult patients with type 1 (insulin-dependent) diabetes. The goals of this study were to assess these patients' oral health behaviors, access to dental care and need for improved health education. METHODS: As part of a dental and periodontal examination, 406 subjects with type 1 diabetes completed a questionnaire regarding their oral health attitudes, behaviors and knowledge. The authors also evaluated 203 age-matched nondiabetic control subjects. RESULTS: The authors found that diabetic subjects' tobacco use and oral hygiene behaviors were similar to those of the nondiabetic control subjects. Diabetic subjects, however, more frequently reported the cost of dental care as a reason for avoiding routine visits. Most of these subjects were unaware of the oral health complications of their disease and the need for proper preventive care. CONCLUSIONS: Patients with diabetes appear to lack important knowledge about the oral health complications of their disease. The results of this survey did not indicate improved prevention behaviors among the subjects with diabetes compared with nondiabetic control subjects. CLINICAL IMPLICATIONS: Dentists have an opportunity and the responsibility to promote good oral health behaviors such as regular dental examinations, proper oral hygiene and smoking cessation that may significantly affect the oral health of their diabetic patients.     

Tobacco cessation: a practical dental service

Tobacco use is a complex addiction that must be addressed in all aspects of health care. Despite the deleterious and costly outcomes of tobacco use, Americans still are smoking and using smokeless tobacco. Dentists are trained to detect oral lesions and periodontal problems that are related to tobacco use. Dentists also are in a position to help prevent the initiation of tobacco use by children and adolescents through the use of positive anti-tobacco messages. Over the past decade, tobacco cessation strategies have been modified for practical use in the dental setting.     

Tobacco-use cessation programs and policies at the University of Manitoba's faculty of dentistry

The deleterious effects of tobacco use on general health and oral health are well documented. While one-third of Manitobans are current smokers, up to 79% report they want to quit. Counselling by health care professionals can help achieve quit rates of 15-20%. Yet many health professionals do not provide tobacco-use cessation counselling because they feel they are not trained to do so. In 1998, the faculty of dentistry of the University of Manitoba implemented a number of tobacco-use cessation interventions in its undergraduate curricula and general teaching clinic. The faculty has also successfully obtained the inclusion of a dental fee code for tobacco-use cessation services in the provincial fee guide and has received approval to allow dentists who have completed an approved course in tobacco-use cessation training to prescribe bupropion HCl (Zyban), in consultation with a patient's physician, to aid smoking cessation.     

The question of cost: reimbursement and remuneration

Dentists and the dental team have been encouraged to become an important part of the effort to curb tobacco use. Many health insurance policies, however, do not cover tobacco cessation programs, especially by dentists. The generosity of insurance for tobacco cessation has been found to influence the use of these programs. The dental profession can help by: 1) training more dental students, dental hygienists, and dental practitioners to provide tobacco cessation counseling; 2) increasing the number of practices routinely monitoring tobacco use and providing tobacco cessation programs; 3) increasing the utilization of the available procedure codes for tobacco cessation, whether it is a covered service or not; and 4) stimulating demand for more tobacco cessation coverage by employees.     

The impact of a brief tobacco-use cessation intervention in public health dental clinics

BACKGROUND: Public health dental clinic patients use tobacco at disproportionately high rates. The purpose of this study was to evaluate a tobacco-use cessation program delivered via public health dental practitioners. METHODS: Two public health dental clinics participated in this quasiexperimental design study. First, all patients in one clinic who used tobacco (n = 178) received usual care. Next, the authors trained all practitioners to conduct a tobacco-use assessment and provide a brief cessation intervention. Subsequently, all patients in both clinics who used tobacco (N = 190) received the intervention. All enrolled patients had an income at or below the federal poverty level. The authors conducted follow-up assessments at six weeks and three and six months after enrollment. RESULTS: Differences in self-reported quitting by condition between participants in the two groups were significant across all endpoints. Patients in the intervention group were more likely to quit than those receiving usual care (15.5 versus 4.3 percent) and after 12 months (18.8 versus 4.6 percent). Controlling for enrollment differences between patients in the two groups (age, race/ethnicity, time to first cigarette after waking), the authors found that differences between groups were significant for quitting at three months (P < .05; odds ratio [OR] = 4.85; 95 percent confidence interval [CI] = 1.20, 19.60), and six months (P < . 01; OR = 5.25; 95 percent CI = 1.35, 20.36). CONCLUSIONS: The results of this study suggest the viability and effectiveness of delivering a tobacco intervention to low-income smokers via public dental practitioners. A randomized clinical trial is warranted. CLINICAL IMPLICATIONS: The potential reach of public health dental clinics is great. Because of the high percentage of tobacco-using patients in these clinics, the public health impact of a program such as the one reported here would be significant.     

A practical guide to tobacco cessation in dental offices

Tobacco use is an important risk factor for advanced periodontitis, poor response to periodontal therapy, oral neoplasms, and dental implant failure. Given the effect of tobacco use on oral health, the dental office may be an ideal place for tobacco cessation intervention, especially since a large proportion of smokers visit their dentist on a regular basis. This paper reviews various tobacco cessation strategies for the dental office and provides practical information on assessing patients' readiness to quit and choosing appropriate tobacco cessation interventions.     

Tobacco and oral health: attitudes and opinions of European dentists; a report of the EU working group on tobacco and oral health

AIM: To discover whether dentists are prepared to advise their patients to stop smoking. DESIGN: Postal questionnaire. SETTING: Member countries of the European Union. PARTICIPANTS: Dentists in 12 EU countries. MAIN OUTCOME MEASURES: Dentists' knowledge of links between tobacco-use, general health and periodontal health. Knowledge of, and preparedness to offer, tobacco-cessation activities for patients. Personal and practice smoking policies. RESULTS: EU-dentists are aware of the harmful effects of tobacco use in general and on oral tissues in particular. Over two-thirds of EU-dentists feel that offering information about tobacco cessation is the dentist's duty, while slightly less actually do so. Lack of time and reimbursement mechanisms are the most often mentioned barriers for co-operation with a campaign. Less than 10 per cent of EU-dentists smoke every day while three-quarters of practices are totally smoke free. CONCLUSIONS: EU-dentists want to be informed and supported on the issue by leaflets, brochures, continuing education and patient education materials. More attention should be paid to the relation of smoking and implant failure.     

Tobacco and dental implants

Dental implants are the ideal standard of care for many oral health care providers. Tobacco use is an impediment to the success of this sophisticated procedure. Dentists who are trained to help their patients stop using tobacco are in position to improve their success rates with dental implants. A suggested protocol for tobacco cessation in the implant practice, if utilized, could raise the standard of health care in the dental office.     

The effect of training on the use of tobacco-use cessation guidelines in dental settings

BackgroundAn increase in the number of dentists conducting tobacco-use cessation treatment is needed. The authors assessed the effects of high-intensity training (HIT) or low-intensity training (LIT) and reimbursement on general dentists' tobacco-use–related attitudes and treatment behaviors.MethodsThe authors randomly selected 265 dentists in three states and assigned them to one of five groups: HIT workshop groups with and without tobacco-use cessation counseling reimbursement, LIT mailed self-study groups with and without reimbursement or a control group. Outcomes at follow-up were dentists' self-reported tobacco-use–related attitudes and behaviors and patients' reports of dentists' behaviors.ResultsSignificantly more dentists in the intervention groups reported having positive attitudes and behaviors at follow-up than did dentists in the control group. Dentists in the HIT groups, however, reported assessing patients' willingness to quit and assisting them with the quitting process significantly more often than did dentists in the LIT groups. Significantly more patients of dentists in the intervention groups who used tobacco reported receiving advice and assistance from their dentists than did patients of dentists in the control group. Adding reimbursement to HIT or LIT conditions did not provide additional intervention effect.ConclusionDentists trained by means of a workshop or self-study program used components of a recommended guideline more frequently and felt more positive toward tobacco-use cessation counseling than did dentists in the control group.Clinical ImplicationsAlthough the workshop training was more successful than the self-study training, the latter's reach among dentists could have a more significant public health impact. The effect of reimbursement needs further study.     

Attitudes of incoming dental students toward tobacco cessation promotion in the dental setting

Dentists can play an important role in helping patients quit using tobacco. The aim of this study was to investigate incoming dental students' attitudes toward tobacco cessation promotion in the dental setting. Such attitudes can impact students' receptivity to training and subsequent involvement in tobacco cessation promotion. A twenty-six-item written survey was administered to freshman students at a midwestern dental school during orientation weeks 2002 and 2003. Questions focused on students' attitudes toward the dental professional's responsibilities and scope of practice in promotion of tobacco cessation. Response rate was 99 percent (139/140). Respondents were 75 percent male, 25 percent female. Mean age was 24.8 +/- 3.0 years. Ninety-nine percent agreed that it is the dental professional's responsibility to educate patients about the oral health risks of tobacco use. Eighty-five percent agreed that it is within the scope of dental practice to advise patients to quit using tobacco, but fewer agreed that it is within the scope of practice to discuss specific strategies for stopping (70 percent) or to prescribe nicotine gum (45 percent). Sixty-nine percent agreed that tobacco cessation counseling in the dental office could impact patients' quitting. Seventy-one percent anticipated that patient resistance could be a barrier to tobacco cessation promotion. Nearly one quarter (23 percent) were only slightly or not interested in receiving tobacco cessation training. Attitudes of incoming dental students appear to be positive regarding the dental professional's responsibility to educate patients about the risks of tobacco use. However, some students may have reservations about the extent to which tobacco cessation services fit within the scope of dental practice, the efficacy of such services, and patient receptiveness. These reservations should be addressed if dental school curricula in tobacco cessation are to be effective.     

Tobacco-associated lesions of the oral cavity: Part I. Nonmalignant lesions

The excessive use of tobacco products has been associated with various lesions in the oral cavity. Tobacco-associated lesions include tooth stains, abrasions, smoker's melanosis, acute necrotizing ulcerative gingivitis and other periodontal conditions, burns and keratotic patches, black hairy tongue, nicotinic stomatitis, palatal erosions, leukoplakia, epithelial dysplasia and squamous-cell carcinoma. A routine intraoral examination by a dental health professional can reveal most of these lesions at an early stage, and early intervention may prevent serious sequelae. Thus, detection of tobacco-associated lesions in conjunction with tobacco-use counselling by dental professionals has become the standard of care. The significance and treatment of nonmalignant tobacco-associated lesions are addressed in the first part of this two-part series. Malignant lesions, basic biopsy principles and prevention and intervention strategies are discussed in the subsequent part.     

Tobacco cessation within the dental curriculum in the United States and internationally

Tobacco use is a worldwide public health issue with enormous costs in morbidity and mortality. Dentists are in a unique position as health care providers to offer tobacco cessation counseling to their patients. In order to do so, clinicians must be properly trained in tobacco cessation skills. The onus falls upon professional schools to include information about tobacco use, its clinical effects, and ways to help patients quit into the dental curriculum. In the past 15 years, there has been an increase in the number of dental schools that have adopted anti-tobacco policies and included tobacco in their clinical courses both here in the United States and in Europe. Dental schools with functional tobacco cessation programs in place must follow up on the activities conducted in their clinics to ensure that dental students are appropriately employing the correct techniques and, thus, learning to provide optimal care to their patients.     

Dental case management: increasing access to oral health care for families and children with low incomes

BACKGROUND: Medicaid beneficiaries have lower rates of dental visits and higher rates of dental disease compared with the rest of the population. Beneficiaries ascribe their low use of services to difficulties finding dentists who treat patients with Medicaid. Dentists cite low reimbursement rates, excessive paperwork, and patients' not keeping appointments and poor oral health literacy as reasons for not accepting patients with Medicaid. The authors pilot-tested the effectiveness of a dental case management program (DCMP) in increasing dentists' participation in Medicaid and Medicaid beneficiaries' use of services. METHODS: A dental case manager recruits dentists to participate in the Medicaid program, arranges training in billing procedures, resolves billing and payment problems, educates clients about the use of dental services and keeping appointments, links clients to dental offices, identifies potential barriers to care and helps clients obtain transportation to appointments. The authors evaluated the levels of participation of dentists in the DCMP in Medicaid and Medicaid beneficiaries' use of services. RESULTS: Dentists accepting new Medicaid patients increased from two to 28, with 145 dental visits a month provided to Medicaid beneficiaries. The percentage of Medicaid beneficiaries receiving dental services increased from 9 to 41 percent after the DCMP was implemented. CONCLUSIONS: The authors found that the DCMP was effective in increasing Medicaid beneficiaries' use of services, increasing dentists' participation in Medicaid, minimizing administrative burdens related to Medicaid participation, and increasing oral health literacy and treatment compliance among clients with low incomes.     

Tobacco control and the dental profession. A survey of the Organisation for Economic Co-operation and Development (OECD) national dental associations

AIM: To explore the current role played by national dental associations (NDAs) in tobacco control and to assess relevant policy initiatives across OECD countries. DESIGN: A self-complete questionnaire survey. SAMPLE: Chief Executive Officers of NDAs of OECD countries. RESULTS: A response rate of 74% was achieved. An overview of tobacco control policies from OECD member states was obtained. Half of the NDAs reported that they had a policy on tobacco control. Furthermore, a minority of OECD countries appear to have tobacco control guidelines that specifically include reference to the role of dental professionals. Dentists are able to prescribe nicotine replacement therapy (NRT) in less than a third of OECD member states. In a small number of OECD countries there was funding available to encourage dentists to become more actively involved in tobacco control activities. Undergraduate training focusing on tobacco control is not universally provided across all OECD countries. CONCLUSIONS: There is an urgent need to put tobacco control initiatives on the oral health policy agenda of NDAs across the OECD. A range of policy opportunities exist to facilitate greater involvement of the dental profession in tobacco control activities.