Key Points
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The profession and individual practices need to agree the roles of the dental team in smoking cessation
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Primary care trusts need to ensure the smoking cessation needs of dental patients are met locally.
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Dental team members providing smoking cessation services should be permitted to prescribe nicotine replacements.
Abstract
The associations between tobacco use and diseases affecting the oral cavity, such as periodontal disease and cancer, are now well recognised.1,2,3 This has lead to proposals from some members of the profession and the BDA that members of the dental team should provide smoking cessation services.4,5,5 Many dentists have positive attitudes towards the idea of dentists encouraging patients to stop smoking.6 However the belief that members of the dental team should engage in delivering smoking cessation interventions is not held by all parties.5,7 More dentists believe that they should offer smoking cessation support than actually do provide it and reasons for not providing it include time and reimbursement issues, need for further training and poor co-ordination of dental and smoking cessation services.6,8,9
Main
This lack of clarity on the role of the dental team in smoking cessation is reflected in guidance on oral health education advice. In the UK the scientific basis of Dental Health Education 4th edition (revised in 2001) makes no reference to avoiding use of tobacco in its summary.10 The role of dentists in smoking cessation needs to be clarified so that both dentists' and patients' expectations and needs are met.
How does smoking cessation best fit the role of the dental team? In simple terms dentists diagnose, advise and treat or refer patients. Options for Change mentions smoking cessation advice as part of the oral health assessment it proposes.11 Dentists are well placed to recognise smokers and dentists can identify the impact of tobacco use in the mouth. This may range from recognising smoker's palate, through a diagnosis of periodontal disease to the management of potentially sinister white, red or speckled lesions.12
most dentists are better trained to provide treatment for oral disease... than they are at assisting people to change their behaviour
Most dentists are better trained to provide treatment for oral disease such as caries or periodontal disease than they are at assisting people to change their behaviour.13 Although it is possible to train dentists or other members of the dental team in smoking cessation advice, the value of doing so without first clearly defining the role of the dental team in smoking cessation should be questioned. There may be other staff already trained who are more able to deliver effective smoking cessation services.
Dental patients who smoke need access to local services to help them stop smoking. A dentist who recognises a patient as a smoker has a duty to inform the patient of the options available to them. Dentists can help their patients to stop smoking by recognising oral signs of tobacco use, informing patients of these and asking patients whether they wish to stop. Then they can refer their patients who wish to stop smoking into smoking cessation services. Not all smokers are ready to quit smoking, some have not considered quitting. Others may be considering stopping but not be sure how to take the next steps. By enquiring and providing advice, members of the dental team can help patients from pre-contemplation, through contemplation towards action.14
The '4 As' model consists of
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Asking about smoking and the desire to stop,
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Advising of the value of quitting,
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Assisting the patient to stop through access to appropriate support, and
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Arranging follow up support.4
This model needs to be applied and all elements available locally whether dentists or others are providing the 'assist' and 'arrange' components.
If dental patients are to benefit from smoking cessation then dentists need to be clear about the roles of their teams nationally, locally and within the team
it should be possible for future, trained and registered PCDs, to prescribe nicotine replacements as part of an individual care plan
If dental patients are to benefit from smoking cessation then dentists need to be clear about the roles of their teams nationally, locally and within the team. Nationally the profession should make it clear to the governments that all dental teams recognise smokers who could benefit from smoking cessation advice and some appropriately trained dental teams provide this service. Dentists leading teams providing support to patients stopping smoking, should be allowed to prescribe nicotine replacements under NHS arrangements. Theoretically it should be possible for future, trained and registered professionals complementary to dentistry, to prescribe nicotine replacements under supplementary arrangements as part of an individual care plan.
Nicotine is only part of the support that patients could benefit from and combining nicotine replacement with counselling increases the successful quit rate.15 Trained members of the dental team can provide advice on when to quit, help the patient to identify problems and strategies to deal with problems, help to encourage support from family members and help the patient to access local and national resources. NHS Smoker's Helpline (0800 169 0 169) offer advice in English and Welsh, but dentists are advised to ring Quitline (0800 00 22 00) to identify support for patients who speak other languages.
Locally, smoking cessation services should be available to dental patients as part of the local plan to improve health. If there is insufficient local capacity for dental patients then this should be rectified through dialogue with the local primary care trust or equivalent organisation. In some cases these organisations may wish to commission smoking cessation service provision from appropriately trained members of a dental team. These teams will need to provide counselling support and to have the ability to prescribe appropriate pharmacological preparations.
Within the dental team if dentists are to effectively diagnose and refer patients for management of smoking in relation to oral health, then all medical histories taken by dentists should include questions on tobacco use. Dentists should be able to recognise oral signs of tobacco use and in addition to providing treatment of the particular disease should offer all smoker patients referral into smoking cessation services delivered by trained personnel.
Members of the dental team and others need clarity on the role of the dental team and dentists in smoking cessation. This will help to ensure that smoking cessation services will be available to all dental patients although the local arrangements for this may differ. Clear messages are required:
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Tobacco products harm the mouth and should be avoided.
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The dental team role is to diagnose tobacco use, advise and offer referral into smoking cessation services.
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Normally these services will lie outside the dental practice although some trained dental teams will be able to provide these services.
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Local discussion will clarify how smoking cessation needs of dental patients are to be met locally.
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Primary care trusts need to ensure that dentists can refer smokers into (or provide) smoking cessation services.
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Trained members of the dental team need to be allowed to prescribe nicotine replacements.
Members of the dental team have the potential to help smokers to better health and oral health. To deliver this they need to be clear about their role as part of the primary healthcare team and to lobby for changes that will allow them to deliver.
References
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Monaghan, N. What is the role of dentists in smoking cessation?. Br Dent J 193, 611–612 (2002). https://doi.org/10.1038/sj.bdj.4801642
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DOI: https://doi.org/10.1038/sj.bdj.4801642
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