Smoking cessation includes drug replacement therapies. Dental hygienists must be familiar with the drugs and be able to teach patients how to properly comply with their drug therapy.
by Ann Eshenaur Spolarich, RDH, PhD
Cigarette smoking is the leading cause of preventable death in the United States. It is the primary risk factor for cardiovascular disease and stroke, and is a major risk factor for lung and oropharyngeal cancers and for chronic respiratory diseases, including chronic bronchitis and emphysema.1 Smoking also is the major contributing risk factor for the initiation and progression of periodontal disease.2 Dental hygienists play an important role in helping their patients to stop smoking. The purpose of this article is to examine medications used with smoking cessation therapy, and related oral health considerations for patients who use tobacco.
Quitting tobacco use is not simply a lifestyle choice for patients. The chemical nicotine found in tobacco actually causes neural changes that stimulate the “reward” pathway or pleasure centers of the brain that are mediated by the neurotransmitter dopamine. Molecules of nicotine stimulate the α4 β2 nicotinic brain receptors that cause the release of dopamine, which then produces feelings of pleasure. Over time, these nicotine receptors become desensitized to the presence of nicotine, so a smoker must increase tobacco use to produce the same sense of pleasure, a phenomenon known as tolerance, which contributes to nicotine dependency. Even after the long-term abstinence of nicotine use, these brain receptors remain altered, which explains why nicotine dependency may legitimately be considered a brain disorder.
Smoking cessation requires a multifactorial approach to be successful. It includes extensive behavioral modification therapy coupled with the individual’s desire to stop smoking. Nicotine replacement therapies and other drugs that decrease cravings and withdrawal symptoms associated with dependency can be used to increase the likelihood of success. When used correctly, these replacement therapies may double the success rate in patients who are attempting to quit smoking.3,4,5,6,7,8 While dental hygienists are not permitted to prescribe these drug therapies, they must be familiar with the drugs, their respective mechanisms of action, dosing schedules, and contraindications, be able to identify patients who are good candidates for these medications, and help teach patients how to properly comply with their drug therapy.
Nicotine is the most commonly used drug for replacement therapy. It is available in both over-the-counter (OTC) preparations as well as prescription-strength products. Nicotine is indicated for the relief of cravings and withdrawal symptoms. OTC preparations are dispensed in multiple delivery forms, such as chewing gum (Nicorette®), lozenges (Commit®), and transdermal patches (Nicoderm® CQ®). Prescription products are delivered as either a nasal spray (Nicotrol® NS) or inhaler (Nicotrol® Inhaler).9
Use of nicotine products may lead to excessive salivation, soreness of the mouth and/or throat, dizziness, nervousness, and gastrointestinal side effects. Chewing gum should not be used in patients with a history of temporomandibular joint dysfunction. General side effects associated with gum, lozenges, and transdermal patches include xerostomia, taste alteration, ulcerative stomatitis, and glossitis. Some patients may also experience increased gingival bleeding. Nicotine is known to cause tachycardia, and overdose can lead to arrhythmias; therefore, dental hygienists should carefully monitor blood pressure and pulse rate in patients using nicotine replacement therapy. Caution should be used when administering local anesthetic with a vasoconstrictor to patients using these products.9
Dental hygienists should teach patients that they may not begin use of a nicotine replacement product until they have set a quit date and agree to stop smoking. They should also inform their patients that smoking while using nicotine products can lead to severe adverse cardiac events, including severe arrhythmias. Compliance with the recommended dosing regimen is essential to treatment success. Nicotine products are used in a step-down dosing regimen over a period of 12 weeks. These products should be used with caution in patients with coronary artery disease, angina, hyperthyroidism, insulin-dependent diabetes, adrenal tumors, and in patients with diminished liver or kidney function. The inhaler should not be used in patients with respiratory disease, and the nasal spray should not be used in those with chronic allergies, rhinitis, sinusitis, or nasal polyps. Safety and efficacy of nicotine has not been tested in children.9
Bupropion (Zyban®) is an antidepressant medication used as an adjunctive therapy for smoking cessation. This drug inhibits the reuptake of norepinephrine and dopamine, which keeps these neurotransmitters in the synapse for longer periods of time, thus increasing feelings of pleasure and well-being. The drug reduces nicotine cravings. Bupropion (Zyban®) is dispensed in 150 mg tablets and is taken for up to 12 weeks. The patient takes 150 mg daily for the first three days and then increases to 150 mg twice daily for a seven to 12 week period. The patient can begin taking the medication one week prior to stopping smoking.10
There are many drug interactions and precautions associated with this medication, and dentists must consult a drug reference guide to ensure compatibility prior to prescribing this drug. Significant oral side effects include xerostomia and taste alteration. This drug is associated with seizures, and the risk of seizure is dose-dependent and associated with the use of certain other medications. Because Zyban® increases norepinephrine, it may elevate blood pressure. Treatment-emergent hypertension is associated with this medication when the drug is used alone and when used in combination with a transdermal nicotine patch. Dental hygienists should monitor vital signs and record blood pressure when treating patients taking this medication. Caution should be used when administering local anesthetics with a vasoconstrictor.9
Varenicline (Chantix™) is a new smoking cessation drug that directly stimulates dopamine activity but to a lesser extent than nicotine, thus reducing cravings and withdrawal symptoms. It also prevents nicotine from stimulating the release of dopamine by occupying the nicotine receptor sites in the brain. Safety and efficacy of varenicline have not been established in children or with concurrent use of other cessation therapy drugs.
Increased side effects are observed when varenicline is used with nicotine replacement therapy. Oral side effects include xerostomia and taste alteration. General side effects include insomnia, headache, abnormal dreams, and nausea. Varenicline is dispensed in 0.5 mg tablets and is used for up to 12 weeks. Patients may begin taking the medication one week prior to their quit date. The patient takes 0.5 mg once daily for the first three days and then 0.5 mg twice daily for days four through seven. The patient is maintained on 1 mg twice daily for weeks two through 12. If the patient successfully quits smoking during the 12 weeks, an additional 12 weeks of drug treatment can be used to help maintain success. If the patient does not quit during the initial 12 weeks of treatment, the medication should be discontinued and factors leading to failure should be reevaluated.9
Tobacco use produces multiple deleterious effects on the oral cavity, including increased gingival disease and risk for oropharyngeal cancer. Cigarette smoking produces multiple effects on the periodontium, including local tissue ischemia, increased loss of attachment and bone, and decreased immunity.2 This immunosuppressant effect on the host contributes to the growth of a more pathogenic bacterial flora within the biofilm.2 Increased calculus formation, oral debris, and staining are frequently apparent in smokers.2 Excellent plaque control measures should be encouraged, including mechanical plaque removal methods and use of chemotherapeutic adjuncts. Brushing with Sonicare®, with its patented fluid-dynamic technology, has been shown to significantly remove more plaque over the entire dentition as well as from interproximal spaces and other difficult-to-access areas.11,12 Sonicare® removes significantly more chlorhexidine and tobacco stain than manual toothbrushing.13
Even with good oral hygiene, smokers demonstrate a less favorable response to periodontal therapy than nonsmokers, thus cessation therapy is critical to help prevent further tissue destruction. However, periodontal complications may persist for years following smoking cessation. Dental hygienists should also teach their patients to perform regular self-examinations to screen for oral cancer and encourage frequent oral examinations and recall visits to maintain oral health.
For additional information about helping patients quit tobacco use, dental hygienists are referred to the American Dental Hygienists’ Association Ask, Advise, and Refer program and the National Network of Tobacco Cessation Quitlines.14,15
About the Author
Ann Eshenaur Spolarich, RDH, PhD, is a licensed dental hygienist with 27 years of clinical practice experience. She holds a PhD in physiology from the University of Maryland at Baltimore. Dr. Spolarich is an internationally recognized author and speaker on pharmacology and the care of medically complex patients. She is the course director of clinical medicine and pharmacology at the Arizona School of Dentistry and Oral Health, instructor and course director of pharmacology in the Audiology Department of the Arizona School of Health Sciences, a clinical associate professor at the USC Dental School, and a clinical instructor on the Dean’s Faculty at the University of Maryland Dental School. In addition to her teaching, Dr. Spolarich is an independent contractor, providing research and educational consulting services to both private and professional organizations. She is chair of the ADHA Council on Research. Dr. Spolarich practices dental hygiene part time in Sun City, Ariz., and in Annapolis, Md. She resides in Phoenix.
References
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14. American Dental Hygienists’ Association Smoking Cessation Initiative. Available at: www.askadviserefer.org.
15. National Network of Tobacco Cessation Quitlines. 1-800-QUIT NOW (784-8669). Available at: www.smokefree.org.
