By Jannette Whisenhunt, RDH, BS, MEd, PhD
It is not uncommon in our office to see patients who smoke. In fact, it is so commonplace that we become a little complacent about our care for these patients. Many times, I ask a patient about his or her tobacco use and smoking habits, and I usually get the same old responses: “Yeah, I know I should stop, but I don’t want to,” and “I can stop whenever I want to, but I’m just not ready now,” and “I know it’s not good for me, but I’m really stressed now and might stop later when things calm down.”
After a few years of seeing very few people who were even interested in stopping their smoking, I just stopped asking. I know this is not what I should have done, but I’m just being honest. I do live in Winston-Salem, North Carolina, a tobacco-growing center. Many patients in this area work for a tobacco company, and many of the farmers grow tobacco. So maybe it is tougher to stop smoking here, but that shouldn’t be an excuse.
When our patients are not ready to stop smoking, or not even ready to start thinking about stopping, it’s very hard to be a motivator and help them. With oral cancer statistics on the rise, we should be asking ourselves whether our neglect of asking patients about their smoking habits may be one of the reasons that our patients are still smoking. It’s a question that makes us stop and think. It should also make us want to do something about it and get back on the bandwagon, as they say, and start asking again. We are the oral health-care providers, and we know that smoking tobacco has many adverse effects on the oral cavity. We need to get busy asking all of our patients who smoke about their habits, and if they’re ready to start thinking about stopping or cutting back on their tobacco use.
As a piggyback on the topic in last month’s column, respiratory diseases, this month’s article will focus on the link between patients who smoke and their periodontal health, and how we can help them improve their oral health. Studies have shown for years that smoking tobacco products is detrimental to a person’s health, but heart issues and respiratory diseases are not the only problems that arise from years of smoking. We see gingival tissue health decrease with smokers, as “it appears that smoking may be one of the most significant risk factors in the development and progression of periodontal disease.”1 Some of the common gingival disturbances we may see in our patients are:
- More attachment loss
- More alveolar bone loss
- Deep probe readings
- More teeth with furcation involvement
- More tooth loss1
As dental hygienists, we notice the tissue differences in our patients who smoke. Many studies have shown that a “positive association was observed between periodontal disease and cigarette smoking. It was found that cigarette smoking was associated with lesser gingival bleeding and deeper pockets as compared to nonsmokers.”2
We can also see that loss of alveolar bone and loss of attachment is very common. “Most epidemiological studies indicate that smoking is directly related to incidence and prevalence of a variety of medical problems, including pulmonary, cardiovascular, gastrointestinal diseases, low birth weight, and cancer. Tobacco smoking causes about 80% of myocardial infarctions before the age of 50 years and 70% of chronic lung diseases. Diagnosis of periodontal disease is still primarily based on the detection of periodontal pockets, loss of connective tissue attachment, and/or assessment of alveolar bone loss performed on radiographs.”3
One study concluded, “The hypothesis that current or former smokers would manifest a higher prevalence of oral health problems than those who have never smoked was supported for most of the indicators used in this study. These findings are consistent with previous clinical research that suggests that smoking is associated with both the prevalence and severity of periodontal disease. In an analysis of the effect of smoking on overall periodontal disease rates in the United States, it was estimated that 41.9% of periodontitis cases were attributable to current smoking and 10.9% were attributable to former smoking.”4
An increased risk of periodontal disease and loss of teeth are not the biggest problems for which smokers have a high risk. The most serious concern for them and our concern should be their risk of oral cancer. “Close to 49,750 Americans will be diagnosed with oral oropharyngeal cancer this year. It will cause over 9,750 deaths, killing roughly one person per hour, 24 hours per day. Of those 49,750 newly diagnosed individuals, only slightly more than half will be alive in five years, approximately 57%. This is a number that has not significantly improved in decades.”5 The Oral Cancer Foundation studies have also shown that “tobacco use in all its forms is number one on the list of risk factors in individuals over 50. Historically at least 75% of those diagnosed at 50 and older have been tobacco users.”5 This is a staggering number, and it is a shame that it has not decreased over the years.
Oral cancer is usually not noticed by patients because it is often not painful. This is another good reason that we as dental professionals should be doing oral cancer screenings for all of our patients, but particularly for those who are current or past smokers. Smoking is a huge cost in our health-care system. “It is estimated that approximately $3.2 billion is spent in the United States each year on treatment of head and neck cancers.” (2010 numbers)5
“A number of researchers have argued that dentists have an important role to play in tobacco control. Brief smoking cessation advice and supportive materials in the context of regular oral health visits can lead to higher smoking cessation rates. Support of community-based efforts to control tobacco and active engagement in the tobacco control debate also contribute to the momentum toward smoking cessation.”6
Dental hygienists also have an important role to play, and that is to be on the forefront of performing oral cancer screenings for all of our patients, and to encourage patients to quit smoking. We need to do a better job of motivating them, and we need to share some statistics about their periodontal disease and how smoking impacts the disease. I know that not everyone will be receptive, and it may be difficult to stay motivated about it, but we need to think that if we can encourage a few to stop smoking, maybe we can save them from developing oral cancer. As a professional group in our regions, states, and country, we can band together and become leaders of our teams to make this happen. We can help oral cancer statistics drop with early detection and better patient response rates. Our patients deserve for us to be their cheerleaders and help them to become healthier, and to provide them with information that can help them stop smoking.
The American Dental Hygienists’ Association has a place to refer our patients for help at askadviserefer.org. There are several other reputable sites that can help, such as smokefree.gov, which has information about phone line services in each state that people can call for support. We just need to help patients see that they can do it, and we can help them understand that now is the time to try to stop smoking! Happy scaling. RDH
Jannette Whisenhunt, RDH, BS, MEd, PhD, is the Department Chair of Dental Education at Forsyth Technical Community College in Winston-Salem, N.C. Dr. Whisenhunt has taught since 1987 in the dental hygiene and dental assisting curricula. She has a love for students and served as the state student advisor for nine years and has won the student Advisor of the Year award from ADHA in the past. Her teaching interests are in oral cancer, ethics, infection control, emergencies and orofacial anatomy. Dr. Whisenhunt also has a small continuing education business where she provides CE courses for dental practices and local associations. She can be reached at [email protected].
1. Nield-Gehrig JS, Willmann DE. Foundation of Periodontics for the Dental Hygienist. 3rd Ed. 2011; Chapter 11. “Smoking and Periodontal Disease.” pp 196-201.
2. Gautam DK, Jindal V, Gupta SC, Tuli A, Kotwal B, Thakur R. “Effect of cigarette smoking on the periodontal health status: A comparative, cross sectional study.” J Indian Soc Periodontol. 2011 Oct;15(4):383-7. doi: 10.4103/0972-124X.92575.
3. Vinni G, Devaraj CG. International Journal of Health Sciences & Research (ijhsr.org) 109; Vol.7; Issue: 1; January 2017.
4. Tomar SL, Asma S. “Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey.” J Periodontol 2000; 71(5):743-51.18.
5. OCF, Oral Cancer Foundation. http://oralcancerfoundation.org/facts/.
6. Millar WJ, Locker D. “Smoking and Oral Health Status.” cda-adc.ca/jcda/vol-73/issue-2/155.html. JCDA March 2007, Vol. 73, No. 2.