Dentists have a focal role to play in Tobacco Intervention Initiative. Though, the number of dentists offering this life-saving therapy is miniscule as compared to the large number of people who consume tobacco. Many dentists are reluctant to take on tobacco intervention as they doubt the efficacy of the treatment, while others don’t have time or training.
Routine screening by dentists can help patients. Dentists are the first to notice the adverse effects of tobacco use and nicotine addiction. These can be ranging from mild to life-threatening like halitosis, abrasions, delayed wound healing, chronic periodontal disease, tobacco keratosis and oral and pharyngeal cancers.
Dental clinics can be used for arousing the patient’s interest and motivation to quit tobacco through counseling. IDA’s initiated Tobacco Intervention Centre equips a dentist with the latest cutting edge training for tobacco intervention.
Dental clinic are an ideal options for tobacco intervention center because of the following reasons:
The above facts clearly depict the important role that dental clinics have in tobacco intervention.
Turn your dental clinic into a TCC Centre
Moreover a TII clinic has the necessary infrastructure to support the tobacco intervention.
When the dental professionals join TII as a specialist you will be taught in detail about the following.
The dentist can motivate\ counsel their patient in the following ways:
The following five steps for motivational intervention (5R™s) can be taken by the dentist if the patient is not ready to quit tobacco. This can be due to misinformation, concern about the effects of quitting or demoralization because of previous unsuccessful quitting attempts. This presents the dentist an opportunity to educate, reassure and motivate.
Once you have motivated a patient to quit, then the 5A™s are a road map for dentist to follow as a guide for helping smokers quit. The 5A's are ask, assess, advise, assist and arrange.
To help assist the 4D’s must be followed, a smoking cessation method for coping with cravings. A combination of counseling and pharmacotherapy. The method is meant to distract the potential smoker from succumbing to the urge to smoke. The 4D™s are:
Assistance can be given as pharmacological options by the dentist in form of Nicotine Replacement Therapy (NRT) . NRT comes in various forms such as patch, gum, inhaler and lozenge. Another medication is the antidepressant Bupropion that has been widely advocated as first line of treatment.
Prescription NRT options include nasal sprays and nicotine inhalers as well as the prescription antidepressant Bupropion, which has been shown to be effective in helping people to quit smoking. Many people feel most comfortable working with their doctor while attempting to quit smoking. The advantage of using a prescribed method is that your doctor or dentist can help to monitor your efforts. Because the doctor is familiar with medical history and the different treatment options, he or she is best equipped to decide which method is right for you.
Dosage: 10 ml bottles (10mg/ml)
1-2 doses/hr (up to 5) for 4-8 weeks
4-6 weeks gradual or abrupt reduction
Bottle = 100 doses; lasts about a week
Contraindications: Chronic respiratory problems.
Side Effects: Coughing, sneezing, runny nose and watery eyes.
Because inhalers mimic the action of smoking, they may or may not be a good idea. On one hand, inhalers can be useful for people who have difficulty giving up the behavioral actions of smoking. On the other hand, inhalers do not allow the user to eliminate this behavior. One of the most difficult things to overcome on the way to smoking cessation is the behavioural cues associated with smoking. Since a person will ideally try to eliminate the cues associated with smoking as they go through the cessation process, nicotine inhalers may not be a good option.
Here nicotine is absorbed through the mouth and not the lungs.The inhaler kit contains 42 cartridges.
Dosage: 6-16 cartridges every day
Gradual reduction after 12 weeks
Puff 1 cartridge for 5 minutes x 4
Contraindications: Allergy to menthol.
Side Effects: Throat irritation, cough and headaches.
Bupropion (an anti-depressant agent) has been used along with NRT as first- line therapy for treating tobacco dependence. However, Bupropion’s efficacy is not because of its anti- depressant properties. The exact mechanism by which Bupropion works is not known. It is presumed that the medicine affects noradrenaline and dopamine, the two chemicals in the brain that may be the key components of the nicotine addiction pathway.
Taking the drug alone produces higher cessation rates than placebo and taking it along with nicotine replacement is even more successful.
Dosage (for adults): 300 mg/day (given as 150 mg twice daily). Begin with a single dose of 150 mg a day in the morning. If the initial dose is adequately tolerated, increase the dosage to 150 mg twice daily and this can be done as early as day 4 of dosing.
There should be an interval of at least 8 hours between successive doses.
Doses above 300 mg/day should not be used.
Set quit date for 1-2 weeks after beginning Bupropion treatment
Course of Treatment: 7-12 weeks
Maintenance: Up to 6 months
It is important that the patient continues to receive counselling and support throughout the treatment with Bupropion, and for a period of time thereafter.
Whether to continue treatment for longer periods for smoking cessation with Bupropion HCl must be individually determined for patients. If no significant progress toward abstinence is seen by the 7th week of therapy, it is unlikely that the patient will quit during the attempt and treatment should probably be discontinued. Dose tapering of Bupropion is not required when discontinuing treatment.
Contraindications: Seizure disorder, concurrent psychiatric medications and eating disorders like anorexia nervosa, bulimia and pregnancy.
Drug Interactions: Antidepressants like Fluoxetine are associated with panic and psychosis; Carbamezapine (Tegretol) increases metabolism.
Side Effects: Dopaminergic effects may be activated with feelings of agitation and restlessness. These however decrease in 1-2 weeks after medication begins. Other effects are insomnia, gastrointestinal upset, appetite suppression and weight loss, headache and lowering of seizure threshold. Seizure incidence is 1 in 4000 but the incidence is rare with sustained release preparations below 400 mg/day.
Varenicline is a selective α4β2 nicotinic acetylcholine receptor partial agonist. It helps in reducing withdrawal symptoms and blocking dopaminergic stimulation.
Dosage: Varenicline should be started one week before the quit date and should be taken after eating food.
Treatment is continued for up to 12 weeks.
Day 1 to Day 3: 0.5 mg, 1 tablet each day
Day 4 to Day 7: 0.5 mg, twice a day
(1 in the morning and 1 in the evening)
Day 8 to the end of treatment: 1 mg twice a day
(1 in the morning and 1 in the evening)
Contraindications: Use with caution in patients with impaired renal function. Not recommended for use in patients under 18. Use in pregnant women only if the potential benefit justifies the potential risk to the foetus. This drug has no significant pharmacokinetic drug interactions.
Side Effects: Nausea, sleep disturbances, constipation, gas, vomiting, some reports of depression, agitation and suicidal thoughts.
Follow up: Meet the patient within one week of the quit date. The next visit must be scheduled within the first month. Other visits may be scheduled as per individual cases. During the follow up, assess pharmacotherapy use and its problems.
If the patient has slipped (consuming tobacco minimally) or relapsed (consuming tobacco according to initial habit pattern), identify the triggers. Reaffirm his commitment towards total abstinence and use the event as a learning experience.
Maintenance: May last for 6 months to a lifetime.