CH32: Patient with Nicotine Use Disorder

Learning objectives

• Recognize the health hazards associated with tobacco use.

• Identify components of tobacco products.

• Identify various alternative tobacco products.

• Explain various mechanisms for nicotine delivery.

• Describe the metabolism of nicotine.

• Recognize the oral manifestations of tobacco use.

• Recognize the effects of environmental tobacco smoke (ETS).

• Assess and develop a dental hygiene care plan for the patient who uses tobacco.

• Recognize protocols for developing a tobacco cessation program.

• Identify the pharmacotherapies and behavioral therapies used for treatment of nicotine addiction.

Health Hazards/Current treads

Nicotine use is the most preventable cause of disease and premature death in the world

• 90% of deaths from lung cancer

There is no safe form to consume (it’s toxic!)

Types:

• Cigars

• Cigarillos

• Regular pipe

• Waterpipe (Hookah)

• Smokeless tobacco

• ENDS: Electronic nicotine delivery systems (2nd most common)

Cigarette smoking most commonly used nicotine product

Components of tobacco products and smoke

• Nicotine is an addictive psychoactive ingredient in tobacco

• Ignition causes mainstream smoke

• >90 chemicals tobacco products and smoke found to be unsafe

• Carcinogenic

Environmental tobacco smoke

• “Secondhand smoke”

• Passive or involuntary smoke nonusers are exposed to

• Most prevalent among children

• At any level it is deemed unsafe!

• Some toxic concentrations are higher in sidestream smoke than in mainstream smoke.

• Sidestream smoke: the material emitted from burning tobacco products between puffs.

Nicotine addiction

• Addiction: “chronic, progressive, relapsing disease characterized by compulsive use of a substance”

• Tolerance-User’s need to smoke or chew the same product which can decrease the effectiveness = resulting in more product use

Withdrawal

Refers to “the effects of cessation of nicotine use by an individual in whom dependence is established”

Symptoms may include:

• Dysphoric or depressed mood

• Insomnia

• Irritability, frustration, anger

• Anxiety

• Difficulty concentrating

• Restlessness

• Decreased heart rate

• Increased appetite or weight gain

• Cravings for substance

• Impulsivity

• Anticipatory anhedonia

Facts:

• Patients may experience symptoms within 3 hours of quitting

• Relapse within a week is common

• Most symptoms diminish after a few weeks when relapse does not occur

• Cravings for nicotine, increased appetite, and weight gain are greatest in first 3 months after cessation

• Nicotine replacement is associated with less weight gain

Alleviating nicotine withdrawal symptoms

Metabolism of nicotine

Absorption can occur through:

• Lungs-smoked

• Skin

• Oral mucosa-smokeless

• Buccal mucosa-smokeless

• GI Tract

Metabolized by liver

Excreted in the urine

Ph levels: the more basic, the easier to absorb

• Chewing tobacco is more alkaline

Systemic effects

Cardiovascular Diseases:

• Atherosclerosis (risk factor for CHD)

• Coronary heart disease (#1 death in US)

Pulmonary Diseases:

• COPD: chromic obstructive pulmonary disease

• Emphysema-destruction of bronchial alveoli

• Chronic Bronchitis: excess mucus

Cancer:

• Lung cancer, leading cause of death among cancers

• Smoking can cause various types of cancer (Table 32-2)

Tobacco Use and Other Drugs:

• Tobacco use can contribute to alcohol use

Prenatal and children

Nicotine use during pregnancy

• Miscarriage

• Low birth weight

• Placenta previa

• Preterm delivery

• Spontaneous abortion

• Stillbirth

• Orofacial clefts

ectopic pregnancy

Infancy

• Chemicals are passed down from breast milk

• ETS can cause respiratory issues and SIDs risk

Children

• ETS can affect lung development

• Secondhand smoking can cause early-onset asthma and wheezing

• Increased incidence of middle ear infections

Oral manifestations of tobacco and nicotine use

Electronic cigarettes

• oxidative stress=increased risk of infection and cell death to epithelium tissue

• cheek and gingival mucosa pain

• increased PD, vasoconstriction, RBL

Tobacco and periodontal infections

Major risk factor

Gingivitis

• Degree of inflammatory response to dental biofilm is reduced

• Nicotine use may affect treatment and therapeutic outcomes for plaque-induced gingivitis

Periodontitis in tobacco & e-cigarette users:

• Increased rate and severity of periodontal destruction

• Increased bone loss, attachment loss, and pockets depths

• Diminished gingival blood flow and gingival crevicular flow

• Increased tooth loss from periodontal causes

• Prevalence and severity may lessen with cessation

Mechanisms of periodontal destruction

Host response= lowered immune response

Impairment of revascularization:

• Disruption of immune response

• Impact on healing

• Increased risk of periodontal disease

Increased levels of inflammatory mediators and greater localized tissue destruction

Negative effect on bone metabolism

Response to periodontal treatment

• Weakened response to conventional therapy

• Negative effect on bone regeneration after periodontal therapy

• Increased risk of implant failure

• Delayed healing

Care plan

Assessment:

1. Patient History

• Tobacco use status is determined

• Identify use of other psychoactive drugs

• Check vital signs

2. Extraoral examination

• Breath and body odor

• Fingers (yellow around fingertips)

• Skin

• Lips (wrinkles)

3. Intraoral examination

• Look for oral consequences of tobacco (Table 32-3)

Clinical treatment procedures

Patients that are tobacco users may require longer and more frequent appointments due to increase of:

• Dental staining

• Calculus

• Dental caries

• Gingival inflammation

• Periodontal issues

1. Dental Biofilm Control

• 1st priority is self-care for daily biofilm control due increased chance of dental problems

• Encourage regular dental care (brushing 2x a day, Flossing) Recommend dental products

2. Nonsurgical Periodontal Therapy

• Inform patient that healing will be delayed because of tobacco use and results will vary

• Tobacco cessation will help to improve results

3. Diet and Nutrition

• Tobacco users may have a poor diet due to effect of tobacco use

• Tobacco cessation focuses on diet as well

Reasons for quitting

2/3rds of smokers report an interest in quitting

• General health awareness

• Specific health problems

• Effect on family

• Effect of smoking on fetus

• Cost

• Coughing/lack of breath while exercising

Treatment methods for nicotine cessation

1) Self-help (unassisted)

2) Assisted strategies

Self-help interventions

The following methods are used singularly or most commonly in conjunction with one another:

• “Cold Turkey”

• Reduce # of nicotine exposures

• Join a family member or friend

• OTC nicotine replacement aids

• Transitioned to a “light” version of cigarettes

Fewer than 1 in 10 report success in this cessation

Assisted strategies for nicotine addiction

Counseling

• Interventions by oral health professionals

Pharmacotherapies

• Table 32-5 (list of FDA-approved first line pharmacotherapies)

Combination

• Counseling and pharmacotherapy

Pharmacotherapies used for treatment of nicotine addiction

1) Nicotine Replacement Therapy

• Objective is to prevent withdrawal symptoms and to promote nicotine cessation

• Nicotine Gum-transmucosal delivery: nicotine is release while chewing

• Nicotine Patch- Transdermal delivery

• Nicotine Inhaler- Transmucosal delivery

• Nicotine Nasal Spray- Nasal Mucous Membrane delivery

• Nicotine lozenge- Transmucosal delivery

2) Nicotine Free Therapy

• Bupropion SR-reduce cravings

• Varenicline Tartrate (see table 32-5)

Tobacco cessation program

An essential compound to create an oral healthcare plan for patients that use tobacco

Requires multiple appointments, repeated interventions, and multiple attempts from the patient

Use Motivation Interviewing

• Person-centered

• Goal-directed method of communication

• Strengthen intrinsic motivations for change

5 As of Smoking Cessation

• Ask

• Advise

• Assess

• Assist

• Arrange

Ask

• Health History

• Present questions carefully and without judgment

• Obtain patient’s confidence and trust

• Recognize the type of tobacco product used

• don’t assume children and teens don’t smoke

Advise

Advise every patient about nicotine use

Never users or former users: praise their behavior

Current user: Stop-Look-Listen

• Stop now: advise the patient to stop and the importance of

  stopping

• Show: hand patients a mirror to observe the oral examination

• Listen: ask the patient their opinion about quitting and why

Assess

Asking the patient if they are ready to quit

If yes: if additional treatment is needed refer to next step

If no: use the 5 R’s

• Relevance-why do/do they not want to quit

• Risks

• Rewards

• Roadblocks

• Repetition-reinforcement

Assist

• Set a quit date (within two weeks)

• Encourage the patient to tell their family and friends!

• Provide practical counseling

• Pharmacotherapy

• Provide educational therapy

• Support patient

Remove all nicotine products, encourage total abstinence, review past quit attempts (triggers, what worked), provide local/state quit number, inform combo of medication and counseling is beneficial, pamphlets + support groups

Arrange

• Follow-up with the patient

• Contact patient before quit date and 1 week after quit date

• Answer questions that patient might have

1st, 2nd, 3rd month of cessation intense withdrawal so follow up

If relapse, let them reflect and affirm

Documentation

Careful and complete documentation is important for every patient!

Including:

• Tobacco history: current and/or past use

• Age, ethnicity, gender, periodontal, and dental status, IOEO exam findings

• Patient interests/confidence and motivation/readiness to quit

• Previous quit attempts and techniques

• Options for cessation provided and referrals