clinic theory II nicotine use disorders and tobacco cessation

tobacco cessation

• when a person stops tobacco use with the goal of achieving permanent abstinence

• majority of people cycle through multiple periods of abstinence and then relapse

tobacco dependance

• chronic disorder characterized by vulnerability to relapse that persists for months

80% of lung cancer deaths

• attributed to smoking

systemic health effects

• nicotine addition

  • cancer

  • cardiovascular disease

  • hypertension, stroke

  • respiratory disease

  • reproductive problems

  • impotence

  • ulcers

  • osteoporosis

  • facial wrinkling

metabolism of nicotine

• nicotine is absorbed through the lungs

• distributes to brain, liver, spreads to nearly all body tissues

components of tobacco products and tobacco smoke

• nicotine

• carcinogenic substances

• cigarette smoke

chemical compounds of nicotine and tobacco products can be

• carcinogenic

• respiratory toxicant

• cardiovascular toxicant

• reproductive or developmental intoxicant

• addictive

smokeless tobacco is

• absorbed in the oral cavity and intestines

systemic effects of tobacco

• cardiovascular diseases (#1 cause of death in US)

• pulmonary diseases (leading cause of COPD)

• main cause of oral cancer

• tobacco and use of other drugs

hallmark of nicotine addiction

• compulsive use

• use, despite its harmful effects

• pleasant (euphoric effects)

• difficulty with quitting or controlling use

• recurrent cravings

• tolerance

• physical dependence

  • relapse after abstinence

neurochemicals released by brain that reinforce effects of nicotine

• dopamine

• norepinephrine

• serotonin

• beta-endorphins

• vasopressin

reinforcing effects of nicotine

• chemicals produce effects in brain that cause user to experience pleasure, anxiety and tension reduction, a sense of well being, arousal, appetite suppression, and short term memory improvement

tolerance of nicotine

• results form neuroadaptation

physical dependence of nicotine

• when nicotine is not available, brain function becomes disturbed, which results in withdrawal symptoms

oral manifestations of tobacco and nicotine use

• vary with type of tobacco used and form in which it is used

• pattern and severity of clinical presentation vary with frequency and duration of use

• ENDS have shown oxidative stress and cell death to epithelium tissue

• extraoral/intraoral examination most efficient and effective method for detecting tobacco related conditions in and around mouth

pipe smokers

• may have nicotine stomatitis on palate

oral health effect of tobacco use

• oral mucosal lesions are typically white, hyperkeratinized, and wrinkled

• three to six times more likely than non smokers to develop periodontal disease

• changes should be described to patients as they might not be aware of oral effects of tobacco use

withdrawal

• duration

• alleviation of symptoms

• prevention of relapse

  • environmental cues like alcohol, coffee, and food may be triggering

    nicotine suppresses appetite so quitting also leads to gaining weight

    on average individuals who quite gain 10 pounds

psychologic aspects of quitting

• provides a sense of comfort, security, or entertainment

behavioral aspects

• relate to responses that tobacco users develop from having experiences various formas of gratification from tobacco use

sensory apsects

• oral gratification

sociocultural aspects

• peer pressure, family influence, social network

characteristics of patient centered communication

• collaborating ( not persuading)

• eliciting information (no imparting imformation)

• emphasizing the clients autonomy (not the authority of expert)

• open ended questions to elicit responses

treatment for tobacco dependenncy

• reasons for quitting: self-efficacy/ personal belief (what are their reasons for quitting, plan intervention specific to patient)

• self help interventions: on their own

• assisted strategies: counseling, medication

pharmacotherapies used for treatment of nicotine addiction

• zyban

• intended to help for cravings, contains slight amount of nicotine

• reduce with drawl syndromes and is much less addictive than tobacco products

• not recommended for those under 21

• dental professionals may educate patients on the use and options for dosage

dental hygiene care for patient who uses tobacco

• majority of smokers state they would like to quit

• specific treatment modifications indicated

• helping patients quit using tobacco becomes integral part of dental hygiene care plan

the five A approach

• ask

• advise

• assess readiness to quit ( are they ready)

• assist (how to go about)

• arrange (instructions and appointments for counseling)

clinical treatment procedures

• dental biofilm control

• stain

• calculus

• nonsurgical periodontal therapy - healing is compromised in smokers

• other patient instruction

  • nutrition/diet ( big, patients are going to want to ear, suggest non cariogenic foods to simulate such as carrots)

  • exercise

tobacco cessation program

• essential component of oral healthcare plan

• often requires multiple appointments, repeated interventions, and multiple attempts to quit

• dental setting provides excellent opportunity to assist in tobacco cessation

• interventions and outcomes will vary

• even minimal intervention may help a patient become tobacco free

ask

• health history

• present questions carefully

• obtain patients confidence (empathy and support of their choice to change, do not judge)

• children, adolescents, parents

advise

• always _ risks about use, but be empathetic and understanding

• commend never users/ former users

• current users: stop look listen approach

• show areas affect by use

assess

• ask if they are ready to quit

assist

• establish a quit plan

• provide practical counseling

• pharmacotherapy

• involve family and friends to give them encouragement

• provide educational information

  • “elicit, provide, elicit”

elicit provide elicit

• elicit- patients reasons to quit

• provide- education, resources, support a quit date

• elicit- “what would you like to do”

arrange

• follow- up

• contact the patient before the quit date

• provide additional resources and encouragement

advoacy

• community oral health education programs

• learn about tobacco legislation and public health policy

documentation

• history and/or current use, type of tobacco, and amount typically used

• age, ethnicity, gender, periodontal, and overall dental status and oral cancer screening findings

• interest/ confidence and motivation/readiness to quit and previous quit attempts and techniques used

• options or cessation presented to patient

factors to teach patient

• never start using tobacco

• how to perform regular self-examination of oral cavity (if anything is changing in size or color)

• pregnant women who use tobacco products can harm developing fetus and newborn infant

• educate parents to provide guidance in young children who may experiment with tobacco/ nicotine products

tobacco and periodontal infections (appearance in oral cavity)

• paler tissue color

• decreased bleeding due to vasoconstriction

• thickened/ fibrotic tissue

• reduced erythema vs extent of disease

• gingival recession

• increased bone loss, probing depths, CAL, and furcation

• response to treatment