Printed version: 1806-7727
Electronic version: 1984-5685
RSBO. 2012 Apr-June;9(2):193-8
Literature Review Article
Tobacco cessation: what role can dental
Abhishek Mehta1Gurkiran Kaur2
Dr. Abhishek Mehta
Associate Professor and Head Dept. of Public Health Dentistry, Dr. H. S.
Judge Institute of Dental Sciences and Hospital, Panjab University
¹ Associate Professor and Head, Dept. of Public Health Dentistry, Dr.H.S.Judge Institute of Dental Sciences and Hospital, Panjab University – Chandigarh (U.T.).
² Reader, Dept. of Oral and Maxillofacial Pathology, Gian Sagar Dental College and Hospital – Banur – Distt. Patiala – Punjab.
Received for publication: June 14, 2011. Accepted for publication: November 17, 2011.
Tobacco dependence is classified as a disease by the
International Classification of Diseases (ICD-10), but, medical and
dental professionals have neither seriously taken this fact nor made
oral medicine; smoking
any serious attempt to tackle this disease. Apart from supporting
wider tobacco control measures, oral health professionals can help
patients to stop using tobacco. This may be the single most important
service dentists can provide for their patients' overall health. Objective:
This review is prepared with the object to help both clinicians and oral health professionals to scale up their involvement in tobacco control activities, including advocacy and smoking cessation programs.
that they want to quit, but a meagre 2�� succeed. The
setting provides a unique opportunity to assist tobacco users in
achieving tobacco abstinence. Still, More than 40�� of dentists do
not routinely ask about tobacco use and 60�� do not routinely advise
tobacco users to quit, while 61.5�� of dentists believe their patients
do not expect tobacco cessation services. Conclusion:
by dentist has been found to be effective in helping people to quit tobacco consumption. A step-wise approach and patience must be adopted while dealing with such patients.
194 – Tobacco cessation: what role can dental professionals play?
on quitting tobacco is still neither a routine part of
clinical practice for many oral health professionals
Currently, there are an estimated 1.3 billion nor are many National Dental Associations (NDAs)
smokers in the world. The total global prevalence involved in tobacco control.
in smoking is 29�� (4�.5�� of men and 10.3�� of
To implement a tobacco cessation program,
women over 15 years of age smoke). Of the 1.3 clinicians should systematically identify all
billion smokers, more than 900 million live in tobacco users at every visit. A system needs to
developing countries out of which 120 million are be implemented in the clinic which ensures that
there in India . Tobacco is the second major cause tobacco use status is obtained and recorded at
of death in the world. It is currently responsible each patient visit. This may be carried out by
for the death of one in ten adults worldwide. Every the clinician or an assistant who may be trained
6.5 seconds one tobacco user dies from a tobacco-
accordingly. The forms of tobacco use such as
related disease somewhere in the world. Cigarettes cigarettes/beedis/gutkha, frequency and duration
kill half of all lifetime users and half of those die of use can be mentioned .
in middle age (35-69 years), losing an average
Current evidence suggests that even brief advice
of 20 to 25 years of life . With current smoking leads to an absolute increase in the cessation rate
patterns, approximately 500 million people alive of about 2.5��. This indicates that for every 40
today will eventually be killed by tobacco use. By patients who receive brief advice, one will quit
2030, tobacco is expected to be the single biggest smoking permanently. Given the high prevalence
cause of death worldwide, accounting for about 10 tobacco consumption and that �0�� see a clinician
million deaths per year .
or a dentist at least once a year, interventions
As research on the effects of tobacco on health with patients who are tobacco users, can have an
continues and the number of affected people enormous impact [�]. As a dentist, one has the
increases, the list of conditions caused by tobacco unique opportunity to link the patient's presenting
has expanded. There is nowadays evidence that illness to his/her tobacco use, and then prescribe
almost every organ in the body is affected by tobacco tobacco cessation therapy. Table I  depicts a
consumption and now it also includes cataracts, brief guideline on how to advice a patient to quit
pneumonia, acute myeloid leukemia, abdominal tobacco.
aortic aneurysm, stomach cancer, pancreatic cancer,
cervical cancer, kidney cancer, and periodontitis. Table I
– Brief guideline on how to advice a patient to
These diseases add on to the already known such as quit tobacco
lung, oesophagus, larynx, mouth and throat cancer,
chronic pulmonary and cardiovascular diseases, 1. The timing of advice
as well as negative effects on the reproductive • First and every patient
system and sudden infant death syndrome. All • Repetition of advice in each patient visit
these diseases are preventable by removing one • Documentation of tobacco cessation advice on
single risk factor i.e. tobacco use. Therefore it is the prescription pad/ discharge slip
imperative that health care professionals including • If patient visits with an acute illness (e.g. pain
dentists must help their patient who are addicted in tooth) then that should be addressed first, and
to this habit and want to quit. This review is advice should be given at 1st and all subsequent
prepared with the objective to help clinicians and
oral health professional to understand in a step-
wise approach, how they can help their individual 2. The type of advice
patients as well as general populations to quit habit • Customize the ill effects of tobacco as per tobacco of tobacco consumption.
user profile. Need to emphasize the ill effects of tobacco usage that would be most relevant to each particular tobacco user
• The patient's current illness needs to be linked to
tobacco use. Clarify that the presenting illness will not resolve unless tobacco usage is discontinued
Tobacco cessation and dentist's role
• Communicate to the tobacco user that there is
help available and that the doctor and his staff are
The dental team has a major role to play in there to help if the tobacco user is interested
smoking prevention. Evidence suggests that smoking • On the basis of patient co- morbidities, age and
cessation interventions are effective [2, �]. A brief motivation quotient, dental clinicians need to
intervention will often result in significant health decide and advice on a preventive or interventional
gain and, in the long term, reduces smoking-related
health-care costs to countries. Unfortunately, advice approach for individual tobacco users
RSBO. 2012 Apr-Jun;9(2):193-8 – 195
Next step will be to assess patient's readiness • Illustrating the other ill-effects of tobacco use
to quit tobacco; it is recommended that every and the positives of quitting; tobacco user's readiness to make a quick attempt • Creating awareness on the availability of medicines should be checked at each visit no matter what to aid in tobacco cessation;the presenting complaint is. Readiness may be • Using successful ex-tobacco users to motivate ascertained in two ways:
• Emphasizing and /or demonstrating that tobacco
1. Self assessment by patient
use is an addiction and not a personal choice or
These questionnaires can be left in the waiting life style.
room or administered by nursing or secretarial
However, if a tobacco user is not feeling fully
staff (table II). While all patients may not be able motivated to quit and instead chooses to reduce to fill this questionnaire accurately but when it the number of cigarettes/bidis/gutkha packets then is used along with the dentist own judgment, it the clinician should utilize this period to reinforce will definitely enhance the assessment of patient's motivation and eventually drive complete tobacco
cessation. This can be done by analyzing the reasons
readiness to quit tobacco use.
not to quit and addressing them appropriately. As
a last resort a clinician may use a strategy called
– Patient assessment — intent to quit
" to motivate the tobacco
questionnaire [10, 11]
user. Under this strategy, the clinician should ask
Q1. Would you like to reduce or quit tobacco use
the tobacco user to choose between continuing to
if you could do so easily?
take numerous medications for the primary illness
or quitting tobacco use. This strategy has been
found to be effective in day to day practice.
Q2. How seriously would you like to reduce or
If there are tobacco users who insist that this
quit tobacco use altogether?
is a matter of personal choice and they can give up
Not at all----0 fairly seriously----2
whenever they decide to, a clinician can demonstrate
Not very seriously----1 very seriously----3
to them that tobacco use is an addiction. Request
the user to give up tobacco use for just one day
Q3. Do you intend to reduce or quit tobacco use
and if they find it difficult, they can come back
in the next 2 weeks?
to the clinician for help. In addition to clinician's
definitely no----0 probably yes----2
individual efforts with tobacco users, they can be
Probably no----1 definitely yes----3
also motivated by displaying educational posters in the clinic and distributing educational material
Q4. What is the possibility that 6 months from
in the form of newsletters, booklets, audio-visual
now you will not have a problem with tobacco
aids and leaflets.
For tobacco users who express willingness to
definitely no----0 probably will----2
try and quit, help set a quit date approximately
Probably no----1 definitely will----3
two weeks away. A day personally significant to the
tobacco user makes it more relevant e.g. birthday,
anniversary etc. The tobacco user should be
2. Assessment by the clinician/dentist
encouraged to announce his/her decision to family
This can be carried out by the clinician on a members, friends and colleagues so as to mobilize
simple assessment of the patient's body language, their support as well as induce accountability. It is
eye contact etc. this can be done on a simple three-
strongly recommended that the tobacco user give
point scale initially- not ready / unsure/ ready to quit up completely in one go on the quit date.
. For those tobacco users who are not ready to quit, an attempt should be made to motivate them Pharmaco-therapeutic interventions
by giving them clear, strong, personalized advice. Building motivation is an important element in
Dental clinicians need to offer the option
moving tobacco users from one stage to the next. of pharmacotherapy to all patients initiating a Like treatment, strategies to build motivation need quit attempt. FDA approved medicines includes: to be individualized. Motivation can be built by Varenicline, Bupropion and Nicotine Replacement using a combination of one or more of the following Therapy (NRT). These medications have been found techniques:
to be safe and effective for the tobacco dependent,
• Linking the present illness to tobacco use, when except in the presence of contraindications or with possible;
specific populations for whom there is insufficient
196 – Tobacco cessation: what role can dental professionals play?
evidence of effectiveness (e.g. pregnant woman and other forms of tobacco and to reduce the severity adolescents). These first line medications have an of nicotine withdrawal. NRT dosage is calibrated established empirical record of effectiveness, and on the basis level of tobacco dependence. The clinicians should consider these agents first in level of tobacco dependency can be checked by choosing a medication.
asking patient to fill a simple six question closed-
ended questionnaire . Forms of NRT currently
Bupropion was approved for smoking cessation
by the US FDA in 199�. Its possible mechanisms a) Nicotine gum (2 mg or 4 mg/OTC)
of action include blockade of neural re-uptake
The gum should be chewed slightly until a
of dopamine and norepinephrine, and blockade peppery/mint flavor is tasted then ‘parked
' in the
of nicotinic acetylcholinergic receptors. It is vestibule with the cycle repeated in approximately
contraindicated in patients with a seizure disorder, 30 minutes. If the gum is chewed too rapidly, the
a current or prior diagnosis of bulimia or anorexia patient may feel ill due to the rapid release of nicotine
nervosa, use of monoamine oxide (MAO) inhibitor into the system. In addition acidic beverages may
within the previous 14 days, or in patients taking interfere with the absorption of nicotine. Patients
another medication that contains Bupropion. with dentures or temporomandibular joint problems
Recommended dosage for Bupropion is150 mg have reported difficulties chewing the gum and may twice daily.
benefit from the NRT lozenge.
2. Varenicline 
b) Nicotine Transdermal Patch (� mg, 14mg, 21
It is clinically proven to be most effective mg / OTC)
smoking cessation treatment and patients should
The transdermal patch is applied directly to
be encouraged to use it. Varenicline is a non-
the skin allowing nicotine to be absorbed through
nicotine medication that was approved for smoking the skin. Up to 50�� of patients experience mild
cessation by US FDA in 2006. It is partial agonist skin irritation, which often clears up in a few days.
at α4β2 receptors designed to provide relief from Insomnia has also been reported in connection
craving and withdrawal (negative reinforcement), with the transdermal patch.
as well as diminish rewa rd from smoking
(positive reinforcement). Varenicline has produced c) Nicotine inhaler (prescription only)
significantly higher quit rates than Bupropion and
Nicotine from the nicotine inhaler is not actually
NRT in multiple randomised controlled trials. It is inhaled. The patient takes a puff from the inhaler,
well tolerated, with nausea being the most commonly holds the aerosols in the mouth and pharynx area,
seen adverse event. To avoid nausea, it should be and then exhales. Mouth and throat irritation,
taken with a glass of water after food. Caution is coughing, and rhinitis are common though these
advised during its use in patients with a history reactions are often temporary.
of neuropsychosis disorder, though a recent cohort
study in UK reported it to be safe and efficacious in d) Nicotine nasal spray (prescription only)
such patients. Recommended dosage and duration
Nicotine nasal spray poses local irritations with
94�� of users reporting moderate to severe nasal
of varenicline are shown in table III.
irritation initially and 81�� reporting irritation
after three weeks of use. In addition about 15-20��
– Recommended dosage and duration of
of patients report using the nicotine nasal spray
longer than recommended because it is potentially
• Minimum duration of therapy : 3 months
• 1st week - 0.5mg once daily for 3 days and
e) Nicotine lozenge (2 mg or 4 mg/OTC)
twice daily for next 4 days
The nicotine lozenge is a new and effective
• 2nd week (quit date) – 1mg twice daily
nicotine replacement delivery system that seems to
• 3rd-12th week (continuing treatment) – 1mg
have addressed many of the drawbacks reported
with other NRTs. When placed in the vestibule, the lozenge is able to deliver the whole dose of nicotine.
3. Nicotine replacement therapies (NRTs) 
Researchers found the lozenge delivered 25�� to 2���
Nicotine replacement therapy medications more nicotine than the same dose of nicotine gum
deliver nicotine with the intent to replace, at least due to the retention of nicotine in the gum base.
partially, the nicotine obtained from cigarettes or With the increase of available nicotine, participants
RSBO. 2012 Apr-Jun;9(2):193-8 – 197
found they experienced less cravings. Similar to
In case the patient relapses, the clinician must
nicotine gum, acidic beverages may interfere with identify cause of relapse (clinician and social), be the absorption of nicotine, therefore, patients should accepting and empathetic towards the patient and be advised to avoid coffee, juices, and soft drinks refer the patient to suitable specialist for co-morbidity 15 minutes before they use the lozenge.
evaluation and treatment, if need is felt.
Once you are sure patient has quit tobacco
Supportive therapy, follow-up and relapse habit successfully, congratulate and encourage the
patient on his/her efforts, discuss coping strategies
for withdrawal symptoms, urges and triggers, review
Dentist must consider supportive therapy for use of tobacco cessation medication, if relevant
use on a case – by – case basis after first line and develop a specific extended follow-up plan that
medications (either alone or in combination)have includes several visits or numerous phone contacts.
been used without success or are contraindicated As a part of extended follow up, clinicians need to
and he/she should consider referrals to specialist monitor the patient for a minimum of three months.
like chest physician or psychiatrist in your area Ideally, follow-up for a year should be done .
for advice and intense counselling.
Tobacco users, who have recently quit, face a Tobacco ce
high risk of relapse. Although most relapse occurs
Dentist can work with government and non-
early in quitting process, some relapse occurs government organizations working for tobacco
months or even years after the quit date. The best cessation in your area, he/she could:
strategy for producing high long term abstinence • Contribute to the formulation of national plans
rates appears to be the use of the most effective of action for tobacco control;
cessation medication during the quit attempt and • Work with other health professional organizations
providing practical advice and motivation in each to develop a common position on tobacco control
visit. The first prescription is advised for at least and consider establishing a coalition;
15 days, making it a point to emphasize the total • Use the news media and work with politicians to
duration therapy, follow up with the patient should make them feel that it is in their interest to accept
be. First month: weekly contact, 2nd and 3rd months: invitations to meetings and other events that focus
monthly and for rest of first year: quarterly. At each on tobacco control issues;
visit, dentist has to check for the typical issues • Campaign for smoke-free/tobacco-free health care
that arise in tobacco cessation therapy and address facilities to make nonsmoking the norm;
them before they result in relapse. Examples of a • Influence the content of health professional
few issues and how to address them are as follows education and motivate students by setting up a (table IV).
tobacco control body;
• Carry out surveys and prepare regular reports on
– Techniques helpful in relapse prevention 
tobacco related issues highlighting tobacco control
• Lobby for public and private reimbursement for
Consider extending the
use of an approved
pharmacotherapy or adding/
The current literature suggests that dental
Provide advice, prescribe
interventions conducted in the dental office and
Negative mood or appropriate medications,
school community setting is more effective than usual
or refer the individual to a
care for promoting tobacco use cessation. The public
health benefits of tobacco cessation interventions
Anxiety, irritation, Reassure the patient that
within the dental setting are potentially significant
feeling depressed these feelings are common
and there is an advantage of cessation interventions
Reassure the patient that
using dental professionals . Tobacco usage is going
some weight gain after
to emerge as a single most known cause of mortality
quitting is common and
and morbidity in the world, therefore, it is imperative
appears to be self-limiting.
that various health agencies and professionals must
Advise on proper diet
work together to help their patients and public quit this habit at the earliest.
198 – Tobacco cessation: what role can dental professionals play?
8. Prabhat Jha. A nationally representative case – control study of smoking and death in India. N
1. Beaglehole RH, Benzian HM. Tobacco or Engl J Med. 2008 Mar;358(11):113�-4�.
oral health: an advocacy guide for oral health professionals. FDI World Dental Federation, 9. Practice of tobacco cessation therapy – a stepwise Ferney Voltaire, France / World Dental Press, algorithm for Indian clinicians. Tobacco Cessation Lowestoft, UK; 2005.
Clinicians Council of India; 2010.
2. Carr A, Ebbert J. Interventions for tobacco 10. Richmond RL. Multivariate models for cessation in the dental setting. Cochrane Database predicting abstention following interventions to of Systematic Reviews; 2006. Issue 1. Art. No.: stop smoking by general practitioners. Addiction. CD005084. DOI: 10.1002/14651858.CD005084.
11. Sobell LC. Fostering self-charge among problem
3. Davis JM. Tobacco cessation for the dental drinkers: a proactive community intervention. team: a practical guide part II: evidence-based Addictive Behaviors. 1996;21(6):81�-33.
interventions. J Contemp Dent Pract. 2005 12. Smoking cessation services in primary care,
pharmacies, local authorities and workplaces,
4. Fiore MC, Bailey WC, Cohen SJ. Treating tobacco particularly for manual working groups, pregnant use and dependence. Clinical practice guideline. women and hard to reach communities. Nice Public Rockville: USDHHS; 2000.
Health Guidance 10. 2008 Feb.
5. Heatherton TF, Kozlowski LT, Frecker RC, 13. Treating tobacco use and dependence: 2008 Fagerstrom KO. The Fagerstrom Test for Nicotine update. U.S. Public Health Service Clinical Practice Dependence: a revision of the Fagerström Tolerance executive summary. 2008 PHS Guidelines Update Questionnaire. Br J Addict.
Panel, Liaisons, and Staff. Respir Care. 2008 Sep;53(9):121�-22.
6. Mathews Sebastian. National Institute of Mental Health and Neuro Sciences: tobacco users a smart 14. Wen CP. Barriers to smoking cessation: are guide WHO India; 200�.
they really insurmountable? World Med Journal. 2009;55(1).
�. Parrott S, Godfrey C, Raw M. Guidance for commissioners on the cost-effectiveness of smoking 15. West R, McNeill A, Raw M. Smoking cessation cessation interventions. Thorax. 1998;53,Suppl guidelines for health professionals: an update. 5(2):S1-S38.
PLM®EDICIÓN 12 0 1 1 dasideb Oe díauG Guía de Manejo de Claudia Milena Gómez Giraldo Médica cirujana, Universidad de Caldas, Manizales. Especialista en medicina interna, Universidad del Valle, Cali. Especialista en endocrinología, Pontificia Universidad Javeriana, Bogotá. Endocrinóloga Hospital Universitario San Ignacio, Bogotá
J Oral Maxillofac Surg66:223-230, 2008 Outcomes of Placing Dental Implants in Patients Taking Oral Bisphosphonates: A Review of 115 Cases Bao-Thy Grant, DDS,* Christopher Amenedo, DDS,† Katherine Freeman, DrPH,‡ and Richard A. Kraut, DDS§ Purpose: In recent years, numerous cases of bisphosphonate-associated osteonecrosis of the jaw havebeen reported involving both intravenous and oral therapy regimens. The majority of these cases haveinvolved intravenous bisphosphonates. Subsequently, drug manufacturers and the US Food and DrugAdministration issued warnings about possible bisphosphonate-associated osteonecrosis of the jaw. TheAmerican Dental Association and the American Association of Oral and Maxillofacial Surgeons assembledexpert panels to formulate treatment guidelines. Both panels differentiated between patients receivingbisphosphonates intravenously and those receiving the drugs orally. However, the recommendationswere based on limited data, especially with regard to patients taking oral bisphosphonates. We wantedto ascertain the extent to which bisphosphonate-associated necrosis of the jaw has occurred in our dentalimplant patients. We also wanted to determine whether there was any indication that the bisphospho-nate therapy affected the overall success of the implants as defined by Albrektsson and Zarb.Patients and Methods: We identified 1,319 female patients over the age of 40 who had received dentalimplants at Montefiore Medical Center between January 1998 and December 2006. A survey about bisphos-phonate therapy was mailed to all 1,319 patients. Responses were received from 458 patients of whom 115reported that they had taken oral bisphosphonates. None had received intravenous bisphosphonates. All 115patients were contacted and informed about the risk of bisphosphonate-associated osteonecrosis of the jaw.Seventy-two patients returned to the clinic for follow-up clinical and radiological evaluation.Results: A total of 468 implants were placed in the 115 patients who reported that they had receivedoral bisphosphonate therapy. There is no evidence of bisphosphonate-associated osteonecrosis of thejaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported nosymptoms. Of the 468 implants, all but 2 integrated fully and meet criteria for establishing implantsuccess. Implant success rates were comparable for patients receiving oral bisphosphonate therapy andthose not receiving oral bisphosphonate therapy.Conclusions: Guidelines for treatment of dental patients receiving intravenous bisphosphonate treatmentsshould be different than for patients taking the oral formulations of these medications. In this study, oralbisphosphonate therapy did not appear to significantly affect implant success. Implant surgery on patientsreceiving bisphosphonate therapy did not result in bisphosphonate-associated osteonecrosis of the jaw.Nevertheless, sufficient evidence exists to suggest that all patients undergoing implant placement should bequestioned about bisphosphonate therapy including the drug taken, the dosage, and length of treatment priorto surgery. For patients having a history of oral bisphosphonate treatment exceeding 3 years and those havingconcomitant treatment with prednisone, additional testing and alternate treatment options should be con-sidered.© 2008 American Association of Oral and Maxillofacial SurgeonsJ Oral Maxillofac Surg 66:223-230, 2008