The changing tobacco landscape: What dental professionals need to know

Eliminating Medicaid dental benefits and early-stage oral cancer diagnoses

BACKGROUND

Despite the importance of regular dental visits for detecting oral cancer, millions of low-income adults lack access to dental services. In July 2009, California eliminated adult Medicaid dental benefits. We tested if this impacted oral cancer detection for Medicaid enrollees.

METHODS

We analyzed Surveillance, Epidemiology, and End Results-Medicaid data, which contains verified Medicaid enrollment status, to estimate a difference-in-differences model. Our design compares the change in early-stage (Stages 0-II) diagnoses before and after dropping dental benefits in California with the change in early-stage diagnoses among eight states that did not change Medicaid dental benefits. Patients were grouped by oropharyngeal cancer (OPC) and non-OPC (oral cavity cancer), type, and the length of Medicaid enrollment. We also assessed if the effect of dropping dental benefits varied by the number of dentists per capita.

RESULTS

Dropping Medicaid dental benefits was associated with a 6.5%-point decline in early-stage diagnoses of non-OPC (95% CI = -14.5, -3.2, p = 0.008). This represented a 20% relative reduction from baseline rates. The effect was highest among beneficiaries with 3 months of continuous Medicaid enrollment prior to diagnosis who resided in counties with more dentists per capita. Specifically, dropping dental coverage was associated with a 1.25%-point decline in the probability of early-stage non-OPC diagnoses for every additional dentist per 5000 population (p = 0.006).

CONCLUSIONS

Eliminating Medicaid dental benefits negatively impacted early detection of cancers of the oral cavity. Continued volatility of Medicaid dental coverage and provider shortages may be further delaying oral cancer diagnoses. Alternative approaches are needed to prevent advanced stage OPC.

Impact of Electronic Cigarettes on the Upper Aerodigestive Tract: A Comprehensive Review for Otolaryngology Providers

Objective

The use and effects of electronic (e)-cigarettes (e-cigs) are particularly relevant for otolaryngology providers as tobacco plays a major role in benign and malignant diseases of the upper aerodigestive tract. This review aims to (1) summarize the recent policies regarding e-cigs and important patterns of use and (2) serve as a comprehensive resource for clinical providers on the known biologic and clinical effects of e-cigs on the upper aerodigestive tract.

Data Sources

PubMed/MEDLINE.

Review Methods

We conducted a narrative review on (1) general information on e-cig use and informative findings in the lower respiratory system and a comprehensive review on (2) the effects of e-cigs on cell and animal models and the clinical implications of these products on human health as is relevant to otolaryngology.

Conclusions

Although e-cigs are likely less harmful than conventional cigarettes, preliminary research on e-cigs suggest several deleterious effects including in the upper aerodigestive tract. Due to this, there has been increased interest in restricting e-cig usage, particularly among the adolescent population, and caution in recommending e-cigs to current smokers.

Implications for Practice

Chronic e-cig use is likely to have clinical implications. It is critical for otolaryngology providers to be aware of the rapidly changing regulations and use patterns regarding e-cigs and how e-cigs influence human health, particularly with regards to the upper aerodigestive tract, to accurately council patients regarding potential risks and benefits of use.

A smoking cessation induction intervention via virtual reality headset during a dental cleaning: protocol for a randomized controlled trial

BACKGROUND

Effective smoking cessation programs exist but are underutilized by smokers, especially by disadvantaged smokers. Cessation interventions in dental settings have been shown to be effective, but are not consistently delivered due to provider burden and lack of training, especially on how to counsel smokers who are not motivated to quit.

METHODS

This study is a 2-arm, phase III longitudinal randomized controlled efficacy trial to motivate utilization of evidenced based treatments (EBTs) for smoking cessation (e.g., state quitline, clinic-based counseling, the National Cancer Institute's text message program, and pharmacotherapy). Patients attending an urban dental clinic (n = 376) will be randomized to an intervention group (INT; smoking cessation induction video delivered via VR headset during their teeth cleaning, brochure about EBTs, and a 4-week text message program) or control group (CTRL; relaxation video delivered via VR headset during teeth cleaning, the same brochure as INT, and assessment-only text messages). Assessments will occur at baseline, immediately after the clinic appointment, one-month post-appointment and 3-and 6 months later. We hypothesize INT will be more likely to contact EBTs vs CTRL and have greater utilization rates of EBTs. Secondary objectives are to test the efficacy of INT on point-prevalence smoking abstinence, quit smoking attempts, and motivation to quit vs. CTRL.

DISCUSSION

Incorporating smoking cessation into a dental clinic visit and targeting all smokers, regardless of motivation to quit, provides proactive reach to cigarette smokers who otherwise may not seek treatment for smoking.

TRIAL REGISTRATION

NCT04524533 Registered August 24, 2020.

Erosive potential of commonly available vapes: a cause for concern?

Objectives Relatively little is known about the erosive potential of vape products, an important consideration for dental health. This study analysed flavoured vapes with potentially low pH, including fruit and drink flavours.Methods The pH of 45 purposefully selected vapes was measured undiluted in triplicate. Serial dilution was conducted on the most erosive product to investigate if/when the erosive potential pH of 5.5 was reached. One of the most erosive samples was tested, undiluted and diluted, after four months of opening. Content analysis of the vape labels determined ingredients, place of manufacture, product usage instructions and health warnings.Results Eighty-four percent of undiluted vape samples had a pH below 5.5. Erosive potential was not predicted by the flavour, with orange and cola samples higher than anticipated (pH 3.56-6.23 and 5.04-5.63, respectively). Products that were predicted to be non-acidic such as vanilla showed considerable variation ranging from pH 4.69-5.63. Freshly opened or stored samples did not reach a non-erosive potential pH of 5.5 or above, even when diluted to represent concentrations used when vaped. Labels were not detailed enough to ascertain which ingredients were contributing to acidity or buffering capacity or to allow consumers to identify the least harmful products in terms of oral health.Conclusions Present labelling of commercially available vapes does not allow consumers to ascertain the erosive potential and possible dental damage that may be inflicted by their use. More effective labelling and/or health warnings are required to educate consumers and dental health professionals on these products.

Nicotine-related misperceptions among faculty and students at a Midwestern dental school

PURPOSE/OBJECTIVES

To determine the perceptions about the ill-effects of nicotine in students and faculty at a Midwestern dental school. This information will help inform the school and improve teaching on this subject during a time when electronic nicotine delivery systems are increasingly popular.

METHODS

An online survey of dental students and faculty of a Midwestern dental school was deployed in November, 2020 to determine their level of misperception about the ill effects of nicotine. An online Qualtrics survey was administered to approximately 212 predoctoral students at a dental institution and approximately 100 part- and full-time faculty at the same school.

RESULTS

The response rate for faculty was 55.1% and that for students was 37.5%. The majority of faculty and students "agreed" or "strongly agreed" that nicotine causes cancer, birth defects, cardiovascular disease, oral inflammation, and Chronic Obstructive Pulmonary Disease.

CONCLUSIONS

Dental school faculty and students linked the risks of smoking tobacco to nicotine. Based on the results of this study, we feel our institution's curriculum should consider including information specific to nicotine in addition to tobacco in general.

Oral Health Implications of Risky Behaviors in Adolescence

Adolescence is a time for new discoveries, which may lead teens to engage in impulsive behaviors. Although social media and the Internet have brought great benefits to the world, they can also have a negative influence on adolescents, facilitating their engagement in risky behaviors. Positive parenting and healthy friendships in adolescence have a protective effect against sensation-seeking behaviors. Dental practitioners also have a significant role in steering young patients toward healthy behaviors. They play an essential role in the early recognition, initiation of appropriate interventions, and referrals for treatment of youth at risk.

Comparative Effects of E-Cigarette Aerosol on Periodontium of Periodontitis Patients

Introduction: Tobacco use is one of the main causes of periodontitis. E-cigarette are gaining in popularity, and studies are needed to better understand the impact of e-cigarettes on oral health. Objective: To perform a longitudinal study to evaluate the adverse effects of e-cigarettes on periodontal health. Methods: Naïve E-cigarette users, cigarette smokers, and non-smokers were recruited using newspaper and social media. Age, gender, and ethnicity, were recorded. Participants were scheduled for two visits 6 months apart. At each visit, we collected data on the frequency and magnitude of e-cigarette and cigarette use, and alcohol consumption. Carbon monoxide (CO) levels, cotinine levels, salivary flow rate, periodontal probing depth (PD), bleeding on probing (BoP), and clinical attachment loss (CAL) were also determined at both baseline and follow-up visits and compared between groups with two-way repeated measures ANOVA. Periodontal diagnosis and other categorical variables were compared between groups with the chi-square statistic and logistic regression. Results: We screened 159 subjects and recruited 119 subjects. One-hundred-one subjects (31 cigarette smokers, 32 e-cigarette smokers, and 38 non-smokers) completed every assessment in both visits. The retention and compliance rate of subjects was 84.9%. The use of social media and craigslist was significant in recruiting e-cigarette subjects. Ethnicity and race differed between groups, as did average age in the male subjects. Carbon monoxide and salivary cotinine levels were highest among cigarette smokers. Bleeding on probing and average PDs similarly increased over time in all three groups, but CAL uniquely increased in e-cigarette smokers. Rates of severe periodontal disease were higher in cigarette smokers and e-cigarette users than non-smokers, but interpretation is confounded by the older age of the cigarette smokers. Conclusion: Among the recruited participants, CAL after 6 months was significantly worse only in the e-cigarette smokers. This study design and protocol will assist in future larger studies on e-cigarette and oral health.

What should every dental health professional know about electronic cigarettes?

Electronic cigarettes (E-cigarettes) have become increasingly popular around the world. Currently, dental professionals' knowledge and attitudes are varied with many clinicians unclear regarding the impact of E-cigarette products on the oral and general health of their patients. With developing social and health-related challenges, advice of dental and medical associations and other regulatory bodies on E-cigarette use is changing. Growing evidence demonstrating the risks of E-cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E-cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non-smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E-cigarette use, the latest position of dental associations and the oral health implications of E-cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E-cigarette use.

Electronic cigarette liquid substances propylene glycol and vegetable glycerin induce an inflammatory response in gingival epithelial cells

Information on the effects of propylene glycol (PG) and vegetable glycerin (VG) and on cytotoxicity and subsequent activation of the biological mediators is limited in periodontal diseases. This study analyzes the effect of unflavored PG/VG alone or in combination with nicotine on gingival epithelial cells. The cells were exposed to different PG/VG (± nicotine) concentrations for 24 h and cytotoxicity was evaluated by calorimetric 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromid assay. The expressions of interleukin (IL)-6, IL-8, and matrix metalloproteinases (MMPs)-9 were measured using an enzyme-linked immunosorbent assay and a western blotting. Stimulation with PG/VG mixtures reduced cell viability compared to nonexposed controls (p < 0.05). Adding PG/VG increased the levels of IL-6, IL-8, and MMP-9, and the amount of PG had more biological impact compared to the VG amount. The nicotine augmented this effect compared to its nicotine-free counterparts. In western blotting result, MMP-9 was clearly activated in almost all samples. These findings suggest that the main constituents PG/VG are cytotoxic and able to induce biological response in gingival cells in vitro. Despite being advertised as less harmful than conventional cigarettes, electronic cigarette liquid pose certain risks on periodontal cells. Awareness about the effects of electronic cigarettes on periodontal diseases must be increased.

Dental Professionals' Engagement in Tobacco, Electronic Cigarette, and Cannabis Patient Counseling

OBJECTIVES

California features low smoking prevalence, cautionary electronic cigarette (e-cigarette) public messaging, and legal recreational cannabis: a unique landscape for dental professionals to navigate tobacco cessation promotion. This cross-sectional study assessed California dental professionals' self-reported tobacco patient counseling behaviors and the correlates of providing such assistance.

METHODS

Statewide surveys of dental hygienists (n = 701) and dentists (n = 725) were distributed electronically. The dentist survey was weighted for sampling and nonresponse. Prevalence of asking patients about use was compared for cigarette and noncigarette products (e.g., e-cigarettes, cannabis). Multivariable models identified independent correlates of providing cessation assistance to tobacco-using patients.

RESULTS

Respondents reported frequently (often/always) documenting patient tobacco use (hygienists: 80%; dentists: 73%) but less commonly provided forms of assistance (hygienists: 27%-49%; dentists: 10%-31%). Most respondents asked patients about cigarette smoking, but noncigarette product use (cigar, hookah, pipe, e-cigarette, or cannabis) was not commonly assessed. Greater confidence and willingness to assist were positively associated with providing assistance in multivariable models, but perceived barriers (e.g., lack of time and remuneration) were not. Results were robust to model specifications.

CONCLUSIONS

California dental professionals often ask about smoking but lag in providing cessation assistance and inquiring about noncigarette products. Successful efforts to encourage dental professionals' engagement in tobacco prevention and cessation must enhance providers' self-efficacy and motivation and likely will require system and organizational change.

KNOWLEDGE TRANSFER STATEMENT

Study findings identify substantial gaps in dental professionals' engagement in patient tobacco cessation. The results identify correlates of providing assistance and of dental professionals' willingness and confidence to do so, which could serve to inform interventions to support and enhance engagement.

Tobacco screening and cessation efforts by dental providers: A quality measure evaluation

OBJECTIVES

The purpose of this study was to adapt, test, and evaluate the implementation of a primary care "Preventive care and Screening" meaningful use quality measure for tobacco use, in dental institutions. We determined the percentage of dental patients screened for tobacco use, and the percentage of tobacco users who received cessation counseling.

METHODS

We implemented the dental quality measure (DQM), in three dental schools and a large dental accountable care organization. An automated electronic health record (EHR) query identified patients 18 years and older who were screened for tobacco use one or more times within 24 months, and who received cessation counseling intervention if identified as a tobacco user. We evaluated EHR query performance with a manual review of a subsample of charts.

RESULTS

Across all four sites, in the reporting calendar year of 2015, a total of 143,675 patients met the inclusion criteria for the study. Within 24 months, including 2014 and 2015 calendar years, percentages of tobacco screening ranged from 79.7 to 99.9 percent, while cessation intervention percentages varied from 1 to 81 percent among sites. By employing DQM research methodology, we identified intervention gaps in clinical practice.

CONCLUSIONS

We demonstrated the successful implementation of a DQM to evaluate screening rates for tobacco use and cessation intervention. There is substantial variation in the cessation intervention rates across sites, and these results are a call for action for the dental profession to employ tobacco evidence-based cessation strategies to improve oral health and general health outcomes.

Electronic Cigarettes: Trends, Health Effects and Advising Patients Amid Uncertainty

Dental professionals can be effective tobacco prevention and cessation partners. Electronic cigarettes (e-cigarettes), which deliver aerosolized nicotine but fewer toxicants than found in cigarette smoke, present new and contentious questions for clinicians, patients, and researchers. Evidence suggests e-cigarettes are not harmless but are less dangerous than cigarettes. Smoking cessation effectiveness is unproven and oral and systemic health effects remain under study. Dental professionals must stay informed to provide patients truthful information as new data emerge.

Evaluation of the Prevalence of Oral Mucosal Lesions in a Population of Eastern Coast of South India

Objective/Aim

The aim of this study is to measure the association between oral mucosal lesions (OMLs) and habit of tobacco and alcohol in the population of Guntur city, Andhra Pradesh, South India.

Material and Method

A cross-sectional study was conducted on 300 participants in Guntur city with the habit of tobacco and alcohol consumption in various forms who were selected by stratified cluster random sampling technique. Guntur city was divided into four zones, that is, North, East, South, and West; and two administrative wards were randomly selected from each zone as clusters. Information was obtained by interviewing the participant regarding various tobacco-related habits followed by standardized clinical examination in the field. Clinical data were collected using a modified 1980 WHO Pro forma where the basis for diagnosis was established as per the criteria provided by the epidemiology guide for the diagnosis of oral mucosal diseases (WHO). Statistical tests such as Pearson Chi-square were exercised to test the significance, using SPSS version 19.0 with 0.05 as cutoff level of significance.

Results

Overall oral soft-tissue lesions were found in 42.4% of the study participants including nicotinic stomatitis, tobacco pouch keratosis, smokers melanosis, mild keratosis of the palate, and chewer's mucosa. In this study, nicotinic stomatitis was found to be the most common soft-tissue lesion among men, while leukoplakia was found to be the most common premalignant lesion with the prevalence being 5.7%. While oral submucous fibrosis was found to be the most common premalignant condition among women. It was found that 13.2% of illiterates (53) were having leukoplakia. In the present study, the lower labial mucosa and buccal mucosa were found to be the most common sites of occurrence of leukoplakia and oral submucous fibrosis.

Conclusion

This study gives information on the association of OML in smokers, chewers, alcoholics, and those with mixed habits. This study highlighted six habit-related OML which included potentially malignant disorders such as leukoplakia and oral submucous fibrosis. Future case-control or cohort studies for individual lesions and with larger sample size are necessary to evaluate the risk for OML including potentially malignant conditions and oral cancer resulting from smoking and chewing habits.

Smoking and attitudes towards its cessation among native and international dental students in Lithuania

Background

Dental professionals are uniquely positioned to discourage smoking among their patients. However, little is known about the role of cultural background and attitudes towards smoking in the education of these professionals. Our study aimed to compare native Lithuanian and international dental students’ smoking habits, knowledge about the harmfulness of smoking and attitudes towards smoking cessation.

Methods

We conducted a cross-sectional survey of smoking and its cessation among dental students at the Lithuanian University of Health Sciences (Kaunas, Lithuania) in 2012. All Lithuanian and international dental students in each year of dental school were invited to participate in the survey during a compulsory practical class or seminar. Altogether 606 students participated in the survey with a response rate of 84.2%. Explanatory factorial analysis (EFA), multivariate Discriminant Analysis (DA) and Binary Logistic Regression (BLR) served for the statistical analyses.

Results

The percentages of occasional/current regular smokers were 41.1% and 55.7% (p = 0.068) among Lithuanian and international male students, and 22.7% and 22.9% (p = 0.776) among Lithuanian and international female students, respectively. The international dental students had a deeper knowledge of the harmfulness/addictiveness of smoking and held more positive attitudes towards smoking cessation among their patients than did the native Lithuanian dental students.

Conclusions

The findings of the study underscored the need to properly incorporate tobacco cessation training into the curriculum of dental education. However, consideration of the cultural background of dental students in building up their capacity and competence for intervening against smoking is essential.