Help improve oral health, overall health by talking to patients about tobacco cessation

Tobacco cessation can be a difficult topic to discuss with patients. But as health care providers, dentists and dental team members can be at the front line of helping patients quit smoking and improving their oral health and overall health, according to tobacco cessation experts.

“We know as health care providers, not just as dentists, that tobacco is one of the leading causes of death,” said Dr. Larry Williams, associate professor at Midwestern University College of Dentistry and a national advocate for smoking cessation in dentistry. “It systemically hurts the patient throughout the body, including the oral cavity. Patients that use tobacco have poor healing with implants, they have stained teeth, they get gum disease, they have more tooth loss, they have receding gingival tissue, they have bad breath, numerous things, and it’s something within our area to talk about. The first signs of disease from tobacco are in the oral cavity. We’re up front and we’re the first line in terms of being able to see tobacco use and talk to patients.”

According to the Ohio Behavioral Risk Factor Surveillance System 2015 survey, although smoking is declining in Ohio, 21.6 percent of Ohio adults reported being current smokers in 2015 for a total of 1.87 million smokers in Ohio.

The good news is, about three out of every five Ohio smokers reported that they tried to quit smoking in 2015, according to the BRFSS survey.

“62 percent of tobacco users would like to quit, that’s pretty good odds,” Williams said. “But you don’t know if you don’t ask.”

Williams added that one barrier for dental teams talking to patients about tobacco cessation can be a concern about alienating patients. But he said tobacco cessation doesn’t have to be alienating.

“All you have to do is inform them,” he said. “If a patient uses tobacco but isn’t ready to quit, then let them know you’re there to help if they decide to do so.”

He added that there are many factors influencing whether or not a person is ready to quit, and often those will change over time.

Dentists also can have an advantage over other health care providers because they are able to show patients the physical effects that smoking has on their mouth, Williams said.

“Our physical presence is better than some other areas of the body because we can show the actual presence of what’s happening to the oral cavity,” he said. “It’s hard to show what’s happening to your lungs.”

Start the Conversation

Williams recommends that the best way to start a conversation with all patients is through the office’s patient health questionnaire. The questionnaire should ask patients if they are smoking cigarettes, smoking e-cigarettes, using some other form of tobacco, or if they recently quit using tobacco.

If the patient answers no to these questions, Williams recommends leaving the conversation at that.

If a patient leaves the question blank, the dental team member who reviews the questionnaire with the patient should ask the patient about their tobacco use in order to fill in the information.

“If it’s left blank, say ‘oh I see you left this question blank on tobacco use, I want to fill that in and make sure we have everything answered,’” Williams said. “Make sure to take away any possible inflection and that you’re not condemning the patient or saying something negative. It is our job to make sure the health questionnaire is filled out.”

If a patient answers yes to using tobacco, a dental team member can then follow up and ask the patient if they would like to quit or if they have thought about quitting, Williams said.

“The patient could respond ‘I don’t want to quit,’ and then you just come back and say ‘I just wanted to ask the question, and if you ever decide to quit in the future let me know because I’d be more than happy to help you.’ Keep it positive,” Williams said. Then at future visits, the patient will continue to be asked about tobacco usage on the health questionnaire.

If a patient says yes they are interested in quitting, then the dentist or dental team member can move into a brief tobacco intervention using either AAR or the 5As – two similar models for discussing tobacco cessation with patients.

Utilize the Brief Tobacco Intervention

One common model for talking to patients about tobacco cessation is the 5As, which stands for Ask, Advise, Assess, Assist and Arrange.

Step one: Ask the patient if they use any forms of tobacco.

Step two: Advise the patient to quit. Advising the patient to quit can be as simple as stating a brief message such as “quitting tobacco is one of the best things you can do for your mouth and body, have you thought about quitting?” Williams said. Advising can also inform the smoker about the health risks of secondhand smoke exposure, especially in children, to encourage smoke-free environments.

Step three: Assess the patient’s readiness to quit. Ask if they are interested in quitting tobacco.

Step four: Assist the patient in quitting. If the patient is ready to quit, dentists and team members can refer patients to the Ohio Quit Line and dentists can prescribe medications if appropriate. If the patient is not ready to quit, the dentist should let the patient know they are there to help them when they are ready.

Step five: Arrange for follow up. Dentists should follow up regularly with patients who are trying to quit.

AAR is an abbreviated version of the 5As and stands for Ask, Advise, Refer.

When utilizing AAR or the 5 As, Williams said it’s important for dental team members not to condemn patients and not to go overboard when encouraging them to quit.

“You’ve got to be positive,” he said. “You cannot afford to be critical or what would be perceived to be condemning somebody about their tobacco use, you want to be positive about it. Talking to people about tobacco cessation is wonderful and an opportunity to help them with oral health as well as overall health.”

Refer Patients to the Tobacco Quit Line

The best place for dentists to refer any patients who are interested in quitting tobacco use is the Ohio Tobacco Quit Line, Williams said.

Patients can access the Quit Line by calling 1-800-QUIT-NOW, or a dentist or dental team member can make a fax or online referral to the Ohio Tobacco Quit Line. For information about fax and online referrals, visit ohio.quitlogix.org and click on health care provider.

Medicaid and Medicare recipients, uninsured people and pregnant women are eligible for services through the Ohio Quit Line. Privately insured Ohioans may or may not be eligible for services, but if they are not eligible for services through the Ohio Quit Line a representative will connect them with other available services. Services through the Ohio Quit Line are free.

According to a 2013 Cochrane review, people who participate in telephone cessation services are 27 percent more likely to quit verses those using self-help to quit.

Amy Gorenflo, Cessation Services program administrator with the Ohio Department of Health, said it can be helpful to involve the entire dental team to make sure patients are actually interested in being referred to the Quit Line and that they aren’t just afraid to say they don’t want to quit. She said it’s extremely important to talk to patients in a non-judgmental way, and that oftentimes asking the patient “do you think the time is right for you to quit? If not, that’s OK and we’ll talk about it next time” can help to get a truthful answer from a patient. Another way to ask a patient is to ask him or her how likely it is he or she would want to quit in the next 30 days on a scale of 1 to 10. If he or she says a low number, a follow up question could be “what could we do to help you feel more motivated to quit next time?”

She cautioned against referring patients to the Quit Line who are not ready to quit, because if the patient doesn’t follow through with the Quit Line they may be less likely to come back for their next dental visit.

“We’re working together to get people into treatment that truly want to quit, and helping others develop readiness and motivation to quit,” she said. “If we’re referring people to the Quit Line and they’re truly not ready to quit, it’s not going to work for anybody.”

She said oftentimes involving a hygienist in the conversation can be helpful because patients may be more comfortable being honest with them about whether or not they’re ready to quit.

Bill for Tobacco Cessation Services

This year, Ohio Medicaid expanded its benefits when it began to cover tobacco cessation counseling services provided by a dentist.

In order to bill for the service through Medicaid, the patient must be a tobacco user or have a history of using tobacco, and tobacco cessation counseling services must be performed in conjunction with another dental service. There is no age restriction on patients utilizing this service.

Providers must document the individual’s use of tobacco and the extent of the counseling session; they must also provide cessation assistance as appropriate, such as referral to a tobacco cessation support hotline, additional counseling, or orders for prescription or non-prescription smoking cessation products or medication.

If a dentist spends time educating a patient about tobacco usage but the patient ultimately decides they are not ready to quit, that should be documented in the patient record and can be billed through Medicaid.

Don Sabol, Medicaid Health System administrator at the Ohio Department of Medicaid, recommended that following and documenting the 5As would be a good way for dentists to ensure they are meeting the requirements to bill Medicaid for tobacco cessation.

Dentists should note that although nicotine replacement treatment is available over the counter, if the dentist writes a prescription for these products, the prescription is covered by Medicaid when the pharmacy fills it, said Tracey Archibald, PharmD.

A dentist must be involved in the counseling in order to bill for the services through Medicaid. This service is represented by procedure code D1320 and the maximum fee is $15. Claims can be submitted for this service twice per calendar year for a patient.

Dr. Paul Casamassimo, a consultant with the Ohio Department of Medicaid and a past president of the ODA, said there are two reasons why the Ohio Department of Medicaid decided to begin reimbursing dental providers for tobacco cessation.

“The first is the fact that dentists are health professionals and we do screenings for diabetes, blood pressure, smoking and other substances in our practices,” Casamassimo said. “The idea is that we’re health providers and these are general health issues that we have the opportunity to see because we see patients on a regular basis. We can contribute to the regular referral of patients. Second, tobacco has an impact on the oral cavity. It has a relationship with periodontal disease, it’s also affecting oral health. Those would be two good reasons.”

He added that many low income patients may not have access to or knowledge of other resources for tobacco cessation other than through Medicaid.

According to the 2015 Ohio Medicaid Assessment Survey, smoking rates among Ohio’s uninsured and Medicaid recipients was at least twice as high as those who had other forms of insurance coverage.

Provide resources to patients

The Ohio Department of Health also has many free resources available for dentists to use with their patients, including pamphlets and promotional materials.

Williams suggested that one non-intrusive way to incorporate tobacco cessation into a practice is by placing handouts near the front desk.

“You don’t have to say anything, in the waiting room just have a little clear plastic holder with tobacco cessation materials right there,” he said. “Patients may not want it for themselves, but they might want to give it to a loved one.”

Williams said front desk staff can play a role in starting the conversation about tobacco cessation because a patient may see a flyer in the waiting room and ask the front desk staff for additional information.

Take a class to learn more

The Ohio Department of Health’s Tobacco Use Prevention and Cessation Program will be providing a tobacco cessation course for the entire dental team at the 2018 ODA Annual Session.

The course – “‘You Don’t Smoke Do You?’ Removing the Judgement from the Question and Other Wins In Helping Tobacco Users Quit” – will be Sept. 13 from 2 to 4 p.m. and will be free for ODA members and staff. Non-member dentists can attend the course for $90.

In the course, dentists and team members will learn how to talk to their patients about tobacco cessation in a non-judgmental way that won’t alienate patients, said Gorenflo, who will be presenting the course.

The course will teach motivational interviewing techniques to help dentists and team members get to the truth about a person’s tobacco usage and help patients to feel comfortable sharing whether or not they’re ready to quit.

The course will also go into detail about how to implement the 5As into a dental practice.

Register for this course using code T25 at www.oda.org/events.

“You’re not going to get rich from tobacco cessation, but you are going to get rich with personal fulfillment helping people make a change that can save their life,” Williams said. “How many times can a dentist advise somebody in a way that can save their life?”

What happens when a patient calls the Ohio Tobacco Quit Line?

Patients are often more comfortable utilizing the Quit Line when they know what to expect when calling or being referred, according to Amy Gorenflo, Cessation Services program administrator with the Ohio Department of Health,

When a patient calls the Ohio Tobacco Quit Line, the call is answered by a coach or counselor. The caller completes an intake questionnaire about demographics and their smoking habits. Then, the first coaching session takes place during that call unless the caller opts out at that time.

For a fax referral, a coach or counselor will contact the patient instead of the patient having to call in. It may be helpful to let patients know that when the call comes in, it will not be identified as the “Ohio Tobacco Quit Line,” and instead will come from the phone number 855-261-2640 in Denver, CO.

Participants in the Ohio Quit Line have five scheduled calls with a coach, where they talk about things like behavior patterns and triggers. Participants are also able to call the Quit Line in between the scheduled calls if they have a question or are concerned they will be triggered.

Quit Line participants can also receive up to eight weeks of nicotine replacement therapy such as nicotine patches, gum or lozenges.

For more details about the Ohio Tobacco Quit Line, visit ohio.quitlogix.org.