Hard-Core Smokers Clinical Cases

Hard-Core Smokers Clinical Cases

To a clinical dental hygienist, opportunities to assist patients in smoking cessation are frequently presented. The one-to-one contact and amount of chair time provide an excellent opportunity to address the smoking issue. Tobacco use habits and attitudes can be explored and information gathered for future assistance when the patient is ready to quit.

For the past several years, periodontal therapy has been my primary focus in our practice. Because tobacco use plays such a significant role in the severity of periodontal disease, addressing that issue was a logical approach as a part of period therapy.

As a clinician I am able to gain information about the patient's tobacco use from the health history. During the usual discussion with the patient about the health history, information regarding degree of tobacco use and habits can be obtained. This information gives me some insight on how to approach the patient regarding tobacco use.

The oral examination enables me to note both periodontal condition and any other nicotine-induced oral tissue changes. Interpersonal observation can also be done to determine if unusual stress may be present that might be a factor in tobacco use. The patient's attitudes toward tobacco use and sense of priorities might be noted. Are good health, appearance, money, etc., important? These can be key factors in determining the best approach to begin a dialogue that might lead to breaking the addiction. It is important to know if there are other addictions affecting the patient, such as alcohol, food or drugs.

Following are 4 cases from my practice.

CASE NO. I was a 52-year-old man who was a successful lawyer. He had been smoking for about 30 years and at times was up to almost 3 packs per day. This patient had advanced periodontal disease with some teeth exhibiting mobility. His oral tissue was generally hyperkeritinized. He had previously had periodontal surgery that left him with a large amount of root exposure. His roots were heavily stained, and he was concerned about their appearance. When scheduled for his 3-month recall appointments for period maintenance, it took 2 one hour appointments with local anesthetic to complete the hygiene treatment. The patient was under a considerable amount of stress both from his demanding Job and his home life.

In November 1989, when this patient was in for his 3-month recall, I asked him if he had ever tried to stop smoking. He said that he had tried some years ago but not recently. I suggested that he consider quitting and that it would help to slow the progression of his periodontal disease. He said he would think about it.

The next time I saw him was 3 months later, and his clinical appearance was about the same. He had recently been hospitalized for dehydration following an episode with an intestinal virus. He said that he felt "tired and run-down." When I asked if he still smoked and if he had given any more thought to stopping, to my surprise, he said, "Yes." He indicated that he had given the topic a considerable amount of thought since he was in the last time, and it had taken him some time to prepare. He agreed that he should quit and now was ready. He said he had not yet told anyone else because he did not need any outside pressure. His stop date was Ash Wednesday, the first day of Lent, which was in March. His stop date was 2 weeks after his dental appointment.

This was, of course, before the transdermal patch was available, so my dentist employer prescribed Nicorette(R). The patient was given instructions for proper use. The patient did stop smoking on his quit date and to the best of my knowledge did not smoke after that time. He used 16 to 18 pieces of 2-mg. Nicorette(R) per day in the beginning. I followed up with weekly phone calls the first month and then monthly calls. He told me that he was decreasing the use of the gum each month. At his 3-month recall he had less stain even though he was a heavy coffee drinker. At his second 3-month recall he reported being down to 5 or 6 pieces of Nicorette(R) per day. I suggested he substitute Trident gum for every other one and begin trying to get off the Nicorette(R) entirely, to which he agreed. At the next recall, which was 9 months after he began the Nicorette(R), he indicated that he was still using 5 or 6 pieces per day. Then one day I saw his wife and she said he was still using at least 10 to 12 per day, and she was afraid he was addicted to the Nicorette(R). I tried to assure her that It was still better for him than smoking.

At his next recall, which was about one year after he stopped smoking, the patient told me that he was aware of his nicotine dependence and could not get off the gum. He was encouraged to reduce gradually the amount he was using. In January 1992, the patient agreed to try the transdermal patch. Habitrol(R) was prescribed by his physician. He wore the 21-mg patch for 4 weeks and then went to the 14-mg patch. He experienced about 5 or 6 days of fairly severe symptoms, including headache, dizziness, anxiety, and muscle pain when he stepped down. After 2 weeks on the 14-mg patch, he went to the 7-mg patch and experienced about 5 or 6 days of the same symptoms. In 2 more weeks, he went to no patch but found the symptoms to be more severe and chewed 2 pieces of Nicorette(R) per day for one week. At that time, he discontinued the gum and has been nicotine-free since then.

This patient returned to my office for his regular hygiene treatment about a month ago, and I asked him how he managed not to smoke considering the amount of difficulty he had with nicotine withdrawal. He said that he knew he could succeed because he was a recovering alcoholic and had learned the 12-step program. He said the only things for which he was not prepared were the severe physical symptoms that he experienced. He had gone to his physician for a complete physical because he was not sure if the discomfort he was experiencing was from nicotine withdrawal or possibly some other cause. His physician did determine there were signs of arthritis in his neck and back that contributed to his discomfort. At the present time he continues to have pain in these areas, but the other symptoms have subsided. The patient also told me to beware of patients' not telling the truth about nicotine use, whether it be smoking, Nicorette(R), or the patch. He said that the urge is so overwhelming that addicted persons often do not like to admit the amount of their use and frequently lie to hide failures.

CASE NO. 2 was a 40-year-old accountant. He had smoked 2 packs of cigarettes a day for 20 years. This patient also had moderate to severe periodontal disease. We had discussed his smoking and its relationship to periodontal disease numerous times, but he felt he Just could not stop. In February 1990, it became necessary for him to have pocket reduction surgery in 2 quadrants. The periodontist also recommended that he quit smoking. Five months later his physician prescribed Nicorette(R), and the physician's receptionist followed up with monthly phone calls to check his progress. In 9 months he was able to discontinue the Nicorette(R) and has been a nonsmoker for 2 years. He reported that his greatest difficulty in the beginning was going from smoking to the gum and in the end from 2 pieces per day to none. During these periods, he experienced dizziness, headache, and rather severe anxiety. He felt that the monthly calls from his physician's office were very helpful because he could report his symptoms and was reassured that they were to be expected. Last year, he went through a divorce but did not go back to smoking. He said that although he frequently has the urge to smoke even yet, he would never do it because he would never want to face going through withdrawal again. He reported, as did the patient in Case No. 1, that the physical symptoms of nicotine withdrawal were far more severe than he had expected.

CASE NO. 3 was a 64-year-old retired mechanic. He smoked more than 2 packs of cigarettes per day and said he could not remember when he began smoking, but it was when he was very young. This patient also had moderate to severe periodontal disease. He had been one of my patients for many years, and we had discussed his smoking numerous times. He had always said that he liked to smoke and had no interest in stopping. In May 1992, increases in periodontal pocket depths were detected in several areas, and once again I mentioned his smoking. He said that he had cut back to 1 / 2 pack per day. I complimented his efforts and asked how he was able to reduce his smoking. He told me that his wife had been after him about it, so he Just did it. I asked him if he was familiar with the transdermal patch, and he said he had read about it. I suggested to him that if he felt it would be helpful, his dentist could prescribe it. It was only then that he told me his physician had already prescribed it, and he pulled up his sleeve to show me that he was wearing the patch and that was how he had cut back to 1/2 pack per day. (He was wearing the 14mg patch.) I instructed him either to stop smoking entirely or quit wearing the patch. (This occurred only about 2 weeks before the news reports of patients having heart attacks while smoking and wearing the patch.) This patient did not want me to follow his progress with phone calls because he did not want to feel pressured to stop.

CASE NO. 4 was a 54-year-old woman who was a homemaker. She was married to a very successful business executive, and her 3 children were all away from home. She and her husband had both been smokers. but she was a much heavier smoker. Whereas he smoked about one pack per day, she often exceeded 2 packs. About 2 years ago, he quit (cold t key) and since then had strongly urged his wife to stop. In April 1992, the transdermal patch was prescribed by my dentist employer. The patient began with the 22-mg ProStep(R) patch on April 17, 1992. I contacted her 3 days later, and she was experiencing only mild discomfort and anxiety. She was managing this with a walking regimen. She said that some of the patches would not come off properly and were wasted, which made them expensive. One month later the patient reported rather severe skin irritation from the patches. She was switched to Habitrol(R) and then to Nicoderm(R). There was less irritation from the last 2 types, but by this time she had so many irritated skin areas that she said she would rather try Nicorette(R). After 2 weeks on the nicotine polacrilex, the patient reported (when I called her) that she was doing well and only chewing 1 or 2 per day. One month later she reported when called that she was using 3 to 4 per day but was doing well. She said she had not smoked since her original quit date. I checked with her one month later, and she said she was chewing about a pack of regular gum per day but no Nicorette(R). A couple of days later another patient who knew this lady came in to my office and casually mentioned that he spoke to her at a party the night before and she said she was chewing 12 to 14 Nicorette(R) per day. I was unable to reach her when I made my next follow-up, but I reached her the first week in August. She said she was using 4 per day and that there were certain times during the day when she felt she really needed them. These times are around 1:00 PM and around 8:00 PM. I suggested she keep a log of exactly when and how many she used per day and then perhaps she could begin gradually to decrease use.

The cases reported here are a sampling of the patient cases from my practice that I have had an opportunity to assist and observe as they attempted to break their nicotine addiction. I have been involved in this endeavor about 4 years and presently recommend smoking cessation to all of my patients who smoke.

The following are observations based upon these cases and other patient cases with whom I have worked in my dental hygiene practice.

Characteristics Common in Hard-Core Smokers:

Periodontal disease is more severe and more rapidly progressive.
There appears to be a link between nicotine addiction and alcohol addiction. Although not all hard-core smokers are addicted to alcohol, most alcoholics whom I have observed are hardcore smokers.
As with other types of addiction, hardcore smokers often try to hide the amount of their nicotine use by not always telling the truth when questioned.
The physical withdrawal symptoms become quite severe and are often frightening to the patient. When using the patch the steps down to lower dosage can create significant discomfort.
It takes a long time to get over nicotine addiction. Patients report craving nicotine for years after withdrawal.
Common Reasons Given to Postpone Quitting:

It is not a good time; the patient is under a large amount of stress.
Someone the patient knew smoked 3 packs a day and lived to be 90.
Patients fear weight gain.
The patient can not afford the patch or Nicorette(R).
The patient enjoys smoking and would be lost without it.
Patients will not admit smoking is an addiction. They say they can stop anytime.
Possible Reasons for Patient Failure:

Failure to understand addiction as being physical, psychological, and social.
Feelings of temptation from other smokers in the home.
Insufficient instruction in the use of either the transdermal patch or gum by the prescribing person. (Patients need verbal instructions because they don't always read the written instruction.)
Insufficient follow-up and support after nicotine replacement is begun.
Outside pressure to quit by someone else rather than making one's own decision.
Fear, when physical withdrawal symptoms become quite severe.
Fear of failure due to numerous previous failures.
Effective Methods to Handle Patient Failure:

Encourage the patient to think through what led to the slip and decide how to handle the situation better the next time.
Encourage the patient to try again as soon as possible.
Reassure the patient that each attempt is one step closer to success.
Concluding Observations:

Patients need time to prepare. They are not always ready to stop smoking when first approached.
Combined support by periodontist, physician, dentist, and/or hygienist is most effective. If patients are told they should stop by more than one health professional, they sometimes get the message that this is really important.
The programs sometimes need to be modified to meet each patient's needs. In some cases patients have chosen on their own to modify and combine the use of the patch and Nicorette(R).
Follow-up is very important. Patients going through withdrawal not only need encouragement but often also need assistance with nicotine replacement and its proper use.
My observations have led me to conclude that hard-core smoking addiction affects persons in all segments of society. The majority of these people would like to break their addiction. Although many patients are unwilling to try for various reasons, those who want to stop need adequate information so that they can understand their addiction and know what to expect as they go through the process of withdrawal. Each case is unique, but many occurrences are common in this process. Because these occurrences are somewhat predictable, perhaps this knowledge can help us deal with them more effectively.

The patient can best be served by a combined effort by the hygienist and dentist or physician who prescribes the nicotine replacement in providing the patient with adequate information, encouragement, and follow-up.

PNG Publications.

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By Martha B. Moriconi

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