Delivering Alcohol Screening and Brief Interventions in General

Dental Practice: Rationale & Overview of the

Evidence

Andrew McAuley, Christine Goodall, Graham Ogden, Simon Shepherd, Karen Cruikshank

Background

SIGN74. The management of harmful drinking and alcohol dependence in primary care (2003)

“…all healthcare professionals have a role to play in identifying harmful and hazardous drinkers…”

So what role for the dentist?

Alcohol and Oral Cancer Alcohol consumption (alongside

smoking) increases the risk of developing oral cancer and periodontal disease (Hashibe et al, 2007; Amaral et al, 2008 & 2009)

The incidence of oral cancer in the UK is increasing Increases significant across

younger age-groups and in both sexes (Conway et al, 2006)

Strongly related to social and economic deprivation (Conway et al, 2008)

Linked to the parallel increases in alcohol consumption over the last 50 years risk for those drinking 20 units per

week (Llewelyn & Mitchell, 1994)

Oral Cancer: Incidence

0

2

4

6

8

10

12

19

75

19

77

19

79

19

81

19

83

19

85

19

87

19

89

19

91

19

93

19

95

19

97

19

99

20

01

20

03

20

05

20

07

Year of diagnosis

Rat

e p

er 1

00,0

00 p

op

ula

tio

n

males females persons

Age standardised (European) incidence rates, by sex, oral cancer, Great Britain, 1975-2007

Source: cancer research UK

Alcohol and Oral Health

There are many other clinical reasons that dentists should ask about alcohol:o Non-carious tooth surface

loss o Medical problems such as

bleeding which may affect treatment

o Drug interactions

Oral disease can also be a sign of poorer general health and well-being.

Alcohol, violence and facial injury

In the West of Scotland…

o 73% of facial injuries due to interpersonal violence

o 82% drinking at the time of injury

(Goodall et al, 2008)

Policy Context

DoH. Modernising NHS Dentistry – Implementing the NHS Plan (2000)

Scottish Executive. Plan for Action on Alcohol Problems (2002)

HEAT: H4 Alcohol Brief Interventions (2008)

British Dental Association Oral Health Inequalities Policy (2009)

The forgotten tribe? Routine alcohol screening and intervention in GDP is relatively

uncommon (Macpherson et al, 2003; Cruz et al, 2005; Miller et al, 2006; Dyer & Robinson, 2006; Shepherd et al, 2011)

We assume doctors, nurses, pharmacists etc will tackle public health issues associated with alcohol and drugs

Dentists often get overlooked

We don’t expect dentists to do this - or do we?o Patients expect dentists to ask them about alcohol and are

receptive to advice (Miller et al, 2006; Goodall, 2006 & 2007; Shepherd et al, 2009)o Dentists view provision of alcohol advice as relevant to their

practice support of relevance (Dyer & Robinson, 2006)

Until Now?...

The case for using alcohol screening and brief interventions in GDP…

Screening Detection of alcohol-related problems and treatment is

facilitated by use of appropriate screening tools (Raistrick et al, 2006)

No formally recognised screening tool specifically designed for use within general dental practice - AUDIT?...

o Using AUDIT; 31% of dental patients in Scotland drinking at hazardous, harmful or dependent levels (Goodall et al, 2006 & 2007)

o Using AUDIT-C; 25% of patients attending dental practice in USA were drinking at hazardous levels (Miller et al, 2006)

Alcohol Brief Interventions (ABIs)

A short, evidence-based, structured conversation about alcohol consumption that seeks in a non-confrontational way to motivate and support an individual to think about and/or plan changes in their drinking behaviour in order to reduce their consumption and/or their risk of harm.

(NHS Health Scotland, 2008)

ABIs: Evidence

Strong evidence for the effectiveness of ABIs in those drinking at harmful / hazardous levels (Raistrick et al, 2006; SIGN74; NICEPHG24; WHO)

Primary Care, A&E

The evidence for effectiveness in delivery of ABIs in GDP has yet to be established but…Identified as a potential setting where they

can be effective (Cruz et al, 2005; Goodall, 2006 & 2007; Dyer et al, 2006; Shepherd et al, 2009; NICEPHG24, 2010)

ABI in GDP: Plausible Theory?

Potential to improve oral and general health Equitable Sustainable Potential to reduce health inequalities:

65% of adults in Scotland are currently registered with a dentist (ISD, 2010)

80% of adults have had access to NHS general dental services over a six-year period (Tilley & Chalkley, 2005)

GDP Health Improvement

Increasing role and willingness to develop skills & participation further (Dyer & Robinson, 2006; McCann et al, 2000)

~ 90% of Scottish dentists having already expanded their remit to include advice to patients on smoking cessation (Chestnutt & Binnie, 1995)

50% seeing a specific role for dentists in counselling patients to stop (Chestnutt & Binnie, 1995)

Patients also consider smoking cessation as part of the GDP role (Campbell et al, 1999)

Barriers

Time

“….if I had lots of time with a patient I think it would be a nice thing to do…I’m much more interested in the bigger picture of their whole health”

Funding

“ ..if I was getting paid to do it I might do it…(alcohol screening)”

Training

“ we have never been educated about how to help someone.. Where do you start if you’ve actually no experience..”

Confidence

“ there’s a fine line…between trying to be helpful to someone and give them advice and being patronising..”

(Goodall, 2006 & 2007)

(Warnakulasuriya & Johnson, 1990; Macpherson et al, 2003; Cruz et al, 2005; Shepherd et al, 2009 & 2010 & 2011)

Facilitators Patients are receptive to

alcohol advice (Miller et al, 2006; Shepherd et al, 2009; Goodall, 2006 & 2007)

Patients were not offended by alcohol screening (Goodall, 2006 & 2007)o Most felt it was important

for the dentist to ask about alcohol (62.9%)

o Most thought it was relevant to their oral health (83.1%) and were happy to discuss it (74.2%)

Frequency & length of dental appts (Cruz et al, 2005)

Were you offended by being asked about your drinking?

0

50

100

150

200

Yes NSF NoN

umber o

f patie

nts

Future?

Alcohol training for dentists?o Embed within the undergraduate curriculumo Provide PG educationo Train

Utilise Professionals Complimentary to Dentistry (PCDs)?

Payment for an alcohol service in GDP?o Oral Heath Assessment Review (OHAR)?

Conclusions Alcohol is a key risk factor for oral cancer

Alcohol is associated with a range of other adverse oral health outcomes

GDPs are attended by the majority of the adult population over time

~ 30% of GDP Patients drinking at Harmful and Hazardous levels.

Increasing role of dentists in health improvement

Patients receptive to screening and intervention

Policy drivers in place

Oral Health Assessment Review – a window of opportunity?

Any questions?Andrew McAuleyPublic Health Adviser (Substance Misuse / Alcohol)NHS Health Scotland Public Health Science, EfA TeamElphinstone House65 West Regent StreetGlasgow, G2 2AF

Tel: 0141 354 2935 (ext: 2935)Fax: 0141 354 2901andrew.mcauley@nhs.net www.healthscotland.com

McAuley, A., Goodall, CA., Ogden, GR., Shepherd, S., & Cruikshank, K. 2011. Delivering alcohol screening and alcohol brief interventions within general dental practice: Rationale and overview of the evidence. Br Dent J, 210: E15.