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 Source: cancer research UK

Alcohol and Oral Health  There are many other clinical reasons that dentists should ask about alcohol: oNon-carious tooth surface loss oMedical problems such as bleeding which may affect treatment oDrug 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… o73% of facial injuries due to interpersonal violence o82% 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? oPatients expect dentists to ask them about alcohol and are receptive to advice (Miller et al, 2006; Goodall, 2006 & 2007; Shepherd et al, 2009) oDentists 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?... oUsing AUDIT; 31% of dental patients in Scotland drinking at hazardous, harmful or dependent levels (Goodall et al, 2006 & 2007) oUsing 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) oMost felt it was important for the dentist to ask about alcohol (62.9%) oMost 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)

Future?  Alcohol training for dentists? oEmbed within the undergraduate curriculum oProvide PG education oTrain  Utilise Professionals Complimentary to Dentistry (PCDs)?  Payment for an alcohol service in GDP? oOral 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 McAuley Public Health Adviser (Substance Misuse / Alcohol) NHS Health Scotland Public Health Science, EfA Team Elphinstone House 65 West Regent Street Glasgow, G2 2AF Tel: (ext: 2935) Fax: McAuley, A., Goodall, CA., Ogden, GR., Shepherd, S., & Cruikshank, K Delivering alcohol screening and alcohol brief interventions within general dental practice: Rationale and overview of the evidence. Br Dent J, 210: E15.