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Tobacco harm reduction core element of periodontal therapy, says head doctor

Smokers experienced a significantly higher incidence of periodontitis and continued tobacco use could preclude an improvement in periodontal health. (Image: Alekseenko Irina/Shutterstock)
By Jeremy Booth, Dental Tribune International
October 29, 2021

FRANKFURT AM MAIN, Germany: Experts are calling for the integration of tobacco harm reduction (THR) strategies into dental care. Prof. Dirk Ziebolz, head doctor at University of Leipzig Medical Center in Germany, says that dental professionals in the EU are in a position to inform their patients about THR, but are currently lacking knowledge on the subject. When it comes to regulatory support, health authorities in the US are pushing ahead with the cautious adoption of THR products, but those in the EU have been accused of showing a failure of innovation and courage by omitting them from policy-making.

German dentist Dr Ingo Schröder keeps examples of novel nicotine products in his clinic in the western German city of Cologne. He shows them to patients who are struggling to give up using combustible cigarettes. “I think that we are on the front line here, and we are the ones who can explain this to our patients,” Dr Schröder said in September 2020.

Speaking about patients who have transitioned from combustible cigarettes to tobacco heating devices, Dr Schröder said: “They see for themselves the difference that quitting smoking would make, but for those who are unable to give it up, we inform them about alternatives.”

Novel tobacco products such as e-cigarettes, tobacco heating devices and nicotine pouches are designed to offer healthier ways to consume nicotine to those who are addicted to the drug. Compared with cigarettes, they deliver fewer harmful components and offer alternative smoking cessation strategies. According to Prof. Ziebolz, novel tobacco products are harmful but less damaging to oral health and systemic health than cigarettes are.

“The exciting part, and the very attractive part of why smoking cessation in the wider context of dental care is worthwhile, is that the benefits of stopping smoking are immediate”
– Prof. Dirk Ziebolz, University of Leipzig Medical Center

Prof. Ziebolz spoke about THR and dentistry at an October conference that was organised by the Institute of Addiction Research at the Frankfurt University of Applied Sciences. During his presentation, titled “E-cigarettes, tobacco heaters, nicotine pouches and co—meaning and consequences for dental care”, Prof. Ziebolz pointed out that smokers experienced a significantly higher incidence of periodontitis and its associated consequences of bone reduction and tooth loss owing to changes to the oral microbiome and that continued tobacco use could preclude an improvement in periodontal health.

“The exciting part, and the very attractive part of why smoking cessation in the wider context of dental care is worthwhile, is that the benefits of stopping smoking are immediate,” Prof. Ziebolz said. Pointing to empirical data, he explained that a former smoker and someone who has never smoked had equal short-term treatment success with respect to the stabilisation of health.

Prof. Ziebolz emphasised that advice about a reduction or cessation of smoking should be a core element of periodontal therapy and that THR could support dental patients in the reduction or cessation of smoking and counteract its negative effects.

“It is absolutely important that encouragement for smokers to sustainably give up smoking comes from the dental clinic. In the end, this is the only strategy that we actually have,” he said.

Citing the cohort study “Electronic cigarettes and oral health, which was published on 25 March in the Journal of Dental Research and summarised the potential advantages and disadvantages of the use of e-cigarettes, Prof. Ziebolz said that, despite the lack of data on the long-term health impacts of vaping, clinical trial reports showed that e-cigarettes were twice as effective as conventional nicotine replacement therapy in helping smokers to quit.

Novel nicotine products are not harmless—they aim to deliver fewer harmful substances than cigarettes and thereby reduce the health risks to individuals who are unable to give up using nicotine. (Image: Ina Lihach/Shutterstock)

“Dentists should address THR as a possible opportunity for complementing or supporting smoking reduction and cessation,” Prof. Ziebolz maintained. In summarising the goals for the future that would be required to incorporate THR strategies into dental treatment, Prof. Ziebolz said that, firstly, it was of great importance that dental professionals be in a position to inform their patients about THR and to evaluate the risks that novel tobacco products pose to oral health. In this regard, he lamented: “Dentists have no idea—no idea at all.”

The development of a concept for prevention of harm caused by tobacco use was necessary, Prof. Ziebolz said, as a strategy for reducing the harm caused by tobacco use. Dentists in Germany and other parts of Europe are facing hurdles in incorporating THR strategies into their practices, however, owing to the fact that EU regulators continue to take a tough stance on novel nicotine products. A range of popular nicotine pouches disappeared from shelves in Germany earlier this year, for example, because health regulators found that a consumer product which contained nicotine but not tobacco did not fall into any legal product category.

Health policy experts decry EU stance on tobacco harm reduction

In October, the US Food and Drug Administration granted its first marketing authorisation order for an e-cigarette, having found that the sale of the product would be appropriate for the protection of public health. Last year, the agency approved the sale of a tobacco heating device as a modified-risk tobacco product. EU regulators, however, have omitted e-cigarettes and other novel nicotine products from a new long-term plan for beating cancer in the bloc.

Tobacco use harms oral and systemic health, and around 27% of all incidences of cancer in the EU can be attributed to it. The backbone of Europe’s Beating Cancer Plan is the provision of €4 billion to member states to aid them in preventing, detecting and treating the disease, as well as in improving the quality of life for cancer patients and survivors. The plan aims to create a “tobacco-free generation” by 2040 without the help of novel nicotine products—it barely mentions them beyond advocating for the enforcement of stricter rules and taxes.

According to Clive Bates, a former director of the UK’s Action on Smoking and Health, the EU has got it wrong. Bates was one of the architects of the World Health Organization’s (WHO’s) overarching Framework Convention on Tobacco Control (FCTC), to which the EU’s new plan is tethered. Bates founded the counterfactual in 2012—an organisation that advocates for science-based harm reduction policies in public health—and since then he has become one of the most vocal critics of WHO and other health bodies that chose not to incorporate THR into their guidance and policy-making.

“The evidence will never be perfect, but what we do know is that the exclusive use of smoke-free products presents risks that are one to two orders of magnitude lower than smoking”
– Clive Bates, the counterfactual

In an April interview with the snus industry-affiliated Snusforumet, Bates said: “There is a vast opportunity to reduce cancer by moving those who use nicotine from high-risk combustible products to low-risk non-combustible products, including snus, vaping, [heated] tobacco products, and novel nicotine pouches.

“The evidence will never be perfect, but what we do know is that the exclusive use of smoke-free products presents risks that are one to two orders of magnitude lower than smoking. Instead of working out how we could exploit that huge difference in risk for public health benefit, Europe’s Beating Cancer Plan appears to make it more difficult and less appealing for smokers to switch.” The result of the plan, he claimed, “will be more smoking and more cancer”.

Bates is not a pariah, nor is he alone in criticising health bodies for not adopting THR policies. An October joint letter to the parties to the WHO FCTC, which urged WHO to promote THR, was signed by Bates and 99 other public health and addiction experts, including Dr David Nutt, Edmond J. Safra Professor of Neuropsychopharmacology at Imperial College London; Dr John Britton, emeritus professor of epidemiology at the School of Medicine at the University of Nottingham; and Dr Caitlin Notley, professor of addiction sciences at Norwich Medical School at the University of East Anglia, all in the UK. A PDF copy of the letter can be accessed here.

On World No Tobacco Day (31 May) this year, Prof. Nutt commented: “Vaping and snus are likely to be the greatest health advance of this coming century and could save nearly a billion lives. The WHO should embrace the opportunity not block it.”

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