In our latest blog, Dr Andrea Mohan discusses her latest research on the role of dental professionals in delivering Alcohol Brief Interventions.
Would you expect your dentist to give you advice about reducing your alcohol consumption, i.e. your drinking? It may not be widely advertised, but in the UK, dentists and other dental professionals (DPs) such as dental hygienists can give you this advice. In fact, national guidance recommends that DPs have conversations about reducing drinking with patients who are at risk of being harmed due to their level of alcohol consumption. There is a large body of evidence that shows alcohol can have detrimental impacts on health. In terms of oral health, alcohol can cause tooth decay, tooth erosion and oral cancer. DPs can diagnose oral cancer in patients, and are more likely to detect oral cancer at an earlier stage compared to general practitioners (GPs). This direct relevance of alcohol to poorer oral health highlights the important public health role that DPs have; they provide oral care to a large percentage of the population and therefore have the potential to help large numbers of people who have an alcohol problem to reduce their drinking. This is especially important in Scotland, where we are experiencing an alcohol public health emergency – the number of people who have died because of alcohol is the highest it’s been since 2015, and health and social care services are facing increased pressure to support people with alcohol problems due to financial and capacity issues. Thus, having an ‘all hands on deck’ approach is needed to address this alcohol emergency.
Our research
In 2023 we conducted research which involved gathering and reviewing the international evidence on the delivery of advice to reduce drinking in dental practice settings. This research was inspired by the work of Dr. Simon Shepherd, a consultant in oral surgery with over 15 years’ experience (and one of our research investigators). His own research in 2010-2011 focused on DPs in Scotland and their attitudes towards giving patients advice to reduce their drinking. He found that most DPs were reluctant to give this advice and has been advocating since then for supportive measures to be put into place to motivate DPs.
Our research expands on Dr. Shepherd’s work to explore internationally: 1) how advice on reducing drinking is delivered to patients in dental practice settings; 2) the factors that help and prevent DPs from giving this advice; and 3) dental patients’ views about receiving such advice from DPs.
We only found 12 studies that focused on the delivery of advice to reduce drinking within dental practice settings, indicating how much little evidence exists on this specific topic. There were only three studies that explored the delivery of this advice in the form of Alcohol Brief Interventions (ABIs). An ABI is a brief, structured and supportive conversation used by healthcare practitioners to motivate and support patients to reduce their drinking. In these three studies, ABIs were delivered either by a dentist or dental hygienist. From 10 studies, we are able to identify several factors that helped and/or prevented DPs from giving this advice. These factors were derived from evidence dating between 2000 and 2021, and we found that not much has changed since Dr. Shepherd’s research in 2011. These were:
- Time: Delivering this advice placed pressure on the already limited time DPs had to spend with patients. Time was considered to be less of an issue for dental hygienists as they tend to spend more time with patients compared to dentists.
- Training: A lack of training on how to deliver this advice was linked to DPs’ limited knowledge and confidence to deliver the advice. Conversely, training DPs facilitated the delivery of this advice.
- Perceptions on the roles of DPs: DPs had mixed views on their role in providing advice to reduce drinking and other health promotion interventions that were thought to not be directly related to oral health. Some considered this an important part of their role while others did not view this as relevant. There were also contrasting views regarding dental hygienists delivering such advice.
- Perceived patient discomfort and non-compliance to DP’s advice: Some DPs believed that discussions about alcohol would discomfort or embarrass patients, and result in disrupting important dentist-patient relationships. Some also believed that patients would not want to receive such advice from DPs, and that patients would not comply with the advice.
- Funding: Insufficient funding or remuneration for delivering this advice and other health promotion interventions prevented DPs from delivering such interventions.
- Referral resources and follow-on care: Concern over the lack of appropriate and relevant information and limited knowledge of services to signpost/refer patients to, and the ethical and legal implications of this made some DPs reluctant to this advice.
Interestingly, we also found evidence from three studies which showed that most patients generally were comfortable with receiving advice to reduce their drinking from DPs and welcomed such advice if their drinking was already impacting their oral health. This contrasts with our finding that DPs believed that patients would not want to receive such advice from them.
Relevance to a review of Scotland’s ABI programme
Scotland launched its ABI programme in 2008, with an aim to deliver 80% of all ABIs in three priority settings, one of which was primary care. Although dental practices are part of primary care, they were not focused on for delivering ABIs. In 2020, the ABI programme was disrupted by the COVID-19 pandemic. Public Health Scotland (PHS) was asked to review the programme in 2022 due to a decrease in the number of recorded ABIs between 2015 and 2020. Reasons cited for this decrease include competing priorities, increasing demand on healthcare professionals and ending of focused investment, which aligns to the barriers to DPs giving advice to reduce patients’ drinking that we found in our research.
We have made several recommendations from our research, and are pleased to see that these complement those in the PHS review, which encourages the Scottish Government to recommit to the ABI programme and aim to embed ABIs across health and social care setting in the next 10 years. PHS recommend that the Scottish Government work with primary care leads, including dentistry leads, to make conversations about alcohol part of everyday wellbeing conversations that practitioners have with their patients. They also highlight the need for collecting and regularly reviewing evidence-based approaches for delivering these conversations in different settings. When it comes to dental settings, we recommend that more research is needed to:
- understand if conversations about alcohol are feasible and effective in helping dental patients to reduce their drinking (the evidence on this is limited)
- explore the use of innovative approaches including virtual and computer-based screening tools and programmes to support DPs to have conversations about alcohol with dental patients
- collect and understand dental patients’ views about their willingness to have conversations about alcohol with their DP
The evidence gathered from this research will help to inform the ways in which barriers to having conversations about alcohol can be addressed in dental settings, and inform the resources used to training DPs to have these conversations. We recommend that policy makers also work collaboratively with DPs and dental patients to inform these evidence-based approaches. PHS highlights the need for strategic leadership to ensure conversations about alcohol are embedded into routine care; for dentistry, this means leaderships from the British and Scottish Dental Associations, and the Scottish Dental Clinical Effectiveness Programme. They will need to work with the government and alcohol services to ensure that there are clear referral pathways and a smooth transition between dental and alcohol services for people who need more support to reduce their drinking.
Finally, PHS highlights the importance of reducing stigma as a key component of embedding conversations about alcohol. As DPs have an important public health role, the way they speak about alcohol with their patients can help to reduce this stigma if done correctly. We therefore recommend that the government, in collaboration with dental leads, consider ways of promoting public awareness of the role of DPs in supporting patients to reduce their drinking, and in contributing in overall public health efforts to reduce alcohol-related harm.
SHAAP Blogposts are published with the permission of the authors. The views expressed are solely the authors’ own and do not necessarily represent the views of Scottish Health Action on Alcohol Problems (SHAAP).