JADA Continuing Education
Alcohol screening in dental patients
The prevalence of hazardous drinking and patients’ attitudes about screening and advice
Peter M. Miller, PhD,
Michele C. Ravenel, DMD,
Abigail E. Shealy and
Suzanne Thomas, PhD
 |
ABSTRACT
|
|---|
Background. Because heavy drinking is a risk factor for oral cancer, dentists should screen patients for alcohol use. The authors investigated heavy drinking in dental patients and patients’ attitudes about alcohol screening.
Methods. A convenience sample of 408 patients attending an emergency walk-in dental clinic served as subjects. Patients completed the Alcohol Use Disorders Identification Test–C (AUDIT-C), a three-item alcohol screening test, and an opinion survey regarding attitudes about the acceptability of alcohol screening and counseling by dentists.
Results. One in four patients had positive screening results for heavy alcohol use. The majority of subjects (> 75 percent) were in support of dentists’ inquiries and advice about alcohol use. Age, sex and drinking status were not predictive of patients’ opinions about alcohol screening.
Conclusions. One hundred three of the dental patients exhibited evidence of hazardous alcohol consumption, a risk factor for oropharyngeal cancer. The majority of patients reported that they would readily accept alcohol screening and alcohol counseling by dentists.
Clinical Implications. Because studies have shown that some dentists hesitate to screen for alcohol use because of a belief that screening is unacceptable to patients, these results may encourage a change in practice.
Key Words: Alcohol; alcoholism; alcohol screening; alcohol counseling; patients’ attitudes
Approximately 30,000 Americans are diagnosed with oropharyngeal cancer (OPC) annually, with 8,000 dying of the disease each year.1 OPC occurs more commonly in middle-aged and older people, with the average age at diagnosis being 60 years.2 It is more prevalent in men than in women.3
|
ALCOHOL CONSUMPTION
|
|---|
There is strong and consistent epidemiologic evidence that alcohol consumption increases the risk of developing cancer of the oral cavity and pharynx.4,5 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimates that nearly 50 percent of cases of OPC are associated with heavy drinking.6 While the combined use of alcohol and tobacco dramatically increases the risk, the major risk factor for never-smokers is alcohol consumption, with an odds ratio threefold higher in drinkers than in nondrinkers.7
Cancer risk.
In a meta-analysis of more than 200 studies investigating the effects of alcohol on the risk of developing cancer, Bagnardi and colleagues7 concluded that alcohol consumption of 50 grams (that is, four standard drinks) or more per day significantly increased the risk of developing OPC. The relative risk (RR) increased with increasing alcohol consumption; for example, studies have shown RRs for moderate-to-heavy drinkers of up to nine times greater than RRs for nondrinkers and RRs up to 35 times greater when alcohol consumption exceeded 100 g per day.8 Research has yet to identify a threshold level of alcohol consumption below which no increased risk is evident. Unfortunately, few drinkers or heavy drinkers realize they are at a greater risk of developing OPC than are nondrinkers.9
Screening and counseling patients.
Dentists have been encouraged to screen and counsel patients about OPC risk factors including alcohol use,10,11 because dental visits provide an opportunity to prevent oral cancer through screening and education.12 Unfortunately, alcohol screening and counseling by dentists is not a common practice. Only 20 percent of dentists in the United Kingdom reported giving advice routinely to patients who drink heavily.13 In addition, nearly one-third of health history forms used in U.S. dental schools do not contain questions to determine risk factors for OPC, including alcohol use.14
Alcohol screening and counseling by dentists is not a common practice.
In addition to time constraints and a lack of training being possible barriers to providing routine alcohol screening, some health care professionals are concerned that patients may be offended by such questions and unwilling to discuss these matters.15 In a survey of primary care and specialty physicians and nurses, Kaariainen and colleagues16 found that 32 percent of the sample considered the discussion of substance use with patients to be prying into their lives and not an acceptable practice in medical settings. Friedmann and colleagues17 surveyed a national sample of primary care physicians and psychiatrists in the United States and found that physicians’ concerns about alienating patients by asking about substance use were associated with low rates of screening and intervention.
These reports reveal a need to empirically examine patients’ attitudes toward alcohol screening. The little evidence that is available in primary care suggests that patients expect physicians to ask about and monitor lifestyle factors that influence their health18 and that most patients feel that general practitioners should be interested in their weight, smoking, drinking and fitness problems.19 Miller and colleagues20 reported that the vast majority of primary care patients are in favor of being screened for and counseled about at-risk drinking.
Whether the same patients’ attitudes apply to screening and advice from dentists is not known. Patients’ attitudes about alcohol screening may differ depending on the health care setting (that is, patients may have an accepting attitude toward screening questions from and discussions with their medical providers, but they may not see this as an appropriate activity for their dentist to perform).
The specific aims of this descriptive study were twofold: to examine the prevalence of hazardous alcohol use in a sample of dental clinic patients and to examine patients’ attitudes about alcohol inquiries and advice from their dentist.
|
SUBJECTS AND METHODS
|
|---|
Patient population.
We studied a convenience sample of 408 patients (168 men, 240 women) seeking treatment at the Medical University of South Carolina’s Emergency Walk-In Dental Clinic, Charleston, between June and September 2005. The clinic is located on an urban university campus and treats 80 to 100 patients per week. Faculty members and students provide clinical services in the Oral Medicine Division of the Department of Stomatology in the university’s College of Dental Medicine. The clinic provides emergency and non-emergency dental care to anyone in the community on a walk-in basis. The clinic serves predominantly low-income patients receving Medicaid. Patients are self-referred or, because of their inability to pay for private dental care, are referred by local private practitioners.
After registering at the clinic, all patients were asked by the clinic receptionist to complete a brief questionnaire while waiting to be seen by the dentist and a dental student. The receptionist asked a total of 454 patients to complete the survey; only two patients refused. Forty-four questionnaires had insufficient data regarding alcohol use and we excluded them. Analyses confirmed that included (n = 408) and excluded (n = 44) patients responded similarly to the dental patient opinion survey (DPOS) (described below), thereby confirming that the results were not systematically biased by excluding the surveys of patients with missing drinking data.
The study was approved by the Institutional Review Board of the Medical University of South Carolina.
Assessment.
The total time needed to complete the questionnaire was approximately 10 minutes. The questionnaire consisted of demographic questions (age, sex, education and ethnicity), patients’ opinions about alcohol screening and a standardized alcohol screening instrument, the Alcohol Use Disorders Identification Test–C (AUDIT-C).
DPOS.
For the purposes of this study, we developed the DPOS, which was adapted from the patient opinion survey that we developed and tested with primary care patients.20 The DPOS consists of 10 attitude statements about alcohol screening by dentists. Patients rated the attitude statements on a five-point Likert scale, from "strongly disagree" to "strongly agree."
Survey items focused on the following areas:
- – attitudes about the appropriateness of screening questions (for example, "How much alcohol I drink is personal and confidential and my dentist should not ask me about it");
- – openness to alcohol biomarker screening21,22 (for example, simple blood tests such as
-glutamyltransferase or carbohydrate-deficient transferrin capable of detecting heavy alcohol use [that is, four drinks or more a day] over the past two to four weeks);
- – emotional reactions to screening (for example, "I would be annoyed if my dentist asked me how much alcohol I drink");
- – the appropriateness of giving advice to reduce drinking (for example, "If my drinking is affecting my health, my dentist should advise me to cut down on alcohol");
- – honesty in answering screening questions (for example, "If my dentist asked me how much alcohol I drink, I would probably not give an honest answer").
Alcohol screening.
The questionnaire also included the AUDIT-C, a three-question alcohol screening test adapted by Bush and colleagues23 from the original AUDIT, which was developed by the World Health Organization for use in health care settings.24 The AUDIT-C is a simple and reliable screening tool that includes questions about frequency of drinking, quantity consumed on a typical occasion and frequency of heavy episodic drinking (that is, six or more standard drinks on one occasion). Scores range from 0 to 12. Scores of 4 or greater indicate probable hazardous alcohol use.
Statistical analyses.
We used statistical software (SPSS version 11, SPSS, Chicago) to store and analyze data. We performed two sets of analyses. The first set determined whether the two AUDIT groups (positive [score 
4] versus negative [score <4]) differed in demographics. Variables of interest were sex, age, educational level and ethnicity. For these analyses, we conducted t tests and 
2 tests of independence. To control for a familywise type I error rate, we set the P value for each test at .01.
The second set of analyses determined the rate of acceptance of alcohol screening by dentists and examined whether a subject’s acceptance of screening was related to his or her AUDIT status (that is, positive versus negative). Frequency analyses of responses to the 10 attitude statements revealed a nonnormal distribution, in which the majority of participants responded that they agreed or strongly agreed (or, in the case of negative statements, disagreed or strongly disagreed) with each statement.
Consequently, we transformed the data to reflect dichotomous responses to each statement; we recoded each response as "agree" (collapsing "strongly agree" and "agree" responses) versus "not agree" (collapsing "neutral," "disagree" and "strongly disagree"). In the case of negative statements (for example, "I would be annoyed if my dentist asked me how much alcohol I drink"), we used a similar recoding approach, although the two responses reflected whether the patient did or did not disagree with the statement. We used logistic regression models to analyze the transformed data, one for each of the 10 opinion statements. To control for a familywise type I error rate, we set the P value for each test at .01.
The overall purpose of the analytic plan was to determine whether individual variables were related to the probability of a subject’s having a positive AUDIT-C status; to determine the acceptability of receiving alcohol screening/advice from dentists; and to determine whether patients’ acceptance of being asked/advised about alcohol use by their dentist was related to their drinking status.
|
RESULTS
|
|---|
Demographics.
The respondents were predominantly female (59 percent), and the average age was 43 years (standard deviation = 16.51 years, range = 18 to 90 years). Most were white (59 percent); a substantial minority (35 percent) were black; the remaining 6 percent of respondents were Hispanic, Asian or members of another racial group. Most respondents (56 percent) had a high school diploma or less. A total of 103 respondents (25 percent) had a score of 4 or higher on the AUDIT-C alcohol screening questionnaire, which is the threshold score used to indicate that he or she may have been drinking at harmful levels. Thirty women (12 percent) had a positive AUDIT-C score and 73 men (43 percent) had a positive AUDIT-C score.
Positive versus negative AUDIT-C groups.
The table
shows a group comparison based on positive versus negative AUDIT-C scores. The percentages reflect the proportion of the positive and negative AUDIT-C score groups who were members of a particular demographic group. For example, 71 percent of the 103 subjects with a positive AUDIT-C score were male. The t tests and 2 tests revealed that the positive AUDIT-C group was composed of more men (2 = 49.83, P = .001) and younger patients (t404 = 3.81, P = .001) than was the negative AUDIT-C group. The two groups were similar with regard to educational level and racial composition.
Patients’ opinions about alcohol screening questions.
The majority of patients expressed favorable opinions with regard to being questioned about their alcohol use by their dentist. The figure shows the rate of agreement or disagreement with each statement. The lowest rate of agreement was with the statement "If my dentist thinks my drinking is affecting my oral health, he or she should feel free to order a blood test to see if I’m drinking too much." This statement also received the lowest support (agreement rate of 71 percent) in a similar survey conducted with primary care patients.20 In general, though, most dental patients (typically > 75 percent) were in support of their dentists’ inquiring and advising them about their alcohol use.
View larger version (63K):
[in this window]
[in a new window]
|
Figure. Percentage of patients agreeing or disagreeing with statements in the dental patient opinion survey. Asterisk: Probability that agreement was related to the Alcohol Use Disorders Identification Test–C (AUDIT-C) status (P = .002) and age (P = .01).
| |
Predicting patients’ opinions.
To examine whether opinions about alcohol screening and advice were related to a patient’s AUDIT-C status, we conducted logistic regression analyses. Because previous analyses revealed that a positive AUDIT-C status was not independent of age and sex (being young or male was associated with a greater likelihood of having a positive AUDIT-C score), we included both age and sex as predictors in each model so that the unique predictive ability of each variable could be determined (that is, with this analytic approach, a significant predictive effect of the AUDIT-C status would indicate that it predicts one’s response to a statement even when the effects of age and sex are statistically controlled).
The study results showed that, in general, age, sex and AUDIT-C status were not predictive of the patient’s opinions about alcohol screening by/receipt of advice from his or her dentist. This finding indicates that patients who are at a relatively greater risk of developing alcohol-related OPC do not differ from those who are at a lower risk in their support of dentists’ inquiries about alcohol use; this is further support that such screening should be considered a standard practice in dental offices.
Only one opinion statement revealed significant predictors of support. For the statement that received the lowest overall support ("... he or she should feel free to order a blood test to see if I’m drinking too much), both age (Wald 2 = 6.68, P = .01) and AUDIT-C status (Wald 2 = 9.61, P = .002) were predictive of the probability of agreement. Specifically, both younger patients and patients with a positive AUDIT-C status were significantly less likely to agree with this statement than were older patients and patients with a negative AUDIT-C status. We should note, however, that even with these lower levels of support in these groups, the majority of patients (63 percent of patients with a positive AUDIT-C status and 71 percent of patients younger than 50 years—an arbitrary age cutoff) were in agreement with this statement.
|
DISCUSSION
|
|---|
Our findings indicate that 25 percent of respondents had positive AUDIT-C scores, indicating probable hazardous alcohol use and an increased risk of developing oral cancer. This prevalence is similar to that reported in samples of primary care patients.25,26 Prevalence rates of hazardous drinking generally are lacking among samples of dental patients, so these data provide valuable information regarding the extent of this OPC risk factor in these patients.
Positive alcohol screens on the AUDIT-C suggest the need for further inquiries from the dentist and are not in themselves indicative of alcohol abuse or dependence. Further assessment, using guidelines such as those provided to health care professionals from the NIAAA,27 can clarify whether the patient is a high-risk drinker (for men: more than 14 drinks a week or more than four drinks on any day; for women and men older than 65 years: more than seven drinks a week or more than three drinks on any day) or exhibits an alcohol use disorder (abuse or dependence). In fact, the majority of patients who have positive results on the alcohol screen will fall into the high-risk category but will not be abusive or dependent drinkers. However, these patients are drinking above the NIAAA-recommended healthy drinking guidelines and should receive advice about reducing their alcohol consumption. This is particularly important because studies have yet to identify a level of drinking below which there is no increased risk of developing OPC.
Both age and sex were independently associated with a positive AUDIT-C score. The highest risk of hazardous alcohol use occurred in men younger than 50 years (58 of these men had positive AUDIT-C scores); however, hazardous drinking also was present in 30 women younger than 50 years and in 15 men older than 50 years. Prevalence rates in the general population are similar to these trends (that is, the heaviest alcohol consumption occurs among younger people (younger than 30 years) and among men.28 However, it is important to note that our results suggest that alcohol screening should not be limited to selected age and sex groups.
Patients generally were supportive of the notion that dentists should ask them about their alcohol use and, if need be, advise them to reduce their drinking. For all statements, a substantial majority (> 60 percent and, in most cases, > 75 percent) were supportive of inquiries and receiving advice about alcohol use. These findings generally are similar to those among primary care patients regarding their attitudes about alcohol screening by their physicians.20 However, patients in this study were of lower income and, thus, we do not know whether middle-to-higher-income patients in a fee-for-service dental setting would respond to these questions in a similar manner.
In general, positive opinions about screening were not related to sex, age or drinking status. Thus, even patients who drank heavily were not averse to answering questions about alcohol use and receiving counseling. This finding is important for dental screening, because some health care professionals have reported being concerned that patients with risk factors for OPC are unwilling to discuss possible changes in their alcohol use.29
|
CONCLUSIONS
|
|---|
Preventing oral cancer through risk factor detection is a key element in reducing the prevalence of OPC. Dentists have been strongly encouraged to screen and counsel patients about tobacco and alcohol use,10,11 the two major risk factors for OPC. In this study, we found a significant prevalence (25 percent) of probable hazardous drinking among dental patients, using a simple three-question screening instrument (AUDIT-C). In general, the results show that patients are in favor of being screened for alcohol use by their dentists. In addition, dental patients, regardless of how much they drink, were in support of dentists’ providing them with advice regarding alcohol use as it relates to OPC.
|
FOOTNOTES
|
|---|
Dr. Miller is a professor, Medical University of South Carolina, Center for Drug and Alcohol Programs, Department of Psychiatry and Behavioral Sciences, 67 President St., P.O. Box 250861, Charleston, S.C. 29425, e-mail "millerpm{at}musc.edu". Address reprint requests to Dr. Miller.
Dr. Ravenel is an assistant professor, Medical University of South Carolina, College of Dental Medicine, Department of Stomatology, Charleston.
Ms. Shealy is a program assistant, Medical University of South Carolina, Center for Drug and Alcohol Programs, Medical University of South Carolina, Charleston.
Dr. Thomas is an assistant professor, Medical University of South Carolina, Center for Drug and Alcohol Programs, Medical University of South Carolina, Charleston.
|
REFERENCES
|
|---|
- Silverman S. Demographics and occurence of oral and pharyngeal cancers: the outcomes, the trends, the challenge. JADA 2001;132 (supplement):7S–11S.
- Neville BW, Day TA. Oral cancer and precancerous lesions. CA Cancer J Clin 2002;52(4):195–215.[Abstract/Free Full Text]
- Silverman S. Oral cancer. 4th ed. Hamilton, Ontario, Canada: Decker; 1998.
- Doll R, Forman D, LaVecchia C, Woutersen R. Alcoholic beverages and cancers of the digestive tract and larynx. In: Macdonald I, ed. Health issues related to alcohol consumption. Oxford, England: Blackwell; 1995:351–93.
- Miller PM, Day TA, Ravenel MC. Clinical implications of continued alcohol consumption after diagnosis of upper aerodigestive tract cancer. Alcohol Alcohol 2005;41(2):140–2.
- National Institute on Alcohol Abuse and Alcoholism. Alcohol alert. Bethesda, Md.: National Institute on Alcohol Abuse and Alcoholism; 1993. No. 21, PH 345. Available at: "http://pubs.niaaa.nih.gov/publications/aa21.htm". Accessed Oct. 27, 2006.
- Bagnardi V, Blangiardo M, La Vecchia C, Corrao G. Alcohol consumption and the risk of cancer: a meta-analysis. Alcohol Res Health 2001;25(4):263–70.[Medline]
- Mashberg A, Boffetta P, Winkelman R. Tobacco smoking, alcohol drinking, and cancer of the oral cavity and oropharynx among U.S. veterans. Cancer 1993;72(4):1369–75.[Medline]
- Hay JL, Ostroff JS, Cruz GD, LeGeros RZ, Kenigsberg H, Franklin DM. Oral cancer risk perception among participants in an oral cancer screening program. Cancer Epidemiol Biomarkers Prev 2002;11(2): 155–8.[Abstract/Free Full Text]
- Horowitz AM, Goodman HS, Yellowitz JA, Nourjah PA. The need for health promotion in oral cancer prevention and early detection. J Public Health Dent 1996;56(6):319–30.[Medline]
- McCann M, Macpherson L, Gibson J. The role of the general dental practitioner in detection and prevention of oral cancer: a review of the literature. Dental Update 2000;27(8):404–8.[Medline]
- Cruz GD, Le Geros RZ, Ostroff JS, Hay JL, Kenigsberg H, Franklin DM. Oral cancer knowledge, risk factors and characteristics of subjects in a large oral cancer screening program. JADA 2002;133(8):1064–71.
- Warnakulasuriya KA, Johnson NW. Dentists and oral cancer prevention in the UK: opinions, attitudes and practices to screening for mucosal lesions and to counseling patients on tobacco and alcohol use—baseline data from 1991. Oral Dis 1999;5(1):10–4.[Medline]
- Yellowitz JA, Goodman HS, Horowitz AM, al-Tannir MA. Assessment of alcohol and tobacco use in dental schools’ health history forms. J Dent Educ 1995;59(12):1091–6.[Abstract]
- Aalto M, Pekuri P, Seppa K. Obstacles to carrying out brief intervention for heavy drinking in primary health care: a focus group study. Drug Alcohol Rev 2003;22(2):169–73.[Medline]
- Kaariainen J, Sillanaukee P, Poutanen P, Seppa K. Opinions on alcohol-related issues among professionals in primary, occupational, and specialized health care. Alcohol Alcohol 2001;36(2):141–6.[Abstract/Free Full Text]
- Friedmann PD, McCullough D, Chin MH, Saitz R. Screening and intervention for alcohol problems: a national survey of primary care physicians and psychiatrists. J Gen Intern Med 2000;15(2):84–91.[Medline]
- Richmond R, Kehoe L, Heather N, Wodak A, Webster I. General practitioners’ promotion of healthy life styles: what patients think. Aust N Z J Public Health 1996;20(2):195–200.[Medline]
- Wallace PG, Haines AP. General practitioner and health promotion: what patients think. Br Med J 1984;289(6444):534–6.[Medline]
- Miller PM, Thomas S, Mallin R. Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcohol 2006;41(3):306–10.[Abstract/Free Full Text]
- Miller PM. Recent developments in alcohol biomarkers: implications for managing alcohol-sensitive diseases. Resid Staff Physician 2004;50(11):11–7.[Medline]
- Miller PM, Anton R. Biochemical alcohol screening in primary health care. Addict Behav 2004;29(7):1427–37.[Medline]
- Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998;158(16):1789–95.[Abstract/Free Full Text]
- Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons With Harmful Alcohol Consumption-II. Addiction 1993;88(6):791–804.[Medline]
- Cleary PD, Miller M, Bush BT, Warburg MM, Delbanco TL, Aronson MD. Prevalence and recognition of alcohol abuse in a primary care population. Am J Med 1988;85(4):466–71.[Medline]
- Fleming MF. Screening, assessment and intervention for substance use disorders in general health care settings. In: Haack MR, Adger H, eds. Strategic plan for interdisciplinary faculty development: arming the nation’s health professional workforce for a new approach to substance use disorders. Providence, R.I.: Association for Medical Education and Research in Substance Abuse (AMERSA); 2002:46–66.
- National Institute on Alcohol Abuse and Alcoholism. Helping patients with alcohol problems. Bethesda, Md.: National Institute on Alcohol Abuse and Alcoholism; 2005. Available at: "http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide2.htm". Accessed Oct. 27, 2006.
- Harford TC, Grant BF, Yi HY, Chen CM. Patterns of DSM-IV alcohol abuse and dependence criteria among adolescents and adults: results from the 2001 National Household Survey on Drug Abuse. Alcohol Clin Exp Res 2005;29(5):810–28.[Medline]
- Aalto M, Pekuri P, Seppa K. Primary health care professionals’ activity in intervening in patients’ alcohol drinking during a 3-year brief intervention implementation project. Drug Alcohol Depend 2003;69(1):9–14.[Medline]
TOP
ABSTRACT
ALCOHOL CONSUMPTION
