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Abstract

It’s on the medical history form and you may feel like you’ve asked it thousands of times: ‘How many units of alcohol do you consume each week?’. But is this question effective at identifying people with alcohol problems? Our authors provide evidence that a new approach to recording alcohol consumption would lead to more and better advice being given to patients.
The General Dental Council (GDC) states in Standards for the Dental Team that dental professionals must adopt ‘a holistic and preventive approach to patient care’, acting to promote and protect not only their patients’ oral health but also their patients’ ‘overall health.’1
Alcohol misuse can impact on both oral and general health of dental patients in numerous ways. For example, drinking regularly in excess is associated with the development of oral, laryngeal, pharyngeal and oesophageal carcinomas, plus oro-facial injury in falls, road accidents and interpersonal violence.2 Excessive alcohol intake is also implicated in the development of dental caries, tooth erosion and periodontal disease.3,4
Excessive consumption compromises general health through increasing the risk of more than 60 systemic diseases and conditions, many of which can result in premature death. Promoting safe drinking among dental patients could therefore improve oral and general health consistent with GDC recommendations.
Other bodies also recommend that dental professionals routinely enquire and advise patients about their drinking. These include the World Health Organization (WHO), the British Dental Association (BDA), the National Institute for Health and Care Excellence (NICE) and The Royal College of Surgeons of England.5–12 The Department of Health estimates that 25% of alcohol consumers in the UK do not comply with their guidelines on safe drinking: for men drinking no more than three to four units per day and for women, no more than two to three units per day, with 48 hours alcohol free between each drinking session.13 The Royal College of Physicians suggests that men should not drink more than 21 units per week and women no more than 14 units per week.14 The Faculty of General Dental Practitioners UK (FGDP(UK)) advises in Clinical Examination and Record Keeping: Good Practice Guidelines that primary care dental professionals should ask all new patients ‘How many units of alcohol do you consume each week?’.15 However, a Dundee study found that although this question is included in medical history forms used in dentistry, 42% of the dentists sampled did not ask this question.16 Furthermore, even when this question was asked and the units per week exceeded recommended limits; advice on reducing consumption was not given. It appears that this units question has not been assessed as a screening instrument in dentistry.
This paper describes two clinical audits of completion of the alcohol item in the standard medical history obtained from patients attending the emergency clinic at the University Dental Hospital, Cardiff. The first audit aimed to assess whether and to what extent the units question, as recommended by the FGDP(UK), was being answered and whether or not the answers recorded were used to advise at-risk patients. Based on the findings of this initial work, a follow-up audit was then completed, taking account of the recommendations for change established in the first audit cycle.

Audit one

Method

Standards for assessing completion rate for the units question were set at 100% because the GDC and FGDP(UK) advise that all patients should be asked about their alcohol consumption.1,15 The audit took place over four weeks using a convenience sample of 10 to 15 male and female, new and follow-up patients, aged 18–75 years old, selected by reception staff each day. Completed medical history forms were examined by the authors.

Results

261 patient records were analysed, in which 233 (89%) included responses to the alcohol question. In 54 of these (23%), numbers of units were not recorded. Instead, responses comprised a phrase or sentence that made it impossible to assess whether the patient was drinking above the recommended limits. Examples included ‘occasionally drinks’ and ‘patient drinks only on weekends’. Notwithstanding this, 18 out of 233 patients (7%) were identified as drinking at dangerous levels, though none of these patients were given information or advice on reducing their consumption.
Figure 1 The Modified-Single Alcohol Screening Question (M-SASQ) and its scoring system17
Figure 2 The Department of Health’s Change 4 Life leaflets20

Discussion and agreed outcomes

This audit demonstrated limited compliance with alcohol units screening, and non-compliance in the provision of advice. In addition, the units question was shown to be unreliable as the levels of consumption for nearly a quarter of patients could not be determined. These findings, together with lack of evidence of the validity of this approach, meant that changes to clinical practice were needed.
Agreed recommendations were:
The medical history alcohol question should be substituted with a reliable and valid screening instrument.
Leaflets should be available for clinic staff to distribute to patients where there was evidence of alcohol misuse.
These changes were agreed by the University Health Board Oral Surgery, Medicine and Pathology clinical audit group. Dental emergency clinic staff were notified of the changes to be made.
The Modified-Single Alcohol Screening Question (M-SASQ) is a single item screening instrument. ‘How often do you have eight or more standard drinks if male, or six or more standard drinks if female, on one occasion?’ (Figure 1).17 This question is identical to the first item of the Fast Alcohol Screening Test (FAST).18 The Screening and Intervention Programme for Sensible drinking (SIPS), funded by the Department of Health, demonstrated that the M-SASQ is an effective and reliable screening tool that could be used quickly in busy emergency medical settings such as A&E departments.19 This screening test was chosen to replace the alcohol units question because of its brevity and extensive evidence of reliability and validity in busy healthcare settings.
The Change 4 Life ‘Don’t let drink sneak up on you’ information leaflet, produced by the Department of Health, includes information for patients on safe drinking levels, why they should comply with these and how to reduce drinking (Figure 2).20 These leaflets were chosen for clinic staff to distribute to those patients shown to be drinking above safe limits. Copies were obtained in Welsh and English from the Welsh Assembly Government Health Promotion Library.

Audit two

The purposes of the second audit were to find out if the new alcohol item (the M-SASQ) was completed more often than the existing alcohol units question and whether patients who were identified through M-SASQ screening as drinking harmfully/hazardously were given the Department of Health Change 4 Life alcohol advice leaflet.

Method

Standards were set at 100%, as before, and the audit was undertaken over 4 weeks. Reception staff selected 10–15 records from the clinic each day, as in Audit One. This time, however, responses to three versions of the medical history form were compared: one with the units question only, one with the M-SASQ only and one with both questions. Medical history forms were then examined to assess the extent to which the alcohol questions were answered. The records were also examined to determine whether leaflets were given to those patients identified as drinking above the M-SASQ threshold.

Results

284 patient records were analysed, of which 74 included a medical history form with the units question only, 81 included both the units question and the M-SASQ and 124 records included the M-SASQ only. Five patient records did not include evidence that a medical history had been recorded.

Forms with the medical history units question only

This alcohol units question was answered by 53 of the 74 (72%) patients but just 27 out of these 53 (51%) included unit numbers; 26 forms included a phrase or sentence of no value. Using this screening question, 3 out of 53 (6%) patients were identified as drinking at harmful levels.

Forms with both the M-SASQ and the units question

76 out of 81 (94%) patients who were asked both the M-SASQ and the units question provided information about their drinking. 55 had answered the M-SASQ only and 21 answered both questions. No forms included answers to the units question only. 30 out of 76 (39%) patients were identified as risky drinkers.

Forms with the M-SASQ only

This screening question was completed by 122 out of 124 (98%) patients. Of these, 25% were identified as drinking above the M-SASQ threshold.

Advice given to patients

Of the three patients who were detected as drinking hazardously/harmfully from answers to the units question, none were given advice leaflets according to the patient records. Out of the 30 patients who were found to be drinking hazardously/harmfully from the medical history forms with both M-SASQ and units questions, 4 were given advice leaflets, according to the records. Out of the 30 patients who were found to be drinking above the M-SASQ threshold only, three were given advice leaflets.

Conclusions

The results of both audits showed that the units question was not completed either usefully or at all by dental emergency clinic staff in a substantial proportion of cases – 89% and 72% respectively in Audits One and Two. The units question was completed incorrectly in 23% and 49% of cases respectively in the first and second audits and, as a result, the drinking levels of these patients were unknown. The M-SASQ, however, was completed far more often than the units question. Even when both the units question and the M-SASQ were present on the medical history form, the M-SASQ was answered much more often. The M-SASQ also identified more patients who had an alcohol problem and its use led to more patients being given alcohol advice.

Actions as a result of this audit

It was agreed by the University Health Board Oral Surgery, Medicine and Pathology clinical audit group that the alcohol units question should be substituted with the M-SASQ on the medical history form used throughout the Cardiff University Dental Hospital. It was also agreed that the Department of Health’s Change 4 Life alcohol advice leaflet should be available in all dental hospital clinics and given to patients scoring above the M-SASQ threshold.

Recommendations

From these audit findings, dental clinics should, wherever the units question is used, substitute it in the medical history form with the M-SASQ. This will help dental professionals screen patients effectively and prompt the provision of advice to those drinking harmfully. Alcohol advice leaflets from the Department of Health, or other evidence-based sources, should be made available to clinical staff. These steps are easy to implement.

References

1.General Dental Council. Standards for the Dental Team. London: GDC; September 2013.
2.Rehm J, Room R, Graham K, et al. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addict 2003; 98: 1209–28.
3.Kwasnicki A, Longman L, Wilkinson G. The significance of alcohol misuse in the dental patient. Dent Update 2008; 35: 7–20.
4.Amaral CSF, Vettore MV, Leao A. The relationship of alcohol dependence and alcohol consumption with periodontitis: A systematic review. J Dent 2009; 37: 643–651.
5.McAuley A, Goodall GR, Ogden GR, et al. Delivering alcohol screening and alcohol brief interventions within general dental practice: rationale and overview of the evidence. Br Dent J 2011; 210: E15.
6.Wanless D. NHS funding and reform: the Wanless Report. 6 May 2002. www.parliament.uk/commons/lib/research/rp2002/rp02-030.pdf (cited 2014).
8.Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Comm Dent Oral Epidemiol 2003; 31:3–24.
9.British Dental Association. The British Dental Association Oral Health Inequalities Policy. London: BDA; 2009.
10.National Institute for Health and Care Excellence. Public Health Guidance 24: Alcohol-Use Disorders: Preventing The Development Of Hazardous And Harmful Drinking. London: NICE; 2010.
11.Shepherd J. Surgery, dental surgery and alcohol: putting alcohol at the heart of patient care. Ann R Coll Surg Engl 2012; 94: 126–127.
12.Royal College of Surgeons of England. Reducing Alcohol Misuse In Trauma And Other Surgical Patients – Position Statement. London: RCSE; March 2010.
13.National Audit Office, Department of Health. Reducing Alcohol Harm: Health Services In England For Alcohol Misuse. London: The Stationery Office; 2008.
14.The Royal College of Physicians. The Evidence Base For Alcohol Guidelines. 6 May 2011. www.publications.parliament.uk/pa/cm201012/cmselect/cmsctech/writev/1536/ag22.htm. (cited 2014).
15.The Faculty of General Dental Practitioners (UK). Clinical Examination And Record-Keeping: Good Practice Guidelines. London: Royal College of Surgeons of England; 2009.
16.Shepherd S, Young L, Clarkson JE, et al. General practitioner views on providing alcohol related health advice; an exploratory study. Br Dent J 2010;E13: 1–5.
17.SIPS factsheet M-SASQ. The M-SASQ 6 May 2008. www.sips.iop.kcl.ac.uk/msasq.php. (cited 2014).
18.Hodgson RJ, Alwyn T, John B, et al. The Fast Alcohol Screening Test. Alcohol Alcohol 2002; 37: 61–66.
19.SIPS factsheet. Alcohol Screening And Brief Intervention In Emergency Departments. ; 6 May 2012. www.alcoholpolicy.net/2012/03/sips-brief-interventions-trial-findings-released.html. (cited 2014).
20.Change 4 Life. Don’t let drink sneak up on you. 6 May 2012. www.nhs.uk/change41ife/Pages/sneaky-drinks.aspx. (cited 2014).

Information & Authors

Information

Published In

cover image Faculty Dental Journal
Faculty Dental Journal
Volume 5Number 3July 2014
Pages: 134 - 137

History

Published in print: July 2014
Published online: 8 May 2015

Keywords

  1. alcohol screening
  2. medical history
  3. dentistry
  4. audit

Authors

Affiliations

Zairah Roked
2013 FDS Research Fellow
School of Dentistry, Cardiff University, Cardiff, CF14 4XY.
Rhys Watson
Final BDS Student
Violence and Society Research Group, Cardiff University, Cardiff, CF14 4XY.
Simon Moore
Professor of Psychology
Violence and Society Research Group, Cardiff University, Cardiff, CF14 4XY.
Jonathan Shepherd
Professor of Oral
Violence and Society Research Group, Cardiff University, Cardiff, CF14 4XY.

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