Understanding the Mental-Dental Health Connection Said to Be Integral to Patient Care

Photo: Woman with toothache

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The impact of oral health conditions on people with mental illness is a major concern for clinicians and public health professionals.A 2022 study by Tamanna Tiwari, MPH, and colleagues Oral Health Frontiers It advises the report that “people with poor mental health are more likely to face financial and emotional difficulties and are more likely to be infected by COVID-19.” Poor oral health “is associated with poor mental health, age, poor socioeconomic status, and irregular dental visits.” Tiwari and colleagues also reported that “over 65% of respondents endorsed poor mental health said they did nothing about their oral health symptoms.”

In addition to the COVID-19 pandemic, fear of judgment, financial factors, anxiety related to medical procedures, and the impact of poor self-concept have also reduced the use of oral care among people with mental illness. Poor oral health can lead to tooth loss, impaired speech and aesthetics, and adverse effects on self-esteem, social interaction and occupational participation. Chronic oral pain is a stressor that lowers serotonin levels, making depression and anxiety more difficult to treat. The social and biological impacts of untreated oral disease often cyclically worsen oral, psychological, and overall health.

What steps can psychiatrists and public health professionals take to improve oral health outcomes for people with mental disorders? First, everyone should be aware of the common oral diseases associated with these conditions. Four key conditions observed in people with mental illness are tooth decay, gum disease, xerostomia (xerostomia), and bruxism (teeth grinding).

Tooth decay usually occurs when people regularly eat foods rich in fermentable carbohydrates. Regular consumption of these carbohydrates keeps them in constant contact with the teeth, and bacteria can convert them into acids that damage the enamel and ultimately the tooth dentin. If left untreated, tooth decay can enter the pulp and cause severe pain and abscesses. The latter can spread to the brain or chest, requiring emergency medical intervention.

Other resources

The Smile for Life National Oral Health Curriculum is a valuable resource for physicians and public health professionals who wish to explore the topics of this article in greater depth. Modules are suitable for a range of professionals, including international development professionals, frontline health workers and medical educators. In addition, many modules also provide continuing education credits for doctors, dentists, nurses, pharmacists, and more. The “Smile Life” course is posted here.

The American Dental Association and the National Council on Mental Health have developed a toolkit that provides a comprehensive set of resources for health care professionals and organizations who want to coordinate or integrate oral, behavioral, and substance abuse care into routine patient care. “Oral Health, Mental Health, and Substance Abuse Treatment: A Framework for Enhanced Coordination and Integration” is published here.

Gum disease ranges from gingivitis to periodontitis. The latter is a cause for concern because it can lead to the loss of the supporting bone and soft tissue attachments around the teeth. Eventually, the tooth may fall out and need to be replaced. Exacerbation of periodontitis is associated with several conditions observed in psychiatric populations, including smoking and marijuana use, diabetes, and malnutrition. Research shows that there is a bilateral relationship between diabetes and periodontitis, and that treatment of periodontitis can protect teeth and enhance blood sugar control.

A key factor that often leads to tooth decay and gum disease is xerostomia. Dry mouth is often seen as a side effect of medications with anticholinergic effects, including many psychotropic medications. People who take multiple medications are also at greater risk of developing xerostomia. Additionally, xerostomia may be seen as a complication of chronic anxiety. Saliva contains enzymes and antibodies that control bacteria that cause oral disease, as well as minerals that can repair damaged enamel. Patients with xerostomia should be encouraged to use over-the-counter oral moisturizers and fluoride mouthwash or toothpaste. Chewing xylitol gum stimulates saliva flow and inhibits the growth of bacteria that cause cavities.

Bruxism is considered a complication of stress, anxiety disorders, traumatic brain injury, and some psychotropic medications. If left unaddressed, it can damage the tooth, causing pain and disfigurement. It can also damage the jaw joint (temporomandibular joint dysfunction), causing pain. Bruxism is treated by providing patients with bite guards and working with a psychiatrist to address medication side effects and psychological factors.

Finally, all people with mental disorders should contact a dental home for ongoing oral care. Individuals without dental insurance may be referred to nonprofit health centers or dental schools because they may provide free or low-cost services.

When discussing oral health issues with patients, psychiatrists should do so in an open-ended, non-judgmental manner, asking patients about any oral health concerns they may have and the barriers they may encounter in resolving them. ■

Photo: Antoinette V. Shappell, MD, and Pierre M. Cartier, DMD, MPH

Antoinette V. Shappell, MD, is an adult, child, and adolescent psychiatrist and senior advisor to the Deputy Assistant Secretary for Health for Patient Care Services at the Department of Veterans Affairs in Washington, DC. , and past president of the District of Columbia Dental Association.

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