Working with Patients with CMI and Their Case Managers

People who have severe or chronic mental illness generally live in the community. Some avoid treatment and formal assistance, but many do attend community programs designed for them. These programs may provide a place to go during the day, providing training in life skills and organized activities. Case managers assigned to clients with CMI help them obtain needed benefits such as social security disability payments, food stamps, housing, job training, medical and oral health treatment, and other basic services. Unfortunately, most case managers have not received specific training regarding the impact of mental illness on oral health. Studies have shown that case managers tend to underestimate their clients’ need for oral health care and that clients rate their own need for dental care higher than case managers do.32 Oral health professionals may be able to work actively with patients’ case managers, helping them understand the importance of dental maintenance and enlisting their aid to locate funding and help reduce obstacles to care.

Case managers help their clients obtain services for which they are eligible. Available funding for an individual client’s oral health care will vary greatly, depending on such factors as eligibility for social security disability (with Medicare), supplemental security income (with Medicaid), as well as the availability of other funding.33 Some programs that cover only medically necessary oral health care (e.g., emergency care for the relief of pain) may cover dentures and extractions with preauthorization. It may be necessary to carefully schedule dental appointments to reduce out-of-pocket expenses for the patient. Other options for patients include saving money for oral health care, asking for family assistance, arranging for a payment plan with the dentist who provides care, or seeking treatment in a free or lowcost dental clinic.

The case manager should, with the permission of the client, supply information on medication and behavior problems to the oral health care provider. The mental health status of some patients may limit the extent of oral health treatment they can reasonably accept. The case manager also may need to arrange appointments, provide reminders and transportation, and possibly remain with the patient during appointments. For patients who fail to keep appointments because of diminished cognitive ability, it may be helpful to schedule appointments at the same time and day of the week, and to work with the case manager to pair oral health care appointments to other client activities and remind the client of appointments as necessary.

Most patients with CMI have poor oral hygiene, although occasionally patients maintain meticulous mouth care. Optimum self-care may not always be possible, but it can be improved with encouragement and monitoring by the case manager. Case managers also can help their clients become aware of how oral health is affected by the factors listed below:

• Poor nutrition (sugary snacks) can lead to tooth decay and periodontal disease.
• Medications can cause dry mouth, mouth sores, and tissue changes affecting denture fit, making regular hygiene especially important.
• Smoking increases the incidence of mouth lesions, staining of teeth, bad breath, and early death.
• Alcohol abuse can lead to periodontal disease, gumline cavities, and poor oral hygiene.
• Smoking combined with alcohol use leads to the highest incidence of oral cancer.
• Drug abuse can lead to decreased self-care contributing to tooth decay and periodontal disease and other soft tissue lesions.