Introduction

In any given year, one in five Americans will have a mental illness and about one in three will have a mental illness at some time in their life. For most, their illness will be transitory. But for about 1 in 30, it is a severe and chronic condition. Common as it is, mental illness is often unrecognized and misunderstood. Emotions, thoughts, health, behavior, and social relationships are all affected by mental illness and its treatment. Mental health and oral health are intertwined in many ways. This course is designed to improve understanding of mental illness and how it affects oral health and treatment.

Historically, the conditions now called mental illness or emotional disorders have been poorly understood. As a consequence, these illnesses still are highly stigmatized in society. In the last few decades, however, a great deal has been learned about characteristics of mental illness, its causes, and treatment. Although a large percentage of people with mental illness can now be effectively treated with psychotherapy and/or medication, about 60% or more of mental illness cases are undiagnosed and untreated. Dental hygienists are in an excellent position to help their patients who may have mental illness recognize and find treatment for their condition. Because mental illness and its treatment are often associated with oral health problems, dental hygienists also have a vital role in maintaining the oral health of patients at risk.

Virtually any oral health care practice will have patients with psychiatric disorders. Only about 3 in every 100 people have an obvious severe or chronic mental illness (CMI), but 20 in 100 will have a transient mental illness in any given year. Therefore, many patients who appear healthy will be dealing with an emotional disorder. These patients need oral health care from providers who understand mental illness and how it affects oral health and treatment. With such knowledge, dental hygienists can, for example, recognize tooth enamel erosion that indicates an eating disorder and facilitate a treatment referral for this life-threatening illness. They can develop communication skills, learn how to avoid potential adverse interactions between drugs used to treat psychiatric disorders and those used in oral health treatment, and become comfortable working with their most challenging patients, all the while understanding that this is where the need for preventive oral health care is likely to be greatest.

A brief overview of mental illness
What is mental illness? Mental illness has been defined as a clinically significant behavioral or psychological syndrome associated with distress, disability, or a significantly increased risk of suffering pain, disability, an important loss of freedom, or death. This syndrome must not simply be an expectable response to a particular event, such as the death of a loved one. Mental disorders are a manifestation of a behavioral, psychological, and/or biological dysfunction in an individual. Neither deviant behavior nor conflicts primarily between the individual and society are mental disorders unless they arise from a dysfunction in the individual.1

The Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) is a standard reference that describes many types of mental illness. It is not a treatment manual, but just as dental codes are used to communicate dental problems, the DSM IV-TR is intended to provide standardized descriptions of mental illness to improve communication about the disorders among treatment providers and researchers. Major categories of mental illness are briefly described below: (Characteristics of some of the more common mental disorders within the following categories are listed in more detail in (Figure 1.)

• Mood disorders include disorders that have a disturbance in mood as the predominant feature. They include the depressive disorders and bipolar disorders.
• Anxiety disorders demonstrate anxiety as the primary characteristic.
• Eating disorders are characterized by severe disturbances in eating behavior.
• Psychotic disorders are characterized by hallucinations, delusions, and other symptoms. Schizophrenia and schizophrenia-like illnesses fall into this category.
• Somatoform disorders are characterized by physical symptoms that suggest a medical condition but are not fully explained by a medical condition, direct effects of a substance, or other mental disorders.
• Cognitive disorders demonstrate significant decrease from previous functioning in ability to think or remember.
• Substance-related disorders are characterized by abuse of substances, including alcohol.

Each of these categories includes two or more mental illnesses defined by the DSM IV-TR (Figure 1). Many more illnesses have been described than can be covered in this CE course, so the emphasis here is on common disorders and those of special importance to oral health professionals. Dual diagnosis, not a category in the DSM IV-TR, is a term often used to characterize clients who have both a substance abuse disorder and a mental illness. The term may also be used in other ways to describe patients with developmental disability and mental illness or with two distinct mental illnesses. In this course, the first definition will be used.