CE Course 10

Mental Illness and the Dental Patient

Credit: Continuing Education Hours: 2
If you have specific questions about the CE requirements in your state, or if you're not sure if the course will be accepted, please consult your state dental board.

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Table of Contents


Course Goals

The purpose of this course is to improve dental hygienists’ awareness of mental illness and how it affects patients’ oral health and ability to accept oral health care. Examples of how dental hygienists can help patients affected by mental illness are reviewed and illustrated with examples.


Learning Outcomes

Upon completion of this course, the participant will be able to:

  1. List and describe the general types of mental illness.
  2. Explain how a person’s mental health can affect oral health and treatment.
  3. Recognize oral conditions that may indicate mental health problems.
  4. Recognize medications often used to treat mental illness and the potential side-effects that can impact oral health.
  5. Explain how to take a mental health history.
  6. Describe the process of making a mental health referral.
  7. Recognize fear and suspicion in patients and respond appropriately.
  8. Describe ways to communicate with people who have chronic mental illness (CMI).
  9. Describe ways to work with CMI patients' case managers.

Assessment Method: Post-test only


Abstract

Virtually every oral health care practice includes patients with mental illness. This continuing education (CE) course gives a practical overview of common psychiatric disorders, their effects on oral and dental health, and conditions associated with mental illness that affect oral health treatment. Following a brief description of mental illnesses, information on conducting a mental health interview and making a psychiatric referral are provided. Oral health problems associated with mental illness and factors affecting treatment delivery are discussed, as well as ideas for avoiding potentially dangerous medication interactions and working with fearful, suspicious, or cognitively impaired patients. Ways in which dental hygienists can work with case managers to provide much needed oral health care to patients whose illness is severe or chronic are covered. Examples are given of work with clients illustrating principles described in the text.

The purpose of this course is to provide oral health personnel the information they need to knowledgeably care for patients who have mental illness. Successful completion will be assessed with a post-test to be completed after reading the article in its entirety, including figures and case-reports. Two continuing education course credit hours will be awarded following successful completion of the post-test.


Pre-Test

The purpose of this pre-test is to alert readers to important information in this continuing education article and to help them assess their own learning.

  1. True or False: Patients with chronic mental illness are more likely to have oral health problems than similar patients without mental illness.
  2. True or False: It is useful to include questions relating to mental health in the patient health history form.
  3. Are there oral health problems that can arise from mental illness and its treatment? If so, please list.
  4. Are there medical problems associated with mental illness and treatment for mental illness that can affect delivery of dental treatment? If so, please list them.
  5. There are potentially dangerous interactions between certain drugs used to treat mental illness and some drugs used in dentistry. Please list them.
  6. What is a mental health case manager? When and how might a dental hygienist work with one?


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.)

  1. Mood disorders include disorders that have a disturbance in mood as the predominant feature. They include the depressive disorders and bipolar disorders.
  2. Anxiety disorders demonstrate anxiety as the primary characteristic.
  3. Eating disorders are characterized by severe disturbances in eating behavior.
  4. Psychotic disorders are characterized by hallucinations, delusions, and other symptoms. Schizophrenia and schizophrenia-like illnesses fall into this category.
  5. 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.
  6. Cognitive disorders demonstrate significant decrease from previous functioning in ability to think or remember.
  7. 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.


The Mental Health

History and Interview Health history form Dental hygienists are accustomed to recording a medical history on each patient. It is helpful to have relevant mental health questions on the health history form along with the medical questions. These may include a question on psychiatric care and mental health status, an alcohol/ drug question, a question about dental fear and previous problems with oral health treatment, and specific questions about depression and panic attacks. Some suggestions are listed in Figure 2. The health history form should include a listing of prescription, over-the-counter (OTC) drugs, and alternative medications the patient has taken in the past 12 months; this information is also helpful for interviewing the patient. By taking a mental health history, important information can be obtained on conditions that affect oral health treatment, as later described.

Interview
The mental health questions elicit information in the patient interview that will help in treatment planning and working with the patient. When asking questions about mental health, use a nonjudgmental, matter- of-fact approach. “Stress” is a good word to use when discussing these issues with patients. One should listen carefully, but not pry, as patients will reveal what they feel comfortable discussing. Many patients with mental health conditions may not discuss their problem for various reasons, perhaps because of the stigma associated with such illnesses, from denial, or from lack of information. Their problems may become apparent later as they encounter stress in treatment or they may reveal them as they feel more comfortable with their providers.

If a patient says that he or she has a mental health condition, one should ask open-ended questions such as, “What can you tell me about this?” Doing so allows the patient to discuss the problem in his or her own way. If the patient is taking psychotropic medications, appropriate questions include:

  • What condition is the medication treating?
  • What are your symptoms?
  • How long have you been taking the medication and does it help?
  • Who is the physician treating the condition?
  • When was your mental illness diagnosed?
  • Are you receiving counseling or therapy, and how frequently do you see the physician or counselor?
  • Bear in mind that “psychotropic” medications may be used for multiple purposes, including some unrelated to mental illness. Bupropion hydrochloride (Wellbutrin®), for example, is indicated for depression and as an aid in smoking cessation. Diazepam (valium) may be used as a premedication prior to medical or dental treatment or to treat convulsive disorders, muscle spasms, spasticity, or anxiety disorders. Hydroxyzine hydrochloride (Atarax) is used to treat pruritis (itching) or anxiety.2
    Sometimes the oral health care professional may wish to consult with a patient’s care provider about a medical or psychiatric condition. Patients with CMI, especially dementia, may be poor historians, so a consultation can be helpful. Patient consent for the consult must always be obtained.

For patients whose mental illness is a continuing and serious problem, questions about previous hospitalizations should be asked. For some patients, symptoms predictably wax and wane; these patients may need to schedule appointments when they are best able to cope with oral health care treatment.

It may be difficult to detect active substance abusers, but those in recovery will usually answer questions about their substance use.3 For alcohol abusers, these questions may include what they drink and how often. For any drug abuser, inquires should be made about what drugs are frequently or occasionally used and when the substances were last used. It is important to know that relapses (or “lapses”) are a common part of recovery. Many of those who successfully discontinue substance abuse have done so after several such lapses. Patients can be encouraged to move toward harm reduction at any stage of substance abuse.4

Ask patients about their previous experiences with oral health treatment. This can be a good indicator of their current level of comfort with treatment and can aid in recognizing dental anxiety when it is present.

Psychiatric referral
With the escalation of substance abuse, especially among younger people, and the prevalence of mental illness, referrals may sometimes be necessary.

Although oral health care professionals may feel this is out of their scope of practice and fear they may offend the patient, referral is consistent with the health care provider role. It also demonstrates willingness to help a patient with a problem. Caring for a patient’s total health can have a profoundly beneficial effect. It is helpful to identify respected mental health professionals in the community whose expertise matches the patient’s needs. Several professional associations provide information on qualified professionals in the community (Figure 3).

The role of dental hygienists is to alert the dentist to problems observed. The best time for a dentist to make the suggestion of a referral is in consultation with the patient in a nonintimidating setting, preferably away from the dental chair.


Psychiatric Disorders— Practical Aspects

There are many ways mental health and oral health can impact each other. Medications used to treat mental illness may interact with drugs used in dentistry. Some oral health problems arise from the manifestations of mental illness, while others may be side effects of psychiatric medications. Unfortunately, patient psychiatric disorders also produce reduced rates of compliance for preventive oral health care, as well as a reduced ability to obtain and tolerate needed oral health treatment. For patients with severe or chronic mental illness, this combination of greater susceptibility to oral health problems and difficulty with oral health maintenance can be devastating. (See case example A: “Can You Help Me with my Teeth?”) Working with oral health care professionals who understand the practical aspects of patients’ oral health care can have tremendous payoffs for these patients. Most patients whose emotional problems affect their oral health care can be helped by oral health professionals who are knowledgeable and sensitive. (See case example B: “Terrified.”)

Oral health conditions associated with mental illness
Certain oral health conditions are virtually diagnostic of a specific mental illness and some have a poorly understood association with mental illness. Others can indicate a personality type or a medication side effect. Atypical odontalgia demonstrates that inexplicable symptoms should not automatically be ascribed to mental illness.5

Enamel erosion, especially diagnostic if the pattern of erosion is on the lingual surfaces of the anterior maxillary teeth, can be an indication of self-induced vomiting, a characteristic of bulimia nervosa and sometimes anorexia nervosa (Figure 1). Patients with an eating disorder also may have increased dental caries, tooth hypersensitivity, margination of restorations, osteoporosis, cardiac abnormalities, muscle cramps, and numerous other health problems. Referring such individuals to a mental health professional, with permission of the patient, can be a service to those who have these serious, potentially life-threatening diseases.6-8

Gingival recession and tooth abrasion can result from aggressive brushing, often a characteristic of perfectionists. Since these individuals are generally eager to please, overzealous brushing may be readily corrected with an explanation from the dental hygienist of the harmful effects.9 On the other hand, these signs can also indicate mania or, in rare cases, cocaine abuse in the form of rubbing on gingival.10

Xerostomia is often seen in patients with mental illness. It can be associated with bulimia, depression, anxiety, systemic diseases, including diabetes, dehydration, and rheumatoid arthritis, or radiation treatment to the head or neck region. It is often a side effect of medications.11 Some of these medications are antidepressants, antipsychotics, sedatives, and hypnotics (Figure 3). The clinical sequelae of chronic, untreated xerostomia can be severe, including oral infection, inflamed, fissured tongue, glandular enlargement and infection, rampant caries, and enamel erosion.

Some patients who take psychotropic medications to improve their quality of life, risk lowering that quality if oral health problems are ignored. More than 400 medications, including most psychotropic drugs, cause xerostomia. For the patient with medication-induced xerostomia, effective, less xerostomatic, alternative drugs may be available; consultation with the patient’s prescribing physician and pharmacist can be helpful. Preventive oral health maintenance with regular recall visits and meticulous oral hygiene is key. Temporary symptomatic relief may be obtained from sipping water and from products specifically formulated to relieve dry mouth symptoms, such as Biotene® mouthwash and dry mouth gum, Natrol DMR (Dry Mouth Relief)® and Roxane® Saliva Substitute. OralBalance® gel and Biotene® toothpaste from Laclede® have been shown to improve gingival health in xerostomatic patients.12

A typical odontalgia (AO) is an oral pain disorder that, if misidentified, can lead to unnecessary, irreversible treatment. AO is characterized by chronic throbbing or burning pain in the teeth, alveolar process, or mucosa without a clear cause. According to early reports, AO was thought to be a manifestation of psychiatric disorder.13 However, recent investigations indicate that the pain of AO is primarily neuropathic, that is, it originates from sensitization of nerves, often following oral health treatment.14 There was lack of knowledge concerning neuropathic pain until recently. Therefore, neuropathic pain is a relatively new term to many oral health care and medical professionals.5 The danger of AO is in misdiagnosis. The moderate to severe pain of AO may mimic dental disease sufficiently to prompt deadening or extraction of teeth without providing lasting relief for the patient.15

Although mental illness does not cause AO, this oral pain disorder is associated with depression or other psychiatric disorders, perhaps because the perception of pain is affected by the emotional state. Patients who have symptoms consistent with AO can be referred to a specialist pain center to test specifically for pain of neuropathic origin, as well as other forms of pain. Testing by a specialist may spare patients extensive and unnecessary dental treatment.14 It can be expected that making a differential diagnosis between atypical odontalgia and somatoform disorder with pain symptoms will lead many more patients to appropriate and effective treatment for their pain.

Temporomandibular disorders (TMD) involve the joints and/or muscles active in chewing. Pain, limited range of jaw motion, and temporomandibular joint noises are common symptoms. Several studies have shown an association between TMD and mental illnesses such as depression, anxiety, and substance abuse.16-18

It is not yet clear which comes first—mental illness or TMD. Life stressors related to mood disorders may lead to facial muscle tension, bruxism, etc., which then leads to TMD.19-20 On the other hand, the pain and stress associated with TMD may contribute to mood disorders. In any case, oral health care personnel should be aware that about half of individuals with TMD have or have had a mood disorder or other psychological diagnosis, especially patients whose symptoms are primarily muscle- and pain-related, as opposed to joint-related.17-18.

Bruxism, as mentioned above, may be related to stress or it may provide a means of coping for patients with constant intraoral pain.14 It can even be a side-effect of antipsychotic and antidepressant medication.21 If this is suspected, consultation can alert the prescribing physician to evidence of bruxism seen on oral examination.

Factors that Affect Treatment Delivery
In addition to the behavioral aspects of psychiatric disorders (discussed later), factors that can affect treatment include neuromuscular side effects of medications, mitral valve prolapse (often associated with panic attacks), medication interactions, and alterations in pain threshold.

Some psychotropic medications can cause movement disorders that damage teeth or interfere with oral health care. Extrapyramidal side effects (EPS) often arise from the neuroleptic-antipsychotic drugs. Early effects can include muscle spasms of the face, tongue, and neck. A Parkinson’s-like syndrome—including slowed movement, rigidity, tremor, and restless movement— can occur days or weeks after initiation of therapy.22 Since these effects are most commonly seen when the medications are started or the dosage is increased, oral health care appointments can be planned to avoid times when a patient's medications are being adjusted.

Tardive dyskinesia is a lateappearing side effect of neurolepticantipsychotic medications which occurs in 20 to 40% of patients taking high doses of these medications long-term. The characteristic sign of tardive dyskinesia is orofacial dyskinesia—an involuntary movements of the tongue, face, or jaws. Involuntary trunk and limb movements also may occur. Unfortunately, unlike the early appearing side effects of these medications, tardive dyskinesia is difficult to reverse once it has appeared, although it may resolve after months or years.23 The uncontrolled oral movements can interfere with oral health care treatment. Some control of the dyskinesia with medication adjustment may be possible; consultation with the patient’s prescribing physician and pharmacist can be helpful. Note that the newer antipsychotic drugs now available (the atypical antipsychotic drugs) are believed to cause tardive dyskinesia less frequently.23

Patients with panic disorder may have mitral valve prolapse as well. Mitral valve prolapse (MVP), an abnormality of one of the heart valves, is often benign, causing no symptoms. However, significantly more patients with panic disorder or agoraphobia have coexisting MVP.24,25 Dental hygienists need to be aware of this condition, since prophylactic antibiotics are recommended before therapy that involves gingival bleeding that could result in exposure to transient bacteria in the bloodstream. To avoid potential cardiac complications, a cardiology consultation is advisable in patients with panic disorder to rule out MVP or to arrange appropriate preventive antibiotic therapy if it is present.26

The potential for interactions between medications used to treat mental illness and medications used in dentistry is a consideration whenever anesthetics or other drugs are used. Figure 4 provides information on potential drug interactions and side effects.

Orthostatic hypotension is a side effect of some medications used to treat mental illness; patients who have this symptom will need to have position changes (horizontal to vertical) made more gradually than usual to avoid dizziness or faintness.27

Pain perception in patients with mental illness may vary. Depressed patients, for example, may be especially sensitive to pain, as may patients with a history of substance use. (See below: “Working with Patients who have Severe or Chronic Mental Illness”). In contrast, patients with schizophrenia may have difficulty recognizing pain when it is present. One should be sensitive to these potential differences in pain perception and provide pain control as needed.

Working with fearful, phobic, suspicious, and cognitively impaired patients
Fear and distrust are common in patients receiving oral health care, especially in those with mental illness. Patients who are fearful and suspicious call for specific responses in oral health care personnel (Figure 5). Case example A illustrates a patient whose schizophrenia did not interfere with her ability to accept gentle oral health care. At the time she received this care, she was in a mental health treatment program and stabilized on medications. The second example is of a fearful patient who was treated in the second author’s office. For patients whose problems with dental phobia seem beyond the expertise available, referral to a clinic specializing in treatment of such patients or working with a professional specializing in treatment of fears and phobias are helpful options.

The patient with a history of sexual abuse may not be aware of this history. The dental hygienist or other oral health care professional may suspect such a history if the patient develops sudden, inexplicable anxiety in response to such actions as lowering the back of the dental chair or working in the oral cavity. For any patient who becomes anxious, it is important to stop working, give control to the patient, and proceed only with the patient's explicit permission and at a pace that is comfortable for the patient. For severe or recurring anxiety, referral is advisable.

Cognitive impairments vary, but often patients with dementia have good recall for the distant past and for the past 15 to 20 minutes. For some patients, a reintroduction to the personnel and the procedures may be necessary if they take longer than the 15 to 20 minute window of shortterm memory. Instructions should be kept short and simple. Provide written instructions for the patient to use at home, and work in conjunction with family members or others who are helping with daily activities.


Case Example A:

“Can you help me with my teeth?”
This 30-year-old African American woman participated in the outpatient psychiatry program at a county hospital in Seattle. She approached PED, a volunteer dental hygienist in the program, with a request: “Can you help me with my teeth?”

Since she had avoided smiling, her oral health problems were not immediately obvious, but clinical examination revealed the worst dental condition in this clinician’s experience—severe periodontal disease, gross caries, and nonrestorable teeth. She had a complex medical history that included schizophrenia with hallucinations, a fear of needles, lupus erythrematosus, Sjogren’s syndrome, and substance abuse (though she last drank 10 years previously). She was eligible for Medicaid funded oral health care.

This married patient became pregnant before treatment could begin. Due to this and her pre-existing medical conditions, it was more than a year before treatment could proceed. The volunteer dental hygienist helped her coordinate appointments to deal with dental emergencies during this time. Eventually, the patient’s teeth were removed under general anesthesia in an operating room. When her denture finally was delivered four months later, her smile was broad.

Notes
This is an extreme example, but this patient illustrates the potential for dental devastation that can result from years of medication effects, poor diet, substance abuse, and lack of professional care and dental maintenance.

Although the patient had hallucinations and delusions, she was very cooperative and treatment elicited no unusual behavioral problems. The dentist used a slow, gentle approach, and over time, the patient developed trust and came to know what to expect from the dentist. Several years later, this patient is now taking care of her two sons, and despite her health problems, appears to be doing well.


Case Example B:

Case example B: “Terrified”
This 37-year-old Caucasian woman came to a private dental practice of PED with a toothache. She had avoided the dentist for years and was apprehensive and fearful. Her appearance was not unusual. She was employed full-time in a responsible business position and her initial history was unremarkable except that she had dental fear.

It was not until her six-month recall visit that it was learned she had suffered from trichotillomania—noticeable hair loss from the recurrent pulling out of one’s hair—since age 14. It is an impulse control disorder that affects 2 to 4 million people in the United States. The most common complication is damage to self-image that can lead to depression. She had tried at least eight different types of treatment, including medications, biofeedback, psychiatry, meditation, and support groups. As a result, she had excellent insight into her illness. In her early appointments, she used nitrous oxide, but over time, it was no longer necessary. The status of her trichotillomania has not changed, but her oral health problems were treated successfully, and she has maintained regular recall for more than 10 years.

Notes
This case can serve as an alert that even people who appear perfectly health can have underlying emotional or psychiatric problems that affect oral health treatment. This patient had been terrified that the dentist would notice her lack of eyelashes and hair. By discussing her illness in an accepting manner, the staff was able to normalize her experience and relieve much of her fear. Treatment for trichotillomania is effective for some patients, but in more than 33 years, this woman has not found a cure. The patient is in a support group, maintains her job and other responsibilities, and manages her illness well.


Working with Patients who have Severe or Chronic Mental Illness

Mood disorders
Both the patient with major depressive disorder and the depressed bipolar patient will frequently have difficulty maintaining oral hygiene or keeping appointments. Also, their recollection of instructions may be poor. These are symptoms of depression. Oral health care providers must avoid placing blame, and work to give the patient a sense of selfacceptance, worth, and of being in control. Their cognitive impairment may be temporary, but it is still important to keep instructions simple and to provide a copy for use at home as in the case of those with other cognitive impairments.

Bipolar patients in the manic phase of their illness may be highly distractible. Therefore, they also may benefit from simple, printed instructions.

Anxiety disorders
About 6 to 14% of the general population is estimated to have dental fear.28 The patient with an anxiety disorder is even more likely to fear dental treatment. (See case B for one example.) The principles listed in Figure 5 are helpful when managing patients who appear fearful or mistrusting. However, one should be prepared to refer such a patient to a mental health professional.

Psychotic disorders
Patients with psychotic disorders must live with thoughts and sensations that do not always accurately represent the world around them. As a result, their behaviors and beliefs may seem bizarre, but in context, they contain a certain logic. For example, people with auditory hallucinations hear apparently real voices with no evident source.1 Some may come to believe they have radio transmitters in their teeth. Their oral health care provider must accept that what they experience is real for them. Arguing is pointless and should be avoided. Instead, a supportive, predictable, non-stressful treatment atmosphere should be provided. With the patient’s permission, oral health care providers may keep in contact with the patient’s case manager or support person for help with oral hygiene and appointment reminders. This contact was very important for coordinating oral health appointments for the woman in case example A.

Dual diagnosis (mental illness and a history of substance abuse) A history of substance abuse is quite common among individuals with mental illness; they may try to use drugs or alcohol to self-medicate. In some cases, substance abuse may induce or amplify symptoms of mental illness.29 A history of drug use can create several problems in the oral health care setting, including cognitive impairment, abnormal bleeding problems, increased susceptibility to infections, and impaired liver detoxification of drugs.27 It is advisable to avoid the use of mood-altering drugs, such as nitrous oxide and IV sedation, and to use nonalcoholic mouthwashes. However, for patients with acute pain, “opiates remain central to therapy, including for addicted patients.”30 Clinical impressions and animal research suggest that patients with a substantial past history of substance abuse may be likely to need more local anesthesia than other patients, although this has not been experimentally verified in humans.31 As always, the patient must be the judge of when pain control is needed.


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. 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.


Conclusion

It is an unfortunate fact that many patients who have chronic mental illness have increased oral health problems. In principle, this can be improved. By working with patients and their case managers to ensure regular oral hygiene and routine professional care, oral health care professionals can work toward maintaining the oral health of all of their patients.

Patients with mild to severe mental illness rely on providers in the community for their oral and dental health care. Providing appropriate care for patients who have mental illness can be complex and challenging, but these are people for whom oral health is especially important and whose risk of oral disease may be high. With understanding, knowledge, and care, working with these patients can be most rewarding.

1.Examine the health history form currently used in the office for questions relevant to mental health. Discuss adding appropriate questions to the form, if needed.

2. Think about a patient in your practice and what his/her mental health status might be. Using references noted in this course or articles in reputable clinical and scientific journals, research the condition to learn more about it, learn potential problems of oral health care management, and seek effective solutions.

3. Take a continuing education course on mental illness and/or treating the oral health needs of patients with mental illness.


Suggested Reading

  • One self-study program, Dental Treatment of the Patient with a Psychiatric Disorder, is offered through the Dental Education in Care of Persons with Disabilities (DECOD) Program of the University of Washington School of Dentistry. For information, write Box 356370, University of Washington, Seattle, WA 98195, or call 206/543-1546.
  • Another self-study course, offered through the Southern Association of Institutional Dentists, is Clinical Concerns in Dental Care for Persons with Mental Illness. Contact Donna Spears, DDS, Box 258, Butner, NC 27509-0258.
  • Consider joining Special Care Dentistry, Academy of Dentistry for Persons with Disabilities. This association meets annually in Chicago and offers continuing education courses relevant to treating persons with mental illness.Write 211 E. Chicago Ave., 5th Floor, Chicago, IL 60611. 312/440-2660; Fax: 312/440-2824; e-mail specialcaredent@yahoo.com; on the Web: www.SCDonline.org


Key Terms

Atypical odontalgia
chronic throbbing or burning pain in the teeth, alveolar process, or mucosa without a clear dental cause. The cause of this pain is primarily neuropathic

CMI
severe or chronic mental illness

DSM IV-R
the Diagnostic and Statistical Manual of Mental Disorder, 4th Edition, Revision. This text, published by the American Psychiatric Association, is a guide to diagnosing mental illness

Delusion
a false belief firmly held despite obvious proof or evidence to the contrary. In addition, the belief is not one ordinarily accepted by other members of the person’s culture or subculture.

Extrapyramidal side-effects
muscle spasms, symptoms similar to those experienced in Parkinson’s disease, or involuntary movements which are potential side-effects of certain antipsychotic medications.

Hallucination
a sensory perception in the absence of an actual external stimulus. It may occur in any of the senses, e.g., auditory, gustatory, olfactory, somatic, tactile, visual.

Mental illness
a behavioral or psychological syndrome associated with significant distress or disability. It is estimated that in any given year, one in five people have a mental illness.

Mitral valve prolapse (MVP)
a heart valve abnormality present in many patients with panic disorders or agoraphobia. Some patients with MVP may require prophylactic antibiotics before oral health treatment.

Mood
a pervasive and sustained emotion that, in the extreme, markedly colors one’s perception of the world. Common examples of mood include depression, elation, and anger.

Neuroleptic
an antipsychotic drug.

Neuropathic pain
pain that originates from sensitization of nerves. It is not a consequence of mental illness.

Psychotropic
a drug used to alter abnormal thinking, feelings, or behavior. It is traditionally divided into classes of antipsychotic, antidepressant, mood stabilizers, and anti-anxiety (anxiolytic) drugs.

Tardive dyskinesia
a late-appearing side-effect of certain psychotropic medications given long-term at high doses. The symptoms include persistent involuntary movements of the tongue, face, or jaws.

Temporomandibular disorder (TMD)
a disorder characterized by pain, limited range of jaw motion, and temporomandibular joint noises. Roughly 50% of patients with TMD have or have had a psychological diagnosis.


Authors

Alison J. Longley, BA, PhD, is a neuro- and behavioral scientist with the Pacific Sciences Institute, Seattle and Friday Harbor, Washington. Patricia E. Doyle, RDH, BS, FADPD, is a private practitioner in Seattle, Washington, a clinical instructor at the University of Washington’s Dental Education in Care of Persons with Disabilities (DECOD) Program, and a technical consultant for Laclede, Inc.