The Oral-Psychiatric Link

MENTAL HEALTH IS NOT CURRENTLY A PART OF THE CONVERSATION
I am not sure how much time was spent talking about mental illness in your hygiene or dental school, but when I was in school, it was a topic either too taboo or, more likely, seen as too unrelated to dentistry to get any floor time. My experience as a mother and dental provider has taught me that mental health and oral health are inextricably linked. As the conversation surrounding the mouth and body is gaining ground, it is important to make sure the mental health of our patients is no longer left out of the conversation. Assessment, treatment, and billing of dental procedures for the mentally ill should not only be considered, they should also be researched and examined alongside other oral-systemic issues. Furthermore, mental healthcare providers should see themselves as oral health first responders when patients present with mental illness, since their patients are 3 times as likely to suffer tooth loss.¹ Their role should be active, not passive, with regard to the condition of the oral cavity. Dental teams should also realize they are often first responders to mental and behavioral issues and thus be trained to refer patients presenting signs of mental illness to the proper networks.

My Story
My daughter was in her first weeks of college when I got “the call.” As a teenager, she had gone through episodes of terrible fear, but this time it was different. She had an episode so severe she had been admitted to the hospital psychiatric ward. The next 3 years of her life (and mine) I refer to as “3 years of horror.” I don’t like to recount the details as they are painful and private to my family, but during that time, I can say that we were hyper-focused on her mental illness. Somewhere along the way, almost silently, another issue crept into our lives.

During her treatment, my daughter began to complain about tooth pain and her mouth feeling dry; her doctors assured me the discomfort was simply a side effect of her medication. Then, I got “the second call.” Seemingly out of nowhere, I learned that my daughter’s teeth were so compromised she needed multiple tooth extractions and root canals. We were faced with a series of very painful and very expensive procedures on top of the already painful and expensive mental healthcare. It was a nightmare for my daughter and for me and our family. I couldn’t believe I had missed the warning signs. I had been so focused on her mental health and at the same time felt that I had failed to protect her.

We spent a lot of time and money to get her healthy. I can happily say that today she is doing very well, but I have not forgotten the emotional and financial strain her mental illness and subsequent dental disease had on our family. I can say with conviction that had we taken proper steps to prevent her oral disease, her mental improvement would have happened much sooner than it did.

Warning Signs
One reason we missed early intervention with my daughter was the lack of urgency expressed by her doctors. Experts confirm there is a glaring lack of knowledge by both medical providers and dental providers on the specific needs of the mentally ill.² Mental health providers must understand that the most common side effect of medication use is dry mouth, or drug-induced xerostomia. Dry mouth can lead to a series of painful oral infections. Mental health professionals should be aware their patients are at risk for the following:

• Dental caries
• Periodontal disease
• Oral infections.

Warning signs of dental distress may manifest in the following ways:

• Complaints of dry mouth
• Complaints of tooth pain
• Bleeding gums
• Difficulty with speech
• Difficulty chewing
• Difficulty swallowing
• Poor denture tolerance
• Dental trauma.²

Had my daughter’s doctors understood the compounding effects of the stress³ and depression⁴ linked to oral disease, I can only assume my daughter’s complaints would have been taken more seriously.

Conversely, dental professionals are in a prime position for early diagnosis of mental and behavioral screening. Certain mental health issues can manifest themselves as problems within the oral cavity. Anorexia and bulimia nervosa are prime examples. Additionally, many psychiatric disorders surface during the adolescent years, a time when many youth are being seen on a monthly basis by their orthodontist, unlike any other healthcare professional.⁵ Therefore, dental teams can and should be screening patients for things that could be related to or a result of mental illness, such as the following:

• Lingual erosion on the palatal surfaces of the maxillary teeth with a smooth, glossy appearance⁶
• Trauma to the soft palate and pharynx
• Soft-tissue lesions such as angular cheilitis, candidosis, glossitis, and oral mucosal ulceration, stemming from nutritional deficiencies⁶
• Medication-induced xerostomia
• Bruxism
• Dyskinesia and dystonia
• Facial pain
• Preoccupation with dentures
• Self-inflicted injury
• Burning mouth syndrome (sign of anxiety and/or depression)7
• Any major change in oral hygiene
• Alcohol and tobacco use/abuse
• Sleep apnea
• Random movement of the tongue, lips, or jaw (facial grimacing)
• Excessive fear or phobias.⁸

Challenges to Care
Elizabeth Feingold, MD, director of the Comprehensive Psychiatric Emergency Program (CPEP) at Harlem Hospital Center states (via email communication, October 1, 2015):

There is no basic protocol for patients getting admitted in regards to their dental care. Unless the patient is complaining of [a dental] issue, they will not be consulted by the dental service. Even if there is a dental issue, it becomes complicated. The acutely mentally ill patients are often neglected by other medical services because of their behavior and hygiene. Other providers, including dental, are often uncomfortable treating mentally ill patients because they may be behaviorally unstable and unpredictable. Also, the patients would have to be brought off the unit to a dental suite that puts our staff at risk and increases the chance of elopement. Basically, people are just afraid of our patients.

In addition, one of the most common barriers to seeking dental care is the perceived cost. However, many dental professionals neglect to realize the potential to bill the patient’s medical insurance for many of the patient’s dental needs.

MY MISSION
As a mother of a child with mental illness, I have witnessed firsthand the devastation this condition can have on a person’s oral health and, in addition, how the deterioration of the mouth intensifies the mental struggle. I firmly believe that mental healthcare providers and dental professionals have an equal responsibility to care for the whole patient. According to the Surgeon General, healthcare providers (including psychiatric and dental professionals) should be ready, willing, and able to work together to provide the best possible care for their patients. Healthcare professionals should be receiving multidisciplinary training in order to offer comprehensive care.⁹ I believe the way to begin this process is to standardize an oral health assessment and referral system within mental health facilities and dental offices. Health providers should be aware of the signs of oral disease and have a network of dental professionals that have been adequately trained in working with mentally ill patients, as well as medical billing to provide care. I realize it is a larger issue than this. There must be systemic change within dentistry, mental health, national and local legislation, and within big insurance. However, I am dedicated to doing what can be done by telling physicians and dentists all over the country my story in an effort to shed light on the importance of the issue. I also offer training for dental teams on how to bill medical insurance for dental procedures.

Although these may be small steps, hopefully, they will be seen by others in the professions as steps in the right direction.

References

1. Rattue G. Tooth loss three times more likely in patients with severe mental illness. medicalnews­today.com/articles/233780.php. Accessed October 21, 2015.
2. Rai B. Oral health in patients with mental illness. The Internet Journal of Dental Science. 2007;6:1-4. ispub.com/IJDS/6/1/11450. Accessed October 21, 2015.
3. Peruzzo DC, Benatti BB, Ambrosano GM, et al. A systematic review of stress and psychological factors as possible risk factors for periodontal disease. J Periodontol. 2007;78:1491-1504.
4. Berk M, Williams LJ, Jacka FN, et al. So depression is an inflammatory disease, but where does the inflammation come from? BMC Med. 2013;11:200.
5. Giddon DB, Swann B, Donoff RB, et al. Dentists as oral physicians: the overlooked primary health care resource. J Prim Prev. 2013;34:279-291.
6. DeBate RD, Tedesco LA, Kerschbaum WE. Knowledge of oral and physical manifestations of anorexia and bulimia nervosa among dentists and dental hygienists. J Dent Educ. 2005;69:346-354.
7. Arizona Department of Health Services. Division of Behavioral Health Services quarterly health initiatives. azdhs.gov/bhs/qhi. Accessed October 21, 2015.
8. National Alliance on Mental Illness. Mental health conditions. nami.org/Template.cfm?Section=By_Illness. Accessed October 21, 2015.
9. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General (Executive Summary). Part Five: What Are the Needs and Opportunities to Enhance Oral Health? Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. nidcr.nih.gov/datastatistics/surgeongeneral/re­port/executivesummary.htm#partfive. Accessed October 21, 2015.

Ms. Taxin is the founder and president of Links2Success, a practice management consulting company to the dental and medical fields. Prior to starting her own consulting company, she served as an administrator of a critical care department at Mt. Sinai Hospital in New York City and managed an extensive multispecialty dental practice in NY. With more than 25 years’ experience as a practice management professional she now provides private practice consulting services, delivers continuing education seminars for dental and medical professionals, and serves as an adjunct professor at the New York University Dental School and Resident Programs for Maimonides Hospital. She can be reached via email at ctaxin@links2success.biz.

Disclosure: Ms. Taxin reports no disclosures.