Many people might wonder how mental health is linked to oral health and the role that psychiatric-mental health nurse practitioners (PMHNP) can play in improving oral health outcomes in their patient population. Because PMHNPs work with a wide range of patients with psychiatric symptoms or behaviors that predispose them to poor oral health consequences, it is crucial that these healthcare professionals recognize the oral health needs of their patients.
Psychiatric-mental health patients have an increased risk of oral health neglect stemming from an amalgam (pun intended!) of mental health and behavioral factors, including severe dental anxiety, high prevalence of substance use (alcohol, tobacco and narcotics) and low mood, motivation and priority placed on oral health and dental care. The issue is further complicated by oral side effects of psychotropic medications that many patients take daily and the lack of access to dental care tailored to the needs of this patient population. This is a “perfect storm” of factors that predispose these individuals to increased risk of oral disease.
A review of oral health of adults with serious mental illness (SMI) found that the prevalence of suboptimal oral health is significantly higher (61%) in individuals with SMI. The most reported outcomes in this population included xerostomia (dry mouth), missing teeth, gross caries, decayed teeth, and periodontal disease (Matevosyan 2010). Co-morbidities associated with psychotropic medications include, but are not limited to: weight gain and obesity, hypertension, dyslipidemia and diabetes, increased risk for oral health problems such as gingivitis, periodontal disease, and tooth loss. More specifically, compared with the general population, patients with SMI are 3 times more likely to have their teeth removed (Kisely et al 2011).
All PMHNPs should be on the look-out for poor oral health status in patients with the following psychiatric disorders:
- Schizophrenia spectrum and other psychotic disorders: patients demonstrate poor goal setting and avolition, inhibiting proper oral hygiene habits and exhibit hallucinations/delusions about dental care
- Eating disorders: people with bulimia demonstrate enamel erosion, while those with anorexia demonstrate decrease in calcium
- Substance-related disorders: stimulants cause dry mouth (xerostomia); the decreased salivary flow provides a medium for bacteria to flourish and increase risk of severe decay
- Depressive disorders: patients demonstrate low motivation inhibiting proper oral hygiene habits
- Bipolar and related disorders: patients often brush too vigorously disrupting tooth enamel
- Obsessive- Compulsive and related disorders: patients often brush too vigorously or whiten teeth obsessively destroying tooth enamel
It is estimated that 20 million Americans avoid the dentist due to dental anxiety (Dental Fears Research Clinic). For some adults and children, their dental anxiety is so extreme that a diagnostic code in both the ICD9 and DSM5, dental phobia, can be used. Dental anxieties and phobias arise from a variety of factors, including dental healthcare notions instilled during upbringing, media portraying painful dental care and personal traumatic experiences. All of these factors can lead to avoidance of timely oral health care.
Mental illness is a continuum ranging from minor personal distress to serious mental illness. PMHNPs must deal with a range of dysfunctional symptoms and behaviors that can significantly impact the oral health status of their patients, which, if left untreated can have serious systemic consequences.
It is the role of PMHNPs to assess, diagnose, manage oral health problems within their scope of practice and refer their patients for oral care. Many patients with SMI have a dental benefit through Medicaid; it is helpful to have a list of dentists who accept this insurance.
Several validated scales are available to assess dental anxiety, including the DAS and MCDAS scales. Simply asking a patient to rate their dental anxiety on a scale from 1-10 can also be an effective method of assessing fear. If PMHNPs detect a dental anxiety issue, they can provide appropriate treatment via psychotherapy, which may include behavioral, cognitive, depth or trauma therapies. Prescribing anti-anxiety medications is inadvisable, as these medications only result in heightened anxiety immediately following the dental intervention, as well as in the long-term.
PMHNPs should encourage their patients to brush and floss regularly, reduce sugar intake, exercise, and work to stop smoking or ingesting alcohol or narcotics. Finally, they should always recommend oral health screening and speak with their patients on how to access dental care. PMHNPs can use an interprofessional approach, involving dentists, primary care physicians, nurse practitioners, physician assistants, pharmacists, nutritionists and social workers to improve the oral health and general health outcomes for this special needs population.
Do you know someone who suffers from dental anxiety?
Learn more about how PMHNPs can address the oral health needs of patients with mental health problems and psychiatric disorders by watching the video of Dr. Candice Knight, PhD, EdD, APN, PMHNP-BC, PMHCNS-BC speaking at the NYU College of Nursing’s Master’s Program Oral Health Preceptor Recognition Breakfast and Professional Development Day.
Matevosyan, N. R. (2010). Oral health of adults with serious mental illnesses: a review. Community mental health journal, 46(6), 553-562.
Milgrom, P. “Anxiety-Free Dentistry.” Article by William Loeffler . Pittsburgh Tribune-Review 9 Apr. 2006: Web. Available on http://triblive.com/x/pittsburghtrib/lifestyles/family/s_440936.html#axzz3TWbMnndj
NYU College of Nursing’s Master’s Program Oral Health Preceptor Recognition Breakfast and Professional Development Day. Perf. Candice Knight. 2014. Available here https://www.youtube.com/watch?v=aLxaDbnFb0E&t=60m26s