Supporting the Oral Health Needs of Individuals with Mental Illness

Shari Harding, DNP

Dental care is a significant concern for individuals experiencing mental health conditions. Individuals with mental illness often face significant risk factors and barriers related to dental health. These challenges affect self-care and professional dental care. As healthcare professionals, nurses are uniquely positioned to leverage our existing relationships with patients to facilitate improved dental care. Nurses across care settings can influence dental outcomes among individuals with mental illness through affective and instrumental supports.

Individuals with mental illness often experience risk factors that may worsen dental health. For example, many mental health medications have potential side effects such as xerostomia, sialorrhea, gingival hyperplasia, bruxism, and/or movement disorders affecting oral muscles. (1,2) In addition to prescribed medications, individuals with any mental illness are more likely to use tobacco and illicit substances, (3) which negatively affect dental health. (1) According to the Substance Abuse and Mental Health Services Administration, 27.2% of adults with any mental illness reported current tobacco use and 38.8% reported past year use of illicit drugs. (3) Excessive caffeine intake is common and contributes to xerostomia and tooth wear. (4) Many of these substances also cause symptoms such as xerostomia and bruxism, as well as increasing the risk of dental caries and oral cancers. (5) Importantly, oral cancers may go unrecognized without appropriate oral exams from primary care providers and routine dental care from dental hygienists and dentists. (6)

Individuals with mental illness experience several barriers to dental care. Barriers to self-care include experiencing mental health symptoms which can lead to self-neglect. Depression itself is a risk factor for poor dental outcomes. (4) Barriers to professional dental care include mental illness stigma, dental anxiety, and access to care. The stigma of mental illness can discourage seeking care (1) and even self-disclosing psychiatric medications on a dental care intake form can create discomfort for some individuals. Dental anxiety is a common psychiatric comorbidity (7) and can cause individuals to delay or even avoid dental care. Lastly, access to dental care is a significant obstacle for many individuals. Dental insurance coverage, especially among adults, is highly variable. Financial constraints are most prevalent for dental care compared to other types of health care, (8) with 52% of Americans citing cost and 31% citing insurance issues as barriers. (9)

To enhance dental outcomes among individuals with mental illness, we need to address the barriers and challenges to self-care and obtaining professional care. Health care professionals, especially nurses, across all care settings often form strong, positive alliances with patients. Being aware of common barriers to dental care (access, cost, anxiety, and recognition of need) helps us when assessing and intervening on individual needs. Nurse-led routine brief screenings can be done within the context of nurse-patient relationships, using an open-ended question such as “Tell me about your dental and oral health needs.” Once we understand an individual’s perceived needs and barriers, we can provide additional direction through focused questions including:

• “How often do you brush your teeth?”

• “How often do you floss your teeth?”

• “When was the last time you went to the dentist?”

• “When was the last time you had your teeth cleaned by a hygienist?”

When we ask direct questions, we demonstrate the importance of dental health behaviors. Affective support such as active listening and empathy helps patients to feel safe and empowered, providing the foundation for addressing health needs.

Instrumental support includes responding to dental needs with information and resources. For example, we can help identify substances that may cause adverse dental effects and then help evaluate the need for continued use. Some necessary medications cause xerostomia and we can support patients with strategies to alleviate symptoms by encouraging use of sugar-free gums or candies, saliva replacements, sips of water, and sucking on ice chips. (10) We can combine education with practical coaching around self-care, such as bundling brushing and flossing with more pleasurable activities such as listening to a favorite song or watching part of a favorite television program, setting reminder alarms, or putting dental care supplies in accessible places alongside other daily activities. We can also assess for and encourage patients to decrease their use of substances such as caffeine, tobacco, sugary drinks or gums, and illicit substances.

To help address professional care needs, we can assist patients in finding dental providers who are sensitive to their needs and who accept their insurance or have income-based fee structures. Sharing an updated list of dental providers and assisting patients in determining which providers accept various insurances and payment methods may be the help they need. For preventive care such as cleanings, local dental provider schools may have affordable clinic options (in Worcester this includes Quinsigamond Community College and the Mass College of Pharmacy and Health Sciences Dental Hygiene Programs). Referrals to behavioral health specialists may also be appropriate to address dental anxiety and other unmet mental health or substance use needs. The most effective referrals for patients with mental and dental health needs are “warm” referrals, with the nurse assisting in communication and regular follow-up with other providers and the patient throughout the process. (11) We can follow up with a phone call, message, or other reminder to help encourage patients to take the steps needed to make and keep dental and mental health appointments. Often, it will take several discussions over time to increase patients’ readiness to engage in care. Nurses are well placed to address these gaps in dental care through their ability to partner with patients to assess and meet individual needs.

References:

1. Clark DB. Mental health issues and special care patients. Dental Clinics of North America. 2016;60(3):551-566.

2. Stahl S. Stahl’s essential psychopharmacology: Prescriber’s guide. Sixth edition. Cambridge University Press; 2017.

3. Key substance use and mental health indicators in the United States: Results from the 2019 national survey on drug use and health. Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/product/ key-substance-use-and-mental-health-indicators-in-the- united-states-results-from-the-2019-national-survey-on-Drug- Use-and-Health/PEP20-07-01-001. Accessed November 6, 2020.

4. Young WG. Tooth wear: diet analysis and advice. International Dental Journal, 2005;55(2):68–72.

5. Tomar SL, Hecht SS, Jaspers I, Gregory, RL, Stepanov, I. Oral health effects of combusted and smokeless tobacco products. Advances in Dental Research, 2019;30(1):4-10.

6. Oral cancer. National Institute of Dental and Craniofacial Research. Accessed November 6, 2020. https://www.nidcr.nih. gov/health-info/oral-cancer/more-info

7. 7. Halonen. H, Nissinen. J, Lehtiniemi H, Salo T, Riipinen. P, Miettunen. J. The association between dental anxiety and psychiatric disorders and symptoms: A systematic review. Clinical Practice and Epidemiology in Mental Health, 2018;14:207-222.

8. Vujicic M, Buchmueller T, Klein R. Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Affairs, 2016;35(12):2176-2182. 9. Brody A. Cost remains barrier to dental care access. Dimensions of Dental Hygiene, 2020;18(2):9. 10. American Dental Association. Managing dry mouth. The Journal of the American Dental Association, 2016;146(2):40.

11. Tips for making trauma-informed warm referrals. Commonwealth of Massachusetts. https://www.mass.gov/ info-details/tips-for-making-trauma-informed-warm-referrals. Accessed November 6, 2020.

Shari Harding, DNP, is an assistant professor at the UMass Medical School’s Graduate School of Nursing. Email: shari.harding@umassmed.edu