Sara Hurley, chief dental officer England, and Professor Tim Kendall, NHS national clinical director for mental health and consultant psychiatrist, recently shared a new NHS dentistry and oral health update, with a special focus on patients with mental illness.
They begin by sharing, “It is an unacceptable fact that people with mental ill health are disproportionately affected by poor oral health. The international evidence is pretty stark, with the impact being both indirect (people with severe and enduring mental illness experiencing poorer oral health as a result of delayed treatment, access issues etc) and direct (the harmful effect of some symptoms of mental illness affecting oral health such as self-induced vomiting):
- People with mental illness are less likely to engage with oral healthcare, with a study finding that only 75 per cent of schizophrenia patients brushed their teeth daily, compared to 96 per cent in the general population.
- Poor mental health is often linked to other factors such as homelessness or substance use, which also have consequences for oral health.
- In a meta-analysis of studies, patients with severe mental illness were almost 50 times as likely to have periodontal disease;
- Patients with eating disorders had five times the odds of dental erosion. In patients with self-induced vomiting, the erosion rate was seven times higher.
“It is true that providing oral care for patients with severe mental illness (for example psychosis, schizophrenia, bipolar disorder) is not straightforward. However, through the use of tailored outreach and a trauma-informed approach to supporting people with SMI - by providing an environment where a person who has experienced trauma feels safe and can develop trust - there is an opportunity to better engage with this group and, in doing so, improve oral health outcomes.”
They end the opening remarks of the update by noting “For years we have campaigned to put the mouth back in the body. We hope that today's bulletin is a useful reminder to think of the mind, too.”
Common oral health conditions for those with mental ill health
They then proceed to explain the common oral health conditions those with mental ill health face, for example:
- Neglect: People with mental illnesses tend to avoid dental care to the extent that their oral hygiene is neglected. This can result in gum disease and tooth decay.
- Anxiety: This can be linked to dental phobia and as a result, people stop seeing their dentist regularly.
- Eating disorders:If a person has a condition such as bulimia, they will often experience dental erosion from the acidity in vomit, and they are likely to have low levels of calcium, which is important for healthy teeth.
- Brushing actions: Over-vigorous brushing actions can result in brushing away the enamel on the surface of the tooth.
- Medication:Some medications can result in adverse oral effects, for example dry mouth as a result of reduced saliva flow.
- Smoking: Smoking rates are three times higher than the general population.
Additional oral health inequalities for those with severe mental illness (SMI)
It is recognised that those with severe mental illness face some of the worst inequalities in mental health, which mirror the social and physical inequalities also experienced by this group.
They explain that the “burden of oral diseases in people with SMI has serious impacts on their mental and physical health. For example, dental conditions were the fourth most common reason for avoidable hospital admissions in people with psychiatric disorders”.
The update again lists specific examples.
Patients with SMIs are at an increased risk of oral disease, including:
- Periodontal disease and caries;
- Oral cancer due to tobacco and alcohol misuse;
- Tooth surface loss due to over vigorous brushing;
- Oral candidiasis;
- Temporomandibular joint dysfunction;
- Facial pain;
Patients with SMIs may be at risk of developing the following oral side effects of medication used for treatment of mental illnesses:
- Dyskinesia and dystonia – abnormal involuntary movements of tongue, or facial muscles sometimes associated with abnormal jaw movements. It not only results in poor oral health but may also cause difficulty in breathing.
Awareness of the signs of mental ill health and when to refer to CDS or specialist services
An important aspect of the update includes raising awareness of the signs of mental ill health and when to refer to CDS or specialist services.
They highlight, “First and foremost, dental teams should aim to create a culture of inclusion where a patient feels comfortable explaining that they may have a mental health condition.
“According to the British Society for Disability and Oral Health, it is important to be aware that the following oral symptoms may be the first manifestation of a mental health issue and to adapt the treatment plan according to the advice below:
- Facial pain (can also be linked with depression);
- Preoccupation with dentures;
- Excessive palatal erosion due to bulimia;
- Self-inflicted injuries;
- Temporomandibular joint dysfunction.
Following this, the update explains that “If you are unsure of if a patient should be referred to CDS or Special Care, or you would like advice on treating the patient, please contact your commissioner and Local Dental Network Chair.
“Following the effects of COVID-19 be aware that waiting list times may have increased for CDS, Special Care Dentistry, level 2 and tertiary referral services. Make sure referrals are appropriate for the given service, contact local services so you are aware if their waiting times and be prepared to manage urgent dental issues and provide preventative advice and recall as indicated.”
Safety and wellbeing adaptations and techniques
Advice is also given on how dental care professionals can try to make patients more comfortable in the dental setting, for example:
- Minimising noises and distractions;
- Limiting the number of people in the room;
- Detailed information on what can be expected during treatment;
- Stop signals and other control mechanisms;
- Use of specific coping mechanisms such as listening to music, breathing, mindfulness;
- Close liaison with the patient’s healthcare team to identify any changes in medication which may have an impact on the patient’s ability to engage with dental care, and conversely to identify to the care team if you have noticed any change in the patient’s symptoms which might indicate an exacerbation of their mental illness;
- The use of pharmacological methods including sedation and general anaesthesia to make treatment more comfortable.
The update concludes with advice for those in a mental health crisis; “There are 24/7 crisis lines available in England if you, or someone you love, is having a mental health crisis. These crisis lines are available to people of all ages, and you can find your local helpline on nhs.uk.
“You can also talk to your GP by giving your GP practice a ring – and you can ask to speak to a GP who you know or trust. You can also speak to your hospital / community doctor or nurse, if you have one, who looks after you.
“Remember, if you feel immediately unsafe and it is an emergency, you can call 999. But this might not be the right thing for you, which is why there are a range of options available.”