Clinical Work

Treat Addiction? Begin with Teeth.

This is a short unpublished editorial on health policy in Massachusetts, though its main points are also applicable elsewhere.

When we think about addiction treatment, we think of hospitals, rehabs, and jails. But it turns out that if we want to promote recovery in Massachusetts, the place to do it may be in an unexpected one: the dentist’s chair.

The evidence comes from a remarkable project begun in Salt Lake City in 2015. Dentists at the University of Utah Dental School, and their students, provided free comprehensive dental care to residents at two local halfway houses.

That’s all. They simply provided all dental care that these residents needed: cleanings, root canals, restorations. The cost came to $1,236 per patient. (For comparison: the cost of a five-day drug or alcohol detox is typically several thousand dollars).

The results were almost miraculous. Patients receiving dental care were over three times as likely to complete addiction treatment than those who did not. They were over twice as likely to be employed after discharge from treatment. And they were over twice as likely to remain abstinent after the end of treatment.

These changes did not come from providing any additional therapy or medication. These patients received the same treatment as everyone else. All that they received, in addition, was adequate dental care.

Why did this work? There are probably a few reasons.

First, inadequate dental care has a familiar and predictable result: pain. Tooth decay hurts. Lacking adequate dental care, people in early recovery naturally turn to a reliable and available pain-killers: heroin and other opiates. Providing dental care takes away one reason for relapse.

Second, inadequate dental care has another result: visibly poor teeth. If someone is in early recovery and is interviewing for a job, applying for an apartment, or just going on a date, their teeth are a visible reminder of their past. Providing comprehensive dental care lets people move forward with their lives.

Third, people in recovery from addiction need the same things that everyone needs: stable housing, groceries, and social supports. This is what experts call “recovery capital” – the material resources that promote recovery. And part of recovery capital is simply adequate dental care.

Therefore, if we want a cost-effective and innovative way to treat addiction and promote recovery, we should think about teeth. And we should think about what kind of dental care people in early recovery are actually getting.

The people in the Utah study were fortunate to be participants in a program that provided most of the dental care they needed, at no cost. Most people in early recovery are not so fortunate. What does dental care look like for them?

In Massachusetts, it could be much better. Many people in early recovery lack private dental insurance and receive their dental benefits through MassHealth. This poses three problems.

First, there is the problem of actually finding a dentist: the most recent statewide oral health report indicates that only one-third of licensed dentists accept MassHealth. This problem is compounded by the current closings and restrictions due to COVID-19.

Second, MassHealth dental benefits are not always well-publicized, and many MassHealth patients fail to take advantage of the services that are available to them – such as two cleanings per year.

Third, even for patients who do find a MassHealth dentist and aware of the benefits available to them, the services actually provided fall well short of comprehensive care. MassHealth covers fillings and extractions (tooth-pullings), but it covers few of the more expensive methods that modern dentistry uses to restore teeth to their natural appearance, such as crowns. It even fails to cover treatments that most of us would consider basic, such as root canals.

This austere approach to oral health is short-sighted. A slight expansion in MassHealth benefits – to include, at a minimum, root canals and crowns – along with psycho-education on the benefits and availability of oral health care, could have a real impact on the treatment of addiction in Massachusetts.

This is the surprising significance of teeth. A modest expansion of state dental benefits is certainly one of the more surprising ways to promote recovery in Massachusetts – but it may turn out to be one of best.

Mental Health and Oral Health

In the 2019-2020 academic year, I had the opportunity to train in behavioral health at an academic dental school. It was a fascinating experience. But I often had difficulty explaining to people what, exactly, I was doing in a dental school. This post is an attempt to answer that question, drawing on some of the varied literature on this topic.

Problems in mental health tend to give rise to problems in oral health. The most well-known of these effects, perhaps, is dental anxiety, a well-documented phenomenon (indeed there are several scales that may be used to measure it). Anxiety in turn leads to the postponement of dental care, which in turn leads to poor oral health. There are also more indirect, but equally pernicious, connections between mental health and oral health.

Substance use disorders are perhaps the clearest case. The effects of methamphetamine use on oral health are well known (in fact it is not the drug itself but the associated “lifestyle” of high sugar consumption and poor self-care that leads to the dental health effects), but substance use disorders generally give rise to oral health problems.

Severe mental illnesses such as schizophrenia have similarly devastating effects. A “DMFT score” measures how many Decayed, Missing, or Filled Teeth a person has. A typical person with severe mental illness has a DMFT score of more than 20 – that is, 20 Decayed Missing or Filled Teeth. Again, the mechanism of action here is indirect: severe mental illness is associated with avoidance of dental care (either directly through dental anxiety or indirectly through poverty and associated outcomes) and poor self-care.

One lesson of these sobering statistics is that mental health care and oral health care should be “integrative,” in the sense that the one should be provided alongside the other. This is done more and more often in (medical) primary care, but it remains non-standard in dental care. In one way, this is precisely the opposite of how things should be. Since dental care can be so urgent, it often brings individuals into the health care system who would otherwise avoid it. Thus, dentistry is a first “point of contact” for individuals who are otherwise adrift from health care generally and mental health care specifically.

There have been a few efforts in this direction that bear mentioning:

“Dental as Anything.” A collaborative program between mental health and oral health services in Melbourne, Australia, focusing on assertive outreach to hard-to-reach populations in Melbourne.

Project FLOSS. In my view, this project at the University of Utah is one of the most innovative interventions for substance use disorders. Providing full-spectrum oral health care to individuals in early recovery is shown to dramatically increase length of abstinence and other positive outcomes.

Treatment of patients with schizophrenia. I am not aware of any specific program that works on this, but there is clearly a need for one. Policies of “deinstitutionalization” have led individuals with schizophrenia to be treated at community health centers rather than in institutions. This presents a challenge for oral health care, as individuals with schizophrenia often have difficulty with oral health treatment, and community dental health centers are often challenged to make adequate accommodations.

As noted above, the literature on this topic is varied, and scattered across the journals of various disciplines. Some of the articles I have found helpful are cited above. I have especially benefited from the work of Steve Kisely, a psychiatrist in Australia who works on (among other things) the connections between psychiatric conditions and physical disorders. See his “No Mental Health without Oral Health”  and this 2015 meta-analysis of connections between oral health and mental health, on which he is lead author: “A Systematic Review and Meta-Analysis of the Association Between Poor Oral Health and Severe Mental Illness.”

The Boston School for Social Workers

I’m currently studying at the Simmons University School of Social Work, which is a direct descendant of the Boston School for Social Workers (sometimes referred to as the “Boston School of Social Work”). This school was an influential and historically significant institution, yet there is pretty minimal documentation of it available online. There’s not even a Wikipedia page. So I thought it might be useful to provide a brief history of the Boston School for Social Workers in this post.

The Boston School for Social Workers was an innovative 12-year collaboration between Simmons and Harvard. It was founded in 1904, and Jeffrey Richardson Bracket – a major figure in philanthropic work, then based at Johns Hopkins – was appointed as its director. The school was located at 9 Hamilton Place, not far from the Park Street T station. Harvard left the arrangement in 1916, at which part the school became the Simmons School of Social Work

The Boston School for Social Workers was, arguably, the very first school of social work in the United States. A useful article by Linda M. Shoemaker indicates that it had two rivals for this claim: the New York School of Philanthropy (also founded in 1904) and the Chicago School of Civics and Philanthropy (founded a year earlier, in 1903). The Boston School for Social Workers, however, is distinctive for its use of the term “social work” in its very title, as well as its university affiliation. In this sense it is the progenitor of what we would now recognize as schools of social work.

It is instructive to consider why the partnership with Harvard ended. Richardson suggests that there was a division between more theoretical and more practical elements of social work, and that this division took on a gendered aspect. The more theoretical side was taken to be the province of men and, hence, of Harvard (then an entirely male university). The more practical side was taken to be the province of women and, hence, of Simmons (then an entirely female college, as it remains at the undergraduate level). As this division grew, and as the school grew more practical in its orientation, Harvard withdrew from the agreement, and diverted its energies towards Harvard’s Department of Social Ethics, an object of historical interest in its own right.



The Squiggle Game

Here is a short piece I recently wrote for the Boston Art Review, on Winnicott and squiggles:

The Squiggle Game

The psychoanalysis of children is an exercise in uncertainty, as there is no mind is as uncertain as a child’s. It is also, when practiced with some measure of self-awareness, an exercise in light comedy. To read the annals of child psychoanalysis is to experience the joy of witnessing some very serious people being slightly silly. Here is Erik Erikson – refugee from 1930’s Vienna, professor of psychology at Harvard, who gave himself the name “Erikson” to indicate he was the son of no one but himself – making a zoo out of building blocks for imagined lions. And here is D.M. Winnicott, perhaps the most profound analyst of the last century, playing the Squiggle Game.

In the Squiggle Game, the analyst blindly draws a “squiggle” on the page, and then the child completes the drawing into something that the child recognizes. Winnicott draws a “squiggle of the closed variety,” and Iiro, a Finnish boy in an orthopedic hospital, decides that it is a duck’s foot, and draws the leg and the webbing. (“It was clear immediately that he wished to communicate on the subject of his disability”). Then the child draws a squiggle, and the analyst completes it. And back and forth like that. A car, a bow-tie, a teapot, a goose, a mountain, the sea. Children rarely want to take the drawings home. While drawing, they talk. Winnicott asks Iiro if he is happy, and Iiro answers: “One knows if one is sad.”