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.”