Mental Illness & Oral Health

Oral Health Profile of People with a Mental Illness

Factors Predisposing People with a Mental Illness
to Oral Disease

Barriers to Oral Health & Accessing Care

Oral Health Profile of People with a Mental Illness

Oral Health Status

• Chronic and significant oral disease is noted in this group. A number of factors contribute to this increased risk
  (Stiefel et al. 1990, Tesini & Fenton 1994).
• Extensive unmet oral health needs, including high need for gum treatment, restorations and extractions
  (Friedlander & Liberman 1991, Barnes et al 1988).
• A legacy of institutionalisation may be that some inpatients were required to have full clearance. Extractions were often a protective strategy against patients biting carers
  (Chalmers 2001).
• Older people in this group tend to experience more anticholinergic and tardive dyskinesia side effects. This is most likely a result of the more traditional drugs, such as Melleril, taken over long periods, compared to newer antipsychotics with less of these side effects
  (Chalmers 2001a).

Oral Health Behaviours

• Lower use of dental services and longer periods between visits
  (Barnes et al 1998).
• Irregular visits leading to increased disease, less favourable and more invasive treatment eg. extractions
  (AIHW 2001).
• Emergency care motivates clients to attend the dental clinic more than general care
  (Chalmers et al 1998).
• Poor knowledge of oral side effects of psychiatric medications despite high usage
  (Chalmers et al 1998).

Oral Health Needs

• Prevention and treatment services required, however need for emphasis on prevention and daily maintenance of oral hygiene before disease development
  (Chalmers et al 1998).
• Patient, parent, staff, and caregiver education and training required
  (Tesini & Fenton 1994).
• Advocacy for daily oral care to motivate and promote patient involvement to encourage independence
  (Tesini & Fenton 1994).

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Factors Predisposing People with a Mental Illness to Oral Disease

• Depressive illness is associated with disinterest in performing oral hygiene
  (Friedlander et al 1993, Stiefel et al 1990).
• Lacking dexterity, physical ability or capacity to perform personal oral hygiene
  (Barnes et al 1988).
• Neglect of a properly balanced diet, with a high sugar content
  e.g. soft drinks and sugary coffee
  (Friedlander et al 1993, Friedlander et al 1993a, Lemon & Reveal 1991).
• Sugar addictions or cravings, 'sweet snack dilemma', a major side effect of antipsychotic medications, lead to uncontrolled consumption of a highly cariogenic diet and subsequent weight gain.
• Xerostomia: reduction in saliva flow due to both anxiety related depression of the parasympathetic nervous system and as a side effect of long term use of psychiatric medications. This reduces natural cleansing and protection of the mouth by saliva, leading to greater predisposition to oral diseases
  (Friedlander et al 1993).
• Higher rates of smoking leading to increased rates of oral cancer, increasing dry mouth and reducing periodontal healing
  (Friedlander et al 1993)
• Prevalence of undiagnosed mental illness in the community.

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Barriers to Oral Health & Accessing Care

Patient Factors

Lack of 'perceived' need

• By patient for treatment, despite high levels
  of clinical need. Often when need is perceived,
  the complaint is due to poor appearance
  (Tesini & Fenton 1994, Walpington et al 2000, AIHW 2001).

Dental fear

• Anxiety due to past experiences, emergency pain and a high need for extractions and treatments, which are more stressful.
• Lack of ongoing links with familiar dental staff
  (Chalmers 2001).

Lack of knowledge

• About oral hygiene & available dental services
  (Walpington et al 2000).

Financial difficulties

• Paying for care/transport/dental aids with limited finances. Often clients are on disability pensions.

Illness characteristics

• Such as withdrawal, anxiety and confusion
  (Lemon & Reveal 1991).
• Inability to keep appointments and follow homecare instructions

Service Factors

• Waiting times
• Complex medical histories
• Long and complex treatment plans
  (Freeman 1999)

Suggested Solutions

• Support clients to identify their oral health needs and understand the causes of oral disease and how this affects their overall wellbeing.
• Reassuring and caring approach required.
• Constant reinforcement of oral hygiene education.
• Exemption from payment.
• Awareness of the symptoms of the illness and its effect on other areas of health and wellbeing.
• Accompaniment by a caregiver recommended where possible to motivate and support clients.
• Priority appointments timed to suit client eg. afternoon.
• Liason between client's GP/case manager and dental staff to provide medical history prior to visit.
• Often efforts seen as a waste of time. Sensitivity to patients attitudes and needs for reassurance is required.
  

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