How linked is patient dental health to patient mental health, and how should this affect taking care of patient oral health in the future?

In recent years, mental health has been brought more into the public eye, and especially how poor mental health can affect your physical health. Mental illness has been linked from the immune system [1] to premature aging [2]. However, there are surprising links between dental health and mental health. These links range from diseases like Alzheimer’s [3] to depression and eating disorders [4] anxiety (more specifically, dental phobia). This essay aims to look at how interconnected mental health and dentistry really are, and how dentistry could change in order to account for these links, regarding patient mental health. Patient mental health will focus on depression, anxiety and eating disorders, as well as how these challenges will be dealt with. Seeing as approximately 1 in 4 people in the UK will experience a mental health problem each year [5], it is important to regard how dentistry takes into account mental, as well as dental health.  My argument will be that dental and mental health are extremely linked, and that dentists can only help to reduce the effect of some mental issues, and that dentists should collaborate with other professions to provide good dental care, and thus provide good oral care. I will also propose that technology could be a force for good in combatting patient mental health.

Before looking at the numerous links with mental health and how dentistry could hypothetically change in order to account for these links, it is first important to say that I am not trying to say that dentists should be psychologists as well as dentists, rather that dentistry should take a more holistic approach to patient welfare, and not simply regard a patient as a set of 32 teeth. Also, there are some key points to take into account in regards to these studies, such as the fact that mental illnesses have variants. A good example of this is how depression has high functioning depression, where consistent symptoms occur over two years or more, but the person can still somewhat continue to run a functional life [24] , and there is also severe depression, where the person feels like that existence is futile and no longer wants to be alive [25]. Also, the bias of various stakeholders, especially with treatments, should be noted. An example is with orthotropics being used in lieu of traditional orthodontics. Whilst the BDA (British Dental Association) are vehemently against orthotropics [26], they have a bias, being that the BDA has many orthodontists, who could see this new treatment as a threat to their industry, despite the BDA having a good reputation.

That being said, it is now possible to move on with the question at hand, first starting with the mental health of the patient and how dentistry could change to accommodate these facts. Poor mental health is associated with poor dental health, with one study with a population size of 10 214 patients observing significantly higher build-up of C-reactive protein (CRP), which is known to cause inflammation, and having depression [6]. This is due to a number of reasons, but most notably due to the lack of energy and motivation to do basic human tasks that come with depression. Also, those with depression (as well as other mental health issues) can develop unhealthy coping mechanisms which can also negatively affect dental health. Chronic drug use is highly correlated with caries due to the use of cough syrup as a recreational drug, as it contains methadone linctus [4]. Smoking to cope with depression is also known to increase calculus build-up [7] and periodontal (gum) disease [8].

 

Stress and anxiety are also large problems with patients, with around 3 million people in the UK alone with an anxiety disorder [9]. Stress normally manifests as bruxism, or teeth grinding, during the night, where occlusal loading causes attrition of the tooth enamel, eventually revealing the sensitive pulp. This is already seen as a growing problem due to our modern lifestyle involving soft drinks which can soften the tooth enamel [10], and so this bruxism would be exacerbated in those with stress and anxiety. Of course, this cannot overlook dental anxiety, also known as ‘dental phobia’, affecting 10-20% of the adult population, is a condition where people are scared of going to the dentist, normally due to poor experiences with dentists in the past, which can lead to infrequent attendance to dentists, and hostility to dental staff [4] which is a risk factor. In extreme cases, those suffering from dental phobia may attempt self-aid, which has led to cases such as using superglue to reattach fallen out teeth [11].

Finally, we come along to eating disorders, namely anorexia and bulimia. Anorexia, also known as anorexia nervosa, is the self-restriction of food, and having a distorted body image to the point that you do not admit your weight loss is serious [12]. Bulimia, also known as bulimia nervosa is an eating disorder involving cycles of overeating (also known as binging) an then regurgitating this food (also known as purging) in order to maintain a healthy weight. Anorexia nervosa is especially deadly, with Thomas Insel, the former NIMH (National Institute of Mental Health) director stating that the mortality rate of anorexia nervosa being around 10 percent [13], largely due to starvation, metabolic collapse, and people taking their own lives. (Please note that I am not saying that anorexia is superior or more serious than other mental illnesses, just that it has a higher mortality rate.). The complications due to these eating disorders are documented, with a study conducted with 11 anorexic and 41 bulimic patients showed significantly increased enamel erosion than the general population [14], as the acidic vomit regurgitated by the patient attacks the enamel, leaving it (the enamel) weaker. In the same study, bulimics were noted to lave inflamed salivary glands, especially the parotid gland. Saliva plays a significant role in the moth, as a lubricant and for digestion of food and for antibacterial purposes, so the salivary glands being affected greatly affects the oral health of the patient.

Now that the main mental health problems have been established, we can look to how the dental system could change due to these issues. This first part will be about general things dentists could do to help the mentally ill. Dental care could become more linked with mental health services in order to mitigate this health problem, such as Samaritans or CAMHS (Child and adolescent mental health services) for any paediatric dentistry cases. More work should be done in order to breakdown the stigma surrounding neglected oral care, as this was suggested as a key issue by the British Society for Disability and Oral Health to help the mentally ill [4]. This would be especially helpful for those with dental anxiety so that they can reduce their fear of the dentist. Talking to patients about their problems could help to reduce the effect of these mental illnesses, or as Dr Barton Goldsmith of Psychology Today candidly says ‘Talk about your problems, please’ [20]. Dental restoration would be a key part of the recovery process, and new stem cell implants could be highly effective procedure for this. Developed by the University of Nottingham and Harvard University [22] it uses stem cells to essentially ‘rebuild’ a tooth, instead of using an implant [21]. Although this method is very uncommon, technological innovation could make this procedure easier to do.

Dentists can help to deal with depression by referring them to a program to stop using unhealthy coping mechanisms. Group based cessation programs should be used, as this increases chance of quitting from 50% to 130% [16]. With cough linctus syrup, a good piece of advice would be to immediately drink water after syrup ingestion to wash away sugar deposits. With depression, dentists have limited power in what they can do, as the reason for the depression is not usually due to the dentist, so normally referral would be the best step. In general, dentists and mental health specialists should be in closer contact. Social media would be pivotal to spread messages in order to fight against poor mental health and thus poor oral health.

Moving on to anxiety and stress, there is a lot for dentists to do in terms of helping the patient. Campaigns to reduce dental anxiety would be important to make people feel more comfortable, such as ‘#NoMoreDentalFear’ in order to reduce this anxiety [17]. Technology would be pivotal in the fight against anxiety, such as social media to spread awareness of how to reduce anxiety. The term reduce should be key here; dentists alone will not be able to stop mental illness, and helping those affected requires many organisations to work together. Laser dentistry is also a promising advancement to reduce dental phobia. It uses lasers to treat numerous conditions, and works by using lasers instead of conventional drills [18]. Water molecules absorb the radiation and vibrate more than other molecules, and so high water content substances (like tooth decay) are affected, whilst the rest of the tooth isn’t damaged. The lack of any noisy mechanisms would help to reduce dental anxiety, as one component of intimidation at the dentist ifs the ‘whirrr’ of the various drill bits and other dental instruments. Dr Andrew Thompson, a dentist in Portland, Oregon, suggests that just talking to a patient helps with reducing dental anxiety, as you get on the patient’s level and reduce the fear [19].

The eating disorders, like depression, are hard for the dentist to help to stop as the core of the problem is not the dentist. However, the dentist could help to create a more nurturing and caring environment for those affected. Restorative surgery would play a greater role, and hopefully if stem cell dental implants become less complex and more affordable for wider use. Advice could be given to reduce the damage on the tooth, such as drinking more water to dilute the vomit in the mouth, and taking calcium pills to maintain bone density. A study in bulimic women found that malocclusions (crooked teeth) were common [23], so the use of orthodontics could be used or even the more recent field of orthotropics. Orthotropics is a branch of orthodontics, which tries to use correct posture, breathing and positon of the tongue in the mouth to treat malocclusions and developing these treatments as habits to maintain aligned teeth after the treatment process, and looks holistically at the face, taking into account facial features such as if the chin is recessed, cheekbones and other indicators of proper facial development. Seeing as how a meta-study from Germany has claimed that there is no evidence that braces have health benefits for teeth in the long term, as teeth over time would become crooked again [28], it seems that orthotropic treatment could become more commonplace in the future.

To conclude, the dental profession can adapt itself in order to be more aware of mental problems and to aid in the fight against them, by reducing the fear around the dental practice, being more open with patients and also with the advent of new technologies that could indirectly help the mentally ill to get the best oral care possible. This research could cause beneficial changes in the dental industry so that patients receive better quality care, and is part of the movement showing that our oral health has implications in surprising places, and that dentistry should not be merely considered as ‘teeth cleaning’ . Moving onto to what I would cover if I was able to, I would look at mental health in dentists themselves, especially with burnout rates being extremely high [27], and how the dentist could mitigate this issue. Also, I think it would have been interesting to look at accessibility of dental care for the mentally ill, and look at how mental illnesses at severe levels affect dental health compared to mild illnesses (e.g. severe vs mild depression). This could have been done by looking at dental health in psychiatric wards, mental hospitals as well as other mental health facilities and institutions.

References

[1] https://www.mqmentalhealth.org/posts/depression-and-the-immune-system-expert-analysis (ACCESSED 14/3/19)

[2] https://www.medicalnewstoday.com/articles/323290.php (ACCESSED 14/3/19)

[3] Debora M. Rethinking Alzheimer’s. New Scientist (2/2/19 edition, pg6-7). (ACCESSED 7/2/19)

[4] J. Griffiths, V. Jones, I. Leeman, D. Lewis, K. Patel, K. Wilson, R. Blankenstein. Oral Health Care for People with Mental Health Problems Guidelines and Recommendations. (ACCESSED 14/3/19)

[5] https://www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/#.XKUpW5hKjIU (ACCESSED 14/3/19)

[6] https://www.sciencedirect.com/science/article/pii/S0163834314000139 (ACCESSED 18/3/19)

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3283937/ (ACCESSED 18/3/19)

[8] Johnson NW, Bain CA. Tobacco and oral disease. EU-Working Group on tobacco and oral health. Br Dent J. 2000;189:200–6. (ACCESSED 18/3/19)

[9] https://www.anxietyuk.org.uk/get-help/anxiety-information/frequently-asked-questions/ (ACCESSED 18/3/19)

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3908810/ (ACCESSED 18/3/19)

[11] http://toothbrushtech.co.uk/dental-phobia/ (ACCESSED 18/3/19)

[12] https://www.nhs.uk/conditions/anorexia/symptoms/ (ACCESSED 20/3/19)

[13] https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2012/spotlight-on-eating-disorders.shtml (ACCESSED 20/3/19)

[14] https://europepmc.org/abstract/med/1700561 (ACCESSED 20/3/19)

[15] https://www.futurelearn.com/courses/discover-dentistry/ (ACCESSED 20/3/19)

[16] https://www.cochrane.org/CD001007/TOBACCO_do-group-based-smoking-cessation-programmes-help-people-stop-smoking (ACCESSED 24/3/19)

[17] https://www.centrefordentistry.com/no-more-dental-fear-mhaw/ (ACCESSED 25/3/19)

[18] https://www.123dentist.com/laser-dentistry-what-is-laser-dentistry/ (ACCESSED 25/3/19)

[19] https://www.youtube.com/watch?v=SKvxQMjnJVQ&list=PL9bdcsEYw54gakkf6N3yrTTrz9Ap6FKAI&index=4 (ACCESSED 26/3/19)

[20] B. Goldsmith Ph.D, Talk About Your Problems, Please. https://www.psychologytoday.com/us/blog/emotional-fitness/201103/talk-about-your-problems-please (ACCESSED 26/3/19)

[21] S. Lin DDS, Will Stem Cells Replace Dental Implants? https://www.verywellhealth.com/will-stem-cells-replace-dental-implants-4147512 (ACCESSED 27/3/19)

[22] https://www.bioeden.com/uk/treatment/dental-treatments/ (ACCESSED 28/3/19)

[23] Woodmansey KF. Recognition of bulimia nervosa in dental patients: implications for dental care providers. Gen Dent. 2000;48:48–52. (ACCESSED 28/3/19)

[24] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. (ACCESSED 31/3/19)

[25] https://www.nhs.uk/conditions/clinical-depression/ (ACCESSED 31/3/19)

[26] P.N.Huntley. Orthotropics: Will we never be free? https://www.nature.com/articles/sj.bdj.2014.707

[27] E. Casals, Burnout among dentists in Catalonia (Spain) https://www.researchgate.net/project/Burnout-among-dentists-in-Catalonia-Spain (ACCESSED 1/4/19)

[28] https://www.thelocal.de/20190103/no-evidence-that-braces-have-health-benefits-for-our-teeth-german-health-ministry (ACCESSED 1/4/19)

Photo Credits due to: http://www.museumdental.ca/mentalhealth-dentalhealth

Sankeith Kirubakaran