Dental News - Hygienists have unique opportunity to provide high-value care to the severely mentally ill

Lisa Stillman, USA

Thu. 6 June 2013

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One in four families in the United States is affected by severe mental illness (SMI), a life-altering disease that can be especially difficult when it emerges just as an individual is beginning to discover the freedoms of adulthood — a common age at which symptoms first present. In addition to the psychosocial challenges faced by this population, many of these individuals also must confront a myriad of oral health issues that often end up being largely ignored — because individuals and families become overwhelmed by the chaos the illness typically brings into their lives.

With basic awareness of the unique needs of patients with an SMI, dental hygienists can play an important role in the effort to better meet not just the oral health care needs of this particularly vulnerable population — but also their overall physical and mental health needs. Three of the most likely mental illnesses that hygienists and other dental professionals should have a basic awareness of are schizophrenia, bipolar disorder and major depression (explained a more detail below).

Correct diagnosis often a challenge

The most important aspect for treatment of an SMI is getting the correct diagnosis. Because of overlapping symptoms, the stigma of receiving a diagnosis, medical privacy laws, civil rights protection for the mentally ill, and a continuing lack of insight by patients, families and society as a whole, individuals developing an SMI may go without treatment — or receive ineffective treatment for years.

At times medication is used to control symptoms before a correct diagnosis can be made.

Understand medication side effects

The health history is the biggest clue for the dental hygienist to consider to gain awareness regarding the possibility that a client is being treated for mental illness.

Some clients diagnosed with mental illness will neglect to state the nature of their illness but will list the medications that they are currently using. These medications will consist of antipsychotics, antidepressants, mood stabilizers, anti-anxieties, anti-epileptics and sleep aids. Other clients might have an SMI that has not been diagnosed, or they might have received a diagnosis, but they are not taking medications. Clues here might include a somewhat disheveled appearance, odd behavior and consistently poor oral hygiene.

People being treated for mental illness often are on several medications, which can cause severe xerostomia, resulting in high caries, erosion, tooth loss, mouth infections, loss of taste and difficulty in chewing and swallowing. Other side effects include bruxism and metabolic cravings for foods high in carbohydrates. The plaque index in patients with an SMI is often quite high, causing decalcification and severe sensitivity.

Smoking, substance abuse common

The need for thorough oral cancer screening is great because statistics show that SMI correlates with tobacco use, substance abuse and other high-risk behavior. General health disorders such as diabetes, high cholesterol, cardiac dysfunction, movement disorders and agranulocytosis are serious side effects that can be attributed to medications.

Individuals affected by SMI often do not seek oral health care services, exacerbating existing disease and leading to new oral-health problems. The dysfunction in such patients’ lives caused by the symptoms of the illness, financial distress, lack of family support and possible hospitalizations or incarceration can interfere with any opportunity to secure consistent dental care. When theses patients are finally able to see a dental health professional they might be extremely self-conscious about the deterioration of their mouth and concerned about facing disapproval — and fearful of that treatment might be painful.

Depending upon the severity and symptoms of the patient’s mental illness, the patient’s beliefs about teeth might be altered — and fall outside the realm of standard beliefs. For example, a client with paranoid schizophrenia may be so concerned about the microbes in his or her mouth that he or she brushes excessively, causing damage to teeth and supporting structures. Another patient with an SMI might believe that dental plaque is natural and should remain on his or her teeth. Delusional beliefs may interfere with compliance.

Handle altered perceptions

When treating a client with an SMI, dental hygienists need to be aware that hallucinations can cause apparent changes in a patient’s perception of touch, taste, sound, sight and smell — with increased or decreased sensitivity.

Topical anesthetics or dentinal anti-sensitivity medicaments may need to be applied for comfort prior to scaling. And special care is required when polishing with the prophy angle, because the vibrations generated may be interpreted as painful or extremely annoying. Using a soft toothbrush may be a better option. The taste of the polish offered should be appealing, otherwise consider substituting polish with fluoridated toothpaste.

For keeping the patient calm, the use of audio to muffle dental sounds can be helpful. It also can help to quickly discard gauze splattered with blood and debris and if possible keep dental instruments out of sight.

Although electric toothbrushes may be ideal for home-care use, some clients may have a low tolerance for the vibrations. Therefore, a manual toothbrush with a comfortable handle and grip may be a better choice. Sometimes relying on a Waterpik, oral rinses, home fluorides, remineralization pastes, probiotic lozenges, xylitol gum and mints may be the only real home care some members of this population will follow because of comfort, taste, smell and/or energy level.

People with an SMI might be extremely self-conscious and easily able to sense if their caregivers are comfortable administering treatment. It can be very important that when administering dental treatment to these clients that consistent eye contact is maintained and genuine interest is shown for their comments or concerns.

Be organized, upbeat, caring

Dental professionals should strive to have a keen understanding of these patients’ unique fears and follow a systematic approach in a well-organized, upbeat, and caring manner.

After evaluating the oral health needs — and understanding the impact of the illness itself on the patient’s thought process and behaviors — the dental hygienist can offer creative and thoughtful suggestions to motivate these dental clients.

Dental hygienists have a unique opportunity to offer not just oral care but to give these clients a safe and secure place to feel “cared for.”

Schizophrenia

Schizophrenia is a chronic, severe and disabling brain disease characterized by a disintegration of the process of thinking, emotional responsiveness and contact with reality and consists of a group of symptoms that show wide variations in disordered thinking, feelings and behavior.

One percent of the U.S. population is affected, primarily between the ages of 17 to 24 in males and 28 to 35 in females. The illness is universal in symptoms across all cultures. It is considered an epigenetic/genetic illness, which means if one carries the phenotype, certain environmental forces over time can cause the expression of those genes. These environmental forces can include: social stress, drug abuse, head trauma, infections and outside factors that can contribute to dysfunctional brain development. Each case is unique and depending upon severity of the symptoms, lifelong treatment can include: medication, hospitalization, psychotherapy, cognitive therapy, job coaching and alternative housing.

Bipolar disorder

Bipolar disorder is a medical illness that causes extreme shifts in mood, energy and functioning. These changes may be subtle or dramatic and typically vary greatly over the course of a person’s life as well as among individuals.

More than 10 million people in the United States have bipolar disorder, and the illness affects men and women equally. Bipolar disorder is a chronic and generally lifelong condition with recurring episodes of mania and depression that can last from days to months that often begin in adolescence or early adulthood — and occasionally present even in children. While medication is one key element in successful treatment of bipolar disorder, psychotherapy, family support and education about the illness are also essential components of the treatment process.

Major depression

Major depression is a serious medical illness affecting 15 million American adults, or approximately 5 to 8 percent of the adult population in a given year.

Unlike normal emotional experiences of sadness, loss or passing mood states, major depression is persistent and can significantly interfere with an individual's thoughts, behavior, mood, activity and physical health.

Among all medical illnesses, major depression is the leading cause of disability in the United States as well as in a number of other developed countries.

(Sources: National Institute of Mental Health; National Alliance on Mental Health)

Note: This article was published in Hygiene Tribune U.S. Edition, Vol. 6 No. 3, April 2013 issue.

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