Dental Voices For Mental Health

Low Level Of Dental Awareness Persists For Those With Mental Illness

By Lisa Stillman, RDH, BS

When I grew up in suburban Maryland and spent my summers on the Rappahannock River in Virginia, I believed that if you lived your life “right” and “tried” to follow the golden rule, you would avoid “bad” things happening to you. I grew up in an idyllic family environment and expected to create that for my children. I was under the mistaken impression that bad things happen to people due to lack of good judgment, and as long as I used good judgment, my family and I would escape serious issues and the stigmas attached to them.

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That was my barometer, my way of measuring my success at being a parent and person. But guess what? I’ve learned differently, and I can thank my son Jordan for that. He brought to my attention just how “judgmental” I was. He slowly opened my mind to realize that I was creating a sense of false security, which caused me to unfairly judge parents for their children’s poor choices. His pain and suffering due to a mental illness taught me that bad things can happen to anybody, and I believe we’re here to learn lessons from life’s challenges, and we can share those lessons with others. It has taken me a long time to want to sit down and write this article, but I feel Jordan is encouraging me with the hopes that it may help others.

When Jordan was 19, I was divorced and living in Damascus, Maryland, with his older and younger sisters. We were all very concerned about Jordan and the changes in his behavior. He started exhibiting great fears, likes, and dislikes. He related these changes to epiphanies that would come to his mind and could be quite convincing when he explained them. Little by little his behavior changes started to affect his health, work, and ability to concentrate in school. Socially his life changed, and he dropped out of his usual social circle and became isolated, or was drawn to people he felt more comfortable with, which became problematic.

His older sister was convinced he was exhibiting symptoms of schizophrenia, something she’d just learned about in Psychology 101. This was not something I wanted to believe. I knew we needed professional help, but where could we find it? The psychiatrist and social workers I knew did not have experience with severe mental disorders, and they initially believed he was fine once they talked to him face-to-face. I was relieved to hear that! Then he stopped eating and drinking and lost 40 pounds in just a few weeks.

We forced him to get treatment through the courts, and that was the beginning of a long journey for our family, navigating the mental health world without a compass. All areas in his life were being negatively affected, and to my horrific dismay, even his teeth were deteriorating! This was not Jordan’s expectation of how his life should be, and I pleaded with him to hang in there with my efforts to help him for as long as possible. After all, he had always been our inventor, mechanic, problem solver, and helpmate in any project. He was going to be a rocket scientist like his grandfather! I kept hoping that his medical specialists would make the correct recommendations for Jordan’s medications and brain therapy. He gave me five years of his love while he grappled with the pain and agony, until he felt that he no longer needed to be here and he ended his life.

So I am now following his trail and teaching others about severe mental illness through this wonderful community of dental hygienists and dentists, and anyone else who wants to listen.

We are just one of many families faced with this same difficult path. Today, one out of four families has someone suffering with a severe mental illness (SMI) diagnosis of schizophrenia, bipolar disorder, or chronic depression. I learned this statistic when I attended CareerFusion in 2008 to learn how to combine my passion for mental illness with dental hygiene to teach others. Out of 50 participants, 25% had a son or daughter dealing with SMI. That was quite shocking to everyone in the room.

Thanks to the open-mindedness and support of CareerFusion, PennWell, Sunstar, RDH/UOR, Xlear, Inc., and GC America, I’ve been able to follow this path of teaching with the intent of bringing healing and understanding to all whose lives are touched by mental illness. At the 2012 RDH/UOR meeting in Las Vegas, Noel Kelsch, RDH, spearheaded the dental impact all-day seminar featuring “Mental Illness and Dental Hygiene.” This was the first of its kind. Little by little mental illness is becoming a subject that we can talk about openly and learn about, and through this effort reduce the stigma and fear associated with our patients’ SMI diagnoses.

Until recently, severe mental disorders or mental illnesses were barely mentioned. Folks diagnosed with a mental illness and their families endured severe scrutiny and stigma. Treatment was a mystery, and the mentally ill were institutionalized, hidden in homes with relatives, or left homeless. Treatment currently offers the majority of people with SMI a chance at being able to live functional lives. Yet unfortunately, this population’s mental health and general health needs overshadow the need for dental care with limited access.

There are few government funds or volunteer services available for dental care, and there is a low level of dental health awareness for those with mental illness. Combine this with the harsh medications, mental health symptoms, and other health issues, and it becomes an impossible dental feat to tackle when a patient is recovering and working to pick up his or her life. Therefore, through education and understanding, hopefully dental professionals will be more cognizant of these folks’ dental needs and will create more dental programs to serve them.

The following provides an overview of schizophrenia, bipolar disorder, schizoaffective disorder, and chronic depression, and the effects these illnesses have on the mouth.

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. (NIMH) A person with this disorder may experience hallucinations, delusional thinking, disorganized speech, cognitive impairments, and loss of emotion, joy, and motivation.

One percent of the population is affected, primarily from the ages of 17 to 24 in males, and 28 to 35 in females, and symptoms are the same in all cultures. It is considered an epigenetic/genetic illness, which means that if one carries the phenotype, certain environmental forces such as social stress, drug abuse, head trauma, infections, and dysfunctional brain development can cause the expression of those genes. Each case is unique, and depending on the severity, lifelong treatment may 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 and among individuals. Over 10 million people in America have bipolar disorder (3%), and the illness affects men and women equally. Bipolar disorder is a chronic and generally lifelong condition (see related article on types of bipolar disorders) with recurring episodes of mania and depression that can last from days to months, and they often begin in adolescence or early adulthood and occasionally in children. While medication is a key element in successful treatment of bipolar disorder, psychotherapy, support, and education about the illness are also essential components of the treatment process. (NAMI.ORG)

Schizoaffective disorder

A person diagnosed with this exhibits symptoms of schizophrenia and mood disorder simultaneously. This disorder is more difficult to treat, has poorer prognosis, and less is known about this disorder. Long-term therapy involving medication and psychosocial interventions is helpful.

Major Depression

Major depression is a serious medical illness affecting 15 million American adults, or approximately 5% to 8% of the adult population. Unlike normal emotional experiences of sadness, loss, or passing moods, major depression is persistent and can significantly interfere with a person’s thoughts, behavior, mood, activity, and physical health. Among all medical illnesses, major depression is the leading cause of disability in the U.S. and many other developed countries. (NAMI.ORG)

Correct Diagnosis

The most important aspect for treatment is getting the correct diagnosis. Due to the overlapping of symptoms, stigma, HIPAA, civil rights, and lack of insight, clients developing SMI may go without treatment or be given the wrong treatment for many years. Medication is often used to control symptoms before a diagnosis can be made, which amounts to diagnosing through a process of elimination of symptoms.

Medication/Side Effects

The health history is the biggest clue for the dental hygienist to determine if a client is being treated for mental illness. Some clients with diagnosed mental illnesses will neglect to state the nature of their illness, but will list the medications they’re currently using. These meds will consist of antipsychotics, antidepressants, mood stabilizers, anti-anxieties, anti-epileptics, and sleep aids. Other clients with SMI that are not diagnosed or are taking medications may appear somewhat disheveled, with odd behavior and consistent poor oral hygiene.

Most people treated for mental illness are on several medications, which causes severe xerostomia and results in high caries, erosion, tooth loss, mouth infections, loss of taste, and difficulty chewing and swallowing. Other side effects include bruxism and metabolic cravings for foods high in carbohydrates. The plaque index is usually very high, causing decalcification and severe sensitivity. General health disorders such as diabetes, high cholesterol, cardiac dysfunction, movement disorders, and agranulocytosis are serious side effects caused by these medications.

The need for a thorough oral cancer screening is great because people living with mental illness have a high rate of smoking. A study by The Journal of the American Medical Association reported that individuals who live with mental illness or substance abuse disorders consume 44.3% of all cigarettes in America. This means that people living with mental illness are about twice as likely to smoke as other persons. (NAMI.ORG)

Individuals affected by SMI often do not seek oral health care services, thereby developing new oral health problems and exacerbating existing disease. The dysfunction in their lives caused by the symptoms of illness, financial distress, lack of family support, and possible hospitalizations or incarceration interferes with any kind of consistent dental care program. When they do finally see dental health professionals, they are usually very self-conscious of the deterioration of their mouths and they fear disapproval and pain.

Depending on the severity and symptoms of their mental illness, standard beliefs about teeth may be altered. For example, clients with paranoid schizophrenia may be so concerned about the microbes in their mouths that they brush excessively, causing damage to their teeth and supporting structures; whereas others may believe that the dental plaque is natural and should remain on their teeth. These delusional beliefs may interfere with compliance.

When treating the dental patient with mental health impairments, the dental hygienist should be aware that hallucinations cause change in the perception of touch, taste, sounds, sight, and smell. The use of topical anesthetics or dentinal antisensitivity medicaments for comfort prior to scaling may be needed. Special care is required when polishing with the prophy angle, as patients may interpret the vibrations as painful or extremely annoying. Using a soft toothbrush may be a better option. The taste of the polish should be appealing; otherwise consider substituting with fluoridated or xylitol toothpaste. The use of audio to muffle dental sounds is helpful to keep patients calm. 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, the mental health population 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 chewing gum, or xylitol mints may be the only real home care some members of this population will follow, due to comfort, taste, smell, or energy level.

Mental health care recipients are often very intuitive and know if their dental hygienists are comfortable administering treatment. It is very important when administering dental treatment to these clients that the hygienist maintain consistent eye contact, listen to their comments or concerns with genuine interest, strive for a keen understanding of their 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 on the 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 be cared for.

How can a dental hygienist be a dental voice for mental health? Through outreach!

The Dental Hygiene Coalition for Mental Health is a dream of mine that is yet to be defined. But with enough interest generated through articles, education, and time, it may be realized. In the meantime, as a dental hygienist you can visit mental health facilities, group homes, drop-in centers, and advocacy groups to talk about oral health. If inclined, find out about your local NAMI affiliate (National Alliance for Mental Illness), and be available as a consultant for dental issues. The ADHA and NAMI organizations are parallel in structure, and it would be wonderful if each ADHA component had an oral health liaison for each NAMI affiliate. These are just some ideas bouncing around in my head. Please share yours. I would love to hear them!

Getting back to Jordan and his short 24 years. His life was about love and helping others. I’ve learned that everything has a purpose, and I will keep following his trail! RDH

Types Of Bipolar Disorders

Bipolar I disorder

• At least one period of acute mania and at least one severe depressive episode
• Episodes have a tendency to be either more mania or more depression
• Men usually start with mania and women with depression

Bipolar I disorder mixed

• More common
• People display symptoms of mania and depression simultaneously
• “Hyped up” depression, anger, sadness
• Risk of suicide high because of “energized” state of despair

Bipolar II disorder

• Recurrent severe depressive episodes that swing into hypomanic episodes
• More common in women
• Do not become psychotic and either overlook periods of hypomania or interpret them as “feeling great”
• Seek treatment solely for depression, which puts them at risk
• An antidepressant taken alone can trigger a manic attack or cause more frequent cycles

Rapid cycling

• The occurrence of four or more mood episodes during a 12-month period
• Occurs mostly in women
• Can arise at the onset of illness, but more typically occurs as an illness progresses
• A rare and more chronic form of this is called ultradian cycling, where mood fluctuations occur many times a day (children)
• Can be triggered by antidepressants

LISA STILLMAN, RDH, BS, is the Northeast Xylitol Educator for Wasatch Sales Force and a practicing dental hygienist in Rockville, Md. for periodontist Dr. Steven Rice. Lisa created an organization called “Dental Voice for Mental Health” to broaden the understanding of the connection of oral health and mental health. She presents courses to her peers at local, state and national venues concerning severe mental illness and oral health. Lisa organizes oral health booths for the NAMI National Alliance for the Mentally Ill (NAMI) and visits mental health facilities to educate mental health professionals, caregivers, and care receivers the importance of oral health.