The intricate relationship between oral health and overall well-being continues to garner significant attention. While many understand the connection between oral health and systemic conditions, such as diabetes and cardiovascular disease, the link between oral health and mental health, particularly depression, is often overlooked. Dental professionals must recognize and address the bidirectional relationship between oral health and depression to provide comprehensive care to our patients.
Signs and symptoms of depression
Nearly 40% of people struggle with depression.1 Depression is characterized by symptoms that last for most of the day or at least two weeks. Symptoms include feeling sad, anxious, empty, hopeless, pessimistic, irritable, frustrated, or guilty. Decreased energy, fatigue, loss of interest, difficulty sleeping, oversleeping, or waking up early are also signs of depression, and another is losing interest in things that once brought pleasure.2
Types of depression
There are many types of depression. Major depression includes a depressed mood or loss of interest for at least two weeks, which makes the individual unable to complete daily activities. Persistent depression consists of less severe symptoms but persists for at least two years. Perinatal depression occurs during or after pregnancy. Seasonal affective disorder (SAD) comes and goes with the seasons, with symptoms typically starting in the late fall and early winter and resolving in spring and summer. Depression with symptoms of psychosis is a severe form where a person experiences hallucinations or delusions. Bipolar depression involves depressive episodes where the person feels sad or hopeless, and manic moods where the person feels elevated or "up."2
Depression and oral health: The bidirectional relationship
Depression and oral health are interconnected in several ways, creating a vicious cycle that can be challenging to break. Those suffering from depression, despite their desire to partake in personal hygiene such as brushing their teeth or showering, can lack motivation or feel exhausted. Understanding this bidirectional relationship is essential for dental professionals to provide a customized approach to partner with the patient and devise a patient-specific routine, which is a critical aspect of prevention.
Impact of depression on oral health
Depression can lead to oral hygiene neglect, resulting in poor oral health outcomes. Individuals with depression may experience:
Decreased motivation: Depression can reduce the motivation to perform daily oral hygiene routines. This can increase the risk of hard and soft tissue diseases.3
Poor nutrition: Depression can affect appetite and dietary choices, often leading to a preference for sugary and carbohydrate-rich foods. Such a diet can increase the risk of dental caries and exacerbate existing oral conditions.
Dry mouth: Many medications used to treat depression can cause reduced salivary flow, resulting in xerostomia (dry mouth). Saliva is essential for maintaining oral health as it helps to neutralize acids, wash away food particles, and provide antimicrobial protection. A decrease in salivary flow and buffering capacity can lead to an increased risk of dental caries and oral infections. Studies demonstrate that stress, anxiety, and depression influence the unstimulated salivary flow rate and lead to hypofunction of the salivary glands.4
Bruxism: Depression and anxiety are often associated with bruxism, which can lead to tooth wear, fractures, and temporomandibular joint (TMJ) disorders.
The role of dental professionals
DeWitt Wilkerson, DMD, describes clenching and grinding as an abnormality that can be a sign of airway dysfunction. Chronic obstructive airway disease (COPD) is associated with depression. An overlap of COPD and depression may cause poor quality of life and an increase in mortality.5 One study found that 46% of patients with obstructive sleep apnea also have depressive symptoms.6
Clinical assessment: When dental professionals evaluate patients, we should assess for signs and symptoms of airway dysfunction and breathing disorders. Patients with a neck circumference greater than 16 inches, Mallampati score greater than 2, scalloped tongue, 40% tongue restriction, nasal stenosis, and a reduced skeletal profile are at higher risk for sleep apnea. Identifying signs and symptoms provides us with an opportunity to refer patients to ENTs and their physicians for referrals to sleep studies and assessments for myofunctional therapy.
Routine screening: Incorporate mental health screening questions into patient assessments. Asking about changes in mood, interest in daily activities, and any recent mental health diagnoses can provide valuable insights into a patient's overall well-being.
Open communication: Create a safe and nonjudgmental environment for patients to discuss their mental health. Encourage patients to share any concerns or challenges they may be facing, including those related to oral hygiene practices.
Patient education and motivation
Patient education: Educate patients on the bidirectional relationship between oral health and depression. Highlight the importance of maintaining good oral hygiene practices and how it can positively impact their mental health. Identify specific ingredients such as stabilized stannous fluoride that offers a 12-hour substantivity, implementing xylitol into their everyday routine, dry mouth products like sprays, gels, or mints, Recaldent technology, fluoride therapies, and hydroxyapatite.
Identify the high-risk habits of the patient when their depression is strongest. For example, I ask patients what they find themselves consuming the most when they’re depressed. If it’s a high-sugar and sticky candy such as Skittles, I advise them to eat a piece of cheese afterward or rinse with water. I tell them that I would rather they eat a sweet that can melt off the surface of their molars rather than a tacky, sticky sweet.
Suggest certain drinks at meals only: Many of us love to sip on beverages such as coffee, wine, or seltzer. When a patient has xerostomia, their buffering capacity is often restricted. Therefore, they should limit the duration and consume these drinks with meals. When possible, drinking alkaline water will help to reset the oral cavity's pH. Additionally, the pH of oral rinses should be considered.
Motivational interviewing: Use motivational interviewing techniques to empower patients to actively participate in their oral health care. Help them set achievable goals and provide them with positive reinforcement to encourage adherence to oral hygiene routines. Determine what time of day is hardest for them and create an oral care plan. For instance, if the patient struggles the most at night, suggest that they implement their preventive oral regimen directly after dinner. Not only will this reduce snacking, but if they fall asleep on the couch, they won't miss brushing before bedtime.
The connection between oral health and depression underscores the importance of a root-cause approach to patient care. As dental professionals, we must recognize the bidirectional relationship between these two aspects of health and take proactive steps to address the oral health needs of patients with depression. By doing so, we can improve not only their oral health but also their overall well-being and quality of life.
Editor's note: This article appeared in the Aug/Sept 2024 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
- Panchal N, Saunders H, Rudowitz R, Cox C. The implications for Covid-19 for mental health and substance use. KFF Researchers. March 20, 2023. Accessed October 23, 2023. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
- Depression. National Institute of Mental Health. U.S. Department of Health and Human Services. Accessed October 23, 2023. www.nimh.nih.gov/health/topics/depression
- Sundararajan S, Muthukumar S, Rao SR. Relationship between depression and chronic periodontitis. J Indian Soc Periodontol. 2015;19(3):294-296. doi:10.4103/0972-124X
- Gholami N, Hosseini Sabzvari B, Razzaghi A, Salah S. Effect of stress, anxiety and depression on unstimulated salivary flow rate and xerostomia. J Dent Res Dent Clin Dent Prospects. 2017;11(4):247-252. doi:10.15171/joddd.2017.043
- Chaisuksant S, Suwannatat P, Sawanyawisuth K. Prevalence and risk factors of depression in patients with chronic obstructive airway disease: a tertiary care hospital, outpatient setting. Multidiscip Respir Med. 2024;19(1):951. doi:10.5826/mrm.2024.951
- Rezaeitalab F, Moharrari F, Saberi S, Asadpour H, Rezaeetalab F. The correlation of anxiety and depression with obstructive sleep apnea syndrome. J Res Med Sci. 2014;19(3):205-210.
