Your NHS dentistry and oral health update

Tuesday 9th November 2021 (Issue 32)

Special focus: Dentistry and patients with mental illness 

An update from Sara Hurley and Tim Kendall

Dear colleague,

It is an unacceptable fact that people with mental ill health are disproportionately affected by poor oral health. The international evidence is pretty stark, with the impact being both indirect (people with severe and enduring mental illness experiencing poorer oral health as a result of delayed treatment, access issues etc) and direct (the harmful effect of some symptoms of mental illness affecting oral health such as self-induced vomiting):

• People with mental illness are less likely to engage with oral healthcare, with a study finding that only 75% of schizophrenia patients brushed their teeth daily, compared to 96% in the general population.
• Poor mental health is often linked to other factors such as homelessness or substance use, which also have consequences for oral health.
• In a meta-analysis of studies, patients with severe mental illness were almost 50 times as likely to have periodontal disease;
• Patients with eating disorders had five times the odds of dental erosion. In patients with self induced vomiting, the erosion rate was seven times higher.

It is true that providing oral care for patients with severe mental illness (for example psychosis, schizophrenia, bipolar disorder) is not straightforward. However, through the use of tailored outreach and a trauma-informed approach to supporting people with SMI - by providing an environment where a person who has experienced trauma feels safe and can develop trust - there is an opportunity to better engage with this group and, in doing so, improve oral health outcomes.

Dentistry is an important part of helping patients with mental illness improve their health and quality of life. Living with toothache or unsightly teeth can increase the risk of social isolation, lower a person's self esteem and / or create communication problems. For people with a mental illness this can be a barrier to their recovery. People with a mental illness are also affected by later cancer diagnosis and higher mortality rates, so dentistry can play an important role in addressing this health inequality - more information is included in our special focus bulletin on mouth cancer.

Understandably, not all of this can be down to the dental professional to address, but NHS dental teams can do a great deal to make a dental appointment a better experience for the patient by working with them to put reasonable adjustments in place. This might include minimising noises, distractions and the number of people in the room, or supporting the patients with specific coping mechanisms. Further detail on safety and wellbeing adaptations and techniques is included below.

For years we have campaigned to put the mouth back in the body. We hope that today's bulletin is a useful reminder to think of the mind, too.

Best wishes,

Sara and Tim

Oral health inequalities for people with a mental illness

Common oral health conditions for those with mental ill health

Mental health is influenced by the conditions people are born into, grow up in, live and work in. Everyone copes with and experiences mental ill health in a different way, nobody is the same. But the evidence suggests those who experience mental illness are disproportionately affected by poor oral health.

Some of the most common mental health problems are anxiety and panic attacks, depression, eating disorders, obsessive-compulsive disorder, and self-harm. All of these can have a negative impact on a person’s oral health.

According to the Oral Health Foundation, the following are common issues for people with a mental illness:

• Neglect: People with mental illnesses tend to avoid dental care to the extent that their oral hygiene is neglected. This can result in gum disease and tooth decay.
• Anxiety: This can be linked to dental phobia and as a result, people stop seeing their dentist regularly.
• Eating disorders: If a person has a condition such as bulimia, they will often experience dental erosion from the acidity in vomit, and they are likely to have low levels of calcium, which is important for healthy teeth. 
• Brushing actions: Over-vigorous brushing actions can result in brushing away the enamel on the surface of the tooth.
• Medication: Some medications can result in adverse oral effects, for example dry mouth as a result of reduced saliva flow.
• Smoking: Smoking rates are three times higher than the general population.

Additional oral health inequalities for those with severe mental illness (SMI)

People with serious mental illness (SMI) experience some of the worst inequalities in oral health. These oral health inequalities mirror the stark social and physical health inequalities experienced by this vulnerable group.

Recent evidence syntheses highlighted the burden of oral diseases in people with SMI, who have significantly higher levels of tooth decay, periodontal disease and tooth loss than the general population and their counterparts with less severe mental illness. People with SMI also have higher mortality rates of different types of cancers (including oral cancer). 

This burden of oral diseases in people with SMI has serious impacts on their mental and physical health. For example, dental conditions were the fourth most common reason for avoidable hospital admissions in people with psychiatric disorders. 

Patients with SMIs are at an increased risk of oral disease, including:

• Periodontal disease and caries;
• Oral cancer due to tobacco and alcohol misuse;
• Tooth surface loss due to over vigorous brushing;
• Oral candidiasis;
• Temporomandibular joint dysfunction;
• Facial pain;
• Bruxism.

Patients with SMIs may be at risk of developing the following oral side effects of medication used for treatment of mental illnesses:

• Xerostomia;

• Dyskinesia and dystonia – abnormal involuntary movements of tongue, or facial muscles sometimes associated with abnormal jaw movements. It not only results in poor oral health but may also cause difficulty in breathing.

Awareness of the signs of mental ill health and when to refer to CDS or specialist services

Awareness of mental ill health

First and foremost, dental teams should aim to create a culture of inclusion where a patient feels comfortable explaining that they may have a mental health condition. 

According to the British Society for Disability and Oral Health, it is important to be aware that the following oral symptoms may be the first manifestation of a mental health issue and to adapt the treatment plan according to the advice below:

• Facial pain (can also be linked with depression);
• Preoccupation with dentures;
• Excessive palatal erosion due to bulimia;
• Self-inflicted injuries;
• Temporomandibular joint dysfunction.

It is also important to be aware that mental health issues are more prevalent in patients with long term health ailments:    

• Asthma;
• Diabetes;
• Hypertension;
• Coronary heart disease;
• Stroke;
• Chronic Obstructive Pulmonary Disease;
• Obesity;
• Additional needs/learning disabilities.

In some cases it may be appropriate to liaise with a patient's GP or medical team.

Referral to NHS Community Dental Services or Specialist Services

It is important that practices make every effort to help patients be seen in general dental services. However where necessary you should refer patients to your local Community Dental Service (CDS) or Special Care Dentistry Service, as per local protocols. If you are unsure of how to do this or your local referral criteria please contact your commissioner or Local Dental Network Chair.

If you are unsure of if a patient should be referred to CDS or Special Care, or you would like advice on treating the patient, please contact your commissioner and Local Dental Network Chair. 

Following the effects of COVID-19 be aware that waiting list times may have increased for CDS, Special Care Dentistry, level 2 and tertiary referral services. Make sure referrals are appropriate for the given service, contact local services so you are aware if their waiting times and be prepared to manage urgent dental issues and provide preventative advice and recall as indicated.

While awaiting referral, dental professionals may share the following resources with patients if they believe it would be helpful for the patient's understanding:

• Oral Health Foundation's commonly asked questions on dental care for those with special needs
• NHS web pages on fear of the dentist 

• Share NHS advice and support pages on accessing mental health support

• The NHS' blog on what to do if you're a young person with an eating problem

Barriers to care and key principles on treating patients with mental illness in primary dental care 

Barriers to accessing dental care

People with mental illness may struggle to access dental care as a result of the following barriers:

• Past trauma

• Lack of self-care;

• Difficulty accessing health services;
• Prior negative experience with healthcare providers;
• Fear, anxiety and phobia;
• Low priorities for oral health;
• Values and expectations of staff not matching that of service users: staff may unintentionally react negatively to patients with mental illness attending the surgery;
• Patients with no fixed address: Dental practices able to take on new NHS patients may wish to be aware that should their care be sought by a patient of no fixed abode, they are able to claim reimbursement in the usual manner by entering the practice’s address as the patient’s address on Form FP17. The NHS Business Service Authority also requires that a note of having done this be added to the patient’s dental records.

Pre-appointment checks and oral health care plans 

Plans should also take into account the following: 

• Risk based recall – due to increased risk to oral disease recall intervals may be shorter
• Patients with mental illness tend to have a high risk of cancelling appointments – discuss with your patients’ effective appointment reminders and motivational prompts to encourage regular attendance

Practices should provide oral health care plans to motivate daily changes to oral care. These should:

• Formulate achievable targets to improve oral care in line with Delivering Better Oral Health;
• Involve patient’s family and friends to provide support;
• Recognise that some patients do not have a social network for support - the dental team has a key role in social prescribing to support these patient;
• HEE e-learning module on social prescribing available here.

Safety and wellbeing adaptations and techniques

Dental care professionals should work with the patient (and / or their carers) to identify what would help them to feel comfortable in the dental setting, which may include, but is not limited to:

• Minimising noises and distractions;

• Limiting the number of people in the room;
• Detailed information on what can be expected during treatment;
• Stop signals and other control mechanisms;
• Use of specific coping mechanisms such as listening to music, breathing, mindfulness;
• Close liaison with the patient’s healthcare team to identify any changes in medication which may have an impact on the patient’s ability to engage with dental care, and conversely to identify to the care team if you have noticed any change in the patient’s symptoms which might indicate an exacerbation of their mental illness;
• The use of pharmacological methods including sedation and general anaesthesia to make treatment more comfortable.

Contingency plan for those with Severe Mental Illness

If possible, have a contact number (with consent by the patient) as a point of contact should they feel that it would be in the best interests of the patient to inform them of a relevant change in the patient’s behaviour / condition.

Also liaise with their GP / Specialist for updates on relevant changes from the psychiatric / medical team’s viewpoint which may impact on the treatment or reasonable adjustments during a dental appointment.

You can also get help from NHS111, the patient’s GP or Samaritans. Mind.org provides further advice.

Please see here for link to further support services.

Advice and resources for communicating with patients 

General advice for those with mental ill health

Practices can provide the following communication to support patients with mental ill health:

• Continue motivating patients towards good dental habits and encouraging them to exercise them on a daily basis;

• Information which aims to reduce fear of attendance and provide clear information about dental charges;

• Promote good general and oral health, highlighting the mental health benefits of healthy eating, regular exercise, dental hygiene and the harmful effects of smoking, drinking and drug use.

Keeping your teeth in mind: a guide for people experiencing psychosis and those who care for them

Right from the Start: Keeping Your Teeth In Mind is a resource to improve the oral health of people experiencing psychosis. 

Advice for those in a mental health crisis 

There are 24/7 crisis lines available in England if you, or someone you love, is having a mental health crisis. These crisis lines are available to people of all ages, and you can find your local helpline on nhs.uk.

You can also talk to your GP by giving your GP practice a ring – and you can ask to speak to a GP who you know or trust. You can also speak to your hospital / community doctor or nurse, if you have one, who looks after you.

Remember, if you feel immediately unsafe and it is an emergency, you can call 999. But this might not be the right thing for you, which is why there are a range of options available.

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Previous NHS dentistry and oral health bulletins 

Previous bulletins can be accessed by clicking on the links below:

NHS primary care bulletin

The NHS primary care bulletin provides resources on health policy and practice and we encourage you to sign up for this, too. It is aimed at teams across general practice, dentistry, community pharmacy and optometry. 

COVID-19 advice, guidance and resources

Communications resources for NHS dental practices

Click on the links below to view and download useful communication resources:

• Click here for social media image cards and patient leaflets
• Click here for social media assets and posters explaining IPC requirements
• Click here to download website/social media copy and scripts for answer machine message, text message and emails.

NHS updates to the profession 

Key letters from the Chief Dental Officer and the NHS dentistry and oral health team are online here. 

Transition to Recovery: Dentistry's standard operating procedure

The latest version was published on Friday 16 July 2021. Changes to the previous SOP are in yellow. You can read the SOP online here. 

COVID-19: infection prevention and control dental guidance

The guidance is an appendix to and should be read in conjunction with the national guidance on infection prevention and control for COVID-19 . You can read the general guidance and the specialist dental appendix online here.

Avoidance of doubt note: provision of phased treatments

This document is to support dental professionals, and to clarify where it might be appropriate to provide phased treatment spanning over several courses of treatment (CoT). You can read it online here.

Health and wellbeing support