The past two years has seen the world ravaged by the Covid-19 virus.
As of today (3/8/2022), the World Health Organization reports over 6 million deaths from this virus. Since the beginning of the outbreak, governments throughout the world mandated mask restrictions and quarantines to prevent continued transmission of this virus. As a result of the quarantines and isolation, mental health has taken a brief spotlight. There are certain aspects that dental clinicians must consider when treating patients with mental health issues and especially depression.
Major depression is a psychiatric disorder in which mood, thought content, and behavioral patterns are impaired for long periods of time (1). One in every five patients who visits a dentist experiences clinically significant symptoms of depression (2). I would like to note that not all patients with depression present with the typical oral manifestations of severe depression and there are many types of depression that exhibit varying degrees and types of oral symptoms.
It (depression) may be associated with a disinterest in performing appropriate preventive oral hygiene techniques, a cariogenic diet, diminished salivary flow, rampant dental decay, advanced periodontal disease, erosive oral lichen planus, and oral dysesthesias (1, 4). Patients with major depression may present with rampant decay and periodontal disease from unintentionally neglecting their teeth or as a side effect of the psychiatric medication used to treat the depression. Antidepressants, anticonvulsants, anxiolytics, antipsychotics, anticholinergics, and alpha agonists can cause xerostomia (dry mouth). The risk of salivary hypofunction increases with polypharmacy and may be especially likely when ≥3 drugs are taken per day (5).
Comorbid depression and anxiety are associated independently with 6+ teeth removed compared with 0-5 teeth removed in a national study conducted in United States (3). It's certainly been my experience that new patients with depression sometimes present with several non-salvageable decayed teeth or have periodontally hopeless teeth requiring multiple extractions. In a small number of cases, the patient needs or requests full mouth extractions and dentures.
Another consideration with depressed patients is their pursuit to feel “normal”. This may include self-medication, sometimes, with illicit drugs such as methamphetamines, cocaine, heroin, LSD, ecstasy, etc. Use of these drugs have their own detrimental effect on the mouth and may be a future blog topic.
The clinical considerations are removing the diseased hard tissue that can’t be saved, replacing the missing teeth, treating specific disease entities, recommending frequent dental visits, using saliva substitutes and adding extra fluoride (perhaps, using fluoride trays).
Clinical considerations when treating patients with depression is to review their medication list for drug-drug interactions and the impact of narcotic analgesics and local anesthetics.
In the dental world, compassion, privacy, and understanding in a nonjudgmental way should be the norm. If a person has uncontrolled major depression, what’s paramount to dental treatment is the patient receiving proper mental health care. It can be an uncomfortable topic, but encourage them to seek a referral from their primary care manager or find a mental health professional on their own. Patients may be reluctant to search for help, but persistence in a strictly confidential manner with feedback from the patient may not only show them you care but give them the boost they need to seek the help. Please note, it may take several attempts and even then, it may be unsuccessful.
1. Oral Surg Oral Med Oral Pathol. 1991 May;71(5):573-8. doi: 10.1016/0030-4220 (91)90365-j.
2. J Mich Dent Assoc. 2003 May;85(5):26-32.
3. Community Dent Oral Epidemiol. 2015 Oct;43(5):433-43. doi: 1111/cdoe.12168. Epub 2015 May 13.
4. Clin Oral Investig. 2018 Nov;22(8):2685-2702. doi: 10.1007/s00784-018-2611-y. Epub 2018 Sep 6.
5. Psychotropic-induced dry mouth: Don’t overlook this potentially serious side effect. Current Psychiatry. 2011 December;10(12):54-58