Caring for dental hygiene patients with depression and anxiety
Clinicians should consider the link between oral and mental health.
Samantha T. Verdadero, BSDH, RDH
I’ve always known that my passion in life was to help people. When I was 15 years old, I started volunteering with my local first-aid and rescue squad, and by the age of 17 obtained my emergency medical technician (EMT) certification. During the six years I served with my rescue squad, I saw a variety of medical emergencies, including life-threatening ones. Learning patient care as an EMT helped me prepare for patient care as a dental hygienist. It taught me the importance of obtaining a medical history and knowing what to ask during a medical history evaluation. My duty as a dental hygienist is to prevent dental emergencies by offering preventive solutions for my patients.
A few years ago, I met a man I will call Frank. We hit it off, but what I didn’t know about him—and what I was oblivious to—was that he suffered from depression and had a history of suicide attempts. We were the same age, shared a lot of common interests, and even dated for a brief period. As I got to know him, I started to notice things that he would say or do that seemed “off” and often concerning. He would be in a great mood one week, and the next week would ask me if I would like him even more if he changed something about himself. There was never anything about Frank I thought needed to be changed until he became more comfortable with telling me about his depression and suicide history.
Depression is a common mental disorder. Globally, more than 300 million people of all ages suffer from depression.1 In a survey done by the Substance Abuse and Mental Health Services Administration in 2017, it was estimated that 4.4 million young adults age 18 to 25, 7.6 million adults age 26 to 49, and 5.2 million older adults over the age of 50 have experienced a major depressive episode.2 Depression comes in many forms: persistent depressive disorder (dysthymia), postpartum depression, seasonal affective disorder, psychotic depression, and bipolar disorder.3 However, signs and symptoms may not be obvious.
Dental providers are a great front line for patients who have depression or another mental illness. Both dentists and hygienists are in a unique position to identify symptoms associated with depression in their patients. They can contribute to their patients’ overall wellness through discussion and referral.4 Depression may be evident in patients’ medical history with medications they are taking, their oral home care routine, how frequently they come to the dentist, and their general demeanor. Although dentists and dental hygienists are not the health-care professionals who treat depression, we can lend time and services to our patients at their time of need. Just as dental providers are advocates for the oral-systemic health link, dentists and hygienists also need to take into consideration the link between oral health and mental health.
When assessing and recording a patient’s medical history, the clinical team should adopt a helpful, unprejudiced attitude because patients may conceal their depression history,5 especially if they are taking antidepressants or antianxiety medications. Detailed history-taking helps to establish the needs and concerns of the patient and create a relationship of trust between the dental team and patient. It should also be made clear to patients that their medical history will be kept confidential and that it ensures their safety during dental treatment.5 Most antianxiety medication and antidepressants have several side effects, which may vary if a patient is taking multiple medications. Symptoms such as xerostomia, bruxism, and hypersalivation are common side effects of antidepressants and antianxiety medications.6 It’s also important to note potential side effects when tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs) interact with local anesthetics, antibiotics, and nonsteroidal anti-inflammatory drugs.5,6
Whether a patient suffers from side effects of antidepressants or presents with major depressive disorder, symptoms of depression, anxiety, and pain are associated with sleep bruxism and tooth wear. Poor periodontal health has been identified with depression based on both biologic and behavioral mechanisms. Psychological distress has been associated with lower toothbrushing frequency and frequent consumption of sugary products. It is also a risk factor for impaired gingival status, self-report of bleeding gums, dental caries, tooth loss, edentulism, and TMD pain.4 Dental providers can provide preventive treatment that can help manage or improve oral health changes when patients are challenged with depression symptoms and medication side effects. Providing patients with a comfortable, safe, and relaxing environment during dental visits is helpful. Treatment considerations for patients with depression may include frequent recare visits, xerostomia products, fluoride varnish treatment, or an occlusal guard.6
Communication, patient education, and trust building are essential when interacting with patients with depression and anxiety. It is imperative to establish a trusting relationship with patients so they can comfortably confide in the dental provider with concerns they have clinically or with anything else they wish to share. Before taking vital or diagnostic information at the start of each dental visit, speak socially to the patient. Communicating effective patient education in a positive manner is also important. “Lecturing” a patient on the ineffectiveness of their current home-care routine may not be ideal for patients with depression or anxiety. Dental providers should always coach and motivate their patients toward good oral health. In practice, I tell my patients that all visits are social and preventive, and that we don’t always have to talk about teeth and oral hygiene. Creating more social interactions with patients helps improve trust in the patient-provider relationship.
We can all be of help to anyone who is living with a mental illness, whether it’s depression, anxiety, or suicidal thoughts. In dentistry especially, we can get caught up with our schedules, day-to-day tasks, and our own lives. Let’s not be oblivious to any signs and symptoms of depression, whether they are in our patients, loved ones, friends, and even ourselves. The most important lesson I learned through my relationship with Frank was that people with depression need to want help. We cannot force people, including our patients, into getting professional treatment or counseling when we suspect worsening depression. As dental providers, we need to always maintain our level of professionalism and have compassion for all our patients. We can be more than just dental providers who do clinical treatment; we can also be helpful and compassionate resources to help our patients with depression. Be aware of how your patients are feeling. If you know someone who is in distress or crisis because of worsening depression, please be a form of support and be aware of available resources such as support groups, professional counseling, and the National Suicide Prevention Lifeline (1-800-273-8255).
1. Depression. World Health Organization website. http://www.who.int/en/news-room/fact-sheets/detail/depression.
2. Bose J, Hedden SL, Lipari RN, Park-Lee E. Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services
nsduh-annual-national-report. Published September 2018.
3. Depression. National Institute of Mental Health website. https://www.nimh.nih.gov/health/topics/depression/index.shtml. Updated February 2018.
4. Hexem K, Ehlers R, Gluch J, Collins R. Dental patients with major depressive disorder. Curr Oral Health Rep. 2014;1(3):153-160.
5. Lambrecht JT, Greuter C, Surber C. Antidepressants relevant to oral and maxillofacial surgical practice. Ann Maxillofac Surg. 2013; 3(2):160-166.
6. Oral Health Fact Sheet for Dental Professionals: Adults with Anxiety. University of Washington School of Dentistry website. https://dental.washington.edu/wp-content/media/sp_need_pdfs/Anxiety-Adult.pdf.
Samantha T. Veradero, BSDH, RDH, is a central New Jersey native. Her passion for patient care started at the age of 15, when she volunteered with the Somerville First Aid and Rescue squad. She later attended New York University College of Dentistry. Presently, Samantha practices dental hygiene full-time in Maryland. She serves as a member of the Professional
Development Committee for the Maryland Dental Hygiene Association and is also a hygiene faculty member for Align Technology.