Behavioral Health in Dental Settings: Resources to Support Integration

ABSTRACT

Background

Decades of research evidence has shown that mental health and substance use are impacted by oral health, and that oral health is impacted by mental health and substance use. As our nation experiences alarming increases in mental health and substance use needs, patients in dental settings are increasingly likely to present with such needs, impacting their ability to successfully access oral health services and improve their oral health.

Discussion

However, dental providers can leverage existing resources and practices toward best supporting patients’ behavioral health, and, ultimately, their oral health. This article includes concepts, tools, and resources to support dental professionals in developing financially sustainable shifts to move the dial toward integrated oral health and behavioral health care.

KEYWORDS:

• Oral Health
• dental care
• medical/dental integration
• mental health
• substance use disorders
• behavioral health
• integrated care
• trauma-informed care
• clinical practice
• resources & tools

Introduction

In the words of psychiatrist Dr. Steve Kisely, there is “no mental health without oral health.”¹ Decades of research evidence have shown the ways that mental health and wellbeing are impacted by oral health: for example, one’s ability to smile with friends and family, get past a job interview, or live without chronic pain.² Increasingly, researchers and care providers alike are becoming aware that there may also be “no oral health without mental health.” With up to 1 in 5 US adults experiencing mental illness and 21.9% of people over age 12 using illicit drugs in the past year,^3,4 behavioral health presentations in the dental clinic have become more common. Accessing oral health care and successfully completing dental treatment plans is greatly facilitated when patients are well prepared for their appointments, can trust that the dental team is on their side, and can manage any potential dental anxiety or emotional dysregulation. Unfortunately, a wide range of behavioral health challenges such as depression, anxiety, eating disorders, and substance use can negatively impact oral health.⁵ As described in more detail in the first article of this series, Why Integrate Dentistry and Behavioral Health: What Every Oral Health Provider Should Know About Mental and Substance Use, the link between behavioral health and oral health is bi-directional and well established; for example, with self-induced vomiting leading to tooth erosion, self-neglect from depression leading to poor oral self-care, and use of addictive substances leading to tooth loss and decay. How, then, can dental providers blend evidence-based approaches and resources into their practice to support patients’ behavioral health, and, ultimately, their oral health? This article includes several models, tools, and resources to support dental professionals in understanding and addressing behavioral health needs within dental settings. For a full list of all models, tools, and resources listed throughout this article, refer to Table 1.

Table 1. Summary of tools & resources.

Universal Precautions to Address Trauma
Trauma-Informed Care Pyramid: The TIC Pyramid can be used to assess your dental practices regarding the provision of trauma-informed care.^Citation8
Trauma-Informed Care as a Universal Precaution: This article provides an overview of the importance of using TIC as a universal precaution, and examples for how to implement TIC approaches within any health care setting.^Citation7
The Depression Center Toolkit: This toolkit includes strategies and tools for supporting others who may be experiencing mental health needs, including examples of validating statements dental providers can use in their practices.^Citation14
Practice-Based Responses to Stigma
Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness: Review and follow the recommendations on how to avoid biases such as “diagnostic overshadowing,” or mistakenly attributing physical complaints to mental illness.^Citation22
Michigan OPEN Stigma Reduction: This resource provides pragmatic recommendations on reducing substance use stigma in dental settings.^Citation23
Michigan OPEN, OPEN for Dentistry: This resource provides detailed guidelines on opioid prescribing and pain management for dental professionals.^Citation24
Evidence-Based Chairside Communication Strategies
CareQuest’s Using Motivational Interviewing in Dentistry: This video series highlights skills and techniques that can be used by dental providers to engage patients in their own oral healthcare.^Citation28
The National Council for Mental Wellbeing’s Motivational Interviewing trainings and resources: This webpage includes trainings, consulting, and resources available for any health provider seeking to enhance their communication and chairside skills with patients.^Citation27
The Agency for Healthcare Research and Quality (AHRQ) Teach-Back Intervention: This webpage provides several resources on implementing the teach-back method, including a quick start guide and detailed steps for implementation of the method into routine practice.^Citation29
The National Network for Oral Health Access User’s Guide for Integration of Behavioral Health and Oral Health: This user’s guide for behavioral and oral health integration includes a readiness assessment, suggestions for integration team composition, guidelines for selecting a population of focus for integration efforts, suggestions for screening tools, and sample workflows.^Citation30
The National Council for Mental Wellbeing’s Oral Health, Mental Health and Substance Use Treatment Toolkit: This toolkit provides a framework for integrating oral health, mental health, and substance use services, and contains several examples of integration in practice, planning questions, and data monitoring strategies.^Citation5
Patient Health Questionnare-9 (PHQ-9) screening tool: This nine-item depression scale of the Patient Health Questionnaire functions as a screening tool, an aid in diagnosis, and a symptom tracking tool to help identify and track a patient’s overall depression severity based on the DSM depression scale.^Citation31
Patient Health Questionnaire-2 (PHQ-2) screening tool: This brief 2-item depression screen consists of the first two questions asked on the PHQ-9, asking about the degree to which an individual has experienced depressed mood and anhedonia within a two-week period.^Citation32
The Indian Health Service uses the PHQ-2: This recorded training course discusses how the Indian Health Services has used the PHQ-2 to screen patients for depression in a dental setting, and provides recommendations for using the tool and how to respond when a patient has a positive screen using a PHQ-2.^Citation33
Identifying Community Behavioral Health Supports
988 Suicide & Crisis Lifeline: This page includes resources and information to support health professionals in understanding and implementing improved suicide prevention and mental health crisis services.^Citation34
Warmline Directory: This directory provides information on how to access warmlines in each state.^Citation35
University of Michigan Eisenberg Depression Center Toolkit and list of apps that are supported by evidence: Dental providers can reference this list of mental health apps when supporting a patient in need of mental health services.^Citation37
Certified Community Behavioral Health Clinics (CCBHCs): The CCBHC model is a comprehensive integrated model of care that allows states and communities to provide a range of mental health and substance use treatment services, often in collaboration and partnership with local health and social services such as schools, law enforcement, and dental clinics. Search for CCBHCs across the nation here.^Citation38
School-based Health Centers (SBHCs): SBHCs are a community-based model that prioritizes integrated school-based health services to support children, youth, and their families.^Citation39
National Alliance on Mental Illness (NAMI) Family Support Groups: Any adult with a loved one who has experienced a mental health condition can join these peer-led support groups to gain support and insight from others facing similar experiences.^Citation42

Universal Precautions to Address Trauma

Traumatic experiences in childhood and adulthood are common,⁶ leading trauma-informed advocates to adopt the language of “universal precautions” when considering practice changes in health care. Universal precaution of trauma-informed care is an approach that acknowledges the widespread nature of trauma by assuming your patient may have a trauma history, then using trauma-informed knowledge and skills to act accordingly.⁷ For example, this could include using the trauma-informed care pyramid (see Figure 1) as a framework to guide dental care, which involves: (1) patient-centered communication; (2) understanding the health effects of trauma; (3) collaborating with other professionals through referral; (4) understanding one’s own trauma history; and (5) screening for traumatic events.⁸

Figure 1. Trauma-informed care pyramid.⁸

Key features of psychological trauma involve physiological and psychological reactivity to reminders of traumatic events.⁹ This reactivity can take many forms: anxiety, nausea, panic, anger, or disgust, among others. A high proportion of experiences with physical and sexual abuse involve injuries to the head, face, and mouth.^10,11 For someone who may have experienced physical or sexual abuse, visiting a dental office or clinic can be challenging. There may be limits in movement or a sense of crowding, one’s body is supine on a dental chair, and one’s head may be touched, which can lead to reminders of previous experiences and re-traumatization, and potentially one’s aversion or avoidance to such an experience altogether.

In dental practice, universal precautions might center choice and control in patient care, as any decisions that improve a patient’s sense of control can make the difference in their completion of a treatment plan. Research has shown that patients having an active role in decision making regarding their care conveys a sense of control, reducing stress and apprehension.¹² For example, there are studies showing that playing instrumental music during a dental appointment, and patient control of that music, can have significant impact in reducing patient fear and anxiety at dental appointments.¹³ Perhaps most importantly, trauma-informed providers remember to consider not only the impact of concerns such as substance use, unhealthy food choices, or frequent no-shows, but also consider their function as well. If patients seem nervous or anxious during a visit, a universal precautions approach might consider the possibility that their reaction is a common trauma response, and that understanding can be reflected and validated – “it is common to have a stress reaction or to experience anxiety in our setting. How can we make this experience better for you?”

Some healthcare providers have a natural facility with such conversations, needing little coaching to come up with ideas for validating statements. Others may struggle to come up with something to say in the moment; a perfectly understandable reaction when bearing witness to another person’s suffering. The Depression Center Toolkit includes examples of validating statements in its section: “supporting others.”¹⁴ It contains a list of validating statements applicable to many situations, such as “I may not really understand what you’re going through, but I am here to support and listen to you.” Is researching or planning such statements “canned” or inauthentic? Perhaps one could instead consider this a form of conscientious preparation for clinical encounters that can be quite challenging and emotionally fraught, reflecting one’s genuine desire to help patients get the most out of their dental appointment. Exhibit 1 shares further examples of patient-centered communication ideas that may be useful for dental providers when engaging with a patient that reports a history of traumatic events.⁸

Exhibit 1: Suggestions on what to say when a patient reports a history of traumatic events.⁸

“I am sorry that happened to you. How are you doing now?”

“Thank you for telling me. Is there anything I can do as your dental provider to make you feel more comfortable?”

“I appreciate your telling me that. No one deserves that to happen to them.”

“Do you think any of these experiences affect you today? If so, would you like a referral to talk more about some of these issues?”

In addition to recognizing the after-effects of trauma, dental providers are often positioned to become aware that a child, elder, or other vulnerable person is currently being abused. As mandated reporters, dental providers may be required to call Child Protective Services if abuse or neglect is suspected. According to the American Academy of Pediatrics, dental providers may more readily identify mouth and gum injuries related to abuse or neglect than do medical providers.¹⁵ Clinics may ease the burden on providers by having the correct hotline numbers and standard documentation forms prepared if a mandated report is necessary.

Practice-Based Responses to Stigma

Stigma and shame can negatively influence health outcomes due to their link to avoidance and challenging health behaviors.¹⁶ Mental illness, substance use disorders, and exposure to psychological trauma are highly stigmatized experiences.¹⁷ As people with mental health and substance use disorders are more vulnerable to oral diseases,¹ they may be doubly challenged with oral health stigma.¹⁸ Defined as “a unique health stigma characterised by both externally applied and internalised processes [including] labelling, stereotyping, social exclusion, and discrimination enacted by society at large on individuals or groups with marked deviations from dominant oral health norms,” oral health stigma affects patients throughout their life course. Studies have found that income level directly impacts oral health service access and prevalence of oral health concerns, leading to increased stigma for low-income communities.¹⁹ An estimated 40% of low-income adults experience untreated caries and are three times more likely to have severe untreated caries compared to higher-income adults. A vivid illustration of oral health stigma can be found in Sarah Smarsh’s essay Poor Teeth, which powerfully illustrates the multifaceted ways that tooth decay has come to represent poverty and disadvantage in the US, leading to psychosocial impacts that go beyond its direct effect on health.²⁰

Stigma impacts both health and healthcare, through mechanisms such as avoidance of care, fear of disclosing their conditions, and receiving lower quality of care.¹⁶ As such, shifts in practice can improve the success of dental treatment plans. Various methods have been employed to reduce the impact of stigma across healthcare practices, such as teaching providers about stigma, patient testimonials, interactive learning, and policy change.²¹ One practice-based change is to educate providers about “diagnostic overshadowing,” or mistakenly attributing physical complaints to mental illness.²² According to the Lancet Psychiatry Commission, diagnostic overshadowing is one driver of healthcare disparities facing individuals with psychiatric disabilities; by becoming aware of this phenomenon, providers are better positioned to avoid it.²² Another practice-based change is to consider the language that providers use to describe behavioral health concerns. For example, using language that frames substance use disorders as medical illnesses rather than “life choices” can reduce stigma. Michigan OPEN’s educational page on stigma reduction includes other suggestions on practice-based stigma reduction, including an addiction language guide for healthcare providers, in addition to its dental-specific guidelines on opioid prescribing and pain management.^23,24

Finally, a better understanding of how behavioral health impacts care-relevant behavior, such as avoidance of care, rejection of care plans, and neglect of at-home care, can lead to better quality approaches to addressing the problems in practice. For example, what function could a broken appointment serve for a person whose avoidance of distress is inextricably linked to their psychological trauma? Organizational change models that reflect a multi-faceted understanding of what makes appointment attendance more likely, such as open-access scheduling, motivational interviewing, health literacy education, and no-show feedback, have been shown to reduce no-shows in dental settings.²⁵

Evidence-Based Chairside Communication Strategies

Use of chairside evidence-based communication strategies is useful for any dental patient. However, for treatment of people living with behavioral health challenges, they may be essential. Depression and anxiety, for example, are often intertwined with pessimism, avoidance, and challenges with motivation, suggesting that communication strategies to support their oral health behavior change can be a critical component of high-quality care.

Motivational Interviewing (MI) is one such chairside approach. Supported by a robust research evidence,²⁶ MI is a conversation style centered around the individualized needs of a patient that strengthens and supports their own motivation and commitment for change, often using open-ended questions and reflective listening to guide the conversation.²⁷ There are many online resources for dental providers to learn more about MI. For example, CareQuest offers the Using Motivational Interviewing in Dentistry series, which demonstrates the skills and techniques that can engage patients in their own oral healthcare.²⁸ The National Council for Mental Wellbeing also offers MI trainings and resources, available for any health provider seeking to enhance their communication and chairside skills with patients.²⁷

The teach-back method is another approach that can be used chairside, in which the provider asks patients or family members to explain in their own words what they need to know or do. Beyond simply repeating what they heard, patients are asked to “teach it back.” The Agency for Healthcare Research and Quality (AHRQ) provides a detailed resource on implementing the teach-back method, including a quick start guide and detailed steps for implementation of the method into routine practice.²⁹

Application of evidence-based conversation tools are financially sustainable practices in many dental settings. Certain counseling-like services provided by licensed oral health providers, often conducted chair-side, may be billable in some states under appropriate Current Dental Terminology (CDT) codes, suggesting possible pathways toward sustainable financing of such approaches. These include tobacco counseling for control and prevention of oral disease (D1320); counseling for control and prevention of adverse oral, behavioral and systemic health effects associated with high-risk substance use (D1321); motivational interviewing (D9993); and/or addressing appointment compliance barriers (D9991).⁵

Toolkits and Resources for Implementing Integrated Care

Dental practices do not need to reinvent the wheel when it comes to behavioral health integration. Several organizations have published integration frameworks, planning guides, and screening tools that can be leveraged toward integration. Michigan OPEN offers pain management and opioid prescribing guidelines specifically designed for dental settings.²⁴ The National Network for Oral Health Access provides a user’s guide for behavioral and oral health integration, which includes a readiness assessment, suggestions for integration team composition, guidelines for selecting a population of focus for integration efforts, suggestions for screening tools, and sample workflows.³⁰ The National Council for Mental Wellbeing’s Center of Excellence for Integrated Health Solutions provides an Oral Health, Mental Health and Substance Use Treatment Toolkit, which contains several examples of integration in practice, planning questions, and data monitoring strategies.⁵

Some sample workflows include the integration of depression screening into routine practice and the electronic dental record. Using a screening instrument allows for efficiency in the dental office, as an interview-based evaluation of depression becomes less necessary with an evidence-based screening instrument. For example, the Patient Health Questionnaire-9 (PHQ-9) is the nine item depression scale of the Patient Health Questionnaire, which functions as a screening tool, an aid in diagnosis, and a symptom tracking tool to help identify and track a patient’s overall depression severity based on the DSM depression scale.³¹ Another option is to use the Patient Health Questionnaire-2 (PHQ-2), which is a brief 2-item depression screen that asks about the degree to which an individual has experienced depressed mood and anhedonia within a two-week period.³² The Indian Health Service uses the PHQ-2 and recommends that when a patient has a positive screen using a PHQ-2 in a dental setting, they should be referred to a behavioral health provider for further evaluation.³³ The PHQ-9 and PHQ-2 screen for depression but do not establish a final diagnosis or monitor depression severity. In workflows, screening tools like these can be followed by providing resources on local mental health supports or referrals to behavioral healthcare.

Identifying Community Behavioral Health Supports

The shift toward more integrated and person-centered health care services continues across our nation, with increased funding supporting new behavioral health service models. In July 2022, the 988 Suicide & Crisis Lifeline was activated in a transition to a three-digit, easy-to-remember, around-the-clock access number for suicide and behavioral health crisis care.³⁴ 988 is a free national resource where people can be connected to a trained counselor through text, website, or phone, when they are in crisis.

For patients who are not in crisis but could benefit from peer support, there are other telephonic resources, or “warmlines,” which are listening lines that are staffed by people who are themselves in recovery from a mental health or substance use disorder. A directory provides information on how to access warmlines state-by-state.³⁵

Emerging evidence also supports the positive impacts of mental health apps in supporting challenges such as depression and anxiety.³⁶ Because of the sheer volume of options for individuals seeking mental health support through apps, the University of Michigan Eisenberg Depression Center Toolkit has curated a list of apps that are supported by evidence, to which dental providers can refer patients for their reference.³⁷

When dental practices become familiar with public mental health resources such as 988, warmlines, and mental health apps, it gives them a broader range of choices in supporting patients with behavioral health concerns, beyond referrals to specialty care. Any member of the dental team can be trained to give a flyer or phone number to patients along with brief motivational encouragement to reach out if needed.

While there are significant access challenges plaguing the behavioral healthcare system, behavioral health support can now be accessed in new ways. For example, Certified Community Behavioral Health Clinics (CCBHCs) are a model that has expanded access to integrated and comprehensive care.³⁸ Similar to Federally Qualified Health Centers (FQHCs) but on the behavioral health service side, the CCBHC model gives states and communities a range of mental health and substance use treatment services, often in collaboration and partnership with local health and social services such as schools, law enforcement, and dental clinics. School-based Health Centers (SBHCs) are another community-based model that prioritizes integrated health services to support children, youth, and their families.³⁹ SBHCs have long understood the importance of providing integrated care to children and young people, specifically the integration of mental health and substance use services. As a result, behavioral health service integration has grown across SBHCs in recent years with 83% of SBHCs reporting providing some level of behavioral health services in 2022.^40,41 CCBHCs and SBHCs are potential referral sources and collaborative partners for dental providers in addition to established private practice and other Community Mental Health services.

Lastly, when a loved one struggles with a mental health or substance use concern, the family can also suffer. Dental practices can refer family members to advocacy organizations such as the National Alliance on Mental Illness (NAMI), which offers a Family Support Group to encourage their obtaining needed education, support, and fellowship.⁴²

Conclusion

As frontline health care providers, dental professionals are strategically placed to be key partners in the integration of behavioral health and oral health. This can encompass practice elements like universal precautions for trauma; expanded consciousness of stigma’s impact on wellbeing and care-seeking; applying evidence-based conversation techniques; and exploring existing integration frameworks to assess which ones are a good fit organizationally. Small, incremental changes are typically within reach in an individual clinician’s practice; larger ones may require organizational changes and a local champion to spearhead integration efforts.

Integrating behavioral health and dental care has significant implications for interprofessional education and practice. An evolved paradigm of interprofessional health care delivery is reflected in Commission on Dental Accreditation Standards for both dental and dental hygiene education. Requiring interprofessional education within dental schools opens the door for medical, behavioral, and oral health integration, with private practitioners as key partners. In an era of rising behavioral health needs, moving the dial toward integrated, whole-person care can improve lives through the provision of comprehensive and high-quality care.

Disclosure Statement

Sarah Neil Mockridge is an employee with the National Council for Mental Wellbeing. Rachael Matulis, Adrienne Lapidos, and Danielle Rulli are consultants with the National Council for Mental Wellbeing.

Additional information

Funding

This article was supported by the National Council for Mental Wellbeing’s Center of Excellence for Integrated Health Solutions (CoE-IHS), funded by a grant award from the Substance Abuse and Mental Health Services Administration and managed by the National Council for Mental Wellbeing. The views, opinions and content expressed in this presentation do not necessarily reflect the views, opinions or policies of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration or the U.S. Department of Health and Human Services.

Notes on contributors

Adrienne Lapidos

Adrienne Lapidos, PhD, is a licensed clinical psychologist and Clinical Associate Professor with the University of Michigan Medical School, Department of Psychiatry. Dr. Lapidos’s research focuses on innovations designed to improve outcomes for people with serious and persistent mental illness, with particular interest in interventions led by Community Health Workers and Peer Specialists that integrate behavioral and oral health. As a practicing clinical psychologist with the University of Michigan Health System, she serves individuals living with psychosis, depression, and PTSD.

Rachael Matulis

Rachael Matulis, MPH, is a Principal with Bowling Business Strategies and a consultant with the National Council for Mental Wellbeing. In this role, she oversees and advises on projects related to innovative payment and delivery system reforms in behavioral health. Her work includes the development of national briefs, webinars, and technical assistance tools designed to help improve care for individuals with mental health and/or substance use disorders. Rachael served as a lead author on the National Council for Mental Wellbeing’s Oral Health, Mental Health and Substance Use Treatment: A Framework for Increased Coordination and Integration.

Sarah Neil Mockridge

Sarah Neil Mockridge, MPH, PMP, serves as the Director, Practice Improvement and Consulting at the National Council for Mental Wellbeing where she directs National Training and Technical Assistance Centers aiming to improve equitable systems of care. Sarah builds and leads dynamic programs and teams that strive to bridge the gaps between community-level needs and national policy advancing comprehensive and integrated care. She has many years of experience managing and directing government contracts, specifically through the Substance Abuse and Mental Health Services Administration, where she led national efforts to improve the integration of oral health within behavioral health programs.

Danielle Rulli

Danielle Rulli, RDH, MS, DHSc, is a Clinical Associate Professor of Dentistry at the University of Michigan School of Dentistry, Department of Periodontics & Oral Medicine, and is the Director of the Master’s of Science in Dental Hygiene program, and the Director of Interprofessional Education for the School of Dentistry. She has been a dental educator for almost 20 years. Dr. Rulli’s research interests include interprofessional education/collaboration and integrated care with a focus on oral health and behavioral health. She is a co-investigator on a number of funded projects researching the integration of oral health and behavioral health. Dr. Rulli was an invited contributor to Oral Health in America: Advances and Challenges, the landmark follow up to the 2000 Surgeon General’s Oral Health in America published by the NIDCR. Dr. Rulli was a subject matter expert for the National Council for Mental Wellbeing and Substance Abuse and Mental Health Services Administration’s toolkit Oral Health, Mental Health and Substance Use: A Framework for Increased Coordination and Integration. Dr. Rulli currently serves as a member of the ADEA Task Force on Envisioning and Transforming the Future of Oral Health Education.