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Review Article

C.E. Credit. Why Integrate Dentistry and Behavioral Health: What Every Oral Health Provider Should Know About Mental Health and Substance Use

, MPH, , PhD, , MPH & , RDH, MS, DHSc
Article: 2353738 | Received 25 Jan 2024, Accepted 06 May 2024, Published online: 03 Jun 2024

ABSTRACT

Background

Mental health and substance use challenges have reached crisis levels in the U.S. Nearly one in three American adults had either a substance use disorder or any mental illness in 2022, and nearly one in four adolescents aged 12 to 17 had a substance use disorder or major depressive episode in the same year. The behavioral health workforce is not able to keep up with this demand, leading to a scarcity of resources and services for individuals with mental health and substance use needs. This need increasingly impacts all health care settings, including dental settings, where providers often have limited resources and supports for addressing the mental health and substance use needs of patients – here referred to with the umbrella term of “behavioral health.”

Discussion

Because of the bi-directional relationship between oral health and behavioral health, providing high-quality dental care often involves considering many aspects of a person’s health, particularly the behavioral health factors that influence oral health. Mental health challenges such as depression, anxiety, or a substance use disorder can negatively impact oral health, and the reverse is also true; poor oral health can create or worsen challenges with behavioral health. This paper provides an overview of the bidirectional connections between oral health and behavioral health, and reviews disparities facing marginalized communities who lack access to care. It also offers promising practices and key resources for dental providers interested in better integrating oral health and behavioral health services.

Continuing Education Credit Available

The practice worksheet is available online in the supplemental material tab for this article. A CDA Continuing Education quiz is online for this article:https://www.cdapresents360.com/learn/catalog/view/20

This article is part of the following collections:
Dentistry and Mental Health

Introduction

The number of deaths by suicide and drug overdose deaths both hit a record high in 2022.Citation1,Citation2 That year, there were over 107,000 drug overdose deaths nationally, with 10,901 of those deaths occurring in California.Citation3 Although California has one of the lowest overall rates of suicide in the country, it has lost over 4,000 people annually to suicide in recent years.Citation4 Alcohol consumption surged during and after the onset of the COVID-19 pandemic, with alcohol-related morbidity and mortality on the rise.Citation5 Mental health challenges, such as certain types of anxiety and depression, have also remained elevated since COVID-19,Citation6 with a 2023 Gallup poll finding 29% of U.S. adults reporting ever being diagnosed with depression, the highest rate on record.Citation7 The declining mental health of children has been called the “defining public health crisis of our time”Citation8 by the U.S. Surgeon General, who has also warned about the negative impacts of social media on mental health and the many harms of loneliness and isolation.Citation9,Citation10 Non-suicidal self-injury – that is, deliberate self-injury without suicidal intent – also remains a public health concern, particularly among adolescents.Citation11,Citation12 The unprecedented increase in need for mental health and substance use treatment is exacerbated by scarcity and maldistribution of behavioral health professionals, which undermines timely access to needed quality care.Citation13

In short, the likelihood of seeing a dental patient with a mental health or substance use challenge is high. California fared worse than the U.S. on many indicators for adults related to substance use, while several indicators related to mental health were generally similar or slightly better than the U.S. average, with the exception of serious thought on suicide (see ).Citation1 The evidence suggests that adults and youth experiencing substance use are not receiving the care they need, particularly in California, which had the second highest rate in the country of adults who needed substance use treatment but did not receive it. For more information regarding mental health and substance use disorder definitions, prevalence data, and treatment options, see and .

Table 1. Overview of selected behavioral health indicators from 2021–2022 National survey on drug use and health: U.S. and California Averages.Citation1

Table 2. Mental Health Definitions and Information.

Table 3. Substance Use Disorder Definitions and Information.

While the connection between oral and behavioral health has previously been referred to as a “blind spot” for the dental profession,Citation25 there has been an increase in national and international recognition of this topic. Nationally, the landmark National Institute of Health report published in 2021, “Oral Health in America: Advances and Challenges,” dedicated an entire section to pain, mental illness, substance use, and oral health in the U.S.Citation26 Also in 2021, the National Council for Mental Wellbeing released a toolkit focused on the need for better coordination and integration for oral health, mental health, and substance use.Citation27 This toolkit includes a framework for bidirectional coordination and integration for oral health and behavioral health providers across a continuum of care, ranging from general education to full integration. Internationally, the United Kingdom launched the “Mental Health Wellness in Dentistry” campaign, which consists of well-being support for dental teams.Citation28 In Australia, the Department of Health in Victoria published evidence-based oral health promotion resources that cover strategies for ensuring access to dental care and oral health education for individuals with mental illness.Citation29

The increased mental health and substance use care needs impact all health care settings, including dental settings, where resources for supporting behavioral health challenges are typically limited. The question, therefore, may not be “Why dentistry and behavioral health?” but rather, “When behavioral health impacts the practice of dental care, how can dental providers better address the needs of their patients?”

Providing high-quality dental care often involves considering the behavioral health factors that impact oral health and dental treatment. Mental health challenges such as depression or anxiety or a substance use disorder can negatively impact oral health. The reverse is also true; poor oral health can create or worsen challenges with substance use, mental health, and/or cognitive health. This paper provides an overview of the various bidirectional connections between oral health, mental health, and substance use. Another paper in this Journal collection, “Integrating Behavioral Health in Dental Settings: Resources to Support Integration,” includes information and tools regarding approaches the dental provider should take to improve integration between oral health and behavioral health, including strategies for responding to patients who they suspect are experiencing mental health or substance use challenges.

I. The Impact of Behavioral Health on Oral Health

Impact of Mental Health on Oral Health

A robust body of research has demonstrated that people with mental health challenges are at greater risk of developing oral health concerns.Citation30 In some cases, mental health challenges can be associated with direct physiological impact on teeth and gums. For example, individuals with anxiety are more likely to suffer from bruxism (teeth grinding). Individuals with eating disorders, particularly self-induced vomiting, have five times the likelihood of dental erosion,Citation31 while those with severe “internalizing” problems (i.e., internally directed feelings such as depression or anxiety) are 1.27 times as likely to have bleeding gums and 1.37 times as likely to have had tooth extraction.Citation32 People with serious mental illness, such as schizophrenia or bipolar disorder, are nearly three times as likely as the general community to have lost all of their teeth.Citation33

Many prescription medications used to treat mental health challenges, including antidepressants, antianxiety, antipsychotics, mood stabilizers, and psychostimulants, produce xerostomia (dry mouth) as a side effect. Some research demonstrates that xerostomia may be associated with consumption of sugar-sweetened beverages,Citation34 which can further erode oral health, as well as avoidance of and preferences for certain food groups that may generally lead to an unhealthy diet.Citation35 Further, individuals with mental health challenges may be more likely to neglect dental visits and self-care.Citation33 Psychosocial stress, inflammation, and immune response have also been cited as plausible pathways for connecting mental health challenges to negative oral health outcomes.Citation32 See for examples of how mental health can impact oral health.

Table 4. Select examples of mental health impact on oral health.

Impact of Psychological Trauma on Oral Health

Traumatic experiences are strongly associated with development of mental health and substance use challenges as well as dental fear.Citation37,Citation38 There is also an association between Adverse Childhood Experiences (ACEs) and poor oral health.Citation39 People who have been subjected to sexual abuse often find the prospect of dental care very stressful, making them less likely to attend preventive visitsCitation36 and demonstrating higher rates of missing teeth, dental caries, periodontal disease, and apical periodontitis.Citation38,Citation40 Signs of experiences with trauma or abuse that may present during dental treatment include patients who frequently shift their gaze, want to rinse repeatedly with water, perspire, cry, and/or report body cramps or nausea.Citation38 Historically marginalized communities, such as Black and Hispanic communities, are more likely to experience ACEs and traumatic events compared to non-Hispanic white communities, as well as increased barriers to accessing needed care, contributing to an increased need for quality oral health and behavioral health services.Citation41,Citation42

Dental providers have a unique vantage point when it comes to identifying the impacts of traumatic events and child abuse, as 60%–75% of child abuse victims present with head, face, and mouth injuries.Citation43 Because trauma in childhood and adulthood are common, trauma-informed advocates use the term “universal precautions” when considering practice changes, urging providers to assume that any patient may have had a trauma exposure.Citation44 See to read a patient’s statement regarding their experiences and perspectives with receiving dental care.

Box 1: In a patient’s words: I am very careful not to let people touch my face. And you know, dentists do just that. I withdraw. I really feel just: “Take your hands away.” And it is something too that dentists have to … have to do of course. But I really dislike it intensely. […] And it has also made me feel sick. (Excerpt from Wolf E, McCarthy E, Priebe G. Dental care – an emotional and physical challenge for the sexually abused)Citation38

Impact of Substance Use on Oral Health

Many illicit substances, including cocaine, methamphetamines, and opioids/heroin, can negatively impact oral health. The specific oral health impacts can vary depending on the type of substance used and how it is administered. For example, cocaine placed directly onto the gingiva is associated with gingival lesions and retraction, whereas cocaine snorted through the nasal septum may result in nasal septum perforation.Citation45 Smoking crack cocaine may produce burns or sores on the lips or inside of the mouth. Methamphetamines are associated with “substantial and distinctive” patterns of dental caries and abscesses due to suppression of salivary flow and increased acidity of the saliva.Citation26 The newest treatment guidelines for stimulant use disorder released by the American Society for Addiction Medicine promote the importance of dental care and good oral hygiene but also recognize challenges with implementation.Citation46

While heroin is also associated with rampant caries and periodontal disease, the pathogenesis is more complex.Citation26 However, studies have shown that its use contributes to risk factors such as personal neglect, poor oral hygiene, and delayed dental treatment, resulting in poor oral health outcomes.Citation47 Use of illicit substances can also impact dental treatment plans and pain management; for example, local anesthetics can be impacted by recent drug use, in some cases resulting in patient safety concerns such as hypertensive crisis or tachycardia.Citation48 Further, medications commonly used to treat substance use disorders, such as methadone and buprenorphine, can negatively impact oral health. In January 2022, the U.S. Food and Drug Administration released a warning noting that dental problems, including tooth decay, cavities, oral infections, and loss of teeth, can be associated with buprenorphine products that dissolve in the mouth, but noted that the benefits of these medications outweigh the risks.Citation48

Additionally, many legal substances, including alcohol, cannabis (now legal for either medical and/or recreational purposes in most states)Citation49 and tobacco/nicotine, can negatively impact oral health. Alcohol consumption, even one drink per day, is associated with increased relative risk of developing several types of cancers, including oral cancer.Citation50 Heavy alcohol drinkers have a five-fold higher risk of cancers in the oral cavity. Marijuana use, which has steadily increased in the U.S. since 2007, is associated with increased risk of oral cancers, dry mouth, and periodontitis.Citation51,Citation52 Tobacco products have a wide range of negative oral health and general health implications, with tobacco use contributing more to mortality and morbidity globally than any other risk factor.Citation53 Emerging evidence suggests more limited oral health impacts for electronic cigarettes, with a recent study noting “for smokers using e-cigarettes as an aid to help them quit, the benefits of quitting tobacco smoking may outweigh any negative oral health impacts of e-cigarette use.”Citation54 See for examples of how substance use can impact oral health, and to read a patient’s statement regarding their experiences with substance use and oral health.

Table 5. Select examples of substance use impact on oral health.

Box 2: In a patient’s words: I was a person challenged with substance abuse issues from the time I was 13 years old, until I entered recovery at 39 years old. On July 27, 2009, I again entered the criminal justice system. At that time, I had seven remaining teeth in my mouth, and it was not a good place for me mentally. When I was able to have my dental health addressed, many things began to change. I was able to obtain dentures, that was a gamechanger. Once I had a full set of teeth, it instilled a greater sense of confidence; my self-esteem shot up. Now, I have a Master of Social Work degree, am fully involved in my family’s life, and am employed as a therapist with New Life Medical Addiction Services. And, I have celebrated over 14 years of sobriety. (Adapted excerpt from the National Council for Mental Wellbeing’s Oral Health, Mental Health, and Substance Use Treatment; A Framework for Increased Coordination and Integration)Citation27

II. Oral Health Impact on Behavioral Health

Oral Health Impact on Mental Health and Cognitive Health

Impaired oral health has been shown to greatly impact vital functioning, self-esteem, and quality of life, which can in turn impact mental health. Visible dental disorders such as tooth loss and untreated decay have been shown to have a “profound impact” on behavior and self-esteem for both children and adults.Citation59 Studies have shown a bidirectional association between laughter frequency and oral health among older adults that was independent of socioeconomic and lifestyle factors.Citation60 Dental fear and anxiety are prevalent among both adults and children and are known determinants of delaying or avoiding dental care. Research has also found associations between racism and elevated levels of dental anxiety.Citation61 An emerging body of research demonstrates that physical inflammation from periodontitis may be a risk factor in developing depression and exacerbating cognitive issues, including Alzheimer’s disease and dementia.Citation62,Citation63 See for examples of how oral health can impact mental and cognitive health.

Table 6. Select examples of oral health impact on mental and cognitive health.

Oral Health Impact on Substance Use

Although opioid prescribing among general and specialist dentists has declined overall in recent years, dentists are still among the most frequent prescribers of opioids in the U.S., with some dentists continuing to prescribe opioids in a high-risk way (i.e., prescribing greater than a three-day supply to opioid-naïve patients, dosage of ≥50 morphine milligram equivalents, and/or opioids with a benzodiazepine overlap).Citation57,Citation64,Citation65 Of the approximately 10 million wisdom tooth extractions completed each year, about a third include a prescription for opioids; historically, about 5% of individuals who receive just one prescription become opioid dependent. That translates into about 16,650 additional people, primarily teenagers and young adults, becoming opioid dependent because of dental care.Citation66 According to the Centers for Disease Control and Prevention (CDC), nonsteroidal anti-inflammatory medications should be considered the first-line medications for acute dental pain.Citation67

However, dental pain should not be ignored. A substantial portion of individuals report using substances in part as pain relievers, and untreated tooth pain can contribute to recurrent use of substances.Citation56 According to the Michigan Overdose Prevention Engagement Network (Michigan OPEN), because acetaminophen and ibuprofen are available over the counter, patients and their caregivers often do not receive instructions on how to use them after surgery, resulting in potential underdosing.Citation68 Michigan OPEN also provides specific practice guidance related to pain management for people with substance use disorders, with a goal of lessening the impact of opioid prescribing in dental settings on the opioid epidemic. See for examples of how oral health can impact substance use.

Table 7. Select examples of oral health impact on substance use.

III. Social Determinants of Health

The bidirectional connections outlined above emphasize the physiological and psychological relationships between selected mental health and substance use challenges and oral health. However, there are social risk factors that influence behavioral and oral health alike. These include insurance status, economic stability, nutrition, housing, transportation, employment, and education status. Although research has shown that the negative impacts of behavioral health challenges on oral health stand even after controlling for these types of social factors,Citation41 social determinants of health remain a major contributor to both negative oral health and behavioral health outcomes.

Is oral health impacted by social determinants of health or is it a social determinant of health in and of itself? The answer may be both. A classic work of medical sociology by Link and Phelan, entitled Social Conditions as Fundamental Causes of Disease, discusses links in the “causal chain” from a social problem to a medical problem.Citation69 Oral deterioration may be an early link in this chain, preceding a more general decline in wellness such as disrupted social connections, shame, job discrimination, chronic pain, disrupted sleep, and nutrition deficits. Likewise, different medical and behavioral health challenges can further contribute to poor oral health, thus creating a vicious cycle of declining health and well-being. According to the National Academy of Medicine, oral health can be seen as a “manifestation of the social and commercial determinants of health affecting one’s systemic and mental health, nutrition, speech, and psychological well-being.”Citation70

Table 8. Oral health’s relationship to social determinants of health.

Partially because of these social factors, health disparities abound in both prevalence of and access to treatment for oral health and behavioral health challenges. The short supply of behavioral health providers is exacerbated for people living in rural and economically stressed cities, those covered by Medicaid and to some extent, Medicare, and historically marginalized communities such as people of color, non-English speakers, and the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) community.Citation13,Citation71 Black, Indigenous, and communities of color are disproportionately impacted by social determinants of health, creating additional barriers to needed health care and increased risk for developing co-occurring health conditions.Citation72 In California, Hispanic communities have one of the lowest mental health care access rates compared to other racial and ethnic groups in the state.Citation73,Citation74 For individuals who speak languages other than English, access to quality services remains much lower than others in California and the U.S. nationally.Citation74

On the dental side, poor oral health in the U.S. has come to serve as the de facto “national symbol of social inequality” given that those with poor oral health are more likely to be low-income, uninsured or underinsured, members of racial and ethnic marginalized groups, immigrants, and/or living in rural areas.Citation75 Communities of color, specifically Black and Hispanic adults, are less likely to access dental care when compared to other racial and ethnic groups,Citation76 likely due to several intersecting factors such as increased impact of social determinants of health, experiences of bias and discrimination, and underrepresentation within the health care workforce.Citation72 Oral health disparities can arise in other marginalized communities such as the LGBTQ+ community; family rejection is a common experience among this group, which may lead to inability to afford and access care and subsequent postponing of needed dental treatment or preventive care.Citation77 In addition, individuals with intersecting identities across various marginalized communities can amplify experiences of health disparities and health inequities, leading health providers across all health sectors to improve equitable, culturally responsive and person-centered care that prioritizes individual needs of patients.Citation78 See for examples of how oral health and social determinants of health are interconnected.

Discussion

While the movement toward more integrated oral health and behavioral health is still nascent, emerging outcomes show that better coordination among these fields can positively impact dental patients and staff. For example, Project Facilitating a Lifetime of Oral Health Sustainability for Substance Use Disorder Patients and Families (FLOSS) – which provided comprehensive dental care to individuals with substance use disorder in Utah – substantially increased recovery rates and enhanced professional satisfaction among dental providers as they drastically improved patients’ lives.Citation79 The ECHO model (Extension for Community Healthcare Outcomes) has also demonstrated to be an effective way to significantly impact dental providers’ knowledge and willingness to treat clients with behavioral health challenges.Citation80 In California, Asian Health Services, a federally qualified health center based in Oakland, has worked since 2015 to help pioneer integration of oral health and behavioral health by screening dental patients for depression, resulting in increased access to mental health care.Citation81 In fact, research shows that better coordinating and integrating care can help increase access, improve patient outcomes, and potentially reduce costs.Citation27 Key resources for dental providers interested in better integrating oral health and behavioral health services include the National Network for Oral Health Access User’s Guide for Integration of Behavioral Health and Oral Health and the National Council for Mental Wellbeing: Oral Health, Mental Health, and Substance Use Treatment: A Framework for Increased Coordination and Integration. Citation27,Citation82 Additional ideas and strategies for addressing mental health and substance use needs within a dental practice can also be found in another paper in this Journal Collection, entitled Integrating Behavioral Health in Dental Settings: Resources to Support Integration.

According to Dr. Christian Stohler, a senior section editor of Oral Health in America: Advances and Challenges, “Without even considering their interrelationship, oral disease, pain, and behavioral and substance use conditions all remain undertreated in vulnerable populations. Given that oral diseases, pain, and behavioral and substance use conditions feed on each other, novel programs are called for that offer an overarching perspective for the millions of impacted Americans to improve their physical and mental well-being and employability. The magnitude of the problem has reached a level of gravity that puts the effectiveness of current care practices into question.”Citation25 Experts have called for increased integration of training on behavioral health conditions – especially those with significant oral health impacts – into curricula for general dentistry and dental residency programs.Citation83 With the U.S. facing dual crises of skyrocketing behavioral health needs coupled with lack of access to care and an understaffed behavioral health workforce, dental providers should proactively plan for how best to support patients with behavioral health challenges when, not if, they come for dental care.

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Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19424396.2024.2353738

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

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.

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.

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 registered dental hygienist, and 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.

References