Management of Dental Patients With Mental Health Problems in Special Care Dentistry: A Practical Algorithm

Introduction Individuals with mental health problems have poor oral health affecting their quality of life with an increased burden on their well-being. Dentists find treating them challenging due to a lack of training and awareness in modifications of dental care delivery in special needs patients. Also, polypharmacy is common in psychiatric care, further complicating dental care while prescribing routine medications as potential drug interactions must be considered. Methods Due to a lack of clinical practice guidelines in the literature and the absence of guidelines issued by dental governing bodies, we attempted to consolidate the existing challenges and propose a model for managing psychiatric special needs patients. Results and discussion Based on the current evidence, we hereby recommend ‘psychiatric dental consultation liaison’ (PDCL) services as the acceptable framework for the management of dental patients with mental health problems in special care dentistry. Conclusion PDCL services will favour both dentists and patients as it includes psychiatric consultation and interventions that will result in the positive execution of comprehensive dental treatment care.


Introduction
'Special needs' or 'special care' patients refer to individuals whose physical, emotional, social, and intellectual skills fall remote of the accepted normal in regards to the existing standards of growth and development and who require special and/or supplementary care throughout their life [1]. Globally, as per the World Health Organization (WHO), one in every eight people lives with mental health problems. The Comprehensive Mental Health Action Plan of 2013-2030 issued by the WHO recommends that people with psychiatric problems should not be stigmatized and discriminated against in their access to high-quality healthcare services to promote their health recovery [2]. In general, mental health is described as a level of well-being in which the individual identifies the skills to cope with routine stressful situations of life and can work effectively and fruitfully by making adequate contributions to society. The indicators of good mental health include emotional, psychological, and social well-being with the ability to learn, manage emotions, build relationships, and cope with uncertainty. Mental or psychiatric illness is referred to as health conditions that are manifested by changes in perception, thinking, behaviour, or mood, or in a combination of all the factors that are related to distress and/or limited functioning [3].
There has been a recognized correlation between dental health and quality of life and self-respect. Oral diseases in patients with mental health problems are often overlooked due to patients' lack of motivation, lack of awareness, poor economic status, phobias, and unwelcoming attitudes by dentists. Hence, this article aims to create a set of clinical practice guidelines for dentists in treating patients with mental health disorders as not much substantial information is currently available in the literature. The objective is to bridge the knowledge gap among dental practitioners and establish a multisectoral treatment approach in delivering oral health care. 1 1 The International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) categorizes mental and behavioural disorders using certain codes for standardization in referencing ( Table  1) [4]. Based on the available literature, we could summarize the general and behavioural aspects of individuals with mental health problems as in Table 2. Based on the available updates, we have proposed our algorithm for the management of dental problems in mental health disorder patients who report for dental care.

Identification of mental health problems
The common psychiatric problems encountered in dental practice, as recognized and described by the American Dental Association (ADA) are anxiety disorders, mood disorders, psychotic disorders, and eating disorders [5]. Anxiety disorders include generalised anxiety disorder (GAD), obsessive-compulsive disorder (OCD), phobias, post-traumatic stress disorder (PTSD), mood disorders including bipolar disorder, major depressive disorder (MDD), psychotic disorders including schizophrenia, eating disorders like anorexia nervosa and bulimia nervosa. Mental health problems are classified as (i) identifiable brain disease (organic) and (ii) no obvious brain structural abnormality (functional), or (i) psychosis and (ii) neurosis. The ICD-10 covers all mental health and behavioural disorders from F00-F99 as listed in Table 1 [4]. Therapies for mental health problems include conventional psychotherapy, psychoactive medications, and cognitive behavioural therapy (CBT).

Identification of determinants that affect mental health
The determinants of mental health are neurotransmitters secreted in the brain like acetylcholine (ACh), epinephrine (adrenaline), dopamine, endorphins and enkephalins, gamma-aminobutyric acid (GABA), glutamate, neuropeptide Y, noradrenaline, oxytocin, phenylethylamine, serotonin (5-hydroxytryptamine, 5-HT), and substance P. There is also recent evidence that relates to neuroimmunomodulation and psychiatric disorders. Poor oral health also precipitates mental health disorders [6,7]. The imbalance in cytokine production namely interleukin (IL)-6, IL-1β, and interferon (INF)-γ with immunosuppression due to periodontal diseases also play a role in the etiopathogenesis of MDD. Understanding this is essential as periodontal diseases are to be effectively managed to prevent the further progression of existing mental health problems [8].

Identification of risk factors in patients with mental health problems in dentistry
The general and behavioural aspects of various mental health problems are listed in Table 1. This gives a clear picture of the requirement of dental and mental health providers to integrate tailored support to impart overall health and well-being by better patronization regardless of their immediate oral health requirements [9]. It is important to recognize the patient as a whole rather than having tunnel vision toward their dental needs only. Another challenge for these special needs patients is polypharmacy in psychiatry where two or more psychiatric medications are given to the patient [10]. This has widened the role of oral physicians to a broader spectrum of learning and keeping par with developments and guidelines in pharmacology while prescribing drugs in dental offices to avoid unwanted drug interactions for patients ( Table 2).

Identification of psychotropic drugs affecting oral health and its interactions
The commonly used drugs in psychiatric care [11][12][13] are antidepressants that include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCA), monoamine oxidase inhibitors, antipsychotics that include typical (older type) antipsychotics and atypical (newer type) antipsychotics, anxiolytics or sedatives that includes benzodiazepines, beta-blockers, psychostimulants, and anticholinergic antiparkinsonian drugs, and drugs for bipolar disorders that include carbamazepine, lamotrigine, lithium, and sodium valproate. The most common side effects of psychotropic drugs are xerostomia leading to candidiasis and dental caries by antidepressants and SSRIs, bruxism in antipsychotics and psychostimulants, postsurgical bleeding due to thrombocytopenia by sodium valproate, and hypersalivation with clozapine. Also, the interactions between psychotropic drugs and drugs commonly prescribed in dental practice are to be known.

Identification of psychotropic drugs that interact with common dental drugs
The common drugs prescribed in dental care are nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, opioids, and tramadol. NSAIDs interact with sodium valproate and SSRI and prolong bleeding [14]. NSAIDs and antibiotics react with lithium, the common antipsychotic drug, to potentiate and increase its toxic defects by reducing renal clearance. Opioids and tramadol interact with antipsychotics or tricyclic antidepressants and lower the seizure threshold [15]. Monoamine oxidase inhibitors are not to be given with tramadol and pethidine as it increases the susceptibility of hypertension and other components of the autonomic nervous systems. Tramadol interacts with antidepressants and causes life-threatening serotonin syndrome due to the overactivation of 5HT-1A and 5HT-1B receptors with most patients reporting in emergency care within six hours [16]. The patients present with altered mental status, muscle rigidity, peripheral hypertonicity, and truncal rigidity leading to respiratory failure if untreated. The macrolides prescribed for dental infections interact with carbamazepine and valproate concentrations with synergistic action and increase drug levels in circulation by CYP3A4 inhibition [17]. Antibiotics increase lithium concentration by reducing renal clearance [18]. When carbamazepine is given concurrent with doxycycline, carbamazepine decreases the doxycycline half-life by up to 50% [19]. Macrolides interact with antipsychotics, tricyclic antidepressants, fluoxetine, or venlafaxine leading to QT prolongation [20].

Discussion
There is a bidirectional relationship between dental and mental health [21]. Despite significant progress in dentistry with advanced technologies implemented in practice, patients with mental health problems do not get access to adequate oral health care. This is due to stigmas surrounding both the dentist and the patient when it comes to treating these special care patients. Also, various other barriers like dependency on family members for travel to the dentist's office and treatment expenses also exist. Dentists' ethical and moral professional duty is to evaluate them without preconceived notions and hesitations and welcome them for proper dental care in the same manner as any healthy individual. Dentists' lack of knowledge and skill in special needs dentistry has been considered a barrier to dental healthcare. Similarly, psychiatrists lack training in screening for oral health unless patients complain of dental symptoms verbally. Hence, it is the need of the hour to bridge this professional gap among practitioners of oral and mental health.
Preventive dentistry must be emphasized as most patients with mental health problems neglect oral healthcare, which draws subsequent dental problems. The dentist must undergo special care or special needs dentistry training in dealing with patients with mental health problems. Extreme empathy, patience, and tact are necessary with essential knowledge of adverse reactions to their common drugs, and potential legislative issues in treating them. The liaison between psychiatrists and dentists is necessary and consultation liaison models have to be created for treating patients with mental health problems. Hence, the proposed framework of Psychiatric Dental Consultation Liaison (PDCL) services is attaining success and popularity for a confident approach towards oral care delivery among dentists [22][23].
In PDCL services, when a patient with a mental health problem reports a dental complaint, it is advised to include psychiatric consultation in effective behaviour management for better patient compliance and motivation toward treatment. The algorithm for using PDCL is described in Figure 1. This multisectoral approach would be more beneficial if the liaison exists among professional circles so that psychiatrists can also be made aware of the early detection of dental problems, and subsequent referrals to dental treatment when deemed necessary. Scheduled oral screenings are to be done every six months for patients with mental health problems irrespective of outpatient care or institutionalized care for the evaluation of oral hygiene status and to reduce the burden of disease progression.

FIGURE 1: Algorithm in the management of dental patients with mental
health problems in special care dentistry PDLC services apart from evaluation and issuing clearance by the psychiatrist for invasive procedures in dentistry also cover a range of services from behavioural relaxation techniques, antipsychotics, hypnotics, antidepressants, hypnosis, biofeedback, rational emotive behavioural therapy (REBT), CBT, and anxiolytics. This transparent consultation enables the patient or patient's caregiver to choose between various behaviour modification techniques and thereby lessens the susceptibility to drug interactions. Additionally, this also overcomes the dentist's barrier and stress in executing proper comprehensive care and boosts the quality of treatment performance.
Another valuable tool that needs to be included in the management of dental patients with psychiatric problems in special care dentistry is clinical audits [21]. This quality improvement process enables reporting the hurdles in treatment care with a candid and supportive approach so that new guidelines and protocols can be created for a conducive professional environment that is built upon compassion in delivering treatment care. The auditing can be prospective or retrospective. This includes topic preparation, selection criteria, measuring outcomes, improvement implementation, and sustaining growth [24].
The types of oral health interventions are educational, physical, a combination of behavioural and educational elements, and a combination of educational and physical elements [25]. However, no single intervention can suit all groups of individuals due to the diversity of mental health problems. To date, no policies have been issued by any governing bodies in India, which is the need of the hour. Therefore, an integrated, multidisciplinary, tailored toolkit is mandatory in approaching treatment planning for patients with mental health problems.

Conclusions
We recommend PDCL services as an indispensable aid for psychiatric patients who require dental care. This framework supports a better understanding among oral physicians and clinical psychiatrists for early diagnosis of health issues and formulation of a proper treatment plan for the welfare of the patient without compromising their comfort. In special care dentistry, this professional liaison and mutual reciprocation eventually leads to complete successful treatment execution without breaks in appointment schedules for individuals with mental health disorders and thereby results in a heightened sense of physical, social, and psychological well-being. Also, future research has to be conducted examining the relationships between oral health-related quality of life [OHRQoL] and diagnosed mental health problems to explore further insights.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.