Psychiatry in Dentistry

Enhanced CPD DO C

Karishma Dusara Hannah Cousins

Management of Severe Mental

Illness in the Dental Setting:
A Grey Matter?
Abstract: Dental professionals treat patients with a range of mental illnesses. This article focuses on severe mental illness (SMI) and
highlights the challenges that people with a severe mental illness may experience when accessing dental care. Additionally, it looks at the
oral implications of SMI and the management strategies that dental professionals can employ to support patients in the dental setting. This
article will not cover all mental illnesses and readers can also consult the recent series on mental health covered by Dental Update.
CPD/Clinical Relevance: Severe mental illness is a condition that may frequently present in patients treated in primary dental care.
Therefore, it is essential dental professionals have an understanding of how this can affect dental care.
Dent Update 2024; 51: 43–47

Severe mental illness (SMI) is a term used
to describe a mental health condition
that has a significant, debilitating impact
on quality of life.1 Functional impairment
and/or limitation are key features of
a spectrum of conditions that include
schizophrenia and bipolar affective
disorder.1 Schizophrenia and bipolar
affective disorder are the main conditions
referred to under the umbrella of SMI and
are the focus of this review.
According to the Impact Mental
Health Report produced by NICE, around
0.9% of the UK population have been
diagnosed with an SMI.2 Over 550,000
people registered with a general medical
practitioner (GP) were diagnosed with
schizophrenia, bipolar affective disorder,
or other psychoses in 2017–2018.2
Karishma Dusara, BDS (Hons), MJDF RCS Eng, DSCD RCS Eng, Specialty Trainee in
Special Care Dentistry, CDS-CIC Bedfordshire. Hannah Cousins, BSc (Hons), BDS, Dental
Officer, Community Special Care Dentistry, King’s College London.
email: karishma.dusara@cds-cic.co.uk
People with SMI have been reported
to be at a higher risk of dying 15–20 years
earlier than those without an SMI.3 While
causation is not clear cut, there are a
number of comorbidities that are more
common in this demographic and are
likely to contribute. In 2018, a Public
Health England analysis conducted on
patients registered with a GP, found
10 comorbidities present at a higher
rate in people with SMI compared
to those without SMI (Figure 1).3
Additionally, the data showed that those
diagnosed with SMI were twice as likely
to have four or more of the above-
mentioned comorbidities.3
Multiple risk factors have been linked
to the increased morbidity and mortality
in this demographic. These include poor
nutrition; smoking; substance abuse; and
alcohol misuse.3 Notably these are all risk
factors for poor oral health.
Schizophrenia
Schizophrenia is a complex and long-term
mental health condition where patients
usually experience hallucinations and
delusions.4 Other symptoms may include
disordered speech, catatonic behaviour
and lack of motivation.4 Historically,
schizophrenia was divided into subtypes:
paranoid; disorganized; catatonic;
undifferentiated; and residual. This was
based on the Diagnostic and Statistical
Manual of Mental Disorders (DSM) IV.
However, these subtypes have now been
removed from diagnostic criteria in the
updated DSM V.5
It is estimated that 1 in 100 adults
may have an episode of schizophrenia
during their lifetime.5 Schizophrenia is
commonly diagnosed between the ages of
20 and 30 years. Men are more likely to be
diagnosed with schizophrenia than women,

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 Psychiatry in Dentistry
1.8 1.3
1.0
Prevalence (%)
10
5 than the general population.14 There is a
0 (DMFT) in this demographic compared
ity a s
s m
be th
O As rte
pe
Hy
Figure 1. Graph to show the prevalence of comorbidities in those diagnosed with SMI aged 15–74
years compared with a control.3 COPD: chronic obstructive pulmonary disease; CHD: coronary heart
disease; AF: atrial fibrillation; HF: heart failure.
but the causation underpinning this
difference is unknown. The aetiology is
yet to be fully elucidated and thought to
be multifactorial.6
There is, however, a strong familial
tendency. A large-scale Danish study on
twins found that there was a 33% risk
of both identical twins being diagnosed
with schizophrenia in their lifetime.7 This
risk is 7% for fraternal twins.7 Overall, it
was found that there was a 79% risk of
schizophrenia being inherited.7
Another proposed risk factor for
developing schizophrenia is cannabis
use. A systematic review found that
those already genetically predisposed
to schizophrenia, received a diagnosis
at an earlier age if they were a cannabis
smoker.8 Additionally, there is evidence
that cannabis use can worsen the
symptoms of schizophrenia and lead to
relapses.8 The review does however note
that the mechanism of action is unclear.8
Other potential risk factors for
schizophrenia include a traumatic life
event, imbalance of certain chemicals in
the brain, brain damage, low birth weight
and alcohol or drug misuse.9
Treatment usually involves cognitive
behavioural therapy as well as the
prescription of antipsychotics.6,9 These
may be second generation antipsychotics,
such as clozapine, or first-generation
antipsychotics, such as haloperidol.6,9
44 DentalUpdate
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 Prevalence in patients with SMI
 Prevalence in all patients
95% Confidence interval
1.8 Rate ratio (numbers in bold indicate
prevalence significantly higher in those
diagnosed with SMI)
1.9
2.1 0.9 1.2
1.6
0.9 1.5
r to peers without SMI.15,16 Illness duration
io
n te PD ce D ke AF HF
ns e CO n CH St
ro
Diab Ca
Physical health condition
Bipolar affective disorder
Bipolar affective disorder is a mental
health condition where a person’s mood
fluctuates between manic and depressive
phases which can last days to weeks.10 The
manic phase is characterized by an elated
mood, hyperactivity, racing thoughts,
poor judgement, and a reduced need for
sleep.10 In contrast, the depressive phase
results in a low mood, greater need to
sleep, withdrawal from social activities
and pessimism.10
According to the Adult Psychiatric
Morbidity Survey (APMS), 1.3 million
people in the UK have bipolar affective
disorder and there is a lifetime prevalence
of 1–2%.11 Two main types of bipolar
affective disorder have been identified.12
Bipolar type I is when there is mania with
or without depression and hallucinations
and delusion are common. Bipolar
type II disorder is diagnosed based on
one hypomanic phase and one major
depressive phase.12
The aetiology is thought to be multi-
factorial and is not yet fully understood;
however, both environmental and social
factors have been implicated.10 The main
causes identified include a stressful life
event or trauma, chemical imbalance, and
genetics.10 Many genome-wide association
meta-analyses have found a genetic link
with bipolar affective disorder.13 There is no
clear predilection for either biological sex.13
As well as psychological supportive
treatment such as cognitive behavioural
therapy, patients are prescribed
medications that include lithium,
anticonvulsants and antipsychotics.10
Oral health and SMI
A meta-analysis conducted in 2021 found
that people diagnosed with SMI were less
likely to visit the dentist or brush their teeth
growing body of evidence to show higher
scores for decayed, missing or filled teeth
has been proposed as one of the most
significant predictors of suboptimal oral
health, second only to the patient’s age.17
All of the above reinforce the importance of
consistent, lifelong preventive care for this
patient group.
Caries
A meta-analysis of case-controlled studies
found that people with schizophrenia had
higher scores of decayed, missing and filled
teeth and overall poorer oral health.18 There
are many reasons as to why people with
SMI can be at a higher risk of developing
caries. It has been suggested that they may
have an overall poor nutrition profile and
rely on food and drinks high in sugar, which
are cariogenic in nature.19 The behavioural
patterns in those with SMI can lead to
lapses in personal care as well as oral
hygiene.15 Motivation may fluctuate daily,
resulting in days where toothbrushing may
not take place.15 People with SMI will also
be on multiple medications that can cause
xerostomia and thus reduce the buffering
capacity of saliva.14
Periodontal health
Periodontal disease is a common oral health
issue in those with SMI. A meta-analysis
found that 50% of patients with SMI had
periodontal disease.15 A study conducted
in outpatient psychiatric care clinics in
London, found 93.9% of dentate patients
required periodontal treatment and 54.5%
required advanced periodontal treatment.20
As previously noted, poorer oral hygiene,
a higher prevalence of tobacco smoking
and diabetes in this demographic could be
suggested as aetiological factors.
A case series has also identified the
prevalence of gingivitis artefacta among
those with SMI.21 Gingivitis artefacta is self-
inflicted injury to the gingiva.22 This can
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 Psychiatry in Dentistry

Drug that interacts with lithium Adverse reaction and severity Manufacturer’s advice
Doxycycline and tetracycline Increased lithium toxicity Avoid or adjust dose
Severity: severe
Benzydamine Increased lithium toxicity Monitor and adjust dose
Severity: severe
Metronidazole Increased lithium toxicity Avoid or adjust dose
Severity: severe
NSAIDs Increased lithium toxicity and nephrotoxicity Monitor and adjust dose
Severity: severe
Table 1. Commonly prescribed drugs by dental professionals and their interactions with lithium.26

Antipsychotic General side effects Oral side effects

Clozapine (second generation) Sedation Hypersalivation
Weight gain
Seizures
Neutropenia
Postural hypotension
Haloperidol (first generation) Sedation Hypersalivation
Tardive dyskinesia (involuntary movement) Involuntary tongue movement as a result of
Parkinsonism tardive dyskinesia
Weight gain
Quetiapine (second generation) Sedation Xerostomia
Anxiety
Tachycardia
Neutropenia
Weight gain
Postural hypotension
Table 2. Common antipsychotics used for SMI and their general and oral side-effects.27

be as a result of ‘picking’ the gingiva using
fingernails or repeated trauma using an
object such as a pen.21 This can occur without
an associated psychiatric disorder.22 It can
result in permanent gingival tissue damage
and lead to severe gingival recession.22
Edentulism
Systematic reviews and meta-analyses have
found that people with SMI are 2.8–3.4 times
likely of being edentulous than the general
population.12,13 They were also found to
have 4.2 less teeth than adults without SMI
in the UK.22 This is due to the higher risk of
developing caries, periodontal disease, and
xerostomia, which inevitably increases the
likelihood of eventual tooth loss.
Tooth wear
Those with SMI can exhibit excessive
toothbrushing behaviours as well as bruxism
which can contribute to severe tooth
wear.14,15 SMI can also be associated with
other mental health conditions, such as
bulimia, which contributes to tooth wear.
Other potential causes could be chronic
excess alcohol intake or substance misuse.14,15
Xerostomia
Owing to the number of antipsychotic
or antidepressant medications a patient
with SMI may be prescribed, the risk of
xerostomia is increased.14 This will in turn
increase the risk of caries, periodontal
disease as well as oral candidiasis.15
Oral cancer
A survey conducted in a secure mental
health unit found that over 56% of those
who had been diagnosed with SMI were
smokers compared to 14% of the UK
population who were smokers.23 Alcohol
misuse has also been found to be higher in
those with SMI. The link between smoking
and oral cancer has been long established.24
Additionally, consumption of alcohol
has been shown to act synergistically in
increasing that risk.24 Therefore, education
and awareness of risk factor control in this
patient group is vital.
Impact of medication used in
the management of SMI
Lithium
This is a common drug used for patients
with bipolar affective disorder and is a
mood stabilizer.25 It helps to reduce the
number of depressive or manic episodes
and reduces their intensity. Long-term
use can induce lithium toxicity resulting
in reduced kidney or thyroid function.25
Lithium also has many drug interactions
with drugs commonly prescribed by dental
professionals.These are listed in the British
National Formulary (BNF) and outlined in
Table 1.26
Oral side effects of antipsychotics used in the
management of SMI
Antipsychotics are commonly used to help
manage SMI. If the patient is on medication

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 Psychiatry in Dentistry
for other comorbidities, polypharmacy
can increase the risk of xerostomia.27
Antipsychotics can cause multiple systemic
side effects, alongside those affecting the
oral cavity, as outlined in Table 2.
Practical dental management
Access
Multiple factors can negatively affect the
ability of those with SMI to access dental
care. This patient group may experience
dental anxiety, which can discourage
contact with necessary services.28
Additionally, patients with SMI may
have previously felt stigmatized or had a
negative dental experience. Homelessness,
a lack of fixed abode or an erratic lifestyle
can also be deterring factors in seeking
treatment.1 Dental professionals should
make reasonable adjustments for people
with SMI. Patient education around
the services available and referrals to
appropriate settings such as community
dental services may be indicated.
Communication and capacity
Owing to the nature of the medication
taken for the management of SMI,
patients can appear distant, drowsy, and
uninterested (Table 2). Capacity may be
transient, but that does not mean it is not
present. It may be necessary to seek a
second opinion and/or to bring a patient
back on an alternative day or at a different
time to make an assessment. Mental
capacity should be assessed on a case-
by-case basis using up-to-date legislative
frameworks as a guide. The five main
principles, detailed in the Mental Capacity
Act (2005), are outlined below: 29
 Assume a person has mental capacity
unless proved otherwise;
 Reasonable steps must be taken to
help support the person to make
a decision;
 A person with capacity can make an
unwise decision;
 The least restrictive option should
be chosen;
 Any decision taken on behalf of the
person should be in their best interests
Conscious sedation
Owing to the high prevalence of dental
anxiety, patients with SMI may request
conscious sedation.30 Although there is no
direct absolute contra-indication for the
use of intravenous sedation in people with
SMI, care must be taken if the patient has
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multiple comorbidities that may render
them unsuitable.30 The patient may be on
certain antipsychotics or benzodiazepines
that may increase the sedative effect of
midazolam.30 Alternative methods, such
as inhalation sedation with behavioural
management, may be recommended.
Oral health advice
Owing to the high risk of caries,
periodontal disease and oral cancer,
patients with SMI should be on a
frequent recall as per NICE guidance.31
It is important to follow the ‘Delivering
Better Oral Health’ guidance and
implement a high level of prevention,
along with smoking cessation, where
appropriate.32 As discussed previously,
oral hygiene may be inconsistent, in
line with fluctuating moods, and dental
professionals should be mindful of this.
A 12-month randomized controlled
trial found that an intensive oral health
promotion programme was effective.33
This included group sessions twice a
week. This highlights the need to provide
a tailored oral health prevention plan for
people with SMI.
Dental treatment
It is important to manage expectations for
this patient group. Restorative treatment
may need to exclude any complex
prosthodontics owing to the high caries
risk.15 Palliative periodontal treatment
may be the only option if oral hygiene
cannot be improved for patients in this
group. If the patient has uncontrollable
facial movements (tardive dyskinesia)
(Table 2), denture work may not be
possible. If the patient has a history of
substance and alcohol misuse, it may be
necessary to obtain blood test results
from the patient’s physician prior to
dental extractions. This will help to assess
the need for additional haemostatic
measures. Those within this patient group
may also require referral to specialist
services or community dental services.
Conclusion
Practical and sustainable adaptation
of care delivery in patients with SMI is
vital to ensure the dental needs of this
patient demographic are met. The ‘Five
Year Forward View for Mental Health’34
published in 2016, set out a framework
for the NHS to improve services in this
domain. Building on this, the 2022 ‘Right
to Smile’ Oral Health Consensus statement
focuses on more specific oral health
needs to provide a thorough, evidence-
based resource for dental professionals.35
SMI is often associated with
stigma, discrimination, socio-economic
disadvantage, unemployment, reduced
quality of life and poor physical health.1
The recent introduction of integrated care
systems within NHS England in July 2022
supports and encourages cross-team
liaison in co-ordinating care for patients.36
Therefore, greater collaboration is
necessary between healthcare providers
in order to improve the overall general
health of people with SMI. The provision
of consistent, appropriate and focused
dental care in this demographic will
continue to be a vital piece of the puzzle.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
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