Dental as Mental Health – Oral Health, Mental Health and Substance Use Treatment Integration at Community Health Centers of South-Central Texas

Did you know that addressing individuals’ oral health concerns is an effective strategy in improving outcomes for those living with mental health or substance use challenges? A growing body of research is demonstrating just that. 

The Relationship Between Oral Health, Mental Health and Substance Use Treatment

Having a mental health condition such as depression, anxiety or a substance use challenge can negatively impact one’s oral health. Vice versa, poor oral health can create or exacerbate challenges associated with mental health, cognitive health and substance use. For example:

  • People living with schizophrenia and other serious mental health conditions are three times more likely as those without mental disorders to lose all their teeth. 
  • People with eating disorders are five times as likely to suffer from tooth erosion. 
  • People using illicit substances experience higher rates of gum disease and tooth decay.

Extensive tooth loss and decay can impact mental wellbeing in many ways, such as impeding speech and the ability to eat, chew or swallow, restricting social contacts and job prospects, inhibiting intimacy, lowering self-esteem and negatively impacting overall quality of life. 

There are many “real-world” examples demonstrating the need for closer coordination across oral health, mental health and substance use treatment. In January 2022, the Food and Drug Administration (FDA) warned of dental problems associated with certain types of buprenorphine medicines used to treat opioid use disorder and pain. In what has been called “a dentist’s nightmare,” dental providers have been inundated with clients exhibiting mental health problems in the face of COVID-19, including dental anxiety and post-traumatic stress disorder. 

NIH (National Institutes of Health) “Call to Action” on Pain, Mental Illness, Substance Use Disorders and Oral Health: To participate completely in an integrated system of health care, oral health professionals must acquire new competencies related to the behavioral health aspects of substance use and mental health issues to provide optimal oral health care for, and appropriately refer, those with substance use and mental health challenges.

Note: Although this “Call to Action” focuses on the role oral health professionals can play to provide optimal care for individuals with behavioral health conditions, the reverse is also true – behavioral health providers should acquire new skills and competencies to provide optimal care for individuals with untreated dental needs.

Successful Integration Efforts

Luckily, there is hope. Impressive outcomes have emerged from several projects, like these:

Community Health Centers of South-Central Texas (CHCSCT) is an exemplary organization working to better coordinate care across oral health, mental health and substance use treatment. CHCSCT is a Federally Qualified Health Center (FQHC) with eight clinical sites serving five counties in South Central Texas. In 2016 screening for depression and substance use began within the organization’s seven dental departments. All patients aged 12 and above at the medical and dental clinics received a Patient Health Questionnaire-9 (PHQ-9) form or the modified version for adolescents, to screen for depression at every visit. This form also incorporates the CAGE Substance Abuse Screening Tool to assess for substance use disorders.

Elevated PHQ-9 scores of 10 or higher are reported to a behavioral health consultant (BHC), who is embedded, either in person or via telehealth, within each of the seven sites offering dental care. Timely behavioral health interventions are provided as needed, often scheduled the same day, depending on the urgency. In 2020, 446 of 1,246 dental clients received PHQ-9 screenings, and 150 who received the PHQ-9 needed behavioral health intervention.

CHCSCT recently added several oral health-related screening questions to their electronic medical record (EMR) form:

  1. Do you have a dentist you regularly visit? 
  2. When was your last dental visit?
  3. Do you have any chief complaints related to your mouth and teeth like cavities, bleeding gums or dry mouth? 

Behavioral health providers use these questions to make referrals to the dental department as needed. Additionally, CHCSCT implemented a new software system that enables dental and behavioral health providers to capture integrated appointments and monitor patients’ status of necessary care. The BHC, medical staff and dental provider have routine morning gatherings to review mutual patients on the schedule and discuss the possible need for a behavioral health consultation, referral or follow-up. CHCSCT’s behavioral health providers also train dental staff on trauma-informed care and motivational interviewing, while dental staff train behavioral health providers on the importance of oral health in overall health, leveraging the free Smiles for Life National Oral Health Curriculum

According to Dr. Urankar, CHCSCT’s chief dental officer, this integration work has yielded many positive benefits, including:

  1. Behavioral health screenings help providers identify barriers to care and encourage looking beyond oral health toward more whole person care. 
  2. BHCs have alleviated dental anxiety for many patients, improving compliance with dental care. 
  3. Leveraging dental offices to help connect patients to behavioral health services has increased access to a significantly underutilized form of care. This approach helps normalize conversations about mental health and substance use and offers a ”no wrong door” approach to treatment. 
CHCSCT Oral Health and Behavioral Health Integration: Client Success Story “A healthy-looking middle aged male client came to our office for his regular dental visit. Upon running the depression screening, his PHQ-9 scores turned out to be very high. I referred him to the behavioral health consultant for same-day counselling due to the high scores. He had had a downpour of emotions during the conversation and reported feeling at ease after the interaction. Turns out, he was a victim of domestic violence and was going through a divorce. The behavioral health consultant helped connect him with resources and secured some follow up appointments. A week later, the patient expressed gratitude for the relief provided.”

Future Implications for Oral Health Integration

Closer integration of oral health, mental health and substance use treatment will only increase as we continue to see the positive outcomes from pioneering providers like CHCSCT, that are on the front lines addressing this rising need. While rates of depression and anxiety were already on the rise in the United States, the COVID-19 pandemic has contributed to unimaginable grief, trauma, isolation and depression. 

Behavioral health screenings in dental offices eliminate another barrier by providing additional means for people to get the care they need. With funding from the CareQuest Institute for Oral Health, the National Council for Mental Wellbeing is working with 16 provider organizations across the country to build the evidence base for more integrated oral health, mental health and substance use care by testing different integrated care models. In the meantime, we should emulate the “food-as-medicine” movement by widely promoting “dental-as-mental health.” 

Guest Author

Rachael Matulis
MPH, Principal
Bowling Business Strategies