Snehal Kadia, MD

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Poor oral health is common among mentally ill people and is related to inadequate nutrition, poor self-care, substance abuse, and medication side effects.¹ Poor oral hygiene is a significant problem because it results in dental pathol­ogy that has an adverse influence on the whole body.

Compared with the general population, mentally ill patients are 3 times more likely to have their teeth removed.² In a survey of mentally ill adults, 92% were found to have tooth decay—of which 23% were untreated and 40% smoked tobacco.³ Approximately 9% have periodontal disease, which most often occurs in those who smoke cigarettes.⁴

Lifestyle contributors
Drug abuse facilitates dental diseases, as evidenced by the high rate of caries among methamphetamine users.⁵ The drug induces xerostomia, encouraging users to drink sweetened beverages; this, combined with limited oral care, results in profound dental decay (“meth mouth”). Oral cocaine users often exhibit dental ero­sions or abrasions, gingival lacerations or necrosis, and mucosal lesions. Smoking Cannabis is associated with an increased rate of gingivitis, alveolar bone loss, leu­koplakia, and oral papilloma or other can­cers.5 Heroin users are at increased risk of tooth decay, periodontal disease, and oral infection.⁵

Alcohol consumption increases the risk of oral cancer. Long-term alcohol use sup­presses bone marrow function, causing leukopenia and resulting in immunosup­pression and an increased incidence of dental infections.⁶ Excessive alcohol con­sumption also can cause thrombocytope­nia and bleeding, which can complicate dental procedures.

Smoking cigarettes increases the inci­dence of periodontal disease, especially necrotizing gingivitis and candidiasis.⁷ Ninety percent of patients with schizo­phrenia smoke—compared with up to 70% of patients with other psychiatric disor­ders, and 19% of the general population.^7,8 Physiologic aspects of schizophrenia rein­force the smoking habit.⁷

Somatic ailments. Psychiatric disorders are strongly associated with diabetes, obe­sity, hypertension, stroke, heart disease, and arthritis, all of which contribute to oral pathology. Older age, greater dysfunction, longer duration of illness, and smoking are predictors of adverse dental outcomes.

Anxiety, depression, stress—all of these these disorders increase the circulating level of cortisol, thus raising the risk that peri­odontal disease will progress.⁹ Periodontitis increases the risk of stroke and heart attack by accelerating atherosclerotic plaque for­mation.¹⁰ Depression, anxiety, and substance abuse can lead to temporomandibular disor­ders that cause pain and restrict jaw move­ment.¹¹ Stressed patients may experience muscle tension and bruxism, which can lead to temporomandibular joint discomfort.

Eating disorders. Patients who induce vomiting may exhibit enamel erosions (especially on the anterior maxillary teeth), increased tooth hypersensitivity, decay, and wear on dental restorative work.

Atypical odontalgia, characterized by chronic, burning pain in teeth and gums, is associated with depression and anxiety.¹¹ Misdiagnosis can result in extractions or procedures without an appropriate indica­tion and failure to alleviate the pain. 

Medication side effects. Xerostomia can increase the risk for caries, periodontal disease, and oral infections such as candi­diasis, glossitis, stomatitis, and parotitis.9 Extrapyramidal side effects (tardive dyski­nesia, dystonia) may cause tooth damage and make managing dentures difficult.⁶

What to tell patients, and what you can do for them
Encourage your patients to reduce their sugar intake, brush and floss regularly, and work to stop smoking or ingesting sub­stances of abuse. Teach appropriate hygiene and nutrition, which reduces the risk of den­tal caries, infection, and related problems. Recommend periodic oral health screening and how to secure such dental care.

From your position of familiarity with patients’ psychopharmacotherapy, make an effort to personalize and adjust their regimens when dental disease is present to address concerns about oral health that can be caused by medication side effects.

A multidisciplinary approach with patient advocacy, involving you and the patient’s dentist and primary care physi­cian, facilitates health care and works to offer the patient access to global medical services.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Joint disease is the most common cause of disability and the source of considerable psychological distress. In the United States, 50 million adults complain of joint pain; in 2007, 1.5 million people suffered from rheumatoid arthritis (RA). A chronic inflammatory autoimmune disease of joints, RA can involve almost all organs.¹

The link to mental illness

Mental illness in RA patients often is underdiagnosed and undertreated. These missed opportunities contribute to poor compliance with medical therapy, suboptimal therapeutic response, greater disability, and diminished quality of life.²

Limited mobility, chronic pain, sleep disturbance, fatigue, and immunological factors predispose RA patients to depression and anxiety.³ The proinflammatory cytokines, tumor necrosis factor-α (TNF-α), interleukin 1 (IL-1), IL-6, and interferon-g have a role in inducing affective symptoms. There also is a relationship between an elevated IL-17 level and anxiety.

Research substantiates a relationship between RA and depression.³ The prevalence of affective illness is approximately 6% among the general population, and 13% to 30% among RA patients.⁴ In arthritic populations, 52% exhibit depression and anxiety; joint discomfort contributes to insomnia in 25% to 42% of cases.⁴

Arthritic pain persists despite suppressed inflammation, which suggests involvement of the CNS.⁵ Increased levels of IL-6 and TNF-α can cause insomnia and affect pain perception.⁶ Decreased conditioned pain modulation, a lower pain threshold, and pressure pain intolerance lead to increased pain awareness and heightened discomfort.

How can you help your patient who has RA?

Because the focus of care in RA is on the disease’s physical attributes, psychiatric symptoms sometimes receive less attention.⁷ And because arthritic symptoms overlap with anorexia, weight loss, fatigue, pain, and insomnia, affective illness can go unrecognized.

Depression rating scales can overestimate affective illness, but a history and follow-up questionnaire can facilitate an accurate diagnosis of depression and help determine the need for, and type of, intervention.

Selective serotonin reuptake inhibitors (SSRIs) are considered first‐line treatment of depression associated with RA.⁷ Although SSRIs for RA can be administered to the maximum recommended dosage, titration is advised in accordance with patient response and tolerance.

Tricyclic antidepressants are not as well tolerated in RA, especially in older patients; however, they have more of an analgesic effect, even at lower dosages.

Joint disease activity and mood are associated with sleep disturbance, and vice versa.⁵ Insomnia calls for patient education about sleep hygiene, avoiding caffeine and other stimulants, and an individualized appraisal of options for pharmacotherapy.

Alleviating RA pain is important for psychosocial health.⁸ Although the medical team’s emphasis should be on controlling inflammation to minimize joint damage and pain, be sure to address your RA patients’ mood symptoms to improve the quality of their life.

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Joint disease is the most common cause of disability and the source of considerable psychological distress. In the United States, 50 million adults complain of joint pain; in 2007, 1.5 million people suffered from rheumatoid arthritis (RA). A chronic inflammatory autoimmune disease of joints, RA can involve almost all organs.¹

The link to mental illness

Mental illness in RA patients often is underdiagnosed and undertreated. These missed opportunities contribute to poor compliance with medical therapy, suboptimal therapeutic response, greater disability, and diminished quality of life.²

Limited mobility, chronic pain, sleep disturbance, fatigue, and immunological factors predispose RA patients to depression and anxiety.³ The proinflammatory cytokines, tumor necrosis factor-α (TNF-α), interleukin 1 (IL-1), IL-6, and interferon-g have a role in inducing affective symptoms. There also is a relationship between an elevated IL-17 level and anxiety.

Research substantiates a relationship between RA and depression.³ The prevalence of affective illness is approximately 6% among the general population, and 13% to 30% among RA patients.⁴ In arthritic populations, 52% exhibit depression and anxiety; joint discomfort contributes to insomnia in 25% to 42% of cases.⁴

Arthritic pain persists despite suppressed inflammation, which suggests involvement of the CNS.⁵ Increased levels of IL-6 and TNF-α can cause insomnia and affect pain perception.⁶ Decreased conditioned pain modulation, a lower pain threshold, and pressure pain intolerance lead to increased pain awareness and heightened discomfort.

How can you help your patient who has RA?

Because the focus of care in RA is on the disease’s physical attributes, psychiatric symptoms sometimes receive less attention.⁷ And because arthritic symptoms overlap with anorexia, weight loss, fatigue, pain, and insomnia, affective illness can go unrecognized.

Depression rating scales can overestimate affective illness, but a history and follow-up questionnaire can facilitate an accurate diagnosis of depression and help determine the need for, and type of, intervention.

Selective serotonin reuptake inhibitors (SSRIs) are considered first‐line treatment of depression associated with RA.⁷ Although SSRIs for RA can be administered to the maximum recommended dosage, titration is advised in accordance with patient response and tolerance.

Tricyclic antidepressants are not as well tolerated in RA, especially in older patients; however, they have more of an analgesic effect, even at lower dosages.

Joint disease activity and mood are associated with sleep disturbance, and vice versa.⁵ Insomnia calls for patient education about sleep hygiene, avoiding caffeine and other stimulants, and an individualized appraisal of options for pharmacotherapy.

Alleviating RA pain is important for psychosocial health.⁸ Although the medical team’s emphasis should be on controlling inflammation to minimize joint damage and pain, be sure to address your RA patients’ mood symptoms to improve the quality of their life.

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Joint disease is the most common cause of disability and the source of considerable psychological distress. In the United States, 50 million adults complain of joint pain; in 2007, 1.5 million people suffered from rheumatoid arthritis (RA). A chronic inflammatory autoimmune disease of joints, RA can involve almost all organs.¹

The link to mental illness

Mental illness in RA patients often is underdiagnosed and undertreated. These missed opportunities contribute to poor compliance with medical therapy, suboptimal therapeutic response, greater disability, and diminished quality of life.²

Limited mobility, chronic pain, sleep disturbance, fatigue, and immunological factors predispose RA patients to depression and anxiety.³ The proinflammatory cytokines, tumor necrosis factor-α (TNF-α), interleukin 1 (IL-1), IL-6, and interferon-g have a role in inducing affective symptoms. There also is a relationship between an elevated IL-17 level and anxiety.

Research substantiates a relationship between RA and depression.³ The prevalence of affective illness is approximately 6% among the general population, and 13% to 30% among RA patients.⁴ In arthritic populations, 52% exhibit depression and anxiety; joint discomfort contributes to insomnia in 25% to 42% of cases.⁴

Arthritic pain persists despite suppressed inflammation, which suggests involvement of the CNS.⁵ Increased levels of IL-6 and TNF-α can cause insomnia and affect pain perception.⁶ Decreased conditioned pain modulation, a lower pain threshold, and pressure pain intolerance lead to increased pain awareness and heightened discomfort.

How can you help your patient who has RA?

Because the focus of care in RA is on the disease’s physical attributes, psychiatric symptoms sometimes receive less attention.⁷ And because arthritic symptoms overlap with anorexia, weight loss, fatigue, pain, and insomnia, affective illness can go unrecognized.

Depression rating scales can overestimate affective illness, but a history and follow-up questionnaire can facilitate an accurate diagnosis of depression and help determine the need for, and type of, intervention.

Selective serotonin reuptake inhibitors (SSRIs) are considered first‐line treatment of depression associated with RA.⁷ Although SSRIs for RA can be administered to the maximum recommended dosage, titration is advised in accordance with patient response and tolerance.

Tricyclic antidepressants are not as well tolerated in RA, especially in older patients; however, they have more of an analgesic effect, even at lower dosages.

Joint disease activity and mood are associated with sleep disturbance, and vice versa.⁵ Insomnia calls for patient education about sleep hygiene, avoiding caffeine and other stimulants, and an individualized appraisal of options for pharmacotherapy.

Alleviating RA pain is important for psychosocial health.⁸ Although the medical team’s emphasis should be on controlling inflammation to minimize joint damage and pain, be sure to address your RA patients’ mood symptoms to improve the quality of their life.

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.