Good oral health is an important element of mental and physical health. Previous reviews have highlighted that oral health is poorer in those with eating disorders and severe mental illness.

The main aim of this review was to determine the association between these common psychological disorders and poor oral health. A secondary aim was to see if there were any differences in oral health between people with dental phobia and other common mental disorders.

Methods

Searches were conducted in the Medline, PsycInfo and Embase databases. Studies focusing on common mental disorders (CMDs) ie. primary diagnoses of depression, generalised anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and phobias were included. Four dental outcomes were considered dental erosion, caries, periodontal disease and tooth loss.

Study selection, was carried out independently by two reviewers with study quality being assessed using the Newcastle-Ottawa Scale (NOS). Meta-analysis was conducted using random effects models because of the level of heterogeneity in the included studies.

Results

• 26 studies involving a total of 334,503 patients were included.
• 19 studies related to depression and/or anxiety, and seven dental phobia/anxiety.
• Oral Health status was ascertained by dental examiners in 19 studies.
• 6 studies reported on dental caries, patients with CMDs had more decayed, missing and filled surfaces than controls. Two studies reported on the presence of caries as a dichotomous measure found that people with common psychological disorders had higher rates of decay OR = 1.21(95%CI;1 .07–1.37). For a subgroup with dental anxiety OR=1.69;(95%CI; 0.22–3.15).
• 15 studies reporting on periodontal disease were included in a meta-analysis. There was no association between psychiatric status and periodontal disease although a single study reported a positive association be- tween panic disorders and periodontal disease.
• 10 studies assessed tooth loss and overall there was a significant association between CMDs and tooth loss.
• A single study compared rates of anxiety in patients with tooth erosion finding no differences.

Conclusions

The authors concluded

In conclusion, the increased focus on the physical health of people with psychiatric illness should include consideration of oral health. Interventions should include advice on lifestyle and oral hygiene, management of iatrogenic dry mouth, and early dental referral.

Comments

The authors have adopted a sound methodological approach for this review. However they highlight a number of limitations to the available evidence related to the cross-sectional design of the included studies. They note that only 3 of the studies established psychiatric caseness using gold standard approaches and that only 15 studies adjusted for a range of potential confounders. To address these issues the authors carried out a number of sensitivity analyses and these confirmed that this did not affect the direction of the findings. The key finding is that patients with CMDs have a greater risk of dental caries and tooth loss although interestingly there was no difference in the levels of periodontal disease. As highlighted in the paper the side effects of psychotropic medications like antipsychotics, antidepressants, and mood stabilizers include dry mouth, and reduced salivary flow is a risk factor for caries.

The negative impact that dental problems, pain, poor dental appearance and problems with both speaking and eating can add to social withdrawal, isolation and low-self-esteem, so the call form the authors for advice on lifestyle, oral hygiene, and early dental referral to help management of dry mouth to prevent development of dental problems is welcome.

Links

Primary paper

Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders – a systematic review and meta-analysis. J Affect Disord. 2016 Aug;200:119-32. doi: 10.1016/j.jad.2016.04.040. Epub 2016 Apr 21. Review. PubMed PMID: 27130961.

Other references

Original review protocol on PROSPERO database

Dental Elf – 2^nd Nov 2015

Eating disorders associated with poor oral health

Mental Elf – 16^th Mar 2015 – Poor oral health and mental health what are the links

Dental Elf – 8^th Sep 2011

Tooth loss three times higher in people with serious mental illness