Oral Health: Adults with Depression: A Guide for Dental Professionals

Oral Health Fact Sheet for Dental Professionals Treating Adults with Anxiety and Depression

Depression is an unpleasant, but not necessarily irrational or pathological, mood state characterized by sadness, despair or discouragement; it may also involve low self-esteem, social withdrawal, and somatic symptoms such as eating and sleep disturbance. (ICD 9 code 311.0). Depression is more than simply feeling “down in the dumps” for a few days; symptoms of depression last at least two weeks. (ICD 9 code 311.0; DSM-IV-TR)

Prevalence

• 7% of adults in any given year experience Major Depressive Disorder.
• Mean age of onset is 32 years.
• Depressive disorders are more common among females (approximately 2:1).

Manifestations

Clinical: most common signs of depression

• Decreased interest or pleasure in activities
• Significant change in weight or appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue
• Feelings of worthlessness or guilt
• Decreased concentration or indecisiveness
• Recurrent thoughts of death

Major Depressive Disorder – 6.7% prevalence rate.

Major depressive disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person’s ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person’s lifetime, but more often, it recurs throughout a person’s life.

Dysthymic Disorder (Dysthymia) – 1.5% prevalence rate

Dysthymic disorder is characterized by long-term (two years or longer) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

Bipolar Disorder – 2.6% prevalence rate Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder often develops in a person’s late teens or early adult years. At least half of all cases start before age 25

Oral Health Impacts

• Neglect of oral hygiene leading to increased risk of dental caries and periodontal disease
• Poor nutrition
• Drug-induced xerostomia
• Avoidance of necessary dental care

Other Potential Disorders/Concerns

• Patients with depression are at increased risk for engaging in high-risk behaviors (promiscuity, smoking, alcohol and drug abuse)

Management

Medication

The list of medications below are intended to serve only as a guide to facilitate the dental professional’s understanding of medications that can be used for Depression. Medication protocols can vary for individuals with Depression.

Patients with depression may be less likely to perceive a dental need and may have fewer dental check-up visits. They may also have decreased motivation for adequate oral hygiene and dental treatment-seeking

Dental Treatment and Prevention

• Obtain accurate medical history including medication regimen. Patients with depression may be reluctant to admit their use of medication for depression.
• Ask patient for medication updates at each appointment. Medication changes can affect the appropriate care of the patient from a medical and/or appointment management standpoint.
• Be supportive and non-judgmental. Discuss dental treatment with treating medical provider if needed.
• As needed for patients with xerostomia:
  • Educate on proper oral hygiene (brushing, flossing) and nutrition. Patients with depression are at increased risk of dental caries due to oral hygiene neglect, preference for carbohydrates due to reduced serotonin levels, and drug-induced xerostomia.
  • Recommend brushing teeth with a fluoride containing dentifrice before bedtime. After brushing, apply neutral 1.1% fluoride gel (e.g. Prevident 5000 gel) in trays or by brush for 2 minutes. Instruct patient to spit out excess gel and NOT to rinse with water, eat or drink before going to bed.
  • Recommend xylitol mints, lozenges, and/or gum to stimulate saliva production and caries resistance Look for signs of physical abuse during the examination. Note findings in chart and report any suspected abuse to Child Protective Services, as required by law. Abuse is more common in children with developmental disabilities and often manifests in oral trauma.

References

• Friedlander, A.H., Mahler, M.E. (2001) Major depressive disorder: Psychopathology, medical management and dental implications. J Am Dent Assoc, 132(5): 629-638.
• Becker, D. E. (2008) Psychotropic drugs: implications for dental practice. Anesthesia Progress, 55(3): 89-99.
• Deykin, EY., Buka, S.L., Zeena, T.H. (1992) Depressive illness among chemically dependent adolescents. Am J Psychiatry, 149(10):1341-1347.
• Anttila, S., Knuuttila, M., Yiostalo, P., Joukamaa, M. (2006) Symptoms of depression and anxiety in relation to dental health behavior and self-perceived dental treatment need. Eur J Oral Sci, 114(2):109–114.
• Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry Jun; 62(6):593-602.
• Numbers count: Mental Disorders in America
• NIH Institute for Depression Disorder and NIH Institute for Anxiety Disorder

Additional Resources

• NIH Institute for Depression Disorder and NIH Institute for Anxiety Disorder
• Free of charge CDE courses: NIDCR CDE (2 CDE hours)