Oral health and mental health

Oral health and mental health

This article explores the measures dental health care professionals (DHCPs) may need to incorporate into their care, to ensure any special needs are met when dealing with patients with possible mental health issues

This article is equivalent to one hour of Enhanced CPD

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Learning Outcomes: A | B | C | D

Aims & Objectives

The aim of this article is to explore the measures dental health care professionals may need to incorporate into their care, to ensure any special needs are met when dealing with patients with possible mental health issues.

On completing this CPD session, the reader will:

  1. Understand the types and prevalence of mental health issues affecting the population
  2. Understand the effect this may have on a patient’s oral health
  3. Understand how to meet the specific needs of any patient with a mental health problem
  4. Understand the findings of Montgomery v Lanarkshire Health Board 2015 and its effect on obtaining consent for dental treatment
  5. Understand the significance of the Mental Capacity Act 2005 in identifying a patient lacking capacity.

This article explores the measures dental health care professionals (DHCPs) may need to incorporate into their care, to ensure any special needs are met when dealing with patients with possible mental health issues

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According to the charity MIND, approximately 1 in 4 people in the UK will experience a mental health problem each year.1Breaking this figure down, in 2016 it was calculated that among every 100 people in the UK, the following number were suffering from the mental health conditions listed below1:

  1. Mixed anxiety and depression – 7.8
  2. Generalised anxiety disorder – 5.9
  3. Post traumatic stress disorder (PTSD) – 4.4
  4. Depression – 3.3
  5. Antisocial personality disorder – 3.3
  6. Phobias – 2.4
  7. Borderline personality disorder – 2.4
  8. Bipolar disorder – 2.0
  9. Obsessive compulsive disorder – 1.3
  10. Psychotic disorder – 0.7
  11. Panic disorder – 0.6.

A two-way street

There is considered to be a ‘two-way association between oral and mental health’: ‘In one direction, about one half of all dental patients experience some anxiety about their dental visits, and in some cases this leads to dental phobia, a form of specific phobia.

Perception of dental pain may also be exacerbated by depression or anxiety, regardless of the degree of oral pathology. For example, burning mouth syndrome is a somatic symptom disorder in people with clinically healthy oral mucosa that is often associated with depression or anxiety.’2

In the other, many psychiatric disorders, such as severe mental illness, affective disorders, and eating disorders, are associated with dental disease: These include erosion, caries, and periodontitis.’2

It is estimated that people with severe mental illness are 2.7 times more likely to lose their teeth, when compared with the general population.2This is the result of a number of factors, as mentioned above, as well as including poor nutrition and oral hygiene, misuse of comorbidities such as tobacco, alcohol and non-prescription drugs, and the side-effects of some prescribed medications.2

Xerostomia, for example, is a frequent side effect of commonly prescribed psychotropic medications, including antipsychotics, antidepressants and mood stabilisers.3In such cases, ‘[…] xerostomia should be considered, monitored, and managed. Patients should be asked whether their saliva seems decreased and whether they have any trouble swallowing, speaking, or eating dry foods. Additional questions include the presence of lip dryness, cracking, halitosis, and mouth sores.2

In addition, ‘The basic messages for oral health promotion and disease prevention should include the following: brushing twice a day with a fluoridated toothpaste; avoidance of sugars in foods or carbonated drinks; healthy eating habits; smoking cessation; and keeping alcohol consumption to a minimum. Saliva substitutes can help with dry mouth secondary to psychotropic medication. Finally, case managers should encourage patients to have regular dental check-ups and be prepared to address dental anxiety and phobia, if present.’3

Dealing with anxious patients

Whilst each of these disorders – alone or in combination – may well have an effect on patient care, perhaps one of the most common mental health problems to present in the dental practice is anxiety.4,5

According to the Adult Dental Health Survey (ADHS) of 2009, 12% of adults who had ever attended an appointment with a dentist attained a Modified Dental Anxiety Scale* (MDAS) score of 19 or more, which is suggestive of ‘extreme dental anxiety’.4A further 36% scored between 10 and 18 on the MDAS, indicating ‘moderate dental anxiety’.4

In practical terms, as stated by Humphris and colleagues (2016): ‘Assessment of dental anxiety should be a prerequisite for any visit to the dentist and can be routinely performed. There are a variety of self-report questionnaires that are simple and easy to complete. The simplest of measures that have been developed is the Modified Dental Anxiety Scale (MDAS).’5

Placing this in the context of the ADHS (2009) findings, they continued: ‘The scale is easily employed in the practice setting as it takes no longer than 2-3 minutes to complete with simple instructions (supplied say by the dental nurse or receptionist). There are normative values for people in the UK. The total score can be compared with results obtained from the last Adult Dental Survey […] There is no evidence that completing the MDAS significantly raises dental anxiety. The cut-off point that has been demonstrated to indicate where respondents would prefer additional assistance when attending the dentist for their own dental fitness is 19. That is patients who score 19 or above are likely to be extremely dentally anxious. Patients who are dentally phobic will nearly always be in this elevated sample.’5

There are some further straightforward steps that may help to calm patients suffering from anxiety when attending the dental practice. For example, Brown and colleagues (2010) suggested: ‘Simple measures aimed at making the dental consultation a pleasant experience may be invaluable, with judicious use of lighting and music and perhaps adjusting one’s attire.’6

Obtaining consent

As the General Dental Council’s (GDC) Standards for the Dental Team (2014) tell us, patients expect to be asked for their consent to treatment before it starts.7

Added to this, in 2015, the decision reached in the case of Montgomery v Lanarkshire Health Board clearly set out what is expected of health care professionals in order to obtain consent for treatment, be it in a medical or dental setting.8

In response, the Royal College of Surgeons, referencing a number of guidance documents, including the General Dental Council’s Standards for the Dental Team (2016) published key principles underpinning the consent process as follows:

  1. ‘The aim of the discussion about consent is to give the patient the information they need to make a decision about what treatment or procedure (if any) they want.’
  2. ‘The discussion has to be tailored to the individual patient. This requires time to get to know the patient well enough to understand their views and values.’
  3. ‘All reasonable treatment options, along with their implications, should be explained to the patient.’
  4. ‘Material risks for each option should be discussed with the patient. The test of materiality is twofold: whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would likely attach significance to it.’
  5. ‘Consent should be written and recorded. If the patient has made a decision, the consent form should be signed at the end of the discussion. The signed form is part of the evidence that the discussion has taken place, but provides no meaningful information about the quality of the discussion.’
  6. ‘In addition to the consent form, a record of the discussion (including contemporaneous documentation of the key points of the discussion, hard copies or web links of any further information provided to the patient, and the patient’s decision) should be included in the patient’s case notes. This is important even if the patient chooses not to undergo treatment.9


It is important to note that the Montgomery case has not resulted in any fundamental change to DHCPs obligations in relation to consent; rather, the law has now caught up with the standards prescribed by the GDC.8

Putting this in context, Standard 3.1 of the GDC’s Standards for the Dental Team asserts: ‘You must obtain valid consent before starting treatment, explaining all the relevant options and the possible costs.’7Sub-section 3.1.3 adds to this: ‘You should find out what your patients want to know as well as what you think they need to know.’7

Moving on to sub-section 3.2.2: ‘You must tailor the way you obtain consent to each patient’s needs. You should help them to make informed decisions about their care by giving them information in a format they can easily understand.’7This standard requires DHCPs to ensure sure that patients – or their representatives – understand the decisions they are being asked to make.7

Legal requirements

Significantly, as the above standards indicate, it is also important to note that, for consent to be valid, it must be given by a person with the capacity to make the decision in question.9

Directing DHCPs in England and Wales in making such an assessment is the Mental Capacity Act (MCA) 2005,9which is, ‘[…] designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment.’10

The MCA is relevant to all people over the age of 16 suffering from any of the following conditions11:

  1. Mental illness
  2. Dementia
  3. Learning disabilities
  4. Brain damage
  5. Confusion
  6. Drowsiness
  7. Loss of consciousness
  8. Delirium
  9. Concussion


It further covers anyone who lacks capacity as a result of alcohol or drug use.11

The MCA is based upon five principles:

  1. Patients are assumed to have capacity until it is shown otherwise
  2. All practical measures have been taken in an effort to help a patient make a decision for themselves
  3. A DHCP’s belief that a decision is unwise does not in itself indicate lack of capacity
  4. Where a person does lack capacity, any decisions made by others must be shown to be in their ‘best interests’**
  5. Any decisions made or actions taken in relation to a person lacking capacity must be the least restrictive in terms of their rights and freedoms (for example, where possible, treatment is carried out under local anaesthetic rather than general anaesthetic or conscious sedation).12


Where it is suspected that a patient may lack capacity, as briefly mentioned earlier, the MCA provides the following two-stage test, which will ultimately enable the DHCP to show proof that the person in question did indeed lack the capacity required to make a treatment decision at the time that it needed to be made:

1. Is there an impairment of, or disturbance in, the functioning of the person’s mind or brain?11

If the answer is yes, the next question asks:

2. Is the impairment or disturbance sufficient such that the person lacks the capacity to make that particular decision?11

Offering practical advice regarding this decision-making process, Modgill and colleagues (2017) wrote: ‘Often individuals who lack capacity will be cared for and/or accompanied to dental appointments by their next of kin, family members, partners or carers who are familiar with the patient’s history and need for treatment. These individuals can be asked for their opinion of appropriate treatment options. Collectively these opinions, together with those of health and social care professionals, will contribute to a best interests process in which a decision regarding the most appropriate treatment for the patient can be reached.’12

Where a patient lacking capacity requires urgent treatment but presents alone (e.g. without next of kin, a parent or adult child), ‘[…] Consent Form 4 can be used to establish and document that the urgent treatment being proposed is in the patient’s best interests. This requires a formally documented discussion between two clinicians and justification of the treatment proposed. The Department of Health no longer produces a generic Consent Form 4 and the responsibility of formulating and updating a local version of this form now lies with hospital trusts.’12

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Care with dignity

Adding a personal touch to this significant issue, Dougall and Fiske (2008) wrote: ‘Professionals working with vulnerable people have a duty of care to treat them with dignity and to use all appropriate methods to facilitate communication so as to be able to assess capacity. This means treating people with respect and ensuring that any treatment options that are chosen on their behalf are in their best interests.’11


A note on terms

* MDAS – the modified dental anxiety scale is: ‘A self-reported psychometric anxiety questionnaire used to objectively evaluate the level of a patient’s anxiety. It is a 5 item questionnaire with a maximum score of 25. A score of 19 or above indicates a highly dentally anxious patient and possibly a dental phobic.’13

** ‘All decisions about medical or dental care must be made in the patient’s best interests. However, the term ‘best interests’ is not defined by the MCA. Instead, the principles of the MCA act as a guide, the application of which allows the best interests of a patient to be determined.’12

‘It is the responsibility of the clinical ‘decision maker’ having considered all possible treatment options (including no treatment) to ascertain which represents that which is the best for the patient. The patient’s past and present wishes and feelings and other factors known to be of importance to them should also be taken into account. In the provision of dental care, the attending dentist often carries out the BIM [best interests meeting]. However, the dentist who conducts the BIM may not necessarily perform treatment. The decision-maker is the clinician that will be responsible for carrying out treatment.’12



  1. Available at: Accessed 22 January 2020

  2. Kisely S. No mental health without oral health. The Canadian Journal of Psychiatry 2016; 61(5): 277-282

  3. Kisely S et al. Advanced dental disease in people with severe mental illness: systematic review and meta-analysis. The British Journal of Psychiatry 2011; 199: 187-193

  4. Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011

  5. Humphris GM et al. Adult dental anxiety: Recent assessment approaches and psychological management in a dental practice setting. Available at: Accessed 22 January 2020

  6. Brown S et al. General medicine and surgery for dental practitioners. Part 5 – psychiatry. BDJ 2010; 209(1): 11-16

  7. Standards for the Dental Team. General Dental Council 2016

  8. Bright E et al. Consent –an update. BDJ 2017; 222(9): 655-656

  9. Consent: supported decision-making. A guide to good practice. RCS Professional and Clinical Standards 2018

  10. Available at: Accessed 22 January 2020

  11. Dougall A, Fiske J. Access to special care dentistry, part 3. Consent and capacity. BDJ 2008; 205(2): 71-81

  12. Mogdill O et al. The Mental Capacity Act 2005: Considerations for obtaining consent for dental treatment. BDJ 2017; 222(12): 923-929

  13. Ireland R. Oxford Dictionary of Dentistry. Oxford University Press 2010; 223