Mental health as a barrier to care

My patient was escorted to our urgent care clinic wearing an ankle monitor. Her chief complaint was that she felt pain around every tooth. When I took a closer look, the source of her pain became apparent. She had a mouth full of non-functional root tips. Almost every root tip showed signs of infection.

My patient was from a local drug rehabilitation center, and she was 10 months sober from a heroin addiction. As a result, she wasn’t allowed any prescription narcotics or nitrous oxide, as instructed by her program due to fear of relapse.

Our school elected to treat patients from this facility at no cost, and we were happy to provide the care she needed. Unfortunately, the ideal treatment for this 28-year-old was full-mouth extraction, followed by complete dentures. To provide her some relief, we planned to extract a few teeth at her urgent care appointment before providing future comprehensive treatment. My patient expressed that she had not seen a dentist in several years due to severe anxiety. We could tell she was uneasy from the beginning. However, she would do anything to relieve the unbearable pain, so she consented to further treatment knowing that we wouldn’t be able to manage her appointment with nitrous.

During the appointment, it became difficult to manage our patient. I was new to treating someone with severe dental anxiety. We proceeded with caution and used many pediatric protocols such as “tell, show, do.” She struggled with every noise and movement. As our oral surgeon stepped in to provide some assistance, our patient swatted the instrument out of his hand. We stopped the procedure after only extracting two root tips of one molar. Unfortunately, this appointment was beyond our patient’s emotional capacity.

We often discuss access to care barriers, and for me, it was eye-opening to see how our patient’s mental health impacted her dental experience. Psychological barriers to care can manifest in many ways including fear, anger or depression. Case acceptance is dependent on multiple factors, but it revolves around our patients’ mental capacity to commit to treatment.

According to a January 2012 study published in the Society for the Advancement of Anesthesia in Dentistry’s journal SAAD Digest, dental professionals report that their most anxious patients are also the ones who suffer from mental illness. The study reports that common mental health disorders encountered at the dental office include bipolar disorder, schizophrenia, depression, generalized anxiety disorder and social phobia. According to the Special Care Dentistry Association, patients with psychological barriers to care have unique treatment considerations, often presenting as high caries risk and requiring sedation to cope with treatment.

As future health care providers, it is important that we ask intentional questions about mental health and that we learn how we can be sensitive to their needs in addition to what post-graduate opportunities we can take advantage of to confidently treat these patients. I encourage dental students and dentists to take the time to accurately identify mental health concerns among their patients and refer responsibly.

~Tahsin Anwar, Roseman ’19, Districts 10-11 Legislative Coordinator