SPEAKER_01 0:00

We acknowledge Aboriginal and Torres Strait Islander peoples as the First Nations and the traditional owners and custodians of the lands and waters known as Australia and Maori as Tagata Fenua in Aotearoa. We honor and respect the elders past and present who weave their wisdom into all realms of life.

SPEAKER_03 0:23

Welcome to another Psych Matters podcast from the Royal Australian and New Zealand College of Psychiatrists. Psych Matters is a series of discussions on training and practice issues facing trainees and fellows of the college and other important topics in mental health.

SPEAKER_00 0:39

Hi everyone, it's lovely to have you listening to this amazing RANs and CP podcasts on oral health and mental health. A bit of a new one for those of you who probably haven't done dentistry or oral hygiene, and maybe there's some dentists listening. So welcome to your first mental health podcast. So today I've got myself, Ava Carter, and Professor Steve Keisley talking to you about the really important link of the bidirectionality of oral health and mental health. Now Steve is obviously one of our very well-known experts in this field and professor at the University of Queensland and a dual-trained public health psychiatrist, and also worked for a long time in Canada as well, I believe, and currently has done a number of podcasts for us here at the RNZCP. I'm a consultation liaison psychiatrist by trade, love CL, and I'm also a medical director at a private hospital in Canberra, Deacon Private. But perhaps more relevant to this podcast, I'm also a dentist, registered and working. And one of the really incredible things about oral health is that it doesn't just affect our teeth. And one of the things that Steve will hopefully talk with us about today is the real importance of both the anatomy and a number of other parts of the mouth and saliva that we often don't get to learn about as psychiatrists. The main reason, though, that we wanted to talk to you guys today about oral health and mental health is that patients often, when they see us as psychiatrists, they may not have a number of other contacts in their life, particularly patients who suffer severe mental illness. Their psychiatrist, their therapist, their GP, maybe the only people that they see on a regular basis throughout most of their life. And what that means is that we're an incredible point of contact for them. And one of the things that we don't get taught in medical school is the mouth. Unless, or maybe some of us got taught that there were 32 teeth, but the lecture may have ended there. And so one of the things I I'll let Steve uh tell us about is some of the really interesting practical ways that we can engage our patients in a day-to-day clinic, in a hospital setting, in an acute inpatient setting. Steve, take it away.

SPEAKER_05 2:52

Um hello everyone. My name is Steve Kisley. I'm a academic psychiatrist and public health physician. And I guess because I'm both a psychiatrist and public health physician, I've had a long-standing interest in physical and psychiatric comorbidity and how psychiatric problems can lead to worsening of physical conditions and conversely, physical conditions have a marked effect on people's mental state and mental health. And one area that is conspicuously ignored is oral health. And I guess that goes back to the situation where medicine and dentistry separated in the 19th century. And we as doctors and specifically us as psychiatrists have largely ignored matters to do with oral health. And that's really unfortunate because oral health has a profound effect both on mental health but also on physical health systemically. So poor oral health is not just an issue of problems with aesthetics or problems with being able to chew, it actually has an effect on the wider physical health. And that's because the mouth has a very rich blood supply. And if you have poor oral health and bacterial colonization, bacteria and the sort of immune response to that infection can enter the bloodstream, and those bacterial immune complexes can spread throughout the body, causing chronic inflammation. And those effects can include low birth weight for children, it can lead to diabetes, cardiovascular disease, pulmonary disease, and increasingly we're aware that many chronic mental health conditions have an inflammatory component, and so it may actually affect mental health directly. But what we have most information about is how people with mental illness have particularly poor oral health, and that stems from a number of factors. Partly that's due to issues such as lifestyle. So we know people, particularly people with severe mental illness, tend to smoke, tend to use substances, and that in their own right can aggravate oral health problems. They also often have limited financial means, and unfortunately, access to dentistry is very much governed by the ability to afford dental care, and that's even if you're able to find a dentist to actually be offered oral health services. And also there's the effect of our psychotropic medications. So, with the exception of clozapine, which of course causes hypersalivation, packaging every single one of our antipsychotics and antidepressants cause dry mouth. And dry mouth in turn predisposes to poor oral health. And that's because, as a dentist friend of mine said to me, saliva is dentition's best friend. So saliva has got a sort of antibacterial, antiseptic quality to it, but also the actual liquid helps move debris from dentition, thereby reducing the possibility of bacterial colonies forming on the on the gums and on the on the teeth. And so as psychiatrists, we should be aware that just as we're aware of the cardiometabolic effects of our medication, we should equally be aware of the effects of our medication in terms of dry mouth.

SPEAKER_00 6:33

One of the other things I would add is that you know saliva is a really important aspect of oral anatomy. And just as you said, people with significant eating disorders, whether that's you know, anorexia nervosa, bulimia, a purging disorder, or eating disorder not otherwise specified, saliva should ideally have a pH between 6.2 and 7.6. And there's a really fantastic study if any of you are particularly interested in the biomarker nature of saliva, Balinga 2013. Essentially the way saliva regulates the mouth. But unfortunately, one of the other things that happens, not only do we cause xerostomia, which is dry mouth, because patients obviously need antidepressants and antipsychotics depending on their diagnosis and whatever it is that we're needing to manage for them so that they can live a hopefully full and healthy life, is that some of the drugs we give patients actually reduces the pH of their saliva as well. So not only is it important that we consider recommending patients who may not have access to a dentist or may have not had a chat to their dentist about their eating disorder, is to try and avoid brushing their teeth, as you said, Steve, because the enamel itself becomes quite soft after people purge or after, you know, if they also, you know, they may have a physical illness that means that they vomit a lot. So one of the really important things is to not brush your teeth after about half an hour of experiencing, you know, vomitus or anything that's got a particularly low pH that's been washing around in your mouth. One of the things you can do, which is also very practical, is to increase the pH. So something that's very basic, so milk is a very useful tool for people to use. I know it's got calories, so it might not be particularly helpful for people that have severe anorexia nervosa, but it is a very useful way of getting the pH back to neutral, as well as things like uh sodium bicarbonate mouthwashes, sodium bicarbonate brushes as well, which we often use in palliative care settings to help people remove the sloughing from around their cheeks, which actually is a process that we normally go through just as we lose skin. The keratinized skin on our external body, the oral cavity also loses a lot of the oral mucosa on a regular basis, and that can actually build up plaque as well. So in the palliative care and oncology settings, we use these sodium bicamidate brushes as well to help improve the pH and remove the risks of plaque buildup too.

SPEAKER_05 9:02

So, what does that mean from the in terms of the epidemiology of poor oral health in people with uh mental illness? Well, there are three main types of dental disease. Most people will be familiar with caries or dental decay, and that is due to bacterial colonization, which in turn leads to erosion of the enamel through to the underlying dentine. Then there's periodontal disease, which is basically an advanced form of gingivitis, so an inflammation infection of the gums, and as the disease progresses, the actual gum tissue will retreat from the base of the tooth, forming what we call pockets, and that in turn can lead to embedding of food scraps and and in turn aggravate the problem some more. And then lastly, there's what we call erosion. So erosion is when the overlying enamel of the tooth rather than eroding because of bacterial action, it actually erodes because of mechanical forces such as grinding your teeth or drinking or eating very acidic foods, particularly thinking of uh carbonated drinks. So taking it each of these conditions in in turn, people with severe mental illness in particular are most at risk of developing both dental decay and periodontal disease of periodontitis. People with common mental disorders also have an increased risk, but to a lesser degree. If you like the endpoint of both uh periodontal disease and dental decay is tooth loss. So the dentists call that identilessness. And uh we've shown in a couple of systematic reviews that people with severe mental illness are nearly three times as likely to have lost uh complete dentition, so to have lost all their teeth than the general population, and that's adjusting for you know the obvious covariates such as uh age and socioeconomic status. And even by more common mental disorders, which are less severe, they have about a 20% increased chance of having lost all their dentition. So that obviously has profound implications for people's well-being and sense of self.

SPEAKER_00 11:30

The other thing I would add as well is perhaps there's a fourth dimension to the the three big areas that you've spoken about, which are all really important, and that's we often forget about the temporomandibular joint, which is that that really annoying thing that clicks and allows us to open our mouth so that we can eat. A lot of people, unfortunately, though, who suffer severe mental illness, particularly patients with post-traumatic stress disorder, tend to have what we call TMJD, which is temporomandibular joint disorder pain. And TMJD results from a number of reasons. Sometimes people are born without cartilage or very thin cartilage in that joint. Think of it a bit like a hip joint, and then it moves up and down and side to side, as you would if you feel your own jaw right now. You can feel that it's a bit of a ball and socket. And unfortunately, people with severe mental illness with PTSD tend to also, as we know, suffer significant bruxism, so grinding of their teeth. And that leads to both erosion of the teeth and abfraction, which means fractures in the teeth. And many of you who work in military and veteran spaces and first responder spaces, or indeed in complex PTSD spaces, will hear from patients occasionally that despite having the most expensive and strong uh implants, they've managed to break them. And indeed, I've seen many patients who have fractured titanium implants because they've been grinding so hard. So TMJD is probably, I would add, the fourth area of dentistry that we tend to class diagnoses or problems into. And that's an area that our oral maxellofacial surgeons do a lot of amazing work in to try and help people, as well as prostodontists. And they're the people that make the splints and and try and improve the oral health of people's teeth with physical implants as well as the periodontists that look at gum disease.

SPEAKER_05 13:17

Erosion is actually quite different because uh erosion more commonly occurs in people with eating disorders because often people with eating disorders have actually quite good oral hygiene, but especially in the presence of self-induced vomiting, the acidic contents of the stomach will basically erode the the enamel and basically uh uh expose the underlying dentine. And one of the major tips you need to offer anyone who does self-induced vomit is that if they uh have vomited, the last thing they should do is brush their teeth, and it's a very uh obvious reaction that you want to brush your teeth after vomiting, but actually that's the worst thing you can do for your for your teeth because the content, the the actual enamel is particularly soft and particularly prone to be uh brushed off. So apart from that, a handy little tip in terms of uh counseling your uh your patients about their eating disorder, what can psychiatrists do in general in terms of helping to uh improve the oral health of people that they see? Well, one of the things is just as we uh talk to people when we prescribe especially second generation antipsychotics, we talk to people about you know metabolic function, we should actually counsel people about being aware of dry mouth and how to manage it. So obvious things are like taking uh frequent sips of water, you can buy artificial saliva or encouraging people to chew sugar-free gum. And these are all very uh simple but effective ways of making sure that we can mitigate the effects of dry mouth as much as possible. And just in the same ways we ask people about the side effects, we ask people about a range of side effects when we you know follow people up after we started describing. Part of that should also include uh asking about any problems with uh with dry mouth and again offering some some tips. Turning to inpatient settings, maybe working with nursing staff in in making sure that a brief review of people's oral health forms part of the admission process, including you know, maybe asking whether they whether people have obvious symptoms of pain, and when was the last time that they saw a dentist? Maybe for people who have actually lost their teeth inquiring about the the state of any, you know, artificial teeth. And again, when was the last time they actually saw a dentist or or a hygienist in terms of making sure that you're optimizing oral function.

SPEAKER_02 15:59

I hope that you're enjoying this podcast. If you have a topic suggestion or would like to participate in a future episode of Psych Matters, we'd love to hear from you. Please contact us by email at psychmatters.feedback at rancp.org.

SPEAKER_00 16:17

You raise uh an amazing point about preventative health care, and oral health in Australia really is at a crisis point in terms of the intersection of oral health and mental health. One of the amazing opportunities I had last year to do was a Churchill Fellowship, and that Churchill Fellowship looked at what models of care overseas can we implement in Australia that would help psychiatrists and dentists and everyone in between to improve the oral health of patients with severe mental illness. And it was a really interesting trip because not only did I find that a number of countries have a very similar problem in terms of the separation of dentistry and medicine, and indeed, as you said, you know, the 19th century was a separation point for dental and medicine. We could even trace back to Baltimore in 1840 when some amazing private dentists tried to get the medical school in Baltimore, the US, to join and form a co-faculty, and when that didn't happen, we sort of see the the beginnings of early privatization of the dental field from there. But really, you know, dentistry is the only major clinical discipline excluded from the national health insurance system. And in Australia, that's a consequence of a 1946 legislative decision that left dental services essentially to the states, and it's never really been addressed. The result is essentially a fee-for-service industry in which access to care is determined largely by income and not always clinical need, although there is always an exception to the rule, and I will say that we have in Australia some amazing philanthropic dentists and oral hygienists and oral health therapists, and I do think that the movement to help people with dental anxiety is certainly growing since COVID. For most Australians, though, this means inconvenience and cost, and approximately 3 to 5% of people in Australia live with severe mental illness, as Steve has mentioned, and that includes psychotic disorders, bipolar disorder, treatment-resistant depression. And it means something far more serious though, because as Steve said, you know, people with SMI are 2.8 times more likely to suffer oral disease, which means that naturally they're more likely to lose all their teeth. And indeed, that term edentialism does mean entire tooth loss. You can have partial dentialism, though. And sometimes that's even worse because whilst identialism in and of itself is a major risk factor and covariate for early mortality by about somewhere between 15 and 20 years on average, although for those with intellectual disability and SMI, it increases to something like 25 or 26 years, the likelihood of patients suffering oral disease with SMI is around sort of 2.8 times more likely. And the fact that partial identialism is often worse because what that means is that not only do you have areas with no teeth, which means that you know the aesthetics will be severely impacted and patients' confidence and willingness to go out and socialize will be reduced. But pain is incredible. They talk we talk about birth being one of the most painful things a human can go through. I'd argue, and I I will admit, I have not given birth, but I would argue that tooth pain, perhaps, is something that would be on par with that, and I hear it a lot from patients. It's painful because of two reasons. There's a number of different uh nerve fibres that run through the teeth, and one of the those nerve fibers is very specialized to tooth structures, and it signals, you know, immediate danger, you know, get the tooth out or get it fixed. And the reason for that is as Steve has alluded to, part of the anatomy of the head and neck is very, very at risk of travelling straight to the brain. We call it the danger triangle, which is in the the front area of the face and the teeth, but it also leads directly, in many ways, the lymph system down into the heart. So tooth infection is very dangerous, and so the body wants us to get rid of it quickly or treat it very, very fast. And one of the ways of doing that for a human is to give us pain. So tooth pain is far more likely to cause major inconveniences for someone with a severe mental illness than full adentilism is, because you can replace your teeth with plastic dentures, it's not great. But to have tooth pain and partial dentalism is often much worse for a number of other reasons, from what a lot of my patients tell me. So poor oral health in this population is not just a cosmetic issue, it's a clinical one. And as you said, huge risks of cardiovascular disease, as well as things like aspiration pneumonia. The risk of type 2 diabetes is around three times higher as well, as is, as Steve's mentioned, the risk of early uh perinatal problems as well as uh problems in terms of early birth. The financial burden is obvious as well. One of the things we don't tend to think about as psychiatrists, because we're clinical diagnosticians, is the cost of dentistry. And I think it's really important we talk about it on this podcast, not only because I'm constantly frustrated by how much it costs our patients to get access to dental care, having gone and you know had the luxury of going to see some of the Norwegian options for public dental health. And obviously, if you get a chance to go overseas to research different, you know, oral health and mental health facilities, you have to go to the Netherlands because they're the gold standard, and then you sort of just pray whatever you can bring back might resemble that in some way. But Australia spends around $11.1.2 billion on dental care every year. But the government really only funds about 20% of that if you look at the data from the ABS. And about 88,000 to 90,000 hospitalizations that are entirely preventable due to dental conditions, and that's in 2023 2024 calendar year alone. So applying a conservative sort of bed per day cost estimate. You know, and you can look at the research from the Grattan Institute here, you can go to the Australian Bureau of Statistics as well. It represents around $195 million in avoidable expenditure. And that's a figure that certainly is underestimated because we're also not including the cost of theatre, the cost of the anaesthetists and the nursing staff, the pharmaceutical industry that would need to be utilized in terms of meeting people, as well as just general staffing, the costs of cleaning a theatre alone, for example, as well as the ICU beds, if you've got someone who has Ludwig's angina, as we know, is a big infection in the throat and it's life-threatening, you know, all of these things are entirely preventable these days. So in 2025, you know, if you want to think about the cost to the individual as well, not only the public health system, about $817, $818 million was withdrawn by the Australian public post-tax with their retirement savings to pay for their private dental treatment. More than one in three Australians essentially avoid dental care since 2021 due to the cost as well, and that's not including people with severe mental illness. We don't know those numbers because we don't research them. And so people with severe mental illness face the additional barrier of cognitive impairment from the illness itself, as we know in schizophrenia, from the medication side effects with the dry mouth, and from the transportation difficulties, dental fear, as well as the motivation they have to have, the physical fitness they have to have to try and even get to a dental clinic. You know, these figures don't constitute a formal economic analysis, of course, but they do indicate the scale of the problem that Steve and I are trying to explain and the cost of that continued inaction. So what are some practical things? Well, you know, simple interventions, as Steve was saying, really do work. You know, a twice-daily oral hygiene protocol with a hospital that I visited in the United States showed that the improvement in patients' oral health resulted in reduced non-ventilator-associated pneumonias in its first year, and this was conducted in a study that was solely focused on ICU patients just brushing their teeth twice a day. I've also been to the United Kingdom and at the NHS they do CBT for dental fear, and that's actually been shown to be able to reduce the cost overall for the NHS system because you're not having to get people a general anesthetic to have a checkup or a tooth clean. You know, you can treat their odontophobia, you can treat their dental anxiety with other means, non-pharmacological means at that, which is fantastic. So immediate low-cost actions, you know, this is for every hospital, this is for every clinic to think about, you know, introducing standardized oral hygiene kits, including high fluoride toothpastes, don't be afraid of fluoride, dry mouth relief products, as Steve was saying, you can buy for about $14, you can buy a product called biotine. It might be $18 now with inflation, but biotine is a synthetic salivary replacement. You can use it every hour, you could use it every half an hour, there's no limit to how much you can use it, and it will make swallowing, eating, and generally speaking so much simpler if you do suffer from dry mouth. A flexible toothbrush, incredibly important. And should this pack should be, really, in my view, a human right to every patient coming into a psychiatric inpatient admission, public or private. As Steve said, mandating a brief oral health assessment uh is part of my recommendations in the Churchill report that I've written, which you can access online, but but really it's a no-brainer. You know, we have 72-hour initial physical health assessments required under most state and territory mental health acts, why the oral cavity is excluded from that. I'm not really sure, given the obvious bidirectional nature of the impact of poor oral health for our psychiatric patients. Really simple things like printing out, you know, pamphlets from the ADA and putting them on the mental health wards, talking about oral health education. I know it sounds a bit like, you know, teaching the teacher, but a lot of our lived experience advocates talk about how little information they get on oral health care, and it can be really helpful to bring the family of patients who suffer severe mental illness on the journey of talking about cleaning their teeth. The other thing I'll say is that establishing clear signage for patients, telling them that they can actually get a toothbrush at the nursing station is actually really helpful. Sometimes, you know, the medications we use and the illness itself can make remembering things like that hard. And so lots and lots of clear signage is very useful. The medium-term sort of structural reforms though, if we're thinking around things like expanding, you know, Medicare benefit schedule items, we could always we could talk, you know, for days, uh, I'm sure, can't we, Steve, on the benefits that you could have of having dental on Medicare. I think it'd be great one day, but until that day does arise, if it does, expanding Medicare benefit schedule items to fund oral health education, both by dentists, oral hygienists, would be very, very helpful and improving that so that it does happen on a regular basis, as well as allowing GPs to use fluoride varnish applications, nurse practitioners and pediatricians in big community settings to apply fluoride varnish would be incredibly useful for patients out in our youth mental health sector, as well as those who have high prevalence and low acuity mental health and severe mental health conditions, because that would allow them to get access to oral health care without having to go through the very difficult systems that do exist in terms of public and would be a lot cheaper for them than going straight to private as well, because they may not even be able to afford that. So those dual-billing pathways where a dental and a psychiatric assessment can occur concurrently doesn't exist in Australia at the moment. Hopefully one day, that's my dream, but it does exist elsewhere across the world, and that would be something that would also be incredibly helpful for our patients with SMI. The big elephant in the room is, of course, the way we're trained, as Steve alluded to earlier. As a dentist, you know, I went straight into private practice straight after I got APRA registered, and as many of my colleagues do. We would, I'm sure, love to have more positions in public. Unfortunately, there's only around 900 public dental positions or 900 FTE that's funded by the Australian government. And much of this is obviously related to state and territory funding as well, and depending on the difficulties of the year, you know, different funding pockets and pools will change and ebb and flow. And so even if we had lots and lots of dentists wanting to do public dental, sometimes it's actually very hard for them to be able to get a job there because we don't have the places for them to train or for them to actually work. So changing that landscape is an incredibly important decision that the government really, really, we should be looking at and we should be talking more about, advocating more for. The Grattan Institute wrote a lot on this in 2019, and I'd encourage anybody to to look at that if they're interested in advocating for that. And Matt Hopcraft from Melbourne University also talks a lot about it in his in his podcast as well. Long-term systemic reform, though, really centres around something that we've missed from in Australia since, you know, the beginning of medicine with us here in this small country, and that's a chief dental officer. We don't have anybody in the Commonwealth uh Department of Health that is able to look at oral health and, you know, advocate specifically for this area. In my opinion, and I think in the opinion of many dentists, it's an appalling outlier among WHO member states because we don't maintain this role. New Zealand has one, so many other first-world countries have one. A CDO would provide national coordination, policy leadership, and international engagement. I think that'd be a really nice thing. And it'd also allow, you know, our chief dental officers to talk with our chief psych officers and our chief medical officers and help look at the systemic oversight of fragmented state-level dental policy that currently is really not supporting our patients with mental illness. So we've talked a lot about oral health and mental health, haven't we, Steve? I think we could say that the cost of inaction is fairly quantifiable at this point, but you know, we can manage a lot of these costs, and many countries do in many different ways. There's no one solution. The cost of action is, I think, tangible, and Australia has already got a number of clinical workforce engagement in this area that are wanting to do things, that are wanting to be involved. There's a huge amount of momentum, really, at the moment, for dentists and oral hygienists and therapists to be engaged in the mental health space, something we've never really seen before COVID, which is fantastic. What's required is a decision really to treat oral health as a an essential and really very much inseparable component of whole person care, not as a discretionary service available to only those who can afford it. Patients with SMI, that's really not a decision that can wait for the next cycle of the health review. And every year that oral health remains outside of routine psychiatric care, the disease burden grows and the preventable hospitalizations accumulate and the gap between needs and access widens. So the models presented today by Steve and myself are really some practical ideas to think about. And I'm sure, uh, as Steve would say, if anybody ever wants to talk about these things, please don't hesitate to email because for it in every measurable sense the gap is overwhelming, but it can be uh shortened.

SPEAKER_05 31:04

So that's really a very brief overview of the extent of the problem and what we as the cartress can do in terms of helping to minimize the oral health problems that the people that we treat might face. Obviously, if at all possible, we should be working with our dental colleagues to facilitate referral for ongoing treatment. And you know, that's often, as I mentioned before, subject to a lot of other factors such as the availability of dental care and the access to dentists, which is why I've really honed in on some practical things that we as psychiatrists can do to optimise the oral health of the people we treat. And thank you very much.

SPEAKER_00 31:50

Thanks, guys. Thanks for listening.

SPEAKER_04 31:54

We hope you enjoyed this episode of Psych Matters. Feel free to share it with others and keep an eye out for future episodes. Psych Matters is produced by the Royal Australian and New Zealand College of Psychiatrists.