Hygiene Tribune U.S. No. 3, 2013
Changing my power brush preference / The severely mentally ill are severely underserved
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HYGIENE TRIBUNE
The World’s Dental Hygiene Newspaper · U.S. Edition
April 2013 — Vol. 6, No. 3
www.dental-tribune.com
Clinical
The severely mentally ill
are severely underserved
Dental hygienists have unique opportunity to provide high-value care
By Lisa Stillman, RDH
O
ne in four families in the United States is affected by severe
mental illness (SMI), a lifealtering disease that can be
especially difficult when it emerges just
as an individual is beginning to discover
the freedoms of adulthood — a common
age at which symptoms first present.
In addition to the psychosocial challenges faced by this population, many
of these individuals also must confront
a myriad of oral health issues that often
end up being largely ignored — because
individuals and families become overwhelmed by the chaos the illness typically brings into their lives.
With basic awareness of the unique
needs of patients with an SMI, dental
hygienists can play an important role
in the effort to better meet not just the
oral health care needs of this particularly vulnerable population — but also
their overall physical and mental health
needs. Three of the most likely mental
illnesses that hygienists and other dental
professionals should have a basic awareness of are schizophrenia, bipolar disorder and major depression [explained a
more detail on page E2].
Correct diagnosis often a challenge
The most important aspect for treatment
of an SMI is getting the correct diagnosis.
Because of overlapping symptoms, the
stigma of receiving a diagnosis, medical
privacy laws, civil rights protection for
the mentally ill, and a continuing lack of
insight by patients, families and society
as a whole, individuals developing an
SMI may go without treatment — or receive ineffective treatment for years.
At times medication is used to control
symptoms before a correct diagnosis can
be made.
Understand medication side effects
The health history is the biggest clue for
the dental hygienist to consider to gain
awareness regarding the possibility that
a client is being treated for mental illness.
Some clients diagnosed with mental
illness will neglect to state the nature of
their illness but will list the medications
that they are currently using. These medications will consist of antipsychotics,
antidepressants, mood stabilizers, antianxieties, anti-epileptics and sleep aids.
Other clients might have an SMI that has
not been diagnosed, or they might have
received a diagnosis, but they are not
taking medications. Clues here might
include a somewhat disheveled appearance, odd behavior and consistently poor
oral hygiene.
People being treated for mental illness
often are on several medications, which
Lisa Stillman, RDH, BS, is a
clinical dental hygienist and the
Northeast Xylitol Educator for
Wasatch Sales Force. She created the organization “Dental
Voice for Mental Health” to help
mental health care recipients
address their oral health needs
though awareness and education. She presents courses to fellow dental professionals, mental health professionals, advocacy groups and mental
health facilities. Stillman is a member of
American Dental Hygienists Association and
the National Alliance of the Mentally Ill. She
is a founding member of the American Academy of Oral Systemic Health. Stillman earned
the 2008 Sunstar/RDH Award of Distinction.
She can be contacted at lisa91156@aol.com.
can cause severe xerostomia, resulting
in high caries, erosion, tooth loss, mouth
infections, loss of taste and difficulty in
chewing and swallowing. Other side effects include bruxism and metabolic
cravings for foods high in carbohydrates.
The plaque index in patients with an SMI
is often quite high, causing decalcification and severe sensitivity.
Smoking, substance abuse common
The need for thorough oral cancer
screening is great because statistics
show that SMI correlates with tobacco
use, substance abuse and other high-risk
behavior. General health disorders such
as diabetes, high cholesterol, cardiac
dysfunction, movement disorders and
agranulocytosis are serious side effects
that can be attributed to medications.
” See UNDERSERVED, page E2
Industry opinion
Changing my power brush preference
By Liz Nies, RDH-EA, AS
When I introduce new products and technologies to my patients, I often use analogies to help them understand how they
work. For example, I compare a manual to
a power toothbrush as a hand saw versus
a chain saw. I start off by explaining that
toothbrushes have been around for more
than 5,000 years in much of the same design. You could never move your brush fast
enough to break through the cell walls of
oral bacteria as you can with a power brush.
Just like if you were going to cut down a
tree, which tool would you use to do it: a
hand saw or a chain saw?
Recently I noticed that many of my patients who use Oral-B power brushes had
improved oral health. I was quite surprised
because that has not always been the case.
This piqued my interest, so while attending
a continuing education retreat, CAREERfusion, I obtained two new Oral-B Deep Sweep
Triaction 5000 power brushes — one for
me and one for my husband. I was skeptical at first to try it out, but have been impressed with the results.
Like many of my patients, my husband
has always preferred a manual toothCDA
brush. I have made him switch beBOOTH
cause I know the benefits of using a
NO. 1166
power brush. However, even with a
power brush, he still brushes in a backand-forth movement. What I like about the
new Deep Sweep brush head is that it combines pulsations and sweeps so it feels like a
more traditional manual brushing motion.
Now, I don’t have to correct him when he
brushes as if he was using his old manual
toothbrush.
While I have always liked using power
brushes, the new Oral-B Deep Sweep Triaction 5000 has shown me that I haven’t
been brushing as properly as I thought.
This brush comes with a separate piece,
the wireless Smart Guide, to place onto the
sink to guide brushing and warn the user
if they’re brushing too hard or not long
enough. The Deep Sweep Triaction 5000
also has a red light built into the handle
have your own personal dental hygienist
that indicates when you are using too
much pressure. I had never realized before
observing you while you’re brushing.
that I brush too hard until my handle startI now feel compelled to share my new
ed lighting up like a disco ball! Having the
preference of the Oral-B Deep Sweep with
wireless Smart Guide feature feels like you
my patients, especially since studies show
The Oral-B Deep Sweep brush head
combines pulsations and sweeps so it feels
more like a traditional manual brushing
motion; but it cleans deep between teeth
and gets to places that manual toothbrushes
normally miss. Photos/Provided by Crest Oral-B
the effectiveness of plaque removal. Like
with my saw analogy, I must now come up
with a metaphor for the Oral-B Deep Sweep,
demonstrating how the power brush has
advanced even further.
[2] =>
E2
Clinical
Hygiene Tribune U.S. Edition | April 2013
◊ UNDERSERVED, page E1
Individuals affected by SMI often do
not seek oral health care services, exacerbating existing disease and leading
to new oral-health problems. The dysfunction in such patients’ lives caused
by the symptoms of the illness, financial distress, lack of family support and
possible hospitalizations or incarceration can interfere with any opportunity
to secure consistent dental care. When
theses patients are finally able to see a
dental health professional they might be
extremely self-conscious about the deterioration of their mouth and concerned
about facing disapproval — and fearful
of that treatment might be painful.
Depending upon the severity and
symptoms of the patient’s mental illness, the patient’s beliefs about teeth
might be altered — and fall outside the
realm of standard beliefs. For example, a
client with paranoid schizophrenia may
be so concerned about the microbes in
his or her mouth that he or she brushes
excessively, causing damage to teeth and
supporting structures. Another patient
with an SMI might believe that dental
plaque is natural and should remain on
his or her teeth. Delusional beliefs may
interfere with compliance.
Handle altered perceptions
When treating a client with an SMI, dental hygienists need to be aware that hallucinations can cause apparent changes
in a patient’s perception of touch, taste,
sound, sight and smell — with increased
or decreased sensitivity.
Topical anesthetics or dentinal antisensitivity medicaments may need to be
applied for comfort prior to scaling. And
special care is required when polishing
with the prophy angle, because the vi-
HYGIENE TRIBUNE
Publisher & Chairman
Torsten Oemus t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid e.seid@dental-tribune.com
Group Editor
Robin Goodman r.goodman@dental-tribune.com
Editor in Chief Dental Tribune
Dr. David L. Hoexter feedback@dental-tribune.com
Editor in Chief Hygiene Tribune
Patricia Walsh, RDH feedback@dental-tribune.com
Managing Editor
Robert Selleck r.selleck@dental-tribune.com
Depending on severity of the mental illness, a patient’s beliefs about teeth might be altered
— and fall outside the realm of standard beliefs. Illustration/Provided by www.dreamstime.com
brations generated may be interpreted as
painful or extremely annoying. Using a
soft toothbrush may be a better option.
The taste of the polish offered should be
appealing, otherwise consider substituting polish with fluoridated toothpaste.
For keeping the patient calm, the use
of audio to muffle dental sounds can be
helpful. It also can help to quickly discard gauze splattered with blood and
debris and if possible keep dental instruments out of sight.
Although electric toothbrushes may
be ideal for home-care use, some clients
may have a low tolerance for the vibrations. Therefore, a manual toothbrush
with a comfortable handle and grip may
be a better choice. Sometimes relying on
a Waterpik, oral rinses, home fluorides,
remineralization pastes, probiotic lozenges, xylitol gum and mints may be
the only real home care some members
of this population will follow because of
comfort, taste, smell and/or energy level.
People with an SMI might be extremely
self-conscious and easily able to sense if
their caregivers are comfortable administering treatment. It can be very important that when administering dental
treatment to these clients that consistent
eye contact is maintained and genuine
interest is shown for their comments or
concerns.
Be organized, upbeat, caring
Dental professionals should strive to
have a keen understanding of these patients’ unique fears and follow a systematic approach in a well-organized, upbeat, and caring manner.
After evaluating the oral health needs
— and understanding the impact of the
illness itself on the patient’s thought process and behaviors — the dental hygienist can offer creative and thoughtful suggestions to motivate these dental clients.
Dental hygienists have a unique opportunity to offer not just oral care but to
give these clients a safe and secure place
to feel “cared for.”
3 severe mental illnesses dominate
Most frequently diagnosed, most likely to be encountered by dental professionals
Schizophrenia
Schizophrenia is a chronic, severe and
disabling brain disease characterized by
a disintegration of the process of thinking, emotional responsiveness and contact with reality and consists of a group
of symptoms that show wide variations
in disordered thinking, feelings and behavior.
One percent of the U.S. population is
affected, primarily between the ages of
17 to 24 in males and 28 to 35 in females.
The illness is universal in symptoms
across all cultures. It is considered an
epigenetic/genetic illness, which means
if one carries the phenotype, certain environmental forces over time can cause
the expression of those genes. These
environmental forces can include: social stress, drug abuse, head trauma,
infections and outside factors that can
contribute to dysfunctional brain development. Each case is unique and
depending upon severity of the symptoms, lifelong treatment can include:
medication, hospitalization, psychotherapy, cognitive therapy, job coaching
and alternative housing.
and the illness affects men and women
equally. Bipolar disorder is a chronic and
generally lifelong condition with recurring episodes of mania and depression
that can last from days to months that
often begin in adolescence or early adulthood — and occasionally present even in
children. While medication is one key el-
ement in successful treatment of bipolar
disorder, psychotherapy, family support
and education about the illness are also
essential components of the treatment
process.
states, major depression is persistent
and can significantly interfere with an
individual's thoughts, behavior, mood,
activity and physical health.
Among all medical illnesses, major
depression is the leading cause of dis-
ability in the United States as well as
in a number of other developed countries.
(Source: National Institute
of Mental Health)
Bipolar disorder
Bipolar disorder is a medical illness that
causes extreme shifts in mood, energy
and functioning. These changes may be
subtle or dramatic and typically vary
greatly over the course of a person’s life
as well as among individuals.
More than 10 million people in the
United States have bipolar disorder,
(Source: National Alliance
on Mental Health
Major depression
Major depression is a serious medical
illness affecting 15 million American
adults, or approximately 5 to 8 percent
of the adult population in a given year.
Unlike normal emotional experiences of sadness, loss or passing mood
(Source: National Alliance
on Mental Health)
Managing Editor Show Dailies
Kristine Colker k.colker@dental-tribune.com
Managing Editor
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
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m.zimmerman@dental-tribune.com
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a.wlodarczyk@dental-tribune.com
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Published by Tribune America
© 2013 Tribune America, LLC
All rights reserved.
Tribune America strives to maintain the utmost accuracy in its news and clinical reports. If you find a
factual error or content that requires clarification,
please contact Managing Editor Robert Selleck at
r.selleck@dental-tribune.com.
Tribune America cannot assume responsibility for
the validity of product claims or for typographical
errors. The publisher also does not assume responsibility for product names or statements made by
advertisers. Opinions expressed by authors are their
own and may not reflect those of Tribune America.
Editorial Board
Dr. Joel Berg
Dr. L. Stephen Buchanan
Dr. Arnaldo Castellucci
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[3] =>
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