Oral and Behavioral Health Integration

May 27, 2021

Jamie: My background has always been in integrated care. From training through licensing, I lived, ate, and breathed integrated care! Coming from a rural community with limited healthcare services, behavioral health and physical health existing in the same space has always just made sense to me. But after a few years of my focus being on behavioral health integration in primary care, I became really curious about how these models of care were being implemented into completely different settings, like in allergist offices, pediatric obesity clinics, and complex care settings, for example. Again, this wasn’t surprising to me and just seemed like a common-sense way to improve patient care outcomes, as well as provider satisfaction. But I will never forget the day I saw a job posting for the role I have now! On one hand, I thought to myself, “Behavioral health integration at the dentist?! How is that going to work?” And on the other hand, I thought, “I’ve got to get in on this!”

Lisa: Oh, I am so glad I am not alone in my curiosity about integrating behavioral health care into oral health care! To be honest, when I first heard about integrating behavioral health into oral health I just wasn’t sure how it would work. At first I thought, well that would be helpful because personally I experience a lot of tension around going to the dentist. I am always up for someone talking to me and helping me feel more relaxed, so that was my initial take on the role of behavioral health in oral health. I thought, when I sit down and feel nervous about my procedure, or about what the dentist is going to say, a behavioral health person could help me manage that stress. But then I learned there was so much more and so many other reasons why behavioral health should be connected and integrated into oral health.

Jamie: Absolutely! At UNC we have done dentistry education without behavioral health for more than 50 years…so I don’t think you’re alone in feeling slight hesitation at the sound of “behavioral health in dentistry.” Changing the way teams are developed and work together, as well as the way patient care is viewed and delivered, is NO small feat. I had a dental colleague put this simply for me one day. He said to me that dentists are incredibly technically skilled professionals. For that reason, they historically have looked at patients and their needs with a 2mm point of view. They are using magnification tools to zoom in on that particular cavity, or that crown. As a behavioral health clinician, I am asking them to back that view up to about a 100-yard view of the patient and ask about their life, their health behaviors, and their own perspectives on their care. This is uncomfortable for most dental providers to think about in the beginning. But as I attend more morning huddles, discuss more patient cases with providers, and meet with more patients in the operatories, I see our dental providers — both learners and faculty — gain a greater understanding of how expanding their care to be more person-centered improves the patient’s experience, as well as theirs.

Lisa: That is very cool, Jamie. I am just fascinated with this whole movement of really connecting ALL of the parts of the body and mind. As an integration specialist, I really have always believed and advocated for whole-person care, but it took a bit of self-education and talking to others in the oral health field to understand the connection between the mouth, the body, and the mind more fully. It is almost a little embarrassing to say, but it also shows how entrenched everyone still can be in their silos, even if there is some overlap with those silos. It is exciting to hear about the work being done at the training level to tear these silos down and create a total culture shift.

I know Greene County Healthcare has been working with Medical Family Therapists in their dental clinics for a while now. In fact, the NC Oral Health Collaborative wrote a piece about the work of one of the MedFTs from Greene County and it was wonderful to hear the great work being done.

While I do think those in training right now — including behavioral health, dentists, and primary care providers — are getting more exposure to whole-person care, I think it is important to share with those currently practicing all of the many reasons that oral health and behavioral health intersect.

Jamie: When I explain the “why” behind integrating behavioral health into dentistry, I like to focus on specific patient presentations that dental providers will see in the dental chair. What we are seeing, especially in NC with the rise of the opioid epidemic, is that substance use and behavioral health can impact everyone, across all socioeconomic levels. So, regardless of where a dentist is practicing, if they came to me and said that they aren’t seeing behavioral health issues in their practice, or these issues are not impacting their patients’ care, I would kindly argue that they just simply aren’t paying attention. The mouth is the messenger for all sorts of things happening in the body, so if you aren’t receiving those messages, then you’re doing something wrong.

Some of the most commonly used substances in our state include cannabis, opioids, and methamphetamines. Cannabis can lead to increased risk of oral cancer and gum disease, use of opioids is associated with tooth loss and decay, and methamphetamine use can cause teeth grinding, tooth wear, and rampant decay. With that being said, poor oral health can also have an impact on substance use. Untreated oral pain can exacerbate factors that lead to substance misuse, or impede recovery from a substance use disorder. As for opioid prescribing patterns, oral health providers have been among the top prescribers of opioids in recent years, including for individuals 10-19 years old (this often happens after wisdom teeth removal). Another example of this is when we see people who are seeking care for oral health problems in emergency rooms being prescribed pain medications instead of receiving comprehensive oral care. Interestingly enough, we have actually seen a very rapid increase in recent years of dentists working in emergency rooms, with the goal being to provide more comprehensive urgent dental treatment in the ER setting.

As for mental health, one of the most interesting things I’ve learned since being in this setting is the significant impact of dry mouth on overall oral health. As you know, anti-depressants and anti-psychotics often cause xerostomia, or dry mouth. Saliva acts as a protective coating on the teeth, and when it is in scarce supply, the teeth and more susceptible to caries and decay. I’ve seen patients here who are high in socioeconomic status start a new anti-depressant medication and come in for their six-month cleaning with significant changes in their oral health. There is also ample evidence in the mouth for eating disorders (tooth erosion), bipolar disorder and OCD (patients get overzealous with brushing and flossing), and trauma or anxiety (habitual teeth grinding and clenching, TMJ disorders). There is also a lot of evidence that poor oral health can exacerbate cognitive decline and functioning, which was a new concept to me! The last connection I’ll mention won’t be a surprise to any behavioral health clinician. When patients experience tooth loss or poor oral health, they see multiple impacts on their quality of life. Their self-esteem is low, their relationships are impacted, it can be difficult to find employment, this list goes on and on.

Lisa: I have to be honest, before talking to you and doing my own research, I just had no idea about so many of these connections. Even though these connections are evident, I would imagine that whenever a new workflow or paradigm shift happens in healthcare, it can feel overwhelming to those practicing because of all that they juggle already to keep their operation flowing smoothly. Is there a framework that can help providers figure out where to start their change process to address some of these issues you’ve talked about?

Jamie: I really like this example framework below developed by the Center of Excellence for Integrated Health Solutions/National Council for Behavioral Health. This framework shows how even minimal integration — such as staff education or screening for needs — can be a big step towards improving patient care outcomes. I’m curious though…as an integration specialist, what are your thoughts on this framework?

Lisa: Well, change for practices, in my opinion, is not a lot different than change for people. We have to figure out where we are, start small, and evaluate the changes to keep moving forward. This framework reminds me of other integration continuum charts that can help providers figure out what part of the puzzle they can put into place in their practices. Even if a dentist is practicing in private practice with no behavioral health professional on site or nearby, and even if a behavioral health clinician is practicing in a traditional private practice, steps can be taken to help heighten the coordination and awareness of the relationship between oral health and behavioral health so that patients start feeling better both physically, orally, and mentally more quickly.

For example, oral health providers can receive mental health first aid training while behavioral health clinicians can receive training on oral health issues. On another deeper level of involvement, oral health providers could receive more intensive training about interventions such as motivational interviewing to help patients with brief interventions if it was clinically appropriate in their appointments, and behavioral health providers can include oral health questions about hygiene and utilization in their biopsychosocial assessments. Integrating behavioral health into oral health can certainly go as far as bringing in a behavioral health clinician into the dentist office, but I think it is a mistake to think that it has to be all or nothing. How would you encourage clinics to get started, Jamie?

Jamie: I agree with you completely on that! Students often ask me what they are supposed to do “in the real world,” meaning if they start their professional career in a setting where they do not have a behavioral health clinician on their team. There really is no wrong way to get started! Maybe I’m thinking a lot like a social worker, but I would say the key is to seek resources, resources, resources. If you are not the expert on your team, it is always good to acknowledge that and stay in your lane. Locate your local experts, or resources, like your local LME-MCO, Mobile Crisis Unit, Crisis Lines, Department of Social Services, 211, etc. Keep a flyer or binder of those resources at the front desk. Ask a staff member to be responsible for connecting with those organizations, learning about what they do, and periodically updating them if needed. North Carolina is fortunate in that it now has an easy-to-use, integrated, state-wide resource network called NCCARE360 that serves as an electronic one-stop-shop for all of the resources available within the local community. This way, you feel confident as a provider knowing that if you ask a patient a question about their behavioral or emotional health, or if a patient brings this up on their own, you know who to direct them to. No matter what type of healthcare you are providing, patients should be assured that there is no wrong door for accessing care and support.

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