Mental Health Participant Dental Care: The community feedback period for this idea began on 4/24/2019 and ended on 6/23/2019. *STATUS UPDATE*

What is the problem that needs to be addressed? Please describe how it is related to mental health.
Dental Care. People experiencing mental illness have specific oral health needs that are described at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4841282/ https://www.integration.samhsa.gov/health-wellness/oral-care https://www.integration.samhsa.gov/health-wellness/Clinical_Concerns_in_Dental_Care_for_Persons_With_Mental_Illness.pdf. The submitter of this Innovations Idea has not observed dental care tailored to the needs of a person experiencing mental illness.

 

 Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
For this discussion, Orange County has two general settings for dental care: Psych Inpatient and Outpatient. In the Psych inpatient setting, patients are provided a toothbrush and sodium floride toothpaste. They are not provided dental floss nor a toothpaste that addresses gingivitis/tartar or plaque control/sensitivity (Stannous Flouride). One of the major dental issues for the mental health population is periodontal disease. Access to interdental cleaners, such as dental floss, and a toothpaste that addresses issues in periodontal disease, such as a Stannous Flouride toothpaste, are basic self care interventions but not available to people in Psychiatric Wards. When a patient has dental sensitivity, the liklihood they will use a sodium flouride toothpaste is quite low because the continued pain associated with toothbrushing is not addressed by sodium flouride. In the outpatient setting, a single dental provider is marketed as the place to go or, alternatively, the patient can find a provider on their own from a list of hundreds of providers. The dental provider that is marketed as the place to go has preditory practices that includes requiring a credit application to balance bill the patient for questionable services that are quite expensive. The preditory practices are not disclosed prior to the visit and the patient is not provided informed consent prior to being exposed to the preditory practices. These financial practices are an unnecessary additional barrier to dental care. This reality is part of the “training” provided to mental health patients to erode their self-care. A previous OC Innovations Idea submission described the refusal of Sanitation services as another “training” that erodes self care. People that are trained to erode their self care are not going to be reintegrating into society or the workforce easily. At some point a retraining in self-care will be required. Common sense suggests it would be easier to not erode self care in the first place. Poor dental health is associated with dementia, cardiac disease, respiratory infections, diabetic complecations and possibly other serious medical issues.

 

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
The above referenced academic source is from Australia. The above referenced SAMHSA sources, which are essentially public policy documents intended to guide future investment, were not found to identify any model programs for dental care in the mental health population. They may exists, but they are not prominently described in the sources reviewed.

 

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
As has been previously noted by the Orange County Healthcare Agency Behavioral Health (OCHCABH) Innovations team, the innovation suggested is not the innovation. Dental floss, stannous flouride toothpaste, etc are not innovative. Developing a dental program that addresses the needs of a mental health population is the innovative part of this idea. How are you going to get Psych wards to start providing stannous flouride toothpaste and dental floss? How are you going to get dental providers billing on Denti-Cal to show interest in the needs of a person with mental illness. That’s the innovative part.

 

What is the project idea? Please describe how this project will operate.
The project idea is to do whatever can be funded via the Prop 63 Innovations process to create a dental care program – both inpatient and outpatient – that addresses the population experiencing mental illness. Addressing patients with lengthy inpatient stays (>6 months) and without dental floss/dentist access should be included in this plan. Training on navigating the Denti-Cal system – with the significant risk of preditory dental financing of dental services of questionable quality – should be part of this plan.

Additional Information:

Respondent skipped this question

 

 

April 9, 2019

3 comments

Innovations Team

Thank you for your submission. The innovation team needs additional information, please elaborate on your responses as best as possible so that we may work through our review process.

•Dental care is available to county residents via low cost and no cost providers, private providers or through Denti- Cal to eligible residents. There is also some support available with navigating available Denti- Cal services via their toll free number. The staff at this number can provide assistance with questions regarding services available, finding a dentist, costs, general questions and complaints. Is what you are proposing more of a specialty dental program with staff trained to serve those receiving mental health services in either an inpatient or outpatient setting?

•What learning objectives could be utilized within this program that would more closely link this idea to mental health outcomes?

When the general public looks for healthcare they look for a few things. Providers that serve a significant number of people similar to themselves. Providers that show cultural competency. Providers that have favorable outcomes.

People experiencing mental illness have specific dental needs that are not addressed by the typical dentist which include:
1) Vigorous brushing/flossing that abrades tissue leading to periodontal disease
2) Dental Phobias which may include etiologies of care quality, cost or lack of soft skills by the provider
3) Substance use/abuse, including tobacco/nicotine products, which can be an opportunity for behavior change
4) Dental self-care strategies in environments without sanitation nor security – how to brush your teeth or not brush your teeth when homeless
5) Post-psych ward discharge associated with poor in-ward hygiene opportunities, medications leading to excessive dry mouth/plaque buildup (an issue with discharge planning and lack of a study to support such care)
6) Depression/Post-depression plaque buildup

Denti-cal has regimented treatment schedules that may not take into account event based dental needs, like departure from a Psych ward. Dental providers tend not to provide educational materials/marketing specific to the needs of people experiencing mental illness. Dental providers tend to not specialize in the mental health population and thus trends across the population may not be understood as well as a dentist specializing in such a population.

Specific needs/outcomes that can be monitored include, but are not limited to:
1) Consumers entering dental care who previously did not participate (Community reintegration)
2) Consumers retaining their dental care on a regular schedule
3) Educational strategies to reduce dental sequelae of a mental illness (Morbidity and mortality prevention)
4) Is transportation a barrier to dental care? (Increased access)
5) What are the key performance indicators for dental care specific to the population experiencing mental illness?

This idea is not tied to any one person to implement and thus it is hoped that the best and brightest can add the open questions in dentistry with respect to mental illness.

Thank you for your idea submission. Upon review and discussion, it was determined that the idea is tied more strongly to public health rather than mental health and it is unclear what new learning this project could contribute to the field of mental health. The Innovation team is unable to continue exploring this idea under the MHSA Innovation component as proposed.

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