Journal of Oral Biology and Craniofacial Research 13 (2023) 544–552

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Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

Importance of oral health in mental health disorders: An updated review

Hans Erling Skallevold a, Nabin Rokaya b, Natthamet Wongsirichat c, Dinesh Rokaya d, *
a
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, 10330, Thailand
b
Humla Hospital District, Huma, 21000, Nepal
c
Faculty of Dentistry, Bangkok Thonburi University, 16/10 Taweewatana, Bangkok, 10170, Thailand
d
Department of Clinical Dentistry, Walailak University International College of Dentistry, Bangkok, 10400, Thailand

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Mental disorders are indeed an expanding threat, which requires raised awareness, education,
Psycho-disorders prevention, and treatment initiatives nationally and globally. This review presents an updated review on the
Mental health relationships between oral health and mental health disorders and the importance of oral health in mental health
Oral health
disorders.
Oral health approaches
Method: A literature search was done regarding mental disorders and oral health approaches in Google Scholar
and PubMed from the year 1995 until 2023. All the English-language papers were evaluated based on the in­
clusion criteria. Publications included original research papers, review articles and book chapters.
Results: Common mental disorders include depression, anxiety, bipolar disorder, Schizophrenia, dementia, and
alcohol and drug use disorders. The interplay of oral health and mental disorders involves dysregulated
microbiome, translocated bacteria, and systemic inflammation, among others.
Conclusion: There is a complex relationship between mental disorders and oral diseases. Various oral health
problems are associated with mental health problems. The interplay of oral health and mental disorders involves
dysregulated microbiome, translocated bacteria, and systemic inflammation, among others. Mental health nurses
including physicians and dental professionals should be involved in the oral health care of mental health disorder
patients. Therefore, multidisciplinary should be involved in the care of mental health disorders, and they should
consider oral health care as an essential part of their care for patients with mental health disorders. Future in­
vestigations should strive to elucidate the exact biological relationships, to develop new directions for treatment.

1. Introduction may be diagnosed based on criteria in The Diagnostic and Statistical

Manual of Mental Disorders, 5th edition, the DSM-5 for short.4 The term
Recently, the importance of mental health has been highlighted in mental disorder, influences several aspects of life and is sometimes
light of the consequences of the covid-19 pandemic.1 The sudden change interchangeably used with psychological and psychiatric disorders.
of living, involving quarantine and social distancing during the Prior to the pandemic, the number of persons with a mental disorder was
pandemic may have contributed to the growing number of reports of counted to be around 792 million globally, this prevalence has surged by
mental health problems.2 The World Health Organization (WHO) pro­ about 25%.2,5,6
motes mental health as an integral part of general health, as they define Several socio-economic aspects, typically unemployment, social
it as the state of “well-being where an individual realizes his or her isolation, and poverty, impact mental disorders.7,8 A number of modi­
abilities, can cope with the normal stresses of life, can work productively fications in people’s health behaviors have occurred as an effect of the
and can make a contribution to his or her community”.3 Mental health is covid-19 pandemic, such as a rise in snacking, tobacco and alcohol
necessary for a well-functioning individual and community, through consumption, and decreased physical activity.9 When negative health
interaction and development. When an individual’s mental state ex­ behaviors combine with stressors such as fear of infections, lack of
hibits certain behavioral or psychological patterns; a mental disorder supplies and information, or financial loss (these are relevant for the

Abbreviations: WHO, World Health Organization; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; DNA, Deoxyribonucleic Acid.
* Corresponding author.
E-mail addresses: [email protected] (H.E. Skallevold), [email protected] (N. Rokaya), [email protected] (N. Wongsirichat),
[email protected] (D. Rokaya).

https://doi.org/10.1016/j.jobcr.2023.06.003
Received 30 December 2022; Received in revised form 5 June 2023; Accepted 14 June 2023
2212-4268/© 2023 The Authors. Published by Elsevier B.V. on behalf of Craniofacial Research Foundation. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
H.E. Skallevold et al. Journal of Oral Biology and Craniofacial Research 13 (2023) 544–552

covid-19 pandemic), oral health may deteriorate.10 As mental disorders Table 1. A mental disorder involves a person’s behavioral or psycho­
are on the rise, one may expect an increase in anti-psychotics and de­ logical patterns; based on criteria in the DSM-5.4 Most encountered
pressants. These medications involve the risk of adverse effects, such as disorders are depression and anxiety, affecting around 3.8% of the world
bruxism and xerostomia, which adversely affect the oral.11–14 The population. Recently, the global prevalence of depression and anxiety,
notion that fear of infection and social interaction, associated with the in adolescents was estimated to be 25–31%.29 More than half of middle-
pandemic, may hinder access to dental, has been reported.15 Worsened and high-income countries’ populations are expected to suffer from one,
anxiety or phobia of dental treatment can result from non-atten­ or more, mental disorders during their lives.30 Poor mental health is a
dance,16,17 making patients exclusively seek dental care during growing burden globally, in the span from 1990 to 2019, the global
emergencies.18 proportion of disability-adjusted life-years ascribed to mental disorders
The pandemic’s impact on mental health is distressing,19 however, went from 3.1 to 4.9%.31 This has a profound impact on the world
this may just be among the first of several sequelae to appear. For economy, as costs involve more than direct costs such as medication and
example, the pandemic may have fueled anxiety through elevated use hospitalization,32 but also income losses because of lost production
and addiction to social media,20–23 social media may also influence the because of missing work or swift retirement.32,33 Such indirect costs did
perception of dental treatment.24,25 Indeed, about 3.5 billion individuals make up 1.7 trillion USD in 2010, while the total costs totaled 2.5 tril­
have untreated oral conditions,26 and the number may grow with the lion, these numbers are only expected to rise with the growing preva­
growing prevalence of mental disorders and as a consequence of the lence.33 The projected lost economic output globally, from 2011 to
pandemic. Mental disorders and oral health’s reciprocal influence is 2030, is estimated to reach 16.3 trillion USD, which surpasses that of
generally neglected and little-known issue.27 However, this issue is cancer and is similar to cardiovascular diseases.33 Mental disorders are
highly relevant following the pandemic and needs to be brought to indeed an expanding threat, which requires raised awareness, educa­
awareness by health professionals to guide policymaking. This review tion, prevention, and treatment initiatives nationally and globally.31
presents an updated review on the relationships between oral health and Common metal disorders include depression, anxiety, bipolar disorder,
mental health disorders and the importance of oral health in mental Schizophrenia, dementia, and alcohol and drug use disorders (Table 2).
health disorders.
3.1. Depression
2. Method
Depression is, together with anxiety, the most common mental dis­
A literature search was done regarding mental disorders and oral
order and one of the major reasons for disability.28 Symptoms mostly
health approaches in Google Scholar and PubMed from the year 1995
involve sadness and loss of interest or pleasure.34 Compromised social
until 2023. All the English-language papers were evaluated based on the
function, impacting education or work, is common and involves a sig­
inclusion criteria. Publications included original research papers, review
nificant risk of suicide.35
articles, and book chapters.

3. Psycho-disorders/mental disorders definition, prevalence, 3.2. Anxiety

types, symptoms, or habits
Anxiety sets off in the presence of an overactivation of a recognized
In 2017, about 792 million individuals were diagnosed with a mental threat or erroneous danger assessment, leading to an excessive and
disorder on a global scale, with females as the dominating gender.28 unfitting fight-or-flight reaction.36 Such irrational fear responses give off
Mental disorders encompass a diverse spectrum, as summarized in a wide scope of symptoms; fear of losing control or of death, diminished
concentration, elevated confusion, impaired memory, tachycardia,
shortness of breath, chest pains, syncope, and so on. People with anxiety
Table 1 tend to avoid triggering situations.37 Several subtypes of anxiety exist, a
Overview of the global prevalence in 2017 of common mental disorders. common one is dental anxiety or dental fear. The more severe version is
Adapted with permission from Dattani et al.28 known as dental phobia, or odontophobia; an extremely irrational fear
Disorder Share of the global Number of Share of males: or aversion to dental-related situations.38 A recent meta-analysis esti­
population with the people with females with mated the global prevalence of dental anxiety in children and adoles­
disorder (2017) the disorder the disorder
cents to be 23.9%. Whereas 36.5% of preschoolers, 25.8% of school
[difference across (2017) (2017)
countries] children, and 13.3% of adolescents, reported dental anxiety.39 Dental
Any mental health 10.7% 792 million 9.3% males
disorder 11.9% females Table 2
Depression 3.4% [2–6%] 264 million 2.7% males Common mental health disorders and their common symptoms.
4.1% females
Common metaldisorders Common Sympoms
Anxiety disorders 3.8% [2.5–7%] 284 million 2.8% males
4.7% females Depression Symptoms mostly involve sadness and loss of interest or
Bipolar disorder 0.6% [0.3–1.2%] 46 million 0.55% males pleasure.
0.65% females Anxiety Anxiety sets off in presence of an overactivation of a
Eating disorders 0.2% [0.1–1%] 16 million 0.13% males recognized threat or erroneous danger assessment,
(clinical 0.29% females leading to an excessive and unfitting fight-or-flight
anorexia & reaction
bulimia) Bipolar disorder Usually comprises manic and depressive episodes, with
Schizophrenia 0.3% [0.2–0.4%] 20 million 0.26% males periods of normal mood in-between. High-speed
0.25% females speech, elevated self-esteem, and reduced need for
Any mental or 13% [11–18%] 970 million 12.6% males sleep, typically characterize a manic episode
substance use 13.3% females Schizophrenia and other Schizophrenia is a typical psychosis, characterized by
disorder psychoses distorted thinking, perception, emotions, and behavior,
Alcohol use 1.4% [0.5–5%] 107 million 2% males with hallucinations of auditory and visual types
disorder 0.8% females Dementia Findings of cognitive decline compared to a former time
Drug use disorder 0.9% [0.4–3.5%] 71 million 1.3% males point, while the person remains independent and well-
(excluding 0.6% females functioning in daily life, is diagnosed with mild
alcohol) cognitive impairment

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H.E. Skallevold et al. Journal of Oral Biology and Craniofacial Research 13 (2023) 544–552

anxiety is common with a 36% prevalence, while dental phobia affects a individuals have dental data.53 The study has shown that the number of
smaller proportion of the population, about 10% globally.40 Dental missing teeth was associated with an increased risk of dementia,53
anxiety and phobia impact oral health and general well-being negatively highlighting the association between cognitive decline and masticatory
and make necessary dental treatment challenging. For these patients, it dysfunction, supported by clinical54 and animal observations.55 These
is vital for the practitioner to offer a safe environment and trust, and use observations suggest tooth loss, is a possible risk factor for cognitive
an array of approaches; information, show-do-tell, coping skills, cogni­ decline54–59 and dementia.57,58,60 7.6% of the global population is
tive behavior therapy, preventive and minimally invasive treatment.41 edentulous, the prevalence increases to 14% in 50+ year-olds.61
Specialists, both medical and dental, or psychologists, with or without Edentulism and tooth loss lead to diminished mastication, so-called
sedation with nitrous oxide or benzodiazepines, or even general anes­ masticatory dysfunction.62 As the Nun study sparked interest in the as­
thesia, may be necessary in select cases.38 sociation of dementia and tooth loss and the brain-stomatognathic, it
may imply that rehabilitating one’s masticatory function can prevent
3.3. Bipolar disorder cognitive decline.51
Rehabilitation of masticatory dysfunction may be achievable by
Close to 46 million people worldwide28 are affected by bipolar dis­ prosthodontic means, such as dentures or dental implants, or by exer­
order. Usually, it comprises manic and depressive episodes, with periods cise. Both approaches show positive findings. The effects on cognitive
of normal mood in-between. High-speed speech, elevated self-esteem, function with masticatory exercise intervention exhibit promising
and reduced need for sleep, typically characterize a manic episode. Bi­ results63–67 Jaw-tapping, a form of masticatory exercise, for four weeks
polar disorder impacts several aspects, such as increased mortality and improves memory function in cognitively impaired patients.63 The oral
disability, and diminished quality of life.42 rehabilitation of four edentulous patients, in the case of converting from
removable dentures to implant-retained dentures, resulted in improved
3.4. Schizophrenia and other psychoses working memory and oral health quality of life. The pilot investigation
suggested that oral rehabilitation influences neurocognitive changes
Schizophrenia is a typical psychosis, characterized by distorted positively.64 Evidence suggests that masticatory function has a positive
thinking, perception, emotions, and behavior, with hallucinations of influence on cognitive function.51,60,63–67
auditory and visual types. Untreated schizophrenia is not compatible Animal studies shed light on possible mechanisms explaining the
with a normal function or role in society, however, effective treatment influence of mastication,59,68–74 and involve cognitive decline as a result
and support can re-integrate the person into society with a productive of decreased cellular proliferation70,71 and brain-derived neurotrophic
life.43 factor,68 increased nitrous oxide75 and extracellular dopamine concen­
trations76 in the hippocampus. These changes have been suggested to be
3.5. Dementia regulated by the cerebellum or movement-compensation in the brain, or
sensory-feedback mechanisms pertaining to the stomatognathic com­
Objective findings of cognitive decline compared to a former time plex.51 However, caution must be exercised as other factors may influ­
point, while the person remains independent and well-functioning in ence these relationships. For example, the chronological order of
daily life, is diagnosed with mild cognitive impairment. The diagnosis of whether cognitive impairment favors poor oral health and thus tooth
dementia requires supplemental findings of significant difficulties in loss and reduced function of mastication, or if masticatory dysfunction
daily life, and that negatively influence the person’s independence.44 leads to cognitive decline, is challenging to prove.56 In addition, the role
That is the consequence of impaired cognitive functions such as mem­ of another cause of tooth loss, specifically periodontitis, needs to be
ory, motivation, thinking, orientation, emotional control, and commu­ taken into consideration.77
nication, among others. Dementia is mostly the product of Alzheimer’s
disease or stroke. The most apparent and significant risk factor is 5. Relationship between oral health and mental health
age.45,46
The global scale prevalence is projected to grow from 57 million Dental caries, severe periodontitis, and tooth loss26 are the main oral
individuals to 152 million by 2050,47 this increase is mainly attributed diseases that remain untreated among 3.5 billion individuals, which
to the extension of life expectancy. The risk of developing dementia reflects oral health as a globally underestimated and undervalued health
grows with increasing age, for 65–69-year-olds the disease will annually challenge.78,79 In 2017, the global burden of all oral diseases reached
occur in 2.4 per 1000 persons, for 90+ year-olds, the incidence rate is 18.3 million years lived with disability (disability-adjusted life-years for
70.2 per 1000 persons.48 oral conditions), representing a 19.9% increase since 1990,80 whereas
Dementia has no curative or course-altering treatment, preventive the global economic burden is 544 billion USD, 187 billion of these are
measures and early diagnosis are therefore vital49 and should aim to due to productivity losses.81
influence modifiable risk factors; such as cardiovascular and lifestyle Indirect costs, such as productivity losses, may be attributed to oral
factors, depression, and head injuries.45,50 health’s influence on social withdrawal and isolation, pain and reduced
mastication, self-esteem, lack of oral health awareness, and mistrust of
4. Brain-stomatognathic axis dental health care providers.82 Individuals with mental disorders may be
considered a vulnerable group because of those influences.82,83 Addi­
The neurological impact of oral health has received little attention. tionally, oral health impacts general health, evidence supports an inti­
However, oral health and the brain may influence the development of mate association with coronary and respiratory diseases, stroke, and
several diseases, reflecting interesting directions of research and po­ diabetes.84–87 Such conditions are frequent comorbidities in those
tential management methods. A complex communication system be­ suffering from mental disorders.14,88 Studies report plenty of associa­
tween the brain, and the stomatognathic system – consisting of the jaws, tions between oral and mental health problems: dental erosion in the
the oral cavity’s interior, and surrounding tissues, constitute the brain- eating disorders anorexia and bulimia, burning mouth syndrome in
stomatognathic axis.51 This system explains the relationship between anxiety and depression,89 dental caries due to high consumption of
observable changes in the brain and oral status.51,52 sugar,90 and increased incidence of periodontal disease due to poor
The colloquially known “Nun study”, began in 1986 and is still hygiene and excessive smoking,14,82,91 and increased risk of temporo­
ongoing, with a focus on aging and Alzheimer’s disease. 678 women mandibular joint dysfunction.92 Reportedly, serious mental disorders
with a mean age of 83 years, agreed to receive cognitive assessments involve 2.8 times higher risk of becoming edentulous in contrast to the
annually, and brain donation on death. Additionally, several of these general population.14,27 Predictors and determinants of poor oral health

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H.E. Skallevold et al. Journal of Oral Biology and Craniofacial Research 13 (2023) 544–552

involve mental disorders and lifestyle factors, illustrating the compli­ care for patients with mental health disorders.105
cated interplay of influencing factors in mental and oral health (Figs. 1
and 2). 7. Mental disorders and dental diseases
Suspicion of mental disorders should be raised at the dental office
when atypical presentations of common oral diseases, or uncommon Periodontitis is a chronic disease, that affects the tissue surrounding
oral diseases, are observed. Common conditions such as loss of surface the tooth structure, with inflammatory disorder, degradation, and ulti­
tooth substance may be attributed to a number of mental disorders based mately loss of the tooth. The treatment constitutes the removal of bac­
on their representations. Dental erosions are present in 38% of patients terial biofilm on the tooth surface regularly by dental professionals and
with an eating disorder,93 the palatal dental surfaces are usually affected demands a high level of adherence to excellent oral hygiene routines.
because of self-induced vomiting, in contrast to the common labial Beyond tooth loss and subsequent masticatory dysfunction, periodon­
erosions due to extrinsic consumption of acidic drinks.94 Bruxism, titis also affects general health.84–86,106,107 Globally, periodontitis is
colloquially known as teeth grinding, is likely to suffer from anxiety or among the most prevalent diseases with 20–50% of the population
depression.95 Bruxism can result in vertical loss of tooth substance, affected.108 The prevalence of periodontitis is projected to increase with
whereas labial surface loss due to frantic tooth brushing, tends to be the aging population and as a larger portion of older adults retain their
linked to obsessive-compulsive disorder.96 Xerostomia, the feeling of dry natural teeth.109 Mental disorders and their relationship with oral dis­
mouth, and hyposalivation are associated with antidepressants and ease, in particular periodontitis, are gaining increasingly more attention
psychotics. For example, tricyclic antidepressants can halve a person’s in the research communities. Several of the relationships are suggested
rate of salivation.97 A dry mouth increases dental caries risk, weakens to be bi-directional, which opens up for future therapeutic, diagnostic,
denture retention and raises the risk of candida infections.98 and preventive measures.110

6. Effect of oral health approaches for psycho-disorders 7.1. Alzheimer’s disease

There is a complex relationship between mental disorders and oral Recent meta-analyses suggest a significant association between
diseases due to the shared social determinants and bidirectional inter­ periodontitis and Alzheimer’s disease.77,111 Indeed, a number of studies
action mechanisms that involve interconnected social, behavioral, psy­ support this association and propose several explanations,112,113 how­
chological, and biological processes.99 Poor oral health has an effect on ever, the mechanism of bacterial translocation contributing to systemic
daily functioning and quality of life especially in patients with mental inflammation, seems plausible.110 This is supported as the DNA of Por­
health disorders.100–102 Therefore, patients with mental disorders are phyromonas gingivalis, one of the main pathogens of periodontitis has
three times more likely to lose their teeth compared to general peo­ been isolated in Alzheimer-diagnosed individuals,114 as well as anti­
ple.103 There is a burden of oral health-related quality of life in patients bodies against several periodontitis-associated bacteria.115,116 Addi­
with a mental health disorder. It is important to develop an oral health tionally, an association between periodontitis severity and Alzheimer’s
toolkit considering its potential effect on oral health-related quality of disease has been reported.111,117,118 Further support for this evidence is
life in mental health.100 Oral health programs should be provided attributed to animal studies where murine subjects were administered
tailored to the needs of the patient. Effective oral care is necessary for live P. gingivalis or their endotoxin, lipopolysaccharide. The adminis­
maintaining the oral health of mental health patients.104 When caring trations resulted in observable reductions of learning and memory
for patients with mental health disorders, it is essential to consider oral functions, and plaques of amyloid-β, a typical histological finding
health care as an essential part of their daily tasks and provide necessary associated with Alzheimer’s disease, in the animals’ hippo­
nursing support. Mental health nurses have an important role in the care campus.119–121 Consequently, these findings have inspired the devel­
of patients with mental health disorders.100 In clinics, mental health opment of gingipain inhibitors, which inhibit P. gingivalis’ proteases. The
nurses including physicians and dental professionals should be involved inhibitors resulted in decreased plaque formation, bacterial volumes,
in the oral health care of mental health disorder patients. Mental health and protective effects on hippocampus cells.114
nurses should be more aware of oral health and oral health risk and Taken together, the literature suggests periodontitis to be a modifi­
should provide long-term interventions to improve oral health. There­ able risk factor for dementia, particularly Alzheimer’s disease, and can
fore, multidisciplinary teams involved in the care of mental health dis­ therefore be an aim for therapeutic and prophylactic measures.122
orders, and should consider oral health care as an essential part of their

Fig. 1. An overview of predictors of poor oral health. Adapted with permission from Kenny et al..27

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H.E. Skallevold et al. Journal of Oral Biology and Craniofacial Research 13 (2023) 544–552

Fig. 2. Overview of determinants of poor oral health. Adapted with permission from Kenny et al..27

7.2. Depression periodontitis and bipolar disorder, compared to patients with peri­
odontitis but mentally healthy.135 These studies support a possible
The role of bacteria may also play a role in the relationship between relationship between bipolar disorder and periodontitis, which warrants
periodontitis and depression. Indeed, significant differences in the oral further investigations.
microbiome in depressed individuals have been reported. 21 taxa
differed in abundance between the healthy and depressed subjects, and 7.4. Parkinson’s disease
elevated levels of Neisseria spp. and Prevotella nigrescens were noted
(REF: Variations in the oral microbiome are associated with depression The biological relationship between Parkinson’s disease and peri­
in young adults.123 Animal studies support the notion that oral admin­ odontitis is less understood. However, some studies do report an
istration of lipopolysaccharide or live periodontitis-associated patho­ elevated prevalence of periodontitis among Parkinson’s patients.136
gens results in elevated inflammatory markers systemically, including Parkinson’s disease causes motor disruption and cognitive impairment
the brain, and depressive-like behavior.124–126 A genetic relationship resulting from neuronal cell death in the brain’s dopamine-producing
has been suggested. An elegant study investigated the role of crosstalk neurons of the substantia nigra.137 Hand tremors and rigidity are com­
genes and neuropeptides in these two diseases. The neuropeptides mon symptoms, which make it challenging to maintain adequate daily
adrenomedullin, insulin-like growth factor 2, prodynorphin, and resistin oral hygiene. The disease itself can arguably be a risk factor for peri­
were identified as mutually expressed in both periodontitis and odontitis, however, epidemiological evidence supports that periodonti­
depression, also playing a role in identifying depression.127 tis increases the risk of Parkinson’s disease.138,139 A protective effect
Epidemiological data reports a 62.5% comorbidity rate of depression against Parkinson’s disease has been observed in patients receiving
among periodontitis patients, compared to healthy individuals periodontal treatment over 5 consecutive years, compared to patients
(38.86%).128 Another study, for 10 years, followed over 60,000 subjects who did not receive treatment at all or for 5 consecutive years.138,139
and reported elevated depression incidence among the ones with peri­ Authors speculate that inflammation initiated and maintained by
odontitis.129 Depression is influenced by psychological and social fac­ periodontitis-associated pathogens entering the brain ultimately con­
tors. Periodontitis symptoms, such as malodor, poor oral hygiene, and tributes to or causes Parkinson’s disease.140 Further research to elabo­
edentulousness may negatively influence psychosocial factors by fa­ rate mechanistic relationships and the influence of periodontal
voring social isolation, shame, and reduced self-esteem, and thus treatment on established Parkinson’s disease may be interesting for
contribute to depression.130,131 When a tooth is lost, it may be replaced future directions.
by a dental implant, however, an implant may also develop
peri-implantitis, similar to periodontitis. Ultimately, the implant may be
7.5. Schizophrenia
lost. Several of the effects and disease relationships may be extrapolated
from periodontitis to peri-implantitis.132 Periodontitis and
Supportive literature on the relationship between periodontitis and
peri-implantitis may be suggestive modifiable risk factors for depres­
schizophrenia is scarce. A few studies have reported that patients with
sion, and if so, simple periodontal intervention and oral hygiene in­
schizophrenia carry an elevated risk of periodontitis and an even higher
struction may prevent or aid in the treatment of depression.133
risk for those consuming antipsychotics.141 Cortisol, commonly impli­
cated in periodontitis, has been ruled out as the levels were lower among
7.3. Bipolar disorder schizophrenia patients compared to healthy ones.142 Interestingly, the
angiotensin-converting enzyme gene’s D allele is reportedly a protective
Chronic inflammation has been reported as a factor in bipolar dis­ factor against schizophrenia143 and periodontitis,144 and may prove to
order. The relationship between bipolar disorder and periodontitis was be a biological connection. In addition, the role of the oropharyngeal
examined from 2001 to 2012 in Taiwan. For bipolar disorder, an microbiome, the salivary microbiome, and periodontitis was suggested
elevated risk was reported among the periodontitis subjects, compared to potentially be associated with schizophrenia, and that periodontitis
to the non-periodontitis subjects.134 Higher bacterial loads of reinforces the role of inflammation in the pathophysiology of schizo­
periodontitis-associated pathogens were reported in subjects with phrenia. Moreover, saliva is a bodily fluid of diagnostic interest for

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H.E. Skallevold et al. Journal of Oral Biology and Craniofacial Research 13 (2023) 544–552

several conditions,145 and may be useful in the diagnostics of schizo­ 2/3 clinical trial.114,165 Potential protective effects of periodontal
phrenia as well, however, the current evidence is still limited.146 treatment should be investigated by longitudinal studies with sizable
populations for similar effects.132 The therapeutic potential of oral
8. Social media influence oral health and mental health health interventions on mental disorders is a little-researched area that
deserves further investigation. For patients with mental disorders,
The impact of social media on mental health,20–23 represents another studies should investigate the effect of, and obstacles in, multidisci­
mechanism of the mental health-oral health relationship. Social media plinary interventions and preventive programs to guide management
constitute an array of web-based services allowing users to interact both recommendations and guidelines.
verbally and visually.147 Social media use is particularly widespread
among teenagers between 13 and 17 years old.148,149 This demographic 11. Conclusion
is worrying as accumulating evidence supports social media’s negative
influence on mental health, as research suggests that half of the mental Mental disorders are indeed an expanding threat, which requires
disorders are formed by the age of 14 and 75% by 18 years old.150,151 A raised awareness, education, prevention, and treatment initiatives na­
recent systematic review highlighted that depression, anxiety, and tionally and globally. There is a complex relationship between mental
psychological distress in adolescents correlated with time spent, activ­ disorders and oral diseases. Various oral health problems are associated
ity, investment, and addiction to social media.152 with mental health problems. The interplay of oral health and mental
Dental practitioners enjoy posting cases on social media,153,154 this disorders involves dysregulated microbiome, translocated bacteria, and
may be interesting for dental professionals, however, the impact of such systemic inflammation, among others. Mental health nurses including
posts has shown an inclination among patients to seek cosmetic modi­ physicians and dental professionals should be involved in the oral health
fications for their smiles.155 Indeed, exposure to “ideal” facial pictures, care of mental health disorder patients. Therefore, multidisciplinary
increased smiles, and face dissatisfaction among young adults.156 Smile should be involved in the care of mental health disorders, and they
dissatisfaction and self-perceived need for dental makeovers affect should consider oral health care as an essential part of their care for
mental well-being,157,158 and may lead to reduced social function and patients with mental health disorders. Future investigations should
negative coping strategies; such as abstaining from showing teeth during strive to elucidate the exact biological relationships, to develop new
laughing, eating, and in social settings.157,159,160 A severe engrossment directions for treatment.
of a self-recognized defect in appearance is known as body dysmorphic
disorder. The engrossment is exaggerated as others do not notice the References
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