The price of a smile
Oral health care coverage in people with severe mental illness – a Nordic overview
Recent scientific publications (1-3) have shown increased risk for oral health problems in people with severe mental illness. Possible explanations for the more frequent oral and dental diseases, as compared to a healthy population, are physical changes due to the mental illness and/or its medication. Many medicines influence the saliva quantity and/or quality, with subsequently a more frequent caries experience, and a more severe development of periodontitis. Also, there are many changes in the immunological and hormonal situation (4,5) secondarily affecting development of oral disease. Fatigue, sleep disturbance and lack of self-care, included oral hygiene, are other factors associated with oral health problems in people with severe mental illness (6). People with mental illness are in risk of more severe and more frequent oral disease, due to the previous mentioned factors, due to socioeconomic reasons, and due to the relative low health competence (7). Oral health is important to quality of life (8,9). Hence, oral health disease should be diagnosed and treated together with general health care issues in people with mental illness. An effort should be made on prevention of disease in this population. The goal for future health care providers should be to treat people with mental illness, and at the same time, prevent somatic and oral health decline. This requires a total health care system with sufficient health care coverage and funding.
Currently, oral health care for children (0-18 year of age (YOA), 0-23 YOA in Sweden) are free in the Nordic countries, as well as in Estonia, Latvia, and Lithuania. Hence, children and adolescents with mental illness will have full oral health coverage. For adults, the coverage is diverse among these countries.
In the Baltic countries, the main idea is self-payment for adults. In Lithuania there are income support dental care, and in Estonia there is a public insurance with a reimbursement for some of the payment for vulnerable persons. In Finland, some patients may receive some financial support through the social insurance institution (KELA).
Information regarding the specific coverage for people with severe illness in the Baltics and in Finland are not easily accessible. Hence, there may be some additional local supported fundings for adults with mental illness in these countries.
Icelandic Health Insurance participates in the cost (in some cases) of dental treatment for people with mental health disabilities.
In Sweden, a yearly, general coverage are given for dental examination. This coverage is currently 600SEK for people 24-29 YOA and above 65 YOA, and 300SEK for people 30-65 YOA. Sweden also has a high-cost protection scheme, in which patients pay 100% up to 3000SEK, 50% from 3000-15000SEK, and 15% for amounts above 15000SEK. Additionally, people with mental illness may receive coverage and funding from regions and municipalities, particularly people with long-term disease in need of regularly health support, and people with odontophobia (10,11). Funding is given to restore oral function (eating and speech), and to treat pain.
In Denmark, there is a Special Dental Care program for vulnerable groups, (i.e., children and adults with reduced mobility or reduced physical and psychological functional capacity unable to utilize the general oral health service) covering oral health services for these groups. The schemes are organized by the municipalities and require a fixed maximum fee per year, except for children. This special dental care program is provided as an outreach, preventive and regularly offer, and aim to reinstall oral function, and contribute to the patient’s physical, psychological, and social well-being through life (12-14).
The author believe it is highly necessary, and in due time for oral health to be part of the health care system, with its inseparable somatic and mental health care.
In Norway, people with severe mental illness are either treated within the public dental service located in the counties, or they are treated in the private dental service funded through the national health insurance. Patients in institutions or patients belonging to the municipal health system are covered within the public dental service free-of-charge. Patients with secondary problems due to dry mouth as a medication side-effect, and people with lacking ability of oral self-care are reimbursed according to the fees in the national health insurance (15,16). Prices in the private dental health care system are not regulated (same as in Sweden and part Denmark). Hence, payment may be problem for many patients with severe mental illness in need of large dental treatment.
In Norway, the laws and regulations for oral health are old (1984). Development of medical treatment methods and the medical system is a problem for implementing oral health care in general health care. New strategies in mental health care, such as ACT (assertive community treatment)/FACT and other ambulatory mental health care are currently excluded from coverage in the public dental service, while severe and current mental illness are a requirement for funding in the national insurance system. To be unable to receive oral health care being severely ill mentally is not uncommon. Hence, a lot of patients are unable to fully use their rights to oral health care. This issue has been addressed to the Government in Norway by the dental association, psychological association, the college of general practice and the psychiatric association in Norway.
The Norwegian government has established a Commission with the mandate of integrate oral health care in the health care system in accordance with WHO’s strategy on oral health care. The author believe it is highly necessary, and in due time for oral health to be part of the health care system, with its inseparable somatic and mental health care. A more similar coverage and funding system within the Nordic countries should also be a goal, understandable for both patients and health care providers. □
References by request
Wey MC, Loh S, Doss JG, Abu Bakar AK, Kisely S. The oral health of people with chronic schizophrenia: A neglected public health burden. Aust N Z J Psychiatry. 2016 Jul;50(7):685-94. doi: 10.1177/0004867415615947. Epub 2015 Nov 11. PMID: 26560842
Kisely S, Baghaie H, Lalloo R, Siskind D, Johnson NW. A systematic review and meta-analysis of the association between poor oral health and severe mental illness. Psychosom Med. 2015 Jan;77(1):83-92. doi: 10.1097/PSY.0000000000000135. PMID: 25526527
Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders - a systematic review and meta-analysis. J Affect Disord. 2016 Aug;200:119-32. doi: 10.1016/j.jad.2016.04.040. Epub 2016 Apr 21. PMID: 27130961
Singh D, Guest PC, Dobrowolny H, Vasilevska V, Meyer-Lotz G, Bernstein HG, Borucki K, Neyazi A, Bogerts B, Jacobs R, Steiner J. Changes in leukocytes and CRP in different stages of major depression. J Neuroinflammation. 2022 Apr 4;19(1):74. doi: 10.1186/s12974-022-02429-7. PMID: 35379263; PMCID: PMC8981816
Khandaker GM, Cousins L, Deakin J, Lennox BR, Yolken R, Jones PB. Inflammation and immunity in schizophrenia: implications for pathophysiology and treatment. Lancet Psychiatry. 2015 Mar;2(3):258-270. doi: 10.1016/S2215-0366(14)00122-9. Epub 2015 Feb 25. PMID: 26359903; PMCID: PMC4595998
McCallum SM, Batterham PJ, Calear AL, Sunderland M, Carragher N, Kazan D. Associations of fatigue and sleep disturbance with nine common mental disorders. J Psychosom Res. 2019 Aug;123:109727. doi: 10.1016/j.jpsychores.2019.05.005. Epub 2019 May 20. PMID: 31376877
Weinberg D, Stevens GWJM, Duinhof EL, Finkenauer C. Adolescent Socioeconomic Status and Mental Health Inequalities in the Netherlands, 2001-2017. Int J Environ Res Public Health. 2019 Sep 26;16(19):3605. doi: 10.3390/ijerph16193605. PMID: 31561487; PMCID: PMC6801857
Chaffee BW, Rodrigues PH, Kramer PF, Vítolo MR, Feldens CA. Oral health-related quality-of-life scores differ by socioeconomic status and caries experience. Community Dent Oral Epidemiol. 2017 Jun;45(3):216-224. doi: 10.1111/cdoe.12279. Epub 2017 Jan 12. PMID: 28083880; PMCID: PMC5506781
Lam PC, John DA, Galfalvy H, Kunzel C, Lewis-Fernández R. Oral Health-Related Quality of Life Among Publicly Insured Mental Health Service Outpatients With Serious Mental Illness. Psychiatr Serv. 2019 Dec 1;70(12):1101-1109. doi: 10.1176/appi.ps.201900111. Epub 2019 Sep 16. PMID: 31522632