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CDHO Advisory: Depression

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with depression.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Depression, 2022-02-06

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Depression

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have depression, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with depression.

MAJOR OUTCOMES CONSIDERED

For persons who have depression: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

Nomenclature varies among clinical centres. The following reflects common though not necessarily universal usages.

Depression, depressive disorder

  1. is a common but serious illness, which 
    1. interferes with the person’s daily life
    2. is considered a disorder of the brain
    3. causes difficulties for the person and people around the affected person 
    4. usually requires treatment
    5. differs from the short-lived feelings of sadness and gloom that are part of normal life and that pass within a day or two 
  2. occurs as
    1. major depressive disorder
    2. dysthymic disorder
    3. minor depression
  3. occurs in conjunction with other conditions or circumstances, chiefly
    1. psychotic depression
    2. postpartum depression
    3. seasonal affective disorder 
    4. childhood depression
    5. occupation-related depression
  4. occurs in co-existence with or as a characteristic of other mental health disorders, such as
    1. bipolar disorder
    2. anxiety disorders (CDHO Advisory)
    3. post-traumatic stress disorder
  5. occurs in co-existence with or as a characteristic of serious illnesses, such as
    1. cancer
    2. diabetes (CDHO Advisory)
    3. heart disease (CDHO Advisory)
    4. HIV/AIDS (CDHO Advisory)
    5. Parkinson’s disease (CDHO Advisory) 
    6. stroke (CDHO Advisory)

Other terminology is as follows.

  1. Bipolar disorder (CDHO Advisory)
    1. is characterized by mood changes that swing between mania and depression
    2. occurs in 5 to 10 percent of persons who experience depression. 
  2. Childhood depression
    1. occurs in children and teenagers
    2. is manifested by unexplained changes in behaviour, such as withdrawal and reluctance to discuss feelings, suggestive of unhappiness and a troubled state of mind.
  3. Delusions, beliefs unfounded in reality.
  4. Dysthymic disorder, dysthymia 
    1. is characterized by symptoms less severe than those of major depression but which may last for two years or more
    2. is less disabling than major depression but nevertheless interferes with normal functioning and is associated with feelings of unwellness
    3. may affect persons who also experience one or more episodes of major depression.
  5. Hallucination, sensory experiences that seem real but aren’t and that can affect all five senses; hearing voices is the most common hallucination, with voices that comment on behaviour, are insulting or give commands; also, seeing, tasting, smelling or feeling something that has no basis in reality.
  6. Occupation-related depression
    1. characterized by problems with performance, attendance and attitude 
    2. may result from 
      1. stress or adverse psychosocial factors in the workplace
      2. the effects on work of depression otherwise unrelated to the workplace.
  7. Major depressive disorder, major depression
    1. is characterized by a combination of symptoms that interfere with the person’s ability to sleep, eat, study, work and enjoy previously pleasurable activities
    2. is disabling and prevents the person from functioning normally
    3. may be experienced as a single episode within the person’s lifetime but more often recurs as multiple episodes.
  8. Minor depression2
    1. is characterized by symptoms 
      1. lasting 2 weeks or longer
      2. that do not meet full criteria for major depression
    2. in the absence of treatment places persons at high risk of developing major depressive disorder.
  9. Postpartum depression
    1. is diagnosed if a mother develops a major depressive episode within one month after delivery
    2. is believed to affect 10 to 20 percent of new mothers.
  10. Post-traumatic stress disorder
    1. may occur to a person following a terrifying event or ordeal
    2. renders the person especially prone to co-existing depression.
  11. Psychotic depression (CDHO Advisory), when a severe depressive illness is accompanied by psychosis, such as hallucinations and delusions.
  12. Seasonal affective disorder 
    1. characterized by the onset of a depressive illness during the winter months
    2. generally lifts during spring and summer.

Overview of depression

Resources consulted

Occurrence

Major depressive disorder, dysthymic disorder and minor depression variously

  1. can affect children, men and women of any age, education, economic or social status 
  2. affect nine percent of Canadians at some point in their lives 
  3. may run in families
  4. in occurrence are related to multiple factors, including
    1. depression in childhood, which 
      1. may persist, recur and continue into adulthood especially if untreated
      2. may predict more severe mental illness in later life
      3. may present warning signals such as 
        1. changes in behaviour suggestive of a troubled and unhappy state of mind
        2. an active and involved child who becomes quiet and withdrawn 
        3. a good student who starts to get poor grades 
      4. may become noticeable because of
        1. signs of changes in feelings such as
          1. anger
          2. fearfulness 
          3. guilt
          4. helplessness 
          5. hopelessness 
          6. loneliness
          7. rejection 
          8. unhappiness
          9. worry
        2. complaints by the child of 
          1. aches and pains of a general nature
          2. constant feelings of tiredness
          3. headaches
          4. lack of energy
          5. sleeping or eating problems
        3. comments by the child indicative of
          1. difficulty concentrating
          2. low self-esteem, self-dislike or self-blame
          3. negative thoughts
          4. thoughts of suicide 
        4. changes in the child’s behaviour
          1. crying easily
          2. over-reacting with sudden outbursts of anger or tears over seemingly small incidents 
          3. reduced interest in play or games previously enjoyed
          4. withdrawal from the company of others
      5. may be manifested in younger children by
        1. clinging to a parent
        2. pretence of sickness
        3. professed worry that a parent may die
        4. refusal to attend school
      6. may be manifested in older children by 
        1. feelings of being misunderstood
        2. getting into trouble at school
        3. negative and irritable behaviour
        4. sulking
      7. can be difficult to diagnose because the clinical picture may be attributed to mood swings considered typical of developing children 
      8. before puberty is equally likely to develop in boys and girls
      9. by age 15,  in the form of major episode of depression, is twice as likely to have been experienced  by girls as boys 
      10. in adolescence
        1. frequently occurs with other disorders such as 
          1. anxiety
          2. disruptive behaviour
          3. eating disorders
          4. substance abuse
        2. may increase suicide risk
      11. responds to medications and psychotherapy 
    2. depression in older adults, which 
      1. is not considered a normal part of aging
      2. may be overlooked because the symptoms are unobtrusive or unacknowledged by the older adult
      3. may be associated with comorbid medical conditions 
      4. may be caused by medications
      5. may result from arteriosclerotic depression in which narrowing of blood vessels reduces blood flow to the brain, among other organs, and which may be associated with stroke or cardiovascular illness 
      6. when undetected is associated with a high suicide rate in men aged 85 or older
      7. responds to medications and psychotherapy
    3. depression in women, which 
      1. is more common than in men
      2. may be linked to biological, life-cycle, hormonal and psychosocial factors unique to women
      3. occurs after giving birth as
        1. a brief episode of depression (‘baby blues’), which resolves without treatment, and which
          1. affects between 50 and 80 percent of mothers
          2. starts one to three days post-delivery
          3. is characterized by 
            1. feelings of vulnerability
            2. irritability
            3. lack of sleep
            4. mood changes
            5. weepiness
        2. postpartum depression, a serious condition of deep and continuing depression, which may be associated with prior depressive episodes, and which 
          1. follows between 3 and 20 percent of births
          2. begins at any time between delivery and 6 months post-delivery
          3. may last up to several months or even a year
          4. is characterized by some combination of
            1. despondency
            2. tearfulness
            3. feelings of
              1. anxiety
              2. fatigue
              3. guilt
              4. inadequacy
              5. irritability
            4. physical symptoms, such as
              1. chest pain
              2. headache
              3. hyperventilation
              4. numbness
            5. maternal ambivalence or negativity towards or disinterest in the child
            6. requires
              1. active treatment with medication 
              2. psychotherapy and emotional support
          5. may not always be 
            1. recognized as depression illness by the mother
            2. diagnosed by the physician
        3. postpartum psychosis, a serious condition which 
          1. occurs in about 0.01 percent of births
          2. is characterized by
            1. agitation
            2. alterations in mood
            3. extreme confusion
            4. fatigue
            5. feelings of hopelessness and shame
            6. hallucinations and rapid speech or mania
          3. ecurs in 10 to 35 percent of mothers with a previous history of postpartum psychosis
      4. may be associated with 
        1. a severe form of premenstrual syndrome
        2. stresses of work , family, family caregiver and home responsibilities 
        3. transition to the menopause
    4. depression in men, which
      1. is experienced differently than in women
      2. is usually acknowledged as symptoms such as 
        1. fatigue
        2. irritability
        3. loss of interest in once-pleasurable activities
        4. sleep disturbances
      3. may lead to use of alcohol or substance abuse in attempts at self-treatment
      4. may be manifested by 
        1. abusive behaviour
        2. anger
        3. discouragement
        4. excessive commitment to work to avoid discussion of the condition with family and friends
        5. frustration
        6. irritability
        7. reckless, risky behaviour
        8. suicide. 

Cause

Major depressive disorder, dysthymic disorder and minor depression  

  1. have no single known cause
  2. are considered likely to result from some combination of genetic, biochemical, environmental, and psychological factors such as stress
  3. are known to be triggered by specific, traumatic and distressing life events, which may be followed by depressive episodes 
  4. may occur without any obvious trigger
  5. may be related to or triggered by workplace factors and circumstances resulting in
    1. impairment of the workplace performance of a person with depression who remains at work without seeking help or who seeks to mask the depression for fear of repercussions
    2. manifestations such as 
      1. decreased dependability
      2. decreased productivity
      3. difficulty in making decisions
      4. frequent lateness
      5. increased health-related absence
      6. lack of enthusiasm for work
      7. poor concentration
      8. proneness to accidents
      9. unusual increase in work-related errors 
    3. dangerous use of alcohol or substances of abuse (CDHO Advisory)
    4. termination of employment, with social consequence that exacerbate the depression regardless of its origin.

Risk factors

Major depressive disorder, dysthymic disorder and minor depression are associated with 

  1. risks that bring on or increase depression, including
    1. alcohol or drug abuse (CDHO Advisory) 
    2. comorbidities, complications and associated conditions
    3. medications, and steroids
    4. sleeping difficulties
    5. stressful life events, such as 
      1. break-up of personal or family relationships; divorce
      2. failure in academic, career or business pursuits
      3. death or illness of someone close 
      4. childhood abuse or neglect
      5. job loss
      6. social isolation, especially in the elderly
  2. risks that are created by depression
    1. suicide
    2. non-compliance with medications and essential care
    3. physical health problems.

Signs and symptoms

Major depressive disorder, dysthymic disorder and minor depression 

  1. distort the way persons 
    1. see themselves, their lives, and the persons around them
    2. perceive things, reflective of 
      1. especially negative attitude
      2. inability to imagine that any problem can be resolved in a positive way
    3. are seen because depression may be manifested as anger and discouragement  and not only sadness and gloom
  2. produce symptoms such as
    1. agitation, restlessness, and irritability
    2. dramatic changes in appetite, often with weight gain or loss
    3. concentration difficulties 
    4. fatigue and lack of energy
    5. feelings of hopelessness and helplessness
    6. feelings of worthlessness, self-hate, and guilt
    7. withdrawal and isolation
    8. loss of interest or pleasure in activities that were once enjoyed
    9. thoughts of death or suicide
    10. trouble sleeping or excessive sleeping
  3. may if severe be accompanied by hallucinations and delusions
  4. vary considerably in duration, reflecting the prognosis
  5. are variously manifested by some combination of 
    1. alcohol, medication or substance abuse (CDHO Advisory)
    2. changes in eating habits
      1. appetite loss
      2. over-eating
    3. changes in sleeping patterns 
      1. early-morning wakefulness
      2. excessive sleeping
      3. insomnia
    4. chronic fatigue and decreased energy
    5. decreased sex drive 
    6. dependence on others to an extreme degree
    7. difficulty in concentration and remembering details
    8. difficulty in decision-making
    9. feelings of 
      1. anxiety 
      2. emotional emptiness
      3. guilt out of proportion to circumstances or lacking reasonable context
      4. sadness or grief to an overwhelming degree
      5. worthlessness, helplessness, hopelessness, pessimism or despair
    10. loss of interest in activities or hobbies once pleasurable
    11. persistent aches or pains, headaches, cramps or digestive problems not eased by treatment
    12. restlessness; irritability extending to hostility
    13. slowness of speech
    14. thoughts of suicide; suicide attempts
    15. withdrawal from
      1. interactions with friends or family
      2. social interactions generally.

Medical investigation

Major depressive disorder, dysthymic disorder and minor depression

  1. are diagnosed when symptoms, signs and manifestations
    1. are severe
    2. last for more than two weeks
    3. interfere with life and work
    4. are reflected in changes in thinking, behaviour and body functions 
  2. are diagnosed and assessed for severity by 
    1. analysis of the medical history and symptoms 
    2. exclusion of causes such as medications and illnesses of which depression is a symptom or accompaniment
    3. psychological or psychiatric evaluation, which covers family history, current symptoms, signs and manifestations, including suicidal thoughts and use or abuse of medications, alcohol and substances of abuse.

Treatment 

Major depressive disorder, dysthymic disorder and minor depression 

  1. have available treatment which
    1. is helpful even with the most severe depression
    2. is nevertheless not sought by some persons
    3. reflects depression’s association with 
      1. suicide, thoughts of which 
        1. constitute a medical emergency
        2. may require hospitalization
        3. in children, adolescents, and young adults require close monitoring for suicidal behaviour, especially during the first few months after starting medications
      2. needs for prompt medical attention in the event of
        1. hallucinations
        2. frequent crying spells with little or no reason
        3. disruption of work, school, or family life
        4. current medications that are
          1. ineffective
          2. causing side effects
        5. the person’s stopping or changing medications without medical advice
  2. are approached by treatment that
    1. necessitates
      1. careful analysis of side effects of medications which may intensify depression
      2. careful advice for women receiving treatment for depression who are pregnant or thinking about becoming pregnant, who should not stop taking antidepressants without first taking medical advice
    2. is supported by evidence or experience that
      1. depression can be successfully treated in some 80 percent of persons 
      2. that treatment is most likely to be successful if it is started as soon as possible after diagnosis 
    3. variously comprises 
      1. medication, which is usually essential in major depression, and which often needs to be taken over a period of months or years
      2. psychotherapy, which may be sufficient for mild-to-moderate depression
      3. medication and psychotherapy combined
      4. cognitive behavioural therapy for
        1. combating negative thoughts
        2. learning problem-solving skills
      5. electroconvulsive therapy (ECT), which
        1. is regarded by some authorities as the single most effective,  generally safe treatment for severe depression, but which is also the subject of controversy
        2. may improve mood for persons with severe depression or suicidal thoughts who do not improve with other treatments
        3. may help treat depression in those who have hallucinations or delusions
      6. transcranial magnetic stimulation (TMS), which uses pulses of energy to stimulate nerve cells in the brain that are believed to affect mood
      7. magnetic seizure therapy (MST), which involves induction of a seizure by applying magnetic stimulation to the brain and that is being investigated as an alternative to ECT
      8. support networks that assist persons in combating negative attitudes to mental illness generally and depression in particular
      9. for seasonal affective disorder 
        1. light therapy; about 50 percent of persons respond to light therapy in wintertime
        2. antidepressant medication and psychotherapy, either alone or in combination with light therapy.

Prevention

Major depressive disorder, dysthymic disorder and minor depression cannot be prevented but, to reduce some of their effects or improve prognosis, precautions can be taken, such as

  1. avoidance of alcohol and substances of abuse, including addictive medications, because these can 
    1. exacerbate depression
    2. lead to thoughts of suicide
  2. close compliance with prescribed medications
  3. attention to side effects of medications
  4. attention to signs of deepening depression
  5. encouragement of healthy habits
    1. getting more exercise
    2. maintaining good sleep habits
    3. seeking out pleasurable activities 
    4. getting involved in group activities
    5. talking about feelings to a trusted person
    6. associating with people who are caring and positive.

Prognosis

Major depressive disorder, dysthymic disorder and minor depression, regarding outlook, are variously influenced by treatment  

  1. with antidepressants for major depression 
    1. which for a few weeks may be sufficient to relieve symptoms 
    2. or which may need to be continued for as long as 9 months for significant improvement and to prevent symptoms from returning
  2. with medications for repeated episodes of depression because avoidance of long-term, severe depression may require not only prompt, but also continuing treatment. 

Social considerations

Major depressive disorder, dysthymic disorder and minor depression 

  1. require social support because they
    1. may affect all aspects of the person’s life
    2. have particular social consequences for children and teenagers
    3. impact family caregivers and the family as a whole because of the challenge of
      1. being with and helping a person who is severely depressed
      2. communicating with a person who, as a result of depression, does not want to be communicated with
      3. maintaining support for a person who, as a result of depression, does not want to be alone.
  2. are the focus of dedicated support groups whose members share common experiences and problems with the intention of easing the burden of depression, such as
    1. Canada
      1. Support Groups
    2. US
      1. American Psychiatric Association
      2. American Psychological Association

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with depression but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Comorbid conditions, complications and associated conditions for depression are chiefly as follows.

  1. Suicide risk.
  2. Conditions that  
    1. may precede depression
    2. may trigger or increase depression   
    3. may be a consequence of depression.
  3. Conditions that include 
    1. anxiety disorders, such as
      1. generalized anxiety disorder
      2. panic disorder
      3. social phobia
    2. obsessive compulsive disorder
    3. post-traumatic stress disorder
    4. alcohol and other substance abuse or dependence 
    5. serious physical illnesses such as 
      1. cancer
      2. diabetes
      3. heart disease
      4. HIV-AIDS
      5. hypothyroidism
      6. Parkinson’s disease
      7. persistent pain
      8. stroke.
  4. Conditions and symptoms that 
    1. may exacerbate or add to the person’s symptoms
    2. are created by the side-effects of medications used for treatment of depression such as those caused by
      1. monoamine oxidase inhibitors, which include
        1. altered sense of taste
        2. daytime sleepiness
        3. diarrhea
        4. dizziness or light-headedness
        5. dry mouth
        6. hypotension
        7. insomnia
        8. muscle aches
        9. nervousness
        10. paresthesia
        11. urination difficulty
        12. weight gain
      2. selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, such as
        1. agitation
        2. headaches
        3. insomnia and nervousness
        4. nausea
      3. tricyclic antidepressants
        1. bladder problems, particularly for older men with enlarged prostates
          1. emptying the bladder
          2. weak stream
        2. blurred vision
        3. constipation
        4. daytime drowsiness 
        5. dry mouth
        6. hypotension
        7. interaction with vasoconstrictors.

Oral health considerations

Resources consulted

  1. Major depressive disorder, dysthymic disorder and minor depression require of the dental hygienist
    1. particular attention to oral healthcare because of the likelihood of poor oral self-care 
    2. consideration of communications because 
      1. some persons with depression
        1. keep to themselves, and may not want to be communicated with
        2. may not want to be left alone
        3. may react strongly to things said or done by the dental hygienist
        4. require encouragement to speak about their feelings and thoughts, and that, if they do so, they will 
          1. be offered non-judgmental support
          2. not be contradicted
          3. not be subject to ‘pep-talks’ about their depression
          4. be assured of confidentiality of the information they share with the dental hygienist
      2. children with depression, which may not be fully recognized, may
        1. complain of fatigue, aches and pains, and low moods which may require the dental hygienist to communicate with the family physician for information about physical causes
        2. be inadvertently made to feel rejected or misunderstood.
    3. consideration of antidepressants, which 
      1. may be in use by as many as 20 percent of persons receiving oral healthcare, with women outnumbering men
      2. may have adverse long-term effects on oral health, such as xerostomia
        1. which is associated with
          1. halitosis
          2. oral yeast infection
          3. periodontal disease
          4. tooth decay
        2. which may require
          1. fluoride application 
          2. salivation stimulation
          3. scheduling of more frequent oral healthcare visits
      3. may have cardiovascular effects, chiefly with tricyclic antidepressants, sometimes when these are taken with other medications, with effects such as
        1. orthostatic hypotension, which may require 
          1. shortening of oral healthcare visits 
          2. positioning the patient/client upright in the dental chair 
          3. monitoring blood pressure 
        2. interaction with vasoconstrictors, which may require
          1. obtaining the prescribing physicians advice
          2. minimizing quantities of vasoconstrictors used with local anesthesia
      4. may be prescribed by the physician when the depression is accompanied by panic attacks and dental phobia.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

  1. Selective serotonin reuptake inhibitors (SSRIs), such as
    citalopram (Celexa®)
    escitalopram (Lexapro®)
    fluoxetine (Prozac®)
    fluvoxamine (Luvox®)
    paroxetine (Paxil®, Pexeva®)
    sertraline (Zoloft®)
  2. Serotonin and norepinephrine reuptake inhibitors (SNRIs), and similar, such as
    desvenlafaxine (Pristiq®)
    duloxetine (Cymbalta®)
    levomilnacipran (Fetzima®)
    venlafaxine (Effexor®)
  3. N-methyl D-aspartate (NMDA) receptor blockers, such as
    esketamine (Spravato®)
  4. Gamma-aminobutyric acid-A (GABAA) modulators, such as
    brexanolone (Zulresso®)
  5. Herbal
    St. John’s wort (many alternative names)
  6. Dopamine reuptake inhibitor
    bupropion (Aplenzin®, Wellbutrin®, Zyban®)
  7. Monoamine oxidase inhibitors, such as
    phenelzine (Nardil®)
    tranylcypromine (Parnate®)
  8. Tricyclics, such as
    amitriptyline
    imipramine (Tofranil®)
    nortriptyline (Pamelor®)

Side effects of medications

See the links above to the specific medications. 

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. seek to overcome reluctance on the part of the patient/client, parent or family caregiver to disclose a history of a mood disorder by expressing 
    1. supportive, nonjudgmental attitudes
    2. reassurance to the patient/client that such information
      1. is necessary for the provision of safe oral health, especially relative to
        1. contraindications
        2. obtaining advice from the appropriate primary care provider(s)
      2. will be kept confidential 
  2. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  3. explore the need for advice from the primary or specialized care provider(s)
  4. inquire about pointers in the medical history of significance to the provision of oral health, such as 
    1. he patient/client’s understanding and acceptance of the need for oral healthcare
    2. symptoms indicative of indifference or resistance to oral healthcare
    3. medications considerations, including over-the-counter medications, herbals and supplements
    4. problems with previous dental/dental hygiene care
    5. problems with infections generally and associated with dental/dental hygiene care
    6. the patient/client’s current state of health 
    7. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition. 

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider 
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client. 

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

  1. There is no contraindication to the Procedures, unless the patient/client displays psychotic signs/symptoms that may pose a risk to the patient/client or the dental hygienist. 
  2. With an otherwise healthy patient/client whose symptoms are under control and whose treatment is proceeding normally, the dental hygienist should implement the Procedures, though these may be postponed pending medical advice, which may be required if the patient/client has
    1. symptoms or signs of recent exacerbation of depression
    2. comorbidity, complication or an associated condition of depression
    3. possible immunosuppression or thrombocytopenia associated with tricyclic antidepressant, monoamine oxidase inhibitor, or antipsychotic medication use (rare in dental hygiene office setting)
    4. not recently or ever sought and received medical advice relative to oral healthcare procedures
    5. recently changed significant medications, under medical advice or otherwise
    6. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    7. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of depression, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test
    1. that he or she has a history of depression\
    2. to the medications he or she is taking
  2. should discuss, as appropriate 
    1. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    4. the importance of an appropriate diet in the maintenance of oral health
    5. the role of the family caregiver for persons with severe depression, with emphasis on maintaining an infection-free environment, and advice on wearing gloves
    6. scheduling and duration of appointments to minimize stress and fatigue 
    7. comfort level while reclining, and stress and anxiety related to the Procedures
    8. medication side effects such as dry mouth, and recommend treatment
    9. mouth ulcers and other conditions of the mouth relating to depression, comorbidities, complications or associated conditions, medications or diet
    10. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have depression.
  2. Reducing the adverse effects, such as the patient/client’s avoiding oral healthcare, by
    1. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    2. using appropriate techniques of communication
    3. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Causing the patient/client to turn away from oral healthcare.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client’s depression is severe enough for oral healthcare to exacerbate it or its complications 
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with depression.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-10-27

DATE OF LAST REVIEW

2011-09-01; 2017-11-30; 2022-02-06

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd, MCOD

Giulia Galloro
RDH, BSc(DH)

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2011, 2017, 2022 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children
2 In this context, the criteria for minor depression are similar to the criteria used in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for the diagnosis, “Other specified depressive disorder, depressive episode with insufficient symptoms” (i.e., the depressive episode is characterized by an insufficient number of symptoms to meet criteria for major depression).