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FACT SHEET: Depression (unipolar depression includes “major depression” [also known as “major depressive disorder” and “clinical depression”], “minor depression”, “dysthymic disorder” [also known as “dysthymia” and “persistent depressive disorder”] “seasonal affective disorder”, “postpartum depression” [PPD], and “depression with psychosis”; depression also occurs in bipolar disorder)

Date of Publication: June 10, 2019
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Note: Unless otherwise specified, this fact sheet addresses unipolar depression. Bipolar disorder is specifically addressed in a separate fact sheet.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No, unless the patient/client displays psychotic signs/symptoms that pose a risk to himself/herself or the dental hygienist during procedures (e.g., disorganized behaviour).

Is medical consult advised?  

  • No, if depression has been previously diagnosed and is well controlled.
  • Yes, if depression is newly suspected or poor control of previously diagnosed depression is suspected. Immediate referral is indicated if suicidality is suspected.
  • Yes, if severe xerostomia is suspected to be related to antidepressant use (which may improve if an alternative antidepressant is a consideration).

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • No, unless the patient/client displays psychotic signs/symptoms that pose a risk to himself/herself or the dental hygienist during procedures (e.g., disorganized behaviour).

Is medical consult advised? 

  • See above.

Is medical clearance required? 

  • No, unless severe leukopenia (i.e., reduced white blood cell count, and hence immunosuppression) is suspected with tricyclic antidepressant (TCA), monoamine oxidase inhibitor (MAOI), or antipsychotic medication use. [This would be a rare situation in the dental hygiene office setting.]

Is antibiotic prophylaxis required?  

  • No (in the absence of immunosuppression).

Is postponing treatment advised?

  • No, unless:
    • medical clearance is pending regarding possible immunosuppression associated with TCA, MAOI, or antipsychotic use;
    • the patient exhibits psychotic signs/symptoms that may pose risk during, or cause inability to perform, procedures, in which case medical treatment is first needed; or
    • severe signs/symptoms of depression exist (in which case attainment of better depression control may be indicated before attempting elective dental hygiene treatment).

Oral management implications

  • Depression is associated with poor oral health, including significant impairment of oral hygiene often coupled with avoidance of necessary dental care. Depressed patients/clients lack interest in caring for themselves, and help with oral hygiene is important. The dental hygienist should be supportive and non-judgmental.
  • During a major depressive episode, many patients/clients are probably best served by addressing only their immediate oral health needs. Following response to medical/psychiatric treatment, more complex dental procedures can be considered.
  • Management of iatrogenic xerostomia is important. Patients/clients should be asked whether their saliva seems reduced and if they have trouble swallowing, speaking, or eating dry foods. Other appropriate queries relate to lip dryness and cracking, halitosis, and mouth sores. If severe antidepressant-related xerostomia is found, the patient/client’s physician may be able to prescribe an antidepressant with less anticholinergic activity.
  • Vasoconstrictors (including epinephrine and levonordefrin) should be used cautiously, if at all, in patients/clients taking tricyclic antidepressants due to the risk of potentiation of pressor effects (including elevation of blood pressure)1.
  • Postural (i.e., orthostatic) hypotension may result from use of tricyclic antidepressants, monoamine oxidase inhibitors, or antipsychotics, which in turn poses a risk of falls. Therefore, upright positioning of the patient/client in the dental chair, slow position changes (particularly from recumbent to standing position), and/or monitoring of blood pressure may be indicated. 
  • Sedatives, hypnotics, and narcotics should generally be avoided, or used in reduced dosages, in patients/clients taking antidepressant medication. MAOIs in particular potentiate the central nervous system and respiratory depressant effects of opioids.

Oral manifestations

  • Dental caries, periodontal disease, pocket depth increase, and tooth loss occur at elevated rates due to reduced oral self-care, impairment of salivary flow, and unhealthy eating and behavioural activities. In particular, the unfavourable oral environment can create conditions leading to smooth-surface caries and candidiasis.
  • Dental erosion results from comorbid bruxism, smoking, and alcohol use. Gastro-esophageal reflux is exacerbated by elevated levels of tobacco and alcohol use.
  • Glossodynia and burning mouth syndrome are common complaints.
  • Xerostomia is a side effect of antidepressants, including TCAs, MAOIs, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and atypicals2. Dry mouth is also an anticholinergic side effect of antipsychotic drugs3 used in the management of depression-associated psychosis. Heavy tobacco and caffeine use further exacerbate dry mouth and related oral manifestations.
  • Dysgeusia (altered sense of taste) can be a side effect of tricyclics, MAOIs, and some atypical antidepressants.
  • Bruxism is associated with SSRI and SNRI use.
  • Stomatitis may result from atypical antidepressant (e.g., bupropion) or TCA use.
  • Sialadenitis, tongue edema, and tongue discolouration may result from TCA use. 
  • Involuntary repetitive movements of the lips (smacking) and tongue (thrusting) may result from antipsychotic use, particularly during the first several days of treatment4. 

Related signs and symptoms

  • Depression is more than simple unhappiness; it is a complex mood disorder caused by various factors, including genetic predisposition, personality, brain chemistry5, and stress6. Like most mood disorders, depression tends to be cyclic.
  • Depression is common. In the Canadian population aged 15 years and over, nearly 5% report symptoms that meet the criteria for major depression. As well, more than 11% of adults identify symptoms that have met the criteria for major depression at some point in their lifetime. Mean age of onset is 32 years, and more than 50% of patients/clients who have an episode of major depression have a recurrence.
  • Depressive disorders overall are more common among females than males (2:1), although the sex difference decreases with age. Male depression is characterized by a higher rate of feeling, irritable, angry, and discouraged, which can make depression more difficult to recognize.  
  • Types of depression include:
    • major depression (also known as major depressive order or clinical depression), which is the most common form of depression and for which at least five characteristic depressive symptoms (one of which must be depressed mood or loss of interest or pleasure) have been present during the same 2-week period;
    • minor depression7, which is characterized by symptoms lasting 2 weeks or longer but which do not meet full criteria for major depression; 
    • dysthymic disorder (also known as persistent depressive disorder), which is a low-grade form of depression for which a chronically depressed mood for most of the day has been present for at least 2 years8;
    • seasonal affective disorder, which is affected by time of the year and the weather (usually occurring in the daylight-reduced winter months in the northern hemisphere);
    • postpartum depression, which occurs in women following the birth of a child (affecting 10% to 20% of new mothers)9;
    • depression with psychosis, which is a severe form of depression involving losing touch with reality and experiencing hallucinations (hearing, seeing, tasting, smelling, or feeling something that is not really present) or delusions (false beliefs with no basis in reality)10; and
    • depression with bipolar disorder, in which depression is interspersed with mania or hypomania (occurring in 5% to 10% of persons who experience depression).11 
  • The main symptom of depression is a sad, despairing mood that is present most days of the week, lasts more than 2 weeks, and impairs a person’s performance at work, at school, or in social relationships.
  • Signs/symptoms of depression include: changes in appetite and weight (decreased or increased); sleep disturbances (including early morning wakening, insomnia, or hypersomnia); loss of interest in work, hobbies, people, and/or sex; withdrawal from family and social contacts; feeling worthless, helpless, hopeless, unduly guilty, and/or pessimistic; having low self-esteem; psychomotor agitation or retardation; fatigue; irritability; difficulty concentrating, remembering, and making decisions; crying easily, or feeling like crying but not being able to; and recurrent thoughts of death or suicide.
  • In children, depression can manifest as pretending to be sick, refusal to go to school, clinging to a parent, worry that a parent may die, sulking, and getting into trouble at school.
  • Increased prevalence of depression12 is associated with chronic or serious diseases/conditions (and/or their associated treatments), such as lupus, hypothyroidism, cancer (breast, prostate, lung, colorectal, oral, etc.), myocardial infarction, stroke, Parkinson’s disease, epilepsy, obesity, osteoarthritis, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), dementia, and AIDS.
  • Risk factors for major depression include current stress burden (including poverty and unemployment); history of early trauma, abuse, neglect, or deprivation; personal and family history of mood, anxiety, and other psychiatric disorders; and personality disorder.
  • Depression can lead to death — about 70% of suicides in North America involve persons with depression. Although women attempt suicide more frequently than men, the rate of completed suicide is 4 times higher for men.

References and sources of more detailed information


Date: November 30, 2017
Revised: February 6, 2022


FOOTNOTES

1 While MAOIs do not potentiate the pressor effects of epinephrine and levonordefrin, they do potentiate the pressor effects of phenylethylamine and phenylephrine, the latter of which is found in many over-the-counter cold remedies, including nasal decongestant sprays. Phenylethylamine and phenylephrine must not be taken by patients/clients taking MAOIs.
2 Treatment of major depression usually involves antidepressant medication. Types of antidepressants include selective serotonin re-uptake inhibitors (which are often first-line drugs of choice, such as citalopram, escitalopram; fluoxetine, paroxetine, sertraline, and fluvoxamine); serotonin-norepinephrine reuptake inhibitors (such as venlafaxine, desvenlafaxine, and duloxetine); atypicals (such as bupropion, trazodone, and mirtazapine); tricyclics (which are less commonly used now given newer, safer, and better tolerated antidepressants; include amitriptyline, nortriptyline, imipramine, and doxepin); and monoamine oxidase inhibitors (which require dietary restrictions and are uncommonly used now given the advent of newer, safer drugs; include phenelzine and tranylcypromine).
3 Antipsychotics include chlorpromazine, thioridazine, fluphenazine, haloperidol, olanzapine, risperidone, clozapine, and quetiapine.
4 Acute side effects are reversible if the offending drug is stopped or if anticholinergic agents are given.
5 Reduced brain concentrations of the neurotransmitters serotonin and norepinephrine have been linked to depression.
6 Treatment for depression includes: pharmacotherapy (antidepressants), psychotherapy (including cognitive behavioural therapy), supportive counselling, hormone therapy, bright light therapy, and brain intervention therapies (such as electroconvulsive therapy [ECT], transcranial magnetic stimulation [TMS], and magnetic seizure therapy [MST]. Self-help and patient support groups can also be an important part of recovery. Clinical depression often needs to be managed over a patient/client’s lifetime.
7 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).
8 Lifetime prevalence of dysthymia is about 2% in women and 4% in men.
9 PPD is a deeper depression and lasts much longer than the “baby blues”. PPD usually starts within the first month after childbirth (although it can occur any time within the first year), and it can last weeks to months. Aside from the fact that it occurs soon after childbirth, PPD is clinically no different from a depressive episode that may occur at any other time in a woman’s life, although the symptoms of PPD tend to focus on infant care and motherhood.
10 So-called “positive” symptoms of psychosis that add to or distort a person’s normal functioning also include disorganized speech, thoughts, or behaviour. “Negative” symptoms involve normal functioning becoming lost or reduced; these symptoms include restricted emotional and facial expression, restricted speech and verbal fluency, difficulty generating thoughts and ideas, reduced motivation and socialization, and reduced ability to begin tasks.
11 Other types of depressive disorders in the diagnostic classification of DSM-5 are premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder (diagnosed in children and adolescents).
12 This association may result from physiological changes associated with disease processes (such changes in neurotransmitters, hormones, and/or the immune system) or from associated disability and poor quality of life. As well, some medications used to treat illnesses may cause depressive symptoms.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.