Experiences and Attitudes Toward the Treatment of Patients with Mental Disorders Among Dentists in Croatia: A Cross-Sectional Pilot Study

Abstract

Background: The aim of this study was to assess the experiences and attitudes of dentists toward treating patients with mental disorders and to investigate how these attitudes correlate with factors such as sex, age, and years of clinical experience. Methods: A cross-sectional pilot study was conducted from March to July 2021 via an online questionnaire. The questionnaire consisted of four sections: demographic information, self-assessment of experiences and attitudes toward treating patients with mental disorders, knowledge of psychotropic drugs and their interactions, and personal experiences with patient care. Results: Overall, 101 dentists, mostly females (78.22%), completed the questionnaire, of which 65.35% consistently checked whether their patients were taking psychotropic drugs and 48.51% inquired about mental disorders when taking medical history. Still, 39.60% reported unpleasant experiences when treating such patients—mostly female dentists—and as many as 14.85% of all dentists refused to treat them. More than 94% of dentists recognized that patients with mental disorders are at greater risk for poor oral health and in need of early referral and professional support. Older dentists demonstrated better knowledge of oral manifestations and drug interactions relevant to dental treatment. Conclusions: Our findings highlight the need for improved training, an interdisciplinary approach, and greater dissemination of new scientific evidence for managing patients with mental disorders in dental practice. Considering that this is a pilot study using a combination of non-probabilistic convenience and snowball sampling method, the findings should be considered preliminary and interpreted with caution, as the sampling method limits the ability to make statistical inferences.

1. Introduction

Mental disorders are defined as syndromes characterized by clinically significant disturbances in an individual’s cognition, emotion regulation, or behavior that reflect dysfunction of the psychological, biological, or developmental processes underlying mental functioning [1]. In Croatia, they account for the largest and fastest-growing categories for the burden of disease [2]. Although nonpharmacological treatments are available, psychotropic drugs remain the key option and are among the most commonly prescribed medicines in Croatia [3].

Available studies agree that oral health in patients with mental disorders is significantly worse than that in the general population [4]. Epidemiological studies also emphasize the importance of oral health as part of one’s general mental well-being [5]. The manifestations of mental disorders in the oral cavity may be due to the patient’s inability to maintain proper oral hygiene or a direct consequence of the medication [6,7]. However, dentists are reluctant to ask patients about underlying mental illnesses and the medication they take. The current guidelines recommend a thorough medical anamnesis, including details on medication [8]. Not considering a patient’s mental state or the side effects of psychotropic drugs may affect the outcome of dental treatment [9,10,11], especially when local anesthetics with vasoconstrictors are administered to patients on antidepressants [8]. Therefore, dentists should adopt a supportive and nonjudgmental approach when treating these patients and perform a comprehensive anamnesis [8,10,12]. Collaboration with the patient’s psychiatrist or general practitioner (GP) is also advisable [12]. Dentists should also be aware that underlying mental disorders can sometimes lead to aggressive or uncooperative behavior, especially in patients with alcoholism, substance abuse, or disorders with manic, depressive, or psychotic episodes [6,9,13,14,15]. Implementing the available recommendations in routine clinical work can be challenging. However, continuous education and training on the appropriate management of patients with mental disorders is crucial to ensure optimal dental treatment [16].

As no prior research in Croatia has examined dentists’ experiences and attitudes toward the treatment of patients with mental disorders, we conducted a questionnaire-based pilot study to address this gap in the literature. The aim of this study was to assess dentists’ experiences and attitudes in treating patients with mental disorders. In addition, we explored how these attitudes correlate with sex, age, and years of clinical experience, and aimed to identify potential needs for further education on this matter.

2. Materials and Methods

2.1. Study Design

This was a cross-sectional, questionnaire-based study that involved dentists across Croatia. The inclusion criteria required participants to be licensed dentists, who were invited via their personal email addresses as well as the email addresses associated with their dental practices. We sent the questionnaire in an e-form to dentists from our private contacts and asked them to forward the questionnaire to their colleagues working in private or public health settings (snowball sampling method). Participation in this study was voluntary, and the questionnaire was anonymous. Before completing the questionnaire, all the participants were fully informed in writing about the purpose of the study. Completing the questionnaire was considered consent for participation. We decided to conduct a pilot study to evaluate the feasibility of our methods, assess the suitability of the questionnaire and identify potential limitations of the study design. The study report was written in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [17].

2.2. Questionnaire

Two team members (BN, TPP) developed the questionnaire based on the available literature on dentists’ experiences and practices concerning the treatment of people with mental disorders [8,10,11,18,19,20,21,22], and the third author (AT) reviewed it. After incorporating suggestions and feedback, we created the final version of the questionnaire in Google Forms and sent it to dentists across Croatia.

The questionnaire consisted of 30 questions, including general information about the age of participating dentists, their sex, and work experience. The remaining questions focused on dentists’ experiences and attitudes in treating patients with any type of mental disorder, and these were structured into three thematic sections. One section assessed respondents’ self-evaluations of their past experiences and their approach to treating patients with mental disorders. These questions were presented as interrogative statements, and the respondents indicated agreement or disagreement with each one. Another section addressed the side effects and interactions of psychopharmaceuticals relevant to dental treatment, which dentists reported with “Yes”, “No” or “I do not know”. The final section included declarative statements about personal experiences in treating patients with mental disorders and the perceived role of dentists in their overall care. A Likert scale (ranging from 1—Strongly disagree, to 5—Strongly agree) was used to gauge dentists’ agreement with these statements. In addition, two multiple-choice questions were incorporated. One presented a clinical scenario that led to a treatment decision, whereas the other examined the frequency with which dentists encountered this patient group in daily practice. The full questionnaire is available in Supplementary File S1.

2.3. Ethical Considerations

The study was approved by the Ethics Committee of the University of Split School of Medicine (Class: 003-08/21-03/0003, Reg. no: 2181-198-03-04-21-0016).

2.4. Data Analysis

Dentists’ responses were collected in an Excel file (Microsoft Office 2007, Microsoft, Redmond, WA, USA), appropriately coded, and analyzed via the STATISTICA 11.0 software package (TIBCO Software Inc., Palo Alto, CA, USA). Frequency tables were generated for each question with a yes/no response. The normality of the data distribution was tested via the Shapiro-Wilk test. Continuous variables are shown as the mean (M) and standard deviation (SD). Pearson correlation coefficients (r) and their significance were calculated to assess the interdependence between the dependent and predictor variables, with statistical significance set at p < 0.05 for all analyses (χ 2-square test). The Mann-Whitney U-test was used to test differences in attitudes between male and female dentists. We used multiple regression analysis, with variables such as sex, age, and years of clinical experience as covariates and dentists’ knowledge of mental disorders as the criterion variable. The results are presented as text, and in tables and figures. We did not calculate the optimal sample size. The final sample size resulted from the dentists’ response dynamics.

3. Results

Overall, 101 dentists with a mean age of 40.0 ± 10.6 years (ranging from 25 to 62 years) participated in this study. Most dentists had less than five years or more than 20 years of experience in clinical practice, and the majority were females (78.22%, N = 79).

Table 1. Participants’ general characteristics.

Characteristics		N	%
Sex	Male	22	21.78
	Female	79	78.22
Clinical experience (years)	Less than 5 years	30	29.70
	5–10 years	10	9.91
	10–20 years	31	30.69
	More than 20 years	30	29.70
Frequency of encountering patients with mental disorders	Less than 5 times per month	82	81.19
	5–10 times per month	14	13.86
	More than 10 times per month	5	4.95

Note: Data are presented as absolute numbers and percentages.

presents the participants’ general characteristics and the frequency of treating patients with mental disorders in their dental offices. Notably, 81.19% (N = 82) of the dentists encountered patients with mental disorders in their practice fewer than five times a month.

As many as 87.13% of the respondents do not believe that they have acquired sufficient knowledge to work with patients who suffer from mental disorders during their college education. Only 12.87% (N = 13) feel they possess adequate knowledge about the pharmacological characteristics of medications for treating mental disorders, and 30.69% consider they can predict the level of patient cooperativity based on this knowledge. A total of 48.51% of the respondents refer to mental disorders when taking a patient’s medical history, whereas 65.35% always check whether the patient is using any psychotropic medications. As many as 76.24% of the dentists consider that their patients may have issues with drug abuse. Additionally, a significant number of participants (81.19%) consider that the presence of a mental disorder influences the outcome of dental therapy and that the oral health of patients with mental disorders is at greater risk than that of the general population. As many as 96.04% of dentists acknowledged the importance of early dental referral and the necessity for professional assistance in maintaining oral hygiene for psychiatric patients. Notably, 39.60% of the respondents reported having any kind of unpleasant experience while treating patients with mental disorders, approximately 14.85% have refused to treat such patients altogether, and 57.43% reported never having consulted a patient’s specialist or general practitioner. Additionally, 92.08% of dentists considered that depression and somatization significantly affect the diagnosis and treatment of orofacial pain (full data shown in

Table 2. Dentists’ attitudes and approaches to patients with mental disorders in everyday practice.

Question		N	%	p-Value
Do you consider you have acquired sufficient knowledge to work with patients with mental disorders during your college education?	Yes	13	12.87	<0.001
	No	88	87.13
Do you consider you have sufficient knowledge about the pharmacological characteristics of medications used in the treatment of mental disorders?	Yes	13	12.87	<0.001
	No	88	87.13
Do you consider you can predict a patient’s level of cooperativity based on your understanding of mental disorders?	Yes	31	30.69	<0.001
	No	70	69.31
When taking patients’ medical histories, do you always inquire about any mental disorders?	Yes	49	48.51	0.765
	No	52	51.49
When taking a patient’s medical history, do you always check if the patient is using any psychotropic medications?	Yes	66	65.35	0.002
	No	35	34.65
Do you consider some of your patients struggle with drug abuse?	Yes	77	76.24	<0.001
	No	24	23.76
Do you consider that an underlying mental disorder affects the outcome of dental treatment?	Yes	82	81.19	<0.001
	No	19	18.81
Have you ever had an unpleasant experience while treating a patient with a mental disorder?	Yes	41	39.60	0.058
	No	60	59.40
Have you ever consulted a specialist or general practitioner involved in a patient’s mental care during dental treatment?	Yes	43	42.57	0.135
	No	58	57.43
Have you ever refused to work with a patient suffering from a mental disorder?	Yes	15	14.85	<0.001
	No	86	85.15
Would you like to receive additional education on the approach to patients with mental disorders?	Yes	87	86.14
	No	14	13.86	<0.001
Do you consider that the oral health of patients with mental disorders is at greater risk than that of the general population?	Yes	95	94.06	<0.001
	No	6	5.94
Do you consider early dental referral is important for maintaining the oral health of patients with mental disorders?	Yes	97	96.04	<0.001
	No	4	3.96
Do you consider that patients with mental disorders require professional assistance in maintaining their oral hygiene?	Yes	95	94.06	<0.001
	No	6	5.94
Do you consider that depression and somatization significantly affect the diagnosis and treatment of orofacial pain?	Yes	93	92.08	<0.001
	No	8	7.92

Note: Data are presented as absolute numbers and percentages; χ 2—chi-square test or Fisher’s exact test; p < 0.05. Statistically significant p-values are shown in bold.

).

Table 3. Dentists’ self-assessed knowledge regarding oral side effects of psychopharmaceuticals and their interactions with local anesthetics.

Question		N	%	p-Value
Do you consider that xerostomia is the most common oral side effect of antidepressant therapy?	Yes	59	58.42	<0.001
	No	7	6.93
	I do not know	35	34.65
Do you consider that it is necessary to take special caution during the administration of local anesthetic if the patient is taking tricyclic antidepressants?	Yes	42	41.58	0.060
	No	23	22.77
	I do not know	36	35.64
Do you consider that taking monoamine oxidase (MAO) inhibitors is one of the contraindications for the administration of local anesthetic with vasoconstrictor?	Yes	58	57.43	<0.001
	No	15	14.85
	I do not know	28	27.72

Note: Data are presented as absolute numbers and percentages; χ 2—chi-square test or Fisher’s exact test; p < 0.05. Statistically significant p-values are shown in bold.

presents dentists’ answers to general questions about the oral side effects of psychopharmaceutical drugs and their possible influence on local anesthetics. More than half of the dentists (N = 59, 58.42%) recognize xerostomia as a common oral side effect of antidepressant therapy. However, only 41.58% (N = 42) knew they should be especially cautious when administering local anesthetics with a vasoconstrictor in patients on tricyclic antidepressants.

Most dentists (N = 86, 85.1%) engage in discussions with patients to gather information about the causes of tooth erosion. Figure 1 illustrates the distribution of responses to the following question: “What actions do you take when you suspect an eating disorder and observe hard dental tissue erosions in adolescent patients”?

Generally, there was a moderate degree of discomfort when encountering a patient with a mental disorder (M = 2.7 ± 1.0 out of 5. Many dentists agreed (M = 4.0 ± 1.0) that they should refer the patient for further treatment if they notice signs of an underlying mental disorder. They were more neutral (M = 2.7 ± 1.2) on asking patients about their mental health. When asked about whether they expect low cooperativity in a patient with a severe mental disorder and would they rather redirect them to another dental care provider for treatment, the answers were generally neutral (M = 2.6 ± 1.1). Dentists agreed that oral diseases in patients dealing with severe mental disorders deserve the same level of attention as other comorbidities (M = 4.3 ± 1.0), and that patients with mental disorders may be classified as high-risk dental patients (M = 3.7 + 1.1). There were no significant differences in experiences in working with patients with mental disorders or in their general knowledge, except for female dentists, who reported feeling more uncomfortable when meeting a patient with a mental disorder (p = 0.041) (full data shown in

Table 4. Dentists’ knowledge and attitudes about mental disorders.

Variable	Sum of Ranks M	Sum of Ranks F	p-Value
During my work in the dental practice, I encounter patients dealing with any kind of mental disorders:	1159	3992	0.658
Do you consider you have acquired sufficient knowledge to work with patients with mental disorders during your college education?	1181	3970	0.406
Do you consider that you have sufficient knowledge about the pharmacological characteristics of medications used in the treatment of mental disorders?	1181	3970	0.406
Do you consider that you can predict the level of patient cooperativity based on your understanding of mental disorders?	1236	3916	0.244
When taking patients’ medical histories, do you always inquire about any mental disorders?	987	4164	0.201
When taking a patient’s medical history, do you always check if the patient is using any psychotropic medications?	1192	3960	0.491
Do you consider some of your patients struggle with drug abuse?	1033	4119	0.320
Do you consider that an underlying mental disorder affects the outcome of dental treatment?	1014	4137	0.191
Have you ever had an unpleasant experience while treating a patient with a mental disorder?	1176	3975	0.604
Have you ever consulted a specialist or general practitioner involved in a patient’s mental care during dental treatment?	939	4213	0.078
Have you ever refused to work with a patient suffering from a mental disorder?	1210	3942	0.245
Would you like to receive additional education on the approach to patients with mental disorders?	1221	3931	0.177
Do you consider that the oral health of patients with mental disorders is at greater risk than that of the general population?	1107	4045	0.763
Do you consider that early dental referral is important for maintaining the oral health of patients with mental disorders?	1129	4023	0.883
Do you consider that patients with mental disorders require professional assistance in maintaining their oral hygiene?	1056	4095	0.188
Do you consider that xerostomia is the most common oral side effect of the antidepressant therapy?	1198	3953	0.475
Do you consider that it is necessary to take special caution during the administration of local anesthetic if the patient is taking tricyclic antidepressants?	1050	4102	0.525
Do you consider that taking monoamine oxidase inhibitors is one of the contraindications for the administration of local anesthetic with vasoconstrictor?	975	4176	0.174
Do you consider that depression and somatization significantly affect the diagnosis and treatment of orofacial pain?	1085	4067	0.515
What actions do you take when you suspect an eating disorder and observe hard dental tissue erosion in adolescent patients? (it is possible to choose multiple answers)	1137	4014	0.904
I feel uncomfortable when meeting a patient with mental disorder.	887	4265	0.041
When noticing signs of an underlying mental disorder, apart from providing dental care, dentist should refer the patient for further treatment.	1275	3876	0.184
I feel uncomfortable asking about patients’ mental health.	954	4198	0.150
I expect a low cooperativity level from a patient with a confirmed diagnosis of severe mental disorder and would rather redirect him to another dental care provider for treatment.	1075	4077	0.688
I consider that oral diseases in patients dealing with severe mental disorders deserve the same level of attention as other comorbidities.	1123	4029	1.000
I consider that patients with mental disorders in the dental practice may be classified as high-risk patients.	1064	4088	0.614

Note: Mann–Whitney U test; p < 0.05. Statistically significant p-values are shown in bold.

).

We found weak but statistically significant results suggesting that age and years of clinical experience are most associated with knowledge about xerostomia as the most common oral side effect of antidepressant therapy, as well as about monoamine oxidase (MAO) inhibitors being one of the contraindications for administering local anesthetic with vasoconstrictor, and about the association of depression and somatization with the diagnosis and treatment of orofacial pain. Figure 2, Figure 3 and Figure 4 illustrate the results of multiple regression analysis, showing that age and years of clinical experience are statistically significant variables with a moderate and positive association with knowledge.

4. Discussion

This study found that most dentists feel insecure about their knowledge of mental disorders. The majority of them claimed to have encountered patients with mental disorders less than five times a month, which is interesting given that mental disorders represent one of the largest categories of disease burden in Croatia [2]. However, the low frequency of patients with mental disorders visiting dental offices is not unexpected since these patients are more likely to miss dental appointments [10,23]. Still, only half of the dentists ask their patients about mental disorders, and only slightly more than half of them check whether patients are on psychotropic medication. Therefore, the actual number of patients with mental disorders in dental offices may be greater.

Numerous studies emphasize the importance of taking a detailed medical history and considering the medication regimen of patients with mental disorders during dental visits, as well as consulting a patient’s psychiatrist and being considerate when treating such patients [12,21,22]. Fewer than half of our dentists consulted their patient’s psychiatrist or a GP. Furthermore, almost 15% of the dentists in this study reported having refused to treat patients with mental disorders at some point. Refusing treatment may constitute a violation of the Code of Dental Ethics and Deontology, by which the dentist has the exclusive right to refuse further treatment only if a patient behaves in an inappropriate, offensive, or threatening manner, unless the patient’s life is in danger [23]. Such behavior in individuals with certain mental disorders may be likely. However, further research of the ethical implications, circumstances, and causes behind treatment refusal decisions made by our respondents is required to provide more reliable conclusions regarding their justification in the context of the Code of Dental Ethics and Deontology.

Interestingly, although dentists do not routinely inquire about mental disorders, many of them consider their patients to have issues with drug abuse. A recent systematic review speaks in favor of this finding, which revealed that although dentists perceive a significant portion of their patients to have substance abuse problems, they do not ask the patients about it [6]. Surprisingly, despite these findings, almost all dentists consider that the outcome of dental therapy is influenced by whether the patient has a mental disorder, which is in line with current evidence [10,11]. Many dentists also agree that if they detect signs of an undiagnosed mental disorder, they should refer the patient for further treatment. While this statement is in line with current recommendations [12,24], statements about their behavior in practice contradict this. For example, fewer than half of the dentists reported that when they observe dental tissue erosion in adolescent patients and suspect an eating disorder, they also suggest psychological help. Somewhat encouraging is that most participants talk to the patient to gather information about the causes of erosion, which is one of the interventions recommended by global research on the relationship between dental tissue erosion and eating disorders [25,26].

Dentists’ views on the oral health of patients with mental disorders are mainly consistent with the conclusions of previous meta-analyses [27]. A high percentage of dentists consider that the oral health of these patients is at greater risk than that of the general population, that early referral to a dentist is crucial for maintaining oral health, and that professional support for maintaining adequate oral hygiene is necessary for this group. Overall, the mean level of discomfort when encountering a patient with a mental disorder was moderate. This finding may reflect the dentists’ ambivalence toward mental disorders. However, female dentists reported being more uncomfortable treating patients with mental disorders, which may be due to sex differences in the stress response, including different hormonal and neurochemical responses in women across the lifespan [28]. The dentists responded similarly to the question of how uncomfortable they feel asking patients about their mental health. Additionally, it is essential to highlight the low percentage of dentists who considered that they had sufficient knowledge of the pharmacological characteristics of the medications used in the treatment of mental disorders. Only one-third of dentists feel that they have enough knowledge about mental disorders to predict patient cooperation. Uncertainty about knowledge was also evident from the responses concerning clinical work. More than half of the dentists did not know whether monoamine oxidase inhibitors (MAOIs) were a contraindication to administering local anesthetics with vasoconstrictors.

In addition, one-third of dentists were unsure whether local anesthetics with vasoconstrictors should be administered to patients taking tricyclic antidepressants, while almost half felt this was necessary. This uncertainty may reflect, in part, conflicting scientific evidence on clinical interactions [8] and suggests efforts to promote more rational use of vasoconstrictors, as recommended in the literature [9]. These results indicate the need for clear clinical guidelines for the use of local anesthetics together with vasoconstrictors. Only about half of the dentists were aware that xerostomia is a common oral side effect of antidepressants. Older and more experienced dentists showed better knowledge about xerostomia, but also about MAOIs as a contraindication to local anesthetics with vasoconstrictors and about depression and somatization having an impact on the diagnosis and treatment of orofacial pain. This suggests that topics on mental health may be underrepresented in continuing professional development. It is also worth emphasizing that the greater knowledge observed among older respondents may be partially explained by their clinical experience and familiarity with older antidepressant medications, such as MAO inhibitors and tricyclic antidepressants, which are less commonly used in current clinical practice. Given that age and years of clinical experience were the strongest predictors positively associated with knowledge, this suggests that training should be specifically targeted at younger and less experienced dentists. While the practical relevance of this finding is notable, the moderate effect size (β ≈ 0.20–0.30) indicates the need to consider additional contributing variables and further refine training strategies. The dentists in this study agreed that patients with mental disorders should be considered as high-risk patients in the dental setting, which underlines the need for the development of specific clinical practice guidelines. What is encouraging is that most dentists expressed a desire for additional education on the management of patients with mental disorders.

The main limitation of this study is its sample representativeness. The sample size is not optimal, and the sampling method lacks probability, as it may have included only dentists willing to participate, which may be younger colleagues or those more prone to this topic. The non-probabilistic snowball sampling method used in this pilot study limits the ability to make statistical inferences and generalize the findings. As a result, we were unable to determine the true response rate, which introduces the possibility of an unknown bias in the sample. Additionally, the data collected through an online survey may be subject to a considerable degree of subjectivity, as it is based on self-reported measures, which may not accurately represent the respondents’ actual knowledge or competencies. Another limitation of this study is that the questionnaire used was not formally validated, which may affect the reliability and robustness of the findings.

Future studies could mitigate this by using larger samples, which may correct this and other random errors. Furthermore, given the heterogeneity of mental disorders, respondents may have been reluctant to answer specific questions due to the general nature of the questions. To address this, future studies should revise and validate our questionnaire. It would also be worthwhile to examine the factors that shape dentists’ views and practices in more depth through a qualitative study. Additionally, since fewer than a quarter of our sample were male dentists, future studies should balance males and females better to reach more reliable findings about sex differences.

5. Conclusions

Our findings indicate that, based on the attitudes and experiences of our respondents regarding the treatment of patients with mental disorders, there is both a strong desire and a clear need for additional training and further education on this topic. They also highlight the importance of adopting an interdisciplinary approach in patient care. Future studies should focus on examining a larger sample and refining research methods to draw more reliable conclusions.