Common mental disorder is associated with periodontitis

The brain-gut axis: communication mechanisms and the role of the microbiome as a neuroprotective factor in the development of neurodegenerative diseases: A literature overview

The study of the brain-gut axis and its impact on cognitive function and in the development of neurodegenerative diseases is a very timely topic of interest to researchers. This review summarizes information on the basic mechanisms of gut-brain communication. We then discuss the roles of the gut microbiome as a neuroprotective factor in neurodegeneration. The gut microbiota is extremely important in maintaining the body's homeostasis, shaping the human immune system and the proper functioning of the brain. The intestinal microflora affects the processes of neuroplasticity, synaptogenesis, and neuronal regeneration. This review aims to explain changes in the composition of the bacterial population of the intestinal microflora among patients with Alzheimer's disease, Parkinson's disease, and multiple sclerosis. Abnormalities in gut microflora composition are also noted in stress, depression, or autism spectrum development. New observations on psychobiotic supplementation in alleviating the symptoms of neurodegenerative diseases are also presented.

Periodontitis and Depressive Disorders: The Effects of Antidepressant Drugs on the Periodontium in Clinical and Preclinical Models: A Narrative Review

Background/Objectives: Several psychological conditions, including stress and depression, can adversely affect oral health; in fact, antidepressants, commonly used to treat depressive disorders, may have conflicting effects on the periodontal status of individuals. The aim of this review was to determine the effects of antidepressants on the periodontium. Methods: A literature search was conducted using electronic databases, Pubmed/MEDLINE, Cochrane Library, focusing on the use of antidepressants and their effects on periodontal health in animals or humans. Results: Seventeen articles have been included with the use of amitriptyline (two studies), desipramine (one study), imipramine (two studies), desvenlafaxine (one study), fluoxetine (six studies), venlafaxine (three studies) and tianeptine (two studies). One study evaluated several categories of antidepressants, such as selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), tricyclic, atypical and monoamine oxidase inhibitors (MAO). Most trials showed improvements in periodontal health, especially with fluoxetine, but also with imipramine, desipramine, desvenlafaxine and tianeptine; on the contrary, worsening of clinical periodontal indices and increased loss of alveolar bone were reported with venlafaxine. Conclusions: This review suggests that in the presence of comorbidity between periodontitis and depression, pharmacological treatment with SNRIs, SSRIs and mixed antidepressants is associated with improvement in periodontal parameters, except for venlafaxine. Healthcare professionals (especially oral and mental health professionals) should investigate proper adherence to medication therapy in patients with a history of periodontitis and depression. Further clinical trials are needed to confirm these results.

Association of anxiety, age and oral health-related quality of life with periodontitis: A case-control study

OBJECTIVE

This case-control study evaluated the association of sociodemographic profile, mental health disorders and oral health-related quality of life (OHRQoL) with periodontitis.

METHODS

Patients with periodontitis (PP, n = 50) and control patients (CP, n = 50) were allocated into 2 groups after a complete periodontal examination. Data collection included age, sex, marital status, education and application of 2 questionnaires: Hospital Anxiety and Depression Scale for the diagnosis of anxiety/depression and Impact Profile on Oral Health (OHIP-14) for classification of well-being. An adjusted multiple binary logistic regression analysis was performed to assess the effect of all studied covariates on periodontitis.

RESULTS

The results show that mean clinical attachment loss and periodontal probing depth were 5.92 (SD = 0.42) and 5.46 (SD = 0.78) in PP and 0.00 (SD = 0.00) and 2.85 (SD = 0.23) in CP, respectively (p < 0.001). The regression analysis demonstrated a significant effect on periodontitis for age (OR = 1.13; p < 0.0001; 95% CI: 1.07-1.20), with the PP having more people aged 50 years or older than CP, anxiety (OR = 1.25; p = 0.020; 95% CI: 1.04-1.50) and OHIP-14 (OR = 1.17; p < 0.0001; 95% CI: 1.08-1.226).

CONCLUSIONS

The findings showed a positive association between anxiety, OHRQoL and age with periodontitis.

Acute periapical abscesses in patients using selective serotonin reuptake inhibitors

AIMS

Depression and anxiety are severe health problems affecting millions of individuals worldwide. Consequently, the use of antidepressants has constantly been on a rise. Selective serotonin reuptake inhibitors (SSRIs) antidepressant are now commonly used due to fewer side effects as compared to other types of antidepressants. The aim of this study was to assess the prevalence of periapical abscesses (PAs)in patients using SSRIs.

METHODS AND RESULTS

Integrated data of hospital patients was used. Data from the corresponding diagnosis codes for SSRIs and acute PAs was retrieved by searching the appropriate query in the database. The different diagnoses were coded using the international coding systems ICD 10. Diagnosis was made by calibrated dentists in a hospital setting based on clinical examination and imaging data. The odds ratio (OR) for the prevalence of acute PAs and its association with the use of SSRIs were calculated and analyzed statistically. It was found that the prevalence of acute PAs was significantly higher in patients using SSRIs as compared to the other hospital patient population. The OR was 2.8 and the difference between patients using SSRIs and patients who do not was statistically significant (p < .0001).

CONCLUSION

Under the conditions of this study, it appears that the prevalence of acute PAs is higher in patients using SSRIs.

Emerging role of the host microbiome in neuropsychiatric disorders: overview and future directions

The human body harbors a diverse ecosystem of microorganisms, including bacteria, viruses, and fungi, collectively known as the microbiota. Current research is increasingly focusing on the potential association between the microbiota and various neuropsychiatric disorders. The microbiota resides in various parts of the body, such as the oral cavity, nasal passages, lungs, gut, skin, bladder, and vagina. The gut microbiota in the gastrointestinal tract has received particular attention due to its high abundance and its potential role in psychiatric and neurodegenerative disorders. However, the microbiota presents in other body tissues, though less abundant, also plays crucial role in immune system and human homeostasis, thus influencing the development and progression of neuropsychiatric disorders. For example, oral microbiota imbalance and associated periodontitis might increase the risk for neuropsychiatric disorders. Additionally, studies using the postmortem brain samples have detected the widespread presence of oral bacteria in the brains of patients with Alzheimer's disease. This article provides an overview of the emerging role of the host microbiota in neuropsychiatric disorders and discusses future directions, such as underlying biological mechanisms, reliable biomarkers associated with the host microbiota, and microbiota-targeted interventions, for research in this field.

The impact of smoking on periodontitis patients' GCF/serum cytokine profile both before and after periodontal therapy: a meta-analysis

BACKGROUND

Smoking is an established modifying factor for the host immune response of periodontitis patients. However, its exact influence remains unclear. We aimed to compare the cytokine profile of periodontitis patients with and without smoking habits both before and after periodontal therapy to preliminarily explore its influence on the host immune response to periodontitis.

METHODS

The protocol of the present meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the code CRD42021255656. Meta-analysis was performed for each cytokine if at least three studies were included. We synthesized the evidence to compare the cytokine profile of periodontitis with and without smoking both in gingival cervical fluid (GCF) and serum to explore the impact of smoking on periodontitis both locally and systemically. Moreover, we also compared the cytokine profile of the two groups of patients after periodontal therapy to explore the effect of smoking on the outcome of periodontal therapy.

RESULTS

Fifteen studies were included in this meta-analysis. We found that there was no significant difference between the two groups of patients in the baseline cytokine profile. However, after periodontal therapy, smoking periodontitis patients showed significantly higher IL-1β levels in their GCF than nonsmoking patients.

DISCUSSION

There was no significant difference between smoking and nonsmoking periodontitis patients in the baseline cytokine profile. However, after periodontal therapy, smoking periodontitis patients showed significantly higher IL-1β levels in their GCF than nonsmoking patients, which indicates that smoking may impair the response of periodontitis to periodontal treatment.

Periodontitis: An Oral Disease with Severe Consequences

Periodontitis, being a multifactorial disorder is found to be the most common oral disease denoted by the inflammation of gingiva and resorption of tooth supporting alveolar bone. The disease being closely linked with fast life style and determined by unhygienic behavioural factors, the internal milieu of oral cavity and formation of plaque biofilm on the dental and gingival surfaces. Porphyromonas gingivalis, being the major keystone pathogen of the periodontal biofilm evokes host immune responses that causes damage of gingival tissues and resorption of bones. The biofilm associated microbial community progressively aggravates the condition resulting in chronic inflammation and finally tooth loss. The disease often maintains bidirectional relationship with different systemic, genetic, autoimmune, immunodeficiency diseases and even psychological disorders. The disease can be diagnosed and predicted by various genetic, radiographic and computer-aided design (CAD) & computer-aided engineering (CAE) and artificial neural network (ANN). The elucidation of genetic background explains the inheritance of the disease. The therapeutic approaches commonly followed include mechanical removal of dental plaque with the use of systemic antibiotics. Awareness generation amongst local people, adoption of good practice of timely tooth brushing preferably with fluoride paste or with nanoconjugate pastes will reduce the chance of periodontal plaque formation. Modern tissue engineering technology like 3D bioprinting of periodontal tissue may help in patient specific flawless regeneration of tooth structures and associated bones.

Periodontitis links to concurrent systemic comorbidities among 'self-perceived health' individuals

BACKGROUND AND OBJECTIVE

Our recent work shows that periodontitis experience reflects host susceptibility to the onset of multiple systemic diseases and conditions. This cross-sectional study further investigated whether and to what extent the existing periodontitis could reflect the concurrent presence of inflammatory comorbidities among 'self-perceived health' individuals.

MATERIALS AND METHODS

There were 115 'self-perceived health' adults who completed a questionnaire on demographic characteristics and lifestyles. Twenty medical diagnostic tests were then performed to detect eight common systemic diseases and conditions. Meanwhile, full-mouth periodontal examination was undertaken, and the subjects were classified as two subgroups with or without Generalized Severe Periodontitis (Stages III/IV, generalized). The interlink of periodontal status and concurrent systemic comorbidities was assessed.

RESULTS

98.3% (113/115) of the subjects exhibited at least one undiagnosed systemic disease/disorder. Of them, 52.2% (59/113) and 47.8% (54/113) concurrently presented with 1-5 or ≥6 abnormal test results, respectively. Overall, 96.5% (111/115) had periodontitis. Generalized Severe Periodontitis was present in 43.2% (48/111) of the periodontitis patients, and it was significantly associated with the profiles of abnormal test results after adjusting potential confounders (abnormal test results 1-5 vs ≥6; OR: 3.23, p = .012).

CONCLUSIONS

The present study shows that existing severe periodontitis could well reflect the concurrent presence of multiple inflammatory comorbidities. Oral and medical professionals can play proactive roles in enhancing health awareness and healthcare, through strong collaboration and teamwork.

A Cross-Sectional Survey on the Association between Dental Health Conditions and University Personality Inventory Scores among University Students: A Single-Center Study in Japan

This study examined the association between dental health conditions and scores on the University Personality Inventory (UPI) among university students in Japan. Participants were freshmen at Yamagata University between 2010 and 2019. Dental check-ups, including dental caries, periodontal disease, malocclusion, and temporomandibular disorders (TMD), and mental health screening using the UPI were performed; 12,433 students were included in the final analysis. A logistic regression analysis was performed to confirm the association between dental health conditions and >30 UPI scores, which indicate the need to consult mental health professionals. Overall, students who required treatment for TMD had a 3.165-fold higher risk of >30 UPI scores (OR = 3.165, 95% CI = 1.710−5.857). Periodontal disease and TMD in male participants (periodontal disease: OR = 1.329, 95% CI = 1.108−1.595; TMD: OR = 3.014, 95% CI = 1.107−8.204) and TMD in female participants (OR = 2.938, 95% CI = 1.340−6.445) were significant risk factors for >30 UPI scores. Students requiring treatment for TMD were at risk of obtaining >30 UPI scores. Although our study has several limitations, students with subjective symptoms (e.g., disturbance in opening the mouth) should take the UPI test or in some cases consult mental health professionals.

Impact of the COVID-19 pandemic on oral health and psychosocial factors

The objective of this study was to investigate oral health-related quality of life (OHRQoL) in times of the COVID-19 pandemic and to examine a possible association to psychosocial factors like psychological stress and symptoms of depression and anxiety disorders. Secondary research questions were whether people changed oral hygiene regimens during the COVID-19 pandemic and to what extent dental symptoms existed and developed compared to pre-pandemic. For this cross-sectional study a survey has been conceptualized to determine OHRQoL, stress, depression and anxiety and their specific confounders in a German cohort. Validated questionnaires as OHIP-G14, PHQ-Stress and PHQ-4 have been implemented. Altogether 1178 participants completed the survey between May and August 2020. The overall OHIP-G14 sum score of 4.8 ± 7.5 indicated good OHRQoL. 21% of the participants (n = 248) reported toothache, 23% (n = 270) mucosal problems, 31% (n = 356) hypersensitivity of the teeth and 27% (n = 305) myofacial pain. The PHQ-Stress score (4.5 ± 3.5) demonstrated a mild severity of stress. Depression and anxiety level has been mild to moderate (PHQ-4 score: 2.4 ± 2.6). 38% of the participants stated subjectively greater emotional burden compared to pre-pandemic. Statistically significant differences exist for OHRQoL, stress, anxiety and depression levels between participants with greater, equal or less emotional burden compared to pre-pandemic. COVID-19 history and aggravated levels of depression, anxiety, and stress seem to associate with lower OHRQoL. Psychosocial consequences during pandemic times and their association to oral health should be further investigated.

Blood and Salivary Inflammatory Biomarkers Profile in Patients with Chronic Kidney Disease and Periodontal Disease: A Systematic Review

Introduction: Periodontitis is the most prevalent inflammatory disease worldwide. Its inflammatory levels spread systemically, which can be associated with chronic kidney disease. Biomarkers have the potential to diagnose and correlate periodontitis and chronic kidney disease, helping to monitor systemic inflammation. Thereby, this study aimed to analyze the association between chronic kidney disease and periodontitis by conducting a biomarker analysis on blood and saliva. Material and methods: An electronic search through PubMed/MEDLINE, EMBASE, and Web of Science databases was conducted to identify clinical studies published in the last ten years, with no language restrictions. Twelve articles met all the inclusion criteria, two randomized controlled trials, one cohort study, and nine observational studies. Results: The studies included a total of 117 patients for saliva biomarkers, with a mean age of approximately 57 years old, and 56.68% of the subjects were female. After analyzing all the included studies, it was possible to verify the following biomarkers assessed: CRP, WBC, fibrinogen, IL-4 and -6, cardiac troponin T, NOx, ADMA, albumin, osteocalcin, cystatin C, PGLYRP1, cholesterol, HDL, LDL, triglycerides, and hemoglobin. Conclusion: A direct cause–effect association between periodontitis and CKD could not be established. However, it was possible to conclude that there was a correlating effect present, through the analyzed biomarkers.

Ethanol- and Cigarette Smoke-Related Alternations in Oral Redox Homeostasis

Alcohol abuse as well as smoking cigarettes has been proven to negatively affect the oral environment. The aim of this work was to provide a systematic review of the literature on the influence of ethanol and cigarette smoking on oral redox homeostasis. A search was performed for scientific articles indexed in the PubMed, Medline and Web of Science databases. We identified 32,300 articles, of which 54 were used for the final review, including the results from 2000 to 2021. Among the publications used to write this article, n = 14 were related to the influence of alcohol consumption (clinical studies n = 6, experimental studies n = 8) and n = 40 were related to the influence of smoking (clinical studies n = 33, experimental studies n = 7) on oral redox homeostasis. The reviewed literature indicates that alcohol abusers and smokers are more likely to suffer from salivary gland dysfunction, as well as develop precancerous lesions due to DNA damage. Compared to alcohol abstainers and non-smokers, alcohol drinkers and smokers are also characterized by a deterioration in periodontal health measured by various indicators of periodontal status. In summary, alcohol abuse and smoking are associated with disrupted oral redox homeostasis, which may lead not only to tooth loss, but also contribute to various adverse effects related to mental health, digestive processes and chronic inflammation throughout the human body.

Association of different antidepressant classes with clinical attachment level and alveolar bone loss in patients with periodontitis: A retrospective study

OBJECTIVE

Our study aimed to determine the relationship of antidepressant medicine use with periodontal diseases, exploring the association of different pharmacological classes of antidepressant with observations of clinical attachment loss (CAL) and alveolar bone level (BL) in patients with periodontitis.

BACKGROUND

Existing evidence on the impact of antidepressant medication on periodontal tissues has focused on some classes only and is still unclear. Therefore, this retrospective study evaluated the association of different antidepressant classes with clinical attachment loss (CAL) and alveolar bone level (BL).

METHODS

This study was carried out in a population of patients aged ≥ 30 years old with periodontitis who sought treatment at the University of Florida from 2014 to 2018. The following variables were obtained from patients' records; usage of antidepressant medications and their pharmacological classes (selective serotonin reuptake inhibitors [SSRI], serotonin-norepinephrine reuptake inhibitors [SNRI], tricyclic, atypical, and monoamine oxidase inhibitors [MAO]), age, gender, smoking habit, mild systemic diseases, CAL, and cement-enamel junction (CEJ) and alveolar bone crest (BC) distance, defined as BL, in the Ramfjord index teeth.

RESULTS

Five hundred and eighty-two periodontitis patients were evaluated, of which 113 (19.4%) were antidepressant users. Antidepressant users exhibited significantly lower BL and fewer sites with severe CAL (≥5 mm), than non-users (p < .05). Among all single-class antidepressant users, the SSRI users showed significantly less CAL and lower BL than non-users (p < .05). Patients taking combinations of the different classes of antidepressants also showed better CAL and BL than non-users. Generalized linear models, including variables such as gender, age, systemic diseases, and smoking, demonstrated that antidepressant users were more likely to have lower mean BL and fewer sites with severe bone loss (i.e. BL > 3 and >5 mm) than non-users (p < .05).

CONCLUSIONS

Antidepressant medications were associated with higher alveolar bone level and less clinical attachment loss in patients with periodontitis. When the different classes of antidepressants were analyzed individually, only the SSRI class users and the multiple-class users showed significantly less periodontal breakdown than non-users.

Pre and Probiotics Involved in the Modulation of Oral Bacterial Species: New Therapeutic Leads in Mental Disorders?

This systematic review aims to identify probiotics and prebiotics for modulating oral bacterial species associated with mental disorders. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline, we search the electronic MEDLINE database published till January 2021 to identify the studies on probiotics and/or prebiotics for preventing and treating major oral dysbiosis that provokes mental disorders. The outcome of the search produces 374 records. After excluding non-relevant studies, 38 papers were included in the present review. While many studies suggest the potential effects of the oral microbiota on the biochemical signalling events between the oral microbiota and central nervous system, our review highlights the limited development concerning the use of prebiotics and/or probiotics in modulating oral dysbiosis potentially involved in the development of mental disorders. However, the collected studies confirm prebiotics and/or probiotics interest for a global or targeted modulation of the oral microbiome in preventing or treating mental disorders. These outcomes also offer exciting prospects for improving the oral health of people with mental disorders in the future.

Periodontal diseases and depression: A pre-clinical in vivo study

AIM

To analyse, through a pre-clinical in vivo model, the possible mechanisms linking depression and periodontitis at behavioural, microbiological and molecular levels.

MATERIALS AND METHODS

Periodontitis (P) was induced in Wistar:Han rats (oral gavages with Porphyromonas gingivalis and Fusobacterium nucleatum) during 12 weeks, followed by a 3-week period of Chronic Mild Stress (CMS) induction. Four groups (n = 12 rats/group) were obtained: periodontitis and CMS (P+CMS+); periodontitis without CMS; CMS without periodontitis; and control. Periodontal clinical variables, alveolar bone levels (ABL), depressive-like behaviour, microbial counts and expression of inflammatory mediators in plasma and brain frontal cortex (FC), were measured. ANOVA tests were applied.

RESULTS

The highest values for ABL occurred in the P+CMS+ group, which also presented the highest expression of pro-inflammatory mediators (TNF-α, IL-1β and NF-kB) in frontal cortex, related to the lipoprotein APOA1-mediated transport of bacterial lipopolysaccharide to the brain and the detection of F. nucleatum in the brain parenchyma. A dysregulation of the hypothalamic-pituitary-adrenal stress axis, reflected by the increase in plasma corticosterone and glucocorticoid receptor levels in FC, was also found in this group.

CONCLUSIONS

Neuroinflammation induced by F. nucleatum (through a leaky mouth) might act as the linking mechanism between periodontal diseases and depression.

Validation of the Hospital Anxiety and Depression Scale and the Perceived Stress Scale and psychological features in patients with periodontitis

BACKGROUND

To investigate the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) and 10-item Perceived Stress Scale (PSS-10) in patients with periodontitis and to evaluate the psychological features of patients with periodontitis.

METHODS

Overall, 460 individuals with periodontitis were enrolled. The HADS and the PSS-10 were administered to all patients. Methodology testing included the exploratory factor analysis, the confirmatory factor analysis (CFA), test-retest reliability, as well as internal consistency.

RESULTS

Regarding the CFA results of the HADS, as well as the PSS-10, a bifactor model fitted the data best. The Cronbach alpha value, as well as the intra-class correlation coefficients value of the two measures were all >0.70. The anxiety, depression, distress manifestations, and moderate-to-high perceived stress prevalence were 35.2%, 18.2%, 24.6%, and 43.9%, respectively. Severity of periodontitis, age, smoking, and disease comorbidities were identified as independent prognosticators of the presence of psychological manifestations in periodontitis.

CONCLUSION

The HADS and the PSS-10 can be used as general measures for psychological assessment in patients with periodontitis.

The Role of the Oral Microbiota Related to Periodontal Diseases in Anxiety, Mood and Trauma- and Stress-Related Disorders

The prevalence of anxiety, mood and trauma- and stress-related disorders are on the rise; however, efforts to develop new and effective treatment strategies have had limited success. To identify novel therapeutic targets, a comprehensive understanding of the disease etiology is needed, especially in the context of the holobiont, i.e., the superorganism consisting of a human and its microbiotas. Much emphasis has been placed on the role of the gut microbiota in the development, exacerbation, and persistence of psychiatric disorders; however, data for the oral microbiota are limited. The oral cavity houses the second most diverse microbial community in the body, with over 700 bacterial species that colonize the soft and hard tissues. Periodontal diseases encompass a group of infectious and inflammatory diseases that affect the periodontium. Among them, periodontitis is defined as a chronic, multi-bacterial infection that elicits low-grade systemic inflammation via the release of pro-inflammatory cytokines, as well as local invasion and long-distance translocation of periodontal pathogens. Periodontitis can also induce or exacerbate other chronic systemic inflammatory diseases such as atherosclerosis and diabetes and can lead to adverse pregnancy outcomes. Recently, periodontal pathogens have been implicated in the etiology and pathophysiology of neuropsychiatric disorders (such as depression and schizophrenia), especially as dysregulation of the immune system also plays an integral role in the etiology and pathophysiology of these disorders. This review will discuss the role of the oral microbiota associated with periodontal diseases in anxiety, mood and trauma- and stress-related disorders. Epidemiological data of periodontal diseases in individuals with these disorders will be presented, followed by a discussion of the microbiological and immunological links between the oral microbiota and the central nervous system. Pre-clinical and clinical findings on the oral microbiota related to periodontal diseases in anxiety, mood and trauma- and stress-related phenotypes will be reviewed, followed by a discussion on the bi-directionality of the oral-brain axis. Lastly, we will focus on the oral microbiota associated with periodontal diseases as a target for future therapeutic interventions to alleviate symptoms of these debilitating psychiatric disorders.

Access to Dental Care and Depressive Illness: Results from the Korea National Health Nutrition Examination Survey

Background and Objectives: Recent evidence suggests that oral health is associated with various systemic diseases including psychiatric illnesses. This study examined the association between depression and access to dental care in Korean adults. Materials and Methods: A cross-sectional evaluation was performed using data from the Sixth Korea National Health and Nutrition Examination Survey 2014. The general characteristics of the participants, the current depression status, and issues with access to dental care were collected to evaluate the factors for not being able to make dental visits according to care needs. Results: The study population comprised a total of 5976 participants who were 19 years of age and older and represented 40.7 million Koreans. A multivariable logistic regression analysis with weighted observations revealed that participants with current depressive illness were about two times more likely to express that they could not make dental visits in spite of their perceived care needs (adjusted odds ratio (OR) = 2.097; 95% confidence interval (CI) 1.046–4.203). The reasons for not making dental visits included financial problems, perceived importance of the dental problem, and fear of visiting dental professionals. Conclusions: Korean adults with current depressive illness were less likely to make dental visits when they had dental care needs. To improve dental health accessibility for patients with depressive illness, coordinated efforts can be considered involving multidisciplinary health care professionals.