Starting in August of 2020, dental hygienists and dentists in Washington State will be required to take a three-hour continuing education course on suicide screening and referral. The course must contain information related to imminent harm and lethal means.
Because dental professionals spend a great deal of time with their clients, often see their clients on a regular basis, and are familiar with their medical history, they are in a good position to screen and refer clients who may be at risk for self-harm. The initial assessment and ongoing, regular appointments provide opportunities to screen for risk factors associated with suicide. The intimate nature of dental work allows oral health professionals to ask about depression, chronic pain, unexplained loss of teeth, mouth lesions, as well as injuries to the head and neck.
Dentistry has a tradition of working to prevent diseases through customized regular examinations and oral healthcare programs. Because of this, medical screenings in dental settings are showing an increasing trend. The benefits of screening in dental settings for early diagnosis and identification of patients at risk are well documented. In a number of surveys, dentists reported that medical screening is a vital public health service and indicated they would be willing to incorporate screenings into their routines, along with additional education and training (Friman et al., 2015).
Studies of patients’ attitudes toward screening for medical conditions in a dental setting have indicated that most clients expressed a favorable attitude toward chair-side screening. They also expressed the importance of the dental professionals’ having the necessary medical knowledge and, when appropriate, the ability to refer to the other healthcare services (Friman et al., 2015).
Screening for suicidal ideation and behaviors in a dental setting is consistent with screening for other health issues such as diabetes and heart disease. As with other healthcare providers, dental clinics must have policies and procedures in place that describe screening tools, employee training, and referral resources. A simple screening tool such as the Patient Health Questionnaire 2 or another short screening tool (discussed in Module 3) or a waiting room questionnaire can be quick and efficient. Dental professionals must be trained in the use of a screening tool and have pre-screened referral resources readily available that include mental health and social services.
Julio Is Facing a Divorce
Julio is a 50-year-old police/firefighter who is facing an unwanted divorce from his wife of 25 years. He has been a client of ABC Dental Services for more than 10 years and is well-known to everyone who works in the office. He has an appointment with Manolo, the dental hygienist, for a cleaning. Keisha, the office manager has asked Julio to fill out a short questionnaire while he is waiting for Manolo.
After a short wait, Manolo escorts Julio into his treatment room. Manolo notices that Julio is very quiet and asks him how he’s doing. Julio tells him that he’s a little depressed because he was recently arrested for drunk driving and he’s been suspended without pay from his job. He says his wife (also a client of ABC Dental) has asked him for a divorce.
As Manolo is prepping for the cleaning, Julio thanks Manolo for the excellent dental care he’s received over the years and asks Manolo to tell the dentist how much he appreciates everyone at the clinic. He tells Manolo that he’s planning a hunting trip and isn’t sure when he’ll be back.
Screening
The ABC Clinic uses the PHQ 2 to screen all clients at each visit and employees have received specialized training in screening and referral for suicidal ideation and behaviors. The clinic maintains a list of pre-screened referral services in the event that a referral is needed for one of their clients.
Manolo excuses himself and asks the office assistant for the results of Julio’s waiting room screen. Keisha lets Manolo know that Julio marked “3” on both of the questions on the waiting room questionnaire (little interest or pleasure in doing things and feeling down, depressed, or hopeless). Because of Julio’s screening answers, Manolo decides to discuss the results with Julio.
Manolo: You mentioned that you feel depressed. On the waiting room questionnaire you indicated that you also feel hopeless and have little interest in anything anymore. Is this true?
Julio: Yes, I’m losing everything that’s important to me—my wife, my job, my driver’s license—even my kids are mad at me.
Manolo: You sound pretty unhappy.
Julio: I am. I just want to get away from all this pressure and try to get my head straight.
Manolo: Sometimes, when people feel hopeless and depressed, they don’t see any reason to go on living. Have you thought about suicide?
Julio: Well, sometimes I do. I have guns, and sometimes think it isn’t worth it anymore. But I don’t think I could really pull the trigger—I’m not that kind of guy.
Manolo: Have you ever tried to hurt yourself in the past?
Julio: Well, about 10 years ago, when I failed the firefighter training exam I was so depressed I downed a bottle of Vicodin and passed out. My roommate at the time called an ambulance and I had to have my stomach pumped. I didn’t really want to die—I just wanted to turn off my brain for a while.
Manolo: I want to thank you for sharing all of this with me. Right now, I’m concerned that you might try to hurt yourself when you leave the office. Are you planning to go back home before you go on your trip?
Julio: Yes, I want to say goodbye to my wife and kids.
Manolo: Would it be okay with you if I called your wife and let her know what’s going on? I’d like to have her to remove your guns and medications from the house. Is that okay with you? I’d also like to have you talk to some people who can help you with your depression and thoughts of suicide. Is that okay? I can ask someone to come over to the clinic right now to talk to you.
Julio: Yes, I would appreciate that.
Discussion
Manolo stays with Julio in a private room while the office manager contacts social services. She also informs the dentist. The office assistant also calls Julio’s wife to let her know the situation and to ask her to remove any guns and narcotic medication from the house. Julio’s wife agrees to do this but refuses to come to the clinic.
The fact that Julio tried to harm himself 10 years ago by overdosing on a narcotic pain medication is a red flag. Manolo discusses the situation with the dentist and they decide that Julio should be seen immediately for a more thorough assessment. The clinic has a list of pre-screened mental health providers who are willing to come to the clinic and talk to Julio. Manolo reaches a social worker who agrees to meet with Julio. Manolo stays with Julio in a private room until the social worker arrives.
When Manolo follows up the next day he learns that Julio has voluntarily admitted himself to the local hospital’s mental health ward.