Pain, Fatigue, and the Dentist’s Chair: When Doing ‘Better’ Isn’t That Simple

“Your gums are inflamed—are you brushing and flossing twice a day?” 

It’s a common question, often asked with good intentions. But for patients living with chronic, invisible illnesses, especially youth, the answer is rarely simple. Much too often, that question can feel like judgment rather than support.

As an oral medicine specialist, I care for patients who carry far more than dental concerns into the clinic. Many are immunocompromised. Most are juggling multiple diagnoses. The majority live with pain, others with fatigue, and nearly all face a lifetime of navigating systems that haven’t been designed with their complexity in mind. When discussing oral health, particularly in this population, we cannot isolate it from the broader context of their lives or their overall well-being.

Patients with autoimmune and rheumatic conditions like Juvenile Idiopathic Arthritis, Scleroderma, Sjögren's disease, Systemic Lupus Erythematosus, and Mixed Connective Tissue disease rarely have “just one thing going on.” Their days are shaped by medication regimens, fatigue, organ involvement, mental health challenges, and fluctuating symptoms that affect everything from eating to attending school or work. In this context, expecting consistent twice-daily brushing, perfect flossing, and regular cleanings without considering the need for flexibility and support may not accurately reflect the realities many patients face.

Disease-modifying antirheumatic drugs (DMARDs), corticosteroids, antidepressants used for chronic pain, and other immunosuppressive therapies are often essential for managing these conditions. However, their benefits can come with significant consequences in the mouth. One of the most common side effects is dry mouth, which not only causes discomfort but also increases the risk of dental caries, oral fungal infections like candidiasis, and burning sensations in the mucosa. Many patients also experience altered taste, mucosal fragility, and delayed healing; issues that may seem minor but can deeply affect diet, confidence, and overall oral function. In addition, because these patients are often immunosuppressed, even routine dental procedures carry a higher risk of infection, which can lead to care being delayed or avoided altogether. These challenges are not abstract; they are daily realities for patients doing their best to stay well.

A patient once told me, “I’m on biologics. I have kidney failure. My hands are stiff most mornings—I can’t do my ‘normal’ anymore. And still, I get judged when my teeth aren’t perfect.” 

This is the paradox we must acknowledge: the very medications that keep these patients stable– biologics, immunosuppressants, pain modulators– can also compromise their oral health, limit their ability to maintain hygiene, and make routine dental care more physically and financially inaccessible.

Oral health is absolutely important (I’m a dentist, so there’s a bit of bias here); the mouth is the start of the rest of our body, but it’s not the only thing these patients are trying to manage. For many youth with chronic illnesses, the priority isn’t plaque or cavities, it’s making it through a school day without joint pain and stiffness, coordinating labs for kidney disease, or trying to get insurance to cover a biologic. Mental health and fatigue often compound these challenges. And somewhere in the middle of all that, they’re expected to floss. We must ask ourselves: are we considering the entire person when we offer oral health guidance, or just their gingiva?

Many patients want to improve their oral hygiene, but their health and life circumstances can make it difficult. As providers, we can either meet them with judgment or with understanding. 

Rather than saying, “You need to brush better,” we can say, “I know brushing can be hard when you’re flaring or tired, can I show you some tools that might make it easier?” 

Instead of “You’re overdue for a cleaning,” try, “Is there something that’s made it hard to come in? Let’s work together to find a time that works.” 

When we notice inflammation, rather than stating, “Your oral hygiene is poor,” we can say, “I’m seeing some inflammation - let’s explore why that might be happening and what we can do about it together.” 

This isn’t about lowering expectations. It’s about raising our sensitivity and adjusting care plans to meet the patient’s reality.

Oral health is part of health, not separate from it. For patients living with chronic illness, especially those who are young, immunocompromised, or navigating invisible diagnoses, dentistry must evolve to reflect the full picture. By shifting our mindset from compliance to collaboration, from judgment to empathy, we become more than providers, we become advocates. Let’s ask thoughtful questions. Let’s keep working across disciplines. And let’s listen deeply when patients share what makes daily care difficult, because for many, oral hygiene isn’t just a routine. It’s something they’re navigating alongside complex health challenges. When we meet them with empathy, we help make oral health feel possible, even in the hardest seasons.