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Pi Y, Jiao Z, Wang L, Zhao Y, Hu W, Chen F, Yu J, Zhang X, Zhao P, Jiang H, Zhang M, Wang F. Genetic evidence strengthens the bidirectional connection between oral health status and psychiatric disorders: A two-sample Mendelian randomization study. J Affect Disord 2024; 351:661-670. [PMID: 38309483 DOI: 10.1016/j.jad.2024.01.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Observational studies cannot accurately infer the causal associations between oral health status and psychiatric disorders. METHODS We conducted univariate and multivariate Mendelian randomization (MR) analyses using single nucleotide polymorphisms (SNPs) associated with eight oral health statuses (periodontitis, DMFS, Nteeth, toothache, loose teeth, painful gums, bleeding gums, and mouth ulcers) and four psychiatric disorders (Schizophrenia, Major Depressive Disorder (MDD), anxiety and stress-related disorder (ASRD), and Bipolar Disorder (BIP)) as instrumental variables. Genetic data were sourced from the Gene-lifestyle interactions in dental endpoints (GLIDE), UK Biobank, Psychiatric Genomics Consortium (PGC), and Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH). The inverse variance-weighted (IVW) approach, supported by a comprehensive sensitivity analysis, was employed. RESULTS Genetically predicted mouth ulcers were significantly linked to higher MDD (OR = 2.17, 95 % CI: 1.33--3.54, P< 0.01) and BIP risks (OR = 2.25, 95 % CI: 1.22-4.15, P = 0.01). BIP heightened bleeding gums risk (OR = 1.01, 95 % CI: 1.00-1.01, P < 0.01). These associations were adjusted for smoking status and alcohol consumption. Painful gums were significantly associated with MDD risk (OR = 96.48, 95 % CI: 2.66-3495.28, P = 0.01), while MDD raised periodontitis risk (OR = 2.15, 95 % CI: 1.24-3.75, P = 0.01), both confounded by smoking and alcohol. Relatively small effects between several variables, while others could not withstand correction for multiple tests. LIMITATIONS The sample size and limitation to European populations limits the study generalizability. CONCLUSIONS This study provide evidence of possible causal relationships between several oral health conditions and mental illness. Focusing on oral health and valuing mental health are important for each other and overall health.
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Affiliation(s)
- Yangyang Pi
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Ziming Jiao
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Luning Wang
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Yi Zhao
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Wenxuan Hu
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Fang Chen
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Jing Yu
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Xi Zhang
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Ping Zhao
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China
| | - Hongjuan Jiang
- Department of Endodontics, Yinchuan Stomatology Hospital, Yinchuan, 750004, People's Republic of China
| | - Ming Zhang
- Department of Endodontics, Yinchuan Stomatology Hospital, Yinchuan, 750004, People's Republic of China.
| | - Faxuan Wang
- School of Public Health, Ningxia Medical University, Yinchuan, 750004, People's Republic of China; Ningxia Key Laboratory of Ministry of Education of Traditional Chinese Medicine for Prevention and Treatment of Regional High Incidence Disease, Ningxia Medical University, Yinchuan, 750004, People's Republic of China.
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Castrillón E, Castro C, Ojeda A, Caicedo N, Moreno S, Moreno F. Oral health status of hospitalised patients with mental disorders: Systematic review of the literature. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2022; 51:51-60. [PMID: 35177352 DOI: 10.1016/j.rcpeng.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/05/2020] [Indexed: 06/14/2023]
Abstract
According to the literature, hospitalised patients with mental disorders have a higher risk of developing cavities and periodontal disease than the general population, associated with the motor difficulty to perform adequate oral hygiene, to the adverse effects caused by drugs for the control of psychiatric symptoms, as well as the lack of oral care and clinical care. The aim was to carry out a systematic review of the literature on the oral health status of hospitalised patients with mental disorders (MD). A systematic search of the literature was carried out in PubMed, according to the PRISMA statement methodology, through the MeSh health descriptors "Dental Caries" and "Mental Disorders" in February 2017. According to the different filters that were applied, 14 articles describing the oral health status were obtained-through the DMF-T index (teeth with cavities, teeth with restorations, missing teeth and teeth with necessary extraction)-of hospitalised patients with MD. The recognition of the importance of oral health by health professionals, carers and family members should be promoted; the oral cavity should be explored to determine the state of health in addition to instructing patients and support personnel in oral hygiene; mental health institutions should establish an intervention programme to eliminate oral infectious sites and then implement a multidisciplinary preventive programme to maintain oral health according to the MD diagnosis.
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Affiliation(s)
- Eduardo Castrillón
- Médico, Especialista en Psiquiatría, Profesor Departamento de Clínicas Médicas, Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana, Cali, Colombia
| | - Camila Castro
- Estudiante de Odontología, Escuela de Odontología, Universidad del Valle, Cali, Colombia
| | - Andrea Ojeda
- Estudiante de Odontología, Escuela de Odontología, Universidad del Valle, Cali, Colombia
| | - Natalia Caicedo
- Médico, Médico Rural Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana, Cali, Colombia
| | - Sandra Moreno
- Odontóloga, Magíster en Ciencias Biomédicas, Profesora Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana, Cali, Colombia
| | - Freddy Moreno
- Odontólogo, Magíster en Ciencias Biomédicas, Profesor Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana, Cali, Colombia.
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Denis F, Siu-Paredes F, Maitre Y, Amador G, Rude N. A qualitative study on experiences of persons with schizophrenia in oral-health-related quality of life. Braz Oral Res 2021; 35:e050. [PMID: 33759972 DOI: 10.1590/1807-3107bor-2021.vol35.0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 10/30/2020] [Indexed: 11/21/2022] Open
Abstract
Our study aimed to explore the views and experiences in oral health and oral-health-related quality of life (OHRQoL) of persons with schizophrenia (PWS) in order to expand the understanding of the factors that either limit or facilitate their healthcare pathway, which can ultimately optimize their oral health and/or OHRQoL. A qualitative study was conducted in France in the Côte d'Or department (530 000 in habitants) centered on PWS's perceived meanings regarding oral health or OHRQoL, and semi-structured individual interviews were used. A conventional content analysis approach was chosen in order to highlight unrevealed themes. A sample of 20 PWS (12 males; 8 females) with a median age was 45.8 (± 9.5) were recruited to assess views and experiences regarding OHRQoL, which were focused on three dimensions: an individual dimension related to experience of "oral symptoms", a second dimension related to experience of "stress and its management", and a third related to "Autonomy dimension in oral health". We showed that PWS clearly expressed their mental representations of oral health and OHRQoL. This study supports that PWS were able to define their needs and had the ability to discuss their oral health and OHRQoL. These finding could be used to support specific interventions for this population to better manage the negative impact of antipsychotics and help them to consult dentists on a regular basis.
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Affiliation(s)
- Frédéric Denis
- Université François-Rabelais, Faculté de Médecine, Santé, Tours, France
| | | | | | - Gilles Amador
- Université de Nantes, Faculté d'Odontologie, Nantes, France
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Singhal V, Heuer AJ, York J, Gill KJ. The Effects of Oral Health Instruction, and the Use of a Battery-Operated Toothbrush on Oral Health of Persons with Serious Mental Illness: A Quasi-Experimental Study. Community Ment Health J 2021; 57:357-364. [PMID: 32519153 DOI: 10.1007/s10597-020-00657-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 06/05/2020] [Indexed: 11/26/2022]
Abstract
People with a diagnosis of serious mental illness (SMI) have a greater incidence of poorer oral health as compared to the general population. The aim of this quasi-experimental study was to determine the effect that a combination of the use of a battery-operated toothbrush and a related educational intervention may have on the oral health of individuals with serious mental illness. Key findings include that the battery-operated toothbrush resulted in a significant improvement in the mean change in gingival index, a common indicator of oral health. The study also found that oral home care instructions, smoking and level of negative symptoms did not have an effect on the mean change in plaque or gingival indices. This project suggests that the implementation of a relatively simple, cost effective measures such as a battery-operated toothbrush may have a positive impact on the oral health in this population.
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Affiliation(s)
- Vaishali Singhal
- Rutgers School of Health Professions, 65 Bergen Street, Newark, NJ, 07107, USA.
| | - Albert J Heuer
- Rutgers School of Health Professions, 65 Bergen Street, Newark, NJ, 07107, USA
| | - Jill York
- Rutgers School of Dental Medicine, 110 Bergen Street, Newark, NJ, 07103, USA
| | - Kenneth J Gill
- Rutgers School of Health Professions, 675 Hoes Lane West, Piscataway, NJ, 08854, USA
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Paredes FS, Rude N, Moussa-Badran S, Pelletier JF, Rat C, Denis F. Coping Strategies for Oral Health Problems by People with Schizophrenia. Transl Neurosci 2019; 10:187-194. [PMID: 31410302 PMCID: PMC6689214 DOI: 10.1515/tnsci-2019-0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/17/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Persons with schizophrenia are particularity susceptible to poor oral health. Symptoms of schizophrenia often affect oral health behaviors and lifestyle. The aim was to explore coping strategies used by people with schizophrenia in oral health in order to understand and to best involve them in the management of their own oral health in daily life. MATERIALS AND METHODS This is systematic review reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements. We included cross-sectional and longitudinal quantitative and qualitative studies that 1) examined coping strategies regarding oral health in persons with schizophrenia or 2) examined coping strategies were used in dental care. We included studies conducted with at least one PWS aged 18 years old more and without restriction on sex, socioeconomic status, or language. RESULTS The 8 studies included suggest that coping strategies depends on complex translation processes that can be either personal (e.g., psychological symptomatology, neuropsychological functioning to adversely affect hope, self-esteem, self-stigma, self-determination, sense of coherence, and resilience) and/or environmental factors (e.g., peer support and efficacy of rehabilitations programs). We further identified that the main factor influencing coping strategies was dental stress situation. CONCLUSIONS This review suggests that coping strategies play a crucial role in the recovery process for oral health of PWS. Translation processes in oral health should be more explored in the future to clarify the capacity of PWS to cope with essential self-care in oral health on daily life.
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Affiliation(s)
- Francesca Siu Paredes
- Université Champagne Ardenne. Faculté d’Odontologie de Reims, 51100Reims, France
- EA 481 Integrative Neurosciences and Clinical, University Hospital of Besançon, F-25000Besançon, France
| | - Nathalie Rude
- EA 481 Integrative Neurosciences and Clinical, University Hospital of Besançon, F-25000Besançon, France
| | - Sahar Moussa-Badran
- Université Champagne Ardenne. Faculté d’Odontologie de Reims, 51100Reims, France
| | - Jean-François Pelletier
- Department of Psychiatry, Montreal University, Yale Program for Recovery and Community Health, Montreal, Canada
| | - Corinne Rat
- Clinical research unit, La Chartreuse psychiatric center, Dijon, France
| | - Frederic Denis
- Clinical research unit, La Chartreuse psychiatric center, Dijon, France
- EA 75-05 Education, Ethique, Santé, Université de Tours, Faculté de Médecine, 37032Tours, France
- Université de Nantes, Faculté d’Odontologie de Nantes, Nantes, France
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Singh A, Purohit BM, Mittal P. Periodontal predicaments and associated risk factors among patients with schizophrenia. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.npbr.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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A Therapeutic Educational Program in Oral Health for Persons with Schizophrenia: A Qualitative Feasibility Study. Int J Dent 2018; 2018:6403063. [PMID: 30344607 PMCID: PMC6174768 DOI: 10.1155/2018/6403063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 08/07/2018] [Accepted: 08/15/2018] [Indexed: 11/17/2022] Open
Abstract
Objective The aim of this study was to test the feasibility of a therapeutic educational program in oral health (TEPOH) for persons with schizophrenia (PWS). Design In a qualitative study, we explored the representation of oral health before and after a TEPOH. Clinical Setting: PWS are at greater risk of decayed and missing teeth and periodontal diseases. In a previous publication, we described the different steps in building a TEPOH by taking into account the experiences of PWS concerning oral health quality of life. This TEPOH aimed at promoting a global health approach. Participants: Voluntary PWS and their caregivers were recruited during face-to-face interviews at "Les Boisseaux" (a psychiatric outpatient centre) in Auxerre (France) and were included in the study between November and December 2016. Intervention: We explored the experiences of participants and their perceptions of oral health before and after the TEPOH with focus group meetings. Results Four females and three males participated in the study, and the mean age was 29.4 ± 5. Before the TEPOH, the PWS produced 28 ideas about oral health perception and 37 after the TEPOH. After the TEPOH, elements relating to the determinants of oral health (smoking and poor diet) emerged. Conclusions These results show an evolution in oral health representation, and after some adjustments to the TEPOH, the second step will be to test this program in a large sample to generate a high level of evidence of the impact of TEPOH in the long term.
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Siu-Paredes F, Rude N, Rat C, Reynaud M, Hamad M, Moussa-Badran S, Denis F. The Schizophrenia Coping Oral Health Profile. Development and Feasibility. Transl Neurosci 2018; 9:78-87. [PMID: 29967693 PMCID: PMC6024692 DOI: 10.1515/tnsci-2018-0014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/22/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this work was to present the creation of appropriate tools to evaluate the coping strategies in Oral-Health-related Quality of Life (OHrQOL) implemented by persons with schizophrenia (PWS), the Schizophrenia Coping Oral Health Profile (SCOOHP), and the results of a feasibility study. METHODS A qualitative investigation was conducted between June 2016 and May 2017.The first step included 26 semi-structured individual interviews, 20 with PWS and 6 with health professionals (HPs), and 2 focus groups (PWS and HPs) to explore the experiences of the participants and how they felt about coping strategies in OHrQOL. The second step was a feasibility study involving a statistical analysis to test the acceptability and internal consistency (Cronbach's α) of the SCOOHP. RESULTS The analysis of these interviews allowed for us to obtain 277 items from 3545 verbatim transcriptions related to various dimensions of OHrQOL. We presented the items selected in coping concepts in this study. After selecting items in several stages, we drew up the SCOOHP scale with 23 items (15 items for positive coping and 8 items for negative coping). The feasibility study showed good acceptability, good understanding of the items and good consistency reliability (α = 0.59). CONCLUSIONS This is the first study that has enabled us to draw up a specific tool to assess coping strategies in OHrQOL of PWS. A multicentre study involving a larger sample of PWS is underway in order to perform the psychometric validation of the SCOOHP. TRIAL REGISTRATION Clinical Trials Gov NCT02730832. Date registered: 21 March 2016.
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Affiliation(s)
- Francesca Siu-Paredes
- Université Champagne Ardenne, Faculté d’Odontologie de Reims, 2 rue du Général Koenig 51100, Reims, France
- EA 481 Integrative Neurosciences and Clinical, University Hospital of Besançon, F-25000Besançon, France
| | - Nathalie Rude
- EA 481 Integrative Neurosciences and Clinical, University Hospital of Besançon, F-25000Besançon, France
| | - Corinne Rat
- Clinical Research Unit, La Chartreuse Psychiatric Centre, 21033Dijon, France
| | - Matthieu Reynaud
- Clinical Research Unit, La Chartreuse Psychiatric Centre, 21033Dijon, France
| | - Mohamad Hamad
- EA 481 Integrative Neurosciences and Clinical, University Hospital of Besançon, F-25000Besançon, France
| | - Sahar Moussa-Badran
- Université Champagne Ardenne, Faculté d’Odontologie de Reims, 2 rue du Général Koenig 51100, Reims, France
| | - Frederic Denis
- Clinical Research Unit, La Chartreuse Psychiatric Centre, 21033Dijon, France
- EA 75-05 Education, Ethique, Santé, Université François-Rabelais Tours, Faculté de Médecine, 37032Tours, France
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Oral Health Is a Challenging Problem for Patients with Schizophrenia: A Narrative Review. IRANIAN JOURNAL OF PSYCHIATRY AND BEHAVIORAL SCIENCES 2018. [DOI: 10.5812/ijpbs.8062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Status and perception of oral health in 6-17-year-old psychiatric inpatients-randomized controlled trial. Clin Oral Investig 2017; 21:2749-2759. [PMID: 28210811 DOI: 10.1007/s00784-017-2077-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Abstract
AIM The following are the aims of the study: assessment of oral health status, oral health-related quality of life (OHRQoL) and the effect of oral health care training over OHRQoL in children and adolescents hospitalized with mental disorders. METHODOLOGY This randomized case controlled prospective interventional study involved 81 child and adolescent psychiatric inpatients (CAP) aged between 6 and 17 years (mean age 10.6 ± 2.4 years), compared to 81 mentally healthy patients attending routine dental examinations (DC group) matched according to age and sex of the CAP group. Oral examinations were performed by two calibrated dentists. OHRQoL was assessed with the German version of the Child Perceptions Questionnaire. CAP inpatients were randomly divided in two equal subgroups, an intervention (IG) and a non-intervention group (non-IG). The IG received oral health care training at admission to the hospital. RESULTS CAP inpatients, especially those with stress-related disorders, revealed significantly higher caries prevalence and experience than DC patients. Although OHRQoL did not differ from the German reference values, CAP inpatients compensated higher impairment due to oral symptoms and functional limitations with lower impairment due to emotional and social well-being. OHRQoL increased in all CAP patients during hospitalization, regardless of receiving oral health care training. CONCLUSION Poorer oral health of CAP inpatients was not accompanied by higher impairment of OHRQoL. Oral problems seem to be overshined by better self-perceived emotional and social well-being. OHRQoL was not improved by individualized oral health care training. CLINICAL RELEVANCE Children and adolescents with mental disorders are at risk for oral diseases and need referral to dental services.
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Slack-Smith L, Hearn L, Scrine C, Durey A. Barriers and enablers for oral health care for people affected by mental health disorders. Aust Dent J 2017; 62:6-13. [PMID: 27164018 DOI: 10.1111/adj.12429] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND People with mental health disorders are reported to have poorer access to dental services and poorer oral health outcomes. The aim of this paper is to analyze current published work regarding barriers and enablers for oral health outcomes and access to dental care for adults with mental health disorders which will be addressed from individual, organizational and systemic perspectives METHODS: A narrative review based on a search of the relevant published work regarding oral health for people with mental health disorders was undertaken using Medline, Web of Science, ERIC and Psychlit. Any relevant systematic reviews were highlighted in this process along with primary studies. RESULTS The published work repeatedly verified poorer oral health and inadequate access to dental services in people with mental health disorders. The published work identified barriers at individual, organizational and systemic levels. Much of the published work focused on barriers with less focus on enablers and interventions. CONCLUSIONS Considerable investigation of barriers had not elucidated options to improve care or outcomes.
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Affiliation(s)
- L Slack-Smith
- School of Dentistry, University of Western Australia, Perth, Australia
| | - L Hearn
- School of Dentistry, University of Western Australia, Perth, Australia
| | - C Scrine
- School of Dentistry, University of Western Australia, Perth, Australia
| | - A Durey
- School of Dentistry, University of Western Australia, Perth, Australia
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Denis F, Millot I, Abello N, Carpentier M, Peteuil A, Soudry-Faure A. Study protocol: a cluster randomized controlled trial to assess the effectiveness of a therapeutic educational program in oral health for persons with schizophrenia. Int J Ment Health Syst 2016; 10:65. [PMID: 27757142 PMCID: PMC5053217 DOI: 10.1186/s13033-016-0096-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 10/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Schizophrenia is a severe mental disorder that affects 1 % of the world's population, including 600,000 people in France. Persons with schizophrenia (PWS) have excess mortality (their life expectancy is reduced by 20 %) and excess morbidity. In addition, such persons may have a large number of missing or decayed teeth. Dental caries and periodontal measurement indexes are often twice as high as the level found in the general population. Poor oral health can also affect quality of life and oral health is inseparable from general health. The management of oral health problems needs a multidisciplinary approach. According to the World Health Organization, the aim of therapeutic education (TE) is to help patients take care of themselves and to improve empowerment and recovery. In this educational approach, it is important to take into account the patient's personal experience. Though rarely investigated, the personal experience of PWS in oral health quality of life (OHRQoL) must be used to build a therapeutic educational programme in oral health (TEPOH) in a multidisciplinary approach, and the effectiveness of this program must be evaluated. METHODS/DESIGN We report the protocol of a randomized controlled cluster study. This study will be conducted in twelve hospitals in France. We hypothesized that a decrease of 20 % in the proportion of patients with CPI ≥ 3 would establish the effectiveness of TEPOH. Therefore, 12 hospitals will be randomly allocated to either TEPOH or no TEPOH. Altogether, they will have to recruit 230 PWS, who will be randomly allocated with a ratio of 1:1 to one of two conditions: control without intervention versus the group benefitting from TEPOH. DISCUSSION If successful, the study will generate methodologically sound results that provide knowledge on the effectiveness of a TEP in oral health for PWS. The results can be used to promote OHRQoL in a global health approach and develop appropriate strategies to encourage and facilitate financial support for healthcare, the multidisciplinary treatment of dental disorders, and the development of training in oral and mental health for caregivers. Trial registration Clinical Trials Gov NCT02512367. Date registered 19 July, 2015.
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Affiliation(s)
- Frederic Denis
- La Chartreuse Psychiatric Centre, 1, boulevard Chanoine Kir, BP 23314, 21033 Dijon Cedex, France
| | - Isabelle Millot
- Instance Régionale d’éducation et de promotion de la santé, 21000 Dijon Cedex, France
| | - Nicolas Abello
- Direction de la Recherche Clinique, University Hospital of Dijon, 21079 Dijon Cedex, France
| | - Maud Carpentier
- Direction de la Recherche Clinique, University Hospital of Dijon, 21079 Dijon Cedex, France
| | - Audrey Peteuil
- Instance Régionale d’éducation et de promotion de la santé, 21000 Dijon Cedex, France
| | - Agnès Soudry-Faure
- USMR-Réseau d’aide Méthodologiste, University Hospital of Dijon, 21079 Dijon Cedex, France
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Wright N, Akhtar A, Tosh GE, Clifton AV. HIV prevention advice for people with serious mental illness. Cochrane Database Syst Rev 2016; 9:CD009639. [PMID: 27609030 PMCID: PMC6457823 DOI: 10.1002/14651858.cd009639.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND People with serious mental illness have rates of Human Immuno-deficiency Virus (HIV) infection higher than expected in the general population for the same demographic area. Despite this elevated prevalence, UK national strategies around sexual health and HIV prevention do not state that people with serious mental illness are a high risk group. However, a significant proportion in this group are sexually active and engage in HIV-risk behaviours including having multiple sexual partners, infrequent use of condoms and trading sex for money or drugs. Therefore we propose the provision of HIV prevention advice could enhance the physical and social well being of this population. OBJECTIVES To assess the effects of HIV prevention advice in reducing morbidity, mortality and preserving the quality of life in people with serious mental illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (24 January 2012; 4 July 2016). SELECTION CRITERIA We planned to include all randomised controlled trials focusing on HIV prevention advice versus standard care or comparing HIV prevention advice with other more focused methods of delivering care or information for people with serious mental illness. DATA COLLECTION AND ANALYSIS Review authors (NW, AC, AA, GT) independently screened search results and did not identify any studies that fulfilled the review's criteria. MAIN RESULTS We did not identify any randomised studies that evaluated advice regarding HIV for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to both people with serious mental illness and HIV risk are possible. AUTHORS' CONCLUSIONS Policy makers, clinicians, researchers and service users need to collaborate to produce guidance on how best to provide advice for people with serious mental illness in preventing the spread of HIV infection. It is entirely feasible that this could be within the context of a well-designed simple large randomised study.
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Affiliation(s)
- Nicola Wright
- University of NottinghamSchool of Health SciencesInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
| | - Athfah Akhtar
- University of NottinghamSchool of Sociology and Social PolicyInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
| | - Graeme E Tosh
- Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH)General Adult DivisionFerham ClinicKimberworth RoadRotherhamSouth YorkshireUKS61 1AD
| | - Andrew V Clifton
- De Montfort UniversityFaculty of Health and Life Sciences3.10 Edith Murphy HouseThe GatewayLeicesterUKLE1 9BH
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Khokhar MA, Khokhar WA, Clifton AV, Tosh GE. Oral health education (advice and training) for people with serious mental illness. Cochrane Database Syst Rev 2016; 9:CD008802. [PMID: 27606629 PMCID: PMC6457656 DOI: 10.1002/14651858.cd008802.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND People with serious mental illness not only experience an erosion of functioning in day-to-day life over a protracted period of time, but evidence also suggests that they have a greater risk of experiencing oral disease and greater oral treatment needs than the general population. Poor oral hygiene has been linked to coronary heart disease, diabetes, and respiratory disease and impacts on quality of life, affecting everyday functioning such as eating, comfort, appearance, social acceptance, and self esteem. Oral health, however, is often not seen as a priority in people suffering with serious mental illness. OBJECTIVES To review the effects of oral health education (advice and training) with or without monitoring for people with serious mental illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (5 November 2015), which is based on regular searches of MEDLINE, EMBASE, CINAHL, BIOSIS, AMED, PubMed, PsycINFO, and clinical trials registries. There are no language, date, document type, or publication status limitations for inclusion of records in the register. SELECTION CRITERIA All randomised clinical trials focusing on oral health education (advice and training) with or without monitoring for people with serious mental illness. DATA COLLECTION AND ANALYSIS We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. MAIN RESULTS We included three randomised controlled trials (RCTs) involving 1358 participants. None of the studies provided useable data for the key outcomes of not having seen a dentist in the past year, not brushing teeth twice a day, chronic pain, clinically important adverse events, and service use. Data for leaving the study early and change in plaque index scores were provided. Oral health education compared with standard careWhen 'oral health education' was compared with 'standard care', there was no clear difference between the groups for numbers leaving the study early (1 RCT, n = 50, RR 1.67, 95% CI 0.45 to 6.24, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect was found. Although this was statistically significant and favoured the intervention group, it is unclear if it was clinically important (1 RCT, n = 40, MD - 0.50 95% CI - 0.62 to - 0.38, very low quality evidence).These limited data may have implications regarding improvement in oral hygiene. Motivational interview + oral health education compared with oral health educationSimilarly, when 'motivational interview + oral health education' was compared with 'oral health education', there was no clear difference for the outcome of leaving the study early (1 RCT, n = 60 RR 3.00, 95% CI 0.33 to 27.23, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect favouring the intervention group was found (1 RCT, n = 56, MD - 0.60 95% CI - 1.02 to - 0.18 very low-quality evidence). These limited, clinically opaque data may or may not have implications regarding improvement in oral hygiene. Monitoring compared with no monitoringFor this comparison, only data for leaving the study early were available. We found a difference in numbers leaving early, favouring the 'no monitoring' group (1 RCT, n = 1682, RR 1.07, 95% CI 1.00 to 1.14, moderate-quality evidence). However, these data are problematic. The control denominator is implied and not clear, and follow-up did not depend only on individual participants, but also on professional caregivers and organisations - the latter changing frequently resulting in poor follow-up, but not a good reflection of the acceptability of the monitoring to patients. For this comparison, no data were available for 'no clinically important change in plaque index'. AUTHORS' CONCLUSIONS We found no evidence from trials that oral health advice helps people with serious mental illness in terms of clinically meaningful outcomes. It makes sense to follow guidelines and recommendations such as those put forward by the British Society for Disability and Oral Health working group until better evidence is generated. Pioneering trialists have shown that evaluative studies relevant to oral health advice for people with serious mental illness are possible.
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Affiliation(s)
- Mariam A Khokhar
- University of SheffieldOral Health and Development15 Askham CourtGamston Radcliffe RoadNottinghamUKNG2 6NR
| | - Waqqas Ahmad Khokhar
- Leicestershire Partnership NHS TrustDepartment of PsychiatryLeicesterLeicestershireUK
| | - Andrew V Clifton
- De Montfort UniversityFaculty of Health and Life Sciences3.10 Edith Murphy HouseThe GatewayLeicesterUKLE1 9BH
| | - Graeme E Tosh
- Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH)General Adult DivisionFerham ClinicKimberworth RoadRotherhamSouth YorkshireUKS61 1AD
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Abstract
BACKGROUND People with a serious mental illness are more likely to smoke more and to be more dependent smokers than the general population. This may be due to a wide range of factors that could include a common aetiology to both smoking and the illness, self medication, smoking to alleviate adverse effects of medications, boredom in the existing environment, or a combination of these factors. It is important to undertake this review to facilitate improvements in both the health and safety of people with serious mental illness who smoke, and to reduce the overall burden of costs (both financial and health) to the smoker and, eventually, to the taxpayer. OBJECTIVES To review the effects of smoking cessation advice for people with serious mental illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group Specialized Trials Register up to 2 April 2015, which is based on regular searches of CENTRAL, BIOSIS, PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, and trial registries. We also undertook unsystematic searches of a sample of the component databases (BNI, CINHAL, EMBASE, MEDLINE, and PsycINFO), up to 2 April 2015, and searched references of all identified studies SELECTION CRITERIA We planned to include all randomised controlled trials (RCTs) that focussed on smoking cessation advice versus standard care or comparing smoking cessation advice with other more focussed methods of delivering care or information. DATA COLLECTION AND ANALYSIS The review authors (PK, AC, and DB) independently screened search results but did not identify any trials that fulfilled the inclusion criteria of this review. MAIN RESULTS We did not identify any RCTs that evaluated advice regarding smoking cessation for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to smokers with serious mental illness is possible. AUTHORS' CONCLUSIONS People with serious mental illness are more likely to smoke than the general population. Yet we could not find any high quality evidence to guide the smoking cessation advice healthcare professionals pass onto service users. This is an area where trials are possible and needed.
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Affiliation(s)
- Priya Khanna
- Northumberland, Tyne and Wear NHS Foundation TrustRehabilitation and Recovery, Adult PsychiatryNewcastleUK
| | - Andrew V Clifton
- University of HuddersfieldSchool of Human and Health SciencesQueensgateHuddersfieldSouth West YorkshireUKHD1 3DH
| | - David Banks
- Queen Margaret UniversitySchool of Health SciencesQueen Margaret DriveMusselburghEdinburghUKEH21 6UU
| | - Graeme E Tosh
- Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH)General Adult DivisionFerham ClinicKimberworth RoadRotherhamSouth YorkshireUKS61 1AD
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Oral health in adults with serious mental illness: needs for and perspectives on care. Community Ment Health J 2015; 51:222-8. [PMID: 25091719 DOI: 10.1007/s10597-014-9758-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 07/06/2014] [Indexed: 10/24/2022]
Abstract
This study used qualitative methods to investigate barriers to and facilitators of oral health care among 25 adult community mental health outpatients with serious mental illness (SMI). Participants completed 30- to 60-min, semi-structured interviews that were recorded and transcribed. Qualitative analysis was used to characterize common themes. Results showed that lack of awareness of dental problems, poverty, and dental care access were key barriers to oral health care. When oral health care was accessed, fear of stigma was associated with missed opportunities to educate about the intersection of mental and oral health. Community mental health providers were viewed as trusted and important sources of advocacy and support for obtaining oral health care when needed. Oral health may be improved for persons with SMI by implementing education in points of frequent service contact, such as community mental health.
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Abstract
BACKGROUND People with serious mental illness have rates of Human Immuno-deficiency Virus (HIV) infection higher than expected in the general population for the same demographic area. Despite this elevated prevalence, UK national strategies around sexual health and HIV prevention do not state that people with serious mental illness are a high risk group. However, a significant proportion in this group are sexually active and engage in HIV-risk behaviours including having multiple sexual partners, infrequent use of condoms and trading sex for money or drugs. Therefore we propose the provision of HIV prevention advice could enhance the physical and social well being of this population. OBJECTIVES To assess the effects of HIV prevention advice in reducing morbidity, mortality and preserving the quality of life in people with serious mental illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (24 January, 2012), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register. SELECTION CRITERIA We planned to include all randomised controlled trials focusing on HIV prevention advice versus standard care or comparing HIV prevention advice with other more focused methods of delivering care or information for people with serious mental illness. DATA COLLECTION AND ANALYSIS Review authors (NW, AC, AA, GT) independently screened search results and did not identify any studies that fulfilled the review's criteria. MAIN RESULTS We did not identify any randomised studies that evaluated advice regarding HIV for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to both people with serious mental illness and HIV risk are possible. AUTHORS' CONCLUSIONS Policy makers, clinicians, researchers and service users need to collaborate to produce guidance on how best to provide advice for people with serious mental illness in preventing the spread of HIV infection. It is entirely feasible that this could be within the context of a well-designed simple large randomised study.
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Affiliation(s)
- Nicola Wright
- School of Health Sciences, University of Nottingham, Institute of Mental Health, Triumph Road, Nottingham, NG7 2TU, UK.
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Tosh G, Clifton AV, Xia J, White MM. General physical health advice for people with serious mental illness. Cochrane Database Syst Rev 2014; 2014:CD008567. [PMID: 24676557 PMCID: PMC10731645 DOI: 10.1002/14651858.cd008567.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is currently much focus on provision of general physical health advice to people with serious mental illness and there has been increasing pressure for services to take responsibility for providing this. OBJECTIVES To review the effects of general physical healthcare advice for people with serious mental illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (last update search October 2012) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register. SELECTION CRITERIA All randomised clinical trials focusing on general physical health advice for people with serious mental illness.. DATA COLLECTION AND ANALYSIS We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. MAIN RESULTS Seven studies are now included in this review. For the comparison of physical healthcare advice versus standard care we identified six studies (total n = 964) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.20, CI -0.47 to 0.87, very low quality of evidence) but another two did for the Quality of Life Medical Outcomes Scale - mental component (n = 487, 2 RCTs, MD 3.70, CI 1.76 to 5.64). There was no difference between groups for the outcome of death (n = 487, 2 RCTs, RR 0.98, CI 0.27 to 3.56, low quality of evidence). For service use two studies presented favourable results for health advice, uptake of ill-health prevention services was significantly greater in the advice group (n = 363, 1 RCT, MD 36.90, CI 33.07 to 40.73) and service use: one or more primary care visit was significantly higher in the advice group (n = 80, 1 RCT, RR 1.77, CI 1.09 to 2.85). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 964, 6 RCTs, RR 1.11, CI 0.92 to 1.35). Comparisons of one type of physical healthcare advice with another were grossly underpowered and equivocal. AUTHORS' CONCLUSIONS General physical health could lead to people with serious mental illness accessing more health services which, in turn, could mean they see longer-term benefits such as reduced mortality or morbidity. On the other hand, it is possible clinicians are expending much effort, time and financial resources on giving ineffective advice. The main results in this review are based on low or very low quality data. There is some limited and poor quality evidence that the provision of general physical healthcare advice can improve health-related quality of life in the mental component but not the physical component, but this evidence is based on data from one study only. This is an important area for good research reporting outcome of interest to carers and people with serious illnesses as well as researchers and fundholders.
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Affiliation(s)
- Graeme Tosh
- Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH)Early Intervention in Psychosis and Community TherapiesSwallownest CourtAughton RoadSwallownestUKS26 4TH
| | - Andrew V Clifton
- University of HuddersfieldSchool of Human and Health SciencesQueensgateHuddersfieldSouth West YorkshireUKHD1 3DH
| | - Jun Xia
- The University of NottinghamCochrane Schizophrenia GroupInstitute of Mental HealthUniversity of Nottingham Innovation Park, Triumph Road,NottinghamUKNG7 2TU
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Abstract
BACKGROUND Current guidance suggests that we should monitor the physical health of people with serious mental illness, and there has been a significant financial investment over recent years to provide this. OBJECTIVES To assess the effectiveness of physical health monitoring, compared with standard care for people with serious mental illness. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (October 2009, update in October 2012), which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. SELECTION CRITERIA All randomised clinical trials focusing on physical health monitoring versus standard care, or comparing i) self monitoring versus monitoring by a healthcare professional; ii) simple versus complex monitoring; iii) specific versus non-specific checks; iv) once only versus regular checks; or v) different guidance materials. DATA COLLECTION AND ANALYSIS Initially, review authors (GT, AC, SM) independently screened the search results and identified three studies as possibly fulfilling the review's criteria. On examination, however, all three were subsequently excluded. Forty-two additional citations were identified in October 2012 and screened by two review authors (JX and MW), 11 of which underwent full screening. MAIN RESULTS No relevant randomised trials which assess the effectiveness of physical health monitoring in people with serious mental illness have been completed. We identified one ongoing study. AUTHORS' CONCLUSIONS There is still no evidence from randomised trials to support or refute current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.
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Affiliation(s)
- Graeme Tosh
- Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH)Early Intervention in Psychosis and Community TherapiesSwallownest CourtAughton RoadSwallownestUKS26 4TH
| | - Andrew V Clifton
- University of HuddersfieldSchool of Human and Health SciencesQueensgateHuddersfieldSouth West YorkshireUKHD1 3DH
| | - Jun Xia
- The University of NottinghamCochrane Schizophrenia GroupInstitute of Mental HealthUniversity of Nottingham Innovation Park, Triumph Road,NottinghamUKNG7 2TU
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Nikfarjam M, Parvin N. Oral health status in three long term care units of schizophrenic patients in chaharmahal-bakhtiari province, iran. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:371-2. [PMID: 24083016 PMCID: PMC3785917 DOI: 10.5812/ircmj.1892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 01/28/2012] [Accepted: 02/01/2012] [Indexed: 11/23/2022]
Affiliation(s)
- Masood Nikfarjam
- Department of Medicine, Shahrekord University of Medical Sciences, Shahrekord, IR Iran
| | - Neda Parvin
- Department of Nursing, Shahrekord University of Medical Sciences, Shahrekord, IR Iran
- Corresponding author: Neda Parvin, Department of Nursing, Nursing and Midwifery Faculty, Shahrekord University of Medical Sciences, Shahrekord, IR Iran, Tel/Fax: +98-3813335654, E-mail:
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An oral health intervention for people with serious mental illness (Three Shires Early Intervention Dental Trial): study protocol for a randomised controlled trial. Trials 2013; 14:158. [PMID: 23714397 PMCID: PMC3669616 DOI: 10.1186/1745-6215-14-158] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 05/13/2013] [Indexed: 11/21/2022] Open
Abstract
Background Oral health is an important part of general physical health and is essential for self-esteem, self-confidence and overall quality of life. There is a well-established link between mental illness and poor oral health. Oral health problems are not generally well recognized by mental health professionals and many patients experience barriers to treatment. Methods/Design This is the protocol for a pragmatic cluster randomised trial that has been designed to fit within standard care. Dental awareness training for care co-ordinators plus a dental checklist for service users in addition to standard care will be compared with standard care alone for people with mental illness. The checklist consists of questions about service users’ current oral health routine and condition. Ten Early Intervention in Psychosis (EIP) teams in Nottinghamshire, Derbyshire and Lincolnshire will be cluster randomised (five to intervention and five to standard care) in blocks accounting for location and size of caseload. The oral health of the service users will be monitored for one year after randomisation. Trial registration Current Controlled Trials ISRCTN63382258.
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Samietz SA, Kindler S, Schwahn C, Polzer I, Hoffmann W, Kocher T, Grabe HJ, Mundt T, Biffar R. Impact of depressive symptoms on prosthetic status—results of the study of health in Pomerania (SHIP). Clin Oral Investig 2012; 17:1191-200. [DOI: 10.1007/s00784-012-0806-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 07/19/2012] [Indexed: 11/28/2022]
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Clifton A, Tosh G, Khokhar W, Jones H, Wells N. Oral health advice for people with serious mental illness. Schizophr Bull 2011; 37:464-5. [PMID: 21345918 PMCID: PMC3080687 DOI: 10.1093/schbul/sbq169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew Clifton
- School of Health, Community & Education Studies, Northumbria University, Newcastle upon Tyne, UK.
| | - Graeme Tosh
- Nottinghamshire Healthcare NHS Trust, Nottingham, Nottinghamshire, UK
| | - Waqqas Khokhar
- Derbyshire Mental Health NHS Trust, Derby, Derbyshire, UK
| | - Hannah Jones
- Academic Unit of Psychiatry, Community Based Medicine, University of Bristol, Bristol, UK
| | - Nicola Wells
- Nottinghamshire Healthcare NHS Trust, Nottingham, Nottinghamshire, UK
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