Barriers and enablers for oral health care for people affected by mental health disorders

Adult mental health impairment and oral health care use in the United States, Medical Expenditure Panel Survey 2017-2021

BACKGROUND

Mental illnesses can cause mental health (MH) impairments such as decreased interest and generalized fatigue. MH impairments can adversely affect oral health. The aim of this study was to investigate the associations between MH impairment, MH care, and oral health care use.

METHODS

This cross-sectional study used nationally representative data of US adults from the 2017-2021 Medical Expenditure Panel Survey. Pearson χ2 test and logistic regressions were used to assess the associations between oral health care use and MH impairment and oral health care use and MH care use. Regressions controlled for age, sex, race and ethnicity, income, education, survey year, marital status, geographic region, and dental insurance status.

RESULTS

MH impairment was associated with lower odds of using any dental care (odds ratio [OR], 0.85; 95% CI, 0.81 to 0.90) and preventive care (OR, 0.79; 95% CI, 0.74 to 0.84) and with higher odds of oral surgery (OR, 1.32; 95% CI, 1.20 to 1.46) use. Receiving MH care was associated with higher odds of using overall dental care (OR, 1.62; 95% CI, 1.43 to 1.82; P < .001), preventive care (OR, 1.72; 95% CI, 1.52 to 1.96; P < .001), and restorative care (OR, 1.26; 95% CI, 1.05 to 1.50; P = .01) use.

CONCLUSIONS

MH impairment was associated with lower odds of preventive and overall dental care use and with higher odds of oral surgery use. For adults with MH impairment, receiving MH care was associated with higher odds of preventive, restorative, and overall dental care use.

PRACTICAL IMPLICATIONS

Mental illness can be a barrier in accessing preventive dental care. However, MH care service may aid in increasing preventive, restorative, and overall oral health care use.

Exploring Oral Health Promotion Among Mental Health Providers: An Integrative Review

Individuals living with mental illness can experience dire oral health and face numerous barriers to oral health care. While mental health providers are important in oral health promotion, there is a major gap in knowledge on their oral health knowledge, attitudes and practices and guidelines/recommendations for best practice. This integrative review addresses this gap by synthesising evidence on mental health providers oral health knowledge, attitudes and practices and available clinical guidelines/recommendations. Searches were undertaken across six databases, supplemented with grey literature searches. The inclusion criteria were mental health providers, including nurses, doctors and allied health providers. Articles or guidelines/recommendations were excluded if they primarily related to drug and alcohol or substance use and eating disorders. A total of 16 studies and five guidelines/recommendations were included (20 were of high-moderate quality). Mental health providers were receptive to playing a role in oral health promotion and screening and this was supported by guidelines/recommendations. However, current practices of mental health providers in promoting oral health are fragmented and inconsistent due to various barriers: limited knowledge, education, and training, lack of collaboration with dental services, heavy workloads, time constraints and challenging client behaviours. This review highlights an urgent need to strengthen supports for mental health providers to promote oral health with professional development in oral health, more detailed clinical practice guidelines, brief and user-friendly oral health screening tools and streamlined dental referral pathways.

Mental and Oral Health: A Dual Frontier in Healthcare Integration and Prevention

Mental and oral health are interrelated, and problems in one area usually affect the other. This review discusses the complex relationships between oral and mental health, particularly the psychosocial challenges faced by individuals with mental health disorders in maintaining oral hygiene, including stigma, lack of access to care, and financial barriers. It also discusses how psychiatric conditions influence oral health, with regard to issues such as dry mouth, gum disease, and tooth decay, and how poor oral health can aggravate mental well-being. Preventive measures, treatment approaches, and solutions to overcome these barriers are also discussed. Methodological rigor was achieved by systematically searching high-impact journals indexed in PubMed and Google Scholar for peer-reviewed publications published between 2000 and 2024. High-impact journals have a high impact factor and rigorous peer-review standards. Articles that did not undergo peer review, articles published in languages other than English, or those that were not accessible (because access was closed unless key information was available through abstracts or summaries) were excluded. It mentions the relevance of integrating mental health services with oral health services, with a focus on individualized care, interdisciplinary cooperation, and creative strategies to break down systemic barriers, resulting in better health outcomes and lower healthcare costs.

[Access to oral health care for patients attending a medical-psychological center]

People with mental health problems have a worse oral health condition than the general population. As part of a qualitative study using semi-directive interviews aimed at analyzing the perceptions of professionals working in medical-psychological centers regarding the difficulties encountered by their patients in accessing dental care, three obstacles were identified: factors intrinsic to the patient, background in prevention and the organization of the healthcare system.

Barriers and facilitators to accessing oral healthcare for older people in the UK: a scoping review

Introduction Access to dental services is a growing problem for older people in the UK. The aim of this scoping review is to identify the barriers and facilitators influencing older people's ability to access oral healthcare in the UK based on the existing literature.Methods The scoping review followed the framework proposed by Levac and colleagues (2010). Peer-reviewed literature was retrieved in April 2023 from Web of Science, Medline, PsycInfo and CINAHL for the period 1973-2023. After screening, data were extracted to identify barriers and facilitators mapped to individual, organisational and policy-level factors. The themes generated were used to identify gaps in the literature and policy recommendations.Results Overall, 27 studies fulfilled the inclusion criteria. Most studies published were from England; there was a large representation of opinion pieces. The main barriers and facilitators related to cost of services, perceptions of dentistry, availability of services and both the dental and social care workforce.Conclusion Multiple barriers exist surrounding access to dental care for older people. Various facilitators exist but not all are successful. More research needs to be carried out on older people's access to dental services in the community, particularly for the 'oldest old' and minority groups.

Effectiveness of oral health interventions among children and adolescents with mental disorders: a systematic review

BACKGROUND

The rising percentage of children and adolescents experiencing mental disorders brought attention to the emerging opportunities for proactive oral health interventions in this population. Currently, existing guidelines focus mainly on oral health in general practice and on adults residing in care homes. This report aims to provide a broad overview of the effectiveness of oral health interventions for children and adolescents with mental disorders.

METHOD

This review followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses 2020) statement. The initial electronic search yielded a total of 3710 articles. The search identified 2354 potential papers after removing duplicates and 2301 articles were excluded by title and abstract. The full texts of the remaining 53 articles and nine articles from the citation searching were screened and 15 articles matched the inclusion criteria. The Mixed-Method Appraisal Tool (MMAT) was used for quality appraisal.

RESULTS

The thematic analysis resulted in four main themes which were educational intervention, physical intervention, clinical intervention, and a combination of both educational and clinical intervention.

CONCLUSION

We presented the findings in a narrative synthesis with the primary outcomes which served as answers to our main research question that prompted this systematic review.

Social determinants of health correlations and resource usefulness at a Milwaukee free clinic for uninsured individuals: A cross-sectional study

Introduction

Addressing social determinants of health (SDOH) is fundamental to improving health outcomes. At a student-run free clinic, we developed a screening process to understand the SDOH needs and resource utilization of Milwaukee's uninsured population.

Methods

In this cross-sectional study, we screened adult patients without health insurance (N = 238) for nine traditional SDOH needs as well as their access to dental and mental health care between October 2021 and October 2022. Patients were surveyed at intervals greater than or equal to 30 days. We assessed correlations between SDOH needs and trends in patient-reported resource usefulness.

Results

Access to dental care (64.7%) and health insurance (51.3%) were the most frequently endorsed needs. We found significant correlations (P ≤ 0.05) between various SDOH needs. Notably, mental health access needs significantly correlated with dental (r = 0.41; 95% CI = 0.19, 0.63), medications (r = 0.51; 95% CI = 0.30, 0.72), utilities (r = 0.39; 95% CI = 0.17, 0.61), and food insecurity (r = 0.42; 95% CI = 0.19, 0.64). Food-housing (r = 0.55; 95% CI = 0.32, 0.78), housing-medications (r = 0.58; 95% CI = 0.35, 0.81), and medications-food (r = 0.53; 95% CI = 0.32, 0.74) were significantly correlated with each other. Longitudinal assessment of patient-reported usefulness informed changes in the resources offered.

Conclusions

Understanding prominent SDOH needs can inform resource offerings and interventions, addressing root causes that burden under-resourced patients. In this study, patient-reported data about resource usefulness prompted the curation of new resources and volunteer roles. This proof-of-concept study shows how longitudinally tracking SDOH needs at low-resource clinics can inform psychosocial resources.

The Development of an Oral Health Nursing Tool for Patients with a Psychotic Disorder: A Human-Centred Design with a Feasibility Test

Patients with psychotic disorders frequently report oral health problems, while mental health nurses (MHNs) seem not to be fully aware of these problems and the risk factors. Therefore, this study aimed to develop supportive tools for MHNs regarding oral health to increase sensitisation among MHNs and provide MHNs with the knowledge to recognise (potential) oral health problems in patients with a psychotic disorder. We used a human-centred design in which the user, MHNs and experts by experience were placed at the centre of the research process. Problems and needs in MHNs working with patients with a psychotic disorder were addressed. To identify key issues of problems as well as needs in terms of resources, we started with focus groups (n = 9). We analysed the data thematically based on the context of patients and MHNs in practice regarding oral health, preferred oral health tools focused on MHNs, and the intended outcomes of tools. A multi-criteria decision matrix was developed and analysed (n = 9) to identify the most optimal and viable solution based on established criteria and issues that are prevalent in the work of MHNs. The most promising result was the development of a brochure with an awareness screener. The brochure with the awareness screener was developed as a low-fidelity prototype for MHNs regarding oral health in patients with a psychotic disorder based on the latest scientific evidence. After testing it, the feasibility was tested through semi-structured interviews (n = 19). MHNs and experts by experience were satisfied with the tool and provided recommendations for adjustments to the content. Significant augmentations to the brochure included a clinical lesson and a toothbrush with toothpaste for patients. We can conclude that a brochure with an awareness screener is feasible for MHNs. Future steps aiming to further refine and optimise care processes for oral health tools in MHNs should take refining eligibility criteria for psychiatric populations and the language level of the target group of a tool into account.

Quantitative analysis on dental utilisation in culturally and linguistically diverse mothers

BACKGROUND

Culturally and linguistically diverse (CALD) mothers are influential in children's behaviours, yet little is known about this population. Furthermore, insufficient quantitative and context-based studies are available with CALD mothers and their access to oral health care. To address this gap, the study investigates oral health behaviours, psychological factors and remoteness area with dental utilisation in CALD mothers, within the NSW context.

METHODS

Informed by middle-range theory and a CALD-specific rainbow model, the 2013 and 2015 NSW Adult Population Health Survey was analysed. Variables for CALD mothers included household structure, age and language spoken. Multivariable analysis was conducted with oral health behaviours, psychological and remoteness variables, with dental utilisation as the outcome.

RESULTS

The sample was weighted (n =190,283). In total, 39.8% did not have a dental visit, and older mothers (aged 36-55 years) sought more dental services than younger mothers (aged 18-35 years). Higher odds for treatment dental care (aOR 2.21, 95% CI 1.12-4.37) than prevention-oriented care were found. Mothers experiencing moderate levels of psychological distress (aOR 0.49, 95% CI 0.31-0.77), or residing in outer regional and remote regions (aOR 0.19, 95% CI 0.04-0.85) were less likely to utilise dental care.

CONCLUSION

Findings underline geographical issues in dental care utilisationand the need for integrated care for CALD mothers experiencing psychological distress, and to encourage uptake of preventive oral health care. Addressing cost barriers necessitates for universal health coverage. Multidisciplinary integration of healthcare services with improved primary sector collaboration between governments and healthcare providers, and the expansion to regional services are required for equity in CALD communities.

Oral health primary preventive interventions for individuals with serious mental illness in low- and middle-income nations: Scoping review

Mental health disorders constitute a major global disease burden, especially in low and middle-income countries (LMICs). Due to issues related to access, hygiene, economic pressures, and communication, the oral health of individuals with serious mental illness (SMI) receives little attention. This scoping review comprehensively maps and synthesises the existing literature on oral health primary preventive interventions (OHPPIs) in LMICs, highlighting key strategies and challenges encountered in addressing oral health disparities in resource-constrained settings. We systematically searched Cochrane Library, Ovid (MEDLINE), PsycINFO and Embase. The search strategy included keywords and MeSH terms related to oral health, SMI interventions, and LMICs. We included all types of OHPPI, (preventive, promotive, behavioural, and educational approaches) implemented in LMICs. We identified three studies focused on OHPPI for SMI patients that met our inclusion criteria. The interventions included were: (I) educational interventions; (II) behavioural interventions combining motivational and educational elements, and (III) self-assessment interventions combining educational and physical elements. Multifaceted barriers and challenges to effective oral health interventions were identified covering limited access to dental services, and socio-economic disparities. This scoping review underscores the need to develop and test context-specific strategies, capacity building, and policy support to improve oral health outcomes in LMICs.

An Ethical Analysis Regarding the COVID-19 Pandemic Impact on Oral Healthcare in Patients with Mental Disorders

During the COVID-19 pandemic, restrictive measures were imposed that significantly impacted the healthcare system in general, and the dental healthcare system in particular. The literature cites a possible association between mental and oral health, as psychiatric patients have decreased awareness of their oral health and, therefore, poor dental status. Moreover, several studies have found a positive association between SARS-CoV-2 infection and oral health conditions, as well as between SARS-CoV-2 infection and mental health status. This context generated multiple ethical dilemmas in the case of persons with mental health disorders who require dental treatment because they are more vulnerable in this respect. This article aims to analyze the ethical issues in dental care for patients with mental disorders concerning the COVID-19 restrictive measures. The ethical aspects involved here are the basic principles of bioethics and the related elements of accessibility, equity, consent, and confidentiality.

Oral health and individuals with a lived experience of an eating disorder: a qualitative study

BACKGROUND

Limited evidence exists describing the impact to oral health when living with an eating disorder and the availability of information or access to oral health services. This study investigated the perceptions of individuals with a lived experience of an eating disorder specifically to understand their needs and recommendations for improving access to early intervention and oral health promotion.

METHODS

Using purposive sampling a total of 12 semi-structured interviews were conducted with participants across Australia who had a lived experience of an eating disorder. A hybrid inductive and deductive approach to thematic analysis was used to construct salient themes and subthemes.

RESULTS

Most participants had experienced some oral health manifestation as part of their eating disorder hence, many felt quite knowledgeable on the topic. Following their eating disorder many participants felt confident in engaging with dental services, although, barriers including embarrassment, shame, and cost compromised access at times. Participants felt strongly that greater emphasis on oral health promotion during an eating disorder was important and this may be achieved by increasing the availability of resources and using trusted non-dental health professionals like dietitians.

CONCLUSIONS

The need for oral health promotion while experiencing an eating disorder was evident, however, dentists can often be a costly option. Non-dental health professionals like dietitians working with clients with an eating disorder may be an acceptable alternative for closing this gap.

A Human-Centered Design Approach to Develop Oral Health Nursing Interventions in Patients with a Psychotic Disorder

In mental health, oral health is often given little attention. Mental health nurses (MHNs) are professionally the appropriate target group to support maintaining and increasing oral health. We aimed to develop and validate personas that reflect the attitudes and needs of MHNs regarding oral health in patients with a psychotic disorder. We used a human-centered design with contextual interviews (n = 10) to address the key issues of the problems and needs of MHNs working with patients with a psychotic disorder. We analyzed the data thematically and reflected on insights into unique personas, which were then validated by conducting semi-structured interviews (n = 19) and member checking. Four personas were found based on attitudes and perspectives, barriers, needs, suggestions for interventions, and site conditions regarding practicing oral care in this patient group. Our findings were as follows: the attitudes and perspectives differed from not feeling any responsibility to a holistic obligation, including oral health; suggestions for interventions for MHNs ranged from interventions focusing on improving skills and knowledge to using practical tools; most MHNs recognized themselves within a persona that had a holistic obligation that included oral health; in addition, the MHNs indicated that they considered the issue of oral health in this patient group important, but, in practice, took little responsibility for that role. These findings suggest that a toolkit with interventions for MHNs that are tailored to the personas that emerged from our research should be developed by MHNs in co-creation with designers. The differences between the perceived role and MHNs' practice in oral health highlighted the need for role clarification and professional leadership of MHNs regarding oral health, which should be considered when developing interventions.

Enabling people with severe mental illness to overcome barriers to access dental treatment: a qualitative study applying COM-B framework analysis

BACKGROUND

The oral health of people with severe mental illness is severely compromised. Rates of premature total tooth loss and tooth decay are substantially higher than in the general population. Causation is complex, restricted access to treatment a major contributing factor.

AIMS

To examine factors enabling people with complex problems related to severe mental illness to attend scheduled dental appointments.

METHOD

Qualitative semi-structured interviews were conducted with 15 service users who attended no-cost treatment at a university clinic, following oral health screening at an inner-city community mental health service. Analysis used a framework approach informed by a theoretical model of behaviour (COM-B).

RESULTS

Complex individual motivations, related variously to function, pain and/or self or social appraisal, were also influenced by expectations of treatment. Capabilities included managing "messy" life circumstances; participants overcame various psychological and physical challenges to attend treatment, enabled by opportunities of social and instrumental support.

CONCLUSIONS

Genuine partnerships between agencies to provide access opportunities, in addition to individual support responsive to personal motivators and adapted to capabilities can enable access to services and improve the lives of people with severe mental illness.

Dietitians' Experiences of Providing Oral Health Promotion to Clients with an Eating Disorder: A Qualitative Study

(1) Background: Eating disorders (EDs) can seriously impact oral health, leading to irreversible dental damage. Dietitians play a key role in the care of people with an ED and are well-placed to promote oral health. However, there is currently little understanding of how dietitians perceive their role in this space. This study aimed to explore the perceptions and role of dietitians in providing oral health promotion to their clients in an ED clinical setting. (2) Methods: This descriptive qualitative study used semi-structured interviews to explore the perceptions of 14 registered dietitians practicing across seven states in Australia. Participants were recruited using a combination of purposive and snowball sampling. A hybrid thematic analysis approach was undertaken to identify and describe the key themes generated from the data. (3) Results: Generally, dietitians were insightful and knowledgeable of the oral health issues that clients with an ED may be experiencing. However, dietitians' practices across education, screening, and referrals were inconsistent. Challenges such as inadequate training, unknown referral pathways, and clear guidelines were cited as significant barriers to practice. (4) Conclusions: The results reinforce the need for education and the development of targeted strategies that address challenges to oral health promotion in dietetic practice.

Exploring the contextual factors, behaviour change techniques, barriers and facilitators of interventions to improve oral health in people with severe mental illness: A qualitative study

People with severe mental illness (SMI) have significantly poorer oral health compared to people without SMI and interventions targetted to improve oral health in this population failed to show any long-term improvement. Interventions are influenced by many contextual factors ranging from individual to systems level. This study aimed to understand the contextual factors, behaviour change techniques of the available oral health interventions and explore the barriers to and facilitators for engagement with these interventions from the perspectives of people with SMI (service users) and related service providers. Intervention details were extracted from 12 intervention studies identified from a previous systematic review using the template for intervention description and replication checklist (TIDieR) and behaviour change techniques (BCTs) were coded using the behaviour change technique taxonomy v1. Sixteen individual BCTs were identified and out of which "4.1 instructions on how to perform the behaviour" (n = 9) and "6.1 demonstration of behaviour" (n = 6) were most frequently used BCTs. Video vignettes prepared from the different intervention components identified from existing studies were shown to service users and service providers in dyadic or one-to-one interview format to elicit their views on barriers and facilitators for engagement with the intervention components. Interviews were analysed using Framework analysis and were guided by theoretical domains framework (TDF); and capability, opportunity and motivation (COM-B) model of behaviour change. Main facilitators identified to increase capability, opportunity and motivation of service users were the involvement of carers/care coordinators and integration of dental and mental health care, provision of oral health/hygiene information/products at an appropriate level and provision of tailored support according to individual needs and preferences. Barriers identified were related to lack of communication skills of the service providers, provision of coordinated care, lack of support in visiting a dentist and navigating the payment system and long follow up times. Appropriate training was considered as a facilitator, and staff turnovers and workload were considered as main barriers by the service providers. The findings suggest that comprehensive interventions that target barriers and enhance facilitators from individual to systems level are needed to improve oral health outcomes of people with SMI.

Dental Service and Resource Needs during COVID-19 among Underserved Populations

Introduction:

In response to the coronavirus disease 2019 (COVID-19) outbreak, dental services in British Columbia, Canada, were restricted to urgent and emergency cases between March 16 and May 18, 2020. It is unclear how the curtailment of oral health services has affected underserved populations who already often have limited access to dental care due to cost, fear, stigma, and discrimination.

Objectives:

To explore the experiences of underserved populations and their community organizations when accessing oral health services and information in British Columbia and identify their coping mechanisms employed during the curtailment of oral health care services.

Methods:

Semistructured, remote interviews were conducted with 13 staff and 18 members from 6 community-based organizations. These organizations serve men and women with a history of incarceration and/or experiencing poverty and homelessness, persons living with human immunodeficiency virus/AIDS, adults living with mental illness, and older adults in long-term care facilities. The interviews were audio-recorded, transcribed verbatim, and coded for emerging themes using NVivo 12 software. Thematic analysis was performed.

Results:

The pandemic raised concerns and hesitancy among underserved populations and further reduced access to care. In turn, those with unmet dental needs resorted to coping mechanisms, including turning to community support or medical services, self-management of dental issues, and not dealing with dental issues altogether. Community organizers and members outlined needed resources such as assistance navigating the dental care system, having a contact for dental-related questions, and member preparation for dental service changes, while emphasizing the importance of positive relationships with dental providers.

Conclusion:

Underserved populations who already face barriers to oral health care services experienced increased difficulty in addressing their oral health needs and concerns during the beginning of the COVID-19 pandemic. Strategies aimed at reaching out to this population and those who support them are needed to help mitigate negative coping strategies and increased oral health disparities.

Knowledge Transfer Statement:

This study depicts ways of addressing unmet oral health–related issues during the COVID-19 pandemic for underserved populations and their community organizations with policy implications as well as practical strategies.

A Qualitative Study Exploring the Barriers and Facilitators for Maintaining Oral Health and Using Dental Service in People with Severe Mental Illness: Perspectives from Service Users and Service Providers

People with severe mental illness suffer from a high burden of oral diseases, which can negatively impact their physical and mental well-being. Despite the high burden, they are less likely to engage in oral health care including accessing dental services. We aimed to identify both the service users' and service providers' perspective on the barriers and facilitators for maintaining oral health and dental service use in people with severe mental illness. Qualitative exploration was undertaken using dyadic or one-to-one in-depth interviews with service users in the UK with a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. Service providers, including mental health and dental health professionals, and informal carers (people identified as family or friend who are not paid carers) were also interviewed. Thematic analysis of the data revealed three main cross-cutting themes at the personal, inter-personal and systems level: amelioration of the problem, using a tailored approach and provision of comprehensive support. The main barriers identified were impact of mental ill-health, lack of patient involvement and tailored approach, and accessibility and availability of dental services including lack of integration of services. The main facilitators identified were service providers' effective communication skills and further support through the involvement of carers. The findings suggest that the integration of dental and mental health services to provide tailored support for overall health and well-being, including the oral health of the patient, can better support people with severe mental illness regarding their oral health needs.

Association Between Mental Health and Oral Health Status and Care Utilization

Studies have shown that mental health and oral health may be correlated, with associations demonstrated between mental health problems and tooth loss, periodontal disease, and tooth decay. The COVID-19 pandemic had alarming implications for individuals' and communities' mental and emotional health. This study examined the associations between mental health status, oral health status, and oral healthcare utilization and highlighted the impact of COVID-19 on mental health. Additionally, this study examines specific sociodemographic factors that may amplify oral health disparities. A nationally representative survey was conducted to capture attitudes, experiences, and behaviors related to oral health, mental health, and unmet oral health needs. Eighteen percent of respondents were categorized as having poor mental health. Visiting the dentist in the last year was more common amongst individuals with good mental health. From the logistic regression model, mental health status, age group, race/ethnicity, education, and last dental visit were all significantly associated with of oral health status. Mental health status, age group, and income groups were all significantly associated with unmet oral health need. Future work should focus on the mental-oral health association, including determining ways to improve oral healthcare utilization and oral health status among people with poorer mental health.

Associations between psychological wellbeing, depression, general anxiety, perceived social support, tooth brushing frequency and oral ulcers among adults resident in Nigeria during the first wave of the COVID-19 pandemic

INTRODUCTION

The aims of this study were to determine the associations between psychological wellbeing, and the frequency of tooth brushing and presence of oral ulcers during the COVID-19 pandemic; and to identify the mediating roles of psychological distress (general anxiety and depression) and perceived social support in the paths of observed associations.

METHODS

This cross-sectional study recruited 996 adults in Nigeria between June and August 2020. Data collected through an online survey included outcome variables (decreased frequency of tooth brushing and presence of oral ulcers), explanatory variable (psychological wellbeing), mediators (general anxiety symptoms, depression symptoms and perceived social support) and confounders (age, sex at birth, educational and employment status). Multivariate logistic regression was used to determine the risk indicators for the outcome variables. A path analysis was conducted to identify the indirect effect of mediators on the association between the outcome and explanatory variables.

RESULTS

Of the 966 respondents, 96 (9.9%) reported decreased tooth-brushing frequency and 129 (13.4%) had oral ulcers during the pandemic. The odds of decreased tooth-brushing during the pandemic decreased as the psychological wellbeing increased (AOR: 0.87; 95% CI: 0.83-0.91; p < 0.001) and as generalized anxiety symptoms increased (AOR: 0.92; 95% CI: 0.86-0.98; p = 0.009). The odds of having an oral ulcer was higher as the generalized anxiety symptoms increased (AOR: 1.15; 95% CI: 01.08-1.21; p < 0.001). Only generalized anxiety (indirect effect: 0.02; 95% CI: 0.01-0.04; P = 0.014) significantly mediated the relationship between wellbeing and tooth-brushing accounting for approximately 12% of the total effect of wellbeing on decreased toothbrushing. Generalized anxiety (indirect effect 0.05; 95% CI: - 0.07-0.03; P < 0.001) also significantly mediated the relationship between wellbeing and presence of oral ulcer accounting for 70% of the total effect of wellbeing on presence of oral ulcer. Depressive symptoms and perceived social support did not significantly mediate the associations between psychological wellbeing, decreased frequency of tooth brushing and the presence of oral ulcers.

CONCLUSION

Patients who come into the dental clinic with poor oral hygiene or oral ulcers during the COVID-19 pandemic may benefit from screening for generalized anxiety and psychological wellbeing to identify those who will benefit from interventions for mental health challenges.

Oral Health Interventions in Patients with a Mental Health Disorder: A Scoping Review with Critical Appraisal of the Literature

Poor oral health affects quality of life and daily functioning in the general population and especially in patients with mental health disorders. Due to the high burden of oral health-related quality of life in patients with a mental health disorder, it is important for nurses to know how they can intervene in an early phase. The aim of this systematic scoping review was to identify and appraise oral health interventions in patients with a mental health disorder. A systematic scoping review with a critical appraisal of the literature was conducted using the Joanna Briggs Institute (JBI) methodology for scoping reviews and their checklists. MEDLINE, CINAHL, PsycINFO and reference lists were searched from their inception until December 2020. Results: Eleven quantitative studies were included in the review: four randomized controlled trials, six quasi-experimental studies and one cohort study. Studies focused on interventions for patients (n = 8) or focused on patients together with their professionals (n = 3). Four types of oral health interventions in mental health were found: (I) educational interventions; (II) physical interventions; (III) interventions combining behavioural and educational elements and (IV) interventions combining educational and physical elements. All studies (n = 11) had an evaluation period ≤12 months. Nine studies showed an effect on the short term (≤12 months) with regard to oral health knowledge, oral health behaviour, or physical oral health outcomes (e.g., plaque index). Two studies showed no effects on any outcome. Overall, the methodological insufficient to good. Conclusion: Four types of interventions with positive effects (≤12 months) on oral health knowledge, oral health behaviour, and physical oral health outcomes in different diagnostic patient groups were found. Due to the heterogeneity in both interventions, diagnostic groups and outcomes, one golden standard oral health intervention cannot be advised yet, although the methodological quality of studies seems sufficient. Developing an integrated oral health toolkit might be of great importance in mental health considering its potential effect on oral health-related quality of life.

Oral health-related quality of life among Brazilian adults with mental disorders

The aim of this study was to investigate associations of sociodemographic, lifestyle, medical conditions, and caries experience with oral health-related quality of life (OHRQoL) in a large sample of adults with mental disorders. A sample of 753 adults diagnosed with schizophrenia or depression, who were users of 10 public mental health outpatient clinics located in the city of São Paulo, Brazil, participated in the study. Participants provided data on sociodemographic characteristics, psychiatric diagnosis, medication use, and health behaviors. Oral examinations to evaluate dental caries (using the decayed, missing, and filled teeth ([DMFT] index) and dental plaque (using the Silness-Löe plaque index) were conducted. Oral health-related quality of life was evaluated using the 14-item Oral Health Impact Profile (OHIP-14) questionnaire. Log-Poisson regression was used to evaluate associations between the outcome and independent variables. The prevalence of one or more OHIP-14 impacts occurring fairly often/often was 72.3%. Physical pain was the OHIP domain with the highest prevalence, followed by psychological discomfort. Multivariable analysis showed that higher prevalence of the reponses 'fairly often/often' in the OHIP-14 was associated with being female, aged 35 to 54 years, having a low family income, a diagnosis of depression, a smoking habit, and fewer than 20 teeth. Adults with mental disorders had a high prevalence of impacts on their OHRQoL, which were associated with caries experience, sociodemographic characteristics, type of psychiatric diagnosis, and behavioral risk indicators.

Barriers and facilitators for dental care among patients with severe or long-term mental illness

Background

Persons who struggle with severe or long‐term mental illness (SMI) have a higher prevalence of oral health problems than the general population. Obtaining and continuing dental treatment is challenging for this patient group for many reasons, and many drop out of active treatment. Our study aimed to explore perceived barriers to obtaining optimal dental health care for patients with SMI. Further, we sought to identify possible ways to facilitate for providing true access to dental services for this population.

Methods

The study utilised a flexible qualitative design with data collected during ordinary clinical practice in a public dental clinic in Norway. We conducted semi‐structured face‐to‐face interviews with 51 persons with SMI twice: an initial interview before dental treatment and a final one after dental treatment. We applied the thematic analysis method.

Results

Thematic analysis revealed two key themes in the participants’ experiences of access to dental health services: practical conditions and relationship with the dentist. Patients reported barriers and facilitators for access to care as factors associated with patients (patient factors), with the dentist (dentist factors) and with healthcare services (system factors).

Conclusions

Our study indicates that persons with SMI appreciate oral health and want to obtain needed oral care and dental treatment, but they encounter barriers on several fronts. The participants offered suggestions for how to facilitate attendance and adherence. Our findings suggest that dental healthcare services require reorganisation to meet the needs of patients with SMI.

Demographic and socioeconomic inequalities in oral healthcare utilisation in Malaysia: evidence from a national survey

Background

Throughout the years, oral healthcare utilisation in Malaysia has been low despite various efforts by the Ministry of Health Malaysia for improvement. This study aimed to determine the prevalence of oral healthcare utilisation and identify factors associated with oral healthcare utilisation among adults in Malaysia.

Methods

Secondary data analysis of adults aged 18 years and over from the National Health and Morbidity Survey 2019 was conducted in this study. Characteristics of respondents and those who utilised oral healthcare were described using complex sample descriptive statistics. Logistic regression analysis was performed to examine the association between the dependent and independent variables. Dependent variable was oral healthcare utilisation in the last 12 months. Independent variables were demographic and socioeconomic factors (predisposing, enabling and need characteristics) based on Andersen’s Behavioural Model.

Results

A total of 11,308 respondents, estimated to represent 21.7 million adults aged 18 years and over in Malaysia were included in the analysis. Prevalence of oral healthcare utilisation in the last 12 months was 13.2%. Demographic factors of sex, age, marital status, and socioeconomic factors of education level and occupation as well as health belief such as medical check-up were significantly related to oral healthcare utilisation. Enabling factor of household income quintile had significant association with oral healthcare utilisation. Inequalities were observed; females (OR = 1.57, 95% CI = 1.25, 1.96), younger adults (OR = 1.64, 95% CI = 1.15, 2.33), those who were married (OR = 1.65, 95% CI = 1.23, 2.22), those with higher education (OR = 2.21, 95% CI = 1.23, 3.99), those who had medical check-up in the last 12 months (OR = 1.86, 95% CI = 1.53, 2.25) and those with higher income (OR = 1.43, 95% CI = 1.04, 1.96) were more likely to utilise oral healthcare.

Conclusion

Understanding factors associated with utilisation of oral healthcare could help in formulating effective interventions to improve oral healthcare utilisation. Demographic and socioeconomic factors are strong determinants of oral healthcare utilisation in Malaysia. Appropriate interventions to strengthen the existing programmes aimed to promote regular and timely oral health check-ups are needed to improve oral healthcare utilisation.

A rapid review of barriers to oral healthcare for people with protected characteristics

Introduction The Equality Act 2010 sets out nine protected characteristics and serves to protect every individual against discrimination. The Act places emphasis on the need to reduce inequalities. An understanding, therefore, of existing barriers to oral healthcare for people with protected characteristics is required to inform policy and the commissioning of services.Aim To conduct a rapid review of current UK literature on barriers to oral healthcare for people with protected characteristics.Methods Electronic searching using Medline via Ovid limited to publications in English from the UK. Publication types included primary and secondary evidence from peer-reviewed journals and reports.Results From a total of 462 citations, 52 articles were included in the final review. Common barriers experienced across the protected characteristic groups were identified in addition to specific barriers experienced by those with protected characteristics.Conclusion This rapid review identified barriers to oral healthcare for people with protected characteristics at individual and organisational levels. Gaps identified in the literature include a lack of information available for barriers experienced by people due to sexual orientation, marital/civil partnership status and gender reassignment. Additionally, there is a gap in the evidence available on policy barriers to oral healthcare for people with protected characteristics.

Barriers to Somatic Health Care for Persons With Severe Mental Illness in Belgium: A Qualitative Study of Patients' and Healthcare Professionals' Perspectives

BACKGROUND

A huge and still growing mortality gap between people with severe mental illness (SMI) and the general population exists. Physical illnesses, mainly cardiovascular diseases, substantially contribute to the high mortality rates in patients with SMI. Disparities in somatic health care access, utilisation, and provision contribute to these poor physical health outcomes.

METHODS

A qualitative study, using semi-structured interviews, was set up to explore SMI patients' and healthcare professionals' perspectives on somatic health care in different psychiatric settings of the three Belgian regions (Flanders, Brussels, Wallonia). Interviews were digitally recorded and transcribed prior to qualitative inductive thematic analysis, using Nvivo software. The COnsolidated criteria for REporting Qualitative research (COREQ) were used for reporting methods and findings.

RESULTS

Collaboration and information flows between psychiatric healthcare professionals, non-psychiatric healthcare professionals, and persons with SMI were troublesome. This seemed to be mainly due to stigma and prejudice and challenging communication and data transfer. Lack of sufficient training and experience to identify and treat somatic health problems in people with SMI (for psychiatrists and psychiatric nurses) and lack of psychiatric knowledge and feeling or sensitivity for psychiatric patients (for non-psychiatric healthcare professionals) further complicated adequate somatic health care. Finally, optimal somatic follow-up of patients with SMI was hampered by organisational problems (unavailability of equipment, unadapted infrastructure, understaffing, hospital pharmacy issues, and insufficient health promotion/lifestyle interventions), patient-related issues (unawareness of physical problems, non-adherence, need for accompaniment) and financial barriers.

CONCLUSION

There is an urgent need for integrated somatic and mental healthcare systems and a cultural change. Psychiatrists and primary care providers continue to consider the mental and physical health of their patients as mutually exclusive responsibilities due to a lack of sufficient training and experience, poor or absent liaison links, time constraints and organisational and financial barriers. Modifying these aspects will improve the quality of somatic health care for these vulnerable patients.

Oral health perceptions and client satisfaction among homeless adults attending a community-centred dental clinic

BACKGROUND

The homeless face significant barriers accessing dental care. Community-centred dental clinics might provide more accessible care to this group. This descriptive epidemiological study aimed to measure oral health perceptions and client satisfaction among homeless and similarly disadvantaged adults receiving community-centred dental care.

METHODS

A sample of 79 clients attending St Patrick's Oral Health Clinic completed Locker's Global Oral Health Item, the Oral Health Impact Profile 14 and the Client Satisfaction Questionnaire 4.

RESULTS

High levels of satisfaction with St Patrick's Oral Health Clinic were based on positive staff attitudes, low cost, time effectiveness and staff sensitivity to anxiety. Ideas for improvement included shorter treatment waiting lists, offering additional treatment types and better communication and advertisement of the service. Compared to the general Australian population, participants reported a relatively poor self-perception of oral health and a high prevalence and severity of oral health impacts.

CONCLUSIONS

Participants experienced significant personal and social impacts due to their oral conditions. High levels of client satisfaction reflect the value of community-centred dental care for this group. An understanding of factors influencing satisfaction might be useful for similar services providing oral care to homeless and similarly disadvantaged groups.

Disentangling a web of causation: An ethnographic study of interlinked patient barriers to planned dental visiting, and strategies to overcome them

OBJECTIVE

To explore barriers to planned dental visiting, investigating how barriers interlink, how they accumulate and change, and how individuals envisage overcoming their combination of barriers through personal strategies.

METHODS

An ethnographic study was conducted of adult urgent dental care attenders who did not have a dentist, including 155 hours of nonparticipant observations, 97 interviews and 19 follow-up interviews in six urgent dental care settings. Data were analysed using constant comparison, first identifying barriers and personal strategies to overcome them, and subsequently analysing interlinks between barriers and personal strategies.

RESULTS

Accounts of barriers to planned dental visiting encompassed multiple barriers, which related to socioeconomic circumstances as well as experiences of oral health care. Barriers were multi-layered and more difficult to overcome when occurring together. Personal strategies to overcome diverse barriers often hinged on increasing importance of oral health to individuals, yet this was not always sufficient. The combination of barriers participants experience was dynamic, changing due to personal, family, or employment circumstances, and with increasing severity of barriers over time. Over time, this could lead to higher cost, and additional barriers, particularly embarrassment.

CONCLUSION

Barriers to planned dental visiting are complex, multi-layered and change over time, constituting a 'web of causation'. This adds a novel perspective to the literature on barriers to dental visiting, and requires that researchers, dental practitioners and policy makers remain open to barriers' interlinked effects, changes in primacy among individual patients' barriers, and their accumulation over time to better support uptake of planned dental visiting.

Eating disorders and oral health: a scoping review on the role of dietitians

BACKGROUND

Compromised nutritional intake due to eating disorder related behaviors, such as binge eating and purging, can lead to multi-system medical complications, including an irreversible impact on oral health. However, dental anxiety, fear or embarrassment may hinder individuals with an eating disorder from seeking assistance for their oral health concerns. As key health professionals in eating disorder treatment, dietitians are well positioned to provide basic dental screening, however, their capacity to perform this role in practice has not been established. The aim of this review was to identify current evidence on the role of dietitians in promoting oral health among individuals with eating disorders.

METHODS

A comprehensive search of eight electronic databases and the grey literature was conducted to address the following three focus areas: 1) guidelines and recommendations on the role of dietitians in oral health 2) knowledge, attitudes and practices of dietitians regarding oral health promotion and; 3) current models of oral health care and resources for dietitians.

RESULTS

Twelve articles were included. The review indicated that current national and international position statements encourage dietitians to conduct basic oral health screening and promote oral health in high risk populations, such as those with an eating disorder. However, no evidence was found to indicate dietitians performed oral health screening or education in populations with an eating disorder. In other population settings, dietitians were found to play a role in oral health promotion, however, were noted to have mixed knowledge on oral health risk factors, prevention and treatment and generally were not providing referrals. Some oral health promotion resources existed for dietitians working in pediatric, HIV and geriatric clinical areas however no resources were identified for dietitians working in eating disorder settings.

CONCLUSION

Despite current evidence showing that dietitians can play a role in oral health care, no models of care exist where dietitians promote oral health among individuals with an eating disorder. There are also no training resources and screening tools for dietitians in this area. Further research is required to develop this model of care and assess its feasibility and acceptability.

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.

Dentists' perspectives on barriers to providing oral health care in French psychiatric hospitals with on-site dental clinics

OBJECTIVES

Psychiatric inpatients suffer from poorer oral health than the general population, and difficulties in accessing necessary dental treatment remain even when a dedicated dental service is available within the psychiatric hospital. The aim of this study was to identify barriers to access dental care from the point of view of dentists working within French psychiatric hospitals.

METHODS

The relatively small number of dentists working in psychiatric hospitals necessitated a qualitative approach. Semi-structured interviews were conducted, recorded, transcribed and coded in a conventional content analysis approach.

RESULTS

Eight interviews were conducted. Six of the dentists interviewed were men, and two were women. Three of them worked full-time in a psychiatric facility, while the other five worked partly in the hospital and partly in private practice. The average duration for interviews was 54 minutes (minimum 24 min, maximum 89 min). The interviews highlighted three dimensions of barriers to access to dental care. The first dimension was directly related to the patient. This may be linked to the patient's psychiatric disorder but not necessarily. This also encompasses refusal of care. A second dimension regrouped events related to the organization of the hospital (locally), such as communication issues between staff members within the dental office, and with other staff members from the psychiatric ward. A third dimension included difficulties related to the overall organization of the healthcare system, including financial issues and deinstitutionalization.

CONCLUSIONS

In-site dental consultations appear as an interesting tool to enhance access to oral care for psychiatric inpatients. However, difficulties remain from the dentists' perspective.

Oral health interventions for people living with mental disorders: protocol for a realist systematic review

BACKGROUND

The increasing number of people who experience mental disorders is a global problem. People with mental disorders have high rates of co-morbidity and significantly poorer oral health outcomes than the general public. However, their oral health remains largely a hidden and neglected issue. A complex range of factors impact the oral health of this group. These include anxiety and dental phobia, dietary habits, including the heavy consumption of sugary drinks, substance misuse of tobacco, alcohol, and/or psychostimulants, the adverse orofacial side effects of anti-psychotic and anti-depression medications, and financial, geographic, and social barriers to accessing oral health care.

METHODS

The aim of this realist systematic review is to (a) identify and synthesise evidence that explores oral health interventions for people living with mental disorders; (b) explore the context and mechanisms that have contributed to the success of interventions or the barriers and challenges; (c) produce program theories on causal, contextual and mechanistic factors to facilitate outcomes and (d) produce recommendations and guidelines to guide future oral health interventions for people with mental disorders at both the policy and practice level. Using a five-step process, that incorporates primary data collection from key stakeholders, a beginning theoretical framework will be developed to describe contextual and mechanistic factors and how they might impact on the success or failure of oral health interventions for people with mental disorders. Key database searches will be conducted, with data extraction focused on the factors that might have impacted on intervention implementation and outcomes. Quality appraisal of studies will occur, and the theoretical framework will be populated with extracted data. Stakeholder input will support the development and refinement of a theory on oral health interventions for people with mental disorders.

DISCUSSION

This will be the first review to take a realist approach to explore the broad scope of causal factors that impact on the success or failure of oral health interventions for people with mental disorders. The approach includes extensive stakeholder engagement and will advance realist systematic review methodology. Review outcomes will be important in guiding policy and practice to ensure oral health interventions better meet the needs of people with mental disorders.Systematic review registration This review protocol is registered with PROSPERO (Number) 155969.

Personalized Dental Caries Management for Frail Older Adults and Persons with Special Needs

Frail older adults and persons with special needs are at higher risk of oral diseases including dental caries. Considering the diverse background of the population, a personalized approach for each patient is mandatory to successfully manage their oral health needs. This article describes a succinct way to assess and categorize the risk of rapid oral health deterioration (ROHD) among this group. The procedures for assessing ROHD risk examine the ROHD risk categories, how risk factors impact treatment strategies, what techniques and materials exist for caries prevention and treatment, and how one effectively communicates caries management plans for this population.

Building oral health capacity in a women's health service

Adult women in Australia are more likely than men to have no teeth, more missing teeth or have a dental hospital admission. Experiences of war, family and domestic violence, mental health or alcohol and other drug use problems may also negatively affect women's oral health. Yet, oral health is often excluded from primary healthcare. Little is known about what helps or inhibits primary healthcare service workers to promote oral health to women in need. Identifying the perceptions and experiences of such workers is a step towards a strategy to develop resources to support them in raising oral health issues with disadvantaged clients. This paper presents findings from a qualitative study conducted at a community-based women's health service, which used focus groups to investigate workers' perceptions of promoting oral health and accessing services for their clients. Findings indicated how structural issues informed oral healthcare, where workers generally did not consider oral health their responsibility, were reluctant to raise the issue with clients and had limited oral health knowledge and resources. To overcome these barriers, workers identified the need for oral health resources and better linkages to the dental system to help support their clients.

Providing oral care for adults with mental health disorders: Dental professionals' perceptions and experiences in Perth, Western Australia

OBJECTIVE

To explore dental professionals' perceptions and experiences of providing oral health care for adults with mild to moderate mental health disorders (MHD) in Perth, Western Australia.

METHODS

A grounded theory approach guided this research which comprised semi-structured interviews with oral health professionals working in private and/or public dental facilities attended by adults with MHD. An iterative analysis of transcripts identified emerging issues that were organized into categories under which key themes were noted, coded, compared, discussed, reviewed and revised independently by two researchers to ensure rigour.

RESULTS

Sixteen interviews were conducted with six general dentists, three dental specialists, four oral health therapists (OHT) and three dental assistants. Barriers to providing oral health care for adults with MHD included limitations of the current model of care, often focused on treating advanced disease; limited inter-professional collaboration; an over-burdened public dental system and the financial constraints of private practice. Personal barriers included perceptions that people with MHD had limited capacity for self-care and preventing oral disease. Factors that would enable oral health care included training and professional development for dental professionals to work effectively with people with MHD and a more flexible, inter-professional approach that involved prevention and inviting family to consultations about oral health in primary health care settings.

CONCLUSIONS

Our study reveals structural barriers where services often appear to be inadequately prepared to meet the oral health needs of people with MHD. This suggests the need for strategies to review current models of care and encourage and support dental professionals to provide oral health care that is inclusive, inter-professional, focused on prevention and sensitive to the social context and lived experience of people with MHD.