Oral Hygiene in Patients With Severe Mental Illness: A Pilot Study on the Collaboration Between Oral Hygienists and Mental Health Nurses

Evaluating the impact of oral hygiene instruction and digital oral health education within cardiac rehabilitation clinics: A protocol for a novel, dual centre, parallel randomised controlled trial

INTRODUCTION

Diseases of the periodontal tissues including gingivitis and periodontitis can affect up to 90% and 50% of the population respectively. These conditions are multifactorial inflammatory conditions involving a dysbiotic biofilm that, if left untreated, can lead to the destruction of the supporting structures of the teeth and have significant systemic implications, specifically on cardiovascular health. The elevation of inflammatory markers, particularly high-sensitive C-reactive protein (hsCRP), are strongly associated with an increased risk of atherosclerosis, a key risk factor for cardiovascular disease (CVD). HsCRP as well as other inflammatory markers can be detected in blood samples as early as 21 days after ceasing toothbrushing, due to the immune response to stagnant oral biofilm. The most effective way to ensure oral biofilm cannot remain on oral tissues, thus preventing periodontitis and reducing inflammatory CVD risk, is with good oral hygiene. The primary aim of this study is to assess whether individualised oral hygiene instruction (OHI) partnered with a digital oral health education (DOHE) package can improve the oral health of patients living with CVD.

METHODS AND ANALYSIS

A total of 165 participants will be recruited from the Westmead and Blacktown Mt Druitt cardiac rehabilitation out-patient clinics into this dual centre, single blind, parallel design, randomised controlled trial. A baseline oral health clinical examination will be completed, followed by a self-report questionnaire before they are randomised in a 1:1:1 ratio into one of 3 arms as follows: individualised OHI partnered with DOHE (Group A), (Group B) DOHE only (Group B), and control/usual care (no oral health education) (Group C). Groups will have their intervention repeated at the 6-week follow-up. After completing the 12-week follow-up, Group B and Group C will receive tailored OHI. Group C will also receive the DOHE package. The primary outcome is the change in approximal plaque index score between baseline and 6-week follow up.

ETHICS AND DISSEMINATION

The study has been approved by the Western Sydney Local Health District Human Ethics Committee 2023/ETH00516. Results will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12623000449639p ANZCTR: https://www.anzctr.org.au/.

Strategies to integrate oral health into primary care: a systematic review

OBJECTIVES

Integration of oral health into primary care has been proposed as a primary healthcare approach for efficient and sustainable delivery of oral health services, and the effective management of oral diseases. This paper aimed to synthesise evidence on the effectiveness of strategies to integrate oral health into primary care.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar were searched without date limits until the third week of June 2022. Reference lists of eligible studies were also searched. Experts in the field and existing professional networks were consulted.

ELIGIBILITY CRITERIA

Only studies that evaluated integration strategies were included in the review. Eligibility was restricted to English language studies published in academic peer-reviewed journals.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and performed the risk of bias assessments. A narrative synthesis approach was used to report review findings. Heterogeneity among included studies precluded a meta-analysis.

RESULTS

The search identified 8731 unique articles, of which 49 were included in the review. Majority of the studies explored provision of oral healthcare by primary care professionals in primary care settings, where integration was primarily via training/education and/or policy changes. Most studies reported results favouring the integration strategy, such as improvements in referral pathways, documentation processes, operating efficiencies, number of available health staff, number of visits to non-dental primary care professionals for oral health issues, proportion of children receiving fluoride varnish applications/other preventive treatment, proportion of visits to an oral health professional and dental caries estimates.

CONCLUSION

The findings from this review demonstrate that the majority of identified strategies were associated with improved outcomes and can be used to inform decision-making on strategy selection. However, more research and evaluation are required to identify best practice models of service integration.

PROSPERO REGISTRATION NUMBER

CRD42020203111.

Risk factors and oral health-related quality of life: A case-control comparison between patients after a first-episode psychosis and people from general population

WHAT IS KNOWN ON THE SUBJECT?: Oral health consists of more than having good teeth; it is an important factor in general health and well-being. Despite its importance, oral health care is still largely overlooked in mental health nursing. There is no research available about oral health risk factors and OHRQoL in patients diagnosed with a psychotic disorder with a psychotic disorder (first-episode). WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This study provides insight into the severity of the problem. It demonstrates the differences in risk factors and OHRQoL between patients diagnosed with a psychotic disorder (first-episode) and the general population. A negative impact on OHRQoL is more prevalent in patients diagnosed with a psychotic disorder (first-episode) (14.8%) compared to the general population (1.8%). Patients diagnosed with a psychotic disorder (first-episode) have a considerable increase in odds for low OHRQoL compared to the general population, as demonstrated by the odds ratio of 9.45, which supports the importance of preventive oral health interventions in this group. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings highlight the need for oral health interventions in patients diagnosed with a psychotic disorder (first-episode). Mental health nurses, as one of the main health professionals supporting the health of patients diagnosed with a mental health disorder, can support oral health (e.g. assess oral health in somatic screening, motivate patients, provide oral health education to increase awareness of risk factors, integration of oral healthcare services) all in order to improve the OHRQoL. ABSTRACT: Introduction No research is available about the oral health risk factors and oral health-related quality of life (OHRQoL) in patients diagnosed with a psychotic disorder. Aim To compare oral health risk factors and OHRQoL in patients diagnosed with a psychotic disorder (first-episode) to people with no history of psychotic disorder. Method A case-control comparison (1:2) multivariable linear regression analysis and an estimation of prevalence of impact on OHRQoL. Results Patients diagnosed with a psychotic disorder (first-episode) have lower OHRQoL with more associated risk factors. Of the patients diagnosed with a psychotic disorder (first-episode), 14.8% reported a negative impact on OHRQoL, higher than the prevalence of 1.8% found in people from the general population. Discussion The high prevalence rate of a negative impact on OHRQoL in patients diagnosed with a psychotic disorder (first-episode) shows the importance of acting at an early stage to prevent a worse outcome. Implications for practice The findings highlight the need for oral health interventions in patients diagnosed with a psychotic disorder (first-episode). Mental health nurses, as one of the main health professionals supporting the health of patients diagnosed with a mental health disorder, can support oral health (e.g. assess oral health in somatic screening) in order to improve the OHRQoL.

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.

Improving oral health in people with severe mental illness (SMI): A systematic review

BACKGROUND

Those with severe mental illness (SMI) are at greater risk of having poor oral health, which can have an impact on daily activities such as eating, socialising and working. There is currently a lack of evidence to suggest which oral health interventions are effective for improving oral health outcomes for people with SMI.

AIMS

This systematic review aims to examine the effectiveness of oral health interventions in improving oral health outcomes for those with SMI.

METHODS

The review protocol was registered with PROSPERO (ID CRD42020187663). Medline, EMBASE, PsycINFO, AMED, HMIC, CINAHL, Scopus and the Cochrane Library were searched for studies, along with conference proceedings and grey literature sources. Titles and abstracts were dual screened by two reviewers. Two reviewers also independently performed full text screening, data extraction and risk of bias assessments. Due to heterogeneity between studies, a narrative synthesis was undertaken.

RESULTS

In total, 1462 abstracts from the database search and three abstracts from grey literature sources were identified. Following screening, 12 studies were included in the review. Five broad categories of intervention were identified: dental education, motivational interviewing, dental checklist, dietary change and incentives. Despite statistically significant changes in plaque indices and oral health behaviours as a result of interventions using dental education, motivational interviewing and incentives, it is unclear if these changes are clinically significant.

CONCLUSION

Although some positive results in this review demonstrate that dental education shows promise as an intervention for those with SMI, the quality of evidence was graded as very low to moderate quality. Further research is in this area is required to provide more conclusive evidence.

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.

The perception of oral health and oral care needs, barriers and current practices as perceived by managers and caregivers in organizations for people with disabilities in Flanders, Belgium

OBJECTIVES

To assess the perception of oral health and oral care needs, barriers and current practices as perceived by managers and caregivers in organizations for people with disabilities in Flanders.

MATERIALS AND METHODS

Two questionnaires were developed, one for managers and one for caregivers. The questionnaires were distributed in all 570 organizations for people with disabilities in Flanders. The survey was carried out in February 2018.

RESULTS

Sixty-five managers completed the questionnaire and 63 of them could be linked to 57 unique organizations (10% of the contacted organizations). Managers perceived oral health to be better (P = 0.019) and mentioned less oral health needs (P = 0.049), when collaboration with a dentist was reported. When an oral health policy had been established in their organization, oral health was also perceived to be better (P = 0.048). The responses of 91 caregivers were included for analysis and 87 of them could be linked to 39 unique organizations (7% of contacted organizations). Seventy percent and 75% of the caregivers mentioned to have enough/comprehensive theoretical knowledge and practical skills, respectively, and 46% were interested in receiving oral health education. Most interest was shown in practical education and education customized to clients' needs. In organizations with an oral health project, more caregivers indicated that the organization was open to oral health questions than in organizations without such a project (97% compared with 81%; P = 0.045). When there was a collaboration with a dentist, the organization was more open to caregivers' questions (96% compared with 72%; P = 0.004) and a clear contact point was more readily available (81% compared with 48%; P = 0.004). Furthermore, caregivers were more interested to receive oral health education (P = 0.023) and mentioned to be more aware of the oral health of their clients (P = 0.015). About 23% and 30% of the caregivers indicated that guidelines were used in their organization for cleaning natural teeth and prostheses, respectively.

CONCLUSIONS

Despite the low response rate to the survey and reaching the management and caregivers of only 10% and 7% of the organizations respectively, this study indicates relevant issues to be incorporated when formulating recommendations for oral health promotion in people with disabilities in Flanders.

CLINICAL RELEVANCE

The results of this survey could affect the development of strategies and interventions to ameliorate the oral health of people with disabilities.

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.

Oral Health Needs and Experiences of Medicaid Enrollees With Serious Mental Illness

INTRODUCTION

Chronic dental diseases are among the most prevalent chronic conditions in the U.S., despite being largely preventable. Individuals with mental illness experience multiple risk factors for poor oral health and need targeted intervention. This study investigated experiences of Kansas Medicaid enrollees with serious mental illness in accessing dental services, examined their oral health risk factors, and identified oral health needs and outcomes.

METHODS

Survey data were collected from October 2016 through February 2017 from 186 individuals in Kansas with serious mental illness enrolled in Medicaid. Data were analyzed quantitatively (descriptive and bivariate statistics) and qualitatively (for major themes).

RESULTS

Despite Medicaid coverage of dental cleanings, 60.2% of respondents had not seen a dentist in the last 12 months. Reasons included out-of-pocket costs, lack of perceived need, uncertainty about coverage, difficulty accessing providers, fear of the dentist, and transportation issues. High rates of comorbid physical health conditions, including diabetes and cardiovascular disease, and current or former tobacco use were also observed.

CONCLUSIONS

Medicaid dental benefits that cover only dental cleanings and low levels of oral health knowledge create barriers to utilizing needed preventive dental care. Lack of perceived need for preventive dental services and lack of contact with dentists necessitates the development of targeted oral health promotion efforts that speak to the specific needs of this group and are disseminated in locations of frequent contact. The Medicaid population with serious mental illness would be an ideal group to target for the integration of chronic oral, physical, and mental health prevention services and control.