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

Oral health knowledge, attitudes, and practices of people living with mental illness: a mixed-methods systematic review

People living with mental illness experience poorer oral health outcomes compared to the general population, yet little is known about their oral health knowledge, attitudes, and practices. The aim of this mixed-methods systematic review was to synthesise evidence regarding oral health knowledge, attitudes, and practices of people living with mental illness to inform preventative strategies and interventions. Database searches were conducted in PubMed, MEDLINE, PsycINFO, CINAHL, ProQuest, and Scopus with no limitations placed on the year of study. All studies available in the English language, that explored the oral health knowledge, attitudes, and/or practices of people with a mental illness were included. Articles were excluded if they primarily pertained to intellectual disability, behavioural and psychological symptoms of dementia, drug and alcohol or substance use, or eating disorders. A thematic synthesis was undertaken of 36 studies (26 high-moderate quality), resulting in 3 themes and 9 sub-themes. Study participants ranged from n = 7 to n = 1095 and aged between 15-83 years with most having a diagnosis of schizophrenia, schizoaffective, or bipolar affective disorder. People diagnosed with a mental illness were found to have limited oral health knowledge, particularly regarding the effects of psychotropic medication. Various barriers to oral health care were identified, including high dental costs, the negative impact of mental illness, dental fears, lack of priority, and poor communication with dental and health care providers. Study participants often displayed a reduced frequency of tooth brushing and dental visits. The findings highlight the potential for mental health care providers, oral health and dental professionals, mental health consumers, and carers to work together more closely to improve oral health outcomes for people with mental illness. The systematic review protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO), (registration ID CRD42022352122).

Developing a Consensus Statement to Target Oral Health Inequalities in People With Severe Mental Illness

INTRODUCTION

Oral diseases are more prevalent in people with severe mental illness (SMI) compared to those without mental illnees. A greater focus on oral health is needed to reverse unacceptable but often neglected oral health inequality in people with SMI. This provided the impetus for developing 'The Right to Smile' consensus statement. We aimed to develop and disseminate a consensus statement to address oral health inequality, highlighting the main areas for concern and recommending an evidence-based 5-year action plan to improve oral health in people with SMI.

METHODS

The Right to Smile consensus statement was developed by experts from several professional disciplines and practice settings (mental, dental and public health) and people with lived experience, including carers. Stakeholders participated in a series of online workshops to develop a rights-based consensus statement. Subsequent dissemination activities were conducted to maximise its reach and impact.

RESULTS

The consensus statement was developed to focus on how oral health inequalities could be addressed through a set of 5-year improvement targets for practice, policy and training. The consensus was reached on three 5-year action plans: 'Any assessment of physical health in people experiencing SMI must include consideration of oral health', 'Access to dental services for people with SMI needs to improve' and 'The importance of oral health for people experiencing SMI should be recognised in healthcare training, systems, and structures'.

CONCLUSION

This consensus statement urges researchers, services and policymakers to embrace a 5-year action plan to improve oral health for people with SMI.

PATIENT OR PUBLIC CONTRIBUTION

The team included people with lived experience of SMI, their carers/family members and mental and dental health service providers. They were involved in every stage of developing the consensus statement, from conception to development and dissemination.

Oral health in home care: Perspectives and experiences of dentists in a Brazilian region

INTRODUCTION

Home care provided by dentists is crucial for ensuring adequate oral care. However, oral health professionals face challenges in delivering treatment at patients' residences due to a lack of resources. Our objective was to explore dentists' perspectives and experiences of dental home care and potential challenges for its implementation.

METHODS

The study took a qualitative approach. Guided by a semi-structured interview schedule, data were gathered using recorded interviews with 22 dental professionals. After transcription, data were analysed thematically using the Discourse of the Collective Subject (DCS) method, using Qualiquantisoft.

RESULTS

The majority of participants were female (n = 20), aged between 30 and 40 years old, and predominantly specialising in primary care (n = 6) or endodontics (n = 6). All participants provided home care, performing general dental procedures, normally responding to requests from the work team (n = 13) or family (n = 7). Six main categories on to the topic emerged: importance and access to home care, procedures performed during home visits, discussions about post-home care, professional competence and patient-centred care, positive aspects of home care, and negative aspects and challenges faced in this type of care.

CONCLUSION

This study highlights the fundamental, yet complex, role of home care in dentistry. Continuity of treatment through adaptability and a patient-centred approach are important.

Prevalence, socio-economic, and associated risk factors of oral cavity parasites in children with intellectual disability from Lorestan province, Iran

Introduction

Children with intellectual disability (ID) often face challenges in maintaining proper oral hygiene due to their motor, sensory, and intellectual impairments, which can lead to compromised oral health; therefore, there is a need to enhance the oral health status of these populations and establish an effective system for administering preventive interventions. Here, we aimed to evaluate the prevalence of Entamoeba gingivalis and Trichomonas tenax among children with ID in Lorestan province, in Western Iran through parasitological and molecular methods.

Methods

The current descriptive investigation involved 215 in children with ID and 215 healthy children (non-ID) who were referred to health facilities in Lorestan province, Iran between October 2022 and March 2024. The prevalence of protozoa in the oral cavity was found through the utilization of both microscopic analysis and conventional polymerase chain reaction (PCR) techniques.

Results

The total prevalence of the E. gingivalis and T. tenax in children with ID was found to be 87 (40.5%) and 92 (42.8%) through microscopic and PCR methods, respectively. Among the positive samples, 57 (61.9%) and 35 (38.1%) children tested positive for E. gingivalis and T. tenax, respectively. In contrast, among the 215 non-ID children in the control group, 39 (18.1%) and 42 (19.5%) tested positive by microscopic and PCR methods, respectively. Among positive samples in non-ID children, 23 (54.7%) and 19 (45.3%) children were positive for E. gingivalis and T. tenax, respectively. Multiple logistic regression analysis indicated that residing in urban areas, parental education, monthly family income, and tooth brushing p<0.001) were identified as independent risk factors for oral cavity parasites.

Conclusion

This study identified a notable prevalence of oral cavity parasites in children with ID in Lorestan province, Western Iran. It is imperative to recognize the primary risk factors associated with these parasites, particularly inadequate teeth brushing, in order to enhance public and oral health strategies for children with ID. Therefore, pediatric dental professionals should remain vigilant regarding these risk factors to effectively recognize and address oral health issues in this population, thereby mitigating the occurrence of oral diseases and infections.

Exploring the determinants of oral health care uptake among women with gestational diabetes mellitus: A qualitative study to develop a logic model and framework for an oral health intervention

INTRODUCTION

Gestational diabetes mellitus (GDM) is a condition of glucose intolerance in pregnancy. Oral health has been shown to mediate blood glucose management and pregnancy outcomes. There is also a greater prevalence of poor oral health in GDM pregnancies when compared to normoglycemic pregnancies. While current guidelines recommend an oral health review as part of diabetes and pregnancy management, it is under-considered in GDM care. Hence, it is important to understand how to improve oral health care in this context.

AIM

To explore the determinants of oral health care uptake among women with GDM to develop a logic model for an intervention to improve awareness and activation of oral health behaviours in this population.

METHODS

Semi-structured interviews were used to collect the data and the Theoretical Domains Framework inspired the interview guide. The study population consisted of UK-based women with GDM over 18 years of age. The data were analysed with Framework Analysis and the COM-B Model was used to orientate the data.

RESULTS

Seventeen women participated in the study. Five themes including knowledge about oral health; the health of the baby; the impact of the GDM diagnosis; social support and barriers and facilitators were found to influence the uptake of oral health care.

CONCLUSIONS

This study developed an evidence-based logic model of the determinants of oral health care uptake among women with GDM. This will serve as a framework for developing an oral health intervention. This study may be the starting point for initiating conversations about implementing oral health care in GDM management.

Shaping research for people living with co-existing mental and physical health conditions: A research priority setting initiative from the United Kingdom

INTRODUCTION

Those with severe and enduring mental ill health are at greater risk of long-term physical health conditions and have a reduced life expectancy as a result. Multiple factors compound this health inequality, and the need for setting research priorities in this area is highlighted with physical and mental healthcare services being separate, and limited multimorbidity research.

METHODS

The aim of this exercise was to work in partnership with healthcare professionals and carers, family, friends and individuals with lived experience of both mental and physical health conditions, to set research priorities to help people with mental health conditions to look after their physical health. The exercise was guided by the James Lind Alliance approach. For this, a steering group was set up, two surveys were completed and a final priority workshop was conducted.

RESULTS

This priority setting exercise guided by people's needs and lived experience has produced a set of well-defined research topics. Initially, 555 research questions were suggested in the first survey, which were refined to 54 questions for the second survey. A priority setting workshop was then conducted to get the final 10 priorities.

CONCLUSIONS

Taking these topics forward to improve services and treatment for both mental and physical ill health may in turn improve physical health and lessen the reduced life expectancy of those living with mental ill health.

PATIENT OR PUBLIC CONTRIBUTION

This work was completed in collaboration with people who have lived experience of mental ill health and physical health conditions, as well as carers, family and friends. Their contribution has been significant for this work from piloting surveys, amending language used and educating the researchers and contributing to this paper. The initial work was completed with a steering group and continued with surveys and workshops.

A two-arm, randomised feasibility trial using link workers to improve dental visiting in people with severe mental illness: a protocol paper

BACKGROUND

People with severe mental illness (e.g. psychosis, bipolar disorder) experience poor oral health compared to the general population as shown by more decayed, missing and filled teeth and a higher prevalence of periodontal disease. Attending dental services allows treatment of oral health problems and support for prevention. However, people with severe mental illness face multiple barriers to attending routine dental appointments and often struggle to access care. Link work interventions use non-clinical support staff to afford vulnerable populations the capacity, opportunity, and motivation to navigate use of services. The authors have co-developed with service users a link work intervention for supporting people with severe mental illness to access routine dental appointments. The Mouth Matters in Mental Health Study aims to explore the feasibility and acceptability of this intervention within the context of a feasibility randomised controlled trial (RCT) measuring outcomes related to the recruitment of participants, completion of assessments, and adherence to the intervention. The trial will closely monitor the safety of the intervention and trial procedures.

METHODS

A feasibility RCT with 1:1 allocation to two arms: treatment as usual (control) or treatment as usual plus a link work intervention (treatment). The intervention consists of six sessions with a link worker over 9 months. Participants will be adults with severe mental illness receiving clinical input from secondary care mental health service and who have not attended a planned dental appointment in the past 3 years. Assessments will take place at baseline and after 9 months. The target recruitment total is 84 participants from across three NHS Trusts. A subset of participants and key stakeholders will complete qualitative interviews to explore the acceptability of the intervention and trial procedures.

DISCUSSION

The link work intervention aims to improve dental access and reduce oral health inequalities in people with severe mental illness. There is a dearth of research relating to interventions that attempt to improve oral health outcomes in people with mental illness and the collected feasibility data will offer insights into this important area.

TRIAL REGISTRATION

The trial was preregistered on ISRCTN (ISRCTN13650779) and ClinicalTrials.gov (NCT05545228).

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.

Management of Dental Patients With Mental Health Problems in Special Care Dentistry: A Practical Algorithm

Introduction Individuals with mental health problems have poor oral health affecting their quality of life with an increased burden on their well-being. Dentists find treating them challenging due to a lack of training and awareness in modifications of dental care delivery in special needs patients. Also, polypharmacy is common in psychiatric care, further complicating dental care while prescribing routine medications as potential drug interactions must be considered.  Methods Due to a lack of clinical practice guidelines in the literature and the absence of guidelines issued by dental governing bodies, we attempted to consolidate the existing challenges and propose a model for managing psychiatric special needs patients. Results and discussion Based on the current evidence, we hereby recommend 'psychiatric dental consultation liaison' (PDCL) services as the acceptable framework for the management of dental patients with mental health problems in special care dentistry. Conclusion PDCL services will favour both dentists and patients as it includes psychiatric consultation and interventions that will result in the positive execution of comprehensive dental treatment care.

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.