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Oral Health of Adults With Serious Mental Illnesses a Review

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

  • Virginia Dickson-Swift1,
  • Marking Gussy2,
  • Susan Kidd3,
  • Dianne Cox1,
  • Mohd Masood4,
  • David Azul1,
  • Carina Chan5,
  • Bradley Christian4,
  • Jacqui Theobold1,
  • Brad Hodge1,
  • Ron Knevel4,
  • Carol McKinstryi,
  • Danielle Couch1,
  • Nerida Hyett1,
  • Prabhakar Veginadu1 &
  • Nastaran Doroud1

International Journal of Mental Wellness Systems book 14, Article number:24 (2020) Cite this article

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Abstruse

Background

The increasing number of people who experience mental disorders is a global problem. People with mental disorders have loftier rates of co-morbidity and significantly poorer oral health outcomes than the full general public. Notwithstanding, their oral wellness remains largely a subconscious 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-low 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 prove 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 plan theories on causal, contextual and mechanistic factors to facilitate outcomes and (d) produce recommendations and guidelines to guide hereafter oral wellness interventions for people with mental disorders at both the policy and practice level. Using a five-pace process, that incorporates chief data collection from key stakeholders, a beginning theoretical framework will exist developed to draw contextual and mechanistic factors and how they might touch on 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 accept impacted on intervention implementation and outcomes. Quality appraisal of studies volition 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 volition exist the first review to take a realist arroyo 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 exist important in guiding policy and practice to ensure oral health interventions better encounter the needs of people with mental disorders.

Systematic review registration This review protocol is registered with PROSPERO (Number) 155969.

Introduction/groundwork

The aim of this realist systematic review [i,2,3] is to identify and synthesise studies that explore oral health interventions for people living with mental disorders. The terms mental disorder and mental illness are often used interchangeably. In this review, nosotros use the term mental disorder consistent with the language of the Globe Health Organization (WHO) [4].

Mental disorders describe a spectrum of conditions affecting people'southward thinking, behaviour, and relationships [v]. It is estimated that almost 50% of people will experience some class of mental disorder in their lifetime [half-dozen, 7]. Authors argue that mental disorders are underreported beyond most countries. In the United States (United states of america), feet and depression touch xi.48% of the total population, in the United kingdom of great britain and northern ireland (UK) 8.77%, Commonwealth of australia 11.2%, and in countries such as China rates are reported every bit 6.34%. Across the world, depression and anxiety disorders are estimated to toll US$1 trillion per year [8]. For disorders such equally schizophrenia and bipolar, prevalence rates are: US 0.98%, UK 1.35%, Australia 1.5%, and China 0.66% [9].

Mental disorders are amongst the leading causes of disability, accounting for 7.4% of global disability-adjusted life years (DALYs), and 22.7% of global years lived with inability YLDs [10]. The severity of mental disorders varies and can pb to persistent episodic symptoms that impact operation, with associated requirements for long-term care [half dozen].

People diagnosed with mental disorders experience high rates of co-morbidity [11]. Life expectancy of people diagnosed with depression prevalence mental disorders, such every bit schizophrenia, schizoaffective disorder, bipolar disorder, and delusional disorders [12] is betwixt ten and 20 years lower than the general population [eleven].

Expert oral health is integral to general health and quality of life and is a fundamental human being correct [13,14,15]. However, approximately 3.five billion people alive with untreated oral conditions [16, 17]. Lives are negatively impacted, and millions of productive hours are lost annually every bit a event of poor oral health [13, 15, 18,19,20]. People with mental disorders accept significantly poorer oral health outcomes than the general population [21,22,23]. Kisely [21] refers to a bi-directional association between oral health and mental health. Actual and predictable dental handling can lead to anxiety and dental phobia. Many mental health disorders (for case, psychotic and eating disorders) are associated with college prevalence and greater severity of dental disease, including erosion, caries, and periodontitis [21]. People hospitalised for their mental disorders have the worst oral health outcomes [24,25,26]. In that location is a lack of current studies that have explored full general amazement associated with dental treatment in people with mental disorders. Nonetheless, in the broader category of special needs, authors have highlighted increased need for full general anaesthesia associated with dental treatment and much higher anaesthetic risk associated with multiple comorbidities [27,28,29,30]. Exploration of oral health intervention studies that consider full general anaesthesia is a gap.

People experiencing mental disorders are negatively impacted by many social determinants of health including poverty, unemployment, housing insecurity, and social isolation [31, 32]. These issues are also significant risk factors/indicators for poor oral health. Poor oral health in people with mental disorders is associated with: poor dietary habits and poor nutrition, heavy consumption of sugary drinks; comorbid substance misuse of tobacco, alcohol, and/or psychostimulants and other medications; and financial, geographic, and social barriers to accessing oral healthcare [21]. People with severe mental disorders are more than susceptible to oral disease because of poor oral hygiene [26], dental phobia [27, 28], dental costs [29, thirty], difficulty in accessing health care facilities [30], and the adverse orofacial side furnishings (including bruxism and xerostomia) of anti-psychotic and anti-depressant medications [22, 33,34,35].

Poor oral wellness can contribute further to the social withdrawal, isolation, and depression cocky-esteem of those with mental disorders who are already highly vulnerable [23, 36, 37]. At that place is a close association between dental disease, coronary wellness disease, stroke, diabetes, and respiratory disease [38,39,40,41,42], weather condition that are commonly experienced by people with mental disorders [22, 40]. For this group, poor oral wellness is a critical issue merely is frequently ignored by policymakers and service providers [21, 36].

Previous systematic reviews have explored the oral wellness of people with schizophrenia and bipolar disorder [22, 36, 43, 44]. A meta-analysis by Matevosyan [36] examined the prevalence of suboptimal oral wellness in adults with severe mental illness, including poor oral hygiene, increased intake of carbonates, poor perception of oral health self-needs, duration of psychotropic treatment, and reduced access to dental care. Two consecutive systematic reviews and meta-analyses investigated the association between edentulism (missing teeth) and measures of dental caries [decayed, missing, filled teeth (DMFT) or surfaces (DMFS)], and serious mental disorders [22, 44]. The findings suggest that people with serious mental disorders face up greater likelihood (2.8 times) of losing all their teeth and significantly higher Rust-covered, Missing and Filled Teeth (DMFT) and Decayed Missing and Filled Surfaces (DMFS) scores compared to the general population. One review focused on the effects of oral wellness didactics, motivational interviewing, monitoring, and standard care on oral wellness and quality of life for people with serious mental illness [43]. The authors concluded that there was bereft evidence from the studies to recommend an intervention.

Reviews have been conducted on the oral health of people diagnosed with eating disorders [45] and demonstrated significantly higher take a chance of dental erosion caused by vomiting when compared to the full general population and meaning association betwixt dental caries and dry out mouth. Other systematic reviews past Kisely et al. [22], Cademartori et al. [46] and Baghaie et al. [47], take identified a greater burden of dental caries and periodontal affliction in populations with feet and low and substance abuse disorders.

Authors [22, 36, 43, 44] accept highlighted a lack of evidence on the effectiveness of oral health interventions for people with mental disorders. There have been calls for the training of mental wellness professionals and closer collaboration between all health professionals [48, 49]. Recommendations for further enquiry include studies focused on oral health education and promotion within mental health service settings (including inpatient and community settings) [23, 49]. While at that place are no contempo studies that have explored dental treatment [27] and general anaesthetics for people with mental illness, authors take called for preventive dental programs for vulnerable populations as a means to reduce anaesthetic risks [thirty]. A recent review by Slack-Smith and colleagues reported that barriers to expert oral health for people with mental disorders savage into three categories; individual, organizational (including wellness providers), and organization-level [23]. While these reviews are useful, no authors have produced a comprehensive synthesis of the context and mechanisms that influence oral health interventions for people with mental disorders. There is a lack of evidence-based theory to guide policy and practice. This review addresses this gap.

In this review, nosotros conceptualise poor oral health as a 'wicked problem', ane that has a meaning bear upon but has proven to be intractable [50,51,52]. Wicked problems are resistant to usual problem-solving approaches, require action past a multifariousness of stakeholders, require major behaviour modify at organisation, service and private levels, and almost 'wicked issues' are characteristic of chronic policy failure [l]. Authors agree that poor oral health for people with mental disorders must exist addressed at a systems level [23, 53, 54], rather than a reliance on more traditional approaches where the individual and the context are reduced to contained, quantifiable factors [51, 54]. By grounding this review in critical realism [i,2,3], we will extend beyond previous systematic reviews and undertake an in-depth exploration at the individual, service, and system levels, to unravel the touch of what works for whom, in what context and how [55]. This will enable an exploration of the success and failures of interventions and the many combinations of the two. This contextually bound arroyo to causality is represented as context + mechanism = outcome [1, ii].

Abayneh, Lempp, Manthorpe and Hanlon [56] draw together literature to define cardinal realist concepts and terms. Context is defined equally a configuration of factors that are non always directly connected to an intervention. These could include features of the intervention site and its location, human resources and the style they interact, and culture. Mechanisms are divers equally a 'generative force triggered in item contexts' or cognitive or emotional responses of individuals experiencing an intervention; carers, service staff, customs members, and those in the broader wellness system. They state that consideration of mechanisms is essential in moving beyond what happened, to why, for whom, and in what circumstances. The interaction between the context and the machinery, or how people respond, can be based on factors such every bit beliefs, values, preferences, and thought processes. The resultant outcomes might atomic number 82 to short, medium- or longer-term alter and can be intended or unintended [56].

We hypothesise that the contexts in which oral wellness interventions are delivered to people with mental health disorders are multi-faceted and dynamic and that interventions rarely piece of work in the aforementioned manner within different contexts. Realist systematic reviews are interpretive, and theory driven. Traditional systematic reviews have focused on intervention or program effectiveness. Yet, in most cases, there is little indication of how the program or intervention worked, what contributed to the success, or the barriers and challenges in implementation. Few reviews explore how the context, circumstances and stakeholders influence outcomes [ane]. Realist systematic reviews explore the interconnectedness between context, machinery, and outcomes (CMO) [55, 57, 58]. From this review, we volition develop all-encompassing understandings well-nigh oral health interventions for people with mental disorders. The developed theory will guide policy and practice.

Aim and review questions

The aim of this realist systematic review is to (a) identify and synthesise studies that explore oral health interventions for people living with mental disorders; (b) explore the context and mechanisms that take 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 hereafter oral health interventions for people with mental disorders at both the policy and practise level [57]. The DSM-5 Diagnostic Classification has been used to guide the disorders that will be considered [59]. The following review questions volition exist answered:

  1. 1

    What are the contextual factors at the local, service, and arrangement level that impact on the success or failure of oral health interventions for people with mental disorders?

  2. 2

    What are the mechanisms that have led to success or failure?

  3. 3

    Are there contextual and mechanistic factors that are consistent across studies of oral health interventions for people with mental disorders?

  4. 4

    What causal theories can describe the impact of these contextual and mechanistic factors, and how might they influence policy and practice?

This review protocol is registered with PROSPERO (Number) 155969.

Methods

The methods used in this review are novel simply aligned to the theory-driven arroyo that underpins the realist systematic review method [56, sixty]. While the approach is based on the five-step process of Pawson et al. [ane]: clarifying scope, searching for evidence, appraising primary studies and extracting data, synthesising evidence and cartoon conclusions, and disseminating, implementing and evaluating, we strengthen the review through integrated primary data drove. A cardinal feature of realist systematic reviews is the input of stakeholders throughout the review to back up theory generation, noesis translation, and bear upon [1, 58]. Cooper and colleagues [61] used this combination of primary (stakeholder input) and secondary (literature searching and synthesis) data in their review of circuitous interventions to forbid adolescents from engaging in multiple risk behaviours. They argued that the incorporation of chief information in their review gave greater insights into causal factors that might not exist identified within the literature and, importantly, provided opportunities for adolescents to have a strong phonation in theory development. In this review, we will draw on our extensive experience of working with policymakers, commissioners, service providers, and people with mental disorders [62,63,64] and our use of innovative methods of data collection, including the use of blogs [65]. Internationally, health policymakers confirm the need for greater public participation in inquiry [66] and mental health consumers in all stages of service pattern, implementation, and evaluation [62, 67, 68]. The approach volition exist multifaceted, flexible, and iterative and will involve triangulation of findings across the entire review.

Clarifying scope

The review team is multidisciplinary (oral health and dentistry, nursing, public health, psychology, folklore, mental health, social work, and allied wellness) to capture a multitude of perspectives in the initial development of the review. Pawson and colleagues [one, 58] confirm the need to 'scavenge' ideas in this phase to develop an initial theoretical framework. An initial search of the literature volition be undertaken to map out showtime theories of how and why oral health interventions for people with mental disorders might work. We volition accept a local and global approach to stakeholder involvement. A state-wide, Australian stakeholder forum (policymakers, commissioners, service providers, consumer acme bodies, mental health consumers, carers and other interested parties) volition be held to consider our initial scoping work and provide good input into a beginning theoretical framework. This framework will draw contextual and mechanistic factors that might touch on the success or failure of oral health interventions for people with mental disorders. We will advertise this forum widely through existing professional and consumer networks, print, and social media. To facilitate nationally and international input, an open-access weblog will be used to firm the start theoretical framework, and we will drive input into this framework via social media. The weblog will link to a website where findings will be regularly updated. Broad input volition be an important component of our integrated knowledge translation approach. Integrated knowledge translation is defined equally a process of engagement between researchers and noesis users (those who will make use of enquiry findings to inform decisions) [69, 70]. This arroyo to cognition translation supports rapid societal impact, a fundamental direction in international inquiry policy [71, 72].

Phase two searching for show

Using the expertise of the enquiry squad a number of primal concepts to guide the search were developed. Table ane outlines the primal concepts that volition be used in the search.

Table 1 Primal concepts for search

Full size table

With the support of a specialist healthcare librarian, detailed search strategies volition be developed for each database [Medline Ovid, Embase Ovid, PsycINFO, Academic Search Complete, CINAHL EBSCO, Cochrane Oral Health Trials Register, Cochrane Key Register of Controlled Trials (CENTRAL) based on the ane developed for MEDLINE (Ovid) [see Table two]. MeSH terms will guide the search. Search terms will include truncation or keywords, the use of thesaurus terms and subject area headings, and combining terms and search strings with the appropriate Boolean operators.

Table 2 Example search for medline

Full size table

Written report designs

In line with the purpose of a realist systematic review [73], quantitative, qualitative, and mixed-method studies will exist included. There are no data range limitations. Included studies must be published in English, reflecting the significant resources implications associated with translation [74].

Participants and setting

Reviewed studies can include participants diagnosed with whatsoever mental health disorder. Studies tin can be carried out in any setting (including inpatient and community settings) and can be in whatever geographical location.

Interventions

The review will include whatsoever interventions designed to accost oral wellness outcomes in people with mental disorders. Content of the interventions could include some or all of the following: dental and oral health, oral affliction and impact on health, general anaesthesia associated with dental treatment, dietary interventions related to improving oral wellness, oral hygiene measures, best oral health practices for people with mental health disorders, oral hygiene promotion and skills training (for people with mental health disorders or those who intendance for them in both inpatient and customs settings).

Screening of studies

The screening process will be conducted in four phases: (ane) title and abstract, (2) full text, (3) search of the reference lists and (iv) search of citations of all included studies for any further suitable studies. This phased approach aims to capture a breadth of studies.

Table 3 outlines the inclusion and exclusion criteria that will guide the review.

Table three Inclusion and exclusion criteria

Full size tabular array

Endnote (bibliographic software programme) and Covidence (Cochrane's systematic review management software) will be used to manage search results. A sample of 25 articles will be assessed by all reviewers to ensure reliability in the application of the inclusion and exclusion criteria. Discussion volition occur to ensure that the team are applying criteria in the same style. Covidence software supports a blind review process, and at each stage, at least two reviewers will screen articles. Conflicts are highlighted by the software and discrepancies will be discussed until consensus is reached. To ensure inclusion of all relevant studies, the reference lists of all studies captured as a event of phases one and 2 volition be examined manually, and Web of Science/Scopus will be used to identify citations of all included full-text articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses, (PRISMA) [75] checklist volition be used to guide the review, and all stages of the study option will be documented using a PRISMA menstruation chart [75].

Data extraction

To address the review questions, data volition be extracted on population, study design, intervention, and outcomes. Consistent with realist review methods and the enquiry questions, information extraction will include the contextual factors at local through to organization level, that impact on the success or failure of oral health interventions for people with mental disorders and the mechanisms that have led to success or failure. A minimum of 2 reviewers will bank check data extraction tables, and disagreements will be discussed until consensus is reached. As data is extracted, the beginning theoretical framework from stage 1 volition exist populated with evidence and shared, using the website and blog.

Quality appraisal

Every bit the aim of realist systematic reviews is to identify the coaction betwixt context, machinery, and outcome [56], no studies will exist excluded based on methodological quality. Three tools will be utilised to assess studies depending on report design: the Cochrane Collaboration Tool for Assessing Risk of Bias in Randomised Trials [76] and the Hazard of Bias in Non-Randomised Studies of Interventions (ROBINS-I) [77] for quantitative studies and the Critical Appraisal Skills Programme (CASP) Checklist for Qualitative Research [78]. A minimum of 2 reviewers volition assess all studies and disagreements between authors volition be resolved through team discussion. Quality appraisal results will be presented in a single table.

Data assay

Data synthesis in realist reviews is guided by the RAMESES Standards [2, 79], which comprises a combination of inductive and deductive belittling processes directed at further building an explanatory theory nearly the context, mechanism, outcome (CMO) relationships of the interventions under investigation. Two reviewers will independently code data segments representing the CMO in each reviewed article. The research team will produce a narrative synthesis that draws upon Pawson'due south [55] techniques: 'juxtaposing' sources to enable broader insights, 'reconciling' dissimilar outcomes within different contexts, 'adjudicating' between studies on the basis of methodological strengths and weaknesses, 'consolidation' of explanations of differences between studies, and 'situating' studies in their contexts. The overall aim volition exist to identify contextual and mechanistic factors that are consequent across studies of oral health interventions for people with mental disorders.

Broadcasting, implementation, and evaluation

An boosted state-broad, stakeholder forum volition exist conducted to refine and confirm the causal theory on the touch on of contextual and mechanistic factors. Give-and-take volition occur on how the theory might influence policy and further development and implementation of interventions. As in the first phase phase, the findings from this forum will be shared via the website and blog for further input.

An integrated knowledge translation (iKT) [69, 70] arroyo will exist adopted throughout this review. To increase the relevance, applicability and impact of the review, key stakeholder participation will exist widely utilized. In addition to traditional academic methods of dissemination such equally publications and conference presentations, other communication modes volition be used, including infographics, blogs, social media postings, webinars, and podcasts.

Strengths and challenges

Previous systematic reviews on the oral wellness of people with mental disorders take focused mainly on oral wellness risks, barriers for oral health, and the effectiveness of interventions. Taking a realist review approach will add together significantly to the knowledge base as context and mechanism will be considered. The work of Abayneh et al. [56], provides a skillful guide to differentiating betwixt context and mechanism, and we volition describe on their processes to ensure team consistency in how central terms and concepts are applied. Team word and codebooks will exist used to document decisions. Nosotros acknowledge the challenges of reproducing a realistic systematic review because of the approaches taken [80]. Past detailing each step and documenting and tabulating summary tables of what is found, we volition clearly bespeak how conclusions were made.

Discussion and conclusion

This volition be the start review to take a realist approach to explore the contextual and mechanistic factors from private, service, and system-level that impact on the success or failure of oral health interventions for people with mental disorders. We will identify factors that are consequent across studies to develop a theory on how the pattern and implementation of oral health interventions might improve meet the needs of the rise number of people with mental disorders.

The novel approach to active stakeholder engagement advances realist systematic review methodology. Through extensive local, national, and international stakeholder appointment, we will gain greater insights into causal factors that might be missed with a more conventional systematic review. Engaging stakeholders in this early stage is also critical for future dissemination and implementation of bear witness. Our approach will ensure that people with lived feel of mental disorders are provided with opportunities to inform the design and development of future oral wellness interventions.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

WHO:

Globe Health Arrangement

DALYs:

Disability-adapted life years

YLDs:

Years lived with disability

DMFT:

Decayed, missing or filled teeth

DMFS:

Decayed, missing or filled surfaces

CMO:

Context, mechanism, upshot

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

RAMESES:

Realist and meta-narrative bear witness syntheses: evolving standards

ROBINS-I:

Risk of bias in non-randomised studies of interventions

CASP:

Critical appraisal skills program

iKT:

Integrated cognition translation

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Acknowledgements

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Affiliations

  1. Violet Vines Marshman Centre for Rural Health Research, LaTrobe Rural Health School, P.O. Box 199, Bendigo, VIC, 3552, Commonwealth of australia

    Amanda Kenny, Virginia Dickson-Swift, Dianne Cox, David Azul, Jacqui Theobold, Brad Hodge, Carol McKinstry, Danielle Couch, Nerida Hyett, Prabhakar Veginadu & Nastaran Doroud

  2. College of Social Scientific discipline University of Lincoln, Brayford Pool, Lincoln, Lincolnshire, LN6 7TS, Uk

    Mark Gussy

  3. Mental Health Nursing, Mental Wellness Nurse Practitioner, Victoria University, Footscray, VIC, Australia

    Susan Kidd

  4. LaTrobe Rural Health School, Health School, Dentistry and Oral Health, P.O. Box 199, Bendigo, VIC, 3552, Australia

    Mohd Masood, Bradley Christian & Ron Knevel

  5. School of Psychology and Public Health, LaTrobe Academy, Bendigo, Commonwealth of australia

    Carina Chan

Contributions

AK, VD and MG conceptualised the report protocol and all authors (AK, VD, MG, SK, DC, MM, DA, CC, BC, JT, BH, RK, CMC, DC, NH, PV and ND) contributed to the development, writing and reviewing of the protocol certificate. All authors read and approved the concluding manuscript.

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Correspondence to Virginia Dickson-Swift.

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Kenny, A., Dickson-Swift, V., Gussy, 1000. et al. Oral health interventions for people living with mental disorders: protocol for a realist systematic review. Int J Ment Health Syst fourteen, 24 (2020). https://doi.org/x.1186/s13033-020-00357-8

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Keywords

  • Mental disorder
  • Oral health
  • Realist systematic review

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