The dental health of people with schizophrenia

Immediate implant placement for schizophrenic patient with outpatient general anesthesia

The difficult oral healthcare in intellectually disabled patients with poor behavioral control has led to debate over the cost-effectiveness and validity of implant treatment in these patients. The patient in the present report had schizophrenia that had led to poor oral care and severe dental caries in the full mouth. Tooth extraction and a removable prosthesis were planned, but the guardian wanted an implant procedure. Since the guardian showed strong will and cooperation with regard to the patient's oral healthcare, extraction followed by immediate implant placement was performed across two rounds of general anesthesia. Since the outcome appears successful, we present this case report. Immediate implant placement after tooth extraction requires fewer surgeries and rounds of general anesthesia, reduces horizontal bone resorption, and can achieve better esthetic results. Therefore, as long as a certain degree of oral care is possible, this can be a positive option for restoration of a partially edentulous mouth, even in intellectually disabled patients.

Promoting physical health for people with schizophrenia by reducing disparities in medical and dental care

OBJECTIVE

Acquiring a diagnosis of schizophrenia reduces life expectancy for many reasons including poverty, difficulties in communication, side-effects of medication and access to care. This mortality gap is driven by natural deaths; cardiovascular disease is a major cause, but outcomes for people with severe mental illness are worse for many physical health conditions, including cancer, fractures and complications of surgery. We set out to examine the literature on disparities in medical and dental care experienced by people with schizophrenia and suggest possible approaches to improving health.

METHOD

This narrative review used a targeted literature search to identify the literature on physical health disparities in schizophrenia.

RESULTS

There is evidence of inequitable access to and/or uptake of physical and dental health care by those with schizophrenia.

CONCLUSION

The goal was to reduce the mortality gap through equity of access to all levels of health care, including acute care, long-term condition management, preventative medicine and health promotion. We suggest solutions to promote health, wellbeing and longevity in this population, prioritising identification of and intervention for risk factors for premature morbidity and mortality. Shared approaches are vital, while joint education of clinicians will help break down the artificial mind-body divide.

Oral health in adults with serious mental illness: needs for and perspectives on care

This study used qualitative methods to investigate barriers to and facilitators of oral health care among 25 adult community mental health outpatients with serious mental illness (SMI). Participants completed 30- to 60-min, semi-structured interviews that were recorded and transcribed. Qualitative analysis was used to characterize common themes. Results showed that lack of awareness of dental problems, poverty, and dental care access were key barriers to oral health care. When oral health care was accessed, fear of stigma was associated with missed opportunities to educate about the intersection of mental and oral health. Community mental health providers were viewed as trusted and important sources of advocacy and support for obtaining oral health care when needed. Oral health may be improved for persons with SMI by implementing education in points of frequent service contact, such as community mental health.

Access to dental care and dental ill-health of people with serious mental illness: views of nurses working in mental health settings in Australia

People with serious mental illness experience higher rates of oral and dental health problems than the wider population. Little is known about how dental health is viewed or addressed by nurses working with mental health consumers. This paper presents the views of nurses regarding the nature and severity of dental health problems of consumers with serious mental illness, and how often they provide advice on dental health. Mental health sector nurses (n = 643) completed an online survey, including questions on dental and oral health issues of people with serious mental illness. The majority of nurses considered the oral and dental conditions of people with serious mental illness to be worse than the wider community. When compared with a range of significant physical health issues (e.g. cardiovascular disease), many nurses emphasised that dental and oral problems are one of the most salient health issues facing people with serious mental illness, their level of access to dental care services is severely inadequate and they suffer significantly worse dental health outcomes as a result. This study highlights the need for reforms to increase access to dental and oral health care for mental health consumers.

A systematic review and meta-analysis of the association between poor oral health and severe mental illness

BACKGROUND

Psychiatric patients have increased comorbid physical illness. There is less information, however, on dental disease, especially tooth decay, despite life-style risk factors or psychotropic-induced dry mouth in this population. Importantly, poor oral health can predispose people to chronic physical disease leading to avoidable admissions to hospital for medical causes.

METHODS

Using MEDLINE, PsycInfo, EMBASE, and article bibliographies, we undertook a systematic search for studies from the last 25 years regarding the oral health of people with severe mental illness (SMI). Results were compared with the general population. The two outcomes were total tooth loss (edentulism) and dental decay measured through the following standardized measures: the mean number of decayed, missing, and filled teeth or surfaces.

RESULTS

We identified 25 studies that had sufficient data for a random-effects meta-analysis. These covered 5076 psychiatric patients and 39,545 controls, the latter from either the same study or community surveys. People with SMI had 2.8 the odds of having lost all their teeth compared with the general community (95% confidence interval [CI] = 1.7-4.6). They also had significantly higher decayed, missing, and filled teeth (mean difference = 5.0, 95% CI = 2.5-7.4) and surfaces scores (mean difference = 14.6, 95% CI = 4.1-25.1).

CONCLUSION

The increased focus on the physical health of people with SMI should encompass oral health. Possible interventions could include oral health assessment conducted using standard checklists that can be completed by non-dental personnel, help with oral hygiene, management of iatrogenic dry mouth, and early dental referral.

Mental health nursing and physical health care: a cross-sectional study of nurses' attitudes, practice, and perceived training needs for the physical health care of people with severe mental illness

Mental health nurses have a key role in improving the physical health of people with a serious mental illness, however, there have been few studies of their attitudes or the extent of their involvement in this work. The aim of this study was to examine mental health nurses' attitudes to physical health care and explore associations with their practice and training. A postal questionnaire survey including the Physical Health Attitude Scale for mental health nurses (PHASe) was used within a UK mental health trust. The 52% (n = 585) of staff who responded reported varying levels of physical health practice; this most frequently involved providing dietary and exercise advice and less frequently included advice regarding cancer screening and smoking cessation. Having received post-registration physical health-care training and working in inpatient settings was associated with greater reported involvement. More positive attitudes were also evident for nurses who had attended post-registration physical health training or had an additional adult/general nursing qualification. Overall, the attitudes of mental health nurses towards physical health care appear positive and the willingness of nurses to take on these roles needs to be recognized. However, there are areas where nurses in our sample were more ambivalent such as cancer screening and smoking cessation.

An oral health intervention for people with serious mental illness (Three Shires Early Intervention Dental Trial): study protocol for a randomised controlled trial

Background

Oral health is an important part of general physical health and is essential for self-esteem, self-confidence and overall quality of life. There is a well-established link between mental illness and poor oral health. Oral health problems are not generally well recognized by mental health professionals and many patients experience barriers to treatment.

Methods/Design

This is the protocol for a pragmatic cluster randomised trial that has been designed to fit within standard care. Dental awareness training for care co-ordinators plus a dental checklist for service users in addition to standard care will be compared with standard care alone for people with mental illness. The checklist consists of questions about service users’ current oral health routine and condition. Ten Early Intervention in Psychosis (EIP) teams in Nottinghamshire, Derbyshire and Lincolnshire will be cluster randomised (five to intervention and five to standard care) in blocks accounting for location and size of caseload. The oral health of the service users will be monitored for one year after randomisation.

Trial registration

Current Controlled Trials ISRCTN63382258.

Dental conditions in inpatients with schizophrenia: a large-scale multi-site survey

BACKGROUND

Clinical relevance of dental caries is often underestimated in patients with schizophrenia. The objective of this study was to examine dental caries and to identify clinical and demographic variables associated with poor dental condition in patients with schizophrenia.

METHODS

Inpatients with schizophrenia received a visual oral examination of their dental caries, using the decayed-missing-filled teeth (DMFT) index. This study was conducted in multiple sites in Japan, between October and December, 2010. A univariate general linear model was used to examine the effects of the following variables on the DMFT score: age, sex, smoking status, daily intake of sweets, dry mouth, frequency of daily tooth brushing, tremor, the Clinical Global Impression-Schizophrenia Overall severity score, and the Cumulative Illness Rating Scale for Geriatrics score.

RESULTS

523 patients were included in this study (mean ± SD age = 55.6 ± 13.4 years; 297 men). A univariate general linear model showed significant effects of age group, smoking, frequency of daily tooth brushing, and tremor (all p's < 0.001) on the DMFT score (Corrected Model: F(23, 483) = 3.55, p < 0.001, R2 = 0.42) . In other words, older age, smoking, tremor burden, and less frequent tooth brushing were associated with a greater DMFT score.

CONCLUSIONS

Given that poor dental condition has been related with an increased risk of physical co-morbidities, physicians should be aware of patients' dental status, especially for aged smoking patients with schizophrenia. Furthermore, for schizophrenia patients who do not regularly brush their teeth or who exhibit tremor, it may be advisable for caregivers to encourage and help them to perform tooth brushing more frequently.

Provision of preventive services for cancer and infectious diseases among individuals with serious mental illness

Individuals living with serious mental illness (SMI) have increased mortality chiefly because of a higher prevalence of chronic disorders, including some cancers and infectious diseases. Although increased prevalence of these disorders may be attributable to lifestyle and risk behaviors, there is evidence that they may not be appropriately addressed by health professionals. We conducted a review of the literature describing preventive services for cancer and infectious diseases provided to individuals with SMI. Most studies demonstrated a 20%-30% reduced likelihood of breast, cervical, and colorectal cancer screening, or immunizations for influenza and pneumonia, in patients with SMI compared with those without SMI. This is most common in those with the most severe forms of SMI. HIV and hepatitis were more commonly screened for in people with SMI than the general population, likely because of the increased risk for these disorders within this group, but there were still substantial proportions of individuals with SMI who had never received a screening, or had not received a recent screening, for these disorders. The mental health nursing profession has an opportunity to address the disparity in care for cancer and infectious diseases, as well as other physical disorders, experienced by mental health consumers. With systemic support and ongoing education, mental health nurses may be capable of conducting or recommending screening for disorders and providing lifestyle advice. These practices may help to reduce the increased prevalence of chronic disease in SMI populations.

An assessment of periodontal health in patients with schizophrenia and taking antipsychotic medication

BACKGROUND AND OBJECTIVE

Severe periodontal disease is prevalent among patients with schizophrenia and is caused by the side effect of their medication, poor dental hygiene and smoking. The objective of this study was to evaluate whether the rate of periodontal disease could be modulated by changing the salivary flow rate (SFR) because of the use of antipsychotic medications in patients with schizophrenia.

METHODS

Group A (n=33) included patients who used medications that may cause xerostomia, or dry mouth and Group B (n=20) included patients who used medications that may cause sialorrhea, an excessive secretion of saliva. The participants' periodontal status was assessed using the plaque index (PI), assessing bleeding on probing (BoP), probing pocket depth (PPD) and clinical attachment levels (CAL).

RESULTS

The mean of PI and BoP was significantly higher in Group A than in Group B (P<0.001), but the PPD, CAL and decayed, missing and filled teeth (DMFT) scores were not significantly different in the two groups according to the statistical results (P>0.05).

CONCLUSIONS

The researcher concluded that there is a high risk of periodontal disease among patients with schizophrenia, and there is an even higher risk of periodontal disease induced by medication that increased SFR. Preventive dental protocol should be increased during the dental health care of this disadvantaged patient group.

Contribution of orodental status to the intensity of orofacial tardive dyskinesia: an interdisciplinary and video-based assessment

BACKGROUND

Tardive dyskinesia (TD) is a neurological motor complication eventually arising in one-third of patients chronically exposed to antipsychotic drugs. Some orodental peripheral factors have been reported to influence TD.

OBJECTIVE

To measure orodental factors such as temporomandibular joint function, static occlusal contacts, and denture condition, and attempt correlations with orofacial TD intensity.

METHODS

In this exploratory cross-sectional pilot study, 31 subjects between 30 and 75 years of age were divided in two groups displaying minimal to mild, or moderate to severe orofacial TD, respectively, and underwent a detailed oral, dental, and prosthetic evaluation to capture various aspects of oral health compared between the two groups. Blinded video-based TD ratings along a validated scale were obtained to compare dentulous and edentulous subjects, and contrast TD intensity in complete denture wearers with and without their own prostheses.

RESULTS

None of the factors examined tightly correlated with orofacial TD intensity. However, edentulism was associated with a higher median orofacial TD rating compared to the dentulous group (p = 0.001). Further, a significant intra-subject difference was observed in the edentulous subjects rated with their own complete dentures in place or not (p = 0.028), the dentures attenuating the mean orofacial ratings by 21.8 ± 7.3%.

CONCLUSION

Of all orodental factors considered, only edentulism and complete denture wearing influenced oral TD expression, calling for the close monitoring of the dental status in antipsychotic drug-exposed patients to prevent tooth loss. Further studies to measure the impact of an adequate prosthodontic rehabilitation in edentulous subjects with orofacial TD seem warranted.

Oral health and the symptoms of schizophrenia

The objectives of this study were to evaluate the oral health of a group of schizophrenic outpatients and a control group without psychiatric illness. The study also aimed to assess the influence of positive and negative symptomatology on oral health among outpatients with schizophrenia. The DMF-T Index (sum of decayed, missing and filled teeth) and the Community Periodontal Index of Treatment Needs (CPITN) were assessed in both groups. We evaluated the psychopathological state of the patient group using the Positive and Negative Syndrome Scale (PANSS). The schizophrenic patients had higher scores than the control group with respect to decayed teeth (4.39 vs. 0.72), missing teeth (5.66 vs. 1.50), the DMF-T index (13.51 vs. 7.8) and CPITN (2.32 vs. 1.04); and lower scores for filled teeth (3.53 vs. 5.54). The PANSS negative subscale score correlated positively with the oral health variables studied, whereas the PANSS positive subscale score correlated negatively and exclusively with the number of missing teeth. Age and smoking status affected oral health in both groups, but even when the influence of these factors was considered, the oral health of the patients was poorer than that of the control group.

Dental care and associated factors among older adults with schizophrenia

BACKGROUND

Few data are available concerning dental care in older adults with schizophrenia. The authors examined the utilization of dental care and factors related to dental treatment in this population.

METHODS

The sample consisted of 198 community-dwelling participants 55 years and older with schizophrenia and a community comparison group of 113 participants. The authors adapted a model of illness behavior in later life as the basis for selection of 18 predictor variables of annual dental care visits.

RESULTS

The study results showed no significant differences between the schizophrenia and community comparison groups with regard to the percentage of participants (28 and 31 percent, respectively) reporting having had at least two dental visits in the previous year or one dental visit (48 and 54 percent, respectively). However, the results showed significant differences in the percentage of participants in the schizophrenia and community comparison groups who stated that they experienced problems with their teeth or dentures (41 and 23 percent, respectively). When examining participants in the schizophrenia group separately, the authors found four variables that were significantly associated with having had at least one dental visit: financial well-being (odds ratio [OR] = 1.12), better executive cognitive functioning (OR = 1.11), fewer perceived problems with teeth or dentures (OR = 0.33) and fewer oral dyskinesias (OR = 0.86).

CONCLUSIONS

Most older adults with schizophrenia in this study did not receive at least two dental visits per year, although their frequency of care was no worse than that of their age-matched peers. Psychiatric assessments should include questions about dental care. The greatest improvement in dental care for such patients likely is to occur by targeting people who report having more problems with their teeth, including oral dyskinesias; those who have greater cognitive impairments, especially in executive functioning; and those who have diminished financial resources.

Schizophrenia, cancer and obstetric complications in an evolutionary perspective-an empirically based hypothesis

OBJECTIVE

Patients diagnosed with schizophrenia have reduced fecundity and premature mortality (both accidental and violent) with no obvious compensatory advantages among kin. The prevalence of the disorder is around 0.7/1%, higher than the expected prevalence of spontaneous mutations. Genes favoring schizophrenia may have been positively selected in the environment of evolutionary adaptation. Literature on potential adaptive genes is reviewed within an evolutionary framework.

METHODS

Literature search on major scientific search engine (PubMed/Medline, Ovid/PsychInfo) on papers aimed at investigating potential pathways justifying a mutation-selection balanced model. Findings are presented with a narrative touch to favor readability and understanding.

RESULTS

Reduced incidence of cancer in both patients diagnosed with schizophrenia and their siblings was reported worldwide. Such findings are notable given higher cancer risk factors in schizophrenia, i.e., smoking, alcohol abuse, obesity, poor diet, and poor adherence to therapy. Some genes involved in cancer proliferation might as well confer protective advantage in immune-surveillance, inflammation, vascular proliferation or apoptosis that otherwise will adversely affect early neurodevelopment.

CONCLUSION

Evidence that reduced risk of certain somatic diseases is associated with schizophrenia is quite significant to progress in the evolutionary epidemiological analysis of psychopathology.

Oral health of psychiatric inpatients: a survey of central Taiwan hospitals

OBJECTIVE

The objective was to investigate the status of oral health and its determinants in a group of psychiatric inpatients in central Taiwan.

METHOD

A cross-sectional study of the oral health of psychiatric inpatients (n=200) in three hospitals in central Taiwan was carried out during a half-year period. Demographic data and data on oral health habits, dental visit frequency, treatment fear and dental health knowledge were collected. Oral health was determined by the Decayed/Missing/Filled Teeth (DMFT) index, Community Periodontal Index (CPI), Plaque Index and Gingival Index.

RESULTS

In terms of prevalence of caries, the mean DMFT score for all patients was 14.9 ± 8.8 (S.D.), which was significantly worse than that in the general population. The CPI showed that only 10% of patients were periodontally healthy, 9.5% had bleeding, 31% had calculus and 49.5% had periodontal pockets. Increasing age, treatment anxiety, neglect of tooth-brushing and chronic ward inpatients were predictive factors for poor periodontal health. The self-awareness of poor oral health was inadequate and the treatment needs were huge in psychiatric inpatients.

CONCLUSION

The oral health of psychiatric inpatients was poor compared with the general population and was generally ignored by the patients themselves. The phenomenon is universal, occurring in both Western and Eastern countries.

A well-being support program for patients with severe mental illness: a service evaluation

BACKGROUND

The risk of cardiovascular disease is increased in patients with severe mental illness (SMI) dramatically reducing life expectancy.

METHOD

A real world pragmatic service evaluation of a Well-Being Support Program (WSP) was conducted. This was a four-session package delivered over a one-year period by mental health practitioners that had received additional training in providing physical health assessment and intervention. Patients' physical health was screened and appropriate one-to-one and group intervention was offered.

RESULTS

212 mental health practitioners were trained in the WSP and 782 patients were enrolled on the program. The majority of our sample was overweight or obese; 66% had a Body Mass Index (BMI) >25. Lifestyle risk factors for cardiovascular disease (CVD) were common and the patients had low self esteem. The average number of formally recorded well-being sessions attended was 2.10. Just under a quarter of those patients enrolled in the program completed. The only cardiovascular risk factor that significantly altered in patients that completed the program was BMI. The qualitative feedback about the program was largely positive.

CONCLUSIONS

The need to intervene to enhance the physical health of people with SMI is beyond doubt. Maintaining patient engagement in a physical health improvement program is challenging. Regular comprehensive physical health monitoring is necessary to establish the benefit of intervention and increase life expectancy and well-being in this population.

Oral health status of psychiatric in-patients in Serbia and implications for their dental care

AIM

To determine oral health status and identify predictors of oral health in a representative sample of psychiatric in-patients in Serbia.

METHODS

The study included 186 psychiatric in-patients and 186 control participants without psychiatric illness matched to the study group by age, sex, marital status, education level, employment, and monthly income. Dental examinations were done in both groups to measure the following indices of oral health: decayed, missing, and filled teeth (DMFT) index; community periodontal index; and plaque index. Participants were also interviewed about their dental health behavior and their medical records were examined.

RESULTS

Psychiatric in-patients had higher caries prevalence, poorer periodontal health, and poorer oral hygiene than controls. The average DMFT score in the patient group was 24.4 and 16.1 in the control group (P<0.001). Periodontal diseases were significantly more prevalent among psychiatric in-patients than among controls (P<0.001). The average plaque index for patients was 2.78 and 1.40 for controls (P<0.001). Multiple regression analysis demonstrated that 1) DMFT index was associated with age, male sex, duration of mental illness, use of antidepressants, time since the last visit to the dentist, and snacking frequency; 2) community periodontal index was associated with male sex; and 3) plaque index was associated with age, male sex, education level, employment, monthly income, tooth brushing technique, and snacking frequency.

CONCLUSION

Psychiatric in-patients in Serbia have poorer oral health than healthy controls. It is necessary to intensify preventive dental care in this vulnerable population.

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.

[Oral lesions in patients with psychiatric disorders]

INTRODUCTION

Oral diseases in psychiatric patients are usually a result of bad oral hygiene and psychopharmaceutical side-effects.

OBJECTIVE

The aim of this study was to detect oral lesions in patients hospitalized in psychiatric institutions with the confirmed diagnosis of psychiatric illness and mood disorder with psychotic characteristics, as well as to discover the factors that can influence these oral lesions.

METHODS

Cross-section study consisted of 186 hospitalized patients with psychiatric disorders in the experimental group, out of whom 87 were males and 99 females. Patients were aged from 18 to 59 years, mean age 46.0 +/- 8.0 years. The control group consisted of 186 healthy persons matched for age and gender. Data on oral lesions were obtained within history and clinical examination of the oral cavity. Other medical data were collected from medical documentation. Statistical analysis was performed by Student's t-test, chi-square test and logistic regression.

RESULTS

Dry mouth was registered in 78.5% of patients. The difference in tongue and lip lesions, burning and stinging symptoms, bruxism, facial pain, low saliva rates, halitosis, taste changes and swallowing difficulties between the patients and healthy persons was highly statistically significant (p < 0.001). Age and gender, as well as the factors of main disease, influence burning and stinging, bruxism, low saliva rates, swallowing difficulties, taste changes and facial pain of the psychiatric patients.

CONCLUSION

Results imply that psychiatric patients are more frequently involved with oral lesions than healthy persons. It is necessary to organize specific preventive and educational oral health programmes with these patients, as well as with doctors who treat the basic illness.

Oral health of adults with serious mental illnesses: a review

(A) To assess the prevalence of suboptimal oral health in adults with SMI in studies published in 1971-2009; (B) To describe approaches that promote oral health among adults with SMI. A total of 57 randomized, quasi-randomized, cross-section, and cohort studies from samples of 38-4,769 mental health consumers are identified through database, journal, and Internet searches (Cochrane, FASTSTATS, PUBMED, WHO.int). Selected studies are inclusive for the sample, reported statistical power, and external validity. Oral health adverse outcomes (xerostomia, sialorrhoea, dental caries, extracted teeth, malocclusion, periodontal disease, edentulous, oral cancer) are considered as measurable outcomes. This review suggests a substantial prevalence of suboptimal oral health (61%) among individuals with serious mental illnesses. The following outcomes are mostly met: xerostomia, gross caries, decayed teeth, and periodontal disease. Poor oral hygiene, higher intake of carbonates, poor perception of oral health self-needs, length of psychotropic treatment, and less access to dental care determine suboptimal oral health among this population. Further replication of this research should generate gender-wise ethnic cohorts, including detailed observations of environmental factors, and medical problems that contribute to suboptimal oral health. This review highlights the importance of bridging dental health education to psychiatric rehabilitation programs.

A partnership evaluation: public mental health and dental services

OBJECTIVE

This study evaluates the partnership between a mental health service and a public dental hospital in providing timely and efficient access to dentistry to patients with a mental illness. In addition, the factors that contributed to the sustainability of the partnership were examined.

METHOD

The partnership was appraised using a survey-based evaluation with 20 patients, 43 community mental health staff and 14 dental staff, and focus groups with mental health and dental staff.

RESULTS

The partnership between the services is the key element to the success of improving access to dental services for patients. Overall feedback received from mental health staff highlighted the importance of the partnership and its role in meeting the oral health needs of patients. Generally, patients were satisfied with the treatment they received and valued the dental service. Results highlighted an ongoing problem of poor dietary and lifestyle choices. Dental staff felt that mental health patients were less likely to take care of their teeth and were more likely to cancel appointments. Dental staff also acknowledged frustration with patients with a mental illness not attending appointments or following through with a recommended course of treatment.

CONCLUSIONS

The partnership with the local dental hospital has created a sustainable way to ensure improved dental health outcomes for patients of mental health services. This partnership has led to increased access to dental services and improved follow-up.

Oral health problems and support as experienced by people with severe mental illness living in community-based subsidised housing--a qualitative study

The purpose of this study was to explore how persons with severe mental illness (SMI) experience oral health problems (especially dry mouth), and weigh the support they received in this regard from professionals and staff at community-based congregate housing through a controlled intervention programme. Oral health problems and dry mouth are found in association with apathy and indifference, cognitive deficits, and long-term medication with psycho-pharmacological drugs. The present study describes the results from one part of a longitudinal intervention programme, which sought effective ways of mitigating dry mouth through increased support with oral health problems. This part consists of 67 informal interviews with ten participants in two community-based urban housing projects between November 2006 and June 2007, with a follow-up session in December 2007. Content analysis of the results yielded five categories: The shame of having poor dental health, history of dental care, experiences of self-care, handling of oral health problems, and experiences of staff support. Poor oral health caused shame and limited participation in social activities. Participants avoided oral health issues by such circumventions as denial of a tooth ache or dental infections, or postponing oral problems with the hope that they would die away. Offers of support were frequently resisted because of unsatisfactory prior encounters with dental professionals and staff. Our findings suggest that self-care needs to be facilitated in an unobtrusive manner with minimal staff involvement, and clients should be referred to dental care providers experienced in treating people with SMI.

Factors associated with dental caries among institutionalized residents with schizophrenia in Taiwan: a cross-sectional study

BACKGROUND

Little research has been done on the relationship between dental caries and the personal characteristics of institutionalized residents diagnosed with schizophrenia. This study investigates the individual and treatment factors associated with the dental caries among institutionalized residents with schizophrenia in Taiwan.

METHODS

An oral health survey of institutionalized residents with schizophrenia in the largest public psychiatric hospital was conducted in Taiwan in 2006. Based on this data, multiple logistic analyses were used to determine the relationship between some explanatory variables and the outcome variables of dental caries among subjects with schizophrenia.

RESULTS

Among the 1,108 subjects with schizophrenia, age was the only variable independently associated with DMFT > 8 (OR = 7.74, 95% CI = 3.86-15.55, p < 0.001 in comparison to residents aged 65 + years vs. 20-44 years; OR = 3.06, 95% CI = 2.03-4.61, p < 0.001 in comparison to residents aged 55-64 years vs. 20-44 years) after making adjustments for other explanatory variables. In addition, those with an education of only elementary school (OR = 1.67, 95% CI = 1.08-2.56, p = 0.021), low income (OR = 1.58, 95% CI = 1.02-2.44, p = 0.039), and length of stay (LOS) of > 10 years (OR = 2.09, 95% CI = 1.30-3.37, p = 0.002) were associated with a care index < 54.7%. Older age, lower educational level, and longer hospital stays were associated with number of remaining teeth being < 24.

CONCLUSIONS

Aging was the most important factor related to a high level of dental caries. Low educational level, low income, and LOS were also associated with the indicators of dental caries among institutionalized subjects with schizophrenia. It is necessary to address the treatment factors such as prolonged stay in institutions when decision-makers are planning for preventive strategies of oral health for institutionalized residents with schizophrenia.

[Health habits, attitudes and behaviour towards oral health of psychiatric patients]

INTRODUCTION

People with psychiatric disorders are at high risk of oral diseases due to the impact of their primary psychiatric condition and the side-effects of antipsychotic medications.

OBJECTIVE

The aim of this study was to identify habits, attitudes and behaviour towards oral health of hospitalized psychiatric patients with psychotic disorders, including mood disorders with psychotic characteristics, as well as to identify factors that could influence those habits, attitudes and behaviour.

METHODS

The experimental group consisted of 186 hospitalized patients with psychiatric disorders (87 males and 99 females), aged from 18 to 59 years (mean age 46.0-8.0 years). The control group consisted of 186 healthy persons matched for age and gender. Data were obtained by using specially designed questionnaires with questions about the subjects' social, economic and demographic characteristics, as well as their habits, attitudes and behaviour concerning their oral health, in a form of a standardized interview. Other medical data were collected from medical documentation of disease history. Statistical analysis was performed by Student's t-test, Chi-square test, ANOVA, Logistic Regression and simultaneous multiple regression.

RESULTS

Psychiatric patients have worse habits, attitudes and behaviour concerning their oral health in comparison with healthy persons (p < 0.001): they wash their teeth more rarely and in a shorter time, have less knowledge of oral diseases and their effect on general health, and visit their dentist more rarely. The obtained results depend on social, economic and demographic characteristics and on the underlying illness of patients.

CONCLUSION

Health educational work concerning oral health of patients should be included in psychiatric treatment, as a part of an existing therapy with the aim of improving the general quality of their life.

Oral health-related quality of life and dental status in an outpatient psychiatric population: a multivariate approach

Research related to oral health in people with mental health problems may deepen our understanding of the quality of life of such individuals. This study aimed to investigate the relationship between oral status, health perceptions and life satisfaction, and their impacts on oral health-related quality of life (OHQoL). Data were collected from 113 patients in outpatient psychiatric care using a structured interview and an oral examination. Six multivariate models (one comprising the total population, three separate diagnostic groups, and two sex groups) investigated the variance in OHQoL. In the total population, the number of teeth, subjective life satisfaction, perception of physical health, sex, and relying on chance accounted for 40% of the variance. In the group consisting of patients diagnosed with schizophrenia 41% of the variance was explained by the variables 'number of teeth' and 'perception of physical health'. In the group diagnosed with mood disorders, the variable 'number of teeth' accounted for 58% of the variance. The variance in the remaining group of diagnoses was explained, up to 38%, by life satisfaction and reliance on chance. The sex models revealed significant differences: men considered the responsibility of caring for their oral health as a health matter, while women saw oral health as a more subjective issue. The perception of OHQoL was found to be dependent on the particular psychiatric diagnosis and sex. Such findings can be of use in the development of rehabilitation, as well as preventive strategies that could be individually tailored to maintain OHQoL and oral health.

Monitoring oral health and dental attendance in an outpatient psychiatric population

Impaired mental health has been associated with an increased need for dental care. Population surveys have indicated that people with enduring mental health problems make less frequent planned visits to the dentist and report a greater number of missing teeth than the general population. The study aims to examine oral health status, attendance to dental care, and medication in an outpatient psychiatric sample. A descriptive study combining a structured interview with a visual oral examination carried out in 113 outpatients under psychiatric care. Dental health was described in terms of sound, missing and/or filled teeth, and showed a relation between these categories and types of psychiatric diagnosis, age and numbers of antidepressant and neuroleptic drugs. Oral hygiene was found to be more neglected among men and in patients with the diagnosis of schizophrenia. The need of dental treatment was widespread, although regular dental visits were commonly reported. In order to maintain good oral health, regular dental check-ups should be encouraged for patients under psychiatric care. Further studies are required to reveal contributory causes for/to decreased oral health. The difficulty such individuals have in maintaining additional self-efficacy raises questions about the necessity for oral health interventions in outpatient psychiatric services.

The effect of exercise on psychological & physical health outcomes: preliminary results from a Norwegian forensic hospital

People with mental illness are more likely to experience physical health problems and die prematurely than are comparable populations. This study evaluated whether exercise, when offered as part of routine treatment, affects the psychological and physical health of patients in a high-secure forensic unit in Norway. Thirteen patients completed a structured exercise program lasting 8 to 12 weeks. After completion of the program, resting heart rate and systolic blood pressure after treadmill testing were significantly improved. In addition, patients' subjective feelings of well-being and safety improved significantly. This study shows that structured exercise is possible to perform with noticeable improvements and low attrition among patients with complex conditions. Implications for future studies and practice are discussed.

Factors affecting the use of protective stabilization in dental patients with cognitive disabilities

The goal of this study was to investigate the effects of various factors on the use of protective stabilization (PS) in patients with cognitive disabilities during dental treatment. An observational, case-control design was used with a case (protective stabilization group or PS group) and a control (usual management group or UM group) to assess a sample of subjects. Forty-eight dental patients were selected from the two groups. Various factors were compared between the groups. The prevalence of patients with profound cognitive disabilities was higher in the PS group (68.7%) than in the UM group (6.2%) (p<0.0001). The odds ratio of using protective stabilization was 6.18 (95% confidence interval, 1.20-31.72) for patients who were prescribed antipsychotic agents. Our results suggest that patients with profound cognitive disabilities and/or prescriptions for antipsychotic medications have more behavioral disturbances during dental treatments and require protective stabilization.

Monitoring patients to improve physical health and treatment outcome

Patients with schizophrenia suffer a number of comorbidities and a range of potential side effects from their medication, which contribute to a negative impact on their quality of life, and are sometimes responsible for lack of compliance and relapse. Side effects, in particular, can be identified by physicians, but only if they examine their patients regularly. Many physicians would suggest that this is good clinical practice for treating patients with schizophrenia, whatever the intended medication. This continuous monitoring might include weight gain, cognitive effects, and blood tests. In fact, patients appreciate being carefully monitored and it contributes to a good patient/physician relationship. This interaction has benefits in terms of impact on compliance and better control of symptoms due to treatment adherence (to appropriate doses), because it enables action before the patient stops taking medication. Good clinical practice suggests that investment in patient monitoring is offset by improved clinical outcomes.

Physical illness and schizophrenia: a review of the literature

OBJECTIVE

The lifespan of people with schizophrenia is shortened compared to the general population. We reviewed the literature on comorbid physical diseases in schizophrenia to provide a basis for initiatives to fight this unacceptable situation.

METHOD

We searched MEDLINE (1966 - May 2006) combining the MeSH term of schizophrenia with the 23 MeSH terms of general physical disease categories to identify relevant epidemiological studies.

RESULTS

A total of 44 202 abstracts were screened. People with schizophrenia have higher prevalences of HIV infection and hepatitis, osteoporosis, altered pain sensitivity, sexual dysfunction, obstetric complications, cardiovascular diseases, overweight, diabetes, dental problems, and polydipsia than the general population. Rheumatoid arthritis and cancer may occur less frequently than in the general population. Eighty-six per cent of the studies came from industrialized countries limiting the generalizability of the findings.

CONCLUSION

The increased frequency of physical diseases in schizophrenia might be on account of factors related to schizophrenia and its treatment, but undoubtedly also results from the unsatisfactory organization of health services, from the attitudes of medical doctors, and the social stigma ascribed to the schizophrenic patients.

Discrimination in health care against people with mental illness

This paper discusses factors associated with low rates of help-seeking and poorer quality of physical healthcare among people with mental illnesses. Evidence is reviewed on the associations between low rates of mental health literacy, negative attitudes towards people with mental illness, and reluctance to seek help by people who consider that they may have a mental disorder. People with mental illness often report encountering negative attitudes among mental health staff about their prognosis, associated in part with 'physician bias'. 'Diagnostic overshadowing' appears to be common in general health care settings, meaning the misattribution of physical illness signs and symptoms to concurrent mental disorders, leading to underdiagnosis and mistreatment of the physical conditions.

Serious mental illness and physical health problems: A discussion paper

People with serious mental illness have higher morbidity and mortality rates of chronic diseases than the general population. This discussion paper explores the complex reasons for these disparities in health, such as limitations of health services, the effects of having a serious mental illness, health behaviours and the effects of psychotropic medication. Physical health can be enhanced by improved monitoring and lifestyle interventions initiated at the start of treatment. There are opportunities for mental health nurses to play a significant role in improving both the physical and mental health of people with serious mental illness.

Pathophysiology of mental illness: A view from the fourth ventricle

The concept of mental disorders as diseases of the brain is as old as the ancient Greek philosopher-physicians. However, for thousands of years, the majority of doctors, as well as laypersons, held strongly to the belief that epilepsy and "madness" (i.e., schizophrenia)--the major disorders discussed in this paper--were caused by demonic "possession." As always, the theory of causation led to apposite therapies: Cast out the devil by whatever means necessary. Later, more enlightened views of etiology led to less punitive "cures," which, to modern sensibilities, still seem barbaric. The 20th century saw the introduction of medications that provide symptomatic relief, if not cures, for seizure disorders and schizophrenia. In this paper, we consider the etiology of absence (petit mal) epilepsy and schizophrenia based on the pathophysiology underlying the shared symptom of impaired sustained attention. We emphasize the role of abnormal functioning of brainstem structures in the region of the fourth ventricle, whether caused by genetic or environmental factors or a combination thereof. Our theorizing relies on the findings of Lindsley, Magoun, and Moruzzi, who delineated the role of the brainstem reticular activating system in sleep, wakefulness, and consciousness. It also relies on the work of Penfield, Jasper, and Gloor, who sought to illuminate the role of brainstem-thalamus-cortical dysfunction in idiopathic generalized epilepsies. We consider evidence from recent studies that emphasize the phasic attentional functions supported by brainstem structures in the region of the fourth ventricle, and possible genetic links among disorders in which impaired attention is a prominent symptom.