Is providing advice about oral health to people with serious mental illness effective?
Background
People with mental health problems have an increased likelihood of oral disease (affecting the teeth, mouth, and gums) and can require more dental treatment than the general population. Oral health is currently not a priority for service users and mental health professionals, even though tooth decay, discolouration, sensitivity, and gum disease can affect such aspects of everyday life as eating, comfort, appearance, feelings of being accepted by others, and self esteem. While unlikely in itself to be fatal, poor dental health can contribute to other physical health problems such as heart disease. Some medications used to treat serious mental illness can cause side effects that lead to oral disease.
Oral health advice from a healthcare professional may encourage people with mental health problems to brush their teeth more regularly, have regular check-ups with their dentist, and seek dental care if suffering from painful tooth decay, increased sensitivity, or gum disease. Advice may include information or counsel that enables the individual to think about and be aware of their dental health. It should educate and inform, aim at preventing problems, and empower people to take better care of their mouth and teeth.
Study characteristics
We ran an electronic search in November 2015 for trials that randomised people with serious mental illness to receive either oral health advice, monitoring, or standard care. Three studies meeting the required standards were found and are included in this review.
Key results
The data available in the included trials suggests that participants receiving oral health education had statistically better plaque index scores than those not receiving oral heath education, but what this actually means clinically is unclear. The trials provided no information about such important issues as number of visits made to dentists or how many times teeth were brushed each day and if there were any potential adverse effects of oral health education. The review authors suggest that although there is currently no real evidence available from trials, it would make sense to follow the guidelines and recommendations put forward by the British Society for Disability and Oral Health working group regarding oral health care for people with mental health problems.
Quality of the evidence
The quality of evidence in the small number of trials available was low to moderate. There is currently a lack of good-quality evidence available from trials to aid in decision-making about the overall effectiveness of oral health advice for people with serious mental illness. More good-quality trials are required to gather better and more concrete evidence.
Ben Gray, Senior Peer Researcher, McPin Foundation. http://mcpin.org/
We found no evidence from trials that oral health advice helps people with serious mental illness in terms of clinically meaningful outcomes. It makes sense to follow guidelines and recommendations such as those put forward by the British Society for Disability and Oral Health working group until better evidence is generated. Pioneering trialists have shown that evaluative studies relevant to oral health advice for people with serious mental illness are possible.
People with serious mental illness not only experience an erosion of functioning in day-to-day life over a protracted period of time, but evidence also suggests that they have a greater risk of experiencing oral disease and greater oral treatment needs than the general population. Poor oral hygiene has been linked to coronary heart disease, diabetes, and respiratory disease and impacts on quality of life, affecting everyday functioning such as eating, comfort, appearance, social acceptance, and self esteem. Oral health, however, is often not seen as a priority in people suffering with serious mental illness.
To review the effects of oral health education (advice and training) with or without monitoring for people with serious mental illness.
We searched the Cochrane Schizophrenia Group's Trials Register (5 November 2015), which is based on regular searches of MEDLINE, EMBASE, CINAHL, BIOSIS, AMED, PubMed, PsycINFO, and clinical trials registries. There are no language, date, document type, or publication status limitations for inclusion of records in the register.
All randomised clinical trials focusing on oral health education (advice and training) with or without monitoring for people with serious mental illness.
We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.
We included three randomised controlled trials (RCTs) involving 1358 participants. None of the studies provided useable data for the key outcomes of not having seen a dentist in the past year, not brushing teeth twice a day, chronic pain, clinically important adverse events, and service use. Data for leaving the study early and change in plaque index scores were provided.
Oral health education compared with standard care
When 'oral health education' was compared with 'standard care', there was no clear difference between the groups for numbers leaving the study early (1 RCT, n = 50, RR 1.67, 95% CI 0.45 to 6.24, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect was found. Although this was statistically significant and favoured the intervention group, it is unclear if it was clinically important (1 RCT, n = 40, MD - 0.50 95% CI - 0.62 to - 0.38, very low quality evidence).These limited data may have implications regarding improvement in oral hygiene.
Motivational interview + oral health education compared with oral health education
Similarly, when 'motivational interview + oral health education' was compared with 'oral health education', there was no clear difference for the outcome of leaving the study early (1 RCT, n = 60 RR 3.00, 95% CI 0.33 to 27.23, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect favouring the intervention group was found (1 RCT, n = 56, MD - 0.60 95% CI - 1.02 to - 0.18 very low-quality evidence). These limited, clinically opaque data may or may not have implications regarding improvement in oral hygiene.
Monitoring compared with no monitoring
For this comparison, only data for leaving the study early were available. We found a difference in numbers leaving early, favouring the 'no monitoring' group (1 RCT, n = 1682, RR 1.07, 95% CI 1.00 to 1.14, moderate-quality evidence). However, these data are problematic. The control denominator is implied and not clear, and follow-up did not depend only on individual participants, but also on professional caregivers and organisations - the latter changing frequently resulting in poor follow-up, but not a good reflection of the acceptability of the monitoring to patients. For this comparison, no data were available for 'no clinically important change in plaque index'.