The Right to Smile

This is a guest blog by the Right to Smile Consensus, which is taking action to improve the oral health of people who experience severe mental ill health. The blog was co-authored by the following people: 

Dr Vishal Aggarwal is a dentist and clinical associate professor at the University of Leeds. 

Dr Carolyn A Chew-Graham is a GP and professor of general practice research at Keele University. 

Gordon Johnston is a person with lived experience of severe mental illness.

David Shiers is a carer for his daughter with severe mental illness.

An ignored health disparity

The importance of protecting the physical health of people experiencing severe mental illness is established, and supported by policies and targets for tackling disorders like diabetes and cardiovascular disease.  By comparison, inequalities in oral health have received scant attention.  Yet, compared to the general population, research shows people with SMI (Chang et al. 2013; Choi et al. 2021; Turner et al.2022):

  • Are three times more likely to lose all their natural teeth
  • Have on average five more decayed teeth
  • Are twice as likely to experience late detection of oral cancer, and less likely to receive specialised treatments
  • Are less likely to brush their teeth 
  • Are less likely to access routine dental services.

A vicious cycle.  

Poor oral health may not be simply experienced as painful tooth decay or inflamed gums.  Poor oral health can have a major impact on the quality of peoples’ lives (Patel et al 2012) and have a direct impact on their mental health:

  • Feeling ashamed to open their mouth because of bad breath or unsightly teeth affects how they feel about themselves
  • Lacking the confidence to laugh, to smile, or to be close to others, can affect relationships and result in social isolation which directly affects mental health
  • Functions as basic as talking and eating may be impaired which impacts on general health and well-being.  

Moreover, poor oral health may interact with other health conditions like diabetes and heart disease (Teeuw et al 2010; Xu et al 2017). For instance, poor oral health can upset diabetes control, while diabetes makes gum disease more likely.  Diabetes and cardiovascular disease are particularly prevalent in this population, potentially creating a vicious cycle of interdependent difficulties for an individual.

An ounce of prevention is worth a pound of cure.  

Dental diseases like tooth decay, gum disease and oral cancer are preventable.   They should not be the inevitable consequence of experiencing a severe mental illness.   We therefore need to shift our focus from ‘downstream’ treatments that commonly involve extraction of teeth and are offered in crisis for advanced tooth decay and gum disease, to ‘upstream’ prevention and early intervention.  The Right to Smile asserts there can be no physical health without oral health and requires a collaborative ‘whole team approach’ between mental health, dentistry, primary care and social care.

The following are some example opportunities for discussing oral health and using services to support people with SMI

Opportunities to discuss oral health in primary care:

1. ‘Making every contact count’ reminds us to consider oral health whenever we consult with our patients with severe mental illness.

2. In the annual physical health check, health promotion advice about healthy eating, tobacco and substance use should prompt discussion and support around oral health to:

a). Reinforce positive oral self-care behaviours such as reducing frequency of sugar intake, cessation of smoking, and limiting alcohol intake.

b). Encourage regular toothbrushing with a fluoride toothpaste.

c). Signpost those not attending regular check-ups to a dental services.

3. Help carers to be aware of the importance of oral health for those they support; offer advice and information on how they can encourage good oral hygiene.

Opportunities for dental services to support people with SMI

    • Recognise and prioritise oral health needs of people with severe mental illness by initiating early intervention to prevent poor oral health outcomes.

    • Adopt a whole-person approach in managing the impact of poor oral health on SMI particularly in relation to social avoidance from poor oral health outcomes related to bad breath and poor aesthetics.

    • Be aware of atypical dental presentations which can on occasion indicate an emerging SMI. If you have such concerns, facilitate prompt onward referral to mental health services (see Dental Mental Health Resources below 1,2,3,4)

Opportunities for commissioners to support people with SMI 

    • Consider the oral health needs of people with SMI within local oral health needs assessments (e.g. Mental health and wellbeing Joint Strategic Needs Assessment)

    • Include oral health in the physical health checks offered to people with SMI

    • Support this vulnerable group to access subsidised / free dental care where applicable 

    • Integrate oral health in commissioned community services /programmes for people with SMI and provide resources and oral hygiene products (toothbrushes / toothpastes) to support oral self-care

The Right To Smile: poor oral health should not be the inevitable consequence of experiencing severe mental illness.  

In response to increasingly robust evidence, The Right to Smile campaign believes that tackling this health inequality is overdue and deserves urgent attention. If we equip people with the right knowledge and skills, while supporting the adoption of healthy routines including regular dental check-ups before things go wrong, we can make a real difference to an individual’s health and their well-being. 

The Personalised Care Institute offers a range of free eLearning courses, webinars and podcasts which explain more about personalised care approaches, such as those described in the Right to Smile consensus statement. Many of our resources are designed to help health and care staff to develop skills such as active listening and engaging in quality conversations. These resources provide valuable CPD for qualified health and care professionals, and embed personalised care as ‘business as usual’.  

The Right to Smile consensus statement was developed by an oral health group spanning experts with lived experience and colleagues from primary care, mental health, and dentistry, established by the Closing the Gap Network

Declaration of Interest: DS is an expert advisor for the NICE Centre for Guidelines. The views expressed in this blog are the authors’ and not those of NICE

Dental Mental Health Resources

    1. Elliott, E., Sanger, E., Shiers, D. and Aggarwal, V.R., 2022. Why does patient mental health matter? Part 2: orofacial obsessions as a consequence of psychiatric conditions. Dental Update49(10), pp.789-793.

    1. Elliott, E., Sanger, E., Shiers, D. and Aggarwal, V.R., 2022. Why does patient mental health matter? Part 3: dental self-neglect as a consequence of psychiatric conditions. Dental Update49(11), pp.867-871.

    1. Elliott, E., Sanger, E., Shiers, D. and Aggarwal, V.R., 2023. Why does patient mental health matter? Part 4: non-carious tooth surface loss as a consequence of psychiatric conditions. Dental Update50(1), pp.28-32.

    1. Aggarwal VR, Sanger E, Shiers D, Girdler J, Elliott E. 2022. Why does Patient Mental Health Matter? Part 5: Chronic orofacial pain as a consequence of psychiatric disorders. Dental Update. (in press)

References: 

    1. Chang TS, Hou SJ, Su YC, Chen LF, Ho HC, Lee MS, Lin CH, Chou P, Lee CC. 2013. Disparities in oral cancer survival among mentally ill patients. PLoS One. 8(8):e70883

    1. Choi J, Price J, Ryder S, Siskind D, Solmi M, Kisely S. 2021. Prevalence of dental disorders among people with mental illness: An umbrella review. Aust N Z J Psychiatry. 48674211042239

    1. Patel R, Gamboa A. Prevalence of oral diseases and oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care. Br Dent J. 2012;213. doi: 10.1038/sj.bdj.2012.177 

    1. Teeuw WJ, Gerdes VEA, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: A systematic review and meta-analysis. Diabetes Care. 2010;33: 421–427. doi: 10.2337/dc09-1378

    1. Turner E, Berry K, Aggarwal VR, Quinlivan L, Villanueva T, Palmier-Claus J. Oral health self-care behaviours in serious mental illness: A systematic review and meta-analysis. Acta Psychiatr Scand. 2022 Jan;145(1):29-41. doi: 10.1111/acps.13308.

    1. Xu S., Song M., Xiong Y., Liu X., He Y., Qin Z. The association between periodontal disease and the risk of myocardial infarction: A pooled analysis of observational studies. BMC Cardiovasc. Disord. 2017;17:50. doi: 10.1186/s12872-017-0480-y. 

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