Oral health of psychiatric in-patients

Abstract

Aim and Method

The aim of the study was to get an estimate of oral health needs of in-patients on acute general adult wards in an inner-city psychiatric unit. Information was collected by means of a cross-sectional survey with patient interviews and a brief oral examination.

Results

A significant majority of patients had carious teeth, inflammation of gums and oral plaque. A majority of patients complained of pain during the preceding 3 months and problems with teeth.

Clinical Implications

Oral health of patients admitted to an acute psychiatric unit is worse than compared to the general population. There appears to be a need for basic dental health education and easy access to dental care on psychiatric wards.

Mental illness is associated with physical ill health (Sims, 1987). Poor diet, lack of exercise and heavy cigarette smoking have all been cited as causal factors in such health problems (Brown et al, 1999). Improving the health of people with mental illness is a specific recommendation of Health of the Nation (Department of Health, 1992). Changes in lifestyle may lead to improvement in the overall health of patients with mental illness, and they should be a priority group for health promotion.

Oral health is an important component of physical health. It affects the personal, social and psychological spheres of life. An adult dental health survey in the UK in 1988 (Office of Population Censuses and Surveys, 1988) reported an improvement in adult dental health during the decade since the last survey. It also highlighted health inequality: 91% of men living in southern England with a non-manual occupational background still had some natural teeth, compared to 52% of women living in northern England with unskilled manual occupational backgrounds.

Patients with mental illness are prone to develop dental problems. This may be owing to general self-neglect associated with mental illness, fear of treatment, worry about the cost of treatment, inability to access dental services and the side-effects of medication. Cormac & Jenkins (1999) have underlined the importance of understanding the oral health of psychiatric patients.

Hede (1995) reported relatively poor oral health among hospitalised patients with mental disorders in Denmark compared to the general population. In that study the presence of decayed tooth surfaces was associated with a neglect of tooth brushing. Stiefel et al (1990) compared samples with and without mental illness in community settings and found that those with chronic mental illness had a significantly higher incidence of self-reported dry mouth, consumption of carbonated beverages, mucosal, lip and tongue lesions, coronal smooth surface caries and more severe plaque and calculus. Roca et al (1987) studied the medical care of chronic psychiatric out-patients and found that gross dental disease was the most common problem among men, with only 11% of male and 26% of female patients receiving appropriate care.

Our study aimed to get a snapshot of the oral health of patients in an inner-city acute psychiatric in-patient unit, so that any unmet need could be addressed locally.

Method

A Medline search was done using the key words ‘dental’, ‘disorder’ and ‘mental’. Of the 66 records found, none specifically described dental health in inner-city acute psychiatric in-patients.

In collaboration with two community dentists, an interviewer-based questionnaire was developed. The questions included items on basic demographic data, dental service utilisation and satisfaction. A dentist (R.D.) also collected data from a brief visual examination of the mouth and teeth. The 1988 UK national household survey (Office of Population Censuses and Surveys, 1988) was used as a reference. The 1988 survey was carried out by selecting a random sample of 4640 addresses and asking all the adults at those addresses to participate (results of the 1998 survey were not available at the time of our study).

Ethical approval was obtained from Riverside Research Ethics Committee. Wards were informed by letter and verbally about the date and time of the interviews. Patients were given information letters and their written consent was obtained at the time of the interviews.

Results

Out of 50 patients invited to participate, 16 refused and 5 were too disturbed to be interviewed, leaving 29. One of these answered the questionnaire but refused oral examination, and two did not have any teeth, so 26 dentate patients took part in the survey. The mean age of the sample was 39 years, with almost an equal male to female ratio, of 14:15. Just over one-half (17/29) were single, 13/29 were living independently alone and 9/29 with their families.

A majority of dentate patients (22/26) had 21 or more of their natural teeth and 20/26 reported problems with their teeth at the time of examination. Twenty-five reported that staff on the ward or their professional carers in the community had never asked them about any dental problems. Twenty-three reported having a tooth-brush in hospital and 20 produced it when the interviewer asked to see it. Out of this 20, 17 brushes were in an adequate state. Twenty-two patients reported brushing their teeth once or twice a day at home, and 20 reported that they were continuing this in hospital. Only two patients were using mouthwash daily. Fifteen of the 26 patients visited the hospital shop to buy chocolate or soft drinks.

About half of the patients (13/26) had had their last dental treatment more than 2 years ago, and a similar number (13/26) had visited their dentist within the past year. The most common reason for not visiting a dentist was fear of treatment, anxiety or lack of faith in the dentist. A majority had worried about their teeth (19/26) or had had dental pain (15/26) over the preceding 3 months. A majority complained of current problems with their teeth and 50% were satisfied with the overall dental care provided in the hospital.

Dental examination revealed that 3/26 of the in-patients had no visible plaque and 23 had plaque. Similarly, only 3 had no visible inflammation of the gums and 23 had visible inflammation. As regards condition of teeth, 9/26 had no carious teeth and 17/26 had carious teeth.

Discussion

The oral health of patients admitted to this acute psychiatric unit was worse than that of the general population. This is consistent with other findings of physical ill health in psychiatric patients (Strathdee, 1993), and has implications for routine clinical practice and service development. Dental problems and dental care need to be considered by mental health staff when comprehensive assessments are conducted, and a care plan should be decided upon.

The limitations of this study are its cross-sectional design and small sample size, which limit the ability to draw valid conclusions. However, this is not entirely unexpected in a study set in a busy inner-city general adult psychiatric unit. Owing to ethical and staffing constraints, a visual assessment of condition of teeth and gums was made and dental probing was not done. It is reasonable to assume that a more detailed examination with probing and radiography may have revealed more disease.

There is a need for basic dental health education in in-patient units, and access to dental care. The anxieties and fears that keep patients away from dentists should be explored and addressed appropriately. Improving liaison between mental health staff and community dental services could help to tackle some of the problems.