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Review
. 2016 Sep 8;9(9):CD008802.
doi: 10.1002/14651858.CD008802.pub3.

Oral health education (advice and training) for people with serious mental illness

Mariam A Khokhar  1 , Waqqas Ahmad Khokhar, Andrew V Clifton, Graeme E Tosh
Affiliations
Review

Oral health education (advice and training) for people with serious mental illness

Mariam A Khokhar et al. Cochrane Database Syst Rev. .

Abstract

Background: 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.

Objectives: To review the effects of oral health education (advice and training) with or without monitoring for people with serious mental illness.

Search methods: 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.

Selection criteria: All randomised clinical trials focusing on oral health education (advice and training) with or without monitoring for people with serious mental illness.

Data collection and analysis: 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.

Main results: 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 careWhen '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 educationSimilarly, 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 monitoringFor 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'.

Authors' conclusions: 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.

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Conflict of interest statement

Mariam Ahmad Khokhar ‐ none known

Waqqas Ahmad Khokhar ‐ none known

Andrew Clifton ‐ none known

Graeme Tosh ‐ none known

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Study flow diagram for 2015 search results
1.1
1.1. Analysis
Comparison 1 Oral health education vs standard care, Outcome 1 Dental state: Average score (modified Quigley‐Hein Plaque Index, high score = bad).
1.2
1.2. Analysis
Comparison 1 Oral health education vs standard care, Outcome 2 Leaving the study early.
2.1
2.1. Analysis
Comparison 2 Motivational interview + oral health education vs oral health education, Outcome 1 Dental state: Average score (modified Quigley‐Hein Plaque Index, high score = bad).
2.2
2.2. Analysis
Comparison 2 Motivational interview + oral health education vs oral health education, Outcome 2 Knowledge: Average score (Oral Health Knowledge Questionnaire, high score = good).
2.3
2.3. Analysis
Comparison 2 Motivational interview + oral health education vs oral health education, Outcome 3 Self regulation: Average score (Treatment Self Regulation Questionnare).
2.4
2.4. Analysis
Comparison 2 Motivational interview + oral health education vs oral health education, Outcome 4 Leaving the study early.
3.1
3.1. Analysis
Comparison 3 Monitoring vs no monitoring, Outcome 1 Leaving the study early.
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  • doi: 10.1002/14651858.CD008802.pub2

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References

References to studies included in this review

Almomani 2006 {published data only}
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ISRCTN63382258 {published data only}
    1. Adams CE, Wells NC, Clifton A, Simpson J, Tosh G, Callaghan P, et al. Randomised trial of dental awareness in EIP mental health teams in Mid and North England. Unpublished.
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    1. NCT02512367. Evaluate the efficacy of a global dental health promotion program on dental hygiene in patients with schizophrenia (EBENE). https://www.clinicaltrials.gov/ct/show/NCT02512367 2015.

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Khokhar 2011
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