Editor's summary

Access. It often comes down to access doesn't it? Direct access, open access, access to the homeless, access to deprived groups...what about access to those with severe mental illness?

Generally, policy is based on evidence and statistics. National surveys providing these statistics are key in informing policy-makers and helping them to decide who gets what from (dwindling) government money pots. The point made by the authors of this paper is that certain community groups, who often suffer the highest burden of disease, such as those with severe mental illness, are under-represented in national surveys. It can be tricky to access those with severe mental illness undertaking psychiatric care in order to get a picture of their oral health.

Mental health remains one of the most neglected and stigmatised areas of health in the UK. Mental health illnesses range from people living with schizophrenia, dementia and bipolar disorder to those fighting bouts of depression and panic attacks. The importance of mental health and caring for those with mental illness now finally appears to be coming to the fore with increased attention in the media and from policy-makers.

UK Labour Party Leader Ed Miliband recently declared mental illness to be the 'biggest UK health challenge' in a speech on the 29th October to the Royal College of Psychiatrists in London. In November 2010, the government produced a public health white paper, Healthy Lives, Healthy People,1 setting out the long-term vision for the future of public health in England which was claimed to be the first public health strategy to give equal weight to both mental and physical health.

Unfortunately, this new-found status of mental health quite likely derives from disgust at cases of neglect, for example at Winterbourne View care home, in addition to the growing prevalence of mental illness.

The authors of this paper call for future research to consider and help tackle the causes of the, now proven, poorer oral health in this population with severe mental illness. Mental illness affects all areas of the individual's life – it can no longer be sidelined.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 213 issue 9.

Ruth Doherty

Managing Editor

Author questions and answers

1. Why did you undertake this research?

When considering research topics for my masters, I noted that little dental research had been undertaken in people with mental illness and that the majority of previous research focused on those in acute care. Only a small proportion of patients suffering with acute episodes of mental disorders will be seen as inpatients in a hospital setting, and the visits will be transient, so it was important that data were collected for the majority of the population, which in this case was in a community setting. Unlike inpatients, patients in the community setting are not subject to continuous exposure to healthcare staff, nor do they have the resources as easily at hand to provide dental care urgently if needed, and thus are at risk of becoming neglected in terms of dental care.

2. What would you like to do next in this area to follow on from this work?

The work acted as a needs assessment and feedback will be given to the related mental health and primary care trusts in the region the data was collected.

This research clearly demonstrates that the dental needs and impact of poor oral health on quality of life in people with severe mental illness is higher than that in the general population. Future research needs to be undertaken to identify the possible causes of poor oral health in this population, and so consider dental public health measures that could improve the dental health status of people with severe mental illness in community-based care.

Commentary

The authors of this unique study need to be congratulated for their success in accessing this hard-to-reach population. As stated in the paper, there is very little literature and research on the oral health of people with mental illness. The more evidence that can be established to show that this group of people experience oral health inequalities will aid targeting oral health promotion (OHP) and preventive measures.

There is some evidence to suggest that people with serious mental illness have a greater risk of experiencing oral disease and have greater oral treatment needs than the general population. The barriers to oral health care experienced by people with mental illness, including lack of awareness of dental services and negative dental staff attitudes, are discussed.

Oral-health-related quality of life is a particularly important factor in patients with mental illness and it is useful to be able to compare this to the general population along with the traditional measurements of oral disease. The study showed that this group had more periodontal disease, tooth loss, dental caries and reported twice the oral-health-related quality of life score of the general adult population. Many of these people have been living with dental pain for some time. It would be good to see figures for statistical significance of these differences.

I would endorse recommendations that include suggestions that members of the dental team should gain a wider knowledge of the impact of mental health on oral health including side effects of anti-psychotic medication and a better understanding of the organisation of mental health services. This would enable a better relationship with the multidisciplinary team (MDT).

Access to information regarding services should be more available and MHP's are well placed to provide encouragement and support to make regular use of dental services and deliver patient centred OHP messages. Access to emergency care is a priority as this may be all that is required as attendance for routine appointments may be too difficult to manage.

A recent systematic review from Kisely et al. covered studies from the past 20 years to compare the oral health of people with severe mental illness with that of the general population. It showed that people with severe mental illness had 3.4 times the odds of having lost all their teeth than the general community (95% CI 1.6-7.2). They also had significantly higher scores for DMFT (MD 6.2, 95% CI 0.6-11.8) and DMFS (MD 14.6, 95% CI 4.1-25.1). They concluded that psychiatric patients have not shared in the improving oral health of the general population. Considering this was an article in a non-dental journal, the suggestion of including the MDT in oral assessments is a vey exciting one and was recommended in the 2000 BSDH guidelines.