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Oral health interventions for people living with mental disorders: protocol for a realist systematic review

  • Virginia Dickson-Swifti,
  • Mark Gussyii,
  • Susan Kiddthree,
  • Dianne Coxi,
  • Mohd Masood4,
  • David Azulone,
  • Carina Chan5,
  • Bradley Christianfour,
  • Jacqui Theoboldi,
  • Brad Hodgeane,
  • Ron Kneveliv,
  • Ballad McKinstryane,
  • Danielle Couchane,
  • Nerida Hyettone,
  • Prabhakar Veginadu1 &
  • Nastaran Doroud1

International Journal of Mental Wellness Systems volume xiv, Article number:24 (2020) Cite this article

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Abstract

Background

The increasing number of people who experience mental disorders is a global trouble. People with mental disorders have high rates of co-morbidity and significantly poorer oral health outcomes than the general public. However, their oral health remains largely a hidden and neglected issue. A complex range of factors impact the oral wellness of this group. These include anxiety and dental phobia, dietary habits, including the heavy consumption of sugary drinks, substance misuse of tobacco, alcohol, and/or psychostimulants, the adverse orofacial side effects of anti-psychotic and anti-low medications, and financial, geographic, and social barriers to accessing oral health care.

Methods

The aim of this realist systematic review is to (a) identify and synthesise evidence that explores oral health interventions for people living with mental disorders; (b) explore the context and mechanisms that have contributed to the success of interventions or the barriers and challenges; (c) produce programme theories on causal, contextual and mechanistic factors to facilitate outcomes and (d) produce recommendations and guidelines to guide hereafter oral health interventions for people with mental disorders at both the policy and practise level. Using a five-pace process, that incorporates primary data drove from central stakeholders, a beginning theoretical framework volition exist adult to describe contextual and mechanistic factors and how they might impact on the success or failure of oral wellness interventions for people with mental disorders. Primal database searches will be conducted, with information extraction focused on the factors that might accept impacted on intervention implementation and outcomes. Quality appraisement of studies volition occur, and the theoretical framework will exist populated with extracted data. Stakeholder input will support the development and refinement of a theory on oral health interventions for people with mental disorders.

Discussion

This will be the first review to take a realist approach to explore the broad scope of causal factors that impact on the success or failure of oral health interventions for people with mental disorders. The approach includes extensive stakeholder appointment and will advance realist systematic review methodology. Review outcomes will exist important in guiding policy and practice to ensure oral health interventions better run into the needs of people with mental disorders.

Systematic review registration This review protocol is registered with PROSPERO (Number) 155969.

Introduction/background

The aim of this realist systematic review [1,2,3] is to place and synthesise studies that explore oral health interventions for people living with mental disorders. The terms mental disorder and mental illness are often used interchangeably. In this review, nosotros use the term mental disorder consistent with the linguistic communication of the World Health Organization (WHO) [4].

Mental disorders describe a spectrum of conditions affecting people's thinking, behaviour, and relationships [five]. It is estimated that about 50% of people volition experience some form of mental disorder in their lifetime [6, 7]. Authors argue that mental disorders are underreported across virtually countries. In the United States (United states), anxiety and depression touch on eleven.48% of the total population, in the United Kingdom (United kingdom of great britain and northern ireland) 8.77%, Australia eleven.2%, and in countries such as Communist china rates are reported as 6.34%. Across the world, low and feet disorders are estimated to cost US$ane trillion per year [8]. For disorders such as schizophrenia and bipolar, prevalence rates are: Us 0.98%, United kingdom of great britain and northern ireland one.35%, Australia 1.v%, and Red china 0.66% [nine].

Mental disorders are among the leading causes of disability, accounting for 7.4% of global disability-adjusted life years (DALYs), and 22.7% of global years lived with inability YLDs [10]. The severity of mental disorders varies and can lead to persistent episodic symptoms that impact operation, with associated requirements for long-term intendance [6].

People diagnosed with mental disorders experience high rates of co-morbidity [11]. Life expectancy of people diagnosed with low prevalence mental disorders, such every bit schizophrenia, schizoaffective disorder, bipolar disorder, and delusional disorders [12] is between x and twenty years lower than the general population [eleven].

Proficient oral health is integral to general health and quality of life and is a fundamental human being right [13,14,15]. Still, approximately three.5 billion people live with untreated oral conditions [16, 17]. Lives are negatively impacted, and millions of productive hours are lost annually as a issue of poor oral health [13, 15, 18,nineteen,twenty]. People with mental disorders have significantly poorer oral health outcomes than the general population [21,22,23]. Kisely [21] refers to a bi-directional association between oral wellness and mental health. Actual and anticipated dental treatment tin can pb to feet and dental phobia. Many mental wellness disorders (for case, psychotic and eating disorders) are associated with higher prevalence and greater severity of dental illness, including erosion, caries, and periodontitis [21]. People hospitalised for their mental disorders accept the worst oral health outcomes [24,25,26]. There is a lack of electric current studies that have explored general anaesthesia associated with dental treatment in people with mental disorders. However, in the broader category of special needs, authors take highlighted increased need for full general anaesthesia associated with dental handling and much higher anaesthetic risk associated with multiple comorbidities [27,28,29,30]. Exploration of oral wellness intervention studies that consider full general anaesthesia is a gap.

People experiencing mental disorders are negatively impacted by many social determinants of health including poverty, unemployment, housing insecurity, and social isolation [31, 32]. These issues are also meaning risk factors/indicators for poor oral wellness. Poor oral health in people with mental disorders is associated with: poor dietary habits and poor diet, heavy consumption of sugary drinks; comorbid substance misuse of tobacco, alcohol, and/or psychostimulants and other medications; and financial, geographic, and social barriers to accessing oral healthcare [21]. People with severe mental disorders are more than susceptible to oral disease considering of poor oral hygiene [26], dental phobia [27, 28], dental costs [29, 30], difficulty in accessing health care facilities [xxx], and the agin orofacial side effects (including bruxism and xerostomia) of anti-psychotic and anti-depressant medications [22, 33,34,35].

Poor oral health can contribute farther to the social withdrawal, isolation, and low cocky-esteem of those with mental disorders who are already highly vulnerable [23, 36, 37]. There is a shut association betwixt dental disease, coronary health disease, stroke, diabetes, and respiratory illness [38,39,twoscore,41,42], atmospheric condition that are unremarkably experienced by people with mental disorders [22, 40]. For this group, poor oral health is a critical issue but is frequently ignored by policymakers and service providers [21, 36].

Previous systematic reviews have explored the oral wellness of people with schizophrenia and bipolar disorder [22, 36, 43, 44]. A meta-analysis by Matevosyan [36] examined the prevalence of suboptimal oral wellness in adults with severe mental illness, including poor oral hygiene, increased intake of carbonates, poor perception of oral wellness cocky-needs, duration of psychotropic treatment, and reduced admission to dental care. 2 sequent systematic reviews and meta-analyses investigated the association between edentulism (missing teeth) and measures of dental caries [decayed, missing, filled teeth (DMFT) or surfaces (DMFS)], and serious mental disorders [22, 44]. The findings advise that people with serious mental disorders face greater likelihood (2.8 times) of losing all their teeth and significantly college Decayed, Missing and Filled Teeth (DMFT) and Rust-covered Missing and Filled Surfaces (DMFS) scores compared to the full general population. One review focused on the furnishings of oral wellness teaching, motivational interviewing, monitoring, and standard care on oral health and quality of life for people with serious mental illness [43]. The authors concluded that there was insufficient evidence from the studies to recommend an intervention.

Reviews have been conducted on the oral health of people diagnosed with eating disorders [45] and demonstrated significantly higher hazard of dental erosion caused by airsickness when compared to the general population and significant clan between dental caries and dry mouth. Other systematic reviews past Kisely et al. [22], Cademartori et al. [46] and Baghaie et al. [47], have identified a greater burden of dental caries and periodontal disease in populations with feet and depression and substance abuse disorders.

Authors [22, 36, 43, 44] take highlighted a lack of bear witness on the effectiveness of oral health interventions for people with mental disorders. There have been calls for the grooming of mental health professionals and closer collaboration between all health professionals [48, 49]. Recommendations for further inquiry include studies focused on oral health instruction and promotion within mental health service settings (including inpatient and community settings) [23, 49]. While there are no recent studies that take explored dental treatment [27] and general anaesthetics for people with mental illness, authors have chosen for preventive dental programs for vulnerable populations as a means to reduce anaesthetic risks [thirty]. A recent review by Slack-Smith and colleagues reported that barriers to good oral health for people with mental disorders savage into three categories; private, organizational (including wellness providers), and organisation-level [23]. While these reviews are useful, no authors take produced a comprehensive synthesis of the context and mechanisms that influence oral health interventions for people with mental disorders. At that place is a lack of show-based theory to guide policy and practice. This review addresses this gap.

In this review, nosotros conceptualise poor oral health equally a 'wicked problem', 1 that has a significant impact only has proven to be intractable [50,51,52]. Wicked issues are resistant to usual trouble-solving approaches, require action by a diverseness of stakeholders, require major behaviour change at system, service and private levels, and most 'wicked problems' are feature of chronic policy failure [50]. Authors hold that poor oral wellness for people with mental disorders must be addressed at a systems level [23, 53, 54], rather than a reliance on more traditional approaches where the individual and the context are reduced to independent, quantifiable factors [51, 54]. By grounding this review in disquisitional realism [1,2,3], we will extend beyond previous systematic reviews and undertake an in-depth exploration at the individual, service, and system levels, to unravel the impact of what works for whom, in what context and how [55]. This will enable an exploration of the success and failures of interventions and the many combinations of the two. This contextually bound arroyo to causality is represented equally context + mechanism = outcome [1, 2].

Abayneh, Lempp, Manthorpe and Hanlon [56] depict together literature to define primal realist concepts and terms. Context is defined as a configuration of factors that are not always straight connected to an intervention. These could include features of the intervention site and its location, human resources and the way they interact, and culture. Mechanisms are defined as a 'generative forcefulness triggered in particular contexts' or cognitive or emotional responses of individuals experiencing an intervention; carers, service staff, customs members, and those in the broader health system. They state that consideration of mechanisms is essential in moving beyond what happened, to why, for whom, and in what circumstances. The interaction between the context and the mechanism, or how people respond, can be based on factors such every bit beliefs, values, preferences, and thought processes. The resultant outcomes might lead to short, medium- or longer-term change and can be intended or unintended [56].

We hypothesise that the contexts in which oral wellness interventions are delivered to people with mental wellness disorders are multi-faceted and dynamic and that interventions rarely work in the aforementioned way within unlike contexts. Realist systematic reviews are interpretive, and theory driven. Traditional systematic reviews have focused on intervention or program effectiveness. Yet, in most cases, in that location is little indication of how the plan or intervention worked, what contributed to the success, or the barriers and challenges in implementation. Few reviews explore how the context, circumstances and stakeholders influence outcomes [1]. Realist systematic reviews explore the interconnectedness between context, mechanism, and outcomes (CMO) [55, 57, 58]. From this review, we will develop extensive understandings about oral health interventions for people with mental disorders. The developed theory volition guide policy and practice.

Aim and review questions

The aim of this realist systematic review is to (a) identify and synthesise studies that explore oral wellness interventions for people living with mental disorders; (b) explore the context and mechanisms that have contributed to the success of interventions or the barriers and challenges; (c) produce program theories on causal contextual and mechanistic factors to facilitate outcomes and (d) produce recommendations and guidelines to guide future oral health interventions for people with mental disorders at both the policy and practice level [57]. The DSM-5 Diagnostic Classification has been used to guide the disorders that will be considered [59]. The post-obit review questions will be answered:

  1. 1

    What are the contextual factors at the local, service, and system level that affect on the success or failure of oral health interventions for people with mental disorders?

  2. two

    What are the mechanisms that take led to success or failure?

  3. three

    Are there contextual and mechanistic factors that are consistent across studies of oral health interventions for people with mental disorders?

  4. 4

    What causal theories can describe the bear upon of these contextual and mechanistic factors, and how might they influence policy and practice?

This review protocol is registered with PROSPERO (Number) 155969.

Methods

The methods used in this review are novel just aligned to the theory-driven approach that underpins the realist systematic review method [56, 60]. While the approach is based on the five-stride process of Pawson et al. [1]: clarifying scope, searching for evidence, appraising primary studies and extracting information, synthesising evidence and cartoon conclusions, and disseminating, implementing and evaluating, we strengthen the review through integrated primary data drove. A key feature of realist systematic reviews is the input of stakeholders throughout the review to back up theory generation, noesis translation, and bear on [ane, 58]. Cooper and colleagues [61] used this combination of primary (stakeholder input) and secondary (literature searching and synthesis) data in their review of complex interventions to preclude adolescents from engaging in multiple risk behaviours. They argued that the incorporation of primary data in their review gave greater insights into causal factors that might non be identified within the literature and, chiefly, provided opportunities for adolescents to accept a strong vocalisation in theory development. In this review, nosotros will describe on our extensive feel of working with policymakers, commissioners, service providers, and people with mental disorders [62,63,64] and our use of innovative methods of data drove, including the employ of blogs [65]. Internationally, health policymakers confirm the need for greater public participation in inquiry [66] and mental health consumers in all stages of service pattern, implementation, and evaluation [62, 67, 68]. The approach will be multifaceted, flexible, and iterative and will involve triangulation of findings across the entire review.

Clarifying scope

The review team is multidisciplinary (oral wellness and dentistry, nursing, public health, psychology, sociology, mental health, social work, and centrolineal health) to capture a multitude of perspectives in the initial development of the review. Pawson and colleagues [1, 58] confirm the need to 'scavenge' ideas in this phase to develop an initial theoretical framework. An initial search of the literature will be undertaken to map out beginning theories of how and why oral health interventions for people with mental disorders might work. Nosotros will accept a local and global approach to stakeholder interest. A state-wide, Australian stakeholder forum (policymakers, commissioners, service providers, consumer acme bodies, mental health consumers, carers and other interested parties) volition be held to consider our initial scoping work and provide expert input into a start theoretical framework. This framework volition describe contextual and mechanistic factors that might impact on the success or failure of oral wellness interventions for people with mental disorders. We will advertise this forum widely through existing professional person and consumer networks, print, and social media. To facilitate nationally and international input, an open-admission weblog will be used to house the beginning theoretical framework, and we will bulldoze input into this framework via social media. The blog will link to a website where findings will be regularly updated. Broad input will exist an important component of our integrated knowledge translation arroyo. Integrated knowledge translation is defined as a process of engagement between researchers and knowledge users (those who will make employ of research findings to inform decisions) [69, 70]. This approach to knowledge translation supports rapid societal impact, a central direction in international research policy [71, 72].

Phase two searching for show

Using the expertise of the inquiry squad a number of primal concepts to guide the search were adult. Table 1 outlines the fundamental concepts that volition be used in the search.

Table 1 Fundamental concepts for search

Full size table

With the support of a specialist healthcare librarian, detailed search strategies will be developed for each database [Medline Ovid, Embase Ovid, PsycINFO, Academic Search Complete, CINAHL EBSCO, Cochrane Oral Health Trials Register, Cochrane Cardinal Register of Controlled Trials (Fundamental) based on the one developed for MEDLINE (Ovid) [see Table two]. MeSH terms will guide the search. Search terms will include truncation or keywords, the utilize of thesaurus terms and subject headings, and combining terms and search strings with the appropriate Boolean operators.

Table 2 Example search for medline

Full size table

Written report designs

In line with the purpose of a realist systematic review [73], quantitative, qualitative, and mixed-method studies will be included. In that location are no data range limitations. Included studies must be published in English, reflecting the significant resource implications associated with translation [74].

Participants and setting

Reviewed studies tin include participants diagnosed with whatsoever mental wellness disorder. Studies tin can be carried out in any setting (including inpatient and customs settings) and tin can be in any geographical location.

Interventions

The review volition include any interventions designed to address oral health outcomes in people with mental disorders. Content of the interventions could include some or all of the following: dental and oral health, oral disease and impact on health, general anaesthesia associated with dental treatment, dietary interventions related to improving oral health, oral hygiene measures, best oral wellness practices for people with mental health disorders, oral hygiene promotion and skills training (for people with mental health disorders or those who care for them in both inpatient and community settings).

Screening of studies

The screening process volition be conducted in four phases: (1) championship and abstract, (2) total text, (3) search of the reference lists and (4) search of citations of all included studies for any further suitable studies. This phased approach aims to capture a breadth of studies.

Table iii outlines the inclusion and exclusion criteria that volition guide the review.

Tabular array iii Inclusion and exclusion criteria

Full size table

Endnote (bibliographic software plan) and Covidence (Cochrane's systematic review direction software) volition be used to manage search results. A sample of 25 manufactures will exist assessed by all reviewers to ensure reliability in the application of the inclusion and exclusion criteria. Discussion will occur to ensure that the team are applying criteria in the same mode. Covidence software supports a bullheaded review process, and at each phase, at least two reviewers volition screen articles. Conflicts are highlighted by the software and discrepancies volition be discussed until consensus is reached. To ensure inclusion of all relevant studies, the reference lists of all studies captured as a result of phases 1 and 2 will be examined manually, and Web of Scientific discipline/Scopus volition exist used to identify citations of all included full-text articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses, (PRISMA) [75] checklist will be used to guide the review, and all stages of the study option will be documented using a PRISMA flow chart [75].

Data extraction

To address the review questions, information will be extracted on population, study design, intervention, and outcomes. Consistent with realist review methods and the enquiry questions, data extraction volition include the contextual factors at local through to organisation level, that impact on the success or failure of oral wellness interventions for people with mental disorders and the mechanisms that accept led to success or failure. A minimum of two reviewers volition check data extraction tables, and disagreements will be discussed until consensus is reached. As data is extracted, the first theoretical framework from stage 1 will be populated with show and shared, using the website and blog.

Quality appraisal

Equally the aim of realist systematic reviews is to identify the interplay between context, mechanism, and effect [56], no studies will be excluded based on methodological quality. Three tools will be utilised to assess studies depending on study pattern: the Cochrane Collaboration Tool for Assessing Run a risk of Bias in Randomised Trials [76] and the Adventure of Bias in Non-Randomised Studies of Interventions (ROBINS-I) [77] for quantitative studies and the Critical Appraisal Skills Program (CASP) Checklist for Qualitative Research [78]. A minimum of two reviewers will assess all studies and disagreements betwixt authors volition be resolved through team discussion. Quality appraisal results will be presented in a single table.

Information assay

Data synthesis in realist reviews is guided by the RAMESES Standards [2, 79], which comprises a combination of inductive and deductive analytical processes directed at farther building an explanatory theory almost the context, mechanism, outcome (CMO) relationships of the interventions nether investigation. Two reviewers volition independently code data segments representing the CMO in each reviewed commodity. The enquiry team will produce a narrative synthesis that draws upon Pawson's [55] techniques: 'juxtaposing' sources to enable broader insights, 'reconciling' unlike outcomes within unlike contexts, 'adjudicating' between studies on the basis of methodological strengths and weaknesses, 'consolidation' of explanations of differences between studies, and 'situating' studies in their contexts. The overall aim volition be to identify contextual and mechanistic factors that are consistent across studies of oral health interventions for people with mental disorders.

Dissemination, implementation, and evaluation

An boosted state-wide, stakeholder forum will be conducted to refine and ostend the causal theory on the impact of contextual and mechanistic factors. Discussion will occur on how the theory might influence policy and further development and implementation of interventions. As in the first stage stage, the findings from this forum will be shared via the website and blog for further input.

An integrated knowledge translation (iKT) [69, 70] approach will exist adopted throughout this review. To increase the relevance, applicability and bear upon of the review, primal stakeholder participation will exist widely utilized. In addition to traditional academic methods of dissemination such every bit publications and conference presentations, other communication modes volition be used, including infographics, blogs, social media postings, webinars, and podcasts.

Strengths and challenges

Previous systematic reviews on the oral health of people with mental disorders have focused mainly on oral health risks, barriers for oral health, and the effectiveness of interventions. Taking a realist review approach will add significantly to the knowledge base as context and mechanism volition exist considered. The work of Abayneh et al. [56], provides a good guide to differentiating between context and mechanism, and we volition describe on their processes to ensure squad consistency in how key terms and concepts are applied. Team discussion and codebooks will be used to document decisions. We acknowledge the challenges of reproducing a realistic systematic review considering of the approaches taken [80]. By detailing each stride and documenting and tabulating summary tables of what is found, nosotros will conspicuously signal how conclusions were fabricated.

Discussion and conclusion

This volition be the first review to take a realist approach to explore the contextual and mechanistic factors from private, service, and system-level that bear upon on the success or failure of oral wellness interventions for people with mental disorders. We will place factors that are consistent across studies to develop a theory on how the blueprint and implementation of oral health interventions might amend encounter the needs of the ascent number of people with mental disorders.

The novel approach to active stakeholder engagement advances realist systematic review methodology. Through extensive local, national, and international stakeholder engagement, nosotros will gain greater insights into causal factors that might be missed with a more conventional systematic review. Engaging stakeholders in this early stage is likewise critical for future broadcasting and implementation of evidence. Our arroyo will ensure that people with lived feel of mental disorders are provided with opportunities to inform the design and evolution of future oral health interventions.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable asking.

Abbreviations

WHO:

World Health Arrangement

DALYs:

Disability-adjusted life years

YLDs:

Years lived with inability

DMFT:

Decayed, missing or filled teeth

DMFS:

Rust-covered, missing or filled surfaces

CMO:

Context, mechanism, effect

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

RAMESES:

Realist and meta-narrative evidence syntheses: evolving standards

ROBINS-I:

Take chances of bias in non-randomised studies of interventions

CASP:

Critical appraisement skills plan

iKT:

Integrated noesis translation

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Acknowledgements

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Author information

Affiliations

  1. Violet Vines Marshman Center for Rural Health Inquiry, LaTrobe Rural Health School, P.O. Box 199, Bendigo, VIC, 3552, Australia

    Amanda Kenny, Virginia Dickson-Swift, Dianne Cox, David Azul, Jacqui Theobold, Brad Hodge, Carol McKinstry, Danielle Couch, Nerida Hyett, Prabhakar Veginadu & Nastaran Doroud

  2. Higher of Social Science University of Lincoln, Brayford Pool, Lincoln, Lincolnshire, LN6 7TS, UK

    Mark Gussy

  3. Mental Health Nursing, Mental Health Nurse Practitioner, Victoria University, Footscray, VIC, Commonwealth of australia

    Susan Kidd

  4. LaTrobe Rural Wellness School, Wellness School, Dentistry and Oral Health, P.O. Box 199, Bendigo, VIC, 3552, Australia

    Mohd Masood, Bradley Christian & Ron Knevel

  5. School of Psychology and Public Health, LaTrobe University, Bendigo, Australia

    Carina Chan

Contributions

AK, VD and MG conceptualised the written report protocol and all authors (AK, VD, MG, SK, DC, MM, DA, CC, BC, JT, BH, RK, CMC, DC, NH, PV and ND) contributed to the development, writing and reviewing of the protocol certificate. All authors read and approved the terminal manuscript.

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Correspondence to Virginia Dickson-Swift.

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Kenny, A., Dickson-Swift, V., Gussy, M. et al. Oral health interventions for people living with mental disorders: protocol for a realist systematic review. Int J Ment Health Syst 14, 24 (2020). https://doi.org/10.1186/s13033-020-00357-viii

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  • DOI : https://doi.org/ten.1186/s13033-020-00357-8

Keywords

  • Mental disorder
  • Oral health
  • Realist systematic review

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