Oral health self-care behaviours in people with a serious mental illness

shutterstock_3909307 middle aged man with missing teeth

A number of studies have highlighted that oral health is poorer in patients with mental health problems. This may be linked to barriers assessing care, smoking and alcohol use and poor diet or dental phobia although drugs used for treatment may also increase risk of dental diseases (Dental Elf – 7th Aug 2017). However good oral health self-care behaviours have the potential to reduce the risk of dental diseases.

The aim of this review was to understand the levels of oral health self-care behaviours in people with serious mental illness (SMI).


Searches were conducted in the Medline, Embase, PsychINFO and CINHAL databases from January 1980 and April 2020.  Case-control, cohort, cross-sectional, longitudinal and epidemiological study designs that included a quantitative measure of oral health self-care and published in English were considered.  Oral health self-care behaviour included as actions to improve or preserve good oral health, e.g., owning a toothbrush, dental care attendance and frequency of toothbrushing.  Serious mental illness (SMI) included people with a diagnosis of a psychotic or a bipolar spectrum disorder and included those with schizophrenia, schizophreniform, schizoaffective disorder, delusional disorder, bipolar I and bipolar II. Initial screening was undertaken by a single reviewer with a 10% sample being assessed by a second reviewer, 2 reviewers screened full papers to confirm inclusion. Data was extracted by a single reviewer and quality assessed by two reviewers using an adapted version of the Effective Public Health Practice Project (EPHPP) tool.


  • 33 studies involving a total of 446,932 people with SMI were included.
  • The quality of 6 studies was rated as strong, 7 moderate and 20 weak.
  • Dental Services use
    • 23 studies, 16 on those with a psychotic disorder, 1 on bipolar disorder, 6 on mixed SMI samples.
    • A weighted average from 8 cross-sectional studies found that 34% had visited a dentist in pervious 12 months with 1 epidemiological study indicating a figure of 43%.
    • 9 studies contributed to a meta-analysis which showed that people with SMI were significantly less likely to access dental services, odds ratio (OR) = 0.46 (95%CI; 0.32 to 0.65).
  • Toothbrushing frequency
    • 21 studies reported on with a weighted average from 10 studies showing that only 39% of patients with a SMI brushed their teeth twice a day.
    • 5 case control studies a meta-analysis showing that those with a SMI significantly less likely to brush their teeth than controls. OR = 0.19 (95%CI; 0.08 to 0.42)
  • Toothbrush ownership and maintenance
    • 2 weak studies reported toothbrush ownership between 64-70% in people with SMI.
    • 3 studies reported on change of toothbrush with one reporting only 1.8% of people with SMI changed their toothbrush every three months with the other studies reporting that between 25% to 33% did.
  • Toothbrush technique
    • 3 weak studies reported on technique finding that between 6% and 98.2% of people with a SMI used the incorrect brushing technique.
  • Flossing frequency
    • 3 weak studies reported that flossing behaviour ranged from 11% to 20% in those with SMI.
  • Mouthwash
    • 3 weak studies reported mouthwash use to range for 4.7% to 35% .


The authors concluded: –

…findings from this review indicate that oral health self-care behaviours are reduced in people with an SMI. Further research is needed to explore which factors affect the uptake of behaviours and how mental health difficulties are a risk factor for poor oral health outcomes. The recent Lancet Commission called for better integration of mental and physical care. The results from this review indicate that this should also encompass dental care to meet the wide-ranging and complex needs of this client group, and to ensure effective early screening, monitoring and intervention in oral health.


The authors registered their review on PROSPERO and searched a number of major databases. 33 studies although the restriction of English language studies in peer reviewed journal may have excluded some relevant studies. A majority of the included studies were of a cross-sectional design (54.5%) with 20 out of the 33 studies being considered to be of weak design. The authors also highlighted that the outcomes of interested were not often the main focus of the included studies so often used unvalidated measures.  The review indicates that people with SMI are significantly less likely to access dental services and frequently brush their teeth when compared to the general population and hints that flossing, mouthwash use and ownership and maintenance of materials for oral health self-care behaviours are low. The reasons are likely to multifactorial but more work is needed to improve access  to oral health services for this group of patients and more high quality research to address and support their oral health needs.


Primary Paper

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. Epub 2021 May 3. PMID: 33862664.

Review protocol on PROSPERO

Other references

Dental Elf – 16th Sep 2016


Dental Elf – 7th Aug 2017

Medication for mental health: Oral health impacts

Dental Elf – 16th Aug 2017

Barriers and enablers to dental care for people affected by mental health disorders

Dental Elf – 6th Mar 2015

Poor oral health and severe mental illness: what are the links?



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