Primary care, mental illness and dental hygiene

No mental health without physical health; and no physical health without oral health.

Carolyn A. Chew-Graham*, Christopher Dowrick and David Shiers *** call for health and social care practitioners to embrace The Right To Smile – a new consensus to tackle this serious and neglected health disparity. 

An ignored health inequality. The importance of protecting the physical health of people experiencing severe mental illness (SMI) is established and supported in many countries by policies and targets for tackling disorders like diabetes and cardiovascular disease (WHO 2018).  By comparison, inequalities in oral health have so far received scant attention.  Yet, compared to the general population, research shows people with SMI (Chang et al. 2013; Choi et al. 2021; Turner et al.2022):

  • Are three times more likely to lose all their natural teeth
  • Have on average five more decayed teeth
  • Are twice as likely to experience late detection of oral cancer, and less likely to receive specialised treatments
  • Are less likely to brush their teeth 
  • Are less likely to access routine dental services.

A vicious cycle.  Poor oral health may not be simply experienced as painful tooth decay or inflamed gums.  Poor oral health also affects the quality of peoples’ lives (Patel et al 2012) and can directly impact on their already precarious mental health:

  • Feeling ashamed to open their mouth because of bad breath or unsightly teeth affects how they feel about themselves
  • Lacking the confidence to laugh, to smile, or to be close to others, can affect relationships and result in social isolation which directly affects mental health
  • Functions as basic as talking and eating may be impaired which impacts on general health and well-being.  

Moreover, the vicious cycle may go beyond an interaction simply between mental and oral health.  Poor oral health can also adversely interact with other health conditions like diabetes and heart disease (Teeuw et al 2010; Xu et al 2017). For instance, poor oral health can impact on diabetes control, while diabetes makes gum disease more likely.  Diabetes and cardiovascular disease are particularly prevalent in this population, potentially creating a complex and harmful cycle of interdependent difficulties for an individual.

An ounce of prevention is worth a pound of cure:  Dental diseases like tooth decay, gum disease and oral cancer are preventable.   They should not be the inevitable consequence of experiencing a severe mental illness.   We therefore need to shift our focus from ‘downstream’ treatments that commonly involve extraction of teeth and are offered in crisis for advanced tooth decay and gum disease, to ‘upstream’ prevention and early intervention. 

Achieving this shift demands a collaborative ‘whole team approach' between mental health, dentistry, primary care and social care.   And within this, General practitioners (GPs) have a key role in promoting health and preventing disease (WONCA Europe 2011), the essence of the Right to Smile.  With some simple actions, GPs can make a real difference to this health inequality:

1.‘Making every contact count’ - consider oral health whenever we consult with our patients with severe mental illness (Parchment et al, 2021)

2.Annual physical health check for people with SMI: (NHS Engalnd Quality Outcome Framework 2022/23) ensure health promotion advice about healthy eating, tobacco and substance use, also prompts discussion and support around oral health

  • Reinforce positive oral self-care behaviours such as reducing frequency of sugar intake, cessation of smoking, and limiting alcohol intake
  • Encourage regular toothbrushing with a fluoride toothpaste  
  • Signpost those not attending regular check-ups to a dental service.

3. Raise awareness in carers of the importance of oral health for those they support; offer advice and information on how they can encourage good oral hygiene.

In response to increasingly robust evidence, The Right to Smile campaign believes that tackling this health inequality is overdue and deserves urgent attention. As trusted and holistic practitioners, GPs can play a critical role in equipping their patients with the right knowledge and skills, while supporting the adoption of healthy routines including regular dental check-ups before things go wrong, we can make a real difference to an individual’s health and their well-being.

* Carolyn A Chew-Graham is a GP in Manchester and Professor of General Practice Research at Keele University, UK.
**Christopher Dowrick is a GP, Past Chair of the WONCA Working Party for Mental Health and Emeritus Professor at the University of Liverpool, UK
***David Shiers is a carer for his daughter with severe mental illness, and a former GP in Leek, UK.


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