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Published Online: 16 September 2019

Oral Health–Related Quality of Life Among Publicly Insured Mental Health Service Outpatients With Serious Mental Illness

Abstract

Objective:

The study investigated factors associated with unmet need for dental care and oral health–related quality of life (OHQoL) among individuals with serious mental illness receiving outpatient care in a public mental health program serving a largely low-income population, mostly from racial-ethnic minority groups.

Methods:

Cross-sectional interview data were collected from a convenience sample (N=150) of outpatients. Adjusted risk ratios (ARRs) and adjusted risk differences (ARDs) were estimated by logistic regression models to examine the independent contribution of sociodemographic and clinical factors to low OHQoL and past-year unmet dental need, defined as inability to obtain all needed dental care.

Results:

More than half of participants reported low OHQoL (54%) and a past-year dental visit (61%). Over one-third (39%) had past-year unmet dental need. Financial barriers (ARR=3.16) and nonfinancial barriers (ARR=2.18) were associated with greater risk for past-year unmet dental need after control for age, gender, high dental anxiety, and limited English proficiency. ARDs for financial and nonfinancial barriers indicated absolute differences of 40 and 27 percentage points, respectively. Unmet dental need (ARR=1.31), xerostomia severity (ARR=1.20), and a schizophrenia spectrum diagnosis (ARR=1.33) were associated with low OHQoL, after control for age and current smoking, with ARDs ranging from 11 to 15 percentage points.

Conclusions:

Improving oral health promotion, oral health service access, and the integration of the mental and oral health systems may help reduce the high prevalence of low OHQoL in this population, given that low OHQoL is partly driven by unmet dental need.

HIGHLIGHTS

Over half of a convenience sample of publicly insured outpatients with serious mental illness reported low oral health–related quality of life (OHQoL) in the past year, a rate much higher than in the general U.S. population, despite having seen a dentist in the past year at a high rate.
Over one-third reported having unmet dental need in the past year, and—controlling for gender, high dental anxiety, and limited English proficiency—financial and nonfinancial barriers were significantly associated with unmet need.
Low OHQoL was significantly associated with past-year unmet dental need, xerostomia severity, and a schizophrenia spectrum diagnosis, after control for age and smoking status.
Public insurance reforms that improve access to dental services, and integration between mental health and dental systems, may help reduce rates of low OHQoL among individuals with serious mental illness receiving public mental health services.
Individuals with serious mental illness, such as schizophrenia or bipolar disorder, tend to have worse oral health than individuals without these psychiatric conditions, including higher rates of untreated caries and temporomandibular joint disorder, increased tooth decay and tooth loss, greater need for tooth extractions, and worse periodontal health (16). Concerns about their patients’ oral health rank high among providers who treat persons with serious mental illness (7), and there is increasing acknowledgment that improving oral health can improve mental health (8).
The causes of the high prevalence of poor oral health among individuals with serious mental illness are unclear. Higher than average poverty rates (9) likely contribute, given that low socioeconomic status is associated with poor oral health (10). Individuals with serious mental illness may be more exposed to barriers to dental service use, such as high dental costs and limited dental insurance coverage, resulting in poor oral health (11, 12). Dental anxiety, a form of apprehension or even phobia about dental procedures, may be elevated among individuals with psychiatric disorders and potentially hinder dental care (13, 14). Limited English proficiency (LEP) may also hamper access to dental services among patient subpopulations (15). However, even when persons with serious mental illness attend dental appointments at similar rates as individuals without these conditions, they are more likely to have unmet dental needs (16), exposing the limitations of the dental services available to them and the role of factors other than service use.
Other factors potentially associated with poor oral health among individuals with serious mental illness include xerostomia (oral dryness), due to the anticholinergic effect of psychiatric medications and associated with caries and periodontal disease (1719); smoking, common among individuals with psychiatric disorders and associated with higher risk of periodontal disease and oral cancers (20, 21); and self-care limitations and poor dietary practices associated with psychiatric diagnoses, especially schizophrenia and related disorders (4, 2224).
To help identify modifiable targets for oral health improvement initiatives among individuals with serious mental illness, we examined potential factors associated with poor oral health in a public mental health outpatient program serving a largely low-income population primarily of individuals from racial-ethnic minority groups, underserved groups at risk of poor oral health (10, 19, 25) and low dental service use (26, 27). First, we examined the association of past-year unmet dental need with past-year dental service use, financial and nonfinancial barriers, dental anxiety, and LEP. Next, after controlling for xerostomia, smoking status, schizophrenia spectrum disorder, and other factors, we examined the association of past-year unmet dental need with low oral health quality of life (OHQoL), a multidimensional subjective assessment associated with health-related quality of life and general well-being (28, 29) that encapsulates functional (e.g., eating) and psychosocial (e.g., self-esteem and social functioning) dimensions (3032).

Methods

Sample

Participants were recruited by using convenience sampling from a public mental health service treating patients with serious mental illness in upper Manhattan in June–September 2014. Patients self-selected for participation by approaching study staff at research tables in the clinic or by completing a sign-up sheet. Study staff screened interested patients for the following eligibility criteria: English or Spanish fluency, absence of dementia on a screening instrument for patients over age 64 (33, 34), and capacity to consent (35). Bilingual research staff conducted interviews in the participant’s choice of language (English or Spanish). Published Spanish translations were used, except for the xerostomia scale, which was forward-translated with bilingual committee review. The Institutional Review Board of the New York State Psychiatric Institute approved this study.
We assessed 189 patients for participation, excluding 39 patients (eligible [incomplete interview, N=1; declined participation, N=9; missed screening, N=15] or ineligible, N=14), for a total of 150 participants.

Measures

OHQoL.

The 14-item Oral Health Impact Profile (OHIP-14) (36, 37) assesses OHQoL (38, 39). Items rate the frequency of the impact of oral health problems in the past 12 months on a scale from 0 (never) to 4 (very often), with higher scores indicating worse OHQoL. The OHIP-14 is reliable in diverse settings and populations, including Latinos (40). Internal reliability in our sample was high (Cronbach’s α=.93). We defined low OHQoL as any OHIP-14 item occurring at least fairly often (37, 41).

Unmet need for dental care.

Past-year unmet need for dental care was based on a binary item from the 2013 National Health and Nutrition Examination Survey (NHANES) section on oral health (42) that asked whether the participant needed dental care in the past year but was unable to obtain all the care that was needed.

Dental visit.

Past-year dental visit was based on patients’ self-reported last visit to a dental care provider (dental hygienist, dentist, orthodontist, oral surgeon, or other dental specialist) during the past year.

Perceived barriers to seeking or receiving needed dental care.

Because cost is the most common barrier to dental care (11, 43), we examined financial and nonfinancial barriers separately using 2013 NHANES oral health items (42). Financial barriers (three items) were lack of dental insurance, inability to pay for dental services, and concern about treatment cost. Nonfinancial barriers (11 items) were lack of transportation, excessive wait for appointment, inability to obtain needed appointments, inability to take time off work, language problems, inconvenient clinic hours, patients without someone to accompany them to the appointment, being excessively busy, fear of visit due to immigration status, not knowing where to seek services, and not thinking problem was serious or expecting it to go away. Both types of barriers were analyzed dichotomously (any/none).

Xerostomia.

The five-item Summated Xerostomia Inventory (SXI) assesses the frequency of dry mouth symptoms on a 3-point scale (1, never; 2, occasionally; and 3, often). Possible scores range from 5 to 15, with higher scores indicating greater severity. This measure performs reliably, with scores associated significantly with a gold-standard measure of oral dryness (44). The SXI had adequate reliability in our sample (Cronbach’s α=.75). SXI score was centered on the sample mean score of 7.72.

Dental anxiety.

The five-item Modified Dental Anxiety Scale (MDAS) (45) measures participants’ expected anxiety at various time points before a dental visit, from the day before to the moment of treatment, on a 5-point scale, from 1, not at all anxious, to 5, extremely anxious. The scale has high reliability (Cronbach’s α=.89) (46), with good reliability in our sample (Cronbach’s α=.82). Summed scores (possible range, 5–25) were analyzed dichotomously (high anxiety, ≥19, and low anxiety, <19) (47, 48).

Psychiatric diagnosis.

Analyses of self-reported psychiatric diagnoses compared outcomes for schizophrenia spectrum diagnoses (schizophrenia or schizoaffective disorder) versus other diagnoses.

Data Analysis

We examined the bivariate associations of past-year unmet dental need with past-year dental visit, barriers in seeking or receiving care, age (5-year units), gender, and LEP (speaking English less than very well) (49). We then examined their adjusted associations using a multivariable binomial logistic regression model. We also examined bivariate associations of low OHQoL with past-year dental visit, xerostomia, age (5-year units), current smoker (smoking ≥5 cigarette packs over the lifespan and currently smoking every day or some days) (50), and schizophrenia spectrum diagnosis; adjusted associations were estimated with a multivariable binomial logistic regression model. We obtained the adjusted risk ratio (ARR) (the ratio of the mean predicted probabilities) and the adjusted risk difference (ARD) (the difference in the mean predicted probabilities or the excess disease burden associated with a factor) using the adjrr package in Stata SE 12.1 (51). This follows recommendations to report relative and absolute measures of association which can provide comprehensive information useful to patients and providers (51, 52). All significance tests were two-sided with α=.05.

Results

Participants (N=150) had a mean±SD age of 50.77±14.98 years and were predominantly female (63%) (Table 1). Most participants were Hispanics (78%), were born in the Dominican Republic (51%), spoke Spanish at home (72%), and had LEP (68%). Most had a high school education or less (73%) and an annual household income under $20,000 (89%). Almost all (94%) were unemployed, disabled, or otherwise out of the labor force. About half of participants reported a lifetime schizophrenia spectrum disorder (53%), and 21% were current smokers. The mean SXI score (7.72) indicated a level of xerostomia in the lower half of the range, and 27% of participants had high dental anxiety. All participants were covered by Medicaid (58%), Medicare (14%), or both (28%).
TABLE 1. Characteristics of a convenience sample of 150 publicly insured outpatients with serious mental illnessa
CharacteristicN%
Sociodemographic  
 Age (M±SD)50.77±14.98 
 Female gender9563
 Race-ethnicity  
  Non-Hispanic white139
  Non-Hispanic black1812
  Non-Hispanic otherb21
  Hispanic11778
 Highest level of education  
  Less than high school6644
  High school graduate/GED4429
  Some college2819
  College graduate or more128
 Annual household income (N=130)  
  <$5,0002620
  $5,000 to $9,9995341
  $10,000 to $19,9993628
  ≥$20,0001512
 Employment status  
  Employed, full- or part-time96
  Unemployed3523
  Disabled8657
  Otherwise not in labor forcec2013
 Country of birth  
  U.S., excluding Puerto Rico5235
  Dominican Republic7751
  Otherd2114
 Limited English proficiency10268
 Language spoken at home  
  English3825
  Spanish10872
  Othere43
Clinical  
 Low oral health–related quality of lifef8154
 Summated Xerostomia Inventory score (M±SD)g7.72±2.38 
 Lifetime schizophrenia spectrum diagnosish8053
 High dental anxiety (N=144)3927
 Current smoker3121
Service-related  
 Past-year unmet need for dental care (N=148)5739
 Past-year dental visit9161
 Health insurance  
  Medicaid only8758
  Medicare only2114
  Medicaid and Medicare4228
 Perceived barriers in seeking or receiving dental care in past year  
  Financial barrier7147
   Concerned about cost (N=148)6645
   Unable to pay for dental services (N=148)5034
   Not having dental insurance (N=147)2819
  Nonfinancial barrier8657
   Did not think anything was seriously wrong/thinking problem would go away (N=147)4128
   Too long a wait for an appointment4128
   Unable to get an appointment when needed (N=148)3624
   No one available to accompany patient to appointment (N=148)2718
   Not knowing where to seek dental services2517
   Not having transportation (N=147)2215
   Language problems (N=147)2215
   Too busy (N=147)2114
   Inconvenient dental clinic hours (N=147)1812
   Afraid because of immigration status (N=147)118
   Unable to take time off work (N=129)86
a
The number of respondents for whom data were available, if less than 150, is provided in parentheses.
b
Responses include Greek Orthodox (N=1) and mixed race (N=1).
c
Includes retired individuals (N=13), students (N=5), and homemakers (N=2).
d
Includes Puerto Rico (N=6); Cuba, Mexico, and Greece (N=2 each); and Costa Rica, Haiti, Jamaica, Nicaragua, Panama, St. Kitts & Nevis, Trinidad, and Yemen (N=1 each).
e
Includes Greek (N=2) and Arabic and Creole (N=1 each).
f
Low oral health–related quality of life was defined as reporting any item on the 14-item Oral Health Impact Profile as occurring at least “fairly often.”
g
Possible scores range from 5 to 15, with higher scores indicating greater severity of xerostomia (dry mouth).
h
Includes self-reported schizophrenia and schizoaffective disorder. Other lifetime diagnoses are bipolar disorders (N=46), other mood disorders (N=39), anxiety disorders (N=49), substance use disorders (N=13), and impulse control disorders (N=11). Some individuals reported more than one disorder.
Low OHQoL was reported by 54% of participants, a past-year dental visit by 61%, and past-year unmet need for dental care by 39% (Table 1). Almost half of participants reported a financial barrier to seeking/receiving needed dental care (47%), with cost concerns reported most commonly (45%). Nonfinancial barriers to seeking/receiving needed dental care were reported by 57% of participants; the most common barriers were thinking that the problem was not serious or expecting it to go away (28%), long wait for appointment (28%), and inability to get an appointment when needed (24%). In post hoc analyses, 44% (N=57) of participants with Medicaid coverage reported any financial barrier compared with 67% (N=14) of participants with Medicare alone (χ2=3.66, df=1, p=0.056).
We examined correlates of past-year unmet dental need initially with unadjusted associations. Nearly 58% (N=33 of 57) of patients who reported past-year unmet need for dental care had a past-year dental visit; this association was nonsignificant. Among participants experiencing any barriers, the proportions reporting an unmet dental need were significantly greater than the proportions without such a barrier (63% with financial barrier versus 16% without, χ2=35.63, df=1, p<0.001; 55% with nonfinancial barrier versus 16% without, χ2=23.74, df=1, p<0.001) (Table 2).
TABLE 2. Association of unmet dental need and characteristics of 150 publicly insured outpatients with serious mental illnessa
CharacteristicTotal NUnmet dental needTeststatisticbpAdjusted risk ratio (ARR)c95% CIAdjusted risk difference (ARD)c95% CI
N%
Aged   t=.85.3971.08.94 to 1.25.02*.00 to .03e
 Unmet need5752.25±13.16       
 No unmet need9150.10±15.95       
Gender         
 Female (reference)944144χ2=2.83.0921.18.79 to 1.76.06–.09 to .21
 Male541630      
Financial barrier         
 Any714563χ2=35.64<.001**3.16*1.79 to 5.57.40*.24 to .55
 None (reference)771216      
Nonfinancial barrier         
 Any854755χ2=23.74<.001**2.18*1.24 to 3.84.27*.11 to .43
 None (reference)631016      
Dental anxiety         
 High391744χ2=.50.481.94.64 to 1.38–.02–.17 to .12
 Low (reference)1053937      
Limited English proficiency         
 Yes1014444χ2=3.43.0641.13.77 to 1.69.05–.10 to .20
 No (reference)471328      
a
Six respondents were excluded from regression models because of missing data for any of the variables. Past-year unmet need was defined as reporting a time in the past 12 months when one could not get needed dental care.
b
df=1.
c
ARRs and ARDs were calculated from multivariable logistic regression models.
d
Age was measured in 5-year increments.
e
.0028 to .0305 before rounding.
*
p<.05, **p<.001.
In the adjusted model, participants with financial barriers (ARR=3.16) and nonfinancial barriers (ARR=2.18) remained significantly more likely to have past-year unmet dental need than participants without these barriers. In terms of absolute differences, participants reporting any financial or nonfinancial barriers had higher risk of past-year unmet dental need by 40 and 27 percentage points, respectively, than those without such barriers. Each 5-year increment in age was associated with greater risk of unmet need in terms of absolute difference (ARD=1.02, 95% confidence interval [CI]=0.00–0.03) but was nonsignificant in terms of relative difference. The associations of gender, high dental anxiety, and LEP with past year unmet need were nonsignificant (Table 2).
A greater proportion of participants with past-year unmet need had low OHQoL than those without unmet need (67% versus 46%; χ2=5.94, df=1, p=0.01) (Table 3). However, the proportion of participants with low OHQoL did not differ by whether participants had a past-year dental visit (54% [N=49 of 91]) versus without a visit (54% [N=32 of 59]).
TABLE 3. Association of low oral health–related quality of life (OHQoL) and characteristics of 150 publicly insured outpatients with serious mental illnessa
CharacteristicTotal NLow OHQoLTest statisticpAdjusted risk ratio (ARR)b95% CIAdjusted risk difference (ARD)b95% CI
N%
Agec   t=1.98d.0501.08.98 to 1.18.02*.01 to.03
 Low OHQoL8152.98±13.52       
 No low OHQoL6948.17±16.25       
Xerostomiae   t=6.28f<.001**1.20*1.12 to 1.29.11*.07 to.16
 Low OHQoL81.98±2.41       
 No low OHQoL69–1.15±1.75       
Past-year unmet dental needg         
 Yes573867χ2=5.94d.015*1.31*1.00 to 1.70.15.00 to.30h
 No (reference)914246      
Current smoker         
 Yes311961χ2=.84d.3611.11.83 to 1.48.06–.11 to .22
 No (reference)1196252      
Schizophrenia-spectrum disorder         
 Yes804658χ2=.85d.3581.33*1.01 to 1.76.15*.01 to .29
 No (reference)703550      
a
Two respondents were excluded from regression models because of missing data for any of the variables. Low OHQoL was defined as reporting that any item on the 14-item Oral Health Impact Profile occurred at least “fairly often.”
b
ARRs and ARDs were calculated from multivariable logistic regression models.
c
Age was measured in 5-year increments.
d
df=1.
e
Xerostomia was assessed with sum score on the Summated Xerostomia Inventory, ranging from 5 to 15, and scores were centered around the sample mean of 7.72±2.38.
f
df=144.
g
Past-year unmet need was defined as reporting a time in the past 12 months when one could not get needed dental care.
h
–.0007 to .2952 before rounding.
*
p<.05, **p<.001.
After control for the relevant factors listed in Table 3, past-year unmet dental need remained significantly associated with increased risk of low OHQoL (ARR=1.31, 95% CI=1.00–1.70), with an absolute difference of 15 percentage points (95% CI=–0.00 to 0.30) (Table 3). Xerostomia score (ARR=1.20) and schizophrenia spectrum disorder (ARR=1.33) were also associated with higher risk of low OHQoL. A 1-point increase in the mean xerostomia score increased the adjusted risk of low OHQoL by 11 percentage points, and having a schizophrenia spectrum disorder increased the adjusted risk of low OHQoL by 15 percentage points. Current smoker status was not significantly associated with risk for low OHQoL in both relative and absolute differences. The association between age and adjusted relative risk of OHQoL was nonsignificant, but each 5-year increment in age significantly increased the adjusted absolute risk of low OHQoL by 2 percentage points.

Discussion

Our exploratory study of the oral health of underserved patients with serious mental illness in a public outpatient mental health program found a high prevalence of unmet dental need and of low OHQoL, despite a high rate of dental visits. Participants with a financial or nonfinancial barrier were more likely to have past-year unmet dental need. Significant independent associations with low OHQoL were found for past-year unmet dental need, xerostomia, and schizophrenia-spectrum disorder, but past-year dental visit was not associated with low OHQoL.
Over half of the participants reported low OHQoL (54%), much higher than the prevalence of 15% found in a U.S. population study that used a version of the OHIP that is psychometrically comparable to the version used in our study (37). Our finding is consistent with findings from the United Kingdom of elevated low OHQoL among people with severe mental illness compared with a national sample (53). This finding is notable given the high rate of past-year dental visit (61%) in our sample, greater than rates of 31% for New York State Medicaid enrollees in 2013–2015 (Behavioral Risk Factor Surveillance System data) (54) and 42% for U.S. adults in 2014 (Medical Expenditure Panel Survey [MEPS] data) (55). It indicates elevated vulnerability in our sample that is likely associated with exposure to intersecting clinical and demographic risk factors (10, 26). It also warrants further research on strategies to improve oral health among individuals with psychiatric disorders, given that this may lead to improved mental health outcomes (8).
Unmet dental need may partly explain why we observed elevated low OHQoL reporting. Over one-third of participants reported any past-year unmet dental need, compared with 10% of participants with serious mental illness in the nationally representative MEPS (16). Unmet need remained independently associated with low OHQoL in our sample, even after adjusting for clinical factors.
Our finding that financial barriers remain a major hurdle to reducing unmet need in a publicly insured sample is consistent with national data and supports the expansion of covered dental services and benefits. Nationally, cost is the top barrier to a past-year dentist visit regardless of age, income, and type of dental insurance coverage (56). Exploratory results suggest that financial barriers to dental care may be more common with Medicare than with Medicaid but the difference was nonsignificant. Further examination is needed to understand variations in unmet dental need associated with different forms of public insurance. Medicaid dental coverage varies widely by state; in November 2018 only 19 states, including New York, provided “extensive” coverage, defined as including more than 100 covered procedures and having a spending cap that exceeds $1,000 per person per year (57). At the time of data collection, New York’s Medicaid coverage excluded root canals, immediate dentures, and most periodontal surgeries (58). Recent changes in New York’s Medicaid program cover prosthodontics (full/partial dentures) and some dental implants (e.g., molar root canals) (58) but require prior approval and substantial documentation. Financial barriers may be worse for those with original Medicare or traditional fee-for-service Medicare, which excludes routine dental care such as cleanings and fillings (59). These findings, combined with the nonsignificant association between a past-year dental visit and low OHQoL, warrant further research on the costs and comprehensiveness of dental coverage for these patients.
Structural impediments were among the most common nonfinancial barriers reported by participants, including problems obtaining an appointment, not having transportation or someone to accompany them, and inconvenient clinic hours. Moreover, 28% of participants reported the lack of perceived need as a reason for not seeking care. Structural barriers may be partly mediated by oral health beliefs (60), and emphasizing the value of oral health for overall health and well-being through oral health promotion initiatives (61) may help individuals with serious mental illness overcome some of these hurdles. Nevertheless, structural barriers may prove particularly challenging. That issues beyond the control of the individual increase the likelihood of having an unmet need for dental care is alarming.
We also found that xerostomia and a schizophrenia spectrum diagnosis are independently associated with low OHQoL. Unexpectedly, the mean xerostomia score for the sample was consistent with mean scores found in nonpsychiatric samples (44). Many psychiatric medications for schizophrenia spectrum disorders have anticholinergic effects that reduce salivary flow, promoting caries and periodontal disease (62). Managing xerostomia may be challenging if high-dose medication use is indispensable, but its impact may be reduced by switching to medications with less severe anticholinergic side effects and by minimizing the risk of dental caries with regular dental visits and oral health assessments, use of sugar-free gum to stimulate salivary flow, and regular consumption of water (62). Age also appears to increase absolute risk of low OHQoL, although the association was nonsignficant in relative terms. Prior studies suggest an inconsistent relationship between age and low OHQoL but controlled for different factors (6365); future studies can help elucidate these complex associations.
These findings suggest areas for further inquiry and possible intervention. First, integrating oral health care in their mental health care may be prudent for patients engaged in mental health services. Qualitative research suggests that individuals with serious mental illness are comfortable speaking with their mental health care providers about oral health concerns and appreciate help with dental care strategies (66). Mental health providers can more actively inquire about their patients’ oral health and medication-associated xerostomia and recommend and follow-up referrals to oral health care services when necessary. Increasingly, dental providers acknowledge the need for greater training in working with patients with mental illness (67, 68) and partnering with the mental health delivery system to integrate oral health and promote prevention within comprehensive care (69, 70).
Second, thinking dental problems were not serious or would go away on their own was a common nonfinancial barrier. Community-based health promotion may increase patients’ awareness of dental services and encourage preventive dental care (71). Third, costs were among the most frequently cited barriers to seeking care and were strongly associated with an unmet dental need in this publicly insured population (58, 59). Policy makers can decrease unmet dental need by implementing reforms in public insurance to reduce dental costs to patients and expanding dental benefits to include preventive care and more covered services (72).
Our results should be interpreted by considering several limitations. First, our exploratory study was based on a convenience sample at a public mental health service and may not be generalizable to all patients with serious mental illness. However, our sample was demographically comparable to the outpatient service population at the study site except for rates of Medicaid coverage (Medicaid only, 58% in our sample versus 38% for the study site population; Medicare-Medicaid, 28% for our sample versus 38% for the study site). Second, our results were based on self-reported data and lacked independent confirmation or comparison with a clinical assessment. Third, factors that were unexamined because of modest sample size (e.g., race-ethnicity, type of insurance) or unassessed (e.g., childhood dental care, type of dental service use) in our study merit examination in larger samples. Fourth, the cross-sectional design limits causal inferences and may contribute to the nonsignificant association between past-year dental visit and unmet dental need, given that we may have interviewed patients at varying stages of dental treatment. Fifth, although the OHIP-14 is widely used to assess OHQoL, it may underestimate the extent of low OHQoL (73), suggesting that our findings may be conservative.

Conclusions

Our study of underserved individuals receiving care for serious mental illness in a public mental health service found markedly low OHQoL, driven by unmet dental care need, xerostomia, and having a schizophrenia spectrum disorder. Financial and nonfinancial barriers were significantly associated with unmet dental need. Our findings underscore the need for further understanding and improving oral health access, oral health promotion, and greater integration between the mental and oral health systems to improve oral health in this population.

Acknowledgments

The authors thank Gabriela Báez, Jason Bastida, D.D.S., Samantha Díaz, M.A., Sebastián Gutiérrez de Piñeres, D.D.S., Bianca Ruíz, Besi Sánchez, and Sissy Silva for help in data collection; Dianna Dragatsi, M.D., Jean-Marie Bradford, M.D., and their staff for granting access and assisting with recruitment and engagement; Goretti Almeida, M.B.A., for clarifying details during data collection and answering follow-up concerns; Leopoldo Cabassa, Ph.D., for guidance during the early stages of the study; Hannah Guz, PsyD, for help in translation; Lynn Tepper, Ph.D., Ed.D., and Kavita Ahluwalia, D.D.S., M.P.H., for contributions to the interview questionnaire; and Marit Boiler, M.P.H., for the initial assembly of interview items.

Supplementary Material

File (appi.ps.201900111.ds001.pdf)

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Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 1101 - 1109
PubMed: 31522632

History

Received: 28 February 2019
Revision received: 22 May 2019
Accepted: 3 July 2019
Published online: 16 September 2019
Published in print: December 01, 2019

Keywords

  1. Community mental health services
  2. Patient needs
  3. oral health-related quality of life
  4. patient needs
  5. financial barriers
  6. publicly insured community mental health services
  7. race/ethnic minority groups
  8. serious mental illness

Authors

Details

Peter C. Lam, M.P.H. [email protected]
New York State Center of Excellence for Cultural Competence (Lam, John, Lewis-Fernández) and Anxiety Disorders Clinic and Hispanic Treatment Program (Lewis-Fernández), New York State Psychiatric Institute, New York; Department of Psychiatry, Vegelos College of Physicians and Surgeons (Galfalvy, Lewis-Fernández), Department of Biostatistics (Galfalvy) and Department of Sociomedical Sciences (Kunzel), Mailman School of Public Health, and Division of Foundational Sciences, Section of Oral, Diagnostic, and Rehabilitation Sciences, College of Dental Medicine (Kunzel), all at Columbia University, New York.
Dolly A. John, Ph.D., M.P.H.
New York State Center of Excellence for Cultural Competence (Lam, John, Lewis-Fernández) and Anxiety Disorders Clinic and Hispanic Treatment Program (Lewis-Fernández), New York State Psychiatric Institute, New York; Department of Psychiatry, Vegelos College of Physicians and Surgeons (Galfalvy, Lewis-Fernández), Department of Biostatistics (Galfalvy) and Department of Sociomedical Sciences (Kunzel), Mailman School of Public Health, and Division of Foundational Sciences, Section of Oral, Diagnostic, and Rehabilitation Sciences, College of Dental Medicine (Kunzel), all at Columbia University, New York.
Hanga Galfalvy, Ph.D.
New York State Center of Excellence for Cultural Competence (Lam, John, Lewis-Fernández) and Anxiety Disorders Clinic and Hispanic Treatment Program (Lewis-Fernández), New York State Psychiatric Institute, New York; Department of Psychiatry, Vegelos College of Physicians and Surgeons (Galfalvy, Lewis-Fernández), Department of Biostatistics (Galfalvy) and Department of Sociomedical Sciences (Kunzel), Mailman School of Public Health, and Division of Foundational Sciences, Section of Oral, Diagnostic, and Rehabilitation Sciences, College of Dental Medicine (Kunzel), all at Columbia University, New York.
Carol Kunzel, Ph.D.
New York State Center of Excellence for Cultural Competence (Lam, John, Lewis-Fernández) and Anxiety Disorders Clinic and Hispanic Treatment Program (Lewis-Fernández), New York State Psychiatric Institute, New York; Department of Psychiatry, Vegelos College of Physicians and Surgeons (Galfalvy, Lewis-Fernández), Department of Biostatistics (Galfalvy) and Department of Sociomedical Sciences (Kunzel), Mailman School of Public Health, and Division of Foundational Sciences, Section of Oral, Diagnostic, and Rehabilitation Sciences, College of Dental Medicine (Kunzel), all at Columbia University, New York.
Roberto Lewis-Fernández, M.D.
New York State Center of Excellence for Cultural Competence (Lam, John, Lewis-Fernández) and Anxiety Disorders Clinic and Hispanic Treatment Program (Lewis-Fernández), New York State Psychiatric Institute, New York; Department of Psychiatry, Vegelos College of Physicians and Surgeons (Galfalvy, Lewis-Fernández), Department of Biostatistics (Galfalvy) and Department of Sociomedical Sciences (Kunzel), Mailman School of Public Health, and Division of Foundational Sciences, Section of Oral, Diagnostic, and Rehabilitation Sciences, College of Dental Medicine (Kunzel), all at Columbia University, New York.

Notes

Send correspondence to Mr. Lam ([email protected]).

Competing Interests

Dr. Galfalvy’s family has equity ownership in Illumina, Inc., and IBM, Inc. Dr. Kunzel receives support from the Health Resources and Services Administration of the U.S. Department of Health and Human Services (H65HA00014). Dr. Lewis-Fernández receives support from the New York Community Trust and the W. T. Grant Foundation. The other authors report no financial relationships with commercial interests.

Funding Information

New York State Office of Mental Healthhttp://dx.doi.org/10.13039/100004866:
This study was supported by funds from the New York State (NYS) Office of Mental Health to the NYS Center of Excellence for Cultural Competence at the NYS Psychiatric Institute.

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