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ANP0010.1177/0004867415615947ANZJP ArticlesWey et al.
Research
The oral health of people with chronic
schizophrenia: A neglected public health
burden
Australian & New Zealand Journal of Psychiatry
1­–10
DOI: 10.1177/0004867415615947
© The Royal Australian and
New Zealand College of Psychiatrists 2015
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Mang Chek Wey1, SiewYim Loh2, Jennifer Geraldine Doss3,
Abdul Kadir Abu Bakar4 and Steve Kisely5
Abstract
Objective: People with chronic schizophrenia have high rates of physical ill-health such as heart disease. However,
there has been less attention to the issue of poor oral health including dental caries (tooth decay) and periodontal (gum)
disease, although both have consequences for quality of life and systemic physical health. We therefore measured tooth
decay and gum disease in Malaysians with schizophrenia.
Methods: We recruited long-stay inpatients with schizophrenia from June to October 2014. Four dental specialists
assessed oral health using the decayed–missing–filled teeth index, the Community Periodontal Index of Treatment
Needs and the Debris Index of the Simplified Oral Hygiene Index. Results were compared with the 2010 Oral Health
survey of the general Malaysian population.
Results: A total of 543 patients participated (66.7% males, 33.3% females; mean age = 54.8 years [standard deviation = 16.0]) with a mean illness duration of 18.4 years (standard deviation = 17.1). The mean decayed–missing–filled teeth
was 20.5 (standard deviation = 9.9), almost double that of the general population (11.7). Higher decayed–missing–filled
teeth scores were associated with both older age (p < 0.001) and longer illness duration (p = 0.048). Only 1% (n = 6) had
healthy gums. Levels of decay and periodontal disease were greatest in those aged between 45 and 64 years, coinciding
with the onset of tooth loss.
Conclusion: Dental disease in people with schizophrenia deserves the same attention as other comorbid physical illness. The disparity in oral health is most marked for dental decay. Possible interventions include oral health assessments
using standard checklists designed for non-dental personnel, help with oral hygiene, management of iatrogenic dry mouth
and early dental referral.
Keywords
Schizophrenia, dental caries, periodontal, decayed–missing–filled teeth, Oral Hygiene Index, institutionalized, inequality,
burden of care, public health, health promotion
Background
People with schizophrenia are known to have high rates of
physical ill-health including heart disease, diabetes and
cancer (Kisely et 
al., 2013, 2015; Montejo, 2010;
Monteleone et al., 2009). By contrast, the presence of conditions such as dental caries and periodontal disease
receives much less attention (Arnaiz et al., 2011). If left
untreated, these conditions can lead to partial or total tooth
loss (edentulism), as well as compromising nutrition and
general physical health.
This population is at greater risk of dental disease
because of poor nutrition and oral hygiene; the heavy consumption of sugary drinks; comorbid substance misuse
1Department
of Paediatric Dentistry and Orthodontics, Faculty of
Dentistry, University of Malaya, Kuala Lumpur, Malaysia
2Department of Rehabilitation Medicine, Faculty of Medicine, University
of Malaya, Kuala Lumpur, Malaysia
3Department of Community Oral Health & Clinical Prevention, Faculty
of Dentistry, University of Malaya, Kuala Lumpur, Malaysia
4Permai Psychiatric Institution, Johor Bahru, Malaysia
5School of Medicine, The University of Queensland, Australia,
Woolloongabba, QLD, Australia
Corresponding author:
SiewYim Loh, Department of Rehabilitation Medicine, Faculty of
Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
Email: [email protected]; [email protected]
Australian & New Zealand Journal of Psychiatry
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including tobacco, alcohol or psychostimulants; and financial or other barriers to accessing dental care (Kisely et al.,
2014). This is aggravated by dry mouth (xerostomia),
which is a common side effect of many psychotropic medications (Bardow et al., 2001).
Dental disease can have important consequences. Aside
from social withdrawal and low self-esteem, poor oral
health is associated with chronic medical conditions such
as myocardial infarction and stroke (Azarpazhooh and
Leake, 2006; Chapple, 2009; Cullinan et 
al., 2009;
Desvarieux et al., 2003; Haumschild and Haumschild,
2009; Humphrey et al., 2008; Rai, 2006; Scannapieco,
2005; Shultis et al., 2007; Williams et al., 2008). One
explanation is that poor oral hygiene allows oral bacteria to
enter the bloodstream. Immune complexes are then formed
that, in turn, elicit inflammatory responses in arteries and
distal organs (Scannapieco, 2005).
Where studies of oral health in people with schizophrenia have been conducted, they have largely come from
Europe, North America, Israel and Australia (Chu et al.,
2011; Gurbuz et al., 2010; Kisely et al., 2014; Lalloo et al.,
2013; Zusman et al., 2010). Any papers from South East
Asia have been restricted to developed countries such as
Japan, Hong Kong and Taiwan (Kisely et al., 2011, 2014;
Tani et al., 2012; Teng et al., 2011). In addition, the literature has focused primarily on caries rather than periodontal
disease, although both contribute to edentulism.
This study therefore examined the oral health status of a
large cohort of people with schizophrenia in a developing
South Eastern Asian country. Importantly, it included all
measures of periodontal disease, dental decay and oral
health needs. It was conducted in one of the largest psychiatric hospitals in Asia, the Permai Psychiatric Institution in
Malaysia. In contrast to other countries, large psychiatry
institutions are the setting where most Malaysians with
schizophrenia are treated.
Results were compared with those of the 2010 Malaysian
Oral Health survey of the adult population (Ministry of
Health, 2010). This is a population-based survey of dental
decay and periodontal disease that is carried out every
10 years across Malaysia (Mohd-Dom et al., 2013; Umer
and Umer, 2011). In the last survey, 8332 dentate adults
were examined (Mohd-Dom et al., 2013). We hypothesized
that the rates and extent of dental disease in people with
schizophrenia would be significantly greater than those of
the general Malaysian population.
Methods
Setting
Malaysia is a developing middle-income country as classified by the World Bank (2015). Mental health care in
Malaysia is mainly provided in government-run institutions,
although the number of private hospitals is increasing.
Australian & New Zealand Journal of Psychiatry
ANZJP Articles
Despite a growing number of psychiatric units in general
hospitals, inpatient care is still largely provided in four
large-scale institutions (Parameshvara Deva, 2004). This
study was conducted at the Permai Psychiatric Institution,
one of the four institutions in Malaysia. Importantly, it took
place in an area where fluoride was present in the water supply at a concentration of 0.5–0.7 mg/L. This is only just below
Australian guidelines for fluoridation of between 0.6 and
1.1 mg/L to achieve the right balance between the reduction
of dental caries and the prevention of fluoride-related harm
(National Health and Medical Research Council, 2007).
Subjects
Upon ethical clearance, four dental specialists carried out
the dental examinations, over a period of 5 months in late
2014. We included all long-stay patients (18 to 65 years of
age) with a diagnosis of schizophrenia (based on the
Diagnosis and Statistical Manual of Mental Disorders, 5th
edition [DSM-5] and who were not on leave. The diagnosis
was by clinical assessment as opposed to a structured interview. For those unable to provide written consent, a surrogate (e.g. the next of kin or legally authorized representative)
gave consent on their behalf. Exclusion criteria were
patients who were acutely unwell or presenting with a first
episode of schizophrenia, as well as those with substance
dependence and medical disorders such as epilepsy or cerebrovascular problems. We also excluded patients with
comorbid learning disability and those at risk of harming
themselves or others. Psychiatric status was determined by
clinical assessment of the treating team.
Ethical clearance was obtained from the Ethical Board of
the University of Malaya’s Medical Centre (UMMC-MEC,
Ref. No.: 926.63) and Ministry of Health (NMRR 13-31015297). Eight trained research staff with backgrounds in
occupational therapy or nursing, and who were fluent in
Malay, Chinese or Tamil, approached potential subjects to
obtain written consent. Clinical staff assisted in assessing
patients’ capacity for informed consent and explaining the
dental examination. About 20% of the sample (n = 110) were
unable to provide written consent. They came mainly from
the long-stay psychogeriatric wards, and in these cases, a
surrogate such as a family member or legally authorized
representative gave consent on their behalf.
Data collection
Demographic data such as age, gender, ethnicity and duration of illness were obtained from hospital records and
medical staff. Psychiatric status was determined by clinical
assessment of the treating health team.
Four dental specialists carried out the dental examinations over a period of 5 months in late 2014. Three examiners were calibrated against one specialist who had conducted
several national surveys for the country. This was done
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Wey et al.
through repeated examinations of a separate pilot sample
using similar indices, followed by meetings to discuss discrepancies and standardize procedures. Kappa scores of 0.9
for inter-rater agreement were achieved. The following
three tools were used in this study:
1. The Decayed–Missing–Filled (DMFT) score. Decay
was assessed using this standardized index to evaluate dental caries with scores ranging from 0 to 32.
This involved examination for dental caries, dental
restorations, fissure sealants, fixed prosthesis, missing teeth and an additional category for traumatized
incisors. High scores indicate worse dental health
(World Health Organization [WHO], 1987, 2013).
Root caries was not assessed in this study.
2. The Community Periodontal Index of Treatment
Needs (CPITN) Index (Ainamo et al., 1982). This
measure was used to score periodontal status and
assess patients’ treatment needs. The initial sign of
periodontal disease is bleeding of the gums. As it
progresses, the gum retracts from the base of the
tooth to form pockets. The deeper the pocket, the
more severe is the periodontal disease. The CPITN
is therefore a 5-point scale as follows: no signs of
periodontal disease (0), gingival bleeding after gentle probing (1), supragingival or subgingival calculus (2), pathologic pockets 4–5 mm deep (3) and
pathologic pockets >5 mm deep (4). Disposable
dental mirrors, tweezers, 0.5 mm ball-ended CPITN
probes (3.5–5.5 mm) and cotton rolls (to remove
plaque) were used.
3. The Debris Index component of the Simplified Oral
Hygiene Index (OHI-S). This tool was used to measure
the amount of debris (Greene and Vermillion, 1964). It
was scored on six tooth surfaces per participant.
Statistical analyses
We used t-tests to compare findings of this study with the
Oral Health survey of adults (Ministry of Health, 2010). A
bivariate model was then used to examine the effects of the
following variables on the DMFT score: age (divided into
10-year groups), gender, ethnicity and duration of illness.
Next, we conducted stepwise multiple linear regression of
DMFT and multinomial logistic regression of CPITN with
age, gender, race and duration of illness as independent
variables to determine factors associated with dental outcome. Pair-wise comparisons were used to compare the
effect of subgroups on DMFT scores.
Results
Demographics of the sample
Figure 1 shows the recruitment flow chart. Of the 545 eligible cases who fulfilled the inclusion criteria, 543 (99.6%)
participated in the study. Table 1 shows their socio-demographic characteristics. About two-thirds (n = 362) were
males and 33.3% (n = 181) females. Of the sample, 42.0%
(n = 228) were Malay, 50.5% (n = 274) Chinese, 5.3%
(n = 29) Indian, 0.7% (n = 4) indigenous Orang Asli, 0.6%
(n = 3) non-Malaysians and 0.9% (n = 5) of undetermined
ethnicity. The mean age was 54.8 years (standard deviation
[SD] = 16.0), ranging from as young as 17 years of age to as
old as 91 years old. The sample was predominately middle
aged or older (Table 1). The mean duration of psychiatric
illness was 18.4 years (SD = 17.1) with a range of 2–61 years.
The average length of stay was 23 years ranging from less
than a year to 54 years.
Dentition status (DMFT scores) and associated demographic
characteristics. The mean DMFT score for the 543 participants was 20.5 (SD = 9.9), significantly higher than the
scores for the general population of 11.7 (Ministry of
Health, 2010). Male patients had a mean DMFT of 19.9
(SD = 10.1), while females had a score of 21.7 (SD = 9.4).
Population variances were equal, suggesting homogeneity
between gender (p < 0.075). Stepwise multiple linear
regression analysis of DMFT using independent variables
of age, gender, race and duration of illness showed that
gender (p = 0.488) and race (p = 0.380) were not associated
with DMFT scores. However, older age (p < 0.001) and
longer duration of illness (p = 0.048) were significantly
associated with increasing scores. Subgroup analyses
showed that DMFT scores were significantly higher than
the normal population across most ages (Ministry of Health,
2010) (p = 0.012) (Table 2).
Periodontal disease and debris
Only 1% (n = 6) had healthy gums whereby all six sextants
were free of pathology. By comparison, it was 3.2% in the
general adult population (Ministry of Health, 2010). Half of
the sample (n = 274) had gingival bleeding in at least one sextant. The mean number of sextants with gingival bleeding
was 1.5 (SD = 1.9) per person compared with 1.8 in the general population (Ministry of Health, 2000). Of the total sample (n = 543), 47.7% (n = 256) had calculus, 19.2% (n = 104)
shallow pocketing of 4–5 mm and 6% (n = 33) deep pockets
measuring 6 mm and more. Severity was largely similar to
that of the general population, except for the mean number of
deep pockets (at 0.10) which were lower in the study population (at 0.37) (Table 3). CPITN scores were also similar to
those of the normal population, with p-values ranging from
0.27 to 0.95 for the various age groups (Table 4).
Multinomial logistic regression analysis showed that
patients in the age range of 45–64 years were more likely to
have gingival bleeding, calculus or pockets (p < 0.001). In
comparison with Malays, Chinese patients were more
likely to have bleeding on probing, calculus and pockets
(p ⩽ 0.001), while Indians were more likely to have
Australian & New Zealand Journal of Psychiatry
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Figure 1. Patient recruitment flow chart.
Table 1. Demographics of study participants (n = 543).
Demographic features
Values
Age (years), mean ± SD (range)
54.8 ± 16.0 (17–91)
75 (14.3)
<40 years, n (%)
41–59 years, n (%)
⩾60 years, n (%)
221 (42.3)
227 (43.4)
Gender
Male, n (%)
Female, n (%)
362 (66.7)
181 (33.3)
Duration of illness, mean ± SD (range)
18.4 ± 17.1 (1–61)
DMFT, mean ± SD (range)
20.5 ± 9.9 (0–32)
CPITN mean ± SD (range)
2.3 ± 0.7 (0–4)
OHI-S, mean ± SD (range)
% with caries, n (%)
1.9 ± 0.9 (0–3)
383 (82.2)
SD: standard deviation; DMFT: decayed–missing–filled teeth; CPITN:
Community Periodontal Index of Treatment Needs; OHI-S: Debris
Index of the Simplified Oral Hygiene Index.
Australian & New Zealand Journal of Psychiatry
calculus (p ⩽ 0.026) and shallow pockets (p ⩽ 0.003). The
mean debris index was 1.9 (n = 441).
Partial and complete edentulism
The mean number of permanent teeth present per person
was 15.5 (SD = 11.0), compared to 22.9 of the general population (Ministry of Health, 2010) (p = 0.77). The proportion of edentulism was 14.2% (n = 77) as opposed to 7.3%
of the general population (p < 0.0001). The percentage of
subjects with at least one natural tooth was 85.8% (n = 466)
as compared to 92.7% of the general population
(p < 0.0001). In all, 43% of the patients (n = 234) had at
least 20 functional teeth compared to 80.6% of the general
population, a statistically significant result (p = 0.04)
(Ministry of Health, 2010) (Table 5). Of the sample, 70.5%
(n = 383) had at least one carious permanent tooth or carious restoration, with the highest prevalence occurring in
45- to 54-year-olds (82.3%) and the lowest in 15- to
24-year-olds (33.3%) (Table 6).
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Wey et al.
Table 2. DMFT comparison between study participants and the general population by age.
National Survey by Ministry of Health Malaysia (2010)
Present study findings
95% CI
95% CI
Age range (years)
Mean
Lower
Upper
Mean
Lower
Upper
15–19
2.28
2.06
2.51
5.67
4.23
7.10
20–24
3.13
2.83
3.42
25–29
4.83
4.48
5.17
8.77
5.62
11.92
30–34
7.75
7.31
8.18
35–44
10.74
10.34
11.14
12.12
10.40
13.83
45–54
16.21
15.71
16.71
18.50
16.93
20.07
55–64
20.76
20.17
21.36
24.24
22.96
25.51
65–74
24.35
23.49
25.21
25.55
24.23
26.87
75+
27.75
26.88
28.61
DMFT: decayed–missing–filled teeth; CI: confidence interval.
p = 0.012.
Table 3. Periodontal severity comparison between study participants and the general dentate population by age.
Mean number of sextants
for bleeding, calculus
or pockets (shallow or
deep) (1 + 2 + 3 + 4)
Mean number of
sextants for calculus
or pockets (shallow
or deep) (2 + 3 + 4)
This
study
MOH
This study
MOH
This
study
MOH
This
study
MOH
This
study
1.67
4.37
4.33
3.46
4.33
0.69
1.33
0.05
0.00
0.08
0.18
0.23
0.35
0.60
0.55
0.17
1.82
0.48
0.59
0.11
3.18
1.51
0.44
0.52
0.06
2.64
1.35
0.37
0.49
0.03
0.92
0.35
0.075
0.029*
Mean number
of sextants for
pockets (shallow
or deep) (3 + 4)
Age
range
(years)
Mean number
of sextants for
healthy (0)
MOH
15–19
1.62
20–24
1.00
25–29
0.76
30–34
0.59
35–44
0.52
0.71
4.97
4.70
4.67
4.60
1.91
45–54
0.41
0.42
4.19
4.01
4.01
3.89
55–64
0.23
0.10
3.47
3.26
3.33
65–75
0.18
0.01
2.84
2.75
2.78
75+
0.10
2.18
2.12
p-value
0.489
0.066
0.115
4.98
1.00
5.16
4.28
4.35
5.23
4.67
0.88
4.08
4.84
1.25
1.46
1.59
Mean number of
sextants for deep
pockets (4)
Ministry of Health (MOH): National Oral Health Survey of Adults (2010).
*p < 0.05.
Australian & New Zealand Journal of Psychiatry
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Table 4. CPITN comparison between study participants and the general population by age.
% dentate
subjects for
calculus (2)
% dentate subjects
for shallow
pockets (3)
% dentate
subjects for
deep pockets (4)
% dentate
subjects for
excluded (X) or
not recorded (9)
Present
study
Present
MOH study
MOH
Present
study
Present
MOH study
MOH
Present
study
3.4
56.5
16.8
20.7
3.0
0
6.9
4.7
0.1
32.5
9.7
0.1
36.1
16.1
0
12.8
0.9
1.2
29.4
7.3
3.4
11.3
16.9
26.4
5.1
7.8
22.1
14.1
26.7
1.9
15.1
36.5
Age
range
(years)
% dentate
subjects for
healthy (0)
MOH
Present
study
MOH
15–19
9.6
3.4
14.1
20–24
4.7
5.6
59.6
25.3
25–29
2.7
3.6
51.4
30–34
1.7
3.1
43.0
35–44
1.8
7.0
1.7
1.2
36.1
66.3
34.2
11.6
25.3
45–54
1.3
0.0
1.3
0.8
29.5
64.5
35.1
16.1
55–64
1.5
0.0
1.4
2.9
31.1
52.9
31.8
65–75
2.0
0.6
1.4
3.2
26.7
43.6
28.1
75+
3.5
p-value 0.34
% dentate
subjects for
bleeding (1)
58.2
6.9
2.0
26.9
26.7
19.0
21.9
0.76
0.27
0.81
0.95
0.01*
CPITN: Community Periodontal Index of Treatment Needs; Ministry of Health (MOH): National Oral Health Survey of Adults (2010).
*p < 0.05.
Table 5. Tooth loss comparison between study participants and the general population by age.
Age range
(years)
National Oral Health Survey of
Adults 2010
Ministry of Health Annual
Report 2012
Present study findings
Edentulous (%)
Subjects with
20 teeth and
more (%)
15–19
0.0
99.9
20–24
0.0
100.0
25–29
0.0
99.3
30–34
0.0
97.7
35–44
1.1
87.8
0.0
84.9
45–54
6.8
60.5
5.6
54.8
55–64
18.1
37.1
17.6
23.2
65–74
32.2
22.1
14.4
28.7
26.9
19.9
75+
53.3
9.4
26.1
16.9
Total
7.3†
80.6*
Edentulous (%)
Edentulous (%)
Subjects with
20 teeth and
more (%)
0.0
100.0
0.0
88.5
Ministry of Health (MOH): National Oral Health Survey of Adults (2010).
*p < 0.05; †p <0.01.
Australian & New Zealand Journal of Psychiatry
Subjects with
20 teeth and
more (%)
14.2†
43.1*
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Wey et al.
Table 6. Caries prevalence comparison between study
participants and the general population by age.
Age range
(years)
National Oral
Health Survey of
Adults 2010 (%)
Present study
findings (%)
15–19
59.0
33.3
20–24
69.7
25–29
83.6
30–34
95.7
35–44
97.2
80.2
45–54
99.1
87.2
55–64
99.6
86.6
65–74
99.9
79.8
75+
100
69.2
(MOH): National Oral Health Survey of Adults (2010).
p < 0.001.
Discussion
This is one of the few studies to assess the oral health status
of people with schizophrenia in a developing country and
the first such study in South East Asia. Previous studies
from the region have been restricted to Japan, Hong Kong
and Taiwan (Kisely et al., 2011, 2014; Tani et al., 2012;
Teng et al., 2011).
Malaysia is also a particularly appropriate setting as it
conducts 10-yearly oral health surveys of the general population including the measurement of periodontal status
(Mohd-Dom et al., 2013; Umer and Umer, 2011). This
therefore allows comparisons between people with schizophrenia and the general population for both decay and periodontal disease.
Strengths of the study include the use of standardized
instruments by trained dental personnel who were calibrated against an expert. We were also able to stratify
results by age in our comparisons between the hospital
sample and the population controls. This is important as
oral health changes as patients grow older. Although a
majority of the hospital sample were male, it is unlikely
that differences in the gender distribution between patients
and community controls would have affected the results
given that the prevalence of dental disease does not vary
greatly by gender. Where differences have been reported,
females have worse dental disease than males (Australian
Institute of Health and Welfare [AIHW] Dental Statistics
and Research Unit, 2008a, 2008b; Krustrup and Petersen,
2007; Palmqvist et al., 2000).
There were several limitations. Although psychiatric
diagnoses were made using diagnostic criteria, this followed a clinical assessment rather than a structured interview. Use of the Malaysian national oral survey as the
control population meant that although it was possible to
stratify results by age, we were unable to take into account
differences in other socio-demographic characteristics such
as education and socio-economic status that could also
have an effect on oral health status. In addition, the dental
assessors were not blind to patients’ psychiatric status. Data
on the prevalence of smoking were not collected. However,
signs of tobacco use were commonly observed during the
dental examinations, especially in male participants.
Finally, the results may have limited generalizability to
shorter stay community-based settings.
Dental decay in patients with schizophrenia was much
higher than in the general Malaysian community but consistent with findings from other psychiatric populations in
developed countries such as the United Kingdom (Lewis
et al., 2001), France (Bertaud-Gounot et al., 2013), Italy
(Angelillo et al., 1995), Spain (Arnaiz et al., 2011; VelascoOrtega et al., 2013), Australia (Lalloo et al., 2013) and
Israel (Ramon et al., 2003; Zusman et al., 2010) (Table 7).
DMFT findings by age groups were also similar to those
from Japan (Tani et al., 2012) and Taiwan (Teng et al.,
2011). By contrast, these results from Malaysia were much
higher than the levels of decay found in psychiatric patients
in other developing nations such as Ethiopia (Kebede et al.,
2012) and India (Kumar et al., 2006). The prevalence of
caries was highest in the age range of 45–54 years, and this
corresponded with the onset of edentulism.
Explanations for increased levels of decay include poor
oral hygiene and the side effects of psychotropic medications like antipsychotics, antidepressants and mood stabilizers. All of these medications induce dry mouth
(xerostomia) through reduced salivary flow and can potentially negate the beneficial effects of fluoride (Friedlander
and Marder, 2002). As with other aspects of physical illhealth, poor dental health may also be related to poor diet,
smoking and poor oral hygiene (McCreadie et al., 2004). It
is possible that the increased dental decay in Malaysian
patients with respect to other developing countries might be
due to differences in diet, access to psychotropic medication, service organization or levels of development. This is
discussed further under section ‘Implications’.
These issues are compounded by difficulties with access
to dental care, either because of availability or because of
fear of pain and dental phobia. Although there is a dental
clinic in the hospital, the dentist only attends twice a week to
treat those with serious dental caries. With a total patient
population of almost 1000, optimal dental care is therefore
difficult to achieve and limited to the treatment of established
dental disease rather than the promotion of oral health.
Australian & New Zealand Journal of Psychiatry
8
ANZJP Articles
Table 7. International comparisons of DMFT scores.
Index DMFT
(mean ± SD)
Decayed
(mean ± SD)
Missing
(mean ± SD)
Filled teeth
(mean ± SD)
Inpatients with
schizophrenia
(n = 543)
20.5 ± 9.9
3.48 ± 4.30
16.60 ± 11.00
0.38 ± 1.06
General
population
(n = 8332)
11.66 ± 0.16
1.70 ± 0.05
8.34 ± 0.15
1.62 ± 0.04
Taiwan (Teng
et al., 2011)
Psychiatric
inpatients (n = 200)
14.92 ± 8.88
3.69 ± 4.66
7.08 ± 6.91
4.16 ± 4.84
Spain (Arnaiz
et al., 2011)
(Velasco-Ortega
et al., 2013)
Outpatients with
schizophrenia
(n = 66)
Psychogeriatric
inpatients (n = 50)
13.51 ± 7.27
28.3 ± 6.6
4.39 ± 3.99
3.1
5.66 ± 7.13
25.2
3.53 ± 3.19
0
France (BertaudGounot et al.,
2013)
Psychiatric
inpatients (n = 161)
15.8 ± 8.8
3.7 ± 4.4
7.3 ± 9.4
4.7 ± 4.9
Italy (Angelillo
et al., 1995)
Psychiatric
inpatients (n = 264)
15.5 ± 7.8
1.7
13.6
0.2
Britain (Lewis
et al., 2001)
Psychiatric
inpatients (n = 326)
19.1 ± 7.9
0.9 ± 2.3
15.9 ± 9.3
2.3 ± 3.1
Israel (Ramon
et al., 2003)
(Zusman et al.,
2010)
Psychiatric
inpatients (n = 254)
Psychiatric
inpatients (n = 431)
23.8 ± 9.1
26.74 ± 7.47
2.7 ± 4.1
6.22 ± 6.53
20 ± 11.2
19.1 ± 56.6
1.1 ± 2.7
1.37 ± 3.34
Australia (Lalloo
et al., 2013)
Psychiatric
outpatients
(n = 50)
17.7 ± 0.91
3.74
9.92
4.04
Ethiopia (Kebede
et al., 2012)
Psychiatric
outpatients
(n = 240)
1.94 ± 2.12
1.28 ± 1.69
0.51 ± 1.28
0.14 ± 0.48
Country
Type of patients
Malaysia
DMFT: decayed–missing–filled teeth; SD: standard deviation.
By contrast, levels of periodontal disease in this sample
were very similar to those in the general Malaysian population and lower than reported among inpatients with schizophrenia from Taiwan (Teng et al., 2011). Where present, it
was most likely to occur between the ages of 45 and 64 years.
The reasons for this disparity are unclear and might be
related to differences in diet or service organization between
the two jurisdictions. Differences in smoking levels could
also contribute. While smoking is a significant risk factor in
the development and progression of periodontal disease
overall, it may also diminish gingival bleeding in the shortterm through changes in the proportion of small to large
blood vessels in the gums (Rivera-Hidalgo, 2003). A further
explanation for lower than expected levels of periodontal
disease might be that different bacteria are responsible for
Australian & New Zealand Journal of Psychiatry
decay and periodontitis. The former is primarily due to
Streptococcus mutans while a wider range of aerobic and
anaerobic bacteria are involved in gum disease (Loesche,
1996). It is therefore possible that the preponderance of one
group of organisms over the other might affect the degree of
decay or periodontal disease.
Implications
This study highlights the poor oral health of long-term
patients in one of Asia’s largest psychiatric institutions in
terms of dentition (DMFT), periodontal status (CPITN) and
debris index. Rates of dental decay in this sample from an
upper middle–income developing country were comparable
to those of high income jurisdictions such as Australia, Japan,
9
Wey et al.
Korea and the European Union and found to be higher than
those from low and lower middle countries (Kebede et al.
2011, 2012, 2014; Kumar et al., 2006). Developing countries
should not therefore be seen as a homogeneous group when
extrapolating results from one country to another.
Our findings also illustrate the need for a greater emphasis
on preventative care, rather than solely treating established
dental symptoms. Interventions should be initiated well
before the onset of tooth loss, which in this population was in
45 years and above. This should be complemented by the promotion of oral hygiene in all ages including the avoidance of
sweets and tobacco, as well as learning the correct techniques
for brushing teeth. An example from Australia is the ‘Dental
as anything’ programme in Victoria (Burchell et al., 2006).
This is an assertive outreach collaboration between mental
and oral health services where teams take mental and oral
health services to ‘hard-to-reach’ settings such as rooming
houses and supported housing. Interventions include both
education and clinical care. In another example, Queensland’s
strategy to improve the physical health of people with severe
mental illness (Activate: Mind & Body) includes both the
promotion of oral hygiene and regular care from a dentist
(General Practice Queensland, 2009).
Oral health is also an important part of comprehensive
care for people in long-term residential or institutional
facilities. Nursing care plans should include the recording
of factors known to cause oral ill-health such as psychotropic medication and tobacco or substance use, as well as
the supply of tooth brushes and denture baths. There are
also simple assessment tools that can be used by non-dentists. An example is the Oral Health Assessment Tool,
which has been evaluated as being reliable and valid in a
study of Australian residential care facilities, including
those with cognitively impaired residents (Chalmers et al.,
2005). This involves assessment of the lips, tongue, gums
and teeth, as well as asking about dentures and the presence of dental pain. The contribution of psychotropic medication to xerostomia should also be considered when
prescribing.
In conclusion, the oral health of psychiatric patients has
been neglected for too long. The management of comorbid
dental diseases should attract the same attention and receive
the same priority as other comorbid physical illness. This
calls for greater collaboration between dental and non-dental staff to improve the quality of life of people with
schizophrenia.
Acknowledgements
The authors thank the inpatients who participated in the study. We
are indebted to the occupational therapy and nursing staff at the
Tampoi Psychiatric Institution and the two dental officers who
contributed to the data collection for this study. S.Y.L. and
A.K.A.B. conceived the initial study; W.M.C and J.G.D. participated in its design and carried out the oral examinations with the
support from S.Y.L. and A.K.A.B; A.K.A.B. and Tampoi’s medical staff assessed the inpatients based on Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition (DSM-5) inclusion criteria; W.M.C. performed the statistical analysis; and W.M.C.,
S.Y.L. and S.K. drafted and refined the manuscript. All authors
read and approved the final manuscript.
Declaration of interest
The author(s) declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was funded by the University of Malaya (UM.C/625/1/HIR/
MOHE/MED/26) with SYL as the PI.
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