Community Ment Health J (2015) 51:222228

DOI 10.1007/s10597-014-9758-z

BRIEF REPORT

Oral Health in Adults with Serious Mental Illness:

Needs for and Perspectives on Care
Christine L. McKibbin Katherine A. KitchenAndren
Aaron A. Lee Thomas L. Wykes
Katelynn A. Bourassa

Received: 4 July 2013 / Accepted: 6 July 2014 / Published online: 5 August 2014
 Springer Science+Business Media New York 2014

Abstract This study used qualitative methods to investigate barriers to and facilitators of oral health care among
25 adult community mental health outpatients with serious
mental illness (SMI). Participants completed 30- to 60-min,
semi-structured interviews that were recorded and transcribed. Qualitative analysis was used to characterize
common themes. Results showed that lack of awareness of
dental problems, poverty, and dental care access were key
barriers to oral health care. When oral health care was
accessed, fear of stigma was associated with missed
opportunities to educate about the intersection of mental
and oral health. Community mental health providers were
viewed as trusted and important sources of advocacy and
support for obtaining oral health care when needed. Oral
health may be improved for persons with SMI by implementing education in points of frequent service contact,
such as community mental health.
Keywords Dental
Care
Treatment
Psychiatric

Stigma
Barriers

Introduction
Individuals with serious mental illness (SMI) experience
substantially higher rates of oral health problems than
adults in the general population (Flammer et al. 2009;
Janardhanan et al. 2011; McCreadie et al. 2004). A number
of factors have been identified that may contribute to oral

C. L. McKibbin (&)
K. A. KitchenAndren

A. A. Lee
T. L. Wykes
K. A. Bourassa
Department of Psychology, University of Wyoming, Dept. 3415,
1000 E. University Ave, Laramie, WY 82071, USA
e-mail: cmckibbi@uwyo.edu

123

health problems among adults with SMI, including sideeffects of psychotropic medications (e.g., xerostomia and
movement disorders; Friedlander and Marder 2002; Kilbourne et al. 2007), lifestyle and health habits (e.g., cigarette smoking, substance use, consumption of carbonated
beverages; Almomani et al. 2009; Brown et al. 1999;
Elmslie et al. 2001; Stiefel et al. 1990), severity of psychiatric symptoms (McCreadie et al. 2004), and cognitive
impairment (McClave et al. 2010; Persson et al. 2010;
Schladweiler et al. 2009) among others.
Underutilization of dental care services is another potential influence on poor oral health among adults with SMI, and
is an area of growing research interest. A self-report study by
McCreadie et al. (2004) found that most-recent dental visits
by adults with SMI in the United Kingdom were often not
preventative. In fact, the last dental visits (i.e., most recent) by
adults with SMI were more likely due to problems with teeth
or gums than the last visits of adults in the general population.
Similarly, other work has documented higher rates of selfreported need for dental services (Dickerson et al. 2003) and
lower rates of dental service use than adults without SMI
(Dickerson et al. 2003; Persson et al. 2009) or adults with
other psychiatric disorders (i.e., affective, paranoid, and
anxiety disorders; Salsberry et al. 2005). Most recently, using
a national Medical Expenditure Panel Survey database, Heaton et al. (2013) examined unmet dental need among three
patient groups. Specifically, these authors compared individuals with any self-reported mental illness (n = 3,525), a
subset of those with mental illness that seriously affected their
functioning (n = 1,264), and individuals with no selfreported mental illness (n = 15,833). The authors found that
adults with SMI had greater unmet dental need than adults
without SMI (Heaton et al. 2013). This difference was primarily accounted for by unmet dental need among those with
and without self-reported diagnoses of depression or anxiety.

Community Ment Health J (2015) 51:222228

However, no differences in unmet need were found between

adults with or without a psychotic disorder (Heaton et al.
2013). It is possible that methods for defining unmet need
(i.e., based on self-report of receiving a delay in care or an
inability to obtain care) lead to an underrepresentation of
actual need among individuals with psychotic disorders or
other form of SMI. For example, individuals with psychotic
disorders may have been less likely than other groups to
identify need for care.
Although quantitative data shows a pattern of poor oral
health among adults with SMI, but not necessarily underutilization of services, there is a limited body of literature
to describe, in depth, the factors that may influence selfcare and service utilization among this population. To date,
one group of researchers from Sweden has used qualitative
methods to examine how individuals with SMI experience
oral health problems (Persson et al. 2010). The authors
found that poor oral health caused feelings of shame and,
consequently, limited participation in social activities.
Participants also avoided dealing with oral health problems
through denial and they postponed treatment hoping that
problems would subside. When support was offered, these
efforts were often resisted because of unsatisfactory past
encounters with dental staff. While this study represents
one of the first detailed examinations of oral health from
the perspective of adults with SMI, these results are generalizable only to adults with SMI living in Sweden, where
the structure of healthcare delivery may be different than
other areas, such as the United States. Therefore, additional
work is needed to examine factors influencing service
utilization among adults with SMI in the United States. The
present study was designed to answer this broad question.

Methods
Semi-structured interviews were conducted to gain an indepth understanding of the influences on oral health service
use among adults with SMI who reside in the United States.
A form of purposive sampling (i.e., criteria sampling) was
used to identify diverse cases rich in information to produce themes (Kuzel 1999). Participants were included who
were at least 18 years of age, diagnosed with a SMI (i.e.,
schizophrenia, schizoaffective disorder, bipolar disorder, or
major depression) receiving mental health services in a
community mental health center in the Rocky Mountain
West, and able to provide informed consent.
Procedures
Study participants were recruited using two strategies.
First, flyers were distributed in community mental health
centers with an invitation to call the study coordinator to

223

enroll. Second, eligible individuals who had taken part in

previous health promotion studies were identified and
invited by telephone to participate. Interested participants
were scheduled for an interview. Following receipt of
informed consent, participants were asked to select a
pseudonym and the interview was then conducted by a
study staff member trained in conducting semi-structured
interviews. All interviews were conducted using a guide
developed by a team of clinical researchers with experience
working with adults with SMI. Six question areas were
discussed during each interview: (1) What have been your
experiences with dental care?; (2) What do you do to
take care of your teeth?; (3) When was the last time you
saw a dentist, and what was the nature of the visit?; (4)
What has prevented you from getting in to see a dentist
and taking care of your teeth?; (5) What would help you
get to your dentist appointments and to take better care of
your teeth?; and (6) What would you want dentists,
community mental health centers, and other health care
providers to know to meet your dental health needs?
These questions were used as a guide to capture a broad
scope of data; however, the interviews were designed to be
open-ended to allow participants to elaborate on topics they
considered important and relevant. All of these questions
were supplemented by probes as necessary. Interviews
were audio recorded and ranged in length from 20 min to
1 h. Each participant received 20 dollars for completing the
interview. Successive interviews were conducted until the
data reached saturation (i.e., new information produced
little or no change to the codebook; Kerr et al. 2010), which
was achieved at the 22nd interview. However, an additional three interviews were conducted to ensure that no
new codes were identified. All interview audio files were
transcribed verbatim by a study staff member who was
trained in qualitative transcription. Finished transcripts
were checked against corresponding audio-recorded interviews for accuracy. The present study was approved by the
appropriate University Institutional Review Board.
Data Analysis
Individual interviews were analyzed across several phases.
Open-coding methods were used to identify important text
areas that were condensed into codes. A codebook was
developed during weekly team meetings, and codes were
discussed and revised (Guest and MacQueen 1998). Before
coding the entire interview set, rigor was established by
assessing inter-rater reliability with a percent-agreement,
paperpencil approach process detailed by Guest and
MacQueen (1998). A total agreement of 85 % or greater
was considered acceptable. Two members of the research
team independently coded selected text segments (e.g.,
pages 5 and 10 of a particular interview transcript) from

123

224

five interviews and an overall percent agreement of 90 %

was established. Agreement for separate codes ranged from
86 to 100 %. Discrepancies were discussed and the codebook was revised until 100 % of the codes were agreed
upon. Finally, during the selective coding phase, inter-code
relationships were examined and themes refined (Corbin
and Strauss 2008). Representative quotes were then selected for each theme.

Results
The study sample included 25 adults (i.e., 13 men and 12
women) diagnosed with bipolar disorder (n = 13, 52 %),
schizophrenia (n = 7, 28 %), schizoaffective disorder
(n = 4, 16 %), or major depression (n = 1, \1 %). The
participants ranged in age from 35 to 63 and mean age was
48.8 (SD = 11.4). A majority of participants were Caucasian (n = 23, 92 %) and had a high school education or
lower (n = 15, 60 %). Sixteen interviewees had some of
their adult teeth still intact and had either no dentures or
partial dentures. Eight interviewees were edentulous (i.e.,
lacking natural teeth) and wore full dentures, and one
individual did not have any teeth or dentures. Data analysis
identified three main themes: (1) lack of awareness, (2)
poverty, and (3) communication and support.
Lack of Awareness
Participants tended to refer to dental pain, cavities, and
missing teeth when evaluating their oral health. Those who
did indicate that they had some or all of their teeth also
reported that these teeth were healthy, despite having
acknowledged that they had multiple dental problems
including multiple cavities or broken or missing teeth.
Evaluation of oral health tended to reflect a lack of dental
pain rather than evidence of dental health. For example, one
participant who had a diagnosis of schizophrenia and retained
some of his adult teeth stated, I think theyre [teeth] pretty
good. They dont hurt or nothing. (Interview 8) The absence
of dental pain also appeared to influence poor initiation of
service use. A majority of these individuals reported waiting
long intervals between dental care visits (i.e., 221 years).
However, those who did attempt to visit the dentist more
often were also more likely to engage in more rigorous oral
self-care. When participants did visit the dentist, pain was
most often the catalyst for seeking treatment.
I guess Ive let it lapse because it wasnt a problem,
but its becoming a problem (Interview 6)
I havent really looked yet, [for a dentist in the
community] cause I dont have a tooth ache or
nothing. (Interview 5)

123

Community Ment Health J (2015) 51:222228

Just never was able to brush teeth. Wait till it got so

bad, then go to the store and get some Oro-gel then
wait a couple days and if that didnt work, then go
and have them pulled. (Interview 13)
Several participants who had full or partial dentures reported
considerable regret for not taking care of their teeth when they
were younger. The verbal expression of regret was accompanied by emotional expression of sadness and grief (e.g.,
frowning, head bowing, crying) and reports of shame accompanied by covering the mouth. Reasons provided for lack of
dental care included never being taught to take care of their
teeth, as well as the lack of motivation for self-care that is
associated with their mental conditions. Irrespective of the
cause for tooth loss, participants reported regret and loss of selfesteem associated with poor oral health and subsequent limitation of social activities. Many of those who did have dentures
reported substantial discomfort and pain related to poor fit and
loose or popping dentures. Poor denture fit caused pain related
to chewing food, particularly hard foods like hard fruits and
vegetables, and caused some to refuse to wear dentures.
I have anger at myself for not taking care of them
when I was told years before that if I started getting
back to taking care of them they might have been able
to save more of em then losing all of them. (Interview 4)
That Im very sorry that I have dentures. I cried when
he told me. He said we have to cut your gums
because you have some dead tissue and theres no
saving any of itAnd when he told me that, I just
bawled like a baby. Cause everything I had gone
through, all the money I had put out, was for nothing.
Nothing. Its very sad. (Interview 1)
I dont eat apples no more. They just make my
teeth popIts horrible. Its frustratinghaving to
learn how to do everything all over again, talk, eat,
drink, breathe because if you get too much air behind
that plate it will pop that plate outthen youre
trying to catch your teeth. (Interview 17)
Overall, these findings indicate that adults with SMI
may use a different benchmark for oral health. Members of
this population may maintain a focus on acute oral health
concerns as an indicator of need. Few social models for
good oral healthcare, limited prospective understanding of
the benefits of preventative oral care, and a lack of motivation for prevention may have contributed to poor oral
health among persons with SMI.
Poverty
A majority of participants (both with and without dentures)
found poverty to be a substantial barrier for access to dental

Community Ment Health J (2015) 51:222228

care. In particular, participants noted difficulties related to

accessing care noting that there were few providers available, particularly in rural areas, who accepted public
insurance. They also identified difficulty with scheduling
timely appointments with providers as a barrier to care. A
majority of the sample also reported that it was hard to
obtain restorative dental procedures, and several participants reported choosing to delay care until an emergency
situation had developed. When participants did attempt to
take care of their teeth, they reported experiencing considerable difficulty affording basic oral hygiene supplies
such as toothpaste or dental floss as well as specific supplies recommended by their dental provider such as a
Waterpik. Often times purchasing supplies or dental care
meant cutting back on other necessities, such as grocery or
rent money. Most indicated a desire for dental care, but a
lack of ability to pay for care above and beyond what is
covered by public assistance:
Its a struggle to find somewhere to help youdo
fillings and stuff cause its a couple hundred bucks
you know and thats a lot. If you have a fillingI
dont even know, like they usually dontlikemy
Medicaid, all they do is pull them, they dont, they
wont fill them So its just, you have one cavity,
you have to get the whole tooth pulled if you want to
be out of pain. (Interview 7)
I had to come up with $1000 down plus $400 a month
before he (the dentist) would even schedule meSo
that took a whilecause I only [receive] $577 on
disability. (Interview 12)
In 2004, I went to Mexico and got 19 teeth pulled and
got dentures.In 2007, they beat me up really
badbroke my bottom dentures in half and knocked
three teeth out of my top and I havent been able to
get them fixed or nothingI dont have Medicaid.
(Interview 20)
Participants also lacked an understanding of what services might be available to them and what their insurance
carrier (including Medicaid) would cover. Many
acknowledged that they would take advantage of the
opportunity to obtain a service if they knew that their
insurance would pay for a procedure. Well, I got insurance and stuff, but I dont know if it would pay for it. If it
would, Id go back. If it wouldnt, I wouldnt go back.
(Interview 8) All participants, regardless of whether or not
they had dentures, noted that having money or financial
assistance would help them to receive needed dental care.
Importantly, these findings suggest that limited financial
resources may serve as a barrier to both preventive selfcare and dental service utilization which may in turn
contribute to poor oral health among adults with SMI.
Limited understanding of the complexities associated with

225

public insurance may further impede preventive oral health

visits among this population.
Communication and Support
Participants who had experienced tooth loss, with and
without dentures, reported only a very basic understanding
about oral health care, including the importance of tooth
brushing and flossing and regular preventative dental visits.
Many participants reported increased understanding of
prevention resulting from lessons learned subsequent to
experiencing extensive decay and tooth loss. However,
nearly all participants had limited knowledge about the
increased risk for poor oral health among adults with SMI
or the relationship of medication side-effects to increased
risk for poor oral health. Interviews revealed that behaviors
on the part of both patient and dentist may have resulted in
missed opportunities to educate and change behavior. Yet,
participants valued having clean, healthy, attractive teeth
and noted the impact of oral health, or lack of oral health,
on their self-esteem. They also acknowledged that their
mental health symptoms impacted their ability or desire to
initiate and maintain self-care behaviors such as brushing
or making and keeping dental appointments. Despite their
awareness of the interaction between mental health symptoms and oral self-care, participants did not perceive a
reason to discuss mental health issues with their dental
providers:
No. I havent [talked to my dentist]. There was no
need to. My medication didnt interfere with anything
as far as I know. (Interview 10)
Never have [talked to dentist about mental health]. I
thought I didnt need to at the time. Thats why I
didnt do it. (Interview 8)
I dont see how it [mental health] would have any
bearing on my teeth. (Interview 12)
Moreover, participants noted that, despite having dental
providers who knew of their mental health status, these
providers did not initiate discussions with them about the
relationship between mental and oral health. For example,
one participant stated, The counseling center arranged it
so they knew that I was from a mental health center and I
was wanting time donated. So he was aware of my mental
health. He didnt ask me, but he was aware of it. I didnt
tell him nothing, but he knew, he said he knew where I was
coming from down here for therapy and stuff so thats
about the most he said for therapy and stuff like that.
(Interview 9) Participants reported, aside from lack of
knowledge, that stigma was a primary barrier that prevented them from initiating conversations about mental
health with others, including dental providers. Participants
feared being devalued and rejected by care providers. For

123

226

example, one 40-year-old female participant with bipolar

disorder stated, People tend to be judgmental. They say
theyre not and they say theyre open-minded and the
minute you say it, it becomes you and me ya know its
because you are frustrated and upset and, if Im angry, Im
just simply dangerous (Interview 7)
In contrast, participants indicated that they often discussed oral health concerns with community mental health
center staff. Further, participants reported that these staff
members were particularly helpful with participants oral
health care by providing assistance with prompting or
reminding about daily self-care as well as obtaining
appointments, completing forms, attending appointments,
and interpreting procedures. Participants also reported that
providers advocated for their needs at times. One 60-yearold participant with schizophrenia who retained some of
his adult teeth noted, They [mental health center staff]
asked me if I would be interested in having a bridge done,
and I said, Yes and they said theyd work on it. They sent
out some letters inquiringI dont know exactly how they
do that, but they did (Interview 10) Another 59-yearold female participant with schizophrenia and full dentures
said, If I dont understand something, she [the case
manager] lets me know what it isshes been my friend
for years. (Interview 3) Finally, another participant with
schizophrenia and some adult teeth referred to the help
with oral health provided by a case manager by stating, I
dont do paperwork at all so if it wasnt for these guys, I
wouldnt have food stamps,housing, or anything. Its the
comprehension part. I can read it but I dont comprehend (Interview 17) Participants also indicated that lay
professionals (e.g., assisted living managers, guardians,
and payees) provided tangible support by helping them
complete forms and keep records of upcoming appointments as well as by providing transportation for them to
and from dental appointments.
Taken together, these results suggest that participants
did not perceive a connection between mental illness and
oral health and, therefore, did not see a need to share
potentially important mental health information with their
dental care provider. However, participants did communicate about oral health with support staff members who
were already aware of and who understood their mental
health conditions.

Discussion
Our study contributes to a developing body of research that
examines factors influencing oral health service utilization
among adults with SMI. Textual analysis of transcripts
from interviews revealed three distinct themes that contribute to knowledge about underutilization of dental

123

Community Ment Health J (2015) 51:222228

services in adults with SMI. Participants in this study

perceived barriers to access and use oral health care services including the lack of awareness of oral health problems, the impact of poverty, and poor communication with
oral health providers. Two of the themes, awareness of oral
health problems and poverty, are consistent with previous
research. The other theme, communication and support,
was less apparent in the literature and suggests an area of
future research.
While recent quantitative literature about whether or not
adults with SMI underutilize dental care services is
somewhat mixed, (Dickerson et al. 2003; Persson et al.
2009; Salsberry et al. 2005), our qualitative work and the
work of others (Persson et al. 2010) adds some understanding about barriers and facilitators of oral health service use. Specifically, prior work, as well findings from the
current study, show that dental pain appears to be a
benchmark by which participants evaluate their oral health
status and need for treatment. Therefore, lack of selfreported unmet need among adults with psychotic disorders, as shown by Heaton and colleagues (Heaton et al.
2013), may in part reflect unrecognized need. In our sample, lack of pain was perceived as lack of a problem. When
pain did result in recognized need, our results also showed
that treatment seeking did not necessarily follow. Among
participants in our sample, treatment was often delayed
with the hope that the problem would diminish, and delay
in seeking care was most commonly due to the cost of oral
healthcare and limited insurance coverage. These findings
corroborate other work with poor or low-income populations showing that the cost of dental care results in long
delays in seeking treatment (Cohen et al. 2007). Still other
work has shown that adults with severe psychological
distress are likely to need dental care and be unable to
afford it (Pratt et al. 2007), suggesting that a relationship
between mental health and oral health may be partially
mediated through lack of dental care access (Pratt et al.
2007).
It is well known that advice from a healthcare professional can have a positive impact on behavior (Kreuter
et al. 2000) by motivating people to seek further treatment
(Sutherland 2003). Recent work, however, has shown that
individuals with SMI are less likely to request medical
advice than members of the general population (Weinmann
et al. 2009). Other evidence has suggested that individuals
with SMI may particularly benefit from oral health advice,
considering that they have greater oral health treatment
needs than the general population (Khokhar et al. 2011).
However, our results showed that opportunities to seek or
receive education about oral health may be missed, particularly tailored education addressing the unique dental
risks among individuals with SMI. Therefore, participants
in this study appeared to lack important knowledge about

Community Ment Health J (2015) 51:222228

their own risk for poor oral health (e.g., current oral health
status, how oral health may be impacted by their mental
health and medication side-effects). This disconnect
between mental health and oral health is consistent with
findings from a somewhat older study which showed that
community-dwelling adult psychiatric patients lacked
knowledge about oral health risks associated with psychotropic medications (Hede and Petersen 1992).
Results from our study also suggest that a lack of
knowledge may result in a lack of patient informationseeking about the intersection of mental and oral health
(i.e., asking questions of providers). Participants in this
study indicated that they chose not to initiate conversations
about mental health with oral health care providers,
believing that mental health is irrelevant to oral health care,
fearing the impact of stigma, or both. In some cases,
opportunities for adults with SMI to receive information
about their oral health risks from providers may have been
missed because the provider did not initiate a conversation
about oral and mental health, even when mental health
status was known. It is possible that dental providers did
initiate these conversations, but that these conversations
were not recalled by the participants. Previous work
highlights the need for dental professionals who provide
care for individuals with severe mental disability to have
specialized expertise, patience, and empathy (Chang and
Seo 2011). Additional work is needed to better understand
the interactions between dental providers and adults with
SMI, as well as the factors (e.g., time, attitudes) that may
impact those interactions. Research is also needed to
examine the impact of oral healthcare advice on knowledge
and self-care behaviors of adults with SMI.
While members of a dental team need to be aware of
how to safely and compassionately provide care to all
adults who receive mental health services (Friedlander
et al. 2003), our findings suggest that other providers
familiar to adults with SMI may also be called upon to
facilitate interactions between patients and their oral health
care teams. This finding is similar to that of Persson et al.
(2010), who examined oral health needs of communitydwelling adults with SMI in Sweden. While a variety of
social supports (e.g., dental providers and peer supports)
were viewed as helpful by participants, those enrolled in
this study noted that community mental health providers
were of assistance in identifying dental providers, obtaining appointments, keeping appointments, and understanding treatment procedures (Persson et al. 2010). Currently,
little is known about the role of non-dental-health providers
in assisting with or promoting oral health care for adults
with SMI. Much of the work that has been done in this area
has focused on improvements in oral health knowledge
among non-dental providers who care for children (Wolfe
and Huebner 2004), and many researchers consider

227

primary medical care as a potential venue for reaching

individuals who do not traditionally make dental visits (i.e.,
children; dela Cruz et al. 2004; Lewis et al. 2000). While
primary care may be a viable avenue for reaching adults
with SMI and educating them about oral health risks
associated with mental health problems and treatments,
mental health care providers may be particularly wellpositioned to reach outpatient psychiatric populations with
oral health care education. McCreadie et al. (2004) have
also suggested that community mental health teams could
be effective advocates for greater use of dental services
among people with schizophrenia.
Mental health providers may play a key role in the
promotion of oral health for several reasons. First, mental
health treatment settings are often primary points of service
delivery for individuals with SMI. It would be feasible to
reach these clients with oral health information by way of
multiple service providers within mental health settings.
These mental health providers also have ample training in
the sequelae of mental disorders and have experience with
the multiple challenges experienced by adults with SMI.
Moreover, some providers within mental health settings
have appropriate training and experience to promote
behavior change. For example, one recent study compared
an oral health education package plus motivational interviewing delivered by a psychologist to oral health education alone. They found that, relative to education only, the
intervention group showed a better dental state and a higher
level of oral health knowledge than those in education
alone, but no difference in the will to brush for personal
reasons (Almomani et al. 2009). Future studies should
explore the feasibility of delivering oral health education
and promotion within mental health service settings, possibly by training mental health nurses or other mental
health care providers in the delivery of oral health education as well as in the delivery of health promotion and
behavior change strategies shown to be efficacious in other
studies. Similarly, an evaluation of oral health status and
treatment needs in a sample of chronic psychiatric inpatients in Turkey recommended that mental health professionals ensure that oral health care is integrated into
routine care (Gurbuz et al. 2010). Further exploration of the
feasibility of engaging mental health providers to aid their
clients in accessing oral health care or aid their clients in
the process of receiving oral health care is warranted.
Researchers may first start by surveying community mental
health centers to ascertain what oral health programming is
in place.
The present findings should be considered within the
context of the studys limitations. Our sample reflected
sociodemographic characteristics of adults with SMI
residing in the Rocky Mountain West, but may not generalize to other groups of adults with SMI residing in other

123

228

areas of the United States. Many of our participants were

simultaneously involved in a larger health-promotion study
focusing on physical health and may have been more
interested in and open to discussing health-related topics
than individuals who are not interested in participating in a
health promotion program. Despite these limitations, this is
one of a small number of studies to provide an in-depth
description of factors influencing oral health care utilization for adults with SMI who are served in community
mental health settings in the United States.

References
Almomani, F., Williams, K., Catley, D., & Brown, C. (2009). Effects
of an oral health promotion program in people with mental
illness. Journal Dental Research, 88(7), 648652.
Brown, S., Birtwistle, J., Roe, L., & Thompson, C. (1999). The
unhealthy lifestyle of people with schizophrenia. Psychological
Medicine, 29(3), 697701.
Chang, J., & Seo, K. S. (2011). Multiple bonded restorations in a
patient with severe mental disability: A case report. Operative
Dentistry, 36(1), 104111.
Cohen, L. A., Harris, S. L., Bonito, A. J., Manski, R. J., Macek, M. D.,
Edwards, R. R., et al. (2007). Coping with toothache pain: A
qualitative study of low-income persons and minorities. Journal
of Public Health Dentistry, 67(1), 2835.
Corbin, J., & Strauss, A. (2008). Basics of qualitative research:
Techniques and procedures for developing grounded theory (3rd
ed.). Los Angeles, CA: Sage.
dela Cruz, G. G., Rozier, R. G., & Slade, G. (2004). Dental screening
and referral of young children by pediatric primary care
providers. Pediatrics, 114(5), e642e652.
Dickerson, F. B., McNary, S. W., Brown, C. H., Kreyenbuhl, J.,
Goldberg, R. W., & Dixon, L. B. (2003). Somatic healthcare
utilization among adults with serious mental illness who are
receiving community psychiatric services. Medical Care, 41(4),
560570.
Elmslie, J. L., Mann, J. I., Silverstone, J. T., Williams, S. M., &
Romans, S. E. (2001). Determinants of overweight and obesity in
patients with bipolar disorder. Journal of Clinical Psychiatry,
62(6), 486491.
Flammer, E., Breier, A., & Steinert, T. (2009). Oral health and
hygiene among persons with severe mental illness. Psychiatry
Services, 60(10), 1402.
Friedlander, A. H., Friedlander, I. K., Gallas, M., & Velasco, E.
(2003). Late-life depression: Its oral health significance. International Dental Journal, 53(1), 4150.
Friedlander, A. H., & Marder, S. R. (2002). The psychopathology,
medical management and dental implications of schizophrenia.
Journal of the American Dental Association, 133(5), 603610.
Guest, G., & MacQueen, K. (Eds.). (1998). Handbook for team-based
qualitative research. Plymouth, UK: Altamira Press.
Gurbuz, O., Alatas, G., Kurt, E., Issever, H., & Dogan, F. (2010). Oral
health and treatment needs of institutionalized chronic psychiatric patients in Istanbul, Turkey. Community Dental Health,
27(3), 151157.
Heaton, L. J., Mancl, L. A., Grembowski, D., Armfield, J. M., &
Milgrom, P. (2013). Unmet dental need in community-dwelling
adults with mental illness: Results from the 2007 Medical

123

Community Ment Health J (2015) 51:222228

Expenditure Panel Survey. Journal of the American Dental
Association, 144(3), e16e23.
Hede, B., & Petersen, P. E. (1992). Self-assessment of dental health
among Danish noninstitutionalized psychiatric patients. Special
Care in Dentistry, 12(1), 3336.
Janardhanan, T., Cohen, C. I., Kim, S., & Rizvi, B. F. (2011). Dental
care and associated factors among older adults with schizophrenia. Journal of the American Dental Association, 142(1), 5765.
Kerr, C., Nixon, A., & Wild, D. (2010). Assessing and demonstrating
data saturation in qualitative inquiry supporting patient-reported
outcomes research. Expert Reviews of Pharmacoeconomics &
Outcomes Research, 10(3), 269281.
Khokhar, W. A., Clifton, A., Jones, H., & Tosh, G. (2011). Oral
health advice for people with serious mental illness. Cochrane
Database Systematic Review, 11, 116.
Kilbourne, A. M., Horvitz-Lennon, M., Post, E. P., McCarthy, J. F.,
Cruz, M., Welsh, D., et al. (2007). Oral health in Veterans
Affairs patients diagnosed with serious mental illness. Journal of
Public Health Dentistry, 67(1), 4248.
Kreuter, M. W., Chheda, S. G., & Bull, F. C. (2000). How does
physician advice influence patient behavior? Evidence for a
priming effect. Archives of Family Medicine, 9(5), 426433.
Kuzel, A. (Ed.). (1999). Sampling in qualitative inquiry. Thousand
Oaks, CA: Sage.
Lewis, C. W., Grossman, D. C., Domoto, P. K., & Deyo, R. A. (2000).
The role of the pediatrician in the oral health of children: A
national survey. Pediatrics, 106(6), E84.
McClave, A. K., McKnight-Eily, L. R., Davis, S. P., & Dube, S. R.
(2010). Smoking characteristics of adults with selected lifetime
mental illnesses: Results from the 2007 National Health
Interview Survey. American Journal of Public Health, 100(12),
24642472.
McCreadie, R. G., Stevens, H., Henderson, J., Hall, D., McCaul, R.,
Filik, R., et al. (2004). The dental health of people with
schizophrenia. Acta Psychiatrica Scandinavica, 110(4), 306310.
Persson, K., Axtelius, B., Soderfeldt, B., & Ostman, M. (2009).
Monitoring oral health and dental attendance in an outpatient
psychiatric population. Journal of Psychiatric and Mental
Health Nursing, 16(3), 263271.
Persson, K., Olin, E., & Ostman, M. (2010). Oral health problems and
support as experienced by people with severe mental illness living
in community-based subsidised housinga qualitative study.
Health and Social Care in the Community, 18(5), 529536.
Pratt, L. A., Dey, A. N., & Cohen, A. J. (2007). Characteristics of
adults with serious psychological distress as measured by the K6
scale: United States, 20012004. Hyattsville, MD: Retrieved
from http://www.ncbi.nlm.nih.gov/pubmed/17432488.
Salsberry, P. J., Chipps, E., & Kennedy, C. (2005). Use of general
medical services among Medicaid patients with severe and
persistent mental illness. Psychiatric Services, 56(4), 458462.
Schladweiler, K., Alexandre, P. K., & Steinwachs, D. M. (2009).
Factors associated with substance use problem among Maryland
Medicaid enrollees affected by serious mental illness. Addictive
Behaviors, 34(9), 757763.
Stiefel, D. J., Truelove, E. L., Menard, T. W., Anderson, V. K., Doyle,
P. E., & Mandel, L. S. (1990). A comparison of the oral health of
persons with and without chronic mental illness in community
settings. Special Care in Dentistry, 10(1), 612.
Weinmann, S., Read, J., & Aderhold, V. (2009). Influence of
antipsychotics on mortality in schizophrenia: Systematic review.
Schizophrenia Research, 113(1), 111.
Wolfe, S. H., & Huebner, C. E. (2004). OPENWIDE: An innovative
oral health program for non-dental health and human services
providers. Journal of Dental Education, 68(5), 513521.