Oral Health of People with Psychiatric Disorders

the and deficient and/or and maxillofacial tissues using biocompatible materials. Periodontology, Periodontics, of oral healthcare supporting structures of teeth, diseases, and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. Oral biology deals with the microbiota and their interaction within the oral region. Research in oral health and systemic conditions concerns the effect of various systemic conditions on the oral cavity and conversely helps to diagnose various systemic conditions.

The one-year prevalence of major psychiatric disorder, minor psychiatric disorder, and all psychiatric disorder were 1.37 %, 4.26 %, and 5.30 %, respectively in Taiwan in 2000.

Schizophrenia
A literature search of schizophrenia-related studies in 2002 showed that 1-year and lifetime prevalence and 1-year incidence of schizophrenia were: 0.34 %, 0.55 %, and 11.1/100,000 persons respectively. (Goldner, Hsu, Waraich, & Somers, 2002) The cumulative prevalence of psychiatric disorders increased from 0.33 % to 0.64 % from 1996 to 2001 in Taiwan. (I. C.  Another review research indicated that the median incidence was 15.2/100,000 persons and the median lifetime prevalence was 0.72% for schizophrenia. (McGrath et al. 2004)

Eating disorders
Eating disorders are psychiatric disorders, which represent a clinical symptoms to oral health professionals because of their unique psychological, medical, dental patterns, and their unique features. (Aranha et al., 2008) The average prevalence for anorexia nervosa and bulimia nervosa among young females are 0.3% and 1%, respectively. (Hoek, 2006) The incidence of anorexia nervosa in women between 15 and 19 years of age was 270 per 100,000 person-years. (Keski-Rahkonen et al., 2007)

Depression
A systematical review on the prevalence and incidence of perinatal depression from 1980 through 2004 was carried out. The combined prevalence estimates ranged from 6.5% to 12.9% for major and minor depression, and the major depression alone from1.0 to 5.6% at different trimesters of pregnancy and months in the first postpartum year. (Gavin et al. 2005) Eaton et al. pointed out that there has been a rise in the prevalence of depression among middle-aged females due to increasing chronicity in the U.S. between 1981 to 1993. (Eaton et al. 2007) There has been a rise in the prevalence of depression among middle-aged females in the U.S.. (Eaton, Kalaydjian, Scharfstein, Mezuk, & Ding, 2007)

Dementia and anxiety
The incidence of dementia was 9.2/1000 person-years in aged 65 or over in UK. (Copeland et al., 1992) A systematic review of literature published between 1980 and 2004 reporting findings of the prevalence and incidence of anxiety disorders in the general population. This study demonstrated that 1-year and lifetime prevalence for total anxiety disorders was 10.6% and 16.6% respectively. (Somers, Goldner, Waraich, & Hsu, 2006)

Social stigma of psychiatric disorders
The stigma on people with psychiatric disorders is extensive among this population. Such stigma varies in nature and frequency in different psychiatric disorders. The stigma harms the self-esteem of many people who have serious psychiatric disorders. Negative opinions indiscriminately are likely to overstress the social handicaps together with psychiatric disorders. (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000) Corrigan et al. reported that two factors that may influence whether a person who might benefit from mental health treatment, such are public stigma and self-stigma. (Corrigan et al. 2003)

Psychiatric disorders and health-related quality of life (QoL)
Most people with psychiatric disorders can obtain the necessary care services to live normally in the community. They use the outreach support skills provided by institutions to help them in the transition to community living.(A. A. Pinkney, 1991) A poor mental health could result in a poor perception of health-related QoL. A patient-centered, routine assessment of QoL provides a supplemental measure that may help improve the understanding of the effects of psychiatric disease on an individual's life. (Llewellyn, Warnakulasuriya, Llewellyn, & Warnakulasuriya, 2003) Health-related QoL is an important outcome index of mental health. Therefore, a rehabilitation protocol that takes into account the financial situation, family support, and social functioning of patients is essential. (Chan et al., 2007)

The oral health status and problems of people with psychiatric disorders 2.1 Prevalence and incidence of oral health problems in patients with psychiatric disorders
The oral health status of people with psychiatric disorders is not desirable in general, but there are also significant variations indicating potential of prevention and improvement. The results of several relevant studies are summarized in table 4.

Factors associated with poor oral health status among people with psychiatric disorders
There are many factors associated with poor oral health status among people with psychiatric disorders. Gender differences between oral health and psychiatric disorder have been reported. (G. M. Eugenio Velasco, Angel Martinez-Sahuquillo, Vicente Rios, Juan Lacalle, Pedro BulloAn,, 1997) Factors such as age and the length of stay in institutions seem to be associated with the oral health of psychiatric patients. (G. M. Eugenio Velasco, Angel Martinez-Sahuquillo, Vicente Rios, Juan Lacalle, Pedro BulloAn,, 1997;Italo Francesco Angelillo, 1995;Kumar, Chandu, Shafiulla, & Kumar, 2006;Rekha et al., 2002;Tang et al., 2004) Researches also reported that severity of psychiatric disorders was related with oral health. (Italo Francesco Angelillo, 1995;Kumar et al., 2006;Thomas, Lavrentzou, Karouzos, & Kontis, 1996) The typical antipsychotics, which are part of a wide array of medications used for schizophrenia treatment, may cause manifest hypo-salivation by blocking the parasympathetic stimulation of the salivary glands. This is likely to intensify the progression of dental diseases. (Friedlander & Marder, 2002;Thomas et al., 1996) Xerostomia is a significant risk factor which influences the oral health of patients with psychiatric disorders. (Hede, 1995;Locker, 2003)

Oral health care for people with psychiatric disorders
Oral health programs for people with psychiatric disorders are rare. Researchers have demonstrated the feasibility and efficacy of the combination of mechanical toothbrush, dental instructions and reminders which resulted in additional improvements for the oral health of people with psychiatric disorders. (Almomani et al., 2006) Studies also showed that people with psychiatric disorders receiving motivational interviewing (MI) had significantly better oral health than those receiving oral health education only. Furthermore MI has been shown to be effective for enhancing short-term oral health behavior change for people with severe mental illness. (Almomani, Williams, Catley, & Brown, 2009)

Barriers to oral health care for people with psychiatric disorders
Most oral health professionals have limited experiences in providing care for people with psychiatric disorders. (Waldman, Perlman, Waldman, & Perlman, 2002) The barriers exist in organization and financing of the care needed as well as in proposing strategies to enhance the delivery of appropriate treatment. (Ridgely, Goldman, & Willenbring, 1990) General health services are widely utilized by people with psychiatric disorders under psychiatric care in long-term care institutions. However, oral health services remain underutilized, and there is a high prevalence of perceived barriers to receiving dental care in this population. (Dickerson et al., 2003) 3.2 Special requirements of oral health care delivery system for people with psychiatric disorders Psychiatric disorders have psychopathological characteristics. In particular, there are specific oral health care requirements and management models for patients with psychiatric disorders. (Clark, 1992) These major requirements for people with psychiatric disorders include prophylaxes, calculus removal, and periodontal therapy Patients' dental treatment needs vary depending on several demographic factors, length of stay in institutions and the patient's psychiatric diagnosis. (Barnes et al. 1988)

Implications for the oral health policies
Since the psychiatric health care system has not yet been fully established in some countries, patients with psychiatric disorders there are not likely to obtain the necessary care in their communities. Individuals suffering from severe psychiatric disorders may be able to attain a more dignified life if they could avail themselves of personalized, private, and high quality care services in pertinent institutions. To stay in long-term care institutions is, perhaps, the alternative solution to living in the community. Therefore, the reform of institutions, particularly for the provision of relevant services and continued care, can compensate for a little imparity of dental care for these patients, and is a more practical solution than de-institutionalization of patients with psychiatric disorders. (Chu et al. 2010) Being not life-threatening in most cases, oral diseases have obvious impacts on patients' quality of life. However, patients with psychiatric disorders also suffer from stigma outside and inside themselves. They are vulnerable to oral diseases due to their limited ability/motivation to take care of themselves and also to the side effects of medications prescribed for treating their psychiatric disorders. Despite of the increased needs for dental prophylaxes and care, oral health care programs for psychiatric patients are rare, underutilized and receiving less attention from the public sectors. In addition to boost oral health services provided for patients with psychiatric disorders in the community, it is important for the health policy-makers to support oral health promotion programs. The programs will aim at the patients and their families/carers to empower their belief that oral health is essential and attainable through their own efforts. The government should initiate on-the-job education programs for the dental and psychiatric professionals to enhance their capability and motivation to provide proper services to their psychiatric patients' oral health through integrated efforts. Oral health is an essential part of general health, and it is certainly true for patients with psychiatric disorders.