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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 4  |  Page : 830-837

Knowledge, attitude and practices towards oral health in psychiatric patients attending a tertiary care centre in Northern India

1 Department of Periodontology, MM College of Dental Sciences and Research, Ambala, Haryana, India
2 Department of Psychiatry, MM Institute of Medical Sciences and Research, Ambala, Haryana, India

Date of Submission28-Jan-2022
Date of Decision01-Oct-2022
Date of Acceptance03-Oct-2022
Date of Web Publication10-Feb-2023

Correspondence Address:
Dr. Shalu Chandna Bathla
782/13; Urban Estate, Karnal - 132 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_40_22

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Background: Dentists frequently treat patients who have noticeable abnormal behavior as well as patients who have psychiatric disorders that are not easily identified. The Psychiatrist usually ignore the oral health and hygiene whereas the Dentist usually ignore the psychological health of the patients. Some patients may be so disturbed that personal hygiene is neglected; leading the patients to neglect oral hygiene and the resultant accumulation of plaque is detrimental to the periodontal tissues. Methods: 237 of the 530 patients presenting to Psychiatry OPD who met the inclusion criteria patients between the age group of 18-60 years, drug-naive patients with a diagnosis of mental illness according to the International classification of diseases – 10. The patients, with co-morbid mental retardation, suffering from neurological conditions, and physical handicap, were excluded from the study sample. The patients requiring emergency treatment due to severity of their psychiatric illness were also excluded. Results: Among the wide range of psychiatric disorder, it was observed that there is a total lack oral health awareness; a slightly better awareness was observed amongst the neurotic disorders; the worst were amongst the psychotic and mood disorders. Conclusions: Poor oral health is the gateway to the overall health. The psychoeducation to the patients and the family member must include the need and awareness towards oral hygiene in addition to the other points. A consultation liaison model must be in place to address these needs of the psychiatric patients as they are hesitant and ignorant towards their oral health.

Keywords: International Classification of Diseases-10, mood disorders, oral health, psychiatric patients, psychosis

How to cite this article:
Bathla SC, Singh AH, Bathla M, Sahoonja C, Usmani SB, Yadav E. Knowledge, attitude and practices towards oral health in psychiatric patients attending a tertiary care centre in Northern India. J Datta Meghe Inst Med Sci Univ 2022;17:830-7

How to cite this URL:
Bathla SC, Singh AH, Bathla M, Sahoonja C, Usmani SB, Yadav E. Knowledge, attitude and practices towards oral health in psychiatric patients attending a tertiary care centre in Northern India. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Jun 7];17:830-7. Available from: https://journals.lww.com/dmms/pages/default.aspx/text.asp?2022/17/4/830/369502

  Introduction Top

Mental well-being is an integral parameter of everyone's overall health. A healthy lifestyle can help to deter the onset of mental illness and vice versa. It is a well-established fact that a person suffering from a mental illness will be unable to maintain a healthy lifestyle and hence deteriorate overall well-being.[1] Another aspect of a good healthy lifestyle is the maintenance of good oral health, thus improving the quality of life. Poor oral health not only affects the overall physical well-being but also affects the social and psychological well-being and thus impacts the mental well-being of a person. Oral health and its inter-relationship become even more evident in the cases of mental illness.[2] Oral health in patients with mental disorders and even institutionalized patients is an array of concerns, as poor oral hygiene not only socially outcasts these patients but also predisposes them to various other medical problems such as respiratory infections, cardiac infections, and gastric infections. The problem further gets augmented by the lack of proper oral health hygiene, inability to follow the protocols to maintain oral hygiene, and inability on the part of caregiver or institute's staff to maintain oral hygiene. Certain mental disorders such as schizophrenia, depression, and mania make it relevantly challenging to diagnose or treat the oral health condition and at the same time, it is difficult to maintain oral health hygiene in these patients.[3] Impaired cognition secondary to a mental illness is another risk factor for impaired oral hygiene. Bad oral hygiene in a person with a psychiatric illness can also be attributed to the chronic nature of the illness, poverty, limited resources, and medications.[4] Smoking is linked independently with poor oral health and is prevalent in people with mental illness. Poor nutrition, intake of sugary foods, consumption of alcohol and sugary drinks, poor food intake and the longer breaks in between meals, cost affairs, and difficulty in accessing dental health facilities are the roadblocks to maintaining oral health and hygiene.[5] The diseases commonly affecting oral health are gum (periodontal) diseases, dental caries, and dental erosions. The final stage of these disorders would lead to tooth loss, which could involve the whole dentures.[6] Another grave long-term effect of dental neglect is oral cancer. As the literature suggests that oral health in terms of hygiene and habits of this marginalized section of the population goes largely unrecognized, it should be given prominence by psychiatrists.[7] This study aims at assessing the awareness concerning knowledge, attitude, and behavior of patients with mental illness about the importance of dental hygiene and oral health.

  Methodology Top

This cross-sectional study was pursued for a period of 3 months (June–August 2021) on the patients visiting the outpatient department (OPD) of psychiatry of a tertiary care center after obtaining the institutional ethical clearance (project number: IEC/MMIMSR/11F; dated April 24, 2021). An especially self-designed proforma was used for the study. It included a total of 32 questions (knowledge – 8 questions; attitude – 7 questions; and behavior – 17 questions). A brief pilot study on fifty patients with their consent was conducted to assess the format and ensure uniformity in criteria, the applicability of codes, and their interpretation by the investigator. The participants of this pilot study were excluded from the final analysis.

All patients presenting to the psychiatry OPD who met the inclusion criteria of the study between the age range of 18 and 60 years, patients who gave valid written consent, patients with a primary diagnosis of psychiatric illness as per the International Classification of Diseases–10, psychotropic-naive patients (i.e., patients who have never received any psychotropic agents continuously for more than 2 weeks and not even in the prior 3 months; ascertained by information obtained from patients and their caregiver, wherever available review of past treatment records was done) were included in the study. Patients with comorbidities such as mental retardation, patients suffering from neurological conditions such as stroke, dementia, delirium, and patients with a physical disability were excluded from the study sample. Patients requiring emergency treatment due to the severity of their psychiatric illness were also excluded.

Literate patients read the consent form themselves, whereas for illiterate patients the content of the consent form was explained in the local language by the investigator. Patients who gave valid consent were included in the study and the data were recorded in a self-designed validated proforma.

A total of 530 consecutive OPD patients, within the age group of 18–60 years, in the said period were screened. After assessment and consideration of the criteria's for inclusion and exclusion, 305 patients were selected for data collection; of these, 68 patients refused consent for various reasons. Hence, a total of 237 patients formed the pool of data.

Statistical analysis

The collected data were analyzed with the help of SPSS version 27.0 software (IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp). The frequency with mean, standard deviation, and percentage was calculated. The P value and the level of significance were calculated using Pearson's Chi-square test. A P < 0.05 was considered statistically significant.

  Results Top


Analysis of the collected sample showed that among psychotic disorders 41.5% of the cases were in the age group 18–25 years, 56.6% were males, 54.7% were married, 26.4% were educated till high school, 58.5% were in lower middle class, 77.4% were Hindus, 71.7% were in a nuclear family, and 66% were of rural locality with a mean duration of illness 35.15 months.

Among mood disorders, 25.5% of the cases were in the age group 41–45 years, 56.9% were females, 82.4% were married, 25.5% were not educated, 45.1% were of the lower middle class, 84.3% were Hindus, 78.4% were in a nuclear family, and 80.4% were of rural locality with a mean duration of illness 45.49 months.

Among substance use disorders, 32.6% of the cases were in the age group 18–25 years, 80.4% were males, 54.3% were married, 32.6% were high school educated, 56.5% were of the lower middle class, 82.6% were Hindus, 73.9% were in a nuclear family, and 73.9% were of rural locality with a mean duration of illness 56.33 months.

Among neurotic disorders, 25% of the cases were in the age group 18–25 years, 57.1% were females, 64.3% were married, 30.4% were high school educated, 57.1% were of the lower middle class, 76.8% were Hindus, 67.9% were in a nuclear family, and 73.2% were of rural locality with a mean duration of illness 33.27 months.

Among other disorders, 29% of the cases were in the age group 18–25 years, 58.1% were males, 58.1% were married, 32% were middle school educated, 38.7% were of the lower middle class, 90.3% were Hindus, 71% were in a nuclear family, and 74.2% were of rural locality with a mean duration of illness 53.29 months [Table 1].
Table 1: Sociodemographic data of the sample

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The majority of the participants had poor knowledge about oral health. This observation was made by the lack of knowledge pertaining to the items such as, gum bleeding, and the reasons for oral cancer, which was statistically significant across all groups [Table 2].
Table 2: Knowledge about the oral health of the sample

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The results of their attitude were also keeping in view their knowledge regarding oral health. The use of gutkha and chewing tobacco; smoking; the use of toothpaste for tooth cleaning; and the replacement of missing teeth (MT) with artificial teeth were the statistically significant items across the groups [Table 3].
Table 3: Attitude about the oral health of the sample

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As the knowledge and attitude were poor, this ultimately led to a poorer outcome in terms of the behavior toward oral health. This observation was made by seeing the scores of the following items such as the frequency of teeth brushing; rinsing of mouth (time of the day); habits such as gutkha/tobacco chewing/smoking; gum bleeding while brushing teeth; and other methods of oral hygiene used besides brushing teeth in daily life, which were found to be statistically significant across the groups [Table 4].
Table 4: Practices about the oral health of the sample

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[Table 5] shows the mean duration of the various mental illness in the participants. This was done to see if the duration of illness impacted the dental care and practices. It was observed that duration of mental illness did not affect the practice methods rather the poor knowledge and malpractices led to the bad oral health as seen in the other tables.
Table 5: Duration of illness of the given sample

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  Discussion Top


From our study, we conclude that the majority of patients with psychosis have faulty knowledge about gum diseases and oral cancer. The poor knowledge is reflected in their attitude toward oral hygiene. Hence, the habits developed such as not brushing the teeth, inculcating tobacco chewing, rinsing the mouth only once, and not following any extra oral hygiene methods. It is not far-fetched to conceptualize that with such faulty knowledge, attitude, and behavior, dental diseases and hence intervention will be more as compared to those of the general population. The concept can be supported by the results of the meta-analysis by Yang et al.[8] who showed that the decayed, missing and filled teeth, decayed teeth, and MT scores in patients with schizophrenia were significantly higher when compared with those of the general population. These results also suggested that the oral health care, status of dental caries, and overall oral health management of patients with schizophrenia were poor than those of the general population. In a developing Southeast Asian country study by Wey et al.,[9] it was reported that dental decay was higher in patients with schizophrenia than that in the general population. The explanation for such a rise in the number of oral health illnesses in psychosis can be due to poor diet and poor hygiene. It was observed that patients with schizophrenia had poor oral health with MT along with tooth decay, dental caries, and consequent dental filling.[10] Poor oral health with caries and MT is observed not only in outpatients with schizophrenia but also in chronically hospitalized inpatients with schizophrenia and in those with difficult-to-manage psychiatric comorbidities.[11] Patients with schizophrenia have halitosis (bad breath) which is a major indicator of bad oral health and dental hygiene.[12] These studies corroborate the concept that poor knowledge, attitude, and behavior can lead to poor oral hygiene, hence increased dental disease burden.

Mood disorders

A majority of patients with mood disorders were not aware of the causes of the gum bleeding, while the majority knew that smoking or tobacco chewing is bad for health, but almost half of the patients had co-morbid use of tobacco or smoking. While the majority of patients knew about brushing, almost half of them brush only once a day, the brushing of each tooth carefully is also not followed, and a regular visit to the dentist is not followed by a majority of the patients. There is also no use of any extra means of maintaining oral hygiene.

Affective disorders including depression with anxiety were associated with poor oral health including a decrease in the frequency of brushing of teeth.[13] During depression (major depressive disorder or bipolar depression), the majority of the patients suffer from fatigue, anhedonia, and decreased interest in self-care, leading to declining oral hygiene which consequently increases in the occurrence of caries and periodontal disease.[14] Factors that influence oral health include the severity and stage of psychiatric illness, mood state, motivation level, self-confidence, socioeconomic strata, self-hygiene, lifestyle, substance use habit (smoking, drinking), attitude, knowledge, and self-awareness of the health issues.[3],[15] The results of the systematic review and meta-analyses by Cademartori et al.[16] show a positive correlation between depression and oral diseases such as dental caries, edentulism, and tooth loss in adults and elders. These reviews corroborate the concept that poor knowledge, attitude, and behavior can lead to poor oral hygiene, hence increased dental disease burden.

Substance use disorders

While the majority of substance use patients were aware of the basic knowledge regarding brushing and gum bleeding, they were aware that tobacco use and smoking are injurious for oral health as well as physical health. Yet the majority of them had a habit of using tobacco and or smoking. The positive aspect is that substance use patients had an increased frequency of mouth rinses as compared to patients with psychotic and mood disorders. It is well known that smoking and chewing tobacco products lead to teeth coloration due to tar deposition, an increased incidence of dental erosion, cervical abrasion, burns in the mucosa, keratotic patches, and necrosis of gingiva.[17] Individuals with substance dependence show poor oral health and lack of saliva secretion, which increases the risk of halitosis, caries, burning mouth syndrome, and oral infections such as gingivitis, stomatitis, angular cheilitis, glossitis, and leukoplakia of the tongue.[18] The meta-analysis by Baghaie et al.[19] has inferred that increased dental diseases are seen in substance users than in nonusers. Substance users have higher dental decay and are more likely to develop periodontitis.

Neurosis and others (epilepsy and migraine)

While most neurotic and other disorder patients such as epilepsy, headache, and other neurological conditions have good knowledge of the basic routine dental and oral hygiene, the knowledge is limited on factors responsible for gum bleeding and diseases. These patients have the attitude to maintain oral hygiene but still lack regular visit to dentists. The behavior of the patients was that a majority of them were not indulging in tobacco chewing or smoking and were maintaining routine oral health care and hygiene. The patients were not visiting dentists regularly but were using mouth rinses as an add-on method of maintaining oral hygiene.

General considerations

Poor oral health in patients with psychiatric illness leads to functional difficulties (tooth pain, tooth loss) and makes it challenging to consume nutritional food. Nutritional deficiency due to decreased fruit and vegetable intake in adults with low socioeconomic status is associated with loss of teeth.[20] Lack of daily self-hygiene, regular brushing of teeth, and improper maintenance of oral hygiene are associated with oral infections, caries, and loss of teeth among patients with psychiatric illnesses irrespective of the diagnosis.[21]

Comprehensive care

The study tries to bridge the gap between psychiatrists and dental health practitioners so that a preventive outlook can be taken toward dental illnesses. A large number of studies as shown by meta-analysis have documented that patients with chronic psychiatric illness have poor oral health, dental erosion, tooth decay, and gum diseases (periodontitis). If left untreated, dental diseases can lead to teeth loss and this has been observed in patients with severe mental illness who have 2.7 times the likelihood of losing their teeth in comparison with the general population.[3] Poor oral health can also affect various social and psychological areas of life for instance eating and speech.[22] This study attempts to identify and elucidate the faulty knowledge, attitude, and behavioral practices among patients with mental illnesses so that proper measures can be taken to preserve the oral, physical, and mental health of the patient.

Psychiatrists and mental health professionals should make efforts to document the dental history, along with conducting an oral and general physical examination. Psychiatrists should address the side effects of psychotropic medication such as xerostomia and should even consider prescribing salivary substitutes and stimulants. They should not only perform a comprehensive dental evaluation but should also ask for a dental consultation as necessary. They should willingly psycho-educate their patients about maintaining good oral hygiene and daily flossing and should even advocate the use of anti-caries agents (fluoridated toothpaste) and chlorhexidine mouthwashes. Dental health practitioners should be trained through the dental school curriculum for early identification of eating disorders and substance use, and the provision of comprehensive dental care should be advocated for the management of patients with psychiatric illnesses.[23] Dental health practitioners should work in liaison with psychiatrists with regard to the patient's medication, level of compliance, mental status, and psychological profile.

  Conclusion Top

Hence, to achieve comprehensive health, there should exist a liaison between the dentists and the psychiatrist; both of them should be aware of the common symptoms of presentation and be able to recognize the importance of psychological health and oral health.[24] Poor oral health is the gateway to overall health. The psychoeducation to the patients and the family member must include the needs and awareness of oral hygiene in addition to the course, prognosis, and the need for treatment. A consultation-liaison model must be in place to address these needs of psychiatric patients as they are hesitant and ignorant about their oral health. Obtaining a piece of advice is better than unnecessary investigations.


The authors would like to thank Dr. Parul Gupta for proofreading the manuscript.

Financial support and sponsorship


Conflicts of interest

The are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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