Oral health status and oral health-related quality of life among a convenience sample of individuals receiving inpatient psychiatric care: a retrospective cross-sectional study

Abstract

Background

Those living with mental illnesses have an increased risk of poor oral health exacerbated by lack of motivation for self-care and reduced help-seeking behaviors. Poor oral health status may lead to reduced oral health-related quality of life (OHRQoL) among this population, including the dimensions of Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact. Despite this, oral health is often neglected in the management of mental illnesses, particularly in inpatient treatment facilities. The purpose of this research is to investigate the relationship between the oral health status and OHRQoL in adults receiving inpatient psychiatric care.

Methods

This retrospective, cross-sectional study examined data from medical records of adults between the ages of 18 and 80 receiving inpatient psychiatric care, who had not opted out of research, were English-speaking, and were seen by a hospital dental hygienist between August 1st, 2024 and January 31st, 2025 in response to a consultation request by hospital staff. Oral health status was measured using the Oral Health Assessment Tool (OHAT), and the four dimensions of OHRQoL was measured using the 5-item Oral Health Impact Profile (OHIP-5). Summary scores were analyzed using means and standard deviations. OHAT and OHIP-5 item analysis was completed using frequencies and percentages. Relationships between outcomes were examined using Pearson correlations, with p < 0.05 considered statistically significant.

Results

Twenty-four patient records met inclusion criteria for analysis. The average time from patient admittance to dental hygiene consult was 17 days, with dental pain being the most common reason for consultation (n = 16). Frequency and percentages showed dental pain, natural teeth, and gums and tissues were most frequently scored as unhealthy on the OHAT assessment. Analysis of OHIP-5 summary scores indicated a mean of (M = 11.17, SD = 6.55), suggesting a moderate average impact on OHRQoL within the sample. Further analysis would be required to determine statistically significant differences or associations. Dental pain was positively correlated with all four dimensions of OHRQoL. No other oral condition was associated with summary or individual items of OHIP-5.

Conclusions

Results showed generally poor oral health among individuals hospitalized for psychiatric care. OHIP-5 summary scores showed oral health problems were associated with moderate impairment of OHRQoL. Findings emphasize the need for interprofessional preventative care and support oral health integration in psychiatric settings. Future research should incorporate baseline and follow-up oral health assessments to evaluate the impact of targeted oral health interventions on oral health status and OHRQoL.

Background

Nearly a billion people worldwide live with a mental illness, with almost a quarter (23.1%) of those represented in the United States (US) population [1, 2]. Mental illnesses are classified as health conditions which involve a change in emotions, thought processes, behaviors, or a combination of these, and can lead to disruption in everyday social, work, or family life [3]. Rates of mental illness have increased worldwide since the COVID-19 pandemic, with depression and anxiety cases increasing by 28%, or an additional 53 million cases [4, 5]. Any mental illness broadly encompasses all mental illnesses, while the subset serious mental illness results in substantial limitations to functionality and daily life [1]. Approximately 6% of the US adult population were living with serious mental illness in 2022 [1]. Further, mental illness is the largest contributor of disabilities largely due to high rates of physical illnesses in this group [6, 7]. Symptoms of mental illness negatively impact self-care behavior and motivation, leading to an increased risk of physical illness and chronic conditions in this population [7]. Those with mental illnesses may be underdiagnosed or undertreated due to overlapping symptoms of mental and physical health [5]. Further, people with mental illnesses face barriers to care including affordability, low health literacy, and stigmatization, which reduce help seeking behaviors leading to increased morbidity and mortality [7–10].

The relationship between mental health and quality of life is interconnected and complex. Health-related quality of life (HRQoL) is multifaceted and describes the perceived physical and mental health of an individual or group [11]. Foundational to the concept of HRQoL, is the understanding that health is multidimensional and encompasses physical, mental, and social aspects of well-being [12]. The concept of HRQoL focuses on the impact of a medical condition and/or it’s therapy on a person’s well-being, which may not necessarily reflect the actual physical health condition [13, 14]. Oral health is a key indicator of HRQoL [15, 16]. The impacts of oral diseases, conditions and/or their therapies contribute to oral health related quality of life (OHRQoL) [14, 15].

OHRQoL is a more specific aspect of the broader HRQoL construct which encompasses four-dimensions: Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact [14]. A recent systematic review and meta-analysis determined that in adult populations there was a moderate correlation between OHRQoL and HRQoL, highlighting how poor oral health can negatively impact both psychological and physical health [17]. Oral health status, OHRQoL, and HRQoL have reciprocal associations, meaning poor oral health can contribute to mental health issues such as anxiety and depression [5, 15, 18–20].

People with mental illness face barriers in accessing oral healthcare leading to a higher likelihood of poor oral health [7, 21, 22]. Mental health symptoms may adversely impact self-care behaviors due to a lack of motivation and increased fatigue [7, 21, 22]. Even when individuals with a mental health diagnosis perceive a need for oral health care, they are less likely to seek regular professional care, increasing their risk for chronic and acute dental disease [21, 22]. A significant portion of emergency department visits are due to mental health reasons [23]. Further, dental-related conditions are the third most common reason for acute and avoidable hospital admissions for those with mental illness [24, 25]. Pain and dysfunction from poor oral health can reduce quality of life, exacerbating feelings of hopelessness, depression and anxiety [15]. One study demonstrated patients with a history of psychiatric treatment were 72% more likely to experience a dental-related avoidable admission compared to those without prior psychiatric treatment [25]. Additionally, inflammatory mediators linked to poor oral health are associated with systemic inflammatory diseases, such as diabetes, cardiovascular disease (CVD), and respiratory illnesses, which are commonly observed in people with mental illness, which may compound the risk for avoidable admissions in this population [7, 25, 26].

The physical, mental, and psychosocial impact of poor oral health underscores the importance of improved oral care and management for the psychiatric population [12]. Despite this, oral health assessments and OHRQoL are often overlooked in the standard of care for mental health disorders [27, 28]. Literature suggests a positive association between oral health status and OHRQoL in the psychiatric population [29–32]. Evidence on effective oral health interventions for individuals with severe mental illness remains limited and insufficient [33, 34] Outpatient interventions in this population such as motivational interviewing (MI), oral hygiene instruction (OHI), oral health assessment tools, and nutritional counseling have shown some promise in improving oral health outcomes [7, 27, 35]. However, oral health is often neglected during hospitalization, with a perceived lack of knowledge and importance cited by both patients and providers, reinforcing its low prioritization in mental health care [36, 37]. Few studies in the United States have investigated the relationship between oral health status and OHRQoL for adults receiving inpatient psychiatric care. Emerging evidence shows individuals hospitalized with acute mental illness experience significantly worse OHRQoL compared to the general population, with a positive correlation between poorer oral health status, reduced oral function, and worse OHRQoL [29, 32, 38].

Psychosis and mood disorders account for approximately 600,000 inpatient hospitalizations in US each year, with national data suggesting this number is increasing [1, 39]. Crisis stabilization and safety are primary foci of inpatient treatment, often achieved by group and individual therapy, and medication management [40, 41]. Hospitalization presents both challenges and opportunities for oral health optimization. While the focus often remains on primary medical conditions, this controlled environment offers a chance to deliver individualized oral health care to at-risk patients. Healthcare providers can be key facilitators of oral health promotion for inpatient care to improve OHRQoL. A proactive, interprofessional approach to address oral health status and OHRQoL in patients with mental health disorders can reduce the comorbidities of poor oral health and dental disease [20].

There is a paucity of research evaluating the interplay of mental health, oral health, and OHRQoL in adults receiving inpatient psychiatric care. Because of the reciprocal relationship between mental health and oral health, it is imperative to investigate how oral health conditions impact OHRQoL to adequately address overall patient well-being. The purpose of our study is to investigate the relationship of oral health status and OHRQoL of patients hospitalized for inpatient psychiatric care. Findings from this study will aid in identifying unmet needs in this population that could be a missing link in their psychiatric care, leading to improved interprofessional care to address physical and psychosocial needs.

Methods

Design and study setting

This study used a retrospective cross-sectional design of a convenience sample of patient medical records who received a dental hygiene consultation during inpatient behavioral health treatment between August 1, 2024 and January 31, 2025 at the University of Minnesota Medical Center (UMMC). Research was determined to be exempt by the University of Minnesota’s Institutional Review Board (IRB) and was assigned study number: STUDY00024095.

At the University of Minnesota Medical Center (UMMC), dental hygiene consultation services are carried out by two licensed dental hygienists (DH) under collaborative dental hygiene practice [42, 43]. Only patients with a formal DH consultation request in the electronic healthcare record are seen by the dental hygienist. Dental hygiene consultations are ordered by the medical doctor, nurse, or therapist for reasons such as optimizing oral health, aiding in surgical clearances, or triaging for infectious source. Patients may also request a DH consultation for situations such as dental pain, oral discomfort, or for assistance in oral care. Dental hygiene services to hospitalized patients include intra- and extraoral assessments, oral hygiene instructions, individualized oral care plans, bedside oral care, triaging oral and dental pain, and obtaining diagnostic imaging using an intraoral camera and digital radiographs in collaboration with a licensed dentist. Assessment data collected by the DH during each visit include oral health status, measured by the Oral Health Assessment Tool (OHAT) [44]. In August 2024, the DH team added the 5-item Oral Health Impact Profile (OHIP-5) to their assessments to measure OHRQoL.

Sample characteristics

Patient data was considered for inclusion in the review if the patient was admitted to one of the inpatient behavioral health units at UMMC; were assessed by the dental hygienist between August 1, 2024 and January 31, 2025; medical documentation stated they had “not opted out” for research; were 18–80 years old, and spoke English. In February 2025, the study team collaborated with the University of Minnesota Health Informatics department to safely mine and deidentify retrospective data from the records of patients meeting the inclusion criteria during the time period from August 1, 2024 and January 31, 2025. The extracted data included age, sex, length of stay at time of dental hygiene consultation visit, reason for the dental hygiene consultation, established dental home, independence level in oral care, OHAT, and OHIP-5 data. Table 1 displays the assessment data collected from patients during each consultation visit.

Table 1.

Dental hygiene consultation assessment form

Dental Hygiene Assessment Data
Length of stay (LOS) at time of consult		# days
Independence in oral care		Fully dependent on others Patient requires some assistance Fully independent
Dental home		Yes No
OHIP-5 Questionnaire
In the past SEVEN days:		Score
Have you had difficulty chewing any foods because of problems with your teeth, mouth, dentures or jaws?		Never (0) Hardly Ever (1) Occasionally (2) Fairly Often (3) Very Often (4)
Have you had painful aching in your mouth?		Never (0) Hardly Ever (1) Occasionally (2) Fairly Often (3) Very Often (4)
Have you felt uncomfortable about the appearance of your teeth, mouth, dentures or jaws?		Never (0) Hardly Ever (1) Occasionally (2) Fairly Often (3) Very Often (4)
Have you felt that there has been less flavor in your food because of problems with your teeth, mouth, denture or jaws?		Never (0) Hardly Ever (1) Occasionally (2) Fairly Often (3) Very Often (4)
Have you had difficulty doing your usual jobs because of problems with your teeth, mouth, dentures or jaws?		Never (0) Hardly Ever (1) Occasionally (2) Fairly Often (3) Very Often (4)
OHIP-5 Summary Score:		0–20
OHAT Assessment:
Category	0 = Healthy	1 = Changes	2 = Unhealthy
Lips	Smooth, pink, moist	Dry, chapped, red at corners	Swelling or lump, white/red/ulcerated patch; bleeding/ulcerated at corners
Tongue	Normal, moist, roughness, pink	Patchy, fissured, red, coated	Patch that is red and/or white, ulcerated, swollen
Gums and Tissues	Pink, moist, smooth, no bleeding	Dry, shiny, rough, red, swollen, one ulcer or sore spot under denture	Swollen, bleeding, loose teeth, ulcers red and/or white patches, generalized redness under dentures
Saliva	Moist tissues, watery and free flowing saliva	Dry, sticky tissues, little saliva present, patient thinks they have dry mouth	Tissues parched and red, very little/no saliva present, saliva is thick, patient thinks they have a dry mouth
Natural teeth (Y/N)	No decayed or broken teeth/roots	1–3 decayed or broken teeth/roots or very worn down-teeth	4 + decayed or broken teeth/roots, or very worn-down teeth, or less than 4 remaining teeth
Dentures (Y/N)	No broken areas or teeth, dentures regularly worn and named	1 broken area/tooth or dentures, only worn for 1–2 h. daily, or dentures not named, or loose	More than 1 broken area/tooth, denture missing or not worn, loose and needs denture adhesive, nor not named
Oral Cleanliness	Clean and no food particles or tartar in mouth or dentures	Food particles/tartar/plaque in 1–2 areas of the mouth or small area of dentures, or halitosis	Food particles/tartar/plaque in most areas of the mouth, or on most of dentures, or severe halitosis
Dental Pain	No behavioral, verbal, or physical signs of dental pain	Verbal and/or behavioral signs of pain such as pulling at face, chewing lips, not eating, aggression	Physical pain signs (swelling of cheek or gum, broken teeth, ulcers), as well as verbal and behavioral signs (pulling at face, not eating, aggression)
Total OHAT score __/16

Adapted from Naik et al., 2016 & Chalmers et al., 2006

Oral health assessment tool (OHAT)

The OHAT was used as a screening tool to assess oral health and serve as a foundation for individualized oral care plans during hospitalization. The OHAT is a validated and reliable screening tool to assess oral health [44]. Designed for ease of use amongst non-dental professionals, it is validated for use in residential faculties and has been adapted for use in medical facilities including hospitals [44, 45]. The OHAT tool was selected as the oral health assessment instrument to ensure patient oral health status could be clearly communicated and used to guide oral care routines by both dental and non-dental hospital staff. The OHAT screens oral health by evaluating eight characteristics: lips, tongue, gums and tissues, saliva, natural teeth, dentures, oral cleanliness, and dental pain [44]. Each item is scored on a 3-point scale: 0 (healthy), 1 (changes, or deviations from healthy), and 2 (unhealthy) [44]. The eight OHAT item scores are added together to yield a total score ranging from 0 (completely healthy) to 16 (most unhealthy). For each criterion, guidance for scoring is provided. For example, under saliva, a score of 0 (healthy), reflects moist tissues and watery and free flowing saliva. A score of 1 (changes), indicates dry, sticky tissues, limited saliva present, or self-reported dry mouth. A score of 2 (unhealthy) reflects parched, red tissues, very little or no saliva, thick saliva, and self-reported dry mouth [44]. Further descriptors for scoring each domain can be found in Table 1.

Oral health impact profile (OHIP-5)

Experts recommend the use of OHIP-5 to measure OHRQoL [46]. The OHIP-5 is a shortened version of the original OHIP-49 questionnaire and has broad applicability in a variety of settings [47]. It is validated and reliable, and one of the most commonly used instruments to measure the OHRQoL and its constructs due to its low burden and ease of use amongst busy clinicians, including non-dental providers. The five items serve as indicators of the four dimensions of OHRQoL: Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact, while the summary score indicates the overall OHRQoL impact. Oral function is characterized by the OHIP-5 items “have you had difficulty chewing any foods because of problems with your teeth, mouth, dentures or jaw?” and “have you felt that there has been less flavor in your food because of problems with your teeth, mouth, dentures or jaw?” Orofacial pain is characterized with the item “have you had painful aching in your mouth?” Orofacial appearance is characterized by the item “have you felt uncomfortable about the appearance of your teeth, mouth, dentures or jaws?” Psychosocial impact is characterized by the item “have you had difficulty doing your usual jobs because of problems with your teeth, mouth, dentures or jaws?”. Because the OHIP-5 includes five items that represent four dimensions of OHRQoL, with two items addressing Orofacial Pain, reporting item-level results reflects each dimension’s impact. Patients were verbally administered the five OHIP questions by the DH using a 7-day recall period. For each question, they responded on a five-point Likert scale: Never (0), Hardly Ever [1], Occasionally [2], Fairly Often [3], and Very Often [4]. Summary scores of OHIP-5 range from 0 to 20, where an increase in summary score correlates with a perception of decreased quality of life [46]. The validity of these dimensions and the structure of the instrument have been supported by both exploratory and confirmatory factor analyses [48–50]. Although the OHIP-5 has shown cross-cultural applicability and has been validated in 45 different languages, the OHIP-5 in our study was only administered in its English form [51].

Statistical analysis

Categorical patient characteristics including sex, independence in oral care, established dental home, and reason for DH consultation were summarized using frequencies and percentages. Numerical patient characteristics including age and length of stay at time of DH consult were summarized using means, standard deviations, and ranges. OHIP-5 item and summary scores were were reported using both frequencies and percentages for each ordered category level and means and standard deviations. OHAT item and summary scores were reported using frequencies and percentages for ordered category levels. Relationships among OHAT and OHIP-5 summary and item scores were examined using Pearson correlations, with a p-value of < 0.05 considered significant. Analyses were conducted using R version 4.4.2.

Results

Patient records (n = 24) met the inclusion criteria for analysis. Patient characteristics are displayed in Table 2. The majority of records were from female patients (62.5%), with ages ranging from 21 to 65. All records indicated patients were completely independent in oral care (100%), meaning they do not require additional help to carry out regular daily oral hygiene practices, such as toothbrushing. Most patients did not have a dental home (70.8%). The average time from admission to the dental hygiene consultation was 17 days (17.17), with a range of 5–60 days. The most common reason for medical providers to consult with the DH service was “oral/dental pain” (66.7%), followed by concern for systemic infection due to a dental-related source (21%), and “poor oral hygiene” (12.5%) (Table 3).

Table 2.

Patient characteristics

Study Participants (n = 24)		Mean (SD)
Age in years		39 (± 13.6)
Length of stay at time of DH consult (days)		17.17 (± 17.29), Range 5–60 days
Sex		n (%)
	Female	15 (62.5%)
	Male	9 (37.5%)
Independence in oral care	Independent	24 (100%)
Established dental home	Yes	7 (29.2%)
	No	17 (70.8%)

Table 3.

Dental hygiene consultation reasons

Reason for DH Consultation	n (%)
Poor oral hygiene	3 (12.5%)
Oral/dental pain	16 (66.7%)
Other (concern for abscess, infection)	5 (21.0%)

OHAT total scores in this study ranged from 1 to 9 on a 0–16 scale, with a score of 9 indicating the unhealthiest oral status (Table 4). Frequency scores of individual items revealed most participants had healthy lips (95.8%), with only one patient showing changes toward unhealthy (4.2%). Most patients had either unhealthy gums or tissues (41.7%) or changes toward unhealthy gums or tissues (37.5%). Saliva was healthy in most patients (87.5%), with three patients (12.5%) having changes toward unhealthy. Most patients had unhealthy natural teeth (54.2%) or changes toward unhealthy (41.7%). Findings for the tongue were generally healthy (79.2%), with five records indicating changes toward unhealthy (20.1%). The majority of patients either did not have dentures or they had dentures in healthy condition (95.8%). Half of patients had oral cleanliness scored as unhealthy or showed changes toward unhealthy (16.7%), with just a third of records (33.3%) indicating health characterized by adequate plaque control and cleanliness. Most patients displayed physical or verbal confirmation of dental pain, with ten patients (41.2%) demonstrating behavioral or verbal signs of pain along with physical symptoms. Five patients (20.1%) exhibited either verbal or behavioral signs of pain. Nine patients (37.5%) had no dental pain on assessment.

Table 4.

OHAT scores

OHAT Category	Frequency of Scores: n(%)
Lips	Healthy: 23 (95.8%) Changes: 1 (4.2%) Unhealthy: 0 (0.0%)
Tongue	Healthy: 19 (79.2%) Changes: 5 (20.8%) Unhealthy: 0 (0.0%)
Gums and Tissues	Healthy: 5 (20.8%) Changes: 9 (37.5%) Unhealthy: 10 (41.7%)
Saliva	Healthy: 21 (87.5%) Changes: 3 (12.5%) Unhealthy: 0 (0.0%)
Dentition	Healthy: 1 (4.2%) Changes: 10 (41.7%) Unhealthy: 13 (54.2%)
Denture Quality	Healthy: 23 (95.8%) Changes: 1 (4.2%) Unhealthy: 0 (0.0%)
Oral Cleanliness	Healthy: 8 (33.3%) Changes: 4 (16.7%) Unhealthy: 12 (50.0%)
Dental Pain	Healthy: 9 (37.5%) Changes: 5 (20.8%) Unhealthy: 10 (41.7%)
OHAT Total Summary Score:	Total Score (0–16):	Frequency: n(%)
	1	2 (8.3%)
	2	0 (0.0%)
	3	5 (20.8%)
	4	1 (4.2%)
	5	5 (20.8%)
	6	2 (8.3%)
	7	4 (16.7%)
	8	2 (8.3%)
	9	3 (12.5%)
	10–16	0 (0.0%)

Summary scores for the OHIP-5 were moderate with a mean (standard deviation) of 11.17(6.55), on a scale of 0–20 (Table 5). Frequency analysis of the of OHIP-5 items revealed that the response “very often” was most frequently selected for OHIP-5 item three, which represents the OHRQoL dimension Orofacial Appearance (58.3%). This finding is followed by OHIP-5 item two (54.2%), representing Orofacial Pain, and OHIP-5 item one (50%) which represents Oral Function. The highest frequency of “never” responses were for OHIP-5 item four (58.3%) which represents Oral Function, and OHIP-5 item five, representing Psychosocial Impact (54.5%).

Table 5.

OHIP-5 scores

OHIP-5 item	Corresponding OHRQoL Dimension	Mean (SD)	Frequency of Scores n(%)
Item 1 “Have you had difficulty chewing any foods because of problems with your teeth, mouth, dentures or jaw?”	Oral Function	2.62 (± 1.71)	Never: 6 (25.0%) Hardly Ever: 1 (4.2%) Occasionally: 1 (4.2%) Fairly Often: 4 (16.7%) Very Often: 12 (50.0%)
Item 2 “Have you had painful aching in your mouth?”	Orofacial Pain	2.71 (± 1.73)	Never: 6 (25.0%) Hardly Ever: 1 (4.2%) Occasionally: 0 (0.0%) Fairly Often: 4 (16.7%) Very Often: 13 (54.2%)
Item 3 “Have you felt uncomfortable about the appearance of your teeth, mouth, dentures, or jaws?”	Orofacial Appearance	2.67 (± 1.81)	Never: 7 (29.2%) Hardly Ever: 0 (0.0%) Occasionally: 1 (4.2%) Fairly Often: 2 (8.3%) Very Often: 14 (58.3%)
Item 4 “Have you felt that there has been less flavor in your food because of problems with your teeth, mouth, dentures, or jaws?”	Oral Function	1.46 (± 1.82)	Never: 14 (58.3%) Hardly Ever: 0 (0.0%) Occasionally: 1 (4.2%) Fairly Often: 3 (12.5%) Very Often: 6 (25.0%)
Item 5 “Have you had difficulty doing your usual jobs because of problems with your teeth, mouth, dentures, or jaws?”	Psychosocial Impact	1.71 (± 1.92)	Never: 13 (54.2%) Hardly Ever: 0 (0.0%) Occasionally: 0 (0.0%) Fairly Often: 3 (12.5%) Very Often: 8 (33.3%)
OHIP-5 Summary Score		11.17 (± 6.55)

Relationships between OHAT and OHIP-5 were examined using correlational tests for both summary and item scores, with statistical significance of a p value < 0.05 (Table 6). No statistically significant correlation was demonstrated between OHAT and OHIP-5 summary scores. Moderately strong positive correlations were found between OHAT item dental pain and total OHIP-5 summary score (r = 0.66 p < 0.05), and OHIP-5 item two, “have you had painful aching in your mouth?” (r = 0.75, p < 0.05). Positive correlations were also observed between “dental pain” and OHIP-5 item one (r = 0.46, p < 0.05), three (r = 0.41, p < 0.05), and five (r = 0.57, p < 0.05) No other statistically significant correlations between OHAT and OHIP-5 item or summary scores were observed that met statistical significance.

Table 6.

Correlation of OHIP-5 and OHAT summary and item scores statistical significance = p = < 0.05*

	OHAT item, pearsons coefficient. Statistical significance p = < 0.05*
OHIP-5 item	Lips	Tongue	Gingiva	Saliva	Dentition	Denture	Cleanliness	Pain	OHAT Total
Difficulty chewing	-0.20	-0.07	0.00	+ 0.16	-0.06	+ 0.05	+ 0.1	+ 0.46*	+ 0.19
Painful aching	+ 0.16	+ 0.09	+ 0.05	-0.08	+ 0.11	+ 0.04	+ 0.11	+ 0.75*	+ 0.39
Uncomfortable about appearance	+ 0.16	− 0.0.14	+ 0.24	0.00	-0.20	+ 0.16	-0.04	+ 0.41*	+ 0.18
Less flavor in foods	-0.17	-0.19	+ 0.36	-0.03	+ 0.02	-0.17	+ 0.08	+ 0.23	+ 0.16
Difficulty doing usual jobs	-0.19	-0.03	+ 0.13	-0.34	+ 0.06	-0.19	+ 0.05	+ 0.58*	+ 0.19
OHIP-5 Summary Score	-0.07	-0.09	+ 0.21	-0.09	-0.02	-0.04	+ 0.08	+ 0.66*	+ 0.30

Discussion

This study found a statistically significant relationship between dental pain and OHRQoL among patients hospitalized for mental illness. The OHAT summary and item-level scores suggested generally poor oral health amongst the inpatient psychiatric population represented in this study, with the majority of patients having at least one unhealthy area, and all patients having changes toward unhealthy, particularly the areas of gums and tissues, natural teeth, oral cleanliness, and dental pain. This aligns with past literature citing patients with mental illness are more likely to experience poor oral health including higher decayed, missing, filled, teeth (DMFT) scores and risk of edentulism compared to the general population [32, 52]. Poor plaque control from diminished self-care behaviors can lead to both problems of the gingiva and the dentition, such as caries, gingivitis and periodontitis.

It is established that patients with psychiatric conditions face barriers to self-care behaviors including daily oral hygiene practices and seeking preventative therapies [7]. In our study, less than half of patients reported having a dental home, a finding that reflects national trends and highlights the difficulty in establishing routine dental care. When preventive dental care is inaccessible, oral disease often progresses to more severe stages, leading to pain among other impacts. Expanding on-site dental services and integrating oral health education into psychiatric treatment can help address barriers. Other services to ensure these patients receive the comprehensive oral care they need could include providing coordinated care between dental and mental health professionals; health providers referring to community dental clinics; providing support for transportation or follow-up after discharge.

Participants in our study reported higher OHIP summary scores than prior research in the psychiatric population [29, 31, 52, 53]. Existing literature shows considerable variation of OHIP summary scores for those with severe mental illness when taking into account differences in research setting, such as inpatient versus outpatient, severity of mental illness, and other social vulnerabilities which likely contribute to the range of self-reported oral health quality of life [29, 31, 52, 53]. It should also be noted that all studies referenced here used the OHIP-14, which is based on an earlier, seven-dimensional OHRQoL model [47]. These findings demonstrate that OHIP scores are highly dependent on the population studied, reinforcing the need for additional population-specific research.

Of the four OHRQoL dimensions, Orofacial Appearance was the most impacted dimension in our study population demonstrated by the highest frequency of “very often” responses to the corresponding OHIP-5 item. This differs from prior literature which found the OHIP-14 dimensio, Physical Pain to be the most impacted dimension in adults with severe mental illness. While related to Orofacial pain, Physical Pain is a more specific construct, related to the older, seven-dimension model of OHRQoL [47]. Orofacial Pain and Oral Function were the second and third most impacted dimensions in our study population. Psychosocial Impact was affected to a lesser extent, suggesting oral health problems did not impact their ability to perform their day-to-day tasks or usual jobs to as great of an extent. This aligns with prior literature that suggests individuals experiencing psychosis or other severe psychiatric symptoms may deprioritize oral health in relation to their more immediate mental health condition [36, 54]. Gemp et al., suggests psychiatric patients may have a mismatched self-perception of oral health despite objective oral conditions, leading to a lesser impact on OHRQoL [20]. Kuipers et al., found minimal impact on the OHIP-49 Social Disability dimension in a psychiatric inpatient population [55]. Similarly, Patel et al., found Social Disability to be the least impacted when observing OHIP-14 scores from adults receiving outpatient psychiatric care [52]. These findings suggest the impact of psychiatric needs and concerns may outweigh the impact of oral health on the Psychosocial Dimension of OHRQoL. Another explanation may be that patients have adjusted to their oral health status, reaching a point of acceptance to where they feel oral/dental problems do not impact their ability to perfom their usual jobs or tasks.

However, our study found an exception in that dental pain was a key OHAT item that may be associated with a persons’ ability to perform daily functions (Psychosocial Impact). This is important because it suggests dental pain may be the point at which oral health problems start to noticeably affect daily life and social interactions. In other words, pain could be the key factor that turns a dental issue into something that really impacts quality of life.

Even though most patients in the study had signs of poor oral health, dental pain was the only issue that clearly connected with all aspects of how people felt their oral health was affecting their lives, demonstrated by the positive correlation with all five OHIP-5 items which reflect the four dimensions of OHRQoL (Table 6). These findings reinforce prior literature identifying a linear relationship between increased DMFT and both psychological and functional pain [30]. Over 60% of dental hygiene consultations in our sample were initiated due to patient-reported pain, further underscoring the consequences of delayed care in this population and setting.

Despite the predisposition to poor oral health, psychiatric inpatients typically do not receive routine oral assessments or interventions as a component of their care [54]. This was evident in this study, as the average time from admission to DH consult was 17 days. The delay represents a missed opportunity to intervene earlier in the disease process, especially as psychiatric hospitalization may be one of the few structured environments where patients are available for coordinated care [27, 34]. These findings further underscore the importance of integrating oral assessments and coordinating dental treatment as a component of outpatient psychiatric care. Early intervention can lead to targeted oral hygiene plans and early identification/resolution of oral problems that if left untreated could otherwise result in pain, disrupting the important mental health care the patient is hospitalized for. Screening tools such as the OHAT are simple, reliable, low-risk interventions that can facilitate dental integration into out- or in-patient psychiatric care. They can be administered by trained non-dental professionals such as nurses, physicians, or mental health staff [27, 34]. The use of the OHAT by speech language pathologists was found to have good reliability and feasibility when used during clinical swallow evaluations [56]. However, in our study setting, DH consultations were only permitted following a referral by medical provider or patient request. This policy constrained proactive assessments and led to delayed oral health care which was often triggered by the presence of pain. This limitation highlights the need for institutional policy change to allow for standing orders, including daily oral care protocols based on oral health assessments administered on admission and during routine daily care. Prior to implementing standardized oral health protocols to inpatient units, barriers to oral health interventions faced by mental health providers should be considered, such as lack of knowledge, confidence, and training. Involving the expertise of multiple professions in team-based care can provide opportunities remove barriers for improved oral health outcomes in this inpatient population. Oda et al., found nurses’ confidence and attitudes toward oral screenings were improved after a hands-on interprofessional training with oral health professionals [57].

Implications for practice

Implications from our study are valuable in providing insight to caring for individuals in inpatient psychiatric settings. Efforts to integrate medical, dental, and mental health are needed. This can be done by implementing interprofessional care protocols which include incorporating DHs into psychiatric care settings. DH are trained, licensed, and qualified to conduct oral health assessments, provide patient and provider education, preventive care, oral health referrals, and triage oral disease [58]. Interprofessional collaboration, education, and training can enhance mental health providers’ comfort and competence in conducting basic oral health assessments, supporting a more patient-centered approach to care [59]. Together, these steps will help ensure a holistic and patient-centered care model that recognizes oral health as an important part of overall health and quality of life.

Limitations and future research

This study was limited by its small sample size. It was conducted in one hospital, so results cannot be generalized outside of the focused study population. Second, since there was a lack of follow-up with oral health status measurements using the OHAT and OHIP-5, the impact of the dental hygienist and oral care plans were not investigated. Because these assessments were only administered once per patient, the scores do not reflect the broader implications of how their oral health or perceptions might change over time. Due to the lack of standardized hospital protocols for the DH and mental health providers, it was not possible to determine whether recommended oral care plans were being implemented. Additionally, institutional policies limited the DH’s ability to assess patients proactively. Consultation was only allowed following a referral from a healthcare provider, such as a physician or nurse. For over half of the patients, this consultation was initiated only after dental pain was reported, which may have disproportionally skewed our results, potentially overstating the prevalence of self-reported dental pain in this population. Because patients were not seen prior to DH consultation, we were not able to assess the baseline oral health status and OHRQoL of all patients hospitalized in the behavioral health units.

Future research should investigate the use of screening tools to assess oral health status and OHRQoL upon admission in the psychiatric inpatient setting. Longitudinal studies are also needed to evaluate the impact of structured oral care interventions on patient-reported outcomes, including OHRQoL in this population. Implementation research exploring effective strategies for integrating oral health into mental health care workflows in hospital settings could inform strategies to address patient care gaps.

Conclusion

This study adds to the growing evidence that oral health and OHRQoL are overlooked for individuals who are admitted to inpatient psychiatric settings. The use of simple screening tools such as the OHAT and OHIP-5 revealed high levels of oral disease, unmet dental needs, and moderate impairments in OHRQoL. Notably, the presence of dental pain was strongly associated with worse OHRQoL across all dimensions. These findings shed light on the need to prioritize oral health within psychiatric inpatient care where opportunities for screening, education, and early intervention are frequently missed. By integrating patient-centered oral health tools into psychiatric settings, providers can take meaningful steps toward improving oral and overall health outcomes for this vulnerable population.

Abbreviations

OHRQoL

Oral health related quality of life

HRQoL

Health related quality of life

DH

Dental hygienist

OHAT

Oral health assessment tool

OHIP-5

Five-item Oral Health Impact Profile

AMI

Any mental illness

SMI

Severe mental illness

DMFT

decayed, missing, filled teeth

Author contributions

KF contributed to the study conception, writing the manuscript, data interpretation and manuscript preparations, DP provided expertise of OHIP-5 and OHRQoL data interpretation, and contributed to manuscript preparation, MV contributed to the study conception, data collection and interpretation, and manuscript preparations, ME provided statistical design and analysis, and manuscript support, CS provided mentorship, contributed to the study conception, supervision, and manuscript preparation. All authors revised and approved the final manuscript.

Funding

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award Number UM1TR004405. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

This retrospective analysis was performed in line with the principles of the Declaration of Helsinki. The University of Minnesota’s Institutional Review Board (IRB) deemed this research exempt (STUDY00024095).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.