BRIEF REPORT

Oral Health in Adults with Serious Mental Illness:Needs for and Perspectives on Care

Christine L. McKibbin • Katherine A. Kitchen–Andren •

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 inves-

tigate 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 tran-

scribed. 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 imple-

menting 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

health problems among adults with SMI, including side-

effects of psychotropic medications (e.g., xerostomia and

movement disorders; Friedlander and Marder 2002; Kil-

bourne et al. 2007), lifestyle and health habits (e.g., ciga-

rette 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 psy-

chiatric 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 poten-

tial 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 self-

reported 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, He-

aton et al. (2013) examined unmet dental need among three

patient groups. Specifically, these authors compared indi-

viduals 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 self-

reported 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 pri-

marily accounted for by unmet dental need among those with

and without self-reported diagnoses of depression or anxiety.

C. L. McKibbin (&) � K. A. Kitchen–Andren �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

Community Ment Health J (2015) 51:222–228

DOI 10.1007/s10597-014-9758-z

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 under-

utilization of services, there is a limited body of literature

to describe, in depth, the factors that may influence self-

care 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 gen-

eralizable 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 in-

depth 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 pro-

duce 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

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 addi-

tional 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 inter-

views 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,

paper–pencil 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

Community Ment Health J (2015) 51:222–228 223

123

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 code-

book 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 selec-

ted 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 Cauca-

sian (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 they’re [teeth] pretty

good. They don’t 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., 2–21 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 I’ve let it lapse because it wasn’t a problem,

but it’s becoming a problem… (Interview 6)

I haven’t really looked yet, [for a dentist in the

community] ‘cause I don’t have a tooth ache or

nothing. (Interview 5)

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 didn’t 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 accompa-

nied by emotional expression of sadness and grief (e.g.,

frowning, head bowing, crying) and reports of shame accom-

panied 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 self-

esteem associated with poor oral health and subsequent limi-

tation 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. (Inter-

view 4)

That I’m 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 there’s no

saving any of it…And 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. It’s very sad. (Interview 1)

…I don’t eat apples no more. They just make my

teeth pop…It’s horrible. It’s frustrating…having 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 out…then you’re

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 moti-

vation 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

224 Community Ment Health J (2015) 51:222–228

123

care. In particular, participants noted difficulties related to

accessing care noting that there were few providers avail-

able, 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 partici-

pants reported choosing to delay care until an emergency

situation had developed. When participants did attempt to

take care of their teeth, they reported experiencing con-

siderable difficulty affording basic oral hygiene supplies

such as toothpaste or dental floss as well as specific sup-

plies 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:

It’s a struggle to find somewhere to help you…do

fillings and stuff cause it’s a couple hundred bucks

you know and that’s a lot. If you have a filling…I

don’t even know, like they usually don’t…like…my

Medicaid, all they do is pull them, they don’t, they

won’t fill them… So it’s 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 me…So

that took a while…cause 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

bad…broke my bottom dentures in half and knocked

three teeth out of my top and I haven’t been able to

get them fixed or nothing…I don’t have Medicaid.

(Interview 20)

Participants also lacked an understanding of what ser-

vices 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 insur-

ance and stuff, but I don’t know if it would pay for it. If it

would, I’d go back. If it wouldn’t, I wouldn’t 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 self-

care and dental service utilization which may in turn

contribute to poor oral health among adults with SMI.

Limited understanding of the complexities associated with

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 symp-

toms and oral self-care, participants did not perceive a

reason to discuss mental health issues with their dental

providers:

No. I haven’t [talked to my dentist]. There was no

need to. My medication didn’t interfere with anything

as far as I know. (Interview 10)

Never have [talked to dentist about mental health]. I

thought I didn’t need to at the time. That’s why I

didn’t do it. (Interview 8)

I don’t 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 didn’t ask me, but he was aware of it. I didn’t

tell him nothing, but he knew, he said he knew where I was

coming from down here for therapy and stuff so that’s

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 pre-

vented them from initiating conversations about mental

health with others, including dental providers. Participants

feared being devalued and rejected by care providers. For

Community Ment Health J (2015) 51:222–228 225

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

disorder stated, ‘‘People tend to be judgmental. They say

they’re not and they say they’re open-minded and the

minute you say it, it becomes you and me ya know it’s

because you are frustrated and upset and, if I’m angry, I’m

just simply dangerous…’’ (Interview 7)

In contrast, participants indicated that they often dis-

cussed 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-year-

old 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 they’d work on it. They sent

out some letters inquiring…I don’t know exactly how they

do that, but they did…’’ (Interview 10) Another 59-year-

old female participant with schizophrenia and full dentures

said, ‘‘If I don’t understand something, she [the case

manager] lets me know what it is…she’s 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

don’t do paperwork at all so if it wasn’t for these guys, I

wouldn’t have food stamps,…housing, or anything. It’s the

comprehension part. I can read it but I don’t compre-

hend…’’ (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 appoint-

ments 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 communi-

cate 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 con-

tribute to knowledge about underutilization of dental

services in adults with SMI. Participants in this study

perceived barriers to access and use oral health care ser-

vices including the lack of awareness of oral health prob-

lems, 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 under-

standing about barriers and facilitators of oral health ser-

vice 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 self-

reported unmet need among adults with psychotic disor-

ders, as shown by Heaton and colleagues (Heaton et al.

2013), may in part reflect unrecognized need. In our sam-

ple, 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 popula-

tions 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 profes-

sional 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, par-

ticularly tailored education addressing the unique dental

risks among individuals with SMI. Therefore, participants

in this study appeared to lack important knowledge about

226 Community Ment Health J (2015) 51:222–228

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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 psy-

chotropic medications (Hede and Petersen 1992).

Results from our study also suggest that a lack of

knowledge may result in a lack of patient information-

seeking 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 community-

dwelling 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, obtain-

ing appointments, keeping appointments, and understand-

ing 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

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 well-

positioned 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 inter-

viewing delivered by a psychologist to oral health educa-

tion 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, pos-

sibly by training mental health nurses or other mental

health care providers in the delivery of oral health educa-

tion 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 in-

patients in Turkey recommended that mental health pro-

fessionals 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 study’s limitations. Our sample reflected

sociodemographic characteristics of adults with SMI

residing in the Rocky Mountain West, but may not gen-

eralize to other groups of adults with SMI residing in other

Community Ment Health J (2015) 51:222–228 227

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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 utiliza-

tion for adults with SMI who are served in community

mental health settings in the United States.

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