Art-4-Morasso
GERODONTOLOGY www.stomaeduj.com
Original Articles
ORAL REHABILITATION AND QUALITY OF LIFE IN
PSYCHIATRIC PATIENTS UNDERGOING
DEINSTITUTIONALIZATION
Ana María Morasso1-6a , María Lujan Pérez Meyer1-5b , Sergio Thefs1-4c , Luciana D´Eramo2-3d , Noemí Bordoni3e ,
Aldo Fabián Squassi2-3f*
1Doctorado en Ciencias de la Administración, Facultad de Ciencias Económicas, Universidad Nacional de La Plata, Buenos Aires, Argentina
2Cátedra de Odontología Preventiva y Comunitaria, Facultad de Odontología, Universidad de Buenos Aires, Buenos Aires, Argentina
3Instituto de Investigaciones en Salud Pública, Facultad de Odontología, Universidad de Buenos Aires, Buenos Aires, Argentina
4Odontología Legal, Facultad de Odontología, Universidad Nacional de La Plata, Buenos Aires, Argentina
5Universidad Nacional de San Antonio de Areco, Buenos Aires, Argentina
6Especialización en Odontología Legal, Facultad de Medicina, Universidad del Salvador, Buenos Aires, Argentina
aDDS; MS; PhD; Professor; e-mail: anamariamorasso@gmail.com; ORCIDiD: https://orcid.org/0000-0001-7471-2383
bPhD; e-mail: malupm@gmail.com; ORCIDiD: https://orcid.org/0000-0003-2251-4371
cPhD; e-mail: sergiothefs@gmail.com; ORCIDiD: https://orcid.org/0000-0001-5378-2155
dDDS; Associated Professor; e-mail: luciana.deramo@odontologia.uba.ar; ORCIDiD: https://orcid.org/0000-0003-0034-8835
eDDS; PhD; Emeritus Professor; e-mail: nbordoni14@gmail.com; ORCIDiD: https://orcid.org/0000-0002-8147-9564
fDDS, PhD; Chairman, PhD; e-mail: aldo.squassi@odontologia.uba.ar; ORCIDiD: https://orcid.org/0000-0001-7687-5805
ABSTRACT https://doi.org/10.25241/stomaeduj.2022.9(3-4).art.4
Introduction Oral Health-Related Quality of Life (OHRQoL) measures can be used in mentally impaired
groups to evaluate the consequences of oral health treatments. The objective of this study was to describe
the impact of a prosthetic rehabilitation treatment on oral health-related quality of life in psychiatric adults
in the process of deinstitutionalization.
Methodology We designed a quasi-experimental study to assess the OHRQoL of patients with mental
disorders before and after prosthetic treatment on a sample of 165 institutionalized neuropsychiatric patients
between 18 and 65 years of age (x=50.24 y.o.; SD= 7.85). Before treatment, the validated Spanish version
of OHIP-14 was filled out by each participant. Caries experience was assessed using the DMFT index. Sex,
age, type of mental disorder, length of hospitalization, and permanence in a deinstitutionalization program
were registered. The diagnoses of the psychiatric pathologies were transcribed from the medical records,
following the DSM-IV criteria. The therapeutic intervention consisted in manufacturing and installing partial
and complete removable acrylic prostheses, according to each patient’s needs.
Results The sample had a DMFT index mean of 19.71 (SD=5.54). Missing teeth represented 86.86% of the
total of the DMFT index. The OHIP-14 score before the intervention had a mean value of 26.06 (SD=8.74).
After the prosthetic treatment, the OHIP-14 score had a mean value of 7.70 (SD=3.96). The statistical analysis
revealed a significant difference between pre and post treatment intervention (p= 0.018).
Conclusion This study showed that oral rehabilitation affected the oral health-related quality of life of
patients with psychiatric disorders included in a social integration program.
KEYWORDS
Quality of Life; Deinstitutionalization; Mental Disorders; Oral Health; Prostheses and Implants
1. INTRODUCTION construct that has become a significant parameter
to assess how oral health impacts daily function,
People with mental disabilities frequently present well-being, and social interaction 1.
poor oral health and require extensive dental There is growing interest in quantifying the
treatment. Dental caries and periodontal disease consequences of the disease that affect function,
are among the most common conditions affecting comfort, and the ability to carry out daily activities or
patients with psychiatric disorders [1]. Poor oral the impact of health care services or the treatment
health can lead to pain, eating problems, sleeping of diseases. In general, dysfunction, discomfort,
disorders, and diminished self-esteem, all of which or disability measures can be used to assess the
can affect an individual’s quality of life. Oral health- "burden of disease" or collectively the social impact
related quality of life (OHRQOL) is a multidimensional [2].
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Morasso AM, Pérez Meyer ML, Thefs S, D´Eramo L, Bordoni N, Squassi AF. Oral rehabilitation and quality of life in psychiatric patients undergo-
ing deinstitutionalization. Stoma Edu J. 2022;9(3-4):103-107.
Received: September 29, 2022; Revised: October 14, 2022 Accepted: October 21, 2022; Published: November 03, 2022.
*Corresponding author: Prof. Aldo Fabián Squassi, Cátedra de Odontología Preventiva y Comunitaria, Facultad de Odontología, Universidad de Bue-
nos Aires, MT de Alvear 2142, 5th floor, Suite B, CP 1122 Buenos Aires, Argentina, Tel/Fax: +54 11 5287 6253; e-mail: aldo.squassi@odontologia.uba.ar
Copyright: © 2022 the Editorial Council for the Stomatology Edu Journal.
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Moraso AM, et al.
www.stomaeduj.com
Oral Health-Related Quality of Life (OHRQoL) Before treatment, the validated Spanish version of
Original Articles measures are beginning to be used in mentally OHIP-14 [7] was filled out by each participant as a tool
impaired groups with examinations and clinical to measure OHRQoL. OHIP-14 includes 14 questions
trials and studies evaluating the consequences of to assess how oral health influences psychosocial and
oral health component programs. They also play physical domains of a person's life. A Likert scale was
an essential role in identifying needs, selecting used for answering as below: 0-never, 1-hardly ever,
therapies, and monitoring patient progress [3]. 2-occasionally, 3-reasonably often, 4-very often. The
When OHRQoL measurements are used to total score of OHIP-14 is between 0 and 56, with higher
accompany traditional clinical indicators to measure scores indicating lower OHRQoL.
states of the oral health component, it is more In addition, intraoral examinations to evaluate dental
understandable to assess the impact of the disease conditions were performed by a trained examiner. The
or the measures applied on some dimensions. These examinations were conducted with the participant
dimensions, which include functional limitation, seated and the examiner using a head flashlight, a
physical pain, psychological discomfort, physical, WHO dental probe, and a mirror. The data that describe
psychological, social, and opportunity disability, do the baseline situation of the oral health component
not exempt the analysis of other domains such as obtained by direct observation were recorded in an
oral functions, orofacial pain, psychosocial impact, individual file, with a graphic diagram of the dental
and appearance, which must also be described [4]. state. This diagram representing the teeth allowed the
One of the proposed instruments is the Oral Health registration based on predetermined symbols of all the
Impact Profile (OHIP) that assesses perceptions of prevalent pathology and the therapeutic resolution
the social impact of diseases or disorders and oral carried out before the moment of observation,
well-being. This questionnaire can be an excellent with the precision of the tooth and each of the five
option to identify the dimensions of Oral Health- surfaces that compose it. Caries experience was
related to quality of life as it is a reliable instrument assessed using the decayed, missing, and filled teeth
sensitive to changes and with adequate consistency (DMFT index), based on the WHO criteria modified
in cultural crossing [5]. The objective of this without taking into account code WHO1 (initial lesions
study was to describe the impact of a prosthetic without cavitation) due to difficulties in managing
rehabilitation treatment on oral health-related patients and ensuring appropriate dryness of dental
quality of life in psychiatric adults in the process of surfaces. Caries experience was evaluated according
deinstitutionalization. to cavitated lesions ('D' component of the index).
Also, during the baseline examination, we
2. METHODS AND MATERIALS registered the sex, age, type of mental disorder,
length of hospitalization, and permanence in a
We designed a quasi-experimental study to assess the deinstitutionalization program, and we considered
OHRQoL of patients with mental disorders before and independent variables. The diagnoses of the
after prosthetic treatment. psychiatric pathologies were transcribed from the
The target population was a universe of 240 medical records, following the DSM-IV criteria [8]
neuropsychiatric patients from a monovalent The therapeutic intervention consisted of the
institution of the Public Health System under the manufacture and installation of partial and complete
Outpatient and Assisted Rehabilitation Program for removable acrylic prostheses, according to the needs
Social Integration. The study was carried out in the of each patient. The same operator carried out the
Community Mental Health Centers (CSMC) of La Plata
treatment. Six months after the prosthetic treatment
(Province of Buenos Aires), institutions dependent on
was completed, the patients were asked to fill out the
a regional hospital. A random sample of adults of both
OHIP-14 for the second time.
sexes was selected through systematic sampling, and
institutional records were used for integration.
We included patients between 18 and 65 years old, 2.1 Statistical analysis
with a permanence under the program for a period The observations were presented for the statistical
of more than two months. We excluded from the treatment as ordinal scale enumeration data. The
study patients who were already carriers of prosthetic arithmetic, median, and dispersion mean, standard
rehabilitation in any of its types; patients with general deviation and interquartile range were estimated as
motor function disorders classified as severe; and central tendency data.
patients who, due to the characteristics, symptoms, Confidence intervals were calculated to infer the
and associated disorders of the psychiatric pathology, data results obtained from the sample to the target
the medical criteria considered the use of prostheses population. The distribution of the DMFT and
as a risk. OHIP14 values were analyzed using Box Plot, Q-Q
In recognition of mental illnesses people’s rights [6], Plot diagrams, and the Anderson-Darling, Cramer-
the study was carried out with the authorization of Von Mises, Shapiro-France, and Kolmogorov-Smirnov
the organization's executive staff and the consent of numerical tests. The students’ t and z-test for DMFT
the authorities, curators, or legal representatives, as were used as hypothesis test. Mann Whitney's non-
well as the consent of the patients. parametric test was used for OHIP14.
104 Stoma Edu J. 2022;9(3-4):103-107 pISSN 2360-2406; eISSN 2502-0285
Oral health and quality of life in psychiatric patients
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3. RESULTS 4. DISCUSSION
Original Articles
The sample was made up of 165 adults (x = 50.24 The proposal for the treatment of patients with chronic
years old; SD = 7.85) of both sexes with a diagnosis evolution pathologies in their reintegration into the
of psychiatric pathologies in the process of community leads to the creation of devices that guide
deinstitutionalization, 97 females (x = 51.91 y.o.; SD the therapeutic objectives to maintain clinical stability
= 7.44) and 68 males (x = 48.97 y.o.; SD = 8.04), without and include rehabilitation and social reintegration.
significant differences between gender (p = 0.185). The study included combined clinical and subjective
The time of institutionalization prior to entering the indicators for a multidimensional approach to the
deinstitutionalization program was 16.40 years (10.96), oral condition and the measurement of the impact of
range 1-62 years. A significant positive correlation was prosthetic rehabilitation on the quality of life as a driver
determined between the age of the patients and the of changes indicating an improvement in general
health. This improvement will allow the inclusion
years of permanence in the hospitalization system
in a comprehensive plan for the social reintegration
prior to admission to the program (r = 0.456; p <0.05).
of psychiatric adults. This study considers that the
Regarding the average length of stay within the
Health-Mental Illness categories are historically
rehabilitation programs of the CSMC, it was 6.90 years
determined by macroeconomic and macrosocial
(5.17), with no significant differences between both
factors with an evaluative charge of what is considered
sexes (p = 0.329) normal and pathological according to the context, the
The DMFT index presented a mean (SD) of 19.71 (5.54) theoretical approaches and diagnostic criteria used,
(Tab. 1). and the philosophical and moral conceptions, current
psychological and prevailing medical models. Adults
Table 1. Distribution of DMFT index by sex. spend long periods in outpatient programs. This
n DMFT x̄ D M F situation reveals that it can be questioned whether
(SD) x̄ x̄ x̄ everything possible in terms of care units makes sense
Male 68 18.28 (5.36) 2.01 15.48 0,79 to be done. It is questioned whether the marginal
return of the different activities is not very low as a
Female 97 21.59 (5.32) 1.23 19.27 1.09 function of the results due to diminishing returns
Total 165 19.71 (5.54) 1.67 17.12 0.92 in the face of biological limitations. The questions
posed to dental care have resulted from factors that
Missed teeth represented 86.86% of the total of the accompany the current model. Accumulated needs
DMFT index. Significant differences were observed that require many clinical units can be highlighted,
in the DMFT between genders (p = 0.033). When as well as long periods of hospitalization with an
analyzing the DMFT values according to categories extension of treatments to reach discharge of patients.
established according to DSM IV criteria, no significant The oral component involves interventions for the
differences were observed (Tab. 2). care, prevention, and rehabilitation of prevalent
diseases. There is growing interest in quantifying the
Table 2. Distribution of DMFT index according psychiatric disorders. consequences of oral diseases that affect function,
comfort, and the ability to carry out daily activities, the
N x̄ SD burden of disease registered in different communities,
Schizophrenia 97 18,80 5,3 or the social impact that they trigger [3].
Mental retardation 39 21,41 5,24 In terms of dental conditions, the results of this study
determined that oral health has not been a priority in
Psychosis 13 21,50 8,06 government agendas for these special populations.
Specific personality disorder 13 18,50 6,45 Therefore, conventional dental care and oral
Substance addictions 3 24,00 0 rehabilitation had to face limitations and difficulties.
In the province of Buenos Aires, the adults with mental
Total 165 19,7 5,54
disorders studied were going through an assisted
externalization program for socio-labor reintegration
Regarding OHIP-14, the total score before the with high levels of missed teeth. This situation affects
intervention has a median of 23, with a value of 20.50 the management of social skills and interpersonal
for the first quartile and 26.50 for the third quartile, relationships, which cannot be fully realized without
with an interquartile range of 3.5. The mean (SD) was rehabilitating the lost dental functionality.
26.06 (8.74). After prosthetic treatment, OHIP-14 total Several studies found similar DMFT values in adults
score has a median of 6, with 5.00 for the first quartile patients with psychiatric disorders [9,10,11,12,13,14],
and 10.00 for the third quartile, and an interquartile ranging from 16 to 25. This clinical variable allowed
range of 4.00. The mean (SD) value was 7.70 (3.96). quantifying dental disease experience, determining
Statistical analysis reveals a significant difference a compromised oral health situation in our sample.
between results pre and post treatment intervention The result of the measurement of functional and
(p= 0.018). aesthetic capacities or the impact of the perceived
Stoma Edu J. 2022;9(3-4):103-107 pISSN 2360-2406; eISSN 2502-0285 105
Moraso AM, et al.
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Original Articles oral condition constituted an essential input in the The aesthetic and functional rehabilitation of
individual evaluation of the residual consequence individuals is, in essence, the background of
of the oral disease, such as tooth loss and the prosthodontics as a discipline. The impact of the
care provided [3]. While some outcomes related change will be significantly different depending on
to prosthetic therapies are difficult to measure, how the person feels or perceives the deficit or that
satisfaction measurement can characterize such residual consequence, such as tooth loss.
intervention benefits. These results are probably some
of the most used as global indicators of the efficacy of 5. CONCLUSION
prosthetic therapy in clinical practice or research [15].
John et al. studied the association between depression This study showed that oral rehabilitation affected
and dissatisfaction in older adults. Their results the oral health-related quality of life of patients with
indicated that depression affects the perception psychiatric disorders included in a social integration
of health and, in particular, perceived health, program.
characterized by OHRQoL measurements. The authors
found a significant association between depression AUTHOR CONTRIBUTIONS
and dissatisfaction with prosthetics in older adults,
contributing to a wealth of data about the influence AMM participated in the research objective proposal, research
of depression on a variety of psychological and protocol design, clinical examinations and data collection
psychosocial outcomes in medical-dental treatments procedures, and also in the scientific writing of the manuscript.
[16]. Several studies evaluated the effects of prosthetic MLPM participated in data interpretation and statistical analysis
rehabilitation on the quality of life and found an ST participated in the clinical examinations and data collection
improvement after completing treatments [15,17]. procedures. LD participated in data interpretation and the scientific
With dementia patients, van de Rijt showed insufficient writing of the manuscript. NB participated in the research protocol
oral function, which was negatively associated with design and critical revision of the manuscript. AS participated in
the quality of life and nutritional status [18]. data interpretation and the scientific writing of the manuscript
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106 Stoma Edu J. 2022;9(3-4):103-107 pISSN 2360-2406; eISSN 2502-0285
Oral health and quality of life in psychiatric patients
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Original Articles
Ana María MORASSO
Specialist in Legal Dentistry (Universidad del Salvador)
Master in Public Health (Universidad de Buenos Aires)
Master in Economics and Administration of Health Systems (Universidad Nacional de La Plata)
PhD in Administration Sciences (Universidad Nacional de La Plata)
Director of the Specialization Course in Legal Dentistry. (Universidad del Salvador)
CV
Professor Ana María Morasso is an educationist, researcher and specialist in legal and forensic dentistry from Argentina. She
received her DDS from the School of Dentistry, Universidad Nacional de La Plata. She obtained a Speciality in Legal Dentistry
degree at the Universidad del Salvador, a Master in Public Health degree at the Universidad de Buenos Aires and a Master in
Economics and Administration of Health Systems at Universidad Nacional de La Plata. She finished her PhD in Administration
Sciences at the Universidad Nacional de La Plata. At present, she has been appointed as Director of the Specialization Course in
Legal Dentistry at the Universidad del Salvador in Buenos Aires, Argentina. She has participated in research projects accredited
by different institutions and authored research papers published in national and international scientific journals.
Questions
1. Which is the role of Oral Health-Related Quality of Life measures in mentally impaired
groups?
qa. Identifying treatment needs, selecting therapies, and monitoring patient progress;
qb. Selecting patients to be treated with simplified techniques;
qc. Reducing costs of treatments;
qd. All of them are correct.
2. Which questionnaire was used in this study to measure Oral Health-Related Quality of
Life?
qa. Oral Health Impact Profile (OHIP-14);
qb. Oral Health Impact Profile (OHIP-49);
qc. DMFT;
qd. Oral Health Assessment Tool (OHAT).
3. According DMFT index seen in this study, what is the need for oral rehabilitation in
patients with mental disorders?
qa. No need;
qb. Low;
qc. Moderate;
qd. High.
4. What it the relationship between oral rehabilitation and the quality of life in patients
with mental disorders?
qa. Impairs quality of life;
qb. Improves quality of life;
qc. Quality of life is not affected;
qd. There is no relation between oral health and quality of life.
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