Journal of Affective Disorders 200 (2016) 119–132

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

The oral health of people with anxiety and depressive disorders – a

systematic review and meta-analysis
Steve Kisely a,b,c,n, Emily Sawyer d, Dan Siskind a, Ratilal Lalloo e
a
School of Medicine, The University of Queensland, Woolloongabba, Qld, Australia
b
Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia
c
Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Canada
d
School of Medicine, James Cook University, Qld, Australia
e
School of Dentistry, The University of Queensland, Herston, Qld, Australia

art ic l e i nf o a b s t r a c t

Article history: Background: Many psychological disorders are associated with comorbid physical illness. There are less
Received 17 February 2016 data on dental disease in common psychological disorders such as depression and anxiety in spite of risk
Received in revised form factors in this population of diet, lifestyle or antidepressant-induced dry mouth.
6 April 2016
Methods: We undertook a systematic search for studies of the oral health of people with common
Accepted 16 April 2016
Available online 21 April 2016
psychological disorders including depression, anxiety and dental phobia. We searched MEDLINE, Psy-
cInfo, EMBASE and article bibliographies. Results were compared with the general population. Outcomes
Keywords: included partial or total tooth-loss, periodontal disease, and dental decay measured through standar-
Depression dized measures such as the mean number of decayed, missing and filled teeth (DMFT) or surfaces
Anxiety
(DMFS).
Dental anxiety
Results: There were 19 papers on depression and/or anxiety, and seven on dental phobia/anxiety (total
Dental phobia
Panic disorders n¼ 26). These covered 334,503 subjects. All the psychiatric diagnoses were associated with increased
Oral health dental decay on both DMFT and DMFS scores, as well as greater tooth loss (OR ¼1.22; 95%CI ¼1.14–1.30).
Dental disease There was no association with periodontal disease, except for panic disorder.
Dental erosion Limitations: Cross-sectional design of included studies, heterogeneity in some results, insufficient studies
Caries to test for publication bias.
Periodontal disease Conclusion: The increased focus on the physical health of psychiatric patients should encompass oral
Tooth loss
health including closer collaboration between dental and medical practitioners. Possible interventions
Edentulousness
include oral health assessment using standard checklists that can be completed by non-dental personnel,
help with oral hygiene, management of iatrogenic dry mouth, and early dental referral. Mental health
clinicians should also be aware of the oral consequences of inappropriate diet and psychotropic medi-
cation.
& 2016 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
2. Method. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
2.1. Oral health outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
2.2. Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2.3. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2.4. Study quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
2.5. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
3.1. Study inclusion and characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
3.2. Dental caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

n
Corresponding author.
E-mail address: s.kisely@uq.edu.au (S. Kisely).

http://dx.doi.org/10.1016/j.jad.2016.04.040
0165-0327/& 2016 Elsevier B.V. All rights reserved.
120 S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132

3.3. Periodontal disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

3.4. Tooth loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
3.5. Erosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
3.6. Other outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
3.7. Sensitivity analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
3.8. Publication bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
4.1. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
4.2. Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

1. Introduction dental phobia and other common mental disorders. We hypothe-

People with psychiatric disorder face important physical co-
morbidities including diabetes, cardiovascular disease, chronic
lung disease and cancer (Lawrence et al., 2013, 2010). There has
been less attention to the issue of oral health even though it is also
an important part of both mental and physical health, (Mirza et al.,
2001) and is linked to many of the above chronic diseases.(Azar-
pazhooh and Leake, 2006; Chapple, 2009; Cullinan et al., 2009;
Rai, 2006).
There have only been three systematic reviews and meta-
analyses of the relationship between mental and oral health. These
were largely restricted to eating disorders (Kisely et al., 2015a), or
severe mental illnesses such as dementia and schizophrenia (Ki-
sely et al., 2015b; Kisely et al., 2011). In all cases, psychiatric
morbidity was associated with worse oral health. For instance,
people with eating disorders had significantly higher levels of
erosion (Kisely et al., 2015a), while in people with severe mental
illness it was caries (Kisely et al., 2015b, 2011). In the case of the
latter, this led them to be almost three times as likely to have lost
all their teeth (Kisely et al., 2015b, 2011).
None of these studies explicitly examined the relationship be-
tween dental disease and common mental disorders such as de-
pression, generalised anxiety disorder (GAD), panic disorder, ob-
sessive-compulsive disorder (OCD), post-traumatic stress disorder
(PTSD) and phobias (The National Institute for Health and Care
Excellence, 2014). This is in spite of the strong potential interaction
between affective disorders and mental health. In one direction,
the prospect of dental treatment can lead to anxiety and phobia
(Cormac and Jenkins, 1999). About one half of all dental patients
experience some anxiety about their dental visits and in some
cases this leads to dental phobia, classified in DSM 5 as a specific
phobia (American Psychiatric Association, 2013). This can take
several forms including the 'blood-injection-injury’ type (usually
needle phobia, fear of drills and injections),'situational’ phobia
(fear of the dental surgery, staff, or associated smells and sounds),
or anxiety about somatic reactions during treatment particularly
gagging (Cormac and Jenkins, 1999).
In the other direction, psychiatric illness can lead to poor oral
health because of lifestyle, poor oral hygiene and difficulties in
access to dental care (Kisely et al., 2015a, 2015b). Dry mouth
(xerostomia) is also a major risk factor and is a side effect of
commonly used psychotropic medications such as antidepressants
(Bardow et al., 2001; Lalloo et al., 2013). The most common dis-
eases that affect oral health are dental erosion, caries (tooth decay)
and periodontal (gum) diseases. The end-stage of these is tooth
loss, which can involve the whole dentition (edentulism or
edentulousness) (Cormac and Jenkins, 1999).
We therefore undertook a systematic review and meta-analysis
to determine the association between these common psychologi-
cal disorders and poor oral health. An additional aim was to see if
there were any differences in oral health between people with
sised that people with dental phobia would have worse oral health
as their mental state would act as an additional barrier to dental
care.
2. Method
The review was registered with PROSPERO, an international
database of prospectively registered systematic reviews in health
and social care based in the United Kingdom (Registration num-
ber: CRD42015029874) (Booth et al., 2012). In addition, we fol-
lowed recommendations for the reporting of meta-analyses of
observational studies in epidemiology (MOOSE), including back-
ground, search strategy, methods, results, discussion and conclu-
sions (Stroup et al., 2000).
2.1. Oral health outcomes
The four outcomes of this study were dental erosion, caries,
periodontal disease and tooth loss. Dental erosion refers to the loss
of dental tissue without the involvement of bacteria (Cormac and
Jenkins, 1999). This can be expressed as either a scale or a di-
chotomous variable. In either situation, the area of the mouth with
the worst pathology determines the overall score. Dental erosion
can be due to attrition such as in bruxism, abrasion from another
agent such as a toothbrush, or erosion where there is chemical
dissolution of the tooth from exposure to carbonated drinks
(Cormac and Jenkins, 1999). Erosion can also occur because of
gastro-oesophageal reflux disorder (GORD), given that patients
with depression and anxiety have higher levels of tobacco and
alcohol use (Cormac and Jenkins, 1999).
By contrast, dental caries is the result of bacterial action leading
to demineralisation of enamel and dentin along with cavities on
the tooth surface (Roberts-Thomson and Do, 2007). Caries is as-
sessed by the number of decayed, missing and filled teeth or
surfaces (DMFT or DMFS) (Roberts-Thomson and Do, 2007). These
are both continuous measures with an increased score meaning
greater decay. DMFS scores are higher as they reflect damage to
the surfaces of each tooth rather than counting the tooth as a
single unit. The maximum possible DMFT is therefore 32, while
the maximum DMFS is 148.
Periodontal disease is the detachment of the gums from the
base of the tooth as result of gingival inflammation (Savage et al.,
2009). It is commonly measured using a manual probe to assess
pocket probing depth (PPD) and clinical attachment loss (CAL). The
threshold for a diagnosis of periodontitis can vary from 2 to 6 mm
of PPD and 3–6 of CAL. In general, PPD of more than 4 mm and a
CAL score of more than 5 mm are clinically significant (Savage
et al., 2009). The data can also be presented continuously as the
number of sites with this degree of pathology (Johannsen et al.,
2005), or the mean probing depth or attachment level across six
 S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132
sites (Solis et al., 2014). An alternative to dental assessment is the
use of panoramic radiographs (Persson et al., 2002).
The end result of dental decay and gum disease is tooth loss,
which can be partial or complete (edentulism or edentulousness).
The latter is usually expressed as a dichotomous variable.
2.2. Inclusion and exclusion criteria
We included studies with a focus on common mental disorders
(CMDs) meaning a primary diagnosis of depression, generalised
anxiety disorder (GAD), panic disorder, obsessive-compulsive
disorder (OCD), post-traumatic stress disorder (PTSD) and phobias
(Kendrick and Pilling, 2012). We included studies using clinical
diagnoses or diagnostic criteria. We gave preference to lifetime as
opposed to current diagnoses when both were presented to re-
duce the possibility that mood state was secondary to periodontal
disease rather than the other way round. We excluded studies of
psychiatric populations that did not separate out common mental
disorders from those with severe mental illness such schizo-
phrenia, or where CMDs did not form the majority of the psy-
chiatric cases. We also excluded studies of people with primary
alcohol or substance use disorders, and learning disability. Finally,
as our focus was on erosion, caries, periodontal disease and tooth
loss, we excluded studies of less severe dental outcomes such as
poor oral hygiene.
2.3. Search strategy
We searched Medline, PsycInfo and EMBASE from January 1988
until December 2015 using the following text, MeSH or Emtree
terms as appropriate: Mental Health Disorders, Mental Disorders,
Mental Illness, Mental Illnesses, Depression, Depressive Disorder,
Mood Disorder, Anxiety, Affective Disorder, Post-Traumatic Stress
Disorder, Posttraumatic Stress Disorder, PTSD, Obsessive Compul-
sive Disorder, OCD, Oral Health, Dental Health Survey, Dental Care,
Dental Health Services, Periodontitis, Periodontal Disease; Eden-
tulism; Edentulousness; Edentulous Mouth, Edentulous Jaw,
Dental Caries, Erosion, Toothloss and Tooth Wear.
Other descriptive words associated with the above MeSH terms
were also used as key terms. We searched for further publications
by scrutinizing the reference lists of initial studies identified and
other relevant review papers. We made attempts to contact se-
lected authors and experts. Two reviewers (SK and ES) in-
dependently assessed abstracts, extracted and checked the data for
accuracy. RL provided content expertise, especially in relation to
oral and dental health issues. For inclusion in the meta-analysis,
studies had to have data on suitable controls collected by the
authors from a similar setting to the psychiatric cases.
2.4. Study quality
We assessed the quality of included studies using the New-
castle-Ottawa Scale (NOS) (Stang, 2010). This assesses the quality
of non-randomized studies in meta-analyses in three areas: the
selection of the study groups; the comparability of the groups; and
the ascertainment of outcome.
2.5. Statistical analysis
We generally used the Cochrane Collaboration's Review Man-
ager Version 5.0 for our analysis. We calculated the mean differ-
ences for continuous data as studies used the same scale for each
outcome (e.g. DMFT, DMFS). We calculated the standardised mean
difference for studies that used different measures of the same
outcome (e.g. the number of sites with periodontal disease, or the
mean probing depth across six sites). For categorical data, we
121
calculated odds ratios given the studies we included were cross-
sectional design. Some papers presented odds ratios without the
associated cell numbers when, for example, reporting the results
of logistic regression. In these cases, we used Win Pepi version
11.34 (Abramson, 2011).
We assessed heterogeneity by using the I-squared statistic. This
provides an estimate of the percentage of variability due to het-
erogeneity rather than chance alone. An I-squared estimate of
greater than or equal to 50% indicates possible heterogeneity.
Scores of 75–100% indicate considerable heterogeneity (Higgins
and Green, 2009) The I-squared statistic is calculated using the
chi-squared statistic (Q) and its degrees of freedom. It has several
advantages over the Q statistic alone in that it does not depend on
the number of studies in the meta-analysis and so has greater
power to detect heterogeneity where the number of studies is
relatively low. The I-squared statistic can also be interpreted si-
milarly irrespective of whether outcome data are dichotomous or
continuous.
We used a random effects model throughout as we found sig-
nificant heterogeneity in the majority of our analyses. A random-
effects model assumes that variations in the effect among different
studies are due to differences in samples or paradigms and have a
normal distribution i.e. that heterogeneity exists. In addition, we
investigated heterogeneity through a sensitivity analysis of the
effect of omitting each study in turn. Other sensitivity analyses
included investigating any difference in results where studies used
two different measures to assess for the same outcome such as the
PPD or CAL for periodontal disease, or where there was un-
certainty over the sampling method. Where possible, we also in-
vestigated the effect of whether the psychiatric assessment was by
structured interview, self-report questionnaire or clinical diag-
nosis, and if the lifetime or current diagnosis was used.
Where there was a sufficient number of studies (n Z10), we
tested for publication bias using funnel plot asymmetry.
3. Results
3.1. Study inclusion and characteristics
We identified 15,605 citations, of which 2565 were duplicates.
Based on the title of these, 12,889 were excluded as they were not
relevant to the objectives of the systematic review. This left 151
abstracts to be scrutinized, of which we evaluated the full-text of
84 articles. Fig. 1 gives details of the reasons for excluding the
other articles. Of the 84 articles examined, we excluded a further
58 for the reasons given in Fig. 1. For instance, twenty–eight did
not have a relevant dental outcome, seven did not include com-
parisons with non-psychiatric controls and twelve did not specify
if the focus was on common psychological disorders as opposed to
psychiatric morbidity in general. We were unable to obtain the
full-text for two of the retrieved abstracts. We were therefore able
to include 26 papers in the meta-analysis (Fig. 1). Eight studies
were from the United States (Bell et al., 2012; Cohen, 1985; Elter
et al., 2002; Khambaty and Stewart, 2013; Okoro et al., 2012;
Persson et al., 2003; Saman et al., 2014; Silveira et al., 2015), three
each from Brazil (Castro et al., 2006; Solis et al., 2014, 2004) and
India (Kumar et al., 2015; Shah et al., 2012; Sundararajan et al.,
2015). There were two studies respectively from Sweden (Jo-
hannsen et al., 2005; Wennstrom et al., 2013), the United Kingdom
(da Silva et al., 1997; Heidari et al., 2015) and Finland (Anttila et al.,
2001; Delgado-Angulo et al., 2015). The remaining studies came
from Australia (Armfield et al., 2009), Croatia (Muhvic-Urek et al.,
2007), Iran (Roohafza et al., 2015), Jordan (Ababneh et al., 2010),
New Zealand (Kruger et al., 1998) and Norway (Wisloff et al., 1995).
These studies covered 334,503 subjects.
122 S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132
Fig. 1. PRISMA diagram.
One US study used data from the Behavioural Risk Factor Sur-
veillance Survey (BRFSS) of 2006 but only provided figures
weighted back to the entire country (Saman et al., 2014). The
unweighted numbers had therefore to be estimated from other
sources (Strine et al., 2008a, 2008b).
Table 1 compares the oral health status of people with common
mental disorders to those of controls with no psychiatric mor-
bidity. Results are presented separately for dental anxiety and all
other common mental disorders. Table 2 compares rates of de-
pression and anxiety in people with dental disease to controls
with good oral health. Study quality varied significantly across the
following categories; selection, comparability and outcome. The
psychiatric diagnosis was made by standardized questionnaires
such as the Zung self-rating depression scale and Beck's Depres-
sion Inventory in 20 studies (Tables 1 and 2), and by a structured
interview in three studies (Delgado-Angulo et al., 2015; Khambaty
and Stewart, 2013; Solis et al., 2014). One further study used a 78-
item anxiety questionnaire but gave no details on its psychometric
properties (Johannsen et al., 2005). In another three studies a
clinical diagnosis was used (Elter et al., 2002; Muhvic-Urek et al.,
2007; Shah et al., 2012), although two of these used diagnostic
criteria (DSM-IV) (Table 1). Six studies recruited subjects and
controls from clinical settings (Ababneh et al., 2010; Elter et al.,
2002; Kumar et al., 2015; Muhvic-Urek et al., 2007; Shah et al.,
2012; Castro et al., 2006). Two studies were of military recruits
(Cohen, 1985; Wisloff et al., 1995), and in another two the exact
details of the sample composition were unclear (Solis et al., 2014;
Sundararajan et al., 2015). All other studies used community cases
and controls (Tables 1 and 2).
Studies took group comparability into account by stratifying
results, checking for baseline socio-demographic differences,
matching or adjustment, and sometimes a combination of these
(Tables 1 and 2). Three studies reported data by age, sex or
smoking status (Anttila et al., 2001; Johannsen et al., 2005; Shah
et al., 2012). Another seven studies checked for differences in age,
gender, socioeconomic status, ethnicity or smoking status (Castro
et al., 2006; Heidari et al., 2015; Kumar et al., 2015; Muhvic-Urek
et al., 2007; Shah et al., 2012; Solis et al., 2014, 2004). Two studies
were restricted to male military recruits of similar age (Cohen,
1985; Wisloff et al., 1995). One study matched by age and gender
(da Silva et al., 1997). Fifteen studies adjusted for differences in
age, gender and at least one other variable, such as socioeconomic
Table 1
Dental disease in psychiatric cases and controls.

Name Year Country N (male %) Range, Mental health measure Oral health measure Summary of results Comparability of samples Comparison
Mean age
Common mental disorders

Dental caries

Ababneh K. T. 2010 Jordan 666 (44%) 31.1 years Depressive symptoms: Gingival index, probing pocket Susceptibility to depression found Periodontal results adjusted for Rates of periodontitis in
Zung self-rating depres- depth (PPD), clinical attachment in 48% non-periodontic and 50% the effect of age, gender and depression vs no-
sion scale level (CAL), Plaque index (PI), periodontic cases plaque depression
DMFT No statistically significant asso-
ciation between depression
symptoms and periodontal
parameters (PPD, CAL, PI and GI
(P 4 0.05))
Subjects with low susceptibility

S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132

to depression had significantly
more FT than subjects highly
susceptible to depression

Muhvic-Urek 2007 Croatia 100 (100%) PTSD: Previous diagnosis DMFT, Community periodontal Patients with PTSD had poorer There were no differences be- Rates of poor oral health in
M (DSM-IV) index (CPI), plaque, calculus, periodontal status tween cases and controls in patients with PTSD vs no-
community periodontal index Non statistically significant dif- terms of gender, age, education PTSD
(CPI) ference between DMFT for the level, marital status or ethnicity
PTSD vs non-PTSD groups
PTSD patients had more de-
cayed and missing teeth

Dental caries and periodontal disease

Anttila S. S. et 2001 Finland 780 (44.2%) 55 years Depressive symptoms: Decayed surfaces (Dental caries), Depressive symptoms were asso- Data on caries and periodontal Rates of edentulousness
al. Zung self-rating depres- Periodontal status (Probing ciated with edentulous-ness disease stratified by age. Results and dental health in de-
sion scale pocket depth), filled surfaces, among non-smoker men. on tooth loss adjusted for age, pression vs non-
number of teeth, oral hygiene Weak although not statistically sex and smoking depression
status significant correlation between
depressive symptoms and
edentulous- ness among
women

Delgado-An- 2015 Finland 5401 (47%) Over 30 Anxiety: Composite in- Dental caries, periodontal dis- On unadjusted analysis, depres- Adjusting for demographic char- Rates of dental caries in
gulo E. K. years ternational diagnostic ease, periodontal pockets sion was significantly associated acteristics, SEP indictors, sys- people with depression vs
interview (4 mm þ ) with number of decayed teeth temic diseases, oral health-re- no-depression
Depression: Beck’s de- only among participants aged 35– lated behaviors & medication
pression inventory 54 old and not with other age use.
groups.
However, after adjustment, de-
pression was significantly asso-
ciated with the number of de-
cayed teeth in the whole
sample.
Anxiety was not associated
with decay
Similarly, anxiety and depres-
sion were not associated with
periodontal disease

123
 124
Table 1 (continued )

Name Year Country N (male %) Range, Mental health measure Oral health measure Summary of results Comparability of samples Comparison
Mean age
Common mental disorders

Shah V. R. 2012 India 133 (66.17%) Mean: Previous diagnosis with DMFT, DMFS, Community peri- Poorer DMFT, DMFS & CPI scores Cases and controls were similar Rates or poor oral health in
40.2 psychiatrist review of odontal index (CPI), oral hygiene in psychiatric patients than in terms of age, gender, marital patients with psychiatric
years diagnosis index simplex (OHIS), shallow controls status and socio-economic sta- disorders vs no-psychiatric
probing pocket (4–5 mm), deep tus. Results were stratified by age disorders
probing pocket (6 mmþ ), calcu-
lus, bleeding gums

Periodontal disease
Elter J. R. 2002 United 697 30–64 Clinical depression Periodontitis, probing depth At baseline there was no associa- Change in periodontal status was Rates of periodontal dis-
States years (DSM-IV): Yes/No (5 mm þ ), change in periodontal tion between depression and adjusted for gender, smoking, ease in patients with de-
status periodontal disease Depression antidepressant use, physical pression vs no-depression
was associated with worse peri- health & baseline oral status
odontal outcome one year later.

S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132

Johannsen A 2005 Sweden 170 (52%) Mean: A 78-item anxiety ques- Questionnaire: periodontal Self-reported anxiety was asso- Results stratified by smoking Rates of periodontal dis-
36.2 tionnaire (no further health ciated with an adverse affect on status. ease in anxiety vs non-
years details) Clinical assessment: plaque in- the gingiva. Anxiety seemed to be anxiety
(54.9%) dex, gingival index, number of associated with increased severity
30–40 pockets 45 mm, number of of periodontal disease in smokers.
years teeth

Khambaty T 2013 United 1979 (45%) Mean: Composite International Periodontal disease: Loss of at- Adults with panic disorder had a Adjusted for age, sex, race-eth- Rates of periodontal dis-
States 29.1 years Diagnosis Interview tachment ( 44 mm) threefold higher odds of having nicity, education level, diabetes, ease in patients with de-
(CIDI-Auto) periodontal disease than those pregnancy pressive and anxiety dis-
(DSM-IV) without this disorder. major de- orders vs no-disorder
pressive disorder and generalised
anxiety disorder, which were not
related to periodontal disease.

Kumar A. 2015 India 60 (32%) 26–67 Hamilton Depression Periodontal disease: number of Significant association between No differences between groups Rates of periodontal dis-
years Rating Scale missing teeth, plaque index, gin- depression and periodontitis in age, gender, educational level, ease in patients with de-
gival index, probing pocket marital status & smoking. pression vs no-depression
DSM-IV depth, clinical attachment level Significant differences in em-
(CAL) ployment status & household
income

Persson G. R. 2003 United 701 (40.5%) Mean: Self report of diagnosis, Tooth loss, periodontitis, probing Depression not associated with Adjusted for other socio- demo- Rates of poor oral health in
States 67.2 years Geriatric Depression pocket depth (5 mm þ), bone loss periodontitis graphic & health factors also as- patients with depression
Scale Radiographs sociated with periodeontal vs no-depression
disease
Solis A. C. 2014 Brazil 72 (18%) Depression: Structured Probing pocket depth, clinical Periodontal clinical parameters There were no differences be- Rates of periodontitis in
clinical interview for attachment level, frequency of were not different between pa- tween depressive cases & con- patients with major de-
DSM-IV(SCID), Hamilton missing teeth, plaque index (PI), tients with MDD and control trols in terms of gender, age, pressive disorder vs no-
Depression Scale (HAM- gingival index (GI) subjects. There was no association education level, martial status, MDD
D-31) between depression and ethnicity & smoking. There were
periodontitis. differences in employment status
& household income but the re-
sulst were unaltered when ad-
justed for potential confounders.
Tooth loss
Okoro C. A. 2012 America 80,486 BRFSS Anxiety and De- Questionnaire: Tooth loss due to Depression and anxiety are asso- Adjusted for age, sex, race ⁄ eth- Rates of tooth loss in pa-
(62.6%) pression module: in- decay or gum disease ciated with tooth loss. In logistic nicity, education, marital status, tients with depression/an-
cluding PHQ-8 regression analyses employing employment status, adverse xiety vs no-depression/
tooth loss as a dichotomous out- health behaviors, chronic anxiety
come (0 versus ‡1) and as a conditions
nominal outcome (0 versus 1–5,
6–31, or all), adults with depres-
sion and anxiety were more likely
to have tooth loss. The adjusted
odds of being in the 1–5 teeth
removed and 6–31 teeth removed
categories versus 0 teeth removed
category were also increased for
adults with lifetime diagnosed
depression or anxiety versus
those without each of these
disorders.
Roohafza H. 2015 Iran 4585 (44%) Hospital Anxiety and Questionnaire: Tooth loss Statistically significant relation- Adjusted for Socio demographic Rates of tooth loss in pa-

S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132

Depression Scale (HADS) ship between depression, anxiety factors, age, gender, marital and tients with psychological
and tooth loss educational status disorders vs no-psycholo-
gical disorders
Saman D. M. 2014 United 217,379 18–99 Patient Health Ques- Partial vs full endentulism Current depression and rural re- Controlled for confounded SES, Rates of edentulism in pa-
States years tionnaire 8 (PHQ-8) sidency are important factors re- health behaviors, chronic dis- tients with depression vs
lated to partial and full edentu- eases, and health service deficits no-dperession
lism after controlling for potential
confounders

Silveira M. L. 2015 United 402 (0%) Anxiety and Depression Tooth loss Two- to threefold increased odds Adjusted for risk factors, socio- Rates of tooth loss in
Stated Module (ADM), Patient of tooth loss and nonuse of oral economic factors, health beha- pregnant women with an-
Health Questionnaire 8 health services among pregnant viors, BMI xiety vs no-anxiety
(PHQ-8) women with a lifetime diagnosis
of anxiety
Respondents with lifetime-di-
agnosed anxiety had a 3.30
times greater odds of tooth loss
as com- pared with those
without anxiety
respondents with lifetime di-
agnosed depression had a 1.45
times increased odds of oral
disease

Dental Anxiety

Dental Caries
Cohen M. E. 1985 United 938 (100%) Modified Corah’s Dental DMFS Dental anxiety is not a predictor Confined to males. No other Rates of poor oral health in
States Anxiety Scale (DAS) of DMFS adjustment patients with dental anxi-
ety vs no-dental anxiety

Kruger E. 1998 New 1006 (51%) 15–18 Corah’s Dental Anxiety DMFS Caries prevalence among those Adjusted for scores at 15 years Rates of poor oral health in
Zealand 547 in years Scale (DAS), Self-reported dental health who were dentally anxious at old but not socio-demographic patients with dental anxi-
meta- both 15 and 18 years was sig- factors ety vs no-dental anxiety
analysis nificantly higher than for those
who were not at either age. Re-
gression analysis revealed that
dental anxiety predicted caries
incidence between ages 15 and 18
years.

125
 126
Table 1 (continued )

Name Year Country N (male %) Range, Mental health measure Oral health measure Summary of results Comparability of samples Comparison
Mean age
Common mental disorders

Wennstrom A. 2013 Sweden 493 (0%) 38 and 50 Dental Fear Survey (DFS) The number of teeth, approximal Individuals with high dental an- Analyses of decay & self-per- Rates of poor oral health in
years of caries, apical periodontitis and xiety also had fewer teeth, more ceived poor oral health were not patients with dental anxi-
age the number of filled surfaces, filled surfaces and more approx- adjusted for socioeconomic ety vs no-dental anxiety
Apical periodontitis (AP) imal caries. status
Radiographs They also had worse self-per-
ceived poor oral health

Wisloff T. F. 1995 Norway 1078 (100%) Mean: Corah’s Dental Anxiety DMFS High dental anxiety is associated Confined to males. No other Rates of poor oral health in
20.1 years Scale (DAS) Radiographs with poorer oral health measured adjustment patients with dental anxi-
as numbers of decayed or filled ety vs no-dental anxiety
surfaces

Dental Caries and Periodontal disease

S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132

Armfield J. M. 2009 Australia 5364 18–91 Dental phobia: Single DMFT, decayed teeth (DT), miss- Higher dental fear was sig- Adjusted for age, sex, income, Rates of dental caries and
(50.5%) item questionnaire ing teeth (MT), probing depth, nificantly associated with more employment status, tertiary periodontal indicators in
clinical attachment level, gingival decayed teeth (DT), missing teeth education, dental insurance sta- patients with dental anxi-
index (MT) and DMFT. The association tus and oral hygiene ety vs no-dental anxiety
between dental fear and DMFT
was significant for adults aged
18–29 and 30–44 years, but not in
older ages
There was an inverted ‘U’ asso-
ciation between dental fear and
the number of filled teeth (FT).
Periodontitis and gingivitis
were not associated with dental
fear.

Periodontal disease
Bell R. A. 2012 United 635 (43%) 65þ Corah’s Dental Anxiety Tooth-specific gingival recession, only sore and bleeding gums had Adjusted for age, ethnicity, gen- Rates of poor oral health in
States years Scale (DAS) specific modified gingival index a significant association with a der, and education patients with dental anxi-
(MGI) (4 mm þ ), periodontal high DAS score ety vs no-dental anxiety
disease

Tooth loss

Heidari E. 2015 United 10,900 Modified Dental Anxiety Decay experience People with dental phobia had a There were significant differ- Rates of poor oral health in
Kingdom (47.3%) Scale (MDAS) Number of sound, missed, filled less restored dentition, increased ences between phobic and non- patients with dental anxi-
teeth numbers of one or more teeth phobic participants in terms of ety vs no-dental anxiety
Numbers of crowns with caries and were more likely gender, age, qualifications, and
Periodontal disease (plaque to have PUFA (puss, ulceration, smoking status, but not marital
score, bleeding pocket depth fistulae, abscess) scores of one or status and personal income. Re-
and loss of attachment) more. They also had increased sults were not adjusted for these.
rates of gingival bleeding
However, people with and
without dental phobia had si-
milar numbers of sound and
missing teeth, and did not have
greater periodontal disease.
People with dental phobia had
significantly worse oral health
related quality of life on both
measures.
Table 2
Comparing rates of psychiatric illness in people with dental disease to controls with good oral health.

Name Year Country N (male %) Range, Mental health measure Oral health measure Summary of results Comparability of samples Comparison
Mean age

Periodontal disease

Castro 2006 Brazil 165 (43%) 35–60 Beck anxiety inventory, Periodontal disease No significant association between There were no differences be- Rates of psychological dis-
State-trait anxiety inventory, periodontitis and psychosocial tween periodontal cases and orders in patients with

S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132

Beck depression inventory, factors controls in marital status or periodontitis vs no-
life events scale income. periodontitis
There were differences in age,
gender, education level and
smoking status.
Adjusting for these variables
did not alter the results

Solis A. C. O. 2004 Brazil 153 (35%) 19–67 Anxiety: State-train anxiety Probing pocket depth, clin- No evidence was found for an as- There were no differences be- Rates of anxiety and de-
years inventory ical attachment level, fre- sociation between depression, tween periodontal cases and pression in people with
Depression: beck depres- quency of missing teeth, hopelessness, psychiatric symp- controls in gender, race, marital periodontal disease vs no-
sion inventory plaque index (PI), gingival toms and established periodontitis status, education level, household periodontitis
Life events scale index (GI) income, or smoking, only age
Self Report Screening
Questionnaire- 20, Beck
Hopelessness Scale
Sundararajan S 2015 India 70 25–55 Beck's depression inventory Oral Hygiene Indirect (OHI): There was a direct correlation be- Rates of depression in pa-
(63%) Years probing depth, clinical at- tween the severity of periodontal tients with chronic peri-
tachment loss disease and the severity of de- odontitis vs no-
pression in patients periodontitis

Erosion

Da Silva 1997 United 90 (42.25%) Mean 39.6 Modifiers and Perceived Tooth wear: erosion, attri- Two case and control groups did Groups were matched by age and Rates of psychological dis-
Kingdom ( 710.7) Stress Scale (MPSS), State- tion, abrasion not differ significantly on the gender orders in patients with
Trait Anxiety Inventory Periodontal disease combined psychosocial factors. tooth wear and attrition vs
(STAI) Probing pocket depth Patients with tooth wear with a no-toothwear and attrition
( 44 mm) significant component of attrition
presented significantly more trait
anxiety than controls.

127
128 S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132
Fig. 2. Caries and common mental disorders. ANX¼ Anxiety, DA ¼ Dental anxiety, DEPR¼ Depression, PTSD ¼Post-traumatic stress disorder.
status, ethnicity or medical history using a multivariate analysis
(Table 1). Only one study did not consider group comparability in
any way (Sundararajan et al., 2015).
Ascertainment of oral status in 19 studies was by trained
dental examiners. Of these, eight studies reported assessor ca-
libration and the measurement of intra-observer (Ababneh
et al., 2010; Armfield et al., 2009; Castro et al., 2006; Delgado-
Angulo et al., 2015; Muhvic-Urek et al., 2007; Persson et al.,
2003; Solis et al., 2014; Wisloff et al., 1995). Three studies also
supplemented the clinical examination with panoramic radio-
graphs (Persson et al., 2003; Wennstrom et al., 2013; Wisloff
et al., 1995). In the case of caries, 11 studies used some or all of
the Decayed, Missing and Filled classification (Fig. 2). Fifteen
studies reported on the periodontal status of patients, including
probing pocket depth and clinical attachment level. Five studies,
primarily of tooth loss, assessed oral status using a ques-
tionnaire (Anttila et al., 2001; Johannsen et al., 2005; Okoro
et al., 2012; Roohafza et al., 2015; Silveira et al., 2015), while one
study provided no description (Sundararajan et al., 2015). Only
two studies reported that the dental assessor was masked to
psychiatric status (Armfield et al., 2009; Muhvic-Urek et al.,
2007). Only one paper reported on socio-demographic differ-
ences between cases or controls who completed the study and
those who did not (Bell et al., 2012).
3.2. Dental caries
Six studies used some or all of the DMFS classification and
another six used DMFT scores. One of these studies used both
(total n¼ 11 studies). Patients with a common mental health dis-
order had more decayed, missing and filled surfaces than controls
(Fig. 2).
Two studies reported on the presence of caries as a dichot-
omous measure (Delgado-Angulo et al., 2015; Kruger et al., 1998).
This again showed that people with common psychological dis-
orders had higher rates of decay (OR¼ 1.21; 95%CI ¼1.07–1.37).
There were similar findings for the subgroup analysis of studies
on dental anxiety. For instance, the mean difference in filled sur-
faces was 1.69 (95% CI ¼0.22–3.15).
3.3. Periodontal disease
Most studies examined the rates of dental health conditions in
patients with a common mental health disorder compared to pa-
tients without a psychiatric illness. We were able to include 15 stu-
dies in a meta-analysis. Pocket depth was the most commonly used
outcome. Eleven studies reported on the presence of periodontal
disease as a dichotomous measure (Fig. 3). There was no association
between psychiatric status and periodontal disease (Fig. 3). The one
 S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132
Fig. 3. Odds ratios for periodontal disease comparing psychiatric cases with non-
cases. ANX ¼Anxiety, DA ¼ Dental anxiety, DEPR ¼Depression, GAD ¼ Generalised
Anxiety Disorder.
exception was the association with panic disorder reported in one
study (Khambaty and Stewart, 2013). The positive association be-
tween panic disorders and periodontal disease, in the absence of any
such effect in anxiety or depression, was thought to be due to greater
tobacco use in the former (Khambaty and Stewart, 2013).
Four additional studies presented the results on periodontal
pocket depth as continuous scores (Anttila et al., 2001; Elter et al.,
2002; Johannsen et al., 2005; Kumar et al., 2015), with there again
being no association with psychiatric status (standardised mean
difference¼0.19; 95% CI ¼  0.07 to 0.45).
There were also three studies that examined the rates of
common mental health disorders in patients with dental health
conditions compared to patients without dental health conditions
(Table 2). As the independent and dependent variables were re-
versed, these studies were analysed separately (Fig. 4). Two stu-
dies examined the rates of anxiety and depression and one study
examined rates of depression in patients with periodontal disease.
There was no significant association between rates of anxiety or
depression and periodontal disease (Fig. 4).
Finally, one study reported on change in periodontal status over
one year (Elter et al., 2002). At baseline, there was no association
between depression and periodontal disease. However, depression
was associated with worse periodontal outcome one year later
even after adjusting for gender, smoking, antidepressant use,
Fig. 4. Psychiatric disorder in people with and without periodontal disease.
129
physical health and baseline oral status.
3.4. Tooth loss
Ten studies assessed tooth loss. Overall, there was a significant
association between common mental health disorders and tooth
loss (Fig. 5). However, results were not significant when only
considering the two studies of patients with dental anxiety
(OR¼ 0.93; 95% CI ¼0.68–1.27). One study divided male partici-
pants into smokers and non-smokers (Anttila et al., 2001). De-
pression was associated with tooth loss in the former group but
not in non-smokers (Fig. 5). Comparable data were not provided
on the female participants but the association with depression was
not significant regardless of smoking status (Anttila et al., 2001).
3.5. Erosion
We found one paper which compared rates of anxiety in pa-
tients with tooth erosion and those with normal dentition (da
Silva et al., 1997). There were no differences in anxiety levels be-
tween the two groups (mean difference¼ 3.00, 95% CI ¼  20.5 to
26.59).
3.6. Other outcomes
Although not a primary focus of this study, six studies reported
on the presence of gum disease as measured by bleeding or the
gingival index (Table 1). It was possible to combine the results of
three studies of dental anxiety in a meta-analysis (Armfield et al.,
2009; Bell et al., 2012; Heidari et al., 2015). This showed a sig-
nificant association between bleeding of the gums and dental
anxiety (OR ¼1.46; 95% CI ¼ 1.25 to 1.72). It was not possible to
combine the results of the three studies of other common psy-
chological disorders but in all cases, bleeding was not associated
with psychiatric caseness. Similarly three studies on dental phobia
reported on self-reported dental health although, again, it was not
possible to combine the data quantitatively. In two out of three,
ratings were worse in people with dental phobia (Heidari et al.,
2015; Wennstrom et al., 2013), even when more objective mea-
sures of oral health were no different (Heidari et al., 2015).
3.7. Sensitivity analyses
There were sufficient studies to undertake sensitivity analyses
for periodontal disease and tooth loss. In terms of the periodontal
outcomes, using the CAL instead of PPD made no difference to the
results. For instance, the odds ratio for the presence of a patho-
logical attachment level in psychiatric cases and controls was 0.78
(95% CI ¼0.59–1.04). Similarly, restricting analyses to those studies
where the psychiatric assessment was by structured interview, or
excluding those that did not use a standardised instrument did not
130 S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132
Fig. 5. Tooth loss. ANX ¼Anxiety, DA ¼Dental anxiety, DEPR ¼Depression,
Smþ ¼ male smokers, Sm ¼male non-smokers.
alter the results. As an example, there was still no association
between periodontal disease and psychiatric status in the three
studies that used a structured interview (OR ¼0.96; 95% C.
I. ¼0.88–1.05) (Delgado-Angulo et al., 2015; Khambaty and Stew-
art, 2013; Solis et al., 2014) There were also no differences if the
current psychiatric diagnosis was used instead of the lifetime one
when both were reported (e.g. tooth loss OR¼ 1.27; 95% C. I. ¼1.12–
1.44). In addition, excluding a study on tooth loss where un-
weighted numbers had to be estimated from other sources (Saman
et al., 2014) did not alter the outcome (OR ¼1.21; 95% C. I.¼ 1.09–
1.36). Restricting analyses to the 15 studies that adjusted for dif-
ferences in age, gender and at least one other variable did not
change the results for either periodontal disease (OR ¼1.03; 95% C.
I. ¼0.93–1.15) or tooth loss (OR ¼1.22; 95% C. I. ¼1.16–1.30). Lastly,
when present, heterogeneity was not greatly affected by omitting
each study in turn.
3.8. Publication bias
There were only sufficient studies to test for publication bias for
periodontal disease and tooth loss. Egger's regression test for
funnel plot asymmetry did not suggest publication bias in either
periodontitis (Intercept¼0.87; 90% C. I. ¼0.24 to 1.50; p ¼0.09) or
tooth loss (Intercept¼ 0.28; 90% C. I. ¼  0.29 to 0.85; p ¼0.507).
4. Discussion
To our knowledge, this is the first meta-analysis of the asso-
ciation between common mental disorders and poor oral health
including any differences between patients with dental phobia and
those with depressive or other anxiety disorders. As expected,
rates of both dental decay and tooth loss were significantly higher
than those in the general population although the disparity was
less marked than for people with severe mental disorders such as
schizophrenia. For instance, patients in this study had a 21%
greater likelihood of tooth loss as opposed to an odds ratio of
2.8 in people with severe mental illness (Kisely et al., 2015b). Si-
milarly, the mean difference in DMFT score was 0.84 as opposed to
5 in people with dementia, schizophrenia or bipolar disorder.
Surprisingly, people with dental phobia were not more dis-
advantaged than those with other common psychological dis-
orders with the exception of bleeding and self-rated oral health.
Indeed, in contrast to people with the other common psycholo-
gical disorders, they were no more likely to have had tooth loss
than the general population.
Explanations for increased levels of decay include poor oral
hygiene and the side effects of psychotropic medications like an-
tipsychotics, antidepressants, and mood stabilizers. All of these
medications induce dry mouth (xerostomia) through reduced
salivary flow and can potentially negate the beneficial effects of
fluoride (Friedlander and Marder, 2002). As with other aspects of
physical ill-health, poor dental health may also be related to poor
diet, smoking and poor oral hygiene (McCreadie, 2004).
By contrast, levels of periodontal disease in people with com-
mon mental disorders were very similar to those in the general
population. This reflects equivocal findings for mental health
problems in general, even severe mental illness. For instance,
some studies report an association between periodontitis and
psychiatric illness (Belting and Gupta, 1961; Gurbuz et al., 2011)
while others do not (Wey et al., 2015). It has been suggested that
the lack of any association may be due to the failure to distinguish
between anxiety and depression especially as both are commonly
comorbid. However, our findings show both have no association.
Similarly, the method of psychiatric assessment has been sug-
gested as contributory, but, again, our results were not affected by
whether a structured psychiatric interview or self–report instru-
ment were used.
One explanation for the lack of any association between psy-
chiatric illness and periodontal disease is that while smoking is a
significant risk factor in the development and progression of
periodontitis overall, it may also diminish gingival bleeding in the
short-term through changes in the proportion of small to large
blood vessels in the gums (Rivera-Hidalgo, 2003). However, stu-
dies of periodontal disease in this review that did investigate the
role of smoking reported no evidence of such a protective effect
(Castro et al., 2006; Heidari et al., 2015; Khambaty and Stewart,
2013; Solis et al., 2014, 2004), although it is possible they were
measuring the long-term rather than short-term periodontal
consequences of tobacco use. Another explanation for lower than
expected levels of periodontal disease might be that different
bacteria are responsible for decay and periodontitis. The former is
primarily due to Streptococcus mutans while a wider range of
aerobic and anaerobic bacteria are involved in gum disease
(Loesche, 1996). It is therefore possible that the preponderance of
one group of organisms over the other might affect the degree of
decay or periodontal disease. The type of periodontal disease may
also be a factor with evidence that more aggressive forms have a
greater association with depression (Monteiro da Silva et al., 1998).
Similarly, we were unable to find clear evidence of increased
erosion when compared to the general population even though
people with anxiety of depression may be at greater risk through
smoking, alcohol and bruxism (Ahmed, 2013). Only one study re-
ported on this variable and found no association between de-
pression and dental erosion (da Silva et al., 1997).
4.1. Limitations
There are a number of limitations to the present study. Study
quality was not optimal. For instance, only three of the studies
established psychiatric caseness using the gold-standard of a
structured standardised interview (Delgado-Angulo et al., 2015;
Khambaty and Stewart, 2013; Solis et al., 2014). However, re-
stricting the analyses to just those three studies did not alter the
results.
Although most of the studies checked for socio-demographic
 S. Kisely et al. / Journal of Affective Disorders 200 (2016) 119–132
differences between cases and controls, or stratified or matched
results by age or sex, only 15 adjusted results adjusted for range
potential confounders such as socio-economic status, ethnicity
and smoking. On the other hand, a sensitivity analysis restricted to
those 15 studies did not change our results. Although dental status
in all the studies was assessed by trained examiners, in only two
was this blind to psychiatric status (Armfield et al., 2009; Muhvic-
Urek et al., 2007). Again, a sensitivity analysis of the effects of only
including blinded outcomes made no difference to the results.
There were other limitations in study quality that we could not
attempt to address using sensitivity analyses such as the calibra-
tion or standardization of dental assessments.
In addition, some of our results showed heterogeneity. We
explored this further through sensitivity analyses of the effect of
omitting each study in turn but this made no difference to the
results. Accordingly, we used a random-effects model throughout
to incorporate heterogeneity into our analyses. However, although
we have tried to minimize the effects of heterogeneity, our results
should still be treated with caution. Although statistically sig-
nificant, the mean differences on DMFT and DNFS score were small
and of unclear clinical significance. This is why we have empha-
sised the more clinically significant finding of a 21% increase in
tooth loss.
Finally, the cross-sectional nature of the studies meant that we
could only establish association not causation. For instance, it is
possible that depression could arise as a consequence of poor
dental health rather than be a cause of it (Hsu et al., 2015).
However, this is unlikely to be the explanation for the poor oral
health found in people with dental anxiety where it is more likely
that the distress preceded the adverse dental outcomes. Further-
more, the exact order of events may be irrelevant as it is likely that
disturbances in affect and poor oral health reinforce each other.
4.2. Implications
The poor oral health of people with common psychological
disorders remains a largely forgotten problem. Although the dis-
parity in oral health is less marked than for people with severe
mental illness, the greater prevalence of common psychological
disorders means that the implications for public health are cor-
respondingly greater.
Our findings have highlighted the greater risk of dental decay
and tooth loss, both of which, in turn, can have significant con-
sequences on people's quality of life. Painful, unsightly dentition or
missing teeth may exacerbate social withdrawal, isolation and
low-self-esteem, as well as cause problems with both speaking
and eating. In addition, there is an association between dental
disease, coronary heart disease, stroke, diabetes and respiratory
disease (Scannapieco, 2005). It is thought that poor oral hygiene
leads to intermittent bacteraemia and secondary immune com-
plexes that result in inflammatory responses in arteries and distal
organs (Scannapieco, 2005).
Clinicians in both primary care and mental health settings
should include oral health as part of a comprehensive assessment
of people with common mental disorders, facilitating dental re-
ferrals when necessary. In particular, physicians should consider
the contributory role of psychotropic medication to dry mouth and
further dental disease when prescribing. If psychiatric admission is
ever required, nursing care plans should include the recording of
factors known to cause oral ill-health such as psychotropic medi-
cation, and tobacco or substance use, as well as the supply of tooth
brushes and denture baths (Barnes et al., 1988).
People with common psychological disorders need to be re-
cognised as a disadvantaged group and, where possible, efforts
made to remove barriers to care, whether these are psychosocial
or financial. Oral hygienists can help through dental education
131
including the use of artificial salivary products (to address xer-
ostomia), as well as mouthwashes and topical fluoride applications
(to address caries). Patients should also be counselled about their
use of alcohol and tobacco. Finally, avoidance of caffeinated bev-
erages reduces xerostomia while sugar-free chewing gum helps to
stimulate salivary flow. Frequent sips of water throughout the day
may also relieve symptoms.
In conclusion, the increased focus on the physical health of
people with psychiatric illness should include consideration of oral
health. Interventions should include advice on lifestyle and oral
hygiene, management of iatrogenic dry mouth, and early dental
referral.
Acknowledgements
Emily Sawyer was supported by the University of Queensland Summer Re-
search programme.
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