Schizophrenia Research 201 (2018) 3–9

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Schizophrenia Research

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

Poor oral health in patients with schizophrenia: A systematic review

and meta-analysis
Mi Yang a,b, Peng Chen c, Man-Xi He a, Min Lu a, Hong-Ming Wang a, Jair C. Soares d, Xiang-Yang Zhang d,⁎
a
The Fourth People's Hospital of Chengdu, Chengdu, Sichuan, China
b
The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
c
School of Physics, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
d
Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, Houston, TX, USA

a r t i c l e i n f o a b s t r a c t

Article history: Increased rates of comorbid physical illness have been commonly reported in patients with schizophrenia. How-
Received 19 February 2018 ever, there are fewer data on dental disease in these patients. We systematically evaluated existing data on the
Received in revised form 14 April 2018 oral health survey of schizophrenia patients through meta-analysis. Using the available databases, we performed
Accepted 19 April 2018
a systematic search to identify the studies examining the oral health in schizophrenia patients from January 1997
to June 2017, based on the inclusion and exclusion criteria. Two investigators extracted the related data indepen-
Keywords:
Schizophrenia
dently. The meta-analysis was performed by using the RevMan 5.3 software after data extraction and quality as-
Oral hygiene sessment. We compared the oral health results between the schizophrenia patients and the general population,
Dental caries including the following measures: the mean number of decayed, missing and filled teeth (DMFT). Eight studies
Meta-analysis comprising 2640 patients with schizophrenia and 19,698 healthy controls were included in the meta-analysis.
The patients with schizophrenia had significantly higher scores of dental caries (mean difference [MD] = 7.77,
95% confidence interval [CI] = 3.27 to 12.27), missing teeth (MD = 7.61, 95% CI = 3.44 to 11.77), and decayed
teeth (MD = 3.44, 95% CI = 2.06 to 4.82) compared to controls (all p b 0.01). By contrast, the schizophrenia pa-
tients had fewer score of filled teeth (MD = −3.06, 95% CI, −4.82 to −1.30) than the controls (p b 0.01), indicat-
ing decreased access to dental care. Our systematic review suggests that patients with schizophrenia have worse
oral health than the general population, but have received less dental care services. Hence, the oral health ser-
vices should be taken into account in the patients with schizophrenia.
© 2018 Elsevier B.V. All rights reserved.

1. Introduction and impact of undernutrition among patients with chronic schizophre-

Schizophrenia is a severe mental illness with a high prevalence that
affects about 1% of the world's population (Soudry-Faure et al., 2016).
Patients with schizophrenia are characterized by positive, negative
symptoms and cognitive deficits, together with less voluntary activity,
and poor functional outcomes and quality of life. Many side effects
caused by long-term treatment with antipsychotic drugs are often
seen in these patients, which are related to oral health, such as dry
mouth and decreased salivary secretion (Hashimoto et al., 2012;
Ogłodek et al., 2014). Moreover, antipsychotics (specifically typical an-
tipsychotics) can make tooth brushing even more difficult in people
with schizophrenia, due to their effect on the extrapyramidal system
(Grinshpoon et al., 2015). Also, it has been proven that negative symp-
toms are more strongly related to poor oral hygiene (Azodo et al., 2012).
The additional factor affecting the dental health of patients with schizo-
phrenia is a poor nutrition. Some studies have examined the prevalence
⁎ Corresponding author at: 1941 East Road, Houston, TX 77054, USA.
E-mail address: xiang.y.zhang@uth.tmc.edu (X.-Y. Zhang).
nia. For example, a recent study reported the higher prevalence of
undernutrition and underweightness in adult patients with schizophre-
nia than in the general population (Sugai et al., 2015). Meanwhile, nu-
merous studies have showed that decreased nutrition was associated
with poor dental health (Pflipsen and Zenchenko, 2017). Therefore,
the individuals with schizophrenia are susceptible to oral diseases. For
example, dental plaque and stones tend to accumulate, and eventually
the incidences of oral disorders are increased in the patients with
schizophrenia, such as caries, gingivitis, and periodontitis (Cormac and
Jenkins, 1999; Ramon et al., 2003; Rekha et al., 2002b). It is well
known that good oral hygiene is important for the physical health.
Some studies have shown that poor oral health conditions are related
to coronary heart disease, stroke, obesity, respiratory and other sys-
temic diseases (Cullinan et al., 2009; Kisely et al., 2016). Moreover, pre-
vious study also indicated that there existed the possible relationship
between periodontal disease and the risk of cardiovascular diseases,
which in itself is high in people with schizophrenia (Desvarieux et al.,
2003). Therefore, while oral problems may affect the patients' eating
behavior and speech function, and interfere with their social and

https://doi.org/10.1016/j.schres.2018.04.031
0920-9964/© 2018 Elsevier B.V. All rights reserved.
4 M. Yang et al. / Schizophrenia Research 201 (2018) 3–9

Total yielded from key items

n=7207

Not meeting the inclusion criteria

n=7129

Possible for scrutinized

n=78

Not suitable for this study

n=42

Scrutinizing for detail

n=36
Excluded
n=7 duplicated
n=9 lack of outcomes
n=3 use a same sample
Paper in meta-analysis
n=9 no suitable controls
n=8

Fig. 1. Flowchart of study selection.

psychological mentality (Mirza et al., 2001), they may also increase the
risk for metabolic syndrome, cardiovascular, respiratory and other sys-
temic diseases, which may have shortened the average life expectancy
of the patients with schizophrenia for 15–20 years (Kisely et al., 2015;
Lee et al., 2017). Therefore, identifying the risk factors for oral health
and implementing preventive intervention are urgent for the individ-
uals with schizophrenia in clinical practice.
However, due to limited studies available regarding dental disease in
psychiatric disorders, there are only a few meta-analyses that have re-
ported the links between mental illness and dental disease. For exam-
ple, a previous meta-analysis showed significantly higher loss of
dentition (edentulism) in patients with severe mental illness (SMI), in-
cluding dementia, schizophrenia, bipolar affective disorder, and other
affective disorders (Kisely et al., 2011). A recent meta-analysis reported
that people with SMI had 2.8 the odds of having lost all their teeth com-
pared with the general community. They also had significantly higher
decayed, missing, and filled teeth and surfaces scores (Kisely et al.,
2015). The most recent meta-analysis showed that people with sub-
stance use disorders had significantly higher mean scores for the
mean number of decayed, missing and filled teeth (DMFT). They also
had greater tooth loss, non-carious tooth loss and destructive periodon-
tal disease compared to controls (Baghaie et al., 2017).However, there
has been no specific meta-analysis on the dental disease in patients
with schizophrenia yet.
The caries index is much easier and more convenient to be obtained
than the periodontal index, with relatively accurate data. Therefore,
many researchers have adopted the DMFT index to assess the oral
health status (Kisely et al., 2015; Baghaie et al., 2017). In the present
study, we undertook a systemic review and meta-analysis focusing on
DMFT index in the oral health surveys among patients with
schizophrenia.
2. Methods
2.1. Search strategy
We followed the Meta-analysis of Observational Studies in Epidemi-
ology guidelines (MOOSE) (Stroup et al., 2000), in search strategy, re-
sults, discussion, and conclusions. We performed a systematic search
in the following databases: PubMed, EMBASE, PsycINFO, Web of Sci-
ence, and other databases dating from January 1997 to June 2017. The
search terms used for the database search were “schizophrenia”,
“schizotypal”, “schizothymia”, “oral health”, “dental health survey”,
“dental care”, “dental health services”, “dental caries” and “teeth loss”.
All documents were independently searched by two researchers.
According to the principle of PICOS in Evidence-based medicine
(EBM), studies were included if they met the following criteria:
(1) types of studies: case–control studies, cohort studies, and cross-sec-
tional studies; (2) diagnosis: the subjects met the diagnosis criteria of
schizophrenia based on the Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (DSM-IV) or the 10th revision of the International
Statistical Classification of Diseases and Related Health Problems (ICD-
10); (3) participants: inpatients or outpatients with schizophrenia

Table 1
Basic information of the included studies in meta-analysis.

Study Country Research type Source Sample size Mean age Outcomes

Velasco et al., 1997 Spain Cross-sectional Inpatients 352 58.0 DMFT, DT, MT, FT
Ramon et al., 2003 Israel Cross-sectional Inpatients 277 54 (18–96) DMFT, DT, MT, FT
Arnaiz et al., 2011 Spain Cross-sectional Outpatients 66 (42/24) 40 ± 11.2 DMFT, DT, MT, FT
Chu et al., 2012 Taiwan Cross-sectional Inpatients 1103 (805/298) 50.8 ± 10.8 DMFT
Bertaud-Gounot et al., 2013 France Cross-sectional Inpatients 59 (18–90) DMFT, DT, MT, FT
Đorđević et al., 2016 Serbia Case–control Inpatients 543 (362/181) 54.8 ± 16.0 (17–91) DMFT
Wey et al., 2016 Malaysia Case–control Inpatients 190 (95/95) 43.6 ± 12.0 (19–67) DMFT, DT, FT
Velasco-Ortega et al., 2017 Spain Case–control Inpatients 50 (39/11) 39.9 (18–64) DMFT, DT, MT, FT

Note: DMFT = decayed, missing and filled teeth; MT = missing teeth; DT = decayed teeth; FT = filled teeth.
 M. Yang et al. / Schizophrenia Research 201 (2018) 3–9 5

Table 2
Basic information of the control groups in meta-analysis.

Study Country Source Size Age

AIvarez-Arenal et al., 1996 Spain Prevalence survey 261 34–74

Sgan-Cohen et al., 2000 Israel Prevalence survey 7139 18–96
Arnaiz et al., 2011 Spain Volunteer 66 (38/28) 39.5 ± 10.9
Y-H, 2006 Taiwan Prevalence survey 2660 (1353/1307) 18+
Hescot et al., 1997 France Prevalence survey 1000 35–44
Health, 2000 Malaysia Prevalence survey 8332
Đorđević et al., 2016 Serbia Outpatients 190 (95/95) 43.20 ± 11.89
Velasco-Ortega et al., 2017 Spain Outpatients 50 (33/17) 39.5 (20–67)

who were dentate; and (4) oral health parameters: the Decayed, Miss-
ing, and Filled Teeth index were adopted.
Exclusion criteria included: (1) the primary diagnosis not being
schizophrenia, such as organic mental disorders, mental disorders
caused by psychoactive substances, bipolar disorder, epilepsy-induced
mental disorders, mental retardation with mental disorders,
schizoaffective psychosis, and other mental disorders; (2) the outcomes
having no DMFT index; (3) the patients with only poor oral hygiene sta-
tus but without caries or other oral lesions; (4) summary or systematic
reviews; (5) multiple reports of the same study; (6) unpublished stud-
ies; and (7) unclear sources of controls and diagnostic criteria, or with-
out a control group.
2.2. Outcomes
The main outcome measures included the DMFT index, Missing
Teeth (MT), Decayed Teeth (DT), and Filled Teeth (FT). A high DMFT
index score indicates the development of dental caries and further re-
flects the deterioration of oral hygiene. The total number of permanent
human teeth is 32; thus, the maximum DMFT index is 32, and the min-
imum value is 0. However, the index varies with geographical and eth-
nic differences. For example, the value is b5 in some areas of India
(Mandal et al., 2001; Rekha et al., 2002a; Singh et al., 2017), but up to
12.8 in the Western countries, such as in Australia(Lewis et al., 2001;
Velasco et al., 1997).
application of proper measures to verify the authenticity of the data;
(7) specification of whether the research considered ethical issues; (8)
evaluation of the appropriateness of the statistical methods; (9) assess-
ment of the appropriateness of the study findings (whether the results
and inference were distinguished, whether the result was derived
from the data or the inference); and (10) clarity of the statement of re-
search value (Institute, 2014).
2.5. Statistical analysis
All statistical analyses were performed using the RevMan 5.3 soft-
ware provided by the Cochrane Collaboration. The outcomes included
continuous variables, with the mean difference (MD) ± standard devi-
ation (SD) and a confidence interval (CI) of 95% as effect quantities. The
study heterogeneity was assessed using the χ2 test and I2 test of homo-
geneity. The studies achieving p b 0.1 or 50% ≤ I2 ≤ 75% were considered
as heterogeneity, and then the random-effects model was used. Those
studies with p N 0.10 and I2 b 50% were considered as homogeneity,
and then the fixed effect model was used (Higgins and Green, 2011). Fi-
nally, if I2 N 75%, we either conducted an exclusive sensitivity analysis or
abandoned the meta-analysis.
3. Results
3.1. Study characteristics

2.3. Data extraction A total of 7207 articles were retrieved from the databases. Of these
articles, 186 originated from PubMed, 2239 from the Web of Science,
Two investigators independently screened and extracted the data by 194 from PsyclNFO, and 4588 from EMBASE. However, 7129 articles
using the inclusion and exclusion criteria. Disagreements were resolved were excluded because of their irrelevance to the present meta-analysis.
via a discussion between them to reach a consensus. The following data On the basis of the abstracts of the remaining 78 articles, 42 of them
were extracted from the studies: author, date of publication, region of were excluded due to disagreement with the purpose of this study,
study, type of study, source of patients, number of subjects, number of and 7 due to redundancy. Thus, we obtained the remaining 29 articles
controls, mean age, and outcome measures. These data were then tabu- with full text. However, 9 of these 29 articles were excluded due to
lated. For the inaccurate or incomplete entries, we contacted the corre- the lack of prevalence investigation or relevant outcome, 3 due to dupli-
sponding authors by email for supplementary information. cated reports of the same study and 9 due to lack of suitable internal or
external controls. Thus, 8 studies were ultimately included in the meta-
2.4. Quality assessment analysis, and a flowchart of study selection has been provided in Fig. 1.
Their detailed information is shown in Table 1. They included 2640
The quality evaluation for each study was assessed using the Austra-
lia Joanna–Briggs Institute (JBI) criteria (Institute, 2014), including 10 Table 3
specific aspects on a scale of 0 to 2. The scoring criteria includes: 0 for Quality assessment of the included studies.
noncompliance, 1 for being mentioned but not described in details, Study 1 2 3 4 5 6 7 8 9 10 Scores
and 2 for a detailed, comprehensive, and correct description. The quality
Velasco et al. 2 2 0 0 2 1 0 1 2 2 12
evaluation was independently conducted and cross-checked by two re-
Ramon et al. 2 2 0 0 2 1 0 1 2 2 12
searchers. In case of disagreement, a third researcher participated in the Ainaiz et al. 2 2 1 1 2 1 2 2 2 2 17
discussion as a final arbiter. Chu et al. 2 1 2 2 2 1 2 2 2 2 18
These 10 evaluation criteria included: (1) clarity of the study pur- Bertaud-Gounot et al. 2 2 1 1 2 1 2 2 2 2 17
Đorđević et al. 2 2 1 2 2 2 2 2 2 2 19
pose; (2) specification of the study population selection process, such
Wey et al. 2 2 2 2 2 2 2 2 2 2 20
as random selection or the application of stratified sampling to improve Velasco-Ortega et al. 2 2 2 2 2 2 2 2 2 2 20
the sampling quality; (3) detailing of the sample inclusion and exclu-
Note: The quality evaluation for each study was assessed using the Australia Joanna–
sion criteria; (4) clarity of the description of the sample features; (5) ex- Briggs Institute (JBI) criteria, including 10 specific aspects on a scale of 0 to 2. The scoring
tent of the validity or reliability of the data collection tools, such as the criteria includes: 0 for noncompliance, 1 for being mentioned but not described in details,
survey by investigator and the repeatability of the survey results; (6) and 2 for a detailed, comprehensive, and correct description.
6 M. Yang et al. / Schizophrenia Research 201 (2018) 3–9
Fig. 2. Meta-analysis results for the decayed, missing, and filled teeth (DMFT) in the patients with schizophrenia versus the controls.
schizophrenia patients and 19,698 controls. Among them, the controls
in the 3 papers (Arnaiz et al., 2011; Đorđević et al., 2016; Velasco-
Ortega et al., 2017) were from the self-comparison themselves, and
the controls in other 5 papers were from prevalence studies (Table 2).
The basic information of the control groups is presented in Table 2,
and the quality assessment of the included articles is shown in Table 3.
3.2. Meta-analysis
3.2.1. DMFT
As shown in Fig. 2, 8 articles were included in the meta-analysis in-
cluding 2640 schizophrenia patients and 19,698 controls. The result
showed that the patients had significantly higher DMFT score than the
controls (MD = 7.77; 95% CI = 3.27 to 12.27, p b 0.01).
3.2.2. MT
As displayed in Fig. 3, 7 articles were included in the meta-analysis
including 1537 schizophrenia patients and 17,038 controls. The result
showed that the patients had significantly higher MT score than the
controls (MD = 7.61, 95% CI = 3.44 to 11.77, p b 0.01).
3.2.3. DT
As presented in Fig. 4, 7 articles were included in the meta-analysis
including 1537 schizophrenia patients and 17,038 controls. The result
showed that the patients had significantly higher DT score than the con-
trols (MD, 3.44; 95% CI, 2.06 to 4.82, p b 0.01).
3.2.4. FT
As shown in Fig. 5, 6 articles were included in the meta-analysis in-
cluding 1185 schizophrenia patients and 16,777 controls. The result
showed that the patients had significantly lower FT score than the con-
trols (MD = −3.06, 95% CI, −4.82 to −1.30, p b 0.01).
3.3. Heterogeneity analysis
In the meta-analysis of each outcome measure, the I2 was larger than
90%, indicating a massive heterogeneity among the studies. The statistical
Fig. 3. Meta-analysis results for Missing Teeth (MT) in the patients with schizophrenia versus the controls.
heterogeneity mainly derived from the clinical heterogeneity, including
the heterogeneity in the characteristics of the subjects, the diagnosis,
the intervention, the research area, and the outcomes. In addition, sub-
group analysis could not be performed because of the insufficient number
of included studies.
3.4. Sensitivity analysis
For each of the four DMFT, DT, MT, and FT indicators, sensitivity anal-
yses of the effect of omitting each study in turn made little difference to
the results, showing that the combined effect of the outcome indicators
did not change significantly. This observation indicated that the stability
of the results was very high.
3.5. Bias analysis
The number of included studies for each outcome in the meta-anal-
ysis did not exceed 10; thus, we did not create a funnel plot. Slight bias
may occur because of the small number of studies included.
4. Discussion
In recent years, with the increasing general health awareness, the
oral health of the general population in many countries has been im-
proved dramatically. However, the oral hygiene among patients with
psychiatric disorders remains under-developed (Kisely et al., 2015;
Matevosyan, 2010). On the basis of MOOSE guidelines (Stroup et al.,
2000), we conducted a meta-analysis on the 8 observational studies.
By combing all these 8 studies, we established a relationship between
the psychiatric condition and caries status or other oral indexes.
The results of this meta-analysis showed that the DMFT, DT, and MT
scores in patients with schizophrenia were significantly higher than
those in general population, whereas the opposite result was observed
for the FT score, indicating reduced assess to dental care. These results
suggest that the oral health, dental caries status, and corresponding oral
health management of patients with schizophrenia were worse than
those in the general population. In the included 8 studies, one reported
 M. Yang et al. / Schizophrenia Research 201 (2018) 3–9
Fig. 4. Meta-analysis results for Decayed Teeth (DT) in the patients with schizophrenia versus the controls.
that the schizophrenia outpatients with less severe illness and higher
self-care brushed their teeth as prescribed and regularly received oral hy-
giene examination and treatment (Arnaiz et al., 2011). Another study re-
ported that the implementation of compulsory oral health protection
measures was provided to low-income people, including those with
mental illness, with the good opportunity to receive free oral treatment
(Bertaud-Gounot et al., 2013). The third study showed that the subjects
were not randomly selected (Chu et al., 2012). Thus, the value of the car-
ies loss index in these 3 studies was lower than that in other studies. De-
spite these limitations, we found that the indexes of DMFT, DT and MT in
the patients were statistically higher than those in the controls.
The poor oral hygiene in patients with schizophrenia may be associ-
ated with the following reasons. First, these patients, especially in acute
episodes have many psychiatric symptoms and irregular activities,
which have prevented them from paying attention to their oral health,
resulting in serious oral problems (MacCabe et al., 2013). Moreover, the
patients were incapable of cooperation with dental treatment due to
their psychiatric symptoms; hence, the dentists were not able to carry
out dental treatment for these patients well, and the patients had to re-
quire dental extraction eventually (McCreadie et al., 2004; Persson et
al., 2009). Second, the patients with schizophrenia often have a long du-
ration of illness, and need to take antipsychotic medications for their psy-
chiatric symptoms for a long-term period. It is well known that
antipsychotic drugs have anticholinergic and anti-alpha-adrenergic ef-
fects, which produce autonomic side effects, such as reduced saliva vol-
ume, mouth dryness and drowsiness, leading to oral diseases, such as
dental caries, cleft lip and ulcers (Friedlander and Norman, 2002). Also,
these antipsychotic drugs impact the immune system and alter the oral
microbiota and some biochemical indicators, which may in turn result
in oral diseases (Dickerson et al., 2017). In addition, some antipsychotics
are associated with extrapyramidal side effects, such as maxillofacial dys-
tonia, pseudo-Parkinson's disease, and dyskinesia, which may aggravate
the damage to oral health and also increase the difficulty for oral treat-
ment (Friedlander and Norman, 2002). Third, schizophrenia patients
have a high rate of smoking, especially among male patients, which is a
common risk factor for oral diseases (Beck and Offenbacher, 2005; Rai,
2007). Taken together, these factors may be responsible for the oral
health problems in patients with schizophrenia.
Fig. 5. Meta-analysis results for Filled Teeth (FT) in the patients with schizophrenia versus the controls.
7
Oral diseases not only affect the aesthetics and function of the mouth
and face, but also are important sources for many systemic diseases
(Joshipura et al., 2000; Kinane and Marshall, 2001; Li et al., 2000). For
example, some infectious or inflammatory pathogenic factors coloniz-
ing the oral cavity are often closely related to systemic diseases, such
as diabetes mellitus, cardiovascular diseases, and bacterial pneumonia.
The persistence of bacterial toxins in oral infection foci, such as dental
caries, may lead to an increase in catecholamine levels in the body and
cause autonomic dysfunction and focal arrhythmias (Hoyer et al.,
2006; Low et al., 2003; Muller-Werdan et al., 2006). Further, poor oral
hygiene can directly cause substantial bacterial colonization and then
lead to the formation of acquired biofilm, alteration of the micro-ecolog-
ical environment of the mouth, and serious damage to the teeth and
periodontal areas (Li et al., 2000). When these anatomically dense mi-
crobial flora enter the bloodstream, the systemic spread of bacterial
products and the subsequent immune responses promote the develop-
ment of bacteremia (Herzberg and Meyer, 1996). Moreover, the distant
colonization of bacteria not only causes chronic inflammation in the
liver, pancreas, and arteries, but also induce or exacerbate the latent dis-
eases, such as atherosclerosis and diabetes (Gocke et al., 2014; Haworth
et al., 2017). In addition, some studies have shown that after some mi-
crobes in the oral cavity enter the blood, these microorganisms deploy
a protein that causes platelet aggregation (Herzberg and Meyer, 1998;
McNicol, 2015). As a result, blood clots form and wrap the bacteria.
This formation not only isolates the pathogen from the body's own im-
mune function, but also renders exogenous antibiotics ineffective
(McNicol, 2015). Further, these tiny blood clots can accumulate in the
heart valve, and the blood infection itself can also reduce the blood sup-
ply to the heart and brain, which may lead to cardiovascular diseases
(Herzberg and Meyer, 1998). Therefore, oral hygiene is much worse in
patients with schizophrenia than in the general population, which
may increase the risk of systemic diseases. The emergence of comorbid-
ity with oral diseases further reduces the quality of life among these
schizophrenia patients and affects the recovery of their psychotic symp-
toms and their social function. Thus, our results highlight the necessity
and urgency of oral health management in patients with schizophrenia.
There are several limitations that need to be mentioned here. First,
some of the articles included in this meta-analysis did not provide a
8 M. Yang et al. / Schizophrenia Research 201 (2018) 3–9
control group, necessitating the use of controls from community sur-
veys. Second, the included 8 articles only used DMFT as the outcome
measures, which are not suitable for other analyses. Third, some of
these studies had no detailed clinical parameters, such as gender, social
status, income status, educational level, and age. Moreover, the patients
and the controls in most of the studies were not randomly selected, and
the proportions of men and women were not balanced in some of the
studies. Fourth, the meta-analysis results in this study showed a high
heterogeneity for the oral hygienic indexes, with the I2 N90%. Thus, the
random-effects model was used for analysis, with potential bias. Fifth,
we did not include schizophreniform psychoses and limit the search
to 1997 onwards, which are considered as the methodological limita-
tions and should be remedied in the further meta-analyses. Sixth, the
use of controls was from both within the included papers themselves
and from prevalence studies. Moreover, no papers did adjust assess,
match or adjust for confounders. Further, they did not stipulate commu-
nity surveys that had to be within a certain number of years of the rele-
vant study given long-term trends in dental caries. Seventh, we used the
Joanna- Briggs criteria in the present study as opposed to the more com-
monly used Newcastle-Ottawa when assessing case controlled and co-
hort data. Hence, the results maybe have some biases. Eighth, there
are some other issues that have not been considered. For example, we
did not obtain the data on how the psychiatric diagnoses derived, clini-
cally or by structured interview, and whether the dental assessments
were done by trained clinicians and further whether their ratings
were calibrated. Ninth, some related factors associated with the poor
oral health like Fluoride concentration in tap water may help to explain
cross-studies differences; however, we did not collect these factors,
which should be remedied in the future study.
In summary, our meta-analysis suggests worse oral health and more
oral diseases in the patients with schizophrenia. Moreover, the schizo-
phrenia patients have low motivation for oral health care and do not
want to seek dental treatment. Further, poor socioeconomic status
may also limit their access to dental care (Tang et al., 2016). Since the
oral diseases may affect the clinical symptoms and antipsychotic treat-
ment, and more importantly may cause a series of serious physical dis-
eases, much attention should be paid to the oral hygiene in the
schizophrenia patients. Thus, active and regular dental assessment and
treatment are particularly necessary for these patients. Moreover, in-
quiring about oral health and performing regular oral examinations
should become a routine work of the comprehensive health assessment
of schizophrenia patients (Tang et al., 2016). In addition, some individ-
ual implementation for oral health can be adopted for each patient, such
as oral health education, regular oral examinations, and even dental
treatments. In addition, due to the limitations of this meta-analysis,
our results should be regarded as preliminary. Further systematic re-
views or meta-analysis on oral health including the more studies, as
well as the more subjects suffering from other mental disorders should
be performed to design personalized oral interventions and manage-
ment measures.
Conflict of interest
No conflict of interest was disclosed for each author.
Contributors
Mi Yang and Peng Chen were responsible for study design, data extraction, statistical
analysis, and manuscript preparation. Mi Yang, Min Lu, Hong-Ming Wang, Jair C. Soares
and Man-Xi He were involved in evolving the ideas and editing the manuscript. Mi Yang
and Xiang Yang Zhang were involved in writing the manuscript. In addition, Mi Yang
was responsible for providing the funding for the study. All authors have contributed to
and have approved the final manuscript.
Role of the funding source
This study was supported by the Project of the Science and Technol-
ogy Department of Sichuan Province (2017JY0094), and the Research
Projects of Sichuan Provincial Health and Family Planning Commission
(16PJ051).
Acknowledgement
We thank the authors of the included 8 papers, who have generously provided us the
detailed data to complete this meta-analysis.
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