0416/2024 - SIGNIFICADOS PRODUZIDOS PELO CIRURGIÃO-DENTISTA NO CUIDADO AO PACIENTE COM TRANSTORNO MENTAL: UM ESTUDO QUALITATIVO
MEANINGS PRODUCED BY DENTISTS IN CARING FOR PATIENTS WITH MENTAL DISORDERS: A QUALITATIVE STUDY
Autor:
• Lucas Gonçalves de Sousa - Sousa, L.G - <gdesousalucas@gmail.com>ORCID: https://orcid.org/0009-0007-1288-4383
Coautor(es):
• Marconi Vitor Santos Xavier - Xavier, M.V.S - <marconi_vitor@hotmail.com>ORCID: https://orcid.org/0009-0008-3632-0950
• Álex Moreira Herval - Herval, A.M - <alexmherval@ufu.br>
ORCID: https://orcid.org/0000-0001-6649-2616
Resumo:
Introdução: A atenção em saúde mental no Brasil avançou notavelmente nas últimas décadas, migrando do modelo manicomial para o cuidado comunitário. Contudo, o avanço no cuidado em saúde bucal é incipiente e soma-se à falta de estratégias que incluam prevenção e promoção de saúde, mantendo esse grupo vulnerável às doenças bucais. Objetivo: Compreender significados produzidos por Cirurgiões-Dentistas da Atenção Primária à Saúde sobre o cuidado odontológico ofertado a pacientes com transtorno mental. Metodologia: Foi realizada uma pesquisa qualitativa com Cirurgiões-Dentistas da Atenção Primária em Saúde. Os dados foram produzidos por meio de entrevistas semiestruturadas, analisados pela Teoria Fundamentada de Dados e interpretados com base em ideias expostas por Canguilhem em “O normal e o patológico”. Resultados: A partir da análise pela codificação aberta e axial foram elaboradas seis categorias: 1) atendimento focado na demanda espontânea; 2) “a gente não tem esse treinamento”; 3) complexidade do atendimento; 4) um paciente “normal”; 5) Um paciente especial; 6) necessidade de suporte da família. Conclusão: Cirurgiões-Dentistas compreendem que o cuidado às pessoas com transtorno mental é deficiente, para eles decorrente da falta de treinamento e desconhecimento sobre a pessoa com transtorno mental.Palavras-chave:
Transtornos mentais. Odontológos. Pesquisa Qualitativa.Abstract:
Introduction: Mental health care in Brazil has advanced considerably over the last few decades, moving awaya mental institution model towards a community care model. However, advances in oral health care for these patients are still incipient, with a lack of promotion strategies, which leaves these patients with high level of vulnerability to developing oral diseases. Objective: To understand the meanings produced by Primary Health Care Dental Surgeons about the dental care offered to patients with mental disorders. Methodology: A qualitative study was carried out with Primary Health Care Dentists. Data was produced through semi-structured interviews and analyzed using the Grounded Theory of Data and interpreted based on ideas presented by Caguilhem in his work “The normal and the pathological”. Results: From the analysis using open and axial coding, six categories were drawn up: 1) care focused on spontaneous demand; 2) "we don't have this training; 3) complexity of care; 4) a "normal" patient; 5) A special patient; 6) need for family support. Conclusion: Dental Surgeons understand that care for people with mental disorders is poor, which for them stemsa lack of training and knowledge about people with mental disorders.Keywords:
Mental Disorders. Dentists. Qualitative Research.Conteúdo:
Acessar Revista no ScieloOutros idiomas:
MEANINGS PRODUCED BY DENTISTS IN CARING FOR PATIENTS WITH MENTAL DISORDERS: A QUALITATIVE STUDY
Resumo (abstract):
Introduction: Mental health care in Brazil has advanced considerably over the last few decades, moving awaya mental institution model towards a community care model. However, advances in oral health care for these patients are still incipient, with a lack of promotion strategies, which leaves these patients with high level of vulnerability to developing oral diseases. Objective: To understand the meanings produced by Primary Health Care Dental Surgeons about the dental care offered to patients with mental disorders. Methodology: A qualitative study was carried out with Primary Health Care Dentists. Data was produced through semi-structured interviews and analyzed using the Grounded Theory of Data and interpreted based on ideas presented by Caguilhem in his work “The normal and the pathological”. Results: From the analysis using open and axial coding, six categories were drawn up: 1) care focused on spontaneous demand; 2) "we don't have this training; 3) complexity of care; 4) a "normal" patient; 5) A special patient; 6) need for family support. Conclusion: Dental Surgeons understand that care for people with mental disorders is poor, which for them stemsa lack of training and knowledge about people with mental disorders.Palavras-chave (keywords):
Mental Disorders. Dentists. Qualitative Research.Ler versão inglês (english version)
Conteúdo (article):
SIGNIFICADOS PRODUZIDOS PELO CIRURGIÃO-DENTISTA NO CUIDADO AO PACIENTE COM TRANSTORNO MENTAL: UM ESTUDO QUALITATIVOMEANINGS PRODUCED BY DENTISTS IN CARE FOR PATIENTS WITH MENTAL DISORDER: A QUALITATIVE STUDY
Lucas Gonçalves de Sousa1
ORCID: https://orcid.org/0009-0007-1288-4383
Marconi Vitor Santos Xavier1
ORCID: https://orcid.org/0009-0008-3632-0950
Álex Moreira Herval2
ORCID: https://orcid.org/0000-0001-6649-2616
1Universidade Federal de Uberlândia – Faculdade de Odontologia
2Universidade Federal de Uberlândia – Faculdade de Odontologia – Departamento de Odontologia Preventiva e Social
RESUMO
Introdução: A atenção em saúde mental no Brasil avançou notavelmente nas últimas décadas, migrando do modelo manicomial para o cuidado comunitário. Contudo, o avanço no cuidado em saúde bucal é incipiente e soma-se à falta de estratégias que incluam prevenção e promoção de saúde, mantendo esse grupo vulnerável às doenças bucais. Objetivo: Compreender significados produzidos por Cirurgiões-Dentistas da Atenção Primária à Saúde sobre o cuidado odontológico ofertado a pacientes com transtorno mental. Metodologia: Foi realizada uma pesquisa qualitativa com Cirurgiões-Dentistas da Atenção Primária em Saúde. Os dados foram produzidos por meio de entrevistas semiestruturadas, analisados pela Teoria Fundamentada de Dados e interpretados com base em ideias expostas por Canguilhem em “O normal e o patológico”. Resultados: A partir da análise pela codificação aberta e axial foram elaboradas seis categorias: 1) atendimento focado na demanda espontânea; 2) “a gente não tem esse treinamento”; 3) complexidade do atendimento; 4) um paciente “normal”; 5) Um paciente especial; 6) necessidade de suporte da família. Conclusão: Cirurgiões-Dentistas compreendem que o cuidado às pessoas com transtorno mental é deficiente, para eles decorrente da falta de treinamento e desconhecimento sobre a pessoa com transtorno mental.
Palavras-chave: Transtornos mentais. Odontólogos. Pesquisa Qualitativa.
ABSTRACT
Introduction: mental health care in Brazil has advanced considerably over the last few decades, moving away from a institutional model towards community care. Advances in oral health care for mental patients are still incipient, however, and strategies that include prevention and promotion are lacking, leaving these patients highly vulnerable to oral diseases. Objective: to understand the meanings produced by dentists working in primary health care about the dental care offered to patients with mental disorders. Methodology: in this qualitative study with dentists in primary health care, data was produced through semi-structured interviews, analysed using Grounded Theory and interpreted drawing on Caguilhem’s “The normal and the pathological”. Results: analysis by open and axial coding yielded six categories: 1) care for spontaneous demand; 2) "We don\'t have that training”; 3) care complexity; 4) a "normal" patient; 5) a special patient; and 6) the need for family support. Conclusion: dentists consider that care for persons with mental disorder is poor, which they see as stemming from a lack of specific, related training and knowledge.
Keywords: mental disorders; dentists; qualitative research.
Introduction
The traditional model of mental health care in place since the 1880s encouraged the emergence of psychiatric asylums1,2. These facilities were usually located away from urban centres and the care they provided focused on meeting basic survival needs and custodial restraint, reinforcing segregative patterns of care and treatment1,2,3. With the end of World War II and the rise of progressive movements, came the endeavour to develop more humane care practices and proposals for new models of mental health care framed by greater integration among hospitals, health services and the community and free from involuntary committal4.
In Brazil, the mental health care model began to change in about the 1970s, when complaints of mistreatment of psychiatric hospital patients prompted discussions of mental health care practices then in place, as well as local projects and alternatives to the conventional psychiatric hospital1,4,5. In that process, known as the Psychiatric Reform, which aligned with construction of Brazil’s Unified Health System (Sistema Único de Saúde, SUS) and was influenced by the Declaration of Caracas and the Pan American Health Organisation1, specific strategies were adopted to de-institutionalise in Brazil and to expand the outpatient mental health system5. As a result, psychosocial care centres were introduced, replacing psychiatric hospitals by multi-professional care, with a view to restoring users’ autonomy and reintegrating them into society and to reducing the number of psychiatric hospital admissions and beds1,5.
The main mental disorders affecting users of psychosocial care centre include schizophrenia, mood and personality disorders, stress- and anxiety-related disorders and depression6,7. The disorders addressed also include misuse of alcohol and other drugs, and health care personnel with specialised training in treating dependence are present5,8. It is important to differentiate mental disorders from intellectual deficiencies. The American Psychiatric Association characterises mental disorder as a clinically significant disturbance in a person’s thoughts, feelings or behaviour that reflects some kind of biological, psychological, or developmental dysfunction underlying their mental functioning9 and results in individual or social suffering or harm10. Intellectual disability, meanwhile, is defined as the existence of limitations on the abilities necessary for participation in daily life11. Intellectual deficiencies relate to the functioning of the intellect proper, rather than to the functioning of the mind12, and entail significant constraints both on intellectual functioning and adaptive behaviour, as expressed in conceptual, social and practical competences13. Although mental disorders and intellectual deficiencies are distinct concepts, they may coexist in some situations.
As regards oral health, individuals with mental disorder are more prone to developing oral pathologies and, although caries and other periodontal diseases are very common in the general population, prevalence is higher in patients with mental disorder14,15,16,17,18. This population’s greater vulnerability to oral diseases may relate to various factors: the side-effects of medications and drugs that can cause xerostomia and bruxism14,19,20,21,22. Failure to realise the importance of caring for oral health, fear of going to a dentist, a cariogenic diet, poor self-care and the impact of social media14,17,23,24,25,26.
Another factor that leaves this population vulnerable is poor access to oral health care24,27,28, a situation that could be improved by strategic action between dentists and mental health care practitioners29. Oral health education measures not only have the potential to improve conditions of oral health but can also favour adherence to treatment30. However, the scientific literature contains no evidence of oral health education strategies designed specifically for persons with mental disorders31. Accordingly, expectations are high for strategies that favour empowerment, such as holding small open groups32, and conversation activities to encourage knowledge sharing, and thus permit proper access to information and enable patients with mental disorder to regain full citizenship33. Receptiveness to and bonding with patients, in addition to forging ties of affection and trust, enable due value to be given to users’ knowledge and, as a result, to their co-responsibility in the production of care34.
Care for persons with mental disorder calls for an individual approach suited to their particular needs35. That approach must thus be multi-dimensional, not restricted to biological dimensions, but embodying the understanding that culturally different conditions are involved36. Healthcare with cultural competence is expected to result in greater adherence to treatment, fewer communication barriers, greater recognition for the patient35,37, and more respectful, less stigmatising treatment14.
Therefore, in view of the model of mental health care proposed in Brazil’s unified public national health system (SUS) and the need for a comprehensive and culturally competent approach, this study endeavoured to understand the meanings produced by dentists in primary health care as regards dental care for persons with mental disorder.
Methodology
Study design and ethical considerations
The qualitative study reported here was framed methodologically by the Grounded Theory as proposed by Strauss38. The research protocol was approved by the human subjects research ethics committee of the Universidade Federal de Uberlândia (CEP/UFU) (CAAE: 23356619.3.0000.5152).
Study participants and sampling
The study was conducted with dentists active in primary health care in the municipal health system of Uberlândia (Minas Gerais). Sampling, which was intentional, selected practitioners who acknowledged having worked with persons with mental disorder. Inclusion was by the “snowball” technique. The first practitioner included in the study was indicated by the technical reference in oral health, which recognised that she had skill with patients with mental disorder. After interview, the first practitioner was asked to indicate other persons who had reported providing care for persons with mental disorder and so on successively.
Sample volume was determined by the saturation theory proposed by Fontanella et al.39: saturation is achieved when no further new meanings about care for patients with mental disorders emerge and it is possible to develop a theory with no explanatory gaps.
Data production
It had been planned to produce data in 2020 and in person. However, as a result of the Covid-19 pandemic, production of qualitative data had to be postponed and took place between January and March 2021. The scenario of constraints imposed by the pandemic also required that the interviews occur by videoconference. Video calls were held when the dentists were away from the primary health care facility, as initially agreed with each practitioner.
In the contacts with the dentists, data were produced in two stages. The first stage yielded information characterising the practitioners participating in the study, including a set of socio-demographic data on the practitioner and their primary health care activities. The second stage, production of qualitative data, place by way of semi-structured interviews supported by a script comprising eight themes relating to organisation of the care provided by dentists, the functioning of the mental health care system, and the dentists’ responsibilities within the system of care for persons with mental disorders. The interviews were recorded for audio and subsequently transcribed; names and any information that might identify the participants were removed.
Data analysis
The qualitative material was analysed at three subsequent levels of coding, in accordance with the Strauss’s grounded theory. The first, Open Coding, involved exploring the qualitative data by successive readings of the qualitative material, identifying passages with meaning for the study and labelling these phenomena (short description). In the second, Axial Coding, the labels assigned to phenomenon in the previous stage were organised so as to form explanatory categories of the meanings dentists attributed to the study object. At the last level of coding, Selective Coding, the categories so formed were interconnected by classification into six analytical categories (causes, contexts, contingencies, consequences, covariances and conditions). In this final stage of coding, categories were formed so as to develop an explanatory model by theorisation influenced by Symbolic Interactionism.
This approach seeks to identify patterns of symbolic interactions and to understand the meanings that study participants attribute to the study object. Theorisation from the data entails analysing key concepts and categories that emerge from the information collected, by which it is possible to create an explanatory model reflecting the participants’ understanding of the study phenomenon. The role played by Symbolic Interactionism is to highlight shared meanings and social interactions in the analysis and to build theories from the empirical data.
Theoretical and interpretative frame of reference
The codes and categories resulting from the analysis using Grounded Theory were interpreted taking Georges Canguilhem’s essay, “The normal and the pathological”40, as the theoretical and interpretative frame of reference. The book offered fundamentals and ideas that broke with discourse current at the time to propose an integrated view of the concepts of “normal” and “pathological”. Canguilhem40 argued that the concept of normal should not be understood as a statistical fact (which was the most prevalent view), but rather on the basis of morphological and functional adaptations to demands placed on the individual. Moreover, what is “normal” conforms not with the rigidity of a coercive collective fact, but rather with the flexibility of a norm that varies with individual conditions.
Canguilhem40 explained that health is defined by the ability to establish new norms in new situations, that is, the ability to be normative. On that rationale, individuals should be considered ill when they are unable to be normative. Sick individuals try to maintain the only norms of life with which they feel relatively normal and manage to master their own environment, as a result, becoming normalised within their setting. Disease must then be recognised as a new dimension of life, albeit in reduced form.
Lastly, as being normal does not necessarily mean being healthy, the pathological cannot always be considered abnormal, given that the pathological is not the absence of any norms, but rather an inferior norm. In that regard, following Canguilhem40, the pathological is not abnormal in any absolute sense, but only as compared with a specific situation, because the pathological is not the absence of a biological norm, but merely the presence of a different norm. Accordingly, even though the pathological is a different norm, it can be considered normal, because it expresses a relation with the normativity of life and is compatible with it, even if in lesser form.
Results
The eight primary health care dentists interviewed identified themselves as women, from 24 to 50 years old, with experience in the public health system and with no specialisation in the collective health, family health or public health fields. Some of the interviewees took part in health team meetings and declared having received training to work with people with mental disorders and/or misuse of alcohol and other drugs. All participants reported knowing people with mental disorder and patients who misused alcohol and other drugs residing in the catchment territory of the primary health care facility. None of the interviewees reported participating in collective action to prevent disorders, to promote mental health or prevent misuse of alcohol and other drugs.
The semi-structured interviews lasted on average approximately 21 minutes and all recorded material was transcribed and analysed in successive coding steps. The six categories formed after open and axial coding are shown in Table 1, together with example passages of discourse: 1) Care focused on spontaneous demand; 2) we do not have that training; 3) complexity of care; 4) a “normal” patient; 5) a special patient; and 6) need for support from the family.
Table 1
Below are the memoranda written after each of the categories formed in coding had been structured.
Care focused on spontaneous demand: the dentists understood patients with a mental disorder to be a priority group and emphasised the need for continuous follow-up of these patients, as well as educational and preventive measures. However, they pointed out that patients with mental disorders received care mainly in acute dental situations, because of the difficulty of providing continuous care and high no-show and dropout rates, but also for lack of self-care.
We do not have that training: on examining the reasons behind this mismatch between recognition of the need for continuous care and that care’s usually responding to acute needs, the dentists pointed to a lack of aptitude, which they put down to a lack of training and capacity building. Other meanings attributed to this mismatch were healthcare system fragmentation and lack of support from psychosocial care centres, psychologists and psychiatrists for provision of care to persons with mental disorder.
Complexity of care: because of this group’s specific characteristics, “complexity of care” was a meaning attributed by dentists to caring for persons with mental disorder. Here, care requires more attention to bonding, establishing trust and retaining patients in dental care. To these patients, they also attributed unpredictable behaviour, which complicated care.
A special patient: the dentists often equated mentally-disordered patients with patients with special needs (a dental speciality intended for patients with complex health syndromes and conditions). On that rationale, the dentists felt that care for patients with mental disorders should be supported by Brazil’s specialist dental care centres.
A “normal” patient: the dentists attributed to dental care for patients with a mental disorder the possibility of providing care as “normal patients”, when the former were calm, that is, not under the effects of alcohol or drugs or in crisis – with the caveat, however, that there was a need to eliminate any judgment or prejudice towards this group.
Need for support from the family: starting from the idea that patients with mental disorder were unable to perform self-care effectively and even attributing to these patients a lack of awareness, the dentist’s indicated that the family should perform this care and encourage these patients to seek dental care.
From these categories, theorisation was formulated as to the meanings that dentists develop with regard to caring for patients with mental disorder. Meanings emerged in a context in which the dentists did not feel equipped to provide comprehensive care to patients with mental disorder. Not knowing the specific needs of this population group, they ended up referring care to specialist dental care centres or performing care only when these patients’ behaviour was what was considered normal patient behaviour, not understanding the patient’s mental disorder as an integral part of their life. As a result of this lack of specific planning for this group, care was ultimately restricted to acute dental situations, reinforcing a demand-oriented model of care rather than one framed by needs. The dentists felt that greater support from the mental health care system and responsibility on the part of the families were factors that could have a favourable effect on the process of care for patients with mental disorder.
Discussion
Theorisation on the meanings produced by primary health care dentists about caring for persons with mental disorder raised important issues for discussion. These included the lack of training in care for this population and the equating of patients with a mental disorder with patients with an intellectual disability, the understanding that persons with a mental disorder should adapt to a state of normality in order to receive care and, lastly, care being focused on acute dental needs, revealing a lack of strategic organisation for care for a population at greater risk of oral diseases.
The lack of training was exemplified in some of the interviews (E1: “I don’t know if there is something else, because we never had that training”; E2: “I never had any specific training”). It was blamed for the lack of aptitude in dealing with people with mental disorder. That justification aligns with the scientific literature41,42,29. Rotoli et al.42 and Mishu et al.27 showed that there was a lack of training for health professionals and a needs to invest in mental health training programmes in order to improve care, acceptance and communication with patients with mental disorder. Carrara et al.43 found that health practitioners are as susceptible as the general public to stigmatising beliefs and behaviour with regard to persons with a mental disorder and, in the same way, the lack of training can lead to inappropriate treatment, stigmatisation of mental disorders and, as a result, impaired adherence to treatment. This all raises barriers to access to oral health care for this portion of the population and to their seeking treatment41.
Training for dental practitioners should not address clinical procedures exclusively, but also teach interpersonal skills. A qualitative study by Mishu et al.29 found that patients with mental disorder feel more well received and have more favourable perceptions of treatment when the practitioner also has effective communication skills, takes care to build bonds of trust and respect and takes an interdisciplinary and comprehensive approach to care. Poudel et al.44 showed that patients who misuse alcohol and other drugs are more responsive to treatment guided by trust, support and communication, which minimises stigma and the fear of dental treatment. Accordingly, dentists should be capacitated and trained to deal with the particular features of care for patients with mental disorder and it should be dentists’ ethical and moral duty to welcome this population with no discrimination or judgment45.
Even though training is important, it should be remembered that complaints about lack of training and the complexity of care may stem from a practice centred on dentists’ working alone, even when forming part of a multi-professional team, and not feeling supported by, and working with, the other health practitioners and services46,47. Primary health care includes tools for in-service learning, such as continuing professional development47, matrix support48 and team meetings. Matrix support is considered an opportunity for developing competences, skills and attitudes, particularly as regards patients with mental disorder48, and may be a source of security and learning in providing dental care for these patients. Matrix support48, team meetings and shared care47 have the potential to support and inform patient care in complex cases, when multi professional care is essential to resolving cases. However, although dentists recognise the potential of inter-professional work, their participation in team meetings is meagre48,49.
The difficulty of planning care supported by a healthcare team and guided by patient needs seems to reflect the hegemony of a model of service known as Market Dentistry. Although typical of private services, it still predominates among dentists working in public health systems and favours individualised, curative care framed by the clinic and oriented towards patient demands and treating disease50. In contrast to this approach, treatment for patients with a mental disorder is expected to be based on a rationale rooted in their culture, with horizontal communication that acknowledges them35,36 and takes due consideration of the kind of existence they are able to establish in view of their mental disorder40.
The dentists in this study understood that it is difficult for individuals with mental disorder to adhere to dental care (E2: “We insist, we insist with the patient, but in the end we too give up”). This meaning is corroborated by the scientific literature, which indicates that this population has difficulty with self-care51,52,24. Turner et al.24 found that many patients are unable to cooperate with care as a result of their mental disorder and that health education alone is not enough to improve the oral health of persons with mental disorder. Similarly, Rossow53 found that patients with drug misuse are less receptive to oral healthcare and tend not to adhere to preventive measures or to attend dental appointments. Turner et al.54 found that, where mental health and oral health interact negatively, with deficient mental health reducing oral health behaviour, oral diseases emerge, in turn, adversely affect psychotic patients’ mental health. Anxiety, fear and worsening mental disorder impair patients’ capacity for self-care55. In addition, the findings of this study, which align with the literature, signal a need for persons with a mental disorder to be considered a priority group for dental care. Canguilhem40 argued that these patients certainly should be prioritised, to put an end to emergency situations and take preventive care thinking to individuals and enable them to be normative in the environment of their lives. However, a literature review on access to dental care in Brazil showed that socially vulnerable populations have less access to oral health services56.
The outcome of the theoretical model of oral health care for the population with mental disorder proposed as a result of this study shows care directed in practice to addressing acute dental problems. Although the dentist’s indicated, in what they say, that one characteristic of the patient with mental disorder is that they seek dental care only when they “are in pain” (E4) or in “cases of emergency” (E1), it has to be understood that this is not exclusively a feature of this population. In addition, limited access to primary health care and the persistence of an unsupportive, demand-focused work process largely mean that this population’s access is restricted to situations of acute need46,56.
Prevention and promotion measures for this population can yield satisfactory results. Singhal et al.57, in a study to evaluate the effects of oral health education, found that, despite the challenges posed by mental disorder, an educational programme directed to this population’s oral health had the potential to increase the frequency of patients’ daily oral hygiene and, when combined with an electric toothbrush, produced even better outcomes. Poudel et al.44 and Cheah et al.26 reported that patients misusing alcohol and other drugs could also benefit from education programmes, especially those based on motivational interviews, free of prejudice and stigma and integrated with other care for the situation of chemical dependency. Lastly, Kuipers et al.25 also indicated the essential need to include intense preventive programmes and long-term interventions for patients with mental disorder. Accordingly, it must be understood that patients with mental disorder are more likely to find it difficult to maintain a routine of dental care, but it has to be understood, at the same time, that this is not due solely to individual characteristics, but also to factors including limited access to health services, stigma, discrimination and marginalisation.
Changing the model of oral healthcare would seem to depend on greater integration between oral health teams and the services providing care for persons with a mental disorder or dependent on alcohol and drugs44,27,4. That integration may also be favoured by matrix-oriented action, from both psychosocial care centres and multi-professional primary health care support teams (e-Multi)48. Wright et al.41 argued that the lack of coordination between services in the healthcare system posed obstacles to effective primary health care. In agreement, Mishu et al.30 found that the lack of integration between mental health services and primary health care could hinder patient access to effective, quality treatment.
Another finding of this study was that the dentists considered dental care for persons with a mental disorder to be more complex, because of possibly unpredictable behaviour. This meaning finds support in moral ideas intrinsic to society, which abnormalise the conditions experienced by these patients and can be used to exert domination in the patient-dentist relationship, with a view to maintaining power structures58. The meaning expressed in the category “A normal patient” refers to situations where dentists consider that care for patients with a mental disorder is carried out within norms (E1: “We ask him to come back in a better state to be treated; then that treatment is performed as with a normal patient”). However, one must be alert to this notion of normality because it can be used as an authoritarian tool to discriminate against groups who do not fit a given norm and, thus, to perpetuate means of oppression and inequality59, a situation in which the dentist would restrict his work to patients considered normal. These statements reinforce the idea that, for lack of an understanding of different concepts of normality, pathologies are objectivised, care generalised and individual protagonism undermined40. When health is understood from a more empathetic and comprehensive perspective, dentists will find it possible for care for this population to be inclusive and comprehensive.
Another meaning attributed by the dentists was that patients with mental disorder are necessarily people with mental disabilities, which highlights once again the lack of training and interaction with other professions (in the same health team, multi-professional teams or even the staffs of psycho-social care centres). This leads to an inability to understand and differentiate, reinforcing stereotypes and prejudices with regard to patients with mental disorder. Therefore, effective capacity building and training that addresses the complex relationship between mental disorder and oral health should involve the psychological, behavioural, social and biological factors bearing on care for these patients. These mechanisms are fundamental to understanding the diversity of individual norms and undertaking specific, complex interventions22 to meet the needs of what is acknowledged to be a priority group. Canguilhem40 stressed the importance of recognising differences among diverse forms of pathology, so as to avoid mistakes in specifying treatment and discrimination in the approach to patients. Note, in the case of mental disorders, that “patients with mental disorders” has been updated semantically to “patients with mental disorder”, although there are various manifestations of mental disorder. On that understanding, the emphasis is directed to the individual and their situation, without prioritising the number of disorders they may present with60.
It has to be understood that the speciality Dental Care for Patients with Special Needs is directed to patients with limitations that prevent conventional dental treatment. This speciality includes patients with severe intellectual and/or behavioural disabilities and/or impairments, patients with decompensated chronic conditions, cancer patients treated with head and neck radiotherapy, women with high-risk pregnancies and other conditions that call for differentiated dental management, equipment, materials and basic and/or advanced life support61 and which may, in complex situations, include patients with mental disorder. The scope of this specialised practice is very broad, but it should not be confused with treatment for “special persons” or “exceptional persons”, which are terms once used for people with disability and today in disuse62.
The discussion of the family’s responsibility in care for patients with mental disorder calls for an inclusive view of the commitment to long-term care that results from partnering between the individual and their family members63. However, Giacomini et al.64 and Ramos65 found that families’ ideas of care for persons with mental disorder, besides being based on concepts grounded in ideologies of charity and solidarity, regarded care as an obligation. This generated feelings of satisfaction in the family members at fulfilling their social obligations by caring for the patient, demonstrating the link between this notion of care and psychiatric hospitalisation. This stigmatising view can influence the behaviour of the person with mental disorder. That said, dentists need to be aware that their attitudes influence how these patients will act in care situations66,67.
This study found that the main limitation on theorisation and discussion of the results was the fact that the great majority of the articles cited are studies that address medical and nursing care in connection with psychosocial care centres, where dentists do not form part of the staff. This study is thus an invitation to discuss dental care, especially methods of comprehensive care, for this population.
Conclusion
This study sought to understand the meanings that dentists attribute to dental care for patients with mental disorder. It found that, on the view that these are complex patients to treat, sometimes being considered abnormal or even confused with patients with intellectual disability, dentists ended up providing care for these patients only in acute dental health scenarios. In a self-critical move, the dental practitioners in this study recognised that this is not the care that should be offered and attributed this attitude to a lack of training.
Discussion of the results found that training for dentists should focus on psychological, behavioural and social aspects, in addition to fostering more empathetic, unprejudiced care. Another point to be clarified was differentiation from patients with intellectual disability. In order for care actually to change, greater integration is necessary between services in the healthcare system and oral health teams.
References
1. Sade RMS, Sashidharan SP, Silva MNRMO. Paths and detours in the trajectory of the Brazilian psychiatric reform. Salud Colectiva 2021;17:e3563
2. Picon FA, Castaldelli-Maia JM. The current status of psychiatric education in Brazil. Int Rev Psychiatry 2019; 32(2):128-132.
3. Heleno JVG, Gomes AM. A inconstitucionalidade da reimplementação dos manicômios no Brasil. RICFDF 2021; 6(1):49-67. ***
4. Oliveira DI, Alencar FC, Reis LC, Viana MFB, Oliveira ARC. Reforma psiquiátrica brasileira e suas influências europeias e norte americanas. Rev AMAzônica 2020; 25(2):333-354.
5. Júnior JMAS, Kuczynski K, Vicenzi C, Lorini A, Jansen K, Rakovski C. Correlation between the implementation of Psychosocial Care Centers and the rates of psychiatric hospitalizations and suicide in Porto Alegre-RS from 2008 to 2018. Trends Psychiatry Psychother 2023; 45:e20210220.
6. Carteri RB, Oses JP, Cardoso TA, Moreira FP, Jansen K, Silva RA. A closer look at the epidemiology of schizophrenia and common mental disorders in Brazil. Dement Neuropsychol 2020; 14(3):283-289.
7. Clark DB. Mental health issues and special care patients. Dent Clin North Am 2016; 60(3):551-566.
8. Castaldelli-Maia JM, Loreto AR, Guimarães-Pereira BBS, Carvalho CFC, Gil F, Frallonardo FP, Ismael F, Andrade AG, Ventriglio A, Richter KP, Bhugra D. Smoking cessation treatment outcomes among people with and without mental and substance use disorders: An observational real-world study. Eur Psychiatry 2018; 52:22-28.
9. American Psychiatric Association (APA). Manual Diagnóstico e Estatístico de Transtornos Mentais DSM-5. 5ª ed. Porto Alegre: Artmed; 2014.
10. Stein DJ, Palk AC, Kendler KS. What is a mental disorder? An exemplar-focused approach. Psychol Med 2021; 51(6):894-901.
11. Linden M. Definition and Assessment of Disability in Mental Disorders under the Perspective of the International Classification of Functioning Disability and Health (ICF). Behav Sci Law 2017; 35(2):124-134.
12. Simões J. Sobre deslizamentos semânticos e as contribuições das teorias de gênero para uma nova abordagem do conceito de deficiência intelectual. Saude Soc 2019; 28(3):185-197.
13. Schalock RL, Luckasson R, Tassé MJ. An Overview of Intellectual Disability: Definition, Diagnosis, Classification, and Systems of Supports (12th ed.). Am J Intellect Dev Disabil 2021; 126(6):439-442.
14. Skallevold HE, Rokaya N, Wongsirichat N, Rokaya D. Importance of oral health in mental health disorders: An updated review. J Oral Biol Craniofac Res 2023; 13(5):544-552.
15. Abdellatif HM. Poor mental health days is associated with higher odds of poor oral health outcomes in the BRFSS 2020. BMC Oral Health 2022; 22:500.
16. Magdaleno MO, Ramirez GR. Effects of drug abuse and mental disorders on oral health: A case report. J Pak Med Assoc 2021; 71(12):2820-2822.
17. Lopes AG, Ju X, Jamieson L, Mialhe FL. Oral health-related quality of life among Brazilian adults with mental disorders. Eur J Oral Sci 2021; 29(3):12774.
18. Jacob L, López-Sanchéz GF, Carvalho AF, Shin JI, Oh H, Yang L, Veronese N, Soysal P, Grabovac I, Koyanagi A, Smith L. Associations between mental and oral health in Spain: a cross-sectional study of more than 23,000 people aged 15 years and over. J Affect Disord 2020; 274(2020):67-72.
19. Choi J, Price J, Ryder S, Sisking D, Solmi M, Kisely S. Prevalence of dental disorders among people with mental illness: An umbrella review. Aust N Z J Psychiatry 2022; 56(8):949-963.
20. Comparelli A, Stampatore L, Costacurta M, Pompili M. Schizophrenia and Dental Health: A Systematic Review. J Nerv Ment Dis 2021; 209(9):684-690.
21. Oflezer OG, Bahadir, H, Gökkaya B, Altinbas K. Evaluation of Bruxism and Its Relation with Treatment Regimens among Remitted Bipolar Patients. Psychiatr Danub 2020; 32(2):205-209.
22. Ngo DYJ, Thomson WM, Subramaniam M, Abdin E, Ang KY. The oral health of long-term psychiatric inpatients in Singapore. Psychiatry Res 2018; 266:206-211.
23. Joury E, Kisely S, Watt RG, Ahmed N, Morris AJ, Fortune F, Bhui K. Mental Disorders and Oral Diseases: Future Research Directions. J Dent Res 2022; 102(1):5-12.
24. Turner E, Berry K, Aggarwal VR, Quinlivan L, Villanueva T, Palmier-Claus J. Oral health self-care behaviours in serious mental illness: A systematic review and meta-analysis. Acta Psychiatr Scand 2021; 145(1):29-41.
25. Kuipers S, Boonstra N, Kronenberg L, Keuning-Plantinga A, Castelein S. Oral Health Interventions in Patients with a Mental Health Disorder: A Scoping Review with Critical Appraisal of the Literature. Int J Environ Res Public Health 2021; 18(15):1-28.
26. Cheah ALS, Pandey R, Daglish M, Ford PJ, Patterson S. A qualitative study of patients\' knowledge and views of about oral health and acceptability of related intervention in an Australian inpatient alcohol and drug treatment facility. Health Soc Care Community 2017; 25(3):1209-1217.
27. Mishu MP, Faisal MR, Macnamara A, Sabbah W, Peckham E, Newbronner L, Gilbody S, Gega L. A Qualitative Study Exploring the Barriers and Facilitators for Maintaining Oral Health and Using Dental Service in People with Severe Mental Illness: Perspectives from Service Users and Service Providers. Int J Environ Res Public Health 2022; 19(7):4344.
28. Braun PCB, Vieira RA, Cristiano DP, Sonego FGF. Impacto da saúde bucal na qualidade de vida dos pacientes usuários do centro de atenção psicossocial II do Município de Criciúma/SC. Rev Odontol Univ Cid São Paulo 2018; 30(2):132-143.
29. Mishu MP, Faisal MR, Macnamara A, Sabbah W, Peckham E, Newbronner L, Gilbody S, Gega L. Exploring the contextual factors, behaviour change techniques, barriers and facilitators of interventions to improve oral health in people with severe mental illness: A qualitative study. Front Psychiatry 2022; 13:971328.
30. Kuo MW, Yeh SH, Chang HM, Teng PR. Effectiveness of oral health promotion program for persons with severe mental illness: a cluster randomized controlled study. BMC Oral Health 2020; 20(1): 290.
31. Johnson AM, Kenny A, Ramjan L, Raeburn T, George A. Oral health knowledge, attitudes, and practices of people living with mental illness: a mixed-methods systematic review. BMC Public Health 2024; 24(2263): 1-25.
32. Ruiz VR, Lima AR, Machado AL. Educação em saúde para portadores de doença mental: relato de experiência. Rev Esc Enferm USP 2004; 38(2):190-196.
33. Nóbrega MPSS, Silva GBF, Sena ACR. Funcionamento da Rede de Atenção Psicossocial-RAPS no município de São Paulo, Brasil: perspectivas para o cuidado em Saúde Mental. 5º Congresso Ibero-Americano em Investigação Qualitativa (CIAIQ2016) 2016; 2:41-49.
34. Jorge MSB, Pinto DM, Quinderé PHD, Pinto AGA, Sousa FSP, Calvacante CM. Promoção da Saúde Mental – Tecnologias do Cuidado: vínculo, acolhimento, co-responsabilização e autonomia. Cien Saude Colet 2011; 16(7):3051-3060.
35. McGregor B, Belton A, Henry TL, Wrenn G, Holden KB. Improving behavioral health equity through cultural competence training of health care providers. Ethn Dis 2019; 29(2):359-364.
36. Fernandes AB, Monteiro AP. Contributo para o estudo de competência cultural em saúde mental de enfermeiros em Portugal. RPESM 2015; 14(14):39-47.
37. Rice AN, Harris SC. Issues of cultural competence in mental health care. J Am Pharm Assoc(2003) 2021; 61(1):e65-e68.
38. Santos JLG, Cunha KS, Adamy EK, Backes MTS, Leite JL, Sousa FGM. Análise de dados: comparação entre as diferentes perspectivas metodológicas da Teoria Fundamentada nos Dados. Rev Esc Enferm USP [periódico na internet]. 2018; 52:e03303.
39. Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27(2): 389-394.
40. Canguilhem G. O normal e o patológico. 6ª ed. Rio de Janeiro: Forense Universitária; 2009.
41. Wright WG, Averett PE, Benjamin J, Nowlin JP, Lee JGL, Anand V. Barriers to and Facilitators of Oral Health Among Persons Living With Mental Illness: A Qualitative Study. Psychiatr Serv 2021; 72(2):156-162.
42. Rotoli A, Silva MRS, Santos AM, Oliveira AMN, Gomes GC. Mental health in Primary Care: challenges for the resoluteness of actions. Esc Anna Nery 2019; 23(2):e20180303.
43. Carrara BS, Fernandes RHF, Bobbili SJ, Ventura CAA. Health care providers and people with mental illness: An integrative review on anti-stigma interventions. Int J Soc Psychiatry 2021; 67(7):840-853.
44. Poudel P, Kong A, Hocking S, Whitton G, Srinivas R, Borgnakke WS, George A. Oral health‐care needs among clients receiving alcohol and other drugs treatment—A scoping review. Drug Alcohol Rev 2023; 42(2):346-366.
45. Poornachitra P, Narayan V. Management of Dental Patients With Mental Health Problems in Special Care Dentistry: A Practical Algorithm. Cureus 2023; 15(2):e34809.
46. Reis WG, Scherer MDDA, Carcereri DL. O trabalho do Cirurgião-Dentista na Atenção Primária à Saúde: entre o prescrito e o real. Saúde Debate 2015; 39(104):56-64.
47. Alves HFC, Collares PMC, Alves RDS, Brasil CCP, Carnaúba JP. Interprofissionalismo na Estratégia Saúde da Família: um olhar sobre as ações de promoção de saúde bucal. Saúde Soc 2021; 30(3):e200648.
48. Santos LCD, Domingos TDS, Braga EM, Spiri WC. Saúde mental na atenção básica: experiência de matriciamento na área rural. Rev Bras Enferm 2020; 73(1):e20180236.
49. Filho AAGG, Amaral RCD. O papel do cirurgião dentista na equipe multiprofissional da Atenção Básica em Saúde, após 19 anos de sua implantação. Arch Health Invest 2021;10(8):1287-1291.
50. Soares CLM, Paim JS, Chaves SCDL, Rossi TRA, Barros SG, Cruz DN. O movimento da saúde bucal coletiva no Brasil. Cien Saude Colet 2017; 22(6):1805-1816.
51. Chen C, Chen Y, Huang Q, Yang S, Zhu J. Self-Care Ability of Patients With Severe Mental Disorders: Based on Community Patients Investigation in Beijing, China. Front Public Health 2022; 10:847098.
52. Baghaie H, Kisely S, Forbes M, Sawyer E, Siskind DJ. A systematic review and meta‐analysis of the association between poor oral health and substance abuse. Addiction 2017; 112(5):765-779.
53. Rossow I. Illicit drug use and oral health. Addiction 2021; 116(11):3235-3242.
54. Turner E, Berry K, Quinlivan L, Shiers D, Aggarwal V, Palmier-Claus J. Understanding the relationship between oral health and psychosis: qualitative analysis. BJPsych Open 2023; 9(3):e59.
55. Ulisses VSM, Melo DTA, Matos KF, Pereira RO, Costa KF, Fontes NM, Paulino MR. Saúde bucal em pacientes com transtorno mental: uma revisão da literatura. Braz J Surg Clin Res 2020; 32(3):59-66.
56. Rabello RELD, Monteiro AX, Lemos SM, Teixeira E, Honorato EJS. Desafios do acesso à saúde bucal: uma revisão integrativa da literatura. Rev. APS. 2021; 24(1):219-235.
57. Singhal V, Heuer AJ, York J, Gill KJ. The Effects of Oral Health Instruction, and the Use of a Battery-Operated Toothbrush on Oral Health of Persons with Serious Mental Illness: A Quasi-Experimental Study. Community Ment Health J 2020; 57(2):357-364.
58. Caminha ECCR, Jorge MSB, Carvalho RRS, Costa LSP, Lemos AM, Costa JP. Relações de poder entre profissionais e usuários da Atenção Primária à Saúde: implicações para o cuidado em saúde mental. Saude Debate 2021; 45(128):81-90.
59. Rost M, Favaretto M, De Clercq E. Normality in medicine: an empirical elucidation. Philos Ethics Humanit Med 2022; 17:15.
60. Sassaki RK. Atualizações semânticas na inclusão de pessoas. Rev Reação 2005; 9(43):9-10.
61. Ministério da Saúde. A saúde bucal no Sistema Único de Saúde. Brasília: Ministério da Saúde/Secretaria de Atenção à Saúde - Departamento de Atenção Básica; 2018.
62. Junior EF, Silva LRD, Solidão YDFB. O atendimento odontológico aos pacientes com necessidades especiais e a percepção dos cirurgiões dentistas e responsáveis/cuidadores. Revista Saber Digital 2020; 13(1):218-231.
63. Kellermann CZ. Cárie dentária entre pacientes com transtornos mentais graves com e sem histórico de internação psiquiátrica [dissertação]. Porto Alegre (RS): Programa de Pós-Graduação em Odontologia da Universidade Federal do Rio Grande do Sul; 2020.
64. Giacomini K, Alexandre LA, Rotoli A, Pinheiro JM. Desafios da família no cuidado da pessoa com transtorno mental: uma revisão integrativa. Res Soc Dev 2022; 11(6):e13311628816.
65. Ramos AC, Calais SL, Zotesso MC. Convivência do familiar cuidador junto a pessoa com transtorno mental. Contextos Clín 2019; 12(1):282-302.
66. Sølvhøj IN, Kusier AO, Pedersen PV, Nielsen MBD. Somatic health care professionals’ stigmatization of patients with mental disorder: a scoping review. BMC Psychiatry 2021; 21:443.
67. Moll MF, Silva LD, Magalhães FHL, Ventura CAA. Profissionais de enfermagem e a internação psiquiátrica em hospital geral: percepções e capacitação profissional. Cogit Enferm 2017; 22(2):e49933.
