The Open Dentistry Journal Exploring Dental Students’ Perceptions of Mental Illness to Address Unmet Needs: A Preliminary Study

: Background: There is little information about dental students’ perceptions about providing care to people with serious mental illnesses (SMI), despite the significant oral health challenges of this population. Objective: This brief report aims to explore gaps in dental students’ knowledge and skills for providing oral health care to people with SMI, along with their attitudes about working with this underserved population. Methods: Post-graduate dental students in the United States at a large northeastern university were asked to provide feedback and responses to 5 open-ended questions prior to an educational module about working with people with SMI, and 22 anonymous responses were received. Qualitative content analysis was used to code responses using independent coding and consensus meetings. Results: Dental students expressed concerns about working with this population and felt unprepared to provide services to them. Seven themes were identified and coded into three primary categories: Knowledge, Skills and Attitudes. Codes representing dental student knowledge gaps included mental health literacy and professional role clarification. Skill deficits were coded as an adaptation of dental care practices, communication skills, crisis management, and management of care. Attitudes were coded as beliefs about people with SMI. Conclusion: Additional attention to mental illness in dental education could assist future professionals in their skills and knowledge to address the extensive unmet oral health needs of people with SMI.


INTRODUCTION
In the United States, approximately 13 percent of the population has a disability [1]. A significant portion of this population also has special healthcare needs (SHCN) based on chronic disabilities or chronic illness. However, many healthcare providers do not receive training in treating patients with special needs [2]. Dental professionals lack the skills to treat patients with special needs due to insufficient training at the predoctoral educational level [3,4]. The population with Serious Mental Illnesses (SMI) is a neglected special needs population in clinical services and research for both general health and oral health. This population has a life span 20% shorter than that of the general population and experiences physical conditions indicative of premature physical aging, including loss of teeth and poor physical functioning [3].
Oral health is an important indicator of general health. The connection between oral health and systemic health is well documented. Research demonstrates that periodontal disease (PDD) is associated with a higher risk of coronary artery disease (CAD), though it is unclear whether the link is causal or if it is due to a common fundamental factor such as an inflammatory process [5]. Similarly, there is likely a link between diabetes and oral health [6]. Despite the connection between oral health and systemic health, the population with SMI experiences a significantly higher rate of general and oral health problems as compared to the general population [7]. Increased consumption of alcohol, illegal substances, tobacco products and sugary carbonated beverages is believed to be a contributing factor to poor general and oral health in this population [8]. One important barrier may be the low relative importance given to oral health of the population with SMI [9]. Other factors further contribute to unmet oral health needs, including lack of finances and access to care; effects of psychotropic medications such as xerostomia and tardive dyskinesias; increased anxiety regarding care; decreased cognitive skills and lack of motivation for self-care; and fear of stigma and discrimination [9 -11].
Healthcare professionals treating people with SMI without any formal education or training in this area contribute to negative attitudes about providing health care services [11]. Negative attitudes towards people with SMI and lack of knowledge and skills in this area lead to a diminished ability by the health professional to provide appropriate care to this population. This is further exacerbated by gaps in professional education, including continuing education post-graduation [12]. Additionally, communication between the healthcare provider and the patient is important for quality care [13]. Disabilities, including SMI, have a negative impact on communication between the provider and patient [13].
In 2004, the U.S. Commission on Dental Accreditation (CODA) updated standards to expand predoctoral education regarding care provided to special needs populations. This population includes those with "developmental disabilities, cognitive impairment, complex medical problems, significant physical limitations and the vulnerable elderly" [14]. Despite the significant need for oral health care and the lack of access, there is little literature regarding dental professional perspectives or dental curriculum teaching about people with SMI [3]. One Australian study examined pre-doctoral dental students' knowledge, attitudes and social distancing perceptions about people with SMI. The researchers provided a 90-minute inter-professional educational activity and measured attitudes before and after through focus groups and surveys [3]. Results suggested that the students had limited perceptions about people with SMI, but had limited understanding of the intersection of dentistry and mental health prior to the learning activity. Lack of familiarity with patients diagnosed with SMI results in stereotyping of this population and hesitation in the provision of care [15]. Empathy towards persons with disabilities results in better patient outcomes, including satisfaction with the treatment provided [13]. One study conducted in Austria found that the attitudes of 4 th -year dental students towards patients with special healthcare needs to be improved after a series of seminars [15]. Similarly, a study conducted in three Asian countries found that the confidence of nurses was linked with the level of involvement of care of patients with SMI [16]. Studies regarding attitudes of dental students and dental hygiene students conducted in the United States are minimal.
The first step to improve dental education, identify standardized competencies needed for working with people with SMI, and ultimately improve the quality of oral health care is to explore specific knowledge and skill gaps experienced by dental students related to treating people with SMI. Research demonstrates that healthcare professionals gain confidence in treating patients with disabilities, including SMI, through educational experiences [13]. Other studies have demonstrated the need for educational programs related to patients with special healthcare needs. Our study explored 3rd year dental students' perspectives about working with people with SMI, and identified recommendations for enhancement of the existing dental curriculum.

Participants
Information was collected from students enrolled in a community dentistry course at a large northeastern university prior to a planned lecture on SMI to tailor the information to be provided. Students in the class were asked to provide feedback via an online platform prior to the synchronous web-based class. No identity-related information was collected. Response to the survey was voluntary, and 22 students out of 125 opted to complete it. As the primary purpose of the project was improvement and evaluation of course quality, the project was determined to be IRB exempt.

Survey
A survey based on 5 questions was designed based upon previous author's study on health professions education about individuals with SMI [17]. The questions were: (1) What have you previously heard about SMI?
(2) What questions do you have about SMI?
(3) What questions do you have about providing care to people with SMI?
(4) What information is important for dental students to learn about SMI?
(5) What additional information would you like to have?

Methodology
Qualitative content analysis was used to identify recurring patterns and themes in the data (Table 1) [18,19]. Table 1. Qualitative content analysis process.
Step 1: Generate initial codes by segmenting data and tagging it with a conceptual label [18] Step 2: Comparisons were made among the initial codes to cluster them for the identification of patterns and a smaller number of categories Step 3: Connections among the categories were identified as themes.
Strategies to ensure the reliability and trustworthiness of the data were used [19]. Researchers conducted team coding and discussed disagreements. The researchers also performed debriefings with content experts. Due to overlapping responses across questions, the questions were analyzed collectively to identify overarching themes.

RESULTS
The data collected were synthesized with respect to the five questions asked from the dental students. Seven themes emerged, with these themes falling into the three primary categories of knowledge, skills, and attitudes ( Table 2). Students identified specific knowledge areas about which they wanted to know more. Many responses focused on improved mental health literacy and their desire to have a better understanding of mental illnesses, their prevalence and common symptoms, psychotropic medications, and common treatment modalities. They also wanted clarification regarding the scope of their professional role as it intersects with patients' mental health needs as well as their responsibilities as dental professionals to address mental health concerns and provide patients with proper mental health care services.
Students reported questions related to the adaptation and application of their skills. They were curious if and how they should modify their dental care practices when working with a patient with SMI. The use of communication skills, specifically, the potential need to change the way they speak to their patients, collect medical and mental health information, and motivate home care, was extended. Students also expressed concerns related to crisis and symptom management with a patient when in an office. They also queried approaches to care management, including concerns around informed consent, undiagnosed mental illness, and overall quality of care.
Through the questions and comments from the students, evidence was collected regarding their attitudes that reflected inaccurate perceptions of people with SMI, primarily that they are dangerous and do not care for their teeth or adhere to treatment plans.

DISCUSSION
Dental students expressed many questions and concerns that suggested they felt unprepared to provide care to people with SMI, a group with significant unmet oral health care needs. The unique oral health issues of this vulnerable population require specific knowledge, skills and attitudes for appropriate treatment. This evaluation identified gaps in knowledge about mental illness etiology, treatment, and patient management. There were also questions about the provision of dental care and oral health management among this population. Dental students expressed a commitment to provide care to people with SMI. However, their responses suggest they hold some negative stereotypes (e.g. fear) that can interfere with optimal care.
One interesting area that stood out was dental students' confusion about their role in providing care for people with SMI and specifically, their responsibilities regarding treating mental health symptoms or identifying mental illness and referring for additional care. Similar to the findings of Holzinger,Lettner and Franz [15], dental students may benefit from training to clarify their role in the treatment of people with SMI; specifically directing issues related to psychiatric symptoms to mental health providers and making referrals when the patient has no mental health provider.
There is limited previous work to compare these findings with. Similar to Patterson and Ford [3], the current study noted a general willingness to treat the population. Additionally, some of the concerns that were identified represented the stereotypes reported in previous assessments of dental students [20]. However, role of identity was an area that was uniquely identified as a knowledge gap in this study. This may represent the differences in health care systems between the United States and those shown in the previous reports (e.g. Australia and India). Interestingly, addressing the unique oral health needs of patients with SMI, such as management of xerostomia or treatment of patients experiencing medication induced movement disorders, was not high.
Results from this study should be interpreted cautiously as the sample size was modest and from a single course at a university, limiting its generalizability. However, it is encouraging that multiple students shared similar notions and gaps in understanding, suggesting that the themes may be relevant across other programs. Another limitation was the interpretation of the qualitative data, which is more subjective than quantitative data analysis, however, all efforts were made to follow best strategies to reduce bias, including separate coding of co-authors and consensus discussions. Additionally, qualitative research does not measure the intensity of beliefs, which leaves questions about the amount of coursework and experience needed to overcome negative beliefs. The limited response rate was due, in part, to time constraints in survey and course offering, which left no time for additional follow-up; however, future efforts to make the activities mandatory would increase participation. Finally, the survey was researcherdeveloped, but was based upon similar previous studies and health profession education literature.
Future research is recommended in this important area to learn more about oral health student attitudes about providing care to people with SMI. Other dental schools should consider asking students questions about people with SMI prior to coursework. Attitudinal surveys and reflective activities could be incorporated into existing assignments to learn more about the knowledge needed and strategies to increase comfort in working with people with SMI. Scheduling administration of such surveys should allow additional time to encourage survey response, and when in the semester students are most likely to participate should be identified. Lastly, future work should identify best practices to expose pre-doctoral students to people with SMI throughout their educational experience.

CONCLUSION
Dental students have gaps in their knowledge and skills for the provision of care to people with SMI, which likely further exacerbates access to quality oral health care. In order to address the unmet dental needs of this population and address their significant oral health difficulties, additional education is needed.

ETHICAL STATMENT
As the primary purpose of the project was improvement and evaluation of course quality, the project was determined to be IRB exempt.

CONSENT FOR PUBLICATION
Not applicable.

AVAILABILITY OF DATA AND MATERIALS
The data supporting findings of this study is available from the corresponding author [M.Z], upon reasonable request.

FUNDING
None.