In Reply: We thank Dr. Flammer and his colleagues for endorsing our findings and reporting the results of their study. We share with them the wish to investigate direct and indirect effects of mental disorders on oral (dental) health.
Dental health and disease are the result of lifestyle and behavior, which are known to be closely related to socioeconomic status. Mental disorders affect both lifestyle and behavior. Therefore, it would be very difficult, and perhaps impossible, to separate the effects of mental disorders from the effects of other variables, such as socioeconomic status, health habits, self-care, oral care, and diet. To control for confounding effects, carefully matched comparison groups are required.
Persons with mental disorders experience a change in their behavior as a whole, and thus it was difficult in our study of inpatients to distinguish changes caused by hospitalization from those caused by the disorders themselves. In addition, psychotropic drug treatment particularly affects patients' oral health. We do not know the relative contributions to oral health of these factors; however, we are aware of the sad fact that the oral health of persons with mental disorders is worse than the oral health of the general population. Therefore, we strongly agree with Dr. Flammer and his colleagues about the urgent need for further efforts to prevent and treat oral diseases—for persons in the general population, psychiatric patients in the community, and institutionalized patients. However, as our study showed, there are grounds for careful optimism: removal of barriers to dental care and delivery of dental services in hospital settings may substantially improve the oral health of inpatients. Training programs for mental health professionals that focus on dental health along with joint service planning by administrators and providers of mental health and dental health services may promote both oral health and access to dental care for persons with mental disorders.