Community Mental Health Teams Get a New Route Into Oral Health Care
People living with severe mental illness face a disproportionate burden of poor oral health, yet they are less likely to brush their teeth regularly or attend dental care. The gap is not cosmetic. Untreated dental disease can worsen pain, nutrition, sleep, self-esteem, and daily functioning, all while competing with the psychiatric symptoms and social barriers that already make routine self-care difficult. This preprint describes how investigators in England co-produced an oral health intervention designed to be delivered inside community mental health services rather than waiting for patients to navigate a separate dental pathway.
The intervention is called SMILE, short for Service Users with Severe Mental Illness to Learn about and Engage with Good Oral Health. Its design matters because the clinical logic is straightforward: if oral health advice is embedded in the setting where people with SMI already receive care, the intervention may reach patients who would otherwise never receive preventive support. Oral health promotion delivered by mental health professionals also addresses a practical workforce reality. Psychiatric teams already know the patient, the care record, and the barriers that surround engagement.
A single sentence captures the central problem: people with SMI are falling through the cracks between psychiatry and dentistry.
Co-Production Shaped the Intervention Around Real-World Use
The development process followed Hawkins’ co-production framework and focused on stages 2 and 3, which covered co-production and prototyping. Four workshops were held in total: two online and two face to face. The combined workshop group included 22 participants, made up of 6 service users with SMI, 8 mental health professionals, and 8 dental health professionals. Two online patient and public involvement consultations and a professional stakeholder meeting added feedback during the process.
That mixed-group structure is clinically important because an intervention for oral health in SMI cannot be built from dental expertise alone. Service users bring the realities of distress, medication side effects, fatigue, and competing priorities. Mental health professionals understand what can actually be delivered in routine appointments. Dental professionals can keep the content accurate and safe. The result is less like a generic health leaflet and more like a workflow that can survive contact with busy community care.
The workshops informed the intervention’s core components, format, and content. Rather than building a narrow pamphlet or a one-off reminder, the group created a bundle of linked actions intended to fit into existing care. That approach reflects the broader pathophysiology of the problem: oral disease in SMI is rarely driven by a single behavior, but by a convergence of reduced self-care, lower preventive attendance, treatment side effects, and system-level fragmentation.
Five Components Emerged From the Prototyping Stage
The co-production process produced five intervention components. These included initiating a conversation about oral health, giving advice to people with SMI on keeping their teeth and mouth healthy, weekly tooth brushing text reminders, and mental health professionals updating the care record to document delivery of the intervention. The manuscript’s abstract names four components explicitly in the results section, while also stating that five components emerged overall.
The package was supported by three co-produced implementation tools: an intervention flowchart, an intervention leaflet for people with SMI, and a training manual for mental health professionals who will deliver the intervention. Those materials are not cosmetic add-ons. In a service with variable time, turnover, and competing priorities, implementation aids determine whether an intervention is remembered next week or disappears after the pilot meeting ends.
Weekly text reminders are a particularly pragmatic element. Tooth brushing is a repeated behavior, and repeated behaviors often fail not because people reject them, but because symptoms, routines, and executive dysfunction interfere with consistency. A brief reminder can support habit formation, especially when it is paired with a conversation and practical advice rather than sent in isolation. Documentation in the care record adds another layer, allowing the oral health intervention to become visible inside routine mental healthcare rather than remaining an optional extra.
Why a Mental Health Setting May Be the Right Delivery Point
The rationale for integrating oral health support into community mental health care is rooted in access. People with SMI are less likely to visit the dentist, and the intervention aims to reduce the distance between need and action. Community teams may be better positioned than dental clinics to start the discussion because they already have ongoing contact with service users, including those who do not routinely seek other forms of healthcare.
There is also a biological and behavioral rationale for prevention at this stage. Oral inflammation and dental decay do not begin as emergencies. They accumulate gradually through plaque buildup, missed brushing, dietary patterns, medication-related dry mouth, and delayed care. By the time pain becomes severe, the intervention window is smaller and treatment is more invasive. A community-based preventive model attempts to intercept that trajectory earlier.
This is why the training manual matters. Mental health professionals need a concise framework for discussing oral health without drifting outside their remit or overwhelming the patient. A structured script, a flowchart, and a leaflet create a shared language across disciplines. In practice, that can make a brief oral health conversation feel feasible rather than aspirational.
Feasibility Comes Next, Not Proof of Effectiveness
The paper does not claim that SMILE improves oral health outcomes yet. It reports intervention development, not a trial of clinical benefit. The next stage is a single-arm feasibility study to determine whether the intervention is acceptable to people with SMI and feasible to deliver within the NHS.
That next step is essential because co-produced interventions often look strong on paper and then encounter barriers in routine care: time pressures, uncertain staff confidence, low patient engagement, or inconsistent documentation. Feasibility work will need to show whether the training can be delivered, whether staff use the materials, and whether service users find the intervention relevant rather than intrusive. It will also need to show whether the weekly text reminders and care-record documentation can be sustained inside real community workflows.
The preprint is also explicit about its ethical and administrative footing. West Midlands South Birmingham Ethics Committee approved the co-production workshop component, and the work was funded by the National Institute for Health and Care Research. The intervention leaflet is attached as an additional file, and summaries of the workshop discussions are available on reasonable request.
For now, the important advance is structural rather than outcome-based: oral health has been moved closer to the front door of mental health care. The feasibility study will determine whether that integration can hold.
The Remaining Test Is Service Delivery in Routine NHS Care
If SMILE can be delivered reliably, it could offer a scalable way to address a long-recognized gap in preventive care for people with SMI. If it cannot be embedded into routine practice, the intervention will remain a well-designed concept rather than a usable service model. The preprint leaves the field with a clear operational question: can community mental health teams sustain an oral health conversation, advice, reminders, and documentation without losing fidelity or burdening staff? The feasibility phase will have to answer that inside the NHS, where the distance between intention and implementation is often the hardest gap to close.