The physical health needs of people with serious mental illness have been neglected for a long time (1), this has initiated the development of guidelines and recommendations from the British Society for Disability and Oral Health (BSDH) for the oral health care for people with serious mental illness (2). Guidelines recommend monitoring and advice and although they are well meaning, randomised controlled trial evidence to support the recommendations is missing (3, 4). Cochrane systematic reviews found no randomised controlled trials of oral health advice or monitoring for people with serious mental illness (5). A Cochrane systematic review of general physical health advice interventions for people with serious mental illness (6) found evidence to suggest such interventions could lead to people accessing more health services. For oral health there is some survey evidence to suggest regular dental check-ups have been found to be associated with better oral health (7), so if a monitoring and advice intervention can influence someone with serious mental illness to visit a dentist this may in turn improve their oral health. A systematic review of 55 studies examining the prevalence of poor oral health and hygiene practices, dental treatment needs, and dental attendance of people with serious mental illness, was conducted to assess the extent to which people with serious mental illness brush their teeth and attend dental appointments. The majority of participants did not practice good oral hygiene, and were more likely not to have seen a dentist for a longer period of time than the general population. Those with serious mental illness also had more decayed teeth, more missing teeth, but fewer filled teeth, than the general population. Most of those with mental illness required some form of dental treatment ranging from oral hygiene instruction to complex dental treatment for those with shallow pockets or deep pockets in their teeth. A narrative review of the knowledge and attitudes regarding oral health in populations with serious mental illness from service users, and mental health and dental professionals’ perspectives found that individuals with serious mental illness were more likely to have poor oral health due to neglecting their oral hygiene and because they did not attend regular dental appointments. Previous negative experiences at dental appointments or general dental anxiety prevented individuals with a mental illness from seeking help until they experienced a dental emergency. The majority of service users reported that support from mental health nurses was helpful, even though nurses tended to report feeling unconfident and inadequately trained to provide this care. A systematic review of randomised controlled trials of interventions for improving the oral health of people with serious mental illness identified four studies which all had such varied interventions and measured different outcomes that combining them in a meta-analysis was not possible. Providing toothbrushes appeared to improve the oral health of people with serious mental illness. Some of the interventions involved an education element which also significantly improved oral health. A pragmatic cluster randomised controlled trial of an oral health intervention for people with serious mental illness involved 1074 service users from the Early Intervention in Psychosis teams in the East Midlands of England being randomised either to receive a dental intervention or standard care. The dental intervention involved completing a checklist with their Care Co-ordinator concerning their oral health and oral hygiene behaviour and the standard care simply involved continuing with standard care for 12 months before then completing the checklist. At baseline only 271/550 service users randomised to the dental intervention group completed dental checklists. Only 98/271 (36.1%) of service users returned a completed dental checklist at the 12 month follow up and for those allocated to standard care 91/524 (17%) returned a completed dental checklist at the 12 month follow up. The checklist did not improve oral health behaviour in people with serious mental illness. The oral health of people with serious mental illness remains a vastly under researched area. Mental health professionals should receive training to improve their oral health care knowledge. Mental health professionals should also provide advice to their patients regarding their oral health, monitor oral health as part of standard care and support patients to attend regular dental check-ups. An effective intervention that can be used within standard care could significantly improve the quality of life for people with serious mental illness.

Clinical reasoning is a skill required by all health professionals in managing patients. Research in clinical reasoning has come mostly from medicine and nursing, less from dentistry. The effect of curriculum on the development of clinical reasoning is still not well understood. Moreover, no research has been conducted to understand what clinical reasoning means to students and what educational strategies are valued by them. The aim of this research is to explore the effect of different educational strategies in different dental schools on clinical reasoning and to discover how students perceive clinical reasoning. Final year students from four different dental schools participated in the current research; a school using an integrated curriculum with conventional teaching, a school using Problem Based Learning (both from the UK) and two Saudi Arabian dental schools; a school using a traditional curriculum and a school using an integrated curriculum. Both UK schools participated in both studies, whereas each one of the Saudi Arabian schools participated in a different study. The research used both quantitative and qualitative methodology. An innovative clinical reasoning test measured final year students’ skills. An interview captured their own understanding of clinical reasoning and its acquisition plus they ‘talked through’ a clinical problem, using a ‘think aloud’ technique. Thematic analysis was used to analyse the transcripts of the recorded interviews. Results obtained were related to curriculum structure. The results indicated that the effect of curriculum structure, unlike teaching and assessment strategies, appeared to be minimal in final year students. Unfamiliarity with the term clinical reasoning was common in students. Students from different schools used different strategies to reason when discussing clinical vignettes. Different behaviours seemed to be affected by cultural factors. This research contributes to a greater understanding of how students learn, understand and apply dental clinical reasoning which hopefully will improve educational practices in the future.