Co-production of an oral health intervention: Enabling Service Users with Severe Mental Illness to Learn about and Engage (SMILE) with Good Oral Health

Oral health is far more than a matter of white teeth or a bright smile; it is a fundamental pillar of overall wellbeing. When teeth decay or gums become infected, the pain can be severe, making it difficult to eat, speak, or sleep, and these physical struggles often erode a person's confidence and ability to connect with others. For people living with severe mental illness, such as schizophrenia or bipolar disorder, the stakes are even higher. These individuals face a perfect storm of challenges: the symptoms of their condition can drain the motivation needed for daily hygiene, medications can cause dry mouths that accelerate tooth decay, and the stigma surrounding mental health often creates a barrier to seeking dental care. As a result, this group loses teeth at nearly three times the rate of the general population, yet they rarely receive the specific support needed to prevent these outcomes.

The gap between the need for care and the availability of support has long been a problem for health systems. While experts know that integrating dental advice into mental health care could help, previous attempts to create such programs have often failed to gain traction or lacked evidence of success. A major reason for this is that many past interventions were designed by researchers or doctors without asking the people who would actually use them or the staff who would deliver them. This disconnect meant that the solutions were often too complex, too clinical, or simply impractical for the real-world settings where mental health care happens. To bridge this gap, a team of researchers in the United Kingdom set out to build a new approach from the ground up, not by dictating a solution, but by working side-by-side with the very people who would shape it.

This paper details the creation of a new program called SMILE, which stands for "Severe Mental Illness to Learn about and Engage with Good Oral Health." The project was not a traditional study testing a pre-made idea; instead, it was a process of co-production, a method where researchers, mental health professionals, dental experts, and people with lived experience of severe mental illness worked together as equal partners to design the intervention. The team held a series of workshops, some online and some in person, where they discussed everything from how to start a conversation about teeth without causing embarrassment to what kind of advice would actually be helpful. They brought together twenty-two participants, including service users, carers, and healthcare staff, to ensure that every part of the program reflected the reality of their lives and the constraints of the healthcare system.

The journey began with a rough draft of an intervention that included five main steps: starting a conversation about oral health, giving tailored advice, offering encouragement, adding oral health to the patient's care plan, and helping them visit a dentist. However, as the workshops progressed, the group realized that some of these steps were too ambitious for the time and resources available to mental health staff. For instance, the idea of mental health professionals actively finding dentists for patients or performing toothbrushing demonstrations was ruled out. The staff felt these tasks were outside their expertise and would take too much time away from their primary duties. Similarly, the group decided that asking patients to fill out complex clinical measurements about their brushing habits would be intimidating and likely to produce inaccurate results.

Through this iterative process of discussion and refinement, the five original steps were streamlined into four practical components that felt manageable and respectful. The first step is simply initiating a conversation. Instead of a formal medical check, the mental health professional is guided to weave the topic into routine discussions about general physical health, using a simple leaflet to help start the dialogue without making the patient feel self-conscious. The second component involves providing "top advice" on keeping teeth and mouths healthy. This advice covers four key areas: brushing techniques, managing dry mouth caused by medication, reducing sugar intake, and cutting down on tobacco and alcohol. Crucially, the advice is flexible; it meets the patient where they are, offering simple, realistic swaps rather than strict rules, and it uses a graphic leaflet with a link to a video demonstration instead of asking staff to perform the demonstration themselves.

The third component is a gentle nudge to keep the habit going. For the first four weeks after the initial conversation, the patient can opt to receive a weekly text message reminder to brush their teeth. This simple digital touchpoint serves as a consistent, non-judgmental prompt. The final component ensures that the care team stays informed. The mental health professional records that the conversation took place and notes any specific concerns or barriers the patient mentioned in their electronic care record. If the patient has urgent dental issues, a letter is sent to their care coordinator to ensure follow-up, but the heavy lifting of arranging appointments remains with the patient or their existing support network, respecting the limits of the staff's capacity.

The result of this collaborative effort is a set of tools ready for testing: a clear flowchart that guides the staff through the process, a training manual that explains how to deliver the care with empathy and confidence, and the patient-facing leaflet that serves as the centerpiece of the conversation. The researchers found that by listening to the people who would use the system, they could strip away the unnecessary complexity and focus on what was truly achievable. The final design acknowledges that mental health professionals are not dentists, but they can be powerful allies in promoting oral health if given the right, simple tools. The paper concludes by noting that this co-produced intervention is now ready for a feasibility study to see if it works in practice within the National Health Service. The work does not claim to have solved the problem of poor oral health for people with severe mental illness, but it has successfully built a bridge between the need for care and the reality of the healthcare system, creating a path forward that is grounded in the voices of those it is meant to serve.