Coping Strategies for Oral Health Problems by People with Schizophrenia

Abstract Background Persons with schizophrenia are particularity susceptible to poor oral health. Symptoms of schizophrenia often affect oral health behaviors and lifestyle. The aim was to explore coping strategies used by people with schizophrenia in oral health in order to understand and to best involve them in the management of their own oral health in daily life. Materials and methods This is systematic review reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements. We included cross-sectional and longitudinal quantitative and qualitative studies that 1) examined coping strategies regarding oral health in persons with schizophrenia or 2) examined coping strategies were used in dental care. We included studies conducted with at least one PWS aged 18 years old more and without restriction on sex, socioeconomic status, or language. Results The 8 studies included suggest that coping strategies depends on complex translation processes that can be either personal (e.g., psychological symptomatology, neuropsychological functioning to adversely affect hope, self-esteem, self-stigma, self-determination, sense of coherence, and resilience) and/or environmental factors (e.g., peer support and efficacy of rehabilitations programs). We further identified that the main factor influencing coping strategies was dental stress situation. Conclusions This review suggests that coping strategies play a crucial role in the recovery process for oral health of PWS. Translation processes in oral health should be more explored in the future to clarify the capacity of PWS to cope with essential self-care in oral health on daily life.

of life are insufficient to explain why PWS rarely consulted a dentist, are more likely to delay seeking care, and are less likely to adhere or receive adequate treatment than general population. Investigating out what's coping strategies PWS used in daily life for taking as example a dentist appointment, brushing their teeth every day, or not, is an issue that warrants being addressed for better understanding why PWS don't use healthcare system and good practices in oral health. We thus hypothesized that coping strategies in the context of schizophrenia plays a crucial role in the recovery processes of oral health when the person must deal with impediments to fulfil their goals

Aim
To explore coping strategies used by PWS in oral health in order to more understand and to best involve them in the management of their own oral health in daily life.

Protocol and registration
Neither a review registration nor a review protocol was completed. This systematic review is reported in accordance with Cochrane Handbook [21] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements for reporting systematic reviews of health sciences [22].

Eligibility criteria
Based on the Participants-Intervention-Comparison-Outcome-Study (PICOS) method, we included cross-sectional and longitudinal quantitative and qualitative studies that1) examined coping strategies regarding oral health in PWS or 2) examined coping strategies were used in dental care. We included studies conducted with at least one PWS aged 18 years old more and without restriction on sex, socioeconomic status, or language. We excluded conference, abstracts, reviews and editorials.

Study selection
Two reviewers (FSP and FD) independently screened the list of titles and abstracts to identify the potentially relevant papers based on the inclusion criteria. If the abstracts were judged to contain insufficient information, then the full studies were reviewed to decide whether they should be included based on the selection criteria. When a discrepancy in the selection decision occurred, the two reviewers engaged in discussion until a consensus was reached. If needed, a third reviewer (NR) resolved the possible conflicts concerning eligibility.

Data extraction and data items
Two reviewers (FSP and FD) independently extracted data from the selected papers on the following items: Coping/adaptation, psychological, resilience, schizophrenia/ rehabilitation and oral health.

Study inclusion
An initial search identified 28 studies. After illustrates the search process [22] is presented in Figure 1.

Characteristics of included studies
Of the 8 studies, all were qualitative and were written in English. These studies were conducted in Brazil (n = 1), Sweden (n = 1), China (n = 1), Romania (n = 1), Australia (n = 2), Taiwan (n = 1), and Switzerland (n = 1). A detailed description of the included studies is presented in Table 1.

Synthesis of results
Due to the heterogeneity of the included studies, findings were evaluated in a descriptive manner. Differents thematic emerged: • Neuropsychological functioning, • Resilience, • Sense of coherence, • Sense and hope, • Sense of personal responsibility and selfdetermination, • Self-esteem, self confidence, stigmatisation, • Stress, • Social support/peer support effective coping skills or to use these mechanisms in a flexible, adaptive manner [25]. It is possible that problem solving skills, planning, abstract thinking, and the ability to access stored knowledge and strategies are the necessary cognitive prerequisites for engaging in activities that help people to redefine their lives and cope with the stressors associated with having a mental illness [26,27].
Kelly et al. 2015, showed that, coping style (specifically emotion-focused) was a more consistent predictor of perceived stress in the healthy control group than with persons with experience of a first-episode psychosis. This suggests that neuropsychological functioning (cognitive deficits in PWS) impact the flexibility with which individuals are able to select and apply a variety of coping strategies, as well as limit the use of active coping [28].

Resilience
According to Grotberg et al., the resilience concept may play a role as a potentiating agent in adaptation to a problem, like tooth loss for example. Resilient behavior is associated with better adaptive abilities (such as coping) when facing adversities and incorporates interactions between diverse factors [29].
Resilience is a dynamic concept indicating that some individuals have a relatively good outcomes despite having experienced serious stresses or personal problems with a high resilience level. They also have better results in daily life than that of other individuals who suffered the same experiences [30]. A study of older adults reported the relationship between adaptive strategies following adverse events (tooth loss) and a positive oral health selfperceived. This suggests that a person with high resilience can cope with a negative fonctional evenement in a acceptable manner [31].

Sense of hope
According to Snyder et al., hope is related to the life goals and expectations of a positive outcome of people's own effort [36,37]. This concept of hope includes emotion, motivation, behavior and cognition [38]. Hope is an anticipation of a future which is good and based upon mutuality (relationships with others), self-steem competence, coping strategies, psychological well-being, purpose and meaning in life, as well as a sense of ''the possible'' . The basic level of hope remains relatively stable over time, which makes it resemble a personality trait. In PWS, the relationships among hope, depression, and self-stigma, sense of personal responsibility and self-determination are interconnected [39,40,41]. This relationship is illustrated with two adaptive tasks, which are common across situations that threaten physical or psychological well-being, managing uncertainty and coping with a changing reality.
Coping fosters hope when it is at low ebb as well as ways in which hope fosters and sustains coping over the long term [42].

Sense of personal responsibility and self-determination
Neither PWS nor their families have been involved in decision-making on dental health services, and they continue to be at risk of social exclusion and discrimination in their oral health care [43].

Self-esteem, self confidence, stigmatisation
Self-esteem is an individual (emotional) evaluation of people's own worth, so encompasses an implicit judgment of people's ability to face life's challenges (problem solving) that affects how you perceive stressors and deal with them (coping process). The adaptative coping strategies, were positively related to stigma resistance, self-stigma, self-esteem, self-reflection, and coping was significantly associated with higher stigma resistance [45].   [48,49] compared to people without a mental illness. PWS often employ a more limited range of coping strategies, which are characterized by a preference for avoidance and passive coping rather than help seeking or active problem-solving approaches [50,51].
Stress is a rather complex concept. However, effective coping enables people to be engaged in activities that may involve stress, such as dentist visits, which is one reason for their infrequent dentist visits [52]. Stress is subjective both in the measurement of severity and experience. The way in which individuals perceive and interpret stressors may vary greatly [53].
Two processes emerged, the perception of the nature and degree of risk divided into "threat" and "challenge" evaluations and the perception of resources or abilities to cope with the stressor.
Kelly et al., suggested that although coping style and neuropsychological functioning are important predictors of perceived stress by PWS, additional factors need to be considered such as social support, expressed emotion, self-esteem, resilience and self-efficacy as trait negative affectivity is significantly related to coping styles and stress reactivity in schizophrenia [28].

Social Support /Peer support
Social supports develop self-esteem based on the feedback of individuals from the environment as a result of social interactions [54,55]. A personal support network is essential for coping, building and maintaining resilience.
Encouragement and support from these relationships is extremely effective in helping people work through stressful periods. Peers can be a vitally important component of support network, because they are likely to be experiencing similar stresses [39].

Religious and spirituallity
Religious coping is multidimensional and refers to functionally oriented expressions of religion in times of stress. Religious coping is operationally defined as "the use of religious beliefs or behaviors to facilitate problemsolving to prevent or alleviate the negative emotional consequences of stressful life circumstances" [56]. Carver et al. [57] suggested that the value of positive reinterpretations is that it not only reduces distress, but also can be used to reappraise a stressful situation and see it more positively.
Studies revealed that adaptive coping strategies were significantly associated with religious and spirituallity as resource of finding meaning and hope were identified as a key component of the process of psychological recovery [58,59,60].
All of this these metacognitive processes are summarized in Figure 2.

CONCLUSSIONS
This is the first study to examine the appraisal and coping processes associated with oral health in PWS. We highlighted that coping strategies for PWS in oral health were considered as the evaluation of a transaction between people and their environment where certain perceptive, emotional or behavioral processes can cope with stressful events.
Although, coping strategies play a crucial role in the recovery process of PWS the mechanisms of this involvement should more specialty explored in the future to clarified the capacity of PWS to cope with essential self-care on daily life for good oral health related quality of life.
These results could be used to implement research in building oral health prevention programs taking into account a metacognitive approach and no only focused in oral health pathologies