107 Oral Health Interventions in Patients with a Mental Health Disorder trum disorder [50]. The methodological quality of the quasi-experimental studies was sufficient. However, the pre-test–post-test design of the studies did not aim to compare an intervention group with a control group. The addition of control groups and sensitivity analyses can support the hypothesis that the intervention is causally associated with the outcome [60]. One 2 × 2 quasi-experimental study met all the requirements of the JBI checklist; however, this study of Singhal et al. [49] lacked the determination of the effect of the calendar. It is not known if there was a Hawthorne effect and if the calendar was a confounder for other independent variables [49]. Furthermore, SMI has to be specified because every patient group has its own needs in managing oral health problems. Additionally, physical interventions should also be examined in other mental health patient groups beside ASD (Autism Spectrum Disorder). The quality of the cohort study (educational intervention [54]) was insufficient as confounders were not clearly identified and no strategies dealing with confounding factors were described [35]. In the literature, confounding has been described as a confusion of effects [58]. To draw appropriate conclusions about the effect of the educational intervention on an outcome, the causal effects should be separated from that of the other factors that affect the outcome (e.g., age) [61]. Strategies (e.g., matching, randomization, stratification) were not used in this cohort study [62]. Due to the lack of controlling for confounding factors in included cohort study [54], it is not clear whether the conclusions were drawn appropriately or that there were other factors that affect the outcome measurements. Reflection on the Effect of Interventions Overall, dental health education or lectures, dental care instructions, brief motivational interviewing, and a reminder system or a treatment plan showed a significant and positive effect on oral health knowledge, Q.H. plaque index, or TRSQ. The use of one of these interventions, combined with a mechanical toothbrush, can improve the oral hygiene of people with mental health disorders. Providing patients with a toothbrush, toothpaste, and mouthwash was helpful to increase access to toothbrushes and brushing twice a day and had a significant effect on plaque index. PMTC showed a significant decrease in probing depth and total number of bleeding sites; however, no significant change on caries activity test and debris accumulation. There was no significant impact of smoking on the mean change in plaque index and gingival index. These effects were tested in patients diagnosed 4
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