Oral health and mental health: Lived experiences of stigma and discrimination for Australians with mental health challenges

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They experience high rates of dental disease due to medication side effects, socioeconomic barriers, and stigma. Despite their high need for dental care, they face reduced access to care, exacerbated by structural inequities and provider biases. Stigma further deters care-seeking, with limited research centering lived experience perspectives. In Australia, where privatized dental care widens inequities, mental health guidelines rarely address oral health, and studies often adopt deficit-based frameworks. Methods This study employed a co-designed, qualitative approach with Australians with lived experience of mental health challenges, exploring barriers, stigma, and systemic failures in oral healthcare. Findings aimed to inform person-centred interventions bridging oral and mental health systems. Informed by interpretive phenomenology, a secondary analysis of data collected by a lived experience-led national survey focused on responses by 198 mental health consumers to four survey questions that explored experiences related to stigma and discrimination. Latent content analysis was used to analyse the data. Each step was underpinned by a lived experience co-design group that met iteratively to design the original survey, provide critical feedback to the analyses and reporting on research outcomes. Results Findings reveal how intersectional stigma—linking mental health status, oral health, socioeconomic disadvantage, and marginalized identities (e.g., Indigenous background, refugee status, substance use, or history of transmissible diseases) perpetuates inequities in dental care, with lifelong health consequences. Stigma operated at multiple levels: experienced, internalized, and anticipated stigma, leading to avoidance of care; diagnostic overshadowing (oral health concerns dismissed as "behavioural"); dehumanizing attitudes (derogatory language, perceived delegitimization of pain); and ethical violations, including exploitation and inadequate consent processes in clinical interactions. Participants described systemic exclusion from preventive care, with compounding effects for multiple marginalized groups. Conclusions This first Australian study on stigma in dentistry reveals how mental health, oral health, and intersectional stigma deter care-seeking and worsen outcomes for marginalized populations. Findings underscore the need for structural interventions, including stigma-informed training for dental practitioners and policy reforms to ensure equitable, trauma-informed care. Addressing these barriers is essential to breaking the cycle of oral health inequities. Oral Health Dentist Mental Health Stigma Discrimination Shame Trauma Dental Services BACKGROUND Health disparities for mental health populations Oral health is an integral component of overall health. Oral diseases such as dental caries, dental erosion, periodontal disease and edentulism (tooth loss) negatively impact health-related quality of life (Haag et al., 2017 ). Oral health constitutes as part of physical health and has been associated with other systemic physical health comorbidities including cardiovascular disease, diabetes and cancer and increased mortality rate (Kisely et al., 2018; Skallevold et al., 2023 ). Poor oral health significantly impacts both functional and psychosocial aspects of daily life; when mechanical functions involving the teeth and mouth—such as speech, chewing, and swallowing—are impaired, essential activities become challenging (Kisely, 2016 ). In addition to these functional challenges for the individual, poor oral health can adversely affect psychosocial well-being, contributing to lower self-esteem, reduced social engagement, and diminished employment opportunities. These effects are particularly pronounced because social value of the face, mouth, and voice are central to human communication and self-presentation, making oral health a key factor in body image and social participation (Doughty et al., 2023 ). Moreover, chronic oral pain, often resulting from conditions such as dental caries, periodontitis, and temporomandibular disorders, has been linked to elevated levels of stress, anxiety, and depression (Karamat et al., 2022 ). Persistent pain may also contribute to sleep disturbances and a reduced quality of life, thereby exacerbating pre-existing mental health conditions (Karamat et al., 2022 ). Studies clearly establishing that adverse oral health conditions such as higher rates of decayed, missing, and filled teeth are higher in prevalence among people with existing mental health challenges compared to the general population (Kang et al., 2024 ). An umbrella review that also identified this strong association between dental outcomes, mental health conditions and substance use issues, also found that certain risk factors contribute to dental diseases in people with existing mental health challenges, including smoking, poor oral hygiene, dry mouth from psychotropic medications and recreational substances (Choi et al., 2022 ). However, research has also found that people with mental health challenges receive less dental care than the general population due to various barriers including costs, dental anxiety and stigma (Kalaigian & Chaffee, 2023 ; Kisely et al., 2015 ; Teng et al., 2016 ; Yang et al., 2018 ). Oral health, mental health and stigma An increasing body of literature recognizes oral health-related stigma as a distinct form of health stigma. It is expressed through labelling, stereotyping, social exclusion, and discrimination against individuals or groups whose oral health deviates from societal norms (Doughty et al., 2023 ). In the context of oral and mental health, stigma can influence every stage of an individual's healthcare journey, often resulting in delayed treatment, worsening oral health outcomes, and diminished quality of life (Ahad et al., 2023 ). A qualitative study conducted in South Punjab, Pakistan, investigating the impact of dental stigma on oral health-seeking behaviours, found that ridicule and discrimination, both from the community and dental professionals, caused significant emotional distress, shame, and lowered self-esteem. Consequently, many individuals postponed seeking treatment until their conditions became unbearable (Zain Ul Abideen et al., 2024 ). Stigma and intersectionality Oral health-related stigma is intensified by disparities in social, political, and economic power, as well as structural violence and overlapping marginalized identities. It both reflects and reinforces disadvantage, causing harm to stigmatized individuals and groups throughout their lives (Doughty et al., 2023 ). Many international studies allude to stigma of mental illness as another barrier to preventive or follow-up dental care for persons with mental health challenges. A qualitative study from the US suggested that service providers, including psychiatrists and dentists, hold the same stigmatised perceptions of mental illness as the general public (Wright et al., 2021 ). In a qualitative study conducted in the UK described mental health-related stigma and discrimination which leads to the lack of involvement of service users in their oral care as one of the inter-personal barriers to improving oral health in people with SMI (Mishu et al., 2022 ). Dental anxiety among patients has also been shown to cause treatment refusal by dentists, especially if those providers have limited mental health training (Wright et al., 2021 ). An Australian mixed-methods systematic review also noted that communication and more specifically the lack of empathy, psychological and trauma-informed language used by dentists are perceived by individuals living with mental health challenges and other at-risk population groups as a barrier to their engagement with dentists (Johnson et al., 2024 ). Johnson and colleagues also discussed the inadequacy in communication about oral health, both between dental practitioners and psychiatrists and with patients, which contributed to gaps in preventative care knowledge among people with mental health challenges. Despite some individuals having high health literacy, misunderstandings still occurred, often due to a lack of empathy, psychologically and trauma-informed approaches, and the use of complex or unclear language by dental professionals. They also highlighted the role of the side effects of psychotropic medications (such as dry mouth and teeth grinding) and their impacts on oral health in this population group (Johnson et al., 2024 ). This limited knowledge, coupled with lower priority for oral health due to the symptomology experienced as part of mental illness, may lead to poor oral care practices such as lower rates of tooth brushing frequency and regular dental visits compared to the general population (Turner et al., 2022 ). Structural stigma in dentistry setting In Australia, where 85% of dental services are provided through the private sector and most of these are subsidised by private health insurance providers, oral health inequities are mainly driven by socioeconomic disparities, as individuals from lower socioeconomic backgrounds often face financial and structural barriers to regular dental care such as long waiting lists for subsidised care and high out-of-pocket fees for dental services (AIHW, 2024). In addition to socioeconomic challenges, vulnerable populations including individuals living with mental health challenges, disability and those experiencing homelessness also face substantial challenges of living with and managing mental health symptoms and their impact on attendance at dental appointments, as well as a higher severity of dental anxiety and phobias (Johnson et al., 2024 ; Wright et al., 2021 ). More notably, individuals experiencing mental health challenges, homelessness, or both, report significantly higher levels of shame and embarrassment as anxiety triggers compared to the general population (Yokota et al., 2020 ). Gaps in practice and literature There is little emphasis on oral health disparities in current mental health practice guidelines for providers regarding treating people with mental health challenges. For example, a recent review of 16 studies and five guidelines/recommendations exploring oral health promotion among mental health providers concluded that their current practices are fragmented and inconsistent, and that more knowledge, education, and training are needed. They noted a number of challenges including workloads and time constraints, lack of collaboration with dental services, and what they termed ‘challenging client behaviours’. They also called for more detailed clinical practice guidelines, more user-friendly oral health screening tools and improved referral pathways between oral health and mental health care providers (Johnson et al, 2025 ). Likewise, guidelines for oral health and mental health to inform practice by oral health providers are in their infancy and are framed as deficits in the person, with only indirect reference to how oral healthcare providers could respond differently. For example, the current Australian Commission on Safety and Quality in Healthcare Guidelines for adult inpatients (2023, p.13) make only one reference to people with mental health challenges, stating, “Patients suffering from cognitive impairment, intellectual disability or mental health conditions may behave in a way that makes it difficult to provide oral care. Consider the need for a dental referral if oral care resistance is prolonged. Implementing the principles of person-centred care and effective communication and can support patients with oral care resistant behaviours, reduce anxiety and encourage participation during oral care”. The existing literature reveals several significant gaps that warrant further exploration. First, there is a notable lack of studies that are led and co-designed by individuals with lived experience of both oral health and mental health challenges. This participatory approach is essential to ensure that research reflects the perspectives and priorities of those most affected. Second, Australian-based research from a lived experience perspective remains limited, highlighting a need for context-specific studies that consider local systems, services, and cultural factors. Third, although there is a growing body of research examining the relationship between oral health and mental health, most studies employ quantitative methods, with comparatively few qualitative studies that explore these associations in depth. Fourth, current literature often adopts a deficit-based lens when discussing people with mental health challenges, frequently framing them in terms of non-compliance or dysfunction. This approach risks reinforcing marginalisation and stigma, underscoring the importance of adopting strengths-based and inclusive research frameworks. Lastly, since the majority of current literature has been derived from research conducted in the United States or other countries, this research is valuable as it focuses on lived experience of people living with mental health challenges in Australia. METHODS Aim The aim of this study was to explore experiences of stigma and discrimination related to oral health and mental health for people with mental health challenges. Research questions What is the lived experience of stigma related to oral health for Australians with mental health challenges? How does oral health stigma interact with mental health stigma for Australians with mental health challenges? Design The theoretical framework to inform this study was interpretive phenomenology which is focused on exploring how human beings make sense of and transform their experiences both individually and as shared meaning (Patton, 2002 ). Setting: The National Survey Study and this Study This study involved a secondary analysis of data collected by a national survey (Lawn et al, 2025) conducted by Lived Experience Australia (LEA), which is an Australian national mental health consumer and carer advocacy organisation ( https://www.livedexperienceaustralia.com.au/ ). The survey was developed in collaboration with a lived experience co-design group (n = 10 individuals drawn from LEA’s national representative panel through an expression of interest call). This group was established to identify the questions to include within the survey and support synthesis of results. They met online for three iterative cycles of discussion and design of the survey questions, and then met to discuss the results, with further feedback on the report via email. Co-design group members included consumers and family carers with lived-living experience of oral health and mental health concerns. Two separate surveys were created, one specifically for people with personal lived experience (consumers) and one for family carers (carers). The aim of the larger study was to gain a better understanding of Australian mental health consumers’ and family carers’ experiences of oral health and mental health. Sample, Recruitment and Data Collection The anonymous survey was sent out electronically via SurveyMonkey to LEA’s email list (2,800 subscribers) and social networks (8,000 followers), with the survey link also distributed voluntarily by other collaborative mental health consumer and carer advocacy peaks and organizations at state and national level. The survey was open from early November to mid December 2024 (5 weeks). There were 234 survey responses in total including 198 consumers and 36 carers participating in the survey. Participants could elect not to answer questions. Consent to participate was provided electronically via the online site through their commencement of the survey. The consumer survey contained 66 questions, consisting of both quantitative and qualitative questions across several areas of interest to the research. For this current study, responses to a subset of four questions was included, focused on stigma and discrimination (see Box 1). Data Analysis We chose latent content analysis (Hsieh and Shannon, 2025) to analyse the data for this study because it is useful for examining lived experiences in order to gain deeper insights into how people understand those experiences. This approach allowed us to organize large amounts of text into categories that reflect a shared meaning of oral health and mental health in relation to stigma experiences. Latent content analysis is an inductive, bottom-up analysis that applies a deeper, interpretive analysis that seeks to describe underlying meaning co-created from the words or phrases being analysed (Kleinheksel et al, 2020 ). It produces phenomenological descriptions that seek to explain the study population’s lived experiences. To analyse the data, all survey responses to the questions focused on stigma were read iteratively. During the process, recurring issues and comments were discussed by the researchers. The researchers (AN & SL) then independently coded the text responses within each survey question into manageable code categories for analysis. We met fortnightly to discuss and debate the coding structure, determining overarching and subordinate ideas within each category. We then collaborated to build descriptive text to capture the meaning around each coding category. A third researcher (AC) reviewed these processes, offering further insights. This combined input provided a diversity of perspectives and challenged each of us to make deeper meaning from the coding ideas. The draft analysis was shared with the co-design lived experience working group which had helped to design the original survey questions, to seek their further insights. These processes enabling robust discussion by all members of the research team, including the lived experience working group, and finalisation of themes within each question area. Box 1. Outline of Overall Survey Question Areas and Questions for this Study Preliminary section (6 questions) Questions seeking demographic information (e.g., age, gender, location) Main Survey (8 Sections / 60 questions) • Information Sources for Oral Health • Looking after your Oral Health (past and present) • Your Contact and Experiences with Dentists and Other Oral Health Staff • Accessing the Dentist • Oral Health and Other Health Conditions • Oral Health and Mental Health • Experiences with Mental Health Professionals • The Health System - What can be done/what needs to change Current Study - Specific Questions in Focus (1) Have you experienced stigma and discrimination from dental staff (e.g. dentists, dental hygienists, dental specialists, administrative staff) when seeking your oral health? (Q28) (2) Have dental staff attitudes made you feel ashamed or to blame for the state of your oral health? (Q30) (3) (if relevant to you) How have the dentist/dental clinic staff behave when/if they have become aware that you have a mental health condition? Please specify (Q40) (4) (if relevant to you) How have the dentist/dental clinic staff behaved when/if they have become aware that you have experienced problems with alcohol and other drugs? Please specify (Q41) RESULTS A summary of participants’ demographic details is provided in Box 2 below. This is followed by results from the latent content analysis from responses to the found questions included in this study, organised as themes within each section with deidentified quotes from participant to demonstrate each theme. Box 2: Demographic Data • All Australian States and Territories were represented. • Most consumers identified as women/female (73%; n = 111 of 153), 21% (n = 32) were men/male, 5% (n = 8) were non-binary, 1 used a different term and 1 preferred not to say. • Two-thirds of consumers (65%; n = 100 of 153) lived in a capital city/metropolitan area, a quarter (26%; n = 40) lived in a regional city/area, and 9% (n = 13) lived in a rural or remote area. • 34% (n = 51) of consumers identified as LGBTIQA+; 14% identified as culturally or linguistically diverse; 4% identified as First Nations. • 62% (n = 93) of consumers identified as a person with a disability. • Consumers ranged in age; most (84%; n = 128 of 152) being between 30–69 years, 11% were 18–29 years and 5% were 70 + years., • 16% of consumers also identified as a family carer of someone with mental ill-health. Have you experienced stigma and discrimination from dental staff when seeking your oral health? Mental health-related stigma can adversely affect diagnosis and treatment. As exemplified by the below participant’s response, upon learning of their mental health history, the dental practitioner prematurely attributed the dental health issues to mental health issues without considering alternative explanations, such as undiagnosed reflux. This reflects confirmation bias and diagnostic overshadowing where negative mental health assumptions obscure accurate clinical assessment. Additionally, the accusatory approach can compromise trust and lead to disengagement from care. This highlights how implicit bias, and a lack of trauma-informed, patient-centred care can result in misdiagnosis, emotional harm, and disrupted therapeutic relationships, deterring patients from seeking or continuing treatment. I'm not sure about stigma, but I do find that I am met some uncomfortable energy when I see a new dentist and explain my situation to them. I once stopped seeing one because she accused me of lying about being bulimic because she saw erosion on my back teeth, often associated with purging, but it was because I had habitual reflux due to an as-yet undiagnosed digestive issue. When participants disclosed dental anxiety or pain and advocated for appropriate support, such as requesting analgesia, they were frequently met with dismissal and invalidation. Several reported feeling trivialised and perceived as exaggerating or fabricating their symptoms. One participant described being perceived as “a bad person” for disclosing dental trauma and requesting pain relief. In one extreme instance, a dentist responded to a participant’s request for anxiety management during a wisdom tooth extraction by telling them to “go to the pub to relax”, despite the individual’s known history of alcohol misuse and active engagement with substance use services. When the participant attempted to construct a collaborative plan with the dentist to accommodate for their needs, the dentist ignored them and proceeded with an assessment against their wishes. Another participant recalled receiving rougher treatment after raising concerns about inadequate analgesia. These accounts highlight how stigma toward mental health and trauma can manifest in clinical interactions through microaggressions leading to further psychological harm and avoidance of care. …It feels like they think I am making up my anxiety and or pain. Some responses reveal a more concerning pattern in which mental health stigma leads dental practitioners to dismiss, downplay, or refuse treatment for legitimate oral health concerns. Participants described not being believed about severe pain, visible wounds, and progressive infections, with one participant being accused of drug-seeking behaviour, a stigmatising and harmful assumption. This dismissiveness appears to stem from implicit biases linking mental illness with exaggeration, unreliability, or manipulation, resulting in care delays and diagnostic neglect. In some cases, conditions were left untreated until they escalated to emergencies, such as necrosis of the jaw or severe abscesses. Such responses reflect not only therapeutic disregard, but potentially constitute clinical negligence, given the avoidable harm caused. Furthermore, the accusations of drug-seeking illustrate how people with mental illness are often subject to moral judgment rather than clinical assessment, particularly when reporting pain. This may lead to undertreatment, distrust, psychological distress and retraumatisation, further compounding the individual’s physical health risks and mental health and wellbeing. I have not been believed about oral health pain and been called a drug seeker I have not been believed about an open wound in my mouth down to my jaw (they said it was just an abscess) which almost turned into necrosis of the bone. Leaving issues present until it becomes emergency i.e. tooth abscess. I was sent away recently despite being in pain. Some participants recounted retraumatising interactions that reflect a lack of trauma-informed practice in dental settings. One individual who disclosed a history of sexual abuse and PTSD claimed being mocked by a dentist when expressing discomfort with oral procedures. This reflected ignorance and insensitivity to trauma, as shown in the below quote. Another reported being asked intrusive and sensitive mental health questions, such as about suicidal ideation, without any explanation or clinical relevance to the dental visit. These experiences suggest breaches in professional boundaries and a failure to provide safe, respectful care for individuals with complex trauma histories. I've been laughed about when expressing my aversion to having stuff put in my mouth. In contrast, several participants described anticipatory stigma , choosing not to disclose their mental health history to avoid expected discrimination. This concealment was due to prior negative healthcare experiences followed by fear of being judged or receiving substandard care. As one participant shared, “I’m frightened they would discriminate if they knew my mental health history,” citing repeated instances of stigma from GPs and hospital staff. Others also avoid disclosure in dental settings specifically to protect themselves from further harm. Participants with concealable stigmatised identities such as HIV-positive status, viral hepatitis, or other transmittable infectious diseases, reported intersectional internalised stigma and anticipatory stigma resulting in increased psychological and emotional distress during their dental visits. Despite no legal obligation, one participant volunteered their history out of concerns for the dentist to take extra precautions. However, after the dentist learned their health status, they were refused treatment. Such negative disclosure reactions and discrimination may have exacerbated their existing internalised stigma, causing further anxiety and fear of disclosure, therefore worsening anticipatory stigma. I had a public dentist refuse to treat me when they learnt I had Hepatitis C. I know this as he left after he asked me about [it]. When I was in the chair, and I heard him say to a nurse outside he was no longer available. Having to discuss my HIV status, I carry additional burden thinking of the dentist’s health and ensuring they remain safe. I know they are responsible for taking necessary precautions. It’s still a risk I have to emotionally grapple with each visit. Participants also reported experiencing intersectional stigma related to their social identities. One individual described socioeconomic discrimination based on their appearance - being perceived as "looking poor." Others from marginalised backgrounds, including migrants, refugees, and racial minority groups, reported ongoing experiences of racism, xenophobia, and classism within dental settings, often facing dismissiveness and lower standards of care. This was demonstrated by clinicians’ behaviour towards them, specifically anticipated patient failure to self-care or have oral health literacy based on stereotypes related to race, class, or perceived capability. Rather than offering education, encouragement, or collaborative care, clinicians prematurely judged patients as unlikely to maintain oral hygiene, leading to the withholding of standard preventive practices, including health education, shared decision-making, and empathetic communication. All through my childhood, the only dental service I received was the dentist who came to my school. There was a lot of racism back then towards Pacific Islander children. I've also experienced discrimination and racism from dentists I've visited as an adult. They've been dismissive, judgmental and you could tell that they didn't think I was going to succeed in looking after my teeth, so they didn't make any effort to show me, ask me or talk to me about my concerns about my teeth . In one case, a participant described undergoing a full-mouth extraction of teeth at a public dental clinic without receiving adequate explanation, informed consent, or discussion of alternative treatments. This experience resulted in lasting dental trauma. …when I arrived in Australia as a single mother of three and a refugee, I've been sent to public dental clinic where they took all my teeth out without any explanation or asked question before the procedure… it is trauma then and forever. Stigma may subtly influence clinical decision-making, particularly in the treatment of individuals with poor oral health or mental health conditions. Many participants expressed dentists’ tendency to perform tooth extraction rather than offering and pursuing preservation technique such as root canal therapy. This suggests an underlying biased attitudes held by dentists in patients’ perceived worthiness or compliance. People with mental health issues may be assumed to have poor oral hygiene, reduced treatment adherence, or lower capacity for self-care, which can lead to discriminatory assumptions about the viability or value of restorative treatment. This also reflects how structural stigma can manifest in treatment planning, where cost-saving or expedient options are prioritised over long-term, preventative patient-centred care, thereby contributing to ongoing health disparities and reinforcing cycles of neglect and disengagement. There is the tendency to pull out teeth rather than try to save them. We should have access to root canal treatment. Public system dentists... Just pull teeth with no other option. No cosmetic dentistry offered to save teeth. No funding I'm guessing! Some dentists are dismissive if you have some oral health issues and are reluctant to do procedures to treat the affected tooth/teeth, preferring to simply pull out the tooth/teeth. I was told I wouldn't be accepted for my dental implants because of my hygiene. The intersectionality of stigma related to substance use and mental health and its stereotypes resulted in many participants recounting experiencing negative attitudes and hostility from dental staff, particularly being judged and shamed for their presumed lifestyle, but also because of their mental health status. In some instances, dental staff often incorrectly attributed poor oral health conditions to the individual’s supposed diet, smoking, alcohol use, or recreational substance use. Many reported being criticised by their dentists for their substance use which lead to increased guilt and shame, worsening internalised stigma. This harmed therapeutic relationships and led them to disengage from the dental service. Dental staff said I have receding gum line and attributed it to my diet, but I believe medications impact my oral health. When they hear the medication that caused the side effects, there is a lot of judgement about it, even just on their faces, and even though I tell them I haven't taken it for a long time. I used to smoke and, due to the constant stigma associated with comments that I received, I stopped going for several years. I also had bad experiences with government dentists when in hospital for mental health treatment. I was no danger to anyone/or myself but the dentist insisted on a security guard with no justification at all to base this on. I've never been back to a government dentist since. I went to see the dentist they told me my teeth wouldn't be this bad if you didn't touch drugs or alcohol. There were also instances of oral health-related stigma reported where participants received counter-productive judgement, reprehension, and humiliation purely for the poor state of their oral health. One participant highlighted how structural stigma results in health inequality/disparity where poor oral health outcomes might stem from lack of dental-oral care education and resources in childhood. Another participant attempted to offer their perspectives on how their mental health affected their ability to care for their oral health. They described being infantilised by the dental practitioners; they were treated and “spoken to like a child” instead of using this as an opportunity to explore and understand the daily challenges they might face as part of living with mental health challenges, to discuss the solutions to address those challenges, or to just offer the person education on practical steps to improve their oral health. They look down on us for having bad teeth. Some don't realise it comes from our childhood where our parents never taught us, and we grew up continuing that. They also don't understand severe mental health. The dentist I saw as a child would chastise me for my poor oral hygiene but not offer practical solutions except for the usual advice of brushing twice a day and so on. As an adult I've had similar experiences like being told by a dentist I have the teeth of a 60-year-old when I was 20. Being spoken to like I was a child when explaining the difficulties I have maintaining my oral hygiene and being told off for not looking after myself better with no understanding of the challenges I face due to my mental health conditions. 'Why did you let your teeth get into such a state?!' Have dental staff attitudes made you feel ashamed or to blame for the state of your oral health? Substance use and health-related stigma Some responses revealed stereotyping by dental staff that related to participants’ past medical history of alcohol or other drug (AOD) use and elevated body mass index (BMI). One participant reported receiving presumptuous, patronising and stereotype-driven advice regarding their lifestyles such as “don’t drink fizzy drinks” or “cut down on the junk food”. Conversely, other responses described stereotyping around diet and smoking arising from failure to review relevant medical history, as shown in the quote below: Many will comment without taking any notice of my medical history, in that my bone density issue is due to a genetic birth defect, but they'll tell me things like I'm not eating properly or it's all due to past smoking etc. Then I have to tell them smoking is the only bad habit that affected my dental health. It's often upsetting that their lack of knowledge regarding my health condition makes them jump to any conclusion that suits their own knowledge . Oral health-related stigma Some participants reported internalised stigma regarding their poor oral health, while many others reported experiencing verbal and non-verbal judgement, negative attitudes, or even reproachful communication for their poor oral health state from dental staff. Consequently, judgement concerning perceived poor choices or neglect of oral hygiene exacerbated participants’ pre-existing feelings of shame, both during and after their encounters with dental care services. Some dentists in the past have been very judgmental and this has contributed to the extreme shame I feel about my teeth. In a way, I am to blame - most of my dental issues are caused by poor choices, but that doesn't make me any less worthy of care and compassion. There have been times that I felt judged by the condition of my oral health when I had poor motivation to look after it. I already felt ashamed about it but then the attitudes of some dental hygienists amplify that feeling.” Internalised and anticipatory stigma Similarly, one participant reported internalised and anticipatory oral health-related stigma including concerns about the appearance of untreated malocclusion (misaligned teeth) due to delayed orthodontic treatment. Another participant described how stigma associated with AOD use further contributed to discomfort and non-disclosure in dental settings driven by anticipated judgement from dental staff. When I was in active addiction, I wasn't comfortable divulging the amount I drank or the drugs I used to dental staff. I frequently feel ashamed that I haven't yet got braces to straighten my teeth at my age . Some participants reported experiencing shame in response to corrective feedback about their oral hygiene practices, despite their efforts to maintain dental health. Sometimes I feel shame when I am told that I have not been brushing/flossing my teeth effectively . Only regarding certain behaviours, such as over brushing . Intersection of mental health-related stigma and oral health stigma Several responses highlighted the intersection of mental health-related and oral health stigma within dental settings. Participants described experiences of shame, dismissal, and a lack of empathy when their oral health concerns were linked to psychiatric conditions. One participant reported feeling ashamed when attributing their dental issues to mental illness, while another noted the absence of open dialogue around the impact of mental health on oral health, such as bruxism associated with chronic anxiety. Another described being shamed by multiple dental professionals before finally receiving empathetic care and appropriate treatment. In one case, a participant with a documented psychiatric history reported being wrongly presumed to have a hallucinatory disorder, leading to the gaslighting by dental staff (intentionally attempting to make another doubt their own sanity) and dismissal of the person’s legitimate dental concerns. Have felt embarrassed when explaining why I haven't brushed my teeth properly is because of mental health. I grind my teeth a lot (a biproduct of chronic anxiety) and this causes oral pain. I need a dentist that is open to conversations about mental health and oral health. In my experience not all dentists are. I had a psychosomatic issue that caused a kind of bulimia anorexia that went on for 6 years, I was shamed by 4 dentists before someone said that that explained where my cavities were located and showed real empathy . My dental concerns have been dismissed as delusions, where I was required to advocate heavily for someone to listen and take my unique situation into consideration. Once they viewed my cracking teeth due to the immense pressure from clenching in my sleep, they saw a night splint was required - but this took me much effort to get through the stigma and dismissal of my concerns as my ‘imagination’, or me supposedly suffering from a hallucinatory form of mental health condition - which I do not; I only have a brain injury and anxiety and complex PTSD which is undoubtedly heightened by the way I am treated. Shame as part of manipulative business strategies Interestingly, some responses suggested that shame was used strategically by dental professionals to exploit participants’ vulnerability and encourage uptake of additional procedures. Participants described the use of shaming or fear-based tactics as a business strategy, which in-turn exacerbated feelings of shame, dental anxiety, and phobia. I pushed back at the shaming that seemed to be occurring during some visits. I was told the dentists had to compete with one another business-wise so they were instructed in conferences to play up the horrible things happening to their patients’ teeth so they can convert that into more procedures and literally scare people to give up their money and engage in oral services.... it was a marketing ploy!!! That further accelerated my dentist phobia. “ Yes, because I refuse extra add-ons like whitening, crowns, caps etc . Unethical practice One account highlighted perceived unethical and exploitative practices in dental care, particularly within teaching environments where power imbalances may be heightened. The participant described the clinically unnecessary removal of a functional composite filling by a student dentist for the purpose of fulfilling graduation requirements. This misuse of authority and potential violation of informed consent led to a cascade of complications, including emergency dental mismanagement, eventual tooth extraction, and significant functional impairment. I had a good compost filling which did not bother me, but the student at the dental school wanted to practice for his graduation project and made me believe it needed to be removed. He replaced it with an amalgam filling which broke not long after. The emergency dentist refused to refill it but chopped it up at a slant angle making it not possible to mend. Eventually it had to be extracted causing me to use the other side heavily. Now, I could not chew on either side of my mouth! How have the dentist/dental clinic staff behaved when/if they have become aware that you have a mental health condition? Inconsistent responses Several responses indicated that, upon learning of participants’ mental health conditions, dental staff adopted more person-centred care including compassionate and caring attitudes and tailored their behaviour or treatment approaches to accommodate psychological needs. My Dentist sat down with me and took the time to listen to my concerns. He provided me with compassion, understanding & respect. He also allowed me to set the pace for my appointments which is useful when I am feeling particularly anxious. They have been very supportive, explaining what they are about to do, making encouraging comments and sometimes the assistant may put their hand on my arm if I am tense. Conversely, some participants again described experiences of infantilisation and assumptions of poor health literacy. One participant reported that, after disclosing their condition, some dentists addressed their partner instead of them, effectively undermining their autonomy. With some, I think they've tended to change how they talk to me, as if I'm intellectually disabled or something. It's a little bit condescending really. Some dentists after learning this about me treat me like a child and will only speak to my partner instead of me. The public dental staff - when I informed them I have an ABI - they have immediately commenced speaking to me like I am a small child in need of consolation after an injury, which is incredibly disconcerting, belittling, and shame inducing. I am highly uncomfortable, and it always requires further explanation that my issue is with memory, processing speed and sensory damage - and that my intelligence is predominantly ok…and please speak to me a little slower, however use your regular discussion interaction, however this is often met with distain, sideways looks between staff, and derision, which makes me want to melt into the floor like I do not exist. Others reported mixed responses from dental staff, ranging from curiosity and neutrality to overt stigma. Some participants recognised such inquiries as part of the standard clinical work-up, including questions about medications and medical history. Notably, one participant observed that psychiatric history was more often discussed during longer appointments with student dentists who were perceived as more thorough and less judgmental. As one remarked, “the students tend to ask these types of questions,” yet “treated me just as another patient.” When I do mention the dental problem and add it could have been my mental health issues, I can see they are trying to compute the information and start to ask for more information from their training. Non-disclosure as a coping mechanism Many participants chose not to disclose their mental health status due to internalised or anticipatory stigma, often shaped by prior negative experiences or intersecting marginalised identities such as Indigenous background or HIV-positive status. Fear of judgment and discrimination emerged as a significant barrier, contributing to hesitancy or reluctance in sharing mental health concerns during dental encounters. Some suggested that disclosure might be more manageable through pre-appointment forms, offering a safer and more structured means of communication. One participant noted they would only engage with dental services in the presence of a support person or advocate. I would not disclose this information as I feel I would just be judged and face discrimination. This is based on many years of real-world live experience . For an Indigenous person we are already pre-judged. They didn't know, just that I had suffered severe DV [domestic violence] and trauma from it .” I get enough judgement for having poor teeth, I am definitely not going to tell them I have amental health condition. I feel they would not understand at all, and it wouldn't make any difference in what they suggest anyway. I never disclosed this information due to embarrassment and shame. Only recently since going to private, holistic dentist have I disclosed my anxiety, but not other mental health condition. “ Sometimes, I choose to disclose if I feel safe enough. But after the discrimination I had at a public dentist, I am very careful and wait till I feel safe to disclose…Hard to shake the real possibility of discrimination. Staff responses to disclosure Numerous participants reported that dental staff became less friendly, more distant, or overtly judgmental following the disclosure of mental health conditions. Staff were described as "stand-offish," speaking less, appearing fearful, or reluctant to provide care. These reactions were often perceived as stemming from stigma or a lack of understanding about mental illness, which undermined trust and discouraged continued engagement with dental services. Rather than acknowledging dental anxiety or adopting trauma-informed approaches, some staff dismissed the relevance of mental health and instead recommended sedation or medication as the default solution. One participant noted that dental professionals appeared ill-equipped to support individuals with autism spectrum disorder or sensory sensitivities. Some dental staff were perceived to hold insensitive views that mental health challenges are invalid explanations for poor oral hygiene. Other participants felt condescended to when attempting to engage with dental care services. They told me that I shouldn't be stressed about things...was not very understanding of my anxiety and that I may have to take medication to have any work done . As if it is no excuse for poor oral hygiene. I did not feel they behaved differently in terms of my diagnoses themselves, but did act in a more judgemental way when learning said diagnoses impacted my oral health & ability to care for my teeth/mouth. They clearly don’t understand that a mental health condition doesn’t mean I am intellectually impaired. I make a special effort to ask relevant questions but there is always a sense of unease about it. How have the dentist/dental clinic staff behaved when/if they have become aware that you have experienced problems with alcohol and other drugs? Inconsistent responses Experiences with dental staff regarding AOD use varied across participants. Some dental staff attempted to discourage AOD use which varied in effectiveness. One participant reported receiving supportive and structured approaches to health education from dental staff. Another participant recalled a positive experience in which dental staff expressed understanding and affirmed their recovery journey. However, another reflected that only after achieving long-term sobriety did they receive more enthusiastic and respectful care, suggesting that prior interactions may have been shaped by stigma and discrimination. Notably, a few participants questioned whether professionalism in responding to disclosure of AOD use varies between private and public dental care settings. Now that I have been sober for 15 years, they seem to want to help more than before.” With my anxiety, I didn't burden them with those issues. I did go through their checklist or questions thoroughly. As my lifestyle changed, their behaviour was very professional and I didn't feel uncomfortable. I guess I was paying the bill? Disclosure , avoidance and blame There appears to be a communication gap around AOD use, with participants often avoiding disclosure due to fear of judgment, while some perceived dental staff deliberately avoided the topic to prevent discomfort. When substance use was known or assumed, many participants reported experiencing various forms of judgment, discrimination, or bias. Negative behaviours included being spoken to condescendingly, treated with less patience, or blamed for their oral health issues. Some participants perceived a lack of empathy, as staff attributed oral health problems to personal fault related to their AOD use rather than recognizing contextual and structural factors, such as the effects of complex trauma. Additionally, one participant described being chastised with a paternalistic “lecture” instead of receiving empathetic dialogue exploring the underlying psychosocial drivers of substance misuse. Judgmental but when I say I have been off drugs since 2008 they congratulate me but it seems forced. Stigma felt as I had caused this, rather than trying to understand the circumstances – complex trauma from childhood sexual abuse . I’ve received a lecture. In the chair is generally not the space to explore what is driving my drug misuse. Even when participants disclosed long-term recovery, acknowledgements from staff were perceived as insincere or performative. Another participant reported explicit discrimination where due to their past substance use, some clinicians showed a lack of compassion and denied them of anaesthetics during treatment. Subsequently, these experiences perpetuated internalised stigma and anticipatory stigma as exemplified by one participant who described experiencing stigma and discomfort when disclosing engagement with opioid dependence treatment (ODTP), often accompanied by feelings of embarrassment and humiliation. Not relevant to me but relevant to an ex-partner. Because it was known that she was a recovering substance user, it was clinicians were sometimes reluctant to give her painkillers and they had little tolerance/compassion when she developed dry socket from smoking . DISCUSSION This study explored how internalised and externally applied oral health-related stigmas intersect with mental illness stigma, particularly among individuals who already hold stigmatised identities. It described key drivers of oral health-related stigma, its various manifestations, and the adverse outcomes it produces across the life course from the perspective of people with mental health challenges. Furthermore, the study highlighted the lived experience of Australians affected by such stigma. Its findings point to the need for stigma reduction strategies to foster safer, more inclusive dental care environments, ultimately improving patients’ oral health behaviours, their relationships with dental health professionals, and their overall physical and mental health outcomes. Layers of stigma Findings from this study shows how intersectional stigma, combining mental health status, oral health, socioeconomic status, and other marginalised identities including Indigenous background, migrant/refugee status, substance use histories, or history of transmittable disease (HIV, Hepatitis B, C, etc.) lead to poorer clinical care and consequently lifelong health consequences within dental care. Oral health and mental health stigma can manifest at multiple levels: (1) interpersonal, or public stigma encompassing societal judgments and direct discrimination; (2) intrapersonal, or self-stigma , referring to internalized negative self-perceptions, typically associated with shame; (3) anticipatory stigma , referring to one’s expectation that other will judge, discriminate or stereotype against oneself in the future (Earnshaw et al., 2012 ); and (4) structural stigma , involving policies that reinforce social exclusion. The Interplay Between Experienced, Internalised, and Anticipatory Stigma Participants in this study reported experiencing both internalised and anticipatory stigma related to poor oral health, mental illness, or AOD use. These forms of stigma frequently led to the non-disclosure of their mental health or substance use histories, a coping mechanism also highlighted in other research (Brondani et al., 2017 ; Ho et al., 2018 ; Zain Ul Abideen et al., 2024 .) A key contributing factor was prior negative experiences following disclosure in other healthcare settings, which eroded trust in health professionals more broadly. These findings suggest that when dental practitioners perpetuate stigma or discrimination regardless of the mediational mechanisms, it can further exacerbate an individual’s pre-existing internalised stigma and reinforce anticipatory stigma, particularly during interactions with dental care services. This compounded stigma is not merely an internal subjective experience; it has tangible consequences. The interaction between public stigma and self-stigma contributes to poorer psychosocial outcomes, including diminished self-esteem, exacerbation of mental health symptoms, and disruptions to recovery and quality of life (Earnshaw et al., 2012 ; Kao et al., 2016 ; Wood et al., 2017 ). Anticipatory stigma and previous dismissive care also contribute to dental fear and anxiety, which are disproportionately common among individuals with mental health challenges. Studies show that these fears are exacerbated when patients anticipate being judged, disbelieved, or mistreated by dental professionals (Armfield et al., 2006 ; Kisely et al., 2015 ; Kanka et al., 2021). This often leads to delayed or avoided appointments, worsening oral health and reinforcing stigma-related avoidance. These experiences highlight a toxic cycle in which stigma leads to disengagement from care, further deterioration of oral and mental health, and widening health disparities (Ahad et al., 2023 ). Addressing this cycle requires a holistic understanding of the complex interplay between individual, social, and structural factors which includes trauma histories, social determinants of health, and the burden of shame. Without such an approach, the delays in care and worsening health outcomes for people with mental health and AOD challenges are likely to persist. How mental-health stigma is manifested in dentistry settings This study also highlights a broader failure of dental health professionals to recognise and accommodate the psychological dimensions of dental care, especially for those with histories of trauma or mental illness. Ways that stigmatisation are mainly expressed through include: Diagnostic overshadowing Diagnostic overshadowing occurs when a clinician incorrectly attributes a patient's physical symptoms, in this case oral or dental issues, to an existing mental health or developmental condition, thereby missing the true underlying cause (Clough & Handley, 2019 ). This study, in line with Hallyburton ( 2022 ), identifies implicit bias as one of three major contributors to diagnostic overshadowing. When clinicians unconsciously allow mental health labels to dominate their clinical judgement, confirmation bias is reinforced, leading to inaccurate assessments, delayed diagnoses, and substandard treatment outcomes. As discussed by Gopal and colleagues ( 2021 ), unexamined biases can impair clinical decision-making, particularly in fast-paced environments where assumptions are made under time pressure. Without intentional efforts to challenge these cognitive shortcuts, even well-meaning clinicians risk overlooking the nuanced needs of vulnerable populations. Improving outcomes therefore requires a trauma-informed, person-centred approach, where curiosity replaces judgement, and clinicians reflect on their own attitudes and decision-making processes. Importantly, dental clinicians must acknowledge that many of the factors contributing to poor oral health in these populations lie outside individual choice or behaviour. These include physical manifestations of psychiatric illness (e.g. bruxism), adverse effects of psychotropic medications (e.g. xerostomia), and medical comorbidities. Failing to recognise this complexity reinforces stigma and perpetuates inequity in oral health care. Perceived delegitimization Another salient theme in this study is the perceived delegitimisation of participants’ experiences, particularly when pain or distress were routinely dismissed or minimised due to their mental health history. Rather than being met with clinical curiosity or compassion, participants described being treated as unreliable, manipulative, or “drug-seeking”, a moralised judgement that reflects underlying stigma toward concealable identities and/or psychiatric conditions. Such assumptions have resulted in diagnostic neglect, undertreatment, and retraumatisation, particularly when reports of severe pain or infection are ignored until they escalate into emergencies (e.g. jaw necrosis, abscesses). This is aligned with broader literature that highlights how provider bias, patient self-doubt, and the stigmatising practice of ‘chart flagging’ contribute to delayed or denied care and, in some cases, worsened health outcomes or even premature death (Watson et al., 2020). Furthermore, this dynamic reveals a power imbalance in the clinical encounter, where the clinician assumes the role of arbiter of credibility. As described by Corrigan et al. ( 2014 ), when symptoms are viewed through a moral rather than medical lens, individuals are cast not as patients but as problems, therefore resulting in punitive rather than therapeutic treatments. Consequently, refusal or minimisation of care not only invalidates the individual’s lived experience but may perpetuate a cycle of self-doubt and shame, deterring future help-seeking. many patients become reluctant to seek help, fearing they will not be taken seriously or treated with dignity due to anticipatory stigma (Clement et al., 2015 ; Doughty et al., 2023 ; Patel et al., 2015 ; Dolezal, 2022 ). In this way, stigma becomes self-reinforcing, manifesting not only in the healthcare provider’s actions but in the patient’s own perception of worthiness and credibility. Language & Dehumanisation Numerous existing studies have identified that communication and lack of trauma-informed practice in dental settings are perceived as barrier to dental care engagement, particularly for individuals with lived experience of mental illness and other at-risk population groups (Johnson et al., 2024 ; Mishu et al., 2022 ). Our findings build on this by detailing the specific forms and the consequences of negative clinician attitudes. Rather than offering empathetic, person-centred education and support, some clinicians employed judgmental language, assumptions of poor health literacy, and reduced communication. Participants reported receiving patronising language, being mocked, shamed, patronised, reprimanded and infantilised, and subjected to presumptions of failure. These interactions reflect a deeper moral framing of patients’ behaviours as a personal failing rather than a consequence of systemic barriers or past trauma. Individuals in this study are blamed for perceived self-neglect, reduced compliance, poor lifestyle or oral hygiene, reinforcing the notion that they are undeserving of care, or they must be corrected or disciplined (Stuewig et al., 2010 ). As discussed by Lawn et al. ( 2015 ), this moralisation leads to blame, shame, and the individuals’ autonomy being undermined. Furthermore, for individuals with trauma histories, infantilisation can retrigger past experiences of disempowerment or abuse, especially when it mirrors dynamics from psychiatric institutions, coercive family environments, or experiences of marginalisation. Ultimately, these encounters shift the therapeutic relationship from one of partnership to one of paternalism and abandonment, effectively withholding opportunities for recovery and health improvement (Drake & Whitley, 2014 ). This cycle also perpetuates a self-fulfilling prophecy of neglect: when dental-care providers expect poor outcomes based on implicit bias, they invest less effort, reduce support, and inadvertently contribute directly to the poor outcomes that they anticipated. Over time, patients may internalise this treatment, leading to reduced self-advocacy and self-stigma. Structural stigma in dentistry: Exploitation, Consent, and Ethical Oversight In social science literature, structural stigma is defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized” (Hatzenbuehler and Link, 2014 , p. 2). Structural oral health inequality often begins in early life, where limited access to dental care education, preventative measures and supportive resources disproportionately affects children from disadvantaged backgrounds. Findings in this study highlight on how negative and traumatic experiences with dental providers in early life— particularly those were explicitly discriminated for their socioeconomic background, race, other marginalised identities—can have a long-lasting impact on their engagement in oral dental care in adulthood. Structural stigma is then embedded in the economic and funding models that shape treatment availability and patient decision-making. In publicly funded systems, dental care decisions are frequently influenced by a triad of factors: the patient’s financial means, the clinical condition of the tooth and surrounding structures, and the constraints of the public service system in which the clinician operates. In private clinics, although more options may technically be available, treatment decisions are often narrowed to what the clinician perceives the patient can afford or maintain, rather than being made collaboratively with full disclosure of all options. The findings in our study illustrate how structural discrimination can manifest in routine clinical interactions, including treatment planning for individuals living with mental health challenges. Similar to current literature, the dental practitioners in this study perceive people with mental health issues to have poor oral hygiene, reduced treatment adherence, or lower capacity for self-care either due to stereotypical perception of mental or cognitive incapability without considering structural or psychosocial factors (Scrine et al., 2019). This, in addition to implicit biases about race, or class, have shaped practitioners’ attitudes and treatment decisions where lower-quality, cost-saving, or expedient options such as extraction-based treatment, are prioritised over long-term, evidence-based preventative care. Interestingly, there were also encounters in this study that reveal how systemic failings incentivise ethically questionable practices within dental practices, particularly those driven by private billing incentives. Participants reported instances where providers use shame- or fear-based tactics, leveraging patient vulnerability to promote costlier procedures, without transparent and informed discussions. These are not solely the result of individual clinician behaviour, but rather manifestations of institutional and economic pressures that lead to the prioritisation of profit over patient-centred care. More importantly, the absence of comprehensive discussion and informed consent reported in these encounters, illustrates how patient autonomy and agency in their own health management are denied. This reflects not only a gross violation of ethical and clinical standards but also highlights the paternalistic gatekeeping that often disproportionately affects individuals from lower socioeconomic and marginalised backgrounds (Macias-Konstantopoulos et al., 2023 ). Structural constraints such as limited time, high patient turnover, and economic pressures in both public and private dental settings may drive providers to choose extractions over more conservative treatments. However, when analysing the long-term economic and health costs of extraction-based treatment approaches, Wigsten and colleagues discussed though extractions are less expensive upfront, they often lead to complications such as bone loss, prosthetic dependency, reduced oral function, aesthetic concerns, and disability associated with denture use (Wigsten et al., 2023 ). These downstream costs—both financial and psychosocial—often outweigh the initial savings of extraction compared to more conservative treatments like root canal therapy and crowns. Yet, due to constrained public funding and assumptions about patients’ ability to pay, these longer-term consequences are frequently overlooked. Structural stigma is further reinforced by systemic fragmentation, under-resourcing, and institutional practices that create barriers to oral health care for people living with mental illness (Harnagea et al., 2017 ). Within Australian oral healthcare settings, structural stigma has been described in the existing literature as arising from siloed models of care, where non-dental health professionals such as GPs, pharmacists and mental health professionals are reluctant or feel ill-equipped to engage in managing oral health care for patients with mental health issues (Scrine et al., 2018 ). Additionally, the long waitlists and delays disallow routine check-ups and preventative care, leading to more advanced disease and emergency procedures for pain relief. The public system’s capacity to accommodate the particular needs of those with mental health challenges is intransigent. Despite having higher oral health needs, those from vulnerable populations experiencing mental health challenges need to continually prove their eligibility for treatments by completing numerous forms in a system designed for people who may not struggle with literacy or transport access. One of the often-overlooked consequences of these structural and systemic barriers is the amplification of dental anxiety. Dental anxiety, also referred to as dental fear, is defined as an "aversive emotional state of apprehension or worry in anticipation of dental procedures" and may be triggered by various factors, including treatment costs, painful or uncomfortable procedures, the use of needles, and gagging (Yokota et al., 2020 ). It is estimated that 16% of the general Australian population experience dental anxiety (Armfield et al, 2010). However, due to concealable stigmatised identities, individuals living with mental health challenges, systemic illnesses (such as HIV, hepatitis B and C), homelessness or a history of addiction can experience dental anxiety at higher rates and with greater severity. This ultimately leads to underutilisation of dental care services, reinforcing the cycle of poor oral health and marginalisation (Brondani et al., 2017 ; Parish et al., 2015 ; Patel et al., 2015 ; Yokota et al., 2020 ). The siloed health system continues to struggle in addressing the complex and intersecting needs of these populations, who are often left navigating a fragmented and stigmatising care environment. Additionally, a US qualitative study that explored systemic barriers to oral health care for people with mental illnesses from the perspectives of patients, psychiatrists and dentists, revealed that socioeconomic challenges are the primary barrier to people seeking dental care, followed by anxiety and fear related to receiving dental treatments (Wright et al., 2021 ). Moreover, these researchers found that there is a lack of oral health screening by mental health professionals and general practitioners due to gaps in their education and training about the role of oral health in mental health. Similarly, they found that oral health professionals have limited training on treating patients with mental health challenges. This indicates a need for improvements to guidelines and training to help educate both oral health and mental health professionals and therefore to improve service interactions for people who experience both the burdens of oral health and mental health challenges. CLINICAL IMPLICATIONS AND RECOMMENDATIONS Improving oral health outcomes for people living with mental health challenges requires a multifaceted and trauma-informed approach across both mental health and dental care settings. The following recommendations are proposed: A multidisciplinary approach involving mental health professionals, dentists and dental staff, and other healthcare providers is crucial for addressing the complex needs of this population. Integrating oral health care into mental health services could significantly improve oral health access and health outcomes for people with mental health challenges. For example, in inpatient units, mental health service environments can be enhanced with oral health education and resources. This may include the provision of oral hygiene tools (e.g., toothbrushes, floss, toothpaste), accessible information leaflets, and brief educational videos followed by discussion. Mental health clinicians, including psychiatrists and nursing staff, should be supported to discuss oral health side effects of psychotropic medications as part of routine care. Oral health guidelines need to be tailored to the specific needs of individuals with mental health challenges, with recognition of the role or stigma and discrimination, in addition to currently understood challenges with mental health, medications, motivation and self-care, and other challenges. User-friendly information and education, co-designed with people with mental health challenges is needed to raise awareness about the link between mental health and oral health and to promote preventive practices. Within dental settings, environments can be co-designed with people with lived experience to reduce sensory overload, including quieter spaces, natural lighting, and calming visual stimuli. Practices should also encourage strategies to support patient comfort, such as allowing the presence of a support person, use of personal headphones/music, or sensory tools like fidget items. More lived experience-informed information, education and training for oral healthcare professionals is needed to raise awareness about the link between mental health and oral health, address stigma and discrimination, and improve practice and to promote trauma-informed practice. For example, there is minimal training about SBIRT (Screening, Brief Intervention, and Referral to Treatment) in dental education regarding substance use and mental health. Incorporating SBIRT—a validated tool used in primary care—into dental training curricula, especially when delivered through a lived experience lens, may help reduce provider stigma and increase confidence in managing patients with AOD or mental health concerns (Fouillen et al., 2022). In a context of poor resources, dental care providers can experience burnout and consequently service users can be perceived as burdensome, time consuming, or annoying (Koschorke et al., 2021 ). Further research is warranted to explore how dentists in public systems navigate resource limitations and economic constraints in treatment planning. A qualitative study capturing public dentists' perspectives could offer critical insights into system-level drivers of care decisions. Though not explicitly mentioned by the participants in this study, another clinical consideration includes courtesy stigma, where a clinician is stigmatised by peers for treating patients with mental illness or substance use issues, can impact clinical decisions and behaviours. This fear of reputational damage or professional isolation contributes to provider stigma and reluctance to engage with marginalised patients, thereby reinforcing cycles of exclusion and poor health outcomes (Parish et al., 2023). Parish and colleagues suggest that stigma-reduction efforts should not only target knowledge gaps but also challenge cultural norms within the dental profession. Training that includes patient narratives and social determinants of health may help shift provider attitudes and reduce distancing behaviours. CONCLUSIONS This is the first in-depth report in Australia that explored the interactions of different types of stigma, and their manifestations in dentistry settings based on the lived experiences of people with mental health challenges. Our study revealed how explicit and implicit mental health, oral health stigma and other intersectional stigma manifest at multiple levels during their dental care help-seeking journey. The compounded effect between experienced, internalised, and anticipatory stigma not only deters these at-risk populations from engaging with dental care services and therefore perpetuates the deterioration cycle, but the structural stigma at-play can also lead to poorer treatment outcomes and permanent irreversible oral health consequences. Acknowledging the damaging effect of stigma in dentistry settings is an important step for policy makers and institutions to enact appropriate education, training and resources to help dental practitioners to become more trauma-informed and empathetic in their clinical practice; as well as to help accommodate and welcome the individuals that need dental care the most. Abbreviations AIHW Australian Institute of Health and Welfare AOD Alcohol and Other Drugs BMI Body Mass Index GP General Practitioner LE Lived Experience LEA Lived Experience Australia LGBTIQA + Lesbian Gay Bisexual Transgender Intersex Queer (or Questioning) Asexual ODTP Opioid Dependence Treatment SBIRT Screening, Brief Intervention, and Referral to Treatment TIC Trauma Informed Care Declarations Ethics approval and consent to participate A Participant Information Sheet was provided, and consent was confirmed online prior to them proceeding to answer the online anonymous survey questions. This research was approved by the Flinders University Human Research Ethics Committee (No.7597). Consent for publication Plans for publication were described in the Participant Information Sheet and consent for publication was then contained within the process of consent to participate in the study. No identifiable data was collected. All direct quotes were de-identified to ensure removal of any potentially identifiable references to specific people, services or locations. Competing interests AN, AC, CK and the Lived Experience Co-Design Working Group (LE-B, PJ, JM, CN, SR, RT and AT) have no competing interests to declare. Funding The larger survey from which this research was drawn was funded in-kind by Lived Experience Australia from within its operating funds. The project reported here was undertaken as part of an Advanced Studies medical student placement which includes a small stipend of $ 2000 to support the student’s project. Author Contribution AN: Conceptualization, Data curation, Methodology, Investigation, Writing – Original Draft, Writing – Review and Editing.SL: Conceptualization, Data Curation, Methodology, Investigation, Project Administration, Resources, Funding Acquisition, Writing – Review and Editing.AC: Investigation, Writing – Review and Editing.LE-B, RH, PJ, JM, CN, SR, RT, AT, CK: Conceptualization, Methodology, Writing – Review and Editing. All authors read and approved the final manuscript. Acknowledgement We wish to express our appreciation to the people who participated in this survey, the Lived Experience Co-design Working Group for their expertise and collaboration in developing the survey questions and Lived Experience Australia their focus on this important topic. Data Availability The datasets generated and/or analysed during the current study are not publicly available due to it being owned by Lived Experience Australia and used with permission for the current study. 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Barriers and facilitators in the integration of oral health into primary care: a scoping review. BMJ Open. 2017;7(9):e016078. 10.1136/bmjopen-2017-016078 . Hatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci Med. 2014;103:1–6. 10.1016/j.socscimed.2013.12.017 . Ho RWH, Chang WC, Kwong VWY, Lau ESK, Chan GHK, Jim OTT, et al. Prediction of self-stigma in early psychosis: 3-Year follow-up of the randomized-controlled trial on extended early intervention. Schizophr Res. 2018;195:463–8. 10.1016/j.schres.2017.09.004 . Hsieh HF, Shannon SE. Three Approaches to Qualitative Content Analysis. QHR. 2005;15(9):1277–88. 10.1177/1049732305276687 . Johnson AM, Kenny A, Ramjan L, Raeburn T, George A. Oral health knowledge, attitudes, and practices of people living with mental illness: a mixed-methods systematic review. BMC Public Health. 2024;24(1):2263. 10.1186/s12889-024-19713-1 . Johnson AM, Kenny A, Ramjan L, Raeburn T, George A. Exploring Oral Health Promotion Among Mental Health Providers: An Integrative Review. Int J Mental Health Nurs. 2025;34:e70007. https://doi.org/10.1111/inm.70007 . Kalaigian A, Chaffee BW. Mental Health and Oral Health in a Nationally Representative Cohort. J Dent Res. 2023;102(9):1007–14. 10.1177/00220345231171108 . Kang J, Wu J, Aggarwal VR, Shiers D, Doran T, Palmier-Claus J. Investigating the Relationship between Oral Health and Severe Mental Illness: Analysis of NHANES 1999–2016. Dent J (Basel). 2024;12(7):191. 10.3390/dj12070191 . Kao YC, Lien YJ, Chang HA, Wang SC, Tzeng NS, Loh CH. Evidence for the indirect effects of perceived public stigma on psychosocial outcomes: The mediating role of self-stigma. Psychiatry Res. 2016;240:187–95. 10.1016/j.psychres.2016.04.030 . Karamat A, Smith JG, Melek LNF, Renton T. Psychologic Impact of Chronic Orofacial Pain: A Critical Review. J Oral Facial Pain Headache. 2022;36(2):103–40. 10.11607/ofph.3010 . Kisely S. No Mental Health without Oral Health. Can J Psychiatry. 2016;61(5):277–82. 10.1177/0706743716632523 . Kisely S, Baghaie H, Lalloo R, Siskind D, Johnson NW. A systematic review and meta-analysis of the association between poor oral health and severe mental illness. Psychosom Med. 2015;77(1):83–92. 10.1097/PSY.0000000000000135 . Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders - a systematic review and meta-analysis. J Affect Disord. 2016;200:119–32. 10.1016/j.jad.2016.04.040 . Kleinheksel AJ, Rockich-Winston N, Tawfik H, Wyatt TR. Demystifying Content Analysis. Amer J Pharm Educ. 2020;84(1):7113–23. 10.5688/ajpe7113 . Koschorke M, Oexle N, Ouali U, Cherian AV, Deepika V, Mendon GB, et al. Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe. PLoS ONE. 2021;16(10):e0258729. https://doi.org/10.1371/journal.pone.0258729 . Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders. BMC Psychiatry. 2015;15:274. 10.1186/s12888-015-0653-0 . Macias-Konstantopoulos WL, Collins KA, Diaz R, Duber HC, Edwards CD, Hsu AP, et al. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. West J Emerg Med. 2023;24(5):906–18. 10.5811/westjem.58408 . Mishu MP, Mehreen Riaz F, Macnamara A, Sabbah W, Peckham E, Newbronner L, et al. A Qualitative Study Exploring the Barriers and Facilitators for Maintaining Oral Health and Using Dental Service in People with Severe Mental Illness: Perspectives from Service Users and Service Providers. Int J Environ Res Public Health. 2022;19(7):4344. 10.3390/ijerph19074344 . Patel N, Furin JJ, Willenberg DJ, Apollon Chirouze NJ, Vernon LT. HIV-related stigma in the dental setting: a qualitative study. Spec Care Dentist. 2015;35:22–8. https://doi.org/10.1111/scd.12078 . Patton MK. Qualitative Research & Evaluation Methods. 3rd ed. New Delhi, India: Sage; 2002. Parish C, Siegel K, Pereyra M, Liguori T, Metsch L. Barriers and facilitators to dental care among HIV-infected adults. Special Care Dentistry. 2015;35(6):294–302. 10.1111/scd.12132 . Scrine C, Durey A, Slack-Smith L. Enhancing oral health for better mental health: exploring the views of mental health professionals. Int J Mental Health Nurs. 2018;27:178–86. 10.1111/inm.12307 . Skallevold HE, Rokaya N, Wongsirichat N, Rokaya D. Importance of oral health in mental health disorders: An updated review. J Oral Biol Craniofac Res. 2023;13(5):544–52. 10.1016/j.jobcr.2023.06.003 . Stuewig J, Tangney JP, Heigel C, Harty L, McCloskey L. Shaming, blaming, and maiming: Functional links among the moral emotions, externalization of blame, and aggression. J Res Personality. 2010;44(1):91–102. https://doi.org/10.1016/j.jrp.2009.12.005 . Teng PR, Lin MJ, Yeh LL. Utilization of dental care among patients with severe mental illness: a study of a National Health Insurance database. BMC Oral Health. 2016;16(1):87. 10.1186/s12903-016-0280-2 . Turner E, Berry K, Aggarwal VR, Quinlivan L, Villanueva T, Palmier-Claus J. Oral health self-care behaviours in serious mental illness: A systematic review and meta-analysis. Acta Psychiatr Scand. 2022;145(1):29–41. 10.1111/acps.13308 . Wigsten E, Kvist T, Husberg M, EndoReCo; Davidson T. Cost-effectiveness of root canal treatment compared with tooth extraction in a Swedish Public Dental Service: A prospective controlled cohort study. Clin Exp Dent Res. 2023;9(4):661–9. 10.1002/cre2.759 . Wood L, Byrne R, Burke E, Enache G, Morrison AP. The impact of stigma on emotional distress and recovery from psychosis: The mediatory role of internalised shame and self-esteem. Psychiatry Res. 2017;255:94–100. https://doi.org/10.1016/j.psychres.2017.05.016 . Wright WG, Averett PE, Benjamin J, Nowlin JP, Lee JGL, Anand V. Barriers to and Facilitators of Oral Health Among Persons Living with Mental Illness: A Qualitative Study. Psychiatri Serv. 2021;72(2):156–62. https://doi.org/10.1176/appi.ps.201900535 . Yang M, Chen P, He M-X, Lu M, Wang H-M, Soares JC, et al. Poor oral health in patients with schizophrenia: A systematic review and meta-analysis. Schizophr Res. 2018;201:3–9. 10.1016/j.schres.2018.04.031 . Yokota K, Yu SW, Tan T, Anderson J, Stormon N. The extent and nature of dental anxiety in Australians experiencing homelessness. Health Soc Care Community. 2020;28:2352–61. https://doi.org/10.1111/hsc.13056 . Zain Ul Abideen M, Ali Bushara NA, Nadeem Baig M, Dilshad Siddiqui Y, Ejaz I, Tareen J, et al. Shining a Spotlight on Stigma: Exploring Its Impact on Oral Health-Seeking Behaviours Through the Lenses of Patients and Caregivers. Cureus. 2024;16(6):e63025. 10.7759/cureus.63025 . Additional Declarations No competing interests reported. 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11:08:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7092307/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7092307/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-026-08216-7","type":"published","date":"2026-04-01T15:58:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":106344267,"identity":"e87be5ce-e7cd-4747-881a-eef9313f0642","added_by":"auto","created_at":"2026-04-07 16:13:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1387579,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7092307/v1/dda84c78-b0e7-4b2c-b0cb-c646021b3913.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Oral health and mental health: Lived experiences of stigma and discrimination for Australians with mental health challenges","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003e\u003cb\u003eHealth disparities for mental health populations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOral health is an integral component of overall health. Oral diseases such as dental caries, dental erosion, periodontal disease and edentulism (tooth loss) negatively impact health-related quality of life (Haag et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Oral health constitutes as part of physical health and has been associated with other systemic physical health comorbidities including cardiovascular disease, diabetes and cancer and increased mortality rate (Kisely et al., 2018; Skallevold et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Poor oral health significantly impacts both functional and psychosocial aspects of daily life; when mechanical functions involving the teeth and mouth\u0026mdash;such as speech, chewing, and swallowing\u0026mdash;are impaired, essential activities become challenging (Kisely, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In addition to these functional challenges for the individual, poor oral health can adversely affect psychosocial well-being, contributing to lower self-esteem, reduced social engagement, and diminished employment opportunities. These effects are particularly pronounced because social value of the face, mouth, and voice are central to human communication and self-presentation, making oral health a key factor in body image and social participation (Doughty et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Moreover, chronic oral pain, often resulting from conditions such as dental caries, periodontitis, and temporomandibular disorders, has been linked to elevated levels of stress, anxiety, and depression (Karamat et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePersistent pain may also contribute to sleep disturbances and a reduced quality of life, thereby exacerbating pre-existing mental health conditions (Karamat et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Studies clearly establishing that adverse oral health conditions such as higher rates of decayed, missing, and filled teeth are higher in prevalence among people with existing mental health challenges compared to the general population (Kang et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). An umbrella review that also identified this strong association between dental outcomes, mental health conditions and substance use issues, also found that certain risk factors contribute to dental diseases in people with existing mental health challenges, including smoking, poor oral hygiene, dry mouth from psychotropic medications and recreational substances (Choi et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, research has also found that people with mental health challenges receive less dental care than the general population due to various barriers including costs, dental anxiety and stigma (Kalaigian \u0026amp; Chaffee, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kisely et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Teng et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Yang et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eOral health, mental health and stigma\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAn increasing body of literature recognizes oral health-related stigma as a distinct form of health stigma. It is expressed through labelling, stereotyping, social exclusion, and discrimination against individuals or groups whose oral health deviates from societal norms (Doughty et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In the context of oral and mental health, stigma can influence every stage of an individual's healthcare journey, often resulting in delayed treatment, worsening oral health outcomes, and diminished quality of life (Ahad et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). A qualitative study conducted in South Punjab, Pakistan, investigating the impact of dental stigma on oral health-seeking behaviours, found that ridicule and discrimination, both from the community and dental professionals, caused significant emotional distress, shame, and lowered self-esteem. Consequently, many individuals postponed seeking treatment until their conditions became unbearable (Zain Ul Abideen et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStigma and intersectionality\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOral health-related stigma is intensified by disparities in social, political, and economic power, as well as structural violence and overlapping marginalized identities. It both reflects and reinforces disadvantage, causing harm to stigmatized individuals and groups throughout their lives (Doughty et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Many international studies allude to stigma of mental illness as another barrier to preventive or follow-up dental care for persons with mental health challenges. A qualitative study from the US suggested that service providers, including psychiatrists and dentists, hold the same stigmatised perceptions of mental illness as the general public (Wright et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In a qualitative study conducted in the UK described mental health-related stigma and discrimination which leads to the lack of involvement of service users in their oral care as one of the inter-personal barriers to improving oral health in people with SMI (Mishu et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Dental anxiety among patients has also been shown to cause treatment refusal by dentists, especially if those providers have limited mental health training (Wright et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn Australian mixed-methods systematic review also noted that communication and more specifically the lack of empathy, psychological and trauma-informed language used by dentists are perceived by individuals living with mental health challenges and other at-risk population groups as a barrier to their engagement with dentists (Johnson et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Johnson and colleagues also discussed the inadequacy in communication about oral health, both between dental practitioners and psychiatrists and with patients, which contributed to gaps in preventative care knowledge among people with mental health challenges. Despite some individuals having high health literacy, misunderstandings still occurred, often due to a lack of empathy, psychologically and trauma-informed approaches, and the use of complex or unclear language by dental professionals. They also highlighted the role of the side effects of psychotropic medications (such as dry mouth and teeth grinding) and their impacts on oral health in this population group (Johnson et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This limited knowledge, coupled with lower priority for oral health due to the symptomology experienced as part of mental illness, may lead to poor oral care practices such as lower rates of tooth brushing frequency and regular dental visits compared to the general population (Turner et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStructural stigma in dentistry setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn Australia, where 85% of dental services are provided through the private sector and most of these are subsidised by private health insurance providers, oral health inequities are mainly driven by socioeconomic disparities, as individuals from lower socioeconomic backgrounds often face financial and structural barriers to regular dental care such as long waiting lists for subsidised care and high out-of-pocket fees for dental services (AIHW, 2024). In addition to socioeconomic challenges, vulnerable populations including individuals living with mental health challenges, disability and those experiencing homelessness also face substantial challenges of living with and managing mental health symptoms and their impact on attendance at dental appointments, as well as a higher severity of dental anxiety and phobias (Johnson et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Wright et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). More notably, individuals experiencing mental health challenges, homelessness, or both, report significantly higher levels of shame and embarrassment as anxiety triggers compared to the general population (Yokota et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eGaps in practice and literature\u003c/b\u003e\u003c/p\u003e\u003cp\u003e There is little emphasis on oral health disparities in current mental health practice guidelines for providers regarding treating people with mental health challenges. For example, a recent review of 16 studies and five guidelines/recommendations exploring oral health promotion among mental health providers concluded that their current practices are fragmented and inconsistent, and that more knowledge, education, and training are needed. They noted a number of challenges including workloads and time constraints, lack of collaboration with dental services, and what they termed \u0026lsquo;challenging client behaviours\u0026rsquo;. They also called for more detailed clinical practice guidelines, more user-friendly oral health screening tools and improved referral pathways between oral health and mental health care providers (Johnson et al, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Likewise, guidelines for oral health and mental health to inform practice by oral health providers are in their infancy and are framed as deficits in the person, with only indirect reference to how oral healthcare providers could respond differently. For example, the current Australian Commission on Safety and Quality in Healthcare Guidelines for adult inpatients (2023, p.13) make only one reference to people with mental health challenges, stating, \u0026ldquo;Patients suffering from cognitive impairment, intellectual disability or mental health conditions may behave in a way that makes it difficult to provide oral care. Consider the need for a dental referral if oral care resistance is prolonged. Implementing the principles of person-centred care and effective communication and can support patients with oral care resistant behaviours, reduce anxiety and encourage participation during oral care\u0026rdquo;.\u003c/p\u003e\u003cp\u003eThe existing literature reveals several significant gaps that warrant further exploration. First, there is a notable lack of studies that are led and co-designed by individuals with lived experience of both oral health and mental health challenges. This participatory approach is essential to ensure that research reflects the perspectives and priorities of those most affected. Second, Australian-based research from a lived experience perspective remains limited, highlighting a need for context-specific studies that consider local systems, services, and cultural factors. Third, although there is a growing body of research examining the relationship between oral health and mental health, most studies employ quantitative methods, with comparatively few qualitative studies that explore these associations in depth. Fourth, current literature often adopts a deficit-based lens when discussing people with mental health challenges, frequently framing them in terms of non-compliance or dysfunction. This approach risks reinforcing marginalisation and stigma, underscoring the importance of adopting strengths-based and inclusive research frameworks. Lastly, since the majority of current literature has been derived from research conducted in the United States or other countries, this research is valuable as it focuses on lived experience of people living with mental health challenges in Australia.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eAim\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe aim of this study was to explore experiences of stigma and discrimination related to oral health and mental health for people with mental health challenges.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResearch questions\u003c/strong\u003e\u003cp\u003e What is the lived experience of stigma related to oral health for Australians with mental health challenges? How does oral health stigma interact with mental health stigma for Australians with mental health challenges?\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDesign\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe theoretical framework to inform this study was interpretive phenomenology which is focused on exploring how human beings make sense of and transform their experiences both individually and as shared meaning (Patton, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2002\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSetting: The National Survey Study and this Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study involved a secondary analysis of data collected by a national survey (Lawn et al, 2025) conducted by Lived Experience Australia (LEA), which is an Australian national mental health consumer and carer advocacy organisation (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.livedexperienceaustralia.com.au/\u003c/span\u003e\u003cspan address=\"https://www.livedexperienceaustralia.com.au/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The survey was developed in collaboration with a lived experience co-design group (n\u0026thinsp;=\u0026thinsp;10 individuals drawn from LEA\u0026rsquo;s national representative panel through an expression of interest call). This group was established to identify the questions to include within the survey and support synthesis of results. They met online for three iterative cycles of discussion and design of the survey questions, and then met to discuss the results, with further feedback on the report via email. Co-design group members included consumers and family carers with lived-living experience of oral health and mental health concerns. Two separate surveys were created, one specifically for people with personal lived experience (consumers) and one for family carers (carers). The aim of the larger study was to gain a better understanding of Australian mental health consumers\u0026rsquo; and family carers\u0026rsquo; experiences of oral health and mental health.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample, Recruitment and Data Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe anonymous survey was sent out electronically via SurveyMonkey to LEA\u0026rsquo;s email list (2,800 subscribers) and social networks (8,000 followers), with the survey link also distributed voluntarily by other collaborative mental health consumer and carer advocacy peaks and organizations at state and national level. The survey was open from early November to mid December 2024 (5 weeks).\u003c/p\u003e\u003cp\u003eThere were 234 survey responses in total including 198 consumers and 36 carers participating in the survey. Participants could elect not to answer questions. Consent to participate was provided electronically via the online site through their commencement of the survey. The consumer survey contained 66 questions, consisting of both quantitative and qualitative questions across several areas of interest to the research. For this current study, responses to a subset of four questions was included, focused on stigma and discrimination (see Box 1).\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eWe chose latent content analysis (Hsieh and Shannon, 2025) to analyse the data for this study because it is useful for examining lived experiences in order to gain deeper insights into how people understand those experiences. This approach allowed us to organize large amounts of text into categories that reflect a shared meaning of oral health and mental health in relation to stigma experiences. Latent content analysis is an inductive, bottom-up analysis that applies a deeper, interpretive analysis that seeks to describe underlying meaning co-created from the words or phrases being analysed (Kleinheksel et al, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). It produces phenomenological descriptions that seek to explain the study population\u0026rsquo;s lived experiences.\u003c/p\u003e\u003cp\u003eTo analyse the data, all survey responses to the questions focused on stigma were read iteratively. During the process, recurring issues and comments were discussed by the researchers. The researchers (AN \u0026amp; SL) then independently coded the text responses within each survey question into manageable code categories for analysis. We met fortnightly to discuss and debate the coding structure, determining overarching and subordinate ideas within each category. We then collaborated to build descriptive text to capture the meaning around each coding category. A third researcher (AC) reviewed these processes, offering further insights. This combined input provided a diversity of perspectives and challenged each of us to make deeper meaning from the coding ideas. The draft analysis was shared with the co-design lived experience working group which had helped to design the original survey questions, to seek their further insights. These processes enabling robust discussion by all members of the research team, including the lived experience working group, and finalisation of themes within each question area.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBox 1. Outline of Overall Survey Question Areas and Questions for this Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreliminary section (6 questions)\u003c/p\u003e\u003cp\u003eQuestions seeking demographic information (e.g., age, gender, location)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMain Survey (8 Sections / 60 questions)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026bull; Information Sources for Oral Health\u003c/p\u003e\u003cp\u003e\u0026bull; Looking after your Oral Health (past and present)\u003c/p\u003e\u003cp\u003e\u0026bull; Your Contact and Experiences with Dentists and Other Oral Health Staff\u003c/p\u003e\u003cp\u003e\u0026bull; Accessing the Dentist\u003c/p\u003e\u003cp\u003e\u0026bull; Oral Health and Other Health Conditions\u003c/p\u003e\u003cp\u003e\u0026bull; Oral Health and Mental Health\u003c/p\u003e\u003cp\u003e\u0026bull; Experiences with Mental Health Professionals\u003c/p\u003e\u003cp\u003e\u0026bull; The Health System - What can be done/what needs to change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCurrent Study - Specific Questions in Focus\u003c/b\u003e\u003c/p\u003e\u003cp\u003e(1) Have you experienced stigma and discrimination from dental staff (e.g. dentists, dental hygienists, dental specialists, administrative staff) when seeking your oral health? (Q28)\u003c/p\u003e\u003cp\u003e(2) Have dental staff attitudes made you feel ashamed or to blame for the state of your oral health? (Q30)\u003c/p\u003e\u003cp\u003e(3) (if relevant to you) How have the dentist/dental clinic staff behave when/if they have become aware that you have a mental health condition? Please specify (Q40)\u003c/p\u003e\u003cp\u003e(4) (if relevant to you) How have the dentist/dental clinic staff behaved when/if they have become aware that you have experienced problems with alcohol and other drugs? Please specify (Q41)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA summary of participants\u0026rsquo; demographic details is provided in Box 2 below. This is followed by results from the latent content analysis from responses to the found questions included in this study, organised as themes within each section with deidentified quotes from participant to demonstrate each theme.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBox 2: Demographic Data\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; All Australian States and Territories were represented.\u003c/p\u003e\u003cp\u003e\u0026bull; Most consumers identified as women/female (73%; n\u0026thinsp;=\u0026thinsp;111 of 153), 21% (n\u0026thinsp;=\u0026thinsp;32) were men/male, 5% (n\u0026thinsp;=\u0026thinsp;8) were non-binary, 1 used a different term and 1 preferred not to say.\u003c/p\u003e\u003cp\u003e\u0026bull; Two-thirds of consumers (65%; n\u0026thinsp;=\u0026thinsp;100 of 153) lived in a capital city/metropolitan area, a quarter (26%; n\u0026thinsp;=\u0026thinsp;40) lived in a regional city/area, and 9% (n\u0026thinsp;=\u0026thinsp;13) lived in a rural or remote area.\u003c/p\u003e\u003cp\u003e\u0026bull; 34% (n\u0026thinsp;=\u0026thinsp;51) of consumers identified as LGBTIQA+; 14% identified as culturally or linguistically diverse; 4% identified as First Nations.\u003c/p\u003e\u003cp\u003e\u0026bull; 62% (n\u0026thinsp;=\u0026thinsp;93) of consumers identified as a person with a disability.\u003c/p\u003e\u003cp\u003e\u0026bull; Consumers ranged in age; most (84%; n\u0026thinsp;=\u0026thinsp;128 of 152) being between 30\u0026ndash;69 years, 11% were 18\u0026ndash;29 years and 5% were 70\u0026thinsp;+\u0026thinsp;years.,\u003c/p\u003e\u003cp\u003e\u0026bull; 16% of consumers also identified as a family carer of someone with mental ill-health.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHave you experienced stigma and discrimination from dental staff when seeking your oral health?\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eMental health-related stigma can adversely affect diagnosis and treatment. As exemplified by the below participant\u0026rsquo;s response, upon learning of their mental health history, the dental practitioner prematurely attributed the dental health issues to mental health issues without considering alternative explanations, such as undiagnosed reflux. This reflects confirmation bias and diagnostic overshadowing where negative mental health assumptions obscure accurate clinical assessment. Additionally, the accusatory approach can compromise trust and lead to disengagement from care. This highlights how implicit bias, and a lack of trauma-informed, patient-centred care can result in misdiagnosis, emotional harm, and disrupted therapeutic relationships, deterring patients from seeking or continuing treatment.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI'm not sure about stigma, but I do find that I am met some uncomfortable energy when I see a new dentist and explain my situation to them. I once stopped seeing one because she accused me of lying about being bulimic because she saw erosion on my back teeth, often associated with purging, but it was because I had habitual reflux due to an as-yet undiagnosed digestive issue.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e When participants disclosed dental anxiety or pain and advocated for appropriate support, such as requesting analgesia, they were frequently met with dismissal and invalidation. Several reported feeling trivialised and perceived as exaggerating or fabricating their symptoms. One participant described being perceived as \u0026ldquo;a bad person\u0026rdquo; for disclosing dental trauma and requesting pain relief. In one extreme instance, a dentist responded to a participant\u0026rsquo;s request for anxiety management during a wisdom tooth extraction by telling them to \u0026ldquo;go to the pub to relax\u0026rdquo;, despite the individual\u0026rsquo;s known history of alcohol misuse and active engagement with substance use services. When the participant attempted to construct a collaborative plan with the dentist to accommodate for their needs, the dentist ignored them and proceeded with an assessment against their wishes. Another participant recalled receiving rougher treatment after raising concerns about inadequate analgesia. These accounts highlight how stigma toward mental health and trauma can manifest in clinical interactions through microaggressions leading to further psychological harm and avoidance of care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026hellip;It feels like they think I am making up my anxiety and or pain.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSome responses reveal a more concerning pattern in which mental health stigma leads dental practitioners to dismiss, downplay, or refuse treatment for legitimate oral health concerns. Participants described not being believed about severe pain, visible wounds, and progressive infections, with one participant being accused of drug-seeking behaviour, a stigmatising and harmful assumption. This dismissiveness appears to stem from implicit biases linking mental illness with exaggeration, unreliability, or manipulation, resulting in care delays and diagnostic neglect. In some cases, conditions were left untreated until they escalated to emergencies, such as necrosis of the jaw or severe abscesses. Such responses reflect not only therapeutic disregard, but potentially constitute clinical negligence, given the avoidable harm caused. Furthermore, the accusations of drug-seeking illustrate how people with mental illness are often subject to moral judgment rather than clinical assessment, particularly when reporting pain. This may lead to undertreatment, distrust, psychological distress and retraumatisation, further compounding the individual\u0026rsquo;s physical health risks and mental health and wellbeing.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI have not been believed about oral health pain and been called a drug seeker I have not been believed about an open wound in my mouth down to my jaw (they said it was just an abscess) which almost turned into necrosis of the bone.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eLeaving issues present until it becomes emergency i.e. tooth abscess.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI was sent away recently despite being in pain.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Some participants recounted retraumatising interactions that reflect a lack of trauma-informed practice in dental settings. One individual who disclosed a history of sexual abuse and PTSD claimed being mocked by a dentist when expressing discomfort with oral procedures. This reflected ignorance and insensitivity to trauma, as shown in the below quote. Another reported being asked intrusive and sensitive mental health questions, such as about suicidal ideation, without any explanation or clinical relevance to the dental visit. These experiences suggest breaches in professional boundaries and a failure to provide safe, respectful care for individuals with complex trauma histories.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI've been laughed about when expressing my aversion to having stuff put in my mouth.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn contrast, several participants described \u003cem\u003eanticipatory stigma\u003c/em\u003e, choosing not to disclose their mental health history to avoid expected discrimination. This concealment was due to prior negative healthcare experiences followed by fear of being judged or receiving substandard care. As one participant shared, \u0026ldquo;I\u0026rsquo;m frightened they would discriminate if they knew my mental health history,\u0026rdquo; citing repeated instances of stigma from GPs and hospital staff. Others also avoid disclosure in dental settings specifically to protect themselves from further harm.\u003c/p\u003e\u003cp\u003e Participants with concealable stigmatised identities such as HIV-positive status, viral hepatitis, or other transmittable infectious diseases, reported intersectional internalised stigma and anticipatory stigma resulting in increased psychological and emotional distress during their dental visits. Despite no legal obligation, one participant volunteered their history out of concerns for the dentist to take extra precautions. However, after the dentist learned their health status, they were refused treatment. Such negative disclosure reactions and discrimination may have exacerbated their existing internalised stigma, causing further anxiety and fear of disclosure, therefore worsening anticipatory stigma.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI had a public dentist refuse to treat me when they learnt I had Hepatitis C. I know this as he left after he asked me about [it]. When I was in the chair, and I heard him say to a nurse outside he was no longer available.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eHaving to discuss my HIV status, I carry additional burden thinking of the dentist\u0026rsquo;s health and ensuring they remain safe. I know they are responsible for taking necessary precautions. It\u0026rsquo;s still a risk I have to emotionally grapple with each visit.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants also reported experiencing intersectional stigma related to their social identities. One individual described socioeconomic discrimination based on their appearance - being perceived as \"looking poor.\" Others from marginalised backgrounds, including migrants, refugees, and racial minority groups, reported ongoing experiences of racism, xenophobia, and classism within dental settings, often facing dismissiveness and lower standards of care. This was demonstrated by clinicians\u0026rsquo; behaviour towards them, specifically anticipated patient failure to self-care or have oral health literacy based on stereotypes related to race, class, or perceived capability. Rather than offering education, encouragement, or collaborative care, clinicians prematurely judged patients as unlikely to maintain oral hygiene, leading to the withholding of standard preventive practices, including health education, shared decision-making, and empathetic communication.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAll through my childhood, the only dental service I received was the dentist who came to my school. There was a lot of racism back then towards Pacific Islander children. I've also experienced discrimination and racism from dentists I've visited as an adult. They've been dismissive, judgmental and you could tell that they didn't think I was going to succeed in looking after my teeth, so they didn't make any effort to show me, ask me or talk to me about my concerns about my teeth\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eIn one case, a participant described undergoing a full-mouth extraction of teeth at a public dental clinic without receiving adequate explanation, informed consent, or discussion of alternative treatments. This experience resulted in lasting dental trauma.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026hellip;when I arrived in Australia as a single mother of three and a refugee, I've been sent to public dental clinic where they took all my teeth out without any explanation or asked question before the procedure\u0026hellip; it is trauma then and forever.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eStigma may subtly influence clinical decision-making, particularly in the treatment of individuals with poor oral health or mental health conditions. Many participants expressed dentists\u0026rsquo; tendency to perform tooth extraction rather than offering and pursuing preservation technique such as root canal therapy. This suggests an underlying biased attitudes held by dentists in patients\u0026rsquo; perceived worthiness or compliance. People with mental health issues may be assumed to have poor oral hygiene, reduced treatment adherence, or lower capacity for self-care, which can lead to discriminatory assumptions about the viability or value of restorative treatment. This also reflects how structural stigma can manifest in treatment planning, where cost-saving or expedient options are prioritised over long-term, preventative patient-centred care, thereby contributing to ongoing health disparities and reinforcing cycles of neglect and disengagement.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThere is the tendency to pull out teeth rather than try to save them. We should have access to root canal treatment.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePublic system dentists... Just pull teeth with no other option. No cosmetic dentistry offered to save teeth. No funding I'm guessing!\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSome dentists are dismissive if you have some oral health issues and are reluctant to do procedures to treat the affected tooth/teeth, preferring to simply pull out the tooth/teeth.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI was told I wouldn't be accepted for my dental implants because of my hygiene.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e The intersectionality of stigma related to substance use and mental health and its stereotypes resulted in many participants recounting experiencing negative attitudes and hostility from dental staff, particularly being judged and shamed for their presumed lifestyle, but also because of their mental health status. In some instances, dental staff often incorrectly attributed poor oral health conditions to the individual\u0026rsquo;s supposed diet, smoking, alcohol use, or recreational substance use. Many reported being criticised by their dentists for their substance use which lead to increased guilt and shame, worsening internalised stigma. This harmed therapeutic relationships and led them to disengage from the dental service.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDental staff said I have receding gum line and attributed it to my diet, but I believe medications impact my oral health.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen they hear the medication that caused the side effects, there is a lot of judgement about it, even just on their faces, and even though I tell them I haven't taken it for a long time.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI used to smoke and, due to the constant stigma associated with comments that I received, I stopped going for several years. I also had bad experiences with government dentists when in hospital for mental health treatment. I was no danger to anyone/or myself but the dentist insisted on a security guard with no justification at all to base this on. I've never been back to a government dentist since.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI went to see the dentist they told me my teeth wouldn't be this bad if you didn't touch drugs or alcohol.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e There were also instances of oral health-related stigma reported where participants received counter-productive judgement, reprehension, and humiliation purely for the poor state of their oral health. One participant highlighted how structural stigma results in health inequality/disparity where poor oral health outcomes might stem from lack of dental-oral care education and resources in childhood. Another participant attempted to offer their perspectives on how their mental health affected their ability to care for their oral health. They described being infantilised by the dental practitioners; they were treated and \u0026ldquo;spoken to like a child\u0026rdquo; instead of using this as an opportunity to explore and understand the daily challenges they might face as part of living with mental health challenges, to discuss the solutions to address those challenges, or to just offer the person education on practical steps to improve their oral health.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey look down on us for having bad teeth. Some don't realise it comes from our childhood where our parents never taught us, and we grew up continuing that. They also don't understand severe mental health.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe dentist I saw as a child would chastise me for my poor oral hygiene but not offer practical solutions except for the usual advice of brushing twice a day and so on. As an adult I've had similar experiences like being told by a dentist I have the teeth of a 60-year-old when I was 20.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e Being spoken to like I was a child when explaining the difficulties I have maintaining my oral hygiene and being told off for not looking after myself better with no understanding of the challenges I face due to my mental health conditions.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e'Why did you let your teeth get into such a state?!'\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHave dental staff attitudes made you feel ashamed or to blame for the state of your oral health?\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubstance use and health-related stigma\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome responses revealed stereotyping by dental staff that related to participants\u0026rsquo; past medical history of alcohol or other drug (AOD) use and elevated body mass index (BMI). One participant reported receiving presumptuous, patronising and stereotype-driven advice regarding their lifestyles such as \u0026ldquo;don\u0026rsquo;t drink fizzy drinks\u0026rdquo; or \u0026ldquo;cut down on the junk food\u0026rdquo;. Conversely, other responses described stereotyping around diet and smoking arising from failure to review relevant medical history, as shown in the quote below:\u003c/p\u003e\u003cp\u003e\u003cem\u003eMany will comment without taking any notice of my medical history, in that my bone density issue is due to a genetic birth defect, but they'll tell me things like I'm not eating properly or it's all due to past smoking etc. Then I have to tell them smoking is the only bad habit that affected my dental health. It's often upsetting that their lack of knowledge regarding my health condition makes them jump to any conclusion that suits their own knowledge\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOral health-related stigma\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Some participants reported internalised stigma regarding their poor oral health, while many others reported experiencing verbal and non-verbal judgement, negative attitudes, or even reproachful communication for their poor oral health state from dental staff. Consequently, judgement concerning perceived poor choices or neglect of oral hygiene exacerbated participants\u0026rsquo; pre-existing feelings of shame, both during and after their encounters with dental care services.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSome dentists in the past have been very judgmental and this has contributed to the extreme shame I feel about my teeth. In a way, I am to blame - most of my dental issues are caused by poor choices, but that doesn't make me any less worthy of care and compassion.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e There have been times that I felt judged by the condition of my oral health when I had poor motivation to look after it. I already felt ashamed about it but then the attitudes of some dental hygienists amplify that feeling.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInternalised and anticipatory stigma\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSimilarly, one participant reported internalised and anticipatory oral health-related stigma including concerns about the appearance of untreated malocclusion (misaligned teeth) due to delayed orthodontic treatment. Another participant described how stigma associated with AOD use further contributed to discomfort and non-disclosure in dental settings driven by anticipated judgement from dental staff.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen I was in active addiction, I wasn't comfortable divulging the amount I drank or the drugs I used to dental staff.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI frequently feel ashamed that I haven't yet got braces to straighten my teeth at my age\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e Some participants reported experiencing shame in response to corrective feedback about their oral hygiene practices, despite their efforts to maintain dental health.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSometimes I feel shame when I am told that I have not been brushing/flossing my teeth effectively\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eOnly regarding certain behaviours, such as over brushing\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntersection of mental health-related stigma and oral health stigma\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral responses highlighted the intersection of mental health-related and oral health stigma within dental settings. Participants described experiences of shame, dismissal, and a lack of empathy when their oral health concerns were linked to psychiatric conditions. One participant reported feeling ashamed when attributing their dental issues to mental illness, while another noted the absence of open dialogue around the impact of mental health on oral health, such as bruxism associated with chronic anxiety. Another described being shamed by multiple dental professionals before finally receiving empathetic care and appropriate treatment. In one case, a participant with a documented psychiatric history reported being wrongly presumed to have a hallucinatory disorder, leading to the gaslighting by dental staff (intentionally attempting to make another doubt their own sanity) and dismissal of the person\u0026rsquo;s legitimate dental concerns.\u003c/p\u003e\u003cp\u003e\u003cem\u003eHave felt embarrassed when explaining why I haven't brushed my teeth properly is because of mental health.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e I grind my teeth a lot (a biproduct of chronic anxiety) and this causes oral pain. I need a dentist that is open to conversations about mental health and oral health. In my experience not all dentists are.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI had a psychosomatic issue that caused a kind of bulimia anorexia that went on for 6 years, I was shamed by 4 dentists before someone said that that explained where my cavities were located and showed real empathy\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eMy dental concerns have been dismissed as delusions, where I was required to advocate\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eheavily for someone to listen and take my unique situation into consideration. Once they\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eviewed my cracking teeth due to the immense pressure from clenching in my sleep, they saw\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ea night splint was required - but this took me much effort to get through the stigma and\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003edismissal of my concerns as my \u0026lsquo;imagination\u0026rsquo;, or me supposedly suffering from a hallucinatory form of mental health condition - which I do not; I only have a brain injury and anxiety and complex PTSD which is undoubtedly heightened by the way I am treated.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eShame as part of manipulative business strategies\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Interestingly, some responses suggested that shame was used strategically by dental professionals to exploit participants\u0026rsquo; vulnerability and encourage uptake of additional procedures. Participants described the use of shaming or fear-based tactics as a business strategy, which in-turn exacerbated feelings of shame, dental anxiety, and phobia.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI pushed back at the shaming that seemed to be occurring during some visits. I was told the dentists had to compete with one another business-wise so they were instructed in conferences to play up the horrible things happening to their patients\u0026rsquo; teeth so they can convert that into more procedures and literally scare people to give up their money and engage in oral services.... it was a marketing ploy!!! That further accelerated my dentist phobia.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eYes, because I refuse extra add-ons like whitening, crowns, caps etc\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eUnethical practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne account highlighted perceived unethical and exploitative practices in dental care, particularly within teaching environments where power imbalances may be heightened. The participant described the clinically unnecessary removal of a functional composite filling by a student dentist for the purpose of fulfilling graduation requirements. This misuse of authority and potential violation of informed consent led to a cascade of complications, including emergency dental mismanagement, eventual tooth extraction, and significant functional impairment.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI had a good compost filling which did not bother me, but the student at the dental school\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ewanted to practice for his graduation project and made me believe it needed to be removed. He replaced it with an amalgam filling which broke not long after. The emergency dentist refused to refill it but chopped it up at a slant angle making it not possible to mend. Eventually it had to be extracted causing me to use the other side heavily. Now, I could not chew on either side of my mouth!\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHow have the dentist/dental clinic staff behaved when/if they have become aware that you have a mental health condition?\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInconsistent responses\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Several responses indicated that, upon learning of participants\u0026rsquo; mental health conditions, dental staff adopted more person-centred care including compassionate and caring attitudes and tailored their behaviour or treatment approaches to accommodate psychological needs.\u003c/p\u003e\u003cp\u003e\u003cem\u003eMy Dentist sat down with me and took the time to listen to my concerns. He provided me with compassion, understanding \u0026amp; respect. He also allowed me to set the pace for my appointments which is useful when I am feeling particularly anxious.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey have been very supportive, explaining what they are about to do, making encouraging comments and sometimes the assistant may put their hand on my arm if I am tense.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eConversely, some participants again described experiences of infantilisation and assumptions of poor health literacy. One participant reported that, after disclosing their condition, some dentists addressed their partner instead of them, effectively undermining their autonomy.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWith some, I think they've tended to change how they talk to me, as if I'm intellectually disabled or something. It's a little bit condescending really.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSome dentists after learning this about me treat me like a child and will only speak to my partner instead of me.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe public dental staff - when I informed them I have an ABI - they have immediately commenced speaking to me like I am a small child in need of consolation after an injury, which is incredibly disconcerting, belittling, and shame inducing. I am highly uncomfortable, and it always requires further explanation that my issue is with memory, processing speed and sensory damage - and that my intelligence is predominantly ok\u0026hellip;and please speak to me a little slower, however use your regular discussion interaction, however this is often met with distain, sideways looks between staff, and derision, which makes me want to melt into the floor like I do not exist.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOthers reported mixed responses from dental staff, ranging from curiosity and neutrality to overt stigma. Some participants recognised such inquiries as part of the standard clinical work-up, including questions about medications and medical history. Notably, one participant observed that psychiatric history was more often discussed during longer appointments with student dentists who were perceived as more thorough and less judgmental. As one remarked, \u0026ldquo;the students tend to ask these types of questions,\u0026rdquo; yet \u0026ldquo;treated me just as another patient.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen I do mention the dental problem and add it could have been my mental health issues, I can see they are trying to compute the information and start to ask for more information from their training.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eNon-disclosure as a coping mechanism\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMany participants chose not to disclose their mental health status due to internalised or anticipatory stigma, often shaped by prior negative experiences or intersecting marginalised identities such as Indigenous background or HIV-positive status. Fear of judgment and discrimination emerged as a significant barrier, contributing to hesitancy or reluctance in sharing mental health concerns during dental encounters. Some suggested that disclosure might be more manageable through pre-appointment forms, offering a safer and more structured means of communication. One participant noted they would only engage with dental services in the presence of a support person or advocate.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI would not disclose this information as I feel I would just be judged and face discrimination. This is based on many years of real-world live experience\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFor an Indigenous person we are already pre-judged. They didn't know, just that I had suffered severe DV [domestic violence] and trauma from it\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cem\u003eI get enough judgement for having poor teeth, I am definitely not going to tell them I have amental health condition. I feel they would not understand at all, and it wouldn't make any difference in what they suggest anyway.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI never disclosed this information due to embarrassment and shame. Only recently since going to private, holistic dentist have I disclosed my anxiety, but not other mental health condition.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSometimes, I choose to disclose if I feel safe enough. But after the discrimination I had at a public dentist, I am very careful and wait till I feel safe to disclose\u0026hellip;Hard to shake the real possibility of discrimination.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStaff responses to disclosure\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Numerous participants reported that dental staff became less friendly, more distant, or overtly judgmental following the disclosure of mental health conditions. Staff were described as \"stand-offish,\" speaking less, appearing fearful, or reluctant to provide care. These reactions were often perceived as stemming from stigma or a lack of understanding about mental illness, which undermined trust and discouraged continued engagement with dental services.\u003c/p\u003e\u003cp\u003eRather than acknowledging dental anxiety or adopting trauma-informed approaches, some staff dismissed the relevance of mental health and instead recommended sedation or medication as the default solution. One participant noted that dental professionals appeared ill-equipped to support individuals with autism spectrum disorder or sensory sensitivities. Some dental staff were perceived to hold insensitive views that mental health challenges are invalid explanations for poor oral hygiene. Other participants felt condescended to when attempting to engage with dental care services.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey told me that I shouldn't be stressed about things...was not very understanding of my anxiety and that I may have to take medication to have any work done\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003e As if it is no excuse for poor oral hygiene.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI did not feel they behaved differently in terms of my diagnoses themselves, but did act in a more judgemental way when learning said diagnoses impacted my oral health \u0026amp; ability to care for my teeth/mouth.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey clearly don\u0026rsquo;t understand that a mental health condition doesn\u0026rsquo;t mean I am intellectually impaired. I make a special effort to ask relevant questions but there is always a sense of unease about it.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eHow have the dentist/dental clinic staff behaved when/if they have become aware that you have experienced problems with alcohol and other drugs?\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInconsistent responses\u003c/b\u003e\u003c/p\u003e\u003cp\u003eExperiences with dental staff regarding AOD use varied across participants. Some dental staff attempted to discourage AOD use which varied in effectiveness. One participant reported receiving supportive and structured approaches to health education from dental staff. Another participant recalled a positive experience in which dental staff expressed understanding and affirmed their recovery journey. However, another reflected that only after achieving long-term sobriety did they receive more enthusiastic and respectful care, suggesting that prior interactions may have been shaped by stigma and discrimination. Notably, a few participants questioned whether professionalism in responding to disclosure of AOD use varies between private and public dental care settings.\u003c/p\u003e\u003cp\u003e\u003cem\u003eNow that I have been sober for 15 years, they seem to want to help more than before.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWith my anxiety, I didn't burden them with those issues. I did go through their checklist or\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003equestions thoroughly. As my lifestyle changed, their behaviour was very professional and I\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003edidn't feel uncomfortable. I guess I was paying the bill?\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003cp\u003e, \u003cb\u003eavoidance and blame\u003c/b\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e There appears to be a communication gap around AOD use, with participants often avoiding disclosure due to fear of judgment, while some perceived dental staff deliberately avoided the topic to prevent discomfort. When substance use was known or assumed, many participants reported experiencing various forms of judgment, discrimination, or bias. Negative behaviours included being spoken to condescendingly, treated with less patience, or blamed for their oral health issues. Some participants perceived a lack of empathy, as staff attributed oral health problems to personal fault related to their AOD use rather than recognizing contextual and structural factors, such as the effects of complex trauma. Additionally, one participant described being chastised with a paternalistic \u0026ldquo;lecture\u0026rdquo; instead of receiving empathetic dialogue exploring the underlying psychosocial drivers of substance misuse.\u003c/p\u003e\u003cp\u003e\u003cem\u003eJudgmental but when I say I have been off drugs since 2008 they congratulate me but it\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eseems forced.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStigma felt as I had caused this, rather than trying to understand the circumstances \u0026ndash; complex trauma from childhood sexual abuse\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI\u0026rsquo;ve received a lecture. In the chair is generally not the space to explore what is driving my drug misuse.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eEven when participants disclosed long-term recovery, acknowledgements from staff were perceived as insincere or performative. Another participant reported explicit discrimination where due to their past substance use, some clinicians showed a lack of compassion and denied them of anaesthetics during treatment. Subsequently, these experiences perpetuated internalised stigma and anticipatory stigma as exemplified by one participant who described experiencing stigma and discomfort when disclosing engagement with opioid dependence treatment (ODTP), often accompanied by feelings of embarrassment and humiliation.\u003c/p\u003e\u003cp\u003e\u003cem\u003eNot relevant to me but relevant to an ex-partner. Because it was known that she was a\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003erecovering substance user, it was clinicians were sometimes reluctant to give her painkillers\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eand they had little tolerance/compassion when she developed dry socket from smoking\u003c/em\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e This study explored how internalised and externally applied oral health-related stigmas intersect with mental illness stigma, particularly among individuals who already hold stigmatised identities. It described key drivers of oral health-related stigma, its various manifestations, and the adverse outcomes it produces across the life course from the perspective of people with mental health challenges. Furthermore, the study highlighted the lived experience of Australians affected by such stigma. Its findings point to the need for stigma reduction strategies to foster safer, more inclusive dental care environments, ultimately improving patients\u0026rsquo; oral health behaviours, their relationships with dental health professionals, and their overall physical and mental health outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLayers of stigma\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFindings from this study shows how intersectional stigma, combining mental health status, oral health, socioeconomic status, and other marginalised identities including Indigenous background, migrant/refugee status, substance use histories, or history of transmittable disease (HIV, Hepatitis B, C, etc.) lead to poorer clinical care and consequently lifelong health consequences within dental care. Oral health and mental health stigma can manifest at multiple levels: (1) interpersonal, or \u003cem\u003epublic stigma\u003c/em\u003e encompassing societal judgments and direct discrimination; (2) intrapersonal, or \u003cem\u003eself-stigma\u003c/em\u003e, referring to internalized negative self-perceptions, typically associated with shame; (3) \u003cem\u003eanticipatory stigma\u003c/em\u003e, referring to one\u0026rsquo;s expectation that other will judge, discriminate or stereotype against oneself in the future (Earnshaw et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2012\u003c/span\u003e); and (4) \u003cem\u003estructural stigma\u003c/em\u003e, involving policies that reinforce social exclusion.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Interplay Between Experienced, Internalised, and Anticipatory Stigma\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants in this study reported experiencing both internalised and anticipatory stigma related to poor oral health, mental illness, or AOD use. These forms of stigma frequently led to the non-disclosure of their mental health or substance use histories, a coping mechanism also highlighted in other research (Brondani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ho et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Zain Ul Abideen et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2024\u003c/span\u003e.) A key contributing factor was prior negative experiences following disclosure in other healthcare settings, which eroded trust in health professionals more broadly. These findings suggest that when dental practitioners perpetuate stigma or discrimination regardless of the mediational mechanisms, it can further exacerbate an individual\u0026rsquo;s pre-existing internalised stigma and reinforce anticipatory stigma, particularly during interactions with dental care services.\u003c/p\u003e\u003cp\u003eThis compounded stigma is not merely an internal subjective experience; it has tangible consequences. The interaction between public stigma and self-stigma contributes to poorer psychosocial outcomes, including diminished self-esteem, exacerbation of mental health symptoms, and disruptions to recovery and quality of life (Earnshaw et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Kao et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Wood et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Anticipatory stigma and previous dismissive care also contribute to dental fear and anxiety, which are disproportionately common among individuals with mental health challenges. Studies show that these fears are exacerbated when patients anticipate being judged, disbelieved, or mistreated by dental professionals (Armfield et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Kisely et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Kanka et al., 2021). This often leads to delayed or avoided appointments, worsening oral health and reinforcing stigma-related avoidance. These experiences highlight a toxic cycle in which stigma leads to disengagement from care, further deterioration of oral and mental health, and widening health disparities (Ahad et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAddressing this cycle requires a holistic understanding of the complex interplay between individual, social, and structural factors which includes trauma histories, social determinants of health, and the burden of shame. Without such an approach, the delays in care and worsening health outcomes for people with mental health and AOD challenges are likely to persist.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHow mental-health stigma is manifested in dentistry settings\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study also highlights a broader failure of dental health professionals to recognise and accommodate the psychological dimensions of dental care, especially for those with histories of trauma or mental illness. Ways that stigmatisation are mainly expressed through include:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDiagnostic overshadowing\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eDiagnostic overshadowing occurs when a clinician incorrectly attributes a patient's physical symptoms, in this case oral or dental issues, to an existing mental health or developmental condition, thereby missing the true underlying cause (Clough \u0026amp; Handley, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This study, in line with Hallyburton (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), identifies implicit bias as one of three major contributors to diagnostic overshadowing. When clinicians unconsciously allow mental health labels to dominate their clinical judgement, confirmation bias is reinforced, leading to inaccurate assessments, delayed diagnoses, and substandard treatment outcomes. As discussed by Gopal and colleagues (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), unexamined biases can impair clinical decision-making, particularly in fast-paced environments where assumptions are made under time pressure. Without intentional efforts to challenge these cognitive shortcuts, even well-meaning clinicians risk overlooking the nuanced needs of vulnerable populations. Improving outcomes therefore requires a trauma-informed, person-centred approach, where curiosity replaces judgement, and clinicians reflect on their own attitudes and decision-making processes. Importantly, dental clinicians must acknowledge that many of the factors contributing to poor oral health in these populations lie outside individual choice or behaviour. These include physical manifestations of psychiatric illness (e.g. bruxism), adverse effects of psychotropic medications (e.g. xerostomia), and medical comorbidities. Failing to recognise this complexity reinforces stigma and perpetuates inequity in oral health care.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePerceived delegitimization\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eAnother salient theme in this study is the perceived delegitimisation of participants\u0026rsquo; experiences, particularly when pain or distress were routinely dismissed or minimised due to their mental health history. Rather than being met with clinical curiosity or compassion, participants described being treated as unreliable, manipulative, or \u0026ldquo;drug-seeking\u0026rdquo;, a moralised judgement that reflects underlying stigma toward concealable identities and/or psychiatric conditions. Such assumptions have resulted in diagnostic neglect, undertreatment, and retraumatisation, particularly when reports of severe pain or infection are ignored until they escalate into emergencies (e.g. jaw necrosis, abscesses). This is aligned with broader literature that highlights how provider bias, patient self-doubt, and the stigmatising practice of \u0026lsquo;chart flagging\u0026rsquo; contribute to delayed or denied care and, in some cases, worsened health outcomes or even premature death (Watson et al., 2020). Furthermore, this dynamic reveals a power imbalance in the clinical encounter, where the clinician assumes the role of arbiter of credibility. As described by Corrigan et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), when symptoms are viewed through a moral rather than medical lens, individuals are cast not as patients but as problems, therefore resulting in punitive rather than therapeutic treatments. Consequently, refusal or minimisation of care not only invalidates the individual\u0026rsquo;s lived experience but may perpetuate a cycle of self-doubt and shame, deterring future help-seeking. many patients become reluctant to seek help, fearing they will not be taken seriously or treated with dignity due to anticipatory stigma (Clement et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Doughty et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Patel et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Dolezal, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In this way, stigma becomes self-reinforcing, manifesting not only in the healthcare provider\u0026rsquo;s actions but in the patient\u0026rsquo;s own perception of worthiness and credibility.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eLanguage \u0026amp; Dehumanisation\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eNumerous existing studies have identified that communication and lack of trauma-informed practice in dental settings are perceived as barrier to dental care engagement, particularly for individuals with lived experience of mental illness and other at-risk population groups (Johnson et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Mishu et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Our findings build on this by detailing the specific forms and the consequences of negative clinician attitudes. Rather than offering empathetic, person-centred education and support, some clinicians employed judgmental language, assumptions of poor health literacy, and reduced communication. Participants reported receiving patronising language, being mocked, shamed, patronised, reprimanded and infantilised, and subjected to presumptions of failure.\u003c/p\u003e\u003cp\u003eThese interactions reflect a deeper moral framing of patients\u0026rsquo; behaviours as a personal failing rather than a consequence of systemic barriers or past trauma. Individuals in this study are blamed for perceived self-neglect, reduced compliance, poor lifestyle or oral hygiene, reinforcing the notion that they are undeserving of care, or they must be corrected or disciplined (Stuewig et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). As discussed by Lawn et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), this moralisation leads to blame, shame, and the individuals\u0026rsquo; autonomy being undermined. Furthermore, for individuals with trauma histories, infantilisation can retrigger past experiences of disempowerment or abuse, especially when it mirrors dynamics from psychiatric institutions, coercive family environments, or experiences of marginalisation. Ultimately, these encounters shift the therapeutic relationship from one of partnership to one of paternalism and abandonment, effectively withholding opportunities for recovery and health improvement (Drake \u0026amp; Whitley, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis cycle also perpetuates a self-fulfilling prophecy of neglect: when dental-care providers expect poor outcomes based on implicit bias, they invest less effort, reduce support, and inadvertently contribute directly to the poor outcomes that they anticipated. Over time, patients may internalise this treatment, leading to reduced self-advocacy and self-stigma.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStructural stigma in dentistry: Exploitation, Consent, and Ethical Oversight\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn social science literature, structural stigma is defined as \u0026ldquo;societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized\u0026rdquo; (Hatzenbuehler and Link, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e, p. 2). Structural oral health inequality often begins in early life, where limited access to dental care education, preventative measures and supportive resources disproportionately affects children from disadvantaged backgrounds. Findings in this study highlight on how negative and traumatic experiences with dental providers in early life\u0026mdash; particularly those were explicitly discriminated for their socioeconomic background, race, other marginalised identities\u0026mdash;can have a long-lasting impact on their engagement in oral dental care in adulthood.\u003c/p\u003e\u003cp\u003eStructural stigma is then embedded in the economic and funding models that shape treatment availability and patient decision-making. In publicly funded systems, dental care decisions are frequently influenced by a triad of factors: the patient\u0026rsquo;s financial means, the clinical condition of the tooth and surrounding structures, and the constraints of the public service system in which the clinician operates. In private clinics, although more options may technically be available, treatment decisions are often narrowed to what the clinician perceives the patient can afford or maintain, rather than being made collaboratively with full disclosure of all options.\u003c/p\u003e\u003cp\u003eThe findings in our study illustrate how structural discrimination can manifest in routine clinical interactions, including treatment planning for individuals living with mental health challenges. Similar to current literature, the dental practitioners in this study perceive people with mental health issues to have poor oral hygiene, reduced treatment adherence, or lower capacity for self-care either due to stereotypical perception of mental or cognitive incapability without considering structural or psychosocial factors (Scrine et al., 2019). This, in addition to implicit biases about race, or class, have shaped practitioners\u0026rsquo; attitudes and treatment decisions where lower-quality, cost-saving, or expedient options such as extraction-based treatment, are prioritised over long-term, evidence-based preventative care. Interestingly, there were also encounters in this study that reveal how systemic failings incentivise ethically questionable practices within dental practices, particularly those driven by private billing incentives. Participants reported instances where providers use shame- or fear-based tactics, leveraging patient vulnerability to promote costlier procedures, without transparent and informed discussions. These are not solely the result of individual clinician behaviour, but rather manifestations of institutional and economic pressures that lead to the prioritisation of profit over patient-centred care. More importantly, the absence of comprehensive discussion and informed consent reported in these encounters, illustrates how patient autonomy and agency in their own health management are denied. This reflects not only a gross violation of ethical and clinical standards but also highlights the paternalistic gatekeeping that often disproportionately affects individuals from lower socioeconomic and marginalised backgrounds (Macias-Konstantopoulos et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStructural constraints such as limited time, high patient turnover, and economic pressures in both public and private dental settings may drive providers to choose extractions over more conservative treatments. However, when analysing the long-term economic and health costs of extraction-based treatment approaches, Wigsten and colleagues discussed though extractions are less expensive upfront, they often lead to complications such as bone loss, prosthetic dependency, reduced oral function, aesthetic concerns, and disability associated with denture use (Wigsten et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These downstream costs\u0026mdash;both financial and psychosocial\u0026mdash;often outweigh the initial savings of extraction compared to more conservative treatments like root canal therapy and crowns. Yet, due to constrained public funding and assumptions about patients\u0026rsquo; ability to pay, these longer-term consequences are frequently overlooked.\u003c/p\u003e\u003cp\u003eStructural stigma is further reinforced by systemic fragmentation, under-resourcing, and institutional practices that create barriers to oral health care for people living with mental illness (Harnagea et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Within Australian oral healthcare settings, structural stigma has been described in the existing literature as arising from siloed models of care, where non-dental health professionals such as GPs, pharmacists and mental health professionals are reluctant or feel ill-equipped to engage in managing oral health care for patients with mental health issues (Scrine et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Additionally, the long waitlists and delays disallow routine check-ups and preventative care, leading to more advanced disease and emergency procedures for pain relief. The public system\u0026rsquo;s capacity to accommodate the particular needs of those with mental health challenges is intransigent. Despite having higher oral health needs, those from vulnerable populations experiencing mental health challenges need to continually prove their eligibility for treatments by completing numerous forms in a system designed for people who may not struggle with literacy or transport access.\u003c/p\u003e\u003cp\u003eOne of the often-overlooked consequences of these structural and systemic barriers is the amplification of dental anxiety. Dental anxiety, also referred to as dental fear, is defined as an \"aversive emotional state of apprehension or worry in anticipation of dental procedures\" and may be triggered by various factors, including treatment costs, painful or uncomfortable procedures, the use of needles, and gagging (Yokota et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). It is estimated that 16% of the general Australian population experience dental anxiety (Armfield et al, 2010). However, due to concealable stigmatised identities, individuals living with mental health challenges, systemic illnesses (such as HIV, hepatitis B and C), homelessness or a history of addiction can experience dental anxiety at higher rates and with greater severity. This ultimately leads to underutilisation of dental care services, reinforcing the cycle of poor oral health and marginalisation (Brondani et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Parish et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Patel et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Yokota et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The siloed health system continues to struggle in addressing the complex and intersecting needs of these populations, who are often left navigating a fragmented and stigmatising care environment.\u003c/p\u003e\u003cp\u003eAdditionally, a US qualitative study that explored systemic barriers to oral health care for people with mental illnesses from the perspectives of patients, psychiatrists and dentists, revealed that socioeconomic challenges are the primary barrier to people seeking dental care, followed by anxiety and fear related to receiving dental treatments (Wright et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Moreover, these researchers found that there is a lack of oral health screening by mental health professionals and general practitioners due to gaps in their education and training about the role of oral health in mental health. Similarly, they found that oral health professionals have limited training on treating patients with mental health challenges. This indicates a need for improvements to guidelines and training to help educate both oral health and mental health professionals and therefore to improve service interactions for people who experience both the burdens of oral health and mental health challenges.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCLINICAL IMPLICATIONS AND RECOMMENDATIONS\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Improving oral health outcomes for people living with mental health challenges requires a multifaceted and trauma-informed approach across both mental health and dental care settings. The following recommendations are proposed:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eA multidisciplinary approach involving mental health professionals, dentists and dental staff, and other healthcare providers is crucial for addressing the complex needs of this population.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Integrating oral health care into mental health services could significantly improve oral health access and health outcomes for people with mental health challenges. For example, in inpatient units, mental health service environments can be enhanced with oral health education and resources. This may include the provision of oral hygiene tools (e.g., toothbrushes, floss, toothpaste), accessible information leaflets, and brief educational videos followed by discussion. Mental health clinicians, including psychiatrists and nursing staff, should be supported to discuss oral health side effects of psychotropic medications as part of routine care.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Oral health guidelines need to be tailored to the specific needs of individuals with mental health challenges, with recognition of the role or stigma and discrimination, in addition to currently understood challenges with mental health, medications, motivation and self-care, and other challenges.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eUser-friendly information and education, co-designed with people with mental health challenges is needed to raise awareness about the link between mental health and oral health and to promote preventive practices.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWithin dental settings, environments can be co-designed with people with lived experience to reduce sensory overload, including quieter spaces, natural lighting, and calming visual stimuli. Practices should also encourage strategies to support patient comfort, such as allowing the presence of a support person, use of personal headphones/music, or sensory tools like fidget items.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMore lived experience-informed information, education and training for oral healthcare professionals is needed to raise awareness about the link between mental health and oral health, address stigma and discrimination, and improve practice and to promote trauma-informed practice. For example, there is minimal training about SBIRT (Screening, Brief Intervention, and Referral to Treatment) in dental education regarding substance use and mental health. Incorporating SBIRT\u0026mdash;a validated tool used in primary care\u0026mdash;into dental training curricula, especially when delivered through a lived experience lens, may help reduce provider stigma and increase confidence in managing patients with AOD or mental health concerns (Fouillen et al., 2022).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIn a context of poor resources, dental care providers can experience burnout and consequently service users can be perceived as burdensome, time consuming, or annoying (Koschorke et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Further research is warranted to explore how dentists in public systems navigate resource limitations and economic constraints in treatment planning. A qualitative study capturing public dentists' perspectives could offer critical insights into system-level drivers of care decisions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThough not explicitly mentioned by the participants in this study, another clinical consideration includes courtesy stigma, where a clinician is stigmatised by peers for treating patients with mental illness or substance use issues, can impact clinical decisions and behaviours. This fear of reputational damage or professional isolation contributes to provider stigma and reluctance to engage with marginalised patients, thereby reinforcing cycles of exclusion and poor health outcomes (Parish et al., 2023). Parish and colleagues suggest that stigma-reduction efforts should not only target knowledge gaps but also challenge cultural norms within the dental profession. Training that includes patient narratives and social determinants of health may help shift provider attitudes and reduce distancing behaviours.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis is the first in-depth report in Australia that explored the interactions of different types of stigma, and their manifestations in dentistry settings based on the lived experiences of people with mental health challenges. Our study revealed how explicit and implicit mental health, oral health stigma and other intersectional stigma manifest at multiple levels during their dental care help-seeking journey. The compounded effect between experienced, internalised, and anticipatory stigma not only deters these at-risk populations from engaging with dental care services and therefore perpetuates the deterioration cycle, but the structural stigma at-play can also lead to poorer treatment outcomes and permanent irreversible oral health consequences. Acknowledging the damaging effect of stigma in dentistry settings is an important step for policy makers and institutions to enact appropriate education, training and resources to help dental practitioners to become more trauma-informed and empathetic in their clinical practice; as well as to help accommodate and welcome the individuals that need dental care the most.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIHW Australian Institute of Health and Welfare\u003c/p\u003e\u003cp\u003eAOD Alcohol and Other Drugs\u003c/p\u003e\u003cp\u003eBMI Body Mass Index\u003c/p\u003e\u003cp\u003eGP General Practitioner\u003c/p\u003e\u003cp\u003eLE Lived Experience\u003c/p\u003e\u003cp\u003eLEA Lived Experience Australia\u003c/p\u003e\u003cp\u003eLGBTIQA\u0026thinsp;+\u0026thinsp;Lesbian Gay Bisexual Transgender Intersex Queer (or Questioning) Asexual\u003c/p\u003e\u003cp\u003eODTP Opioid Dependence Treatment\u003c/p\u003e\u003cp\u003eSBIRT Screening, Brief Intervention, and Referral to Treatment\u003c/p\u003e\u003cp\u003eTIC Trauma Informed Care\u003c/p\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e A Participant Information Sheet was provided, and consent was confirmed online prior to them proceeding to answer the online anonymous survey questions. This research was approved by the Flinders University Human Research Ethics Committee (No.7597).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003ePlans for publication were described in the Participant Information Sheet and consent for publication was then contained within the process of consent to participate in the study. No identifiable data was collected. All direct quotes were de-identified to ensure removal of any potentially identifiable references to specific people, services or locations.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eAN, AC, CK and the Lived Experience Co-Design Working Group (LE-B, PJ, JM, CN, SR, RT and AT) have no competing interests to declare.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe larger survey from which this research was drawn was funded in-kind by Lived Experience Australia from within its operating funds. The project reported here was undertaken as part of an Advanced Studies medical student placement which includes a small stipend of \u003cspan\u003e$\u003c/span\u003e2000 to support the student\u0026rsquo;s project.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAN: Conceptualization, Data curation, Methodology, Investigation, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review and Editing.SL: Conceptualization, Data Curation, Methodology, Investigation, Project Administration, Resources, Funding Acquisition, Writing \u0026ndash; Review and Editing.AC: Investigation, Writing \u0026ndash; Review and Editing.LE-B, RH, PJ, JM, CN, SR, RT, AT, CK: Conceptualization, Methodology, Writing \u0026ndash; Review and Editing. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe wish to express our appreciation to the people who participated in this survey, the Lived Experience Co-design Working Group for their expertise and collaboration in developing the survey questions and Lived Experience Australia their focus on this important topic.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to it being owned by Lived Experience Australia and used with permission for the current study. The dataset is available from Lived Experience Australia on reasonable request ([email protected]).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhad AA, Sanchez-Gonzalez M, Junquera P. Understanding and Addressing Mental Health Stigma Across Cultures for Improving Psychiatric Care. 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Cureus. 2024;16(6):e63025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.63025\u003c/span\u003e\u003cspan address=\"10.7759/cureus.63025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Oral Health, Dentist, Mental Health, Stigma, Discrimination, Shame, Trauma, Dental Services","lastPublishedDoi":"10.21203/rs.3.rs-7092307/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7092307/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Oral health disparities persist among people with mental health challenges. They experience high rates of dental disease due to medication side effects, socioeconomic barriers, and stigma. Despite their high need for dental care, they face reduced access to care, exacerbated by structural inequities and provider biases. Stigma further deters care-seeking, with limited research centering lived experience perspectives. In Australia, where privatized dental care widens inequities, mental health guidelines rarely address oral health, and studies often adopt deficit-based frameworks.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study employed a co-designed, qualitative approach with Australians with lived experience of mental health challenges, exploring barriers, stigma, and systemic failures in oral healthcare. Findings aimed to inform person-centred interventions bridging oral and mental health systems. Informed by interpretive phenomenology, a secondary analysis of data collected by a lived experience-led national survey focused on responses by 198 mental health consumers to four survey questions that explored experiences related to stigma and discrimination. Latent content analysis was used to analyse the data. Each step was underpinned by a lived experience co-design group that met iteratively to design the original survey, provide critical feedback to the analyses and reporting on research outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFindings reveal how intersectional stigma\u0026mdash;linking mental health status, oral health, socioeconomic disadvantage, and marginalized identities (e.g., Indigenous background, refugee status, substance use, or history of transmissible diseases) perpetuates inequities in dental care, with lifelong health consequences. Stigma operated at multiple levels: experienced, internalized, and anticipated stigma, leading to avoidance of care; diagnostic overshadowing (oral health concerns dismissed as \"behavioural\"); dehumanizing attitudes (derogatory language, perceived delegitimization of pain); and ethical violations, including exploitation and inadequate consent processes in clinical interactions. Participants described systemic exclusion from preventive care, with compounding effects for multiple marginalized groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis first Australian study on stigma in dentistry reveals how mental health, oral health, and intersectional stigma deter care-seeking and worsen outcomes for marginalized populations. Findings underscore the need for structural interventions, including stigma-informed training for dental practitioners and policy reforms to ensure equitable, trauma-informed care. Addressing these barriers is essential to breaking the cycle of oral health inequities.\u003c/p\u003e","manuscriptTitle":"Oral health and mental health: Lived experiences of stigma and discrimination for Australians with mental health challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 17:57:18","doi":"10.21203/rs.3.rs-7092307/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-15T09:46:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T19:09:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-03T12:46:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98832761256923575262686828535954289358","date":"2025-09-15T23:13:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184507379715706391447514283715248656278","date":"2025-09-11T08:14:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291462082529125943404066079522392619254","date":"2025-09-11T07:05:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300317812617381645594912643905235411683","date":"2025-09-08T17:45:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-06T02:17:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-15T06:57:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-15T06:56:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-07-10T10:52:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5126f2ca-6a9f-44ac-bcbe-41589c4464c3","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:08:16+00:00","versionOfRecord":{"articleIdentity":"rs-7092307","link":"https://doi.org/10.1186/s12903-026-08216-7","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2026-04-01 15:58:30","publishedOnDateReadable":"April 1st, 2026"},"versionCreatedAt":"2025-09-15 17:57:18","video":"","vorDoi":"10.1186/s12903-026-08216-7","vorDoiUrl":"https://doi.org/10.1186/s12903-026-08216-7","workflowStages":[]},"version":"v1","identity":"rs-7092307","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7092307","identity":"rs-7092307","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}