Dental prosthetic treatment needs of inpatients with schizophrenia in Taiwan: a cross-sectional study.

0.11 MB·English

by  Chu, Kuan-Yu

Chuetal.BMCOralHealth2013,13:8
http://www.biomedcentral.com/1472-6831/13/8
RESEARCH ARTICLE Open Access
Dental prosthetic treatment needs of inpatients
with schizophrenia in Taiwan: a cross-sectional
study
Kuan-Yu Chu1*†, Nan-Ping Yang2,3, Pesus Chou2, Lin-Yang Chi4† and Hsien-Jane Chiu5†
Abstract
Background: The need to obtain information onthe dental prosthetic treatmentneeds (DPTNs) of inpatients with
schizophrenia is unrecognized. This study aims to assess the DPTNs ofthis population and investigate the
association between theseneeds and related factors.
Methods: The results ofan oral health survey involving 1,103schizophrenicadult inpatients in a long-term care
institution inTaiwan were used. Chi-square tests and multiple logistic analyses were used to measure the
independent effects ofthecharacteristicsof each subject on their DPTNs.
Results: Ofthe subjects, 805(73.0%)were menand 298 (27.0%) were women. The mean age was 50.8 years. A
total of 414(37.5%)required fixed prosthesis, whereas 700 (63.5%) needed removable prosthesis.Multivariate
analyses show that fixed prosthesis is associated with age only after adjusting for otherpotential independent
variables. Older subjects who had a lower educational attainment or a longer length of stay required removable
prosthesis.
Conclusions: The findingsof this study show that theDPTNs of schizophrenic inpatients are not being met.
Therefore, a special approach to thedental prosthetictreatmentof these patients should be developed.
Keywords: Fixed prosthesis,Removable prosthesis,Treatment needs, Schizophrenia
Background The factors that affect dental prosthetic treatments
Dentalprosthesisisveryimportantforpatientswithpost- have not been appropriately recognized. Researchers
endodontic therapy and who are partially or completely have reported that gender has a significant influence on
edentulous because it improves their chewing ability, di- the need for a fixed or removable prosthesis [9]. Studies
gestion, aesthetics, and quality of life. The need to obtain have also indicated that age, educational level, and
information on the dental prosthetic treatment needs length of stay (LOS) in institutions are important factors
(DPTNs) of handicapped individuals in general [1-3] and that determine dental treatment needs [8,10,11]. Schizo-
of inpatients with psychiatric disorders in particular has phrenic patients that require dental treatment often
beengainingrecognition[4,5]. come from poor families with limited access to dental
Schizophrenia is a severe psychiatric disorder that has care. Moreover, the dental care provided to patients who
a significantly negative effect on the self-care ability of stay in long-term-care institutions for a considerable
patients,whichleadstopoororal hygieneaswell ashigh amount of time is insufficient [6,12]. Furthermore, some
DPTNs [6,7]. Previous studies found high levels of den- schizophrenia medications, such as the typical anti-
taltreatmentneedsinschizophrenicpopulations[8]. psychotic drugs, may have side effects that can lead to
increasedDPTNs[13,14].
Professional clinical examinations are reportedly more
effective than self-assessment or questionnaire-based
*Correspondence:[email protected]
†Equalcontributors screeningsin assessingindividual dental treatment needs
1DepartmentofDentistry,Tao-YuanGeneralHospital,DOH,Tao-Yuan,Taiwan [3,15], particularly if done with the aid of radiographs
Fulllistofauthorinformationisavailableattheendofthearticle
©2013Chuetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
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Chuetal.BMCOralHealth2013,13:8 Page2of5
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[16,17]. The planning of preventive oral health improve- tooth for the bridge follows Ante’s Law, which states that
mentstrategiesbasedonDPTNsaswellasonrelatedfac- the root surface area of the abutment teeth should equal
tors associated with a population is important. However, or surpass that of the pontics [22]. An FP with cantilever
few studies have been conducted on the DPTNs of hos- extension units usually has higher failure rates than con-
pitalizedpatientswithschizophreniabasedonclinicaloral ventional designs [23]; thus, a bridge with an end abut-
examinations via periapical radiography. Schizophrenic ments was used in this study. Dental implants were
inpatients probably belong to a disadvantaged minority excluded from the treatment plans because of financial
and thus receive inadequate dental care. The aim of this limitations.
study is to obtain descriptive epidemiological information On the other hand, an RP is recommended for patients
on the DPTNs of hospitalized schizophrenic patients and whoseremainingteethlackthestrengthtosupportafixed
toidentifytheassociationbetweenDPTNsandseveralpo- bridge. RPs are classified into partial dentures and
tentiallyrelatedfactorsthataffectthesepatients. complete dentures. RPDs that do not cross the midline
areclassifiedas0.5units.
Methods
Participants Independentvariables
This study involved a sample hospital that offers long- The independent variables included age, educational at-
term medical care for chronic psychotics. The hospital is tainment, marital status, grade of disability, use of anti-
locatedineasternTaiwanbutreceivespsychiatricpatients psychotic medication, and LOS. Age was classified into
from all over the country. As of mid-2006, the hospital four strata: 20–44, 45–54, 55–64, and over 65 years old.
had admitted 2,330 patients. In recruitingsubjects for the Educational attainment was divided into two categories:
study,allhospitalpatientswithschizophreniaas themain 6 years and below, and above 6 years. Marital status was
psychiatric diagnosis (ICD-9 code: 295) were selected to classified into three categories:single, married,and sepa-
undergoastandardizedDPTNassessmentinthehospital’s rated/divorced/widowed. Disability was divided into
Department of Dentistry. A total of 1,468 schizophrenic three grades: mild or moderate (moderate), severe, and
patients were involved in the study. Of these, 1,103 profound. These grades are in accordance with the dis-
(response rate: 75.1%) participated and completed the ability certificate issued by theTaiwan Ministry of Inter-
DPTN evaluation. Ethical clearance was obtained from the ior. The use of antipsychotic medications was stratified
Ethical Committee of Yuli Hospital, Department of Health into two categories based on records obtained for six
(DOH),Taiwan,andallparticipantsgaveinformedconsent. months prior to the study period [24]. Antipsychotic
medications comprised first-generation antipsychotics
DPTNassessment (FGAs, e.g. chlorpromazine, clopenthixol, flupenthixol
DPTN assessment was performed under standard condi- HCl, haloperidol, loxapine, sulpiride, and thioridazine)
tionsusingadentalchairwithadequatelight,properden- and non-FGA medications. Non-FGAs included second-
tal instruments, and periapical radiographs, as needed. A generation antipsychotics (SGAs, e.g. clozpaine, olanza-
trained dentist performed all oral examinations with the pine, risperidone, and quetiapine) and third-generation
helpofanexperiencedassistant,whorecordedtheDPTN antipsychotics (TGAs, e.g. aripiprazole). The length of
dataaswellasinformationonindependentvariables. stay (LOS) cut-off point, which refers to the number of
TheDPTNitemsusedwereconsistentwiththoserecom- yearssince admission tothehospital,was10years[13].
mended by the World Health Organization, [18] which
included (1) fixed prosthesis (FP); and (2) removable pros- Datacollectionandanalysis
thesis (RP), such as a removable partial denture (RPD; DatacollectionwasconductedfromJanuarytoDecember
those crossing the midline were defined as bilateral RPD) 2006. The DPTN items werethen prepared and summar-
andcompletedentures. ized. The data files were then designed using MS Access
The principle behind dental prosthetic treatment is the and analyzed using SPSS software version 15.0. Propor-
restorationorreplacementofalllostteeth,excludingthird tions, group means, and standard deviations (SDs) were
molars. An FP is generally preferred because the reported calculated. Univariate analysis using the chi-square test
survival rate of patients with FPs is higher than that of compared the differences between the independent va-
patients with removable RPDs [19,20]. Thus, FPs are the riables and the DPTNs. Statistical significance was set at
firstchoiceforreplacingmissingteethinpartiallyedentu- theP<0.05level.
louspatients. Multiple logistic regressions were used to estimate the
An FPconsists ofa single crown and a bridge. The sin- association between the independent variables and
glecrownisacementedveneerrestorationthatreplacesa DPTNs of the participants. The independent variables
tooth suffering from deep decay or undergoing post- were included in the multivariable logistic models, with
endodontic therapy [21]. The selection of the abutment a cut-off of P < 0.05 from the univariate analyses. The
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odds ratios (OR) of the independent variables (as com- Of the subjects, 414 (37.5%) required FP, with 1,854
paredtothereferencecategory),thesignificance(P-value), units and a mean unit of 1.7 (SD = 2.89) per person. On
and 95% confidence intervals (95% CI) were estimated theotherhand,700(63.5%)patientsrequiredRP,whereas
from the multiple logistic regression models. Areas under 645 (58.5%) required RPD, including 28 (2.5%) unilateral,
a receiver-operating characteristic curve (AUC) were also 240 (21.8%) bilateral, 26 (2.4%) unilateral combined with
calculatedtodeterminethepredictedprobabilityofthelo- bilateral, and 351 (31.8%) two bilateral arches. Moreover,
gisticmodels. 145 (13.1%) patients required complete dentures, with 93
(8.4%)requiringa singlearchand52(4.7%)requiringtwo
Results arches. Table 1 shows the numbers and percentages of
Descriptivestatistics DPTNsofthesubjectswhorequireFPorRP.
Ofthe1,103schizophrenicinpatientsevaluatedforDPTNs,
805 (73.0%) were men and 298 (27.0%) were women. The Univariateanalysis
meanagewas50.8years(SD=10.8),andtheaverageLOS Thechi-squaretestshowsthatage(P<0.001),educational
inthehospitalwas8.4years(SD=5.7).Atotalof55(5.0%) attainment (P = 0.032), and LOS (P = 0.011) were asso-
inpatientswerefoundtobeedentulous. ciated with the need for FP treatment. In other findings,
Table1Numberandpercentage(withinparentheses)ofdentalprosthetictreatmentneedsamonginpatientswith
schizophreniainTaiwan
Variables Total Fixedprosthesis Pvalue Removableprosthesis Pvalue
Total 1103(100) 414(37.5) 700(63.5)
Sex
Men 805(73.0) 302(37.5) 1.000 518(64.3) 0.325
Women 298(27.0) 112(37.6) 182(61.1)
Age(yrs)
20-44 301(27.3) 142(47.2) <0.001 127(42.2) <0.001
45-54 425(38.5) 183(43.1) 272(64.0)
55-64 257(23.3) 67(26.1) 191(74.3)
65+ 120(10.9) 22(18.3) 110(91.7)
Education(yrs)
>6 468(42.4) 193(41.2) 0.032 250(53.4) <0.001
≤6 635(57.6) 221(34.8) 450(70.9)
Marriage
Single 848(76.9) 320(37.7) 0.657 538(63.4) 1.000
Married 115(10.4) 39(33.9) 73(63.5)
Separated 140(12.7) 55(39.3) 89(63.6)
Disability
Moderate 237(21.5) 99(41.8) 0.250 131(55.3) <0.001
Severe 744(67.5) 274(36.8) 474(63.7)
Profound 122(11.1) 41(33.6) 95(77.9)
Lowincome
No 240(21.8) 91(37.9) 0.940 137(57.1) 0.023
Yes 863(78.2) 323(37.4) 563(65.2)
FGAusing
No 692(62.7) 272(39.3) 0.123 424(61.3) 0.053
Yes 411(37.3) 142(34.5) 276(67.2)
LOS(yrs)
≤10 517(46.9) 215(41.6) 0.011 272(52.6) <0.001
>10 586(53.1) 199(34.0) 428(73.0)
Abbreviations:FGA:firstgenerationantipsychotic;LOS:lengthofstay.
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age(P<0.001),educationalattainment(P<0.001),disabi- $18,000; bilateral RPD, NT$24,000; and a complete
lity (P < 0.001), low income (P = 0.023), use of FGAs in dentureperarch,NT$27,000.Hence,theaveragebudgetfor
borderline cases (P = 0.053), and LOS (P < 0.001) deter- the prosthetic treatment needs of an inpatient is calculated
minedtheneedforRPtreatments. as follows: [1,854 × NT$4,000 + (28+26) × NT$18,000 +
(240 + 26 + 351 × 2) × NT$24,000 + (93 + 52×2) × NT
Multivariatelogisticanalysis $27,000] ÷ 1,103 subjects = NT$33,490. In other words,
Basedonthemultivariatelogisticanalysisresults(Table2), the cost of providing the prosthetic treatment needs of an
age was negatively associated with FP. The analysis also average schizophrenic inpatient in Taiwan is approximately
revealsthattheneedforRPwasassociatedwithage,edu- US$1,158(USD).
cationalattainment,andLOS. In terms of human resources, as of July 2010, the ratio
of the general population to dentists in Taiwan was
Discussion 1,995: 1. The availability of only one full-time dentist for
This study investigated the DPTNs and several poten- 2,300 inpatients with severe psychiatric disorders in this
tially related factors that affect schizophrenic inpatients hospitalisclearly insufficient.
using a large sample from a specific psychiatric hospital The acceptance of dental prosthetic treatment for
inTaiwan.Thestudyobtainednotonlydescriptiveinfor- missing teeth would seem reasonable. However, studies
mation on DPTNs, but also indicated that age, educa- proposed a compromise that involves a shortened dental
tion, and LOSare associated with DPTNsinsome of the arch. In this treatment, the restoration of four occluding
subjects. These findings may help oral health policy pairs of premolars can provide sufficient occlusal stabi-
decision-makers in allocating adequate resources and in lity andmasticatory function [29,30].
developingeffectivestrategiestomeettheDPTNsofthis Discussion on extended issues such as costs of various
specialneeds population. prosthetic treatments is beyond the scope of this study,
FPwasassociatedwithageonlyafteradjustingforother since it entails the value discount, different prices of
independentvariables.Oldersubjectswhohadloweredu- prosthetic treatments between urban and rural areas,
cationalattainmentorhadlongerLOSrequiredRP.These andthosebetweenfixedandremovableprosthesisofdif-
findings are only partly consistent with those of previous ferent materials. Furthermore, some limitations of this
studies on the oral health of inpatients with psychiatric study should be noted. First, the sample may not be rep-
disorders. However, these data sets do complement one resentative of all schizophrenic inpatients in Taiwan. For
another[5,25-28]. practical reasons, only a selected number of inpatients
We estimated the average budget of prosthetic treat- were examined. Given that the survey design focused
ment needs for schizophrenic in-patients. Based on the only on schizophrenic patients with DPTNs in a public
feecollectionpoliciesofYuliHospital,DOH,abase-metal psychiatric hospital, patients with very limited life ex-
crown treatment costs NT$4,000; unilateral RPD, NT pectancy and those not hospitalized were excluded.
Table2Multivariateanalysesoffactorsassociatedwithdentalprosthetictreatmentneedsamonginpatientswith
schizophreniainTaiwan
Variables Fixedprosthesisa RemovableprosthesisRPb
B OR P 95.0%CIforOR B OR P 95.0%CIforOR
Age(yrs)
20-44 1(r) 1(r)
45-54 −0.16 0.85 0.297 0.63-1.16 0.72 2.06 <0.001 1.50-2.83
55-64 −0.93 0.40 <0.001 0.27-0.59 1.04 2.82 <0.001 1.91-4.18
65+ −1.37 0.25 <0.001 0.15-0.44 2.28 9.75 <0.001 4.78-19.87
Education(yrs)
>6 1(r)
≤6 0.40 1.49 0.004 1.13-1.95
LOS(yrs)
≤10 1(r)
>10 0.36 1.43 0.016 1.07-1.91
AUC 0.62 0.71
Abbreviations:LOS:lengthofstay;AUC:areaundercurve;r:reference.
Variablesentered:aage,education,LOS;bage,education,gradeofdisability,lowincome,useofFGA,LOS.
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Second,despiteourbestefforts,anumberofpracticaldif- 8. BarnesGP,AllenEH,ParkerWA,LyonTC,ArmentroutW,ColeJS:Dental
ficulties regarding DPTNs were encountered during the treatmentneedsamonghospitalizedadultmentalpatients.SpecCare
Dentist1988,8(4):173–177.
assessment. In addition, a large number of schizophrenic
9. Al-GhannamNA,Al-ShammeryAR,WyneAH,KhanNB,Al-GhannamNA,Al-
patients were unaccounted for during the process. Third, ShammeryAR,WyneAH,KhanNB:Prostheticdentaltreatmentneedsin
weacknowledgethattheevidencesupportingthisassump- Eastern[corrected]SaudiArabia.[ErratumappearsinSaudiMedJ.2002
Nov;23(11):1427].SaudiMedJ2002,23(8):975–980.
tion is limited and that further research on the develop-
10. AngelilloIF,NobileCGA,PaviaM,FazioP,PucaM,AmatiA:Dentalhealth
ment of an effective preventive program for the unmet andtreatmentneedsininstitutionalizedpsychiatricpatientsinItaly.
DPTNsofschizophrenicinpatientsisurgentlyrequired. CommunityDentOralEpidemiol1995,23(6):360–364.
11. ChuK-Y,YangN-P,ChouP,ChiuH-J,ChiL-Y:Factorsassociatedwith
dentalcariesamonginstitutionalizedresidentswithschizophreniain
Conclusions Taiwan:across-sectionalstudy.BMCPublHealth2010,10(1):482.
12. KilbourneAM,Horvitz-LennonM,PostEP,McCarthyJF,CruzM,WelshD,
The considerable unmet treatment needs of hospitalized
BlowFC:OralHealthinVeteransAffairsPatientsDiagnosedwithSerious
schizophrenicpatientsinTaiwanwereobserved.Age,edu- MentalIllness.JPublicHealthDent2007,67(1):42–48.
cationalattainment,andLOSarethethreemostsignificant 13. ThomasA,LavrentzouE,KarouzosC,KontisC:Factorswhichinfluencethe
oralconditionofchronicschizophreniapatients.SpecCareDentist1996,
factors associated with the need for RP treatment. The
16(2):84–86.
results reveal the need for the development of a prompt 14. SzabadiE,TavernorS:Hypo-andHypersalivationInducedby
oral health care delivery service model for patients with PsychoactiveDrugs:IncidenceMechanismsandTherapeutic
Implications.CNSDrugs1999,11:449–466.
specialneeds.
15. RobinsonPG,NadanovskyP,SheihamA:CanQuestionnairesReplace
ClinicalSurveystoAssessDentalTreatmentNeedsofAdults?JPublic
Competinginterests HealthDent1998,58(3):250–253.
Theauthorsdeclarethattheyhavenocompetinginterests. 16. BeckerT,LevinL,ShochatT,EinyS,BeckerT,LevinL,ShochatT,EinyS:
HowmuchdoestheDMFTindexunderestimatetheneedforrestorative
Authors'contributions care?JDentEduc2007,71(5):677–681.
KYCcarriedouttheDPTNassessment,participatedinthesequence 17. HeyesG,RobinsonPG,HeyesG,RobinsonPG:Pilotstudytoassessthe
alignmentanddraftedthemanuscript.NPYparticipatedinthedesignofthe validityofthesingleassessmentprocessasascreeningtoolfordental
studyandperformedthestatisticalanalysis.PCandLYCconceivedofthe treatmentneedsinolderpeople.Gerodontology2008,25(3):142–146.
study,andparticipatedinitsdesignandcoordinationandhelpedtodraft 18. WHO:OralHealthSurvey:BasicMethods.4thedition.Geneva:1997.
themanuscript.HJCparticipatedinthesequencealignment.Allauthorsread 19. GlantzP-OJ,NilnerK,JendresenMD,SundbergH:Qualityoffixed
andapprovedthefinalmanuscript. prosthodonticsafter15years.ActaOdontolScand1993,51(4):247–252.
20. VermeulenAHBM,KeltjensHMAM,van'tHofMA,KayserAF:Ten-year
evaluationofremovablepartialdentures:Survivalratesbasedon
Acknowledgements
retreatment,notwearingandreplacement.JProsthetDent1996,
WeacknowledgeMissHui-MeiYewhocontributedtowardsthearticleby
76(3):267–272.
makingsubstantialcontributionstodatacollection.WealsothankYuli
21. ShillingburgHT,Jr,HoboS,WhitsettL:FundamentalsofFixed
Hospital,DOH,whichcontributedmaterialsessentialforthestudy.
Prosthodontics:DiagnosisandTreatmentPlanning.vol.1,2ndedn.
Chicago:QuintessencePublishingCo.;1981:13–53.
Authordetails
1DepartmentofDentistry,Tao-YuanGeneralHospital,DOH,Tao-Yuan, 22. AnteIH:Thefundermentalprinciplesofabutments.MichStateDentSoc
Taiwan.2InstituteofPublicHealth&CommunityMedicineResearchCenter, Bul1926,8.
NationalYang-MingUniversity,Taipei,Taiwan.3DepartmentofGeriatrics, 23. KarlssonS:Failuresandlengthofserviceinfixedprosthodonticsafter
Tao-YuanGeneralHospital,DOH,Tao-Yuan,Taiwan.4Departmentof long-termfunction.Alongitudinalclinicalstudy.SwedDentJ1989,13
Dentistry,NationalYang-MingUniversity,Taipei,Taiwan.5Departmentof (5):185–192.
24. JansenENH:ClozapineinthetreatmentoftremorinParkinson'sdisease.
Psychiatry,JiananMentalHospital,DOH,Tainan,Taiwan.
ActaNeurologicaScandinavica1994,89(4):262–265.
25. KenkreAM,SpadigamAE:Oralhealthandtreatmentneedsininstitutionalized
Received:5November2012Accepted:16January2013
psychiatricpatientsinIndia.IndianJDentRes2000,11(1):5–11.
Published:19January2013
26. RamonT,GrinshpoonA,ZusmanSP,WeizmanA:Oralhealthand
treatmentneedsofinstitutionalizedchronicpsychiatricpatientsinIsrael.
References EurPsychiatry2003,18(3):101–105.
1. WhymanRA,TreasureET,BrownRH,MacFadyenEE:Theoralhealthof
27. TangWK,SunFCS,UngvariGS,O'DonnellD:OralHealthofPsychiatric
long-termresidentsofahospitalfortheintellectuallyhandicappedand In-PatientsinHongKong.IntJSocPsychiatry2004,50(2):186–191.
psychiatricallyill.NZDentJ1995,91(404):49–56.
28. ZusmanSP,PonizovskyAM,DekelD,MasarwaA-e-S,RamonT,NatapovL,
2. LesterV,AshleyFP,GibbonsDE:Therelationshipbetweensocio-dental
GrinshpoonA:Anassessmentofthedentalhealthofchronic
indicesofhandicap,feltneedfordentaltreatmentanddentalstateina
institutionalizedpatientswithpsychiatricdiseaseinIsrael.SpecCare
groupoffrailandfunctionallydependentolderadults.CommunityDent Dentist2010,30(1):18–22.
OralEpidemiol1998,26(3):155–159.
29. WitterDJ,vanPalensteinHeldermanWH,CreugersNHJ,KäyserAF:
3. HennequinM,FaulksD,RouxD:Accuracyofestimationofdental
Theshorteneddentalarchconceptanditsimplicationsfororalhealth
treatmentneedinspecialcarepatients.JDent2000,28(2):131–136. care.CommunityDentOralEpidemiol1999,27(4):249–258.
4. VelascoE,BullonP:PeriodontalstatusandtreatmentneedsamongSpanish
30. KannoT,CarlssonGE:Areviewoftheshorteneddentalarchconcept
hospitalizedpsychiatricpatients.SpecCareDentist1999,19(6):254–258.
focusingontheworkbytheKäyser/Nijmegengroup.JOralRehabil2006,
5. KumarM,ChanduGN,ShafiullaMD:Oralhealthstatusandtreatment 33(11):850–862.
needsininstitutionalizedpsychiatricpatients:oneyeardescriptivecross
sectionalstudy.IndianJDentRes2006,17(4):171–177.
doi:10.1186/1472-6831-13-8
6. FriedlanderAH,MarderSR:Thepsychopathology,medicalmanagementand
Citethisarticleas:Chuetal.:Dentalprosthetictreatmentneedsof
dentalimplicationsofschizophrenia.JAmDentAssoc2002,133(5):603–610.
inpatientswithschizophreniainTaiwan:across-sectionalstudy.BMC
7. YaltirikM,KocaelliH,YargicI,YaltirikM,KocaelliH,YargicI:Schizophrenia OralHealth201313:8.
anddentalmanagement:reviewoftheliterature.QuintessenceInt2004,
35(4):317–320.