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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 27-32

Oral health status and treatment needs of psychiatric patients in a psychiatric care center, Jammu


1 Department of Public Health Dentistry, Indira Gandhi Dental College and Hospital, Jammu, Jammu and Kashmir, India
2 Department of Public Health Dentistry, Himachal Dental College, Sundarnagar, Shimla, Himachal Pradesh, India
3 Department of Public Health Dentistry, Government Hospital Sarwal, Jammu, Jammu and Kashmir, India
4 J and K Health Services, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir, India
5 Medical Officer, Government Hospital, Indira Gandhi Government Dental College, Jammu, Jammu and Kashmir, India

Date of Submission24-Oct-2019
Date of Decision10-Dec-2019
Date of Acceptance15-Dec-2019
Date of Web Publication27-Jan-2020

Correspondence Address:
Amarpreet Singh
Department of Public Health Dentistry, Himachal Dental College and Hospital, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_117_19

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  Abstract 


Objective: Health is a very important asset of all individuals, worldwide. The prevalence of mental disease is increasing in an alarming rate, which is estimated to be 6–7 million people torment with severe mental disorders and is about ten times more with mild mental disorders. This study is conducted to assess the oral health status and estimate the dental treatment needs of hospitalized psychiatric patients. Materials and Methods: This study was conducted for a period of 2 months at a psychiatric hospital. In the study, 275 patients were examined by the investigator. The Chi-square test was applied to discrete data and one-way ANOVA for continuous data. Multivariate analyses were carried out to test the association of age, frequency of cleaning teeth, and materials used for cleaning teeth. Results: The results revealed high caries prevalence, poor oral hygiene and periodontal health, and extensive unmet dental treatment needs. Conclusion: Psychiatric patients are the special groups in the community who require special care and social support from not only from the family but also from the society. Dentists are required to understand the psychiatric illness and oral health implications and carry out preventive measures to prevent oral diseases, for which the psychiatric patients are at high risk to occur.

Keywords: Dental caries, periodontal status, psychiatric patients


How to cite this article:
Singh I, Singh A, Kour R, Menia A, Singh A, Singh R. Oral health status and treatment needs of psychiatric patients in a psychiatric care center, Jammu. Indian J Dent Sci 2020;12:27-32

How to cite this URL:
Singh I, Singh A, Kour R, Menia A, Singh A, Singh R. Oral health status and treatment needs of psychiatric patients in a psychiatric care center, Jammu. Indian J Dent Sci [serial online] 2020 [cited 2020 Feb 25];12:27-32. Available from: http://www.ijds.in/text.asp?2020/12/1/27/276881




  Introduction Top


Health is a very important asset of all individuals, worldwide, it is multidimensional, and as per the World Health Organization (WHO), it is defined as “A state of complete physical, mental, and social well being and not merely the absence of disease or infirmity.“[1] Among these, three dimensions the mental health can be stated as the equitable evolution of person character, temperament, and emotional outlook or perspective which makes him/her to live in an amicable manner with others.[2]

The prevalence of mental disease is increasing in an alarming rate, which is estimated to be 6–7 million people torment with severe mental disorders and is about ten times more with mild mental disorders.[3] Thus, a larger proportion of the population is suffering from mental disorders, which is impacting the productivity of the nation due to detriment and increased budget on health care by the government.[4] Mental illness is broadly grouped in two forms – the major and the minor type. There are multiple causative factors such as hereditary factors, changes in brain configuration, depressed childhood evidence, conflicts strife in the family, various real-life accentuation and burdens, civil problem, and many other factors complexly intertwine and causes the symptoms of mental diseases.[2] It usually takes a continual course with remissions and aggravation. The mentally ill or psychiatry patients form a demented segment of the society; there is a disturbance in their sense of well-being and serenity.[5] Numerous psychic or intellectual behaviors such as thinking, affections, remembrances, acumen, perception, judgment, and decision-making are also disorganized or disordered. There is an abnormality in talking and behavioral ability of individuals resulting in nonsatisfaction in work leading to upheaval in individual's civil, social, financial situation and fecundity.[6] The psychiatric coterie faces negligence due to bewilderment, ignorance, despair, stigma, delusion, fallacy, and faulty behavior. There is the presence of flawed debilitated level of functioning, amended approach of oral health, forgetfulness, and nonorganized life pattern among psychiatric patients influencing their oral health care habits and negligence of dental health.[7] The oral health care is directly proportional to general health. Oral health care includes a state of complete normalcy and functional ability of dentition and supporting structures and other encompassing parts of the oral cavity and numerous structures impacting mastication and maxillofacial complex.[8] Maintenance of positive oral hygiene is necessary for optimal oral health. The prevalence of dental disease among psychiatric patients is increasing at a very rapid rate in modern society, as these patients lack physical and mental ability to perform oral hygiene procedures making them susceptible to many dental/oral problems in addition to their other related problems.[9] Various drugs used to cure or modify the behavior of psychiatric patients are also responsible for increasing central appetite and satiety centers, often resulting in weight gain and fondness for sweets and carbonated beverages.[10] These drugs also result in severe adverse oral conditions such as decreased salivation or dry mouth, perioral tumors, and dystonia of the jaws and tongue, causing trismus and protrusions. Perioral movements are most common and include darting, twisting, and protruding movements of the tongue, chewing and lateral jaw movements, lip smacking, puckering, and facial grimacing.[11] Very few studies have been conducted to determine the oral health status of psychiatric patients. To quote, Hede and Petersen[2] of Denmark and Angelillo et al.[12] of Italy have reported that these patients constitute a high group for dental disease and have high caries prevalence, poor oral hygiene and periodontal status, and extensive dental care needs, and hence, require special attention.[2],[12] Since data concerning oral health status and detailed and specific dental care requirements of psychiatric patients are rare, no literature is available pertaining to their oral health status in our country. This study is conducted to assess the oral health status and estimate the dental treatment needs of hospitalized psychiatric patients.


  Materials and Methods Top


The present study is a descriptive, cross-sectional study conducted to assess the prevalence of oral health status and treatment needs of institutionalized psychiatric patients.

Study area and duration of the study

The study was carried out at a government psychiatric hospital, Jammu.

Study population and sampling procedure

The study was conducted for a period of 2 months at a psychiatric hospital. In the study, 275 patients were examined by the investigator.

Pilot study

A pilot study was designed and carried out to check the feasibility and relevance of the survey pro forma among a total of 20 patients at a psychiatric hospital. The questionnaire was structured in the English language. Certain questions which were found to be irrelevant were deleted and those questions which were in comprehensive were modified/rephrased to suit the comprehension level of survey patients. The modified pro forma was used for the main study.

Sampling procedure and inclusion criteria

All patients of the hospital of all age available at the time of examination were included in the study (who were cooperative).

Preparation of pro forma

The WHO-modified pro forma was used for the purpose of recording the data. The pro forma consisted of two sections: the first section consisted of certain specific questions to obtain data pertaining to oral hygiene practices. The second section, i.e., oral examination, consisted of oral health status and treatment needs. The oral health status and treatment needs were assessed using the WHO, oral health survey, and basic methods (1997).

Training and calibration of the investigator

The clinical examination for every patient was comprehensively carried out by single investigator. Prior to conducting the study, the investigator was calibrated at the Department of Public Health Dentistry, Indira Gandhi Dental College, under the guidance of the professor to limit the examiner variability. To assess reliability, the investigator and the professor applied the modified WHO oral health pro forma on 20 selected patients and recorded the findings separately. The results so obtained were subjected to kappa statistics. Kappa coefficient value for inter values for inter-examiner reliability with respect to oral health status was 0.81.

Organizing the survey

Ethical clearance

Necessary permission was obtained from the authorities before the start of the survey. Ethical clearance to conduct this study was granted by the Jaipur Dental College Ethical Committee and SMS Medical College, Jaipur.

Scheduling

The time limit set for collection of data and examination of a patient participating in the study was for 2 months from February 16, 2010, to April 15, 2010.

The interview and examination of a single subject took about 10–15 min on most of the occasions. A detailed schedule of the survey was prepared well in advance. The schedule was kept flexible to accommodate for any unforeseen lapses. The investigator visited the study area 3–4 days a week during the study period, examining and recording an average of 15–20 patients/forms a day.

Examination area

The examination was conducted in the hospital wards of the study participants. The recorder was made to stand close to the examiner so that instructions and codes could be easily heard and the examiner could see that findings were being recorded correctly.

Lighting

Almost all the examinations performed under the natural daylight. The participants were positioned outside their wards to receive maximum natural light illumination. Artificial illumination (battery torchlight) was used sparingly when the natural light sources were scanty. Armamentaria such as sufficient numbers of sterile instruments were made available for the oral examination during the study. The following materials were used for the study.

  • Plane mouth mirrors
  • Community periodontal index probes
  • Tweezers
  • Kidney trays
  • Immersol (instrument disinfectant solution). Composition: glutaraldehyde 7 g, 1,6-dihydroxy, and 2.5 dioxahexane.
  • Gauze and cotton
  • Disposable gloves and mask
  • Torch
  • Data recording pro forma.


Statistical analysis

Data were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 20 (SPSS-Inc., Chicago, IL). The Chi-square test was applied to discrete data and one-way ANOVA for continuous data. Multivariate analyses were carried out to test the association of age, frequency of cleaning teeth, and materials used for cleaning teeth.


  Results Top


[Table 1] shows that among 275 participants, 180 (65%) were male and 95 (34.54%) were female, and according to the age distribution, 139 (50.54%) were in the younger age group between 14 and 33 years, 114 (41.45%) were in the middle age group between 34 and 53 years of age, and 22% were in the old age group who were 54 years and above.
Table 1: Distribution of cases according to age and sex

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In [Table 2] it has been found that 19 (6.91%) participants had professional degree or MA, 36 (13.09%) had BA or BSC degree, 17 (6.18%) had done intermediate or posthigh school, 29 (9.45%) had high school certificate, 57 (20.73) had done middle school, 27 (9.82%) had done primary school, and 91 (33.09%) were illiterate.
Table 2: Distribution of cases according to educational status and sex

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The [Table 3] shows that 115 (41.82%) participants take care of maintaining of oral hygiene and 160 (58.18%) do not care for maintaining oral hygiene. When seen among males who comprised 180 participants, 89 (49.44%) cared for their oral hygiene, and among 95 female participants, 26 (27.37%) cared for maintaining oral hygiene.
Table 3: Distribution of oral hygiene care among the psychiatric patients

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In [Table 4] it is seen that in the younger age group (14–33 years), 7 (5.03%) participants had leukoplakia, 7 (5.03%) had lichen planus, 4 (2.89%) had ulceration, 1 (0.72%) had acute necrotizing gingivitis, and 13 (9.35%) had candidiasis. In the middle age group (33–54 years), 7 (5.26%) participants had leukoplakia, 21 (18.42%) had lichen planus, and 7 (6.14%) had candidiasis. In the older age group (54 years above), 1 (4.54%) had leukoplakia and ulcerations and 6 (27.27%) had lichen planus.
Table 4: Distribution of oral mucosal conditions of cases according to the age

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The [Table 5] shows that the highest CPI score showing periodontal status showed 34 (12.36%) participants bleeding on probing, 40 (14.54%) with calculus, 130 (47.27%) participants showed shallow pockets, 66 (24.09%) participants had deep pockets, and 4 had excluded sextants since no teeth were present.
Table 5: Distribution of cases according to the age and CPI score

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[Table 6] is showing that the mean decayed, missing, and filled teeth (DMFT) score was 4.11 ± 5.06. the mean DMFT score increased with advancing age groups. In the younger age group, it was 2.8 ± 2.1, in the middle age group, it was 4.2 ± 4.8, and in the older age group, it was 12.0 ± 10.7.
Table 6: Distribution of dental caries among the psychiatric patients

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The total mean score of decayed was 2.27 ± 2.03. The decayed mean score in the younger group was 2.3 ± 1.9, in the middle age group, it was 2.2 ± 2.0, and in the older age group, it was 2.2 ± 2.7.

The total mean score for missing teeth was 1.77+ 4.89. The mean score of missing in the younger age group was 2.0 + 4.2, and in the last age group, it was 9.9 + 11.6.

The total mean score for filled teeth was 0.06 + 0.32, mean score of filled in younger age group was 0.1 + 0.4, in middle age group was 0.0 ± 0.3, and in the last age group it was 0.0 + 0.0.

[Table 7] shows that only 3 (1.14%) participants had good oral hygiene, whereas 39 (14.83%) had fair oral health status, and 221 (84.03%) participants reported poor oral health status.
Table 7: Distribution of simplified oral hygiene index status of cases according to the age and sex

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  Discussion Top


The present study was a cross-sectional study to assess the oral health status and treatment needs of the institutionalized psychiatric patient at a government psychiatric hospital for 2. A sample of 275 patients were taken who admitted for 2 months and of those who are cooperative.

Caries status

In the present study, 74.18% of the participants had caries prevalence. Regarding different components of DMFT, a higher decayed tooth with a mean of 2.27 ± 2.03 was found in the present study. The mean score for decayed teeth among psychiatric patients in the present study is similar to that reported by Shah et al.[13] which was 2.10, Strayer et al.[14] which was 2.4, and higher to reported by Vigild, et al.[15] who reported means of 1.3 which could be due to the geographic variation and due to the fact that the above-mentioned studies were done in a developed country where good dental health care was available.

Not surprising, the F (filled) component was almost not existed in psychiatric patients with a mean of 0.06 ± 0.32. This reflects the lack of professional care and no availability of dental services, and also, the inability of patients to describe their symptoms, only emergency care in the form of extraction is provided.

The finding was not in accordance to Angelillo, et al.[12] and Vigild, et al.'s studies[15] who reported a high prevalence of filled teeth in some age groups and accounted it to regular dental visiting habits of patients. This was because of our country which is still a developing country.

The combined DMFT mean was 4.11 ± 5.05. However, other studies conducted among psychiatric patients reported a higher prevalence. Vigild et al. (1993)[15] reported the mean DMFT of 26.1, Angelillo, et al.[12] reported the mean of 15.5, and Kenkere and Spadigam[4] reported the mean of 13.5.

The portable explanation of caries experience among the study population could be due to the water fluoride concentration of Jammu and also the reason for lower DMFT mean would be due to the reason that more than 37% were from rural areas and more than 4% from periurban area where fluoride level war reported to be more. Hence, the above-mentioned points which state that more number of patients stayed in a rural area were groundwater is the only source of drinking water, which contains a high level of fluoride, would be the reason for increased fluorosis and decreased DMFT.

Compared with Kumar et al.'s study,[7] the DMFT scores increased with ages, which was consistent with other studies conducted on psychiatric patients by Angelillo, et al.,[12] Kenkere and Spadigam,[4] Rekha, et al.,[16] and Kumar et al.[7]

However, the finding that irregular toothbrushing habit leads to increased dental caries prevalence was consistent with Hede and Petersen (1992).[2]

The results revealed high caries prevalence, poor oral hygiene and periodontal health, and extensive unmet dental treatment needs, which are in conformity with the studies conducted by Angelillo et al. (1995), Hede and Peterson,[2] Kenkere and Spadigam[4] and Stiefel et al.,[17] and Vigild, et al.[15]

Periodontal status

CPITN scores showed a periodontal status of 36 (2.7%) participants bleeding on probing, 42 (15.27%) with calculus on probing, 130 (47.27%) with shallow pockets, and 66 (24.09%) with deep pockets. The overall prevalence of periodontal disease, particularly shallow and deep pockets, is high among the participants and could be accounted to negligence toward toothbrushing, improper oral hygiene practices followed leading to incomplete removal and accommodation of plaque and calculus, the influence of psychiatric disturbances, and the effect of xerostomia. The above results were in conformity with the results of the study done by Shah et al.,[13] Kyong et al.,[18] Kenkere and Spadigam,[4] Rekha, et al.,[16] Vigild, et al.,[15] and Kumar et al.[7] The only difference was in the measurement; they had used either simplified oral hygiene index, Russell periodontal index, or CPITN index, whereas in the present study, we have utilized the CPITN index. Multiple logistic regression analysis shows that in the present study, periodontal status worsened with increasing age.

The relationship of increasing age and worsening periodontal status is reflected not only in CPI scores for pockets but also by a large number of excluded sextants because of the absence of dentition due to increase in the tooth loss. This is consistent with other studies of Angelillo et al.,[12] Kenkere and Spadigam,[4] and Kumar et al.[7]

Simplified oral hygiene index

Oral hygiene status of 263 patients showed that only 3 (1.14%) had good status, 39 (14.83%) had fair status, and 221 (84.03) had poor status.

According to the age group distribution of 263 participants, poor simplified oral hygiene index score increased with advancing age, i.e., 81.02% in the younger age group, 86.11% in the middle age group, and 94.44% in the older age group. This is in the accordance with other studies of Angelillo, et al.,[12] Kenkere and Spadigam,[4] and Kumar et al.[7]

Oral mucosal lesion

Candidiasis and leukoplakia were noticed among psychiatric groups. Isolation of a large number of Candida colonies in psychiatric patients is reported by Lucas (1993) who attributes that the reduction of IGA along with xerostomia, predisposes CANDIDA growth and increases adherence and survival of colonies.

In the present study, leukoplakia was found in 5.45% participants, lichen planus in 12.36%, ulceration in 1.82%, acute necrotizing gingivitis in 0.36% participants, and candidiasis in 7.27% participants.

Much higher numbers of Candida colonies from the palatal mucosa in 52% were found in a study done by Lucas.[19]

So poor oral hygiene and reduced salivary secretions could have had a significant side effect of psychotropic drugs appeared to be important factors predisposing Candida growth to that extent.

As far as other conditions such as lichen planus were found in 12.36%, ulcerations were seen in 1.82% and acute necrotizing gingivitis in 0.36%, which may be attributed to stress which is a usual finding of psychiatric patients.

The percentage of patients with conditions such as leukoplakia was 5.45% which can be attributed to the strict rules of the psychiatric hospital which did not allow tobacco products inside the hospital, as tobacco is one of the predisposing factors for these lesions, so less percentage of these lesions may be attributed to these factors.

Oral hygiene care

As per the present study, only 3 (1.14%) of the participants had good oral hygiene, whereas 39 (14.83%) has fair oral health status, and 221 (84.03%) participants reported poor oral health status. It was due to reason that the participants did not care for their oral hygiene. The reason when asked for not caring for oral hygiene due to mental illness, not able to concentrate, negligent toward oral hygiene, and they were not aware of the importance of oral hygiene. Furthermore, majority of cases cleaned their teeth with finger and the tooth powder and very few use the brush for cleaning

The above results may be attributed to the reason that hospital authorities did not allow or provide toothbrush to the patients, as psychiatric patients would use them as weapons against each other and may injure or harm eachother or staff. Only patients living in special cottages were allowed to have brushes for cleaning their teeth

In a study done by hede B (1995)[2] reported that 17 55% of individuals neglect toothbrushing. This difference could be due to the reason that this study was conducted in a developed country and patients care is much more in a developed country than in a developed co untry like ours.

The high level of irregular oral hygiene practices can be attributed to the nature of mental disorders which induces changes in their behavior, forgetfulness, deterioration in personal hygiene, and disinterest in performing appropriate oral hygiene practices.


  Conclusion Top


Psychiatric patients are the special groups in the community who require special care and social support from not only from the family but also from the society. They also need concern from the health professionals. They should be treated as other individuals without any inhibitions. Dentists are required to understand the psychiatric illness and oral health implications and carry out preventive measures to prevent oral diseases, for which the psychiatric patients are at high risk to occur.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Hede B, Petersen PE. Self-assessment of dental health among Danish noninstitutionalized psychiatric patients. Spec Care Dentist 1992;12:33-6.  Back to cited text no. 2
    
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Gatchel RJ, Paul J, Garofalo, Ellis E, Holt C. Psychological disorders with acute and chronic temporomandibular disorders (TMD). JADA 1996;6:255-7.  Back to cited text no. 3
    
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Kenkere AM, Spadigam AE. Oral health and treatment needs in institutionalised psychiatric patients in India. IJDR 2000;11:5-11.  Back to cited text no. 4
    
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Ramon T, Grinshpoon A, Zusman SP, Weizman A. Oral health and treatment needs of institutionalized chronic psychiatric patients in Israel. Eur Psychiatry 2003;18:101-5.  Back to cited text no. 5
    
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Bhowate R, Dubey A. Dentofacial changes and oral health status in mentally challenged children. J Indian Soc Pedod Prev Dent 2005;23:71-3.  Back to cited text no. 6
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Kumar M, Chandu GN, Shafiulla MD. Oral health status and treatment needs in institutionalized psychiatric patients: One year descriptive cross sectional study. Indian J Dent Res 2006;17:171-7.  Back to cited text no. 7
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Gowda EM, Bhat PS, Swamy MM. Dental health requirements for psychiatric patients. Med J Armed Forces India 2007;63:328-30.  Back to cited text no. 9
    
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Ellefsen B, Holm-Pedersen P, Morse DE, Schroll M, Andersen BB, Waldemar G. Caries prevalence in older persons with and without dementia. J Am Geriatr Soc 2008;56:59-67.  Back to cited text no. 10
    
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Ponizovsky AM, Zusman SP, Dekel D, Natapov L, Weizman A. Effects of implementing dental services in Israeli Psychiatric hospitals on the oral and dental health of inpatients. Psychiatr Serv 2009;60:799-803.  Back to cited text no. 11
    
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Angelillo IF, Nobile CG, Pavia M, De Fazio P, Puca M, Amati A. Dental health and treatment needs in institutionalized psychiatric patients in Italy. Community Dent Oral Epidemiol 1995;23:360-4.  Back to cited text no. 12
    
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Shah VR, Jain P, Patel N. Oral health of psychiatric patients: A cross-sectional comparision study. Dent Res J (Isfahan) 2012;9:209-14.  Back to cited text no. 13
    
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Vigild M, Brinck JJ, Christnen J. Oral health status of persons institutionalised for dementia. JDR 1987;66:234-7.  Back to cited text no. 14
    
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Vigild M, Brinck JJ, Christensen J. Oral health and treatment needs among patients in psychiatric institutions for the elderly. Community Dent Oral Epidemiol 1993;21:169-71.  Back to cited text no. 15
    
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Rekha R, Hiremath SS, Bharath S. Oral health status and treatment requirements of hospitalized psychiatric patients in Bangalore city: A comparative study. J Indian Soc Pedod Prev Dent 2002;20:63-7.  Back to cited text no. 16
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Strayer M. A comparasion of the oral health of persons with and without chronic mental illness in community settings. Spec Cre Dentist 1990;10:6-12.  Back to cited text no. 17
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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