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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 40-47

Oral health treatment needs and dental service utilization among outpatients with mental disorders in Nigeria: A cross-sectional study

1 Department of Preventive and Community Dentistry, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
2 Department of Preventive and Community Dentistry, Aminu Kano University Teaching Hospital, Kano, Kano State, Nigeria
3 Department of Mental Health, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
4 Department of Preventive and Community Dentistry, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria

Date of Submission18-Apr-2021
Date of Decision08-Jul-2021
Date of Acceptance17-May-2021
Date of Web Publication9-Aug-2021

Correspondence Address:
Dr. McKing Izeiza Amedari
Department of Preventive and Community Dentistry, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijohs.ijohs_7_21

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Aim: The aim of the study was to determine the dental treatment needs and the level of dental service utilization among patients with mental disorders (PWMD).
Setting: This was a cross-sectional study at a tertiary hospital in Nigeria conducted between March and November 2018.
Methodology: The community periodontal index of treatment of needs and the Decayed, Missing and Filled Teeth index were used to determine the dental and periodontal treatment needs. Dental service utilization was determined using a self-reporting assessment questionnaire. All data analyses were carried out using the IBM SPSS® Statistics version 20 and the statistical significance was set at P < 0.05.
Results: A total of 116 PWMD participated in the study with 51.7% being females. The age range was between 19 and 57 years and the mean age was 37.16 (±10.52). Dental treatment need was 40.8%, while 66% needed a range of periodontal interventions and this showed no statistically significant differences in terms of gender (P = 0.67, P = 0.15, respectively). While 32.7% had made previous dental visits, past caries experience, and other factors such as gender were significant predictors for dental visits.
Conclusion: There was a high dental and periodontal treatment need among PWMD, yet the dental service utilization was low. More collaborations between oral and mental health specialists are needed to improve dental service utilization and promote holistic health care for PWMD.

Keywords: Collaboration, dental service utilization, dental treatment needs, patients with mental disorders

How to cite this article:
Amedari MI, Jeboda SO, Akinsulore A, Ogunbodede E O. Oral health treatment needs and dental service utilization among outpatients with mental disorders in Nigeria: A cross-sectional study. Int J Oral Health Sci 2021;11:40-7

How to cite this URL:
Amedari MI, Jeboda SO, Akinsulore A, Ogunbodede E O. Oral health treatment needs and dental service utilization among outpatients with mental disorders in Nigeria: A cross-sectional study. Int J Oral Health Sci [serial online] 2021 [cited 2021 Nov 28];11:40-7. Available from: https://www.ijohsjournal.org/text.asp?2021/11/1/40/323535

  Introduction Top

Patients with mental disorders (PWMD) represent a vulnerable population who face self-neglect, poor nutrition, and the side effects of medications which affect their oral health and thus increase their need for oral health care.[1],[2],[3] A meta-analysis showed that the odds of losing all of the dentition in PWMD such as in schizophrenia, bipolar disorders, and other affective disorders was almost three times more than the general population.[4]

High scores of the Decayed, Missing, and Filled Teeth (DMFT) index of up to 20 have been recorded among patients with severe mental disorders in high-income countries, while in low-to-middle income countries, the scores were lower.[5] According to Kebede et al. in a study in Ethiopia, about 76% of the participants needed periodontal treatments and a mean DMFT of 1.94 (±2.12) was reported.[6] Similarly, in a local study, Adeniyi et al. reported a dental treatment need of 78.1% among the respondents as well as 88.6% who required scaling and polishing and advanced periodontal therapy.[7]

Dental treatment needs or periodontal treatment needs are not the only considerations for utilizing oral health services.[8] Dental service utilization is referred to as the proportion of the population who access dental services over a given period[9] and is also a proxy indicator for access to oral health care.[10] In Nigeria, financial limitation to access to oral health care arises due to the high out of pocket payment required for dental treatments at both private and public dental hospitals.[11] Moreover, lower dental service utilization has also been reported among PWMD compared to the general population and this contributes to the poor oral health in this target population.[3]

There has been negligible research into oral and mental health interrelationships in Nigeria, despite the evidence of increased risks for poor oral health in this population. While dental service utilization in the general population has been studied previously and found to be generally low in Nigeria,[12] there is yet insufficient research on the dental service utilization among PWMD in Nigeria even though they are a vulnerable population. The aim of this study is therefore to determine the dental and periodontal treatment needs of out-PWMD and the level of dental service utilization among PWMD.

  Methodology Top

The design of this study was cross-sectional, and data were collected between March and November 2018. The study population consisted of outpatients with either schizophrenia, affective disorders, or bipolar disorder who were diagnosed by a consultant psychiatrist. Adult patients aged 18–70 years were included in the study. Patients who had comorbidities, chronic oral diseases, severe anatomical variations in their dentition as well as pregnant and lactating mothers were excluded from the study.

Study setting

The study location was the mental health clinic of the Obafemi Awolowo University Teaching Hospital. The clinic runs twice a week and questionnaires were administered on consecutive and consenting patients at the clinic who met the inclusion and exclusion criteria.

Sample size

The sample size was determined using the formula for calculating sample size for observational studies (Z1-α/22 P [1 − P]/d2).[13] Where Z1-α/2 represented the critical value and standard value for the equivalent 95% confidence interval which was 1.96. P, the prevalence was from the Adeniyi et al. findings of 30.5% need for extraction among PWMD,[7] while a 10% precision was used for this study. A minimum sample size of 90 was reached after including the 10% attrition rate, but 116 participants agreed to participate in this study.

Ethical clearance

Ethical clearance was obtained from the Research and Ethics committee of the Obafemi Awolowo Teaching Hospital Complex and protocol number ERC 2017/07/08 was assigned. Informed consent was obtained from all participants or their accompanying guardian depending on the verbal and physical cues of the participants.


Information about the perceived state of their oral health was obtained using a questionnaire adapted from the World Health Organization (WHO) survey methods self-assessment tool.[14] Xerostomia, sialorrhea, use of removable partial denture, and difficulty chewing were self-reported. Dental service utilization was determined as a function of previous dental visits. This was considered as a binomial variable of a YES/NO response to the question: “have you visited a dentist in the past?”

Examiner calibration

All measurements were conducted by the principal investigator who had over 5-year postgraduate residency training experience. A duplicate examination for the first ten participants in the study was carried out and the intraexaminer reliability determined. A kappa score was 0.8 was obtained demonstrating significant reliability of the measurements.

Oral examination

The intraoral examination was conducted using natural light with each participant sitting uprightly on chair. Information was obtained using the DMFT, Community Periodontal Index of Treatment of Needs (CPITN) indices as well as the intervention urgency scale.[14]

The caries experience was evaluated using the DMFT index which was calculated based on the 32 permanent teeth including the third molar. A decayed tooth, D, was recorded on finding a frank cavity with undermined enamel walls. While the Filled teeth, F represented any restored tooth, which was previously carious. The Missing tooth, M, represented an extracted tooth that was previously carious. The mean DMFT was calculated as the total DMFT (D + M + F) divided by the total population examined. Also, the dental treatment need was calculated as a proportion of the decayed teeth, D, out of the total DMFT score in percentage. While the restorative index was calculated as RI = F/D + F × 100 (which represented patients who obtained restorative treatment).[15]

The CPITN[16] was used to assess periodontal health and the treatment needs. The classification of the scores was as follows: Code 4: A pocket depth of 6 mm or more, Code 3: A pocket depth of 4 or 5 mm, Code 2: Calculus and plaque retaining factors, Code 1: Bleeding on gentle probing, and Code 0: Healthy gingivae.

The periodontal treatment need for each participant was therefore determined as follows:

TN0: For a record of Code 0 needing no treatment.

TN1: For a record of Code 1 or higher, needing or oral hygiene improvement.

TN2a: For a record of Code 2 or higher, needing scaling and polishing as well as TN1.

TN2b: For a record of Code 3 or higher, needing Root planning in addition to TN2a, TN1 treatment.

TN3: For a record of Code 4, requiring advanced periodontal treatments in addition to TN2b, TN2a, TN1 treatment.

Intervention urgency for each participant was also determined based on the WHO Oral Health Survey-Basic Methods.[14] The scale was as follows: Code 0 = No therapy indicated, Code 1 = Prophylactic or routine treatment indicated, Code 2 = Prompt treatment (including scaling) indicated, Code 3 = Immediate (urgent) treatment indicated due to pain of dental or oral origin, and Code 4 = Participant referred for complete medical/dental treatment (systemic conditions).


All data were collected and entered into the SPSS software (version 20) (IBM, Armonk, NY). The categorical data were summarized using frequencies and percentages, whereas the continuous data were summarized using means and standard deviations. Bivariate analysis was used to make gender comparisons and logistic regression was used to determine predictors for dental service utilization. The regression model included age, gender, previous experience of dental pain, duration of mental disorder, and caries experience as independent variables, while the dependent variable was a previous dental visit (being a YES/NO response). All analytical tests were subjected to a level at P < 0.05 for the test of significance.

  Results Top

A total of 116 outpatients who were diagnosed with a severe form of mental illness (either schizophrenia, affective disorder, or bipolar disorder) participated in the study.

[Table 1] highlights the sociodemographic characteristics of the participants in the study. The age range was between 19 and 57 years and the mean age was 37.16 (±10.52). The majority of the participants were within the age range of 20–39. The participants had an almost equal gender distribution as well as in terms of marital status. Only ten participants had tertiary education while a majority had primary education.
Table 1: Sociodemographic characteristics of the participants (n=116)

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[Table 2] highlights the self-reported oral health assessment of the participants and the dental service utilization. The majority of the respondents reported either good or excellent state of their oral health. Almost 40% of the respondents had experienced pain and discomfort in the past 12 months. Other notable complaints were sialorrhea, xerostomia, difficulty in chewing, and difficulty speaking. Almost a third of the participants had made previous dental visits. However, most of those visits were in the past 5 years. Dental pain was the most important self-reported reason for a visit to a dentist, while nonreferral to a dentist was among the top two reasons for not visiting a dentist. Of the 38 patients who visited the dentist, more than 70% of the costs were self-funded (out-of-pocket).
Table 2: Self-reported oral health assessment and dental service utilisation of patients with mental disorders

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The mean DMFT was 0.54 (±1.15). Decayed teeth ranged from 0 to 6 and the dental treatment need was 40.8%, while the restorative index was 6.7%. There was no statistically significant difference regarding gender (P = 0.67, P = 0.15). [Figure 1] is a summary of the periodontal treatment needs for the participants. About 66% of the participants needed a range of periodontal intervention; from oral hygiene improvement with scaling and polishing in 40.5% to those needing oral hygiene improvement with professional scaling and polishing as well as root planning in 25.9% of the participants. There was also no statistically significant difference in terms of gender (P = 0.89) [Table 3]. The intervention urgency scale revealed that a majority (60.3%) of the participants needed preventive and routine dental interventions. In addition, a third of the participants also needed prompt treatments including scaling and polishing and minimal dental restorations [Figure 2].
Figure 1: Periodontal Treatment Needs of patients with mental disorders

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Table 3: Findings from the community periodontal index of treatment needs (gender disaggregated)

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Figure 2: Intervention urgency scale for patients with mental disorders

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The binary regression model showed that the independent variables could predict between 32.3% (Cox and Snell R2) and 45.1% (Nagerlkerke R2) of the variability of the dependent variable, dental visit. Caries experience and sex were the two most significant predictors in the model. The odds for a dental visit was 9 times more among those with a caries experience compared with those without and females were less likely to utilize dental services compared with the male counterparts [Table 4].
Table 4: Result of logistic regression model for the predictors of dental visit

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  Discussion Top

The participant's perceived oral health need (s) in this study were assessed through a self-reported oral health assessment questionnaire, and more than 60.3% rated their oral health as excellent, very good, or good. This is much higher than the self-rating of oral health status among the general population in Nigeria of 48.3%.[12] However, our findings are similar to what was reported by Farrahi-Avval, among PWMD in which 59% claimed good, very good, or excellent oral health status.[17] In this study, apart from the most common complaint which was pain, difficulty chewing, speaking, sialorrhea, and xerostomia were also identified as oral health problems by the PWMD. Self-rated oral health evaluates oral health through a patient-centered approach and is reported in the view of the patient. Thus, it reveals the patient's own self-perceived need for oral care, and it is also essential in planning oral health programs. It is however limited because it is usually based on the sociodemographic characteristics and the oral health literacy of the patient and not a normative assessment of a health expert.[15]

In this study, the DMFT and the CPITN were used to determine normative dental and periodontal treatment needs in the participants. The DMFT scores ranged from 0 to 6 and 40.8% needed dental treatments including simple and complex restorations for cavities and dental extractions for grossly carious teeth. Our study also showed that the proportion of patients who had received restorative care out of those with previous caries experience was 6.7%. This highlights the low “met needs” and the gap in the amount of restorative dental care obtained among PWMD who suffered a caries experience.

The dental treatment need was lower than what was reported by Adeniyi et al.[7] (78.1%), however, it is noteworthy that both studies are in agreement concerning the high dental treatment needs among PWMD. This is also corroborated by the findings of Singh et al.[18] and Velasco-Ortega et al.[19] who also reported extensive need for dental treatment among this cohort. This implies that, irrespective of geographical location, other common factors such as the lack of oral hygiene advice, family support, and poor access to dental care are contributory to this increased level of dental treatment need.[1],[20]

The findings of this study reveal that a majority of the participants had Codes 2 and 3 of the CPITN index which corresponded to treatment needs of TN2a and TN2b, these periodontal needs are in the background of the chronic mental disorder with a long-term neglect of oral health. Sixty-six percent of the participants in this study needed periodontal treatments including scaling and polishing, root planning, complex periodontal procedures as well as oral hygiene improvement. The primary mental disorder reduces the motivation for oral care and also compromises their ability for adequate tooth brushing.[21] Moreover, the chronic use of antipsychotics gives rise to side effects such as involuntary movements of the tongue, lips, and jaws which limits effective tooth brushing. Apart from the antipsychotics, the use of anticholinergics to manage these extrapyramidal side effects produces xerostomia which further accentuates plaque and calculus build up in the oral cavity by reducing the ability of the oral cavity to cleanse itself.[21] A local study also reported a similar high need for scaling and polishing in about 88.6% of the outpatients seen in PWMD.[7]

The WHO oral health survey methods introduced the intervention urgency to guide referral to an appropriate health facility when needed.[14] The proportion of participants in this study requiring prompt and urgent dental treatment further buttresses the fact that PWMD pay little attention to their oral hygiene and consequently need prompt dental prophylaxis as well as dental restorations for cavities. The scale also revealed that a vast majority (60.3%) needed preventive and routine treatments. It is noteworthy that these study participants utilized a tertiary hospital for their mental health care without awareness of their oral health needs even though the same institution also had a dental hospital with a comprehensive range of dental services available.

Despite the recorded need for dental care in this study, 32.7% of the study participants had made previous dental visits. This prevalence is lower when compared with Teng et al.'s study which utilized the Taiwan's National Health Insurance Research dataset, in which 40% of patients with severe mental illnesses including schizophrenia and bipolar disorder had made previous dental visits.[22] Unlike the Taiwan study where the national health insurance program is a compulsory single-payer system for all its citizens granting equal access to health care, the National health insurance scheme (NHIS) in Nigeria covers only 5% of its citizens, principally for persons working in the formal sector or government-paid jobs and caters for a few curative dental services.[23] This may have contributed to the low dental service utilization among the participants in our study. Similarly, only 10.5% of the participants who had previous dental visits, benefited from the NHIS in full for the payment of the cost of their treatments, while the majority, 73.7%, made out of pocket payment for the services they received. This limits financial access to dental care, given that most of these persons already face an economic disadvantage as evidenced by the unemployment level of 21% in this study.

The common reason for not visiting a dentist was the absence of a dental complaint. This is corroborated by the self-assessment rating of the participants' oral health in this study, as a majority of the participants rated their oral health status as good or excellent hence, most of the participants will have considered a dental visit unnecessary. Notably, the second most common reason for not making a dental visit was the lack of referrals to a dentist. This shows the lack of a coordinated health-care referral system, the low oral health awareness among mental health professionals, and the existence of specialist health services as independent silos of care. The need for a stronger collaboration with oral health professionals and support for integrated health care has been buttressed by Šarac et al.,[24] who noted that such existing gaps between these professions should be bridged through improved training among mental health professionals and by overcoming communication barriers among dental professionals.

From the regression analysis carried out in this study, previous dental caries experience, as well as gender, were the two most important predictors of making a dental visit among PWMD. The caries experience refers to dental decay (cavity) or a previous treatment of restoration of a carious cavity or extraction of a carious tooth. The participants with previous caries experience were nine times more likely to make another dental visit unlike those participants without such history. Inferentially, persons only consider dental care a necessity when there is already a dental problem. The impact of untreated dental decay on persons with mental disorders worsens their quality of life, especially in the context of the behavioral challenges due to the primary illness. Moreover, some of these patients may make some unusual complaints such as difficulty chewing, eating, and speaking at the mental health clinic which may be misjudged as only a symptom of the mental disorder by the physician. Hence, it will be important for the attending physician at the mental health clinic to be alert to such oral health complaints and make appropriate referrals when necessary because some of these patients may find it difficult identifying and articulating their oral health needs. Although this study highlights a gender difference in terms of predicting dental service utilization, it is however contrary to the findings on gender in the studies among the general population in Nigeria about dental service utilization, which showed no difference.[12]

Overall, the perceived and the normative oral health needs among PWMD have been presented in this study, as well as the low level of dental service utilization. This information will be useful in policy conversations and formulations for the planning of integrated delivery of care to this cohort. This study showed no statistically significant gender differences regarding dental treatment needs, periodontal treatment needs, or intervention urgencies (which warrant dental visits), but studies with larger sample sizes are needed to more accurately determine any differences. Furthermore, qualitative research on this subject can provide in-depth analysis of the social considerations for dental service utilizations such as employment, education, and the decision making ability to seek oral care.

  Conclusion Top

PWMD has high dental treatment and periodontal needs but dental visits are still low. Although clinical variables such as previous dental caries experience may motivate dental visits, this study showed that the restorative care received was also low. More focus should be directed toward prompt referral by the mental health professional and improved insurance cover which can influence dental service utilization. There is a need to discourage separate silos of health-care practices as more collaboration between oral and mental health specialties will be necessary to promote more holistic and patient-centered health care. Furthermore, more research on oral and mental health interrelationships are needed in Nigeria. This can reveal potential gender differences that may also influence dental service utilization and affect the oral health outcomes in PWMD.

Duration of mental disorder

Ref = Reference; males and females were coded as categorical independent predictor variables during the analysis, and the male gender was used as reference point. Similarly, the presence or absence of the characteristic of interest for caries experience and pain were coded and the absence was used as reference point. Age and duration of mental disorder were continuous variables in the model.


The authors acknowledge Dr. Usoyibo at the department of mental health who assisted by providing technical support at the clinic during recruiting of the PWMD.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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