Oral health of psychiatric inpatients: a survey of central Taiwan hospitals

Evaluation of oral health education programs among patients with schizophrenia in India: An interventional study

BACKGROUND

Schizophrenia is a mental disease that can drastically affect oral health. Hence, this remains a significant factor that affects oral health-related quality of life (OHRQoL). Assessing the OHRQoLin schizophrenic patients is one of the primary needs. The oral health impact profile is an impressive range of instruments that assesses the impact of oral conditions on well-being and quality of life.

MATERIALS AND METHODS

A 100 schizophrenic individuals were randomly selected from the Psychiatry Department of Government Hospital, Patna, Bihar, India, and grouped into two groups: (a) Group I with.group-based sessions and (b) Group II with one-on-one interactions. Inclusion criteria: (a) Individuals who received the clinical confirmatory diagnosis of schizophrenia, (b) Patients who regularly reported to the psychologist for periodic evaluation, and (c) Patients who could follow instructions. Exclusion criteria: (a) Patients or their caregivers who were unwilling to participate in the study, (b) Patients with any other mental health disability other than schizophrenia, (c) Patients with muscular or nervous system disorders, and (d) Patients who could not follow instructions. Patients were educated on the modified Bass technique, and mean ± standard deviation plaque scores were compared at the baseline and after 12 weeks of intervention.

RESULTS

Statistical analysis was performed using the Chi-square analytical test and paired "t-test." Statistically significant differences were observed in plaque scores in both groups (P < 0.001).

CONCLUSION

Educational training tools help in improving oral health in schizophrenic patients.

The effect of antipsychotic medication and the associated hyperprolactinemia as a risk factor for periodontal diseases in schizophrenic patients: a cohort retrospective study

BACKGROUND

Periodontal disease is a major health problem that results in tooth loss and thus affects oral health, which affects quality of life. In particular, schizophrenic patients are at higher risk for periodontal disease due to several factors, including the effect of antipsychotic medications received by those patients. Accordingly, the aim of the present cohort retrospective study is to explore the effect of antipsychotics on periodontal health and the possible effect of antipsychotic-induced hyperprolactinemia as a risk factor for periodontal disease progression in schizophrenic patients.

METHODS AND OUTCOMES

The study population consisted of three groups: Group A (n = 21): schizophrenic patients that have been taking "prolactin-inducing" antipsychotics for at least 1 year; Group B (n = 21): schizophrenic patients who have been taking "prolactin-sparing" antipsychotics for at least 1 year; and Group C (n = 22): newly diagnosed schizophrenic patients and/or patients who did not receive any psychiatric treatment for at least 1 year. The study groups underwent assessment of periodontal conditions in terms of pocket depth (PD), clinical attachment loss (CAL), gingival recession, tooth mobility, and bleeding on probing (BOP). Also, bone mineral density was evaluated using DEXA scans, and the serum prolactin level was measured by automated immunoassay.

RESULTS

Results revealed a statistically significant difference in PD, CAL, and serum prolactin levels (P ≤ 0.001, P = 0.001, and P ≤ 0.001, respectively) among the 3 study groups. For both PD and CAL measurements, group A has shown significantly higher values than both groups B and C, whereas there was no statistically significant difference between the values of groups C and B. Concerning serum prolactin levels, group A had significantly higher values than groups B and C (P ≤ 0.001 and P ≤ 0.001 respectively). There was a statistically significant difference (P ≤ 0.001) between the 3 study groups in terms of bone mineral density. Moreover, there was a statistically significant direct relation between serum prolactin level and other parameters including clinical attachment loss, pocket depth measurements and bone mineral density.

CONCLUSION

According to our results, it could be concluded that all antipsychotics contribute to the progression of periodontal disease, with a higher risk for prolactin-inducing antipsychotics. However, further long term, large sampled, interventional and controlled studies are required to reach definitive guidelines to allow clinicians properly manage this group of patients.

A Systematic Review and Meta-Analysis of the Association Between Periodontal Disease and Severe Mental Illness

BACKGROUND

Periodontal disease represents a global public health concern, with a disproportionate burden being borne by vulnerable populations. One such group is people with severe mental illness (SMI), and this study examined whether periodontal health is poorer in people with SMI than the general population.

METHODS

We conducted a systematic search for studies published before March 2021 on the periodontal health of people with SMI using the following databases: PubMed, PsycINFO, EMBASE, China National Knowledge Infrastructure, and Chongqing VIP. Outcomes were periodontitis, periodontal disease, and shallow and deep periodontal pockets. Results were compared with the general population.

RESULTS

Seventeen studies had sufficient data for a random-effects meta-analysis, consisting of 4404 psychiatric patients and 95,411 controls. SMI was associated with an increased prevalence of periodontitis (odds ratio = 1.97, 95% confidence interval [CI] = 1.15-3.35) compared with the general population. People with SMI had 4.28 the odds of having periodontal disease compared with controls (95% CI = 2.54-7.21). They also had 3.65 the odds of shallow pockets (95% CI = 1.80-7.42) and 2.76 the odds of deep pockets (95% CI = 1.10-6.93).

CONCLUSIONS

Our findings highlight the increased prevalence and severity of periodontal disease in people with SMI. Oral health is often considered the gateway to overall health and should be a public health priority for this population.

Improving oral health in people with severe mental illness (SMI): A systematic review

BACKGROUND

Those with severe mental illness (SMI) are at greater risk of having poor oral health, which can have an impact on daily activities such as eating, socialising and working. There is currently a lack of evidence to suggest which oral health interventions are effective for improving oral health outcomes for people with SMI.

AIMS

This systematic review aims to examine the effectiveness of oral health interventions in improving oral health outcomes for those with SMI.

METHODS

The review protocol was registered with PROSPERO (ID CRD42020187663). Medline, EMBASE, PsycINFO, AMED, HMIC, CINAHL, Scopus and the Cochrane Library were searched for studies, along with conference proceedings and grey literature sources. Titles and abstracts were dual screened by two reviewers. Two reviewers also independently performed full text screening, data extraction and risk of bias assessments. Due to heterogeneity between studies, a narrative synthesis was undertaken.

RESULTS

In total, 1462 abstracts from the database search and three abstracts from grey literature sources were identified. Following screening, 12 studies were included in the review. Five broad categories of intervention were identified: dental education, motivational interviewing, dental checklist, dietary change and incentives. Despite statistically significant changes in plaque indices and oral health behaviours as a result of interventions using dental education, motivational interviewing and incentives, it is unclear if these changes are clinically significant.

CONCLUSION

Although some positive results in this review demonstrate that dental education shows promise as an intervention for those with SMI, the quality of evidence was graded as very low to moderate quality. Further research is in this area is required to provide more conclusive evidence.

Effectiveness of oral health promotion program for persons with severe mental illness: a cluster randomized controlled study

OBJECTIVE

To evaluate the effectiveness of a composite oral health promotion program designed to reduce dental plaque among persons with severe mental illness in a psychiatric institution.

METHODS

A cluster randomized controlled study was carried out in chronic psychiatric wards of a general hospital in central Taiwan. Sixty-eight eligible male individuals admitted to 2 wards were randomly assigned to an experimental and a control group. Participants in the experimental group underwent an oral health promotion program that consisted of biweekly group education sessions, and a 12-week individual behavioral modification for oral hygiene course. The participants in the control group received usual care only. Dental plaque (measured by the Plaque Control Index) was examined by a single dentist before and after the experiment. Each participant responded to a questionnaire regarding oral health knowledge, attitude and behavior before and after the experiment.

RESULTS

Fifty-eight individuals completed the study. Before the experiment, the plaque index was similar between the intervention group (68.9; N = 27) and the control group (69.8; N = 31). After the experiment, the plaque index was significantly better in the intervention group than in the control group (42.6 vs. 61.8; P < 0.001). Participants in the intervention group also demonstrated better oral health knowledge, attitude and behavior than those in the control group after the experiment.

CONCLUSIONS

A composite oral health promotion program using both group education and individual behavioral methods over a 12-week period was effective in both reducing dental plaque and improving the oral health knowledge of persons with severe mental illness in the institution.

TRIAL REGISTRATION

This study was retrospectively registered in Clinicaltrials.gov, with number NCT04464941, dated 7/7/2020. https://register.clinicaltrials.gov/RD103035018 .

Access to Dental Care and Depressive Illness: Results from the Korea National Health Nutrition Examination Survey

Background and Objectives: Recent evidence suggests that oral health is associated with various systemic diseases including psychiatric illnesses. This study examined the association between depression and access to dental care in Korean adults. Materials and Methods: A cross-sectional evaluation was performed using data from the Sixth Korea National Health and Nutrition Examination Survey 2014. The general characteristics of the participants, the current depression status, and issues with access to dental care were collected to evaluate the factors for not being able to make dental visits according to care needs. Results: The study population comprised a total of 5976 participants who were 19 years of age and older and represented 40.7 million Koreans. A multivariable logistic regression analysis with weighted observations revealed that participants with current depressive illness were about two times more likely to express that they could not make dental visits in spite of their perceived care needs (adjusted odds ratio (OR) = 2.097; 95% confidence interval (CI) 1.046–4.203). The reasons for not making dental visits included financial problems, perceived importance of the dental problem, and fear of visiting dental professionals. Conclusions: Korean adults with current depressive illness were less likely to make dental visits when they had dental care needs. To improve dental health accessibility for patients with depressive illness, coordinated efforts can be considered involving multidisciplinary health care professionals.

Dentists' perspectives on barriers to providing oral health care in French psychiatric hospitals with on-site dental clinics

OBJECTIVES

Psychiatric inpatients suffer from poorer oral health than the general population, and difficulties in accessing necessary dental treatment remain even when a dedicated dental service is available within the psychiatric hospital. The aim of this study was to identify barriers to access dental care from the point of view of dentists working within French psychiatric hospitals.

METHODS

The relatively small number of dentists working in psychiatric hospitals necessitated a qualitative approach. Semi-structured interviews were conducted, recorded, transcribed and coded in a conventional content analysis approach.

RESULTS

Eight interviews were conducted. Six of the dentists interviewed were men, and two were women. Three of them worked full-time in a psychiatric facility, while the other five worked partly in the hospital and partly in private practice. The average duration for interviews was 54 minutes (minimum 24 min, maximum 89 min). The interviews highlighted three dimensions of barriers to access to dental care. The first dimension was directly related to the patient. This may be linked to the patient's psychiatric disorder but not necessarily. This also encompasses refusal of care. A second dimension regrouped events related to the organization of the hospital (locally), such as communication issues between staff members within the dental office, and with other staff members from the psychiatric ward. A third dimension included difficulties related to the overall organization of the healthcare system, including financial issues and deinstitutionalization.

CONCLUSIONS

In-site dental consultations appear as an interesting tool to enhance access to oral care for psychiatric inpatients. However, difficulties remain from the dentists' perspective.

Periodontal disease and effects of antipsychotic medications in patients newly diagnosed with schizophrenia: a population-based retrospective cohort

AIM

Compared with the general population, individuals with schizophrenia have a higher risk of periodontal disease, which can potentially reduce their life expectancy. However, evidence for the early development of periodontal disease in schizophrenia is scant. The current study investigated risk factors for periodontal disease in patients newly diagnosed with schizophrenia.

METHODS

We identified a population-based cohort of patients in Taiwan with newly diagnosed schizophrenia who developed periodontal disease within 1 year of their schizophrenia diagnosis. Treatment with antipsychotics and other medications was categorised according to medication type and duration, and the association between medication use and the treated periodontal disease was assessed through logistic regression.

RESULTS

Among 3610 patients with newly diagnosed schizophrenia, 2373 (65.7%) had an incidence of treated periodontal disease during the 1-year follow-up. Female sex (adjusted odds ratios [OR] 1.40; 95% confidence interval [CI] 1.20-1.63); young age (adjusted OR 0.99; 95% CI 0.98-0.99); a 2-year history of periodontal disease (adjusted OR 2.45; 95% CI 1.84-3.26); high income level (adjusted OR 2.24; 95% CI 1.64-3.06) and exposure to first-generation (adjusted OR 1.89; 95% CI 1.54-2.32) and secondary-generation (adjusted OR 1.33; 95% CI 1.11-1.58) antipsychotics, anticholinergics (adjusted OR 1.24; 95% CI 1.03-1.50) and antihypertensives (adjusted OR 1.91; 95% CI 1.64-2.23) were independent risk factors for periodontal disease. Hyposalivation - an adverse effect of first-generation antipsychotics (FGAs) (adjusted OR 2.00; 95% CI 1.63-2.45), anticholinergics (adjusted OR 1.27; 95% CI 1.05-1.53) and antihypertensives (adjusted OR 1.90; 95% CI 1.63-2.22) - was associated with increased risk of periodontal disease. Therefore, hypersalivation due to FGA use (adjusted OR 0.72; 95% CI 0.59-0.88) was considered a protective factor.

CONCLUSIONS

The current study highlights that early prevention of periodontal disease in individuals with schizophrenia is crucial. Along with paying more attention to the development of periodontal disease, assessing oral health regularly, helping with oral hygiene, and lowering consumption of sugary drinks and tobacco, emphasis should also be given by physicians to reduce the prescription of antipsychotics to the extent possible under efficacious pharmacotherapy for schizophrenia.

The oral health of long-term psychiatric inpatients in Singapore

This cross-sectional study aims to describe the dental caries experience, treatment needs, and experience of dry mouth of 191 long-term psychiatric inpatients in Singapore. Medical history, dental caries experience [represented by the Decayed Missing or Filled Teeth index (DMFT)], salivary flow, and treatment needs were recorded. Information on brushing, pain (when eating), and xerostomia was gathered. Bivariate analysis was used to examine the associations of DMFT, saliva flow, the presence of salivary gland hypofunction (SGH), and xerostomia. Simple linear regression was used to examine the association between SGH and DMFT. The sample comprised 143 men (74.9%) and 48 women (25.1%), aged 24 to 80 years old. 169 patients (88.5%) had schizophrenia. DMFT ranged from 0 to 32, with a mean of 21.6 (SD 9.7). Mean DMFT scores were significantly higher among males and older patients. 77 of 176 patients (43.8%) were found to have SGH. SGH was associated with a higher mean DMFT. Those taking classical antipsychotics and anticholinergics had significantly lower mean saliva flow and tended to have SGH. 107 of 165 patients (64.8%) were found to experience xerostomia. Long-term psychiatric inpatients in Singapore have poor oral health, unmet treatment needs, and suffer from dry mouth.

Status and perception of oral health in 6-17-year-old psychiatric inpatients-randomized controlled trial

AIM

The following are the aims of the study: assessment of oral health status, oral health-related quality of life (OHRQoL) and the effect of oral health care training over OHRQoL in children and adolescents hospitalized with mental disorders.

METHODOLOGY

This randomized case controlled prospective interventional study involved 81 child and adolescent psychiatric inpatients (CAP) aged between 6 and 17 years (mean age 10.6 ± 2.4 years), compared to 81 mentally healthy patients attending routine dental examinations (DC group) matched according to age and sex of the CAP group. Oral examinations were performed by two calibrated dentists. OHRQoL was assessed with the German version of the Child Perceptions Questionnaire. CAP inpatients were randomly divided in two equal subgroups, an intervention (IG) and a non-intervention group (non-IG). The IG received oral health care training at admission to the hospital.

RESULTS

CAP inpatients, especially those with stress-related disorders, revealed significantly higher caries prevalence and experience than DC patients. Although OHRQoL did not differ from the German reference values, CAP inpatients compensated higher impairment due to oral symptoms and functional limitations with lower impairment due to emotional and social well-being. OHRQoL increased in all CAP patients during hospitalization, regardless of receiving oral health care training.

CONCLUSION

Poorer oral health of CAP inpatients was not accompanied by higher impairment of OHRQoL. Oral problems seem to be overshined by better self-perceived emotional and social well-being. OHRQoL was not improved by individualized oral health care training.

CLINICAL RELEVANCE

Children and adolescents with mental disorders are at risk for oral diseases and need referral to dental services.

The association between oral hygiene and periodontitis: a systematic review and meta-analysis

Objective: Dental plaque accumulation and inadequate personal oral hygiene (OH) are known major risk factors of periodontitis. Nevertheless, the magnitude of their effects has not yet been the subject of a meta-analysis. Material and methods: The Medline and Scopus databases were searched up to May 2016. Observational studies were eligible if they assessed associations between OH and periodontitis in adult subjects. A multivariate random-effects meta-analysis was used to pool the effects of fair/poor OH versus good OH on periodontitis across studies. The associations between oral care habits and periodontitis were also assessed. Results: A total of 50 studies were eligible; 15 were used for pooling the effect of fair OH versus good OH and poor OH versus good OH on periodontitis, with pooled odds ratios (ORs) of 2.04 [95% confidence interval (CI): 1.65–2.53] and 5.01 (95% CI: 3.40–7.39), respectively. Eleven studies examined oral care habits measured according to toothbrushing regularity and dental visit frequency; pooled ORs of 0.66 (95% CI: 0.47–0.94) and 0.68 (95% CI: 0.47–0.98) were obtained, respectively. Conclusions: Fair to poor OH increases the risk of periodontitis by two- to five-fold. This risk can be reduced by regular toothbrushing and dental visits.

Utilization of dental care among patients with severe mental illness: a study of a National Health Insurance database

Background

The oral health of patients with severe mental illness is poor, in general, and this may be attributed, in part, to inadequate dental care. This study investigated dental care utilization among patients with severe mental illness using a national representative sample.

Methods

This study used Taiwan’s National Health Insurance Research Dataset for 2009. Patients with the diagnosis of severe mental illness (ICD-9-CM: 290–298) were recruited as the study sample, and others comprised the control. Any visit to a dentist was defined as positive in terms of dental care utilization. Regression analyses were applied to determine the odds of dental care utilization for each diagnostic entity of severe mental illness, compared with the general population and controlling for potential covariates.

Results

Only 40 % of 19,609 patients with severe mental illness visited the dentist within 12 months. This was significantly lower than the dental visit rate of 48.3 % for the control population (odds ratio [OR] = .72, 95 % confidence interval [CI] = .69–.74; P <0.0001). The odds of dental care utilization differed among the severe mental illness diagnostic categories; e.g., the odds were lowest among those with alcohol psychoses (OR = .54, CI = .43–.68), senile dementia (OR = .55, CI = .52–.59) and other organic psychoses (OR = .58, CI = .52–.65), and highest among those with mood disorder (OR = .89, CI = .85–.94), with schizophrenic patients occupying a mid-level position (OR = .63, CI = .59–.67).

Conclusions

Patients with severe mental illness received less dental care than the general population. Health care providers and caregivers of patients with severe mental illness should encourage them to visit the dentist regularly, in order to improve the oral health of these vulnerable patient groups.

The oral health of people with chronic schizophrenia: A neglected public health burden

OBJECTIVE

People with chronic schizophrenia have high rates of physical ill-health such as heart disease. However, there has been less attention to the issue of poor oral health including dental caries (tooth decay) and periodontal (gum) disease, although both have consequences for quality of life and systemic physical health. We therefore measured tooth decay and gum disease in Malaysians with schizophrenia.

METHODS

We recruited long-stay inpatients with schizophrenia from June to October 2014. Four dental specialists assessed oral health using the decayed-missing-filled teeth index, the Community Periodontal Index of Treatment Needs and the Debris Index of the Simplified Oral Hygiene Index. Results were compared with the 2010 Oral Health survey of the general Malaysian population.

RESULTS

A total of 543 patients participated (66.7% males, 33.3% females; mean age = 54.8 years [standard deviation = 16.0]) with a mean illness duration of 18.4 years (standard deviation = 17.1). The mean decayed-missing-filled teeth was 20.5 (standard deviation = 9.9), almost double that of the general population (11.7). Higher decayed-missing-filled teeth scores were associated with both older age (p < 0.001) and longer illness duration (p = 0.048). Only 1% (n = 6) had healthy gums. Levels of decay and periodontal disease were greatest in those aged between 45 and 64 years, coinciding with the onset of tooth loss.

CONCLUSION

Dental disease in people with schizophrenia deserves the same attention as other comorbid physical illness. The disparity in oral health is most marked for dental decay. Possible interventions include oral health assessments using standard checklists designed for non-dental personnel, help with oral hygiene, management of iatrogenic dry mouth and early dental referral.

A systematic review and meta-analysis of the association between poor oral health and severe mental illness

BACKGROUND

Psychiatric patients have increased comorbid physical illness. There is less information, however, on dental disease, especially tooth decay, despite life-style risk factors or psychotropic-induced dry mouth in this population. Importantly, poor oral health can predispose people to chronic physical disease leading to avoidable admissions to hospital for medical causes.

METHODS

Using MEDLINE, PsycInfo, EMBASE, and article bibliographies, we undertook a systematic search for studies from the last 25 years regarding the oral health of people with severe mental illness (SMI). Results were compared with the general population. The two outcomes were total tooth loss (edentulism) and dental decay measured through the following standardized measures: the mean number of decayed, missing, and filled teeth or surfaces.

RESULTS

We identified 25 studies that had sufficient data for a random-effects meta-analysis. These covered 5076 psychiatric patients and 39,545 controls, the latter from either the same study or community surveys. People with SMI had 2.8 the odds of having lost all their teeth compared with the general community (95% confidence interval [CI] = 1.7-4.6). They also had significantly higher decayed, missing, and filled teeth (mean difference = 5.0, 95% CI = 2.5-7.4) and surfaces scores (mean difference = 14.6, 95% CI = 4.1-25.1).

CONCLUSION

The increased focus on the physical health of people with SMI should encompass oral health. Possible interventions could include oral health assessment conducted using standard checklists that can be completed by non-dental personnel, help with oral hygiene, management of iatrogenic dry mouth, and early dental referral.

Oral health status and treatment needs among psychiatric inpatients in Rennes, France: a cross-sectional study

BACKGROUND

Severe mental disorders have a chronic course associated with a high risk for co-morbid somatic illnesses and premature mortality and oral health is critical for overall systemic health. But general health care needs in this population are often neglected. Some studies have aimed at determining the oral health status of psychiatric in-patients but to date, no emphasis has been placed on oral health of psychiatric patients in France. The goal of this study was to assess the oral health and treatment needs of institutionalized patients in a large psychiatric hospital, where a dental service was available and free, to compare it with the average population, with psychiatric in-patients in other countries and to provide recommendations for psychiatrists and care-giving staff.

METHODS

The dental status (DMFT), the oral hygiene (OHIS: Simplified Oral Hygiene Index), the saliva flow rate were recorded on a randomized patient sample. Demographic and medical data were retrieved from the institutional clinical files.

RESULTS

Among the 161 examined patients, 95 (59.0%) were men and 66 (41.0%) were women. The mean age was 46.9 ± 17.5 years. The majority was diagnosed schizophrenia (36.6%) or mood disorders (21.1%). The mean OHIS was 1.7 ± 1.1. Among the 147 patients who agreed to carry out the salivary examination, the average saliva flow rate was 0.3 g ± 0.3 g/min. Saliva flow under the average rest saliva flow (0.52 mg/min) was found for 80.3% of the patient. The mean DMFT was 15.8 ± 8.8 (D = 3.7 ± 4.4, M = 7.3 ± 9.4, F = 4.7 ± 4.9) and significantly increased with age (p < 0.001) and degree of disability (p = 0.003) (stepwise linear regression). Eighteen patients (11.2%) were edentulous.

CONCLUSIONS

The DMFT was similar to low income French population but psychiatric patients had almost 4 times more decayed teeth, slightly less missing teeth and 1.5 times less filled teeth. Oral health appeared to be better than in most other countries. But compared to general population, the still unmet dental and prosthetic needs indicated the major need of enhanced access to dental care and specific preventive programs.

Outcomes of surgery in lung cancer patients with schizophrenia

PURPOSE

There are very few reports regarding the outcome of lung cancer surgery in patients with schizophrenia, and the clinical features of such patients are still unclear.

METHODS

From 2004 to 2012, 11 lung cancer patients (six male, five female; mean age, 62.7 years) with schizophrenia underwent lung resections at our institutions. All patients had been institutionalized because they were unable to live independently at home. We retrospectively evaluated their postoperative clinical outcomes and long-term results.

RESULTS

Ten of the 11 patients had comorbidities, such as diabetes mellitus and chronic obstructive pulmonary disease. Preoperatively, two patients had a history of treatment for other primary cancers in other organs, and one was on hemodialysis. A lobectomy was performed in nine patients, a segmentectomy in one, and a partial resection in one. There were no hospital deaths. The postoperative morbidity included two cases of pneumonia, one of atelectasis, and one of prolonged air leakage lasting more than 7 days. Wandering was postoperatively observed in two patients; one of these fell and fractured the left femur. At the time of our investigation, two patients were deceased, and the overall 5-year survival rate was 74.1 %.

CONCLUSIONS

The postoperative morbidity and long-term results of schizophrenic patients with lung cancer were acceptable. Therefore, even in patients with schizophrenia, surgical treatment for lung cancer should be recommended when deemed to be necessary.