Self Medication among Dental Patients Visiting Tertiary Care Hospital, During COVID-19

INTRODUCTION:

WHO defines self-medication as “the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms”.1 Consuming one or more drugs without prescription of the doctor either for treating their symptoms or self-diagnosis is termed as self-medication. Self-medication is a noteworthy concern globally, affecting both developed and developing countries especially economically.2 In current times, COVID-19 has been declared as a global public health emergency by World Health

Organization.3 Self-medication practices among dental patients, showed a remarkable increase during period of

COVID-19 Pandemic lockdown due to lack of services to general population by dental facilities, due to fear among

patients to visit hospitals where the risk of spread of virus is perceived to be high, travel restrictions, COVID SOPs of

physical distancing set up by the government of Pakistan in response to this pandemic and spread of misinformation

through social media.4,5,6 Changes among societies in rules regarding access to dental services for elective procedure are seen, as only emergency procedures are being done and many private clinics were shut down during lockdown. According to literature, pandemic is influencing self-medication behaviours among the patients7

and dangerous side effects and shortage of drugs for the people who actually need them are the consequence of such behaviors.8

Even death has been reported from different parts of the world among the people who had self-medicated with

medicines that shouldn’t have been taken without prescription of a physician.9 There has been increase in self-medication even among health care professionals during pandemic from 36.2% to 60.4% in Kenya.10 In Poland during the lockdown, 40% of respondents had taken prescription drugs without any medical consultation.7 In Nepal, 62.6% dental patients self-medicated and toothache was the most common reason (60.8%) for that. (11) In India,78.6% adolescents self-medicated in 2019 before pandemic.12

A variety of self-prescribed and Over-The-Counter (OTC) drugs, either alone or in combination with other drugs are being used for recreational purposes.13 According to study in Tanzania; 58% contributors admitted that they

self-medicated and more than 90% of them reported to go to the pharmacy for care when they fall sick instead of going to a physician.14 According to a research conducted in Islamabad and Rawalpindi commonly known as twin cities of Pakistan, 71.4% self-medicated, painkiller being the most common medication used.15

A wide range of researches on the use of drugs without prescription has been done in medical field and before the

COVID-19 lockdown but there is dearth of research on dental patients in the period of lockdown due to pandemic.

Rationale of this study is to find its prevalence, factors, sources and change in the patterns during the lock down period of COVID-19 among Dental patients, also the correlation between socioeconomic status, education and self-medication visiting a tertiary care hospital; Fauji Foundation Hospital Rawalpindi, Pakistan.

METHODOLOGY:

This cross-sectional study was conducted from 20th September,2020 to 5th December 2020 among patients

reporting to dental OPD of a tertiary care hospital of Rawalpindi post lock down. All the patients reporting in

dental OPD (Out Patients) of all ages were included regardless of their presenting complaint and co-morbidities. Ward patients (In patients) that came for dental consultation were excluded from this study. Prior to the commencement of the study, a written ethical approval under letter no: FF/FUMC/215-39/Phy/20 from the ethical society of Foundation University Medical College Islamabad and informed consent from patients participating in the study was obtained. The setting of this study was Dental OPD (Oral Medicine and diagnostic department) of Fauji Foundation Hospital, Rawalpindi, Pakistan.

Data collection was done via face-to-face interviews using self-structured questioner from patients visiting dental

OPD and consenting for the study. Self-structured questionnaire (Cronbach alpha 0.736) was used in this study.

The questionnaire was piloted on 49 participants who were excluded from the final study. Self-medication was explained in the beginning of questionnaire. Questionnaire was divided into three sections; first section containing six questions to gather data pertaining to demographic profile of respondents (mentioning names was optional to respect patient’s privacy). Second part containing sixteen questions about self-medication, it’s reasons and sources leading to selfmedication and third part comprised of three questions related to perception regarding self-medication.

Collected Data was entered and analyzed by using Statistical Package Programme for Social Science (SPSS)

version 21.0. Data was analysed and summarized using descriptive and inferential statistics, and later presented in

tables, percentages, graphs.

RESULTS:

Out of 451 patients who participated in the study 185 were of age group 41-60. Among these patients, 86.5%

patients self-medicated. (Figure 1) There were 383 (84.9%) females, 68 (15.1%) males who responded to the questioner

Among the participants 40.1% patients had only primary education, 29.3 % patients had secondary education, 18%

patients had attended college, 9.5% patients were undergraduates and only 3.1% did postgraduation. Most of

the patients presenting in OPD belonged to middle socioeconomic status i.e., 47 %. Among these patients who

self-medicated during the period of lockdown females were more as compared to males. (Figure 2) Toothache (56.8%) being the most common reason, followed by sensitivity of teeth (37.5%), gum bleeding (22.2%), tooth mobility (11.3%), mouth ulcers (4.4%) and trauma (3.8%) being the least common reason. (Table 1) Most common medication used

during this period of lockdown without the prescription of any physician were Pain relievers (68.5%) then antibiotics

(35.5%), 18.6% didn’t even know what type of medication they are taking and few used steroids (6.5%). (Table 2) Tablets (67.4%) were the most common source of medication used by the participant’s, Medicated toothpastes were used by 36.4% patients, 35.5% took medication as capsules, 21.7% used gels and 18.8% used medicated mouthwash.

Many of the patient’s, around 68.5% said that their symptoms were relieved by medication, (Table 3) but a few (6%)

encountered adverse reactions from the medication they took and many (18%) were not sure if they encountered any

because of the medication they consumed. (Table 4) Most of the patients (74.7%) had a view that self-medication is

acceptable, only few (10%) think it as unacceptable. Some patients, around 15.3% patients even find it good.

(Figure 3) An inverse relation is seen between level of education and self-medication practices. Less educated people mostly with only primary schooling self-medicated the most. Similarly, socio economic status also has inverse relation with this malpractice. More self-medication is done by patients with lower income. (Table 5).

DISCUSSION:

This study specifically conducted after lockdown of COVID-19 was lifted by Government of Pakistan to investigate the prevalence of self-medication, the leading factors, sources of self-medication, association of educational

and socioeconomic status of patients with self-medication and the perception of general public regarding self-medication. COVID-19 pandemic was declared to be a global health emergency as the disease spread exponentially around the globe.

Coronaviruses characterise a heterogeneous clusters of single-strand large RNA viruses that are widely scattered

among mammals and birds. Virus is grouped in a family of Coronaviridae. It spreads through direct or indirect contact.16 To avoid this spread governments all around the world implemented lockdowns and “stay at home” policies. Self-medication was being practiced before this pandemic as well but has increased remarkably from 71.4% according to a study conducted in similar settings in 2016 i.e before COVID-19 to 86.2% after COVID-19.15 Prevalence of selfmedication is considerably high in all parts of the world. During the lockdown in Poland 40% of respondents had taken prescription medications without any medical consultation.2 In a study conducted in Nepal 62.6% dental patients practiced self-medication.11 A similar prevalence of 82% among undergraduate students, who admitted that they had practiced self-medication in a private university in Nigeria was reported.17 A study conducted in India revealed 78.6 % adolescents practiced self-medication.12 According to study in Tanzania; 58% contributors acknowledged that they self-medicated and 90% or even more of them admitted that they visit a pharmacy for care if they feel sick rather than going to a doctor/physician.

The results of this study show that females practiced self-medication more as compared to the males which is

contrary to study conducted in 2016 at twin cities of Pakistan but similar to a study conducted in Brazil,17 Nigeria; where among females it was 88.2% and 70.5% in males11 and a meta-analysis conducted from world wide data also suggests the same.18 Use of unprescribed drugs is more common in

people with low socioeconomic status. Our results are agreeing with the statistics of a study conducted in Sindh,

Pakistan which states that the commonest reason behind self-medication remained economic reasons i.e.,88.0%.19 In a systemic analysis done 2017, the lowest numbers of prevalent cases of oral diseases were observed in highincome countries and the highest prevalence lower-middleincome countries.20 Hence, self-medication might follow the same trend as it can be a reason for self-medication. Similar findings of another review highlighted prevalence ranging from 81% to 93%, which is considerably high and its association with the gender of participants, education level and their incomes (monthly).21

Pain relievers were the most commonly used drugs among dental patients in this study; 68.5% followed by

antibiotics 35.5% similar to the results of a study in which analgesics being most common (58%), followed by antipyretics and antibiotics were reported among people.22 Around 1 in 16 older adults participating in an awareness survey in Arizona reported self-medication with nonprescribed antibiotics.23 Another community-based study held in Jordon shows 40.4% participants used an antibiotic without any prescription in the preceding month.24

In 1980s self-medication became popular when WHO (World Health Organization) permitted some prescription

medication to be sold without any physician’s prescription over the counter to reduce burden upon Health Care Workers. This step was taken for the ease and benefit of health care professionals but misuse of this has proven many unwanted effects; it can lead to many problems including wrong or late diagnosis of disease especially malignant or fatal diseases which get masked, addiction or dependance upon drugs, over/under dosage of drugs and the global rise of MultiDrug Resistant pathogens, these practices dearth clinical evaluation from a medical/dental professional hence causing enormous adverse effects.25

Results of present study show that the most common symptom for which a patient seeks medication is toothache

(56.8%) followed by sensitivity of teeth (37.5%) then gum bleeding (22.2%), tooth mobility (11.3%), mouth ulcers (4.4) and least commonly used as medication after trauma (3.8%) which is in agreement with a study in Malaysia showing majority of the participants (79.1%) experienced symptom of toothache during the past one month and 95.6% of the participants took pain relievers for it by themselves.26

This study result proves that the most common medication used during the period of lockdown were Pain relievers (68.5%) in form of tablets which is quite higher percentage than a study of Malaysia which reports around more than a quarter i.e.29.4% participants practiced self-medication with pain relievers or analgesics and also in agreement with study of Reema Dograa and Anjana Goyal conducted in India stating that patients commonly used medication are analgesic anti-inflammatory drugs( paracetamol, diclofenac, aspirin, naproxen and ibuprofen)27 Antibiotics (35.5%) used in capsule form by dental patients were lesser than pain relievers but not unremarkable and it has increased considerably from 10% calculated in a study of twin cities, Pakistan conducted before COVID-19 and the use of medicated toothpastes increased from 35.8% to 36.4%. It is still lesser than prevalence of self-medication of antibiotics (34%) among dental patients visiting University of Buenos Aires, Argentina,28 45% among the university students (non-medical) of Punjab, Pakistan, who used antibiotics without consulting doctor in the past six months29 and lesser than and 41.9% among patients with Respiratory symptoms presenting to a hospital in Cameroon, Africa.30 Surprisingly in this study, 18.6% didn’t even know what type of medication they are

taking and few used steroids (6.5%). According to results of this study, 18% patients were not sure that their drug

reactions or adverse effects were due to medication they used and only 6% noted the adverse effects by the drugs

they used, which is still higher than percentage of reactions due to self-medication in French hospitals (1.72%).31 Sadly, most of the patients (74.7% among 451 responders) thought self-medication is acceptable only few (10.%) agreed that it is unacceptable. Around 15.3% patients even find it as a good practice. This perception shows that this malpractice of self-medication needs urgent and firm actions by the policy makers and health care authorities.

CONCLUSION:

1) The practice of self-medication is still not given enough consideration, especially in lower to middle income

countries like Pakistan.

2) Self-medication practices strongly existed among the dental patient during covid 19 and these practices have

shown a remarkable increase during the period of lockdown due to lack of services.

3) However, this generates the need to equip all the patients regarding the harmful effects of self-medication to stop such practices in society at large scale.

RECOMMENDATIONS:

There must also be regulation and implementation of laws which limit the sale and purchase of prescription drugs

lacking a written validated prescription by a licensed dental practitioner. During such periods of pandemics an alternative method such as teleconsultations should be setup so that medications be prescribed by a professional health care worker. Furthermore, health care organizations should also execute public awareness programs for spreading awareness regarding self-medication and patient’s safety.

CONFLICT OF INTEREST:

None to declare

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