Prevalence of Self-Medication in Dental Patients: A Case Study of Saudi Arabia

The present study focuses on the prevalence of self-medication in dental patients’ pre-post dental consultation-a case study of Saudi Arabia. It was a descriptive study based on a structured close-ended interviewer-administered questionnaire. The questionnaire consisted of socio-demographic characteristics and also encompassed reasons, sources, duration, types of medicines used for self-medication, and reasons for hesitancy towards dental consultation. Respondents were selected using a non-probability convenience sampling technique, the data were analyzed using SPSS ver 22. Outcomes of the present study envisage that self-medication is quite prevalent among dental patients using both orthodox and traditional drugs. Results of Bivariate analysis revealed that the majority of patients were not cognizant of the specific dental ailments as revealed in pre-post diagnosis. The multivariate technique of decision trees exhibited that two groups of patients need to be focused on regarding self-medication – those who are less than 20 years of age and Non-Saudi Arabic speakers who are more than 20 years of age. The results of the present study can form the basis for framing future policies for easy accessibility of dental consultation to the populace which may result in containment of self-medication within the Saudian context.

Throughout a person's life teeth are incessantly exposed to a variety of liquids and food items and if proper dental care is not practiced daily it may result in the decaying of teeth. In present times generally, people in urban areas are quite cognizant of dental care, courtesy of social/print/electronic media. But still, the majority of people do not consider dental decay as something very serious like other health issues, for instance, high/low blood pressure, high/low sugar levels or heart diseases, etc, etc. In Eastern culture whenever a person is afflicted by a dental problem the first remedy he/she resorts to, is always indigenous, like using cloves (aromatic flower buds of a tree in the family Myrtaceae) or taking some sort of simple medicine suggested by some family member, friend or colleague. After temporary relief, the person thinks his/her dental problem has been whittled out and sees no reason to consult a dentist. But tooth problem once initiated needs to be taken seriously because when it rebounds it comes with more serious dental issues. Avoidance/hesitancy towards seeing a dental consultant may be due to the interaction of multiple apprehensions -just to name a few-like higher cost, non-accessibility to a professional consultant, fear of the unknown, and so on.  defined self-medication as the use of medicines without advice and monitoring by a physician or the use of medicine without consulting a qualified healthcare professional to relieve stress or disorders such as diseases, depression, and anxiety. But according to World Health Organization (WHO), self-medication is defined as the use of medicines to treat self-diagnosed disorders or symptoms or the intermittent or continuous use of prescribed drugs for chronic or recurrent diseases. Skliros et al. (2010) conducted a cross-sectional multicenter study addressing self-medication with antibiotics in a rural population in Greece and observed that the prevalence of self-medication was 44.6%. Medication usage of dental patients across some socio-demographic characteristics was thoroughly studied by Siddiqui et al. (2021) in the USA. In India a cross-sectional survey to study self-medication practices and consultancy avoidance by conducted by Surenthar et al. (2021).
Going through the relevant literature one comes across a plethora of research on self-medication but the same was not much-studied viz-e-viz dental ailments and especially in the middle eastern region which is still a developing region and is faced with more oral health burden than developing countries. The present study focuses on the prevalence of self-medication before dental consultation. It also highlights the reasons for resorting to self-medication and also reasons leading to hesitancy towards dental consultation. Moreover, the present study will also discuss the sources from where the medicines were bought, the duration of the self-medication before dental consultation, and matching the prior and post-diagnosis to study the awareness of the dental patients about the ailment they are suffering from. The results of the present study will provide guidelines for oral health practitioners on how to devise future policies to tackle the menace of self-medication among dental patients in Saudi Arabia.

Format of the Study
The rest of the paper is organized as follows: section 2 elaborates, on methods and data collection tools along with the statistical techniques used to address the research questions, section 3 exhibits the results covering socio-demographics of the respondents, univariate, bivariate and multivariate analysis. Discussion/Conclusion of the results is carried out in section 4, and section 5 highlights some limitations of the current study.

Study Design
Cross-sectional quantitative retrospective design with one-time contact with the respondents.

Instrument
The questionnaire for the present study was adapted from Afolabi et al. (2010), with minor adjustments to match Middle Eastern culture. The questionnaire consisted of two parts; Part A consisted of questions regarding the socio-demographic characteristics of the respondents while Part B was based on information about medicine utilization before consultation and diagnosis post consultation. Before the administration of the questionnaire, it was translated into the Arabic language for ease of comprehension through the method of transliteration for eliciting the right perspective of the respondents. The questionnaire used to elicit information from the respondents/patients is given in Appendix 'A1'.

Study Setting /Sample Size/Data Collection
Data from the respondents were collected from seven private dental clinics located in Jeddah, Saudi Arabia from May 5, 2023, to May 20, 2023. A total of 130 questionnaires were collected of which 18 were discarded due to incomplete information so the response rate for the present study was 86% (112). Questionnaires were completed for each patient in the Dental Clinics by the researchers with the help of one trained dental assistant who was briefed on how to assist the patient fill the questionnaire.

Data Analysis
Statistical software SPSS was used to analyze the data. Apart from univariate analysis-using absolute and relative distribution of respondents, the present study also carried out bivariate analysis -types of dental ailment in pre-post consultation phases and Multivariate analysis using a decision tree to analyze the association between self-medication and some socio-demographic characteristics.

Socio-Demographic Characteristics
Absolute and relative distribution of the patients are shown in Table 1. Table 1 exhibits the total responses and percentage of total responses who resorted to self-medication. From the total responses of 112 respondents, there are 27% more male patients than female patients which points to the fact that the results may be more male-oriented. The rest of the socio-demographic characteristics are as follows: the majority of the patients were Saudis (91%) who were married, had post-intermediate education level, are employed (Government/Private), earned between SR 5000 to SR 15000, and resided in urban areas. Regarding the absolute and relative distribution of the respondents/patients resorting to self-medication (n = 81) the pattern of the frequencies and percentages change as compared to total responses. As a percentage of total responses, 75.6% of female patients resorted to self-medication whereas 70.4% of male patients resorted to self-medication. In the case of Age patients with age less than 20 years 92.9% resorted to self-medication. In marital status, we see that 74.5% of the bachelors took self-medication. But in educational level, a decrease in taking self-medication is witnessed as the educational level increases. As far as occupation, monthly income, and area of residence are concerned more than 65% of patients resorted to self-medication. The biggest pattern change is witnessed in the case of nationality in the case of total responses there were 91.2% of Saudis but in the case of the percentage of total responses resorting to self-medication 100% Non-Saudis Arabic speaking resorted to self-medication.

Prevalence and Symptoms Leading to Self-Medication
Figure 1 and 2 provides a clear picture of how many patients resorted to self-medication and what were the main symptoms due to which the patients resorted to self-medication. Doughnut chart in Figure 1 exhibits that 72.32%(81) patients resorted to self-medication (i.e. prevalence of practice of self-medication among dental patients) which matches the prevalence rate in Surenthar et; al (2021), 19.64%(22) took medication prescribed by the consultant and only 8.04%(9) never resorted to any kind of self-medication prior to consultancy, the present study we will only focus on these 81 patients who resorted to self-medication prior to consultancy. The doughnut chart in Figure 2 shows the number and percentage of patients who resorted to self-medication (81). The majority 62%(50) patients resorted to self-medication were having toothache followed by Pulpitis 22%(18) and then Periodontitis 9%(7) and Pericoronitis 7%(6). The majority of the patients were not aware of the exact dental ailment they are suffering and generally termed it as toothache.

Hesitancy towards Consultation (Multiple Response Variable)
As this variable is a multiple response variable a respondent can select more than one option therefore, table 2 exhibits the percentage of responses by the respondents. The most common reason for hesitancy towards consultation is fear of (surgical) dental treatment (27.2%) followed by the perception that dental ailment is a usual thing and does not warrant seeing a dentist (21%) and that the patient has to wait for a long time to get dental treatment (16%).  Don't know where to receive dental treatment 3 3.7 The ailment is simple and I need not see a dentist 17 21.0 No time for dental consultation 9 11.1 No money for dental treatment 2 2.5 My house is far from the hospital/dental clinic 9 11.1 Confidence in chemist and pharmacy 1 1.2 Unavailability of Dental Surgeon 5 6.2 Waiting time is very long 13 16.0 The least common reasons for hesitancy are confidence (1.2%) and monetary (2.5%) issues since the majority of the respondents are employed (Government =40.2% and Private = 24.1%) having sufficient monthly income ranging from SR 5000 -15000.

Sources and Duration of and Type of Self-medication Before Consultation
The main source from where respondents/patients acquired medicine for self-medication was a pharmacy store (43.2%) followed by family and friends (30.9%) and none of the respondents opted for purchasing online. The majority of the respondents (58%) kept on using self-medication between 2-6 days prior to dental consultation. Concerning the type of medicine used for self-medication, in the orthodox case again 58% of respondents used analgesics without knowing the toxic effect of these medicines. Regarding unidentified traditional medicine 90.1% used dried cloves.

Diagnosis Post-Consultation
As this variable is also a multiple response variable a respondent can select more than one option therefore, the total of frequencies =116 is not equal to the total number of respondents = 81. Table 4 exhibits the number of responses 'f' from 81 respondents along with percentages. After the post-consultation majority of patients (42%) were diagnosed with pulpitis, approximately one-third of patients (34.6%) were diagnosed with tooth caries and one-fourth of patients (25.9%) had periodontitis.

Bivariate Analysis (Pre-Post Diagnosis)
Pre-Consultation symptoms along with Post-Consultation diagnoses are exhibited in Table 5. It is quite evident from the descriptive data shown in Table 5 that 50 out of 81 (62%) patients did not know of the real reason behind their simple toothache. Most of the patients having toothache in the pre-consultation phase were diagnosed with pulpitis (50%), tooth caries (30%), and periodontitis (20%) the total number of responses can add up to more than 100% since both variables in the table are multi-response variables. Patients having periodontitis in the pre-consultation phase were diagnosed with tooth caries (43%), periodontitis (29%), and pericoronitis (29%). Patients having pulpitis in the pre-consultation phase were diagnosed with periodontitis (50%), tooth caries (39%), and pulpitis (39%). Patients having pericoronitis in the pre-consultation phase were diagnosed with tooth caries (50%). Scrolling through the results one can easily infer that without resorting to professional consultancy patients may opt for indigenous/temporary remedies that will eventually aggravate their dental ailment.

Multivariate Analysis (Decision Trees)
A decision tree is a multivariate technique that examines complex relationships among variables very quickly and is a very popular classification method. It is a non-parametric approach and does not require any distributional assumptions about the data under study and handles any type of data (categorical or continuous). Decision trees provide a very succinct visual representation of the most important information regarding the Dependent variable which in our case is self-medication. This kind of visual descriptive analysis identifies which pieces of information are strongly related to respondents opting for self-medication. The most commonly used classification procedures used in Decision trees are CHAID (Chi-square Automatic Interaction Detection) and CRT (Classification and Regression Trees). CRT splits the data into segments that are as homogeneous concerning the dependent variables. As CRT can handle mixed types of data i.e. both categorical and continuous so for the present study we used CRT to study the relationship between the dependent variable, self-medication, and some other socio-demographic variables. CRT reveals that of all the socio-demographic variables Age is the most significant variable to focus on while studying self-medication among dental patients. For age groups less than 20 years 92.9% resort to self-medication. The second most important variable associated with self-medication is occupation, 70% of patients greater than 20 years of age and with their own business or working in private organizations resort to self-medication. 78.6% of government employees greater than 21-40 years of age opt for self-medication. Another group of patients who resort to self-medication more than other groups is those who have monthly salaries between SR 5000-10000 and are in the age bracket less than 21-40 years and work in government organizations.  Vol. 15, No. 8;2023 4.

Discussion/Conclusion
The present study provides insight into the key drivers that influence the decision of patients with dental ailments, regarding self-medication and also looks into the profiles of such patients. Socio-demographics reveal that patients less than 20 years of age with lower educational levels and Arabic-speaking Non-Saudis resort more to self-medication. Out of a total of 112 patients 81(72.32%) resorted to self-medication and of those who resorted to self-medication 50 (62%) opted for the general category of toothache as they were not aware of the exact nomenclature of their dental ailment. Significant reasons for hesitancy towards consultancy were fear of invasive procedures involved in dental treatment followed by not treating dental ailment a serious health issue and the impression that one has to wait for a long time to see a dental consultant. The main sources for getting temporary relief medicines were pharmacy stores and family/friends and the orthodox medicines used was paracetamol in 58% of the cases and a traditional herb 'clove' was used in 90.1% of the cases, a total may sum up to more than 100% as it is a multiple response item where a patient can select more than one option. The majority of patients were on self-medication from 2 to 6 days before contacting a dental consultant. Bivariate analysis of pre-post consultancy unleashed that in the pre-consultancy phase, 62% complained about simple toothache but in the post-consultancy phase many of the patients who had toothache were diagnosed with Periodontitis, Tooth caries, and Pulpitis but most of the patients opted for analgesics without knowing the toxic effect of these medicines. Moreover, the patients also used traditional things like dried cloves for temporary relief which were not the right kind of remedies and will eventually aggravate their dental ailment. Using dried cloves inside of the mouth can cause sensitivity and irritation as well as damage the dental tissues. The decision tree revealed four groups that need to be focused on while studying self-medication and these are patients with an age group less than 20 years, the second group consists of patients having their own business or working in a private organization with age greater than 20 years, the third group consists of patients with age group greater than 21-40 years working in government organizations, the fourth groups are those who are earning more than SR5000-10000 and are less than 21-40 years age group and working in government organization. Most of the results of the present study match Afolabi et al. (2010), Uzma et al. (2018), and Idowu et al. (2019). The results of the present study can also provide guidelines to medical administration to customize their future policies regarding minimizing the practice of self-medication in patients with dental ailments. This study underscores the need for devising educational programs highlighting the need to contain the usage of medicines and the government should also formulate new procedures on the sale of medicines that could reach individuals.

Limitations
The study was conducted in only one urban metropolitan city Jeddah with more urban dwellers and fewer rural respondents. In future studies, data on the study variables may be collected from more metropolitan cities of Saudi Arabia e.g. Riyadh, Dammam, Buraydah, etc; etc and some rural towns as well with a much larger sample.
3 I believe the ailment is simple and I need not see a dentist