Attitude and Awareness of Dentists Practicing in Southern India Toward Non-steroidal Anti-inflammatory Drugs.

BACKGROUND: Pain management is an everyday challenge in dentistry. Analgesics are the group of drugs prescribed for effective pain management, of which nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed drugs. Selection of NSAIDs must be judiciously made considering their pharmacological properties and adverse effects. AIM: This study aimed to analyze the attitude toward analgesic prescription among practicing dentists and the awareness to update their knowledge about them.
MATERIALS AND METHODS: The study was carried out among 100 dental practitioners, where a questionnaire consisting of 16 questions was formulated based on the awareness of indication and contraindication, actual practice, and required future trends for updating the knowledge. The questionnaire was distributed among the practitioners; the answered questionnaire was collected and tabulated. Statistical analysis included χ2 test to evaluate the significance.
RESULTS: Of 100 dental practitioners, 63% prescribed drugs based on the diagnosis. Aceclofenac was found to be the effective drug in postoperative pain management, whereas paracetamol was considered to be the safest among NSAIDs in clinical conditions such as bleeding disorders, gastric irritation, chronic kidney disease, and during pregnancy. All practicing dentists showed their willingness to participate in awareness programs in updating their knowledge.
CONCLUSION: This study showed that dental clinical practitioners are well aware of the drugs to be prescribed in different clinical conditions but pitfalls have been observed in areas of systemic complication, where continuous educational programs are needed to overcome the same.

INTRODUCTION

Pain is the most common symptom for which the patient approaches the dentist. Humanity is blessed with the ability to surmount pain by built-in natural mechanisms as well as fabricated methods of pain control. Pain management can be traced 2400 years back, when Hippocrates first used Willow bark to alleviate the pain of childbirth. Evolution from this led to the development of drugs including derivatives of salicylic acid and referred to as “Analgesics.” These drugs selectively relieve pain by acting on central and peripheral pain mechanisms by inhibiting the release of prostaglandins.[1] Vane and coworkers observed that nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase, which is responsible for the conversion of arachidonic acid into prostaglandin, thromboxane, and prostacyclins, precursors collectively called “eicosanoids.”[2] In the field of dental practice, pain management plays a vital role and drugs should be judiciously selected based on factors such as intensity of pain, medical status of the patient, pharmacokinetic and pharmacodynamic properties of the drug, the logistics, and the cost of obtaining the medicine.

Studies relating to other pharmacological agents such as antibiotics are plenty. This is perhaps due to the widespread paranoia regarding antibiotic resistance and the emergence of resistant strains. Studies pertaining to the prescription of analgesics particularly in dental practice are few, but their relevance cannot be overemphasized. Keeping these facts in mind, we decided to study the practice of analgesic prescription among the dental practitioners in the southern subcontinent of India.

MATERIALS AND METHODS

We carried out a questionnaire-based study to evaluate the attitude and awareness of general dental practitioners toward the prescription of analgesics. We included practicing dentists in the southern part of India; dental students and other health-care professionals were excluded from the study. A total of 100 dentists formed a part of the study sample. A questionnaire comprising 16 questions formulated from relevant literature was distributed. The questions were framed based on the awareness of indication and contraindication of analgesics, the actual practice, and preferred future trends for education and awareness. The questionnaires were distributed among 200 dental practitioners, and the dentists were asked to return the answered questionnaires. Three reminders were given at an interval of 1 week, failing to respond to which the practitioners were excluded from the study. The results from the questionnaires were tabulated, and the response were segregated and statistically analyzed.

Statistical analysis

Data were analyzed using SPSS software, version 20.0. The χ2 test was used for data analysis, where a P value of <0.05 was considered significant before starting with the study.

RESULTS

A total of 100 practicing dentists in Southern India have participated in the study and questionnaire was distributed to them. Of 100 dental practitioners, 63% preferred prescribing analgesics based on the diagnosis of the condition, 30% based on the pharmacological action, and 7% based on the convenience and cost of drug availability. Statistical analysis revealed a significant P value of <0.05.

In patients presenting with pericoronitis, 47% practitioners prescribed based on the anti-inflammatory effect of analgesics, 47% based on the analgesic action of NSAIDs, and 4% based on the antipyretic action. Statistical analysis revealed a significant P value of < 0.05.

For early relief of postoperative pain after minor surgical procedure, 50% practitioners preferred prescribing diclofenac sodium, 31% preferred ibuprofen, 9% preferred paracetamol with codeine, and 10% preferred other drugs. After endodontic procedures, only 18% practitioners preferred ibuprofen whereas 65% preferred diclofenac sodium, 14% preferred paracetamol, and 3% preferred other drugs. Statistical analysis revealed a significant P value of <0.05).

In patients with asthma, 84% practitioners averted the use of ibuprofen, 7% the use of diclofenac sodium, and 8% the use of naproxen. Other NSAIDs were prescribed by 65% practicing dentists when the patient is on aspirin, whereas 35% showed their reluctance. Statistical analysis revealed a significant P value of <0.05.

In patients presenting with severe gastric irritation, 50% practitioners choose piroxicam, 35% preferred aceclofenac, 6% preferred ketoprofen, and 9% preferred other drugs. Statistical analysis did not reveal significant P value (P > 0.05).

In patients with chronic kidney disease, 80% practitioners prescribed paracetamol, 5% preferred aspirin, 6% preferred ibuprofen, and 9% preferred other drugs. In case of pregnancy, 88% practitioners preferred paracetamol, 3% preferred aspirin, 2% preferred aceclofenac, and 7% preferred other drugs to be safer. Statistical analysis revealed a significant P value of P < 0.05. For pediatric patients, 66% practitioners preferred prescribing antibiotics along with NSAIDs and 57% clinicians preferred syrup. To update their knowledge on NSAIDs, 98% dentists preferred continuing dental education (CDEs) and other written literatures. 90% showed their willingness to educate the patients about the adverse effects of NSAIDs and 10% showed their reluctance. 100% showed a positive willingness to update their knowledge on NSAIDs. The overall awareness was moderate (47%) [Figures 1 and 2].

Figure 1

Representation of the overall awareness

Figure 2

Representation of overall awareness of practicing dentists to individual questions

DISCUSSION

All clinical practitioners prescribe NSAIDs routinely in their clinical practice. Our study was conducted to analyze the prevalent practice with respect to prescription of analgesics among the dental practitioners. Our study corroborates that dental practitioners have awareness about the indication and contraindication of NSAIDs in various clinical conditions; however, regular honing of skill is recommended in fields of systemic complication.

Dental practitioners in their routine practice choose analgesics based on the clinical condition. Pain may be of odontogenic origin, neuropathic, or of vascular origin. In patients with acute and chronic dental pain, ibuprofen 400 mg is considered superior to other drugs. The first and most important step is to diagnose the condition before starting with the treatment.[3] In periodontal diseases, a study conducted by Jeffcoat and coworkers affirm that ketorolac oral rinse proved to be effective in preserving alveolar bone because NSAIDs reduce the level of prostaglandins in the gingival crevicular fluid.[45] In our survey, 63% practitioners prescribed drugs based on the diagnosis and 30% based on the pharmacological properties of the drug. In a study conducted by Troullos et al.,[6] practitioners preferred ibuprofen for relieving postoperative pain after surgical procedure as it suppresses the release of β-endorphin due to surgical stress and postoperative pain. Many studies have been conducted for assessing the effectiveness of analgesics in dental pain in which ibuprofen is found to be effective of all but aceclofenac is the preferred drug of choice because of its good tolerability profile in painful condition.[7] Thus, pharmacological property of the drug should also be considered, which relies on the diagnosis of the clinical condition.

In cases such as pericoronitis, 47% practitioners prescribed based on the analgesic action and 47% based on the anti-inflammatory effect of NSAIDs. A study conducted by Dionne and McCullagh[8] stated that NSAIDs suppress the swelling associated with inflammatory process, particularly ibuprofen by modulating the neurohumoral responses.

According to studies, diclofenac proved to be effective in managing postoperative dental pain after minor surgical procedures.[9] In our study, 50% practitioners opted for diclofenac whereas 31% opted for ibuprofen. A study conducted by Dionne et al.[10] stated that ibuprofen suppresses pain and the onset of severity when given at a dosage of 200–800 mg. Diclofenac was the preferred drug because of its good tolerability and tissue penetrability when compared to ibuprofen, whereas the latter provides faster pain relief.[1]

Endodontic pain is an uncommon complication arising mainly due to instrumentation beyond the apex and flare-ups. Flare-ups are periradicular inflammations caused by the entry of necrotic debris in the periapical region secondary to intracanal procedures.[11] Apical extrusion of debris and chemical during instrumentation can be prevented by preparation of gliding path prior to instrumentation and prescription of appropriate analgesics after the procedure.[12] In our survey, 65% practitioners preferred aceclofenac and 18% preferred ibuprofen. In such conditions, aceclofenac has been proved to be effective as it has good tissue penetrability, which is in line with results of a study conducted by Pavithra et al..[13]

NSAID-exacerbated respiratory diseases are more common among children, and thus NSAIDs must be prescribed with caution. Most dental practitioners avert the use of NSAIDs, particularly ibuprofen (84%), followed by diclofenac (8%), and naproxen (7%). A study conducted in Taiwan by Lo et al.[14] affirms that ibuprofen and diclofenac increase the risk of asthma. NSAIDs inhibit the cyclooxygenase pathway, whereas the lipoxygenase pathway is activated, which in turn produces leukotrienes and exacerbates asthma in patients sensitive to these drugs.[15]

COX-1–produced thromboxane produces vasoconstriction and enhances the aggregation of platelets, and COX-2–produced prostacyclin produces vasodilatation and inhibit the aggregation of platelets.[1] Aspirin has an irreversible action on platelets, whereas other drugs have a reversible action; hence, discontinuation of other NSAIDs will revert the platelet function. In cases when patient is on aspirin, 65% dental practitioners prescribed NSAIDs, as other NSAIDs have a reversible effect on platelet function.[16] Paracetamol is considered the safest drug among the NSAIDs.[1]

The most common adverse effect of NSAIDs is gastric irritation. Prostaglandins maintain the integrity of gastric mucosa by maintaining the normal blood flow, whereas NSAIDs inhibit prostaglandins and lead to erosion of the gastric mucosa.[17] In a meta-analysis conducted by Henry et al.,[18] the drug with least gastric irritation was ibuprofen followed by diclofenac when compared with piroxicam and ketoprofen. A study conducted by Castellsague J et al.[19] also affirmed the same. In our study, 50% practitioners chose piroxicam, followed by aceclofenac (35%) and ketoprofen (6%). Here in our survey, piroxicam was the preferred drug that shows lack of awareness among the practitioners in comparison with other studies.

Prostaglandins maintain the normal renal blood flow and glomerular filtration rate. NSAIDs have a well-known direct nephrotoxic effect by inhibiting the synthesis of prostaglandins.[20] Acetaminophen has been considered as the safest drug. However, it must be used with caution as chronic higher doses may be nephrotoxic.[21] Acetaminophen has been proved to be efficient and safe during all stages of pregnancy without involving the risk of congenital anomalies.[22] Other NSAIDs have shown to produce premature ductal closure during the stages of pregnancy.[23] In our survey, acetaminophen was the preferred drug for both chronic kidney disease (80%) and pregnancy (88%).

It was also clear from the study that of 100 dental practitioners who participated in our study, 98% showed keen willingness to enhance their knowledge on this group of drugs through various modes such as CDEs and journals, which showed a more positive approach to study and update the knowledge.

CONCLUSION

Our study was carried out with the aim of appraising the attitude and awareness of dentists practicing in Southern India toward the practice of analgesia to identify the pitfalls, if any, and suggest alternative measures to overcome the same. Immense studies have been carried out with NSAIDs. We saw promising results from our study with practitioners being well aware of the prescription pattern of analgesics in different clinical conditions with mild lacunae observed in the area of systemic complications. Based on the analysis of results from our study, we conclude that much importance should be given for the diagnosis of the clinical condition, the pharmacological properties with their adverse effects which is of prime importance before prescribing a drug. The overall awareness was moderate in our study. From a dentist’s perspective, it is difficult to choose an appropriate medicine from the plethora of medication, where the real challenge lies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.