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| ORIGINAL ARTICLE |
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| Year : 2013 | Volume
: 10
| Issue : 2 | Page : 86-90 |
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Analgesics prescription in Nigerian dental healthcare services
Clement C Azodo, Agnes O Umoh
Department of Periodontics, University of Benin, Benin City, Edo State, Nigeria
| Date of Web Publication | 7-Dec-2013 |
Correspondence Address:
Clement C Azodo
Room 21, 2nd Floor, Department of Periodontics, Prof A. O. Ejide Dental Complex, University of Benin Teaching Hospital, Private Mail Bag - 1111, Ugbowo, Benin City, Edo State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0331-8540.122768
Introduction: Alleviation of pain is considered high priority care and service in dental and medical practice worldwide. The study was conducted to evaluate analgesics prescription among dentists in Nigeria. Materials and Methods: This descriptive cross-sectional study was conducted among dentists attending continuing education courses in Nigeria organized by the Faculty of Dental Surgery of the National Postgraduate Medical College of Nigeria and Regional Centre for Oral Health Research and Training Initiatives for Africa. Results: Out of the 150 questionnaires distributed, 138 questionnaires were returned giving a 92.0% response rate. Males constituted 88 (63.8%) while the remaining 50 (36.2%) were females. The most common prescribed analgesic among the respondents was paracetamol 54 (39.1%). Factors that influenced the choice of prescribed analgesics among the respondents in descending order were severity of pain or intended pain, patient medical condition, type of procedure, age of the patient, delayed treatment, economic status, uncertainty of diagnosis and patient request Conclusion: The non-opioid analgesics specifically paracetamol was the most commonly prescribed by the respondents and the choice of analgesics was influenced by variety of factors . Keywords: Analgesics, continuing education, dentists, prescription
How to cite this article:
Azodo CC, Umoh AO. Analgesics prescription in Nigerian dental healthcare services. Niger J Basic Clin Sci 2013;10:86-90 |
| Introduction | |  |
Pain is a leading cause of morbidity worldwide justifying the rapidly growing demand for safe and effective pain management. [1] It has been reported that unrelieved pain exerts negative influences on the physical and mental health, social and intimate relations, sleep and daily tasks performance, work productivity and financial well-being. [2]
Pain has been consistently identified as the most common reason for seeking dental attention and an inevitable sequela of some dental treatment because it is a feature of infection and inflammatory oral diseases, which are the predominant oral diseases affecting mankind. [3],[4],[5],[6] The reduction of pain with intricate improvement of clinical outcomes makes pain management, an integral part of dental practice. Pain control is therefore an essential service and duty of dentists, and the appropriate selection and use of the analgesics will facilitate the delivery of this service with the optimal safety and efficacy. [7] Proper pain management, which includes expert knowledge about analgesics, is an essential element of dentistry and noted deficiencies have prompted authors to recommend the development of prescribing guidelines and educational initiatives as a way of encouraging the rational and appropriate use of analgesics in dentistry. [8] Although, Nigeria has the National Drug Policy, which insist on rational prescription, there is no specific guidelines on analgesics prescription in dentistry in Nigeria. [9] The development of pain management strategies, which will equip dentists with additional treatment options in providing effective pain relief, is important because an experience of poorly managed pain related to dental treatment can lead to avoidance or postponement of treatment by patients. [10]
In dental healthcare services, analgesics of opioids (narcotics) and non-narcotic types (non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol) are among the most commonly prescribed drugs among dental patients accounting for 33.8-43.7%. [8],[11],[12],[13] The optimal benefit of analgesics prescribed for the relief of acute pain, postoperative pain and chronic pain and for controlling adjunctive intra-operative pain and mitigation of post-operative pain could only be harnessed with the adoption of rational prescription. [14]
Reye's syndrome which is a rare condition that most often affects children and teenagers recovering from a viral infection and manifesting with detrimental liver and brain effects is linked with aspirin thereby hampering the use of such analgesics in children. [15] However, studies on drug prescription relating to analgesics among dentists are scarce in the literature despite the increasing availability of analgesics and issues of rational drug prescription. The objective of the study was to evaluate analgesics prescription among dental in Nigeria.
| Materials and Methods | | |
A total of 150 questionnaires were distributed to dentists that attended the continuing education courses organized by Faculty of Dental Surgery of the National Postgraduate Medical College of Nigeria (NPMCN) in Lagos State and the Regional Centre for Oral Health Research and Training Initiatives (RCORTI) for Africa (Formerly Inter Country Centre for Oral Health for Africa) in Jos Plateau State of Nigeria. The continuing education course by Faculty of Dental Surgery was a revision course for dentists attempting different categories of Fellowship examination ranging from primaries, part I to part II examinations while that by RCORTI was on atraumatic restoration (ART). The selection of this group of dentists was to ensure that the participants were actively practicing dentists because they are the group that attends continuing education courses. All the participants at the courses except those that did not consent were included in the study. The questionnaire elicited information on demography, most commonly prescribed analgesics, factors influencing the choice of prescribed analgesics, knowledge of contraindication of NSAIDs, knowledge of antidote for narcotic overdose, knowledge of suicidal dose for paracetamol and the analgesics that cause Reye's syndrome. Paracetamol being commonly available analgesics without gastrointestinal and nervous side effect could be abused in the self-medication of dental pain to the extent of ingesting toxic doses. The knowledge of suicidal dose for paracetamol among dentists is important in preventing such mortality and for effective advice to the public. Ethical approval was not sought, however, voluntariness of participation was adhered to and informed consent was obtained from all participants after having been informed of the objective of the study. The questionnaire were distributed to the participants during the course and collected at the end of the day. The data was analysed using Statistical Package of Social Science (SPSS version 17.0). Test of significance was done using Chi-square statistics. P < 0.05 was considered significant. The knowledge of contraindications of NSAIDs was categorized as good, fair and poor knowledge during the data analysis. Participants who correctly reported ≥6 contraindications were deemed as having good knowledge, those that reported 3-5 and 0-2 contraindications were grouped as fair and poor knowledge, respectively.
| Results | | |
Out of the 150 questionnaires distributed, 138 of them were returned giving a 92.0% response rate. Males constituted 88 (63.8%) while the remaining 50 (36.2%) were females. A total of 88 (63.8%) of the respondents have practiced for less than 10 years and 88 (63.8%) have not attended any postgraduate course on prescription. The most common prescribed analgesics by the respondents was paracetamol by 54 (39.1%) of the respondents [Figure 1]. Factors that influence the choice of prescribed analgesics among the respondents in descending order were severity of pain or intended pain, patient medical condition, type of procedure, age of the patient, treatment had to be delayed, economic status, uncertainty of diagnosis and patient request [Table 1]. | Table 1: Factors influencing the choice of prescribed analgesics among the respondents
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Correct knowledge about Reye's syndrome and antidote for narcotic overdose was found among the 76 (55.1%) and 72 (52.2%) of the respondents, respectively. Only 36 (26.1%) exhibited correct knowledge about the suicidal dose of paracetamol [Table 2]. | Table 2: Knowledge of Reye's syndrome, suicidal doses of paracetamol, antidote of narcotic overdose among the respondents
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A total of 38 (27.5%) of the respondents had good knowledge of contraindication to the prescription of NSAIDs analgesics. This good knowledge was higher more among male, younger dentists and those that reported attendance of continuing medical education (CME). However, this was not statistically significant [Table 3]. | Table 3: Knowledge of contraindication to the prescription of non-steroid anti-inflammatory drugs analgesics among the respondents
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| Discussion | | |
Analgesics prescription in medical and dental practice contributes to wide spread overuse of these drugs. [16],[17] Analgesics with advantages tempered by undesirable side effects are increasingly available for utilization in the management of pain among dentists. [18] A variety of analgesics were reported as the most commonly prescribed analgesics among the respondents in this study. Aspirin and acetaminophen have been recognized for many years as prototypes of the peripherally acting analgesics of particular importance to dentists because of their role in acute pain treatment on the daily basis. The fact that appropriate dental treatment removes the cause of the pain with rapid resolution of the symptoms may be the reason for predominant prescription of peripherally acting analgesics even when majority of pain among dental patients in Nigeria are of either severe or very severe intensity. [19] The preference of non-narcotics analgesics to narcotics analgesics for all clinical endodontic situations among American endodontists is tandem with this study finding. [20]
Specifically, paracetamol, which possess very effective analgesics with little anti-inflammatory action, was the most common prescribed analgesics among the respondents. This concurred with findings of studies in tertiary hospitals in Karachi, Pakistan [21] and Oral Surgery Clinic in Benin City, Nigeria where paracetamol was the most frequently prescribed analgesics. [22] The fact that paracetamol is an effective analgesic with virtually no adverse effects, except for those related to over dose may have favoured the prescription. NSAIDs provide excellent pain relief due to their anti-inflammatory and analgesic action. Ibuprofen, a propionic acid derivative of NSAIDs, which constitutes the largest group of aspirin alternatives, was the second most prescribed analgesics in this study. Others in descending order include diclofenac, tramadol and piroxicam. This contrasted with findings in primary healthcare units in Brazil where diclofenac, both the sodium and potassium forms, were the most commonly prescribed medications. [23] In comparison, ibuprofen was found to be the most frequently prescribed systemic analgesics and non-opioid analgesics among patients attending the dental outpatient departments at Manipal Teaching Hospital in Nepal, respectively. [8],[13] Despite the high level of prescription of non-centrally acting analgesics exemplified by paracetamol and NSAIDs by the respondents, the knowledge of the suicidal dose of paracetamol, Reye's syndrome and contraindication to the prescription of NSAIDs remained inadequate. The knowledge of the suicidal dose of paracetamol is important as paracetamol overdose for dental pain is increasingly reported [24],[25],[26] emphasizing uniquely position of dentists in fashioning ways to prevent such occurrences. The intricate detail showed that the knowledge in relation to contraindication to the prescription of NSAIDs was higher among males, younger dentist in practice (<10 years' experience) and those respondents that had attended CME rich with analgesics content compared with their counterparts [Table 3]. However, this was not statistically significant and implies that CME alone may not be adequate in correcting the noted deficiency. The development of pain management strategies, prescribing guidelines and educational initiatives recommended by Sarkar et al., [8] and Mehlisch [10] may apply with possible favourable outcome. The influence of education on analgesics knowledge and prescription in this study lent support to the varied prescription of analgesics among endodontists based on board-certification. [20]
Although opioids are the cornerstone for management of moderate-to-severe acute pain, they are frequently underutilized and at lower than effective doses as a result of misconceptions and fears regarding their use. [27] Several undesirable effects of opiods like respiratory depression, urinary retention, sedation, nausea and vomiting, constipation, analgesic tolerance, dependence and addiction hampers the prescription among doctors. [28],[29] In this study, only 8.7% of the respondents commonly prescribed opioids, which contrasted with finding from a study conducted to analyse dental prescribing patterns for analgesics which revealed that respondents still rely on narcotic analgesics for pain relief and generally exceed needed potency and quantities in their prescribing habits. [3] The low prescription of opioids may be responsible for why only 36 (52.2%) of the respondents exhibited good knowledge of antidote for narcotic overdose.
Analgesics serve majorly as adjunct in management of pain as appropriate dental treatment facilitates the removal of the cause of the pain and rapid resolution of other symptoms. [5] The selection of analgesics must be individualized for each patient, depending on the cause and severity of the pain as well as patients' age and concomitant medical conditions that may alter the drug response. [10],[30],[31] In this study, factors that influence the choice of prescribed analgesics among the respondents in descending order were severity of pain or intended pain, patient medical condition, type of procedure, age of the patient, treatment had to be delayed, economic status, uncertainty of diagnosis and patient request. The severity of pain has been documented as a known fact that influences the choice of analgesics. For example, paracetamol and NSAIDs (ibuprofen, naproxen, diflunisal and others) are the most appropriate choices for the treatment of mild-to-moderate acute dental pain among patients lacking the contraindications for such drugs while opioids are powerful analgesics with significant side effects, which are commonly reserved for severe pain only. [5],[10],[32],[33] On event of analgesics failure, patients take desperate steps to seek pain relief therefore careful selection of effective analgesic regimen based on the amount and type of pain the patient expected to have can prevent the stress and anxiety associated with breakthrough pain. [34],[35] Medical condition may be a contraindication or may alter the metabolism of drugs heightening the chances of toxicity. [33],[36] The major contraindications to NSAIDs prescription, which include ulcer, asthma, allergy, diabetes, gout, influenza, bleeding diathesis, pregnancy and hepatic/renal disease are illustrations of the influence of medical history on analgesics prescription. [32]
Age of patients influences choice of analgesics because of the reported implication in Reyes syndrome. Epidemiological data indicated that aspirin usage during or shortly after these viral diseases like influenza or chickenpox in children increases the risk of developing Reye's syndrome. [37] The non-selective NSAIDs are best avoided in the older patient because of increased tendencies for gastrointestinal bleeding with increasing age. [37] The lower likelihood of children than adults with the same complaint to receive narcotics has been reported. [38] Affordability of drug is part of rational drug prescription and socioeconomic status of individual influence the prescription of analgesics as medical care payment in Nigeria is mostly out of pocket expenses. Socioeconomic background and other demographic factors like patient age have been related to the likelihood of receiving a prescription drug related to a dental visit. [39] Provision of appropriate treatment after dental surgery requires a careful medical history and educated anticipation of the level of pain the patient may encounter. This therefore highlight the influence of types of procedure with accompanying inflammation and anticipated severity of pain and other functional disturbances on analgesics prescription choices and pattern among the respondents. [10]
Although, this study is limited by mode of recruitment and method of selection of participants, the findings could be considered valuable in reference to information on analgesics prescription relating to actively practicing dentists in Nigeria.
| Conclusion | | |
A variety of analgesics are prescribed commonly in Nigerian dental healthcare settings and a number of factors influence the choice of these analgesics .The non-opioid analgesics were commonly prescribed by the respondents. Insufficient knowledge relating to analgesics was also documented among the respondents. The development of pain management strategies, prescribing guidelines and educational initiatives are recommended as possible ways to overcoming the noted deficiencies.
Clinical significance
Insufficient knowledge relating to analgesics may impair rational drug prescription with attendant adverse consequences among patients utilizing Nigerian dental healthcare services.
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[Figure 1]
[Table 1], [Table 2], [Table 3]
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