Summary
AMAÇ: İstanbul'daki diş hekimleri tarafından ağrı kesici reçetelendirme modelini ve bu ilaçların kullanımı konusunda hastaya verilen bilgileri belirlemek.YÖNTEM: İstanbul'da çalışan 250 diş hekimine anket dağıtılmıştır. Anketler, diş hekimlerine elden verilmiştir. Anketteki sorular; diş hekimliğinde ağrı kesici kullanımı hakkında açık uçlu sorulardı. Anketler analiz edildi ve her bir soruya verilen yanıtlar, mutlak frekanslar olarak belirlendi. Vakalar ve diş hekimleri tarafından her bir vaka için reçete edilen ağrı kesiciler, tanımsal istatistik yöntemi olan ”sıklık”la analiz edildi.
SONUÇLAR: Dağıtılan anketlerin 130 adedi yanıtlandı (%52). Başlıca yazılan ağrı kesici bir nonsteroidal antiinflamatuvar ilaç (NSAİİ) olan naproksen idi. Bununla birlikte diş hekimlerinin dental ağrı için selektif COX-2 inhibitörlerini veya opioid analjezikleri reçetelendirmedikleri belirlenmiştir. Diş hekimlerinin bazıları aynı hasta için birden fazla NSAİİ reçetelendirdiklerini belirtmişlerdir (n=11 durum). Her ne kadar diş hekimlerinin %75'inden fazlası hastalarını ağrı kesici kullanımı konusunda bilgilendirdikleri belirtmiş olmalarına rağmen, bilginin içeriği sınırlıdır.
TARTIŞMA: Diş hekimlerine uygulanan anketlerin sonuçları; diş hekimlerinin dental ağrının tedavisi için en sık naprokseni yazdıklarını ve nadir de olsa uygun olmayan ağrı kesici kombinasyonlarını reçetelendirdiklerini göstermektedir. Sonuçlar ayrıca, diş hekimlerinin hastalarını ağrı kesici kullanımı konusunda yetersiz şekilde bilgilendirdiğini göstermiştir. Reçetelendirilen ilaçların ilaç etkileşmeleri, saklama koşulları ve fiyatları konusunda diş hekimleri tarafından yetersiz bilgilendirilme, çalışmanın, tedavi başarı oranı ve hasta uyuncunu da etkileyebilecek önemli bir noktasıdır.
Introduction
Pain management has always been an important part of dental care. Nonopioid analgesics; paracetamol as an antipyretic analgesic and nonsteroidal anti-inflammatory drugs (NSAIDs) (i.e. ibuprofen, naproxen, flurbiprofen) are commonly used in dental pain. Rarely opioid analgesics (i.e. hydrocodone, oxycodone, meperidine, propoxyphene, pentazocine, tramadol) are also used in the management of moderate to severe dental pain[1-5].NSAIDs are very effective in the initial pain with inflammation and they provide excellent analgesia for mild to moderate pain. Because of their analgesic and anti-inflammatory effects these drugs are commonly used in dental pain[3,4].
NSAIDs effects via inhibiting the cyclooxygenase (COX) enzymes which has primary role in the synthesis of prostaglandins and other eicozanoids. This pharmacologic effect of these drugs also causes irritation and bleeding in gastrointestinal tract[1-2,4]. In order to eliminate the gastrointestinal adverse effects of these drugs, selective COX – 2 inhibitor types were developed, but after a while increased risk of myocard infarction and other cardiac diseases (including sudden cardiac death, stroke) were determined in patients using some of these type of drugs (i.e. rofecoxib). In a recent study it is mentioned that NSAIDs (both selective COX–2 and non selective COX inhibitors) should be used cautiously in patients with cardiac diseases. Widely use of these drugs in the management of dental pain increases the risk of adverse effects (including gastrointestinal, hematologic, broncopulmoner, renal etc.) due to these drugs[3].
On the other hand paracetamol which is also a widely used analgesic in dentistry, has no evident anti-inflammatory effect on peripheral tissues, and consequently provides little risk on gastrointestinal mucosa damage. The most serious adverse reaction due to paracetamol therapy is “hepatotoxicity” which can occur in high doses[1-2,6-9].
Due to widespread use of analgesics, there are concerns about drug-induced toxicity (i.e. NSAID-induced toxicity) which can be significant health hazard. No drugs are without adverse effects or perfectly safe, but their safe use in clinical practice would entail maximizing the therapeutic efficacy and minimizing the adverse effects[1-2,4].
An important increasing parameter of the effectiveness is to inform the patients adequately about the prescribed drugs. This information includes not only dose and dose interval of the drugs but also adverse reactions, drug interactions, storage conditions and the price of the prescribed drugs. When the dentists informed their patients about these subjects, it also required briefing of these explanations by patients. This prevents misunderstanding of the information given. On the other hand perfect information of the patient will increase the success ratio of the therapy, compliance of the patient, quality of the life and cost-effectiveness[10,11].
There have been studies of analgesic prescribing in dentistry[1-4]. The aim of this study is to evaluate the analgesic use in dental practice and the information given to their patients about use of these drugs by dentists in Istanbul, Turkey.
Methods
QuestionnaireA questionnaire was devised to examine dentists' analgesic prescribing patterns. The questionnaire was anonymous but investigated the place of graduation, age (banded from 21 to 30, 31 to 40, 41 to 60 years and 60 years and older), sex, place of work and whether any postgraduate education had been attended.
The questionnaire investigated: a) 5 of the most analgesic prescribed indications from dentists, b) 3 indications they prescribed combined nonsteroidal anti-inflammatory drug therapy and c) The information given to patients about use of these drugs.
Sample and data handling
Before starting this study, the approval of the health authority
and the list of the dentists were received from “Chamber of
Dentists of Istanbul”. Dentists in the list were chosen from different
regions of Istanbul in order to make a homogenous distribution.
The questionnaires were handed out directly to the
dentists. The delivery of the questionnaires started in June
2007 and the delivery and collecting processes finished in June
2008.
The questionnaires received were entered into a Statistical Package for Social Science® (SPSS) version 15.0. From this database the overall response rate was calculated, together with the percentage responses for each question. The cases and the analgesics dentists prescribe for each case was determined by the descriptive statistics method; “frequency”.
Results
A total of 130 replies (out of 250 questionnaires sent) were received giving response a rate of 52%. Out of the 130 respondents, 68 (52.7%) were males and 61 (47.3%) were females (one of the respondents didn't check the gender box). Demographic and professional characteristics of respondents are shown in Table 1. Analysis of the graduation showed that majority of the respondents graduated from dental schools of Istanbul University and Marmara University (67 out of 128; 52.3% and 38 out of 128; 29.7% respectively). The number of those who had attended any postgraduate education is 73 (57.5%) (This mainly includes postgraduate courses). And as seen in Table 1 majority of the respondents works at dental practices (66 out of 94 respondents; 70.2%).TABLE 1: Demographics and professional characteristics of participating dentists.
Table 2 shows the prescribing patterns of dentists in Istanbul. The answers given to our open-ended questions showed a wide variety. For this reason the analgesic prescribing indications given by dentists were grouped as; “periodontal procedures”, “surgical procedures” and “endodontic procedures”.
TABLE 2: Analgesics prescribed in the management of dental pain among dentists in Istanbul.
Periodontal procedures include; acute and chronic apical periodontitis, periodontal infection, gingival infections and inflammation, and flare up.
Surgical procedures include; dental abscess, bone infection, tooth extraction, postoperative pain, periapical ostitis and trauma.
Endodontic procedures include; acute and chronic apical abscess, pulpitis, tooth inflammation, dental pain with or without inflammation.
Endodontic procedures were the most common procedures dentists prescribed analgesics (237 out of 333 case given by dentists; 71.1%), followed by surgical (50 out of 333 case; 15.0%) and periodontal procedures (26 out of 333 case; 7.8%), and special conditions [including dental pain in pregnant women (12 out of 333 cases; 3.6%), temporomandibular joint (TMJ) problems and trismus (5 out of 333; 1.5%) and dental pain in pediatric patients (3 out of 333 cases; 0.9%)].
Naproxen was the most favored analgesic in periodontal, surgical and endodontic procedures. The cases respondents preferred combined nonsteroidal anti-inflammatory therapy and the drugs they chose were given in Table 3. Endodontic procedures and TMJ problems and trismus were the most common procedures the respondents preferred combined nonsteroidal anti-inflammatory therapy (6 out of 16 cases given by respondents; 37.5% for each cases), followed by and surgical procedures (4 out of 16 cases given by respondents; 25%).
Majority of the respondents (102 out of 130 respondents; 78.5%) reported they gave information to their patients about analgesic use. Table 4 shows the information given by respondents to their patients about analgesic use. As seen in the table; the most common information given by the respondents to their patients were “warning about the adverse reactions of these drugs on gastrointestinal system” (69 out of 252 information given; 53.5%) and “to obey the dose and dose interval rules given” (60 out of 252 information given; 46.5%).
TABLE 4: Information given by dentists to their patients about analgesic use.
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