Amlodipine-Associated Gingival Hyperplasia: A Case Report and Review of Literature

Amara Butt1                     BDS
Kanwal Sohail2                BDS, M.Phil
Amber Kiyani3                 BDS, MS, FAAOMP, Dip-ABOMP

 

 

Gingival overgrowth can be adverse reaction of calcium channel blockers. Although nifedipine is commonly associated with
this process, some case reports have also implicated amlodipine as a possible etiology. Here we present a case of a 59-yearold Pakistani female who developed gingival hyperplasia secondary to amlodipine use. We believe that the knowledge about
amlodipine-associated gingival hyperplasia is necessary for dentists, so they can accurately diagnose this condition and provide
appropriate management.
KEYWORDS: Drug-induced gingival overgrowth (DIGO), gingival hyperplasia, amlodipine
HOW TO CITE: Butt A, Sohail K, Kiyani A. Amlodipine-associated gingival hyperplasia: A case report and review of literature.
J Pak Dent Assoc 2021;31(1):55-58.
DOI: https://doi.org/10.25301/JPDA.311.55
Received: 10 February 2021, Accepted: 23 August 2021

Download PDF

Amlodipine-Associated Gingival Hyperplasia: A Case Report and Review of Literature

 

 

Amara Butt1                     BDS
Kanwal Sohail2                BDS, M.Phil
Amber Kiyani3                 BDS, MS, FAAOMP, Dip-ABOMP

 

 

Gingival overgrowth can be adverse reaction of calcium channel blockers. Although nifedipine is commonly associated with
this process, some case reports have also implicated amlodipine as a possible etiology. Here we present a case of a 59-yearold Pakistani female who developed gingival hyperplasia secondary to amlodipine use. We believe that the knowledge about
amlodipine-associated gingival hyperplasia is necessary for dentists, so they can accurately diagnose this condition and provide
appropriate management.
KEYWORDS: Drug-induced gingival overgrowth (DIGO), gingival hyperplasia, amlodipine
HOW TO CITE: Butt A, Sohail K, Kiyani A. Amlodipine-associated gingival hyperplasia: A case report and review of literature.
J Pak Dent Assoc 2021;31(1):55-58.
DOI: https://doi.org/10.25301/JPDA.311.55
Received: 10 February 2021, Accepted: 23 August 2021

INTRODUCTION
Gingival overgrowth is hereditary or acquired enlargement of attached gingiva.1 It results from increased proliferative activity of fibroblasts that cause accumulation of extracellular matrix and collagen in gingival connective tissue. While hereditary gingival hyperplasia may be seen in association with multiple syndromes and conditions, acquired is attributed to chronic trauma, granulomatous diseases, nutritional deficiencies, endocrine problems, neoplastic diseases and medications.2 There are several medications that have been implicated as a direct cause of gingival overgrowth. The common ones include anticonvulsants, cyclosporin, antibiotics, oral contraceptives and calcium channel blockers.1
Calcium channel blockers are a class of antihypertensives.
Although little is known about the exact mechanism by which they cause gingival overgrowth, there are a couple of
explanations available in the literature. The first explanation claims that calcium channel blockers decrease folic acid
uptake by cells, thus retarding aldosterone synthesis and increasing adrenocorticotropic hormone activity. This interferes with collagenase synthesis leading to build up of collagen in gingival tissues. The second theory claims that build of drug concentration in the gingival crevicular fluid causes inflammation in the gingival tissues. The release of
inflammatory cytokines in the gingiva leads to excessive collagen deposition.3
The most calcium channel block linked to gingival hyperplasia is nifedipine.4,5 Since amlodipine has an identical mechanism of action to nifedipine, it is commonly used as a replacement drug to nifedipine when adverse effects like
tachycardia, facial flushing and gingival overgrowth arise. However, the literature now documents a correlation between gingival overgrowth and amlodipine.6-8
Here we present a case of a 59-year-old Pakistani female who developed medication-related gingival overgrowth. Our patient was taking amlodipine among other antihypertensives. Since amlodipine is commonly prescribed antihypertensive medication, our case is a good reminder for dentists to consider amlodipine as a potential cause for gingival hyperplasia.

CASE REPORT
A 59-year-old female was seen in the Oral Medicine clinics at Riphah International University with a complaint
of bleeding gums, halitosis and gingival enlargement for over one month. Her medical history was positive for unstable hypertension and a prior episode of myocardial infarction. She was currently taking telmisartan 80mg, metoprolol 100mg, aspirin 75mg, amlodipine 5mg, valsartan 50 mg, atorvastatin 10mg and alprazolam 0.5mg. She has been on this medication for almost 3 years.
On clinical examination gingival hyperplasia was identified. While the attached gingiva of both jaws was involved, it was more pronounced in the anterior region (Figure 1). The most affected area was mandibular lingual region. The hyperplasia was accompanied by heavy calculus deposits, periodontal pocketing and bleeding on probing. There was intrinsic staining noted on the anterior maxillary teeth.
We discussed the condition with the patient and explained potential causes of gingival hyperplasia. Following exclusion of other causes of gingival enlargement, a diagnosis of medication-associated gingival overgrowth was made. The patient was referred to the Periodontology department for oral hygiene prophylaxis (scaling and polishing of teeth). We also wrote a letter to patient’s physician recommending discontinuation of amlodipine.
Following the plaque and calculus removal, the patient was prescribed chlorhexidine rinse and antibiotics for week. She then saw her physician who updated her medications but persisted with use of both amlodipine and
metoprolol. The cardiologist did modify the treatment plan after numerous attempts from us to get in touch with him.
On follow up the patient no longer had complaints of halitosis and gingival bleeding. However, some degree of gingival hyperplasia still persisted (Figure 2). Our patient was offered gingivectomy to get rid of the extra tissue, but she refused. She remains on follow up and gets her calculus and plaque deposits removed through instrumentation regularly.

DISCUSSION
An increasing number of drugs are involved in causing gingival hyperplasia. The common drugs involved in causing
this are calcium channel blockers, anticonvulsants, immunosuppressants and -blockers. Since our patient was
using a medicine implicated in gingival overgrowth; amlodipine, drug-associated gingival overgrowth remained
the only option in our differential diagnosis. Drug-induced gingival overgrowth shows a female predilection, women
between the ages of 45 to 60-years are mostly affected.7,9 Our patient was also female between the favored age group.
Amlodipine is classified as a dihydropyridine in the category of calcium channel blockers. FDA has approved
amlodipine for managing hypertension and coronary artery diseases. It reduces hypertension by blocking the voltage
gated L-Type channels. This prevents activation and phosphorylation of myosin, contraction of vascular smooth muscle, and increase in blood pressure. The same mechanism of action also prevents the precipitation of angina.10
Like all medications, amlodipine is associated with some adverse effects. These include pulmonary and peripheral edema, heart failure, dizziness, headaches, nausea and abdominal pain. In the head and neck region, amlodipine is
associated with gingival overgrowth, taste alterations (dysgeusia), total loss of taste sensations (ageusia) and smell
disturbances (dysosmia).11 The mechanism of gingival overgrowth is a consequence of changes in size of cell, division of cells, increased matrix production, angiogenesis in gingiva and altered phenotype of fibroblasts. This coupled with reduced metalloproteinase production causes enlargement of gingival tissues.12 The enlargement of the gingiva can sometimes become more likely if other medications like metoprolol, a common -blocker, is being used. A study has shown that over 25% of patients using both amlodipine and metoprolol were more
likely to develop gingival overgrowth.13 Our patient was using both medications at the time of presentation.
Amlodipine-associated gingival hyperplasia presents as generalized painless swelling of the gingiva. Prominent
involvement of interdental papillae initiating soon after drug consumption is usually seen.14 The hyperplasia can range from localized bead-like enlargements of interdental papillae to pronounced gingival overgrowth. Both arches are commonly involved. The anterior gingiva is more prominently involved.15 The overgrowth is firm to hard on palpation. Loss of scalloped margins, gingival bleeding and erythema due to inflammation may also occur. Bleeding on probing may be a rare finding. Mobility and eventual loss of teeth is noted in chronic cases. Since only dentate areas demonstrate gingival hyperplasia, loss of teeth often results in resolution of overgrowth. Patients see dentists due to esthetic or functional concerns.15,16 While most of these features were noted in our patient, there was also a complaint of halitosis.
Diagnosis of drug induced gingival enlargement made based on thorough dental and medical histories, clinical presentation and histology, where appropriate. Evaluation and complete record of location, nature and extent of involvement, probing depth, presence of plaque or calculus needs to be made. Other causes of gingival overgrowth like chronic trauma, granulomatous diseases, nutritional deficiencies, endocrine problems, and neoplastic diseases
need to be ruled out.2 Common serology investigations including complete blood picture, glucose tolerance test and
renal function tests can rule out leukemia, infection, diabetes and renal failure. Pregnancy tests may be needed for women in child-bearing age. Histopathology of the enlarged tissues shows proliferation of fibroblasts and collagen. The collagen is often thick and ropy in appearance and streaming vertically. The surface oral epithelium may exhibit hyperkeratosis, acanthosis and elongated rete-ridges. Sprinkling of chronic inflammatory cells may be seen.17 Absence of multinucleated giant cells or neoplastic cells also helps in establishing definitive diagnosis.2
Management of drug-associated gingival overgrowth requires discontinuation of the offending agent and surgical
excision of excess tissue. Recurrence is a frequent problem, especially in cases when the medication cannot be stopped.18 Non-surgical intervention includes scaling and root planning along with irrigation of all subgingival pockets with 1% chlorhexidine. This gets rid of harmful organisms and prevent secondary inflammation. Oral hygiene instructions are strongly recommended.19 It was difficult for us to proceed with management due to reluctance of the cardiologist in switching medications. It took us several phone calls and 2 letters before the medications were discontinued. Our patient refused any invasive procedures, she chose to undergo scaling and polishing was given a chlorhexidine mouthwash. We believe that this is the reason why her hyperplastic tissue persisted on the 3 months follow up.
In conclusion, we discuss a case of gingival overgrowth associated with a common antihypertensive medication;
amlodipine. We believe that this knowledge is necessary for dentists so they can correctly identify medication-associated gingival hyperplasia and appropriately manage this condition by coordinating with the patient’s physician.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Tungare S, Paranjpe AG. Drug Induced Gingival Overgrowth (DIGO). StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2020, StatPearls Publishing LLC.; 2020.

2. Agrawal AA. Gingival enlargements: Differential diagnosis and review of literature. World J Clin Cases. 2015;3:779-88.
https://doi.org/10.12998/wjcc.v3.i9.779

3. Brown RS, Arany PR. Mechanism of drug-induced gingival overgrowth revisited: a unifying hypothesis. Oral Dis. 2015;21:e51- 61.
https://doi.org/10.1111/odi.12264

4. Madi M, Shetty SR, Babu SG, Achalli S. Amlodipine-induced Gingival Hyperplasia – A Case Report and Review. West Indian Med J. 2015;64:279-82.
https://doi.org/10.7727/wimj.2014.089

5. Mohan RP, Rastogi K, Bhushan R, Verma S. Phenytoin-induced gingival enlargement: a dental awakening for patients with epilepsy. BMJ Case Rep. 2013;2013.
https://doi.org/10.1136/bcr-2013-008679

6. Sharma S, Sharma A. Amlodipine-induced gingival enlargement– a clinical report. Compend Contin Educ Dent. 2012;33:e78-82.

7. Tomar LR, Aggarwal A. Missing diagnosis: gingival hypertrophy due to amlodipine. Indian Heart
J. 2015;67:491-2.
https://doi.org/10.1016/j.ihj.2015.06.011

8. Carty O, Walsh E, Abdelsalem A, MaCarthy D. Case report: druginduced gingival overgrowth associated with the use of a calcium channel blocker (amlodipine). J Ir Dent Assoc. 2015;61:248-51.

9. Krishnamoorthy KM, Nair K. Gingival overgrowth due to amlodipine.Indian Heart J. 2016;68:431.
https://doi.org/10.1016/j.ihj.2016.03.036

10. PubChem. PubChem Compound Summary for CID 2162, Amlodipine. Bethesda (MD): National Library of Medicine (US), National Center for Biotechnology Information; 2004

11. Schiffman SS. Influence of medications on taste and smell. World Journal of Otorhinolaryngology – Head and Neck Surgery. 2018;4:84- 91.
https://doi.org/10.1016/j.wjorl.2018.02.005

12. Brown R, Arany P. Mechanism of Drug-Induced Gingival Overgrowth Revisited: A Unifying Hypothesis. Oral diseases. 2014;21.
https://doi.org/10.1111/odi.12264

13. Gopal S, Joseph R, Santhosh VC, Kumar VV, Joseph S, Shete AR. Prevalence of gingival overgrowth induced by antihypertensive drugs: A hospital-based study. J Indian Soc Periodontol. 2015;19:308-11.
https://doi.org/10.4103/0972-124X.153483

14. Livada R, Shiloah J. Calcium channel blocker-induced gingival enlargement. J Hum Hypertens. 2014;28:10-4.
https://doi.org/10.1038/jhh.2013.47

15. Lafzi A, Farahani RM, Shoja MA. Amlodipine-induced gingival hyperplasia. Med Oral Patol Oral Cir Bucal. 2006;11:E480-2.

16. Joshi S, Bansal S. A rare case report of amlodipine-induced gingival enlargement and review of its pathogenesis. Case Rep Dent. 2013;2013:138248.
https://doi.org/10.1155/2013/138248

17. Akca A, Ortakoglu K, Pikdöken L, Deveci S. Histopathological Evaluation of Five Unusual Gingival Enlargement Cases. Military medicine. 2005;170:986-90.
https://doi.org/10.7205/MILMED.170.11.986

18. Zoheir N, Hughes FJ. The Management of Drug-Influenced Gingival Enlargement. Prim Dent J. 2020;8:34-9.
https://doi.org/10.1308/205016820828463816

19. Pundir AJ, Pundir S, Yeltiwar RK, Farista S, Gopinath V, Srinivas TS. Treatment of drug-induced gingival overgrowth by full-mouth disinfection: A non-surgical approach. J Indian Soc Periodontol. 2014;18:311-5.
https://doi.org/10.4103/0972-124X.134567

Xerostomia Diagnosis – A Narrative Review

Ayesha Khalid1            BDS
Savaiz Elahi2                BDS
Arsha Qurban3             BDS
Saira Atif 4                    BDS, BSc, M.Phil

 

 

Xerostomia can be defined as a feeling of dryness of mouth, which may or may not be accompanied with reduced salivary
secretions. Xerostomia may result in localized and systemic disturbances within the body. The overall global prevalence of
xerostomia is 22% with wide variation among different countries due to difference in target population. This review presents
the recent literature on the diagnostic methodologies that are present in recent times through subjective and objective corridors.
The most commonly used subjective methods for the xerostomia diagnosis include: Fox questionnaire, Visual Analogue Scale
(VAS), Xerostomia Inventory (XI), and Shortened Xerostomia Inventory (SXI). Objective xerostomia diagnostic tools include
salivary flow rate assessment. Aside from this, there are numerous radiographical modalities that can be used especially in
diagnosing salivary gland disorders or radiation exposure due to oncological treatments which can also provide the added
information to diagnose or monitor xerostomia. These radiographic tools include computer tomography (CT), scintigraphy,
sialography, magnetic resonance imaging (MRI), and ultrasonography. Different combination of tools gives a better xerostomia
assessment, selection of which also depends on the age and health condition of the patient.
KEYWORDS: flow rate; hyposalivation; diagnosis; oral dryness; salivary gland dysfunction
HOW TO CITE: Khalid A, Elahi S, Qurban A, Atif S. Xerostomia diagnosis - A narrative review. J Pak Dent Assoc 2021;31(1):
49-54.
DOI: https://doi.org/10.25301/JPDA.311.49
Received: 30 April 2021, Accepted: 16 November 2021

Download PDF

Xerostomia Diagnosis – A Narrative Review

 

 

Ayesha Khalid1            BDS
Savaiz Elahi2                BDS
Arsha Qurban3             BDS
Saira Atif 4                    BDS, BSc, M.Phil

 

 

Xerostomia can be defined as a feeling of dryness of mouth, which may or may not be accompanied with reduced salivary
secretions. Xerostomia may result in localized and systemic disturbances within the body. The overall global prevalence of
xerostomia is 22% with wide variation among different countries due to difference in target population. This review presents
the recent literature on the diagnostic methodologies that are present in recent times through subjective and objective corridors.
The most commonly used subjective methods for the xerostomia diagnosis include: Fox questionnaire, Visual Analogue Scale
(VAS), Xerostomia Inventory (XI), and Shortened Xerostomia Inventory (SXI). Objective xerostomia diagnostic tools include
salivary flow rate assessment. Aside from this, there are numerous radiographical modalities that can be used especially in
diagnosing salivary gland disorders or radiation exposure due to oncological treatments which can also provide the added
information to diagnose or monitor xerostomia. These radiographic tools include computer tomography (CT), scintigraphy,
sialography, magnetic resonance imaging (MRI), and ultrasonography. Different combination of tools gives a better xerostomia
assessment, selection of which also depends on the age and health condition of the patient.
KEYWORDS: flow rate; hyposalivation; diagnosis; oral dryness; salivary gland dysfunction
HOW TO CITE: Khalid A, Elahi S, Qurban A, Atif S. Xerostomia diagnosis - A narrative review. J Pak Dent Assoc 2021;31(1):
49-54.
DOI: https://doi.org/10.25301/JPDA.311.49
Received: 30 April 2021, Accepted: 16 November 2021

INTRODUCTION
Whole saliva is a vital oral fluid that helps in preservation of healthy oral tissues. 1 Disturbances in the salivary flow rate may affect oral health, which can directly impact the quality of life of the individual.2 Less saliva in oral cavity may lead to caries, frequent oral ulcers and blisters, oral malodor, periodontal problems, difficulties in swallowing and speech. One such consequence is xerostomia. Xerostomia is defined as feeling of mouth dryness3 which may or may not be accompanied with hyposalivation. Hence, may be classified as subjective and objective xerostomia. Xerostomia from objective hyposalivation has been termed as true xerostomia, whereas subjective oral dryness despite normal salivaryn  function has been referred as pseudo xerostomia.3 Additionally, the terms “xerostomia” and “salivary gland hypofunction” have been used for the same phenomenon but in reality are separate entities.4
This solidifies the pseudo element of the condition because not all patients exhibit a pathological salivary gland dysfunction.3 Owing to its subjective trait, xerostomia poses difficulty in better understanding of its nature. The overall global prevalence of xerostomia is 22% with wide variation among different countries due to difference in target population.5 In developed countries such as Australia, xerostomia prevalence is reported to be 13%6 , whereas, in Iran, the prevalence is about 8%.7 In Pakistan, limited studies have been reported on prevalence
of xerostomia in general population. In a study conducted on Pakistani army soldiers with hepatitis C, the reported
prevalence was 70%.8 Xerostomia predisposition in females and especially among the geriatrics is well reported.7
An array of systemic diseases can be affiliated with hyposalivation. Autoimmune diseases encompassing: Sjogren syndrome, Systemic lupus erythematosus (SLE), AIDS, Parkinson’s disease, rheumatoid arthritis, and hepatitis
C virus (HCV) infection play a significant part in altering salivary glands functions.3 Moreover, hormonal, psychogenic, and neurologic diseases such as anxiety, depression, schizophrenia, bipolar disorders, also have abrief or irretrievable impact on the salivary flow rate of the
patients.9 Xerogenic drugs or chemicals such as tricyclic antidepressants, antihistamines, diuretics, antihypertensive drugs, decongestants etc. also have a potential of lowering salivary flow or causing dry mouth in individuals.3
Furthermore, hyposalivation is one of the most commonly reported and detrimental side effect occurring in 95% of
the patients that undergo radiotherapy in the region of the head and neck.10
Xerostomia can cause dental caries, frequent fungal and bacterial infections, oral ulcerations and halitosis1 , taste disturbances, difficulty in eating, swallowing and speaking9 , atrophic mucosa11, burning mouth, and difficulty in retention of dentures.3 All of which may result in malnutrition.12 Wide ranges of clinical features present a serious impediment in its diagnosis and treatment. To date no standard diagnostic protocol is present for xerostomia.13

Subjective diagnosis of xerostomia
Comprehensive history taking plays an important role in the diagnosis of a disease even before performing any
physical examinations and tests.14 Evaluation and diagnosis of xerostomia requires detailed questioning about past medical history, practice of polypharmacy, altered taste, and difficulty in any of these: eating, swallowing, chewing,
and wearing dentures.3 Multiple questionnaires are framed to identify and assess the rate of xerostomia. As xerostomia needs to be understood from patient’s perspective, a patientreported outcome measure (PROM) is essential to evaluate xerostomia.

1. Fox’s questionnaire Fox questionnaire was first introduced in 1987 and  comprises 9 items pertaining to experience of oral dryness. Four of the items in the questionnaire indicates a direct correspondence to reduced salivary flow and if the patients respond positively to any one of these four questions, they are identified as xerostomic patients.15 The purpose of this questionnaire is to identify presence of reduced saliva secretion, difficulty during swallowing, and the necessity to take sips of water with dry food.16 For patients who are
non-compliant in terms of saliva collection for salivary flow rate assessment, this questionnaire plays a vital role in the evaluation of the symptoms;16 however, questionnaire results might not draw a parallel with the salivary flow rate effectively,17 as xerostomia may exist in the absence of hyposalivation and vice versa.18

2. Xerostomia Inventory (XI)
The Xerostomia Inventory (XI) is one of the extensively used and validated PROM, introduced by Thomson et al.
in 199919. This consists of 11-items which are to be answered and then graded from 1 to 5: 1 being ‘never’ while 5 being ‘very often’. The score ranges from 11 to 55, a higher score represents poor quality of life.20 XI was introduced to better understand and record the severity of xerostomia in individuals.19 XI covers two separate aspects one being the experience of xerostomia felt by individuals and second one involving the consequences of the disease.19

3. Shortened Xerostomia Inventory (SXI)
For greater convenience a shortened 5-item PROM, SXI was endorsed in 2011 by Thomson et al.18 The need to
shorten the XI was essential as some of the questions appeared to be redundant and unnecessary i.e. those
associated to facial skin, nose and eyes.21 In SXI, 5 of the 11 items used are answered by choosing one of the three
response option: 1 ‘never’, 2 ‘occasionally’, and 3 ‘often’.  XI focuses on recording the experiences felt by individuals having a dry mouth while the behavioral consequences of oral dryness are not included in the questionnaire.18 SXI is
a valid and reliable instrument for assessment of xerostomia and has been widely used in epidemiological and clinical studies in conjunction with objective assessment of xerostomia.21 The use of SXI is popular in many parts of
the world and is validated in Dutch, Portuguese, English, Chinese and Japanese.22

4. Quality of Life Questionnaire Head and Neck
(QLQ-H&N35)
The European Organization for Research and Treatment of Cancer has approved a valuable questionnaire specifically related to head and neck cancers/radiation therapy; Quality of Life Questionnaire Head and Neck (QLQ-H&N35). Related to xerostomia, this questionnaire has 4-item scales for assessing swallowing and single-item scales for presence of dryness of mouth and sticky/thick saliva. Scores may range from zero to 100.23 This questionnaire serves as a valuable instrument for the assessment of quality of life of head and neck cancer patients before, during, and after radiation therapy.24

5. Visual Analogue Scale (VAS)
VAS was introduced as a reliable tool for clinical diagnosis of xerostomia and comprised of 8-items. This
scale involves examination for two key aspects for salivary production: (i) Dryness of oral mucosa and (ii) functional
incompetence due to dryness; and two universal components regarding the mouth dryness. Results have shown that VAS can be used in monitoring changes or improvements in salivary flow rate and can be effectively used as a  continuous evaluation instrument for patients suffering from salivary gland dysfunctions. Nearly all the components of VAS have proven to be reliable; however, when compared with objective salivary flow rate of normal individuals, they show poor to moderate validity.25

Objective diagnosis of xerostomia
The unstimulated salivary flow rate ranges from 0.3- 0.5 ml/min and flow rate below 0.1 ml/min is considered
hyposalivation26 indicating a functional loss of salivary glands.27 When the salivary flow rate is less than the fluid
absorption and evaporation rate in the oral cavity, it is referred to as objective hyposalivation.28 Objective salivary
flow rate is best measured by collecting saliva from the three major salivary glands namely: Parotid, submandibular,
and sublingual salivary glands. Different tools and techniques  are used in practice for accurate collection of saliva from individual glands: Carlson-Crittenden collector or modified Lashley cup is used for collecting glandular saliva from the Stensen’s duct of the parotid gland, and Wolff collector is used for collecting saliva from the ducts of submandibular and sublingual glands.29 The term resting or unstimulated saliva is used when any stimulus either external or pharmacological are not used for the collection of saliva. Methods such as spitting and passive drooling are commonly used for the collection of unstimulated saliva. When a stimulus, in the form of a mechanical or gustatory such as chewing gum or citrus, are used for saliva acceleration and collection, it is termed as stimulated saliva.30 Rate for both the stimulated and unstimulated saliva can be assessed; pH value of the saliva is lower in the unstimulated than in the stimulated saliva.31 Significant differences are observed for both stimulated and unstimulated salivary flow rates during the day time and evening.32

Radiographically diagnosing xerostomia
Radiographic methods can also be of aid when it comes  to diagnosing xerostomia i.e. sialography, scintigraphy,
ultrasound (US), MRI, CT, and (18) F-FDG positron emission tomography (PET);33 which may be useful in
situations in which salivary glands function are affected by some underlying disease or radiation therapy.

1. Sialography
Sialography is considered as a valuable and reliable exam, centred on cannulation of main salivary ducts and
injecting an iodinated contrast medium, which henceforth allows radiographic imaging of the entire anatomy of the
main salivary glands. The shortcoming of this method is its invasiveness and exposure to the radiation.34 It detects changes in the course of salivary gland ducts and thus is helpful in diagnosing patients with a chief complaint of
mouth dryness.35 Sialography is a non-aggressive procedure and can be a painless method if handled accurately;36
however, breach in ductal arrangement, hostile reactions to contrast agent, and instigation of some clinically dormant infections might pose as a complication.33 Sialography serves as an effective diagnostic tool to check for the severity of xerostomia.37

2. Ultrasonography
Recently, sialography has been replaced by highresolution ultrasound for the detection of salivary stones, also known as sialolithiasis.33 Ultrasound is widely gaining acceptance as a diagnostic tool for the evaluation of salivary
glands in diseases such as xerostomia. Some of the advantages of this technique are that it is a noninvasive
procedure, cost-effective, and safe without exposure to ionizing radiation.38 Ultrasound is a simple and reliable method, but has its limitations when exploring mild parenchymal variations, and can only detect obvious variations.39 Moreover, American-European Consensus Group (AECG) guidelines have declined to include ultrasound as an accepted imaging modality in the diagnosis of xerostomia associated with Sjögrens syndrome.40 For this imaging technique to come under authentication, it still needs further multicentric studies.38

3. Scintigraphy
Scintigraphy is one of the most frequently used methods for the evaluation of salivary gland function in various
diseases: Sjögren’s syndrome, xerostomia, and radiation therapy for head and neck cancers.41 This technique not only aids in the interpretation of both salivary accumulation and release but is also used for the quantitative analysis.42 99m Technetium pertechnetate are radionuclides that are intravenously injected and are taken up by the salivary glands and eventually secreted. Extent of functional acinar tissue depends on the degree of uptake and secretion into the oral cavity.43 Scintigraphy is a reliable and an effective method to study the progression and severity of xerostomia and salivary gland functions.44 Scintigraphy results are based on Schall’s classification,
which is widely considered the standard method of evaluation, showing salivary gland function that is
categorized into four grades corresponding to the uptake and activity of the gland after injecting the radionuclide (Grade 1 being normal and grade 4 showing a total lack of function or uptake).45 A drawback of this technique is
chances of any errors due to the misinterpretation by the evaluator as it is an observer dependent process.46

4. MRI
MRI detects any salivary gland anomaly due to its
ability to visualize and detect water-containing structures.43
These masses result in the obstruction of salivary flow. MRI
reveals the minor details of the anatomy of glands, which
aids in
better understanding of xerostomia diagnosis.47

5. [18F] fluorodeoxyglucose-labelled positron emission
tomography-CT (FDG-PET-CT) biomarkers
FDG-PET-CT imaging delivers efficient evidence about
the metabolic activity of tissue especially in head and neck
cancer patients. Xerostomia caused by radiation exposure
is a subsequent side effect of head and neck cancer which
can best be diagnosed using PET biomarkers.48
11C-methionine PET-CT unveils the metabolic clearance
of 11C-methionine whenever there is an augmented amount
of radiation dose; hence, this serves as an important
biomarker that correlates with salivary flow rate.49

CONCLUSION
There are numerous methods used to identify and
monitor xerostomia, largely depending on the underlying
medical condition. These methods may be used alone or in
combination, such as using both subjective and objective
tools, which may help the clinician to approach xerostomia
holistically. Different combination of tools gives a better
xerostomia assessment, selection of which also depends on
the age and health condition of the patient.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Turner MD. Hyposalivation and xerostomia: Etiology, complications, and medical management. Dent Clin North Am. 2016;60:435-43.
https://doi.org/10.1016/j.cden.2015.11.003

2. Jeganathan S, Carey H, Purnomo J. Impact of xerostomia on oral health and quality of life among adults infected with HIV-1. Spec Care Dentist. 2012;32(4):130-5.
https://doi.org/10.1111/j.1754-4505.2012.00247.x

3. Millsop JW, Wang EA, Fazel N. Etiology, evaluation, and management of xerostomia. Clin Dermatol. 2017;35:468-76.
https://doi.org/10.1016/j.clindermatol.2017.06.010

4. Ying Joanna ND, Thomson WM. Dry mouth – An overview. Singapore Dent J. 2015;36:12-7.
https://doi.org/10.1016/j.sdj.2014.12.001

5. Agostini BA, Cericato GO, Silveira ERd, Nascimento GG, Costa FdS, Thomson WM, et al. How common is dry mouth? Systematic review and meta-regression analysis of prevalence estimates. Braz Dent J. 2018;29:606-18.
https://doi.org/10.1590/0103-6440201802302

6. Jamieson LM, Thomson WM. Xerostomia: Its prevalence and associations in the adult australian population. Aust Dent J. 2020;65(S1):S67-S70.
https://doi.org/10.1111/adj.12767

7. Ghapanchi J, Rezazadeh F, Fakhraee E, Zamani A. Prevalence of xerostomia in patients referred to Shiraz dental school, Shiraz, Iran during 2006-2013. Iran J Public Health. 2016;45:1665-6.

8. Azhar J. Clinical evaluation of xerostomia in patients infected with chronic hepatitis c virus. PODJ. 2018;34.

9. Tschoppe P, Wolgin M, Pischon N, Kielbassa AM. Etiologic factors of hyposalivation and consequences for oral health. Quintessence Int. 2010;41(4):321-33.

10. Chambers MS, Rosenthal DI, Weber RS. Radiation-induced xerostomia. Head & neck. 2007;29:58-63.
https://doi.org/10.1002/hed.20456

11. Shirzaiy M, Bagheri F. Prevalence of xerostomia and its related factors in patients referred to zahedan dental school in iran. Dent Exp Clin J. 2016;2.
https://doi.org/10.5812/dcej-7138

12. Barbe AG. Medication-induced xerostomia and hyposalivation in the elderly: Culprits, complications, and management. Drugs Aging. 2018;35:877-85.
https://doi.org/10.1007/s40266-018-0588-5

13. Donaldson M, Goodchild JH. A systematic approach to xerostomia diagnosis and management. Compend Contin Educ Dent. 2018;39(suppl 5):1-9; quiz 10.

14. Muhrer J. The importance of the history & physical in diagnosis. Nurse Pract. 2014;39.
https://doi.org/10.1097/01.NPR.0000444648.20444.e6

15. Carramolino-Cuéllar E, Lauritano D, Silvestre F-J, Carinci F, Lucchese A, Silvestre-Rangil J. Salivary flow and xerostomia in patients with type 2 diabetes. J Oral Pathol Med. 2018;47:526-30.
https://doi.org/10.1111/jop.12712

16. Chamani G, Shakibi M, Zarei M, Rad M, Pouyafard A, Parhizkar A, et al. Assessment of relationship between xerostomia and oral health-related quality of life in patients with rheumatoid arthritis. Oral Dis. 2017;23:1162-7.
https://doi.org/10.1111/odi.12721

17. Dyasanoor S, Saddu SC. Association of xerostomia and assessment of salivary flow using modified schirmer test among smokers and healthy individuals: A preliminutesary study. J Clin Diagn Res. 2014;8:211-3.

18. Thomson WM, van der Putten GJ, de Baat C, Ikebe K, Matsuda K, Enoki K, et al. Shortening the xerostomia inventory. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112:322-7.
https://doi.org/10.1016/j.tripleo.2011.03.024

 

19. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. Thexerostomia inventory: A multi-item approach to  measuring dry mouth. Community Dent Health. 1999;16:12-7.

20. Thomson WM, Williams SM. Further testing of the xerostomia inventory. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89:46-50.
https://doi.org/10.1016/S1079-2104(00)80013-X

21. Wimardhani YS, Rahmayanti F, Maharani DA, Mayanti W, Thomson WM. The validity and reliability of the indonesian version of the summated xerostomia inventory. Gerodontology. 2021;38:82-6.
https://doi.org/10.1111/ger.12494

22. Thomson WM. Subjective aspects of dry mouth. In: Carpenter G, editor. Dry mouth: A clinical guide on causes, effects and treatments. Berlin, Heidelberg: Springer Berlin Heidelberg; 2015. p. 103-15.
https://doi.org/10.1007/978-3-642-55154-3_7

23. Hohenberger R, Baumann I, Plinkert PK, Brinster R, Krisam J,nAffolter A, et al. Validating the Xerostomia Inventory in a radiationinduced xerostomia population in German language. Oral Dis. 2019;25:1744-50.
https://doi.org/10.1111/odi.13154

24. Bjordal K, Hammerlid E, Ahlner-Elmqvist M, Graeff A, Boysen M, Evensen J, et al. Quality of life in head and neck cancer patients:nValidation of the european organization for research and treatmentnof cancer quality of life questionnaire-H&N35. J Clin Oncol. 1999;17:1008-19.
https://doi.org/10.1200/JCO.1999.17.3.1008

25. Pai S, Ghezzi EM, Ship JA. Development of a Visual Analogue Scale questionnaire for subjective assessment of salivary dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91:311- 6.
https://doi.org/10.1067/moe.2001.111551

26. Gholami N, Hosseini Sabzvari B, Razzaghi A, Salah S. Effect of stress, anxiety and depression on unstimulated salivary flow rate and xerostomia. J Dent Res Dent Clin Dent Prospects. 2017;11:247-52.

27. Atif S, Syed SA, Sherazi UR, Rana S. Determining the relationship among stress, xerostomia, salivary flow rate, and the quality of life of undergraduate dental students. J Taibah Univ Med Sci. 2020;16:9- 15.
https://doi.org/10.1016/j.jtumed.2020.10.019

28. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag. 2014;11:45- 51.
https://doi.org/10.2147/TCRM.S76282

29. Navazesh M, Kumar SKS. Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc. 2008;139:35S-40S.
https://doi.org/10.14219/jada.archive.2008.0353

30. Muddugangadhar BC, Sangur R, Rudraprasad IV, Nandeeshwar DB, Kumar BHD. A clinical study to compare between resting and stimulated whole salivary flow rate and pH before and after complete denture placement in different age groups. J Indian Prosthodont Soc. 2015;15:356-66.
https://doi.org/10.4103/0972-4052.164907

31. Forcella L, Filippi C, Waltimo T, Filippi A. Measurement of unstimulated salivary flow rate in healthy children aged 6 to 15 years. Swiss Dent J. 2018;128:962-7.

32. Kawanishi N, Hoshi N, Masahiro S, Enomoto A, Ota S, Kaneko M, et al. Effects of inter-day and intra-day variation on salivary metabolomic profiles. Clin Chim Acta. 2019;489:41-8.
https://doi.org/10.1016/j.cca.2018.11.030

33. Afzelius P, Nielsen MY, Ewertsen C, Bloch KP. Imaging of the major salivary glands. Clin Physiol Funct Imaging. 2016;36:1-10.
https://doi.org/10.1111/cpf.12199

34. Zablotskyy O, Tomczyk M, Blochowiak K. Current recommendations for treatment and diagnosing of xerostomia in sjögren’s syndrome. Eur J Clin Exp Med. 2020;17:356-63.
https://doi.org/10.15584/ejcem.2019.4.12

35. Tanaka T, Ono K, Ansai T, Yoshioka I, Habu M, Tomoyose tT, et al. Dynamic magnetic resonance sialography for patients with xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:115-23.
https://doi.org/10.1016/j.tripleo.2008.03.012

36. Hasson O. Modern sialography for screening of salivary gland obstruction. J Oral Maxillofac Surg. 2010;68:276-80.
https://doi.org/10.1016/j.joms.2009.09.044

37. Wada A, Uchida N, Yokokawa M, Yoshizako T, Kitagaki H. Radiation-induced xerostomia: Objective evaluation of salivary gland injury using mr sialography. Am J Neuroradiol. 2009;30:53-8.https://doi.org/10.3174/ajnr.A1322

38. Martire MV, Santiago ML, Cazenave T, Gutierrez M. Latest advances in ultrasound assessment of salivary glands in sjögren syndrome. J Clin Rheumatol. 2018;24:218-23.
https://doi.org/10.1097/RHU.0000000000000625

39. Mortazavi S, Imanimoghaddam M, Davachi B, Pakfetrat A, Alimohammadi M. Evaluation of magnetic resonance sialography and ultrasonography findings in salivary glands of patients with xerostomia. Cumhur Dent J. 2016;19.

40. Thomas BL. Imaging of salivary glands. In: Carpenter G, editor. Dry Mouth: A clinical guide on causes, effects and treatments. Berlin, Heidelberg: Springer Berlin Heidelberg; 2015. p. 133-44.
https://doi.org/10.1007/978-3-642-55154-3_9

41. Kaviani H, Khayamzadeh M. The application of salivary gland scintigraphy in quantitative analysis of xerostomia as a frequent salivary gland dysfunction: A review article. J Contemp Med Sci. 2019;5.

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

Numrah Shakeel Malik1            BDS
Muhammad Umair2                   BDS, MCPS, ACMED
Iqraa Shakeel Malik3                 BDS, M.Phil

 

 

OBJECTIVE: The aim of this study was to evaluate trends in self-medication practices among dental patients during the period
of lockdown. Self-medication or using drugs without prescription of a doctor is a common practice round the world since a
long time. During lockdown due to COVID-19 pandemic all the dental facilities were either closed or were only offering
emergency-treatments, therefore lack of services led general population to the practice of self-medication. This should be taken
in account for the health and safety of patients.
METHODOLOGY: A quantitative cross-sectional study was conducted among the dental OPD patients visiting a tertiary care
hospital post COVID-19 lockdown, from 20th September,2020 to 5th December 2020. Sample size was 451 and study participants
were selected by convenient sampling technique.
RESULTS: A total of 389 out of 451 patients self-medicated (383 females and 68 males). Most common reason was tooth ache
(56.8%) followed by sensitivity of teeth (37.5%) and dental trauma (3.8%) was the least common reason. Hence, Pain relievers
(68.5%) were used by most of the patients followed by antibiotics (35.5%). Prevalence was higher in patients of low socioeconomic
status. Most of the patients thought self-medication practice to be acceptable.
CONCLUSION: It was distressing that Self-medication practices among dental patients showed a remarkable increase during
period of COVID-19 Pandemic as most of them had practiced self-medication, most commonly for relief from toothache. This
issue, being a sensitive one needs to be given required consideration.
KEYWORDS: Self-medication, COVID-19, pandemic, Dental OPD, Pain relievers, Tooth ache.
HOW TO CITE: Malik NS, Umair M, Malik IS. Self Medication among dental patients visiting tertiary care hospital, during
COVID-19. J Pak Dent Assoc 2021;31(1):43-48.
DOI: https://doi.org/10.25301/JPDA.311.43
Received: 05 May 2021, Accepted: 02 November 2021

Download PDF

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

 

 

Numrah Shakeel Malik1            BDS
Muhammad Umair2                   BDS, MCPS, ACMED
Iqraa Shakeel Malik3                 BDS, M.Phil

 

 

OBJECTIVE: The aim of this study was to evaluate trends in self-medication practices among dental patients during the period
of lockdown. Self-medication or using drugs without prescription of a doctor is a common practice round the world since a
long time. During lockdown due to COVID-19 pandemic all the dental facilities were either closed or were only offering
emergency-treatments, therefore lack of services led general population to the practice of self-medication. This should be taken
in account for the health and safety of patients.
METHODOLOGY: A quantitative cross-sectional study was conducted among the dental OPD patients visiting a tertiary care
hospital post COVID-19 lockdown, from 20th September,2020 to 5th December 2020. Sample size was 451 and study participants
were selected by convenient sampling technique.
RESULTS: A total of 389 out of 451 patients self-medicated (383 females and 68 males). Most common reason was tooth ache
(56.8%) followed by sensitivity of teeth (37.5%) and dental trauma (3.8%) was the least common reason. Hence, Pain relievers
(68.5%) were used by most of the patients followed by antibiotics (35.5%). Prevalence was higher in patients of low socioeconomic
status. Most of the patients thought self-medication practice to be acceptable.
CONCLUSION: It was distressing that Self-medication practices among dental patients showed a remarkable increase during
period of COVID-19 Pandemic as most of them had practiced self-medication, most commonly for relief from toothache. This
issue, being a sensitive one needs to be given required consideration.
KEYWORDS: Self-medication, COVID-19, pandemic, Dental OPD, Pain relievers, Tooth ache.
HOW TO CITE: Malik NS, Umair M, Malik IS. Self Medication among dental patients visiting tertiary care hospital, during
COVID-19. J Pak Dent Assoc 2021;31(1):43-48.
DOI: https://doi.org/10.25301/JPDA.311.43
Received: 05 May 2021, Accepted: 02 November 2021

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

REFERENCES
1. Alghanim SA. Self-medication practice among patients in a public health care system. East Mediterr Health J. 2011;17:409-16.
https://doi.org/10.26719/2011.17.5.409

2. Noone J, Blanchette CM. The value of self-medication: summary of existing evidence. J Med Econ.
2018;21:201-11.
https://doi.org/10.1080/13696998.2017.1390473

3. Ward MP, Li X, Tian K. Novel coronavirus 2019, an emerging public health emergency. Transbound Emerg Dis. 2020;67:469-70.
https://doi.org/10.1111/tbed.13509

4. Blenkinsopp A, Bradley C. Over the Counter Drugs: Patients, society, and the increase in self medication. BMJ. 1996;312(7031):629- 32.
https://doi.org/10.1136/bmj.312.7031.629 5. Malik M, Tahir MJ, Jabbar R, Ahmed A, Hussain R. Self-medication
during COVID-19 pandemic: challenges and opportunities. Drugs ther perspect. 2020;3:1-3.
https://doi.org/10.1007/s40267-020-00785-z

6. Erku DA, Belachew SA, Abrha S, Sinnollareddy M, Thomas J, Steadman KJ, et al. When fear and misinformation go viral: Pharmacists’ role in deterring medication misinformation during the ‘infodemic’ surrounding COVID-19. Res Social Adm Pharm. 2021;17:1954-63.
https://doi.org/10.1016/j.sapharm.2020.04.032

7. Makowska M, Boguszewki R, Nowakowski M, Podkowinska M. Self-Medication-Related Behaviors and Poland’s COVID-19 Lockdown. Int J Environ Res Public Health. 2020;17:8344.
https://doi.org/10.3390/ijerph17228344

8. Mallhi TH, Khan YH, Alotaibi NH, Alzarea AI, Alanazi AS, Qasim S, et al. Drug repurposing for COVID-19: a potential threat of selfmedication and controlling measures. Postgrad Med J. 2020:postgradmedj-2020-138447.
https://doi.org/10.1136/postgradmedj-2020-138447

9. Alia E, Grant-Kels JM. Does hydroxychloroquine combat COVID19? A timeline of evidence. J Am Acad Dermatol. 2020;83:e33-e4.
https://doi.org/10.1016/j.jaad.2020.04.031

10. Onchonga D, Omwoyo J, Nyamamba D. Assessing the prevalence of self-medication among healthcare workers before and during the 2019 SARS-CoV-2 (COVID-19) pandemic in Kenya. Saudi Pharm J. 2020;28:1149-54.
https://doi.org/10.1016/j.jsps.2020.08.003 47

11. Bhattarai R, Khanal S, Shrestha S. Prevalence of Self-medication Practices for Oral Health Problems among Dental Patients in a dental college: A Descriptive Cross-sectional Study. JNMA J Nepal Med
Assoc. 2020;58(224):209-13.
https://doi.org/10.31729/jnma.4866

12. Mathias EG, D’Souza A, Prabhu S. Self-Medication Practices among the Adolescent Population of South Karnataka, India. J Environ Public Health. 2020;2020:9021819-.
https://doi.org/10.1155/2020/9021819

13. Chiappini S, Schifano F. What about “Pharming”? Issues Regarding the Misuse of Prescription and Over-the-Counter Drugs. Brain Sci. 2020;10:736.
https://doi.org/10.3390/brainsci10100736

14. Horumpende PG, Said SH, Mazuguni FS, Antony ML, Kumburu HH, Sonda TB, et al. Prevalence, determinants and knowledge of antibacterial self-medication: A cross sectional study in North-eastern
Tanzania. PLoS One. 2018;13:e0206623-e.
https://doi.org/10.1371/journal.pone.0206623

15. Durrani OK, Malik IS, Khan K, Zahoor S, Khurshid A, Mukhtar H, et al. self medication among dental patients visiting a tertiary care dental hospital. PODJ. 2016;36(4).

16. Galbadage T, Peterson BM, Gunasekera RS. Does COVID-19 Spread Through Droplets Alone? Public Health Front. 2020;8:163-.
https://doi.org/10.3389/fpubh.2020.00163

17. Arrais PS, Fernandes ME, Pizzol TD, Ramos LR, Mengue SS, Luiza VL, et al. Prevalence of self-medication in Brazil and associated factors. Rev Saude Publica. 2016;50(suppl 2):13s.
https://doi.org/10.1590/s1518-8787.2016050006117

18. Behzadifar M, Behzadifar M, Aryankhesal A, Ravaghi H, BaradaranHR, Sajadi HS, et al. Prevalence of self-medication in university students: systematic review and meta-analysis. East Mediterr Health J. 2020;26:846-57.
https://doi.org/10.26719/emhj.20.052

19. Bilal M, Haseeb A, Khan MH, Arshad MH, Ladak AA, Niazi SK, et al. Self-Medication with Antibiotics among People Dwelling in Rural Areas of Sindh. J Clin Diagn Res : JCDR. 2016;10:Oc08-13.
https://doi.org/10.7860/JCDR/2016/18294.7730

20. Jamhour A, El-Kheir A, Salameh P, Hanna PA, Mansour H. Antibiotic knowledge and self-medication practices in a developing country: A cross-sectional study. Am J Infect Control. 2017;45:384- 8.
https://doi.org/10.1016/j.ajic.2016.11.026

21. Torres NF, Chibi B, Middleton LE, Solomon VP, MashambaThompson TP. Evidence of factors influencing self-medication with antibiotics in low and middle-income countries: a systematic scoping review. Public health. 2019;168:92-101.
https://doi.org/10.1016/j.puhe.2018.11.018

22. Arora H, Singh A, Pathak RK, Goel S, editors. Extent and pattern of self medication use among adult residents of a jurisdiction in north, IJPSR, 2017; Vol. 8: 2205-2212.

23. Roberts EP, Roberts BS, Burns A, Goodlet KJ, Chapman A, Cyphers R, et al. Prevalence and dental professional awareness of antibiotic self-medication among older adults: Implications for dental education. J Dent Educ. 2020;84:1126-35.
https://doi.org/10.1002/jdd.12239

24. Nusair MB, Al-Azzam S. The prevalence and patterns of selfmedication with antibiotics in Jordan: A community-based study. Int J Clin Pract 2021;75:e13665.
https://doi.org/10.1111/ijcp.13665

25. Alghanim S. Self-medication practice among patients in a public health care system. East Mediterr Health J. 2011;17:409-16.
https://doi.org/10.26719/2011.17.5.409

26. Mittal P, Chan OY, Kanneppady SK, Verma RK, Hasan SS. Association between beliefs about medicines and self-medication with analgesics among patients with dental pain. PLoS One. 2018;13:e0201776-e.
https://doi.org/10.1371/journal.pone.0201776

27. Doomra R, Goyal A. NSAIDs and self-medication: A serious concern. J Family Med Prim Care. 2020;9:2183-5.
https://doi.org/10.4103/jfmpc.jfmpc_201_20

28. Stolbizer F, Roscher DF, Andrada MM, Faes L, Arias C, Siragusa C, et al. Self-medication in patients seeking care in a dental emergency service.AOL. 2018;31:117-21.

29. Gillani AH, Ji W, Hussain W, Imran A, Chang J, Yang C, et al. Antibiotic Self-Medication among Non-Medical University Students in Punjab, Pakistan: A Cross-Sectional Survey. Int J Environ Res Public Health. 2017;14:1152.
https://doi.org/10.3390/ijerph14101152

30. Ngu RC, Feteh VF, Kika BT, F EKN, Ayeah CM, Chifor T, et al. Prevalence and Determinants of Antibiotic Self-Medication among Adult Patients with Respiratory Tract Infections in the Mboppi Baptist Hospital, Douala, Cameroon: A Cross-Sectional Study. 2018;6.
https://doi.org/10.3390/diseases6020049

31. Asseray N, Ballereau F, Trombert-Paviot B, Bouget J, Foucher N, Renaud B, et al. Frequency and severity of adverse drug reactions due to self-medication: a cross-sectional multicentre survey in emergency departments. Drug Saf. 2013;36:1159-68.
https://doi.org/10.1007/s40264-013-0114-y

Correlation of Education Level with Severity of Gingivitis and Plaque Score

Hina Mahmood1                 BDS, MDS
Faizana Wasiq Khan2        BDS
Manal Raouf 3                    BDS

 

 

OBJECTIVE: The objective of this study was to find the correlation of educational level with severity of gingivitis and plaque
score of patients reporting to the OPD of periodontology department.
METHODOLOGY: Cross sectional study was conducted at Islamabad Dental Hospital from May 2018 to May 2019. A total
of 376 patients diagnosed with gingivitis were selected using convenience sampling technique. For correlation, participants
were equally divided into four educational groups categorized as illiterate, primary, secondary and tertiary. Informed consent
was taken from the participants and information regarding socio demographic data and education level was recorded. Oral
examinations included visible plaque index (VPI) by Ainamo & Bay and for severity of gingivitis, modified gingival index
(MGI) by Lobene and Weatherford was used. Severity of gingivitis was categorized into mild, moderate and severe. Visible
plaque score was calculated as percentage on the basis of presence or absence of plaque which was divided into two categories
having plaque score < 30 and plaque score > 30. Correlation was calculated by Spearman's correlation test with statistical
significance < 0.01 at 95% confidence interval.
RESULTS: Results revealed that moderate gingivitis was most prevalent among all four education groups. Highest percentage
of severe gingivitis was observed for illiterate subjects 42(50%) whereas highest percentage of mild gingivitis was observed
for subjects with tertiary education 23(65.7%). For subjects with primary and secondary education moderate gingivitis was
most prevalent with 72(28%). Correlation of education with severity of gingivitis and plaque score was statistically significant
(p-value < 0.01) when spearman's correlation test was applied indicating that as the education level increased severity of
gingivitis and plaque score decreased.
CONCLUSION: Hence it was concluded that low educational status is moderately correlated with poor oral hygiene and high
prevalence of moderate to severe gingivitis making it necessary for the community service programs to inculcate oral health
care workshops in early years of school and to the communities where higher education is far reached.
KEYWORDS: Severity of gingivitis, plaque score, education level
HOW TO CITE: Mahmood H, Khan FW, Raouf M. Correlation of education level with severity of gingivitis and plaque score.
J Pak Dent Assoc 2021;31(1):38-42.
DOI: https://doi.org/10.25301/JPDA.311.38
Received: 08 July 2021, Accepted: 16 November 2021

Download PDF

Correlation of Education Level with Severity of Gingivitis and Plaque Score

 

 

Hina Mahmood1                 BDS, MDS
Faizana Wasiq Khan2        BDS
Manal Raouf 3                    BDS

 

 

OBJECTIVE: The objective of this study was to find the correlation of educational level with severity of gingivitis and plaque
score of patients reporting to the OPD of periodontology department.
METHODOLOGY: Cross sectional study was conducted at Islamabad Dental Hospital from May 2018 to May 2019. A total
of 376 patients diagnosed with gingivitis were selected using convenience sampling technique. For correlation, participants
were equally divided into four educational groups categorized as illiterate, primary, secondary and tertiary. Informed consent
was taken from the participants and information regarding socio demographic data and education level was recorded. Oral
examinations included visible plaque index (VPI) by Ainamo & Bay and for severity of gingivitis, modified gingival index
(MGI) by Lobene and Weatherford was used. Severity of gingivitis was categorized into mild, moderate and severe. Visible
plaque score was calculated as percentage on the basis of presence or absence of plaque which was divided into two categories
having plaque score < 30 and plaque score > 30. Correlation was calculated by Spearman's correlation test with statistical
significance < 0.01 at 95% confidence interval.
RESULTS: Results revealed that moderate gingivitis was most prevalent among all four education groups. Highest percentage
of severe gingivitis was observed for illiterate subjects 42(50%) whereas highest percentage of mild gingivitis was observed
for subjects with tertiary education 23(65.7%). For subjects with primary and secondary education moderate gingivitis was
most prevalent with 72(28%). Correlation of education with severity of gingivitis and plaque score was statistically significant
(p-value < 0.01) when spearman's correlation test was applied indicating that as the education level increased severity of
gingivitis and plaque score decreased.
CONCLUSION: Hence it was concluded that low educational status is moderately correlated with poor oral hygiene and high
prevalence of moderate to severe gingivitis making it necessary for the community service programs to inculcate oral health
care workshops in early years of school and to the communities where higher education is far reached.
KEYWORDS: Severity of gingivitis, plaque score, education level
HOW TO CITE: Mahmood H, Khan FW, Raouf M. Correlation of education level with severity of gingivitis and plaque score.
J Pak Dent Assoc 2021;31(1):38-42.
DOI: https://doi.org/10.25301/JPDA.311.38
Received: 08 July 2021, Accepted: 16 November 2021

INTRODUCTION
Oral health is an integral component of general health, negligence in it can lead to a variety of dental problems.1 Dental professionals counsel their patients for oral health care and regular oral hygiene maintenance. Oral hygiene is the practice of keeping the oral cavity clean and healthy. Oral health status is greatly influenced by oral hygiene habits which include tooth brushing, use of oral hygiene aids, proper dietary practice and routine dental visits.1
It prevents plaque buildup, calculus and stain formation on teeth.2 Plaque biofilm is a complex community of multiple microorganisms found on a tooth surface. It has been established through clinical studies and microbiological analysis that plaque has a major role in initiation and progression of gingival inflammation as well
as other oral diseases.3 This inflammation remain unresolved as long as this microbial biofilm of plaque is present.4
General and oral health are both affected by the social determinants which include education, poverty, gender and
sustainability as stated by Human Development Index report 2020.5 These determinants have an impact on oral hygiene practices.2 Educational status is an important indicator of the awareness and behavior of the people for oral health.6 Educated individuals tend to have more knowledge about oral diseases, their prevention and are more likely to attend preventive or follow-up visits. They have better oral health status than those individuals who have lower education levels.1 They also comply better with oral health care regimens.6 A study conducted on elderly population of Nigeria reported high scores of plaque index among the individuals with primary education.2 Longitudinal study with span of 32 years found association of education level with brushing habits and revealed high plaque scores among the individuals with low educational levels.7 Gingivitis has been defined as the reversible plaque induced inflammation of the gingiva without detectable bone loss or clinical attachment loss. Clinically it presents as
erythematous, sore, swollen and bleeding gums.8 It effects more than 75% of the population worldwide and is the second most common oral disease.4 Presence of dental plaque is strongly associated with the presence of gingival
inflammation.3 A study conducted among Saudi adult population showed that males who presented with excessive plaque accumulation showed more severe signs of gingival inflammation.4
Education level has a significant association with severity of gingivitis.9 A study conducted on adult male population in Nigeria reported higher prevalence of gingivitis among the participants with low educational level.10
Literature indicates a weak link of education status with oral hygiene and gingivitis, however direct correlation of
education status with plaque score and severity of gingivitis is still lacking. The present study was designed to find
correlation of plaque scores and severity of gingivitis in patients with different education levels reporting to
periodontology department at Islamabad Dental Hospital. To find correlation participants of groups were equally
distributed. A base line data from this study will help in identifying the current oral health status of local population
belonging to different education levels.

METHODOLOGY
This cross-sectional study was conducted at the Periodontology department of Islamabad Dental Hospital
(IDH) from May 2018 to May 2019, after the approval from Institutional Review Board (IRB) (Ref# IMDC/DS/IRB/118). The sample size was calculated to be 91 per group with absolute precision of 0.1 and anticipated proportion for gingivitis as 0.62 at 95% confidence level. Therefore, the minimum total sample size was 364 which was inflated to 384 to manage any incorrect or insufficient data. Out of these 8 were excluded (2 from each group) due to incomplete information. The final sample included 376 patients (94 per group). Since there was no such study reporting the correlation of education level with severity of gingivitis therefore prevalence of gingivitis was used for sample size calculation. The study population included systemically healthy patients (excluding those who were diabetic, immunocompromised, receiving psychological treatment, suffering from metabolic disorders etc.) of age 23 and above, presenting with symptoms of gingivitis. Patients with compromised hand dexterity and those who have received scaling within last one month were also not included in the study.
After taking informed consent, socio demographic data and complete medical history was recorded. Intraoral examination was conducted for plaque and gingival scores. Participants were equally recruited into four educational
groups having 94 patients in each group. Educational groups were categorized as illiterate (no formal education), primary (grade 1-8), secondary (grade 9-12) and tertiary (with bachelor’s, master’s and doctoral degrees).
Each group was evaluated on basis of visible plaque index (VPI) and modified gingival index (MGI). Clinical
examination was carried out by two trained examiners. Interexaminer reliability for both the indices was calculated on 30 patients which was 80% for plaque index and 75% for modified gingival index. Absence (0) or presence (1) of
dental plaque was visually assessed according to Ainamo and Bay index and percentage was calculated. Educational
group was further divided into two subgroups for plaque index i.e., plaque < 30 % and > 30%. Modified Löe -Silness
index was used for assessment of gingival status. Four surfaces (Disto-buccal, mid buccal, mesio-buccal and lingual)
were scored for each tooth except for third molars. For MGI index each educational group was further divided into three subgroups (mild, moderate and severe gingival inflammation) having scores of (0.1 -1.0), (1.1-2.0) and (2.1-3.0)
respectively.11 Percentages of mild, moderate and severe periodontitis were calculated for each group and spearman’s correlation test was applied to find out the relation of education level with plaque score and severity of gingivitis. Spearman’s correlation test was also applied to find the relation between VPI score and MGI score. P-value of <0.01 was considered significant at 95% confidence interval.

RESULTS
Study sample consisted of 376 patients out of which 186 (49.5%) were females and 190 (50.5%) were males. Individuals of age 23 and above were included since the average age of graduation in Pakistan is 23 yrs. Majority
of males 53 (28.5%) had tertiary education, 52 (28%) were uneducated, while 56 (29.5%) females were educated till primary and 51 (27.4%) had secondary education. Regarding the severity of gingivitis, majority of females 136 (73.1%) had moderate inflammation. Higher percentage of males 46 (24.7%) showed severe gingival inflammation as compared to females 38 (20%). More males (58.1%) presented with VPI score > 30 as compared to females (54.7%).
Table 1 shows the frequency of gingivitis by severity in groups of different education levels. Over all moderate
gingivitis was most prevalent. The illiterate group presented with the highest percentage 42 (44.6%) of severe gingivitis and lowest percentage 7 (7.4%) was observed in tertiary group. Similarly, highest percentage 23 (24.4%) of mild gingivitis was observed in tertiary group whereas primary and secondary groups presented with highest percentage 72(28%) of moderate gingivitia.
A Spearman’s correlation of -0.2 (p-value<0.001) was observed for plaque score and -0.3 (p-value<0.001) was
observed for gingival index which is a fair correlation and implies that as the education level increased gingival and
plaque scores decreased.
The Spearman’s correlation between plaque score and gingival index also demonstrated a moderate, positive correlation (= 0.5, p-value< 0.001) which indicates that greater score of VPI corresponds to greater value of MGI score.

DISCUSSION
Education plays a pivotal role in positive behavioral changes. In Pakistan as majority of the individuals belong
to primary education status,12 it is therefore, extremely important to inculcate dental health education in early years.
Education level has an impact on oral hygiene status.13 Present study concluded that lower level of education is
moderately co-related to poor oral hygiene with coefficient of -0.2 and a good relation was observed between poor oral hygiene and higher scores of gingival inflammation with coefficient of 0.5. Reports have shown that the participants with primary education and VPI > 30% presented with moderate gingival inflammation.14 A study carried out on Swiss Army recruits reported that individuals who completed 9 years of education presented with a mean plaque score of (1.41), whereas the university students merely showed a mean plaque score of (1.26) and the difference was statistically significant.15 Another study conducted on elderly reported that higher percentage of individuals who attended high school presented with acceptable plaque index as compared to those who didn’t attend high school.16 Lower educational status has been associated with lack of oral hygiene awareness resulting in higher levels of dental plaque, a primary etiological factor for development of gingival diseases.10,11
Gingival inflammation is a reversible condition and appropriate plaque control methods and professional dental
care can prevent disease progression.14 The results of present study also revealed higher scores of plaque among male subjects which coincide with the results of adults in Latin
America showing males with greater percentage of supragingival plaque sites than females.17 Ericsson JS et al
also reported that females had significantly lower level of dental plaque (41%) than males (53%).18
With regard to severity, moderate gingival inflammation (68.35%) was the most predominant type observed. Results of the current study are in agreement with those of previous reports that have documented high prevalence of moderate levels of disease.19 Regarding gender, men had higher MGI scores compared to women. According to international studies males presented with significantly higher frequency of severe gingivitis than did women.20,21 However, results of a cross sectional study revealed no statistical differences between genders when considering gingival inflammation which could be due to the overall low mean MGI score (1.2) for both groups.22
This study also reported a higher prevalence of gingivitis in individuals with low educational attainment with a moderate correlation of -0.3 which was statistically significant having p value of < 0.001. Some of the literature supports the present results, underscoring the relation of low education level with severe gingival inflammation.9,23,24
Most of the confounders in this study were controlled and all the educational groups had equal number of
participants, which is the strength of this study. Silness-Löe plaque index and gingival index was not used which can
give us a better assessment of quantity of plaque buildup and gingival inflammation respectively. Brushing habits should also have been analyzed which could have given a clearer picture.

CONCLUSION
It was concluded that participants belonging to low educational status presented with higher scores of plaque
and gingival index. Individuals with tertiary education presented with lower levels of plaque score and increased
prevalence of mild to moderate gingivitis. Females presented with better oral hygiene and gingival status than males.
Nearly two-third of the participants presented with moderate gingival inflammation.

RECOMMENDATIONS
Under the light of the current results, it is prudent that the community based programs should include not only
dental education but also oral hygiene related workshops in early school years. It is necessary to increase the capacity
of these programs to the far reached areas where education level is low.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Bonfim Mde L, Mattos FF, Ferreira e Ferreira E, Campos AC, Vargas AM. Social determinants of health and periodontal disease in Brazilian adults: a cross-sectional study. BMC Oral Health. 2013;13:22.
https://doi.org/10.1186/1472-6831-13-22

2. Braimoh O, Soroye M. Oral hygiene status of elderly population in Port Harcourt, Rivers State, Nigeria. African J Medical and Health Sciences. 2017;16:109-14.
https://doi.org/10.4103/ajmhs.ajmhs_39_17

3. Sreenivasan PK, Prasad KV. Distribution of dental plaque and gingivitis within the dental arches. J Int Med Res. 2017;45:1585-96.
https://doi.org/10.1177/0300060517705476

4. Idrees MM, Azzeghaiby SN, Hammad MM, ., Kujan OB. Prevalence and severity of plaque-induced gingivitis in a Saudi adult population. .35:1373-7. Saudi Med J. 2014;35:1373-7.

5. Conceição P, Jacob Assa, Cecilia Calderon, Fernanda Pavez Esbry, Ricardo Fuentes, Yu-Chieh Hsu, et al. The Next Frontier: Human development and the anthropocene. United Nations; 2020.

6. Kapoor D, Gill S, Singh A, Kaur I, Kapoor P. Oral hygiene awareness and practice amongst patients visiting the Department of Periodontology at a Dental College and Hospital in North India. Indian J Dent. 2014;5:64-8.
https://doi.org/10.4103/0975-962X.135262

7. Broadbent JM, Thomson WM, Boyens JV, Poulton R. Dental plaque and oral health during the first 32 years of life. J Am Dent Assoc. 2011;142:415-26.
https://doi.org/10.14219/jada.archive.2011.0197

8. Chrysanthakopoulos NA. Prevalence of gingivitis and associated factors in 13-16-year-old adolescents in Greece. European J Gen Dent. 2016;40:58-64.
https://doi.org/10.4103/2278-9626.179536

9. Sreenivasan PK, Prasad KVV, Javali SB. Oral health practices and prevalence of dental plaque and gingivitis among Indian adults. Clin Exp Dent Res. 2016;2:6-17.
https://doi.org/10.1002/cre2.15

10. Umoh AO, Azodo CC. Prevalence of gingivitis and periodontitis in an adult male population in Nigeria. ;9:65-9. Niger J Basic Clin Sci. 2012;9:65=9.
https://doi.org/10.4103/0331-8540.108465

11. Carvajal P, Gomez M, Gomes S, Costa R, Toledo A, Solanes F, et al. Prevalence, severity, and risk indicators of gingival inflammation in a multi-center study on South American adults: a cross sectional study. J Appl Oral Sci. 2016;24:524-34.
https://doi.org/10.1590/1678-775720160178

12. Shah D, Khan MI, Yaseen M, Kakli MB, Piracha ZF, Zia MA, et al. Pakistan Education Statistics 2017-18: NEMIS-AEPAM; 2021.

13. Umoh AO, Azodo CC. Association between periodontal Status, oral Hygiene status and tooth wear among adult male population in Benin city, Nigeria. Ann Med Health Sci Res. 2013;3:149-54.
https://doi.org/10.4103/2141-9248.113652

14. Elias-Boneta AR, Toro MJ, Rivas-Tumanyan S, Rajendra-Santosh AB, Brache M, Collins CJ. Prevalence, Severity, and Risk Factors of Gingival Inflammation in Caribbean Adults: A Multi-City, CrossSectional Study. P R Health Sci J. 2018;37:115-23.

15. Rothlisberger B, Kuonen P, Salvi GE, Gerber J, Pjetursson BE, Attstrom R, et al. Periodontal conditions in Swiss army recruits: a comparative study between the years 1985, 1996 and 2006. J Clin Periodontol. 2007;34:860-6.
https://doi.org/10.1111/j.1600-051X.2007.01124.x

16. Lacerda TeSP. Factors Associated With the Presence of Dental Plaque in an Urban Cohort of Elderly (Epidoso). MOJ Gerontology & Geriatrics. 2017;1:68-72.
https://doi.org/10.15406/mojgg.2017.01.00014

17. Oppermann RV, Haas AN, Rosing CK, Susin C. Epidemiology of periodontal diseases in adults from Latin America. Periodontol 2000. 2015;67:13-33.
https://doi.org/10.1111/prd.12061

18. Ericsson JS, Ostberg AL, Wennstrom JL, Abrahamsson KH. Oral health-related perceptions, attitudes, and behavior in relation to oral hygiene conditions in an adolescent population. Eur J Oral Sci.2012;120:335-41.
https://doi.org/10.1111/j.1600-0722.2012.00970.x

19. Murillo G, Vargas MA, Castillo J, Serrano JJ, Ramirez GM. Prevalence and severity of plaque-induced gingivitis in three Latin American cities: Mexico City-Mexico, Great Metropolitan Area-Costa Rica and Bogota-Colombia. Odovtos. Int J Dent Sc. 2018;20:91-102.
https://doi.org/10.15517/ijds.v20i2.32451

20. Mostafa B, El-Refai I. Prevalence of Plaque-Induced Gingivitis in a Sample of the Adult Egyptian Population. Open Access Maced J Med Sci. 2018;6:554-8.
https://doi.org/10.3889/oamjms.2018.131

21. Elias-Boneta AR, Encarnacion A, Rivas-Tumanyan S, BerriosOuslan BC, Garcia-Godoy B, Murillo M, et al. Prevalence of Gingivitis in a Group of 35- to 70-Year-Olds Residing in Puerto Rico. P R Health Sci J. 2017;36:140-5.

22. Jordan RA, Lucaciu A, Fotouhi K, Markovic L, Gaengler P, Zimmer S. Pilot pathfinder survey of oral hygiene and periodontal conditions in the rural population of The Gambia (West Africa). Int J Dent Hyg.
2011;9:53-9.
https://doi.org/10.1111/j.1601-5037.2009.00435.x

23. Australian Research Centre for Population Oral Health TUoASA. Periodontal diseases in the Australian adult population. Aust Dent J. 2009;54:390-3.
https://doi.org/10.1111/j.1834-7819.2009.01167.x

24. Ababneh KT, Abu Hwaij ZM, Khader YS. Prevalence and risk indicators of gingivitis and periodontitis in a multi-centre study in North Jordan: a cross sectional study. BMC Oral Health. 2012;12:1.
https://doi.org/10.1186/1472-6831-12-1

Assessment of Precautionary Measures Medical Students & Doctors Practiced at Eid-ul-Adha during COVID-19

Usama Saeed1
Javaria Saeed2
Nabiha Farasat Khan3            BSc, M.Phil, MHPE, CME
Muhammad Saeed4                BDS

 

 

OBJECTIVE: To analyze the precautionary measures that medical students and clinicians practiced during Eid-ul-Adha' 2020."
METHODOLOGY: An online cross-sectional survey was conducted on medical students and doctors/clinicians/faculty in
Balochistan, where the questionnaire (10 items) was posted on google platforms after Eid-ul-Adha between 10th to 31st
December 2020. Inclusion criteria consisted of first to third year medical students and clinicians whereas fourth and final year,
house officers and postgraduate students were excluded. Pilot study demonstrated reliability of questionnaire Cronbach's alpha
0.624. SPSS version 23 was used for analysis.
RESULTS: In current study majority (n=82/126) of the study participants were males, more than half of them were medical
students (n=73/126). Eighty percent (80%) participants (n=66/82) offered Eid's congregational prayer in masjids, 11/82 prayed
at home only five (n=5/82) of them didn't perform prayer at all; majority (64%) of them practiced SOPs at the time of prayer
in Masjid. In family gatherings, 73% followed all precautionary measures whereas 10% avoided SOP's. At the time of ritual
livestock sacrifice, 62% participants followed whereas only 10% didn't follow to any precautions. During meat distribution,
68.5% study participants practiced all precautionary measures and just 2.7% did not follow SOP's during meat distribution.
No significant difference was found between medical students and doctors in practicing precautionary measures, except during
meat distribution (p-0.009).
CONCLUSION: Medical students and doctors practiced precautionary measures well. However, statistically significant relation
was found between medical students and doctors praying in masjids and maintaining a safe distance in Eid gatherings during
this pandemic.
KEYWORDS: COVID-19, Eid-ul-Adha, Precautionary Measures, Medical Students, Doctors.
HOW TO CITE: Saeed U, Saeed J, Khan NF, Saeed M. Assessment of precautionary measures medical students & doctors
practiced at Eid-ul-Adha during COVID-19. J Pak Dent Assoc 2021;31(1):32-37.
DOI: https://doi.org/10.25301/JPDA.311.32
Received: 13 June 2021, Accepted: 01 Ocotber 2021

Download PDF

Assessment of Precautionary Measures Medical Students & Doctors Practiced at Eid-ul-Adha during COVID-19

 

 

Usama Saeed1
Javaria Saeed2
Nabiha Farasat Khan3            BSc, M.Phil, MHPE, CME
Muhammad Saeed4                BDS

 

 

OBJECTIVE: To analyze the precautionary measures that medical students and clinicians practiced during Eid-ul-Adha' 2020."
METHODOLOGY: An online cross-sectional survey was conducted on medical students and doctors/clinicians/faculty in
Balochistan, where the questionnaire (10 items) was posted on google platforms after Eid-ul-Adha between 10th to 31st
December 2020. Inclusion criteria consisted of first to third year medical students and clinicians whereas fourth and final year,
house officers and postgraduate students were excluded. Pilot study demonstrated reliability of questionnaire Cronbach's alpha
0.624. SPSS version 23 was used for analysis.
RESULTS: In current study majority (n=82/126) of the study participants were males, more than half of them were medical
students (n=73/126). Eighty percent (80%) participants (n=66/82) offered Eid's congregational prayer in masjids, 11/82 prayed
at home only five (n=5/82) of them didn't perform prayer at all; majority (64%) of them practiced SOPs at the time of prayer
in Masjid. In family gatherings, 73% followed all precautionary measures whereas 10% avoided SOP's. At the time of ritual
livestock sacrifice, 62% participants followed whereas only 10% didn't follow to any precautions. During meat distribution,
68.5% study participants practiced all precautionary measures and just 2.7% did not follow SOP's during meat distribution.
No significant difference was found between medical students and doctors in practicing precautionary measures, except during
meat distribution (p-0.009).
CONCLUSION: Medical students and doctors practiced precautionary measures well. However, statistically significant relation
was found between medical students and doctors praying in masjids and maintaining a safe distance in Eid gatherings during
this pandemic.
KEYWORDS: COVID-19, Eid-ul-Adha, Precautionary Measures, Medical Students, Doctors.
HOW TO CITE: Saeed U, Saeed J, Khan NF, Saeed M. Assessment of precautionary measures medical students & doctors
practiced at Eid-ul-Adha during COVID-19. J Pak Dent Assoc 2021;31(1):32-37.
DOI: https://doi.org/10.25301/JPDA.311.32
Received: 13 June 2021, Accepted: 01 Ocotber 2021

INTRODUCTION
Eid-ul-Adha, one out of the two Islamic festivals, is celebrated with great zeal and enthusiasm annually on 10th of Dul-Al-Hajj, the last month of Islamic Calendar. Muslims gather with their families and friends to pray, sacrifice animals and distribute meat to the needy and destitute in order to please Allah Almighty. This Islamic celebration holds a symbolic value as well; it honors the willingness of Ibrahim (AS) to sacrifice his son, Ismael (AS), as an act of obedience to Allah’s command. 1 However, amid COVID-19 pandemic having already affected around 16 million individuals worldwide in the month of July’2020 and a further risk of its spread, social gatherings. 2 This
Eid-ul-Adha in August’2020 was considered problematic due to the overcrowding of people amongst the hustle and
bustle of the great event; animal transportation from rural to urban areas for sale, Eid Congregational Prayer, sacrifice in public areas and/or during social gatherings in amusement parks, restaurants, picnic points or homes.
3 All Muslims including Pakistanis celebrated Eid-Ul-Adha during the first week of August’2020 in this pandemic. Muslims sacrificed animals including goats, cows, sheep and camels. Eid celebration and sacrifices made it quite challenging for the Ministry of Health not only in Pakistan but also in the entire Muslim world to control the situation, as the chances of a drastic rise of COVID-19 infection were very high.3,4 COVID-19 is a viral infection, primarily affecting the respiratory system, transmitted directly or indirectly when a healthy person contacts the saliva, respiratory secretions or respiratory droplets of an infected individual.5 The index case was first recognized in China’s Wuhan city in December’20195 , and was declared a Global Health Emergency in January’2020 by WHO due to its worldwide spread and regulations were asked to be administered.6 The SOPs advised by health care workers included wearing face mask and gloves, physical and social isolation, washing hands for 20sec with soap, monitoring and controlling religious and social gatherings. During Eid-ul-Adha, animal sacrifice was also confined to specific areas with strict regulations to contain the disease transmission.2,3,7
Pakistan is a low-middle income country with a population of 207.8 million, predominantly Muslim population of over 95% residing in five different provinces i.e. Gilgit-Baltistan, Punjab, Sindh, Khyber Pakhtunkhwa (KPK), and Baluchistan.8 To overcome the consequences of COVID-19, the government had opted smart lockdown to arrest risk of infection spread towards individuals, families and communities. To promote and encourage adoption of key measures to prevent and minimize the spread of the infection, government officials directed the observation of SOPs. The commitment of Pakistanis to these control measures was a key factor in deciding the fate of battle against COVID-19.9 The purpose of this survey was to analyze precautionary measures adopted during social and religious practices by medical students and doctors during COVID-19 pandemic during Eid al Adha’2020.

METHODOLOGY
After taking IRB from Bolan University of Medical and Health Sciences Quetta (No.00009/BUMHS/IRB/2020),
quantitative survey was designed and conducted on previous research reports and WHO guidelines for COVID-19.2
Due to pandemic, it was difficult to conduct a community-based survey and collect data so we opted for online Google platform survey. On-line questionnaire included gender, qualification, occupation and designation for background information of the participants and to analyze practice of precautionary measures among 126 medical students of four medical colleges (Makran Medical College in Turbat, Jahalawan Medical College in Khuzdar, Loralai Medical College in Loralai and Bolan Medical College in Quetta) and doctors of Balochistan during Eid-ul-Adha in this pandemic. As the newly inaugurated medical colleges of Makran, Jhalawan and Loralai comprise only three batches each, with neither house job nor post-graduation started so far, we included just first to third year medical students from Bolan Medical College to correspond data with that of the other three medical colleges. Data was collected during 10th to 20th December 2020.
After completing conceptualization of this survey, two medical educationists tested the face and content validity
of the instrument. The approved version of the instrument had 10 items only and had two parts. The first part contained questions related to the demographic information of the participants such as gender, occupation, designation and qualification (in case of clinicians/physicians) while the second part consisted of questions affiliated to precautionary measures including wearing face masks and gloves, keeping a distance of 6-feet, washing hands with soap for 20 sec and avoid touching the face with unwashed hands to prevent virus entry into mouth or nose. Participants were asked to answer in yes and no.
Prior to its official release, pilot testing was done on a small group of people having same characteristics as the
study group through a messaging and voice-over service, WhatsApp to check if the questions were clear and
unambiguous. Questionnaire was acceptable as its reliability was Cronbach’s alpha 6.24%. After this pilot survey, the
questionnaire was distributed to participants through internet into WhatsApp groups of author We used purposive and snowball sampling to recruit participants. The valid response rate was 90% after excluding invalid responses. Informed consent was obtained from all respondents. A brief introduction to the study was provided in the questionnaire on study objectives, questionnaire filling duration, as well as the names and contact information of the investigators. Participation in the survey was voluntary. All respondents were informed that they were free to continue or quit at any time, and the submission of the questionnaire would be regarded as consent to participate.
Second part of the questionnaire consists of six questions that assisted in assessing precautionary measures medical students and doctors were practicing during this pandemic in Eid-ul-Adha. One of these questions have two options: “yes”, and “no”. Whereas others have practiced-based questions focused on the attitude toward COVID-19 and Eid prayers, which precautionary measures did participants practice during family gatherings questions related to precautionary measures participants practice during sacrifice and during meat distribution including wear facemask and gloves, wash hands before and after sacrifice, make a distance of 6-feet, didn’t touch face with unwashed hands

ANALYSIS
The data was analyzed by using SPSS version 23. Frequency and percentage were given for gender, occupation
and responses pertaining to precautionary measures practices overall during Eid-ul-Adha. Chi-square was used to
determine the association of occupation and precautionary measures practiced overall during Eid-ul-Adha. A p-value
< 0.05 was taken as significant.

RESULTS
    One hundred and fifty participants from Makran Medical College, Jahalawan Medical College, Loralai Medical
College and Bolan Medical College across Balochistan responded to our research questionnaire. After scrutiny,
completed questionnaires (n = 126) were included in the study.
Out of 126 participants, majority (65.1%, n=82/126) were males whereas 58% (n=73/126) were medical students. Table 1 demonstrates demographic details. Table 2 presents details about the male participant’s response about precautionary measures during performing prayer, family gathering, practiced on SOP’s advised by local health authorities, observing sacrifice of the animal/s and meat distribution to neighbors and family members. Correlation
between occupations and precautionary measures practiced while meat distribution to family and friends is displayed in Table 3.

DISCUSSION
Overall results of participants following precautionary measures in COVID-19 pandemic were satisfactory. Almost
half of them followed all the precautionary measures in all items; giving an average of 73% during social gatherings,
64% during Eid-ul-Adha Prayers at Masjid, 62% during sacrifice while 68% during meat distribution. In comparison
with the results of other studies in which medical students and doctors demonstrated an overall better response towards SOPs, Hayat I from Punjab detected 81.22%6 while 92% students from Soltan’s study in Egypt practiced precautionary measures to avoid COVID-19 infection.10 The highest ratio (95%) was observed among study participants of Noreen et al research paper.11 In case of washing hands time and again, illiterate background and lack of childhood training serve as contributing factors to its low score.12 Basically majority of the population in Balochistan faces poverty13 which may be a cause of why participants (especially medical students) did not follow the precaution of wearing face masks and gloves attentively (average result 18%); whereas ignorance adds to this point as well. The result of participants maintaining a distance of 6 feet is poor as well; this may be due to the fact that this region of Pakistan has a tradition of shaking hands as well embracing each other especially on Eid Festivals; the younger ones even have to kiss the hands of the elderly as a sign of respect. These cultural norms not observed by any member create social stigma in society.
Medical students demonstrated interest to participate in the current study. More than half (58%) population of our research work (n=73/126) were medical students, remaining 42.1% (n=53/82) were doctors, 18/126 were Assistant  Professors, eight Associate Professors and nine Professors. Remaining 18 participants were also doctors but they were serving on administrative posts (MS, DHO, and registrar). We observed very low percentage of professors who participated in the study, which authenticates their busy schedule and short time for extra clinical activities. On the other hand only 49.7% Lebanese Physicians practiced precautionary measures.
During sacrifice, 42.7% (n=35/82) participants seems to have practiced precautionary measures, 23.2% (n=19/82)
avoided touching their face with unwashed hands, 21% (n=17/82) wore facemasks, whereas 12.2% (n=10/82) maintained a distance of 6feet. During meat distribution, 37.8% (n=31/82) practiced all precautionary measures, 22% (n=18/82) washed their hands with soap for 20sec before and after meat distribution, 17.1% (n=14/82) did not touch their face with unwashed hands, whereas only 7.3% (n=6/82) wore masks, whereas 9.8% participants (n=8/82) did not follow precautionary measures. Athough not on Eid-ul-Adha but other studies carried out on COVID-19 discuss percentage of participants on the basis of gender who wash their hands regularly. A study consisted of 1257 study samples out of which 632 (90.3%) females washed their hands in comparison 85.6% males for 20sec with soap.6
Only 8.2% of our study participants washed their hands for 20 sec during social gathering, however 31% (n=16/52) medical students washed their hands before and after meat distribution. When comparing practices of precautionary measures among undergraduates, majority of the study participants of Hayat K, Khasawneh et al, Soltan and Noreen K washed their hands regularly for 20 sec with resulting percentages of 87%, 88.1%, 90% and 91% respectively.9-11,15 This observation points towards the lazy nature, lack of time and/or non-serious attitude of medical students of Balochistan towards COVID-19.
Possibly the reasons responsible in maintaining low mortality in doctors and medical students would be performing prayers in home. As we found a statistically significant association when we compared Eid-ul-Adha prayer in masjid and /or in home among medical students and doctors (p-0.003). Medical students exhibited lack of time and extra burden of their studies that hinder all sorts of physical activities, and deficit social interactions that in-turn impeded them for performing prayers.16 When comparing responses there was no significant difference between medical students and doctors in wearing facemask, gloves, washing hands for 20 seconds and touching the face, statistically significant difference was observed between occupation of study participants and meat distribution after sacrifice (p-0.09). It may also be worth mentioning that despite of being blamed of fundamentalism, majority of the population in this region willingly reduced the religious rituals to a bare minimum level.17,18,19,20,21 Strict adherence to local, cultural and religious practices which include ablution almost five times in a day, use of face covering by the adult females and maintaining social distances as between genders at gatherings and educational institutions may have been the major contributory factors.22-24,25,26,27
Majority (80.5%, n=66/82) participants of current study offered Eid prayers in masjids; 39% wore facemasks (n=32/66), 22% (n=18/66) observed sufficient gap between namazis in masjid whereas 21% (n=17/66) follow all
precautionary measures. As they all were educated, they were aware of the severity and complications associated with COVID-19, so majority of the medical students and doctors practiced precautionary measures.
Balochistan is primarily a male predominating society and this aspect is confirmed in our study as 65% (n=82/126) study participants were males.28 Though various components work as contributing factors in low female literacy rate in Balochistan as compared to the other parts of the country including remote educational institutes, financial constraints, social problems and cultural barriers.28,29 However, in the current research work, the percentage of females was low as they offer prayers at home, and/or sacrifice ritual and
meat distribution during Eid-ul-Adha is related to men. In contrast, studies conducted by Hayat I, Hayat K, Soltan ,
Dhahri et al and Noreen K during this pandemic related to the adaptation of hygienic and precautionary measures
demonstrated female predominance (73.77%, 55. 7%, 61.1%, 65.9%, 71.4% respectively)6,9,11,30 and were not linked to a specific event.
This type of study had not been conducted before so the author was unable to discuss and compare results of current study with others research work.

STRENGTH OF STUDY
Medical students were keener to participate in online surveys and knew about their practices during this pandemic.
Doctors, being more mature, practice precautionary measures carefully and strictly to avoid any infection. This is the first ever study to analyze medical students and doctors about the precautionary measures they practice. It was a small-scale study. To assess the perceptions, attitude and knowledge it should be done on a larger scale
among medical students and doctors. As it was an online survey, there is a chance of questionnaire bias. There may
be sampling bias, as survey may be restricted to those participants who were more active on social media. However
to reduce sampling bias, questionnaire was distributed to different online channels to improve its visibility among
respondents. There may also be response bias, which the respondents consciously or subconsciously did. As still, no
work was done on this forum to check and analyze which precautionary measures medical students and doctors were practicing, so it was impossible to compare our results with any other survey or study.

CONCLUSION
Doctors demonstrate more responsible behavior towards precautionary measures advised by healthcare workers as
compared to medical students.

ACKNOWLEDGEMENT
Author offers her thanks to all volunteer participants of
this online survey.

AUTHOR CONTRIBUTION
Usama Saeed and Javaria Saeed: data collection (students), literature search
Muhammad Saeed: data collection (doctors), analysis
Nabiha Farasat Khan: manuscript writing, methodology
Attia Bari: review and final approval of manuscript

FUNDING RESOURCES
None

CONFLICT OF INTEREST
None

REFERENCES
1. Khan MS, Mohyuddin A. Symbolic Importance of Ritual of Sacrifice on Eid Ul Adha ( Research Based Study on Satellite Town Rawalpindi). Impact Int J Res Applied, Nat Soc Sci. 2013;1:59-62. Available from: https://www.academia.edu/4873580/ Symbolic_importance_of_ritual_of_sacrifice_on_eid_ul_adha_resea rch_based_study_on_satellite_town_rawalpindi_

2. World Health Organisation. Safe Eid al Adha practices in the context of COVID-19 Interim guidance. 2020. Available from:
https://www.who.int/publications/i/item/clinical-management-ofCOVID-1

3. Mallhi TH, Khan YH, Alotaibi NH, Alzarea AI, Tanveer N, Khan A. Celebrating Eid-ul-Adha in the era of the COVID-19 pandemic in Pakistan: potential threats and precautionary measures. Clin Microbiol Infect. 2020;(xxxx):7-8.
https://doi.org/10.1016/j.cmi.2020.07.019

4. Butt MH, Ahmad A, Misbah S, Mallhi TH, Khan YH. CrimeanCongo hemorrhagic fever and Eid-Ul-Adha: A potential threat during the COVID-19 pandemic. J Medi Virol. 2020.
https://doi.org/10.1002/jmv.26388

5. Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Adv Res [Internet]. 2020;24:91-8.
https://doi.org/10.1016/j.jare.2020.03.005

6. Hayat I, Waseem M, Usman F, Asghar M. Are Pakistani Medical Students Ready and To What Extend?: Knowledge , Attitude and Practice During the Covid-19 Covid-19 Pandemic: a Cross-Sectional Study on Medical. IAJPS. 2020;7:597-605.

7. Govt of Pakistan, Ministry of National Health Services R and C. Guidelines for Eid ul Adha for Prevention of Corona Virus. 2020 p. 1-5.

8. Wazir MA, Goujon A. Assessing the 2017 Census of Pakistan Using Demographic Analysis: A Sub-National Perspective. Vienna Inst Demogr Austrian Acad Sci. 2019;(April):0-43. Available from:
www.oeaw.ac.at/vid

9. Hayat K, Rosenthal M, Xu S, Arshed M, Li P, Zhai P, et al. View of Pakistani residents toward coronavirus disease (COVID-19) during a rapid outbreak: A rapid online survey. Int J Environ Res Public Health. 2020;17:1-10.
https://doi.org/10.3390/ijerph17103347

10. Soltan EM, El-Zoghby SM, Salama HM. Knowledge, Risk Perception, and Preventive Behaviors Related to COVID-19 Pandemic Among Undergraduate Medical Students in Egypt. SN Compr Clin Med. 2020;2568-75.
https://doi.org/10.1007/s42399-020-00640-2

11. Noreen K, Zil-E- Rubab, Umar M, Rehman R, Baig M, Baig F. Knowledge, attitudes, and practices against the growing threat of COVID-19 among medical students of Pakistan. PLoS One. 2020;15: 1-12.
https://doi.org/10.1371/journal.pone.0243696

12. Noreen N, Dil S, Ullah S, Niazi K, Naveed I, Khan NU, et al. Coronavirus disease (COVID-19) Pandemic and Pakistan; Limitations and Gaps. Limitations Gaps Glob Biosecurity 2020;1. Available from: https://jglobalbiosecurity.com/articles/ 63/galley/170/download/
https://doi.org/10.31646/gbio.63

13. Bashir S. Poverty Eradication in Balochistan:A Study of Community Development Programs. Annu Res J Hanken. 2019;10(August): 1-89. Available from: https://www.researchgate.net/ publication/335401493

14. Abou-Abbas L, Nasser Z, Fares Y, Chahrour M, El Haidari R, Atoui R. Knowledge and practice of physicians during COVID-19 pandemic: A cross-sectional study in Lebanon. BMC Public Health. 2020;20:1-9.
https://doi.org/10.1186/s12889-020-09585-6

15. Khasawneh AI, Humeidan AA, Alsulaiman JW, Bloukh S, RamadannM, Al-Shatanawi TN, et al. Medical Students and COVID-19: Knowledge, Attitudes, and Precautionary Measures. A Descriptive Study From Jordan. Front Public Heal. 2020;8:1-9.
https://doi.org/10.3389/fpubh.2020.00253

16. P. T, P.L. B, H.B. P, S.C. E, M.A. M, L.B. S. What do medical students think about their quality of life? A qualitative study. BMC Med Educ. 2012;12:106. Available from: http://ovidsp.ovid.com/ ovidweb.cgi?T=JS&PAGE=reference&D=emed11&NEWS=N&AN =23126332
https://doi.org/10.1186/1472-6920-12-106

17. Algahtani FD, Alzain MA, Haouas N, Angawi K, Alsaif B, Kadri A, et al. Coping during COVID-19 Pandemic in Saudi Community?: Religious Attitudes , Practices and Associated Factors. IJERPH 2021;1-13.
https://doi.org/10.3390/ijerph18168651

18. Erdem H, Lucey DR. Healthcare worker infections and deaths due to COVID-19: A survey from 37 nations and a call for WHO to post national data on their website. Int J Infect Dis. 2021;102: 239-41.
https://doi.org/10.1016/j.ijid.2020.10.064

19. Atif M, Malik I. Why is Pakistan vulnerable to COVID-19 associated morbidity and mortality? A scoping review. Int J Health Plann Manage. 2020;35:1041-54.
https://doi.org/10.1002/hpm.3016

20. Hafeez E, Fasih T. Growing Population of Pakistani Youth: A Ticking Time Bomb or a Demographic Dividend. J Educ Educ Dev. 2018;5:211.
https://doi.org/10.22555/joeed.v5i2.2022

21. Simon AK, Hollander GA, Mcmichael A, Mcmichael A. Evolution of the immune system in humans from infancy to old age. Proc Biol Sci. 2015;282(1821):1-12.
https://doi.org/10.1098/rspb.2014.3085

22. Ahmad EF, Mohammed M, Al Rayes A, Al Qahtani A, Elzubier A, Suliman F. The effect of wearing the veil by Saudi ladies on the occurrence of respiratory diseases. J Asthma. 2001;38:423-6.
https://doi.org/10.1081/JAS-100001497

23. Sibli SA. Cleanliness in Islam: Exploring Through COVID- 19 Pandemic Precautions and Concerns. SSRN Electron J. 2020;preprint a:15.
https://doi.org/10.2139/ssrn.3688410

24. Ashraf H, Faraz A, Raihan M, Kalra S. Fighting pandemics: Inspiration from Islam. J Pak Med Assoc. 2020;70(5):S153-6.
https://doi.org/10.5455/JPMA.34

25. Jia R, Ayling K, Chalder T, Massey A, Broadbent E, Coupland C, et al. Mental health in the UK during the COVID-19 pandemic: crosssectional analyses from a community cohort study. BMJ Open. 2020;10:e040620.
https://doi.org/10.1136/bmjopen-2020-040620

26. Aiyer A, Surani S, Ratnani I, Surani S. Mental Health Impact of COVID-19 on Healthcare Workers in the USA?: A Cross-Sectional Web-Based Survey. 2020;1-8.

27. Arshad MS, Hussain I, Nafees M, Majeed A, Imran I, Saeed H, et al. Assessing the Impact of COVID-19 on the Mental Health of Healthcare Workers in Three Metropolitan Cities of Pakistan. Psychol Res Behav Manag [Internet]. 2020 Nov 20 [cited 2021 Feb 10];Volume 13:1047-55. Available from: https://www.dovepress.com/assessingthe impact-of-covid-19-on-the-mental-health-of-healthcare-wo-peerreviewed-article-PRBM
https://doi.org/10.2147/PRBM.S282069

28. Bashir K, Tobwal, Usman KUBSS. Social and Cultural Barrier to female Education in Balochistan?; an Assessment study with focus on district Pishin. Balochistan Rev. 2019;XXXIV:163-72.

29. Fauzia Maqsood SM, HammadRaza. Getting higher education?: is it really a challenge for females in Pakistan? Acad Res Int. 2012;2:352- 60.

30. Dhahri AA, Arain SY, Memon AM, Rao A, Mian MA. “The psychological impact of COVID-19 on medical education of final year students in Pakistan: A cross-sectional study.” Ann Med Surg. 2020;60:445-50.
https://doi.org/10.1016/j.amsu.2020.11.025