Assessment of COMMUNITY Pharmacists' Knowledge, Attitude, and Practice Towards Oral Health Care in Jordan

Oral health and pharmacy

Oral diseases involve a substantial percentage of the world’s population, nearly 3.4 billion globally, and are essential to an individual’s overall health. Furthermore, oral health affects systemic health, especially in patients with diabetes and cardiovascular diseases.¹ The World Health Organization (WHO) defined oral health as “the state of the mouth, teeth and orofacial structures that enable individuals to perform essential functions such as eating, breathing and speaking and encompasses psychosocial dimensions such as self-confidence, well-being and the ability to socialize and work without pain, discomfort and embarrassment”.²

Traditionally, the dental profession has provided advice on oral health. Nonetheless, increasing evidence supports directing patients seeking urgent dental advice and offering preventative oral health advice to non-dental health professionals, such as community pharmacists (CPs).³ The (CP’s) responsibilities are not limited to dispensing medication to patients but are broadened to offer the general public dental advice. In addition, (CP’s) are in an advantageous position to recognize patient needs because of their professional understanding and simple accessibility.⁴

The most common oral diseases known and widespread among the general population include dental caries, periodontal disease or gingival bleeding, halitosis, and xerostomia. Most often, these conditions are diseases caused by behavior and habits that a person adheres to as a part of their daily duties.⁵ In addition, oral health issues might herald unfavorable outcomes, so oral health issues, such as mouth ulcers, toothaches, gingival bleeding, and loose dentures are the most prevalent complaints a (CPs) receives.⁴ Teething troubles, mouth rinse selections, and toothpaste and toothbrush choices are less commonly consulted oral health issues. However, because many oral diseases, such as oral thrush and mouth ulcers, are benign, many people go to their (CPs) instead of the dentist to immediately relieve their symptoms.^6–8

It has been reported that (CPs) receive at least one query per week regarding an oral health issue, with over half of those inquiries being about mouth ulcers. Additional research showed that most individuals with oral health issues may be effectively treated in a pharmacy environment.

Studies have been conducted on pharmacists’ knowledge, attitudes, and self-care practices concerning dental care in England, Australia, India, and Saudi Arabia.^3,7,9–11 The general healthcare system considers (CPs) as healthcare advisors, educators, promoters, and preventers. According to a South African study, over 37% of respondents named (CPs) their first option for medical attention in an emergency, and roughly 26.5% said (CPs) were their first choice regarding healthcare providers.¹²

The public is prevented from receiving good dental care for several reasons, including expense, fear of dentists, and difficulty accessing dentists due to time and geographical constraints.¹³ The (CPs) active role in the healthcare system is attributed to several factors, including their strategic location in key areas that facilitate public access to healthcare providers and require little time and effort for symptomatic relief without the need for hospital appointments and associated costs.⁶ According to a Saudi study, the primary reasons are that people sought care from (CPs) due to the lack of time and difficulties securing a doctor’s or dentist appointment.⁷

Many people who complain of oral diseases may go to a pharmacy instead of a dentist to relieve the pain as fast as possible. They may suffer from inflammation, bleeding gums or severe toothache, dental hypersensitivity, or even it is possible to get rid of bad breath.⁶

Choosing the appropriate toothpaste or toothbrush for the patient’s condition is a significant factor in preventing many oral problems, such as tartar, cavities, receding gums, or poor appearance.⁹ The pharmacies market have the most items needed to maintain or treat oral health issues.^9,10 Consequently, (CPs) are qualified to provide appropriate advice about using dental items in the pharmacy, such as toothpaste and mouthwash to prevent tartar buildup and toothdecay, denture hygiene, and gum care.⁶ Moreover, within their training and experience limits, (CPs) recognize the warning signs and symptoms of the most common oral health issues and know when to recommend a patient to a dentist or physician.¹⁴

Hajj et al. exemplified that toothaches (84.5%) were the most common oral ailment for which patients asked (CPs) for advice. These were followed by mouthwash, tooth whitening products, and bleeding gums (74.6%, 71.8% and 70.6%) respectively.⁹ Thirty-six percent of (CPs) reported being approached regarding denture issues.⁹

In the literature review, no studies were conducted in Jordan to evaluate the role of (CPs) knowledge, attitude, and practice in oral health care. On this basis, this investigational study assessed the knowledge, attitude, and practice of Jordanian (CPs) in northern Jordan regarding oral health care as a primary objective.

Methods

A prospective cross-sectional self-administered study was conducted in community pharmacies in 4 cities, Irbid, Jerash, Ajloun, and Al-Mafraq, in northern Jordan. Full-time (CPs) in northern Jordan employed in pharmacies were invited to participate between September and November. A cover letter in the survey questionnaire contained a brief overview of the study and its importance. The survey was amended to include a disclaimer alerting respondents that their completion and return of the questionnaire would be interpreted as implicit permission.

Results

From the 250 questionnaires distributed, One hundred ninety-eight (CPs) from different cities in northern Jordan participated in this study, returning a 97.2% response rate. Most respondents were females (54.5%). The mean age of the respondents was 29 (±6.93) years. Most respondents (78.3%) had a B.Sc. of Doctor of Pharmacy qualification (a six-year study curriculum). Forty percent of the respondents had 6–10 years of experience. Approximately 167 (84.8%) of the respondents had a bachelor’s degree in pharmacy, and a small faction held a master’s degree 10 (5.05%) and held a PhD 7 (3.5%) qualification. The vast majority, 104 (52.5%) of the respondents were from Irbid. The lowest number of respondents was from Ajloun 13 (6.6%) (Table 1).

The (CPs) demonstrated high oral health knowledge, scoring 58.2%. Approximately 53% of respondents knew inadequate dental hygiene was the primary cause of gingival bleeding. Conversely, around 60% of respondents thought bad breath was caused mainly by inadequate dental hygiene. Forty-one percent believed periodontal disease was the most common cause of tooth loss. Most respondents said “yes” to the correct definition of plaque (83%) that tea and coffee beverages caused tooth stains (90%), that dental health was associated with general health (89%), and that they had knowledge of proper tooth brushing techniques (68%). A significant discovery was that only 5.6% knew the ideal fluoride levels in toothpaste for adults and children. At the same time, almost 20% believed children should have less than 1000 parts per million (PPM) fluoride in toothpaste (Table 2).

The majority of the respondents demonstrated excellent oral health attitudes, scoring (71.05%). Approximately 26% of the respondents agreed that maintaining excellent oral health required cleaning one’s teeth twice daily. Regarding the issue of sweet and sugary meals causing dental caries, 13% of the respondents were impartial. Approximately 6% of the respondents disagreed that sugar-free gum benefits dental health (Table 3).

Regarding (CPs)’ practice to address customer concerns regarding their oral health, 82% of the respondents suggested mouthwashes to their customers as an appropriate oral hygiene tool to eliminate bad breath. Almost 63% of the respondents recommended changing their toothbrushes to their consumers every three months. The majority of respondents (48.5%) suggested fluoridated toothpaste to their customers. At the same time, 61% of respondents suggested drinking water compared to 45.5% who advocated sugar-free gum for treating dry mouth. According to the respondents, gingivitis and toothaches account for 43% and 39% of oral health concerns voiced by patients, respectively. Dental floss as an oral aid between teeth was promoted by 57% of respondents compared to 43% who encouraged dental floss between crowded teeth. However, 41% proposed V-shape brushes as oral hygiene for those wearing orthodontic appliances (Table 4).

The result of the association between knowledge scores and respondents’ education level showed that there was a strong association (p = 0.00). (CPs) Possessing a master’s degree scored the highest knowledge level (60%) in terms of education level, followed by those with a bachelor’s degree (52.7 %). However, those with a PhD degree scored the highest knowledge level (57.1%) in the “poor” category of knowledge (Table 5). At a 95% confidence level, there was a significant association between knowledge score groups (p < 0.001).

The result of the association between practice scores and respondents’ city showed that there was an association (p = 0.017). (CPs) from the city of Jerash in the poor category scored the lowest practice level (24.4%), followed by those from the city of Ajloun (23.1%) (Table 6). However, Al Mafraq and Irbid cities have lesser percentages in this group, with 7.5% and 9.6%, respectively. At a 95% confidence level, there was a significant association between practice score groups (p < 0.05).

The association between knowledge scores and the education level shwed that approximately 53 percent of those with postgraduate certification had good knowledge regarding oral healthcare, closely followed by those with a bachelor’s degree. Those who scored the least score within the good category with a diploma. The association between knowledge scores and the education level demonstrated statistical significance (p < 0.05).

The results of the association of knowledge in relation to the Cities; the majority of thr CPs (77.5%) from Al Mafraq demonstrated high levels of knowledge, and the lowest score within the same category was scored by those from Ajloun (46%).

Regard to the distribution of gender in relation to scores; the female CPs demonstrated statistically significantly higher mean (7.5 ± 1.9) knowledge levels than their male counterparts (<0.05). However, whilst not statistically significant, the male CPs in the attitude (28 ± 3.4) and practice (4.5 ± 1.9) scores.

The results showed that the education level in relation to scores, those with a bachelor’s degree demonstrated statistically significantly higher mean (7.4 ± 2.0) knowledge levels than those with a diploma or postgraduate certification (p < 0.05).

Discussion

The current study was undertaken to study the pharmacists’ oral health knowledge, attitudes, and practices in northern Jordan on the supposition that CPS are effective oral health providers in a community environment., including their knowledge, attitude, and self-care behaviors related to oral health as pharmacies were the first to go to as they provided round-the-clock service to meet people’s healthcare requirements.

Since pharmacies were the first to be relied upon because they offered 24-hour service to meet people’s healthcare needs, the current study was conducted to examine the oral health knowledge, attitudes, and practices of pharmacists in northern Jordan on the assumption that CPS are effective oral health providers in a community setting.

Several studies have emphasized that people visited their local pharmacy for several reasons, which included general health and dental hygiene advice. Other reasons included insufficient money for dental or doctor’s fees, trouble getting in to see the local dentist or doctor, lack of nearby hospitals or private clinics, and lack of time.^4,6,9–12

The World Health Organization (WHO) asserts that maintaining good oral health improves people’s quality of life globally and that dental health is essential to overall health and well-being.² In order to avoid oral health issues, they should be addressed as soon as they arise or send patients to the appropriate healthcare providers when necessary, who should work in concert to establish policies that support oral health based on scientific data.²

The (CPs) are highly regarded and reliable healthcare providers who may be essential in improving people’s access to and satisfaction with healthcare. Several studies have demonstrated that the general public often talks to their (CPs) on a wide range of issues on their oral health.^3,10,18,19 Similar findings have been demonstrated in the current study in that most (CPs) understand their role in promoting oral health care for the community. In Jordanian culture, females are more willing to work the morning shifts while their male counterparts are willing to work the night shifts.

The findings in the current study demonstrated that the (CPs) in Jordan had a good knowledge score, and the majority of (CPs) knew that poor oral hygiene was the primary cause of bad breath and gingival bleeding. These findings contrast the findings of Baseer et al., which demonstrated only moderate knowledge, a negative attitude, and insufficient self-care habits related to oral health.⁷ Furthermore, in this study, only 40.9% agreed that periodontal disease is the most frequent reason for tooth loss, and 82.8% claimed to be familiar with dental plaque.

In addition, the (CPs) in this study further demonstrated an average understanding of oral health for several reasons advocated: a lack of time, the limited encounter with dentists, a lack of possibilities for professional growth, but perhaps the most importantly, a lack of knowledge and training in oral health for the (CPs). Similar findings regarding average oral health have also been reported in Lebanese, Saudi, and Malaysian studies.^7,9,20

In the present study, the CPs have an excellent attitude toward oral health because of their relatively good knowledge, experience, and extensive practical training during their studies. Furthermore, pharmacists are willing to provide customers consultations in oral health care. The average attitude score demonstrated in the current study was high, which could be attributed to their high levels of self-reported knowledge and satisfactory levels of practice. This finding is mirrored by the study of Hajj et al., who demonstrated a positive attitude of pharmacists toward oral health.⁹ However, this contrasts with a study by Baseer et al., who obtained a negative attitude toward pharmacists’ inadequate self-care practices toward oral health.⁷ Another study by Badran demonstrated a negative attitude and inadequate self-care practices toward oral health.²¹

The current study found a substantial beneficial relationship between the (CPs) knowledge and their actual behavior. The majority of (CPs) suggest that their customers use dental floss, which could be explained by the high level of knowledge and practice of the importance of dental floss in maintaining good oral hygiene.

The primary oral health problems that cause customers to visit the local pharmacy are bad breath, changing toothbrushes, brushing frequency, dry mouth, dental floss, and oral aids for orthodontic appliances. These individuals’ self-awareness concerning oral self-care activities is positively affected by their general oral health knowledge. The current study’s findings align with the studies of Maunder et al. and Priya et al., who demonstrated that 66% of their customers asked about oral health matters and sought the advice of their (CPs).^10,11

The rewards, as exhibited by this study, are the sizeable sample and the variety of dental health inquiries sought reveal the participants’ knowledge, attitudes, and self-care levels. Since this is the first known Jordanian study to evaluate CPs’ knowledge and attitudes regarding oral health, it is hoped that it will be considered baseline data for future studies. Moreover, the variations of data collection from dispersed geographic locations (4 provinces) make the result more generalized to similar contexts.

The limitations of the present study were its dependence on a questionnaire, which may sometimes provide inaccurate results due to misconstrued understanding and the phrasing of the questions. Also, due to cultural issues, when the questionnaire was distributed (daytime working hours), it could be an issue covering more females than male pharmacists. Finally, due to the limited “free” time, a CP has to read and comprehend the question correctly to provide a suitable answer.

Access to a more comprehensive database is needed to devise and develop a practical approach to enhance pharmacists’ oral health. Further research would need to be undertaken nationally, ideally with a sample size typical of Jordanian pharmacists. By addressing the public’s oral health requirements, pharmacists in community pharmacy settings may function as oral health promoters with the help of their expanded knowledge and skills in this area.

Conclusion

The (CPs) surveyed in this study displayed good oral health knowledge, a positive attitude, and inadequate university training. This study explicitly demonstrates that despite all obstacles and challenges, Jordanian (CPs) have the general knowledge and attitude needed to play a significant part in dental care.

The (CPs) surveyed in this study also noted that they desired more active participation in their roles of CPs as well as more education and training to improve their practice. The medical and paramedical colleges at the universities should take on a more active role in implementing various training, educational conferences, and seminars for oral health, which may enhance the pharmacist’s curriculum.

Competencies in counselling, particularly those relating to smoking cessation, denture cleanliness, the proper use and selection of dental products, and mouthwashes, could improve pharmacists’ basic understanding of oral health and help patients take better care of themselves.

Ethics and consent

The study protocol was approved by the Jordan University of Science and Technology (JUST) Institutional Review Board, Jordan, with protocol number (2022/602). The objectives and protocols of the study were explained to the participants and obtained written informed consent from each subject before participation in the study.

Human and animal rights

No animals were used in this research. All human research procedures followed were in full accordance with the ethical standards of the committee responsible for human experimentation (institutional and national) and with the World Medical Association Declaration of Helsinki of 1975, as revised in 2018.

Author contributions

SA, AT, TF, AR, and RT concpetulized and designed the study, reviewed the literature, collected data, interpreted data contributed in writing manuscripts. AT analysed, interpreted the data, and contributed in writing the manuscript. SA contribued to study design, interpreted the data, and was a major contributor in writing the manuscript. All authors read and approved the final manuscripts.