|Year : 2020 | Volume
| Issue : 3 | Page : 210-215
The challenge of late presentation by dental patients in our climes: Reasons behind the enigma
Adebayo Aremu Ibikunle1, Abdurrazaq Olanrewaju Taiwo1, Ramat Oyebunmi Braimah1, Olawale Adamson2, Azeez Fashina2, Mujtaba Bala1
1 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Submission||29-Aug-2019|
|Date of Decision||25-Feb-2020|
|Date of Acceptance||16-Jun-2020|
|Date of Web Publication||24-Oct-2020|
Adebayo Aremu Ibikunle
Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Late presentation among patients is a global phenomenon. It exerts deleterious effects on health-care indices. Aim: The aim of the study was to assess reasons for late presentation by patients and interventions implemented. Materials and Methods: This study was done at the dental outpatient clinic of Usmanu Danfodiyo University Teaching Hospital following ethical approval. A survey of patients aged 18 years and above who presented with more than 1-month history of symptoms was done using an adaptation of a validated questionnaire. Data analysis was done using the IBM SPSS Statistics version 20 (IBM Corp., Armonk, NY, USA). Categorical data were compared among groups using Chi-square test and the level of statistical significance was set at P < 0.05. Results: One hundred and seven participants were included in the analysis. A male-to-female ratio of 1.4:1 and a mean age of 30.9 ± 11.4 years were observed. Most participants were of low socioeconomic status. A comparison of the socioeconomic status of the participants between genders revealed no statistically significant difference (P = 0.289). Forty-five (42.1%) participants had never visited a dental clinic before. Notably, the pain was the most common symptom encountered in 63 (58.9%) participants. Majority of the respondents had experienced symptoms for 1–3 months 30 (28%). The most frequent reason for the late presentation was that respondents had “tried other medications” (23 [21.5%]). Fear alone or in combination with other factors was the reason in 18 (16.8%) patients, majority of whom were females (11 [61.1%]). Where fear was the underlying reason, the fear of contracting disease had a significant presence (8 [44.4%]). Conclusion: The reasons underlying the late presentation in our climes are varied. Self-medication featured prominently and should therefore be discouraged. Moreover, awareness of dental treatment among the populace should be improved.
Keywords: Awareness, dental care, dental clinics, developing countries, self-medication
|How to cite this article:|
Ibikunle AA, Taiwo AO, Braimah RO, Adamson O, Fashina A, Bala M. The challenge of late presentation by dental patients in our climes: Reasons behind the enigma. J Indian Assoc Public Health Dent 2020;18:210-5
|How to cite this URL:|
Ibikunle AA, Taiwo AO, Braimah RO, Adamson O, Fashina A, Bala M. The challenge of late presentation by dental patients in our climes: Reasons behind the enigma. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2021 Apr 11];18:210-5. Available from: https://www.jiaphd.org/text.asp?2020/18/3/210/299006
| Introduction|| |
Late presentation for treatment among dental patients is a common phenomenon in our environment., Despite the deleterious effects that neglected dental diseases have on patients' quality of life, this trend continues to plague health care, especially in developing countries., Several reports of devastating complications of seemingly insidious long-standing dental diseases exist in the literature.,,, This is especially so among patients from the developing world., Some of the reported complications of dental diseases include empyema thoracis, necrotizing fasciitis, Ludwig's angina, sepsis, and death.,
The reasons for late presentation among dental patients are adjudged to be multifaceted, including financial and nonfinancial issues., Moreover, understanding these reasons may form the basis for combating the menace of late presentation among patients, thus reducing the negative impact of late presentation on health-care indices.
One of the initial steps toward reducing the incidence of late presentation among patients is the identification and analysis of the reasons why patients embrace this hazardous trend. This would enable policymakers and other stakeholders to make successful action plans toward eliminating this menace. Ultimately, this would result in an improvement in the national health indices and the general well-being of the Nigerian population.
Furthermore, there would be a reduction in the strain on existing health-care structures since patients who present early are less likely to spend long periods on hospital admission and are likely to recover faster than those who present late., Consequently, an improvement in productivity is likely as there would be a reduction in the number of years lost due to disability or early death (i.e., the disability-adjusted life years) among the populace.
In spite of the high prevalence of late presentation in our climes and the importance of assessing the reasons for such, very few specific studies on this important issue exist. This study aimed to assess reasons for late presentation by patients and interventions implemented thereby fill this knowledge gap and to provide a platform for possible interventions targeted at reducing this menace.
| Materials and Methods|| |
A cross-sectional study of dental patients aged 18 years and above who presented at the dental clinic of Usmanu Danfodiyo University teaching Hospital, Sokoto, with >1 month duration of symptoms between January 2018 and July 2018 was done. Ethical approval for this study was obtained from the Health Research Ethics Committee of the Hospital (UDUTH/HREC/2019/No. 798). Consecutive patients who satisfied the criteria and consented to the study were included in the study. Data were obtained via the administration of an adaptation of the validated structured questionnaire used by Kakatkar et al. and Anyanechi and Saheeb. It is a structured questionnaire consisting of 12 questions that explore possible reasons for late presentation among dental patients. A backward and forward translation of the English version of the questionnaire was made by two independent translators and discrepancies between the two translations were harmonized. A pretest of the questionnaire was done on ten random patients and was found to be satisfactory.
A sample size of 102 respondents was determined based on a 95% confidence interval, adoption of a value of 5% for type I error, an estimated proportion of patients attending our clinic who admitted to having >1 month history of symptoms of 90%, and an absolute error margin of 5%. Informed consent was obtained from prospective respondents before the administration of the questionnaires. Demographic data such as age, sex educational level, occupation, and marital status were obtained. In addition, data pertaining to the reasons for the late presentation were obtained. Furthermore, patients were categorized into socioeconomic groups based on the classification proposed by Oyedeji.
Data analysis was done using SPSS (IBM SPSS Statistics for Windows version 20 [IBM Corp., Armonk, NY, USA]). Descriptive statistics were utilized, and the results were presented as proportions, frequencies, percentages, mean, and standard deviations. Moreover, a comparison of categorical variables such as gender and socioeconomic status among various groups was done using Chi-square test. The level of statistical significance was set at P < 0.05.
| Results|| |
A total of 107 participants were included in the final analysis. Most of the patients were male 62 (57.9%), giving a male/female ratio of 1.4:1. The mean age of the respondents was 30.9 ± 11.4 years. Most of the respondents were in their third decade of life 42 (39.3%) and of low socioeconomic status [Figure 1]. No statistically significant difference was found in a comparison of the socioeconomic status of the participants between genders (P = 0.289). Forty-five (42.1%) of them had never visited a dental clinic before. Among those who had visited a dental clinic before, only 18 (29%) went for routine assessments, while the others (44 [71%]) had visits instigated by existing dental issues.
Majority of the participants (30 [28%]) claimed to have had symptoms for 1–3 months, while 26 (24.3%) have had symptoms for more than 15 months [Figure 2]. A comparison of the duration of symptoms before presentation between the two genders revealed no statistically significant difference (df = 3.177, P = 0.868). The pain was the most common symptom at presentation 63 (58.9%) [Figure 3]. The most frequent diagnosis made was acute apical periodontitis 30 (28%), followed by pericoronitis around impacted mandibular third molars 21 (19.6%) [Figure 4].
The most frequent reason for the late presentation was that respondents had “tried other medications” that they hoped would cure their ailments 23 (21.5%) [Figure 5]. Fear alone or in combination with other factors was the reason in 18 (16.8%) patients. Where fear was the underlying reason, the fear of contracting disease had a significant presence 8 (44.4%). A larger proportion of females (11 [61.1%]) cited fear as a factor for late presentation than their male counterparts (7 [6.5%]).
In an assessment of the awareness among the participants of the variety of oral surgery procedures available, 20 (18.7%) were aware of extraction only, while 2 (1.9%) knew of none [Figure 6]. Notably, their scope of knowledge was quite narrow, with majority of them not being aware of the full complement of treatment options available [Figure 6]. A commendable number of participants 30 (28%) described their experience during previous visits to the dentist as pleasant.
| Discussion|| |
Several authors have proposed various reasons for the frequent observation of late presentation among dental patients., Discrepancies between normative, felt, and expressed needs typically exist among patients in different climes. This observation is usually worse in developing countries like ours and among socioeconomically disadvantaged persons., While several authors have alluded to the significant prevalence of late presentation in our environment, few have scientifically researched the subjective reasons behind this public health concern.
A male prevalence was observed in this study. This observation is in accordance with the general pattern of patient attendance of dental clinics. Furthermore, it is in keeping with some reports on a late presentation by dental patients that exist in the literature. However, it is at variance with the report of Msolla  and Anyanechi and Saheeb., The pattern observed in this study may have also been influenced by the penchant of males to neglect their health care in comparison to females. The age and socioeconomic characteristics of the participants are similar to that described in the literature.,, A link between low socioeconomic status and poor health seeking behavior has been established by multiple authors., The dominance of out-of-pocket payment for health care in our climes may have contributed to this since financial incapacitation may have constituted an additional barrier to health-care accessibility.,
In this study, the general attitude of the populace toward preventive care as evidenced by the relatively low proportion of patients who make routine dental visits appears to be poor. This is akin to the report by Oginni where only 1.4% of the individuals presented for routine clinical assessments. Furthermore, Kusekwa and Kikwilu in a study of a Tanzanian population stated that 80% of their respondents experienced at least five episodes of dental pain before the presentation, indicating the preponderance of delayed presentation among patients. The observation made in this research may be related to the generally poor awareness about oral health care among our local populations, the poor integration of oral health care into the national primary health care program and the high prevalence of out-of-pocket payment in our environs. Therefore, the presence of symptoms, which often indicates advanced or advancing disease, often serves as the instigating factor for a dental visit.
The duration of symptoms was >3 months in majority of the patients. Indeed, almost a quarter of the patients had symptoms of >15 months duration. This suggests poor health-seeking behavior and increases the chances that patients would present with complications of primary dental diseases. This finding complements reports by several authors, who assert that late presentation is prevalent in our society.
Pain is the most commonly encountered symptom associated with dental diseases; thus, it is unsurprising that a similar trend was observed in this study. Nevertheless, it should be noted that swellings with or without fluid discharge constituted a significant proportion of the associated symptoms. This may be related to the high frequency of late presentation among the patients. Without intervention, dental caries often progresses to involve the pulp and thence the periapical tissues. Further spread of the infection may trigger the formation of abscesses which may then result in the development of discharging sinuses. All these possible sequelae of dental caries are typically consequences of delay in seeking treatment.
Apical periodontitis was the single most frequently diagnosed disease in this study, while dental caries, which is classically the precursor to its development, was diagnosed in only three patients. This may be an indication that patients often delay treatment until the condition becomes symptomatic. Therefore, since dental caries is often asymptomatic, they characteristically do not present at this stage of the disease progression.
A large proportion of the patients had explored self-medication before a presentation and this was cited as the most common reason for late presentation. In fact, the single most prominent reason for late presentation in this study was that patients had tried other medications. This observation is at variance with the report of Anyanechi and Saheeb who reported patients' belief that symptoms would resolve on its own as the most common reason for late presentation in their study. Notably, the second most common reason for late presentation reported by Anyanechi and Saheeb was that patients had “tried other medications.”
Importantly, these findings are probably associated with the ease of access to medications by patients without due consultation or prescriptions in our environment. Interestingly, in an Indian study, Nagarjuna et al. reported that patients' assumption that – “dental diseases were not serious enough”-constituted the most frequent reason for late presentation. In this study, a large proportion of the patients believed that the dental problems they had would resolve on its own. This perception may be associated with the degree of severity accorded to dental diseases by the patients.
Furthermore, patients in our climes often have access to antibiotics and analgesics.,, These drugs are often consumed without appropriate patient evaluation nor prescription by relevant healthcare personnel. In a significant proportion of cases, the drugs are recommendation by individuals who do not have the required training to do such. This behavior may also be promoted by the fact that patients frequently avoid or delay visiting the hospitals where appropriate decisions and prescriptions may be made., Thus, they are inclined to explore other purported alternatives to existing orthodox medicosurgical options. Late presentation by patients is a global phenomenon; the reasons for a delay in hospital presentation or complete avoidance of hospitals by patients are multiple, ranging from financial to logistic ones, and these are well stated in the literature.,,,
Fear of dental treatment was also stated as the reason for the late presentation by a significant proportion of the patients. Several authors have identified the fear of dental treatment as a deterrent to seeking dental treatment among different populations. Kakatkar et al. identified fear as a major reason for late presentation in their study. The observation that more females than males presented late on account of fear as a sole factor or in combination with other factors is in agreement with existing studies in the literature. A research has shown that females exhibit higher levels of preoperative anxiety than males;, this may increase the likelihood that they would attempt to avoid hospital visits and therefore delay in seeking health care.
In this study, participants showed varying levels of knowledge about the scope of dental treatments available. Notably, their scope of knowledge was quite narrow. This is in consonance with the report by Rahman, who conducted a cross-sectional study of an Indian population to assess their knowledge of treatment options for edentulousness. He reported a low awareness of the various treatment options. Gbadebo et al. in a Nigerian study also reported a similar finding. However, the settings in which a study is done as well as the socioeconomic characteristics of the participants appear to exert an imposing influence on the results obtained from such studies. This must therefore be taken into cognizance when such studies are considered.
Hence, a dichotomy is often observed between the results of studies conducted in developed countries among persons of high socioeconomic statuses and those conducted in developing countries. This is exemplified by the comparatively high levels of awareness of dental treatment options for edentulousness reported by several authors., Furthermore, poor awareness about the availability of treatment options for their conditions may have contributed to late presentation observed among the participants in this study.
| Conclusion|| |
The reasons for late presentation among patients in our environment vary significantly among patients. Although several factors influence late presentation among patients, self-medication plays a major role in this regard. Hence, there is a need to address all the factors identified and implement relevant policies.
This study would include only patients who attend the outpatient clinic of the Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital. This may result in the exclusion of patients who seek treatment at other dental facilities in the state. The data gathering instrument is a questionnaire. This may limit the variety of responses that may be obtained from respondents. Thus, some information may not be transmitted and may therefore be uncaptured.
Policies that would improve coverage of health insurance, improve regulation of pharmaceutical drug retailers, curb unethical practices by quacks, and generally, improve access to good-quality health care would have tremendous positive impact on the current situation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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