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Year : 2016  |  Volume : 14  |  Issue : 3  |  Page : 323-326

Assessment of pharmacists' oral health advice to clients without prescription using “By Proxy” method

1 Department of Public Health Dentistry, Bapuji Dental College and Hospital, Davangere, Karnataka, India
2 Department of Preventive Dental Sciences, College of Dentistry, Qassim Private Colleges, Al Qassim, Saudi Arabia

Date of Web Publication6-Sep-2016

Correspondence Address:
Savithra Prakash
Department of Public Health Dentistry, Bapuji Dental College and Hospital, MCC B' B Block, Davangere - 577 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-5932.189839

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Background: In India, people commonly approach pharmacies rather than health professionals for their common ailments including oral health problems. Aim: To assess the type of medication and advice to clients without prescription provided for common oral health problems by pharmacists in Davangere city. Materials and Methods: A cross-sectional survey was conducted in which ten simulated clients visited pharmacy outlets and presented with different oral problems to the pharmacists. The response of the pharmacists was recorded and analyzed. Results: Pharmacists mostly dispensed antibiotics (44.4%), antipyretics (33.4%), mouth wash (60%), and Vitamin B complex (66.6%) for tooth ache, tooth ache with fever, bad breath, and ulcer. Seven pharmacists refused to provide medications without prescription from a dentist. Twenty six (42.6%) pharmacists recommended the subjects to visit a dentist, whereas 35 (57.4%) did not. Conclusion: Pharmacists provided medications to the simulated clients who came without prescription from a dentist. More than half of them did not recommend the clients to visit a dentist.

Keywords: By proxy method, mouth diseases, oral ulcer, pharmacists, simulated clients

How to cite this article:
Prakash S, Potdar S, Lakshminarayan N. Assessment of pharmacists' oral health advice to clients without prescription using “By Proxy” method. J Indian Assoc Public Health Dent 2016;14:323-6

How to cite this URL:
Prakash S, Potdar S, Lakshminarayan N. Assessment of pharmacists' oral health advice to clients without prescription using “By Proxy” method. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2022 Nov 28];14:323-6. Available from: https://www.jiaphd.org/text.asp?2016/14/3/323/189839

  Introduction Top

Community pharmacists are considered as medication experts in the health care team. Pharmacists can play a pivotal role in delivering healthcare. Pharmacists have been reported as the second most used source of advice on general health matters and therefore may also be used in the oral health capacity.[1] The unique position of the pharmacists in healthcare system, their easy access, rigid appointment system to meet health professionals, financial constraints, and lack of time are common reasons for the public to approach pharmacists for health advice.[2],[3],[4]

Chestnutt et al. discussed the potential contribution of pharmacy staff in oral disease prevention, identification, management, and referral. This include promoting the use of topical fluorides and round-ended soft-bristle toothbrushes; encouraging effective oral hygiene practices, healthy eating habits, and use of dental services and preventive therapies; and giving parents/caretakers oral health information, motivation, and basic skills to prevent oral diseases.[5],[6] The role of pharmacists in providing medications and advice for common ailments have been documented previously.[7],[8],[9],[10],[11],[12] However, their role in promoting oral health has not been adequately reported. Hence, a cross-sectional survey was conducted among pharmacists in Davangere city to assess the type of medication and advice provided for common oral health problems.

  Materials and Methods Top

Ethical clearance was procured from the Institutional Review Board. A cross-sectional survey was conducted for 3 months between February and April 2012. List of all pharmacy outlets in Davangere city was obtained from the Drug Control Department, Davangere. From the pool of 305 retail pharmacy outlets in Davangere city, slightly >20% of the population was chosen to compensate for nonresponse. A total of 68 outlets were randomly chosen by lottery method. To avoid the social desirability bias and the design did not permit to seek informed consent from the pharmacists.

A situation of purchasing medicine for mouth diseases was artificially created using simulated clients. Simulated client method was used to evaluate the client provider interaction. Para-dental staff and undergraduate students acted as simulated clients to simulate the clients with different age, gender, socioeconomic status, and education level. These clients were trained before and during pilot study. A pilot study was conducted to ascertain the feasibility of the study and to train the simulated clients. A mock drill of the body language, dressing, tone, and tenure with voice modulation on how to ask for medicines was done in pairs for simulated clients well before they reached the pharmacy.

The simulated clients presented a fictional scenario of oral problems. Two simulated clients aged 21 years described severe tooth ache since 3–4 days; a simulated client aged 55 years described tooth sensitivity after having cold or hot food items since few days; a simulated client aged 22 years described severe tooth ache since 15 days and fever since 3 days; A simulated client aged 26 years complained of bleeding gums while brushing; three simulated clients aged 21 years complained of ulcer in mouth since 3–4 days with pain and burning sensation while having food; a simulated client aged 21 years complained bad breath since few days; a simulated client aged 55 years asked medication for 11-year-old grand child who is suffering from tooth ache since 3–4 days. When simulated clients did not get full information, they elicited answers with few additional questions such as (a) How to use the drug? (b) How many days it has to be used? (c) Are there any side effects for this drug? (d) Do I have to visit Dentist? The simulated clients purchased the drugs dispensed by the pharmacists which were later evaluated for the type of the drugs provided. Conversation between the clients and pharmacists was recorded in mobile phones by simulated clients without the knowledge of pharmacists. Later, the audio recordings were scrutinized to ascertain the exact content of conversation. Required data was collected in a field setting. This information was later sorted out and tabulated. Frequencies and percentages of the qualitative data were generated manually.

  Results Top

All 9 (100%) pharmacists dispensed drug for tooth ache, tooth ache and sensitivity, and ulcer. Out of 68 shops visited by the simulated clients, seven pharmacists (10.3%) refused to give any medications and asked them to return with the prescription from a dentist. All 61 pharmacists who dispensed drug explained about how to use medicines only upon specifically asking how to use it. Except 1 (1.47%) pharmacist, none explained about any side effects of the drug even after asking about side effects. After enquiring whether they have to visit a dentist, only 26 pharmacists recommended visiting [Table 1].
Table 1: Pharmacists' response to oral problems complained by simulated clients without prescription

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Majority of the pharmacists dispensed antibiotics (44.4%), antipyretics (33.4%), mouth wash (60%), and Vitamin B complex (66.6%) for tooth ache, tooth ache with fever, bad breath, and ulcer, respectively. For tooth ache and sensitivity, bleeding gums and medication for others pharmacists distributed desensitizing paste (33.4%), mouth wash (40%) and desensitizing paste (40%), and antipyretics (30%), respectively [Figure 1].
Figure 1: Type of medications dispensed by pharmacists in percentage for various oral problems

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Pharmacists recommended using medicines 1–3 times a day. Fifteen pharmacists did not give directions for how many times the drug has to be used. Duration of the days the medicines was to be used ranged between 1 and 15 days. Antibiotic ofloxacin was advised for 1 day and sensodyne paste for 4 days. Few pharmacists delivered listerine and chlorhexidine mouth washes for halitosis. They also instructed their clients to use it along with hot water, neem stick, lemon, and salt [Table 2]. These unconventional methods of prescriptions are not mentioned anywhere in the literature.
Table 2: Details of medications delivered by the pharmacists

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  Discussion Top

Except a few, majority of the pharmacists dispensed appropriate drugs. However, they did not give correct directions for use, adverse effects of medicines and necessity of visiting a dentist. Many of them advised some unconventional methods of use of medicines which is nowhere found in literature. Pharmacists are one of the most visible and accessible members of the healthcare team for the general public. He is ideally situated to maximize oral health and dental care. Thus, pharmacists must exercise caution in their professional behavior.

A direct question or an interview was to be conducted to assess the type of medication and advise provided to their clients, there was a high tendency for them to answer in a manner that would be viewed favorably by the investigator leading to social desirability bias. Social desirability is the resultant of two factors: Self-deception and others deception. There are several methods to prevent or reduce social desirability bias, including the use of forced choice items, randomized response technique, bogus pipeline, self-administration of the questionnaire, selection of interviewers, and the use of proxy subjects. We employed the proxy subjects' method by training the simulated clients as done in the Van Sickle and Amidi et al. study.[12],[13]

Wrong prescriptions and incorrect directions for use of medicine were a common finding in the study. Dexamethasone for 2 and 5 days; Dologel to be applied topically for bleeding gums; glycerine application for apthous ulcer; to use Listerine mouth wash with hot water. Side effects on long term use of these like staining of teeth and altered taste sensation were never revealed to clients. A majority of them prescribed Vitamin B complex for 3–5 days. Usually, Vitamin B complex tablets are prescribed for a period of 6 months for recurrent apthous stomatitis which is not followed by the pharmacists.[14]

In our study, only 10.3% of the pharmacists advised the clients to visit the dentist when they came without prescription, whereas in a previous study, a higher percentage of clients (94.1%[6] and 24.5%[15]) were advised to visit a dentist when they came without prescription. In a study by Priya et al.,[15] 38% of the pharmacists asked their clients to consult a nearby dentist after dispensing drugs. In our study, we observed 42.6% of such cases.


As a preliminary study in dentistry, this methodology was tested in a small sample (20% of population) which may be a limitation of this study. As The Belmont Report [16] and deontological approach states, we consider that “keeping the participants in dark about the research” as a limitation of the study. However, in the light of Mill,[17] teleological perspective one can consider that no harm is done to the subjects because the subject who is unaware of research cannot feel disrupted or harmed. As the benefits of the situation outweigh the potential for harm, we recorded the conversation. Within the limits of the study design, it was not possible to know whether the drug dispenser was a qualified pharmacist or a pharmacy attendant is another limitation.

  Conclusions and Recommendations Top

In conclusion, pharmacists responded unscientifically with their clients who approached them for oral problems without a prescription. They dispensed drug and did not provide sufficient information about directions to use. Most of all, they did not recommend clients to visit a dentist. We recommend that pharmacists should only dispense the drugs when their clients have prescription and they should also direct them to a dentist for proper oral health care. Further large scale research is recommended using this design and objective which may open new vistas.


We acknowledge the help of the simulated clients rendered during the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ghalamkari HH, Rees J, Saltrese-Taylor A, Ramsden M. Evaluation of pilot health promotion project in pharmacies: Clients' initial views on pharmacists advice. Pharm J 1997;258:314-7.  Back to cited text no. 1
Iwanowicz SL, Marciniak MW, Zeolla MM. Obtaining and providing health information in the community pharmacy setting. Am J Pharm Educ 2006;70:57.  Back to cited text no. 2
Pine CM, Adair PM, Burnside G, Nicoll AD, Gillett A, Borges-Yáñez SA, et al. Barriers to the treatment of childhood caries perceived by dentists working in different countries. Community Dent Health 2004;21 1 Suppl:112-20.  Back to cited text no. 3
Graham L, Stensland S. Pharmacist's Expanding Role in Oral Health and Dental Care. Available from: https://www.secure.pharmacytimes.com/lessons/200406-04.asp. [Last accessed on 2012 Jun 10].  Back to cited text no. 4
Chestnutt IG, Taylor MM, Mallinson EJ. The provision of dental and oral health advice by community pharmacists. Br Dent J 1998;184:532-4.  Back to cited text no. 5
Maunder PE, Landes DP. An evaluation of the role played by community pharmacies in oral healthcare situated in a primary care trust in the north of England. Br Dent J 2005;199:219-23.  Back to cited text no. 6
Igun UA. The knowledge-practice gap: An empirical example from prescription for diarrhoea in Nigeria. J Diarrhoeal Dis Res 1994;12:65-9.  Back to cited text no. 7
Calva J, Bojalil R. Antibiotic use in a periurban community in Mexico: A household and drugstore survey. Soc Sci Med 1996;42:1121-8. Erratum in: 1996;43:1121-8.  Back to cited text no. 8
Rajeswari R, Balasubramanian R, Bose MS, Sekar L, Rahman F. Private pharmacies in tuberculosis control – A neglected link. Int J Tuberc Lung Dis 2002;6:171-3.  Back to cited text no. 9
Marsh VM, Mutemi WM, Muturi J, Haaland A, Watkins WM, Otieno G, et al. Changing home treatment of childhood fevers by training shop keepers in rural Kenya. Trop Med Int Health 1999;4:383-9.  Back to cited text no. 10
Chalker J, Chuc NT, Falkenberg T, Do NT, Tomson G. STD management by private pharmacies in Hanoi: Practice and knowledge of drug sellers. Sex Transm Infect 2000;76:299-302.  Back to cited text no. 11
Van Sickle D. Management of asthma at private pharmacies in India. Int J Tuberc Lung Dis 2006;10:1386-92.  Back to cited text no. 12
Amidi S, Ajamee G, Sadeghi HR, Yourshalmi P, Gharehjeh AM. Dispensing drugs without prescription and treating patients by pharmacy attendants in Shiraz, Iran. Am J Public Health 1978;68:495-7.  Back to cited text no. 13
Volkov I, Rudoy I, Freud T, Sardal G, Naimer S, Peleg R, et al. Effectiveness of Vitamin B12 in treating recurrent aphthous stomatitis: A randomized, double-blind, placebo-controlled trial. J Am Board Fam Med 2009;22:9-16.  Back to cited text no. 14
Priya S, Madan Kumar PD, Ramachandran S. Knowledge and attitudes of pharmacists regarding oral health care and oral hygiene products in Chennai city. Indian J Dent Res 2008;19:104-8.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
Department of Health, Education, and Welfare. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington, DC: OPRR Reports; 1979.  Back to cited text no. 16
Mill JS. Utilitarianism. In: Crisp R, Mill JS, editors. Utilitarianism. New York, NY: Oxford University Press; 1998. p. 47-110.  Back to cited text no. 17


  [Figure 1]

  [Table 1], [Table 2]

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