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Knowledge, attitude and practice of ethnomedicine in common oral and dental diseases in patients attending IIUM dental polyclinic
Available online at www.sciencedirect.com
ScienceDirect Materials Today: Proceedings 16 (2019) 2219–2225
www.materialstoday.com/proceedings
Bio-CAM 2017
Knowledge, attitude and practice of ethnomedicine in common oral and dental diseases in patients attending IIUM dental polyclinic Susi Sukmasaria, Anati Amirah Kamarudina, Tengku Nur Fatihah Ihsan TYa, Noorhazayti Ab Halima a
Kulliyyah of Dentistry, International Islamic University Malaysia. Kuantan Malaysia.
Abstract Information from the user of ethnomedicine is required as the baseline data for further research and to conserve local medicine. To identify the association between knowledge, attitude, and practice (KAP) of ethnomedicine in common oral and dental diseases. A cross-sectional descriptive and analytical study was conducted on patients attending IIUM dental clinic within three months. A total of 87 participants aged 18 and above were conveniently selected to answer quantitative questionnaires. The relationship between knowledge, attitude and practice scores was analysed using Spearman correlation coefficient. The participants were Malay, Chinese, Indian and Others with frequency of 49 (56.3%), 28 (32.2%), 4 (4.6%) and 6 (6.9%), respectively. They were 41.4% male and 58.6% female. 97.7% were educated. The participants were knowledgeable in common oral diseases (96.6%). Knowledge of ethnomedicine was correlated with attitude (rho=0.283, p=0.008) and practice (rho=0.251, p= 0.019), while attitude was correlated with practice (rho=0.436, p=0.000). There was a clear pattern of using ethnomedicine to treat oral and dental diseases with significant correlation between KAP. Therefore, further studies on the efficiency and efficacy of the findings described in this study is highly advisable. Keywords: Knowledge; Attitude; Practice; Ethnomedicine; Common Oral and Dental Diseases
1. Introduction Ethnomedicine is the study of traditional, alternative, folk and indigenous medical practice that is concerned with the cultural interpretation of health, disease and illness. It also addresses the healthcare seeking process and healing practices [1] [2]-[8]. According to Boloor et al., ethnomedicine is also known as alternative, complementary, unconventional or integrative medicine [9]. Generally, ethnomedicine is classified into three: plant-based, environment-based and spiritual healing [3]. Neumann classified ethnomedicine practitioners into four categories, namely spiritual or magico-religious healers, herbalists, technical specialists and traditional birth attendants [10]. * Corresponding author. Tel.: +60179040567 E-mail address: [email protected] 2214-7853 © 2019 Elsevier Ltd. All rights reserved. Selection and/or Peer-review under responsibility of Biomedical and Advanced Materials (Biocam 2017).
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Oral and dental diseases that are commonly experienced are dental caries, gingivitis, periodontitis, oral ulcers, oral thrush, temporomandibular joint diseases and stomatitis [11], [12]. Limitation in seeking dental medication has been an obstacle that has not been fully resolved. There are a variety of reasons, such as ethnographic causes, lack of awareness and high costs [11], [13]. They tend to use alternative treatments such as ethnomedicine. According to P. Pushpangadan and Pradeep K.R., a large part of the undeveloped population are dependent on traditional plant remedies for dental diseases, despite the ease of access of modern medicine [7], [8] . This is observed by Rahimah whereby many Orang Asli villagers seek treatment from their traditional man, and not from modern government dental clinics, even if in pain [13]. Due to unawareness, lack of identification and interest, restricted resources, and difficulty in collection, preparation and preservation procedures, soon, this valuable knowledge passed down from ancestors may disappear. Hence, increasing awareness and obtaining, preserving and conserving the rich sources of ethnomedicine by proper record and identification of methods and practices is critical before it is permanently lost [4], [7]. Information on ethnomedicine is required to identify activities and to gain insight on local practices before carrying out further laboratory research, animal and clinical trials. Traditional knowledge and experiential databases gained from clinical practice are important contributors in increasing the success rate of drug discovery by reducing the time consumed, money spent, and occurrence of toxicity [2], [5], [8], [14]. However, comprehensive knowledge of ethnomedicine, especially in multi-herbal prescriptions is still inadequate. At the present time, drugs are innovated based on ethnomedicine, especially herbal remedies. The knowledge is applied extensively and researcher interest in scientific proof and molecular analysis is growing [15]. It is essential to recognize native healers and time-tested ethnomedical practices, as the loss of local traditions and associated ethnomedicinal information will negatively impact the health of society [8]. The combination of current medicine and ethnomedicinal knowledge may develop a modernized traditional medicine system [8]. In addition to that, with the study of ethnomedicine, we may be able to elevate the chances of these communities to accept and receive good oral health, at least according to their traditional medicine man [6], [13]. By carrying out this research, it is hoped that it will provide useful information on the identification of ethnomedicine practices and encourage further investigations into the use of ethnomedicine, especially using native medicinal plants and herbs. For instance, the use of various oral hygiene practices and local cures for the management of oral maladies, including preparation methods and administration modes leads to sustainable cultivation and preservation of unknown therapeutic plants, helps develop formulations for sustainable use, and provides a foundation for further studies [2], [4]-[6], [14]. Additionally, exact scenarios and trends in medicinal plant use by different ethnic groups can be obtained, despite large differences in application methods [7], [16]. The objective of this study was to know the association between knowledge, attitude, and practise of ethnomedicine in common oral and dental diseases. 2. Materials and Methods The study took place at dental polyclinic of Kulliyyah of Dentistry, International Islamic University Malaysia (IIUM), Kuantan, Malaysia. The targeted group was patients attending IIUM dental polyclinic. This was a crosssectional study done by guided questionnaire. The participants were selected based on a few inclusion criteria, that was only registered patients with the age of 18 and above. Those patients should be able to understand either Malay or English or both languages. The dental team such as dental officers, dental lecturers, dental students and dental staff were excluded from the survey. A total of 87 participants were conveniently selected from IIUM dental polyclinic. The survey was conducted from October until middle of December 2015. Referencing the population size from the total number of patients who attended the IIUM dental polyclinic with confidence level of 95%, sample size was 84. For this study, we managed to collect a sample of 87 participants. Informed consent forms and questionnaires were prepared in two sets of languages, which were English and Malay. The questions were relevant to knowledge, attitude and practice. The questionnaires were divided into two parts. The first part consisted of demographic information such as age, race, marital status and level of education. The second part consisted of quantitative questions on knowledge, attitude, and practice. The questions were to evaluate the understanding of participants on commonly experienced oral and dental diseases.
S. Sukmsari et al. / Materials Today: Proceedings 16 (2019) 2219–2225
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Semi-quantitative questions were provided in the second part of the questionnaire to assess the participants’ knowledge on frequency of oral and dental diseases experienced and the expected time for each disease to heal. Next, four questions on attitude towards ethnomedicine, modern medication and a combination of modern and ethnomedicine in treating common oral dental diseases and their side effects were provided. The questionnaires were constructed as dichotomous, Likert scale. The validity of the questionnaire checked by experts and a pilot study was carried out for face validity. Permission to carry out the survey was granted by the IIUM Research Ethics Committee (IREC) on 1st April 2015. Data compilation and analysis was done using SPSS Version 16. The frequency and percentage of answer scores on knowledge, attitude and practice questions were calculated. As this study involved a non-parametric statistic, Spearman correlation coefficient was used to determine the associations between knowledge, attitude and practice. 3. Results A total of 87 patients attending dental clinic, Kulliyyah of Dentistry, International Islamic University Malaysia (IIUM) participated in this study. The participants’ mean age was 43.53 years (SD = 16.383). Among them, 51 (58.6%) participants were female, while 36 (41.4%) participants were male. The distribution of participants’ race consisted of 49 Malay participants (56.3%), followed by 28 Chinese participants (32.2%), four Indian participants (4.6%) and six other race participants (6.9%). The distribution of participants’ marital status saw a total of 25 single participants (28.7%) and the rest of the participants, 62 (71.3%) married. Level of education was divided into six, namely: literate, primary school, secondary school, pre-university and university with frequency distribution of 2 (2.3%), 6 (6.9%), 34 (39.1%), 6 (6.9%) and 39 (44.8%), respectively. In terms of participants’ income, it was classified into low monthly income, which was below RM1500, moderate monthly income between RM1500 and RM4000, and high monthly income, which was more than RM4000. 55 participants (63.2%) were from low income class, 13 participants (14.9%) from moderate income class and 19 participants (21.8%) from high income class. 3.1. Knowledge of Participants Regarding Common Oral Diseases and Ethnomedicine Our results show that majority of the participants (n=84, 96.6%) had knowledge of common oral and dental diseases. A number of 81 (93.1%), 77 (88.5%), 69 (79.3%), 46 (52.9%), and 61 (70.1%) participants knew about dental caries, gingivitis, periodontitis, oral ulcer, oral thrush and temporomandibular joint disease, respectively. However, 44 participants (50.6%) had no knowledge of oral stomatitis in Table 1 Table 1: Knowledge of participants regarding common oral and dental diseases (N=87).
Statements Knows about common oral and dental diseases Statements Knows about oral and dental diseases: i. Dental caries ii. Gingivitis iii. Periodontitis iv. Oral ulcer v. Oral thrush vi. Temporomandibular joint diseases vii. Oral stomatitis s *the highlighted numbers are highest in frequency
N (%) Yes 84 (96.6%) True
No 3 (3.4%) False
Don’t know
81 (93.1%) 77 (88.5%) 69 (79.3%) 77 (88.5%) 46 (52.9%) 61 (70.1%) 41 (47.1%)
5 (5.7%) 3 (3.4%) 6 (6.9%) 3 (3.4%) 4 (4.6%) 5 (5.7%) 2 (2.3%)
1 (1.1%) 7 (8.0%) 12 (13.8%) 7 (8.0%) 37 (42.5%) 21 (24.1%) 44 (50.6%)
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As shown in table 2, 44 participants (50.6%) knew that each ethnic group such as Malay, Chinese, Indian and Others had their own traditional ways to treat common oral and dental diseases. Plus, 50 participants (57.5%) had knowledge that certain traditional medications were effective to treat common oral and dental diseases, while 41.4% (n=36) knew that certain traditional medications had harmful effects.
Table 2: Knowledge of participants regarding ethnomedicine (N=87)
Statements Knows that each ethnic group has its own traditional ways to treat common oral and dental diseases Knows that certain traditional medications are effective to treat common oral and dental diseases Knows that certain traditional medications have harmful effects *the highlighted numbers are highest in frequency
N (%) True 44 (50.6)
False 2 (2.3)
Don’t know 41 (47.1)
50 (57.5)
9 (10.3)
28 (32.2)
24 (27.6)
27 (31.0)
36 (41.4)
3.2. Attitude of Participants Towards Ethnomedicine As shown in Table 3, 44 participants (50.6%) showed positive attitude towards the effectiveness of traditional medicine in treating common oral and dental diseases. However, majority of the participants (n=83, 95.4%) believed that modern medications are effective in treating common oral and dental diseases and 56 (64.4%) showed positive attitude towards a combination of traditional and modern medications. 36 participants (41.4%) disagreed that traditional medications had harmful effects. Table 3: Attitude of participants regarding ethnomedicine (N=87)
Statements Believes that traditional medications are effective in treating common oral and dental diseases Believes that modern medications are effective in treating common oral and dental diseases Believes that a combination of modern and traditional medications are effective in treating common oral and dental diseases Believes that certain traditional medications have harmful effects *the highlighted numbers are highest in frequency
Agreed 44 (50.6)
N (%) Disagreed 14 (16.1)
Don’t know 29 (33.3)
83 (95.4)
2 (2.3)
2 (2.3)
56 (64.4)
13 (14.9)
18 (20.7)
24 (27.6)
36 (41.4)
27 (31.0)
3.3. Practice of Ethnomedicine Among Participants Based on table 4, out of 87 participants, only 52 participants (59.8%) seldom or always applied traditional medicine practices to treat common oral and dental diseases. Further questions regarding the materials used were asked to participants who answered either ‘Always’ or ‘Seldom’. As shown in table 5, only a few participants used aloe vera (n=4, 7.7%), clove (n=23, 44.2%), ginseng (n=5, 9.6%), guava leaves (n=4, 7.6%), long jack (n=2, 3.8%), shy plants (n=1, 1.9%), miswak sticks (n=15, 28.8%), neem twigs (n=3, 5.8%), peppermint leaves (n=16, 30.8%), piper betel leaves (n=10, 19.2%), charcoal (n=14, 26.9%), milk (n=8, 15.4%), honey (n=13, 25%), and spiritual methods (n=1, 1.9%). Being the mostly used material, salt was used seldom or always by 42 participants (86.5%). Among all the participants, none practised oil pulling. Table 6 shows the reasons 52 participants practise ethnomedicine. Most of the participants agreed that they practised ethnomedicine because of its accessibility, followed by affordability, effectiveness, acceptability and time delay to the hospital or dental clinic
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Table 4: Practice of ethnomedicine among participants (N=87) Statements Practises traditional medicine to treat common oral and dental diseases
Always 9 (10.3)
N (%) Seldom 43 (49.4)
Never 35 (40.2)
Always 1 (1.9) 5 (9.6) 0 (0) 0 (0) 1 (1.9) 0 (0) 6 (11.5) 1 (1.9) 4 (7.6) 4 (7.6) 5 (9.6) 3 (5.7) 7(13.4) 0 (0) 1 (1.9) 15 28.8) 1 (1.9) 4 (7.6)
N (%) Seldom 3 (5.7) 18 (34.6) 5 (9.6) 4 (7.6) 1 (1.9) 1 (1.9) 9 (17.3) 2 (3.8) 12 (23.1) 6 (11.5) 9 (17.3) 5 (9.6) 6 (11.5) 0 (0) 0 (0) 27 (51.9) 9 (17.3) 12(23.1)
Never 48 (92.3) 29 (55.7) 47 (90.3) 48 (92.3) 50 (96.2) 51 (98.1) 37 (71.2) 49 (94.2) 36 (69.2) 42 (80.8) 38 (73.1) 44 (84.6) 39 (75.0) 52 (100) 51 (98.1) 10 (19.2) 42 (80.8) 36 (69.2)
Table 5 Practice of ethnomedicine among participants (N= 52) Statements i. Aloe vera ii. Clove iii. Ginseng iv. Guava leaves v. Long Jack vi. Mimosa pudica vii. Miswak sticks viii. Neem twigs ix. Peppermint leaves x. Piper betel leaves xi. Charcoal xii. Milk xiii. Honey xiv. Oil pulling xv. Ayurveda xvi. Salt xvii. Spiritual xviii. Others *the highlighted numbers are the highest frequency
Table 6 Reasons for participants’ practising ethnomedicine (N=52) Statements
N (%) Yes
Practised traditional medications due to: i. Affordability ii. Accessibility iii. Acceptability iv. Effectiveness v. Delay to hospital / clinic
41 (47.1%) 49 (56.3%) 36 (41.4%) 37 (42.5%) 34 (39.1%)
No 11 (12.6%) 3 (3.4%) 16 (18.4%) 15 (17.2%) 18 (20.7%)
3.3. Association between Knowledge, Attitude and Practice of Ethnomedicine As displayed in table 7, there was a statistically significant correlation between knowledge and attitude towards ethnomedicine (rs= 0.283, p = 0.008), while knowledge and practice were positively correlated (rs= 0.251 and p = 0.019) .Furthermore, there was moderately significant correlation between attitude and practice (rs= 0.436, p = 0.000) of ethnomedicine . Table 7 Correlation between knowledge, attitude and practice of ethnomedicine rs -value
p-value
Knowledge and attitude
+0.283
0.008
Knowledge and practice
+0.251
0.019
Attitude and practice
+0.436
0.000
Variables
*Spearman correlation coefficient
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4. Discussion Ethnomedicine is utilized globally. 87 respondents participated in this study, consisting of 49 Malays, 28 Chinese, four Indians and six other races in line with the Kuantan population percentages except for other races in accordance to Population by Ethnic Pahang (2015). The possible reason for higher number of participants from ‘Other’ races compared to Indian is because the IIUM dental polyclinic is part of the International Islamic University, whereby more internationals come seeking dental treatment compared to other dental facilities around Kuantan city. Although there was a greater number of female (51.8%) respondents compared to male (41.4%), the difference was not too large. Therefore, there was no gender bias during this investigation. Looking at the educational level of the respondents, most of them were well-educated, whereby 45 (51.7%) attended pre-university and university. 71.3% of the participants were married. It can be assumed that they may be able to pass their knowledge to their children in order to preserve the knowledge, attitude and practice of ethnomedicine in treating common oral and dental diseases, as suggested by Singh [17]. All the participants were expected to understand and answer all the questions as per assisted by the investigators. The participants’ experience of common oral and dental diseases helps them to identify, understand and handle or manage the diseases by practising ethnomedicine. However, quite a high number of the participants could not answer the questions about oral thrush and oral stomatitis. The Malaysian terms for stomatitis and oral thrush needed to be clarified to them. As described from the previous study, most of the respondents agreed that their ethnomedicine practices were effective and had no side effects [2], [4], [6], [14], [17]. Only a minority of them were uncertain of the effectiveness of these ethnomedicine practices. Even though most of the participants believed that modern medicine was more effective than traditional medicine, they still agreed that traditional medicine was not harmful and can be used as an alternative medicine when there are some reasons to not seek modern medicine immediately. The participants seemed to still have respect for their ancient medicine practices that they have sourced from several sources. With reference to this finding, it is interesting to know deeper about ethnomedicine in dentistry. Our interest is not only the materials or herbs that can be used, but further exploration regarding what is prescribe and how to apply the traditional medicine historically and in current times. While the materials or herbs used can be investigated in the laboratory via animal or clinical settings, it is more challenging to investigate the original prescription of ancient ethnomedicine in current times. Knowledge, attitude and practice of ethnomedicine are important as it aids in information gathering and exploitation for further research [2], [4], [5], [7], [14], [16]. The results of this study show moderately significant correlation between attitude and practice of ethnomedicine. However, correlation between knowledge of the respondents with attitude and practice of ethnomedicine was statistically significant, though it was weak. Referring to some ethnomedicine studies in the world, the variation of ethnomedicine practices was associated with culture and beliefs about disease causation, presentation of illness, success of modern treatment, and accessibility to traditional healers and health facilities, then the possible reasons that majority of participants have high knowledge and belief of ethnomedicine but not practicing most types of ethnomedicine in Malaysia need to be further investigate. 5. CONCLUSION In conclusion, the study was successfully carried out to assess the association between knowledge, attitude and practice of ethnomedicine in treating common oral and dental diseases. The results of this research show that knowledge of ethnomedicine among participants was correlated with attitude and practice. They were know and believe that certain oral and dental diseases can be treated by a variety of ethnomedicine practices. 6. Acknowledgement The publication of this study is under International Islamic Univerisity grant 2016: RIGS16-325-048
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References [1] C. N. Herndon, M. Uiterloo, A. Uremaru, M. J. Plotkin, G. Emanuels-Smith, and J. Jitan, Disease concepts and treatment by tribal healers of an Amazonian forest culture, Journal of Ethnobiology and Ethnomedicine., 5 (2009) 27. [2] G. Meyer-Hamme, K. Beckmann, J. Radtke, T. Efferth, H. J. Greten, M. Rostock, and S. Schröder, A survey of chinese medicinal herbal treatment for chemotherapy-induced oral mucositis, Evid Based Complement Alternat Med. 4(2013) 1–16. [3] L. Williams, Ethnomedicine, West Indian Medical Journal, 55 (2006). [4] M. Jose, V. Pai, M. Shantaram, and M. Cyriac, Antimicrobial properties of coconut husk aqueous extract on cariogenic bacteria., Archives of Medicine and Health Sciences 1 (2013) 126. [5] M. Rahmatullah, W. Haq, R. Jahan, A. Biswas and S. Seraj, An ethnomedicinal survey of cucurbitaceae family plants used in the folk medicinal practices of Bangladesh 1, Chronicles of Young Scientists 3 (2012) 212. [6] M. Adnan, I. Ullah, A. Tariq, W. Murad, A. Azizullah, A. Khan, and N. Ali, Ethnomedicine use in the war affected region of northwest Pakistan., Journal of Ethnobiology and Ethnomedicine 10 (2014) 16. [7] P. Kumar, Ethno medicinal plants used for oral health care in India, International Journal of Herbal Medicine 2 (2014) 1–7. [8] P. Pusphangadan and V. George, Ethnomedical practices of rural and tribal populations of India with special reference to the mother and childcare, Indian Journal of Traditional Knowledge, 9 (2017) 1–8. [9] V. A. Boloor, R. Hosadurga, A. Rao, H. Jenifer, and S. Pratap, Unconventional Dentistry in India – An Insight into the Traditional Methods., Journal of Traditional and Complementary Medicine 4 (2014) 153–158. [10] A. K. Neumann and P. Lauro, Ethnomedicine and biomedicine linking, Social Science & Medicine 16 (1982) 1817–1824. [11] T. Sarumathi, B. Saravanakumar, M. Datta, and T. Nagarathnam, Awareness and Knowledge of Common Oral Diseases Among Primary Care Physicians, Journal of Clinical and Diagnostic Research, 7(4) (2013) 768–771. [12] P. Deep, Screening for Common Oral Diseases, Journal of the Canadian Dental Association, 6(66) (2000) 1–2. [13] R. Saub and N. Jaafar, A dental-anthropological study of health and illness behaviour among Orang Asli of the Semai Tribe: the perspective of traditional healers, Med. J. Malaysia 56 (2001) 401–407. [14] J. B. Taheri, S. Azimi, N. Rafieian, and H. Akhavan Zanjani, Herbs in dentistry, International Dental Journal, 61 (2011) 287–296. [15] K. G. Ramawat, Ed., Herbal Drugs: Ethnomedicine to Modern Medicine. Berlin, Heidelberg: Springer Berlin Heidelberg, (2009) 1–27. [16] H. C. Ong, R. M. Zuki, and P. Milow, Traditional Knowledge of Medicinal Plants among the Malay Villagers in Kampung Mak Kemas, Terengganu, Malaysia, (2011) 1–11. [17] S. J. K. A, Budhiraja Hooda, Ethnomedicine: use in dental caries, Brazilian J Oral Sciences, 6 (2007) 1–5.
ScienceDirect Materials Today: Proceedings 16 (2019) 2219–2225
www.materialstoday.com/proceedings
Bio-CAM 2017
Knowledge, attitude and practice of ethnomedicine in common oral and dental diseases in patients attending IIUM dental polyclinic Susi Sukmasaria, Anati Amirah Kamarudina, Tengku Nur Fatihah Ihsan TYa, Noorhazayti Ab Halima a
Kulliyyah of Dentistry, International Islamic University Malaysia. Kuantan Malaysia.
Abstract Information from the user of ethnomedicine is required as the baseline data for further research and to conserve local medicine. To identify the association between knowledge, attitude, and practice (KAP) of ethnomedicine in common oral and dental diseases. A cross-sectional descriptive and analytical study was conducted on patients attending IIUM dental clinic within three months. A total of 87 participants aged 18 and above were conveniently selected to answer quantitative questionnaires. The relationship between knowledge, attitude and practice scores was analysed using Spearman correlation coefficient. The participants were Malay, Chinese, Indian and Others with frequency of 49 (56.3%), 28 (32.2%), 4 (4.6%) and 6 (6.9%), respectively. They were 41.4% male and 58.6% female. 97.7% were educated. The participants were knowledgeable in common oral diseases (96.6%). Knowledge of ethnomedicine was correlated with attitude (rho=0.283, p=0.008) and practice (rho=0.251, p= 0.019), while attitude was correlated with practice (rho=0.436, p=0.000). There was a clear pattern of using ethnomedicine to treat oral and dental diseases with significant correlation between KAP. Therefore, further studies on the efficiency and efficacy of the findings described in this study is highly advisable. Keywords: Knowledge; Attitude; Practice; Ethnomedicine; Common Oral and Dental Diseases
1. Introduction Ethnomedicine is the study of traditional, alternative, folk and indigenous medical practice that is concerned with the cultural interpretation of health, disease and illness. It also addresses the healthcare seeking process and healing practices [1] [2]-[8]. According to Boloor et al., ethnomedicine is also known as alternative, complementary, unconventional or integrative medicine [9]. Generally, ethnomedicine is classified into three: plant-based, environment-based and spiritual healing [3]. Neumann classified ethnomedicine practitioners into four categories, namely spiritual or magico-religious healers, herbalists, technical specialists and traditional birth attendants [10]. * Corresponding author. Tel.: +60179040567 E-mail address: [email protected] 2214-7853 © 2019 Elsevier Ltd. All rights reserved. Selection and/or Peer-review under responsibility of Biomedical and Advanced Materials (Biocam 2017).
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Oral and dental diseases that are commonly experienced are dental caries, gingivitis, periodontitis, oral ulcers, oral thrush, temporomandibular joint diseases and stomatitis [11], [12]. Limitation in seeking dental medication has been an obstacle that has not been fully resolved. There are a variety of reasons, such as ethnographic causes, lack of awareness and high costs [11], [13]. They tend to use alternative treatments such as ethnomedicine. According to P. Pushpangadan and Pradeep K.R., a large part of the undeveloped population are dependent on traditional plant remedies for dental diseases, despite the ease of access of modern medicine [7], [8] . This is observed by Rahimah whereby many Orang Asli villagers seek treatment from their traditional man, and not from modern government dental clinics, even if in pain [13]. Due to unawareness, lack of identification and interest, restricted resources, and difficulty in collection, preparation and preservation procedures, soon, this valuable knowledge passed down from ancestors may disappear. Hence, increasing awareness and obtaining, preserving and conserving the rich sources of ethnomedicine by proper record and identification of methods and practices is critical before it is permanently lost [4], [7]. Information on ethnomedicine is required to identify activities and to gain insight on local practices before carrying out further laboratory research, animal and clinical trials. Traditional knowledge and experiential databases gained from clinical practice are important contributors in increasing the success rate of drug discovery by reducing the time consumed, money spent, and occurrence of toxicity [2], [5], [8], [14]. However, comprehensive knowledge of ethnomedicine, especially in multi-herbal prescriptions is still inadequate. At the present time, drugs are innovated based on ethnomedicine, especially herbal remedies. The knowledge is applied extensively and researcher interest in scientific proof and molecular analysis is growing [15]. It is essential to recognize native healers and time-tested ethnomedical practices, as the loss of local traditions and associated ethnomedicinal information will negatively impact the health of society [8]. The combination of current medicine and ethnomedicinal knowledge may develop a modernized traditional medicine system [8]. In addition to that, with the study of ethnomedicine, we may be able to elevate the chances of these communities to accept and receive good oral health, at least according to their traditional medicine man [6], [13]. By carrying out this research, it is hoped that it will provide useful information on the identification of ethnomedicine practices and encourage further investigations into the use of ethnomedicine, especially using native medicinal plants and herbs. For instance, the use of various oral hygiene practices and local cures for the management of oral maladies, including preparation methods and administration modes leads to sustainable cultivation and preservation of unknown therapeutic plants, helps develop formulations for sustainable use, and provides a foundation for further studies [2], [4]-[6], [14]. Additionally, exact scenarios and trends in medicinal plant use by different ethnic groups can be obtained, despite large differences in application methods [7], [16]. The objective of this study was to know the association between knowledge, attitude, and practise of ethnomedicine in common oral and dental diseases. 2. Materials and Methods The study took place at dental polyclinic of Kulliyyah of Dentistry, International Islamic University Malaysia (IIUM), Kuantan, Malaysia. The targeted group was patients attending IIUM dental polyclinic. This was a crosssectional study done by guided questionnaire. The participants were selected based on a few inclusion criteria, that was only registered patients with the age of 18 and above. Those patients should be able to understand either Malay or English or both languages. The dental team such as dental officers, dental lecturers, dental students and dental staff were excluded from the survey. A total of 87 participants were conveniently selected from IIUM dental polyclinic. The survey was conducted from October until middle of December 2015. Referencing the population size from the total number of patients who attended the IIUM dental polyclinic with confidence level of 95%, sample size was 84. For this study, we managed to collect a sample of 87 participants. Informed consent forms and questionnaires were prepared in two sets of languages, which were English and Malay. The questions were relevant to knowledge, attitude and practice. The questionnaires were divided into two parts. The first part consisted of demographic information such as age, race, marital status and level of education. The second part consisted of quantitative questions on knowledge, attitude, and practice. The questions were to evaluate the understanding of participants on commonly experienced oral and dental diseases.
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Semi-quantitative questions were provided in the second part of the questionnaire to assess the participants’ knowledge on frequency of oral and dental diseases experienced and the expected time for each disease to heal. Next, four questions on attitude towards ethnomedicine, modern medication and a combination of modern and ethnomedicine in treating common oral dental diseases and their side effects were provided. The questionnaires were constructed as dichotomous, Likert scale. The validity of the questionnaire checked by experts and a pilot study was carried out for face validity. Permission to carry out the survey was granted by the IIUM Research Ethics Committee (IREC) on 1st April 2015. Data compilation and analysis was done using SPSS Version 16. The frequency and percentage of answer scores on knowledge, attitude and practice questions were calculated. As this study involved a non-parametric statistic, Spearman correlation coefficient was used to determine the associations between knowledge, attitude and practice. 3. Results A total of 87 patients attending dental clinic, Kulliyyah of Dentistry, International Islamic University Malaysia (IIUM) participated in this study. The participants’ mean age was 43.53 years (SD = 16.383). Among them, 51 (58.6%) participants were female, while 36 (41.4%) participants were male. The distribution of participants’ race consisted of 49 Malay participants (56.3%), followed by 28 Chinese participants (32.2%), four Indian participants (4.6%) and six other race participants (6.9%). The distribution of participants’ marital status saw a total of 25 single participants (28.7%) and the rest of the participants, 62 (71.3%) married. Level of education was divided into six, namely: literate, primary school, secondary school, pre-university and university with frequency distribution of 2 (2.3%), 6 (6.9%), 34 (39.1%), 6 (6.9%) and 39 (44.8%), respectively. In terms of participants’ income, it was classified into low monthly income, which was below RM1500, moderate monthly income between RM1500 and RM4000, and high monthly income, which was more than RM4000. 55 participants (63.2%) were from low income class, 13 participants (14.9%) from moderate income class and 19 participants (21.8%) from high income class. 3.1. Knowledge of Participants Regarding Common Oral Diseases and Ethnomedicine Our results show that majority of the participants (n=84, 96.6%) had knowledge of common oral and dental diseases. A number of 81 (93.1%), 77 (88.5%), 69 (79.3%), 46 (52.9%), and 61 (70.1%) participants knew about dental caries, gingivitis, periodontitis, oral ulcer, oral thrush and temporomandibular joint disease, respectively. However, 44 participants (50.6%) had no knowledge of oral stomatitis in Table 1 Table 1: Knowledge of participants regarding common oral and dental diseases (N=87).
Statements Knows about common oral and dental diseases Statements Knows about oral and dental diseases: i. Dental caries ii. Gingivitis iii. Periodontitis iv. Oral ulcer v. Oral thrush vi. Temporomandibular joint diseases vii. Oral stomatitis s *the highlighted numbers are highest in frequency
N (%) Yes 84 (96.6%) True
No 3 (3.4%) False
Don’t know
81 (93.1%) 77 (88.5%) 69 (79.3%) 77 (88.5%) 46 (52.9%) 61 (70.1%) 41 (47.1%)
5 (5.7%) 3 (3.4%) 6 (6.9%) 3 (3.4%) 4 (4.6%) 5 (5.7%) 2 (2.3%)
1 (1.1%) 7 (8.0%) 12 (13.8%) 7 (8.0%) 37 (42.5%) 21 (24.1%) 44 (50.6%)
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As shown in table 2, 44 participants (50.6%) knew that each ethnic group such as Malay, Chinese, Indian and Others had their own traditional ways to treat common oral and dental diseases. Plus, 50 participants (57.5%) had knowledge that certain traditional medications were effective to treat common oral and dental diseases, while 41.4% (n=36) knew that certain traditional medications had harmful effects.
Table 2: Knowledge of participants regarding ethnomedicine (N=87)
Statements Knows that each ethnic group has its own traditional ways to treat common oral and dental diseases Knows that certain traditional medications are effective to treat common oral and dental diseases Knows that certain traditional medications have harmful effects *the highlighted numbers are highest in frequency
N (%) True 44 (50.6)
False 2 (2.3)
Don’t know 41 (47.1)
50 (57.5)
9 (10.3)
28 (32.2)
24 (27.6)
27 (31.0)
36 (41.4)
3.2. Attitude of Participants Towards Ethnomedicine As shown in Table 3, 44 participants (50.6%) showed positive attitude towards the effectiveness of traditional medicine in treating common oral and dental diseases. However, majority of the participants (n=83, 95.4%) believed that modern medications are effective in treating common oral and dental diseases and 56 (64.4%) showed positive attitude towards a combination of traditional and modern medications. 36 participants (41.4%) disagreed that traditional medications had harmful effects. Table 3: Attitude of participants regarding ethnomedicine (N=87)
Statements Believes that traditional medications are effective in treating common oral and dental diseases Believes that modern medications are effective in treating common oral and dental diseases Believes that a combination of modern and traditional medications are effective in treating common oral and dental diseases Believes that certain traditional medications have harmful effects *the highlighted numbers are highest in frequency
Agreed 44 (50.6)
N (%) Disagreed 14 (16.1)
Don’t know 29 (33.3)
83 (95.4)
2 (2.3)
2 (2.3)
56 (64.4)
13 (14.9)
18 (20.7)
24 (27.6)
36 (41.4)
27 (31.0)
3.3. Practice of Ethnomedicine Among Participants Based on table 4, out of 87 participants, only 52 participants (59.8%) seldom or always applied traditional medicine practices to treat common oral and dental diseases. Further questions regarding the materials used were asked to participants who answered either ‘Always’ or ‘Seldom’. As shown in table 5, only a few participants used aloe vera (n=4, 7.7%), clove (n=23, 44.2%), ginseng (n=5, 9.6%), guava leaves (n=4, 7.6%), long jack (n=2, 3.8%), shy plants (n=1, 1.9%), miswak sticks (n=15, 28.8%), neem twigs (n=3, 5.8%), peppermint leaves (n=16, 30.8%), piper betel leaves (n=10, 19.2%), charcoal (n=14, 26.9%), milk (n=8, 15.4%), honey (n=13, 25%), and spiritual methods (n=1, 1.9%). Being the mostly used material, salt was used seldom or always by 42 participants (86.5%). Among all the participants, none practised oil pulling. Table 6 shows the reasons 52 participants practise ethnomedicine. Most of the participants agreed that they practised ethnomedicine because of its accessibility, followed by affordability, effectiveness, acceptability and time delay to the hospital or dental clinic
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Table 4: Practice of ethnomedicine among participants (N=87) Statements Practises traditional medicine to treat common oral and dental diseases
Always 9 (10.3)
N (%) Seldom 43 (49.4)
Never 35 (40.2)
Always 1 (1.9) 5 (9.6) 0 (0) 0 (0) 1 (1.9) 0 (0) 6 (11.5) 1 (1.9) 4 (7.6) 4 (7.6) 5 (9.6) 3 (5.7) 7(13.4) 0 (0) 1 (1.9) 15 28.8) 1 (1.9) 4 (7.6)
N (%) Seldom 3 (5.7) 18 (34.6) 5 (9.6) 4 (7.6) 1 (1.9) 1 (1.9) 9 (17.3) 2 (3.8) 12 (23.1) 6 (11.5) 9 (17.3) 5 (9.6) 6 (11.5) 0 (0) 0 (0) 27 (51.9) 9 (17.3) 12(23.1)
Never 48 (92.3) 29 (55.7) 47 (90.3) 48 (92.3) 50 (96.2) 51 (98.1) 37 (71.2) 49 (94.2) 36 (69.2) 42 (80.8) 38 (73.1) 44 (84.6) 39 (75.0) 52 (100) 51 (98.1) 10 (19.2) 42 (80.8) 36 (69.2)
Table 5 Practice of ethnomedicine among participants (N= 52) Statements i. Aloe vera ii. Clove iii. Ginseng iv. Guava leaves v. Long Jack vi. Mimosa pudica vii. Miswak sticks viii. Neem twigs ix. Peppermint leaves x. Piper betel leaves xi. Charcoal xii. Milk xiii. Honey xiv. Oil pulling xv. Ayurveda xvi. Salt xvii. Spiritual xviii. Others *the highlighted numbers are the highest frequency
Table 6 Reasons for participants’ practising ethnomedicine (N=52) Statements
N (%) Yes
Practised traditional medications due to: i. Affordability ii. Accessibility iii. Acceptability iv. Effectiveness v. Delay to hospital / clinic
41 (47.1%) 49 (56.3%) 36 (41.4%) 37 (42.5%) 34 (39.1%)
No 11 (12.6%) 3 (3.4%) 16 (18.4%) 15 (17.2%) 18 (20.7%)
3.3. Association between Knowledge, Attitude and Practice of Ethnomedicine As displayed in table 7, there was a statistically significant correlation between knowledge and attitude towards ethnomedicine (rs= 0.283, p = 0.008), while knowledge and practice were positively correlated (rs= 0.251 and p = 0.019) .Furthermore, there was moderately significant correlation between attitude and practice (rs= 0.436, p = 0.000) of ethnomedicine . Table 7 Correlation between knowledge, attitude and practice of ethnomedicine rs -value
p-value
Knowledge and attitude
+0.283
0.008
Knowledge and practice
+0.251
0.019
Attitude and practice
+0.436
0.000
Variables
*Spearman correlation coefficient
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4. Discussion Ethnomedicine is utilized globally. 87 respondents participated in this study, consisting of 49 Malays, 28 Chinese, four Indians and six other races in line with the Kuantan population percentages except for other races in accordance to Population by Ethnic Pahang (2015). The possible reason for higher number of participants from ‘Other’ races compared to Indian is because the IIUM dental polyclinic is part of the International Islamic University, whereby more internationals come seeking dental treatment compared to other dental facilities around Kuantan city. Although there was a greater number of female (51.8%) respondents compared to male (41.4%), the difference was not too large. Therefore, there was no gender bias during this investigation. Looking at the educational level of the respondents, most of them were well-educated, whereby 45 (51.7%) attended pre-university and university. 71.3% of the participants were married. It can be assumed that they may be able to pass their knowledge to their children in order to preserve the knowledge, attitude and practice of ethnomedicine in treating common oral and dental diseases, as suggested by Singh [17]. All the participants were expected to understand and answer all the questions as per assisted by the investigators. The participants’ experience of common oral and dental diseases helps them to identify, understand and handle or manage the diseases by practising ethnomedicine. However, quite a high number of the participants could not answer the questions about oral thrush and oral stomatitis. The Malaysian terms for stomatitis and oral thrush needed to be clarified to them. As described from the previous study, most of the respondents agreed that their ethnomedicine practices were effective and had no side effects [2], [4], [6], [14], [17]. Only a minority of them were uncertain of the effectiveness of these ethnomedicine practices. Even though most of the participants believed that modern medicine was more effective than traditional medicine, they still agreed that traditional medicine was not harmful and can be used as an alternative medicine when there are some reasons to not seek modern medicine immediately. The participants seemed to still have respect for their ancient medicine practices that they have sourced from several sources. With reference to this finding, it is interesting to know deeper about ethnomedicine in dentistry. Our interest is not only the materials or herbs that can be used, but further exploration regarding what is prescribe and how to apply the traditional medicine historically and in current times. While the materials or herbs used can be investigated in the laboratory via animal or clinical settings, it is more challenging to investigate the original prescription of ancient ethnomedicine in current times. Knowledge, attitude and practice of ethnomedicine are important as it aids in information gathering and exploitation for further research [2], [4], [5], [7], [14], [16]. The results of this study show moderately significant correlation between attitude and practice of ethnomedicine. However, correlation between knowledge of the respondents with attitude and practice of ethnomedicine was statistically significant, though it was weak. Referring to some ethnomedicine studies in the world, the variation of ethnomedicine practices was associated with culture and beliefs about disease causation, presentation of illness, success of modern treatment, and accessibility to traditional healers and health facilities, then the possible reasons that majority of participants have high knowledge and belief of ethnomedicine but not practicing most types of ethnomedicine in Malaysia need to be further investigate. 5. CONCLUSION In conclusion, the study was successfully carried out to assess the association between knowledge, attitude and practice of ethnomedicine in treating common oral and dental diseases. The results of this research show that knowledge of ethnomedicine among participants was correlated with attitude and practice. They were know and believe that certain oral and dental diseases can be treated by a variety of ethnomedicine practices. 6. Acknowledgement The publication of this study is under International Islamic Univerisity grant 2016: RIGS16-325-048
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