Factors associated with the use of herbal medicines for oral problems by patients attending the clinics of the School of Dentistry, Federal University of Juiz de Fora, Brazil

Aim: To evaluate differences in sociodemographic characteristics (gender, age, educational level and income) between users and nonusers of phytotherapy for dental purposes; the degree of population’s knowledge of herbal medicines for dental needs; and whether patients inform the health professional about their use of phytotherapy. Methods: A questionnaire was applied to 100 patients in waiting rooms of the School of Dentistry of the Federal University of Juiz de Fora, in 2008, to inquire about sociodemographic variables and other factors associated with the use of phytotherapy. Statistical analyses were carried out using the chi square statistical test to calculate association between the variables, with 0.05 as level of significance. Results: It was observed that 64.8% of participants were women with a mean age of 43.9±15.1 years. Phytotheraphy use for treatment of oral problems was reported by 37% of patients interviewed in this study. Significant differences were found between users and non-users of herbal medicines for oral problems, associated with the patient’s age (p<0.05) and previous experience with use of phytotherapy to treat general health problems (p<0.001). Conclusions: The results emphasize the need for more scientific evidence of the efficacy of herbal medicinal products already incorporated in the popular knowledge to treat oral problems in order to make it an accessible and alternative method for prevention and therapy in dentistry.


Introduction
Herbal products have been used since antiquity by humans as a way to reach or recover health. Over the decades, many plants with biological and antimicrobial properties have been studied by pharmaceutical companies as sources for new phytotherapeutic agents 1 . Since the Declaration of the Alma-Ata in 1978, the World Health Organization (WHO) has expressed the need to appreciate the use of medicinal plants in public health systems, as some studies have indicated that almost 80% of world population uses these plants in primary care [2][3] .
In the first US national survey, Eisenberg, et al. 4 reported an increase in the prevalence of the use of complementary and alternative medicine (CAM). In 1990, this prevalence in the American adult population was 33.8% and increased to 42.1% seven years later. As regards people using herbal therapies, the same author detected 10% increase from 1990 to 1997. According to Druss,et al. 5 , the majority of people use CAM therapies in conjunction with the conventional medical treatment. In Brazil, the population and municipal health systems have shown growing interest in the use of CAM since the 1980s. In 2006, the National Policy for Complementary and Integrative Practices within the Brazilian National Health System 6 was established. Among the practices, Traditional Chinese Medicine, Acupuncture, Homeopathy, Phytotherapy (herbal medicines), Anthroposophical Medicine and Thermalism-Crenotherapy have become prominent 6 .
The use of these practices has also been incorporated into Dentistry. Numerous studies have been conducted to evaluate vegetable species in Dentistry, natural agents that are economically feasible and provide effective alternatives for treating oral diseases 1,7-8 . Over the years, the Brazilian population has used different forms of plant extracts to treat diseases of the oral cavity 9 . Singh, et al. 10 showed that the prevalence of oral diseases is high and medicinal plants are increasingly gaining attention because of their antimicrobial properties. Abdulwahab and Al-Kholani 11 confirmed the increasing interest in natural products by presenting a study about a herbal dentifrice tested in a randomized trial, and demonstrating that there was no difference between using this dentifrice in comparison with the traditional one.
Although various studies have evaluated the reasons for and individual factors associated with the use of herbal remedies by primary care patients, the characteristics of the population that use herbal medicines for oral health problems are relatively unknown. However, by means of studies along these lines, health managers and researchers are able to find strategies for future studies on herbal medicines and health professional training. Thus, studies such as those of Tomazzoni et al. 12 are encouraged in Dentistry because they support the inclusion of phytotherapies in the Brazilian public health care system.
The aims of this exploratory study were to evaluate: (1) differences in sociodemographic characteristics (gender, age, educational level and income) between users and nonusers of phytotherapy for dental purposes; (2) the degree of population's knowledge of herbal medicines for dental needs; and (3) whether patients inform the health professional about their use of phytotherapy.

Material and methods
The research project was submitted to and approved by the Research Ethics Committee (Nº 336/2008) of the Federal University of Juiz de Fora, Brazil. The participants' consent was obtained for inclusion in the study.
The study had a cross-sectional research design and the sample was determined by convenience, selected from the patients present in the waiting room of all clinics of the School of Dentistry, Federal University of Juiz de Fora, from August 2008 to November 2008. Juiz de Fora is one of the pioneering cities in the industrial state of Minas Gerais, Brazil, and its predominating economic sectors are industry and services. The city has about 570,000 inhabitants, spread over a wide range of socioeconomic backgrounds, of whom 98.91% have access to fluoridated water 13 .
A self-administered questionnaire was applied by a researcher before the scheduled visit. The survey instrument included questions about the patient's social and demographic characteristics, including age, sex, education, household income and use of phytotherapy for treatment oral and general health conditions (Figure 1).
For participation in the study, patients had to be at least 18 years of age and be under treatment at one of the dental school clinics. Patients who agreed to participate were given the survey questionnaire to complete on their own. The researcher was available onsite to answer any questions the patients had in order to help to improve their understanding of the questionnaire used in the survey.
Descriptive and statistical analyses were performed using SPSS statistical software version 17 (SPSS Inc., Chicago, IL, USA) for data analysis at a 0.05 level of significance. The chisquare test was used to test the association of phytotherapy use for oral health problems and the sociodemographic characteristics of the sample, such as gender, age and use of phytotherapy for other health problems.
1. Do you use phytotherapy for general health problems or treating oral problems? 2. Name of herbal medicine used for dental problems.

Results
Of the 100 eligible study participants, 64.8% were women with a mean age of 43.9 years with standard deviation of ± 15.1 years (age range: 18-78 years). The characteristics of the study sample, the use of phytotherapy for general health problems and its association with use of phytotherapy for oral health problems are summarized in Table 1.
Of all patients interviewed in this study, 71 affirmed that they used phytotherapy for general health problems and 37 were using some form of phytotherapy for treating oral problems.
In the association of phytotherapy with the sociodemographic characteristics of the sample, it was  , infection and swelling   pain, inflammation, swelling   Pain   Pain, infection   pain , infection   pain   inflammation   pain , infection   infection   Pain   Pain   Pain   Pain   Pain   Pain   inflammation   pain and inflammation   Pain   Pain   inflammation   Table 2. List of phytotherapy most commonly used in Dentistry by respondents of the study survey observed that the age group (p<0.05) and use of phytotherapy for general health problems (p<0.001) were found to be significantly associated with use of phytotherapy for oral health problems. The 37 patients using herbal medicines for dental problems mentioned 52 plants, listed in Table 2. The most common phytotherapy products reported as being used at present were Ipomoea batatas and Plantago lanceolata, for pain, inflammation, infection or swelling. Table 3 presents the information about use the phytotherapy for oral health treatment. The main reason for using phytotherapy for oral health treatment was that it was recommended by family tradition (78.4%), and in most cases the plants were obtained the plants were grown by the patients  Table 3. Information about use the phytotherapy for oral health treatment. themselves (56.8%). The users of phytotherapy for oral problems reported consumption of the plant in the form of tea (43.2%), mouthwash and tampons (56.8%). In almost all cases, the duration of use was up to 10 days. All patients who used medicinal plants for oral problems reported satisfaction with this type of treatment and absence of adverse effects. Among them, 54.1% affirmed that they generally informed the health professional (doctor or dentist) in the clinical interview that they were using herbal medicines.
The justifications for not reporting their use to the health professional were, in a descending order: the patient did not think it was important (6 participants); the professional did not ask (4 participants); the plant is not harmful to health (2 participants); tea is simple to take and it does not interfere with treatment (1 participant); some doctors do not like the patient to use medicinal plants (1 participant). Three participants did not justify the reason for not reporting the use of medicinal plants to health professionals.
Among all participants of the research, 94% wanted more information on the therapies with herbal medicines for treating health problems.

Discussion
In the present study it was found that the majority of users of herbal medicines for oral problems were women between the ages of 31 and 64 years, with fewer than 8 years of schooling, and family income less of than two minimum wages. However, gender, educational level and household income were not signiûcantly associated with the use of medical plants for these problems.
This is similar to ûndings by Tam, et al. 14 studying patients treated at dental clinics and dental practices in the U.K., and the study of Elder et al. 15 , which found no significant differences in the use of CAM therapies associated with the above-mentioned variables. On the other hand, Hasan, et al. 16 found signiûcant associations between phytotherapy use for oral problems and age, educational level and income in a study on CAM users. In comparison with descriptive data in another Brazilian study, Santos et al. 17 , observed that the prevalence results were similar: most of the sample were women with family income of fewer than two minimum wages.
One of the most important findings of this study was the strong association (p<0.001) between use of herbal medicines for other general health problems and use for oral problems. As affirmed by Hasan, et al. 16 , the popularity of unconventional therapies indicated an increase in patients' preference for a holistic approach to health care. The research results showed that 71% of participants reported using herbal medicines for general health problems, proving the high popularity of this type of therapy.
This fact makes it important for health professionals to address the use of phytotherapy and unconventional therapies by their patients, by explaining the benefits and limitations of this type of treatment to them, and more importantly to establish whether there are any potential drug interactions or adverse drug reactions. Hasan el al. 16 also proposed that conventional health practitioners should acquire and develop essential skills in the area of CAM practice and its education should be incorporated into the medical and health science curriculum.
The proportion of participants that related the use of phytotherapy for oral diseases was 37%, but it was difficult to make a comparison with other results because there are few similar studies in the literature. In studies evaluating phytotherapy users, the authors found that 53% 9 , 55% 12 , 26% 5 , 50% 10 of the studied samples used herbal medicines for general health problems. Only the study of Santos, et al. 17 presents this data, stating that 80% of participants used herbs for dental problems.
A significant number of patients who reported using herbal medicines for oral health problems omitted this information from their physicians, pharmacists or dentists (45.9%). Similar to the data found by Hasan, et al. 16 , Clay, et al. 18 and Santos, et al. 17 , as these authors verified that 54.6%, 20.6% and 77,5%, respectively, of the patients did not inform their health care professionals about CAM use. In the study of Druss, et al. 5 with patients who used CAM, 91.2% of patients reported that they did not inform the physician of their use of unconventional therapies. When relating these findings to those of the study of Viegas Jr. 19 , one can assume that the reason why many patients do not report the use of herbal health professionals may be due to the culture of selfmedication, very common among Brazilians.
The relevant number of patients who affirmed that they did not inform health professionals of their use of medicinal plants demonstrates their insecurity in discussing their other options of health care treatments in addition to those of traditional medicine. This information confirms the professionals' need to be aware of the profile of the population served and to include questions related to this topic in the patient's medical history in order to attribute the appropriate value to and popularity of the use of herbal medications.
According to the literature, Elder et al. 15 confirmed that it is important for physicians to know about their patients' use of alternative medicine. Eisenberg et al. 4 , affirmed that it is a very common belief worldwide that 'herbal products' are safe. Spector 17 warned that dentists must be better informed of the adverse effects and contraindications of CAM, based on scientific evidences. In a study conducted in a health center, Genovés et al. 22 found that one in every five patients being treated with medicines was also taking herbal medicines by self-medication, confirming that the health authorities and physicians should know and advise the population about the possible risks to health and the contraindications of these products.
Among all participants, 94% wanted to be better informed about these therapies with herbal medicines for health problems, suggesting the need for more scientific evidence to be developed and transmitted to the population about the use of CAM. Little 21 affirmed that clinical trials demonstrated that certain CAM treatments are effective and safe and they can be incorporated into conventional Medicine and Dentistry. Based on their use and popular knowledge, the important growth of phytotherapy within preventive and curative programs has stimulated the evaluation of the action of different plant extracts 23 .
Studies should be conducted and information disseminated to the population. In the present study, 79% of participants used medicinal herbs by family tradition, ignoring scientific data confirming their safety. Begnami and Mialhe 24 found that even with the advancement of pharmaceutical discoveries, the tradition of using medicinal plants was not abandoned. Therefore, this research presents the people's interest in this type of therapy and public health policies, such as the Policy for Complementary and Integrative Practices within the Ministry of Health in Brazil 6 , are valid as regards encouraging the use of herbal medicines.
For Palombo 25 , given the incidence of oral disease, increased resistance of bacteria to antibiotics, adverse affects of some antibacterial agents at present used in dentistry and financial considerations in developing countries, there is a need for alternative prevention and treatment options that are safe, effective and economical. The search for alternative products continues and natural phytochemicals isolated from plants used as traditional medicines are considered good alternatives 1,25 .
However, the data of this research should be interpreted within the context of some limitations. The study was exploratory; the sample does not represent the entire population, since a convenience sample was used instead of identifying patients by a randomized sampling. This study did not include measures of quality of life or questions about patient satisfaction with the use of herbal medication exclusively in order to determine how the treatment with Phytotherapy interfered with patients' quality of life.
From the results of this investigation, it would appear that phytotherapy is a matter of great importance to the population, and is of interest to the different areas of health. Since the first step taken by the WHO in 1978, there have been a growing number of studies on medicinal plants throughout the world. The present study characterized the profile of the patients in the sample using and enjoying herbal remedies for oral problems, allowing new questions to be raised for other researches in this area, collaborating with the planning of public health services in dentistry.
The present study verified that a large number of patients use phytotherapy for the treatment of general health problems, and among them, 37% use it for the treatment of oral health problems. Previous history of use for general problems and the patient's gender were variables associated with use of herbal medicines for oral problems. The development of further studies is necessary to promote scientific evidence of the efficacy and safety of products already enshrined in popular knowledge in order to enable them to become accessible alternatives in public health services for the prevention and treatment of oral health problems. However, dentists need to be aware of their patients' use of herbal remedies, know their potential risks, side effects and possible drug interactions, in order to provide the population with the best care.