1. Introduction
Dental practitioners play a vital role in the effective management of oral pain. When patients present with acute dental pain caused by issues such as dental caries, trauma, or dental procedures, practitioners should conduct a comprehensive examination. After determining the underlying causes and establishing a diagnosis, a tailored treatment plan aimed at alleviating the patient’s pain should be formulated. In certain situations, pharmacotherapy might be involved [
1].
The medications frequently prescribed for acute oral and dental pain include non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and opioids. NSAIDs, such as ibuprofen or nimesulide, are often the first choice for managing oral pain due to their anti-inflammatory and analgesic properties [
2,
3]. Studies have shown that, compared to opioids, NSAIDs demonstrated great pain relief after dental extraction and postoperative endodontic pain [
4,
5,
6]. In cases of severe pain, or where NSAIDs are contraindicated, paracetamol or metamizole, associated with codeine, might be an alternative therapeutic option [
3]. Some studies indicated an increasing trend that dental practitioners are prescribing these drugs more frequently [
7,
8,
9,
10,
11].
Park et al. assessed the longitudinal pattern of the top twenty most prescribed drugs by Australian dental practitioners from 2006 to 2018 [
10]. Over a decade, a significant annual increase in the prescription count was reported for paracetamol + codeine, ibuprofen, and naproxen [
10]. In Croatia, prescriptions of NSAIDs increased by approximately 46% between 2014 to 2018 [
9]. The utilization of ibuprofen, as the preferred NSAID among German dentists, witnessed a notable surge, with the prescription rate rising from 61.9% in 2012 to 88.1% in 2016 [
12]. Ibuprofen was also the most prescribed NSAID in Nigeria, Colombia, and Brazil [
11,
13,
14]. The upward trend in the use of drugs in dentistry reflects improved healthcare accessibility for diverse populations, thereby indicating progress in public health. Nonetheless, inequalities related to access to pain medication have been reported [
14,
15,
16].
Previous literature has demonstrated a positive association between the density of dentists, the percentage of the population accessing dental care within the past year, and household income with higher regional consumption rates of pain medication [
15,
16]. In a cross-sectional survey conducted in the southeastern region of Brazil, it was observed that prescriptions of NSAIDs and analgesics were noticeably lower in cities with limited access to dental healthcare services and few oral health teams [
14]. However, these associations have not been evaluated over the long run.
Drug utilization research offers valuable insights regarding medication use within populations and the temporal fluctuations. Moreover, such research holds pivotal importance in guiding the allocation of healthcare resources and ensuring equitable access to drugs [
17]. Nevertheless, the scarce and fragmented data on drug utilization in numerous developing nations, including Brazil, restricts our comprehension of the population consumption of drugs [
17,
18]. In this context, the objectives of this study were to describe trends of dentist-prescribed NSAIDs, and analgesics distributed through the Brazilian National Health System (BNHS). Additionally, we aimed to examine the relationship between these trends and the characteristics of public oral health services in Minas Gerais, Brazil.
4. Discussion
The analysis, utilizing data from Sigaf, revealed an overall increase in both the prescription count and DDD/1000 inhabitants/year of NSAIDs and analgesics prescribed by dental practitioners and dispensed under the BNHS. Ibuprofen and metamizole were the most frequently prescribed NSAID and analgesic, respectively. At the town-level, a positive association was observed between toothache prevalence and prescriptions of NSAIDs, whereas none of the covariates influenced the rates of analgesic prescriptions. This finding suggests that individual-level factors, such as clinical diagnosis and patient’s pain threshold, may play a significant role in prescribing decisions.
The preference of ibuprofen, over other NSAIDs observed in this study aligns with findings reported elsewhere [
7,
9,
11,
13]. This favorability might stem from ibuprofen’s well-established efficacy, safety profile and low cost. Current evidence demonstrates that, when compared to other NSAIDs, ibuprofen poses a relatively low risk of cardiovascular adverse effects, gastrointestinal bleeding, and renal impairment [
28,
29]. On the other hand, in Minas Gerais, diclofenac prescriptions have been decreasing over time. Similarly, research from Croatia showed a 22% decrease in diclofenac prescriptions [
9], and in Australia there has been a decline in diclofenac consumption [
10]. These trends could be attributed to diclofenac’s higher propensity for inducing adverse events, such as myocardial infarction, stroke, and hepatoxicity. Even with short-term use, diclofenac is recognized as the NSAID most likely to cause severe side effects [
30,
31]. The decrease in diclofenac usage might indicate that dentists are relying on evidence-based information when prescribing. Regardless, it remains crucial to exercise caution when prescribing NSAIDs due to their potential side effects and interactions with other medications. Providers should carefully consider each patient’s medical history, allergies, and any contraindications before prescribing NSAIDs.
Metamizole sodium was the most commonly prescribed analgesic by dental care providers in the towns in Minas Gerais. A nationwide survey, representative of Brazilian households, found that metamizole accounted for 52.8% of the primary drug used for pain relief by the population [
32]. Although some studies suggest that metamizole is a safe choice when compared to other analgesics, such as opioids, it has been banned in several countries due to concerns regarding the risk of agranulocytosis [
33,
34]. In Brazil, metamizole can be purchased both with a prescription and over-the-counter medication. Given the restricted availability of metamizole in many parts of the world, direct comparisons with our data are limited.
The observed growth in NSAID and analgesic prescriptions in our study aligns with international trends of increasing drug utilization to treat painful dental inflammatory conditions. In Australia, Hollingworth et al. examined the patterns of drugs, listed on the Pharmaceutical Benefits Schedule, prescribed to dental patients during the period spanning from 2001 to 2012. Over these 12 years, NSAID prescriptions surged from 4039 in 2001 to 6855 in 2012, marking a nearly 70% increase [
7]. Meanwhile, in Croatia, prescriptions of NSAIDs and analgesics by dental care providers soared between 2014 and 2018, leading to an overall increase of 46% over the five years [
9]. In contrast, Halling et al. reported a decline of 100,000 (3.4%) painkiller prescriptions in Germany from 2012 to 2016 [
12]. These variations among countries may be attributed to various factors, including the distinctive characteristics and scope of public healthcare systems, pain medication availability, and the range of drugs subsidized by governments, whether provided free or requiring copayments.
Dentists prescribe analgesic medications to mitigate the discomfort arising from untreated dental conditions, such as dental caries, periodontal diseases, and oral trauma, as well as pre- and post-operative interventions. Previous research showed a positive association between toothache and the prescription and consumption of pain relievers [
35,
36]. Moeller et al. reported that 10% of residents in British Columbia, Canada, experienced toothache during the study investigated period. Of these, nearly 80% used some painkillers [
35]. Another cross-sectional survey conducted in Iran showed that pain relievers were commonly taken among those with dental pain [
36]. Our findings provided additional evidence to support the positive association between the occurrence of toothache and the prescription of NSAIDs. Given the proven effectiveness of NSAIDs in managing various painful inflammatory dental conditions [
2], it is logical for this class of medication to be a preferred choice among dentists. Interestingly, our study did not detect a significant role of toothache in the prescription of analgesics in the studied towns. These findings suggest the presence of unidentified factors that could potentially influence the prescribing patterns of pain relievers in Minas Gerais.
Other covariates, including population coverage by primary oral health care and estimates of dental procedures, did not exhibit a significant influence on the outcome. These covariates serve as proxy indicators for access to services. A higher number of dental procedures in certain regions suggests improved accessibility to curative dental care. While some cross-sectional studies have indicated a positive association between access to care and increased drug prescriptions [
14,
37], our time-series data analysis did not confirm this relationship with statistical significance. This suggests that additional individual-level factors, such as pain thresholds and clinical diagnoses, may play a central role in influencing dentists’ decisions to prescribe pain relievers [
38,
39]. Further investigations incorporating different covariates are necessary to comprehend the complex interactions pertaining to prescription patterns in dental practice.
This study is subject to inherent limitations commonly encountered in investigations utilizing secondary data, such as the inability to control and ensure data quality. The analysis was restricted to data from a limited number of towns (thirty-eight and forty-three) in the state of Minas Gerais, where NSAIDs and analgesics were prescribed over an eleven-year period. This limitation affects the external validity of the findings. Nonetheless, Sigaf remains a valuable source of information for research, especially given the current scarce and fragmented evidence about the populational usage of drugs in the Latin American region [
17,
18]. The Sigaf database, however, lacks information on specific diagnoses associated with drug prescriptions, making it impossible to evaluate the appropriateness and quality of the drug usage. Despite these drawbacks, to the best of our knowledge, this study represents the first time-series analysis to investigate prescribing patterns and associated factors regarding pain relievers in Brazil. The findings of this study offer insights about drug utilization, which may be particularly valuable for pharmaco-surveillance and can inform the development of strategies aiming to improve equitable and rational access to medication.
Future research should continue monitoring the rise in NSAID and analgesic prescriptions in dental practices, while conducting comparative analyses across diverse geographic regions. It is crucial to explore the factors influencing prescription patterns with a focus on individual-level factors. Furthermore, a comprehensive assessment of the appropriateness of prescribed NSAIDs and analgesics, dosage regimens, and potential interactions with concurrently administered medication is necessary. Addressing these gaps will help enhance the pharmaceutical management of public services and ensure patient safety related to drug utilization.