Using Herbal Medicine for Dental Pain in Saudi Arabia: Prevalence and Knowledge Assessment

a Restorative and Dental Materials Department, Faculty of Dentistry, Taif University P.O Box 11099 Taif, 21944, Saudi Arabia. b for Medical Studies, Jeddah, Kingdom of Saudi Arabia. c King Khalid University, Abha, Saudi Arabia. d Ministry of Health, Najran, Saudi Arabia. e Umm Al Qura University, Makkah, Saudi Arabia. f Ministry of Health, Saudi Arabia. g Ibn Sina National College, Jeddah, Saudi Arabi. h PGD in Endo, Ministry of Health, Kingdom of Saudi Arabia.


INTRODUCTION
Herbal medicine or Traditional medicine (TM) is known as "complementary and alternative medicine" (CAM) in some countries. The World Health Organization (WHO) defines TM as "the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures" [1]. Herbal medicinal products are a common component of CAM [2]. The Knowledge among Arabs relies on centuries of faith, observations, and a wealth of history in medicine [3]. The dental community has started to use natural plant properties to relieve dental pain [4]. Although, the prognosis of medicinal plant could be delayed, but its healing impact is miraculous [5].
On the other hand, traditional home solutions and medical data aid from google have been used during the COVID 19 pandemic lock-downs at critical times by patients at home for emergency oral problems and dental pain relief [6]. However, there are still limitation in evidence that prove their applications and implication [4]. The history of traditional medicine can be traced back to early civilizations, which were shared with the next generation since they were a significant source of healthcare. Traditional medicine was used to cure medical problems; however, an increasing trend of TM in dentistry was performed to reduce tooth pain, oral mucosal illnesses, and periodontal inflammation [7].
According to the WHO, 80% of people throughout the world depend on their basic health needs on herbal medicine. 25 percent of medical medicinal products are derived from plants in developed countries [8]. The Prevalence of using complementary alternative medicines (CAM) increases. In 1990, this frequency of adults in the US reached 33.8% and years later to 42.1%. As far as individuals are concerned, from 1990 to 1997 [9]. Herbs have been often used to control and prevent dental diseases for decades. Herbal extracts are useful as they react inside the body with certain chemical receptors. Herbal medications have minimal adverse effects, but side effects do exist Compared with conventional drugs. The main issue and concern is the shortage of knowledge on the effects of herbal medicine on the oral cavity [10]. In the limited resources region, the prevalence of illness rate has been increased, and that is the reason why the therapeutic methods with their alternative prevention are in high demand worldwide for dental disorders that are considered safe, efficient and affordable [11]. Moreover, antibiotic resistance is a result of the frequent consumption of contemporary medications. So, alleviating or suppressing serious disorders by dietary supplements derived from herbs are progressively being integrated to maintain body and dental health [12]. Thus, the studies for substitute options continue, with natural phytochemicals obtained from plants used in traditional medicine being considered excellent substitutes for synthetic compounds [11].
Even though, before CAM product utilization for oral health, dentist consultation should be taken to decrease adverse impact and unpredictable interaction of medication, even if it has a wide range of treatments throughout the world [13]. The reason for conducting this topic is that in the field of dentistry, a favorable outcome manifestation with the herbal medicine usage [14]. compared with chemical components drug [15]. Several previous studies in dentistry about the benefit of herbal medicinal products claim that herbal products could be employed as alternative medicinal drug materials. Worldwide, mainly in regions with limited resources, an alternative and herbal remedy can be a beneficial aid to the people [14].
Besides their significant serious side effect, Herb's ingredients should be chosen wisely [2]. However, many studies are conducted to find out the herb's information due to the lack of randomized controlled clinical trials [16]. The aim of this study was to assess the prevalence and the knowledge of the effect of using herbal medicine for dental pain among Saudi population.

MATERIALS AND METHODS
This is an observational cross-sectional study was conducted in Saudi Arabia between September 2020 and October 2021. based on a structured questionnaire among Saudi populations. The study's population consisted of Saudi males and females using herbal medicine within the age group 20-80 years old and individuals who agree to participate in the study, from all regions of the kingdom of Saudi Arabia. Adolescence younger than 20 years old and older than 80 years old Saudi males and females, the individuals who have psychological disorders and who disagree to participate in the study were excluded. The sample dimensions were calculated with a calculator Qualtrics of 95%, a sample size of 384.

Data Collection and Tool
Structured self-administrated questionnaires in English and Arabic languages was used as a study tool. Authors collected the information using social media channels through google forms. The questionnaire includes demographic features such as (age, gender, educational level and income status). However, the questions are about assessing the knowledge about herbs, the use of herbal medicine and the source of recommendation to use them. The participants asked to list any natural herbs they currently use, additional questions about systemic health and if the participant is currently diagnosed with any medical condition, and if they are using over-thecounter medication. The last part aimed at assessing the participant's knowledge about the side effects of some of the most used herbs in Saudi Arabia. This includes clove oil, ginger, garlic, and myrrh, etc.

Statistical Analysis
SPSS 26 was used for data entry and data analysis. Descriptive statistics: Categorical variables including primary variables was described using frequencies and Continuous variables for normally distributed data was described using mean and SD. Inferential statistics: Univariate analysis was conducted for categorical variable using Chi-square test to check for all the possible risk factors The prevalence was given in percentage with 95% confidence level. Tests with a P-value < 0.05 was considered significant.

RESULTS
According to table (1); The study included 4213 participants. 25% of study sample were males and 75% were females. 51.6% aged between 20-30 years old. 32% of all participants were from western region in the kingdom. Only 67% had university education. 90% live in the city and 10% live in a village. 44.1% had low family income, 16.4% moderate and 16.2% had high income.
In table (2); 61.8% of all participants use herbs to relieve toothache (82% of them use clove or clove oil and 36% use thyme). During the COVID-19 ban period, herbs were used as an emergency solution to relieve dental pain by 39.6% of participants (Fig. 1).
84.2% have Relatives and friends use herbs for toothache relief. 62.8% Advise relatives and friends to use herbs to relieve toothache. 73.1% of participants reported that Level of pain or inflammation decreased after using herbs while 8.7% reported increased Level of pain or inflammation after using herbs. 54.4% of all participants Think herbs are safe and free from side effects in treating toothache. 8% noticed side effects or damage while using herbs to relieve dental pain (27% of them swelling, 21% sharp stomach pain, 21% hypersensitive and 17% bleeding).
Regarding source of information about herbal medicine, 74% reported relatives and friends as source of information, 42% old habits, 23% social media and only 1% reported dentist as source of information.
In Table (3); the use of herbs to relieve toothache was significantly associated with gender, age, residence area and average monthly income.

DISCUSSION
Dental health is linked to a higher standard of living that goes beyond the functions of the craniofacial complex. Systemic circumstances have the potential to affect the relationship between biofilm and the inflammatory response, as well as the progression and severity of periodontal disease. The unhealthy teeth may eventually be lost as a result of this procedure [17,18].
Herbal medicine with medical properties has been used for an extended period to prevent and treat various diseases of dental disease. Herbal medicine is useful in preventing cavity, toothache, gingivitis, mouth ulcers, swollen tonsil, oral thrush and hairy tongue [19]. The natural photochemical might be a viable alternative to antibiotics, as well as a potential strategy for preventing and treating numerous oral infections. Herbal medicines offer an advantage over conventional antibiotics, which have a low benefit to high danger ratio compared to herbal therapies, which have a high benefit to low-risk ratio [20].
Herbal extracts are useful because they interact with certain chemical receptors in the body and, in a pharmacodynamic sense, are medications in their own right. Their potency might vary. As a result, while picking herbs, attention must be given to examine the effect of herbs on oral tissues, the mechanism of action, and side effects [21].
Several herbal formulations have been shown in the literature to have the ability to regulate the generation of proinflammatory mediators, hence controlling several inflammatory processes. Herbal anti-inflammatory compositions were proven to be safer than chemical antiinflammatory medications when used for a longer length of time [22]. In our study, 61.8% of all participants use herbs to relieve toothache (82% of them use clove or clove oil and 36% use thyme). 73.1% of participants reported that Level of pain or inflammation decreased after using herbs while 8.7% reported increased Level of pain or inflammation after using herbs. In India, more than 70% of the population uses herbal drugs and this constitutes mostly the rural population who depends solely upon herbalbased products [23].
Antibacterial, antimycosal, and antiviral activities are found in a few plants used as nutritional supplements and as a therapeutic method in dentistry. Herbal medications, when administered in suitable quantities, do not disrupt or change the natural flora. Herbal derivatives are a common ingredient in toothpastes because of their antibacterial qualities, which help to prevent plaque development and bacterial adhesion to the pellicle [24].
Plants like miswak have been utilized as chewing sticks in numerous civilizations throughout the world under various names. Other plant components, such as eucalyptus leaves, are used to mask undesirable mouth odors in the mouth; onion and lime juices are used as gargles and to treat toothache [25]. Aerosols, gels, different mouth-rinsing solutions, and medicaments such as infusions or decoctions are some of the additional dental therapy treatments that utilize the anti-inflammatory and antibacterial capabilities of the herbal components [26].

CONCLUSION
The Saudi population show relatively good knowledge level and practice towards herbs use in dentistry. The use of herbs to relieve toothache was significantly associated with female gender, age, residence area in western region and average monthly income. It is important for the health of consumers to scientifically demonstrate the real effects of natural medicine, as well as clarify and establish their possible therapeutic applications.

LIMITATIONS OF THE STUDY
The main limitation of the study was lack of previous studies with similar or relative objective to compare our results along with.

CONSENT
Informed consent was obtained from all Participants included in the study.

ETHICAL APPROVAL
It is not applicable.

DATA AND MATERIALS AVAILABILITY
All data associated with this study are presented in the paper.