Objective: To assess knowledge, attitudes and practices of people regarding dental quackery.
Method: The descriptive, knowledge-attitude-practice study was conducted from June 2 to August 1, 2022, at the Dentistry Department of Ayub Medical Complex, Abbottabad, Pakistan, and comprised adult subjects of either gender belonging to lower or middle socioeconomic class and visiting the dental outpatient clinic. Data was collected using a predesigned questionnaire. The subjects' knowledge, attitude and practice about dental quackery was assessed. Data was analysed using SPSS 21.
Results: Of the 261 subjects. 135(51.7%) were males and 126(48.3%) were females. The overall mean age was 29.15+/-10.15 years. Of the total, 243(93.1%) participants had satisfactory socioeconomic status and 18(6.9%) had unsatisfactory status. There were 97(37.2%) subjects having good knowledge, 217(83.1%) with good attitude, and 53(67.1%) showing good practices towards dental quackery. Low socioeconomic status, low awareness, and easy accessibility were the main reasons for people visiting dental quacks. Increasing the number of public hospitals was suggested as the main solution by 119(45.6%) subjects.
Conclusion: The level of knowledge, attitude and practice regarding dental quackery was good. Low socioeconomic status and lack of awareness were the two important reasons for quackery.
Key Words: Dentistry, Frauds, Healthcare, Malpractice, Quackery.
(JPMA 73: 1236; 2023) DOI: 10.47391/JPMA.5209
Submission completion date: 19-08-2022— Acceptance date: 02-02-2023
Despite the advancement in science and technology, developing countries are still struggling to provide people with standard dental treatment. Majority of the dentists practice in cities, while remote areas often remain deprived of professional dental care1. This forces the people to seek care from unqualified dental practitioners who often indulge in malpractices and are therefore harmful to society. Also, due to high professional charges, people avoid visiting the dentists, and opt for unqualified practitioners who charge much lower fees2. According to the Random House dictionary, a quack is “a fraudulent or ignorant pretender to medical skill” or “a person who pretends, professionally or publicly, to have skill, knowledge, or qualification he or she does not possess; a charlatan”3. The goal of the quack is to make money. They do this without any formal dental education and they practice unethically and use unscientific techniques2. As the saying goes, a robber demands one’s money or life, but a quack demands one’s money and life!4
Dental quackery causes physical, psychological, emotional and financial harm to the patients because of the treatment and the fact that due to this, access to proper treatment remains denied5. Unlicensed dental practitioners often do treatments at the roadside with poor sterilisation and often with unconventional instruments, like screwdrivers and pliers. They also use self-cure acrylic for denture work2. Recently, teeth whitening and bogus braces are also being offered to improve dental aesthetics6. All this results in damage to teeth and their surrounding structures. Wrong or missed diagnoses also lead to undue suffering for the patients7. Self-acrylic is carcinogenic and lack of asepsis in the procedure as well as reusing contaminated needles cause transmissible diseases,1 like Hepatitis B, Hepatitis C and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)8. It is particularly dangerous for medically compromised patients, like those with diabetes mellitus9. Quacks claim to offer quick and painless remedies that make them attractive to the patients1. They treat carious teeth10 as well as mobile teeth with self-cure acrylic, and fix dentures permanently with suction discs2. They learn some dental procedures working with some dentist or from their family before becoming ‘professionals’ themselves3. They often learn from the internet, such as from tutorial videos on YouTube11. In high-income countries (HICs), as opposed to low- and middle-income countries (LMICs), dental quackery is largely controlled, although dubious methods of dentistry and health fraud in the form of a promotion and distribution of unverified dental products are sometimes detected12.
Street dentistry is a significant problem in South-East Asia, especially India and Pakistan8. There are about 40,000 dental quacks operating in Pakistan13. In Malaysia, from 2015 to 2017, 46 complaints were filed for quackery malpractice, resulting in fines and governmental action. These complaints are related to orthodontics (29.6%), operative dentistry (28.6%), oral surgery (26.5%) and prosthodontics (15.3%)8. Fake braces are worn especially by teenagers for fashion or to display wealth. These are also in vogue in China, Indonesia and Thailand8. In Pakistan, the majority of patients visiting dental quacks were reportedly older, had low awareness and were uneducated. The barriers related to dental consultation are high costs, low awareness and knowledge, long waiting times, long appointment dates often with repeated appointments, less time at the clinic and low number of public dental hospitals14.
In Nigeria, frequency of dental extraction performed by quacks was 46.4%. Death caused by dental extraction complications was 11% and, among them, 96.2% had their procedure done by quacks15. In India, about 64% of people in a study faced problems with dentures and 74.2% were not even aware of any qualified dental practitioner16. Another study in India reported that 42% subjects visited dental quacks, with age and level of education being significant markers17. In Karachi, there are around 4,000 quacks who are putting patient’s lives in danger18.
To the best of our knowledge, no study has been conducted in Pakistan assessing the knowledge, attitude and practice (KAP) regarding dental quackery in Abbottabad. The current study was planned to fill the gap by assessing KAP levels of people regarding dental quackery.
Subjects and Methods
The descriptive, KAP study was conducted from June 2 to August 1, 2022, at the Dentistry Department of Ayub Medical Complex, Abbottabad, Pakistan. After approval from the institutional ethics review committee, the sample size was calculated using the World Health Organisation (WHO) calculator19 with 95% confidence level, 0.06 absolute precision and assumed prevalence 42.1%16 of people visiting dental quacks. The sample was raised using non-probability convenience sampling technique. Those included were adult subjects of either gender belonging to lower or middle socioeconomic class and visiting the dental outpatient department (OPD). Those aged <18 years, and those belonging to upper socioeconomic class were excluded.
After taking informed written consent from the subjects, data was collected using a predesigned questionnaire adapted from literature16, which explored demographic variables and KAP levels of the participants. Questionnaire was made available in both English and Urdu for easy understanding by the subjects. A similar questionnaire was used by Parlani et al.,16 in India. This questionnaire was passed through multiple revisions and then pilot testing was done amongst intended participants. It was also checked by an expert of Community Dentistry ensuring its content validity. The results obtained during pilot testing and actual data collection were consistent ensuring reliability of the questionnaire. KAP scoring was done using a criterion adapted from literature20. Responses ranged 0-5. Cut-off values 3-5 indicated good knowledge and 0-2 showed poor knowledge. Cut-off value 2-3 indicated good attitude and 0-1 indicated poor attitude. Score of 1 indicated good practice and 0 indicated poor practice.
Data analysis was done using SPSS 21. Frequencies and percentages were calculated for the categorical variables, and mean and standard deviation values were calculated for age.
Of the 261 subjects. 135(51.7%) were males and 126(48.3%) were females. The overall mean age was 29.15+/-10.15 years. Of the total, 243(93.1%) participants had satisfactory socioeconomic status, 18(6.9%) had unsatisfactory status, 130(49.8%) were married, 131(50.2%) were unmarried, 250(95.8%) were literate and 11(4.1%) were illiterate.
There were 97(37.2%) subjects having good knowledge and 164(62.5%) with poor knowledge (Table 1). There were 217(83.1%) participants with good attitude and 44(16.9%) with poor attitude. Increasing the number of public hospitals was suggested as the main solution by 119(45.6%) subjects (Table 2).
There were 182(69.7%) people who had never visited a dental quack. Among the remaining, 79(30.3%) subjects, 53(67.1%) showed good practices and 26(32.9%) showed poor practice (Table 3) with regard to dental quackery.
The current study was conducted to assess the knowledge, attitude and practice of people towards quackery in dentistry. The KAP values indicate low literacy and lack of awareness. This is in line with a study,16 according to which, unawareness, low socioeconomic status and lack of access to dental care are the main reasons due to which people visit quacks.
Most participants in the current study were of the view that increasing the number of public dental hospitals could help in discouragement of quackery. Keeping in mind the low socioeconomic status of the people, dental insurance programmes should be initiated by the government which will help in improving accessibility of the people to qualified dental practitioners16.
According to a study, dentist-to-population ratio in Pakistan is 1:1,305,811, whereas the World Health Organisation (WHO) recommends that the ratio for developing countries should be 1:75,00018.
According to 14.6% participants of the study, unqualified dental practitioners or quackery should be encouraged with referral from other person being the main reason for this. In such circumstances, educating the people about quackery and quacks would play a great role.
Strict rules should be made and implemented in society against quacks. A majority of participants of the research (69.7%) were in favour of punishing the quacks who are putting people’s lives in danger. Dentists are using social media for spreading awareness about the practices of unlicensed dental practitioners in order to counter the hazardous consequences of quackery11.
In Pakistan, there are multiple malpractices that dental quacks indulge in13. There are numerous reasons which lead to the higher prevalence of dental quackery. These include illiteracy, lack of proper healthcare system, no knowledge and awareness of oral problems in the community3, low socioeconomic status of the patients, the affordability power of patients as well as high costs of treatment, quick pain relief for poor patients2, unavailability of dentists in rural areas with low dentist-patient ratio21, and no government policy for providing quality dental services at affordable prices. Even some people belonging to higher socioeconomic status who can afford good treatment resort to visiting the quacks for saving money2. A study in Pakistan showed that there are numerous misconceptions about proper oral healthcare in the community, and, therefore, instead of obtaining evidence-based care from dentists, people go to dental quacks who reinforce their confused beliefs22.
The current study has some limitations as it was an observational study which could not produce strong evidence. Also, the sampling technique used was non-probability convenience sampling, which means the results are not generalisable. Finally, most of the participants visited quacks for prosthodontic reasons, and, as such, better results could not be obtained about other forms of dental quackery.
Despite the limitations, however, the study has underlined the need for further studies to explore the menace of dental quackery in society.
The level of knowledge, attitude and practice regarding dental quackery in the study population was good. Low socioeconomic status and lack of awareness were the two important reasons for quackery.
Acknowledgements: We are grateful to the Department of Dentistry, Ayub Medical Complex, and Dr Farhan Ahmad Khan in particular.
Conflict of Interest: None.
Source of Funding: None.
1. Jain A. Dental quackery in India: an insight on malpractices and measures to tackle them. Br Dent J 2019; 226: 257-9.
2. Kumari S, Mishra SK, Mishra P. An evidence-based review on quackery in dentistry. BLDE Uni J Health Sci 2018; 3: 75-8.
3. Siwach P, Pawar VJ, Thakur A, Shaikh F. Havoc of dental quacks in a district in India: A case series. Indian J Dent Res 2020; 31: 323-5.
4. Gupta A, Jain D, Gedam U, Varma A. Suction Cup Induced Palatal Perforation: Havoc of Dental Quacks. Saudi J Oral Dental Res 2021; 6: 385-8.
5. Zeya S, Sharma JB, Chaturvedi P, Doshi A, Mathur S, Shah N, et al. Dental quacks: Liars to the society. Int J Appl Dent Sci 2021; 7: 289-91.
6. Nor NAM, Hassan WNW, Makhbul MZM, Yusof ZYM. Fake braces by quacks in Malaysia: an expert opinion. Ann Dent 2020; 27: 33-40.
7. Humagain M, Bhattarai BP, Rokaya D. Quackery in dental practice in Nepal. J Nepal Med Assoc 2020; 58: 543-6.
8. Hassan H, Othman WMNBW, Idaham NIB. Exploring the Experience of Klang Valley Youths on Fake Braces by Bogus Dentists. Malaysian Journal of Science, Health and Technology 2021; 7: 69-74.
9. Mattoo KA, Rathi N, Jindal S. The hazard of treatment by dental quack-non recognition of underlying systemic disease. J Adv Med Dent Scie Res 2019; 7: 131-3.
10. Abishek L, Keerthi E, Dileep S, Sugavasi GD. Combined tooth crown-A case of dental quackery. Int J Med Dent Case Rep 2018; 5: 1-3.
11. Rani H, Arjunaidy B, Roslan NA, Muhamad WNSAW, Yahya NA. A descriptive summary of unlicensed dental practice. Malaysian J Public Health Med 2020; 20: 252-60.
12. Goldstein BH. Unconventional dentistry: Part III. Legal and regulatory issues. J Canadian Dent Assoc 2000; 66: 503-6.
13. Rana A, Naseer H, Kashif M. Quackery in Dentistry. Ann Abbasi Shaheed Hospital Karachi Med Dent Coll 2018; 23: 66-77.
14. Faiq SK, Faiq SS, Ali SI-e, Din FU, Rehman B, Khattak SY. Knowledge and priorities regarding dental practitioner selection among educated people: a cross-sectional study. J Khyber Coll Dent 2019; 9: 63-8.
15. Akhiwu B, Akhiwu H, Mudashiru T, Ijehon B, Aderemi A, Bwala L, et al. Quackery as a cause of maxillofacial infections and its implications. J West Afr Coll Surg 2021; 11: 24-8.
16. Parnali S, Tripathi S, Bhoyar A. A cross-sectional study to explore the reasons to visit a quack for prosthodontic solutions. J Indian Prosthodontic Soc 2018; 18: 231-8.
17. Reddy KVG, Bansal V, Singh PK, Bhambal A, Gupta M, Gupta S. Perceptions Regarding Treatment by Dental Quacks and Self-Rated Oral Health Among the Residents of Bhopal City, Central India. J Indian Assoc Public Health Dent 2017; 15: 84-8.
18. The Agha Khan University Hospital. Role of Dentists and the Value of Dental Hygienists in Dental Practice Karachi, Pakistan: The Agha Khan University Hospital; 2018. [Online] [Cited 2022 Sep 15]. Available from: URL: https://hospitals.aku.edu/pakistan/AboutUs/News/Pages/Roleof-Dentists-and-Value-of-Dental-Hygienists.aspx.
19. Lun KC, Peter WY. Adequacy of Sample Size in Health Studies. Geneva, Switzerland: World Health Organization; 1998.
20. ul Haq N, Hassali MA, Shafie AA, Saleem F, Farooqui M, Aljadhey H. A cross sectional assessment of knowledge, attitude and practice towards Hepatitis B among healthy population of Quetta, Pakistan. BMC Public Health 2012; 12: 692.
21. Bansal V, Mowar A, Malik N. Quackery: A Case Report. IOSR J Dent Med Sci 2018; 17: 1-3.
22. Hashim Z, Gilani SI, Kabir S, Israr MY, Khan MA, Riasat M. Fake news, myths and remedies regarding oral health care in patients coming to a private teaching dental hospital of Peshawar, Pakistan. J Khyber Coll Dent 2020; 10: 57-62