Dental Caries across Saudi Arabia: Systematic Review

Falah R Alshammari^1*, Hamdan Alamri², Ahmed Almalaq³, Mohammad Albakry⁴, Marwan Aljohani⁵, Wael Sabbah⁶, Lucy O’Malley⁷ and Anne-Marie Glenny⁷

^*Correspondence: Falah R Alshammari, Dental public Health and Community Dentistry, College of Dentistry, University of Ha’il, Ha’il, Kingdom of Saudi Arabia, Email:

Author info »

Introduction

Dental caries is one of the most common diseases in the world, which makes it considered as a public health problem. A World Health Organization report on oral health stated that 60 to 80% of children in the world suffer from dental caries and almost 100% of adults have dental caries [1]. In Saudi Arabia, several studies have been conducted to measure the dental caries prevalence; most of them concluded that there is a high prevalence of dental caries among children and adults. Some of the studies were systematic reviews; for example, Al Agili et al. conducted a systematic review to measure the prevalence of dental caries in Saudi Arabia between 1988 and 2010 [2]. They concluded that 70 % of children at primary school had caries of permanent dentition, while 80% of them had dental caries cavity in their primary dentition. Another review concluded that the amount of dental caries in permanent dentition is high, with mean DMFT of 3.34; they also found that mean dmft in primary dentition is 5.38 [3]. Similarly, Al-Ansari et al. found that the mean dmft for primary dentition is 7.34, while the mean DMFT in permanent dentition for adults is 7.35 [4]. Other studies across Saudi Arabia have reported different amounts of dental caries in different areas [5–11]. Owing to the wide variation in reported dental caries prevalence across Saudi Arabia; a systematic review was conducted to identify all relevant reports and risk factors. Each of these reports was critically appraised. This review will help to improve the understanding of caries prevalence in this country. Furthermore, this study will attempt to identify reasons behind this variation of outcomes regarding the prevalence of dental caries in Saudi Arabia. This will be supported by the assessment of the risk of bias of identified studies to determine if methodological factors might impact on the findings.

Materials and Methods

The search strategy was designed to be as comprehensive as possible; following the PRISMA statement. Three databases used to identify articles published from 1999 to 2019: Medline via OVID, EMBASE via OVID and the Cochrane Library. Hand searching of the Saudi Dental Journal was also undertaken from 1999 to 2019. A mix of free text terms and MeSH terms was utilized for both of the key concepts: dental caries and Saudi Arabia. Given that the systematic review was looking at all study designs suitable for assessing caries prevalence, no study design filter was applied to the search. There was no restriction with regard to the geographical coverage of the study (i.e. it may be in a local community setting, town, city, province or country-wide).

Inclusion criteria

Studies had to measure or report the dental caries experience in any area of Saudi Arabia by using valid measurement tool (for example: DMFT, DMFS; ICDAS; proportion caries free). Included studies could be conducted on adults and/or children as primary study. They could also focus on specific populations identified, for example, by employment status, systemic disease or age. Studies had to be published in 1999 or after.

Exclusion criteria

Studies were excluded if: They measure incidence of other oral conditions and did not consider dental caries; not conducted in Saudi Arabia; published in a language other than English and Arabic. Not primary study or published prior to 1999.

Identified studies were collected and checked for duplication in Endnote.9. A visual double check was conducted to identify any duplication that could have been missed by Endnote. Titles and abstracts of all the remaining articles were read in order to check for relevance according to the inclusion criteria. Irrelevant articles were excluded at this stage.

Selection of studies

Three reviewers (FA, LOM and AMG) independently reviewed all the papers. Full copies of all potentially relevant articles were retrieved and reviewed until final agreement was reached regarding inclusion.

Data extraction

Once the included studies had been identified, relevant data from those papers were extracted and transferred from the paper source to a prespecified data table.

Assessment of risk of bias

All included studies were assessed with their potential risk of bias using a modification of the Newcastle-Ottawa Scale (NOS) appraisal tool and the findings were tabulated [12]. The NOS items included sample methods, sample size, outcomes validity, outcomes reliability, confounders identified and dealing with confounding factors. The assessment of the studies was undertaken by FA, LOM and AMG.

Data analysis

In order to interpret the findings from the included studies, caries data were to be plotted according to geographical location, separating out data by primary and permanent dentition. Narrative synthesis analysis was applied.

Results

Search results

A total of 167 articles were found through the electronic searching. These were imported into Endnote X 9. Only one duplicate record was identified and deleted. Two additional records were identified through hand searching.

After screening of titles and abstracts, 71 records appeared to meet the inclusion criteria. However, on further assessment, 22 were excluded due to: multiple publications of the same study, not primary studies or did not provide data on dental caries experience. The final number of studies included in the review was 49 (Figure 1). All of these studies were cross-sectional in design.

Figure 1. PRISMA flow chart.

Risk of bias

None of the identified studies scored ‘Yes’ for all domains assessed. However, 9 studies were considered to be of moderate quality scoring ‘Unclear’ for one or two items, but ‘Yes’ for all others. All others studies scored ‘No’ for at least one item. Summary of the risk of bias assessment present in (Table 1).

Table 1: Assessment of included studies using a modified Newcastle Ottawa Scale (NOS).

Sampling

The sampling procedures utilised in the majority of the studies (82%; 40 studies) were threefold: random sampling; total population sampling, and convenience sampling. Random sampling was used in 33 of the studies. Three studies used random sampling based on the fluoride concentration zone [8,13,14]. Six studies included all their target populations. Finally, only one study used a convenience sampling approach [15]. On other hand, seven studies did not indicate the sampling process used. The sampling method was not clear in two studies.

Sample size

The sample sizes across the including studies ranging from 74 to 82,250 participants. Almost half of the studies (49%; 23 studies) had justified their sample size. Eleven (23%) studies’ justification of their sample size was unclear. While the rest they did not justified their sample size.

Responders/Non-responders

All of the included studies either failed to include or had vague descriptions regarding the comparison of responders and non-responders.

Valid outcome assessment

In terms of the tools that were used to measure dental caries prevalence, all the included studies had used a valid dental caries measurement. Forty-five studies used the DMFT index to quantify the extent of dental caries, whilst 39 of those also followed the WHO diagnosis criteria. Of the remaining studies, two used the Basic Screening Survey (BSS). Finally, one study used the Arabic version of the Oral Health Questionnaire (GOHAI-Ar) as well as DMFT index.

Reliable outcome assessment

We found that more than half (31 studies) had an outcome reliability evaluation. However, 12 studies did not and, for six studies, it was unclear if outcome assessment was reliable or not.

Confounding factors–identified

Less than half of the studies (43%) listed potential confounding factors. These included socio-economic status (SES), oral hygiene practice, water fluoridation, smoking habits and sugar consumption. Details of those factors are listed in (Table 2).

Table 2: Indicated the risk factors.

Confounding factors–adjusted for

Among the studies that identified risk factors: only 31% adjusted for confounding factors, while 46% of the studies did not. In almost a quarter 23% of the studies, adjustment for confounding was unclear.

Study settings

The studies were divided into three main geographical settings

✓ Two studies were national surveys covering the whole country

✓ Three studies were conducted across two provinces; Riyadh and two other cities (Jeddah and Qassem).

✓ Forty-four studies were conducted in a single Saudi city (Medina, Jeddah, Dammam, Riyadh, Jazan, AL_Hassa, Al Kharj, Qaseem, Hail and Asir).

Target population

National surveys

The two national surveys recruited children who attend either primary or intermediate schools with ages ranging from 6 to 18 years old. 7 recruited children based on SES status and living place (urban or rural) to make a comparison of dental caries experience in urban and rural settings from all SES status. The second study conducted by Aldosari et al. [13]. They recruited the sample based on water fluoridation concentration, to measure dental caries in each area and see the effect of water fluoridation and the dental caries prevalence as well.

Cross-province surveys

The three studies that made comparisons across provinces recruited the sample either based on oral health condition or based on water fluoridation zone. Fadel et al. evaluated the dental caries prevalence in adult periodontal patients with mean age 38 years old in Riyadh and Jeddah [16]. AlDosari et al. and Wyne recruited their samples from primary/intermediate schools in Riyadh and Qaseem according to water fluoridation concentrations; the age ranged from 6 to 19 years in both studies [8,14].

Jeddah

14 studies conducted in Jeddah to measure the prevalence of dental caries. The ages range was from 10 months to 40 years old. The youngest participants were aged from 10 months to three years, and were recruited by Alamoudi et al. with their mothers [17]. This study recruited mothers who attended the dental hospital in Jeddah. Also, Mannaa et al. recruited mothers with their children as volunteers who visited the King Abdul-Aziz University (KAU) dental clinic [18]. In both studies the mothers were aged above 25 years old. Two studies recruited children from nursery [19,20], the age ranged from 2 to 5 years. Three studies recruited children from primary schools aged 6 to 12 years old [6,10,21]. Al-Malik et al. and Alkarimi et al. both recruited children from primary military schools [6,10]. Al Agili et al. recruited their sample from both primary schools and middle schools aged from 9 to 14 years old [22]. Al Agili et al. evaluated oral health status in adolescents using smokeless tobacco among high school students aged from 13 to 20 years old [23]. Al Zahidy et al. recruited the sample from high schools aged from 16 to 18 years old [24]. Alaki et al. evaluated the effects of asthma and asthma medication on dental caries in children aged from 5 to 13 years old [25]. Farsi eta l. recruited from those aged 6 to 40 years who had attended the dental clinic at KAU [26]. One study recruited adults only, focusing on those adults with endodontically treated teeth; they were above 18 years old [27].

Riyadh

17 studies conducted in Riyadh, 14 studies were conducted on children, with ages ranging from 3 years to 12 years old. Of these 14 studies, six focused on specific populations. Alhammad et al. evaluated the dental caries across children with cerebral palsy (CP); Al-Qahtani et al. recruited their sample from blind, deaf and mentally disordered children; Brown et al. assessed the oral health status of children with metabolic disorder, heart diseases and haematology disease; Al-Jobair et al. evaluated the dental caries across orphaned children; Al-Banyan et al. outlined the dental caries prevalence in national guard school children; Mansour et al. investigated the oral health status of military schools’ female children [28–33]. The remaining four studies of children recruited preschool/ school children in general [9,34–40].

Al-Meedani et al. and Alghamdi et al. conducted their study on children at intermediate school who were aged from 14 to 16 years old [41,42]. Furthermore, one study conducted on adults, with age range from 20 to 50 years old, and sample was recruited from people with psychiatric problems [43].

Dammam

Three studies conducted in Dammam. Two of these studies recruited children and onerecruited adults. In the two studies on children, the age ranged from 6 years to 12 years old. One study performed on adults: Atieh (2008) outlined the oral health status of Saudis aged above 60 years [44].

Al-Hassa

There were two studies conducted in Al-Hassa; the ages ranged from 3 to 14 years old [11,45].

Jizan

Two studies were conducted on public school children. Al-hebshi et al. focused on male primary school children aged from 6 to 12 years [46]. However, Quadri et al. involved both male and female children from primary and intermediate schools with ages ranging from 6 to 15 years old [47].

Medina

A single study was conducted in Medina on male children aged 12 years from public primary schools [48].

Al-Kharj

Paul et al. conducted their study on preschool children aged 5 years [49].

Qaseem

Two studies conducted in the Qaseem area. The first study focused on children who lived either in the desert of Qaseem or around it; the age ranged from 4 to 10 years old 38. The second study was conducted by Al-Otaibi et al. who recruited children aged from 6 to 12 years old. Their samples were children with Down’s Syndrome (DS) [50].

Hail

One study was conducted in Hail city. Aljanakh et al. recruited their sample from high school students who were aged 16 to 18 years old [51].

Asir

A single study conducted by Alshahrani et al. who targeted all the students in Asir who were aged from 15 to 17 years old [52]. All the study characteristics are presented in (Table 3).

Table 3: Summary of study characteristics and outcome measures.

Caries data

The caries data is divided into two groups based on the type of teeth.

Primary dentition

Twenty-nine studies presented data for primary dentition, across seven geographical locations (AL Hassa, Al-Kharj, Dammam, Jeddah, Jazan, Qasseem, Riyadh, Riyadh and Qassem) and one study across the whole of Saudi Arabia. There is substantial heterogeneity in the effect estimates (I2=99%), even when controlled for location of the study, which made it inappropriate to pool data across the studies. The proportion of caries prevalence within primary teeth overall is ranged from 0.21 to 1.00 (Figure 2).

Figure 2. Effect estimates for caries prevalence in primary dentition.

In Al Hassa the proportion of dental caries prevalence among the primary teeth ranged from 0.63 to 0.69; in Al- Kharj, 0.85; Dammam ranged from 0.66 to 0.78; Jeddah ranged from 0.45 to 0.96; Jazan, 0.91; Qassem ranged 0.21 to 0.57; Riyadh ranged 0.27 to 1.00; and in Riyadh and Qassem, 0.91.

Two studies were conducted at the same time period and targeted the same population in two cities of Saudi Arabia. In Dammam, Farooqi et al. targeted children aged from 6 to 12 years old who attended primary schools [53]. They recruited 711 children and found that the prevalence of dental caries among them to be 78%. Al Shahrani et al. recruited 307 primary school children aged between 9 and 11 years and found the proportion of dental caries among them to be 0.66 [54]. The difference in the prevalence of dental caries can be explained by the difference in age group and sample size.

In Jeddah, Al Agili et al. recruited 1,655 children aged 9 to 14 years from public primary and intermediate schools; the dental caries proportion was 0.92 [22]. Alkarimi et al. recruited 417 children aged 6 to 8 years old who attended military schools, measuring the dental caries proportion as 0.87 [10]. This difference can be explained due to the age difference regarding sample size as well as the target population.

Moving to Riyadh, three studies were conducted in the same year and came with different results regarding prevalence of dental caries. Alotaibi et al. recruited 224 pre-school children aged 3 to 4 years from rural area in Riyadh province (Aldwadmi) and recorded the dental caries proportion is 0.73 [36]. The same age group was recruited by Alosaimi et al. but with sample size of 530 children. The study recorded the dental caries proportion as 0.94 [55]. Alamri et al. recruited 1844 children primary school children aged 6 to 9 years and found the dental caries proportion 0.86 [34]. This difference in dental caries can be explained due to variation in the sample size and age group.

Permanent dentition

Eighteen studies presented data for permanent dentition, across seven city locations (Asir, Dammam, Hail, Jeddah, Jazan, Medina, Riyadh, Riyadh and Qassem and one study across the whole of Saudi). There is substantial heterogeneity in the effect estimates (I2=100%), even when considered by location of the study, which made it inappropriate to pool data across the studies. The proportion for caries prevalence among the permanent teeth ranged from 0.05 to 0.99 (Figure 3).

Figure 3. Effect estimates for caries prevalence in permanent dentition.

In Asir the proportion of dental caries prevalence among the permanent teeth is (0.73), in Dammam is (0.68), in Hail is (0.79), in Jeddah ranged from (0.05 to 0.99), in Jazan (0.93), in Medina is (0.58), in Riyadh ranged (0.41 to 0.99), in Riyadh, in Qassem ranged (0.90 to 0.94) and in whole Saudi Arabia (0.72).

Discussion

This study aimed to undertake a systematic review of all studies evaluating the prevalence of dental caries in Saudi Arabia from 1999 to 2019. It identified 49 studies. The proportion of dental caries among primary teeth ranged from 0.21 to 1.00 and in permanent teeth ranged from 0.05 to 0.99.

The included studies showed a substantial amount of heterogeneity (I2=100), with regard to the prevalence of dental caries, both in primary and permanent dentition. This heterogeneity between studies came as a result of weak methodology. The weakness is most likely explained to the variation of the sample size across the studies, target population and the setting place.

The sample sizes were varied, ranging from 74 up to 82,250 participants. Furthermore, almost half of the included studies (49%) had justified their sample size, while the other studies either did not justified or the justification of their sample size was unclear. Another part, associated with populations variation. For example, targeted specific populations, such as those with specific medical conditions such as: cleft lip and palate, blind, deaf, mental disorders, children with cerebral palsy (CP), orphaned children, and participants with asthma. Previous studies have shown such conditions are associated with high risk of dental caries [56,57]. This is supported by the findings of the included studies. Alaki et al. concluded that dmft :(8.96) with asthma; dmft: (8.03) without asthma; DMFT: (2.16) with asthma; DMFT: (1.96) without asthma. Dental caries among children with cleft and palate is 91.9%, while in healthy children dental caries prevalence is 86% [30].

The location of the studies also varied, with most of the studies being conducted into two main cities: Riyadh (35%) and Jeddah (29%), leaving some parts of Saudi Arabia with either a single study or no studies at all.

Previous systematic review conducted to measure the prevalence of dental caries in Saudi Arabia among school children, concluded that 70% of children at primary school had caries of permanent dentition, while 80% of them had caries in their primary dentition [2]. However, this review did not assess the quality of the including studies. Without exploring the quality of the studies, it is difficult to interpret differences in the identified rates of caries

As a result, this systematic review was limited by the quality of the studies identified. This, alongside the significant heterogeneity means that the findings can only be interpreted with caution. That make the present study the first review of its kind to assess the quality of primary studies evaluating dental caries in Saudi Arabia.

The dental caries prevalence in countries neighbouring Saudi Arabia were found to be lower. In Kuwait, Al-Mutawa et al. found the dental caries prevalence among children aged 12 to 14 years old is 18%, Ali et al. found the dental caries among children aged 12 to 16 years old is 52% [58,59]. In Oman, Al-lsmaily et al. found the dental caries prevalence among children aged 12 years is 58.1% [60]. In Qatar, the dental caries prevalence among children aged 5 to 15 years old is 73% [61] and 85% among children aged 12 to 14 years old [62].

With regard to reporting of outcomes other than dental caries, few studies reported clear data on issues such as diet and oral hygiene behaviours. Regarding oral health behaviours, none of the studies reporting on this indicate high levels of oral health hygiene/oral health practice. Moreover, some studies report the consumption of foods high in sugar. There is clear, wellestablished evidence that brushing teeth with fluoride toothpaste is effective in preventing dental caries [63,64]. Similarly, the role of high sugar consumption in the development of dental caries is well established [65], with the WHO recommending that sugar consumption be reduced, and strongly recommending that consumption of free sugary food should be below 10% of the total energy provided by food [66].

Even given that dental services are free in Saudi Arabia, none of the included studies provided any information regarding the access to dental services. Only a few studies gave some information about dental insurance; however, they did not indicate how this could help in improving oral health.

Due to the methodological weaknesses of the included studies, the clinical heterogeneity demonstrated and the gaps in the populations/ geographical areas covered, the results of this study cannot be generalised to the general population in Saudi Arabia. In order to truly develop a good understanding of dental caries in Saudi Arabia, and determine whether caries levels are increasing or decreasing, it would be helpful to develop a national protocol to conduct regular surveys of both adults and children. Such methods exist in other countries; for example, in the UK there are regular epidemiological surveys Public Health England, which can be used to help inform dental public health policy [67]. Have such surveys system in Saudi Arabia will help the country to run periodically surveys to measure the dental caries prevalence or other dental condition. That will help in updating dental caries across Saudi Arabia and give the policy maker where dental service is needed.

Conclusion

This study found out that the methodology quality of the including studies are poor in general. Furthermore, dental caries proportion level ranged from 0.05 to 0.99 across the permanent teeth, while dental caries proportion level ranged from 0.21 to 1.00 across the primary teeth. That give us a clear idea that dental caries prevalence level in Saudi Arabia is really high. However, current data does not provide a complete assessment of dental caries across Saudi Arabia.

Recommendations

This study is outlining the need to have a criteria regarding future research to measure the prevalence of dental caries across Saudi Arabia.

Source of Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not for- profit sectors.

Conflict of Interest

The authors have no conflict of interest to declare.

Ethical Approval

There was no need for ethical approval.

Consent

No need for it, as there were no participants among this study.

Acknowledgment

Authors will like to thanks the University of Ha’il, Saudi Arabia.

Authors Contributions

FA, LOM and AMG: conceived and designed the study, conducted research, criticism the including studies and wrote the final manuscript.

HA, FA: analyzed and interpreted data.

MA and WS: developed the methodology and count the factors biases.

AMG: supervision the whole process.

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