Dental Health and Health Care in Saudi Arabia

Transcription

1 Special Communication Dental Health and Health Care in Saudi Arabia Basil H. Al-Khadra, BDS, MsD From the College of Dentistry, King Saud University, Riyadh. Address reprint requests and correspondence to Dr. Al-Khadra: College of Dentistry, King Saud University, P.O. Box 8363, Riyadh 11482, Saudi Arabia. Accepted for publication 15 February We review the available literature on dental health and health care in Saudi Arabia. While detailed epidemiologic data are not available, the following conclusions may be drawn. The Saudi population experiences the same dental diseases that other populations do; however, the extent and severity of these diseases are slightly different. Caries, while low, appear to be increasing. Periodontal disease and dental fluorosis are widespread among the population. Malocclusion is present almost to the same extent as in Western countries. Data about oral cancer in Saudis are very limited. One serious problem is the acute shortage of dental professionals in Saudi Arabia. BH Al-Khadra, Dental Health and Health Care in Saudi Arabia. 1989; 9(6): Saudi Arabia is the largest of several countries located in the Arabian peninsula, occupying approximately 80% of its total land mass. The population in 1986 was 11.5 million, as reported by Merrick. 1 While unofficial estimates of the population of Saudi Arabia have been made, the first survey by the Central Department of Statistics, conducted in 1962, estimated the population to be 3.2 million with 20.8% living a nomadic life. 2 Due to the unreliability of such estimations, the government of Saudi Arabia planned and executed the first official population census in Several studies followed and various agencies were involved. Table 1 shows the population of Saudi Arabia from 1970 to 1986, as reported in previous studies. 3-7 Distribution of the population has changed inthe past few years, and in response to persistent efforts by the Saudi government, a large number of the nomadic population has increasingly settled in urban locations. Ruwaythy 2 reported that there has been a continuous increase in the urban population since 1932: in 1932 it was estimated to be 42.30% of the total population; in 1974 it was 73.13%. In addition to the relocation policy of the Saudi government, environmental factors have played a role in the process of urbanization. The nomadic population has been reduced in size by 2 to 4% annually. The government's Second Five-Year Plan ( ) reported a 2% annual reduction in the nomadic population. 8 The dentist-population ratio is far short of being ideal. In 1974 there were 224 dentists practicing in Saudi Arabia. 9 Although the number rose to 1,200 dentists 10 by mid-1986, it is clear that most are expatriates practicing either in the private sector or more commonly in government institutions. There are few dentists of Saudi nationality and most have received their training in neighboringcountries. In 1976, the first dental school in Saudi Arabia was established, and ten students were enrolled. Currently, the average student enrollment is 100 to 153 per year. By 1987, the total number of graduates reached 152, the vast majority being Saudis (Table 2). 11,12 Dental Practice in Saudi Arabia With the implementation of its First Five-Year Plan, the Ministry of Health (MOH) made an effort to both improve and more equitably redistribute dental care facilities throughout the Kingdom. Such efforts have resulted in a current total of more than 550 dental operatories and about 478 dentists working within the MOH. 10 The goal of the MOH is to attend to the total dental needs of the population. To meet these needs, the MOH has rationalized the

2 provision of its services within three categories: Primary dental care: MOH clinics, providing preventive and emergency treatment. Intermediate care: dental departments within central and general hospitals, providing treatment beyond emergency care but not extending to comprehensive care. Specialized centers: Comprehensive dental care is provided (e.g., the Riyadh and Medina centers). The MOH also works with the health department of the Ministry of Education (MOED) to provide periodic examinations and treatment of schoolchildren whenever needed. However, this aspect of its dental health care policy is fairly new and is still under evaluation. The delivery of dental services is available within both the public and private sectors: Public sector: includes MOH, Ministry of Defence and Aviation (MODA), MOED, Ministry of Interior, and the National Guard. Private sector: private clinics, clinics within private hospitals or dispensaries, and dental clinics attached to major private companies and institutions (e.g., ARAMCO). There are about 80 private dental offices in Saudi Arabia, and a further 178 clinics are incorporated into private hospitals or dispensaries. 10 The dental department of the MOH in Riyadh is currently undertaking an epidemiologic study of dental disease patterns in Saudi Arabia. However, this project is limited by a small study population, and only 6- to 12-year olds are included, with emphasis on the 9- to 10-year age groups. 13 A more comprehensive project, funded by King Abdulaziz City for Science and Technology, is investigating the prevalence of dental diseases in all age groups. The Central Province phase of this study is in the process of completion. The dental profession in Saudi Arabia is considered a "new" profession because it was practiced in the past by a few foreign dentists and denturists. The population of Saudi Arabia has increased by 4.1% annually since 1980 and totaled 11.5 million inhabitants by The total number of dentists in 1986 was 1,200, giving a dentist-population ratio of 1:9,600; this compares to a ratio of 1:28,000 in ,21 While the population of Saudi Arabia increased by about 25% in that period (Table 3), the number of dental professionals increased by about 400%, and this may be largely ascribed to the increase in the number of foreign dentists. Table 1. Population of Saudi Arabia. Year Population ,198, ,250, ,229, ,238, ,500,000 Table 2. Number of graduates from individual classes. Class No. of graduates Table 3. Comparison between the increase in population size and numbers of dentists. Year Population No. of dentists ,012, ,229, ,238, ,500,000 1,200

3 As has already been mentioned, the dental department of the Ministry of Health in Riyadh has begun to describe dental disease patterns in Saudi Arabia. Notwithstanding the obvious limitations of this study in formulating an overall planning strategy, its usefulness in planning services for children, at least, is clear. The supply of dentists is drawn from two main pools graduates of the College of Dentistry in Riyadh and foreign dentists. While the dental college in Riyadh has graduated about 45 dentists annually, the number of graduates is expected to rise in 1989 since the number of students enrolled in 1982 was 109. Local training facilities are rapidly increasing. King Abdulaziz University in Jeddah has recently started its undergraduate dental program, and planning for a dental school at King Faisal University in Dammam is at an advanced stage. 14,15 The other source of dental personnel are foreign dentists. Searle et al 16 stated that "because Saudi Arabia can solve its short-term problems by importing technology and physicians, it will no doubt continue to do so, even though it delays the time when it will become self-sufficient." Although dentists were not specifically mentioned, it would appear that the government's strategy is to rely on foreign dentists (and other health professionals) to attend to the current needs, while working on preparing a well-qualified resource of national dentists. This policy was emphasized in a statement by the MOH in Oral Health Dental Caries Dunbar 15 believed that Saudi Arabians suffered from dental caries in an epidemic proportion, and that the upsurge in the incidence of caries is a relatively recent phenomenon. In a study of 570 people residing in the Makkah region, El Tannir 18 reported a 37.4% prevalence of caries. Keene et al, 19 in a study of 217 Saudi Arabian naval recruits, reported that the incidence of caries was considerably lower than that for the U.S. recruits of comparable age. The Saudi mean decayed, missing, or filled teeth (DMFT) index was 3.7 ± 3.4 (SD). Wirthin et al, 20 in a study of 52 Saudi naval recruits, reported a mean DMFT index of 3.5 ± 2.9. Youness and El Angbawi 21 studied 1378 schoolchildren and found a mean DMFT index of 2.9 ± 2.6, which was considered low. In a report for the World Health Organization (WHO) by Barmes and Zahran 9 on the oral health situation in Saudi Arabia, it was reported that the mean DMFT index for 12-year-old children was 2.0, whereas that of 15-year-old children was 2.3. Given the large percentage of nomadic/rural Saudis without access to dental care or dental health education, a high prevalence of caries in this group might be expected. However, the dental caries rate in this group is actually low. Dunbar 15 stated that he had "gained the impression that Saudi Arabians should have a fairly low index of dental caries," and this view coincided with those of epidemiologists working at the National Institute of Dental Research and the WHO. A low caries incidence may be attributed to diet and a high content of natural fluoride in drinking water, 9,18-22 and this may account for the lower incidence of caries in rural as compared to urban children (Table 4). The move toward urbanization and the increased consumption of refined sugars usually accompanying such moves may explain the overall increase in the caries experience in the Saudi population. 9 Periodontal Diseases In a study of 1173 schoolchildren (573 boys and 601 girls), El Angbawi and Youness 22 reported a high prevalence of periodontal disease, with a mean incidence of "intense gingivitis" of 2.3 ± 1.79 and an absence of advanced periodontitis. A mean calculus score of 1.06 ± 1.17 was found. While no details of indices used were given, theauthors claimed to have used "WHO criteria." Barmes and Zahran 9 observed a "moderate to high level" of periodontal disease. Wirthlin et al 20 reported a high prevalence of marginal gingivitis in young men, aged 17 to 26 years, from Saudi Arabia based on a sample of 52 subjects. None of the subjects showed generalized chronic periodontitis, while 24 subjects showed signs of generalized "chronic marginal gingivitis." No definitions of the terms used are provided by the authors. In El Tannir's study, 18 38% of 570 people residing in Makkah showed signs of periodontal disease that varied from mild to severe. Eid and Zulqarnain, 23 in his study utilizing patients' radiographs, reported that periodontal disease is common in the Saudi population. However, the extent and severity of the disease did not differ greatly from groups in Western societies.

4 Dental Fluorosis Table 4. Comparison between the DMF score for the 12-and 15-year-old groups. Location Age(y) No. D M F DMFT Riyadh Jeddah Abha* Total * Rural area. D = decayed, M = missing, F = filled, T = teeth. Source: Adopted from Barmes and Zahran. 9 El Tannir 18 reported that 70.5% of his sample population of 570 showed varying degrees of "tooth mottling" due to a high fluoride concentration in the drinking water. Barmes and Zahran 9 stated that the fluoride content of water in Saudi Arabia varied greatly, being high in certain areas, adequate in others, but occasionally low and needing supplementation. Malocclusion Available literature of the prevalence of malocclusion does not provide adequate information. Nossier 13 reported that 15 to 17% of the population is estimated to be in need of some orthodontic treatment. Nashashibi et al, 24 in a study involving 1000 Saudi children (mean age, 11.8 years) from the Riyadh region, reported that 57.7% of the children required some kind of orthodontic treatment. The low prevalence of malocclusion reported by Nossier was in his opinion largely due to the large jaw sizes among Semitic poeple. However, the figures reported by Nashashibi et al agree with those of other countries in the Middle East. Comparing the figures of the latter workers with those reported by Gardiner, 25 it is apparent that the Saudi population falls in the middle of the scale between France (54%) and Germany (63%). Oral Cancer While the available literature about oral cancer in Saudi Arabia is limited, Mani, 26 in a survey of 674 dental patients, reported no cancer for Saudis. The prevalence of other lesions was as follows: leukoplakia, 1.7%; leukoedema, 6.9%, nicotinic stomatitis, 2.5%; and lichen planus, 0.9%. Salem et al 27 surveyed 661 people from the Southern Region of Saudi Arabia for oral malignancy. He reported that 68% (129) of the native snuff users had signs of leukoplakia. Al Dosari 28 reviewed 206 cases of neoplastic oral lesions in Riyadh Central Hospital: 74.3% were squamous cell carcinoma, 10.2% were malignant lymphomas, and 3.9% were malignant undifferentiated neoplasms. Public Knowledge and Awareness Although there appears to be no published work on public knowledge of dental care, increasing attendance rates at the College of Dentistry, King Saud University, point to an improved awareness. This may be largely attributed to the efforts in dental health education being made by the concerned government agencies. Conclusions Saudis suffer from the same dental diseases as do other nations. In light of the available literature, there are no major differences between Western societies and Saudis regarding the prevalence of periodontal disease and malocclusion. Dental caries, however, appear to be increasing in incidence; this is in contradistinction to developed countries, where a reduction in caries has been occurring. References 1. Merrick T. Population reference bureau. Associated Press, 1986.

5 2. Ruwaythy MA. Population of Saudi Arabia: geographic and demographic study. Cairo, Biographical Directory: Who's Who in the Arab, World, ed 7. Lebanon: Publitec Publications, Saudi Arabia, Ministry of Finance and National Economy, Central Dept. of Statistics: The Statistical Indicator, 1406 (1986). 5. Saudi Arabia, Ministry of Finance and National Economy, Central Dept. of Statistics: Statistical Yearbook, 1406 (1986). 6. Saudi Arabia, Ministry of Finance and National Economy, Central Dept. of Statistics: The Statistical Yearbook, 1403 (1982). 7. Saudi Arabia, Ministry of Finance and National Economy, Central Dept. of Statistics: The Statistical Yearbook, 1402 (1981). 8. Saudi Arabia, Ministry of Planning, Saudi Arabia. Third Development Plan ( ). 9. Barmes DE, Zahran M. Oral Health Situation Analysis Report. Saudi Arabia,6-20/3/1979 (unpublished). 10. Abdulhameed S. Ministry of Health, Dental Department, Saudi Arabia. (Personal Communication, 1986). 11. Shalhoub SY, Badr A. Professional dental education in the Kingdom of Saudi Arabia an overview. Odonstomatol Trop 1987;10(3/4): Sulaimani S. (Personal communication, 1987). 13. Nossier M. Confronting the Cola Culture. Middle East Dentistry , Jan-Feb, Zaki HA, Tamimi TM. The acute shortage of dental health manpower in Saudi Arabia. Saudi Med J 1984;5(1): Dunbar JB. Report of a two-week visit to King Faisal University and the Eastern Province concerning dental health and dental education, Searle CM, Gallagher EB. Manpower issues in Saudi health development. Milbank Mem Fund Q 1983;61(4): Gezairy H. Health Manpower in Saudi Arabia: past, present and future. Middle East J. Anaesthesiol 1979;5(3): El Tannir MD. Mottling of enamel in Mecca and the Arabian Peninsula. J Pub Health 1959;49(l): Keene HJ, Shaklair IL, Anderson DM, Mickel GJ. Relationship of Streptococcus mutans biotypes to dental caries prevalence in Saudi Arabian naval men. J Dent Res 1975 ;56(4): Wirthlin MR, Keene HJ, Shaklair IL. Gingivitis, bacterial plaque and Streptococcus in naval recruits from Saudi Arabia. J Periodontol 1977;48(4): Youness SA, El Angbawi MF. Dental caries prevalence in intermediate Saudi school-children in Riyadh. Community Dent Oral Epidemiol 1982;10: El Angbawi MF, Youness SA. Periodontal disease prevalence and dental needs among school-children in Saudi Arabia. Community Dent Oral Epidemiol 1982;10: Eid M, Zulqarnain BJ. The prevalence of interproximal bone loss in Saudi children and young adults. Quint Int 1989;20: Nashashibi I, Darwish S, Khalifa E. Prevalence of malocclusion and treatment needs in Riyadh (Saudi Arabia). Odonstomatol Trop 1983;4: Gardiner J. An orthodontic survey of Libyan school children. Br J Ortho 1982;9: Mani N. Preliminary report on prevalence of oral cancer and precancerous lesions among dental patients in Saudi Arabia. Community Dent Oral Epidemiol 1985;13: Salem G, Juhl R, Schiodt T. Oral malignant and pre-malignant changes in Shammah users from Gizan Region, Saudi Arabia. Acta Odontol Scand 1984;42: Al-Dosari A. Preliminary study of oral cancer in Saudi Arabia. Saudi Med J 1987;8(5):