International Dental Journal (2004) 54, 383–388

Oral health in Syria

N. Beiruti Damascus, Syria W.H. van Palenstein Helderman Nijmegen, The Netherlands

The aim of this paper is to describe and analyse the oral health situation in The Syrian Arab Republic lies on Syria in the last two decades and to propose recommendations for improve- the Eastern coast of the Mediterra- ment of the current situation. The epidemiological data on caries of the last nean Sea. The land area is 185,500 two decades did not indicate a decrease in the DMFT value of various age km2 and the total population was groups, nor was a decrease in the percentage of untreated caries apparent. about 17 million in 2002, of which The unequal distribution of oral health care continued to exist throughout 18% lived in the capital Damascus. the country, despite an enormous increase in the number of dentists from The estimated annual population about 2,000 in 1985 to about 14,500 in 2002. The affluent part of the growth rate was 2.6%. Infant population is served with technically oriented expensive dental services. mortality was 23/1,000 and life The public sector suffers from limited finance, the absence of appropriate expectancy for women was 75 technology in restorative dentistry and the lack of a community and years and for men 72 years, with preventive oriented approach. It is recommended to utilise dental hygienists 41% of the population comprising in the public sector, since these auxiliaries if appropriately trained can offer 4–18-year-olds. The GNP per the preventive and curative oral care wanted and demanded by the poor and capita was US$1,130 in 2002. that the government and the people can afford. About 45% of the population was Key words: Epidemiology, oral health status, dental workforce, oral health dependent on agriculture as a live- care, Syria lihood. The allocation for health, including oral health was 3% of the general budget1. The aim of this paper is to describe and analyse the oral health situation in Syria over the last two decades and to make recommen- dations for improvement.

Dental caries The results of studies using WHO criteria showed a high prevalence of dental caries among 5-year-old children. The prevalence of caries of 5-year-olds in Damascus was 77% in 19852 and 74% in 19913 and the mean dmft score was 5.2 and 4.6, respectively. The mean DMFT scores for different age groups and cohorts are presented in Figure 1. In the last two decades, the mean DMFT score of 12-year-old-children showed a fluctuating pattern rang- ing from 1.4 to 2.5. A secular Correspondence to: Dr. Nabil Beiruti, School Health Department, Jisser Alabiad Square, P.O Box 60184, Damascus, Syria. E-mail: [email protected] change of caries experience was not

© 2004 FDI/World Dental Press 0020-6539/04/06383-06 384

Figure 1. DMFT-values of various age cohorts in Syria, recorded between 1980–1998. The y-axis represents the DMFT-score. Each x-axis represents a specific age cohort. Each z-axis shows cohorts of increasing age. apparent for 12-year-olds nor was Oral hygiene and periodontal general medical risk, but are respon- a change over time apparent for diseases sible for the occurrence of dental the 15-year-olds. fluorosis. For example, it was According to the national oral The mean DMFT score of 5- reported that 78% of 13–15-year- health survey of 1998 only 6–15% year olds and the mean DMFT old children in Palmyra exhibited of 15-year- and 35–44-year-olds score of 12 and 15-year-old chil- fluorosis of which 31% had it in a were free of gingival bleeding, dren consisted mainly of the D- moderate to severe form15. In calculus and periodontal pockets11. component; 80–90% in the 5-year Alhasaka, 15% of 12-year-old Poor oral hygiene was common and 12-year-olds, and 70–80% in children were reported to have among 15-year-olds of whom 94% the 15-year-olds (Figure 2). The moderate to severe fluorosis14. had a high accumulation of dental percentages of untreated caries have The prevalence of dental inju- plaque12. About 3–11% of the 35– not changed substantially over the ries to the permanent incisors of 44-year-old Syrians suffered from last two decades. Dentine lesions children in Damascus was 5% severe periodontal diseases13. in children up to the age of 12 among 9-year-olds and 12% among years are predominantly observed 12-year-olds16. in occlusal surfaces of first molars. Other conditions The high percentage of untreated There are several areas in Syria caries in children resulted in an M where the fluoride content of Perceived oral health problems component of the DMFT count water is elevated, ranging from and knowledge on oral health of 40–50% in the 35–44-year- 0.8 to1.9ppm F14. These fluoride With regard to perceived oral olds4–10. concentrations do not pose a health, only 27% of 13–15-year-

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Figure 2. Proportional distribution of the DMFT components in 5-year-old children and the DMFT components of 12-, 15-, and 35-44-year- old Syrians in the period 1981–1998.

old children in Palmyra reported Table 1 Number of dentists and dental auxiliaries in Syria between being free of oral health problems. 1985–2002 Overall, 29% mentioned pain due Year Dentists Dentist/pop ratio Hygienists Technicians to untreated caries, 24% to gingival bleeding and 24% to orthodontic 1985 1,975 5,200 150 500 cosmetic problems15. Poor oral 1990 3,272 3,800 250 750 1995 8,500 2,150 450 2,200 health knowledge was found 1998 11,506 1,500 575 2,900 among 15-year-old children and 2002 14,610 1,172 750 4,000 among schoolteachers, school nurses and physicians17,18. areas in either their own private 1985 to 2002 is shown in Table 1. clinic or in a public dental clinic for The number of dental technicians Dental education and dental two years. The large and increasing is high and many have started workforce number of qualified dentists poses working in another profession, a considerable socio-economic and whereas dental hygienists face Dental education professional problem as they difficulties in finding jobs in public There are four public dental prefer to stay in the more affluent and private sectors. colleges in Syria, in Damascus cities rather than working in rural (1919), Aleppo (1984), Hama areas. About 10% of them have (1984) and Lattakia (1995). The found employment in Arabic Gulf Oral health care system number of graduating dentists countries20. Public oral health care is delivered increased dramatically in the to the population under the period 1985 to 2002 (Table 1)19. authority of the Ministry of Health The dental curriculum lasts for five Auxiliary education in Maternity and Child Health years and is mainly based on a west- Three intermediate dental institutes Centres (MCH) and in 15 hospitals ern, technically oriented training for dental technicians and dental where specialists render oral surgi- rather than on a community and hygienists have been established in cal procedures. Under the Ministry preventive oriented approach that Damascus (1973), Aleppo (1988) of Education, school oral health meets the needs and requirements and in Hama (1997). The duration programmes and services are of the population. About 10% of of training is two years. The curricu- delivered to children aged 6–18 the newly graduated dentists lum for dental hygienists is not years. The private sector, including become enrolled in postgraduate tailored to the priority needs of the dental services in companies and education organised by the Dental majority of the population. About industries comprise the majority of College in Damascus, the Ministry 300 dental technicians and 50 curative dental services. of Health and Military Medical dental hygienists per year have In 1990, the National Oral Services Department. Dentists who graduated in recent years21. The Health Plan (NOHP) was compiled do not enrol in postgraduate number of dental technicians and aimed at achieving the WHO education, have to serve in rural dental hygienists graduating from global goals for the year 200022.

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The NOHP was based on the adop- Oral health education and promotion unit. The services given to the tion of: This component was directed schoolchildren are restorative treat- • A preventive strategy through towards 1st and 6th grades. ment through the traditional and providing comprehensive oral Facilitators were dentists, school the ART approach, treatment of health education and promo- health assistants and in-service periodontal tissues and extractions. tion programmes for target trained schoolteachers. About 50% Limited applications of fissure seal- groups. of primary schoolchildren were ants were provided in some school • A supportive curative strategy involved in this programme. In dental clinics. through providing oral care 1998, the action oriented school About 5% of the target children services for mothers and their health curriculum (AOSHC) was (grades 2 and 5) have benefited children aged 0–18 years. adopted in the school oral health from the school dental curative programme24. This AOSHC is an services27. This coverage percent- innovative approach based on the age has not substantially changed Maternity and Child Health principle of ‘discover, do and use’. since 1990. Limited financial resources Care Centres (MCH) It is thought that schoolchildren and problems with maintenance Curative oral care in MCH centres acquire motivation and skills to care of the technical dental equip- is delivered on demand. There are perform actions beneficial to them- ment have restricted this type of 1,114 MCH centres in the country selves, their community and their school curative dental service. compared with 235 in 1990; 476 environment. AOSHC calls for In the last five years, initiatives of them are now equipped with a parents, teachers and children to have been launched to promote dental unit. The total number of assist in achieving these goals. the application of ART28 in the dentists working in MCH centres is school dental services. Most school about 1,800 compared to 234 in Preventive programme dentists have been trained in the 1990. This change has resulted in The preventive programme included ART technique and they have been employment of, on an average, school-based fluoride mouth rins- encouraged to apply it. Oral health three dentists per MCH centre ing for the 2nd–6th grade children25. records show an increase in the use having only one dental unit. Health This is carried out by in-service of the ART approach in school workers or nurses assist the dentists. trained schoolteachers. About 12% dental services during recent years. Only about 40 dental hygienists are of the target group children partici- Results of clinical research conducted employed in MCH centres. Oral pate in this programme. Compliance during the last eight years in the health care services in MCH centres of teachers with this programme WHO Centre for Demonstration, include the provision of oral health was poor and extending this Training and Research for Oral education by nurses and health programme faced administrative Health in Damascus showed that workers to pregnant mothers and and personnel obstacles25. Besides ART is an appropriate technology29. mothers with infants, and limited these obstacles, an evaluation study The costs involved are a fraction preventive measures such as the showed low benefit in caries of the expenses needed for the provision of fluoride tablets for prevention through mouth rinsing traditional restorative approach. infants. Curative services on demand programmes with only 0.2 DMFT include restorative treatment (fillings), reduction after 5 years of applica- scaling, extractions and emergency tion26. Therefore, fluoride mouth Private sector care. rinsing was replaced in many schools The private sector delivers most of Currently, about 8% of the with topical fluoride solution the oral health services in different population benefit from these oral application by oral health personnel. specialties to people who can health care services. This percent- afford it. Private dental clinics are age has remained unchanged since Supportive curative service almost exclusively located in cities 1990, despite the substantial increase These services were delivered and towns. in dental units and the enormous mainly to the 2nd and 5th grade In addition, the Military Medi- increase in number of dentists. children and on demand to other cal Services Department and the children. There are at present 105 Ministry of Interior provide dental school dental clinics equipped with services for their employees and School oral health services a dental unit. These school dental their families. These services are The school oral health programme clinics are only located in cities and provided on demand. They include for primary schoolchildren started towns with about 210 dentists and emergency care, extraction, oral in 1991. It contained three compo- 115 dental hygienists. This implies surgery, restorative procedures, nents: oral health education and that on average two dentists and periodontal disease treatment and promotion, a preventive programme one dental hygienist work in a limited prosthodontic and ortho- and a supportive curative service23. school dental clinic with one dental dontic treatment. Some industries

International Dental Journal (2004) Vol. 54/No.6 (Supplement) 387 and big companies have their own • The number of dental hygien- be promoted, preferably a locally dental clinics for delivering basic ists is low and those employed produced toothpaste, which will oral care to their workers and are underutilised in the public contribute to the country’s employees. Others have an insur- sector. economy and which is regularly ance system and refer their monitored for quality control. This employees to private dental clinics locally produced fluoride tooth- for restorative and curative treat- Rationale for a change paste should be exempted from ment and pay a minimum fee. Common risk factor approach cosmetic taxes by the government The common risk factor approach to make it affordable for all is much in discussion at the people Summary of the prevailing moment. Over-consumption of problems in oral health care sugar and the use of tobacco as Low fluoride bottled water in Syria well as traffic and sport accidents With regard to areas where dental • The prevalence of caries in chil- are causes of both oral and general fluorosis is endemic, it is not advis- dren and adults has not decreased disorders and diseases. However, able to de-fluoridate drinking in the last two decades restriction of the consumption of water in the range of 0.7–1.9ppm • The high percentages of untreated sugar and the use of tobacco and F. Such fluoride contents are effec- caries in 12-year and 15-year- safety in traffic and sports in legis- tive in preventing the development old children (80% and 70%, lation is not feasible by political of caries for all ages and do not respectively), have not decreased pressure of the dental profession. pose any health risk besides dental in the last two decades. Most of The dental profession must liaise fluorosis. The latter situation can the caries in children is observed with the politically more powerful be prevented if children under the in occlusal surfaces medical profession when initiatives age of 5 years drink fluoride free, • The level of oral hygiene is poor are launched by the medical bottled water. and the prevalence of bleeding profession to promote legislation gums and calculus is high in all for improved health. Dental hygienists in the public age groups sector • The awareness of behaviour Tooth brushing with fluoride tooth- Extension of oral health care serv- conducive to oral health is poor paste ices with the intention improving • The authorities do not address As long as legislation for improved the existing inequity in provision the problem of dental fluorosis health is not implemented, decreas- of services can be achieved by • The percentage of people and ing the prevalence of caries can involving appropriately trained schoolchildren treated in MCH only be accomplished by raising dental hygienists who offer centres and school dental clinics people’s awareness and by stimu- preventive and curative oral care has not substantially increased lating people’s self care through services that meet people’s first in the last two decades information on oral health and by needs. These oral health auxiliaries • There is a limited community creating a healthy environment. A should have a similar position and and preventive oriented approach way to achieve this goal is through function as health auxiliaries work- towards oral health in public oral health promotion with ing in the primary health care dental clinics emphasis on tooth brushing with system. Dental hygienists if prop- • The extension of two compo- fluoride toothpaste. The MCH erly trained can carry out all tasks nents of the school oral health centre is an excellent place to start mentioned in the WHO report programme, the preventive oral health promotion through ‘Basic Package of Oral Care fluoride programme and the nurses and midwifes to mothers (BPOC)’30. BPOC contains three supportive curative service, is and their infants. Early tooth brush- main components: providing emer- limited due to application of ing with a pea sized amount of gency care, introduce prevention expensive and inappropriate fluoride toothpaste after the infant’s of dental caries and gum disease technology first tooth has erupted is an impor- through the use of affordable fluo- • The undergraduate curriculum tant message. Nurses and midwifes ride toothpaste and introduce for dental students and dental should be taught about the practi- prevention through ART sealants hygienists is inadequate and is cal implications of this message and restorative care through ART not tailored towards the prior- during their professional education. restorations. The involvement of ity needs and disease situation dental hygienists in oral care allows of the population Availability of affordable fluoride the system to expand, since they • There is a high surplus of dentists toothpaste can implement BPOC without the • There is a high surplus of dental The availability of effective, anti- use of expensive equipment that technicians caries fluoride toothpaste should the dentist is trained to use.

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Reshaping the content and Dentistry, College of Dental Sciences, 17. Beiruti, N, Taifour D, Boles W et al. workforce in school oral health Nijmegen University, for his assist- The Oral-health-related knowledge Dental hygienists are particularly ance in the preparation of this and behavior of a group of 15-year- manuscript. old school children from Damascus, useful in school oral health services Syria. Int J Pediatr Dent 1995 5: 187– where they can stimulate and guide 188. the teachers in oral health education 18. Beiruti N. Oral health behaviour for schoolchildren. School-based References among a sample of schoolteachers, tooth brushing under the supervi- 1. UNICEF. At a glance: Syrian Arab physicians and nurses in the Syrian sion of teachers can be promoted Republic. http://www.unicef.org/ Arab Republic. East Mediterr Health J and stimulated by dental hygienists infobycountry/syria_statistics.html 1997 3: 258–262. 2. Beiruti, N. The prevalence of dental 19. Darwish A. 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International Dental Journal (2004) Vol. 54/No.6 (Supplement)