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Dental Caries Prevalence among Primary Male Schoolchildren in Riyadh, Saudi

Arabia: A Cross‑Sectional Survey

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DOI: 10.4103/jioh.jioh_111_17

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Original Research

Dental Caries Prevalence among Primary Male Schoolchildren

in Riyadh, Saudi Arabia: A Cross‑Sectional Survey
Abdullah A. Alamri, Mohammed S. Aldossary, Sattam A. Alshiha, Hessa M. Alwayli, Yazeed K. Alfraih, Mohammed A. Hattan
Department of Dentistry, Ministry of Health, Riyadh, Saudi Arabia

Abstract
Aims: The aim of the study was to assess caries prevalence among 6–9‑year old children in Riyadh, Saudi Arabia and to compare between
results based on nationality, grade levels, and location of residence. Materials and Methods: A total of 1844 male students from 17 public
male primary schools in Riyadh city were examined according to the World Health Organization diagnostic criteria. The decayed‑missing‑filled
teeth (dmft) index and its components were measured. One‑way analysis of variance, Student’s t‑test, and Chi‑square test were used to determine
the significance differences, at α = 0.05. Results: The overall mean of the decayed teeth (dt) for all children was 3.15 (standard deviation [SD]:
3.36) which increased to 4.57 (SD: 3.14) when excluding children without active caries. The mean dmft score was 4.30 (SD: 3.87) which raised
to 5.37 (SD: 3.60) following excluding caries‑free children (dmft = 0). The caries prevalence was 80.15%. Although the non‑Saudi children
showed slightly fewer values compared to Saudi children, there were no statistically significant differences in all values (P > 0.05). The dmft
index score was higher for second grade (4.42, SD: 3.78), followed by third grade (4.26, SD: 3.54) and first grade (4.24, SD: 4.19). However,
there were no statistically significant differences (P > 0.05). The dmft values ranged between 2.69 (SD: 3.25) for Central and 5.0 (SD: 4.13)
for West of Riyadh. The ascending order was Central < North < East < South < West. Conclusions: This study supports the high prevalence
of caries among children of this age group necessitating the urgent need for effective community‑based preventive programs.

Keywords: Caries prevalence, dental caries, oral health, school children

Introduction
Dental caries is a persistent public health problem among
children in Saudi Arabia with a high prevalence reported
in both preschool and schoolchildren.[1‑3] Epidemiological
surveys are important to monitor the trends of dental caries,
to assess dental needs, and to plan appropriate preventive
programs.[4‑7]
A number of epidemiological surveys in Saudi Arabia have
been reported in the literature, both nationally and regionally,
for different target groups. The surveys have been carried out as
age‑specific or for preschool children and schoolchildren, and
some surveys were trying to determine caries risk/preventive
factors and their association to the caries prevalence. All of
which reported results of wide variations although presenting
high caries prevalence.[2,3]
Riyadh city is the capital and the largest city of Saudi
Arabia. Since 2000, five surveys for caries prevalence have
been published specifically for primary schoolchildren in
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Riyadh,[8‑12] with low sample size, and the most recent two
surveys were conducted in 2004.[10,12] Therefore, there seemed
to be a need to conduct another study as follow‑up on the
previous studies to observe the changes in caries prevalence
in this specific age group; 6–9‑year‑old children.
Furthermore, different governmental and private organizations
in Saudi Arabia provide independently preventive programs,
and it is worth to follow up and monitor the efficiency of the
applied dental health education and preventive programs and
dental services in general.
The aim of this study was to assess dental caries prevalence in
the primary dentition among 6–9‑year old public male primary
school children  (first, second, and third grades) in Riyadh
Address for correspondence: Dr. Mohammed S. Aldossary,
P. O. Box: 13743, Riyadh 11414, Saudi Arabia.
E‑mail: msfd99@hotmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
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How to cite this article: Alamri AA, Aldossary MS, Alshiha SA,
DOI: Alwayli HM, Alfraih YK, Hattan MA. Dental caries prevalence among
10.4103/jioh.jioh_111_17 primary male schoolchildren in Riyadh, Saudi Arabia: A cross‑sectional
survey. J Int Oral Health 2017;9:146-150.

146 © 2017 Journal of International Oral Health | Published by Wolters Kluwer - Medknow
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Alamri, et al.: Caries prevalence among male children in Riyadh
city, Saudi Arabia and to compare dental caries by factors of
nationality, age/grade, and location of residence.
Materials and Methods
Population
This cross‑sectional study was conducted during October
2015 to May 2016 at public male primary schools in Riyadh
city, Saudi Arabia. It was carried out as a part of the annual
dental preventive program targeting primary schoolchildren,
organized by the Preventive Dentistry Department, Ministry
of Health, Riyadh, Saudi Arabia. The program includes
educational part on oral hygiene and topical fluoride
application. Ethical approval was obtained from the Preventive
Dentistry Committee, Ministry of Health, Riyadh, Saudi
Arabia (H‑01‑R‑009‑1352).
In the 2015–2016 academic year, the total number of
Riyadh public male primary schools was 512 schools, with
a total number of 169,439 students. The Saudi children
counted for 129,092 (76.2%) and the non‑Saudi children
were 40,347 (23.8%) students (Statistical and Information
Technology Department, Ministry of Education, KSA,
1436‑1437 H, Personal Communication). The non‑Saudi
children included other Arabic‑speaking nationalities from
Middle East such as Yemenis, Palestinians, Egyptians,
Sudanese, and Syrians.
The list obtained from the Ministry of Education (Statistical
and Information Technology Department, Ministry of
Education, KSA, 1436‑1437 H, Personal Communication)
served as sampling frame for the study. A total of 17 public
male primary schools were randomly selected using stratified
random sampling from different five locations within Riyadh
city (North, East, West, South, and Central).
The schools were officially informed, and visitation
permissions and coordination with the schools were obtained
from the Ministry of Education and school principals to arrange
a day for data collection. Written consents were obtained from
children’s parents.
In this survey, 1844 male students were examined, which
included all children with obtained consent form, in the first
three grades within the selected school (first, second, and third
grades). The age of schoolchildren at first grade is 6–7, second
grade is 7–8, and third grade is 8–9 years old.
Before commencing the examination, a brief orientation and
oral hygiene instructions to the students were carried out.
Topical fluoride varnish (Clinpro™ 5% Sodium Fluoride White
Varnish, 3M ESPE, St. Paul, MN, USA) was applied following
examination to the children with obtained informed consent.
Oral examination
Dental caries was assessed using the World Health Organization
diagnostic criteria for oral health survey.[13] The decayed
teeth (dt), missing teeth (mt) due to caries, and filled teeth (ft)
primary teeth; the (decayed‑missing‑filled teeth [dmft])
Journal of International Oral Health  ¦  Volume 9  ¦  Issue 4  ¦  July‑August 2017
index (primary teeth only) was used to assess the caries
prevalence.
Oral examination was conducted by ten examiners (trained and
calibrated male hygienists) who were divided into five teams.
In this way, each team included two examiners; one either
conducted examination or assisted in data entry in a designed
data collection form.
The children were examined in their classroom with the child
sitting on a conventional, nondental classroom chair, with a
disposable mouth mirror, tongue blade, and a probe, when
needed, under adequate natural light and under all infection
control measures. The probe was used sparingly on doubtful
surfaces. In case of any doubt, the tooth was marked sound.
Tooth was recorded as mt due to caries if the tooth was not
present at an age when normal exfoliation would not be a
sufficient explanation for its absence. No radiographs were
taken.
Statistical analyses
Inter‑ and intra‑examiner reproducibility was assessed using
kappa statistics by re‑examining a group of fifty children,
4 weeks after the start of the study. A very high degree of
agreement was demonstrated (κ > 0.80).
All data were managed and edited using Microsoft ®
Excel® (Microsoft® Office 2007, Microsoft® Corp, Redmond,
WA, USA). All statistical analyses were performed using
Statistical Package for the Social Sciences (IBM SPSS
Statistics 20.0 Armonk, NY, USA). Frequencies, means, and
standard deviation (SD) were generated.
One‑way analysis of variance and Student’s t‑test were used to
determine statistical significance differences between means
of results. Chi‑square test was used to assess the significance
of differences in proportions.
Comparisons were made based on factors of nationality
(Saudi and non‑Saudi), grades (first, second, and third), and
location of residence (North, East, West, South, and Central).
The level of statistical significance was set at α = 0.05.
Results
This study consisted of 1,844 public male primary
schoolchildren in the first three grades, who were examined
for dental caries from 17 schools in Riyadh city. The detailed
caries prevalence results for the whole participants are
presented in Table 1.
The overall mean of the dt for all children was 3.15 (SD: 3.36)
which increased to 4.57 (SD: 3.14) when excluding children
without active caries (dt = 0; n = 572). The active caries‑free
children accounted for 31.02% of the examined children,
which indicated that 69.08% of children were with active,
untreated caries.
The range of dt was 0–20. There were only two children with
dt = 20, both children were in first grade; one child was Saudi
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Alamri, et al.: Caries prevalence among male children in Riyadh

in West of Riyadh and the other was non‑Saudi child in the However, following excluding children with dmft  =  0,
Central. The mean of the mt due to caries was 0.97 (SD: 1.55) (n = 366), the mean dmft score was raised to 5.37 (SD: 3.60).
and the mean of the ft was 0.18 (SD: 0.69). Children with at In other words, the children who had not experienced dental
least one filling accounted for 9.44% (n = 174). caries were 19.85%, and the caries prevalence was 80.15%,
The dt component was the major constituent of the dmft indicating the proportion of the children who had one or more
index (73.3%). The mean dmft score was 4.30 (SD: 3.87). dt, mt due to caries, or ft.
When comparing children based on nationality, Table 2,
Table 1: Caries prevalence of the whole participants (n=1844) there was no statistically significant differences in all
values (P > 0.05) between Saudi (n  =  1571, 85.2%) and
Parameter Value non‑Saudi (n = 273; 14.8%) children although the non‑Saudi
The dt children showed slightly fewer values compared to Saudi
Range 0-20 children.
Mean (SD) 3.15 (3.36)
Students with (dt)=0, n (%) 572 (31.02) Comparing children based on grade levels is shown in
Mean (SD); after excluding (dt)=0 4.57 (3.14) Table  3. The mean  (dt) for first, second, and third grades
The mt due to caries were decreasing, 3.36 (SD: 3.75), 3.09 (SD: 3.15), and
Range 0-11 2.96 (SD: 3.04), respectively. However, this was not
Mean (SD) 0.97 (1.55) statistically significant (P > 0.05). The dmft index score was
Students with (mt)=0, n (%) 1099 (59.60) higher for second grade (4.42, SD: 3.78) followed by the
Mean (SD); after excluding (mt)=0 2.41 (1.56) dmft for third grade  (4.26, SD: 3.54) and the dmft for first
The ft grade (4.24, SD: 4.19). However, there were no statistically
Range 0-7 significant differences (P > 0.05).
Mean (SD) 0.18 (0.69)
Students with (ft)=0, n (%) 1670 (90.56) The detailed comparisons between children based on the
Mean (SD); after excluding (ft)=0 1.90 (1.32) location of residence are presented in Table 4. The (dt)
The (dmft) index values ranged between 2.20 (SD: 3.14) for Central and
Range 0-20 3.83 (SD: 3.52) for West of Riyadh. The ascending order was
Mean (SD) 4.30 (3.87) Central <South <North <East <West.
Students with (dmft)=0, n (%) 366 (19.85)
Mean (SD); after excluding (dmft)=0 5.37 (3.60) The dmft values ranged between 2.69 (SD: 3.25) for Central
dt: Decayed teeth, SD: Standard deviation, mt: Missing teeth, ft: Filled and 5.0 (SD: 4.13) for West of Riyadh. The ascending order
teeth, dmft: Decayed‑missing‑filled teeth was Central <North <East <South <West.

Table 2: Caries prevalence comparison based on nationality

The dt Mean (SD) The (dmft) index
Mean (SD) dt=0, n (%) Mean (SD) The mt due The ft Mean (SD) dmft=0, n (%) Mean (SD)
after excluding to caries after excluding
(dt)=0 (dmft)=0
Saudi (n=1571) 3.16 (3.34) 486 (30.94) 4.58 (3.10) 1.0 (1.56) 0.19 (0.72) 4.35 (3.88) 307 (19.54) 5.41 (3.60)
NonSaudi (n=273) 3.08 (3.46) 86 (31.5) 4.50 (3.33) 0.83 (1.42) 0.11 (0.44) 4.02 (3.79) 59 (21.61) 5.13 (3.55)
P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
dt: Decayed teeth, SD: Standard deviation, mt: Missing teeth, ft: Filled teeth, dmft: Decayed-missing-filled teeth

Table 3: Caries prevalence comparisons based on grade level

The dt Mean (SD) The (dmft) index
Mean (SD) dt=0, n (%) Mean (SD) The mt due The ft Mean (SD) dmft=0, Mean (SD)
after excluding to caries n (%) after excluding
(dt)=0 (dmft)=0
First grade 3.36a (3.75) 220 (32.74)b 5.0c (3.57) 0.70e (1.37) 0.18g,h (0.70) 4.24i (4.19) 158 (23.51%)j 5.55l (3.97)
(n=672)
Second grade 3.09a (3.15) 181 (30.57)b 4.45d (2.86) 1.19f (1.70) 0.13g (0.54) 4.42i (3.78) 111 (18.75%)k 5.44l (3.47)
(n=592)
Third grade 2.96a (3.04) 171 (29.48)b 4.20d (2.82) 1.07f (1.52) 0.23h (0.80) 4.26i (3.54) 97 (16.72)k 5.11l (3.27)
(n=580)
Vertical: Same superscript letter=No significant difference (P>0.05). dt: Decayed teeth, SD: Standard deviation, mt: Missing teeth, ft: Filled teeth, dmft:
Decayed‑missing‑filled teeth

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Alamri, et al.: Caries prevalence among male children in Riyadh
Table 4: Caries prevalence comparisons based on
location of residence
Mean (SD)
The dt The mt due The ft The (dmft)
to caries index
North (n=627) 2.88a,c (3.13) 0.64d (1.13) 0.23g (0.69) 3.75h (3.43)
East (n=216) 3.56a,b (3.68) 0.13e (0.54) 0.20g (0.85) 3.88h (3.76)
West (n=593) 3.83b (3.52) 1.66f (1.83) 0.15g (0.67) 5.0i (4.13)
South (n=234) 2.48c (2.93) 1.37f (1.87) 0.15g (0.64) 4.0h (3.81)
Central (n=174) 2.20c (3.14) 0.39d,e (0.88) 0.11g (0.55) 2.69j (3.25)
Vertical: Same superscript letter=No significant difference (P>0.05).
dt: Decayed teeth, SD: Standard deviation, mt: Missing teeth, ft: Filled
teeth, dmft: Decayed‑missing‑filled teeth
Discussion
A number of caries prevalence surveys in Saudi Arabia have
been conducted in different cities or regions. In Riyadh, the
studies among primary schoolchildren showed a persistence
high prevalence of caries.
A survey in Riyadh by Al‑Banyan et  al.[8] showed a dmft
value of 3.8 among 272 male and female children group aged
5–12 years old. The caries prevalence (%dmft >0) was very
high reaching 99.3%.
In another study included 449 children of 8–9 years old, the
caries prevalence was 94% with a dmft value of 6.3.[11]
Al‑Wazzan[10] conducted a study in 2004 included 602 male
and female children in the first grade primary schools, aged
6–7 years old. The prevalence of caries was 94.4% and the
dmft was 7.34 for both male and female children. However,
the dmft index for male children only was higher; 8.13.
Al Dosari et  al.,[12] investigated the caries prevalence for
children of 6–7 years old, resulted in caries prevalence of
91.2% in both Riyadh and Qaseem cities, and the dmft was 6.53
for Riyadh children group. These reports were with quite low
sample size and showed very high caries prevalence and dmft
values. Since then, there were no recent or updated surveys.
A literature review in 2013 by Al Agili[2] suggested the need for
updating the baseline information regarding caries prevalence.
Comparison to previous studies would be difficult and
challenging due to the variation in study design, populations
examined, target groups, and sample size. However, as stated
earlier, this survey was conducted to update the literature.
The present study showed a slight decrease in caries prevalence
but still high. The mean dmft for the children was 4.30 and 5.37
following excluding the caries‑free (dmft = 0) children. The
caries prevalence (% dmft >0) was 80.15%. Many previous
studies in Saudi among children have reported decay (dt)
as the major component of dmft score.[14‑17] This is a similar
finding in the current study, which the dt accounted for 73.3%
of the dmft score.
The proportion of children with active caries was 68.98%, and
most of the dt were unrestored; children with at least one filling
Journal of International Oral Health  ¦  Volume 9  ¦  Issue 4  ¦  July‑August 2017
n = 174 (9.44%). The children who had at least one mt due
to caries accounted for 40.4% of the examined children. This
would highlight the high prevalence of active, untreated caries
with extraction being more treatment choice over fillings. Our
results showed that the treatment provided, as determined by
the ft and mt due to caries, was low, accounting for only 26.7%
of the dmft score. This is similar to the findings by Alamoudi
et al.,[18] Farsi et al.,[19] and Marya et al.[20]
This may be a reflection of poor dental awareness and lack of
education in seeking treatment. In fact, our clinical experience
shows that many patients seek treatment only when there are
serious signs and symptoms.
In Saudi Arabia, male and female schools are separated, and it
is not allowed for male investigators to access female students
and schools according to Saudi community traditions. For this
reason, this study involved only male students.
The public schools are usually attended by children of low to
middle socioeconomic class. However, investigating its effect
on caries prevalence was not a scope of the current study.
With the limitation of this study regarding the examination
setting, especially with regard to using natural light and class
room chair, there is always concern about detecting proximal
caries and tooth‑colored restoration and could be missed during
our screening.[21,22] This would result in underestimating the
dmft values.[4]
This study supports the high prevalence of caries among
children of this age group; 6–9 for both Saudi and non‑Saudi
children in Riyadh. The variation between locations of
residence would be beneficial to be investigated more in further
studies. The investigation of underlying risk and preventive
factors was not scope of the current study.
However, we noted that, from the Central (n  =  174), there
were 102 non‑Saudi (58.6%) and 72 Saudi children. From the
West (n = 593), there were 53 non‑Saudi (8.9%) and 540 Saudi
children. The difference in proportion could be the speculation
that can be made, in view of that non‑Saudi children showed
less caries prevalence. Non‑Saudis would be with different
awareness about oral hygiene, life style, and cultural factors,
giving greater attention to oral hygiene.
Although this study based on visual inspection only without
radiographs examination, this is often the only choice for
many epidemiologic studies with acceptable sensitivity and
specificity of the visual inspection for caries diagnosis.[22‑24]
Surveys are used to monitor the trends in oral health and
disease, to develop policy, to evaluate dental health programs,
and to assess the dental needs.[4,5]
This study has provided useful baseline data for future
comparisons. The caries prevalence information would assist
in the determination of treatment needs and preventive efforts,
planning programs, formulation of appropriate strategies, and
to be used in the future for the design of oral health education
programs for this specific age group. With these results, there
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Alamri, et al.: Caries prevalence among male children in Riyadh
is a need for immediate attention facilitating the dental access,
making referrals to these students, and making their parents
more aware of the existing problems.
Conclusions
• This study supports the high prevalence of caries among
children of this age group; 6–9 for both Saudi and
non‑Saudi children in Riyadh
• High caries prevalence in schoolchildren necessitates
effective prevention and management of dental caries in
earlier stage
• More organized prevention, promotion, and education
programs are needed in Saudi communities to increase
awareness about the importance of oral health.
Acknowledgments
The authors express thanks to the teachers for their cooperation
and for the field examiners for their appreciated efforts.
Financial support and sponsorship
The study was funded by Ministry of Health, Riyadh,
Saudi Arabia.
Conflicts of interest
There are no conflicts of interest.
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