International Dental Journal (2002) 52.

87-93

Caries in preschool children in

Amman, Jordan and the relationship
to socio-demographicfactors
A. Sayegh
Amman, Jordan
E.L. Dini, R.D. Holt and R. Bedi
London, UK

Objective: To determine the prevalence and severity of caries in children The Hashemite Kingdom of Jordan
attending kindergartens in Amman and the relationship between caries has an estimated population of 4.9
experience and socio-demographic factors including age, social class million, with an annual average
based on the father's occupation, the level of mother's education and increase of 3.6 per cent since 1994.
the fee level of the kindergarten attended. Design: Cross sectional About 38 per cent of the popula-
survey including a dental examination of the child and a questionnaire tion lives in Amman, the capital
completed by the parents. Setting: Kindergarten schools in Amman. city. As in other countries in the
Participants: 1,140 children including 569 4-year-olds and 571 5-year- region, a high proportion of the
olds. Results: Prevalence of caries in 4 year olds was 62% and in 5 year population are children and it has
olds it was 73%. The dmft values were 3.1 and 4.1 in 4 and 5 year olds been estimated that 17 per cent of
respectively. Lower caries prevalence was recorded for children of families the population are less than 6 years
where the father had a non-manualoccupation, those whose mothers had old, with 35 per cent of this age
higher levels of educational attainment and for children attending kinder- group living in Amman'.
gartens with higher tuition fees. Conclusion: Caries prevalence and
During the 1970s and much of
severity in children attending kindergartenschools in Amman are similar to
the 1980s, levels of dental decay in
those seen in studies of children of the same age in Saudi Arabia and
higher than those in children in westernised countries such as the UK. As children in many industrialised
in other countries, caries experience in young children in Amman is clearly counmes showed a dramatic decline2.
relatedto social factors. Findings illustrate the need for effectiveoral health Although there has been some
promotion accessibleto all social groups in this middle eastern capital. Fee suggestion that the trend may have
scale of the schools appears to be an effective measure to use in designing plateaued3-' more recent studies
appropriatestrategies. suggest that it may have continued'.
Trends are less clear in developing
Key words: Dental caries, preschool children, social class, mother's countries (including those in tran-
education sition), particularly in preschool
children where oral health has been
less well documented than in school
children'. Nevertheless, evidence
suggests that caries experience in
young children in some middle
eastern countries has remained very
high. Studies have been carried out
in Saudi Arabia"I5, Kuwait"-",
Iraq", Oman2', Abu Dhabi2'*22 and
and have shown wide
variation in disease in primary teeth,
Correspondence to: Dr. R.D. Holt, Dept. of Transcultural Oral Health, Eastman Dental
Institute, University College London, 256 Gray's Inn Road, London W C l X 8LD, UK. with, for example, dmft values
Email: R.Holt@eastman.ucl.ac.uk ranging from 1.2 to 8.4 per child at

0 2002 FDlMlorld Dental Press

0020-6539/02/02087-07
88
ages from 3 to 5 years. Two stud-
ies have been carried out in Jordan,
both in children from Amman.
Both showed children to have high
levels of disease. In one, 72 per
cent of a sample of children aged 3
to 6 had some caries experience”
and in the second, 63 per cent of
the 6 year olds26.
Many previous studies have
shown clear relationships between
socio demographic factors and
caries but results in the two previ-
ous Jordanian studies were incon-
clusive. In the study reported by
Hamdan and Rockz6, dmft was
lowest in 6-year-old children from
private schools and in those coming
from high social classes. In contrast,
Janson and Fakh0uriz5failed to find
differences in disease with social
class measured either in terms of
the father’s occupation or the moth-
er’s education. Both of these two
studies used relatively small sample
sizes (255 and 400) and were
confined to selected areas and
schools in Amman. Measurement
of social class may also have been
problematic since methods used in
western countries may not be
directly applicable to Jordan. In
both cases therefore samples may
have been too heterogeneous and
methods of assessment insufficient
to detect social class differences.
The aim of the present study
was therefore to determine the
prevalence and severity of dental
caries in a sample of preschool
children attending kindergartens
in Amman, Jordan, and to assess
the relationship between caries
experience and socio-demographic
characteristics in the sample in terms
of age and social class based on
father’s education and on level of
mother’s education.
Material and methods
Population and sampling
At the time of the study, schools in
Amman were independent and not
State funded. Therefore, participa-
tion in the study was obtained
separately for each school. A list of
International Dental Journal (2002) Vol. 52/No.2
kindergartens in the city and the
numbers of children attending these
were obtained from the Depart-
ment of Education. A total of
22,569 children were enlisted in the
kindergartens at the time of the
study. The 275 kindergartens on
the list were then stratified by
monthly tuition fee into seven
categories: I 10JDs; 1I-20JDs;
21-30JDs; 31-40JDs; 41-50JDs;
51-60JDs; >60JDs. The number
of kindergartens (K) and of chil-
dren attending them (N) in each
category were: category 1 (K=16;
N=1,129), category 2 (K=105;
N=8,806), category 3 (K=49,
N=4,516), category 4 (K=49;
N=2,935), category 5 (K=16;
N=1,806), category 6 (K=16;
N=1,110), category 7 (K=24;
N=2,267).
A two-stage sampling proce-
dure was used within each strata.
In the first stage a proportional
simple random sampling procedure
was used to select the kindergartens
for the study. Using this method,
34 kindergartens were selected. The
number of kindergartens (K) and
of children attending the selected
kindergartens 0by category were:
category 1 (K=2; N=137), category
2 (K=13; N=1,069), category 3
(K=6; N=534), category 4 (K=6;
N=377), category 5 (K=2; N=214),
category 6 (K=2; N=138), category
7 (K=3; N=279). Headteachers
were asked to consent to their
kindergarten being a part of the
survey. O n refusal another kinder-
garten from the same stratum was
randomly selected.
In the second stage and using
class lists of children classified by
age and gender from the sampled
kindergartens,children were selected
using a systematic random sampling
procedure. Schools were asked to
circulate parents of the selected chil-
dren a letter explaining the nature
and purpose of the study, seeking
consent to their child taking part
and to collect the returns. Of the
1,200 children selected, forms were
returned for a total of 1,140 chil-
dren (95 per cent). Of the 60 who
did not return their forms, 43 (72
per cent) were of children in schools
in the highest tuition fee stratum.
Questionnaires
The questionnaire, which had been
devised and tested in a pilot study
in three schools not included in the
main study, was sent to the parents
before the child was examined. The
form sought information on
parental educational attainment and
the occupation of the head of the
family. The questionnaire was sent
at the same time as the letter seek-
ing consent.
The occupation of the father
recorded in the questionnaire was
subsequently coded using the
Registrar General classification of
occupation. These were then
grouped to provide three catego-
ries of occupational status: 1-111
Non Manual, I11 Manual-V and
not classified in this way.
The level of educational attain-
ment of the child’s mother was
recorded using seven categories
which for the purpose of this analy-
sis were aggregated into three;
intermediate college and university,
vocational and secondary and
primary, preparatory and unspeci-
fied or not stated.
Seven categories were recorded
for the type of kindergartens
according to monthly fees in
Jordanian Dinars ODs), which were
also aggregated into three larger
categories: More than 40 JDs per
month, 21-40 JDs per month and
20 or fewer JDs per month.
Clinical examination and
diagnostic criteria
All examinations were conducted
by one examiner (AS). At the time
of the examination, the investiga-
tor was unaware of the parent’s
response to the questionnaire.
Children were examined at
kindergartens under natural light.
For examination, the child was
seated in a chair facing a window.
A plane mirror and a periodontal
 89

probe were used. Diagnostic crite-
ria depended on visual evidence of
a lesion, with the periodontal probe
being only used to remove plaque
and not to confirm or refute doubt-
ful diagnoses.
Caries was recorded using the
dmft index. A tooth was consid-
ered decayed (d) if there was
visible evidence of a cavity that
involved dentine. Filled teeth with
recurrent caries were included as
decayed. The missing component
(m) included teeth lost through
caries. For children under the age
of five any missing tooth was
considered as extracted due to
caries. For five-year-olds, a miss-
ing incisor tooth was considered as
exfoliated and not recorded in the
(m) component unless caries was
defintely present in anterior teeth
adjacent to the space when the miss-
ing tooth was regarded as lost due
to caries2'.
The examiner was trained and
calibrated with an experienced
epidemiologist (RH) before data
collection began. Calibration was
carried out in two kindergartens
not selected for the main study on
a total of 49 children. Duplicate
examinations were also carried out
for 10 per cent of the sample
during the main study. Kappa
statistics for the presence o r
absence of caries was 0.86 for
inter-examiner variability and 0.97
for intra-examiner variability.
Only those children who had
been dentally examined and for
whom a completed questionnaire
had been returned were included
in the study.
Data analysis
All data were processed and
analysed at the Computer Centre,
University of Jordan using SAS
software and at the Eastman
Dental Institute using SPSS. Preva-
lence rates and mean dmft were
calculated. Chi-square was utilised
to test the association between
grouped dmft (dmft=O, dmft=l-
4 and dmft> 4) and each of the
socio-demographic variables. Non-
parametric tests (Mann-Whitney
U-test and Kruskal-Wallis) were
used to compare dmft values
between groups based on socio-
demographic variables. Multiple
logistic regression was used to
determine which variables had an
independent effect on caries when
others were taken into account. All
variables in the study were entered
into a model for logistic regression
analysis.
Results
There were 582 boys and 558 girls
in the sample. Of the 1,140 chil-
dren included, 569 were aged 4
years and 571 were 5 years old at
the time of examination. Of the
children, 765 (67 per cent) had
some caries experience. O n aver-
age children had a dmft score of
3.6 per child; 375 children (33 per
cent) were clinically caries free, 391
(34 per cent) had a dmft between 1
and 4 and 374 (33 per cent) had
more than four decayed missing or
filled teeth. Caries prevalence, mean
dmft and distributions in terms of
dmft values are shown in Table 1 in
relation to age and gender. Older
children had a significantly higher
mean dmft and fewer were caries
free. Differences in caries distribu-
tion and mean dmft between
genders were not statistically
significant.
Values for dmft and its compo-
nents in relation to age are shown
in Table 2 and graphically in Figtre
1. For the group as whole, the mean
dmft value of 3.6 was made up of
3.2 decayed teeth (89 per cent of

Table 1 Number and percentage of children with caries experience, caries distribution and mean
dmft (sd) according to age and gender.

With caries Caries distribution

n n(O/o) dmft(sd) dmft=O dmftl-4 dmfb-4
Age (years)
4 569 351 (61.7) 3.1 (3.9) 218(38.3) 202(35.5) 149(26.2)
5 571 414 (72.5) 4.1 (4.0)' 157(27.5) 189(33.1) 225(39.4)2

All 1140 765 (67.1) 3.6 (4.0) 375(32.9) 391 (34.3) 374(32.8)
Gender
Boys 582 409 (70.3) 3.7 (3.9) 173(29.7) 21 3(36.6) 196(33.7)
Girls 558 356 (63.8) 3.5 (4.1)3 202(36.2) 178(31.9) 178(31.9)4
l P < 0.0001 (Mann-Whitney U-test)
P c 0.0001 (Chi-square test)
P = 0.062(Mann-Whitney U-test)
P = 0.06 (Chi-square test)

Table 2 Dmft and its components in relation to age.

decayed missing filled

Age n mean(sd) (%) mean(sd) (%) mean (sd) (%)
4 569 2.8 (3.7) (90.3) 0.1 (0.3) (0.0) 0.3 (1.0) (9.7)
5 571 3.6 (3.7) (87.8) 0.1 (0.4) (2.4) 0.4(1.1) (9.8)
All 1140 3.2 (3.7) (88.9) 0.1 (0.3) (2.8) 0.3 (1.1) (8.3)

Sayegh eta/.: Canes in preschool children in Amman, Jordan

90

Percentage of dmft components according to age. cent) attended those with the
middle range and 521 (46 per cent)
attended kindergartens with the
% W decayed lowest monthly fees. It can be seen
W missing from Table 3 that there were
filled consistent differences in caries
prevalence and dmft across the
three proxy measures of social class.
Thus, prevalence was higher in chil-
dren whose father’s occupation was
in the manual category, or could
not be classified, in those whose
mothers had received the least
education and in those who
attended schools with the lowest
fees. Mean dmft values were also
4 5 higher in these groups and there
age (yeam) were more children with dmft
Figure 1. Percentageof dmft components according to age values greater than 4. Differences
showed consistent trends across the
three social class groupings based
the total), 0.1 missing (2.8 per cent) mothers of children in the sample, on father’s occupation (P<O.OOOl)
and 0.3 filled teeth (8.3 per cent). 631 (55 per cent) had received an and across the three groups in rela-
Decayed teeth made up 90 per cent education that included time spent tion to monthly fees for the
of the mean dmft in 4-year-olds at an intermediate college o r kindergartens attended (P<O.OOOl).
and 88 per cent of that in 5-year- university. For a further 376 (33 Differences across the three groups
olds. Caries prevalence and dmft per cent), their education had been in relation to mother’s education
values in relation to the three meas- limited to secondary school and/ also showed significant differences
ures of social classification are or vocational education. Mothers (P<0.003) but there appeared to
shown in Table 3. of the remaining 133 children (12 be little difference in outcome
Of the children, 73 per cent had per cent), had received no school- measures for caries between those
fathers whose occupation fell into ing or had only primary school whose mothers had education
the non-manual categories (I-I11 education or had not specified what which included intermediate college
Non-manual), 19 per cent in the their level of education had been. and/or university education and
manual categories (I11 Manual - V) Two hundred and thirty five of those whose mothers had educa-
and the occupation of fathers of the children (21 per cent) attended tion limited to vocational and/or
the remaining (8 per cent) could kindergartens with the highest secondary school level.
not be classified in this way. Of the tuition fees. A further 384 (34 per The results of multi-variate

Table 3 Number and percentage of children with caries experience and caries distribution according to father’s occupation,
mother’s education and kindergarten fees.
With caries Caries distribution
n n (%) dmft(sd) dmft=O dmftl4 dmfb4
Father’s occupation
1-111 Non-manual 835 530 (63.5) 3.3 (3.9) 305 (36.5) 278 (33.3) 252 (30.2)
111 Manual - V 212 161 (75.9) 4.0 (3.9) 51 (24.1) 82 (38.7) 79 (37.3)
Not classified 93 74 (79.6) 5.0 (4.6)’ 19 (20.4) 31 (33.3) 43 (46.2)*
Mother’s education
Intermediate collegeNniversity 631 410 (65.0) 3.5 (3.9) 221 (35.0) 211 (33.4) 199 (31.5)
Secondary schoolNocational education 376 249 (66.2) 3.5 (4.0) 127 (33.8) 136 (36.2) 113 (30.0)
No schoolinglPrimary schoollNot specified 133 106 (79.7) 4.6 (4.0)3 27 (20.3) 44 (33.1) 62 (46.6)‘
Kindergarten fees
> 40 JDs 235 124 (53.0) 2.4 (3.2) 1 1 1 (47.2) 77 (32.8) 47 (20.0)
2 1 4 0 JDs 384 261 (68.0) 3.6 (4.1) 123 (32.0) 134 (34.9) 127 (33.1)
I 10-20 JDs 521 380 (72.9) 4.1 (4.2)’ 141 (27.1) 180 (34.6) 200 (38.4)*
P c 0.0001 (Kruskal-Wallis)
P c 0.0001 (Chi-square test)
3 P < 0.002 (Kruskal-Wallis)
P c 0.003 (Chi-square test)

International Dental Journal (2002) Vol. 5UNo.2

 91

Table 4 Logistic regression: P values, odds ratios and 95% confidence intervals for the association between caries
prevalence and severity with all variables in study.
~~ ~~

Caries prevalence Caries severity

(dmft2l /dmft=O) (dmftA/dmft54)
P OR (95%CI) P OR (95%CI)
Age
5 yrsM yrs 0.0001 1.6 1.2-2.1 0.0001 1.8 1.4-2.3
Gender
Boys/girls 0.02 1.4 1.0-1.7 0.54 1.1 0.8-1.4
Father’s occupation
Not classified, IIIM-V/I-I IINM 0.01 1.5 1.1-2.1 0.28 1.2 0.9-1.7
Mother’s education
No school, primary, not specified/
Intermediate, university, secondary, vocational education 0.09 1.5 0.9-2.4 0.03 1.5 1.1-2.3
Kindergarten fees
10-20 JDs/>21 JDs 0.02 1.4 1.1-1.8 0.01 1.4 1.1-1.9

analysis using a stepwise multiple
regression procedure are summa-
rised in Table 4. It can be seen that
age of the child, gender, social class
based on the father’s occupation
(between those in social classes
1-111 Non-manual and those in
other groups), and fee scale of the
kindergarten attended, all had a
statistically significant independent
effect on caries prevalence when
other variables were taken into
account. Older children had 1.6
times the likelihood of having
caries, those who were from fami-
lies in social classes 111Manual-V
or who could not be classified had
1.5 times the risk and those attend-
ing kindergartens with the lowest
fee scales had 1.4 times the risk. In
the case of caries involving four or
more teeth, age, mother’s educa-
tion and kindergarten fees had a
significant independent effect with
older children having 1.8 times the
risk of having a dmft greater than
4.
Discussion
This investigation considered the
prevalence and severity of caries in
a sample of preschool children
attending kindergartens in Amman,
Jordan. The sample was larger than
previous studies including over
1,100 children and was selected
to be representative of children
attending kindergartens throughout
the city. The study was the first to
employ a series of three proxy
measures of social class, including
fee scale of the kindergartens
attended by the child.
Sixty seven per cent of the 1,140
children had some caries experi-
ence and the mean dmft score was
3.6 per child. These data compare
poorly with equivalent values for
children in developed counmes such
as the United Kingdom. In one
recent UK survey 36 per cent of a
nationally based sample of 4-6 year
olds had some caries and mean
dmft was 1.O per child’. However,
comparison with results from
studies in countries neighbouring
Jordan and reported in the last 5
years suggests that caries levels may
be slightly lower than in some of
these. In Saudi Arabia for exam-
ple, a prevalence of 73 per cent
and a mean dmft of 4.8 was
recently reported for a large
sample of children in Jeddah” and
in Kuwait, 81 per cent of a sample
of 4 year olds were seen to have
cariesI8. Values reported here are
also a little lower than the 75 per
cent prevalence reported by Janson
and Fakhouri in 199325for 3-6-
year-olds in Amman.
Prevalence appears to be simi-
lar to that seen in the sample
studied by Hamdan and RockZ6,
(who report a prevalence of 63 per
cent) but severity may be higher,
with a mean value of 2.15 dmft
being reported by these authors,
more than one tooth per child less
than was seen in the current study.
Prevalence increased significantly
Sayegh eta/.:Canes in preschool children in Amman, Jordan
with age, suggesting that caries
activity was continuing in these 4-5
year old children. There was also
some suggestion, seen in the
multivariate analysis, that caries was
more prevalent in boys than girls.
Although this finding may be a
real one and concur with results
reported by ~ t h e r s ’ ~ * ’ ’the J~*~~,
difference was small in absolute
terms, and was not seen in single
variate analysis.
Results did show a clear rela-
tionship between caries prevalence
and social class factors, with chil-
dren from social classes I11 Manual
-V, or who could not be classi-
fied, those attending kindergartens
with the lowest monthly fees and
those whose mothers had received
less education, having higher levels
of disease. This finding falls into
line with those from numerous
other investigations in industrial-
ised countries and confirms the
findings of a relationship by
Hamdan and Rockz6in the same
city. In Saudi Arabia too, the same
relationship between social class
and caries has now been well
d e m o n ~ t r a t e d ’ ~ J ’ but
* ~ ~ ;it is in
contrast with results reported by
Janson and Fakhouriz5who failed
to find a relationship in their
smaller and more selected sample.
A number of proxy measures
for social class are available. Class
based on occupation of the head
of household is one that has been
commonly used in countries such
as the UK. Although classifications
92
may be thought to be inappropri-
ate outside the country and culture
for which they were designed, in
this study the Registrar General’s
classification, designed for use in
the UK, appears to have been a
reasonably satisfactory indicator,
perhaps indicating the westernised
culture of the city. School type
attended, indicated by fee scale in
the present study, has proved a valu-
able indicator in Jordan and in Saudi
Arabia11 , 1 5 3 and was of value in
this study also. In multivariate analy-
sis fee scale, in terms of those
attending the cheapest kinder-
gartens and other children, showed
a consistent independent effect with
both caries prevalence and with
more extensive caries. In single
variate analysis it also proved to
have consistent relationships to
caries and to dmft values.
The level of the mother’s
education proved to be a signifi-
cant factor in single variate analysis
for both prevalence and dmft. The
high prevalence of caries seen
among children of mothers with
the lowest educational level is
consistent with findings of some
other s t u d i e ~ ~ ’ . ~but
. ~ the
~ - ~differ-
~,
ence seen here was not consistent
across all three of the groups in
relation to education. The relation-
ship was also less strong and
consistent when entered into
multivariate analysis, perhaps
suggesting that education of the
mother had little independent
effect on top of those of social
class and may have caused some
element of confounding. The find-
ings may also suggest that the
index was a less good proxy meas-
ure in the sample of children
included. Relatively few mothers
of children had education confined
to primary school or less and the
lack of discrimination may reflect
the higher levels of educational
achievement now enjoyed by the
majority of Jordanian women, or
at least by those whose children
attended kindergarten schools in
Amman.
In real terms, the caries preva-
International Dental Journal (2002) Vol. 52/No.2
lence and severity reported here
are likely to be underestimates of
disease among young children in
the city. It is the children from the
poorest families who have least
access to kindergartens and the
present results suggest that these
children are likely to have high
levels of disease. The social rela-
tionships seen here demonstrate
again the need for effective oral
health promotion measures that
have the capacity to benefit chil-
dren in all social class groupings
and not be confined to those who
already have good access to oral
health care. The children included
were of pre-school age, and results
show that caries is well established
in the majority by the time children
attend kindergarten and that it
continues to increase with age.
Thus, to be effective in preventing
disease and in promoting oral
health, measures must be directed
towards children from their earli-
est years and be continued into
school life.
Study results have shown consist-
ency in relation to caries experience
between the three social class meas-
ures included. School tuition fee,
which represents readily accessible
information and does not require
questions to be put to parents,
proved to be a good discriminant
variable. This index may therefore
be of particular value in the plan-
ning of oral health promotion
strategies for kindergarten children
in Amman.
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K{E:ji: University of London

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Sayegh eta/.:Canes in preschool children in Amman, Jordan