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Primary Health Care: Open Access
Tamimi and Pani, Primary Health Care 2015, 5:2
http://dx.doi.org/10.4172/2167-1079.1000195
Volume 5 • Issue 2 • 1000195
Primary Health Care
ISSN: 2167-1079 PHCOA, an open access journal
Open Access
Review Article
Dietary and Geographic and Cultural Factors as Predictors of Dental
Caries Risk among Children in Saudi Arabia – A Systematic Review
Hazem Al Tamimi1* and Sharat Chandra Pani2
1Department of Medical Dental, Security Forces Hospital, Riyadh, Saudi Arabia
2Department of Preventive Dental Sciences,Riyadh Colleges of Dentistry and Pharmacy, Saudi Arabia
Abstract
The widespread prevalence of dental caries in Saudi Arabia has been a cause for concern. As the largest country
in the Middle East region and with a population of over 20 million, geographic and socio demographic challenges play
a role in understanding caries risk in the country. The aim of this systematic review was to use the PRISMA guidelines
to conduct a systematic review of the dietary, geographic and socio demographic factors that could inuence the
prevalence of dental caries in Saudi Arabia. A review of the MEDLINE, Pubmed Central, Google Scholar and EBSCO
databases revealed 47 relevant articles. This review discusses the through the ndings of the above mentioned articles
the dietary, geographic and socio demographic factors that could inuence the prevalence of dental caries in children
in Saudi Arabia.
*Corresponding author: Hazem AlTamimi, Department of Medical Dental
Security Forces Hospital, Riyadh, Saudi Arabia,Tel: +966553660099; E-mail:
dr.haltamimi@gmail.com
Received March 26, 2015; Accepted July 03, 2015; Published July 10, 2015
Citation: Tamimi HAl, Pani SC (2015) Dietary and Geographic and Cultural
Factors as Predictors of Dental Caries Risk among Children in Saudi Arabia – A
Systematic Review. Primary Health Care 5: 195. doi:10.4172/2167-1079.1000195
Copyright: © 2015 Tamimi HAl, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Keywords: Diet; Dental caries; Children; Early childhood caries;
Geographic factors; Socio-demographic factors
Introduction
Dental caries has been recognized by the World Health Organization
as an infectious disease that could impact the physical, social and
emotional well-being of children. e widespread prevalence of caries
in Saudi Arabia has been attributed to a variety of factors including diet,
lack of education, and a lack of parental awareness [1-3].
A recent systematic review suggests that dental caries in Saudi
children could be higher than 80% in the primary teeth of children
fewer than 12 years of age [4]. Such a high prevalence of dental caries
oen negates the eectiveness of caries risk tools used in the West as
they classify almost all children as “High Risk” leaving little room for
dierentiation or sensitivity.
Caries risk assessment requires a detailed understanding of the
dietary and cultural factors that contribute to the occurrence of caries
[5-8].
Saudi Arabia is a “young country” with over 50% of the population
being under 12 years of age [9]. Since the rst studies on prevalence of
dental caries in the Kingdom of Saudi Arabia were carried out in the
1990’s, the severity of the disease and the impact it has had on children
has been documented in detail [10-13].Although the prevalence of
dental caries in Saudi Arabia has been reviewed and even meta-analyze
[4,14], few have attempted to review the cultural, regional and dietary
variations in dental caries in Saudi Arabia.
e aim of this systematic review is to analyze the data currently
available in literature with regards to the impact of diet, geography and
cultural factors that could inuence the prevalence of dental caries
among children in Saudi Arabia.
Methodology
is systematic review was performed using the Preferred Reporting
Items for Systematic Reviews and Metanalyses (PRISMA) guidelines for
systematic reviews and meta-analyses. e following sets of keywords
were used to identify articles of interest from the MEDLINE, Pubmed
Central, Google Scholar and EBSCO databases,
1) Diet, dietary factors, Saudi Arabia, dental caries
2) Region, Saudi Arabia, dental caries
3) Cultural Factors, Saudi Arabia, dental caries
e articles that appeared on the search were then ltered for
relevance (Table 1) and then subjected to the PRISMA ow-chart
(Figure 1).
A total of 47 studies matched the aim of this systematic review. e
studies were then analyzed to identify geographic, cultural and dietary
factors that could inuence the prevalence and severity of dental caries
among children in Saudi Arabia.
Results
Dietary Habits
e role of dietary habits and the relationship of these habits to
socio-economic status, order of birth and the education of the mother
have been documented in literature [15]. Attempts have been made
to document the dietary behavior of Saudi children and how this is
impacted by factors such as the availability of fermentable carbohydrates
in schools or the socio-cultural traits of parents [1-10].
Al Dossary et al studied the feeding patterns of children in Saudi
Arabia and found that the use of milk is rare and breast feeding is
common but higher number of children are breast fed g before sleep
[16]. ere has also been documentation of an increase in the use of
Keywords
Total number of responses
Pubmed Google-
Scholar
Relavant
Articles
Diet, dietary factors, Saudi Arabia, dental caries 7 4790 39
Cultural Factors, social factors, Saudi Arabia,
dental caries 1 3100 34
Region, Saudi Arabia, dental caries 109 8940 43
Table 1: Summary of the ndings of the keyword searches.
Citation: Tamimi HAl, Pani SC (2015) Dietary and Geographic and Cultural Factors as Predictors of Dental Caries Risk among Children in Saudi
Arabia – A Systematic Review. Primary Health Care 5: 195. doi:10.4172/2167-1079.1000195
Page 2 of 5
Volume 5 • Issue 2 • 1000195
Primary Health Care
ISSN: 2167-1079 PHCOA, an open access journal
bottled milk and carbonated drinks in bottles [14,17-19]. Wyne et al
reported that carbonated drinking items are popular and give these
contents in feeding bottles to the children [15]. Several studies have
corroborated these ndings, with some suggesting that as many as
seventy ve percentages of the Saudi children took so drinks and fruit
juices in feeding bottle [17-19]. e consumption of sugar containing
drinks has also been reported in older children. AlSadhan and Salwa
showed that the use of sugar containing drinks increased to three times
a day in Intermediate school children (13-18 years of age) as compared
to once daily in primary school children (aged 6-12 years) [20].
ere have been reported incidences of success through enforced
diet control. For example a group of children living in a social welfare
institute in Jeddah city where a strict dietary control and regular
application of oral hygiene measures showed lower prevalence of dental
caries [21]. However this systematic review was unable to nd evidence
of such programs being implemented in non-institutionalized children
in Saudi Arabia.
Geographic Factors
Saudi Arabia is a large country with a population of around 28.2
million individuals, over half this population is under the age of 12
years [9]. e Kingdom of Saudi Arabia also has a land area of 2,149,690
km² making it the largest country in the Arab world. Although the
Kingdom is spread over 13 main administrative regions the bulk of the
population is concentrated in the three major urban regions of Riyadh,
Jeddah and Dammam [9], it is therefore natural that a majority of the
studies have been reported from these areas (Figure 2).
Many studies show that caries distribution in the Kingdom varies
from 90-95%, with some studies suggesting that only 4% of Saudi children
aged between 6-7years of age were free of dental caries [8,12,21,22].
Nainar and Wyne, in a study conducted in Riyadh suggested that
preschool children had anterior and posterior teeth problems in about
90% and almost all the pre-school children had posterior caries [23].
Aldosari et.al. found that dental caries in AlQaseem area was 90.5% and
91.1% in Riyadh city is 91.1%. e mean DMFT score in Qaseem was
7.05 and 7.35 in Riyadh [16].
A recent Meta-analysis of caries in the dierent regions of Saudi
Arabia put the prevalence of dental caries at 85%. e paper also
pointed out that while publication bias observed in the analyses might
overestimate the level of dental caries in the permanent dentition, there
was no overestimation of dental caries in the primary dentition [14].
e dierence between the caries rates between urban and rural
populations is a factor that has received little attention. Results derived
Full-text arcles assessed
for eligibility
(n = 52)
Studies included in
qualitave synthesis
(n = 47)
Full-text arcles excluded,
with reasons
(n = 5; arcles did not
correspond to the
research queson)
Records excluded
(n = 2; full text unavailable)
Records screened
(n = 54)
Records aer duplicates removed
(n = 54)
Addional records idenfied
through other sources
(n = 2)
Eligibility
Included
Screening
Records idenfied through
database searching
(n =116)
Idenficaon
Figure 1: PRISMA (2009) Flow Diagram of the literature reviewed.
Citation: Tamimi HAl, Pani SC (2015) Dietary and Geographic and Cultural Factors as Predictors of Dental Caries Risk among Children in Saudi
Arabia – A Systematic Review. Primary Health Care 5: 195. doi:10.4172/2167-1079.1000195
Page 3 of 5
Volume 5 • Issue 2 • 1000195
Primary Health Care
ISSN: 2167-1079 PHCOA, an open access journal
from the rst national oral health survey suggested that children in
rural parts of Saudi Arabia had higher caries rates when compared
to their urban counterparts [13]. Despite this higher prevalence of
dental caries in rural children a study showed that only one h of
Bedouin children had poor oral hygiene and these children have
alower caries prevalence than both their urban and rural counterparts
[2]. e nature of population distribution has meant that most studies
have been done in the densely populated Riyadh, Makkah and Eastern
Provinces, with little detailed data available from other regions, it is
also seen that some regions do not have adequate published data
(Figure 2).
Geographic Considerations to Fluoride Exposure
Since there is no centralized water uoridation program in the
Kingdom of Saudi Arabia, the uoride intake of children through
water remains determined by geographic considerations. ere have
been attempts made to estimate the uoride levels in the water from
dierent parts of the Kingdom of Saudi Arabia [24].Al Dossary et al,
in their extensive study of the relationship between uoride levels
and dental caries in the Kingdom found that children from areas with
high levels of uoride in the water did not show signicantly lower
caries rates than their counterparts in areas with low levels of uoride
[16,24,25].
e lowest (DMFT) was found in children from lowest water
uoride level and higher DMFT from areas with more optimum water
uoride level [16]. ere have been several explanations postulated for
this lack of linear relationship between uorides and dental caries. It has
been suggested that extremely poor dietary habits combined with an
apparent lack of awareness, water down the probable eects of Fluoride
[26]. Another explanation that has been preferred is that the absence
of accurate data on the source of potable water, and an in adequate
data on the number of children consuming bottled water makes it
dicult to evaluate the relationship between uoride and dental caries
[25]. However, a more recent study, based on the relationship between
dental uorosis and dental caries showed that at levels above 0.6ppm,
there was evidence of mild dental uorosis in a signicant number of
children [24].
In majority of regions in Saudi Arabia the uoride level was lower
than recommendations and the highest uoride level in water was in
Hail region and it was 1.27 PPM while the lowest mean in uoride
levels found in As per region [24]. However it must be remembered
that Saudi Arabia is an arid desert country with average temperatures
approaching 36o C (960F). e water consumption would therefore
needs to be adjusted for this higher temperature and relative lack of
humidity. Given these factors there is a need to critically analyze the
optimum uoride levels in the Kingdom of Saudi Arabia.
Cultural and Socioeconomic Factors and their Impact on
Dental Caries
e literature reviewed suggests that cultural and socioeconomic
factors have an inuence on the prevalence and severity of dental caries.
is is visible in terms of the impact of these factors on the type of
oral hygiene practices used in children as well as the parents attitude
towards dental visits
Figure 2: Map showing the reporting of caries data in the major administrative regions of Saudi Arabia.
Citation: Tamimi HAl, Pani SC (2015) Dietary and Geographic and Cultural Factors as Predictors of Dental Caries Risk among Children in Saudi
Arabia – A Systematic Review. Primary Health Care 5: 195. doi:10.4172/2167-1079.1000195
Page 4 of 5
Volume 5 • Issue 2 • 1000195
Primary Health Care
ISSN: 2167-1079 PHCOA, an open access journal
Oral Hygiene Practices
Recent reviews and Meta analyses show that poor oral hygiene
rates exist among the children of the dierent Saudi regions [14,16].
ere are cultural factors related to oral hygiene practices and dietary
habits which produce a comparatively higher rate of dental caries
among Saudi people [27].
A study from Riyadh showed that more than ten percent of children
had poor and about y percent had reasonable oral hygiene [28].
Tooth cleaning with the brush is at the age of two years are rare among
children and the age of brushing their teeth is beginning aer three
years of maturation [29-31]. Oral hygiene care practices in the Saudi
population seem to start later than the suggested time for the teeth
cleaning. It has been reported that about forty percent of preschoolers
in Riyadh city did not brush their teeth [32]. Similar ndings were
observed in in Alkharj city [33]. While in Tabuk city which located in
the north west region the studies showed that the mother educational
level play an important factor in oral hygiene practices [34,35].
e birth-order of the child or number of children in the family
does not seem to aect the brushing practices or rst dental visit pattern
[36]. Wyne et.al. In their survey showed that although a majority of the
children were aware that oral health is an essential factor towards the
general health of a person about one h reported that they have no
idea about eective brushing for their teeth [36]. In another study one
fourth had not been taught how to brush their teeth [37]. is general
lack of willingness of children to brush their teeth, and a lack of the will
to educate them seems to suggest that traditional methods may oer
some hope.
e use of miswak which is a tooth cleaning twig is a socially
recognized dental cleaning method prevailing in Saudi Arabia and has
been reported to result in signicant reductions in plaque [38,39]. A
study conducted in 10 regions of Saudi Arabia based on 3117 persons
een years and older revealed that half the population studied used
miswak for their dental cleaning [40].
is habit has religious support as well as social acceptance.
Generally a large part of the society follows the use of miswak. e use of
miswak among young Saudis seems to cut across social, economic and
regional lines with multiple studies conrming acceptance of this habit
[29,38-41]. Children are oen inuenced by their teachers and studies
have shown that between two third and a h of all school teachers
surveyed used only miswak (Figure 3) to maintain oral hygiene [42].
Education also seems to play a role in the prevention of dental
caries. Mothers with a college education have been shown to give more
care to their children’s dental cleaning, including the use of adjuncts
such as dental oss [20]. It has also been demonstrated that maternal
education plays a much more signicant role than the education of the
father when it comes to parental awareness towards the oral health of
Saudi children [43].
Dental Visits
It has been shown that parents in Saudi Arabia have a lack of
knowledge about the benets of regular dental check-ups for their
children [19]. 12.5% completed their initial appointment at age 12
months and the average number of children is 4.36 per family that is
high rate contrast with western countries [19].
While the usual reason for not visiting a dentist is the unavailability
of dental care, data from Saudi Arabia seems to contradict this. About
one fourth of the students sampled in Jeddah city; a large city with the
highest number of registered dentists in Saudi Arabia (MOH 2012);
had never visited a dentist [44]. In Riyadh city, only below een
percentages of children are ready to visit the dentist for a regular
check-up [45]. It has been repeatedly documented that children go to a
dentist in Saudi Arabia only under the condition of pain in their teeth
[1,4,22,36,46]. Moreover, 40.0% of children thought that one must visit
the dentist only in case of pain in the teeth [3]. While in AlJubail city
which located in the east region about two third visited the dentist only
in case of dental problems [47].
Conclusion
is systematic review reveals that the Dietary factors (including
uoride exposure), Cultural factors such as feeding practices in infants
and the use of miswak, and the diverse geographic distribution of
population in Saudi Arabia, each in their own way inuence the
prevalence of dental caries among children.
However the review also shows that there is little attempt to study
these factors on a large scale. How these issues are addressed in future
oral health surveys will be important if a tool is to be developed to
assess caries risk in children in Saudi Arabia.
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Citation: Tamimi HAl, Pani SC (2015) Dietary and Geographic and Cultural Factors as Predictors of Dental Caries Risk among Children in Saudi
Arabia – A Systematic Review. Primary Health Care 5: 195. doi:10.4172/2167-1079.1000195
Page 5 of 5
Volume 5 • Issue 2 • 1000195
Primary Health Care
ISSN: 2167-1079 PHCOA, an open access journal
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Citation: Tamimi HAl, Pani SC (2015) Dietary and Geographic and Cultural
Factors as Predictors of Dental Caries Risk among Children in Saudi Arabia
– A Systematic Review. Primary Health Care 5: 195. doi:10.4172/2167-
1079.1000195
