Impact of war on oral health among the Gaza population: a comparative cross-sectional study

Abstract

Background

Armed conflict disrupts health systems and daily self-care practices, yet quantitative evidence on its impact on oral health is scarce. This study compared self-reported oral health status, hygiene behaviours, and access to dental care among residents of the Gaza Strip before and during the 2023–2024 war.

Methods

A comparative cross-sectional survey was conducted among 599 Gaza residents using a structured, self-developed 34-items online questionnaire. Participants reported oral health conditions and behaviours for two periods: before October 2023 and during the war. Paired categorical data were analysed using Bowker’s test of symmetry for multi-category variables, and McNemar’s test for binary variables, and subgroup associations were examined using chi-square tests.

Results

Significant deterioration was observed across all 12 assessed domains (p < 0.001 for 11 variables; p = 0.013 for the remaining variable). The proportion reporting severe oral pain increased from 6.5% pre-war to 73.8% during the war, while those reporting no pain decreased from 25.5% to 2.0%. Favourable self-rated dental status (excellent/good) declined from 85.3% to 9.7%, and the proportion reporting healthy gums decreased from 88.1% to 12.4%. Twice-daily tooth brushing fell from 77.5% to 9.5%, and complete cessation of brushing increased from 0.8% to 38.4%. Unmet dental care needs rose from 11.7% to 92.7%, with insecurity and lack of dental services as the main barriers. Stress-related oral habits increased markedly, and 86.0% of participants reported dependence on canned foods. Overall, 95.5% perceived their oral health to have worsened since the onset of the war.

Conclusion

The Gaza war was associated with profound deterioration in self-reported oral health status, hygiene practices, and access to dental care. These findings highlight oral health as a neglected dimension of humanitarian crises and underscore the need to integrate essential dental services into emergency health responses and post-conflict reconstruction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-09428-7.

Introduction

Oral diseases are among the most common non-communicable conditions worldwide and are increasingly recognized as a major public health problem. The World Health Organization (WHO) estimates that oral diseases affect about 3.7 billion people, with untreated dental caries in permanent teeth being the single most prevalent health condition globally [1]. These conditions cause pain, impaired nutrition, reduced quality of life, and substantial economic costs, particularly in low- and middle-income countries (LMICs), where three-quarters of those affected live [2]. Despite this burden, oral health has historically been neglected and often remains weakly integrated into primary care and universal health coverage efforts [3].

In recent years, attention has turned to the intersection between oral health and humanitarian crises. War, armed conflict, and state fragility disrupt health systems, supply chains, and social determinants of health, and oral health is no exception [4]. Editorials and systematic reviews highlight that conflict-affected populations experience higher levels of untreated dental caries, periodontal disease, and tooth loss, alongside major barriers to preventive and curative dental care [4–6]. Mechanisms include destruction or closure of dental facilities, shortages of materials and staff, displacement, food insecurity, unsafe water, and psychological trauma that undermines self-care practices [5, 6]. In refugee and internally displaced populations, studies consistently report high unmet treatment needs, low access to oral health services, and limited integration of oral care into emergency health packages [5, 6]. The occupied Palestinian territory, and particularly the Gaza Strip, represents a protracted crisis setting where these dynamics are especially acute. Even before the current phase of hostilities, Gaza had endured a long-standing blockade, recurrent military escalations, high poverty, and chronic under-resourcing of its health system. WHO and global burden of disease analyses indicate that oral diseases in Palestine rank among the leading causes of morbidity [7, 8]. Zhu et al. note that in 2021, oral diseases were a major contributor to disability in Palestine, reflecting high prevalence of dental caries, periodontal disease, and other oral conditions in a system already struggling with shortages of personnel, infrastructure, and preventive programmes [7].

Within Gaza, oral healthcare was historically provided by a mix of Ministry of Health (MoH) clinics, UNRWA (United Nations Relief and Works Agency) services for refugees, nongovernmental organizations, and private practices, supplemented by university dental clinics [9, 10]. Before October 2023, the two dental schools (Al-Azhar University and University of Palestine) operated around 156 dental units, treating approximately 500 patients per day and graduating 300–400 new dentists annually, thereby playing a crucial role in both service provision and workforce development [9]. However, even in this “pre-war” period, many Gazans faced financial and geographic barriers to accessing oral healthcare, and preventive services were limited [7–10].

The escalation of hostilities beginning on 7 October 2023 has transformed this chronic vulnerability into an acute catastrophe. WHO situation reports describe a health system “severely under-resourced” after a 16-year blockade, now further degraded by intensive bombardment, power cuts, fuel shortages, and restrictions on humanitarian access [11].

Oral health has been a “silent casualty” of this collapse [11, 12]. University dental clinics have been destroyed along with other higher-education institutions, eliminating hundreds of dental units that previously delivered daily care and training [9]. Almadhoon et al. report that at least 48 dentists, 26 dental students, and two university staff had been killed by mid-2024 [9].

Between 7 October 2023 and 22 July 2024, only 2,445 trucks carrying medical supplies entered Gaza, just 8.5% of all incoming aid, while deliveries of dental supplies were almost absent. As a result, the cost of dental materials has risen tenfold, forcing dentists to rely on basic tools and methods, often working in tents with very limited resources. Many patients avoid treatment due to fear of procedures without proper pain control. Even when clinics have the materials for advanced care, constant displacement and ongoing airstrikes disrupt clinic operations and prevent patients from returning for follow-ups. This situation leaves many dentists with no choice but to perform last-resort treatments like tooth extractions [9].

At the same time, the social and biological factors influencing oral health in Gaza have worsened significantly. Dentists report sharp rises in conditions linked to malnutrition, such as gum bleeding, scurvy-related gingivitis, and enamel loss caused by limited, nutrient-poor diets dominated by canned food. Chronic stress, anxiety, depression, and PTSD (Post –Traumatic Stress Disorder), which already affected over half of Gaza’s children before the war, further reduce daily oral hygiene and clinic attendance. Meanwhile, the extreme workload, personal trauma, and malnutrition faced by dental professionals themselves are leading to burnout and diminished ability to deliver care [9, 11].

Despite growing commentaries and policy briefs, there is still limited quantitative evidence describing how the Gaza conflict has changed oral health outcomes over time. Existing publications largely consist of editorials, situation reports, and descriptive accounts that emphasize the urgency of integrating oral health into humanitarian response, especially in conflict areas and among refugees [5, 6, 11]. To our knowledge, no study has systematically compared oral health status and oral health service utilization in Gaza before and during the current war using standardized indicators such as caries experience, periodontal status, tooth loss, pain, oral health–related quality of life, and patterns of dental care-seeking.

A comparative analysis of the pre-war and during-war periods in Gaza would therefore address an important evidence gap. This study aimed to quantify changes in self-reported oral health status, hygiene behaviors, and access to dental care among Gaza Strip residents before and during the war. We hypothesized that the conflict would be associated with significant deterioration across all assessed oral health domains, driven by disruption of health services, food insecurity, displacement, and increased psychosocial stress. By linking oral health trends to specific conflict-related exposures such as displacement, food insecurity, attacks on health facilities, and loss of income, it would also illuminate key pathways through which armed conflict is associated with worse oral health outcomes. The findings could inform humanitarian agencies, Palestinian health authorities, and international partners in designing emergency oral health responses, prioritizing resource allocation and planning the post-war reconstruction of a resilient, equity-oriented oral healthcare system in Gaza.

Methods

Study design

This study employed a cross-sectional comparative survey design to assess differences in oral health status, behaviors, and access to dental care among residents of the Gaza Strip before the war and during the war. Cross-sectional surveys are widely used in conflict-related public health research because they allow rapid data collection under unstable conditions and provide population-level estimates of health needs [4, 5]. Data were collected using an online self-administered questionnaire distributed via Google Forms, which is an effective tool for health surveys in settings with restricted mobility or security challenges [13]. A total of 599 participants from the Gaza Strip completed the survey between May 2025 and October 2025, as shown in Fig. 1.

Fig. 1.

Graphic abstract of study methodology and comparative analysis of oral health care

Sample size

Participants were eligible if they lived in any governorate of the Gaza Strip and could access and complete the online questionnaire. Given the absence of reliable sampling frames in displaced and mobile populations, non-probability methods such as convenience sampling were deemed the only feasible option for this survey [14]. A formal a priori sample size calculation was not feasible due to the absence of a reliable sampling frame and the rapidly evolving conflict setting in Gaza; therefore. The population of the Gaza Strip was approximately 2.3 million before October 2023. To evaluate the precision of the achieved sample (n = 599), a post hoc estimation based on the standard formula for a population proportion (n = Z²·p·(1 − p)/d²) was performed. Under the conservative assumption (p = 0.50) at 95% confidence and ± 4% precision, the required sample size is 601, which is closely approximated by the obtained sample size of 599. Using the observed primary outcome proportion (95.5%) with ± 2% precision, the required sample size is 413, which is exceeded by the current sample. Although these calculations assume random sampling, they indicate that the achieved sample provides reasonable precision for estimating key outcome proportions. The survey link was distributed via WhatsApp groups, Facebook community pages, and Telegram channels targeting Gaza residents, as well as through direct sharing by Ministry of Health contact networks.

Questionnaire development

Our questionnaire was developed based on: WHO oral health indicators, including self-reported oral health status, oral hygiene behaviors, and service utilization [15], prior research documenting oral health challenges in conflict and displacement settings [4, 5], and Contextual information about Gaza’s health system during wartime disruptions [9].

A structured self-administered questionnaire was developed for this study, comprising 34 items organized into three sections. The first section collected socio-demographic information across seven variables: sex, age group, occupational status, level of educational attainment, monthly household income, displacement situation, and residential area. The second and principal section addressed oral health status and hygiene behaviours across 12 clinical and behavioural domains, each assessed twice — once with reference to the period before the war and once with reference to the period during the war. These domains were: (1) experience of oral pain or discomfort; (2) self-rated condition of the teeth; (3) self-rated condition of the gums; (4) frequency of tooth brushing; (5) timing of tooth brushing; (6) dental cleaning implements used; (7) recency of last dental visit; (8) reason for last dental visit; (9) unmet dental care need; (10) barriers to accessing dental care; (11) tobacco use; and (12) stress-related parafunctional oral habits and dietary pattern. The third section captured current wartime-specific outcomes: perceived overall deterioration in oral health, the most common current oral complaint, and the type of dental service considered most urgently needed. All response options were pre-specified in a closed-ended format. For self-rated teeth condition, a five-point scale was used (excellent, good, acceptable, bad, very bad). Brushing frequency was assessed on a four-point ordinal scale (twice a day, once a day, less than once a day, never). Recency of the last dental visit was assessed across four ordered categories (less than 6 months, 6–12 months, more than a year, never visited). The remaining items used nominal response categories. Most questions used multiple-choice items, Likert scales, and paired pre-war vs. during-war responses to allow direct comparison. The English version of the complete questionnaire is provided as Supplementary File 1.

Validity and reliability

To ensure content validity, the questionnaire was reviewed by experts in oral public health, Gaza-based dentists, and the Health Research Department in the Palestinian Ministry of Health, with firsthand knowledge of war-related service disruptions, consistent with best practices for survey development in conflict settings [16]. Questions were adapted to reflect the unique challenges described in recent Gaza oral health reports [11]. A pilot test with 50 participants evaluated clarity and comprehension. Necessary linguistic and formatting revisions were made before final dissemination.

Data collection

The survey was open from May 2025 to October 2025. Participation was voluntary and anonymous. Respondents were allowed to complete the form using mobile devices, a critical method during war conditions where electricity and computer access may be unreliable. Duplicate entries were prevented using Google Forms with a limit to one response feature.

Outcome measures

Key outcome measures included self-reported oral health status (teeth condition, gum condition and oral pain), oral hygiene behaviors (such as brushing frequency, tools used and any interruption of hygiene practices), access to dental services (last dental visit, unmet dental needs and barriers to care), lifestyle and psychosocial factors (including diet changes, stress-related habits and tobacco use) and overall perception of worsening oral health. All variables were assessed for two time periods: pre-war (before October 2023) and during the war, allowing paired, individual-level before and after comparisons, an approach recommended in conflict settings where baseline clinical examinations are not feasible [5].

Statistical analysis

Data were exported from Google Forms into Microsoft Excel and analyzed using IBM SPSS (Statistical Package for the Social Sciences) version 27.0.1 and R 4.4.3. Descriptive statistics for all variables are reported as frequencies and proportions, calculated relative to the total sample of 599 participants. For paired before-and-during comparisons, Bowker’s test of symmetry was applied as the primary inferential test for more than 2 categories, and McNemar’s test for binary variables. These tests are appropriate for paired categorical data where the same participants are assessed under two conditions, as they evaluate whether changes are symmetrically distributed in both directions. The test statistic follows an approximate chi-square distribution; a significance p < 0.05 was adopted. Associations between potential predictors and oral health deterioration during the war were assessed using chi-square tests.

Ethical considerations

Ethical approval for this study was obtained from the Ethics Committee of Dalian Stomatological Hospital (DLKOLL20250109) and the Ethical Approval Committee for Research, Ministry of Health – Gaza Strip (Palestinian Ministry of Health). The study was conducted in accordance with the Declaration of Helsinki. Due to wartime conditions and the anonymous nature of the online survey, the committees granted expedited review.

Informed consent to participate was obtained from all participants before enrollment. For participants under 18 years of age, questionnaires were completed by the minor with parental/guardian oversight; parents/guardians provided consent and were instructed to assist in clarifying questions if needed, but to record the minor’s own assessment of oral health status and behaviors. All participants (or their parents/guardians for minors) provided electronic informed consent. Participants were informed of the study’s purpose and anonymity at the beginning of the survey. Participation was entirely voluntary. No personal identifiers were collected, ensuring confidentiality and compliance with ethical standards for research in crisis settings [17].

Results

Socio-demographic characteristics

A total of 599 respondents from the Gaza Strip completed the questionnaire. Slightly more than half were male 51.60%, n = 309, and 48.40% (n = 290) were female. The age distribution was broadly young to middle-aged: 35.9% (n = 215) were 18–29 years, 37.6% (n = 225) were 30–44 years, 13.4% (n = 80) were under 18 years, and 13.2% (n = 79) were 45 years and older. Regarding occupation, workers constituted 33.6% (n = 201) of the sample, students 31.2% (n = 187), and unemployed individuals 24.9% (n = 149), with the remainder reporting other occupations. Over half of respondents (57.3%, n = 343) reported university-level education, and a further 18.0% (n = 108) had completed high school. Nearly half of the sample (47.4%, n = 284) reported a monthly household income below 100 USD (United States Dollars), whereas 18% (n = 108) reported more than 500 USD. Displacement was almost universal: 83.8% (n = 502) reported being currently displaced, 11.5% (n = 69) had been displaced but returned home, and only 4.7% (n = 28) reported being non-displaced. Participants were distributed across all governorates, with the largest proportions from Khan Younis (28.0%), the Central Region (18.9%), North Gaza (18.5%), Rafah (17.9%), and Gaza City (16.7%), as described in Table 1. The seemingly paradoxical co-occurrence of high educational attainment and very low income likely reflects the severe economic disruption caused by the war, which drastically reduced employment and income even among educated professionals.

Table 1.

Socio-demographic characteristics

Variable	n	%	Total	Variable	n	%	Total
Sex			599	Family monthly income			599
Male	309	51.60%		Under $100	284	47.40%
Female	290	48.40%		$100–$300	104	17.40%
Age group			599	$301–$500	86	14.40%
Under 18 years old	80	13.40%		Over $500	108	18.00%
18–29 years	215	35.90%		Not reported	17	2.80%
30–44 years	225	37.60%		Displacement situation			599
45 years and older	79	13.20%		Currently displaced	502	83.80%
Occupation			599	Displaced but returned home	69	11.50%
Student	187	31.20%		Non-displaced	28	4.70%
Unemployed	149	24.90%		Residential area			599
Worker/Employee (Factor)	201	33.60%		Khan Younis	168	28.00%
Other	62	10.40%		Central region	113	18.90%
Level of education			599	North Gaza	111	18.50%
Primary	23	3.80%		Rafah	107	17.90%
Secondary	108	18.00%		Gaza City	100	16.70%
University	343	57.30%
Postgraduate studies	38	6.30%
Student (in school)	65	10.90%
No formal education	22	3.70%

Self-reported oral health status before vs. during the war

Table 2 demonstrates the results of the comparative Statistical Analysis of Oral Health Status before and during the War in Gaza (Fig. 2).

Table 2.

Oral health status before and during the war in Gaza

Variable / Category	Before the War n (%)	During the War n (%)	p value
Pain/discomfort in teeth or mouth			< 0.001
Yes, sometimes	407 (67.9%)	145 (24.2%)
Yes, very much	39 (6.5%)	442 (73.8%)
No	153 (25.5%)	12 (2.0%)
Self-reported condition of teeth			< 0.001
Excellent	186 (31.1%)	6 (1.0%)
Good	325 (54.3%)	52 (8.7%)
Acceptable	78 (13.0%)	111 (18.5%)
Bad	4 (0.7%)	215 (35.9%)
Very bad	6 (1.0%)	215 (35.9%)
Self-reported condition of gums			< 0.001
Healthy	528 (88.1%)	74 (12.4%)
Bleeding	33 (5.5%)	171 (28.5%)
Painful	23 (3.8%)	211 (35.2%)
Swollen	10 (1.7%)	109 (18.2%)
Receding	5 (0.8%)	34 (5.7%)
Number of times brushing per day			< 0.001
Twice a day	464 (77.5%)	57 (9.5%)
Once a day	122 (20.4%)	127 (21.2%)
Less than once	8 (1.3%)	185 (30.9%)
Never	5 (0.8%)	230 (38.4%)
When teeth are usually brushed			< 0.001
After meals	360 (60.1%)	31 (5.2%)
Before bed	127 (21.2%)	175 (29.2%)
In the morning	98 (16.4%)	91 (15.2%)
Other	9 (1.5%)	43 (7.2%)
Never brushed	5 (0.8%)	259 (43.2%)
Tools used to clean teeth			< 0.001
Brush & toothpaste	575 (96.0%)	203 (33.9%)
Siwak	10 (1.7%)	61 (10.2%)
Salt/Baking soda	1 (0.2%)	55 (9.2%)
Mouthwash	5 (0.8%)	26 (4.3%)
Dental floss	5 (0.8%)	20 (3.3%)
Coal	0 (0.0%)	15 (2.5%)
Other	3 (0.5%)	219 (36.6%)
Time since last dental visit			< 0.001
Less than 6 months	235 (39.2%)	221 (36.9%)
6–12 months	194 (32.4%)	111 (18.5%)
More than a year	138 (23.0%)	156 (26.0%)
Never visited	32 (5.3%)	111 (18.5%)
Reason for dental visit			< 0.001
Periodic check	247 (41.2%)	7 (1.2%)
Filling/Treatment	212 (35.4%)	116 (19.4%)
Pain/Problem	63 (10.5%)	267 (44.6%)
Tooth extraction	35 (5.8%)	103 (17.2%)
Gum problem	20 (3.3%)	39 (6.5%)
Other	22 (3.7%)	67 (11.2%)
Needed dental care but could not access it			< 0.001
Yes (unmet need)	70 (11.7%)	555 (92.7%)
No	529 (88.3%)	44 (7.3%)
Tobacco use			0.015
No	557 (93.0%)	570 (95.2%)
Cigarettes	30 (5.0%)	20 (3.3%)
Shisha	11 (1.8%)	5 (0.8%)
Smokeless tobacco	1 (0.2%)	1 (0.2%)
Other	0 (0.0%)	3 (0.5%)
Stress-related habits			< 0.001
None	536 (89.5%)	247 (41.2%)
Nail biting	36 (6.0%)	201 (33.6%)
Teeth grinding	14 (2.3%)	105 (17.5%)
Jaw tightening	13 (2.2%)	46 (7.7%)
12. Dietary Pattern
Dietary pattern			< 0.001
Balanced diet	377 (62.9%)	0 (0.0%)
Rich in fruits & vegetables	134 (22.4%)	0 (0.0%)
Natural	88 (14.7%)	0 (0.0%)
Depends on canned goods	0 (0.0%)	515 (86.0%)
No major changes	0 (0.0%)	53 (8.8%)
Less fresh food	0 (0.0%)	31 (5.2%)

Fig. 2.

Distribution of oral health status and behaviors before and during the war in Gaza. Combined heatmap displaying percentage distribution across 12 paired variables, each variable occupies two consecutive rows before and during war, representing the percentage of the total sample (N = 599). Complete mapping of column numbers to response categories for each variable. Pain [1–3]: No, Sometimes, Very much. Teeth [1–5]: Excellent, Good, Acceptable, Bad, Very bad. Gums [1–5]: Healthy, Bleeding, Painful, Swollen, Receding. Brushing frequency [1–4]: Twice/day, Once/day, < Once/day, Never. Brushing timing [1–5]: After meals, Before bed, Morning, Other, Never. Cleaning tools [1–7]: Brush + paste, Siwak, Salt/soda, Wash, Floss, Coal, Other. Last visit [1–4]: <6mo, 6–12mo, > 1 year, Never. Visit reason [1–6]: Periodic, Treatment, Pain, Extract, Gum, Other. Unmet need [1–2]: No, Yes. Tobacco [1–4]: No, Cigarettes, Shisha, Other. Stress habits [1–4]: None, Nail biting, Grinding, Jaw tightening. Diet [1–6]: Balanced, Fruits/veg, Natural, Canned, No change, Less fresh

Oral pain and discomfort

Statistically significant shifts in the experience of oral pain were recorded between the pre-war and wartime periods (p < 0.001). Before the conflict, the majority of participants reported occasional discomfort (n = 407, 67.9%), with only 39 participants (6.5%) describing severe and frequent pain, and 153 (25.5%) reporting no pain whatsoever. This pattern reversed markedly during the war: 442 participants (73.8%) reported severe, persistent oral pain, while those experiencing only occasional discomfort declined to 145 (24.2%). The proportion reporting a complete absence of pain contracted to a mere 12 participants (2.0%), underscoring a near-universal deterioration in this dimension of oral health.

Self-reported dental and periodontal condition

Pre-war self-assessments of dental condition were predominantly favourable: 186 participants (31.1%) rated their teeth as excellent and 325 (54.3%) as good, with fewer than 1.7% (n = 10) reporting bad or very bad status. By contrast, wartime assessments reflected a collapse in perceived dental health. The proportion rating their teeth as “bad” rose to 35.9% (n = 215), and an equivalent proportion rated them as very bad (n = 215, 35.9%), while only 1.0% (n = 6) retained an excellent rating (p < 0.001).

Self-reported periodontal status exhibited a similarly dramatic deterioration. Before the war, 88.1% of participants (n = 528) described their gums as healthy, with the remainder reporting bleeding (n = 33, 5.5%), pain (n = 23, 3.8%), swelling (n = 10, 1.7%), or recession (n = 5, 0.8%). During the conflict, only 74 participants (12.4%) reported healthy gums. Pain became the dominant presentation (n = 211, 35.2%), followed by bleeding (n = 171, 28.5%) and swelling (n = 109, 18.2%), with gingival recession increasing more than sixfold to 34 cases (5.7%). The magnitude of this shift was highly significant (p < 0.001).

Oral hygiene practices

Substantial changes in oral hygiene behaviors were observed across all measured dimensions. Regarding brushing frequency, 77.5% of participants (n = 464) had brushed twice daily before the war; this fell to 9.5% (n = 57) during the conflict. Conversely, complete cessation of brushing, reported by fewer than 1% (n = 5) before the war, was documented in 38.4% of participants (n = 230) during wartime, with a further 30.9% (n = 185) brushing less than once per day (p < 0.001).

Brushing timing patterns shifted correspondingly. Post-meal brushing, the predominant pre-war practice (n = 360, 60.1%), fell to 31 participants (5.2%) during the war. The largest wartime category was complete non-brushing (n = 259, 43.2%), a state that had applied to only 0.8% before the conflict (p < 0.001).

The choice of dental cleaning implements also changed markedly. Before the war, the use of a toothbrush and toothpaste was near-universal (n = 575, 96.0%). During the conflict, this fell to 33.9% (n = 203), while the use of improvised or traditional alternatives expanded substantially: Siwak (n = 61, 10.2%), salt or baking soda (n = 55, 9.2%), coal (n = 15, 2.5%), and a broad “other” category (n = 219, 36.6%), reflecting the collapse of conventional supply chains and the forced adoption of available substitutes ( p < 0.001).

Access to dental care and unmet needs

Timing and reason for dental visits

Pre-war dental attendance was comparatively regular: 39.2% of participants (n = 235) had last visited a dentist within six months, and 32.4% (n = 194) within the preceding year, with only 5.3% (n = 32) having never attended. During the war, the proportion who had never visited a dentist more than tripled to 18.5% (n = 111), and those whose last visit exceeded one year rose to 26.0% (n = 156), changes that reached high statistical significance (p < 0.001). The apparent increase in those reporting ‘never visited a dentist’ during the war from 5.3% to 18.5% warrants interpretation. This category, during the wartime period, captures individuals who had not accessed dental care at any point during the conflict, including those who might have otherwise attended for the first time. This finding reflects a complete cessation of dental care-seeking among a substantial segment of the population rather than a historical absence of attendance.

The reasons for dental attendance shifted from preventive to emergency-driven. Before the conflict, routine periodic check-ups were the most frequently cited reason for the last dental visit (n = 247, 41.2%), with restorative treatment ranking second (n = 212, 35.4%). During the war, pain or acute dental problems became the primary driver (n = 267, 44.6%), and routine check-ups had effectively ceased (n = 7, 1.2%). Tooth extraction, cited by 35 participants (5.8%) pre-war, rose to 103 (17.2%) during the conflict, reflecting the absence of infrastructure for more conservative dental procedures (p < 0.001).

Unmet dental care needs and barriers to access

The proportion of participants reporting unmet dental care needs increased dramatically during the conflict. Whereas 88.3% (n = 529) had been able to meet their dental care needs before the war, 92.7% (n = 555) reported unmet needs during wartime — a reversal of access that was statistically significant at the highest threshold (p < 0.001).

Lifestyle factors

Tobacco use

Tobacco use declined modestly but significantly during the war compared with the pre-war period (p = 0.015). Cigarette smoking fell from 5.0% (n = 30) to 3.3% (n = 20), and shisha use from 1.8% (n = 11) to 0.8% (n = 5). The rate of non-use increased from 93.0% (n = 557) to 95.2% (n = 570), likely reflecting supply interruption rather than deliberate cessation. This variable showed the smallest effect size among all paired comparisons in the study.

Stress-related parafunctional habits

War-related psychological distress was reflected in a striking increase in parafunctional oral habits (p < 0.001). The proportion of participants reporting no such habits fell from 89.5% (n = 536) to 41.2% (n = 247). Nail biting was the most marked individual change, rising from 6.0% (n = 36) to 33.6% (n = 201). Bruxism increased from 2.3% (n = 14) to 17.5% (n = 105), and jaw tightening from 2.2% (n = 13) to 7.7% (n = 46). These findings are consistent with the established relationship between psychological trauma and parafunctional behavior, and carry direct implications for temporomandibular and periodontal health.

Dietary change and nutritional implications

Dietary patterns underwent near-total transformation during the conflict (p < 0.001). Before the war, 62.9% of participants (n = 377) described their diet as balanced, 22.4% (n = 134) as rich in fruits and vegetables, and 14.7% (n = 88) as natural or unprocessed. During the conflict, 86.0% of participants (n = 515) reported dependence on canned goods, with only 8.8% (n = 53) reporting no major dietary change and 5.2% (n = 31) noting a reduction in fresh food. This shift toward cariogenic, low-fibre, nutrient-poor diets carries recognized implications for both dental caries development and periodontal resilience.

Perceived overall oral health deterioration and current clinical burden

Table 3 shows that when asked directly whether their oral health had worsened since the onset of the war, 95.5% of participants (n = 572) affirmed that it had, 2.8% (n = 17) were uncertain, and only 1.7% (n = 10) reported no perceived change. This near-unanimous subjective assessment corroborates the self-reported deterioration documented across all assessed domains in this study.

Table 3.

Perceived overall impact of war on oral health

Oral health worsened since the war	N	%	Total
Yes	572	95.50%	599
Not sure	17	2.80%
No	10	1.70%
Most Common Current Oral Problems
Toothache	359	59.90%	599
Tooth loss	102	17.00%
Bleeding/swollen gums	84	14.00%
Difficulty chewing	32	5.30%
Other	22	3.70%
Most Urgently Needed Dental Services in Gaza
Emergency pain relief	329	54.90%	599
Tooth extraction	63	10.50%
Gum treatment	63	10.50%
Dental restorations (Compositions)	62	10.40%
Children’s dental treatment	41	6.80%
Preventive care	41	6.80%

Toothache was the most prevalent current oral complaint, affecting 359 participants (59.9%). Tooth loss was reported by 102 participants (17.0%), bleeding or swollen gums by 84 (14.0%), difficulty chewing by 32 (5.3%), and other complaints by 22 (3.7%). Regarding the type of dental service considered most urgently required in Gaza, emergency pain relief was cited by the largest share of participants (n = 329, 54.9%), followed by tooth extraction (n = 63, 10.5%), gum treatment (n = 63, 10.5%), restorative work (n = 62, 10.4%), pediatric dental treatment (n = 41, 6.8%), and preventive care (n = 41, 6.8%). The prominence of emergency services reflects the immediate burden of untreated acute pathology, while the demand for pediatric and preventive care points to longer-term consequences requiring sustained attention in any post-conflict reconstruction of dental services.

Overall, the survey demonstrates a profound deterioration in self-reported oral health status, oral hygiene practices, and access to dental care among Gaza residents during the war, with statistically significant worsening in pain, teeth and gum condition, brushing frequency, and unmet treatment needs (all p < 0.001). These changes were significantly associated with widespread displacement, increased psychosocial stress, and severe disruption of health services and food supply.

Factors associated with oral health deterioration

Table 4 demonstrates predictors of oral health deterioration during the war. Displacement status. Displacement was significantly associated with oral pain severity (p < 0.001), teeth condition (p < 0.001), and unmet dental care need (p = 0.025). Currently displaced participants reported higher rates of severe pain (77%) and unmet care needs (94%) than returnees or non-displaced individuals, suggesting that displacement was associated with greater barriers to oral healthcare. Socio-demographic factors. Age, sex, income, and education were not significantly associated with perceived oral health deterioration, which exceeded 93% across all subgroups, suggesting a broadly distributed impact of the conflict. Oral hygiene behaviours. Frequency of tooth brushing strongly predicted gum (p < 0.001) and teeth condition (p < 0.001). Participants maintaining twice-daily brushing were more likely to retain healthy gums (39%) compared with those who ceased brushing (2%), consistent with a protective role of oral hygiene practices even under adverse conditions. Stress-related parafunctional habits. Bruxism and other stress-related behaviours were associated with poorer gum (p < 0.001) and teeth condition (p = 0.013), consistent with associations between psychological trauma and oral pathology. Geographic variation. Unmet dental care varied across governorates (p = 0.014), with Rafah (98%) and North Gaza (96%) reporting the highest deficits. Oral pain distribution also differed by region (p < 0.001), reflecting local disparities in conflict exposure and service availability. Barriers to care. The type of access barrier was strongly linked to current oral problems (p < 0.001), suggesting that security, provider availability, and economic constraints shape distinct patterns of untreated oral pathology. Displacement, hygiene behaviour, stress-related habits, geographic location, and access barriers emerged as key determinants of oral health during the conflict. The widespread deterioration across socio-demographic groups underscores the pervasive association between war and oral health deterioration, while maintaining tooth brushing highlights a potentially modifiable factor for intervention in humanitarian settings, as shown in Figs. 3 and 4.

Table 4.

Predictors of oral health deterioration during the war using

Predictor Variable	Outcome Variable	X²	df		p-value
Displacement status	Oral pain (during)	21		4	< 0.001
	Teeth condition (during)	31.04		8	< 0.001
	Unmet dental need (during)	7.39		2	0.025
Age group	Perceived worsening	7.54		6	0.273
Sex	Perceived worsening	0.56		2	0.757
Monthly income	Perceived worsening	11.9		6	0.064
Education level	Perceived worsening	8.63		10	0.568
Brushing frequency (during)	Gum condition (during)	111.82		12	< 0.001
	Teeth condition (during)	256.39		12	< 0.001
Stress-related habits (during)	Gum condition (during)	34.92		12	< 0.001
	Teeth condition (during)	25.47		12	0.013
Residential area	Unmet dental need (during)	12.42		4	0.014
	Oral pain (during)	37.27		8	< 0.001
Barrier type (during)	Current oral problem	136.2		24	< 0.001

Fig. 3.

Factors associated with oral health outcomes during war. A Severe pain by displacement (χ² = 21.0, p < 0.001). B Unmet need by displacement (χ² = 7.4, p = 0.025). C Healthy gums by brushing frequency (χ² = 111.8, p < 0.001). D Unmet need by area (χ² = 12.4, p = 0.015). Values are percentages. N = 599

Fig. 4.

Stress-related habits and gum condition during war

Discussion

The findings of this comparative cross-sectional survey demonstrate a profound deterioration in oral health status, hygiene behaviors, and access to dental care among Gaza residents during the current war, highlighting the severe and multifactorial association between armed conflict and deterioration in self-reported oral health. Consistent with our hypothesis, significant deterioration was observed across all 12 assessed domains (p < 0.001 for 11 of 12 variables), confirming the profound impact of armed conflict on oral health. This deterioration aligns with previous literature describing how war disrupts health systems, supply chains, and social determinants of health, disproportionately affecting vulnerable populations (Barma et al., 2024; Benzian et al., 2023b). However, to our knowledge, this study is the first to quantify changes in oral health indicators among Gazans before and during the current conflict, thereby filling an important evidence gap previously identified in policy briefs and editorials [11, 12].

A significant worsening in self-reported pain, teeth condition, and gum condition was observed, with the proportion of participants reporting severe pain increasing nearly tenfold during the war. This substantial decline in oral health aligns with reports from Gaza-based clinicians who have documented rising cases of dental pain, gingival bleeding, and scurvy-related gingivitis, consistent with reports of widespread malnutrition and reliance on canned, nutrient-poor diets during the conflict [9]. Malnutrition, chronic stress, and psychological trauma are well-established contributors to poor oral and periodontal health and are known to exacerbate inflammatory conditions of the oral cavity [18–20]. The sharp increase in painful, swollen, or bleeding gums among respondents is consistent with a combination of biological vulnerability and psychosocial stressors, in the context of severely reduced access to preventive and restorative dental services. The deterioration was statistically significant, p < 0.001, indicating a systematic, population-wide negative shift in perceived oral health rather than random variation. These findings are consistent with multifactorial pathways through which wartime conditions — including scarcity of dental supplies, compromised clinic functionality, disrupted hygiene routines, and displacement-related barriers — may be associated with increased oral disease burden.

Regular tooth-brushing is a cornerstone of oral hygiene and one of the most effective measures for preventing dental caries, periodontal disease, and oral pain. Adequate brushing mechanically removes dental plaque, reduces the bacterial load responsible for enamel demineralization and gingival inflammation, and helps maintain periodontal health, thereby preventing progression to more severe oral conditions. Consistent oral hygiene practices are also associated with lower treatment needs, reduced dental pain, and better oral health–related quality of life, particularly in populations with limited access to professional dental care. Disruption of brushing routines, therefore, has immediate and cumulative consequences for both dental and periodontal health. In our study, a dramatic decline in brushing frequency was observed. While nearly all participants brushed at least once daily before the war, the majority reported not brushing at all during the conflict. This decline mirrors conflict-related disruptions described in prior studies, where displacement, lack of clean water, limited privacy, and scarcity of hygiene supplies impede daily self-care [5, 21]. The shift toward alternative cleaning methods (e.g., salt, baking soda, miswak, or improvised tools) further highlights resource scarcity and reflects coping strategies commonly reported in crisis settings [4, 22]. Given that adequate oral hygiene is foundational to caries and periodontal disease prevention, these behavioral disruptions were likely associated with the rapid deterioration of self-reported oral health indicators observed in this study.

The most striking findings relate to access to dental care. Unmet dental needs rose from 11.7% before the war to 92.5% during the war. This aligns with WHO reports describing Gaza’s health system as “severely under-resourced” due to bombardment, fuel shortages, and restrictions on aid [11]. The near disappearance of regular check-ups, alongside the dominance of pain-driven visits and increased extractions, reflects a shift from preventive to emergency-only dentistry, a phenomenon documented in other conflict zones [5, 6].

Structural barriers, including unsafe environments, closed clinics, and a shortage of dentists, were the most commonly cited impediments, consistent with the destruction of university dental clinics, the death of dental staff, the displacement of clinicians, and the near absence of dental supplies entering Gaza [9]. Rising material costs, reported to have increased up to tenfold, were associated with further compounding of access barriers, with treatment becoming unaffordable even when services were technically available.

The sharp rise in stress-related habits such as teeth grinding, nail biting, and jaw clenching is consistent with the intense psychological strain associated with war (p < 0.001). These stress-related behaviors are recognized as risk factors for tooth wear, temporomandibular disorders, and dental pain, consistent with mechanisms through which psychological stress may be associated with declining oral health outcomes.

Diet plays a fundamental role in maintaining oral and periodontal health, influencing tooth integrity, gingival condition, salivary function, and the oral microbiome. Adequate intake of fresh fruits, vegetables, proteins, and micronutrients, particularly vitamins C and D, calcium, and phosphorus, is essential for enamel mineralization, periodontal tissue integrity, immune function, and wound healing within the oral cavity. Conversely, diets high in refined carbohydrates, acidic foods, and ultra-processed products promote cariogenic bacterial activity, increase plaque acidity, and accelerate demineralization, while micronutrient deficiencies are associated with gingival bleeding, delayed healing, and increased susceptibility to periodontal disease. Nutritional adequacy is therefore a critical determinant of oral health, especially in settings where access to professional dental care is limited. In this study, dietary patterns deteriorated markedly during the war, with most participants reporting near-total reliance on canned and packaged foods and a sharp reduction in access to fresh and nutritionally diverse meals. This shift reflects widespread food insecurity, disruption of supply chains, and dependence on humanitarian aid, all of which are characteristic of prolonged conflict settings. Such dietary changes were likely associated with the observed worsening of self-reported oral health indicators. Diets dominated by processed and carbohydrate-rich foods increase the frequency and duration of acid attacks on tooth surfaces, which may be associated with accelerated caries progression, particularly in the absence of adequate oral hygiene. At the same time, reduced intake of fresh fruits and vegetables may lead to deficiencies in vitamin C and other essential micronutrients, increasing the risk of gingival inflammation, bleeding, and scurvy-related periodontal manifestations, which have been increasingly reported by clinicians in Gaza during the conflict. A pattern consistent with reports from crisis-affected populations globally [5, 23, 24].

The worsening oral health trends observed in this study must also be viewed within the broader global context. Oral diseases affect an estimated 3.7 billion people worldwide, with untreated dental caries being the most prevalent condition [1]. In LMICs, where three-quarters of the global burden exists, oral health systems are often under-resourced even before crises [2]. Palestine has long reported a high prevalence of dental caries and periodontal disease [7, 8]. Thus, the deterioration of oral health in Gaza reflects the convergence of an already fragile baseline with catastrophic disruptions to healthcare, food security, and daily living conditions.

The overwhelming demand for emergency pain relief, extractions, and gum treatment highlights a shift toward urgent, symptomatic care and underscores the need to integrate oral health into humanitarian health packages, an area historically neglected [4]. Emergency dental kits, mobile dental units, and training of non-dental health workers to address basic oral conditions may be essential in the short term. In the long term, rebuilding dental infrastructure, including universities, clinics, and supply chains, must be prioritized to restore service capacity and workforce development [9].

A key strength of this study is its large sample size (n = 599) spanning all Gaza governorates during an active conflict, which is rarely feasible in war research. The paired before–and–during comparison provides valuable insight into temporal changes associated with the conflict period, following recommended methodologies for crisis settings [5].

However, limitations include the use of self-reported measures, which may introduce recall bias, and non-probability convenience sampling, which may underrepresent individuals without internet access or those experiencing the most severe hardships. Clinical examinations were not feasible due to security constraints, but self-reported indicators are widely used and validated in humanitarian oral health research [6]. The overrepresentation of university-educated individuals (57.3%) compared to the general Gaza population suggests a selection bias toward those with internet access and higher literacy. This may lead to an underestimation of oral health deterioration among less-educated and more socioeconomically deprived groups who are less likely to have completed an online survey. Despite these limitations, this study provides the first systematic quantitative assessment of oral health conditions during active armed conflict in Gaza. The data document a humanitarian crisis requiring urgent intervention and establish a baseline for evaluating future recovery efforts.

Conclusion

This study reveals a severe, statistically significant deterioration in self-reported oral health status, hygiene behaviors, and access to dental care among Gaza residents during the current war. The findings underscore the urgent need to incorporate oral health into humanitarian response efforts and highlight the importance of rebuilding a resilient, equitable oral healthcare system in Gaza. By providing the first quantitative evidence of war-associated oral health deterioration in the region, this study contributes essential data for policymakers, humanitarian organizations, and health authorities planning both immediate interventions and long-term recovery.

Abbreviations

WHO

World Health Organization

LMICs

Middle-Income Countries

MoH

Ministry of Health

UNRWA

United Nations Relief and Works Agency

PTSD

Post –Traumatic Stress Disorder

SPSS

Statistical Package for the Social Science

USD

United States Dollars

Authors' contributions

Ahmed Awad, Omran Altos, and Ahmed Bashah conceptualized and designed the study, developed the questionnaire, coordinated data collection, and drafted the initial manuscript. Zaher Madi, Ayman Musleh, and Bassel AbuNasser contributed to questionnaire validation, participant recruitment, survey dissemination in Gaza, and provided contextual input regarding oral health services during the war. Shaffanath M. Fahumy contributed to data management, statistical analysis, and interpretation of results. Hongtao Jiang supervised the study, provided methodological and scientific oversight, critically revised the manuscript, and served as the corresponding author.All authors participated actively throughout the study process and contributed significantly to manuscript revision, interpretation of findings, and approval of the final version of the manuscript.

Funding

No external funding was received for this study. The authors carried out this research independently without financial support from any funding bodies.

Data availability

Data is available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ethics Committee of Dalian Stomatological Hospital (DLKOLL20250109), and the Ethical Approval Committee for Research, Ministry of Health – Gaza Strip (Palestinian Ministry of Health). This study was conducted in full accordance with the principles of the Declaration of Helsinki. No personal identifiers were collected. All participants (or their parents/guardians for minors) provided electronic informed consent.

Consent for publication

Not applicable.

Competing interest

The authors declare no competing interests.