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. 2020 Nov 3;64(4):173–180. doi: 10.1111/idj.12092

Dental caries in Arab League countries: a systematic review and meta-analysis

Soban Qadir Khan 1,*
PMCID: PMC9376421  PMID: 24506766

Abstract

Objective: The aim of this review was to determine prevalence of dental caries in primary and permanent teeth in the 2-20-year-old population of the Arab league. Methods: A literature search was performed on Pubmed, Summon and Google Scholar using the key words ‘Dental caries’, ‘dmft’ and ‘DMFT’. A total of 293 articles were found, of which 35 passed our inclusion criteria and were included in analysis. Tables were made separately for primary and permanent teeth; the age group for primary teeth was 2–12 years and for permanent teeth 6–20 years. Results: A meta-analysis was run by using data extracted from the studies included. Heterogeneity was tested by forest plot and chi-square test, and considerable heterogeneity was found. Mean decayed, missing and filled teeth (dmft) was 4.341 (95% CI 3.714, 4.969) and in permanent teeth (DMFT) was 2.469 (95% CI 2.019, 2.919) from a random effect model. Publication bias diagnostics suggested missing of four studies of primary teeth caries data and eight studies of permanent teeth caries data to obtain symmetry in the funnel plot. Conclusion: The incidence of caries in primary teeth was found to be high compared with caries in permanent teeth in the Arab League. This study does not provide a comprehensive picture of caries prevalence in the Arab League because in many of these countries only a few studies were performed. Therefore, these data cannot provide a complete picture of the prevalence of caries in those countries. Additional studies are needed to better evaluate the prevalence of caries in children and young adults in Arab League countries.

Key words: Dental caries, meta-analysis, dmft, DFT

INTRODUCTION

One of the most common infectious diseases is dental caries. More than 80% of the population living in high-income countries has been affected by caries1., 2., 3.. However, in the high-income population there is only half the likelihood of having untreated teeth compared with low income families4. The prevalence of dental caries among preschool children was initially examined in the UK5., 6.. Since then, a number of studies have been performed in other parts of the developed world to determine the prevalence of caries7., 8.. This topic has now become a part of the studies which are being conducted in other parts of the world9., 10., 11., 12..

Studies have been published on the prevalence of caries for several decades and researchers still take great interest in reviewing published studies. Several review articles have been published reporting on the caries burden during certain periods of time and in certain part of the world. Cleaton-Jones et al. in 1999 reported a trend of dental caries in Africa. They considered all studies on dental caries during the previous 30 years13. Li et al.14, in 2012, studied the association between dental erosion and dietary factors using studies published during 1992–2011. Khan et al.15, in 2013, conducted a systematic review of all published articles during 1999–2008 that reported prevalence of dental caries in the population living in Saudi Arabia.

A meta-analysis is a procedure in which the results from the individual studies are combined to obtain a more valid and appropriate analysis than traditional reviews. The broad aim of a meta-analysis is to more powerfully estimate the true size effect as opposed to a less precise size effect resulting from a single study under a given single set of assumptions and conditions. In this study, we collected all the published articles reporting dental caries during 1999–2012 in Arab League countries. Countries in the Arab League are Algeria, Chad, Egypt, Ethiopia, Liberia, Mauritania, Morocco, Somalia, Sudan, Tunisia, Bahrain, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria, United Arab Emirates and Yemen. A meta-analysis was performed to determine the prevalence of caries in countries of the Arab League during the period 1999–2012.

MATERIALS AND METHODS

The aim of the literature search was to discover published articles on dental caries during 1999–2012. PubMed, Summon and Google Scholar databases were used to search articles using the key words ‘Dental caries’, ‘dmft’ and ‘DMFT’. In August 2013, a literature search was started on dental caries in Arab League countries at the College of Dentistry, University of Dammam, Saudi Arabia. The objective of the study was to find mean decayed, missing and filled data in primary and permanent teeth in the young Arab League population. The literature search revealed 293 articles with the required key words.

The inclusion criteria were: (1) availability of dmft or DMFT values or both; (2) age range for primary teeth 2–12 years and for permanent teeth 6–20; (3) sample size must be separate if study contained different age groups. (Figure 1).

Figure 1.

Figure 1.

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Flow diagram of literature search.

After employing the first inclusion criterion, 45 studies remained for further screening. Out of 45, remaining studies, eight failed to pass the second inclusion criterion16., 17., 18., 19., 20., 21., 22., 23. but only two articles failed the third inclusion criterion24., 25.. Information was gathered into two separate tables, the first was prepared for primary teeth caries (dmft) and other was prepared for permanent teeth caries (DMFT) (Tables 1 and 2). The pattern of information in articles was different: some revealed information about the prevalence of caries in primary teeth and few about the prevalence in permanent teeth, while some studied both primary and permanent teeth. Among 35 selected articles, 14 studied primary teeth caries and 10 revealed information on mean decayed, missing and filled teeth in permanent teeth; the remainder studied caries in both primary and permanent teeth.

Table 1.

Studies and variables included after inclusion criteria (in chronological order) on reported prevalence of caries in primary teeth

Author Country Year Sample Age (years) dmft SD
Al-Banyan et al.27 Saudi Arabia 2000 272 5–12 3.8 3.2
Al-Malik et al.28 Saudi Arabia 2000 80 4–5 0.95 2.03
Khan et al.29 Saudi Arabia 2001 457 6–7 4.45 3.76
Wyne et al.30 Saudi Arabia 2001 1016 4.51 8.6 3.4
Wyne et al.31 Saudi Arabia 2001 77 4 0.91 2.42
Shyama et al.32 Kuwait 2001 832 3–12 5.4 3.63
Wyne et al.33 Saudi Arabia 2002 449 7–11 6.3 3.5
Wyne et al.34 Saudi Arabia 2002 322 3–5 2.92 3.51
Rodd et al.35 Somalia 2002 238 4–10 2.085 2.64
Sayegh et al.36 Oman 2002 569 4 3.1 3.9
Al-Malik et al.37 Saudi Arabia 2003 987 2–5 4.8 4.87
Paul38 Saudi Arabia 2003 103 5 7.1 4.14
Al-Dosari et al.39 Saudi Arabia 2004 249 6–7 6.53 4.3
Al-Dosari et al.39 Saudi Arabia 2004 182 6–7 6.35 3.83
Jamel et al.40 Iraq 2004 1047 6–7 2.3 2.4
Al-Malik et al.10 Saudi Arabia 2006 300 6–7 8.06 4.04
Hashim et al.41 United Arab Emirates 2006 1297 5–6 4.4 4.3
Al-Mutawa et al.42 Kuwait 2006 2298 5–6 4.6 3.39
Wyne et al.43 Saudi Arabia 2008 789 3–5 6.1 3.9
Al-Haddad et al.44 Yemen 2010 490 6–8 6.68 3.8
Al-Haddad et al.44 Yemen 2010 485 9–11 3.62 3.56
Al-Haddad et al.44 Yemen 2010 321 12–14 1.13 1.48
Farsi45 Saudi Arabia 2010 510 4–5 3.9 3.185
Hazza’a et al.46 Jordan 2011 36 4–8 1.44 1.33
Hazza’a et al.46 Jordan 2011 24 8–12 2.05 1.53
Al-Majed et al.47 Saudi Arabia 2011 522 8–10 4.96 3.03
Togoo et al.48 Saudi Arabia 2011 836 7–10 2.74 1.18
Al-Khadra49 Saudi Arabia 2011 57 3–6 4.71 0.27
Al-Khadra49 Saudi Arabia 2011 116 7–14 6.09 2.34
Qadri et al.50 Syria 2012 400 3–5 4.25 4.2
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dmft, decayed, missing and filled teeth.

Table 2.

Studies and variables included after inclusion criteria (in chronological order) on reported prevalence of caries in permanent teeth

Author Country Year Sample Age (years) DMFT SD
Abolfotouh et al.51 Saudi Arabia 2000 959 6–13 0.79 2.84
Al-Banyan et al.27 Saudi Arabia 2000 272 5–12 2 1.9
Al-Sharbati et al.52 Libya 2000 762 6–12 1.63 1.03
Wyne et al.31 Saudi Arabia 2001 76 9.7 0.72 1.96
Wyne et al.33 Saudi Arabia 2002 449 7–11 1.6 1.5
Rodd et al.35 Somalia 2002 238 11–14 1.37 0.59
Dosari et al.53 Saudi Arabia 2003 734 16.4 7.2 4.785
Al-Dosari et al.39 Saudi Arabia 2004 392 11–12 5.06 3.65
Al-Dosari et al.39 Saudi Arabia 2004 281 11–12 4.53 3.57
Jamel et al.40 Iraq 2004 1011 11–12 1.6 2.9
Jamel et al.40 Iraq 2004 939 14–15 1.9 1.8
Al-Ismaily et al.54 Oman 2004 2860 15 3.23 3.70
Al-Malik et al.10 Saudi Arabia 2006 300 6–7 0.41 0.86
Al-Mutawa et al.42 Kuwait 2006 2290 12–14 3.25 3.73
Ahmed et al.55 Iraq 2007 392 12 1.7 1.9
Farag et al.56 Egypt 2009 90 14–15 6.7 2.3
Nurelhuda et al.57 Sudan 2009 1109 12 0.49 1.06
Al-Haddad et al.44 Yemen 2010 474 6–8 1.17 1.52
Al-Haddad et al.44 Yemen 2010 492 9–11 2.3 1.63
Al-Haddad et al.44 Yemen 2010 507 12–14 3.22 1.92
Al-Dosari et al.58 Saudi Arabia 2010 3903 12–13 2.93 3.2
Al-Dosari et al.58 Saudi Arabia 2010 4467 15–18 4.08 5.12
Hazza’a et al.46 Jordon 2011 36 4–8 0.3 0.48
Hazza’a et al.46 Jordon 2011 24 8–12 0.95 0.78
Al-Khadra49 Saudi Arabia 2011 116 7–14 3.93 1.64
Huew et al.59 Libya 2012 791 12 1.68 1.86
Al-Otaibi et al.60 Yemen 2012 400 12 2.22 1.56
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DMFT, decayed, missing and filled teeth.

In some studies included, standard deviations were missing and so regression analysis was used to estimate missing values. Tables 1 and 2 were used separately and two equations were formulated. Weighted regression was used and sample sizes were used as weights. Five studies did not have standard deviation along with mean32., 35., 38., 42., 45., so the estimated line of regression for primary teeth data (SD = 2.015 + 0.30 × mean, r2 = 0.835) was used to obtain estimated standard deviations. Similarly, in the case of permanent teeth data (Table 2) a line of regression was (SD = −1.696 + 1.671 × mean, r2 = 0.788) used to estimate missing standard deviations35., 42., 45., 47., 58..

Consideration of bias

A funnel plot shows the magnitude of effect of all the studies in order to address the issue of publication bias. Published effects may be larger than true effects because of effects that are larger simply because of sampling variation. There should be symmetry in the plot and means studies should fall equally on both sides of funnel plot26 A symmetrical funnel plot indicates no publication bias but for other situations this means that there is publication bias.

RESULTS

Data were compiled into two different tables, Table 1 presents the studies reporting on the prevalence of caries in primary teeth and Table 2 presents the studies reporting on the prevalence caries in permanent teeth. The sum of sample sizes of those studies that were placed in Table 1 was 15,361 and for Table 2 the total was 24,364. The average sample size of the studies conducted on primary and permanent teeth caries were 512 and 902, respectively. A large proportion of studies were carried out in Saudi Arabia (about 52% of total studies included). Libya, Oman, Iraq, Yemen and Kuwait each had two studies published during the period considered. In Egypt, Sudan, Somalia, Syria, UAE and Jordan only one was publication was found. The remaining Arab League countries did not have any publications related to primary or permanent teeth caries.

Meta-analysis was used separately for primary and permanent teeth caries data. A forest plot in Figure 2 represents studies that had mean dmft values. Visual inspection of the forest plot indicates the presence of heterogeneity; a Q statistic (chi-square test) was used to authenticate the presence of heterogeneity. The test provided a significant P-value (<0.001), which confirms that the heterogeneity and index of heterogeneity was also considered and that high heterogeneity was found (I2 > 90%). A random effect model was used to find mean dmft by employing Table 1. The average of dmft was estimated as 4.34 (95% CI 3.714, 4.969). Analysis was performed again over the data set that had mean DMFT values (Figure 3). Heterogeneity was checked first by forest plot and then by a chi-square test. Visual inspection of forest plot and chi-square (P < 0.001) gave adequate evidence of heterogeneity in the data set and the index of heterogeneity was also very high (I2 > 90%). Therefore, the random effect model was used to estimate mean DMFT and this was found to be 2.469 (95% CI 2.019, 2.919).

Figure 2.

Figure 2.

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Study-specific and summary effect estimates [mean and 95% confidence interval (CI)] for mean decayed, missing and filled teeth (dmft) in studies, 1999–2012.

Figure 3.

Figure 3.

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Study-specific and summary effect estimates [Mean and 95% confidence interval (CI)] for mean decayed, missing and filled teeth (DMFT) in studies 1999–2012.

Sources of heterogeneity were tested by stratification of the data. Groups were made from year of publication, sample size and age of study population (Table 3). Stratification was done for both Table 1 and Table 2 and effects were estimated. Heterogeneity was found in every strata, mean decayed, missing and filled (dmft/DMFT) was calculated separately by random effect model for each group made using the variables (year of publication, sample size and age). However, the mean of each group was closer to overall mean except the mean prevalence of caries in permanent teeth of 12- to 18-year-olds. The mean DMFT in the 12- to 18-year-old population was 1.77 (95% CI 1.36, 2.18) while the prevalence of caries in permanent teeth was 2.469 despite the age of study group.

Table 3.

Prevalence of caries in primary and permanent teeth from main and stratified meta analysis in 1999–2012

Random effect model, mean (95% CI)
Primary teeth
Overall dmft 4.341 (3.714, 4.969)
Study year
1999–2005 4.37 (3.1, 5.64)
2006–2012 4.31 (3.55, 5.08)
Sample size
<512 4.16 (3.32, 5.0)
More than 512 4.69 (3.52, 5.88)
Age group
2–7 4.49 (3.72, 5.26)
7–14 4.15 (2.96, 5.34)
Permanent teeth
Overall DMFT 2.469 (2.019, 2.919)
Study year
1999–2005 2.62 (2.039, 3.205)
2006–2012 2.347 (1.65, 3.039)
Sample size
<912 2.54 (2.049, 3.04)
More than 912 2.28 (1.28, 3.287)
Age group
6–12 2.82 (2.16, 3.48)
12–18 1.77 (1.36, 2.18)
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dmft, decayed, missing and filled primary teeth; DMFT, decayed, missing and filled permanent teeth.

Funnel plot and statistical tests were employed to check for the possibility of publication bias. The shape of funnel plot should be symmetrical in the absence of publication bias. In other cases, asymmetry in the shape of the funnel plot shows potential publication bias. The funnel plot for the primary dentition shows a symmetrical shape at the top and middle of the plot but slight asymmetry can be found in the bottom of the plot (Figure 4). Statistical tests were used (Egger’s and Begg’s test) for confirmation. Insignificant results from both tests (Egger’s test P = 0.2 and Begg’s test P = 0.2) indicate no publication bias. The trim and fill method suggested the inclusion of four studies to obtain symmetry in the funnel plot and reduced the effect estimate from 4.341 to 3.8 in the random effect. Asymmetry was found in the funnel plot for the permanent dentition (Figure 5), Egger’s and Begg’s test also confirmed the presence of publication bias. Significant results were obtained from both Begg’s test (P = 0.56) and Egger’s test (P = 0.0016). The trim and fill method also suggested inclusion of eight more studies to obtain symmetry in the funnel plot and the effect estimate was slightly reduced from 2.469 to 1.47 in the random effect model.

Figure 4.

Figure 4.

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Mean decayed, missing and filled teeth (dmft) according to precision of the mean dmft in studies 1999–2012.

Figure 5.

Figure 5.

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Mean decayed, missing and filled teeth (DMFT) according to precision of the mean DMFT in studies 1999–2012.

DISCUSSION

A number of studies have been conducted to determine the prevalence of caries burden in Arab League countries but there was no comprehensive review of such published literature. The purpose of this study was to review the published data related to Arab League countries and analyse this to determine the caries burden in primary and permanent teeth from 1999 to 2012. A total of 35 studies were found that were relevant for analysis: 14 studies were on primary teeth caries, 10 were on permanent teeth caries and 11 studies had been performed to reveal information about caries in both primary and permanent teeth. The prevalence of caries in primary teeth from a random effect model was found to be 4.341 (95% CI 3.714, 4.969) and in permanent teeth it was 2.469 (95% CI 2.019, 2.919).

Reviews of literature related to caries burden have also been performed in some other countries. A systematic review of the articles on the prevalence of caries in Saudi Arabia was performed by Khan et al.15. The aim of that study was to review articles related to dental caries published in 1999–2008. The study found that a high prevalence of caries was found in primary teeth (mean dmft 5.38) compared with permanent teeth (mean DMFT 3.34)15. Cleaton-Jones and Bonecker61 also researched to find trend in caries in 5–6-year-old and 11–13-year-old Latin American and Caribbean populations. They also found that primary teeth were affected by caries more than permanent teeth. Some review studies not only discussed the prevalence of caries but also the factors associated with caries. Maupome et al.62 studied the association between asthma and caries. Soft drinks may also cause dental problems63, as all food and drinks having pH below 5.0–5.7 provoke erosion effects64.

This study has some limitations. The period covered in the study was 1999–2012, and a study with a long period of data collection may have an effect on the results. In addition, in this study, only prevalence of dental caries was studied and the factors associated with caries were not considered for analysis. However, the current systematic review revealed that the prevalence of caries in primary teeth was higher than in permanent teeth. In addition, more than half of the studies recruited for this systematic review were performed in Saudi Arabia. The African countries of the Arab League were least focused on by researchers. Furthermore, in many countries only one or two studies were performed during the 14-year period considered. This systematic review indicates a real need to perform repeated studies, as in Saudi Arabia, to create an accurate picture of the prevalence of caries in Arab League countries. as the results presented in this study may not give the true picture of the burden of caries in the population.

Acknowledgement

I thank Prof. Dr Nazeer Khan, director of the research department at Dow University of Health Sciences, Pakistan, for providing his expert opinions and continuous support. And I also thank to Dr Imran Alam Moheet and Faraz Ahmed Farooqi for their expertise and for their valuable help.

Conflict of interest

None declared.

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