European Archives of Paediatric Dentistry

https://doi.org/10.1007/s40368-018-00412-6

ORIGINAL SCIENTIFIC ARTICLE

Caries prevalence, clinical consequences and self-reported pain

experienced by children living in the West Bank
H. J. Rogers1   · U. Tariq2 · L. Olsson3 · S. A. Riaz4 · M. R. Miah5

Received: 4 May 2018 / Accepted: 13 December 2018

© The Author(s) 2019

Abstract
Aim  To investigate both caries prevalence and clinical consequences experienced by deprived children in the West Bank,
using a child-centred approach.
Materials and methods  Children were invited by their social workers to attend free dental screening sessions held across
clinics in the north of the West Bank. Data were collected using the dmft/DMFT and pufa/PUFA indices. Dental pain was
reported by children using the Wong-Baker FACES® pain scale. Data were analysed using SPSS Version 22.0.
Results  Data were collected for 177 children aged 4 to 18 years. Caries prevalence was 95.5% with only eight children pre-
senting clinically caries-free. The sample had a dmft of 3.88, and DMFT of 3.44. The Care Index was calculated at 0.1 (mft/
dmft). Clinical consequences of caries were identified in 64% of the sample, with a mean pufa score of 2.12, and a PUFA
score of 0.55. Dental pain was experienced by 45% of children.
Conclusion  Deprived children living in the West Bank experience high levels of untreated dental caries, with significant
clinical consequences and self-reported pain.

Keywords  Caries · Deprivation · Child-centred

Introduction Dental Aid Network (DAN) is a registered charity

founded by a group of dentists in Glasgow, United King-
The situation in the West Bank can only be described as dom. The charity aims to provide humanitarian aid to those
uncertain. There is ongoing conflict, high military presence less fortunate in order to prevent and relieve pain and suf-
and a tense atmosphere. The possibility of a peaceful two- fering from dental disease. DAN volunteers work closely
state solution is looking unlikely, which has had adverse with the Palestinian Children’s Relief Fund (PCRF) in sev-
economic effects. Growth rates have been slow since the eral areas of Nablus; a city in the north of the West Bank
2014 conflict, and unemployment figures are high, estimated approximately 30 miles north of Jerusalem with an estimated
at 18% in the West Bank (World Bank 2017). Donor related population of 125,000.
income has increased although this is unsustainable in the The DAN team have undertaken several aid missions to
long run due to continued border restrictions and political Nablus over a number of years, working together with local
stagnation (World Bank 2017). dentists to help secure the oral health of Palestinian children
currently affected by the difficult political situation (Dental
Aid Network 2017). The 2016/17 DAN mission allowed the
* H. J. Rogers team to improve the oral health of disadvantaged children,
[email protected]
whilst providing an opportunity to further explore the impact
1
Academic Unit of Oral Health, Dentistry and Society, School of oral disease on children living within this conflict zone.
of Clinical Dentistry, University of Sheffield, Sheffield, UK This study aimed to investigate both caries prevalence and
2
Lauriston Dental Care, Edinburgh, UK the clinical consequences of caries experienced by the chil-
3
Departments of Oral Medicine and Oral Surgery, Glasgow dren in the West Bank, using a child-centred approach.
Dental Hospital, Glasgow, UK
4
The Avenue Dental Surgery, Greater Manchester, UK
5
DHS Dental, Oldham, UK

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 European Archives of Paediatric Dentistry

Materials and methods diagnostic criteria, using a dental chair, light and mirror.
Teeth were dried using cotton wool only. Whilst each team
This cross-sectional study was undertaken alongside the member had some knowledge of the Arabic language,
DAN mission to the West Bank in December 2016. Local interpreters were provided where required. Following data
approval for this study was gained through the Palestine collection, the children were offered subsequent appoint-
Children’s Relief Fund, in accordance with the Declaration ments to have the recommended treatment completed.
of Helsinki guidance. Collected data were analysed for descriptive statistics using
A convenience sample was formed of children and ado- SPSS Version 22.0. Correlations between dmft/DMFT, pufa/
lescents who attended a free dental screening session run PUFA and pain scores were analysed using Pearson’s correla-
by the DAN team at three clinics in the area. Local social tion coefficient.
workers invited children under their care to attend, many
of whom lived in deprived circumstances, had lost one Results
or both parents or had additional needs, such as learning
difficulties or hearing impairments. Consent for data col- Data were collected for 177 children aged 4–18  years
lection was provided by the primary caregiver, and verbal (mean = 11 years; median = 11 years) with a male to female
assent was sought from children and adolescents them- ratio of 3:2.
selves. Standardised data collection forms were designed The overall caries prevalence was 95.5% with only 8 chil-
to systematically record dmft/DMFT, pufa/PUFA and pain dren presenting clinically caries-free. Mean caries experience
scores as described below. (Table 1) in the primary dentition was 3.88 dmft, with 3.44
The dmft/DMFT index has been widely used for over for the decayed component. The Care Index for the primary
half a century as a means of collecting easily compara- dentition can be calculated at 0.1 (mft/dmft) with only eight
ble data on caries prevalence and treatment provision children having received restorations. Mean caries experience
from different populations (Klein et  al. 1938; Monse in the permanent dentition was 3.44 DMFT, with 2.98 for the
et al. 2010). Nonetheless, this index fails to consider the decayed component. In the permanent dentition, 18 children
clinical consequences of untreated caries—an important had received restorations and 15 had undergone extractions,
indicator of dental neglect addressed by the pufa/PUFA placing the Care Index at 0.1.
index. The pufa index was proposed in 2010 by Monse The overall presence of clinical consequences of caries,
and co-workers to gain data regarding the severity of oral identified using the pufa/PUFA index was 64%. The mean pufa
conditions related to untreated caries (Monse et al. 2010). index for the primary dentition was 2.12, and the PUFA index
Since conception, it has been used successfully with chil- for the permanent dentition was 0.55. The ‘Untreated Caries,
dren in a variety of settings including those with limited PUFA Ratio’ was calculated at (2.67/6.42 × 100) 42%. This
access to dental care (Baginska et al. 2013; Grund et al. indicates that 42% of the decayed primary and permanent teeth
2015; Ramazani et al. 2017). The ‘p’ corresponds to pul- had developed an odontogenic infection (Monse et al. 2009).
pal involvement, ‘u’ for ulceration arising as a result of a Significant correlations (ρ < 0.005) were identified between
carious tooth, ‘f’ for a fistula and ‘a’ for a dental abscess. high dmft/DMFT and pufa/PUFA scores (ρ = 0.000 for pri-
The Arabic translation of the Wong-Baker FACES® mary and permanent teeth). As the data were non-parametric,
pain scale was used to gain children’s report of dental pain. the Mann–Whitney U test was undertaken to identify any dif-
This measure was developed in 1988 and has been vali- ferences between males and females for dmft/DMFT and pufa/
dated for use with children as young as 3 years and older PUFA scores. As seen in Table 1, no significant differences
(Wong-Baker FACES® Foundation 2015). Laminated cop- were identified.
ies of the Wong-Baker FACES® pain scale were available Dental pain (Fig. 1) was experienced by 45% of the chil-
in each clinic. dren, with 17% (n = 29) experiencing lower levels of pain
Data were collected by 11 dental professionals from (scores 1–5) and 27% (n = 47) reporting higher levels of pain
different occupational backgrounds and with varying lev- (scores 6–10). Pain scores were missing for three participants
els of experience. The team took part in a 3-h training and hence were excluded from this part of the analysis. No
and calibration exercise prior to data collection, involv- significant correlations were found between change in pain
ing familiarisation with the indices through a series of score and pufa/PUFA or dmft/DMFT scores.
example cases.
Dental screenings were held across three clinics—one
in Nablus centre and one in each of the neighbouring
towns of Salfeet and Qalqilya. Examinations were under-
taken according to the World Health Organisation (WHO)

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European Archives of Paediatric Dentistry

Table 1  Prevalence (dmft/ Number (%) Gender .Sig Overall (%)

DMFT) and clinical
consequences (pufa/PUFA) of Male (%) Female (%)
dental caries experienced by
this sample 106 (60) 71 (40) 177 (100)
Median IQR Median IQR Minimum Maximum Median IQR Mean

dt 3 6 1 5 0.149 0 19 2 6 3.44
mt 0 0 0 0 0.197 0 8 0 0 0.38
ft 0 0 0 0 0.101 0 2 0 0 0.06
Total dmft 4 7 2 6 0.137 0 19 3 7 3.88
DT 2 4 3 4 0.978 0 16 3 4 2.98
MT 0 0 0 0 0.998 0 5 0 0 0.15
FT 0 0 0 0 0.757 0 8 0 0 0.27
Total DMFT 3 4 3 3 0.784 0 16 3 3 3.44
p 1 3 0 3 0.302 0 14 0 3 1.92
u 0 0 0 0 0.413 0 2 0 0 0.01
f 0 0 0 0 0.471 0 3 0 0 0.09
a 0 0 0 0 0.75 0 5 0 0 0.1
Total pufa 1 4 0 3 0.207 0 17 0 4 2.02
P 0 0 0 1 0.384 0 6 0 0 0.48
U 0 0 0 0 1 0 0 0 0 0
F 0 0 0 0 0.534 0 1 0 0 0.02
A 0 0 0 0 0.187 0 1 0 0 0.05
Total PUFA 0 0 0 1 0.416 0 6 0 1 0.55

comparable to other studies investigating caries prevalence

in children and adolescents in the West Bank (Livny et al.
2007; Mahfouz and Abu Esaid 2014). Nonetheless, these
figures are significantly higher than those seen in the
neighboring country of Jordan, which has a reported mean
dmft/DMFT of 2.8/0.7 (Rajab et al. 2002). Moreover, a
recent systematic review reported an average dmft of 3.3
and DMFT of 1.1 for children living in the Arab-league
countries (Khan 2014). This indicates that children living
in the West Bank have a higher caries prevalence than
those living in other parts of this transcontinental region.
The association between dental caries and socioeco-
nomic deprivation is widely acknowledged (Watt et al. 1999;
Mathur et al. 2014; Schwendicke et al. 2014) and will have
contributed greatly to these findings. A high percentage of
the population in the West Bank live in poverty which is
Fig. 1  Graph displaying frequency and severity of pain experienced partly due to the occupation of the territory and economic
by the sample population
sanctions facing the country (United Nations Development
Programme 2015). The poverty line by national stand-
Discussion ards for Palestine, as set by Palestinian Central Bureau of
Statistics (PCBS) in 2011, is 2293 NIS ($637) per month
Using three validated indices this study reports data on car- for a family of two adults and three children, based on the
ies prevalence, impacts and consequences, representative of average consumption of essential food, clothing, housing,
deprived and orphaned children living in the West Bank. housekeeping, personal supplies, health care, education, and
Children and young people participating in the current transportation. The most recent survey estimated that nearly
study had an average dmft/DMFT of 3.88/3.44, which is 20% of West Bank’s population lived in poverty and 7.8%
were considered to be in ‘deep poverty’ which calculates as

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 European Archives of Paediatric Dentistry

a family income of less than $509 a month (Palestinian Cen- toothache to be reported by up to 30% of young children
tral Bureau of Statistics 2007). The impact of this situation from deprived areas. Further impacts relating to pain have
on children’s general health is significant, with a reported also been widely reported such as time off school, difficulty
33.5% of children suffering from anaemia in the West Bank sleeping and speaking and interference with daily activities
and 2.9% from acute malnutrition (Quota and Odeh 2005). (Ratnayake 2005; Pau et al. 2007; Krisdapong et al. 2009b).
The Palestinian Ministry of Health operates 41 dental As anticipated, pain experience in this sample was positively
clinics which provide subsidised treatment for over 4 mil- correlated with an increase in dmft/DMFT and pufa/PUFA.
lion children and adults across the West Bank and Gaza (Al-
Attrash 2014). Nonetheless, individuals must have govern- Strengths, limitations and generalisability
mental health insurance to be able to access these services,
and certain interventions, such as endodontic treatment, are This aid mission facilitated an opportunity to explore the
not routinely provided. A large proportion of dental care prevalence, clinical consequences and impacts of caries in
in Palestine is provided via private dental clinics or Non- a vulnerable population in an unstable part of the world. To
Governmental Organisations. the authors knowledge, this is the first dental study in the
Further to the financial barriers to families accessing West Bank to use a child-reported outcome measure.
dental care, a physical restriction is often present. Many Self-report of children’s pain is considered to be the gold
residents in the West Bank and Gaza are required to obtain standard and preferred over observational reports, given that
specific travel permission to pass through occupied territory, pain is a subjective experience (Franck et al. 2000; Wong
or move between different areas of the West Bank. Not only et al. 2015). Furthermore, by involving children in this way,
can this prevent families trying to access dental care, but this study has acknowledged current recommendations to
it can also limit the provision of dental care, and importa- actively involve children in research (Marshman and Hall
tion of dental equipment (Kateeb 2007). A low care index 2008; UN Convention 2009). It is anticipated that this will
was present in both the primary and permanent dentitions of encourage further involvement of children in research as
our sample; 1.55 and 7.85 respectively, indicating that few active participants in the Middle East.
participants had received prior dental treatment. This is in As data for this study was collected during a humanitar-
stark contrast to the United Kingdom, where 90% of children ian aid mission, the volunteers ranged in experience, from
visited a dentist in 2013 accessing free-of-charge dental care recently-graduated dentists, to those with specialist train-
via the National Health Service (NHS) (ONS 2015). ing in oral surgery and paediatric dentistry. One dentist had
Dental pain was reported by almost half of the sample, received formal training in DMFT assessment and provided
presenting with clinical consequences of untreated den- a calibration session for the rest of the dentists prior to com-
tal caries, primarily pulpal involvement and fistulae. The mencing data collection. Nonetheless, the inter-examiner
prevalence of pufa/PUFA recorded in this sample was 64%. variance may have reduced the reliability of the results
Whilst there are few studies available that can afford a direct recorded. One suggestion to improve the accuracy of diag-
comparison due to the specific sample characteristics of the nosis would be the use of bitewing radiographs. However
present study, it can be noted that this is a relatively high dental radiography is not commonly employed for WHO
prevalence in comparison to other populations. For example, studies on dental caries, and was not available for use during
the prevalence of pufa/PUFA was reported at 55.7% in a this aid mission.
study of Filipino schoolchildren by Benzian and coworkers Local staff helped with translation during assessments,
(2011). Pulpal involvement was identified in 47% of primary with only three of the assessing dentists able to speak the
teeth and 25% of permanent teeth in our sample, consist- native language. Whilst this language barrier may have
ent with findings from research by Ramazani and cowork- presented some difficulties when taking a dental history or
ers (2017) who reported pulpal involvement to be the most undertaking treatment, it is unlikely to have interfered with
commonly reported clinical consequence. Whilst the present data collection. All data collection was undertaken through
study did not explore the wider impact of clinical conse- clinical assessment with the exception of the pain scores. For
quences of caries, the aforementioned study by Benzian and this component, written instructions in Arabic were provided
coworkers (2011) identified an increased risk of having a for children, advising them to simply point to the number
‘below normal’ BMI in children with caries into the pulp that best represented their current pain experience.
when compared to children without odontogenic infections, The sample size of this study was relatively small for
emphasising the important role of oral health as a determin- an epidemiological study, and it should be noted that the
istic factor for general health. findings may not relate to all children in the West Bank, as
Almost half of the children in this sample reported some our subjects were mainly those of the lowest level of dep-
form of dental pain (n = 80, 45%). This is slightly higher rivation, such as orphans and those with additional needs.
than previous research by Slade (2001), which found Nonetheless, whilst the findings from this study hold limited

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European Archives of Paediatric Dentistry

generalisability, they contribute to a limited evidence base East. Materials and equipment were also kindly donated for this mis-
in a conflict zone. sion by a number of sponsors.

Compliance with ethical standards 

Future considerations
Conflict of interest  The authors report no conflicts of interest.
The Palestinian Ministry of Health initiated a school-based
screening programme in 1997, aiming to address the difficul- Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
ties in accessing dental care. This programme provided oral tutional and/or national research committee and with the 1964 Helsinki
health education, and referred students with caries to Min- declaration and its later amendments or comparable ethical standards.
istry of Health operated clinics for treatment. Whilst a slight
reduction in overall dmft/DMFT was noted during the years Informed consent  Informed consent was obtained from all individual
participants included in the study.
2002 to 2004, it remains clear that a predominantly preven-
tative programme is key (Kateeb 2007). The success of the
NHS-funded Scottish programme ‘Childsmile’, introduced OpenAccess  This article is distributed under the terms of the Crea-
tive Commons Attribution 4.0 International License (http://creat​iveco​
in 2008, provides supervised toothbrushing, the distribu- mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribu-
tion of toothpaste and toothbrushes to families with young tion, and reproduction in any medium, provided you give appropriate
children, and twice yearly high fluoride varnish application credit to the original author(s) and the source, provide a link to the
in nurseries, schools and in the primary dental care setting Creative Commons license, and indicate if changes were made.
(Macpherson et al. 2012). This cost-effective strategy has led
to an increase in the number of children with no caries expe-
rience, from 53% of 11-year-old children in 2005 to 75% in
2015 (SDECC 2015). Whilst a preventative programme such References
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