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Year : 2018  |  Volume : 29  |  Issue : 3  |  Page : 317-322
Dental caries and fluorosis among children in Lebanon

Professors in Dental Public Health, School of Dentistry, Lebanese University, Beirut, Lebanon

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Date of Web Publication13-Jun-2018


Purpose: The purpose of this study is to assess caries and enamel fluorosis in a sample of 1433 children aged 6–8, 12, and 15 years from 48 schools in 6 regions of Lebanon, selected by probability proportional to size. Methods: Children were examined according to the World Health Organization criteria. Results: Our results showed a mean of decayed, missing, and filled teeth (DMFT) of 0.6 (dft of 5.15), 3.42, and 5.44 corresponding respectively to the groups of 6–8-, 12-, and 15-year-old children. In the same groups, the percentage of DMFT = 0 for the 6–8-year-old category was 74%, the 12-year-old category was 20.9%, and for the 15-year-old category was 9.7%; Ten (2.1%) 12 year olds had moderate and one (0.2%) severe scores; these children had been born in other countries. Conclusions: Survey results confirm the need to implement nationwide dental caries prevention measures. Since water fluoridation is not feasible, salt fluoridation would be the alternative.

Keywords: Children, dental caries, enamel fluorosis, Lebanon, oral health status

How to cite this article:
Doumit M, Doughan B. Dental caries and fluorosis among children in Lebanon. Indian J Dent Res 2018;29:317-22

How to cite this URL:
Doumit M, Doughan B. Dental caries and fluorosis among children in Lebanon. Indian J Dent Res [serial online] 2018 [cited 2023 Mar 22];29:317-22. Available from:

   Introduction Top

Oral health has been recognized as an integral component of general health and well-being. However, dental caries remains the most common disease in children, and some population groups suffer disproportionately in regard to prevalence, severity, and its consequences. It is also known that although dental caries has steadily declined in countries that have implemented community prevention programs, underprivileged populations in both developed and developing countries remain seriously afflicted.[1],[2] Data from the World Health Organization (WHO) global data bank indicated that dental caries index (decayed, missing, and filled tooth [DMFT]) in Lebanese children 12 years of age had worsened from 1.2 in 1961 to 3.6 in 1974. According to data from an oral health survey conducted in 1994, the severity had further worsened to 5.72.[3] In 1986, a study was conducted in Lebanon to assess fluoride concentration in water supplies. Results indicated fluoride concentration ranging between 0.1 and 0.4 ppm.[4] A study conducted in 1995 and in 2012 showed that caries prevalence in Lebanese children is high and severe, dental fluorosis (dental fluorosis being very common, it is characterized by hypomineralization of tooth enamel due to excessive ingestion of fluoride during enamel formation) occurrence was shown to be negligible, fluoride concentration in urine of children is approximately one half of optimal levels, and renal fluoride excretion rates indicate insufficient fluoride exposure for protection against dental caries.[4],[5] Water fluoridation was considered not feasible due mainly to lack of centralized community water supplies. In 1996 with assistance from the WHO/Eastern Mediterranean Regional Office division of healthy lifestyle promotion, a study was conducted to explore fluoridation alternatives, and recommendations made to explore salt fluoridation and conduct required baseline studies.[6]

The aim was to assess dentition status in selected groups of children aged 6–8, 12, and 15 years including caries prevalence and severity and occurrence of enamel fluorosis and categorize treatment urgency.

   Methods Top

All baseline studies conducted in Lebanon were endorsed by the Ministry of Health officials and complied with general requirements for the protection of participants. Local coordinators authorized by the Ministry of Health made the necessary arrangements with schools selected for the study. Explanatory notes about the study purpose were translated in Arabic and served to secure consent from parents to allow participation of their children.

Samples were selected randomly, and enrollment lists of 1433 children aged 6–8, 12, and 15 years in public, private, and private nonprofit schools in each of the subregions of the country were obtained from the Ministry of Education. Only schools enrolling 30 or more were included in the study [Table 1] and [Table 2].
Table 1: Lebanon survey on dental caries and fluorosis 2012

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Table 2: Sample distribution by age and school location

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Enamel fluorosis scores obtained were used to calculate the absence or presence and the degree of fluorosis affecting the buccal surface of the upper anterior teeth following Dean's criteria; thus, scores were tabulated to establish whether children had no fluorosis and whether the condition was questionable, very mild, mild, moderate, or severe.[7],[8],[9]

The results showed that the largest group of children had no fluorosis, and thirteen received moderate scores and only one child was scored with severe fluorosis [Table 3]. This method of reporting enamel fluorosis takes into consideration the two teeth most severely affected; when a difference exists, the lesser score is recorded. The results indicated that unsightly fluorosis is not a common occurrence in Lebanon.
Table 3: Oral health status in Lebanon 2012; enamel fluorosis by age and by region

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It must be noted that children found to be in moderate and severe categories reported having been born in countries other than Lebanon.

Probability proportional to size sampling was used to select examination sites at each stratum. The school population was used as the sampling frame. Sixteen schools in each stratum were sampled, and schools selected at random. Thirty children in each stratum at each school were selected at random with an approximate equal number of females and males. [Table 1] depicts enrollment size and actual number of children examined by strata, sample distribution by country of birth and location type, and sample distribution by declared region of residence, sex, and age, and [Table 2] summarizes sample distribution by age and school location.

Prospective examiners were calibrated following the WHO guidelines.[7],[10] The purpose of the calibration exercise was to ensure uniform interpretation, understanding, and application of the criteria for the various diseases and conditions to be observed and recorded, to ensure that each examiner could examine consistently to a standard, and to minimize variations between different examiners. Groups of children aged 6–8, 12, and 15 years were examined following the WHO criteria.[7],[11],[12] The criteria were selected for conducting the survey so that results could be compared with previous studies conducted in the country as well as to facilitate regional and international comparisons.[13],[14] Enamel fluorosis was assessed based on examining the six upper permanent anterior teeth because of these being more esthetically important.[8],[9]

Results of the calibration exercise indicated satisfactory agreement for tooth status. Considering that enamel fluorosis was not known to be a frequent finding in the country, several color photographs of children with various degrees of enamel fluorosis were projected for improving examiner's ability to discern degree of severity.[15],[16]

Clinical recording and data management

Clinical examination findings were recorded in a modified version of the WHO data collection instrument. The simplified data collection version includes fields for recording demographic information, enamel fluorosis, dentition status, and treatment urgency. Data were transferred into special software program for analysis using SPSS/SAS/SUDAAN statistical packages.

   Results Top

Results showed that for the 6–8-year-old group, the highest prevalence of caries history was found in the primary teeth (88.05%) with an 86.16% rate of untreated patients. For the 12- and 15-year-old groups, they had a higher prevalence of caries history in permanent teeth with a percentage of 80.38% and 90.57%, respectively, of which 77.16% and 81.55% of patients were untreated [Table 4].
Table 4: Oral health status is Lebanon, 2012

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For the 6 to 8 year olds, caries severity was denoted by the mean DMFT in primary dentition was 5.15. In permanent dentition, mean DMFT in 15-year-old group was the highest 5.44, followed by the 12-year-old group with a DMFT of 3.42 and the 6–8-year-old group with a DMFT of 0.6 [Table 5].
Table 5: Dental caries severity by age

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The highest specific contribution of the dmft and DMFT elements was decayed teeth. In primary dentition, the percentage of decayed teeth was 93.56% (standard error [SE]: 0.85) in 6–8-; 99.06% (SE: 0.68) in 12-, and 100% (SE: 0) in 15-year-old group. In the permanent dentition, the percentage of decayed teeth was 94.43 (SE: 1.84) in 6–8-; 86.92 (SE: 1.38) in 12-, and 77.65 (SE 1.56) in 15-year-old group. A summary of relative contribution of the dmft and DMFT elements among children with dmft and DMFT >0 all ages included and by age is presented in [Table 6]. Dental caries severity per the WHO classification is presented in [Table 7] for all age groups included in the survey. Children aged 6–8 had 11.95% dmft = 0; 34% had dmft between 4 and 6 and 34% >7. In the permanent dentition, 70% of 6–8-year-old group had DMFT = 0; 19.62% in 12 years old and 9.43% in 15 years old. Tabulating results per the WHO classification further confirms severity of dental caries of children in Lebanon.
Table 6: Age-specific relative contribution of the decayed, missing, and filled tooth elements among those with decayed, missing, and filled tooth >0 and contribution of the decayed, missing, and filled tooth elements among those with decayed, missing, and filled tooth >0

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Table 7: Oral health status in Lebanon 2012 dental caries - World Health Organization severity by age

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Children with need of dental treatment were classified in this study from “no need for treatment” to “urgent dental care needed;” only 10.61% of the 1433 children examined were in no need of dental treatment, 55.90% needed prompt treatment, and 16.68% needed urgent dental care [Table 8].
Table 8: Oral health status in Lebanon, 2012

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   Discussion Top

Dental caries history in Lebanese children in the primary dentition is very high; 88% of children aged 6–8 years had caries history and 86% had untreated primary teeth. In the permanent dentition, 80% of 12-year-old group children had caries history and 75% had untreated permanent teeth. The situation was much worse in 15-year-old children who had 90% caries history and 81% untreated permanent teeth although mean dental caries severity in permanent dentition of Lebanese children declined from 1994 to 2012 in the three age groups included in the study. However, the calculated means for 12 (3.42) and 5.44 for 15-year-old group require urgent attention. The mean dmft in children aged 6–8 years was 5.15, which is also severe. Caries decline from 1994 to 2012 could be attributed to possible improvement in oral hygiene awareness as well as to greater availability of preventive agents including dentifrices. It should be noted however that lower caries indices between surveys could be due to differences in diagnostic criteria and assessment methodology. In the 1994 survey, the WHO methodology recommended the use of sharp explorers, while in 2012, the WHO methodology recommends the use of a probe with 0.5-mm hemispherical end to confirm visual evidence of dental caries. Although differences in assessment criteria and diagnostic methods may not have a serious impact in assessing caries for program planning, it should be taken into consideration when comparing differences in results from surveys conducted at different times and using different criteria and diagnostic methods. Despite this theoretical reduction, data from the year 2012 indicates that the largest component of the dmft and DMFT indices corresponded to decayed teeth in both dentitions. Over 50% of children in all ages required prompt dental treatment, 22% in the 6–8 years' age group and 15% required urgent dental treatment in each of the 12 and 15 years' groups. Caries severity of Lebanese children is higher than that found in children of the same age groups in Kuwait,[17] Tunisia,[18] Oman,[19] Jordan,[20] Syria,[21] Kenya,[22] South Africa [23] and Iran [24] although 15-year-old Iranian children had a mean DMFT of 5.0 in 1999. The conclusion is that Lebanese children suffer disproportionately from dental caries prevalence and severity than any of their counterparts in the countries of the Eastern Mediterranean region and that effective oral health preventive intervention must be implemented. Enamel fluorosis was negligible in 6–8- and 12-year-old group; in the 15-year-old group, three children were recorded as having moderate and 3 having severe fluorosis. However, it was reported that these children had been born in other countries. At the time the survey was conducted, enamel fluorosis was not a concern; it is known that community preventive programs including fluorides may slightly increase occurrence of mottled enamel, but if program quality is carefully controlled, enamel mottling should not be a concern, and the benefits of caries prevention outweigh its possible occurrence. Careful monitoring and periodic assessment of renal fluoride excretion is recommended by the WHO.[12],[13],[14],[25],[26]

   Conclusions Top

Although dental caries has declined since 1994, prevalence and severity in children aged 6–8, 12 and 15 years remain at undesirable levels.

The use of fluorides for prevention of dental caries has been proven to be a safe and effective public health strategy to reduce burden of dental disease of the population in industrialized and developing countries. Various vehicles such as water, salt, or milk are available and can be implemented with remarkable success. Water fluoridation is not feasible to be implemented in Lebanon and salt fluoridation would be the alternative of choice.

Adequate program monitoring and quality control maintenance can minimize occurrence of enamel mottling in communities using fluorides for dental caries prevention.

Unless an effective community prevention intervention is instituted soon, children and adult population of Lebanon will continue unjustly suffering from a preventable disease.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Doumit M. Benefits of water fluoridation in Lebanon. Beirut: Département de Santé Dentaire Publique, Publications de l'Université Libanaise; 1995.  Back to cited text no. 4
Doumit M, Doughan B, Baez R. Oral Health programme in Lebanon, Technical Assistance Provided for Development of Baseline Studies for Salt Fluoridation – Final Report in Data collection-WHO-L.U; 2012.  Back to cited text no. 5
Abdel Rahim IM. A Proposal for Salt Fluoridation in Lebanon, Project Document Prepared by WHO/Lebanon WHO/EMRO; May, 1999.  Back to cited text no. 6
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Petersen PE. Challenges to improvement of oral health in the 21st century – The approach of the WHO Global Oral Health Programme. Int Dent J 2004;54:329-43.  Back to cited text no. 12
Villa A, Anabalón M, Cabezas L, Rugg-Gunn A. Fractional urinary fluoride excretion of young female adults during the diurnal and nocturnal periods. Caries Res 2008;42:275-81.  Back to cited text no. 13
Baez RJ, Marthaler TM, Baez MX, Warpeha RA. Urinary fluoride levels in Jamaican children in 2008, after 21 years of salt fluoridation. Schweiz Monatsschr Zahnmed 2010;120:21-8.  Back to cited text no. 14
Pessan JP, Buzalaf MR. Historical and recent biological markers of exposure to fluoride. Monogr Oral Sci 2011;22:52-65.  Back to cited text no. 15
European Academy of Paediatric Dentistry. Guidelines on the use of fluoride in children: An EAPD policy document. Eur Arch Paediatr Dent 2009;10:129-35.  Back to cited text no. 16
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Correspondence Address:
Dr. Mounir Doumit
PO Box: Antelias 70570, Beirut
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_475_17

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]

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