Oral Health in Saudi Arabia

Oral Health in Saudi Arabia
153
Ammar Ahmed Siddiqui, Abdulmjeed Sadoon Al-Enizy,
Freah Alshammary, Sameer Shaikh, and Junaid Amin
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3512
Oral Health and General Health: Is There a Connection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3514
Common Dental and Oral Diseases in Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3515
Dental Caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3515
Periodontal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3517
Oral Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3519
Oral Health Knowledge and Practice in Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3521
Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3522
Teachers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3523
Peers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3524
A. A. Siddiqui (*)
Division of Dental Public Health, Department of Preventive Dental Sciences, College of Dentistry,
University of Ha’il, Ha’il, Saudi Arabia
e-mail: ammarqta2002@hotmail.com
A. S. Al-Enizy
College of Dentistry, University of Ha’il, Ha’il, Saudi Arabia
e-mail: Abdulmjeedsadoon@gmail.com
F. Alshammary
Division of Pediatric Dentistry, Department of Preventive Dental Sciences, College of Dentistry,
University of Ha’il, Ha’il, Saudi Arabia
e-mail: dr_freah@yahoo.com
S. Shaikh
Divisions of Oral Diagnosis and Oral Medicine, Department of OMFS and Diagnostic Sciences,
College of Dentistry, University of Ha’il, Ha’il, Saudi Arabia
e-mail: smrshaikh@gmail.com
J. Amin
Department of Physiotherapy, College of Applied Medical Sciences, University of Ha’il, Ha’il,
Saudi Arabia
e-mail: junaid768@hotmail.com
© Springer Nature Switzerland AG 2021 3511

I. Laher (ed.), Handbook of Healthcare in the Arab World,
https://doi.org/10.1007/978-3-030-36811-1_200
3512 A. A. Siddiqui et al.
Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3525
Health Care Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3525
Cancer Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3526
Oral Health Challenges and Solutions in Saudi Arabia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3527
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3528
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3529
Abstract
Oral health is the fundamental component of the physical health. Oral health is also a
crucial indicator of physical wellness and quality of life. Without accomplishing the
oral health, the World Health Organization’s definition of “health” – “a state of
complete physical, mental, and social well-being and not merely the absence of
disease and infirmity” – will remain incomplete. Notwithstanding the critical impor-
tance of oral health, it is frequently overlooked by healthcare policy makers. The
integration of the disciplines of “medicine” and “dentistry” is important for bridging
the gaps linking primary care and oral health. Filling these gaps will help to diminish
the disparities in access to oral health services. The topic of oral health is incomplete
without the inclusion of oral diseases and conditions that include dental caries,
periodontal disease, tooth loss, oral mucosal diseases, oral cancer, dental fluorosis,
oral manifestations of HIV infection, oro-dental trauma, and congenital anomalies
such as cleft lip and palate. Saudi Arabia is a country of immense geostrategic
importance that comprises the majority of the Arabian Peninsula. Over the past few
decades, Saudi Arabia has undergone rapid socioeconomic development and related
lifestyle modifications. Despite the development and economic prosperity, the inci-
dence rate of the oral and dental diseases in Saudi Arabia considerably exceeds the
rate in the developed and developing countries alike. In this chapter, after presenting
an overview of the oral health, emphasis is directed to the current scenario of the oral
health in Saudi Arabia, thereafter, focusing on the future plans for oral health
promotion and oro-dental disease prevention in the country.
Keywords
Oral health · Dental caries · Periodontal disease · Oral cancer · Oral health
promotion
Introduction
Oral health is considered a very important indicator of the overall well-being and
health. It involves a variety of conditions and diseases affecting the oral and dental
structures which includes dental caries, periodontal diseases, oral cancers, different
types of trauma, genetic/developmental, and many other different diseases and
conditions. The World Health Organization (WHO) defined health as, “a state of
complete physical, mental, and social well-being and not merely the absence of
disease and infirmity.” Recent developments in the definition of health and mea-
surement of health status have little impact on dentistry. In 2016, The World Dental
153 Oral Health in Saudi Arabia 3513
Federation (FDI) put forward a new definition of oral health as, “Oral health is multi-
faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow
and convey a range of emotions through facial expressions with confidence and
without pain, discomfort and disease of the craniofacial complex.” This new defini-
tion is of phenomenal value in the FDI’s framework for its 2020 vision (Glick et al.
2016; Da Silva and Glick 2012).
The status of the oral health in many different populations is very unsatisfactory,
and “Dentistry,” as a discipline, continues to be greatly disconnected from other
healthcare systems. Oral health is frequently ignored by policy makers, and for this
reason, the discipline of “Dentistry” is still not fully integrated into the concept of
general healthcare. Hence, it is important to understand and realize that the quality of
life (QoL) measures are not an alternative for measuring the outcomes associated
with diseases, rather adjunctive (Higginson and Carr 2001). Oral health should be
considered as a core element of the general health. Oral diseases and conditions are a
major burden to the global public health community and negatively affect QoL.
Although some diseases are more common than others, diseases such as dental caries
and gingivitis/periodontitis affect a significant proportion of the world population
(General Assembly 2011). Oral diseases cause a major economic burden on the
healthcare system. Besides the direct cost of dental treatment, there is also the
indirect cost. As an example, in the United States, there was an estimation that
more than two million working days were lost for the reason of work absences for
attending treatment visits of dental and oral diseases (Beaglehole et al. 2009). The
effect of oral diseases is not limited to negatively impacting QoL, and it could also
lead to death in some cases. The healthcare system in Saudi Arabia was formed by a
Royal decree in 2002. The aim was to assure that healthcare is provided to all
inhabitants in the Kingdom, in a way that is affordable, equitable, and organized. In
Saudi Arabia, there are 13 health regions, and the Ministry of Health (MOH) is
considered to be the main provider for healthcare, offering more than 60% of all
health services. The rest are provided by other nongovernmental and other govern-
mental sectors. Each region has its own independent dental center that receive
referrals from other clinics which are connected to the hospitals and different health
centers in each region (World Health Organization 2006).
Oral diseases in general are considered socially patterned, and usually the people
who are in the lower-income category are at a disproportionate disadvantage and
more affected as compared to others. This association exists in all age groups and
across different categories in both developed and developing countries (Hobdell
et al. 2003a; Peres et al. 2019).
It is estimated that oral diseases and conditions are affecting 3.5 billion people
around the world, and untreated dental caries is considered to be the most common
health condition in the world (Cooper 2018). The treatment of oral conditions is
costly. In most high-income and developed countries, the budget allocation for
dental care usually is around 5% only in the total health expenditure for healthcare.
On other hand, most of the low-income countries are not even capable of providing
basic services for treating or preventing oral and dental diseases. In this chapter, we
will present an overview of the oral health and how it is connected to the general
health. The emphasis of this chapter is focused on the past and current status of the
oral health in Saudi Arabia, with the discussion of the widely prevalent oral diseases
and conditions in the country and strategies implemented to tackle them. The future
for oral health promotion and disease prevention in Saudi Arabia are also outlined.
Oral Health and General Health: Is There a Connection?
“Certain common and simple disorders of the teeth may involve prompt or insidious
development of serious and possibly fatal ailments in other parts of the body,” this
statement was made by Gies in the 1920s (Gies 1926), reflecting how serious are the
diseases that could arise from neglecting the connection between the mouth and the
different systems of the human body. Oral health may influence physical, mental,
and psychological health. Impaired oral health significantly affects the social behav-
iors (Locker 1997). Oral diseases by adversely affecting the quality of life (QoL)
immeasurably hinder the well-being of its sufferers.
The global burden of diseases from 1990 to 2010 emphasized that oral diseases by
themselves were responsible for 15 million disability-adjusted life-years (DALYs)
around the world (Marcenes et al. 2013). The relationship between oral health of the
people and their overall health is absolutely evident, and there are many oral diseases
and conditions that correlate, associate, or even could be the starting point for a
systemic disease. In preschool children, dental carious lesions may be left untreated,
resulting in severe pain, discomfort, and possible infections. In children, educational
performance suffers due the disturbance that they may have in their sleeping hours
because of the dental pain, and even while eating, especially if it is affecting and
limiting their food choices which might lead to malnourishment of the children
(Sheiham 2006). Thus, it could also negatively affect their growth development
(Sheiham 2006; Duijster et al. 2013). When it comes to adults and the geriatric
population, tooth loss from periodontal diseases or dental caries will negatively alter
dietary choices and habits, especially with consumption of vegetables and fruits
(Tsakos et al. 2010). The most common oral diseases are mentioned in Table 1 with
some of their negative effect on the general health.
Periodontal diseases have many negative effects on the general health. One of the
most common effect of periodontal diseases on the general health is the negative
impact on patients with diabetes. It may alter glycemic control (Löe 1993; Taylor
2001; Teeuw et al. 2010; Borgnakke et al. 2013). Periodontal disease and poor oral
Table 1 Negative effects of dental caries and periodontal diseases on the general health
Oral disease Negative effects
Periodontal Oral malodor, tooth loss, chronic and acute pain, systemic infections, alter
diseases pregnancy, alter diabetes
Dental caries Tooth loss, chronic and acute pain, systemic infections, alter speech, negative
impact on patient self-esteem
hygiene are considered to be risk factors for pneumonia and also perhaps for chronic
obstructive pulmonary disease (Azarpazhooh and Leake 2006; Sjögren et al. 2008).
Periodontal diseases have been associated with many different diseases and
conditions, such as pregnancy, respiratory diseases, and cardiovascular diseases
(Albert et al. 2011; Offenbacher et al. 2006; Scannapieco et al. 2003b; Tarannum
and Faizuddin 2007; Vergnes and Sixou 2007; Scannapieco and Ho 2001; Blaizot
et al. 2009; Janket et al. 2003; Scannapieco et al. 2003a; Slavkin and Baum 2000).
Factors that could contribute to oral diseases include bad dietary habits, especially
intake of foods high in sugar, tobacco use, and alcohol consumption. Dental caries is
a multifactorial disease; however, the major contributing cause is the food and drinks
high in sugar. Moreover, there is a strong link between high-sugar diets and ov-
erweight and obesity (World Health Organization 2003). Toothache may cause
students to be absent from school, thus hindering their academic performance. In
the USA, dental problems alone were accounted for losing at least 117,000 hours of
school per 100,000 children (Gift et al. 1992). In Saudi Arabia, this issue needs to be
investigated more since, so far based on our best knowledge, there is only one
research paper that described this major issue. In this chapter, the impact of dental
pain on school attendance among students studying in secondary schools was
assessed. Approximately, 18% of students were absent at one point as a result of
the toothache (Shaikh et al. 2016).
Common Dental and Oral Diseases in Saudi Arabia
Oral health is far more than just cleaning the teeth. There are many oral diseases and
disorders, acute and chronic, and the etiology behind each one of them is usually
different from the others. Although caries and periodontal diseases are the most
common oral diseases, other oral conditions and diseases also carry a significant
burden on the health system.
Dental Caries
Dental caries has been recognized by the World Health Organization (WHO) as an
infectious noncommunicable disease that could impact the physical, social, and emo-
tional well-being of the children. In the 1990s, we had our first studies that established
how much prevalent dental caries is in Saudi Arabia, and since then, the prevalence has
been staggering (Akpata et al. 1992; Guile 1998; Alamoudi et al. 1996; Al-Shammery
et al. 1990). Dental caries is a cumulative condition, and its prevalence has the tendency
to increase with age. The Global Burden of Disease (GBD) study in 2010 found that the
untreated dental caries in the permanent dentition was the most prevalent condition
worldwide, affecting approximately 35% of the people in the world, around 2.43 billion
people (Marcenes et al. 2013). The WHO in 2003 along with FDI highlighted the need
to reduce the global burden of dental caries to achieve optimal health by setting global
goals to be achieved by 2020. These goals act as guidelines to set policies by healthcare
policy makers to enhance the oral health status in their populations (Hobdell et al.
2003b). The prevalence of dental caries in children tends to increase. This factor may
falter the goals of caries control set by WHO and FDI, including hitting a target of 50%
prevalence in 2000 (Fédération Dentaire Internationale 1982). Dental caries is endemic
in the Middle East. Until 2013, all studies suggest that the prevalence of dental caries in
Saudi Arabia is very high and estimated to be around 80% (Farooqi et al. 2015;
Al-Shammery et al. 1990; Wyne et al. 2002; Alamoudi et al. 1996; Al-Malik and
Rehbini 2006; Al Agili 2013). Unfortunately, there are gaps in knowledge regarding
the baseline data on oral health and modifiable factors of dental caries which restrict the
ability of many developing and semideveloping countries, including Saudi Arabia for
achieving the goals set by WHO. Many factors, such as income and the level of
education of parents which affect the socioeconomic status of population, have been
associated with dental caries, and along with other factors they need to be modified to
decrease the severity of dental caries (Gautam et al. 2012; Elani et al. 2012; Lasser et al.
2006; Narang et al. 2013; Alshammary et al. 2019a). Factors related to feeding practices
or the child’s brushing habits are much easier to modify compared to the socioeconomic
status. It is very important to modify these factors by certain practices and good behavior
like regular brushing, rinsing of the mouth after meals with water, and flossing (Amin
and Al-Abad 2008). Likewise, sugary food and drinks were also established to play a
significant role in the process (Woodward and Walker 1994). It is very important to
establish a baseline data about the norms in Saudi Arabia when it comes to these
different factors and their effects on dental caries prevalence. A study was done to
estimate the prevalence of dental caries in primary teeth and identifying key associated
factors in 6–8-year-old school children in Riyadh city of Saudi Arabia. (Alhabdan et al.
2018). This study contributed towards the knowledge of dental caries by enriching the
baseline data for the Riyadh region, and determining population-specific risk factors of
such a highly prevalent and preventable condition. They explored and analyzed factors
covering four major risk areas related to dental caries:
1. Children oral health practices and behavior

2. Child feeding habits
3. Dietary lifestyles
4. Parental socioeconomic status
It was reported that the first three risk areas in Saudi Arabia are more relevant than
parental socioeconomic status when it comes to the association with dental caries.
This was similar in developed countries like United States and Canada where the
individual factors like feeding habits and oral health practices were more important
to dental caries compared with the socioeconomic factors (Attaran et al. 2016; Elani
et al. 2012; Reisine and Psoter 2001). However, that does not mean that we should
neglect the socioeconomic factor. It needs to be addressed and improved, even
though it is the hardest to change (Al Agili and Alaki 2014; Al-Meedani and
Al-Dlaigan 2016; Peres et al. 2005; Traebert et al. 2009). On the contrary, when it
comes to developing countries, studies showed that socioeconomic factors could
Table 2 Caries prevalence Mean DMFT Prevalence

in GCC countries (DMFT:
Kingdom of Saudi Arabia 0.41–7.35 57.2–92.3%
decayed, missing, and filled
teeth) Qatar 4.5 73–85%
Kuwait 2.91–3.25 18.83–52%
Oman 1.53–3.23 58.1
United Arab of Emirates 1.6–3.27 54–65%
have a more influential role on dental caries (Al-Meedani and Al-Dlaigan 2016;
Peres et al. 2005; Rajab et al. 2014; Traebert et al. 2009).
WHO recommends to use the index for decayed, missing, and filled teeth (DMFT
index) for permanent teeth. WHO had set a basic global indicator for oral health 2000,
the DMFT which is higher than 6.6 in 12 years of age children is considered very high,
if it is between 4.5–6.5, it is considered high, between 2.7–4.4 is considered moderate,
1.2–2.6 is low, and lower than that can be considered very low (World Health
Organization Oral Health Programme 1996). Numerous studies done in Saudi Arabia
showed that DMFT scores are ranging from moderate to high, and sometimes it can
reach to very high scores.
In Gulf Cooperation Council (GCC) countries, there are multiple epidemiological
studies that assessed caries prevalence and DMFT index scores. One systemic review
was done in 2017 by Alayyan et al. (2017), to evaluate and analyze the prevalence and
the severity of dental caries in school children in the GCC region (Table 2). The most
commonly stated reason of the high prevalence of dental caries was the exposure to
cariogenic food and drinks.
In 1999, a study evaluated dental caries experience in 1873 children who were
12–13 years of age in 10 administrative provinces in Saudi Arabia (Al-Shammery
1999). The caries prevalence in rural areas was found to be less than urban areas,
69% and 74% respectively. However, this study did not find any significant differ-
ence between the two areas when it comes to severity of dental caries DMFT, 2.69 in
the urban areas while it was 2.65 in the rural areas. In 2010, a study included 12,200
children from 11 administrative regions of Saudi Arabia. This study measured the
dental caries experience along with assessing the fluoride exposure in 11 regions that
were included in the study (AlDosari et al. 2010). The prevalence of caries in the
permanent dentition ranged from 59–80%. This variation in the prevalence was
related to the difference in the fluoride levels in different regions of Saudi Arabia.
The DMFT scores were 1.53–2.93 in children aged 12–13 years old and 2.24–4.08 in
children aged 15–18 years old. The prevalence of caries was found to be higher in
the primary teeth ranging from 74–90%, and the DMFT was 3.39–6.15.
Periodontal Disease
The periodontium having four components is a complex structure. Any pathologic

change occurring in one, will have adverse implications on the remaining ones
(Bartold et al. 2000). Periodontal disease is the second most common oral disease
after dental caries, found in more than 75% of the world’s population (Papapanou
1999; Petersen 2003). Periodontal diseases can affect both young and old people;
however, the latter are more prone. Most of the people have gingival inflammation,
and around 11% of them have a progressive type of periodontal disease which
ultimately will lead to tooth loss (Marcenes et al. 2013). There are many classifica-
tions for periodontal diseases; however, in 2017 a consensus was reached on a new
classification for periodontal and peri-implant diseases and conditions along with
different subclassifications (Papapanou et al. 2018; Berglundh et al. 2018; Chapple
et al. 2018; Jepsen et al. 2018). In 2000, the United States Surgeon General released
a report mentioning dental caries and periodontal disease as a silent epidemic in the
country, underlining that millions of people suffering from these two diseases in the
USA (Dental and Research 2000). The prevalence of periodontal diseases usually
varies in different countries and population, differs among different age groups, and
also depend on which types have been investigated. Gingivitis in its mildest form
starts in childhood, and becomes more aggressive and prevalent as the children ages
(Stamm 1986; Russell 1971). Nevertheless, numerous studies were conducted in
Saudi Arabia related to the oral and periodontal health; however, still there is no a
national surveillance system for oral health in the Kingdom (Metrics and Evaluation
2013). The first epidemiological study that measured how much prevalent the
periodontal disease was in Saudi Arabia was conducted in 1982. This study recruited
schoolchildren as subjects, both males and females, and the results were very
depressing. It was found that 96% of the children had some form of periodontal
disease (El-Angbawi and Younes 1982). In 2014, a study was done to evaluate how
prevalent and severe is the plaque-induced gingivitis among Saudi adult population.
Unfortunately, the study found that every participant had gingivitis, with prevalence
of gingivitis being 100% among these adults, aged between 18 and 40 years old
(Idrees et al. 2014). In 2018, a study was conducted among high-school children to
check the prevalence of periodontitis. It was revealed that 8.6% of the students had
periodontitis, and only 34.5% of them had a healthy periodontium, which by new
definition was equivalent to stage 1 periodontitis as per the 2017 periodontal diseases
classification (Papapanou et al. 2018). Periodontitis is found to be higher in popu-
lation with specific risk factors. Smoking and diabetes are two of the most important
risk factors that have been associated with periodontal diseases (Martinez-Canut
et al. 1995; Taylor 2001). Unfortunately, high prevalence of smoking in Saudi
Arabia poses a high risk to the periodontal tissues (Moradi-Lakeh et al. 2015),
having said that, dentist have role to play in smoking cessation advice. To the best
of our knowledge, only 1 study was conducted in Saudi Arabia during the year 2018
which evaluated the knowledge and practice of smoking cessation advice in dental
practice (Alhobeira et al. 2018). Diabetes mellitus (DM) is also a serious health
concern. Number of patients with DM is increasing with time (Abdulaziz Al Dawish
et al. 2016). These two risk factors might affect the prevalence and the severity of
periodontitis in Saudi Arabia. It is highly recommended to have further studies,
together with advocating oral hygiene habits, However, a study by Siddiqui et al.
(2018b) measured the performance of various oral hygiene maintenance practices
and also recommended further improvements based on the recommendations of the

American Dental Association (Siddiqui et al. 2018b).
In Saudi Arabia, besides tooth-brushing, Miswak is also used as a traditional/
Islamic method for cleaning teeth. It is a branch from a tree called Arak. The end of
this branch is trimmed to give it a shape of a regular brush for tooth-brushing
(Al-Khateeb et al. 1991). The use of miswak has long been a part of Islamic traditions
(Bos 1993). A study in 1991, observed that miswak when used, the need for periodon-
tal treatment was reduced in the people who used it; however, the rates of periodontitis
were not measured (Al-Khateeb et al. 1991). Interestingly, a study from Hail reported
other cultural way of cleansing teeth with soda, bleach, and olive oil (Siddiqui et al.
2018a). There is no scientific evidence behind use of such methods. It was suggested
to create awareness among masses to prevent its use.
Oral Cancer
Oral cancer is as a malignancy that involves the oral cavity and can involve any area
beginning at the lips and ending at the anterior faucial pillars (Neville et al. 2002).
Approximately 1 out of 2 cases of head and neck cancers occur in the oral cavity. In
2018, there were an estimation that the new cases reached 355,000 and the deaths
exceeded 177,000 globally for oral cavity cancers (Bray et al. 2018). The worldwide
male to female incidence ratio is 2:1. Incidence and mortality of oral cancers are on
the decline in developed countries when compared to developing countries (Wild
et al. 2020).
Prevalence of mortality rates of oral cancer worldwide shows variation in the
different regions of the world. In 2010, WHO reported a mortality rate of oral cancer
of 2 per 100,000 in Middle Eastern countries, which is lower than India and United
States (Ferlay et al. 2010). In Saudi Arabia oral cancer is the third most common
cancer after lymphoma and leukemia (Tandon et al. 1995). Among all the head and
neck malignancies detected yearly in Saudi Arabia, oral malignancies accounts for
approximately 26% of them. The latest data on prevalence of oral cancer is in Saudi
Arabia comes from a systematic review that was done in 2019, showing that the
prevalence of oral cancer in Saudi Arabia ranged between 22% to 69%. This is a very
significant health issue, especially in the southern part of the kingdom. Most of the
patients reported were at advanced stages of the cancer (III and IV), and the study
found that the 5-year survival rate was ranging between 13% and 24% (Basha
et al. 2019).
One of the main differences in Oral Squamous Cell Carcinoma (OSCC) occur-
rence between different countries and regions of the world is the affected sites. In the
Western countries, more than 50% of the cases were found to be occurring at
the ventrolateral aspects of the tongue and floor of the mouth (Boyle et al. 1990).
On the other hand, in the southeastern part of the Asian continent, oral cancer was
significantly higher in the region of buccal mucosa. The distribution of affected sites
in the Arab countries differs; however, the tongue and the lips were the most affected
areas (Al-Jaber et al. 2016). This was associated directly with the chewing of tobacco
or keeping it in the mouth for prolonged periods of time (Ezzat et al. 1996). In Saudi
Arabia, the tongue is affected more than any other part of the oral cavity, followed by
the floor of the mouth, and then alveolar ridge (Basha et al. 2019).
The etiology of oral cancer is multifactorial including behavioral, social, envi-
ronmental, and genetic risk factors. The major risk factors are tobacco chewing,
tobacco smoking, and consumption of alcohol (Notani 2000). The incidence of
oropharyngeal cancers tends to decrease if there is a decline in using cigarettes,
tobacco products, and alcohol. Although alcohol is not a major issue in Saudi
Arabia, smoking and tobacco chewing are posing critical concerns in Saudi Arabia,
and there is at least one anti-smoking clinic in each directorate of health for the
purpose of education, counseling, and rehabilitation (World Health Organization
2006).
Among the different causes of oral cancer in Saudi Arabia, smokeless tobacco
is considered to be the main cause. Shammah is common in Saudi Arabia,
especially in the southern part of the Kingdom. It is a traditional type of chewing
tobacco and a mixture of other ingredients. Shammah is placed in the lower buccal
or labial vestibule of the oral cavity. Shammah has been associated with oral
mucosal lesions which may lead to development of malignant lesions (Al-Tayar
et al. 2015; Allard et al. 1999). Khat is another harmful substance that have been
used in Saudi Arabia for decades. It is a psychostimulant herb that grows in the
countries bordering the Red Sea (Gebissa 2010). Although Khat is not regarded as
a tobacco, both mechanical and chemical irritation of Khat chewing may result in
a number of changes in the oral mucosa, which may transform into oral cancer
(Marway 2016). The frequent use of Shammah and Khat is strongly associated
with the high prevalence of oral cancer in Saudi Arabia. Jazan province, located in
the southern region of the country, has the highest the consumption of both Khat
and Shamma (Table 3). As a consequence, this area has the higher prevalence of
oral cancers compared to other regions (Tandon et al. 1995; Amer et al. 1985;
Quadri et al. 2015; Ibrahim et al. 1986).
Early detection is pivotal in the successful treatment of oral cancers; however, it
remains a challenging and daunting prospect in the general medical and dental
practice. Notwithstanding that oral cancer from the practical standpoint is an easily
visible lesion, most dentists or general medical practitioners misdiagnose it for more
innocuous lesions that clinically show a similar appearance (Al-Rawi and Talabani
2008). However, there are not many studies regarding public knowledge and aware-
ness of oral cancer (Altamimi et al. 2019a). Further research is needed to evaluate
that aspect.
Table 3 Main differences between Khat and Shamma

Khat Shamma
Psychostimulant herb named Catha edulis Chewing tobacco mixed with other
ingredients
The leaves chewed for hours, then stored between Placed in the lower buccal or labial
cheeks vestibule
Oral Health Knowledge and Practice in Saudi Arabia
There are many factors that play key roles in the perception and practice of oral
health (Fig. 1). Parents can be one of the most important factors. Children as they
grow can be influenced by external influences, including their peers, friends, and
teachers. Health professionals also have a major role to educate and correct any
misconception that children or adults might have regarding different oral health care
practices. Moreover, Internet and social media in the recent years have made a huge
impact on people accessing information about different health topics. Studies in
Saudi Arabia about oral health perception and practices were done in different
regions. Various studies on this topic from the same region can vary greatly in
their results. Sample number and instruments that were used in conducting these
studies are key factors in this variation.
Good oral health practices should include both the utilization of dental services,
which are usually provided by professionals, and development of good oral health
habits like brushing and flossing that people do by themselves. Many studies support
that brushing twice a day with fluoridated toothpaste is the best practice to prevent
dental caries and periodontal disease (Ainamo 1980). One of the earliest studies that
explored oral health preventive knowledge and practices in Saudi Arabia was
conducted in Jeddah city. This study showed limited knowledge in preventive dental
measures. Although more than two-thirds of the participants in this study used
Miswak for cleaning their teeth, only one third of them brush their teeth twice
daily, and less than 10% of them floss their teeth (Jamjoom 2001). More than 80%
of intermediate schoolchildren in Abha City showed a good overall knowledge about
oral health and its link to the general health. However, knowledge alone is not enough.
Even though these children knew about importance of maintaining oral health, they
did not practice it. Two-thirds of children did not brush their teeth on daily basis, and
most of them did not use dental floss (Al-Qahtani et al. 2020).
Parents
Health professionals Teachers
Internet Peers
Fig. 1 Key factors influencing oral health

Another study assessed the knowledge and attitude regarding periodontal health
among Saudi students that were in high-school and intermediate schools. It was
found that most of the students know that brushing could decrease the chance of
developing periodontal diseases. Another interesting finding was that females used
dental floss more than males; however, miswak was used more often by males than
females (Farsi et al. 2004). Dental caries prevalence was found to be very high
among primary-school students in a major study that was conducted in Riyadh. Only
3% of primary school students included in study were caries-free (Al-Shammery
et al. 1990). In 2008 (Amin and Al-Abad 2008), in a study to assess different factors
associated with caries in primary school male students concluded that there are five
important risk factors for dental caries in these children:
1. Poor oral hygiene practice

2. Lack of proper dental health knowledge
3. Lack of parental guidance
4. The frequency of exposure to cariogenic foods
5. Sociodemographic factors
In Al-Baha region, a study explored oral health status of Saudi students aged
12–15 years, followed by evaluating their attitudes and behaviors. The plaque
deposits, dental caries, and gingival bleeding were observed to be very high. Only
16% of these students brush their teeth twice a day. Most of the participants had
moderate attitudes toward oral health (Alzahrani et al. 2018).
Parents
Parents’ ability to act as role models can immensely influence their children’s oral
health practices, their perception to what is good or bad regarding food choices, oral
care methods, and many other things that could contribute to either enhancement or
deterioration of their oral health (Kwon et al. 2016). There are certain parental
factors which greatly influences adolescents, such as oral hygiene and sugar intake
of the mothers, and the fathers’ smoking habits (Astrøm 1998). Parents’ oral health
knowledge and practices influences their children tooth-brushing habits (Rajab et al.
2002). Arabs, including Saudi Arabia have collectivist cultures, in contrast to the
Western cultures like United States that is more likely to be individualistic (Buda and
Elsayed-Elkhouly 1998). In such cultures, children and teenagers can be more
welcoming and receptive to parental control regarding their behavior and consider
them to be beneficial for themselves (Soenens and Beyers 2012).
The first dental visit of the child is one of the most important visits. This visit
should be done before the child reaches first year of age. Usually the timing of
children’s first dental visit reflects how the future of their oral health will be (Widmer
2003). In 2015, a research study included a question regarding this issue, and it
seems that the majority of Saudi mothers were having poor understanding of how
important this visit is (Kamil et al. 2015).
Also, there is the need for creating awareness regarding the drinks which are
suitable for infants and children, as it seems that there is a lack of knowledge about
how dangerous certain drinks can be to children’s oral health, like soft drinks, juice,
and other sweetened drinks (Al-Zahrani et al. 2014).
The different psychological and physiological changes that a mother had during
pregnancy may impose a burden compelling her to neglect the oral health. Maternal
oral health knowledge has been associated with the status of children’s oral health
(Dye et al. 2011). One study assessed this association among pregnant Saudi women.
Approximately, 70% of them showed that they have a good oral health knowledge
related to pregnancy and infancy (Gaffar et al. 2016). However, it appears that some
aspects of oral health practices are not well known or well understood. Moawed et al.
(2014) found that the majority of Saudi pregnant women in their study did not know
what exactly plaque is, and what time is best when it comes to flossing, which is
before brushing. This is an indication that women were not knowledgeable enough
regarding certain oral health methods and practices that might help them in reducing
the chances of some diseases to occur, like periodontitis and gingivitis (Moawed
et al. 2014).
Another misconception that some parents in Saudi Arabia have, is the belief that
the primary teeth are less important than permanent teeth (Al-Shetaiwi et al. 2018).
One study was conducted in Hail region to check parents’ knowledge and attitudes
toward their children oral health. Most of the parents had satisfactory knowledge
about oral hygiene maintenance of their children (Alshammary et al. 2019b). In
Aseer region, it seems that parents have insufficient knowledge about their children’s
oral health (Alshehri and Nasim 2015).
A pilot study was done to see the difference in perception between Saudi fathers
and mothers toward their children oral health. The findings suggest that Saudi
mothers have a relatively better understanding. Although Saudi fathers showed
some concerns about their children’s oral health. However, these concerns didn’t
reflect on their children oral health status (Pani et al. 2012).
Teachers
Teachers are can play an influential role in affecting different behaviors of young
children including their oral health-related behaviors. The number of primary school
teachers has been estimated to be around 234,562 teachers in Saudi Arabia (Ministry
of Education Statistics 2019). Hence, teachers’ knowledge related to oral health is
very important for their own oral health, as well as for their students whom they are
teaching and interacting with on a daily basis.
The degree of knowledge and practices of oral hygiene habits in both males and
females in knowledge and practice of oral hygiene habits among Saudi male
and female teachers, in both primary and secondary schools, was similar (Almas
et al. 2003).
Two studies were done in Al-Madinah city (Ahmad 2015; Al-Johani and Elanbya
2019). Both of the studies have similar results regarding primary school teacher’s
knowledge and attitudes about their oral health. These studies showed that teachers
have acceptable knowledge, as well as positive attitudes toward oral health practices.
However, the teachers still need to improve their knowledge and should discuss
more oral health issues with their students, as there are only 15% of teachers which
revealed that they discuss such subjects with their students. In Hail region, a similar
study was done (Aljanakh et al. 2016); however, it was done in secondary school
teachers for assessing their dental health knowledge, and their interest in using this
knowledge for educating their students. They found that that more than 80% of
teachers had the sufficient knowledge about different causes of dental caries and
periodontal diseases, also on how to prevent them. Teachers in Hail showed an
incredible enthusiasm regarding oral health promotion, and more than 90% of them
thought that oral health topics should be included in education and school curriculum.
School teacher’s role in preventing dental trauma at school is of crucial impor-
tance, it was reported from one of the regions that 70% of teachers confronted a
dental trauma at school and more than half of them were unaware of its management
(Siddiqui et al. 2017). Besides for creating awareness related to trauma prevention,
schoolteachers were surveyed about the best way of educating them as per their
perceptions, and most of them answered to get awarded by means of mobile
application (Altamimi et al. 2019b).
Peers
Adolescence is an important period in life. Psychological and physiological changes

occur mostly during this period, and in children from age of 10, one can see these
changes affecting their behavior (American Psychological Association 2002).
During this period, adolescents start to be more independent of their parents, and
more influenced by their peers and friends. External influences will affect their
behaviors greatly (American Psychological Association 2002; De Goede et al.
2009). Oral health is adversely affected among adolescents that may have poor
dietary habits, unsatisfactory oral hygiene practices, or unhealthy habits like tobacco
use (Resnick et al. 1997; Majewski 2001). Teenagers peer and close-friendship
relationships were reported to have a significant influence on their brushing habits
(Dorri et al. 2010). One study found that Peer-led strategy is more effective than a
teacher-led strategy to improve teenager’s oral heath behaviors (Haleem et al. 2012).
In Saudi Arabia (El Tantawi et al. 2017), investigators explored the association
between four coexisting different oral health practices among Saudi teenagers:
1. Tobacco use
2. Brushing twice a day
3. Daily drinking sugary drinks
4. Daily eating sugary foods
They analyzed differences between the effect of a close friend and that of
distant peer like classmate, and both parents. They found that teenager’s tooth-
brushing habits were parental influenced, especially the mother. The father was
having more influence when it was related to the tobacco use. Both drinking and
eating sugary foods were influenced by the close friends, followed by their
classmates.
Media
In Saudi Arabia, Internet and social media are very commonly used for different
purposes. More than half the population are using them on a daily basis (Ministry
of Communications and Information Technology 2016; MediaCT 2012), and this
can be applied when it comes to oral health (Almaiman et al. 2016). One study
investigated what teenagers might favor when it comes to receiving oral hygiene
instructions and what factors might be associated with this preference. It was
found that approximately 57% of Saudi adolescents preferred using social media
over other means (El Tantawi et al. 2019). This finding might be associated with
the fact that using Internet is very easy and made oral health information readily
available.
Health Care Professionals
Dental practitioners and other healthcare professionals know exactly how important
oral health is, and that a good oral health is associated with good overall health, and
vice versa. There are many different oral diseases that are strongly associated with
systemic diseases. Total health care necessitates joint efforts of all of the medical and
dental staff (Harris and García-Godoy 2004). Until 2018, there are more than 38,000
dentists and physicians working in the Ministry of health, while other governmental
sectors had more than 14,000. Nurses in governmental sectors alone were estimated
to be more than 120,000 in number. There were so more than 22,000 pharmacists
working in both governmental and private sectors (Ministry of Health Statistical
Yearbook 2018). These large numbers of healthcare professionals, if trained and
utilized to educate and promote oral health knowledge and practices to people, will
make a huge impact.
In 2012, Baseer and colleagues conducted a study to assess oral health knowledge
and practices among other health professionals in Riyadh (Baseer et al. 2012). This
study included physicians and medical students, nurses, technicians, and pharma-
cists. In this study, they found that knowledge level was different among these
groups. Among the different health professionals involved in this study, physicians
showed superior knowledge compared to the other groups of health care profes-
sionals. Only one-third of all healthcare professionals knew what dental plaque is,
and what its role in dental caries and periodontal diseases is. This is considered much
lower than what to be expected from health professionals, who had a higher literacy
level in the health field.
Pediatricians
Infancy and childhood are the most vulnerable periods for a child to have oral
diseases including Early Childhood Caries (ECC). Pediatricians among all health
care professionals can play a major role in recognizing most of the oral health
conditions and diseases in infants and children. The awareness of pediatricians
about oral health issues could contribute to the achievement of better oral health
in infants and children (Soares et al. 2013). In Saudi Arabia, although pediatri-
cians did not receive any formal training in oral health in their curriculum, they
showed a very good knowledge and practices about oral health. Most of them
knew that white spots on teeth could be a sign of early carious lesions. Also, most
of them knew that parents should bring their children to their dentist before
reaching the age of 12 months. Their good knowledge might be related to the
fact that they usually perform routine visual examinations of the mouth (Tikare
et al. 2019).
Pharmacists
The pharmacists’ role in promoting oral health is very important, by giving cos-
tumers and patients oral health information. Most of the pharmacists believed that
providing oral health advice is within the realm of their profession (Buxcey et al.
2012). Pharmacists are in a unique place to identify the needs of patients by their
daily interactions with patients. Furthermore, patients that lack access to dental and
oral health services, for a variety of reasons, are more likely to seek advice in oral
health and dental problems from pharmacists (Cohen et al. 2009). Patients usually
seek advice from pharmacists when they have some doubts regarding different
dental products, such as toothpastes or toothbrushes. One study investigated the
knowledge, attitude, and practices about oral health among pharmacists working in
Saudi Arabia (Baseer et al. 2016). Unfortunately, it was found that pharmacists had
an average knowledge, negative attitude, and inadequate self-care practices toward
oral health.
Cancer Awareness
Detecting oral cancer at an early stage is the most effective way to increase survival
rate and decrease mortality (Scott et al. 2008). Any increase in the understanding
about early signs and symptoms of oral cancer among the population can definitely
improve the prevention and early detection of oral cancers. Al-Maweri and col-
leagues assessed the public levels of awareness in Saudi Arabia concerning the
knowledge about the signs and risk factors are related to oral cancer (Al-Maweri
et al. 2017). This study discovered a significant lack of knowledge regarding risk
factors and early signs of oral cancer. It was identified that this lack of knowledge
could be addressed by public health promotion and awareness campaigns.
In Jazan region, which has the highest prevalence of oral cancer in Saudi Arabia
(Allard et al. 1999), Quadri and colleagues explored the knowledge and awareness of
oral cancer among the youth and found it to be low (Quadri et al. 2014). Through the
same study, participants were provided with information regarding oral cancer.
These kinds of studies, especially in high-risk regions are required to enhance the
public awareness.
Oral Health Challenges and Solutions in Saudi Arabia
A few factors influence oral health status as we have mentioned, and among these
factors, there are many that could act as obstacles in the way of improving oral health
in any country. One of the issues is that oral health in many countries usually is not
given the importance that it needs, and Saudi Arabia is not an exception to that.
Given the fact that the population of Saudi Arabia is only around 30 million, the
kingdom has a relatively low number of dentists compared to physicians and
pharmacists in the Kingdom, as well as to dentists in other developed countries.
The health work density in 2014 was only 4.11 dentists per 10,000 population, and it
only increased to 5 dentists per 10,000 in the year 2017 (Ministry of Health
Statistical Yearbook 2018).
In USA and Canada, the numbers were 6.1 and 6.3 dentists per 10,000 popula-
tion, in 2015 and 2016, respectively (Global Health Observatory 2019). The sad
story of dental diseases is that most of these diseases and conditions are highly
preventable, and generally easy to manage and treat in their early stages. Prevention
of dental diseases is a crucial component in the practice of dentistry, by reducing the
financial cost and improving the patient’s quality of life (AlShammery 2017). In the
past, prevention was considered as a field that is far from the dental profession,
which is no longer true. With recent trends in “minimal intervention” dentistry that
every dentist should know the basics in preventing different oral diseases.
In 2016, Saudi Arabia announced its vision 2030, it includes a National Trans-
formation Plan (NTP) and one of the important goals in this vision is to improve the
health system in all aspects; however, to meet these ambitious goals it will require a
very strategic plan to face the challenges that the system currently has (Saudi Vision
2030 2018).
The strategic objectives of NTP related to developing the health workforce gave
higher priority to medical training and advocated for the establishment of educational
institutes and partnering with different international universities including different
institutions in the private sector. As most of the dentists in the high-income nations
work in the private sector and providing their services under an organized oral health
system, Saudi Arabia has a long road to reach their objective in this specific issue.
Saudi Arabia through the NTP is pushing the health sector to reform itself, by
encouraging all businesses that provide health care services in the private sector
(Saudi Vision 2030 2018). Vision 2030 gives the chance for additional healthcare
services to grow and support the public health systems. In dentistry, the visions 2030
is accomplishing this by facilitating and supporting the start of new private dental
clinics in all the regions (Ahmad et al. 2016).
One of the biggest challenges is how actually to set a specific plan to resolve oral
health issue, when in the first place the data and the studies that are available are not
actually giving an accurate picture of the oral health status in general in Saudi
Arabia. National epidemiological studies are mandatory to resolve this challenge.
1. School oral health promotion programs

2. Disease prevention and health promotion/the focus
In the area of tobacco control, Saudi Arabia is working hard on different aware-
ness programs by social media, anti-smoking media campaign, and also providing a
national website which offers tobacco control services that includes: Health promo-
tion, clinics appointment and locations, and the Fagerstrom test for the nicotine
dependence. The tobacco control programs offer specialized clinics to help people
quit smoking. Until 2015, there was at least 10 mobile clinics and 100 fixed clinics.
The staff is trained in tobacco control, and all the medications for smoking cessation
are free of charge and are available at public health centers. In addition, the program
has also established a call center and developed a national guideline for smoking
cessation services. Along with that they have also set up electronic program for
recording the patient data that includes all of visits and appointments for better
evaluation and monitoring purposes (WHO 2015).
One mean that we have mentioned before was Internet usage and social media,
utilizing these channels in health promotion is essential part to develop and enhance
the knowledge that people can obtain. They will provide low-cost, reliable, and
professional oral health information. This can be done by encouraging dentists and
specialists in the field to have a professional presence on social media. Their
presence also will reduce the chance of getting wrong information (El Tantawi
et al. 2019).
Conclusion
The prevalence of oral and dental diseases in Saudi Arabia is significantly high. In
order to improve the oral health status in the country, school-based oral health
promotion and disease preventive programs should be promoted and supported,
and any national strategy to control oral diseases should take into consideration
the proclivities in such diseases. The strategy is that oral disease prevention and
the promotion of oral health needs to be integrated with general health promotion
and chronic disease prevention. For the reason that most oral diseases and chronic
diseases have common risk factors and the risks to the health are linked. As is the
case for major chronic diseases, many oral diseases are linked to unhealthy
environments and behaviors, particularly the widespread use of tobacco and
excessive consumption of sugar. Promotion of population-based and strategic
planning studies is essential to assist policymakers in determining the number
of oral health facilities needed to meet the increasing oral health demands of the
population in Saudi Arabia. We identified the needs of having longitudinal studies
for measuring and tracking chronic oral diseases at regional levels. General public
knowledge, attitude, and practice towards oral health need to be improved by

healthy intervention at community level.
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Oral Health in Saudi Arabia

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Oral Health and General Health: Is There a Connection?

Common Dental and Oral Diseases in Saudi Arabia

1. Children oral health practices and behavior

Table 2 Caries prevalence Mean DMFT Prevalence

The periodontium having four components is a complex structure. Any pathologic

and also recommended further improvements based on the recommendations of the

Table 3 Main differences between Khat and Shamma

Oral Health Knowledge and Practice in Saudi Arabia

Health professionals Teachers

Fig. 1 Key factors inﬂuencing oral health

1. Poor oral hygiene practice

Adolescence is an important period in life. Psychological and physiological changes

Health Care Professionals

Oral Health Challenges and Solutions in Saudi Arabia

1. School oral health promotion programs

knowledge, attitude, and practice towards oral health need to be improved by

Almaiman S, Bahkali S, Alabdulatif N, Bahkaly A, Al-Surimi K, Househ MS (2016) Promoting

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