Oral health and socio-economic status among children during Syrian crisis: a cross-sectional study

Prevalence and Risk Factors of Traumatic Dental Injuries among Conflict-Affected Schoolchildren in Syria (2023-2024)

AIM

The prevalence of traumatic dental injuries (TDIs) and their contributing factors among Syrian children has not been explored in any previous epidemiological studies since the onset of the crisis. This study aimed to assess the prevalence of TDIs and their associated characteristics among schoolchildren aged 9 to 12 in Damascus, Syria.

MATERIALS AND METHODS

We conducted this cross-sectional study from 2023 to 2024, collecting sociodemographic data and performing dental examinations, and the presence of TDIs, which were classified according to the World Health Organization's guidelines. We recorded Screen time and categorized it into two groups. We measured Overjet in millimeters, and the statistical significance was set at P < 0.05.

RESULTS

We identified TDIs in 17.6% of children, with uncomplicated crown fractures being the most common. Falls were the leading cause, and the home was the most frequent injury location. Significant risk factors included age, gender, socioeconomic status, screen time, Body Mass Index, and overjet. Males had twice the risk of TDIs compared to females (OR = 2.104, 95% CI: 1.399-3.165), and children from lower socioeconomic backgrounds had a 2.29 times higher risk (OR = 2.299, 95% CI: 1.364-3.877).

CONCLUSION

This study found that a significant proportion (17.6%) of Syrian children experienced TDIs, highlighting the urgent need for preventive programs and improved dental care for Syrian children affected by TDIs.

CLINICAL RELEVANCE

Early identification of children at higher risk, prompt management of dental trauma, and educational initiatives for parents and educators are essential. Schools, as primary injury sites, should adopt safety measures, while dentists should engage in community outreach to enhance awareness, early diagnosis, and intervention.

Prevalence and clinical risk factors of dental caries in Syrian children: a cross-sectional study

This study aimed to estimate dental caries' prevalence and potential risk factors among schoolchildren aged 8-12 in Damascus, Syria. The study was cross-sectional and conducted between February 2023 and April 2024, the target population was 1,052 children selected using multi-stage cluster sampling. Dental caries were determined using the DMFT/dmft index, while additional information on sociodemographic status, and attitude towards oral hygiene practices, were collected via a structured questionnaire. Data analyses were conducted using the Statistical Package for Social Sciences (SPSS). The overall prevalence of dental caries was 90.8%. Males had a slightly higher prevalence (91.9%) than girls (89.8%). Children aged [10-12] years showed the highest caries prevalence (91.7%). The mean DMFT/dmft score was 2.07 ± 1.91/3.74 ± 2.25, respectively. Caries prevalence was significantly associated with the type of school attended, family size, socioeconomic status, and parental education. Additionally, the frequency of tooth brushing, dental flossing, and irregular dental visits were significantly linked to higher caries incidence. It was found that caries experience remains high in the children in Damascus, with many associated factors including their sociodemographic factors and oral behaviors. We confirm that visiting the dentist regularly, using dental floss, and brushing regularly decreased the prevalence of dental caries among children.

Management of deep carious lesions among Syrian dentists: a cross-sectional study

BACKGROUND

Deep carious lesions present significant challenges in dental practice, requiring effective management strategies to preserve tooth sensibility and function. This study aimed to assess Syrian dentists 'practices related to deep carious lesions and managing exposed pulps in teeth with reversible pulpitis in permanent teeth. It also examined the impact of dentists' experience and specialization on their choice of techniques and diagnostic tools.

METHODS

A cross-sectional study was conducted using a self-administered paper-based questionnaire distributed to dentists in Damascus. The questionnaire collected 1- demographic data, 2- clinical decisions before the start of the treatment, and 3- clinical decisions to treat deep carious lesions in different clinical cases and the management of exposed pulps. Data were analyzed to identify trends and differences in practices based on experience and specialization. Data were coded into excel and analyzed using SPSS V.25.

RESULTS

The study included responses from 252 dentists. The majority of dentists chose to take radiographs before treatment (69.4%), or do a sensibility test (70.6%). A strong preference for minimally invasive techniques was observed, such as partial caries removal to avoid pulp exposure (71.7%) and the use of hand excavators (53.2%). Dentists with more than 10 years of experience were more likely to work without rubber dam (< 0.001), while endodontists tended to apply rubber dam more than other clinicians (< 0.001). Experienced and specialist dentists were more likely to use rubber dam (p = 0.001) and perform sensibility tests (p = 0.000). The unique context of practicing in Syria, marked by conflict and political sanctions, significantly influenced decision-making of the biomaterials used, with the majority using calcium hydroxide (60.7%) and avoiding other materials, such as MTA and Biodentine, due to cost (31.5%) and availability (9.2%).

CONCLUSIONS

This study documented the clinical decision among Syrian dentist before and during the treatment of deep carious lesions. Clinical decisions and practices are significantly affected by years of experience and whether the dentist is specialized or not. General dentists and other specialists were less likely to perform vital pulp therapies when pulp exposed in teeth with reversible pulpitis than endodontists. Complementary education of Syrian dentists in the domain of pulps exposed management appears necessary regarding current recommendations.

Impact of war on oral health: a systematic review

AIM

To systematically review the evidence from published literature about the impact of war on oral health among children and adults.

METHODOLOGY

The electronic search was carried out in the following databases Pubmed, Cochrane, Scopus, Embase, Google Scholar. In vitro studies, cross-sectional, case control studies, and randomized controlled trials conducted during the war time were included. Cross-sectional and case control studies were assessed based on the Newcastle-Ottawa Scale, whereas randomized controlled trials were assessed based on the ROBINS-I tool. In-vitro studies included in this review were assessed using the United States national toxicology program tool.

RESULTS

The search strategy yielded a total of 5126 articles and finally 21 articles were included in the review. The influence of war on oral health was categorized among both the children and adult population. A total of 14 studies were carried out in children whereas the remaining seven studies were carried out in adults. A decrease in dental caries was observed in more war-prone areas due to the limited availability of carbohydrates and sugar. Severe periodontal disease in the adult population, mainly due to less availability of food and diminished oral hygiene habits, was also reported.

CONCLUSIONS

This review underscores the multifaceted impact of war on oral health, revealing a notable prevalence of periodontal problems, craniofacial injuries and varying rates of dental caries across affected populations.

Health status and visit reasons for children attending the Pediatric Dentistry department in damascus university, damascus, Syria: A retrospective study

Objectives

This study aimed to discuss the health status and treatment requirements of children visiting the Department of Pediatric Dentistry at the Faculty of Dentistry.

Materials and Methods

A retrospective study included the records of patients attending the Department of Pediatric Dentistry, from November 29, 2021, to December 14, 2023.

Results

The study reviewed 2417 patient records, excluding 312. The majority of patients were primary school children aged 6 - <12, primarily from Rif-Dimashq governorate. About 18 % displayed negative behavior during examinations, and 8 % had special health care needs. The most frequent type of disability was medical disabilities, followed by neurological disorders, with percentages of 40.2 % and 28.9 %, respectively. Dental caries were the primary reason for visits, with a mean of 3.94 ± 3.13. A negative association was found between the number of decayed teeth and the following: age classification, visit year, and Salviov-Tinawi scale. The percentage of males who came for cosmetic problems was higher than females at 57.2 % and 42.8 %, respectively.

Conclusions

The Department of Pediatric Dentistry at the Faculty of Dentistry, Damascus University, is a public dental clinic that is visited by patients from all governorates, providing free specialized treatments.

Clinical relevance

Unmet dental needs are a significant issue for both healthy children and those with special health care needs. The Department of Pediatric Dentistry serves as a research and educational center, offering comprehensive dental treatments to children from all socioeconomic backgrounds. Therefore, understanding the dental needs of children is crucial for providing effective support.

Effect of the 2008 economic crisis on oral health in Spain: analysis of serial cross-sectional, population-based health surveys

OBJECTIVES

To evaluate the impact of the economic crisis on the oral health of individuals in Spain based on variables including sex, unemployment, social class and educational level.

DESIGN

This was an analysis of serial cross-sectional, population-based health surveys conducted before the crisis (2003 and 2006) and during the crisis (2011, 2014 and 2017).

SETTING

National Health Surveys of Spain and the European Health Survey in Spain.ParticipantsA total of 189 543 participants were recruited.

OUTCOME MEASURES

The independent variables were sex, employment, social class and educational level. The dependent variables were related to oral health. Descriptive statistics, χ² tests and the Cochran-Mantel-Haenszel test were performed.

RESULTS

The results showed that there were differences (p<0.001) in all oral health indicators before and after the crisis. Compared with the precrisis period, men had a higher probability of tooth extractions (OR 1.41, 95% CI 1.37 to 1.45), dental fillings (OR 1.30, 95% CI 1.27 to 1.34), prostheses (OR 1.04, 95% CI 1.01 to 1.07) and missing teeth (OR 1.35, 95% CI 1.31 to 1.39). Unemployed individuals were more likely to have dental caries (OR 1.08, 95% CI 1.00 to 1.16) and missing teeth (OR 1.36, 95% CI 1.27 to 1.46). Working class individuals had a higher probability of tooth extractions (OR 1.63, 95% CI 1.59 to 1.67), bleeding gums (OR 1.04, 95% CI 1.01 to 1.07), prostheses (OR 1.05, 95% CI 1.02 to 1.07) and missing teeth (OR 1.36, 95% CI 1.33 to 1.39). Participants with a basic or intermediate level of education had a higher probability of dental mobility (OR 1.13, 95% CI 1.07 to 1.19), prostheses (OR 1.11, 95% CI 1.08 to 1.14) and missing teeth (OR 1.42, 95% CI 1.38 to 1.46).

CONCLUSIONS

The economic crisis affected the oral health of the Spanish population, with a more significant deterioration among men, working class individuals and unemployed individuals.

Post-traumatic stress disorder (PTSD), anger and mental health of school students in Syria after nine years of conflict: a large-scale school-based study

BACKGROUND

The Syrian crisis has entered its ninth year with many being affected by the war. This is the largest-scale study that aims to evaluate the psychological profile of secondary school students in Syria.

METHODS

This is a cross-sectional study in schools in Damascus, Syria. The surveys assessed working habits, smoking, war exposure, grades, socioeconomic status (SES), social support, health-related quality of life (HRQL), post-traumatic stress disorder (PTSD), problematic anger, and other parameters.

RESULTS

This study included 1369 students of which 53% suffered from PTSD and 62% from problematic anger. Around 46% declared a fair or worse general health and 61% had moderate or severe mental health. Only 9.3% did not report exposure to any war-related variable. War exposure had an impact on PTSD, anger, and HRQL, but not on students' grades. Smoking, having consanguineous parents, and working did not have a clear association with grades or anger. Social support weakly reduced PTSD and anger scores. Interestingly, working was associatedwith lowerPTSD scores but was associated with a worse physical component of HRQL.

CONCLUSION

This is the largest study on school students in Syria that reports the psychological ramifications of war. Although the direct effects of war could not be precisely described, the high burden of PTSD and anger distress was a strong reflection of the chronic mental distress.

Oral health and dental caries experience among students aged 7–15 years old with autism spectrum disorders in Tehran, Iran

Background

Autism spectrum disorders (ASD) are a set of developmental, psychological, and neurological disorders that occur in early childhood. The most important characteristic of individuals with autism is difficulty in social interactions and communication. Researchers in the field of oral health have not paid enough attention to these individuals due to their specific behavioral characteristics. Therefore, due to the limitations of the studies in this field in Iran, increasing prevalence of autism, and importance of oral health in people with ASD, this study was conducted to evaluate the oral health status of primary school students with autism (7–15 years old) in autism schools in Tehran.

Methods

Students from seven governmental special primary schools in Tehran were selected for this study. Data about oral health behavior and the presence of each of the seven barriers of tooth brushing task was collected via questionnaires completed by parents. During the dental examination, the cooperation level according to the Frankle Index, oral hygiene status according to the Simplified Oral Hygiene Index, and caries experience (DMFT) of the students were recorded by a calibrated dentist. A psychologist assessed the level of ASD using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM5). Data analysis including descriptive and regression analysis was done using the SPSS software version 24.

Results

Two hundred and seventeen students aged 7–15 years participated in this study, of whom 65.4% brushed their teeth once or more every day, 85.7% had sugary snacks twice or less per day, 73.7% used fluoridated tooth paste, and 80% brushed their teeth with parents’ help. The most common barrier to tooth brushing was difficulty in brushing (51.6%). The cooperation level was definitely positive in 46.1%. The mean Simplified Oral Hygiene Index (OHI-S) and caries experience (DMFT) scores were 1.92 ± 0.55 and 2.36 ± 2.38, respectively.

Conclusion

The clinical indices of OHI-S and caries experience (DMFT) were used to evaluate the oral health status in the students with ASD in Tehran, Iran. A better oral hygiene status was related to higher brushing frequency and lower sweet snack consumption. The findings of the present study indicate that educational interventions regarding oral hygiene and healthy diet may improve oral self-care in individuals with ASD.

Oral Hygiene Awareness, Practices and Attitudes among Syrian Refugees in Zaatari Camp and Their Impact on Oral Health Status

PURPOSE

To characterise the oral hygiene habits, attitudes, and oral health practices in relation to sociodemographic factors among refugees in Jordan and to investigate their impact on the oral health status of these refugees.

MATERIALS AND METHODS

This cross-sectional study consisted of two parts. First, a face-to-face interview was conducted using a structured questionnaire including demographic and oral health-related questions. Second, clinical oral examination was performed using WHO criteria, DMFT and oral health indices (OHI-S). The participants were adults, aged 18 and older. All patients attending dental clinics and accompanying personnel in the waiting areas at Zaatari camp during the study period were invited to participate, with a sample size of 547 refugees (males = 212, females = 335).

RESULTS

547 adult refugees participated. 75.3% reported toothbrushing less than twice daily, while flossing was uncommon (9.5%). Toothbrushing habits were significantly associated with gender and smoking status. Untreated carious lesions had a high incidence (94.1%); the mean number of decayed teeth was 5.4 and was statistically significantly higher in males and smokers. The mean number of missing teeth was 3.2 and was significantly associated with males, age, smoking, and presence of chronic disease. Participants who reported conditions that had persisted 1 year or more and required ongoing medical attention or limited activities of daily living or both (e.g. diabetes mellitus, hypertension, heart diseases, thyroid disease, chronic renal disease, rheumatoid arthritis, anemia, peptic ulcer, or asthma) were recorded as having chronic disease. The mean number of filled teeth was 3.2 and was statistically significantly associated with age and presence of chronic disease. The mean DMFT was 11.8 and was statistically significantly higher in males, older people, smokers, and those with chronic disease. The OHI-S was 2.2. The most common complaint was pain (92.2%), and only 1.1% visited a dentist for a check-up.

CONCLUSION

The prevalence of caries was extremely high, with poor oral hygiene practices among refugees, justifying the urgent need to develop and implement targeted oral health promotion, preventive programs and curative strategies and to enable collaboration of the oral healthcare providers and funding agencies to design the most appropriate interventions for this disadvantaged population. In addition, this information can be used as a basis upon which preventive programs can be assessed for efficacy.

Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria

BACKGROUND

The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict.

METHODS

As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria.

RESULTS

Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria.

CONCLUSIONS

Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.

Oral health assessment in a sample of displaced people as a result of the war in Syria in Damascus city: results of non-profit initiative

BACKGROUND

War on Syria extended for a long time and resulted in significant impacts on various aspects, one of these aspects was displaced people crisis, and thus its impact on complete neglecting of oral health despite of its importance and impacts on the general health. This study aims to assess the oral health of the displaced Syria sample as a result of the war on Syria.

METHODS

The sample included 118 patients of displaced families from different regions and cities to shelters in Damascus city, and the study included 118 control samples from the Faculty of Dentistry, Damascus University. The non-profit initiative team included 20 dentists of all dental specialties. Oral health was assessed using DMFT index. Data were analyzed using SPSS V.22 in comparison with the gender of the patients, age groups, and socioeconomic status. Finally, the number of the treatment provided by the non-profit initiative was collected and presented in the study.

RESULTS

No significant differences found in the DMFT index between children and adults (P = 0.750), DMFT value ranged between (0 and 11) with a mean value (2.4). The total DMFT value for adults was (2.77), while for children (2.12). Also, no statistical difference was found between males and females (P = 0.688). While the control group had an average DMFT value of (2.37), the difference between the displaced and control samples was not significant. Over 200 dental treatments were provided by the team.

CONCLUSION

This study concluded that the DMFT value is high among the displaced people as one of the consequences of the war on Syria, however, no significant difference was found when the results of the displaced sample was compared to a control sample.

Public health consequences after ten years of the Syrian crisis: a literature review

Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article.

Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID − 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system.

Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.

Knowledge and awareness of dental implants among Syrian refugees: a cross sectional study in Zaatari camp

Background

The popularity of implant dentistry is increasing dramatically, but the success of implant treatment depends on a patient’s knowledge and expectations.

Methods

This study aimed to assess dental implant knowledge among refugees as a treatment option (n = 565), using face-to-face interviews. The frequency distribution of the responses in general and according to age, gender and education was calculated.

Results

81.8% of the interviewees had missing teeth, however, only 26.2% replaced them. 16.6% of participants had never/hardly heard about implants. Females who never heard of implants were more than males (P < 0.001). 51.3% of participants described dental implants as a screw, and only 35.4% knew implants were placed in jawbones. 6.2% of respondents reported that implants required more care than a natural teeth, with 47.6% believing that diseases affect implant success. Friends were the main source of information (61.4%). Highly educated participants showed higher knowledge about implants.

Conclusions

The surveyed sample revealed limited knowledge about dental implants with high cost being a major obstacle, warranting more strategies to increase awareness and to make implants more affordable for this population.

The oral health of refugees: Issues and challenges arising from a case series analysis

OBJECTIVES

Little is known of the oral health of refugees globally. The objective of this study was to characterize the oral health and care-seeking behaviours of refugees by investigating patterns of dental services provided to Syrian refugees in Jordan and their association with their oral health status.

METHODS

Clinical records from 444 patients who had received dental treatment over a 9-month period were retrieved and analysed. Collected data included gender, age and the type and number of treatment procedures provided for each patient.

RESULTS

Of the total sample (51.8% female; 48.2% male; aged 18-60 years), pain was the most common presenting complaint (73.0%), with poor aesthetics (17.1%) the second most common presenting complaint. About 63.3% of patients received only one procedure due to patients' lack of follow-up. Over half (54.5%) of dental treatments carried out were extractions, 74.1% of which were due to dental caries; 27.4% were fillings. Endodontic treatment was the least provided procedure (18.2%).

CONCLUSIONS

The oral health status of Syrian refugees is a major concern, given the often-deplorable living conditions in camps and limited, often inadequate access to oral healthcare services. This situation dramatically negatively affects a refugee's oral health. There is an urgent need to provide targeted dental services for this at-risk population. Additional research is warranted on refugees worldwide, and on the provision of appropriate interventions to enable optimal oral health for this population.