Khalifa et al. BMC Oral Health 2012, 12:5
http://www.biomedcentral.com/1472-6831/12/5
RESEARCH ARTICLE
Open Access
A survey of oral health in a Sudanese population
Nadia Khalifa1*, Patrick F Allen2, Neamat H Abu-bakr3, Manar E Abdel-Rahman4 and Khalda O Abdelghafar5
Abstract
Background: We aimed to assess the oral health status and risk factors for dental caries and periodontal disease
among Sudanese adults resident in Khartoum State. To date, this information was not available to health policy
planners in Sudan.
Methods: A descriptive population-based survey of Sudanese adults aged ≥ 16 years was conducted. After
stratified sampling, 1,888 adult patients from public dental hospitals and dental health centres scattered across
Khartoum State, including different ethnic groups present in Sudan, were examined in 2009-10. Data were
collected using patient interviews and clinical examinations. Dental status was recorded using the DMFT index,
community periodontal index (CPI), and a validated tooth wear index.
Results: Caries prevalence was high, with 87.7% of teeth examined having untreated decay. Periodontal disease
increased in extent and severity with age. For 25.8% of adults, tooth wear was mild; 8.7% had moderate and 1%
severe toothwear. Multivariate analysis revealed that decay was less prevalent in older age groups but more
prevalent in southern tribes and frequent problem based attenders; western tribes and people with dry mouths
who presented with less than18 sound, untreated natural teeth (SUNT). Older age groups were more likely to
present with tooth wear; increasing age and gender were associated with having periodontal pocketing ≥ 4 mm.
Conclusions: The prevalence of untreated caries and periodontal disease was high in this population. There
appear to be some barriers to restorative dental care, with frequent use of dental extractions to treat caries and
limited use of restorative dentistry. Implementation of population-based strategies tailored to the circumstances of
Sudanese population is important to improve oral health status in Sudan.
Background
According to the World Health Organisation (WHO),
“oral health means being free of diseases and disorders
that affect the mouth and oral cavity” [1]. Several factors
including social [2], behavioural [3], and medical [4]
seem to play a role in oral disease progression. Descriptive population health surveys provide a basis for estimation of the oral health status of a population and its
future needs for oral health care.
Dental caries experience is commonly recorded using
the decayed, missing, and filled teeth (DMFT) index [5].
Mean DMFT scores are used to give an estimate of caries prevalence and its treatment (either by tooth extraction of restorations). Periodontal status in population
studies is recorded using the Community Periodontal
Index (CPI) [5]. The main outcome measures of CPI are
* Correspondence: nadiakhalifa@uofk.edu
1
Prosthodontic Department, Faculty of Dentistry, Khartoum University,
Khartoum, Sudan
Full list of author information is available at the end of the article
presence of gingival bleeding on gentle probing, dental
calculus, and probing periodontal pocket depth (PPD):
4-5 or ≥ 6 mm.
Partial mouth recordings have been utilized to record
level of tooth wear [6,7] and partial recording of 12 anterior
teeth was found appropriate to measure tooth wear [8].
There is a high prevalence of oral disease globally and
the consequences of oral disease pose substantial public
health problems including pain, impairment of function
and, reduced quality of life [9]. In the US population,
oral conditions caused more days of work loss than
stroke, and in younger adults, as much work loss as all
neoplasia combined [10].
Decision makers and health planners need information
about risk factors for oral disease to help identify individuals who are at risk of developing oral disease and to
target population level interventions. This includes the
need to collect data on social and medical status, health
behaviours and demographic data in addition to clinical
data. Only a few studies exist considering adult oral
© 2012 Khalifa et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Khalifa et al. BMC Oral Health 2012, 12:5
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health in sub-Saharan Africa [11-16]. Findings of these
studies suggest that the prevalence of dental disease is
generally low in African populations, and that limited
access to dental services leads to retention of carious
teeth.
There is a relative lack of data pertaining to adults in
the developing world in general and in Sudan in particular. Most of the studies focused on school children or
used small samples.
The aim of this study was to assess the oral health status and associated risk indicators for oral disease in
Sudanese adults attending outpatient clinics in Khartoum State.
Methods
Study design
This cross-sectional oral health survey was part of a study
designed to assess the functional and psychosocial impact
of dental disease and was carried out between August 2009
and March 2010. The study participants were recruited
from among those attending outpatient dental hospitals
and health centers distributed among the seven provinces
(Um Durman, Khartoum Bahri, Khartoum, Jabal Aulia,
Sharg En Nile, Karary, and Um badda) of Khartoum State.
Sudan was the largest country in Africa before South
Sudan became an independent country on 9 July 2011. It
was divided into 25 states, with Khartoum State the capital
being the most densely populated state (Figure 1). The
study population comprised 1,888 patients. The sample
size was calculated using the formula for proportion estimates considering a tooth loss prevalence of 67% according
to previous Sudanese studies [17,18] and precision of 3; the
design effect was set as 2. The sampling frame for the
study was the public dental service in Sudan. There are 3
levels (federal, state, and locality) of health care systems in
Khartoum. All the dental outpatient clinics of these facilities were included in the sampling frame. The sample size
of each outpatient clinic was obtained by the following
equation: nh = (Nh/N)*n; where nh was the sample size of
each outpatient clinic h, Nh the population size (no. outpatients/3 months of the specific hospital/dental health center
[DHC]) for stratum h, N the total population size (total no.
outpatients/3 months of all hospitals and DHC), and n
total sample size (1,888) (Table 1). Patients were selected
consecutively until the required number of patients from
the different hospitals and DHCs were obtained. Written
consent was obtained from all patients. The study protocol
was approved by the National Ethical Clearance Committee of the Federal Ministry of Health in Khartoum, Sudan.
Data collection
Socio-demographic variables included age, gender, ethnic group, and socioeconomic status (occupation, total
monthly income, education).
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Behavioural variables included frequency and reason
for dental visits, if applicable number of teeth removed
at final visit, tobacco use and way of consumption, as
well as frequency and method used for dental hygiene.
Because of the developing interest in the relationship
between oral and general health, it was considered
necessary to try to establish some of the main medical
characteristics of the population sample through questions such as use of medication, previous surgery and
details of diagnosed medical conditions. Participants
were also asked “How often does your mouth feel dry?”
with response options “always”, “frequently”, “occasionally”, or “never”. At the analysis stage, those who had
responded “always” or “frequently” were designated as
xerostomic.
Data were collected using a questionnaire administered in interviews by researchers not involved in the
treatment of the patients. The interviews took 15-20
minutes prior to the clinical examinations.
Clinical examinations were undertaken by five calibrated dentists, including the lead author. Following a
period of training in clinical examination procedures
and calibration, inter-examiner reliability was checked
using intra-class correlation coefficients (ICC). Interexaminer reliability was assessed in 20 patients at the
beginning of the survey, and during the survey. Field
checks were also carried out during the survey by the
main investigator who also acted as gold standard.
Inter-examiner reliability was assessed by intra-class
correlation coefficient (ICC) on clinical measures of
CPI, DMFT, and tooth wear at 2-3 weeks apart. ICC for
CPI, DMFT, and tooth wear the before start of survey
was 0.67 (95%CI, 0.56-0.83), 0.96 (95%CI, 0.92-0.97),
and 0.55 (95% CI, 0.41-0.75), respectively, and during
the survey was 0.61 (95% CI, 0.55-0.68), 0.85 (95% CI,
0.81-0.87), and 0.59 (95%CI, 0.49-0.62), respectively.
Thus, according to Fleiss [19], ICC for CPI ranged from
fair to good, for DMFT excellent, and for tooth wear
fair to good.
Once a satisfactory level of examiner reliability was
established, clinical examinations were undertaken using
WHO criteria for population oral health surveys.
DMFT was used to obtain estimates of how much the
dentition was affected by dental caries. The clinical
examination included a full mouth recording for 32 teeth
[5]. Decay was recorded if a carious cavity was visually
present and a CPI probe was used to confirm visual evidence of caries. A tooth was recorded as missing due to
caries if there was a history of extraction because of the
presence of a cavity prior to extraction. Periodontal
health was assessed by CPI [5]. The three indicators used
for this assessment were gingival bleeding, calculus, and
periodontal pockets. A specially designed lightweight
WHO CPI probe was used to record clinical data by
Khalifa et al. BMC Oral Health 2012, 12:5
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Page 3 of 9
Figure 1 Map of Sudan.
sextant, and coded as 0 (no disease), 1 (gingival bleeding
detected), 2 (calculus detected), 3 (pockets ≤ 5.5 mm) or
4 (pockets of ≥ 6 mm)
The 12 upper and lower anterior teeth were examined
for toothwear. The index used was that used in the survey of Oral Health in Irish Adults 2000-02 [20] and the
Adult Dental Health Survey in the United Kingdom in
1998 [7]. It was a descriptive index using partial recording of the labial, incisal, and palatal surfaces of the
upper six permanent anterior teeth. On the upper incisal
surfaces, wear typical of erosion was scored if present.
The condition of the most worn surface of the lower six
permanent anterior teeth was recorded. Wear was
recorded when it had progressed through tooth enamel
into the dentine because considerable inter-examiner
variability has been reported when trying to record wear
confined to tooth enamel.
Tooth wear was classified as “mild” (tooth wear just
exposing the dentine), “moderate” (tooth wear exposing
the dentine for more than one third of the individual
surface), or “severe” (complete loss of tooth enamel,
with the pulp or secondary dentine exposed).
Khalifa et al. BMC Oral Health 2012, 12:5
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Table 1 Proportional sample size calculation of hospital/
dental center
H
Nh
Khartoum Teaching Dental Hospital
21,000
343
Umdurman Dental Hospital
23,275
382
Bahrey Dental Hospital
13,046
211
nh
Police Dental Hospital
24,500
400
Military Dental Hospital
19,784
323
Dental Health Centers
14,025
229
115,632 = N
1,888 = n
All data were recorded on standardized proformae and
entered into a spreadsheet for analysis. Random checking was undertaken to verify the accuracy of data entry.
Data analyses
Analyses were performed using the statistical software
package STATA Release 9 (Stata Statistical Software 2005;
StataCorp LP, College Station, TX, USA). Summary data
were reported using frequency distributions. The categorical-dependent or outcome variables were reduced to binary variables such as: < 18 and ≥ 18 sound untreated
natural teeth (SUNT); zero decayed teeth (DT) and ≥ 1
DT; no tooth wear and tooth wear; healthy periodontal tissues and those with periodontal pockets ≥ 4 mm. Bivariate
analysis of these data was undertaken using Pearson’s chi
square tests. The independent factors used in these analyses included sociodemographic such as sex, age group,
ethnic group, occupation, monthly household income, and
education level achieved; behaviours such as frequency of
dental visits, tobacco use, and frequency and type of dental
hygiene and,; medical, such as how often mouth feels dry,
history of surgery, and, current medical status. Multivariate logistic regression modeling was used to ensure allowance for potential confounding variables.
Results
Sociodemographic, behavioral, and medical
characteristics
The number of adults examined was 1,888 split into
seven age groups “see Additional file 1“. According to
their ethnic group, most probands (57%) came from
northern and central tribes followed by western tribes
(33.7%). For nearly three quarters of subjects, the head
of household had an income of < 250 SDG (< 75 Euro
monthly); 25.8% never went to school or only went to
khawla, a type of kindergarten, with 20% completing
only primary school and 60% having semiskilled or
unskilled jobs.
Over sixty percent of subjects went to the dentist less
frequently than every 2 years, 16.7% went more frequently than every 2 years, and 22.7% never went,
indicating poor attendance. Only 9% went for regular
checkups whereas > 91% of patients only went to the
dentist when they were in pain.
In terms of treatment received during the most recent
dental visit, more than 55% of people had a single tooth
extraction as their only treatment. When asked about
the reason for extraction, nearly 80% stated that this
was the advice given by the dentist.
Tobacco use was prevalent in approximately 17%. of
the sample. Besides cigarette smoking (62%), the use of
smokeless tobacco, locally known as toombak, was
reported in 51% of the sample.
In terms of dental hygiene behaviours only, 53%
reported that they brushed their teeth twice daily. Additional methods of oral hygiene such as use of a mouth
rinse (11%) and inter-dental cleaning (3%) were rarely
used.
Of the people who reported medical problems (17%),
27% had hypertension and 17% diabetes mellitus. This
was also reflected in similar pattern by people on medication (14%) among whom 21% were on antihypertensive and 14.6% on antidiabetic medications. The feeling
of dry mouth was assessed using a validated xerostomia index [20]. In response to the question “How
often does your mouth feel dry?” (response options:
always, frequently, occasionally, or never), those who
had responded with “always” or “frequently” were
designated as xerostomic. Nearly one fifth (19.3%) of
participants reported that their mouth felt dry occasionally or more frequently, with 3.5% to the point of
being xerostomic.
Frequencies of clinical findings: CPI, DMFT, tooth wear
In the 35-44 age group 36.1% had healthy periodontal
tissues, 10.9% bleeding, 42.0% calculus, 8.5% 4-5-mm
periodontal pocketing, 0.7% periodontal pocketing of
≥ 6 mm, and 1.8% excluded sextants (Figure 2).
The mean DMFT for age group 35-44 years was 8.7
(SD, 5.9) (Table 2). The overall mean number of missing
teeth was 3.6 (SD, 4.9) and in the age group 35-44 years
was 4.2 (SD, 4.1). Surprisingly, the mean number of
teeth was high 28.4 (SD, 4.9); however, percent DT was
87%. Even though teeth existed, they were badly decayed
due to lack of treatment. This was substantiated by the
finding that the filled component of DMFT was 0.2%.
The prevalence of root caries in adults aged ≥ 16 years
on exposed teeth was 23.6%. Root caries was more prevalent with increasing age.
More than one third (35.5%) of adults had some
degree of wear of their anterior teeth that involved at
least some dentine. In 25.8% of adults the wear was
mild; 8.7% had moderate and 1% severe wear. Mild
tooth wear decreased with age whereas moderate and
severe increased with age.
Khalifa et al. BMC Oral Health 2012, 12:5
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Page 5 of 9
Figure 2 Distribution of adults according to periodontal conditions.
that should be considered when interpreting the data
presented in this study. Given the available infrastructure, it is not possible to conduct a randomly selected
sample representative of the entire Sudanese population.
Whereas it is possible to obtain some information on
oral health issues from patients attending outpatient
facilities of hospitals and dental health centres of Khartoum State, the findings may not be representative of
the whole of Sudan. The sample was biased in that visits
by the individuals attending these clinics were problem
based. However, the sampling strategy employed ensures
that the sample recruited from the country’s most populated state is broadly representative of Sudan. Given the
limited infrastructure for oral health services delivery in
Khartoum, the prevalence rates of conditions reported
in this paper are unlikely to be overestimated. Many
people in Sudan do not receive regular dental care and
have acute problems when seen by a dentist. In Sudan
the dentist-to-patient ratio is 1:33,000 compared with
approximately 1:2,000 in most industrialized countries
[21]. Relative to the size of the Sudanese population,
there are very few dentists and this restricts access to
regular dental care. Other factors which influence dental
attendance in Sudan include the lack of public funding
for oral healthcare and dental insurance schemes to
Multivariate logistic regression analysis
Independent factors found significant by Pearson’s chi
square analysis were all entered in one step, into four
separate multivariate logistic regression models, investigating the likelihood of having decay, ≥ 18 SUNT, tooth
wear, and periodontal pockets ≥ 4 mm. Details of variables with increased/decreased odds of predicting oral
disease are presented “see Additional file 1“, with R 2
values showing how much variation can be explained by
each model. The multivariate logistic regression analysis
revealed that presence of decay seemed less prevalent in
older than younger age groups. Those who were educated, went for checkups, and cleaned between teeth
had a decreased likelihood of having dental decay. Western tribes (OR, 1.83) as well as those with occasional
dry mouth (OR, 2.18) were more likely to present with
< 18 SUNT.
As expected, older age groups presented more tooth
wear than younger age groups. In terms of periodontal
disease, increasing age and being a male were characteristics associated with periodontal pocketing ≥ 4 mm.
Discussion
This study is the first large population based study of
adult oral health in Sudan. There were some limitations
Table 2 Mean DMFT according to age group
Age group
N
Mean
DMFT
Std. Deviation
Std. Error of mean
Mean
D(SD)
Mean
M(SD)
Mean
F(SD)
16-24
413
4.2
3.4
0.2
2.9(2.6)
1.2(1.9)
0.1(0.6)
25-34
616
5.5
4.1
0.2
3.3(2.9)
1.9(2.5)
0.3(1.0)
35-44
368
8.7
5.9
0.3
4.1(3.4)
4.2(4.1)
0.3(0.9)
45-54
253
9.8
6.8
0.4
4(4)
5.5(5.4)
0.2(0.7)
55-64
133
12.2
8.3
0.7
3.9(4)
8(6.5)
0.3(0.8)
65-74
77
14.4
8.0
0.9
3(2.9)
11.3(7.9)
0.2(0.6)
75+
22
15
10.8
2.3
3.3(3.9)
11.8(10)
0(0)
Total
1,882
7.4
6.2
0.1
3.5(3.2)
3.6(4.9)
0.2(0.8)
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ameliorate the cost of care. In that sense, the dental
attendance experience of this sample is not untypical of
the wider Sudanese context.
One of the most striking findings from the study is
the apparent lack of restorative or preventive dental
care, as shown by the filled component F (0.2%) and
treatment is limited to pain relief or emergency care by
tooth extraction. Dentists’ attitudes toward dental treatment were shown greatly to influence tooth extractions
in this study. It would appear that there are barriers to
the provision of restorative dental care which are multifactorial in origin and worthy of further investigation.
There were relatively few participants aged ≥ 65 years,
but this reflects the age distribution of the Sudanese
population according to the population Census of Khartoum State 2007 [22]. In Khartoum state, only 2% of the
population are aged over 65 years. Also of interest is the
observation that life expectancy at birth of Sudanese is
55-60 years according to United Nations [23]. People
from older age groups might also have lower expectations or less money available for dental treatment.
The low level of literacy observed in Khartoum (which
is probably amplified in other Sudanese states) as well
as low income level, could have had profound effects on
the level of oral health observed in this study. The
impact of socioeconomic status on oral health has been
documented in other studies [24,25].
In terms of accessing dental care, only 16.7% reported
attending more frequently than every 2 years, which is
much lower than reported elsewhere. For example, the
Irish Oral Health Survey of adult oral health in 2000-02
reported that 44-57% visited the dentist more frequently
than every 2 years.
Because nearly one fifth of subjects used tobacco in
some form, the strong correlation between smoking
habits, severity of periodontal disease, and tooth mortality, as established in various studies, should be considered [26,27]. Smokeless tobacco “Toombak” has been
linked to oral health hazards such as cancer in a few
studies [28,29].
The finding that just over half the population brushed
their teeth twice daily is similar to the findings of the
Irish National Oral Health Survey 2000-02 [20], whose
authors commented that people who brushed at least
twice daily had a greater number of teeth and lower
DMFT and were more likely to have ≥ 18 SUNT. Very
few participants used additional methods of oral hygiene
such as floss or mouthwashes, and this might be due to
lack of awareness or inability to purchase them.
The prevalence of xerostomia in Khartoum at 3.5%
was much lower than in other studies, where approximately one fifth of older people [30], and 10% of subjects aged in their early 30s [31] reported the condition.
This might be due to more limited exposure of the
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Sudanese population to medications which reduce saliva
flow. Further investigations using objective besides subjective measures for xerostomia are needed to observe
whether any associations between medications or other
factors such as medical condition and xerostomia exist;
this is beyond the scope of the present study.
In this study, it was decided to use CPI to give an indication of the periodontal status of subjects. There are,
however, some shortcomings to CPI such as it does not
distinguish between gingival inflammation and periodontal destruction because of its hierarchical scoring principle. Furthermore, the use of index teeth instead of a full
mouth recording has been shown to increase underestimation of the prevalence of periodontal pockets [32].
However, the use of alternative indices would allow direct
comparison with only a few other studies, which is the
reason that we decided to use the CPI in this study. The
results of CPI were very different to those of a study carried out in Sudan in by Ali in 1991 [33] who included
126 adolescents and 138 adults from areas inside as well
as around cities of Khartoum and El Obeid. In that study
of adults aged 35-44 years, only 3% had calculus, 71.3%
had probing pocket depth between 4 and 5 mm, and
25.7% ≥ 6 mm. These results revealed a much higher prevalence and severity of periodontal disease than our
study, which could be due to a combination of factors
such as differences in sample design. The more severe
periodontal disease could also have resulted from a
decreased awareness towards oral health at the time
when Ali’s study was carried out almost 20 years ago
[33]. Geographic region could have also played an important role because approximately half the population studied was from Obeid, which is outside Khartoum State.
One could speculate that different methods of dental
self-care might have been more common then, such as
using the miswak (a teeth-cleaning twig of the Salvadora
persica tree) instead of toothbrush and fluoridated toothpaste. Our results show that there is a need for preventive
programs to improve oral hygiene levels, bearing in mind
that the ultimate goal is to prevent more severe periodontal disease prevalence, which is complex to treat.
The mean DMFT 8.7 (SD, 5.9) of our study according
to WHO criteria can be considered as low in the 35-44year age group when compared with same age groups
with dental caries levels worldwide. In world map of
dental caries prevalence published by the WHO [1], a
mean DMFT < 5.0 is considered very low, 5.0-8.9 low,
9.0-13.9 moderate, and > 13.9 high. Our results are
slightly higher than other African countries such as
Niger (mean DMFT = 5.7) and Uganda (mean DMFT =
3.4) [13,14] but lower than Madagascar (mean DMFT =
13.1) [12].
The mean number of missing teeth in the age group
35-44 years was 4.2 (SD, 4.1), which is in agreement
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with the study carried out in Madagascar (4.8) but much
higher than Uganda (0.6) and Niger (0.4). The finding
that the filled component of DMFT was only 0.2% in
total population gives an indication of how little dental
treatment is actually done, which has important implications for service planning and advocacy.
Virtually all community prevention programmes in
Sudan target children and adolescents and as a result,
decay among adults is more likely to remain untreated.
The mean number of untreated decayed teeth among
Sudanese adults in our study was about 9 times that
among 12-year-old schoolchildren (DT, 0.4) [34], underscoring the importance of initiating caries-prevention
programs for adults.
Among adults aged ≥ 65 years, one third of exposed
root surfaces had root caries lesions in the United Kingdom [6], which is considerably higher than our results
where those aged ≥ 65 years had caries on only 12% of
exposed roots. One reason for this may be the increased
life expectancy in the UK, which exposes teeth to the
cumulative effect of dental disease for longer. The lower
level of root caries may also be partly explained by the
relatively low prevalence of wearing partial dentures
(3%), which has been shown adversely to affect the
remaining dentition through greater incidence of caries
[35].
Even though the percent exposed roots in our study
was lower in younger adults, their exposed roots were
more affected by decay. This may be because of differences such as diet with increased sugar consumption.
Toothwear was recorded when it had progressed
through tooth enamel into the dentine because considerable inter-examiner variability has been reported when
trying to record wear confined to tooth enamel. Results
similar to those of our study were obtained in the UK
survey [6], where two thirds of all adults had some wear
into dentine on anterior teeth. Moderate wear (extensive
involvement of dentine) occurred in 11% of adults and
1% had severe wear. Tooth wear has been considered a
problem for individual patients rather than being community based. Albeit the trend that tooth wear is
increasingly recognized as problematic, it is difficult to
foresee who will be affected and true prevention is
therefore difficult to accomplish. Presently, treatment is
aimed at limiting further tooth wear in individuals
already affected by this condition.
Considering the multivariate analysis, dental caries
seems less prevalent in older than younger age groups,
even after controlling for the effects of confounding variables. This might be because of the small numbers of
people present in that category or that teeth presenting
decay had already been extracted. The observation that
southern tribes are more likely to present with decay
than other tribes suggests a cultural dimension to the
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pattern of decay. The revelation that frequent attenders
have higher odds of having decay could emanate from
the implication that they experience more pain due to
decay and are therefore more likely to seek treatment.
Frequent attendance in this survey is not the same as regular checkups, because 91% of patients only went to the
dentist when they experienced pain. Those who did go
for regular dental checkups in this study were less likely
to present with decay. The importance of regular checkups has also been highlighted by others [3] who showed
that patients who attended only when they had some
trouble with their teeth had one less tooth on average,
were twice as likely to have active decay, and six times
more likely to have unrestorable caries than those who
attended for regular checkups. The finding that people
who were educated had lower caries rates is similar to
observations made by other authors [25]. Recording the
number of ≥ 18 SUNT, which is an arbitrary cut off
point, was previously used in adult national oral health
surveys in the United Kingdom [7] and Ireland [20].
Western tribes were associated with having lower rates of
≥ 18 SUNT possibly because of some cultural differences
or increased consumption of sugar. To clarify the cause
further investigations would be necessary. Probands who
reported occasional dry mouth also had lower rates of ≥
18 SUNT. Having a dry mouth has been associated with
more decay and tooth loss [36], which might explain the
decrease in SUNT observed in the present study.
Increasing age and being male were characteristics
associated with periodontal pocketing of ≥ 4 mm. This
is consistent with findings from other studies such as
the US National Health and Nutrition Examination Survey, 1999-2004 in adults aged 20-64 years. Tobacco
users were also more likely to present with periodontal
pockets, which is in accordance with other studies by
[20,37] wherein smokers had a higher prevalence periodontitis, suggesting poorer periodontal health in these
individuals.
Conclusions
Untreated oral disease was highly prevalent in this study,
and we report a low level of literacy, low level of
income, high caries prevalence, and lifestyle-related risk
factors for oral disease. The low level of literacy might
present problems in oral health promotion, which
necessitates further development work to determine best
delivery mode for health promotion
There was a lack of restorative treatment, which could
be due to prohibitively high cost, attitudes on the
patients’ part, or, prevailing attitude of dentists towards
caries management. Containment of disease could be
done by simple, minimally invasive, and affordable dentistry. Wider access to restorative dental care could be
helped by provision of sufficient manpower and
Khalifa et al. BMC Oral Health 2012, 12:5
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continuing education of dentists to ensure that oral
health care providers have sufficient skills and depth of
understanding of aspects of oral health care.
As advocated by the WHO, prevention programs to
reduce lifestyle-related risk factors of non-communicable diseases such as hypertension, diabetes, and cardiovascular diseases as well as cessation of tobacco use
could help prevent some of the oral health outcomes
they cause.
Page 8 of 9
8.
9.
10.
11.
12.
13.
14.
Additional material
15.
Additional file 1: Distribution of participants’ characteristics, their
association with and likelihood of having decay, ≥ 18 SUNT, tooth
wear, and periodontal pockets ≥ 4 mm.
16.
17.
Acknowledgements
This work was supported by the Ministry of Health, Khartoum State and
special thanks are extended to Dr. Isam M. Ahmed who made it possible.
18.
Author details
1
Prosthodontic Department, Faculty of Dentistry, Khartoum University,
Khartoum, Sudan. 2Department of Restorative Dentistry, Cork University
Dental School & Hospital, Wilton, Cork, Ireland. 3Conservation Department,
Faculty of Dentistry, Khartoum University, Khartoum, Sudan. 4School of
Maths, Khartoum University, Khartoum, Sudan. 5Department of Statistics,
Federal Ministry of Health, Khartoum, Sudan.
19.
Authors’ contributions
NK: principle investigator was actively involved in the planning, conducting,
conception, and design of the study, and had the main responsibility for
writing the paper. PFA: was involved in the design of the study as well as
manuscript writing. NHA: helped in the study and manuscript writing. MEA:
performed statistical analyses. KOA: performed data entry and statistical
analysis. All authors have approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 19 April 2011 Accepted: 24 February 2012
Published: 24 February 2012
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Khalifa et al. BMC Oral Health 2012, 12:5
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Cite this article as: Khalifa et al.: A survey of oral health in a Sudanese
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