National Oral Health Survey of Oral Health Status of Bahraini School Children Aged 6, 12 & 15 Year Olds

Dental News Volume XXIII, Number II, June, 2016

By Dr. Azhar Ali Ahmed Naseeb, Ministry of Health, Kingdom of Bahrain

Abstract

Objectives: to provide information about prevalence and trends of oral and dental diseases among children aged 6, 12 and 15 year olds and provides information about risk factors that has effect on children’s oral health.

Method: cross-sectional survey was conducted to 2134 Bahraini students aged 6, 12 and 15 years old who randomly selected from governmental schools distributed in five governorates. Samples were subjected to clinical examination except 12 years old children were subjected to clinical and interview.

Results: 29%, 52%, and 48% at 6, 12 and 15 years old children respectively have gingival bleeding. Periodontal pocket 4-5mm and >6mm was discovered in 33% and in 1.23% respectively of 15 years old children. Prevalence of dental caries was equal to 88%, 70% and 75% with mean dmft=4.56, DMFT=2.26 and 2.71 in 6, 12 and 15 years old students respectively. No sign of enamel fluorosis, erosions and traumatic injuries were recorded in 45.5%, 81.4% and 81.5% child respectively. 

Conclusion

There is an overall minute improvement in oral health status of Bahraini children with mean of national DMFT=2.26 of 12 years-old but still it is considered higher than the global standard of DMFT for year 2010 that should not >1, also there is a dental caries incidence and an occurrence of gingival bleeding among all age groups however periodontal pocket found in 15 year old children. Hence, it can be understand that childhood dental caries and periodontal diseases is a serious dental public health problem among Bahraini children.

Keywords: Children, Dental caries, periodontal diseases, Fluorosis, Epidemiology, Bahrain

Introduction

Despite the fact that dental health have been improved tremendously over the last century but still prevalence of dental caries in children remains a significant clinical problem and it is still the single most common chronic disease of childhood, occurring five to eight times as frequently as asthma, the second most common chronic disease in children (AMCHP, 1999).

Epidemiological studies done in Gulf Council Country (GCC) proved that dental caries prevalence among children ranged between 80-90% as this becoming a priority for the GCC Ministries of Health. Since oral diseases include dental caries and periodontal diseases, yet these diseases are very expensive to treat as identified by U.S. Department of Health and Human Services in 2000 that: “ddental caries is painful, expensive to treat, and can harm nutrition and overall health (USDHHS, 2000) also the same  Watt, R. 2005 has stated that: “Since oral diseases include dental caries, dental erosion, dental fluorosis, and periodontal diseases, but these are expensive to treat but at the same time they are largely preventable”(Watt, R., 2005), also it is important to monitor there occurrence in children to most effectively preventive efforts, also, it is important to understand the pattern of dental caries as one of most common disease in children.

Thus, that the limited public resources can be used most effectively so that they have the greatest effect in preventing the disease such as the establishment of school based preventive programmes is attributed to the improvement of oral health in developed countries (Petersen, 2003 cited by Varnne et al, 2006).   Also a need for consistent and regular measures of oral health in order to determine the need for a state programs and to design such preventive programs to produce the most benefit throughout conducting a wide broaden study  or a national survey. This report presents summarized results of the oral health of 6, 12 and 15 years old school children surveyed in the school year 2011-12, the fourth national oral and dental health survey of this age group. The survey reported here provides information on the prevalence and severity of dental decay (caries), periodontal diseases, dental fluorosis and erosion, traumatic injuries to teeth, oral mucosa lesions and complete or partial denture in 6,12 and 15 years-old children attending governmental schools. Further reports will be produced including summary reports of face to face interview questionnaire that 12 years children have subjected to. Thus, aim of this survey is to study prevalence and trends of oral and dental diseases among children aged 6, 12 and 15 year olds and provide information about risk factors that has effect on children’s oral health in order to offer the necessary data for strengthening dental public health programs in Kingdom of Bahrain.

Method

The survey was undertaken during the 2011-12 school year. The sampling frame was children attending governmental schools who were aged 6, 12 and 15 years old at the time of the survey. Data was collected by trained and calibrated examiners who were dentists employed by Ministry of Health of Bahrain providing community dental services. The training and calibration of examiners was carried out using at the beginning of month of October 2011; a two day training and calibration for inter and intra-examiner reproducibility exercises (Eklund S, Moller IJ, LeClercq. World Health Organization, (1993)-WHO, (2013), was conducted to all examiners the dentists and their recorders who were dental hygienists to control epidemiological and clinical data in a constant manner. Interviewer, field organizers and supervisors were also attended the training workshops, all to be on the same page. Training involved an explanation of survey protocol, method of data collection, definition of terminology, and standardization of diagnostic criteria infection control procedures, using slides based on the Oral Health survey booklet provided by World Health Organization (WHO), Eklund S, Moller IJ, LeClercq MH.(1993)-WHO(2013).

Thereafter, Kappa statistical test of both exercise (inter and intra) were done. Result of first and second findings was perfectly matched with each other by consistency level not below (85%-90%) according to WHO recommendations Eklund S, Moller IJ, LeClercq MH. (1993)-WHO (2013). Five skillful survey teams were available to execute the project in all five governorates in order to collect data in even manner. Each team were included all the following members of human resources: calibrated dentists and dental hygienist as an examiner and recorder respectively, another dental hygienist as an interviewer, field organizer and project manager as well as field supervisor who was a dental public health consultant. The examinations area for conducting examinations were planned and arranged for maximum efficiency and ease of operation by field organizer who contacted the schools and arranged with them the sport or activity hall as a survey sites filed with available of day light to assure light standardization in all schools. Survey sites were provided with following setup: examination table to let student’s participants to lay on a table, and the examiner sits behind the participant's head, chair, one instruments table, interview table. Nevertheless, infection control procedures were highly strict in the survey sits hence to reduce the risk of cross infection to children. All dental team were using disposable masks and gloves and the wearing of protective glasses during children examination on progress. A sterilization team were responsible of sterilization of each day instruments and to assure providing the survey sites with sterilized supplies of instrument included examination set: mouth mirror, the CPITN periodontal probe, tweezers, and pair of gauzes, cotton roles, plastic disposable cup and clinical sheets, one big tray for sterilized instruments and another small container for used instruments, protective tools: mask & pair of gloves, paper hand towel and others stationery that included identification cards, WHO Clinical examination Forms, interview forms, white sheet for recording participant name and identification number (A4), blue pen, pencil, sharpener, eraser and clips. 

A positive consent was obtained before the survey from the child’s parent or from someone with the competence to give consent on behalf of the child. Requests for consent for sampled children were sent to parents and followed by a second request where no response was made to the first. Clinical data was collected from each subject selected in sample and recorded in World Health Organization (WHO) Assessment Form. First section of WHO Assessment Form will be responsible to collect data on general information from follows:

While second section of WHO Assessment Form will be responsible to collect data on clinical data from as follows:

Clinical Data

The following clinical data will be recorded at WHO form/2004:

Sampling methods and Sample Size

According to Central Informatics Organization in Kingdom of Bahrain data base in year 2012, Kingdom of Bahrain is located centrally on the southern shores of the Arabian Gulf with total area of 769.77 sq. km and Manama is the capital city. Population of Bahrain estimated to be equal to1, 208, 96 people (ww.cio.gov.bh/cio. eng, 2016).

Bahrain population is mixed of Bahraini and non-Bahraini residence with different socio-cultural context. Sampling method of this survey has been passed through two sampling methods phases: first sampling method was the cluster random sampling as these results from two stage process in which the population divided into clusters and subset of the clusters that randomly selected. Clusters are bases on the followings: governorates clusters :( Muharraq, Capital, Central, Northern, and Southern) and then geographic areas cluster that involved schools in each of the governorate which were selected and coded accordingly. The second phase of sampling was stratified random sampling; were population is divided into homogenous groups or strata and a simple random sample is drawn from each strata as the followings: age group (6, 12 & 15 years old), educational level (primary, intermediate and secondary), gender (male & female), nationality (Bahraini & non-Bahraini). The survey was conducted over six months between October 2011 and March 2012. To consider a sample frame of this study, schools is the convenient place to find all subjects of target sample at same instance during their education learning and school-working hour, thus, a strong cooperation with the Ministry of Education has articulated to obtain students lists. This has been took a place during month of August to September 2011 at least to get their support before and during survey execution and implementation phases. Because of resources limitation, time consuming, great massive effort of human resources required as well as the high cost that require in surveying all population; surveying sample of 2500 was selected with following inclusive criteria: Bahraini children, aged 6, 12 and 15 years old, spoke Arabic language without orthodontic appliances and free from any medical compromised or mental diseases from whole population of each age group was considered in sample size to pledge equitable of results, while exclusion criteria were considered those children not from age mentioned above, spoke other language than  Arabic, have orthodontic appliance and were medical or mental ill. The 12 years students also participated in answering face-to face interview questionnaire about oral health practices and the use of dental health services. Both collected sociological and clinical data was entered and analyzed using SPSS 15.0 by presenting descriptive, mean of DMFT and periodontal disease, and percentages of all diseases in the study: dental caries, periodontal disease, dental fluorosis, erosion and traumatic injuries and trend of DMFT and periodontal disease by using pie graphs chart with secular trend as needed accordingly.

Results

Of the total drawn of 2500 schoolchildren, a response rate of 2134(85.4%) school children at age 6, 12 and 15 years old were clinically examined and included in the final analysis. Results had a small proportion of non-respondent that equal to 366 (14.6%). This because some of parents 4% were actively stated they did not want their children included in the survey and only 0.6% of children with consent declined to take part on the day. Absenteeism on the day of examination accounted for a loss of 4% of consented children, 6% the non-response to the request was the most common reason to reduce the sampled students despite two requests and schools actively seeking returned forms. 

Target sample of 2134 (85.4%) schoolchildren were clinically examined where, 896 (42%), 810 (38%) and 428 (20%) were at age 6, 12 and 15 years old respectively (Fig.1) with 1140 (53%) female and 996 (47%) male students (Fig.2).

Results had revealed also, that 260 (29%) out of 896 at 6 years old children (Fig.3) have got gingival bleeding. Trends of bleeding condition among 6 years old children plotted since year 2005 =54% and in year 2012 showed bleeding condition among those children has decreased and to be =29% (Fig.4).

421 (52%) out of 810 at age 12 years old children (Fig.5 & Fig.6) and 207(48.52%) out of 428 at 15 years old children have gingival bleeding (Fig.7).

Periodontal pocket of 4-5mm have been discovered in 141(33%) and pocket >6mm also discovered in 5 (1.23%) of 15 years old school children (Fig.7). Periodontal Status in this survey was measured by using a light weighted periodontal probe with a 0.5-mm ball tip was used, bearing a black band between 3.5 and 5.5 mm from the ball tip. CPI is an Indicator for: Three indicators of periodontal status are used for this assessment: absence of gingival bleeding, presence of gingival bleeding and Periodontal Pockets-subdivided into Shallow (4-5mm) and deep (6mm or more Supra or sub-gingival calculus was not recorded in accordance to 5th Edition Oral Health Surveys Basic Method, 2013.

Prevalence of dental caries in children aged 6 years old was equal to 88% (Fig. 8) and mean dmft= 4.56 (Fig.9) that compared with dmft resulted from survey conducted in year 2005; dmft= 4.66(Fig.10).

Mean DMFT =2.71 (Fig.13& Fig.15) at age 15 years old compared with 2005 DMFT=2.78 (Fig.13); Thus, trends of dental caries experience among children in all age groups plotted to be minute decreasing, however the prevalence of dental caries at age 15 years old is equal to 75% (Fig. 14).

Result was revealed also that the uppermost DMFT was recorded in southern governorate among all other governorates and equal to 12.64(dmft at 6 years old =5.33) + (DMFT at 12Years old =2.93) + ( DMFT at a15 Years old=4.38) and that because of new dental caries incidence found in age 6 and 15 years old except age 12 years old found to be the highest score recorded in Muharraq governorate (Fig.16).

The severity of dental caries was recorded in all age groups  in term of how many tooth as per child has exposed to dental caries; score zero was consider to be child free of dental caries, one tooth, 2-5 teeth , 6-10 teeth and more than 10 teeth with dental caries (Fig.17).

Result of dental fluorosis was showed that there were no sign of dental fluorosis to be recorded in 45.5% child, while 54.5% were recorded to have variety of enamel fluorosis on the labial surfaces of upper anterior incisors and canine’s teeth with symmetrical diffusing format. (Fig.18)

Also the result of enamel and dental erosion was recorded in 81.4% child, while 17.4% were recorded to had enamel lesion and 0.8% in dentin lesion. (Fig.19)

Children with no sign of traumatic injury were 81.5% of the total examined and the reaming of children were had range of trauma that included enamel(6.7%), enamel & dentin (1.5%), pulp involvement(0.5%) fracture and missing tooth due to trauma (1.1%), only 0.5% found to be treated from trauma. (Fig. 20)

The results were disclosed that all the children have no sign of mucosal lesions, upper or lower denture and or an urgent intervention were required.

A 12 years school children were subjected to face to face interview and results was revealed that 8.1% of children at age 12 years old did not know how to describe health of their teeth

And gum while 91.9% knew how to describe health of their teeth and gum that varies in knowledge from very poor to excellent that was scored equal to 15.2% only. (Fig. 21)

A 30.6 % of children were unsatisfied with the appearance of their teeth while 51.8 % of

them were satisfied and 17.6% only were answered normal i.e. neither satisfied nor unsatisfied (Fig.22),  22.2% of the children were found that they avoided smiling/laughing because of their teeth appearance (Fig.23), and 8% of the children were found that other schoolchildren make fun of them because of their teeth appearance(Fig.24)

A 25.2% of children were responded that they never had toothache or felt discomfort during the past 12 months, while 74.8% of them they had(Fig.25), a 17.1% of the children were missed their school classes due to dental pain (Fig.26).

The results showed also, that 33.8% of the children were never go to dentist during the last 12 months while 66.2% of them they visited the dentist. On how frequent per year they visited dentist they responded as follows: a 7% of children had visited the dentist more than four times, 1.6% had visited four times, and 7.2% three times, 17.5% two times and 23.8% they had visited the dentist once a year (Fig. 27).

Pain in teeth and gum was scored 54% as uppermost reasons that let children visited their dentist during last 12 months (Fig.28). 

A 96.7% of the students were brushed their teeth by using a brush and toothpaste; 58.2% of them reported to brush twice or more a day, 22.7% once a day, 6.8% several time a week or a month and 2.3% brushed their teeth once a week(Fig.29). However, 3.3% only of the students were reported they never brushed their teeth at all (Fig.29).
 

Children were asked about using fluoridated tooth paste while brushing their teeth; 40.3% answered yes, while 8.6% answered no and another 48.4 responded that they do not know about fluoridated tooth paste and 2.6% only of children were never used tooth paste while brushing their teeth(Fig.30).

Also children were asked about their dietary habit; 20.9% of children several time a day were reported to have fresh fruits, 19.4% chewing gum with sugar, 18.4% soft drinks, 16.0% sweets, 12.9% biscuits, 8.3 milk with sugar, 7.2 tea with sugar and 2.4 honey (Fig.31).    

Regarding smoking habit results revealed that 96.8 % and 93.6% of children were not smoking cigar/pipe and chewed tobacco respectively; however it has been discovered that 1.5% and 0.8% children at age 12 years old were smoking cigar/pipe and chewed tobacco respectively (Fig.32)

Discussion

This is the fourth national oral health survey conducted in the Kingdom of Bahrain; Survey reported here to provide information on the prevalence and severity of dental decay (caries), periodontal diseases, dental fluorosis and erosion, traumatic injuries to teeth, oral mucosa lesions and complete or partial denture in 6,12 and 15 years-old children attending governmental schools. Further reports will be produced including summary reports of face to face interview questionnaire. This report also highlights the wide variation in the levels of dental decay experienced by same age groups living in different parts of the country that’s mean different life circumstances. Though in Kingdom of Bahrain there is well established oral health preventive program but still dental caries remain high prevalence among children group in the country this might be still elevated in its percentage of prevalence because those children frequently had exposure of their teeth and dental tissue to fermentable carbohydrates, most commonly through eating and drinking sugary snacks and drinks (Rugg-Gunn, A. J. 1992). 

 The variation in dental decay reported at the different governorates was very well defined in this study that need to re-engineer of the preventive programs accordingly and a serious consideration should be given to this when preventive strategies and local interventions are being developed. The survey targeted 6, 12 and 15 years old school students throughout the kingdom; by using cluster sampling method ensured the external validity of the survey.

It is clear that there is minute improvement in dental caries level of the Bahraini students for all age groups. At age 6 years old, the mean dmft= 4.56 which is lower than in 2005 (dmft=4.66), however in age 12 years old children the mean DMFT=2.26 while in year 2005 the DMFT=2.3 but still this considered higher than the global standard DMFT for the year 2010 which should not be higher than (1) one (Hobdell et al, 2000)). At age 15, the mean DMFT is 2.71 which is not significantly different from DMFT in year 2005 (DMFT= 2.78), (Naseeb, A., (2005). The minute improvement in dental caries experiences can be attributed to the introduction of Oral Health Promotion Strategy for age from birth to age 18 years old since year 2009. It was obvious that the d/D component of the dmft/DMFT i.e. the decayed/Decayed(d/D) component in all ages was detected to be the highest share among the others component of the dmft/DMF and this can be determined that the incidence of decayed components is the responsible one to rose dmf/DMF score to its uppermost.

The severity of dental caries was recorded in all age groups  in term of how many tooth as per child has exposed to dental caries; score zero was consider to be child free of dental caries, one tooth, 2-5 teeth , 6-10 teeth and more than 10 teeth with dental caries and it has been found that 2-5 teeth has got dental caries was scored the highest among all age groups(43-44%) that led to curative services as a specific treatment needs
 for  all age groups children having caries experience (Decayed, Missed, Filled/DMF. Although the incidence of other dental diseases such as erosion, traumatic injuries and fluorosis was found to be low among all age children but the still curative management and services should be provided to 18.6%, 54.5% and 18% respectively of children due to enamel discoloration or traumatic injuries.  Therefore, a specific clinic should be available all through kingdom of Bahrain to serve those children, because those children if go throughout available community dental services then awaiting time will be very long to get appointment, and disease will be exacerbate; thus an attentive commencement of dental school based preventive programmes which is tugged from “Oral Health Promotion Strategy for age from birth to age 18 years old” is crucial; This reinforced by Petersen, 2003 cited by Varnne et al, 2006 “establishment of school based preventive programmes is attributed to the improvement of oral health in developed countries” Petersen, PE., (2003) cited by Varnne et al, (2006).

Almost 50% of children have diversities of dental fluorosis; therefore no need to add an artificial fluoride in the drinking water in Bahrain; nevertheless periodic evaluation of fluoride concentration from different water desalination sources throughout Kingdom of Bahrain is highly significant to make sure that the fluoride concentration is at optimal level.

In this survey a Periodontal status (CPI) modified has been used to measure the gingival health status and adults with specific pocket scores. “The CPI modified system includes recording of signs of periodontal disease in all the teeth that are present. WHO, (2013). (5th Edition Oral Health Surveys Basic Method, 2013).  Results had revealed that all children in all age groups have got gingival bleeding. Periodontal pocket of 4-5mm and >6mm have been recorded in 15 years old school children, this reflect the short come of current oral health educational programs; nevertheless, it’s a driving force to implement new trend of  dental caries management; Caries Management by Risk Assessment approaches or CAMBRA. The primary purpose of CAMBRA is to assess the patient’s risk for caries and to determine appropriate preventive and therapeutic tactic; the dental hygienist can be the key dental team member responsible for the creation, implementation and evaluation of CAMBRA instead of waste of resources. This approach was proposed by a group of experts based on scientific literature as a means of caries risk assessment through disease indicators, risk factors and protective factors to determine the associated clinical protocols or interventions Featherstone, J.D.B., Domejean-Orliaguet, S., Jenson, L., Wolff, M., & Young, D.A. (2007) and ⁽Featherstone, J.D., Adair, S.M., Anderson, M.H., Berkowitz, R.J., Bird, W.F., Crall, J.J., Den Besten, P.K., Donly, K.J., Glassman, P., Milgrom, P., Roth, J.R., Snow, R., & Stewart, R.E. (2003). 

World Health Organization (WHO) defined health as the "complete state of physical, mental, and social well-being and not merely the absence of infirmity" (WHO 1948). In this definition, WHO indicates three dimensions of well-being. Physical well-being that relates to function normally in activities such as bathing, dressing, eating, and moving around. Mental well-being implies that intellectual faculties are intact and that there is no burden of fear, anxiety, stress, depression, or other negative emotions. Social well-being relates to one's ability to participate in society, fulfilling roles as family member, friend, worker, or citizen or in other ways engaging in interactions with others.  Bergner M, Bobbitt RA, Carter WB, Gilson BS. (1981). As Gift and Atchison (1995) stated, measuring health-related quality of life allows assessment of "the trade-off between how long and how well people live." Gift and Atchison (1995). Diseases and disorders that result in dental and craniofacial defects can frustrate that goal, disturbing self-image, self-esteem, and well-being. Oral complications can compromise the quality of life such as child could face problems with appearance, speaking, chewing, taste, and bad smell from oral cavity due to dental caries; and periodontal disease. In this study the psychological impact of teeth appearance has been found that 30.6 % of children were unsatisfied with the appearance of their teeth and 22.2% of the children were found that they avoided smiling/laughing because of their teeth appearance, and 8% of the children were found that other schoolchildren make fun of them because of their teeth appearance. A 17.1% of children were more likely had experienced dental pain and missed school, and perform poorly in school.  A 74.8% of children were responded that they had toothache or felt discomfort during the past 12 months. From above presented result it can be concluded that oral health has direct impact on  people’s life; Davied Locker stated that “Oral health affects people physically and psychologically and influences how they grow, enjoy life, look, speak, chew, taste food and socialize, as well as their feelings of social well-being (Locker D. 1997). Also, Sheiham, A. (2016) supported the same idea “Severe caries detracts from children’s quality of life: they experience pain, discomfort, disfigurement, acute and chronic infections, and eating and sleep disruption as well as higher risk of hospitalization, high treatment costs and loss of school days with the consequently diminished ability to learn” (Sheiham, A, 2016). These findings suggest that improving children's oral health status may be a vehicle to enhancing their educational experience.

Furthermore, 33.8% of the children were never go to dentist during the last 12 months, and 23.8% of them were once a year had visited the dentist. However, pain in teeth and gum was the uppermost reasons that driven children to visit their dentist in the last twelve months as this reported by (54.5 %) students. Oral diseases are the fourth most expensive diseases to treat. Treating caries, estimated at US$ 3513 per 1000 children, would exceed the total health budget for children of most low-income countries (Yee R, Sheiham A. 2002). The situation for adults in developing countries is worse, as they suffer from the accumulation of untreated oral diseases. Millions with untreated caries have cavities and suppuration, yet planners continue to overlook oral diseases, despite their significant impact on cost and quality of life. This oversight will lead to more decay and expensive, ineffective clinical interventions. (Yee R, Sheiham, 2002).

Brushing teeth helps to remove food and plaque the sticky film that forms on your teeth and contains bacteria. American Dental Association (ADA) recommended that in addition to brushing teeth at least twice a day, person should floss daily, eat a healthy diet and limit between-meal snacks, replace toothbrush every three to four months or sooner if the bristles are frayed, and schedule regular dental checkups American Dental Association, (2013).

Fortunately, 96% of interviewed children were brushing their teeth, but only 33.8% never brushed their teeth. Though 33.8% never visited a dentist in the last 12monthes but still there is vast majority 66.2% of children did either once or more than four times and the main reason about 54.5% of children were visiting the dentist is because of pain in teeth or gum. Children found also that they consumed sugary food and drinks several time a day and moreover they are not regularly visit the dentist; this explains the high component of dmft/DMFT.

Though enamel fluorosis free was 45.5% among all age groups but still different rankings of fluorosis incidences was discovered during this study about 54.5% and most of it was in the form of symmetrical diffuse. This can be explained by the fact that most areas in Bahrain are fluoridated and more over people consumption drinks and food from as other sources that contain fluoride. Thus, an artificial adding of fluoride should be scientifically studied very well.

Conclusion

Despite there is an overall minute improvement in oral health status of Bahraini 6,12 and 15year olds children and mean of national DMFT=2.26 for 12 years-old is considered higher than the global standard DMFT for the year 2010 which should not be higher than (1) one (Hobdell et al, 2000 ), furthermore still there is a dental caries incidence among all age groups and an occurrence of gingival bleeding among all age groups also periodontal pocket 3-4mm and periodontal pocket more than 6mm was found in 15 year old children. Hence, it can be understand that childhood dental caries and periodontal diseases is a serious dental public health problem among Bahraini children, particularly the very young children. Prevalence of dental caries and periodontal disease are high across Kingdom of Bahrain. Therefore, a serious actions by all dental health services authorities to prevent dental caries and periodontal disease become a priority, dental disease and periodontal diseases surveillance should be encouraged and as well as more studies should be carried out to tackle risk factors associated with same diseases, and implementation of strategies that directing to prevent and control oral diseases in the Kingdom of Bahrain. Nevertheless, a mutual cooperation between all sectors governmental and privet towards caries free generation should be addressed along with one should not forget prevention always better than curative services.

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