Special Communication
Dental Health and Health Care in Saudi Arabia
Basil H. Al-Khadra, BDS, MsD
From the College of Dentistry, King Saud University, Riyadh.
Address reprint requests and correspondence to Dr. Al-Khadra: College of Dentistry, King Saud University, P.O. Box 8363, Riyadh 11482, Saudi Arabia.
Accepted for publication 15 February 1989.
We review the available literature on dental health and health care in Saudi Arabia. While detailed epidemiologic
data are not available, the following conclusions may be drawn. The Saudi population experiences the same dental
diseases that other populations do; however, the extent and severity of these diseases are slightly different. Caries,
while low, appear to be increasing. Periodontal disease and dental fluorosis are widespread among the population.
Malocclusion is present almost to the same extent as in Western countries. Data about oral cancer in Saudis are very
limited. One serious problem is the acute shortage of dental professionals in Saudi Arabia.
BH Al-Khadra, Dental Health and Health Care in Saudi Arabia. 1989; 9(6): 592-596
Saudi Arabia is the largest of several countries located in the Arabian peninsula, occupying approximately 80%
of its total land mass. The population in 1986 was 11.5 million, as reported by Merrick.1 While unofficial estimates
of the population of Saudi Arabia have been made, the first survey by the Central Department of Statistics,
conducted in 1962, estimated the population to be 3.2 million with 20.8% living a nomadic life. 2 Due to the
unreliability of such estimations, the government of Saudi Arabia planned and executed the first official population
census in 1974. Several studies followed and various agencies were involved. Table 1 shows the population of Saudi
Arabia from 1970 to 1986, as reported in previous studies.3-7
Distribution of the population has changed inthe past few years, and in response to persistent efforts by the
Saudi government, a large number of the nomadic population has increasingly settled in urban locations. Ruwaythy2
reported that there has been a continuous increase in the urban population since 1932: in 1932 it was estimated to be
42.30% of the total population; in 1974 it was 73.13%.
In addition to the relocation policy of the Saudi government, environmental factors have played a role in the
process of urbanization. The nomadic population has been reduced in size by 2 to 4% annually. The government's
Second Five-Year Plan (1975-1980) reported a 2% annual reduction in the nomadic population. 8
The dentist-population ratio is far short of being ideal. In 1974 there were 224 dentists practicing in Saudi
Arabia.9 Although the number rose to 1,200 dentists10 by mid-1986, it is clear that most are expatriates practicing
either in the private sector or more commonly in government institutions. There are few dentists of Saudi nationality
and most have received their training in neighboringcountries. In 1976, the first dental school in Saudi Arabia was
established, and ten students were enrolled. Currently, the average student enrollment is 100 to 153 per year. By
1987, the total number of graduates reached 152, the vast majority being Saudis (Table 2). 11,12
Dental Practice in Saudi Arabia
With the implementation of its First Five-Year Plan, the Ministry of Health (MOH) made an effort to both
improve and more equitably redistribute dental care facilities throughout the Kingdom. Such efforts have resulted in
a current total of more than 550 dental operatories and about 478 dentists working within the MOH. 10 The goal of
the MOH is to attend to the total dental needs of the population. To meet these needs, the MOH has rationalized the
Dental Health and Health Care in Saudi Arabia
provision of its services within three categories:
Primary dental care: MOH clinics, providing preventive and emergency treatment.
Intermediate care: dental departments within central and general hospitals, providing treatment beyond
emergency care but not extending to comprehensive care.
Specialized centers: Comprehensive dental care is provided (e.g., the Riyadh and Medina centers).
The MOH also works with the health department of the Ministry of Education (MOED) to provide periodic
examinations and treatment of schoolchildren whenever needed. However, this aspect of its dental health care policy
is fairly new and is still under evaluation. The delivery of dental services is available within both the public and
private sectors:
Public sector: includes MOH, Ministry of Defence and Aviation (MODA), MOED, Ministry of Interior, and the
National Guard.
Private sector: private clinics, clinics within private hospitals or dispensaries, and dental clinics attached to
major private companies and institutions (e.g., ARAMCO). There are about 80 private dental offices in Saudi
Arabia, and a further 178 clinics are incorporated into private hospitals or dispensaries.10
The dental department of the MOH in Riyadh is currently undertaking an epidemiologic study of dental disease
patterns in Saudi Arabia. However, this project is limited by a small study population, and only 6- to 12-year olds
are included, with emphasis on the 9- to 10-year age groups.13 A more comprehensive project, funded by King
Abdulaziz City for Science and Technology, is investigating the prevalence of dental diseases in all age groups. The
Central Province phase of this study is in the process of completion.
The dental profession in Saudi Arabia is considered a "new" profession because it was practiced in the past by a
few foreign dentists and denturists. The population of Saudi Arabia has increased by 4.1% annually since 1980 and
totaled 11.5 million inhabitants by 1986. The total number of dentists in 1986 was 1,200, giving a dentist-population
ratio of 1:9,600; this compares to a ratio of 1:28,000 in 1980. 8,21 While the population of Saudi Arabia increased by
about 25% in that period (Table 3), the number of dental professionals increased by about 400%, and this may be
largely ascribed to the increase in the number of foreign dentists.
Table 1. Population of Saudi Arabia.
Year
Population
1970
1975
1980
1985
1986
6,198,000
7,250,000
9,229,000
11,238,356
11,500,000
Table 2. Number of graduates from individual classes.
Class
No. of graduates
1981-82
1982-83
1983-84
1984-85
1985-86
7
11
29
38
25
1986-87
42
Table 3. Comparison between the increase in population size
and numbers of dentists.
Year
Population
1974
1980
1985
1986
7,012,000
9,229,000
11,238,356
11,500,000
Annals of Saudi Medicine, Vol 9 No. 6; 1989
No. of
dentists
224
280
865
1,200
Dental Health and Health Care in Saudi Arabia
As has already been mentioned, the dental department of the Ministry of Health in Riyadh has begun to describe
dental disease patterns in Saudi Arabia. Notwithstanding the obvious limitations of this study in formulating an
overall planning strategy, its usefulness in planning services for children, at least, is clear.
The supply of dentists is drawn from two main pools–graduates of the College of Dentistry in Riyadh and
foreign dentists. While the dental college in Riyadh has graduated about 45 dentists annually, the number of
graduates is expected to rise in 1989 since the number of students enrolled in 1982 was 109.
Local training facilities are rapidly increasing. King Abdulaziz University in Jeddah has recently started its
undergraduate dental program, and planning for a dental school at King Faisal University in Dammam is at an
advanced stage.14,15 The other source of dental personnel are foreign dentists. Searle et al16 stated that "because
Saudi Arabia can solve its short-term problems by importing technology and physicians, it will no doubt continue to
do so, even though it delays the time when it will become self-sufficient." Although dentists were not specifically
mentioned, it would appear that the government's strategy is to rely on foreign dentists (and other health
professionals) to attend to the current needs, while working on preparing a well-qualified resource of national
dentists. This policy was emphasized in a statement by the MOH in 1978. 17
Oral Health
Dental Caries
Dunbar15 believed that Saudi Arabians suffered from dental caries in an epidemic proportion, and that the
upsurge in the incidence of caries is a relatively recent phenomenon. In a study of 570 people residing in the
Makkah region, El Tannir18 reported a 37.4% prevalence of caries.
Keene et al,19 in a study of 217 Saudi Arabian naval recruits, reported that the incidence of caries was
considerably lower than that for the U.S. recruits of comparable age. The Saudi mean decayed, missing, or filled
teeth (DMFT) index was 3.7 ± 3.4 (SD). Wirthin et al, 20 in a study of 52 Saudi naval recruits, reported a mean
DMFT index of 3.5 ± 2.9. Youness and El Angbawi21studied 1378 schoolchildren and found a mean DMFT index of
2.9 ± 2.6, which was considered low. In a report for the World Health Organization (WHO) by Barmes and Zahran 9
on the oral health situation in Saudi Arabia, it was reported that the mean DMFT index for 12-year-old children was
2.0, whereas that of 15-year-old children was 2.3.
Given the large percentage of nomadic/rural Saudis without access to dental care or dental health education, a
high prevalence of caries in this group might be expected. However, the dental caries rate in this group is actually
low. Dunbar15 stated that he had "gained the impression that Saudi Arabians should have a fairly low index of dental
caries," and this view coincided with those of epidemiologists working at the National Institute of Dental Research
and the WHO. A low caries incidence may be attributed to diet and a high content of natural fluoride in drinking
water,9,18-22 and this may account for the lower incidence of caries in rural as compared to urban children (Table 4).
The move toward urbanization and the increased consumption of refined sugars usually accompanying such moves
may explain the overall increase in the caries experience in the Saudi population. 9
Periodontal Diseases
In a study of 1173 schoolchildren (573 boys and 601 girls), El Angbawi and Youness22 reported a high
prevalence of periodontal disease, with a mean incidence of "intense gingivitis" of 2.3 ± 1.79 and an absence of
advanced periodontitis. A mean calculus score of 1.06 ± 1.17 was found. While no details of indices used were
given, theauthors claimed to have used "WHO criteria." Barmes and Zahran 9 observed a "moderate to high level" of
periodontal disease. Wirthlin et al20 reported a high prevalence of marginal gingivitis in young men, aged 17 to 26
years, from Saudi Arabia based on a sample of 52 subjects. None of the subjects showed generalized chronic
periodontitis, while 24 subjects showed signs of generalized "chronic marginal gingivitis." No definitions of the
terms used are provided by the authors. In El Tannir's study,18 38% of 570 people residing in Makkah showed signs
of periodontal disease that varied from mild to severe. Eid and Zulqarnain, 23 in his study utilizing patients'
radiographs, reported that periodontal disease is common in the Saudi population. However, the extent and severity
of the disease did not differ greatly from groups in Western societies.
Annals of Saudi Medicine, Vol 9 No. 6; 1989
Dental Health and Health Care in Saudi Arabia
Table 4. Comparison between the DMF score for the 12-and 15-year-old groups.
Location
Riyadh
Jeddah
Abha*
Total
Age(y)
12
15
12
15
12
15
12
15
No.
76
88
25
20
21
20
122
128
D
2.01
2.19
1.68
2.5
1.33
1.05
1.83
2.06
M
0.12
0.14
0.10
0.20
0.05
0.08
0.13
F
0.07
0.11
0.05
0.04
0.09
DMFT
2.20
2.44
1.72
2.75
1.33
1.01
1.95
2.28
* Rural area.
D = decayed, M = missing, F = filled, T = teeth.
Source: Adopted from Barmes and Zahran.9
Dental Fluorosis
El Tannir18 reported that 70.5% of his sample population of 570 showed varying degrees of "tooth mottling"
due to a high fluoride concentration in the drinking water. Barmes and Zahran9 stated that the fluoride content of
water in Saudi Arabia varied greatly, being high in certain areas, adequate in others, but occasionally low and
needing supplementation.
Malocclusion
Available literature of the prevalence of malocclusion does not provide adequate information. Nossier13
reported that 15 to 17% of the population is estimated to be in need of some orthodontic treatment.
Nashashibi et al,24 in a study involving 1000 Saudi children (mean age, 11.8 years) from the Riyadh region,
reported that 57.7% of the children required some kind of orthodontic treatment. The low prevalence of
malocclusion reported by Nossier was in his opinion largely due to the large jaw sizes among Semitic poeple.
However, the figures reported by Nashashibi et al agree with those of other countries in the Middle East. Comparing
the figures of the latter workers with those reported by Gardiner, 25 it is apparent that the Saudi population falls in the
middle of the scale between France (54%) and Germany (63%).
Oral Cancer
While the available literature about oral cancer in Saudi Arabia is limited, Mani, 26 in a survey of 674 dental
patients, reported no cancer for Saudis. The prevalence of other lesions was as follows: leukoplakia, 1.7%;
leukoedema, 6.9%, nicotinic stomatitis, 2.5%; and lichen planus, 0.9%. Salem et al27 surveyed 661 people from the
Southern Region of Saudi Arabia for oral malignancy. He reported that 68% (129) of the native snuff users had
signs of leukoplakia. Al Dosari28 reviewed 206 cases of neoplastic oral lesions in Riyadh Central Hospital: 74.3%
were squamous cell carcinoma, 10.2% were malignant lymphomas, and 3.9% were malignant undifferentiated
neoplasms.
Public Knowledge and Awareness
Although there appears to be no published work on public knowledge of dental care, increasing attendance rates
at the College of Dentistry, King Saud University, point to an improved awareness. This may be largely attributed to
the efforts in dental health education being made by the concerned government agencies.
Conclusions
Saudis suffer from the same dental diseases as do other nations. In light of the available literature, there are no
major differences between Western societies and Saudis regarding the prevalence of periodontal disease and
malocclusion. Dental caries, however, appear to be increasing in incidence; this is in contradistinction to developed
countries, where a reduction in caries has been occurring.
References
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Annals of Saudi Medicine, Vol 9 No. 6; 1989
Dental Health and Health Care in Saudi Arabia
2. Ruwaythy MA. Population of Saudi Arabia: geographic and demographic study. Cairo, 1978.
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Annals of Saudi Medicine, Vol 9 No. 6; 1989