A NEEDS-BASED APPROACH FOR HEALTH HUMAN RESOURCES … · A Needs-Based Approach for Health Human Resources Planning for Dentistry in Jeddah, Saudi Arabia Ph.D / Dental Public Health

A NEEDS-BASED APPROACH FOR HEALTH HUMAN RESOURCES

PLANNING FOR DENTISTRY IN JEDDAH, SAUDI ARABIA

by

Akram Fareed Qutob

A thesis submitted in conformity with the requirements

for the degree of Ph.D / Dental Public Health

Graduate Department of Dentistry

University of Toronto

© Copyright by Akram Fareed Qutob 2009

ii

A Needs-Based Approach for Health Human Resources Planning for Dentistry in

Jeddah, Saudi Arabia

Ph.D / Dental Public Health 2009

Akram Fareed Qutob

Graduate Department of Dentistry

University of Toronto

Abstract

This study aims to provide a human resource planning example to inform

government bodies in Saudi Arabia to reallocate community resources towards

better dental health. This was achieved by: conducting an inventory on

government human and structural oral health care resources in Jeddah and

Bahrah; assessing the oral health status and treatment needs for Saudi citizens

following the WHO criteria for oral health surveys; exploring the potential

differences between oral health supply and treatment needs; and providing 16

models of the number and mix of dentists and hygienists to balance requirements

and supply.

We conducted a population-based sample survey to collect data on dental status

and service requirements through self-administered questionnaires and clinical

examinations. We also conducted a census of dentists and assessed their total

service output by means of self-administered questionnaires. The population’s

treatment needs time was estimated using the clinically assessed treatment

needs multiplied by time units contained in the 2001 ODA fee-guide. Dentists’

iii

available time was calculated from dentists’ questionnaires and the activity

assessment forms. The times for treatment needs and supply of services were

compared to identify differences in treatment hours.

Of the 2000 participants aged 6, 12, 16, 24-29 and 35-44, 76.8% rated their oral

health as excellent and 29.2% reported visiting the dentist at least once a year.

The prevalence of periodontal conditions as described by the CPITN was 86.1%.

The caries prevalence for the permanent and deciduous dentitions was 71.3%

(mean DMFT=4.92) and 85.5% (mean dmft=5.45) respectively.

One hundred seventy-five government and university dentists (56.6% response

rate) completed the total service output instruments. When the projected total

FTE-dentists needed to treat the incidence of oral diseases/ conditions (11,214)

is contrasted with the total available supply in Jeddah and Bahrah (289 dentists)

the remaining FTEs needed to meet the needs becomes 10,925 FTE-dentists.

Health promotion strategies and increased productive hours could reduce this to

2,729 dentists and 1,595 hygienists.

The General Directory of Health Affairs of Jeddah will need to develop different

approaches to oral health promotion and/or care provision to meet the population

needs.

iv

Acknowledgments

This study was generously funded by the Zamzam Society for Voluntary Health

Services in Jeddah, Saudi Arabia.

I would like to thank the dental interns of class 2006 from the Faculty of Dentistry,

King Abdulaziz University in Jeddah for their outstanding contribution and

dedication of their time and personal efforts during the January-April 2007 data

collection period.

I would like to extend my warmest gratitude to my Ph.D supervisor, Professor

James Leake, and my advisory committee members: Professor Hassan

Ghaznawi, Dr. Stephen Birch and Dr. David Zakus. To Professor Leake I extend

an extra appreciation for his help, support and respect during the course of my

study at the Faculty of Dentistry, University of Toronto. It was my great honor to

be his last Ph.D student to supervise before retirement.

v

Table of Contents Page

I List of Tables……………………………………………………………. viii II List of Figures…………………………………………………………... xiv III List of Figures…………………………………………………………...

xv

1.0 Introduction……………………………………………………………… 1 1.1 The importance of planning and evaluation…………………………... 2

1.2 The need for national health information……………………………… 4

1.3 Oral health surveys internationally and in the Middle East………….. 4

1.4 Need, demand, supply and health human resource planning

methods……………………………………………………………………

5

1.5 Health human resource planning in dentistry and in other health

professions - literature review …….……………………………………

11

2.0 Background on Saudi Arabia………………………………………… 17 2.1 Geography………………………………………………………………... 18

2.2 Political system and administrative regions…………………………… 20

2.3 The Saudi population……………………………………………………. 22

2.4 Discussion of the Saudi economy……………………………………… 22

2.5 The Saudi culture………………………………………………………… 24

2.6 Description of the health care delivery system in Saudi Arabia…….. 26

2.7 Oral health status and oral health resources in Saudi Arabia;

review of previous research……………………………………………..

28

3.0 Aim and Objectives……………….…………………………………….

39

4.0 The Initial Data Collection Phase……………………………………. 43

vi

Table of Contents Cont. Page

5.0 Materials and Methods………………………………………………… 50 5.1 Stage 1: preparatory…………………………………………………….. 52

5.2 Stage 2: operational……………………………………………………... 52

5.3 Stage 3: analytical………………………………………………………..

63

6.0 Results…………………………………………………………………… 69 6.1 Requirements…………………………………………………………….. 70

1) Perceived oral health status and behaviors……………………….. 71

2) Epidemiologically assessed oral health status ……………………. 72

3) Treatment needs and time estimates………………………………. 75

6.2 Supply…………………………………………………………………….. 77

1) Supply and practice characteristics………………………………… 78

2) Supply time estimates………………………………………………... 79

6.3 Matching requirements and supply…………………………………….. 80

6.4 Models to balance requirements and supply………………………….

86

7.0 Discussion………………………………………………………………. 98 7.1 Regional, national and international comparisons…………………… 99

7.2 Anticipating and overcoming threats to internal validity and ways to

improve internal consistencies………………………………………….

104

7.3 Generalizability of the research results to the Saudi population……. 107

7.4 Limitations and suggestions for improvement for future similar

studies……………………………………………………………………..

108

7.5 Impacts and Implications …..…………………………………………… 111

7.6 Potentials for success…………………………………………………… 114

vii

Table of Contents Cont. Page

8.0 List of Reference...……………………………………………………...

117

9.0 Tables……………………………………………………………………..

126

10.0 Figures……………………………………………………………………

199

11.0 Appendices……………………………………………………………… 204

viii

I. List of Tables

Table Page

1 Types and numbers of dental care providers and dentist

population ratio for Saudi Arabia………………………………………

127

2 The distribution of target population and the degree of

comprehensive provision of health services among different

government bodies……………………………………………………..

128

3 Schematic representation of the interpretation of survey data from

field patient examinations to treatment needs to time requirement

estimates…………………………………………………………………

129

4 Dental procedures’ time estimate as adopted from the Ontario

Dental Association (ODA) fee guide for the different treatment

needs……………………………………………………………………..

130

5 Participants’ perceptions of oral health rating and satisfaction for

all groups and by age, gender and place of residence……………..

132

6 The impact of oral health problems on avoiding eating, speaking

or performing usual daily activities in the past 12 months for all

groups and by age, gender and place of residence…………………

133

7 Reported experiences of different oral health problems during the

past month for all groups and by age, gender and place of

residence………………………………………………………………...

134

8 Perceived oral health treatment needs for all groups and by age,

gender and place of residence………………………………………...

135

ix

List of Tables Cont. Table Page

9 The frequency of teeth brushing for all groups and by age, gender

and place of residence…………………………………………………

137

10 The frequency of regular dental visits for all groups and by age,


138

11 Time since last dental visit, reason for last dental visit and the

degree of satisfaction with the last dental visit for all groups and

by age, gender and place of residence……………………………….

139

12 The frequency of dental visits to the different types of dental

clinics that Saudi citizens in Jeddah and Bahrah usually go to for


140

13 The frequencies of different oral mucosal conditions for all groups

and by age, gender and place of residence………………………….

141

14 Enamel opacities and hypoplasia in the permanent dentition for all

groups and by age, gender and place of residence…………………

142

15 The prevalence of dental fluorosis by severity level for all groups

and by age, gender and place of residence………………………….

143

16 The overall frequencies of the different scores of the community

periodontal index for treatment needs (CPITN) for all groups and

by age, gender and place of residence……………………………….

144

17 The frequencies of the different scores of the community

periodontal index for treatment needs (CPITN) in each sextant for


145

x


18 The overall frequencies of the periodontal loss of attachment

(LOA) for ages 16,24-29 & 35-44 years and by gender and place

of residence……………………………………………………………...

147

19 Prosthetic status and needs for all groups and by age, gender and

place of residence………………………………………………………

148

20 Prevalence and severity of dental caries in the permanent

dentition (Decayed, Missing and Filled permanent teeth - DMFT)

for all groups and by age, gender and place of residence………….

149

21 Prevalence and severity of dental caries in the deciduous

dentition (decayed, missing and filled deciduous teeth - dmft) for

age 6 years and by gender and place of residence…………………

150

22 Prevalence and severity of root caries in the permanent dentition

(Decayed and Filled roots - DFR) for ages 16,24-29 & 35-44 years

and by gender and place of residence………………………………..

151

23 Mean annual individual treatment needs time for all groups and by

age, gender and place of residence…………………………………..

152

24 Mean annual individual treatment needs time for the study’s five

age groups after factoring in the caries increments (teeth/ year)

and the modal restorative service time to reduce the restorative

needs time for ages 12, 16, 24-29 and 35-44………………………..

153

25 Mean annual individual simple and complex periodontal treatment

needs time in for all groups and by age, gender and place of

residence………………………………………………………………...

154

xi


26 Annual estimated treatment time per person requirements (hrs)

according to reported visiting pattern………………………………...

155

27 Annual estimated treatment time per person requirements (hrs)

according to reported visiting pattern after factoring in the caries

increments (teeth/ year) and the modal restorative service time to

reduce the restorative needs time for ages 12, 16, 24-29 and 35-

44…………………………………………………………………………

159

28 Demographic of Jeddah and Bahrah government dentists by

dentists’ current occupation……………………………………………

163

29 Characteristics of oral health care provision among government

dentists by their employer, gender and place of practice…………..

164

30 The mean stated and actual number of patients seen in a normal

working day among government dentists by their employer,


165

31 Busyness and job satisfaction among government dentists by

their employer, gender and place of practice………………………..

166

32 Percentages of types of dental procedures performed by general

dentists and dental specialists in Jeddah and Bahrah……………...

167

33 Mean daily and mean annual dentist time in hours for all

government dentists and by dentists’ current occupation…………..

168

xii


34 Dental procedures’ time estimate as adopted from the two day

activity assessment form filled by Saudi dentists in Jeddah for

different dental procedures (the Saudi procedures’ time estimates

do not include lab’s procedures time)………………………………...

169

35 Saudi and ODA dental procedures’ time estimates used in the

projection of the treatment needs’ time estimates………………….

176

36 Total population count for each age group for all groups and by

age, gender and place of residence…………………………………..

178

37 Mean annual total individual treatment needs time that can be met

by dentists and by dental hygienists for all groups and by age,


179

38 Jeddah and Bahrah population total treatment needs time that can

be met by dentists and by dental hygienists for ages 6, 12, 16, 24-

29 and 35-44………………………………………………………...…..

180

39 Annual estimated treatment time requirements (hrs) according to

reported visiting pattern with varying annual utilization

rates………………………………………………………………………

181


reported visiting pattern with varying annual utilization after

factoring in the caries increments (teeth/ year) and the modal

restorative service time to reduce the restorative needs time for

ages 12, 16, 24-29 and 35-44…………………………………..……..

185

xiii

List of Tables Cont.

Table Page



reducing restorative needs time by 50% for the study’s five age

groups.….………………………………………………………..………

189



factoring in the caries increments (teeth/ year) and the modal

restorative service time to reduce the restorative needs time for

ages 12, 16, 24-29 and 35-44 and reducing restorative needs time

by 50% for the study’s five age groups……………………………....

193

43 The health human resources needed for the projected models to

balance the supply and the requirements sides……………….…….

197

xiv

II. List of Figures Figure Page 1 The dental manpower analytical model……………………………..

200

2 The conceptual framework of Andersen’s behavioral model……..

201

3 Dental human resource supply and requirement conceptual

model……………………………………………………………………

202

4 The population pyramid of the Saudi population obtained from

the 2000 census……………………………………………………….

203

xv

III. List of Appendices Appendix Page

A Ethics approval letters received form the ethic review unit at

the University of Toronto………………………………………….

205

B The supporting letter issued from the Faculty of Dentistry at

the University of Toronto………………………………………….

208

C The supporting letters issued from the Faculty of Dentistry

and the administration of King Abdulaziz University in

Jeddah, Saudi Arabia……………………………………………..

210

D Data summary forms (A, B.1 and B.2) and list of Tables (A.1,

A.2, A.3, A.4, B.1 and B.2)………………………………………..

213

E Clinical examination manual……………………………………...

224

F Participants’ consent form (English and Arabic versions)……..

252

G Clinical examination form…………………………………………

256

H1 Elementary schoolchildren’ questionnaire (English and Arabic

versions)…………………………………………………………….

264

H2 Intermediate and high-school schoolchildren’ questionnaire

(English and Arabic versions)…………………………………….

279

H3 Adults’ questionnaire (English and Arabic versions)………….. 295

xvi

List of Appendices Cont.

Appendix Page

I Dentists’ consent form…………………………………………….

311

J Dentists’ questionnaire……………………………………………

313

K Two days activity assessment form……………………………... 319

1

1.0 Introduction

2

1.1 The Importance of Planning and Evaluation

Dental health services, like any other services, should be well planned and

continually assessed and evaluated in order to improve their quality. Planning is

essential in order to guide choices that will lead to successful achievement of

improved health outcomes through precise and effective decision making.

Accordingly, the community’s resources could then be allocated efficiently to

meet its actual needs. Planning is also vital because it focuses on active

involvement in decision making, successful setting of priorities and a more

precise guiding of community resources towards best outcomes.

McCarthy’s rational planning model provides a basic guide for the planning

process (1). This model involves assessing needs and resources, identifying

priorities, developing aims and objectives, as well as aiding in their

implementation and evaluation. Although the model provides a logical and

practical approach, its implementation appears to be complicated. In some

situations, when there is lack of essential information, goals will go unattained.

Planning is most useful in achieving goals when implementation is aimed at

small, practically attainable goals. At the end, those small goals will add up and

become the main big goals. It is also important to note that planning requires

careful attention to the context within which the goals are being planned, such as

cultural attitudes and beliefs, financial and economical factors, all of which will

affect the implementation of any given plan.

Health care planning requires some basic information that is essential for the

planning process. This information includes a socio-demographic population

profile (age, ethnicity, social class and population mobility), disease levels

(epidemiological data, range of conditions, severity of disease, disease

distribution and trends in disease), existing service provisions (availability of

services, range of treatments available, costs of care, location of services, access

to services and effectiveness of interventions), and public concerns (population

priorities, views of health services and demands on health services) (1). The

gathering of such information should be done in a logical sequence so that

3

valuable decisions are made at the right time and ultimate outcomes are

achieved with the greatest impact possible.

The dental manpower analytical model provides a useful conceptual map of the

key factors that influence the degree of balance between the volume of needed /

demanded health care services and the volume and types of services that can be

produced by the health care delivery system (2) (Figure 1). This model compares

the volume of health services required with the volume of services that can be

produced (human resources and supply of health care services). As illustrated in

Figure 1, the outer right and left peripheries of the model diagram demonstrate

the important analytical factors. The right side of the model represents oral health

requirements, designated by the letter R, and the left side represents oral health

supply, designated by the letter S. By moving towards the center of the diagram,

the variables become the focus of concern, measurements become more

complex and often more indirect. Whenever the key variables are difficult to

measure, surrogate or proxy measures are introduced into the model; these are

designated in the diagram by the broken arrows. At the center of the model, a

comparison of supply and requirements, a comparison that quantifies the gap

between them, takes place. The closer the planner to the center of the model, the

better is the estimation of the gap. This comparison between supply and

requirements will demarcate the amount of shortage or surplus that exists so that

improved planning of health care services can be achieved.

The dental manpower analytical model could be supplemented by the conceptual

framework of an expanded version of Andersen’s behavioral model of health

services utilization (3)(Figure 2). Andersen’s model conceptualizes health

behaviors; (personal practices and the utilization of dental services) as

intermediate dependent variables, which in turn influence oral health outcomes;

(evaluated and perceived health status, and patient satisfaction). Using the

elements in the Andersen’s model such as health services utilization rates and

the evaluated oral health status will help account for the changing nature of such

elements which subsequently affects the overall projection of health human

resources.

4

1.2 The Need for National Health Information

In order to improve the health of a population through planning, health care

services require a fundamental base of information. National health information

does not improve the health of a given nation on its own but it plays a crucial role

in planning and establishing policies and properly allocating a nation’s resources.

Among a nation’s resources are health care resources; these include human

resources (health care providers and administrative staff), infrastructure

(hospitals, health care centers and clinics), equipment and materials (hospital

equipment and medication) and health educational and training institutions

(medical and dental schools and allied health colleges). Among other

requirements, it is important that resources be allocated properly in order to meet

the nation’s health needs and demands. Those allocation decisions can only be

appropriately made on the solid base of comprehensive national health

information.

1.3 Oral Health Surveys Internationally and in the Middle East

Oral health surveys are intended to provide data on the general oral health status

of a given community or nation. These data are then used in planning and

allocating resources to meet the needs and demands of that nation. Several oral

health conditions are measured and among them are: dental caries, periodontal

conditions, dental fluorosis and others. To that end, a number of developed

countries have included assessments of oral health in their health surveys. The

National Health and Nutrition Examination Survey (NHANES) and many surveys

filed with the Dental, Oral and Craniofacial Data Resource Center have been

implemented by the United States (4;5). The Australian Institute of Health and

Welfare has conducted several oral health surveys (6). The Community Dental

Health Service and the British Association for Study of Community Dentistry in

the United Kingdom have conducted several national surveys (7;8). In Canada, a

number of national surveys that included oral health have taken place since the

late sixties. However, these surveys have not used any clinical assessments

since 1970 (9;10). However, the Canada Health Measures Survey was launched

in 2007 and had included clinical dental health measures as part of the survey.

5

In the Middle East, several national oral health surveys have been conducted but

none of them included comprehensive evaluation of the oral health status that are

used for health human resources planning projects. In 1987, the Ministry of

Public Health in Kuwait conducted a national health survey that included

information about oral health (11). In Jordan, two national epidemiologic studies

took place in 1984 and 1990s (12). However, these surveys were limited in that

they did not include Jordanian adults in their samples when they measured the

oral health status of the Jordanian population (12). In 1998, a national oral health

survey was carried out in Syria (13). In Tunisia, four such surveys took place in

1981, 1988, 1994 and 2003 (14).

Information about surveys in Saudi Arabia is discussed in detail in section 2.7.

1.4 Needs, Demand, Supply and Health Human Resource Planning Methods

The concepts of need, demand and supply are fundamental to any discussion of

health human resource planning. They are of prime importance since they reflect

the existence of a shortage, an excess or a correct amount of health care

resources. The terms of need, demand and supply are defined as (2):

- Need: a professional judgment as to the amount and kind of health or

medical care services required by individuals having certain characteristics

in order to attain or maintain some standard level of health.

- Demand: the volume and type of health care services that an individual

desires to consume at some level of price. Demand is different from

utilization, which is the volume and type of services actually consumed.

Utilization is also called effective demand.

- Supply: referred to as the quantity of health care services (provided or

available).

In 1971, the World Health Organization (WHO) scientific group defined health

human resource planning as (15):

6

The process of estimating the quantity and type of knowledge, skills and

abilities needed to introduce predetermined alterations in the functioning of a

health system so as to make it more probable that the desirable changes in

the health of a population will be achieved.

And the goal of such planning in the view of the WHO group was to provide the

mixture of the professional and auxiliary health workers needed for the effective,

efficient and safe delivery of the required services of the highest quality

compatible with the resources of the population.

The same group has presented four methods for health human resource

planning. The choice between these methods depends on the form and the

availability of data. The human resource planning methods are:

1. Population Ratio Approach

This method uses human resource supply to population ratio to express the

human resource requirement. For example, if 1000 health care providers are

needed to meet the health care needs of a population of one million, the human

resource supply to population ratio is 1 to 1000. A target ratio is assigned and

ratios in other areas are compared with it to explore a shortage or a surplus. This

method is useful in providing an overview of the supply in relation to the total

population.

Advantages:

:

• Easy to use and to explain to health authorities and the public

• Modest data requirements and the data are usually insensitive to errors within

the validity of the underlying assumptions

• Low cost

• Provides baseline projections of the different kinds of human resources

required to maintain the current situation

• Useful shortcut for short-range and intermediate-range planning

7

Disadvantages:

• The selection of an appropriate ratio for judgment is open to question

• Generally used with single occupational categories leading to discount the

examination of the adequacy of the human resource mix

• Relatively difficult to estimate costs because of the lack of detailed data

• Assumes that the relationship remains unchanged by factors such as

demographics, socioeconomic conditions and health care technology, things

that can affect validity

• Some methods of selecting target ratios will inevitably show a shortage in

health resources

• With primary emphasis on human resources, the potential for improving

productivity, distribution, utilization and relevance of services may be

neglected

• Ignores health services needs

Indications:

Suitable for countries with:

• Reasonably adequate health conditions and health delivery systems

• A relatively stable health sector

• Limited planning resources

• Either an active or a passive approach for the delivery of services

• Either public or private sector dominance

• Reasonably comparable international models on which to pattern their health

care system

2. Service Targets Approach

:

This method focuses primarily on setting targets for the production and delivery of

health services, not for human resources. Health service targets are set by

experts taking into account the priorities, health wants, technical, administrative

and financial feasibility of providing health services. Then the human resources

required to meet those targets are estimated by means of productivity standards.

8

Active involvement by a health system is required in this method in order to take

action in shaping sectoral development.

Advantages:

• Facilitates matching of each component part of the health system with the

most appropriate method for estimating demand

• Draws attention to the importance of productivity and ways to improve it

• Easy to explain the planning rationale to health authorities and the public

• Cost estimation is relatively simple

• Utilizable with other planning methods

• Assists health team planning

• Revisions of the demand model are possible with the availability of new

information

• Entails modest data and planning capabilities

Disadvantages:

• Setting of standards may be unrealistically based on desires

• The method promotes excessively detailed planning for demand components

that are difficult to control

Indications:


• Dominant public sector with relatively strong control over human resources

and the delivery of services

• Active government policy towards delivery of services

3. Demand Approach

In this method, surrogate measures such as patient visits and expenditures on

health services are translated into effective health demands. Then they are

evaluated against the supply of those services for a given population. For this

method, health information on health needs is of secondary importance.

:

9

Advantages:

• Assists in recognizing the dynamics and determinants of demand

• Permits disaggregation of various demand components

• Inclined to produce economically realistic projections

• Results in a good estimate of the minimum growth in demand likely to occur

and ensures that the level of future satisfaction at least equals that of the

present

• This approach includes some simple variants

• Sometimes the method provides useful information for comparing the

economic returns from training in health occupations with those in other fields

Disadvantages:

• May require sophisticated data and can be complicated and costly

• May ignore political and societal reasons needed to improve service

distribution and delivery

• May not consider quality of services and their relevance to country’s health

problems

• Some aspects do not consider ways to improve human resource productivity

• Results and rationales may be difficult to explain to health authorities and the

public

• May produce inequalities in access to care

Indications:


• Dominant private sector

• Passive government attitude towards delivery of services

• Relatively minor imbalances in the provision of services to different segments

of the population

10

4. Health Needs Approach

Health professionals in this method determine the health services needed to

achieve and preserve good health. Then those needs are used to calculate the

human resources needed to meet population health needs.

Advantages:

:

• The method has an appealing and clear logic

• Consistent with ethic of providing services based on need and not social or

economic conditions

• Aids studies of productivity, utilization and staffing ratios, since it focuses on

the production of services

• Allows evaluation of health technology

• Promotes proper allocation of resources where they will have the greatest

impact on health

• Promotes concern about quality of care

• Cost estimation is relatively simple

• Assists health team planning

Disadvantages:

• Requires extensive and detailed data and considered to be costly and

complicated

• May encourage excessively detailed planning

• Setting of standards is complicated because of the lack of consensus on

optimum care and on health effects of care

• Likely to result in projected service requirements well in excess of country’s

ability to provide them and/or in excess of consumer willingness to use them

• Tend to be based on existing health provider model(s) for health services

delivery

Indications:


• Sophisticated data systems, survey capabilities and planning experience

11

• Relatively adequate health care delivery system

• Active government policy towards delivery of services

• Dominant public sector with relatively strong control over human resources

and delivery of services

• Relatively high public awareness and knowledge about health matters

Moreover, this method may be more applicable to preventive, public health and

specific health programs.

The prerequisites to the needs-based approach are to:

• Determine the disease-specific prevalence and treatment needs of a region or

country

• Prepare norms governing the services required to meet those treatment needs

• Prepare staffing norms so as to convert the various services into the amount of

time required of the oral health care provider to perform the services

• Calculate the total personnel hours needed in the target year for the projected

population to meet all treatment needs

• Divide the total personnel hours needed by the total number of hours worked

annually to determine the total supply of health human resources required

The same WHO group has presented other planning methods such as the

functional analysis method, mostly performed at the level of simple institutions

e.g. hospitals, and the use of other models which are not used widely in health

workforce planning.

1.5 Human Resource Planning in Dentistry and in other Health Professions

- Literature Review

In the 1960s, estimates of dental human resources were usually based on the

dentist to population ratio approach that neglected important variables such as

treatment needs, demand, utilization and productivity of dentists (16).

Consequently, these estimates have resulted in decisions that led to an

oversupply of dentists in the eighties. Thus, using only the dentist to population

12

ratio approach to estimate dental human resources is no longer considered

acceptable (17), as the inclusion of utilization and productivity levels along with

the assessment of treatment needs and supply are considered fundamental to

dental human resource planning.

Human resource planning in dentistry has been reported in the literature and

different methods have been utilized. A needs-based combined with the demand-

weighted approach, a modification of the needs approach, was utilized in the

dental manpower study that was sponsored by the North Carolina Dental Society

during the period from 1976 to 1980 (2). The study collected epidemiological data

on the health status of the state-wide community coupled by quantification of

consumer demand for utilization of dental services and dental office productivity

levels. Then these data were converted into time units needed by a dentist to

treat disease condition. The total number of hours worked by a dentist in a given

year was then calculated and compared to the total time needed to treat all the

cases in that given year. The study also assessed dentist productivity in terms of

number of auxiliaries involved in the practice and the number of patients seen per

day of practice.

The same method was used to calculate the present and future needs and

demands of dental manpower in Miyun County in Beijing (18).

A dental human resource planning model was used by the Indian Health Service

to provide a fair distribution of dental providers for the American Indian and

Alaskan Native population (19). The model was based on the dental needs of the

population and was developed within the limits of annual appropriations of funds.

At the start of the program, dental treatment needs were determined for various

age-groups based on annual patient examinations. Later however, these needs

were obtained from periodic surveys. Estimates of treatment needs were then

adjusted by anticipating the level of utilization of dental services. Dentists’ time

available to provide care was calculated after subtracting the estimated non-

clinical activity time and comparing it with the time needed to treat the identified

treatment needs. The model has been used by Indian Health Service since the

sixties and had exhibited utility and flexibility over time. It also allowed for

13

determination of clinic size (number of operatories) and dental staffing

requirements, and may be applied by other public health programs if an accurate

assessment of utilization rate and treatment needs could be made for a defined

population.

The children’s dental health research project report that was conducted in British

Columbia provided a comprehensive and useful model that studied needs and

utilization, delivery system designs and costs, educational capacity requirement

and costs, and administration, legislation, quality control and evaluation (20).

Furthermore, the project made use of a computer simulation planning model to

test practice model alternatives for which comparable experience was not

available. The model incorporated data on clinical teams, reasons for visits and

procedure times as an estimate of utilization of each type of dental personnel,

patients’ waiting time and a projected practice financial statement. Despite the

fact that the findings from this research project were not implemented for political

reasons, it provided the most comprehensive planning model to that time.

In another study that was conducted to estimate manpower requirements and

cost projections for three optional models of delivering dental care to children in

Manitoba, a method that defines the maintenance care dental needs of children

at specific age-groups was utilized (21). The method then assigns the time

required to deliver the service by the appropriate type of personnel or the

Manitoba dental fee was calculated instead. At last, the required number of

dental personnel and the costs were obtained through estimating the number of

children using these dental services.

Several studies were also carried out in the medical field that utilized the needs-

based approach. This approach was used in a study to estimate the requirements

for primary care physicians (22). However, the study assumed static levels of

diseases, productivity of health providers, and utilization of services among the

studied population.

In 1982, the Graduate Medical Education National Advisory Committee

(GMENAC) conducted a study to project physicians’ requirements for child health

14

care (23). The committee adopted a modified generic needs-based requirement

model that was a hybrid between needs-based approach based on the provision

of all services needed by the entire population and a demand-based approach

based on the current utilization patterns. The parameters of the model were then

estimated by groups of experts using a modified Delphi method, which was used

to adjust needs and account for physician productivity to estimate physicians’

requirement by specialty. The GMENAC evaluated projected supply and

requirements, for all major specialties, and recommended strategies to bring

them into reasonable balance. The model that was developed by the GMENAC

was utilized in another study that estimated physician’s requirements for

neurology (24).

In another study, staffing needs for the public sector, outpatient, mental health

service system was determined by a needs-based model (25). The model

involved a series of calculations relating demographic variables, workers’

productivity, anticipated demand and standards concerning annual visits per

patient distributed among mental health care professions. Treatment sessions of

20 or 30 minutes were used as the standard in the calculation of total sessions

required, while the number of such sessions provided by each full time equivalent

practitioner was used to measure their productivity level.

In a recent study, an analytical framework was developed as an adjusted needs-

based approach to human resource planning in health professions. The

framework introduces the use of production functions into human resource

planning and was based on the production of health care services and the

determinants for health human resource planning. These determinants were:

population size and demography, epidemiology of diseases in that population

(prevalence and incidence), the standards of care and the productivity level of

health care providers (26).

It is apparent from the previous literature that different approaches and a variety

of modifications of these approaches can be utilized in the planning of health

human resources. The choice between these approaches depends on the

15

context within which these planning projects are conducted and the availability of

and accessibility to data of varying degrees of detail and sophistication. This

implies that no particular approach will suit all situations and that the state of the

government activity, dominance or compliance of the private practice and the

sophistication of available information all play a role in planning activities.

Subsequently, this will determine the validity of the estimates that come out of

these projects. By that we can acknowledge the limitations that go side by side

with the different planning approaches.

Based on the dental manpower analytical model of DeFriese and Barker (Figure

1), some elements from the conceptual framework of Andersen’s behavioral

model (Figure 2) and the important variables observed in previous literature, the

following conceptual model was produced (Figure 3). This model starts by

gathering information on the dental resource supply and dental services

requirement sides. Then, based on the best available data, the potential sum of

minutes/ hours worked by all dentists per year at the current level of total service

output is estimated on the supply side. And the potential sum of minutes/ hours

required to achieve population treatment needs per year at the current level of

utilization is estimated on the requirement side. Accordingly, the potential

difference between supply of dental human resources and service requirement

can be estimated, based on the best available data.

However, supply of resources and service requirements are probably unstable

and variable over time. Thus, the model has been designed so that it may be

adjusted to account for the dynamic nature of supply and requirements so it can

be used at any point of time. On the supply side of the model, a change in the

number of dentists, their working life or their level of total service output will

necessitate recalculation of the potential sum of minutes/ hours worked by all

dentists per year at the new level of total service output. The total service output

has three main determinants:

1. Participation rate: which is the measurement of the actual number of

licensed dental care providers who are actually providing patient care

16

2. Activity rate: which is the amount of daily work time spent on providing

patient care; and

3. Productivity level: which is the amount of work produced per unit of time

Changes in any of these determinants will affect the total supply time that can be

provided on the supply side.

On the requirement side of the model, a change in the level of health service

utilization, a change in the level of disease, an introduction of a health promotion

program or an alternative public policy that leads to a reduction of disease levels,

will necessitate recalculation of the potential sum of minutes/ hours required to

achieve population treatment needs per year at the new level of utilization.

Recommendations coming from the model findings will depend on the potential

difference between dental resources supply and dental service requirements. If

there were a shortage of supply, then along with health promotion to reduce

needs, improvement of the level of total service output of the existing staff could

be recommended; and if that was limited, then an increase in the number of the

best mix of dental care providers (i.e. not only the number of dentists) could be

suggested which, at the same time, could increase the total service output of the

existing staff. On the other hand, if there were an excess of supply over

requirements, then reducing dental schools’ class-sizes or closing some of the

dental programs could be suggested. If the utilization were already high and

needs were being met, a reallocation of the available resources (reducing class-

sizes) or closing of dental programs could be suggested.

17

2.0 Background on Saudi Arabia

18

2.1 Geography (27)

Saudi Arabia is located in Southwest Asia and is the largest country in the

Arabian Peninsula. Its total area is approximately 2,250,000 square kilometers all

of it land. The total land boundaries measure 4,415 km

The Southern region (Asir) is the relatively fertile area of coastal mountains in the

extreme southwest (near Yemen). Mountain peaks rise up to 3,000 meters

bringing ample rainfall that supports natural vegetation and cultivation. Asir, with

and the total coastline

measures 2,640 km. Saudi Arabia is bordered on the north by Jordan (728 km),

Iraq (814 km), and Kuwait (222 km). On the east it is bordered by the Arabian

Gulf (Persian Gulf), Bahrain (an island), Qatar (60 km), UAE (457 km), and Oman

(676 km); from the south by Yemen (1,458 km) and from the west by the Red

Sea.

Geographically, Saudi Arabia is divided into four (and if the Rub al-Khali is

included, five) major regions. The first is the Central region, a high country in the

heart of the Kingdom; secondly, the Western region, which lies along the Red

Sea coast. The Southern region, in the southern Red Sea-Yemen border area,

constitutes the third region. Fourthly, there is the Eastern region, the sandy and

stormy eastern part of Saudi Arabia, the richest of all the regions in petroleum.

The Central region is a vast eroded plateau, consisting of areas of uplands, broad

valleys and dry rivers. The area also contains a number of marshes. Most of the

Central region is arid, with some oases in the north around Qasim. The climate of

the region is hot and dry in summer and cold in winter. Summer temperatures

sometimes exceed 45 degrees centigrade, while in winter the temperature falls to

5 degrees centigrade or lower.

The Western region (the Hijaz) includes the west coast of the Kingdom, north of

Asir. It contains a mountain chain (with peaks rising to 3,000 meters), running

south to north, decreasing gradually in elevation as it moves northward, and a

coastal plain bordering the Red Sea. The coastal area of the Western region is

renowned for its humidity, with summer temperatures rising to above 40 degrees

centigrade.

19

some juniper trees, wild olive trees and even some larger trees is the only part of

the Kingdom of Saudi Arabia to support forests.

The Eastern region is generally barren and characterized by rocky plateaus that

drop in elevation from 400 meters in the west to 240 meters in the east. Further

east, the terrain changes abruptly to the flat lowlands of coastal plain and

becomes generally featureless and covered with gravel and sand. A special

weather phenomenon affecting chiefly the Eastern region are the north-westerly

winds called the Shamals. These are prevalent during late spring and early

summer, reaching their greatest frequency in June.

In the south of the Kingdom is the famous Rub Al-Khali (the Empty Quarter), a

massive, trackless expanse of shifting sand dunes - one of the largest sand

deserts in the world - which covers an area of more than 650,000 km2. The Rub

Al-Khali is one of the driest places on earth, receiving almost no rain at all.

Water Resources

1. Surface water, which is to be found predominantly in the west and south-

west of the country.

:

In a country with the geography and climate of the Kingdom, water is a natural

resource which must be highly valued and conserved. The Kingdom draws its

water from four main sources:

2. Ground water, held in aquifers, some of which are naturally replenished,

while others are non-renewable. However, it is noteworthy that most of this

water comes from non-renewable aquifers.

3. Desalinated seawater, a source of water production in which the Kingdom

is now a world leader. Desalination technology, which also produces

electricity, has reached an advanced stage of technology in the Kingdom.

4. Reclaimed wastewater, a source of water which is still in its early stages

but which offers scope for considerable expansion.

20

According to the Saline Water Conversion Corporation, in 2000, there were 27

desalination plants producing 814 million cubic meters of desalinated water (more

than 600 million gallons a day) and providing more than 70% of the required

drinking water.

2.2 Political System and Administrative Regions (27)

The Kingdom of Saudi Arabia was unified in 1932 by King Abdul Aziz bin Abdul

Rahman Al Saud who established a monarchy as the means of governing in

which no political parties exist. Rule passes to the sons of the founding King,

Abdul Aziz Al Saud and today, the Kingdom is governed by King Abdullah bin

Abdul Aziz (the sixth king), in power since the first of August, 2005. The King

holds the position of head of state and prime minister.

The Council of Ministers was established in 1953 by the founder King, Abdul Aziz

bin Abdul Rahman Al Saud. The Council has responsibility for drafting and

overseeing the implementation of internal, external, financial, economic,

educational, defense policies and general affairs of state. Of all the agencies and

organized bodies of the government of Saudi Arabia, the Council of Ministers is

the most potent. It derives power directly from the King. It can examine almost

any matter in the Kingdom. The ministries of Saudi Arabia include:

1) Agriculture

2) Civil Service

3) Commerce and Industry

4) Communications and Information Technology

5) Culture and Information

6) Defense and Aviation

7) Economy and Planning

8) Education

9) Finance

10) Foreign Affairs

11) Hajj (Pilgrimage)

12) Health

21

13) Higher Education

14) Interior

15) Islamic Affairs, Endowment, Dawa and Guidance

16) Justice

17) Labor

18) Municipal and Rural Affairs

19) Petroleum and Mineral Resources

20) Social Affairs

21) Transportation

22) Water and Electricity

For administrative purposes, the Kingdom of Saudi Arabia is divided into thirteen

administrative regions. Each of these regions has a regional governor (a prince

from the royal family) with the rank of minister who is responsible to the Minister

of Interior. The regions and the cities in which the administrative headquarters of

each region are located are:

The Region

The Regional Headquarter City

1) Riyadh

2) Makkah

3) Madinah

4) Qasim

5) Eastern

6) Asir

7) Tabouk

8) Hail

9) Northern Border

10) Jizan

11) Najran

12) Al-Baha

13) Al-Jouf

-Riyadh (the royal capital of Saudi Arabia)

-Holy City of Makkah (In this region is the busy seaport of

Jeddah, known as the Islamic Port of Jeddah, a thriving

commercial center)

-Holy City of Madinah

-Buraidah City

-Dammam City

-Abha City

-Tabouk City

-Hail City

-Ar’ar City

-Jizan City

-Najran City

-Al-Baha City

-Sikaka City

22

2.3 The Saudi Population (28)

According to the general census, in 2004 the population of Saudi Arabia was

estimated at 22,673,538, with an annual population growth rate of 2.4%. Saudi

nationals constitute 72.9% of the total population and the rest (27.1%) are non

Saudi nationals. In regards to gender distribution of Saudi nationals, 50.1% of

them are males and 49.9% are females; while for the non-Saudi nationals, the

gender distributions are 69.5% for males and 30.5% for females reflecting the

predominance of expatriate labor among the non-Saudi nationals. The age

structure, according to the general census in the year 2000, is as follows:

- 0-14: 40.3%

- 15-64: 56.7%

- 65 and over: 3.0%

The 2004 census also showed that the regions of Riyadh, Makkah and the

Eastern region are populated by 64.5% of the total population; Riyadh region

(24.1%), Makkah region (25.6%) and the Eastern region (14.8%). There are three

major cities in Saudi Arabia that have a population exceeding one million and

those are:

- Riyadh City with a population of 4,137,280

- Jeddah City with a population of 2,883,169

- Makkah City with a population of 1,338,341

2.4 Discussion of the Saudi Economy (27;29)

The Kingdom's development plans have considered every aspect of the

economy, identifying its infrastructural, agricultural, industrial and commercial

needs and formulating strategies, all compatible with each other, to achieve

clearly defined national goals. The Saudi economy is an oil-based one, with

strong government controls over major economic activities. Saudi Arabia has the

largest reserves of petroleum in the world (more than 20.0% of proven reserves),

ranks as the largest exporter of petroleum, and plays a leading role in the

23

Organization of Petroleum Exporting Countries (OPEC). The petroleum sector

accounts for roughly 75.0% of budget revenues, 45.0% of gross domestic product

(GDP), and 90.0% of export earnings. According to CIA World Fact Book, 2007

estimates (29), the Saudi Arabian gross domestic product (GDP) values are:

- GDP - purchasing power parity: $564.6 billion

- GDP - real growth rate: 4.1%

- GDP - per capita purchasing power parity: $23,200

Oil revenues have made the government the driving force behind the economy

and, out of those oil revenues, the government has provided the essential

infrastructure without which the economy could not mature. At the same time,

Saudi Arabia operates a market economy in which free enterprise can flourish.

The economic policy of Saudi Arabia is based on the pillars of comprehensive

social welfare. It embraces the concept of a free economy and a free market for

capital, goods, services and products in order to secure the following goals:

• The welfare of society.

• Provision of jobs and optimum use of manpower.

• Control of public debt within secure and reasonable limits.

• Fair distribution of national income and opportunities for investment and

labor.

• Diversification of the economic base and an increase in the sources of

public revenues.

• Development of savings and development of saving channels and

frameworks for safe investment.

• Increase the income of the state thereby linking it with the movement and

growth of the national economy.

• Increase investment of domestic capital and savings in the national

economy.

• Increase the contribution of the private sector, expansion of its contribution

to the national economy and contribution to the government's program for

privatization.

24

• Enhance the ability of the national economy to cope efficiently with

international economic changes.

A key element in the Saudi Arabian government's economic strategy is industrial

diversification, a process which has as its primary objective the reduction of the

country's dependence on oil revenues by encouraging private sector growth. To

this end, the government has encouraged the development of a wide range of

manufacturing industries. Furthermore, in 1999, the government announced

plans to begin privatization of some of the governmental bodies such as the

Saudi electricity company and the Saudi telecommunications company. Indeed,

as those privatization processes took place, private sector growth had been

encouraged with the aim of increasing employment opportunities for the swelling

Saudi population. Although the Saudi economy largely depends upon foreign

labor, efforts are being made to lessen this dependence. The bulk of expatriate

workers are coming from Egypt, Pakistan, India and the Philippines.

As a marker for the expansion of the Saudi economy, the Saudi Arabian stock

market has grown over the last ten years and is now the largest in the Arab

world, with a capital of $58 billions. The number of joint stock companies which

trade shares has increased steadily. There are about 70 firms listed on the stock

market. The market is supervised by the Saudi Arabian Monetary Agency

(SAMA) which, in 1997, approved the participation of international investors in the

Saudi stock market through mutual funds. With the expansion of the kingdom's

economy and the need to consolidate the commercial base, the network of

Chambers of Commerce has played an increasingly active role in the

development of the country’s commercial activity.

2.5 The Saudi Culture

The overwhelming majority of Saudi citizens are Arabs, descended from the

indigenous tribes and until today maintaining tribal affiliation (27). There are a few

other ethnic groups among the Saudi population, including Afro and Asian

ethnicities.

25

Saudi society is a totally Islamic one with Islam being the official religion of the

country and the official language is Arabic. No churches, synagogues, temples or

shrines of other religions exist and no proselytizing by other faiths is allowed. The

public practice of any religion other than Islam is not allowed either. Saudi Arabia

embraces the two holy Islamic cities of Makkah and Madinah. Makkah city is the

birthplace of Islam and the Prophet Mohammed (peace be upon him) in which the

Holy Mosque is located, towards which all Muslims direct their prayers. The city

attracts millions of Muslims throughout the year, especially during the Islamic

months of Ramadan and Hajj (the month during which Muslims perform their

annual pilgrimage). Madinah city is the second holy city in Saudi Arabia where

the Prophet's Mosque and his burial place are located.

As Islamic guidance strengthens the values of intimate family relations, the family

is considered to be the kernel of the Saudi society. The society continues to

aspire towards strengthening family ties, maintaining its Arabic and Islamic

values, and caring for all of its members. Thus, hardly ever do you find elderly

people living in elder care homes because the majority of them reside with their

sons and daughters. In addition, sexes are strictly segregated in public (e.g.

schools, universities and some other public settings). The rules of Saudi Arabia

also do not allow women to drive cars; however, the government is now

considering modification of these rules. Saudi society thus depends largely on

private drivers and taxis for transportation within cities, and public transportation

is not that common.

During leisure times, people usually enjoy indoor or outdoor family or friends’

gatherings, shopping and other physical activities, mainly soccer. In those

gatherings, especially in the last ten years or so, smoking has become common

among young, as well as old, adults of both sexes. Most of the outdoor gathering

places, such as cafes and restaurants, provide different forms of smoking in

addition to cigarettes (e.g. Shisha and Mo’assel), where tobacco is burned by

charcoal and inhaled through a rubber-like tube and a water filter. Also some

people in the south west part of the country are still using smokeless tobacco in

addition to other forms of smoking.

26

2.6 Description of the Health Care Delivery System in Saudi Arabia

Few attempts have been made to describe the Saudi Arabian health care delivery

system (30) and even fewer made to describe the dental component of the

system. Al Shammery and Guile did attempt to describe the dental care delivery

system in Saudi Arabia in 1986 and 1987 (31;32). At that time dental care was

just developing in Saudi Arabia but it has changed dramatically since that time.

In my attempt to describe the Saudi Arabian health care delivery system,

including dental care, I have relied on two main sources. The first was the review

by Al Yousef et al (30) and the second was based on information and

documentation gathered during the initial data collection phase (see section 4.0)

from interviews with chief dental officers and officials at the Ministry of Health, the

National Guard, the Armed Forces, the Interior Security Forces, University

hospitals and the Ministry of Education.

There are two main forms of health care delivery systems in Saudi Arabia: the

government and the private sector. The government sector is composed of the

Ministry of Health, as the major health provider, plus other independent

government bodies that serve certain populations. The major independent

government bodies are:

- The National Guard

- The Armed Forces

- The Interior Security Forces

- The Ministry of Higher Education (University Hospitals)

- The Ministry of Education

- The Saudi Intelligence Agency

The government sector is totally owned, delivered and financed by the

government. All health services that are provided by the government sector are

free at the point of delivery. Health care personnel are reimbursed by monthly

salaries while the facilities are funded by annual budgets. There are several types

of working personnel: physicians, dentists, medical and dental auxiliaries (nurses,

27

dental assistants and dental hygienists), pharmacists, allied medical and dental

personnel, technical personnel, administrative personnel and workers. The types

and numbers of dental care providers are presented in Table 1 (33).

The Ministry of Health and most independent government bodies have a

decentralized health care delivery system. Each regional health authority is

responsible for strategic planning, formulating specific health policies and

supervising health service delivery programs. The three levels of care (primary,

secondary and tertiary) are integrated vertically into the system both for the

Ministry of Health and for some independent government bodies. Both the

Ministry of Health and independent government bodies have accountability for

planning, training, human health resources, achieving health outcomes, financing

and coverage.

The target population and the degree of provision of comprehensive health

services differ among the different government bodies and the distribution is

illustrated in Table 2.

Conversely, the private health care system is composed of private for profit

hospitals, polyclinics, and physician and dentist offices. The private sector is

owned, delivered and financed privately, either by personal ownership, in most

cases, or by companies that provide health services for their employees. Those

owners hire and/or contract full- or part-time health care providers depending on

practice needs. Private practices are independent of each other and are self-

governed. The private sector is supervised by the Ministry of Health which is

involved in licensing and health policies that guide clinical practices in this sector.

Patients pay for all health services that are provided by this sector either out of

pocket or by private insurance. Health care personnel are reimbursed by various

methods including: monthly salary, fee-for-service, capitation or a mixture of the

previous methods. The facilities and clinics are funded by budgets or fee-for-

service by the owners. The types of health care personnel working in the private

sector are similar to those in the government sector. However, their numbers

differ among different private practices.

28

The private sector has three levels of care, (primary, secondary and tertiary), but

they are not integrated vertically. The degree of comprehensiveness of health

services differs among different private practices according to the size of the

practice.

The utilization rate of health services as projected by visits to health care centers

and Ministry of Health hospitals was estimated at 66.8%, of which 14.3% were

dental visits (33). The rest of the visits were made to other government sectors

(15.1%) and the private sector (18.1%).

2.7 Oral Health Status and Oral Health Resources in Saudi Arabia; Review

of Previous Research

Several previous studies have been conducted in Saudi Arabia to determine the

prevalence of different oral conditions. Those studies took place nationwide as

well as regionally. Additionally, some of the studies were comprehensive (i.e.,

measuring two or more oral conditions) while others were not.

I- Prevalence Studies - Nationwide:

Two nationwide prevalence studies have been conducted but neither was

comprehensive either in the conditions measured or the target age groups. The

first compared the dental caries experience of urban and rural children aged 12

and 13 years in ten administrative regions (34). The prevalence of caries was

74.0% among urban residents and 67.0% among rural residents. No statistically

significant differences were found between urban and rural children in caries

severity (mean DMFT= 2.6 in urban areas and mean DMFT= 2.6 in rural areas).

Although the study was published in 1999, it was actually conducted in 1994.

The second study set out to determine the prevalence of dental fluorosis among

people aged 6 to 74 in ten administrative regions (35). Dental fluorosis varied

from a low of 7.7% among 6 to 7 year-olds to a high of 37.5% among the 20 to 29

year-olds. A significant difference was found between rural and urban residents

(p < 0.01). The researchers concluded that 24.6% of the Saudi population has

some form of fluorosis (from questionable to severe fluorosis), but the prevalence

29

of severe fluorosis was not a great country-wide problem. Although the study

provided good data about dental fluorosis, the sampling frame for the age-group

15 to 74 was not mentioned.

II- Prevalence Studies - Regionally:

Regional prevalence studies included a mix of comprehensive and non-

comprehensive ones that took place in some but not all administrative regions.

While comprehensive studies measured two or more oral conditions, the non-

comprehensive studies measured a single oral condition such as dental caries,

periodontal conditions, oral mucosal lesions, temporomandibular joint disorders

or malocclusion.

a) Riyadh Region:

Comprehensive Studies

The second study assessed dental caries, oral hygiene, dental fluorosis and the

oral health knowledge of 22 to 52 year-old primary school male teachers of

Riyadh city (37). High caries severity scores were observed among the study

population (mean DMFT= 14.5 ± 5.6). Fair and poor oral hygiene was seen in

50.2% and 15.8% of the sample respectively. Dental fluorosis affected the whole

:

Three comprehensive studies have been carried out in Riyadh region. The first

was an oral health survey of 5 to15 year-old children of National Guard

employees in Riyadh city (36). The study assessed the following oral conditions:

oral hygiene, gingival health, dental fluorosis and dental caries. Oral hygiene

scores indicated that most of the examined tooth surfaces had detectable plaque

(mean DI-S= 1.7). Gingivitis was present in all of the children with moderate to

severe levels in 14.0% of the sample (mean GI= 1.2). Mild fluorosis was

observed in 14.0% of the children. There was a high prevalence of dental caries

of 99.3% (mean dmft= 3.8±3.2 and mean DMFT= 2.0±1.9). The study provided

comprehensive information but it was confined to a specific population in a limited

age-group and no rural areas were included.

30

sample with varying levels of severity; however, no severe levels of fluorosis

were found (normal: 24.6%; questionable: 15.2%; very mild: 15.7%; mild: 21.5%;

moderate: 6.4%). Study results found that 65.0% of teachers reported having no

knowledge of tooth decay, while 54.2% of them reported having no knowledge of

gum diseases. Although the study was comprehensive in the conditions it

measured, it did not include females or cover rural areas.

The third more comprehensive study assessed caries prevalence and oral

hygiene status of special needs female schoolchildren (blind, deaf and mentally

retarded) aged 6 to 7 and 11 to 12 in Riyadh city (38). Caries prevalence and

severity was high in all the special groups ranging from 88.2% to 100% (mean

dmft from 6.5 to 7.3 and mean DMFT from 3.8 to 8.0). The number of children

with poor oral hygiene was also high among the whole sample (46.3%). The

study provided data for a very limited population and did not cover males.

Non-comprehensive Studies:

Dental Caries

In the 1990s, Al Mohammed et al. found that dental caries prevalence was high

for ages 2, 4 and 6 year-old in Riyadh city (41). Fifty-five percent (55.0%) of 4

year-olds were affected with a mean dmft= 3.0, while among the 6 year-old age-

group it was 89% (mean dmft= 5.0). In Al Kharj town, caries prevalence among 5

year-old children reached 96.5% with mean dmft of 7.1±5.6 (42). Caries severity

among schoolchildren aged 6, 9 and 12 year-old was assessed (43). The mean

dmft ranged from 4.1 to 3.4 for the 6 year-old group, 2.9 to 3.5 for the 9 year-old

group while the mean DMFT for the 12 year-old group was 1.6. The prevalence

:

Several studies have assessed dental caries prevalence in Riyadh region. During

the eighties, the dental caries was measured for 13, 14 and 15 year-old

schoolchildren in Riyadh city and the mean DMFT was 2.9±2.6 (39). An older

age-group of 20 to 60+ year-old was examined and the mean DMFT was 9.7±6.7

(40).

31

of dental caries among 12 to 13 year-old schoolchildren in Riyadh city was 83.7%

with mean DMFT of 3.0 (44).

More recently, the prevalence of dental caries of 5 year-old preschool children

was 27.3% with a mean dmft of 8.6±3.4 (45). Caries prevalence was assessed

and compared among 6 to 7 year-old females attending public and armed forces

schools in Riyadh city (46). The prevalence was found to be 92.9% with a mean

dmft of 6.0±3.7 for public schoolchildren and 97.0% with a mean dmft of 8.1±4.1

for armed forces schoolchildren. The same age-group (6 to 7) in another study

was assessed among schoolchildren in Riyadh city and its suburb (47). Dental

caries prevalence was 94.4% with mean dmft of 7.3±4.0.

Two studies were conducted in the regions of Riyadh and Qasim to assess dental

caries prevalence (48;49). The first study measured the prevalence among 6 to 7

and 12 to 13 year-old schoolchildren in both regions. Caries prevalence among

the 6 to 7 year-old group was 91.2% in both regions with a mean dmft of 6.5±4.3

and 6.3±3.8 for Riyadh and Qasim regions respectively. On the other hand, the

12 to 13 year-old group had a prevalence of 92.3% (mean DMFT= 5.0±3.6) and

87.9% (mean DMFT= 4.5±3.5) for Riyadh and Qasim regions respectively. The

second study assessed caries prevalence among 15 to 19 year-old

schoolchildren in the same regions. The prevalence was 91.1% (mean DMFT=

7.3±4.9) and 90.5% (mean DMFT= 7.0±4.5) for Riyadh and Qasim regions

respectively.

Periodontal Conditions

Few studies have been conducted to assess the periodontal conditions in Riyadh

region. These studies took place in the 1980s and the early nineties. The first

study measured the prevalence of periodontal disease among 13, 14 and15 year-

old schoolchildren in Riyadh city (50). It was found that 94.0% of the sample

needed treatment. The mean scores for debris, calculus, intense gingivitis and

advanced periodontal involvement were 1.1±1.2, 1.0±1.1, 2.6±1.7 and

0.007±0.087 respectively. The second study assessed the prevalence and

severity of periodontal disease in schoolchildren aged 6, 9 and 12 in Riyadh city

:

32

(51). The study found that 40.0% of the 6 year-old group had bleeding gums,

48.7% of the 9 year-old group had bleeding gums while 7.8% of them had

calculus, and 52.0% of the 12 year-old group had bleeding gums while 16.0% of

them had calculus. The third study measured the periodontal status of adults

between the ages of 15 to 64 in Riyadh city (52). The prevalence of periodontal

disease was 67.9% in the age-group 15 to 19 and 95.4% in the age group 35 to

44.

These periodontal disease prevalence studies are few in number, relatively out of

date and did not cover rural areas. Moreover, some of them targeted the young in

which these kinds of conditions are not usually prevalent.

Oral Mucosal Lesions:

A single study assessed the prevalence of oral cancer and precancerous lesions

among dental patients in King Saud University in Riyadh city (53). The

prevalence of leukoplakia was 1.9%, leukoedema 8.3%, nicotinic stomatitis 2.5%,

lichen planus 0.6% and one case of oral cancer.

Temporomandibular Joint Disorders (TMDs)

:

The prevalence of the signs and symptoms of TMDs was assessed among male

dental students in the age range of 20 to 29 in Riyadh city (54). Two thirds of the

sample had no signs or symptoms of TMDs. Another study measured the

prevalence of TMDs among 8, 14 and 18 year-old females seeking orthodontic

treatment in King Saud dental school in Riyadh city (55). It was found that the

prevalence of signs and symptoms of TMDs was 41.0% and 30.0% respectively.

A third study assessed the prevalence of TMDs’ signs and symptoms among

Saudi military students aged 18 to 25 in Riyadh city and found that 75.0% of them

had TMD signs and/or symptoms (56).

The previous studies were conducted on specific populations (dental students

and patients) and did not involve a representative community-wide population.

33

Malocclusion:

The only prevalence study on malocclusion in Riyadh region was conducted

among 14 year-old male schoolchildren (57). It was found that 62.4% of the

children had one or more malocclusion features related to dentition, occlusion or

space.

b) Makkah Region:

Non-comprehensive Studies:

Dental Caries

In 1990, dental caries prevalence of 6, 12 and 15 year-old private and

government schoolchildren was assessed in Makkah city, Jeddah city and

Rabagh town (62). Both of the means of dmft and DMFT were higher in

government than in private schoolchildren in the three locations visited. The

mean dmft for six year-olds in Makkah, Jeddah and Rabagh was: 2.7 (private),

2.8 (government); 2.9 (private), 6.3 (government) and 1.5 (private), 2.8

(government) respectively. The mean DMFT for the 12 and 15 year-olds showed

similar trends between government and private schoolchildren with values

ranging from low as 1.5 to high as 6.3. Jeddah city showed the highest mean

values.

:

The prevalence of dental caries in preschool children in Jeddah city was

assessed in three studies. The first study (1996) measured the prevalence of

nursing bottle syndrome among ages 3 to 6 and found it to be 20.0% (58). The

second study (2000) assessed the prevalence of caries among 2 to 6 year-old

children living in a social welfare institute in Jeddah city; it was 30.0% (59). The

third study (2003) found that caries prevalence of preschool children, aged 2 to 5,

was 73.0% with a mean dmft of 4.8±4.8 (60).

In 1996, caries prevalence of schoolchildren aged 6 to 9 in Jeddah city was

73.9% with a mean dmft of 4.2 and mean a DMFT of 1.8 (61).

34

The previous studies have provided measures of the prevalence of dental caries

among preschool children but the prevalence of caries in the older population as

well as in those who live in rural areas remains understudied. Moreover, these

studies were conducted in the early to mid nineties, except for the preschool

children group.

Periodontal Conditions:

The prevalence of localized juvenile periodontitis was assessed in the age-group

17 to 23 in Makkah city from patients’ files. The prevalence was 0.4% (63).

Temporomandibular Joint Disorders (TMDs):

TMDs prevalence of 3 to 7 year-old schoolchildren in Jeddah city was studied

and found to be 16.5% (64).

Two studies were conducted in two cities in the Eastern region to determine the

prevalence of dental caries among schoolchildren. The first study took place in Al

Khobar city and found a prevalence of 87.5% among schoolchildren aged from 7

to17 (66). The second study took place in Al Ahsa city and the prevalence among

6 to 7 year-old schoolchildren was 82.9% with a mean dmft of 4.4±3.7 (67).

Malocclusion:

The prevalence of crowding, attrition, and midline discrepancies was measured in

the primary dentition of 4 to 6 year-old children in Jeddah city (65). Crowding was

found in 14.7% of the children, 10.0% of the children presented with midline

discrepancies and 33.3% of them showed dental attrition.

The prevalence of periodontal conditions, TMDs and malocclusion was clearly

under studied and was not targeted at the age-groups where those conditions

were most likely to be found.

c) Eastern Region:

35

d) Madinah Region:

The prevalence of dental caries of 6 and 12 year-old schoolchildren in Madinah

city was 87.0% (mean dmft= 6.4) and 83.0% (mean DMFT= 2.9) respectively

(68).

e) Qasim Region:

Dental fluorosis prevalence in urban and rural areas of Qasim region was

assessed among male subjects aged 12, 15, 35-44 and over 65. It was found that

fluorosis was more prevalent in rural than urban populations (69). Of the whole

sample, 24.0% to 67.0% had fluorosis, with 12.5% of the cases in the moderate

to severe levels of fluorosis.

f) Hail Region:

In 1993, the prevalence of dental fluorosis among 12 to 15 year-old rural

schoolchildren in Hail region was over 90.0% with 24.0% of the cases in the

severe level (70).

g) Tabouk Region:

Caries severity in 7 and 11 year-old schoolchildren at King Abdulaziz military city

in Tabouk city showed a mean dmft of 7.7 in the 7 year-old group and a mean

DMFT of 2.9 in the 11 year-old group (71). In a second study, the prevalence of

dental caries was assessed among 1 to 5 year-old children attending the Well

Baby Clinic at the Armed Forces hospital in Tabouk city and found to be 26.5%

(72).

h) Jizan Region:

Dental caries was measured in preschool children attending the pediatric clinic at

Jizan hospital in Jizan city and showed a mean dmft of 1.2 (73). Another study

assessed the dental caries in primary dentition and oral hygiene status among

36

schoolchildren aged 6 to 8 in urban and rural areas of Jizan region (74). It was

found that males had worse oral hygiene than women and the mean dft in rural

subjects was 3.1 compared to 4.6 in urban subjects.

The prevalence of lichen planus was assessed in patients aged 18 to 73

attending the dental department at King Fahd central hospital in Jizan city

between 1982 and 1987 and was found to be 1.7% (75). Another study was

conducted by the same researcher to determine the prevalence of recurrent

aphthous ulceration among patients attending the same hospital between 1984

and 1989 (76). The prevalence was found to be 1.5%.

Review of Findings

• There is a lack of recent comprehensive nation-wide data on the prevalence of

oral health conditions among all age groups in Saudi Arabia.

:

After critically appraising and summarizing the results of the previous literature of

Saudi Arabia, I found the following shortcomings:

• Most of the non-comprehensive studies that assessed different oral conditions,

were limited to younger age groups therefore yielding very poor information

about the distribution of oral conditions in the adult population.

• The lack of both comprehensive measures and wide age distribution was also

evident regionally.

• There are no data about oral health care resources that would improve oral

health outcomes.

• There is little recent information on dental educational programs and

institutions. The studies that addressed this topic are old, and major changes

have occurred since then (31;32;77-80).

37

• There are a few studies on dental treatment needs (81-86). These studies

lacked comprehensiveness, were limited to certain age groups and, in some

situations, limited to one gender.

• There is a lack of studies that estimate the gap between oral health supply and

treatment needs in Saudi Arabia.

• There is little or no information on the utilization of dental services and the

factors affecting it.

• There is a lack of information on the total service output and busyness of

dentists and the most frequent pattern of dental care delivered by dental

practices in both government and private clinics.

Research Questions:

This all leads to the main theme of the study. Based on the best available data, is

there a difference between oral health care supply and estimated treatment

needs of the population in Jeddah city and its suburb (Bahrah) in Saudi Arabia? If

yes, is it a surplus or a deficit and how could this potential difference be re-

estimated in the future, given the changing nature of the supply and

requirements? In light of these estimates, what recommendations can be made to

change or sustain the total number of dentists or mix of dental care providers

required to meet the dental treatment needs in Jeddah and Bahrah?

The Research Hypothesis

Based on the best available data, there is no potential difference between oral

health care supply and estimated treatment needs in Jeddah and Bahrah and,

further, there is no need to change the total number of dentists or mix of dental

:

The Null Hypothesis:

38

care providers required to meet the dental treatment needs of the target

population.

The Alternative Hypothesis:

Based on the best available data, there is a potential difference between oral

health care supply and estimated treatment needs in Jeddah and Bahrah.

Therefore, there is a clear need to change the total number of dentists or mix of

dental care providers required to meet the dental treatment needs of the target

population.

39

3.0 Aim and Objectives

40

Aim:

The study sets out to assess the potential capacity of the oral health care

resources, as compared to the treatment needs and actual utilization of dental

services, for Saudi citizens in Jeddah city and its suburb (Bahrah) in Saudi

Arabia. The study findings will examine the relationship between oral health

supply and treatment needs, based on the best available data, in order to help

improve the oral health status and services in Jeddah and Bahrah.

General Objectives

I. To conduct an inventory of government oral health care resources in Jeddah

and Bahrah with respect to both human and non-human resources.

:

II. To assess the oral health status and treatment needs for Saudi citizens in

Jeddah and Bahrah following the WHO criteria for oral health surveys.

III. To explore the potential differences between oral health supply and treatment

needs based on the best available data. And to give recommendations to

either change or sustain the total number of dentists or mix of dental care

providers required to meet the dental treatment needs in Jeddah and Bahrah

by projecting different models to treat the prevalence and the incidence of oral

diseases.

Specific Objectives

1) the distribution and numbers of different categories of oral health care

providers among different government institutions.

:

I. To conduct an inventory of government oral health care resources in Jeddah

and Bahrah with respect to both human and non-human resources. The

objectives are to determine:

41

2) the distribution of age, gender, nationality and specialty among those

providers.

3) the number of dental operatories (chairs) belonging to government

institutions.

4) the extent of the busyness of the government’s dental practices and the

most frequent pattern of care provided in these practices.

II. To assess the oral health status and treatment needs for Saudi citizens in

Jeddah and Bahrah following the (WHO) criteria for oral health surveys (87).

The objectives are to:

1) Assess the prevalence and distribution of the following oral conditions: oral

mucosa status, enamel opacities / hypoplasias, dental fluorosis, cleft lip

and / or cleft palate, dentition status, periodontal status, and prosthetic

status.

2) Identify oral health treatment needs in terms of procedures and hours of

care needed.

3) Assess the utilization of dental services; (number of dental visits in the last

year, time since last visit and type of service received).

III. To explore the potential differences between oral health supply and treatment

needs based on the best available data. And to give recommendations to

either change or sustain the total number of dentists or mix of dental care

providers required to meet the dental treatment needs in Jeddah and Bahrah

by projecting different models to treat the prevalence and the incidence of oral

diseases. The objectives are to estimate:

1) The total working hours of oral health care providers that can be estimated

by calculating dentists’ total service output. The total service output is

determined by the participation rate, which is the measurement of the

actual number of licensed dental care providers who are actually providing

patient care, the activity rate, which is the amount of daily work time spent

on providing patient care; and the productivity level, which is the amount of

work produced per unit of time.

42

2) The total number of hours needed to achieve all treatment needs at the

current level of utilization and compare them with the total working hours

of oral health care providers.

3) The optimal numbers and mix of health human resources to deal with the

prevalence and the incidence of oral diseases in Jeddah and Bahrah.

43

4.0 The Initial Data Collection Phase (July / August 2005)

44

At this point in the project, certain information was needed to examine the

feasibility of meeting the aim and objectives of the project. That information was

designed to help explore options that could or could not be utilized during the

second phase of data collection, when the actual survey was to take place. All of

this was needed in order to properly plan for the commencement of the project.

As a result the initial data collection phase was carried out to:

1. Collect data on the description of the health care delivery system, oral health

care resources and dental educational institutes and programs

2. Explore with key informants the feasibility of the proposed plans to carry out:

I- A survey of oral health status, treatment needs and utilization of dental

services.

II- A census on the total service output and busyness of government dentists.

The choice to include only government dentists in the census was based on the

fact that the Ministry of Health is considered the major health provider. On the

other hand private dentists were excluded from the census due to lack of time

and resources to collect their data. Also the existence of an overlap between

government and private dentists who occasionally work for both sectors requires

extra time and effort to sort them out and to avoid double counting of dentists.

After the tentative plan for the initial data collection phase had been prepared, a

copy of the proposal outline was sent to the ethical review unit to obtain an

expedited review and approval. After ethics approval was received (Appendix A),

a supporting letter was requested from the associate Dean for

Graduate/Postgraduate Studies at the Faculty of Dentistry, University of Toronto,

to facilitate data collection during the trip (Appendix B).

Methodology

In order to facilitate data gathering and scheduling of interviews, a formal

supporting letter in Arabic was requested from the dean of the Faculty of

45

Dentistry at King Abdulaziz University in Jeddah (Appendix C). The letter was

issued with reference to the supporting letter obtained earlier from the University

of Toronto. Several copies of the supporting letter were prepared to present to

any institution to be visited or contacted.

1. Collecting data describing health care delivery system, oral health care

resources and dental educational institutes and programs:

Since most of the government head offices were based in Riyadh city (the

capital), a trip there was made to visit government institutions. Two lists of the

institutions to be visited or contacted were prepared. The first list included

government institutions that would be able to provide information about health

care delivery system and oral health care resources.

The first list

• The Ministry of Health

:

The dental departments at:

• The National Guard Health Affairs

• The Directorate General for Armed Forces Medical Services

• The Directorate for Interior Security Forces Medical Services

• The Directorate General for School Health at the Ministry of Education

(males and females sections)

The second list was prepared according to the information provided by the

Ministry of Higher Education and the Saudi Counsel for Health Specialties

(SCHS). The list included government and private institutions that provide dental

educational programs.

The second list

• King Saud University – Faculty of Dentistry (Riyadh)

:

Government Institutions:

• King Abdulaziz University – Faculty of Dentistry (Jeddah)

46

• King Faisal University – Faculty of Dentistry (Dammam)

• King Khaled University – Faculty of Dentistry (Abha)

• Taibah University – Faculty of Dentistry (Madinah)

• The Directorate General for Health Colleges and Secondary Health

Institutes at the Ministry of Health (Riyadh)

• The Saudi Counsel for Health Specialties (Riyadh)

Private Institutions:

• The Private College of Dentistry and Pharmacy (Riyadh)

• The Institute of Health Sciences (Riyadh)

• The Specialist Academy for Medical Training (Riyadh, Jeddah, Madinah

and Buraidah)

• Ibn Sina National College of Medical Sciences (Jeddah)

• Ohod Technical Institute for dentistry (Madinah)

• Al Bakkari Academy (Madinah)

• The International Academy for Health Sciences (Buraidah and Najran)

Each institution was visited or contacted (by telephone or fax) either once or

twice. In the first visit or contact, key informants (institution managers or chief

dental officers or Deans of faculties or Heads of dental educational programs)

were provided with a copy of the formal supporting letter and were also given a

brief description of the aim of the study. Depending on whether key informants

were free to be interviewed and the availability of data at the first visit, they were

either interviewed in the same visit to provide the data required in the forms A, B.1 and B.2 (Appendix D) or they were given the forms and asked to fill them out.

A second visit then was then scheduled to collect those data. The forms were

targeted to the first and second lists as follows:

- Form A was targeted to key informants in the first list.

- Form B1 was targeted to key informants in the second list.

- Form B2 was targeted to key informants in the second list, specifically to

the Saudi Counsel for Health Specialties.

47

Unfortunately, no one could provide detailed national data about the oral health

care resources at the head offices in Riyadh. The detailed data were available at

the regional health units meaning that a visit to each regional health unit was the

only way to obtain them. The search was therefore restricted to Jeddah city and a

third list was prepared to collect the data about oral health care resources from

government institutions. The same strategy for data collection was used during

the visits with the use of form A only.

The third list

• The Ministry of Health - Health Affairs Directorate in Jeddah

:

The dental departments at:

• King Abdulaziz University – Faculty of Dentistry

• King Fahd Armed Forces Hospital

• King Abdulaziz Medical City (National Guard Hospital)

• Interior Security Forces Health Care Center

• King Faisal Specialty Hospital and Research Center

The information about the private oral health care resources in Jeddah was

obtained from the medical licensure administration at the Ministry of Health -

Health Affairs Directorate in Jeddah.

2. Exploring with key informants the feasibility of the proposed plans to carry out

I-

:

II-

A survey of oral health status, treatment needs and utilization of dental

services

A census on the total service output and busyness of government

dentists

Several meetings were scheduled with key informants in government health

institutions, the Ministry of Education, the Saudi Dental Society (SDS) and some

faculty members at the faculty of dentistry, King Abdulaziz University in Jeddah.

In these meetings, various options of carrying out the survey were discussed and

whenever possible verbal approval was obtained for them.

48

The option of sending a questionnaire about government dentists’ productivity

and busyness was discussed with the vice president of the Saudi Dental Society

(SDS), a group regarded as the representative body of dentists in Saudi Arabia.

Data about dental educational institutes, such as type of educational programs

offered, annual number of graduates and length of program, were obtained from

Meeting the Aims of the Initial Data Collection Phase

Data describing the health care delivery system in Saudi Arabia were based on

information and documentation gathered from interviews with chief dental officers

and officials at the Ministry of Health, the National Guard, the Armed Forces, the

Interior Security Forces, the University hospitals and the Ministry of Education.

After visiting the central offices at the Ministry of Health and the major

independent government bodies in Riyadh city, the country’s capital, I discovered

that detailed national data about oral health care resources were not available

centrally. Although the Ministry of Health’s annual statistical book (88) provided

information about oral health care resources, those resources were lacking some

details. For instance, the book provided the numbers of dentists in different cities

without specifying their specialties. Additionally the numbers of auxiliaries were

given collectively for both medical and dental auxiliaries and no data existed

about the numbers of different categories of dental auxiliaries. It was also not

possible to obtain detailed data about scholarship programs that are provided by

different government institutions.

Gathering detailed national data would have required collecting data from each

administrative region or city across the country, well beyond the resources

available for this study. As a consequence, the search was limited to Jeddah city.

Data were collected from the Regional offices of the Ministry of Health and the

major independent government bodies in Jeddah. The Ministry of Health also

provided data about the resources of the private sector through the medical

licensure administration at the Ministry of Health - Health Affairs Directorate in

Jeddah.

49

government and private educational institutions. These data were collected

successfully except at some educational institutions; at these, certain key

informants were on holiday and unavailable at the time when the data collection

took place. Those deficient data were collected later during the operational stage.

Informal primary verbal approval was obtained from key informants in

government health institutions and the Ministry of Education to conduct the

survey at their facilities as required. Supportive attitudes were noticed among

different government institutes towards the intended survey.

With regard to the feasibility of the productivity and busyness questionnaire

option, the vice president of the (SDS) expressed reservations about the

compliance of dentists in responding to mailed questionnaires by either regular or

electronic mailing methods. He recommended that the best way to achieve good

compliance would be by personal distribution of those questionnaires to all

government dentists in Jeddah.

50

5.0 Materials and Methods

51

This cross-sectional study dealt with several aspects that were dependent on one

another. Thus, it was conducted in an orderly sequence of three stages in the

following order:

I- A survey of oral health status, treatment needs and utilization of dental

services

Stage 1: Preparatory

1. Collecting data describing the health care delivery system, oral health care

resources and dental educational institutes and programs.

2. Exploring with key informants the feasibility of the proposed plans in carrying

out:

II- A census on the total service output and busyness of government

dentists

3. Obtaining ethical approval for the operational stage

Stage 2: Operational

1. Survey of oral health status, treatment needs and utilization of dental

services.

2. Census of the total service output and busyness of government dentists

Stage 3: Analytical

Data analysis and synthesis.

Each stage had its own methodology that was explained separately. Stages 1

and 2 provided the data that were then analyzed and synthesized in stage 3.

52

5.1 Stage 1: Preparatory

Steps 1 and 2 of this stage were accomplished during the initial data collection

phase. The methodology was described and illustrated in full in section 4.0, the

initial data collection phase.

After approval of the proposal by the PhD committee, the proposal was submitted

to the scientific committee of the Faculty of Dentistry at the University of Toronto

for approval. The proposal was then submitted to the research ethics units at

both the University of Toronto and to the Saudi institutions from which study

subjects were sampled, such as the Ministry of Health, the Ministry of Education

(male and female sections), King Abdulaziz University, and other private

educational institutes, in order to obtain final approval (Appendix A and C).

5.2 Stage 2: Operational

The aim of this stage was to conduct:

1. A survey of oral health status and treatment needs and utilization of dental

services.

2. A census of the total service output and busyness of government dentists

1. Survey of oral health status and treatment needs and utilization of dental

services

Study Design

Clinical examinations were to be performed by two examination teams, one male

and one female. However, this plan was changed for two reasons. The first was

:

A population-based cross sectional study design was utilized. The study

assessed oral health status, treatment needs and utilization of dental services in

Jeddah and Bahrah following the WHO criteria for oral health surveys (87). Data

were collected through clinical examinations that were supplemented by self-

administered questionnaires translated into Arabic.

53

administrative: the scholarship administration at King Abdulaziz University

required the completion of data collection in three months, i.e., reducing the data

collection time to half of what was planned. The second reason was the difficulty

in recruiting volunteers for the examination teams. To that end, the Faculty of

Dentistry at King Abdulaziz University graciously provided me with 35 dental

interns, who were supposed to spend some time of their rotations providing

community dental service, to help as examiners, recorders, and organizing clerks

for this study. About half of those 35 dental interns were scheduled to help in the

first month and a half after which the rest would help in the remaining time. This

assistance from the Faculty of Dentistry at King Abdulaziz University was

determined by using half of these interns to work on alternate days of the week

i.e. some interns were assigned to help on Saturdays, Mondays and

Wednesdays; the rest were to help on the remaining days (Sundays and

Tuesdays). This resulted in having a total of four examination teams, two males

and two females in the first month and a half, and four similar teams for the rest

of the data collection period. Each team consisted of: an examiner, a recording

clerk and one or more organizing clerks.

The survey assessed the prevalence, severity, and treatment needs of the

following oral conditions:

• Cleft lip and / or cleft palate

• Oral mucosal conditions

• Enamel opacities / hypoplasias

• Dental fluorosis

• Periodontal status and needs

• Prosthetic status and needs

• Dentition status and needs

For most of the basic oral diseases and conditions (periodontal, prosthetic and

dentition status), the WHO method of oral health surveys provided a useful way

of recording oral health conditions while, at the same time, assigning the

treatment needed to treat the identified oral condition. For example if a tooth has

been identified as having dental caries, the examiner will immediately assign a

54

code for a one or two surface filling to restore that decay as the needed

treatment. This assignment of treatment need is based on the extent of the decay

and the clinical judgment of the examiner. In turn these identified needs are then

translated into units of time required to meet these needs in the clinic. These time

units are based on the dental procedures time estimates as it will be discussed

later on. This unique feature of the WHO method, which allows the concurrent

assessment of conditions and appropriate treatment needs, plays an important

role in our study since our estimations are based on comparison of units of time

between the requirements and the supply sides. Other needs-based methods

lack this kind of detail and hence the WHO method was adopted.

Study Subjects and Locations

Dental epidemiologists in developed countries have used the workplace to

measure the population’s oral health status. For example, in the United States

the national survey of oral health in the U.S employed adults and seniors (89). So

for this work, in Jeddah city, the 25-29 and 35–44 year age-groups were sampled

using King Abdulaziz University employees. University employees provided a

sample over a range of socioeconomic status and equal gender representation.

However, when the survey started, some of the examination teams failed to make

:

The WHO manual for basic methods of oral health surveys (87) recommended

the inclusion of the following age groups: 5, 12, 15, 35-44 and 65-74. However,

because of time and resource limitations along with the difficulty of accessing the

5 and 65-74 year-old age groups, the survey included Saudi male and female

subjects of the following age groups: 6, 12, 16 and 35-44. Moreover, a minor

adjustment was made to include 25-29 year-olds. This adjustment was based on

the fact that the added age group constitutes a large proportion of the Saudi

population. This can be seen clearly by looking at the Saudi population pyramid,

which shows a classical distribution (Figure 4).

The survey took place within the confines of Jeddah and Bahrah. The 6, 12 and

16 year-olds were sampled from schoolchildren in all geographic locations within

Jeddah and Bahrah.

55

sure that the participants answered all questions in the self-administered

questionnaires. This has resulted in losing study participants; to make up for this

loss, other educational institutions and business companies were been contacted

so their employees could be included in the study sample.

In contrast, in Bahrah (Jeddah’s suburb), the same age-groups (25-29 and 35–

44) were to be sampled from the previously examined schoolchildren’s families

who agreed to be screened at the Ministry of Health clinic. Although the latter

suburban sample could be more representative than university employees, the

city life style and the parents’ poor attendance at school events, as reported by

school boards, would make a parents’ sample inappropriate. Unfortunately, this

plan was difficult to implement too and I ended by examining residents who were

attending at Bahrah’s Ministry of Health clinic for medical and dental reasons.

However, in an attempt to improve the attendance at the clinic and to have a

more representative sample, I met Bahrah’s governor and requested him to

kindly announce the study in Bahara’s Mosques and encourage Bahra’s

residents to be part of this study and to attend at the Ministry of Health clinic to be

examined.

Clinical examinations were held in assigned rooms within visited schools,

University sites, business companies, and Bahrah’s Ministry of Health clinic using

portable dental chairs equipped with a light source in order to standardize the

clinical examinations. Scheduling these visits required contacting officials at the

visited sites one week ahead of time to schedule the visit and to get driving

directions.

Sampling

In order to have valid survey results, the sampling method should yield a

representative sample. A multistage stratified cluster sampling method was used

to sample study subjects from schools in Jeddah and Bahrah and from university

employees in Jeddah. In the first stage of the sampling process, schools and

University Faculties and administrations were randomly sampled using the

random digit generator after assigning numbers to schools and University sites

:

56

(Faculties and administrations). In the second stage, classrooms within schools

and departments within University Faculties and administrations were numbered

and then randomly sampled from a bowl. In the final stage, 15 schoolchildren and

University and other educational and business companies’ employees were

randomly selected from these clusters using a list of their names. Whenever the

schoolchildren clusters were unequal in size -more than 15% size difference

among the sampled schools- the probability proportional to size approach (90)

was applied to avoid over- or under-sampling of unequal sized clusters. The

sample was stratified by the area of residence: (urban or suburban), age and

gender. For the adult population in Bahrah, a stratified systematic sampling was

used to randomly select subjects who attended the Ministry of health primary

health care center in Bahrah. Every other patient was selected after satisfying the

stratification by age and gender.

Sample Size

• 300 subjects divided equally between genders, 150 males and 150 females,

per each age-group in Jeddah city

:

For the 6,12 and 16 year-olds, sample size was calculated according to the

estimated prevalence of dental caries of 73.9% (61); the minimum sample size to

estimate the prevalence, with 95.0% confidence, within 5.0% (69.0% - 79.0%)

was calculated to be 297 subjects per each age-group. The prevalence of

periodontal conditions of 67.9% (52) was used to calculate the sample size for

the 24-29 and 35-44 year age-groups, and the minimum sample size was

calculated to be 335 subjects per age-group. However, given the number of

subgroup comparisons, the minimum expected cell size of 15-20 subjects per

subgroup and the differences in population sizes, the overall sample size was

increased to 400 subjects per each age-group distributed as follows:

• 100 subjects divided equally between genders, 50 males and 50 females, per

each age-group in Jeddah suburb.

Given that there are five age-groups, the target sample size of the study was

2000 subjects.

57

Survey Procedures

i) Pre-field trip procedures, including:

:

Commencement of clinical examinations; the methods that were used to measure

oral conditions were confined to those methods and indices recommended by the

WHO in their manual (87).

After the survey teams were assembled, the following procedures were

performed during the course of the survey. These procedures were grouped into

the following sequence:

• Addressing letters from the Dean of the Faculty of Dentistry at King

Abdulaziz University to the respective authorities in each selected site to

get their participation approval.

• Training and calibration that were achieved in four phases:

Phase 1: The Instructional Phase:

During this, examination teams were given a description of the

study, its aim, objectives and the methodology to be followed.

Then, clinical examination procedures and the indices were

introduced and a clinical examination manual was distributed

(Appendix E). Thereafter duties were assigned to each member in

these teams.

Phase 2: The Standardization (training) Phase:

The indices were introduced and explained in detail and examiners

performed clinical exercises to familiarize themselves with those

indices. This phase lasted for two days. Then an interval of a few

days followed to allow examiners time to assimilate knowledge of

the indices and practice the procedures.

58

Phase 3: The Calibration Phase:

During this phase, inter and intra examiner reproducibility were

tested for examination consistency. This process lasted for a

minimum of 2-3 days. Recalibration was to be performed after the

first week of the survey, half way through the survey and close to

the end of the survey. However, because the data collection period

was reduced to three months and the availability of two groups of

examination teams, only one recalibration session (half way

through the survey) was performed for each group of examination

teams. The first recalibration session took place in February and

the second session took place in March 2007.

Phase 4: The Pilot Study Phase:

At the end of the first calibration phase, a pilot study took place at

selected sites to examine and refine different survey instruments

as well as to experience clinical examinations in a real survey

environment.

These four phases were performed twice since there were two groups of

examination teams half of which were assigned to help in the first month and

a half; the rest of them took over after that time.

• Consent forms (Appendix F) were provided to school principals who

distributed them to schoolchildren. Consent forms were signed by parents

or guardians and were collected on the examination day. For older age-

groups in Jeddah and Bahrah, consents were obtained on site.

• Site visits were performed to identify where the examination will take place

and to pre set the examination field.

• Examination kits, supplies, consent forms, examination forms, and

questionnaires were prepared for the field trip

59

ii) Field trip procedures:

• Distribution and/or collection of consent forms

• Distribution and collection of questionnaires. For the 6 year-olds, the

questionnaires were filled in by their parents or guardians. Over-sampling

was used to ensure having the required number of participants whose

parents successfully answered all questions in the questionnaire.

• Performing clinical examinations

iii) Post-field trip procedures:

• Sterilization and packing of examination kits

• Preparation of examination kits, supplies, consent forms, examination

forms, and questionnaires for the following field trip

Instruments and Measures:

The WHO manual (87) was followed in recording oral health conditions using a

clinical examination form (Appendix G), and the following indices were utilized:

• The modified developmental defects of enamel index (DDE) to record

enamel opacities / hypoplasias

• Dean’s index to record dental fluorosis

• The community periodontal index for treatment needs (CPITN) and loss of

periodontal attachment measures were used to record periodontal status

• The decayed, missing and filled index for teeth and for teeth surfaces

(DMFT, for permanent dentition; dmft, for primary dentition) to record

dentition status

Clinical examinations were supplemented by self-administered questionnaires

(Appendices H1, H2 and H3). These questionnaires included questions on:

60

• The rate of utilization of dental services; number of dental visits in the last

year, time since last visit and type of service received

• The factors affecting the utilization of dental services (e.g. time off work, time

off school, transportation expenses and waiting time at dental offices)

• Oral health risk behaviors; (oral hygiene practices, dietary and smoking

habits)

• Socioeconomic status

• The degree of satisfaction with the dental services provided.

2. Census of the total service output and busyness of government dentists

The aim of this census was to check the total service output and busyness of

dental practices among all government dental clinics in Jeddah and Bahrah. In

order to complete this census, the data collection period was extended from three

to four months after getting approval from the scholarship administration at King

Abdulaziz University.

Study Subjects and Census Procedures

Those government dentists in Jeddah and Bahrah who consented to participate

were included in the census. First, consent forms (Appendix I) were personally

distributed, by the principal investigator to dentists at their dental practices. Those

who agreed to participate were handed self-administered questionnaires and

activity assessment forms. These were collected by the principal investigator

after one week. However, in some situations, more than one follow-up visit was

made in an attempt to improve the response rate.

Instruments and Measures:

Self-administered questionnaire (Appendix J) and an activity assessment form

(Appendix K) were utilized as measurement tools for this census.

The questionnaires included questions on:

61

• Demographics; (age, gender, nationality and location of practice; i.e. urban

or rural) and qualifications of the dentist

• Type of government practice (e.g. Ministry of Health, University clinics or

other government bodies)

• Number and type of auxiliaries utilized

• The most frequent pattern of care provided

• The average number of patients seen per day

• The number of working hours per day, days per week and months per year

• The busyness of the dental practice

The activity assessment forms included a full two working days of patients’ log

tables. Dentists were asked to record all dental procedures performed on each

patient and the time required to perform these dental procedures in minutes.

Counting started from the time the patient sat on the dental chair to the time

he/she moved from the chair.

The census measured the three determinants of total service output:

1. participation rate, which is the measurement of the actual number of

licensed dental care providers who are actually providing patient care

2. activity rate, which is the amount of daily work time spent on providing

patient care; and

3. productivity level, which is the amount of work produced per unit of time

Total service output = participation X activity X productivity

Ethical Issues:

a. Informed Consent:

Consent forms were distributed and collected for the survey and the census as

described earlier. All subjects had the right to refuse being involved in the survey

/ census at any point during the course of the study project.

62

b. Recruitment:

All institutions that provided participation approval were included in the sampling

frame. Subjects who provided signed consent forms for the survey and the

census participated in the study.

c. Risks and Benefits:

The survey components involved no risk or harm to participants. All examinations

were performed by trained dentists and involved recording information about

different oral conditions following the WHO criteria for oral health surveys. All

examiners used disposable non-latex gloves and masks per each subject

examination. Appropriate disinfectants were used to disinfect the portable dental

chairs and light handles. Plastic or foil wraps were used to cover the disinfected

surfaces that the examiner might touch during his/her examination. These wraps

were changed after each clinical examination. During the clinical examination,

sterilized dental mirrors, periodontal probes, dental explorers and disposable

tongue depressors, were used. All dental examination kits were sterilized and

packed after each field trip. During the field trip, used instruments were kept in a

separate container. All disposals were contained in plastic bags and disposed.

Participants did not receive any kind of dental treatment throughout the survey

period except for dental emergencies for which the participant was given an

appointment and treated at the Faculty of Dentistry, King Abdulaziz University by

members of the research team.

d. Confidentiality:

All survey procedures were supervised by the principal investigator whenever

possible. The investigator was in charge of the survey process including data

entry and analysis. The survey teams assisted the principal investigator during

clinical examinations and during the distribution and collection of questionnaires

and consent forms.

In order to facilitate the analysis process, number codes were assigned to study

subjects to indicate the group that they belonged to. No names, addresses or

contact information were included in any survey materials. Study subjects and/or

63

their parents or guardians were notified about the strict confidentiality. All study

materials were kept secured in a locked filing cabinet and secured computer files

in the office of the principal investigator at the Faculty of Dentistry, King Abdulaziz

University in Jeddah, Saudi Arabia. At the end of the data collection period, all

study materials were shipped by the principal investigator to his office at the

Faculty of Dentistry at the University of Toronto. Study materials were again

secured in the same previous manner. After data entry into the information

database for analysis, all paper files were destroyed.

e. Compensation:

Study subjects did not receive any compensation during or after the course of the

study. The only compensation that was given to study subjects was in the form of

emergency dental treatments.

f. Conflict of Interest:

The investigators at the University of Toronto and King Abdulaziz University in

Jeddah, Saudi Arabia have no relationship with the study subjects.

5.3 Stage 3: Analytical

Raw data were entered into Epi Data spread-sheets. This was followed by data

cleaning using appropriate strategies to deal with missing data, duplicate data,

out of range data and to check for internal inconsistencies. Records were then

imported to SPSS, statistical package for social sciences, version 15.0, for data

analysis.

The needs-based approach was used to estimate the potential difference

between dental resources supply and dental service requirements, based on the

best available data. This choice was based on the context of Saudi Arabia where

the government role is dominant and can impose and implement changes to the

health care system. The dental human resource supply and requirement

conceptual model was used (Figure 3).

64

First, on the supply side, descriptive statistics were performed and the distribution

and percentages of the following data were tabulated and depicted:

- different categories of oral health care providers among different

government institutions

- demographics and qualifications of those providers

- the number of dental operatories (chairs) belonging to government

institutions

- where the majority of chair-side time is spent (preventive, surgical, etc.) in

government dental practices

- the extent of the total service output and busyness of dentists’ practices in

government dental clinics; (e.g. mean number of patients seen, mean

number of patient visits, mean number of hours worked by providers and

the number of working hours per day, days per week and months per year)

Finally the total number of chairside hours worked annually by all dentists,

adjusted at the current level of total service output, was calculated to represent

the capacity of the supply side.

On the requirements side, a schematic representation of the interpretation of

survey data from field patient examinations to treatment needs to time

requirement estimates was illustrated in Table 3. The process starts with the

collection of survey data through patient examination, acknowledging the fact that

these epidemiologically collected data do differ from what can be detected in a

full clinical setting (91). Then these data were translated into treatment needs and

procedures following the WHO manual (87). These treatment needs were further

divided into simple and complex procedures. Simple procedures are those which

could be performed by a dental hygienist, while complex ones are those which

could only be performed by dentists. All treatment needs were then assigned time

estimates, in minutes, required to meet these procedures based on available

literature estimates (e.g. the Ontario Dental Association (ODA) fee guide) (92-

96). The lowest time estimates for examination and diagnosis, preventive,

periodontal, prosthetic, and surgical treatment needs were adopted as is from the

ODA fee guide. However, time estimates for restorative and endodontic needs

were calculated based on weighting the treatment times that were obtained from

65

the ODA fee guide and factoring in the number of teeth needing a particular filling

or endodontic treatment i.e. one or two surfaces filling. The weighting formula

was used to estimate treatment time for anteriors, premolars, and molars

separately and then these estimates were summed up to represent the weighted

time for a one or two surfaces filling or a root canal treatment. The weighting

formula is:

The weighted treatment need for restorative or endodontic services

=

The number of teeth (anteriors or premolars or molars) needing (x) surfaces

filling or root canal treatment

÷

Total number of teeth (anteriors, premolars and molars together) needing (x)

surfaces filling or root canal treatment

x

The time needed to perform the specified procedure for the ODA fee guide

Several treatment codes were used for each type of filling or root canal treatment

as shown in Table 4. The mean of the potential individual treatment needs time

estimate for each treatment need category needed in the target year was then

converted to units of hours and summed up to represent the mean of the

potential total treatment needs on an individual level.

The mean of the individual potential total treatment needs time needed to meet

all treatment needs was used to project the potential estimate of the requirements

side time for the population of Jeddah and Bahrah at the selected age groups.

This age-specific selection is based on the assumption that the disease levels at

those selected age-groups represent the amount of accumulated dental diseases

up to the selected point of age. For example, the disease level that is assessed

at age six represents the accumulated amount of expected dental diseases from

birth up to the age of six years and so on for the rest of the age groups until age

66

44. The time needed to meet population treatment needs was then compared to

the total supply time available by all dentists in Jeddah and Bahrah.

The selected age groups in this study represent 29.2% of the total population of

Jeddah and Bahrah (2,883,169). Although the age-specific approach will be used

in the projection of the dental workforce for the study population, it is essential to

accommodate meeting the oral health needs for the rest of the target population

at the remaining age groups as an essential element for projecting the dental

workforce. Projecting the needs of the remaining 70.8% will be explained in

section 6.3.

Incidence data are important in the process of estimating ongoing annual

treatment requirements as opposed to the needs accumulated over an unknown

period of time, i.e., the accumulated backlog of needs. The projection of health

human resources has to be based on the actual incidence of oral diseases, i.e.,

the ongoing annual disease. Basing the projection of health human resources

simply on the prevalence of diseases will inescapably result in a huge surplus of

health human resources on the supply side. Eventually, those over-projected

health human resources will have to deal with the incidence of the disease, which

is generally much lower than its prevalence. Thus, to avoid such over-projection,

our projection of the dental workforce to balance requirements and supply sides

will take into consideration projecting the best number and mix of health human

resources to deal with the annual ongoing diseases and conditions, while letting

the current prevalence of oral diseases fade by service demands over time.

However, annual incidence data can not be collected within the scope and

limitations of the cross-sectional design of this study. In an attempt to

accommodate this limitation, and given that we had the information on whether

the participant made regular visits, where we assumed the patients backlog of

needs had been treated, we felt that the ongoing annual requirements could be

more closely estimated by examining the needs of the participants reportedly

making ‘regular’ dental visits.

Although this approach seems to be logically sound, it still invites some degree of

uncertainty and inaccuracy as compared to the use of actual incidence studies’

67

data. However, given the study circumstances and limitations and the lack of

incidence data, this approach provides the best available estimate of the ongoing

annual requirements for dental services in Jeddah and Bahrah.

As seen in Table 3 the method should allow us to provide prevalence rates, mean

severity, mean numbers of conditions and services, and the detailed

requirements’ mean time estimates by person, category; (age, gender or area of

residence), and by type of treatment required; (simple or complex).

For the target year, the potential difference between dental resources supply and

dental service requirements was estimated according to the following formula:

The difference between dental resources supply and service requirements for 1 year

=

∑ hours required to meet the treatment needs of the target population per 1 year

– (minus)

∑ hours worked by all dental care providers per 1 year serving the target population

This potential difference will show either a shortage or a surplus of dental

resources supply needed to meet the treatment needs of the defined population

in a selected year. Then the total number of dentists or mix of dental care

providers required to meet the excess treatment need can be estimated by

dividing the total number of hours needed to meet all treatment needs by the total

number of hours worked by one full time dentist in that particular year.

A second set of findings can also be obtained by factoring in the caries

increments (teeth/ year) and the modal restorative service time in an attempt to

reduce the restorative needs for ages 12, 16, 24-29 and 35-44. Caries

increments can be calculated by dividing the difference of the mean DMFT of two

consecutive age groups by the age difference between those age groups. This

attempt to reduce the restorative needs time at ages 12 and older was made

based on the assumption that after meeting the restorative needs of the

68

population at age six, they would probably have fewer restorative needs when

they get older.

Different models will be presented in the results section. These models aim to

provide the Saudi government with different approaches to balance the

requirements and supply sides and at the same time minimizing the risk of over-

production of supply.

69

6.0 Results

70

Results are presented under the following headings:

I. Requirements

1) Perceived oral health status and behaviors

2) Epidemiologically assessed oral health status

3) Treatment needs and time estimates

II. Supply

1) Supply and practice characteristics

2) Supply time estimates

III. Matching requirements and supply

IV. Models to balance requirements and supply

6.1 Requirements

Results for the requirements side were collected through a population-based

cross sectional survey that was described in the methods section. To recap, the

survey data were collected through self-administered questionnaires (for the 6

year-olds, the questionnaires were filled in by their parents or guardians) and

clinical examinations for the participants in the selected age groups (6, 12, 16,

24-29, and 35-44) for whom the item-response rate was 100% (2000

participants). This response rate was achieved by over-sampling whenever a

participant withdrew at any point of time during the survey. One thousand and

five hundred of the 2000 participants were included to represent Jeddah

residents at the selected age groups up to the age of 44 who are estimated at

823,296. The rest of the sample (500) was included to represent Bahrah

residents at the selected age groups who are estimated at 18,210. The ratio of

Jeddah to Bahrah residents is estimated at 45:1 whereas in our study was 3:1. At

the level of the clusters sampling weights were not applied since the clusters

were almost equal in size -less than 15% size difference among the sampled

clusters and there was no risk of over- or under-sampling of unequal sized

clusters.

Although a home based survey like the one conducted in the United States for

The National Health and Nutrition Examination Survey (NHANES) is considered

ideal for collecting representative data on the adult population, sampling from

71

working adults population like the University employees in Jeddah is also

considered appropriate to utilize in Saudi Arabia. The criticism of sampling from

the working adult population as was done in the 1985-6 National Survey of Oral

Health in U.S Employed Adults and Seniors centered around the problem of

representativeness since the findings may be biased toward better health

outcomes since this population is covered by health insurance and have a better

socioeconomic status than the unemployed adults population. These drawbacks

of this kind of sample are less likely to apply to the Saudi population since all

Saudi citizens are covered by the national health care system with no effect of

the employment status. Moreover, unemployed adults are supported financially

by the Saudi government as well as families who traditionally continue to support

their unemployed family members until they get employed and thus reducing the

socioeconomic status difference between employed and unemployed adults.

Further, conducting a home based surveys are not so popular among the Saudi

culture and are surrounded by difficulties such that even the Ministry of Health did

not embark on such a sampling method to gather data for their yearly statistical

book and instead hospital based data were used.

The results of calibration sessions that were conducted before the survey and

midway through the survey indicated that the examiners were consistently

examining to the same standards. The kappa scores for inter and intra examiner

reproducibility were within the range of 0.7 and 0.9, i.e., substantial to almost

perfect agreement (97).

Results from the survey are presented for the total sample and by age, gender,

and place of residence as:

1) Perceived oral health status and behaviors

Table 5 presents participants’ perceptions of oral health ratings and their

satisfaction with their overall mouth health and teeth appearance. Of the 2000

participants, 76.8% rated their own oral health as being good to excellent and

76.3% and 70.3% were satisfied with their overall mouth health and teeth

appearance respectively. The impact of oral health problems showed that 74.9%

:

72

avoided eating certain types of food and drinks, 36.2% avoided speaking, and

22.8% avoided usual daily activities (Table 6).

When the participants were asked about their experiences with different oral

health problems during the past month, 56.5% reported gum bleeding with

brushing, 43.3% reported toothache, and 50.0% reported toothache with cold /

hot drinks and food. Other oral health problems were reported as shown in Table

7. Among the perceived oral health treatment needs, the need for teeth cleaning

was reported by 57.5%, while 33.9% reported the need for teeth filling, and

18.4% reported the need for pain relief. Table 8 has more details on other

perceived treatment needs; surprisingly the perceived need for teeth whitening

was 46.0%.

Oral health behaviors were reflected in questions about the frequency of teeth

brushing (Table 9) and some characteristics about dental visits. Regular dental

visitors, those who visit the dentist at least once a year, accounted for 25.5%;

52.6% reported visiting the dentist only for emergency care (Table 10). When the

participants were asked about their last dental visit, 57.5% reported that their last

dental visit was more than six months ago, and 47.2% reported visiting the

dentist because something was hurting or bothering them, while 67.2% were

satisfied about their last dental visit (Table 11). Table 12 shows that 22.1% of the

participants usually go to government dental clinics whereas 41.7% attended

private dental clinics and 17.0% reported going to both.

2) Epidemiologically assessed oral health status:

Prevalence rates of several oral diseases and conditions were obtained by

means of clinical examination using WHO criteria. Results of the clinical

examination are presented in Tables 13-22 for the total sample and by age,

gender, and place of residence as:

73

a) Cleft lip and palate (not shown in any table):

Of the 2000 participants, only two males were identified with unilateral cleft lip

and palate.

b) Oral mucosal conditions (Table 13):

Most (92.2%) of the participants had normal oral mucosa with the majority of

the conditions being ulceration and abscess. Residents of Bahrah had slightly

higher ulceration and abscess rates (2.8%) than Jeddah residents of whom

2.1% had ulceration and 1.8% had an abscess. There were no identified

cases of malignant tumors (oral cancer) or oral lichen planus among the study

participants.

c) Enamel opacities and hypoplasia(Table 14):

These conditions were reported only for permanent dentition. Of these, 18.6%

were normal, 57.5% had enamel opacity in one or more permanent teeth, and

8.4% had enamel hypoplasia with or without opacity in one or more

permanent teeth. The opacities included demarcated and diffused ones.

d) Dental fluorosis (Table 15):

50.5% of the sample had normal dentition with no signs of fluorosis. Dean’s

fluorosis index showed a range of fluorosis severity of questionable (22.7%),

very mild (12.5%), mild (5.5%), moderate (2.7%), and severe fluorosis (0.2%).

Mild, moderate and severe conditions were more prevalent in the two oldest

age groups. Residents of Bahrah showed higher levels of fluorosis than the

residents of Jeddah for the very mild, mild, and moderate fluorosis categories

(15.0%, 10.8%, and 4.8% respectively).

74

e) Periodontal status and needs:

The prevalence of periodontal conditions as described by the Community

Periodontal Index of Treatment Needs (CPITN) was 86.1% (Table 16); 23.5%

was bleeding (score 1), 55.0% was calculus (score 2), 6.0% and 1.6% for

CPITN scores of 3 and 4 respectively. As seen in Table 17, higher scores

(worse health) were more prevalent in the mandibular arch, i.e., sextants 4, 5,

and 6. The second measure for periodontal conditions was the periodontal

loss of attachment (LOA) that was recorded for participants 15 or older. Table

18 shows that the prevalence of LOA that was recorded for six sites (the

same six sextants that were used in recording the CPITN) was 3.2% of which

only scores 2 and 3 were found among the study participants (2.8% and 0.4%

respectively).

f) Prosthetic status and needs:

Almost all (99.9%) of the participants were dentate, and only 3.8% had

prosthesis in one or both arches. The need for prosthesis in one or both

arches among the study participants was 23.0% with more than half of the

older age group (35-44) needing one or more prostheses.

g) Dentition status:

The prevalence and severity of dental caries was obtained for both the

permanent and deciduous dentitions. For the permanent dentition (Table 20),

the caries prevalence was 71.3% and the mean number of decayed, missing

and filled teeth (DMFT), the caries severity index, scored 4.92 with a standard

error (SE) of 0.12. The mean of the decayed component of the DMFT was

2.66 (SE=0.07), showing that 54.0% (2.66/4.92) of the diseased teeth were

untreated. The mean of the missing and filled components were 0.89

(SE=0.05) and 1.37 (SE=0.06) respectively. The caries prevalence for

permanent dentition among Jeddah residents was 11.1% higher than for

Bahrah residents. Moreover, the mean scores of the missing and filled

components for Jeddah residents were 0.80 (SE=0.05) and 1.62 (SE=0.07)

75

respectively compared to Bahrah residents who scored 1.16 (SE=0.12) and

0.62 (SE=0.07) respectively.

Using the data from Table 20, the annual increment of DMFT can be

calculated by dividing the difference of the mean DMFT of two consecutive

age groups by the age difference between those age groups (98). The annual

increment of DMFT between age 6 and 12 is 0.43 teeth per year [(2.89-0.32 /

(12-6)]; between 12 and 16, 0.44 teeth/yr; between 16 and 26.5 - the mid-

point of the next group - 0.28 teeth/yr; and between 26.5 and 39.5, 0.11

teeth/yr. I will use these calculated increments as the basis for deriving a

second set of models of workforce needs in section 6.4.

For the deciduous dentition in the 6 year-olds (Table 21), the caries

prevalence was 85.5% and the mean dmft scored 5.45 (SE=0.22). The mean

of the decayed component of the dmft was 4.75 (SE=0.20) (87.0% of the

disease was untreated) while the mean of the missing and filled components

were 0.30 (SE=0.04) and 0.40 (SE=0.06) respectively. The same trend of

caries prevalence and severity for Jeddah and Bahrah residents continues.

The caries prevalence for the deciduous dentition among 6 year-olds in

Jeddah was 22.0% higher than Bahrah residents, i.e., double the difference in

the permanent dentition. Moreover, the mean dmft score was 6.03 for Jeddah

residents compared to 3.72 for Bahrah residents. The mean scores of the

decayed component for Jeddah and Bahrah residents were 5.22 (SE=0.24)

and 3.34 (SE=0.36).

Root caries prevalence and severity were recorded for the adult age groups

16, 24-29, and 35-44 (see Table 21). The prevalence of root caries was

13.1% and the mean decayed and filled roots index (DFR) was 0.28

(SE=0.03). The prevalence in Bahrah was found to be higher (by 7.5%) than

in Jeddah. Virtually none of the root caries was restored.

3) Treatment needs and time estimates

Table 23 displays the mean individual treatment need times in hours for the total

sample and by age, gender, and place of residence. Treatment needs included:

:

76

examination and diagnosis, preventive, restorative, periodontal, endodontic,

surgical and prosthodontic needs. Table 24 shows the mean individual treatment

need times in hours for the study’s five age groups after factoring in the caries

increments (teeth/ year), that were calculated earlier in section 6.1 under the

epidemiologically assessed oral health status, and the modal restorative service

time in an attempt to reduce the restorative needs for ages 12, 16, 24-29 and 35-

44. This attempt to reduce the restorative needs time at ages 12 and older was

made based on the assumption that after meeting the restorative needs of the

population at age six, they would probably have fewer restorative needs when

they get older. The modal restorative service was found to be the one surface

filling for ages 12 and older and which was estimated to require 18.9 minutes

(0.32 hours) of the dentist’s time to perform (as obtained from Table 4).

Multiplying the caries increment of each age group (12 year-olds and older) by

the time needed to perform the modal service (0.32 hours) would give us the new

restorative needs time at the selected age groups and this was used to calculate

the new total annual treatment needs time.

The periodontal needs were further divided into simple and complex ones and

their time estimates are presented in Table 25. Simple periodontal needs denote

those services that can be provided by dental hygienists e.g. cleaning and

scaling, while complex periodontal services denote services that can only be

provided by a dentist. This subdivision allowed us to project a mix of the dental

providers (dentists and dental hygienists) instead of projecting dentists only.

Treatment needs time estimates were calculated as displayed in Table 4. The

values of the mean of the individual treatment needs time, for the different

categories of needs, range from as low as 0.12 hours for preventive needs to as

high as 2.54 hours for restorative needs. The mean annual individual total

treatment needs time for the total sample was estimated at 4.22 hours per

person. This mean differed when the sample was stratified by age, rather than

gender or place of residence. The mean hours needed ranged from a minimum of

2.45 hours for the 12 year-old group to a maximum of 5.60 hours for the 35-44

year-old group. The mean individual periodontal treatment needs time was 0.35

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hours (0.24 hours for simple periodontal needs and 0.11 hours for complex

ones). The highest mean time needed to treat simple periodontal needs was 0.42

hours and it was found among the 24-29 year-old group as shown in Table 25.

Table 26 shows another way of calculating the population treatment needs based

on the dental visiting patterns. The estimated total, epidemiologically assessed,

mean annual individual treatment needs time for the selected age groups in

Jeddah and Bahrah ranged from 2.24 - 4.73 hours for those who reported

themselves as regular dental visitors (those who visit the dentist at least once a

year [groups A and B]), to 2.19 – 6.55 and 2.47 – 5.99 hours for those who

reported visiting the dentist less than once a year and those who see the dentist

only for emergency care respectively [groups C and D]. The estimated total

treatment needs time for those who reported never being to a dentist ranged from

2.43 – 4.80 hours [group E]. Table 26 also shows that the mean annual individual

treatment needs time estimates for groups A and B (the regular dental visitors)

are lower than those of groups C, D and E (the irregular dental visitors) with

treatment needs hours ranging from 2.24 - 4.73 and 2.55 – 5.95 respectively.

Table 27 shows the same results as in Table 26 but after factoring in the caries

increments (teeth/ year), that were calculated earlier in section 6.1 and the modal

restorative service time in an attempt to reduce the restorative needs for ages 12,

16, 24-29 and 35-44.

Results and estimations were presented based on stratification by age rather

than gender or place of residence. Sample weights were not applied based on

place of residence even though the ratios of the sample to the population count

were quite dissimilar for Jeddah (1:550) and Bahrah (1:36). The weights were

also not applied for the clusters since their sizes were similar (less than 15%

difference among clusters) and thus over- or under-sampling of unequal sized

clusters was not an issue of concern.

6.2 Supply

Results for the supply side were collected through a census of dentists in Jeddah

and Bahrah as previously described in the methods section. The information on

78

dental practices was collected through self-administered questionnaires and

activity assessment forms provided to all government dentists. Of the 309

government dentists, 175 responded to the census instruments giving a response

rate of 56.6%. This moderately good response rate was achieved by giving a

brief description about the study and its importance, personal handling, following

up, and retrieval of the census materials. Officials at the Armed Forces, the

National Guard, and the Interior Security Forces refused to allow the participation

of their dentists in the census due to military confidentiality issues. Supply results

are presented as:

1) Supply and practice characteristics

The characteristics of oral health care provision among government dentists are

shown in Table 29. Ninety-five percent of Jeddah and Bahrah dentists are still

providing patient care and 82.9% of them work with one dental assistant. None of

the government dentists work with dental hygienists and only 21.1% of them work

with more than one dental assistant. Table 30 shows the mean stated and actual

number of patients seen in a normal working day among the different government

bodies. The mean stated number of patients seen per day was obtained from

dentists’ questionnaires, while the mean actual number of patients seen per day

was obtained from the activity assessment forms that were filled out by dentists

for a full two working days. The mean actual number of patients seen in a normal

:

Supply and practice characteristics results are presented in Tables 28-32. Of the

309 government dentists, only two (a male and a female) work for the Ministry of

Health in Bahrah and the rest work in Jeddah. As seen in Table 28, government

dentists work for the Ministry of Health [135], the Ministry of Education [7], and

King Abdulaziz University [167]. Among Jeddah and Bahrah dentists, 52.6% are

males, 73.7% are Saudis, and the mean dentist’s age is 38.1 years. The general

dentist to specialist ratio differs among the three government bodies. For the

Ministry of Health, 79.5% of its dentists are general practitioners while the

percentage of general practitioners at King Abdulaziz University constitutes

25.0%. On the other hand, the Ministry of Education has only general

practitioners.

79

working day (Table 30) differs among the different government bodies and

ranged from four patients per day, for King Abdulaziz University dentists, to eight

patients per day, for Ministry of Health dentists. Although 41.7% of the dentists

stated that their practices were too busy to treat all patients who requested

treatment, 92.0% of them were nonetheless satisfied with their jobs.

The percentage of government dentists who described their pattern of care as

one that provided almost equal distribution between regular, preventive, and

emergency treatments was 40.6%. This percentage differed among government

bodies and ranged from 23.9% for King Abdulaziz University dentists, to 56.6%

for Ministry of Health dentists, to 75.0% for dentists at the Ministry of Education.

The practice profile for Jeddah and Bahrah dentists as established from the

activity assessment forms reveals that, over two consecutive working days,

18.8% of the dental procedures were diagnostic and preventive while 81.2% were

curative. The curative services range from 1.2% for periodontal treatments to

32.0% for restorative ones as shown in Table 32.

2) Supply time estimates

Supply time estimates for Jeddah and Bahrah dentists were obtained from

dentists’ questionnaires and the activity assessment forms and are presented in

Table 33. The dentists’ questionnaires helped in obtaining the mean stated daily

and annual dentist work hours, while the activity assessment forms helped in

obtaining the mean actual dentist clinical hours. The mean stated and the actual

daily and annual dentist hours differ among the different government bodies.

Such a difference is important because it affects the business of projecting an

accurate estimate of the total annual dentists’ time, since the number of dentists

in these bodies differs too. The mean stated daily dentist time ranged between

2.06 and 5.27 hours while the mean actual daily dentist clinical time ranged

between 1.69 and 3.24 hours. Dentists who work for King Abdulaziz University

were more consistent in their estimation of their stated dentist clinical time as

compared to those who work for the Ministry of Health and the Ministry of

Education. The mean actual annual dentist clinical time ranged between 192 and

685 hours. For Jeddah and Bahrah government dentists at the Ministry of Health,

:

80

the Ministry of Education, and at King Abdulaziz University, the total actual

annual dentists’ time was estimated at 127,094 clinical hours. However, this

number becomes smaller if we factor in just those dentists who are still providing

patient care (95.4% of 309 dentists). Thus the final estimate of the total actual

annual dentists’ time becomes an estimated 121,336 clinical hours or about 412

(121,336 / [309 x 0.954]) clinical hours per year per dentist.

The mean time estimates for Saudi dental procedures as adopted from the two-

day activity assessment forms are shown in Table 34. These procedures were

given codes similar to the ODA ones with some code modifications for some

procedures. Some of the Saudi and ODA dental procedures’ time estimates that

were used in the projection of the treatment needs’ time estimates were

comparable, as shown in Table 35. However, the ODA ones are used in this

study for the treatment needs time projection because they are established and

published. More details are needed to establish accurate estimations of the Saudi

dental procedures’ time estimates. With these details, the Saudi dental

procedures’ time estimates found in this study can be used as a baseline data for

future estimations.

6.3 Matching Requirements and Supply

The mean individual total treatment needs time is used to project the total

treatment needs time (requirements side) for the Jeddah and Bahrah populations

for the selected age groups obtained from calculations from the general Saudi

census (28) and shown in Table 36. The projection of the total treatment needs

time was run for the age groups that were used in this study. The population

count for each age group was multiplied by the number of age-specific hours

required to provide the care needed as determined in the epidemiological

assessment (see Tables 37 and 38). The total treatment needs’ time for the

study’s five age-groups in Jeddah and Bahrah population under this assumption

is estimated at 4,186,091 hours. This estimation represents the prevalence of

oral diseases for the population of Jeddah and Bahrah for the study’s five age-

groups. Of this estimated prevalence of 4,186,091 hours of treatment needs,

3,827,109 hours could only be met by dentists and 358,982 hours could be met

by dental hygienists (see Table 38). This prevalence translates into 6,111 full

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time equivalent (FTE) dental professionals (5586 dentists and 525 dental

hygienists) needed to treat this prevalence in one year. This estimation of

professional-equivalents was calculated using the Ministry of Health’s mean

actual annual dentist time of 685 hours (see Table 33) since they are considered

the main providers of health services and any new staff would likely be added to

the government clinics.

However, hiring this large number (6,111) of FTE dentists and dental hygienists is

unrealistic even it was done over several years. It would need several years to

build up an infrastructure to accommodate this large number of dentists.

Moreover, basing our projection of the dental workforce on the prevalence of oral

diseases is considered improper in the sense that those projected FTEs will

eventually need to deal with an incidence of oral diseases which is much less

than the prevalence. Thus our projection of the dental workforce will be based on

the incidence of oral diseases and conditions, while the current prevalence of oral

diseases will be left to fade by ongoing dental services’ demands over time.

As seen in Table 39, the needs were also estimated using the same methods

according to the reported dental visiting patterns as shown in Tables 10 and 26.

This estimation was intended to represent the time needed to deal with the

incidence of oral conditions in Jeddah and Bahrah by using the treatment time

estimates for those who reported themselves as regular dental visitors. The

notion was that regular visitors (group A and B) would have had their treatment

needs fulfilled at their last dental visit, and that the findings on the examination for

this study would represent just the newly acquired conditions. Thus their needs

would act as a surrogate measure for oral disease and re-treatment incidence.

Table 39 shows that the estimated total, epidemiologically assessed, treatment

needs time for the selected age groups in Jeddah and Bahrah ranged from

3,641,551 hours for those who reported themselves as regular dental visitors

(those who visit the dentist at least once a year [group A and B]), to 4,456,834

and 4,617,156 hours for those who reported visiting the dentist less than once a

year (group C) and those who visit the dentist only for emergency care (group D)

respectively. These time estimates show a trend of increasing treatment needs

time for those who don’t visit the dentist on a regular basis. However, this trend

82

was interrupted for those who reported never being to a dentist as their estimated

total treatment needs time was reduced to 3,136,530 hours. As seen in the table,

the total annual treatment time, if all people in those age groups in the region

were regular dental visitors (group A and B), is estimated at 3,641,551 hours

which translates into 4,813 FTE dentists and 504 dental hygienists or 5,317 FTE

professionals. This estimation of dentist dental hygienist equivalents was

calculated again using the Ministry of Health’s mean actual annual dentist time of

685 hours (see Table 33) since they are considered the main providers of health

services, and any new staff would likely be added to government clinics.

Table 39 also shows the trade-off in the total FTEs required to meet the needs at

the changing utilization rates from 100% to 30%. For this study, we decided to

estimate the hours needed to treat the incidence of oral diseases and conditions

in Jeddah and Bahrah based on an annual utilization rate of 50% (2,659 FTE

dentists and dental hygienists) - note that currently 25.5% visit regularly (Table

10). Choosing this utilization rate was based on an anticipated increase in the

current utilization rate (among the regular dental visitors in Jeddah and Bahrah,

who could be reached by health education and promotion programs). A similar

utilization rate has been reported for the Canadian and Australian cultures, for

which the rates of regular dental visitors are 52.4% and 53.1% respectively

(99;100).

Since we are planning to reduce the incidence of oral diseases and conditions by

prevention and treatment and by planning and implementing health promotion /

prevention programs in Jeddah and Bahrah, we decided to choose different

utilization rates in our projection of the FTE staff needed for preventive and

curative treatment needs. For curative needs, which can only be met by dentists,

a 50% utilization rate will be used to estimate the needed FTE staff; this

translates into 2,407 FTE dentists (as shown in Table 39). On the other hand, for

preventive needs that can be met dental hygienists, a 100% utilization rate will be

used to estimate the needed FTE staff. This translates into 504 FTE dentists or

dental hygienists (see Table 39). This would bring the estimated total FTE staff

needed to deal with the incidence of oral diseases and conditions in these age

83

groups in Jeddah and Bahrah to 2,911 (2,407 FTE dentists [at 50% utilization

rate] and 504 FTE dental hygienists [at 100% utilization rate]).

A second set of findings can also be obtained by factoring in the caries

increments (teeth/ year), that were calculated earlier in section 6.1 under the

epidemiologically assessed oral health status, and the modal restorative service

time to provide an attempt to estimate the incidence of restorative needs for ages

12, 16, 24-29 and 35-44. This attempt to reduce the restorative needs time at

ages 12 and older was made based on the assumption that after meeting the

restorative needs of the population at age six, they would probably have fewer

restorative needs when they get older. The modal restorative service was found

to be the one surface filling for ages 12 and older and which was estimated to

require 18.9 minutes (0.32 hours) of the dentist’s time to perform (as obtained

from Table 4).

Multiplying the caries increment of each age group (12 year-olds and older) by

the time needed to perform the modal service (0.32 hours) would give us the new

restorative needs time at the selected age groups and this was used to calculate

the new total annual treatment needs time that can only be met by dentists (see

Table 27). Table 40 shows the calculations of the total annual treatment time and

the required FTEs at the varying utilization rates that were based on the new

assumption of reducing the restorative needs time for ages 12 and older. The

calculations in Table 40 are parallel to those displayed in Table 39 and show that

the estimated total FTE staff needed to deal with the incidence of oral diseases

and conditions in the study’s five age groups in Jeddah and Bahrah (group A and

B) would be reduced from 2,911 (2,407 FTE dentists [at 50% utilization rate] and

504 FTE dental hygienists [at 100% utilization rate]), as obtained from Table 39,

to 2,197 (1,693 FTE dentists [at 50% utilization rate] and 504 FTE dental

hygienists [at 100% utilization rate]), as obtained from Table 40.

Up to this point in our projections of the dental workforce needed to deal with the

incidence of oral diseases and conditions, we have addressed the needs of those

who are regular dental visitors (group A and B). In an attempt to have a more

precise estimation of the incidence, we have added the treatment needs of the

irregular dental visitors (group C, D and E) to that of group A and B. Utilization

84

rates of 33% for curative dental care and 100% for preventive dental care were

used again in the estimation of the needed FTEs for this added 33% of treatment

needs that were expressed as demands (1,939 FTE dentists + 540 FTE dental

hygienists [as calculated from Table 39 and shown in Table 43]).

Projecting the dental workforce for the study’s five age groups alone, which

represent only 29.2% of the population of Jeddah and Bahrah, would seem

inadequate since the oral diseases and conditions for the rest of those

populations (70.8%) would certainly need to be treated as well. In an attempt to

accommodate the needs of the remaining 70.8%, we have projected their needs

based on the needs of those who visit the dentist only for emergency care (group

D) and added them to that of groups (A and B) and (C, D and E). The selection of

group D to represent the needs for the rest of Jeddah and Bahrah population was

used, as this visiting pattern was the most prevalent one (52.6%) among Jeddah

and Bahrah residents (see Table 10). Utilization rates of 33% for curative dental

care and 100% for preventive dental care were used again in the estimation of

the needed FTEs to meet the needs that were expressed as demands for the rest

of the target population (4,476 FTE dentists + 1,133 FTE dental hygienists [as

shown in Table 43]).

Based on the calculations from Table 39 and after adding the additional 33% of

treatment needs from group C, D and E and that of the rest of Jeddah and

Bahrah population to group A and B, the projected FTEs to meet the estimated

total annual treatment needs time that was used to represent the incidence of

oral diseases and conditions in Jeddah and Bahrah becomes 8,822 FTE dentists

and 2,177 FTE dental hygienists (as calculated from and shown in Table 43).

These numbers could be reduced to 6,040 FTE dentists and 2,177 FTE dental

hygienists, if the caries increments and the modal restorative service time were

used in the calculations of the needed dental workforce (see Tables 40 and 43).

The available supply time from all government dentists in Jeddah and Bahrah

was estimated in section 6.2 at 121,336 hours of actual annual dentists’ clinical

work time. However, basing our projections only on government dentists’ clinical

work time is biased since we ignored private dentists’ clinical work time. Thus, the

total available annual supply time should consist of the total annual government

85

and private dentists’ clinical work time. However, since this study did not collect

data about the annual individual clinical work time of private dentists, we

assumed that their annual individual clinical work time is half of that of a Ministry

of Health’s dentist, i.e., 342 hours per year. This assumption was based on the

fact that most private practices receive most of their patients in the evening. The

total number of private dentists in Jeddah and Bahrah, as obtained from the

department of medical licensing at the Ministry of Health, is 223 dentists. This

would bring the total available annual supply time provided by all private dentists

to 76,266 hours per year. Adding the private dentists’ clinical work time to that of

all government dentists would bring the total available annual supply time in

Jeddah and Bahrah to 197,602 hours per year which translates into 289 FTE

dentists.

When the projected total of FTE dentists that are needed to treat the incidence of

oral diseases and conditions (8,822 FTE dentists and 2,177 FTE dental

hygienists [as shown and calculated from Table 43]) is contrasted with the total

available supply of all government and private FTE dentists in Jeddah and

Bahrah, 289 FTE dentists, the remaining current requirement for FTE dentists

who are needed to meet the treatment needs that were expressed as demands

on the requirements side becomes 8,533 FTE additional dentists (8,822 - 289).

This balance could be further reduced to 5,751 FTE dentists (6,040 – 289), if the

caries increments and the modal restorative service time were used in the

projection of the dental workforce (see Table 43). However, overcoming this

deficit will require further analysis and presentation of different models that take

into account the multifactorial nature of such a projection; these models are

presented in the following section.

Along with the projection of the models that are aimed at providing curative and

preventive care, it is imperative to note that health promotion/ preventive

programs should also be planned and implemented as part of our projection of

the dental workforce. These programs are designed to reduce the burden of oral

diseases in Jeddah and Bahrah and may include a combination of a population-

wide approach of water fluoridation, promoting the use of fluoridated tooth paste,

the use of dental screening, and professionally applied topical fluoride and fissure

86

sealant programs. In our attempt to project the dental workforce (health

promoters/ dental hygienists) needed to implement the dental screening,

professionally applied topical fluoride and fissure sealant programs, we chose to

project the workforce for these programs based on targeting schoolchildren aged

6-8 and 12-14 who represent 15.7% (453,279) of the population of Jeddah and

Bahrah (as projected from Table 36 by multiplying the population count at ages

six and 12 by three to provide the count per each age range). Two hundred and

fifteen FTE health promoters/ dental hygienists will be recruited to serve in those

health promotion/ prevention programs. Each of the 215 FTE health promoters/

dental hygienists would be required to provide dental screening, professionally

applied topical fluoride and fissure sealant services for 12 schoolchildren per day

(6 hours per day and 30 minutes per child) during the academic school year that

is estimated to last for eight months with an average of 22 days per month. This

dental workforce will be added to the total required dental work force for each of

the projected models in the next section.

6.4 Models to Balance Requirements and Supply

In this study, estimation of the total treatment needs time under the requirements

side was based on the prevalence of oral disease. However, projection of health

human resources has to be based on the actual incidence of oral diseases, i.e.,

the ongoing annual disease. Basing the projection of health human resources

simply on the prevalence of diseases will inescapably result in a huge surplus of

health human resources on the supply side. Eventually, those over-projected

health human resources will have to deal with the incidence of the disease, which

is generally much lower than its prevalence. Thus, to avoid such over-projection,

the models that are developed here to balance requirements and supply sides

took into consideration projecting the best number and mix of health human

resources to deal with the annual ongoing diseases and conditions, while letting

the current prevalence of oral diseases fade by service demands over time.

Since this study did not provide incidence rates and until such data are made

available, the treatment needs time among the different patterns of dental visitors

87

visiting patterns (see Table 43) was used as a surrogate measure to represent

the disease incidence as discussed earlier in section 6.3 and in Tables 39-43.

The models that are aimed to balance requirements and supply sides are shown

in Table 43. The upper part of Table 43 represents the total FTEs required as

projected by adding the needs that were expressed as demands of groups A & B,

plus C, D and E (for the study population) to that of the rest of Jeddah and

Bahrah population which was based on the needs that were expressed as

demands of group D at different utilization rates (as obtained from Tables 39 and

41). This part of the table provides findings one, that were based on Tables 39

and 41, and findings two, that were based on Tables 40 and 42 (the calculated

incidence from the age-specific epidemiological findings). These two sets of

findings were the bases from which two sets of eight models originated giving a

total of 16 different models as shown in the lower part of Table 43. Each set of

eight models was developed by the interaction between three main factors:

changing the mix of dental providers (dentists/ dental hygienists); increasing the

total service output of dental staff by 50%, i.e., increasing their actual annual

clinical work time from 685 to 1,027.5 hours per year; and reducing the

restorative needs time by 50% for the study’s five age-groups.

The projected number of health promoters/ dental hygienists needed to

implement health promotion and prevention programs is estimated at 215 FTE

health promoters/ dental hygienists (to serve 12 schoolchildren per day [30

minutes/ child]) for models 1, 3, 5, 7, 9, 11, 13 and 15 and 143 FTE health

promoters/ dental hygienists (to serve 18 schoolchildren per day [30 minutes/

child]) for models 2, 4, 6, 8, 10, 12, 14 and 16.

The following first set of models (models 1 to 8) is based on the findings that

were obtained from Tables 39 and 41, i.e. the estimates based on the needs of

regular visitors

Model 1: In this model, the projection of health human resources is based on utilizing

dentists at their current level of total service output (685 hours/ year) and without

88

reducing the restorative needs time. This model, as well as the rest of the

models, also aims to utilize health promoters/ dental hygienists in the

implementation of health promotion/ prevention programs for schoolchildren aged

6-8 and 12-14.

The projected total of FTE dentists needed for this model as well as for the rest of

the models was calculated by adding the projected number of FTE dentists which

was based on the study population’s (29.2% of Jeddah and Bahrah population)

needs to those of the rest of population (70.8%). For the study population, the

projected number of FTEs was based on: the needs that were expressed as

demands of group A and B (25.5% of the study population) at a utilization level of

50% for curative care (2,407 FTE dentists) and at 100% for preventive care (504

FTE dentists); and the needs that were expressed as demands of group C, D and

E (74.5% of the study population) at a utilization level of 33% for curative care

(1,939 FTE dentists) and at 100% for preventive care (540 FTE dentists). On the

other hand, for the rest of the target population, the projected number of FTE

dentists was based on the needs that were expressed as demands of group D

(52.6% of the study population) at a utilization level of 33% for curative care

(4,476 FTE dentists) and 100% for preventive care (1,133 FTE dentists).

Based on this model, the projected total dental workforce needed to treat the

incidence of oral diseases and conditions of Jeddah and Bahrah comes to 10,999

FTE dentists and 215 FTE health promoters/ dental hygienists. The population to

combined professional (dentist/ dental hygienist) ratio for this model is 257:1.


dentists after increasing their current total service output by 50% (1,027 hours/

year) without reducing the restorative needs time. This desired increase in the

total service output can be achieved in several ways; among these is changing

the method of reimbursing dentists from a salary-based to a fee-for-service one

or a mix of both. Although changing the method of reimbursing the dental staff

may be considered as a valid way of increasing the total service output, there are

89

other factors that are considered having equal or even more importance than the

method of reimbursement. Among these factors are implementing a well

structured quality control that includes a well detailed management information

system and achieving a synergy in teamwork between dentists and dental

hygienists at any clinical setting.

For group A & B of the study population, the projected number of FTEs was

1,605 FTE dentists for curative care and 336 FTE dentists for preventive care.

While for group C, D & E, the projected number of FTEs was 1,293 FTE dentists

for curative care and 360 FTE dentists for preventive care. On the other hand, for

the rest of the target population, the projected number of FTEs was 2,984 FTE

dentists for curative care and 756 FTE dentists for preventive care.






dentists at their current level of total service output (685 hours/ year) but after

reducing the restorative needs time by 50% for all age groups.






dentists for curative care and 1,133 FTE dentists for preventive care.





90

Model 4:

In this model, the projection of health human resources are based on utilizing


year) and after reducing the restorative needs time by 50% for all age groups.






dentists for curative care and 756 FTE dentists for preventive care.






dentists and dental hygienists at their current level of total service output (685

hours/ year) and without reducing the restorative needs time. This model (as well

as models six, seven and eight) introduces and adds dental hygienists to the mix

of health human resources for dentistry in Saudi Arabia.


2,407 FTE dentists for curative care and 504 FTE dental hygienists for preventive

care. While for group C, D & E, the projected number of FTEs was 1,939 FTE

dentists for curative care and 540 FTE dental hygienists for preventive care. On

the other hand, for the rest of the target population, the projected number of FTEs

was 4,476 FTE dentists for curative care and 1,133 FTE dental hygienists for

preventive care.

91



FTE dentists, 2,392 FTE dental hygienists and 215 FTE health promoters/ dental

hygienists. The population to combined professional (dentist/ dental hygienist)

ratio for this model is 257:1.


dentists and dental hygienists after increasing their current total service output by

50% (1,027 hours/ year) without reducing the restorative needs time. This desired

increase in the total service output can be achieved in several ways as discussed

in model two.






was 2,984 FTE dentists for curative care and 756 FTE dental hygienists for

preventive care.








hours/ year) but after reducing the restorative needs time by 50% for all age

groups.

92







preventive care.






Model 8:



50% (1,027 hours/ year) and after reducing the restorative needs time by 50% for

all age groups.







preventive care.






93

The following second set of models (models nine to sixteen) is based on findings

two that were obtained from Tables 39 and 41 and which were based on factoring

in the caries increments (teeth/ year) and the modal restorative service time in an

attempt to reduce the restorative needs for ages 12, 16, 24-29 and 35-44.

Model 9: In this model, the projection of health human resources is based on the

incremental caries needs calculated from the epidemiologic survey (see page 74)

and estimating the number of dentists at their current level of total service output

(685 hours/ year) and without reducing the restorative needs time.



While for group C, D & E , the projected number of FTEs was 1,396 FTE dentists


the rest the target population, the projected number of FTE dentists was 2,951

FTE dentists for curative care and 1,133 FTE dentists for preventive care.







year) without reducing the restorative needs time.



While for group C, D & E, the projected number of FTEs was 931 FTE dentists for

curative care and 360 FTE dentists for preventive care. On the other hand, for the

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rest of the target population, the projected number of FTE dentists was 1,968

FTE dentists for curative care and 756 FTE dentists for preventive care.






dentists at their current level of total service output (685 hours/ year) but after

reducing the restorative needs time by 50% for all age groups.





the rest of the target population, the projected number of FTE dentists was 2,902

FTE dentists for curative care and 1,133 FTE dentists for preventive care.





Model 12:



year) and after reducing the restorative needs time by 50% for all age groups.



95

While for group C, D & E, the projected number of FTEs was 900 FTE dentists for

curative care and 360 FTE dentists for preventive care. On the other hand, for the

rest of the target population, the projected number of FTE dentists was 1,935

FTE dentists for curative care and 756 FTE dentists for preventive care.







hours/ year) and without reducing the restorative needs time. This model (as well

as models 14 to 16) introduces and adds dental hygienists to the mix of health

human resources for dentistry in Saudi Arabia as the case for models five to

eight.







preventive care.






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50% (1,027 hours/ year) without reducing the restorative needs time.



care. While for group C, D & E, the projected number of FTEs was 931 FTE




preventive care.








hours/ year) but after reducing the restorative needs time by 50% for all age

groups.







preventive care.

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Model 16:



50% (1,027 hours/ year) and after reducing the restorative needs time by 50% for

all age groups.



care. While for group C, D & E, the projected number of FTEs was 900 FTE




preventive care.



FTE dentists, 756 FTE dental hygienists and 143 FTE health promoters/ dental



Table 42 shows full details of the previously explained models showing the

number of health human resources needs for each of the models by FTE dentists

and dental hygienists and the population to professional (dentist/ dental hygienist)

ratio associated with them. The projected models did not account for the currently

available number of FTE dentists in Jeddah and Bahrah (289) and so this number

needs to be subtracted from each model to provide the balance in the supply side

that need to be added to the currently available supply.

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7.0 Discussion

99

7.1 Regional, National and International Comparisons

The comprehensive nature of this study made it hard to find similar studies with

which to compare its end results. However, results of the oral health status can

still be compared regionally with previous studies in Makkah region, nationally

with other cities in Saudi, and internationally with the United States and Australia.

The prevalence of dental caries and periodontal disease was reported regionally

in Makkah region. When the mean dmft and DMFT scores of schoolchildren aged

6, 12 and 15 in Makkah, Jeddah and Rabegh were compared to our study, the

scores of the dmft at age six ranged from 2.7-6.3 (62) as compared to 5.45 in our

study. For ages 12 and 15, the DMFT scores ranged from 1.5 to 6.3 as compared

to 2.8 at age 12 and 4.6 at age 16 in our study. In 1996, the prevalence of dental

caries of schoolchildren aged six to nine in Jeddah city was 73.9% (mean

dmft=4.2; mean DMFT=1.8) (61) as compared to 85.5% (mean dmft=5.4; mean

DMFT=0.3) for the six year olds in our study. On the other hand, there were no

studies assessing the periodontal health status, except for one, that have

reported the prevalence of localized juvenile periodontitis at ages 17 to 23 in

Makkah city from patients’ files (0.4%) (63). This has resulted in a lack of a

comparator for all basic measures of periodontal health that was reported in our

study.

It is apparent from this comparison that regional data have provided measures of

prevalence and severity of dental caries among urban schoolchildren, but have

left the older population, as well as in those who live in rural areas, understudied.

Although these data were collected in the early to mid nineties, they were not that

different from ours. However, our study provided more details and hence better

and more comprehensive representation of oral diseases, since more disease

conditions were evaluated and a wider range of age groups were included in the

sample. This comprehensive oral examination and the use of a wider age

distribution have accounted for better understanding of the prevalence, severity

and distribution of oral diseases among different age groups in Jeddah and

Bahrah.

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Nationally there were only two studies. The first one compared the prevalence of

dental caries of urban and rural children aged 12 and 13 years in ten

administrative regions (34). The prevalence of caries was 74.0% among urban

residents and 67.0% among rural residents (mean DMFT=2.6 for urban areas;

mean DMFT=2.6 for rural areas) as compared with the results of our study of

77.3% in Jeddah and 55.0% in Bahrah (mean DMFT=3.1 in Jeddah; mean

DMFT=1.9 in Bahrah) showing the same trend but with lower mean DMFT scores

for the rural areas (Bahrah).

The second study set out to determine the prevalence of dental fluorosis among

people aged 6 to 74 in ten administrative regions (35). The researchers

concluded that 24.6% of the Saudi population has some form of fluorosis (from

questionable to severe fluorosis) fluorosis as compared with 49.5% in our study.

Although the prevalence of dental fluorosis in our study was almost double that

found in the national study, 22.7% of the identified cases were questionable

fluorosis and only 0.2% were severe ones.

The national comparison was also similar to the regional one in that it lacked a

comprehensive assessment of oral diseases as well as lacking a wide age

distribution in the dental caries study.

Internationally, two main studies were used in our comparison. The first study is

the trends in oral health status in the United States (1999-2004) (101). The

percentages of people who visited the dentist at least once in the past year for

ages 6-11, 12-15, 16-19, 20-34, and 35-49 were 76.8%, 76.8%, 68.5%, 54.6%,

and 62.5% respectively. The corresponding percentages in our study for ages 6,

12, 16, 24-29, and 35-44 are 18.5%, 30.0%, 23.8%, 27.0%, and 28.3%. The

percentages in our study are lower than what were found in the American study

but show a similar trend as the population gets older.

When people were asked about their perception of the condition of their mouth

and teeth, 63.6 % of those aged 20-34 and 61.4% of those aged 35-49 rated the

condition of their mouth and teeth as good to excellent as compared to 36.4%

and 38.6% of the same respective age groups, who rated their oral health as fair

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to poor. This can be compared to ages 24-29 and 35-44, in our study, as 68.0%

and 65.8% who rated their oral health as good to excellent and 30.5% and 33.8%

who rated it as fair to poor. The older age group in both studies shows lower

percentages for the good to excellent rating and higher percentages for the fair to

poor rating as compared with the younger age groups; i.e. showing the same

trend.

The prevalence of dental caries for deciduous and permanent dentitions among

the 6-11 year-olds was 51.2% [mean dft=1.8 and mean decayed component=0.5]

and 10.1% [mean dft=0.1 and mean decayed component=0.06]. These

percentages and the associated severity of dental caries were higher for the six

year-olds in our study (85.5% [mean dft=5.4 and mean decayed component=4.7]

and 15.2% [mean dft=0.3 and mean decayed component=0.3]). For ages 12-15

and 16-19, the prevalence of dental caries was 50.6% [mean DMFT=1.7 and

mean decayed component=0.3] and 67.4% [mean DMFT=3.3 and mean decayed

component=0.5] as compared to much higher percentages for ages 12 and 16 in

our study (71.7% [mean DMFT=2.8 and mean decayed component=2.3] and

82.5% [mean DMFT=4.6 and mean decayed component=3.2]). The prevalence

and severity scores of dental caries for the older age groups (20-34 and 35-49)

were almost similar for both studies except for the mean scores of the decayed

component which were higher for our sample. The prevalence and severity

scores for the American study were 85.5% [mean DMFT=6.1 and mean decayed

component=0.9] and 94.3% [mean DMFT=10.9 and mean decayed

component=0.7] for ages 20-34 and 35-49 respectively. In our study, these

scores were 92.2% [mean DMFT=7.6 and mean decayed component=4.1] and

95.0% [mean DMFT=9.1 and mean decayed component=3.2] for ages 24-29 and

35-44 respectively.

The prevalence of root caries was reported for ages 20-34 and 35-49 as 8.1%

and 14.8%, as compared to the prevalence in our study of 13.5% and 19.0% for

ages 24-29 and 35-44. Although the prevalence of root caries in our study

appears to be higher than the American study, it still follows the same trend of

having higher percentages for the older age group.

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The second international study that is used in our comparison is the Australian

national survey of adult oral health (99). The percentages of people who visit the

dentist at least once a year for ages 15-34 and 35-54 were 51.0% and 51.8%

respectively. The corresponding percentages in our study for ages 16, 24-29, and

35-44 are 23.8%, 27.0%, and 28.3%. The percentages in our study are lower

than those of the Australian study but show a similar trend as the population

ages.

When people were asked about their perception of the condition of their mouth

and teeth, 13.4 % of those aged 15-34 and 18.2% of those aged 35-54 rated the

condition of their mouth and teeth as poor to fair as compared to 11.5%, 30.5%,

and 33.8%, for ages 16, 24-29, and 35-44 in our study. These percentages were

found to be higher for the older age groups in both studies, making them

consistent with the American study.

The percentages of people experiencing toothache for ages 15-34 and 35-54

were 18.7% and 15.3%. On the other hand, the percentages of people who avoid

eating certain types of food for the same age groups were 14.7% and 17.7%. In

contrast, in our study, 40.5%, 49.0%, and 49.3% were the percentages of people

who have experienced toothache at ages 16, 24-29, and 35-44 respectively. It

was also found that 68.0%, at age 16, 84.3% at age 24-29, and 83.0% at age 35-

44, have reported avoiding eating certain types of food due to dental problems.

Toothache experience appears to fade as a person gets older in the Australian

study while our study shows slightly higher rates of toothache as the person gets

older. This difference might be related to the large component of the untreated

decayed component of the DMFT at these age groups in Jeddah and Bahrah. On

the other hand, the same trend applies for both studies in regards to the

increased percentages of people who avoided eating certain types of food due to

dental problems as they get older.

The perceived need for dental extractions or fillings was reflected by 33.6% at

age 15-34 and by 36.1% at age 35-54, while the percentages for the perceived

need for teeth replacement by dentures or bridges were 1.2% and 5.0% for the

same age groups respectively. In our study, the percentages for those who

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reported the need for dental extractions or fillings for ages 16, 24-29, and 35-44

were 35.0%, 54.3%, and 61.6% respectively. On the other hand, the perceived

need for teeth replacement (by dentures or bridges) was reported by 4.8% at age

16, 10.5% at age 24-29, and by 20.0% at age 35-44. Although the perceived

need for dental treatments showed higher percentages in our study as compared

to the Australian study, both studies shared the tendency towards more dental

treatment needs for older age groups.

The prevalence of dental caries among ages 15-34 and 35-54 were 25.8% [mean

DMFT=4.5] and 27.1% [mean DMFT=14.4]. In our study, these percentages and

the associated severity of dental caries were higher than the Australian study.

These percentages were 82.5% [mean DMFT=4.6], 92.2% [mean DMFT=7.6],

and 95.0% [mean DMFT=9.1] for ages 16, 24-29, and 35-44 respectively.

The prevalence of root caries was reported for ages 15-34 and 35-54 as 1.6%

and 7.1%, as compared to the numbers in our study which were 6.1%, 13.5%,

and 19.0% for ages 16, 24-29, and 35-44. Although the prevalence of root caries

in our study appears to be higher than the Australian study, it still follows the

same trend of having higher percentages for the older age group.

For the Australian study, the prevalence of periodontal loss of attachment that is

greater than four millimeters was 42.5% while in our study this prevalence was

estimated at 3.2%. This finding reflects a low prevalence of loss of periodontal

attachment but it is also possible that more could be detected in Jeddah and

Bahrah if our sample was expanded to include ages older than 44.

It is apparent from the above comparisons with the American and the Australian

studies that dental caries in Jeddah and Bahrah remains largely untreated when

compared to Americans and Australians. This observation was reflected in the

high mean scores of the decayed component for both deciduous and permanent

dentitions for Jeddah’s and Bahrah’s residents.

Although the sample in our study for the older age groups was obtained from

employed adults rather than households, the results of our study were similar

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when compared to the American and the Australian studies that used households

in their sampling. This observation supports the validity of including employed

adults as a representative sample of the community. It could be used in the future

in Saudi, in cases where the households’ sample is difficult to obtain due to

unacceptability issues related to culture.

7.2 Anticipating and Overcoming Threats to Internal Validity and Ways to Improve Internal Consistencies

At several stages of this study there were challenges that, if not managed and

accounted for, would have introduced a great deal of bias and would have posed

a threat to the internal validity of the study findings. These challenges were

encountered during the survey of the oral health status, the census of dentists

and during the analytical stage of this study.

Although great effort was spent to recruit a representative sample, differences in

the level of strength of the sample representativeness do exist among the study’s

age groups. For schoolchildren age groups, the strength of representation was

strong while for the adult population the strength of representation was less

powerful and variable based on the place of residence. In Jeddah, sampling from

a working adult population was not ideal when compared to a home-based one.

However, given the circumstances of the Saudi culture which opposes a home-

based examination and interview survey, sampling from working adults makes

the strength of representation an acceptable one. In Bahrah, the sample of the

adult population probably less representative since it was a clinic population.

Such differences in the strength of representativeness is a limitation of this study

but whether this can be improved in future studies depends on the

successfulness of spending more efforts to reduce some of the cultural barriers to

obtaining a home-based survey in Saudi Arabia. Nonetheless improving the

sampling process is needed to improve the projection of health needs and its

required workforce.

Having a total of eight examination teams could have affected the examiners’

ability to examine to the same standards. The same applies to the ability of each

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examiner to be consistent in his/her consecutive examinations over the entire

data collection period. These anticipated threats to validity were addressed in the

phases of the pre-field procedures (see section 5.2). The instructional and

training sessions and the multiple calibration and recalibration sessions that were

supplemented by the pilot survey all helped in establishing and maintaining a

substantial to almost perfect level of agreement among and between examiners

during the recording of oral conditions as indicated by the results of the kappa

statistics in section 6.1.

The number of examiners, as compared to the total number of participants

surveyed in this study (14 examiners to 2000 participants), was comparable to

that of the Australian national survey of adult oral health (30 examiners to 5505

participants) (99).

Although it was anticipated that the large number of examiners, recorders and

organizing clerks (35 dental interns) would be difficult to organize and manage

during the data collection period, they were highly motivated as they understood

the importance of this study and were keen to follow instructions from the

principal investigator. This has resulted in easy management, smooth

organization and better involvement of those respected dental interns during the

data collection period. This was reflected by the group’s willingness to replace the

90 participants who were lost at the start of the survey because they failed to

answer all the items on the self-administered questionnaires. All of this helped in

attaining the planned sample size and achieving the 100% response rate for the

survey of oral health status.

The dental procedures’ time estimates that were used to project the treatment

needs time estimates at the requirements side were based on the ODA fee guide.

This choice was made because of the lack of detailed data about Saudi dental

procedures’ time estimates, and also because the ODA ones were already

established and published. Although the ODA dental procedures’ time estimates

were based on a market where fee-for-service is the method of payment, a

system quite different from the salary-based one in Saudi Arabia, some of the

Saudi dental procedures’ time estimates, adopted from the two-day activity

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assessment of Saudi dentists, were similar to those of the ODA (see Table 35). It

is worth noting too that the ODA times, while published and representing a

standard, were established to justify fees of the different dental procedures and

so may be inflated. Moreover, they were established for single procedures and

did not include the time saved by doing quadrant dentistry which the high

prevalence of dental caries in Jeddah and Bahrah would permit.

The use of a surrogate measure to represent the incidence of oral diseases,

eventually used to better project the dental workforce requirements for Jeddah

and Bahrah, was a far better tool for us than basing our projection for the ongoing

needs on prevalence data which tend to give higher projections of health human

resources. However, original incidence studies should be conducted in the future

to give more precise and stable dental workforce requirements projections since

our assumption for the surrogate measure may invite some degree of bias due to

the uncertainty of whether or not those who visited the dentist regularly had all

their treatment needs met during their last dental visit. Such uncertainty may

have resulted in an over-estimation of our projections but until such longitudinal

studies, that could provide data on oral diseases incidence or could answer

whether or not those who visited the dentist regularly had all their treatment

needs met during their last dental visit, are made available, the use of the

surrogate measure appears valid and justifiable.

Although the incidence of oral diseases and conditions in Jeddah and Bahrah,

based on the needs of different dental visiting patterns and at different utilization

rates (see Table 43), seemed high for models 1-8 and to some extent moderately

high for models 9-16 after factoring in the caries increments (teeth/ year) and the

modal restorative service time in an attempt to reduce the restorative needs for

ages 12, 16, 24-29 and 35-44, and may have subsequently resulted in an over-

projection of the dental workforce, the overall projection of dental human

resources required to reduce the incidence in Jeddah and Bahrah might not be

affected much, i.e., over-projected. This is because we have only considered the

most basic dental treatment needs and we have followed the epidemiological rule

of going with the lower time estimates for dental procedures’ needs whenever

possible. On top of that, the identification of the needs were done using oral

107

examinations without the aid of radiographs or other diagnostic aids that are able

to detect more hidden oral diseases.

The population to combined professional ratio that was displayed for the

suggested models in Table 43, ranged from 352-699 and this can be compared

to 440-2,382 for Canada (102). However, the ratios in this study might be more

valid since it was based on needs.

The dentists’ response rate of 56.6% that was obtained from the census on their

total service output and busyness might be considered as one of the threats to

the internal validity of this study. However, since this is a census and no sample

size was specified, this response rate could be considered acceptable.

Adding the private dentists’ time to that of the government dentists was essential

to have more accurate projection of the supply time. However, it is also important

to acknowledge the limitation of such addition since this study did not collect data

on the total service output of private dentists in Jeddah and Bahrah.

Although assuming the increase in the current total service output by 50% may

seem somehow high. This desired increase in the total service output can be

achieved in several ways; among these is changing the method of reimbursing

dentists from a salary-based to a fee-for-service one or a mix of both. Although

changing the method of reimbursing the dental staff may be considered as a valid

way of increasing the total service output, there are other factors that are

considered having equal or even more importance than changing the method of

reimbursement. Among these factors are implementing a well structured quality

control that includes a well detailed management information system and

achieving a synergy in teamwork between dentists and dental hygienists at any

clinical setting.

7.3 Generalizability of the Research Results to the Saudi Population

Although this study was carried out in Jeddah and Bahrah, several factors make

the results of this study generalizable for the Makkah Region. Generalizability to

the Saudi population elsewhere in the country may not be appropriate at this

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stage until a more representative sample can be obtained from other parts across

Saudi Arabia.

Jeddah is the second most highly populated city in the country with about 12.8%

of the Saudi population and it is located close to the third most highly populated

city, Makkah, which has about 6% of the Saudi population. Jeddah is also located

in the most highly populated administrative region of Makkah (25.7% of the Saudi

population). These population statistics show how likely it is that the results of this

study centering on Jeddah can be generalized to Makkah Region.

The very high response rate (100%) from the survey of oral health status in this

study along with the fair age distribution and sampling frame which included

sampling a small number of subjects from each cluster (15 subjects). The sample

size of this study was favorable in terms of generalization of its results. As

compared to the Australian national survey of adult oral health (99) which

recruited 5505 participants to represent data on that country, our study recruited

2000 participants (about one third the sample size of the Australian study) from

Jeddah and Bahrah to represent part of the country that indeed can fairly

represent the oral health status of Makkah Region. All this made the results of

this study representative of the oral health status of the Saudi population in

Jeddah and Bahrah and even the Makkah Region in general.

The comparability of the results of the epidemiologically assessed oral health

status of this study to that of other regional, national and international studies

(see section 7.1), support the likelihood that generalizing the results of this study

is a plausible thing to do.

7.4 Limitations and Suggestions for Improvement for Future Similar Studies

If this study were to be repeated in the future or if similar studies were to be

planned, there are some aspects that need to be amended, things that we could

not address due to limitations of the resources allotted for this Ph.D study.

Among these are:

109

• Including younger and older age groups (less than six years and older than 44

years) as part of the surveyed sample to explore the oral health status and

treatment needs for these ages and eventually give a better representation of

the oral health status and needs of Jeddah and Bahrah’s population

• Including private dentists in the total service output and busyness census of

dentists to obtain their annual clinical working time so that the needs for a

dental workforce in Jeddah and Bahrah can be better projected

• Conducting an ongoing census of the total service output and busyness of

dentists

• Conducting a more detailed survey on the non-clinical dentists’ time in an

attempt to reduce it to the minimum

• Conducting a comprehensive and closely monitored survey on Saudi dental

procedures’ time estimates in order to provide future projections of treatment

needs times in Saudi Arabia

• Collecting data on the current capacity of all dental schools in Saudi Arabia

which will aid in future planning for more dental schools or expanding the

capacity of the existing schools

• Conducting a repeated cross-sectional study to follow up on the prevalence

and incidence rates of oral diseases in Jeddah and Bahrah

• Obtaining longitudinal data on services and needs on regular, irregular and

emergency dental visitors, measured independently would be a high priority in

improving future estimates. That could lead to a much better modeling that

could account for both needs and demands and the transition of patients from

one state of visiting, say irregular, to another of maintenance care.

In Jeddah, the high use of private dentists (48.2% as seen in Table 12) strongly

suggests the need for more investigation among private dentists which was not

explored in this study due to limitations in time and resources. This high use of

private dentists in Jeddah may be caused by barriers that are resonating among

Jeddah residents such as long waiting time and avoiding having time off school

or work to attend at a government clinic. On the care provision side at private

clinics, no data exist on the type or level of care being delivered there which if

110

made available would provide more clarification on the pattern of care provided

there as compared to government clinics. However, these factors (wait times,

pattern and quality of care in private clinics as compared to government clinics)

are still to be investigated and no statement can be made in that regard until full

exploration of such matter takes place.

Nonetheless the omission of the services provided by private dentists might have

affected our projections of the needed dental workforce since we could only

estimate the current contribution of the private sector. Thus the omission of

private dentists from the census of dentists is recognized as one of the limitations

of this study which added uncertainty to the projections of supply in terms of the

total service output.

Although this added uncertainty may have biased our projections of the required

dental work force for Jeddah, ignoring this sector totally would have resulted in

more biased projections given the current situation of the high use of private

dentists by Jeddah residents and the overlap between the government and the

private sectors demonstrated by having dentists who work for both sectors. Thus

future studies that aim at collecting data on both the government and private

providers will eventually help in producing a better and more balanced projection

of the dental workforce for both sectors. This also means that collecting data on

the pattern of dental care provision, levels of care and the type of clients

receiving care in private clinics, which may or may not differ from that of

government clinics, are essential to have a detailed view of what is happening in

both sectors. Ultimately this will allow us to better estimate and project a more

balanced mix of supply whether being geared more toward government or private

dentists who are required to meet the treatment needs of the community.

The outcomes of future efforts to reduce the barriers to dental services provision

among government clinics (such as reducing long waiting times) will dictate

whether or not future projections of the dental workforce will be geared toward

providing more for either the government or the private sector or with differing

degrees among both.

111

7.5 Impacts and Implications

Health human resources planning and projection of the dental workforce is

indeed a complicated area of research. This is due to the inherent multifactorial

nature and limitations associated with the different components of such projects.

Among these factors are:

A) The training and production of the dental workforce:

This may involve opening more schools or increasing the capacity of the

classes of existing dental schools. This would provide a more stable

workforce than one requiring importing an expatriate dental workforce (foreign

trained dentists) but if not balanced with the annual attrition rate and the

changing oral disease levels, could result in an oversupply of the workforce

which then can be difficult to manage and correct.

B) The importing of foreign-trained dental workforce:

This may provide a temporary solution to the existing shortage without

risking a permanent oversupply if disease levels do change. However, this

approach could face financial and infrastructure barriers.

C) The rate of attrition of the existing dental workforce

The models suggested in this study will indeed stimulate discussion among

decision makers who will be enlightened about the different implications

associated with each model. Implementing any of the suggested models will not

come about overnight; indeed, it needs a few years to build up the desired

workforce. However, before this the Saudi government has to work on

:

This could be due to retirement or early retirement, leaves (sick or maternity

leaves) which can not be predicted, migration to other cities within the

country or to other countries or migration to other administrative or even

sometimes non-health related jobs, and/ or death.

Acknowledging these changing factors and anticipating them is essential to

comprehensive and potentially successful health human resources planning.

112

implementing certain important policies that would strongly amend the

implementation of any chosen model. The main aim of these policies is to help

reduce the burden of illness and invest more in prevention care in an attempt to

help improve the oral health outcomes of the Saudi population. Among these

policies are: the implementation of a population-wide approach of water

fluoridation, promoting the use of fluoridated tooth paste, the use of dental

screening, and professionally applied topical fluoride and fissure sealant

programs for schoolchildren. The government should also be encouraged to

utilize health promoters, increase the dental hygienists workforce and possibly

think of introducing dental therapists into the mix of dental health care providers

who can run school-based programs and provide preventive and curative care for

schoolchildren. Failure to implement these policies which favor prevention

strategies will most likely result in an endless need of increasing the dental

workforce and subsequently wasting community resources.

The Saudi government could work towards building up this workforce either by

increasing the capacity of existing dental schools or by opening new dental

schools; in either case, it has to be done with extreme caution. While this build-up

of the workforce is taking place, the government could temporarily hire expatriate

dentists (foreign trained dentists) who are employed on short-term contracts. It is

important also to note that the projection of health human resources should be

accompanied by an increase in the capacity of such non-human resources as

dental operatories. As well, human resources staff such as dental assistants,

secretarial and other managerial and supporting staff need to be increased.

Encouraging a steady increase in the build-up of the dental workforce would

provide enough time to accommodate the associated expansion in non-human

resources, i.e., buildings and facilities that can accommodate the desired

increase in the dental workforce.

Building the required number of the Saudi workforce could be reached in 20

years from now, after which the Saudi government would have reduced the use

of expatriate dentists to the minimum. This build up of the Saudi workforce over

the next 20 years can come about without concern regarding the annual attrition

rate of the current workforce due to retirement, since the average age of the

113

current workforce is about 38 (see Table 28). Among the current workforce of

dentists in Jeddah and Bahrah, 65.7% are aged 40 or younger and 34.3% are

over 40. Over the coming 20 years, the average annual attrition rate of dentists is

estimated at 1.7%. This means that no major attrition will affect the current dental

workforce since the age of retirement for Saudi government employees is set at

60. However, it is worth acknowledging that other factors can contribute to the

attrition of the dental workforce as mentioned earlier in this section.

For example, currently on the supply side, the Faculty of Dentistry at King

Abdulaziz University in Jeddah graduates about 120 dentists annually (60 males

and 60 females). This means if we assumed that the Saudi government was to

recruit all who graduate from the dental school in Jeddah to work in Jeddah and

Bahrah for the next 20 years, before the majority of the current staff start to retire,

it would have recruited 2,400 FTE dentists which would bring the total supply of

FTE dentists to 2,689 (2400 + 289 [the currently available number of FTE dentists

in Jeddah and Bahrah]). This is just under the desired workforce number of 2,930

FTE dentists that was suggested in model 16 (see Table 43). However, there is

no guarantee that all dentists who graduate from King Abdulaziz dental school

would want to work for the Ministry of Health, let alone work in Jeddah or Bahrah.

However, the number of graduates in the following years (that come after the first

20) should be monitored closely and the dental schools’ class-sizes should be

adjusted accordingly as the annual attrition rate may not be large enough to

balance the annual production of dentists. In the end, the Saudi government

should work on balancing the production of dentists so that when the desired

number of the dental workforce has been reached, this number should be kept as

stable as possible by graduating dentists at a pace guided by the annual dentists’

attrition rate.

Obviously, as we mentioned in the previous paragraph, the aim here is to

balance the number of the dental workforce at all times so that the annual attrition

in the workforce is replaced by approximately the same number of freshly

graduated dentists over 20 or so years. However, while this is happening, the

backlog of oral diseases will continue to build up since the currently available and

growing dental workforce will not be large enough to cope with the projected

114

annual incidence of oral diseases in Jeddah and Bahrah. The Saudi government

should therefore start working toward building the desired workforce steadily but

work at a faster pace to increase the dental hygienists’ workforce by temporarily

hiring expatriate dental hygienists, opening new dental hygiene programs or by

increasing the capacity of existing dental hygiene programs. This interest in

building the dental hygienists’ workforce will facilitate quicker implementation of

oral health promotion/ prevention programs and thereby reduce the incidence of

oral diseases and conditions in Jeddah and Bahrah while the desired dental

workforce is being built. It is also advisable that periodic cross-sectional surveys

be planned and implemented every three to five years to monitor the incidence

and the prevalence of oral diseases in Jeddah and Bahrah. This would allow re-

projection of the desired dental workforce based on continually updated incidence

and prevalence data that will simultaneously help better adjust dental schools’

class-sizes to avoid over production of the dental workforce.

Considering the study results by the General Directory of Health Affairs of Jeddah

and the ministries of Economy and Planning, Health, Higher Education and

Education in Saudi Arabia would hopefully help in better planning and improved

oral health outcomes for the people of Jeddah and Bahrah, and eventually the

rest of the Saudi population when other regions of the country were to follow a

similar planning strategy. This in turn will lead to a fairer distribution of both

community resources, and the Saudi government’s budget. It may also free up

resources that can be used to solve other health related or non-health related

problems thus addressing any associated opportunity cost. This study should be

conducted on a wider scale, after overcoming the limitations mentioned earlier, to

include all administrative regions of Saudi Arabia and be repeated every three to

five years to monitor the disease levels and utilization rates and to better inform

the planning authorities in Saudi Arabia about the health human resources

requirements for dentistry for the Saudi population.

7.6 Potentials for Success

Rosenheck has identified several key strategies essential to the success of

implementing research findings (103). Among these key strategies are

115

constructing coalitions between researchers and policy makers and linking

research recommendations to organizational goals and values. Therefore it is

worth while to point out that the findings of this research are considered highly

relevant and possess practical and political benefits for the Saudi government.

This aspect of the research findings is supported by several factors that likely

spell success for the knowledge transfer of this study’s findings. These factors

include first, the initiative that was launched in 2006 by King Abdullah Bin

Abdulaziz, the King of the Kingdom of Saudi Arabia, in which he ordered the

formation of a special committee to study and establish a health human

resources strategic plan aimed at predicting the health care workforce needed to

meet the needs of the Saudi population and detailing needs for physicians and

dentists. This initiative, which falls within the mainstream of this research, reflects

the interest of the Saudi government, represented by its king, in strategic

planning for health human resources and reflects the eagerness of the Saudi

government to embark on change and improvement.

Second, the positive verbal feedback that was obtained from chief dental officers

of different government organizations in Jeddah city and nationally that took

place during the initial data collection phase of the research project suggest a

high level of interest in the research findings and reflect the poverty of baseline

data on dental human resources in Saudi Arabia.

Third, the government began to invest more in higher education in something I

call “ scholarships epidemic”, a new movement which started in 2005 by,

awarding internal (in Saudi Arabia) and external (out of Saudi Arabia)

scholarships to high school and university graduates as well as to government

employees. These awards are offered today by many ministries but the majority

of them come from the ministry of higher education and the ministry of health.

This high interest showed by the Saudi government in investing in higher

education was also reflected in what I call “college and university booms”, and

manifested by several royal decrees that established new colleges and

universities across the country. As an example, dental schools have increased in

number from two (in 1993) to nine (in 2007) of which two were founded in 2007.

The “scholarships epidemic” and the “college and university booms” phenomena

116

demonstrate a clear desire within the Saudi government to invest more in higher

education, making the uptake of the research recommendations more likely to

happen, especially given the nature of this research which focuses on dental

human resource planning.

Finally, the existing good connections and mutual understanding between the

principal researcher and chief dental officers of different government

organizations in Jeddah city, as well as nationally, add to the high potential for

improving and adopting the research recommendations.

117

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126

9.0 Tables

127

Table 1: Types and numbers of dental care providers and dentist population ratio for Saudi Arabia (33).

Total Number of Dental Personnel

Population to Dentist Ratio

Type of Dental Personnel

Dentists

4,073

• 1581 work for the

Ministry of health

• 641 work for other

government

bodies

• 1851 work for the

private sector

5235 : 1

Dental Therapists NA*

Dental Hygienists No data available

Dental Assistants No data available

Denturists NA*

* NA = Not Applicable

128

Table 2: The distribution of target population and the degree of comprehensive provision of health services among different government bodies

Government Body

Target Population Degree of

Comprehensive Health Services

The Ministry of Health

Saudis

All are eligible with no restriction to geographic distribution

Health care centers, hospitals, medical, dental and drugs

Non Saudis

Eligibility is restricted to legal residents who are under individual affiliations


The National Guard

Employees of the National Guard and their dependants


The Armed Forces

Employees of the Armed Forces and their dependants


The Interior Security

Forces

Employees of the Interior Security Forces and their dependants


The Ministry of Higher

Education (university hospitals)

Saudis

All are eligible

Hospitals, medical, dental and drugs

Non Saudis

Eligibility is restricted to legal residents who are under individual affiliations

The Ministry of

Education

Government schoolchildren

Health care centers, medical (primary care), dental (primary care) and drugs

The Saudi Intelligence Agency

Employees of the Saudi Intelligence Agency and their dependants

Health care centers, medical, dental and drugs

129

Table 3: Schematic representation of the interpretation of survey data from field patient examinations to treatment needs to time requirement estimates

* A: gives the prevalence and mean severity of dental conditions ** BCD: gives the prevalence and mean numbers of needed treatments *** E: gives the mean time, required to meet the treatment needs, by: person, category; (age, gender

or area of residence), and by type of treatment required; (simple or complex)

State

Condition Present

*A

Treatment

Times (in hours)

***E

Needed

**B

Type

Yes Yes Simple **C

No No Complex **D Diagnosis Yes

No Complex Prevention Yes Simple

No Complex Cleft lip and or cleft palate Yes Yes Simple

No No Complex Oral Mucosa Yes Yes Simple

No No Complex Dentate (prosthodontics) Yes Yes Simple

No No Complex For dentate participants only:

Enamel Opacities/ Hypoplasias and Fluorosis

Yes Yes Simple No No Complex

Periodontal Diseases Yes Yes Simple No No Complex

Decayed teeth Yes Yes Simple No No Complex

Missing teeth Yes Yes Simple No No Complex

Filled teeth Yes Yes Simple No No Complex

Total of Hours Required for Simple Treatments per Patient

Total of Hours Required for Complex Treatments per Patient

Grand Total of Hours Required per Patient

130

Table 4: Dental procedures’ time estimate as adopted from the Ontario Dental Association (ODA) fee guide for the different treatment needs.

ODA Procedure Code Treatment Type Time Estimate in Minutes

Examination & Diagnosis

01102 Examination and diagnosis for permanent dentition 30.0

01103 Examination and diagnosis for mixed dentition 22.5

Preventive

12101 Topical fluoride application 7.5

13401 Pit and fissure sealant 7.5

Restorative

Weighted time for one surface filling* One surface amalgam (for posterior teeth) or composite (for anterior teeth) filling 18.9

Weighted time for two surfaces filling* Two surfaces amalgam (for posterior teeth) or composite (for anterior teeth) filling

30.45

27602 Porcelain veneer or laminate 105.0

27211 Porcelain fused to metal crown 150.0

* Calculations were based on weighting the treatment times that were obtained from the ODA fee guide after factoring in the number

of teeth needing a particular filling (one or two surfaces filling). Three treatment codes were used for each type of filling: a) for one surface filling: code 23411 for anterior teeth, code 21211 for premolars and code 21221 for molars. b) for two surfaces filling: code 23412 for anterior teeth, code 21212 for premolars and code 21222 for molars.

131

Cont. Table 4.

ODA Procedure Code Treatment Type Time Estimate in Minutes

Endodontic

Weighted time** Root canal treatment 166.2

Periodontal

11117 Scaling (scores 2 & 3 of the CPITN) 7.5 / sextant

43421 Complex treatment (score 4 of the CPITN) 15.0 / sextant

Prosthetic

67211 Porcelain fused to metal retainers (bridge) 150.0

53201 Tooth-borne partial denture with cast frame , clasps and rests (per arch) 195.0

67211+53201 A combination of bridge and partial denture 345.0

51101 Complete denture (per arch) 165.0

Surgical

71101 Uncomplicated tooth extraction 15.0

** Calculations were based on weighting the treatment times that were obtained from the ODA fee guide after factoring in the number

of teeth needing Endodontic treatment. Three treatment codes were used in the weighting process: code 33111 for anterior teeth, code 33121 for premolars and code 33131 for molars.

132

A) Oral health perceptions and behaviors: Table 5: Participants’ perceptions of oral health rating and satisfaction for all groups and by age, gender and place of residence.

Oral Health Rating %

Mouth Health Satisfaction %

Teeth Appearance Satisfaction %

Good to Excellent

Poor to Fair DK* Satisfied Dissatisfied DK* Satisfied Dissatisfied DK*

All groups n=2000 76.8 20.4 2.9 76.3 20.7 3.1 70.3 28.4 1.4

Age

6 Y n=400 81.3 18.0 0.8 83.3 15.8 1.0 78.5 21.0 0.5

12 Y n=400 83.0 8.0 9.0 79.0 13.0 8.0 66.0 31.0 3.0

16 Y n=400 86.0 11.5 2.5 79.3 17.8 3.0 70.0 27.0 3.0

24-29 Y n=400 68.0 30.5 1.5 72.3 25.5 2.3 68.0 31.8 0.3

35-44 Y n=400 65.8 33.8 0.5 67.5 31.3 1.3 69.0 31.0 0.0

Gender M

n=1000 77.2 20.6 2.2 78.1 18.9 3.0 70.1 28.3 1.6

F n=1000 76.4 20.1 3.5 74.4 22.4 3.2 70.5 28.4 1.1

Place of Residence

J** n=1500 79.1 18.1 2.8 78.7 18.7 2.7 71.2 27.8 1.0

B*** n=500 70.0 27.0 3.0 69.0 26.6 4.4 67.6 30.0 2.4

NOTE: Row totals may not add due to rounding

* DK =Don’t know or don’t remember ** J =Jeddah *** B =Bahrah

133

Table 6: The impact of oral health problems on avoiding eating, speaking or performing usual daily activities in the past 12 months for all groups and by age, gender and place of residence.

NOTE: Row totals may not add due to rounding * DK =Don’t know or don’t remember ** J =Jeddah *** B =Bahrah

Avoiding Eating %

Avoiding Speaking %

Avoiding Usual Daily Activities

%

Yes No DK* Yes No DK* Yes No DK*

All groups n=2000 74.9 22.8 2.4 36.2 60.1 3.8 22.8 73.3 4.0

Age

6 Y n=400 67.5 31.3 1.3 23.5 73.5 3.0 19.3 78.3 2.5

12 Y n=400 71.8 24.3 4.0 29.0 64.0 7.0 22.0 70.3 7.8

16 Y n=400 68.0 27.3 4.8 34.3 60.5 5.3 25.0 71.8 3.3

24-29 Y n=400 84.3 15.3 0.5 50.3 48.3 1.5 27.0 70.3 2.8

35-44 Y n=400 83.0 15.8 1.3 43.8 54.3 2.0 20.8 75.8 3.5

Gender M

n=1000 75.4 22.8 1.8 37.2 58.7 4.1 22.9 73.3 3.8

F n=1000 74.4 22.7 2.9 35.1 61.5 3.4 22.7 73.2 4.1

Place of Residence

J** n=1500 77.7 20.2 2.1 36.5 60.1 3.4 23.4 73.5 3.1

B*** n=500 66.6 30.4 3.0 35.2 60.0 4.8 21.0 72.6 6.4

134

Table 7: Reported experiences of different oral health problems during the past month for all groups and by age, gender and place of residence.

Toothache %

Toothache with Cold/ Hot Drinks

& Food %

TMJ Pain %

Severe Oral Pain at Night

%

Pain Elsewhere

in the Mouth

%

Gum Bleeding

with Brushing

%

Dry Mouth %

Bad Breath

%

Yes DK* Yes DK* Yes DK* Yes DK* Yes DK* Yes DK* Yes DK* Yes DK*

All groups n=2000 43.3 3.3 50.0 3.2 14.4 4.1 17.0 4.0 21.1 5.7 56.5 3.0 21.7 5.8 29.9 8.3

Age

6 Y n=400 38.0 2.5 32.5 2.3 4.3 3.3 14.5 3.8 14.0 6.0 26.3 4.3 9.0 5.8 27.5 6.0

12 Y n=400 39.8 3.0 50.3 4.3 12.8 5.3 17.5 6.3 22.0 6.5 60.8 3.5 22.8 7.8 25.5 10.5

16 Y n=400 40.5 6.0 52.8 5.5 16.8 6.0 15.8 3.5 18.0 7.0 64.0 4.8 22.3 7.0 26.8 13.3

24-29 Y n=400 49.0 2.0 60.8 2.3 16.0 2.8 18.3 3.0 25.0 5.0 72.8 1.5 24.3 4.8 36.0 6.5

35-44 Y n=400 49.3 2.8 53.5 1.8 22.0 3.0 19.0 3.3 26.5 3.8 58.5 1.0 30.0 3.5 33.5 5.3

Gender M

n=1000 42.2 3.2 50.3 3.3 13.0 4.3 15.9 3.1 19.9 6.4 54.6 3.2 21.0 5.4 32.1 7.5

F n=1000 44.4 3.3 49.6 3.1 15.7 3.8 18.1 4.8 22.3 4.9 58.3 2.8 22.3 6.1 27.6 9.1

Place of Residence

J** n=1500 43.4 3.3 49.7 3.5 13.9 4.0 16.1 4.1 21.6 5.3 55.5 3.1 21.5 5.9 28.0 8.5

B*** n=500 43.0 3.2 50.8 2.4 15.8 4.2 19.6 3.6 19.6 6.6 59.2 2.8 22.2 5.4 35.4 7.8


135

Table 8: Perceived oral health treatment needs for all groups and by age, gender and place of residence.


Nothing Needed

%

Teeth Cleaning

%

Relief of Pain

%

Treatment of Dental

Trauma %

Denture or Bridge Repair

%

Treatment of TMD

% Teeth Filling

%

All groups n=2000 7.5 57.5 18.4 6.6 9.7 2.9 33.9

Age

6 Y n=400 19.0 44.5 15.3 10.3 2.0 1.0 33.8

12 Y n=400 10.5 47.0 21.5 1.5 4.3 2.5 17.3

16 Y n=400 2.5 59.0 15.3 5.5 4.0 3.8 28.5

24-29 Y n=400 3.0 70.0 20.3 6.3 14.0 3.3 43.0

35-44 Y n=400 2.3 67.0 19.8 9.3 24.0 3.8 46.8

Gender M

n=1000 8.1 57.1 18.6 6.9 9.1 1.9 32.2

F n=1000 6.8 57.9 18.2 6.2 10.2 3.8 35.5

Place of Residence

J** n=1500 5.5 58.9 19.3 7.5 9.4 3.1 36.1

B*** n=500 13.4 53.2 15.6 3.8 10.4 2.0 27.2

136

Cont. Table 8.


Teeth

Replacement %

Teeth Extraction

%

Gum Treatment

%

Root Canal Treatment

%

Orthodontic Treatment

%

Teeth Whitening

% DK* %

All groups n=2000 7.6 11.6 21.6 8.8 21.4 46.0 4.4

Age

6 Y n=400 2.0 17.0 10.3 3.8 10.5 12.8 6.0

12 Y n=400 0.8 8.5 9.3 4.8 30.3 48.0 6.3

16 Y n=400 4.8 6.5 25.5 6.3 32.5 61.0 4.0

24-29 Y n=400 10.5 11.3 32.5 12.5 24.0 57.3 2.0

35-44 Y n=400 20.0 14.8 30.3 16.5 9.5 51.0 3.5

Gender M

n=1000 7.9 11.4 19.9 6.9 18.8 41.9 4.4

F n=1000 7.3 11.8 23.2 7.9 23.9 50.1 4.3

Place of Residence

J** n=1500 8.3 12.0 21.3 9.8 23.7 49.4 3.7

B*** n=500 5.4 10.4 22.4 5.6 14.2 35.8 6.2

137

Table 9: The frequency of teeth brushing for all groups and by age, gender and place of residence.

NOTE: Row totals may not add due to rounding * J =Jeddah ** B =Bahrah

> 2 Times / Day %

2 Times / Day %

1 Time / Day %

< 1 Time / Day but

> 1 Time / Week %

1 Time / Week %

< 1 Time / Week %

All groups n=2000 15.2 38.8 25.3 8.4 5.3 7.2

Age

6 Y n=400 7.3 35.8 33.8 10.5 4.8 8.0

12 Y n=400 17.8 38.0 21.8 6.5 8.3 7.8

16 Y n=400 15.0 34.3 23.0 8.8 7.5 11.5

24-29 Y n=400 15.3 40.5 25.5 9.5 3.8 5.5

35-44 Y n=400 20.5 45.3 22.3 6.5 2.3 3.3

Gender M

n=1000 10.2 27.1 30.3 11.9 8.7 11.8

F n=1000 20.1 50.4 20.2 4.8 1.9 2.6

Place of Residence

J* n=1500 15.9 41.1 25.7 7.9 4.1 5.4

B** n=500 13.0 31.6 24.0 9.8 9.0 12.6

138

B) Dental visits:

Table 10: The frequency of regular dental visits for all groups and by age, gender and place of residence.


(A) > Once /

Year %

(B) Once / Year

%

(A + B) Regular Dental

Visitors %

(C) < Once / Year

%

(D) Only for

Emergency Care

%

(E1) Never

%

(E2) DK* %

(C+D+E) Irregular Dental

Visitors %

All groups n=2000

13.6 (272)

11.9 (238)

25.5 (510)

3.7 (74)

52.6 (1,052)

16.8 (336)

1.4 (28)

74.5 (1490)

Age

6 Y n=400

8.5 (34)

10.0 (40)

18.5 (74)

2.0 (8)

49.3 (197)

30.0 (120)

0.2 (1)

81.5 (326)

12 Y n=400

19.0 (76)

11.0 (44)

30.0 (30)

3.5 (14)

40.0 (160)

23.5 (94)

3.0 (12)

70.0 (280)

16 Y n=400

15.8 (63)

8.0 (32)

23.8 (95)

3.3 (13)

52.5 (210)

18.7 (75)

1.7 (7)

76.2 (305)

24-29 Y n=400

12.5 (50)

14.5 (58)

27.0 (108)

4.5 (18)

57.3 (229)

9.8 (39)

1.4 (6)

73.0 (292)

35-44 Y n=400

12.3 (49)

16.0 (64)

28.3 (113)

5.3 (21)

64.0 (256)

2.0 (8)

0.4 (2)

71.7 (287)

Gender M

n=1000 10.8 (108)

11.8 (118)

22.6 (226)

4.0 (40)

53.3 (533)

18.8 (188)

1.3 (13)

77.4 (774)

F n=1000

16.4 (164)

12.0 (120)

28.4 (284)

3.4 (34)

51.9 (519)

14.8 (148)

1.5 (15)

71.6 (716)

Place of Residence

J** n=1500

15.5 (233)

12.3 (185)

27.8 (418)

3.7 (55)

54.7 (821)

12.3 (184)

1.5 (22)

72.2 (1,082)

B*** n=500

7.8 (39)

10.6 (53)

18.4 (92)

3.8 (19)

46.2 (231)

30.4 (152)

1.2 (6)

81.6 (408)

139

Table 11: Time since last dental visit, reason for last dental visit and the degree of satisfaction with the last dental visit for all groups and by age, gender and place of residence.



Time Since Last Dental Visit

% Reasons for Last Dental Visit

% Degree of Satisfaction with

Last Dental Visit %

≤ 6 months

> 6 months DK*

Went on own or called by a

dentist for exam or

treatment

Something was

hurting or bothering

Went for treatment of a condition previously diagnosed

DK* Satisfied Dissatisfied DK*

All groups n=2000 31.2 57.5 11.4 21.5 47.2 10.5 20.9 67.2 11.9 21.0

Age

6 Y n=400 24.5 65.0 10.5 17.5 39.8 5.5 37.3 51.8 11.8 36.5

12 Y n=400 25.3 49.8 25.0 18.8 41.3 10.3 29.8 63.5 7.8 28.8

16 Y n=400 30.0 57.5 12.5 21.3 42.0 14.8 22.0 64.5 11.8 23.8

24-29 Y n=400 36.0 59.5 4.5 22.3 54.0 12.3 11.5 72.0 16.0 12.0

35-44 Y n=400 40.0 55.5 4.5 27.5 59.0 9.5 4.0 84.0 12.0 4.0

Gender M

n=1000 29.2 61.1 9.7 20.6 45.9 9.4 24.1 65.3 11.5 23.2

F n=1000 33.1 53.8 13.1 22.3 48.5 11.5 17.7 69.0 12.2 18.8

Place of Residence

J** n=1500 33.5 55.3 11.2 23.0 48.5 12.0 16.5 72.1 11.7 16.2

B*** n=500 24.0 64.0 12.0 16.8 43.4 5.8 34.0 52.4 12.2 35.4

140

Table 12: The frequency of dental visits to the different types of dental clinics that Saudi citizens in Jeddah and Bahrah usually go to for all groups and by age, gender and place of residence.

Types of Dental Clinics Usually Visited %

Government Clinics

Private Clinics Both DK*

All groups n=2000 22.1 41.7 17.0 19.2

Age

6 Y n=400 20.5 38.3 13.5 27.8

12 Y n=400 24.5 31.3 9.8 34.5

16 Y n=400 22.5 40.0 15.8 21.8

24-29 Y n=400 22.8 47.0 20.3 10.0

35-44 Y n=400 20.3 52.0 25.8 2.0

Gender M

n=1000 25.0 36.4 18.0 20.6

F n=1000 19.2 47.0 16.0 17.8

Place of Residence

J** n=1500 19.1 48.2 17.7 15.1

B*** n=500 31.2 22.2 15.0 31.6



141

C) Epidemiologically assessed oral health status:

Table 13: The frequencies of different oral mucosal conditions for all groups and by age, gender and place of residence.

Condition

Normal %

Leukoplakia %

Ulceration (Aphthous, Herpetic,

Traumatic) %

Acute Necrotizing Gingivitis

%

Candidiasis %

Abscess %

Other Conditions

%

All groups n=2000 92.2 0.8 2.3 0.3 0.7 2.1 2.2

Age

6 Y n=400 92.8 0.0 1.8 0.0 0.3 4.0 1.3

12 Y n=400 93.5 0.0 1.5 0.3 0.3 1.8 3.3

16 Y n=400 91.3 0.8 2.5 0.3 0.8 2.0 2.8

24-29 Y

n=400 92.0 1.3 3.3 0.5 1.8 0.3 1.8

35-44 Y

n=400 91.5 2.0 2.3 0.3 0.3 2.3 2.0

Gender M

n=1000 92.4 0.8 2.8 0.2 0.8 2.5 0.9

F n=1000 92.0 0.8 1.7 0.3 0.5 1.6 3.5

Place of Residence

J* n=1500 93.8 0.4 2.1 0.1 0.7 1.8 1.3

B** n=500 87.4 2.0 2.8 0.8 0.4 2.8 5.0

* J =Jeddah ** B =Bahrah

142

Table 14: Enamel opacities and hypoplasia in the permanent dentition for all groups and by age, gender and place of residence.

Normal

(all permanent teeth) %

Enamel Opacity (on one or more permanent teeth)

%

Enamel Hypoplasia with or without Opacity

(on one or more permanent teeth) %

All groups n=2000 18.6 57.5 8.4

Age

6 Y n=400 2.5 28.0 2.5

12 Y n=400 33.3 56.8 4.8

16 Y n=400 30.5 58.3 3.3

24-29 Y n=400 18.0 71.3 15.8

35-44 Y n=400 11.0 73.0 15.5

Gender M

n=1000 18.6 55.7 4.1

F n=1000 18.5 59.2 12.6

Place of Residence

J* n=1500 18.8 55.5 8.5

B** n=500 17.8 63.2 7.8


143

Table 15: The prevalence of dental fluorosis by severity level for all groups and by age, gender and place of residence.

Severity of Fluorosis

Normal %

Questionable %

Very Mild %

Mild %

Moderate %

Severe %

All groups n=2000 50.5 22.7 12.5 5.5 2.7 0.2

Age

6 Y n=400 52.0 9.8 6.5 2.3 1.8 0.0

12 Y n=400 63.8 23.0 8.8 2.3 2.3 0.0

16 Y n=400 63.5 20.8 9.5 3.5 1.5 0.0

24-29 Y n=400 40.3 28.5 15.5 10.5 3.8 1.0

35-44 Y n=400 32.8 31.3 22.0 8.8 4.0 0.0

Gender M

n=1000 45.8 22.6 16.0 6.4 2.9 0.3

F n=1000 55.1 22.7 8.9 4.5 2.4 0.1

Place of Residence

J* n=1500 52.9 23.5 11.6 3.7 1.9 0.2

B** n=500 43.0 20.0 15.0 10.8 4.8 0.2


144

Table 16: The overall frequencies of the different scores of the community periodontal index for treatment needs (CPITN) for all groups and by age, gender and place of residence.

Score

0 Healthy

%

1 Bleeding

%

2 Calculus

%

3 Pocket 4-5mm

%

4 Pocket ≥ 6mm

% All groups

n=2000 13.9 23.5 55.0 6.0 1.6

Age

6 Y n=400 44.0 50.8 5.3 NA* NA*

12 Y n=400 12.0 37.8 50.3 NA* NA*

16 Y n=400 7.5 20.8 65.8 5.8 0.3

24-29 Y n=400 3.8 5.0 77.0 9.8 4.5

35-44 Y n=400 2.3 3.3 76.8 14.5 3.3

Gender M

n=1000 16.5 20.8 56.9 5.3 0.5

F n=1000 11.3 26.2 53.1 6.7 2.7

Place of Residence

J** n=1500 14.8 22.1 56.2 5.6 1.3

B*** n=500 11.2 27.6 51.4 7.2 2.6

* NA = Not Applicable ** J =Jeddah *** B =Bahrah

145

Table 17: The frequencies of the different scores of the community periodontal index for treatment needs (CPITN) in each sextant for all groups and by age, gender and place of residence.

Sextant

1 2 3

Score

0 Healthy

%

1 Bleeding

%

2 Calculus

%

3

Pocket 4-5mm

%

4

Pocket ≥ 6mm

%

0 Healthy

%

1 Bleeding

%

2 Calculus

%

3

Pocket 4-5mm

%

4

Pocket ≥ 6mm

%

0 Healthy

%

1 Bleeding

%

2 Calculus

%

3

Pocket 4-5mm

%

4

Pocket ≥ 6mm

% All groups

n=2000 38.3 29.3 28.3 2.8 0.6 54.5 26.0 15.4 1.5 0.3 38.9 28.5 28.5 3.0 0.6

Age

6 Y n=400 75.3 22.8 2.0 NA* NA* 76.8 13.8 0.0 NA* NA* 77.0 22.0 1.0 NA* NA*

12 Y n=400 34.5 43.3 22.3 NA* NA* 49.3 41.0 9.8 NA* NA* 36.0 43.8 20.3 NA* NA*

16 Y n=400 33.0 34.0 29.5 2.5 0.0 49.5 33.5 15.5 1.5 0.0 33.5 33.8 29.8 2.0 0.0

24-29 Y n=400 20.3 24.3 47.8 5.3 1.8 46.8 22.5 27.3 2.5 0.5 17.5 20.8 54.0 5.5 2.3

35-44 Y n=400 28.5 22.0 40.0 6.0 1.0 50.3 19.0 24.5 3.3 0.8 30.3 22.0 37.5 7.3 0.5

Gender M

n=1000 42.7 28.8 25.4 2.6 0.1 58.6 25.0 13.2 1.2 0.2 43.3 24.4 28.6 3.1 0.1

F n=1000 33.9 29.7 31.2 2.9 1.0 50.4 26.9 17.6 1.7 0.3 34.4 32.5 28.4 2.8 1.0

Place of Residence

J** n=1500 39.4 27.5 29.3 2.7 0.4 54.7 26.5 15.1 1.1 0.2 40.2 26.1 30.5 2.0 0.6

B*** n=500 35.0 34.6 25.2 3.0 1.0 54.0 24.2 16.4 2.6 0.4 34.8 35.6 22.4 5.8 0.4


146

Table 17. Cont.

Sextant

4 5 6

Score

0 Healthy

%

1 Bleeding

%

2 Calculus

%

3

Pocket 4-5mm

%

4

Pocket ≥ 6mm

%

0 Healthy

%

1 Bleeding

%

2 Calculus

%

3

Pocket 4-5mm

%

4

Pocket ≥ 6mm

%

0 Healthy

%

1 Bleeding

%

2 Calculus

%

3

Pocket 4-5mm

%

4

Pocket ≥ 6mm

% All groups

n=2000 32.6 31.8 32.5 1.3 0.6 35.0 13.4 50.2 0.5 0.2 34.7 34.2 28.3 1.7 0.5

Age

6 Y n=400 70.5 28.0 1.3 NA* NA* 84.8 9.0 3.5 NA* NA* 71.3 27.8 0.8 NA* NA*

12 Y n=400 33.8 47.3 18.5 NA* NA* 40.8 29.0 30.3 NA* NA* 34.8 52.5 12.8 NA* NA*

16 Y n=400 26.5 37.5 35.0 0.0 0.0 30.3 18.8 50.3 0.5 0.3 29.0 44.5 24.5 1.3 0.0

24-29 Y n=400 14.3 25.8 54.8 3.3 1.0 12.3 6.8 80.0 0.8 0.3 16.0 25.0 54.0 3.0 1.5

35-44 Y n=400 18.0 20.5 53.0 3.3 1.5 6.8 3.3 86.8 1.3 0.5 22.3 21.0 49.5 4.3 0.8

Gender M

n=1000 36.1 28.6 33.9 0.3 0.2 37.1 9.2 52.6 0.3 0.0 37.7 32.9 28.2 0.9 0.0

F n=1000 29.1 35.0 31.1 2.3 0.9 32.8 17.5 47.7 0.7 0.4 31.6 35.4 28.4 2.5 0.9

Place of Residence

J** n=1500 33.9 29.9 33.7 1.3 0.4 35.9 13.1 49.8 0.5 0.0 36.1 33.0 28.5 1.4 0.4

B*** n=500 28.8 37.6 29.0 1.4 1.0 32.2 14.2 51.2 0.4 0.8 30.2 37.6 27.8 2.6 0.6


147

Table 18: The overall frequencies of the periodontal loss of attachment (LOA) for ages 16,24-29 & 35-44 years and by gender and place of residence.

LOA Score

0 Healthy

%

2 LOA

6-8mm %

3 LOA

9-11mm %

All groups (16,24-29 & 35-44 y)

n=1200 96.8 2.8 0.4

Age

16 Y n=400 0.0 0.0 0.0

24-29 Y n=400 98.3 1.8 0.0

35-44 Y n=400 92.0 6.8 1.3

Gender M

n=600 96.0 3.3 0.7

F n=600 97.5 2.3 0.2

Place of Residence

J** n=900 97.4 2.1 0.4

B*** n=300 94.7 5.0 0.3


148

Table 19: Prosthetic status and needs for all groups and by age, gender and place of residence.

Dentate %

Have a Prosthesis in One or Both Arches

%

Needs a Prosthesis in One or Both Arches

% All groups

n=2000 99.9 3.8 23.0

Age

6 Y n=400 100.0 0.0 0.0

12 Y n=400 100.0 0.0 6.0

16 Y n=400 100.0 0.2 17.2

24-29 Y n=400 100.0 4.2 37.2

35-44 Y n=400 99.9 14.5 54.2

Gender M

n=1000 99.9 4.2 24.4

F n=1000 100.0 3.4 21.7

Place of Residence

J* n=1500 100.0 4.2 22.8

B** n=500 99.9 2.6 23.8


149

Table 20: Prevalence and severity of dental caries in the permanent dentition (Decayed, Missing and Filled permanent teeth - DMFT) for all groups and by age, gender and place of residence.

DMFT >0 DMFT D M F

% Mean SE* Mean SE* Mean SE* Mean SE* All groups

n=2000 71.3 4.92 0.12 2.66 0.07 0.89 0.05 1.37 0.06

Age

6 Y n=400 15.2 0.32 0.04 0.30 0.04 0.00 0.01 0.02 0.01

12 Y n=400 71.7 2.89 0.16 2.34 0.15 0.06 0.02 0.49 0.07

16 Y n=400 82.5 4.66 0.19 3.25 0.15 0.28 0.04 1.13 0.11

24-29 Y n=400 92.2 7.61 0.27 4.13 0.20 1.13 0.09 2.36 0.16

35-44 Y n=400 95.0 9.12 0.30 3.28 0.17 2.97 0.17 2.87 0.16

Gender M

n=1000 66.5 4.05 0.15 2.21 0.09 0.83 0.06 1.01 0.07

F n=1000 76.2 5.79 0.18 3.11 0.11 0.94 0.07 1.74 0.09

Place of Residence

J** n=1500 74.1 5.1 0.13 2.68 0.08 0.80 0.05 1.62 0.07

B*** n=500 63.0 4.37 0.26 2.59 0.16 1.16 0.12 0.62 0.07

* SE = standard or error ** J = Jeddah *** B = Bahrah

150

Table 21: Prevalence and severity of dental caries in the deciduous dentition (decayed, missing and filled deciduous teeth - dmft) for age 6 years and by gender and place of residence.

dmft >0 dmft d m F

% Mean SE* Mean SE* Mean SE* Mean SE*

Age 6 Y n=400 85.5 5.45 0.22 4.75 0.20 0.30 0.04 0.40 0.06

Gender M

n=200 81.5 4.93 0.30 4.38 0.29 0.28 0.06 0.28 0.06

F n=200 89.5 5.98 0.31 5.12 0.28 0.33 0.06 0.53 0.93

Place of Residence

J** n=300 91.0 6.03 0.25 5.22 0.24 0.34 0.05 0.47 0.07

B*** n=100 69.0 3.72 0.39 3.34 0.36 0.20 0.06 0.18 0.08


151

Table 22: Prevalence and severity of root caries in the permanent dentition (Decayed and Filled roots - DFR) for ages 16,24-29 & 35-44 years and by gender and place of residence.

DFR >0 DFR D F

% Mean SE* Mean SE* Mean SE* All Groups

(16,24-29 & 35-44 y) n=1200

13.1 0.28 0.03 0.27 0.03 0.01 0.01

Age

16 Y n=400 6.1 0.10 0.02 0.10 0.02 0.00 0.00

24-29 Y n=400 13.5 0.27 0.05 0.27 0.05 0.00 0.00

35-44 Y n=400 19.0 0.46 0.06 0.45 0.06 0.02 0.01

Gender M

n=600 14.3 0.32 0.04 0.32 0.04 0.00 0.00

F n=600 11.8 0.23 0.04 0.22 0.03 0.01 0.01

Place of Residence

J** n=900 11.2 0.21 0.03 0.21 0.03 0.00 0.01

B*** n=300 18.7 0.47 0.08 0.46 0.08 0.01 0.01


152

D) Treatment needs and time estimates:

Table 23: Mean annual individual treatment needs time for all groups and by age, gender and place of residence.


Needs

Preventive Treatment

Needs

Restorative Treatment

Needs

Periodontal Treatment

Needs

Endodontic Treatment

Needs

Surgical Treatment

Needs

Prosthetic Treatment

Needs

Total Treatment

Needs

Mean Examination & Diagnosis Time

(h*)

Mean Preventive

Time (h*)

Mean Restorative

Time (h*)

Mean Periodontal

Time (h*)

Mean Endodontic

Time (h*)

Mean Surgical

Time (h*)

Mean Prosthetic

Time (h*)

Mean Total Treatment

Time (h*)

All Groups n=2000 0.48 0.12 2.54 0.35 0.87 0.16 0.93 4.22

Age

6 Y n=400 0.38 0.10 4.03 0.01 1.94 0.28 0.02 4.43

12 Y n=400 0.38 0.13 1.75 0.14 0.59 0.09 0.18 2.45

16 Y n=400 0.50 0.18 2.12 0.24 0.62 0.03 0.56 3.42

24-29 Y n=400 0.50 0.11 2.77 0.44 0.67 0.15 1.50 5.21

35-44 Y n=400 0.50 0.06 2.30 0.41 0.54 0.24 2.39 5.60

Gender M

n=1000 0.45 0.04 2.46 0.24 0.89 0.16 0.99 4.14

F n=1000 0.45 0.20 2.72 0.26 0.86 0.16 0.88 4.30

Place of Residence

J** n=1500 0.45 0.10 2.60 0.25 0.83 0.15 0.87 4.18

B*** n=500 0.45 0.18 2.56 0.25 1.02 0.20 1.10 4.35

* h=hours ** J=Jeddah *** B=Bahrah

153

Table 24: Mean annual individual treatment needs time for the study’s five age groups after factoring in the caries increments (teeth/ year) and the modal restorative service time to reduce the restorative needs time for ages 12, 16, 24-29 and 35-44.


Needs

Preventive Treatment

Needs

Restorative Treatment

Needs

Periodontal Treatment

Needs

Endodontic Treatment

Needs

Surgical Treatment

Needs

Prosthetic Treatment

Needs

Total Treatment

Needs

Mean Examination & Diagnosis Time

(h*)

Mean Preventive

Time (h*)

Mean Restorative

Time (h*)

Mean Periodontal

Time (h*)

Mean Endodontic

Time (h*)

Mean Surgical

Time (h*)

Mean Prosthetic

Time (h*)

Mean Total Treatment

Time (h*)

Age

6 Y n=400 0.38 0.10 4.03 0.01 1.94 0.28 0.02 4.43

12 Y n=400 0.38 0.13 0.14 0.14 0.59 0.09 0.18 0.24

16 Y n=400 0.50 0.18 0.14 0.24 0.62 0.03 0.56 0.49

24-29 Y n=400 0.50 0.11 0.09 0.44 0.67 0.15 1.50 0.49

35-44 Y n=400 0.50 0.06 0.04 0.41 0.54 0.24 2.39 0.60

* h=hours

154

Table 25: Mean annual individual simple and complex periodontal treatment needs time in for all groups and by age, gender and place of residence.

Simple

Periodontal Treatment Needs Time (h*)

Complex Periodontal Treatment Needs Time

(h*) All Groups

n=2000 0.24 0.11

Age

6 Y n=400 0.01 0.00

12 Y n=400 0.14 0.00

16 Y n=400 0.24 0.00

24-29 Y n=400 0.42 0.02

35-44 Y n=400 0.39 0.02

Gender M

n=1000 0.23 0.01

F n=1000 0.24 0.02

Place of Residence

J** n=1500 0.24 0.01

B*** n=500 0.23 0.02


155

Table 26: Annual estimated treatment time per person requirements (hrs) according to reported visiting pattern.

Dental Visiting Pattern (A)

> Once / Year (B)

Once / Year Treatment time

that can only be met by dentists

h* (mean individual treatment time)

Treatment time that can be met by dental hygienists


Total h*

(n**)

Treatment time that can only be met by dentists


Treatment time that can be met by

dental hygienists h*

(mean individual treatment time)

Total h*

(n**)

Age

6 Y 4.47 0.12 4.59 (34) 3.34 0.10 3.44

(40)

12 Y 1.94 0.25 2.19 (76) 1.95 0.35 2.30

(44)

16 Y 2.38 0.41 2.79 (63) 2.71 0.27 2.98

(32)

24-29 Y 4.42 0.49 4.91 (50) 4.07 0.48 4.55

(58)

35-44 Y 5.28 0.48 5.76 (49) 3.52 0.43 3.95

(64)

* h=hours ** As obtained from Table 10

156

Cont. Table 26.

Dental Visiting Pattern (A & B)

Regular Dental Visitors (C)

< Once / Year Treatment time




h* (mean individual

treatment time)

Total h*

(n**)


h* (mean individual

treatment time)




Total h*

(n**)

Age

6 Y 3.86 0.11 3.97 (74) 6.53 0.02 6.55

(8)

12 Y 1.95 0.29 2.24 (30) 1.74 0.45 2.19

(14)

16 Y 2.49 0.37 2.86 (95) 2.38 0.33 2.71

(13)

24-29 Y 4.23 0.49 4.72 (108) 4.26 0.43 4.69

(18)

35-44 Y 4.28 0.45 4.73 (113) 5.84 0.46 6.30

(21)


157

Cont. Table 26.

Dental Visiting Pattern (D)

Only for Emergency Care (E)

Never Treatment time





Total h*

(n**)






Total h*

(n**)

Age

6 Y 5.07 0.12 5.19 (197) 3.24 0.12 3.36

(120)

12 Y 2.21 0.26 2.47 (160) 2.43 0.29 2.72

(94)

16 Y 3.71 0.40 4.11 (210) 1.87 0.56 2.43

(75)

24-29 Y 5.41 0.58 5.99 (229) 2.15 0.51 2.66

(39)

35-44 Y 5.51 0.45 5.96 (256) 4.26 0.54 4.80

(8)


158

Cont. Table 26.

Dental Visiting Pattern (C, D & E)

Irregular Dental Visitors Treatment time





Total h*

(n**)

Age

6 Y 4.42 0.12 4.54 (326)

12 Y 2.27 0.28 2.55 (280)

16 Y 3.16 0.44 3.60 (305)

24-29 Y 4.83 0.56 5.39 (292)

35-44 Y 5.49 0.46 5.95 (287)


159

Table 27: Annual estimated treatment time per person requirements (hrs) according to reported visiting pattern after factoring in the caries increments (teeth/ year) and the modal restorative service time to reduce the restorative needs time for ages 12, 16, 24-29 and 35-44.


> Once / Year (B)






Total h*

(n**)






Total h*

(n**)

Age

6 Y 4.47 0.12 4.59 (34) 3.34 0.10 3.44

(40)

12 Y 1.31 0.25 1.56 (76) 1.26 0.35 1.61

(44)

16 Y 1.40 0.41 1.81 (63) 1.71 0.27 1.98

(32)

24-29 Y 2.56 0.49 3.05 (50) 2.53 0.48 3.01

(58)

35-44 Y 3.83 0.48 4.31 (49) 2.53 0.43 2.96

(64)


160

Cont. Table 27.







h* (mean individual

treatment time)

Total h*

(n**)


h* (mean individual

treatment time)




Total h*

(n**)

Age

6 Y 3.86 0.11 3.97 (74) 6.53 0.02 6.55

(8)

12 Y 1.30 0.29 1.59 (30) 1.24 0.45 1.69

(14)

16 Y 1.50 0.37 1.87 (95) 1.26 0.33 1.59

(13)

24-29 Y 2.53 0.49 3.02 (108) 3.05 0.43 3.48

(18)

35-44 Y 3.09 0.45 3.54 (113) 3.86 0.46 4.32

(21)


161

Cont. Table 27.








Total h*

(n**)






Total h*

(n**)

Age

6 Y 5.07 0.12 5.19 (197) 3.24 0.12 3.36

(120)

12 Y 1.36 0.26 1.62 (160) 1.56 0.29 1.85

(94)

16 Y 2.34 0.40 2.74 (210) 1.15 0.56 1.71

(75)

24-29 Y 3.46 0.58 4.04 (229) 1.33 0.51 1.84

(39)

35-44 Y 4.02 0.45 4.47 (256) 3.75 0.54 4.29

(8)


162

Cont. Table 27.







Total h*

(n**)

Age

6 Y 4.42 0.12 4.54 (326)

12 Y 1.43 0.28 1.71 (280)

16 Y 1.98 0.44 2.42 (305)

24-29 Y 3.10 0.56 3.66 (292)

35-44 Y 4.00 0.46 4.46 (287)


163

E) Supply characteristics and supply time estimates: Table 28: Demographic of Jeddah and Bahrah government dentists by dentists’ current occupation.

Place of Practice %

Gender %

Nationality %

Qualification % Mean Dentists’

Age (years) Jeddah Bahrah Male Female Saudi Non-Saudi General

Practitioner Specialist

All Government Dentists

n=309 99.4 0.6 52.6 47.4 73.7 26.3 52.6 47.4 38.1

Ministry of Health Dentists

n=135 98.8 2.7 44.6 55.4 84.3 15.7 79.5 20.5 35.7

Ministry of Education Dentists

n=7 100.0 0.0 57.1 42.9 100.0 0.0 100.0 0.0 34.5

King Abdulaziz University Dentists

n=167 100.0 0.0 58.0 42.0 62.5 37.5 25.0 75.0 40.5

164

Table 29: Characteristics of oral health care provision among government dentists by their employer, gender and place of practice.

Percentage of dentists

who are still

providing patient care

Assistance at Work Pattern of Care Provision

One Dental Assistant

%

> 1 dental Assistant

%

A Regular

Treatment %

B Preventive Treatment

%

C Emergency Treatment

%

Almost Equal Distribution

between A, B & C

% All Government

Dentists n=175

95.4 82.9 21.1 52.0 0.6 2.3 40.6

Dentists’ Employer

Ministry of Health n=83

100.0 86.7 25.3 38.6 0.0 4.8 56.6

Ministry of Education

n=4 100.0 100.0 0.0 0.0 25.0 0.0 75.0

King Abdulaziz University

n=88 90.9 78.4 18.2 67.0 0.0 0.0 23.9

Gender

Male n=92 96.7 81.5 23.9 58.7 1.1 1.1 35.9

Female n=83 94.0 84.3 18.1 44.6 0.0 3.6 45.8

Place of Practice

Jeddah n=174 95.4 82.8 21.3 52.3 0.6 2.3 40.2

Bahrah n=1 100.0 100.0 0.0 0.0 0.0 0.0 100.0

165

Table 30: The mean stated and actual number of patients seen in a normal working day among government dentists by their employer, gender and place of residence.

Mean Stated Number of Patients / Day

Mean Actual Number of Patients / Day

All Government Dentists n=175 10 6


Ministry of Health n=83 15 8

Ministry of Education n=4 17 7


n=88 5 4

Gender

Male n=92 10 6

Female n=83 10 6

Place of Residence

Jeddah n=174 10 6

Bahrah n=1 14* 9*

* This is the stated and actual number of patients seen in a normal working day and not the mean since this refers to a single dentist.

166

Table 31: Busyness and job satisfaction among government dentists by their employer, gender and place of practice.

Degree of Busyness Job Satisfaction

Too busy to treat all patients

%

Received all patients but felt

rushed %

Provided treatment for enough but not too many patients

%

Not busy at all

% Satisfied

% Dissatisfied

%

All Government Dentists

n=175 41.7 27.4 24.0 2.3 92.0 8.0


Ministry of Health n=83

37.3 32.5 26.5 3.6 85.5 14.5

Ministry of Education

n=4 50.0 0.0 50.0 0.0 100.0 0.0


n=88 45.5 23.9 20.5 1.1 97.7 2.3

Gender

Male n=92 47.8 28.3 19.6 1.1 92.4 7.6

Female n=83 34.9 26.5 28.9 3.6 91.6 8.4

Place of Practice

Jeddah n=174 41.4 27.6 24.1 2.3 92.0 8.0

Bahrah n=1 100.0 0.0 0.0 0.0 100.0 0.0

167

Table 32: Percentages of types of dental procedures performed by general dentists and dental specialists in Jeddah and Bahrah.

Type of Dental Procedure %

Examination and Diagnosis 16.3

Preventive 12.5

Restorative 32.0

Endodontic 11.1

Periodontal 1.2

Prosthodontic 6.9

Surgical 15.3

Orthodontic 4.8

168

Table 33: Mean daily and mean annual dentist time in hours for all government dentists and by dentists’ current occupation

* h=hours

Mean Daily Dentist Time (h*)

Mean Annual Dentist Time (h*)

Total Annual Dentists Time (h*)

Stated Actual Stated Actual Stated Actual

A) Ministry of Health Dentists n=135 5.27 3.24 1,109 685 149,715 92,475

B) Ministry of Education Dentists

n=7 3.25 1.69 699 365 4,893 2,555

C) King Abdulaziz University Dentists

n=167 2.06 2.05 203 192 33,901 32,064

Total (A, B & C) n=309 188,509 127,094

169

Table 34: Dental procedures’ time estimate as adopted from the two day activity assessment form filled by Saudi dentists in Jeddah for different dental procedures (the Saudi procedures’ time estimates do not include lab’s procedures time).

Equivalent ODA’s Procedure Code Treatment Type Mean Time Estimate

in Minutes


01101 Examination & diagnosis of complete primary dentition 23.3 01102 Examination & diagnosis of complete mixed dentition 20.0 01103 Examination & diagnosis of complete permanent dentition 10.3 01202 Recall examination 9.9 01204 Specific examination & diagnosis 13.5 01205 Emergency examination & diagnosis 7.6 04312 Soft oral tissue biopsy by incision 18.8

Preventive

11101 Polishing (one unit of time i.e. 15 min) 11.0 11102 Polishing (two units of time i.e. 30 min) 5.0 11107 Polishing (one half unit of time i.e. 7.5 min) 5.1 11111 Scaling (one unit of time i.e. 15 min) 16.1 11112 Scaling (two units of time i.e. 30 min) 27.3 11113 Scaling (three units of time i.e. 45 min) 41.0 11117 Scaling (one half unit of time i.e. 7.5 min) 5.0 12101 Topical fluoride application 8.3 13101 Nutritional counseling (one unit of time i.e. 15 min) 10.0 13211 Oral hygiene instructions (one unit of time i.e. 15 min) 6.1 13301 Finishing restorations (one unit of time i.e. 15 min) 15.0 13302 Finishing restorations (two units of time i.e. 30 min) 30.0 13401 Pit and fissure sealants 6.2 14101 Maxillary removable appliance to control oral habits 10.0 15101 Space maintainer band type (fixed unilateral) 7.0

170

Cont. Table 34.


in Minutes

Restorative

20111 Caries removal and temporization 17.8 20121 Caries removal and temporization with the use of bands for retention 17.8 20131 Trauma control and smoothening of fractured tooth surfaces 10.0 21111 One surface non-bonded amalgam restoration for primary teeth 18.8 21112 Two surfaces non-bonded amalgam restoration for primary teeth 21.6 21211 One surface non-bonded amalgam restoration for permanent premolars 15.5 21212 Two surfaces non-bonded amalgam restoration for permanent premolars 24.9 21213 Three surfaces non-bonded amalgam restoration for permanent premolars 23.3 21221 One surface non-bonded amalgam restoration for permanent molars 18.8 21222 Two surfaces non-bonded amalgam restoration for permanent molars 25.5 21223 Three surfaces non-bonded amalgam restoration for permanent molars 40.0 21225 Five surfaces non-bonded amalgam restoration for permanent molars 37.0 22211 Stainless steel crown for posterior primary molar 17.4 22511 Prefabricated temporary crown for posterior permanent molar 22.5 23103 Three surfaces non-bonded tooth colored restoration for permanent anteriors 22.0 23111 One surface bonded tooth colored restoration for permanent anteriors 17.4 23112 Two surfaces bonded tooth colored restoration for permanent anteriors 20.8 23113 Three surfaces bonded tooth colored restoration for permanent anteriors 25.8 23114 Four surfaces bonded tooth colored restoration for permanent anteriors 25.7 23115 Five surfaces bonded tooth colored restoration for permanent anteriors 33.3 23211 One surface non-bonded tooth colored restoration for permanent premolars 20.0 23214 Four surfaces non-bonded tooth colored restoration for permanent premolars 30.0 23221 One surface non-bonded tooth colored restoration for permanent molars 18.0 23222 Two surfaces non-bonded tooth colored restoration for permanent molars 22.0 23223 Three surfaces non-bonded tooth colored restoration for permanent molars 32.0 23311 One surface bonded tooth colored restoration for permanent premolars 14.8

171

Cont. Table 34.


in Minutes 23312 Two surfaces bonded tooth colored restoration for permanent premolars 26.8 23313 Three surfaces bonded tooth colored restoration for permanent premolars 31.0 23321 One surface bonded tooth colored restoration for permanent molars 17.2 23322 Two surfaces bonded tooth colored restoration for permanent molars 30.1 23323 Three surfaces bonded tooth colored restoration for permanent molars 41.4 23324 Four surfaces bonded tooth colored restoration for permanent molars 47.5 23325 Five surfaces bonded tooth colored restoration for permanent molars 40.7 23401 One surface non-bonded tooth colored restoration for primary anteriors 15.0 23411 One surface bonded tooth colored restoration for primary anteriors 12.5 23412 Two surfaces bonded tooth colored restoration for primary anteriors 15.0 23413 Three surfaces bonded tooth colored restoration for primary anteriors 20.0 23501 One surface non-bonded tooth colored restoration for primary molars 8.6 23502 Two surfaces non-bonded tooth colored restoration for primary molars 21.3 23503 Three surfaces non-bonded tooth colored restoration for primary molars 40.0 23511 One surface bonded tooth colored restoration for primary molars 17.3 23512 Two surfaces bonded tooth colored restoration for primary molars 21.3 23513 Three surfaces bonded tooth colored restoration for primary molars 30.0 23601 Non-bonded tooth colored core 30.0 25131 One surface non-bonded ceramic inlays 20.0 25711 Single section casted metal post (as a separate procedure) 45.5 25721 Single section casted metal post in conjunction with impression for crown 33.8 25751 One prefabricated post with non-bonded amalgam core 50.0 25754 One prefabricated post with non-bonded composite core 60.0 25764 One prefabricated post with bonded composite core 46.7 27113 Acrylic crown (indirect) 60.0 27211 Porcelain fused to metal crown 39.7 27601 Laboratory processed bonded composite veneer 25.0 27602 Laboratory processed bonded porcelain veneer 21.7 29101 Recementation or rebonding of inlays or crowns (one unit of time i.e. 15 min) 15.0

172

Cont. Table 34.


in Minutes

29102 Recementation or rebonding of inlays or crowns (two units of time i.e. 30 min) 30.0

29103 Recementation or rebonding of inlays or crowns (three units of time i.e. 45 min) 45.0

Endodontic

32231 Pulpotomy of primary teeth (as a separate procedure) 19.1 32232 Pulpotomy of primary teeth concurrent with restorations 21.3 32311 Pulpectomy or permanent teeth (one canal) 21.9 32312 Pulpectomy or permanent teeth (two canals) 29.6 32313 Pulpectomy or permanent teeth (three canals) 32.3 32314 Pulpectomy or permanent teeth (four canals) 32.9 32322 Pulpotomy of primary molar 23.5 33111 Root canal therapy for permanent tooth (one canal) 38.9 33121 Root canal therapy for permanent tooth (two canals) 48.7 33131 Root canal therapy for permanent tooth (three canals) 58.1 33141 Root canal therapy for permanent tooth (four or more canals) 63.5

Periodontal 41301 Desensitization or exposed roots (one unit of time i.e. 15 min) 5.0 42111 Surgical curettage to include root planning 40.3 42311 Uncomplicated gingivectomy per sextant 58.6 42421 Curettage of osseous defect (flap approach) 90.0 42711 Guided tissue regeneration per site 75.0 43421 Root planing (one unit of time i.e. 15 min) 16.9 43422 Root planing (two units of time i.e. 30 min) 25.0 43611 Maxillary bruxism appliance 15.0

173

Cont. Table 34.


in Minutes Prosthetic

56212 Mandibular direct complete denture reline 30.0 56213 Mandibular and maxillary direct complete denture reline 30.0 56222 Mandibular direct partial denture reline 30.0

51101-2* Maxillary complete denture (initial and final impressions) 15.0 51101-3* Maxillary complete denture (jaw relation records) 17.5 51101-5* Maxillary complete denture (insertion) 13.3 51101-6* Maxillary complete denture (adjustments) 12.5 51102-2* Mandibular complete denture (initial and final impressions) 15.0 51102-3* Mandibular complete denture (jaw relation records) 15.0 51102-5* Mandibular complete denture (insertion) 16.7 51102-6* Mandibular complete denture (adjustments) 16.7 53201-2* Maxillary removable partial denture (treatment planning) 20.3

53201-3* Maxillary removable partial denture (mouth preparation and master impressions) 31.0

53201-4* Maxillary removable partial denture (framework try in and jaw relation records) 20.0

53201-5* Maxillary removable partial denture (insertion and equilibration) 6.5 53201-6* Maxillary removable partial denture (adjustments) 12.4 53202-2* Mandibular removable partial denture (treatment planning) 17.4

53202-3* Mandibular removable partial denture (mouth preparation and master impressions) 26.0

53202-4* Mandibular removable partial denture (framework try in and jaw relation records) 30.0

53202-5* Mandibular removable partial denture (insertion and equilibration) 18.0 53202-6* Mandibular removable partial denture (adjustments) 12.7

66224 Repair of a fixed bridge (four units of time 1h) 60.0

* The (-) represent a break down of the ODA procedure code e.g. primary impression or metal try in of a prosthesis.

174

Cont. Table 34.


in Minutes 66301 Recementation of a bridge (one unit of time i.e. 15 min) 10.0 66312 Recementation of an implant supported bridge (two units of time i.e. 30 min) 30.0 67121 Acrylic bridge (direct) as a temporary restoration 25.4 67355 Metal bridge 45.0

67211-1* Primary impression for a porcelain fused to metal (PFM) bridge 21.4 67211-2* Metal or porcelain try-in for a PFM bridge 25.0 67211-3* Teeth preparation and impression for a PFM bridge 51.1 67211-4* Cementation of a PFM bridge 31.5

Surgical

71101 Uncomplicated extraction of erupted teeth (single tooth) 14.9

71109 Uncomplicated extraction of erupted teeth (additional teeth in the same quadrant and at the same appointment) 4.5

71201 Complicated extraction of erupted teeth 27.8 72111 Extraction of soft tissue impacted teeth (single tooth) 22.3

72211 Extraction of bony impacted teeth with or without sectioning of teeth (single tooth) 25.7

72221 Extraction of bony impacted teeth with sectioning of teeth (single tooth) 27.5 72311 Extraction of residual erupted roots (single tooth) 11.6

72319 Extraction of residual erupted roots (additional teeth in the same quadrant and at the same appointment) 12.0

72321 Extraction of soft tissue impacted roots (single tooth) 22.5 72531 Surgical exposure of un-erupted tooth with orthodontic attachment 90.0 73111 Alveoplasty in conjunction with extractions (15 min per sextant) 11.3 73121 Alveoplasty not in conjunction with extractions (30 min per sextant) 37.5 73211 Gingivoplasty (45 min per sextant) 60.0 74111 Surgical excision of benign tumors (1cm or under) 15.0

* The (-) represent a break down of the ODA procedure code e.g. primary impression or metal try in of a prosthesis.

175

Cont. Table 34.


in Minutes 75112 Incision and drainage of soft tissue abscess 15.0 76121 Nasal spine wiring 20.0 76202 Open mandibular reduction (single) 240.0 77801 Upper labial frenectomy 30.0 79951 First stage surgical placement of an implant in the maxilla 90.0 79952 First stage surgical placement of an implant in the mandible 60.0 79953 Second stage surgical placement of an implant in the maxilla 30.0

176

Table 35: Saudi and ODA dental procedures’ time estimates used in the projection of the treatment needs’ time estimates.

ODA’s Procedures

Codes Treatment Type ODA Time

Estimates Equivalent Saudi Time Estimates

Examination and Diagnosis

01102 Examination & diagnosis of complete mixed dentition 30 20.0 01103 Examination & diagnosis of complete permanent dentition 22.5 10.3

Preventive

12101 Topical fluoride application 7.5 8.3 13401 Pit and fissure sealants 7.5 6.2

Restorative

21211 One surface non-bonded amalgam restoration for permanent premolars 15 15.5 21212 Two surfaces non-bonded amalgam restoration for permanent premolars 26.25 24.9 21221 One surface non-bonded amalgam restoration for permanent molars 18.75 18.8 21222 Two surfaces non-bonded amalgam restoration for permanent molars 30 25.5 23111 One surface bonded tooth colored restoration for permanent anteriors 30 17.4 23112 Two surfaces bonded tooth colored restoration for permanent anteriors 45 20.8 27602 Porcelain veneer or laminate 105 21.7* 27211 Porcelain fused to metal crown 150 39.7*

Endodontic

33111 Root canal therapy for permanent tooth (one canal) 120 38.9 33121 Root canal therapy for permanent tooth (two canals) 150 48.7 33131 Root canal therapy for permanent tooth (three canals) 195 58.1

* Laboratory procedures not included.

177

Table 35 Cont.

ODA’s Procedures

Codes Treatment Type ODA Time

Estimates Equivalent Saudi Time Estimates

Periodontal

11117 Scaling (scores 2 & 3 of the CPITN) 7.5 / sextant 5.0 43421 Complex treatment (score 4 of the CPITN) 15 / sextant 16.9

Prosthetic

67211 Porcelain fused to metal retainers (bridge) 150 129.0* 53201 Tooth-borne partial denture with cast frame , clasps and rests (per arch) 195 90.2*

67211+53201 A combination of bridge and partial denture 345 219.2* 51101 Complete denture (per arch) 165 58.3*

Surgical

71101 Uncomplicated tooth extraction 15 14.9

* Laboratory procedures not included.

178

Table 36: Total population count for each age group for all groups and by age, gender and place of residence.

Total Population Count*

All Groups 841,506

Age

6 Y 81,808

12 Y 69,285

16 Y 54,378

24-29 Y 239,210

35-44 Y 396,825

Gender Males 420,753

Females 420,753

Place of Residence Jeddah 823,296

Bahrah 18,210

* As calculated from the Saudi statistical yearbook (28)

179

Table 37: Mean annual total individual treatment needs time that can be met by dentists and by dental hygienists for all groups and by age, gender and place of residence.

Mean Total Individual Treatment

Needs that Can Only be Met by Dentists

(h*)

Mean Total Individual Treatment Needs that Can be Met by Dental

Hygienists (h*)

All Groups n=2000 3.86 0.36

Age

6 Y n=400 4.32 0.11

12 Y n=400 2.17 0.28

16 Y n=400 2.99 0.42

24-29 Y n=400 4.67 0.54

35-44 Y n=400 5.15 0.45

Gender M

n=1000 3.86 0.28

F n=1000 3.86 0.45

Place of Residence

J** n=1500 3.83 0.35

B*** n=500 3.94 0.42


180

Table 38: Jeddah and Bahrah population total treatment needs time that can be met by dentists and by dental hygienists for ages 6, 12, 16, 24-29 and 35-44.

Population Total Treatment

Needs that Can Only be Met by Dentists

(h*)

Population Total Treatment Needs that Can be Met by

Dental Hygienists (h*)

Total (h*)

Age

6 Y n=81,808 353,411 8,999 362,410

12 Y n=69,285 150,348 19,400 169,748

16 Y n=54,378 162,590 22,839 185,429

24-29 Y n=239,210 1,117,111 129,173 1,246,284

35-44 Y n=396,825 2,043,649 178,571 2,222,220

Total n=841,506 3,827,109 358,982 4,186,091

* h=hours

181

Table 39: Annual estimated treatment time requirements (hrs) according to reported visiting pattern with varying annual utilization rates.


> Once / Year (B)



(h*) (mean individual

treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)


dental hygienists (h*)

(mean individual treatment time x n)

Total (h*)

Age

6 Y n=81,808

(4.47 x n) 365,682

(0.12 x n) 9,817 375,499 (3.34 x n)

273,239 (0.10 x n) 8,181 281,420

12 Y n=69,285

(1.94 x n) 134,413

(0.25 x n) 17,321 151,734 (1.95 x n)

135,106 (0.35 x n) 24,250 159,356

16 Y n=54,378

(2.38 x n) 129,420

(0.41 x n) 22,295 151,715 (2.71 x n)

147,364 (0.27 x n) 14,682 162,046

24-29 Y n=239,210

(4.42 x n) 1,057,308

(0.49 x n) 117,213 1,174,521 (4.07 x n)

973,585 (0.48 x n) 114,821 1,088,406

35-44 Y n=396,825

(5.28 x n) 2,095,236

(0.48 x n) 190,476 2,285,712 (3.52 x n)

1,396,824 (0.43 x n) 170,635 1,567,459

Total N=841,506 3,782,059 357,122 4,139,181 2,926,118 332,569 3,258,687

Hours (FTE** Dentists /

Dental Hygienist) of

Care at Varying

Utilization Rates

100% 5,522 522 6,044 4,272 486 4,758 80% 4,418 418 4,836 3,418 389 3,807 60% 3,313 313 3,626 2,564 292 2,856 50% 2,761 261 3,022 2,136 243 2,379 40% 2,209 209 2,418 1,709 195 1,904 30% 1,657 157 1,814 1,282 146 1,428

* h=hours ** FTE= full time equivalent (calculations were based on the Ministry of Health’s mean actual annual dentist time of 685 hours)

182

Cont. Table 39.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(3.86 x n) 315,779

(0.11 x n) 8,999 324,778 (6.53 x n)

534,206 (0.02 x n) 1,636 535,842

12 Y n=69,285

(1.95 x n) 135,106

(0.29 x n) 20,093 155,199 (1.74 x n)

120,556 (0.45 x n) 31,178 151,734

16 Y n=54,378

(2.49 x n) 135,401

(0.37 x n) 20,120 155,521 (2.38 x n)

129,420 (0.33 x n) 17,945 147,365

24-29 Y n=239,210

(4.23 x n) 1,011,858

(0.49 x n) 117,213 1,129,071 (4.26 x n)

1,019,035 (0.43 x n) 102,860 1,121,895

35-44 Y n=396,825

(4.28 x n) 1,698,411

(0.45 x n) 178,571 1,876,982 (5.84 x n)

2,317,458 (0.46 x n) 182,540 2,499,998

Total n=841,506 3,296,555 344,996 3,641,551 4,120,675 336,159 4,456,834



Care at Varying

Utilization Rates

100% 4,813 504 5,317 6,016 491 6,507 80% 3,850 403 4,253 4,813 393 5,206 60% 2,888 303 3,191 3,610 295 3,905 50% 2,407 252 2,659 3,008 246 3,254 40% 1,925 202 2,127 2,407 197 2,604 30% 1,444 152 1,596 1,805 148 1,953


183

Cont. Table 39.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(5.07 x n) 414,767

(0.12 x n) 9,817 424,584 (3.24 x n)

265,058 (0.12 x n) 9,817 274,875

12 Y n=69,285

(2.21 x n) 153,120

(0.26 x n) 18,014 171,134 (2.43 x n)

168,363 (0.29 x n) 20,093 188,456

16 Y n=54,378

(3.71 x n) 201,742

(0.40 x n) 21,751 223,493 (1.87 x n)

101,687 (0.56 x n) 30,452 132,139

24-29 Y n=239,210

(5.41 x n) 1,294,126

(0.58 x n) 138,742 1,432,868 (2.15 x n)

514,302 (0.51 x n) 121,997 636,299

35-44 Y n=396,825

(5.51 x n) 2,186,506

(0.45 x n) 178,571 2,365,077 (4.26 x n)

1,690,475 (0.54 x n) 214,286 1,904,761

Total n=841,506 4,250,261 366,895 4,617,156 2,739,885 396,645 3,136,530



Care at Varying

Utilization Rates

100% 6,205 536 6,741 4,000 580 4,580 80% 4,964 429 5,393 3,200 464 3,664 60% 3,723 322 4,045 2,400 348 2,748 50% 3,103 268 3,371 2,000 290 2,290 40% 2,482 215 2,697 1,600 232 1,832 30% 1,862 161 2,023 1,200 174 1,374


184

Cont. Table 39.





treatment time x n)



treatment time x n)

Total (h*)

Age

6 Y n=81,808

(4.42 x n) 361,591

(0.12 x n) 9,817 371,408

12 Y n=69,285

(2.27 x n) 157,277

(0.28 x n) 19,400 176,677

16 Y n=54,378

(3.16 x n) 171,834

(0.44 x n) 23,926 195,760

24-29 Y n=239,210

(4.83 x n) 1,155,384

(0.56 x n) 133,958 1,289,342

35-44 Y n=396,825

(5.49 x n) 2,178,569

(0.46 x n) 182,540 2,361,109

Total n=841,506 4,024,655 369,641 4,394,296



Care at Varying

Utilization Rates

100% 5,876 540 6,416 80% 4,701 432 5,133 60% 3,526 324 3,850 50% 2,938 270 3,208 40% 2,351 216 2,567 30% 1,763 162 1,925


185

Table 40: Annual estimated treatment time requirements (hrs) according to reported visiting pattern with varying annual utilization after factoring in the caries increments (teeth/ year) and the modal restorative service time to reduce the restorative needs time for ages 12, 16, 24-29 and 35-44.


> Once / Year (B)




treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(4.47 x n) 365,682

(0.12 x n) 9,817 375,499 (3.34 x n)

273,239 (0.10 x n) 8,181 281,420

12 Y n=69,285

(1.31 x n) 90,763

(0.25 x n) 17,321 108,084 (1.26 x n)

87,299 (0.35 x n) 24,250 111,549

16 Y n=54,378

(1.40 x n) 76,129

(0.41 x n) 22,295 98,424 (1.71 x n)

92,986 (0.27 x n) 14,682 107,668

24-29 Y n=239,210

(2.56 x n) 612,378

(0.49 x n) 117,213 729,591 (2.53 x n)

605,201 (0.48 x n) 114,821 720,022

35-44 Y n=396,825

(3.83 x n) 1,519,840

(0.48 x n) 190,476 1,710,316 (2.53 x n)

1,003,967 (0.43 x n) 170,635 1,174,602

Total N=841,506 2,664,792 357,122 3,021,914 2,062,692 332,569 2,395,261



Care at Varying

Utilization Rates

100% 3,891 522 4,413 3,012 486 3,498 80% 3,113 418 3,531 2,410 389 2,799 60% 2,335 313 2,648 1,807 292 2,099 50% 1,946 261 2,207 1,506 243 1,749 40% 1,556 209 1,765 1,205 195 1,400 30% 1,167 157 1,324 904 146 1,050


186

Cont. Table 40.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(3.86 x n) 315,779

(0.11 x n) 8,999 324,778 (6.53 x n)

534,206 (0.02 x n) 1,636 535,842

12 Y n=69,285

(1.30 x n) 90,071

(0.29 x n) 20,093 110,164 (1.24 x n)

85,913 (0.45 x n) 31,178 117,091

16 Y n=54,378

(1.50 x n) 81,567

(0.37 x n) 20,120 101,687 (1.26 x n)

68,516 (0.33 x n) 17,945 86,461

24-29 Y n=239,210

(2.53 x n) 605,201

(0.49 x n) 117,213 722,414 (3.05 x n)

729,591 (0.43 x n) 102,860 832,451

35-44 Y n=396,825

(3.09 x n) 1,226,189

(0.45 x n) 178,571 1,404,760 (3.86 x n)

1,531,745 (0.46 x n) 182,540 1,714,285

Total n=841,506 2,318,807 344,996 2,663,803 2,949,971 336,159 3,286,130



Care at Varying

Utilization Rates

100% 3,386 504 3,890 4,307 491 4,798 80% 2,709 403 3,112 3,446 393 3,839 60% 2,032 303 2,335 2,584 295 2,879 50% 1,693 252 1,945 2,154 246 2,400 40% 1,354 202 1,556 1,723 197 1,920 30% 1,016 152 1,168 1,292 148 1,440


187

Cont. Table 40.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(5.07 x n) 414,767

(0.12 x n) 9,817 424,584 (3.24 x n)

265,058 (0.12 x n) 9,817 274,875

12 Y n=69,285

(1.36 x n) 94,228

(0.26 x n) 18,014 112,242 (1.56 x n)

108,085 (0.29 x n) 20,093 128,178

16 Y n=54,378

(2.34 x n) 127,245

(0.40 x n) 21,751 148,996 (1.15 x n)

62,535 (0.56 x n) 30,452 92,987

24-29 Y n=239,210

(3.46 x n) 827,667

(0.58 x n) 138,742 966,409 (1.33 x n)

318,149 (0.51 x n) 121,997 440,146

35-44 Y n=396,825

(4.02 x n) 1,595,237

(0.45 x n) 178,571 1,773,808 (3.75 x n)

1,488,094 (0.54 x n) 214,286 1,702,380

Total n=841,506 3,059,144 366,895 3,426,039 2,241,921 396,645 2,638,566



Care at Varying

Utilization Rates

100% 4,466 536 5,002 3,273 580 3,853 80% 3,573 429 4,002 2,618 464 3,082 60% 2,680 322 3,002 1,964 348 2,312 50% 2,233 268 2,501 1,637 290 1,927 40% 1,786 215 2,001 1,309 232 1,541 30% 1,340 161 1,501 982 174 1,156


188

Cont. Table 40.





treatment time x n)



treatment time x n)

Total (h*)

Age

6 Y n=81,808

(4.42 x n) 361,591

(0.12 x n) 9,817 371,408

12 Y n=69,285

(1.43 x n) 99,078

(0.28 x n) 19,400 118,478

16 Y n=54,378

(1.98 x n) 107,668

(0.44 x n) 23,926 131,594

24-29 Y n=239,210

(3.10 x n) 741,551

(0.56 x n) 133,958 875,509

35-44 Y n=396,825

(4.00 x n) 1,587,300

(0.46 x n) 182,540 1,769,840

Total n=841,506 2,897,188 369,641 3,266,829



Care at Varying

Utilization Rates

100% 4,230 540 4,770 80% 3,384 432 3,816 60% 2,538 324 2,862 50% 2,115 270 2,385 40% 1,692 216 1,908 30% 1,269 162 1,431


189

Table 41: Annual estimated treatment time requirements (hrs) according to reported visiting pattern with varying annual utilization after reducing restorative needs time by 50% for the study’s five age groups.


> Once / Year (B)




treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(3.59 x n) 293,691

(0.12 x n) 9,817 303,508 (2.65 x n)

216,791 (0.10 x n) 8,181 224,972

12 Y n=69,285

(1.55 x n) 107,392

(0.25 x n) 17,321 124,713 (1.53 x n)

106,006 (0.35 x n) 24,250 130,256

16 Y n=54,378

(1.82 x n) 98,968

(0.41 x n) 22,295 121,263 (2.14 x n)

116,369 (0.27 x n) 14,682 131,051

24-29 Y n=239,210

(3.44 x n) 822,882

(0.49 x n) 117,213 940,095 (3.25 x n)

777,433 (0.48 x n) 114,821 892,254

35-44 Y n=396,825

(4.53 x n) 1,797,617

(0.48 x n) 190,476 1,988,093 (3.01 x n)

1,194,443 (0.43 x n) 170,635 1,365,078

Total N=841,506 3,120,550 357,122 3,477,672 2,411,042 332,569 2,743,611



Care at Varying

Utilization Rates

100% 4,556 522 5,078 3,520 486 4,006 80% 3,645 418 4,063 2,816 389 2,855 60% 2,734 313 3,047 2,112 292 2,404 50% 2,278 261 2,539 1,760 243 2,003 40% 1,823 209 2,032 1,408 195 1,603 30% 1,367 157 1,524 1,056 146 1,202


190

Cont. Table 41.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(3.08 x n) 251,969

(0.11 x n) 8,999 260,968 (5.72 x n)

467,942 (0.02 x n) 1,636 469,578

12 Y n=69,285

(1.55 x n) 107,392

(0.29 x n) 20,093 127,485 (1.42 x n)

98,385 (0.45 x n) 31,178 129,563

16 Y n=54,378

(1.93 x n) 104,950

(0.37 x n) 20,120 125,070 (1.75 x n)

95,162 (0.33 x n) 17,945 113,107

24-29 Y n=239,210

(3.34 x n) 798,961

(0.49 x n) 117,213 916,174 (3.61 x n)

863,548 (0.43 x n) 102,860 966,408

35-44 Y n=396,825

(3.67 x n) 1,456,348

(0.45 x n) 178,571 1,634,919 (4.83 x n)

1,916,665 (0.46 x n) 182,540 2,099,205

Total n=841,506 2,719,620 344,996 3,064,616 3,441,702 336,159 3,777,861



Care at Varying

Utilization Rates

100% 3,971 504 4,475 5,025 491 5,516 80% 3,177 403 3,580 4,020 393 4,413 60% 2,383 303 2,686 3,015 295 3,310 50% 1,986 252 2,238 2,513 246 2,759 40% 1,588 202 1,790 2,010 197 2,207 30% 1,191 152 1,343 1,508 148 1,656


191

Cont. Table 41.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(4.04 x n) 330,504

(0.12 x n) 9,817 340,321 (2.65 x n)

216,791 (0.12 x n) 9,817 226,608

12 Y n=69,285

(1.71 x n) 118,477

(0.26 x n) 18,014 136,491 (1.92 x n)

133,027 (0.29 x n) 20,093 153,120

16 Y n=54,378

(2.95 x n) 160,415

(0.40 x n) 21,751 182,166 (1.44 x n)

78,304 (0.56 x n) 30,452 108,756

24-29 Y n=239,210

(4.38 x n) 1,047,740

(0.58 x n) 138,742 1,186,482 (1.70 x n)

406,657 (0.51 x n) 121,997 528,654

35-44 Y n=396,825

(4.75 x n) 1,884,919

(0.45 x n) 178,571 2,063,490 (3.98 x n)

1,579,364 (0.54 x n) 214,286 1,793,650

Total n=841,506 3,542,055 366,895 3,908,950 2,414,143 396,645 2,810,788



Care at Varying

Utilization Rates

100% 5,171 536 5,707 3,525 580 4,105 80% 4,137 429 4,566 2,820 464 3,284 60% 3,103 322 3,425 2,115 348 2,463 50% 2,586 268 2,854 1,763 290 2,053 40% 2,068 215 2,283 1,410 232 1,642 30% 1,551 161 1,712 1,058 174 1,232


192

Cont. Table 41.





treatment time x n)



treatment time x n)

Total (h*)

Age

6 Y n=81,808

(3.57 x n) 292,055

(0.12 x n) 9,817 301,872

12 Y n=69,285

(1.78 x n) 123,327

(0.28 x n) 19,400 142,727

16 Y n=54,378

(2.50 x n) 135,945

(0.44 x n) 23,926 159,871

24-29 Y n=239,210

(3.92 x n) 937,703

(0.56 x n) 133,958 1,071,661

35-44 Y n=396,825

(4.73 x n) 1,876,982

(0.46 x n) 182,540 2,059,522

Total n=841,506 3,366,012 369,641 3,735,653



Care at Varying

Utilization Rates

100% 4,914 540 5,454 80% 3,931 432 4,363 60% 2,948 324 3,272 50% 2,457 270 2,727 40% 1,966 216 2,182 30% 1,474 162 1,636


193

Table 42: Annual estimated treatment time requirements (hrs) according to reported visiting pattern with varying annual utilization after factoring in the caries increments (teeth/ year) and the modal restorative service time to reduce the restorative needs time for ages 12, 16, 24-29 and 35-44 and reducing restorative needs time by 50% for the study’s five age groups.


> Once / Year (B)




treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(3.59 x n) 293,691

(0.12 x n) 9,817 303,508 (2.65 x n)

216,791 (0.10 x n) 8,181 224,972

12 Y n=69,285

(1.24 x n) 85,913

(0.25 x n) 17,321 103,234 (1.19 x n)

82,449 (0.35 x n) 24,250 106,699

16 Y n=54,378

(1.33 x n) 72,323

(0.41 x n) 22,295 94,618 (1.57 x n)

85,373 (0.27 x n) 14,682 100,055

24-29 Y n=239,210

(2.52 x n) 602,809

(0.49 x n) 117,213 720,022 (2.49 x n)

595,633 (0.48 x n) 114,821 710,454

35-44 Y n=396,825

(3.81 x n) 1,511,903

(0.48 x n) 190,476 1,702,379 (2.51 x n)

996,031 (0.43 x n) 170,635 1,166,666

Total N=841,506 2,566,639 357,122 2,923,761 1,976,277 332,569 2,308,846



Care at Varying

Utilization Rates

100% 3,747 522 4,269 2,886 486 3,372 80% 2,998 418 3,416 2,309 389 2,698 60% 2,248 313 2,561 1,732 292 2,024 50% 1,874 261 2,135 1,443 243 1,686 40% 1,499 209 1,708 1,154 195 1,349 30% 1,124 157 1,281 866 146 1,012


194

Cont. Table 42.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(3.08 x n) 251,969

(0.11 x n) 8,999 260,968 (5.72 x n)

467,942 (0.02 x n) 1,636 469,578

12 Y n=69,285

(1.16 x n) 80,371

(0.29 x n) 20,093 100,464 (1.17 x n)

81,063 (0.45 x n) 31,178 112,241

16 Y n=54,378

(1.43 x n) 77,761

(0.37 x n) 20,120 97,881 (1.19 x n)

64,710 (0.33 x n) 17,945 82,655

24-29 Y n=239,210

(2.49 x n) 595,633

(0.49 x n) 117,213 712,846 (3.01 x n)

720,022 (0.43 x n) 102,860 822,882

35-44 Y n=396,825

(3.07 x n) 1,218,253

(0.45 x n) 178,571 1,396,824 (3.84 x n)

1,523,808 (0.46 x n) 182,540 1,706,348

Total n=841,506 2,223,987 344,996 2,568,983 2,857,545 336,159 3,193,704



Care at Varying

Utilization Rates

100% 3,247 504 3,751 4,172 491 4,663 80% 2,598 403 3,001 3,338 393 3,731 60% 1,948 303 2,251 2,503 295 2,798 50% 1,624 252 1,876 2,086 246 2,332 40% 1,299 202 1,501 1,669 197 1,866 30% 974 152 1,126 1,252 148 1,400


195

Cont. Table 42.






treatment time x n)



treatment time x n)

Total (h*)



treatment time x n)




Total (h*)

Age

6 Y n=81,808

(4.04 x n) 330,504

(0.12 x n) 9,817 340,321 (2.65 x n)

216,791 (0.12 x n) 9,817 226,608

12 Y n=69,285

(1.29 x n) 89,378

(0.26 x n) 18,014 107,392 (1.49 x n)

103,235 (0.29 x n) 20,093 123,328

16 Y n=54,378

(2.27 x n) 123,438

(0.40 x n) 21,751 145,189 (1.08 x n)

58,728 (0.56 x n) 30,452 89,180

24-29 Y n=239,210

(3.42 x n) 818,098

(0.58 x n) 138,742 956,840 (1.29 x n)

308,581 (0.51 x n) 121,997 430,578

35-44 Y n=396,825

(4.00 x n) 1,587,300

(0.45 x n) 178,571 1,765,871 (3.73 x n)

1,480,157 (0.54 x n) 214,286 1,694,443

Total n=841,506 2,948,718 366,895 3,315,613 2,167,492 396,645 2,564,137



Care at Varying

Utilization Rates

100% 4,305 536 4,841 3,165 580 3,745 80% 3,444 429 3,873 2,532 464 2,996 60% 2,583 322 2,905 1,899 348 2,247 50% 2,153 268 2,421 1,583 290 1,873 40% 1,722 215 1,937 1,266 232 1,498 30% 1,292 161 1,453 950 174 1,124


196

Cont. Table 42.





treatment time x n)



treatment time x n)

Total (h*)

Age

6 Y n=81,808

(3.57 x n) 292,055

(0.12 x n) 9,817 301,872

12 Y n=69,285

(1.36 x n) 94,228

(0.28 x n) 19,400 113,628

16 Y n=54,378

(1.91 x n) 103,862

(0.44 x n) 23,926 127,788

24-29 Y n=239,210

(3.06 x n) 731,983

(0.56 x n) 133,958 865,941

35-44 Y n=396,825

(3.98 x n) 1,579,364

(0.46 x n) 182,540 1,761,904

Total n=841,506 2,801,492 369,641 3,171,133



Care at Varying

Utilization Rates

100% 4,090 540 4,630 80% 3,272 432 3,704 60% 2,454 324 2,778 50% 2,045 270 2,315 40% 1,636 216 1,852 30% 1,227 162 1,389


197

Table 43: The health human resources needed for the projected models to balance the supply and the requirements sides.

Study Population

(29.2% of Jeddah and Bahrah Population*)

Others (70.8% of Jeddah

and Bahrah Population*)

Health Promotion/ Prevention Program

Requirements

Total FTEs**

Population* to Professional

Ratio (population per

one professional)

% of Population

for Different Utilization Patterns

25.5%

A & B (Regular Dental

Visitors)

74.5%

C, D & E (Irregular Dental

Visitors)

52.6%

Based on Group D (Emergency Care

Visitors)

100% of Population at Ages 6-8 Y &

12-14Y (15.7% of Jeddah


Dentists

Dental H

ygienists

Com

bined

Dentists

Dental H

ygienists

Com

bined

Utilization Rate 50% 100% 33% 100% 33% 100%

Type of FTE** Staff Dentists Dental

Hygienists Dentists Dental Hygienists Dentists^ Dental

Hygienists^^ Health Promoters/ Dental Hygienists

Findings 1*** 2,407 504 1,939 540 4,476 1,133 215 (12 kids/day) 8,822 2,392 11,214 327 1,205 257

Models

Model 1*** 2,911 NA++ 2,479 NA++ 5,609 NA++ 215 (12 kids/day) 10,999 215 11,214 262 13,410 257 Model 2*** 1,941+++ NA++ 1,653+++ NA++ 3,740+++ NA++ 143 (18 kids/day) 7,334 143 7,477 393 20,162 386 Model 3+ 2,490 NA++ 2,162 NA++ 4,802 NA++ 215 (12 kids/day) 9,454 215 9,669 305 13,410 298 Model 4+ 1,660+++ NA++ 1,441+++ NA++ 3,202+++ NA++ 143 (18 kids/day) 6,303 143 6,446 457 20,162 447

Model 5*** 2,407 504 1,939 540 4,476 1,133 215 (12 kids/day) 8,822 2,392 11,214 327 1,205 257 Model 6*** 1,605+++ 336+++ 1,293+++ 360+++ 2,984+++ 756+++ 143 (18 kids/day) 5,882 1,595 7,477 490 1,808 386 Model 7+ 1,986 504 1,622 540 3,669 1,133 215 (12 kids/day) 7,277 2,392 9,669 396 1,205 298 Model 8+ 1,324+++ 336+++ 1,081+++ 360+++ 2,446+++ 756+++ 143 (18 kids/day) 4,851 1,595 6,446 594 1,808 447

* (2,883,169) Jeddah and Bahrah population as obtained from the Saudi statistical yearbook (28) ** FTE= full time equivalent (calculations were based on the Ministry of Health’s mean actual annual dentist time of 685 hours) *** Numbers were obtained and calculated from Table 37 + Numbers obtained and calculated from Table 39 ++ NA= not applicable +++ Calculations were based on the Ministry of Health’s mean actual annual dentist time after increasing it by 50% (1,027.5 hours / year) ^ Calculations were based on a mean annual individual treatment time of 4.55 h/ year for models 1, 3, 5, & 7 and 3.73 h/ year for models 2, 4, 6 & 8 ^^ Calculations were based on a mean annual individual treatment time of 0.38 h/ year

198

Cont. Table 43

Study Population

(29.2% of Jeddah and Bahrah Population*)

Others (70.8% of Jeddah


Health Promotion/ Prevention Program

Requirements

Total FTEs**

Population* to Professional

Ratio (population per

one professional)

% of Population

for Different Utilization Patterns

25.5%

A & B (Regular Dental

Visitors)

74.5%

C, D & E (Irregular Dental

Visitors)

52.6%

Based on Group D (Emergency Care

Visitors)

100% of Population at Ages 6-8 Y &

12-14Y (15.7% of Jeddah


Dentists

Dental H

ygienists

Com

bined

Dentists

Dental H

ygienists

Com

bined

Utilization Rate 50% 100% 33% 100% 33% 100%

Type of FTE** Staff Dentists Dental

Hygienists Dentists Dental Hygienists Dentists^ Dental

Hygienists^^ Health Promoters/ Dental Hygienists

Findings 2*** 1,693 504 1,396 540 2,951 1,133 215 (12 kids/day) 6,040 2,392 8,432 477 1,205 342

Models

Model 9*** 2,197 NA++ 1,936 NA++ 4,084 NA++ 215 (12 kids/day) 8,217 215 8,432 351 13,410 342 Model 10*** 1,465+++ NA++ 1,291+++ NA++ 2,724+++ NA++ 143 (18 kids/day) 5,480 143 5,623 526 20,162 513 Model 11+ 2,128 NA++ 1,890 NA++ 4,035 NA++ 215 (12 kids/day) 8,053 215 8,268 358 13,410 349 Model 12+ 1,419+++ NA++ 1,260+++ NA++ 2,691+++ NA++ 143 (18 kids/day) 5,370 143 5,513 537 20,162 523

Model 13*** 1,693 504 1,396 540 2,951 1,133 215 (12 kids/day) 6,040 2,392 8,432 477 1,205 342 Model 14*** 1,129+++ 336+++ 931+++ 360+++ 1,968+++ 756+++ 143 (18 kids/day) 4,028 1,595 5,623 716 1,808 513 Model 15+ 1,624 504 1,350 540 2,902 1,133 215 (12 kids/day) 5,876 2,392 8,268 491 1,205 349 Model 16+ 1,083+++ 336+++ 900+++ 360+++ 1,935+++ 756+++ 143 (18 kids/day) 3,018 1,595 5,513 955 1,808 523

* (2,883,169) Jeddah and Bahrah population as obtained from the Saudi statistical yearbook (28) ** FTE= full time equivalent (calculations were based on the Ministry of Health’s mean actual annual dentist time of 685 hours) *** Numbers were obtained and calculated from Table 38 + Numbers were obtained and calculated from Table 40 ++ NA= not applicable +++ Calculations were based on the Ministry of Health’s mean actual annual dentist time after increasing it by 50% (1,027.5 hours / year) ^ Calculations were based on a mean annual individual treatment time of 3.00 h/ year for models 9, 11, 13 & 15 and 2.95 h/ year for models 10, 12, 13 & 16 ^^ Calculations were based on a mean annual individual treatment time of 0.38 h/ year

199

10.0 Figures

200

Figure 1: The dental manpower analytical model (2)

201

Figure 2: The conceptual framework of Andersen’s behavioral model (3)

202

Figure 3: Dental human resource supply and requirement conceptual model

The potential sum of hours worked by all dentists / 1 year at the current level of

productivity based on the best available

data

The potential sum of hours required to

achieve population treatment needs / 1 year at the current level of utilization based on the best

available data

Encourage utilization of dental services if the utilization was low;

otherwise reallocate the available resources or

open new dental programs based on community needs

If there is an excess of supply

Improve the level of productivity of the

existing staff; and if that was limited, then

increase the number of the best mix of dental

care providers (i.e., not only the number of

dentists)

If there is a shortage of supply

If the number of dentists or their

working life increases or decreases

If the level of total service output increases or decreases

If the level of disease changes

If the level of utilization increases or decreases

Recalculate Recalculate

Recalculate

Recalculate

• Assessment of oral health status (prevalence and incidence)

• Identification of

dental procedures needed

• Average

number of procedure-minutes (needs) i.e., Sum of the number and type of procedures needed x minutes for that procedure

• Utilization of

dental services (number of dental visits in the last year, time since last visit and type of service received)

Dental resources SUPPLY side Dental service REQUIREMENTS side

Health promotion programs or alternative public policies that reduce disease levels

The potential difference between supply of dental

human resources and service requirements is estimated based on the

best available data

Start Start

• Number of dentists by specialty

• Dentist productivity

(mean number of chair-side minutes worked by a dentist per day, week and year; mean number of patient-visits per week)

• Dentist age,

gender and working life

• Number of

auxiliaries by type • Pattern of practice

(dentist auxiliary mix and the pattern of service provision)

• Number of

operatories • Busyness of

dentists

203

Figure 4: The population pyramid of the Saudi population obtained from the 2000 census (28).

204

11.0 Appendices

205

Appendix A

Ethics approval letters received form the ethic review unit at the University of

Toronto

206

207

208

Appendix B

The supporting letter issued from the Faculty of Dentistry at the University of

Toronto

209

210

Appendix C

The supporting letters issued from the Faculty of Dentistry and the administration

of King Abdulaziz University in Jeddah, Saudi Arabia

211

212

213

Appendix D

Data Summary Forms (A, B.1 and B.2)

And

List of Tables (A.1, A.2, A.3, A.4, B.1 and B.2)

214

Form A Health Care Delivery System and Oral Health Care Resources

1. Name of the institute, clinic or polyclinic ________________________ 2. Address: City: ______________ Tel #: ______________

Fax #: ______________ E-mail: ________________________________

Postal Address: ________________________________

3. Date of data collection (D/M/Y): __ __ / __ __ / __ __ __ __ 4. Health sector

1 Government 2 Private

5. System structure:

1 Primary level 2 Primary & secondary levels 3 Primary, secondary & tertiary levels

6. Setting for health service delivery:

1 Hospitals 2 Health care centers 3 Hospitals & health care centers 4 Clinics (single or poly)

215

7. Services offered / carried out: Check each that apply:

Clinical care Preventive advice to patients

Health promotion within the community Epidemiological surveying Population Screening Research Quality assurance and review Staff development programs

8. Target population: ________________________________________

9. Check the referral systems that exist: Referral system exist within the hospitals, health care centers and

clinics (single and poly) Referral system exist between hospitals, health care centers and

clinics (single and poly) in the same health sector Referral system exist between different health sectors (governmental

& private) 10. Please fill in Tables: A.1, A.2, A.3 and A.4

216

Form B1

Educational Programs

1. Name of institute: __________________________________________

2. Name of the faculty, school or college: _________________________

3. Type:


4. Address: City: ______________ Tel #: ______________

Fax #: ______________ E-mail: ________________________________

Postal Address: ________________________________

5. Date of data collection (D/M/Y): __ __ / __ __ / __ __ __ __ 6. Please fill in Table B.1

217

Form B2

Educational Programs

1. Name of institute: __________________________________________

2. Type:


3. Address: City: ______________ Tel #: ______________

Fax #: ______________ E-mail: ________________________________

Postal Address: ________________________________

4. Date of data collection (D/M/Y): __ __ / __ __ / __ __ __ __ 5. Please fill in Table B.

218

Table A.1

Showing a. Numbers and geographic distribution of hospitals, health care centers and clinics (single or poly).

b. Numbers and distribution of dental chairs and their working condition together with numbers and distribution of dental labs.

Name of Institution: ______________________________ City / Village: ______________

District

No. of Hospitals

No. of Dental Chairs and Dental Labs per Hospital

No. of Health Care

Centers

No. of Dental Chairs and Dental Labs per Health Care Center

No. of Clinics (single

or Poly)

No. of Dental Chairs and Dental Labs per Clinics (single or Poly)

Dental Chairs Dental Labs



Functioning Non-Functioning



Total

219

Table A.2

System Reimbursement

Name of Institution: ______________________________

Source of Funds

Reimbursement System Government

Private

Clinic Reimbursement

Annual Budget

Fee for service

Capitation

Sessional Arrangements

Other (please specify)

Staff Reimbursement

Staff Category

Salary

Fee for service

Capitation

Sessional Arrangements

Other (please specify)

Dentists

Dental Hygienists

Dental Assistants

Dental Lab Technician

220

Table A.3

Distribution of Age, Sex, Nationality and Specialization among Dentists


1 = Restorative Dentist; 2 =Periodontist; 3 = Oral & Maxillofacial Surgeon; 4 = Orthodontist; 5 = Pedodontist; 6 = Prosthodontist; 7 = Endodontist

Age

No. of Saudi Male Dentists

No. of Saudi Female

Dentists

No. of Non-Saudi Male

Dentists

No. of Non-Saudi Female Dentists

GP

Type of

Dental Specialists

G P

Type of

Dental Specialists

G P

Type of

Dental Specialists

G P

Type of

Dental Specialists

1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7

≤ 29 30-39 40-49

≥ 50

Total

221

Table A.4

Distribution of Age, Sex, Nationality among Dental Auxiliaries


DH = Dental Hygienist DA = Dental Assistant DLT = Dental Lab Technician

Age

No. of Saudi Male Dental Auxiliaries

No. of Saudi Female

Dental Auxiliaries

No. of Non-Saudi Male

Dental Auxiliaries

No. of Non-Saudi Female

Dental Auxiliaries

DH

DA

DLT

DH

DA

DLT

DH

DA

DLT

DH

DA

DLT

≤ 29

30-39

40-49

≥ 50

Total

222

Table B1

Data about Dental Educational Programs


Degree

Established in Year

Length of the

Program

Tuitions (in SR)

Annual No. of Graduates

Total Annual No. of

Graduates

No. of Males

No. of

Females

1995

2000

2005

2010*

1995

2000

2005

2010*

1995

2000

2005

2010*

* Projected

223

Table B2

Data about the Saudi Dental Board Programs


Specialty Program

Established in Year

Length of the

Program

Tuitions (in SR)

Annual No. of Graduates

Total Annual No. of

Graduates

No. of Males

No. of

Females

1995

2000

2005

2010*

1995

2000

2005

2010*

1995

2000

2005

2010*

* Projected

224

Appendix E

Clinical Examination Manual

225

An Assessment of Oral Health Status, Treatment Needs

and Supply of Dental Services in Jeddah, Saudi Arabia

2007

Faculty of Dent is t ry K ing Abdulaziz Univers i ty

Saudi Arab ia

Facu lty of Dent is t ry Univers i ty of Toronto

Canada

226

Dear colleague; Thank you for accepting to participate in this study. The manual, in hand, has been

prepared to help you with the clinical examinations of the study participants and to

provide you with detailed information about each component of the clinical

examination form. The manual will also help you get familiar with the indices and

measures used to record the different oral conditions that will be assessed in the

study. Please read the manual carefully and do not hesitate to contact me if you

need any further explanations.

Thank you again for your participation

Akram Qutob

227

Before you start your clinical examination please make sure that the participant’s ID number

1. Lip and palate assessment

in the first section of the clinical examination form matches the

participant’s ID number in the first section of the participant’s questionnaire so that

the clinical examination form and the questionnaire corresponds to the same

participant.

The oral conditions that will be recorded in the clinical examination form are ordered

as:

2. Oral mucosa

3. Enamel opacities / hypoplasia

4. Dental fluorosis

5. Periodontal status

6. Prosthetic status and prosthetic need

7. Dentition status and need

The instructions on how to record each of these conditions are detailed as follows:

Lip and Palate Assessment: The examination will include the upper lip and the soft and hard palate. A cleft palate

will be recorded if the cleft was involving the hard and / or

0 No abnormality detected

1 Unilateral cleft lip

2 Unilateral cleft palate

3 Bilateral cleft lip

4 Bilateral cleft palate

5 Unilateral cleft lip & palate

6 Bilateral cleft lip & palate

7 Unilateral cleft lip & bilateral cleft palate

8 Unilateral cleft palate & bilateral cleft lip

the soft palate. You will

need to record the code number that applies to the participant in the box provided in

the clinical examination form. The code numbers and the criteria are:

Codes

228

Oral Mucosa:

The examination should be thorough and systematic and be performed in the

following sequence:

(a) Labial mucosa and labial sulci (upper and lower)

(b) Labial part of the commissures and buccal mucosa (right and left)

(c) Tongue (dorsal and ventral surfaces, margins)

(d) Floor of the mouth

(e) Hard and soft palate

(f) Alveolar ridges/gingiva (upper and lower)

One mirror and the handle of the periodontal probe can be used to retract the

tissues. The absence, presence, or suspected presence, of the conditions coded 1

to 7 should be recorded in the boxes provided in the clinical examination form. Code

8 should be used to record a condition not mentioned in the pre-coded list; for

example, hairy leukoplakia or Kaposi sarcoma. The codes are:

0 No abnormal condition

1 Malignant tumor (oral cancer)

2 Leukoplakia

3 Lichen planus

4 Ulceration (aphthous, herpetic, traumatic)

5 Acute necrotizing gingivitis

6 Candidiasis

7 Abscess

8 Other condition (specify if possible)

9 Not recorded

Codes

229

The location of the oral mucosal lesion(s) should be recorded in the boxes provided

as follows:

0 Vermilion border

1 Commissures

2 Lips

3 Sulci

4 Buccal mucosa

5 Floor of the mouth

6 Tongue

7 Hard and/or soft palate

8 Alveolar ridges/gingiva

9 Not recorded

For example, if a person has leukoplakia on both the buccal mucosa and the

commissures, the coding would be as follows:

Similarly, where a person has oral cancer on the commissures and the lower lip, and

candidiasis on the tongue, the coding should be as follows:

a. Condition b. Location

i ii iii

i ii iii


i ii iii

i ii iii

Codes

2

9

1 2

0

4

1

2

6 6

1

1

230

Some of the more important pathological conditions affecting the oral mucosa are

illustrated in Plate 1.

Enamel Opacities / Hypoplasia Enamel abnormalities are classified into one of three types on the basis of their

appearance. They vary in their extent, position on the tooth surface, and distribution

within the dentition. The codes are:

0 Normal

1 Demarcated opacity:

In enamel of normal thickness and with an intact surface, there is an

alteration in the translucency of the enamel, variable in degree. It is

demarcated from the adjacent normal enamel with a distinct and clear

boundary and can be white, cream, yellow or brown in color.

2 Diffuse opacity:

Also an abnormality involving an alteration in the translucency of the enamel,

variable in degree, and white in color. There is no clear boundary between the

adjacent normal enamel and the opacity can be linear or patchy or have a

confluent distribution.

3 Hypoplasia:

A defect involving the surface of the enamel and associated with a localized

reduction in the thickness of the enamel. It can occur in the form of: (a) pits-

single or multiple, shallow or deep, scattered, or in rows arranged horizontally

across the tooth surface; (b) grooves-single or multiple, narrow or wide (max.

2mm); or (c) partial or complete absence of enamel over a considerable area

of dentine. The affected enamel may be translucent or opaque.

4 Other defects

5 Demarcated and diffuse opacities

6 Demarcated opacity and hypoplasia

7 Diffuse opacity and hypoplasia

8 All three conditions

9 Not recorded

Codes

231

Photographs of typical examples of enamel opacities and hypoplasias are shown in

Plates 2 and 3.

Ten index teeth should be examined on the buccal surfaces only and coded in the

boxes provided.

Buccal surfaces, i.e. from the incisal edges or cuspal points to the gingiva and from

the mesial to the distal embrasure, should be inspected visually for defects and, if

there is any doubt, areas such as hypoplastic pits should be checked with the

periodontal probe to confirm the diagnosis. Any gross plaque or food deposits

should be removed and the teeth should be examined in a wet condition.

Specific areas of concern in differentiating between enamel opacities and other

changes in dental enamel are: (a) white spot decay; and (b) white cuspal and

marginal ridges on premolar and molar teeth and, occasionally, on lateral incisors.

If there is any doubt about the presence of an abnormality, the tooth surface should

be scored "normal" (code 0). Similarly, a tooth surface with a single abnormality less

than 1 mm in diameter should be scored "0". Any abnormality that can not be readily

classified into one of the three basic types should be scored "other defects" (code 4).

A tooth should be regarded as present once any part of it has penetrated the mucosa and any abnormality present on the erupted portion should be recorded. If any index teeth are missing or if more than two-thirds of a tooth surface

is heavily restored, badly decayed or fractured, it should not be examined (code 9).

Dental Fluorosis:

Fluorotic lesions are usually bilaterally symmetrical and tend to show a horizontal

striated pattern across the tooth. The premolars and 2nd molars are most frequently

affected, followed by the upper incisors. The mandibular incisors are least affected.

14 13 12 11 21 22 23 24

46 36

232

The examiner should note the distribution pattern of any defects and decide if they

are typical of fluorosis. The defects in the "questionable" to "mild" categories (the

most likely to occur) may consist of fine white lines or patches, usually near the

incisal edges or cusp tips. They are paper white or frosted in appearance like a

snow-capped mountain and tend to fade into the surrounding enamel.

It is recommended that Dean's index criteria (3) be used. The recording is made on the basis of the two teeth that are most affected. If the two teeth are not equally affected, the score for the less affected of the two should be recorded.

When teeth are scored, the examiner should start at the higher end of the index, i.e.

"severe", and eliminate each score until he or she arrives at the condition present. If there is any doubt, the lower score should be given. The codes are:

0 Normal:

The enamel surface is smooth, glossy and usually a pale creamy-white color.

1 Questionable:

The enamel shows slight aberrations from the translucency of normal enamel,

which may range from a few white flecks to occasional spots.

2 Very mild:

Small, opaque, paper-white areas scattered irregularly over the tooth but

involving less than 25% of the labial tooth surface.

3 Mild:

The white opacity of the enamel of the teeth is more extensive than for code

2, but covers less than 50% of the tooth surface.

4 Moderate:

The enamel surfaces of the teeth show marked wear and brown stain is

frequently a disfiguring feature.

5 Severe:

The enamel surfaces are badly affected and hypoplasia is so marked that the

general form of the tooth may be affected. There are pitted or worn areas and

brown stains are widespread; the teeth often have a corroded appearance.

8 Excluded (e.g. a crowned tooth)

9 Not recorded

Codes

233

Examples of coding of dental fluorosis according to Dean's index criteria and of other

abnormalities of the enamel are shown in Plates 2 and 3.

Periodontal Status: Community Periodontal Index for Treatment Needs (CPITN):

Three indicators of periodontal status are used for this assessment: gingival

bleeding, calculus and periodontal pockets. A specially designed light-weight CPITN

probe (WHO probe) with a 0.5-mm ball tip is used, with a black band between 3.5

and 5.5mm and rings at 8.5 and 11.5 mm from the ball tip.

The mouth is divided into sextants defined by tooth numbers: 18-14, 13-23, 24-28,

38-34, 33-43 and 44-48. A sextant should be examined only if there are two or more

teeth present which are not indicated for extraction.

For adults aged 20 years and over, the teeth to be examined are:

The two molars in each posterior sextant are paired for recording and, if one is

missing, there is no replacement. If no index teeth or tooth is present in a sextant

qualifying for examination, all the remaining teeth in that sextant are examined and

the highest score is recorded as the score for the sextant. In this case, distal

surfaces of third molars should not be scored.

For subjects under the age of 20 years, only six index teeth16, 11, 26, 36, 31 and 46

are examined. This modification is made in order to avoid scoring the deepened

sulci associated with eruption as periodontal pockets. For the same reason, when

children under the age of 15 are examined, pockets should not be recorded, i.e. only

bleeding and calculus should be considered.

An index tooth should be probed, using the probe as a "sensing" instrument to

determine pocket depth and to detect subgingival calculus and bleeding response.

The sensing force used should be no more than 20 grams. A practical test for

17/16 11 26/27

47/46 31 36/37

234

establishing this force is to place the probe point under the thumb nail and press

until blanching occurs. For sensing subgingival calculus, the lightest possible force

that will allow movement of the probe ball tip along the tooth surface should be used.

When the probe is inserted, the ball tip should follow the anatomical configuration of

the surface of the tooth root. If the patient feels pain during probing, this is indicative

of the use of too much force.

The probe tip should be inserted gently into the gingival sulcus or pocket and the

total extent of the sulcus or pocket explored. For example, the probe is placed in the

pocket at the disto-buccal surface of the second molar, as close as possible to the

contact point with the third molar, keeping the probe parallel to the long axis of the

tooth. The probe is then moved gently, with short upward and downward

movements, along the buccal sulcus or pocket to the mesial surface of the second

molar, and from the disto-buccal surface of the first molar towards the contact area

with the premolar. A similar procedure is carried out for the lingual surfaces, starting

distolingually to the second molar.

The index teeth, or all remaining teeth in a sextant where there is no index tooth,

should be probed and the highest score recorded in the appropriate box. The codes

are:

0 Healthy

1 Bleeding observed, directly or by using a mouth mirror, after probing.

2 Calculus detected during probing, but the entire black band on the probe

visible.

3 Pocket 4-5 mm (gingival margin within the black band on the probe).

4 Pocket 6mm or more (black band on the probe not visible).

5 Excluded sextant (less than two teeth present).

9 Not recorded.

These codings are illustrated in Plate 4 and Fig. 3.

Codes

235

Loss of Attachment: Information on loss of attachment may be collected from index teeth in order to

obtain an estimate of the lifetime accumulated destruction of the periodontal

attachment. This permits comparisons between population groups but is not

intended to describe the full extent of loss of attachment in an individual.

The most reliable way of examining for loss of attachment in each sextant is to

record this immediately after recording the CPITN score for that particular sextant.

The highest scores for CPITN and loss of attachment may not necessarily be found

on the same tooth in a sextant.

Loss of attachment should not be recorded for children under the age of 15.

Fig. 3 Examples of coding according to the Community Periodontal Index for

Treatment Needs, showing the position of the CPITN probe

Probing pocket depths gives some indication of the extent of loss of attachment.

This measurement is unreliable when there is gingival recession, i.e. when the

cementoenamel junction (CEJ) is visible. When the CEJ is not visible and the

highest CPITN score for a sextant is less than 4 (probing depth less than 6 mm), any

loss of attachment for that sextant is estimated to be less than 4mm (loss of

attachment score = 0). The extent of loss of attachment is recorded using the

following codes (see Fig. 4):

236

0 Loss of attachment 0-3 mm (CEJ not visible and CPITN score 0-3)

If the CEJ is visible:

1 Loss of attachment 4-5mm (CEJ within the black band or if the CEJ is not

visible and the CPITN score is 4)

2 Loss of attachment 6-8 mm (CEJ between the upper limit of the black band

and the 8.5-mm ring)

3 Loss of attachment 9-11 mm (CEJ between the 8.5-mm and 11.5-mm rings)

4 Loss of attachment 12 mm or more (CEJ beyond the 11.5-mm ring)

5 Excluded sextant (less than two teeth present)

9 Not recorded (CEJ neither visible nor detectable)

Fig. 4 Examples of coding for loss of attachment with a CPITN probe

Dentition Status and Treatment Need: The examination for dental caries should be conducted with a plane mouth mirror.

Radiography for detection of approximal caries is not recommended because of the

impracticability of using the equipment in all situations. Likewise, the use of

fibreoptics is not recommended. Although it is realized that both these diagnostic

aids will reduce the underestimation of the need for restorative care, the extra

complication and frequent objections to exposure to radiation outweigh the gains to

be expected.

Codes

237

Examiners should adopt a systematic approach to the assessment of dentition

status and treatment needs. The examination should proceed in an orderly manner

from one tooth or tooth space to the adjacent tooth or tooth space. A tooth should be

considered present in the mouth when any part of it is visible. If a permanent and

primary tooth occupy the same tooth space, the status of the permanent tooth only

should be recorded.

Dentition status and treatment needs will be recorded in the boxes provided in the

clinical examination form for upper and lower primary and permanent teeth.

Permanent teeth have 2 rows of boxes that correspond to the status of crown and

root of all permanent teeth. However, for primary teeth, only the crown status will be

recorded. An entry must be made in every box.

Note: Considerable care should be taken to diagnose tooth-colored fillings, which

may be extremely difficult to detect. Codes for the dentition status of primary and

permanent teeth (crowns and roots) are given in the table below.

Crown / Root

The criteria for diagnosis and coding are:

0 Sound Crown

A crown is recorded as sound if it shows no evidence of treated or untreated

clinical caries: The stages of caries that precede cavitation, as well as other

conditions similar to the early stages of caries, are excluded because they

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

Sound Decayed Filled- with decay Filled- no decay Missing- due to caries Missing- any other reason Fissure sealant Bridge abutment, crown, veneer or implant Unerupted tooth or crown or unexposed root Trauma (fracture)

Status Codes

Codes

238

cannot be reliably diagnosed. Thus, a crown with the following defects, in the

absence of other positive criteria, should be coded as sound:

- white or chalky spots

- discolored or rough spots that are not soft to touch with a metal CPITN

probe

- stained pits or fissures in the enamel that do not have visual signs of

undermined enamel, or softening of the floor or walls detectable with a

CPITN probe

- dark, shiny, hard, pitted areas of enamel in a tooth showing signs of

moderate to severe fluorosis

- lesions that, on the basis of their distribution or history, or visual / tactile

examination, appear to be due to abrasion.

Sound Root

A root is recorded as sound when it is exposed and shows no evidence of

treated or untreated clinical caries. (Unexposed roots are coded 8.)

1 Decayed Crown

Caries is recorded as present when a lesion in a pit or fissure, or on a smooth

tooth surface, has an unmistakable cavity, undermined enamel, or a

detectably softened floor or wall. A tooth with a temporary filling, or one which

is sealed (code 6) but also decayed, should also be included in this category.

In cases where the crown has been destroyed by caries and only the root is

left, the caries is judged to have originated on the crown and therefore scored

as crown caries only. The CPITN probe should be used to confirm visual

evidence of caries on the occlusal, buccal and lingual surfaces. Where any

doubt exists, caries should not be recorded as present.

Decayed Root

Caries is recorded as present when a lesion feels soft or leathery to probing

with the CPITN probe. If the root caries is discrete from the crown and will

require a separate treatment, it should be recorded as root caries. For single

carious lesions affecting both the crown and the root, the likely site of origin of

the lesion should be recorded as decayed. When it is not possible to judge

239

the site of origin, both the crown and the root should be recorded as decayed.

2 Filled crown with decay

A crown is considered filled, with decay, when it has one or more permanent

restorations and one or more areas that are decayed. No distinction is made

between primary and secondary caries (i.e. the same code applies whether or

not the carious lesions are in physical association with the restoration(s)).

Filled root with decay

A root is considered filled, with decay, when it has one or more permanent

restorations and one or more areas that are decayed. No distinction is made

between primary and secondary caries.

In the case of fillings involving both the crown and the root, judgment of the

site of origin is more difficult. For any restoration involving both the crown and

the root with secondary caries, the most likely site of the primary carious

lesion is recorded as filled, with decay. When it is not possible to judge the

site of origin of the primary carious lesion, both the crown and the root should

be recorded as filled, with decay.

3 Filled crown with no decay

A crown is considered filled, without decay, when one or more permanent

restorations are present and there is no caries anywhere on the crown. A

tooth that has been crowned because of previous decay is recorded in this

category. (A tooth that has been crowned for reasons other than decay, e.g. a

bridge abutment, is coded 7)

Filled root with no decay

A root is considered filled, without decay, when one or more permanent

restorations are present and there is no caries anywhere on the root.

In the case of fillings involving both the crown and the root, judgment of the site of

origin is more difficult. For any restoration involving both the crown and the root, the

most likely site of the primary carious lesion is recorded as filled. When it is not

240

possible to judge the site of origin, both the crown and the root should be recorded

as filled.

4 Missing tooth as a result of caries

This code is used for permanent or primary teeth that have been extracted

because of caries and is recorded under coronal status. For missing primary

teeth, this score should be used only if the subject is at an age when normal

exfoliation would not be a sufficient explanation for absence.

Note: The root status of a tooth that has been scored as missing because of caries

should be coded "4" or "7".

In some age groups, it may be difficult to distinguish between unerupted teeth (code

8) and missing teeth (codes 4 or 5). Basic knowledge of tooth eruption patterns, the

appearance of the alveolar ridge in the area of the tooth space in question, and the

caries status of other teeth in the mouth may provide helpful clues in making a

differential diagnosis between unerupted and extracted teeth. Code 4 should not be

used for teeth judged to be missing for any reason other than caries.

5 Permanent tooth missing for any other reason

This code is used for permanent teeth judged to be absent congenitally, or

extracted for orthodontic reasons or because of periodontal disease, trauma,

etc.

Note: The root status of a tooth scored 5 should be coded "5" or "7".

6 Fissure sealant

This code is used for teeth in which a fissure sealant has been placed on the

occlusal surface; or for teeth in which the occlusal fissure has been enlarged

with a rounded or "flame-shaped" bur, and a composite material placed. If a

tooth with a sealant has decay, it should be coded as 1.

7 Bridge abutment, special crown or veneer

This code is used under coronal status to indicate that a tooth forms part of a

fixed bridge, i.e. is a bridge abutment. This code can also be used for crowns

241

placed for reasons other than caries and for veneers or laminates covering

the labial surface of a tooth on which there is no evidence of caries or a

restoration.

Note: Missing teeth replaced by bridge pontics are coded 4 or 5 under coronal and

root status.

8 Unerupted Crown

This classification is restricted to permanent teeth and used only for a tooth

space with an unerupted permanent tooth but without a primary tooth. Teeth

scored as unerupted are excluded from all calculations concerning dental

caries. This category does not include congenitally missing teeth, or teeth lost

as a result of trauma, etc. For differential diagnosis between missing and

unerupted teeth, see code 5.

Unexposed Root

This code indicates that the root surface is not exposed, i.e. there is no

gingival recession beyond the CEJ.

9 Trauma (fracture)

A crown is scored as fractured when some of its surface is missing as a result

of trauma and there is no evidence of caries.

Treatment requirements should be assessed for the whole tooth, including both

coronal and root caries. Immediately after the status of a tooth is recorded, and

before proceeding to the next tooth or tooth space, the type of treatment required, if

Treatment needs of individual teeth

Examiners are encouraged to use their own clinical judgment when making

decisions on what type of treatment would be most appropriate, based on what

would be the probable treatment for the average person in the community or

country. This could extend to scoring code "0" even though the dentition status has

been given a different score.

242

any, should be recorded. If no treatment is required, code "0" should be placed in

the appropriate treatment box.

The codes and criteria for treatment needs are:

0 None (no treatment)

This code is recorded if a crown and a root are both sound, or if it is decided

that a tooth should not receive any treatment.

1 Preventive, caries-arresting care

2 Fissure sealant

3 One surface filling

4 Two or more surface fillings

One of the codes 1, 2, 3 or 4 should be used to indicate the treatment required to:

- treat initial, primary or secondary caries

- treat discoloration of a tooth, or a developmental defect

- treat lesions due to trauma, abrasion, erosion or attrition

- replace unsatisfactory fillings or sealants.

A sealant is considered unsatisfactory if partial loss has extended to exposure of a

fissure, pit, or junction or surface of the dentine which, in the examiner's opinion,

requires resealing.

0 = None

1 = Preventive, caries arresting care

2 = Fissure sealant

3 = One surface filling

4 = Two or more surface fillings

5 = Crown for any reason

6 = Veneer or laminate

7 = Pulp care and restoration

8 = Extraction

9 = Need for other care (specify): _____________

Treatment Codes

Codes

243

A filling is considered unsatisfactory if one or more of the following conditions exist:

• A deficient margin to an existing restoration that has leaked or is likely to permit

leakage into the dentine. The decision as to whether a margin is deficient should

be based on the examiner's clinical judgment, on evidence gained from the

insertion of a CPI probe at the margin, or on the presence of severe staining of the

tooth structure.

• An overhanging margin of an existing restoration that causes obvious local irritation

to the gingiva and cannot be removed by re-contouring of the restoration.

• A fracture of an existing restoration that either causes it to be loose or permits

leakage into the dentine.

• Discoloration.

5 Crown for any reason

6 Veneer or laminate (may be recommended for aesthetic purposes)

7 Pulp care and restoration

This code is used to indicate that a tooth probably needs pulp care prior to

restoration with a filling or crown because of deep and extensive caries, or

because of tooth mutilation or trauma.

Note: A probe should never be inserted into the depth of a cavity to confirm the

presence of a suspected pulp exposure.

8 Extraction

A tooth is recorded as "indicated for extraction", depending on the treatment

possibilities available, when:

- caries has so destroyed the tooth that it cannot be restored

- periodontal disease has progressed so far that the tooth is loose, painful or

functionless and, in the clinical judgment of the examiner, cannot be restored

to a functional state

- a tooth needs to be extracted to make way for a prosthesis

- extraction is required for orthodontic or cosmetic reasons, or because of

impaction.

244

9 Need for other care

The examiner should specify the types of care for which codes 7 and 8 are

used. The use of this code should be kept to a minimum.

Prosthetic Status

The presence of prostheses should be recorded for each jaw. The following codes

are provided for this:

0 No prosthesis

1 Bridge

2 More than one bridge

3 Partial denture

4 Both bridge(s) and partial denture(s)

5 Full removable denture

9 Not recorded

Prosthetic Need

A recording should be made for each jaw on the perceived need for prostheses

according to the following codes:

0 No prosthesis needed

1 Need for one-unit prosthesis (one tooth replacement)

2 Need for multi-unit prosthesis (more than one tooth replacement)

3 Need for a combination of one- and/or multi-unit prostheses

4 Need for full prosthesis (replacement of all teeth)

9 Not recorded

Codes

Codes

245

Color Plates

246

Plate 1 Examples of pathological conditions affecting the oral mucosa

A: malignant tumor (oral cancer) (code 1), on tongue

B: malignant tumor (oral cancer) (code 1), on floor of mouth

C: malignant tumor (oral cancer) (code 1), on lips

D: leukoplakia (code 2), on commissures

E: leukoplakia (code 2), on floor of mouth and tongue

F: lichen planus (code 3), on buccal mucosa

247

Cont. Plate 1 G: herpetic ulceration (code 4), on lips

H: acute necrotizing gingivitis (code 5), on alveolar ridges/gingiva

I: candidiasis (code 6), on buccal mucosa and hard and/or soft palate

J: abscess (code 7), on alveolar ridges/gingiva

248

Plate 2 Examples of coding of enamel opacities and hypoplasia

A: upper right first incisor-normal (code 0), lower left second incisor-

demarcated opacity (code 1)

B: upper right first incisor-demarcated opacity (code 1), upper left first incisor-

demarcated opacity and hypoplasia (code 6)

C: upper right first incisor-diffuse opacity (code 2), upper left first incisor-

demarcated and diffuse opacities (code 5)

D: upper first incisors-diffuse opacity (code 2)

E: upper first incisors-diffuse opacity (code 2)

F: upper first incisors-diffuse opacity (code 2)

249

Cont. Plate 2 G: upper first incisors-diffuse opacity (code 2)

H: upper first incisors-diffuse opacity (code 2)

I: upper right canine and first premolar-diffuse opacity and hypoplasia (code 7)

J: upper left second incisor diffuse opacity and hypoplasia (code 7)

K: upper first incisors-hypoplasia (code 3)

L: upper left second incisor-hypoplasia (code 3)

250

Plate 3 Examples of coding of fluorosis according to Dean's index criteria

A: code 0 (normal)

B: code 1 (questionable)

C: code 2 (very mild)

D: code 3 (mild)

E: code 4 (moderate)

F: code 5 (severe)

251

Plate 4 Examples of coding according to the Community Periodontal Index

A: CPI = 0

B: CPI = 1

C: CPI = 2

D: CPI = 3

E: CPI = 4

252

Appendix F

Participants’ Consent Form (English and Arabic versions)

253

You / your child have been randomly selected to take part in a study that will

assess the dental health status, dental treatment needs and supply of dental

services in Jeddah city and Bahrah, Saudi Arabia. Participants will have a risk free

dental clinical examination conducted by a dentist and will be asked to fill out a

questionnaire. There will be no any kind of dental treatment provided as part of our

study. However, if we find any dental emergency that requires referral, then dental

care will be provided to the participant at the Faculty of Dentistry, King Abdulaziz

University in Jeddah city by members of the research team. The study forms will

not include participants’ names and the results will not include information that

would reveal participant’s identification and only group results will be presented.

Participants’ Consent Form Dear participant / child’s parent,

Your / your child’s participation is totally voluntary and you / your child can

refuse to continue participating at any time during the study period. However,

your / child’s participation is valuable and will help improve the dental health

services in Jeddah and Bahrah to best serve you and your children.

This study is part of a PhD degree requirement and is supervised by the

University of Toronto in Canada and King Abdulaziz University in Saudi Arabia. If

you have any questions about the study, please contact the Faculty of Dentistry,

King Abdulaziz University at this phone number: 6403443 Ext. 20388. Thank you for your support Do you agree to take part in this study? If yes, then please sign below. I have read the study description and understand what it will involve and agree to participate in it to the best of my ability. Participant / Child’s parent signature: _____________________ Date: _____________________

F a c u l t y o f D e n t i s t r y K i n g A b d u l a z i z U n i v e r s i t y

S a u d i A r a b i a

F a c u l t y o f D e n t i s t r y U n i v e r s i t y o f T o r o n t o

C a n a d a

254

نموذج موافقة مشارك

عزيزي المشارك / المشاركه:لقد تم اختياركم عشوائيًا في هذه الدراسة العلمية الهادفة لتقييم الوضع الصحي لألسنان و االحتياجات

العالجية وتوفر الخدمات العالجية لألسنان في مدينة جده وبحره حيث سيخضع المشاركون لكشف عام من المشاركين تعبئة استبيان مكون من بللفم واألسنان يقوم به أطباء وطبيبات أسنان سعوديون وسيطل

مجموعة أسئله، علمًا بأنه لن يقدم أي نوع من العالج للمشاركين في البحث إال إذا كانت هناك حالة عن طريق التحويل إلى عيادات كلية طب –طارئه؛ عندها سيقدم العالج للمشاركين- حسب رغبتهم

األسنان بجامعة الملك عبد العزيز حيث سيقوم فريق البحث بتقديم العالج الطارئ هناك.

تجدر اإلشاره هنا إلى أن جميع نماذج البحث لن تحتوي على أي أسماء للمشاركين أو أي بيانات تدل أن نتائج البحث ستعرض إجماًال لجميع المشاركين سوية.اعلى هوية المشارك باإلطالق، كم

إن مشاركتكم ستكون تطوعية ومن حقكم كمشاركين رفض االستمرار في المشاركة في أي وقت خالل

فترة الدراسة، إال أن مشاركتكم ستكون ذات قيمة عالية لتطوير الخدمات العالجية لألسنان في جدة وبحرة بما سيعود عليكم وعلى المجتمع بالنفع الكبير والفائدة العميمة.

إن هذه الدراسة هي جزء من رسالة دكتوراه يشرف عليها باحثون من جامعة تورونتو بكندا ومن جامعة

الملك عبد العزيز بجدة. إذا كانت لديكم أي استفسارات أو أسئلة عن الدراسة فتفضلوا باالتصال بكلية ، وسنسعد ظهرًا١٢ صباحًا الى الساعه ١٠طب األسنان جامعة الملك عبد العزيز مابين الساعه

٢٠٣٨٨ تحويله: ٦٤٠٣٤٤٣ باإلجابة على استفساراتكم على الرقم التالي:

شاكرين لكم دعمكم عجلة العلم واألبحاث في هذا البلد الكريم والتي تخدم الوطن والمواطنين.

هل توافق على المشاركة في البحث ؟ إذا كانت اإلجابة بنعم فالرجاء التوقيع أدناه. لقد قرأت شرح البحث وفهمت ما سيطلب مني المشاركة به أثناء البحث وأوافق على المشاركة.

هـ۱٤۲۸توقيع المشارك / المشاركه :ــــــــــــــــ التاريخ / /

كلية طب األسنان جامعة الملك عبدالعزيز المملكه العربيه السعوديه

كلية طب األسنان جامعة تورونتو

كندا

255

نموذج موافقة مشارك عزيزي ولي أمر الطالب/الطالبة:

لقد تم اختيار ابنك/ابنتك عشوائيًا في هذه الدراسة العلمية الهادفة لتقييم الوضع الصحي لألسنان و االحتياجات العالجية وتوفر الخدمات العالجية لألسنان في مدينة جده وبحره حيث سيخضع المشاركون

من المشاركين تعبئة استبيان بلكشف عام للفم واألسنان يقوم به أطباء وطبيبات أسنان سعوديون وسيطلمكون من مجموعة أسئله، علمًا بأنه لن يقدم أي نوع من العالج للمشاركين في البحث إال إذا كانت هناك

عن طريق التحويل إلى عيادات كلية –حالة طارئه؛ عندها سيقدم العالج للمشاركين- حسب رغبتهم طب األسنان بجامعة الملك عبد العزيز حيث سيقوم فريق البحث بتقديم العالج الطارئ هناك.

تجدر اإلشاره هنا إلى أن جميع نماذج البحث لن تحتوي على أي أسماء للمشاركين أو أي بيانات تدل

أن نتائج البحث ستعرض إجماًال لجميع المشاركين سوية.اعلى هوية المشارك باإلطالق، كم إن مشاركة ابنك / ابنتك ستكون تطوعية ومن حقهم كمشاركين رفض االستمرار في المشاركة في أي وقت خالل فترة الدراسة، إال أن مشاركتهم ستكون ذات قيمة عالية لتطوير الخدمات العالجية لألسنان

في جدة وبحرة بما سيعود عليهم وعلى المجتمع بالنفع الكبير والفائدة العميمة.

إن هذه الدراسة هي جزء من رسالة دكتوراه يشرف عليها باحثون من جامعة تورونتو بكندا ومن جامعة الملك عبد العزيز بجدة. إذا كانت لديكم أي استفسارات أو أسئلة عن الدراسة فتفضلوا باالتصال بكلية

، وسنسعد ظهرًا١٢ صباحًا الى الساعه ١٠طب األسنان جامعة الملك عبد العزيز مابين الساعه ٢٠٣٨٨ تحويله: ٦٤٠٣٤٤٣ باإلجابة على استفساراتكم على الرقم التالي:

شاكرين لكم دعمكم عجلة العلم واألبحاث في هذا البلد الكريم والتي تخدم الوطن والمواطنين.

هل توافق على مشاركة ابنك / ابنتك في البحث ؟ إذا كانت اإلجابة بنعم فالرجاء التوقيع أدناه.

لقد قرأت شرح البحث وفهمت ما سيطلب من ابني / ابنتي المشاركة به أثناء البحث وأوافق على مشاركة ابني /ابنتي.

ه۱٤۲۸توقيع ولي أمر الطالب/الطالبة :ــــــــــــــــ التاريخ: / /

كلية طب األسنان جامعة الملك عبدالعزيز المملكه العربيه السعوديه


كندا

256

Appendix G

Clinical Examination Form

257



2007


Saudi Arab ia


Canada

258

Clinical Examination Form

School Name (if applicable): ____________________________ Participant ID #_______

Place of residence: Examiner ID # _______

□ Jeddah

□ Bahrah

Participant’s age

For each of the following categories, please type the appropriate code number(s) that applies, in the boxes provided.

Lip and Palate Assessment:

Codes

0 No abnormality detected

1 Unilateral cleft lip

2 Unilateral cleft palate

: _______ years

3 Bilateral cleft lip

4 Bilateral cleft palate

5 Unilateral cleft lip & palate

6 Bilateral cleft lip & palate

7 Unilateral cleft lip & bilateral cleft palate

8 Unilateral cleft palate & bilateral cleft lip

259

Oral Mucosa: (Record the condition(s) present under the heading (a) then record the location of the identified condition(s) under the heading (b) in the same order that correspond to the condition(s))

b) Location: Codes

0 Vermilion border

1 Commissures

2 Lips

3 Sulci

4 Buccal mucosa

5 Floor of mouth

6 Tongue

7 Hard and / or soft palate

8 Alveolar ridges / gingiva

9 Not recorded

a) Condition: Codes

0 No abnormal condition

1 Malignant tumor (oral cancer)

2 Leukoplakia

3 Lichen planus

4 Ulceration (aphthous, herpetic, traumatic)

5 Acute Necrotizing gingivitis

6 Candidiasis

7 Abscess

8 Other condition (specify if possible) __________________ 9 Not recorded


i ii iii

i ii iii

260

Enamel Opacities / Hypoplasia: (Permanent teeth only) Codes

0 Normal 1 Demarcated opacity 2 Diffuse opacity 3 Hypoplasia 4 Other defects 5 Demarcated and diffuse opacities 6 Demarcated opacity and hypoplasia 7 Diffuse opacity and hypoplasia 8 Demarcated opacity, diffuse opacity, and hypoplasia 9 Not recorded

Dental Fluorosis: Codes

0 Normal 1 Questionable 2 Very mild 3 Mild 4 Moderate 5 Severe 6 Excluded 9 Not recorded

14 13 12 11 21 22 23 24

46 36

261

Community Periodontal Index for Treatment Needs (CPITN): Codes

0 Healthy

1 Bleeding

2 Calculus

3 * Pocket 4-5 mm (black band on probe partially visible)

4 * Pocket 6 mm or more (black band on probe not visible)

5 Excluded sextant

9 Not recorded

• Not recorded under 15 years of age

Loss of Attachment: (Not recorded under 15 years of age)

Codes 0 0-3 mm

1 4-5 mm (cemento-enamel junction (CEJ) within black band)

2 6-8 mm (CEJ between upper limit of black band and 8.5-mm ring)

3 9-11 mm (CEJ between 8.5-mm and 11.5-mm rings)

4 12 mm or more (CEJ beyond 11.5-mm ring)

5 Excluded sextant

9 Not recorded

17/16 11 26/27

47/46 31 36/37

17/16 11 26/27

47/46 31 36/37

262

Prosthetic Status: Codes

0 No prosthesis

1 Bridge

2 More than one bridge

3 Partial denture

4 Both bridge(s) and partial denture(s)

5 Full removable denture

9 Not recorded

Prosthetic Need: Codes

0 No prosthesis needed

1 Need for one-unit prosthesis

2 Need for multi-unit prosthesis

3 Need for a combination of one- and/or multi-unit prostheses

4 Need for full prosthesis (replacement of all teeth)

9 Not recorded

Upper arch

Lower arch

Upper arch

Lower arch

263

Dentition Status and Treatment Need:

Status Codes Treatment Codes Crown / Root

Crown

Root

Treatment

Crown

Root

Treatment

55 54 53 52 51 61 62 63 64 65

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

85 84 83 82 81 71 72 73 74 75

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

Sound Decayed Filled- with decay Filled- no decay Missing- due to caries Missing- any other reason Fissure sealant Bridge abutment, crown, veneer or implant Exfoliated or unerupted tooth or crown or unexposed root Trauma (fracture)

0 = None 1 = Preventive, caries

arresting care 2 = Fissure sealant 3 = One surface filling 4 = Two or more surface fillings 5 = Crown for any reason 6 = Veneer or laminate 7 = Pulp care and restoration 8 = Extraction 9 = Need for other care (specify): _____________

Crown

Crown

264

Appendix H1

Elementary Schoolchildren’ Questionnaire (English and Arabic versions)

265



(Elementary Schoolchildren)

2007

Facu lty of Dent is t ry K ing Abdulaziz Univers i ty

Saudi Arab ia


Canada

266

School Name : __________________________ Participant ID #_______ Place of residence: □ Jeddah

□ Bahrah Please note that the participant’s ID number does not identify your child however, it is intended only to organize recording of the study findings and only group results will be presented.

Please circle the appropriate number that applies to your child or fill in the blanks provided for each of the following questions:

First

1. In general, how would you describe the condition of your child’s mouth including his / her natural teeth or dentures, gums, tongue, lips and jaw joints? Would you say that it is:

: Questions about the health of your child’s mouth and teeth and the dental care habits that he / she performs to take care of them:

1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 9 Don’t know or don’t remember

2. In general, how satisfied is your child with:

a) the health of his / her mouth? 1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied 9 Don’t know or don’t remember b) the appearance of his / her natural teeth or dentures: 1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied 9 Don’t know or don’t remember

3. In the past 12 months, how often has your child found it uncomfortable to eat any food because problems with his / her mouth?

1 Often 2 Sometimes 3 Rarely 4 Never 9 Don’t know or don’t remember

267

4. In the past 12 months, how often have your child avoided conversation or contact with other people because of the condition of his / her teeth, mouth or dentures?


5. In the past 12 months, has your child taken time away from school or his / her normal

activities because of the need to have dental treatment including dental check-ups or because of problems with his / her mouth?

1 Yes 2 No (Go to Question # 7) 9 Don’t know or don’t remember

6. In the past 12 months, did anyone in the family miss any time from school,

work or from normal activities to assist your child with a dental treatment including dental check-ups or because of problems with his / her mouth?

1 Yes 2 No 9 Don’t know or don’t remember

7. In the past month have your child had persistent or on-going:

Yes a) Toothache? b) Pain in the teeth when consuming hot or cold foods or drinks? c) Pain in or around the jaw joints? d) Severe tooth or mouth pain at night? e) Other pain anywhere in your child’s mouth? f) Bleeding gums when he / she brushes his / her teeth? g) Dry mouth? h) Bad breath?

No

8. What type of dental care do you think your child need now? (Circle all that apply to your child)

1 None 2 Teeth cleaning and polishing 3 Relief of pain 4 Treatment of injury 5 Treatment for his / her dentures or bridges 6 Treatment of his / her jaw joints 7 Tooth filling(s) 8 Tooth replacement(s) (e.g. crowns and/or bridges or dentures) 9 Tooth extraction(s) 10 Gum treatment 11 Root canal treatment 12 Orthodontic care 13 Teeth whitening 14 Other, (please specify): ___________________ 99 Don’t know

1 1 1 1 1 1 1 1

2 9 2 9 2 9 2 9 2 9 2 9 2 9 2 9

Don’t know or don’t remember

268

9. How often your child does brush his / her teeth? 1 More than twice a day 2 Twice a day 3 Once a day 4 Less than once a day but more than once a week 5 Once a week 6 Less than once a week 9 Don’t know or don’t remember

10. How often in the past week did your child eat / drink the following?

Times per week None or one 2-3

Traditional local food (Masoob or hareesa) Cookies, cakes, ice cream, doughnuts Soft drinks / pop (not diet) Jams, honey, or tihenia Chewing gum with sugar Candy Tea or coffee with sugar

More than 3

11. Does your child try to avoid sugary foods in order to prevent tooth decay? 1 Yes 2 No 9 Don’t know or don’t remember

Second

12. Does your child usually visit a dentist:

: Questions about your child’s dental visits and the dental services provided:

1 More than once a year for check-ups or treatment? 2 About once a year for check-ups or treatment? 3 Less than once a year for check-ups or treatment? 4 Only for emergency care? 5 Never? 9 Don’t know or don’t remember

13. About how long has it been since your child last visited a dentist?

1 6 months or less 2 More than 6 months, but not more than 1 year ago 3 More than 1 year ago, but not more than 3 years ago 4 More than 3 years ago 5 Never have been 9 Don’t know or don’t remember

a) b) c) d) e) f) g)

1 1 1 1 1 1 1

2 2 2 2 2 2 2

3 9 3 9 3 9 3 9 3 9 3 9 3 9


269

14. What was the main reason that your child last visited a dentist? 1 Went in on own for check-up, examination or cleaning 2 Was called in by the dentist for check-up, examination or cleaning 3 Something was wrong, bothering or hurting 4 Went for treatment of a condition that dentist discovered at earlier

check-up or examination 5 Other (please specify):_________________ 9 Don’t know or don’t remember

15. For your child’s last dental visit, how long was it from the time he / she made the appointment until he / she saw the dentist?

1 Less than one day 2 1 to 6 days 3 1 week but less than 2 weeks 4 2-3 weeks 5 1-2 months 6 3 months or more 9 Don’t know or don’t remember (Go to Question # 17)

16. Do you think that this time was longer than you would have liked?


17. For your child’s last dental visit, about how many minutes did your child have to wait at

the dentist’s office before being seen by the dentist? 1 Did not wait at all 2 Less than 15 minutes 3 15-29 minutes 4 30-59 minutes 5 1 hour or more 9 Don’t know or don’t remember (Go to Question # 19)

18. Do you think this waiting time was long?


19. How well where your child satisfied with his / her last dental visit?

1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied 9 Don’t know or don’t remember

270 20. What are the reasons that prevent you from going to a dentist?

(Circle all that applies to your child) 1 Fear 2 No need to go 3 No teeth 4 High travel costs 5 Didn’t have time 6 Other priorities 7 Too long waiting time in the clinic 8 Difficulty in getting appointment 9 Don’t like / trust / believe in dentists 10 Would have to travel too far 11 Didn’t have a way to get there 12 Hours not convenient 13 Didn’t have anyone to care for children or other family members 14 Other reason (please specify): _____________________ 15 No reason to prevent my child from going to a dentist 99 Don’t know or don’t remember

21. What kind of dental clinic does your child usually go to?

1 Government dental clinic 2 Private dental clinic 3 Both 9 Don’t know or don’t remember

Third: Questions about your child’s education and your family income:

Please note again that the study information are extremely confidential and only group results will be presented

22. What school grade is your child currently enrolled in? _______________

23. What is the family monthly income? 1 Less than 1000 SR 2 Between 1000 and 3000 SR 3 Between 3000 and 5000 SR 4 Between 5000 and 7000 SR 5 Between 7000 and 10’000 SR 6 More than 10’000 SR 9 Don’t know or don’t remember

24. How many persons including you are sharing this income?

* _____ persons

9 Don’t know or don’t remember

Please send this questionnaire back, with your child, to his / her school and thank you for taking the time to fill in this questionnaire

271

ه۱٤۲۸ - م۲۰۰۷

كلية طب األسنان جامعة الملك عبد العزيز المملكة العربية السعودية


كندا

تقييم وضع صحة الفم و األسنان واالحتياجات العالجية وتوفر اخلدمات العالجية لألسنان يف مدينة جدة

باململكة العربية السعودية

272

عزيزي ولي أمر الطالب/الطالبة:

ابنتك عشوائيًا في هذه الدراسة العلمية الهادفة لتقييم الوضع الصحي لألسنان و / لقد تم اختيار ابنك

االحتياجات العالجية وتوفر الخدمات العالجية لألسنان في مدينة جده وبحره حيث سيخضع المشاركون

من المشاركين تعبئة استبيان بلكشف عام للفم واألسنان يقوم به أطباء وطبيبات أسنان سعوديون وسيطل

مكون من مجموعة أسئله، تجدر اإلشاره هنا إلى أن جميع نماذج البحث لن تحتوي على أي أسماء

أن نتائج البحث ستعرض إجماًال لجميع اللمشاركين أو أي بيانات تدل على هوية المشارك باإلطالق، كم

المشاركين سوية.

ان مشاركتهم ستكون ذات قيمة عالية لتطوير الخدمات العالجية لألسنان في جدة وبحرة بما سيعود

عليهم وعلى المجتمع بالنفع الكبير والفائدة العميمة.

الرجاء االجابه على كل األسئله بوضع دائره حول الرقم المقابل الختيارك

) يتطلب االجابه على كل فقره بنعم أو بال أو بال أعرف وذلك ۷الرجاء المالحظة أن السؤال رقم (

باختيار الرقم المقابل لكل فقره.

) يتطلب االجابه على كل فقره وذلك باختيارعدد المرات في األسبوع المحدد ۱ ۰والسؤال رقم (

بالرقم المقابل لكل فقره.

شاكرين لكم دعمكم عجلة العلم واألبحاث في هذا البلد الكريم والتي تخدم الوطن

.والمواطنين

273

____________ :Participant ID : ________________________اسم المدرسه

مكان االقامة

جدة

بحرة

الرجاء المالحظة أن نماذج البحث لن تحتوي على أي بيانات تكشف هوية المشارك وأن نتائج البحث ستعرض باالجمال لجميع المشاركين سويةً .

ضع دائرة حول اإلختيار المناسب والذي ينطبق على ابنك / ابنتك أو امأل الفراغات لكل من االسئلة

التالية:

: أسئلة حول صحة فم وأسنان ابنك / ابنتك والعادات المتّبعه للعناية باألسنان : أوالً عموماً ، كيف تقيم الحالة الصحية الخاصة بابنك / ابنتك فيما يتعلق بالفم ، االسنان ، اللثة ، اللسان ، ۱

الشفاه ، ومفصل الفك ؟ ممكن أن تقول عموماً أن الوضع الصحي :

ممتاز ۱ جيد جداً ۲ جيد ۳ مقبول٤ غير مقبول ٥ ال أعرف أو ال أتذكر ۹

عموماً، ماهي درجة رضا ابنك / ابنتك عن التالي : ۲

أ ) صحة الفم؟

راض جداً ۱ راض ۲ ليس راض وليس غير راض ۳ غير راض ٤ غير راض جداً ٥ ال أعرف أو ال أتذكر ۹

ب) مظهر االسنان ؟


274

شهراً الماضية، هل واجه ابنك / ابنتك صعوبه في اكل األطعمه المختلفه بسبب مشاكل في ۱۲ خالل ال ۳

الفم واالسنان ؟

دائماً ۱ أحياناً ۲ نادراً ۳ لم يحدث أبداً ٤ ال أعرف أو ال أتذكر ۹

شهراً الماضية، هل تجنب ابنك / ابنتك الكالم أو المحادثة أو التفاعل مع االخرين ۱۲ خالل ال ٤

بسبب حالة الفم واالسنان؟


شهراً الماضية ، هل غاب ابنك / ابنتك عن المدرسة أو تجنب نشاطه اليومي المعتاد ۱۲ خالل ال ٥

بسبب الذهاب لطبيب االسنان للعالج أو للكشف أو بسبب مشاكل في الفم و االسنان ؟

نعم ۱ )۷اذا كانت االجابة "ال" فانتقل للسؤآل رقم ال ( ۲ ال أعرف أو ال أتذكر ۹

شهراً الماضية ، هل فقد أي فرد من أفراد العائلة وقت من حضور المدرسة أو ۱۲ خالل ال ٦

العمل أو النشاطات اليومية لمرافقة ابنك / ابنتك لطبيب االسنان للعالج او الكشف أو بسبب

مشاكل في الفم و االسنان ؟

نعم ۱ ال ۲ ال أعرف أو ال أتذكر ۹

: خالل الشهر الماضي هل عانى ابنك / ابنتك من ۷

أ) آالم في االسنان ؟ ب) آالم في االسنان مع المأكوالت و المشروبات الباردة أو الساخنة ؟

ج) آالم في أو حول مفاصل فك الفم ؟ د) ألم شديد في الفم أو االسنان ليالً ؟

هـ) أي آالم اخرى في أي مكان في الفم ؟ و) خروج دم من اللثة عند تنظيف االسنان بالفرشاه ؟

ز) جفاف في الفم ؟ ح) رائحة كريهه للفم ؟

نعم ۱ ۱ ۱ ۱ ۱ ۱ ۱ ۱

ال ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹

ال أعرف أجب على كل فقره باالختيار من أو ال أتذكر

275

في اعتقادك، أي نوع من عالج االسنان يحتاج اليه ابنك / ابنتك حالياً ؟ ۸على ابنك / ابنتك ) ( ضع دائرة حول جميع الخيارات التي تنطبق

ال شيء ۱ تنظيف لالسنان ۲ التخلص من االلم ۳ عالج الصابة سنية ٤ عالج لتركيبات ثابتة او متحركة ٥ عالج لمفاصل فك الفم٦ حشو اسنان ۷ تعويض اسنان كالتيجان أوالتركيبات الثابتة أو المتحركة۸ خلع اسنان ۹

عالج لثه ۱۰ عالج لعصب االسنان ۱۱ تقويم االسنان ۱۲ تبييض االسنان۱۳ عالجات اخرى (الرجاء تحديد العالج): __________________________۱٤ ال أعرف۹۹

كم مره يقوم ابنك / ابنتك بالتنظيف بالفرشاه و المعجون ؟ ۹

أكثر من مرتين في اليوم ۱ مرتين في اليوم ۲ مرة في اليوم۳ أقل من مرة في اليوم ولكن اكثر من مرة في االسبوع٤ مرة في االسبوع٥ أقل من مرة في االسبوع ٦

كم مرة خالل االسبوع الماضي تناول ابنك / ابنتك الماكوالت والمشروبات التالية ؟۱۰

مرات ۳أكثر من مرات۳-۲ وال مره أو مرة واحدة

مأكوالت شعبية ( معصوب أو هريسة) )‌أ

بسكوتات أو كيك أو اسكريم أو دونت )‌بالمشروبات الغازية )‌جمربة أو عسل أو حالوة شامي )‌د

هـ) لبان (علكه) تحتوي على سكر الحلويات والسكاكر بأنواعها )‌وشاهي أو قهوة مع السكر )‌ز

هل تجنب ابنك / ابنتك تناول المأكوالت الحلوة لمنع تسوس االسنان ؟ ۱۱

نعم ۱ ال ۲ ال أعرف أو ال أتذكر۹

ال أعرف

أو ال أتذكر

۱ ۱ ۱ ۱ ۱ ۱ ۱

۲ ۲ ۲ ۲ ۲ ۲ ۲

۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹

أجب على كل فقره باالختيار من

عدد المرات في االسبوع

276

ابنك / ابنتك لطبيب االسنان وخدمات طب االسنان المقدمة: : أسئلة عن زياراتثانياً

هل يزور ابنك /ابنتك طبيب االسنان بصفة دائمة : ۱۲

أكثر من مرة في السنة للكشف أو العالج ۱ مرة في السنة تقريباً للكشف أو العالج۲ أقل من مرة في السنة للكشف أو العالج۳ في الحاالت الطارئة فقط٤ وال مرة ٥ ال أعرف أو ال أتذكر۹

منذ متى كانت اخر زيارة البنك /ابنتك الى طبيب االسنان؟ ۱۳

أشهر أو أقل ٦ ۱ أشهر ولكن ليس أكثر من سنة ٦ أكثر من ۲ أكثر من سنة ولكن ليس أكثر من ثالث سنوات ۳ أكثر من ثالث سنوات ٤ لم يزر ابني / ابنتي طبيب االسنان أبداً ٥ ال أعرف أو ال أتذكر۹

ماذا كان السبب الرئيسي لزيارة ابنك / ابنتك لطبيب األسنان ؟ ۱٤

ذهب أو ذهبت تلقائياً للكشف أو التنظيف ۱ طلب طبيب االسنان منه / منها المراجعة للكشف أو التنظيف ۲ كان هناك شيئ يزعج أو يؤلم ابنك /ابنتك ۳ ذهب أو ذهبت لتلقي العالج لمرض شّخصه طبيب األسنان خالل كشف سابق ٤٥ ___________________________ أسباب أخرى ( الرجاء التحديد ) ال أعرف أو ال أتذكر ۹

فيما يخص آخر زيارة إلبنك / ابنتك ، لطبيب األسنان كم استغرق الوقت ما بين تحديد الموعد ۱٥

وبدأ تلقي العالج ؟

أقل من واحد يوم ۱ أيام ٦- ۱ ۲ اسبوع واحد أو أقل من أسبوعين ۳ أسابيع ۳- ۲ ٤ شهر الى شهرين ٥ أشهر أو أكثر ۳ ٦ )۱۷( اذا اخترت "ال أعرف" فانتقل الى سؤال رقم ال أعرف أو ال أتذكر ۹

هل تعتقد ان وقت االنتظار المذكور في السؤال السابق كان أطول من الالزم ؟ ۱٦


277

فيما يخص آخر زيارة البنك / ابنتك لطبيب االسنان ، كم دقيقة اضطر ابنك / ابنتك لإلنتظار في ۱۷

العيادة قبل الدخول على طبيب االسنان ؟

لم ننتظر ابداً ۱ دقيقة ۱٥ أقل من ۲ دقيقة ۲۹- ۱٥ ۳ دقيقة ٥۹- ۳۰ ٤ ساعة أو أكثر ٥ )۱۹( اذا اخترت "ال أعرف" فانتقل الى سؤال رقم ال أعرف أو ال أتذكر ۹

هل تعتقد ان وقت االنتظار المذكور في السؤال السابق كان أطول من الالزم ؟ ۱۸


ما مدى رضا ابنك / ابنتك عن آخر زيارة لطبيب االسنان ؟ ۱۹

راض جداً ۱ راض ۲ ليس راض وليس غير راض ۳ غير راض ٤ غير راض جداً ٥

ال أعرف أو ال أتذكر ۹

ما هي االسباب التي تمنع ابنك / ابنتك من الذهاب الى طبيب االسنان ؟ ۲۰ابنك / ابنتك ) ( ضع دائرة حول جميع الخيارات التي تنطبق علي

الخوف ۱ ال توجد حاجة للذهاب ۲ ال توجد اسنان في الفم ۳ تكاليف التنقل ٤ عدم توفر الوقت ٥ أولويات أخرى ٦ االنتظار لفترات طويلة في العيادة ۷ صعوبة الحصول على مواعيد ۸ ال يفّضلون ، ال يثقون ، ال يؤمنون بأطباء االسنان ۹

يلزمنا التنقل لمسافات بعيدة ۱۰ ليس لدينا وسيلة للوصول الى طبيب االسنان ۱۱ أوقات المواعيد غير مناسبة ۱۲ ال يوجد أحد يعتني باالطفال أو أحد أفراد العائلة في البيت خالل وقت الزيارة ۱۳ أي أسباب أخرى ( الرجاء التحديد ):________________________ ۱٤ ال يوجد سبب يمنع ابني / ابنتي من الذهاب الى طبيب االسنان ۱٥ ال أعرف أو ال أتذكر ۹۹

278

أي نوع من عيادات االسنان يذهب اليها ابنك / ابنتك عادةً ؟ ۲۱

عيادات األسنان الحكومية ۱ عيادات االسنان الخاصة ۲ العيادات الحكومية و الخاصة سوية ۳ ال أعرف أو ال أتذكر۹

: أسئلة عن المستوى التعليمي والدخل العائلي:ثالثاًً

الرجاء المالحظة مجدداً أن معلومات البحث ستكون سرية للغاية بحيث ال تكشف عن هوية المشاركين

وأن النتائج ستعرض باالجمال لجميع المشاركين سوية

في أي صف دراسي يدرس ابنك / ابنتك حالياً ؟ في الصف _________________ ۲۲

كم تقدر تقريباً دخل العائلة الشهري ؟ ۲۳

لایر ۱۰۰۰ أقل من ۱ لایر ۳۰۰۰ -۱۰۰۰ ما بين ۲ لایر ٥۰۰۰ -۳۰۰۰ مابين ۳ لایر ۷۰۰۰ -٥۰۰۰ ما بين٤ لایر ۱۰۰۰۰ - ۷۰۰۰ ما بين٥ لایر ۱۰۰۰۰ أكثر من٦ ال أعرف أو ال أتذكر۹

كم عدد أفراد االسرة اللذين يصرف عليهم من هذا الدخل الشهري متضمناً نفسك ؟ ۲٤

_________ أفراد *


شكراً لتفضلك بهذا الوقت الثمين لتعبئة هذا االستبيان والهادف لتحسين الخدمات العالجيه لألسنان

في جده و بحرة

279

Appendix H2

Intermediate and High-school Schoolchildren’ Questionnaire (English and Arabic versions)

280



(Intermediate and High-school Schoolchildren)

2007

Facu l ty of Dent is t ry K ing Abdulaziz Univers i ty

Saudi Arab ia


Canada

281

Place of residence: Participant ID #_______ □ Jeddah

□ Bahrah Please note that the participant’s ID number does not identify you however, it is intended only to organize recording of the study findings and only group results will be presented.

Please circle the appropriate number that applies to you or fill in the blanks provided for each of the following questions:

First

1. In general, how would you describe the condition of your mouth including your natural teeth or dentures, gums, tongue, lips and jaw joints? Would you say that it is:

: Questions about the health of your mouth and teeth and the dental care habits that you perform to take care of them:


2. In general, how satisfied are you with:

a) the health of your mouth? 1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied

9 Don’t know or don’t remember b) the appearance of your natural teeth or dentures: 1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied 9 Don’t know or don’t remember

3. In the past 12 months, how often have you found it uncomfortable to eat any food because problems with your mouth?


282

4. In the past 12 months, how often have you avoided conversation or contact with other people because of the condition of your teeth, mouth or dentures?


5. In the past 12 months, have you taken time away from work or your normal

activities because of the need to have dental treatment including dental check-ups or because of problems with your mouth?



work or from normal activities to assist you with a dental treatment including dental check-ups or because of problems with your mouth?


7. In the past month have you had persistent or on-going:

Yes No a) Toothache? b) Pain in the teeth when consuming hot or cold foods or drinks? c) Pain in or around the jaw joints? d) Severe tooth or moth pain at night? e) Other pain anywhere in your mouth? f) Bleeding gums when brushing your teeth? g) Dry mouth? h) Bad breath?

8. What type of dental care do you think you need now? (Circle all that apply to you) 1 None 2 Teeth cleaning and polishing 3 Relief of pain 4 Treatment of injury 5 Treatment for my dentures or bridges 6 Treatment of my jaw joints 7 Tooth filling(s) 8 Tooth replacement(s) (e.g. crowns and/or bridges or dentures) 9 Tooth extraction(s) 10 Gum treatment 11 Root canal treatment 12 Orthodontic care 13 Teeth whitening 14 Other, (please specify): ___________________ 99 Don’t know or don’t remember

1 1 1 1 1 1 1 1

2 9 2 9 2 9 2 9 2 9 2 9 2 9 2 9


283

9. How often do you brush your teeth? 1 More than twice a day 2 Twice a day 3 Once a day 4 Less than once a day but more than once a week 5 Once a week 6 Less than once a week 9 Don’t know or don’t remember

10. How often in the past week did you eat / drink the following?


Traditional local food (Masoob or hareesa) Cookies, cakes, ice cream, doughnuts Soft drinks / pop (not diet) Jams, honey, or tihenia Chewing gum with sugar Candy Tee or coffee with sugar

More than 3

11. Do you try to avoid sugary foods in order to prevent tooth decay? 1 Yes 2 No 9 Don’t know or don’t remember

Second

12. Do you usually visit a dentist:

: Questions about your dental visits and the dental services provided:


13. About how long has it been since you last visited a dentist?


14. What was the main reason that you last visited a dentist?

1 Went in on own for check-up, examination or cleaning 2 Was called in by the dentist for check-up, examination or cleaning 3 Something was wrong, bothering or hurting 4 Went for treatment of a condition that dentist discovered at earlier


a) b) c) d) e) f) g)

1 1 1 1 1 1 1

2 2 2 2 2 2 2

3 9 3 9 3 9 3 9 3 9 3 9 3 9


284

15. For your last dental visit, how long was it from the time you made the

appointment until you saw the dentist? 1 Less than one day 2 1 to 6 days 3 1 week but less than 2 weeks 4 2-3 weeks 5 1-2 months 6 3 months or more 9 Don’t know or don’t remember (Go to Question # 17)

16. Do you think that this time was longer than you would have liked? 1 Yes 2 No 9 Don’t know or don’t remember

17. For your last dental visit, about how many minutes did you have to wait at the dentist’s

office before being seen by the dentist? 1 Did not wait at all 2 Less than 15 minutes 3 15-29 minutes 4 30-59 minutes 5 1 hour or more 9 Don’t know or don’t remember (Go to Question # 19)



19. How well where you satisfied with your last dental visit?


285

20. What are the reasons that prevent you from going to a dentist?

(Circle all that applies to you) 1 Fear 2 No need to go 3 No teeth 4 High travel costs 5 Didn’t have time 6 Other priorities 7 Too long waiting time in the clinic 8 Difficulty in getting appointment 9 Don’t like / trust / believe in dentists 10 Would have to travel too far 11 Didn’t have a way to get there 12 Hours not convenient 13 Didn’t have anyone to care for children or other family members 14 Other reason (please specify): _____________________ 15 No reason to prevent me from going to a dentist 99 Don’t know or don’t remember

21. What kind of dental clinic do you usually go to?


Third: Questions about smoking habits as one of the factors related to

your oral health (Circle the category that applies): 22. At the present time, do you smoke cigarettes, mo’assel or shisha daily, occasionally

or not at all? 1 Daily Print either: the number of cigarettes you usually smoke each day _____ and / or the number of times you usually smoke mo’assel or shisha each day _____ (Go to Question # 24) 2 Occasionally Print either: the number of cigarettes you usually smoke each week _____ and / or the number of times you usually smoke mo’assel or shisha each week ____ (Go to Question # 24) 3 Not at all 9 Don’t know or don’t remember 23. Have you ever smoked cigarettes, mo’assel or shisha daily? 1 Yes – At what age did you stop smoking each day? At _____ years old 2 No 9 Don’t know or don’t remember

286

24. How old were you when you first started smoking cigarettes, mo’assel or shisha? 1 I have never smoked before (Go to Question # 26) 2 7 years old or younger 3 8 or 9 years old 4 10 or 11 years old 5 12 years or older 9 Don’t know or don’t remember 25. Has a dentist ever advised you to stop smoking? 1 Yes 2 No 9 Don’t know or don’t remember Fourth: Questions about your education and your family income:

Please note again that the study information are extremely confidential and only group results will be presented

26. What school grade are you currently enrolled in? _______________

27. What is your family’s monthly income? 1 Less than 1000 SR 2 Between 1000 and 3000 SR 3 Between 3000 and 5000 SR 4 Between 5000 and 7000 SR 5 Between 7000 and 10’000 SR 6 More than 10’000 SR 9 Don’t know or don’t remember


* _____ persons


Thank you for taking the time to fill in this questionnaire

287

ه۱٤۲۸ - م۲۰۰۷



كندا



288

____________ :Participant ID : ___________________اسم المدرسه

مكان االقامة

جدة

بحرة

الرجاء المالحظة أن نماذج البحث لن تحتوي على أي بيانات تكشف هوية المشارك وأن نتائج البحث ستعرض باالجمال لجميع المشاركين سويةً .

ضع دائرة حول اإلختيار المناسب والذي ينطبق عليك أو امأل الفراغات لكل من االسئلة التالية:

: أسئلة حول صحة الفم واألسنان والعادات المتّبعه للعناية باألسنان : أوالً

عموماً ، كيف تقيم الحالة الصحية الخاصة بك فيما يتعلق بالفم ، االسنان ، اللثة ، اللسان ، الشفاه ، ۱

ومفصل الفك ؟ ممكن أن تقول عموماً أن الوضع الصحي :


عموماً، ماهي درجة رضاك عن التالي : ۲





289

شهراً الماضية ، هل واجهت صعوبه في اكل األطعمه المختلفه بسبب مشاكل في الفم ۱۲ خالل ال ۳

واالسنان ؟


شهراً الماضية ، هل تجنبت الكالم أو المحادثة أو التفاعل مع االخرين بسبب حالة ۱۲ خالل ال ٤

الفم واالسنان؟


شهراً الماضية ، هل غبت عن المدرسة أو تجنبت نشاطك اليومي المعتاد بسبب ۱۲ خالل ال ٥

الذهاب لطبيب االسنان للعالج أو للكشف أو بسبب مشاكل في الفم و االسنان ؟

نعم ۱ )۷اذا كانت االجابة "ال" فانتقل للسؤآل رقم ال ( ۲ ال أعرف أو ال أتذكر ۹


العمل أو النشاطات اليومية لمرافقتك لطبيب االسنان للعالج او الكشف أو بسبب مشاكل في الفم و

االسنان ؟


(أجب على كل فقره) خالل الشهر الماضي هل عانيت من : ۷





نعم ۱ ۱ ۱ ۱ ۱ ۱ ۱ ۱

ال ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹

ال أعرف أو ال أتذكر

290

في اعتقادك، أي نوع من عالج االسنان تحتاج اليه حالياً ؟ ۸( ضع دائرة حول جميع الخيارات التي تنطبق عليك )


عالج لثه ۱۰ عالج لعصب االسنان ۱۱ تقويم االسنان ۱۲ تبييض االسنان۱۳ عالجات اخرى (الرجاء تحديد العالج): __________________________۱٤ ال أعرف۹۹

كم مره تقوم بالتنظيف بالفرشاه و المعجون ؟ ۹


)أجب على كل فقره كم مرة خالل االسبوع الماضي تناولت الماكوالت والمشروبات التالية ؟ (۱۰



بسكوتات أو كيك أو ايسكريم أو دونت )‌بالمشروبات الغازية )‌جمربة أو عسل أو حالوة شامي )‌د


هل تجنبت تناول المأكوالت الحلوة لمنع تسوس االسنان ؟ ۱۱


ال أعرف


۱ ۱ ۱ ۱ ۱ ۱ ۱

۲ ۲ ۲ ۲ ۲ ۲ ۲

۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹



291

: أسئلة عن زياراتك لطبيب االسنان وخدمات طب االسنان المقدمة:ثانياً

هل تزور طبيب االسنان بصفة دائمة : ۱۲


منذ متى كانت اخر زيارة لك الى طبيب االسنان؟ ۱۳

أشهر أو أقل ٦ ۱ أشهر ولكن ليس أكثر من سنة ٦ أكثر من ۲ أكثر من سنة ولكن ليس أكثر من ثالث سنوات ۳ أكثر من ثالث سنوات ٤ لم أزر طبيب االسنان أبداً ٥ ال أعرف أو ال أتذكر۹

ماذا كان السبب الرئيسي لزيارتك لطبيب األسنان ؟ ۱٤

ذهبت تلقائياً للكشف أو التنظيف ۱ طلب طبيب االسنان مني المراجعة للكشف أو التنظيف ۲ كان هناك شيئ يزعجني أو يؤلمني ۳ ذهبت لتلقي العالج لمرض شّخصه طبيب األسنان خالل كشف سابق ٤٥ ___________________________ أسباب أخرى ( الرجاء التحديد ) ال أعرف أو ال أتذكر ۹

فيما يخص آخر زيارة لك ، لطبيب األسنان كم استغرق الوقت ما بين تحديد الموعد وبدأ تلقي العالج ؟ ۱٥




292

فيما يخص آخر زيارة لك لطبيب االسنان ، كم دقيقة اضطررت لإلنتظار في العيادة قبل الدخول على ۱۷

طبيب االسنان ؟

لم أنتظر ابداً ۱ دقيقة ۱٥ أقل من ۲ دقيقة ۲۹- ۱٥ ۳ دقيقة ٥۹- ۳۰ ٤ ساعة أو أكثر ٥ )۱۹( اذا اخترت "ال أعرف" فانتقل الى سؤال رقم ال أعرف أو ال أتذكر ۹



ما مدى رضاك عن آخر زيارة لطبيب االسنان ؟ ۱۹



ما هي االسباب التي تمنعك من الذهاب الى طبيب االسنان ؟ ۲۰( ضع دائرة حول جميع الخيارات التي تنطبق عليك )

الخوف ۱ ال توجد حاجة للذهاب ۲ ال توجد اسنان في الفم ۳ تكاليف التنقل ٤ عدم توفر الوقت ٥ أولويات أخرى ٦ االنتظار لفترات طويلة في العيادة ۷ صعوبة الحصول على مواعيد ۸ ال أفّضل ، ال أثق ، ال أؤمن بأطباء االسنان ۹

يلزمني التنقل لمسافات بعيدة ۱۰ ليس لدي وسيلة للوصول الى طبيب االسنان ۱۱ أوقات المواعيد غير مناسبة ۱۲ ال يوجد أحد يعتني باالطفال أو أحد أفراد العائلة في البيت خالل وقت الزيارة ۱۳ أي أسباب أخرى ( الرجاء التحديد ):________________________ ۱٤ ال يوجد سبب يمنعني من الذهاب الى طبيب االسنان ۱٥ ال أعرف أو ال أتذكر ۹۹

293

أي نوع من عيادات االسنان تذهب اليها عادةً ؟ ۲۱


: أسئلة عن عادات التدخين وآثارها على صحة الفم واألسنان :ثالثاً

هل تدخن سجائر او معسل او شيشه يوميا ، او احيانا، او ال تدخن اطالقا ؟ ۲۲( ضع دائره حول االجابه المناسبه ثم امأل الفراغات التي تنطبق عليك )

يومياً ۱

الرجاء تحديد :

عدد السجائر التي تدخنها في يوم ___________

و، أو عدد المرات التي دخنت فيها معسل أو شيشه في اليوم _________

) ۲٤( اذا اخترت هذه االجابه فاذهب الى السؤال رقم

أحياناً ۲


عدد السجائر التي تخنها في االسبوع ___________

و، أو عدد المرات التي دخنت فيها معسل أو شيشه في االسبوع _________

)۲٤ ( اذا اخترت هذه االجابه فاذهب الى السؤال رقم

ال أدخن اطالقا ۳ ال أعرف أو ال أتذكر۹

هل سبق أن دخنت سجائر أو معسل أو شيشه بصفة يومية ؟ ۲۳

نعم _ في أي عمر توقفت عن التدخين بصفة يومية ؟ عند عمر______ سنة\سنين ۱ ال۲ ال أعرف أو ال أتذكر۹

كم كان عمرك عندما بدأت بتدخين السجائر أو المعسل أو الشيشه ؟ ۲٤

)۲٦( اذا اخترت "لم أدخن اطالقا فانتقل الى السؤال رقم لم أدخن اطالقاً من قبل ۱ سنوات أو أقل ۷ عند عمر ۲ سنوات ۹ أو ۸ عند عمر ۳ سنة ۱۱ أو ۱۰ عند عمر ٤ سنه أو أكبر۱۲ عند عمر ٥ ال أعرف أو ال أتذكر ۹

294

هل نصحك أي طبيب أسنان من قبل بالتوقف عن التدخين ؟ ۲٥


: أسئلة عن المستوى التعليمي والدخل العائلي:رابعاً



۲٦ ______________________ في أي صف دراسي تدرس حالياً ؟ في الصف

كم تقدر تقريباً دخل العائلة الشهري ؟ ۲۷

لایر ۱۰۰۰ أقل من ۱ لایر ۳۰۰۰ -۱۰۰۰ ما بين ۲ لایر ٥۰۰۰ -۳۰۰۰ مابين۳ لایر ۷۰۰۰ -٥۰۰۰ ما بين ٤ لایر ۱۰۰۰۰ - ۷۰۰۰ ما بين٥ لایر ۱۰۰۰۰ أكثر من ٦ ال أعرف أو ال أتذكر۹

كم عدد أفراد االسرة اللذين يصرف عليهم من هذا الدخل الشهري متضمناً نفسك ؟ ۲۸

_________ أفراد *




295

Appendix H3

Adults’ Questionnaire (English and Arabic versions)

296



2007

Facu l ty of Dent is t ry K ing Abdulaziz Univers i ty

Saudi Arab ia


Canada

297 Place of residence: Participant ID #_______ □ Jeddah



First

1. In general, how would you describe the condition of your mouth including your natural teeth or dentures, gums, tongue, lips and jaw joints? Would you say that it is:

: Questions about the health of your mouth and teeth and the dental care habits that you perform to take care of them:


2. In general, how satisfied are you with:

a) the health of your mouth? 1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied

9 Don’t know or don’t remember b) the appearance of your natural teeth or dentures: 1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied 9 Don’t know or don’t remember

3. In the past 12 months, how often have you found it uncomfortable to eat any food because problems with your mouth?


298

4. In the past 12 months, how often have you avoided conversation or contact with other people because of the condition of your teeth, mouth or dentures?


5. In the past 12 months, have you taken time away from work or your normal

activities because of the need to have dental treatment including dental check-ups or because of problems with your mouth?



work or from normal activities to assist you with a dental treatment including dental check-ups or because of problems with your mouth?


7. In the past month have you had persistent or on-going:

Yes No a) Toothache? b) Pain in the teeth when consuming hot or cold foods or drinks? c) Pain in or around the jaw joints? d) Severe tooth or moth pain at night? e) Other pain anywhere in your mouth? f) Bleeding gums when brushing your teeth? g) Dry mouth? h) Bad breath?

8. What type of dental care do you think you need now? (Circle all that apply to you) 1 None 2 Teeth cleaning and polishing 3 Relief of pain 4 Treatment of injury 5 Treatment for my dentures or bridges 6 Treatment of my jaw joints 7 Tooth filling(s) 8 Tooth replacement(s) (e.g. crowns and/or bridges or dentures) 9 Tooth extraction(s) 10 Gum treatment 11 Root canal treatment 12 Orthodontic care 13 Teeth whitening 14 Other, (please specify): ___________________ 99 Don’t know or don’t remember

1 1 1 1 1 1 1 1

2 9 2 9 2 9 2 9 2 9 2 9 2 9 2 9


299 9. How often do you brush your teeth?

1 More than twice a day 2 Twice a day 3 Once a day 4 Less than once a day but more than once a week 5 Once a week 6 Less than once a week 9 Don’t know or don’t remember

10. How often in the past week did you eat / drink the following?


Traditional local food (Masoob or hareesa) Cookies, cakes, ice cream, doughnuts Soft drinks / pop (not diet) Jams, honey, or tihenia Chewing gum with sugar Candy Tee or coffee with sugar

More than 3

11. Do you try to avoid sugary foods in order to prevent tooth decay? 1 Yes 2 No 9 Don’t know or don’t remember

Second

12. Do you usually visit a dentist:

: Questions about your dental visits and the dental services provided:


13. About how long has it been since you last visited a dentist?


14. What was the main reason that you last visited a dentist?

1 Went in on own for check-up, examination or cleaning 2 Was called in by the dentist for check-up, examination or cleaning 3 Something was wrong, bothering or hurting 4 Went for treatment of a condition that dentist discovered at earlier


a) b) c) d) e) f) g)

1 1 1 1 1 1 1

2 2 2 2 2 2 2

3 9 3 9 3 9 3 9 3 9 3 9 3 9


300

15. For your last dental visit, how long was it from the time you made the appointment until you saw the dentist?

1 Less than one day 2 1 to 6 days 3 1 week but less than 2 weeks 4 2-3 weeks 5 1-2 months 6 3 months or more 9 Don’t know or don’t remember (Go to Question # 17)

16. Do you think that this time was longer than you would have liked? 1 Yes 2 No 9 Don’t know or don’t remember

17. For your last dental visit, about how many minutes did you have to wait at the dentist’s

office before being seen by the dentist? 1 Did not wait at all 2 Less than 15 minutes 3 15-29 minutes 4 30-59 minutes 5 1 hour or more 9 Don’t know or don’t remember (Go to Question # 19)



19. How well where you satisfied with your last dental visit?


301

20. What are the reasons that prevent you from going to a dentist? (Circle all that applies to you)

1 Fear 2 No need to go 3 No teeth 4 High travel costs 5 Didn’t have time 6 Other priorities 7 Too long waiting time in the clinic 8 Difficulty in getting appointment 9 Don’t like / trust / believe in dentists 10 Would have to travel too far 11 Didn’t have a way to get there 12 Hours not convenient 13 Didn’t have anyone to care for children or other family members 14 Other reason (please specify): _____________________ 15 No reason to prevent me from going to a dentist 99 Don’t know or don’t remember

21. What kind of dental clinic do you usually go to?


Third: Questions about smoking habits as one of the factors related to

your oral health (Circle the category that applies): 22. At the present time, do you smoke cigarettes, mo’assel or shisha daily, occasionally

or not at all? 1 Daily Print either: the number of cigarettes you usually smoke each day _____ and / or the number of times you usually smoke mo’assel or shisha each day _____ (Go to Question # 24) 2 Occasionally Print either: the number of cigarettes you usually smoke each week _____ and / or the number of times you usually smoke mo’assel or shisha each week ____ (Go to Question # 24) 3 Not at all 9 Don’t know or don’t remember 23. Have you ever smoked cigarettes, mo’assel or shisha daily? 1 Yes – At what age did you stop smoking each day? At _____ years old 2 No 9 Don’t know or don’t remember

302

24. How old were you when you first started smoking cigarettes, mo’assel or shisha? 1 I have never smoked before (Go to Question # 26) 2 7 years old or younger 3 8 or 9 years old 4 10 or 11 years old 5 12 or 13 years old 6 14 or 15 years old 7 16 years old or older 9 Don’t know or don’t remember 25. Has a dentist ever advised you to stop smoking? 1 Yes 2 No 9 Don’t know or don’t remember UFourthU: Questions about your education and your family income:

UPlease note again that the study information are extremely confidential and only group results will be presented

26. How old are you? _______________ years old

27. What is the highest degree, certificate or diploma you completed? 1 Less than high-school certificate 2 High-school certificate 3 Trades certificate or diploma from a vocational school or apprenticeship

training 4 Non-university certificate or diploma from a college 5 University certificate below bachelor’s level 6 Bachelor’s degree 7 University degree, certificate or diploma above bachelor’s degree 9 Don’t know or don’t remember

28. What is your family’s monthly income? 1 Less than 1000 SR 2 Between 1000 and 3000 SR 3 Between 3000 and 5000 SR 4 Between 5000 and 7000 SR 5 Between 7000 and 10’000 SR 6 More than 10’000 SR 9 Don’t know or don’t remember


* _____ persons



303

ه۱٤۲۸ - م۲۰۰۷



كندا



304

____________ :Participant ID مكان االقامة

جدة

بحرة

الرجاء المالحظة أن نماذج البحث لن تحتوي على أي بيانات تكشف عن هوية المشارك وأن نتائج البحث

ستعرض باالجمال لجميع المشاركين سويةً .

ضع دائرة حول اإلختيار المناسب والذي ينطبق عليك أو امأل الفراغات لكل من االسئلة التالية:

: أسئلة حول صحة الفم واألسنان والعادات المتّبعه للعناية باألسنان : أوالً عموماً ، كيف تقيم الحالة الصحية الخاصة بك فيما يتعلق بالفم ، االسنان ، اللثة ، اللسان ، الشفاه ، ۱

ومفصل الفك ؟ ممكن أن تقول عموماً أن الوضع الصحي :


عموماً، ماهي درجة رضاك بالتالي : ۲




راض جداً ۱ راض ۲ ليس راض وليس غير راض ۳ غير راض ٤ غير راض جداً ٥ ال أعرف أو ال أتذكر۹

305

شهراً الماضية ، هل واجهت صعوبه في اكل األطعمه المختلفه بسبب مشاكل في الفم ۱۲ خالل ال ۳

واالسنان ؟

دائماً ۱ أحياناً ۲ نادراً ۳ لم يحدث أبداً ٤ ال أعرف أو ال أتذكر۹

شهراً الماضية ، هل تجنبت الكالم أو المحادثة أو التفاعل مع االخرين بسبب حالة ۱۲ خالل ال ٤

الفم واالسنان


شهراً الماضية ، هل غبت عن المدرسة أو تجنبت نشاطك اليومي المعتاد بسبب ۱۲ خالل ال ٥

الذهاب لطبيب االسنان للعالج أو للكشف أو بسبب مشاكل في الفم و االسنان ؟

نعم ۱ )۷اذا كانت االجابة "ال" فانتقل للسؤآل رقم ( ال ۲ ال أعرف أو ال أتذكر ۹


العمل أو النشاطات اليومية لمرافقتك لطبيب االسنان للعالج او الكشف أو بسبب مشاكل في الفم و

االسنان ؟


) أجب على كل فقره خالل الشهر الماضي هل عانيت من : (۷





نعم ۱ ۱ ۱ ۱ ۱ ۱ ۱ ۱

ال ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹ ۲ ۹

ال أعرف أو ال أتذكر

306

في اعتقادك، أي نوع من عالج االسنان تحتاج اليه حالياً ؟ ۸( ضع دائرة حول جميع الخيارات التي تنطبق عليك )


عالج للثة ۱۰ عالج لعصب االسنان ۱۱ تقويم االسنان ۱۲ تبييض االسنان۱۳ عالجات اخرى (الرجاء تحديد العالج): __________________________۱٤ ال أعرف۹۹

كم مره تقوم بالتنظيف بالفرشاه و المعجون ؟ ۹


كم مرة خالل االسبوع الماضي تناولت الماكوالت والمشروبات التالية ؟ (أجب على كل فقره)۱۰



بسكوتات أو كيك أو اسكريم أو دونت )‌بالمشروبات الغازية )‌جمربة أو عسل أو حالوة شامي )‌د


هل تجنبت تناول المأكوالت الحلوة لمنع تسوس االسنان ؟ ۱۱


ال أعرف


۱ ۱ ۱ ۱ ۱ ۱ ۱

۲ ۲ ۲ ۲ ۲ ۲ ۲

۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹ ۳ ۹



307

: أسئلة عن زياراتك لطبيب االسنان وخدمات طب االسنان المقدمة:ثانياً

هل تزور طبيب االسنان بصفة دائمة : ۱۲


منذ متى كانت اخر زيارة لك الى طبيب االسنان؟ ۱۳

أشهر أو أقل ٦ ۱ أشهر ولكن ليس أكثر من سنة ٦ أكثر من ۲ أكثر من سنة ولكن ليس أكثر من ثالث سنوات ۳ أكثر من ثالث سنوات ٤االسنان أبداً أزر طبيب لم ٥ ال أعرف أو ال أتذكر۹

ماذا كان السبب الرئيسي لزيارتك لطبيب األسنان ؟ ۱٤

ذهبت تلقائياً للكشف أو التنظيف ۱ طلب طبيب االسنان مني المراجعة للكشف أو التنظيف ۲ كان هناك شيئ يزعجني أو يؤلمني ۳ ذهبت لتلقي العالج لمرض شّخصه طبيب األسنان خالل كشف سابق ٤٥ ___________________________ أسباب أخرى ( الرجاء التحديد ) ال أعرف أو ال أتذكر ۹

فيما يخص آخر زيارة لك ، لطبيب األسنان كم استغرق الوقت ما بين تحديد الموعد وبدأ تلقي العالج ؟ ۱٥




308

فيما يخص آخر زيارة لك لطبيب االسنان ، كم دقيقة اضطررت لإلنتظار في العيادة قبل الدخول على ۱۷

طبيب االسنان ؟

لم أنتظر ابداً ۱ دقيقة ۱٥ أقل من ۲ دقيقة ۲۹- ۱٥ ۳ دقيقة ٥۹- ۳۰ ٤ ساعة أو أكثر ٥ )۱۹( اذا اخترت "ال أعرف" فانتقل الى سؤال رقم ال أعرف أو ال أتذكر ۹



ما مدى رضاك عن آخر زيارة لطبيب االسنان ؟ ۱۹



ما هي االسباب التي تمنعك من الذهاب الى طبيب االسنان ؟ ۲۰( ضع دائرة حول جميع الخيارات التي تنطبق عليك )

الخوف ۱ ال توجد حاجة للذهاب ۲ ال توجد اسنان في الفم ۳ تكاليف التنقل ٤ عدم توفر الوقت ٥ أولويات أخرى ٦ االنتظار لفترات طويلة في العيادة ۷ صعوبة الحصول على مواعيد ۸ ال أفّضل ، ال أثق ، ال أؤمن بأطباء االسنان ۹

يلزمني التنقل لمسافات بعيدة ۱۰ ليس لدي وسيلة للوصول الى طبيب االسنان ۱۱ أوقات المواعيد غير مناسبة ۱۲ ال يوجد أحد يعتني باالطفال أو أحد أفراد العائلة في البيت خالل وقت الزيارة ۱۳ أي أسباب أخرى ( الرجاء التحديد ):________________________ ۱٤ ال يوجد سبب يمنعني من الذهاب الى طبيب االسنان ۱٥ ال أعرف أو ال أتذكر ۹۹

309

أي نوع من عيادات االسنان تذهب اليها عادةً ؟ ۲۱


: أسئلة عن عادات التدخين وآثارها على صحة الفم واألسنان :ثالثاً

هل تدخن سجائر او معسل او شيشه يوميا ، او احيانا، او ال تدخن اطالقا ؟ ۲۲( ضع دائره حول االجابه المناسبه ثم امأل الفراغات التي تنطبق عليك )

يومياً ۱


عدد السجائر التي تدخنها في يوم ___________

و، أو عدد المرات التي دخنت فيها معسل أو شيشه في اليوم _________

) ۲٤( اذا اخترت هذه االجابه فانتقل الى السؤال رقم

أحياناً ۲


عدد السجائر التي تخنها في االسبوع ___________

و، أو عدد المرات التي دخنت فيها معسل أو شيشه في االسبوع _________

)۲٤ ( اذا اخترت هذه االجابه فانتقل الى السؤال رقم

ال أدخن اطالقا ۳ ال أعرف أو ال أتذكر۹

هل سبق أن دخنت سجائر أو معسل أو شيشه بصفة يومية ؟ ۲۳

نعم _ في أي عمر توقفت عن التدخين بصفة يومية ؟ عند عمر______ سنة\سنين ۱ ال۲ ال أعرف أو ال أتذكر۹

كم كان عمرك عندما بدأت بتدخين السجائر أو المعسل أو الشيشه ؟ ۲٤

)۲٦( اذا اخترت "لم أدخن" فانتقل الى السؤال رقم لم أدخن اطالقاً من قبل ۱ سنوات أو أقل ۷ عند عمر ۲ سنوات ۹ أو ۸ عند عمر ۳ سنة ۱۱ أو ۱۰ عند عمر ٤ سنه ۱۳ أو۱۲ عند عمر ٥ سنه ۱٥ أو۱٤ عند عمر ٦ سنه أو أكبر ۱٦ عند عمر ۷ ال أعرف أو ال أتذكر۹

310

هل نصحك أي طبيب أسنان من قبل بالتوقف عن التدخين ؟ ۲٥


: أسئلة عن المستوى التعليمي والدخل العائلي:رابعاً



كم عمرك ؟ ________ عاماً ۲٦

ما هي أعلى درجة علمية، أو شهادة، أو دبلوم حصلت عليها ؟۲۷

أقل من شهادة الثانوية العامة۱ شهادة الثانوية العامة ۲ شهادة تجارية أو دبلوم من معهد أو منشأة تعليمية۳ شهادة علمية أو دبلوم من كلية علمية٤ شهادة جامعية أقل من مرحلة البكالوريوس٥ شهادة بكالوريوس٦ شهادة جامعية أو دبلوم أعلى من درجة البكالوريوس ۷ ال أعرف أو ال أتذكر۹

كم تقدر تقريباً دخل العائلة الشهري ؟ ۲۸

لایر ۱۰۰۰ أقل من ۱ لایر ۳۰۰۰ -۱۰۰۰ ما بين۲ لایر ٥۰۰۰ -۳۰۰۰ مابين۳ لایر ۷۰۰۰ - ٥۰۰۰ ما بين ٤ لایر ۱۰۰۰۰- ۷۰۰۰ ما بين ٥ لایر ۱۰۰۰۰ أكثر من ٦ ال أعرف أو ال أتذكر۹

كم عدد أفراد االسرة اللذين يصرف عليهم من هذا الدخل الشهري متضمناً نفسك ؟ ۲۹

_________ أفراد *




311

Appendix I

Dentists’ Consent Form

312

You have been selected to take part in a study that will assess the dental

health status, dental treatment needs and supply of dental services in

Jeddah and Bahrah, Saudi Arabia. Participating dentist will be asked to fill

out a questionnaire and a 2 days activity assessment form. The study forms

will not include your name and the results will not include information that

would reveal your identification and only group results will be presented.

Dentists’ Consent Form Dear Colleague,

Your participation is totally voluntary and you can refuse to continue

participating at any time during the study period. However, your participation

is valuable and will help improve the dental health services in Jeddah and

Bahrah to best serve our community.

This study is part of a PhD degree requirement and is supervised by the

University of Toronto in Canada and King Abdulaziz University in Saudi

Arabia. If you have any questions about the study, please contact me at this

phone number: 0560020205. Your support is highly appreciated.

Sincerely,

Akram Fareed Qutob, BDS, PhD candidate

King Abdulaziz University & the University of Toronto

Do you agree to take part in this study? If yes, then please sign below. I have read the study description and understand what it will involve and agree to participate in it to the best of my ability. Dentist’s signature ______________________

Date: _____________________

F a c u l t y o f D e n t i s t r y K i n g A b d u l a z i z U n i v e r s i t y

S a u d i A r a b i a

F a c u l t y o f D e n t i s t r y U n i v e r s i t y o f T o r o n t o

C a n a d a

313

Appendix J

Dentists’ Questionnaire

314



2007


Saudi Arab ia


Canada

315

Place of practice: Participant ID #_______ □ Jeddah



First

1. How old are you?

: Questions about you:

__________ years old

2. Are you:

1 Male? 2 Female?

3. What is your nationality?

1 Saudi 2 Non Saudi

4. Are you: 1 General dentist? 2 Specialist? (please specify) ____________________

5. In what year did you graduate from dental school?

Year __ __ __ __

6. For how many years have you been in clinical (patient care) practice?

_________ Years

Second

7. What best describes your current primary occupation?

: Questions about your clinical practice:

1 Dentist at the Ministry of Health 2 Dentist at: Armed Forces, National Guard, Interior Security Forces

or Ministry of Education 3 Dental school faculty / staff member

8. Do you still provide patient care?

1 Yes 2 No (Go to Question # 22 )

316

9. At your office, do you: (Circle all that apply to you) 1 Work unassisted? 2 Work with one dental assistant? 3 Work with more than one dental assistant? 4 Work with one dental hygienist? 5 Work with more than one dental hygienist?

10. What is the majority of your chair-side time spent providing?

1 Regular treatment 2 Preventive treatment 3 Emergency treatment 4 Almost equal distribution between regular, preventive and

emergency treatments

11. How many hours of patient care do you provide in a normal working day?

_________ hours / day

12. What percentage of your normal working day hours (in average) is spent on: 1 Patient care? _______ % 2 Unfilled appointments? _______ % 3 Canceled or failed appointments? _______ % 4 Administrative tasks? _______ % 5 Meetings and phone calls? _______ % 6 Others (please specify): ______________________ _______ %

13. How many days of patient care do you provide in a normal working week?

__________ days / week

14. How many days of vacation (other than national holydays) do you have during a year?

__________ days / year

15. How many patients do you usually see in a normal working day?

__________ patients / day

16. Chose the category that best describes your practice? 1 Too busy to treat all people requesting appointments 2 You receive all patients requesting treatment but felt more rushed

and worked more hours than would you like to 3 You provide treatment for all who requested and had enough but

not too many patients 4 You are not busy enough and would like to have had more patients 17. How well are you satisfied with your practice?

1 Very satisfied 2 Satisfied 3 Neither satisfied nor dissatisfied 4 Dissatisfied 5 Very dissatisfied

317

Third

1 Less than one day

: Questions about the dental services provided:

18. For most of the dental appointments, how long your patients have to wait from the time they book an appointment till you see them?

2 1 to 6 days 3 1 week but less than 2 weeks 4 2-3 weeks 5 1-2 months 6 3 months or more 9 Don’t know or don’t remember (Go to Question # 20)

19. Do you think that this time is long?

1 Yes 2 No

20. For most of the dental appointments, about how many minutes do your

patients have to wait at your office before you are able to see them? 1 Did not wait at all 2 Less than 15 minutes

3 15-29 minutes 4 30-59 minutes 5 1 hour or more

9 Don’t know or don’t remember (Go to Question # 22) 21. Do you think this waiting time is long?

1 Yes 2 No

22. What do you think are the reasons that most often prevent your patients from going to a dentist? (Circle all that you think do apply to patients)

1 Fear 2 No need to go 3 No teeth 4 High travel costs 5 Didn’t have time 6 Other priorities 7 Too long waiting time in the clinic 8 Difficulty in getting appointment 9 Don’t like / trust / believe in dentists 10 Would have to travel too far 11 Didn’t have a way to get there 12 Hours not convenient 13 Didn’t have anyone to care for children or other family members 14 Other reason (please specify): _____________________ 15 No reason to prevent them from going to a dentist


318

23. What do you think needs improvement in government dental clinics? (Circle all that apply)

1 Difficulty in getting appointment 2 Too long waiting time in the clinic 3 Inconvenient working hours 4 Decreased number of dentists 5 Decreased availability of dental auxiliaries 6 Decreased availability of materials and / or supplies 7 Bad working conditions of dental units 8 Improper clinic administration 9 No improvements needed 99 Don’t know

Fourth: Questions about smoking habits: 24. At the present time, do you smoke cigarettes, mo’assel or shisha daily, occasionally

or not at all? 1 Daily Print either: the number of cigarettes you usually smoke each day _____ and / or the number of times you usually smoke mo’assel or shisha each day _____ (Go to Question # 26) 2 Occasionally Print either: the number of cigarettes you usually smoke each week _____ and / or the number of times you usually smoke mo’assel or shisha each week ____ (Go to Question # 26) 3 Not at all 9 Don’t know or don’t remember 25. Have you ever smoked cigarettes, mo’assel or shisha daily? 1 Yes – At what age did you stop smoking each day? At _____ years old 2 No

9 Don’t know or don’t remember 26. How old were you when you first started smoking cigarettes, mo’assel or shisha? 1 I have never smoked before 2 7 years old or younger 3 8 or 9 years old 4 10 or 11 years old 5 12 or 13 years old 6 14 or 15 years old 7 16 years old or older 9 Don’t know or don’t remember 27. Have you ever advised your patients to stop smoking? 1 Yes 2 No 9 Don’t know or don’t remember


319

Appendix K

Two Days Activity Assessment Form

320



2007

Facu lty of Dent is t ry K ing Abdulaziz Univers i ty

Saudi Arab ia


Canada

321

Activity Assessment Form

Place of practice: Participant ID #_______

□ Jeddah

□ Bahrah

Please note that the participant’s ID number does not identify you or your practice however, it is intended only to organize recording of the study findings and only group results will be presented.

For 2 full days, please record the dental procedure / procedures provided to each patient and

the amount of time (in minutes) utilized to achieve that particular procedure. Time counting

should starts from the time the patient sat on the dental chair to the time he/she moved from the

chair. Examples on how to record the description of dental procedures and its time are provided

in the table below. You are provided with tables to fill during any 2 working days of the week and

you may use one or more rows for the same patient. At the end of the week, please keep the

completed form and a member of the research team will pass by your office to pick it up.

Patient

No. Procedure

Time in

Minutes Procedure

Time in

Minutes

1 Scaling 20 Tooth# 46, fissure sealant 10

simple extraction 15

2 Tooth # 37, one surface (or 2 or 3

surfaces) amalgam restoration 25 Metal try in for a removable denture 15

3 Tooth # 12, pulp extirpation and

temporary filling 40

Thank you in advance for taking the time to fill in this form

322 Day 1

Patient No.

Procedure Time in Minutes



323 Day 1

Patient No.




324 Day 1

Patient No.




325 Day 2

Patient No.




326 Day 2

Patient No.




327 Day 2

Patient No.




Documents

A NEEDS-BASED APPROACH FOR HEALTH HUMAN RESOURCES … · A Needs-Based Approach for Health Human Resources Planning for Dentistry in Jeddah, Saudi Arabia Ph.D / Dental Public Health