International Dental Journal (2004) 54, 367–372
Oral health in Iran Hamid Reza Pakshir Shiraz, Iran
The health network in the Islamic Republic (I.R.) of Iran is an integrated public health system with a four-level Dental Health Care System integrated into it by 1997. The first level is one of primary prevention at ‘health houses’, at the next, oral hygienists and dentists in health centres perform basic oral health care services such as fillings, scaling and extractions. At the third level, dentists manage and treat oral diseases in ‘urban health centres, while the last level is for advanced treatment by specialists in university health centres in the big cities. There are about 13,000 dentists nationwide (1 dentist: 5,500 population) and nearly 1,200 specialists in universities and private practices. Data from surveys in the past two decades, show a marked decline in dental caries from DMFT of 4 to 1.5 in 12-year-old children. However, the general level of oral health is still not satisfactory, particularly among children. The percentage of caries-free children (deciduous and permanent teeth) among 6- and 9-year-olds is 13.8 and 11.5 respectively and more than 50% of 12-year-old children have caries experience, with the decayed component being the greatest component. The main objective would be to cope with the dental caries problem in primary teeth and, in this respect, the national oral health plan should be aimed at developing oral hygiene skills, reducing the frequency of sugar intake, instituting water fluoridation, improving access to fissure sealants and regular dental care, and finally promoting dental health services toward minimum treatment intervention and effective preventive strategies and health promotion.
Key words: Oral health status, oral health planning, caries, Iran
The Islamic Republic of Iran, covers an area of approximately 1,648,000 km2, in southwest Asia. The Middle East region, is divided into 28 provinces, 285 districts and over 66,000 villages. The country has a population of more than 71,000,000 people, nearly 60% of whom live in urban areas. Approximately 52% of the population is under 20 years of age, making Iran one of the youngest countries in the world1. Oral and dental services
Dental services are provided by both public and private sectors. In the rural areas, which include 40% of the countrys population, oral health services are mostly delivered by the governmental sector (70%), while 80% of the service delivery is offered by private sector in the cities1. In the rural areas and small towns, the services are offered by oral hygienists. They are selected from local communities and trained for three years in special dental schools in oral health education, simple fillings, scaling and extractions. A total of 2,000 oral hygienists were returned to their local rural communities during 1981 1993 to serve the people for at least for six years2. Primary health care structure
Correspondence to: Dr. Hamid Reza Pakshir, Shiraz University of Medical Sciences, Dental Faculty, Orthodontic Department, Shiraz, Iran. E-mail:
[email protected] © 2004 FDI/World Dental Press 0020-6539/04/06367-06
The health network in I.R. of Iran is an integrated system. In 1972, Iran collaborated with the World Health Organisation (WHO) to streamline health care delivery into
368
Figure 1. The Structure of PHC Network in Iran
four levels: health houses, rural health centres, urban health centres and district centres. After 1979, the Ministry of Health and Medical Education designed the new health system based on the Primary Health Care (PHC) network3 (Figure 1). A Health House is the basic rural facility, covering a population of 1,500 and has between two and five satellite villages. Each health house is staffed by a male and a female health worker, called Behvarz, who offer PHC services to the population in the area including maternal child care, family planning, diagnosis and follow-ups, limited symptomatic treatment, environmental and occupational health, school health, oral health and health education and nutrition promotion. Behvarzes are selected from among young and interested residents and are trained for two years at a Behvarz Training Centre. At present, there are nearly 15,000 health houses, and 35,000 Behvarzes in the villages, covering 85% of the rural population2,4. A Rural Health Centre is a
village-based facility staffed by a physician, health technicians and aid nurses. It covers a population of 7,500 and provides supervision to three to six health houses. These centres receive referrals from health houses and provide preventive, health promotion and curative care2. An Urban Health Centre, which has nearly the same responsibility and personnel as a rural health centre, covers a population of approximately 50,00060,000 urban inhabitants. These centres receive referrals from health posts and are supervised by the staff of District Health Centres3. A Health Post, which is staffed by family health technicians, an environmental health technician and a midwife, covers a population of 12,000 and is the first contact level for the urban population. It has duties similar to those of health houses in rural areas and is supervised by the staff of an urban health centre2. A District Health Centre is responsible for planning, monitoring and evaluation of health
International Dental Journal (2004) Vol. 54/No.6 (Supplement)
programmes at district levels. It is staffed by physicians, health technicians and general service staff and provides technical and logistic support to rural/urban health centres. A district health centre is supervised by the staff of a Provincial Health Centre2,4. A Provincial Health Centre provides managerial, technical and logistic support to district health centres and is responsible for planning, monitoring and evaluation of health programmes at provincial level. It is supervised by the Oral Health Department of the Ministry of Health and Medical Education at the national level4. Dental health delivery system
The Oral Health Department of the PHC network implemented a pilot project in 1995/1996 to integrate oral health care into the public domains in four districts and, accordingly, the Dental Health Care Delivery System (DHDS) was established1. It was completed and expanded all over the country by
369 Table 1 The Dental Health Delivery System (DHDS) Level 1 2 3 4
Trained professionals
Treatment
‘Behvarzes’ Oral hygienists Dentists and dental nurses and technicians Specialists
Primary Health Care (PHC, primary prevention) Health and treatment (Secondary prevention) Management and treatment (tertiary prevention) Research and evaluation, implants, laser, maxillofacial prosthetics
1997 and aimed to improve community involvement in oral health by both promoting public awareness and delivering oral services more effectively. Following this, four levels of the DHDS were established1 (Table 1). In the first level of the health network, Behvarzes are responsible for providing oral health care to the target groups in rural areas, including oral health education, periodic examination of the teeth, referrals to the higher levels (rural or urban health centres) and the follow-up of the outcome. They also supervise sodium fluoride mouth rinsing in rural areas1,5. At the second level, dentists and oral hygienists deliver primary oral health care services such as fillings, pulpotomies, extractions of infected roots, fluoride therapy and scaling. They supervise the activity of Bevarzes in the health houses within their jurisdiction1,5. At the third level, management and treatment of dental and oral diseases is provided by dentists, dental nurses and technicians as tertiary prevention. Finally, at the fourth level, advanced treatment is offered by the specialists at University Health Centres in the cities5. This specialised treatment can be transferred to the district health centres when the required facilities and manpower are reasonably available1,5.
the national level with the main objective of the promotion of oral health in the communities through the increase of public awareness and quantitative and qualitative improvement of oral health care. Over the last decade, the Department has published numerous posters, books and brochures, made films, prepared and distributed dental ID cards and made 0.2% sodium fluoride mouth rinse widely available in primary schools2. Following the integration of oral health care into the PHC, which provided national coverage in 19971998, the Oral Health Department prepared a plan to have better access for the 612 years age group in cities, focusing on three components including health education, prevention and treatment. The plan started with the School Health Programme, utilising school health technicians and volunteer teachers to educate children and their parents on the importance of oral health, supervise tooth brushing in the schools and weekly mouthrinsing with (0.2% sodium fluoride)3. The main objective of the third component of the project, i.e. treatment, is to provide low cost facilities in relation to three essential curative targets, including extraction of infected roots, tooth restoration (with priority given to molars) and fluoride therapy2.
Role of the Oral Health Department in improving oral and dental health
Oral health manpower
The Oral Health Department (OHD) as one of the departments of the Under-Secretary for Public Health of the Ministry of Health and Medical Education, is responsible for policy making and planning of oral health care programmes at
The number of dentists in Iran is estimated to be 13,000, i.e. one dentist for every 5,500 citizens and it continues to grow steadily as 700 graduates each year from 18 dental schools join the existing dentists. Only 10% of dentists work in public services and nearly 79% have private practices. Around 1,200
specialists work either in the universities or have private practices6. The number of oral hygienists in the rural areas have been reduced to approximately 650 because every year, around 100 hygienists, after six years of offering service in local rural communities, enter a university to continue their education to obtain the degree of Doctor of Dental Surgery if they can pass the University Entrance Exam successfully1. So the number of this category of health personnel is steadily decreasing each year. The reason for stopping the project was mainly their inappropriate involvement in clinical issues, which were far beyond their educational capabilities or job responsibilities. This shows that the situation has to be reviewed and modified, if necessary, to introduce a new mandate, focusing primarily on health promotion and disease prevention issues, to account for limitations in human resources available in rural communities2. It is worth mentioning that around 6,000 dental assistants, dental laboratory workers and denturists without any official educational backgrounds have their own private practices all around the country. They have been licensed following political pressures exerted on the ministry at different times. In rural communities, approximately 35,000 auxiliary health workers, known as Behvarzes, offer PHC services including oral health care to the population2. Oral health status
In spite of the execution of a number of local and nationwide epidemiological surveys, systematic data which allow assessment of Pakshir: Oral health in Iran
370 Table 2
The percentage of caries experience and tooth decay according to selected ages in 1992¹¹
% with caries exp.DMF ³ 1 % with tooth decayD ³ 1 DT MT FT DMFT
long-term trends in oral diseases are not yet available. The proportion of children affected by dental caries or the percentage of cariesfree children have not been recorded systematically. Although the WHO78 has strongly recommended that national epidemiological surveys should be conducted in order to monitor changes in oral health status of selected age populations, the epidemiological tradition in Iran is relatively weak and regular regional and national oral health surveys have not been carried out. So at present, systematic data are badly needed to assist the reorganisation of oral health care. Collecting epidemiological data concerning dental health among various age groups is of primary importance, as has been recommended and stressed by WHO9. In an assignment report on oral health care in Iran, Leous10 reviewed the results of 12 surveys which had been conducted to assess dental caries and the mean average of decayed (D), missing (M) and filled teeth (F), (DMFT) during a period of 30 years (19591989). His report revealed that the mean caries experience in 12-year-old children in Iran had increased from 1.8 to 4 DMFT. There is no data on the percentage of caries free people in this report. The first nationwide survey11 was conducted in 19901992 on a total of 34,985 children and adults aged 669 years. One out of every 1,000 Iranian families was randomly selected for oral health examination to determine the level of oral diseases. Dental examinations were
6 years (n=1480)
12 years (n=1426)
15–19 years (n=4774)
35–44 years (n=3712)
13.1 11.4 0.2 0.1 – 0.3
68.7 66.1 2.2 0.1 0.1 2.4
87.3 83.6 4.3 0.4 0.3 5.0
98.8 87.1 4.8 5.4 1.1 11.3
carried out using the DMFT index according to WHO criteria. The study revealed that, 6-year-old children had a mean caries prevalence of 0.3 DMFT and 88.6% of this age group were caries free. Mean caries prevalence of 2.4 DMFT was recorded for 12-year-olds with 68.7% having caries experience. The prevalence of dental caries among the 1519 and 3544-year-olds was 87.3% and 98.8% with the mean of 5 and 11.3 DMFT recorded respectively (Table 2). In the second survey12 in 1995 assessing the 12-year-old DMFT indices, the students in the fifth grade were classified by sex and place of residence (urban/rural) in all districts and provinces of the country. The analysis revealed that the mean caries experience in 12year-olds was 2.02 DMFT, which is considered low according to WHO criteria, but only 17% of children were caries free. The decayed component (D) was the major contribution to the total caries experience and first permanent molars were the most carious teeth with a higher DMFT index for girls compared with boys. The third national investigation of children was undertaken in 19981999 by the Oral Health Department of the Ministry of Health and Medical Education13. The main objective of the survey was to evaluate the oral health status of Iranian children by determining the DMFT of 3- and 12year-old children at national level and for that of the 6- and 9-yearolds provincially. The samples were selected randomly from both urban and rural areas with a total
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population of 6,901 children. The results provided convincing evidence on the magnitude and severity of dental caries in the primary teeth as a major problem that should receive special attention. This survey showed that the prevalence of dental caries in the 3year-old children was 46.8% with the mean dmft of 1.8. The caries experience increased to 85.9% with 4.8 teeth per person in the 6-yearold children. Regarding the 9-yearolds, these figures were 84% and 3.4 respectively. When comparing the prevalence among urban and rural areas, no significant differences were observed. The d-component of dmft was 98% for 3-, 90% for 6- and 80% for 9-yearold children respectively. The prevalence of dental caries in the 12-year-olds was 52.3% with DMFT of 1.5 (Table 3). In the bivariate analyses, only minor differences in caries experience were found according to location and gender. The d/D-component in all age groups had a major contribution to total caries experience and more than 80% of both the primary and permanent dentition comprised decayed teeth. In this regard, less than 4% of primary and 12% of permanent teeth had been filled. There was a significant difference in the percentage of filled teeth between urban and rural children. It was evidenced that higher decay rates generally were found among poor and low-income families and children whose parents had less than a high school education. These high rates might have been related to restricted access to oral health serv-
371 Table 3
The mean caries experience (dmft, DMFT) and percentage of caries free according to age in 1998–1999¹³ 3 year (n=701)
6 year (n=2714)
9 year (n=2740)
12 year (n=746)
% of caries free
53.2
14.1
16
69.7
dmft and SD % of caries free DMFT and SD
1.8 ± 0.02 – –
4.8 ± 0.04 88.5 0.2 ± 0.02
3.35 ± 0.01 58 0.9 ± 0.05
0.58 ± 0.08 47.7 1.5 ± 0.01
–
13.8
11.5
32.8
% of caries free (deciduous and permanent)
Table 4
The mean caries experience (DMF-T) according to age and location in 2001–2002¹ 4
15–19 years
Urban (n=5133)
Rural (n=3669)
Total (n=8801)
DT MT FT DMFT
2.5 0.7 1 4.2
35–44 years
(n=5122)
(n=3619)
(n=8741)
DT MT FT DMFT
2 9.9 2.8 14.7
2.7 11.4 0.73 14.83
2.3 10.51 2 14.8
3 0.78 0.22 4
2.75 0.74 0.61 4.1
Figure 2. DMFT at 12-year-olds in Iran 1988–1998
ices, a low level of education, poor hygiene and diet. Finally, the most recent survey14 was carried out in 20012002 by OHD to determine the caries experience and periodontal status of two different age groups, 15 19- and 3544-year-olds, with a population of 8,801 and 8,741 respectively. The DMFT scores showed to be 4.1 for the first and 14.8 for the second age group with the decayed and missing teeth as the major contributors to caries
experience for the two groups respectively (Table 4). Concerning caries experience, over a period of ten years (1988 1998), there was a clear decrease, from 4 DMFT to 1.5 DMFT, in the 12-year-old children (Figure 2). Unfortunately, the periodontal status has not been surveyed nationwide systematically during the last two decades, and the only unpublished data is from an investigation conducted in 20012002, which used the community peri-
odontal index (CPI) for this purpose. The index suffers from numerous limitations, reducing its value as a sound epidemiological tool and, hence, the results have to be referred to cautiously. The periodontal status of the two groups, i.e. 1519- and 3544 year olds, demonstrated that approximately 80% of the 1519years-olds were either normal (8.85%) or needed just primary prevention for their periodontal problems (70% with bleeding and Pakshir: Oral health in Iran
372 Table 5
The percentage distribution of CPI scores according to residential location in 2001–2002¹ 4
15–19 years Urban (n=5133) Rural (n=3668) Total (n=8801) 35-44 years Urban (n=5122) Rural (n=3619) Total (n=8741)
calculus), while in the second group, owing to their increased age, more than 50% of them manifested severe periodontal problems requiring extensive periodontal treatment (Table 5). The results of this survey have not been published nationally. Conclusion and recommendations
Bearing in mind the scarce public resources for oral health care and in light of the current pattern of oral disease in Iran, the introduction of a national oral health policy that emphasises preventive and restorative efforts is recommended. The implementation of a community based oral health promotion programme was, and still is, a matter of urgency and, in relation to children, such programmes have already been initiated through health promoting school projects. School oral health education by active involvement of schoolteachers and widespread usage of 0.2% NaF mouth rinse in primary schools since 1999 are the elements in the preventive part of the project. The future changing pattern of oral diseases among Iranian children could result from the initiatives taken to implement preventive oral care programmes for school children, including oral health education. With recognition of the fact that parents play an important role in caries prevention for their children, the national oral health plan should consider raising their awareness and
Score 0 9.9 7.8 8.85 Score 0 1.2 1.2 1.2
Score 1
Score 2
Score 3
28.5 22.8 25.6
40.5 48.6 44.4
20.6 19.5 20
Score 1
Score 2
Score 3
39.5 42.7 41.1
42.4 42.8 42.5
6.6 3.6 5.1
providing knowledge of dental health care particularly for mothers. The main objective is to cope with the caries problem in the primary teeth and, in this respect, mothers are the target population for health education. Also the national oral health plan should aim at: Developing oral hygiene skills (tooth brushing, with fluoride toothpaste, and flossing) Reducing intake and frequency of sugar consumption Fluoridating drinking water Improving access to dental sealants Improving access to dental examination and providing regular dental care Giving priority to preventive oral health over treatment interventions. In summary, more emphasis should be placed on community based oral health policies founded on the recently developed principles of preventive oral care. References 1. Pakshir HR. Dental Education and Dentistry System in Iran. Med Princ Pract 2003 12(Suppl): 5660. 2. Country report on Oral Health in the Islamic Republic of Iran. 1st ed. Tehran: Ministry of Health and Medical Education, Under-secretary for Public Health; Oral Health Department, June 2000. 3. Oral and dental health in Health Centres, Guidelines for the directors of health centres. 1st ed. Tehran: Ministry of Health and Medical Education, Oral Health Department, 1998.
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Score 4 0.8 1.3 1.05 Score 4 103 9.4 10
4. Sadrizadeh B. Primary Health Care (PHC) structures in Iran. Available at: http://www.icsbhs.org/presentation/ Sadrizadeh 5. Sadr SJ. Dental education in Iran. A retrospective review for two decades (19781998). Beheshti Univ Dent J 2001 18: 12. 6. Dental Education Program in Dental Schools of the Islamic Republic of Iran. 1st ed. Tehran: Ministry of Health and Medical Education, Council for Dental and Sub-dental Education, 2000. 7. Monitoring and evaluation of oral health. Geneva: World Health Organisation, 1989. 8. Oral health surveys Basic methods. 3 rd ed. Geneva: World Health Organisation, 1987. 9. A guide to oral epidemiological investigations. Geneva: World Health Organisation, 1979. 10. Leous P. Oral health care in the Islamic Republic of Iran. Assignment report, Jan 1990, available at http://www.WHO/ ORH/EIS/12YR Book/1993/ pp 4,12. 11. Jaberi Ansari Z. A review on the rate of caries experience in Iran during 19901992. Beheshti Univ Dent J 1998 17: 246254. 12. Samadzadeh H, Hesari H, Nori M. A survey on the DMFT trend in 612 year olds Iranian school children. Beheshti Univ Dent J 2001 19: 229 329. 13. Oral Health Situation of Iranian Children. 1st ed. Tehran: Ministry of Health and Medical Education, Under-secretary of Health, Oral Health Bureau, 19981999. 14. Oral health survey in 1519 and 35 44-year-olds in the Islamic Republic of Iran, 20012002. Data from Oral Health Department, Ministry of Health and Medical Education (unpublished).
