Exploring Proximal and Distal Factors of Dental Caries in Underserved Populations Utilizing Charitable Mobile Dental Services: A Cross-Sectional Study, Saudi Arabia

Abstract

Objective This study aimed to assess and identify the associated proximal and distal factors of dental caries in underserved populations using charitable mobile dental services in Al Madinah Province, Saudi Arabia.

Materials and Methods A cross-sectional analytical study was conducted among adults aged ≥18 years attending a charitable mobile clinic in the rural areas of Al Madinah Province, Saudi Arabia, between June and September 2023. Calibrated dentists examined the dental caries among patients who completed a questionnaire.

Statistical Analysis Spearman's rho test, Mann–Whitney and Kruskal–Wallis tests, and negative binomial regression analyses were conducted.

Results Of the 414 participants, 195 (47%) were males, and the age median/interquartile range (IQR) was 39 (19) years. Caries were identified in 412 of the sample with a median (IQR) decayed, missing, and filled teeth (DMFT) score of 13 (9). Age showed a statistically significant positive association with DMFT scores (β = 0.015; rate ratio [RR] = 1.015; 95% confidence interval [CI]: [1.101, 1.02], p < 0.001) and likewise nationality and place of residence associated significantly with DMFT scores (β = −0.203; RR = 0.816; 95% CI: [0.676, 0.986], p = 0.035 and β = 0.161; RR = 1.175; 95% CI: [1.037, 1.331], p = 0.012, respectively). Educational level (university level) was negatively associated with DMFT scores (β = −0.079; RR = 0.924; 95% CI: [0.855, 0.998], p = 0.044). Visiting dentists was negatively associated with DMFT scores (β = −0.104; RR = 0.902; 95% CI: [0.858, 0.947], p < 0.001), but income, diabetes, hypertension, teeth brushing practice, use of fluoridated toothpaste, and acidic food consumption showed nonsignificant associations.

Conclusion This study highlights the significance of age, nationality, place of residence, educational level, and visiting dentists as factors associated with increases in DMFT scores, while income, oral hygiene practices, and certain chronic conditions showed no significant impact within this population.

Keywords

adults - dental caries - behavioral factors - oral hygiene practice - socioeconomic factors - underserved population - caries detection - tooth brushing - toothpastes

Introduction

Dental caries remains a significant global public health concern, with the World Health Organization (WHO) estimating that approximately 2.5 billion individuals worldwide suffer from dental caries in their permanent teeth.[1] In Saudi Arabia, the issue is particularly challenging, as multiple studies have reported an high prevalence and severity of dental caries across various population subgroups, with rates ranging between 93.7 and 97%.[2] [3] [4] [5] Oral health is influenced by various factors encountered over a person's lifetime, broadly categorized into proximal and distal influences.[6] Proximal influences have a direct or relatively direct impact oral health outcomes, while distal influences shape these proximal factors and exert their effect indirectly.[6]

In Al Madinah Al Munawarah, dental services are predominantly available within a 6-km radius of the city center, with no clinics more than 15 km away.[6] This distribution leaves approximately 37% of the city's districts, primarily in the outer regions, as areas with a relative need for dental services.[6] People in these outer metropolitan areas have no convenient access to public or private dental health care. The lack of access to dental services worsens oral health disparities and impacts overall health and quality of life.[7] The goal of achieving equitable access to dental care is to improve overall health outcomes and advance equity and quality of life for all individuals, regardless of their socioeconomic, geographic, or cultural backgrounds.[8] No data exist on the prevalence of dental caries among underserved populations in Saudi Arabia. Underserved populations face social barriers that limit their access to essential services, for example, dental care.[9] [10]

In Saudi Arabia, numerous charitable organizations are focused on providing health care services, including dental care, to those who are unable to afford treatment. These charities play a crucial role in addressing the health care needs of the underserved populations by offering free or reduced-cost dental care, preventive services, and oral health education. By providing financial assistance and improving access to care, these organizations promote better oral health outcomes and overall well-being.[11]

Recognizing and addressing the needs of underserved populations is essential for promoting equity and ensuring that everyone has equal access to the necessary resources and services. Although the influence of social determinants on oral health has been recognized in the literature,[12] [13] little is known about the predictive roles of socioeconomic factors, chronic health conditions, oral hygiene practices, and behavioral influences on the dental caries experience in Saudi Arabia's underserved populations. This study aimed to assess and identify the associated proximal and distal factors of dental caries in the underserved populations in Al Madinah Province, Saudi Arabia. Understanding these factors informed targeted interventions and policies to reduce the burden of dental caries and improve oral health equity in the region.

Materials and Methods

Study Design and Sampling

A cross-sectional analytical study was conducted among adults aged ≥18 years attending a charitable mobile clinic in Al Madinah Province, Saudi Arabia, rural areas, between June and September 2023. The Charitable Mobile Dental Clinic is a specialized vehicle that travels to different locations and offers dental care services to underserved populations who lack access to regular dental health care. These clinics are nonprofit charities aiming to improve oral health and provide dental services to needy people. A convenience sampling approach was used to select the sample. All patients who met our inclusion criteria attended the charitable mobile clinic during the study period, agreed to participate, and were included. A sample size of 379 respondents was targeted based on the estimated population size (23,740) by using the Qualtrics sample size platform to achieve a 95% confidence level with a 5% margin of error.

A consent form was obtained from each patient, providing a detailed explanation of the study's content and purpose. All adult patients presenting at the mobile clinic during the study period were included; otherwise, all children were excluded. Two calibrated dentists examined the dental caries among patients who completed the questionnaire. Intraclass correlation coefficient (ICC) testing was calculated to test the intra-rater reproducibility and assess the collected data's validity. A high degree of reliability was found between repeated measurements of the decayed, missing, and filled teeth (DMFT). An average ICC of 0.991 with a 95% confidence interval (CI) from 0.989 to 0.993 (p = 0.001) was found.

Data Collection

Dental caries was assessed using the WHO DMFT index.[14] The DMFT score for each patient was calculated by summing up the total number of decayed teeth (DT), missing teeth (MT), and filled teeth (FT). In addition to the dental examination, patients were asked about various aspects, including demographic and socioeconomic information, chronic health conditions, oral hygiene practices, health risk behaviors, and other relevant variables related to oral health and dental care. Non-Arabic speakers were offered translation assistance to help them understand and answer the research questions. The dental examination and questionnaire data for each patient were recorded anonymously in an electronic form with the assistance of the examiners. An Excel spreadsheet was downloaded and imported to the Statistical Package for Social Sciences (SPSS software for Windows, version 28, IBM) for data coding, processing, and analysis.

Model Adaptation

The conceptual framework for this analysis was adapted from Petersen,[7] the WHO's model for oral health surveillance[15] and the variables reported in the 2023 Saudi Arabia Demographic and Health Survey.[16] The framework categorized oral health influences into two main categories: distal (indirect) and proximal (direct). The distal influences included (1) sociodemographic factors such as age, gender, citizenship, and place of residency; (2) socioeconomic factors like education level, monthly income, and employment status; and (3) general health factors including histories of hypertension, diabetes, and iron deficiency anemia. The proximal influences comprised (1) oral health service use, measured by dental visit frequency, and (2) oral health risk behaviors, which included oral hygiene practices, consumption of sugary foods, and smoking.

Statistical Analysis

A descriptive analysis was conducted to describe the characteristics of the participants and their oral health practices using frequencies, percentages, and median and interquartile ranges (IQR). These analyses were performed for the entire sample and further analyzed according to the overall DMFT scores and their components. Spearman's rho test was performed to investigate the possibility of a statistically significant correlation between age, monthly income and the dependent variable, total DMFT, and its components. Mann–Whitney and Kruskal–Wallis tests were conducted to explore potential statistically significant associations between explanatory factors and the dependent variable. Negative binomial regression analyses were conducted to identify the predictive factors as the model fit indicates overdispersion. Statistical significance was set at p < 0.05. The variables included in the negative binomial regression were selected based on their statistical significance in the Spearman rho, Mann–Whitney, and Kruskal–Wallis tests analyses (p < 0.05). In this analysis, the exponential of the regression coefficient (exp(β)) was reported as the Rate ratio (RR).

Results

In this study, 414 adult patients receiving care from the charity mobile dental clinic consented to participate. Among these patients, 98% presented with at least one DT, MT, or FT, with only two individuals having a DMFT score of zero. The median (IQR) of the DMFT score was 13 (9), the DT score was 6 (5), the MT score was 3 (5), and the FT score was 1 (3). [Table 1] presents and summarizes the patients' distal factors included in the study. Age showed a medium positive correlation with the DMFT score and MT component (Spearman's rho = 0.409 and 0.469, respectively, p < 0.001), indicating that an increase in age is significantly associated with higher DMFT and MT scores.

Table 1 The association between participant's distal factors with decay, missing, and filled teeth (DMFT) score and its components (N = 414)

Distal factors		Total, median (IQR)[a]	DMFT[b]	p-value	DT[b]	p-value	MT[b]	p-value	FT[b]	p-value
Continuous variables
Age (y)		35 (19)	0.409	< 0.001	−0.023	0.648	0.469	< 0.001	0.292	< 0.001
Monthly income (SR)[c]		1,500 (1,200)	0.134	0.006	0.059	0.230	0.097	0.049	0.159	0.001
Categorical variables		Total, F (%)	DMFT, median (IQR)[a]	p -value	DT, median (IQR)[a]	p -value	MT, median (IQR)[a]	p -value	FT, median (IQR)[a]	p -value
Gender[d]	Male	195 (47)	14 (9)	0.43	6 (6)	0.17	3 (5)	0.86	1 (3)	0.84
	Female	219 (53)	12 (9)		6 (6)		3 (5)		1 (3)
Nationality[d]	Saudi	41 (10)	17 (8)	< 0.001	8 (6)	0.08	5 (5)	< 0.001	2 (4)	0.045
	Non-Saudi	373 (90)	12 (9)		6 (5)		3 (5)		1 (3)
Place of residence within Al-Madinah[e]	Peri-urban districts	312 (75.4)	12 (9)	0.001	6 (5)	< 0.001	3 (5)	0.13	1 (3)	.49
	Exurban districts	86 (20.8)	12.5 (10)		6 (5)		4 (6)		0 (2)
	Rural communities	16 (3.9)	18 (5)		11 (3)		4 (5)		0.50 (2)
Educational level[e]	Illiterate/primary	166 (40)	14 (10)	0.017	7 (6)	0.11	4 (6)	0.02	0.50 (2)	0.03
	Intermediate/Secondary	195 (47)	12 (8)		6 (6)		3 (4)		1 (3)
	University	53 (13)	12 (8)		5 (4)		3 (4)		2 (4)
Employment status[d]	Employed	157 (38)	14 (9)	0.271	7 (5)	0.006	3 (4)	0.671	1 (3)	0.621
	Unemployed	257 (62)	12 (9)		5 (6)		3 (5)		1 (3)
Diabetes	No	353 (85)	12 (8)	< 0.001	6 (6)	0.074	3 (4)	< 0.001	1 (3)	0.014
	Yes	61 (15)	17 (5)		8 (5)		6 (7)		2 (4)
Hypertension	No	369 (89)	12 (9)	< 0.001	6 (5)	< 0.739	3 (4)	< 0.001	1 (3)	0.82
	Yes	45 (11)	17 (12)		7 (6)		6 (8)		1 (3)
Iron deficiency anemia	No	399 (96)	13 (9)	0.252	6 (5)	0.518	3 (5)	0.679	1 (3)	0.135
	Yes	15 (4)	11 (11)		5 (11)		3 (4)		0 (1)

^a IQR, interquartile range.

^b Spearman's rho test, significant at p < 0.05.

^c SR, Saudi Riyal

^d Mann–Whitney test, significant at p < 0.05.

^e Kruskal–Wallis test, significant at p < 0.05.

Similarly, monthly income positively correlated with the DMFT score (Spearman's rho = 0.134, p = 0.006), suggesting that higher income levels are associated with a better dental caries experience. Gender and employment status did not show significant associations with DMFT scores. However, differences were observed across subgroups regarding nationality, place of residence, and educational attainment. In particular, Saudi participants, individuals residing in rural communities, and those with lower levels of education (illiterate or primary) had significantly higher median DMFT scores. Detailed associations of the participant's socioeconomic characteristics with each DMFT component are presented in [Table 1]. The median DMFT score of individuals with diabetes (17) was significantly different (p < 0.001) from those without diabetes (12). Similar trends were observed for MT and FT, with diabetics showing higher medians and significant p-values than nondiabetics. Findings have also revealed that hypertensive individuals had significantly higher median DMFT scores of 17 (IQR: 12) and DT scores of 6 (IQR: 8) relative to their nonhypertensive counterparts. Iron deficiency anemia showed no significant association with the overall DMFT score or its components.

[Table 2] explores the association between proximal (oral hygiene practices and oral health risk behavior) factors in relation to the DMFT score, including its components: DT, MT, and FT. Participants who did not brush their teeth had significantly higher median DMFT scores of 16 (IQR: 9) than those who brushed regularly or sometimes, with median scores of 11 (IQR: 9) and 14 (IQR: 9), respectively. The frequency of teeth brushing was not statistically significant for the overall DMFT score. Individuals using soft toothbrushes had a median MT score of 2 (IQR: 4), significantly different from those using medium or hard brushes. Surprisingly, using fluoridated toothpaste was associated with lower DMFT scores, with a significant p-value of 0.019 for nonusers. Participants who visited dentists only when necessary had a higher median DMFT score of 14 (IQR: 9) and a higher median DT score of 7 (IQR: 6) compared with those attending dental visits twice a year (11, IQR: 9 and 5, IQR: 5, respectively). Those visiting the dentist once a year had significantly higher median MT and FT scores of 4 and 2 than those who visited only when necessary, who scored 3 and 1, respectively. The association between DMFT and its components with behavioral factors is presented in [Table 2].

Table 2 The association between participant's proximal factors with decay, missing, and filled teeth (DMFT) score

Proximal factors
Oral hygiene practice		Total, F (%)	DMFT, median (IQR)[a]	p-value[c]	DT, median (IQR)[a]	p-value[c]	MT, median (IQR)[a]	p-value[c]	FT, median (IQR)[a]	p-value[c]
Teeth brushing	No	56 (13)	16 (9)	< 0.001	9 (8)	< 0.001	4 (4)	0.004	0 (2)	0.068
	Yes	244 (59)	11 (9)		6 (8)		3 (4)		1 (3)
	Sometimes	114 (28)	14 (9)		6 (5)		4 (5)		1 (3)
Frequency of teeth brushing[b]	Once/d	212 (51)	12 (8)	0.282	6 (5)	0.052	2 (4)	0.583	1 (3)	0.792
	Twice/d	125 (30)	10 (9)		5 (4)		3 (4)		1 (3)
	≥3 times/d	21 (5)	12 (8)		4 (8)		3 (4)		1 (2)
Type of toothbrush[b]	Soft	125 (30)	10 (8)	0.438	6 (5)	0.059	2 (4)	0.018	1 (2)	0.793
	Medium	98 (24)	11 (9)		5 (5)		3 (5)		1 (3)
	Hard	27 (7)	12 (11)		4 (5)		3 (10)		1 (3)
	I do not know	81 (20)	13 (9)		7 (5)		3 (4)		0 (3)
Use of fluoridated toothpaste[b]	Yes	55 (13)	14 (8)	0.019	7 (6)	0.052	3 (2)	0.709	2 (4)	0.046
	No	10 (3)	8.5 (8)		4.5 (4)		3 (2)		1 (5)
	I do not know	266 (64)	11 (10)		6 (6)		3 (4)		0 (3)
Dental attendance
Visiting dentists	When necessary	273 (66)	14 (9)	< 0.001	7 (6)	0.042	3 (4)	< 0.001	1 (3)	< 0.001
	Once a year	18 (4)	13 (9)		5.5 (4)		4 (5)		2 (4)
	Twice a year	69 (17)	11 (9)		5 (5)		3 (5)		1 (3)
	First visit ever	54 (13)	8 (11)		5 (7)		1 (3)		0 (0)
Oral health risk behavioral
Habit (yes)	Acidic food consumption	87 (21)	11 (7)	0.028	5 (6)	0.043	2 (3)	0.008	1 (4)	0.922
	Teeth grinding	23 (6)	10 (9)	0.498	6 (5)	0.62	2 (5)	0.23	2 (4)	0.183
	Nail biting	15 (4)	13 (6)	0.721	6 (6)	0.724	2 (3)	0.007	3 (6)	0.028
Smoking	No	330 (80)	12 (9)	0.303	6 (5)	0.091	3 (5)	0.796	1 (3)	0.195
	Yes	84 (20)	14 (9)		7 (6)		3 (3)		1 (3)

^a IQR, interquartile range.

^b Only participants indicating tooth brushing and fluoride use have been considered for this analysis.

^c Kruskal Wallis test.

The negative binomial regression analysis, as shown in [Table 3], examines the association between individuals' distal and proximal factors and the overall DMFT score. Age showed a statistically significant positive association with DMFT scores (β = 0.015; RR = 1.015; 95% CI: [1.101, 1.02], p < 0.001). Nationality and place of residence were found to have statistically significant associations with DMFT scores. Nationality (non-Saudi) had a negative association (β = −0.203; RR = 0.816; 95% CI: [0.676, 0.986]; p = 0.035), while place of residence (rural communities) showed a positive association (β = 0.161; RR = 1.175; 95% CI: [1.037, 1.331]; p = 0.012). Educational level (university level) was negatively associated with DMFT scores (β = −0.079; RR = 0.924; 95% CI: [0.855, 0.998]; p = 0.044). Income, having diabetes, and hypertension were not significantly associated with DMFT scores.

Table 3 Negative binomial regression analysis association of individual's distal and proximal factors with the overall DMFT score (N = 414)

Independent variable	Model			p-value
	β	RR	95% CI
Age (y)	0.015	1.015	1.101–1.02	<0.001
Monthly income	8.71 × 10−6	1.00	1.00–1.00	0.624
Nationality	−0.203	0.816	0.676–0.986	0.035
Place of residence	0.161	1.175	1.037–1.331	0.012
Educational level	−0.079	0.924	0.855–0.998	0.044
Diabetes	0.163	1.177	0.993–1.395	0.060
Hypertension	−0.079	0.924	0.759–1.125	0.431
Teeth brushing	0.074	1.077	0.951–1.219	0.244
Use of fluoridated toothpaste	−0.074	0.928	0.867–0.994	0.033
Visiting dentists	−0.104	0.902	0.858–0.947	<0.001
Acidic food consumption	0.054	1.055	0.932–1.194	0.396

Abbreviation: CI, confidence interval; DMFT, decayed, missing, and filled teeth; RR, rate ratio.

Note: Bold signify p < 0.05.

Tooth brushing practice and fluoridated toothpaste showed no significant association with DMFT scores. However, visiting dentists was negatively associated with DMFT scores (β = −0.104; RR = 0.902; 95% CI: [0.858, 0.947]; p < 0.001). Acidic food consumption did not correlate significantly with DMFT scores in the model.

Discussion

This study aimed to assess and identify the associated proximal and distal factors of dental caries in underserved populations in Al Madinah Province, Saudi Arabia. The study revealed a high prevalence of DMFT among the studied population, with the majority presenting with at least one DT, MT, or FT. This finding is similar to previous studies conducted in the United States, Southeast African, South Asia, Norway, and India.[17] [18] [19] [20] [21]

In the regression model, it was observed that age showed a statistically positive association with DMFT scores, suggesting that older individuals have a higher prevalence of dental caries, which is consistent with existing literature that often reports an increased effect of dental caries and tooth loss with aging,[22] [23] attributed to factors such as poor diet and reduced saliva production or medication use.[24] In addition, older adults may lack access to regular dental care, leading to higher rates of untreated dental caries.[25]

Income, on the other hand, did not show a significant association with DMFT scores. This study's lack of a strong income effect on dental caries suggests that factors beyond just socioeconomic status may be driving oral health outcomes in that rural community. Other social, environmental, and access-related barriers could play a more significant role in shaping the prevalence of dental caries.

Conversely, place of residence had a positive association, suggesting that individuals residing in rural communities may have higher DMFT scores. This finding may underline the significance of considering geographic and cultural factors in dental interventions.

Educational level was negatively associated with DMFT scores, indicating an association between low education levels and higher DMFT scores among the study sample, which aligns with the WHO's notion that education can enhance health literacy and promote healthier behaviors, ultimately improving health.

The study found a high DMFT score among individuals who did not visit the dentist regularly, often seeking dental care only when experiencing pain. This finding is similar to that previously reported,[22] reinforcing the importance of routine dental checkups for prevention and early intervention. However, in terms of oral hygiene practice, this study did not find a clear association between tooth brushing practice and fluoridated toothpaste with dental caries. Various factors can influence dental caries development beyond just brushing and fluoride use, such as diet, saliva composition, oral hygiene habits, socioeconomic status, and access to dental care. These confounding variables may have obscured the relationships in this study. Recent research indicates that smoking may increase the risk of dental caries lesions compared with nonsmokers.[26] However, a comprehensive review of the literature found that, while smoking was related with an increased risk of dental caries, the overall quality of evidence was low, underlining the need for a more thorough prospective research to establish a conclusive causal link on this topic.[27]

Interestingly, no direct association was found between the DMFT score and the presence of diabetes or hypertension, suggesting that, while these factors are essential for overall health, their direct impact on dental caries may be less significant in this study.[28] [29] [30] Research on the association between dental caries and systemic health issues yielded conflicting results. Some research revealed links between increased caries index and hypertension and diabetes,[31] whereas others found no direct link between dental caries and these systemic disorders.[32] These contradictory findings imply that the link between dental caries and systemic health is complex and may be altered by a variety of settings.

The strengths of this study are its sample size, detailed data on behavioral factors, and use of fluoridated toothpaste. Our study has some limitations. This cross-sectional study sought inferences about causal factors without establishing temporal relationships. Furthermore, no individual variables related to bacterial or salivary factors were collected. Dental caries development involves many factors not always accounted for in statistical models, leading to variations in caries that cannot be explained by the variables assessed.

Conclusion

High DMFT scores among Al Madinah's underprivileged communities point to a significant burden on the region's health care system and highlight the urgent need for preventative and comprehensive oral health programs. However, this demographic was not significantly impacted by income, dental hygiene habits, or specific chronic illnesses highlighting the importance of examining unique local contexts, especially when studying underserved populations.

No conflict of interest has been declared by the author(s).

Acknowledgments

The authors acknowledge all those who provided unwavering support during the study period. The authors would also like to thank the participants for their support throughout the study and for making it possible.

Recommendations

Further research is required to highlight the significance of examining unique local contexts when studying underserved populations. Exploring all the factors contributing to high DMFT scores within these communities is crucial, as well as developing comprehensive solutions to address this oral health disparity by profoundly understanding the underserved groups' distinct local circumstances, challenges, and needs. Researchers and policymakers can design more effective, tailored interventions to improve these populations' access to dental care and oral health outcomes.

Ethical Approval

After receiving verbal and written explanations of the study protocol and its aims, the participants signed a written informed consent written in both English and Arabic before the start of the study. Permission was obtained from Taibah University, College of Dentistry, Research Ethics Committee (TUCD-REC) with the approval number TUCDREC/010323/MGamer.

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Publication History

Article published online:
14 February 2025