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Oral health status and related risk factors among adolescents attending high schools in Khartoum, Sudan: A cross-sectional study

Open AccessPublished:June 01, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101080

      Abstract

      Objectives

      Effective dental services must be based on reliable evidence of oral diseases status and treatment needs. The aim of this study was to assess oral health status and associated risk factors among adolescents attending high school in Khartoum, Sudan.

      Methods

      A school-based survey was conducted among 420 adolescents (13–18 years old). Participants completed a questionnaire about their socio-demographics and oral habits. They received clinical examination, assessing their oral health status using the World Health Organization (WHO) oral health survey for dentition and periodontal status; mean Decayed, Missing and Filled Teeth (DMFT), and Community Periodontal Index (CPI).

      Results

      High dental caries prevalence of 91.1%, with mean DMFT of 3.3 (±1.8) and Significant Caries index (SIC) of 5.2 were found among the participants. Untreated decayed teeth dominated the DMFT scores (DT = 3.06 ± 1.7). The results of CPI depicted that 96% of participants had unhealthy periodontium, with majority of subjects (79.5%) having CPI maximum scores of 2. Increased age and being enrolled in a public school were the main risk factors associated with caries (p = 0.01). Increased CPI scores were found to be significantly higher among males (p = 0.006) and among public schools' attendees (p = 0.039). High maternal education was associated with participants’ healthier periodontium (p < 0.01).

      Conclusions

      Sudanese adolescents have high prevalence of caries and unhealthy periodontium, which imposes a need for preventive and treatment programs to improve their oral health status. The significant associations between participants' oral health status and their gender, school-type and age may suggest considering these when designing schools’ oral health programs.

      Keywords

      1. Introduction

      Oral health is an integral part, and has a close reciprocal associations with the overall systemic well-being.
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      The WHO defines oral health as the standard of oral tissues which enables an individual to eat, speak and socialize without active disease, discomfort or embarrassment, thus contributing to general well-being.
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      This comprehensive definition emphasizes the impact of oral diseases on the quality of life of the individual.
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      Several factors play a role in determining the oral health status, including a) biological e.g. host susceptibility; b) behavioural, e.g. toothbrushing, quality of the nutrition, tobacco use, and dental services utilization; c) socioeconomic factors e.g. level of education and income; and d) macro-ecological such as fluoridation and sealants and accessibility to dental services.
      • Petersen P.E.
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      The global burden of oral diseases and risks to oral health.
      The American Academy of Paediatric Dentistry recognizes adolescence as a period requiring specific oral health attention due to (1) a potentially high caries rate caused by increased intake of cariogenic-substances; (2) a tendency for poor oral hygiene, and altered nutritional habits; (3) hormonal changes; (4) increased risk for periodontal disease and traumatic injury; (4) increased aesthetic desire; and (6) potential use of tobacco and other drugs.
      American Academy of Pediatric Dentistry
      Adolescent Oral Health Care. The Reference Manual of Pediatric Dentistry.
      Although these physiological and socio-behavioural changes and practices may adversely affect adolescents’ oral health, but adolescence remains as an opportunity for improving oral health, as health behaviours established during adolescence may last into adulthood, making this high risk age-group an excellent target for oral screening and prevention programs.
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      • Organization W.H.
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      The WHO recommends evaluating the oral health status by assessing the dentition and periodontal status. The dentition status can be assessed using dental caries indices on either the tooth or surface levels (dmft/s and or DMFT/S), and the periodontal status using CPI in which periodontal indicators (gingival bleeding, presence of calculus and periodontal pockets) are used for this assessment.
      • Organization W.H.
      Oral Health Surveys: Basic Methods.
      For effective surveillance, the WHO suggests that clinical oral health surveys should be conducted regularly every five to six years in the same community.
      • Organization W.H.
      Oral Health Surveys: Basic Methods.
      Although dental caries and periodontal diseases are considered to be major oral health problems globally, but they appear to be neither as prevalent nor as severe in African countries as in the developed ones.
      • Organization W.H.
      Promoting Oral Health in Africa: Prevention and Control of Oral Diseases and Noma as Part of Essential Noncommunicable Disease Interventions.
      Regionally, the prevalence and severity of oral diseases, among adolescents aged 10–14 years from Uganda, Tanzania and Kenya revealed low prevalence of caries and mean DMFT ranging from 0.3 to 0.7.
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      • Omolo J.
      • Smith P.
      Nevertheless the profile of oral disease is not homogenous across Africa, with well-established epidemiological disparities within and between countries and regions, suggesting the need for each country to periodically assess its oral health status.
      • Thorpe S.J.
      Development of oral health in Africa.
      Few studies have investigated the oral health status of Sudanese population in the past decades.
      • Nurelhuda N.M.
      • Trovik T.A.
      • Ali R.W.
      • Ahmed M.F.
      Oral health status of 12-year-old school children in Khartoum state, the Sudan; a school-based survey.
      ,
      • Khalifa N.
      • Allen P.F.
      • Abu-bakr N.H.
      • Abdel-Rahman M.E.
      • Abdelghafar K.O.
      A survey of oral health in a Sudanese population.
      Untreated caries prevalence was found to be high (30.5% among the twelve years old, and 87.7% among subjects ≥16 years old), and the periodontal status varied based on the age group.
      • Nurelhuda N.M.
      • Trovik T.A.
      • Ali R.W.
      • Ahmed M.F.
      Oral health status of 12-year-old school children in Khartoum state, the Sudan; a school-based survey.
      ,
      • Khalifa N.
      • Allen P.F.
      • Abu-bakr N.H.
      • Abdel-Rahman M.E.
      • Abdelghafar K.O.
      A survey of oral health in a Sudanese population.
      Elamin et al. reported that 16.3% and 8.2% of Sudanese high school adolescents had at least one tooth with ≥4 and ≥ 5 mm periodontal attachment loss, respectively.
      • Elamin A.M.
      • Skaug N.
      • Ali R.W.
      • Bakken V.
      • Albandar J.M.
      Ethnic disparities in the prevalence of periodontitis among high school students in Sudan.
      Overall, studies assessing Sudanese periodontal health status were characterized by variations in assessment methodologies and findings (Table 1).
      • Nurelhuda N.M.
      • Trovik T.A.
      • Ali R.W.
      • Ahmed M.F.
      Oral health status of 12-year-old school children in Khartoum state, the Sudan; a school-based survey.
      ,
      • Khalifa N.
      • Allen P.F.
      • Abu-bakr N.H.
      • Abdel-Rahman M.E.
      • Abdelghafar K.O.
      A survey of oral health in a Sudanese population.
      ,
      • Yousif M.A.
      • Miskeen E.I.
      Prevalence and management of periodontal diseases in Gezira province (Central Sudan).
      • Darout I.A.
      • Albandar J.M.
      • Skaug N.
      Periodontal status of adult Sudanese habitual users of miswak chewing sticks or toothbrushes.
      • Ali R.W.
      • Lie T.
      Periodontal conditions as measured by CPITN in Sudanese adolescents and adults in two cities in Sudan.
      • Dowty A.M.
      Oral health of children in southern Sudan.
      • Emslie R.
      A dental health survey in the Republic of the Sudan.
      Table 1Periodontal health status of adolescents and adults in Sudan reported in the literature (1966–2012).
      Author/s and yearRegionStudy sample (n)Age (years)Assessment method of periodontal health (Index)Main periodontal health status findings
      Emslie 1966 (20)Butana, Gezira, Khartoum city and Kordofan river9954–60Russell index (PI)High prevalence of periodontal disease associated with poor oral hygiene.

      Three cases of periodontosis (currently known as periodontitis) were found among 645 (age group 15–19 years), yielding a prevalence of 0.47%.
      Ali and Lie 1994 (18)Khartoum city and El-Obeid city26415–64CPITNHigh prevalence of periodontal diseases among adolescents.

      95.2% having pockets 4–5 mm.

      4% having pocket depths 6 mm.
      Yousif et al., 2008 (16)Gezira Province (urban and rural) Central Sudan649Adults (age not specified)Periodontal Index (PI)Calculus was the most predominant periodontal problem in both the urban and rural areas.

      Periodontitis is a least prevalent condition in urban and rural areas (12.4% and 13.1% respectively).
      Elamin et al., 2010 (15)Khartoum State120013–19Gingival recession, probing depth, gingival bleeding and periodontal attachment loss was calculated.
      Using the recommendation of the International Workshop for Classification of Periodontal Diseases and Conditions.
      16.3% and 8.2% of the subjects had at least one tooth with ≥4 and ≥ 5 mm attachment loss, respectively.

      A significantly higher percentage of subjects of African tribal ethnicity had attachment loss ≥4 and ≥ 5 mm compared to Afro-Arab tribes (19.8% vs. 14.7%, P = 0.02; and 12% vs. 6.4%, P = 0.004, respectively).
      Khalifa et al., 2012 (14)Khartoum State1888adults aged ≥16community periodontal index (CPI), and a validated tooth wear index.In the 35–44 years age group 36.1% had healthy periodontal tissues, 10.9% bleeding, 42.0% calculus, 8.5% 4-5-mm periodontal pockets, 0.7% periodontal pockets of ≥6 mm, and 1.8% excluded sextants.
      a Using the recommendation of the International Workshop for Classification of Periodontal Diseases and Conditions.
      In Sudan, oral health services are combination of public and private providers, with substantial maldistribution between urban and rural areas. The lack of regular school-linked preventive oral health programs, and population-linked recording systems hinders the tasks of understanding the oral health status and the associated factors needed to offer a basis for developing effective oral health interventions.
      • Organization W.H.
      Promoting Oral Health in Africa: Prevention and Control of Oral Diseases and Noma as Part of Essential Noncommunicable Disease Interventions.
      Furthermore, similar to many developing countries in Africa, oral health services are almost entirely curative and are poorly distributed reaching only urban communities and those with higher income.
      • Thorpe S.J.
      Development of oral health in Africa.
      In an effort to periodically assess the oral health profile of the Sudanese population, we identified a gap in the literature related to the oral health status of Sudanese adolescents. Therefore, the aim of this study was to assess oral health status and related factors among Sudanese adolescent attending high schools in Khartoum, Sudan.

      2. Methods

      The target population was Sudanese adolescents aged 13–18 years old, attending public and private high schools in Khartoum locality, Sudan. This locality consists of three administrative units (Khartoum, Al-Shuhada and Khartoum-East), with a total population of 745.938 inhabitants. A total of 158 high schools; with 16410 students enrolled in the public schools (55% boys and 45%girls), and 15343 students in the private schools (50% boys and 50%girls). A minimum sample size of 385 participants was calculated, using Cochran formula (n = Z2pq/e
      • Petersen P.E.
      The World oral health report 2003: continuous improvement of oral health in the 21st century–the approach of the WHO global oral health programme.
      ).
      • Jain S.
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      • Jain D.
      Estimation of sample size in dental research.
      To obtain a representative sample of the study population, multistage stratified random sampling design was performed.
      • Organization W.H.
      Oral Health Surveys: Basic Methods.
      To achieve this, a list of all high schools in the locality was obtained from the Ministry of Education, Sudan. Primary sampling units consisted of schools and were stratified by school type (private vs. public)/(boys' schools vs. girls' schools). Twenty schools were randomly selected, as follows: five public boys' schools, five public girls' schools, five private boys' schools and five private girls’ schools. In the second stage, 21 students were randomly selected from the three academic grades in each school, seven from each class, rounding the total sample size to 420 participants. The inclusion criteria for this study were consenting, generally healthy students and who were also present at school on the day of the examination. Students who had undergone prolonged use of medications or had chronic diseases were excluded from this study.
      Data were collected by means of questionnaires and clinical examinations. Participants were interviewed to complete a full structured questionnaire which consisted of two sections: (a) sociodemographic (e.g.: age, school type, parents’ education levels and self-rated financial status), and (b) oral health habits and practices (toothbrushing, oral hygiene aids, and dental services visits).
      For the oral health assessment, the WHO oral health survey guidelines and criteria (DMFT and CPI) were used.
      • Organization W.H.
      Oral Health Surveys: Basic Methods.
      All dental examinations were performed at schools, by one experienced calibrated dentist (HO). The examination was conducted under field-conditions with the participant seated on an office chair facing a window with natural sunlight. The dental examination was carried out using plane-faced dental mirror, and 0.5 mm ball-ended Community Periodontal Index Probe (CPI probe) (WHO-probe, YDM Ltd., Tokyo, Japan). The following were recorded for each participant: a) the WHO caries-scoring index for permanent dentition (DMFT) to describe the dental caries status, and CPI (score 0: healthy; score 1: gingival bleeding observed with no pocket and no calculus; score 2: gingival calculus present and no pocket >3 mm; score 3: pocket present 4 or 5 mm deep; score 4: pocket > 6 mm) to describe the periodontal health status.
      The statistical software package SPSS version 24.0 was used for statistical analyses. The CPI data were analysed according to WHO recommendations whereby participants were categorized by maximum CPI score and the mean number of sextants was computed. Mean DMFT was used to determine the extent of caries. The SiC was calculated, according to the WHO formula by selecting the one third of the study participants having the highest DMFT values.
      • Bratthall D.
      Introducing the Significant Caries Index together with a proposal for a new global oral health goal for 12-year-olds.
      Chi square and Kruskal Wallis tests were used for testing associations between indices and selected variables as appropriate. A multivariate logistic regression model was applied and included variables that had shown statistical significance in univariate tests. A P-value <0.05 was considered statistically significant.

      3. Results

      A total of 420 adolescents completed questionnaires and received clinical examinations. Table 2A, Table 2B describes the sample characteristics. Table 2A shows sociodemographic characteristics of high school students participating in the study. Table 2B describes the sample characteristics with regards to oral hygiene practices and dental habits. Majority of participants brushed their teeth daily (61%), while 2.8% reported to brush their teeth irregularly. Majority of participants (98.2%) were using toothbrush as the brushing tool, whereas six participants reported to use Miswak and dental floss. Over third of the participants (35.5%) never visited a dentist before and 38.1% of the participants self-rated their oral health as good (Table 2B).
      Table 2ASample characteristics: The sociodemographic characteristics of high school students, Khartoum, Sudan (n = 420).
      Variablen%
      Age group (in years)
      13–1519245.7
      16–1822854.3
      Sex
      Boys22252.9
      Girls19847.1
      School type
      Public23756.4
      Private18343.6
      Father's education
      No formal education153.6
      Elementary education215.0
      Secondary education/high school13131.2
      Bachelor's degree16338.8
      Post graduate studies9021.4
      Mother's education
      Two subjects did not report the mother's level of education.
      No formal education184.1
      Elementary education7116.2
      Secondary education/high school28064
      Bachelor's degree5111.6
      Post graduate studies184.1
      Self-rated household financial status
      Poor112.6
      Average30773.1
      Wealthy10224.3
      Two subjects did not report the mother's level of education.
      Table 2BSample characteristics: oral hygiene practices and dental visits among high school students, Khartoum, Sudan (n = 420).
      Variablen%
      Tooth brushing frequency
      irregularly or never122.8
      Once a day25661.0
      ≥Twice daily15236.2
      Mouth cleaning/brushing device used
      Toothbrush41298.2
      Wooden toothpicks10.2
      Dental floss30.7
      Miswak30.7
      Mouth wash10.2
      Type of toothpaste used
      Fluoride-free toothpaste389.0
      Fluoride toothpaste38291.0
      Dental visits frequency (during the past 12 months)
      Never visited or received dental care before14935.5
      Had not visited the dentist during the past 12 months13031.0
      Once6916.4
      Twice266.2
      ≥3 time Three times255.9
      Self-rated oral health
      Poor6515.5
      Average71.7
      Good16038.1
      Excellent6315.0
      Do not know12529.8
      Table 3A, Table 3B describe the participants' periodontal health status. The percentage of study participants with CPI maximum scores and the mean number of sextants with CPI-scores is presented in Table 3A. Most of the subjects (79.5%) had a score of 2 (calculus) as their highest CPI score, while only 6% had healthy periodontium (CPI = 0). When assessing the participants’ periodontal health status measured by CPI and divided by age group, gender and school-type significant differences in CPI scores were found between genders, where boys were found to have higher maximum CPI scores, i.e., scores 2 and 3, whereas girls were found to have more of scores 0 and 1 (p = 0.006) (Table 3B). Moreover, the percentage of subjects affected by gingival bleeding and calculus (score 2) was significantly higher among adolescents enrolled in public schools than those enrolled in private schools (82.7% vs 75.4% respectively, p = 0.039) (Table 3B). Analysis of the association between the sociodemographic characteristics, oral practices and CPI scores revealed that adolescents with mothers having higher educational level (i.e., university degree or above), have significantly healthier periodontium than those with mothers who have lower education (high school education or below) (p < 0.01) (Table 3B).
      Table 3AThe periodontal health status of Sudanese high schools’ participants: The percentage of CPI maximum scores and the mean number of sextants with CPI-scores (n = 420).
      CPI scoring VariablesnCPI max (%)Mean no. of sextants
      Score 0 (Healthy)256.0%1.88
      Score 1 (Bleeding)5613.3%1.52
      Score 2 (Calculus)33479.5%2.58
      Score 3 (pocket 4–5 mm)51.2%0.01
      *None of the participants were score 4 (periodontal pocket ≥6 mm).
      Table 3BThe periodontal health status of Sudanese high schools’ participants measured by Community Periodontal Index (CPI) and divided by age group, gender, and school type (n = 420).
      CharacteristicCPI scores
      None of the participants were CPI score 4 (periodontal pocket ≥6 mm).
      P-value
      Score 0 n (%)Score 1 n (%)Score 2 n (%)Score 3 (n (%)
      Age group
      13–15 years12 (6.3)19 (9.9)159 (82.8)2 1.0)0.292
      16–18 years13 (5.7)37 (16.2)175 (76.8)3 (1.3)
      Sex
      Boys10 (4.5)21 (9.5)186 (83.8)5 (2.3)0.006
      Girls15 (7.6)35 (17.7)148 (74.7)0 (0.0)
      School type
      Public12 (5.1)29 (12.2)196(82.7)0 (0.0)0.039
      Private13 (7.1)27 (14.8)138 (75.4)5 (2.7)
      None of the participants were CPI score 4 (periodontal pocket ≥6 mm).
      Overall, only 37 subjects were found to be caries free (8.9%), indicating that the prevalence of dental caries among high school students in Khartoum was 91.1%. A significantly higher occurrence of caries was found among the older age group, i.e., the 16–18 years old (p = 0.013) (Fig. 1).
      Fig. 1
      Fig. 1Caries experience among Sudanese high school students divided by gender, age group and school type (n=420).
      In the study sample, the mean DMFT was found to be 3.3 (±1.8), and the SIC was 5.2. Over 92% of the mean DMFT score was contributed by untreated decayed teeth (DT = 3.06 ± 1.7). Only 23 subjects were found to have teeth with restorations contributing to a low mean FT (0.2 ± 1.0), and 46 participants had undergone extractions (MT = 0.4 ± 0.9).
      Table 4 shows the caries experience among study participants described by DT, MT, FT and mean DMFT scores divided by gender, age, and school type. The mean DMFT scores for 13-15- and 16–18-year-old participants were 3.0 (±1.7), 3.5 (±1.9) respectively (Table 4). This indicates that as the age of the subjects increased from 13 to 18 years old, caries significantly increased (p = 0.01). Moreover, the mean DMFT was significantly higher among subjects attending public schools (p = 0.01). The DT was significantly higher among public schools' attendees than private schools' attendees (p = 0.007), while the MT component was significantly higher among subjects ages 16–18 years old than the younger age group (p = 0.004). Analysis of the association between the oral practices and dental caries revealed that adolescents who visited the dentist once or more that year had significantly higher mean DMFT 2.93 (±1.78), than those who didn't have dental visits in the past year or never visited a dentist before (p = 0.002) (Table 4).
      Table 4Caries experience among study participants described by DT, MT, FT and mean DMFT scores, divided by gender, age and school type (n = 420).
      Decayed (DT)Missing (MT)Filled (FT)DMFT score
      n (%)xSDP*n (%)xSDP*n (%)xSDP*n (%)xSDP*
      Gender
      Boys193 (86.9)2.91.90.1724 (10.8)0.20.50.9312 (5.4)0.10.40.9195 (87.8)3.21.90.1
      Girls188 (94.9)3.21.622 (11.1)0.20.511 (5.6)0.10.6188 (94.9)3.41.7
      Age (years)
      13–15170 (88.5)3.21.70.1212 (6.2)0.20.30.0049 (4.7)0.10.40.5171 (89.1)3.01.70.01
      16–18211 (92.5)3.21.834 (14.9)0.20.614 (6.1)0.10.6212 (93.0)3.51.9
      School type
      Public215 (90.7)3.31.90.00730 (12.7)0.20.60.189 (3.8)0.10.30.08216 (91.1)3.51.90.01
      Private166 (90.7)2.81.616 (8.7)0.10.414 (7.7)0.20.7167 (91.3)3.01.6
      Abbreviations: x, Mean. SD, standard deviation.
      *P Significance evaluated by the chi-square test.
      To examine the associations between the independent variables, multiple logistic regression model was constructed, and the analysis found no statistical significant associations.

      4. Discussion

      In Sudan, like many other developing countries, oral diseases have been neglected and are not prioritized by health planners, which may have been reflected on the overall oral health status of the population.
      • Organization W.H.
      Promoting Oral Health in Africa: Prevention and Control of Oral Diseases and Noma as Part of Essential Noncommunicable Disease Interventions.
      We assessed the oral health status and associated risk factors among high school adolescents, in Khartoum, Sudan. The present study reported concerning neglect of oral health among Sudanese high school students in Khartoum, where a high caries prevalence of 91.1% was found among the assessed high school students. Untreated decayed teeth dominated the DMFT scores in this study, indicating a high rate of unmet treatment needs. Moreover, the periodontal health status was also alarming with 96% of participants having unhealthy and gingiva and periodontium with CPI maximum scores ranging 1–4.
      Global trends of dental caries indicate that although caries rates are declining worldwide, the prevalence of the disease is still rather high in some countries.
      • Lagerweij M.
      • Van Loveren C.
      Declining caries trends: are we satisfied?.
      Over the past two decades number of attempts -despite their scarcity-have been made to map the oral health status in Sudan.
      • Nurelhuda N.M.
      • Trovik T.A.
      • Ali R.W.
      • Ahmed M.F.
      Oral health status of 12-year-old school children in Khartoum state, the Sudan; a school-based survey.
      In this study the mean DMFT was of 3.3 and SiC of 5.2 were found to be higher than those reported in a study assessing the oral health status of WHO index age of 12 years old students in Khartoum state, where authors reported a mean DMFT of 0.42 with SiC of 1.4.
      • Nurelhuda N.M.
      • Trovik T.A.
      • Ali R.W.
      • Ahmed M.F.
      Oral health status of 12-year-old school children in Khartoum state, the Sudan; a school-based survey.
      Despite the present study assessing slightly older age groups, yet it is indicative of increased caries experience among adolescents in Sudan. Furthermore, the prevalence of caries reported in the current study was found to be higher than those reported among Sudanese adults aged ≥16 years (91.1% vs. 87.7% respectively).
      • Khalifa N.
      • Allen P.F.
      • Abu-bakr N.H.
      • Abdel-Rahman M.E.
      • Abdelghafar K.O.
      A survey of oral health in a Sudanese population.
      The alarming rise reported among the younger age group in this study suggests an increasing trend of caries, with worsening of oral health outcomes among adolescents in Khartoum over the past decade.
      • Khalifa N.
      • Allen P.F.
      • Abu-bakr N.H.
      • Abdel-Rahman M.E.
      • Abdelghafar K.O.
      A survey of oral health in a Sudanese population.
      These are also in agreement with reviews from the African region indicating that there is a marked increase in the prevalence of caries affecting children as well as adults, and may be related to well-known issues of socioeconomics, lack of preventive efforts and dietary changes.
      • Organization W.H.
      Promoting Oral Health in Africa: Prevention and Control of Oral Diseases and Noma as Part of Essential Noncommunicable Disease Interventions.
      In this study, the DT accounted for 92% of the DMFT value as it had a 3.06 contribution to the mean DMFT, which may indicate an under-utilization of dental healthcare services. These results are similar to the other studies, finding the decayed component to be the major contributor to caries index scores.
      • Smadi L.
      Oral health status and behaviour in Jordanian adolescents aged 12–18 years.
      ,
      • Hou R.
      • Mi Y.
      • Xu Q.
      • et al.
      Oral health survey and oral health questionnaire for high school students in Tibet, China.
      In offering an explanation for the high DT rates, it has been suggested that almost 90% of cases of caries go untreated among the African people due to lack of financial affordability and unmet dental treatment needs.
      • Organization W.H.
      Promoting Oral Health in Africa: Prevention and Control of Oral Diseases and Noma as Part of Essential Noncommunicable Disease Interventions.
      Moreover, it is suggested that the burden of African life outweigh the need to seek treatments for dental caries.
      • Organization W.H.
      Promoting Oral Health in Africa: Prevention and Control of Oral Diseases and Noma as Part of Essential Noncommunicable Disease Interventions.
      ,
      • Jessani A.
      • Quadri M.F.A.
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      • et al.
      Oral health status and patterns of dental service utilization of adolescents in Lesotho, southern Africa.
      In this study, the periodontal health was assessed using the highest CPI score and revealed that the most frequently observed condition was calculus with or with-out bleeding. This is comparable with results from different regions in Sudan, where calculus was found to be the most prevalent periodontal manifestation among Sudanese adults using different periodontal indices.
      • Khalifa N.
      • Allen P.F.
      • Abu-bakr N.H.
      • Abdel-Rahman M.E.
      • Abdelghafar K.O.
      A survey of oral health in a Sudanese population.
      ,
      • Yousif M.A.
      • Miskeen E.I.
      Prevalence and management of periodontal diseases in Gezira province (Central Sudan).
      What remains of great concerns is the high proportion of adolescents with calculus in this study as well as the lower prevalence of those who have healthy periodontal tissues compared to previous reports among the older age groups of 35–44 years (79.5% vs. 42.0%, and 6.0% vs. 36.1%, respectively)
      • Khalifa N.
      • Allen P.F.
      • Abu-bakr N.H.
      • Abdel-Rahman M.E.
      • Abdelghafar K.O.
      A survey of oral health in a Sudanese population.
      marking a possible worsening of effective oral hygiene practices among the Sudanese population. Furthermore, significantly poorer periodontal health was reported among male participants and public schools' attendees in this study. Others have reported male-gender as risk of poorer periodontal health, attributing it to gender-related differences in hygiene behaviours and practices rather than true biological differences between the sexes.
      • Elamin A.M.
      • Skaug N.
      • Ali R.W.
      • Bakken V.
      • Albandar J.M.
      Ethnic disparities in the prevalence of periodontitis among high school students in Sudan.
      Maternal education was found to be a protective factor for periodontal health in this population. Several studies have shown that parental educational level, in particular the mother's education, to significantly influencer their children's oral health status.
      • Fisher-Owens S.A.
      • Gansky S.A.
      • Platt L.J.
      • et al.
      Influences on children's oral health: a conceptual model.
      In theoretical framework involving predictors of children's oral health that were grouped into community- family- and child-level influences, the authors demonstrated the critical importance of the familial factors in determining the children's oral health.
      • Fisher-Owens S.A.
      • Gansky S.A.
      • Platt L.J.
      • et al.
      Influences on children's oral health: a conceptual model.
      The participants' periodontal health status assessed by attachment loss in this study found fewer young participants having shallow pockets (score 3), and no deep pockets (periodontal pocket ≥6 mm) were recorded. This is in agreement with previous report assessing periodontal status of 12 and 15-year-old Greek adolescents, where the majority had calculus with or without gingival bleeding, and the occurrence of shallow and/or deep periodontal pockets was very low (0.2%).
      • Vadiakas G.
      • Oulis C.
      • Tsinidou K.
      • Mamai-Homata E.
      • Polychronopoulou A.
      Oral hygiene and periodontal status of 12 and 15-year-old Greek adolescents. A national pathfinder survey.
      Conversely a higher prevalence of attachment loss were reported among 15- to 17-year-old students in Sudan, where 16.3% and 8.2% of the subjects had at least one tooth with ≥4 and ≥ 5 mm attachment loss, respectively.
      • Elamin A.M.
      • Skaug N.
      • Ali R.W.
      • Bakken V.
      • Albandar J.M.
      Ethnic disparities in the prevalence of periodontitis among high school students in Sudan.
      Nevertheless, it is argued that the CPI system may either underestimate or overestimate the prevalence and severity of periodontal parameters.
      • Baelum V.
      • Manji F.
      • Fejerskov O.
      • Wanzala P.
      Validity of CPITN's assumptions of hierarchical occurrence of periodontal conditions in a Kenyan population aged 15–65 years.
      Hence the direct comparison of the present findings for bleeding and calculus with findings from other studies must be interpreted with caution.
      • Darout I.A.
      • Albandar J.M.
      • Skaug N.
      Periodontal status of adult Sudanese habitual users of miswak chewing sticks or toothbrushes.
      Our finding that those who visit dentists regularly have a higher DMFT is in agreement with studies suggesting that dental services utilization practices maybe more focused on treatment rather than on dental caries prevention.
      • Lu H.-X.
      • Wong M.C.M.
      • Lo E.C.M.
      • McGrath C.
      Risk indicators of oral health status among young adults aged 18 years analyzed by negative binomial regression.
      In this study, toothbrushing with toothpaste together with the use of Misswak were the most common reported oral hygiene practices. The affordability of toothbrushes and Misswak, and the fact that they don't require a high level of skill compared to other modern methods such as a flossing may explains these oral hygiene practices among the participants.

      5. Conclusion

      The oral health status of Sudanese high school students signals a pending oral public health crisis. In this study, the main risk factor associated with dental caries was increased age, while male-gender adolescents had significantly higher CPI scores. Public school attendees had significantly higher rates of dental caries and CPI scores. The significant associations between participants' oral health status and their gender, school-type and age may suggest considering these risk groups when designing schools’ oral health programs. The lack of preventive efforts and collapsing oral health system raises considerable fears that the dental caries is likely to rise, especially among adolescents. This imposes a need for adopting for a school-based health promotion approaches that are cost-effective, sustainable and that includes a mix of preventive and curative care.

      Ethical approval

      This study received full ethical approval from Sudan Medical Specialization Board (SMSB).
      Approvals were also obtained from schools’ managements. Prior to participation written consents were obtained from all participants, and parents/guardians. Only consenting participants were included in the study.

      Funding statement

      This research received no specific grant from any funding agency.

      CRediT authorship contribution statement

      Hajir Omara: Conceptualization, Methodology, Software, Formal analysis, Investigation, Data curation, Writing – original draft. Amal Elamin: Software, Validation, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision.

      Declaration of competing interest

      The authors declare no conflicts of interests.

      Acknowledgements

      We thank the students, schools' managements/staff for participating in this study. We would also like to thank Dr. Elsadig Eltayeb for his guidance.

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