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Rodan et al.

BMC Res Notes (2015) 8:662

DOI 10.1186/s13104-015-1532-y


Prevalence andseverity ofgingivitis

inschool students aged 611years inTafelah
Governorate, South Jordan: results ofthe survey
executed byNational Womans Health Care
RaniaRodan1, FeryalKhlaifat2, LeenaSmadi3*, ReemAzab4 andAsmaAbdalmohdi5

Background: A cross-sectional census was conducted on 994 public school students aged 6-11years living in 3
different parts of Tafeleh GovernorateSouth of Jordan, to determine the prevalence, and severity of gingivitis and
to evaluate the oral hygiene habits among them as a part a survey executed by National Womans Health Care Center.
All students were examined for gingival index (GI) and plaque index (PI), information about oral hygiene habits was
Results: Only 29.8% had healthy gingiva, 38.5% had mild gingivitis, 31.4% had moderate gingivitis, and 0.3% had
severe gingivitis. The difference between both genders was not statistically significant P>0.05. 36.8% of the exam-
ined students never brushed their teeth. Average gingival index (GI) and average plaque index (PI) were 0.77 and 0.61
Conclusions: Fair oral hygiene with mild to moderate gingivitis is highly prevalent among Tafelah school children.
This study indicated that oral health status among schoolchildren in Tafelah is poor and needs to be improved. Long-
term school based oral health education programme is highly recommended.
Keywords: Gingivitis, Prevalence, Oral hygiene, Gingival index, Plaque index

Background least twice a day. In addition to improved oral hygiene,

Periodontal diseases are the ones of the most prevalent which prevents periodontal diseases, frequent brushing
oral diseases that get its roots early in childhood [1, 2]. As with fluoride toothpaste increases the resistance of denti-
a consequence of these diseases, if they are not treated on tion to dental caries [4, 5].
time, the destructive processes are progress in both solid Tooth brushing and other behaviors that comprise
and soft tissues together with losing teeth [3]. young peoples lifestyles may directly or indirectly
Adequate daily removal of dental plaque prevents peri- impinge on their health in the short or long term. Most of
odontal diseases and dental caries [3]. The most common behavioral patterns were established in early childhood.
and effective way to promote oral hygiene is tooth-brush- Oral health behavior may constitute an integral part of an
ing; therefore brushing is recommended to be adopted as individuals lifestyle. It is essential to develop an effective
a habit, which is repeated every morning and evening, at education programs for oral health and practice targeted
at young people.
*Correspondence: Periodontal diseases including gingivitis and periodon-
Department ofConservative Dentistry, University ofJordan, P.O titis are serious infection that if left untreated can lead
Box855066, Amman11855, Jordan to tooth loss. Gingivitis is reversible with professional
Full list of author information is available at the end of the article

2015 Rodan etal. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(, which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Rodan et al. BMC Res Notes (2015) 8:662 Page 2 of 7

treatment and good oral home care, whereas periodon- The Oral Health Survey (OHS) 2014 for students aged
titis is irreversible as this progress with destruction of 611years of age was conducted at Tafelah Governorate
bone. Untreated gingivitis can advance to periodonti- schools (south of Jordan) to obtain relevant informa-
tis. Hence if gingivitis and periodontitis are assessed in tion on both the oral health condition of the students in
an early stage it will minimize the chance of tooth loss. this underprivileged area of Jordan and to assess the oral
Epidemiological studies are helpful in planning and health related behaviors of the students in this area. The
implementing oral health programs. This would help in survey focuses on two most common but preventable
combating these diseases. oral diseases, tooth decay (dental caries) [8] and gum dis-
According to the World Health Organization (WHO), ease (periodontal disease), which affect many students; in
oral health is integral to general health and essential for this article we will review the results of gum disease part
well-being [6]. Surveillance of oral health on community of the survey.
level thus has to be done at regular intervals.
One of the tasks of the Jordanian National Womans Methods
Health Care Center is to assess the health status and The survey methodology comprised of a series of field-
needs of the underprivileged communities throughout work surveys which were conducted from October 2013
Jordan by collection and interpretation of reliable health through March 2014. The survey includes students aged
information. 611 years of age in six public schools within the gov-
Tafelah is one of these communities, (Fig.1) it is a gov- ernorate (distributed between all districts).The schools
ernorate in south of Jordan with a population estimated selection was based on the two largest schools per dis-
by the Department of Statistics of Jordan at the end of trict, these schools include classes with mixed gender
year 2012 to be 89,400, which account for 1.4% of Jordan (grade 1grade 4) after which mixed classes are not
Population (of them 45,500 males and 43,900 females). allowed and male students have to move to a boys only
Tafelah is divided into three districts: Tafelah District schools, all students examined after grade 4 were girls
(62.3% of population), Bsaira District (25.7%) and Hasa (age group 1011).
District (12%). The study protocol was approved by the ethical com-
The number of schools in Tafelah is 48, 41 of them are mittee at Ministry Of Health. Due to many logistic bar-
for boys and rest are for girls accommodate 26,548 stu- riers it was difficult to get written parents permission for
dents (13,085 girls and 13,463 boys). The population of each examined student individually, though all parents
Tafelah is served by 16 dental clinic distributed through- were informed by a letter sent with their children inform-
out the governorate [7]. ing them of the screening and examination which will be
done as part of Ministry of Health, Ministry of Education
and the National Women Health Care cooperation pro-
gramme. We did not have any single refusal or objections
from students parents; the ethical committee was satis-
fied with this arrangement.
The clinical examination was carried out by three
dentists (examiners) all through the survey. The clini-
cal judgment differences were minimized through
pre- survey training for all examiners to homogenize
and standardize the examination. Information on the
behavior of students was collected using a questionnaire
which was completed by the students themselves with
the assistance of specially trained dental nurse. Before
the survey, the draft questionnaire was pre-evaluated by
dentists and dental care nurses working for the School
Dental Care Service of the Ministry of Health. Sev-
eral revisions were made on the questionnaire before
it was finalized. Students were examined in a mobile
dental clinic which is fully equipped with all the neces-
Fig.1 Tafelah Province: this map shows the location of Tafelah prov-
sary examination instruments, cross infection control
ince within Jordan, it shows also the relative size of this province to methods.
the total size of Jordan. Source In the process of the research, all the schoolchildren
dia/commons/2/25/Tafilah_in_Jordan.svg were interviewed according to a standard questionnaire
Rodan et al. BMC Res Notes (2015) 8:662 Page 3 of 7

(Additional file1). Clinical examinations were carried out Results

according to World Health Organization (WHO) meth- Demographic data
ods [9]. A mouth mirror and a WHO ball-tip probe were The sample population was 995 students, 64 % of them
used for the examination. Oral plaque was estimated by were females distributed almost equally over the three
running the side of the probe along the teeth surfaces. districts, and the students were examined in the 6 schools
The children were examined for oral hygiene status, of the three districts.
gingival conditions and dental caries. Oral hygiene was
evaluated by examining the dental plaque present on Oral hygiene behavior andstatus
the inner and outer aspects of the six index teeth, using Figure 2 shows that 36.8 % of the interviewed students
the criteria of the plaque index of Silness and Le [10]. stated that they never brushed their teeth, 19.4% brush
The six indexed teeth are: upper right first molar, upper their teeth once per day, 34.8 % twice daily, 9.0 % three
right lateral incisor, upper left first premolar, the lower times a day. According to plaque index 34.5% was con-
right first premolar, the lower left lateral incisor and first sidered to have good oral hygiene (plaque index 0.0),
molar. Missing teeth are not substituted. The gingival 61.5% was considered to have Fair oral hygiene (plaque
condition was determined for the same teeth using the index 0.1-1.9) and 4.0% was considered to have bad oral
criteria of the gingival index of Le and Silness [11]. hygiene (plaque index 2.03.0). (Figure 3) The mean
Table1 shows the criteria used for plaque index accord- plaque index was 0.61 0.57 for the whole sample, the
ing to Silness-Le. difference between both genders was not statistically
Objective research was performed evaluating the state significant.
of oral hygiene during the examination as follows: Good
(plaque index 0.0 i.e. absence of plaque), Fair (plaque Oral health status
index 0.11.9 i.e. presence of plaque) Bad (plaque index Among the students examined 70.2 % had gingivitis.
2.03.0 i.e. plaque seen by naked eye) [12]. According to gingival index 29.8 % had healthy gingiva,
The gingival index, given by Le and Silness [9] was 38.5% had mild gingivitis (GI 0.11.0), 31.4% had mod-
used for recording the severity of gingivitis. Gingival erate gingivitis (GI 1.12.0), and 0.3% had severe gingi-
index, given by Loe and Silness 1963 measures severity vitis (GI 2.13.0). (Figure4) The mean gingival index was
of gingivitis on a scale ranging from 0.1 to 3.0 (0.11.0: 0.770.68 for both genders.
mild gingivitis, 1.12.0: moderate gingivitis, and 2.13.0:
severe gingivitis) [13, 14]. Discussion andconclusions
Table 2 shows the criteria used for gingival index In Jordan very few studies looked at oral health among
according to Le and Silness 1963. school children, all of them neither examined oral health
Statistical analysis The analysis of the data was per- at neither south of Jordan nor studied specifically preva-
formed using SPSS 20.0 for Windows (SPSS Inc., Chi- lence of gingivitis in primary schools [1518].
cago, IL, USA).

Table1 Criteria used forplaque index (PI)

Score Criteria

0 No plaque
1 A film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may be seen insitu only after appli-
cation of disclosing solution or by using the probe on the tooth surface
2 Moderate accumulation of soft deposit s within the gingival pocket, or the tooth and gingival margin which can be seen with the
naked eye
3 Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin

Table2 Criteria used forgingival index (GI)

Score Criteria

0 No inflammation
1 Mild inflammation, slight change in color, slight edema, no bleeding on probing
2 Moderate inflammation, moderate glazing, redness, bleeding on probing
3 Severe inflammation, marked redness and hypertrophy, ulceration, tendency to spontaneous bleeding
Rodan et al. BMC Res Notes (2015) 8:662 Page 4 of 7

40 45
35 40 38.5

30 35
25 30

% 20 19.4
% 25

15 20

10 9

5 10

0 5
Never Once/Day Twice /Day Three me/Day
Frequency of teeth brushing 0.3
Fig.2 Frequency of teeth brushing. The frequency of teeth brushing Normal Mild Gingivis Moderate Gingivis Sever Ginigivis

as reported by students extracted from their answer using a pre- Gingival Status
prepared questionnaire Fig.4 Gingival status according to gingival index (GI). The Gingival
status is demonstrated using the gingival index (GI) for all students
examined during the survey, the status was classified as Normal, Mild
61.5 Gingivitis, Moderate Gingivitis, and Sever Gingivitis


40 34.5
school children of older age group of 1115 have also
showed that>50% of them complaining of gum bleeding
[19]. In Kaunas a survey have shown that 59.6% of school
4 children aged 68 suffered of light gingivitis [20]. In Teh-
0 ran it was shown that 87.7% of schoolchildren aged 913
Good Fair Poor
Oral Hygiene status
had gingivitis [21]. On the other hand a survey on perio-
Fig.3 Oral hygiene status according to plaque index (PI). The oral dontal status of Greek 12years old population has shown
hygiene status is demonstrated using the plaque index (PI) for all that 41.5%had bleeding on probing [22]. Gingival bleed-
students examined during the survey, the status was classified as ing was found in 32.8% of the childrenaged 612years
Good, Fair and Poor from the Danube Delta Biosphere Reserve [23].
Gingival index and plaque index were chosen for this
study as it has been widely used to evaluate the level
The present study is among the foremost efforts to gingival inflammation and the level of oral cleanliness
determine the oral behaviors and prevalence and severity in epidemiological studies [14]. This relatively simple
of gingivitis in school children aged 611 in one of the assessment is fairly reproducible, easy to use since the
most unprivileged areas of Jordan. criteria are objective and the examinations can be carried
This survey was also conducted to assess the need out quickly with a high level of reproducibility and with
to start a local campaign to raise the public aware- minimum training.
ness for oral hygiene and the need to modify polices for This study revealed that the mean plaque index and
early access to preventive dental services among school gingival index for the total subjects was 0.61 and 0.77
children. respectively. Those results were interpreted that school
The results of this surveys shows that 69.9% of school children of this age group 611 had fair oral hygiene with
children aged 6-11 had gingivitis of mild to moderate mild gingivitis. Regarding gender variations, the differ-
severity. Those results are similar to the results of other ence was statistically non-significant, (p = 0.636 for PI
parts of the word of similar cultural and socioeconomic and 0.790 for GI) between both genders. These findings
status. A recent survey in Lucknow/India of school chil- disagreed with earlier studies in 1314 year old North-
dren aged 816 have shown that 71.11% of school chil- ern Jordanian schoolchildren that reported plaque index
dren aged 810 suffered of gingivitis of mostly mild to scores were 1.82 and 1.63 during 1993 and 1999 respec-
moderate severity [13]. Another survey on Lithuanian tively [24]. Furthermore, gingival index scores reported
Rodan et al. BMC Res Notes (2015) 8:662 Page 5 of 7

in the same study [24] were 1.89 in 1993 and 1.67 in private schools [27] and in lower socio-economic back-
1999 which were also higher than the figure found in ground when compared to a higher socio- economic
this study. A more recent study took place in 2006 for background [26]. As all the surveyed students were from
1415 year old schoolchildren in Jerash district and public schools and almost of similar socio- economic
reported a plaque index score of 1.46 and gingival index background this factor was not investigated in our survey.
score of 1.56 [15]. But these results are still higher than Oral health education is an important aspect. All stu-
results obtained in this study. The higher results can be dents should get at least one oral health education les-
explained by the difference in the age group, a previous son with a supervised tooth brushing exercise every
cross-sectional study of gingival health status among school year. Oral health education sessions should be
5- and 12-year-old children in Yemen showed increased organized for parents and pregnant mothers and dental
prevalence and severity of gingivitis in a 12 years old health education programmes should be conducted for
children when compared to a 5 years old children as schoolteachers.
the plaque index increased as well [14]. Regarding gen- Post-intervention 9 months oral health education on
der variations, a previous study that described trends oral hygiene knowledge, practices, plaque control and
in oral health in Jordanian male and female schoolchil- gingival health of 13- to 15-year-old school children in
dren, showed that boys had higher plaque and gingival Bangalore city, there was significant improvement in
scores than girls within this age group. This gender dif- oral hygiene knowledge and practices in experimen-
ference with regard to plaque and gingival scores may be tal groups. There were significant reductions in mean
related to the patterns of personal oral hygiene, hormonal plaque index and gingival index scores in the experimen-
changes occurring during puberty and grooming effect at tal groups [28]. Plaque and Gingival score reductions
this age [24]. Another study found that girls scored more were highly significant after a school dental educa-
favorably on behavioral measures, showed more interest tion program in improving oral health knowledge and
in oral health, and perceived their own oral health to be oral hygiene practices and status of 12- to 13-year-old
good to a higher degree than did boys [19]. Those gender school children, and were not influenced by the socio-
differences were not obvious among school children sur- economic status. When oral health knowledge was
veyed in this study. evaluated, highly significant changes were seen in inter-
With regard to hormonal changes occurring during vention schools; more significantly in schools receiving
puberty that affect the gingiva, several cross-sectional more frequent interventions [29]. A cluster randomized
studies have demonstrated an increase in gingival inflam- controlled trial education programme for 6-year-olds
mation without an accompanying increase in plaque lev- concluded that oral hygiene instruction to 6-year-old
els during puberty [25]. children and their parents improves their dental health
Tooth brushing is not common or routinely practiced [30].
in schoolchildren in Tafelah. The proportion of children Prevention and treatment of early stages of periodon-
reported to be brushing at least once to twice per day tal diseases are relatively simple and very effective. In
was 54.2 % in the Tafelah health survey. Although there many cases it is enough to have the social education and
is good evidence to recommend tooth brushing twice instructions for correct and regular oral hygiene. The
daily for control of plaque and gingivitis [5], 36.8 % of preventive component of lifestyle should be induced and
611year-old children reported that they never brushed accepted at a young age. Epidemiological investigations
their teeth. Routine dental visits are not a habit for the of periodontal status and oral hygiene are an important
children in Tafelah. Results showed that 85.9 % of the part of such preventive program.
surveyed school children had never been to a dentist.
Unlike the results of this survey where frequency of Information provided by the present study can be used
teeth brushing was similar in boys and girls several other as preliminary data and further large scale epidemio-
epidemiological surveys have shown that the factor most logical studies can be under taken to assess and con-
consistently associated with teeth brushing and other firm other dental diseases and their associated risk
oral hygiene habits frequency was gender. Girls were factors in Tafelah, Jordan. School dental health pro-
more concerned about their personal hygiene than boys. grams and dental camps at school level are necessary
They have also shown the importance of social-eco- in this region and they should be conducted at regu-
nomic background for determining childrens tooth lar intervals, because children in this region do not
brushing behavior [26]. Children from rural areas have accessed to standard dental care and treatment.
reported higher percentage of inadequate oral hygiene Because schools children do not know much about
than children from urban areas [19]. Similar results were dental diseases, methods of their prevention and to
also demonstrated in public schools when compared to maintain proper oral hygiene, therefore education and
Rodan et al. BMC Res Notes (2015) 8:662 Page 6 of 7

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