Managing dental caries in children in Turkey - a discussion paper
BMC Oral Health
Managing dental caries in children in Turkey - a discussion paper
Asli Topaloglu-Ak 1
Ece Eden 1
Jo E Frencken 0
0 Nijmegen International Centre for Oral Health, Radboud University Nijmegen Medical Centre, College of Dental Sciences , Nijmegen , the Netherlands
1 Department of Paediatric Dentistry, Ege University , Bornova, Izmir, 35100 , Turkey
Background: This paper describes the oral healthcare system and disease situation amongst children in Turkey. Considering the high prevalence and severity of dental caries, a proposal for improvement of oral health in this population group is formulated. Discussion: A virtual absence of palliative, preventive and restorative care characterises juvenile oral healthcare in Turkey. Consequently, carious cavities remain untreated, which may lead to pain, discomfort and functional limitation and, further, may impact negatively upon general health and cognitive development. As a first step to controlling dental caries, a national health programme including promotional, preventive and minimal intervention approaches for managing dental caries is proposed. The pros and cons of community-oriented caries-preventive measures are discussed. Daily tooth brushing with fluoridated toothpaste at home, in mother- and child-care centres, kindergartens, and schools is highlighted. Summary: The dental profession, government, university officials and other stakeholders need to meet and determine how best the oral health of children in Turkey can be improved. The present proposed plan is considered a starting point.
Worldwide, the contribution of dental caries to the
burden of oral diseases is about 10 times higher than that of
periodontal disease, the other common oral condition
. Owing to its globally high prevalence, dental caries in
children has been described as a 'pandemic' disease
characterised by a high percentage of untreated carious cavities
causing pain, discomfort and functional limitations .
Untreated carious cavities, furthermore, have a significant
impact on the general health of children and on the social
and economic wellbeing of communities  and are more
common in developing, than in developed countries .
In the latter, the low prevalence of dental caries is
predominantly due to children's intensive use of promoted
preventive oral health measures, supported by appropriate
curative care provided by an umbrella of accessible clinics
and affordable health insurance. In contrast, most
developing countries and those in transition lack the resources
and infra-structure required to provide children with the
necessary care and attention.
Turkey is a country in transition, whose economy has
grown tremendously during the last decade. Although the
proportion of the national budget allocated to healthcare
has been increased, however, there are signs that the
juvenile population suffers from the consequences of dental
This paper aims to contribute to the discussion on how
best to improve the management of dental caries in
children in Turkey. It begins with a situation analysis of the
oral health infra-structure, disease levels and utilization of
oral care, continues with a discussion of possible
solutions and concludes with some recommendations.
Oral healthcare infrastructure
Turkey is an upper-middle-income country with a
population of about 72 million people, 38% of whom lived in
rural areas. Those under the age of 15 constitute 28% of
the population . It has more than 22,000 active dentists
but no institutions for training auxiliary dental personnel.
Almost 1000 dentists graduate from the country's 20
dental schools annually . In 2007, 61% of the dentists
worked in private practices, 24% in government hospitals,
9% in university hospitals and 6% in other institutions
. Most newly graduated dentists find employment in
private practices, which are predominantly found in
urban areas but are unevenly distributed over the
country's 81 cities . Of the total dentist population, 20%
practise in stanbul, which has a dentist-population ratio
of 1:1978, whereas the highest dentist-population ratio of
1:1438 is found in the capital city, Ankara, where 5% of
the dentists reside. The city of anlurfa has the lowest
dentist-to-population ratio (1:12,980). The ratio in rural
areas is even lower. The average dentist-population ratio
in Turkey is 1: 3209 in 2008, which is much lower than in
most Western European countries .
Oral healthcare, like all other health services, is mainly
provided by the Ministry of Health, SSK (Social Insurance
Organization), universities, the Ministry of Defence,
private practitioners and paramedical professionals. The
number of private hospitals is low whereas not all of them
are providing oral health care. The organisation of health
service delivery needs to be improved.
Oral healthcare financing
For a long time there were three main sources of
healthcare financing in Turkey: the state, social security
institutions and direct payment by the patient. During the last
decades health insurance companies have emerged,
offering services throughout the country. This has resulted in
the private health insurance sector's having become the
country's most fast-developing insurance branch.
However, oral health treatments have rarely been included in
the package and the patient pays the private dental
Deficiencies of the health insurance systems, with results
such as unequal and unaffordable use of oral health
services, led politicians to call for the development of a new
health insurance system for all. The national health
insurance system was introduced in 2008 and covers oral
healthcare. It aims at decreasing the cost of health services
and encouraging preventive health practices. As part of the
introduced changes, some groups in the society are given
special preference: for example in oral health, children
aged between 5 and 15 years are entitled to apply to any
of the institutions and the private sector for orthodontic
treatments, restoration of teeth and root canal therapy on
first and second permanent molars, on demand. People
ineligible for participation in the national health
insurance but accepted as very poor are entitled to free oral
healthcare, with the exception of orthodontic and
prosthodontic treatment. However, the introduction of the
new insurance system has increased the demand for
dental services in state hospitals and clinics, resulting in long
waiting queues. Consequently, the rural population and
the urban poor experience difficulty in obtaining dental
services when they need them.
Utilization of dental services
It has been reported that the ordinary Turkish person does
not perceive oral health as important and considers it to
be of low priority . An adult survey of residents from 9
provinces revealed that only 40% had visited dental
facilities within the previous year . The predominant reason
for using the services was the occurrence of a dental
problem, less than 2% of adults having visited the dental
facilities for a routine check-up . The attendance pattern
among children was similar. The 2004 national oral
health survey revealed that 18% of 5-year-olds and 59% of
12- and 15-year-olds had visited a dentist . The main
reason among 5-year-olds was that they required a
checkup, while among 12-year olds (55%) and 15-year olds
(46%) it was the need for tooth extraction. In these ages,
the predominant motivation for attending dental clinics
It can be concluded that utilization of oral health services
among children and adolescents is low to medium, and
irregular. Seeking relief from pain/toothache is the main
reason given for visiting the dentist. The routine of going
for regular check-ups has not been established.
Cross-cultural studies have revealed that dental attitudes,
knowledge and behaviour are dependant upon cultural
beliefs and economic factors. The family structure in
Turkey is characterized by high parental control,
protectiveness and involvement with children . Very few studies
have been conducted on behavioural and cultural aspects
related to oral health in Turkey. It is generally accepted
that dental attendance rates increase with an increase in
the educational status of the people  and that mothers'
education levels play an important role in their children's
oral health. In Turkey women's primary role is to care for
the family and raise children. Their levels of dental anxiety
correlate positively with those of their children, so a child
may develop a high level of anxiety if the dental anxiety of
the mother is high . It is reported that women with
more than 11 years of education have fewer children than
those with less and achieve higher socioeconomic status
 and that a higher socio-economic maternal profile
positively affects the dental visit frequency, dental anxiety
and oral health of the children [10,11].
Turkey has not yet developed a system in which routinely
regular dental visits are the accepted norm. In addition,
oral health culture has not been developed either. It
appears, therefore, that the population needs to be
educated about the advantages of regularly visiting a dentist.
For the dental caries prevalence among the youth to be
reduced and their oral health to be improved, responsible
policymakers would need to develop and implement
appropriate oral health promotion and care programmes
for use in mother-and-child health centres, day-care
centres and primary schools. Links with the private sector,
which provides the lion's share of oral care in the country,
should also be established. Studies evaluating the
appropriateness and effectiveness of the oral care delivery
systems in the country are not currently available.
Oral health status of children
Few oral-health-related epidemiological surveys covering
children have been carried out. Most of these were
conducted in cities, in dental schools at universities, and
covered low numbers of participants [12-14]. Therefore, the
general information regarding the oral health status of
children in Turkey originates from the two national
surveys of 1988  and 2004 . The latter one was carried
out by the Ministry of Health in cooperation with
Hacettepe University. In both surveys WHO criteria [16,17]
were used in diagnosing caries respectively. The caries
prevalence and caries experience (dmft) in 6-year-olds in
1988 were 84% and 4.4, and in 5-year-olds in 2004 they
were 70% and 3.7, respectively. Both surveys found hardly
any restorations in these age groups. The caries prevalence
and caries experience (DMFT) of 12-year-olds were 84%
and 2.7 in 1988, and 61% and 1.9 in 2004. The care index
of the 12-year-olds was low: 11% in 1988 and 5% in
2004. Both studies show a high prevalence of dental caries
and a high caries experience among 5-6-year-olds and
12year-olds. Only 1% of 5-6-year-olds had had decayed
Characteristics of caries control in Turkey
Dental services in Turkey are mainly technically oriented.
A firm belief persists that caries control is achieved
through technical perfection in restorative care. For many,
caries management is still based on the currently outdated
paradigm that carious lesions can be treated through
mechanical methods only. Reference is made to the
principles of GV Black's cavity design and use of the 'extension
for prevention' concept. General dental practitioners in
Turkey do not frequently apply even the technically
preventive measure of sealing fissures, owing to a lack of
interest and insufficient knowledge . The traditional
restorative approach to managing dental caries has been
deeply integrated into the legislative and remuneration
systems, the dental school curricula and public
knowledge. Some dental schools have recently embraced the
modern cariology concepts but implementation of these
in practice is seriously hampered by the
restorative-oriented insurance system. They teach sealant and fluoride
application. It appears that not only do dental schools
need to change the emphasis in their curricula, from
traditional restorative care towards applied preventive and
modern restorative care concepts, but education should
also be further updated for the older graduates.
Oral health education and promotion
Oral health education (OHE) aimed at improving oral
health through the acquisition of knowledge, eventually
leading to motivation and finally, to behavioural change
according to the health belief model, has for decades been
considered the panacea that would provide people with
better oral health. OHE studies have been performed in
many countries [19,20] including Turkey [21-23].
However, accumulating evidence reveals that focusing on
individual behaviour, without giving attention to the
socioeconomic, cultural and ecological situations in which
people live, does not lead to improved oral health . It
appears that individuals do not easily change their
behaviour, because it is mainly determined by the environment
As sustainable benefits of OHE are not apparent and
comprehensive and OHE programmes are expensive in terms
of finance and human resources, the health authorities in
Turkey, as part of their oral health promotion strategies,
need to focus on pruning the OHE programmes in order
to provide essential information only.
Community-oriented evidence-based caries-preventive
In principle there are three ways to control carious lesion
development: by weakening promoting factors (e.g. sugar
consumption), by reinforcing protective factors (e.g.
fluoride) or by a combination of both. It is postulated that
behavioural changes regarding dietary habits at a national
level may be achievable through approaches similar to
those used in reducing smoking: strong regulation of food
labelling, restrictions on advertising of unhealthy food,
taxation of unhealthy food, legislation to control
unhealthy food, better accessibility to healthy food and a
of policies promoting twice-daily brushing of teeth with
fluoridated toothpaste .
The other determinant for caries control is fluoride.
Application of fluoride in various forms has shown dramatic
effects in reducing the prevalence and severity of carious
lesions. The oldest community-based fluoride delivery
system is water fluoridation. The carious-lesion-reducing
effect of water fluoridation, however, diminishes
considerably if fluoridated toothpaste is used on a daily basis
. Therefore, as no fluoridated drinking water is
available in Turkey and as it has been shown that caries levels
diminish when people brush their teeth daily with
fluoride toothpaste, introducing expensive water fluoridation
schemes is not considered the best way forward for
controlling dental caries development in the country .
Another community-based fluoride measure is salt
fluoridation. Early salt fluoridation trials, in Hungary between
1966 and 1976  and in Columbia between 1964 and
1972 , reported a reduction in carious lesions in
children when all salt for human consumption was
fluoridated. However, the evidence-based anticaries effect of
salt fluoridation still has to be ascertained .
Embarking on a country-wide introduction of salt fluoridation in
Turkey would therefore, not be advisable.
Encouraging daily tooth brushing with fluoride
toothpaste is also considered a community-based measure, but
compliance is a prerequisite for its effectiveness. A
systematic review of the effectiveness of fluoride toothpaste for
prevention of dental caries in children examined 74
randomized controlled trials and found, on average, a 24%
reduction in decayed, missing and filled tooth surfaces
(DMFS) in the permanent dentition of children aged 6 to
16 years . The effect of fluoride toothpaste increased
with higher baseline levels of DMFS, higher fluoride
concentration, higher frequency of use, and supervised
brushing. No significant differences were found between the
trials using sodium monofluorophosphate, stannous
fluoride, sodium fluoride, and amine fluoride as the active
The conclusion, reached after consideration of the pros
and cons of the above- mentioned community-oriented
caries preventive measures, is that brushing teeth daily
with fluoride toothpaste appears to be the best way of
reducing the development of caries lesions in children
and should therefore be strongly promoted. Brushing
teeth with fluoride toothpaste has the additional effect of
being beneficial for periodontal tissues, which no other
fluoride delivery method provides.
Another focus of attention for oral health authorities
should be on the development of an advocacy process and
The need for a new strategy for managing dental caries in
The new strategy should take the following into account:
The low level of access to and utilization of oral care;
The high level of dental caries and the high percentage
of untreated carious cavities in children;
These issues warrant the formulation of a clear and
feasible national oral health strategy focused on providing
basic oral care for all children, using the resources
Basic oral care for children
As has been argued above, the sequelae of untreated
carious cavities have significant and often underestimated
impacts on the wellbeing of children and communities.
The reality is that carious lesions do not seriously affect
children unless they cause pain, discomfort and
functional limitations. There is no doubt that carious lesions
should be treated preventively and if a cavity has
developed, appropriate restorative care should be rendered.
Traditional restorative dental treatment using rotary
instruments is expensive. It has been estimated that 5% to
10% of public health spending in high-income countries
is allocated to oral care, caries being the fourth-most
expensive disease to treat . Obviously, the costs exceed
the financial resources available in low- and
middleincome countries. What are the alternatives?
Extraction might be expected as a less expensive, easily
administered treatment for pain relief in children. Studies
have indicated that children with associated poor weight
gain had an increase in weight after tooth-extraction .
Significant improvement in the children's eating
preferences, quality of food eaten, social behaviour and sleeping
habits was also reported by their parents after tooth
extraction [36-38]. Therefore, extraction of painful
primary teeth should be considered an adequate treatment
for improving the general health of the child.
Nevertheless, it should be taken into account that early loss of
primary teeth such as incisors, causing aesthetic problems, or
of molars, causing space loss in the dental arch, may lead
to further problems. Extracting permanent teeth of
children should be avoided as far as possible; particularly
those teeth that affect appearance and speech (front teeth,
including the first and second premolars).
The preventive and curative caries management approach
of ART offers a suitable alternative to extraction of
children's teeth. Initial caries lesions, which mainly occur in
pits and fissures, can be treated with ART sealants, while
caries cavities can be treated with ART restorations . A
meta-analysis revealed a 6-year survival rate of 72% for
single-surface ART restorations, whereas the annual
dentine lesion development for ART sealants was only 1%
. In view of the above, the following components of
basic oral care for children are suggested:
a) Increasing availability of affordable and effective fluoride toothpaste;
b) Brushing of teeth with fluoride toothpaste at an early age, with parental help;
c) Participation in daily programmes of brushing teeth with fluoride toothpaste, to stimulate the habit of tooth-brushing in a community;
d) Restoration or extraction of carious cavities in primary teeth whenever needed;
e) Use of the ART approach as the first option for managing carious lesion development preventively and restoratively;
f) Adoption by private practitioners, of modern oral care concepts that render treatment in a child-friendly way and encourage children and parents to consult dental professionals;
g) Increasing of the oral health budget, by the govern
ment, to finance wider coverage of oral healthcare
services for children. Representatives of the
government, the dental association and the health insurance
companies should reassess the dental insurance
system and include remuneration for promotional and
preventive oral health services.
These suggested components of a basic oral care
programme for use in children in Turkey are further discussed
Recommendations for achieving improved dental health
a) Increase the availability and usage of affordable and effective
Fluoride toothpaste is available to a large section of the
population. In recent years quality checks have been
performed in a number of countries on the freely available
ionisable fluoride in toothpaste. Results have shown that
not all fluoride toothpastes contain sufficient amounts of
freely available fluoride to be effective in controlling
carious lesion development . Setting up an independent
system of quality control regarding the efficacy of fluoride
toothpaste in Turkey would therefore be advisable. The
recommendations specified in the WHO Basic Package of
Oral Care could serve as a guide . Affordability of
fluoride toothpaste to consumers could be improved by
stimulating local manufacturers to produce low-cost
fluoride toothpaste and by introducing a government tax
reduction or exemption.
b) Promote daily brushing of teeth with fluoride toothpaste
It will take some time for all Turkish children to get used
to brushing their teeth with fluoride toothpaste daily.
Therefore, this preventive measure should receive ample
attention and needs to be vigorously advocated from the
start. As parents will need to support children in brushing
their teeth, an approach encouraging the whole
population to brush their teeth twice daily should be the first
priority. This advocacy process should be a concerted effort
involving the dental profession, the government, the
toothpaste industry, consumer associations and other
c) Stimulate the habit of daily tooth brushing with fluoride toothpaste in mother- and child- health centres, day-care centres and kindergartens
The introduction of programmes encouraging daily
toothbrushing with fluoride toothpaste in mother- and
childhealth centres, day-care centres and kindergartens is
considered essential for promoting tooth-brushing behaviour
in children and in the rest of the population. Mothers with
small children are an important target group for the
promotion of daily tooth-brushing with fluoride toothpaste.
The rationale behind prioritizing oral healthcare for small
children is that because they are at the beginning of their
lives, the chance for preventing of disease and establishing
lifelong healthy habits will be maximized . The
promotion of self-care and prevention at the earliest age
possible has a dramatically beneficial effect on caries levels
later in life . Midwives and nurses regard themselves
as important healthcare providers and are also highly
respected by the mothers. These health personnel could
play an important role in conveying the oral health
message of the importance of brushing teeth daily with
fluoride toothpaste at an early age . In kindergartens and
day-care centres, caretakers could supervise daily
toothbrushing with a pea-sized amount of fluoride toothpaste.
The parents should be encouraged to ensure routine
dental checkups, starting as early as possible. Nurses and
caretakers of pre-school children should be trained to
recognize toothache in young children, so as to be able to
inform parents when a visit to a dentist is needed.
d) School health programmes
The 2007 WHO resolution on oral health includes an
article entitled "develop and implement the promotion of
oral health and prevention of oral diseases for preschool
and schoolchildren as part of activities in health
promotion schools". It explicitly calls on governments to engage
actively in implementing the resolution. School-based
OHE should be integrated into the broader frame of
health promotion, according to the Ottawa Charter .
Since oral diseases share many risk factors inherent in
other diseases , diet, hygiene, smoking, alcohol use,
exercise and trauma are issues to be addressed by a
school's health team. The Health Promotion Schools'
Programme  emphasises a range of policies that create a
healthy environment not only for students, but also for
staff and the community. Such approaches have shown
significant gains in a range of oral health outcomes,
including caries and dento-facial injuries [49,50]. Their
success is highly dependent on the participation of the
community. Teachers, parents, and school and health
authorities should participate in the planning,
implementation and review processes of programmes like the
Health Promotion Schools' Programme. In Indonesia and
China daily kindergarten- and school-based programmes
of tooth-brushing with fluoride toothpaste have shown a
resultant 23-43% reduction in carious lesions [51,52].
Basic oral care for children requires that painful and
infected primary teeth be treated; not neglected as they
currently are. The ART approach of preventing and
restoring initial and early cavitated caries lesions in primary and
permanent teeth should be provided in primary schools.
Studies in Turkey have shown that ART restorations can be
performed adequately in schools  and are on a par
with composite resin restorations [53,54]. These results
indicate that expensive rotary equipment is not needed to
provide preventive and restorative care as part of basic oral
care for schoolchildren. MID is certainly less costly than
traditional dentistry  and is provided in a
childfriendly way [56,57]. However, the number of studies
having assessed the effectiveness of OHP programmes is
e) Application of Minimal Intervention Dentistry (MID) by Dentists in Private Dental Clinics
Most dental care delivery to children and adults occurs in
the consulting rooms of dental practices. If the oral health
of children is to improve, dentists need to provide
promotional, preventive and restorative care in a manner
acceptable to the child. This implies, for example, that dentists
should not necessarily use outdated traumatizing
restorative techniques but should resort to modern approaches
that are adequate and atraumatic for the child. Modern
treatment approaches follow the principles of MID. This
concept is based on understanding the biological
approach to carious lesions and consists of accurate
diagnosis, application of preventive measures, periodic
monitoring and determination of the individual's risk status.
When there is cavitation, an invasive operative approach
is unavoidable. The focus must then be directed towards
removing only infected dentine, while leaving affected
dentine behind for remineralisation. Therefore, within
MID, Black's standard cavity designs are redundant, as is
the total removal of a defective failed restoration. The
defective part of the restoration can be repaired instead.
The standard dental clinic is equipped with rotary
machines. Studies have shown that many children are
afraid of these [56,58]. Therefore, the use of the drill
should be avoided as much as possible and less traumatic
devices, such as hand instruments and chemomechanical
caries removal gel, should be used instead. One suitable
method is ART, which aims to treat carious cavities by
using hand instruments. ART (which is in line with MID)
can be used by dentists in modern dental clinics in Turkey,
as it has been in other developed countries such as the UK
, the USA  and the Netherlands , as an
alternative to the conventional approach . This less
traumatic, child-friendly approach could also help to
overcome dental anxiety in children, which is often
triggered by traditional invasive operative treatments [56,62].
If dentists in private practice would adopt MID,
universities stop teaching traditional restorative approaches only
and offer postgraduate academic courses on MID, oral
health for an increased number of children in Turkey
could become a reality.
An effort has been made to improve the oral health of
children in Turkey through describing the current oral
health situation and through using evidence-based
alternatives to the prevalent failing methods of providing oral
care. The time is now ripe for the dental profession, the
Turkish Dental Association, the government, university
officials, and other stakeholders to discuss the current
plan, make adjustments and agree on a set of guidelines
that would make the plan work. One obvious aspect of a
positive strategy would be a move from the current way in
which oral health services are directed to children,
towards preventive and promotional activities under the
umbrella of Minimal Intervention Dentistry. The
prevailing oral health strategies should be abandoned, as they
have been shown to be not very beneficial to children.
The authors declare that they have no competing interests.
ATA, EE and JEF altogether collected the dental literature
and wrote the manuscript. All authors read and approved
the final manuscript.
We are very grateful for the contribution made by Prof. W.H. van
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