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International Dental Journal (2004) 54, 367–372
Oral health in Iran
Hamid Reza Pakshir
Shiraz, Iran
The health network in the Islamic Republic (I.R.) of Iran is an integrated
public health system with a four-level Dental Health Care System integrated
into it by 1997. The first level is one of primary prevention at ‘health houses’,
at the next, oral hygienists and dentists in health centres perform basic oral
health care services such as fillings, scaling and extractions. At the third
level, dentists manage and treat oral diseases in ‘urban health centres,
while the last level is for advanced treatment by specialists in university
health centres in the big cities. There are about 13,000 dentists nationwide
(1 dentist: 5,500 population) and nearly 1,200 specialists in universities and
private practices. Data from surveys in the past two decades, show a
marked decline in dental caries from DMFT of 4 to 1.5 in 12-year-old
children. However, the general level of oral health is still not satisfactory,
particularly among children. The percentage of caries-free children (deciduous and permanent teeth) among 6- and 9-year-olds is 13.8 and 11.5
respectively and more than 50% of 12-year-old children have caries experience, with the decayed component being the greatest component. The
main objective would be to cope with the dental caries problem in primary
teeth and, in this respect, the national oral health plan should be aimed at
developing oral hygiene skills, reducing the frequency of sugar intake,
instituting water fluoridation, improving access to fissure sealants and
regular dental care, and finally promoting dental health services toward
minimum treatment intervention and effective preventive strategies and
health promotion.
Key words: Oral health status, oral health planning, caries, Iran
The Islamic Republic of Iran,
covers an area of approximately
1,648,000 km2, in southwest Asia.
The Middle East region, is divided
into 28 provinces, 285 districts and
over 66,000 villages. The country
has a population of more than
71,000,000 people, nearly 60% of
whom live in urban areas. Approximately 52% of the population is
under 20 years of age, making Iran
one of the youngest countries in
the world1.
Oral and dental services
Dental services are provided by
both public and private sectors. In
the rural areas, which include 40%
of the country’s population, oral
health services are mostly delivered
by the governmental sector (70%),
while 80% of the service delivery is
offered by private sector in the
cities1.
In the rural areas and small
towns, the services are offered by
oral hygienists. They are selected
from local communities and trained
for three years in special dental
schools in oral health education,
simple fillings, scaling and extractions. A total of 2,000 oral hygienists were returned to their local
rural communities during 1981–
1993 to serve the people for at
least for six years2.
Primary health care structure
Correspondence to: Dr. Hamid Reza Pakshir, Shiraz University of Medical Sciences,
Dental Faculty, Orthodontic Department, Shiraz, Iran. E-mail: [email protected]
© 2004 FDI/World Dental Press
0020-6539/04/06367-06
The health network in I.R. of Iran
is an integrated system. In 1972,
Iran collaborated with the World
Health Organisation (WHO) to
streamline health care delivery into
368
Figure 1. The Structure of PHC Network in Iran
four levels: health houses, rural
health centres, urban health centres
and district centres. After 1979, the
Ministry of Health and Medical
Education designed the new health
system based on the Primary Health
Care (PHC) network3 (Figure 1).
A Health House is the basic
rural facility, covering a population
of 1,500 and has between two and
five satellite villages. Each health
house is staffed by a male and a
female health worker, called
‘Behvarz’, who offer PHC services
to the population in the area
including maternal child care,
family planning, diagnosis and
follow-ups, limited symptomatic
treatment, environmental and
occupational health, school health,
oral health and health education
and nutrition promotion. Behvarzes
are selected from among young
and interested residents and are
trained for two years at a Behvarz
Training Centre. At present, there
are nearly 15,000 health houses,
and 35,000 Behvarzes in the
villages, covering 85% of the rural
population2,4.
A Rural Health Centre is a
village-based facility staffed by a
physician, health technicians and aid
nurses. It covers a population of
7,500 and provides supervision to
three to six health houses. These
centres receive referrals from health
houses and provide preventive,
health promotion and curative
care2.
An Urban Health Centre, which
has nearly the same responsibility
and personnel as a rural health
centre, covers a population of
approximately 50,000–60,000 urban
inhabitants. These centres receive
referrals from health posts and are
supervised by the staff of District
Health Centres3.
A Health Post, which is staffed
by family health technicians, an
environmental health technician and
a midwife, covers a population of
12,000 and is the first contact level
for the urban population. It has
duties similar to those of health
houses in rural areas and is supervised by the staff of an urban health
centre2.
A District Health Centre is
responsible for planning, monitoring and evaluation of health
International Dental Journal (2004) Vol. 54/No.6 (Supplement)
programmes at district levels. It is
staffed by physicians, health technicians and general service staff and
provides technical and logistic
support to rural/urban health
centres. A district health centre is
supervised by the staff of a Provincial Health Centre2,4.
A Provincial Health Centre
provides managerial, technical and
logistic support to district health
centres and is responsible for planning, monitoring and evaluation of
health programmes at provincial
level. It is supervised by the Oral
Health Department of the Ministry
of Health and Medical Education
at the national level4.
Dental health delivery
system
The Oral Health Department of
the PHC network implemented a
pilot project in 1995/1996 to integrate oral health care into the
public domains in four districts
and, accordingly, the Dental Health
Care Delivery System (DHDS) was
established1. It was completed and
expanded all over the country by
369
Table 1 The Dental Health Delivery System (DHDS)
Level
1
2
3
4
Trained professionals
Treatment
‘Behvarzes’
Oral hygienists
Dentists and dental nurses and technicians
Specialists
Primary Health Care (PHC, primary prevention)
Health and treatment (Secondary prevention)
Management and treatment (tertiary prevention)
Research and evaluation, implants, laser, maxillofacial prosthetics
1997 and aimed to improve
community involvement in oral
health by both promoting public
awareness and delivering oral services more effectively. Following
this, four levels of the DHDS were
established1 (Table 1). In the first
level of the health network, Behvarzes
are responsible for providing oral
health care to the target groups in
rural areas, including oral health
education, periodic examination of
the teeth, referrals to the higher
levels (rural or urban health centres)
and the follow-up of the outcome.
They also supervise sodium fluoride mouth rinsing in rural areas1,5.
At the second level, dentists and
oral hygienists deliver primary oral
health care services such as fillings,
pulpotomies, extractions of infected
roots, fluoride therapy and scaling.
They supervise the activity of
Bevarzes in the health houses within
their jurisdiction1,5.
At the third level, management
and treatment of dental and oral
diseases is provided by dentists,
dental nurses and technicians as
tertiary prevention. Finally, at the
fourth level, advanced treatment
is offered by the specialists at
University Health Centres in the
cities5. This specialised treatment
can be transferred to the district
health centres when the required
facilities and manpower are reasonably available1,5.
the national level with the main
objective of the promotion of oral
health in the communities through
the increase of public awareness
and quantitative and qualitative
improvement of oral health care.
Over the last decade, the Department has published numerous
posters, books and brochures, made
films, prepared and distributed
dental ID cards and made 0.2%
sodium fluoride mouth rinse widely
available in primary schools2.
Following the integration of oral
health care into the PHC, which
provided national coverage in
1997–1998, the Oral Health
Department prepared a plan to
have better access for the 6–12
years age group in cities, focusing
on three components including
health education, prevention and
treatment. The plan started with
the School Health Programme,
utilising school health technicians
and volunteer teachers to educate
children and their parents on the
importance of oral health, supervise tooth brushing in the schools
and weekly mouthrinsing with (0.2%
sodium fluoride)3. The main objective of the third component of the
project, i.e. treatment, is to provide
low cost facilities in relation to three
essential curative targets, including
extraction of infected roots, tooth
restoration (with priority given to
molars) and fluoride therapy2.
Role of the Oral Health
Department in improving oral
and dental health
Oral health manpower
The Oral Health Department
(OHD) as one of the departments
of the Under-Secretary for Public
Health of the Ministry of Health
and Medical Education, is responsible for policy making and planning
of oral health care programmes at
The number of dentists in Iran is
estimated to be 13,000, i.e. one
dentist for every 5,500 citizens and
it continues to grow steadily as 700
graduates each year from 18 dental
schools join the existing dentists.
Only 10% of dentists work in
public services and nearly 79% have
private practices. Around 1,200
specialists work either in the universities or have private practices6.
The number of oral hygienists
in the rural areas have been
reduced to approximately 650
because every year, around 100
hygienists, after six years of offering
service in local rural communities,
enter a university to continue their
education to obtain the degree of
Doctor of Dental Surgery if they
can pass the University Entrance
Exam successfully1. So the number
of this category of health personnel is steadily decreasing each year.
The reason for stopping the project
was mainly their inappropriate
involvement in clinical issues, which
were far beyond their educational
capabilities or job responsibilities.
This shows that the situation has to
be reviewed and modified, if
necessary, to introduce a new
mandate, focusing primarily on
health promotion and disease
prevention issues, to account for
limitations in human resources
available in rural communities2.
It is worth mentioning that
around 6,000 dental assistants,
dental laboratory workers and
denturists without any official
educational backgrounds have their
own private practices all around
the country. They have been
licensed following political pressures
exerted on the ministry at different
times. In rural communities,
approximately 35,000 auxiliary
health workers, known as
‘Behvarzes’, offer PHC services
including oral health care to the
population2.
Oral health status
In spite of the execution of a
number of local and nationwide
epidemiological surveys, systematic
data which allow assessment of
Pakshir: Oral health in Iran
370
Table 2
The percentage of caries experience and tooth decay according to selected ages
in 1992¹¹
% with caries exp.DMF ³ 1
% with tooth decayD ³ 1
DT
MT
FT
DMFT
long-term trends in oral diseases
are not yet available. The proportion of children affected by dental
caries or the percentage of cariesfree children have not been
recorded systematically. Although
the WHO7–8 has strongly recommended that national epidemiological surveys should be conducted
in order to monitor changes in oral
health status of selected age
populations, the epidemiological
tradition in Iran is relatively weak
and regular regional and national
oral health surveys have not been
carried out. So at present, systematic data are badly needed to assist
the reorganisation of oral health
care. Collecting epidemiological
data concerning dental health
among various age groups is of
primary importance, as has been
recommended and stressed by
WHO9.
In an assignment report on oral
health care in Iran, Leous10 reviewed
the results of 12 surveys which had
been conducted to assess dental
caries and the mean average of
decayed (D), missing (M) and filled
teeth (F), (DMFT) during a period
of 30 years (1959–1989). His
report revealed that the mean caries
experience in 12-year-old children
in Iran had increased from 1.8 to 4
DMFT. There is no data on the
percentage of caries free people in
this report.
The first nationwide survey11
was conducted in 1990–1992 on a
total of 34,985 children and adults
aged 6–69 years. One out of every
1,000 Iranian families was randomly
selected for oral health examination to determine the level of oral
diseases. Dental examinations were
6 years
(n=1480)
12 years
(n=1426)
15–19 years
(n=4774)
35–44 years
(n=3712)
13.1
11.4
0.2
0.1
–
0.3
68.7
66.1
2.2
0.1
0.1
2.4
87.3
83.6
4.3
0.4
0.3
5.0
98.8
87.1
4.8
5.4
1.1
11.3
carried out using the DMFT index
according to WHO criteria. The
study revealed that, 6-year-old children had a mean caries prevalence
of 0.3 DMFT and 88.6% of this
age group were caries free. Mean
caries prevalence of 2.4 DMFT was
recorded for 12-year-olds with
68.7% having caries experience. The
prevalence of dental caries among
the 15–19 and 35–44-year-olds was
87.3% and 98.8% with the mean
of 5 and 11.3 DMFT recorded
respectively (Table 2).
In the second survey12 in 1995
assessing the 12-year-old DMFT
indices, the students in the fifth
grade were classified by sex and
place of residence (urban/rural) in
all districts and provinces of the
country. The analysis revealed that
the mean caries experience in 12year-olds was 2.02 DMFT, which
is considered low according to
WHO criteria, but only 17% of
children were caries free. The
decayed component (D) was the
major contribution to the total
caries experience and first permanent molars were the most carious
teeth with a higher DMFT index
for girls compared with boys.
The third national investigation
of children was undertaken in
1998–1999 by the Oral Health
Department of the Ministry of
Health and Medical Education13.
The main objective of the survey
was to evaluate the oral health
status of Iranian children by determining the DMFT of 3- and 12year-old children at national level
and for that of the 6- and 9-yearolds provincially. The samples were
selected randomly from both
urban and rural areas with a total
International Dental Journal (2004) Vol. 54/No.6 (Supplement)
population of 6,901 children. The
results provided convincing evidence
on the magnitude and severity of
dental caries in the primary teeth as
a major problem that should
receive special attention.
This survey showed that the
prevalence of dental caries in the 3year-old children was 46.8% with
the mean dmft of 1.8. The caries
experience increased to 85.9% with
4.8 teeth per person in the 6-yearold children. Regarding the 9-yearolds, these figures were 84% and
3.4 respectively. When comparing
the prevalence among urban and
rural areas, no significant differences were observed. The d-component of dmft was 98% for 3-,
90% for 6- and 80% for 9-yearold children respectively. The
prevalence of dental caries in the
12-year-olds was 52.3% with
DMFT of 1.5 (Table 3). In the
bivariate analyses, only minor
differences in caries experience
were found according to location
and gender. The d/D-component
in all age groups had a major
contribution to total caries experience and more than 80% of both
the primary and permanent dentition comprised decayed teeth. In
this regard, less than 4% of
primary and 12% of permanent
teeth had been filled. There was a
significant difference in the percentage of filled teeth between urban
and rural children. It was evidenced
that higher decay rates generally
were found among poor and
low-income families and children
whose parents had less than a high
school education. These high rates
might have been related to
restricted access to oral health serv-
371
Table 3
The mean caries experience (dmft, DMFT) and percentage of caries free according to age in
1998–1999¹³
3 year
(n=701)
6 year
(n=2714)
9 year
(n=2740)
12 year
(n=746)
% of caries free
53.2
14.1
16
69.7
dmft and SD
% of caries free
DMFT and SD
1.8 ± 0.02
–
–
4.8 ± 0.04
88.5
0.2 ± 0.02
3.35 ± 0.01
58
0.9 ± 0.05
0.58 ± 0.08
47.7
1.5 ± 0.01
–
13.8
11.5
32.8
% of caries free (deciduous and permanent)
Table 4
The mean caries experience (DMF-T) according to
age and location in 2001–2002¹ 4
15–19 years
Urban
(n=5133)
Rural
(n=3669)
Total
(n=8801)
DT
MT
FT
DMFT
2.5
0.7
1
4.2
35–44 years
(n=5122)
(n=3619)
(n=8741)
DT
MT
FT
DMFT
2
9.9
2.8
14.7
2.7
11.4
0.73
14.83
2.3
10.51
2
14.8
3
0.78
0.22
4
2.75
0.74
0.61
4.1
Figure 2. DMFT at 12-year-olds in Iran 1988–1998
ices, a low level of education, poor
hygiene and diet.
Finally, the most recent survey14
was carried out in 2001–2002 by
OHD to determine the caries
experience and periodontal status
of two different age groups, 15–
19- and 35–44-year-olds, with a
population of 8,801 and 8,741 respectively. The DMFT scores
showed to be 4.1 for the first and
14.8 for the second age group with
the decayed and missing teeth as
the major contributors to caries
experience for the two groups
respectively (Table 4).
Concerning caries experience,
over a period of ten years (1988–
1998), there was a clear decrease,
from 4 DMFT to 1.5 DMFT, in
the 12-year-old children (Figure 2).
Unfortunately, the periodontal
status has not been surveyed
nationwide systematically during
the last two decades, and the only
unpublished data is from an investigation conducted in 2001–2002,
which used the community peri-
odontal index (CPI) for this
purpose. The index suffers from
numerous limitations, reducing its
value as a sound epidemiological
tool and, hence, the results have to
be referred to cautiously.
The periodontal status of the
two groups, i.e. 15–19- and 35–44
year olds, demonstrated that
approximately 80% of the 15–19years-olds were either normal
(8.85%) or needed just primary
prevention for their periodontal
problems (70% with bleeding and
Pakshir: Oral health in Iran
372
Table 5
The percentage distribution of CPI scores according to residential location in
2001–2002¹ 4
15–19 years
Urban (n=5133)
Rural (n=3668)
Total (n=8801)
35-44 years
Urban (n=5122)
Rural (n=3619)
Total (n=8741)
calculus), while in the second group,
owing to their increased age, more
than 50% of them manifested
severe periodontal problems
requiring extensive periodontal
treatment (Table 5). The results of
this survey have not been published
nationally.
Conclusion and
recommendations
Bearing in mind the scarce public
resources for oral health care and
in light of the current pattern of
oral disease in Iran, the introduction of a national oral health policy
that emphasises preventive and
restorative efforts is recommended.
The implementation of a community based oral health promotion
programme was, and still is, a
matter of urgency and, in relation
to children, such programmes have
already been initiated through
health promoting school projects.
School oral health education by
active involvement of schoolteachers and widespread usage of 0.2%
NaF mouth rinse in primary schools
since 1999 are the elements in the
preventive part of the project. The
future changing pattern of oral
diseases among Iranian children
could result from the initiatives
taken to implement preventive oral
care programmes for school children, including oral health education.
With recognition of the fact that
parents play an important role in
caries prevention for their children,
the national oral health plan should
consider raising their awareness and
Score 0
9.9
7.8
8.85
Score 0
1.2
1.2
1.2
Score 1
Score 2
Score 3
28.5
22.8
25.6
40.5
48.6
44.4
20.6
19.5
20
Score 1
Score 2
Score 3
39.5
42.7
41.1
42.4
42.8
42.5
6.6
3.6
5.1
providing knowledge of dental
health care particularly for mothers. The main objective is to cope
with the caries problem in the
primary teeth and, in this respect,
mothers are the target population
for health education.
Also the national oral health plan
should aim at:
• Developing oral hygiene skills
(tooth brushing, with fluoride
toothpaste, and flossing)
• Reducing intake and frequency
of sugar consumption
• Fluoridating drinking water
• Improving access to dental sealants
• Improving access to dental
examination and providing
regular dental care
• Giving priority to preventive
oral health over treatment interventions.
In summary, more emphasis
should be placed on community
based oral health policies founded
on the recently developed principles of preventive oral care.
References
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Dentistry System in Iran. Med Princ
Pract 2003 12(Suppl): 56–60.
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Health; Oral Health Department, June
2000.
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and Medical Education, Oral Health
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Score 4
0.8
1.3
1.05
Score 4
103
9.4
10
4. Sadrizadeh B. Primary Health Care
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http://www.icsbhs.org/presentation/
Sadrizadeh
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1990, available at http://www.WHO/
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