Indian Journal of Oral Health and Research

: 2018  |  Volume : 4  |  Issue : 1  |  Page : 10--15

Seven years of war in Syria: The relation between oral health and PTSD among children

M. H. D. Bahaa Aldin Alhaffar, Khattab Mustafa, Samira Sabbagh, Kamal Yabrode, Ghalia Shebib, Chaza Kouchaji 
 Department of Pediatric Dentistry, Faculty of Dentistry, Damascus University, Damascus, Syria

Correspondence Address:
Dr. M. H. D. Bahaa Aldin Alhaffar
Alqusour st., Alkhateeb sq, Damascus


Background: Studying the prevalence of dental caries in a population located in a specific geographic area and the effect of the psychological factors on the people is considered essential to build a database to assess and compare future results of preventive programs and to assess health and social needs of the communities. Aim of this Research: This study aims to study oral health situation using (decayed, missing, and filled teeth [DMFT], plaque index [PI], and gingivitis index [GI]) indices, and the prevalence of posttraumatic stress disorder (PTSD) among 12-year-old children in Damascus, and the effect of PTSD on oral health. Materials and Methods: The sample included 811 children divided into five geographic areas in Damascus. Special questionnaires were used to measure PTSD level, and the oral health status was measured by clinical examination. Results: Data analysis showed that dental caries prevalence was 86%, DMFT value was 3.36. In detail, the D value was 2.86, M value was 0.48, and F value was 0.02. As for PI value, it was 0.79 and GI value was 0.85. The prevalence of PTSD was 91.5%. The study showed a statistically significant relationship between both DMFT and GI values, and PTSD value; however, there was no statistically significant relationship between PI value and PTSD value. Conclusion: The prevalence of poor oral health among 12-year-old children in Damascus schools was high as was the prevalence of PTSD, where we found in our study a statistically significant relationship between oral health index and PTSD.

How to cite this article:
Bahaa Aldin Alhaffar MD, Mustafa K, Sabbagh S, Yabrode K, Shebib G, Kouchaji C. Seven years of war in Syria: The relation between oral health and PTSD among children.Indian J Oral Health Res 2018;4:10-15

How to cite this URL:
Bahaa Aldin Alhaffar MD, Mustafa K, Sabbagh S, Yabrode K, Shebib G, Kouchaji C. Seven years of war in Syria: The relation between oral health and PTSD among children. Indian J Oral Health Res [serial online] 2018 [cited 2019 Jan 24 ];4:10-15
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Full Text


The Syrian Arab Republic lays on the east coast of the Mediterranean. Damascus is the capital of Syria and its largest city. For seven years, Syria has faced a crisis that continues to have significant impacts on all aspects of life. In Syria, there are about 13 million people in need of medical services now, but according to the World Health Organization, “Resources are stretched to the limit;” in 2016, The World Health Organization received one-third of the necessary funding to carry out humanitarian response activities.[1] As for the oral health situation, the study of the relation between war and its impacts on oral health is usually neglected. Nevertheless, oral health can reflect general health better than other health-related aspects. Oral health represents a sensitive system's exposure to harmful effects, such as war and war-related activity, and the reason is most likely the relative expensiveness and complexity of dental health services. A postwar study in Bosnia and Herzegovina showed high-postwar decayed, missing, and filled teeth (DMFT) values.[2] In Syria, as far as we know, no research has been done yet to study the impacts of the Syrian crisis on oral health. However, low access to health and education services has been highlighted as an important impact of the Syrian crisis.[3] Hundreds of clinics were closed and also hundreds of specialists in dental health-care emigrated during the Syrian crisis.[4]

Posttraumatic stress disorder (PTSD) is considered one of the most common and severe disorders, especially among children. It has two main types – when stress and symptoms last for <4 weeks, it is called acute stress disorder, but when symptoms last for more than that, it is called PTSD. Symptoms may occur after the shock or may be delayed for days or even months.[5],[6],[7] PTSD is also defined as a disorder that happens to a person after undergoing a very painful event (shock) which exceeds the limits of human experience. This painful event makes the person relive the same shock from wars, seeing violent acts, killing, rape, floods, or earthquakes after a period of being exposed to the event as if he or she is getting through it now. This leads to the unacceptance of reality and affects their adaptation to it; it also affects their social behavior and the level of their academic achievement and may lead to learning difficulties.[8]

Dental caries exists all worldwide, and their prevalence varies between developed and developing countries. However, it is considered a common health issue.[9] The prevalence of dental caries is increasing in the developing countries, and the reason could be bad social and economic situations and the changes in lifestyle.[10] The main factors causing dental caries are numerous and can be affected by biological, behavioral, and environmental factors.[11] It also depends on the balance between pathological and protective factors or between demineralization and remineralization processes.[12] It is also caused by mineral decalcification and so mineral decalcification causes the development of caries and pain, and if not treated, causes the loss of the tooth.[13] Oral diseases, especially dental caries, gingival diseases, periodontal diseases, and tooth loss, are considered diseases that could affect general health and the standard of living.[14] The high pathogenicity of dental caries increases the costs of general healthcare and the financial burden on families and societies.[15]

The study of prevalence of dental caries in a population group located in a specific geographic area of society and the study of the impact of psychological factors on them is essential for finding information that constitutes a basis for comparison and for evaluating the results of preventive and curative programs, which help in assessing the health and social needs of the community. It also provides a clear picture to those in charge of oral health and orients them to develop health and preventive programs.[16]

Aims of the research

Study the level of oral health among 12-year-old children in Damascus during the Syrian crisisStudy the prevalence of PTSD among 12-year-old children in Damascus during the Syrian crisisStudy the effect of PTSD on oral health.

 Materials and Methods

Research methodology

A cross-sectional research is to study the prevalence of dental caries, PTSD, and the relation between them on a sample of young school students in Damascus.


The original sample population includes seventh-grade schoolchildren, where most of the registrants are 12 years old. This age is considered very important as it is the age the child moves from primary school; therefore, it is the last age in which a reliable sample can be collected easily through the school system. It is also more likely that most of the permanent teeth (except the third molar) have emerged. Therefore, this age group was chosen to express significant global comparisons and orientations of diseases.[17] The sample size was calculated based on the recorded numbers in the Directorate of Education in Damascus. Simple random sampling technique was used to select the schools from which the sample would be collected to cover most areas of Damascus. Damascus has a total of 1200 schools, about 145 of them include seventh-grade classes. The number of students enrolled in the seventh-grade during the academic year (2017–2018) was about 35,000 students.[18]

Sample analysis: The sample size was 811 children, after deleting three questionnaires due to incomplete data. The median age was 12.5 years. The number of males was 431 (53.1%) and females 380 (46.9%) with a 95% confidence level and a ±3.39 confidence interval.

Materials used

A questionnaire for collecting data consists of four sections:

Personal information: gender, age, current and previous residence, and current gradeExposure to the crisis' variant events: it includes six variable events, in addition to the time of the occurrence of these painful events. The variant events mentioned were based on the variant events in the study of Dr. Murad (2015)PTSD evaluation questionnaire: the questionnaire mentioned was based on the DSM-V criteria. The questionnaire was originally developed by Davidson and amended by Dr. Murad (2015) on a sample of Syrian children.[8] It consists of 25 questions divided into three basic symptoms: memory recall, hyperhidrosis, and avoidance symptomsThe number of missing, decayed, and filled teeth in children according to DMFT index, gingival index according to Löe-Silence, and plaque and periodontitis index according to Ramfjord.

Examination tools used

Dental mirror, gingival probes (the WHO probe), tweezers, boxes for used instruments, and other ones for sterilized instruments, face masks, gloves, and hands and surfaces sanitizer.

Research procedure

The schools were selected according to the geographic distribution of Damascus. The capital was divided into five areas (Northeast, Northwest, Southeast, Southwest, and downtown). Ten schools were selected randomly from Damascus.

Ethical approval has been obtained from the Ministry of Higher Education, the School Health Directorate, and from the Deanship of the Faculty of Dentistry. The PTSD questionnaire was distributed, and the students' oral examination was done according to the WHO guidelines for conducting surveys, which was published in the oral health surveys basic methods, 5th edition.

[Figure 1] shows the geographic distribution of randomly selected schools from Damascus, and the rates of PTSD in each geographical area.{Figure 1}

Schools were visited from September 11, 2017, to October 19, 2017.

Statistical analysis

The data were analyzed using SPSS V.22 (Statistical Package for the Social Sciences, IBM software, Chicago) according to the following tests:

ANOVA test

To examine the existence of statistical differences between PTSD and DMFT.


To study the significant relationship between gender and PTSD, also between gender and DMFT.

Pearson's correlation test

To examine the presence and value between DMFT and PTSD.


Prevalence of posttraumatic stress disorder

Data analysis shows that most children were exposed to factors causing psychological trauma. [Figure 2] shows the main variables introduced by the Syrian crisis, which caused psychological trauma and its prevalence. Hearing the sound of explosions or shells was the factor causing most of the psychological distress in children (75%), while the loss of home due to war was the second factor causing psychological distress (51.6%), followed by the loss of a family member due to the war (27.6%).{Figure 2}

The prevalence of PTSD was very high. Data analysis showed that 91.5% of the children suffered from PTSD with varying rates [Figure 3]. The median value was 1.99 on a scale of 1–3. The avoidance symptoms in children (the isolation from friends and parents, the unwillingness to talk, and the avoidance of talking about the painful event) had the highest value on the scale on the PTSD scale 2.11.{Figure 3}

[Figure 1] shows the prevalence of PTSD in various areas of Damascus; the southeastern region showed the highest value of PTSD 2.84. The lowest PTSD level in Damascus was 1.68. It also shows the distribution of schools by geographical area [Table 1].{Table 1}

Relationship between posttraumatic stress disorder and child gender

Male children showed greater tendency to have PTSD. T-test showed no significant relationship between the two variables, so there is no significant relationship between gender and PTSD (P = 0.098).

The oral health level in children

Data analysis showed different levels of caries in children, for example, the DMFT index average value was 3.36 and the highest value was 13. The average values of decayed, filled, and missing teeth among children are shown in [Table 2] in comparison to gender and PTSD. The number of children with completely healthy teeth is 14% of sample size; however, there are 86% of children with at least one decayed, filled, or missing tooth.{Table 2}

The number of decayed teeth is between 0 and 12, the average number of decayed teeth is 2.93, the average number of missing teeth is 0.48, and the average number of filled teeth is 0.02.

The relation between PTSD and the oral health (DMFT) is shown in [Table 3], (P = 0.045).{Table 3}

Furthermore, there is a relation between PTSD level and the DMFT value (P = 0.028), and the correlation between the two variables, according to Pearson's correlation, is significant and positive (P = 0.035). The higher degree of PTSD, the higher the DMFT, which indicates poor oral health.

Moreover, the plaque index (PI) average value is 0.79 with prevalence rate 84.3%, and the value of gingivitis index is 0.085 with prevalence rate 47.6%. [Table 4] shows no statistically significant relationship between PI and PTSD indices, on the other hand, statistical correlation between GI and PTSD is shown.{Table 4}


The reported DMFT values among 12-year-old children in Syria are in 1988 (1.9), 1994 (2.5), and 1998 (2.3); those values are lower than the mean DMFT value in this study, which is 3.36.[19] Compared to the global DMFT average in 2000 for the same age group, which was 2.4, the DMFT value in our study is conceded high.[20]

A study in Lattakia, Syria, showed that the DMFT value was 2.35 among 12-year-old children. This value is lower than the value in our study, and that may be due to several factors. For example, sweet foods are more available in Damascus compared to Lattakia.[21] It should also be noted that there is a time difference between the two studies, which increases the exposure time of the crisis variables on children in our study.

Regionally, a study in eastern Saudi Arabia in 2014 showed DMFT value (1.94 ± 2.0) among 10–12-year-old children,[22] while in Eritrea, the DMFT value was 2.50 (±2.21) in 2017 for the same age group,[23] those values are lower than the mean DMFT value in our study.

Globally, a study in Ambala (India) reported that the prevalence of dental caries was (34.3%), and the DMFT value was (0.82) among 12-year-old children.[24] In Nepal, the DMFT value was (2.3 ± 1.5).[25] These values are lower than the values in our study. The DMFT value in Poland among 12-year-old in 2000 was (3.8)[26] while a study in Croatia in 2013–2015 showed a (4.18) DMFT value for children <12-year-old. These values are higher than the values in our study.[27] The global goal for the WHO in 2000 was a global average for dental caries to be no more than (3); the value in our study exceeds this goal value.[20]

The percentage of filled teeth in Syria in 1985 among 12-year-old children was (6%), and (11%) in 1991 of the total DMFT value,[19] while in this study, the percentage of filled teeth is (0.02) of the total DMFT value which is very low compared to the previous two values.

A study in Saudi Arabia found that the percentage of filled teeth was (0.93 ± 0.24) among 12-year-old children,[22] while in Portugal, the mean DMFT value was (0.74 ± 0.04) among 12 years old.[28] The two previous values are higher than the value in this study. The relative cost and complexity of dental health services present a sensitive system to harmful factors such as the war or the events related.[2] This might be the reason behind the low-filled teeth value in our study compared to other studies. In Eritrea, the value of filled teeth was (0.01 ± 0.2) among 12-year-old children, which is lower than the value in our study.[23] The poor economic situation in Eritrea is likely to play an important role in reducing the value of filled teeth index.

With regard to the prevalence of gingival diseases, according to the national survey of oral health in Syria in 1998, about 94%–85% of 15-year-old children were suffering from gingival bleeding or periodontal pockets.[29] A study in Syria in 1996 showed that poor oral health had high prevalence among the age of 15 years and 94% of them had high aggregation of dental plaque.[30] In a previous study in Palmyra, about the oral health problems among the ages of 13–15 years, 24% of children were suffering from gingival bleeding.[31]

A study in Jordan showed that 49.1% of 12-year-old children have gingival bleeding,[32] while in Nepal, 24.1% of 12-year-old children suffered from gingival bleeding.[24] Since the first gingivitis manifestation is bleeding, it can be said that the results in Jordan are similar to the results we had in this study, and the results in Nepal show low-gingival bleeding prevalence compared Damascus.

Regarding the value of PTSD, the results showed a large spread of posttraumatic stress among children in Damascus, as a result of new variables introduced by the Syrian crisis that we studied in our research. The global prevalence of posttraumatic stress among children is normally 4%–6% and ranges in the general population with rates between 1% and 3%. The prevalence percentage was 30% in soldiers returning from the Vietnam war, and between 30% and 75% in other studies, while in our study, we found that the prevalence was extremely high among children.[33],[34],[35]


We cannot deny the effect of Syrian crisis on posttraumatic stress among children. The results in our study showed high percentage of exposed children to PTSD, which affects, directly or indirectly, lifestyle, health, and social and educational level. We found in our study a reduction of oral health among children with PTSD, which refers to the need of plans to improve social support, oral healthcare, and general health.

The prevalence of poor oral health among 12-year-old children in Damascus schools was high as was the prevalence of PTSD, where we found in our study a statistically significant relationship between oral health index and PTSD.


Based on the results of this study, we recommend as follows:

Special designed programs aimed to focus on children with PTSD caused by the Syrian crisis and provide psychological support for themHealth awareness campaigns for people both directly and indirectly affected by the Syrian crisisWe recommend to do further studies that target all crisis-affected areas in Syria.



All data have been collected from schools after obtaining an official approval from the dean of the faculty of dentistry – Damascus University, Ministry of Education and Damascus Directorate of Education. Oral approval from each student was obtained before clinical examination.


This research could not be completed without the great efforts of the medical team, which contributed in the collection of data over the period of conducting this research from all Damascus districts. Furthermore, we gratefully acknowledge the help provided by Dr. Hanna Issawi in proofreading the final manuscript.

Financial support and sponsorship

The authors confirm the independence of this research completely from any governmental or nongovernmental authorities or local/international organizations, and the research is self-funded by the authors.

Conflicts of interest

There are no conflicts of interest.


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