Dental health is a fundamental component of general health and well-being. Effective oral hygiene acts as a barrier against pathogenic microorganisms. Given their complex etiology, oral diseases must be detected early. Notably, in developing countries poor oral conditions lower nutrition levels and impede nutritive index of children. Adolescents’ mental well-being and school performance is hindered due to inadequate oral health and they are at risk of social isolation. [1] Oral conditions estimated for over 50 million hours of lost time in schools annually. [2]

Globally, oral diseases affect ~ 3.5 billion people—surpassing collective burden of the next five most common non-communicable diseases. Untreated dental decay, advanced periodontal disease, complete tooth loss, and oral/lip cancer are key contributors. [3] As part of the 2030 SDGs, Universal Health Coverage (UHC) is essential for achieving the broader objective of SDG 3, which promotes health and well-being for all populations. Despite this focus, the incorporation of oral health into UHC initiatives has been limited, and progress toward universal oral health coverage (UOHC) has been slow.[4] Adolescence is characterized by hormonal, behavioral, and psychological changes that affect diet and aesthetics, making them susceptible to cavities, malocclusion, gingivitis, and periodontal disease. The poor oral health diminishes self-confidence, academic outcome and social participation. Oral health–related quality of life is strongly influenced by socioeconomic factors, maternal education and family income. [5] A significant population of Pakistan lack basic oral health. The children specifically are thought to have poor dental health due to their lifestyle choices and factors related to socioeconomic status. [1] Poor dental health among the major health problems of Pakistan. It plays a significant role in appearance, interpersonal connections, dietary habits, nutritional intake, and speech. While reviewing the available literature, it becomes explicit that there exists a significant gap in data regarding oral health in Mohmand Agency, a tribal district in Khyber Pakhtunkhwa, Pakistan. This contrasts with the relatively more abundant data on other medical conditions like infectious diseases, maternal and child health, and nutrition. This discrepancy highlights the urge for dedicated research on dental health to address this neglected area. Dental health has been degraded as a result of absence of awareness and unavailability of dental clinics. Numerous research studies revealed a link between dental health and the entire well-being. Adoption of oral health care and promotion aligns with the goals of SDG3. Hence the aims of this study were (a) to determine the oral health status of school going adolescents through DMFT index and (b) to ascertain various determinants based on Anderson model affecting DMFT Index among school going adolescents. This will alleviate the burden on the healthcare system and help to devise a policy and health care system for dental care in that area.

This cross-sectional study was conducted among adolescents aged 13–18 years enrolled in classes 6–10 in Ghallanai, Mohmand Agency, Pakistan. A multistage cluster random sampling was applied: of 37 schools, 6 met the eligibility criteria (> 100 students in classes 6–10), and 4 were randomly selected by lottery. From these schools, 400 students were invited; 15 were excluded (7 undergoing dental treatment, 8 with deciduous dentition), yielding a final sample of 385 participants. Ethical approval was obtained from the Armed Forces Post Graduate Medical Institute’s Ethical Review Board (Re: 538-AAA-ERC-AFPGMI/31st October 2024) and it was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Written informed consent was obtained from parents/guardians of participants younger than 18 years, along with adolescents’ assent, while those aged 18 years provided consent on their own. The sample size was calculated using the WHO sample size calculator (95% confidence level, 5% margin of error, and an assumed prevalence of 50%), giving a required sample of 385. From13th January to 13th July 2025 data was collected.

Participants seated on regular school chairs while the principal investigator, a licensed dentist, performed oral examinations using a disposable mirror and dental probe in daylight. With the exception of third molars, every permanent tooth was evaluated for caries, restorations, and missing teeth, and the DMFT index was calculated. Data collection was followed by administration of a pre-translated Urdu questionnaire, previously reliability-tested (Cronbach’s alpha = 0.76). The administration of the questionnaire and the clinical examination were carried out by the principal investigator. The first two sections covered predisposing and enabling factors and their effect on dental service use. Participants’ self-reported oral health conditions are targeted by need based variables which is the fifth and concluding segment. [6] [7]

WHO-based interpretation of average DMFT scores for the population [8]

Very low (less than) 1.2

Low 1.2–2.6

Moderate 2.7–4.4

High 4.5–6.5

Very high (more than) 6.5

The study included 385 adolescents, mostly aged 13–14 years (53.2%); males comprised 83%. Mostly (66.2%), earning PKR 10,000–50,000 while only 3.4% earned above PKR 200,000. Systemic disease and regular medication use were reported by 3.9% and 4.9%. Only 8.6% were brushing twice or more daily and 58.4% using toothpaste. The majority (75.3%) had never smoked. Self-rated oral health was average in 44.7%, and 41% reported tooth pain in the past year. Access to care was limited: 44.2% reported no nearby facility, and only 12.2% visited a dentist in the past year, while 39% had never visited. Major barriers to dental care were lack of services (41.6%), cost (20.5%), and fear (14.3%) (Table 1).

(Table 2) shows that among 385 participants, 17.9% had five decayed teeth and 17.1% had six, while only 2.3% had none, reflecting untreated decay. For missing teeth, 28.8% had two and 28.3% had one, with only 12.5% reporting none. Most (84.2%) had no filled teeth; 3.9% had one, 7.5% had two, and none had more than four. The median number of decayed teeth was 5.0 (IQR = 3.0), missing teeth 2.0 (IQR = 2.0), and filled teeth 0.0 (IQR = 0.0).

Average DMFT scores across Classes 6–10 ranged from 6.27 to 7.65, all within WHO’s “very high” category, indicating a consistently high burden of untreated caries. Overall, dental caries prevalence was 97.7% (Table 3).

In (Table 4) The Kruskal–Wallis H test showed no significant association between age groups and DMFT scores (p = .095). Similarly, no significant differences were observed across educational levels (p = .327). In contrast, a significant difference in DMFT scores was found across parental income groups, (p < .001) and last dental visit (p < .001).

Mann–Whitney U post hoc tests with Bonferroni correction (adjusted p < .005) showed adolescents from the lowest-income households (PKR 10,000–50,000) had significantly higher DMFT scores than those from higher-income groups (p ≤ .003). Similarly, adolescents who had never visited a dentist had higher DMFT scores than all other visit categories (p < .001), except between those who visited 2–5 years ago and 6–12 months ago, where no significant difference was observed (p = .841). (Table 5).

b = p- value from Mann Whitney U Post-Hoc Comparison with Bonferroni Correction

This study assessed adolescent oral health using the DMFT index within Andersen’s Behavioral Model. Oral health was significantly associated with socio-demographic, enabling, and behavioral factors, while age showed no significant association (p = 0.095), despite reported increases: 5.19 to 8.90 at 14–20 vs. 21–25 years (p < 0.001) [9], from 0.6 at 9 to 1.23 at 11 years in Iran [10], and from 2.32 at 12 to 4.09 at 15 years in Serbia [11]. Gender was skewed (83% males); prior studies show higher female DMFT in the UK (IRR 1.28–1.16; mean 6.37 vs. 4.66) [12] and similar findings in Pakistan, India, Saudi Arabia, and the Philippines [13]. Education showed no association (p = 0.327), whereas studies in Norway [14] and Italy (DMFT 4.37 ± 3.06; p < 0.05) [15] found higher caries with lower education. Longer intervals between visits corresponded to poorer oral health, consistent with Quetta [16], while a China study linked more visits to higher caries due to symptom-driven care (p < 0.001) [17]. Oral hygiene was suboptimal (30.1% brushed once, 8.6% twice, 9.1% never), aligning with Brazil (40% higher caries with twice vs. ≥3 times brushing), China (32.6% brushed twice) [18], Sweden/Denmark (26–33%) [19], and Pakistan (76% suboptimal; OR = 1.86; p = 0.04) [16]. Toothpaste use was 58.4%, compared with 91% in China (77.8% fluoridated) [18]; Pakistani daily fluoride users had 20% caries vs. 50% in occasional and 40% in non-users (p < 0.001) [20]. Smoking (6.5%) remained harmful, with Lithuanian adolescents showing higher caries and poorer periodontal health (p = 0.023) [21], and Pakistani smokers demonstrating higher DMFT, periodontal disease (45%), lesions (15%), and increased odds of caries (OR = 2.8) and periodontal disease (OR = 3.5) [22]. Self-rated oral health reflected clinical need: 44.7% rated their teeth as average, 5.7% as poor, and 41% reported discomfort, consistent with Northwest China (11% poor, 53% moderate, 36% good) [23] and Pakistan (59.1% average) [1]. Caries prevalence was 97.7%, with median scores of 5.0 decayed, 2.0 missing, and 0.0 filled teeth; most had 5–6 decayed teeth, and 84.2% had no restorations, indicating substantial unmet need. International prevalence ranges from 72.9%–88.6% in Saudi Arabia and Poland (DMFT 4–5) [24] [25], while an Indian review reported 54.2% [26]. Pakistani studies report 69.4%–76% prevalence, confirming widespread untreated decay [26] [27]. Most adolescents (66.2%) belonged to households earning PKR 10,000–50,000, and DMFT scores varied significantly by income (p < .001). The lowest-income group had the highest mean rank (227.80), while higher-income households (PKR 100,000–200,000) had lower ranks, confirming socioeconomic gradients in caries. Similar findings were reported in Korea (p < 0.001) [28] and a meta-analysis of 493,360 European adolescents (p < 0.01) [11]. In Pakistan, low-SES children show poorer oral health [26], though data specific to ages 13–18 remain limited. Geographic barriers were substantial: 44.2% reported no facility nearby; 50.6% were unsure of travel time; 27.5% travelled over an hour, and only 8.1% had access within 30 minutes. Similar disparities exist in the U.S., where 1.7 million lack a clinic within 30 minutes and 24.7 million live in shortage areas (1 dentist per 5,000) [29], and in Malaysia and Saudi Arabia, where only ~ 40% access clinics within 30 minutes [30]. The main barriers to dental visits were service unavailability (41.6%) [31], cost (20.5%) [32, 33], fear (14.3%) [31], time constraints (10.4%) [33], lack of perceived need (6.8%) [34], and other reasons (6.5%).This study highlights how predisposing, enabling, and need-based factors shape adolescent oral health in rural Pakistan, underscoring the need for targeted public health interventions. Much of the information was self-reported, which may introduce recall or reporting bias. The sample was predominantly male and limited to a single district, so the findings may not fully represent all adolescents. Additionally, we did not collect objective measures of access such as travel time or mapping of nearby facilities. A high burden of untreated dental decay was observed. To address these gaps, efforts must focus on expanding access, affordability, and raising awareness for underserved populations.