A National Strategy for the Prevention of Dental Diseases for the Children of Armenia

This work-in-progress document proposes changes to the health strategy for Armenia, recognizing dental decay as the most common chronic disease and dental prevention as a cornerstone in upgrading Armenia's national health program.

For presentation at AMWC2025 in Madrid

Contents:

• Proposal by Dr Allukian
• Proposal by Dr Weiss updated May 2025
• Comments by the dental session planning team
• Link to WHO Oral Health Assessment form, modified

 

 

5/25/2025 Draft

A National Strategy for the Prevention of Dental Diseases for the Children of Armenia

Myron Allukian Jr. DDS MPH*

     Oral diseases are “a neglected epidemic” in most countries and especially in Armenia where children beginning at a very young age have extensive tooth decay and need treatment. In Armenia, about 91% of children have tooth decay in their baby teeth, and about 87.5% of 12-year-olds in their permanent teeth (1).

     The best way to deal with any disease is to prevent it so this is a proposal for a national strategy to prevent tooth decay in the children of Armenia, the most common disease which affects them. There are approximately 35,000-40,000 children in Armenia for each age from 6 to 12 years of age, for a total of 274,378 children. For children aged 5 and under there are approximately 217,800 children total (2).

     The most susceptible teeth to tooth decay are the biting surfaces of the 6-year molars which are also the cornerstone of the dental arch, and the second most susceptible teeth arethe biting surfaces of the 12-year molars. This is why it is most important that these teeth are protected from tooth decay. The most cost-effective preventive measure for these 8 teeth is dental sealants. This is why a school prevention program for children, which includes dental sealants and fluoride varnish, is so important.

For children 5 and under, the best way to reach them is through their parents, pre-school programs and/or their dentists, pediatricians, or health care providers.

A. School Dental Prevention Program

A school dental prevention program, which includes dental sealants and fluoride varnish, is the most cost-effective way to prevent tooth decay for children other than community water fluoridation or salt fluoridation.

Dental sealants and fluoride varnish would be provided to the children in school beginning withage 6 and moving upward, in addition to making 12-year-olds a priority for dental sealants.

Screening and referral, and health education about proper oral hygiene and the use of fluoride toothpaste would also be part of the program.

     Dental Sealants – would be applied to the biting surfaces of the 6-year and 12-year permanent molars as soon as these teeth erupt. This could be done by a trained dental assistant, nurse, or dentist. Dental sealants prevent biting surface tooth decay on 6- and 12-year molars by about 80% (3).

     Fluoride Varnish – Fluoride varnish helps prevent tooth decay for all teeth. The varnishwould be applied on all the teeth of all the children once or twice a year, it is more effective twice a year. This could be done by a trained teacher, nurse, parent, dental assistant, or dentist. Fluoride varnish prevents tooth decay in permanent and baby teeth by approximately 26% and 33%, respectively (4).

     School age child population - There are approximately 35,500 Armenian children aged 6 in the schools. The Karagheusian Foundation currently has a school prevention program withsealants and fluoride varnish, seeing about 4,000 children a year. This can be used as a model which could be expanded to all school children with 6- and 12-year-olds being the highest priority for sealants, and all children getting fluoride varnishes.

How can this be done?

Getting dental students and the dental schools involved would reach more children at risk and give the dental students a great learning experience.

Currently there is one state dental school in Armenia, a five-year program at Yerevan State Medical University, with about 1000 students. These students could have rotations in the schools, providing fluoride varnish and sealants to school children.

This could then be expanded to include the two private dental schools, both five-year programs, Yerevan Haybusak University and University of Traditional Medicine, and there is also a new dental assisting school which could be included in the school prevention program.

The World Federation of Public Health Associations has done a casebook on school dental prevention programs (5).

B. Medical schools and physician training

Medical schools, internships and residencies should be teaching their students/residents about oral health and oral diseases and looking at the oral cavity in addition to the rest of the body.

C. Pediatricians (MDs) providing fluoride varnish and silver diamine fluoride (SDF) to the young patients aged five and under

Another resource for preventing tooth decay in very young children, especially for baby teeth,are pediatricians. This could be done during well-child visits for very young children. Most dentists do not see children aged 1- to 5-years-old.

Most children, under age five, see a pediatrician before they see a dentist. In the United States, the American Academy of Pediatrics recommends that pediatricians provide fluoride varnish to their young patients in addition to silver diamine fluoride (SDF) as needed. SDF is used to stop tooth decay from proceeding and serves as a restoration until the baby teeth shed especially for those who are unable to get dental care.

D. Obstetricians/gynecologists should be educating their pregnant patients and families about the importance of their oral health and the oral health of their newborn.

The importance of oral health should be included in the training of obstetricians and gynecologists.

Maternal and child health programs should include oral health.

E. Taxes on sugar-sweetened beverages and commercial candies and sweets

Armenian children have the highest sweet consumption among children across 50 nations, 64% of girls and 56% of boys aged 15 consume sweets multiple times a day (6).

Taxes on sugar-sweetened beverages have been successful in reducing the number of individuals who consume these beverages (7). Similar results would be expected with commercial candies and sweets. It would be up to the government to implement such taxes. WHO has recommended such taxes (8).

The money from these taxes could be used to support a national dental prevention program for children, and the reimbursement for fluoride varnishes done by dental and medical personnel.

F. Salt fluoridation

Community water fluoridation and salt fluoridation are the most cost-effective preventive measures for tooth decay as everyone in the community benefits. The school prevention program would be an added prevention benefit for children.

In Armenia, salt fluoridation would probably be more feasible than water fluoridation asdifferent communities have a different number of water source inlets. For example, Yerevan has about 10-12 water inlets.

In Armenia, about 80-85% of the iodized salt that is used is produced in Armenia (9). This makes it easier to fluoridate the salt as it would be in addition to the iodization of salt, and the costmay be negligible. Depending on other preventive measures, salt fluoridation would prevent tooth decay substantially (10).

About 35 million people in the world consume fluoridated salt, mostly in Europe, Mexico, and South America (11). Switzerland has been using fluoridated salt for over 70 years (10).

G. Contact sports, head gear and mouth guards

In contact sports, such as football, soccer and ice hockey, head gear and mouth guards should be required for students in public schools, colleges, and amateur sports.

H. Tobacco control

Tobacco control and education should be included in all public schools in Armenia, as well as medical, dental, and nursing schools. As of 2022, approximately 22.5% of Armenians aged 15 and older in Armenia were current tobacco smokers (12). Tobacco uses and vaping should notbe allowed in hospitals, public buildings, transportations, parks, workplaces, and other shared community spaces to protect public health and reduce exposure to secondhand smoke.

Dentists, physicians, nurses and all health personnel should be role models for better health and be educating their patients about tobacco use.

How Would a National Strategy for the Prevention of Dental Diseases for the Children of Armenia Be Developed?

A. School Prevention Program

In order to develop and implement a national school prevention program for children, thesupport of the school system, health department, government officials, dental schools and practicing dentists would be very helpful. Fortunately, we already have an active schoolprevention program for children through the Karagheusian Foundation, and this may be used as a model for the school prevention program. This could be done on a step-by-step or incremental basis building on the existing school prevention program year by year.

B. Prevention for Children 5 and Under

A multi-disciplinary approach should be initiated so that oral health becomes part of total health care for pregnant women, parents of newborn, pre-school programs and/or their dentists, pediatricians, or health care providers.

C. Total Population Prevention

How to move ahead with salt fluoridation and taxing soft-drinks and candies would requiremore discussion.

*Dr. Allukian has been the dental advisor for the Karagheusian Foundation since 1993. He was the City of Boston dental director for 34 years, was the chair of the US Surgeon General’s Work Group for fluoridation and dental health for the 1990 National Health Objectives which are now known as Health People 2030. A past president of the American Public Health Association, he is also on the faculty of both the Harvard and Boston University Schools of Dental Medicine.

References

1. Kharazyan, G., and A. Melikyan. "Oral Health Status and Indicators in Children of Armenia Based on the National Surveys." Minerva Pediatrics, vol. 74, no. 6, 2022, pp.738–745. https://www.minervamedica.it/en/journals/minervapediatrics/article.php?cod=R15Y2022N06A0738.

2. Armenia Population (2025). Worldometer, https://www.worldometers.info/worldpopulation/armenia-population/ . Accessed 5 June 2025.

3. Ng, Toby Cheuk-Hang et al. “A concise review of dental sealants in cariesmanagement.” Frontiers in oral health vol. 4 1180405. 17 Apr. 2023,https://pmc.ncbi.nlm.nih.gov/articles/PMC10149715/

4. Baik, Alaa et al. “Fluoride Varnishes for Preventing Occlusal Dental Caries: AReview.” Dentistry journal vol. 9,6 64. 3 Jun. 2021,https://pmc.ncbi.nlm.nih.gov/articles/PMC8229232/#sec3-dentistry-09-00064

5. World Federation of Public Health Associations. Global School Oral HealthCasebook. World Federation of Public Health Associations, 2024,https://www.wfpha.org/global-school-oral-health-casebook/ . Accessed 25 May 2025.

6. Melkumova, Marina. “Armenian Children Lead World in Sugar Consumption,Sparking Health Concerns.” The Armenian Mirror-Spectator, 19 Nov. 2024,https://mirrorspectator.com/2024/11/19/armenian-children-lead-world-in-sugarconsumption-sparking-health-concerns/ . Accessed 5 June 2025.

7. Royo-Bordonada, Miguel Ángel, et al. "Impact of an Excise Tax on theConsumption of Sugar-Sweetened Beverages in Young People Living in PoorerNeighbourhoods of Catalonia, Spain: A Difference in Differences Study." BMC Public Health, vol. 19, 2019, p. 1553. Springer Nature,   https://doi.org/10.1186/s12889-019-7908-5. Accessed 5 June 2025.

8. World Health Organization. Fiscal Policies for Diet and Prevention ofNoncommunicable Diseases: Technical Meeting Report. WHO, 2016,https://www.who.int/news-room/detail/11-10-2016-who-urges-global-action-tocurtail-consumption-and-health-impacts-of-sugary-drinks. Accessed 5 June 2025.

9. Avan Salt Plant. About Us. Avan Salt Plant, 2025,   https://www.armsalt.am/default_eng.htm . Accessed 25 May 2025.

10. Estupiñán-Day, Saskia, editor. Promoting Oral Health: The Use of Salt Fluoridation toPrevent Dental Caries. Pan American Health Organization, 2005,https://www3.paho.org/hq/dmdocuments/2009/salt%20book%20eng.pdf.6

11. Barker, Judith C., et al. “Acceptability of Salt Fluoridation in a Rural Latino Communityin the United States: An Ethnographic Study.” PLOS ONE, vol. 11, no. 7, 2016,e0158540. https://doi.org/10.1371/journal.pone.0158540 .

12. Global State of Tobacco Harm Reduction. Armenia: Country Profile. 2023,https://gsthr.org/countries/profile/arm/1 . Accessed 23 May 2025.

13. Dutt, Upasna. Prevalence of Early Childhood Caries and Its Association with ParentalKnowledge, Attitude, and Practice in the Lori Region of Armenia. Master’s thesis,American University of Armenia, 2024. https://chs.aua.am/files/2025/01/Upasna-Dutt-Final-2024-December.pdf.

14. World Health Organization. Oral Health Country Profile: Armenia. World HealthOrganization, 2022. https://cdn.who.int/media/docs/default-source/country-profiles/oralhealth/oral-health-arm-2022-country-profile.pdf.

 

 

Developing a Strategy for a

National Dental Prevention Program for the Children of Armenia

 

The Problem:

The Armenian Medical World Congress (AMWC) recognizes the importance of education,
preventive services, diagnosis, and treatment necessary for optimal oral health of infants,
children, and adolescents. Comprehensive health cannot be achieved unless oral care is
included in all health service programs as it has a significant effect on overall health and well-
being.

Dental caries is the most common chronic disease in children in the United States.¹  It is 4 times
more common than childhood asthma and 7 times more common than hay fever. According to
the NHANES, the prevalence of dental caries has risen from 24% to 28% between 1988–1994
and 1999–2004 and ∼42% of children ages 2 to 11 years have dental caries in their primary
teeth. After decreasing from the early 1970s to the mid-1990s, the prevalence of dental caries in
children has been increasing, particularly in young children ages 2 to 5 years.²  The American
Academy of Pediatrics recommends an oral health assessment for all children by age 6 months
and a first dental visit by age 1 year. ³    Dental-related concerns lead to the loss of more than 54
million school hours each year.⁴  Regular tooth brushing with fluoride toothpaste by children is
very important in preventing dental caries.⁵

In a 2022 study ⁶ of children in Armenia, it was found that the prevalence of caries in primary
teeth was 91.7% on the average. In 12-year-old schoolchildren the average prevalence of caries
in permanent teeth was 87.5%. The prevalence of periodontal lesions in children was 47.8% on
the average.

The Solution:

Developing a National Dental Program is a major advance toward caries free children. It also is
a daunting project involving public, private, and government agencies. The best approach for
Armenia at this time in developing a National Dental Prevention Program for the Children of
Armenia involves working with the Ministry of Health, the Ministry of Education, and the
Governors and Educators of each region. We envision this to be a national educational,
screening, and preventive program in all schools. It would include health education, including
instruction for proper brushing with fluoride toothpaste, and educating regarding the dietary
influences of high sugar foods. These programs would include screening and charting of dental
disease in each student, treatment planning of needed care, educating the parents of each child
of the needs, and referral to the proper facilities for completion of care. A fluoride varnish and
dental sealant program should be initiated in each school to prevent additional dental disease
possibly by supervised auxiliaries.

Recommend a subject added to the school curriculum. The school principal and nurse should
be involved adding dental health as a subject in the curriculum. A method and program
need to be developed for both these ideas for classroom education and monitoring.
Tasks include: tooth brushing technique explanation and demonstration – includes plaque
indicator. "General" explanation about the caries disease mechanism. Training of (kindergarten)
teachers (aides).

Development of a unique training course for the kindergarten teachers to be trained as
motivating instructors in oral hygiene. These kindergarten teachers will be given the training to
explain the basics of Dental Caries and other mouth and gum diseases. Training will also
include correct tooth brushing techniques and healthy nutritional habits. Workshops will be held
in kindergarten classes, with the goal of turning the visit into a positive experience for the children, while increasing awareness and motivation for maintenance of good oral hygiene. The cost would be for time of teacher/aide, a toothbrush, and a worksheet for each child and
handout to each parent.

Also, a program of outreach and education to parents of preschool children should be created.
This has been done successfully by the Karagheusian Foundation in Armenia since 2021-2022
and the Oral Health Foundation for Children of Amenia -OHFAR (formally Hand in Hand) in
Artsakh since 2005.

Initially, an agreement between the Government, schools, and providing organizations need to
be signed. Then a detailed written plan of how the program would work would be established,
including how to contact the appropriate parties in each school district. Also, a specific written
system would be developed to standardize the charting and delivery of each service, eg,
fluoride varnish and sealants. The process would be that there be a group of approved
organizations and dentists that would follow these protocols and provide the services.

Outreach to the dental schools will be done and would be valuable to make sure there is a
proper preventive dental care curriculum and to involve the students and dental assistants to
apply fluoride varnishes and dental sealants in the public schools.

Perinatal and early childhood oral health care needs to be considered. The perinatal period
begins with the completion of the 20th to 28th week of gestation and ends four weeks after birth.
The infant/early childhood period extends to the age 5. Oral health providers and physicians
have an important role in preventing dental disease. Educating new parents and screening
young children, and evaluating the child’s dental health is invaluable. Educating these providers
regarding these periods up to five years old with respect to common oral conditions, anticipatory
guidance, and early dental caries preventive care is vital.

Early Childhood Caries (ECC) is defined as the presence of one or more decayed (noncavitated
or cavitated lesions), missing or filled (due to caries) surfaces, in any primary tooth of a child
under six years of age. ECC, is a bacterial induced, sugar-driven, multifactorial disease that
results in demineralization of teeth. Bacterial species may be transmitted vertically from
caregiver to child or between other members of a family or children in daycare through salivary
contact. ECC is seen frequently in Armenia and can have major impact on the child and is a
health and financial burden to the family and community.

An educational program for the medical schools and for practicing physicians should be
developed to include allied health professionals to let understand the caries process and
preventive solutions to the caries process, especially from birth to school age. More children
could be reached if pediatricians could be trained to do fluoride varnishes and understand when
and how to diagnose appropriate situations on and when to use SDF. Fluoride varnishes are
recommended for pediatricians to apply by the American Academy of Pediatrics.

A specific pediatric dental charting for all organizations doing dental care should be established
in Armenia so that we can have up to date, accurate data on the status of children’s oral health
in Armenia. This will enable us to compile data to use to advocate for their care. It should
include name, date, date of birth, a full charting of all teeth, whether they are decayed, missing,
or filled, a simple orthodontic and oral hygiene description, behavior status, and urgency of care
rating. WHO has a form that is close, and I made a few minor modifications for our use and
also propose it to WHO. We should make this part of our declaration. (Click here for a link to Modified WHO Oral Health Assessment Form for Children, 2013)

Community water fluoridation is not realistic for Armenia given different sources of water in
different communities. Salt fluoridation would probably easier to move forward, but more
information and politicking would be needed. Both are safe and extremely cost effective. This
would be an additional project.

The programs would need to be evaluated for cost and implementation. Reimbursement for
preventive dental services needs to be discussed. Preventive measures are far less expensive
than restorative/surgical dentistry. One solution for revenue could be from a “Sugar Tax” on
sweetened beverages, candies, etc. that could generate some funds.

While this is a major project, the significance of the efforts and the potential results are
exponential in eliminating dental disease in children.
 
REFERENCES  
1. National Center for Health Statistics. Healthy People 2010 Final Review. Hyattsville,
MD: National Center for Health Statistics; 2012.
Available at:  www.cdc.gov/nchs/healthy_people/hp2010/hp2010_final_review.htm
Accessed January 28, 2014    
2. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994
and 1999-2004. Vital Health Stat 11. 2007;(248): 1–92 35.  
3. Ismail AI, Bandekar RR. Fluoride supplements and fluorosis: a meta-analysis.
Community Dent Oral Epidemiol. 1999;27(1):48–56   
4. US Department of Health and Human Services. Oral Health in America: A Report of
the Surgeon General. Rockville, MD: US Department of Health and Human Services,
National Institute of Dental and Craniofacial Research, National Institutes of Health;
2000.   
5. Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing
dental caries in children and adolescents. Cochrane
6. Minerva Pediatr (Torino), 2022 Dec;74(6):738-745, doi: 10.23736/S2724-
5276.22.07082-3

 

 

 Comments by the Dental Session Planning Team

KM: I have been studying at the three-year Master's program with specialization in Oral Surgery at the International University of Catalonia in Barcelona and I have been informed about the dental prevention program from my Spanish colleagues. 

 In Spain they have the PADI program which is a national program in Spain: (Programa de Atención Dental Infantil) program in Spain generally follows a preventive and basic restorative care protocol,

 Enrollment:

• Children eligible by age (usually 6–15)
• Parents are often informed through letters or school notices.

 Choice of Dentist:

• Public dental clinics.
• Annual visit is scheduled, usually starting around from age 6 until 15y

 Annual Dental Visit:

• During this visit, the dentist conducts a full oral examination and follows a standardized preventive care protocol

 Record-Keeping:

• The dentist records findings and treatment in the patient’s 
• Future studies to understand if the prevalence have been increased or decreased in the future from these outcomes

 Similar protocol – Common Components:

1. Clinical Examination

• Full intraoral check-up, medical history, associated with medical pathologies
• Assessment of dental eruption, occlusion, caries, and hygiene and peridontal status.

2. Preventive Measures

Depending from the assessment to decide which tx 

• Oral hygiene education (brushing techniques, diet advice).
• Fluoride varnish application
• Fissure sealants on permanent molars, especially the first and second molars.
• Topical fluoride gel if caries risk is moderate to high.

3. Restorative Treatments: from most urgent until monitored (evaluation after some months)

• Fillings for decayed teeth (usually only permanent teeth).
• Extractions (simple, if non-restorable).
• Evaluation or tx of molar incisor hypomineralization (MIH) depending from the severity.

 4.  Recall and Follow-up:

• High-risk children may be recalled every 6 months instead of annually.
• Evaluation for high risk caries patients

Most important is the screening, evaluation of the current situation - have records about the prevalence of the disease

 Selection of the professional who will make the treatment:

• Dental students 
• Dental assistant with specialized training 

 Different training to be undergone by these students/dental assistants to have the optimal training to perform these type of procedures

As for dental students unlike with other countries that students work in the university hospital this does not happen at least in YSMU, neither to other universities

At International university of Catalunya (UIC BARCELONA) - specific contract done by the students where they operate and undergo treatment with the direct supervision of the professors. 

Similar program could be customized for Armenia’s rural area situation. 

 

GM:  We need to offer different areas of advice, to the State/MoH, to the dentists, to the schools, to the families and to the children.  Different messages to each.

• State/MoH - a comprehensive plan including the outline above, with updated info about # of children, distribution of resources, costs for materials, supervision, transportation.  Rewrite the pediatric practice protocols to allow fluoride varnish and sealant (and possibly SDF) application by pediatricians and pediatric nurses before many of the children have ever seen a dentist.
• Dentists, pediatricians- importance of reaching the children before critical teeth are damaged.  Importance of oral exam for clues that other conditions are present, e.g. oral cancers or obstructive airway.  Application of sealants and varnishes at the pediatric office.  We might include OBGYN practitioners given the need for proper oral health during pregnancy.
• Schools - teaching of proper brushing habits, contact with child's family, liaison with dental services for in-school sealants, varnishes, exams and SDF.
• Families - importance of protecting baby teeth, importance of well-child visits
• Children - proper brushing habits,
  • https://stellkey.com/
  •  https://www.youtube.com/watch?v=CK2si5aFXek , 
  • https://www.youtube.com/watch?v=paqu90vtMf0  (with collaboration students of universities)

GM: In France, the government pays for free dental exams every 3 years from age 6 to 24.  There is a plan to increase that to yearly.  In the Danish system, they go so far as to mandate these visits.

 JM: In addition to Karagheusian and OHFAR, dental services are provided by UMAF and COAF.  What other organizations might we find if we look hard enough?

JM: Some tasks for us to do soon:

• learn what dental record keeping is currently being done
• can we anticipate the overall costs of various programs: in-school screening, varnishes, sealants, SDF including material costs, and the current government payments for these services?
• What are licensure requirements for these services?  Why can't some of them be done by pediatricians?  or nurses?