One hundred thirty-seven studies met the review’s inclusion criteria in the databases searched. Of those, only 23 studies were retained for full-text review. Figure 1 shows that eight studies were excluded for the following reasons: not finding the full text of the record, the study not being conducted in one of the WHO-EMR countries, or the study design not evaluating the OHCS in these countries. In total, fifteen studies were included in the review for data extraction (Fig. 1). The included peer-reviewed studies were published between 1987 and 2016. In addition, two reports were identified from the grey literature: [1] the OHCS provided by UNRWA, found in the annual health report published by UNRWA [22], and [2] the global oral health status report [5].

The data related to oral and dental healthcare in the reviewed studies and grey literature is summarised in Tables 2, 3 and 4. While, the data related to oral and dental healthcare from the WHO global oral health report [5] was summarised in Table 5.

Table 2 The political and socio-demographic characteristics of countries included in the reviewTable 3 Oral Health Services Profile in WHO EMRO CountriesTable 4 Oral health related programmes and responsiveness indicators in the included studiesTable 5 Oral care services profile in the WHO-EMRO countries (World Health Organization, 2022)Demographic characteristics of the included populations

Based on the list of Development Assistance Committee (DAC) in the United Nations [37], the included studies reviewing the OHCS in three high-income countries (Saudi Arabia, Kuwait, Oman), two upper-middle-income countries (Libya, Jordan) and five LMICs (Iran, Egypt, Syria, Pakistan, Tunisia). The information about OHCS provided by UNRWA to the Palestinian refugees living in the refugee camps located in the Palestinian Territories (Gaza Strip and West Bank), Jordan, Syria, and Lebanon was extracted from the most recent UNRWA Health Department Annual Report for the year 2022 [22].

Table 2 summarises the political and socio-demographic characteristics of the countries in the included studies. Most countries had stable political statuses when the studies were conducted, except for Libya [34] and Palestinian refugees’ camps [22]. Among the included studies, Pakistan had the highest populous size (̴ 152 million), whereas Kuwait was the lowest (̴ 2.2 million) [20]. Population growth rates ranged between 2% and 2.7%. In 1988, the reported growth rate in the rural areas of Egypt (29.7%) was the highest in the WHO-EMR and the world [36].

In 2022, Pakistan's population doubled (227.2 million) and remained the highest in the region. Meanwhile, Djibouti (1.1 million) accounted for the lowest population size, as shown in Table 4.

Healthcare and oral healthcare services

The assessment of the performance of OHCS in this review followed the WHO framework for health system performance assessment and health services research tools [1, 23,24,25, 38].

In included countries, governmental MOHs are the dominant provider of these services. UNRWA is the main provider of OHCS for Palestine refugee camps in five fields of operation (Jordan, West Bank, Gaza Strip, Syria, and Lebanon) [13] (Table 3).

The contribution percentage of Gross Domestic Product to Health Expenditure/year was the lowest in Pakistan (0.7%) and the highest in Libya (4%). Oral healthcare services accounted for 5%, 15.5%, and 3.7% of the national health budgets in Saudi Arabia (1984), Iran (2009) and UNRWA (2022) respectively (Table 2). Table 5 shows that in 2021, the contribution of per capita National health expenditure to per capita oral health expenditure was the highest in Iran (4.8%). In the high-income countries, it ranges between 3% in Qatar and 0% in Oman, while for all the rest of the countries, it is less than 1.3%.

The information regarding health insurance coverage for OHCS is rare; only Tunisia, Saudi Arabia, and UNRWA illustrated that health insurance covers essential treatments (fillings and extractions) and preventative dental care where available.

The oral health profile, services, and workforce are detailed in Tables 3 and 4. Syria, Oman, Iran, Saudi Arabia, Pakistan, Tunisia, and Kuwait included OHCS within the country’s national health plan. No study provided any information about gross national product allocation for oral health per year.

In some countries, the private sector, the Ministry of Education (for school oral health programmes), the Ministry of Defence (military medical services) and schools of dentistry in the local universities contribute to OHCS. The proportion of the population receiving OHCS from government MOH was reported only in Syria (8%), Pakistan (55%), Iran (70% by government in rural areas and 80% by private sectors in cities) and Saudi Arabia (100%), as shown in Table 3.

Oral and dental health status

Table 3 illustrates that dental caries and oral diseases were highly prevalent in the countries included and significantly higher in poor groups. Pakistan had the second-highest oral cancer prevalence in the world [19]. Dental caries prevalence and experience (decay, missing and filled deciduous teeth (dmft) and Decayed, Missing, and Filled Permanent Teeth (DMFT)) was high among children and adults in all the reviewed studies and increased over the years. For example, dental caries in Iran were highly prevalent in all age groups (up to 98.8%). Moreover, the prevalence of dental caries and periodontitis was higher among older age groups [33, 35]. A large part of decayed primary and permanent teeth was left untreated in Syria [16]. The prevalence of gingivitis and periodontal disease is also extraordinarily high, with high plaque accumulation as it reached 94% among 15-year-old children in Syria. Tunisia had the highest prevalence of malocclusion compared to other EMR countries [29, 39]. Poor oral health and toothbrushing practices were common among most of the included populations, except in Tunisia, which reported good toothbrushing practices among its population [29] despite the high prevalence of dental caries.

Table 5 shows that, most recently, Saudi Arabia had the highest level of untreated deciduous and permanent decayed teeth (53.2% and 38.8%, respectively) in the region despite it being a high-income country. Generally, sugar intake is extremely high among the population of the EMR (46.8 - 112.8 g/day).

Workforce in oral healthcare

Dentist to population ratio varies widely between countries; a shortage in this ratio was detected in Pakistan and southern Tunisia (1 dentist: 120,000 inhabitants). The availability of dental auxiliary and administrative staff was deficient in the studies included, mainly in Ministries of Health. Libya, Egypt, Oman, Bangladesh and UNRWA provided no information (Table 3).

Recent figures show countries where the dentists to population ratio is less than 2:10,000 are Yemen, Djibouti, Afghanistan, Bahrain, Pakistan, and Morocco. Most countries do not have a national oral health policy or action plan. Thus, oral health has not yet been incorporated into the NCD programmes at the Ministries of Health (Table 5).

Oral healthcare curative and preventive services (Table 4)

The OHCS programmes and responsiveness information are presented in Table 4. Water fluoridation for the prevention of dental caries is applied in Saudi Arabia, Iran, and Oman. Most of the included studies' oral health prevention programmes varied between screening and applying fissure sealant and fluoride modalities (e.g., fluoride mouth rinse, toothbrushing with fluoride toothpaste and fluoride varnish).

Oral healthcare-related research and surveillance are rare. In addition, there are remarkable shortcomings in the management of information and analysis of available data to use these data for bureaucratic purposes. Only UNRWA illustrated that an annual assessment of the oral health programme’s staff workload, needs, productivity, and efficiency is conducted in all five fields. Otherwise, existing dental care prevention programmes were not assessed for their effectiveness. Finally, all health planners in the included studies agree on shifting from curative to preventive oral health strategies.

The countries applying tax strategies on sugary diets are Bahrain, Afghanistan, Oman, Pakistan, Iran, Saudi Arabia, Tunisia, Morocco, and the United Arab Emirates (Table 5). Oral health screening is unavailable in Jordan, Sudan, Lebanon, and Somalia. The latter three countries do not provide basic restorative dental procedures to treat existing dental decay. In addition to that, Somalia does not offer urgent treatment for emergency oral care or pain relief. Countries that included oral health interventions in governmental public Health Benefit Packages (routine and preventive oral healthcare, essential curative oral healthcare, advanced curative oral/dental care, and rehabilitative oral healthcare) are Oman, Tunisia, Iran, the United Arab Emirates, Kuwait, and Syria (Table 5).