Gingivitis, characterized by reversible inflammation of the gingival tissues without loss of connective tissue attachment, represents the most prevalent form of periodontal disease affecting children and adolescents worldwide [1]. This inflammatory condition manifests clinically as erythema, edema, and bleeding upon probing, typically developing as a consequence of bacterial plaque accumulation along the gingival margin [2]. While gingivitis is generally painless and reversible with appropriate oral hygiene measures, its progression to more severe forms of periodontal disease can result in irreversible tissue destruction and tooth loss if left untreated [3].

Recent global epidemiological data indicate that gingivitis affects approximately 20% of children up to 12 years of age, with significant variations observed across different geographical regions and socioeconomic populations [4]. A comprehensive study by Olczak-Kowalczyk et al. (2024) involving 3,558 children aged 3–7 years reported a gingivitis prevalence of 12.25%, demonstrating the substantial burden of this condition in pediatric populations [1]. Similarly, contemporary research from various countries has documented prevalence rates ranging from 10% to 40%, highlighting the persistent global challenge of maintaining optimal gingival health in children [5, 6]. The etiology of gingivitis in children is multifactorial, with dental plaque serving as the primary etiological factor [7]. The accumulation of bacterial biofilms along the gingival margin triggers an inflammatory response characterized by increased vascular permeability, neutrophil infiltration, and the release of inflammatory mediators [8]. Contributing factors include inadequate oral hygiene practices, dietary habits, socioeconomic status, access to dental care, and individual susceptibility factors [9]. Recent investigations have highlighted the crucial role of oral hygiene behaviors, specifically toothbrushing frequency and technique, in influencing gingival health outcomes in pediatric populations [10].

The school-age period represents a crucial developmental phase for establishing lifelong oral health behaviors and preventing the onset of periodontal diseases [11]. Children aged 7–11 years are particularly vulnerable to gingival inflammation due to several factors, including the mixed dentition period, developing motor skills for effective plaque removal, and varying levels of parental supervision regarding oral hygiene practices [12]. Furthermore, this age group often experiences increased consumption of cariogenic foods and beverages, which can contribute to both dental caries and gingival inflammation [13].

In the Middle Eastern context, limited contemporary data exist regarding the prevalence and associated factors of gingivitis among school children. Iraq, in particular, has experienced significant challenges in healthcare delivery and oral health promotion due to ongoing socioeconomic difficulties and the long-term effects of conflict [14]. The country’s healthcare system has been severely weakened by decades of war, sanctions, and instability, leading to disruptions in preventive healthcare services and a decline in public health infrastructure [15]. This post-conflict environment creates unique challenges for oral health, as access to dental care, availability of oral hygiene products, and health education programs are often limited. Therefore, prevalence data from a post-conflict region like Al-Najaf is crucial for understanding the specific oral health needs of the population and for developing targeted interventions. Al-Najaf, one of Iraq’s prominent cities with a population exceeding 1.2 million, serves as an essential setting for understanding the oral health status of Iraqi children [14, 15]. Previous studies from the region have suggested varying prevalence rates of gingival diseases, but comprehensive, methodologically rigorous investigations remain scarce [16].

The identification of modifiable risk factors associated with gingivitis in children is essential for developing targeted prevention strategies and public health interventions [17]. Recent systematic reviews have highlighted the effectiveness of school-based oral health education programs in improving gingival health outcomes, emphasizing the importance of early intervention and health promotion activities [18, 19]. Understanding the local epidemiology of gingivitis and its determinants can inform evidence-based policy decisions and resource allocation for pediatric oral health programs.

Given the limited contemporary data on gingivitis prevalence among Iraqi school children and the need for evidence-based oral health planning, this study aimed to determine the prevalence of gingivitis and identify associated risk factors among primary school children aged 7–11 years in Al-Najaf City, Iraq. The findings of this investigation will contribute to the growing body of literature on pediatric periodontal epidemiology and provide valuable insights for developing targeted oral health promotion strategies in similar populations.

This cross-sectional study offers important current evidence on the prevalence and determinants of gingivitis among primary school children in Al-Najaf, Iraq. The overall prevalence of gingivitis at 16.6% aligns with global estimates and shows that gingival inflammation continues to be a significant oral health issue in this population. This finding is particularly noteworthy when compared to the comprehensive study by Olczak-Kowalczyk et al. (2024), which reported a 12.25% prevalence among younger children (3–7 years) in Poland, suggesting that gingivitis prevalence may increase with age during the primary school years [1]. The strong links found between gingivitis and modifiable risk factors, especially dental plaque buildup and toothbrushing frequency, underscore the preventable nature of this condition and the potential for targeted interventions to improve oral health outcomes.

The World Health Organization's recent estimates, indicating approximately 20% prevalence in children up to 12 years of age, further support the validity of our findings within the global context [4].

The age-related increase in gingivitis prevalence observed in this study, from 12.4% in 7-year-olds to 22.9% in 11-year-olds, reflects important developmental and behavioral changes occurring during the primary school period. This trend is consistent with previous epidemiological investigations and can be attributed to several factors, including the transition from primary to mixed dentition, increased independence in oral hygiene practices, and potential changes in dietary habits and parental supervision [24]. The mixed dentition period, characterized by the presence of both primary and permanent teeth with varying eruption stages, creates anatomical challenges for effective plaque removal and may contribute to increased susceptibility to gingival inflammation [25]. Furthermore, as children mature, they often assume greater responsibility for their oral hygiene routines, which may result in less consistent or effective plaque control compared to parental supervision in younger children. The increase in gingivitis prevalence with age during the primary school years emphasizes the importance of early intervention and establishing effective oral hygiene habits during this critical developmental period.

The strong association between dental plaque accumulation and gingivitis observed in this study reinforces the fundamental role of bacterial biofilms in the pathogenesis of gingival inflammation. The finding that 69.0% of children with any degree of plaque accumulation had gingivitis, compared to only 6.7% of those without visible plaque, demonstrates the critical importance of effective plaque control in maintaining gingival health. This relationship is well-established in the periodontal literature and has been consistently reported across different populations and age groups [26]. The correlation coefficient of 0.68 between plaque and gingival indices in our study is comparable to values reported in recent pediatric studies, indicating that plaque remains the primary modifiable risk factor for gingivitis in children [27].

The findings reveal significant deficiencies in oral hygiene practices, with over one-third of children never brushing their teeth and limited access to preventive dental care. The finding that 36.7% of children never brush their teeth is concerning and substantially higher than rates reported in developed countries, where regular toothbrushing is more universally practiced [28]. This disparity may reflect socioeconomic factors, limited access to oral hygiene products, inadequate oral health education, or cultural differences in oral hygiene practices. These observations highlight the urgent need for comprehensive oral health promotion strategies that address both individual behaviors and systemic barriers to optimal oral health. The clear dose-response relationship between toothbrushing frequency and gingivitis prevalence, with a progressive reduction in inflammation from 31.3% in non-brushers to 5.0% in frequent brushers, underscores the preventive potential of improved oral hygiene behaviors.

Recent systematic reviews and meta-analyses have consistently demonstrated the effectiveness of regular toothbrushing with fluoride toothpaste in preventing and reducing gingival inflammation in children [29, 30]. The observation that 79.5% of children who brushed their teeth used fluoride toothpaste is encouraging, as fluoride provides additional benefits beyond mechanical plaque removal, including antimicrobial effects and enamel remineralization [31]. However, the substantial proportion of children with inadequate brushing frequency highlights the need for targeted interventions to improve oral hygiene practices in this population. From a clinical perspective, the results support the implementation of evidence-based prevention strategies, including regular toothbrushing with fluoride toothpaste, professional oral health education, and improved access to preventive dental services. The school setting represents an ideal platform for delivering population-based interventions that can reach large numbers of children and potentially reduce oral health inequalities.

The association between dental caries experience and gingivitis observed in this study reflects the shared risk factor approach to oral diseases, where common determinants such as poor oral hygiene, dietary factors, and limited access to preventive care contribute to multiple oral health conditions simultaneously [32]. Children with caries experience had 2.1 times higher odds of having gingivitis, which is consistent with findings from recent epidemiological studies demonstrating clustering of oral diseases within individuals [33]. This relationship has important implications for preventive strategies, as interventions targeting common risk factors can potentially address multiple oral health problems concurrently, improving cost-effectiveness and population health outcomes.

The socioeconomic gradient observed in this study, with higher gingivitis prevalence among children attending public schools compared to private institutions, reflects broader health inequalities that affect oral health outcomes. This disparity likely encompasses multiple factors, including family income, parental education, access to dental care, and availability of oral hygiene resources [34]. Recent research has emphasized the importance of addressing social determinants of health in oral disease prevention, recognizing that individual behavioral interventions alone may be insufficient to eliminate health inequalities [35]. The finding that 56.1% of children had never visited a dentist further illustrates the challenges in accessing preventive dental care in this population and highlights the need for improved healthcare delivery systems.

The multivariate analysis results provide valuable insights into the independent contributions of various risk factors to gingivitis development. The identification of plaque accumulation as the strongest predictor (OR = 4.8) confirms the primacy of bacterial factors in gingivitis etiology and supports the continued emphasis on plaque control in prevention strategies. The persistent significance of toothbrushing frequency in the multivariate model (OR = 3.2 for never brushing vs. twice daily) demonstrates that behavioral factors remain important even after accounting for plaque levels, suggesting that brushing frequency may serve as a proxy for overall oral health awareness and self-care behaviors.

Contemporary research has increasingly focused on developing and evaluating school-based oral health interventions, recognizing schools as ideal settings for reaching large numbers of children and implementing population-level prevention strategies [36]. Recent studies have demonstrated the effectiveness of supervised toothbrushing programs, oral health education initiatives, and fluoride varnish applications in school settings [37, 38]. The findings of this study support the potential value of such interventions in the Al-Najaf context, where significant proportions of children exhibit poor oral hygiene practices and limited access to dental care [39, 40].

The study's strengths include its representative sampling methodology, standardized clinical examination procedures, and comprehensive assessment of potential risk factors [41, 42]. The use of established indices for gingival and plaque assessment ensures comparability with international studies, facilitating meta-analyses and systematic reviews. The relatively large sample size provides adequate statistical power to detect meaningful associations and supports the generalizability of the findings to the broader population of school children in Al-Najaf.

Several limitations should be acknowledged when interpreting the findings of this study. The cross-sectional design precludes the establishment of causal relationships between risk factors and gingivitis, limiting our ability to determine temporal sequences in disease development. The reliance on self-reported data for oral hygiene practices and dietary habits may have introduced recall bias and social desirability bias, potentially affecting the accuracy of behavioral assessments. Additionally, the study was conducted in a single city (Al-Najaf), which may limit the generalizability of findings to other regions of Iraq or countries with different socioeconomic, cultural, and healthcare contexts.

The public health implications of these findings extend beyond individual clinical care to encompass policy development and healthcare system strengthening. The high proportion of children with no previous dental visits indicates the need for expanded access to preventive services and the integration of oral health into broader healthcare delivery systems. Investment in oral health promotion programs, particularly those targeting school-age children, could yield significant long-term benefits for population health and healthcare cost reduction.

Future research directions should include longitudinal studies to better understand the natural history of gingivitis in children and identify critical periods for intervention. Investigating the effectiveness and cost-effectiveness of various prevention strategies in the local context would provide valuable evidence for policy decision-making. Additionally, research examining the role of social determinants of health in oral disease patterns could inform more comprehensive approaches to addressing health inequalities.

This cross-sectional study offers important current evidence on the prevalence and determinants of gingivitis among primary school children in Al-Najaf, Iraq. The overall prevalence of gingivitis at 16.6% aligns with global estimates and shows that gingival inflammation continues to be a significant oral health issue in this population. The strong links found between gingivitis and modifiable risk factors, especially dental plaque buildup and toothbrushing frequency, underscore the preventable nature of this condition and the potential for targeted interventions to improve oral health outcomes.

The findings reveal significant deficiencies in oral hygiene practices, with over one-third of children never brushing their teeth and limited access to preventive dental care. These observations highlight the urgent need for comprehensive oral health promotion strategies that address both individual behaviors and systemic barriers to optimal oral health. The increase in gingivitis prevalence with age during the primary school years emphasizes the importance of early intervention and establishing effective oral hygiene habits during this critical developmental period.

From a clinical perspective, the results support the implementation of evidence-based prevention strategies, including regular toothbrushing with fluoride toothpaste, professional oral health education, and improved access to preventive dental services. The school setting represents an ideal platform for delivering population-based interventions that can reach large numbers of children and potentially reduce oral health inequalities.

The public health implications of these findings extend beyond individual clinical care to encompass policy development and healthcare system strengthening. The high proportion of children with no previous dental visits indicates the need for expanded access to preventive services and the integration of oral health into broader healthcare delivery systems. Investment in oral health promotion programs, particularly those targeting school-age children, could yield significant long-term benefits for population health and healthcare cost reduction.