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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 617-622

Impact of oral health problems on the quality of life among low income group in an urban area in Malaysia: A preliminary study

1 Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
2 Hospital Pakar Kanak Kanak, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Date of Submission23-Jun-2021
Date of Decision21-Sep-2021
Date of Acceptance12-Oct-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Dr. Ratnah T Subramanam
Department of Family Oral Health, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, 50300 Kuala Lumpur.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIOH.JIOH_154_21

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Aim: The aim of this article is to investigate the association between quality of life (QoL) and oral health problems among residents from low income groups in an urban area. Materials and Methods: Forty-five participants aged between 18 and 70 years residing in a residential area allocated for Malaysian citizens from the bottom 40% household income range (B40) in Kuala Lumpur were included in this study. A self-administered questionnaire adapted from the short version of Malaysian Oral Health Impact Profile [S-OHIP(M)] was used as an instrument to measure QoL of the participants. The respondents were separated into two groups, those aged below 40 years (<40) and those aged above 40 years (≥40). Results: In general, the residents within the B40 community participating in this study occasionally experienced the impact of their oral conditions as the percentages of “frequent” and “moderate” responses were higher in most of the items asked. The most frequent impact of oral disorders experienced by both age groups was physiological discomfort (89%). A significant association between the two age groups and the impact caused by bad breath was found. The perceived needs within this community were high (88.64%), and there was a low prevalence of edentulism. Conclusion: The majority of residents from a lower socioeconomic status in an urban area experienced the impact of oral health problems either frequently or moderately. Satisfaction with their oral health status and the perceived dental treatment need is deemed to be high.

Keywords: Adult, Oral Health, Quality of Life, Socioeconomic Factors

How to cite this article:
Kuppusamy E, Yahya NA, Mansor N, Awal SH, Subramanam RT, Yazid F. Impact of oral health problems on the quality of life among low income group in an urban area in Malaysia: A preliminary study. J Int Oral Health 2021;13:617-22

How to cite this URL:
Kuppusamy E, Yahya NA, Mansor N, Awal SH, Subramanam RT, Yazid F. Impact of oral health problems on the quality of life among low income group in an urban area in Malaysia: A preliminary study. J Int Oral Health [serial online] 2021 [cited 2022 Aug 18];13:617-22. Available from:

  Introduction Top

In 2016, the FDI World Dental Federation introduced the universal definition of oral health. Oral health is viewed as “multifaceted and includes the ability to speak, smile, smell, taste, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex.”[1] The traditional belief that oral health represents mere absence of disease failed to consider a person’s values, outlook, and expectations, which all together can have an impact on the quality of life (QoL) of an individual. Oral health-related QoL (OHRQoL) is “the impact of oral diseases on aspects of daily life that are valuable to individuals, in sufficient magnitude whether in terms of severity, frequency or duration affect a person’s perception of their life overall.”[2] Oral disease brings great consequences to the individuals and community as a whole due to pain and suffering, deterioration of function, and impaired QoL.[3]

Globally, oral disease is a huge public health problem particularly among low socioeconomic groups in developed and developing countries. There is also a significant difference in the distribution pattern and severity of disease across different geographical areas, even within the same country or region.[3] By the year of 2017, it was reported that the oral health status of elderly population in Malaysia is still unsatisfactory as only 41.4% of 60 years had 20 or more teeth.[4] From the annual report in 2017, for the malignant cases detected from 2003 to 2017, only 24.5% were detected at stage 1 and 58.4% were detected at the later stage. In Indonesia, the national report in 2013 showed an increase of active caries prevalence from 2007 to 2013, with the highest increase at the age of 12 (13.7%) and 65 years (14.3%).[5]

As treatment for oral diseases continues to evolve to cater the changing needs of population, the study by Bhandari et al.[6] concluded that through multi-country comparison, there was a presence of inequalities of adult’s oral health across multiple low- and middle-income countries. In Malaysia, based on the Report of Household Income and Basic Amenities Survey 2016, the Department of Statistic Malaysia defines Top 20% (T20), Middle 40% (M40), and Bottom 40% (B40) as populations with median household incomes of RM13,148, RM6,735, and RM3,000, respectively.[7] Sim and Han[8] suggested that children growing up in low-income families had higher risks of developing periodontal disease. The same pattern was observed in Tehran, Iran where adults from low socioeconomic background experienced more oral disorders when compared with high income adults.[9]

The oral health impact profile (OHIP), developed by Slade and Spencer, measures seven domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. OHIP is a self-reported tool to measure degree of difficulty and disability related to oral diseases. The Malaysian version of OHIP [L-OHIP(M)] contains 45 items grouped into seven domains, derived from the original version. However, the short version used in this study was created following the cross-cultural adaptation which consists of 14 items grouped into seven domains.[10] The aim of this study is to evaluate the impact of oral health problems on the QoL among residents from low income groups in an urban area using the Malaysian Oral Health Impact Profile [S-OHIP(M)].

  Materials and Methods Top

Study design, setting, and subjects

This was a preliminary cross-sectional study conducted in a People’s Housing Project (PPR) located in Kuala Lumpur. This residence area is allocated specifically for those who are from the lower socioeconomic class, i.e., B40 group. Convenience sampling of 45 subjects aged between 18 and 70 years was done during a 1-day Health Carnival organized by Universiti Kebangsaan Malaysia (UKM) in 2018. One of the limitations arising in our sampling method is selection bias as participants were selected based on accessibility and availability. To reduce this, we have used a homogeneous sample in which convenience sampling was narrowed down to only the residents of the PPR, which is a population of low income. This brings us closer to an accurate representation of the B40 population in the study. All the subjects provided their written informed consent to participate in this study; therefore, the response rate was 100%. Inclusion criteria for this study were adults ≥18 years who reside in the residence area and able to converse in Malay language. Respondents submitting incomplete questionnaires are to be excluded.

Research instrument

The questionnaire utilized in this study was the short version of the Oral Health Impact Profile (S-OHIP). The S-OHIP, containing psychometric properties and easily applied, is frequently used in the field of dentistry to measure the OHRQoL due to its solid conceptual and empirical foundation. A version of the questionnaire in Malay language [S-OHIP(M)] was developed and validated following the cross-cultural adaptation of the long form of OHIP by Saub et al.[10] Consent from the authors to use the research instrument had been obtained before the commencement of the study.

The questionnaire consists of three sections which are as follows: (i) demographic information, (ii) 14 items on the perceived oral health problems and their impact on QoL using 5-point Likert scale (very often, fairly often, hardly ever, occasionally, and never), and (iii) seven items consisting of questions related to perceived oral health status (good, fair, poor), perceived dental treatment need (yes, no), satisfaction with oral health (yes, no), and dental status (yes and no). Subjects were required to recall the frequency of experiencing the impact of oral disease for the past 12 months.

Statistical analysis

Microsoft Excel was used for data entry and data analysis using SPSS version 22.0, (Chicago, IL, USA). Descriptive analysis using frequency was used to analyze the demographics and all the items in the questionnaire. The χ2 test was used to assess the differences between age groups in each item for the perceived oral health problem section. A result of P < 0.05 was accepted as statistically significant.

  Results Top

Participants’ characteristics

A total of 45 subjects were invited to participate in this study. The response rate was 100%; however, one of the questionnaires was excluded due to incomplete information. Demographic data of the subjects engaged in this study are shown in [Table 1]. The age range of the subjects was from 18 to 70 years, and the subjects were categorized into two age groups: age below 40 years (<40) to represent young-to-middle-aged adults and age 40 years and above (≥40) which represents middle-to-older-aged group. The mean age was 40.27 years. The majority of the subjects are from the age group of 40 years and above (59.09%) and dominated by females (79.55%) and Malay ethnic (68.18%).
Table 1: Demographic details of the respondents

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Perceived oral health problems

The response to the 14 items evaluating the perceived oral health problems was further categorized into seven domains, as listed in [Figure 1]. For analysis purposes, the 5-point Likert scale was reduced to three groups: “frequent” for very often and fairly often, “moderate” for occasionally and hardly ever, and “never” remaining as a group. In general, the findings show that the majority of the residents revealed that they have experienced the oral health problems included in five domains (functional limitation—75%, physical pain—75%, physiological discomfort—89%, physical disability—68%, and handicap—53%) to some extent as the total percentages of “frequent” and “moderate” responses were higher than the “never.” However, the majority of the residents never experienced the items in the domains of psychosocial disability (52%) and social disability (70%). The descriptive analysis of individual items divided into two age groups is shown in [Table 2]. In general, the most frequent oral health problem reported by respondents was discomfort due to food stuck (47.72%). This item was also most frequently reported by both <40 and ≥40 years old (20.45% vs. 27.27%). A large percentage of the respondents had never experienced social disability as around 68% of them never avoid going out as their oral health condition has minor or no impact on their social interaction. A statistical significance was found between the age group and the frequency of bad breath caused by dental problems (P = 0.048, df=2).
Figure 1: Perceived oral health problem among respondents (%)

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Table 2: Perceived oral health problems among respondents

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Perceived oral health status, dental treatment need, satisfaction with oral health and dental status

A vast majority of the subjects, 33 people (75%), rated their oral health as fair, followed by 7 people (15.9%) as good status and 4 (9.09%) respondents rated their oral health as poor, and this was statistically significant (P < 0.001, df=2). [Table 3] shows the descriptive analysis of the perceived dental treatment need and satisfaction of oral health. The perceived treatment need among the participants in this study was high, as 88.64% of them believed that they required dental treatment for their oral health problems (P < 0.001, df=1). In addition, 68.28% (P = 0.016, df=1) of the subjects were not satisfied with their current oral health conditions, despite the majority of the subjects claiming that they had a fair oral health. There were low incidents of edentulism on arch within the B40 community in PPR in Kuala Lumpur as a low percentage (9%) of the respondents reported that they had missing all teeth in either upper or lower arch. Out of three subjects who had fully edentulous upper arch, only one of them wore an upper denture whereas none of them wore a lower denture, although one of the subjects also has an edentulous lower arch. However, this study has not assessed whether the subjects wore a partial or full denture.
Table 3: Percentage of perceived oral health status, dental treatment need, and oral health satisfaction n (%)

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  Discussion Top

This study was conducted to evaluate the impact of oral health problems on the QoL among residents from low income groups in an urban area. Numerous studies in dentistry have demonstrated that oral health is significantly poorer in the bottom group of socioeconomic class when compared with the upper group. A study done in Sweden reported that poor OHRQoL was more prominent in community with lower education, lower income, and economic resources, and this is contributed by factors such as dental anxiety, financial burden, and poor self-reported oral health.[11] Rosli Tanti et al.[12] report that patients with lower level of education background has significantly reduced mean Mini Nutritional Assessment (MNA) score and number of teeth, indicating the relationship between malnourishment and poor dentition status.

The dominant group of participants for this study is from the Malay ethnic group. This can be a reflection of the demographic of the B40 community in Malaysia as this ethnic group contributes to the highest population in the lower income group. According to the Eleventh Malaysia Plan, 2.7 million people were identified as B40 community and of these, 68% are native people termed as Bumiputera (Malays, indigenous people in east and west Malaysia) and other 32% consist of other ethnic groups (Chinese, Indian, and other minor ethnicities). Higher percentage of the B40 group is reported in urban areas when compared with rural areas. There are 56% B40 community in the urban area and remaining 44% in the rural area.[13]

The results revealed that a substantial proportion of the residents involved in this study experienced the impact associated with their oral health condition. However, only the presence of bad breath caused by dental problems was found to be statistically significant between the younger and older age group. This is in contrast to findings by AlSadhan,[14] where there was no difference in self-reported halitosis in different age groups. The association of halitosis and routine oral care such as daily tongue cleaning has been reported before[15]; however, this cannot be established in this study as the participants’ oral health behavior were not investigated. A different study revealed that halitosis or oral malodor can affect social interaction as they felt anxious, depressed, uncomfortable of having conversation with others, and difficulty to smile and dating.[16] The study also found that more individuals with lower monthly income and lower level of education struggle with concern of oral malodor, in comparison with individuals of higher monthly income who had the highest prevalence in disguising their malodor.

Both age groups most frequently reported discomfort due to food impaction as the most frequent oral health problem. Discomfort due to food impaction is suggestive of underlying neglected decays in the mouth or poor periodontal health. A similar study assessing relationship between oral disease and its impact on carrying out daily performance done in Saudi Arabia also shows eating and enjoying food was the most commonly faced challenge (54.4%) among their study groups and had close association with complaints of toothache.[17] A study done in Brazil suggests that individuals in the older age category were more prone to have chewing difficulty, which explains that the impairment of the natural dentition has a direct impact on chewing disability and intake of healthy diet.[18]

The majority of the participants (88.64%) reported that they do need dental treatment, whereas less than a quarter of the participants perceived that they have good oral health. However, this may not be an accurate representation of the dental treatment need and oral health status as Heft et al.[19] claimed that the use of dichotomous “yes” or “no” options does not provide clear understanding on the assessment of perceived need. “Yes” does not solely indicate the need of dental treatment, but can also indicate the need of regular routine dental examinations. Similarly, “no” does not signify absence of dental problem only, it could be that the problem perceived by an individual does not require immediate attention from dental healthcare professionals. The reported high dental treatment need may also reflect the underutilization of dental healthcare services, which has been associated with lower income population. The population in this study resides in an urban location with accessible public dental services; however, the overcrowding and long waiting time in public facilities may reduce their motivation to attend dental visits.[20]

According to the National Oral Health Plan for Malaysia 2011–2020, the key oral health goals by year 2020 are that 0% of adults in the age group 35–44 are edentulous and 60% of 60-year olds have at least 20 teeth.[21] In this study, there was a low percentage of denture wearer reported. The participants who reported that they are denture wearers were below 40 years old and although two participants who were ≥40 years were fully edentulous; they did not own any dentures. The reasons for not wearing dentures were not explored in this study; however, edentulous individuals should be encouraged to obtain further care from dental professionals. Elderly who wear dentures had improved OHRQoL in comparison to non-denture wearers due to easier chewing, less avoidance of food, and the comfort in eating.[21] The limitation of the study lies on the method of recruitment of the subject. As the study was done during a health carnival, people who have more significant oral health problems that affect their quality of life may have not participated in this study. Therefore, this study is not a representation of the whole B40 community and a larger sample size with multiple PPR housing areas can be explored in the future. Another limitation is that we only assessed the association of two age groups and their QoL; however, other social demographic factors and their oral health behavior factors possibly have an impact on their perceived oral health problems. The final limitation will be recall bias as respondents had to answer based on their past experience leading to under- or over-reporting of the condition. Overall, this preliminary study has provided an overview of the impact of oral health problems in low income groups (B40) in Malaysia. Future research needs to be done to include a larger sample size of the population and to correlate the OHRQoL instrument with clinical findings in the low income group.

  Conclusion Top

In conclusion, the majority of residents from a lower socioeconomic status in an urban area experienced the impact on QoL mostly pertaining to physiological discomfort. Majority of the residents were not satisfied with their oral health status, and the perceived dental treatment need is deemed to be high. Assessment of social inequalities in oral health is crucial so that we can reflect on differences in oral health care needs and preventive practices. This ensures that priorities in the oral health system are made accordingly.


Our grateful thanks and deepest appreciation to Universiti Kebangsaan Malaysia (UKM) for granting this study under research fund (GGPM-2018-046) and to all the faculty staff, Dewan Bandaraya Kuala Lumpur and the residents involved for the support.

Financial support and sponsorship

This research was funded by Universiti Kebangsaan Malaysia (UKM) under research fund (GGPM-2018-046).

Conflicts of interest

There are no conflicts of interest.

Authors’ contribution

Data collection was done by FY and NM, data acquisition and analysis were done by SHA, NAY, and EK, data interpretation by NAY, FY, and EK and finally the manuscript was written by EK, FY, and RTS.

Ethical policy and Institutional Review Board statement

Ethical approval (UKM PPJ/111/8/JEP-2018-402) was granted from the Research Ethics Committee, Universiti Kebangsaan Malaysia.

Patient declaration of consent

All the subjects involved in the survey have provided written informed consent to participate in this cross-sectional study.

Data availability statement

Data are available upon reasonable request from the corresponding author at [email protected]

  References Top

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Locker D, Allen F. What do measures of “oral health-related quality of life” measure? Community Dent Oral Epidemiol 2007;35:401-11.  Back to cited text no. 2
WHO l World Oral Health Report 2003 [Internet]. 2019 [cited November 21, 2019]. Available from: [Last accessed on January 26, 2021].  Back to cited text no. 3
Annual Report 2017. Oral Health Program Ministry of Health Malaysia [Internet]. 2019 [cited November 21, 2019]. Available from: [Last accessed on February 7, 2021].  Back to cited text no. 4
Pratiwi NL. The trend analysis of the availability of dental caries and dental health personnel in Indonesia. Dentistry 2016;6:360.  Back to cited text no. 5
Bhandari B, Newton JT, Bernabé E. Social inequalities in adult oral health in 40 low- and middle-income countries. Int Dent J 2016;66:295-303.  Back to cited text no. 6
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Wide U, Hakeberg M. Oral health-related quality of life, measured using the five-item version of the oral health impact profile, in relation to socio-economic status: A population survey in Sweden. Eur J Oral Sci 2018;126:41-5.  Back to cited text no. 11
Rosli Tanti I, Ting Kathy BY, Mei Lim H, Xin Lim R, Ashar Nor A, Yeo S. Dentition and risk of malnutrition among elderly patients in Faculty of Dentistry, Universiti Kebangsaan Malaysia, Malaysia: A cross-sectional study. Int J Med Sci Public Health 2020;9:13-9.  Back to cited text no. 12
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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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