INTRODUCTION:

The state of wellbeing or healthiness is often determined by factors that assess the quality of life (QoL). The factors that assess QoL consider that the impacts of a certain disease or related disability cannot always be determined by clinical examination ¹.Oral diseases are also known to hinder the daily routine activities which may result in discontinuity or absence at work/school ^2,3. The poor oral health and associated deviation from a state of well-being significantly takes a toll on a person’s personal satisfaction levels. Oral disorders such as dental pain, tooth abscesses, tooth decay, fractured teeth, and gum disease are reported to affect the QoL of children. This can occur due to indirect effects on the social and mental aspects of health and by posing challenges in carrying out routine tasks such as eating and playing ^1,2.

The Child Oral Impacts on Daily Performances (Child-OIDP) index is one of the most widely used tools to assess Oral Health Related Quality of Life (OHRQoL) in children⁴. The child- OIDP was developed in 2004 based on modifications to its framework made from the World Health Organisation (WHO) International Classification of Impairment, Disabilities and Handicaps standards⁵. The Child-OIDP index allows an investigator to assess a range of OHRQoL dimensions ranging from oral health impairments, functional limitations and disabilities thus making it an ideal tool for measuring impacts of oral health in children⁶.The tool is a questionnaire which measures performance of 8 daily activities namely eating, speaking clearly, cleaning teeth, relaxing, emotional stability (being impatient and easily agitated), smiling/ laughing, doing schoolwork/ housework and socialising. The Child-OIDP scores are not only useful to assess oral health impacts in children but also useful in helping clinicians to prioritize their treatment needs⁶. Furthermore, the index may be adopted in evaluating treatment needs/ treatment outcomes or may direct policy makers to conduct population surveys and interventional community programs ^7,8.

Various studies in children assessing their OHRQoL were conducted in Asian countries such as China ⁹,India ^1,10and Iran ¹¹.However, studies which assessed OHRQoL in Malaysia are few especially among school children thus there is a need to assess the impact of oral health on QoL in this set of the population. This is particularly important for school children in many rural and religious schools across Malaysia which are not covered for annual screening and treatment (where needed) by the Government School Oral Health Services due to resource constraints. A Malay version of the Child-OIDP index (pretested and validated) developed with reference to the existing English version was found ¹².Permission was granted to use this validated Malay version of the index in this study. This will to a certain extent ensure that the Malay school children selected as the sample for this study will be able to understand the questionnaire better. Thus, the aim of the of the present study was to use the validated Malay version of the Child-OIDP index to measure the prevalence of oral impacts on daily performances and OHRQoL among 12–16-year-old school children in a rural religious school in Kedah state, Malaysia.

MATERIALS AND METHODS:

This study was conducted at Madrasah (Religious School) Zubaidiyah, Merbok Kedah. Ethical clearance was obtained from the AIMST University Human Ethics Committee before commencement of the study.

The study was conducted on 195 participants, recruited by purposive sampling, belonging to age group of 12-16 years. Necessary permission from the school authorities along with written informed consent (from parents/ guardians) from all the subjects was obtained before commencement of the study. Those students who were in the age group of 12 -16 years who were not having any diagnosed physical/mental disabilities and willing to answer the survey were included. Those who were unwilling/ uncooperative or with diagnosed reading disabilities were excluded from the study.

A pre-validated and pre-tested structured Child-OIDP self-administered questionnaire which was a Malay version of the existing tool was used to assess the outcome of the study. This questionnaire, which was previously employed for similar studies in Malaysia, had psychometric properties and validity (of the content and construct) and reliability (internal and test-retest) was shown to be as robust as the English version ¹².

A briefing in Malay was given to all children in the sample in small groups according to their school class to ensure that the Malay school children in the rural school were able to read and understand the questionnaire before answering. The first part of the questionnaire asked the school children to select their perceived oral health problems in the last 3 months from a list of 17 oral health problems. They were then asked to complete the second part which assessed the oral impacts on performance of 8 daily activities. If the children reported that there was an impact on any activity, they were asked to score the frequency and severity of each reported oral impact. The frequency and severity of each impact were scored on a 3-point Likert scale (1- being once or twice a month, 2- once or twice a week, and 3- three or more times a week; For severity the scores were: 1- little effect, 2 - moderate effect and 3 - severe effect). Each performance score is obtained by multiplying the frequency score by the severity score. The overall Child - ODIP score was calculated as the sum of the 8 performance scores ranging from 0 to 72 ⁹.

Children who reported an impact on their daily activity were further asked to identify the oral conditions from the same list of 17 oral health problems as in the first part of the questionnaire that they felt were causes of their impacts.

The participants were given printed questionnaire sheets (in Malay language) and were asked to answer them in the presence of the principal investigator. The procedure was well explained prior to the provision of these printed copies. The answered copies were collected, data was coded, entered in excel sheets, and subjected to statistical analysis.

Statistical analysis:

Statistical analysis was carried out using SPSS version 22 software, (IBM Corp, Armonk NY). The mean OIDP scores were calculated for gender and age differences with p<0.05 considered for significance. Impacts on the 8 daily performances due to oral health problems were expressed as frequency and percentages.

RESULTS:

The study population consisted of 195 participants with 49.7% (n=97) boys and 50.3% (n=98) girls. The maximum participants were aged 14 years [31.3% (n=61)] followed by 13 years 26.2% (n=51). The age wise distribution is depicted in table 1. The distribution of the mean OIDP scores among study population were elucidated in table 2.

Table 1: The age and gender distribution of the study population

Age group	Sex	n	Frequency
13 years	Boys	28	54.9%
13 years	Girls	23	45.1%
Total		51	100
14 years	Boys	33	54.1%
14 years	Girls	28	45.9%
Total		61	100
15 years	Boys	16	43.3%
15 years	Girls	21	56.7%
Total		37	100
16 years	Boys	12	42.9%
16 years	Girls	16	57.1%
Total		28	100
17 years	Boys	8	44.4%
17 years	Girls	10	55.6%
Total		18	100

The overall mean OIDP scores were 20.0±6.40 and 20.2±5.31 for boys and girls respectively with insignificant inter-gender differences (p=0.847). The mean OIDP scores were not significant between the different age groups of 13 to 17 years old (p=0.444). (Table 3)

Table 2: The distribution of the mean OIDP scores among study population

Age group	Sex	n	Mean OIDP score
13 years	Boys	28	22.42±6.23
13 years	Girls	23	20.13±5.94
Total		51	21.39±6.15
14 years	Boys	33	18.81±6.85
14 years	Girls	28	20.71±5.68
Total		61	19.68±6.36
15 years	Boys	16	18.37±3.50
15 years	Girls	21	20.42±3.68
Total		37	19.54±3.70
16 years	Boys	12	19.66±7.65
16 years	Girls	16	18.87±3.51
Total		28	19.21±5.56
17 years	Boys	8	20.12±6.55
17 years	Girls	10	20.20±8.17
Total		18	20.16±7.28

Table 3. The distribution of the overall mean and p values among the study population

Mean

P value

Gender

Male

Female

20.0±6.40

20.2±5.31

0.84

Age

13 to 17 Years

21.2±4.21

0.44

Activity 1: (Difficulty in Eating)

38.5% (n=75) reported difficulty in eating some types of foods because of their oral problems in the last 3 months. Among those who reported difficulties, 18.5% (n= 36) reported the issue to occur once or twice a month, 13.8% (n=27) reported that the issue occurred once or twice a week and 6.2% (n=12) reported issues three times or more a week. About the level of disruption of daily living due to these issues, 18.5 % (n=36) of the participants reported low disruption, while 17.9% (n=35) and 2.1% (n=4) reported a moderate and high level of disruption of daily living respectively. The frequency of responses for activity 2 (difficulty speaking clearly) and activity 3 (difficulty cleaning the teeth) are shown in table 4.

Table 4. Responses for Activity 2 (difficulty in speaking clearly) and Activity 3 (difficulty in cleaning the teeth) of study population.

Activity	Question/ frequency of issue/ level of effect	Frequency	Percentage
Activity 2 – Difficulty in speaking clearly

Prevalence	In the last 3 months, have you had difficulty in speaking clearly because of your oral problem?
	Yes	26	13.3
	No	169	86.7
Severity (frequency)	Once or two times a month	12	6.2
	Once or two times a week	10	5.1
	Three times or more a week	4	2.1
Severity (Level of disruption)	Low	14	7.2
	Moderate	10	5.1
	High	2	1.0
Activity 3 – Difficulty in cleaning the teeth
Prevalence	In the last 3 months, have you had difficulty in cleaning your teeth because of your tooth and mouth problem?
	Yes	74	37.9
	No	121	62.1
Severity (frequency)	Once or two times a month	39	20.0
	Once or two times a week	21	10.8
	Three times or more a week	14	7.2
Severity (Level of disruption)	Low	43	22.1
	Moderate	26	13.3
	High	5	2.6

Activity 4: (Difficulty Relaxing)

13.3% (n=26) reported they had difficulty in relaxing (including resting and sleeping) because of their oral problems. Among those who reported the difficulties, 6.2% (n= 12) reported the issue to occur once or twice a month, 5.6% (n=11) reported the issues occurred once or twice a week and 1.5% (n=3) reported the issues occurred three times or more a week. The level of disruption of daily living due to these issues also showed the same pattern of reporting.

The frequency of responses for activity 5 (emotional stability), activity 6 (difficulty in smiling and laughing) and activity 7 (difficulties in carrying out schoolwork/ housework) are shown in table 5.

Table 5. Frequency of responses for activity 5-7 of study population

Activity	Question/ frequency of issue/ level of effect	Frequency	Percentage
Activity 5 – Emotional stability
Prevalence	In the last 3 months, have you had a ‘different feeling’ and were impatient, easily angered or easily offended because of your oral problem?
	Yes	36	18.5
	No	159	81.5
Severity (frequency)	Once or twice a month	18	9.2
	Once or twice a week	12	6.2
	Three times or more a week	6	3.1
Severity (Level of disruption)	Low	20	10.3
	Moderate	10	5.1
	High	6	3.0
Activity 6 – Difficulty smiling and laughing
Prevalence	In the last 3 months, have you had difficulty in smiling, laughing and showing your teeth because of your oral problem?
	Yes	57	29.2
	No	138	70.8
Severity (frequency)	Once or twice a month	25	12.8
	Once or twice a week	11	5.6
	Three times or more a week	21	10.8
Severity (Level of disruption)	Low	26	13.3
	Moderate	16	8.2
	High	15	7.7
Activity 7 – Difficulty carrying out schoolwork/housework
Prevalence	In the last 3 months, have you had difficulty in carrying out schoolwork/housework because of your oral problem?
	Yes	25	12.8
	No	170	87.2
Severity (frequency)	Once or twice a month	14	7.2
	Once or twice a week	8	4.1
	Three times or more a week	3	1.5
Severity (Level of disruption)	Low	10	5.1
	Moderate	12	6.2
	High	3	1.5

Activity 8: (Difficulty in Socializing)

17.9% (n=35) reported they had difficulty in socializing with others (such as going out or meeting with friends) because of their oral problems. Among those who reported difficulties, 8.2% (n= 16) reported the issue to occur once or twice a month, 5.6% (n=11) reported the issues occurred once or twice a week, and 4.1% (n=8) reported issues three times or more a week. Regarding the level of disruption of daily living due to these issues, 5.1 % (n=10) of the participants reported a low level of disruption, while 9.2% (n=18) and 3.6% (n=7) had reported a moderate and high level of disruption of daily living respectively.

The oral health problems relating to the respective activity had open-ended options and were not answered by some participants making an overall analysis difficult. The results of those who reported problems are summarized in percentages. Tooth pain (28.2%), tooth decay (33.2%), mouth ulcer/painful ulcers (12.1%) were most reported for causing ‘difficulties in eating’. Gaps between teeth (10.5%), discolored teeth (22.2%) and tooth decay (33.2%) were reported as major reasons for ‘difficulty in speaking clearly’. Swollen gums (6.3 %) and mouth ulcer/painful ulcers (12.1%) were the chief reasons reported for ‘difficulty in cleaning the teeth’. Malocclusion (23.3%), bad breath (33.5%) and loss of tooth (22.7%) were reported for ‘feeling different/emotional stability due to oral problems. Malocclusion (23.3%), gaps between (14.2%) teeth and tooth discoloration (33.4%) were reported for ‘difficulty in smiling, laughing and showing your teeth’. Mouth ulcer/painful ulcers (18.1%), decayed tooth (22.1%) and bad breath (16.2%) were reported for ‘difficulty in carrying out schoolwork/housework’. Decayed teeth, bad breath, discolored teeth, mouth ulcers, and missing teeth were all reported for more than one disrupted activity. Overall, the main dental problems reported were decayed teeth (38.2%), tooth pain (32.8%), mouth ulcers (25.6%), discolored teeth (21.2%), bad breath (20.5%), malocclusion (18.2%) and gaps between teeth (16.2%) considering all activities.

DISCUSSION:

The study population consisted of 195 participants with 49.8% boys and 50.2% girls belonging to the age group 13 – 17 years. Clark and Watson indicated that for an index with less than 20 items or less, a sample size between 100 to 200 subjects was reasonable. Thus, for this study using the Malay Child-OIDP index with eight items, the sample size of 195 subjects was deemed appropriate ¹⁶.

An Indian study was conducted on a total of 100 children, in which 63% were males and 37% females with a mean age of participants of 15.1 years ± 2.1 ¹_.The mean age is in line with the current study, but not the gender distribution. A higher representation of female subjects in the current study has a positive aspect to be mentioned. The gender distribution described here was like that of an Iranian study (51.4% females vs. % 48.6% males) ¹¹.

In the current study, the mean OIDP scores showed insignificant inter-gender differences (p=0.847), which was also reported in a previous study ¹¹. However, another study reported that male participants had higher OIDP scores as compared to females, but the age distribution of participants was uneven in the study¹_.Evidence from the current study suggests that the rural background had brought about variations in OIDP scores/ OHRQoL rather than gender ^9,13.

The current study showed that the four most prevalent performance difficulties due to oral problems (from highest to lowest) was difficulty in eating in 38.5%, difficulty in cleaning the mouth in 37.9%, difficulty in smiling and laughing in 29.2% and disrupted emotional stability in 18.5% of the students respectively. This was followed by difficulty in socializing in 17.9%, difficulty in speaking clearly in 13.3%, difficulty in relaxing in 13.3% and difficulty in carrying out school activities in 12.8% of the students respectively.

The overall duration and intensity of the problem bothering them was also found to be severe in fewer subjects compared to other studies. These problems did not differ significantly between boys and girls, and between the age groups. A previous study on oral health behaviors had reported similar findings but reported a difference in terms of ‘oral health behavior’s and not in the rest of the assessed parameters of the OIDP index ¹⁰.

In the current study, there was substantial non-participation and low uniformity for the last part of the questionnaire regarding the dental problems causing the difficulty in daily performance of the activity under each of the eight activity-based questions. This is possibly attributable to the ‘open ended nature’ of the questions and lack of understanding of dental disease terminologies by the school students. Marking multiple options (sometimes 10-12 options) for a single activity was often encountered in the answering pattern. This may be a disadvantage of the questionnaire and could be addressed in forthcoming modifications to the questionnaire. This also posed a concern regarding the accuracy of whether the difficulty in a specific activity could be attributed to a particular dental problem. However, overall, the dental problems most reported to be causing difficulty in performing the eight daily activities were decayed teeth, tooth pain, mouth ulcers, discolored teeth, malocclusion, gaps between teeth and bad breath in that order.

The finding that tooth decay was a main cause for OHRQoL lowering which further endorsed by a recent Indian study, showed that OHRQoL was significantly associated with the 'decayed' component only and that multiple regression analysis showed OHRQoL to be significantly associated with dental caries¹³.A meta-analysis had reported that a high level of dental caries was associated with poor OHRQoL and that children with higher prevalence of dental caries were 1.66 times more likely to have poor OHRQoL than caries-free children ^14,15. Another study also concluded that the relative risk of negative impact on OHRQoL was 4 folds higher among children having early childhood caries (ECC). A significant upward trend of impaired OHRQoL with increasing standard caries scores was also reported ¹⁵. Other dental problems were also cited in studies apart from decayed teeth. The most common problem among urban and rural residents was dental pain, perceived self-consciousness, and embarrassment in a Chinese study. The study also showed that a short version of the Oral Health Impact Profile (OHIP-14) and the OIDP index (used in the current study) had a slight advantage for the OHIP-14 in determining OHRQoL though both had a good degree of validity ⁹.

The strength of the present study lies in the sizeable sample size and addressing children in an unexplored locality especially in a rural religious based school. The limitations lie in the methodology which was dependent on subjective reported responses of children chosen as a convenience sample. Another was there no objective clinical verification of the dental problems reported. We recommend an adjunct clinical verification of the dental problems reported by the subjects for their difficulties in performing the eight daily dental activities and affecting their OHRQoL to get a better understanding of the data collected. A recent systematic review had pointed out that factors such as lower age, gender, lower income levels, and low maternal education were significantly linked with poor OHRQoL among children ¹⁴. Thus, a future study could also investigate other factors affecting OHRQoL in the context of rural and religious school-based children.

CONCLUSION:

The validated Malay version of the Child-OIDP questionnaire used in this study has been shown to be a useful tool to determine OHRQoL among Malay speaking school children in Malaysia. A sizeable number of children in the rural based school reported difficulties in performing eight daily activities thus affecting their OHRQoL due to their dental problems. Dental problems namely decayed tooth, tooth pain, mouth ulcers, discolored teeth, and malocclusions/ gaps between teeth in that order were reported to be causing these difficulties in performing the activities.

CONFLICTS OF INTEREST:

The authors declare that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.

ACKNOWLEDGEMENTS:

The school authorities of Madrasah Zubbadiyah, Merbok, Kedah for their assistance and support in data collection from their students. The Research Management Centre, AIMST University for their guidance in getting this article published.

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Received on 08.03.2023 Modified on 16.04.2023

Research J. Pharm. and Tech 2023; 16(5):2347-2352.

DOI: 10.52711/0974-360X.2023.00386