This study aimed to determine the prevalence of oral healthcare utilisation and used Andersen’s Behavioural Model to identify associated factors of oral healthcare utilisation by adults in Malaysia. Oral healthcare utilisation in the last 12 months by adults in Malaysia was 13.2%. Inequalities were observed; females, married individuals, younger adults, those with higher education, those who had medical check-up in the last 12 months, and those with higher income were more likely to utilise oral healthcare.
Oral healthcare utilisation in Malaysia is still low, considering the efforts done by the Ministry of Health Malaysia to encourage participation and utilisation of oral healthcare services. Every year, various oral health promotion activities such as community outreach programmes which offers free oral examination and awareness talk to target groups were conducted by the Ministry of Health Malaysia to increase oral health awareness and encourage oral healthcare utilisation among the public. However, participation is often low  which prompts a need for future studies to explore the reasons for the lack of enthusiasm among the public towards programmes conducted by the Ministry of Health Malaysia. Across 27 Organisation for Economic Co-operation and Development (OECD) countries, around 63% of individuals reported oral healthcare utilisation in the past year , which was higher compared to Malaysia. Compared to neighbouring countries like Thailand [range of 6.63% (aged 60 years and over)—8.81% (aged 15–24 years)]  and Indonesia [regular users: 1.2% (aged 15 years and over)] , Malaysia fared better in oral healthcare utilisation. However, Malaysia’s oral healthcare utilisation was low when compared to middle income countries like Brazil [less than one year since last dental visit: 44.4% (aged 18 years and over)] . Nonetheless, these data are not directly comparable due to differences in methods and variable measured. Low oral healthcare utilisation may be associated with low perceived need for oral healthcare . In 2010, adults in Malaysia who never sought oral healthcare stated not having any oral healthcare problem as the most common reason for non-utilisation of oral healthcare . In 2015, 73.4% of the population in Malaysia experienced oral health problem(s) but did not seek oral healthcare, with the majority (46.1%) practising self-medication .
The NOHSA 2010 indicated that 27.4% of the adult population aged 15 years and above utilised oral healthcare in the past one year, a finding much higher than our study. A possible explanation could be the fact that the NOHSA 2010 was conducted by interviewers who were oral healthcare professionals while our study interview was conducted by research assistants who were not oral healthcare professionals . Study have shown interviewer effect on respondents during data collection in public health surveys which tend to introduce a bias where the respondent reports the desired answer to escape negative consequences or out of fear [33, 34]. The NOHSA 2010 also included respondents aged 15 to 17 years old compared to our study which included only respondents aged 18 years and above . The incremental school oral health programme in Malaysia covers students up to the age of 17 years old, which could explain the higher oral healthcare utilisation rate in NOHSA 2010 compared to our study .
Published literature suggests an inverse relationship between regular oral healthcare utilisation and increasing age . In this study, working age adults (18–59 years) were more likely to utilise oral healthcare than the elderly (≥ 60 years). Lo et al.  found oral healthcare utilisation of preventive purpose in young adults (35 to 44 years) and curative purpose in the elderly (65 to 75 years). Harford et al.  indicated a high proportion of adults (25–44 years) going for oral health check-up. Oral Health Care Programme for the Elderly was introduced by the Ministry of Health Malaysia in 1983 as an initiative to promote oral health among the elderly . Its implementation was confined within residential institutions, while a revised guideline in 2002 included national oral health goals such as domiciliary oral healthcare services, facilities and delivery systems improvement, elderly care training for oral health professionals and caregivers, and multi-sector collaborations to promote oral health for the elderly . Oral healthcare utilisation among the elderly was still low despite the various efforts; 14.7% of Malaysians aged 60 years and over had never seen a dentist, and 86.1% did not use oral healthcare during the previous year . Having a problem (65.2%), completing treatment (18.6%), and being sent a reminder (1.5%) was the main reason for their last oral healthcare utilisation . The same study indicated that less than 10% of adults in Malaysia reported the need for timely oral healthcare utilisation . Barriers to elderly oral healthcare utilisation were not specifically reported, with around 24.8% expressing some fear of oral healthcare utilisation .
This study showed that higher educated groups utilise oral healthcare services more than the less educated, a finding consistent with other study . Education may be correlated with higher health consciousness which stimulates preventive behaviour such as regular oral healthcare utilisation . According to findings from NHMS 2019, only 29.9% of population with oral health problems within two weeks prior to the interview perceived the need to seek treatment from a healthcare practitioner . The main reasons for not seeking care from a healthcare practitioner when they had oral health problems were not being sick enough to necessitate treatment, work commitment, and self-medication . These findings indicate that there is still a lack of awareness among the population in Malaysia regarding the importance of prevention in oral health. A national population study in Malaysia conducted in year 2019 showed sufficient health literacy level in only 40.7% of the population, followed by limited health literacy level in 35.0% and excellent health literacy level in 24.3% of the population . However, data from the World Bank in 2018 shows that adults in Malaysia had literacy rate of 94.85% which is relatively high compared to some neighbouring country such as Thailand which had literacy rate of 93.77% in the same year . This prompts the need to explore other factors such as local culture, beliefs, and taboos which could have contributed to the lack of awareness on the importance of prevention in oral health, leading to low utilisation of oral health services.
The higher odds of oral healthcare utilisation among population with medical check-up in this study could be attributed to the antenatal programme , as antenatal check-up was considered a form of medical check-up in NHMS 2019. Oral health is integral to general health. Having a health condition would necessitate a medical check-up and those with long standing health condition have been associated with higher utilisation of oral healthcare services . Additional knowledge on oral health among other healthcare groups would ensure patient’s oral health needs are addressed and appropriate referral to the dentist is made during routine medical check-up. For instance, individuals with risk factor for oral health problem such as non-communicable diseases and smoking should be referred to the dentist whenever possible . As such, medical, nursing, and allied-health programmes in institutions of higher learning could incorporate inter-professional and multidisciplinary oral health education as part of their curriculum to enable identification of oral health conditions and make appropriate referrals for oral healthcare, in preparation for future healthcare teams to manage people holistically in their general health as well as oral health [4, 43].
In our study, the richest income quintile had greater odds of visiting the dentist than the poorest income quintile, in line with the positive effect of income on oral healthcare utilisation . A study among low income Canadians indicated oral healthcare utilisation as a competing financial demand for economically constrained adults . In OECD countries, differences in visits between high and low-income groups were almost 20% (72% of wealthier individuals visited a dentist, compared with 54% among those from the lowest income quintile), indicating large socioeconomic disparities . Low socioeconomic status may be associated with more emotional and physical consequences of seeking care when complications have occurred . In Malaysia, health-related tax relief are available for complete medical examination and medical expenses for serious diseases for self, spouse, child, as well as medical expenses for parents but oral healthcare services are not considered for income tax relief . Income tax relief for oral health examination for self, spouse, or child and oral healthcare expenses for parent(s) could be implemented in a similar way to that of medical healthcare as a way to promote utilisation of oral healthcare services in the country, especially in the private sector for those who can afford it, to reduce congestion in the public sector . Andersen  noted that oral healthcare utilisation was more likely explained by predisposing social structure (e.g. education), predisposing health belief, and enabling factors (e.g. income).
The trend of oral healthcare utilisation among the population of all age groups in Malaysia has always been low. Recent studies indicated the prevalence of oral healthcare utilisation ranged from 22.4 to 23.7% between 2011 and 2019 [23, 32, 47]. Regular oral healthcare utilisation is important to prevent more complicated and costly procedures in the future. Therefore, it is important to improve the rate of oral healthcare utilisation among the population. Inequalities and inequities in oral healthcare services are prevalent worldwide [48,49,50]. Oral healthcare inequities in low and middle income countries are rooted in access to services and lack of preventative care . Globally, lack of access to oral healthcare remains a major burden to public health. Although oral healthcare in Malaysia is accessible to all, there are still significant inequalities in oral healthcare utilisation, with the higher income population having better conditions to access these services . Barriers in oral healthcare primarily centred on cost, public health prioritisation, and access; both organisational and geographical [53,54,55,56]. In Malaysia, studies have indicated dental fear, time constraints, dissatisfaction with the services rendered such as long waiting time and no immediate treatment given by the dentist, and perception of not having any oral health problems as barriers to oral healthcare utilisation [57, 58]. By understanding factors which influence utilisation of oral healthcare, improvement in oral healthcare utilisation could be achieved through appropriate interventions. Oral healthcare inequalities could be reduced through the implementation of effective and appropriate oral health promotion policies such as population-oriented preventive approach and integrated public health policies [59, 60].
Strengthening collaboration between the public and private sectors, non-governmental organisations (NGO), and social welfare groups to deliver oral healthcare outreach services to vulnerable groups such as the elderly could help improve oral healthcare access . Enhancement of the existing domiciliary oral healthcare services for the elderly in Malaysia to cater to more individuals who are unable to attend oral healthcare clinics could also help boost utilisation . Campaigns which advocate the importance of and interrelationship between general health and oral health through multi-sector collaboration and concerted efforts could help improve public awareness and health services utilisation . In Malaysia, collaboration between the Ministry of Health Malaysia and various organisations not limiting to the Institute of Teacher Education, Oral Cancer Research and Coordinating Centre Malaysia and religious bodies were established to provide oral health talks and free oral examination through outreach programmes to the community they collaborate with . Public–private collaboration such as the Alliance for a Cavity-Free Future Programme between the Ministry of Health Malaysia and the dental industry had a vision of achieving a future generation with zero cavity and better oral health . Continuous monitoring and evaluation of existing programmes such as community empowerment programmes are essential for continuity of the programmes and their success in imparting oral healthcare knowledge to the public especially among those with lower levels of education . In Malaysia, monitoring and evaluation of programmes are routinely done to gauge their effectiveness and acceptance, but in many instances there was poor uptake of the activities of the programmes by the community , which suggest a need to explore the public’s perception on the effectiveness of these approaches as well as barriers which led to the poor response of the programmes in future studies.
Improving the population’s social determinants of health could help improve oral healthcare access [59, 64]. In line with the universal health coverage agenda, oral health check-up and basic oral healthcare should be included as part of primary healthcare benefits package to strengthen healthcare financial mechanism . In Malaysia, oral healthcare in the public sector is largely subsidised by the government and accessible to all citizens, yet utilisation is still low. The long waiting time to see the dentist in the public sector due to overcrowding in public facilities may have reduced the motivation of the population from their regular dental check-up . In order to reduce this waiting time, the Ministry of Health Malaysia in year 2009 implemented a key performance indicator (KPI) for patient waiting time . Over the years, Malaysia has seen an increase in the number of dentists in Malaysia, but without an appreciable increase in infrastructure or equipment  and this incompatibility between the number of professionals and facilities does not translate into better access to oral health for the public. Further study to understand the reasons for non-utilisation of oral healthcare despite the efforts poured by the Ministry of Health Malaysia to encourage participation is required so that appropriate interventions that cater to the needs of the population could be formulated to boost up oral healthcare utilisation in Malaysia.
This study used a large sample size involving nationwide population which enables generalisation of results across adults in Malaysia. One limitation to consider is that possible explanations for utilisation differences in oral healthcare like need factors (such as perception and attitudes to oral healthcare, and health literacy) , community-related factors (such as availability of health personnel and facilities, travelling cost, distance to facility, and waiting time)  and social determinants of health (such as social networks, social interactions, and culture)  were not captured in this study. Another limitation is that NHMS data is a twelve-month self-recall data which is subjected to potential recall bias and the possibility of under-reporting .