Oral Health Perceptions Among Elite Athletes and Elite Para-Athletes: Psychosocial Impacts, Sports Performance

Oral Health Perceptions Among Elite Athletes and Elite Para-Athletes: Psychosocial Impacts, Sports Performance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Oral Health Perceptions Among Elite Athletes and Elite Para-Athletes: Psychosocial Impacts, Sports Performance Jessica Francis, Lynn Wei Linn Ko, Aisyah Ahmad Fisal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7308874/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: Oral health, part of general health, is essential for optimal athletic performance and well-being. Aims: To compare perceived oral health status, psychosocial and performance impacts among national elite para-athletes (EP) and elite athletes (EA). Methods: An cross-sectional, descriptive and comparative study was conducted using purposive sampling of EP & EA at the National Sports Institute, Malaysia. A validated questionnaire adapted from the Oral Health Screening Toolkit for Athletes (University College London) was administered from February 2022 to February 2024. Data were analysed descriptively and inferentially. Results: Participation involved 57 EP and 57 age- and sex-matched EA. Perceived oral health was positive in 40(70.1%) EP and 35(61.4%) EA, with more perceiving their general health positively. Perceived general or oral health showed no significant differences across groups. Psychosocial impacts were comparable, but EA reported significantly greater performance-related impacts (mean difference = 7.84, p = 0.019). Stronger correlations between perceived oral and general health were observed in EA. Discussion: The higher performance-related impacts among EA may reflect sport-specific physical demands and psychosocial factors. Correlations between perceived oral and general health underscore the importance of integrated care. Conclusion: Accessible, athlete-specific oral healthcare is needed to support well-being and performance in both groups. Health sciences/Health care/Dentistry/Special care dentistry Figures Figure 1 Introduction Oral health is fundamental to overall health, well-being and quality of life 1 . It influences not only physical function—such as eating and speaking—but also psychosocial domains including self-esteem and social participation 2 , 3 , 4 . Among athletes, oral health plays a crucial yet often overlooked role in influencing both general health and athletic performance 5 , 6 , 7 , 8 . The relationship between sports participation and oral health has largely been investigated through the lens of risk of trauma to oral health 5 , 9 . However, recent literature highlights broader oral health concerns in elite athletes, including dental caries, periodontal disease, erosive tooth wear, and third molar pathology 6 , 7 , 10 , 11 , 12 , 13 . These conditions can contribute to pain, reduced quality of life, and impaired sports performance 6 , 14 , 15 . Elite athletes (EA) are defined as individuals competing at an international level and could include teams or individuals of any gender, age, or ethnicities” 16 . The International Paralympic Committee defines a para-athlete as a sportsperson with an impairment participating in competitive sport 17 . For elite para-athletes (EP), the challenges of maintaining oral health are compounded by systemic and structural barriers commonly faced by persons with disabilities (PWDs), such as limited access to dental care, transportation difficulties, and complex medical comorbidities 18 , 19 , 20 , 21 . While adapted sports have been shown to improve physical and psychological outcomes among PWDs, including enhanced quality of life and life satisfaction, para-athletes remain at elevated risk for poor oral health 22 . This dual burden—being both an elite athlete and a PWD—may exacerbate oral health neglect and its consequences. Despite the increasing recognition of oral health issues among EA, research examining the psychosocial impacts and performance-related consequences of oral health in EP remains scarce. To date, no study has directly compared these impacts between EA and EP. This study aims to fill this knowledge gap by exploring and comparing oral health perceptions, psychosocial impacts, and performance implications among EA and EP. Such insights are essential to inform inclusive, targeted strategies in both dental and sports medicine domains 23 . Methods The study design is depicted in Fig. 1 . A cross-sectional quantitative study was conducted among EA and EP aged 16 years and above, trained at the National Sports Institute (NSI), Malaysia. A purposive sampling strategy was used. The EP population size (N = 68) formed the reference group, with the minimum sample size (n = 58) calculated using a finite population correction formula at 95% confidence level and 5% precision 24 . An equal number of EA were sampled for comparison. Inclusion criteria were EP and EA aged 16 and above being trained at the NSI with the ability to understand and consent to participate. Exclusion criteria included athletes who were unavailable during data collection, declined consent, or had medical, cognitive, or intellectual impairments that precluded participation. The study was registered with the National Medical Research Register (NMRR). Ethical approval was obtained from the Faculty of Dentistry Medical Ethics Committee (FDMEC), Universiti Malaya, and the National Sports Institute Research Ethics Committee. All participants received a Participant Information Sheet and provided informed consent, in compliance with the Declaration of Helsinki (2008). Participant data were kept confidential, accessible only to the research team, and only aggregated group data were analysed and reported, in compliance with the Personal Data Protection Act 2010. Data collection occurred between February and June 2022 for EP, and April 2023 to February 2024 for EA. Scheduling was coordinated with annual medical screening to maximise participation. Consent was obtained via signed physical forms or secure digital forms through Google Form, following distribution of a written Participant Information Sheet. The questionnaire used was adapted from the Oral Health Screening Toolkit by the Centre for Oral Health and Performance, UCL Eastman Dental Institute 25 . It captured sociodemographic data, self-perceived general and oral health, psychosocial impacts, and effects of oral health on sports performance. Translated Malay versions had been validated and pilot tested previously. The bilingual (Malay/English) questionnaire was self-administered or interviewer-assisted when needed. Interviewers adhered to a fixed script, with permission to paraphrase in lay terms to aid understanding for participants with limited literacy or disabilities. Hard copy questionnaires were used when digital access was limited. Participation was further encouraged by displaying QR codes in NSI clinics and sending reminders via athlete networks. Participants received a voucher as a token of appreciation. Age- and sex-matching was conducted to compare EA with EP. Exact age matching was not feasible; instead, a ± 3-year age margin was applied to allow for flexibility while maintaining comparability 26 . A total of 116 EA were recruited to match 58 EP. One age outlier (49 years) was excluded. The final matched sample achieved a mean age difference of 1.78 years. Matching by sport was not possible due to the smaller size of the EP population. Data were entered and analysed using a standard statistical package (IBM SPSS Statistics, version 26.0). Self-rated health and oral health were measured using a 5-point Likert scale, later dichotomised into “good/very good” vs. “fair/poor/very poor.” Psychosocial impacts were assessed through questions on eating, relaxing, and smiling due to oral health, with responses dichotomised as “no impact” or “any impact”. Impacts on sports performance were based on reported difficulties in training/competition, pain, and training reduction over the past 12 months. Responses were similarly dichotomised 25 . A severity score out of 100 was also calculated for impact quantification. Normality of data was assessed using the Kolmogorov-Smirnov test, followed by skewness and kurtosis (± 2 threshold) 27 . Depending on distribution, Pearson or Spearman correlations were used to examine associations. Group comparisons between EA and EP employed independent t-tests or Mann-Whitney U tests for numerical data and chi-square tests for categorical variables. A significance level of 0.05 was used. The study adhered to the STROBE reporting guidelines 28 . Results Table 1 tabulates the sociodemographic and sports characteristics of participants. The sample included a diverse representation of indigenous ethnicities. Most EP (70.2%) achieved higher secondary or pre-university education, with seven (12.3%) attaining tertiary education. In contrast, 33(57.9%) EA had higher secondary or pre-university education, while 21(36.9%) held tertiary qualifications, including postgraduate degrees. The distribution of education levels differed significantly between EP and EA (P = 0.006), indicating a significant association between education level and athlete category (Supplementary Table 1). The mean sports career duration is 8.7 years (SD 4.44) for EP and 13.0 years (SD 4.50) for EA. Participants represented 11 para sports and 12 elite sports disciplines. As shown in Table2, most of the respondents generally rated their general health and oral health as good or very good, though 11(19.3%) EP and 14(24.6%) EA reported otherwise. In total, 17(29.8%) EP and 22(38.6%) EA were bothered by their oral health. Over half of both groups experienced oral health-related psychosocial impacts in the past 12 months — 30 (52.6%) EP and 38 (66.7%) EA (Table 2). This is evidenced by a non-zero score for: difficulty with eating or drinking (40.3% EP; 59.6% EA), difficulty to relax (28.1% EP; 40.4% EA) and difficulty smiling, laughing or showing teeth without embarrassment (26.3% EP; 31.6% EA) (Supplementary Table 2). Severity scores for oral health-related psychosocial impacts recorded the highest score of 50 for EP and 83.33 for EA. Similarly, 29 (50.9%) EP and 33 (57.9%) EA reported oral health-related sports performance impacts within the last 12 months (Table 2). This included difficulty to participate in regular training and competition (15.8% EP; 33.3% EA), reduced training volume (15.8% EP; 33.3% EA), affected performance (17.5% EP; 28.1% EA) and oral pain (45.6% in both groups) (Supplementary Table 3). The highest severity score were 41 for EP and 80 for EA. There was no significant difference in perceived general health status between EP and EA (χ²(1) = 0.46, p = 0.497) (Supplementary Table 4), nor in perceived oral health status (χ²(1) = 0.97, p = 0.324) (Supplementary Table 5). Similarly, Mann-Whitney test indicated the total psychosocial impact scores did not differ significantly between EP (Median=8.33, IQR=20.83) and EA (Median=8.33, IQR=25.0, p > 0.05) (Supplementary Table 6). Independent t-test showed significant difference in total sports performance impact score between EP (M=9.23, SD=12.14)) and EA (M=17.07, SD=21.59) with a difference of -7.84 (95% CI,-14.3 to -1.3), t (112)=2.39, p =0.019 (Table 3). Spearman’s correlation showed a positive association between perceived general health and oral health in both groups, with a weak correlation among EP (r = 0.35, p = 0.008) and a moderate correlation among EA (r = 0.55, p < 0.01) (Table 4). Discussion Sociodemographic profile The age- and sex-matched design enabled valid comparisons between the groups. The shorter sports career observed among EP may reflect later entry into elite-level sports due to acquired disabilities or less early development opportunities for para sports. This trend is consistent with previous findings reflecting inequalities in sports access for PWDs 29 . A significant disparity in educational attainment was noted, with fewer EPs achieving tertiary education compared to EAs. This aligns with known barriers to education for PWDs, including inaccessible infrastructure, limited academic support, and financial constraints 29 . Literature indicates that lower educational attainment is associated with poor oral health knowledge, inadequate oral hygiene and lower retention of natural teeth 30 , 31 . In contrast, international data suggest higher tertiary education rates among elite athletes—for instance, 47.4% of elite athletes in UK who had or were in the midst of attaining a university degree; and 52.6% with higher education qualification in a population of Dutch athletes qualified for the Olympic and Paralympic Games, though the proportion of para-athletes was not stated 14 , 32 . These educational disparities may affect oral health literacy and access to preventive care. Perceived Oral Health Status The perceived general and oral health status was relatively similar across groups. However, differences emerged when comparing self-perceived oral health status. A higher proportion of EP reported poor or fair oral health compared to EA, similar to that reported in a UK study where 30.8% of EA perceived their oral health negatively 14 . Interestingly, both groups rated their oral health less favourably than their general health, suggesting oral health remains a low priority or more problematic aspect of well-being. This supports prior findings that oral health concerns, such as pain and aesthetics, may exert disproportionate influence on quality of life 1 , 33 . The relative positivity in general health ratings, particularly among EPs, may reflect adaptive expectations or resilience in response to chronic health conditions—consistent with the “disability paradox,” where subjective well-being does not necessarily mirror objective health status 34 . Correlations Between Perceived Health and Oral Health The correlation between perceived oral and general health was positive in both groups, stronger among EA. This reinforces the growing recognition of the interdependence between oral and systemic health 1 , 2 . Similar associations have been reported in diverse populations, such as Yemeni dental patients and the general German population 3 , 4 . While this study cannot infer causality, it suggests that perceptions of oral health may influence overall well-being, and vice versa. Among athletes, this relationship may be particularly important, given the systemic impacts of high-sugar diets, sports supplements, dehydration, and acidic beverages used during training 6 . Psychosocial and Sports Performance Impacts of Oral Health The study revealed substantial oral health-related psychosocial impacts. EAs experienced slightly higher psychosocial effects, though not significant. One possible explanation is the higher level of public visibility and media exposure faced by EAs, which can heighten concern about appearance and aesthetics 35 , 36 . The high prevalence of difficulties in eating, smiling, or social engagement suggests that oral health significantly influences psychological comfort and daily functioning. This highlights the importance of addressing oral health not only from a clinical standpoint but also as a determinant of mental and social well-being. A substantial proportion of both groups reported that oral health affected their sports performance. While EAs had higher impact scores overall, both groups cited oral pain as a major concern. These results highlight how even seemingly minor oral problems can compromise training, concentration, and performance outcomes. Compared with international benchmarks, the rates of oral health-related psychosocial and sports performance impacts observed in this Malaysian sample were higher than those reported among athletes in the UK, Netherlands, and at the London 2012 Olympics 7 , 11 , 14 , 32 (Supplementary Table 7). They also exceeded previous Malaysian data on elite athletes, suggesting a possible worsening trend or differences attributable to sample characteristics 10 . It is plausible that the matched age groups in this study presented with more accumulated oral health issues compared to earlier studies that included younger athletes. Results from the present study align with Malaysian adult population, whereby 52.8% reported impact of oral conditions on quality of life 37 . Implications for EA & EP Functional limitations from oral discomfort, especially during training and competition, can impair performance by affecting nutrition, hydration, and focus 7 , 11 , 14 Moreover, sports diets rich in carbohydrates and energy drinks elevate risk for caries, erosion, and inflammation, which further compromise athletic performance 13 . Pain and chewing difficulty may hinder food intake, digestion, and recovery, all of which are critical for athletic success 5 , 14 . These mechanisms reinforce the need for integrating athlete-centred oral healthcare protocols into sports performance management frameworks 23 . While these challenges affect all athletes, EP face additional, compounding barriers to maintaining oral health, such as reduced dexterity for oral hygiene, dietary modifications, altered salivary flow due to medications or systemic conditions, and limited access to dental care 12 , 38 , 39 , 40 . Though not directly measured in this study, these risk factors likely contribute to the high prevalence of oral health-related psychosocial and performance impacts observed among EP. The findings affirm the need for preventive strategies tailored to both athlete groups, including individualised oral hygiene education, accessible dental services, and athlete-specific nutrition advice. In parallel, sports governing bodies should integrate oral health into routine health screenings and medical support services, particularly for vulnerable groups like EP. Conclusions This is the first known global comparison of oral health perceptions, psychosocial effects, and performance impacts between EA and EP. While both groups reported good general health, over half experienced oral health-related impacts—particularly performance-related issues, which were significantly higher among EA. These findings highlight the critical role of oral health in overall well-being and athletic success. Integrating oral health into sports medicine is essential, especially for EP, an underrepresented population who face additional barriers. Tailored prevention, screening, and access to dental care within sports medicine and public health frameworks are needed to support equitable health and performance outcomes across athlete populations. Declarations Author contributions All authors conceptualised and designed the study. LK obtained ethics approval and funding, liaised with the National Sports Institute for participant recruitment, coordinated project administration, conducted data collection and analysis in consultation with a faculty statistician, and drafted the manuscript. AAF reviewed and validated the data analysis. JF and AAF supervised the project and critically revised the manuscript for content. All authors approved the final version of the manuscript. Acknowledgements The authors thank Universiti Malaya (UM), the National Sports Institute of Malaysia, participating athletes, supervisors, colleagues, and support staff for their contributions to this research. This study was registered with the NMRR (ID-23-00571-R4T) and approved by FDMEC (DF CD2325/0050(P)) and the NSI Research Ethics Committee (RE/A/004/2023-002/2023). Funding was provided by the UM Dental Postgraduate Research Grant (UMG011E-2023). Data availability The datasets generated and/or analysed during the current study contain personal data and are not publicly available due to participant confidentiality and GDPR requirements. Aggregated and anonymised summary data are included within this article. References Sheiham A. Oral health, general health and quality of life. Bull World Health Organ. 2005;83(9):644. Chapple I, Wilson N. Chronic non-communicable diseases. Br Dent J. 2014;216(9):487-. Alhajj MN, Halboub E, Amran AG, Alkheraif AA, Al-Sanabani FA, Al-Makramani BM, et al. Link between perceived oral and general health status among Yemeni adult dental patients. BMC Oral Health. 2019;19(1):93. Reissmann DR, John MT, Schierz O, Kriston L, Hinz A. Association between perceived oral and general health. Journal of Dentistry. 2013;41(7):581–9. Ashley P, Di Iorio A, Cole E, Tanday A, Needleman I. Oral health of elite athletes and association with performance: a systematic review. Br J Sports Med. 2014;49(1):14–9. Needleman I, Ashley P, Fine P, Haddad F, Loosemore M, de Medici A, et al. Oral health and elite sport performance. Br J Sports Med. 2015;49(1):3–6. Needleman I, Ashley P, Petrie A, Fortune F, Turner W, Jones J, et al. Oral health and impact on performance of athletes participating in the London 2012 Olympic Games: a cross-sectional study. Br J Sports Med. 2013;47(16):1054–8. Gomes TC, Gomes Moura JL, Baia-da-Silva DC, Lima RR, Rodrigues PdA. Twenty-first century knowledge mapping on oral diseases and physical activity/exercise, trends, gaps, and future perspectives: a bibliometric review. Front Sports Act Living. 2024;6:1410923. Derman W, Schwellnus M, Jordaan E, Blauwet CA, Emery C, Pit-Grosheide P, et al. Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff. Br J Sports Med. 2013;47(7):420–5. Mohammad-Hassan NH, Mohd Noor NS, Mohamed Nazari NS, Abidin ZZ, Azami NH, Needleman I. High level of oral disease and self-reported performance impacts in Malaysian elite athletes [Poster presentation]. Br J Sports Med. 2021;55(Suppl 1):A172-A3. Needleman I, Ashley P, Meehan L, Petrie A, Weiler R, McNally S, et al. Poor oral health including active caries in 187 UK professional male football players: clinical dental examination performed by dentists. Br J Sports Med. 2015;50(1):41–4. Attin T, Körner P, Wegehaupt F. Erosive tooth wear among athletes. Quintessence Int. 2021;52(10):912–9. Schulze A, Busse M. Sports Diet and Oral Health in Athletes: A Comprehensive Review. Medicina. 2024;60(2):319. Gallagher J, Ashley P, Petrie A, Needleman I. Oral health and performance impacts in elite and professional athletes. Community Dent Oral Epidemiol. 2018;46(6):563–8. Schwesig R, Born P, Kurz E, Schulze S, Panian M, Marshall RP, et al. Oral Health Conditions and Physical Performance in Two Different Professional Team Sports in Germany: A Cross-Sectional Study. Sports. 2025;13(7):206. Swann C, Moran A, Piggott D. Defining elite athletes: Issues in the study of expert performance in sport psychology. Psychology of Sport and Exercise. 2015;16:3–14. Weiler R, Blauwet C, Clarke D, Dalton K, Derman W, Fagher K, et al. Concussion in para sport: the first position statement of the Concussion in Para Sport (CIPS) Group. Br J Sports Med. 2021;55(21):1187–95. Klenck C, Gebke K. Practical management: common medical problems in disabled athletes. Clin J Sport Med. 2007;17(1):55–60. Vanlandewijck YC, Thompson WR. Handbook of sports medicine and science: The Paralympic athlete: John Wiley & Sons; 2011. Hamzah S. Special Needs Dentistry (Snd) In Malaysia: A Way Forward. Malaysian Dental Journal. 2012;34(1):33–6. Lee J-Y, Lim K-C, Kim S-Y, Paik H-R, Kim Y-J, Jin B-H. Oral health status of the disabled compared with that of the non-disabled in Korea: A propensity score matching analysis. PloS one. 2019;14(1):e0208246-e. Yazicioglu K, Yavuz F, Goktepe AS, Tan AK. Influence of adapted sports on quality of life and life satisfaction in sport participants and non-sport participants with physical disabilities. Disabil Health J. 2012;5(4):249–53. Júdice A, Botelho J, Machado V, Proença L, Ferreira LMA, Fine P, et al. Sports dentistry intricacies with season-related challenges and the role of athlete-centered outcomes. Front Oral Health. 2025;6:1531653. Krejcie RV, Morgan DW. Determining sample size for research activities. Educational and Psychological Measurement. 1970;30(3):607–10. Needleman I, Ashley P. UCL Oral Health Screening Toolkit. University College London, Eastman Dental Institute; 2017. Rosenbaum PR, Rubin DB. The Central Role of the Propensity Score in Observational Studies for Causal Effects. Biometrika. 1983;70(1):41–55. George D, Mallery P. SPSS for Windows Step by Step: A Simple Guide and Reference, 17.0 Update: Allyn & Bacon; 2010. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9. Vaquero-Cristóbal R, Maciá-Andreu MJ, Díaz-Aroca Á, Meroño L, García-Roca JA, Abenza-Cano L, et al. Exploring the perception of barriers to a dual career by student-athletes with/out disabilities. PLOS ONE. 2023;18(5):e0286152. Márquez-Arrico CF, Almerich-Silla JM, Montiel-Company JM. Oral health knowledge in relation to educational level in an adult population in Spain. J Clin Exp Dent. 2019;11(12):e1143-e50. Paulander J, Axelsson P, Lindhe J. Association between level of education and oral health status in 35-, 50-, 65- and 75-year-olds. J Clin Periodontol. 2003;30(8):697–704. Kragt L, Moen MH, Van Den Hoogenband C-R, Wolvius EB. Oral health among Dutch elite athletes prior to Rio 2016. Phys Sportsmed. 2019;47(2):182–8. Locker D. Psychosocial consequences of dental fear and anxiety. Community Dent Oral Epidemiol. 2003;31(2):144–51. Albrecht GL, Devlieger PJ. The disability paradox: high quality of life against all odds. Social Science & Medicine. 1999;48(8):977–88. Rees L, Robinson P, Shields N. Media portrayal of elite athletes with disability - a systematic review. Disabil Rehabil. 2017;41(4):374–81. Kovacs A, Doczi T. Elite athletes and media appearances: opportunity or obligation? Sport in Society. 2020;23(7):1136–45. Saub R, Locker D. The impact of oral conditions on the quality of life of the Malaysian adult population: preliminary results. Med J Malaysia. 2006;61(4):438–46. Andrade RA, Evans PL, Almeida AL, da Silva Jde J, Guedes AM, Guedes FR, et al. Prevalence of dental trauma in Pan American games athletes. Dental Traumatol. 2010;26(3):248–53. Navarro Azevedo de Azeredo F, Silva Guimarães L, Azeredo A. Antunes L, Santos Antunes L. Global prevalence of dental caries in athletes with intellectual disabilities: An epidemiological systematic review and meta-analysis. Spec Care Dentist. 2019;39(2):114 – 24. Ostrowska A, Szymański W, Kołodziejczyk Ł, Bołtacz-Rzepkowska E. Evaluation of the Erosive Potential of Selected Isotonic Drinks: In Vitro Studies. Adv Clin Exp Med. 2016;25(6):1313–9. Tables Table 1 Sociodemographic and Sports Characteristics Elite Para-Athletes (n=57) Elite Athletes (n=57) n (%) n (%) Gender Male 47 (82.5) 47 (82.5) Female 10 (17.5) 10 (17.5) Mean Age (years) 26.98 25.19 PWD Category Physical disability 40 (70.2) Learning disability 9 (15.8) Visual Impairment 7 (12.3) Multiple disabilities 1 (1.8) Education Level SPM or equivalent 37 (64.9) 29 (50.9) STPM or equivalent 3 (5.3) 4 (7.0) Diploma or equivalent 5 (8.8) 9 (15.8) Degree 2 (3.5) 11 (19.3) Postgraduate (Master/PhD) - 1 (1.8) Others 10 (17.5) 3 (5.3) Ethnic Group Malay 41 (71.9) 32 (56.1) Indian 3 (5.3) 13 (22.8) Chinese 5 (8.8) 7 (12.3) Sabah Bumiputera 1 (1.8) 4 (7.0) Sarawak Bumiputera 6 (10.5) 1 (1.8) Multi-ethnic - - Others 1 (1.8) - Mean Sports career duration (years) 8.75 13.02 Type of Para Sports Para Athletics, Field & Track 19 (33.3) Para Cycling 7 (12.3) Para Badminton 6 (10.5) Para Archery 4 (7) Boccia 3 (5.3) Para Powerlifting 4 (7) Para Swimming 4 (7) Para Table Tennis 4 (7) Wheelchair Fencing 4 (7) Para Shooting 1 (1.8) Wheelchair Tennis 1 (1.8) Table 1 (continued) Sociodemographic and Sports Characteristics Elite Para-Athletes (n=57) Elite Athletes (n=57) n (%) n (%) Type of Sports Field Hockey 2 (3.5) Karate - Kumite 12 (21.1) Shooting 3 (5.3) Table Tennis 4 (7) Sepaktakraw 8 (14) Squash 2 (3.5) Taekwondo - Kyorugi 2 (3.5) Boxing 6 (10.5) Boxing Sparring 1 (1.8) Silat- Sparring 7 (12.3) Silat- Artistic 8 (14) Brazilian Jiu-jitsu 2 (3.5) Table 2 Perceived Health & Oral Health Status, Psychosocial & Sports Performance Impacts Elite Para-Athletes (n=57) Elite Athletes ( n=57) n(%) n(%) Perceived Health Status Very good 21 (36.8) 15 (26.3) Good 25 (43.9) 28 (49.1) Fair 9 (15.8) 13 (22.8) Poor 2 (3.5) 1 (1.8) Perceived Oral Health Status Very good 10 (17.5) 9 (15.8) Good 30 (52.6) 26 (45.6) Fair 9 (15.8) 18 (31.6) Poor 8 (14) 4 (7.0) Psychosocial Impacts No Impact 27 (47.4) 19 (33.3) Any Impact 30 (52.6) 38 (66.7) Psychosocial Impacts Score (%) 11.4 (mean) 8.33 (median) Impact on Sports Performance No Impact 28 (49.1) 24 (42.1) Any Impact 29 (50.9) 33 (57.9) Sports Performance Impacts Score (%) 9.23 (mean) 17.07 (mean) Table 3 Comparing mean total impact score for oral health related sports performance impacts between elite para-athletes and athletes Variable n Total Sports Performance Impact Score Mean (SD) Mean difference (95% CI) t statistic ( df ) p -value a Elite Athletes -7.84 (-14.3, -1.3) 2.39 (112) 0.019 Para-Athletes 57 9.23 (12.14) Athletes 57 17.07 (21.59) Note: a Independent t test SD= Standard Deviation CI= Confidence Interval n = frequency df = Degrees of Freedom Table 4 Correlation between perceived health and oral health status among elite athletes Perceived Oral Health Status Elite Para-Athletes Elite Athletes Correlation coefficient p value Correlation coefficient p value Perceived Health Status 0.349 p<0.05 (0.008) 0.549 p<0.001 Additional Declarations There is no duality of interest Supplementary Files SupplementaryTable17MSS20251093.docx Supplement Table 1-7 Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: revise 05 Jan, 2026 Review # 3 received at journal 02 Jan, 2026 Reviewer # 3 agreed at journal 13 Dec, 2025 Reviewer # 2 agreed at journal 04 Oct, 2025 Review # 1 received at journal 17 Aug, 2025 Reviewer # 1 agreed at journal 17 Aug, 2025 Reviewers invited by journal 15 Aug, 2025 Editor assigned by journal 11 Aug, 2025 Submission checks completed at journal 11 Aug, 2025 First submitted to journal 06 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7308874","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":501066928,"identity":"f420a043-107a-44c6-b48f-625961482876","order_by":0,"name":"Jessica Francis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYBACxgYgkcDAwA/mJTDYgGkJYrRINkC0pBHWAgMQLQwMhwlrYW5vf/zhQY2dhHn72YMfHvw5n7i2gfngbR6GbYkNuBzWc8ZMIuFYsoTMmbxkicS224nbDrAlW/Mw3MatZUYOG0NiA3OdBEOOGZAB0sJjJo1Xy/znjz8kNtRLSPC/MWNI+HMOqIX/G34tMxgMJBIbDktISABtSWA7ALKFDb+WnhyQX44DtbwxBvol2XjbYTZjyzkGt41xaTFsP/7444+aaqDDcgw//vhjJ7vtePPDG28qbsvi1IIpwQwiDBgccWmRxyHOwGCPU2YUjIJRMApGGgAAjftai5hOyC4AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-2216-3922","institution":"Universiti Malaya","correspondingAuthor":true,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Francis","suffix":""},{"id":501066929,"identity":"88ef7389-2c35-4b97-b733-5b3ca4974b49","order_by":1,"name":"Lynn Wei Linn Ko","email":"","orcid":"","institution":"Universiti Malaya","correspondingAuthor":false,"prefix":"","firstName":"Lynn","middleName":"Wei Linn","lastName":"Ko","suffix":""},{"id":501066930,"identity":"07304222-33dd-4f5d-bbd5-83fac7d140b6","order_by":2,"name":"Aisyah Ahmad Fisal","email":"","orcid":"","institution":"Faculty of Dentistry, Universiti Malaya","correspondingAuthor":false,"prefix":"","firstName":"Aisyah","middleName":"Ahmad","lastName":"Fisal","suffix":""}],"badges":[],"createdAt":"2025-08-06 10:41:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7308874/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7308874/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90285164,"identity":"94516fe9-836f-49df-bc52-fb0141fda9cd","added_by":"auto","created_at":"2025-09-01 05:54:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29463,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Design\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7308874/v1/db644a636ea49144274e0489.png"},{"id":90285224,"identity":"817423e5-df3c-4568-ba84-7721df989853","added_by":"auto","created_at":"2025-09-01 05:54:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":957724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7308874/v1/8fa293c5-ab3d-4984-b206-6f33898a89db.pdf"},{"id":90285149,"identity":"db5dfe25-3d08-40b1-9088-ad1e65a30579","added_by":"auto","created_at":"2025-09-01 05:54:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31631,"visible":true,"origin":"","legend":"Supplement Table 1-7","description":"","filename":"SupplementaryTable17MSS20251093.docx","url":"https://assets-eu.researchsquare.com/files/rs-7308874/v1/0b3db5ea1c2e9eb2fc10de3a.docx"}],"financialInterests":"There is no duality of interest","formattedTitle":"Oral Health Perceptions Among Elite Athletes and Elite Para-Athletes: Psychosocial Impacts, Sports Performance","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOral health is fundamental to overall health, well-being and quality of life \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It influences not only physical function\u0026mdash;such as eating and speaking\u0026mdash;but also psychosocial domains including self-esteem and social participation \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Among athletes, oral health plays a crucial yet often overlooked role in influencing both general health and athletic performance \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe relationship between sports participation and oral health has largely been investigated through the lens of risk of trauma to oral health \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. However, recent literature highlights broader oral health concerns in elite athletes, including dental caries, periodontal disease, erosive tooth wear, and third molar pathology \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. These conditions can contribute to pain, reduced quality of life, and impaired sports performance \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eElite athletes (EA) are defined as individuals competing at an international level and could include teams or individuals of any gender, age, or ethnicities\u0026rdquo; \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The International Paralympic Committee defines a para-athlete as a sportsperson with an impairment participating in competitive sport \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. For elite para-athletes (EP), the challenges of maintaining oral health are compounded by systemic and structural barriers commonly faced by persons with disabilities (PWDs), such as limited access to dental care, transportation difficulties, and complex medical comorbidities \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWhile adapted sports have been shown to improve physical and psychological outcomes among PWDs, including enhanced quality of life and life satisfaction, para-athletes remain at elevated risk for poor oral health \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. This dual burden\u0026mdash;being both an elite athlete and a PWD\u0026mdash;may exacerbate oral health neglect and its consequences.\u003c/p\u003e\u003cp\u003eDespite the increasing recognition of oral health issues among EA, research examining the psychosocial impacts and performance-related consequences of oral health in EP remains scarce. To date, no study has directly compared these impacts between EA and EP.\u003c/p\u003e\u003cp\u003eThis study aims to fill this knowledge gap by exploring and comparing oral health perceptions, psychosocial impacts, and performance implications among EA and EP. Such insights are essential to inform inclusive, targeted strategies in both dental and sports medicine domains \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study design is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A cross-sectional quantitative study was conducted among EA and EP aged 16 years and above, trained at the National Sports Institute (NSI), Malaysia. A purposive sampling strategy was used. The EP population size (N\u0026thinsp;=\u0026thinsp;68) formed the reference group, with the minimum sample size (n\u0026thinsp;=\u0026thinsp;58) calculated using a finite population correction formula at 95% confidence level and 5% precision \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. An equal number of EA were sampled for comparison.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eInclusion criteria were EP and EA aged 16 and above being trained at the NSI with the ability to understand and consent to participate. Exclusion criteria included athletes who were unavailable during data collection, declined consent, or had medical, cognitive, or intellectual impairments that precluded participation.\u003c/p\u003e\u003cp\u003eThe study was registered with the National Medical Research Register (NMRR). Ethical approval was obtained from the Faculty of Dentistry Medical Ethics Committee (FDMEC), Universiti Malaya, and the National Sports Institute Research Ethics Committee. All participants received a Participant Information Sheet and provided informed consent, in compliance with the Declaration of Helsinki (2008). Participant data were kept confidential, accessible only to the research team, and only aggregated group data were analysed and reported, in compliance with the Personal Data Protection Act 2010.\u003c/p\u003e\u003cp\u003eData collection occurred between February and June 2022 for EP, and April 2023 to February 2024 for EA. Scheduling was coordinated with annual medical screening to maximise participation. Consent was obtained via signed physical forms or secure digital forms through Google Form, following distribution of a written Participant Information Sheet. The questionnaire used was adapted from the Oral Health Screening Toolkit by the Centre for Oral Health and Performance, UCL Eastman Dental Institute \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. It captured sociodemographic data, self-perceived general and oral health, psychosocial impacts, and effects of oral health on sports performance. Translated Malay versions had been validated and pilot tested previously. The bilingual (Malay/English) questionnaire was self-administered or interviewer-assisted when needed. Interviewers adhered to a fixed script, with permission to paraphrase in lay terms to aid understanding for participants with limited literacy or disabilities. Hard copy questionnaires were used when digital access was limited. Participation was further encouraged by displaying QR codes in NSI clinics and sending reminders via athlete networks. Participants received a voucher as a token of appreciation.\u003c/p\u003e\u003cp\u003eAge- and sex-matching was conducted to compare EA with EP. Exact age matching was not feasible; instead, a\u0026thinsp;\u0026plusmn;\u0026thinsp;3-year age margin was applied to allow for flexibility while maintaining comparability \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. A total of 116 EA were recruited to match 58 EP. One age outlier (49 years) was excluded. The final matched sample achieved a mean age difference of 1.78 years. Matching by sport was not possible due to the smaller size of the EP population.\u003c/p\u003e\u003cp\u003eData were entered and analysed using a standard statistical package (IBM SPSS Statistics, version 26.0). Self-rated health and oral health were measured using a 5-point Likert scale, later dichotomised into \u0026ldquo;good/very good\u0026rdquo; vs. \u0026ldquo;fair/poor/very poor.\u0026rdquo; Psychosocial impacts were assessed through questions on eating, relaxing, and smiling due to oral health, with responses dichotomised as \u0026ldquo;no impact\u0026rdquo; or \u0026ldquo;any impact\u0026rdquo;. Impacts on sports performance were based on reported difficulties in training/competition, pain, and training reduction over the past 12 months. Responses were similarly dichotomised \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. A severity score out of 100 was also calculated for impact quantification.\u003c/p\u003e\u003cp\u003eNormality of data was assessed using the Kolmogorov-Smirnov test, followed by skewness and kurtosis (\u0026plusmn;\u0026thinsp;2 threshold) \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Depending on distribution, Pearson or Spearman correlations were used to examine associations. Group comparisons between EA and EP employed independent t-tests or Mann-Whitney U tests for numerical data and chi-square tests for categorical variables. A significance level of 0.05 was used. The study adhered to the STROBE reporting guidelines \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable 1 tabulates the sociodemographic and sports characteristics of participants. The sample included a diverse representation of indigenous ethnicities. Most EP (70.2%) achieved higher secondary or pre-university education, with seven (12.3%) attaining tertiary education. In contrast, 33(57.9%) EA had higher secondary or pre-university education, while 21(36.9%) held tertiary qualifications, including postgraduate degrees. The distribution of education levels differed significantly between EP and EA (P = 0.006), indicating a significant association between education level and athlete category (Supplementary Table 1). The mean sports career duration is 8.7 years (SD 4.44) for EP and 13.0 years (SD 4.50) for EA. Participants represented 11 para sports and 12 elite sports disciplines.\u003c/p\u003e\n\u003cp\u003eAs shown in Table2, most of the respondents generally rated their general health and oral health as good or very good, though 11(19.3%) EP and 14(24.6%) EA reported otherwise. In total, 17(29.8%) EP and 22(38.6%) EA were bothered by their oral health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOver half of both groups experienced oral health-related psychosocial impacts in the past 12 months\u0026nbsp;— 30 (52.6%) EP and 38 (66.7%) EA (Table 2). This is evidenced by a non-zero score for: difficulty with eating or drinking (40.3% EP; 59.6% EA), difficulty to relax (28.1% EP; 40.4% EA) and difficulty smiling, laughing or showing teeth without embarrassment (26.3% EP; 31.6% EA) (Supplementary\u0026nbsp;Table 2). Severity scores for oral health-related psychosocial impacts recorded the highest score of 50 for EP and 83.33 for EA.\u003c/p\u003e\n\u003cp\u003eSimilarly, 29 (50.9%) EP and 33 (57.9%) EA reported oral health-related sports performance impacts within the last 12 months (Table 2). This included difficulty to participate in regular training and competition (15.8% EP; 33.3% EA), reduced training volume (15.8% EP; 33.3% EA), affected performance (17.5% EP; 28.1% EA) and oral pain (45.6% in both groups) (Supplementary Table 3). The highest severity score were 41 for EP and 80 for EA.\u003c/p\u003e\n\u003cp\u003eThere was no significant difference in perceived general health status between EP and EA (χ²(1) = 0.46, \u003cem\u003ep\u003c/em\u003e = 0.497) (Supplementary Table 4), nor in perceived oral health status (χ²(1) = 0.97, \u003cem\u003ep\u003c/em\u003e = 0.324) (Supplementary Table 5). Similarly, Mann-Whitney test indicated the total psychosocial impact scores did not differ significantly between EP (Median=8.33, IQR=20.83) and EA (Median=8.33, IQR=25.0, \u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05) (Supplementary Table 6). Independent t-test showed significant difference in total sports performance impact score between EP (M=9.23, SD=12.14)) and EA (M=17.07, SD=21.59) with a difference of -7.84 (95% CI,-14.3 to -1.3), \u003cem\u003et\u003c/em\u003e(112)=2.39, \u003cem\u003ep\u003c/em\u003e=0.019 (Table 3). Spearman’s correlation showed a positive association between perceived general health and oral health in both groups, with a weak correlation among EP (r = 0.35, p = 0.008) and a moderate correlation among EA (r = 0.55, p \u0026lt; 0.01) (Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic profile\u003c/h2\u003e\u003cp\u003eThe age- and sex-matched design enabled valid comparisons between the groups. The shorter sports career observed among EP may reflect later entry into elite-level sports due to acquired disabilities or less early development opportunities for para sports. This trend is consistent with previous findings reflecting inequalities in sports access for PWDs \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA significant disparity in educational attainment was noted, with fewer EPs achieving tertiary education compared to EAs. This aligns with known barriers to education for PWDs, including inaccessible infrastructure, limited academic support, and financial constraints \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Literature indicates that lower educational attainment is associated with poor oral health knowledge, inadequate oral hygiene and lower retention of natural teeth \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. In contrast, international data suggest higher tertiary education rates among elite athletes\u0026mdash;for instance, 47.4% of elite athletes in UK who had or were in the midst of attaining a university degree; and 52.6% with higher education qualification in a population of Dutch athletes qualified for the Olympic and Paralympic Games, though the proportion of para-athletes was not stated \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. These educational disparities may affect oral health literacy and access to preventive care.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePerceived Oral Health Status\u003c/h3\u003e\n\u003cp\u003eThe perceived general and oral health status was relatively similar across groups. However, differences emerged when comparing self-perceived oral health status. A higher proportion of EP reported poor or fair oral health compared to EA, similar to that reported in a UK study where 30.8% of EA perceived their oral health negatively \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Interestingly, both groups rated their oral health less favourably than their general health, suggesting oral health remains a low priority or more problematic aspect of well-being. This supports prior findings that oral health concerns, such as pain and aesthetics, may exert disproportionate influence on quality of life \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. The relative positivity in general health ratings, particularly among EPs, may reflect adaptive expectations or resilience in response to chronic health conditions\u0026mdash;consistent with the \u0026ldquo;disability paradox,\u0026rdquo; where subjective well-being does not necessarily mirror objective health status \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eCorrelations Between Perceived Health and Oral Health\u003c/h3\u003e\n\u003cp\u003eThe correlation between perceived oral and general health was positive in both groups, stronger among EA. This reinforces the growing recognition of the interdependence between oral and systemic health \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Similar associations have been reported in diverse populations, such as Yemeni dental patients and the general German population \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. While this study cannot infer causality, it suggests that perceptions of oral health may influence overall well-being, and vice versa. Among athletes, this relationship may be particularly important, given the systemic impacts of high-sugar diets, sports supplements, dehydration, and acidic beverages used during training \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePsychosocial and Sports Performance Impacts of Oral Health\u003c/h2\u003e\u003cp\u003eThe study revealed substantial oral health-related psychosocial impacts. EAs experienced slightly higher psychosocial effects, though not significant. One possible explanation is the higher level of public visibility and media exposure faced by EAs, which can heighten concern about appearance and aesthetics \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. The high prevalence of difficulties in eating, smiling, or social engagement suggests that oral health significantly influences psychological comfort and daily functioning. This highlights the importance of addressing oral health not only from a clinical standpoint but also as a determinant of mental and social well-being. A substantial proportion of both groups reported that oral health affected their sports performance. While EAs had higher impact scores overall, both groups cited oral pain as a major concern. These results highlight how even seemingly minor oral problems can compromise training, concentration, and performance outcomes.\u003c/p\u003e\u003cp\u003eCompared with international benchmarks, the rates of oral health-related psychosocial and sports performance impacts observed in this Malaysian sample were higher than those reported among athletes in the UK, Netherlands, and at the London 2012 Olympics \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e (Supplementary Table\u0026nbsp;7). They also exceeded previous Malaysian data on elite athletes, suggesting a possible worsening trend or differences attributable to sample characteristics \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. It is plausible that the matched age groups in this study presented with more accumulated oral health issues compared to earlier studies that included younger athletes. Results from the present study align with Malaysian adult population, whereby 52.8% reported impact of oral conditions on quality of life \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eImplications for EA \u0026 EP\u003c/h3\u003e\n\u003cp\u003eFunctional limitations from oral discomfort, especially during training and competition, can impair performance by affecting nutrition, hydration, and focus \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Moreover, sports diets rich in carbohydrates and energy drinks elevate risk for caries, erosion, and inflammation, which further compromise athletic performance \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Pain and chewing difficulty may hinder food intake, digestion, and recovery, all of which are critical for athletic success \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. These mechanisms reinforce the need for integrating athlete-centred oral healthcare protocols into sports performance management frameworks \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWhile these challenges affect all athletes, EP face additional, compounding barriers to maintaining oral health, such as reduced dexterity for oral hygiene, dietary modifications, altered salivary flow due to medications or systemic conditions, and limited access to dental care \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. Though not directly measured in this study, these risk factors likely contribute to the high prevalence of oral health-related psychosocial and performance impacts observed among EP.\u003c/p\u003e\u003cp\u003eThe findings affirm the need for preventive strategies tailored to both athlete groups, including individualised oral hygiene education, accessible dental services, and athlete-specific nutrition advice. In parallel, sports governing bodies should integrate oral health into routine health screenings and medical support services, particularly for vulnerable groups like EP.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis is the first known global comparison of oral health perceptions, psychosocial effects, and performance impacts between EA and EP. While both groups reported good general health, over half experienced oral health-related impacts\u0026mdash;particularly performance-related issues, which were significantly higher among EA. These findings highlight the critical role of oral health in overall well-being and athletic success. Integrating oral health into sports medicine is essential, especially for EP, an underrepresented population who face additional barriers. Tailored prevention, screening, and access to dental care within sports medicine and public health frameworks are needed to support equitable health and performance outcomes across athlete populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor contributions\u003c/h2\u003e\n\u003cp\u003eAll authors conceptualised and designed the study. LK obtained ethics approval and funding, liaised with the National Sports Institute for participant recruitment, coordinated project administration, conducted data collection and analysis in consultation with a faculty statistician, and drafted the manuscript. AAF reviewed and validated the data analysis. JF and AAF supervised the project and critically revised the manuscript for content. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors thank Universiti Malaya (UM), the National Sports Institute of Malaysia, participating athletes, supervisors, colleagues, and support staff for their contributions to this research. This study was registered with the NMRR (ID-23-00571-R4T) and approved by FDMEC (DF CD2325/0050(P)) and the NSI Research Ethics Committee (RE/A/004/2023-002/2023). Funding was provided by the UM Dental Postgraduate Research Grant (UMG011E-2023).\u003c/p\u003e\n\u003ch2\u003eData availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study contain personal data and are not publicly available due to participant confidentiality and GDPR requirements. Aggregated and anonymised summary data are included within this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSheiham A. Oral health, general health and quality of life. Bull World Health Organ. 2005;83(9):644.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChapple I, Wilson N. Chronic non-communicable diseases. Br Dent J. 2014;216(9):487-.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlhajj MN, Halboub E, Amran AG, Alkheraif AA, Al-Sanabani FA, Al-Makramani BM, et al. Link between perceived oral and general health status among Yemeni adult dental patients. BMC Oral Health. 2019;19(1):93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReissmann DR, John MT, Schierz O, Kriston L, Hinz A. Association between perceived oral and general health. Journal of Dentistry. 2013;41(7):581\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAshley P, Di Iorio A, Cole E, Tanday A, Needleman I. Oral health of elite athletes and association with performance: a systematic review. Br J Sports Med. 2014;49(1):14\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeedleman I, Ashley P, Fine P, Haddad F, Loosemore M, de Medici A, et al. Oral health and elite sport performance. Br J Sports Med. 2015;49(1):3\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeedleman I, Ashley P, Petrie A, Fortune F, Turner W, Jones J, et al. Oral health and impact on performance of athletes participating in the London 2012 Olympic Games: a cross-sectional study. Br J Sports Med. 2013;47(16):1054\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGomes TC, Gomes Moura JL, Baia-da-Silva DC, Lima RR, Rodrigues PdA. Twenty-first century knowledge mapping on oral diseases and physical activity/exercise, trends, gaps, and future perspectives: a bibliometric review. Front Sports Act Living. 2024;6:1410923.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDerman W, Schwellnus M, Jordaan E, Blauwet CA, Emery C, Pit-Grosheide P, et al. Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff. Br J Sports Med. 2013;47(7):420\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohammad-Hassan NH, Mohd Noor NS, Mohamed Nazari NS, Abidin ZZ, Azami NH, Needleman I. High level of oral disease and self-reported performance impacts in Malaysian elite athletes [Poster presentation]. Br J Sports Med. 2021;55(Suppl 1):A172-A3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeedleman I, Ashley P, Meehan L, Petrie A, Weiler R, McNally S, et al. Poor oral health including active caries in 187 UK professional male football players: clinical dental examination performed by dentists. Br J Sports Med. 2015;50(1):41\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAttin T, K\u0026ouml;rner P, Wegehaupt F. Erosive tooth wear among athletes. Quintessence Int. 2021;52(10):912\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchulze A, Busse M. Sports Diet and Oral Health in Athletes: A Comprehensive Review. Medicina. 2024;60(2):319.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGallagher J, Ashley P, Petrie A, Needleman I. Oral health and performance impacts in elite and professional athletes. Community Dent Oral Epidemiol. 2018;46(6):563\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchwesig R, Born P, Kurz E, Schulze S, Panian M, Marshall RP, et al. Oral Health Conditions and Physical Performance in Two Different Professional Team Sports in Germany: A Cross-Sectional Study. Sports. 2025;13(7):206.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwann C, Moran A, Piggott D. Defining elite athletes: Issues in the study of expert performance in sport psychology. Psychology of Sport and Exercise. 2015;16:3\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeiler R, Blauwet C, Clarke D, Dalton K, Derman W, Fagher K, et al. Concussion in para sport: the first position statement of the Concussion in Para Sport (CIPS) Group. Br J Sports Med. 2021;55(21):1187\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlenck C, Gebke K. Practical management: common medical problems in disabled athletes. Clin J Sport Med. 2007;17(1):55\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVanlandewijck YC, Thompson WR. Handbook of sports medicine and science: The Paralympic athlete: John Wiley \u0026amp; Sons; 2011.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHamzah S. Special Needs Dentistry (Snd) In Malaysia: A Way Forward. Malaysian Dental Journal. 2012;34(1):33\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee J-Y, Lim K-C, Kim S-Y, Paik H-R, Kim Y-J, Jin B-H. Oral health status of the disabled compared with that of the non-disabled in Korea: A propensity score matching analysis. PloS one. 2019;14(1):e0208246-e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYazicioglu K, Yavuz F, Goktepe AS, Tan AK. Influence of adapted sports on quality of life and life satisfaction in sport participants and non-sport participants with physical disabilities. Disabil Health J. 2012;5(4):249\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJ\u0026uacute;dice A, Botelho J, Machado V, Proen\u0026ccedil;a L, Ferreira LMA, Fine P, et al. Sports dentistry intricacies with season-related challenges and the role of athlete-centered outcomes. Front Oral Health. 2025;6:1531653.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrejcie RV, Morgan DW. Determining sample size for research activities. Educational and Psychological Measurement. 1970;30(3):607\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeedleman I, Ashley P. UCL Oral Health Screening Toolkit. University College London, Eastman Dental Institute; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosenbaum PR, Rubin DB. The Central Role of the Propensity Score in Observational Studies for Causal Effects. Biometrika. 1983;70(1):41\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGeorge D, Mallery P. SPSS for Windows Step by Step: A Simple Guide and Reference, 17.0 Update: Allyn \u0026amp; Bacon; 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVaquero-Crist\u0026oacute;bal R, Maci\u0026aacute;-Andreu MJ, D\u0026iacute;az-Aroca \u0026Aacute;, Mero\u0026ntilde;o L, Garc\u0026iacute;a-Roca JA, Abenza-Cano L, et al. Exploring the perception of barriers to a dual career by student-athletes with/out disabilities. PLOS ONE. 2023;18(5):e0286152.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eM\u0026aacute;rquez-Arrico CF, Almerich-Silla JM, Montiel-Company JM. Oral health knowledge in relation to educational level in an adult population in Spain. J Clin Exp Dent. 2019;11(12):e1143-e50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaulander J, Axelsson P, Lindhe J. Association between level of education and oral health status in 35-, 50-, 65- and 75-year-olds. J Clin Periodontol. 2003;30(8):697\u0026ndash;704.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKragt L, Moen MH, Van Den Hoogenband C-R, Wolvius EB. Oral health among Dutch elite athletes prior to Rio 2016. Phys Sportsmed. 2019;47(2):182\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLocker D. Psychosocial consequences of dental fear and anxiety. Community Dent Oral Epidemiol. 2003;31(2):144\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlbrecht GL, Devlieger PJ. The disability paradox: high quality of life against all odds. Social Science \u0026amp; Medicine. 1999;48(8):977\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRees L, Robinson P, Shields N. Media portrayal of elite athletes with disability - a systematic review. Disabil Rehabil. 2017;41(4):374\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKovacs A, Doczi T. Elite athletes and media appearances: opportunity or obligation? Sport in Society. 2020;23(7):1136\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaub R, Locker D. The impact of oral conditions on the quality of life of the Malaysian adult population: preliminary results. Med J Malaysia. 2006;61(4):438\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndrade RA, Evans PL, Almeida AL, da Silva Jde J, Guedes AM, Guedes FR, et al. Prevalence of dental trauma in Pan American games athletes. Dental Traumatol. 2010;26(3):248\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNavarro Azevedo de Azeredo F, Silva Guimar\u0026atilde;es L, Azeredo A. Antunes L, Santos Antunes L. Global prevalence of dental caries in athletes with intellectual disabilities: An epidemiological systematic review and meta-analysis. Spec Care Dentist. 2019;39(2):114\u0026thinsp;\u0026ndash;\u0026thinsp;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOstrowska A, Szymański W, Kołodziejczyk Ł, Bołtacz-Rzepkowska E. Evaluation of the Erosive Potential of Selected Isotonic Drinks: In Vitro Studies. Adv Clin Exp Med. 2016;25(6):1313\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Sociodemographic and Sports Characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite Para-Athletes (n=57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAthletes\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(n=57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e47 (82.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e47 (82.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e10 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e10 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e26.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e25.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePWD Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePhysical disability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e40 (70.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eLearning disability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e9 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eVisual Impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e7 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eMultiple disabilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSPM or equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e37 (64.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e29 (50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSTPM or equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eDiploma or equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e5 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e9 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eDegree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e11 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePostgraduate (Master/PhD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e10 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnic Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eMalay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e41 (71.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e32 (56.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eIndian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e13 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e5 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e7 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSabah Bumiputera\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSarawak Bumiputera\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e6 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eMulti-ethnic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Sports career duration (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e8.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e13.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Para Sports\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Athletics, Field \u0026amp; Track\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e19 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Cycling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e7 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Badminton\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e6 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Archery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eBoccia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Powerlifting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Swimming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Table Tennis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eWheelchair Fencing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003ePara Shooting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eWheelchair Tennis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1 (continued) Sociodemographic and Sports Characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite Para-Athletes (n=57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite\u0026nbsp;\u003c/strong\u003e \u003cstrong\u003eAthletes (n=57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\u003cbr\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003eType of Sports\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eField Hockey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eKarate - Kumite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e12 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eShooting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eTable Tennis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSepaktakraw\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e8 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSquash\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eTaekwondo - Kyorugi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eBoxing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e6 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eBoxing Sparring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSilat- Sparring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e7 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eSilat- Artistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e8 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003eBrazilian Jiu-jitsu\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 Perceived Health \u0026amp; Oral Health Status, Psychosocial \u0026amp; Sports Performance Impacts\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite Para-Athletes (n=57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite Athletes\u003c/strong\u003e (\u003cstrong\u003en=57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Health Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e21 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e15 (26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e25 (43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e28 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eFair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e9 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e13 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e1 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Oral Health Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e10 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e9 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e30 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e26 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eFair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e9 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e18 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e8 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e4 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychosocial Impacts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eNo Impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e27 (47.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e19 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eAny Impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e30 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e38 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePsychosocial Impacts Score (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e11.4 (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e8.33 (median)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact on Sports Performance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eNo Impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e28 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e24 (42.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 229px;\"\u003e\n \u003cp\u003eAny Impact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e29 (50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e33 (57.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSports Performance Impacts Score (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e9.23 (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 192px;\"\u003e\n \u003cp\u003e17.07 (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3 Comparing mean total impact score for oral health related sports performance impacts between elite para-athletes and athletes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"553\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Sports Performance Impact Score\u003cbr\u003e\u0026nbsp;Mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean difference (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et statistic (\u003cem\u003edf\u003c/em\u003e)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite Athletes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-7.84\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-14.3, -1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2.39 (112)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePara-Athletes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e9.23 (12.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAthletes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e17.07 (21.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e \u003csup\u003ea\u003c/sup\u003eIndependent\u0026nbsp;\u003cem\u003et\u003c/em\u003e test SD= Standard Deviation CI= Confidence Interval\u003cbr\u003e\u003cem\u003en\u003c/em\u003e= frequency \u003cem\u003edf\u003c/em\u003e= Degrees of Freedom\u003c/p\u003e\n\u003cp\u003eTable 4 Correlation between perceived health and oral health status among elite athletes\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"553\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 412px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Oral Health Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite Para-Athletes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eElite Athletes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003eCorrelation coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Health Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 80px;\"\u003e\n \u003cp\u003ep\u0026lt;0.05\u003cbr\u003e\u0026nbsp;(0.008)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 119px;\"\u003e\n \u003cp\u003e0.549\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 89px;\"\u003e\n \u003cp\u003ep\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"british-dental-journal","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bdj","sideBox":"Learn more about [British Dental Journal](http://www.nature.com/bdj/)","snPcode":"41415","submissionUrl":"https://mts-bdj.nature.com/cgi-bin/main.plex","title":"British Dental Journal","twitterHandle":"@the_bdj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7308874/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7308874/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Oral health, part of general health, is essential for optimal athletic performance and well-being.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims: \u003c/strong\u003eTo compare perceived oral health status, psychosocial and performance impacts among national elite para-athletes (EP) and elite athletes (EA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e An cross-sectional, descriptive and comparative study was conducted using purposive sampling of EP \u0026amp; EA\u003cstrong\u003e \u003c/strong\u003eat the National Sports Institute, Malaysia. A validated questionnaire adapted from the Oral Health Screening Toolkit for Athletes (University College London) was administered from February 2022 to February 2024. Data were analysed descriptively and inferentially.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eParticipation involved\u003cstrong\u003e \u003c/strong\u003e57 EP and 57 age- and sex-matched EA. Perceived oral health was positive in 40(70.1%) EP and 35(61.4%) EA, with more perceiving their general health positively. Perceived general or oral health showed no significant differences across groups. Psychosocial impacts were comparable, but EA reported significantly greater performance-related impacts (mean difference = 7.84, p = 0.019). Stronger correlations between perceived oral and general health were observed in EA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion: \u003c/strong\u003eThe higher performance-related impacts among EA may reflect sport-specific physical demands and psychosocial factors. Correlations between perceived oral and general health underscore the importance of integrated care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Accessible, athlete-specific oral healthcare is needed to support well-being and performance in both groups.\u003c/p\u003e","manuscriptTitle":"Oral Health Perceptions Among Elite Athletes and Elite Para-Athletes: Psychosocial Impacts, Sports Performance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 05:53:27","doi":"10.21203/rs.3.rs-7308874/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2026-01-05T23:43:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2026-01-03T02:22:56+00:00","index":3,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-12-13T22:04:07+00:00","index":3,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-10-04T11:57:41+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-08-17T12:47:25+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-08-17T11:35:57+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-08-15T16:05:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-11T16:58:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-11T16:58:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"British Dental Journal","date":"2025-08-06T10:38:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"british-dental-journal","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bdj","sideBox":"Learn more about [British Dental Journal](http://www.nature.com/bdj/)","snPcode":"41415","submissionUrl":"https://mts-bdj.nature.com/cgi-bin/main.plex","title":"British Dental Journal","twitterHandle":"@the_bdj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f627428d-bd90-4aec-bf14-b441808e0c23","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":53229514,"name":"Health sciences/Health care/Dentistry/Special care dentistry"}],"tags":[],"updatedAt":"2026-03-20T16:41:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 05:53:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7308874","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7308874","identity":"rs-7308874","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}