Dental Hypotheses

: 2014  |  Volume : 5  |  Issue : 2  |  Page : 53--58

Oral health and quality of life in children: A cross-sectional study

Mahmood Reza Kalantar Motamedi1, Ali Behzadi1, Nasim Khodadad1, Azadeh Khazaei Zadeh1, Firoozeh Nilchian2,  
1 Dental Students Research Center, Department of Dental Public Health, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
2 Dental Materials Research Center, Department of Dental Public Health, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran

Correspondence Address:
Firoozeh Nilchian
Department of Dental Public Health, Torabinejad Dental Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan


Introduction: The relationship of oral health (OH) with the quality of life (QL) is multidimensional; the extent to which oral disorders disrupt an individual«SQ»s normal function may affect health-related QL, particularly among children. The current study aimed to examine the relationship between clinical OH variables, psychological, social, and demographic factors with regard to OH-related QL (OHRQL) in the children of Isfahan province, Iran. Materials and Methods: Data relevant to the characteristics, psychological, dental, and demographic factors of 336 children aged 11-15 were assessed. These characteristics included sociodemographic data, sense of coherence (SOC), self-esteem, and children«SQ»s health locus of control (HLC). The clinical variables that were implicated to be effective on the QL were assessed via an oral examination. The parameters assessed included caries, periodontal disease, malocclusion, and traumatic dental injuries. Finally, the data was analyzed using Statistical Package for the Social Sciences (SPSS) software and P-value was set at 0.05. Results: The results indicate that oral disease, the extent of treatment-need, self-reported symptoms, and degree of dysfunction were influential in QL. Bivariate (Spearman and Pearson) analysis showed that there was a relationship between decayed, missing, and filled teeth (DMFT) and QL score (r = 0.4, P-value = 0.03) and gender and total self-esteem (r = 0.8, P-value = 0.009). Self-esteem and index of orthodontic treatment need (IOTN) (P-value = 0.01), education level of the parents (P-value = 0.03), and overall health (P-value = 0.001) significantly influenced OHRQL. Conclusions: The findings of our study indicate that oral disease, the extent of treatment-need, self-reported symptoms, and degree of dysfunction were influential in the QL.

How to cite this article:
Motamedi MK, Behzadi A, Khodadad N, Zadeh AK, Nilchian F. Oral health and quality of life in children: A cross-sectional study.Dent Hypotheses 2014;5:53-58

How to cite this URL:
Motamedi MK, Behzadi A, Khodadad N, Zadeh AK, Nilchian F. Oral health and quality of life in children: A cross-sectional study. Dent Hypotheses [serial online] 2014 [cited 2022 Aug 10 ];5:53-58
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Oral health-related quality of life (OHRQL) assesses the extent to which oral disorders disrupt an individual's normal function and quality of life (QL). Over recent years, the impact of oral health (OH) on QL has become an important focus for assessing the impact of a range of oral conditions on well-being, and the outcomes of treatment in improving QL. [1],[2] Measures of QL in children have typically relied on parents or clinicians to provide proxy information. [3] However, there is often a lack of concordance between such proxy reports and information provided by the children themselves. [4] As a result, there has been a greater motivation over recent years to collect information regarding OH and QL directly from the children themselves. Previous studies show that OH can influence children's functioning and well-being. However, none of these studies have incorporated the range of clinical, psychological, and demographic factors that may influence children's OH and QL in this country. Psychological factors such as sense of coherence (SOC), health locus of control (HLC), self-esteem are the factors that can be evaluated in children. [5]

HLC or an individual's belief in his/her ability to control his/her health [6] has been associated with several health behaviors and indicators including regular dental visits and prevention of caries. [7]

Self-esteem or one's overall evaluation or appraisal of one's own value is associated with greater life satisfaction, fewer health problems, more frequent tooth brushing and dental visits, and fewer OH problems in adolescents. [8]

SOC, or a generalized orientation that facilitates successful coping with stresses in daily life, [9] is related to better self-rated health and QL. [10] The primary aim of the current study was to assess the relationships between clinical, psychological, social, and demographic variables with regard to OH and QL in students aged between 11 and 15 years.

 Materials and Methods

This non-blind cross-sectional study was conducted via clinical examination and self-reported questionnaires. The target population was school children aged between 11 and 15 years in the Isfahan province, Iran. The accessible population was children of this age attending schools in three districts of Isfahan (south, middle, and north of Isfahan, in sequence from the richest to the poorest). Considering a 25% drop out rate and a 75% recruitment rate within a 6-month study period, 500 children were provided with a consent letter and information leaflets. The ethics committee approval was obtained from the Isfahan University of Medical Sciences. Finally, 336 school children with an informed written consent form and recruitment criteria from six schools participated in the study.

Any child whose parent did not provide a written consent form, or whose age was outside the range of the intended sample, and who was not able to fill in the form, or was medically compromised, was excluded from the study. Only those children with a written consent form and a fulfilled parental/guardian questionnaire were considered for the final sample.

Data on psychological and demographic factors that would represent individual characteristics were collected; it included the sociodemographic characteristics of children and their families, including the following:

Psychological factors evaluated

SOC,HLC,Self-esteem, andOH beliefs

Social and demographic factors

Gender,Family income,Parental education; family income and level of education were collected from children's parents.

Sense of coherence

SOC was measured by Antonovsky's Orientation to Life Questionnaire, [11] a short form (SOC-l3) consisting of l3 statements on a seven-point Likert-type scale ranging from "Never" to "Always." Antonovsky reports that the short-form SOC is reliable and reasonably valid. [9],[11],[12]


Self-esteem of the participants was measured using Rosenberg's self-esteem scale (RSES). [13] The scale is a 10 item self-report of total self-esteem and is answered on a four-point Likert scale range from "strongly agree" to "strongly disagree." This scale is widely used to measure total self-esteem and is well validated.

Children's HLC scale

Locus of control (LOC) refers to the extent to which individuals consider themselves as being responsible for their experiences in a life situation. Children's HLC (CHLC) [14] assesses children's beliefs about whether they are responsible for what happens to them. If the child strongly believes being responsible for the things that happen in his/her life, the child is considered as having internal control or exhibiting a certain degree of independence. The CHLC has an acceptable level of reliability, internal consistency, and validity. CHLC consists of 20 Yes/No items. [14],[15]

Clinical variables

The clinical variables included caries, periodontal disease, malocclusion, and traumatic dental injuries assessed via oral examination. The normative indices for trauma, caries, and periodontal disease were based on the criteria published in the World Health Organization (WHO) OH Survey Basic fourth edition. [16] Periodontal diseases and malocclusions were based on the community periodontal index (CPI) and the index of orthodontic treatment need (IOTN), respectively.

OH-related QL questionnaire

Symptoms and functional status were assessed using the child perceptions questionnaire (CPQ). [17] For this part, questions numbered 11-14 were used. The CPQ conforms to contemporary child health as a self-assessed questionnaire consisting of questions organized into four health domains:

Oral symptoms,Functional limitation,Emotional well-being, andSocial well-being. [18]

General health perception

Perceived general health status was measured using questions numbered 1, 2, and 11 of the SF-36 Health Survey. [19] SF-36 is one of the most widely used measures of health status. SF-36 shows excellent psychometric properties in terms of sensitivity, validity, and internal consistency, and test-retest reliability. [20]

Overall health belief questionnaire

Question number 35 from the CPQ questionnaire also assessed the child's belief about his/her overall well-being (OWB). [21],[22]

Clinical factors assessed

Decayed, missing, and filled teeth (DMFT),IOTN, andCPI.

Oral examination

Whole mouth examination was carried out by two dentists, who were WHO trained epidemiologists, according to the survey criteria. [23] To calibrate the oral examinations between the two examiners, they followed a same criteria, and a consensus was achieved. The clinical examination required minimal equipment (source of light, mouth mirrors, and periodontal probes) with a high standard of infection control. Dental caries, malocclusion, trauma, and periodontal disease were among the variables that were recorded.

Data collection

The parents were asked to fill the questionnaire pertaining to their level of education and income. The students filled a questionnaire at school and then they had their mouths examined. The data were entered into the Statistical Package for the Social Sciences (SPSS) (SPSS Inc., Version 21, Chicago, USA), and analyzed using Cox's regression model, Spearman's test, and Pearson's tests. A probability level of P < 0.05 was considered to be statistically significant.


Data obtained from 336 students aged between 11 and 15 years from six schools were assessed. The percentage of females (49.4%) was equal to males (50.6%).

Participant details

The mean age of children at initial examination was 13 years (Standard Error (SE) = 1.6), and there were an equal number of boys and girls. Children had a high caries experience, with a mean DMFT at baseline of 2.8 (SD = 2.4). Clinical factors (DMFT, IOTN, and CPI), presented in [Table 1], indicated that disease and treatment-need levels (mean DMFT = 2.8; IOTN_AC (Aesthetic Component) = 2.60, IOTN_DHC (Dental Health Component = 1.57) were high.{Table 1}

Relation of DMFT with demographic and psychological factors

Cox's regression model showed significant differences for the DMFT index and OHRQL (CPQ score) and the other variables [Table 2] (P-value = 0.03).{Table 2}

Relationship of IOTN_DHC and IOTN_AC with demographic and psychological factors

The relation between IOTN_DHC and nonclinical factors indicated that gender and the mother's job were significantly associated with IOTN_DHC (when IOTN_DHC increases, the total score of these indices decreases, [Table 3]). The mother's occupation and self-esteem had a significant relationship with IOTN_AC [Table 4].{Table 3}{Table 4}

Using Cox's regression model, no significant differences were found for CPI index and other variables [Table 5].{Table 5}

Bivariate (Spearman's and Pearson's test) analysis showed that there was a significant relationship between gender and the total score of self-esteem (r = 0.8, P-value = 0.009), total score of self-esteem and IOTN_DHC (r = 0.6, P-value = 0.01), OHRQL and father's and mother's education level (r = 0.4, P-value = 0.03), and CHLC and SF-36 overall health belief (r = 0.9, P-value = 0.001).


The present study is the first study to evaluate the relationships between clinical and nonclinical variables with regard to children's OH and QL in our country.

Analysis of our data lends broad support to the hypothesis that psychosocial factors in OH beliefs affect daily living, health perceptions, and overall QL, supporting previous studies. [24],[25] Despite the results of previous studies, [20] clinical factors such as DMFT and CPI did not show significant relationships with psychological factors.

Although earlier results linked a strong SOC with better adult health-related QL, [2],[26],[27] OH-related factors, [28],[29] and clinical and nonclinical factors [30] of this study did not support previous results. Bivariate (Spearman's and Pearson's) analysis showed that there was a strong relationship between gender and total self-esteem. Self-esteem and IOTN, education level of the parents, and overall health significantly influenced QL.

However, the interpretations should be considered in the context of the methodological strengths and limitations of the study. The current study benefits from the following strengths: first, the sample included over 300 nationally representative 11-15-year-old children and there was an excellent participation rate; second, distribution of children was well-performed (three different provinces from the richest to the poorest areas); third, a wide range of OH-related factors was assessed; and fourth, all the oral examinations were performed using the same examiner. However, this study also had some potential limitations. Because the information relied on self-reports, it may be subject to bias. Although observational methods can be thought of as an alternative to self-reports, they are expensive, time-consuming, and not exempt of bias. The results indicate that OH and QL were associated with well-being and partially mediated the impact of both clinical signs and symptom status on subjective well-being. Such data confirm that oral disease can influence an individual's well-being on QL, physical, psychological, and social functioning, factors that should be considered in OH policies. The results indicate the importance of including OHRQL along with clinical indicators, disease-specific symptom measures, and wider subjective well-being.

OHRQL was associated with wider well-being and partially mediated the impact of both clinical signs and symptom status on subjective well-being. Such data confirm that oral diseases can influence an individual's wider well-being by impacting on everyday physical, psychological, and social functioning, which should be taken into account in making OH policy in this regard. As OHRQL is less concerned in developing countries, DMFT index has increased despite the great ratio of dentists to population.

It seems that in developing countries, parents are not that eager to describe the accurate income of family and thus parental socioeconomic status information is difficult to obtain from adolescents. Hence, the authors suggest some validated questionnaires be used for future studies, [31],[32] which indirectly estimate the socioeconomic status of families via filling the questionnaire by children.

In conclusion, our results indicate that oral disease, the extent of treatment needed, self-reported symptoms, and degree of dysfunction influenced the QL.


This study was supported by the Isfahan University of Medical Sciences Research Grant # 290119. The authors would also like to thank Dr. Mahdi Moshki for providing the validated Persian form of the CHLC questionnaire.


1Allen PF, McMillan AS, Locker D. An assessment of sensitivity to change of the Oral Health Impact Profile in a clinical trial. Community Dent Oral Epidemiol 2001;29:175-82.
2Locker D, Clarke M, Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res 2000;79:970-5.
3Schmidt LJ, Garratt AM, Fitzpatrick R. Child/parent-assessed population health outcome measures: A structured review. Child Care Health Dev 2002;28:227-37.
4Eiser C, Morse R. Quality-of-life measures in chronic diseases of childhood. Health Technol Assess 2001;5:1-157.
5Baker S, Mat A, Robinson PG. What psychosocial factors influence adolescents' oral health? J Dent Res 2010;89:1230-5.
6Wallston KA, Wallston BS, Smith S, Dobbins CJ. Perceived control and health. Curr Psychol 1987;6:5-25.
7Steptoe A, Wardle J. Locus of control and health behaviour revisited: A multivariate analysis of young adults from 18 countries. Br J Psychol 2001;92:659-72.
8Agou S, Locker D, Streiner DL, Tompson B. Impact of self-esteem on the oral-health-related quality of life of children with malocclusion. Am J Orthod Dentofac Orthoped 2008;134:484-9.
9Antonovsky A. Health, stress, and coping: New perspectives on mental and physical well-being. San Francisco, Jossey-Bass; 1979.
10Eriksson M, Lindström B. Antonovsky's sense of coherence scale and its relation with quality of life: A systematic review. J Epidemiol Community Health 2007;61:938-44.
11Antonovsky A. Unraveling the mystery of health: How people manage stress and stay well. San Francisco, Jossey-Bass; 1987. Available from: [Last accessed on 2014 Feb 15].
12Antonovsky A. The structure and properties of the sense of coherence scale. Soc Sci Med 1993;36:725-33.
13Rosenberg M. Society and the adolescent self-image. Middletown: Wesleyan University Press; 1989. Available from: [Last accessed on 2014 Feb 15].
14Parcel GS, Meyer MP. Development of an instrument to measure children's health locus of control. Health Educ Monogr 1978;6:149-59.
15Moshki M, Ghofranipour F, Hajizadeh E, Azadfallah P. Validity and reliability of the multidimensional health locus of control scale for college students. BMC Public Health 2007;7:295.
16Oral health surveys. Basic methods, 4 th ed. Geneva: World Health Organization; 1987. Available from: [Last accessed on 2014 Feb 15].
17Jokovic A, Locker D, Stephens M, Kenny D, Tompson B, Guyatt G. Validity and reliability of a questionnaire for measuring child oral-health-related quality of life. J Dent Res 2002;81:459-63.
18Marshman Z, Rodd H, Stern M, Mitchell C, Locker D, Jokovic A, et al. An evaluation of the Child Perceptions Questionnaire in the UK. Community Dent Health 2005;22:151-5.
19Ware JE Jr, Keller SD, Gandek B, Brazier JE, Sullivan M. Evaluating translations of health status questionnaires. Methods from the IQOLA project. International Quality of Life Assessment. Int J Technol Assess Health Care 1995;11:525-51.
20Ware JE, Kosinski M. Interpreting SF-36 summary health measures: A response. Qual Life Res 2001;10:405-13.
21Hilton A, Skrutkowski M. Translating instruments into other languages: development and testing processes. Cancer Nurs 2002;25:1-7.
22Peters M, Passchier J. Translating instruments for cross-cultural studies in headache research. Headache 2006;46:82-91.
23Oral health surveys. Basic methods, 5 th ed. Geneva: World Health Organization; 2013. Available from: [Last accessed on 2014 Feb 15].
24Baker SR, Pearson NK, Robinson PG. Testing the applicability of a conceptual model of oral health in housebound edentulous older people. Community Dent Oral Epidemiol 2008;36:237-48.
25Baker SR, Pankhurst CL, Robinson PG. Testing relationships between clinical and non-clinical variables in xerostomia: A structural equation model of oral health-related quality of life. Qual Life Res 2007;16:297-308.
26Flensborg-Madsen T, Ventegodt S, Merrick J. Sense of coherence and physical health. A review of previous findings. ScientificWorldJournal 2005;5:665-73.
27Lindmark U, Stegmayr B, Nilsson B, Lindahl B, Johansson I. Food selection associated with sense of coherence in adults. Nutr J 2005;4:9.
28Freire MC, Sheiham A, Hardy R. Adolescents' sense of coherence, oral health status, and oral health-related behaviours. Community Dent Oral Epidemiol 2001;29:204-12.
29Savolainen JJ, Suominen-Taipale AL, Uutela AK, Martelin TP, Niskanen MC, Knuuttila ML. Sense of coherence as a determinant of toothbrushing frequency and level of oral hygiene. J Periodontol 2005;76:1006-12.
30Savolainen J, Suominen-Taipale A, Uutela A, Aromaa A, Harkanen T, Knuuttila M. Sense of coherence associates with oral and general health behaviours. Community Dent Health 2009;26:197-203.
31Currie C, Molcho M, Boyce W, Holstein B, Torsheim T, Richter M. Researching health inequalities in adolescents: The development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale. Soc Sci Med 2008;66:1429-36.
32Ghorbani Z, Ahmady AE, Lando HA, Yazdani S, Amiri Z. Development of a socioeconomic status index to interpret inequalities in oral health in developing countries. Oral Health Prev Dent 2012;11:9-15.