Quality of Life Research

https://doi.org/10.1007/s11136-018-1903-7

Oral health-related quality of life of children and adolescents

with and without migration background in Germany
Ghazal Aarabi1 · Daniel R. Reissmann1 · Darius Sagheri2 · Julia Neuschulz3 · Guido Heydecke1 · Christopher Kofahl4 ·
Ira Sierwald5,6

Accepted: 3 June 2018

© Springer International Publishing AG, part of Springer Nature 2018

Abstract
Objectives  To compare oral health-related quality of life (OHRQoL) in children and adolescents with and without migra-
tion background, and to assess whether potential differences in OHRQoL can be sufficiently explained by oral health
characteristics.
Materials und methods  A consecutive sample of 112 children and adolescents was recruited in a German university-based
orthodontic clinic, and a convenience sample of 313 children and adolescents of German public schools was enrolled in the
study (total N = 425, age range 7–17 years). However, 29 participants were excluded due to insufficient information regarding
migration background. Accordingly, the non-migrant group consisted of 262 participants (61.6%). For children with migra-
tion background, two groups were classified: (i) one parent born in a foreign country (N = 41, 9.6%, single-sided migration
background), and (ii) both parents and/or child born in a foreign country ( N= 93, 21.9%, double-sided migration background).
OHRQoL was assessed using the German 19-item version of the Child Oral Health Impact Profile (COHIP-G19). Addition-
ally, physical oral health of 269 children with classified migration background was determined in a dental examination.
Results  Overall, OHRQoL was significantly lower in the group with double-sided migration background indicated by lower
COHIP-G19 summary scores (mean: 58.6 points) than in the group with single-sided migration background (mean: 63.3
points) or the non-migrant group (mean: 63.2 points). Likewise, the summary scores of the subscale “oral health well-being”
and the subscale “social/emotional, school, and self-image” were also lower in the double-sided migrant group than in the
other two groups. Linear regression analysis showed an association between double-sided migration background and impaired
OHRQoL, even after statistically controlling for demographic, socioeconomic, and oral health characteristics.
Conclusion  Children and adolescents with double-sided migration background have poorer OHRQoL than comparably aged
migrants with single-sided migration background or non-migrations. Between-group differences in OHRQoL could not be
sufficiently explained by effects of socioeconomic status or physical oral health characteristics. Thus, other methodological,
cultural, or immigration-related factors might also play an important role for the observed effects.

Keywords  Child Oral Health Impact Profile · Oral health-related quality of life · Children · Migration

4
* Ghazal Aarabi Department of Medical Sociology, Center for Psychosocial
g.aarabi@uke.de Medicine, University Medical Center Hamburg-Eppendorf,
Hamburg, Germany
1
Department of Prosthetic Dentistry, Center for Dental 5
Private Orthodontic Practice Kieferorthopaedie Buxtehude,
and Oral Medicine, University Medical Center Hamburg-
Buxtehude, Germany
Eppendorf, Hamburg, Germany
6
2 Department of Orthodontics, Dentofacial Orthopedics
Department of Public and Child Dental Health, Dublin
and Pedodontics, Charité – Universitätsmedizin Berlin,
Dental University Hospital, Dublin, Ireland
Berlin, Germany
3
Department of Orthodontics, University Medical Center
of Cologne, Cologne, Germany

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 Quality of Life Research

Introduction Aim of this study was to compare OHRQoL of children

and adolescents with and without migration background, and
Considering the high rate of migration worldwide, oral to assess whether potential differences in OHRQoL can be
disease prevention in people with migration background sufficiently explained by oral health characteristics.
represents an important public health challenge, particu-
larly considering children and adolescents. Most studies
on this subject have been on physical oral health, i.e., prev- Materials and methods
alence of dental caries, and oral self-care [1–3]. Besides
the social gradient’s influence, oral health is also affected Participants, design, and setting
by origin and culture. The representative population-based
studies on children’s and adolescents’ health in Germany In this exploratory cross-sectional study, participants were
[4] clearly showed that children of immigrants have both recruited during the development of the German version of
worse physical oral health and oral health-care utiliza- the Child Oral Health Impact Profile (COHIP-G19) [11] in
tion than their German counterparts [3]. These surveys two different settings. The first sample consisted of ortho-
also showed that these differences are quite low between dontic patients consecutively recruited at the Department of
native German families and binational families in which Orthodontics, University of Cologne, Germany, from May
one parent is born and socialized in Germany, but they are through June 2010 (N = 112). Patients of the orthodontic
remarkably pronounced when native German families are sample were enrolled in the study independently of their
compared with those whose both parents are immigrants. current treatment phase; hence, the orthodontic sample com-
However, this is not true for higher educated immigrants prised patients involved in the entire range of orthodontic
from industrialized countries as opposed to children of treatment (baseline examination to post treatment check-up).
Eastern European or Middle East Asian origin [5]. The second sample consisted of students recruited at public
In contrast, little is known about potential effects of schools in Greifswald, Germany (convenience community
migration background on oral health-related quality of sample), from November through December 2010 (N = 313).
life (OHRQoL) of children and adolescents [6]. OHRQoL Classes (second to eighth grades) of eligible schools were
has been established as a measure to quantitatively assess randomly selected. All students/patients aged 7 to 17 years
perceived effects of oral health and treatment outcomes on were asked to participate in the study. Participants completed
peoples’ well-being. Considering the findings on physical a self-administered, paper-based questionnaire. For further
oral health and oral health-care utilization with signifi- details of inclusion/exclusion criteria and administration,
cantly lower levels in migrants than in native Germans [3], see Sierwald et al. [11]. 29 participants were excluded due
higher OHRQoL impairment in children and adolescents to insufficient information regarding migration background,
with migration background is very likely. Furthermore, resulting in 396 participants for the main analyses.
OHRQoL is not only affected by physical oral health The study protocol (Reg. No. 07-161) was reviewed and
but also by a person’s internal standards and references. approved by the Cologne University Hospital’s Research
Accordingly, measures of OHRQoL instruments could dif- Ethics Committee. All parents/legal guardians of children
fer between subjects just because of different concepts of who fulfilled the inclusion criteria were fully informed
OHRQoL, i.e., how they perceive and rate specific oral before giving consent and allowing their children to take
health problems. So far, cross-cultural measurement invar- part.
iance has not been established for OHRQoL instruments
in children and adolescents. The influence of migration on Socio‑demographic characteristics
health is the result of a complex interplay of protective and
adverse effects which depend on country of origin, migra- Country of birth was recorded for all children and adoles-
tion experience and migration route, the situation within cents as well as their parents’ country of origin. Participants
the host country, and individual resources. Migration per were divided into three groups: (i) Children and adoles-
se is not disease causing, but in many cases associated cents without a migration background (non-migrants) were
with special risks and negative social determinants [7, 8]. defined as children of parents who both were born in Ger-
Since several studies provided evidence for the effect of many, (ii) children with a single-sided migration background
these cultural circumstances in adults and seniors [9, 10], had one parent born in a foreign country, and (iii) children
such effects can also be expected in children and adoles- with a double-sided migration background had both parents
cents. Therefore, it can be presumed that cultural differ- born in a foreign country or were born in a foreign country
ences and the degree of acculturation have an impact on themselves.
OHRQoL in children and adolescents. Information regarding gender, age, and level of education
were also obtained for all participants. Level of education

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was categorized according to primary/elementary school migration background could not be performed, resulting in
(first to fourth grade—usually 6th to 10th life year) or sec- 269 conclusively classified participants with clinical data.
ondary/middle school (fifth to tenth grade—usually 10th The examiners and recorders were trained and calibrated
to 16th life year). The Family Affluence Scale (FAS) [12] prior to conducting the fieldwork to ensure reliability of
was used to assess the familial socioeconomic status. The the measurement indices. The trainer, who was a dentist
FAS is composed of socioeconomic indicators addressed to with extensive experience in oral health surveys, provided
children and adolescents, including family car ownership, the standard against which the examiners were calibrated
having their own unshared room, the number of computers (German national DAJ-calibration for community dentistry,
at home, and times the family spent on holiday in the past Kappa > 0.85).
12 months, with possible values ranging from 0 (low fam-
ily affluence) to 7 (high family affluence). Participants’ oral Assessment of oral health‑related quality of life
hygiene behavior was operationalized as the frequency of
tooth brushing and was assessed with a single item on a five- OHRQoL was assessed using the German 19-item version
point ordinal response scale: 1 = never, 2 = less than once a of the Child Oral Health Impact Profile (COHIP-G19) [11].
week, 3 = at least once a week but less than daily, 4 = once a The questionnaire was paper-based and self-administered.
day, 5 = more than once a day. The COHIP-G19 is organized in three subscales, named
“oral health well-being” (five items), “functional well-
Oral health characteristics being” (four items), and “social/emotional, school and self-
image” (ten items).
The oral health examination included an assessment of the For each of the 19 COHIP questions, subjects were
caries status of the mixed dentition (deciduous and perma- asked how frequently they had experienced a positive or
nent teeth) and the calculation of number of decayed teeth negative impact during the past 3 months. Responses were
(DT) and filled teeth (FT) as part of the DMFT index accord- made on a Likert-type scale (0 = never, 1 = almost never,
ing to the WHO criteria, without distinction between decidu- 2 = sometimes, 3 = fairly often, 4 = almost all of the time).
ous and permanent teeth [13]. Furthermore, the condition All scorings of negatively worded items were reversed for
of the periodontium was assessed by determination of the calculating summary scores for the overall instrument and
Community Periodontal Index (CPI) [14]. Only the pres- the subscales scores. The possible COHIP-G19 summary
ence or absence of calculus and gingival bleeding were taken scores thus ranged between 0 (worst OHRQoL) and 76 (best
into account and only the six index teeth were examined, as OHRQoL).
is recommended for subjects below 20 years of age [14]. Internal consistency as a measure of reliability of the
Gingival bleeding or calculus in at least one sextant was COHIP-G19 was determined by calculation of Cronbach’s
interpreted as an indicator for the presence of gingivitis. alpha [17] and average inter-item correlation. According to
Sagittal relationship of the front teeth (overjet) was meas- commonly applied guidelines, the resulting alpha of 0.79
ured with a ruler. Aesthetic need for orthodontic treatment and the average inter-item correlation of 0.16 indicate satis-
due to current malocclusion was assessed with means of factory internal consistency [18, 19].
the Modified Aesthetic Component (AC) of the Index of
Orthodontic Treatment Need (IOTN) [15, 16]. While the Data analyses
AC in its original form is a 10-point ordinal rating scale of
dental attractiveness, those malocclusions with a definite For the description of the sample, socio-demographic char-
treatment need (AC grades 8, 9, and 10) were distinguished acteristics, physical oral health status, oral hygiene behav-
from dental conditions without a definite treatment need (AC ior, and perceived oral health were presented as means and
grades 1–7) in the current study. Additionally, the presence standard deviations (SD) or frequencies and percentages for
of any form of cleft lip, cleft palate, or cleft lip and pal- all three groups separately. As the first step of the analy-
ate (Q35.1–Q37.9) was recorded based on the ICD-10-GM sis, the three groups (non-migrants, single-sided migration
version 2009. In subjects currently undergoing orthodontic background, double-sided migration background) were com-
treatment, the presence and kind of the orthodontic device pared with respect to these descriptive data using analysis
(fixed or removable) was recorded. of variance (ANOVA) for continuous data (age, FAS sum-
The participation rate for the clinical examination was mary score, DT, FT, overjet), Kruskal–Wallis test for ordinal
99.1% (N = 111) for the orthodontic sample and 55.6% data (AC, global oral health rating), and Chi-square test for
(N = 174) for the community sample. However, one par- categorical data (gender, school, gingivitis, cleft lip/palate,
ticipant from the orthodontic sample and 15 participants orthodontic treatment/device, tooth brushing frequency).
from the community sample were excluded, because Differences in OHRQoL between the three groups were
conclusive identification of presence or classification of tested for statistical significance by means of ANOVA using

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COHIP-G19 item, subscale, and summary scores. This was Table 1  Distribution of migrants according to birth country of father
followed by several linear regression analyses with COHIP- and mother
G19 subscale and summary scores as criterion variables Country of birth Father N (%) Mother N (%)
in unadjusted models, partly adjusted models, and fully
Africa 15 (12.1) 9 (8.4)
adjusted models to statistically control for socio-demo-
Asia 24 (19.4) 26 (24.3)
graphic characteristics (partly and fully adjusted model) and
EU-28 22 (17.8) 16 (15.0)
oral health status (fully adjusted model only).
Europe, non-EU 6 (4.8) 5 (4.7)
No conclusive identification of presence and classifica-
Middle East 16 (12.9) 15 (14.0)
tion of migration background was possible for 29 partici-
Middle and South America – 2 (1.9)
pants (6.8%). They were excluded from the study, resulting
Russia 4 (3.2) 4 (3.7)
in a final sample size of 396 participants. The number of
Turkey 36 (29.0) 30 (28.0)
COHIP-G19 items with missing information was small. All
USA 1 (0.81) –
19 items were complete in 84.7% of non-migrants, in 90.2%
Total 124 (100) 107 (100)
of participants with single-sided migration background,
and in 89.3% of those with double-sided migration back-
ground, without statistically significant differences between
groups (Chi-square test: p = 0.412). Up to two (10%) missing differences in DT scores missed the level of statistical sig-
answers were replaced using regression imputation for miss- nificance (p = 0.066; Table 2). The other clinical indicators
ing data on all single items as applied for other OHRQoL of oral health such as number of filled teeth, presence of
instruments [20]. Five non-migrants (1.9%), one participant gingivitis, amount of overjet, and presence of cleft lip/palate,
with single-sided migration background (2.4%), and four as well as perceived oral health did not differ substantially
participants with double-sided migration background (4.3%) between groups. However, more non-migrants were classi-
had more than two items with missing information and were fied as in need of orthodontic treatment (AC grades 8–10)
therefore excluded from calculations of COHIP-G19 domain and were undergoing orthodontic treatment than participants
and summary scores and corresponding analyses. in both migration groups. The proportion of non-migrants
All analyses were performed using the statistical software that wore removable or fixed appliances was approximately
package STATA/MP (Stata Statistical Software: Release twice as high as of participants with a one- or a double-sided
13.1, StataCorp LP, College Station, TX, USA), with the migration background. Interestingly, the proportion of par-
probability of a type I error set at the 0.05 level. ticipants brushing their teeth at least twice a day was nearly
the same in the group of non-migrants (90.0%) and in par-
ticipants with single-sided migration background (87.7%),
Results and both of them significantly higher than in those with
double-sided migration background (76.1%).
Participants’ characteristics
Oral health‑related quality of life and migration
The study population consisted of 262 participants without background
migration background, 41 participants with single-sided, and
93 with double-sided migration background. Concerning the Overall, OHRQoL was significantly more impaired in the
two migrant groups, the birth countries of the fathers and group with a double-sided migration background indicated
mothers were predominantly outside of Europe (Table 1). by lowest COHIP-G19 summary scores (mean: 58.6 points)
The largest fraction was from Turkey, followed by Europe, than in the groups with a single-sided (mean: 63.3 points)
Asia, the Middle East, and Africa. or without migration background (COHIP-G19 mean: 63.2
The mean age of the three groups ranged from 10.1 to points; Table 3). These differences in OHRQoL were also
10.9 years, and about half of the participants were females pronounced in the COHIP-G19 subscales “oral health well-
without statistical between-group differences (Table  2). being” and “social/emotional, school, and self-image.” Even
Family affluence was significantly lower in both groups with though the difference in the scores in the subscale “func-
migration background compared to the group without. The tional well-being” showed the same pattern, it missed the
lowest FAS summary score was present in participants with level of statistical significance (p = 0.100). Higher OHRQoL
double-sided migration background, and highest scores were impairment of the double-sided migration background group
observed in the non-migrants. in the COHIP-G19 subscales “oral health well-being” was
Even though participants in both migration groups pre- reflected in significant between-group differences in the
sented twice as much decayed teeth (mean DT: 0.5 and single items #1 (pain in teeth/toothache) and #5 (bleeding
0.4, respectively) than non-migrants (mean DT: 0.2), the gums), and in the subscale “social/emotional, school, and

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Table 2  Socio-demographic Non-migrants Migrants p value

characteristics, oral health
characteristics, and perceived Single-sided Double-sided
oral health migration back- migration back-
ground ground
N = 262 N = 41 N = 93
Mean (SD) or N (%)

Socio-demographic characteristics
 Demography
  Gender [female] 138 (53.5) 20 (48.8) 52 (57.1) 0.659
  Age [years] 10.6 (2.2) 10.9 (1.8) 10.1 (2.2) 0.061
 Education 0.027
  Primary/elementary school 160 (61.1) 28 (68.3) 71 (76.3)
  Secondary/middle school 102 (38.9) 13 (31.7) 22 (23.7)
 Familial affluence
  FAS summary score 5.2 (1.4) 4.5 (1.6) 4.0 (1.5) < 0.001
Oral health characteristics
 Clinical ­indicatorsa
  Decayed teeth (DT) 0.2 (0.7) 0.5 (1.0) 0.4 (0.8) 0.066
  Filled teeth (FT) 0.8 (1.5) 0.9 (1.3) 1.1 (1.7) 0.331
  Gingivitis (CPI) 29 (17.1) 7 (20.0) 14 (21.9) 0.682
  Overjet [mm] 2.7 (2.7) 2.8 (1.7) 2.4 (1.6) 0.646
  Cleft lip/palate (ICD-10 Q.35–Q.37) 23 (13.5) 1 (2.9) 6 (9.4) 0.166
 Modified aesthetic component (AC)a < 0.001
  Grade 1–7 126 (77.8) 33 (100.0) 55 (93.2)
  Grade 8 20 (12.4) 0 (0.0) 3 (5.1)
  Grade 9 12 (7.4) 0 (0.0) 1 (1.7)
  Grade 10 4 (2.5) 0 (0.0) 0 (0.0)
 Orthodontic treatment/devicea < 0.001
  None 59 (39.6) 22 (66.7) 45 (75.0)
  Removable orthodontic appliance 37 (24.8) 5 (15.2) 4 (6.7)
  Fixed orthodontic appliance 53 (35.6) 6 (18.2) 11 (18.3)
 Tooth brushing frequency 0.004
  At least twice a day 233 (90.0) 36 (87.8) 70 (76.1)
  Less than twice a day 26 (10.0) 5 (12.2) 22 (23.9)
Perceived oral health
 Global oral health rating 0.657
  Excellent 59 (23.1) 12 (30.8) 25 (27.5)
  Good 139 (54.3) 19 (48.7) 43 (47.3)
  Average 41 (16.0) 7 (18.0) 15 (16.5)
  Moderate 17 (6.6) 1 (2.6) 7 (7.7)
  Poor 0 (0.0) 0 (0.0) 1 (1.1)
a
 Based on 269 participants with oral examination (Non-migrants: N = 170; one parent born in foreign coun-
try: N = 31; Both parents born in foreign country: N = 68)

self-image” in the items #11 (feeling worried or anxious), Regression analyses revealed in the unadjusted mod-
#12 (avoided smiling or laughing with other children), #14 els statistically significant differences in COHIP-G19
(been worried about what other people think about your…), summary and subscales scores between the double-sided
#15 (been teased, bullied, or called names by other children), migration background group and non-migrants, while
#17 (not wanted to speak/read out loud in class), and #18 the single-sided migration background group did not dif-
(been confident), with consistently lower scores than in the fer significantly from non-migrants (Table 4). On aver-
non-migration and the single-sided migration group. age, COHIP-G19 summary scores of the double-sided

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Table 3  COHIP-G19 item, subscale, and summary scores

Subscales and items Non-migrants Migrants p value
Single-sided Double-sided
migration back- migration back-
ground ground
# Content Mean (SD)

Oral health well-being

 1 Had pain in your teeth/toothache 3.3 (0.9) 3.4 (0.9) 2.9 (1.0) < 0.001
 2 Had discolored teeth or spots on your 3.4 (0.9) 3.4 (0.8) 3.3 (1.0) 0.612
teeth
 3 Had crooked teeth or spaces between 2.3 (1.4) 2.4 (1.4) 2.1 (1.3) 0.308
your teeth
 4 Had bad breath 3.4 (0.8) 3.5 (0.9) 3.2 (1.0) 0.254

 5 Had bleeding gums 3.2 (0.9) 3.0 (1.1) 2.7 (1.2) < 0.001
 COHIP-19 Oral Health Subscale 15.7 (2.7) 15.6 (2.9) 14.2 (3.5) < 0.001
Functional well-being
 6 Had difficulty eating foods you would 3.5 (0.9) 3.5 (0.9) 3.6 (0.8) 0.908
like to eat

 7 Had trouble sleeping 3.8 (0.6) 3.9 (0.4) 3.6 (0.8) 0.140
 8 Had difficultly saying certain words 3.6 (0.8) 3.7 (0.7) 3.4 (1.0) 0.014
 9 Had difficulty keeping your teeth clean 3.4 (0.8) 3.6 (0.9) 3.3 (1.1) 0.296
 COHIP-19 functional well-being subscale 14.4 (2.0) 14.6 (1.6) 13.9 (2.7) 0.100
Social/emotional, school, and self-image
 10 Been unhappy or sad 3.6 (0.9) 3.5 (0.8) 3.4 (1.1) 0.233
 11 Felt worried or anxious 3.7 (0.7) 3.6 (0.9) 3.4 (1.0) 0.008
 12 Avoided smiling or laughing with 3.7 (0.7) 3.9 (0.4) 3.5 (1.1) 0.034
other children
 13 Felt that you look different 3.6 (0.9) 3.8 (0.7) 3.5 (0.9) 0.262
 14 Been worried about what other people 3.5 (0.9) 3.5 (0.9) 3.1 (1.1) 0.002
think about your…
 15 Been teased, bullied, or called names 3.7 (0.8) 3.6 (0.9) 3.4 (1.1) 0.016
by other children
 16 Missed school for any reason 3.8 (0.6) 3.8 (0.7) 3.7 (0.7) 0.554
 17 Not wanted to speak/read out loud in 3.9 (0.5) 4.0 (0.2) 3.7 (0.8) 0.013
class
 18 Been confident 2.0 (1.6) 2.0 (1.7) 1.4 (1.5) 0.007
 19 Felt that you were attractive (good 1.7 (1.5) 1.5 (1.4) 1.4 (1.6) 0.345
looking)
 COHIP-19 social/emotional, school, and self-image subscale 33.1 (4.4) 33.1 (4.4) 30.4 (5.2) < 0.001
COHIP-19 summary score 63.2 (7.0) 63.3 (6.7) 58.6 (9.2) < 0.001

Note: Scores of negatively worded items (all items except #18 and #19) were reversed before analyses

migration background group were 4.6 points lower than Discussion

in non-migrants, and 1.4 points lower in the subscale “oral
health well-being,” 0.5 points in the subscale “functional This explorative cross-sectional study compared OHRQoL
well-being,” and 2.6 points in the subscale “social/emo- in three German groups of children and adolescents with
tional, school, and self-image.” Neither the adjustment respect to migration background. The group with a double-
for socio-demographic characteristics nor the additional sided migration background showed significantly lower
adjustment for oral health characteristics changed the find- OHRQoL than non-migrants or the single-sided migration
ings noteworthy.

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Table 4  Impact of migration background on COHIP summary and characteristics (Model 2) and fully adjusted for socio-demographic
subscale scores based on unadjusted linear regression analysis (Model and oral health characteristics (Model 3)
1), and on regression analysis partly adjusted for socio-demographic

Criterion Predictor Model 1 Model 2 Model 3

Unadjusted Partly ­adjustedb Fully ­adjustedc
 N= 386 N = 366 N  = 223
Coefficient (95% CI)

COHIP-19 summary score Non-migrantsa – – –

One parent born in foreign country 0.1 (− 2.4; 2.6) 0.9 (− 1.7; 3.6) 1.0 (− 2.2; 4.2)
Both parents born in foreign country − 4.6 (− 6.4; − 2.8) − 3.9 (− 5.9; − 2.0) − 3.8 (− 6.6; − 1.0)
Oral health well-being score Non-migrantsa – – –
One parent born in foreign country − 0.1 (− 1.1; 0.9) 0.2 (− 0.8; 1.2) 0.2 (− 0.9; 1.4)
Both parents born in foreign country − 1.4 (− 2.1; − 0.7) − 1.2 (− 1.9; − 0.4) − 1.0 (− 2.0; 0.0)
Functional well-being score Non-migrantsa – – –
One parent born in foreign country 0.2 (− 0.5; 0.9) 0.4 (− 0.4; 1.1) 0.4 (− 0.4; 1.3)
Both parents born in foreign country − 0.5 (− 1.0; 0.0) − 0.5 (− 1.0; 0.1) − 0.3 (− 1.0; 0.5)
Social/emotional, school, and Non-migrantsa – – –
self-image score One parent born in foreign country 0.0 (− 1.5; 1.6) 0.4 (− 1.2; 2.0) 0.3 (− 1.6; 2.3)
Both parents born in foreign country − 2.6 (− 3.8; − 1.5) − 2.3 (− 3.5; − 1.1) − 2.6 (− 4.3; − 0.8)

Numbers in bold: p ≤ 0.05

a
 Reference
b
 Gender [female], age [years], family affluence [FAS summary score]
c
 Gender [female], age [years], family affluence [FAS summary score], decayed teeth [number], gingivitis [presence], orthodontic treatment
[type], tooth brushing frequency [> 1 daily]

group. Likewise, the subscale “oral health well-being” and were not specifically addressed in the present study, should
the subscale “social/emotional, school, and self-image” be the focus of future studies. Furthermore, differences in
showed also higher impairment in the double-sided the measurement model of the COHIP-G19 between the
migrant group than in the other two groups. groups could potentially explain the findings. This should
Several linear regression models were constructed to also be addressed in further studies on cross-cultural meas-
assess whether the effect of migration background can be urement invariance.
sufficiently explained by differences in the socioeconomic As this is the first study comparing OHRQoL in children
status (SES) and physical oral health characteristics. How- and adolescents with respect to migration background, com-
ever, adjusting for gender, age, and SES hardly changed the parisons with the literature are limited. The results regarding
resulting coefficients neither for the models of the COHIP- clinical indicators of the KiGSS survey, which showed that
G19 sub-scores nor the summary scores. Likewise, addi- a doubled-sided migration background has a large influence
tional adjustments for the number of decayed teeth, presence compared to a single-sided migration background or non-
of gingivitis, type of orthodontic treatment, or tooth brush- migration background [3, 4], corresponds with our results.
ing frequency hardly changed the coefficients resulting from This study has strengths and limitations. Based on the
the unadjusted model. Accordingly, the association between cross-sectional design, we cannot formally establish a
double-sided migration background and impaired OHRQoL causal relationship between exposure and outcome. How-
was essentially independent of the employed adjustments. ever, it is plausible that the investigated OHRQoL indica-
These results suggest that likely other, so far, non-identi- tors are affected by migration background and not vice
fied factors may be important for the relationship between versa. The study population cannot be considered to be
OHRQoL and the degree of migration background. Family representative of children and adolescents in Germany in
members with at least one parent born in Germany may have general because participants were recruited in one clinic
better lingual abilities and may be better integrated into the only and a few schools in a single middle-sized German
society. Lack of acculturation in families with a double-sided town. While participants recruited in the public schools
migration background could have an impact particularly on can be considered as representative of the general popu-
the social/emotional, school, and self-image subscale of the lation in this region, the orthodontic sample comprised
COHIP-G19. These potentially important covariates, which patients involved in orthodontic treatment and, therefore,

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