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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Introduction
Considering the high rate of migration worldwide, oral
disease prevention in people with migration background
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-
alence of dental caries, and oral self-care [1–3]. Besides
the social gradient’s influence, oral health is also affected
by origin and culture. The representative population-based
studies on children’s and adolescents’ health in Germany
[4] clearly showed that children of immigrants have both
worse physical oral health and oral health-care utiliza-
tion than their German counterparts [3]. These surveys
also showed that these differences are quite low between
native German families and binational families in which
one parent is born and socialized in Germany, but they are
remarkably pronounced when native German families are
compared with those whose both parents are immigrants.
However, this is not true for higher educated immigrants
from industrialized countries as opposed to children of
Eastern European or Middle East Asian origin [5].
In contrast, little is known about potential effects of
migration background on oral health-related quality of
life (OHRQoL) of children and adolescents [6]. OHRQoL
has been established as a measure to quantitatively assess
perceived effects of oral health and treatment outcomes on
peoples’ well-being. Considering the findings on physical
oral health and oral health-care utilization with signifi-
cantly lower levels in migrants than in native Germans [3],
higher OHRQoL impairment in children and adolescents
with migration background is very likely. Furthermore,
OHRQoL is not only affected by physical oral health
but also by a person’s internal standards and references.
Accordingly, measures of OHRQoL instruments could dif-
fer between subjects just because of different concepts of
OHRQoL, i.e., how they perceive and rate specific oral
health problems. So far, cross-cultural measurement invar-
iance has not been established for OHRQoL instruments
in children and adolescents. The influence of migration on
health is the result of a complex interplay of protective and
adverse effects which depend on country of origin, migra-
tion experience and migration route, the situation within
the host country, and individual resources. Migration per
se is not disease causing, but in many cases associated
with special risks and negative social determinants [7, 8].
Since several studies provided evidence for the effect of
these cultural circumstances in adults and seniors [9, 10],
such effects can also be expected in children and adoles-
cents. Therefore, it can be presumed that cultural differ-
ences and the degree of acculturation have an impact on
OHRQoL in children and adolescents.
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Quality of Life Research
Aim of this study was to compare OHRQoL of children
and adolescents with and without migration background, and
to assess whether potential differences in OHRQoL can be
sufficiently explained by oral health characteristics.
Materials and methods
Participants, design, and setting
In this exploratory cross-sectional study, participants were
recruited during the development of the German version of
the Child Oral Health Impact Profile (COHIP-G19) [11] in
two different settings. The first sample consisted of ortho-
dontic patients consecutively recruited at the Department of
Orthodontics, University of Cologne, Germany, from May
through June 2010 (N = 112). Patients of the orthodontic
sample were enrolled in the study independently of their
current treatment phase; hence, the orthodontic sample com-
prised patients involved in the entire range of orthodontic
treatment (baseline examination to post treatment check-up).
The second sample consisted of students recruited at public
schools in Greifswald, Germany (convenience community
sample), from November through December 2010 (N = 313).
Classes (second to eighth grades) of eligible schools were
randomly selected. All students/patients aged 7 to 17 years
were asked to participate in the study. Participants completed
a self-administered, paper-based questionnaire. For further
details of inclusion/exclusion criteria and administration,
see Sierwald et al. [11]. 29 participants were excluded due
to insufficient information regarding migration background,
resulting in 396 participants for the main analyses.
The study protocol (Reg. No. 07-161) was reviewed and
approved by the Cologne University Hospital’s Research
Ethics Committee. All parents/legal guardians of children
who fulfilled the inclusion criteria were fully informed
before giving consent and allowing their children to take
part.
Socio‑demographic characteristics
Country of birth was recorded for all children and adoles-
cents as well as their parents’ country of origin. Participants
were divided into three groups: (i) Children and adoles-
cents without a migration background (non-migrants) were
defined as children of parents who both were born in Ger-
many, (ii) children with a single-sided migration background
had one parent born in a foreign country, and (iii) children
with a double-sided migration background had both parents
born in a foreign country or were born in a foreign country
themselves.
Information regarding gender, age, and level of education
were also obtained for all participants. Level of education
Quality of Life Research
was categorized according to primary/elementary school
(first to fourth grade—usually 6th to 10th life year) or sec-
ondary/middle school (fifth to tenth grade—usually 10th
to 16th life year). The Family Affluence Scale (FAS) [12]
was used to assess the familial socioeconomic status. The
FAS is composed of socioeconomic indicators addressed to
children and adolescents, including family car ownership,
having their own unshared room, the number of computers
at home, and times the family spent on holiday in the past
12 months, with possible values ranging from 0 (low fam-
ily affluence) to 7 (high family affluence). Participants’ oral
hygiene behavior was operationalized as the frequency of
tooth brushing and was assessed with a single item on a five-
point ordinal response scale: 1 = never, 2 = less than once a
week, 3 = at least once a week but less than daily, 4 = once a
day, 5 = more than once a day.
Oral health characteristics
The oral health examination included an assessment of the
caries status of the mixed dentition (deciduous and perma-
nent teeth) and the calculation of number of decayed teeth
(DT) and filled teeth (FT) as part of the DMFT index accord-
ing to the WHO criteria, without distinction between decidu-
ous and permanent teeth [13]. Furthermore, the condition
of the periodontium was assessed by determination of the
Community Periodontal Index (CPI) [14]. Only the pres-
ence or absence of calculus and gingival bleeding were taken
into account and only the six index teeth were examined, as
is recommended for subjects below 20 years of age [14].
Gingival bleeding or calculus in at least one sextant was
interpreted as an indicator for the presence of gingivitis.
Sagittal relationship of the front teeth (overjet) was meas-
ured with a ruler. Aesthetic need for orthodontic treatment
due to current malocclusion was assessed with means of
the Modified Aesthetic Component (AC) of the Index of
Orthodontic Treatment Need (IOTN) [15, 16]. While the
AC in its original form is a 10-point ordinal rating scale of
dental attractiveness, those malocclusions with a definite
treatment need (AC grades 8, 9, and 10) were distinguished
from dental conditions without a definite treatment need (AC
grades 1–7) in the current study. Additionally, the presence
of any form of cleft lip, cleft palate, or cleft lip and pal-
ate (Q35.1–Q37.9) was recorded based on the ICD-10-GM
version 2009. In subjects currently undergoing orthodontic
treatment, the presence and kind of the orthodontic device
(fixed or removable) was recorded.
The participation rate for the clinical examination was
99.1% (N = 111) for the orthodontic sample and 55.6%
(N = 174) for the community sample. However, one par-
ticipant from the orthodontic sample and 15 participants
from the community sample were excluded, because
conclusive identification of presence or classification of
migration background could not be performed, resulting in
269 conclusively classified participants with clinical data.
The examiners and recorders were trained and calibrated
prior to conducting the fieldwork to ensure reliability of
the measurement indices. The trainer, who was a dentist
with extensive experience in oral health surveys, provided
the standard against which the examiners were calibrated
(German national DAJ-calibration for community dentistry,
Kappa > 0.85).
Assessment of oral health‑related quality of life
OHRQoL was assessed using the German 19-item version
of the Child Oral Health Impact Profile (COHIP-G19) [11].
The questionnaire was paper-based and self-administered.
The COHIP-G19 is organized in three subscales, named
“oral health well-being” (five items), “functional well-
being” (four items), and “social/emotional, school and self-
image” (ten items).
For each of the 19 COHIP questions, subjects were
asked how frequently they had experienced a positive or
negative impact during the past 3 months. Responses were
made on a Likert-type scale (0 = never, 1 = almost never,
2 = sometimes, 3 = fairly often, 4 = almost all of the time).
All scorings of negatively worded items were reversed for
calculating summary scores for the overall instrument and
the subscales scores. The possible COHIP-G19 summary
scores thus ranged between 0 (worst OHRQoL) and 76 (best
OHRQoL).
Internal consistency as a measure of reliability of the
COHIP-G19 was determined by calculation of Cronbach’s
alpha [17] and average inter-item correlation. According to
commonly applied guidelines, the resulting alpha of 0.79
and the average inter-item correlation of 0.16 indicate satis-
factory internal consistency [18, 19].
Data analyses
For the description of the sample, socio-demographic char-
acteristics, physical oral health status, oral hygiene behav-
ior, and perceived oral health were presented as means and
standard deviations (SD) or frequencies and percentages for
all three groups separately. As the first step of the analy-
sis, the three groups (non-migrants, single-sided migration
background, double-sided migration background) were com-
pared with respect to these descriptive data using analysis
of variance (ANOVA) for continuous data (age, FAS sum-
mary score, DT, FT, overjet), Kruskal–Wallis test for ordinal
data (AC, global oral health rating), and Chi-square test for
categorical data (gender, school, gingivitis, cleft lip/palate,
orthodontic treatment/device, tooth brushing frequency).
Differences in OHRQoL between the three groups were
tested for statistical significance by means of ANOVA using
13

COHIP-G19 item, subscale, and summary scores. This was
followed by several linear regression analyses with COHIP-
G19 subscale and summary scores as criterion variables
in unadjusted models, partly adjusted models, and fully
adjusted models to statistically control for socio-demo-
graphic characteristics (partly and fully adjusted model) and
oral health status (fully adjusted model only).
No conclusive identification of presence and classifica-
tion of migration background was possible for 29 partici-
pants (6.8%). They were excluded from the study, resulting
in a final sample size of 396 participants. The number of
COHIP-G19 items with missing information was small. All
19 items were complete in 84.7% of non-migrants, in 90.2%
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
answers were replaced using regression imputation for miss-
ing data on all single items as applied for other OHRQoL
instruments [20]. Five non-migrants (1.9%), one participant
with single-sided migration background (2.4%), and four
participants with double-sided migration background (4.3%)
had more than two items with missing information and were
therefore excluded from calculations of COHIP-G19 domain
and summary scores and corresponding analyses.
All analyses were performed using the statistical software
package STATA/MP (Stata Statistical Software: Release
13.1, StataCorp LP, College Station, TX, USA), with the
probability of a type I error set at the 0.05 level.
Results
Participants’ characteristics
The study population consisted of 262 participants without
migration background, 41 participants with single-sided, and
93 with double-sided migration background. Concerning the
two migrant groups, the birth countries of the fathers and
mothers were predominantly outside of Europe (Table 1).
The largest fraction was from Turkey, followed by Europe,
Asia, the Middle East, and Africa.
The mean age of the three groups ranged from 10.1 to
10.9 years, and about half of the participants were females
without statistical between-group differences (Table  2).
Family affluence was significantly lower in both groups with
migration background compared to the group without. The
lowest FAS summary score was present in participants with
double-sided migration background, and highest scores were
observed in the non-migrants.
Even though participants in both migration groups pre-
sented twice as much decayed teeth (mean DT: 0.5 and
0.4, respectively) than non-migrants (mean DT: 0.2), the
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Quality of Life Research
Table 1  Distribution of migrants according to birth country of father
and mother
Country of birth Father N (%) Mother N (%)
Africa 15 (12.1) 9 (8.4)
Asia 24 (19.4) 26 (24.3)
EU-28 22 (17.8) 16 (15.0)
Europe, non-EU 6 (4.8) 5 (4.7)
Middle East 16 (12.9) 15 (14.0)
Middle and South America – 2 (1.9)
Russia 4 (3.2) 4 (3.7)
Turkey 36 (29.0) 30 (28.0)
USA 1 (0.81) –
Total 124 (100) 107 (100)
differences in DT scores missed the level of statistical sig-
nificance (p = 0.066; Table 2). The other clinical indicators
of oral health such as number of filled teeth, presence of
gingivitis, amount of overjet, and presence of cleft lip/palate,
as well as perceived oral health did not differ substantially
between groups. However, more non-migrants were classi-
fied as in need of orthodontic treatment (AC grades 8–10)
and were undergoing orthodontic treatment than participants
in both migration groups. The proportion of non-migrants
that wore removable or fixed appliances was approximately
twice as high as of participants with a one- or a double-sided
migration background. Interestingly, the proportion of par-
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%),
and both of them significantly higher than in those with
double-sided migration background (76.1%).
Oral health‑related quality of life and migration
background
Overall, OHRQoL was significantly more impaired in the
group with a double-sided migration background indicated
by lowest COHIP-G19 summary scores (mean: 58.6 points)
than in the groups with a single-sided (mean: 63.3 points)
or without migration background (COHIP-G19 mean: 63.2
points; Table 3). These differences in OHRQoL were also
pronounced in the COHIP-G19 subscales “oral health well-
being” and “social/emotional, school, and self-image.” Even
though the difference in the scores in the subscale “func-
tional well-being” showed the same pattern, it missed the
level of statistical significance (p = 0.100). Higher OHRQoL
impairment of the double-sided migration background group
in the COHIP-G19 subscales “oral health well-being” was
reflected in significant between-group differences in the
single items #1 (pain in teeth/toothache) and #5 (bleeding
gums), and in the subscale “social/emotional, school, and
Quality of Life Research

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),
#12 (avoided smiling or laughing with other children), #14
(been worried about what other people think about your…),
#15 (been teased, bullied, or called names by other children),
#17 (not wanted to speak/read out loud in class), and #18
(been confident), with consistently lower scores than in the
non-migration and the single-sided migration group.
Regression analyses revealed in the unadjusted mod-
els statistically significant differences in COHIP-G19
summary and subscales scores between the double-sided
migration background group and non-migrants, while
the single-sided migration background group did not dif-
fer significantly from non-migrants (Table 4). On aver-
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
well-being,” and 2.6 points in the subscale “social/emo-
tional, school, and self-image.” Neither the adjustment
for socio-demographic characteristics nor the additional
adjustment for oral health characteristics changed the find-
ings noteworthy.
This explorative cross-sectional study compared OHRQoL
in three German groups of children and adolescents with
respect to migration background. The group with a double-
sided migration background showed significantly lower
OHRQoL than non-migrants or the single-sided migration

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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 – – –

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

13

represents only a subgroup of the general population.
However, a previous study has shown that these two
groups do not differ substantially in their clinical measures
of oral health such as number of decayed teeth or pres-
ence of gingivitis, and not in their COHIP-G19 summary
scores [11]. Accordingly, both groups were well compa-
rable and could be collectively analyzed. Nonetheless, we
statistically controlled the final analyses not only for clini-
cal oral health measures but also for presence and type
of orthodontic treatment. According to the latest German
census of 2011 [21], 15.3 million (19%) of the 80.5 million
people living in Germany had a migration background.
About 9.6 million (63%) were immigrants from almost all
countries worldwide. The largest immigration group con-
sisted of German resettlers from the former Soviet Union,
the second largest group was of Turkish origin (~ 1.6 mil-
lion). Thus, children originating from families of German
resettlers from the former Soviet Union were underrep-
resented in our study. However, because of the explora-
tive nature of this study this should not be too concern-
ing. Another limitation could be that responding to some
COHIP-G19 items may have been biased by low German
language skills which may be more common in children
with double-sided than single-sided or no migration back-
ground. However, language skills were not assessed, and
number of items with missing information did not differ
between groups, suggesting that language barriers were
not a problem.
In conclusion, German children and adolescents with
double-sided migration background have lower OHRQoL
than their peers with single-sided or no migration back-
ground. Since between-group differences in OHRQoL
could not be sufficiently explained by effects of SES or
physical oral health indicators, other methodological, cul-
tural, or immigration-related factors might also play an
important role for the observed effects.
Funding  This study was partly funded by the German Orthodontic
Society (DGKFO; Grant Reference: 49). The funder had no role in
study design, data collection and analysis, decision to publish, or prepa-
ration of the manuscript.
Compliance with ethical standards  methods (5th ed.). Geneva: World Health Organization.
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical approval  This article does not contain any studies with animals
performed by any of the authors. All procedures performed in studies
involving human participants were in accordance with the ethical stand-
ards of the institutional research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
Informed consent  Informed consent was obtained from all individual
participants included in the study.
13
Quality of Life Research
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