Received: 10 September 2020 Revised: 28 November 2020 Accepted: 29 December 2020

DOI: 10.1111/scd.12563

ARTICLE

Oral health status and oral health-related quality of life in

children with attention-deficit hyperactivity disorder and
oppositional defiant disorder

Zahra Jamali1 Parisa Ghaffari2 Naser Asl Aminabadi3 Sanaz Norouzi4

Sajjad Shirazi5

1 Department of Oral Medicine, Faculty of

Dentistry, Tabriz University of Medical Abstract

Sciences, Tabriz, Iran
2 Department of Pediatric Dentistry,
Faculty of Dentistry, Zanjan University of
Medical Sciences, Zanjan, Iran
3Department of Pediatric Dentistry,
Faculty of Dentistry, Tabriz University of
Medical Sciences, Tabriz, Iran
4 Department of Psychiatry (Child and
Adolescent Ward), Razi Psychiatry
Hospital, Tabriz University of Medical
Sciences, Tabriz, Iran
5Department of Oral Biology, College of
Dentistry, University of Illinois at
Chicago, Chicago, Illinois
Correspondence
Sajjad Shirazi, Department of Oral Biology,
College of Dentistry, University of Illinois
at Chicago, Chicago, IL.
Email: s.shirazi.tbzmed88@gmail.com
Aims: Oral diseases can affect various aspects of life in patients with attention
deficit hyperactivity disorder/oppositional defiant disorder (ADHD/ODD). This
study aimed to assess the oral health status and oral health-related quality of life
(OHRQOL) in ADHD/ODD children.
Methods: Forty ADHD/ODD and 80 control children aged 3-7 years old were
included in the study. Gingival index (GI), dmft score, and the pediatric oral
health-related quality of life (POQL) questionnaire were used to determine the
oral health status and OHRQOL, respectively.
Results: The mean dmft and GI were significantly higher in the ADHD/ODD
group than the control group (P = .002 and P = .001). In the ADHD/ODD
children, the total score of OHRQOL and the mean scores of the emotional,
physical, role, and social domains were lower than that in the control group
(P = .0004, P = .027, P = .002, P = .014, and P = .043, respectively). Poisson’s
regression showed that there was a significant relationship between OHRQOL
and dmft scores (P-value < .001). However, the association between GI and
OHRQOL scores was not significant.
Conclusion: Higher dmft and GI scores were found in children with
ADHD/ODD than the control children. A lower POQL score was detected in
ADHD/ODD patients, which translates to a better level of OHRQOL.

KEYWORDS
ADHD, children, oral health, quality of life

1 INTRODUCTION
Attention-deficit hyperactivity disorder (ADHD) is among
the most common behavioral disorders in childhood that
often manifests during the preschool and early school
years. ADHD has its origins in childhood and can con-
tinue through adolescence and adulthood in 30-50%.1
This chronic disorder is characterized by inattention,
low frustration tolerance, developmentally inappro-
priate activity level, impulsivity, distractibility, poor

© 2021 Special Care Dentistry Association and Wiley Periodicals LLC

178 wileyonlinelibrary.com/journal/scd Spec Care Dentist. 2021;41:178–186.

JAMALI et al. 179

organizational behavior, and inability to sustain attention 2 MATERIALS AND METHODS

and concentration.2 Genetic and environmental factors
affecting the dopamine neurotransmitter are believed This study was conducted according to the STROBE
to play a role in the development of ADHD.1 Although guidelines after obtaining approval from the Ethics
ADHD is under-diagnosed in females, it is three to eight Committee (dated June 12, 2018; approval number:
times more common in males.3 TBZMED.REC.1398.540) following the World Medical
Oppositional defiant disorder (ODD) is a mental disor- Association Declaration of Helsinki. The study was car-
der with a frequent persistent pattern of angry/irritable ried out at the Department of Psychiatry, Razi Hospital
mood, argumentative/defiant behavior, or vindictiveness and the Department of Pediatric Dentistry, Faculty of
manifested during interactions with at least one non- Dentistry, from June 23, 2019 to March 21, 2020.
sibling individual. The mean prevalence of ODD is esti-
mated at 3.3% (range 1-11%) and clinically co-occurs with
2.1 Sampling
ADHD in about 60-80% of children. Thus, ODD and
ADHD are often studied together.2 ADHD and ODD share
The study group consisted of children with a definite
many temperamental risk factors; thus, their differential
diagnosis of ADHD/ODD according to the diagnostic and
diagnosis is often challenging.2
statistical manual of mental disorders by the American
Previous studies have addressed some oral health issues
Psychiatric Association.2 All of the ADHD/ODD children
in children with ADHD. Several studies have reported
had been diagnosed and referred to the Department of
higher decayed, missing and filled teeth index scores
Pediatric Dentistry by an experienced child psychologist
in permanent (DMFT) and primary (dmft) dentition in
from Razi Psychiatry Hospital. A total of 40 patients with
ADHD patients than the normal children.4–6 However, the
ADHD/ODD aged 3-7 years of age participated in this
evidence is somewhat inconsistent. For instance, a study
study.
found no significant difference in the prevalence of den-
The control group included 80 children aged 3-7 years
tal caries compared with controls despite the lower oral
old who were selected from children referred to the Depart-
hygiene of ADHD patients.7 Another study indicated that
ment of Pediatric Dentistry for a routine dental examina-
children with ADHD tended to have higher DMFT values
tion and were matched with the ADHD group in terms of
than the control group, while there was no significant dif-
gender, age and parent’s age, and their economic and edu-
ferences in dmft, approximal plaque index, bruxism, and
cational status. The parents rated the financial well-being
oral hygiene habits between the two groups.
of their family according to five categories, as follows: (a)
On the other hand, oral conditions such as den-
not at all well-off, (b) not very well-off, (c) average, (d)
tal caries and periodontal disease have physical, eco-
somewhat well-off, and (e) very well-off.13 The educational
nomic, social, and psychological consequences, and can
status of the parents was recorded as years spent for study-
negatively affect the quality of life in various aspects
ing. These children were then referred to Razi Psychiatry
such as oral function, esthetic appearance, and interper-
Hospital to confirm the absence of any kind of psychiatric
sonal relationships.9 Oral health-related quality of life
disorder and ODD/ADHD. The diagnosis was established
(OHRQOL) is the perceived impact of one’s oral health
by the same pediatric psychiatrist as the ADHD/ODD
on daily life and assesses the patients’ perceptions regard-
group, using the same criteria and techniques.
ing the effects of oral health status on function as well as
The exclusion criteria included the presence of a con-
emotional and social wellbeing.10 A strong relationship has
founding medical history, severe mental disorder, or any
been reported between OHRQOL and dental caries experi-
other psychological condition, and were applied to both
ence in children.11 To further address this topic, Hunting-
the ADHD/ODD and control groups.13
ton et al developed pediatric oral health-related quality of
life (POQL) particularly focusing on the input of parents
and children from low-income populations.12 2.2 Oral health status
Therefore, considering the ambiguous profile reported
in the literature on the oral health status of ADHD/ODD Written informed consent was obtained from the parents
patients and the potential association of oral health or legal guardians of the children. In order to assess the
parameters with OHRQOL, this study aimed to assess oral health status, one previously educated and calibrated
the oral health status of ADHD/ODD children com- postgraduate student who was blind to the mental health
pared with controls in the context of OHRQOL. We situation of participants, evaluated the dmft index and
hypothesize that there is no difference in oral health the gingival index (GI) under the supervision of an
status and OHRQOL between ADHD/ODD and control experienced pediatric dentist. Before conducting the
groups. study, the postgraduate student (examiner) was trained by
180
the same experienced pediatric dentist according to WHO
caries diagnostic criteria. The examiner then evaluated
dmft and GI scores in 15 patients in two appointments with
2 days interval. The intra-examiner reliability was then
calculated using kappa statistics (kappa statistics = 0.89).
Considering the variable nature of GI and the fact that the
patients could have received dental treatments after the
first session leading to change in dmft index, we decided
to conduct inter-examiner reliability within in this short
interval to avoid inconsistencies.
Clinical examination was performed according to the
World Health Organization caries-diagnostic criteria. The
children were clinically examined on a dental chair using
a dental explorer, dental mirror, and World Health Orga-
nization periodontal probe to determine their dmft index
and GI.1,13 Bitewing dental radiographs were obtained only
when needed to verify the diagnosis of dental caries.13 Sil-
ness Löe GI was used for assessment of the gingival condi-
tion. The scores of the four surfaces of each tooth includ-
ing facial, mesial, distal, and lingual were determined, and
the gingiva was scored from normal (score 0) to severely
inflamed with a tendency to bleed spontaneously (score
3). Gingiva that was mildly inflamed without bleeding on
probing (BOP) was given a GI score of 1; whereas moder-
ately inflamed gingiva with BOP was scored 2. The sum of
scores was calculated and divided by the number of teeth
examined to calculate the GI for each subject.14
At the same appointment, the parents were requested
to fill out the POQL questionnaire to determine the
OHRQOL of their children. In this study, the “parent
report on child” version of the POQL, which is adjusted
for preschool children, was used. The 10-item preschool
version of the POQL assesses the caregiver’s perception
of the extent to which his/her child’s function had been
negatively affected by oral health experiences.12 The
original “parent report on child” version, consisted of
four domains namely physical function (having pain,
having trouble eating), role function (having trouble
paying attention at school, missing school), social impact
(having trouble laughing or smiling, feeling that he/she
was not as good looking to others, child unhappy with the
way he/she looked), and emotional impact (feeling angry
or upset, feeling worried, crying). The POQL measures
five outcomes including one total impact score and four
domains (physical, role, social, and emotional). For each
item, the respondents were asked to rate how often the
event occurred for their child in the past 3 months. The
answer choices were “all the time,” “sometimes,” “once
in a while,” and “never” happened. For each item, the
respondents were asked how bothered the child was by
the event over the past 3 months. The answer choices
were “very bothered,” “somewhat bothered,” “bothered a
little,” “never bothered,” and “did not happen.”
JAMALI et al.
The POQL scores were calculated by reverse-scoring of
all items, such that higher scores indicated greater fre-
quency or bother. Thereafter, the scores were multiplied
by the frequency score (0-3) and by the bother score (0-
4) to obtain the "impact” score of the respective item. A
total POQL score was created by multiplying “how often”
by “how bothered”; the sum of the multiplied scores from
each survey was divided by the total sum of the multiplied
scores.15
In order to assess the consistency and reliability of the
Persian form of this questionnaire, two experts fluent in
English separately and independently translated the ques-
tionnaire from English to Persian. In the second stage,
both translations were back-translated into English inde-
pendently and blindly to the original scale by two bilingual
translators. Then, the original English version of POQL
and the two back-translations were compared by the native
English speakers. Corrections were made, and reconcil-
iation was done to obtain a single Persian version. The
Persian version was pretested on a target population of
20 children selected by convenience sampling. The feed-
back from the interviews with the pre-test children was
incorporated, and the final Persian version was created.
Its reliability was assessed by measuring the internal con-
sistency and reproducibility of the Persian version of the
questionnaire.16,17
The final version of the Persian POQL was assessed for
internal consistency and test-retest reliability. The inter-
nal consistency of the questionnaire was measured using
Cronbach’s alpha coefficient showing a good Cronbach’s
alpha of 0.805. The test-retest reliability was examined
with an intra-class correlation coefficient by comparing
scores among 20 patients (nine boys and 11 girls) who
completed the Persian POQL at two different time points.
The average retest interval between the initial and second
observation periods was 14 ± 2 days. At baseline (day 1)
the same children in the same environment were given the
questionnaire and then asked to repeat the same survey
again 2 weeks later (day 14). The ICC value indicated good
reliability (ICC = 0.872).
2.3 Statistical analysis
Descriptive statistics were used to establish the demo-
graphic characteristics of the patients assessed. Data were
analyzed using SPSS version 22 via the Mann Whitney
U test and independent samples t-test. The chi-square or
Fisher’s exact test was used based on the distribution of
variables in the two groups. Poisson’s regression analysis
was carried out to examine the relationship between
categorical predictor (dmft and GI) and OHRQOL. P < .05
was considered statistically significant.
JAMALI et al. 181

T A B L E 1 Demographic variables in study groups (children (children with moderately inflamed gingiva with BOP)
with and without ADHD/ODD) was significantly higher in the ADHD/ODD group than
Control that of the control group (P = .001). Meanwhile, the fre-
ADHD/ODD* Group quency of children with normal (score 0), mildly (score 1),
Variables group (n = 40) (n = 80) and severely (score 3) inflamed gingiva was significantly
(Mean ± SD) higher in normal children than the corresponding value
Age (month) 62.27 ± 2.49 61.37 ± 1.36 in children with ADHD/ODD (P = .001).
Parent age 36.86 ± 0.64 38.82 ± 1.87 Table 4 presents the OHRQOL total and domain scores
Educational status of 11.30 ± 0.72 11.87 ± 4.09 in the two groups. All domains and total scores of the
parents (years) OHRQOL showed a significant difference between the
Frequency (%) two studied groups. The mean scores of the emotional,
Gender physical, role, and social domains, in the ADHD/ODD
Girls 13 (32.50 %) 38 (47.50 %) group, were lower than that in the control group (P = .027,
27 (67.50 %) 42 (52.50 %) P = .002, P = .014, and P = .043). The OHRQOL total score
in the ADHD/ODD group was significantly lower than that
Boys
in the control group (P = .0004).
Economic Status
In view of this finding, Poisson’s regression analysis was
Not at all well-off 7 (17.50 %) 13 (16.25 %)
carried out to examine the relationship between categor-
Not very well-off 8 (20.0 %) 8 (10.0 %)
ical predictor (dmft and GI) and OHRQOL considering
Average 22 (55.0 %) 53 (66.25 %) gender as a confounding factor. The results showed that
Somewhat well-off 3 (7.50 %) 6 (7.50 %) the effects of gender on two models were not significant.
Very well-off 0 (0.0 %) 0 (0.0 %) In addition, there was a significant relationship between
The study groups were matched and not statistically difference for the men- OHRQOL and dmft scores. The effect size of this variable
tioned variables. was 3.61 (95% CI, 1.84-7.08) on dmft (P-value < .001). The
*ADHD/ODD, attention deficit hyperactivity disorder/oppositional defiant
intuition underlying this result is that a one-score increase
disorder.
in dmft index was associated with 3.61 times increase in the
OHRQOL score. Indeed, every one score increase in dmft
3 RESULTS index was associated with a 26% increase in the OHRQOL
score.
This study assessed a total of 120 children between 3 and We found no significant association between GI and
7 years. The participants consisted of 40 ADHD/ODD chil- OHRQOL. This finding suggests that the value of the GI
dren in the patient group and 80 children in the control score was not significant in predicting the OHRQOL score
group. (Table 5).
Table 1 illustrates the mean age and gender of the partic-
ipants in both groups. Significant differences between age
and gender were not observed between the ADHD/ODD 4 DISCUSSION
and the control children, respectively (62.27 ± 2.49 months
and 61.37 ± 1.36 months and 13 girls and 27 boys, 38 girls This study intended to assess the oral health status and
and 42 boys, respectively) (P > .05). The economic status OHRQOL of patients with ADHD/ODD. To the best of our
of the children did not indicate a significant difference knowledge, the current study is the first investigation in
between the two groups (P = .464). No statistically which oral health-related quality of life and oral health sta-
significant differences were observed between the two tus of a well-characterized and clinically diagnosed sample
groups in terms of the mean age of the parents (P = .949) of patients with ADHD/ODD were compared with control
and the level of education of the parents (P = .243). peers.
Table 2 reveals one of the key findings of this research; The ADHD/ODD and control children were matched in
the mean dmft score of ADHD/ODD group was signifi- terms of demographic variables such as age, gender, and
cantly higher than that of the control group (P = .002). parents’ financial status, age, and the level of education.
To explain this in more detail, the mean scores of decayed Overall, our results revealed significant differences in
teeth (P = .012), missing teeth (P = .03) and filled teeth terms of dmft score, GI score, and different domains
(P = .001) in ADHD/ODD group were higher than the cor- of OHRQOL including the emotional, physical, role,
responding values in the control group. and social domains between ADHD/ODD and control
Table 3 illustrates the distribution of the mean of children. As expected, the dmft score was significantly
GI scores in the two groups. The frequency of score 2 higher in the ADHD/ODD patients than the control
182 JAMALI et al.

TA B L E 2 Mean dmft score of ADHD/ODD and control group

95 % Confidence
ADHD/ODD Control group Mean interval
Variables group (n = 40) (n = 80) difference P-value Lower Upper
Decay 9.71 ± 0.74 3.74 ± 2.01 −6.03 ± 1.53 .012 −0.18 −9.12
Missing 2.88 ± 0.69 1.46 ± 0.18 −1.42 ± 0.33 .030 −2.70 −0.14
Filling 2.25 ± 0.94 1.62 ± 1.14 −0.70 ± 0.20 .001 −0.15 −1.91
Total 10.10 ± 0.80 5.25 ± 1.97 −5.15 ± 1.17 .002 −1.90 −7.20

TA B L E 3 Frequency of GI scores within ADHD/ODD and control groups

ADHD/ODD group Control group
GI* (n = 40) (n = 80) Pearson chi-square P-value
Normal 1 (2.50 %) 10 (12.50 %) 16.9091 .001
1 14 (35.0 %) 49 (61.25 %)
2 25 (62.50 %) 20 (25.0 %)
3 0 (0.0 %) 1 (1.25 %)
*GI (gingival index) had four categories (0 = normal, 1 = mildly inflamed gingiva with without bleeding on probing, 2 = moderately inflamed gingiva with bleeding
on probing, and 3 = severely inflamed gingiva with a tendency to spontaneously bleeding).

children. Considering the dmft value, our result agrees
well with the results obtained by Broadbent et al, in
which, ADHD children were shown to be at high risk of
caries.4
Furthermore, in line with our finding, Blomqvist et al
study showed a statistically significant increase in the
DMFT score of children with ADHD.18 More importantly,
decayed surfaces (D) were significantly higher in children
with ADHD than the control children. In accordance with
our finding, Aminabadi et al found significantly higher
DMFT/dmft scores in children with ODD/ADHD than the
control group.13 The observed higher DMFT/dmft scores in

TA B L E 4 Oral health-related quality of life, total and domain scores in the two groups

ADHD/ODD
group Control group Mean 95 % confidence interval
Variables (n = 40) (n = 80) difference P-value Lower Upper
Emotional 5.15 ± 1.13 7.96 ± 0.85 2.81 ± 1.45 .027 0.071 5.691
Physical 4.90 ± 0.94 8.83 ± 0.77 3.93 ± 1.28 .002 1.380 6.481
Role 0.556 ± 0.29 0.562 ± 0.19 0.011 ± 0.33 .014 -0.68 −0.66
Social 0.90 ± 0.66 2.47 ± 0.70 1.57 ± 1.09 .043 0.40 2.90
Total 0.096 ± 0.020 0.165 ± 0.01 0.069 ± 0.02 .0004 0.01 0.12

TA B L E 5 Poisson’s regression analyses of significant factors associated with the DMFT and GI
95% confidence interval
Coefficient Standard error P-value Lower Upper
DMFT dependent variable
Intercept 8.33 0.09 <.001 6.867 10.119
Sex 1.08 0.11 .46 0.877 1.337
Total score 3.61 0.34 <.001 1.841 7.085
GI dependent variable
Intercept 1.468 0.2419 .113 0.914 2.358
Sex 0.991 0.2663 .974 0.588 1.670
Total score 2.434 0.9044 .325 0.414 14.329
JAMALI et al.
children with ADHD can be attributed to the medication-
induced xerostomia, change in diet and appetite.7,19 In gen-
eral, treatment for ADHD consists of a combination of
behavioral and pharmacologic therapies. Medicines used
to suppress the symptoms of ADHD induce xerostomia or
dry mouth, and it has been hypothesized that xerostomia
may contribute to a higher prevalence of dental caries.4,20
Moreover, our finding can somehow be explained by
lower brushing ability and oral hygiene maintenance and
undesirable dietary habits in ADHD patients.4,7 Up to half
of the children who are diagnosed with ADHD also exhibit
a form of movement dysfunction because of deficits in
fine motor function and skill such as poor handwriting
and upper limb functions in children with ADHD.21 Mean-
while, children with ADHD were 1.74 times more likely to
eat or drink more than five times a day than the control
subjects.7 In addition, parents of children with ADHD are
more likely to reward their children with cariogenic food
and sweet beverages.22
In contrast to our results, Pinar-Erdem et al found no
significant difference in df(t)/df(s), DMF(T)/DMF(S),
d/D values, or presence of the white spot lesions between
children with ADHD and control subjects.1 Similarly,
Blomqvist et al found no significant difference in the
prevalence of dental caries in children with ADHD than
the controls all aged 13 years despite the poorer oral
hygiene of ADHD patients.7 The difference between the
results of these studies and our findings may be partly
explained by the difference in the age of the participants
in different studies. The literature suggests that ADHD
symptoms decrease with age, and their relationships with
co-occurring mood disorders and cognitive performance
also change.23 It seems that self-cleaning ability and com-
pliance of children with ADHD to maintain oral hygiene
gradually increase as the age advanced. Moreover, the
differences between given societies should be taken into
consideration when evaluating the effect of oral health
habits on DMFT/dmft scores.
We found significantly higher rate of the GI score of
2 in the ADHD/ODD patients than the control children.
This finding is in line with the results of Bimstein et al
study which showed a statistically higher prevalence of
bleeding gums in children with ADHD. This result might
be explained by the poorer oral health behavior in ADHD
group.24 However, in contrast to our data, Farhanaz et al
found no significant difference in mean GI between
the ADHD group and the control group.25 Similarly,
Aminabadi et al found a higher mean GI score in the
ADHD/ODD group in comparison to the control group,
however, the difference was not statistically significant.13
We assume that the inconsistency in the GI score is likely
due to the data presentation mode difference. In this
study, we reported a higher rate of the GI score of 2 instead
183
of the mean GI score among ADHD/ODD and control
groups which were reported in the studies of Farhanaz
et al25 and Aminabadi et al.13 In overall and considering
the low attention span and higher dental treatment needs
of ADHD/ODD children, the treatment appointment
can be challenging and long which leads to behavioral
management problems.26
The total and domain scores of the OHRQOL were sig-
nificantly lower in ADHD/ODD group than that of the
control group, which indicates a significantly better qual-
ity of life in these patients. The OHRQOL score consists
of four domain scores including emotional, physical, role,
and social. It has been noted that poor health or pres-
ence of disease does not inevitably mean poor quality of
life.27 Allison et al attempted to further explain this phe-
nomenon by suggesting quality of life as “dynamic con-
struct,” and thus likely to be subject to change over time.
Individual attitudes are not constant, vary with time and
experience, and are modified by phenomena such as cop-
ing, expectancy, adaptation, optimism, self-control, and
self-concept.28
The emotional domain of OHRQOL refers to “feel-
ing angry, upset, worried or crying due to problem
in child’s teeth or mouth.” A comprehensive literature
review showed that children and adults with ADHD are
highly likely to manifest low frustration tolerance, impa-
tience, quickness to anger, and being easily excited to
emotional reactions.2 However, in our study, the emo-
tional score of OHRQOL was identified better in children
with ADHD/ODD than the matched control subjects. This
better emotional score may be attributed to decreasing
in severity of ADHD/ODD symptoms following medical
and psychological treatment. Furthermore, it is reason-
able to postulate that parents were not able to differenti-
ate whether the child’s emotional morbidity was caused by
his/her underlying disease or oral health problem which
consequently could alter the emotional score in the ques-
tionnaire which was answered by parents.
The physical domain of OHRQOL is characterized as
pain or troubles of eating foods (hot/cold or hard food). In
our study, ADHD/ODD children were found to have better
scores in the physical domain of OHRQOL. This outcome
could be explained by the study conducted by Wolff et al
in which ADHD children under methylphenidate admin-
istration showed significantly lower pain perception than
the control individuals.29 Notably, the vast majority of the
patients in our study were receiving medical treatment
at the hospital and subsequently the physical domain of
OHRQOL likely to be influenced by the medication being
used. Furthermore, the disruptive pattern of eating foods,
unwillingness to eat fruits and vegetables, and lower per-
ception of pain among ADHD/ODD children could alter
the physical score in the questionnaire.22
184
The role domain in this questionnaire is defined as
“missed school days and having trouble paying attention
in school due to problems in the child’s teeth or mouth.” In
our study, the “role” domain of the OHRQOL is proved to
be better in ADHD/ODD children than the controls. How-
ever, the question could be highly controversial since the
parents were not able to differentiate whether the child’s
attention problem in school is caused by ADHD symptoms
or due to the child’s oral or dental problems. The findings
of the Klimkeit et al study revealed that despite the fact
children with ADHD possessed more disorganized, disrup-
tive, and impulsive behaviors; they do not report less inter-
est in school activities nor more anxiety than the children
without ADHD.30 Therefore, the result of the Klimkeit et al
study may explain our finding of the better role domain
score in ADHD/ODD patients.
The social domain is defined as “laughing or smiling
around other people, feeling that he/she is not as good
looking to others, unhappy with the way he/she looks.”
In our study, the social domain of OHRQOL was signif-
icantly better in ADHD/ODD children. Various studies
have been conducted to assess this factor in both adults and
children population. Newark et al found that adults with
ADHD showed significantly lower levels of self-esteem
and self-efficacy.31 However, Hoza et al32 found no dif-
ferences between clinically diagnosed ADHD and control
groups in terms of self-esteem. Appropriate medical treat-
ment including medication and early rehabilitation of the
ADHD/ODD patients during childhood can explain the
unexpected results of the role and the social domains.
These mediating factors promote the performance and
functioning of the ADHD patients which enable them to
operate effectively in the society leading to the observed
better role and the social domains scores.
The Poisson’s regression analysis revealed a statistically
significant relationship between OHRQOL and dmft
scores. As might be expected, the OHRQOL decreased by
increasing the dmft score. This result was in line with the
result of Kumar et al study which showed that individuals
with greater caries experience exhibited poorer OHRQOL
and recorded the poorest domain scores of the OHRQOL.33
Children with untreated dental caries suffering from pain
and discomfort which could influence the physical domain
of the OHRQOL. In addition, a high caries experience had
significant negative impacts on appearance of children
that could also affect the level of the parent’s /child’s
satisfaction from the way s/he looks, and their social
domain of questionnaire. Missing school on account of
toothache and discomfort could also negatively impact
the role domain.34
On the other hand, the Poisson’s regression analysis
of the data showed that the GI score was not significant
JAMALI et al.
in predicting the OHRQoL score. Consistently, Tomazoni
et al study indicated that the presence of extensive levels
of gingivitis might be negatively associated with OHRQOL
score, while low-level/no gingival bleeding did not showed
a significant effect on OHRQOL.35
This study has a number of limitations most of which are
inherent in its nature. It is important to note that contex-
tual factors often play a pivotal role in the outcome of inter-
ventions. Consequently, the results from individual studies
should be seen as indicative rather than precise when gen-
eralizing them to other settings. In addition, the question-
naire information was obtained from the parents rather
than children themselves, and children’s understanding of
health and quality of life may be different from that of
their parents. Evidence shows that parents and children
often have different perceptions of quality of life. In our
study, the POQL questionnaire was used for the evalua-
tion of OHRQOL. It evaluates patients in four domains
namely emotional, physical, role, and social. Replying to
the items of this questionnaire was difficult for the par-
ents as they could be confused by the signs of ADHD/ODD.
The result of this questionnaire should be prepared care-
fully and interpreted with caution. An objective question-
naire may provide more accurate data in this group of
patients.
5 CONCLUSION
Our results indicated significant differences in terms of
dmft score, GI score, and different domains of OHRQOL
including the emotional, physical, role, and social domains
between ADHD/ODD and control children. Despite the
higher mean dmft and GI scores in the children with
ADHD/ODD compared to control children, a lower score
of OHRQOL was detected in ADHD/ODD patients which
translates to a better level of OHRQOL.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest that
could be perceived as prejudicing the impartiality of the
research reported
E T H I C A L A P P R O VA L
This study was reviewed and approved by the Ethics Com-
mittee of Tabriz University of Medical Sciences (dated June
12, 2018; approval no. IR.TBZMED.REC.1398.540).
ORCID
Sajjad Shirazi https://orcid.org/0000-0002-3996-6772
JAMALI et al.
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JAMALI et al.
How to cite this article: Jamali Z, Ghaffari P,
Aminabadi NA, Norouzi S, Shirazi S. Oral health
status and oral health-related quality of life in
children with attention-deficit hyperactivity
disorder and oppositional defiant disorder. Spec
Care Dentist. 2021;41:178–186.
https://doi.org/10.1111/scd.12563