Region-specific lifestyle and subjective perception are associated with oral health-related quality of life among Tibetan adolescents: a cross-sectional study

doi:10.21203/rs.3.rs-3071403/v1

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Region-specific lifestyle and subjective perception are associated with oral health-related quality of life among Tibetan adolescents: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-3071403/v1

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Background

Research on the predictors of oral health-related quality of life (OHRQoL) in Tibetan adolescents is limited. The aim of this study was to investigate the OHRQoL of Tibetan adolescents in Ganzi, Sichuan, and to determine whether the region-specific lifestyle, subjective perception and objective conditions of oral health could predict Tibetan adolescents’ OHRQoL.

Methods

A cross-sectional survey of Tibetan adolescents aged 11–15 years was conducted in Ganzi, Sichuan. Relevant data was collected via a self-reported questionnaire and a complete oral examination. The OHRQoL was measured using the standardized Child Oral Impacts on Daily Performances (sC-OIDP) scores. Binary logistic regression was used to explore the association between region-specific lifestyle, subjective perception, objective conditions and OHRQoL.

Results

Four hundred and eighty-five Tibetan adolescents participated in the study. The sC-OIDP ranged from 39.44 to 99.70 (mean55.41 ± SD11.19) with 288 (59.38%) adolescents reported an sC-OIDP above 50. It was revealed that Tibetan adolescents living at a higher altitude of 3300m than 1400m were more likely to report a poorer OHRQoL (OR = 1.880, 95%CI 1.101–3.209, P = .021). Also, buttered tea consumption by adolescents (OR = 2.284, 1.200-4.348, P = .012) or by mother (OR = 2.278, 1.171–4.432, P = .015) and boarding student (OR = 1.761, 1.180–2.626, P = .006) were significantly associated with poorer OHRQoL. Regarding the subjective perception, adolescents that rated a bad or very bad oral health (OR = 4.360, 2.341–8.120, P < .001) was more likely to have poorer OHRQoL compared to those with good or very good oral health. Furthermore, self-reported dental pain was significantly related to poorer OHRQoL (OR = 2.836, 1.836–4.382, P < .001). Interestingly, objective conditions, such as BOP, DC and DMFT were not related to OHRQoL.

Conclusion

Region-specific lifestyle and subjective perception on oral health were the key predictors affecting the OHRQoL of Tibetan adolescents. To improve OHRQoL, it is recommended to weigh the pros and cons of buttered tea and take moderate consumption among adolescents and their mothers and improve communication of students in boarding school with their parents can boost self-confidence. Additionally, developing good oral hygiene habits and keeping more healthy teeth to prevent dental pain is equally important for improving OHRQoL.

OHRQoL

Cross-sectional study

Ethnic minority

Region-specific lifestyle

Subjective perception

Adolescence is the crucial period of oral health. Oral health problems during adolescence not only negatively impact physical health but also psychological and social well-being(1, 2). To reveal individual’s comfort and satisfaction on their oral health, oral health-related quality of life (OHRQoL) has become an increasingly significant oral health outcome(3), which is a multidimensional construct to encompasses the impacts of oral health on physical, psychological and social well-being of individuals. A systematic review on the OHRQoL in adolescents with 23 articles and a total of 12,604 participants found that the prevalence of oral impact was high in all the included studies(4). Also, according to the 4th National Oral Health Survey (NOHS) of China, which included 89,582 adolescents aged 12–15 years, 76.6% of them reported oral impacts, indicating a less optimistic OHRQoL of adolescents (5).

According to the Seventh National Population Census of 2020, it is indicated that there are less than 8 million Tibetan in China. As a minority ethnic group, the Tibetan population accounts for mere 0.5% of the whole population. Ganzi Tibetan Autonomous Prefecture is located at the southeastern edge of the Kang-Tibet Plateau, in the west of Sichuan Province, China. With an average altitude of 3,500 m above sea level(6), Ganzi is characterized by harsh natural conditions, cold climate, and low oxygen, resulting in distinct lifestyles. To accommodate cold climate, local Tibetans prefer to have a high-fat and high-sodium drink(7), buttered tea, a traditional Tibetan food made from tea leaves, yak butter, water, and salt. In recent decades, large numbers of young adults couples migrate from Ganzi to seek employment in large cities, leaving behind their children in the care of other family members(8, 9). Those left-behind children often board at school experiencing separation from their parent(s) for more than 6 months(10).

The disparities of oral health can present among adolescents of different ethnicities in certain areas as a result of inequalities in medical and health service(11–13). It was observed that Tibetan adolescents seemed to be susceptible to oral diseases, such as dental fluorosis and periodontal disease(14, 15), which might result from their region-specific lifestyle including living at high altitudes or drinking buttered tea(6, 16). Poor oral health may weaken self-confidence, reduce self-evaluation, and deeply affect the quality of life. However, the evidence of association between region-specific lifestyle, subjective and objective oral health and OHRQoL among Tibetan adolescents is scarce.

Hence, to improve our understanding of the OHRQoL in Tibetan adolescents, this paper sought to assess the effects of region-specific lifestyle, subjective perception and objective conditions of oral health on OHRQoL of Tibetan adolescents in Ganzi.

The current study followed the Strengthening the Reporting Observational Studies in Epidemiology (STROBE) guidelines.

All the data used in the study were extracted from the cross-sectional survey of Tibetan adolescents at the age of 11–15 years (studying in the 6th and 7th grades) conducted in Ganzi, September 2016. Ethics approval of this survey was obtained from the Stomatological Ethics Committee of the Chinese Stomatological Association (Approval No. 2014-003) and the Ethics Committee of the West China Hospital of Stomatology, Sichuan University (WCHSIRB-OT2016-077). Information consent to conduct the study and to publish was also obtained from adolescent parent or statutory guardian.

Sampling and sample sizes

The sample size was determined based on the formula below:

$$n=\frac{{\mu }^{2}\left(1-p\right)}{{\epsilon }^{2}p\left(1-nonresponse\right)}$$

in which n is the sample size, p (66.83%) is the prevalence rate of dental caries among Tibetan adolescents according to the 4th NOHS(15), µ (1.96) is the level of confidence, and ε (0.1) is the margin of error and the nonresponse rate is 20%. The formula above indicated that a minimum sample size of 238 adolescents were required.

A multistage stratified random-cluster sampling design was adopted in the survey to obtain representative Tibetan adolescents in Ganzi. In the first stage, three towns were randomly selected to present three altitude with an average altitude of 1400 m, 2560 m and 3300 m by the stratified sampling using probability-proportional-to-size (PPS) method(17). In the second stage, two schools were randomly selected from each town using PPS method. In the third stage, specific participants were chosen using quota sampling. Only 11- to 15-year-old Tibetan adolescents attending schools who could complete the questionnaire independently in Chinese language were included in the survey. Adolescents who were uncooperative, who were only familiar with Tibetan language, or who had serious systemic diseases were excluded. A total of 490 adolescents were included in the survey, of which 4 were excluded from the current study for unrecorded age and 1 for missing information of gender. Ultimately, 485 Tibetan adolescents were included in our study.

Questionnaire and clinical examinations

All the participants were asked to fill a paper-based questionnaire individually in their classroom, which included closed-ended questions of demographic characteristics, socio-economic status, region-specific lifestyle and subjective perception on oral health, and the Child Oral Impacts on Daily Performances (C-OIDP) tool.

With the Community Periodontal Index (CPI) probes, examination of dental caries and gingival status was conducted in schools by three training examiners and one calibrating examiner according to the basic method of oral health survey recommended by World Health Organization (WHO)(18). In the study, examiners’ kappa coefficients were all > 0.80 for dental caries and gingival health status. All the examiners were blinded to the results of questionnaires.

Outcomes

OHRQoL was evaluated using the overall score of C-OIDP (19, 20), the most commonly used tool for assessing OHRQoL in adolescents (21, 22). This tool comprises 8 items assessing the impact of oral health on 3 domains: physical (eating, speaking, cleaning teeth), psychological (sleeping, grinning, emotion) and social (studying, social contact) in the past six months with the following response options (23, 24): (zero point) “no impact”, (one point) “little impact”, (two points) “moderate impact” and (three points) “severe impact”. A transferred C-OIDP score (tC-OIDP) was calculated by adding the scores of the 8 items, then divided by the maximum score (24 points) and multiplied by 100. The tC-OIDP score was then standardized using the mean and standard deviation (SD) of the tC-OIDP of adolescents in the whole Sichuan Provence (25, 26):

$$\text{s}\text{t}\text{a}\text{n}\text{d}\text{a}\text{r}\text{d}\text{i}\text{z}\text{e}\text{d} \text{s}\text{c}\text{o}\text{r}\text{e}=\frac{\text{t}\text{r}\text{a}\text{n}\text{s}\text{f}\text{e}\text{r}\text{r}\text{e}\text{d} \text{s}\text{c}\text{o}\text{r}\text{e}-{\mu }}{\sigma }*10+50$$

in which µ (17.53) is the mean tC-OIDP in Sichuan Province and σ (16.59) is the SD of tC-OIDP according to the oral health survey of Sichuan Province, 2015–2016.

Higher sC-OIDP indicated poorer OHRQoL, while lower sC-OIDP correspond to better OHRQoL. Finally, the sC-OIDP was dichotomized, yielding the categories ‘OHRQoL was better than the average of Sichuan (sC-OIDP < 50)’ and ‘OHRQoL was poor than the average of Sichuan (sC-OIDP > 50)’. This formula was also used to calculate the standardized score of 3 aspects and 8 items. In this study, the Cronbach’s alpha was 0.75 [95%CI 0.71 to 0.78].

Exposure variables

Objective oral health variables, including decayed, missing, and filled teeth (DMFT) index, gingival bleeding on probing (BOP) and dental calculus (DC). BOP and DC were studied as a dichotomous variable(27): “Absence/Presence of gingival bleeding or calculus deposit”.

Region-specific lifestyle variables, including residence altitude (1400m/2560m/3300m, relevant data were recorded by the data entry staff), buttered tea consumption by adolescents themselves in childhood (“Don't drink/Drink”) and by their mothers (“Don't drink/Drink”) and whether the adolescent was a boarding student (“No/Yes”).

Subjective perception variables, including self-rated oral health (“Good or very good/Fair/Poor or very poor”) and self-reported dental pain (“No/Yes”).

Confounders

The following demographic variables were taken as covariates in the study: age, gender (“Male/Female”), household type (“Non-agricultural family/Agricultural family”) and maternal education (“High”: “Tertiary or bachelor’s degree or above”, “Medium”: “High school”, “Low”: “Junior high school or below”, “Other”: “Unknown or orphan”).

Statistics

Descriptive analysis was used to characterize the sample and the distribution of each category of the Tibetan adolescents in Ganzi. Continuous variables were described using mean and SD, and categorical variables using absolute and relative values. Bivariate analysis was performed using parametric tests (2-sample t-test or one-way ANOVA). Binary logistic regression analysis was conducted to determine whether region-specific lifestyle, subjective perception and objective oral health conditions associated with oral impacts and was adjusted for age, gender, household type and maternal education. The association measurements were calculated as crude and adjusted odds ratios (ORs) values and respective 95% confidence intervals (95%CIs). Data were analyzed by SPSS version 20.0 (IBM corporation, Armonk, NY, USA). P values less than 0.05 were considered statistically significant (2-tailed test).

A total of 485 Tibetan adolescents at a mean age of 12.11 ± 0.54 years was included in the study, of whom 225 (46.4%) were boys. The proportion of agricultural family was higher (83.3%) than non-agricultural family (16.7%). Most mothers (60.8%) only had a junior high school degree or less. The majority of Tibetan adolescents (90.9%) and their mothers (90.9%) had buttered tea. In terms of oral health conditions, more than half had dental pain (64.5%), BOP (75.5%) and DC (82.7%).

The mean tC-OIDP of the adolescents was 26.50 ± 18.57. After standardization, the mean sC-OIDP of the participants was 55.41 ± 11.19 and 288 (59.4%) adolescents had a sC-OIDP higher than 50 which indicated a relatively poor OHRQoL. The distribution of adolescent demographic characteristics, region-specific lifestyle, subjective perception and sC-OIDP was shown in Table 1.

The frequency distribution of three domains and eight items of oral impact performance among Tibetan adolescents was shown in Fig. 1. More than half of people had oral impacts on daily performances in physiological, psychological, and social domains. As for eight items, emotion was the most commonly affected performance (sC-OIDP > 50, 62.7%), followed by cleaning teeth (sC-OIDP > 50, 56.1%) while oral impact on eating became the slightest impacted item (sC-OIDP > 50, 36.7%).

Table 1

Demographic characteristics of the Tibetan adolescents in Ganzi, Sichuan.
Variables		All participants	tC-OIDP	Participants with sC-OIDP < 50	Participants with sC-OIDP > 50
Variables		Mean ± SD/count (%)	Mean ± SD	Mean ± SD/count (%)	Mean ± SD/count (%)
Age		12.11 ± 0.54	26.50 ± 18.57	12.12 ± 0.59	12.10 ± 0.50
Gender	Male	225 (46.4)	28.38 ± 19.22	84 (37.3)	141 (62.7)
Gender	Female	260 (53.6)	24.87 ± 17.86	113 (43.5)	147 (56.5)
Household type	Non-agricultural family	81 (16.7)	27.95 ± 19.42	31 (38.3)	50 (61.7)
Household type	Agricultural family	404 (83.3)	26.21 ± 18.40	166 (41.1)	238 (58.9)
Maternal education	Low	295 (60.8)	27.28 ± 18.85	113 (38.3)	182 (61.7)
	Medium	32 (6.6)	24.24 ± 19.51	15 (46.9)	17 (53.1)
	High	55 (11.3)	19.81 ± 15.21	33 (60.0)	22 (40.0)
	Other	103 (21.2)	28.54 ± 18.49	36 (35.0)	67 (65.0)
Residence altitude	1400 m	180 (37.1)	25.72 ± 17.97	74 (41.1)	106 (58.9)
	2560 m	194 (40.0)	23.33 ± 16.57	93 (47.9)	101 (52.1)
	3300 m	111 (22.9)	33.32 ± 21.07	30 (27.0)	81 (73.0)
Buttered tea consumption by children	Don't drink	44 (9.1)	22.24 ± 18.53	26 (59.1)	18 (40.9)
Buttered tea consumption by children	Drink	441 (90.9)	26.93 ± 18.54	171 (38.8)	270 (61.2)
Buttered tea consumption by mother	Don't drink	41 (8.4)	23.56 ± 17.54	24 (58.5)	17 (41.5)
	Drink	441 (90.9)	26.76 ± 18.60	172 (39.0)	269 (61.0)
	Other	3 (0.6)	27.99 ± 30.68	1 (33.3)	2 (66.7)
Boarding student	No	278 (57.3)	23.20 ± 16.97	132 (47.5)	146 (52.5)
Boarding student	Yes	207 (42.7)	30.93 ± 19.70	65 (31.4)	142 (68.6)
Self-rated oral health	Good or very good	116 (23.9)	20.74 ± 17.28	63 (54.3)	53 (45.7)
	Fair	272 (56.1)	25.82 ± 17.97	114 (41.9)	158 (58.1)
	Poor or very poor	97 (20.0)	35.30 ± 18.67	20 (20.6)	77 (79.4)
Self-reported dental pain	No	125 (25.8)	20.02 ± 17.54	71 (56.8)	54 (43.2)
	Yes	313 (64.5)	29.51 ± 18.49	103 (32.9)	210 (67.1)
	Unknown	47 (9.7)	23.71 ± 17.18	23 (48.9)	24 (51.1)
BOP	No	119 (24.5)	26.57 ± 19.72	49 (41.2)	70 (58.8)
BOP	Yes	366 (75.5)	26.48 ± 18.20	148 (40.4)	218 (59.6)
DC	No	84 (17.3)	28.26 ± 20.86	32 (38.1)	52 (61.9)
DC	Yes	401 (82.7)	26.13 ± 18.06	165 (41.1)	236 (58.9)
DMFT		0.87 ± 1.49	26.50 ± 18.57	1.03 ± 1.42	0.77 ± 1.53
sC-OIDP		55.41 ± 11.19		44.98 ± 3.19	62.54 ± 8.85
tC-OIDP, transferred Child Oral Impacts on Daily Performances score; sC-OIDP, the Child Oral Impacts on Daily Performances score that standardized to the Sichuan adolescent mean score; SD, standard deviation; BOP, gingival bleeding on probing; DC, dental calculus; DMFT, decayed, missing, and filled teeth

In the binary logistic regression analysis, adjusted by age, gender, household type and maternal education, a total of 7 variables including residence altitude of 3300m (OR = 1.880, 95%CI 1.101 to 3.209, P = .021), buttered tea consumption by adolescents (OR = 2.284, 1.200-4.348, P = .012) or by mother (OR = 2.278, 1.171–4.432, P = .015), boarding student (OR = 1.761, 1.180–2.626, P = .006), poor or very poor of self-rated oral health (OR = 4.360, 2.341–8.120, P < .001) and self-reported dental pain (OR = 2.836, 1.836–4.382, P < .001) showed a significant negative association with sC-OIDP. Interestingly, objective conditions, such as BOP, DC and DMFT were not related to OHRQoL. (Table 2).

Table 2

Binary logistic regression analysis of the associations between sC-OIDP scores and predictors.
Variables			OR^crude (95%CI)	OR^adjusted (95%CI)
Region-specific lifestyle	Residence altitude
		1400 m	Reference group
		2560 m	0.758 (0.504–1.142)	0.900 (0.583–1.390)
		3300 m	1.885 (1.128–3.150)	1.880 (1.101–3.209) *
	Buttered tea consumption by children
		Don't drink	Reference group
		Drink	2.281 (1.214–4.286)	2.284 (1.200-4.348) *
	Buttered tea consumption by mother
		Don't drink	Reference group
		Drink	2.208 (1.153–4.230)	2.278 (1.171–4.432) *
	Boarding student
		No	Reference group
		Yes	1.975 (1.356–2.877)	1.761 (1.180–2.626) **
Subjective perception	Self-rated oral health
		Good or very good	Reference group
		Fair	1.647 (1.064–2.552)	1.556 (0.997–2.429)
		Poor or very poor	4.576 (2.480–8.445)	4.360 (2.341–8.120) ***
	Self-reported dental pain
		No	Reference group
		Yes	2.681 (1.752–4.101)	2.836 (1.836–4.382) ***
Objective conditions	BOP
		No	Reference group
		Yes	1.031 (0.677–1.570)	0.950 (0.617–1.464)
	DC
		No	Reference group
		Yes	0.880 (0.543–1.427)	0.828 (0.505–1.356)
	DMFT		0.889 (0.786–1.005)	0.904 (0.798–1.025)
sC-OIDP, the Child Oral Impacts on Daily Performances score that standardized to the Sichuan adolescent mean score; OR^crude, crude odds ratio; OR^adjusted, adjusted odds ratio; CI, confidence interval; BOP, gingival bleeding on probing; DC, dental calculus; DMFT, decayed, missing, and filled teeth.
^# Adjusting for age, gender, household type and maternal education.
P < .05, P < .01, **P < .001 (highlighted in bold).

In terms of the association of exposure variables and three domains and all eight items assessing the impact of oral health was displayed in the Supplementary Table 1 (Table S1) and Supplementary Table 2 (Table S2), respectively. Objective oral health was not correlated with any items of oral impact or any domains except that DMFT was correlated with oral impact in social domain (OR = 0.88, 95%CI 0.78-1.00, P < 0.05). Oral impact on eating was the most serious item comparing tC-OIDP (40.76 ± 32.13). However, after standardization, studying was the most seriously affected performance with a mean sC-OIDP of 54.72 ± 14.11, followed by emotion (53.78 ± 11.64) and sleeping (53.45 ± 12.89), while oral impact on eating became the last but one seriously impacted item (52.50 ± 11.08).

This is the first study to assess the OHRQoL among Tibetan adolescents. Overall, the study revealed a relatively poorer OHRQoL of Tibetan adolescents in Ganzi than the average of adolescents in Sichuan. Also, it was observed that region-specific lifestyle such as living at a high altitude, mother or adolescents drinking buttered tea, boarding at school and subjective perception including self-rated poor oral health and self-reported dental pain were associated with a poorer OHRQoL, however, there was no significant association between objective oral conditions, such as BOP, DC and DMFT.

Our study found the mean tC-OIDP of the adolescents was 26.50 (SD 18.57) which was significantly higher than the similar study in Guangxi Province of China (17.84)(24), Turkey (13.11)(28), Nepal (2.4)(29), suggesting that the OHRQoL of Tibetan adolescents in Ganzi was relatively poor. Differences in ethnicity, customs, culture and geographical circumstance might explain the differences. After transferred treatment, the highest impact was on eating showed in the current population, which was corresponded to multitude of previous studies(23, 30–32). Dental pain caused by decay and bleeding gingiva might interfere with the biting behavior and the taste of food. However, after the standardized treatment, the highest impact was on studying, while the last but one serious impact was on eating. This result suggests that, compared with adolescents in Sichuan Province, studying was the most seriously impacted performances in Ganzi. C-OIDP score standardization can highlight issues of particular locality and help to propose targeted planning for interventions at certain area. Notably, if the C-OIDP scores reported in different research can be standardized based on regional or national data, the comparability across research will be greatly improved.

Drinking buttered tea is a traditional dietary characteristic among Tibetan. High fluoride concentration in buttered tea had been reported in various literature(33), which was the major reason for endemic dental fluorosis(34, 35). As described in previous study(16), drinking buttered tea by mother was strongly risk factor for children’s fluorosis. It was observed that buttered tea consumption by mother or children was associated with OHRQoL. This founding might be explained that dental fluorosis makes changes in tooth color, meanwhile, causes aesthetic concerns of adolescents(35).

Living in high altitude area was related to poor OHRQoL. The atmosphere at high altitudes is typically dry, cold, and hypoxic. In high altitude areas, residents often experience dry mouth and dry tongue (36), which can be uncomfortable. Moreover, it’s reported that altitude was a risk factor to oral microbiota disorders(37). An imbalance in the oral microbiota is associated with dental caries(38), periodontitis, peri-implantitis, mucosal diseases, and oral cancers.

Referring to other factors in region-specific lifestyle, the boarding student was worthy of attention. Currently, there were some studies that illustrated parental involvement had relevance to OHRQoL(39). Similarly, the result in our research showed that boarding student had poorer life quality was found when compared with non-boarding student (40). Due to the absence of parental involvement, adolescents might have poor oral health (41) and negatively affected psychological health(42).

Subjective perception of oral health was affirmed to affect OHRQoL. The association was consistent with the previous studies that reported similar observations(43–47) and might be illustrated by two following explanations: the concept of OHRQoL proposed was to reveal people’s comfort and satisfaction on their oral health, which was a subjective as well as a sophisticated index. Poor self-rated oral health may contribute to increased depressive symptoms (48). Besides, a previous study indicated dental pain may be responsible for a lower emotional state and poorer OHRQoL(5).

Interestingly, objective oral health variables were not associated with adolescent OHRQoL. Although it is revealed that DMFT was associated with social domain, OR value ranged from 0.78-1.00 (1.00 inclusive) and P value close to 0.05. Thus, it can be assumed that there is no statistical significance of the relationship between DMFT and social domain. A negative association between BOP, DC and children’s OHRQoL was found in some literatures (24, 49) However, previous studies showed that BOP or DC were not related to children’s OHRQoL(49, 50), similar conclusion was reached in this study. One possible explanation for these counterintuitive results was that the perception of OHRQoL has a subjective component and thus, varies from one cultural background to another(51). Direct comparisons with the published articles between different groups must be interpreted with caution(52). In addition, periodontal health was assessed by presence or absence of BOP or DC. Collectively, the association between self-perceived and objective oral health condition deserves further exploring based on more details of severity and extent of oral problems.

The finding of the present study should be interpreted within some limitations. The data used in the study were extracted from a cross-sectional survey, which hampered the inference of causality(53). Then, questionnaires were self-reported by Tibetan adolescents under explanation from qualified dentists in class, which might be introduced response bias into the study in contrast to interview. Also, this survey conducted among school adolescents might cause selection bias because those out-of-school adolescents were excluded from the survey. Even so, the investigation combined with Tibetan characteristic dietary habits and parents' involvement is an innovation deserves further exploring.

Tibetan adolescents living in Ganzi seemed to have a relatively poor OHRQoL. Region-specific lifestyle including residing at high altitude (3000m), consuming buttered tea for themselves or their mothers, boarding at school, and subjective perception including poor oral health and dental pain were the key predictors affecting their OHRQoL. Local government should develop measures to reduce inequalities in housing between low- and high-altitude regions and to provide an adequate supply of clean drinking water. An easier access to dental care and regular check-ups is also needed to help local adolescents maintain good oral health and prevent dental pain. Meanwhile, communication and support from their parents and adolescent psychological assistance from schools and society may boost the self-perception of adolescents. Contrary to the findings of previous research, no relationship between DMFT and OHRQoL was detected in this study. Additional investigation is necessary for this issue.

OHRQoL, Oral health-related quality of life; C-OIDP: Child Oral Impacts on Daily Performances; NOHS, National Oral Health Survey; PPS, Probability-proportional-to-size; CPI, Community Periodontal Index; WHO, World Health Organization; DMFT, Decayed, missing, and filled teeth; BOP, Gingival bleeding on probing; DC, Dental calculus; SD, Standard deviation; STROBE, Strengthening the Reporting Observational Studies in Epidemiology

Acknowledgements

Special thanks to the individuals who participated in the oral health survey of Tibetan adolescents in Ganzi, and all the staff and teachers in local schools for assisting with recruitment.

Authors’ contributions

TH and HC made a substantial contribution to conception of the study, data analysis and interpretation, drafting and revising the manuscript. SD and RT contributed to study design, data analyses, data interpretation and the drafting of the article. QS, CZ and HY contributed to the research conduction, data collection and article revision. All authors have read and approved the final manuscript.

Funding

This work was supported by the National Natural Science Foundation of China (No. 72104162).

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The Stomatological Ethics Committee of the Chinese Stomatological Association and the Ethics Committee of the West China Hospital of Stomatology, Sichuan University has approved and regulates the ethical execution of this research.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

SupplementaryTable1.xls
Supplementary Table1.xls Binary logistic regression analysis of the associations between sC-OIDP scores and predictors in three domains.
SupplementaryTable2.xls
Supplementary Table2.xls Binary logistic regression analysis of the associations between sC-OIDP scores and predictors in eight items.

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Region-specific lifestyle and subjective perception are associated with oral health-related quality of life among Tibetan adolescents: a cross-sectional study

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