Skip to main content
NCBI home page
Journal of Migration and Health logoLink to Journal of Migration and Health
. 2025 Feb 7;11:100309. doi: 10.1016/j.jmh.2025.100309

Oral health literacy and oral health status of a german adult population with migration background – findings from the MuMi Study

Berit Lieske a,1, Christopher Kofahl b,1, Katrin Borof a, Kristin Spinler a, Anna Poth a, Demet Dingoyan b, Thomas Beikler a, Guido Heydecke c, Ghazal Aarabi a,⁎
PMCID: PMC11891734  PMID: 40066255

Abstract

Background

People with migration background in Germany demonstrate poorer oral health and different oral health behaviors compared to people without migration background. One crucial factor for achieving and maintaining good oral health is a person's oral health literacy. This article presents results on oral health and oral health literacy from the baseline data of the cluster-randomized controlled MuMi study (Promotion of oral health literacy and oral health of persons with migration background).

Methods

Comparative cross-sectional data on oral health and oral health literacy of patients with and without migration background were examined in 40 dental practices in Hamburg, Germany. Oral examination included a full dental status, the degree of caries restoration, and the approximal plaque index (API). To assess oral health literacy, the Oral Health Literacy Profile (OHLP) was used. Associations between migration status and oral health or oral health literacy were analyzed with linear mixed regression, adjusted for age, sex, education level. The relationship between oral health literacy and oral health was calculated using logistic regression.

Results

Participants with and without migration background differed significantly in oral health literacy and clinical parameters of oral health. The former showed significantly lower oral health literacy (lower OHLP-Scores) and poorer oral health (higher API values as well as a more problem-oriented dental service use). Furthermore, the degree of caries restoration is significantly lower among participants with migration background than those without. Lastly, the logistic regression analysis revealed a significant association between better oral health literacy and lower API values.

Discussion

Migration background appears to be a risk factor in its own right, as the differences in oral health literacy and oral health status remain even after statistically controlling for several confounders. In order to better reflect the diversity within the population with migration background, information on potential access barriers and migration-related factors must be included in further analyses.

Conclusion

Oral health literacy has been found to be a strong predictor for an individual's oral health outcome. Improving the oral health literacy of patients may help in the efforts to improve oral health behaviors and the overall treatment outcomes. Thus, future research should focus on tailored preventive measures for improving oral health literacy, thereby helping to strengthen equal opportunities in oral health in Germany.

Keywords: Migration, Oral health, Oral health literacy, Intervention study, Dentistry

1. Introduction

Germany is a country of immigration with a long history of various migration movements. In 2021, more than one-quarter (27.2 %) of Germany's population had a migration background, defined as a person who themselves or at least one of their parents were not born in Germany (Statistisches Bundesamt 2023). The most common countries of origin are Turkey (12 %), followed by Poland (10 %), the Russian Federation (6 %), Kazakhstan (6 %), and Syria (5 %) (Statistisches Bundesamt 2023). The population with migration background is a very heterogeneous group with respect to their immigration motives, origin, socio-economic status, religious and cultural backgrounds, language skills as well as resident status (Wiessner et al., 2020). Research on the topic of migration and health shows that health status and behavior vary significantly depending on different migration-related determinants. Immigrants and their children often differ in their risks for certain diseases, in their resources to cope with these risks, and regarding their access to treatment (Razum and Wenner, 2016). Concerning oral health, people with migration background in Germany often show different oral health behaviors and a diverse utilization of health care services compared to individuals without migration background. For example, the former tend to use oral health care services less frequently and visit the dentist more often problem- rather than prevention-orientated (Brzoska et al., 2017; Erdsiek et al., 2017; Schenk and Knopf, 2007; Krause et al., 2018). In addition, studies demonstrate poorer oral health in terms of a higher number of decayed teeth and a lower degree of caries restoration among children and adolescents with migration background in comparison to those without migration background (Kühnisch et al., 2003; Heinrich-Weltzien et al., 2007; Bissar et al., 2007; AR Bissar et al., 2007). However, data on the oral health status of the adult migrant population in Germany is still inadequate.

One crucial factor for achieving and maintaining good oral health is a person's oral health literacy (OHL), defined as an individual's ability to obtain, process, understand, and use information, enabling them to make appropriate decisions regarding their oral health in order to prevent oral diseases and promote oral health (Alzahrani et al., 2025; Horowitz and Kleinman, 2012). Low OHL is significantly associated with higher prevalence of oral diseases (Horowitz and Kleinman, 2012; Baskaradoss, 2018; Batista et al., 2017; Ueno et al., 2013), problem-oriented dental service use (Batista et al., 2017), poorer oral hygiene behavior (Ueno et al., 2013; Cho et al., 2020), and less regular dental check-ups (Ueno et al., 2013). With regard to migrant populations, studies investigating OHL are scarce (Valdez et al., 2022). In order to describe health inequalities and to achieve equal oral health opportunities for all, there still is a considerable need for more research and action to improve knowledge and understanding to target appropriate interventions.

The aim of the MuMi study (Original Title: Förderung der Mundgesundheitskompetenz und Mundgesundheit von Menschen mit Migrationshintergrund; Promotion of oral health literacy and oral health of persons with migration background) was to investigate whether and how OHL explains the disparities in oral health between people with and without migration background. The study was conducted between July 2018 – June 2022 at the University Medical Center Hamburg-Eppendorf in Germany in co-operation with 40 dental practices in Hamburg. It examined the efficacy, acceptability, and feasibility of a digital migration-sensitive prevention program (the MuMi-App) (Weil et al., 2023), developed as part of the project, to improve OHL and consequently the oral health of people of different cultural origin.

In this paper, cross-sectional comparative results on oral health and OHL of study participants with and without migration background are presented.

2. Material and methods

2.1. Subjects, study design and setting

The study is based on the analysis of the baseline data of the cluster-randomized controlled MuMi trial (Spinler et al., 2021).

Consecutive recruitment, interviewing, and examination of the sample took place in 40 dental practices in Hamburg between December 2019 and March 2021. The practices were located in districts with a proportion above average of people with migration background. Patients were eligible for inclusion if they were at least 18 years old, used a cell phone or tablet (IOS or Android devices), and understood at least one of the following languages: German, English, Russian, Arabic, or Turkish. All participants signed an informed consent as well as a privacy statement (available in all five languages). Dental practices received financial incentives of 50 € per case for their participation. The participating patients were given an incentive in form of oral hygiene kits (toothbrushes, mouth rinse, and dental floss). The MuMi study was approved by the relevant ethics committee (Local Psychological Ethics Committee at the Center for Psychosocial Medicine) (LPEK-0027). The final data set for analysis is made up of all respondents who fulfill the inclusion criteria and have given complete valid information on their sex, age, and individual migration characteristic. In total, n = 1456 out of n = 1518 participants were selected for analysis.

2.2. Assessment of migration background

For migration-sensitive health monitoring, a basic set of indicators was used to record migration-related determinants (Schenk et al., 2006), including place of birth, citizenship, length of stay in Germany, place of birth of both parents, language skills, subjective sense of belonging to society, and self-reported experiences of discrimination. For the identification of the participants in people with and without migration background, the items related to their own place of birth (“Were you born in Germany?”, “In which country were you born?”) and that of the parents (“Where were your parents born?”) were evaluated, followed by a few further items for specification. Persons who answered the first question negatively or answered that at least one parent was born outside of Germany are classified as a person with migration background. Participants who themselves and also both of their parents were born in Germany are classified as a person without migration background.

The population with migration background is further differentiated into three sub-groups: a) immigrants (born in a different country and immigrated to Germany), b) two-sided migration background (born in Germany but both parents born in a foreign country), and one-sided migration background (one parent born in a foreign country and the other parent born in Germany) (Statistisches Bundesamt 2020).

2.3. Assessment of oral health literacy

OHL was assessed with the oral health literacy profile (OHLP), a questionnaire developed within the MuMi study (Spinler et al., 2021). It includes the following modules: 1) oral health behaviors (7 items: e.g., general questions about respondents' oral hygiene practices, such as tooth brushing duration and utilization of dental services), 2) oral health knowledge (10 items: e.g. tooth-friendly diet, relationship between oral health and general health), and 3) knowledge of the dental care system in Germany (5 items: e.g., which dental services are covered by health insurance). Additionally, the questionnaire contains an emotional component with two questions on fear of high costs and of pain as potential barriers to dental visits. Lastly, the OHLP includes one question on the reason for the last dental visit and two self-assessment questions on one's own oral health and one's own oral health knowledge.

Respondents have the option of answering "don't know" for all multiple-choice questions in order to minimize guessing. All correctly answered questions are awarded one point, while incorrect answers and the answer "don't know" result in zero points. The percentage of points achieved relative to the total number of the respective module items was converted into a scale from 0 to 100, with higher scores reflecting better OHL. All modules together result in the total OHLP-Score, which is also scaled to 0–100 points. Item nonresponses of the individual modules were indexed as "don't know" and thus indexed as "wrong answer" in the evaluation. The OHLP is available in German, English, Russian, Arabic, and Turkish.

2.4. Dental examinations

Oral examination included a full dental status (existing/non-existing or replaced teeth, caries, treated/non-treated teeth) and the approximal space plaque index (API). Dentists from the MuMi project team calibrated the dental practice personnel, including dentists, dental hygienists, or prophylaxis assistants, prior to the start of the data collection. As part of the calibration, a presentation and practical exercises were used to introduce the project and clinical data collection as well as all documents, materials and procedures relevant to the implementation of the project in dental practices. This was to ensure high interrater reliability. The API measures the frequency of plaque in the interdental spaces and was used as an indicator for oral hygiene (Weber, 2017). According to Lange et al. (Lange et al., 1977), API was visually assessed without staining the interdental spaces (plaque present: yes/no) and was calculated as follows:

Sumofpositiveplaquemeasurementsx100Totalnumberofexistingproximalspacemeasurementpoints

This results in values from 0 to 100, with lower values indicating better oral hygiene. An index of <25 % stands for ‘optimal’ oral hygiene, 25–39 % for ‘good’, 40–69 % for ‘moderate’, and 70–100 % for insufficient oral hygiene (Lange et al., 1977).

Based on the dental status, secondary variables were calculated, such as the DMFT-Index (number of Decayed, Missing, Filled Teeth), and the degree of caries restoration. The latter one was used as an indicator of the need for caries treatment. It was calculated on the basis of the dental status data:

Numberoffilledteethx100Numberoffilled+decayedteeth

The higher the proportion of filled teeth in relation to decayed teeth in need of filling, the higher the degree of restoration.

2.5. Assessment of additional variables

Age, sex, educational level, and net equivalent income (net household income adjusted for household size) were collected and analyzed as socio-demographic variables. Net equivalent income was calculated based on the new OECD scale. It assumes a needs weighting of 1.0 for the first adult in the household and a needs weighting of 0.5 for each additional person aged 14 and over and a needs weighting of 0.3 for household members under 14 (Kott, 2018; Asghar Zaidi et al., 1994). However, in order to shorten the length of the questionnaire, number and age of children were not recorded in our study. Therefore, each additional household member was included by a factor of 0.4 as a rough estimate of the factor mean value. Education level was specified based on the International Standard Classification of Education 2011 (Schneider, 2013) and divided into three levels: low, medium, and high.

2.6. Statistical analyses

Descriptive analyses were stratified by migration status (with migration background vs. without migration background) (Table 1). Continuous variables are displayed as mean and standard deviation [mean (±SD)]. Categorical variables are displayed as absolute numbers and percentages [n (%)]. Group differences between participants with and without migration background in terms of socio-demographics, OHL, utilization behavior, oral hygiene behavior, and clinical parameters, were calculated using the Wilcoxon rank sum test for continuous variables and Pearson's Chi-squared test or Fisher's exact test for categorical variables. Table 2 gives a more detailed overview of the cohort with migration background (one-sided, two-sided, immigrants) with regard to migration-related determinants. Like in table 1, continuous variables are displayed as mean and standard deviation [mean (±SD)]. Categorical variables are displayed as absolute numbers and percentages [n (%)]. Group differences were calculated using Pearson's Chi-squared test and Kruskal-Wallis rank sum test.

Table 1.

Descriptive Characteristics of the MuMi Baseline Cohort.

Characteristics Overall N = 14,561 Migration background
 p-value2
Without migration background N = 552 (38 %)1 With migration background N = 904 (62 %)1
Socio-demographics
Age (in years) 44 (±16) 50 (±17) 40 (±14) <0.001
 Missing 9 0 9
Sex 0.821
 Male 600 (41 %) 230 (42 %) 370 (41 %)
 Female 853 (59 %) 322 (58 %) 531 (59 %)
 Missing 3 0 3
Education 0.520
 Low 578 (41 %) 224 (41 %) 354 (41 %)
 Moderate 414 (29 %) 152 (28 %) 262 (30 %)
 High 419 (30 %) 170 (31 %) 249 (29 %)
 Missing 45 6 39
Net equivalent income (in Euros) 1822 (±1004) 2102 (±993) 1634 (±968) <0.001
 Missing 270 77 193
Self-Assessment
Self-reported oral health 0.297
 Excellent/very good 364 (26 %) 129 (24 %) 235 (26 %)
 Good/satisfactory/poor 1062 (74 %) 409 (76 %) 653 (74 %)
 Missing 30 14 16
Self-reported knowledge of oral health issues 0.853
 Excellent/very good 239 (17 %) 89 (16 %) 150 (17 %)
 Good/satisfactory/poor 1204 (83 %) 456 (84 %) 748 (83 %)
 Missing 13 7 6
Oral Health Literacy
OHLP-Score 53 (±17) 61 (±14) 49 (±18) <0.001
 Missing 4 2 2
Module-Score „Oral health knowledge“ 41 (±24) 47 (±22) 37 (±24) <0.001
 Missing 2 1 1
Module-Score “Knowledge of the dental care system in Germany” 69 (±22) 78 (±14) 63 (±24) <0.001
 Missing 6 1 5
Module-Score „Oral health behavior“ 62 (±20) 70 (±18) 57 (±20) <0.001
 Missing 188 74 114
Fear of high costs3 2.70 (±1.26) 2.60 (±1.25) 2.76 (±1.26) 0.024
 Missing 71 19 52
Fear of pain3 2.71 (±1.28) 2.68 (±1.23) 2.72 (±1.31) 0.655
 Missing 53 10 43
Utilization behavior
Last visit to the dentist 0.042
 Within the last 12 months 1257 (89 %) 497 (91 %) 760 (88 %)
 >12 months ago 150 (11 %) 47 (8.6 %) 103 (12 %)
 Never 4 (0.3 %) 0 (0 %) 4 (0.5 %)
 Missing 45 8 37
Last professional teeth cleaning <0.001
 Within the last 12 months 852 (64 %) 375 (72 %) 477 (58 %)
 >12 months ago 330 (25 %) 109 (21 %) 221 (27 %)
 Never 156 (12 %) 34 (6.6 %) 122 (15 %)
 Missing 118 34 84
Reason for the last dental visit:
 Prevention/routine check-up 837 (57 %) 356 (64 %) 481 (53 %) <0.001
 Missing 0 0 0
 Pain/dental problem 382 (26 %) 113 (20 %) 269 (30 %) <0.001
 Missing 0 0 0
 Planned therapy 318 (22 %) 136 (25 %) 182 (20 %) 0.044
 Missing 0 0 0
Oral hygiene behavior
Use of toothbrush (electric or manual) <0.001
 At least twice a day/at least once a day 1370 (95.3 %) 537 (98.5 %) 833 (93.4 %)
 Weekly/never 67 (4.7 %) 8 (1.5 %) 59 (6.6 %)
 Missing 19 7 12
Use of dental floss or interdental brushes <0.001
 At least twice a day/at least once a day 591 (44 %) 256 (50 %) 335 (41 %)
 Weekly/never 740 (56 %) 256 (50 %) 484 (59 %)
 Missing 125 40 85
Tooth brushing time <0.001
 ≥ 2 mins 1157 (80 %) 475 (87 %) 682 (76 %)
 < 2 mins 285 (20 %) 72 (13 %) 213 (24 %)
 Missing 14 5 9
Oral Health – Clinical Parameters
API <0.001
 Optimal/good 595 (42 %) 279 (51 %) 316 (36 %)
 Moderate/insufficient 837 (58 %) 265 (49 %) 572 (64 %)
 Missing 24 8 16
DMFT Index 13 (±8) 15 (±8) 12 (±7) <0.001
 Missing 17 3 14
Decayed Teeth 1 (±3) 1 (±3) 1 (±2) <0.001
 Missing 17 3 14
Missing Teeth 3 (±5) 4 (±6) 3 (±5) <0.001
 Missing 17 3 14
Filled Teeth 9 (±6) 10 (±6) 8 (±6) <0.001
 Missing 17 3 14
Degree of caries restoration (in %) 87 (±25) 91 (±21) 84 (±27) <0.001
 Missing 125 40 85
Open in a new tab
1

n (%).

2

Wilcoxon rank sum test; Pearson's Chi-squared test; Fisher's exact test.

3

Scale of 1–5 (1-excellent and 5- very poor)

API = approximal plaque index; DMFT = decayed, missing, filled teeth; OHLP = Oral Health Literacy Profile.

Table 2.

Descriptive Analysis of the Cohort with Migration Background.

Characteristics Overall N = 14,561 Migration background
 p-value2
One-sided N = 94 (10 %)1 Two-sided N = 170 (19 %)1 Immigrants N = 636 (71 %)1
Region of origin
 Northwestern Europe 29 (3.3 %) 10 (11 %) 2 (1.2 %) 17 (2.7 %)
 Mediterranean region 57 (6.4 %) 6 (6.5 %) 18 (11 %) 33 (5.2 %)
 Eastern Europe 325 (37 %) 17 (18 %) 29 (17 %) 279 (44 %)
 Middle East 328 (37 %) 27 (29 %) 97 (58 %) 204 (32 %)
 Southeast Asia 42 (4.7 %) 6 (6.5 %) 8 (4.8 %) 28 (4.5 %)
 Pacific Region 8 (0.9 %) 1 (1.1 %) 1 (0.6 %) 6 (1.0 %)
 North America 5 (0.6 %) 3 (3.3 %) 0 (0 %) 2 (0.3 %)
 Central and South America 30 (3.4 %) 2 (2.2 %) 1 (0.6 %) 27 (4.3 %)
 North Africa 15 (1.7 %) 3 (3.3 %) 4 (2.4 %) 8 (1.3 %)
 Sub-Saharan Africa 41 (4.6 %) 12 (13 %) 6 (3.6 %) 23 (3.7 %)
 Caribbean 7 (0.8 %) 5 (5.4 %) 0 (0 %) 2 (0.3 %)
 Missing 13 2 4 7
Citizenship and length of stay <0.001
Citizenship
 Other 405 (45 %) 5 (5.3 %) 29 (17 %) 371 (59 %)
 German 373 (42 %) 79 (84 %) 122 (72 %) 172 (27 %)
 German + Other 113 (13 %) 10 (11 %) 18 (11 %) 85 (14 %)
 Missing 9 0 1 8
Length of stay in Germany (in years) 19 (±14) NA (±NA) NA (±NA) 19 (±14) <0.001
 Missing 309 94 170 45
Language skills
Main language spoken in the household is German (yes) 264 (36 %) 64 (81 %) 69 (48 %) 131 (26 %) <0.001
 Missing 168 15 26 127
German language skills: reading3 1.91 (±1.07) 1.13 (±0.39) 1.21 (±0.50) 2.22 (±1.10) <0.001
 Missing 10 0 1 9
German language skills: speaking3 1.92 (±1.02) 1.09 (±0.32) 1.22 (±0.47) 2.24 (±1.04) <0.001
 Missing 42 1 4 37
Open in a new tab
1

n (%); Mean (±SD).

2

Pearson's Chi-squared test; Kruskal-Wallis rank sum test.

3

Scale of 1–5 (1-excellent and 5- very poor).

We used linear mixed regression analyses, adjusted for age, sex, education level, and migration status, to identify associations between the OHLP-Score (outcome) and selected predictor variables (exposure) (Table 3), or the API (outcome) and selected predictor variables (exposure) (Table 4). The model assumptions were checked and approved. Lastly, the relationship between OHL and API as indicator for oral hygiene was calculated using logistic mixed regression (Table 5). For this purpose, the OHLP-Score (above sample-average OHLP-Score [≥ 53 points]) and API (good or optimal API [≤39 %]) were dichotomized into “yes” or “no”. Potential confounding factors were gradually added to the calculation models. Odds ratios were used to evaluate association strength in the logistic model. All mixed regression models included dental practice site as random effect.

Table 3.

Linear Mixed Model for the outcome OHLP-Score: stepwise adjustment to include further indicators.

OHLP-Score
 OHLP-Score
 OHLP-Score
 OHLP-Score
Predictors Estimates p Estimates p Estimates p Estimates p
Age 0.13 (0.07 – 0.18) <0.001 0.13 (0.08 – 0.19) <0.001 0.07 (0.01 – 0.13) 0.015 0.62 (0.33 – 0.90) <0.001
Sex [Female]
Reference: Male 		5.75 (4.00 – 7.51) <0.001 5.90 (4.15 – 7.65) <0.001 5.89 (4.20 – 7.58) <0.001 5.79 (4.11 – 7.47) <0.001
Education [Moderate]
Reference: Low education 		2.36 (0.26 – 4.46) 0.028 2.14 (0.11 – 4.16) 0.038 2.24 (0.22 – 4.25) 0.030
Education [High]
Reference: Low education 		6.37 (4.29 – 8.45) <0.001 6.11 (4.11 – 8.11) <0.001 5.72 (3.72 – 7.72) <0.001
Migration status [With MB]
Reference: Without MB		 -10.86 (-12.79 – -8.93) <0.001 -10.99 (-12.91 – -9.06) <0.001
Age^2 -0.01 (-0.01 – -0.00) <0.001
Open in a new tab

MB = migration background; OHLP = Oral Health Literacy Profile.

Table 4.

Linear Mixed Model for the outcome API: stepwise adjustment to include further indicators.

Predictors API
 API
 API
Estimates p Estimates p Estimates p
Age -0.00 (-0.10 – 0.10) 0.997 -0.00 -0.11 – 0.10) 0.946 0.03 (-0.08 – 0.13) 0.631
Sex [Female]
Reference: Male 		-9.60 (-12.57 – -6.64) <0.001 -9.68 (-12.70 – -6.65) <0.001 -9.68 (-12.70 – -6.65) <0.001
Education [Moderate]
Reference: Low education 		-5.11 (-8.73 – -1.48) 0.006 -4.97 (-8.59 – -1.35) 0.007
Education [High]
Reference: Low education 		-6.17 (-9.76 – -2.58) 0.001 -5.89 (-9.48 – -2.31) 0.001
Migration status [With MB]
Reference: Without MB		 5.80 (2.27 – 9.34) 0.001
Open in a new tab

MB = migration background; API = approximal plaque index.

Table 5.

Logistic Mixed Model: Relationship between predictor OHL (OHLP-Score) and outcome oral hygiene (binary API): stepwise adjustment to include further indicators.

Odds Ratio Confidence Interval p
Model 1
Above sample-average OHLP [Yes]
Reference: Below sample-average OHLP 		2.41 1.91 - 3.04 <0.001
Model 2
Above sample-average OHLP [Yes]
Reference: Below sample-average OHLP 		2.26 1.78 - 2.87 <0.001
Migration status [With MB]
Reference: Without MB		 0.68 0.52 - 0.90 0.006
Model 3
Above sample-average OHLP [Yes]
Reference: Below sample-average OHLP 		2.04 1.59 - 2.62 <0.001
Migration status [With MB]
Reference: Without MB		 0.66 0.50 - 0.88 0.004
Age 1.00 0.99 - 1.00 0.270
Sex [Female]
Reference: Male 		1.60 1.25 - 2.05 <0.001
Education [Moderate]
Reference: Low education 		1.22 0.91 - 1.64 0.175
Education [High]
Reference: Low education 		1.27 0.95 - 1.70 0.103
Open in a new tab

Good to optimal API ≤ 39 %; above sample-average OHLP ≥ 53 points; API = approximal plaque index; OHLP = Oral Health Literacy Profile; MB = migration background

A 95 % confidence interval was estimated for all models. All statistical analyses were performed using the computing software R (Version 4.0.3) with standard p-value <0.05 for statistical significance.

3. Results

3.1. Descriptive analysis of the cohort

3.1.1. Socio-demographic and oral health literacy-related indicators

Table 1 displays descriptive characteristics of the entire cohort with migration status (n = 1456). 904 participants (62 %) had a migration background and 552 participants (38 %) had no migration background. There are significant differences between the groups in terms of age, net equivalent income, OHL, clinical parameters, the use of dental services, and oral hygiene behaviors (Table 1). When compared to people without migration background, the participants with migration background were significantly younger (median age 40 vs. 50 years), had a significantly lower mean net equivalent income (1634€ vs. 2102€), and performed significantly worse in the area of OHL (mean OHLP-Score 49 vs. 61). These differences were also evident when observing the different OHLP modules separately. The biggest differences between the groups in terms of the mean scores were found in the modules "oral health behaviors" (70 (±18) for those without migration background, 57 (±18) for those with migration background) and "knowledge of the dental care system in Germany" (78 (±14) for those without migration background, 63 (±24) for those with migration background). Additionally, participants with migration background had statistically significantly higher mean values when asked about their fear of high costs (2.76 vs. 2.60).

3.1.2. Oral hygiene and utilization behavior

In terms of use of dental services and oral health behaviors, 58 % of participants with migration background stated that they had their teeth professionally cleaned in the last 12 months, while it was 72 % for participants without migration background. Significantly fewer people of the participants with migration background had visited a dentist in the last 12 months compared to those without (88 % vs. 91 %), whereby the reason for the last dental visit was significantly more often "pain/dental problem" (30 % vs. 20 %). While 98.5 % of the participants without migration background reported to brush their teeth at least once a day or twice a day, with 93.4 % the percentage was significantly lower for participants with migration background. Moreover, significantly more of the latter never or only weekly use dental floss or interdental brushes (59 % vs. 50 %). In addition, 76 % of the participants with migration background compared to 87 % of those without migration background reported brushing their teeth for at least 2 mins.

3.1.3. Clinical parameters

There are also clear group differences in the clinical parameters. The participants with migration background had significantly higher percentages of moderate and insufficient API (64 % vs. 49 %). Furthermore, they showed a significantly lower degree of caries restoration (mean value 84 vs. 91). When it comes to the DMFT-Index, participants with migration background presented significantly lower mean values (12 vs. 15).

3.2. Descriptive analysis of the cohort with migration background

Of the participants with migration background, 10 % had a one-sided migration background (n = 94), 19 % had a two-sided migration background (n = 170), and 71 % were immigrants (n = 636) (Table 2). The most frequent regions of origin are Eastern Europe (37 %) and the Middle East (37 %). The majority of immigrants does not have German citizenship (59 %). Not surprisingly, this proportion is significantly lower for people with one-sided (5.3 %) and two-sided (17 %) migration background, as they were born in Germany and early obtained the right for German citizenship. The mean length of stay for the immigrants is 19 years. Almost three-quarters (74 %) of immigrants and more than half (52 %) of participants with two-sided migration background do not speak German in their own household. The proficiency of German language skills in terms of reading and speaking is significantly lower for immigrants.

3.3. Regression analyses

The linear mixed regression analysis for the outcome OHLP-Score (Table 3) revealed that women, higher educated persons, and participants without migration background performed significantly better in their OHLP-Score. For example, the OHLP-Score of participants with any migration background was on average 10.99 points lower than that of participants without migration background (adjusted for sex, education, and age as polynomial grade 2) (estimate:10.99, 95 %-CI:12.91 – -9.06, p < 0.001).

Similarly, the linear mixed regression analysis with the API as outcome variable (Table 4) showed that women, higher educated persons, and participants without migration background demonstrated significantly better API values. The API for participants with migration background was on average 5.80 values higher than that of participants without migration background (adjusted for age, sex, and education) (estimate: 5.80, 95 %-CI: 2.27 – 9.34, p = 0.001).

The logistic mixed model (Table 5) shows a significant association between higher OHL (predictor) and better oral hygiene (outcome). The analysis confirms that above-average OHL (OHLP-Score ≥ 53 points) increases the probability of having good to optimal API (API ≤39 %), even after controlling for confounding variables such as migration background, age, sex, and education (OR=2.04, 95 %-CI: 1.59 - 2.62, p < 0.001). While female sex increases the probability of having good to optimal oral hygiene (OR=1.60, 95 %-CI: 1.25 - 2.05, p < 0.001), a migration background reduces it (OR=0.66, 95 %-CI: 0.50 - 0.88, p = 0.004).

4. Discussion

There are clear differences between the participants with and without migration background in terms of their OHL and oral health status. The former show significantly lower OHLP-Scores and higher API values as well as a more problem-oriented dental service use rather than preventive oral health check-ups. Furthermore, the degree of caries restoration is significantly lower among participants with migration background than those without, which demonstrates a higher need for treatment. Overall, migration background is a significant predictor for lower OHLP-Scores and higher API values. Lastly, the logistic mixed regression analysis revealed a significant association between better OHL and lower API values.

A lot of research of OHL among vulnerable populations focuses on OHL in association with ethnic differences in multi-cultural societies (Atchison et al., 2010; Divaris et al., 2011; Messadi et al., 2018; Tam et al., 2015). Members of ethnic communities or minorities in these studies have often lived in the countries concerned for several generations and are therefore different from immigrants with personal migration experience or their children as part of the so-called second generation with migration background. Overall, there is a lack of research on OHL among (im)migrant populations globally. Yet, the limited literature points to different attitudes and knowledge of dental health among this population (Calvasina et al., 2016; Chen et al., 2014; Geltman et al., 2014; Skeie et al., 2006; Balasundaram et al., 2024). To our knowledge, the MuMi study is the first study providing data on the OHL of people with migration background in Germany.

In a cross-sectional study on immigrant-native differences in oral health behaviors in Taiwan (Chen et al., 2014), the authors found significantly lower levels of caries-related knowledge, and less appropriate attitudes and oral health behaviors in immigrants compared to natives. The study only examines knowledge on caries-related topics. Thus, direct comparisons with the MuMi study are problematic due to differences in the operationalization of OHL. The literature shows that there are differences between individuals with migration background and those without with regard to their health-related information-seeking behavior (Baumann et al., 2020). As a consequence, people with migration background might require a tailored approach with different information packages. In a study among immigrant parents in Norway (Mustafa et al., 2021), Mustafa et al. reported that specific attitudes and subjective norms negatively influence oral health behavior, despite having adequate oral health knowledge. In an explorative qualitative study within the MuMi project, we also identified perceived significance of oral health and overall health socialization as barriers towards dental treatment and prevention for individuals with migration background in Germany (Spinler et al., 2022). The existing evidence suggests that additional factors such as health socialization, which in turn might be closely related to the country of origin or cultural background, need to be considered as they might affect health risks and preventive opportunities (Razum et al., 2024).

Our findings on clinical parameters are in line with results from international studies, which also point to inadequate oral health behaviors and lower oral health status among migrant populations in contrast to the majority population of the respective country (Lauritano et al., 2021; Lauritano et al., 2022; Pabbla et al., 2021; Pabbla et al., 2024; Arora et al., 2016; Delgado-Angulo et al., 2018; Lebano et al., 2020; Olerud et al., 2016). In Germany, studies among children and adolescents with and without migration background also indicate a discrepancy in oral health status and behaviors (Schenk and Knopf, 2007; Krause et al., 2018; Kühnisch et al., 2003; Heinrich-Weltzien et al., 2007; Bissar et al., 2007; Bissar et al., 2007) as well as oral health-related quality of life (Aarabi et al., 2018). Available data on the oral health of middle-aged and older people with migration background in Germany, however, remains insufficient. First study results among seniors and adults with migration background largely focus on utilization behavior, reporting lower chances of utilizing regular dental check-ups among individuals with migration background (Brzoska et al., 2017; Erdsiek et al., 2017), which is consistent with our findings. In a cross-sectional explorative study with a convenience sample recruited from dental practices in Hamburg, Germany, Aarabi et al. (Aarabi et al., 2018) found significantly more decayed teeth (5.3 vs. 2.1, p < 0.001) as well as higher API values among migrants in comparison to non-migrants (55.3 % vs. 33.0 %, p = 0.002). Similar trends with regard to the differences between people with and without migration background can be observed in our study. However, it is important to add that our study population is on average 20–30 years younger, which makes a direct comparison between the two studies difficult. To date, the most important epidemiological studies in Germany – the German Oral Health Studies (DMS) (Jordan et al., 2016) – have not provided any information on the oral health of people with migration background as they simply did not gather the migration status of the participants. Now, as part of the sixth DMS, the migration status has been surveyed and documented for the first time. Data and results, however, will first be published in 2025 only.

The relationship between OHL and oral health outcomes has been explored in other research. According to a study by Baskaradoss with a convenience sample of dental patients from Ohio, United States, subjects with limited OHL levels had poorer oral health, including significantly higher mean values for missing teeth, lower mean values for filled teeth, and a higher percentage of severe periodontitis compared to subjects with high OHL (Baskaradoss, 2018). Similarly, Ueno et al. (Ueno et al., 2013) found that among Japanese participants of the “Akita Oral Health Survey” study subjects with low OHL demonstrated poorer oral health behaviors, had significantly higher mean numbers of decayed teeth, and fell into higher categories of the community periodontal index, indicating a higher prevalence of periodontal diseases. In our study, the logistic regression analysis also confirmed that higher OHL increases the probability of having better oral hygiene (measured as API), while a migration background decreased the odds of having good to optimal oral hygiene.

Overall, migration background appears to be a risk factor in its own right, as the differences in OHL and oral health status remain even after statistically controlling for age, gender, and education. This is also consistent with the results of other studies (Arora et al., 2016; Batra et al., 2019; Rommel et al., 2015). However, the review of the literature reveals differences with regard to the definition and operationalization of migration status. In general, people with migration background usually represent a very heterogeneous group of individuals with varying socio-economic backgrounds, language proficiencies, length of stay, and resident status as well as oral health knowledge, beliefs, and attitudes, shaped by their culture and past experiences in the respective health care system of their home countries.

Language proficiency and length of stay is commonly seen as a key driver of social integration and to facilitate adaptation to a new culture (Jasemi and Gottardo, 2023; Zane and Mak, 2003; Martinovic et al., 2009). In regards to dental care and oral health outcomes, language may represent a barrier or facilitator for effective patient-doctor communication. Additionally, in a study examining the relationship between ethnicity, migration background, and oral health outcomes, the authors found that age at arrival and length of residence among immigrants were positively associated with DMFT-Index (Delgado-Angulo et al., 2018). What is more, both the sense of belonging to society as well as self-reported experiences of discrimination are linked to subjective and physical health (Bartig et al., 2023). These factors mentioned here are often used as proxies for measuring acculturation (Tiwari and Albino, 2017; Dahlan et al., 2019; Kajikhina et al., 2023), a process in which an individual adopts, acquires and adjusts to a new cultural environment. Cultural variations, as a result of moving to a new country and adapting to a new culture, can have implications on health (Dahlan et al., 2019). Studies show a positive association between the level of acculturation and oral health status or behaviour (Dahlan et al., 2019; Luo et al., 2024). For instance, in a study among Asian Americans, those with high acculturation scores were more likely to engage in dental flossing and visit the dentist regularly compared to those with lower acculturation scores (Luo et al., 2024).

Hence, in order to better reflect the diversity within our population with migration background, the other migration-related factors (country of origin, country of origin of both parents, citizenship, length of stay in Germany, language skills, subjective sense of belonging to society, and self-reported experiences of discrimination) should be included in future analyses. Separate consideration of different migration-related determinants in relation to health outcomes could be essential to develop targeted health interventions.

4.1. Strengths and limitations

Although it seems plausible that OHL is a strong predictor of an individuals’ health‐related behavior and health outcomes, this is not self-evident. The results can be interpreted as an indication that a higher level of OHL is actually reflected in better oral health, therefore making it a key contributor to effective disease management and the overall efficiency of the healthcare system. However, the cross-sectional design does not allow such a causal relationship to be assumed. Because of different operationalizations of OHL, the complex and multidimensional construct is not easily measured (Kofahl and Trojan 2017). Nonetheless, with all its components, the OHLP (Spinler et al., 2021) can be assessed as a feasible and sensitive instrument to assess the most relevant dimensions of OHL in everyday practice.

An additional strength of the study design was that during data collection, the project team made regular monitoring visits to the dental practices to ensure continuous and consistent high-quality data collection. Unfortunately, the Covid-19-pandemic with its lock-downs hit directly into the main phase of data collection. Additional precautionary measures or practice closures – which in few instances even led to practitioner changes – prolonged the time frame for data collection considerably.

As the recruitment took place in dental practices, a selection bias cannot be ruled out. First, only people who in fact visited a dental practice could be included in the study. Those who do not seek dental care at all can therefore not be represented. Completing the questionnaires in the dental practice could have led to a social desirability bias, e.g. for the questions on oral hygiene behavior. It should also be noted that some questions on oral hygiene behavior, such as tooth brushing duration, are based on self-reports, which could over- or underestimate actual behavior. In addition, the OHLP covers many but not all dimensions of OHL like communication skills or interactive competencies with the dentist.

5. Conclusion

Lower OHL, worse oral health status and lower utilization of dental services among individuals with migration background suggest that these do not benefit from group and individual prophylaxis services in the same way as people without migration background in Germany.

In view of the consistent influx of immigrants or refugees in Germany, it can be assumed that the health care system in Germany will have an additional need for medical and specifically dental treatment in the future. These aspects should become the focus of further research in order to develop tailored preventive measures and to improve dental care for people with migration background, finally, to promote oral health equity.

Funding sources

The MuMi-Project was funded by the Innovation Fund of the Joint Federal Committee (G-BA), Berlin, Germany (grant number 01VSF17051).

Ethics statement

The studies involving human participants were reviewed and approved by the University Clinic Hamburg-Eppendorf Ethics Committee (Lokale Psychologische Ethikkommission am Zentrum für Psychosoziale Medizin) No: LPEK-0027. The patients/participants provided their written informed consent to participate in the study.

CRediT authorship contribution statement

Berit Lieske: Writing – review & editing, Writing – original draft, Visualization, Validation, Project administration, Methodology, Formal analysis, Data curation. Christopher Kofahl: Writing – original draft, Validation, Supervision, Methodology, Investigation, Funding acquisition, Conceptualization. Katrin Borof: Writing – review & editing, Formal analysis. Kristin Spinler: Project administration, Data curation. Anna Poth: Project administration, Data curation. Demet Dingoyan: Data curation. Thomas Beikler: Resources. Guido Heydecke: Resources. Ghazal Aarabi: Writing – review & editing, Validation, Supervision, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We would like to thank all cooperating dental practices that took part in the study and Procter & Gamble Service GmbH, which provided us with free oral hygiene sets (Oral-B: toothbrush, toothpaste, mouthwash, dental floss) as incentives for the study participants. We acknowledge financial support from the Open Access Publication Fund of UKE – Universitätsklinikum Hamburg-Eppendorf.

Contributor Information

Berit Lieske, Email: b.lieske@uke.de.

Christopher Kofahl, Email: kofahl@uke.de.

Katrin Borof, Email: k.borof@uke.de.

Demet Dingoyan, Email: d.dingoyan@uke.de.

Thomas Beikler, Email: t.beikler@uke.de.

Guido Heydecke, Email: g.heydecke@uke.de.

Ghazal Aarabi, Email: g.aarabi@uke.de.

References

  1. Aarabi G, Reissmann DR, Sagheri D, Neuschulz J, Heydecke G, Kofahl C, et al. Oral health-related quality of life of children and adolescents with and without migration background in Germany. Qual. Life Res. 2018;27(10):2619–2627. doi: 10.1007/s11136-018-1903-7. [DOI] [PubMed] [Google Scholar]
  2. Aarabi G, Reissmann DR, Seedorf U, Becher H, Heydecke G, Kofahl C. Oral health and access to dental care - a comparison of elderly migrants and non-migrants in Germany. Ethn. Health. 2018;23(7):703–717. doi: 10.1080/13557858.2017.1294658. [DOI] [PubMed] [Google Scholar]
  3. Alzahrani AY, El Meligy O, Bahdila D, Aljawi R, Bamashmous NO, Almushayt A. Health and oral health literacy: A comprehensive literature review from theory to practice. Int J Paediatr Dent. 2025;35(2):434–445. doi: 10.1111/ipd.13255. [DOI] [PubMed] [Google Scholar]
  4. Arora G, Mackay DF, Conway DI, Pell JP. Ethnic differences in oral health and use of dental services: cross-sectional study using the 2009 Adult Dental Health Survey. BMC. Oral Health. 2016;17(1):1. doi: 10.1186/s12903-016-0228-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Asghar Zaidi M, Hagenaars A, de Vos K. Luxembourg Office for Official Publications of the European Communities; 1994. Poverty Statistics in the Late 1980s – Research based On Micro-Data. [Google Scholar]
  6. Atchison KA, Gironda MW, Messadi D. Der-Martirosian C. Screening for oral health literacy in an urban dental clinic. J. Public Health Dent. 2010;70(4):269–275. doi: 10.1111/j.1752-7325.2010.00181.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Balasundaram RB, Boateng S, Yockey RA, Yording H, Tran D, Nguyen U-SDT. Oral health literacy, knowledge, practice and beliefs among Asian Americans: a scoping review. Community Dent. Oral Epidemiol. 2024;52(6):786–798. doi: 10.1111/cdoe.12988. [DOI] [PubMed] [Google Scholar]
  8. Bartig S, Koschollek C, Bug M, Blume M, Kajikhina K, Geerlings J, et al. Gesundheit von menschen mit ausgewählten staatsangehörigkeiten in Deutschland – Ergebnisse der studie GEDA Fokus. J. Health Monit. 2023;(1):7–35. [Google Scholar]
  9. Baskaradoss JK. Relationship between oral health literacy and oral health status. BMC. Oral Health. 2018;18(1):172. doi: 10.1186/s12903-018-0640-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Batista MJ, Lawrence HP, Sousa M. Vol. 18. BMC Public Health; 2017. p. 60. (Oral Health Literacy and Oral Health Outcomes in an Adult Population in Brazil). [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Batra M, Gupta S, Erbas B. Oral health beliefs, attitudes, and practices of South Asian migrants: a systematic review. Int. J. Environ. Res. Public Health. 2019;16(11) doi: 10.3390/ijerph16111952. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Baumann E, Czerwinski F, Rosset M, Großmann U, Calhoun K. Stiftung Gesundheitswissen (SGW); Hannover: 2020. Wie Informieren Sich Menschen mit Migrationshintergrund zum Thema Gesundheit? [Google Scholar]
  13. Bissar A-R, Schulte AG, Muhjazi G, Koch MJ. Caries prevalence in 11- to 14-year old migrant children in Germany. Int. J. Public Health. 2007;52(2):103–108. doi: 10.1007/s00038-007-5102-5. [DOI] [PubMed] [Google Scholar]
  14. Bissar AR, Oikonomou C, Koch MJ, Schulte AG. Dental health, received care, and treatment needs in 11- to 13-year-old children with immigrant background in Heidelberg. Germany. Int J Paediatr Dent. 2007;17(5):364–370. doi: 10.1111/j.1365-263X.2007.00846.x. [DOI] [PubMed] [Google Scholar]
  15. Brzoska P, Erdsiek F, Waury D. Enabling and predisposing factors for the utilization of preventive dental health care in migrants and non-migrants in Germany. Front. Public Health. 2017;5:201. doi: 10.3389/fpubh.2017.00201. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Calvasina P, Lawrence HP, Hoffman-Goetz L, Norman CD. Brazilian immigrants' oral health literacy and participation in oral health care in Canada. BMC. Oral Health. 2016;16:18. doi: 10.1186/s12903-016-0176-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Chen C, Sx Chiou, Ting C, Lin Y, Hsu C, Chen F, et al. Immigrant-native differences in caries-related knowledge, attitude, and oral health behaviors: a cross-sectional study in Taiwan. BMC. Oral Health. 2014;14(3) doi: 10.1186/1472-6831-14-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Cho HA, Im AJ, Sim YR, Jang HB, Lim HJ. Vol. 20. BMC Public Health; 2020. p. 1074. (The Association Between Oral Health Literacy and Oral Health Behaviors in North Korean defectors: a Cross-Sectional Study). [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Dahlan R, Badri P, Saltaji H, Amin M. Impact of acculturation on oral health among immigrants and ethnic minorities: a systematic review. PLoS. One. 2019;14(2) doi: 10.1371/journal.pone.0212891. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Delgado-Angulo EK, Marcenes W, Harding S, Bernabé E. Ethnicity, migration status and dental caries experience among adults in East London. Community Dent. Oral Epidemiol. 2018;46(4):392–399. doi: 10.1111/cdoe.12381. [DOI] [PubMed] [Google Scholar]
  21. Divaris K, Lee JY, Baker AD, Vann WF., Jr The relationship of oral health literacy with oral health-related quality of life in a multi-racial sample of low-income female caregivers. Health Qual. Life Outcomes. 2011;9:108. doi: 10.1186/1477-7525-9-108. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Erdsiek F, Waury D, Brzoska P. Oral health behaviour in migrant and non-migrant adults in Germany: the utilization of regular dental check-ups. BMC. Oral Health. 2017;17(1):84. doi: 10.1186/s12903-017-0377-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Geltman PL, Hunter Adams J, Penrose KL, Cochran J, Rybin D, Doros G, et al. Health literacy, acculturation, and the use of preventive oral health care by Somali refugees living in massachusetts. J. Immigr. Minor. Health. 2014;16(4):622–630. doi: 10.1007/s10903-013-9846-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Heinrich-Weltzien R, Kühnisch J, Goddon I, Senkel H, Stösser L. [Dental health in German and Turkish school children–a 10-year comparison] Gesundheitswesen. 2007;69(2):105–109. doi: 10.1055/s-2007-970149. [DOI] [PubMed] [Google Scholar]
  25. Horowitz AM, Kleinman DV. Oral health literacy: a pathway to reducing oral health disparities in Maryland. J. Public Health Dent. 2012;72(Suppl 1):S26–S30. doi: 10.1111/j.1752-7325.2012.00316.x. [DOI] [PubMed] [Google Scholar]
  26. Jasemi A, Gottardo A. Second language acquisition and acculturation: similarities and differences between immigrants and refugees. Front. Commun. (Lausanne) 2023;8 [Google Scholar]
  27. Jordan A, Micheelis W, Cholmakow-Bodechtel C, Füßl-Grünig E, Geyer S, Hertrampf K, et al. Fünfte Deutsche Mundgesundheitsstudie (DMS V) 2016.
  28. Kajikhina K, Koschollek C, Sarma N, Bug M, Wengler A, Bozorhmehr K, et al. Empfehlungen zur erhebung und analyse migrationsbezogener determinanten in der public-health-Forschung. J. Health Monit. 2023;8(1):55–77. [Google Scholar]
  29. Kofahl C, Trojan A. In: Kooperation Und Integration – das Unvollendete Projekt des Gesundheitssystems. Brandhorst A, Hildebrandt H, Luthe E-W, editors. Springer Fachmedien Wiesbaden; Wiesbaden: 2017. Health literacy und selbstmanagement im kontext von kooperation und integration; pp. 493–513. [Google Scholar]
  30. Kott K. Datenreport 2018. Bundeszentrale für politische Bildung; Berlin: 2018. Einkommensverteilung. [Google Scholar]
  31. Krause L, Kuntz B, Schenk L, Knopf H. Oral health behaviour of children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study and trends. J. Health Monit. 2018;3(4):3–19. doi: 10.17886/RKI-GBE-2018-096. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Kühnisch J, Senkel H, Heinrich-Weltzien R. Vergleichende Untersuchung zur zahngesundheit von deutschen und ausländischen 8- bis 10-Jährigen des westfälischen Ennepe-Ruhr-Kreises. Gesundheitswesen. 2003;65:96–101. doi: 10.1055/s-2003-37694. [DOI] [PubMed] [Google Scholar]
  33. Lange DE, Plagmann HC, Eenboom A, Promesberger A. [Clinical methods for the objective evaluation of oral hygiene] Dtsch. Zahnarztl. Z. 1977;32(1):44–47. [PubMed] [Google Scholar]
  34. Lauritano D, Moreo G, Carinci F, Campanella V, Della Vella F, Petruzzi M. Oral health status among migrants from middle- and low-income countries to Europe: a systematic review. Int. J. Environ. Res. Public Health. 2021;18(22) doi: 10.3390/ijerph182212203. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Lauritano D, Moreo G, Martinelli M, Campanella V, Arcuri C, Carinci F. Oral health in migrants: an observational study on the Oral health status of a migrant cohort coming from middle- and low-income countries. Applied Sci. 2022 [Google Scholar]
  36. Lebano A, Hamed S, Bradby H, Gil-Salmerón A, Durá-Ferrandis E, Garcés-Ferrer J, et al. Migrants' and refugees' health status and healthcare in Europe: a scoping literature review. BMC. Public Health. 2020;20(1):1039. doi: 10.1186/s12889-020-08749-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Luo T, Beiter K, Tseng TS. Association between acculturation, dental floss use, dental visits and unmet dental needs among Asians in the United States: findings from National Health and Nutrition Examination Survey (NHANES) 2011-2018. Community Dent. Oral Epidemiol. 2024;52(1):101–110. doi: 10.1111/cdoe.12906. [DOI] [PubMed] [Google Scholar]
  38. Martinovic B, Fv Tubergen, Maas I. Changes in immigrants’ social integration during the stay in the host country: the case of non-western immigrants in The Netherlands. Soc. Sci. Res. 2009;38(4):870–882. [Google Scholar]
  39. Messadi DV, Macek MD, Markovic D, Atchison KA. Oral health literacy, preventive behavior measures, and chronic medical conditions. JDR. Clin. Trans. Res. 2018;3(3):288–301. doi: 10.1177/2380084418769835. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Mustafa M, Nasir EF, Åstrøm AN. Attitudes toward brushing children's teeth—A study among parents with immigrant status in Norway. Int. J. Paediatr. Dent. 2021;31(1):80–88. doi: 10.1111/ipd.12683. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Olerud E, Hagman-Gustavsson ML, Gabre P. Oral health status in older immigrants in a medium-sized Swedish city. Spec. Care Dentist. 2016;36(6):328–334. doi: 10.1111/scd.12195. [DOI] [PubMed] [Google Scholar]
  42. Pabbla A, Duijster D, Grasveld A, Sekundo C, Agyemang C, van der Heijden G. Oral health status, Oral health behaviours and Oral health care utilisation among migrants residing in Europe: a systematic review. J. Immigr. Minor. Health. 2021;23(2):373–388. doi: 10.1007/s10903-020-01056-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Pabbla A, Agyemang C, van der Heijden G, Duijster D. Oral health status, behaviours and Oral healthcare utilization among Indian migrants compared to the host population in The Netherlands: a descriptive cross-sectional study. J. Immigr. Minor. Health. 2024;26(2):325–333. doi: 10.1007/s10903-023-01553-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Razum O, Wenner J. Social and health epidemiology of immigrants in Germany: past, present and future. Public Health Rev. 2016;37(1):4. doi: 10.1186/s40985-016-0019-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Razum O, Butler J, Spallek J. In: Handbuch Lokale Integrationspolitik. Gesemann F, Filsinger D, Münch S, editors. Springer Fachmedien Wiesbaden; Wiesbaden: 2024. Gesundheitliche Chancen und Risiken von Migrant*innen: handlungsmöglichkeiten einer kommunalen Gesundheitspolitik; pp. 1–23. [Google Scholar]
  46. Rommel A, Saß AC, Born S, Ellert U. Die gesundheitliche lage von Menschen mit migrationshintergrund und die bedeutung des sozioökonomischen status. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2015;58(6):543–552. doi: 10.1007/s00103-015-2145-2. [DOI] [PubMed] [Google Scholar]
  47. Schenk L, Knopf H. [Oral health behaviour of children and adolescents in Germany. First results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)] Bundesgesundheitsblatt. Gesundheitsforschung. Gesundheitsschutz. 2007;50(5–6):653–658. doi: 10.1007/s00103-007-0226-6. [DOI] [PubMed] [Google Scholar]
  48. Schenk L, Bau AM, Borde T, Butler J, Lampert T, Neuhauser H, et al. Mindestindikatorensatz zur erfassung des Migrationsstatus. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2006;49(9):853–860. doi: 10.1007/s00103-006-0018-4. [DOI] [PubMed] [Google Scholar]
  49. Schneider SL. The International Standard Classification of Education 2011. In: Elisabeth Birkelund G, Ed. Class and Stratification Analysis. Comparative Social Research. 30: Emerald Group Publishing Limited; 2013. p. 365–79.
  50. Skeie MS, Riordan PJ, Klock KS. Espelid I. Parental risk attitudes and caries-related behaviours among immigrant and western native children in Oslo. Community Dent. Oral Epidemiol. 2006;34(2):103–113. doi: 10.1111/j.1600-0528.2006.00256.x. [DOI] [PubMed] [Google Scholar]
  51. Spinler K, Weil M-T, Valdez R, Walther C, Dingoyan D, Seedorf U, et al. Mundgesundheitskompetenz von Menschen mit migrationshintergrund – Erste Auswertungen der MuMi-Studie. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2021;64(8):977–985. doi: 10.1007/s00103-021-03371-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Spinler K, Valdez R, Aarabi G, Dingoyan D, Reissmann DR, Heydecke G, et al. Development of the oral health literacy Profile (OHLP)-psychometric properties of the oral health and dental health system knowledge scales. Community Dent. Oral Epidemiol. 2021;49(6):609–616. doi: 10.1111/cdoe.12688. [DOI] [PubMed] [Google Scholar]
  53. Spinler K, Kofahl C, Ungoreit E, Heydecke G, Dingoyan D, Aarabi G. Access barriers to dental treatment and prevention for Turkish migrants in Germany - A qualitative survey. Front. Public Health. 2022;10 doi: 10.3389/fpubh.2022.862832. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Statistisches Bundesamt . Ergebnisse Des Mikrozensus 2019. Statistisches Bundesamt; Wiesbaden: 2020. Bevölkerung und erwerbstätigkeit. Bevölkerung mit migrationshintergrund. [Google Scholar]
  55. Statistisches Bundesamt . Ergebnisse Des Mikrozensus 2021. Statistisches Bundesamt; Wiesbaden: 2023. Bevölkerung und erwerbstätigkeit. Bevölkerung mit migrationshintergrund. [Google Scholar]
  56. Tam A, Yue O, Atchison KA, Richards JK, Holtzman JS. The association of patients' oral health literacy and dental school communication tools: a pilot study. J. Dent. Educ. 2015;79(5):530–538. [PMC free article] [PubMed] [Google Scholar]
  57. Tiwari T, Albino J. Acculturation and pediatric minority oral health interventions. Dent. Clin. North Am. 2017;61(3):549–563. doi: 10.1016/j.cden.2017.02.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Ueno M, Takeuchi S, Oshiro A, Kawaguchi Y. Relationship between oral health literacy and oral health behaviors and clinical status in Japanese adults. J. Dent. Sci. 2013;8(2):170–176. [Google Scholar]
  59. Valdez R, Spinler K, Kofahl C, Seedorf U, Heydecke G, Reissmann DR, et al. Oral health literacy in migrant and ethnic minority populations: a systematic review. J. Immigr. Minor. Health. 2022;24(4):1061–1080. doi: 10.1007/s10903-021-01266-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Weber T. In: Memorix Zahnmedizin. 5, Unveränderte Auflage. Weber T, editor. Thieme Verlag; Stuttgart: 2017. Plaque-indizes (Mundhygiene-Indizes) Hrsg. [Google Scholar]
  61. Weil MT, Spinler K, Lieske B, Dingoyan D, Walther C, Heydecke G, et al. An evidence-based digital prevention program to improve oral health literacy of people with a migration background: intervention mapping approach. JMIR. Form. Res. 2023;7:e36815. doi: 10.2196/36815. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Wiessner C, Keil T, Krist L, Zeeb H, Dragano N, Schmidt B, et al. Personen mit migrationshintergrund in der NAKO Gesundheitsstudie – soziodemografische Merkmale und vergleiche mit der autochthonen deutschen bevölkerung. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2020;63(3):279–289. doi: 10.1007/s00103-020-03097-9. [DOI] [PubMed] [Google Scholar]
  63. Zane N, Mak W. American Psychological Association; Washington, DC, US: 2003. Major Approaches to the Measurement of Acculturation Among Ethnic Minority populations: A content Analysis and an Alternative Empirical strategy. Acculturation: Advances in theory, measurement, and Applied Research; pp. 39–60. [Google Scholar]

Articles from Journal of Migration and Health are provided here courtesy of Elsevier

RESOURCES