Oral health-related quality of life, mental health profile and their association in pre-university high school students, Iran

Abstract

Background & objectives

Oral health-related quality of life (OHQoL) refers to an individual’s perception of their oral condition and its impact on various aspects of life. Due to lack of comprehensive data that address the anxiety and stress among pre-university students with high tensions of admission exam, this study aimed to assess the mental health, anxiety and stress impact on OHQoL in high school students in Iran before university entrance exam.

Materials and methods

This is a cross-sectional study conducted on 622 high school students in Qom. Students were recruited through multi-stage sampling. The data required for the study were collected with three questionnaires, including a demographic questionnaire, 14-item Oral Health Impact Profile-14 (OHIP-14) questionnaire, and general health questionnaire (GHQ-28). Data were analyzed using SPSS version 26 software, by Pearson correlation tests, as well as stepwise multivariate linear regression.

Results

The mean age of the students participating in the study was 19.69 ± 0.871 years, of which 55.3% were female and 9.8% were non-Iranian. The mean overall general health and OHQoL scores in the studied students were 29.71 ± 10.96 and 16.43 ± 9.37 respectively. There is a direct and significant correlation between the general health score and its dimensions and the OHQoL score and its dimensions in students. The results of linear regression showed that a higher general health score, male gender, poor general health score, male gender, non-Iranian nationality, and higher father’s education level are predictors of OHQoL.

Conclusion

According to the results of the present study, as the general health score is impaired, the quality-of-life score and its various dimensions are impaired, and in students with impaired general health, the OHQoL will lose. In addition, the OHQoL is not suitable in male students, non-Iranians who have poor general health score and fathers with low literacy. Therefore, comprehensive and community-based interventions in students.

Introduction

Oral health-related quality of life (OHQoL) refers to an individual’s perception of their oral condition and its impact on various aspects of life. Studies show that oral problems can have negative effects on various aspects of an individual’s life, including social relationships and general mental health, and people with dental problems are more likely to experience dissatisfaction and reduced quality of life [1–3]. According to the results of various studies, factors such as social and economic status and parental education level are effective in OHQoL [4]. In addition, stress levels and negative emotions, psychological and emotional experiences caused by dental problems can negatively affect life satisfaction and health behaviors, ultimately leading to increased dental caries and decreased quality of life [1, 4–7].

Adolescence due to academic and social pressures can lead to poor health behaviors such as neglecting oral hygiene. Studies have shown that stress can affect the body’s hormonal balance and, due to physiological effects, can lead to oral health problems such as bruxism (teeth grinding), gum disease, and ultimately a higher prevalence of tooth decay [8–11]. Stress is one of the important psychological factors that is increasingly observed among students, especially in high school students. Academic pressures, social relationships, and parental expectations can lead to the experience of severe stress in adolescents. Current statistics indicate that 31.9% of adolescents aged 13 to 18 have or currently have an anxiety disorder, and 31.5% have experienced symptoms of depression [12]. Therefore, oral health, as one of the fundamental pillars of public health, has direct and indirect effects on the quality of life of individuals [13]. According to a study by Khodabakshi et al. in Guilan, OHQoL as a multifaceted construct affects various aspects of appearance and beauty, oral comfort, and eating restrictions as very important components in quality of life and life satisfaction [14].

Some other studies have shown that stress can have a significant impact on oral health, leading to reduced attention to health care and, consequently, an increased risk of dental caries [8, 9]. Moreover, oral problems can have negative effects on various aspects of an individual’s life, including social relationships and general health, and people with dental problems are more likely to experience feelings of dissatisfaction and reduced quality of life [15, 16]. People who experience stressful lives value their oral health less and high school students who face intense academic pressures and social challenges may be particularly vulnerable to dental problems and reduced quality of life, daily activities and disruption of students’ social lives [4, 17–19].

Mental health is defined by the World Health Organization (WHO) as “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community” [20]. Nevertheless, existing data provide valuable information about individual components of general mental health, stress and quality of life, limited researches have simultaneously examined these interrelationships in the adolescent population, especially in secondary schools who are in high stress of admission exam to university. Previous studies have mainly focused on the epidemiology of dental caries or the psychosocial aspects of stress without integrating these perspectives into a single framework. Therefore, it is necessary to examine the multifaceted relationships between general mental health, stress levels, and OHQoL in pre-university high school students. The present study aimed to investigate the relationship between dental caries index and OHQoL with stress in high school students in Qom, Iran.

Materials and methods

Study setting

This is a cross-sectional-analytic study conducted on 622 high school students who are trying to enter to the university during the autumn of 2025 in Qom, Iran.

Participants and sampling

Secondary high school students in Qom who were in high stress due to admission exam to university were the statistical population of this study. The required sample size for the study calculated according to the results of a similar study by AlJameel et al. [21], and considering the pooled standard deviation equal 13 in OHIP-14 score in students and mean difference equal 3, the study power 90%, and 95% confidence interval, the minimum sample size required for the study was 295. Nevertheless, considering the type of cluster sampling and the application of the design effect coefficient (df = 2), 622 students were included. The students were recruited through multi-stage sampling. First, cluster sampling was used and educational districts were considered as a cluster, and in 4 districts of the city, two girls’ schools and two boys’ schools were randomly selected from each district. Then, four schools selected and, in each school, three different classes selected by the simple random sampling. Finally, the eligible students who were consent for participating in the study were selected through convenient sampling.

Inclusion criteria were including all high school students who were in grade 10th, 11th and 12th who educating in Qom schools during the academic year 2025–2026 and were susceptible and eager to register in the university admission exam were eligible to participate in the study. Furthermore, disagreement for participating in the study, lack of cooperation for examination and data collection, or failure to answer at least 80% of the questions were exclusion criteria.

Data collection

DMFT

The data collection tool in this study collected using Decay, Missed, Filled Tooth (DMFT) clinical checklist and three different questionnaires. First, the DMFT clinical checklist was used to determine the DMFT index of students, their health records completed by a dentist and a trained dental student, and then, questionnaires delivered to students. Demographic questionnaire included questions such as student age, student gender, parents’ age, nationality, number of children, parents’ education level, parents’ occupation, family income level, and primary and supplementary insurance coverage. The second questionnaire used in this study was the 14-question Oral Health Impact Profile-14 (OHIP-14) questionnaire to measure the oral health impact profile. In the aforementioned questionnaire, questions include the effects of oral health on the individual’s quality of life in 7 different areas including functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. Students must choose one of the options never, seldom, sometimes, often, and always to answer the questions. A score of zero indicates the absence of any impact (never) and a score of 4 indicates the worst impact (always) of OHQoL. The range of scores is between zero and 56, and a higher score indicates a lower OHQoL. This questionnaire was translated into Persian by Dr. Ravaghi and colleagues, and its validity and reliability have been confirmed [22]. It has been used in various studies in Iran [23–25]. The third questionnaire was the General Health Questionnaire (GHQ), developed by Goldberg and Hiller in 1979, to determine the level of stress of students. It has 28 questions and examines the general health of the individual and four different subscales including somatic symptoms (items 1–7), anxiety/insomnia (items 8–14), social dysfunction (items 15–21) and severe depression (items 22–28). The items are scoring based on a scale from 0 to 3. Each question is scored from 0 to 3, and a higher score indicates a disorder in the individual’s general health, as a higher score shows lower general health status. In this test, if the individual obtains a total score below 22 and in the range below 6, his health is normal, but obtaining a score of 22 to 40 indicates a weak disorder, 41 to 60 indicates a moderate disorder, and above 60 indicates a severe disorder [26]. The validity and reliability of the aforementioned questionnaire have been conducted and confirmed in Iran and Iranian studies [27–29].

Ethical consideration

Before starting the study, in accordance with the Declaration of Helsinki, the purpose of the study were explained to the target group. The human ethics and consent declarations elaborated for all subjects for confidentiality of the information, and every student provided its informed consent for participation. Then, a clinical examination was performed by a dentist or a trained final-year dental student, and the results of the examination were immediately communicated to the student. Finally, the questionnaires used were provided to the target group and the required information was collected. In addition, the study protocol is approved in Approval Committee and Internal Review Board (IRB) of Qom University of Medical Science with code IR.MUQ.REC.1404.124.

Data analysis

Data were analyzed using SPSS version 26 software, and in addition to descriptive statistics (mean, standard deviation, frequency, and percentage). Before testing the hypotheses, the normality of the data was checked with the Shapiro-Wilk test and the indices of kurtosis and skewness, and the homogeneity of variances was checked with the Levene test. To analyze the relationships and examine the correlation between the variables under study and the determinants of OHQoL, Pearson and Spearman correlation, and multivariate linear regression model with stepwise method were used to examine the relationship between demographic variables and the OHQoL index. The significance level for all tests was considered to be 0.05.

Results

The mean age of the students who participating in the study was 19.69 ± 0.871 years and ranged between 17 and 19 years old. The mean of overall general health and OHQoL scores calculated 29.71 ± 10.96 and 16.43 ± 9.37, which indicated that 453 students (72.8%) were affected to impaired general health. Further analysis showed that 169 students (27.2%) were without any mental disorder, and off 72.8% with mental health disorder, 317 students (51%) were with mild impairment and 136 students (21.8%) were with moderate impairment (Fig. 1).

Fig. 1.

The general health profile of studied student based on the general health scores

Table 1, depicted the demographic characteristics of subjects and showed that 55.3% were female and 9.8% were non-Iranian. The distribution of subjects based on parents’ education and job and family income are showing that almost 70% of subjects were in low to moderate range of socioeconomic status like other people of Iran and our sample was a representative of our community.

Table 1.

Demographic characteristics of participated students in the study

Variables		Number	Percent
Gender	Girls	334	55.3
	Boy	278	44.7
Nationality	Iranian	561	90.2
	Non-Iranian	61	9.8
Father education	Lower diploma	253	40.7
	Diploma	192	30.9
	University degree	177	28.4
Mother education	Lower diploma	240	38.6
	Diploma	176	28.3
	University degree	206	33.1
Father job	Unemployed	72	11.6
	Laborer	261	42
	Employee	159	25.6
	Other	130	20.9
Mother job	Housekeeper	457	473.5
	Employee	165	26.5
Self-rated family-income level	Poor	163	26.2
	Moderate	271	43.6
	Higher moderate	101	16.2
	Good	87	14

The mean of GHQ and its subscales is showed in Table 2. The mean score of GHQ is calculated above the critical point of 22, and the mean score of all subscales except severe depression was above the critical point 6 for each subscale. Moreover, the mean score of overall OHIP-14 and its subscales brought and the results of overall mean OHIP-14 showed better situation in OHQoL than the general health. Based on the results, the poorest score of OHQoL observed in psychological discomfort subscale 3.57 ± 1.84 and the best score of OHQoL observed in Functional limitation and social disability subscales with 1.68 ± 1.77 and 1.85 ± 1.44, respectively.

Table 2.

The mean and SD of general health (GHQ-28), OHIP-14 and their domains in participated students in the study

	Variables	Minimum	Maximum	Mean (SD)
GHQ	Overall GHQ Score	2	53	29.71(10.96)
	Somatic symptoms	0	21	7.34(3.71)
	Anxiety/insomnia	0	19	7.72(4.80)
	Social dysfunction	0	21	9.80(4.29)
	Severe depression	0	21	4.86(4.94)
OHIP-14	Overall score of OHIP-14	0	34	16.43(9.37)
	Functional limitation	0	6	1.68(1.77)
	Physical pain	0	8	2.74(1.78)
	Psychological discomfort	0	8	3.57(1.84)
	Physical disability	0	8	2.15(1.80)
	Psychological disability	0	8	2.25(1.71)
	Social disability	0	8	1.85((1.44)
	Handicap	0	8	2.07(1.82)

The analysis of OHIP-14 (Table 3) showed that the highest prevalence of problems observed in item 5 in psychological discomfort subscale “Have you been self-conscious because of your teeth or mouth” with 88.9% and item 3 in physical pain subscale as “Have you had painful aching in your mouth?” with 80.4%. while the lowest prevalence observed in item 1 of functional limitation subscale as “Have you had trouble pronouncing any words because of problems with your teeth or mouth” with 49.7%. Moreover, item 5 in psychological discomfort subscale as “Have you been self-conscious because of your teeth or mouth” acquired the maximum score and shows that have had the maximum negative effect on OHQoL of students. In addition, both questions of functional limitation subscale including “Have you had trouble pronouncing any words because of problems with your teeth or mouth” and “Have you felt that your sense of taste has worsened because of problems with your teeth or mouth” have the minimum negative effect on OHQoL.

Table 3.

The students’ responses, mean and standard deviation of each item of OHIP-14 in participants

		Responses					Mean (SD)	Prevalence
Domain	Items	Never	Seldom	Sometimes	Often	Always
Functional limitation	Have you had trouble pronouncing any words because of problems with your teeth or mouth	313(50.5)	126(20.3)	154(24.8)	21(3.4)	6(1)	0.84(0.98)	49.7
	Have you felt that your sense of taste has worsened because of problems with your teeth or mouth	303(48.9)	140(22.6)	155(25)	20(3.2)	2(0.3)	0.84(0.933)	51.3
Physical pain	Have you had painful aching in your mouth?	122(19.6)	159(25.6)	235(37.8)	91(14.7)	14(2.3)	1.54(1.03)	80.4
	Have you found it uncomfortable to eat any foods because of problems with your teeth or mouth?	191(30.8)	176(28.3)	204(32.9)	44(7.1)	6(1)	1.19(0.98)	69.3
Psychological discomfort	Have you been self-conscious because of your teeth or mouth	69(11.1)	95(15.3)	219(35.3)	91(14.7)	147(23.7)	2.24(1.28)	88.9
	Have you felt tense because of problems with your teeth or mouth	184(29.6)	160(25.8)	207(33.3)	34(5.5)	36(5.8)	1.32(1.13)	70.4
Physical disability	Has been your diet been unsatisfactory because of problems with your teeth of mouth?	215(34.7)	153(24.7)	216(34.8)	27(4.4)	9(1.5)	1.13(0.99)	65.4
	Have you had to interrupt meals because of problems with your teeth or mouth?	233(37.5)	176(28.3)	186(29.9)	22(3.5)	5(0.8)	1.02(0.94)	62.5
Psychological disability	Have you found it difficult to relax because of problems with your teeth or mouth	208(33.5)	187(30.2)	195(31.5)	23(3.7)	7(1.1)	1.09(0.94)	66.6
	Have you been a bit embarrassed because of problems with your teeth or mouth	224(36)	154(24.8)	176(28.3)	52(8.4)	15(2.4)	1.16(1.08)	64
Social disability	Have you been a bit irritable with other people because of problems with your teeth or mouth?	242(39)	150(24.2)	194(31.3)	29(4.7)	5(0.8)	1.04(0.98)	61.1
	Have you had difficulty doing your usual jobs because of problems with your teeth or mouth?	248(40)	164(26.5)	187(30.2)	16(2.6)	5(0.8)	0.98(0.93)	60.1
Handicap	Have you felt that life in general was less satisfying because of problems with your teeth or mouth?	230(37.1)	163(26.3)	199(32.1)	17(2.7)	11(1.8)	1.06(0.98)	63
	Have you been totally unable to function because of problems with your teeth or mouth?	265(42.7)	122(19.7)	193(31.1)	38(6.1)	2(0.3)	1.02(1.0)	57.4

The higher score in both GHQ and OHIP-14 shows bad situation of general health and OHQoL. The Pearson correlation coefficient test (Table 4) showed a direct and significant correlation between the general health score and its dimensions and the OHQoL score and its dimensions in students. These results demonstrated that by worsen the general health score in student the OHQoL score will worsen.

Table 4.

The correlation coefficients among the GHQ and OHIP scores of students

Domains	Overall GHQ Score	Somatic symptoms	Anxiety/insomnia	Social dysfunction	Severe depression
Overall score of OHIP-14	0.459**	0.494**	0.523**	0.220**	0.328**
Functional limitation	0.409**	0.417*	0.455**	0.107**	0.234**
Physical pain	0.376**	0.438**	0.459**	0.224**	0.255**
Psychological discomfort	0.111**	0.182**	0.132**	0.142**	0.104**
Physical disability	0.344**	0.404**	0.394**	0.173**	0.225**
Psychological disability	0.366**	0.365**	0.417**	0.179**	0.285**
Social disability	0.384**	0.363**	0.426**	0.162**	0.305**
Handicap	0.418**	0.422**	0.462**	0.180**	0.317**

*; Significant at p = 0.008

**; Significant at < 0.001

The analysis of variance test (Table 5) showed that there was a significant difference among three different group of students based on the GHQ categorization in overall score of OHIP-14 and all seven domains (P < 0.001). In addition, The Tukey post hoc test showed that the overall score of OHIP-14 and all its domains, the mean score of OHIP is significantly increase by increseing the severity of general health disorders. Nevertheless, the Tukey test showed that the mean score of psychological discomfort in students without disorder and mild disorder was not significant (P = 0.985), but the mean score in both of these groups was lower than the moderate group(p < 0.001). The results of multivariate linear regression (Table 6) showed that higher general health score, male gender the higher father’s education level and non-Iranian nationality, are predictors of poor OHQoL.

Table 5.

Comparing the mean score of OHIP-14 and its domains in students based on the mental health categorization

OHIP-14 Scores	Without disorder Mean ± SD, n = 167	Mild disorder Mean ± SD, n = 317	Moderate disorder Mean ± SD, n = 169	P Value
Overall score of OHIP-14	10.58 ± 6.26	16.98 ± 9.12	22.40 ± 9.01	< 0.001
Functional limitation	0.54 ± 0.98	1.88 ± 1.72	2.58 ± 1.93	< 0.001
Physical pain	1.94 ± 1.65	2.73 ± 1.67	3.74 ± 1.70	< 0.001
Psychological discomfort	3.42 ± 2.18	3.44 ± 1.72	4.03 ± 1.56	0.004
Physical disability	1.28 ± 1.53	2.27 ± 1.72	2.94 ± 1.72	< 0.001
Psychological disability	1.38 ± 1.46	2.32 ± 1.58	3.13 ± 1.77	< 0.001
Social disability	1.08 ± 1.34	2.12 ± 1.73	2.93 ± 1.78	< 0.001
Handicap	1.01 ± 1.27	2.21 ± 1.80	3.06 ± 1.81	< 0.001

Table 6.

The multivariate regression results for related factors of oral health-related quality of life

Variables	Beta Coefficient	Standard Error of β	Standardized β	P Value	Confidence interval 95%
					Loewer	Upper
Higher GHQ score	0.311	0.027	0.363	< 0.001	0.257	0.364
Male gender	3.53	0.656	0.187	< 0.001	2.24	4.81
Higher father education	-1.16	0.242	-0.160	< 0.001	-1.63	-0685
Non-Iranian nationality	2.38	1.01	0.076	0.019	0.395	4.36

Discussion

The prevalence of OHQoL disorders in all its dimensions was 60% on average, and more than 70% of the students studied had mild or moderate mental health disorders, which indicates that the mental health status and OHQoL in the present study were not appropriate. However, in a similar study in Iran by Khodabakhshi and colleagues in patients aged 20–50 years in Gorgan, they showed a relative level of satisfaction with quality of life, and an inverse effect of the dental caries index on the quality of life of patients (level of individual satisfaction) was obtained [1].

In the present study, a direct and significant correlation was observed between the total OHQoL score and all its dimensions with the total general health score. In other words, when the general health score is impaired, the OHQoL score and its various dimensions are impaired. Another study examined the relationship between poor OHQoL and mental health and showed that anxiety has a negative impact on oral health, and higher levels of anxiety are associated with fewer filled teeth and a higher dental mass index [2]. In addition, in a study by AlJameel et al. in students in Riyadh, Saudi Arabia, the negative impact of mental health on quality of life was shown, such that with increasing severity of mental disorder, the oral and dental quality of life status decreases [3].

Like the present study, where problems and limitations of teeth, mouth or prosthesis caused effects on word pronunciation (49.7%), changes in food and diet, and diet interruption (up to 60%), other studies have addressed the effects of oral problems and tooth decay or dental treatments on daily activities. In another study by Mamani et al., daily activities were affected in more than 91% of participants, 35% of whom had pain and 58.5% of whom were dissatisfied with their oral health [4]. In Riyadh, 11.6% of students reported difficulty pronouncing certain words due to oral and dental issues [3]. In a review study by Botelho-Filho et al. in 2024 to assess the impact of dental caries on daily activities, using the Oral Impacts on Daily Performances (OIDP) and Child-OIDP instruments in adolescents, in the Child-OIDP subgroup, up to 66% reported experiencing dental caries and up to 72% reported negative impact on daily activities [5]. Moreover, in the study by Amiri et al. in 8–10-year-old students in Shiraz, 69.8% of children had experienced at least one oral problem affecting their daily activities during the past three months using the aforementioned questionnaire. They reported that eating was the most common problem of children was pain and bleeding from the gums was the most common cause of problems. Significant correlation was observed between the child-OIDP and OHQoL score. In addition, caries index and the quality of life is impaired with increasing caries index [6]. The observed correlation between OHQoL and mental health scores suggests that individuals experiencing greater oral health problems tend to report poorer overall well-being. Oral conditions such as pain, discomfort, impaired chewing, and aesthetic concerns may negatively influence daily functioning, social interactions, and psychological status. In addition, the chronic and multifactorial nature of oral diseases can contribute to stress, anxiety, and reduced self-perceived health. These findings support the concept that oral health is closely interconnected with both physical and mental dimensions of general health.

In a study by Chaudhary, higher levels of anxiety, lower levels of self-esteem, and social support were associated with higher DMFT and OHIP-14 scores, worse periodontal and oral hygiene conditions, and less tooth brushing and visits to the dentist, and the main barriers to using oral health care were psychological and social issues [7]. In a study of dentists living in Hong Kong, dental anxiety may be a significant risk factor for poor dental and periodontal status and was associated with worse OHQoL [8]. In addition, in a similar cross-sectional study by Vasiliou and colleagues on 2412 participants in Toronto, a positive relationship was reported between current stress levels and general oral health and oral pain [9]. Therefore, it seems that people with higher perceived stress will have poorer oral health, which is consistent with the results of the present study. However, in another study in Shahediyeh, Yazd Province, no significant relationship was seen between the DMFT index and the psychological profiles of the participants [2].

The results of multivariate linear regression on predictors of OHQoL showed that DMFT index and general health score (higher), male gender, and non-Iranian nationality were factors affecting the deterioration of OHQoL. In addition, the higher level of father education is a factor in improving OHQoL. In other words, the OHQoL in male, non-Iranian students with poor general health score and DMFT index and poorly educated fathers is not appropriate. The higher education of students’ parents are related to higher health literacy, better socioeconomic status, supportive family, as well as excessive utilization of preventive healthcare. Nevertheless, increased numbers of decayed, missing, and filled teeth may lead to pain, functional limitations, dissatisfaction with appearance, and reduced social confidence, all of which negatively affect perceived oral health quality of life. Moreover, female adolescents probably are more sensitive to oral conditions because of the social and psychological importance of appearance and peer interactions during this developmental period. Therefore, poorer oral health status, as reflected by higher DMFT scores, is expected to be associated with worse OHQoL. In the study of Ghobadi et al., the use of dental floss and mouthwash, socioeconomic status, parental education, and frequency of brushing are the most important factors affecting the tooth decay index [10]. The study of Klarić et al. shows significant oral health problems and reduced quality of life, especially in people with lower socioeconomic status [11]. Moreover, in the logistic regression model of the study by Duangthip et al., children with higher dmft scores were more likely to have poorer OHRQoL. While child gender, parental education level and respondent-to-child ratio were not associated with OHRQoL. Therefore, caries experience is associated with lower OHRQoL in Hong Kong preschool children [12]. In another study by Mamani et al., not using a toothbrush, using chewable foods, absenteeism from school and being rural were risk factors for poor OHQoL [4]. Therefore, implementing various educational and therapeutic interventions to reduce dental caries and increase OHQoL can be helpful especially in higher risk students and families who are in higher risk.

Studies have shown that stress can have a significant impact on oral health, leading to decreased attention to health care and, consequently, an increased risk of dental caries [9, 13]. People who experience high levels of stress are less likely to value their oral health, and high school students who face intense academic and social pressures may be particularly vulnerable to dental problems and reduced quality of life. According to research, high prevalence of dental caries can lead to reduced daily activities and disruption of students’ social lives [14]. According to the results of this study, it is necessary to design and implement targeted educational and clinical interventions including fluoride therapy, fissure sealants, and fluoride varnishes in schools, regular dental checkups, and targeted oral health education is essential to promote oral health in high school students. However, based on the results of the present study and other existing studies, the stress of the entrance exam in high school students has been transferred to students in tenth to twelfth grades and the impact of mental health on the OHQoL and oral hygiene has been proven. Therefore, developing integrated care programs, including regular oral health monitoring, nutritional counseling, and regular referral to a dentist, psychologist, and psychiatrist, and obtaining academic counseling during the high school years can be effective. Furthermore, informing families about the impact of mental health on oral health and the need to take care of them is of great importance.

The study has several strengths, including a relatively large sample size, the use of validated questionnaires (OHIP-14 and GHQ-28), and the investigation of an important but underexplored population group. Moreover, psychosocial and oral health dimensions association was evaluated to increase the public health relevancy. Nevertheless, using self-rated questionnaire was the limitation of this study.

Conclusion

The present study showed that more than 70% of high school students in Qom, Iran suffer from mild or moderate mental health disorders, which can be caused by university entrance exam anxiety. Moreover, the OHQoL in this group is not appropriate, and the prevalence of its disorders is higher than 50%, and a significant positive correlation was observed between poor mental health status and poor OHQoL. Considering the impact of demographic factors along with some socio-economic variables, it is of great importance to pay attention to the mental health of high school students who are experiencing high stress and anxiety due to entrance exams and final exams. Therefore, it is necessary to design therapeutic and educational interventions in adolescents and students, especially high school students, along with the necessary measures to improve their access to medical and preventive care, so that in addition to improving the level of oral health, prevention and control of dental caries led to improving the OHQoL.

Abbreviations

OHQoL

Oral health-related quality of life

OHIP-14

14-item Oral Health Impact Profile-14

GHQ-28

General Health Questionnaire- 28 items

SPSS

Statistical Package for Socia Sciences

DMFT

Decay, Missed, Filled Tooth

OIDP

Oral Impacts on Daily Performances

Authors’ contributions

All authors worked on manuscript preparation and final approval of manuscript. **AMB and SM: ** data collection, data entry and data analysis. **AMB and AM** study concept and design, management. **AMB and AM** analysis and interpretation of data, critical revision of the manuscript for important intellectual content. **SM and AMB** : statistical analysis and interpretation of data.

Funding

This study received finding from Qom University of Medical Sciences.

Data availability

The data supporting the findings of this study are available from the corresponding authors upon request.

Declarations

Ethics approval and consent to participate

The human ethics and consent to participate declarations elaborated for all subjects for confidentiality of the information, and if every student signed the informed consent for participation, they have included in the study.

Consent for publication

Informed consent to participate in the study obtained from all students. They were between 17 and 19 years old.

Competing interests

The authors declare no competing interests.