OBJECTIVES: To evaluate the associations between oralhealth-related quality of life (OHRQoL) and emotionalstatuses in children and preadolescents.METHODS: One hundred and forty-five Brazilian students(8–14 years) were clinically examined for caries,gingivitis, fluorosis, malocclusions, and temporomandibulardisorders (TMD). OHRQoL was measured using twoglobal ratings of oral health (OH) and overall well-being(OWB). The Revised Children’s Manifest Anxiety Scale(R-CMAS) and Children’s Depression Inventory (CDI)were used to assess anxiety and depression, respectively.Saliva was collected 30 min after waking and at night todetermine the diurnal decline in salivary cortisol (DDSC).The results were analyzed using non-paired t test ⁄ onewayANOVA, Pearson’s correlation test, and multiplelinear regression analyses.RESULTS: 11–14-year-old participants had higher CDIscores (P < 0.01) and DDSC concentrations (P < 0.001).Participants with fewer caries and without gingivitis hadhigher DDSC concentrations (P < 0.05). TMD patientshad higher DDSC concentrations and OWB ratings(P < 0.001). Girls had higher Revised Children’s ManifestAnxiety Scale (RCMAS) scores (P < 0.01). There waspositive correlation between RCMAS and CDI scores andOWB ratings (P < 0.05). The OH model retained age (b=0.312; P < 0.001) and the OWB model retained TMD(b = 0.271; P < 0.001) and CDI scores (b=0.175; P < 0.05).CONCLUSIONS: Children and preadolescents with pooremotional well-being are more sensitive to the impacts ofOH and its effects on OWB.Oral Diseases (2012) 18, 639–647Key words: anxiety; child; depression; oral health-related qualityof life; preadolescent; salivary cortisolIntroductionOver the past two decades, subjective oral healthindicators have been used to assess and compare theimpact of oral disease across populations. Oral healthrelatedquality of life (OHRQoL) in child and adolescentpopulations has been of particular interest because oraldisorders may produce many symptoms that havephysical, social, and psychological effects and influenceday-to-day living or quality of life (QoL) in this agegroup (McGrath et al, 2004). A recent review of theOHRQoL literature in pediatric patients showed that,for the most part, studies have focused on the associationsbetween clinical variables and OHRQoL (Barbosaand Gavia˜ o, 2008) with little emphasis on the underlyingpsychological characteristics of the patients. This findingis surprising because studies have shown that oralconditions mainly affect socio-emotional aspects ofwell-being in this population (O’Brien et al, 2007). Ameta-analysis concluded that determinants of QoL aremainly psychological, further supporting the importanceof psychological factors in mediating patient-centeredQoL outcomes (Smith et al, 1999). Accordingly, it is notunusual to find only modest associations betweenclinical indicators and child-reported OHRQoL. Thisfinding is consistent with anecdotal clinical experience(Agou et al, 2008); some children are very unhappyabout relatively mild oral diseases, while paradoxically,others are tolerant of severe oral conditions (Barbosaet al, 2009). This finding is also consistent with theoreticalmodels of disease, which posit that health outcomesexperienced by an individual are determined not only bythe nature and severity of the disease but also bypersonal and environmental characteristics (Wilson andCleary, 1995).According to Kressin et al (2001), the accurateinterpretation of OHRQoL measures requires an understandingof not only the properties of OHRQoLmeasures but also contextual factors that might influencesubjects’ assessments of their health and well-being.Previous studies have suggested that psychologicalattributes, such as self-esteem, may be predictive of theeffect of health conditions on the QoL of children and