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ORIGINAL ARTICLE
Year : 2020  |  Volume : 38  |  Issue : 1  |  Page : 14-19
 

The prevalence of molar incisor hypomineralization of school children in and around Muvattupuzha, Kerala


1 Department of Pedodontics and Preventive Dentistry, Annoor Dental College, Muvattupuzha, Kerala, India
2 Department of Public Health Dentistry, Mar Baselios Dental College, Kothamangalam, Kerala, India

Date of Submission27-May-2018
Date of Decision14-May-2019
Date of Acceptance18-Oct-2019
Date of Web Publication12-Mar-2020

Correspondence Address:
Dr. Tharian B Emmatty
Department of Pedodontics and Preventive Dentistry, Annoor Dental College, Muvattupuzha, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_152_18

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   Abstract 


Background: Molar incisor hypomineralization (MIH) is a developmental dental defect and has a significant impact on the quality of life of affected individuals. Most of the prevalence studies of MIH have been carried out in the European countries; very little data are available from India. Aim: The aim and objective of this study was to determine the prevalence of MIH in 8–15-year-old Malayalee school children in and around Muvattupuzha, Kerala. Settings and Design: A cross-sectional epidemiological study was conducted in 5318 healthy Malayalee school children aged between 8 and 15 years in and around Muvattupuzha. Materials and Methods: The first permanent molars (FPMs) and all permanent incisors were examined for MIH using the European Academy of Paediatric Dentistry 2003 diagnostic criteria. The severity of hypomineralization was recorded according to the Wetzel and Reckel scale. Statistical Analysis: The data were analyzed using the Statistical Package for the Social Sciences software version 20.0, and a comparison between groups was carried out using the Chi-square test. P ≤ 0.05 was considered for statistical significance. Results: A total of 216 children were diagnosed with MIH. The maximum MIH-affected tooth was found to be mandibular right FPM (186), followed by mandibular left FPM (172), maxillary left FPM (160), and maxillary right FPM (156). Conclusion: The prevalence of MIH in permanent dentition of Malayalee school children in and around Muvattupuzha was 4.1%. Among the MIH-affected children, very few have undertaken dental treatment for the same. Hence, proper awareness and planned preventive and restorative programs are required to minimize the problem.


Keywords: Molar incisor hypomineralization, posteruptive enamel breakdown, prevalence, severity


How to cite this article:
Emmatty TB, Eby A, Joseph MJ, Bijimole J, Kavita K, Asif I. The prevalence of molar incisor hypomineralization of school children in and around Muvattupuzha, Kerala. J Indian Soc Pedod Prev Dent 2020;38:14-9

How to cite this URL:
Emmatty TB, Eby A, Joseph MJ, Bijimole J, Kavita K, Asif I. The prevalence of molar incisor hypomineralization of school children in and around Muvattupuzha, Kerala. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2020 Jul 11];38:14-9. Available from: http://www.jisppd.com/text.asp?2020/38/1/14/280507





   Introduction Top


Tooth development may be influenced by various genetic and environmental factors during, before, or after birth.[1] Enamel is a unique hard tissue which does not undergo remodeling like bone, and as a result, the structure of enamel is affected during its formation permanently. During the various stages of enamel formation, there can be interruptions.[2]

The permanent first molar (PFM) is one of the first permanent teeth to erupt in oral cavity and a cornerstone tooth in function and occlusion.[3] They exhibit a greater control over the teeth that erupt later. In the oral cavity, they are positioned in such a way that they influence the vertical distance of the maxilla and mandible, the occlusal height, and esthetic proportions. The premature loss of these teeth will lead to adverse impacts on the dental arch in both function and occlusion.[3],[4] The PFMs are considered the most caries-susceptible teeth in the permanent dentition because of their early eruption, high load of mastication, long calcification period, deep pits and fissures, high cariogenic dietary habits, poor oral hygiene practice, lack of parental awareness about the time of eruption and its importance in the dentition, and parental concept that the first permanent molars (FPMs) might be a deciduous tooth and have a predecessor.[4],[5],[6] In children, maxillary permanent incisors are more prone to traumatic dental injuries and fracture[7] which may lead to pain, infection, poor esthesis, and speech defects and thus affect the child's quality of life.[8],[9] A prevalent factor that predisposes these teeth to caries and fracture, which is also the most frequently unrecognized or overlooked condition, is a developmental enamel defect, referred to as molar incisor hypomineralization (MIH).[5]

MIH is getting the attention among epidemiologists and clinicians worldwide due to its widespread presence and long-term clinical impact which can affect the quality of life of candidates involved.[10],[11],[12] The characteristic feature of MIH is a clear demarcation between the affected and sound enamel. Radiographic evaluation of the affected tooth may show normal morphology of the crown, but reduced enamel opacity, which may be similar to that of dentine.[13]

The very first epidemiological study describing this condition as “idiopathic enamel hypomineralization” was reported from Sweden.[12] The reported prevalence rates showed a wide range from 2.8% (Hong Kong)[14] to 40.2% (Brazil).[15] Prior to the establishment of the European Academy of Paediatric Dentistry (EAPD) 2003 criteria[16] for the diagnosis of MIH, there have been misinterpretations in the prevalence values. Most of the prevalence studies of MIH have been carried out in European countries.[10] Although few prevalence reports have been noted in India, not many have come from Kerala mapped under the EAPD 2003 guidelines. Hence, the present study attempted to determine the prevalence of MIH in 8–15-year-old Malayalee children studying in schools in and around Muvattupuzha, Kerala, and to determine the distribution/clinical characteristics of MIH.


   Materials and Methods Top


The present study was approved by the institutional ethical committee and concerned school authorities prior to the commencement of the study.

Muvattupuzha is a municipality in the eastern side of Ernakulam district, Kerala. It is the merger place of three rivers, namely Thodupuzha River, Kaliyar River, and Kothayar River. The confluence of these three rivers is called Muvattupuzha. Muvattupuzha municipality has a population of 29,230; males constitute 49% and females 51%, with a literacy rate of 86%.

The study population comprised of 5318 (2705 males and 2613 females) children in the age group of 8–15 years from 17 schools (9 government/government-aided schools and 8 private schools) in and around Muvattupuzha. Multistage cluster sampling technique was applied to select the study population. In the first stage of sampling, Muvattupuzha educational subdistrict was divided into four zones, namely North, South, East, and West, to meet geographic requirement. In the next stage of sampling, two government/government-aided schools and two private schools were randomly selected from each zone except for South Zone, wherein three government/government-aided schools were selected to meet adequate proportion. In the third stage of sampling, from each selected school, one division from each standard (from third standard to tenth standard) was randomly selected. Children who were native of Kerala were included in the study.

The oral examination was carried out by a single trained calibrated examiner under natural daylight with sterilized disposable mouth mirror and blunt probe. Intraexaminer reliability kappa value was 0.84 in this study. The examination chart contained a section of demographic variables such as name, age, gender, school, and a chart for entry of the diagnosis and severity of MIH. The indexed teeth considered were permanent eight incisors and four FPMs. MIH was diagnosed clinically based on the diagnostic criteria established by the EAPD 2003.

The EAPD criteria 2003 for the diagnosis of MIH were as follows:[16]

  • 0 – Normal
  • 1 – Demarcated opacity: A demarcated defect involving an alteration in translucency of the enamel, variable in degree. The defective enamel is of normal thickness with a smooth surface and can be white, yellow, or brown in color
  • 2 – Posteruptive enamel breakdown: A defect that indicates deficiency of the surface after eruption of the tooth. Loss of initially formed surface enamel after tooth eruption. The loss is often associated with a preexisting demarcated opacity
  • 3 – Atypical restorations: The size and shape of restorations are not conforming to the temporary caries picture. In most cases in molars, there will be restorations extended to the buccal or palatal smooth surface. At the border of the restorations frequently, an opacity can be noticed. In incisors, a buccal restoration can be noticed not related to trauma
  • 4 – Extracted molar due to MIH: The absence of a FPM should be related to the other teeth of the dentition. Suspected for extraction due to MIH are opacities or atypical restorations in other FPMs combined with the absence of a FPM. Furthermore, the absence of FPMs in a sound dentition in combination with demarcated opacities on the incisors is suspected for MIH. It is not likely that incisors will be extracted due to MIH.


The exclusion criteria were children with non-Keralite origin, generalized hypoplasia, amelogenesis imperfecta, dentinogenesis imperfecta, tetracycline or diffuse hypoplasia like fluorosis, grossly broken and missing PFM where the reason of MIH could not be established, and children with special health-care needs.

The severity of hypomineralization was also recorded according to the Wetzel and Reckel scale.[17]

  • Degree 1 (mild): Isolated white and cream to yellowish-brown discolorations on the chewing surface and upper part of the crown
  • Degree 2 (Moderate): Hypomineralized yellowish-brown enamel affecting more or less all the humps on top of the crown but with only a slight loss of substance
  • Degree 3 (severe): Large-scale mineral deficiency with distinct yellowish-brown discolorations and defects in crown morphology resulting from extensive loss of enamel.


Statistical analysis

The data were analyzed using the Statistical Package for the Social Sciences software version 20.0 for Windows (SPSS Inc., Chicago, IL, USA). A descriptive analysis of the prevalence and distribution of the clinical recordings was performed. A comparison between groups was carried out using the Chi-square test. For all tests, P ≤ 0.05 was considered to be of statistical significance.


   Results Top


Prevalence of molar incisor hypomineralization

Out of 5318 children (2705 males and 2613 females) examined, 216 (120 males and 96 females) were diagnosed with MIH revealing a prevalence of 4.1% in and around Muvattupuzha, Kerala. Among the MIH-affected students (216), there was no statistically significant difference between the males (120) and females (96) but more frequently observed in males than in females (P = 0.16).

Prevalence of molar incisor hypomineralization according to age

The prevalence of MIH was highest among 8-year-old children (8.8%) and the least prevalence was seen in 14-year-old children (0.41%) [Table 1].
Table 1: Prevalence of molar incisor hypomineralization according to age

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Prevalence of molar incisor hypomineralization in private and government schools

The prevalence of MIH in government/government -aided schools and private schools showed that 4% of MIH-affected children in both schools [Figure 1].
Figure 1: Prevalence of molar incisor hypomineralization in private and government schools

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Individual prevalence of molar incisor hypomineralization for index teeth

Index teeth considered for evaluation were maxillary and mandibular incisors (centrals and laterals) as well as the maxillary and mandibular FPMs. The result shows a maximum prevalence in mandibular right FPM followed by mandibular left FPM, then maxillary left and right FPM, maxillary right and left central incisor, mandibular left and right central incisors, maxillary right lateral incisors and left lateral incisors, and finally, mandibular left and right lateral incisors [Table 2].
Table 2: Individual prevalence of molar incisor hypomineralization for index teeth

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Prevalence of molar incisor hypomineralization in molars and incisor teeth

More number of MIH-involved molar teeth were found among mild and severe groups, whereas incisor teeth were predominated in the mild group. Comparing the total number of molar teeth versus incisors, more MIH involvement was seen in molar teeth with a statistically significant difference between the incisors (P ≤ 0.00001) [Table 3].
Table 3: Prevalence of molar incisor hypomineralization in molars and incisor teeth with degree of severity

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Prevalence of molar incisor hypomineralization on the right and left halves of the jaw (face)

MIH was more observed on the right side of the jaw (609) when compared with the left side (599), and there was no statistically significant difference between them. In all categories of degree of severity, i.e.; mild, moderate, and severe, MIH was more observed on the right side (mild = 408 [67%], moderate = 89 [14.6%], and severe = 112 [18.4%]) when compared to the left side (mild = 407 [68%], moderate = 84 [14%], and severe = 108 [18%]).

Prevalence of molar incisor hypomineralization-affected teeth in maxilla and mandible

The distribution of MIH shows that maxillary teeth (619) were more involved than mandibular teeth (589), but there was no statistically significant difference between them. The mild and moderate defects were more seen in the maxilla (mild = 423 [68.3%], moderate = 93 [15.02%], and severe = 103 [16.64%]), whereas severe defects were more seen in the mandible (mild = 392 [66.5%], moderate = 80 [13.6%], and severe = 117 [19.9%]).

Prevalence of molar incisor hypomineralization in maxillary and mandibular incisor teeth

The maxillary incisors were more involved than mandibular incisors in all groups, and there was a statistically significant difference between MIH-affected maxillary incisors and mandibular incisors [Table 4].
Table 4: Prevalence of molar incisor hypomineralization in maxillary and mandibular incisor teeth with degree of severity

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Prevalence of molar incisor hypomineralization in maxillary and mandibular molar teeth

Comparing the MIH-affected maxillary molar teeth with mandibular molar teeth, more MIH involvement was seen in mandibular molars (358) than in maxillary molars (316), but there was no statistically significant difference. In all categories, i.e.; mild, moderate, and severe, the severity of hypomineralization was more observed on mandibular molars (mild = 188 [52.5%], moderate = 54 [15.1%], and severe = 116 [32.4%]) when compared to maxillary molars (mild = 173 [54.8%], moderate = 49 [15.5%], and severe = 94 [29.7%]).


   Discussion Top


MIH is taken into consideration a task in dental practice both for the dentist and the affected person. Early diagnosis is important to prevent extensive enamel breakdown and severe complications due to MIH. The importance of early diagnosis stresses the need for prevalence data in India, but only a few studies have been reported. As per the available literature, there are very limited studies regarding the prevalence of MIH in Kerala. Keeping these facts in mind, a cross-sectional epidemiological study was conducted to report the prevalence rate and characteristics of MIH in and around Muvattupuzha, Kerala (South India).

The examination of the entire study population was carried out by a single calibrated examiner experienced in clinical diagnosis of MIH. Thus, the diagnostic criteria are reliable and may have produced true prevalence data.

Even though most of the MIH studies were conducted in children of age group 8–12 years, the age group selected in this study was 8–15 years because at this age, all the four PFMs as well as the incisors would have erupted for most children[14],[15] and also to assess the prevalence and degree of severity of MIH in older children and subsequent need for early treatment.

Wide ranges of MIH prevalence have been reported across the globe ranging from 2.8% to 40.2%.[14],[15] The reason for variations of MIH prevalence could be due to difference in ethnicity, sample size, recording methods, diagnostic criteria used, and age group.[18],[19] In the present study, the prevalence of MIH was found to be 4.1%. This was significantly less when compared to the prevalence reported in other regions of India (10.48% in Gautam Buddh Nagar,[20] 9.46% in Udaipur,[21] 14.9% in Jammu,[22] 8.9% in Davangere,[23] and 9.7% in Chennai[24]). At the same time, the current study prevalence is at par with studies conducted in Tiruchengode, India[25] (5.25%), Suzhou, China[26] (4.45%), and Plovdiv, Bulgaria[27] (3.58%). The number of children examined in the present study was high (5318) when compared to other studies conducted in India, probably the reason why the present study achieved lesser prevalence.

We found no significant difference between male and female children diagnosed with MIH, which was in agreement with other prevalence studies.[14],[28],[29] However, male children showed a slightly high incidence of MIH as compared with female children, which is in agreement with the preceding studies.[15],[17],[21],[30],[31],[32],[33] Studies on Australian[34] and Jordanian[35] children, however, have reported a higher prevalence in girls.

In this study, the distribution of MIH was more in 8 years of age, whereas the least affected age group was 14 years. The findings of this study differ from previous reports,[24],[33] where MIH was more in 10 years of age and least at 12 years of age. This could have been because more number of children were screened at 8 years of age (1060 children) in the present study.

Evaluating the results based on socioeconomic status, 48 children in government/ government-aided schools out of 1,187 children who were screened and 168 children in private schools out of 4,131 students who were screened, had MIH. There is no significant difference based on socioeconomic status, which was in agreement with studies on Wellington[36] and Chennai[24] children.

The present study showed a statistically significant difference when MIH-affected molars are compared with that of incisors, and this is in agreement with Kirthiga et al.[23] and Yannam et al.[24] The prevalence of MIH on the right and left halves of the jaw shows no significant difference similar to the findings by Yannam et al.[24] The severity chart of MIH-affected teeth showed that great majority belonged to a mild form of MIH. This is in agreement with that of previous studies.[23],[24],[37]

In the present study, in total, more maxillary teeth (619 teeth) were affected when compared to the mandibular teeth (589), which was in accordance with the Swedish and Chennai population study.[24],[28] However, when molars were evaluated, mandibular molars were more affected than maxillary molars. Similar findings were reported in previous studies[11],[20],[21],[32],[33],[38] but contradict with studies conducted in Iraqi,[31] German,[17] Greek,[37] and Nepali[39] children where maxillary molars are more affected than mandibular. The reason for this discrepant observation remains doubtful. It could be due to differences in examination conditions which may make it difficult to view maxillary molars as clear as mandibular molars and also early eruption of mandibular molars with resultant early posteruptive enamel breakdown.[21],[35]

When incisors were considered, maxillary incisors were more frequently affected, and there was a statistically significant difference between MIH-affected maxillary and mandibular incisors, which is in agreement with most of the studies on different population.[14],[17],[21],[24],[31],[32],[33],[37] The loss of tooth structure in these teeth may be due to abrasive toothbrushing.[30]


   Conclusion Top


The prevalence of MIH in permanent dentition of Malayalee schoolchildren aged between 8 and 15 years in and around Muvattupuzha was 4.1%. In this study, the mandibular right FPMs are most commonly affected, and the mild form of MIH was more found. Most of the MIH-affected children are unaware about the disease and its treatment modalities. MIH is a frequently occurring developmental dental anomaly in children with vast complications. Hence, early diagnosis and properly planned preventive and restorative programs are needed to combat the risk.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of ineterest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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  2005 - Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 
Online since 1st May '05