Hind Nsour BDS*, Nader Masarwa BDS *, Hytham Al-Rabadi BDS *, Tamara Alzoubi BDS *, Ahmad S Aladwan BDS *

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1 Prevalence, etiology, severity and treatment of Molar Incisor Hypomineralization for 7 to 9 years old children attending Royal Medical Services clinics in Amman Jordan Hind Nsour BDS*, Nader Masarwa BDS *, Hytham Al-Rabadi BDS *, Tamara Alzoubi BDS *, Ahmad S Aladwan BDS * ABSTRACT Objectives: To assess the prevalence, etiology, severity and treatment approaches for schoolaged children, with Molar Incisor Hypomineralization (MIH) and live in Amman - Jordan. Methods: Six hundred children, aged from seven to nine years old, were examined by experienced dentists. The severity and distribution of enamel defects were analyzed, and treatment performed for the MIH affected teeth was recorded. Prenatal and postnatal medical records were reviewed to identify several etiological factors, including high fever, maternal chronic diseases, Cesarean Section and complicated deliveries, and neonatal hospitalization. Analysis of data was performed with p-value set at Results: The prevalence of MIH in patients was 17.3, where 80.8 of the affected children recorded various medical problems associated with the condition either at prenatal, perinatal or postnatal period. 54 of the affected children had more than one medical problem throughout different chronological periods, such as patients having postnatal high fever and complicated delivery. The majority of the affected children had postnatal medical problems. The white creamy discolorations on the chewing surface and coronal third of the crown formed majority of defects; affecting 81 of children of affected children with MIH have only molar hypomineralization with no incisors affected of patients with MIH have all four first permanent molars affected.in 71.2 of the cases, teeth were mostly treated by composite fillings. Conclusion: MIH is a prevalent finding in Amman. It could be due to different causative disturbances that could take place at different chronological periods. Structural defects vary according to the degree of severity, and there are different clinical management strategies utilized to treat this condition. Key words: Etiology, Molar Incisor Hypomineralization, Treatment. JRMS April 2018; 25(1):70-77/DOI: / Introduction Molar incisor hypomineralization (MIH) is defined by European Academy of Pediatric Dentistry (EAPD)as enamel hypomineralization of unclear origin, of 1 to 4 permanent first molars, frequently associated with affected incisors (1). This qualitative defect of enamel can be clearly identified based on the EAPD criteria, and From Department of: * Dentistry, Royal Medical Services. Correspondence should be addressed to Dr. Hind Nsour, nsourhind@yahoo.com Manuscript Received Aug 17,2017,Accepted May 10,2018. according to the degree of severity. This severity can be seen as demarcated creamy white, yellowish brown opacities with/without post-eruptive breakdown (PEB) or as an atypical restoration found on any of the first permanent molars (FPMs) (2,3). The degree of severity usually ranges from the distinct mild opacity to the moderate severe defects; involving enamel breakdown and 70

2 atypical restorations (4). This variation is not only between patients, but within the patients themselves as asymmetrical pattern in the patients dentition (5). Many studies have been conducted worldwide among pediatric dental patients in order to review the prevalence of this condition. It was found that there was great variation in the prevalence among the population ranging from 2.4 to 40.2 (6). Genetically, the process of amelogenesis is highly regulated, but sensitive to environmental disturbances. Researchers suggested that these qualitative defects are due to the disruption at the late maturation stage of amelogenesis (7). The associated etiological factors causing MIH are complex and still not well identified. In addition to the genetic factors, the environmental influences encountered during the third trimester of pregnancy till the third year of age highly contribute to MIH defects. This is considered to be a sensitive stage of mineralization of the first permanent molars and incisors crowns (8). According to the timing of systemic insults, possible etiological factors can be divided into prenatal, perinatal and postnatal medical conditions. Finding and providing treatment for MIH patients is considered a challenge for both patients and dentists, since restorative and esthetic needs can be complex (3). Since there are no consistent clinical management strategies for such cases, treatment plan ranges from prevention, restorations to extractions. The aim of the study is to determine the prevalence, possible etiological factors, degree of severity and treatment of MIH for children aged seven to nine years old in Amman, Jordan. Methods Study Population A cross sectional study was conducted on a random sample of 870 normal healthy school children, aged 7 to 9 years, having MIH or MH, residing in all regions of Amman, and attending two military medical centers located in the East and West regions of the city. Patients are considered a mixture of all layers within the society, with different backgrounds, income and educational levels. Total of 600 children were involved in the study based on the selected inclusion criteria. The sample size was calculated with a confidence level of 95 and a relative precision of 5. Exclusion and Inclusion Criteria Children presented with demarcated defect on at least one surface of any of their permanent molars, whether the incisors were affected or not, were involved within our criteria. The most severe defects detected on permanent incisors and first permanent molars of more than 2mm were registered. Note that all teeth had to be wet at the time of the examination. Children without informed consent, or with hypodontia, anodonita, amelogenesisimperfecta, fluorosis, or those having fixed appliances were excluded from the study. Examination and Data Collection Data was collected in a record chart designed for the study. The patients age, gender and teeth affected were recorded. Based on EAPD criteria (3), defect types and severity were recorded. Mild defects presented with demarcated enamel opacities without enamel breakdown and are associated with occasional sensitivity. However, severe defects presented as demarcated opacities with enamel breakdown, spontaneous sensitivity, and affecting aesthetic and function. Possible etiological factors of the condition were also recorded. Information on maternal medical status during pregnancy as maternal chronic diseases, perinatal complications as premature birth or complications during delivery, as well as the child s birth weight and medical history from birth till the 3 rd year of life was also registered. The association of risk factors was based on the ability of the mother to recall the history of pregnancy and the occurrence of early childhood illness, as well as tracking the timing of the etiological factors retrospectively from medical records. The type of treatment performed with different management strategies of MIH affected teeth were registered. The treatment involved prevention, restorations or extractions. 71

3 Examiners Calibration A record chart was discussed with experienced examiners in diagnosis and management of MIH cases. This chart included several photographs and clinical images. All examiners confirmed the suitability of the chart for the diagnosis of MIH cases. The diagnosis agreement resulted in excellent intra and interexaminer reliability (Kappa coefficient 0.9). Ethical Considerations Prior to conducting the study, informed consent was obtained by patients parents or guardians, and an approval from the Ethics and Research Board review committee of the Jordanian Royal Medical Services was also obtained. For de-identification purposes, all personal information of the patients was hidden in order to secure their privacy. Statistical Analysis Data obtained were subjected to statistical analysis, using SPSS (version 20.0). Descriptive statistics were performed. Differences were considered to be statistically significant (student t-test with P value <0.05). Results Out of the 600 children examined, 104 (17.3) were affected by MIH, while (11.3) were having only molar hypomineralization (MH) with no incisors affected. There was no statistically significant gender differences in MIH prevalence between males and females (8.2 and 9.2 respectively) as p value was calculated to be > (Table I). According to the timing of the insult, possible etiological factors were divided into prenatal, perinatal or postnatal problems. 20 out of the 104 affected children (19.2) had no significant medical conditions associated with MIH lesions, while 84 children (80.8) had related medical factors.54 (56 cases) of the affected children appeared to have medical problems in more than one chronological period. Table II shows the majority of children (135 cases) recorded postnatal problems, while etiological factors duringthe prenatal period produced the fewest cases of MIH compared with the other two periods. In the postnatal period, the possible main cause of this condition appeared to be the recurrent episodes of high fever affecting 29.6 of the overall sample (135 cases). In perinatal period, the main cause was the caesarean section (CS) delivery that affected 41.5 of the 41 cases affected at this stage. In prenatal period, the most common cause of this condition was the recurrent episodes of maternal high fever affecting 33.3 of the affected 15 cases. The most common lesion type was the mild one with the creamy white demarcated opacities found in 81 of the affected children. Upper right first permanent molars were the most frequently involved (Table III). Table IV shows the frequency of MIH affected teeth in relation to the number of affected children of the affected children were presented only with molar hypomineralization and with no incisors affected of the affected children have all four first permanent molars involved. Majority of children (71.2) having this condition were treated by applying composite fillings and 55.8 were treated by Fluoride application. Extraction was considered in only 19.2 of the affected children (Table V). Table I: Distribution of Children having MIH and MH Male N Female N Total N Number of Children Examined 348 (58.0) 252 (42.0) 600 (100) Number of Children with molar incisor 49 (8.2) 55 (9.2) 104 (17.3) hypomineralization MIH Number of Children with molar hypomineralization (without incisors) MH 34 (5.6) 34(5.6) 68 (11.3) 72

4 Table II : Distribution of affected children in relation to timing of the etiological factor Prenatal Etiology Perinatal Etiology Postnatal Etiology 15 cases 41 cases 135 cases Possible etiological factor Count Pre MIH Group Count Peri MIH Group High fever Medication during last month Maternal Chronic Diseases (HTN, DM) Others (Chickenpox, Malnutrition, Vomiting) Total CS Delivery Complicated Delivery Premature Low birth weight Count Post MI H Gro up Total High fever Otitis Bronchitis Asthma Tonsillitis Neonatal (Hospitalization, Incubator, other) Prolong use of medication Seizures Antibiotics Use Prolonged breast feeding Table III: Clinical appearance and characteristics of MIH defects in study population Lesion Type Count n Teeth Mostly Affected* Total Teeth Least Affected* Demarcated Creamy-White Demarcated Yellow-Brown Post Enamel Breakdown Atypical Restoration *Tooth numbering is according to FDI system 73

5 Table IV : No. of affected children in relation to the frequency of MIH affected teeth Number of children with affected molars n Number of affected One molar Two molars Three molars Four molars Total incisors Zero 16 (15.4) 8 (7.7) 10 (9.6) 34 (32.7) 68 (65.4) One 8 (7.7) 6 (5.8) 4 (3.8) - 18 (17.3) Two 5 (4.8) 1 (1.0) 4 (3.8) 4 (3.8) 14 (13.5) Three 1 (1.0) 1 (1.0) - 1 (1.0) 3 (3.0) Four (1.0) 1 (1.0) Total 30 (28.8) 16 (15.4) 18 (17.3) 40 (38.5) 104 (100) Table V: Type of treatment performed for molars and incisors in affected children Filling Type Count n Teeth Mostly Treated* Teeth Least Treated* Glass Ionomer /31 Cement Composite /36 Stainless Steel Crown Amalgam Filling /36 - Extraction Fluoride Varnish *Tooth numbering is according to FDI system Discussion This study comprised children from seven to nine years old as this age is the optimal age for clinical examination of MIH defects recommended by the EAPD experts (1). It is the age where the first molars and incisors have already erupted in the mouth before being subjected to caries, post eruptive enamel breakdown, or large restorations that will make the identification process more difficult. Little information on the prevalence and etiology of this condition was found in the Middle East despite the large number of studies conducted worldwide (9,10). One of the studies showed that the pooled prevalence of MIH was 14.2 globally (11). Other studies showed that prevalence varied between 3.5 to 40.2 (12,13), while it was 17.3 in this study. There was no difference in MIH prevalence by gender. A cross sectional study on MIH prevalence in Jordan showed that MIH was common among Jordanian children of seven to nine years old with a prevalence of 17.6 and it was gender related (14). The prevalence of MIH observed in our study was close to that study and was within the range of values reported in Iraq (21.5) (15) and Spain (17.8) (16), but higher than that in Libya (9.0) (17). The prevalence however, was lower than that reported in Brazil (40.2) (13) and much greater than that in the Southeast Sweden (3.5) (12). Although some studies showed that MIH prevalence is gender related (14), the data obtained in our study were online with the data reported by many other authors; concluding that there is no difference in the MIH prevalence by gender (16,18,19). This wide variation in prevalence between different areas and countries could be attributed to different diagnostic measures, variations in the methods of investigation and recording, and variety of ages examined. In addition, the sociodemographic variability of the sample, and the ability to access the healthcare facilities in those areas easily could have an effect on this wide variation (6, 10). As data was collected from two medical centers located within Amman, children observed were residing mainly in Amman city, which might be considered a limitation, as it lacks the involvement of patients residing in other parts of the country. Some factors might have an impact on the study results, since patients living in Amman are considered more educated, and can access medical centers easily compared to others living in other parts of the country. Despite this, no previous studies in Amman city were conducted, and planning to perform similar study to cover the whole country might be useful in the future. MIH is most likely to be caused by several etiological factors (1), as both genetic and environmental factors can act together to increase the risk of having this condition (20). 74

6 Although the etiology is not yet fully known, the mineralization of the first permanent molars and incisors is known to be affected by insults at prenatal, perinatal or postnatal periods (10). In our study, the majority of children having MIH had postnatal problems (135 child), and the least number of children (15 child) had prenatal problems. This is similar to a study done by NA Lygidakis et alon Greek children; where prenatal problems were the least etiological factors involved (4). The recurrent episodes of high fever at postnatal period is commonly faced in our sample, affecting 29.6 of the 135 cases. This is similar to a study done by Silva MJ et al 2016,which concluded that early childhood illness like fever in particular appears to be greatly associated with MIH (21). During perinatal period, caesarian section was most common cause of increasing the risk of MIH; affecting 41.5 of the 41 children having MIH. This finding is in agreement with the results of other studies carried out in Greece (4), Iran (22), and in Thai children where the results of the study revealed that CS delivery was associated with twofold increase in the risk of MIH (23). Whereas in another Swedish study, there was no link between those two previous conditions (24). During prenatal period, the greater factor that contributes to this condition is found to be the recurrent episodes of maternal high fever affecting 33 of 15 affected children. Some studies connected maternal throat infections and high fever during pregnancy with MIH (20), while others did not specify any disease, but they correlated maternal illness during pregnancy with MIH defects in children (4,25). In this retrospective study, all efforts were made to get accurate and liable data from patients records. However, it also depended on parental recall in completing our questionnaire which may not be totally reliable. This is also considered a limitation for this study and for other similar studies (26). As for the severity of MIH enamel defects, teeth diagnosed with mild MIH involved having demarcated opacities that may not need treatment. Moderate MIH lesions involved teeth with broken and rough enamel, while severe defects involved lesions affecting enamel and dentine, atypical restorations or extracted teeth (27). The commonest lesion type was the mild one with the creamy white demarcated opacities affecting 81 of the affected children. This is similar to a study done in Jordan (14), and in other countries as Germany (28), Nigeria (19) and Austria (29), where the most common defects were the mild demarcated opacities. This presentation of the mild formula of MIH defects in Amman could be related to the patients socio-demographic distribution, mainly the middle and high socioeconomic status, where they are more aware and educated regarding the importance of attending multiple early checkup visits, oral hygiene measures and early treatments. Furthermore, their access to the healthcare services may be easier than others of affected children have all four first permanent molars involved, while 65.4 of the affected children have their molars affected with no incisors involvement. MIH presentation has asymmetrical distribution. In addition to the variation between number of affected teeth from patient to another, different presentation may be noticed in the mouth of the same individual. (5) 71.2 of the affected children were treated by applying composite restorations, 55.8 were treated by preventive measures as Fluoride varnish application, to desensitize teeth and prevent caries progression, while extraction was performed in only 19.2 of patients. In this study, most of the defects were mild in nature, and composite resin material was shown to have long term stability in MIH teeth compared to other restorative materials, with a success rate of 74 to 100 during a 4-year follow up period as it was shown in other studies (3,30). Conclusion MIH is common among seven to nine years old children in Amman city, with no sex predilection. It is of unknown multifactorial etiology; could be related to systemic insults affecting mothers or children at certain periods. It has no common pattern of presentation, and can be treated by different modalities according to its severity. References 75

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