DOI: 10.1111/ipd.
12271
Do parents and children perceive molar–incisor
hypomineralization as an oral health problem?
~ OLIVEIRA & ANA PAULA DIAS RIBEIRO
SORAYA C LEAL, TEREZA RAQUEL MOURAO
School of Health Sciences, University of Brasılia, Brasilia, Brazil
International Journal of Paediatric Dentistry 2016
Summary
Background. Very little is known about how
patients perceive molar–incisor hypomineraliza-
tion (MIH).
Aim. The aim of this study was to identify
whether parents and children perceive opacities
associated with MIH as an oral health problem.
Design. A case–control study was designed in
which 131 children diagnosed with MIH were
matched by age, sex, and school to 131 children
without MIH. The Child and Parent Questionnaire
about Tooth Appearance was used to assess reports
from parents, who were interviewed by telephone,
and children, who were interviewed on school pre-
mises. The Spearman correlation and Wilcoxon and
Fisher’s exact tests were used to assess the data.
Introduction
Molar–incisor hypomineralization (MIH) is
characterized by demarcated opacities associ-
ated with an enamel development defect that
can vary in size and colour1. In addition to
the clinical problems associated with MIH,
such as post-eruption enamel breakdown and
the higher chance of the development of cari-
ous lesions, it also compromises tooth appear-
ance2.
In the last decade, MIH has been described
as an oral health problem. The first report on
the condition was found in PubMed in 20013.
Since then, many aspects related to the prob-
lem have been investigated with emphasis on
MIH classification, prevalence, and aetiology.
Still, there are many gaps to be filled. Among
them, there is a need to assess how patients
Correspondence to:
Prof. Dra. S. C. Leal, Departamento de Odontologia,
Faculdade de Ci^ encias da Sa
ude, Universidade de Brasılia,
Campus Universit ario Darcy Ribeiro, Asa Norte, Brasilia,
DF 70910-900, Brazil. E-mail: sorayaodt@yahoo.com
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Results. For the first part of the questionnaire,
children avoided smiling because of the appear-
ance of their teeth, and mothers seemed to be
distressed by the appearance of their children’s
teeth (P < 0.05). For the second part, children
showed dissatisfaction with their ‘tooth align-
ment’ and ‘tooth discoloration’ compared with
the controls, while mothers were not satisfied
with their children’s tooth discoloration in com-
parison with controls (P < 0.05). Children and
mothers were concerned about tooth discol-
oration (P < 0.05).
Conclusion. Poor agreement was found between
the reports of children and their mothers, but
both children and mothers in the MIH group per-
ceived MIH opacities negatively in comparison
with controls.
perceive MIH and whether this perception
influences their well-being. The abnormal
appearance of the maxillary incisor teeth
because of trauma, enamel defects, and mor-
phology is associated with the level of patient
dissatisfaction and may negatively affect chil-
dren’s quality of life and their social interac-
tion4,5.
Historically, oral health was measured
exclusively through clinical criteria. This
meant that the impact of a condition on an
individual’s daily activities was not investi-
gated6. As a result, specific tools were devel-
oped to assess an individual’s self-perception
of oral health problems, physically, socially,
and psychologically. The results from studies
using these tools showed that oral health
problems such as dry mouth7 and toothache8
have a negative effect on people’s quality of
life, while other problems like fluorosis have
much less impact9.
The impact of MIH on patients’ quality of
life or whether they perceive it as an oral
health problem is not known. To answer
these questions, ideally, information should
1
2 S. C. Leal, T. R. M. Oliveira & A. P. D. Ribeiro
be gathered from both children (who are
affected by the condition) and their parents,
as the diagnosis of MIH is made when the
patient is too young to make important deci-
sions such as visiting a dentist by themselves.
Moreover, studies have shown that parents
and children usually have different views
about the same oral health problem10,11. Chil-
dren and adolescents perceive themselves and
the world according to their stage of develop-
ment, which might explain the commonly
observed disagreement between child and
parent. Nevertheless, age aside, the way peo-
ple perceive their body has a direct impact on
their well-being, something which should not
be neglected when a treatment decision is
made12.
A literature search indicated that no instru-
ment has yet been developed to assess how
patients perceive MIH. An instrument, how-
ever, exists to evaluate the perception of den-
tal fluorosis. The Child and Parent
Questionnaire about Tooth Appearance was
proposed by colleagues from the Oral Health
Research Institute of Indiana13 and has been
validated in English, Spanish, and Por-
tuguese14. Initially, the questionnaire was
validated simultaneously in two different
populations, in the USA and in Mexico,
showing that the instrument was able to
measure the same dimensions and related
issues in populations with different back-
grounds13. In Brazil, the questionnaire was
validated in a group of 12-year-old children
and their parents from two regions, showing
a high Cronbach’s alpha and interclass corre-
lation coefficient14. The main purpose of this
instrument was to measure concerns caused
by the perceptions of dental appearance of
both children and their parents. It was devel-
oped to address concerns and perceptions
about discoloration and other oral conditions,
including tooth colour. As yet, it has only
been tested in children with fluorosis, but it
does not exclude other problems involving
aesthetic issues. Taking into account that MIH
is an oral health problem that affects tooth
appearance, the instrument was considered
suitable for also investigating how children
and their parents perceive MIH and whether
the condition is a source of concern.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Therefore, the purpose of this study was to
assess whether MIH is perceived as an oral
health problem by patients and their families
and whether children and their parents share
the similar opinion about MIH and, finally, to
determine whether MIH is a concern when
perceived as an oral health problem.
Materials and methods
Sample selection
A case–control study was carried out in a
group of schoolchildren aged between seven
and 13 years from public schools in the low-
income suburb of Paranoa in the Federal Dis-
trict of Brazil. The sample was selected from
an epidemiological survey on dental caries
and molar–incisor hypomineralization that
included 1971 students in which 184 were
identified as presenting with MIH. From this
total, 131 children were included in the pre-
sent investigation, with the inclusion criterion
being that they were probably in contact with
their mothers. The control group was formed
by matching children without MIH consider-
ing school, age, and sex.
Carious lesions and MIH were registered
using the Caries Assessment Spectrum and
Treatment instrument15 and the EAPD crite-
ria16 by three trained and calibrated examin-
ers. In addition, children were grouped
according to MIH severity as follows: mild
(opacities without post-eruptive enamel
breakdown); moderate (opacities with post-
eruptive breakdown involving only enamel);
and severe (opacities with post-eruptive
breakdown involving dentine, atypical
restorations, and tooth extraction because of
MIH).
The study was approved by the Ethical
Committee of the Faculty of Health Science
of the University of Brasılia (FS 014/2011),
and all parents signed the informed consent.
Data collection
The Child and Parent Questionnaire about
Tooth Appearance was given to students and
mothers of both the MIH group and the con-
trol group. The questionnaire was divided

into three sections, including 12 items and
subitems. The first section was composed of
three questions assessing whether children
felt upset (physical domain), worried (psycho-
logical domain), or kept from smiling freely
(social domain) because of their tooth appear-
ance. For the first section, the answers ranged
from ‘nothing’ to ‘a lot’ (1–4). The second
section contained four subitems in which
children and parents were asked about their
perception of the pleasantness, alignment,
colour, and health of the children’s teeth and
whether their perception was a matter for
concern. For the first part of this section, the
answers ranged from ‘very attractive/aligned/
white and healthy’ to ‘very unattractive/
crooked/stained and unhealthy’ (1–5). In the
second part, concern was evaluated as yes or
no. Finally, the following sentence: ‘The col-
our of my teeth (or the teeth of my child) is
attractive and beautiful.’ was used to evaluate
the pleasantness of the child’s tooth colour.
The answers for this third section ranged from
‘totally agree’ to ‘totally disagree’ (1–5).
Children replied to the child’s version of
the questionnaire on the school premises
under the supervision of the evaluator.
Mothers were interviewed via telephone by
the same trained evaluator and replied to the
parent’s version of the questionnaire. At no
time, either children or mothers were
informed whether they or their children
presented with MIH.
Statistical analysis
The Spearman correlation was used to assess
responses of children and mothers in both the
patient and the control groups in relation to the
variable ‘tooth appearance’ for the three
domains (physical, psychological, and social). To
compare the answers regarding tooth pleasant-
ness, alignment, staining, and health, the score
distribution given by pairs of participants with
MIH and controls was assessed using the Wil-
coxon signed-rank test (a = 0.05). For the ques-
tions about the concern of children and parents
regarding the variables pleasantness, alignment,
staining, and health, the McNemar’s exact test
was used (a = 0.05). To analyse the degree of
agreement between the children and their
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
MIH perception 3
parents or guardians, the weighted kappa was
used for ordinal categorical variables and the
unweighted kappa coefficient was used for
dichotomous variables. Finally, the association
between concern about tooth discoloration and
the presence of opacities in the anterior teeth
and MIH severity scores was analysed using the
Spearman correlation.
Results
Sample descriptive analysis
A total of 262 children took part in this study:
131 children with MIH (cases) and 131 chil-
dren without the condition (controls). Of this
total, 138 (53%) were boys and 124 (47%)
were girls aged between seven and 13 years
(mean age = 9.61). Of the 131 children in the
group with MIH, 64 children (48.85%)
showed opacities in both molars and incisors,
while 67 children (51.15%) showed opacities
only in molars. All 64 children presented with
incisor opacities in the maxilla. Regarding the
MIH classification, 59 children (45%) pre-
sented with mild MIH, 19 children (14.5%)
presented with moderate MIH, and 53 chil-
dren presented with severe MIH (40.5%).
Questionnaire analysis
The first part of the questionnaire showed
that both the children and the mothers in the
MIH group were not as satisfied as those from
the controls, at least for one domain (Spear-
man’s correlation; P < 0.05). The children
said that they avoided smiling because of the
appearance of their teeth, and the mothers
were distressed by the aspect of their chil-
dren’s teeth (Table 1).
In regard to the second section of the ques-
tionnaire, the answers of the children and the
mothers in the MIH group and in the control
group were compared, and the results are
presented in Table 2. Children with MIH dif-
fered statistically in their perception of the
variables tooth alignment and tooth discol-
oration compared with those in the control
group, while mothers in the MIH group dif-
fered in opinion from mothers in the control
group as to tooth discoloration. When the
4 S. C. Leal, T. R. M. Oliveira & A. P. D. Ribeiro

Table 1. Comparison between responses of cases and The degree of concordance between the
controls (children and mothers) regarding the first section
of the questionnaire.
information reported by children and that
reported by their mothers regarding areas of
Questions Children Mothers concern, perception of appearance, and satis-
faction with tooth colour was also investi-
1) How upset have you been P = 0.329 P = 0.029*
about the way your teeth look?
gated, and the results showed poor
2) How much has the way P = 0.623 P = 0.107 concordance (Table 3).
your teeth looked worried you? Regarding the MIH group, the concern with
3) How much has the way P = 0.044* P = 0.924
your teeth look kept you
tooth discoloration associated with the pres-
from smiling freely? ence of opacities in the anterior teeth and
with the severity (mild, moderate, or severe)
Spearman correlation; *indicates statistical difference between of MIH was also investigated. Of the 131 chil-
cases and controls.
dren with MIH, 64 (48.85%) showed opaci-
ties in the anterior teeth. Of these 64
Table 2. Comparison between the scores given by cases children, 29 (45.31%) were diagnosed with
and controls (children and mothers) for the variables
satisfaction with ‘tooth pleasantness’, ‘tooth alignment’,
mild MIH, 9 (14.06%) with moderate MIH,
‘tooth discolouration’, and ‘tooth health’ and the concern and 26 (40.63%) with severe MIH. No associ-
with these variables. ation between concern about tooth discol-
oration and the presence of opacities in the
Item Children Mothers
anterior teeth and with the severity of MIH
Tooth pleasantness P = 0.357◆ P = 0.338◆ was observed for children or parents
Concern with tooth P = 0.0627* P = 0.0186* (Table 4).
pleasantness (OR = 1.71; (OR = 2.13;
CI = 0.97–3.0) CI = 1.12–4.24)
Tooth alignment P = 0.020◆ P = 0.152◆
Discussion
Concern with tooth P = 1.00* P = 0.6889*
alignment (OR = 1; (OR = 0.87;
In general, this study has shown that children
CI = 0.60–1.66) CI = 0.49–1.51)
Tooth discolouration P = 0.028◆ P = 0.000◆ with MIH and their mothers perceived the
Concern with tooth P = 0.0295* P = 0.0002* condition as an oral health problem. In that
discolouration (OR = 1.76; (OR = 2.68; regard, it is important to highlight that nei-
CI = 1.05–3.00) CI = 1.56–4.81)
Tooth health P = 0.389◆ P = 0.192◆ ther group of children and mothers knew
Concern with P = 0.1925* P = 0.1114* whether the children had been diagnosed as
tooth health (OR = 1.46; (OR = 1.67; having MIH. This information was provided
CI = 0.84–2.56) CI = 0.89–3.17)
at the end of the interview, and all of them
◆
Wilcoxon signed-ranked test. reported that they had never heard of that
*McNemar’s exact test; P-value (odds ratio, OD; confidence inter- condition, reinforcing the idea that they were
val, CI). Bold letters indicate statistically significant difference blinded to the problem.
between cases and controls (children andparents).
The instrument that was used to measure
the children’s and mothers’ perception is of
concern about these variables was investi- particular relevance. The Child and Parent
gated, both the children and the mothers Questionnaire about Tooth Appearance is a
from the MIH group were concerned about tool that was initially developed and validated
tooth discoloration, while only mothers from to be used in patients with fluorosis, not
the MIH group were concerned about tooth MIH; however, both conditions, although
pleasantness. presenting distinct aetiological origins, are
For the last question that enquired about classified as enamel developmental defects.
their opinion on the statement: ‘The colour of Therefore, the Child and Parent Question-
my teeth (my child’s teeth) is pleasing and naire about Tooth Appearance may also be
looks nice’, a significant difference was applicable to patients with MIH, and the
observed between the MIH and the control results of the present investigation demon-
groups for children and parents (Wilcoxon strate that the instrument was able to dis-
signed-rank test; P < 0.001). criminate those who had the condition from

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 MIH perception 5

Table 3. Agreement between mothers and children from MIH cases and controls.

Question from the child’s and parent’s questionnaire Kappa coefficient (CI)
about teeth appearance Kappa coefficient (CI) for cases for controls

Appearance bothers respondent 0.092 ( 0.009 to 0.139) 0.051 ( 0.132 to 0.066)

Appearance concerns respondent 0.058 (0.003–0.229) 0.020 ( 0.111–0.113)
Appearance caused the child to stop smiling 0.051 (0.010–0.229) 0.057 (0.038–0.099)
Dissatisfaction with teeth 0.007 ( 0.070 to 0.101) 0.066 ( 0.009 to 0.163)
Concern with teeth 0.0016 ( 0.078 to 0.0807) 0.1510 (0.076–0.23)
Alignment 0.049 (0.030–0.113) 0.002 ( 0.095 to 0.126)
Concern with alignment 0.3124 ( 0.40 to 0.22) 0.0265 ( 0.06 to 0.11)
Discoloration 0.049 (0.030–0.111) 0.033 ( 0.016 to 0.086)
Concern with discoloration 0.1128 ( 0.2 to 0.025) 0.0867 ( 0.17 to 0.0027)
Health of teeth 0.091 (0.043–0.134) 0.047 ( 0.110 to 0.009)
Concern for health of teeth 0.0806 ( 0.16 to 0.009) 0.0224 ( 0.05 to 0.09)
Color of teeth nice and pretty 0.139 (0.047–0.165) 0.067 (0.005–0.088)

Table 4. Association between concern with tooth

discolouration and the presence of opacities in the anterior
teeth and MIH severity scores.
Spearman’s
correlation
coefficient
(P-value)
for cases
Variables (children)
Association between 0.0507 (0.5655)
opacities in the anterior
teeth and concern
with tooth discoloration
Association between MIH 0.0254 (0.7735)
severity and concern
with tooth discoloration
those who did not. Moreover, it is a question-
naire that covers both the children’s and par-
ents’ perception, which is essential in any
research that aims to investigate subjective
aspects related to oral health in young people.
The opinion of parents and peers, among
other factors, may be associated with an indi-
vidual’s satisfaction or dissatisfaction with his/
her teeth.17
With respect to the analysis of the first sec-
tion of the questionnaire, in which parents
and children expressed their feelings in regard
to tooth appearance, children and mothers in
the MIH group had different opinions from
those in the control group – in the social
domain for children and in the physical
domain for mothers. The fact that children
and mothers had a different perception of the
same oral health problem was not
unexpected. A systematic review has shown
that parents easily perceive observable prob-
lems (physical domain) but not non-observa-
Spearman’s
correlation ble problems18. Therefore, the results of the
coefficient present investigation corroborate this state-
(P-value) ment, as the mothers were aware and upset
for cases
(parents)
with the appearance of their children’s teeth,
but did not necessarily know they were
0.0211 (0.8113) avoiding smiling because of this oral health
problem. Unlike the mothers in the MIH
group, the children better expressed dissatis-
0.0186 (0.8332) faction with their teeth in the social domain.
The negative impacts of an emotional and
social nature associated with abnormal visible
dental conditions have already been described
in a group of 10- to 11-year-old children5. It
is known that the child’s perception of health
and disease varies according to his/her cogni-
tive skills, which are associated with the
child’s age and with the different stages of
emotional, social, and linguistic develop-
ment19.
The second part of the questionnaire aimed
to assess not only how children and mothers
perceived the children’s tooth pleasantness,
alignment, colour, and health but also
whether these factors were a matter of con-
cern. The results showed that mothers in the
MIH group replied differently from mothers
in the control group regarding satisfaction
with their children’s tooth colour, while, in
addition to tooth colour, children in the MIH
group were also dissatisfied with their tooth
alignment when compared with the children
in the control group. When the association of

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 S. C. Leal, T. R. M. Oliveira & A. P. D. Ribeiro
their rates of satisfaction with concern were
analysed, only tooth colour was a concern for
both mothers and children. Moreover,
although mothers in the MIH group did not
show to be dissatisfied with their children’s
teeth pleasantness, they indicated that it was
a matter of concern, which might most prob-
ably be explained by the MIH condition of
their children. Consistent with the responses
to the first section of the questionnaire, the
analysis of its second part also showed that
those affected by MIH rated their condition as
an oral health problem and were concerned
about it.
The limited number of published studies
with similar methodology makes the discus-
sion of these results difficult. One study with a
group of children aged between 7 and 16 years
with a diagnosis of either MIH, fluorosis, or
amelogenesis imperfecta (AI) observed that
those children reported to be very worried
about the appearance of their teeth and reluc-
tant to smile.5 With regard to other develop-
mental defects, MIH seems to have a more
negative impact than fluorosis, but less per-
haps than AI. Studies have shown that mild
fluorosis is not perceived by parents or children
as a major aesthetic problem10, and even
though it is highly prevalent, tooth appearance
did not concern or dissatisfy teenagers or their
parents11. Patients diagnosed with AI have
shown high levels of social avoidance and dis-
tress, as well as higher levels of discomfort and
dysfunction, when compared with individuals
without AI20. Nevertheless, this hypothesis
needs to be further investigated.
In the present investigation, children from
the MIH group had noticed that their teeth
were not as aligned as those of the children
in the control group, but this was not a
source of concern. Whether these results are
reliable or not is impossible to judge as no
occlusion assessment was carried out. Consid-
ering the children’s age and the fact that they
were not concerned about it, however, we
speculated that they were simply more critical
of the changes in their occlusion than those
in the control group.
At the end of the questionnaire, the
respondents had to totally agree or disagree
with the statement that the tooth colour was
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
pleasing and nice. In the response, both
mothers and children from the MIH group
differed from those in the control group by
disagreeing with the statement. Thus, when
the answers obtained in the three sections of
the questionnaire were analysed in conjunc-
tion with one another, it strengthened the
results of each section individually. Those in
the MIH group reported being more dissatis-
fied with the appearance of their teeth, based
mostly on the colour.
As observed in the first part of the question-
naire, the agreement between mothers and
children was weak in both groups regarding
areas of concern, perception of appearance,
and satisfaction with tooth colour. Similar
results have been previously reported11, and
agreement between children and parents is
known to be better in situations where the
child presents with a chronic disorder18. Inter-
estingly, both mothers and children in the
MIH group, although they expressed their con-
cern about tooth discoloration, did not judge
the discoloured teeth as unhealthy. This might
explain, in part, the raw concordance between
children and mothers. Moreover, it has been
recognized that parental and child question-
naires measure realities according to each
respondent’s perception, meaning that the
reports of parents and children should be seen
as complementary and that information will be
lost if just one part is heard21.
Finally, it could be expected that the sever-
ity of MIH and the presence of opacity in a
maxillary anterior tooth would influence per-
ception of MIH in children and mothers, but
no correlation was found when a separate
analysis was made comparing children with
MIH affecting only molars with those with
MIH affecting also the maxillary incisors.
About 50% of the children with MIH had at
least one maxillary incisor affected by MIH
and 40.5% of the sample were classified as
presenting with severe MIH. These results
indicate that even when the opacity was
located exclusively on the posterior teeth,
both children and mothers could perceive the
condition. As MIH opacities are demarcated
independently of colour, presumably they can
be noticed differently from the opacities
observed in mildly fluorotic teeth, which are

diffuse and were not a concern for either
parents and children10.
This study has some limitations. The first is
related to the impossibility of evaluating
whether socio-economic status influenced
how children/parents perceive MIH, as the
participants belonged to a community of
great social vulnerability as assessed by the
Human Development Index of the Paranoa
community. Moreover, quality-of-life ques-
tionnaires were not used to identify whether
the presence of perceived MIH would also
impact the quality of life of the child or the
mother. The main goal of this study was to
verify whether parents and children perceive
MIH as an oral health problem, however. As
far as the authors are aware, this is the first
time MIH was identified as a concern, basi-
cally because of tooth discoloration, by chil-
dren and parents when answering a
questionnaire validated for fluorosis. More
studies aiming to assess the impact of MIH on
children’s quality of life and aesthetic percep-
tion should be carried out to confirm the
results found in this investigation.
Conclusion
Children affected by MIH were kept from
smiling freely, while their mothers felt upset
about the appearance of their children’s
teeth. Both children and mothers were dissat-
isfied and concerned in regard to the discol-
oration of their children’s teeth. Overall,
mothers and children who presented with the
condition negatively perceived MIH opacities
as an oral health problem.
Why this paper is important to paediatric dentists
● This paper explores how children and their mothers
perceive molar–incisor hypomineralization
● This paper indicates that children affected by MIH
avoid smiling because of their tooth appearance
● This paper shows that children affected by MIH might
change their behaviour because of the problem, but
to what extent this aspect influences their quality of
life has not yet been explored.
Conflict of interest
The authors declare no conflict of interest.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
MIH perception 7
Authors’ contribution
Leal SC contributed to conception, design,
and interpretation and drafted the manu-
script; Oliveira TRM collected the data and
critically revised the manuscript; Ribeiro APD
contributed to data analysis and interpreta-
tion and critically revised the manuscript.
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