Clinical Oral Investigations

https://doi.org/10.1007/s00784-019-02955-4

ORIGINAL ARTICLE

Reliability and validity of a new classification of MIH

based on severity
Renata Nunes Cabral 1 & Bente Nyvad 2 & Vera Ligia Vieira Mendes Soviero 3 & Eduardo Freitas 4 & Soraya Coelho Leal 1

Received: 13 March 2019 / Accepted: 6 May 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Objectives To describe a new molar-incisor hypomineralization (MIH) severity scoring system (MIH-SSS) that focuses on the
defects’ severity and to assess the system’s validity and reliability over 3 years.
Materials and methods One hundred eighty-one children diagnosed with MIH were examined by MIH-SSS. For reliability
assessment, 15–20 children were examined twice, and analyses were performed at the tooth level at four different cutoff points.
Follow-up examinations were performed over 36 months. Only teeth presenting MIH opacities at baseline were assessed. Odds
ratios were calculated to evaluate the chance of post-eruptive breakdown (PEB) occurrence related to the colors of MIH defects.
Survival curves were created for different types of teeth (molars and incisors) based on white and yellow opacities. The Kaplan-
Meier method was used with PEB as the outcome.
Results According to the MIH-SSS, kappa values ranged from 0.82 to 0.88. Regarding the longitudinal evaluation, for molars
and incisors, yellow/brown opacities had a significantly higher chance to evolve to dentin breakdown compared with white/
creamy opacities (OR = 2.54, OR = 10.58, respectively). Survival analysis showed that the occurrence of PEB was more frequent
in the first evaluation period (12 months).
Conclusion MIH-SSS, which provides detailed information about MIH severity, is a valid instrument presenting high reliability.
Yellow/brown opacities progressed more than did white/creamy opacities.
Clinical relevance It is of paramount importance to detect any surface breakdown as early as possible to be able to avoid pain and
caries progression. Moreover, this is the first paper that shows survival curves for MIH enamel breakdown over time.

Keywords Enamel . Child dentistry . Diagnostic systems

Introduction pandemic health problem [2] whose prevalence in 7- to 13-

The term Bmolar-incisor hypomineralization^ (MIH) was first
introduced in 2001 to describe a systemic condition that af-
fects from one to four first permanent molars (FPM), frequent-
ly associated with affected incisors [1]. It is considered a
year-old children varies around the world, ranging from 2.8 to
40.2% [3]. This variation can partly be explained by the lack
of standardization of methods for collecting information about
MIH [4], compromising comparability between and among
studies [5].

* Renata Nunes Cabral 1

School of Health Science, Department of Dentistry, University of
renatancabral@gmail.com Brasilia, Brasilia, DF 70910-900, Brazil

Bente Nyvad 2
Aarhus Universitet, Nordre Ringgade 1, 8000 Aarhus, Denmark
bente.nyvad@odont.au.dk
Vera Ligia Vieira Mendes Soviero 3
Preventive and Community Dentistry, Universidade do Estado do
verasoviero@gmail.com Rio de Janeiro, Boulevard 28 de Setembro, 157, Rio de Janeiro, Rio
de Janeiro 20551-030, Brazil
Eduardo Freitas
eduardo.estatistica@hotmail.com
4
Campus Darcy Ribeiro, University of Brasilia,
Soraya Coelho Leal Brasilia, DF 70910-900, Brazil
sorayaodt@yahoo.com

Clinically, MIH is characterized by asymmetric and well-
demarcated opacities on the affected teeth. The color of the
defects can vary from white/creamy to yellow/brown, and the
defects quite often evolve to post-eruptive breakdown (PEB)
[6]. There is some evidence that the darker the opacity, the
higher are the chances of a PEB to occur [6]. Furthermore,
PEBs are more common in molars than in incisors, likely due
to the powerful masticatory forces exerted in the molar region
[7].
Different diagnostic systems have been proposed to evalu-
ate developmental enamel defects (DDE) such as the DDE
and the modified DDE index, FDI [8, 9], the modified
Clarkson and O’Mullane DDE index [10], and the enamel
defects index (EDI) [11]. With respect to the classification of
MIH, the criteria most used are the modified DDE index [9]
and the criteria recommended by the European Association of
Paediatric Dentistry (EAPD) in 2003 [4]. An integrated sys-
tem combining both indices has recently been proposed, but
the system does not specify the severity of PEBs, which is an
important variable in relation to MIH severity classification
[12, 13].
Independently of the criteria used, researchers who have
been interested in studying the transition patterns of an MIH
opacity over time needed to include several methodological
modifications to the indices used [6, 14], because the criteria
currently available are not comprehensive enough to cover the
spectrum of MIH defects.
Attempts to create diagnostic systems designed to improve
the classification of MIH severity [15–17] have been pro-
posed. Some criteria classify MIH severity according to the
clinical features of the defects (mild or severe) [12, 17, 18] or
add a Bmoderate^ stage to the classification [15]. This is con-
fusing, since what is considered moderate in one system may
be classified as severe in another. Severity has also been
assessed in terms of sensitivity to temperature and tooth
brushing [19]. The inclusion of such a subjective variable
may be seen as a limitation of the system.
On the basis of the above arguments, it is clear that there is
still a need for a scoring system able to capture the total spec-
trum of MIH defects, leading to a valid classification of MIH
severity according to its clinical characteristics. Therefore, the
aims of the present study were to describe a MIH severity
scoring system (MIH-SSS) that focuses on the defects’ sever-
ity and to assess the reliability and validity of the system over
3 years in a group of Brazilian schoolchildren.
Materials and methods
MIH severity scoring system
A new MIH diagnostic system was developed in which not
only the presence of the condition but also its severity can be
Clin Oral Invest
registered. The description and the clinical features of the
system are presented in Fig. 1. Briefly, the MIH severity scor-
ing system (MIH-SSS) is based on ten codes: code 0, no
enamel opacity; code 1, the presence of white/creamy enamel
opacity without post-eruptive breakdown (PEB); code 2, the
presence of yellow/brown opacity without PEB; code 3, PEB
restricted to the enamel with white/creamy opacity; code 4,
PEB restricted to the enamel with yellow/brown opacity; code
5, PEB exposing dentin (hard when probed); code 6, PEB
exposing dentin (soft when probed); code 7, atypical restora-
tion without marginal defect; code 8, atypical restoration with
marginal defect; and code 9, tooth extracted due to MIH.
Code 9 (extraction of first permanent molar due to MIH) is
recorded if the condition is diagnosed in another first perma-
nent molar (white or yellow opacities, PEB, or atypical resto-
rations). If no other first permanent molar is affected, code 9
should be recorded only in cases where incisors are affected
[4].
Before the examination is initiated, under artificial light, all
tooth surfaces should be cleaned with a toothbrush.
Compressed air should not be required, but excessive moisture
must be controlled with gauze or cotton rolls. Per-surface ex-
aminations are then performed with the aid of a plain mouth
mirror, with an explorer used to remove any debris and to
check dentin hardness (codes 5 and 6) and margins of atypical
restorations (codes 7 and 8). The most severe condition re-
corded in a tooth surface should be used to determine the level
of severity of the tooth.
Study participants and examinations
An epidemiological census was carried out in a suburban area
of Brazil’s Federal District (n = 1.943). From 917 children
with first permanent molars and incisors erupted, 185 chil-
dren, aged 7–12 years, were diagnosed as having MIH and
invited to participate. Children whose parents did not sign the
informed consent were excluded, which resulted in 181 chil-
dren included at baseline. Thus, as 181 accepted to participate
on the present investigation, a sample size calculation was not
needed. Thereafter, the same children were re-examined four
times between the years 2013 and 2016. The flowchart is
presented in Fig. 2. Thirty-one children dropped out of the
study, for the reasons of either school transfer or transfer to
another city.
All clinical examinations were carried out by one of the
authors (RNC). Prior to the study, the examiner had been
extensively trained on using the MIH-SSS, through discus-
sions with the other authors and by practical exercises for a
period of 4 weeks. Afterwards, 32 children of the same ages as
those in the studied group, but who did not participate in the
present investigation, were examined. Almost a perfect agree-
ment (kappa > 0.8) was obtained.
Clin Oral Invest
Fig. 1 Codes of the molar-incisor
hypomineralization scoring se-
verity system and their descriptors
Examinations were conducted on school premises
equipped with portable beds and according to a standard-
ized protocol. Immediately before the examinations, the
examiner brushed each child’s teeth. Teeth were examined
at surface level by means of a mouth mirror with a
battery-powered built-in light (Kudos, Hong Kong,
China) and a standard explorer (Explores 5, Duflex,
MG, Brazil). Only permanent molars and incisors were
examined for MIH. All demarcated opacities > 1 mm in
diameter were recorded. In cases of the presence of two or
more defects in the same tooth surface, the most severe
condition was recorded: opacity < PEB restricted to
enamel < atypical restoration without marginal defect <
PEB with dentin exposed < atypical restoration with
marginal defect < extraction. Duplicate examinations were
conducted at an interval of 2 weeks.
Reliability assessment
At each follow-up examination, from 15 to 20 children were
re-examined for assessment of the intra-examiner reliability
that was assessed at tooth level at four different cutoff points:
sound × opacity (all opacities regardless of color); white/
creamy opacity × yellow/brown opacity; sound × PEB; and
PEB restricted to enamel × PEB exposing dentin. The data
from the reliability assessment were expressed as percentages
of agreement and by Cohen’s kappa. Any misclassifications of
MIH defects were analyzed in cross tabulations, and the

Fig. 2 Flowchart showing the number of children assessed at each examination period and numbers of dropout
percentages of disagreement regarding the cutoff points were
calculated.
Longitudinal assessment
Follow-up examinations were performed 12, 18, 24, and
36 months after the baseline (2013) evaluation. All children
were re-assessed according to the same protocol, under the
same conditions, and by the same examiner (RNC). For this
analysis, only teeth recorded as codes 1 and 2 at baseline were
included. An increase in MIH severity over time was recorded
if the tooth presented any type of PEB or atypical restoration
or had been extracted in any of the evaluation periods.
Ethical aspects
The study was approved by the Ethics Committee of the
Health Science Faculty of the University of Brasília (no.
31973413.0.0000.0030) and was supported by the local
Secretary of Education. All children involved in the study
who required treatment at any evaluation period were referred
to the pediatric dental clinic at the Hospital of the University
of Brasília or were treated on school premises by atraumatic
restorative treatment (ART) [20].
Statistical analysis
For the assessment of increases in MIH severity, descriptive
analyses were performed relative to baseline. Additionally,
odds ratios were calculated for evaluation of the chance of
PEB occurrence related to white and yellow opacities.
Clin Oral Invest
Finally, survival curves were created for different types of
teeth (molars and incisors) and white and yellow opacities.
For this analysis, the Kaplan-Meier method was used with
post-eruptive breakdown as the outcome. For the comparison
of survival curves, the log-rank test was performed. Data were
analyzed with the use of STATA 12.0 software (Stata
Corporation, College Station, TX, USA).
Results
Baseline sample characteristics
The sample was 50.3% male and 49.7% female, with a mean
age and standard deviation of 9.04 ± 1.44 years. The numbers
of affected teeth were 431 FPM (first permanent molars)
(59.53%) and 142 permanent incisors (9.46%). With respect
to the percentages of affected FPM according to arch, 54.75%
were maxillary and 45.24% were mandibular. The percent-
ages of maxillary and mandibular incisors affected by MIH
were 54.22% and 45.77%, respectively.
Reliability
The percentages of agreement of MIH diagnoses ranged
from 94.6 to 97.9%. For the intra-examiner examina-
tions, the kappa values ranged from 0.82 to 0.88. The
high level of agreement was maintained over all follow-
up periods.
The distribution of diagnoses at intra-examiner exam-
inations according to the MIH-SSS is presented in
Clin Oral Invest

Table 1 Distribution of
diagnoses at intra-examiner ex- Examination Examination 2
aminations according to the MIH 1
severity scoring system Mild Moderate Severe

Sound W- Y- PEBW PEBY PEBH PEBS SAR UAR EXT Total

OP OP

Sound 503 13 0 1 0 0 0 0 0 0 517

W-OP 13 78 1 3 2 0 0 0 0 0 97
Y-OP 0 2 27 0 1 0 0 0 0 0 30
PEBW 1 0 0 1 0 0 0 0 0 0 2
PEBY 0 2 1 1 16 0 1 0 0 0 21
PEBH 0 0 0 0 0 1 0 0 0 0 1
PEBS 0 0 0 0 0 2 29 0 0 0 31
SAR 0 0 0 0 0 0 0 22 0 0 22
UAR 0 0 0 0 0 0 0 0 2 0 2
EXT 0 0 0 0 0 0 0 0 0 7 7
Total 517 95 29 6 19 3 30 22 2 7 730

W-OP/Y-OP white/yellow opacity, PEBW/PEBY post-eruptive breakdown associated with white/yellow opacity,
PEBH/PEBS post-eruptive breakdown with exposed dentin (hard and soft, respectively), SAR/UAR satisfactory
and unsatisfactory atypical restorations, EXT extraction due to MIH

Table 1. There were 44 misclassifications, the majority Longitudinal assessment

of which involved sound surfaces and surfaces with
opacities (59%). In 6.8% of the cases, the misclassifica-
tions involved surfaces with white or yellow opacities.
Misclassification between surfaces with post-eruptive
breakdown and sound surfaces and surfaces with opac-
ities occurred in 4.5% and 15.9% of the cases, respec-
tively. Post-eruptive breakdown with and without ex-
posed dentin involved 2.2% of the misclassifications.
The numbers of FPM and incisors with MIH opacities that
progressed over time are shown in Fig. 3. An example of
increased severity of a yellow/brown opacity in a smooth sur-
face of a FPM not fully erupted is presented in Fig. 4.
For molars and incisors, there was a statistically significant
difference between risk estimates when white/creamy and
yellow/brown opacities were compared. For both molars and

Fig. 3 Increase in MIH severity observed for white/creamy and yellow/brown opacities and for enamel breakdown over time for first permanent molars
and incisors (n number of cases)

Fig. 4 Progression of MIH severity
in the buccal surface of a first
permanent molar over 18 months. a
MIH yellow/brown opacity on the
buccal surface at baseline, b post-
eruptive breakdown of enamel on
the buccal surface after 12 months,
and c the severity of MIH increased
to dentin exposure after 18 months
incisors, yellow/brown opacities had a significantly greater
chance of evolving to PEB over the 36-month follow-up in
comparison with white/creamy opacities (OR 2.54, 10.28;
95% CI 1.60–4.01, 2.56–41.31), respectively.
Survival analysis
The survival analysis showed that the occurrence of PEB
was more frequent in the first evaluation period (12 months).
In addition, incisors presented higher survival rates than mo-
lars, for both white/creamy (P < 0.01) and yellow/brown
opacities (P < 0.008) (Fig. 5).
Discussion
Molars affected by MIH were initially described as Bcheese
molars^ [21], since very little was known about the condition,
but soon it became evident that there was a need to develop a
classification system for such defects. Since then, several clas-
sification criteria have been proposed [4, 12, 19, 22], but none
is sufficiently comprehensive to describe the spectrum of
changes that may occur with an MIH opacity over time.
Therefore, the proposal of a new MIH classification is
justified.
Fig. 5 Survival curves according to the Kaplan-Meier method for inci-
sors and FPM according to colors of the opacities. Times 2, 3, 4, and 5
correspond to 12-, 18-, 24-, and 36-month follow-up periods, respectively
Clin Oral Invest
A literature search revealed that the criteria proposed by the
European Association of Paediatric Dentistry (EAPD) [4] are
the most frequently used in MIH surveys. More recently,
Ghanim and colleagues [23] developed and tested another
criterion system which, according to the authors, should re-
place the EAPD system from 2003. When these two systems
are compared with the new MIH-SSS criteria, some aspects
merit consideration. First, the MIH-SSS is composed of ten
hierarchical codes that facilitate the understanding of the tran-
sition pattern of an opacity to a more severe condition.
Second, the new criteria take into account both the level of
the post-eruptive breakdown (restricted to enamel and/or ex-
posing hard or soft dentin) and the status of atypical restora-
tions (with or without marginal defects). Finally, a distinction
between the colors of the opacity (white/creamy or yellow/
brown) is made. With regard to the last point, it has already
been shown that the darker the opacity, the greater the chances
of a post-eruptive breakdown over time [6, 14, 24, 25]. This is
important clinical information justifying that the color of a
MIH defect should always be part of any MIH classification.
Unfortunately, many classification systems in dentistry are
recommended without having been properly tested for their
reliability and validity. This is also true for MIH criteria. It is
imperative that new diagnostic criteria be clearly described in
a standardized protocol, prior to being tested for their repro-
ducibility within and between examiners. Diagnostic criteria
that cannot be reproduced in clinical settings are not reliable.
Moreover, the criteria should be valid, i.e., they should mea-
sure what they claim to measure [26], such as the transition of
a white/creamy or yellow/brown opacity to a more severe
condition (post-eruptive breakdown). If transition patterns of
specific clinical conditions in a classification system can be
followed over time, we can estimate the prognosis of the re-
spective conditions. This aspect is most useful for the practi-
tioner because, based on such knowledge, he or she can adjust
the treatment plan and recall intervals accordingly.
The results of the present investigation clearly showed that
the suggested MIH-SSS criteria have predictive validity be-
cause yellow/brown opacities had a poorer prognosis in com-
parison with white/creamy opacities. This was true for both
molar teeth and incisors. This means that the color of an MIH
opacity can be used to guide the clinician in prescribing recall
Clin Oral Invest
intervals for a child to avoid the condition deteriorating with-
out being noticed. While this observation might not seem
novel [6, 14], it is in fact the first time that the color of an
MIH enamel opacity has been shown to be statistically signif-
icantly linked with the prognosis of the condition. In addition,
the two mentioned studies were restricted to a single re-
evaluation after 18- and 12-month intervals, respectively. To
our knowledge, this is the first time that changes in MIH
opacities have been followed by a sequential re-assessment
over a 36-month period.
The survival analysis, which was applied for the first time
in a MIH study, showed that, independently of the color of the
opacity, post-eruptive breakdown was more prone to develop
during the initial periods of observation, especially in molars.
The observation might simply reflect that teeth severely af-
fected by MIH are more disposed to breakdown shortly after
eruption because of masticatory forces. In any case, clinicians
should be particularly alert when they encounter yellow/
brown MIH opacities in erupting molars.
Few studies have considered enamel or dentin breakdown
separately [6, 14], and the results are conflicting. While the
proportions of surface breakdown found in the present inves-
tigation were similar to those reported by Neves and col-
leagues at similar follow-up [14], they differed considerably
from the results of da Costa-Silva and colleagues [6]. A pos-
sible explanation for these differences might be related to de-
mographic variables and children’s ages, reported in the study
published by da Costa-Silva and colleagues [6].
The MIH-SSS proved to be a reliable instrument, since
intra-examiner agreement was consistently high throughout
the study. The kappa values found in the present investigation
were similar to those reported in studies in which more simple
criteria were used [18, 27, 28]. Therefore, it can be inferred
that the higher number of codes in the MIH-SSS did not com-
promise the reliability of the system. Misclassifications were
mainly observed between sound surfaces and surfaces with
white demarcated opacities. This is not an unexpected obser-
vation, since white opacities in enamel, such as in dental car-
ies, are often confused with sound surfaces [29]. Furthermore,
it should be taken into account that the current study was a
field study in which full salivary control was not always pos-
sible. Yet, the new system was able to differentiate MIH de-
fects at all stages of severity.
This study showed that clinicians using a more detailed
classification system can detect successive stages of severity
of MIH without compromising the system’s reliability.
Moreover, it brings new and relevant information about the
transition pattern of MIH opacities over time. Nonetheless, it
presents some limitations related to the fact that the system
was applied longitudinally by only one examiner, and al-
though the survival analysis indicated that surface break-
downs occurred more frequently during the first year of ob-
servation, it was not possible to indicate precisely when such
breakdowns really occurred. It could also be argued that our
validation of the MIH-SSS criteria included only the earlier
stages of surface breakdown up to exposed dentin, and not the
whole spectrum of scores including restorations. However,
from a patient perspective, it is of crucial importance to detect
any surface breakdown as early as possible to be able to inter-
fere with potential development of pain and caries progres-
sion. Finally, the MIH-SSS should be validated in different
countries and populations.
Conclusions
In conclusion, the MIH severity scoring system is a valid
instrument presenting high reliability. Furthermore, post-
eruptive breakdown is more likely to occur in teeth presenting
darker opacities than in teeth with white opacities.
Acknowledgments We thank the local educational departments, direc-
tors, and students of schools from CAIC, Paranoá, Federal District,
Brasília, Brazil.
Funding The study was partially supported by CAPES, CNPQ, and the
National Council for Scientific and Technological Development from the
Brazilian Government, under grant 306852/2016-0.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and the national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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