DOI: 10.1111/j.1365-263X.2011.01172.
Prevalence of molar–incisor hypomineralisation observed
using transillumination in a group of children from Barcelona
(Spain)
TERESITA PATRICIA MARTÍNEZ GÓMEZ1, FRANCISCO GUINOT JIMENO1, LUIS J. BELLET
DALMAU1 & LUIS GINER TARRIDA2
1
Department of Paediatric Dentistry, Faculty of Dentistry, Universitat Internacional de Catalunya, Barcelona, Spain, and
2
Research Department Director, Faculty of Dentistry, Universitat Internacional de Catalunya, Barcelona, Spain
International Journal of Paediatric Dentistry 2012; 22:
100–109
Objectives. The objectives were to investigate the
prevalence of the condition, by using trans-
illumination, in a group of children. Analysed
the prevalence with regard to gender, jaw
affected, and the teeth that exhibited dysplasia
most commonly.
Methods. A sample of 550 children aged 6 to 14
years was selected at the Department of Paediatric
Dentistry at the Universitat Internacional de Cata-
lunya, but among those selected only 505 children
were eligible for inclusion in the study. The gen-
der and age of the child, number of permanent
Introduction
The term molar–incisor hypomineralisation
(MIH) was proposed by Weerheijm et al.1 in
2001 to describe dysplasia of tooth enamel
caused by a disturbance that affects the amelo-
blasts during the early maturation stage of
amelogenesis.2 The process of calcification of
the tooth enamel that is involved occurs during
development between the last period of gesta-
tion and the age of 3 years. Given that enamel
is a tissue that does not regenerate itself, any
disturbance that occurs during its formation is
registered permanently on the surface of the
tooth.3 For such a condition to be diagnosed as
MIH, one of the first permanent molars must
be involved.4 In fact, this qualitative defect is
defined as hypomineralization of systemic
origin that affects one or various first perma-
Correspondence to:
Teresita P. Martı́nez Gómez, Department of Paediatric
Dentistry, Faculty of Dentistry, Universitat Internacional de
Catalunya, Josep Trueta, s ⁄ n. 08190, St. Cugat del Vallès,
Barcelona, Spain. E-mail: ytap10@hotmail.com
100 International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
teeth, number of teeth affected by MIH and their
position were registered.
Results. Ninety patients (17.85%) had MIH. Of
these, 45 were girls (50%) and 45 were boys
(50%). A total of 8062 permanent teeth were
observed. Of these, 344 (4.2%) were affected by
MIH. Of the teeth affected, 198 (57.7%) were
located in the maxilla and 146 (42.4%) in the
mandible. This result was statistically significant
(P = 0.003).
Conclusions. The population studied showed a
prevalence of MIH of 17.8%. The presence of the
defect did not differ according to sex in this popu-
lation. Defects were more common among teeth
in the maxilla.
nent molars and is associated frequently with
incisors.4
Clinically, MIH appears as a disturbance to
the translucency of the enamel.5–7 The condi-
tion is characterised by opacities with a well-
defined border that separate the affected
enamel from the adjacent normal enamel.4
These demarcated opacities are white, cream,
yellow, or brown.4,6–8 MIH varies in terms of
its location and severity among patients, and
even within a single patient. However, it has
been observed that when a larger number of
molars are affected, there is a greater possibil-
ity of disturbance to the incisors, in terms of
both number and severity. The number of
teeth that is involved and the severity with
which they are affected depend on the dura-
tion and intensity of the disturbance.2,4,6,8
Molar–incisor hypomineralisation is impor-
tant clinically because it can lead to the rapid
development of caries even during the erup-
tion of affected teeth. Post-eruptive enamel
breakdown (PEB) is characterised by poor
aesthetic appearance and sensitivity to ther-
mal and mechanical stimuli.4,7–9
 2011 The Authors

Affected molars tend to require complex
treatment and retreatment,10–12 because of
the continuous disintegration of the enamel
or difficulties encountered when different
materials are bonded to the damaged tis-
sue.13,14 Treatment can be complicated fur-
ther by difficulties in achieving adequate
anaesthesia, which can cause anxiety, fear, or
dental phobia in some patients.10 Specific
treatment guidelines have been established
that depend on the degree of severity of
MIH.15–17
The aetiology of MIH remains unknown,
although it has been related to different envi-
ronmental factors that are associated with
systemic conditions during the prenatal per-
iod (the last 3 months of pregnancy) and dur-
ing the perinatal and postnatal periods. These
factors may include: (1) a long period of
breast feeding, which may expose the child to
environmental contaminants such as dioxins,
(2) low birth weight, and (3) the use of medi-
cation.2,4,5,17–24
The majority of studies on the prevalence
of MIH have been conducted in Europe,25,26
but the prevalence of MIH has been studied
recently in China, Libya, Australia, Kenya,
and Brazil.27–31 At present, the prevalence
varies between 2.4% and 40.2%.6–9,20–23,27–43
Jälevik has grouped the results of the MIH
prevalence studies (Table 1).44
At the beginning of the 1970s, the use of
transillumination was introduced as a new
method for diagnosing caries. Its use was
based on the fact that less light is transmitted
through enamel that has been damaged, as a
result of decalcification caused by caries, than
through healthy enamel.45
The study reported herein was conducted
in response to the high incidence of MIH in
Barcelona (Spain). The aim was to establish
the prevalence of the condition, by using
transillumination, in a group of children. The
authors analysed the prevalence with regard
to gender, jaw affected, and the teeth that
exhibited dysplasia most commonly.
Materials and methods
The study was approved by the Ethics Com-
mittee of the Universitat Internacional de
 2011 The Authors
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
MIH prevalence using transillumination 101
Catalunya and was conducted from Novem-
ber 2008 to October 2009 in the Department
of Paediatric Dentistry of the Faculty of Den-
tistry of the Universitat Internacional de Ca-
talunya (Barcelona, Spain). All the parents or
guardians of the children aged between 6 and
14 years who participated in the study were
informed about the study before enrolment
and they gave voluntary consent.
Inclusion criteria
All children with permanent first molars that
had erupted totally or partially.
Exclusion criteria
These are given in detail in Table 2.
Before the start of the study, the observa-
tions made by the examiner (T.P. Martı́nez)
were calibrated using a series of photographs
supplied by Weerheijm,4,46 together with
photographs of diffuse opacities, amelogenesis
imperfecta, and fluorosis.
The diagnostic criteria used for MIH were
those established in 2003: demarcated opaci-
ties, PEB, atypical restoration, and extractions
because of MIH and failure of eruption.46 The
severity of the condition was evaluated in
accordance with the classification criteria of
Mathu-Muju and Wright.15
Children with bacterial plaque underwent
dental prophylaxis36,40–43 to avoid any false
positives being recorded during the observa-
tion by transillumination. All teeth had to be
wet at the moment of examination. The C
setting of the Nr 2517 Dental Curing Light
(Vivadent, Shaan, Liechtenstein) was used.
The patient code, age, gender, date of birth,
number of permanent teeth, and the number
and location of the teeth affected were
recorded on a document created for data col-
lection.
Statistical analysis
The data were analysed using the statistical
software Statgraphics Plus version 5.1 (Stat-
point Technologies, Warrenton, VA, USA).
The prevalence of gender and location of
tooth most affected was used to analyse the
 Table 1. Summary of epidemiological studies of MIH.
102

Population Sample Drop- Wet = W Degrees of Frequency

Study Country Criteria Study group based Age size outs Calibration Dry = D Size severity (%)

Alaluusua Finland Dental defects, Prospective cohort No 6–7 102 NR NR NR ‡2 mm 3 17

et al. 1996a fluorosis, or examined for
major dioxin in breast
disturbances milk
related
to general
health excluded
Alaluusua Finland Alaluusua 1996a Prospective cohort No 12 97 NR NR NR ‡2 mm 3 25
et al.1996b examined for
T. P. Martı́nez Gómez et al.

dioxine in breast
milk
Arrow 2008 Australia mDDE Age cohort Yes* 7 511 R Yes D NR NR 22
examined for MIH
Balmer et al. UK mDDE Consecutive patients No 8–16 25 NR Yes NR NR NR 40
2005 Australia in orthodontic 25 44
practice
Calderara et al. Italy mDDE, MIH krit Age cohort Yes 7–8 227 R Yes W ‡2 mm 3 13.7
2005 2001 examined for MIH
Cho et al. 2008 Hong Kong EAPD 2003 Study of records No 11–14 2635 NR Yes W NR NR 2.8
Dietrich et al. Germany mDDE Patients at annual No 8 age 2408 R Yes NR NR 3 2.4–11,
2003 dental screening cohorts, mean 5.6
10–17
Fleita et al. 2006 Libya mDDE, MIH krit School cohorts No 7–9 378 NR Yes W ‡2 mm 3 2.9
2001
Jasulaityte et al. Lithuania EAPD 2003 School cohort, Yes 6.5–8.5 1277 NR Yes W NR 2 9.7
2008 randomly selected
schools
Jasulaityte et al. Netherlands MIH krit 2001 Age cohorts No 9 442 R Yes D NR NR 14.3
2007 insured by DNHIF
Jälevik et al. 2001 Sweden mDDE Age cohort Yes 8 519 R Yes W ‡2 mm 3 18.4
Kemoli 2008 Kenya Demarcated School cohort, Yes 6–8 3591 NR Yes W NR 1 13.70
opacities, randomly selected
post-eruptive schools
defects, extensive
restorations
Koch et al. 1987 Sweden Colour and surface Age cohorts Yes 6 age 2252, NR Yes NR ‡1 ⁄ 3 3 3.6–15.4
changes. AI, cohorts, 343–423 in of a tooth
fluorosis, or 8–13 the cohorts unit
hypomin
of known
origin excluded

International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
 2011 The Authors
 Table 1. (Continued)

 2011 The Authors

Population Sample Drop- Wet = W Degrees of Frequency
Study Country Criteria Study group based Age size outs Calibration Dry = D Size severity (%)

Kukleva et al. Bulgaria EAPD 2003 Randomly Yes Eight age 2970, 370 NR NR W NR NR 2.4–7.8,
2008 selected. cohort, 7–14 in each age mean 3.6
Stratified age groups cohort
Kuscu et al. Turkey EAPD 2003 Patients No 7–9 147 NR Yes W NR 2 14.9
2008
Kuscu et al. Turkey EAPD 2003 Two school No 7–10 109 and 44 NR Yes W NR NR 9.1; 9.2
2009 cohorts
industrialised ⁄
nonindustrialised
area
Leppäniemi Finland Alaluusua Two school cohorts No 7–13 488 NR NR NR ‡2 mm 3 19.3
et al. 2001 et al.1996
Lygidakis Greece EAPD 2003 Consecutive No 5.5–12 3518 NR Yes NR Clearly 2 10.2
et al. 2008 patients in visible
Community
Paediatric Dental
Center
Muratbegovic Bosnia EAPD 2003 Randomly Yes 12 560 NR NR NR ‡2 mm NR 12.3
et al. 2007 Herzegovina selected Stratified
school groups
Preusser et al. Germany Koch et al. Schoolchildren No 6–12 1002 NR Yes W NR 3 5.9
2007 1987
Soviero et al. Brazil EAPD 2003 School cohort No 7–13 249 R Yes W NR 2 40.2

International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
2009
Weerheijm Netherlands mDDE Age cohort No 11 497 NR NR NR NR NR 9.7
et al. 2001 insured by DNHIF
Wogelius Denmark MIH 2003 Age cohorts Yes 6–8 647 R Yes W Clearly 2 37.50
et al. 2008 visible
Zagdown UK mDDE School cohorts. No 7 307 R Yes W NR NR 14.6
et al. 2002 Selected with
account of ethnicity
and socioeconomy

MIH, molar–incisor hypomineralisation; NR, Not reported; R, Reported, *Participation 45%.

MIH prevalence using transillumination
103
104 T. P. Martı́nez Gómez et al.

Table 2. Exclusion criteria. Table 3. Distribution of results according to age.

Hereditary Environmental Appliance Children Children Total

with MIH without sample
Amelogenesis Hypoplasia Carriers bands Age (%) MIH (%) (%)
imperfecta Diffuse opacities Carriers brackets
Demarcated opacities Carriers crowns 6 7 (1.30) 26 (5.15) 33 (6.53)
<2 mm 7 12 (2.38) 44 (8.71) 56 (11.09)
Demarcated opacities 8 17 (3.37) 58 (11.49) 75 (14.85)
only incisors 9 21 (4.16) 62 (12.28) 83 (16.44)
Demarcated opacities 10 7 (1.39) 55 (10.89) 62 (12.28)
in second molar and 11 10 (1.98) 56 (11.09) 66 (13.07)
premolars 12 7 (1.39) 53 (10.50) 60 (11.88)
Fluorosis 13 6 (1.19) 36 (7.13) 42 (8.32)
Turner’s tooth 14 3 (0.59) 25 (4.95) 28 (5.54)
Total 90 (17.82) 415 (82.18) 505 (100.00)
Children with no erupted permanent teeth were excluded.
MIH, molar–incisor hypomineralisation.

results by Student’s t-test. The prevalence at

different locations of the affected teeth, jaws,
and ages was analysed using the chi-squared
test. Differences were considered statistically
significant if P £ 0.05.

Results
During the 12 months of the study, 550 chil-
dren were evaluated. Forty-five children were
excluded because of the absence of any first
permanent molars (n = 13), the presence of
demarcated opacities in the premolars and
second permanent molars (n = 10), the pres-
ence of appliances (n = 8), or attendance at
Fig. 1. Distribution of individuals according to the number
the clinic unaccompanied by their parents
of affected teeth. 53 (58.88%) were true molar–incisor
(n = 14). Hence, 505 children, 246 girls hypomineralisation (MIH) as both molars and incisors were
(48.7%), and 259 boys (51.3%) were affected, eight children (8.88%) had four MIH molars, ten
included in the study. children (11.11%) had three molars, ten children (11.11%)
The prevalence of MIH was 17.85% (90 had two molars and only nine children (10%) had one
children); 16% of the entire cohort had more affected molar.

than one affected first permanent molar (81

children), and only 1.7% had one affected
first permanent molar (nine children). There
were no differences in prevalence with
respect to gender: 50% (45) of the affected
children were girls and 50% (45) were boys.
Although there were differences in preva-
lence related to age, these were not statisti-
cally significant (P = 0.88). The age
distribution of the sample of children, with
and without MIH, is shown in Table 3.
Of the 90 children with MIH, 58.88% (53
children) had both molars and incisors that
were affected, 8.88% (eight children) had
four affected molars, 11.11% (ten children)
had three affected molars, 11.11% (ten chil-
dren) had two affected molars, and 10%
(nine children) had one affected molar
(Fig. 1). These results show that a large num-
ber of children had both affected molars and
incisors, in contrast with a smaller number of
children who had only one affected molar.
In total, 8026 permanent teeth were observed
by using transillumination, of which 344
(4.28%) were affected by MIH (mean = 3.82).
Of the affected teeth, 198 (57.5%) were located
in the maxilla and 146 (42.4%) in the mandi-
ble. This difference was statistically significant
(P = 0.003). In terms of severity, of the 90

 2011 The Authors

International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd

Fig. 2. Distribution of the most affected tooth.
children with MIH, 45 (50.00%) presented
with mild lesions, 26 (28.89%) with moderate
lesions, and 19 (21.11%) with severe lesions.
The maxillary right first molar was the
molar affected most commonly, and the least
frequently affected was the mandibular right
first molar. With regard to the incisors, the
maxillary right central incisor was affected
most frequently, and the least frequently
affected was the mandibular right lateral inci-
sor (Fig. 2).
Discussion
The results obtained in this study show that
MIH is a common condition among children
in Barcelona, with a prevalence of 17.8%.
However, there is a difference in the preva-
lence of MIH among studies.6–9,20–23,27–44 This
could be due to differences in methodology
and the conditions of examination.
This study was the first study that used trans-
illumination for the diagnosis of MIH. The
authors decided to use this approach because of
the advantages that transillumination affords,
namely: (1) easy access to the caries-free sur-
faces of the enamel; (2) improved visualisation
of the different types of lesion; and (3) it is a
straightforward and portable method, as
reported by Buhler et al.47
In this study, the observer was trained
using photographs, as other authors have
described,27,35 because this is thought to
enable defects within the dental structure to
be recognised and differentiated.
There is debate as to whether or not to dry
teeth before they are examined. On the one
hand, light may reflect off the saliva when
the teeth are wet, causing a shine. Yet on the
 2011 The Authors
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
MIH prevalence using transillumination 105
other hand, small white demarcated opacities
are observed commonly, especially on the
incisors, when the enamel is dried. In this
study, the authors examined the teeth when
they were wet, to avoid detecting these small
demarcated opacities, and because it is diffi-
cult to keep teeth dry when using the transil-
lumination lamp.
The authors included demarcated opacities
that were >2 mm in diameter. Similarly to
other authors,7–9,22,28,32,37 the authors think
that the clinical consequences of such lesions
are greater than those of smaller lesions.
However, the criteria for MIH that were
established in 2003 do not mention the size
of the demarcated opacities,46 although the
World Dental Federation recommends count-
ing opacities that are >1 mm.48
To avoid conditioning factors, the observer
did not review the medical history of the
patient or the parents’ motive for consulta-
tion. The sample was made up of children
aged 6–14 years to register any defects before
the onset of PEB and ⁄ or caries, and to estab-
lish whether the older children had lost any
first permanent molars. Some authors rec-
ommend examining the molars during erup-
tion or immediately afterwards, to obtain a
more exact figure for the prevalence of
MIH.9 However, other authors8 suggest that
the examination should be carried out at 7
or 8 years of age to minimise the risk of
defects in the enamel being hidden by caries
or large restorations, while ensuring that the
first permanent molars have erupted. If
assessment of first molars as well as incisors
is required, the recommended age is
8 years.46 In this study, none of the children
had lost any of their permanent molars. Of
the sample, two patients with MIH had
molars that had failed to erupt for no appar-
ent reason.
Molar–incisor hypomineralisation has been
recognised on various continents during
recent years.25–31 It is thought that the defect
did occur in previous centuries, but the high
incidence of caries made its identification dif-
ficult.49 The current culture of prevention
means that children attend dental clinics at
an earlier age than previously, which enables
MIH to be identified more efficiently.
106 T. P. Martı́nez Gómez et al.
The first epidemiological study, in which
the condition was called ‘Idiopathic enamel
hypomineralisation’, was carried out in Swe-
den. This study was conducted on children
from different birth groups, and the highest
prevalence (15.4%) was found among the
children born in 1970.6 In Germany, Dietrich
et al.23 studied patients born between 1985
and 1992 (aged 10–17 years; 300 patients per
age cohort) and found that the most affected
group was the group of 14–16-year-olds (born
between 1989 and 1991). Table 3 shows the
distribution of MIH by age in this study.
In the sample of 505 children recruited to
this study, the prevalence of MIH was
17.85%. However, if only children with more
than one affected molar were included, the
prevalence was 16%. These results are similar
to those obtained in Finland in 20007 and in
Sweden in 2001.8 In Sweden,8 the prevalence
of children with more than one affected
molar was 14.5% (77 children). In this study,
16% (81 children) had more than one
affected molar, which meant that 90% of the
children with MIH had more than one
affected molar. As stated previously, systemic
reasons may cause children to have more
than one tooth affected by MIH,9 and further
investigation is needed to determine the pre-
cise aetiology of this condition.
Other studies with similar samples found a
lower prevalence than this study.9,34,37 The
prevalence found in this study in the group
of children from Barcelona (Spain) (17.8%)
was greater than that found in the area of
Madrid (Spain), where a prevalence of 12.4%
was obtained.34 This latter study was retro-
spective and involved the evaluation of the
dental records of 193 children. The authors
excluded records that showed the presence of
fillings and extractions of first permanent
molars.34 It is possible that the exclusion of
such records explains why the prevalence
was lower than in this study because, accord-
ing to the criteria established in 2003,46 chil-
dren with these types of record were included
in this study.
In this study, an equal number of male and
female patients were affected by MIH. In a
study in China in 2008, the ratio of boys with
MIH to girls with MIH was found to be 1 : 1.2,27
International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd
and in Greece, the proportion of girls was also
slightly higher than that of boys.36 However,
most other studies did not reveal a predilection
to developing MIH according to
sex.8,28,32,35,37,41 Although the evidence is not
conclusive, in the absence of further research to
explain the disparity in these different sets of
results, it is likely that there is no predilection to
developing MIH according to sex.
Of the 8026 permanent teeth observed
under transillumination in this study, 344
were affected by MIH. Of these, 198 (57.5%)
were located in the maxilla and 146 (42.4%)
in the mandible. In agreement with the
majority of studies,7,28,29,33,36,37,41 statistically
significant differences were found between
the numbers of affected teeth located in the
maxilla and the mandible (P = 0.003). How-
ever, in the study conducted in Sweden in
2001, a larger number of affected teeth were
found in the mandible, although the differ-
ence between the jaws was not statistically
significant.8 Calderara et al.32 also found that
mandibular molars were affected more fre-
quently; however, they found that the maxil-
lary incisors had more defects. It is not yet
known why teeth in the maxilla should be
affected more frequently by MIH than teeth
in the mandible.
Of the 90 affected children in this study, 53
(58.88%) showed true MIH because both
molars and incisors were affected, eight chil-
dren (8.88%) had four affected molars, ten
children (11.11%) had three, ten children
(11.11%) had two, and only nine children
(10%) had one affected molar. Although
most affected children in the sample were
aged 9 years, there were 16 children aged 6
or 7 years (17.7%) who had defects in their
molars, but whose incisors had not all
erupted. As a consequence, it was difficult to
tell whether these incisors were going to
erupt with defects, which would have
increased the number of children with true
MIH. Other authors33,40 found greater
involvement of both molars and incisors than
hypomineralisation of molars alone. The max-
illary right first molar was the molar affected
most frequently, and the mandibular right
first molar was the least affected. With regard
to the incisors, the maxillary right central
 2011 The Authors

incisor was affected the most frequently and
the mandibular right lateral incisor the least
frequently. Some studies33,36 show similar
findings, with slight differences. However, in
Turkey, Kuscu et al.38,39 obtained different
results in two separate studies with respect to
the teeth affected most commonly. Thus,
studies conducted thus far have not found
any common pattern of expression of MIH.
Conclusions
The following conclusions from the results of
this investigation can be drawn:
1 The prevalence of MIH obtained in this
study was 17.8%.
2 There was no difference in prevalence with
regard to sex, but MIH was found to be
more frequent in the maxilla than in the
mandible, with the right first permanent
molar being the tooth affected most com-
monly.
3 Further studies are required to determine
the cause of MIH and particularly to deter-
mine whether it has systemic causes.
What this paper adds
d This is the first study on the prevalence of molar–inci-
sor hypomineralisation carried out in this region of
Spain.
d The results of the study show that there is a high
prevalence of MIH among paediatric patients in this
region.
Why this paper is important to paediatric dentists
d All paediatric dentists should be aware of the high
prevalence of molar–incisor hypomineralisation at the
present time. They should also be aware of the clinical
complications of the condition, in order for treatment
to be as successful as possible from the point of view
of both patient and professional.
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 2011 The Authors

International Journal of Paediatric Dentistry  2011 BSPD, IAPD and Blackwell Publishing Ltd