Received: 14 May 2018
| Revised: 13 July 2018
| Accepted: 9 August 2018
DOI: 10.1111/ipd.12425
ORIGINAL ARTICLE
The severity and degree of hypomineralisation in teeth and its
influence on oral hygiene and caries prevalence in children
Markus Ebel1 | Katrin Bekes2 | Christian Klode3 | Christian Hirsch4
1
Dr. Richard Schmitz and Markus Ebel,
M.Sc., Bergisch Gladbach, Germany
2
Department of Paediatric Dentistry,
School of Dentistry, Medical University
of Vienna, Vienna, Austria
3
Department of Knowledge Management,
School of Business & Economics,
Philipps University of Marburg, Marburg,
Germany
4
Department of Paediatric Dentistry,
School of Dentistry, University of
Leipzig, Leipzig, Germany
Correspondence
Markus Ebel, Odenthaler Str. 132,
Bergisch Gladbach, Germany.
Email: markus-ebel@gmx.de
1 | INTRODUCTION
Over the past few years, the enamel disorders molar
incisor hypomineralisation (MIH) and primary molar
hypomineralisation (DMH) have steadily gained attention
and importance in paediatric dentistry, presenting major
challenges for dentists and patients worldwide.1-5 Weer-
heijm et al1 first described the term “MIH” in 2001 to
determine specific developmental enamel defects typically
affecting permanent first molars and permanent incisors.
Affected teeth are characterised by a white/yellow‐to‐
brown discoloration and posteruptive enamel fractures.
The number of affected teeth (single tooth or several
Int J Paediatr Dent. 2018;1–10.
Aim: The purpose of this study was to investigate the relationship between the
severity of hypomineralised teeth, plaque accumulation, hypersensitivity, associ-
ated caries risk, and oral health‐related quality of life limitations of affected chil-
dren.
Materials and Methods: A total of 250 children (mean age 9.0 years) presenting
with at least one hypomineralised molar or incisor were included in the study.
The hypersensitivity of the teeth was evaluated using the Schiff Cold Air Sensi-
tivity Scale and the Wong‐Baker Faces Scale. Furthermore, the Decayed, Missing,
and Filled Teeth Index was documented, the Quigley Hein Index was obtained,
and personal questioning was used to document the patients’ limitations with
intake of food. These data were analysed using general linear models that control
influencing factors such as age and sex.
Results: The Quigley Hein Index increased with the severity of the hypominer-
alised teeth (1.64 in the unaffected, 2.77 in the moderately, and 3.63 in the
severely affected teeth). Problems with intake of food were only observed in sub-
jects with severe hypomineralisation. There was no immediate effect on dental
caries.
Conclusion: Increased severity of tooth hypomineralisation leads to increased
hypersensitivity, which resulted in inadequate oral hygiene among children and
limitations to their daily life.
KEYWORDS
caries risk, dietary restrictions, hypersensitivity, MIH, oral hygiene, plaque distribution
teeth with MIH), as well as the severity of the single
defects, may vary.6
The faulty composition of the enamel, including phos-
phate, carbonate, and calcium,2 forms the basis of the MIH
and DMH symptoms: due to reduced hardness and elastic-
ity, the enamel wears down quickly during use, exposing
the dentin, which results in increased hypersensitivity, mak-
ing it difficult for affected children to maintain proper oral
hygiene.7 Due to the high prevalence of MIH in the global
population (up to 40.2%4,7-10), there is an increased need
for appropriate MIH therapy and awareness among dental
health care professionals about the effects of MIH on
patients’ overall dental hygiene and quality of life.
wileyonlinelibrary.com/journal/ipd © 2018 BSPD, IAPD and John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2
| EBEL
The aetiology is currently unclear. Although prenatal or
early childhood health factors are suspected, yet no conclu-
sive evidence has been found. Several prenatal and perina-
tal exposures, including maternal smoking, illnesses, and
medicine intake, low birthweight, caesarean delivery, and
birth complications, have been discussed to be contributing
factors to MIH.11 Fever and the usage of antibiotics in
early childhood are discussed as strong supplemental fac-
tors.11
It has yet to be clarified whether the clinical findings
depicting the severity‐dependent effect of MIH/DMH
would indicate different therapeutic approaches for the
dental professional. Therefore, the purpose of this cross‐
sectional study was to investigate the relationships between
the severity of MIH/DMH and plaque accumulation (Quig-
ley Hein Index [QHI]), the hypersensitivity of the affected
teeth (Schiff Cold Air Sensitivity Scale [SCASS]/Wong‐
Baker Faces Scale [WBFS]), and dental caries risk. The
main hypothesis is that an increased severity of MIH/DMH
leads to poorer oral hygiene and more dental caries. More-
over, we assume that the impact of MIH/DMH bring along
problems with the intake of food (PwIoF), which results in
a decreased oral health‐related quality of life (OHRQoL).
2 | MATERIALS AND METHODS
2.1 | Key elements of study design
In this study, several dental investigations (oral hygiene,
dental caries, hypersensitivity, and oral health‐related qual-
ity of life limitations) were conducted with respect to the
severity of MIH/DMH within a consecutive sample of chil-
dren to detect relevant effects on the observed outcomes.
2.2 | Setting
Patients were recruited from the Leo Löwenzahn paediatric
dentistry practice in Bergisch Gladbach, North Rhine‐West-
phalia, Germany, between January and June 2017. The den-
tal staff was briefed in a designated meeting to inform the
lead examiner (Markus Ebel) in case they detected a poten-
tial participant. Children then were diagnosed based on clini-
cal examination by a proficient dentist (M.E.) always in the
same dental unit and lightning environment (artificial) using
an airflow handpiece with standardised probes and mirrors.
Information about the content of the study was kept to a min-
imum so that the patient did not change behaviour in oral
hygiene, thus modifying potential results.
2.3 | Participants
The patients had to be between 3‐15 years of age and
present with at least one MIH‐/DMH‐affected tooth to be
ET AL.
WHY THIS PAPER IS IMPORTANT TO
PAEDIATRIC DENTISTS
• For paediatric dentists, it is important to realise
that MIH increases hypersensitivity, which can
lead to poor oral hygiene in patients; therefore,
particular attention should be paid to desensitis-
ing affected teeth, and an effective preventive
regime should be established to prevent future
dental disease and to increase the oral health-
related quality of life.
included. To have a standardised, strategic diagnosis, the
guidelines of the European Academy of Paediatric Den-
tistry (EAPD)4,12 were applied to identify an MIH‐posi-
tive tooth: clearly definable opacity and/or buccal
surfaces of the crowns; white/yellow‐to‐brown discol-
orations; MIH defects of at least 1 mm in diameter; the
presence of hypersensitivity; the presence of atypical
restorations; and extraction of permanent teeth due to
MIH/DMH. We included children who consented to the
examination and who had at least one tooth impaired by
DMH or MIH. Patients undergoing orthodontic therapy
were excluded from the study population due to the
potential influence of fixed appliances on the mainte-
nance of oral hygiene.
2.4 | Sample size
This cross‐sectional study included 250 children (124 girls
and 126 boys). G*Power Software (www.gpower.hhu.de)
was used to analyse and eliminate calculation errors of the
sample size. According to the main hypothesis, the chil-
dren's sample size was evaluated by estimating a univariate
analysis of variance with (a) three groups in total, and (b)
two groups in direct comparison. We used the default val-
ues concerning effect size f (=0.25) and error probability
of alpha (=0.05), resulting in a sample size of n = 252 for
(a) and n = 210 for (b) so we declared a sample size of
n = 250 as sufficient.
2.5 | Variables
The QHI was defined as the first quantitative outcome vari-
able and the Decayed, Missing, and Filled Teeth (dmft/
DMFT) Index as the second quantitative outcome variable.
MIH/DMH groups served as predictors. The SCASS and
WBFS were defined as intermediating quantitative vari-
ables, which may work as dependent or independent vari-
ables. In addition, we made use of other endogenous
binary variables such as PwIoF and tooth decay risk
EBEL ET AL.
(TDR). Gender, social status groups, and age functioning
were the control variables.
2.6 | Data sources/measurement
With the official consent of the legal guardian, data were
collected by M.E. and a dental assistant to verify the input
and decrease potential uncertainties such as misunderstand-
ings. Storage was held in a digital form in the dental prac-
tice servers and was approved by M.E. The previously
mentioned control variables together with the patient's
number and the date of registration were used as general
information.
The dmft/DMFT Index, based on the World Health
Organization (WHO) criteria, was used for quantification
and comparability. The caries index was calculated as the
single value sum of the decayed D(d), missing M(m), and
filled F(f) teeth. The combined DMF/dmf (T/t) value was
determined for children in the mixed dentition phase who
were 6‐9 years old.
The QHI was used to document dental plaque distribu-
tion.13 Plaque distribution was scaled from degrees 1‐5
after applying a plaque revelator (PlaqSearch, TePe®, Tepe
D‐A‐CH GmbH, Hamburg, Germany; 0: no plaque; 1: iso-
lated plaque islands; 2: up to 1‐mm‐thick contiguous pla-
que line at the gingival margin; 3: plaque expansion in
cervical tooth thirds; 4: plaque expansion to the middle
third; and 5: plaque expansion to the coronal third). In
accordance with numerous studies, QHI ultimately served
as an indicator for an increased caries risk: the higher the
plaque accumulation, the higher the risk for developing car-
ies.14-16 The TDR was tested in consideration of the recom-
mendations of the Deutsche Arbeitsgemeinschaft für
Jugendzahnpflege (DAJ).17 The DAJ methodologically
works with children's caries experiences and defines the
20% of all children with the highest caries incidence in
their age group as high risk. The classification of high car-
ies risk of the DAJ was done using the dmft/DMFT Index:
2‐3 years old with a dmft/DMFT of >0; 4 years old with a
dmft/DMFT of >2; 5 years old with a dmft/DMFT of >4;
6‐7 years old with a dmft/DMFT of >5 or DT of >0; 8‐
9 years old with a dmft/DMFT of >7 or a DT of >2; and
10‐15 years old with a dmft/DMFT of >0 on proximal or
smooth surfaces.
The sensitivity of teeth was tested by the air stimulus
and recorded by the SCASS18 and WBFS.19 The air stimu-
lus (dental unit air syringe, pressure: 60 ± 5 psi, tempera-
ture: 20 ± 2°C) was applied for 1‐2 seconds at a distance
of 1 cm from the affected tooth's facial surface to test each
patient's response. The air stimulus was applied to all
MIH‐/DMH‐affected teeth. Furthermore, all unaffected
teeth from the same dental group were tested with the same
method. As an example, if the upper first molar was
| 3
affected by MIH, the other three unaffected first molars
were also tested in the same manner. The reaction was cat-
egorised in degrees from 0 to 3 to evaluate the SCASS (0:
no response; 1: response from the patient, but no request to
remove the stimulus; 2: response to stimulus—the patient
requests removal and moves away from the airflow; 3:
response to stimulus—the patient requests removal, moves
away, and feels pain). In addition to the SCASS, the
WBFS was used to rank the pain intensity after the air
stimulus was applied to each MIH‐/DMH‐affected tooth.
The children subjectively judged their pain perception by
using a display (smiling face = scale 0: no pain; crying
face = scale 10: hurts most).19
After clinical examination, each patient and his or her
legal guardian were questioned about PwIoF due to MIH
conditions. Questions concerning general nutritional restric-
tions based on the Child Perceptions Questionnaire (CPQ‐
G11‐14)20 were used. The included questions concerned
issues with chewing solid foods, including whether there
were problems with consuming hot, cold, sweet, sour, or
spicy foods and drinks. If the patient positively answered
one of the questions, the presence of nutritional restrictions
was noted.
The plaque accumulation (QHI) and the resulting caries
risk, which were evaluated according to the DAJ criteria
and the dmft/DMFT, were suspected to depend on the
number of affected teeth and the severity of the damage
type of MIH (Figure 1). The patients’ data were subdivided
into three severity categories based on the calculated value
resulting from the severity of the MIH, as defined by
Mathu‐Muju and Wright,21 and the number of affected
teeth. Nonaffected and mildly affected teeth were rated
with 0 “risk points” since they did not show any influence
on QHI and therefore no increased TDR was expected.
Moderately affected teeth were rated with 2 risk points,
and severely affected teeth were rated with 3 risk points.
For each patient, the risk points were added to calculate a
personal severity score which combined the number of
damaged teeth and the degree of disintegration of the teeth,
leading to a certain category. Patients with a severity score
of 0 were included in the low severity category (LSC),
patients with a severity score of 2‐4 were included in the
medium severity category (MSC), and patients with a
severity score of >4 were included in the high severity cat-
egory (HSC).
2.7 | Bias
One potential source of bias might be the patients’ individ-
ual pain thresholds, which could modify the data collected
for the SCASS and WBFS, bringing along systematic vul-
nerability due to differences in the process of acquiring
data. Also, PwIoF might be based on preferred dietary
4
| EBEL
MIH/DMH affected teeth
Severity Types of MIH by Mathu-Muju K, Wright JT (2006);
Risk Points: idea of the authors (M.E., K.B., C.K.,C.H.)
I Mild Type (0 Risc Points)
Demarcated opacities are in nonstress-bearing areas
of the molar
There are isolated opacities
No enamel loss from fracturing is present in opaque areas
There is no history of dental hypersensitivity
There are no caries associated with the affected enamel
involvement is usually mild if present
II Moderat Type (2 Risc Points)
Intact atypical restorations can be present
Demarcated opacities are present on occlusal/incisal third of
teeth without posteruptive enamel breakdown
enamel breakdown/caries are limited to 1 or 2
surfaces without cuspal involvement.
sensitivity is generally reported as normal
Esthetic concerns are frequently expressed by the patient
or parent
III Severe Type (3 Risc Points)
Posteruptive enamel breakdown is present and frequently
occurs as the tooth is emerging
There is a history of dental sensitivity
Frequently, widespread caries are associated
with the affected enamel III
Crown destruction can readily advance to involve
the dental pulp
Defective atypical restoration is present
Esthetic concerns are expressed by the patient or parent
F I G U R E 1 Schematic presentation for detection of the Severity Score of the patients MIH‐/DMH‐affected teeth to divide them into Severity
Categories
habits. For example, a child who does not eat spicy food
on a regular basis will evaluate the taste on a higher level
than another patient might. Moreover, the QHI can be
influenced by whether the patients brushed their teeth
before the dentist appointment and the effectiveness of the
plaque‐disclosing agent used. To reduce potential sources
of bias, standardised methods mentioned in the setting sec-
tion were implemented. The QHI was tested with the same
plaque‐disclosing agent each time; therefore, differences in
effectiveness by manufacturer were ruled out, and if the
QHI could not be taken at the first appointment, the infor-
mation provided to parents and children was purposely
kept to a minimum to avoid changes in the children's oral
hygiene procedure before the next appointment. Taking
these circumstances into account, a high level of meaning-
fulness for the research was attempted.
2.8 | Statistical methods
The hypothesis was tested by several relations between
variables through three different statistical approaches.
Firstly, the univariate analysis of variance was conducted,
in which the differences between the categories of the MIH
ET AL.
Severity categories
I I
Low severity
category
0 RP 0 RP
(0 risc points)
Medium severity
Sum of risk points category
= severity score (2 4 risc points)
3 RP 2 RP High severity
II category
(>4 risc points)
RP = Risc Points
index and severity index related to dependent measure-
ments (QHI, SCASS, and WBFS) and three manifestations
of the dmft/DMFT were tested. Secondly, logistic regres-
sion analysis was applied to test differences in gender,
social status, PwIoF, TDR, and the effect of age on differ-
ences between the categories of the severity index. Thirdly,
general linear models were used to test for significant rela-
tionships among the quantitative variables. Fourthly, certain
direct and indirect effects were estimated within all mea-
surements by modelling mediated regression using the
Mplus software program (www.statmodel.com).
The intention was to check whether the measurement of
pain differed with respect to the effects of MIH on the
QHI when controlling for PwIoF. Therefore, significant
indirect effects were tested on the one hand, from (A) MIH
on the QHI via the SCASS together with PwIoF, and on
the other hand, from (B) MIH on QHI via the WBFS and
PwIoF within one global model (Figure 2). In case of
incomplete data, the participants were excluded from the
study.
The patients’ legal representatives were informed about
the study procedures in written and verbal forms, and they
gave their informed consent according to the Declaration of
EBEL ET AL. | 5

Concerning the permanent dentition, MIH defects were

most often seen with the first molars (in 36.5% of all first
permanent molars and 9.9% of all permanent teeth). The
second most regularly affected teeth were the mandibular
and maxillary central incisors (18.7% of all permanent cen-
tral incisors and 4.8% of all permanent teeth). The second
molars group showed the third‐highest MIH prevalence
(15.6% of all permanent second molars and 0.7% of all per-
manent teeth). Of the patients, 24.8% had only one MIH‐/
DMH‐affected tooth, 30% had two MIH‐/DMH‐affected
teeth, and 18.4% had three MIH‐/DMH‐affected teeth.
26.8% had more than three MIH‐/DMH‐affected teeth.
Table 1 shows the classification of all teeth according
to their degree of MIH/DMH severity according to Mathu‐
Muju and Wright,21 along with their corresponding mea-
F I G U R E 2 Scheme of Modelling indirect effects mediated by surements concerning the QHI, SCASS, and WBFS. With
SCASS (pathways A) and by WBFS (pathways B)
regard to the dental plaque distribution and sensitivity of
the teeth, no statistical difference was observed between
Helsinki for examination and pseudonymous data inclusion unaffected (MIH‐0) and mildly affected teeth (MIH‐1;
and for the study's analysis. The study was approved by mean QHI: 1.64 to 1.66; mean SCASS: 0.22 to 0.22; mean
the Ethics Committee of the University of Leipzig (AZ: WBFS: 0.56 to 0.68). In contrast, highly significant
187/17‐ek). increases (P = 0.00) were observed in the mean QHI
among the unaffected (MIH‐0/QHI = 1.64), moderately
affected (MIH‐2/QHI = 2.77), and severely affected teeth
3 | RESULTS (MIH‐3/QHI = 3.63). The mean SCASS (0.22 to 1.34 to
2.08) and mean WBFS (0.56 to 3.57 to 6.14) also had
3.1 | Participants highly significant increases (P = 0.00) among the unaf-
An almost equal distribution was reached concerning gen- fected teeth (MIH‐0) compared to the moderately affected
der: of the 250 children included in the study, 126 were (MIH‐2) and severely affected teeth (MIH‐3).
male and 124 were female. The median subjects’ age was
9 years old; again, boys and girls were almost equal in this
aspect (boys: 9.1 years, girls: 9.0 years). The majority of T A B L E 1 Tests for significant differences between MIH group
the participants (71.6%, n = 179) belonged to the mixed specific means (teeth) concerning QHI, SCASS, and WBFS,
including 95% confidence intervals (95% CI)
dentition group, 11.6% (n = 29) belonged the primary den-
tition group, and 16.8% (n = 42) belonged to the perma- (n = 5859 teeth)
nent dentition group. The gender distribution was almost 95% CI 95% CI
equal in all groups. From the patient pool, approximately Dependent var > MIH‐ P‐value Lower Upper
15% were non‐Caucasian. Additionally, of the patients, 66 independent var group (Model) Mean bound bound
(26.4%) could be assigned to a high social status, meaning MIH‐Group > MIH‐0 <0.00 1.64 1.60 1.66
that at least one parent had an academic degree. QHI (mean) MIH‐1 1.66 1.56 1.75
MIH‐2 2.77 2.58 2.95
3.2 | Main results MIH‐3 3.63 3.32 3.93

In total, 5859 teeth were examined, of which, 46.2% were MIH‐Group > MIH‐0 <0.00 0.22 0.18 0.25
SCASS (mean) MIH‐1 0.22 0.17 0.26
primary teeth and 53.8% were permanent teeth. Among the
primary teeth, the second primary molars showed DMH MIH‐2 1.34 1.24 1.42
(8.2% of all second primary molars and 2.4% of all primary MIH‐3 2.08 1.93 2.22
teeth) most frequently. The second most commonly affected MIH‐Group > MIH‐0 <0.00 0.56 0.46 0.65
teeth were the primary canines (5.7% of all primary canines WBFS (mean) MIH‐1 0.68 0.55 0.80
and 1.6% of all primary teeth). The mandibular canines were
MIH‐2 3.57 3.34 3.79
more frequently damaged than the maxillary canines. Only
15 other primary teeth were affected by DMH (12.4% of all MIH‐3 6.14 5.76 6.51
DMH‐affected primary teeth). Considered as significant if P‐value <0.05.
6
| EBEL
Table 2 classifies the patients, rather than the teeth, into
severity categories, as explained in the materials and meth-
ods section. Of the participants, 62.8% (157 of 250
patients) had mildly affected teeth and were classified to
the LSC (severity score: 0), compared to 23.6% to the
MSC (severity score: 2‐4) and 13.6% to the HSC (severity
score: >4). For all measured variables (QHI, SCASS, and
WBFS), the mean score increased for higher severity cate-
gories. The mean QHI increased significantly from 1.54 in
the LSC to 2.18 in the HSC. Between the LSC and MSC
as well as the MSC and HSC, the differences in the QHI
were not significant due to overlapping confidence inter-
vals. For the SCASS and WBFS, all three groups differed
in a highly significant manner (P = 0.00). The mean
SCASS increased from 0.22 in the LSC to 1.03 in the
HSC. The same tendency was shown in the increase in the
mean WBFS from 0.59 in the LSC to 2.90 in the HSC.
Table 3 differentiates the participants of the individual
severity categories by gender, social status, and caries risk.
Concerning the gender distribution, boys and girls were
approximately equally distributed in the LSC (girls:
51.6%). In the MSC, the amount of girls was relatively
lower (35.6%). In the HSC, the girls were slightly more
prevalent at 64.7%. Social status had a small impact on the
distribution within the severity categories. Children who
belonged to the high social status group were generally
speaking less prevalent compared to the average. Addition-
ally, the percentage in the LSC among the high social sta-
tus group was the highest (29.9%), which was marginally
higher than in the other two categories (MSC: 20.3% and
HSC: 20.6%). Of the children, 45 (18%) showed an
increased TDR according to the DAJ criteria. The percent-
ages of discrepancy in the three groups were only minor
(LSC: 17.2%; MSC: 22.0%; HSC: 14.7%).
In Table 4, the participants were initially classified into
their appropriate dmft/DMFT group according to the WHO
Test analysis (n = 250 patients)
Dependent var > Severity P‐value
independent var category (Model) Mean
Severity Category > Low (n = 157) 1.54
QHI (mean) Medium (n = 59) <0.00 1.79
High (n = 34) 2.18
Severity Category > Low (n = 157) 0.22
SCASS (mean) Medium (n = 59) <0.00 0.57
High (n = 34) 1.03
Severity Category > Low (n = 157) 0.59
WBFS (mean) Medium (n = 59) <0.00 1.62
High (n = 34) 2.90
Considered as significant if P‐value <0.05.
ET AL.
criteria and then into the severity categories. In the dmft/
DMFT group of patients aged 3‐5 years old (n = 29), no
continuous increase in the mean dmft/DMFT could be
detected (mean dmft/DMFT: LSC: 1.17; MSC: 2.31; HSC:
1.00). The same finding accounts for the children aged 10‐
15 years old (n = 85). Also, for this age group, no continu-
ous increase in the dmft/DMFT could be detected (mean
dmft/DMFT: LSC: 0.90; MSC: 1.30; HSC: 0.37). In the
age group of 6‐9 years old, a continuous increase in the
mean dmft/DMFT could be seen (mean dmft/DMFT: LSC:
1.74; MSC: 2.31; HSC: 3.24), yet the results were not sig-
nificant due to overlapping confidence intervals.
Table 5 showed that, in total, 56 patients in the entire
examination group (250 children) complained about PwIoF
(22.4%). The PwIoF was subsided into three different fields
(PwIo hot or cold food, PwIo solid food, and PwIo spicy
food) together with the total values in relation to the MIH/
DMH severity categories. The evaluation shows a rising
probability of PwIoF in the higher severity categories. Only
0.6% of the LSC patient group announced nutritional
restrictions, in contrast to 79.4% in the HSC group. This
testing was significant (P = 0.000). All patients who had
dietary restrictions also had issues with hot or cold food.
Additionally, the second most occurring restriction was the
chewing of solid food. Intake of spicy food caused the
least problems. The rising tendency from the LSC to the
HSC was maintained.
3.3 | Further analyses
The quantitative variables (SCASS and WBFS) showed a
significant effect on QHI and a high correlation with each
other (see Appendix A). This is a necessary condition for
testing the intervening effects of our pain measurements
(SCASS and WBFS) when estimating the effects of MIH/
DMH through PwIoF on QHI (Figure 2). The intervening
T A B L E 2 Tests for significant
differences between severity category
95% CI 95% CI specific means (patients) concerning QHI,
Lower bound Upper bound SCASS, and WBFS, including 95%
1.41 1.67 confidence intervals (95% CI)
1.63 1.95
1.91 2.45
0.16 0.28
0.45 0.68
0.80 1.26
0.43 0.75
1.32 1.91
2.32 3.48
EBEL ET AL. | 7

T A B L E 3 Ratios for different severity categories concerning gender, social status and tooth decay severity
Severity score 0 Severity score 2‐4 Severity score >4
Low’ Medium’ High’
Reference category Category 1 Category 2
Model
n % n % n % P‐value
Total n = 250 157 62.8% 59 23.6% 34 13.6%
Gender “female,” n = 124 (vs “male”) 81 51.6% 21 35.6% 22 64.7% <0.00
Social Status “high,” n = 66 (vs “average”) 47 29.9% 12 20.3% 7 20.6% <0.00
Tooth Decay Severity “high,” n = 45 (vs “average”) 27 17.2% 13 22.0% 5 14.7% 0.62

Considered as significant if P‐value <0.05.

T A B L E 4 Tests for significant Dependent var > P‐value 95% CI 95% CI

differences between severity category independent var MIH‐group (Model) Mean Lower bound Upper bound
specific means (patients) concerning three
Severity Category > Low (n = 18) 1.17 0.03 2.30
dmft variations including 95% confidence
dmft (mean), Medium (n = 6) 0.93 1.50 −1.87 4.87
intervals (95% CI)
3‐5 years, n = 29
High (n = 5) 1.00 −0.24 2.24
Severity Category > Low (n = 79) 1.74 1.13 2.34
dmft/DMFT Medium (n = 36) 0.09 2.31 1.41 3.21
(mean), 6‐9 years,
High (n = 21) 3.24 1.68 4.80
n = 136
Severity Category > Low (n = 60) 0.90 0.41 1.39
DMFT (mean), Medium (n = 17) 0.51 1.30 0.22 2.37
10‐15 years, n = 85
High (n = 8) 0.37 −0.25 1.00
Considered as significant if P‐value <0.05.

effects are defined as the sum of all indirect effects (see
Appendix B). The analysis revealed a significant
(P = 0.035) positive total indirect standardised effect via
the SCASS (pathway A) and a not significant total indirect
standardised effect via the WBFS (pathway B).
4 | DISCUSSION
The present study has shown significant relationships
between the severity and number of MIH‐/DMH‐affected
teeth and the resulting hypersensitivity (SCASS/WBFS),
oral hygiene (QHI), and dietary restrictions (PwIoF). The
TDR based on the DAJ criteria did not show a relationship
with the MIH severity categories. Also, the mean value for
the dmft/DMFT only increased among children in the
mixed dentition phase as the MIH severity category
increased, but the results were not significant. Since the
evaluation of the hypersensitivity of MIH teeth mainly
depends on the individual's perception of pain, it might be
influenced by the environment (a more calming environ-
ment, often found in specialised paediatric practices, can
result in lower SCASS and WBFS scores), the temperature
of the room (examinations performed during winter or

T A B L E 5 Ratios for different severity Severity Score 0 Severity Score 2‐4 Severity Score >4
categories concerning problems with intake Low’ Medium’ High’
of food (PwIoF) Reference category Category 1 Category 2
n % n % n %
Total n = 250 157 62.8% 59 23.6% 34 13.6%
PwIoF “yes,” n = 56 1 0.6% 28 47.5% 27 79.4%
PwIo hot or cold Food 1 0.6% 28 47.5% 27 79.4%
“yes,” n = 56
PwIo solid Food “yes,” n = 35 1 0.6% 14 23.7% 20 58.9%
PwIo spicy Food “yes,” n = 21 0 0.0% 7 11.9% 14 41.2%
8
| EBEL
summer increase or decrease the SCASS and WBFS,
respectively), the presence or absence of parents or a care-
giver during the examination (which decreases or increases
the SCASS and WBFS, respectively), and the temperature
of the airflow applied to the teeth. Furthermore, the QHI is
very much dependant on the patient's oral hygiene before
the appointment; therefore, discussing the study design
with the parents and children before the appointment at
which the QHI was taken could possibly direct the oral
hygiene procedure towards a more profound hygiene pro-
cess, which would result in higher QHI values. Since most
of these potential sources of bias can be minimized, as
explained in the setting section of the Materials and Meth-
ods section, their influence on the study results can be
rated rather low.
The analyses of the overall data in terms of study
cohorts showed that more than half of the MIH/DMH par-
ticipants were between 6 and 9 years old, and almost three‐
quarters of the participants were in the mixed dentition
phase; however, no gender‐specific differences were
detected. These observations coincide with those of similar
studies.4,22-25 Concerning the number of affected teeth per
patient (approximately one‐third had 1 tooth affected, one‐
fourth had 2 teeth affected, and a bit less than half had >2
teeth affected), our distribution of structurally damaged
teeth was equivalent to those of comparable studies.1,4
These facts show the representative character of our con-
secutive sample.
Considering the essential question of this study examin-
ing the relationship between DMH/MIH and oral hygiene,
the results prove that issues exist. These results coincide
with those of related studies.1,4,25 As expected, with an
increase in MIH/DMH severity, a rise in hypersensitivity
(SCASS and WBFS) and a deterioration in oral hygiene
(QHI) were seen. When evaluating this relationship on the
basis of individual teeth, as seen in Table 1, the effects are
much more pronounced than when compared to Table 2,
which reflects the patients’ entire dentition. A reason might
be that the MIH‐/DMH‐affected teeth and the neighbouring
teeth received less hygiene due to their increased hypersen-
sitivity. The increase in the QHI from 1.54 (LSC) to 2.18
(HSC) was significant but relatively minor. The mean QHI
for all patients was 1.69. Due to numerous differences in
the study designs and patients’ medical histories, these data
are difficult to compare to the given studies.26 Assuming
that a higher plaque accumulation (QHI) may be a reason
for higher caries risk,14-16 the situation emerged as follows:
the unaffected and mildly affected teeth again showed no
statistically different QHI scores; therefore, no increase in
caries risk is expected, in contrast to the moderately
affected and severely affected teeth. The affected teeth
showed much higher sensitivity to cold stimuli, and the
ability to maintain proper oral hygiene drastically
ET AL.
decreased, which was reflected by an increase in the QHI.
This should have also increased the caries risk of those
teeth. The finding was in line with the expectations that
teeth presenting a mild defect are unlikely to present signif-
icant changes in the enamel surface area and that mildly
affected teeth are usually not hypersensitive.21 One expla-
nation might be the increasing severity of the MIH/DMH,
which leads to poorly brushed teeth and poor oral hygiene
due to heightened surface roughness and enhanced sensitiv-
ity. This assumption was confirmed by the observations
regarding the sensitivity to air stimuli (SCASS) and the
participants’ experienced pain (WBFS), both of which
increased along with the MIH value. The values between
unaffected and mildly affected teeth did not differ signifi-
cantly, whereas the SCASS and WBFS values of the mod-
erately and severely affected teeth showed highly
significant increases due to their nonoverlapping confidence
intervals.
Regarding the three severity categories, as described
before, almost two‐thirds of the patients were included in
the LSC, followed by approximately one‐fourth of the
patients in the MSC. The proportion of over one‐third of
patients having teeth ranked in the HSC appears to be
rather high; however, this is because classification used
here is not comparable to those of previously published
prevalence studies.8,25 These studies mainly differentiate
teeth according to tooth severity types,21 whereas we dif-
ferentiated patients according to severity categories. The
classification into severity categories also showed increas-
ing sensitivity and pain values with increases from LSC to
HSC. The evaluation clearly shows the relationship
between the degree of severity, the sensitivity of the teeth
to thermal stimuli, and felt pain experienced. The slight
differences between the control teeth (unaffected) and
mildly affected teeth seem to be a result of the classifica-
tion; in that, these teeth are usually not associated with
hypersensitivity.13,27 Coinciding with the study results, an
increasing sensitivity to air stimuli (SCASS) led to a sig-
nificant increase in the felt pain (WBFS), explained by the
reciprocal relationship seen in the scheme (Appendix B).
Furthermore, even the HSC patients had a slight increase
in the QHI; this moderate increase in the QHI most likely
has little effect on the overall caries risk of the remaining
teeth. This is also reflected by the present study's caries
risk evaluation. Concerning the DAJ criteria, no connection
with the MIH/DMH severity categories could be detected,
and the dmft/DMFT values showed only a tendency
towards increasing values. The dmft/DMFT values repre-
senting primary and permanent teeth showed no clear sta-
tistically significant variation, which was apparently due to
the reduced sample sizes, especially for the primary teeth.
For example, the age group of 3‐5 years old only con-
tained 29 children, of whom, only one‐third were placed in
EBEL ET AL.
the HSC. For that reason, the comparison of all dmft/
DMFT values was rather difficult. In the largest group of
6‐9 years old, the expected result of an increasing dmft/
DMFT with an increasing MIH/DMH severity could be
observed; however, it must be conceded that the anamnes-
tic conditions were very different from those of similar
studies. An important consideration is the rather small
patient pool of this study compared to those of studies
which are epidemiologically associated with dental caries
evaluation.7,28-30
Moreover, this study's patient pool was obtained from a
dental practice which is the only specialised paediatric
practice in the recruitment area of 100 000 inhabitants.
Thus, the patient population included many children in
need of restorative treatment, which might have led to
increases in the dmft/DMFT Index. Apart from that, many
children were included in an intensive prophylaxis pro-
gramme, which might have reduced their dmft/DMFT
scores compared to other cohorts. The inconsistent patient
population could have caused the variations in the dmft/
DMFT values within the individual age groups. Consider-
ing this, a significant relationship cannot be observed
between the dmft/DMFT Index and the severity categories.
The statistical analysis, tested with correlation and
regression analyses, SCASS and WBFS, revealed a highly
significant relationship to the QHI, within a global model,
wherein we simultaneously evaluated the PwIoF. Based on
these findings, we conclude that children with hypersensi-
tive teeth are not brushing the affected teeth as efficiently.
In this context, parents or caregivers and dental health care
professionals should be aware of this condition and should
be informed to supervise—and assist with, if necessary—
the children's oral hygiene.
This study has manifested an association between the
rising severity of MIH/DMH and the probability of encoun-
tering PwIoF. This issue is becoming even greater with
increases in the affected teeth and rising severity of the
MIH/DMH disease. This clearly proves the severity classi-
fication of the patients. Children in the LSC basically
showed no dietary restrictions, as opposed to those in the
HSC, almost all of whom had PwIoF. The study results
also proved that the amount of different types of increased
dietary restrictions changed as a function of the severity of
MIH/DMH. One of the reasons for these phenomena might
be the more pronounced demineralisation and thus heavier
loss of tooth substance, which involves an increasing sever-
ity of hypomineralisation, which leads to hypersensitivity
of the affected teeth towards thermal and chemical stimuli,
which is manifested in pain perception. It is important to
understand the extent to which the MIH/DMH causes prob-
lems for the patient. The high incidence of MIH/DMH
worldwide does not mean that the OHRQoL is restricted to
the same degree. Although HSC‐affected patients are in
| 9
need of therapy because of limited oral health‐related qual-
ity of life, the LSC patients will probably not be symp-
tomatic and therefore are not in need of therapeutic
intervention.
The results of this study are valid for every patient pre-
senting with MIH‐/DMH‐affected teeth, since the symp-
toms, depending on the severity category, are very similar
between patients worldwide. Independent from the MIH
prevalence in the present region, the issues of the affected
patients must be seen individually. Because of that, this
study's results can be used to categorise patients into indi-
vidual risk categories.
5 | CONCLUSION
This study has shown how closely a significant increase in
plaque accumulation (QHI) is associated with increased
MIH/DMH severity types, in terms of a dose‐effect relation-
ship. Furthermore, it was demonstrated how oral hygiene
efficacy significantly decreases with rising hypersensitivity,
measured by the SCASS or WBFS, of the MIH‐affected
teeth. A severity grade‐dependent increase in the TDR and
an increase in the dmft/DMFT values could not be detected.
Moreover, MIH/DMH severity also has a systemic
impact via impaired food intake. In clinical practice, more
attention must be paid to desensitising hypomineralised
teeth to enable adequate oral hygiene and thus improve the
oral health of affected children and adolescents, as a pre-
requisite for systemic health with respect to unimpaired
nutrition.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
AUTHORS’ CONTRIBUTION
M.E., K.B., and C.H. conceived the premise of the study.
M.E. performed the clinical testing, led the data collection,
and wrote the manuscript. C.K. analysed the data, com-
pleted the statistical analysis, and wrote the statistical por-
tion of the manuscript. K.B., C.H., and C.K. interpreted the
results and critically reviewed the manuscript.
ORCID
Markus Ebel http://orcid.org/0000-0002-4023-7470
REFERENCES
1. Weerheijm KL, Jälevik B, Alaluusua S. Molar–incisor hypomin-
eralisation. Caries Res. 2001;35:390‐391.
10
| EBEL
2. Baroni C, Marchionni S. MIH supplementation strategies:
prospective clinical and laboratory trial. J Dent Res. 2010;90:371‐
376.
3. Bekes K, Hirsch C. What is known about the influence of dentine
hypersensitivity on oral health‐related quality of life? Clin Oral
Investig. 2013;17:45.
4. Lygidakis NA, Wong F, Jälevik B, Vierrou A, Alaluusua S, Espe-
lid I. Best Clinical Practice Guidance for clinicians dealing with
children presenting with molar‐incisor‐hypomineralisation (MIH).
Eur Arch Paediatr Dent. 2010;11:75‐81.
5. Jälevik B, Klingberg GA. Dental treatment, dental fear and beha-
viour management problems in children with severe enamel
hypomineralization of their permanent first molars. Int J Pediatr
Dent. 2002;12:24‐32.
6. Weerheijm KL, Duggal M, Mejare I, et al. Judgement criteria for
molar incisor hypomineralisation (MIH) in epidemiologic studies:
a summary of the European meeting on MIH held in Athens,
2003. Eur J Paediatr Dent. 2003;4:110‐113.
7. Petrou MA, Giraki M, Bissar A-R, et al. Molar‐incisor‐hypomi-
neralisation (MIH): prevalence and therapeutic needs in Germany.
Dtsch Zahnärztl Z. 2014;69:647‐650.
8. Heitmueller D, Thiering E, Hoffmann U, et al. Is there a relation-
ship between hyperactivity/inattention symptoms and poor oral
health? Results from the GINIplus and LISAplus study. Clin Oral
Investig. 2013;17:1329‐1338.
9. Jälevik B. Prevalence and diagnosis of molar‐incisor‐hypominera-
lisation (MIH): a systematic review. Eur Arch Paediatr Dent.
2010;11:59.
10. Schwendicke F, Elhennawy K, Reda S, Bekes K, Manton DJ,
Krois J. Global burden of molar incisor hypomineralization. J
Dent. 2018;68:10‐18.
11. Silva MJ, Scurrah KJ, Craig JM, Manton DJ, Kilpatrick N. Etiol-
ogy of molar incisor hypomineralization–a systematic review.
Commun Dent Oral Epidemiol. 2016;44:342‐353.
12. Weerheijm KL. Molar incisor hypomineralisation (MIH). Eur J
Paediatr Dent. 2003;4:115‐120.
13. Quigley GA, Hein JW. Comparative cleansing efficiency of man-
ual and power brushing. J Am Dent Assoc. 1962;65:26‐29.
14. Menghini G, Steiner M, Imfeld T. Early childhood caries—facts
and prevention. Ther Umsch. 2008;65:75‐82.
15. Walsh LJ. Dental plaque fermentation and its role in caries risk
assessment. Int Dent South Afr. 2006;8:34‐40.
16. Newman HN. The relation between plaque and dental caries. J R
Soc Med. 1986;79:1‐5.
17. DAJ: Deutsche Arbeitsgemeinschaft für Jugendzahnpflege e.V.
DAJ-Grundsätze zur Definition von Kindern mit Hohem Karies-
risiko. Bonn: Presseinformation; 1993.
18. Schiff T, Dotson M, Cohen S, De Vizio W, McCool J, Volpe A.
Efficacy of a dentifrice containing potassium nitrate, soluble
pyrophosphate, PVM/MA copolymer, and sodium fluoride on
dentinal hypersensitivity: a twelve‐week clinical study. J Clin
Dent. 1994;5:87‐92.
ET AL.
19. Wong DL, Baker CM. Pain in children: comparison of assesment
scales. Pediatr Nurs. 1988;14:9‐17.
20. Bekes K, John MT, Schaller H-GG, Hirsch C. The German ver-
sion of the child perceptions questionnaire on oral health‐related
quality of life (CPQ‐G11‐14): population‐based norm values. J
Orofac Orthop. 2011;72:223‐233.
21. Mathu-Muju K, Wright JT. Diagnosis and treatment of molar
incisor hypomineralization. Compend Contin Educ Dent.
2006;27:604‐610; quiz 611.
22. Krishnan R, Ramesh M. Molar incisor hypomineralisation: a
review of its current concepts and management. SRM J Res Dent
Sci. 2014;5:248‐252.
23. Allazzam SM, Alaki SM, El Meligy OA. Molar incisor hypominer-
alization, prevalence, and etiology. Int J Dent. 2014;2014:234508.
24. Ahmadi R, Ramazani N, Nourinasab R. Molar incisor hypominer-
alization: a study of prevalence and etiology in a group of Iranian
children. Iran J Pediatr. 2012;22:245‐251.
25. Jasulaityte L, Weerheijm KL, Veerkamp JS. Prevalence of molar‐
incisor‐hypomineralisation among children participating in the
Dutch National Epidemiological Survey (2003). Eur Arch Paedi-
atr Dent. 2008;9:218.
26. Sharma A, Arora R, Kenchappa M, Bhayya DP, Singh D. Clini-
cal evaluation of the plaque‐removing ability of four different
toothbrushes in visually impaired children. Oral Health Prev
Dent. 2012;10:219‐224.
27. Knapp V, Nies S. Molar‐incisor‐hypomineralization. Zahnmedizin
Up2date. 2009;3:491‐510.
28. Elfrink MEC, Cate JM, Jaddoe VWV, Hofman A, Moll HA,
Veerkamp JSJ. Deciduous molar hypomineralization and molar
incisor hypomineralization. J Dent Res. 2012;91:551‐555.
29. Condò R, Perugia C, Maturo P, Docimo R. MIH: epidemiologic
clinic study in paediatric patient. Oral Implantol. 2012;5:58‐69.
30. Bekes K, Zyriax R, Schnaller HG, Hirsch C. Does dental caries
have an impact on oral health‐related quality of life inchildren
and adolescents? Oralprophylaxe. 2010;32:176‐181.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
How to cite this article: Ebel M, Bekes K, Klode C,
Hirsch C. The severity and degree of
hypomineralisation in teeth and its influence on oral
hygiene and caries prevalence in children. Int J
Paediatr Dent. 2018;00:1–10. https://doi.org/10.1111/
ipd.12425