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49
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
Molar incisor hypomineralization: Prevalence
and defect characteristics in Indian
schoolchildren
Neeti Mittal, Bharat B. Sharma
Department of Pediatric and Preventive Dentistry, Santosh Dental College and Hospital, Ghaziabad, Uar Pradesh, India
Access this article online
Quick Response Code: Website:
www.craniomaxillary.com
DOI:
10.4103/2278-9588.151904
Correspondence to:
Dr. Neeti Mial, Department of Pediatric and Preventive Dentistry, Santosh Dental College and Hospital, Ghaziabad, Uar Pradesh, India.
E‑mail: dr.neetipgi@gmail.com
describing this condition as “idiopathic enamel
hypomineralization” was reported from Sweden.[2]
Since then, a number of terms have been employed
to address this condition, i.e. idiopathic enamel
hypomineralization,[2] hypomineralized FPMs,[3]
non‑fluoride hypomineralization,[4] and cheese
molars.[5] The present terminology and uniform
definition were coined during the fifth Congress of the
European Academy of Paediatric Dentistry (EAPD).[1]
MIH is gaining considerable interest amongst
epidemiologists and clinicians worldwide probably
owing to its widespread presence and clinical
impact.[1,6,7] MIH defects vary on a clinical spectrum
INTRODUCTION
Molar incisor hypomineralization (MIH) has
been described as the hypomineralization of one
to four first permanent molars (FPMs) with/without
concomitant involvement of the permanent
incisors (PIs).[1] The very first epidemiological study
ABSTRACT
Objectives: To report the prevalence and clinical features of molar incisor hypomineralization (MIH) in 8‑12‑year‑old
Indian schoolchildren.
Study Design: A cross‑sectional survey including a random sample of 1,240 schoolchildren aged 8‑12 years from
Gautam Budh Nagar was conducted. The examination was performed by a single, well‑trained calibrated examiner
in wet conditions using an articial light source. The diagnostic criteria were set as per the European Academy of
Paediatric Dentistry (EAPD) 2003 criteria. Restorative treatment needs (RTN) owing to MIH were calculated as the
number of affected subjects with post‑eruptive breakdown (PEB), quantitative loss of tooth substance, or caries
owing to MIH. The descriptive data were expressed as mean ± SD and/or n (%). For data analysis, the t‑test and the
Wilcoxon signed‑rank test were used.
Results: A prevalence of 10.48% (130/1240) was reported, with RTNs in 42.31% (55/130). Buccal surfaces were the
most commonly affected surfaces (P < 0.001), while white opacity was the commonest lesion (P < 0.001). Both the
arches were equally affected (P = 0.212), with mandibular rst permanent molars (FPMs) being the most frequently
affected type of teeth (P = 0.001).
Conclusion: The present study reported a prevalence of 10.48% with RTNs in 42.31% of the affected subjects.
Further studies mapping the prevalence from various other geographical areas of India are required.
Keywords: India, MIH prevalence, MIH severity, molar incisor hypomineralization
Original Article
Mittal and Sharma: Prevalence of molar incisor hypomineralization in Indian children
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
50
from being isolated creamy white opacities to
yellowish brown discolorations with/without
structural defects [post‑eruptive breakdown (PEB)].[1]
There exist wide disparities in the reported
prevalence rates of MIH. The reported prevalence
rate of 2.8% from Hong Kong[8] lies at the lower end,
while the highest rate (40.2%) hasbeen reported
among Brazilian subjects.[9] The prevalence of MIH
has been reported globally but major chunks of
data were generated from European regions. The
reported range of prevalence in these countries
is 3.6[2] ‑37.5%.[10] The data reported from Asian
countries[8,11‑14] are scant.
There are ongoing discussions on this subject
regarding whether these widely varying prevalence
rates are truly due to real differences between study
populations. The basis of this thought lies in the fact
that uniform criteria for the recording of MIH have
only been proposed as late as in 2003.[15] Prior to
this, non‑uniform methods of recording MIH were
employed. These often included the Developmental
Defects of Enamel (DDE) index[16] or even individual
authors’ self‑invented diagnostic criteria.[4,17,18]
Further, the inclusion of varying cohorts of age
groups and improper examination conditions such
as the absence of artificial light source and/or
non‑calibrated examiners could have contributed
to methodological flaws.[19]
Owing to this, there is currently a need to map
the prevalence of MIH on the basis of the EAPD
criteria. This is especially true for regions of Asia
including India, as preliminary reports have
shown that MIH is a significant problem in these
regions.[11‑14] Both of the earlier Indian studies[13,14]
examined the subjects in natural light and because
of this, the prevalence rates (6.31%, 9.2%) may have
been underreported. Further, in one study younger
children, i.e. 6‑9‑year‑olds were examined.[13]This
could also have contributed to a lower prevalence
rate, as not all teeth have erupted at this stage. This
information highlights the fact that there is a relative
lack of data on the prevalence of MIH in Indian
children.
Keeping this in mind, the present study was
planned to report the prevalence of MIH in Indian
schoolchildren.
MATERIALS AND METHODS
Study design and sampling procedure
The present study was approved by the
Institutional Ethical Committee and the Review
Board. This cross‑sectional observational study was
conducted in Gautam Budh Nagar District, Uttar
Pradesh, India. This district is located in northern
India, one of the fastest‑growing regionsof India.
The district has a population of 1,674,714, with a
literacy rate of 82.2%.[20] The ground‑water fluoride
levels in the city range from 0.27 to1.2 pm.
The study population comprised 1,240 children
8‑12 years old, studying in schools in Gautam
Budh Nagar. The preset target population for
the present study had been 1,000; however, we
exceeded our target and finally examined a total
of 1,240 children. Schools were selected randomly
according to the number of schools in each area
to ensure broad geographical and socioeconomic
coverage. Only private schools from urban areas
were selected. A written elaboration of the condition
MIH and its impact on overall oral health was sent
to the administrative authorities of the schools.
Then, written permission was sought to conduct oral
examination in those schools. Informed parental
consents were obtained by school authorities.
Cohorts of children born in 2000‑2004 and
studying in selected schools in the academic year
2012‑2013 were included. A stratified random
sample was selected and every fifth child from
the targeted age group was included.Only those
children with fully erupted FPMs and PIs and for
whom there was parental consent were included
in the present study. Children presenting with
other developmental defects such as amelogenesis
imperfecta, dentinogenesis imperfecta, tetracycline
staining, or diffuse hypoplastic lesions (i.e. fluorosis)
on index teeth were excluded from the study.
Schools for children with special health‑care
needs were excluded. Also, children with grossly
brokenand/or missing FPMs where the causes of
breakage or tooth loss could not be determined
were excluded from the study.
Study settings, examination and diagnostic
criteria
The examinations were conducted in the
children’s respective schools. School teachers
Mittal and Sharma: Prevalence of molar incisor hypomineralization in Indian children
51
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
with PEB, quantitative loss of tooth substance, or
caries owing to MIH were classified as defects with
restorative treatment needs (RTN). The atypical
restorations with marginal breakdown in need of
repair or replacement were also included in this
category.
Data analysis
The entire sets of data were first entered on
structured pre‑printed proforma. These proforma
and/or case sheets had provisions to record each
subject’s demographic details and surface‑wise
record of defect type and extent. From the proforma
data were entered in Excel spreadsheets (Microsoft
Office®, Microsoft®, Redmond, Washington, USA)
and then transported to SPSS® version 22 (IBM,
New York, USA) for statistical analysis. Descriptive
statistics were calculated to be expressed as
mean ± SD and/or number (percentage).
Comparative intra‑group and inter‑group statistics
were computed using the student’s t‑test. A P value
of ≤0.05 was considered to be statistically
significant.
RESULTS
A total of 130 out of 1,240 subjects were found
to be affected with MIH, resulting in an overall
prevalence rate of 10.48%. The mean age of
subjects was 8.73 ± 1.833 years. The majority of
subjects were 8 year‑olds. A total of 71 males and
59 females were reported to be affected. Both sexes
presented with similar numbers of affected teeth,
i.e. 4.28 ± 1.951 teeth/subject in males versus
4 ± 2.742 teeth/subject in females (P = 0.496).
A total of 4.15 ± 2.338 teeth/subject and
6.95 ± 5.255 surfaces/subject were reported
to be affected with MIH. The maximum number
of subjects presented with 4 affected teeth
(range 1‑12) [Figure 1]. Buccal surfaces were
the most commonly affected surfaces, while
the lingual surfaces were least commonly
involved [Table 2]. An equivalent predilection
was reported for maxillary and mandibular teeth.
Mandibular FPMs were the most commonly
affected teeth, while mandibular PIs were the least
commonly affected teeth [Table 3, Figure 2a and
b]. Concomitant involvement of PIs was reported
in 61/130 (46.92%) subjects.
were instructed to ensure that students brushed
prior to the examination. Any remaining debris
were removed by making the child rinse again. If
required, remnants of debris were removed by using
the blunt‑ended probe.Examination was performed
using dental mirror, blunt probe, and a source of
artificial light.
The entire examination was conducted by an
examiner (NM) actively involved in MIH research
and clinical management. The details of calibration
of the examiner have been published elsewhere[13].
The intra‑examiner reliability was computed by
re‑examining 10% of total sample on the day of
examination. The kappa statistics for intra‑examiner
reliability were reported as excellent, i.e. 0.97.[21]
EAPD 2003 diagnostic criteria[7,15] [Table 1] were
used to score defects of index teeth (FPMs and PIs).
A tooth was considered to have erupted when more
than half of it was visible in the oral cavity. Surfaces
examined included buccal, palatal/lingual, and
occlusal. A positive finding was recorded when
defectdimensionswere≥2mm.[16] The extent of the
defects was scored according to the surface area
of involvement.[16] Defects were graded as Defect
1 (<1/3rd of tooth surface), Defect 2 (involving
1/3rd to 2/3rd of tooth surface), and Defect
3 (>2/3rd of tooth surface). The severity of defect
was graded employing criteriaas per Mittal et al.’s
criteria.[13] The gradation criteria in ascending order
of severity were creamy white opacities without
breakdown (mild), yellowish brown opacities without
breakdown (moderate), and creamy white or
yellowish brown opacities with breakdown/atypical
restorations/extraction (severe). Defects presenting
Table 1: Diagnostic criteria for MIH as proposed by EAPD
2003*
Demarcated opacity (white/creamy-white/yellowish/yellowish
brown)
Posteruptive breakdown; PEB (loss of surface enamel often
associated with a preexisting opacity)
Atypical restorations (frequently extended to the buccal or
palatal smooth surfaces, reecting the distribution of hypoplastic
enamel and often associated with opacities at margin)
Extracted tooth because of MIH
*Examination to be performed in wet conditions: Index teeth;
FPMs and PIs, index age group: 8-12 years. MIH=Molar incisor
hypomineralization, EAPD=European Academy of Paediatric Dentistry,
PEB=Post-eruptive breakdown
Mittal and Sharma: Prevalence of molar incisor hypomineralization in Indian children
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
52
The most commonly observed lesion type was
creamy white opacity (P = 0.000) [Table 4]. Out
of a total of 906 affected surfaces, the majority,
i.e. 691 (76.27%) had creamy white opacities,
while the rest, i.e. 215 (23.73%) had yellowish
brown opacities.PEB was noted more often in
yellowish brown opacities compared to creamy
white opacities (P = 0.000) [Table 4]. A significantly
lower number of affected surfaces had >2/3rd of
surface area involvement compared to ≤2/3rd of
surface area involvement, i.e. Defect 1 and Defect
2 (P = 0.000) [Table 4].Defects with greater
than >1/3rd of surface area involvement were more
often associated with PEB (R = 0.25; P = 0.004).
Also, brown opacities were found to be positively
associated with PEB (R = 0.90; P = 0.000). Applying
Mittal et al.’s criteria to assess defect severity, it was
found that 59/130 (45.38%) subjects had mild
defects, 16/130 (12.31%) had moderate defects,
and 55/130 (42.31%) subjects had severe defects.
A total of 1.32 ± 1.934 affected surfaces/subject
presented with PEB. A total of 42.31% (55/130) of
subjects had RTNs owing to MIH.
For most of the parameters, no significant
difference could be observed in the two analyzed
age groups [Table 5]. However, more severe defects
were observed in older age groups as a significantly
greater number of surfaces exhibited PEB in
children > 10 years of age (P = 0.016).
Figure 1: Frequency distribution of affected teeth/subject
Table 3: Distribution of defect by affected tooth type
Tooth type Mean±SD P*
Maxillary incisor 0.85±1.264 0.000†
Mandibular incisor 0.34±0.885
Maxillary FPMs 1.32±0.874 0.001†
Mandibular FPMs 1.64±0.659
Maxillary teeth 2.18±1.714 0.212
Mandibular teeth 1.98±1.204
*Calculated on the basis of the student’s t-test, †Signicant P value.
SD=Standard deviation, FPMs=First permanent molars
Table 2: Surface-wise distribution of MIH
Surface Mean±SD P
Occlusal 2.75±2.456 ≤0.001*†
Buccal 3.39±2.547
Lingual 0.83±1.490
*Signicant P value †Calculated on the basis of the Wilcoxon signed-rank
test. MIH=Molar incisor hypomineralization
Figure 2: Distribution of MIH according to tooth type
Table 4: Distribution of defect type and extent in study
population
Defect characteristic Mean±SD P*
Creamy-white opacity 5.32±4.649 0.000†
Yellowish brown opacity 1.65±2.281
PEB 1.32±1.934 -
Creamy white opacities
with breakdown
0.05±0.227 0.000†
Yellowish brown
opacities with breakdown
1.26±1.919
≤1/3rd of surface area
involved (defect 1)
3.46±3.912 0.328‡; 0.000†§
1/3rd to 2/3rd of surface
area involved (defect 2)
2.90±4.295 0.328; 0.000†§
≥2/3rd of surface area
involves (defect 3)
0.65±3.140 0.000†||; 0.000†‡
*Calculated using the student’s t-test, †Signicant P value, ‡wrt defect 2,
§wrt defect 3, ||wrt defect 1. SD=Standard deviation, PEB=Post-eruptive
breakdown
Mittal and Sharma: Prevalence of molar incisor hypomineralization in Indian children
53
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
DISCUSSION
MIH is a condition of clinical interest.[6,22,23]
The affected teeth, in addition to posing esthetic
concerns, are prone to undergo PEB soon after
eruption owing to masticatory forces. PEB coupled
with high sensitivity often compromises the oral
hygiene of the affected teeth.[23] Further, carious
involvement of such teeth leads to rapid decay,[23]
which can even result in the necessity of untimely
removal of teeth.[24] MIH lesions are dynamic,
and early diagnosis and preventive therapies can
minimize such consequences. The importance of
early diagnosis stresses the need for prevalence
data, which are lacking in Asian countries
including India. The need for research to map MIH
prevalence in different geographical locations has
been stressed earlier too. Bearing these facts in
mind, we conducted the present study to report the
prevalence rate of MIH in a northern Indian region.
We employed a stratified random sampling
technique and were able to recruit 1,240 subjects.
Thus, the sample can be considered to be
representative of the study population.We used the
EAPD diagnostic criteria to assess MIH, which is
currently an expert consensus‑based, validated, and
reproducible set of criteria to diagnose and record
MIH.[7,15] It has been developed and introduced
to epidemiologists to ensure uniform recording
and reporting of prevalence data of MIH globally.
The examinations of the entire study population
were carried out by a single calibrated examiner
experienced in clinical diagnosis and management
of MIH. Thus, our diagnostic criteria are reliable
and may have produced true prevalence data. In
our sample, we recruited the index age group,
i.e. 8‑12 years.[7,15] In this age range all FPMs and
PIs have erupted, and thus false negatives are
minimized.
We reported a prevalence of 10.48%, which
is almost similar to that reported by Parikh
et al.[14] (9.2%) but is greater than the prevalence
reported by Mittal et al.(6.31%).[13] The difference
between the prevalence rates amongst these
Indian studies could be due to real differences in
prevalence rate, as these studies were conducted
in different geographical regions. However,
both of these studies relied on natural light, and
additionally the recruitment of younger subjects
by Mittal et al.[13] Could have resulted in the
under‑reporting of true prevalence.Only a few
studies have been carried out in Asian regions.
The reports of prevalence rate in those studies
are much different from the prevalence reported
in the present study. The reported prevalence
rates include 2.8% in Hong Kong,[8] 17.6% in
Jordan,[25]18.6% in Iraq,[11] and 20.2% in Iran.[26]
However, recently a study reported a prevalence
of 12.5% in Singaporean children,[12] which is not
very different from what is reported by us. Similar
rates have been reported from Greece (10.2%),[27]
Lithuania (9.7%),[28] Turkey (9.2%),[29] and Bosnia
and Herzegovina (12.3%)[30] using similar diagnostic
criteria.
An almost equivalent proportion of subjects
had “only molar involvement” or “concomitant
involvement of incisors.” This finding of our study
is in agreement with data reported from northern
India,[11] but is in conflict with data from the
western Indian region.[12] While comparing this
finding with global data, we noted that most of the
studies[25,27,28,31] have reported a lower prevalence
of the “only molar involvement” phenotype.
In the present study, a significantly greater number
of mandibular molars were affected with MIH
compared to maxillary molars (P = 0.001). A similar
predilection has been reported for children from
Table 5: Comparative statistics among various age groups
Parameter ≤10years
of age
n=90
>10 years
of age
n=40
P*
Affected teeth 4.07±1.901 4.35±3.126 0.597
Affected surfaces 7.02±4.857 6.78±6.121 0.806
Occlusal surfaces 2.91±2.498 2.40±2.351 0.275
Buccal surfaces 3.37±2.195 3.45±3.234 0.864
Lingual surfaces 0.74±1.576 1.03±1.271 0.324
Creamy white opacities 5.54±4.660 4.80±4.642 0.402
Yellowish brown opacities 1.47±2.199 2.08±2.433 0.161
PEB 1.00±1.565 2.05±2.449 0.016†
Surfaces with <1/3rd of
involvement (defect1)
3.16±4.363 4.15±2.547 0.106
Surfaces with 1/3rd-2/3rd
of involvement (defect 2)
3.00±4.269 2.68±4.399 0.692
Surfaces with >2/3rd of
involvement (defect 3)
0.87±3.733 0.15±0.662 0.081
*Calculated using the student’s t-test, †Signicant P value. PEB=Post-
eruptive breakdown
Mittal and Sharma: Prevalence of molar incisor hypomineralization in Indian children
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
54
western India,[14] Jordan,[25] and Lithuania.[27] On the
other hand, more frequent involvement of maxillary
molars has been reported for Spanish,[32] Finnish,[4]
German,[33] and Australian[34] children. On the other
hand, an almost equivalent involvement of both
arches has been reported for Hong‑Kong Chinese,[8]
Dutch,[18] and Swedish[17] children.The reasons for
these discrepant observations remain dubious.
Most of these studies were conducted following the
standard EAPD 2003 diagnostic criteria.[15] Thus,
the inconsistent clinical features reported in different
populations could be accounted to real differences.
Diverse study locations, ethnicity, and genetics could
have been responsible for observed discrepancies
in global data.
Although the prevalence rate reported in the
present study is different from the prevalence rate
reported by Mittal et al.,[13] the mean number of
affected teeth/subject is similar for the two study
populations. Surprisingly, similar involvement has
been reported from a few European regions[10,32]
and lower involvement has been reported from
most of the Asian countries.[8,11,12] An insight into the
etiological factors may provide answers for these
discrepant observations.
The most commonly observed lesion was
creamy white opacity. This lesion was scored as
being the least severe one. This observation of
our study is in agreement with both of the Indian
studies.[13,14] Further, similar observations have
been reported for various other populations,
i.e. Swedish,[17] Greek,[27] and Iraqi.[11] A total
of 42.31% of subjects exhibited severe defects,
i.e. PEB. Similar findings have been reported from
India. This means that 4.45% (55/1,240) of the
study population had RTNs owing to MIH. This
proportion is of concern. Further, MIH lesions are
often dynamic. Thus, a preventive intervention such
as remineralization therapy at an early stage can
minimize the proportion of PEB.
Greater severity of defects was noted in the
older age group (>10 years of age) compared to
theyoungeragegroup(≤10yearsofage).Similar
observations have been reported from western
India,[12] Finland,[4] Lithuania,[28] and Greece.[27]
In the older children, weakened hypomineralized
tooth structure has been exposed to masticatory and
other stresses for a longer time period. This could
have resulted in more severe lesions and increased
PEB in older children.
The main limitation of the present study was
the recruitment of unequal numbers of subjects
in various age cohorts. Even though a stratified
random approach for sample recruitment was
followed, we did not attempt to balance for recruiting
equal numbers of subjects in various age cohorts.
However, this limitation may not have affected the
overall findings of our study, as the recommended
age group by EAPD 2003 was 8‑year olds and the
mean age of our sample group was 8.73 years.
The reported prevalence in the present study was
approximately 10%. This figure is of concern in such
a thickly populated country with a minimal budget
for oral health care as India. Ignoring MIH at an
early age can lead to a cumulative unnecessary
economic burden. Early diagnosis and timely and
planned follow‑up with provisions of preventive
intervention can minimize the clinical consequences
of MIH. In addition, no study from India has explored
the possible association of MIH with putative risk
factors viz., genetic, socio‑demographic, and
systemic. Thus, there is a definite need to investigate
the same in this area.
CONCLUSION
In a nutshell, the prevalence of MIH was 10.48%
in the northern Indian region. The most commonly
observed lesion was creamy white opacity. PEB
was observed in 42.31% of the affected subjects.
Mandibular molars were the most frequently affected
tooth type. Further studies to map the prevalence in
different geographical areas are required for public
health authorities to formulate preventive policies
for MIH.
ACKNOWLEDGMENTS
The authors are thankful to the Dr Manoj Goyal,
Dean, Santosh Dental College and Hospital, Ghaziabad
for his help and support in conducting this study. The
authors are also thankful to the school authorities, the
children, and their parents.
Mittal and Sharma: Prevalence of molar incisor hypomineralization in Indian children
55
Journal of Cranio-Maxillary Diseases / Vol 4 / Issue 1 / January 2015
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How to cite this article: Mittal N, Sharma BB. Molar incisor hypomineralization:
Prevalence and defect characteristics in Indian schoolchildren. J Cranio Max
Dis 2015;4:49-56.
Source of Support: Nil. Conict of Interest: None declared.
Submission: Sep 18, 2014, Acceptance: Jan 03, 2015
