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Co-morbidities associated with molar-incisor hypomineralisation in 8 to 16year old pupils in Ile-Ife, Nigeria

Co-morbidities associated with molar-incisor hypomineralisation in 8 to 16year old pupils in... Background: This study aimed to identify the prevalence of oral co-morbidities in 8 to 16 years old children with Molar Incisor Hypomineralisation (MIH) and compare this with the prevalence of same oral lesions in children without MIH. Method: Study participants were selected through a multi-staged sampling technique. The children were asked if they had dentine hypersensitivity or any concerns about their aesthetics. Children were examined for MIH, caries, traumatic dental injury and their oral hygiene status. The association between MIH and each of the independent variables was determined. Results: Only children with MIH had aesthetic related concerns and dentine hypersensitivity. The differences in the oral hygiene status (p < 0.001) and caries prevalence (p < 0.001) of children with and without MIH were statistically significant. The prevalence of traumatic dental injury did not differ statistically between children with MIH and those without MIH (p = 0.24). Conclusion: Children with MIH had more oral pathologies than children without MIH. These co-morbidities (dentine hypersensitivity, aesthetic concerns, caries and oral hygiene) are capable of impacting negatively on the quality of life of the children. Screening for children with MIH may help facilitate prompt access to treatment. Keywords: Hypomineralisation, Co-morbidities, Dentine sensitivity Background great concern to the parents, and pose management Molar-Incisor Hypomineralisation (MIH) is a lesion of problems for the clinician [6]. systemic origin affecting one to four permanent first mo- Unfortunately, the affected molars are more difficult to lars, and may affect the permanent incisors [1]. The risk anaesthetise due to the subclinical inflammation of the of involving the permanent incisors increases as the pulpal cells, resulting from porosity of the enamel, which number of permanent first molars affected increases [2]. allows bacterial toxins to penetrate and cause pulpal Clinically, the defect caused by MIH appears as white, reactions [6]. Due to the difficulties in achieving adequate yellow or brown discolouration, often affects the occlusal anaesthesia and the frequent treatments required, children surfaces of the first permanent molars and may be more with MIH also run the risk of developing dental fear and frequent in the maxilla than mandible [3-5]. The defect- anxiety [6]. Continuous disintegration of the enamel of ive enamel can cause tooth sensitivity, disfigurement, the affected teeth, and difficulties with bonding with den- rapid plaque retention, caries and its sequelea [6,7]. This tal materials [8,9], suggests that children with MIH require causes considerable discomfort for the child, it can be of extensive and often repeated restorative treatment, espe- cially on the molars [6]. * Correspondence: [email protected]; [email protected] There are still very few studies on MIH, especially in Equal contributors Africa. The aim of this study is to determine the preva- Department of Child Dental Health, Obafemi Awolowo University Teaching lence of MIH and its co-morbidities in children in Hospitals Complex, Ile-Ife, Nigeria Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria. Specifically, the study will determine and compare Nigeria © 2015 Oyedele et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Oyedele et al. BMC Oral Health (2015) 15:37 Page 2 of 5 the proportion of children with or without MIH who has children and to allow for meaningful subgroup ana- concerns with tooth sensitivity, aesthetic concerns, caries, lysis, all children who met the inclusion criteria at the poor oral hygiene and traumatic dental injury. The find- recruitment sites were recruited for the study. ings should help improve clinicians’ diagnosis, and pre- vention therapies instituted in children with MIH. Data collection The data collection tool captured details of the age and Methods sex of each child. Respondents were also asked if they Study population had tooth sensitivity and if they were satisfied with their This study was across-sectional study which recruited tooth appearance. Specifically, children were asked whether children aged eight to sixteen years, resident in Ife Central they could feel any shocking sensation while drinking Local Government of Ile-Ife, a sub-urban town in the water, any cold drink and or while eating, to determine south-western Nigeria. Pupils whose legal guardian presence of absence of dentine hypersensitivity. Each child consented to their participation, and those who gave was also asked about their satisfaction (or lack of it) with assent to study participation, were eligible to partici- the appearance of their teeth. Respondents who showed pate in the study. Only those who had fully erupted per- concern were noted as having concerns about their manent first molars and incisors were enrolled. Children aesthetics, while those who showed no concern were with hypodontia, anodontia and amelogenesis imperfecta noted as having no aesthetic concerns. were excluded from the study. Study participants were selected through a multi-staged Intra-oral examination sampling technique that resulted in the selection of a rep- Intra-oral examination was conducted for each respond- resentative sample of children from all the socioeconomic ent under natural light while seated on the classroom strata. Selection of study participants through a propor- chair. The teeth were examined wet after debris was re- tional representation of public and private schools in the moved with gauze. Each tooth was examined for MIH, sampling frame helped to ensure that children from all caries, and traumatic dental injury. The status of oral hy- the socioeconomic strata were recruited for the study. giene was also assessed. Sampling technique Molar-incisor-hypomineralisation First, Ife Central Local Government was divided into A diagnosis of MIH was made based on the criteria de- three geographical areas each consisting of four political scribed by Jalevik [5]. First, the presence of absence of wards. One political ward was selected from each of the MIH was determined for each child. For children with geographical areas by ballot. Second, in each ward, the MIH, affected tooth were identified. Foe each affected schools were stratified into public primary, private pri- tooth, the severity (mild, moderate or severe) of the le- mary, public junior secondary, private junior secondary, sion was also identified. Mild lesions were those with public senior secondary and private senior secondary demarcated opacities present in the non-stress bearing schools respectively. A list of schools obtained from the areas of the molars with no enamel loss from fracturing Osun State Ministry of Education was used for the [5]. Moderate lesions were those with presence of any stratification. One school was randomly selected from atypical restoration, demarcated opacities present on the each strata by balloting. In effect, six schools were ran- occlusal/incisal third of the teeth with no post eruptive en- domly selected from each ward and 18 schools from Ife amel break down or with post-eruptive enamel breakdown Central Local Government were used for the study. limited to one or two surfaces without cuspal involvement Third, the lists of the children in each class in each of [5]. Severe lesions were those with post eruptive enamel the selected schools were reviewed. Classes with the breakdown [5]. The severity of the lesion for each child high numbers of children who met the age criteria for the was defined by the most severe defect on the affected study were selected for study participation. All selected tooth/teeth. All children diagnosed with MIH would have study participants were invited to participate in the study at least one molar was affected, with or without the in- and were given informed consent forms for their parents. volvement of the incisors. Sample size Caries The sample size was determined by the statistical for- Caries was diagnosis using the World Health Oral Health mula proposed by Araoye [10]. The estimated propor- Survey recommendations [11]. Each tooth was examined tion of children with MIH was 40%, using the highest for dental caries using a plane mouth mirror, using natural reported prevalence from various studies reported [5]. light while the child was seated on a chair. Caries status The minimum sample size for the study population was was assessed using the Decayed Missing and Filled 405 children. To ensure adequate representation of (DMFT) index. Decayed (D) teeth were defined as any Oyedele et al. BMC Oral Health (2015) 15:37 Page 3 of 5 tooth whose crown had an unmistakable cavitation on describe the demographic variables (age and sex). The the pits or fissures, or on a tooth surface or a filled difference in the frequency of observed pathologies in crown with decay, when it has one or more permanent children with and without MIH was determined using restorations that are decayed. The F was defined as a Chi-Square test. Statistical significance was established filled crown with no decay, when it has one or more at p values equal to or less than 0.05. permanent restorations, and there is no caries any- where on the crown. The M was defined as a missing Ethical consideration tooth due to caries; when a tooth has been extracted Ethics approval for the study was obtained from the Obafemi due to caries. To arrive at a DMFT score for an indi- Awolowo University Teaching Hospitals Complex, Ile-Ife, vidual patient’s mouth, three values must be deter- Health Research Ethics Committee (ERC/2011/06/03). mined: the number of teeth with carious lesions, the Approval was also obtained from the Ministry of Educa- number of extracted teeth due to caries, and the num- tion and the Heads of all the schools that participated in ber of teeth with fillings or crowns [12]. The number the study. Only children whose legal guardian consented of teeth are then summed together to give the DMFT to their participation and those who gave assent to study score for the permanent dentition. participation were eligible to participate in the study. Each child was examined in an empty room to ensure privacy. Traumatic dental injury All children with oral lesions, with or without MIH, Trauma to the anterior teeth of each study participant were referred to the paediatric dental unit of Obafemi was determined using Ellis and Davey classification [13]. Awolowo University Teaching Hospitals’ Complex, Ile-Ife, Trauma was classified as present when there was a sim- for management. All treatments were offered free. ple fracture of the crown involving little or no dentine; extensive fracture of the crown involving considerable dentine and exposure of dental pulp, or loss of the entire Results crown. Parental consent and assent was received from 2,165 children but only 2,107 (97.3%) met the inclusion criteria. Oral hygiene status These include 1,125(53.4%) females and 982(46.6%) males. Oral hygiene was recorded using the simplified-oral hy- The mean age of study participants was 12.57 ± 2.39 years. giene index (OHI-S) described by Greene and Vermillion Two hundred and sixty seven (12.7%) children had [14]. The OHI-S has two components; the debris index MIH. Table 1 shows the profile of the study participants. and the calculus index. Each of these indexes in turn, is There was no significant difference in the proportion of based on numerical determinations representing the children with and without MIH by age (p = 0.23) and sex amount of debris or calculus found on the preselected (p = 0.14). Of the 267 children with MIH, 179 (66.9%) tooth surfaces. The calculus index simplified (CI-S) and had mild lesion, 52 (19.6%) had moderate lesion and 36 debris index simplified (DI-S) value may range from 0 to 3, (13.5%) had severe lesion. theOHI-S valuewhich is thesum of CI-S andDI-Srange Table 2 shows the distribution of the children with from 0 to 6. Oral hygiene index score of 0–1.2 means good and without MIH who expressed concerns with their oral hygiene; 1.3-3.0 means fair oral hygiene and 3.0-6.0 aesthetics, reported dentine hypersensitivity, had trau- means poor oral hygiene. matic dental injury and caries and their oral hygiene status. Only children with MIH expressed aesthetic re- Standardization of examiner lated concerns (19.1%) and had dentine hypersensitivity Prior to the commencement of the study, one of the au- (15.0%). thors (T.O) underwent a series of calibration exercises. Calibration for the diagnosis of MIH was done using Table 1 Profile of the study participants coloured picture chartsof MIH affected teeth, with vary- Variables MIH absent (%) MIH present (%) Total p value ing degree of severity of the lesion. This was followed by n=1,840 n=267 N=2,107 the use of live patients with MIH. The lesions were Age graded as mild, moderate and severe, according to the 8-10 386 (21.0%) 83 (31.1%) 469 (22.2%) P = 0.23 criteria earlier stated. The intra examiner kappa variabil- 11-13 668 (36.3%) 98 (36.7%) 766 (36.4%) ity score was 0.90. 14-16 786 (42.7%) 86 (32.2%) 872 (41.4%) Data analysis Sex The data generated from this study was subjected to Male 842 (45.8%) 140 (52.4%) 982 (46.6%) P = 0.14 suitable statistical analysis conducted with the use of Female 998 (54.2%) 127 (47.6%) 1,125 (53.4%) STATA, version 12.0. Descriptive analysis was used to Oyedele et al. BMC Oral Health (2015) 15:37 Page 4 of 5 Table 2 Associated co-morbidity This study makes a unique contribution to the grow- MIH absent (%) MIH present (%) Total (%) p value ing literature on MIH. Studies such as ours are import- n = 1,840 n=267 N=2,107 ant because of evidence of regional and racial disparity Oral hygiene in the occurrence of dental lesions. Currently, there is no data on MIH from Nigeria: this study provides the Good 879(47.8%) 67(25.1%) 946(44.9%) <0.001 first data on MIH in the country. However, the study Fair 675(36.7%) 127(47.6%) 802(38.1%) has three limitations. First, this was a school based sur- Poor 286(15.5%) 73(27.3%) 359(17.0%) vey. This implies that the data generated cannot be gen- Carious teeth <0.001 eralized to all the children in the study population since Caries 109 (5.9%) 68 (25.5%) 177 (8.4%) a significant number of children in the community do No caries 1,731(94.1%) 199(74.5%) 1,930(91.6%) are not in school [15]. The inclusion of children in pub- lic and private schools helped to increase the probability Sensitive teeth of including children from all the socioeconomic status Present - 40(15.0%) 40(1.9%) in the study sample. This is important as children in Absent 1,840(100.0%) 227(85.0%) 2,067(98.1%) public schools are likely to have low socioeconomic sta- Aesthetic concern tus while those in private schools are likely to have high Yes - 51(19.1%) 51(2.4%) socioeconomic status [16]. Second, the study population No 1,840(100%) 216(80.9%) 2,056(97.6%) included children between the ages of 11 and 16 years. This age range is larger than the appropriate age for de- Traumatic dental injury termining the prevalence of MIH. The appropriate age Present 141(7.7%) 26(9.7%) 167(7.9%) range for determining the prevalence of MIH is eight to Absent 1,699(92.3%) 241(90.3%) 1,940(92.1%) 0.241 ten years [5]. The proportion of children who had MIH Total 1,840(87.3%) 267(12.7%) 2,107(100.0%) in this study can therefore not be representative of the prevalence of MIH in the study population. Third, the Approximately 45% of the pupils had good oral hy- diagnosis of MIH and caries and MIH was made using giene, about 38% had fair oral hygiene and 17% had poor natural light. This may have resulted in the examiner oral hygiene. More children with MIH had fair and poor missing some cases of caries and some cases of MIH. oral hygiene when compared with children without Also, the use of the World Health Organisation criteria MIH while more children without MIH had good oral for the diagnosis of caries also implies that less number hygiene. The difference in oral hygiene status of chil- of carious lesions could have been detected. dren with and without MIH was statistically significant Despite these limitations, the study provides useful in- (p < 0.001). formation that is important for the clinical management One hundred and seventy seven (8.4%) children had of patients with MIH. The higher prevalence of children caries in the permanent dentition. The proportion of with MIH who had poor oral hygiene when compared children with MIH who had caries, was significantly with children without MIH is an important finding. The more than those without MIH and had caries (25.5% vs poorer oral hygiene may have resulted from increased 5.9%; p < 0.001). The DMFT of children with MIH was plaque retention due to the rough surface of the enamel, 0.5 while the DMFT of children without MIH was 0.1. from poor tooth brushing due to the hypersensitivity There was a significance difference in the DMFT of chil- and or poor tooth brushing due to the pain associated dren with and without MIH (p < 0.001). with the presence of caries. Unfortunately, the poor oral One hundred and sixty seven (7.9%) children had frac- hygiene status may be a mediating risk factor for the ture of the anterior teeth. The proportion of children with higher prevalence of caries in children with MIH. MIH who had fracture of the anterior teeth was not sig- Education about oral toileting, including the use of nificantly more than the children without MIH who had fluoridated toothpaste twice daily, may be very benefi- fracture of the anterior teeth (9.7% vs 7.7%; p = 0.24). cial for children with MIH: It may serve as a protect- ive factor for caries and poor oral hygiene. Discussion The high incidence of dentine hypersensitivity associated This study shows that children with MIH had signifi- with MIH in this study had been reported in prior studies cantly more oral pathologies when compared with [6,7]. Dentine sensitivity results from the porosity of the en- children without MIH: children with MIH reported amel and disorganised enamelrodsstructure found inMIH experiencing dentine sensitivity, had concerns with the [7], from the post-eruptive crown breakdown sequeale to aesthetic appearance of their teeth, had more carious MIH, and from dentine caries. The plausibility that the lesions and were more likely to have poor oral hygiene dentine sensitivity was a result of caries is low, since none of status. the children without MIH complained of dentine sensitivity. Oyedele et al. BMC Oral Health (2015) 15:37 Page 5 of 5 This study, like other studies [17,18], shows that chil- 9. William V, Burrow MF, Palamara JE, Messer LB. Microshear bond strength of resin composite to teeth affected by molar incisor hypomineralisation using dren with MIH have higher risk for caries. This study 2 adhesive systems. Paediatr Dent. 2006;28:233–41. fails to report the relationship between post-eruptive 10. Araoye MO. Research methodology with statistics for health and social breakdown and caries, a relationship that would have science. Ilorin: Nathadex Publisher; 2003. p. 115–9. 11. World Health Organization. Oral health survey-basic method. 4th ed. shown whether post eruptive breakdown is responsible Geneva: WHO; 1997. for the reported high caries experienced in children with 12. Krapp K: Dental Indices. Encyclopedia of Nursing & Allied Health. Ed. Vol. 2. MIH, when compared with children without MIH. Gale Cengage. eNotes.com. http://www.enotes.com/dental-indices-reference/. Assessed 2 Jan, 2012. The high prevalence of co-morbidities associated with 13. Ellis RG, Davey EW. The classification and treatment of injuries to the teeth MIH makes it imperative that efforts should be made to of children. 5th ed. Chicago: Year Book Medical Publisher; 1970. p. 56–199. promote early diagnosis and management of MIH. While 14. Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc. 1964;68:7–13. the authors could not find any study on the quality of life 15. Global Monitoring Report EFA. Education for all global monitoring report: and MIH, there are a few studies that have shown that the Policy Paper 09 Schooling for millions of children jeopardized by quality of life of children is negatively affected by caries reductions in aid (2013/ED/EFA/MRT/PP/09 REV). France: UNESCO Institute for Statistics; 2013. [19-21], dentine sensitivity [22] and poor aesthetics [23]- 16. Benson J, Borman G. Family, neighborhood, and school settings scross three morbidities significantly associated with MIH. seasons: when do socioeconomic context and racial composition matter for the reading achievement growth of young children? Teach Coll Rec. 2010;112:1338–90. Conclusion 17. Groselj M, Jan J. Molar incisor hypomineralisation and dental caries among This study demonstrates that MIH is associated with oral children in Slovenia. Eur J Paediatr Dent. 2013;4:241–5. 18. Jeremias F, De Souza JF, Silva CM, Cordeiro RC, Zuanon AC, Santos-Pinto L. health morbidities that affect the quality of life. Prompt Dental caries experience and molar incisor hypomineralisation. ActaOdontoScand. diagnosis and management of MIH, to prevent post erup- 2013;71:870–6. tive breakdown, can help reduce the co-morbidities identi- 19. Do LG, Spencer A. Oral health-related quality of life of children by dental caries and fluorosis experience. J Public Health Dent. 2007;67:132–9. fied in this study. 20. Mashoto KO, Åstrøm AN, Skeie MS, Masalu JR. Changes in the quality of life of Tanzanian school children after treatment interventions using the Competing interests Child-OIDP. Eur J Oral Sci. 2010;118:626–34. The authors declare that they have no competing interests. 21. Martins-Junior PA, Oliveira M, Marques LS, Ramos-Jorge ML. Untreated dental caries: impact on the quality of life of children of low socioeconomic status. Authors’ contributions Paediatr Dent. 2012;34:49–52. TAO conceived the idea of the study, developed the protocol for the study, 22. Bekes K, Hirsch C. What is known about the influence of dentine carried out the field work and took part in the data analysis and final hypersensitivity on oral health-related quality of life? Clin Oral Investig. drafting of the manuscript. MOF, CAA and EOO were involved with the 2012;7:s45–51. study design, interpretation of the data and drafting of the manuscript. All 23. Al-Zarea BK. Satisfaction with appearance and the desired treatment to the authors agree to the final version of the manuscript. All authors read and improve aesthetics. Int J Dent. 2013;2013:912368. approved the final manuscript. Acknowledgement The authors thank the parents and the children who gave their consent/ assent to participate in the study, and the management of Obafemi Awolowo University Teaching Hospitals Complex, where the study was carried out. Received: 13 October 2014 Accepted: 19 February 2015 References 1. Weerheijm KL, Jalevik B, Alaluusua S. Molar-incisor hypomineralization. Caries Res. 2001;35:390–1. 2. Muratbegovic A, Markovic N, Ganibegovic SM. Molar incisor hypomineralisation in Bosnia and Herzegovina: aetiology and clinical consequences in medium caries activity population. Eur Arch Paediatr Dent. 2007;8:189–94. Submit your next manuscript to BioMed Central 3. Kellerhof NM, Lussi A. Molar-Incisor Hypomineralisation. SchweizMonatsschrZahmed. 2004;114:243–53. and take full advantage of: 4. Alaluussua S. Aetiology of molar-incisor hypomineralization: a systematic review. Eur Arch of Paediatr Dent. 2010;11:53–8. • Convenient online submission 5. Jälevik B. Prevalence and Diagnosis of Molar-Incisor-Hypomineralisation (MIH): • Thorough peer review A systematic review. Eur Arch Paediatr Dent. 2010;11:59–64. 6. Jalevik B, Klinberg GA. Dental treatment, dental fear and behavioural • No space constraints or color figure charges management problems in children with severe hypomineralisation of their • Immediate publication on acceptance first permanent molars. Int J Paediatr Dent. 2002;12:24–32. • Inclusion in PubMed, CAS, Scopus and Google Scholar 7. Jalevik B, Noren JG. Enamel hypomineralisation of permanent first molars: A morphology study and survey of possible aetiology factors. Int J Paediatr Dent. • Research which is freely available for redistribution 2000;10:278–89. 8. Fayle SA. Molar incisor hypomineralization: Restorative management. Eur J Submit your manuscript at Paediatr Dent. 2003;4:121–6. www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Oral Health Springer Journals

Co-morbidities associated with molar-incisor hypomineralisation in 8 to 16year old pupils in Ile-Ife, Nigeria

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Copyright © 2015 by Oyedele et al.; licensee BioMed Central.
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Dentistry; Dentistry; Oral and Maxillofacial Surgery
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1472-6831
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25887347
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Abstract

Background: This study aimed to identify the prevalence of oral co-morbidities in 8 to 16 years old children with Molar Incisor Hypomineralisation (MIH) and compare this with the prevalence of same oral lesions in children without MIH. Method: Study participants were selected through a multi-staged sampling technique. The children were asked if they had dentine hypersensitivity or any concerns about their aesthetics. Children were examined for MIH, caries, traumatic dental injury and their oral hygiene status. The association between MIH and each of the independent variables was determined. Results: Only children with MIH had aesthetic related concerns and dentine hypersensitivity. The differences in the oral hygiene status (p < 0.001) and caries prevalence (p < 0.001) of children with and without MIH were statistically significant. The prevalence of traumatic dental injury did not differ statistically between children with MIH and those without MIH (p = 0.24). Conclusion: Children with MIH had more oral pathologies than children without MIH. These co-morbidities (dentine hypersensitivity, aesthetic concerns, caries and oral hygiene) are capable of impacting negatively on the quality of life of the children. Screening for children with MIH may help facilitate prompt access to treatment. Keywords: Hypomineralisation, Co-morbidities, Dentine sensitivity Background great concern to the parents, and pose management Molar-Incisor Hypomineralisation (MIH) is a lesion of problems for the clinician [6]. systemic origin affecting one to four permanent first mo- Unfortunately, the affected molars are more difficult to lars, and may affect the permanent incisors [1]. The risk anaesthetise due to the subclinical inflammation of the of involving the permanent incisors increases as the pulpal cells, resulting from porosity of the enamel, which number of permanent first molars affected increases [2]. allows bacterial toxins to penetrate and cause pulpal Clinically, the defect caused by MIH appears as white, reactions [6]. Due to the difficulties in achieving adequate yellow or brown discolouration, often affects the occlusal anaesthesia and the frequent treatments required, children surfaces of the first permanent molars and may be more with MIH also run the risk of developing dental fear and frequent in the maxilla than mandible [3-5]. The defect- anxiety [6]. Continuous disintegration of the enamel of ive enamel can cause tooth sensitivity, disfigurement, the affected teeth, and difficulties with bonding with den- rapid plaque retention, caries and its sequelea [6,7]. This tal materials [8,9], suggests that children with MIH require causes considerable discomfort for the child, it can be of extensive and often repeated restorative treatment, espe- cially on the molars [6]. * Correspondence: [email protected]; [email protected] There are still very few studies on MIH, especially in Equal contributors Africa. The aim of this study is to determine the preva- Department of Child Dental Health, Obafemi Awolowo University Teaching lence of MIH and its co-morbidities in children in Hospitals Complex, Ile-Ife, Nigeria Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria. Specifically, the study will determine and compare Nigeria © 2015 Oyedele et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Oyedele et al. BMC Oral Health (2015) 15:37 Page 2 of 5 the proportion of children with or without MIH who has children and to allow for meaningful subgroup ana- concerns with tooth sensitivity, aesthetic concerns, caries, lysis, all children who met the inclusion criteria at the poor oral hygiene and traumatic dental injury. The find- recruitment sites were recruited for the study. ings should help improve clinicians’ diagnosis, and pre- vention therapies instituted in children with MIH. Data collection The data collection tool captured details of the age and Methods sex of each child. Respondents were also asked if they Study population had tooth sensitivity and if they were satisfied with their This study was across-sectional study which recruited tooth appearance. Specifically, children were asked whether children aged eight to sixteen years, resident in Ife Central they could feel any shocking sensation while drinking Local Government of Ile-Ife, a sub-urban town in the water, any cold drink and or while eating, to determine south-western Nigeria. Pupils whose legal guardian presence of absence of dentine hypersensitivity. Each child consented to their participation, and those who gave was also asked about their satisfaction (or lack of it) with assent to study participation, were eligible to partici- the appearance of their teeth. Respondents who showed pate in the study. Only those who had fully erupted per- concern were noted as having concerns about their manent first molars and incisors were enrolled. Children aesthetics, while those who showed no concern were with hypodontia, anodontia and amelogenesis imperfecta noted as having no aesthetic concerns. were excluded from the study. Study participants were selected through a multi-staged Intra-oral examination sampling technique that resulted in the selection of a rep- Intra-oral examination was conducted for each respond- resentative sample of children from all the socioeconomic ent under natural light while seated on the classroom strata. Selection of study participants through a propor- chair. The teeth were examined wet after debris was re- tional representation of public and private schools in the moved with gauze. Each tooth was examined for MIH, sampling frame helped to ensure that children from all caries, and traumatic dental injury. The status of oral hy- the socioeconomic strata were recruited for the study. giene was also assessed. Sampling technique Molar-incisor-hypomineralisation First, Ife Central Local Government was divided into A diagnosis of MIH was made based on the criteria de- three geographical areas each consisting of four political scribed by Jalevik [5]. First, the presence of absence of wards. One political ward was selected from each of the MIH was determined for each child. For children with geographical areas by ballot. Second, in each ward, the MIH, affected tooth were identified. Foe each affected schools were stratified into public primary, private pri- tooth, the severity (mild, moderate or severe) of the le- mary, public junior secondary, private junior secondary, sion was also identified. Mild lesions were those with public senior secondary and private senior secondary demarcated opacities present in the non-stress bearing schools respectively. A list of schools obtained from the areas of the molars with no enamel loss from fracturing Osun State Ministry of Education was used for the [5]. Moderate lesions were those with presence of any stratification. One school was randomly selected from atypical restoration, demarcated opacities present on the each strata by balloting. In effect, six schools were ran- occlusal/incisal third of the teeth with no post eruptive en- domly selected from each ward and 18 schools from Ife amel break down or with post-eruptive enamel breakdown Central Local Government were used for the study. limited to one or two surfaces without cuspal involvement Third, the lists of the children in each class in each of [5]. Severe lesions were those with post eruptive enamel the selected schools were reviewed. Classes with the breakdown [5]. The severity of the lesion for each child high numbers of children who met the age criteria for the was defined by the most severe defect on the affected study were selected for study participation. All selected tooth/teeth. All children diagnosed with MIH would have study participants were invited to participate in the study at least one molar was affected, with or without the in- and were given informed consent forms for their parents. volvement of the incisors. Sample size Caries The sample size was determined by the statistical for- Caries was diagnosis using the World Health Oral Health mula proposed by Araoye [10]. The estimated propor- Survey recommendations [11]. Each tooth was examined tion of children with MIH was 40%, using the highest for dental caries using a plane mouth mirror, using natural reported prevalence from various studies reported [5]. light while the child was seated on a chair. Caries status The minimum sample size for the study population was was assessed using the Decayed Missing and Filled 405 children. To ensure adequate representation of (DMFT) index. Decayed (D) teeth were defined as any Oyedele et al. BMC Oral Health (2015) 15:37 Page 3 of 5 tooth whose crown had an unmistakable cavitation on describe the demographic variables (age and sex). The the pits or fissures, or on a tooth surface or a filled difference in the frequency of observed pathologies in crown with decay, when it has one or more permanent children with and without MIH was determined using restorations that are decayed. The F was defined as a Chi-Square test. Statistical significance was established filled crown with no decay, when it has one or more at p values equal to or less than 0.05. permanent restorations, and there is no caries any- where on the crown. The M was defined as a missing Ethical consideration tooth due to caries; when a tooth has been extracted Ethics approval for the study was obtained from the Obafemi due to caries. To arrive at a DMFT score for an indi- Awolowo University Teaching Hospitals Complex, Ile-Ife, vidual patient’s mouth, three values must be deter- Health Research Ethics Committee (ERC/2011/06/03). mined: the number of teeth with carious lesions, the Approval was also obtained from the Ministry of Educa- number of extracted teeth due to caries, and the num- tion and the Heads of all the schools that participated in ber of teeth with fillings or crowns [12]. The number the study. Only children whose legal guardian consented of teeth are then summed together to give the DMFT to their participation and those who gave assent to study score for the permanent dentition. participation were eligible to participate in the study. Each child was examined in an empty room to ensure privacy. Traumatic dental injury All children with oral lesions, with or without MIH, Trauma to the anterior teeth of each study participant were referred to the paediatric dental unit of Obafemi was determined using Ellis and Davey classification [13]. Awolowo University Teaching Hospitals’ Complex, Ile-Ife, Trauma was classified as present when there was a sim- for management. All treatments were offered free. ple fracture of the crown involving little or no dentine; extensive fracture of the crown involving considerable dentine and exposure of dental pulp, or loss of the entire Results crown. Parental consent and assent was received from 2,165 children but only 2,107 (97.3%) met the inclusion criteria. Oral hygiene status These include 1,125(53.4%) females and 982(46.6%) males. Oral hygiene was recorded using the simplified-oral hy- The mean age of study participants was 12.57 ± 2.39 years. giene index (OHI-S) described by Greene and Vermillion Two hundred and sixty seven (12.7%) children had [14]. The OHI-S has two components; the debris index MIH. Table 1 shows the profile of the study participants. and the calculus index. Each of these indexes in turn, is There was no significant difference in the proportion of based on numerical determinations representing the children with and without MIH by age (p = 0.23) and sex amount of debris or calculus found on the preselected (p = 0.14). Of the 267 children with MIH, 179 (66.9%) tooth surfaces. The calculus index simplified (CI-S) and had mild lesion, 52 (19.6%) had moderate lesion and 36 debris index simplified (DI-S) value may range from 0 to 3, (13.5%) had severe lesion. theOHI-S valuewhich is thesum of CI-S andDI-Srange Table 2 shows the distribution of the children with from 0 to 6. Oral hygiene index score of 0–1.2 means good and without MIH who expressed concerns with their oral hygiene; 1.3-3.0 means fair oral hygiene and 3.0-6.0 aesthetics, reported dentine hypersensitivity, had trau- means poor oral hygiene. matic dental injury and caries and their oral hygiene status. Only children with MIH expressed aesthetic re- Standardization of examiner lated concerns (19.1%) and had dentine hypersensitivity Prior to the commencement of the study, one of the au- (15.0%). thors (T.O) underwent a series of calibration exercises. Calibration for the diagnosis of MIH was done using Table 1 Profile of the study participants coloured picture chartsof MIH affected teeth, with vary- Variables MIH absent (%) MIH present (%) Total p value ing degree of severity of the lesion. This was followed by n=1,840 n=267 N=2,107 the use of live patients with MIH. The lesions were Age graded as mild, moderate and severe, according to the 8-10 386 (21.0%) 83 (31.1%) 469 (22.2%) P = 0.23 criteria earlier stated. The intra examiner kappa variabil- 11-13 668 (36.3%) 98 (36.7%) 766 (36.4%) ity score was 0.90. 14-16 786 (42.7%) 86 (32.2%) 872 (41.4%) Data analysis Sex The data generated from this study was subjected to Male 842 (45.8%) 140 (52.4%) 982 (46.6%) P = 0.14 suitable statistical analysis conducted with the use of Female 998 (54.2%) 127 (47.6%) 1,125 (53.4%) STATA, version 12.0. Descriptive analysis was used to Oyedele et al. BMC Oral Health (2015) 15:37 Page 4 of 5 Table 2 Associated co-morbidity This study makes a unique contribution to the grow- MIH absent (%) MIH present (%) Total (%) p value ing literature on MIH. Studies such as ours are import- n = 1,840 n=267 N=2,107 ant because of evidence of regional and racial disparity Oral hygiene in the occurrence of dental lesions. Currently, there is no data on MIH from Nigeria: this study provides the Good 879(47.8%) 67(25.1%) 946(44.9%) <0.001 first data on MIH in the country. However, the study Fair 675(36.7%) 127(47.6%) 802(38.1%) has three limitations. First, this was a school based sur- Poor 286(15.5%) 73(27.3%) 359(17.0%) vey. This implies that the data generated cannot be gen- Carious teeth <0.001 eralized to all the children in the study population since Caries 109 (5.9%) 68 (25.5%) 177 (8.4%) a significant number of children in the community do No caries 1,731(94.1%) 199(74.5%) 1,930(91.6%) are not in school [15]. The inclusion of children in pub- lic and private schools helped to increase the probability Sensitive teeth of including children from all the socioeconomic status Present - 40(15.0%) 40(1.9%) in the study sample. This is important as children in Absent 1,840(100.0%) 227(85.0%) 2,067(98.1%) public schools are likely to have low socioeconomic sta- Aesthetic concern tus while those in private schools are likely to have high Yes - 51(19.1%) 51(2.4%) socioeconomic status [16]. Second, the study population No 1,840(100%) 216(80.9%) 2,056(97.6%) included children between the ages of 11 and 16 years. This age range is larger than the appropriate age for de- Traumatic dental injury termining the prevalence of MIH. The appropriate age Present 141(7.7%) 26(9.7%) 167(7.9%) range for determining the prevalence of MIH is eight to Absent 1,699(92.3%) 241(90.3%) 1,940(92.1%) 0.241 ten years [5]. The proportion of children who had MIH Total 1,840(87.3%) 267(12.7%) 2,107(100.0%) in this study can therefore not be representative of the prevalence of MIH in the study population. Third, the Approximately 45% of the pupils had good oral hy- diagnosis of MIH and caries and MIH was made using giene, about 38% had fair oral hygiene and 17% had poor natural light. This may have resulted in the examiner oral hygiene. More children with MIH had fair and poor missing some cases of caries and some cases of MIH. oral hygiene when compared with children without Also, the use of the World Health Organisation criteria MIH while more children without MIH had good oral for the diagnosis of caries also implies that less number hygiene. The difference in oral hygiene status of chil- of carious lesions could have been detected. dren with and without MIH was statistically significant Despite these limitations, the study provides useful in- (p < 0.001). formation that is important for the clinical management One hundred and seventy seven (8.4%) children had of patients with MIH. The higher prevalence of children caries in the permanent dentition. The proportion of with MIH who had poor oral hygiene when compared children with MIH who had caries, was significantly with children without MIH is an important finding. The more than those without MIH and had caries (25.5% vs poorer oral hygiene may have resulted from increased 5.9%; p < 0.001). The DMFT of children with MIH was plaque retention due to the rough surface of the enamel, 0.5 while the DMFT of children without MIH was 0.1. from poor tooth brushing due to the hypersensitivity There was a significance difference in the DMFT of chil- and or poor tooth brushing due to the pain associated dren with and without MIH (p < 0.001). with the presence of caries. Unfortunately, the poor oral One hundred and sixty seven (7.9%) children had frac- hygiene status may be a mediating risk factor for the ture of the anterior teeth. The proportion of children with higher prevalence of caries in children with MIH. MIH who had fracture of the anterior teeth was not sig- Education about oral toileting, including the use of nificantly more than the children without MIH who had fluoridated toothpaste twice daily, may be very benefi- fracture of the anterior teeth (9.7% vs 7.7%; p = 0.24). cial for children with MIH: It may serve as a protect- ive factor for caries and poor oral hygiene. Discussion The high incidence of dentine hypersensitivity associated This study shows that children with MIH had signifi- with MIH in this study had been reported in prior studies cantly more oral pathologies when compared with [6,7]. Dentine sensitivity results from the porosity of the en- children without MIH: children with MIH reported amel and disorganised enamelrodsstructure found inMIH experiencing dentine sensitivity, had concerns with the [7], from the post-eruptive crown breakdown sequeale to aesthetic appearance of their teeth, had more carious MIH, and from dentine caries. The plausibility that the lesions and were more likely to have poor oral hygiene dentine sensitivity was a result of caries is low, since none of status. the children without MIH complained of dentine sensitivity. Oyedele et al. BMC Oral Health (2015) 15:37 Page 5 of 5 This study, like other studies [17,18], shows that chil- 9. William V, Burrow MF, Palamara JE, Messer LB. Microshear bond strength of resin composite to teeth affected by molar incisor hypomineralisation using dren with MIH have higher risk for caries. This study 2 adhesive systems. Paediatr Dent. 2006;28:233–41. fails to report the relationship between post-eruptive 10. Araoye MO. Research methodology with statistics for health and social breakdown and caries, a relationship that would have science. Ilorin: Nathadex Publisher; 2003. p. 115–9. 11. World Health Organization. Oral health survey-basic method. 4th ed. shown whether post eruptive breakdown is responsible Geneva: WHO; 1997. for the reported high caries experienced in children with 12. Krapp K: Dental Indices. Encyclopedia of Nursing & Allied Health. Ed. Vol. 2. MIH, when compared with children without MIH. Gale Cengage. eNotes.com. http://www.enotes.com/dental-indices-reference/. Assessed 2 Jan, 2012. The high prevalence of co-morbidities associated with 13. Ellis RG, Davey EW. The classification and treatment of injuries to the teeth MIH makes it imperative that efforts should be made to of children. 5th ed. Chicago: Year Book Medical Publisher; 1970. p. 56–199. promote early diagnosis and management of MIH. While 14. Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc. 1964;68:7–13. the authors could not find any study on the quality of life 15. Global Monitoring Report EFA. Education for all global monitoring report: and MIH, there are a few studies that have shown that the Policy Paper 09 Schooling for millions of children jeopardized by quality of life of children is negatively affected by caries reductions in aid (2013/ED/EFA/MRT/PP/09 REV). France: UNESCO Institute for Statistics; 2013. [19-21], dentine sensitivity [22] and poor aesthetics [23]- 16. Benson J, Borman G. Family, neighborhood, and school settings scross three morbidities significantly associated with MIH. seasons: when do socioeconomic context and racial composition matter for the reading achievement growth of young children? Teach Coll Rec. 2010;112:1338–90. Conclusion 17. Groselj M, Jan J. Molar incisor hypomineralisation and dental caries among This study demonstrates that MIH is associated with oral children in Slovenia. Eur J Paediatr Dent. 2013;4:241–5. 18. Jeremias F, De Souza JF, Silva CM, Cordeiro RC, Zuanon AC, Santos-Pinto L. health morbidities that affect the quality of life. Prompt Dental caries experience and molar incisor hypomineralisation. ActaOdontoScand. diagnosis and management of MIH, to prevent post erup- 2013;71:870–6. tive breakdown, can help reduce the co-morbidities identi- 19. Do LG, Spencer A. Oral health-related quality of life of children by dental caries and fluorosis experience. J Public Health Dent. 2007;67:132–9. fied in this study. 20. Mashoto KO, Åstrøm AN, Skeie MS, Masalu JR. Changes in the quality of life of Tanzanian school children after treatment interventions using the Competing interests Child-OIDP. Eur J Oral Sci. 2010;118:626–34. The authors declare that they have no competing interests. 21. Martins-Junior PA, Oliveira M, Marques LS, Ramos-Jorge ML. Untreated dental caries: impact on the quality of life of children of low socioeconomic status. Authors’ contributions Paediatr Dent. 2012;34:49–52. TAO conceived the idea of the study, developed the protocol for the study, 22. Bekes K, Hirsch C. What is known about the influence of dentine carried out the field work and took part in the data analysis and final hypersensitivity on oral health-related quality of life? Clin Oral Investig. drafting of the manuscript. MOF, CAA and EOO were involved with the 2012;7:s45–51. study design, interpretation of the data and drafting of the manuscript. All 23. Al-Zarea BK. Satisfaction with appearance and the desired treatment to the authors agree to the final version of the manuscript. All authors read and improve aesthetics. Int J Dent. 2013;2013:912368. approved the final manuscript. Acknowledgement The authors thank the parents and the children who gave their consent/ assent to participate in the study, and the management of Obafemi Awolowo University Teaching Hospitals Complex, where the study was carried out. Received: 13 October 2014 Accepted: 19 February 2015 References 1. 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Published: Mar 13, 2015

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