20 October 2023: Clinical Research
Knowledge and Attitudes of a Group of Dental Students in Turkey About Molar Incisor HypomineralizationAyse Gunay1ABCDEFG*
Med Sci Monit 2023; 29:e941824
BACKGROUND: This study aimed to evaluate the knowledge and attitudes of 4th- and 5th-year students of Dicle University Faculty of Dentistry (Diyarbakır) about molar incisor hypomineralization (MIH).
MATERIAL AND METHODS: The questionnaires previously used in other countries were modified and the questionnaire forms consisting of 23 questions were distributed to the students online. The results of the analysis are presented as frequencies. The significance level was set as P<0.05.
RESULTS: A total of 111 4th-year students (51%) and 107 5th-year students (49%) participated in our study. A statistically significant difference was found between the 4th-year students (68.5%) and the 5th-year students (98.1%) in terms of having heard of the term MIH before (P<0.001). While most students reported knowing the clinical features of MIH, only 26.1% were confident in their diagnosis. A statistically significant difference was found between the 4th- and 5th-year students who thought that MIH was a clinical problem, in the distribution of those who had problems both in terms of aesthetics, and in providing adequate restoration (P=0.012).
CONCLUSIONS: Although most of the students were theoretically familiar with MIH, they were not confident in their diagnosis and found it difficult to differentiate MIH from other dental anomalies. However, the awareness of 5th-year dental students was better than that of the 4th-year students.
Keywords: Dental Enamel Hypoplasia, Knowledge, Surveys and Questionnaires
Molar incisor hypomineralization (MIH) was first described by Weerheijm et al  in 2001 as a developmental enamel defect of systemic origin affecting at least 1 first permanent molar and usually associated with lesions in permanent incisors . Although the etiology is not clear, it is currently thought to be related to genetic factors, environmental factors, diseases and smoking during pregnancy, low birth weight, birth complications, diseases and medications in the first 3 years after birth, and vitamin D deficiency [3–5].
MIH clinically presents as white to yellow-brown opaque lesions with a distinct line between the lesion and healthy enamel. Depending on the severity, teeth with MIH may exhibit rapid wear, enamel loss after enamel breakdown and eruption under functional masticatory forces, increased sensitivity to caries, loss of fillings and, above all, severe sensitivity that often causes serious discomfort [6–11]. In addition, MIH causes a higher risk of caries in children, both in the permanent and primary dentition .
Considering several clinical problems that may arise, the clinical management of MIH can be challenging for the dentist . Molars are often hypersensitive and can be difficult to anesthetize ; however, post-eruptive enamel breakdown can occur rapidly following eruption and may make teeth more susceptible to caries . In addition to the potential for post-eruptive enamel breakdown in these teeth, MIH-affected enamel has structural differences such as higher protein content and lower mineral density than healthy enamel . This, in turn, leads to poor retentive etching patterns and higher failure rates in adhesive fillings, which, among other factors, makes clinical management of MIH-affected teeth regarding cavity design and material choices a serious issue . As it is a difficult condition for clinicians to manage, it is crucial for clinicians to develop awareness, identification skills, and knowledge of its treatment to provide efficient and high-quality oral health care to those affected .
At present, there is a scientific concern that MIH should be included as an essential topic in undergraduate curricula . We suggest that the knowledge and experiences acquired at the undergraduate level are crucial in shaping students’ medical careers, and it is necessary to investigate the knowledge and attitudes of future dentists regarding diagnosis and treatment. For these reasons, this study was conducted to evaluate the knowledge, attitudes, and practices of 4th- and 5th-year dental students about MIH.
Material and Methods
The data were analyzed with IBM SPSS V23. Yates’ correction and Pearson’s chi-square test were used to compare the responses to the questionnaire questions according to student year and sex, and multiple comparisons were made with the Bonferroni corrected Z test. The results of the analysis are presented as frequencies (percentages). The significance level was set as
A total of 218 4th- and 5th-year dental students from among 259 (4th-year: 137, 5th-year: 122) students participated in our study. The detailed distribution was as follows: 111 4th-year students with 47 women and 64 men (51%) and 107 5th-year students with 46 women and 61 men (49%). Table 1 shows the responses of the participants to the questionnaire according to their year in the order in which they appear in the survey.
A statistically significant difference was found between the distributions of the participants’ having heard the term MIH before (
While the rate of those who knew the clinical features of MIH was 55.9% in the 4th-year students, this rate was 89.7% in the 5th-year students (
While there was no statistically significant difference between the years in terms of difficulty in distinguishing MIH from other dental anomalies, dentinogenesis imperfecta anomaly was found to be statistically significant in the distribution of those who had difficulty in distinguishing it (
To the question “Are you aware of the prevalence of MIH in Turkey?”, 14.4% of the 4th-year students answered yes, whereas 30.8% of the 5th-year students answered yes (
The students in both years stated that they mostly used composite resin material in the treatment ol1 f molars with MIH and emphasized the aesthetic factor in material selection.
MIH is widely recognized as a clinical challenge for dentists and patients . Severe MIH can affect quality of life and oral function in children . If left untreated, after 2 years, molars affected by mild MIH can progress to moderate or severe MIH with enamel breakdown . Developing countries bear most of the global burden of MIH . If preventive measures are not taken, the cost of treating MIH will be very high for countries and individuals . Therefore, it is important to study the etiology, treatment, and awareness of MIH, and the curricula of universities, especially in developing countries, must keep pace with this growing challenge and provide future dentists with the necessary training to deal with this problem.
The importance of this research is that it assessed the inadequacies of dental students on this subject and our results can be used to increase their awareness. There has been great interest in MIH in many countries, and surveys for dentists have been conducted [27–29]. In Indonesia, Switzerland, Austria, Syria, and Germany, students’ knowledge on this topic was specifically assessed [20–22,30,31]. To the best of our knowledge, this is the first study to examine the knowledge and attitudes of dental students in Turkey about MIH.
When the results of this cross-sectional study were analyzed, it was found that students generally have heard the term MIH, but 5th-year students were more familiar with it. In similar studies conducted in Austria, Egypt, Germany and Switzerland [20–22,32], it was reported that most students were familiar with MIH, but in a study conducted in Saudi Arabia, 64% of students had not heard the term MIH . This may be related to the fact that the studies were conducted at different times. MIH, which has a history of 20 years, has become more publicized over time. When we evaluated where they heard the term MIH, lectures are the primary sources of knowledge in many countries [20,21,31], which is compatible with our study. MIH is included in the curriculum of the university where this study was conducted. It is explained to the students theoretically in the 3rd-year pediatric dentistry course.
According to the research at King Saud University in Riyadh, it was reported that 35% of the 4th-year students and 25% of the 5th-year students knew the clinical features of MIH , whereas in our study, these rates were 68% and 98%, respectively. It was observed that the level of students’ knowledge about the clinical features of MIH increased as their education progressed. Our results are in line with studies conducted in other countries [21,22,34].
While most of the students who participated in the present study stated that they were somewhat confident in diagnosing MIH, the number of students who chose the option of being very confident was quite low, in line with the results of a similar study conducted in Germany . In a similar study conducted among dentists in Kuwait, 72% of general dentists reported that they were not confident, similar to our study .
With regard to this study’s results, all of our students stated that they had difficulty in distinguishing MIH from other dental anomalies, as in similar studies [18,31]. In a study conducted at the University of Nevada School of Dentistry in Las Vegas , postdoctoral dentists reported that they most often confused it with fluorosis, followed by amelogenesis imperfecta, whereas in a similar study in Syria , senior dental students reported that they had the most difficulty distinguishing it from amelogenesis imperfecta and enamel hypoplasia. In our study, the 4th-year students stated that they confused it with amelogenesis imperfecta and enamel hypoplasia and the 5th-year students confused it with enamel hypoplasia and amelogenesis imperfecta, respectively. These differences between studies may be due to the participants’ pre- and postgraduation status.
In a study conducted in Istanbul, the prevalence of MIH was found to be 14.2%, the same level as the global prevalence of MIH found by Zhao et al in 2018, and they concluded that it was a common condition [36,37]. However, most of the students who participated in the present study reported that they were not aware of the prevalence of MIH and that it would be worth investigating. However, both the 4th-year and 5th-year students stated that the prevalence of MIH in Turkey is less than 25%, which is consistent with the prevalence in these studies.
Most of the participants encountered significant hypomineralized defects in permanent teeth, except for the first molars and incisors. This is consistent with the findings of the study conducted by Skaare et al . However, in their study, these defects were mostly encountered in permanent canine teeth, whereas in our study, these defects were mostly encountered in premolars by the 4th-year students and in the second molars followed by premolars by the 5th-year students. In a study conducted in Australia and Chile, MIH-like defects were mostly encountered in premolar teeth .
A study conducted by Hussein et al in Malaysia reported that the most common defects encountered by dental nurses were yellow/brown defects, whereas white defects were more often encountered by general practitioners . In similar studies, it was reported that yellow/brown defects were encountered most frequently [27,38]. In the present study, the most common defect encountered by the 4th-year students was white defect (38.7%), whereas yellow/brown defect (47.7%) was more often encountered by 5th-year students. The prevalence of defects with enamel loss was low in both years, and the defect may have been masked by extensive caries or atypical restorations.
When questioned about the etiology of MIH, most of the 4th-year and 5th-year students indicated they thought it was genetic. In a study conducted at Wuhan University School of Stomatology, the 4th-year students emphasized genetics (87%) and pregnancy and postnatal factors (87%), whereas 87% of the 5th-year students reported genetics as the etiology . In studies conducted in Egypt and Greece, similar to the present study, participants stated that genetics was the most important etiology [32,40].
In a similar study conducted in Syria, the senior dental students stated that they had the most difficulties in the long-term success of restoration and diagnosis . In a study conducted in Greece, they reported that they most frequently had problems with aesthetics . Most students who participated in our study reported that MIH is a clinical problem. Both the 4th-year and 5th-year students had the most problems with esthetics, but they also frequently reported problems with diagnosis, providing adequate restoration, and determining the cavity boundaries of the affected enamel.
Serna-Muñoz et al found that most participants preferred resin-modified glass ionomer cement for the treatment of post-eruption fractures and opacities, whereas they preferred composite resin for hypomineralized incisors . In the study of Hamza et al in Syria, the senior dental students reported that they preferred stainless steel crowns (40.6%) and composite (40%) in the treatment of molars with MIH . In the present study, similar to the results of Bekes et al and Gamboa et al, composite resin was the preferred material for treatment of teeth with MIH [22,42]. The students who participated in the present study also based their choice of materials on esthetic factors, as in the study by Yehia et al .
Since this study was limited to dental students in a single university, it cannot be generalized to the current knowledge on MIH of the overall population in Turkey. There is a need for studies with larger samples by including dental faculties of other universities. In fact, a similar questionnaire study can be applied to postgraduate dentists and the results can be compared. Another limitation of the study is that the questionnaire was presented to the students online; therefore, they could look up the information before answering, especially given that internet access is widely available and they are aware that their answers will be used for research or other purposes.
Although most of the students were theoretically familiar with MIH, they were not confident in diagnosis and found it difficult to differentiate MIH from other dental anomalies, but the awareness of 5th-year dental students was better than that of the 4th-year students. Nevertheless, MIH warrants greater emphasis in the theoretical and practical dental curricula.
1. Weerheijm KL, Jälevik B, Alaluusua S, Molar-incisor hypomineralisation: Caries Res, 2001; 35(5); 390-91
2. Lygidakis NA, Garot E, Somani C, Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): An updated European academy of Paediatric dentistry policy document: Eur Arch Paediatr Dent, 2022; 23(1); 3-21
3. Portella PD, Menoncin BL, de Souza JF, Impact of molar incisor hypomineralization on quality of life in children with early mixed dentition: A hierarchical approach: Int J Paediatr Dent, 2019; 29; 496-506
4. Santos M, Maia LC, Molar incisor hypomineralization: morphological, aetiological, epidemiological and clinical considerations: Contemporary approach to dental caries, 2012; 423-66, InTech
5. Crombie F, Manton D, Kilpatrick N, Aetiology of molar-incisor hypomineralization: A critical review: Int J Paediatr Dent, 2009; 19(2); 73-83
6. Alevizakos V, Bekes K, Steffen R, von See C, Artificial intelligence system for training diagnosis and differentiation with molar incisor hypomineralization (MIH) and similar pathologies: Clinical Oral Investigations, 2022; 26(12); 6917-23
7. Almuallem Z, Busuttil-Naudi A, Molar incisor hypomineralisation – an overview: Br Dent J, 2018; 225; 601-9
8. Giuca MR, Cappè M, Carli E, Investigation of clinical characteristics and etiological factors in children with molar incisor hypomineralization: Int J Dent, 2018; 2018; 7584736
9. Alaluusua S, Aetiology of molar-incisor hypomineralisation: A systematic review: Eur Arch Paediatr Dent, 2010; 11; 53-58
10. Teixeira RJPB, Andrade NS, Queiroz LCC, Exploring the association between genetic and environmental factors and molar incisor hypomineralization: Evidence from a twin study: Int J Paediatr Dent, 2018; 28; 198-206
11. Fagrell TG, Dietz W, Jälevik B, Norén JG, Chemical, mechanical and morphological properties of hypomineralized enamel of permanent first molars: Acta Odontol Scand, 2010; 68; 215-22
12. Mazur M, Corridore D, Ndokaj A, MIH and dental caries in children: A systematic review and meta-analysis: Healthcare, 2023; 11(12); 1795
13. William V, Messer LB, Burrow MF, Molar incisor hypomineralization: Review and recommendations for clinical management: Pediatr Dent, 2006; 28(3); 224-32
14. Rodd HD, Morgan CR, Day PF, Boissonade FM, Pulpal expression of TRPV1 in molar incisor hypomineralisation: Eur Arch Paediatr Dent, 2007; 8(4); 184-88
15. Americano GC, Jacobsen PE, Soviero VM, Haubek D, A systematic review on the association between molar incisor hypomineralization and dental caries: Int J Paediatr Dent, 2017; 27(1); 11-21
16. Elhennawy K, Manton DJ, Crombie F, Structural, mechanical and chemical evaluation of molar-incisor hypomineralization-affected enamel: A systematic review: Arch Oral Biol, 2017; 83; 272-81
17. Papageorgiou SN, van Waes H, Prophylaxis and desensitizing of MIH teeth: Molar incisor hypomineralization: A clinical guide to diagnosis and treatment, 2020; 113-25, Springer International Publishing
18. Negrescu J, Kodra L, Ziada H, Awareness among postdoctoral dental residents: A cross-sectional study: Dent J, 2022; 10; 64
19. Fernández-Bonet J, MIH should be a core component of every dental curriculum: Eur Arch Paediatr Dent, 2023; 24; 427-28
20. Hamza B, Elhennawy K, van Waes H, Papageorgiou SN, Knowledge, attitudes, and beliefs regarding molar incisor hypomineralisation amongst Swiss dental students: BMC Oral Health, 2021; 21(1); 548
21. Elhennawy K, Anang M, Splieth C, Knowledge, attitudes, and beliefs regarding molar incisor hypomineralization (MIH) amongst German dental students: Int J Paediatr Dent, 2021; 31(4); 486-95
22. Bekes K, Melichar K, Stamm T, Elhennawy K, Dental students’ knowledge, attitudes and beliefs regarding molar incisor hypomineralization (MIH): A survey in Vienna, Austria: J Multidiscip Healthc, 2021; 14; 2881-89
23. Gomez MJR, Mejia LP, Velandia LM, Alvarez LV, Oral health-related quality of life in Colombian children with molar-incisor hypomineralization: Acta Odontol Latinoam, 2018; 31(1); 38-44
24. Neves AB, Americano G, Soares DV, Soviero VM, Breakdown of demarcated opacities related to molar-incisor hypomineralization: A longitudinal study: Clinical Oral Investigations, 2019; 23; 611-15
25. Schwendicke F, Elhennawy K, Reda S, Global burden of molar incisor hypomineralization: J Dent, 2018; 68; 10-18
26. Schneider PM, Silva M, Endemic molar incisor hypomineralization: A pandemic problem that requires monitoring by the entire health care community: Curr Osteoporos Rep, 2018; 16; 283-88
27. Skaare AB, Houlihan C, Nybø CJ, Brusevold IJ, Knowledge, experience and perception regarding molar incisor hypomineralisation (MIH) among dentists and dental hygienists in Oslo, Norway: Eur Arch Paediatr Dent, 2021; 22(5); 851-60
28. Crombie FA, Manton DJ, Weerheijm KL, Kilpatrick NM, Molar incisor hypomineralization: A survey of members of the Australian and New Zealand Society of Paediatric Dentistry: Aust Dent J, 2008; 53(2); 160-66
29. Shalaby MS, El-Shahawy OI, Alaa E, El-Shiekh MA, Assessment of knowledge, attitude and practice of molar-incisor hypomineralisation among a group of Egyptian dentists (observational cross-sectional study): Future Dental Journal, 2022; 8(1); 29-35
30. Dian E, Amir LR, Maharani DA, Knowledge and perceptions on molar incisor hypomineralization among dental students in Indonesia: Journal of International Dental and Medical Research, 2022; 15(1); 243-49
31. Hamza B, Karkoutly M, Papageorgiou SN, Bshara N, Molar-incisor hypomineralisation: Knowledge and perception of Syrian undergraduate and postgraduate dental students: Eur J Dent Educ, 2023; 27(2); 343-52
32. Yehia AM, Abdelaziz AM, Badran A, Knowledge, clinical experience, and perceived need for training regarding molar-incisor hypomineralization among a group of Egyptian dental students: A cross-sectional study: BMC Oral Health, 2022; 22(1); 323
33. Silva MJ, Alhowaish L, Ghanim A, Manton DJ, Knowledge and attitudes regarding molar incisor hypomineralisation amongst Saudi Arabian dental practitioners and dental students: Eur Arch Paediatr Dent, 2016; 17; 215-22
34. Liu Y, He M, A survey on knowledge and attitudes towards molar-incisor hypomineralization among undergraduate and postgraduate students at the School of Stomatology, Wuhan University: BMC Oral Health, 2022; 22(1); 19
35. Alanzi A, Faridoun A, Kavvadia K, Ghanim A, Dentists’ perception, knowledge, and clinical management of molar-incisor-hypomineralisation in Kuwait: A cross-sectional study: BMC Oral Health, 2018; 18(1); 34
36. Koruyucu M, Özel S, Tuna EB, Prevalence and etiology of molar-incisor hypomineralization (MIH) in the city of Istanbul: J Dent Sci, 2018; 13(4); 318-28
37. Zhao D, Dong B, Yu D, The prevalence of molar incisor hypomineralization: evidence from 70 studies: Int J Paediatr Dent, 2018; 28(2); 170-79
38. Gambetta-Tessini K, Mariño R, Knowledge, experience and perceptions regarding Molar-Incisor Hypomineralisation (MIH) amongst Australian and Chilean public oral health care practitioners: BMC Oral Health, 2016; 16; 75
39. Hussein AS, Ghanim AM, Abu-Hassan MI, Manton DJ, Knowledge, management and perceived barriers to treatment of molar-incisor hypomineralisation in general dental practitioners and dental nurses in Malaysia: Eur Arch Paediatr Dent, 2014; 15; 301-7
40. Seremidi K, Amend S, Krämer N, Gizani S, A cross-sectional survey on knowledge and attitudes of Greek dentists regarding molar incisor hypomineralisation diagnosis and treatment: BMC Oral Health, 2022; 22(1); 498
41. Serna-Muñoz C, Martínez-Beneyto Y, Pérez-Silva A, Perception, knowledge, and attitudes towards molar incisor hypomineralization among Spanish dentists: A cross-sectional study: BMC Oral Health, 2020; 20; 260
42. Gamboa GCS, Lee GHM, Ekambaram M, Yiu CKY, Knowledge, perceptions, and clinical experiences on molar incisor hypomineralization among dental care providers in Hong Kong: BMC Oral Health, 2018; 18(1); 217
28 Nov 2023 : Clinical ResearchImpact of Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography on Therapeutic Decisions and ...
Med Sci Monit In Press; DOI: 10.12659/MSM.942122
28 Nov 2023 : Clinical ResearchLong-Term Outcomes of Decompression and Grafting in Acute Pathological Proximal Femur Fractures in Children...
Med Sci Monit In Press; DOI: 10.12659/MSM.943031
27 Nov 2023 : Clinical ResearchComparison of Outcomes from Emergency Admissions to a Major Trauma Center in Turkey of 1646 Elderly Patient...
Med Sci Monit In Press; DOI: 10.12659/MSM.942916
Most Viewed Current Articles
13 Nov 2021 : Clinical ResearchAcceptance of COVID-19 Vaccination and Its Associated Factors Among Cancer Patients Attending the Oncology ...
Med Sci Monit 2021; 27:e932788
30 Dec 2021 : Clinical ResearchRetrospective Study of Outcomes and Hospitalization Rates of Patients in Italy with a Confirmed Diagnosis o...
Med Sci Monit 2021; 27:e935379
14 Dec 2022 : Clinical ResearchPrevalence and Variability of Allergen-Specific Immunoglobulin E in Patients with Elevated Tryptase Levels
Med Sci Monit 2022; 28:e937990
08 Mar 2022 : Review articleA Review of the Potential Roles of Antioxidant and Anti-Inflammatory Pharmacological Approaches for the Man...
Med Sci Monit 2022; 28:e936292