PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18

CROSS-SECTIONAL STUDY

U.S. Pediatric Dentists’ Perception of Molar Incisor Hypomineralization​

Azza Tagelsir, BDS, MSc1 • Jeffrey A. Dean, DDS, MSD, CAE2 • George J. Eckert, MAS3 • Esperanza A. Martinez-Mier, DDS, MSD, PhD4

Abstract: Purpose: The purpose of this survey-based study was to target U.S. pediatric dentists in the Midwest region to determine their knowl-
edge, perceptions, and clinical management strategies of molar incisor hypomineralization (MIH). Methods: After obtaining appropriate author-
izations, all pediatric dentists identified by the American Academy of Pediatric Dentistry’s 2016 to 2017 membership directory in the 12 Midwest
states were invited to take part in the study. The questionnaire, adopted from previous studies, incorporated information of the participants’
demographics and educational/clinical backgrounds and MIH-focused questions. Descriptive statistics and chi-square tests were used for analysis.
An alpha level less than 0.05 was considered statistically significant. Results: A total of 251 out of 975 surveys were completed (26 percent).
Nearly all participants were familiar with MIH. The majority reported the MIH prevalence to be less than 10 percent in their clinical practice
(62 percent). Most respondents were either very confident (65 percent) or confident (34 percent) when diagnosing teeth with MIH. The most
cited clinical challenge in managing MIH teeth was “long-term success of restorations” (79 percent). When analyzed individually, responses dif-
fered significantly for different demographics and educational characteristics of the respondents (P<0.05). Conclusion: MIH is generally well
acknowledged by U.S. Midwest pediatric dentists, with differences related to their perceptions of the condition’s prevalence as well as clinical
and restorative management challenges. (Pediatr Dent 2018;40(4):272-8) Received March 12, 2018 | Last Revision April 30, 2018 | Accepted
May 7, 2018
KEYWORDS: MOLAR HYPOMINERALIZATION, UNITED STATES, DENTISTS

Molar incisor hypomineralization (MIH) is defined as a spec- To date and to the best of our knowledge, no attempt had
trum of developmental qualitative hypomineralization enamel been made to answer these questions in the United States.
defects affecting the permanent first molars (PFMs) with or Thus, the purposes of this study were to investigate the
without involvement of the permanent incisors. These defects level of perception of the molar incisor hypomineralization
are distributed in an asymmetrical fashion and have discernible problem among U.S. pediatric dentists practicing in the Mid-
variations in severity, ranging from demarcated white, yellow, west, determine their insight of the problem’s frequency in their
or brown opacities to severe defects with post-eruption disin- practice, and determine their diagnostic and clinical challenges
tegration of enamel.1,2 The condition was formally designated and management strategies related to MIH.
as MIH in 2001 and has attained growing attention in the
scientific community ever since. A recent comprehensive anal- Methods
ysis of 70 prevalence MIH studies showed that the problem is Ethical approval was obtained from the Institutional Review
very common, with a global estimate of approximately 14 per- Board of Indiana University, Indianapolis, Indiana, USA (study
cent and the highest prevalence seen in South America and IRB no. 1610874604). The Midwest region of the United
Spain.3 States—one of the four geographic regions defined by the
MIH poses extensive oral health challenges1,2 and substan- United States Census Bureau—consists of 12 states occupying
tial psychological and economical dental treatment burdens4-6 the north central United States (Illinois, Indiana, Iowa, Kansas,
for affected children and their families. MIH affected teeth also Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio,
pose substantial challenges for dental practitioners.7-11 Although South Dakota, and Wisconsin).15 After attaining appropriate
one of the pioneer reviews on the management and diagnosis of authorization from the American Academy of Pediatric Den-
MIH was published by U.S. scholars,12 most of the continuing tistry, (AAPD), our target population, determined from the
worldwide growing attention of MIH has been from outside AAPD’s 2016 to 2017 Membership Directory, comprised all
the U.S. The available U.S. published reports on prevalence of pediatric dental practitioners who were listed as active or life
enamel opacities have been limited to data from the primary AAPD members in any of the 12 states of the Midwestern
dentition.13 However, scholarly enquiries into the existence of region. To maintain uniformity and limit responses to clinicians
MIH among child populations in the U.S. and whether U.S. who have practiced or are actively practicing pediatric den-
dentists are cognizant of the problem are few or nonexistent.14 tistry in the U.S., affiliate, associate, international, and student
AAPD membership categories were excluded from our sample. 
As per the AAPD’s definition, affiliate and associate members
1Dr. Tagelsir is a PhD candidate, and 4Dr. Martinez-Mier is professor and chair, both in of the AAPD constitute a wide range of dental professionals, in-
the Department of Cariology, Operative Dentistry, and Dental Public Health; 2Dr. Dean cluding but not limited to foreign-qualified pediatric dentists,
is a Ralph E. McDonald professor of pediatric dentistry and professor of orthodontics who may or may not be practicing pediatric dentistry.
and dentofacial orthopedics, Department of Pediatric Dentistry and Department of
Orthodontics, School of Dentistry; and 3Mr. Eckert is a biostatistician supervisor, Depart-
Email invitations to take part in the study enclosed a link
ment of Biostatistics, School of Medicine, all at Indiana University, Indianapolis, to read the study information sheet and, if interested, complete
Indiana, USA. the questionnaire. The survey was completely anonymous; the
Correspond with Dr. Azza Tagelsir at azzahmed@iupui.edu investigator obtained a complete list of potential participants’

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 PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18

full names, their emails, and state of practice as they appear take part in the study. Seven questionnaires failed to deliver
on the AAPD directory. However, no individual identifica- to the recipient, and a total of 251 surveys were returned,
tion appeared on the completed questionnaires and it was not yielding an overall response rate of 26 percent.
possible to identify participants or link individual answers to a Table 1 illustrates the study participants’ descriptive charac-
specific participant. Two consequent reminders were sent four teristics. More than 40 percent of the survey participants com-
and eight weeks after the initial emailing. The online version of pleted their predoctoral training/qualification (DDS) and their
the questionnaire was accessible through a secure web applica- postgraduate (PG) pediatric dentistry training/qualifications
tion: REDCap, an electronic data capture tool for building between 1990 and 2009 (n equals 123, 46 percent; and n
and managing online surveys and databases hosted at the equals 117, 43 percent, respectively). A negligible number of
Indiana Clinical and Translational Sciences Institute (Indiana participants did not receive formal postgraduate training in
CTSI). To ensure concealment, all data were unidentified and pediatric dentistry (n equals five, two percent). The majority of
all information collected from the questionnaire was kept con- participants were board certified in pediatric dentistry (73 per-
fidential and stored in a password-protected electronic format. cent), practiced pediatric dentistry in a suburban location (70
The data collection instrument was adopted from the ques- percent), had more than 20 pediatric patients (younger than
tionnaire utilized in previous studies, with minor modifica- 18 years old) in a typical workday (71 percent), and were not
tions. Based on these previous studies,7-9 the questionnaire was involved in academic/teaching posts (75 percent).
comprised of two main sections. The first section covered demo- Knowledge, perceived prevalence, and incidence of
graphics, education background, and clinical practice charac- MIH. Nearly all participants were familiar with teeth afflicted
teristics. The second section included questions about with MIH. More than half and over one third of the participants
knowledge and perceptions of MIH’s estimated prevalence, recalled first learning about MIH during postgraduate residency
incidence, diagnosis, etiology, clinical challenges, and restorative or predoctoral DDS trainings (58 percent and 34 percent, re-
options in MIH management. In the demographics section, spectively). The bulk of survey respondents (n equals 165, 62
information about the participant’s gender, age, and dental percent) indicated that they observe MIH in less than 10 percent
education background were gathered. Questions about the of their patients, but more than one third (n equals 94, 35 per-
characteristics of the participant’s practice as a pediatric dentist— cent) perceived the prevalence of MIH to be approximately 10
such as the location of the primary practice, involvement in to 25 percent in their clinical practice. The vast majority (90
academia, and the average number of pediatric patients exam- percent) were not aware of MIH-published prevalence data
ined per workday—were also included in this section. for the U.S., yet 85 percent believed that MIH is a significant
The second section of the questionnaire was further di- clinical problem that requires investigation. More than 40 per-
vided into four subcategories. The first category included the cent were uncertain if the incidence of MIH has increased over
participant’s views on diagnosis of MIH, confidence in diag- the last 10 years or in the period of their practice. When com-
nosing MIH, and conditions they may consider challenging to paring perceived prevalence of MIH, responses differed signifi-
differentiate from MIH. The second subcategory involved ques- cantly per age group, gender, and year of completion of PG
tions about the participant’s personal estimation of prevalence
and severity of hypomineralized PFMs and primary second
molars (PSMs) in their clinical practice. A third subcategory Table 1. GENERAL DESCRIPTIVE CHARACTERISTICS OF THE
incorporated questions about the participant’s perception re- STUDY RESPONDENTS
garding possible etiological factors implicated in MIH. The
list of putative factors included “genetics, chronic medical con- Variable n (%)
dition(s) of the pregnant mother, antibiotics taken by the preg- Demographics
nant mother, antibiotics/medications taken by child, acute
Age in years (mean±SD) 47.5±13.1
medical condition(s) that affect the pregnant mother, acute
medical condition(s) that affect the child, preterm birth/birth Participants’ gender Male: 143 (53), female 126 (47)
and delivery complications, environmental contaminants, high Dental education background
fluoride, and others.” For each etiological factor, the participant
Year of completion of post- Before 1990s: 71 (26),
selected one of the following answers: “yes,” “no,” “maybe,” or graduate pediatric dentistry between 1990s and 2009: 117 (43),
“I don’t know.” training/qualification after 2009: 81(30)
The MIH-related risk factors question was designed as a
Has postgraduate pediatric 264 (98)
check all that apply question. The fourth subcategory explored dental qualification
the most common clinical challenges that face participants in
managing MIH and their decisions on restorative material when Has board certification in 197 (73)
pediatric dentistry
treating MIH-affected molars.
Data were entered into an Excel spreadsheet and analyzed Dental practice characteristics
using SAS 9.4 software (SAS Institute Inc., Cary, N.C., USA). Currently practicing 260 (97)
Descriptive statistics were used to describe the characteristics of pediatric dentistry
the study participants. Associations between survey items were Primary area of practice Rural 22 (9), suburban 179 (70),
analyzed using chi-square tests. Results at an alpha level less urban 53 (21)
than 0.05 were considered statistically significant. Average pediatric patients <10 patients: 10 (4), 10-20
(<18 years) per day patients: 65 (25),
Results more than 20 patients:187 (71)
General descriptive characteristics of study respondents. A Involvement in academic 66 (25)
total of 975 active and life members of the AAPD, distributed post/teaching
across the 12 Midwest states, were sent email invitations to

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PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18

pediatric dental residency. For example, the estimated MIH pre- 12, four percent), and amelogenesis imperfecta (n equals 41,
valence in the practice decreased with age (i.e., the older age 15 percent). Male respondents and those in the older age group
group of respondents was more likely to estimate the MIH (over 55 years old) were significantly more likely to feel confi-
prevalence to be less than 10 percent in their practice; Table 2). dent when diagnosing MIH teeth (data not shown).
Perception of MIH incidence over the period of the parti- MIH clinical challenges and management. In the re-
cipants’ practice also differed significantly per age group, gender, spondents’ view of the clinical challenges in the management
year of completion of PG pediatric dental residency, and of MIH teeth, the vast majority agreed that the most common
board certification (data not shown). More than three fourths of clinical challenge was “long-term success of restorations” (n
participants (n equals 203, 76 percent) agreed that comparable equals 201, 79 percent), followed by “providing adequate re-
defects of the PSMs were observed less frequently than those storation” (n equals 175, 69 percent), “determining the extent
of the PFMs. Participants who were in the 35- to 55-year-old (or margins) of the affected tooth” (n equals 172, 67 percent),
group and those who were board certified in pediatric den- and “achieving adequate local anesthesia” (n equals 170, 67
tistry were significantly more likely to report less frequency of percent). The least commonly reported clinical management
defects in the PSMs (data not shown). challenge was “diagnosis” (n equals 27, 11 percent). Clinical
Diagnosis and differentials of MIH. Most respondents challenges encountered when managing teeth with MIH dif-
affirmed that they were very confident (n equals 174, 65 per- fered significantly per age group, gender, year of completion of
cent) or confident (n equals 91, 34 percent) in diagnosing teeth postgraduate pediatric dentistry training, and board certifica-
with MIH, although more than one third (n equals100, 37 per- tion. For example, factors associated with being more likely to
cent) had none of the differential diagnoses checked. Partici- report achieving adequate local anesthesia of MIH teeth as a
pants who checked differential diagnoses found it most diffi- clinical challenge were age 35 or younger, female gender, board
cult differentiating between MIH and chronological hypoplasia certification, and residency completion after 1990 (Table 3).
and fluorosis (36 percent and 34 percent, respectively) but least For the restorative management options, stainless steel
difficult differentiating between MIH and tetracycline staining crowns (SSCs) and composite resins came as the first and second
(n equals two, one percent), dentinogenesis imperfecta (n equals chosen “most used” (n equals 81, 32 percent; and n equals 73,

Table 2. COMPARISON BETWEEN AND THE PARTICIPANTS’ DEMOGRAPHIC AND DENTAL EDUCATION CHARACTERISTICS AND THEIR
PERCEIVED PREVALENCE OF MOLAR INCISOR HYPOMINERALIZATION (MIH) AND HYPOMINERALIZED PRIMARY SECOND
MOLAR (PSM) (CHI-SQUARE TEST)
Demographic characteristics Age (years) Gender
<=35 36-55 >55 P-value Male Female P-value
n (%) n (%) n (%) n (%) n (%)
In approximately what <10% 21 (37) 76 (60) 68 (83) 0.000* 102 (72) 63 (50) 0.000*
percentage of your patients
~10-25% 33 (58) 47 (37) 14 (17) 38 (27) 56 (45)
do you observe MIH?
>25% 3 (5) 4 (3) 0 (0) 1 (1) 6 (5)

How frequently do you More frequently 1 (2) 10 (8) 7 (9) 0.042* 12 (9) 6 (5) 0.259
notice this defect in the
Less frequently 47 (82) 100 (79) 56 (68) 107 (76) 96 (77)
primary second molar tooth
in comparison to the Uncertain 7 (12) 6 (5) 12 (15) 13 (9) 12 (10)
permanent first molar The same as for the 1 (2) 4 (3) 6 (7) 7 (5) 4 (3)
tooth? permanent first molar

Dental education characteristics Board certification Year of completion of pediatric dental

n (%) residency n (%)
No Yes P-value Before 1990-2009 After P-value
1990 2009

In approximately what <10% 49 (69) 116 (59) 0.336 62 (89) 69 (59) 34 (43) 0.000*
percentage of your patients
~10-25% 20 (28) 74 (38) 8 (11) 43 (37) 43 (54)
do you observe MIH?
>25% 2 (3) 5 (3) 0 (0) 4 (3) 3 (4)

How frequently do you More frequently 6 (8) 12 (6) 0.028* 5 (7) 12 (10) 1 (1) 0.090
notice this defect in the
Less frequently 46 (65) 157 (81) 49 (70) 89 (77) 65 (81)
primary second molar tooth
in comparison to the Uncertain 13 (18) 12 (6) 10 (14) 5 (4) 10 (13)
permanent first molar
The same as for the 4 (6) 7 (4) 4 (6) 5 (4) 2 (3)
tooth?
permanent first molar

* Statistically significant differences (P<.05) using chi-square test.

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 PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18

29 percent, respectively) and “sometimes used” (n equals 154, the most common checked etiologies were “acute medical con-
61 percent; and n equals 114, 45 percent, respectively) dental dition(s) that affect the involved child” (n equals 160, 63 per-
material options by respondents. Resin-modified glass ionomer cent), followed by “chronic medical condition(s) that affect
(RMGI) emerged as the third chosen restorative option, fol- the mother during pregnancy” (n equals 124, 49 percent).
lowed by glass ionomer (GI) in both categories (RMGI: n Respondents were mostly uncertain about environmental con-
equals 54, 22 percent and n equals 104, 42 percent; GI: n taminants as a putative aspect involved in MIH etiology (n
equals 42,17 percent and n equals 102, 41 percent). Amalgam equals 113, 45 percent), followed by “acute maternal illnesses
was the least used restorative option (n equals 59, 24 percent); during pregnancy” and “child intake of antibiotics” (n equals
however, more than one fifth of the respondents (n equals 52, 102, 41 percent and n equals 77 percent, 39 percent, respec-
21 percent) cited amalgam as a “sometimes used” restorative tively). Exposure to high fluoride remained the least proposed
option for molars with MIH. Cast restoration was largely the MIH etiology (n equals 108, 44 percent). The first year of
most unused restorative option (n equals 231, 92 percent), fol- life was the most selected timing of insult (n equals 90, 35
lowed by compomer and amalgam (n equals 181, 72 percent percent), followed by “pregnancy to first year of life” (n equals
and n equals 136, 52 percent, respectively). Year of residency 75, 29 percent) and “pregnancy to third year of life” (n equals
completion appears to have an effect across multiple restoration 47, 18 percent).
types. Residency completion after 1990 was associated with not
using cast restorations and compomer, and completion after Discussion
2009 was associated with increased use of RMGI. Amalgam or This study is the first to report on U.S. dentists’ perception of
composite resin use did not significantly differ per age group, MIH. Recognition of MIH as a clinical problem from the
gender, year of completion of PG pediatric dental residency, perspective of pediatric dental practitioners is considered a con-
or board certification status (Table 4). crete step involved in exploring this problem, especially in
Etiology and time of insult. There was considerable in- regions where the actual population-based estimates of the
consistency in the respondents’ understanding of MIH etiology. problem are scarce or nonexistent. The study population com-
Overall, more than 40 percent of the participants had a re- prised of pediatric dentists in the Midwestern region who were
sponse other than “no” marked for all 10 etiology options, currently practicing pediatric dentistry (active members) or
assuming that MIH has a multifactorial etiology. Individually, have maintained their AAPD active status for extended time

Table 3. COMPARISON BETWEEN THE PARTICIPANTS’ DEMOGRAPHIC AND DENTAL EDUCATION CHARACTERISTICS AND
THE CLINICAL CHALLENGES IN THE MANAGEMENT OF MOLAR INCISOR HYPOMINERALIZATION (MIH)
(CHI–SQUARE TEST)
Demographic Age Gender
characteristics n (%) n (%)
<=35 36-55 >55 P-value Male Female P-value

Diagnosis of teeth with MIH* Yes 10 (19) 10 (8) 7 (9) 0.108 13 (10) 14 (12) 0.596

Achieving adequate local anesthesia* Yes 50 (93) 92 (75) 28 (36) 0.000† 74 (55) 96 (80) 0.000†
Determining the extent Yes 39 (72) 84 (69) 49 (62) 0.421 82 (61) 90 (75) 0.015†
(or margins) of the affected tooth*

Providing adequate restoration* Yes 46 (85) 83 (68) 46 (58) 0.004† 81 (60) 94 (78) 0.002†
Long-term success of restoration* Yes 51 (96) 96 (79) 54 0.001† 98 (73) 103 (87) 0.006†
Achieving patient comfort* Yes 46 (85) 87 (72) 28 (36) 0.000† 71 (53) 90 (75) 0.000†

Dental education Board certification Year of completion of pediatric dental

characteristics n (%) residency n (%)
No Yes P-value Before 1990-2009 After P-value
1990 2009

Diagnosis of teeth with MIH * Yes 7 (10) 20 (11) 0.830 4 (6) 11 (10) 12 (16) 0.163

Achieving adequate local anesthesia* Yes 35 (50) 135 (73) 0.000† 22 (33) 79 (71) 69 (90) 0.000†
Determining the extent Yes 44 (63) 128 (69) 0.336 37 (55) 84 (76) 51 (66) 0.018†
(or margins) of the affected tooth*
Providing adequate restoration* Yes 46 (66) 129 (70) 0.537 33 (49) 82 (74) 60 (78) 0.000†
Long-term success of restoration* Yes 51 (73) 150 (82) 0.129 41 (61) 92 (83) 68 (89) 0.000†
Achieving patient comfort* Yes 35 (50) 126 (69) 0.005† 23 (35) 77 (70) 61 (79) 0.000†

* Categories of common clinical challenges that face practitioners in managing teeth with MIH.
† Statistically significant differences (P<.05) using chi-square test.

MOLAR HYPOMINERALIZ ATION AND U.S. DENTISTS 275

PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18

(life members) at the time of administration of the survey. Al- general population, low response is an identified impediment in
though there is discernable disparity in the pediatric dentists- health professionals’ surveys.18 As recommended, cover letters,
to-child ratio across the different states, 16 most Midwestern multiple follow-up reminders, and personalized second re-
states share relatively comparable ratios of pediatric dental prac- minders were all used as response enhancement strategies.19 The
titioners to child populations, with a range of 2.43 (Michigan) authors believe that issues such as the anonymous nature of the
to 4.38 (Indiana) per 100,000 children and a total average of survey precluding the use of a multimode administration (phone
3.33 per 100,000 children.17 calling and postal surveys) and possible administrative staff/
The major limitations of our study are the low response gatekeepers scrutiny, where participants enlisted their business
rate and potential self-selection bias, which may compromise or group practice email address, may have further augmented
the ability to generalize our findings. However, compared to the the nonresponse rate.18

Table 4. COMPARISON BETWEEN THE PARTICIPANTS’ DEMOGRAPHIC AND DENTAL EDUCATION CHARACTERISTICS AND
RESTORATIVE MANAGEMENT OPTIONS OF MOLAR INCISOR HYPOMINERALIZATION (MIH) (CHI-SQUARE TESTS)
Demographic characteristics Age Gender
n (%) n (%)
<=35 36-55 >55 P-value Male Female P-value

Stainless 0 (not at all used) 3 (6) 3 (2) 1 (1) 0.239 2 (1) 5 (4) 0.029*
steel
crowns 1 (least used) 1 (2) 6 (5) 5 (6) 8 (6) 4 (3)
2 (sometimes used) 39 (72) 70 (57) 45 (58) 72 (54) 82 (68)
3 (most used) 11 (20) 43 (35) 27 (35) 52 (39) 29 (24)

Cast 0 (not at all used) 53 (98) 116 (97) 62 (81) 0.000* 118 (90) 113 (94) 0.194
restoration
1 (least used) 1 (2) 2 (2) 10 (13) 7 (5) 6 (5)
2 (sometimes used) 0 (0) 2 (2) 5 (6) 6 (5) 1 (1)

Resin modified 0 (not at all used) 5 (9) 31 (26) 24 (31) 0.012* 31 (24) 29 (24) 0.413
glass ionomer
1 (least used) 3 (6) 20 (17) 9 (12) 17 (13) 15 (13)
2 (sometimes used) 32 (59) 44 (37) 28 (36) 59 (45) 45 (38)
3 (most used) 14 (26) 24 (20) 16 (21) 23 (18) 31 (26)

Dental education characteristics Board certification Year of completion of pediatric dental

n (%) residency n (%)

No Yes P-value Before 1990-2009 After P-value

1990 2009

Glass 0 (not at all used) 28 (42) 43 (23) 0.026* 23 (35) 24 (22) 24 (31) 0.206
ionomer
1 (least used) 6 (9) 30 (16) 6 (9) 20 (18) 10 (13)
2 (sometimes used) 25 (37) 77 (42) 29 (45) 42 (39) 31 (40)

3 (most used) 8 (12) 34 (18) 7 (11) 23 (21) 12 (16)

Cast 0 (not at all used) 59 (88) 172 (93) 0.261 52 (80) 105 (96) 74 (96) 0.001*
restoration
1 (least used) 6 (9) 7 (4) 9 (14) 2 (2) 2 (3)
2 (sometimes used) 2 (3) 5 (3) 4 (6) 2 (2) 1 (1)
Resin modified 0 (not at all used) 23 (35) 37 (20) 0.046* 22 (34) 30 (28) 8 (10) 0.001*
glass ionomer
1 (least used) 6 (9) 26 (14) 6 (9) 21 (19) 5 (6)
2 (sometimes used) 28 (42) 76 (41) 24 (37) 36 (33) 44 (57)
3 (most used) 9 (14) 45 (24) 13 (20) 21 (19) 20 (26)

Compomer 0 (not at all used) 51 (76) 130 (71) 0.527 39 (59) 78 (72) 64 (84) 0.006*
1 (least used) 6 (9) 14 (8) 4 (6) 11 (10) 5 (7)
2 (sometimes used) 9 (13) 29 (16) 19 (29) 13 (12) 6 (8)
3 (most used) 1 (1) 10 (5) 4 (6) 6 (6) 1 (1)

* Statistically significant differences (P<.05) using chi-square test.

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 PEDIATRIC DENTISTRY V 40 / NO 4 JUL / AUG 18

Mirroring the findings from previous studies7,8 conducted than pediatric dentists in other similar studies.8,23,28 Because the
exclusively or partially among pediatric dentists, almost all our defect severity and eruption status of MIH-affected teeth were
survey participants acknowledged acquaintance with MIH not sought when constructing the question of the restorative
and the vast majority agreed on the clinical significance of ex- material option of molar teeth with MIH, the considerable
ploring MIH. However, very mixed responses were uncovered fraction of pediatric dentist respondents identifying RMGIs
on questions of perceived prevalence, restorative management and GI after composite resin and SSCs might very likely reflect
options, and etiological factors of the MIH defects. their adoption of interim restoration strategy before definite
There were remarkable discrepancies among respondents treatment. The relatively recent introduction and improved
regarding perceived prevalence of MIH in their clinical practice. characteristics of RMGI29 might also explain their remarkably
While most respondents conformed with the fact of unavail- magnified use among those who have recently completed their
ability of published prevalence estimates of MIH from the U.S., residency training (after 2009). Nevertheless, the unexpected
the bulk leaned toward an estimate of less than 10 percent, percentage (more than one fifth) who have cited amalgam as an
which is smaller than the up-to-date MIH average global preva- occasional restorative option of MIH molars remains unwar-
lence (14 percent).3 While this may reflect regional variations ranted and contradictory to findings from other countries8,10,23,28
of MIH prevalence consistent with the findings from the Euro- but coincides with the overall current U.S. clinicians’ inclina-
pean survey,7 further analysis revealed that respondent pedi- tion toward the continued use of amalgam restorations.30
atric dentists who were younger or those who have completed The plausibility of MIH being a multifactorial condition,
residency training recently (after 2009) were more likely to with systemic, environmental, and genetic components, is now
report higher estimated prevalence of MIH (between 10 and 25 generally accepted.31-33 A recent systematic review32 has high-
percent). In agreement with previous reports,8,9 these findings lighted the ample implication of early childhood illnesses in the
could further imply that the issue of hypomineralized PFM is etiology of MIH as opposed to the weaker evidence of prenatal
actually increasingly emerging; yet a considerable proportion and perinatal factors. Remarkably, fewer respondents indicated
of respondents were uncertain about the subject of escalating that maternal prenatal and perinatal disturbances are potential
incidence of MIH. Likewise, the findings could reveal the MIH risk factors in comparison to postnatal (childhood ill-
alleged existence of MIH and provide partial answers to ques- nesses), which coincides with the aforementioned suggestions
tions about whether MIH exists among the U.S. child popula- and findings from earlier surveys.8,9 The further perplexity, en-
tion. In fact, a recent analysis has projected that MIH prevalent countered by participants, about the involvement of genetics
cases are highest in high-income countries like the U.S. 20 and environmental contaminants as alleged MIH risk factors
Nevertheless, our study’s conclusions reflect only the clinician’s agrees with the conflicting and preliminary findings in the
personal perceptions of the MIH problem and don’t supersede literature.34-36 Unexpectedly, most respondents drifted toward
the imperative demand for parallel population-based epidemio- underrating the timing of insult occurrence to around preg-
logical surveys of MIH from the U.S. nancy and the first year of life, negating the longer enamel
Gender differences in caries diagnostic and management mineralization of the PFM period that could extend to an
approaches among clinicians may help explain the same gender average of three years after birth.37
differences observed in this study.21 However, the pronounced
influence of participants’ other demographics (i.e., age) and Conclusions
their educational background characteristics on their perceived Based on this study’s findings, the following conclusions can
diagnostic and management abilities for teeth with MIH might be made:
hint at wide variations in education and teaching practices in 1. Pediatric dentists from the Midwest who responded
pediatric dentistry residency programs, 22 inherent variations to this survey were well aware of the problem of molar
of the frequency of defects in the participant’s own practice, incisor hypomineralization. However, discrepancies,
and the length of their clinical experiences. similar to those reported in previous studies, were pro-
As opposed to diagnosing teeth with MIH, U.S. clinicians nounced in most aspects of the problem, such as MIH’s
reported they were more challenged by providing adequate and perceived prevalence, clinical management, restorative
long-term restorations of teeth affected by MIH—a finding material choices, and etiological aspects.
consistent with their European, Australian/New  Zealander, 2. Factors, such as the participants’ demographics and
South American, and Middle Eastern counterpart clini- educational characteristics, were significantly associated
cians.7-9,11,23 Rigorous restorative guidelines of MIH-affected to the different perceptions and approaches reported.
teeth, based on substantial and long-term clinical evidence, are
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