Received: 18 September 2018 

|  Revised: 5 February 2019 

|  Accepted: 7 February 2019

DOI: 10.1111/ipd.12482

ORIGINAL ARTICLE

Impact of molar incisor hypomineralization on quality of life in

children with early mixed dentition: A hierarchical approach

Paula Dresch Portella  | Bruna Leticia Vessoni Menoncin  | Juliana Feltrin de Souza   |

José Vitor Nogara Borges de Menezes   | Fabian Calixto Fraiz   |
Luciana Reichert da Silva Assunção

Pediatric Dentistry, Department of
Stomatology, Universidade Federal do
Background: Molar incisor hypomineralization (MIH) is associated with unfavour-
Paraná, Curitiba, Brazil able dental conditions such as dental caries and may consequently impact oral health-­
related quality of life (OHRQoL).
Correspondence
Luciana Reichert da Silva Assunção, Objective: To assess the impact of MIH on OHRQoL in children with early mixed
Pediatric Dentistry, Department of dentition.
Stomatology, Universidade Federal do
Method: A population-­based cross-­sectional study of 728 8-­year-­old children from
Paraná, Curitiba, Brazil.
Email: lurassuncao@yahoo.com.br the public school system in Curitiba, Brazil, was conducted. The Child Perception
Questionnaire for 8-­to 10-­year-­olds (CPQ8-10) was used to evaluate OHRQoL. MIH
Funding information
was diagnosed according to the European Academy of Paediatric Dentistry (EAPD)
Coordenação de Aperfeiçoamento
de Pessoal de Nível Superior - Brasil criteria. The assessments of MIH, dental caries, and malocclusion were performed by
(CAPES), Grant/Award Number: 001 four calibrated examiners (κ ≥ 0.80). Demographic and socioeconomic data (DSE)
were obtained from the children's parents/caregivers using a structured questionnaire.
The analysis of OHRQoL determinants was performed through a three-­level hierar-
chical approach: mesial (DSE), intermediate (clinical conditions), and distal (child's
oral self-­perception), using Poisson regression with robust variance (α = 0.05).
Results: The prevalence of MIH was 12.1% (95% CI: 10-­15). An association was
found between MIH and OHRQoL in the “oral symptoms” domain of the CPQ8-10
(PR: 1.07, 95% CI: 1.03-­1.11, P < 0.001) after adjusting for other clinical variables
and DSE.
Conclusion: Molar incisor hypomineralization was associated with a greater impact
on OHRQoL in children's oral symptoms.

KEYWORDS
dental enamel hypoplasia, oral health, quality of life, tooth demineralization

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© 2019 BSPD, IAPD and John Wiley & Sons A/S. Int J Paediatr Dent. 2019;29:496–506.
Published by John Wiley & Sons Ltd
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1  |   IN T RO D U C T ION
WHY THIS PAPER IS IMPORTANT TO
Molar incisor hypomineralization (MIH) is a qualitative PAEDIATRIC DENTISTS
dental enamel defect (DED) that affects the first permanent • The impact of MIH on oral symptoms that was
molars and occasionally the incisors of the same dentition.1 found in this study demonstrates the need to in-
The diagnostic criteria for this alteration were defined by clude the patient's perception in clinical practice
the European Association of Paediatric Dentistry (EAPD) when devising treatment strategies.
in 2003 and include opacities of white, yellow, or brown • The impact of MIH on OHRQoL that was ob-
coloration, post-­ eruptive fractures, atypical restorations, served in a population with a high frequency of
and extractions that are attributable to MIH.1 The world- lesions that are considered mild demonstrates the
wide prevalence of MIH varies from 2.4% in China2 to need to develop preventive and/or therapeutic
40.2%3 in Brazil. A recent Brazilian study reported a prev- strategies for cases with less severe defects.
alence of 16.2%.4
The teeth affected by MIH are more susceptible to the
rapid development of caries due to increased enamel porosity
and loss of enamel structure5 and exposure of dentinal tubules individual can be detected in earlier stages of the disease.
that facilitate pulpal inflammation.6 The problems in these The EAPD suggests that cross-­sectional studies should as-
teeth are aggravated because children tend to avoid brushing, sess MIH in 8-­year-­old children.14
causing an increase in dental plaque stagnation.5 Therapeutic When assessing the impact of an oral condition on
interventions for these teeth pose a challenge for clinicians OHRQoL, socioeconomic and demographic conditions,
because there are usually failures in restorations and ex- however, should be considered,15 as well as the hierar-
tractions of the tooth6 and poor aesthetics once MIH may also chy of possible associations.16 Individuals who live under
affect the incisors, especially the upper.2,3 Thus, MIH tends lower socioeconomic conditions are more exposed to risk
to have a negative impact on children's oral self-­perception,7 factors that can affect oral health and consequently their
the perception of the family regarding their children's oral functional, psychological, and social environment.15,17 In
health,8 and oral health-­related quality of life (OHRQoL).8 such cases where multiple determinants are involved in a
The concept of OHRQoL refers to the impact of oral single outcome, the hierarchy of these factors should be
conditions on daily activities, emotional well-­ being, and determined, which may facilitate evaluations of indepen-
social well-­being according to the individual's perception.9 dent variables and allow the identification of potential con-
Evaluating OHRQoL may represent the real needs of a popu- founding factors.16
lation, combining perceived needs (evaluated by the popula- Therefore, the objective of this study was to evaluate the
tion) and normative and technical needs (assessed by dental impact of MIH on OHRQoL in children with early mixed
professionals).10 dentition by performing a hierarchical analysis.
Studies that have evaluated the relationship between DED
and OHRQoL have shown a greater impact in children with
more severe hypoplasia11 and diffuse opacities.12 Despite
2  |  M ATERIAL AND M ETHODS
the clinical complexity of MIH, studies that have evaluated
2.1  |  Study design, sample size, and
the impact of this change on OHRQoL are scarce. A recent
participants
study evaluated 11-­to 14-­year-­old Brazilian adolescents
and their parents using the Child Perception Questionnaire A population-­based cross-­sectional study was conducted be-
(CPQ11-14) and Parental-­ Child Perception Questionnaire tween December 2016 and September 2017 with 8-­year-­old
(P-­CPQ), respectively. A greater impact of severe MIH children who were enrolled in the public education system
lesions was found in the “oral symptoms” domain, which in the city of Curitiba, Brazil. The choice to evaluate only
includes spontaneous or induced pain reports, bad breath, children from public schools is due to the homogeneity of
and food impaction, and in the “functional limitations” socioeconomic conditions of this population once that, in the
domain, which includes difficulties in chewing food and Brazilian context, the type of school can be used as an indica-
sleep disturbances. These findings derived from relatively tor for socioeconomic status.18
older children who have a higher prevalence of severe MIH Curitiba is the capital of the state of Paraná in southern
injuries, such as post-­eruptive fractures and atypical res- Brazil, which has 1 908 359 inhabitants and a municipal
torations.8 Molar incisor hypomineralization presents high human development index of 0.855, which is 10th in the
clinical variability that is influenced by age.13 Therefore, Brazilian ranking system according to the United Nations
evaluating the impact of MIH on OHRQoL in younger chil- Development Program. In 2016, 143 701 8-­year-­old children
dren is justified because the needs that are perceived by the were enrolled in the public school system in Curitiba. For the
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498       PORTELLA et al.

sample calculation, the finite population was used by con- The instrument also has two items for patient identification
sidering a prevalence of 50% of OHRQoL, with an accuracy (gender and age) and two global items on the child's oral self-­
of 5% and drawing effect of 1.8. The calculation resulted in perception and general well-­being of the child (“Do you think
a sample of 690 children, which was increased by 20% to your teeth and your mouth are___?” and “How much do your
compensate for possible attrition. Therefore, the maximum teeth and your mouth bother you?”). The application of this
sample was 863 children. questionnaire was performed in a school environment and su-
The sampling process used a two-­stage cluster random- pervised by the examiners.
ization. First, the schools were randomly selected in each of
the nine sanitary districts within Curitiba. The students were
2.3  |  Clinical data
randomly selected by respecting the proportion of students
who were enrolled in each district. Access to the software The clinical examination was performed in the school setting
that generated the randomization and allocation of the data is under artificial light, with the aid of no. 5 flat mirrors and
freely available online (www.randomizer.org). probes with a blunt tip. The dental surfaces were dried with
Children who presented four permanent first molars that gauze prior to the exam to improve the diagnostic conditions.
were fully erupted at the time of the clinical examination The MIH diagnosis was performed according to the EAPD
were included in the study. The exclusion criteria were the criteria, in which at least one permanent first molar should
following: current or past use of orthodontic appliances and present a marked opacity, post-­eruptive fracture, the presence
other types of developmental defects of enamel (DDE) asso- of atypical restoration, or exodontia that is attributable to
ciated or not to syndromes as hypoplasia, dental fluorosis, MIH.1 The opacities were further classified according to col-
and imperfect amelogenesis. oration: white, yellow, or brown. To evaluate the severity of
MIH, mild injury (opacity) and severe injury (post-­eruptive
fractures, atypical restorations, and tooth extraction attribut-
2.2  |  Nonclinical data
able to MIH) were considered.4 Only defects >1.0 mm in di-
ameter were recorded.14 Differential diagnosis of other types
2.2.1  |  Demographic and socioeconomic
of DDE associated or not to syndromes was also performed
data and parents/caregivers’ perception
by four trained examiners.
The children's parents or caregivers completed a self-­ The decayed, missing, and filled teeth index for perma-
administered questionnaire that contained demographic and nent teeth (DMFT) and primary teeth (dmft) were used to
socioeconomic (DSE) information, such as level of educa- estimate the presence of untreated caries, extraction due to
tion, the degree of kinship to the child, family structure (nu- caries and restorations, respectively.21 Traumatic dental inju-
clear family for children who lived with both parents), the ries (fractures) were assessed according to the World Health
child's gender, and monthly family income. The parents’/ Organization criteria.21 Dental occlusion was classified ac-
caregivers’ perceptions of the children's oral health were de- cording to Grabowski et al22 for occlusal findings for mixed
termined by asking the question, “What do you think of your dentition. Individuals who were classified as having maloc-
child's oral health?” The possible answers were good, reason- clusion had any occlusal abnormality, such as anterior open
able, and bad. bite, anterior or posterior crossbite, deep bite, excessive over-
jet, and anterior crowding.22
Prior to clinical data collection, four examiners were cal-
2.2.2  |  Oral health-­related quality of life
ibrated using theoretical and practical steps. Satisfactory re-
(OHRQoL)
sults for intra-­and inter-­examiners agreements were found
The validated and translated version of the Child Perception for all of the clinical parameters: MIH (κ ≥ 0.94), dental car-
Questionnaire (CPQ) for children aged 8-­10 years (CPQ8-10) ies (κ ≥ 0.80), traumatic dental injuries (κ ≥ 0.80), and mal-
to Brazilian Portuguese19,20 was used to measure the impact occlusion (κ ≥ 0.80).
on OHRQoL. The CPQ8-10 is composed of 25 items that
are divided into four domains: oral symptoms (five items),
2.4  |  Pilot study
functional limitations (five items), emotional well-­ being
(five items), and social well-­being (10 items). The items A pilot study was first conducted with 30 children, selected
determined about how often events occurred in the month by convenience, and their parents/caregivers in a public
prior to application of the instrument. The response options school. The children in this pilot study were of the same age
were on a 5-­point scale: once = 0, once or twice = 1, some- as the children in the main study. The clinical examination
times = 2, often = 3, and every day or almost every day = 4. and interviews were performed under the same conditions
The children could have scores that ranged from 0 (no im- and with the same criteria that were established in the main
pact on OHRQoL) to 100 (maximum impact on OHRQoL). study. The results demonstrated no need for modifications of
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F I G U R E   1   Conceptual hierarchical framework of associations between DSE factors, clinical conditions, and children's oral self-­perception
and the impact on oral health-­related quality of life (OHRQoL)

the proposed methods. The children in the pilot study did not The stepwise forward selection modelling process was
participate in the main study. used in the analysis. The stepwise forward selection was used
in the multiple regression models to test the associations be-
tween impact on OHRQoL and their distal, intermediate, and
2.5  |  Data analysis
proximal determinants according to the theoretical hierarchi-
The statistical analyses were performed using STATA 12.0 soft- cal framework (Figure 1). All of the independent variables
ware (StataCorp, College Station, PA, USA). The level of signifi- presented P < 0.20 in the univariate analysis were selected
cance that was adopted for all of the analyses was 5%. The impact and maintained in the final model those that remained sig-
on OHRQoL in each domain of the CPQ8-10 was considered the nificant (P < 0.05) after adjusting or allowing a better adjust-
dependent variable, dichotomized into the following: no impact ment of the model.
(score = 0) and impact (score ≥ 1). Dichotomization was used to The analysis of associations between the other indepen-
discriminate children who reported any impact of oral conditions dent variables and the impact on OHRQoL was performed
on OHRQoL from children who did not report such an impact. using Fisher's exact test. The severity of MIH (mild/severe)
Multiple regression using a conceptual hierarchical ap- was categorized using the individual as a sample unit, con-
proach was performed to detect possible associations be- sidering the worst clinical condition. Therefore, children who
tween the independent variables and impact on OHRQoL had at least one tooth with a severe defect were included in
(outcome) using Poisson regression with robust variance. the “severe” group; children presenting only opacities were
The variables were allocated to levels according to their included in the “mild” group. The children were also clas-
proximity to the outcome (distal, intermediate, and prox- sified according to the presence or absence of “yellow and/
imal; Figure 1). Level 1 or distal determinants consisted or brown opacity”, “post-­eruptive fracture”, and “atypical
of DSE factors. These variables were categorized accord- restoration”. Fisher's exact test was also used to analyse the
ing to their median or according to theoretical reference as association between untreated dental caries and OHRQoL in
the following: nuclear family (yes/no), parents’/caregivers’ the MIH group.
schooling (>8 years of study/≤8 years of study), child's For the descriptive analysis of the types of MIH (opacity/
gender (male/female), and family income (>2 × minimum post-­eruptive fracture/atypical restoration/extraction attribut-
wage/≤2 × minimum wage). The family income was cate- able to MIH), the absolute number and proportion of teeth
gorized according to the median value found in this popula- were considered.
tion. The unit of minimum wage was based on the Brazilian The parents’/caregivers’ perceptions of the children's oral
monthly income at the time of the study (USD$237). The health were evaluated by asking the question, “What do you
intermediate determinants (Level 2) were composed of think about your child's oral health?” The answers were di-
clinical conditions, which were dichotomized according to chotomized (“good”/“reasonable and bad”), and the associ-
their presence or absence: MIH (with MIH/without MIH) ation with MIH was analysed using the Pearson chi-­square
and malocclusion (with malocclusion/without malocclu- test.
sion). The dmft and DMFT indexes were analysed based
on the presence or absence of each component: d/D (un-
2.6  |  Ethics statement
treated caries), m/M (extraction due to caries), and f/F (res-
torations). The proximal determinant (Level 3) was the oral The investigation followed the parameters of the Declaration
self-­perception of the child, which was determined by ask- of Helsinki and was approved by the Human Ethics
ing the question, “Do you think your teeth and your mouth Committee of the Federal University of Paraná (UFPR; ap-
are___?” The answers were categorized as “very good and proval no. 1.689.362) and the Department of Education of
good” and “ok and poor”. the Municipality of Curitiba. The parents/caregivers of the
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500       PORTELLA et al.

children were invited to participate in the study and signed a post-­eruptive fractures (n = 18), and atypical restorations
free and informed consent form. (n = 9) presented an impact in the oral symptoms domain but
without statistical significance (P > 0.05; Table 2).
From the 88 children with MIH, 24 (27.3%) presented
3  |   R ES U LTS untreated dental caries in the permanent first molars. There
was no statistically significant difference between children
A total of 863 informed consent forms were sent to par- with or without untreated dental caries and the impact on
ents/caregivers, of whom 820 returned the form (response OHRQoL in the MIH group (P = 0.727).
rate = 95.0%). On the day of the examination, 51 children A total of 15 children presented fractures in 17 anterior
were missing, and 39 were not included in the sample be- permanent teeth. There was no statistical significance be-
cause they were 9 years old. Thus, a total of 730 children tween the presence of fractures and the impact on the oral
were examined, two of whom were excluded because of the symptoms (P = 0.616), functional limitations (P = 0.761),
use of orthodontic appliances at the time of the examination, emotional well-­ being (P = 1.000), and social well-­ being
resulting in a final sample of 728 children. Of these, 372 (P = 0.583) domains of the CPQ8-10.
(51.5%) were male. The demographic and socioeconomic The parents’/caregivers’ perceptions of the oral health of
questionnaire was completed mostly by the mothers (85.1%). their children were not significantly associated with MIH
The presence of an impact of the clinical and DSE vari- (P = 0.812).
ables on OHRQoL in each domain of the CPQ8-10 is presented The results of the multivariate analysis using the concep-
in Table 1. Most of the children belonged to nuclear families, tual hierarchical approach are shown in Table 3. The effect
with a reported income of ≤ 2 × the minimum wage, and of family structure (nuclear or non-­nuclear family) remained
the parents/caregivers had more than 8 years of schooling. significant in the oral symptoms (P = 0.041), functional lim-
A higher prevalence of untreated caries and restorations was itations (P = 0.031), and emotional well-­being (P = 0.018)
found in primary teeth, and as lower prevalence were found in domains. The effect of the parents’/caregivers’ schooling
permanent teeth. Few children had extractions due to caries in remained significant only in the functional limitations do-
their primary teeth, while missing permanent teeth were not main (P = 0.005). The gender of the child was significantly
observed. Most of the children did not present malocclusion. associated with OHRQoL only in the oral symptoms do-
A higher frequency of negative reports of the children's oral main (P = 0.005). With regard to clinical conditions, MIH
self-­perception was observed. Most of the parents/caregivers (P < 0.001) and restorations on primary teeth (P < 0.033)
reported an unfavourable oral condition of the children. were significantly associated with the impact on OHRQoL
The prevalence of an impact on OHRQoL was 93.1%, in the oral symptoms domain after adjusting for other clinical
76.5%, 73.5%, and 66.6% in the oral symptoms, functional variables and those that belonged to the distal determinants.
limitations, emotional well-­being, and social well-­being do- Extractions of primary teeth were significantly associated
mains of the CPQ8-10, respectively. Molar incisor hypomin- with the impact in the functional limitations (P = 0.011),
eralization was observed in 12.1% (n = 88) of the children. emotional well-­ being (P = 0.011), and social well-­ being
Among the children who were diagnosed with MIH, 63 (P = 0.031) domains. An association was found between the
(71.6%) had mild MIH, and 25 (28.4%) had severe MIH. children's oral self-­perception and impact on OHRQoL in all
Incisors were diagnosed with MIH in 48 (54.5%) children, of domains of the CPQ8-10 after adjusting for variables of the
whom 37 (77.1%) presented the alteration in the upper arch. previous determinants.
Of the 8434 first molars and permanent incisors that were
evaluated, 308 (3.5%) were diagnosed with MIH. Of these,
264 (85.7%) had demarcated opacities, 29 (9.4%) had post-­ 4  |  DISCUSSION
eruptive fractures, and 15 (4.9%) had atypical restorations.
No extraction that was attributable to MIH was detected. This study evaluated the impact of MIH on OHRQoL in a
Among the 308 teeth with MIH, 212 (68.8%) were first mo- representative sample of children with early mixed dentition.
lars and 96 (31.2%) were incisors. A higher prevalence of af- In the adjusted model, only the oral symptoms domain of the
fected incisors was found in the upper arch (n = 61), of which CPQ8-10 was associated with MIH. A recent study reported
45 (73.8%) were diagnosed with white opacities, 14 (22.9%) an impact of MIH in all domains of the CPQ8-10 in a sample
were diagnosed with yellow opacities, and 2 (3.3%) were di- of 88 Colombian students aged 7-­10 years.23 This previous
agnosed with post-­eruptive enamel fractures. study did not perform an analysis that adjusted for confound-
No significant difference in the impact on OHRQoL was ing variables, which is an important aspect when considering
found when considering the presence of MIH in incisors the multidimensionality of quality of life. Additionally, this
and the severity of MIH (P > 0.05). All of the children who previous study evaluated children from a single educational
were diagnosed with yellow and/or brown opacities (n = 68), institution, thus limiting possible external validity.
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The oral symptoms domain consists of items that address recent systematic review has observed a significant association
the history of pain in the last 30 days (including pain that is between MIH and dental caries,24 which could explain the im-
stimulated by cold), bad breath, and food impaction.19,20 A pact of MIH in this domain. Nonetheless, this study did not find

T A B L E   1   Demographic and socioeconomic variables, clinical conditions, and children's oral self-­perception according to the presence of an
impact on OHRQoL in each domain of the CPQ8-10 (n = 728)

Oral symptoms Functional limitations Emotional well-­being Social well-­being

Variable With impact, n (%) With impact, n (%) With impact, n (%) With impact, n (%)
Child’s gender (n [%])
 Male (n = 372) 337 (90.6) 275 (73.9) 265 (71.2) 244 (65.6)
 Female (n = 356) 341 (95.8) 282 (79.2) 270 (75.8) 241 (67.7)
Nuclear family (n [%])
 Yes (n = 498) 459 (92.2) 369 (74.1) 352 (70.7) 322 (64.7)
 No (n = 219) 211 (96.3) 182 (83.1) 177 (80.8) 158 (72.1)
Family income (n [%])
 >2 × minimum wage (n = 258) 232 (89.9) 185 (71.1) 175 (67.8) 154 (59.7)
 ≤2 × minimum wage (n = 470) 446 (94.9) 372 (79.1) 360 (76.6) 331 (70.4)
Parents/Caregivers years of schooling (n [%])
 >8 y (n = 517) 481 (93.0) 382 (73.9) 368 (71.2) 333 (64.4)
 ≤8 y (n = 203) 192 (94.6) 172 (84.7) 162 (79.8) 149 (73.4)
MIH
 No (n = 640) 591 (92.3) 488 (76.2) 469 (73.3) 424 (66.2)
 Yes (n = 88) 87 (98.9) 69 (78.4) 66 (75.0) 61 (69.3)
Untreated caries on permanent teeth (n [%])
 No (n = 607) 564 (92.9) 463 (76.3) 444 (73.1) 402 (66.2)
 Yes (n = 121) 114 (94.2) 94 (77.7) 91 (75.2) 83 (68.6)
Restoration on permanent teeth (n [%])
 No (n = 697) 648 (93.0) 530 (76.0) 509 (73.0) 464 (66.6)
 Yes (n = 31) 30 (9.8) 27 (87.1) 26 (83.9) 21 (67.7)
Untreated caries on primary teeth (n [%])
 No (n = 360) 334 (92.8) 265 (73.6) 255 (70.8) 238 (66.1)
 Yes (n = 368) 344 (93.5) 292 (79.3) 280 (76.1) 247 (67.1)
Extraction due to caries of primary teeth (n [%])
 No (n = 642) 596 (92.8) 482 (75.1) 462 (72.0) 416 (64.8)
 Yes (n = 86) 82 (95.3) 75 (87.2) 73 (84.9) 69 (80.2)
Restoration on primary teeth (n [%])
 No (n = 521) 479 (91.9) 390 (74.9) 380 (72.9) 340 (65.3)
 Yes (n = 207) 199 (96.1) 167 (80.7) 155 (74.9) 145 (70.0)
Malocclusion (n [%])
 No (n = 437) 409 (93.6) 337 (77.1) 322 (73.7) 298 (68.2)
 Yes (n = 289) 267 (92.4) 219 (75.8) 212 (73.4) 186 (64.4)
Child’s oral self-­perception (n [%])
 Very good and good (n = 290) 365 (90.4) 305 (71.6) 278 (65.3) 256 (60.1)
 Ok and poor (n = 397) 286 (96.9) 245 (83.1) 250 (84.7) 223 (75.6)
Parents’/Caregiver’ perception
 Good (n = 290) 270 (93.1) 210 (72.4) 197 (67.9) 179 (61.7)
 Reasonable and bad (n = 397) 369 (92.2) 313 (78.8) 302 (76.1) 276 (69.5)
Frequencies lower than 728 are due to lack of data for the variable. Extraction due to caries of permanent teeth was not computed due to absence of cases for this variable.
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502       PORTELLA et al.

T A B L E   2   Association between different evaluation criteria of Parent Questionnaire about tooth appearance.7 The authors ob-
MIH and the impact on the oral symptoms domain of the CPQ8-10 in served negative perception of the parents and children in the
children with the condition (n = 88) case group, but in different aspects of the majority of the ques-
With impact, n Without impact, n tions that were asked. Only concerns about aesthetics with re-
(%) (%) P* gard to tooth discoloration were reported by both caregivers and
children.7 In this study, no association was found between MIH
Yellow and/or brown opacity
and parents’/caregivers’ perceptions or between MIH and the
 Yes 68 (100.0) 0 0.227
impact on OHRQoL in the emotional well-­being domain of the
 No 19 (95.0) 1 (5.0)
CPQ8-10. The emotional well-­being domain addresses such is-
Post-­eruptive fracture sues as “being ashamed”, “worrying about what people think”,
 Yes 18 (100.0) 0 0.793 and “not being so pretty” because of the teeth and mouth.19,20
 No 69 (98.6) 1 (1.4) The differences between the present results and the study by
Atypical restoration Leal et al7 can be attributed to the difference between the instru-
 Yes 9 (100.0) 0 0.897 ments of data collection. The Child and Parent Questionnaire
 No 77 (98.7) 1 (1.3) on tooth appearance was developed to analyse the perception
about dental fluorosis26 and includes the perception about dis-
*Fisher's Exact Test.
coloration and other oral conditions including the colour of
an association between children with or without untreated den- the tooth and, for that reason, can be considered more accu-
tal caries and the impact on OHRQoL in the MIH group. Other rate than the CPQ to measure the concerns about the opacities
studies should be conducted in order to verify a worsening of of MIH. Another explanation could be the higher prevalence
oral symptoms, including pain of dental origin, in children with (73.8%) of white opacities in the upper incisors observed in
this alteration. In this sense, one of the first articles on the sub- this study, which did not have a major impact on the issues that
ject suggested that teeth affected by MIH can present pain and are addressed by the emotional well-­being domain. Therefore,
sensitivity even in lesions that are considered less severe.5 To the aesthetic impact of different types of MIH on children's
date, there are no clinical reports evaluating the relationship be- OHRQoL is one aspect that deserves further investigation.
tween dental sensibility and MIH. An experimental study has This study found a prevalence of MIH of 12.1%, similar to
observed that the wider exposure of dentinal tubules in affected a recent study that was conducted in Brazil.4 Researches that
teeth allows the oral bacteria penetrate through enamel gener- have been performed in other countries reported a prevalence
ating inflammatory reactions in the pulp.6 Children with MIH of 2.8%2 to 40.2%.3 Ethnic differences and the variety of en-
also tend to avoid molars and incisors while brushing, leading vironmental and genetic factors may explain this high vari-
to biofilm accumulation and food stagnation.5 ability in the prevalence of MIH. Furthermore, the sample
The impact of MIH on OHRQoL was previously evaluated size, study design, and age may also contribute to this wide
in 11-­to 14-­year-­old Brazilian children using the CPQ11-14, range of prevalence.27
which is specific to this age group. The authors who applied the In the primary teeth, there was an impact of restorations in
CPQ11-14 also observed an impact of MIH in the oral symptoms the oral symptoms domain as well as extractions in the func-
domain but only in individuals with severe lesions, such as post-­ tional limitation, emotional well-­being, and social well-­being
eruptive fractures.8 An association was found between severe domains. A study conducted with 826 6 to 7-­year-­old Brazilian
MIH and OHRQoL in the functional limitations domain of the children has also observed that the history of extractions of
CPQ11-14, which addresses difficulties with chewing, sleep, and primary teeth has negatively influenced OHRQoL.28 No
speech.19,20 In the previous study,8 a higher prevalence of more impact of other clinical variables (ie, malocclusion and un-
severe MIH lesions was observed (50.5%), which was different treated dental caries) on OHRQoL was observed. Few studies
from the present results, in which these changes were uncom- have addressed malocclusion in children with mixed denti-
mon (28.4%). The loss of dental structure increases the accu- tion. A previous study that included a representative sample
mulation of biofilm5 and facilitates the transport of bacteria of 1204 Brazilian children, aged 8-­10 years, however, found
to dentin, thus aggravating sensitivity because there is greater an association between malocclusion and OHRQoL.29 The
exposure of dentinal tubules.6 Another Brazilian study of ad- disagreement between this previous study and the present
olescents found that enamel and/or dentin fracture can impair findings may be explained by the wider age range of the chil-
dental function, such as eating and speech.25 Thus, preventive dren who were evaluated by those authors.29 With regard to
strategies are needed to prevent the clinical aggravation of teeth dental caries, the study of Leal et al,28 using the International
that are affected by MIH, preventing an exacerbated impact on Caries Detection and Assessment System (ICDAS), has re-
OHRQoL in children with this alteration. ported that the presence of dentin lesions was negatively
A case-­ control study evaluated the perception of MIH associated with OHRQoL. A higher prevalence of untreated
in parents and 7-­to 13-­year-­old children using the Child and dental caries was observed in this previous study (74.8%)29
T A B L E   3   Hierarchical multiple regression for determining associations between variables of interest and the impact on OHRQoL according to all domains of the CPQ8-10 (n = 728)

Oral symptoms Functional limitations Emotional well-­being Social well-­being

PRc (95% CI) PRa (95% CI) PRc (95% CI) PRa (95% CI) PRc (95% CI) PRa (95% CI) PRc (95% CI) PRa (95% CI)
PORTELLA et al.

a
Level 1—Demographic and socioeconomic factors
Child’s gender
Male 1 1 1 1 1
Female 1.06 (1.02-­1.10) 1.06 (1.02-­1.10) 1.07 (0.99-­1.16) 1.06 (0.98-­1.16) 1.03 (0.93-­1.14)
P 0.005 0.005 0.093 0.159 0.547
Nuclear family
Yes 1 1 1 1 1 1 1 1
No 1.05 (1.01-­1.09) 1.04 (1.00-­1.08) 1.13 (1.04-­1.22) 1.10 (1.00-­1.19) 1.15 (1.05-­1.25) 1.12 (1.02-­1.22) 1.12 (1.01-­1.25) 1.07 (0.96-­1.20)
P 0.009 0.041 0.003 0.031 0.001 0.018 0.030 0.194
Family income
>2 × mini- 1 1 1 1 1 1 1 1
mum wage
≤2 × mini- 1.06 (1.01-­1.10) 1.05 (0.99-­1.09) 1.10 (1.01-­1.21) 1.04 (0.95-­1.15) 1.13 (1.02-­1.25) 1.08 (0.97-­1.20) 1.18 (1.05-­1.33) 1.13 (0.99-­1.28)
mum wage
P 0.022 0.056 0.031 0.401 0.015 0.181 0.005 0.053
Parents’/Caregiver’ schooling
>8 y 1 1 1 1 1 1 1 1
≤8 y 1.02 (0.98-­1.06) 1.01 (0.96-­1.05) 1.16 (1.07-­1.25) 1.12 (1.04-­1.22) 1.12 (1.03-­1.23) 1.08 (0.99-­1.18) 1.15 (1.03-­1.27) 1.09 (0.98-­1.22)
P 0.303 0.777 <0.001 0.005 0.010 0.099 0.010 0.109
Level 2—Clinical conditionsb
MIH
No 1 1 1 1 1
Yes 1.07 (1.04-­1.11) 1.07 (1.03-­1.11) 1.03 (0.91-­1.16) 1.02 (0.90-­1.16) 1.05 (0.90-­1.22)
P <0.001 <0.001 0.643 0.726 0.553
Untreated caries on permanent teeth
No 1 1 1 1
Yes 1.02 (0.97-­1.07) 1.02 (0.92-­1.13) 1.03 (0.92-­1.15) 1.04 (0.91-­1.18)
P 0.581 0.773 0.631 0.606
  
|   503

(Continues)
 |

TA B L E 3  (Continued)
504      

Oral symptoms Functional limitations Emotional well-­being Social well-­being

PRc (95% CI) PRa (95% CI) PRc (95% CI) PRa (95% CI) PRc (95% CI) PRa (95% CI) PRc (95% CI) PRa (95% CI)
Restoration on permanent teeth
No 1 1 1 1
Yes 1.04 (0.97-­1.11) 1.15(1.00-­1.32) 1.15 (0.98-­1.35) 1.02 (0.79-­1.30)
P 0.244 0.061 0.092 0.891
Untreated caries on primary teeth
No 1 1 1 1
Yes 1.00 (0.97-­1.05) 1.07 (0.99-­1.17) 1.07 (0.98-­1.17) 1.02 (0.92-­1.13)
P 0.709 0.069 0.110 0.773
Extraction due to caries of primary teeth
No 1 1 1 1 1 1 1
Yes 1.03 (0.98-­1.08) 1.16 (1.06-­1.27) 1.13 (1.03-­1.24) 1.18 (1.07-­1.31) 1.14 (1.03-­1.27) 1.24 (1.10-­1.40) 1.21 (1.07-­1.36)
P 0.308 0.001 0.011 0.001 0.011 <0.001 0.003
Restoration on primary teeth
No 1 1 1 1 1
Yes 1.05 (1.01-­1.09) 1.04 (1.00-­1.08) 1.08 (0.99-­1.17) 1.03 (0.93-­1.13) 1.07 (0.96-­1.20)
P 0.019 0.033 0.078 0.587 0.203
Malocclusion
No 1 1 1 1
Yes 0.99 (0.95-­1.03) 0.98 (0.90-­1.07) 1.00 (0.91-­1.09) 0.94 (0.85-­1.05)
P 0.538 0.679 0.922 0.290
Level 3—Oral self-­perceptionc
“Do you think your teeth and your mouth are___?”
Very good 1 1 1 1 1 1 1 1
and good
Ok and poor 1.07 (1.03-­1.11) 1.07 (1.03-­1.11) 1.15 (1.07-­1.25) 1.14 (1.06-­1.23) 1.29 (1.18-­1.40) 1.27 (1.17-­1.38) 1.25 (1.13-­1.38) 1.23 (1.12-­1.36)
P <0.001 0.001 <0.001 0.001 <0.001 <0.001 <0.001 <0.001
Significance results highlighted in bold. Extraction due to caries of permanent teeth was not computed due to absence of cases for this variable.
CI, confidence interval; PR, prevalence ratio for the reference category calculated by means of Poisson regression; PRa, adjusted prevalence ratio; PRc, crude prevalence ratio.
a
Adjusted by variables of the same level included in the model.
b
Adjusted by variables of the same level and by DES determinants.
c
Adjusted by DES and clinical condition determinants.
PORTELLA et al.
PORTELLA et al.   
|
   505

compared with the findings of this study. In contrast, the dmft and likely presented less favourable socioeconomic condi-
and DMFT indexes do not discriminate the depth of the cari- tions compared with children who attend private schools.
ous lesions and may underestimate the results. In conclusion, the present results suggest that MIH con-
Demographic and socioeconomic factors were associated siderably increases children's negative self-­perceptions of
with an impact on OHRQoL in most of the domains of the oral symptoms, which include pain from dental origin.
CPQ11-14. Many studies indicated that the most disadvan-
taged socioeconomic levels tend to be negatively associ-
ACKNOWLEDGMENTS
ated with good oral health and consequently an individual's
OHRQoL.15,17 These factors may influence health habits and This study was financed in part by the Coordenação de
oral self-­perception because of difficulties accessing informa- Aperfeiçoamento de Pessoal de Nível Superior -­Brasil
tion and dental services.17 Furthermore, previous studies that (CAPES) -­Finance Code 001.
investigated the impact of demographic and socioeconomic
variables in each of the domains of the CPQ11-14 found that
CONFLICT OF INTEREST
monthly family income8,15 and family structure had a high
impact on OHRQoL.15 The hypothesis of the association be- The authors declare no conflict of interest.
tween the family structure and oral health-­related quality of
life has been poorly evaluated and can be explained by the
AUTHOR CONTRIBUTION
strong influence of both biological parents on the school-
children's self-­perception and on the family environment in P.D. Portella collected the data, interpreted data and wrote
relation to oral health habits.15 These results emphasize the the manuscript. B.L.V. Menoncin collected and interpreted
importance of considering socioeconomic and demographic the data. J.F. de Souza was one of the responsible for the
factors in public oral health strategies. study design, performed the calibration of the clinical pa-
In this study, female children presented a higher preva- rameters and performed the critical review of the manu-
lence of an impact on OHRQoL in the oral symptoms domain script. J.V.N.B. de Menezes was one of the responsible for
of the CPQ8-10. Other studies reported similar results, indicat- the study design and performed the critical review of the
ing that female children present a greater impact of oral con- manuscript. F.C. Fraiz contributed to the interpretation of
ditions on OHRQoL compared with male children.8,15 This data and performed the critical review of the manuscript.
association might be explained by the greater concern of girls L.R.S. Assunção was the research adviser, was one of the
with oral and aesthetic health problems.30 responsible for the study design, performed the statistical
The children's oral self-­perception about their teeth and analysis and interpretation of data and performed the criti-
mouth was significantly associated with all domains of the cal review of the manuscript.
CPQ8-10 when adjusted by other determinants of the hierar-
chical model. This variable was obtained in one of the ques-
ORCID
tions of CPQ8-10, which does not belong to the domains and
is not included for the total calculation of the instrument: Juliana Feltrin Souza  https://orcid.
“Do you think your teeth and your mouth are____?” Thus, org/0000-0001-9969-3721
students with a negative self-­perception presented a higher José Vitor Nogara Borges Menezes  https://orcid.
prevalence of an impact on OHRQoL. This result reinforces org/0000-0001-9178-0898
the efficacy of the CPQ8-10 for measuring OHRQoL, in which
Fabian Calixto Fraiz  https://orcid.
oral self-­perception was used as one of the global indicators
org/0000-0001-5290-7905
in the instrument validation process.15,19,20
This study has some limitations that are inherent to its Luciana Reichert da Silva Assunção  https://orcid.
methodological design. The data reflect the individual's org/0000-0002-7380-8583
perception at the moment of evaluation. Thus, a longitu-
dinal design is needed to analyse the impact of MIH on
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