Community Dental Health (2021) 38, 178–181 © BASCD 2021

Received 23 August 2020; Accepted 9 February 2021 doi:10.1922/CDH_00242Reis04

Risk factors for developmental defects of enamel in children

from southeastern Brazil
Caio L. B. Reis,1,2 Mariane C. F. Barbosa,3 Daniela C. de Lima,2 João A. Brancher,4 Célia
M. C. F. Lopes,5 Flares Baratto-Filho,5 Erika C. Küchler1 and Daniela S. B. de Oliveira2
1
Department of Pediatric Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil;
2
Department of Clinic and Surgery, School of Dentistry, Federal University of Alfenas, Brazil; 3Department of Child and Adolescent Health,
School of Dentistry, Federal University of Minas Gerais, Brazil; 4School of Life Sciences, Pontificia Universidade Catolica do Parana,
Brazil; 5Department of Dentistry, University of the Region of Joinville - Univille, Joinville/SC, Brazil.

Introduction: Developmental Defects of Enamel (DDEs) comprise qualitative and/or quantitative changes to the enamel during amelogenesis.
The aetiology of DDE remains inconclusive. Aim: To determine the association of pre, peri, and postnatal factors with the presence of
DDE. Design: Cross-sectional study with 353 children (8 to 11 years-old) in a Brazilian town. Methods: One calibrated dentist assessed
DDE using the Developmental Defects of Enamel Index and a questionnaire collected medical and sociodemographic data. Main outcomes:
Children with at least one type of DDE were categorized into the DDE group. Subtypes of DDE were also recorded. Results: 63.1% of
children had at least one type of DDE. Diffuse opacity was present in 36.7%, demarcated opacity in 14.8%, and hypoplasia in 5.83% of
the children. In multivariate analysis, demarcated opacities and hypoplasia were associated with birth weight < 2500g (OR = 4.82; 95%
CI 1.23-1.95). Conclusion: Low birth weight predicted DDE.

Keywords: Growth and Development, Dental Enamel Hypoplasia, teeth abnormalities, Tooth Hypomineralization, Odontogenesis Prenatal
Injuries, Neonatal Diseases

Introduction in different populations have investigated prenatal, peri-

natal, and postnatal factors in DDE, the results for some
Developmental Defects of Enamel (DDEs) occur due factors, such as maternal age, medications and prenatal
to alterations in one or more of the three stages of care remain inconclusive (Masumo et al., 2013). Thus,
amelogenesis (secretory, calcification, and maturation) the aim of this study was to determine the associations
and manifest as two major alterations: Hypoplasia and/ between DDEs and pre-, peri-, and postnatal risk factors
or Hypomineralization. Hypoplasia is characterized by in a Brazilian population.
defective enamel formation in the secretory stage, result-
ing in loss of structure and reduced enamel thickness
Method
(Vargas-Ferreira et al., 2018). Defects during calcification
or maturation affect only translucency, with the thickness The STROBE guideline was followed to inform the design
and surface of the enamel remaining regular. These le- and conduct of the study. This study was approved by
sions are known as hypomineralization defects and may the local Human Research Ethics Committee (HREC),
manifest as demarcated or diffuse opacities. Demarcated protocol number 78568217.7.0000.5142. Written consent
opacity is a confined opaque area in enamel, whereas was obtained from the parents through an Informed
diffuse opacity is continuously distributed with varying Consent Form, and an assent term form was used for
degrees of translucency (Massignan et al., 2016). the children (appropriate for their age).
Amelogenesis, is a complex and sensitive process that The available population for this cross-sectional study
begins in the uterine period and extends to early child- was children enrolled in public schools in Alfenas, Minas
hood (Masterson et al., 2018). DDEs can be influenced Gerais State, in southeastern Brazil. Alfenas is a medium-
by gene, local and/or systemic factors. Prenatal and sized city of 73,774 inhabitants, mainly composed of
perinatal factors, such as cigarette smoking and maternal European and African descendants (Brazil, 2010). The
health problems during pregnancy and premature and public water supply has controlled fluoride adjustment
underweight birth have been associated with greater risk (Reis et al., 2020). A sample size calculation (α= 0.05; β=
of DDEs (Corrêa-Faria et al., 2013; Cortines et al., 2019). 0.80%; Cohen’s d for an effect size of 0.98 [Mastora et
Health problems such as asthma, urinary tract infections, al., 2017]) predicted a minimum of 276 children (http://
gastrointestinal disturbances, and diphtheria during the clincalc.com; https://www.psychometrica.de/effect_size.
first three years of postnatal life are also associated with html). A sample of all children enrolled in four schools
a higher risk (Wong et al., 2014). Although many studies was anticipated to exceed this target. One school was

Correspondence to: Prof. Daniela Silva Barroso de Oliveira Email: barrosodaniela@hotmail.com

selected at random from each of four different regions of had two or three types. Diffuse opacity was the most com-
the city. This sample was previously described in Reis et mon form (36.8%) (Table 1). DDE was present in both
al. (2020). Children of both genders (8 to 11 years old) arches in 55.2% of children, 31.4% had DDE only in the
were sampled, irrespective of racial or ethnic origin. The maxilla 13.4% only in the mandible. Incisors and canines
exclusion criteria were individuals who were biologically were affected in 44.85%, premolars and molars in 13.9%.
related to a previous participant (to avoid a cluster of DDE affected all types of teeth in 41.3% of the sample.
children with similar genetic backgrounds), those with Less than 1/3 of the clinical crown was affected (Type
dental prostheses, orthodontic or orthopedic appliance, 1) in 68.6% of children have. Type 2 DDE was present in
severe facial or dental anomalies, carious lesion with 6.7%. Only one child had Type 3 DDE. Almost one quarter
extensive coronary destruction, systemic disorders with (24.2%) of children had a combination of DDE types.
cognitive or behavioral problems, syndromes or those who Table 2 shows the associations between DDE with
reported a history of trauma to their primary dentition. pre, peri and postnatal factors. In bivariate analysis, ad-
Medical and sociodemographic data were collected vanced maternal age (≥ 35 years) was associated with the
from February to May 2018, using a validated self- presence of DDE but in the adjusted logistic regression
complete questionnaire. The questionnaire was given to analysis (Table 3), only low birth weight (< 2500g) was
parents/guardians to completed at home and enquired associated with the frequency of demarcated opacities and
about sociodemographic data, medical history during the hypoplasia (OR, 4.82; 95% CI, 1.23-18.95). Bivariate
prenatal period (prenatal care, health problems during analyses for each type of DDE are available at https://
pregnancy, alcohol and cigarette consumption during drive.google.com/drive/folders/17OUiFRGMx2ky_N5FI
pregnancy, complications at birth, use of vitamin sup- GrXR6xFbQw3MBPy?usp=sharing).
plements, calcium or medicines) and peri- and postnatal Some factors (Vitamins during pregnancy and illness
periods - the first three years of the child’s life (premature or medications before the age of three) were divided into
birth, type of delivery, childbirth complications, health subgroups for analyses, but were not associated with
problems and use of medications). Self-care included use DDE. Self-report of use of dental floss, brush teeth before
of dental floss, toothbrushing before bed and frequency sleep and how often brush teeth per day were also not
of brushing per day. associated with DDE (data not shown).
DDEs were diagnosed using the Developmental
Defect Enamel Index (FDI, 1992). To standardize the Discussion
diagnoses, a single dentist was trained and calibrated.
The dentist then examined 45 children on two occasions A recent meta-analysis review pointed out that more
one week apart. Cohen’s Kappa for the reliability of studies should be performed to improve the evidence
DDE diagnoses was 0.87, indicating near perfect reli- about the risk factors for DDE, due the low quality of the
ability. Clinical examinations started after calibration, and previous studies (Fatturi et al., 2019). The roles of some
participants in the calibration were not included in the medical and social factors, such as maternal age, vitamins
final sample). Children were examined at school under during pregnancy and medications during childhood have
natural light using tongue depressors, cotton wool rolls, not yet been fully explored in the aetiology of DDE.
gauze, standard mouth mirrors and ball-ended explorers, The prevalence of DDE in this sample was high, but
according to WHO guidelines. similar to that of previous Brazilian studies (Vargas-Ferreira
DDE were categorised by type (marked or diffuse et al., 2018; Ruschel et al., 2019). Social factors such as
opacity and hypoplasia) and the extent of the alterations: low quality of life, poor access to health care and nutritional
up to 1/3 (Type 1), from 1/3 to 2/3 (Type 2), and greater problems, common in developing countries as well as Brazil,
than 2/3 (Type 3) of the surface of the dental crown. are related to the high prevalence of DDE (Corrêa-Faria
Single diffuse abnormalities were considered as present et al., 2013). Many children (42.6%) had more than one
if they were more than 1mm in diameter. Smaller lesions type of DDE. This suggests that the children experienced
were classified as “normal”. constant exposure to one or more factors, because each type
Children were classified into two groups: with DDE of develops at a different time during infancy.
any type or extent in at least one permanent or deciduous
tooth (DDE Group) and without enamel defects (Control).
The results were analysed using the software Epi Info Table 1. Distribution of DDEs in 353 children
7. The dependent variables were the presence or absence %
of DDE and the DDE subgroups. The independent vari-
DDE Present 63.17
ables were the medical and sociodemographic factors.
Chi-square or Fisher exact tests were used to compare DDE Absent 36.83
frequencies among groups. Unadjusted and adjusted model Types of DDEs
logistic regressions were performed and odds ratios (OR) Demarcated Opacities 14.80
and 95% confidence intervals (CI) were estimated. The Diffuse opacities 36.77
statistical significance level adopted was 0.05.
Hypoplasia 5.83
Demarcated and diffuse opacities 24.21
Results
Demarcated opacities and hypoplasia 10.76
Among 353 included children, 51.84% were girls and Diffuse opacities and hypoplasia 0.90
48.16% boys. Almost two thirds had a DDE (63.17%),
Combination of all three defects 6.73
most (57.4%) of whom had only one type, while 42.6%

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Table 2. Medical factors and the presence of DDE in 353 children
No Yes p (Chi sq.)
(n = 130) (n = 223)
% %
Prenatal care (n = 351)
Yes 98.4 98.4
0.858
No 1.5 1.6
Maternal age (n=329)
< 34 years 96.5 90.1
0.033
≥ 35 years 3.5 9.9
Health problem during pregnancy (n=350)
Yes 14.0 13.2
0.825
No 86.0 86.8
Smoked (n=351)
Yes 18.6 19.8
0.781
No 81.4 80.2
Alcoholic drinks (n=349)
Yes 9.3 9.5
0.968
No 90.7 90.5
Vitamins during pregnancy (n=348)
Yes 71.1 67.7
0.512
No 28.9 32.3
Complicated delivery (n=344)
Yes 8.67 7.8
0.786
No 91.3 92.2
Natural 44.8 47.2
0.661
Caesarean 55.2 52.8
Birth weight (g) (n=312)
< 2500 12.8 12.8
>0.99
≥ 2500 87.2 87.2
Premature birth (n=332)
Yes 11.7 10.4
0.959
No 89.3 89.6
Breastfeeding (n=351)
Yes 91.8 78.8
0.542
No 8.2 21.2
Illness in first three years (n=347)
Yes 24.8 30.3
0.274
No 75.2 69.7
Medication in first three years (n=331)
Yes 19.8 25.2
0.262
No 80.2 74.8

Table 3. Logistic Regression for predictors of demarcated factors including systemic conditions such as anemia
opacities and hypoplasia in 353 children. and hypocalcemia. Low birthweight also reflects poor
Unadjusted Adjusted nutritional status during pregnancy. The immaturity of the
OR (CI 95%) OR (CI 95%) respiratory system and gastrointestinal tract in underweight
children may restrict the metabolism of nutrients necessary
Birthweight ≥ 2500 Reference
for the normal development of the teeth, and may require
Birthweight < 2500 4.21(1.41-12.61) 4.82 (1.23-18.95) hospitalisation (Jacobsen et al., 2014). Some studies only
associate low birth weight with hypoplasia (Masumo et
* Variables at p < 0.05 in chi square analysis were tested. Prenatal al., 2013). However, the disturbances of calcium metabo-
care and maternal age were not associated in logistic regression lism in low birth weight children can affect both matrix
¶
Adjusted for other perinatal factors (Complicated delivery, development and mineralization, increasing susceptibility
type of delivery and prematurity)
to hypoplasia and opacities (Jacobsen et al., 2014).
Alcoholic drinks and smoking were not associated
Corroborating Corrêa-Faria et al. (2013), Masumo et al. with DDE, as was the case with other Brazilian studies
(2013), and Cortines et al. (2019) we found an association (Corrêa-Faria et al., 2013, Vargas-Ferreira et al., 2018).
between low birth weight and both demarcated opacities Inference about alcoholic drinks and smoking is difficult
and hypoplasia. Low birth weight may cause developmental because mothers may feel uncomfortable reporting these
defects in several ways. First, it predisposes to perinatal behaviours, and may omit answering them.

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 To the best of our knowledge, this study was the first Cortines, A.A.D.O., Corrêa-Faria, P., Paulsson, L., Costa, P.S.
to assess vitamin intake during pregnancy as a risk factor and Costa, L.R. (2019): Developmental defects of enamel in
to DDE. However, we did not find an association. There is the deciduous incisors of infants born preterm: Prospective
insufficient evidence available on the effects of vitamins on cohort. Oral Diseases, 25, 543-549.
Fatturi, A.L., Wambier, L.M., Chibinski, A.C., Assunção,
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L.R.D.S., Brancher, J. A., Reis, A. and Souza, J. F. (2019):
discussion, thus, further studies should be conducted. A systematic review and meta-analysis of systemic ex-
In Brazil, prenatal or antenatal care includes general posure associated with molar incisor hypomineralization.
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(Viellas et al., 2014). Pregnant women who do not perform FDI (1992): A review of the developmental defects of enamel
prenatal care may be more susceptible to external fac- index (DDE Index). Commission on Oral Health, Research
tors that might alter normal tooth formation in their baby & Epidemiology. Report of an FDI Working Group. Inter-
(Salanitri and Seow, 2013). However, prenatal care was not national Dental Journal, 42(6).
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and Poulsen, S. (2014): Developmental enamel defects
literature regarding the association of premature birth and
in children born preterm: a systematic review. European
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the need for neonatal intubation, which may cause trauma M. and Cardoso, M. (2016): Prevalence of enamel defects
and thus be associated with developmental defects of the and association with dental caries in preschool children.
teeth (Tourino et al., 2016). We did not find associations European Archives of Paediatric Dentistry. 17, 461-466.
between prematurity or prenatal factors and DDE. Mastora Masumo, R., Bårdsen, A. and Åstrøm, A.N. (2013): Develop-
et al. (2017) found more enamel defects among children mental defects of enamel in primary teeth and association
with asthma and suggested that using bronchodilators, with early life course events: a study of 6–36 month old
children in Manyara, Tanzania. BMC Oral Health, 13, 21.
antihistamines, and corticosteroids may cause DDE. We
Mastora, A., Vadiakas, G., Agouropoulos, A., Gartagani-Pana-
did not find an association between DDE and medication giotopoulou, P. and Engesaeth, V.G. (2017): Developmental
use in early years. Further studies could clarify this factor. defects of enamel in first permanent molars associated with
Given the complexity of amelogenesis, it may be that use of asthma drugs in preschool aged children: A retrospec-
the effects of any one risk factor are relatively small, so that tive case-control study. European Archives of Paediatric
very large samples are required to identify them. One other Dentistry, 18, 105-111.
limitation of this study was that the guardians completed Masterson, E.E., Fitzpatrick, A.L., Enquobahrie, D.A., Mancl,
the questionnaire at home. Despite accelerating the process L.A., Eisenberg, D.T., Conde, E. and Hujoel, P.P. (2018).
of epidemiological surveys, the use of questionnaires may Dental enamel defects predict adolescent health indicators:
a cohort study among the Tsimane’of Bolivia. American
restrict the collection of detailed information such as type
Journal of Human Biology, 30, e23107.
of vitamins or other medications or the history of diseases. Pinho, J.R.O., Thomaz, E.B.A.F., Ribeiro, C.C.C., Alves, C.M.C.
This study incorporated potential risk factors that and Silva, A.A.M.D. (2019): Factors associated with the
have received little attention, including prenatal care, development of dental defects acquired in the extrauterine
maternal age and vitamins during pregnancy. Other stud- environment. Brazilian Oral Research. 33, e094
ies should be performed in other populations to improve Reis, C.L.B., Barbosa, M.C.F., Machado, B.M.D.S.M., Baratto,
the evidence relating to these risk factors and to explore S.S.P., de Lima, D.C., Paza, A.O., Filho, F. B., Brancher, J.
other possible factors. A., Küchler, E. C. and de Oliveira, D.S.B. (2020). Genetic
polymorphisms in interleukin-6 and interleukin-1-beta were
associated with dental caries and gingivitis. Acta Odonto-
Conclusion logica Scandinavica, 79, 96-102.
Ruschel, H. C., Vargas-Ferreira, F., Tovo, M. F., Kramer, P. F.
This study investigated many independent variables as and Feldens, C. A. (2019). Developmental defects of enamel
predictors of DDE in 353 children in Brazil. Low birth in primary teeth: highly prevalent, unevenly distributed in the
weight was associated with the presence DDE. oral cavity and not associated with birth weight. European
Archives of Paediatric Dentistry. 20, 241-248.
Salanitri, S. and Seow, W. K. (2013). Developmental enamel
Conflict of interest
defects in the primary dentition: aetiology and clinical
None. management. Australian Dental Journal. 58, 133-140.
Tourino, L. F. P. G., Correa-Faria, P., Ferreira, R. C., Bendo,
C. B., Zarzar, P. M. and Vale, M. P. (2016). Association
Acknowledgments between molar incisor hypomineralization in schoolchildren
and both prenatal and postnatal factors: a population-based
The Research Support Foundation of the State of Minas study. PLoS One, 11, e0156332.
Gerais (FAPEMIG) and National Council for Scientific Vargas-Ferreira, F., Peres, M. A., Dumith, S. C., Thomson, W. M.
and Technological Development (CNPq) funded this study. and Demarco, F. F. (2018). Association of pre-peri-and postnatal
factors with developmental defects of enamel in schoolchildren.
Journal of Clinical Pediatric Dentistry. 42, 125-134.
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