Vol 7, No 1 (2019) 
ISSN 2167-8677 (online) 

DOI 10.5195/d3000.2019.90 

 

 

 

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Aesthetic perception and psychological impact of molar-incisor 
hypomineralisation among patients and parents 
Fernanda Mafei Felix da Silva1, Christiane Vasconcelos Cruz1, Luise Leal1, Marcelo de Castro Costa1 

 
1 Department of Pediatric Dentistry and Orthodontics, School of Dentistry,  

Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

Abstract 

The aim  this study was investigate`s patient and parent’s aesthetic perception and psychological impact of 
molar-incisor hypomineralisation (MIH) and to assess the correlation of MIH with caries experience. The 
sample comprised 56 children, 28 with MIH and 28 without MIH (comparison group), and their gardens 
(n=56). For the perception data we used the Child and Parent’s Questionnaire of Teeth Appearance. We used 
the European Academic of Paediatric Dentistry (EAPD) criteria to define MIH. Caries experience was assessed 
by Decayed, Missing and Filled Teeth (DMFT) index. Chi-square, Student’s t-test and correlation tests were 
used with significance level set at 5%. Most children were male (n=35; 62.5%) and patients with MIH 
perceived their affected teeth as stainned (p=0.01). MIH was considered by parents (6.96±1.7) to enhance 
psychosocial condition (social, physical, and psychological social) of their children (p<0.01). Patients with 
severe MIH showed the worst perception about the color of the teeth (p=0.07). There was no correlation 
between DMFT scores and presence of MIH (p=0.80). Patients and parents perceived MIH. Groups with 
severe MIH (children/ parents) showed the worse aesthetic perception. 
 

Citation: Silva FMF, et al. (2019) Aesthetic 
perception and psychological impact of molar-
incisor hypomineralisation among patients and 
parents Dentistry 3000. 1:a001 
doi:10.5195/d3000.2019.90 

Received: November 26, 2018 
Accepted: March 28, 2018 
Published:  July 25, 2019 
Copyright: ©2019 Silva FMF, et al. This is an open 
access article licensed under a Creative Commons 
Attribution Work 4.0 United States License. 
Email: pttpo2009@yahoo.com.br

 

 

Introduction 

Molar incisor hypomineralisation 
(MIH) is defined as a qualitative 
enamel defect that occurs during 
amelogenesis [1,2]. Its aetiology 
has been linked to both 
environmental factors 
(disturbances during pregnancy, 
severe infections, frequent use of 
antibiotics in childhood) and 
genetic factors (genetic variations 
in TUFT1, TUFT11, AMELX and 
ENAM) [3, 4-6]. The prevalence of 
this condition varies considerably 

in different parts of the world 
ranging from 2.4 to 40% in Europe 
[7,8] and from 12.3% to 40.2% in 
Brazil [9,10]. 

One of the main characteristics of 
MIH is enamel porosity and 
discoloration, which may vary from 
white to yellowish and brown [11]. 
It usually affects one or more 
permanent molars and/ or may the 
permanent incisors [10,12]. In 
most of the, MIH may cause loss of 
tooth structure, resulting in 
functional and aesthetic problems 

for the individual, which may affect 
their quality of life [13,14]. There 
are few literature reports on the 
social impact of MIH, especially in 
cases of changes in color and 
dental caries susceptibility [14, 15, 
16]. 

Over the years, aesthetic demands 
of the smile has been increasing 
worldwide, especially among 
children and adolescents [17, 18, 
19]. However, it is difficult to 
measure the impact caused by 
changes in tooth enamel, since the 

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aesthetic evaluation is subjective. 
Thus, the aims of this study were to 
determine children, parents’ 
perceptions, and psychological 
impact of MIH before and after 
treatment to add to the relatively 
sparse literature. We also aimed to 
assess possible correlation 
between MIH and caries 
experience.  

Methods 

Study population 

This study was performed after 
approval from the local Ethics 
Committee for Research (Hospital 
Universitário Clementino Fraga 
Filho – HUCFF/UFRJ – Number: 
44598514.7.00005257). All 
subjects/guardians read and 
signed a written informed consent 
before their participation in the 
study. A convenience sample 
consisting in invidious of both 
sexes divided by children between 
7 and 14 years old treated at 
Paediatric Dentistry Clinic of the 
Federal University of Rio de Janeiro 
and their parents.  

The sample was divided into 
children with MIH (n=28) and 
children without MIH (n=28) in 
treated at Paediatric Dentistry 
Clinic of the Federal University of 
Rio de Janeiro, and their parents 
(n=56). The inclusion criteria for 
both groups were having 
permanent incisors, first 
permanent molars erupted, and in 
the MIH group, the permanent 
incisors had to be affected. The 
exclusion criteria for both groups 
included children with syndromes, 

dental trauma or the use of a fixed 
appliance. 

The clinical examination was 
performed by one calibrated 
dentist (FMF) and was carried out 
with a mirror and a probe in the 
dental chair after dental 
prophylaxis using artificial light. 
Caries experience was assessed by 
the DMFT index [20, 21]. MIH was 
evaluated using the EAPD criteria 
(European Academic of Paediatric 
Dentistry) [11,12]. Mild MIH cases 
was considered when the tooth 
presented demarcated opacity, 
without any loss of structure, while 
severe cases were considered 
when the teeth showed loss of 
structure past or current lesion 
requiring treatment  or  presence 
of atypical restorations were 
defined as having severe MIH [11].  

To assess the intra examiner-
reliability, an exercise was 
previously applied by the examiner 
(S.FM) and in the gold standard 
(C.MC) evaluator with 20 clinical 
pictures of dental enamel defects 
(eight with MIH). Two weeks after 
the first assessment, a new 
assessment was carried out by the 
examiner and the resulting kappa 
was 0.88. At the end of the clinical 
examination, each patient and 
parents received oral hygiene 
instructions. In addition, the 
patients received a dental 
prophylaxis and a topical fluoride 
application  

Questionnaires 

A perception survey was carried 
out using The Child and Parent’s 

Questionnaire of Teeth 
Appearance [22]. This instrument 
has been validated and adapted to 
the Brazilian context [23] and 
represents a standard tool for 
estimating the impact of aesthetic 
perceptions of enamel opacities. 

This instrument, has a version for 
children and adults, includes 
physical, psychological and social 
issues. In addition, questions about 
the dental color aspects, dental 
appearance, alignment and oral 
health. 

The response options for the five 
questions and sub-items were 
presented in the form of multiple-
choice items. Responses are grade 
ranging from best condition (0) to 
worst possible condition (4). The 
first three questions investigate 
how the child or her/his parent has 
felt over the past two months and 
whether he or she has felt 
uncomfortable, concerned or has 
been prevented from smiling 
because of the appearance of his or 
her teeth, according to the views of 
his or her parents/guardians and 
himself or herself.  

An additional question with four 
subratings for the perception of 
children and their parents about 
appearance, position, colour and 
health of their teeth (or their 
children) was asked. The last item 
asked the interviewee about 
his/her opinion on satisfaction or 
dissatisfaction with the colour of 
the teeth, according to the 
following sentence: ‘The colour of 

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my teeth (or the tooth of my son) 
are nice and beautiful’.  

Statistical analysis 

Data were analysed using SPSS 
version 20.0 (Statistical Package for  

Social Sciences, SPSS Inc., Chicago, 
III). Descriptive statistics was 
performed. A Shapiro-Wilks test 
was carried out to evaluate the 
pattern of sample distribution. 
Student’s t-test and binary logistic 
regression were performed to 

assess the difference between 
groups (patients and parents). Chi-
square and correlation tests, with 
significance level set at 5%, were 
applied to disclose the associations 
and correlation between MIH and 
caries experience.  

Results 

A total of 112 individuals (parents 
and children) completed 
questionnaires. The majority of the 
parents were female (87.5%; 
n=49), with an average age of 

39.3±7.4 and most of children were 
male (62.5% n=35) (table 1). In the 
groups with MIH (n=28) and 
control (n=28) there was no 
difference (p>0.05) between sex, 
ethnicity, socio-economic 
condition or dental caries 
experience (Table1). 

 

Patients with MIH perceived their 
stained teeth (p=0.01) (Table 2). 
There was no statistically 
significant difference between the 
two groups when comparing 
individuals with MIH (4.18±1.3) 
and the comparison group 
(4.82±2.1) regarding physical, 
psychological and social conditions 
(Table 2). In addition, in the MIH 
parent group, a worse perception 
(6.96±1.7) than the one in the 
comparison group (6.50±2.9) was 
seen, which was statistically 
significant with regards to staining 
perception of teeth and to opinion 
about oral health (p=0.01 and 
p=0.03, respectively) (Table 2). 

Perception between parents and 
children showed the former had a 
worse perception in both 
psychosocial conditions (6.96±1.7) 
and appearance (21,81±3.9) (Table 
3). Regarding the severity of the 
MIH, 64.3% (n=18) showed mild 
and 35.7% (n=10) showed severe 
MIH. Patients with severe MIH 
(4.80±1.2) and their parents 
(7.5±2.0) showed the worst 
perception on physical, 
psychological and social 
conditions. In addition, children 
with severe MIH showed greater 

TABLE 1. CHARACTERISTICS OF THE SAMPLE 

 CHILDREN MHI GROUP CONTROL 

GROUP 

P 

VALUE 

MEAN AGE (SD) 9.39(2.04) 9.43(1.91) 9.36(2.19) - 

Sex n (%)    0.58 

Female 35(62.5) 19(67.9) 16(57.1) 

Male 21(37.5) 

 

9(32.1) 12(42.9) 

a CCEB n (%)     

 

 

 

0.77 

 

 

 

  0.80 

 

  

B2 18(32.1) 10(35.7) 8(28.6) 

C1 27(48.2) 14(40) 13(46.4) 

                         C2                         8(14.3) 3(10.7) 5(17.9) 

D2 3(5.4) 1(3.6) 2(7.1) 

    

b DMFT X MIH 0.95(± 1.6) 1.00(±1.54) 0.89(±1.68)          

 - - - 

a Brazilian  economic classification criteria  CCEB   B2< R$ 3.118, C1< R$1.865 C2<R$ 1.277 
D2<R$ 895 
bCorrelation test performed between MIH group and controls.  
Note: P value was based on Chi Square (p<0.05). 

 

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dissatisfaction with tooth 
coloration.  (Table 4).  

Discussion 

Aesthetic alterations in dental 
enamel may have a significant 
impact on the physical, social and 
psychological well-being of 
individuals and also affect their 
families [24,25]. MIH may be 
considered as  

an impacting enamel disturbance 
because it highly affects aesthetic 
and function. Moreover, in the 
most severe cases, it may lead to 
loss of structure and dental 
sensitivity as well as an increase in 
caries experience [26,27].  

Physical, psychological and social 
conditions related to children and 
their parents were perceived in the 
present study and may affect their 
quality of life. Furthermore, the 
appearance of MIH teeth 
(displayed as the perception of 
teeth being stained) was perceived 
by and influenced both children 
and parents. According to a study, 
the most severe enamel defects 
were related to aesthetic 
complaints by the patients and 
sometimes required aesthetic 
restorative treatment [14].  

In relation to tooth alignment 
(tooth position), this was perceived 
by both children and parents in the 

control group. This leads us to 
support that the position of the 
teeth can also be related to a 
negative impact on perception of 
the smile aesthetics. This study 
showed that parents were more 
concerned than children with 
regard to dental appearance, 
colour of teeth and tooth 
alignment [19]. 

Regarding dental caries in the 
present study, there was no 
statistically significant association 
between MIH and dental caries, 
although other studies related to 
MIH showed increased caries 
susceptibility in MIH patients 
[26,27]. In this context, we can 

TABLE 2. Evaluation of agreement between parents/children (MIH and controls) for aesthetic perception and 
psychosocial conditions. 

 

 Subjects (children) P value Parents P value 

 MIH group Controls  MIH group Controls  

*PHYSICAL, 
PSYCHOLOGICAL, 

AND SOCIAL 
CONDITIONS 

4.18(±1.3) 4.82(±2.1) 0.17 6.97(±1.7) 6.50(±2.9) **  

CONCERNS WITH 
TOOTH POSITION 

2.75(±1.37) 2.96(±1.73) 0.61 3.29(±1.4) 2.93(±1.5) 0.73 

TOOTH CONDITION 2.54(±1.20) 2.24(±1.73) 0.22  2.68(±1.0) 2.75(±1.4) 0.04 

STAINING 
PERCEPTION TEETH 

2.75(±1.04) 2.07(±0.85) 0.01 3.21(±0.83) 2.64(±1) 0.01 

ORAL HEALTH 
OPINION 

2.0(±1.12) 1.71(±1.08) 0.33 2.71(±1.0) 2.04(±1.2) 0.03 

SATISFACTION WITH 
THE COLOUR OF THE 

TOOTH 

2.64 (±1.2) 2.24 (±1.0) 1.00  3.61(±0.95) 3.14(±1.1) 0.10  

*The sum of the first three questions: Discomfort with appearance of their teeth, Concern about the appearance of the teeth and Discomfort with smile, was 
assed by Student’s t-test (p<0.05).  

  

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suppose that the severity of MIH 
may be related to caries 
experience, since in this study, mild 
MIH was predominant. It is 
noteworthy that some studies 
reported that even MIH patients 
with lower dental caries activity 
needed to be carefully monitored. 
This is because the teeth affected 
with MIH present more porous 
enamel, leading to fractures, 

facilitating accumulation of the 
biofilm [28]. 

In our study, all patients received 
oral hygiene instructions, fluoride 
application and restorative 
treatment, if necessary. Children 
with MIH received treatments 
ranging from preventive care 
(application of sealants and 
fluoride varnish) to restorations. 
The majority of treated teeth were 
at the severe level and most of 

them were first permanent 
molars.  Some studies have shown 
that regardless of the affected 
tooth or locality, patients with 
enamel defects after treatment 
have a better perception of their 
quality of life [12]. 

As limitations, we can mention the 
child’s age. This may have an 
influence on perception, because 
the sample was patients less than 
14 years old. Age could hamper 
the understanding of the 
questions because the older the 
children, the higher the aesthetic 
concerns. Furthermore, caries 
experience (DMFT scores) tends to 
increase with age, but we do not 
think that age influenced our 
results since the MIH group and 
controls presented a similar mean 
age. This study demonstrated that 
children and their parents had the 
knowledge about the existence of 
the MIH, in which may affected 
their quality of life, supposing that 
color alteration can influence the 
negative perception in the patient. 

We suggest that other studies 
about the aesthetic perception 
among individuals with MIH will be 
performed by group of teenagers 
or adults who have a higher level of 
aesthetic requirements. Also, 
assess the actual need for aesthetic 
treatment in patients with MIH 
affecting incisors without a loss of 
structure. 

Conclusion 

MIH was perceived by both 
patients and parents as affecting 
physical, psychological or social 

 

 

 

TABLE 3. Comparison of aesthetic perceptions between children and parents 

with MIH and controls. 

 MIH                    Controls   P-

value 

Children 

n=28 

Parents  

n=28 

     Children 

n=28 

Parents 

n=28 

*Physical, 

psychologi

cal, and 

social 

conditions 

4.18(±1.3) 6.96(±1.7)  4.82(±2.1) 6.50(±2.9) 0.03 

**Aesthetic 

perception 

of 

position, 

staining, 

oral, 

health and 

satisfactio

n with the 

colour of 

the teeth 

20.25(±3.7)  25.07(3.7) 20.11(±5.1) 22.86(2.0) 0.03 

Note: P-value was assessed by Student’s t-test (p<0.05) comparing children and parents. *The sum of 
the first three questions: Discomfort with appearance of their teeth, Concern about the appearance of 
the teeth and Discomfort with smile. **The sum of additional question with four sub-ratings of the 
perception and last question of satisfaction with the colour of the tooth. 

 

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features, and parents showed 
worse perception scores than 
children. Caries experience was not 
correlated to MIH in this sample. 

Acknowledgements 

This study was financed in part by 
the Coordenação de 
Aperfeiçonamento  Pessoal de 
Nivel Superior Brasil- (CAPES) - 

This study is part of  the  Masters 
Dissertation of the first author. 

 

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TABLE 4. Evaluation of agreement between parents/children (MIH group) for aesthetic perception and 

psychosocial conditions accord into level of severity. 

 

 
                        GROUPS WITH MIH 

                 Children                   Parents  

Mild  Severe  P value Mild  Severe P value 

*PHYSICAL, 

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AND SOCIAL 

CONDITIONS 

3.94(±1.24) 4.55(±1.30) 0.23   6.9(±1.32) 7.5(±2.30) 0.90 

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TOOTH POSITION 

2.35(±1.27) 3.36(±1.36) 0.60   3.29(±1.36) 3.27(±1.68) 0.97 

TOOTH CONDITION 2.65(±1.17) 2.36(±1.36) 0.56  2.88(±1.11) 2.36(±0.81) 0.19 

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*The sum of the first three questions: Discomfort with appearance of their teeth, Concern about the appearance of the teeth and Discomfort 

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