Impact of molar incisor hypomineralization and hypersensitivity on oral health-related quality of life

doi:10.21203/rs.3.rs-4103169/v1

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Impact of molar incisor hypomineralization and hypersensitivity on oral health-related quality of life

https://doi.org/10.21203/rs.3.rs-4103169/v1

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Objectives: Evaluate the impact of molar incisor hypomineralization (MIH) and hypersensitivity on oral health-related quality of life (OHRQoL) in school children.

Materials and Methods: A representative random sample of 568 eight-year-old children, enrolled in public schools in Curitiba, Paraná, Brazil, were selected. The children were clinically evaluated to diagnose MIH by Ghanin (2015) criteria, hypersensitivity by the Schiff Cold Air Sensitivity Scale (SCASS) scale, and dental caries by ICDAS criteria. OHRQoL was assessed by the Child Perceptions Questionnaire (CPQ_8-10) and the Pediatric Quality of Life Inventory^TM (PedsQL™). The OHRQoL scores were compared according to the clinical outcomes by the U - Mann-Whitney and Kruskal-Wallis test. The CPQ and PedsQL™ scores were tested by Spearman correlation (𝛂=0.05).

Results: The prevalence of MIH was 17% (IC95% 14% - 20%), in which 36,1% was mild and 63,9% moderated/severe. Although the presence of MIH did not impact significantly OHRQoL, children with severe MIH harmed the OHRQoL. Thus, the presence of hypersensitivity reports in MIH-affected teeth or the presence of post-eruptive or dental caries cavity in MIH-affected teeth impacts significantly the OHRQoL, for both questionnaires (p<0,05). The scores of both Questionnaires had a significantly strong correlation (r=-0,761;p<0,05).

Conclusions: Only the presence of MIH did not impact the OHRQoL, however, the clinical consequences of MIH, such as post-eruptive or cavity caries lesions and the presence of hypersensitivity harmed OHRQoL.

Clinical Relevance: Dental hypersensitivity is a common symptom present in cases of hypomineralization, recognizing its impact on quality of life makes it possible to develop patient-centered outcomes.

molar incisor hypomineralization

oral health-related quality of life

hypersensitivity

dental caries

epidemiology

Molar Incisor Hipomineralization (MIH) is a qualitative defect in dental enamel that affects at least one first permanent molar and may also affect the incisors of this same dentition [1, 2]. The worldwide prevalence reported of MIH is 14,2% [3]. According to the criteria of the European Academy of Pediatric Dentistry (EAPD, 2003), teeth with MIH present demarcated opacity with clear and defined limits and may be white, yellow, or brown [4, 5]. These opacities may present some clinical consequences, such as post-eruptive fracture, be associated with restorations, or atypical caries lesions that may even lead to the loss of the tooth element [2, 6].

These structural changes in MIH-enamel, mainly the high porosity and lower microhardness [7], favor the penetration of harmful external stimuli, resulting in dental hypersensitivity. In a previous epidemiological study, was observed that 29,8% of children only with opacities of MIH and 55% of children with port operative breakdown present hypersensibility [8]. Children with dental hypersensitivity may avoid brushing the affected teeth due to pain, leading to greater biofilm accumulation and food impaction [8, 9], which results in a greater risk of dental caries lesions [10]. MIH-affected enamel has a greater risk of post-eruptive fracture and can result in unprotected dentin, further facilitating the rapid development of caries lesions, and also exacerbating the patient's report of pain or hypersensitivity. [2, 4, 9].

Epidemiological studies have been investigating the impact of MIH on the quality of life related to oral health (OHRQoL) [4, 5, 9, 11–19]. It refers to the impact that oral conditions have on an individual's daily activities, well-being, and social well-being [20]. These patient’s patient-centered information allows the researchers and clinical professionals to comprehend and focus on the real patient’s necessity for treatment. Health-related quality of life (HRQoL) is a term that gained prominence in research from the 1960s onwards, as this intersection between QoL and health enables professionals to use comprehensive and interdisciplinary approaches with their patients [21].

Regarding the association between MIH and OHRQoL, the literature is controversial. Jalevik, 2022 et al. carried out a systematic review about the influence of MIH on dental fear and anxiety, as well as, on the OHRQoL of children and adolescents. These authors found relatively recent studies that showed that the presence of MIH can impact OHRQoL, mainly in the domains of ‘oral symptoms’, which includes reports of pain and hypersensitivity; and ‘functional limitations’, which refers to difficulties in functions, such as chewing and speaking [22]. A recent study conducted in the city of Curitiba, Southern Brazil, showed that children with MIH had only a negative impact on the “oral symptoms” domain of the Child Perception Questionaire (CPQ_8-10) [4]. Thus, according to these studies, it is not clear what clinical aspects related to MIH impact the quality of life.

Despite the increase of studies associating MIH and OHRQoL in children, to our best knowledge, epidemiological studies with representative samples that control the clinical confounders for OHRQoL, such as dental carious lesions and the presence of hypersensitivity are not yet well explored. Furthermore, there is a repetitive cycle of the clinical consequences of MIH, which are hypersensitivity and post-eruptive enamel fracture, leading to an increase in dental caries activity, which consequently increases the pulpal inflammatory response, and then increases hypersensitivity. Thus, this cross-sectional study aims to evaluate if MIH impacts the OHRQoL of children, considering the presence of hypersensitivity, MIH severity, and the presence of dental caries lesions.

We hypothesize that MIH negatively impacts the OHRQoL of schoolchildren, especially when the affected teeth have clinical consequences such as post-eruptive enamel and/or hypersensitivity.

ETHICAL ASPECTS

This study was approved by the Human Research Ethics Committee of the Health Sciences Sector of the Federal University of Paraná (UFPR) – process number 4.095.306, and by the Ethics Committee of the Municipal Health Department of Curitiba-PR. The parents or legal guardians and children drawn from the municipal education system themselves who agreed to participate in the study signed an informed consent form. The execution of this study followed the recommendations of the STROBE Initiative (Strengthening the Reporting of Observational Studies in Epidemiology) for cross-sectional studies [23].

SAMPLE SELECTION AND SIZE

To determine the sample size, a proportion calculation was used for an infinite population. The proportion of MIH [24] was 50%, with an accuracy of 5%, a confidence interval of 95%, and a drawing effect of 1.4. The calculation resulted in a sample of 538 children, which was increased by 20% to compensate for possible attrition. Therefore, the ideal sample size should be from 538 to 645 children.

The sampling process was carried out by a two-stage conglomerate. Initially, schools were randomly selected proportional to the size of each health district in the city of Curitiba-PR. After the schools were drawn, children from each school were selected using simple random sampling.

Children of both sexes, aged 8, enrolled in the public school system in the city of Curitiba, Paraná, were included. Children who did not have at least one first permanent molar with less than 1/3 of the crown erupted at the time of the clinical examination, use of orthodontic appliances, or who had reported syndromic conditions were excluded. Also, children who had some cognitive disability, or whose parents did not speak Portuguese as their native language were excluded.

CLINICAL DATA

The clinical examination was carried out by three previously trained and calibrated examiners (T.Z.R, A.C.S., and L.G.S) in a private school environment. The children were placed individually in chairs and evaluated under artificial light, with the aid of n^o5 plane mirrors and OMS-type probes. Dental surfaces were cleaned using gauze. Previously, the examiners were trained and had been calibrated according to the MIH-index and ICDAS criteria. Firstly, the examiners participated in theoretical and practical training using more than 70 intra-oral photographs of all scores of ICDAS and 70 intra-oral photographs of all scores of MIH-index.

Then the calibration process was performed. The examiners evaluated and classified, independently, another 40 photographs of different dental caries lesion stages according to ICDAS. At this stage, they also evaluated another 40 photographs of different types of dental enamel defects, including different severity of MIH according to the MIH index. Then, after 7 days, the examiner evaluated again the same photographs and classified them. The scores of the three examiners were compared with their selfies and with a standard examiner using the kappa coefficient for the intra and inter-ratio. The intra and inter-ratio were higher than 0.75.

The MIH-index was used to diagnose and classify MIH severity, as proposed by Ghanim, 2015 [25]. The completed version of the MIH-index was applied for a differential diagnosis of MIH with other enamel defects. Only defects larger than 1.0mm in diameter were recorded [26]. The presence of MIH was considered when at least one first permanent molar has demarcated creamy-white or yellow-brown opacity, post-eruptive fracture, atypical restoration, or presence of atypical cavity [27].

Dental hypersensitivity was evaluated in children with MIH, using the Schiff Cold Air Sensitivity Scale (SCASS) instrument [28, 29] by a trained examiner. The SCASS is a scale developed to investigate sensitivity to air stimulation, whose response possibilities range from 0 to 3, where 0 - The subject does not respond to the air stimulus; 1 - the subject does not respond to the stimulus, but considers the stimulus to be painful; 2 -subject responds to air stimulus and moves from the stimulus; and 3 = subject responds to air stimulus, moves from the stimulus, and requests immediate discontinuation of the stimulus. The examiner observed the child's reaction to the applied air jet stimulus and wrote down the corresponding value on the patient's record. The air jet test was carried out using an air compressor coupled to a silkscreen pen. The air jet was initially applied to a healthy tooth, without MIH or cavities, so that the child could become familiar with the air jet. Then, it was applied for 1 second to the tooth affected by MIH. Adjacent teeth were isolated with cotton rolls.

The detection and classification of dental caries lesions was performed using the International Caries Detection and Assessment System (ICDAS II) codes. Each tooth was given an ICDAS score between 0 and 6, where 0 – Slight or no change in enamel translucency after drying for 5 s; 1 – Hardly visible opacity on the wet surface, but noticeable after drying; 2 – Visible opacity without drying; 3 – Cavitation on the opaque or pigmented enamel, without visible dentin; 4 – Shading of underlying dentin, with or without enamel rupture; 5 – Cavitation on opaque or pigmented enamel with exposure of the underlying dentin; 6 – Cavitation on opaque or pigmented enamel with exposure of the underlying dentin, involving more than 50% of the surface [30].

NON-CLINICAL DATA

The participants’ legal guardians completed a questionnaire containing socioeconomic and demographic information.

Before the clinical examination, the children were invited to fill out the questionnaire to assessOHRQoL, Child Perceptions Questionnaire_8-10. This questionnaire is applied in the form of an interview and has 25 questions, including five items on oral symptoms, five on functional limitations, five on emotional well-being, and ten on social well-being.

These questions refer to the frequency of events occurring in the four weeks before the application of the instrument. The response options follow a five-point Likert scale, ranging from score 0 to score 4 for each item. The following options are used: “Never” = 0; “Once/twice” =1; “Sometimes” = 2; “Often” = 3 and “Every day or almost every day” =4. In addition to the 25 questions, two initial questions about global perception of oral health and general well-being are asked: “Do you think your teeth and mouth are:” followed by the options “Very good”, “Good”, “More or less” or “Bad” and the question “How much do your teeth or mouth bother you?” with the response options “Doesn’t bother”, “Almost nothing”, “A little” or “A lot”.

In addition, they were also invited to fill out the “PedsQL™ Oral Health Scale 8–12” questionnaire related to oral health quality of life (OHRQoL) [31, 32]. The Pediatric Quality of Life Oral Health Scale” (“PedsQL™) is a brief (consisting of 5 response items) and practical instrument to measure the OHRQoL of healthy children and adolescents or those with a chronic or acute health condition [31, 32]. This questionnaire was validated and translated into Brazilian Portuguese by Klatchoian, et.al., 2008 [33]. For each age group, there are two questionnaires, one for the child and one for the parents/caregivers. All items have 5 response options on a scale: 0 (never), 1 (rarely), 2 (sometimes), 3 (almost always) and 4 (always). The scores are then transformed from zero to 100 and the calculation is done by scale, the average score is then the sum of the items. If more than 50% are not answered, the questionnaire is not counted. All items are aimed at the difficulty of being, participating in, or carrying out some activity according to the perception of the individual or their guardian. The higher the average value (closer to 100), the lower the difficulty, that is, the higher the OHRQoL. Parents or guardians also completed the “PedsQL™ Oral Health Scale”.

STATISTICAL ANALYSIS

For dental caries, all teeth were examined. The presence of dental caries was considered when the children had at least one tooth with ICDAS codes higher than 3, and children without dental caries were considered who had teeth with ICDAS up to 2 codes, for primary and/or permanent teeth.

For MIH, the teeth level was classified according to MIH-index in white or creamy demarcated opacities, yellow or brown demarcated opacities, post-eruptive breakdown, atypical restoration, atypical caries or missing due to MIH [25]. The children with MIH were categorized according to Mathu-Muju and Wright [34], as mild MIH when only demarcated opacities were present, with the absence of dental caries lesion, and no report of hypersensitivity in the MIH-affected teeth; and as severe MIH, when they had at least one MIH-affected teeth with beside the opacity, there is a post-eruptive fracture, and/or atypical restoration, and/or atypic cavity, and/or hypersensitivity report [34].

Hypersensitivity data was obtained using the SCASS scale. In addition, it was also considered children’s self-reports by the Pediatric Quality of Life Inventory^™ (PedsQL™) question: “I have pain or sensitivity in my teeth when I eat or drink something hot, cold, or sweet” to which the child could respond within the 5 options “Never”, “Rarely”, “Sometimes”, “Almost always” or “Always”. Children with hypersensitivity were considered when they presented SCASS scores higher than 1 and/or question answers as “Sometimes”, “Almost always” or “Always”.

The CPQ8-10 and PedsQL™ were analyzed numerically using the respective scales, with CPQ_8-10 ranging from 0-100, indicating that the higher the value, the greater the impact on OHRQoL; while the PedsQL™ scale ranged from 0-500, with higher values indicating less impact.

To compare CPQ_8-10 and PedsQL™ scores about MIH and other clinical outcomes, these values were analyzed for distribution using the Kolmogorov-Smirnov test. The values presented non-parametric data (p < 0.05). Therefore, the comparison between OHRQOL scores about MIH, as well as the severity of MIH (without MIH, mild MIH, and severe MIH) was analyzed respectively using the Mann-Whitney and Kruskal-Wallis tests. These scores were also compared about the presence of dental caries (in all teeth) and hypersensitivity using the Mann-Whitney U test.

Finally, to evaluate the correlation between the OHRQoL scales, Spearmann’s correlation was applied. The significance level adopted for all analyses was 0.05. Data were analyzed using SPSS software (IBM, United States, Version 25).

The sample consisted of 587 children selected from 20 schools in Curitiba. Among these children, 19 were not included because they were not present on the clinical visit days had some cognitive disability, or their parents did not speak Portuguese as their native language. Thus the total sample was comprised of 568 school children.

Of the 568 children included in the study, 49.3% were girls. The majority of parents (77.1% for mothers and 74.4% for fathers) had more than 8 years of study and the family’s monthly income in 50.5% of cases was less than 2 Brazilian minimum wages (Table 1).

Table 1

– Demographic and socioeconomic characteristics of children N = 568
Demographic and socioeconomic characteristics	N (%)
Children’s Sex Male Female	288 (50,7) 280 (49,3)
Maternal Education ≥ 8 years Less than 8 years old	. 390 (77,1) 116 (22,9)
Paternal Education ≥ 8 years Less than 8 years old	319 (74,4) 110 (25,6)
Monthly income ≥ 2 Brazilian minimum wages Less than 2 Brazilian minimum wages	241 (49,5) 246 (50,5)
Children’s Age (Mean (SD))	7,84 (0,57)
Mother’s Age (Mean (SD))	35,0 (7,5)
Note: The current Brazilian minimum wage of R$1,320.00

Of the total sample, 199 (35%) children had dental carious lesions and 33.4% reported hypersensitivity. The prevalence of MIH was 17.1% (n = 97) (95% CI 0.14–0.20), of which 35 (36.1%) were classified as mild and 62 (63.9%) as severe. MIH was considered severe when there was the presence of MIH with reports of hypersensitivity and/or post-erupted enamel fracture or atypical cavities (Table 2).

Table 2

– Clinical characteristics of children
Clinical characteristics	N (%)
MIH presence Without MIH With MIH	471 (82,9) 97 (17,1)
MIH Severity Mild Moderate/Severe	35 (36,1) 62 (63,9)
Hypersensitivity No reports of hypersensitivity With reports of hypersensitivity	373 (66,6) 187 (33,4)
Dental caries lesion No dental caries lesion With dental caries lesion	369 (65) 199 (35)
Note: Hypersensitivity: computed through the child’s report in question 2 of the PedsQL™ “I have pain or sensitivity in my teeth when I eat or drink something hot, cold or sweet” and/or by the SCASS scale.

Among the clinical conditions that significantly impacted OHRQoL, it was observed that children with the presence of dental caries lesions had a significant impact on OHRQoL. The presence of dental caries was significantly associated with worst scores, in both PedsQL™ for guardians and children, as well as, all domains of CPQ_8− 10 scores except for the social well-being domain of CPQ_8− 10 (Table 3).

Regarding the reporting of hypersensitivity, children who reported hypersensitivity presented significantly higher scores for both instruments when compared to those who did not report (Table 4).

Table 3

– Values of oral health-related quality of life instruments (CPQ8-10 and PedsQL™) about cavitated caries lesions. Curtiba, 2023 (N = 568).
	Dental caries lesion		P Value
	No caries lesion Med (mín-max)	Cavitated Caries Lesion Med (mín-max)	P Value
PedsQL™ Parente	90 (10–100)	75 (10–100)	< 0,001*
PedsQL™ Children	85 (0-100)	75 (0-100)	< 0,001*
CPQ_8 − 10 Total	11 (0–86)	14 (0–79)	0,001*
CPQ_8 − 10 Oral Symptoms	5 (0–16)	6 (0–19)	< 0,001*
CPQ_8 − 10 Functional Limitations	2 (0–20)	3 (0–17)	0,004*
CPQ_8 − 10 Emocional Well Being	2 (0–20)	3 (0–20)	0,007*
CPQ_8 − 10 Social Well Being	1 (0–36)	1 (0–35)	0,140
Note: The presence of dental caries was considered when the children had at least one tooth with ICDAS codes higher than 3, and children without dental caries were considered who had teeth with ICDAS up to 2 codes, for primary and/or permanent teeth.

Table 4

– Comparison of the scores of the oral health-related quality of life instruments (CPQ and PedsQL™) about hypersensitivity. Curitiba, 2023 (N = 568).
	Hypersensitivity		P Value
	Without report Med (mín-max)	With report Med (mín-max)	P Value
PedsQL™ Parents	90 (10–100)	80 (10–100)	0,030*
PedsQL™ Children	90 (25–100)	65 (0-100)	< 0,001*
CPQ_8 − 10 Total	9 (0–52)	20 (0–86)	< 0,001*
CPQ_8 − 10 Oral Symptoms	4 (0–13)	7 (0–19)	< 0,001*
CPQ_8 − 10 Functional Limitations	2 (0–14)	4 (0–20)	< 0,001*
CPQ_8 − 10 Emocional Well Being	2 (0–20)	4,5 (0–20)	< 0,001*
CPQ_8 − 10 Social Well Being	1 (0–27)	4 (0–36)	< 0,001*

When considering only the presence of MIH, there was no statistically significant difference in the instruments evaluated (Table 5). In Table 6, the total scores of CPQ_8− 10 were statistically different between the groups without MIH, mild MIH, and severe MIH. It could be also observed in each CPQ domain, that there were significant differences in the severity of MIH, except for the oral symptoms domain. It is important to realize that PedsQL™ was able to detect differences between children without MIH and those with severe MIH (parents PedsQL™) while for children PedsQL™ there were differences between the MIH severity. There could be statistical differences between mild to severe MIH.

Table 5

– Scores of the oral health-related quality of life instruments (CPQ and PedsQL™) about HMI. Curitiba, 2023 (n = 568).
	MIH		P Value
	Without MIH Med (mín-max)	With MIH Med (mín-max)	P Value
PedsQL™ Parents	85 (10–100)	85 (15–100)	0,126
PedsQL™ Children	85 (0-100)	85 (5-100)	0,265
CPQ_8 − 10 Total	12 (0–86)	12 (0–53)	0,609
CPQ_8 − 10 Oral Symptoms	5 (0–19)	5 (0–14)	0,653
CPQ_8 − 10 Functional Limitations	2 (0–20)	2 (0–10)	0,387
CPQ_8 − 10 Emocional Well Being	2 (0–20)	2 (0–16)	0,831
CPQ_8 − 10 Social Well Being	1 (0–36)	1 (0–22)	0,569

Table 6

– Scores of the oral health-related quality of life instruments (CPQ and PedsQL™) about the severity of MIH. Curitiba, 2023.
	MIH Severity			P Value
	Without MIH Med (mín-max)	Mild MIH Med (mín-max)	Severe MIH Med (mín-max)	P Value
PedsQL™ Parents	85 (10–100)^a	85 (50–100)^a,b	80(15–100)^b	0,137
PedsQL™ Children	85 (0-100)^a	90 (25–100)^b	75 (5-100)^c	< 0,001*
CPQ_8 − 10 Total	12 (0–86)^a	9 (0–43)^b	12 (0–53)^c	0,004
CPQ_8 − 10 Oral Symptoms	5 (0–19)^a,b	4 (0–12)^a	5 (0–14)^b	0,148
CPQ_8 − 10 Functional Limitations	3 (0–20)^a	2 (0–9)^b	2 (0–10)^a	0,010
CPQ_8 − 10 Emocional Well Being	2 (0–20)^a,b	1 (0–13)^a	3 (0–16)^b	0,003*
CPQ_8 − 10 Social Well Being	1 (0–36)^a	0 (0–12)^b	1 (0–22)^c	0,001*
Note: P-value by Kruskal-Wallis test. Different letters represent statistically significant differences when comparing lines using the Mann-Whitney U test. Mild was considered when only demarcated opacities were present, with the absence of dental caries lesion, and no report of hypersensitivity in the MIH-affected teeth; Severe was considered when they had at least one MIH-affected teeth beside the opacity, there is a post-eruptive fracture, and/or atypical restoration, and/or atypic cavity, and/or hypersensitivity report.

Of the OHRQoL instruments used, the PedsQL™ for parents and guardians and children is presented as a scale, the closer to 500, the better the quality of life-related to oral health. For CPQ8-10, the higher the value, the worse the quality of life-related to oral health. We observed a strong negative correlation between these two instruments (r=-0.761; p < 0,001).

The objective of the present study was to verify whether the presence of MIH, as well as, the clinical consequences of MIH, impact negatively the OHRQoL of schoolchildren. To our knowledge, this was the first population-based epidemiological study that applied the PedsQL™ Oral Health Scale to evaluate the association between OHRQoL and HMI in both the child and parent versions.

In the present study, it was observed that the presence of MIH, without considering its clinical consequences such as post-eruptive fracture and hypersensitivity, did not impact OHRQoL. However, when considering the clinical severity of MIH, that is, reports of hypersensitivity associated with enamel fractures or atypical cavities and caries lesions, there was an impact of these consequences on OHRQoL. Also, when we consider these clinical consequences, we observed that when evaluating the CPQ_8-10 domains separately, we also found a statistically significant difference, except for the oral symptoms domain.

The report by parents/guardians and children on OHRQoL using the PedsQL™ Oral Health Scale did not show a significant difference in the presence of MIH but detected a difference between children without MIH and severe MIH (parents PedsQL™). Besides that, the PedsQL™ Oral Health Scale for children detects significant differences between the MIH severity (Table 6). These data demonstrated that the PedsQL™ Oral Health Scale is feasible to evaluate OHRQoL such as CPQ_8-10. Moreover, one advantage of PedsQL™ is a shorter questionnaire and it can be applied to parents as a proxy measure.

This result corroborates the studies by Folayan et al.( 2018), Fernades et al. (2021), and Vanhee et al.(2022), which also found no difference between the group with and without MIH about OHRQoL [15, 17–18]The studies by Gutierrez et al. (2019), Elhennawy et al. (2022), Michaelis et al.(2021) and Joshi et al. (2022) observed that the more severe the MIH, the greater the impact on OHRQoL [9, 12, 14, 16]. It is worth mentioning that the studies that observed the impact of the presence of MIH without considering its clinical consequences were studies carried out without a representative sample of the population, while the studies that did not observe the impact of the presence of MIH were population epidemiological studies.

In a previous study also conducted with children enrolled in public schools in Curitiba, Brazil, found no significant difference in the impact on OHRQoL considering the severity of MIH. On the other hand, the same research observed an impact in the domain of oral symptoms CPQ_8-10 for those children who presented yellow-brown opacities, post-eruptive fractures, and atypical restorations, but without a statistical difference (P > 0 .05) [4]. These authors analyzed the results of the CPQ by dichotomizing them into 'with' and 'without' impact on OHRQoL using a cut-off point in the scores. In the analysis of the present study, the results were compared considering the numerical and scaled scores.

As already described, the structural alteration of the enamel with MIH can lead to loss of tooth structure due to fracture or the development of associated caries lesions and consequently, there is an increase in the patient's reports of hypersensitivity. The results found in this study corroborate those of Raposo et al. (2019), who found a prevalence of 34.7% of hypersensitivity in molars with MIH, and in severe cases (post-eruptive fracture involving dentin and atypical restorations) this prevalence was 55% [8]. In the same study, the prevalence of hypersensitivity in molars with MIH was 34.7%, 29.8% of which were teeth showing only opacities and 51.6% related to post-eruptive dentin fracture or atypical restoration. When the presence of a caries lesion in dentin was considered, 90% of molars affected by MIH with post-eruptive fracture in dentin showed hypersensitivity, which could indicate another symptom of the cavitated carious lesion and not of IMH.

In this sense, the presence of cavitated dental caries may be a confusing clinical outcome. In the present study, it was observed that cavitated caries lesions impact OHRQoL both by CPQ8-10 and PedsQL™ in all domains, since cavitated caries is the main cause of dental pain in children [35], which impacts QoL and the absence of children's school and work activities in their families. Americano et.al (2016) carried out a systematic review of the literature on the association between MIH and dental caries and found that children with MIH were 2.1 to 4.6 times more likely to have carious lesions than children without MIH [10], that is, MIH and caries may be concomitant conditions in first permanent molars. In the present study, discrimination of these conditions was possible through the classification of severity.

Another important point in the assessment of OHRQoL, HMI, and caries is the child's age. It is known that for a better diagnosis of teeth with MIH, it is recommended for epidemiological studies that this evaluation is carried out at 8 years of age, as at this age the first permanent molars are already erupted, but may not yet present the clinical consequences of MIH, such as post-eruptive fracture and even extensive carious lesions. The difficulty of differential diagnosis between a tooth with MIH presenting a post-eruptive fracture, a tooth affected by MIH, and a cavitated carious lesion, is made using an appropriate clinical criterion that discriminates these situations, such as the criteria described by Ghanim et al. 2015.

When considering the impact of dental caries on the OHRQoL of patients with MIH, most studies [4,5,1114,15,18,] choose to use the DMFT index for caries assessment, however, this index has limitations, such as the stage of the carious lesion present is not considered. In the present study, the ICDAS index was used, which considers the stages of the lesion and the child's caries experience. This index allowed the analysis to be adjusted considering the more advanced stages of the injury.

Based on the results of this study, we observed the need to consider the impact of oral conditions on the OHRQoL of children and their families to develop a more assertive treatment plan. Considering the use of the CPQ, despite being the most used questionnaire in the literature, the clinical practice of the dental surgeon can be laborious and costly, as it is an extensive questionnaire with 29 questions that demand the child's attention. In the present study, the PedsQL™ Oral Health Scale was also used in both versions for parents/guardians and children. The instrument applied to the study sample was easy and quick to apply and was strongly correlated with the scores of CPQ_8-10 (r = -0.761), which shows that both instruments presented similar results. Our data corroborate a study by Bendo and collaborators to validate the PedsQL™ in the Brazilian version, which found a strong negative correlation with CPQ_8-10 (r=-0.86) [36]. As shown in our results, the version of PedsQL™ for parents/guardians, despite being more subjective and not considering a real assessment of children and their perceptions, can be considered as a proxy.

The results of the present work lead us to conclude that the clinical consequences of MIH hurt children's OHRQoL. However, due to the clinical complexity of MIH, which has other clinical consequences, such as caries and hypersensitivity, future studies should consider such observations.

Among the strengths of the present study, we can mention some methodological precautions such as the use of a representative sample, the use of instruments valid for the age range of the study sample, and calibrated examiners for clinical index. Furthermore, confounding clinical variables were considered when evaluating the association between MIH and OHRQoL. As a possible limitation of the present study, we can mention that the instruments were not self-administered due to the reading difficulties of the included children.

Based on this population-based observational study, we can conclude that the presence of cavitated caries lesions and hypersensitivity significantly impacts the OHRQoL of children. MIH has shown an impact on OHRQoL only when the severity of its clinical consequences was considered such as the presence of hypersensitivity and associated caries. Furthermore, the PedsQL™ and CPQ8-10 instruments showed a strong correlation.

Author Contribution

All authors contributed to this study conception and design. Material preparation and data collection were performed by A. C. S., T. Z. C. R, L. G. S, Y. L, I. A, and J. V. N. B. M. The statistical analysis was performed by A. C. S, L. R. A. Z., and J. F. S. The first draft of the manuscript was written by A. C. S and J. F. S and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Fundings

No funding was obtained for this study

Ethics Approval and Consent to Participate

The study was approved by the Human Research Ethics Committee of the Health Sciences Sector of the Federal University of Paraná (UFPR) – process number 4.095.306, and by the Ethics Committee of the Municipal Health Department of Curitiba-PR. A written informed consent was obtained from each parents or legal guardians and children participant prior to study enrollment.

Conflict of Interests

The authors have no conflicts of interest to declare.

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No competing interests reported.

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Impact of molar incisor hypomineralization and hypersensitivity on oral health-related quality of life

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INTRODUCTION

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