Prevalence of Molar Incisor Hypomineralization in Brazilian Children and Adolescents: A Systematic Review and Meta-Analysis

ABSTRACT

Objective:  To summarize data on the prevalence of Molar Incisor Hypomineralization (MIH) in Brazilian children and adolescents and to evaluate its frequency and geographic distribution.

Material and Methods:  A systematic review was conducted using the following databases: PubMed, Scopus, Latin American Literature in Health Sciences (LILACS), EMBASE, Scientific Electronic Library Online (SciELO), Virtual Health Library (BIREME), Cochrane Library, and Web of Science, covering studies published from 2000 to 2023. The inclusion criteria were studies assessing the prevalence of MIH in Brazilian children and adolescents, published in English, Portuguese, or Spanish, with samples of Brazilians aged 5 to 15 years. Two reviewers conducted the study selection under the PRISMA and MOOSE guidelines. The risk of bias was assessed using the JBI Critical Appraisal Tool for Analytical Cross-Sectional Studies. A total of 12 studies met the inclusion criteria, with a combined sample of 8,312 participants. A meta-analysis was performed to determine the pooled prevalence of MIH using random-effects models.

Results:  The pooled prevalence of MIH in the Brazilian population is 15.9% (95% CI: 11.3-20.5). The Southeast region has the highest prevalence, at 20.2%, followed by the Northeast at 16.7%, the South at 13%, and the Midwest at 11.5%.

Conclusion:  These findings suggest that the prevalence of MIH in Brazil is comparable to the global estimate, albeit with regional variations.

Keywords:
Molar Hypomineralization; Prevalence; Child; Adolescent

Introduction

Molar incisor hypomineralization (MIH) is a condition that affects the mineralization of at least one permanent molar, which may also affect the incisors, resulting in changes to their color, shape, and texture [¹]. This dental feature can significantly impact the oral health of children and adolescents and their quality of life and self-esteem [²,³,⁴]. MIH has a multifactorial etiology influenced by genetic, environmental, and nutritional factors [⁵]. However, the etiology of MIH has not yet been fully clarified due to its complexity [⁶]. Factors contributing to this complexity include exposure to clinical and environmental conditions during pregnancy and/or the early years of life when teeth are developing [⁷].

The European Academy of Paediatric Dentistry (EAPD) proposed a classification for MIH widely recognized in the scientific community [⁸]. The condition is categorized into mild and severe based on specific criteria. Demarcated opacities on the affected tooth characterize mild cases and are not associated with a carious process. Well-defined opacities identify severe cases, the presence of a post-eruptive enamel fracture, associated carious lesions, cusp involvement, persistent and spontaneous sensitivity, incisor opacities, coronal destruction with possible dentin exposure, pulp involvement, atypical restorations, and significant aesthetic concerns [⁹,¹⁰].

Diagnosing MIH requires careful clinical observation of the affected teeth and a radiographic evaluation.

Early diagnosis of MIH is crucial for successful treatment, as it enables lesions to be identified in the early stages and allows for more straightforward preventive and restorative measures to be adopted [¹¹,¹²]. The treatment of MIH ranges from preventive measures, such as fluoride application and the use of fluoride varnishes and sealants, to oral health education to interceptive procedures, including restorative, endodontic, and dental extraction procedures, depending on the degree of involvement of the affected teeth [⁹,¹³]. Restorative treatment for MIH involves removing the demineralized tissue and reconstructing the teeth with restorative materials, such as composite resin or glass ionomer [¹⁴].

The prevalence of MIH ranges from 2.8% to 40.2%, depending on the country and location, with a global prevalence estimated at 13.5% [⁶]. Most of these studies used the criteria proposed by the EAPD to diagnose MIH [⁸]. However, epidemiological studies on the prevalence of MIH in Brazil still vary considerably and can be challenging to interpret. Despite advances in understanding MIH, there is a lack of representative data from various regions of the country [¹⁵]. This data may aid in formulating preventive and therapeutic strategies for public health policies that consider potential regional variations in MIH indicators in Brazil. Therefore, this study aimed to identify the prevalence of MIH in Brazilian children and adolescents and establish its frequency by geographical region.

Material and Methods

Protocol and Registration

The protocol for this systematic review was registered on the National Institute for Health Research PROSPERO, International Prospective Register of Systematic Review (https://www.crd.york.ac.uk/prospero/, number: CRD42023458792). The review followed the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [¹⁶, ¹⁷], while the meta-analysis adhered to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines [¹⁸].

Focus Question and Eligibility Criteria

This study aimed to address the following focused question: "What is the prevalence of molar incisor hypomineralization (MIH) in Brazilian children and adolescents?" The POS framework was applied to define the eligibility criteria as follows: Brazilian children and adolescents aged 5 to 15 years (Population, P), prevalence of MIH (Outcome, O), and observational study design (Study Design, S).

Studies were considered eligible for inclusion based on the following criteria: (i) cross-sectional or cohort studies reporting on the prevalence of MIH, (ii) English, Portuguese, and Spanish languages, (iii) a sample of Brazilians aged between 5 and 15 years, (iv) studies published between 2000 and 2023. Studies that only evaluated primary teeth, case-control studies, and replicated studies were excluded.

Search Strategy

The strategic process for identifying the studies was developed by combining MeSH terms with Boolean operators (AND, OR, and NOT), as shown in Table 1. The search for studies was conducted in the electronic databases of Medline, PubMed, Scopus, Latin American and Caribbean Literature on Health Sciences (LILACS), EMBASE, Scientific Electronic Library Online (SciELO), Virtual Health Library (BIREME), Cochrane Library, and Web of Science. This review was conducted between July 2023 and February 2024.

Table 1
Search strategy in the databases.

Base	Search Terms	Filters	Results
PubMed	((child OR (children) OR (adolescent) OR (children adolescent)) AND ((molar incisor hypomineralization) OR (cheese molars) OR (hypomineralization) OR (incisor hypomineralization) OR (molar hypomineralization) OR (mih dental) OR (pediatric dentistry mih) OR (hypoplasia)) AND ((prevalence) OR (mih prevalence)) ) AND ((child OR (children) OR (adolescent) OR (children adolescent)) AND ((molar incisor hypomineralization) OR (cheese molars) OR (hypomineralization) OR (incisor hypomineralization) OR (molar hypomineralization) OR (mih dental) OR (pediatric dentistry mih) OR (hypoplasia)) AND ((prevalence) OR (mih prevalence)))	English, Portuguese, and Spanish; Preschoolers aged 2-5; Children aged 6-12; Observational study; Adolescents aged 13-18; 2000-2023	413
Medline Scopus LILACS EMBASE SciELO BIREME Web of Science CAPES	((child OR (children) OR (adolescent) OR (children adolescent)) AND ((molar incisor hypomineralization) OR (cheese molars) OR (hypomineralization) OR (incisor hypomineralization) OR (molar hypomineralization) OR (mih dental) OR (hypoplasia)) AND ((prevalence) OR (mih prevalence))	Observational study; Prevalence study; English, Portuguese, and Spanish; 2000-2023	403 594 311 98 41 320 45 156
	Total	2,381

Study Selection

Two reviewers (RCM and JPCP) independently analyzed the studies identified and assessed the titles and abstracts of the selected files. Any discrepancies were resolved by a third examiner (PAMN). After selecting the studies, to verify inter-examiner agreement, Fleiss's Kappa reliability statistic was calculated, yielding a Kappa of 0.902 (n = 2381; Z = 44.0; p<0.001), indicating high consistency and agreement in the inclusion of articles in this systematic review. The full texts were then analyzed, eliminating those that did not meet the inclusion criteria and duplicate files.

Data Extraction

Data collection was conducted independently by two examiners, RCM and JPCP. Using an electronic spreadsheet (Excel software version 2019, Microsoft Corporation, USA), the following data were taken from all included articles: author's name, year of publication, Brazilian geographic region and state, type of study, total sample size, number of people affected by MIH, methods used to diagnose and assess the severity of MIH, main findings, and the funding of the studies.

Risk of Bias Assessment

The overall methodological rigor of each study was reviewed to supplement the risk of bias assessment, considering the appropriateness of its design, sample selection, measurement tools, and statistical analysis. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tool for Analytical Cross-Sectional Studies, updated in 2020 [¹⁹]. This tool consists of eight questions, each with four possible responses: "yes," "no," "uncertain," and "not applicable." It evaluates various aspects of study design and methodology, including sample size, selection criteria, data collection methods, and statistical analysis, to assess the risk of bias in each study.

Two calibrated examiners (RCM and JPCP) independently assessed each study and scored each item based on the responses provided. The scores were then summed to categorize the studies into one of three quality levels: 0-4 points as low quality (indicating significant methodological weaknesses), 5-6 points as moderate quality (indicating some methodological concerns), and 7-8 points as high quality (indicating minimal methodological flaws and more substantial study validity) [²⁰]. Discrepancies in scoring between the two examiners were resolved through discussion or consultation with a third examiner (PAMN), ensuring consistency and accuracy in the bias assessment process. This method of assessment allowed for an objective evaluation of study quality, providing a clearer understanding of the potential risk of bias in the findings of the included studies.

Data Analysis

The meta-analysis was conducted to determine the reported prevalence of MIH in children and adolescents using the R-based Jamovi software (version 2.3.24, The Jamovi Project, Sydney, Australia). Studies rated as low quality were excluded from the meta-analysis to minimize the risk of bias in the overall findings of the systematic review. A random effects model with restricted maximum likelihood estimation was used for all analyses. Pooled proportions were reported with 95% confidence intervals (95% CI). Cochran's Q test and I² statistics were also used to assess heterogeneity. Heterogeneity was considered high if I² > 50%. In addition, the pooled odds ratio (OR) and 95% CI were calculated for sex differences (male/female) in the prevalence of MIH. A p-value <.05 was considered statistically significant.

Results

Study Selection

A total of 2,381 files were identified through the search process. Titles and abstracts of these files were analyzed, and 81 studies remained after excluding 2,300 files. Of these studies, 57 were duplicates, an excluded. Five articles were also excluded because they did not meet the eligibility criteria. Thus, 19 articles were included in the systematic review (Figure 1).

Figure 1
PRISMA flowchart.

Study Characteristics

Nineteen cross-sectional studies from 11 Brazilian states and the Federal District were identified [²¹,²²,²³,²⁴,²⁵,²⁶,²⁷,²⁸,²⁹,³⁰,³¹,³²,³³,³⁴,³⁵,³⁶,³⁷,³⁸,³⁹]. The studies were published between 2010 and 2022. A total of 15,694 participants were included in this review, comprising 5,551 girls and 5,071 boys. However, six studies did not present the sample distribution by sex, and eight articles did not report the prevalence of MIH by sex. Sixteen studies used the diagnostic criteria recommended by the European Academy of Pediatric Dentistry (EAPD) to diagnose MIH (Table 2).

Table 2
Summary of included studies.

Author, Year (Reference)	Study Design	Brazilian Macro-Regions/ States	Funding	Age Range	MIH Criteria	Sample Size	MIH Prevalence
Costa-Silva et al., 2010 [21]	Cross-sectional	Southeast/ Minas Gerais	NR	6-12 years	EAPD	918	19.8
Jeremias et al., 2013 [22]	Cross-sectional	Southeast/ São Paulo	FAPESP and CNPQ	6-12 years	EAPD	1,157	12.3
Hanan et al., 2015 [23]	Cross-sectional	North/Amazonas	NR	6-10 years	EAPD	2,062	9.12
Rodrigues et al., 2015 [24]	Cross-sectional	Northeast/ Maranhão	NR	7-14 years	mDDE	1,179	2.5
Tourino et al., 2016 [25]	Cross-sectional	Southeast/ Minas Gerais	NR	8-9 years	EAPD	1,181	20.4
Sé et al., 2017 [26]	Cross-sectional	Midwest/ Distrito Federal	NR	6-11 years	EAPD	858	14.69
Dantas-Neta, 2017 [27]	Cross-sectional	Northeast/ Piauí	CAPES	8-10 years	EAPD	1,202	15.5
Raposo et al., 2019 [28]	Cross-sectional	Midwest/ Distrito Federal	NR	8 years	[40]	631	16.1
Reyes et al., 2019 [29]	Cross-sectional	South/ Paraná	NR	8 years	EAPD	731	12.1
Dourado et al., 2020 [30]	Cross-sectional	Northeast/ Piauí	NR	8-14 years	EAPD	251	46.6
Silva et al., 2020 [31]	Cross-sectional	Southeast/ Rio de Janeiro	CAPES	7-14 years	EAPD	407	14.5
Bonzanini et al., 2021 [32]	Cross-sectional	South/ Rio Grande do South	NR	5-14 years	EAPD	513	19.7
Duarte et al., 2021 [33]	Cross-sectional	Midwest/ Distrito Federal	NR	11-14 years	[40]	400	18
Farias et al., 2021 [34]	Cross-sectional	Northeast/Paraíba	FAPESQ/PB	8-10 years	EAPD	471	9.8
Fernandes et al., 2021 [35]	Cross-sectional	Northeast/ Paraíba	CAPES/FAPESQ/PB	6-12 years	EAPD	610	9.8
Fragelli et al., 2021 [36]	Cross-sectional	Southeast/ São Paulo	NR	8-12 years	EAPD	467	19.7
Reis, 2021 [37]	Cross-sectional	Southeast/ Rio de Janeiro	NR	8 years	EAPD	450	28.7
Sarmento et al., 2022 [38]	Cross-sectional	Southeast/ Espírito Santo	NR	8-10 years	EAPD	864	21
Oreano et al., 2022 [39]	Cross-sectional	South/ Santa Catarina	CAPES	8-10 years	EAPD	1,342	7.7

• NR: Not Reported; FAPESP: Fundação de Apoio à Pesquisa do Estado de São Paulo (in Portuguese); FAPESQ/PB – Fundação de Apoio à Pesquisa do Estado da Paraíba (In Portuguese); CNPQ: Conselho Nacional de Desenvolvimento Científico e Tecnológico (in Portuguese); EAPD: European Academy of Paediatric Dentistry; mDDE: Modified Developmental Defects of Enamel.

Risk of Bias

Sixteen studies received a perfect score of 8/8 [²¹,²²,²³,²⁴,²⁵,²⁷,²⁸,²⁹,³⁰,³²,³³,³⁴,³⁵,³⁶,³⁷,³⁸,³⁹], while two studies scored 7/8 [²⁶,³⁸] when assessed for risk of bias using the JBI Analytical Cross-Sectional Study Critical Appraisal Tool (Figure 2). One study was classified as having low methodological quality, scoring 4/8 [³¹], and was subsequently excluded from the meta-analysis. This study was removed due to insufficient sample description and inadequate methodological detail.

Figure 2
Risk of Bias and Study Quality Assessment Using the JBI Appraisal Tool.

Prevalence of MIH

Eighteen studies were included in the meta-analysis [²¹,²²,²³,²⁴,²⁵,²⁶,²⁷,²⁸,²⁹,³⁰,³²,³³,³⁴,³⁵,³⁶,³⁷,³⁸,³⁹]. The overall prevalence of MIH in Brazil was estimated at 15.9% (95% CI: 11.3-20.5, Z = 6.79, p<0.001) among 15,287 participants. Statistical analysis revealed significant heterogeneity among the studies (I² = 99.01%, p<0.001) (Figure 3). Additionally, no significant difference was found in the prevalence of MIH between male and female groups (overall pooled OR = 1.03, 95% CI: 0.91-1.18).

Figure 3
Forest plot of the meta-analysis (A) and funnel plot (B) for the prevalence of MIH in the total samples of the included studies from all regions of Brazil.

A subgroup analysis of the prevalence of MIH across different Brazilian geographic regions is presented in Figure 4 and Table 3. The Southeast region had the highest prevalence at 20.2% (95% CI: 16.1-24.3, p<0.001, I² = 92.87%) [²¹,²²,²⁵,³⁶,³⁷,³⁸]. The Northeast region showed a prevalence of 16.7% (95% CI: 1.8-31.6, p=0.028, I² = 96.23%) [²⁴,²⁷,³⁰,³⁴,³⁵], while the South region had a prevalence of 13.0% (95% CI: 6.2-19.8, p<0.001, I² = 99.6%) [²⁹,³²,³⁹]. The Midwest region had a prevalence of 11.5% (95% CI: 1.7-21.1, p=0.021, I² = 98.25%) [²⁶,²⁸,³³]. A meta-analysis could not be performed for the North region because only one study [²³] was included.

Figure 4
Forest plot of subgroup analysis based on the Midwest (A), Northeast (B), North (C), and Southeast (D) regions.

Table 3
Summary of the measures estimated by the random-effects models and heterogeneity statistics.

Variables	Random-Effect Model Estimates (MIH Prevalence)						Heterogeneity Statistics
	Estimate	SE	Z	p-value	95% CI
					LL	UL	I²	Q	p-value
Brazil (k = 18)	15.9%	2.3	6.79	<0.001	11.3%	20.5%	99.01%	1010.6	<0.001
Geographic Region
Midwest (k = 3)	11.5%	4.9	2.31	0.021	1.7%	21.1%	98.25%	142.4	<0.001
Northeast (k = 5)	16.7%	7.6	2.19	0.028	1.8%	31.6%	99.61%	323.1	<0.001
South (k = 3)	13.0%	3.4	3.74	<0.001	6.2%	19.8%	96.23%	43.5	<0.001
Southeast (k = 6)	20.2%	2.1	9.62	<0.001	16.1%	24.3%	92.87%	72.1	<0.001

• SE = Standard Error; 95% CI = 95% Confidence Interval; LL = Lower Limit; UL = Upper Limit.

Discussion

The present meta-analysis provides a comprehensive overview of the prevalence of MIH in Brazil. The data presented are very heterogeneous, but we could estimate a pooled prevalence of MIH of 15.9% (11.3-20.5%) in Brazilian children and adolescents. This finding is similar to the prevalence in the Americas, which is 15.3% [⁶]. This study suggests that the prevalence of MIH in Brazil is consistent with global estimates, highlighting the importance and reliability of the data collected.

Based on data from a previous meta-analysis that summarized the global, superregional, regional, and national prevalence of MIH [⁴¹], the global prevalence of MIH was 13.1% (11.8-14.5%), which was slightly lower than the prevalence reported in the present study. At the superregional level, their data showed that South Asia had the lowest prevalence at 9.5% (7.8-11.8%), whereas Latin America (prevalence 15.4%, 95% CI: 11.6-20.3%) and high-income countries (14.9%, 95% CI: 12.7-17.6%) had the highest prevalence. These geographical differences may reflect differences in the distribution of predictors associated with the pathogenesis of MIH between countries. Possible country-specific factors should be investigated in future ecological studies.

The present findings are consistent with previous studies [⁶,⁴¹], which indicate that there is no significant difference in the prevalence rates of MIH between males and females. However, it is essential to note that several studies included in the meta-analysis [²⁴,²⁶,²⁸,³²,³³,³⁶,³⁹] did not report the sex distribution of diagnosed cases, a crucial demographic indicator for understanding the epidemiology of MIH. Therefore, future studies conducted in Brazil should report prevalence rates categorized by sex, pregnancy variables, and child development, which could help identify predisposing factors in the Brazilian population.

In the present meta-analysis, the lowest MIH prevalence was estimated in the Midwest region (11.5%) and the highest in the Southeast (20.2%) and Northeast (16.7%) regions. In addition, the only study conducted in Northern Brazil showed an MIH prevalence of 9.1% [²³]. It is noteworthy that Brazilian microregions exhibit disparate levels of the Human Development Index (HDI), reflecting regional variations in educational attainment, income, and longevity indicators (Midwest = 0.757, North = 0.667, Northeast = 0.663, Southeast = 0.766, South = 0.754) in 2010 [⁴²]. The data from the national hospital-based survey in Brazil, which included 19,117 postpartum women, revealed regional variations in the profiles of women and prenatal care indicators [⁴³]. The study mentioned above indicated that the prevalence of women attending at least six antenatal appointments was higher in Brazil's South, Midwest, and North regions.

Additionally, a previous meta-analysis estimated that the prevalence of childhood obesity is higher in more developed Brazilian macro-regions, which could be attributed to differences in dietary patterns and social inequalities between regions [⁴⁴]. Evidence from national surveys has also shown that, despite improvements in nutritional indicators for Brazilian children under five years of age, there were regional disparities in the prevalence of exclusive breastfeeding among children under six months, anemia, and vitamin A deficiency [⁴⁵]. Therefore, differences in the prevalence of MIH among Brazilian macro-regions may be partially attributable to variations in the demographic profile, along with indicators related to pregnancy and child development.

When analyzing the prevalence of MIH in different regions of Brazil, it is clear that there is a lack of studies in certain parts of the country. This represents a significant gap in understanding these regions' epidemiological situation. The lack of prevalence data may lead to an underestimation of the true prevalence of MIH in Brazil, making it difficult to obtain accurate results. Encouraging new research, particularly in areas outside major urban centers, is crucial to support and promote public policies that aim to improve the oral health of Brazilian children and adolescents.

The quality of the included studies was assessed, yielding an overall high score, indicating good methodological quality. This enhances the reliability of the results and the representativeness of the review's conclusions. The only study categorized as having low methodological quality employed a mixed study design [³¹], which made it difficult to fit into the tool used to assess the risk of bias of the included studies. Therefore, the presence of this study does not impact the results obtained in this systematic review.

Developing a critical sense is necessary when designing a study methodology aimed at providing concrete scientific evidence. Therefore, it is essential to be aware of the type of study being carried out and to standardize the criteria used to classify MIH [⁸]. This subject is widely discussed in the literature, and standardizing the criteria will help establish a reliable epidemiological picture. This, in turn, will aid in developing action plans for public policies that are consistent with the population situation. Therefore, future studies should establish clear criteria for investigating prevalence to deepen understanding of the specificities of MIH and potential regional differences.

The age group of 5-15 years was selected for this study on MIH in permanent teeth due to its relevance to both the eruption timeline and the clinical significance of MIH. During this period, children typically enter the mixed dentition stage, which is characterized by the eruption of permanent molars and incisors. This age range is critical for observing the development of permanent teeth, as the first permanent molars generally erupt around the age of 6, followed by the incisors and second molars in subsequent years [⁴⁶]. Furthermore, understanding the eruption sequence of permanent teeth in this age group provides valuable insights into the potential impact of MIH on the development and function of permanent dentition, making this age group an ideal target for studying the prevalence of MIH and its associated factors.

The present study utilized the PRISMA and MOOSE guidelines to ensure a well-defined methodology. This study aims to determine the prevalence of MIH in Brazil by conducting a systematic review of observational studies from different regions of the country. The results comprehensively show MIH's geographical and demographic distribution in Brazilian children and adolescents.

A potential limitation of this systematic review is the lack of data from several states in the country, which is attributed to a scarcity of studies. Additionally, analyses of prevalence differences between macro-regions should be approached with caution, as the confidence intervals between regions overlap, raising the possibility that there may not be a statistically significant difference between them. Therefore, it is recommended that scientific research on the subject be increased, particularly in currently underrepresented regions.

Due to its high prevalence and the increasing demand for specialized resources in the dental system,

MIH significantly impacts public health. The difficulty in early diagnosis and the absence of standardized protocols further complicate the challenge [⁹], especially for vulnerable populations with limited access to treatment. Evidence has shown that the most common consequences of MIH are caries lesions, hypersensitivity, and post-eruptive breakdown [⁴⁷]. Prevention strategies, education, and professional training are needed to mitigate the effects of MIH, along with investments in public policies that promote equity in healthcare [⁴¹]. Furthermore, the severity of MIH plays a crucial role in its clinical significance, as the condition can range from mild discoloration to severe structural defects that impact both the function and aesthetics of the affected teeth, negatively affecting the oral health-related quality of life in children with MIH [⁴⁸]. These variations in severity can lead to different treatment needs and outcomes, underscoring the importance of early diagnosis and tailored interventions. Thus, comprehensive public health strategies should address the full spectrum of MIH severity to improve long-term oral health outcomes for Brazilian children and adolescents.

Conclusion

The present meta-analysis indicates that the prevalence of MIH was 15.9% in the Brazilian population. Additionally, a variation in the prevalence of MIH was observed across different regions of the country, with rates ranging from 11.5% (Midwest region) to 20.2% (Southeast region). These findings align with the expected range in the global context, offering insight into the epidemiological landscape. Therefore, further research should be conducted to better understand the epidemiological status of MIH in Brazil. This may facilitate the development of public policies tailored to the specific needs of Brazil's different regions.

• Financial Support
  This research was supported by the Brazilian Coordination for Higher Education Personnel Improvement (CAPES) [Finance Code ⁰⁰¹] and the Foundation for Research and Scientific and Technological Development of Maranhão (FAPEMA).

Data Availability

The data supporting the findings of this study can be made available upon request to the corresponding author.

References

• ¹ Weerheijm KL, Jalevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res 2001; 35(5):390-391. https://doi.org/10.1159/000047479
  » https://doi.org/10.1159/000047479
• ² Jälevik B, Sabel N, Robertson A. Can molar incisor hypomineralization cause dental fear and anxiety or influence the oral health-related quality of life in children and adolescents?—A systematic review. Eur Arch Paediatr Dent 2022; 23(1):65-78. https://doi.org/10.1007/s40368-021-00631-4
  » https://doi.org/10.1007/s40368-021-00631-4
• ³ Vanhée T, Poncelet J, Cheikh-Ali S, Bottenberg P. Prevalence, caries, dental anxiety and quality of life in children with MIH in Brussels, Belgium. J Clin Med 2022; 11(11):3065. https://doi.org/10.3390/jcm11113065
  » https://doi.org/10.3390/jcm11113065
• ⁴ Dantas-Neta NB, Moura LDFADD, Cruz PF, Moura MS, Paiva SM, Martins CC, et al. Impact of molar-incisor hypomineralization on oral health-related quality of life in schoolchildren. Braz Oral Res 2016; 30(1):e117. https://doi.org/10.1590/1807-3107BOR-2016.vol30.0117
  » https://doi.org/10.1590/1807-3107BOR-2016.vol30.0117
• ⁵ Jeremias F, Bussaneli DG, Restrepo M, Pierri RAG, Souza JFD, Fragelli CMB, et al. Inheritance pattern of molar-incisor hypomineralization. Braz Oral Res 2021; 35:e035. https://doi.org/10.1590/1807-3107bor-2021.vol35.0035
  » https://doi.org/10.1590/1807-3107bor-2021.vol35.0035
• ⁶ Lopes LB, Machado V, Mascarenhas P, Mendes JJ, Botelho J. The prevalence of molar-incisor hypomineralization: A systematic review and meta-analysis. Sci Rep 2021; 11(1):22405. https://doi.org/10.1038/s41598-021-01541-7
  » https://doi.org/10.1038/s41598-021-01541-7
• ⁷ Juárez-López MLA, Salazar-Treto LV, Hernández-Monjaraz B, Molina-Frechero N. Etiological factors of molar incisor hypomineralization: A systematic review and meta-analysis. Dent J 2023; 11(5):111. https://doi.org/10.3390/dj11050111
  » https://doi.org/10.3390/dj11050111
• ⁸ Weerheijm KL, Duggal M, Mejàre I, Papagiannoulis L, Koch G, Martens LC, et al. Judgement criteria for molar incisor hypomineralisation (MIH) in epidemiologic studies: A summary of the European meeting on MIH held in Athens, 2003. Eur J Paediatr Dent 2003; 4(3):110-113.
• ⁹ Lygidakis NA, Garot E, Somani C, Taylor GD, Rouas P, Wong FSL. Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): An updated European Academy of Paediatric Dentistry policy document. Eur Arch Paediatr Dent 2022; 23(1):3-21. https://doi.org/10.1007/s40368-021-00668-5
  » https://doi.org/10.1007/s40368-021-00668-5
• ¹⁰ Ghanim A, Silva MJ, Elfrink MEC, Lygidakis NA, Mariño RJ, Weerheijm K, et al. Molar incisor hypomineralisation (MIH) training manual for clinical field surveys and practice. Eur Arch Paediatr Dent 2017; 18(4):225-242. https://doi.org/10.1007/s40368-017-0293-9
  » https://doi.org/10.1007/s40368-017-0293-9
• ¹¹ Mazur M, Corridore D, Ndokaj A, Ardan R, Vozza I, Babajko S, et al. MIH and dental caries in children: A systematic review and meta-analysis. Healthcare 2023; 11(12):1795. https://doi.org/10.3390/healthcare11121795
  » https://doi.org/10.3390/healthcare11121795
• ¹² Almuallem Z, Busuttil-Naudi A. Molar incisor hypomineralisation (MIH)–An overview. Br Dent J 2018; 225:601-609. https://doi.org/10.1038/sj.bdj.2018.814
  » https://doi.org/10.1038/sj.bdj.2018.814
• ¹³ Somani C, Taylor GD, Garot E, Rouas P, Lygidakis NA, Wong FSL. An update of treatment modalities in children and adolescents with teeth affected by molar incisor hypomineralisation (MIH): A systematic review. Eur Arch Paediatr Dent 2022; 23(1):39-64. https://doi.org/10.1007/s40368-021-00635-0
  » https://doi.org/10.1007/s40368-021-00635-0
• ¹⁴ Weber KR, Wierichs RJ, Meyer-Lückel H, Flury S. Restoration of teeth affected by molar-incisor hypomineralisation: A systematic review. Swiss Dent J 2021; 131(12):988-997. https://doi.org/10.61872/sdj-2021-12-764
  » https://doi.org/10.61872/sdj-2021-12-764
• ¹⁵ Silva MJ, Scurrah KJ, Craig JM, Manton DJ, Kilpatrick N. Etiology of molar incisor hypomineralization–A systematic review. Comm Dent Oral Epidemiol 2016; 44(4):342-353. https://doi.org/10.1111/cdoe.12229
  » https://doi.org/10.1111/cdoe.12229
• ¹⁶ Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021; 372:n71. https://doi.org/10.1136/bmj.n71
  » https://doi.org/10.1136/bmj.n71
• ¹⁷ Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. Updating guidance for reporting systematic reviews: Development of the PRISMA 2020 statement. J Clin Epidemiol 2021; 134:103-112. https://doi.org/10.1016/j.jclinepi.2021.02.003
  » https://doi.org/10.1016/j.jclinepi.2021.02.003
• ¹⁸ Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: A proposal for reporting. JAMA 2000; 283(15):2008-2012. https://doi.org/10.1001/jama.283.15.2008
  » https://doi.org/10.1001/jama.283.15.2008
• ¹⁹ The Joanna Briggs Institute. The Joanna Briggs Institute Critical Appraisal Tools for Use in JBI Systematic Reviews Checklist for Analytical Cross-Sectional Studies. North Adelaide, Australia: The Joanna Briggs Institute; 2017. Available from: https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf [Accessed on January 10, ²⁰²⁴].
  » https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf
• ²⁰ Bouqoufi A, Laila L, Boujraf S, Hadj FAE, Razine R, Abouqal R, et al. Prevalence and associated factors of self-medication in worldwide pregnant women: Systematic review and meta-analysis. BMC Publ Heal 2024; 24(1):308. https://doi.org/10.1186/s12889-023-17195-1
  » https://doi.org/10.1186/s12889-023-17195-1
• ²¹ Costa-Silva CM, Jeremias F, de Souza JF, Cordeiro RCL, Santos-Pinto L, Zuanon ACC. Molar incisor hypomineralization: prevalence, severity and clinical consequences in Brazilian children. Int J Paediatr Dent 2010; 20(6):426-434. https://doi.org/10.1111/j.1365-263X.2010.01097.x
  » https://doi.org/10.1111/j.1365-263X.2010.01097.x
• ²² Jeremias F, Souza JFD, Silva CMDS, Cordeiro RCL, Zuanon ACC, Santos-Pinto L. Dental caries experience and molar-incisor hypomineralization. Acta Odontol Scand 2013; 71(3-4):870-876. https://doi.org/10.3109/00016357.2012.734412
  » https://doi.org/10.3109/00016357.2012.734412
• ²³ Hanan SA, Alves-Filho ADO, Medina PO, Cordeiro RCL, Santos-Pinto L, Zuanon ACC. Molar-incisor hypomineralization in schoolchildren of Manaus, Brazil. Pesq Bras Odontopediatr Clin Integr 2015, 15(1):309-317. https://doi.org/10.4034/PBOCI.2015.151.33
  » https://doi.org/10.4034/PBOCI.2015.151.33
• ²⁴ Rodrigues FCN, Ribeiro PHB, Thomaz EBAF, Lima GQT, Neves PAM, Ribeiro CCC. Molar-incisor hypomineralization in schoolchildren of São Luís, Brazil, Maranhão: Prevalence and associated factors. Pesq Bras Odontopediatr Clin Integr 2015; 15(1):271-278. https://doi.org/10.4034/PBOCI.2015.151.29
  » https://doi.org/10.4034/PBOCI.2015.151.29
• ²⁵ Tourino LFPG, Corrêa-Faria P, Ferreira RC, Bendo CB, Zarzar PM, Vale MP. Association between molar incisor hypomineralization in schoolchildren and both prenatal and postnatal factors: A population-based study. Plos One 2016; 11(6):e0156332. https://doi.org/10.1371/journal.pone.0156332
  » https://doi.org/10.1371/journal.pone.0156332
• ²⁶ Sé MJDSF, Ribeiro APD, Santos-Pinto LAM, Cordeiro RCL, Cabral RN, Leal SC. Are hypomineralized primary molars and canines associated with molar-incisor hypomineralization? Pediatr Dent 2017; 39(7):445-449.
• ²⁷ Neta NBD. Hipomineralização molar-incisivo: Prevalência, fatores associados e impacto na qualidade de vida relacionada à saúde bucal de escolares. PhD thesis – Universidade Federal de Minas Gerais, Belo Horizonte; 2017. In Portuguese].
• ²⁸ Raposo F, Rodrigues ACC, Lia EN, Leal SC. Prevalence of hypersensitivity in teeth affected by molar-incisor hypomineralization (MIH). Caries Res 2019; 53(4):424-430. https://doi.org/10.1159/000495848
  » https://doi.org/10.1159/000495848
• ²⁹ Reyes MRT, Fatturi AL, Menezes JVNB, Fraiz FC, Assunção LRDS, Souza JFD. Demarcated opacity in primary teeth increases the prevalence of molar incisor hypomineralization. Braz Oral Res 2019; 33:e048. https://doi.org/10.1590/1807-3107bor-2019.vol33.0048
  » https://doi.org/10.1590/1807-3107bor-2019.vol33.0048
• ³⁰ Dourado DG, Lima CCB, Silva RNC, Tajra FS, Moura MS, Lopes TSP, et al. Molar-incisor hypomineralization in quilombola children and adolescents: A study of prevalence and associated factors. J Publ Heal Dent 2021; 81(3):178-187. https://doi.org/10.1111/jphd.12429
  » https://doi.org/10.1111/jphd.12429
• ³¹ Silva FMFD, Zhou Y, Vieira FGDF, Carvalho FMD, Costa MDC, Vieira AR. Defining the prevalence of molar incisor hypomineralization in Brazil. Pesq Bras Odontopediatr Clin Integr 2020; 20:e5146. https://doi.org/10.1590/pboci.2020.021
  » https://doi.org/10.1590/pboci.2020.021
• ³² Bonzanini LIL, Arduim A da S, Lenzi TL, Hugo FN, Hilgert JB, Casagrande L. Molar-incisor hypomineralization and dental caries: A hierarchical approach in a populational-based study. Braz Dent J 2021; 32(6):74-82. https://doi.org/10.1590/0103-6440202104511
  » https://doi.org/10.1590/0103-6440202104511
• ³³ Duarte MBS, Carvalho VR, Hilgert LA, Ribeiro APD, Leal SC, Takeshita EM. Is there an association between dental caries, fluorosis, and molar-incisor hypomineralization? J Appl Oral Sci 2021; 29:e20200890. https://doi.org/10.1590/1678-7757-2020-0890
  » https://doi.org/10.1590/1678-7757-2020-0890
• ³⁴ Farias L, Laureano ICC, Fernandes LHF, Forte FDS, Vargas-Ferreira F, Alencar CRBD, et al. Presence of molar-incisor hypomineralization is associated with dental caries in Brazilian schoolchildren. Braz Oral Res 2021; 35:e013. https://doi.org/10.1590/1807-3107bor-2021.vol35.0013
  » https://doi.org/10.1590/1807-3107bor-2021.vol35.0013
• ³⁵ Fernandes IC, Forte FDS, Sampaio FC. Molar-incisor hypomineralization (MIH), dental fluorosis, and caries in rural areas with different fluoride levels in the drinking water. Int J Paediatr Dent 2021; 31(4):475-482. https://doi.org/10.1111/ipd.12728
  » https://doi.org/10.1111/ipd.12728
• ³⁶ Fragelli C, Barbosa TS, Bussaneli DG, Restrepo M, Cordeiro RCL, Santos-Pinto L. Aesthetic perception in children with molar incisor hypomineralization. Eur Arch Paediatr Dent 2021; 22(2):227-234. https://doi.org/10.1007/s40368-020-00541-x
  » https://doi.org/10.1007/s40368-020-00541-x
• ³⁷ Reis PPG, Jorge RC, Americano GCA, Pontes NDST, Peres AMAM, Soviero VM. Prevalence and severity of molar incisor hypomineralization in Brazilian children. Pediatr Dent 2021; 43(4):270-275.
• ³⁸ Sarmento LC, Rezende KM, Ortega ALDO. El impacto de la hipomineralización molar incisivo en la calidad de vida de los niños brasileños. Rev Odontopediatr Latinoam 2022; 12(1):202001. https://doi.org/10.47990/alop.v12i1.1 [In Spanish].
  » https://doi.org/10.47990/alop.v12i1.1
• ³⁹ Oreano MD, Santos PS, Borgatto AF, Bolan M, Cardoso M. Association between dental caries and molar-incisor hypomineralisation in first permanent molars: A hierarchical model. Comm Dent Oral Epidemiol 2023; 51(3):436-442. https://doi.org/10.1111/cdoe.12778
  » https://doi.org/10.1111/cdoe.12778
• ⁴⁰ Cabral RN, Nyvad B, Soviero VLVM, Freitas E, Leal SC. Reliability and validity of a new classification of MIH based on severity. Clin Oral Invest 2020; 24(2):727-734. https://doi.org/10.1007/s00784-019-02955-4
  » https://doi.org/10.1007/s00784-019-02955-4
• ⁴¹ Schwendicke F, Elhennawy K, Reda S, Bekes K, Manton DJ, Krois J. Global burden of molar incisor hypomineralization. J Dent 2018; 68:10-18. https://doi.org/10.1016/j.jdent.2017.12.002
  » https://doi.org/10.1016/j.jdent.2017.12.002
• ⁴² Instituto de pesquisa econômica aplicada (IPEA). Desenvolvimento humano nas macrorregiões brasileiras. Brasília: IPEA; 2016. p 1-55. Available from: http://www.ipea.gov.br/portal/images/stories/PDFs/livros/livros/20160331_livro-idhm.pdf [Accessed on April 25, ²⁰²⁴]. [In Portuguese].
  » http://www.ipea.gov.br/portal/images/stories/PDFs/livros/livros/20160331_livro-idhm.pdf
• ⁴³ Leal MDC, Esteves-Pereira AP, Viellas EF, Domingues RMSM, Gama SGND. Prenatal care in the Brazilian public health services. Rev Saude Publ 2020; 54:8. https://doi.org/10.11606/s1518-8787.2020054001458
  » https://doi.org/10.11606/s1518-8787.2020054001458
• ⁴⁴ Ferreira CM, Reis NDD, Castro ADO, Höfelmann DA, Kodaira K, Silva MT, et al. Prevalence of childhood obesity in Brazil: Systematic review and meta-analysis. J Pediatr 2021; 97(5):490-499. https://doi.org/10.1016/j.jped.2020.12.003
  » https://doi.org/10.1016/j.jped.2020.12.003
• ⁴⁵ Castro IRRD, Anjos LAD, Lacerda EMDA, Boccolini CS, Farias DR, Alves-Santos NH, et al. Nutrition transition in Brazilian children under 5 years old from 2006 to 2019. Cad Saude Publ 2023; 39(Suppl 2):e00216622. https://doi.org/10.1590/0102-311XEN216622
  » https://doi.org/10.1590/0102-311XEN216622
• ⁴⁶ Oznurhan F, Ekci ES, Ozalp S, Deveci C, Delilbasi AE, Bani M, et al. Time and sequence of eruption of permanent teeth in Ankara, Turkey. Pediatr Dent J 2016; 26(1):1-7. https://doi.org/10.1016/j.pdj.2015.09.002
  » https://doi.org/10.1016/j.pdj.2015.09.002
• ⁴⁷ Fernandes LHF, Laureano ICC, Farias L, Prates CDC, Alencar CRBD, Cavalcanti AL. Impact of molar incisor hypomineralization on oral health-related quality of life in Brazilian schoolchildren aged 8 to 10 years. Pesq Bras Odontopediatr Clin Integr 2024; 24:e230194. https://doi.org/10.1590/pboci.2024.030
  » https://doi.org/10.1590/pboci.2024.030
• ⁴⁸ Gevert MV, Wambier LM, Ito LY, Souza, JFD, Chibinski ACR. Which are the clinical consequences of Molar Incisor hypomineralization (MIH) in children and adolescents? Systematic review and meta-analysis. Clin Oral Invest 2024; 28(7):415. https://doi.org/10.1007/s00784-024-05800-5
  » https://doi.org/10.1007/s00784-024-05800-5

Edited by

• Academic Editor:
  Catarina Ribeiro Barros de Alencar

Publication Dates

• Publication in this collection
  28 Nov 2025
• Date of issue
  2026

History

• Received
  19 Aug 2024
• Reviewed
  27 Dec 2024
• Accepted
  10 Feb 2025