Rita Pangjaj
5th year, group 14Knowledge and awareness toward MIH among dental students at LSMU
Master’s ThesisSupervisor Doctor, Sandra Petrauskienė
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
CLINIC PREVENTIVE AND PAEDIATRIC DENTISTRY
Knowledge and awareness toward MIH among dental students at LSMU Master’s Thesis
The thesis was done
by student ... Supervisor ... (signature) (signature)
... ... (name surname, year, group) (degree, name surname)
... 20…. ... 20…. (day/month) (day/month)
CONTENTS
ABBREVATION ... 4
SUMMARY ... 5
INTRODUCTION ... 6
1. REVIEW OF LITTERATURE ... 9
2. MATERIAL AND METHODS ... 11
3. RESULTS ... 13 4. DISCUSSION ... 19 5. CONCLUSIONS ... 21 6. ACKNOWLEDGEMENT ... 21 7. ENSURING OF CONFIDENTIALITY ... 21 8. PRACTICAL RECOMMENDATIONS... 21 9. REFERENCES ... 22 10. ANNEXES ... 26
4 ABBREVATION
LSMU – Lithuanian University of Health Sciences MIH- Molar-incisor hypominseralisation
CI - Confidence interval
GDPs – General dental practitioners PDs – Paediatric dental specialists FPMs – First permanent molars
EAPD – European Academy of Paediatric Dentistry GIC – Glass ionomer cement
5 Knowledge and awareness toward MIH among dental students at LSMU
SUMMARY
The aim of study: To evaluate the knowledge and awareness toward MIH among dental students at Lithuanian University of Health Sciences.
The material and methods: A cross-sectional study enrolled dental students at LSMU during the academic year of 2019/2020. 187 students participated with a response rate of 81.7%. A self-administrated questionnaire covered information about definition, etiology and treatment of MIH. Statistical analysis was performed with SPSS 19. To establish the correlation between variables, the chi-squared test was applied. The level of significance was set at p<0.05 with a CI of 95 %. The study was approved by LSMU Bioethics Center (No BEC-OF-59).
Results: 45.6% of undergraduates knew a correct definition of MIH. Considering the etiology factors, final year participants showed better knowledge regarding to period of MIH development than 4th academic year students (88.8 % vs. 67.1 %) (P<0.001). 68.7% of participants reported knowing clinical MIH features. More Lithuanian students knew clinical MIH features than international ones (75.5 % vs. 39.5 %) (P<0.001). Only 18.5 % of undergraduates reported knowing the MIH diagnosis criteria. The most common challenge in treating patients with MIH (41.1 %) was insufficient training among participants.
Conclusion:
The overall knowledge and awareness toward MIH among dental students at LSMU was insufficient. Knowledge of MIH aetiological risk factors was low among dental students at LSMU. More senior dental students reported that they are able to implement MIH diagnosis criteria and they have experience in treatment of MIH than younger ones.
Keywords: MIH definition, MIH aetiology, MIH clinical criteria, MIH diagnosis, knowledge of dental students, awareness of dentists
6 INTRODUCTION
Molar-incisors hypomineralisation (MIH) remains an ongoing concern in paediatric dentistry [1-4]. The term was introduced for the first time in 2001 at the congress of the European Academy of Paediatric Dentistry as 'hypomineralisation of systemic origin, presenting as demarcated, qualitative defects of enamel of one to four first permanent molars (FPMs) frequently associated with affected incisors' [5]. Although MIH is a relatively new condition, it is more common than we may think. Studies show that worldwide prevalence of MIH ranges from 2.8 % to 44 % [6-8].
The etiology of MIH remains uncertain [4,6,9]. However, researchers suggest that MIH originates due to systemic cause and affects ameloblasts in early stage of maturation – or even earlier at the late secretory phase [10]. Any temporary or permanent interruption of the ameloblast function may result in enamel hypomineralisation. Defects occurring in infancy can be detected when teeth have erupted years later, as the enamel does not undergo remodeling [11].
Studies show that predisposing factors may be such as prenatal, perinatal complications, environmental conditions or any form of paediatric respiratory tract problem at early childhood period [12,13].
Additionally, MIH may be a consequence of use of antibiotics, oxygen starvation and low birth weight [14].
Clinical features, diagnosis and challenges in treatment
The clinical features of MIH are influenced by its level of severity and may include clinical features such as opacities ranging from cream-white to yellow-brown in color. The lesions are usually larger than 1 mm and post eruptive enamel breakdown to atypical caries is located on minimum one first permanent molar (regardless involvement of incisors). FPMs show rapid caries progress in teeth with MIH shortly after eruption – in majority of patients – resulting in serious complications to patients as well challenges in treatment management by dentists [15].
Early studies classified the severity levels of MIH as following [16] mild, moderate and severe. Clinical characteristics of MIH vary from the demarcated opacities located at non-stress bearing areas to post-eruptive enamel breakdown and crown destruction, while patients with MIH affected teeth may report dental sensitivity and aesthetic concerns [16].
Examination for early diagnosis is recommended to begin around the age of eight, as all PFMs and most of incisors will be present. Early diagnosis of MIH prevents further post eruptive breakdown to happen. During examination dentist should check for the presence of changes in enamel color, opacities and areas of enamel loss in places where commonly affects the posterior teeth [17].
7 To confirm diagnosis, dentist should ask parents if they are aware of any illness that occurred during prenatal, perinatal or postnatal period that may have resulted in this condition [15].
Treatment of teeth with MIH can be based on non-operative and operative dental treatment approaches [18-20]. For instance, usage of an arginine paste reduces dental sensitivity due to sealing of dentinal tubules and decreasing the number of exposed sensory afferents – achieving block of hydrodynamic pain mechanism [18,21]. Moreover, fluoride varnish is another suggested therapeutic option [19]. Considering the success rate of operative restorative treatment, significantly greater success rate at 12 months was found after treating tooth with glass ionomer restorations compared to resin composite restorations [20]. In contrary, studies revealed controversial results, several studies showed that resin composite was used often as a restorative material for teeth with MIH [22,23].
However, other studies indicate high variety in choice of dental material in treating MIH-affected tooth. One study picked the main preferred choice of filling as resin-modified glass ionomer cement [23] and other study chose glass ionomer cement [24].
Management of young patients with severe hypomineralized molars, requires stainless steel crowns to prevent further tooth loss [20,25].
On the other hand, tooth bleaching, micro-abrasion or composite fillings may be required because of the aesthetical defect of the anterior teeth. In addition, the application of hydrogen-peroxide-based gels on enamel of MIH-affected teeth can result the decreased hardness of tooth structure and
morphological alterations causing mineral loss [26].
Management of young patients with severe hypomineralized molars, requires stainless steel crowns to prevent further tooth loss [20].
Due to its high prevalence [6-8] MIH-affected patients are frequently encountered in the dental practice worldwide [15,22]. However, dental practitioners and undergraduates [2,27-29,30] show low
knowledge, awareness and perception regarding prevalence, aetiology and treatment management for MIH-affected teeth. Therefore, dental practitioners and undergraduates must stay up to date and should be provided new information on MIH – thus increasing the quality of life for the patients through effective early preventative care.
Hypothesis
We expect that 5th year dental students have a greater knowledge and awareness than 4th year students regarding molar-incisors hypomineralisation.
8 The aim of study: To evaluate the knowledge and awareness toward molar-incisors
hypomineralisation among dental students at Lithuanian University of Health Sciences.
Objectives:
1. To collect and analyze the data related to the knowledge and awareness toward MIH among 4th and 5th year dental students of English and Lithuanian program.
2. To compare dental students’ knowledge and awareness towards MIH based on academic year. 3. To compare dental students’ knowledge and awareness towards MIH based on program of
9 1. REVIEW OF LITTERATURE
1.1 The prevalence of MIH in Lithuania
Study performed by Jasulaitytė et al. revealed that 9.6% of children aged 7-9 years had moderate MIH [31] in comparison to worldwide studies which showed a variation ranging from 2.4%–40.2% [32,33].
1.2 Worldwide studies conducted to evaluate dentists’ perception and knowledge of MIH Numerous studies were conducted to measure perception and knowledge of MIH among dental care workers.
Study carried out in In Hong Kong revealed that majority (71.4 %) of pediatric dentists and general practice dentists MIH-affected cases during their dental practice, while pediatric dentists showed significantly higher level of knowledge of MIH. However, majority of participants claimed requiring continuing education on MIH [2].
Furthermore, Irish general dentists working in private practice or from the age 36 (or above) claimed having less experience in MIH-related cases. Subsequently, a half of participants encountered MIH at least weekly. Thus, dental education for dental practitioners might be recommended for effective treatment planning for MIH [22].
Study performed in Kuwait showed a high awareness of MIH due to frequent MIH cases in their practice. Moreover, dental specialists indicated higher confidence in diagnosis of MIH-affected teeth than general practice dentists [25].
1.2.1 Worldwide studies conducted among undergraduates in regard of MIH
Study carried out in Saudi Arabia compared dentist (general and specialists) and dental students and found, that majority of undergraduates (64%) had never heard of MIH and required more training in diagnosis, while dentist required more training in treatment [30].
Equally many undergraduates (11.4 %) chose composite resin and glass ionomer cement as the most used dental material in treating MIH-affected teeth. However, only 2 % claimed using preformed crowns [30].
1.3 Challenges in managing treatment of MIH-affected teeth
Recent study suggested the biggest challenge in managing treatment was the child's behavior. The second biggest challenge was achievement of successful local anesthesia [22].
Another study conducted on dentists undergoing specialist training in paediatric dentistry in UK indicated that the biggest challenge in managing MIH was distinguishing it from other conditions. The
10 trainees’ main concern was the pain of children and the clinical appearance of the condition. Both GDPs and undergoing specialists claimed parental anxiety appeared in mainly all of the cases. Due to the presence of challenges, both groups claimed it having a negative influence on the quality of life of the affected paediatrics patients [34].
1.4 New treatment index to establish clear treatment guidelines
In 2007 a new treatment index was assessed and called the “The Würzburg MIH concept: the MIH treatment need index” (MIH TNI). It was made to establish guidelines in treatment management of MIH-affected teeth, and it is based on examination and evaluation of primary or permanent dentition. All typical present MIH symptoms are recorded as “MIH yes” and no presence of teeth
hypersensitivity, atypical restorations or other typical clinical features of MIH as “MIH no”. The MIH-TNI can be used in diagnosis of individual cases of MIH as well as treatment planning depending severity [35].
1.5 Preferred treatment management of MIH among dentists worldwide
Multiple therapeutic approaches (fluoride varnish, fissure sealant, filling with composite, stainless steel crown, and extraction) can be used to establish impact on oral hygiene and hypersensitivity in MIH-affected children [35]. Study showed, that patients with mild symptoms, or class I usually are treated with fluoride varnish. However, teeth on the characteristic edge between class I or class II, were treated with fissure sealants or fillings. In severe MIH, or class III, required treatment was stainless steel crown preparation [36].
Study carried out in Norway revealed that 53.5 % of the dentist would prefer application of fluoride varnish for newly erupted first permanent molar with moderate MIH. Consequently, sealing the fissure with GIC material would be the second choice. Moreover, majority of dentists would treat severe MIH through a conventional glass ionomer restoration and only minority would treat it with stainless steel crown [37].
Another study showed a high survival rate in managing MIH class I, II and II defects with sealants, composite resin and stainless steel after 1-year follow-up period. The highest survival rate was for sealants, while the lowest survival rate was seen in treatment management with composite resin and glass ionomer cement [38].
11 2. MATERIAL AND METHODS
A cross-sectional study was conducted to assess the knowledge and awareness toward MIH among dental students at LSMU during the academic year of 2019/2020. Request application to conduct the study was approved by Head of LSMU Bioethics Center Dr. E Peičius (No BEC-OF-59).
Participation was voluntary and anonymous; thus, the return of a completed questionnaire and the consent signed by subjects was considered as acceptance to participate.
2.1 Subjects
A self-administrated English and Lithuanian questionnaire was distributed among 4th and 5th year dental students (programs: Dentistry in Lithuanian and Dentistry in English) at Lithuanian University of Health Sciences.
A total of 46 students of Dentistry in English program (4th and 5th academic year) and 183 students of Dentistry in Lithuanian program (4th and 5th academic year) study at LSMU during the 2019/2020 study year. All dental students (4th and 5th academic year) were invited to participate in this study. Overall, 187 students participated in the study. Response rate was 81.7%.
The inclusion criteria of subjects were dental students of the 4th and 5th academic year and willingness to participate, while the exclusion criteria were students of other faculties and dental students of other academic year at LSMU. Exclusions were made as following participants had lack of knowledge regarding research topic. Meanwhile fourth year students were used as a control group, to assess level of academic knowledge related to MIH – in comparison to final year students.
2.2 Questionnaire
An anonymous self-administrated questionnaire was developed by researcher (P.R.) and supervisor (P.S.). Two versions of questionnaire (Lithuanian and English) were prepared to distribute.
The questionnaire composed of 16 questions covering general information (gender, program of study and academic year) of the participants, their knowledge and awareness toward MIH, personal attitude and experience in treatment of teeth with MIH and necessity of additional literature sources.
The knowledge and awareness toward MIH was assessed by asking to select a correct definition of MIH (options were: MIH, dental caries, fluorosis and dental erosion), a correct period of MIH development (options were: prenatal or postnatal until 3rd year of life and any period in life). Question about knowing of clinical MIH features had two options (yes or no). Question about risk factors of MIH had the following options genetic factors, environmental contaminants, medical conditions that affect mother during pregnancy and/or the child, antibiotics/medications taken by the
12 mother during pregnancy and/or the child and fluoride exposure. Later, answers of this questions were regrouped as know the risk factors “yes” (environmental contaminants, medical conditions and
medications that affect mother during pregnancy and/or the child as options), do not know the risk factors “no” genetic factors and fluoride exposure) and “partially know” (selected several correct options).
Considering the personal attitude and experience in treatment of teeth with MIH, questions inquired about knowing the clinical criteria to diagnose MIH (options were “yes, and know how to implement”, “yes, but do not know to implement them” and “ no”), about personal lack of self confidence in
different stage of treatment of MIH (assessing diagnosis, defining risk factors of MIH and choosing the proper treatment), about challenges while treating patient with MIH (dental treatment needs long time to be accomplished, child’s behavior, difficulty in achieving local anesthesia or insufficient training to treat children with MIH), about the most proper restorations for MIH (amalgam, composite resin, glass ionomer cement, compomer or pre-formed crowns) and about the most important characteristics of filling choice for tooth with MIH ( adhesion, aesthetics, patient/parent preference, durability, remineralization potential abilities, sensitivity reducing or personal experience).
Questions regarding to necessity of deepening the knowledge asked if students needed additional information or courses (yes or no), and which type of literature sources are used to improve knowledge (dental journals, lecture notes, brochures or pamphlets, internet or textbooks).
2.3 Statistical analysis
Statistical data analysis was made through the use of SPSS Statistics version 19. To establish the correlation between variables, the chi-squared test was applied. The level of significance was set at p<0.05 with a confidence interval of 95 %.
13 3. RESULTS
In this study females (76.9%) dominated over males (23.1%). Considering the academic year of studies, 55.8 % of 5th year and 44.2 % of 4th year dental students were enrolled in this study. In
addition, dental students of Dentistry program in Lithuanian (78.8%) prevailed in this study (Table 1).
Table 1. Characteristics of participants by gender, academic year of studies and program of Dentistry (N=187). Variables N (%) Gender (Missing N=5) Male 42 (23.1) Female 140 (76.9) Total N (%) 182 (100.0)
Academic year of studies (Missing N=6)
4th 80 (44.2)
5th 101 (55.8)
Total N (%) 181 (100.0)
Program of Dentistry (Missing N=8)
Lithuanian 141 (78.8)
English 38 (21.2)
Total N (%) 179 (100.0)
Chi-square test; comparison between participants by gender, academic year and program of Dentistry (p>0.05).
Table 2 presents participants’ knowledge and awareness toward MIH. Overall, only 45.6% of under graduates knew a correct definition of MIH. More dental students of 4th academic year knew a correct definition than senior ones (48.0% vs. 43.8%) (P=0.58) (Table 2).
A majority (79.2%) of dental students knew a correct period of MIH development. Moreover, significantly more final year dental students showed better knowledge regarding to period of MIH development than 4th academic year students significantly greater awareness regarding development period of MIH (88.8 % vs. 67.1 %) (P<0.001). Overall, 68.7% of participants reported knowing clinical MIH features, while senior students were self-confident than younger ones (86.9% vs. 46.2%)
(P<0.001) (Table 2). Furthermore, significantly more Lithuanian students knew clinical MIH features than international dental students (75.5 % vs. 39.5 %) (P<0.001) (Table 3).
Considering the risk factors of MIH, a majority (91.7%) of dental students answered partially correctly. Consequently, only 9% of final year students and 1.3 % of 4th year students knew all risk factors of MIH correctly (P=0.002) (Table 2).
14 Table 2. Participants’ knowledge and awareness toward MIH by academic year (N=187).
Variables Academic year N (%) Total N (%) p- value 4th year 5th year
Knowing of MIH definition (Missing N=16)
Yes 36 (48.0) 42 (43.8) 78 (45.6) 0.58
No 39 (52.0) 54 (56.2) 93 (54.4)
Total N (%) 75 (100.0) 96 (100.0) 171 (100.0) Knowing of MIH development period (Missing N=9)
Prenatal and postnatal (until 3 years old) 53 (67.1) 88 (88.8) 141 (79.2) <0.001 Anytime in life 26 (32.9) 11 (11.1) 37 (20.8)
Total N (%) 79 (100.0) 99 (100.0) 178 (100.0) Knowing of clinical MIH features (Missing N=8)
Yes 37 (46.2) 86 (86.9) 123 (68.7) <0.001
No 43 (53.8) 13 (13.1) 56 (31.3)
Total N (%) 80 (100.0) 99 (100.0) 179 (100.0) Knowing of risk factors of MIH (Missing N=7)
Yes 1 (1.3) 9 (9.0) 10 (5.5) 0.002
No 3 (3.7) 2 (2.0) 5 (2.8)
Partially knowing 76 (95.0) 89 (89.0) 165 (91.7) Total N (%) 80 (100.0) 100 (100.0) 180 (100.0)
15 Table 3. Participants’ knowledge and awareness toward MIH by Dentistry program (N=187).
Variables Program of study Total N (%) p-
value
Lithuanian International Knowing of clinical MIH features (Missing N=10)
Yes 105 (75.5) 15 (39.5) 120 (67.8) <0.001
No 34 (24.5) 23 (60.5) 57 (32.2)
Total N (%) 139 (100) 38 (100) 177 (100) Personal lack of self confidence in different stage of treatment of MIH (Missing N=11) Assessing diagnosis 25 (17.9) 6 (16.2) 31 (17.6) 0.048 Defining risk factors of MIH 19 (13.7) 2 (5.4) 21 (12)
Choosing the proper treatment 46 (33.1) 7 (18.9) 53 (30.1) Several reasons 49 (35.3) 22 (59.5) 71 (40.3) Total N (%) 139 (100) 37 (100) 176 (100)
Challenges in treating patients with MIH (Missing N=14)
Treatment takes more time 6 (4.4) 6 (16.7) 12 (7) 0.001 Child's improper behavior 10 (7.3) 7 (19.4) 17 (9.8)
Difficulty in local anesthesia 11 (8) 2 (5.5) 13 (7.5) Insufficient training 66 (48.2) 6 (16.7) 72 (41.6) Several reasons 44 (32.1) 15 (41.7) 59 (34.1) Total N (%) 137 (100) 36 (100) 173 (100)
The need of additional information (Missing N=10)
Yes 122 (87.8) 34 (89.4) 156 (88.1) <0.001
No 17 (12.2) 4 (10.5) 21 (11.9)
Total N (%) 139 (100) 38 (100) 177 (100)
Chi-square test; comparison between participants by Dentistry program.
Table 4 presents knowledge, personal attitude and experience in treatment of MIH among the participants. Overall, only 18.5 % of undergraduates reported that they knew the MIH diagnosis criteria. Subsequently, significantly more dental students of 5th academic year would be able to
implement MIH diagnosis criteria than 4th academic year ones (27.3 % vs. 7.6 %) (P<0.001). 40.4 % of dental students stated having personal lack of self confidence in different stages of treatment of MIH such as assessing diagnosis, defining risk factors of MIH or choosing the proper treatment (Table 4). Moreover, significantly more international dental students reported several reasons than Lithuanian dental students (69.5% vs. 35.3%) (P=0.0048) (Table 3).
Furthermore, a minority (6.1%) of participants had experience in treatment of MIH. In addition, significantly more senior year dental students reported having experience in treatment of MIH than the 4th academic year ones (10.0% vs. 1.3%) (P=0.015) (Table 4).
16 The most common challenge in treating patients with MIH (41.1 %) was insufficient training among participants in both 4th and 5th academic year groups (P=0.003) (Table 4). Subsequently, significantly more international dental students chose several reasons, while Lithuanian dental students reported insufficient training (41.7% vs. 48.2%) (P=0.001) (Table 3).
Regarding question of the most proper restoration for MIH, a half (52.2 %) of dental students mentioned several proper restorations. Additionally, composite resin (31.2 %) was the most popular option among 4th year students, while several options (70.4%) were the most common among senior dental students (P<0.001) (Table 4). A majority (78.3 %) of students reported several characteristics of filling for tooth with MIH. In addition, significantly more 5th year dental students chose more than one characteristic of filling for tooth with MIH than 4th year dental students (86.0% vs. 68.7%) (P=0.016). Overall, 88.3 % of all students claimed they needed additional information regarding MIH (Table 4).
17 Table 4. Participants’ knowledge, personal attitude and experience in treatment of MIH by their
academic year (N=187).
Variables Academic year N (%) Total N (%)
4th year 5th year
Knowing of MIH diagnosis criteria (Missing N=9)
Would implement in practice 6 (7.6) 27 (27.3) 33 (18.5) Would not implement in practice 30 (38) 51 (51.5) 81 (45.5) Would not know how to diagnose MIH 43 (54.4) 21 (21.2) 64 (36.0) Total N (%) 79 (100.0) 99 (100.0) 178 (100.0)
Personal lack of self confidence in different stage of treatment of MIH (Missing N=11) Assessing diagnosis 10 (12.5) 21 (21.4) 31 (17.4) Defining risk factors of MIH 14 (17.5) 7 (7) 21 (11.9) Choosing the proper treatment 24 (30.0) 30 (30.6) 54 (30.3) Several reasons 32 (40.0) 40 (41.0) 72 (40.4) Total N (%) 80 (100.0) 98 (100.0) 178 (100.0)
Having of experience in MIH treatment (Missing N=7)
Yes 1 (1.3) 10 (10.0) 11 (6.1)
No 79 (98.7) 90 (90.0) 169 (93.9)
Total N (%) 80 (100.0) 100 (100.0) 180 (100.0) Challenges in treating patient with MIH (Missing N=12)
Treatment takes more time 8 (10.4) 4 (4.1) 12 (6.9) Child's improper behavior 12 (15.6) 5 (5.1) 17 (9.7) Difficulties in local anesthesia 10 (12.9) 4 (4.1) 14 (8) Insufficient training 24 (31.2) 48 (48.9) 72 (41.1) Several reasons 23 (29.9) 37 (37.8) 60 (34.3) Total N (%) 77 (100.0) 98 (100.0) 175 (100.0)
The most proper restorations for MIH (Missing N=9)
Amalgam 1 (1.3) 0 (0.0) 1 (0.5) Composite Resin 25 (31.2) 11 (11.2) 36 (20.2) GIC 17 (21.2) 13 (13.3) 30 (16.8) Compomer 5 (6.3) 1 (1.0) 6 (3.4) Pre-formed Crowns 8 (10.0) 4 (4.1) 12 (6.9) Several 24 (30.0) 69 (70.4) 93 (52.2) Total N (%) 80 (100.0) 98 (100.0) 178 (100.0) The most important characteristics of filling choice for tooth with MIH (Missing N=7)
Adhesion 1 (1.3) 0 (0.0) 1 (0.6)
Aesthetics 4 (5.0) 3 (3.0) 7 (3.9)
Durability 4 (5.0) 6 (6.0) 10 (5.6)
Abilities to remineralise, sensitivity reducing 12 (15.0) 5 (5.0) 17 (9.4) Personal experience 4 (5.0) 0 (0.0) 4 (2.2) Several reasons 55 (68.7) 86 (86.0) 141 (78.3) Total N (%) 80 (100.0) 100 (100.0) 180 (100.0)
The need of additional information (Missing N=8)
Yes 70 (87.5) 88 (88.9) 158 (88.3)
No 10 (12.5) 11 (11.1) 21 (11.7)
Total N (%) 80 (100.0) 99 (100.0) 179 (100.0)
18 Figure 1 presents participants’ commonly used literature sources to study about MIH. Overall, majority (55 %) of 4th year dental students reported that they do not need any additional literature sources to study about MIH, while most (55.5%) of the 5th year dental students explained using several sources of literature to deepen the knowledge toward MIH (P>0.05).
Chi-square test; comparison between participants by academic year (P>0.05) Figure 1. Variety of literature sources about MIH used by dental students at LSMU.
19 4. DISCUSSION
Overall, less than a half of 4th and 5th year dental students of English and Lithuanian program knew a correct definition of MIH, thus knowledge toward MIH dental students was low insufficient in this study. Moreover, a minority of dental students chose aetiological risk factors of MIH correctly. Dental students are introduced and taught about developmental defects of enamel in various specialty subjects during the Dentistry studies at LSMU. Consequently, results revealed that knowledge and awareness toward MIH among dental students should be improved.
This study showed that a high share (88.3%) of participants are interested to study additional literature sources regarding to MIH. Moreover, study performed in Australia and Chile highlighted the
importance of up-to-date guidelines regarding MIH in order to increase awareness and understanding about MIH among general practitioners [29].
Considering the most proper restorative materials for MIH-affected teeth, in this study most senior students preferred using several dental materials when managing MIH-affected teeth. Furthermore, the same line of findings was noticed in the other studies as well [22,23]. In addition, composite filling was common choice among dental students at LSMU. Subsequently, recently carried out another study reported a high success rate for composite in MIH-affected teeth and it was recommended in the EAPD guidelines [22].
On the other hand, dentists' poor knowledge and improper treatment of MIH can have consequences in the MIH-affected children throughout adolescents. If defect of MIH becomes too severe, it may result in tooth loss. Later, esthetical complication can have a huge impact on the self-esteem among the patients suffering this condition [39]. Thus, improving of curriculum of pediatric dentistry and other subjects may improve knowledge and raise awareness among dental students and general practitioners later.
Furthermore, a majority (79.2 %) of the undergraduates was able to identify correct time of insult of MIH such as “prenatal or postnatal until 3rd year of life”. Hence, other study discussed the possibility of an aetiological agent causing the diseases to express itself until the age of 5 or even 6 years of age [7].
20 Overall, knowledge regarding diagnosis criteria of MIH was low and most students experienced
challenges in managing MIH due to insufficient training. Another study comparing general dental practitioners and dental specialists, showed that GDPs had significantly lower confidence in diagnosing MIH – and claimed that one of the barriers to treat MIH patients was insufficient training.
Consequently, their request for further clinical training was significantly high [28]. Furthermore, a similar request for a training course regarding MIH was reported among Saudi dentists [30].
Our study reported low confidence among the dental students in different stages of treatment of MIH such as assessing diagnosis, defining risk factors of MIH or choosing the proper treatment.
On contrary, a study showed that over 90 % of the paediatric dentist were confident in terms of diagnosis in MIH – in comparison to 55.7% of GDPs [2]. Furthermore, while more than half of pediatric dentists claimed receiving information on MIH, only 8.8% of the GDPs reported receiving some information on MIH. The reason behind the high confidence among PDs is the essential training they get on MIH during their training course. However, it implemented the need for continuing
education seminars and guidelines in Hong Kong – so more GPDs can recognize and diagnose MIH and manage treatment of simple cases for secondary care [2].
This is a condition with high prevalence [6-8] and frequently encountered in the dental clinics [15, 22] therefore, the awareness must increase regardless of level of profession among dentists.
Overall, final year students showed better knowledge regarding clinical MIH features (68.7%). Furthermore, significantly more Lithuanian students knew clinical MIH features than international dental students (75.5 % vs. 39.5 %). However, these results may be misleading due to such unequal distribution among dental students of Lithuanian and English program. For a more concrete result, equal number of students from respectively program of Dentistry, should have conducted in the study.
Our results confirm our hypothesis as dental students of 5th academic year had significantly greater awareness, in comparison to undergraduates, in majority of aspects.
21 5. CONCLUSIONS
1. The overall knowledge and awareness toward MIH among dental students at Lithuanian University of Health Sciences was insufficient.
2. More dental students of 4th academic year knew a correct definition than senior ones. Knowledge of MIH aetiological risk factors was low among both 4th and 5th academic year students. More senior dental students reported that they would be able to implement MIH diagnosis criteria than 4th academic year ones. Significantly more senior year dental students reported having experience in treatment of MIH than the 4th academic year ones.
3. Significantly more Lithuanian dental students knew clinical MIH features than international dental students. Meanwhile, international dental students tended to sort out several reasons of challenges in treatment of MIH affected teeth, while Lithuanian dental students reported mainly insufficient training.
6. ACKNOWLEDGEMENT
I would like to thank my supervisor Dr. Sandra Petrauskienė for her invaluable assistance and guidance through this period of time. In addition, the author would also like to acknowledge all the odontology students who were willing to participate in the survey and make this study possible.
7. ENSURING OF CONFIDENTIALITY
Confidentiality of participants was ensured as no personal data needed to be shared. The name, surname and address were not included in this survey.
8. PRACTICAL RECOMMENDATIONS
Proper knowledge of dental students in regards of MIH can influence better prevention and treatment management of MIH in the future. Therefore, I believe it is necessary to raise awareness about MIH among dental students, and dental practitioners, early in their practice. This can be achieved through adding MIH-related cases in the curriculum of paediatric dentistry.
22 9. REFERENCES
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6. Giuca MR, Cappè M, Carli E, Lardani L, Pasini M. Investigation of Clinical Characteristics and Etiological Factors in Children with Molar Incisor Hypomineralization. Int J Dent. 2018 May 9;2018:7584736.
7. Zhao D, Dong B, Yu D, Ren Q, Sun Y. The prevalence of molar incisor hypomineralization: evidence from 70 studies. Int J Paediatr Dent. 2018 Mar;28(2):170-179.
8. Chawla N, Messer LB, Silva M. Clinical studies on molar-incisor-hypomineralisation part 1: distribution and putative associations. Eur Arch Paediatr Dent. 2008 Dec;9(4):180-90 9. Beentjes VE, Weerheijm KL, Groen HJ. Factors involved in the aetiology of molar-incisor
hypomineralisation (MIH). Eur J Paediatr Dent. 2002 Mar;3(1):9-13.
10. Weerheijm KL. Molar incisor hypomineralization (MIH): clinical presentation, aetiology and management. Dent Update. 2004 Jan-Feb;31(1):9-12.
11. Sidaly R, Schmalfuss A, Skaare AB, Sehic A, Stiris T, Espelid I. Five-minute Apgar score ≤ 5 and Molar Incisor Hypomineralisation (MIH) - a case control study. BMC Oral Health. 2016 Jul 22;17(1):25.
12. Kühnisch J, Mach D, Thiering E, Brockow I, Hoffmann U, Neumann C, Heinrich-Weltzien R, Bauer CP, Berdel D, von Berg A, Koletzko S, Garcia-Godoy F, Hickel R, Heinrich J; GINI Plus 10 Study Group. Respiratory diseases are associated with molar-incisor hypomineralizations. Swiss Dent J. 2014;124(3):286-93.
23 13. Mast P, Rodrigueztapia MT, Daeniker L, Krejci I. Understanding MIH: definition,
epidemiology, differential diagnosis and new treatment guidelines. Eur J Paediatr Dent. 2013 Sep;14(3):204-8.
14. Weerheijm KL. Molar incisor hypomineralization (MIH): clinical presentation, aetiology and management. Dent Update. 2004 Jan-Feb;31(1):9-12.
15. Almuallem, Z., Busuttil-Naudi, A. Molar incisor hypomineralisation (MIH) – an overview. Br Dent J 225, 601–609 (2018).
16. Mathu-Muju K, Wright JT. Diagnosis and treatment of molar incisor hypomineralization. Compend Contin Educ Dent. 2006 Nov;27(11):604-10; quiz 611.
17. Garg N, Jain AK, Saha S, Singh J. Essentiality of early diagnosis of molar incisor hypomineralization in children and review of its clinical presentation, etiology and management. Int J Clin Pediatr Dent. 2012 Sep;5(3):190-6.
18. Bekes K, Heinzelmann K, Lettner S, Schaller HG. Efficacy of desensitizing products containing 8% arginine and calcium carbonate for hypersensitivity relief in MIH-affected molars: an 8-week clinical study. Clin Oral Investig. 2017 Sep;21(7):2311-2317.
19. Restrepo M, Jeremias F, Santos-Pinto L, Cordeiro RC, Zuanon AC. Effect of Fluoride Varnish on Enamel Remineralization in Anterior Teeth with Molar Incisor Hypomineralization. J Clin Pediatr Dent. 2016;40(3):207-10.
20. da Cunha Coelho ASE, Mata PCM, Lino CA, Macho VMP, Areias CMFGP, Norton APMAP, Augusto APCM. Dental hypomineralization treatment: A systematic review. J Esthet Restor Dent. 2019 Jan;31(1):26-39.
21. Sharif MO, Iram S, Brunton PA. Effectiveness of arginine-containing toothpastes in treating dentine hypersensitivity: a systematic review. J Dent. 2013 Jun;41(6):483-92.
22. Wall A, Leith R. A questionnaire study on perception and clinical management of molar incisor hypomineralisation (MIH) by Irish dentists. Eur Arch Paediatr Dent. 2020 Mar 17.
23. Uhlen MM, Valen H, Karlsen LS, Skaare AB, Bletsa A, Ansteinsson V, Mulic A. Treatment decisions regarding caries and dental developmental defects in children - a questionnaire-based study among Norwegian dentists. BMC Oral Health. 2019 May 10;19(1):80.
24. Hussein AS, Ghanim AM, Abu-Hassan MI, Manton DJ. Knowledge, management and perceived barriers to treatment of molar-incisor hypomineralisation in general dental practitioners and dental nurses in Malaysia. Eur Arch Paediatr Dent. 2014 Oct;15(5):301-7.
24 25. Alanzi A, Faridoun A, Kavvadia K, Ghanim A. Dentists' perception, knowledge, and clinical
management of molar-incisor-hypomineralisation in Kuwait: a cross-sectional study. BMC Oral Health. 2018 Mar 7;18(1):34.
26. Mastroberardino S, Campus G, Strohmenger L, Villa A, Cagetti MG. An Innovative Approach to Treat Incisors Hypomineralization (MIH): A Combined Use of Casein Phosphopeptide-Amorphous Calcium Phosphate and Hydrogen Peroxide-A Case Report. Case Rep Dent. 2012;2012:379593.
27. Weerheijm KL, Mejàre I. Molar incisor hypomineralization: a questionnaire inventory of its occurrence in member countries of the European Academy of Paediatric Dentistry (EAPD). Int J Paediatr Dent. 2003 Nov;13(6):411-6.
28. Crombie FA, Manton DJ, Weerheijm KL, Kilpatrick NM. Molar incisor hypomineralization: a survey of members of the Australian and New Zealand Society of Paediatric Dentistry. Aust Dent J. 2008 Jun;53(2):160-6.
29. Gambetta-Tessini K, Mariño R, Ghanim A, Calache H, Manton DJ. Knowledge, experience and perceptions regarding Molar-Incisor Hypomineralisation (MIH) amongst Australian and
Chilean public oral health care practitioners. BMC Oral Health. 2016 Aug;16(1):75. 30. Silva MJ, Alhowaish L, Ghanim A, Manton DJ. Knowledge and attitudes regarding molar
incisor hypomineralisation amongst Saudi Arabian dental practitioners and dental students. Eur Arch Paediatr Dent. 2016 Aug;17(4):215-22.
31. Jasulaityte L, Veerkamp JS, Weerheijm KL. Molar incisor hypomineralization: review and prevalence data from the study of primary school children in Kaunas/Lithuania. Eur Arch Paediatr Dent. 2007 Jun;8(2):87-94.
32. Yannam SD, Amarlal D, Rekha CV. Prevalence of molar incisor hypomineralization in school children aged 8-12 years in Chennai. J Indian Soc Pedod Prev Dent. 2016 Apr-Jun;34(2):134-8. 33. Subramaniam P, Gupta T, Sharma A. Prevalence of molar incisor hypomineralization in
7-9-year-old children of Bengaluru City, India. Contemp Clin Dent. 2016 Jan-Mar;7(1):11-5. 34. Kalkani, M., Balmer, R.C., Homer, R.M. et al. Molar incisor hypomineralisation: experience
and perceived challenges among dentists specialising in paediatric dentistry and a group of general dental practitioners in the UK. Eur Arch Paediatr Dent 17, 81–88 (2016).
35. Steffen R, Krämer N, Bekes K. The Würzburg MIH concept: the MIH treatment need index (MIH TNI): A new index to assess and plan treatment in patients with molar incisior
25 36. Fütterer, J, Ebel, M, Bekes, K, Klode, C, Hirsch, C. Influence of customized therapy for molar
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37. Kopperud, S.E., Pedersen, C.G. & Espelid, I. Treatment decisions on Molar-Incisor
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26 10. ANNEXES
10.1 Questionnaire in English
KNOWLEDGE AND AWARENESS TOWARD MIH (MOLAR-INCISOR HYPOMINERALIZATION) AMONG DENTAL STUDENTS AT LSMU ABOUT YOU:
Gender: Male/Female
I am a student of the following program of Odontology: Lithuanian/ English Academic year of studies: 4 / 5
Please choose the most suitable answer of the following questions (please circle):
What is the correct definition of MIH? □ It is a common disorder, characterized by hypomineralization of tooth enamel caused by ingestion of excessive fluoride during enamel formation.
□ It is a deficit in the mineralisation process of permanent first molars and, less frequently, incisors, resulting from a lack of calcium and phosphate fixing on the matrix formed by the ameloblasts.
□ It is a heritable disorder, which manifests as hypoplasia, hypocalcification or
hypomaturation of enamel.
□ It is a localized chemical dissolution of the tooth surface caused by metabolic events taking place in the biofilm (dental plaque) covering the affected area.
What time/period do you think the insult occurs?
□ Prenatal or postnatal until 3rd year of life □ Period of life does not play a role.
Do you know the clinical features of MIH? □ Yes.
□ No.
Do you know if there are clinical criteria to diagnose MIH?
□ Yes, and know how to implement them. □ Yes, but do not know how to implement them.
□ No.
Which factors are involved in the aetiology of MIH?
□ Genetic factors.
□ Environmental contaminants.
□ Medical conditions that affect mother during pregnancy and/or the child.
□ Antibiotics/Medications taken by the mother during pregnancy and/or the child.
□ Fluoride exposure.
What type of material do you often use in treating MIH tooth?
□ Amalgam. □ Composite Resin. □ Glass Ionomer Cement. □ Compomer.
27 Which factors/factor do/does influence your
choice of restorative material? □ Adhesion.
□ Aesthetics.
□ Patient/parent preference. □ Durability.
□ Remineralization potential abilities. □ Sensitivity reducing.
□ Personal experience.
Which of following would represent a barrier performing MIH management? □ Dental treatment that needs long time to be accomplished.
□ Child's behavior (uncooperative child). □ Difficulty in achieving local anesthesia. □ Insufficient training to treat children with MIH.
Have you ever treated a patient with MIH during your dental school training? □ Yes.
□ No.
Would you suggest including more MIH-associated cases in the curriculum of the ”Paediatric dentistry”?
□ Yes. □ No.
What are the areas do you think you need to know/be taught about the most?
□ Diagnosis. □ Aetiology. □ Treatment.
Are you receiving any information on MIH? □ Yes.
□ No.
If YES, through which source? □ Dental journals.
□ Lecture notes.
□ Brochures or pamphlets. □ Internet.
28 10.2 Questionnaire in Lithuanian
LSMU ODONTOLOGIJOS STUDENTŲ ŽINIOS IR SUVOKIMAS APIE KANDŽIŲ-MOLIARŲ HIPOMINERALIZACIJĄ.
APIE JUS:
Lytis: Vyras /Moteris
Aš studijuoju Odontologiją LSMU: Lietuvių kalba / Anglų kalba Studijų kursas : 4 / 5
Pažymėkite jums tinkamiausią atsakymą: Kuris iš šių teiginių yra moliarų-kandžių hipomineralizacijos apibrėžimas?
□ Tai sisteminė liga, kuri atsiranda dėl ilgalaikio lėtinio per didelio fluoro kiekio poveikio ameloblastams danties formavimosi ir mineralizacijos metu.
□ Tai liga, kuri atsiranda dėl kalcio ir fosfatų jonų trūkumo kandžių ir pirmųjų nuolatinių krūminių dantų užuomazgų vystymosi laikotarpiu.
□ Tai susirgimas, kuris išsivysto dėl anomalijos tam tikruose genuose ir pasireiškia sistemine emalio hipoplazija, bei nėra lydimas jokios kitos bendrinės patologijos.
□ Tai daugiapriežastinė lėtinė kietųjų danties audinių liga, sukelianti emalio ir dentino demineralizaciją.
Kaip manote, kuriuo gyvenimo periodu įvyksta šis danties audinių pažeidimas? □ Prenataliniu ar postnataliniu periodu iki 3 metų.
□ Bet kuriuo gyvenimo periodu. Ar žinote kandžių-moliarų
hipomineralizacijos klinikinius požymius? □ Taip.
□ Ne.
Ar žinote kokiais klinikiniais kriterijais remiantis diagnozuojama kandžių-moliarų hipomineralizacija?
□ Taip, žinau ir moku pritaikyti praktikoje. □ Taip, žinau, bet nemoku pritaikyti praktikoje. □ Nežinau.
Kuris/Kurie iš šių veiksnių gali sukelti kandžių-emalio hipomineralizaciją? □ Genetiniai faktoriai.
□ Aplinkos tarša.
□ Mamos ligos bei būklės nėštumo periodu. □ Antibiotikų ar kitų medikamentų vartojimas nėštumo periodu ar ankstyvosios vaikystės metu.
□ Per didelis fluoridų kiekis.
Kuri/Kurios restauracinė/ės medžiaga/os tinkamiausios plombuojant dantis, pažeistus moliarų-kandžių hipomineralizaciją?
□ Amalgama.
□ Kompozicinė restauracija. □ Stiklo jonomerinis cementas. □ Kompomeras.
29 Kuris/Kurie iš šių veiksnių labiausiai lemia
restauracinės medžiagos pasirinkimą? □ Resauracijos adhezijos ypatumai. □ Restauracijos estetika.
□ Paciento ar jo tėvų įgeidžiai.
□ Restauracijos ilgaamžiškumas (laikomumas). □ Remineralizacinės plombos savybės.
□ Dantų jautrumo mažinimas. □ Asmeninė patirtis.
Su kokiais sunkumais susiduriat gydydami kandžių-moliarų hipomineralizacijos pažeistus dantis?
□ Dantų gydymas ilgiaus trunka nei įprastai. □ Neigiama vaiko reakcija į dantų gydymą. □ Silpniau veikiantis vietinis nuskausminimas. □ Patirties stoka gydant vaikus su kandžių moliarų hipomineralizaciją.
Ar savo praktikoje jau pasitaikė pacientų su kandžių-moliarų hipomineralizacija?
□ Taip. □ Ne.
Ar norėtųsi, jog daugiau dėmesio būtų skiriama kandžių-moliarhipomineralizacijai ”Vaikų odontologijos” studijų programoje? □ Taip.
□ Ne.
Kurioje iš šių sričių labiausiai trūksta žinių? □ Nustatant diagnozę.
□ Įvardijant etiologija.
□ Pasirenkant gydymo taktiką.
Ar randate informacijos apie kandžių-moliarų hipomineralizaciją?
□ Taip. □ Ne.
Jei atsakėte TAIP, kokiais informacijos šaltiniais naudojatės?
□ Žurnalais apie odontologiją. □ Paskaitų medžiaga.
□ Lankstinukais. □ Internetu. □ Vadovėliais.
30 10.3 Bioethics approval
