DOI: 10.1111/ipd.
12233
REVIEW
A systematic review on the association between molar incisor
hypomineralization and dental caries
GABRIELA CALDEIRA ANDRADE AMERICANO1, PERNILLE ENDRUP JACOBSEN2,
VERA MENDES SOVIERO3 & DORTE HAUBEK2
1
Innovation Department, Rio de Janeiro State University, Rio de Janeiro, Brazil, 2Department of Dentistry, Health, Aarhus
University, Aarhus, Denmark, and 3Department of Preventive and Community Dentistry, Faculty of Dentistry, Rio de
Janeiro State University, Rio de Janeiro, Brazil
International Journal of Paediatric Dentistry 2017; 27: 11–21
Summary
Background. Molar incisor hypomineralization
(MIH) is a defect of enamel. The lower strength of
the enamel can lead to fractures that predispose
for plaque accumulation and caries.
Aim. This systematic review aimed to assess the
association between MIH and caries.
Design. Studies involving children of all ages,
which reported results on MIH and caries in the
permanent dentition, were considered eligible. A
search was performed in PubMed and was limited
to the period from January 2003 to November
2015, and to studies written in English. Reviews,
meta-analyses, and case reports were excluded.
Introduction
Molar incisor hypomineralization (MIH) is a
dysfunctional mineralization process of the
enamel, affecting one to four-first permanent
molars (FPMs). In addition, permanent inci-
sors (PIs) can be affected as well1,2. Clinically,
the hypomineralization is characterized by
opacities of varying size and can be discolored
from white to yellow/brownish. The opacities
have normal enamel thickness and a defined
demarcation between the affected and the
sound enamel. Opacities occur more often on
the occlusal and buccal surfaces2. MIH is clas-
sified as 1: mild, when there are demarcated
opacities without posteruptive enamel
Correspondence to:
Gabriela Caldeira Andrade Americano, Faculdade de
Odontologia – UERJ, Boulevard Vinte e Oito de Setembro,
157, sala 509 – Vila Isabel, 20551-030 - Rio de Janeiro,
RJ, Brasil. E-mail: americanogabriela@gmail.com
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
The studies were evaluated by use of the
Newcastle-Ottawa Quality Assessment Scale (NOS).
Results. Seventeen publications were compiled in
the review. Most publications reported that chil-
dren with MIH have higher caries experience. One
study did not observe a difference in DMF values
among children affected or not by MIH. Three
studies reported that children with MIH were 2.1
to 4.6 times more likely to have caries in the
permanent dentition than children without MIH.
Conclusions. A significant association between
MIH and caries was found. The results should,
however, be interpreted cautiously due to the lack
of high-quality studies. The present systematic
review confirms the need for further well-
designed studies.
breakdown and 2: severe, when posteruptive
enamel breakdown occurs2.
The hypomineralized enamel is less hard
than the normal enamel as it contains a
higher content of protein3. The normal
enamel shows a well-organized and distinct
prism and crystal structure4. In contrast, the
hypomineralized enamel has less distinct
prism edges and crystals, and the interpris-
matic space is more marked. Therefore, the
hypomineralized enamel is more porous than
the normal enamel4. The lower strength of
the hypomineralized enamel can result in
posteruptive breakdown soon after tooth
eruption or later under the effect of the mas-
ticatory forces1,2. Consequently, the
posteruptive enamel breakdown facilitates
plaque accumulation and development of
dental caries1,2,5. The plaque accumulation is
also favored when children with MIH do not
brush their teeth due to hypersensitivity of
the affected teeth5. Moreover, it is possible
11
12 G. C. A. Americano et al.
that the mild enamel defects as well as the
severe ones become even more severely
affected when cariogenic bacteria invade and
destroy the hypomineralized enamel and
dentine6. The severity of MIH has a signifi-
cant impact on the treatment need in the
FPMs6. Researchers have reported that chil-
dren with MIH have undergone dental treat-
ment of their FPMs much more often than
children without MIH7. The hypomineralized
teeth can be sensitive to cold foods, and/or
cold and warm air, even when there is no
additional posteruptive enamel breakdown1.
Due to the possibility of oral bacteria pene-
trating through the hypomineralized enamel
into the dentinal tubules, a subclinical
inflammatory response of the pulp cells can
contribute to hypersensitivity of the affected
teeth8. The teeth with hypersensitivity often
create problems for patients and dentists. For
children, the sensitivity can hinder the
brushing1. For dentists, the sensitivity
becomes problematic when it hinders the
possibility of obtaining sufficient pain control
(e.g., analgesia) 2. Besides the porosity of the
hypomineralized enamel, which may compli-
cate the bonding of the dental restorative
materials and predispose the breakdown of
the enamel next to restorations, an inappro-
priate pain control is also a probable reason
for failures of fillings placed in the hypomin-
eralized teeth, due to the difficulty in carry-
ing out the necessary treatment procedures.
Thus, restorations in hypomineralized teeth
are replaced more often than in normal
teeth6. One study has reported that fillings
and sealants in children with MIH are more
than three times as likely to need retreat-
ment as interventions performed in children
without MIH7.
It is recognized that MIH is of increasing
concern to clinicians worldwide. Therefore, it
is relevant to increase the knowledge on the
clinical impact of MIH defects on oral health.
Several studies9–11 have showed that children
with MIH are more likely to have dental car-
ies than children without MIH, although it is
controversial12.
This study aimed to perform a systematic
review to assess the association between MIH
and dental caries in the permanent dentition.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Material and methods
Inclusion and exclusion criteria
All original studies involving children of all
ages which reported results on MIH and dental
caries in permanent dentition were considered
eligible for the present review. The search was
limited to human studies and included only
publications published in English. The defini-
tion and the name ‘MIH’ was proposed in
20011 based on previous observations about
enamel defects affecting first permanent
molars6. The criterion for the diagnosis of MIH
was, however, not published before 200313;
thus, the search covered the period from Jan-
uary 2003 to November 2015. Reviews, meta-
analyses, and case reports were excluded.
Search strategy
A search in MEDLINE using PubMed
(www.pubmed.gov) was performed using the
following terms: ‘dental enamel hypoplasia’
(MeSH), ‘enamel defects’, ‘mih’, ‘molar incisor
hypomineralization’, alone or with ‘AND’—
combined with terms as ‘dental caries’
(MeSH), ‘caries’, and ‘prevalence’. The search
was conducted by the first author in collabora-
tion with an experienced research librarian.
The publications were inserted into the End-
Note X5â software and a list of references was
generated for further analysis and selection.
Selection of publications and data extraction
Selection of publications was conducted in
three phases, based on (i) the title alone, (ii)
the abstract, and (iii) the full-text publication
(Fig. 1). To further complement the original
search, a hand search of the reference lists of
the publications entering the review was per-
formed. A total of seventeen publications
were included in our study (Fig. 1). The rea-
sons for exclusion, in the first and second
phases, are mentioned in Fig. 1. Table 1
shows the reasons for exclusion in the third
phase. The first phase was conducted by two
independent reviewers (GCAA and VMS).
The other two phases were conducted by
three independent reviewers (GCAA, PEJ,

Fig. 1. Search procedure for the present systematic review.
and DH). Disagreement was resolved by dis-
cussion to reach consensus.
Quality assessment
The quality of the studies was evaluated by
the use of the Newcastle-Ottawa Quality
Table 1. The reasons for exclusion in the third phase.
Papers located by hand search
Brog

ardh-Roth S, Matsson L, Klingberg G. Molar incisor
hypomineralization and oral hygiene in 10- to 12-yr-old
Swedish children born preterm. Eur J Oral Sci 2011; 119: 33–39
Papers reviewed based on article
Alaluusua S. Defining developmental enamel defect-associated
childhood caries:
where are we now? J Dent Res 2012; 91: 525–527
Carmody J. Enamel opacities. J Ir Dent Assoc 2012; 58: 130,143
Cole E, Ray-Chaudhuri A. Molar incisor hypomineralization (MIH).
Dent Update 2012; 39: 222.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
MIH and dental caries 13
Assessment Scale (NOS),14 which comprises
assessment tools for cohort and case–control
studies. As an assessment tool was not avail-
able to apply on cross-sectional studies, these
studies were assessed using the NOS for
cohort studies. NOS includes eight items. A
study can be awarded a star for each item.
Reason
The authors report the caries experience and the presence of
MIH in preterm and full-term children. They do not, however,
compare the caries experience between children with MIH and
without MIH.
Reason
They are not original studies.
14 G. C. A. Americano et al.

Only one item (‘Comparability’) can get two
stars, resulting in a total of nine stars per
study. One item (item ‘4’ under ‘Selection’)
was, however, irrelevant for the topic
addressed in our study, resulting in a maxi-
mum of eight stars per publication in this
study. A study is rated as high quality if the
total score was seven or higher. The reviewers
predefined methodologically suitable cut-off
points for the assessment. The cut-off points
were as follows: The primary confounder (let-
ter ‘a’ under ‘Comparability’) was chosen to
be dental caries in the primary dentition,
because it is a relevant and well-known risk
predictor for caries development in the per-
manent dentition15,16; other possible con-
founders (letter ‘b’ under ‘Comparability’)
were chosen to be other risk predictors for
dental caries in the permanent dentition,
such as different socioeconomic factors, teeth
and host susceptibility, sucrose intake fre-
quency, salivary buffer capacity and flow, and
high counts of Streptococcus mutans; regarding
the assessment of the outcome (item ‘1’
under ‘Outcome’), the independent blind
assessment was considered when dental caries
and MIH were evaluated by different examin-
ers. It is impossible for an examiner to evalu-
ate the outcome (dental caries) without
seeing the exposure (MIH); a suitable follow-
up period (item ‘2’ under ‘Outcome’) was set
to two years or more as the first permanent
molars have already erupted. It is necessary
to have some time for a possible caries lesion
to develop; thus, the children included in the
studies needed to be older than eight years in
order to get a star. Finally, the participation
rate was required to be higher than 50%
(item ‘3’ under ‘Outcome’).
Results
Quality assessment
Using the NOS14 for cohort studies, none of
the studies was classified as high quality
(Table 2). Most studies got three
stars9,11,12,17–23.

Table 2. Quality assessment using the Newcastle-Ottawa Scale.

Criteria

Outcome/
Selection Comparability Exposure

Total score
Reference Year Country Study design 1 2 3 4 5 6 7 8 Maximum

Bhaskar & Hegde23 2014 India Cross-sectional * * * 3

Garcia-Margarit et al.24 2014 Spain Cross-sectional * * * * * 5
Pitiphat et al.11 2014 Thailand Cross-sectional * * * 3
Petrou et al.25 2014 Germany Cross-sectional * * 2
Heitmu € ller et al.12 2013 Germany Cross-sectional * * * 3
Groselj & Jan22 2013 Slovenia Cross-sectional * * * 3
Jeremias et al.10 2013 Brazil Cross-sectional * * * * 4
Ahmadi et al.21 2012 Iran Cross-sectional * * * 3
Ghanim et al.27 2012 Iraqi Cross-sectional * * * * 4
Jalevik & Klingberg28 2012 Sweden Cohort * * * * * 5
Mahoney & Morrison20 2011 New Zealand Cross-sectional * * * 3
Costa-Silva et al.9 2010 Brazil Cross-sectional * * * 3
Mahoney & Morrison19 2009 New Zealand Cross-sectional * * * 3
Cho et al.18 2008 China Cross-sectional * * * 3
Muratbegovic et al.26 2007 Bosnia and Cross-sectional * * * * * 5
Herzegovina
Preusser et al.17 2007 Germany Cross-sectional * * * 3
Kotsanos et al.7 2005 Greece Cohort * * * * 4

The significance of “*” is that the paper scored in the respective item of the Newcastle-Ottawa Scale.
Criteria (1) Representativeness of the exposed cohort. (2) Selection of the non-exposed cohort. (3) Ascertainment of exposure. (4) Compa-
rability on the basis of confounding control in the design or analysis. (5) Additional confounding control. (6) Assessment of outcome. (7)
Duration of follow-up period. 8) Adequacy of follow-up.

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Basic results
All the extracted results are displayed in Table 3.
The studies were published in the period from
20057 to 201411,23–25. They were conducted in
different countries: Bosnia and Herzegovina,26
Brazil,9,10 China,18 Germany,12,17,25 Greece,7
India,23 Iran,21 Iraq,27 New Zealand,19,20 Slove-
nia,22 Spain,24 Sweden,28 Thailand.11 The
majority was cross-sectional studies, and only
two were cohort studies7,28.
Population characteristics
Only four studies reported that the sample
group was representative for the population
studied10,24,26,27. All studies used controls
recruited from the same area as the exposed
children. The number of participants assessed
through oral examinations in the seventeen
studies ranged from 6728 to 263518. The age
of the participants in the studies varied from
six9–11,17,22 to eighteen28 years.
Measures of dental caries and MIH
The majority of the studies7,9–12,17–26,28 evalu-
ated dental caries using the criterion estab-
lished by the World Health Organization
(WHO) 29. One study12 used the universal
visual scoring system to evaluate non-
cavitated caries lesions, and another one27
used the International Caries Detection and
Assessment System II (ICDAS-II). The param-
eters used for the assessment of dental caries
were the following: decayed, missing, or filled
teeth (DMFT) considering all permanent
teeth10–12,17–20,22,24,25,28 or FPMs12,22,26; mean
non-cavitated caries lesion considering all
permanent teeth12; decayed, missing, or filled
surfaces (DMFS) considering all permanent
teeth24 or FPMs7; prevalence of FPMs without
dental caries27; and prevalence of children
with dental caries considering all permanent
teeth9–11 or FPMs23. All studies, except for
one,18 calculated P-value. In three of seven-
teen studies, odds ratios were reported9–11. In
one study, odds ratio values were adjusted for
potential confounders9.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
MIH and dental caries 15
The EAPD criterion13 was clearly described
by most of the studies for diagnosing
MIH7,9–12,20,22–27. Five studies17–19,21,28 diag-
nosed MIH based on the same clinical param-
eters using the terminology MIH, although
the specific EAPD criterion13 was not men-
tioned in the methodology section. MIH was
evaluated in all permanent teeth,12,28 in
FPMs and PIs,9–11,17,18,21–27 or in FPMs
only7,19,20. The results on MIH were reported
as prevalence rates. As shown in Table 3,
most of the studies reported a significant
association between MIH and dental caries.
Discussion
A substantial amount of studies performed in
countries of America, Asia, Europe, and Ocea-
nia has reported MIH and caries results,
which show that many researchers through-
out the world are interested in the association
between MIH and dental caries. Thus, MIH is
a global clinical problem due to severe impact
on oral health.
As an assessment tool was not available to
apply on cross-sectional studies, the authors
believe that the choice of the NOS14 for
cohort studies was efficient for the following
reasons: The NOS has been validated,14 the
authors predefined methodologically suitable
cut-off points for the assessment, excluding
the possibilities of subjectivity, the scores
were awarded when there was enough infor-
mation, and the authors had familiarity with
the NOS14. Among the studies included in
the present review, all7,9–12,17–24,26–28 used
EAPD criterion13 for diagnosing MIH and all,
except for one,27 assessed dental caries
according to WHO29. Then, the comparison of
the results regarding both MIH and dental
caries was possible. In all studies,7,9–12,17–
24,26–28
original data on MIH and dental caries
were collected during clinical examinations,
which limited the risk of observational bias.
Usually, assessments are considered blinded,
when an examiner evaluates outcomes
without knowing the presence or not of the
exposure. In the present type of studies, it is
impossible for an examiner to assess dental
caries without seeing MIH. Thus, we
 16

Table 3. Study characteristics and results.

Number Teeth Criterion Teeth

of children examined for for the examined for
Country and age the recording recording the recording Prevalence
Reference and year Study design groups of MIH of caries of caries of MIH Occurrence of caries P-value

Bhaskar & India 2014 Cross-sectional 1173 FPM + PI DMFT FPM 9.4% MIH: 54% of the P < 0.001
Hegde23 8–13 children had caries
G. C. A. Americano et al.

Not MIH: 15.8% of

the children had caries
Garcia-Margarit Spain 2014 Cross-sectional 840 FPM + PI DMFT All 21.8% MIH: P < 0.05
et al.24 8–9 DMFT = 0.5 (0.3–0.6)
DMFS = 1.2 (0.9–1.4)
Not MIH:
DMFT = 0.2 (0.1–0.2)
DMFS = 0.7 (0.6–0.9)
Pitiphat et al.11 Thailand 2014 Cross-sectional 484 FPM + PI DMFT All 20% MIH: 35% of the P < 0.001
6–7 children had caries
DMFT = 0.6  1
Not MIH: 10% of
the children had caries
DMFT = 0.1  0.5
OR = 4.6 (2.7–7.9)*
Petrou et al.25 Germany 2014 Cross-sectional 2395 FPM + PI DMFT All 10.1% MIH: P < 0.001
7–10 DMFT = 0.2  0.6
Not MIH:
DMFT = 0.1  0.5
Heitmu€ ller Germany 2013 Cross-sectional 693 All DMFT All FPM 36.5% MIH: Not
et al.12 10 Non-cav caries lesion: DMFT = 0.5  0.9 significant
Through Universal Non-cav = 1.4  1.7
Visual Scoring System DMFS = 0.6  1.2
Not MIH:
DMFT = 0.3  0.8
Non-cav = 1.2  1.5
Hyp FPM:
DMFT = 0.5  0.9
DMFS = 0.7  1.3

(Continued)

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Table 3. (Contd.)

Number Teeth Criterion Teeth

of children examined for for the examined for
Country and age the recording recording the recording Prevalence
Reference and year Study design groups of MIH of caries of caries of MIH Occurrence of caries P-value
22
Groselj & Jan Slovenia 2013 Cross-sectional 478 FPM + PI DMFT All FPM 21.4% MIH: DMFT:
6–11.5 DMFT = 0.9  1.2 P = 0.023
Not MIH: FPM DMFT:
DMFT = 0.6  1.1 P = 0.016
Hyp FPM: FPM DMFS:
DMFT = 0.9  1.2 P = 0.012
DMFS = 1.3  2
Non-hyp FPM:
DMFT = 0.6  1
DMFS = 0.8  1.6
Jeremias et al.10 Brazil 2013 Cross-sectional 1157 FPM + PI DMFT All 12.3% MIH: 45.8% of the P = 0.0001
6–12 children had caries
DMFT = 0.8  1.1
Not MIH: 20.7% of
the children had caries
DMFT = 0.4  1
OR = 3.2 (2.2–4.6)*
Ahmadi et al.21 Iran 2012 Cross-sectional 433 FPM + PI DMFT Not given 12.7% MIH: P < 0.001
7–9 DMFT = 1.4  0.9
Not MIH:
DMFT = 0.7  1.3
Ghanim et al.27 Iraqi 2012 Cross-sectional 823 FPM + PI ICDAS-II FPM Not given Hyp FPM: 20% P < 0.001

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
7–9 were sound
Non-hyp FPM:
66.3% were sound
Jalevik & Sweden 2012 Cohort 67 All DMFT All Not given MIH: P < 0.01
Klingberg28 18 DMFT = 3.8  2.9
Not MIH:
DMFT = 1.7  2.6

Mahoney & New Zealand Cross-sectional 234 FPM DMFT All 18.8% MIH: P < 0.05
Morrison20 2011 7–10 DMFT = 0.6  1.1
Not MIH:
DMFT = 0.2  0.6

(Continued)
MIH and dental caries
17
 18
Table 3. (Contd.)

Number Teeth Criterion Teeth

of children examined for for the examined for
Country and age the recording recording the recording Prevalence
Reference and year Study design groups of MIH of caries of caries of MIH Occurrence of caries P-value

Costa-Silva Brazil 2010 Cross-sectional 918 FPM + PI DMFT All 19.8% Urban Urban
et al.9 6–12 MIH: 11.7% of P < 0.001
the children had caries Rural
Not MIH: 38.5% of P = 0.02
the children had caries
OR = 2.3 (1.5–3.5)
G. C. A. Americano et al.

OR† = 2 (1.2–3.1)
Rural
MIH: 19% of the
children had caries
Not MIH: 48.2% of
the children had caries
OR = 2.1 (1.1–3.8)
OR† = 2.8 (1.4–5.6)
Mahoney & New Zealand Cross-sectional 522 FPM DMFT All 14.9% MIH: P < 0.05
Morrison19 2009 7–10 DMFT = 0.5  1.1
Not MIH:
DMFT = 0.1  0.5
Cho et al.18 China 2008 Cross-sectional 2635 FPM + PI DMFT All 2.8% MIH: Not given
11–14 DMFT = 1.5
Not MIH:
DMFT = 0.8
Muratbegovic Bosnia and Cross-sectional 138 FPM + PI DMFT FPM 12.3% Hyp FPM: P = 0.001
et al.26 Herzegovina 12 DMFT = 3.5  0.9
2007 Non-hyp FPM:
DMFT = 2.4  1.3
Preusser et al.17 Germany 2007 Cross-sectional 1002 FPM + PI DMFT All 5.9% MIH: P = 0.009
6–12 DMFT = 0.7
Not MIH:
DMFT = 0.5
Kotsanos et al.7 Greece 2005 Cohort 72 FPM DMFT FPM Not given MIH: P = 0.001
MIH: 7.7 DMFS = 2.8  3.2
SD = 1.3 Not MIH:
Not MIH: 7.5 DMFS = 0.8  1.3
SD = 1.2

*CI 95%.
†Value adjusted according to age; CI 95%.
FPM, first permanent molar; PI, permanent incisor; OR, odds ratio; Non-cav, non-cavitated caries lesion; Hyp FPM, hypomineralized first permanent molar; Non-hyp FPM, non-hypomineralized
first permanent molar; SD, standard deviation.

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

considered blind assessment as carried out
when MIH and dental caries were evaluated
by two different examiners. Only three stud-
ies followed, however, that procedure7,11,28.
In unblinded assessments, observational bias
can occur and hamper the validity of the
studies. Furthermore, potential confounders
were considered only in three studies7,9,26.
This can also generate biased results. The
diagnosis of MIH must be established when
all the FPMs are erupted. It has been recom-
mended to assess MIH at eight years of age13.
Nonetheless, eleven7,9–11,17,19–22,25,27 of sev-
enteen studies evaluated 6- to 7-year-old chil-
dren; thus, DMF values might have been
underestimated because a certain period of
time is necessary until a cavitated caries
lesion occurs.
Most publications included in the present
review reported that children with MIH have
higher caries experience, mainly represented
by higher DMF index7,10,11,17–22,24–26,28.
Three studies reported DMF values of 2.8,7
3.5,26 and 3.8,28 which were much higher
than the other studies included in the present
review. Records of dental caries in children
from a dental clinic7 or in a selected group of
18-year-old children with severe MIH28 could
have been the reasons for the high values of
DMF. In samples from dental clinics, the
number of patients with operative treatment
needs may be higher than in a population-
based sample and therefore hamper the result
due to the selection bias. Concerning the lat-
ter reason, it is clear that at higher ages, the
time period of exposure of the permanent
teeth to caries risk factors and to complica-
tions from MIH is longer, increasing the risk
of development of dental caries. Besides that,
MIH is classified as severe when there is
posteruptive enamel breakdown2. Therefore,
caries evaluation of children with severe MIH
can also overestimate the DMF values,
because these children certainly need treat-
ment. One study found the DMF value of
0.2, which was much lower than in the other
studies25. This low value may be due to the
fact that the authors did not include caries-
free posteruptive enamel breakdown in the
individual DMF values25. In many circum-
stances, it may be hard to differentiate
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
MIH and dental caries 19
between the posteruptive enamel breakdown
related to hypomineralization alone and those
caused by the caries process, particularly
when both are present on the same tooth
surface. One study did not, however, observe
the difference in DMF values among children
affected or not by MIH12. Probably, it hap-
pened because the atypical restorations were
not scored as caries-associated restorations
and, hence, they were not included in the
DMF index12. Restorations are considered
atypical when their size and shape are differ-
ent from the traditional manifestation of car-
ies, and they often have opacity at the
border13.
In terms of prevalence, four studies
reported that dental caries was significantly
more prevalent in children with MIH than in
children without MIH9–11,23. One study may
have found the prevalence of dental caries in
children with MIH slightly higher than the
other studies, because they recorded dental
caries in children from a dental clinic23. Chil-
dren from dental clinics may have more oper-
ative treatment needs than children in a
population-based sample. This can increase
the selection bias. In addition, three studies
reported that children with MIH were 2.1 to
4.6 times more likely to have dental caries in
the permanent dentition than children with-
out MIH9–11.
The aim of the DMF scoring system is to
demonstrate the caries status and the treat-
ment performed due to dental caries in the
permanent dentition29. In the presence of
MIH, caries experience recorded by the ‘miss-
ing’ and ‘filled’ components of DMF may rep-
resent tooth extractions and restorations
made as a result of dental caries solely,
posteruptive breakdown of the hypomineral-
ized enamel only, or a combination of both.
The need of treatment posed by the ‘decay’
component of DMF may represent caries
lesions that started without or with some
influence of the hypomineralization or
posteruptive breakdown of the hypomineral-
ized enamel exclusively. Thus, we cannot
exclude the possibility that some part of the
recorded DMF value may not reflect ‘tradi-
tional’ dental caries. Hence, the DMF value
may be overestimated in children with MIH
20 G. C. A. Americano et al.
as cavities, tooth extractions, and fillings
might have resulted from posteruptive break-
down of the hypomineralized enamel without
dental caries occurring. On the other hand,
although teeth with posteruptive enamel
breakdown have been restored or missed
without caries lesions occurring, these teeth
were more likely to be affected by dental car-
ies than normal teeth. When posteruptive
enamel breakdown occurs, the cavity formed
may facilitate the plaque accumulation and,
at the same time, ‘protect’ the biofilm1,2,5.
Unless the patient is able to clean this area,
the biofilm tends to remain ‘undisturbed’
inside the cavity and start a caries lesion30. In
addition, the surface characteristics of the
hypomineralized enamel contribute to bacte-
rial adhesion and, even on apparently ‘intact’
surfaces, the pore sizes are big enough to
allow the invasion and destruction by cario-
genic bacteria throughout the enamel and
dentine6. From this point of view, we can
expect that MIH contributes to the develop-
ment of the caries lesions that may end up
being reflected in higher DMF values.
Past caries experience, sucrose intake fre-
quency, brushing, frequency of exposition to
fluorides, salivary buffer capacity and flow
rate, high counts of Streptococcus mutans, as
well as sociodemographic, socioeconomic, and
behavioral factors have been associated with
dental caries in all permanent teeth15,16. Due
to its impact on caries increment, mainly in
FPMs, MIH should also be considered a rele-
vant factor associated with dental caries in
epidemiological studies, to establish efficient
controlling strategies of dental caries in
hypomineralized teeth or avoid an overesti-
mated DMF value in children with MIH.
Once the ‘traditional’ caries risk factors are
controlled, as it happens in populations which
are called ‘low caries risk population’, the
impact of MIH on caries increment may be
more evident than in populations which are
called ‘high caries risk population’.
In conclusion, the findings of the present
systematic review show a significant associa-
tion between MIH and dental caries. Both
DMF index and caries prevalence were higher
in children with MIH than in children with-
out MIH. As none of the studies included in
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
the present review was, however, classified as
high-quality studies, the results should be
interpreted cautiously. This confirms the need
for further well-designed studies to provide
evidence of this association.
Why this paper is important to paediatric dentists
 Pediatric dentists must be aware of:
 The importance to follow up children with MIH.
 The need to strengthen controlling strategies of dental
caries in children with hypomineralized teeth.
 Possibilities of having overestimated DMF values in
children with MIH in epidemiological studies.
Conflict of interests
The authors declare no conflict of interests.
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