Do patients with molar incisor hypomineralization have more dental anxiety and behavior management problems? A systematic review with meta-analysis

REIS, Patrícia Papoula Gorni; JORGE, Roberta Costa; FERREIRA, Daniele Masterson Tavares Pereira; MARAÑÓN-VÁSQUEZ, Guido Artemio; MAIA, Lucianne Cople; SOVIERO, Vera Mendes

doi:10.1590/1807-3107bor-2023.vol37.0069

Patrícia Papoula Gorni REIS

Universidade do Estado do Rio de Janeiro – UERJ, Department of Pediatric Dentistry, Rio de Janeiro, RJ, Brazil.

http://orcid.org/0000-0001-6159-0911

Roberta Costa JORGE

Centro Universitário UNIFASE, Dental School, Petrópolis, RJ, Brazil.

http://orcid.org/0000-0002-1668-9143

Daniele Masterson Tavares Pereira FERREIRA

Universidade Federal do Rio de Janeiro – UFRJ, Health Science Center, Central Library, Rio de Janeiro, RJ, Brazil.

http://orcid.org/0000-0001-7108-1117

Guido Artemio MARAÑÓN-VÁSQUEZ

Universidade Federal do Rio de Janeiro – UFRJ, School of Dentistry, Department of Pediatric Dentistry and Orthodontics, RJ, Brazil.

http://orcid.org/0000-0001-7029-0347

Lucianne Cople MAIA

Universidade Federal do Rio de Janeiro – UFRJ, School of Dentistry, Department of Pediatric Dentistry and Orthodontics, RJ, Brazil.

http://orcid.org/0000-0003-1026-9401

Vera Mendes SOVIERO

Universidade do Estado do Rio de Janeiro – UERJ, Department of Pediatric Dentistry, Rio de Janeiro, RJ, Brazil.

http://orcid.org/0000-0002-0572-3174

Corresponding Author: Lucianne Cople Maia E-mail: maia_lc@odonto.ufrj.br

Declaration of Interests: The authors certify that they have no commercial or associative interest that represents a conflict of interest in connection with the manuscript.

MEDLINE (PubMed)	#1 (dental enamel hypoplasia[MeSH Terms]) OR (dental enamel hypoplasia[Title/Abstract]) OR (enamel defect[Title/Abstract]) OR (enamel opacit[Title/Abstract]) OR (enamel hypoplas[Title/Abstract]) OR (molar incisor hypomineralization[Title/Abstract]) OR (MIH[Title/Abstract]) OR (molar incisor[Title/Abstract]) OR (hypomineral[Title/Abstract]) OR (cheese molar[Title/Abstract]) OR (demarcated opacit[Title/Abstract]) OR (demarcated defect[Title/Abstract])
	#2 (Anxiety[MeSH Terms]) OR (anxiety disorder[MeSH Terms]) OR (dental anxiety[MeSH Terms]) OR (fear[MeSH Terms]) OR (behavior[MeSH Terms]) OR (Anxiety[Title/Abstract]) OR (Anxiety disorder[Title/Abstract]) OR (dental anxiety[Title/Abstract]) OR (fear[Title/Abstract]) OR (dental fear[Title/Abstract]) OR (odontophobia[Title/Abstract]) OR (behavio[Title/Abstract]) OR (phobia dental[Title/Abstract]) OR (Anxieties Dental[Title/Abstract])
	#1 AND #2
Elsevier (Scopus)	#1 TITLE-ABS-KEY (“dental enamel hypoplasia” OR “enamel defect” OR “enamel defects” OR “enamel opacity” OR “enamel opacities” OR “enamel hypoplasia” OR “enamel hypoplasias” OR “molar incisor hypomineralization” OR mih OR “molar incisor” OR hypomineral* OR “cheese molar” OR “demarcated opacity” OR “demarcated opacities” OR “demarcated defect” OR “demarcated defects”)
	#2 TITLE-ABS-KEY (Anxiety OR “Anxiety disorder” OR “dental anxiety” OR fear OR “dental fear” OR odontophobia* OR behavio* OR “phobia dental” OR “Anxieties dental”)
	#1 AND #2
Clarivate (Web of Science)	#1 TS=(“dental enamel hypoplasia” OR “enamel defect” OR “enamel defects” OR “enamel opacity” OR “enamel opacities” OR “enamel hypoplasia” OR “enamel hypoplasias” OR “enamel hypoplastic” OR “molar incisor hypomineralization” OR mih OR “molar incisor” OR hypomineralization OR hypomineralisation OR Hypomineralized OR “cheese molar” OR “demarcated opacity” OR “demarcated opacities” OR “demarcated defects” OR “demarcated defect”)
	#2 TS=(Anxiety OR “Anxiety disorder” OR “dental anxiety” OR fear OR “dental fear” OR odontophobia* OR behavio* OR “phobia dental” OR “Anxieties dental”)
	#1 AND #2
Elsevier (Embase)	#1 ‘enamel hypoplasia’/exp OR ‘enamel hypoplasia’:ab,ti OR ‘enamel defect’: ab,ti OR ‘enamel opacit: ab,ti OR ‘enamel hypoplas: ab,ti OR ‘molar incisor hypomineralization’: ab,ti OR ‘mih’: ab,ti OR ‘molar incisor’: ab,ti OR ‘cheese molar’: ab,ti OR ‘demarcated opacit’: ab,ti OR ‘demarcated defect*: ab,ti
	#2 ‘ansiety”/exp OR ‘anxiety disorder’/exp OR ‘dental anxiety’/exp OR ‘fear’/exp OR ‘behavior”/exp OR anxiety:ab,ti OR ‘anxiety disorder’:ab,ti OR fear:ab,ti OR behavior:ab,ti OR ‘dental anxiety”: ab,ti OR ‘dental phobia’:ab,ti OR ‘phobia dental’:ab,ti OR ‘anxiet* dental’:ab,ti
	#1 AND #2
Lilacs (BBO/VHL)	#1 tw:((mh:(dental enamel hypoplasia)) OR (mh:(hipoplasia do esmalte dentário)) OR (tw:(“dental enamel hypoplasia” )) OR (tw:(“hipoplasia do esmalte dentário”)) OR (tw:(“enamel defect”)) OR (tw:(“defeito de esmalte”)) (tw:(“enamel defects”)) OR (tw:(“defeitos de esmalte”)) OR (tw:(“enamel opacity”)) OR (tw:(“opacidade de esmalte”)) OR (tw:(“enamel opacities”)) OR (tw:(“opacides de esmalte”)) OR (tw:(“enamel hypoplasia”)) OR (tw:(“hipoplasia de esmalte”)) (tw:(“enamel hypoplasias”)) OR (tw:(“hipoplasias de esmalte”)) (tw:(“enamel hypoplastic”)) OR (tw:(“esmalte hipoplastico”)) OR (tw:(“molar incisor hypomineralization”)) OR (tw:(“hipomineralização molar incisivo”)) OR (tw:(mih)) OR (tw:(hmi)) OR (tw:(“molar incisor”)) OR (tw:(“molar incisivo”)) OR (tw:(hypomineralization)) OR (tw:(hipomineralização)) OR (tw:(hypomineralisation)) OR (tw:(hipomineralização)) OR (tw:(hypomineralized)) OR (tw:(hipomineralizado)) OR (tw:(“cheese molar”)) OR (tw:(“molar de queijo”)) OR (tw:(“cheese molars”)) OR (tw:(“molares de queijo”)) OR (tw:(“demarcated opacity”)) OR (tw:(“opacidade demarcada”)) OR (tw:(“demarcated opacities)”) OR (tw:(“opacidades demarcadas”)) OR (tw:(“demarcated defect”)) OR (tw:(“defeito demarcado”)) OR (tw:(“demarcated defects”)) OR (tw:(“defeitos demarcados”)))
	#2 tw:((mh:(anxiety )) OR (mh:(ansiedade)) OR (mh:(desordens de ansiedade)) OR (mh:(anxiety disorders)) OR (mh:(dental anxiety)) OR (mh:( ansiedade dental)) OR (mh:(fear)) OR (mh:(medo)) OR (mh:(behavior)) OR (mh:(comportamento)) OR (tw:(anxiety)) OR (tw:(ansiedade)) OR (tw:(“anxiety disorder”)) OR (tw:(“desordem de ansiedade”)) OR (tw:(“dental anxiety”)) OR (tw:(“ansiedade dental”)) OR (tw:(fear)) OR (tw:(medo)) OR (tw:(comportamento)) OR (tw:(behavior)) OR (tw:(odontophobia)) OR (tw:(odontofobia)) OR (tw:(“phobia dental”)) OR (tw:(“fobia dentaria”)) OR (tw:(“anxieties dental”)) OR (tw:(“ansiedade dentaria”)) OR (tw:(“phobia dental”)) OR (tw:(“fobia dental”)))
	#1 AND #2
Wiley (Cochrane Library)	#1 “dental enamel hypoplasia” OR enamel defect* OR enamel opacit* OR enamel hypoplas* OR “molar incisor hypomineralization” OR mih OR “molar incisor” OR hypomineral* OR “cheese molar” OR demarcated opacit* OR demarcated defect*
	#2 MeSH descriptor: [Dental Enamel Hypoplasia] explode all trees
	#3 MeSH descriptor: [Anxiety] explode all trees
	#4 MeSH descriptor: [Anxiety Disorders] explode all trees
	#5 MeSH descriptor: [Dental Anxiety] explode all trees
	#6 MeSH descriptor: [Fear] explode all trees
	#7 MeSH descriptor: [Behaviorism] explode all trees
	#8 Ansiety OR “Anxiety disorder” OR “dental anxiety” OR fear OR “dental fear” OR odontophobia* OR “phobia dental” OR “anxieties dental” OR behavio*
	#9 #3 OR #4 OR #5 OR #6 OR #8
	#10 #3 OR #4 OR #5 OR #6 OR #7 OR #8
	#11 #1 OR #2
	#12 #11 AND #10
PsycINFO (Google Scholar	((Any Field: (“dental enamel hypoplasia”)) OR (Any Field: (enamel defect)) OR (Any Field: (enamel opacity)) OR (Any Field: (enamel hypoplas)) OR (Any Field: (“molar incisor hypomineralization”)) OR (Any Field: (MIH)) OR (Any Field: (molar incisor)) OR (Any Field: (hypomineral)) OR (Any Field: (“cheese molar”)) AND (Any Field: (demarcated opacit)) AND* (Any Field: (demarcated defect))) AND*
	((Any Field: (Anxiety)) OR (Any Field: (Anxiety disorder)) OR (Any Field: (“dental anxiety”)) OR (Any Field: (fear)) OR (Any Field: (“dental fear”)) OR (Any Field :(odontophobia)) OR (Any Field: (behavior)) OR (Any Field: (“phobia dental”)) OR (Any Field: (“Anxieties Dental)) AND* Publication Type: Journal
	#1 “molar incisor hypomineralization” OR MIH OR “demarcated opacity”
	#2 Anxiety OR “Anxiety disorder” OR “dental anxiety” OR fear OR “dental fear” OR odontophobia* OR behavio* OR “phobia dental” OR “Anxieties dental”
	#1 AND #2
Open Grey	#1 (“dental enamel hypoplasia” OR “enamel defect” OR “enamel opacit” OR “enamel hypoplas” OR “molar incisor hypomineralization” OR mih OR “molar incisor” OR hypomineral OR “cheese molar” OR “demarcated opacit” OR “demarcated defect*”)
Open Grey	#2 (Anxiety OR “Anxiety disorder” OR “dental anxiety” OR fear OR “dental fear” OR odontophobia* OR behavio* OR “phobia dental” OR “Anxieties dental”)

Author (Year), Country	Description of the study design by authors	Sample / Groups	Age (years)	Diagnostic criterion	Outcome	Instrument	Main results	Conclusions/Comments by the authors	Critical appraisal
Laureano et al. (2020), Brazil	Cross-sectional	n = 466 G1 (with MIH) = 56 G2 (no MIH) = 410	8–10	Ghanin 2019	DFA	CFSS-DS answered by patients	G1 = 27% have DFA G2 = 20.9 % have DFA PR (95% CI) G1 = 1.27 (0.89 - 1.82) G2 = 1	“MIH was not associated with dental fear.”	The sample was relatively large and was representative of the population. MIH was not signficantly associated with DFA.
Özükoç (2019), Turkey	Cross-sectional	n = 112 G1 (with MIH) = 58 mild MIH = 26 moderate MIH = 19 severe MIH = 13 G2 (no MIH) = 54	8–12	Not mentioned	DFA	CFSS-DS answered by patients	G1 mild = 24.7 (SD 13.3) G1 moderate = 26.3 (SD 15.2) G1 severe = 41.5 (SD 14.5) G2 = 23.5 (SD 12.3)	“The study showed that there is actually a relationship between the severity of MIH and DFA, and DFA increases as MIH also increases.”	Sample is not representative and is relatively small. The criteria used for the assessment of exposure were not described.
Menocin et al. (2018), Brazil	Cross-sectional	n = 731 G1 (with MIH) = 88 G2 (no MIH) = 643	8	EAPD	DFA	DAQ answered by parents	G1: 64.8% (57/ 88) G2: 54.1% (348/ 643)	“Although the prevalence of DFA was higher among schoolchildren with MIH, the association between these two conditions was not significant.”	The study had a representative sample and confounding factors (caries experience and age) were controlled for.
Arrow (2017), Australia	Cohort	n = 88 G1 (Demarc. Opac.) = 18 G2 (no Enamel Defects) = 26 G3 (Diffuse Opac.) = 44	14.7 (13.7–15.8) SD = 0.3	DDE	DFA	MCDASf answered by patients	Overall mean = 20.6 (SD = 7.5)	No significant association between the presence of enamel defects and DFA. .	Data related to DFA and enamel defects were cross-sectional. We assume that demarcated opacities are MIH, but the diagnosis did not follow specific criteria for MIH. Confounding factors were controlled. Caries experience was considered in the analysis and age range was narrow. The sample was relatively small.
							G1: 18.9 (SD = 7.1) G2: 21.0 (SD = 8.2)
							G3: 20.2 (SD = 6.8)
Kosma et al. (2016), Greece	Cross-sectional	n = 2335 G1 (with MIH) = 498 G2 (no MIH) = 1837	8 (n = 1179) 14 (n = 1156)	EAPD	DFA	CFSS-DS answered by patients	G1: mean = 26.5 (SD 9.6) G2: mean = 26.2 (SD 9.9)	“No statistically significant difference was found between the mean CFSS-DS score in children with and without MIH.”	Study with representative sample. Age was controlled for in the selection of participants. Caries experience was not controlled for.
Kosma et al. (2016), Greece	Cross-sectional	n = 2335 G1 (with MIH) = 498 G2 (no MIH) = 1837	8 (n = 1179) 14 (n = 1156)	EAPD	DFA	CFSS-DS answered by patients
Jalevik & Klingberg (2012), Sweden	Case-control	n = 67 G1 (severe MIH) = 30 G2 (no MIH) = 37	18	DDE	DFA	CFSS-DS answered by patients	G1: mean = 22.0 (SD 6.2); CFSS-DS > 29 = 13.3% (4/30). G2: mean = 21.7 (SD 5.8); CFSS-DS > 29 = 16.2% (6/37).	“DBMPs were still more common in patients with severe MIH, whereas DFA did not differ between patients with severe MIH and controls.”	As the participants were selected by the exposure (MIH) and not by the outcome (DFA), we assume that the study followed a cross-sectional design. The sample was representative, but relatively small. All the children were included in the cohort with 8-year-olds followed up to the age of 18 years. DFA was assessed at a specific point in time. Data on DBMPs were retrieved retrospectively from dental records. Age was controlled for in the sample selection. Caries experience was not controlled for in the analysis.
Jalevik & Klingberg (2012), Sweden	Case-control	n = 67 G1 (severe MIH) = 30 G2 (no MIH) = 37	18	DDE	DBMPs	Notes in the dental records	G1: 20% 6/30 G2: 2.7% 1/37
Jalevik & Klingberg (2002), Sweden	Case-control	n = 73	7-8 y	DDE	DFA	CFSS-DS answered by parents	G1: mean = 23.3 (SD 7.5); CFSS-DS > 29 = 25% (8/32). G2: mean = 20.8 (SD 5.4); CFSS-DS > 29 = 4.9% (2/41).	“There were more children in the MIH-group than in the control group who had high levels of DFA (CFSS-DS scores ≥ 29) and DBMPs.”	As the participants were selected by the exposure (MIH) and not by the outcome (DFA), we assume that the study followed a cross-sectional design. Age of the participants was controlled for, but dental caries was not considered as a confounding factor. The sample was representative, but relatively small. Data on DBMPs were retrieved retrospectively from dental records.
		G1 (severe MIH) = 32			DFA	CFSS-DS answered by parents
		G2 (no MIH) = 41			DBMPs	Notes in the dental records	G1: 46.9% (15/32) G2: 2.4% (1/41)

Authors (year)	Newcastle-Ottawa Scale

	Country	Selection (max 5/4)	Comparability (max 2*)	Outcome (max 3*)	Total
Dental fear and anxiety
Laureano et al. (2020)	Brazil	*****	*	**	8*/10
Özükoç et al. (2019)	Turkey	*	*	**	4*/10
Menocin et al. (2018)	Brazil	*****	**	**	9*/10
Arrow (2017)	Australia	**	**	**	6*/9
Kosma et al. (2016)	Greece	*****	*	**	8*/10
Jalevik and Klingberg (2012)	Sweden	***	*	**	6*/9
Jalevik and Klingberg (2002)	Sweden	***	*	**	6*/9
Dental behavior management problem
Jalevik and Klingberg (2012)	Sweden	**	*	**	5*/9
Jalevik and Klingberg (2002)	Sweden	**	*	**	5*/9

[1] Corresponding Author: Lucianne Cople Maia E-mail: maia_lc@odonto.ufrj.br

Brasil

Brasil

Do patients with molar incisor hypomineralization have more dental anxiety and behavior management problems? A systematic review with meta-analysis

Abstract