133

Relationship between Molar Incisor Hypomineralization (MIH)

severity and cavitated carious lesions in schoolchildren

Teresa Villanueva-Gutiérrez 1, Cecilia C. Barrera-Ortega 2, Alvaro García-Pérez 2,

Alvaro Edgar González-Aragón Pineda 2
1 Universidad Autónoma Metropolitana Xochimilco (UAM-X), Departamento de Atención a la Salud, México.
2
Universidad Nacional Autónoma de México (UNAM), Facultad de Estudios Superiores (FES) Iztacala,
Especialización en Estomatología Pediátrica, Mexico.

ABSTRACT with MIH than in those without MIH (55.8% vs. 44.2%, p<0.001).
The aim of this study was to identify the relationship between In the multinomial model, children with MIH in the moderate/
molar incisor hypomineralization (MIH) severity and cavitated severe category were more likely (OR=3.28; CI95% 1.01 – 10.6,
carious lesions in schoolchildren. This cross­sectional study p<0.048) to present cavitated lesions. The presence of MIH at
included 506 schoolchildren selected from public schools. mild levels was not associated with cavitated carious lesions. A
The prevalence and severity of MIH was evaluated using the high prevalence of MIH was observed. Moderate and severe
European Academy of Pediatric Dentistry criteria (EAPD), while levels of MIH were associated with cavitated carious lesions. To
the prevalence and severity of caries was evaluated by applying prevent dental caries, it is important to identify MIH in children,
the ICDAS (International Caries Detection and Assessment particularly in the moderate and severe categories.
System). The prevalence of MIH was 42.4%, with a severity of Received: May 2019; Accepted: October 2019
21.7% mild, 7.7% moderate, and 13.0% severe. Prevalence was
61.6% for incipient lesions and 34.0% for cavitated lesions. The Keywords: Dental enamel hypoplasia, severity of illness index
prevalence of ICDAS II ≥4 lesions was higher in schoolchildren caries, oral hygiene.

Asociación entre la severidad de Hipomineralización Incisivo-Molar (HIM)

y lesiones cavitadas de caries en escolares

Resumen escolares con HIM que en aquellos sin HIM (55.8% vs 44.2%,
El objetivo de este estudio fue identificar la asociación entre la p<0.001). En el modelo multinomial, los niños con HIM en
severidad de la Hipomineralización Incisivo­Molar (HIM) la categoría moderada / severa tienen mayor probabilidad
y las lesiones cavitadas de caries en escolares. Estudio (RM = 3.28; IC95% 1.01­10.6, p<0.048) de presentar lesiones
transversal que incluyó a 506 escolares seleccionados de cavitadas de caries. La presencia de HIM en niveles leves no
escuelas públicas. La prevalencia y la severidad de HIM se se asoció con la presencia de lesiones cavitadas de caries. Se
evaluó utilizando los criterios de la European Academy of observó una alta prevalencia de HIM. Los niveles moderados
Pediatric Dentistry (EAPD), mientras que la prevalencia y y severos de HIM se asociaron con lesiones cavitadas de caries.
severidad de caries se evaluó mediante los criterios del ICDAS Para prevenir la caries dental, es importante identificar la HIM
(International Caries Detection and Assessment System). La en los niños, particularmente en las categorías moderada y
prevalencia de HIM fue del 42.4%, por severidad: 21.7% leve; severa.
7.7% moderado y 13.0% severo. La prevalencia de lesiones
incipientes fue de 61.6% y 34.0% para lesiones cavitadas de Palabras clave: Hipoplasia del esmalte dental, indicador de
caries. La prevalencia de ICDAS II ≥4 lesiones fue mayor en severidad, caries, higiene bucal.

INTRODUCTION hypomineralization3. Clinically, MIH is characte­

Molar Incisor Hypomineralization (MIH) is a rized by creamy white, yellow or brown demarcated
developmental defect in the structure of the dental opacities on the enamel surfaces, while in severe
enamel, affecting the mineralization of one to four presentations, the tooth structure is lost4.
first permanent molars, frequently associated with The etiology of MIH has not been entirely
affected mineralization in one to eight permanent elucidated. MIH is usually caused by systemic
incisors1. alterations occurring during the prenatal period or
Histologically, the hypomineralized enamel shows during the first three years of life, thus affecting
areas of increased porosity2 and the enamel structure enamel development5, 6. Furthermore, it has been
itself is disorganized, depending on the degree of proposed that the etiology of this condition is

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134 Teresa Villanueva-Gutiérrez, et al.

associated with the gene variations involved in of Mexico), in which 55.5% of people over 15 years
amelogenesis7. Teeth affected by MIH, due to the of age did not have higher education, and 55.8%
hypomineralization and their morphological had access to health services. Government statistics
characteristics may cause sensitivity and pain, indicated a very low socioeconomic level in study
particularly in children. Moreover, affected molars area17. For convenience, three schools were
are more susceptible to the accumulation of biofilm, selected, one each from the northern, central and
due to the loss of enamel structure, which occurs southern sections of the study area.
after tooth eruption and is usually caused by The sample size was calculated to detect an Odds
mastication forces8. Epidemiological studies show Ratio (OR) = 2.5 with 80% power and an alpha of
a wide range in the prevalence of MIH, from 2.8% 0.05, considering a probability of 0.18 and MIH=
in children in Hong Kong, 9 to 9.7% in children in 0.30 = dental caries. The study group included
India 10 and 40.2% in children in Brazil11. The schoolchildren aged 8 to 12 years presenting the
literature provides information on the association eruption of at least one first permanent molar. The
between dental caries and MIH, and studies in Spain exclusion criterion was presence of orthodontic
show that children with severe MIH are more likely attachments that prevented the examination of the
to present dental caries12. However, a study tooth surface. A total 650 parents were asked to
conducted on German children found no association provide consent to the participation of their
between MIH and dental caries13. While a children in the study, with 600 accepting and
systematic review of published research suggested signing an informed consent form (response
an association between these conditions, the results rate 92.3%). Ninety­four of the potentially eligible
should, however, be interpreted with caution due to 600 schoolchildren were excluded: 1 due to
the lack of high­quality studies14. the presence of an orthodontic appliance, 83
The limitations to comparing the results found for the because they did not attend school on the days of
association between MIH and dental caries include examination, and 10 who did not present the
the different criteria used in the studies to evaluate eruption of any first permanent molars when
the presence and severity of MIH and dental caries. the oral evaluation was performed. Thus, 506
In recent years, new caries indices have been used, schoolchildren were included in the study.
one such being ICDAS (International Caries The study was approved by the Ethics Committee
Detection and Assessment System). ICDAS considers of the Faculty of Dentistry at the National
the degree of progress of the carious lesion, and Autonomous University of Mexico (Protocol
includes the identification of incipient lesions, 20180515).
microcavities, and lesions that involve the destruction The research was conducted in full accordance with
of more than half the tooth surface. Furthermore, the the World Medical Association Declaration of
criteria developed by the European Academy of Helsinki.
Paediatric Dentistry for the evaluation of MIH in The variables included in the study were: age (in
index teeth considers the extent of the affected area, years); sex (boy/girl); toothbrushing frequency
the loss of tooth structure and color of the lesion, (number of times a day); and, the Simplified Oral
which are characteristics associated with the severity Hygiene Index (OHI­S) dichotomized into poor
of MIH15, 16. The use of these indices would enable a (OHI­S≥2 score) and good hygiene (OHI­S<2
more detailed analysis of the association between score). Dental caries were evaluated by applying
MIH and dental caries. Therefore, the aim of this ICDAS II criteria, forming the categories ICDAS
study was to identify the relationship between molar II=0, ICDAS II= 1­3, and ICDAS II= 4­6. MIH was
incisor hypomineralization (MIH) severity and evaluated using the criteria of the European
cavitated carious lesions in schoolchildren in Mexico. Academy of Paediatric Dentistry (EAPD) and was
classified in terms of presence/absence and severity
MATERIAL AND METHODS of the lesion and in three categories: mild, moderate
Study group and severe18. The MIH level in each child was
This study comprised a cross­sectional design. The individually defined according to the first permanent
area selected had a population of 833,779 molar or permanent incisor most severely affected
inhabitants (5.4% of the total population of the State by MIH.

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MIH and cavitated carious lesions 135

Clinical oral examination examiner calibration of 0.81 and 0.84 for MIH
The evaluation of MIH included the inspection of and dental caries, respectively. Infection control
permanent occlusal /incisal buccal and palatal surfaces standards for the examination of the children’s oral
of all erupted molars and incisors, which were cavity were followed.
classified according to the criteria for EAPD19. This
index classified MIH based on visual clinical Statistical analysis
presentation, the extension of the surface affected by Comparisons were made for age, sex, toothbrushing,
the lesion (I ­ less than one third of the affected tooth, oral hygiene (OHI­S) and MIH between school­
II ­ at least one third but less than two surfaces, and III children with and without caries, using the Pearson Xi
­ post­eruptive presence of structure loss) and the color square test for categorical variables and the Kruskal­
of the lesion (white or creamy opacities and yellow or Wallis test for continuous variables. The association
brown opacities). Based on the index, the following between the independent MIH variable was classified
MIH severity categories / criteria were constructed: as mild, moderate or severe at subject level, while the
dependent caries variable for incipient lesions (ICDAS
Severity criteria II = 0 and ICDAS II = 1­3) and cavitated lesions
Mild: One white or creamy demarcated opacity (ICDAS II ≥4) was assessed via multinomial logistic
with a diameter ˃1 mm and affecting less than one regression models, adjusting for the covariates age,
third of the tooth surface. sex, toothbrushing and oral hygiene. Logistic
Moderate: One yellow or brown demarcated opacity regression analysis was also performed to determine
with a diameter ˃1 mm and affecting less than one the association between MIH and cavitated caries
third of the tooth surface; two or more white or lesions (ICDAS II ≥4) at tooth level. The construction
creamy demarcated opacities ˃1 mm affecting at of the logistic regression models considered the
least one third but less than two thirds of the tooth correlation between teeth within each individual via
surface, on which rough enamel is frequently found; the cluster option. The Odds Ratio (OR) and a 95%
post­eruptive enamel breakdown ≤2 mm; and, confidence interval (95%) were obtained. Values of p
atypical restorations involving at least one third but ≤ 0.05 were considered statistically significant.
less than two thirds of the affected tooth surface. Theoretically plausible interactions, such as oral
Severe: Two or more yellow or brown demarcated hygiene and MIH and age and MIH, were also
opacities with a diameter˃1 mm affecting at least explored. The analysis was performed using the Stata
one third or more of the tooth surface; two or more 14 program (Stata Corp, College Station, TX, USA).
white or creamy demarcated opacities with a
diameter ˃1 mm, affecting at least two thirds of the RESULTS
tooth surface; post­eruptive enamel breakdown ˃2 A total 506 schoolchildren were included in the study,
mm; and, atypical restoration involving more than with mean age 9.74 (± 1.36) years. The percentage of
two thirds of the affected tooth surface. girls and boys examined was 49.4% and 50.6%,
The assessment of dental caries was performed by respectively. It was ascertained that 61.1% brushed
applying the ICDAS II criteria, which include the their teeth twice a day or more frequently, and 38.9%
identification of incipient lesions (white spots and less than twice a day, with 98.9% using toothpaste
microcavities on the enamel) and cavitated carious and, according to the OHI­S evaluation, 44.9% of
lesions, including in the highest category the schoolchildren having good oral hygiene and 55.1%
destruction of more than half of the tooth surface. having poor oral hygiene. By sex, a higher proportion
This index classified caries with scores ranging of girls reported that they brushed their teeth twice a
from 0 to 6, with higher values indicating greater day or more frequently, which was more frequent
severity of the carious lesions20. compared to the boys (54.0% vs. 45.9%, p = 0.009).
Clinical oral evaluations were conducted by one
dentist using dental mirrors (# 5), WHO probe and Molar incisor hypomineralization
type artificial light, with the teeth brushed prior to The prevalence of MIH was 42.4% (215/506),
the procedure. The measurements taken by this distributed by sex as 51.6% boys and 48.4% girls
dentist had previously been standardized with gold (p=0.390). Of the schoolchildren who presented
standard, with Cohen’s kappa coefficient for intra­ MIH; 29.5% presented sensitivity and 8.7% pain.

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136 Teresa Villanueva-Gutiérrez, et al.

When only children with four erupted permanent (ICDAS II ≥4) in primary dentition [OR=1.60 (1.09­
first molars (PFMs) were considered (n=496), the 2.34; p=0.015)].
prevalence of MIH was 42.9%, comprising 40.9% The prevalence of caries in permanent dentition
in boys and 45.1% in girls (p=0.359). The results, (ICDAS II ≥4) was higher in schoolchildren with MIH
according to the MIH followed by showed that compared to children without MIH (44.7% vs. 26.1%,
57.5% of the schoolchildren did not present enamel p<0.001). Teeth with MIH showed a higher percentage
defects; 21.7% presented mild, 7.7 % moderate and of cavitated carious lesions compared to teeth without
13.0% severe enamel defects. MIH. Table 1 presents the distribution of MIH severity
While the frequency of toothbrushing reported by scores by ICDAS index and the association observed
the children was not associated with MIH (61.9% between these conditions, demonstrating that most of
MIH vs. 60.5% non­MIH, p=0.753), poor oral the children with severe forms of MIH showed
hygiene (OHI­S≥2) was not associated with the cavitated caries lesions (p˂ 0.001).
presence of MIH in children with and without MIH, In the multinomial logistic regression model
58.6% and 52.6%, respectively (p=0.178). undertaken at subject level for incipient caries
lesions (ICDAS II= 1­3) and MIH, controlling for
Dental caries age, sex, toothbrushing frequency and oral hygiene,
The prevalence of caries (ICDAS II 1­6) was no significant association was found between MIH
95.6%, which, by category (ICDAS II 1­3 and and initial caries lesions in the mild [OR=0.63
ICDAS II ≥4) translated as 61.6% and 34.0%, (CI95% 0.19 – 2.09) p=0.457], or moderate/severe
respectively. The mean number of carious lesions categories [OR=1.11 (CI95% 0.34 – 3.55) p=0.854
was 3.80 (±3.53) for ICDAS II 1­3 and 1.53 (±2.72) (Table 2). On the other hand, for cavitated caries
for ICDAS II ≥4. Six point six percent (6.6%) of lesions (ICDAS II ≥4), the schoolchildren with
schoolchildren had restorations in permanent teeth presence of moderate/severe MIH were more likely
and 7.4% had pit and fissure sealants. to have lesions, ICDAS II ≥4 lesions [OR=3.28
(CI95% 1.01 – 10.6); p=0.048], compared to the
Dental caries and MIH group without MIH. In the category of mild MIH
The prevalence of caries in primary dentition and cavitated lesions, no significant association was
(ICDAS II ≥4) was higher in schoolchildren with found (p=0.131). Poor oral hygiene was associated
MIH compared to children without MIH (56.3% vs. with cavitated caries lesions (ICDAS II ≥4) in
46.0%, p=0.023). In the logistic regression model schoolchildren with MIH (OR=3.62 (CI95% 1.36 –
an association was found between MIH and caries 9.61); p=0.010) (Table 2).

Table 1: Characteristics in schoolchildren aged 8 to 12 years with and without caries from the State of Mexico.
ICDAS II=0 ICDAS II=2-3 ICDAS II=4-6 Value p*
n=22 n=312 n=172
Age 8.95 (±1.29) 9.86 (±1.34) 9.62 (±1.35) 0.003
Sex
Male 11 (50.0) 175 (56.1) 70 (40.7) 0.005
Female 11 (50.0) 137 (43.9) 102 (59.3)
Toothbrushing frequency
< 2 times a day 12 (54.6) 176 (56.4) 121 (70.4) 0.009
≥ 2 times a day 10 (45.4) 136 (43.6) 51 (29.6)
Oral hygiene (OHI-S)
Poor hygiene 7 (31.8) 162 (51.9) 110 (63.9) 0.003
Good hygiene 15 (68.2) 150 (48.1) 62 (36.1)
MIH
Normal 14 (63.6) 201 (64.4) 76 (44.2) <0.001
Mild 6 (27.3) 79 (25.3) 25 (14.5)
Moderate 2 (9.1) 18 (5.8) 19 (11.1)
Severe 0 (0.0) 14 (4.5) 52 (30.2)
*Chi-square test, **Kruskal Wallis Test.

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MIH and cavitated carious lesions 137

The results of the regression model for dental caries was OR=3.69 [(CI95% 1.00 – 13.5), p=0.048]
and the number of permanent first molars affected compared to non­MIH children. Finally, an association
(Table 3) showed a significant association with the between enamel hypomineralization and dental caries
number of teeth with MIH­associated cavitated in PFMs was detected when individual teeth were
carious lesions (ICDAS II ≥4). Children presenting considered as the units of analysis (Table 4). The
three or four permanent first molars with MIH were PFMs with MIH were more likely to have cavitated
more likely (OR=4.30; CI95% 1.17 – 15.8, p=0.028) lesions (ICDAS II ≥4) compared to molars without
to present cavitated caries lesions (ICDAS II ≥4), MIH (OR=2.24; CI95% 1.52 – 3.28, p<0.001). No
while for one or two molars with MIH, the association interaction was identified in the models.

Table 2: Adjusted odds ratios from the multinomial logistic regression model for dental caries and Molar
Incisor Hypomineralization (MIH) in schoolchildren 8 -12 years of age.
ICDAS II codes 1-3b ICDAS II codes 4-6b
Variables Odds Ratio (95%CI)a p Odds Ratio (95%CI)a p
Age 1.70 (1.15 – 2.51) 0.008 1.39 (0.93 – 2.07) 0.107
Sexc 0.70 (0.23 – 1.71) 0.447 1.29 (0.52 – 3.22) 0.582
Oral Hygiene (OHI-S) d 1.96 (0.76 – 5.06) 0.163 3.62 (1.36 – 9.61) 0.010
Toothbrushing frequency 1.04 (0.42 – 2.54) 0.934 2.00 (0.79 – 5.09) 0.149
Severity MIHe
Mild 0.63 (0.19 – 2.09) 0.457 0.82 (0.23 – 2.84) 0.131
Moderate/Severe 1.11 (0.34 – 3.55) 0.854 3.28 (1.01 – 10.6) 0.048
aOR= Odds ratio; CI= confidence interval. Reference group: ICDAS IIb =0, Sexc= Male, OHI-Sd= Good, Severity MIHe= non MIH,

Toothbrushing frequency ≥ 2 times a day.

Table 3: Adjusted odds ratios from the multinomial logistic regression model for the association between enamel
hypomineralization and dental caries in permanent first molars in schoolchildren 8 -12 years of age.
ICDAS II codes 1-3b ICDAS II codes 4-6b
Variables Odds Ratio (95%CI)a p Odds Ratio (95%CI)a p
Age 1.74 (1.17 – 2.58) 0.006 1.32 (0.88 – 1.98) 0.172
Sexc 1.08 (0.44 – 2.67) 0.856 1.87 (0.74 – 4.68) 0.181
Oral Hygiene (OHI-S) d 2.26 (0.85 – 6.05) 0.102 3.88 (1.43 – 10.5) 0.008
Molar MIH e

1-2 molars 0.72 (0.19 – 2.67) 0.627 3.69 (1.00 – 13.5) 0.048
3-4 molars 0.79 (0.21 – 2.90) 0.721 4.30 (1.17 – 15.8) 0.028
a
OR= Odds ratio; CI= confidence interval. Reference group: ICDAS IIb =0, Sexc= Male, OHI-Sd= Good, molar MIHe= non molar MIH

Table 4: Association between enamel hypomineralization and caries (ICDAS II ≥4) in permanent first molars
among schoolchildren with molar incisor hypomineralization: tooth level analysis.
Variables ORa Crude (95%CI) p ORa adjusted (95%CI) p
Age 0.90 (0.79 – 1.04) 0.165 0.85 (0.74 – 0.99) 0.037
Sexb 1.83 (1.26 – 2.65) 0.001 1.87 (1.27 – 2.74) 0.001
Oral Hygiene (OHI-S)c 1.73 (1.18 – 2.52) 0.004 1.82 (1.22 – 2.70) 0.003
d
MIH 2.28 (1.56 – 3.32) <0.001 2.24 (1.52 – 3.28) <0.001

Logistic Regression: aOR= Odds ratio; CI= confidence interval. Reference group: Sexb= Male, OHI-Sc= Good, MIHd= non MIH.

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138 Teresa Villanueva-Gutiérrez, et al.

DISCUSSION undertaken in populations in India (9.7%) 10 and

In this study, the presence of MIH was associated Thailand (20.0%) 6, but similar to MIH prevalence
with cavitated carious lesions assessed using reported in the study undertaken on schoolchildren in
ICDAS II. Furthermore, the severity of MIH showed Brazil, (40%)11. It may be difficult to compare MIH
an impact on dental caries, with schoolchildren with prevalence among different studies, considering the
moderate/severe categories of MIH being more different indices used for MIH assessment, the age of
likely to have cavitated lesions compared to the participants and the caries risk for the specific
schoolchildren without MIH. The association found study group, among other factors.
between cavitated carious lesions and MIH is In the Mexican children included in this study, most
consistent with the results of studies conducted in of the MIH cases detected presented a moderate
other population groups14, 21, 22. Children in Thailand level of severity. While the MIH index of the
with MIH were 4.6 times as likely to have caries in European Academy of Pediatric Dentistry is widely
permanent teeth than children without MIH6. used in epidemiological and clinical studies, it does
Similarly, an association between MIH and caries not directly classify MIH severity; nevertheless, it
experience was found in 6 to 12­year­old Brazilian does assess tooth characteristics that facilitate the
schoolchildren23. It is likely that the association construction of a severity score.
between MIH and dental caries is easier to Advanced carious lesions (ICDAS II 4­6) and
recognize in groups with high risk of caries and high incipient carious lesions (ICDAS II 1­3) were
severity of MIH. evaluated in this study. The small lesions were not
The association between MIH and caries could be associated with the presence or severity of MIH.
explained by the morphological changes observed Ismail et al., in a study conducted on infants and
in teeth with MIH because the hypomineralized their caregivers in low­income families in Detroit,
enamel microstructure is disorganized, with the Michigan, identified that the risk factors for
interprismatic spaces being less compact than in incipient lesions were not necessarily the same as
healthy enamel24. Moreover, mechanical properties those for cavitated lesions27.
such as hardness, elasticity and chemical composi­ In this study, incipient and cavitated lesions were
tion are deteriorated, compared to healthy enamel3. assessed by applying ICDAS II criteria, which
As the enamel in teeth presenting MIH becomes provide a broad perspective on the caries process
brittle, it is clinically possible to detect loss of by considering initial lesions previously excluded
continuity, fractures or even loss of tooth structure, by both clinical and epidemiological studies. In this
which favor the accumulation of biofilm on the research, incipient lesions (ICDAS II 1­3) were
porous enamel and the exposed dentin. found in more than half of the study group, and
Accordingly, children with MIH showed a greater cavitated lesions (ICDAS II ≥4) in approximately
level of biofilm accumulation. Biofilm accumulation one third of the group. Similarly, studies conducted
is favored by the porous surface of the affected teeth, in Spain on 12­year­old children using the same
leading to penetration by cariogenic bacteria, which cutoff value (ICDAS II ≥4) found a 37.7% caries
destroys hypomineralized enamel more quickly than prevalence in permanent dentition28.
sound enamel14. Additionally, schoolchildren with Some of the limitations of this study are related to its
teeth affected by MIH may suffer from dentinal cross­sectional design, as some teeth affected by MIH
sensitivity and are more likely to find it difficult to were likely not to have been detected due to the pre­
brush their teeth properly25. While this study sence of restorations that could mask the occurrence
revealed an MIH prevalence of 42.4%, Gurrusquieta of MIH. However, only 6.6% of participants in the
BJ et al., found that prevalence in Mexican children study group presented dental fillings in permanent
aged 6 to 12 years was 15.8%, i.e., lower than that teeth. The extrapolation of the results of the study to
found in the present study26. This differences in other groups from different areas of Mexico has
prevalence of MIH among school children could be limitations due to the heterogeneity of children in the
due to the differences in etiological factors, lifestyle city; however, the schools featured in this study are
and genetic characteristics in the populations studied. located in low income neighborhoods, the type of
The percentage of children affected by MIH in the neighborhood where more than 50% of the families
study group was higher than that identified in studies featured in this study live.

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MIH and cavitated carious lesions 139

The identification of an association between MIH cohort study showed that it is possible to maintain
and dental caries is considered important, particularly the tooth structure of the areas with MIH opacities,
in children presenting various dental problems, with the authors of said study recommending a
such as poor oral hygiene, hypersensitivity, high conservative approach in mild MIH cases16.
caries risk and high treatment needs. The results In conclusion, this study shows that more than one
suggest that when MIH is mild, the dentist may third of the children had MIH, identifying an
select a conservative approach based on general association between MIH and dental caries evaluated
preventive measures such as brushing with fluoridated through ICDAS II. It is important that children with
toothpaste. However, when MIH is moderate/ MIH are diagnosed early in order that they receive
severe, a proactive approach is important, as is the preventive measures and timely treatment to protect
use of additional measures for preventing caries, the tooth structure affected and prevent the deterio­
such as the application of glass ionomer sealants. A ration of oral health and, thereby, quality of life.

FUNDING CORRESPONDENCE
The authors acknowledge the support of the Pediatric Stomatol­ Dr. Alvaro García Pérez
ogy Specialties Faculty of Higher Studies (FES) Iztacala. Avenida de los Barrios Número 1
National Autonomous University of Mexico (UNAM), Mexico. Colonia Los Reyes Ixtacala Tlalnepantla
Estado de México, C.P. 54090.
[email protected]

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