External validation of an artificial intelligence-based method for the detection and classification of molar incisor hypomineralisation in dental photographs.

OBJECTIVES: This ex vivo diagnostic study aimed to externally validate an open-access artificial intelligence (AI)-based model for the detection, classification, localisation and segmentation of enamel/molar incisor hypomineralisation (EH/MIH). METHODS: An independent sample of web images showing teeth with (n = 277) and without (n = 178) EH/MIH was evaluated by a workgroup of dentists whose consensus served as the reference standard. Then, an AI-based model was used for the detection of EH/MIH, followed by automated classification and segmentation of the findings (test method). The accuracy (ACC), sensitivity (SE), specificity (SP) and area under the curve (AUC) were determined. Furthermore, the correctness of EH/MIH lesion localisation and segmentation was evaluated. RESULTS: An overall ACC of 94.3 % was achieved for image-based detection of EH/MIH. Cross-classification of the AI-based class prediction and the reference standard resulted in an agreement of 89.2 % for all diagnostic decisions (n = 594), with an ACC between 91.4 % and 97.8 %. The corresponding SE and SP values ranged from 81.7 % to 92.8 % and 91.9 % to 98.7 %, respectively. The AUC varied between 0.894 and 0.945. Image size had only a limited impact on diagnostic performance. The AI-based model correctly predicted EH/MIH localisation in 97.3 % of cases. For the detected lesions, segmentation was fully correct in 63.4 % of all cases and partially correct in 33.9 %. CONCLUSIONS: This study documented the promising diagnostic performance of an open-access AI tool in the detection and classification of EH/MIH in external images. CLINICAL SIGNIFICANCE: Externally validated AI-based diagnostic methods could facilitate the detection of EH/MIH lesions in dental photographs.

Molar-Incisor Hypomineralisation: Severity, caries and hypersensitivity.

OBJECTIVES: To investigate distribution of affected teeth and severity of molar-incisor hypomineralisation (MIH) in 8-9-year-old children. A second aim was to study association between severity of MIH and hypersensitivity, caries, and affection of incisors and second primary molars (SPM). METHODS: A total of 3013 children in one age cohort participated in a cross-sectional study, of which 851 children were diagnosed with MIH. A majority of these children were re-examined and MIH diagnosis based on the European Academy of Paediatric Dentistry criteria was confirmed in 538 children. The re-examinations were undertaken at the local clinics by one calibrated dentist. Data were tested with bivariate logistic regression analysis. Results were reported using frequencies, proportions, odds ratios (OR) and confidence intervals (CI). RESULTS: Almost half of the children with MIH (46.8 %) had at least one severely affected molar. Incisors were affected in 51.9 % of children with MIH, and the prevalence was higher in children with severe affection (57.4 %, p < 0.01). Among children with MIH, second primary molars were affected in 29.6 %, hypersensitivity in at least one first permanent molar was reported by 25.8 and 30.8 % had caries extending to dentine. Children classified with severe MIH were more likely to suffer from hypersensitivity (OR 5.62, 95 % CI 3.61-8.74) and dentine caries (OR 10.32, 95 % CI 6.46-16.50) than children with mild MIH. CONCLUSION: Prevalence of hypomineralised incisors and SPM were high in the studied children with MIH. Children with severe MIH had higher probability of incisor affection, dentin caries and hypersensitivity. CLINICAL SIGNIFICANCE: This study highlights the importance of understanding the association between MIH, caries and hypersensitivity, especially in children with severe MIH. These children need extensive and individualized care in the dental services to prevent caries and pain.

Comparison between intraoral scanning and direct visual analysis for the assessment of developmental defects of enamel.

OBJECTIVE: To compare direct visual analysis (DVA) and intraoral scanning (IOS) for the assessment of developmental defects of the enamel (DDE). METHODS: Thirty-nine extracted permanent human teeth with DDE were selected by an experienced examiner and digitised using IOS. The scanning was recorded using the OBS Studio software parallel to the IOS software to obtain a coloured high-definition MP4 file of the process. Two other experienced, blinded, and calibrated examiners randomly analysed the same teeth through DVA and IOS. A third examiner resolved any disagreements between the two examiners. Descriptive statistics were used to analyse the frequencies of the scores. Cohen's kappa test was used to determine whether the DVA scores were different from those assigned using IOS. Spearman's test was used to verify non-random examiner errors. The Chi-square test was used to compare score frequencies. Statistical significance was set at p <0.05. RESULTS: Scores indicating more severe and extended DDE (p <0.05) were more frequently assigned with IOS than with DVA (IOS: 25.64%, 25.64%, 38.46%, and 35.90% between one-third to two-third of the lingual, occlusal, mesial, and distal surfaces, respectively; vs. DVA: 10.26%, 7.69%, 15.38%, and 10.26% for the respective aforementioned tooth surfaces). Contrarily, 'no visible enamel defect' was significantly less assigned for IOS than for DVA (IOS: 15.38%, 43.59%, 35.90%, 15.38%, and 17.95% for buccal, lingual, occlusal, mesial, and distal surfaces, respectively; vs. DVA: 38.46%, 66.67%, 56.41%, 51.28%, and 43.59% for the respective aforementioned tooth surfaces). Kappa agreement ranged from fair to moderate when comparing DVA and IOS; the correlation between both methods was positive, indicating that the examiners assigned the scores properly and the differences arose from employing different methods. CONCLUSION: The assessment of DDE differed depending on the method used. IOS scores indicated more severe and extended DDE than DVA scores. Clinical investigation is the next step in validating the use of IOS for DDE diagnosis. CLINICAL SIGNIFICANCE: This study showed that DDE can be assessed differently using IOS. It is clinically relevant as it directly affects the determination of the severity of the defect and dental treatment planning.

Molar-incisor hypomineralisation in Norwegian children: Prevalence and associated factors.

This study investigated the prevalence and associations of molar-incisor hypomineralisation (MIH) in 8-9 year-old children in Oslo. A total of 3013 children in one age cohort participated in the study during their regular dental examination at the Public Dental Service. Hypomineralised enamel defects were recorded according to the European Academy of Paediatric Dentistry criteria for MIH. Information on health and medications used during pregnancy and in the child's first 3 years of life was obtained from a questionnaire administered to parents. The overall prevalence of MIH was 28.2%, with no gender difference. A higher prevalence of MIH was found in children who had been ill or had used medication in early life and in those whose mother had been ill during pregnancy. No association was found between MIH and prematurity or maternal use of medication during pregnancy. The multivariable analyses showed that children with MIH were more likely to have suffered from illness in early life (OR = 1.41, 95% CI: 1.17-1.70), used antibiotics during the first year of life (OR = 1.68, 95% CI: 1.19-2.35), experienced tooth pain (OR = 1.33, 95% CI: 1.03-1.72), and experienced pain while toothbrushing (OR = 2.17, 95% CI: 1.46-3.23) than children without MIH. The prevalence of MIH was high in the children participating in this study.

Maternal vitamin D status in pregnancy and molar incisor hypomineralisation and hypomineralised second primary molars in the offspring at 7-9 years of age: a longitudinal study.

PURPOSE: The study aimed to investigate associations between maternal vitamin D status during pregnancy and molar incisor hypomineralisation (MIH) and hypomineralised second primary molars (HSPM) among children. METHODS: The study had a longitudinal design using prospectively collected data from 176 mother and child pairs. Mothers were initially recruited in a randomised controlled trial to assess a pregnancy exercise programme. Along with the 7-year follow-up, we invited the children to a dental examination. The exposure variable was maternal serum 25-hydroxyvitamin D in gestational weeks 18-22 and 32-36, categorised as insufficient (< 50 nmol/l) and sufficient (≥ 50 nmol/l). Negative binomial hurdle models were used to analyse potential associations between the exposure variables and MIH or HSPM. The models were adjusted for potential confounders. RESULTS: Among the children (7-9 years old), 32% and 22% had at least one tooth with MIH or HSPM, respectively. A significant association was found between insufficient maternal vitamin D measured in gestational weeks 18-22 and the number of affected teeth among those with MIH at 7-9 years (adjusted RR = 1.82, 95% CI 1.13-2.93). CONCLUSION: Considering any limitations of the present study, it has been shown that insufficient maternal serum vitamin D at mid-pregnancy was associated with a higher number of affected teeth among the offspring with MIH at 7-9 years of age. Further prospective studies are needed to investigate whether this finding is replicable and to clarify the role of maternal vitamin D status during pregnancy and MIH, as well as HSPM, in children.

The influence of lesion characteristics on application time of an infiltrate applied to MIH lesions on anterior teeth: An exploratory in vivo pilot study.

OBJECTIVES: To evaluate the factors that influences the kinetics of resin infiltration of molar incisor hypomineralisation (MIH) lesions on permanent anterior teeth. METHODS: Demarcated MIH lesions with homogeneous and heterogeneous lesion body appearance, Types 1 (n = 14) and 2 (n = 18), respectively, were selected. After removal of the lesion surface layer using a tapered diamond finishing bur, the lesions were etched and ethanol was applied to the lesions and it was determined if the lesion was still visible or not. Images were taken just prior infiltrant (Icon; DMG) application (T0), during the infiltration process (Tx) and when infiltration had ceased progressing or opacity disappearance was clinically apparent (Tmax). Surface-area measurements of the opacity and infiltrated area were calculated and the infiltration proportion (IPx) was calculated over the infiltration time. RESULTS: Type 1 and positive ethanol test lesions showed significantly lower mean Tmax (3.4 min) in comparison with Type 2 and negative ethanol test lesions (9.9 min) [Student t-test/Fisher's exact test; p < .01]. A non-linear correlation was observed (R2 = 0.88) indicating that the IPx was rapid at the beginning of resin application, decreasing over time. CONCLUSION: In comparison with Type 1 and positive ethanol test lesions, Type 2 and negative ethanol test lesions require longer application time to infiltrate. CLINICAL SIGNIFICANCE: MIH-lesion type and the 'ethanol test' were reliable predictive factors for the application time required for infiltrating MIH lesions on permanent anterior teeth.

Structural and chemical enamel characteristics of hypomineralised second primary molars.

PURPOSE: Although hypomineralised second primary molars (HSPM) are considered belonging in the same entity as molar incisor hypomineralisation (MIH), the structure and chemistry of their defected enamel have not been described. We aimed to study these in justifying any similarities with MIH. METHODS: Nine HSPM and five first permanent molars with MIH were either fractured or sectioned longitudinally through their defective enamel and examined by scanning electron microscopy. Relative amounts of calcium (Ca), phosphorus (P), oxygen (O), carbon (C) and the Ca:P ratio were calculated in the primary molar samples by energy -dispersive spectrometry. RESULTS: Rod width was deficient in the defected enamel of HSPM resulting in wide interrod spaces and suggesting similarities to permanent enamel structure in MIH. In areas with breakdown, cracks and disrupted coherence between enamel rods were more marked. Differences in Ca, P, O, C and Ca:P ratio between hypomineralised and sound enamel in HSPM followed the same trend as in MIH without reaching statistical significance. CONCLUSION: Marked structural differences between sound and hypomineralised enamel of HSPM and similarity to MIH enamel were verified.

Medical and dental characteristics of children with chromosome 22q11.2 deletion syndrome at the Royal Children's Hospital, Melbourne.

BACKGROUND: Chromosome 22q11.2 deletion syndrome (22q11.2DS) is a multifaceted syndrome with a variable phenotype. Few studies have described the associated dental characteristics and their relationship with medical co-morbidities; and no Australian data exist. AIM: To determine the clinical manifestations and correlations between oral and medical conditions in children with 22q11.2DS. DESIGN: A retrospective observational study. Children genetically diagnosed with 22q11.2DS at the Royal Children's Hospital Melbourne were selected; their medical and dental characteristics were collated and analysed. RESULTS: The study population (n = 57; mean age 11.5 years, range 2-27 years) experienced a range of medical conditions involving multiple medical systems; of whom 44 (77.2%) had caries experience, 7 (12.3%) developmentally missing teeth, and 31 (54.4%) developmental defects of enamel (DDE). Smaller proportions of primary teeth were affected by DDE in children with congenital heart disease (2.2% vs 9.7%; P = .02), and cardiac surgery (0.2% vs 9%; P = .001). Conversely, children with hypoparathyroidism (n = 2) had significantly higher proportions of primary teeth affected by DDE (27.5% vs 4%; P = .02). CONCLUSIONS: Significant associations existed between medical conditions (congenital heart disease, history of cardiac surgery, and hypoparathyroidism) and primary dentition DDE in children with 22q11.2 DS.

Relationship between caries experience and demarcated hypomineralised lesions (including MIH) in the permanent dentition of 15-year-olds.

OBJECTIVE: This cross-sectional study compared the caries experience in 15-year-olds with and without demarcated hypomineralised lesions (DHL) in permanent teeth. MATERIAL AND METHODS: One thousand three hundred and two 15-year-old adolescents from two ongoing birth cohorts (GINIplus15 and LISAplus15) were examined to determine non-cavitated carious lesions (NCCL) and the DMF index. Furthermore, DHL was scored on all permanent teeth/surfaces according to the molar-incisor hypomineralisation criteria of the European Academy of Paediatric Dentistry (MIH/EAPD). Adolescents with DHL were categorised into those with a minimum of one DHL in the permanent dentition (DHL ≥ 1), with DHL on at least one first permanent molar (MIH/EAPD) and with DHL on at least one first permanent molar and permanent incisor (MIH/Severe). The study was conducted in the metropolitan area of Munich. RESULTS: The proportion of children without caries amounted to 63.7% (DMF > 0) and 26.0% (D1-4MF > 0); the caries experience was mean = 4.0(SD = 5.2) NCCL/T and 0.9(1.7) DMF/T. Existence of DHL ≥ 1, MIH/EAPD and MIH/Severe was detected in 40.2, 17.2 and 9.8% of all adolescents, respectively. The corresponding DMF/T values were: no DHL 0.9(1.7); DHL ≥ 1 1.0(1.7); MIH/EAPD 1.1(1.6); MIH/Severe 1.1(1.7). The group of adolescents with MIH/EAPD and MIH/Severe were found to have statistically higher caries rates in comparison to those with no DHL. CONCLUSIONS: Caries and DHL are prevalent and influenced the dental health of 15-year-old adolescents. A significant positive association existed between the presence of caries and DHL. CLINICAL RELEVANCE: Children with MIH/EAPD or MIH/Severe had a higher probability to develop carious lesions in the permanent dentition.

Molar incisor hypomineralisation (MIH) training manual for clinical field surveys and practice.

BACKGROUND: Despite clear assessment criteria, studies of molar incisor hypomineralisation (MIH) and hypomineralised second primary molars (HSPM) are marked by inconsistency in outcome measurements. This has detracted from meaningful comparisons between studies and limited interpretation. AIM: To provide a comprehensive manual as a companion to assist researchers in planning epidemiological studies of MIH and HSPM, with particular reference to outcome measurement. METHODS: This manual begins with a succinct review of the clinical problems and evidence for management of the conditions. The subsequent sections guide researchers through diagnosis of MIH and HSPM and implementation of both the long and short forms of a recently proposed grading system. MIH and HSPM can often be confused with fluorosis, enamel hypoplasia, amelogenesis imperfecta, and white spot lesions but can be distinguished by a number of unique clinical features. Based on the grading system, a standardised protocol is proposed for clinical examinations. Intra and inter-examiner reliability is of key importance when outcome measurement is subjective and should be reported in all epidemiological studies of MIH. The manual concludes with an exercise forum aimed to train examiners in the use of the grading system, with answers provided. CONCLUSION: The use of a standardised protocol, diagnostic and grading criteria will greatly enhance the quality of epidemiological studies of MIH.

Developmental defects of enamel in primary teeth - findings of a regional German birth cohort study.

BACKGROUND: The aim was to assess the prevalence, distribution and associated risk factors of developmental defects of enamel (DDE) in 3-year-old Thuringian children in 2013 as part of a prospective cohort study. METHODS: The subjects (n = 377) were all participants in a Thuringian oral health programme. Children of the birth cohort 2009/2010 were invited to dental examination in the first year of life, followed up with continuous dental care over the next 3 years. Dental caries was scored using the WHO diagnostic criteria expanded to the d1-level without radiography. Enamel defects were assessed according to the modified DDE Index. Data were analysed statistically (multivariate logistic regression). RESULTS: The children were aged 3.3 ± 0.7 years and 52.5 % of them were male. Caries prevalence was 15.6 % and caries experience 0.9 ± 3.3 d1-4mfs. The prevalence of DDE was 5.3 % with an average of 2.7 (±1.4) affected teeth. Second primary molars were the most affected teeth and demarcated opacities the most prevalent type. No child had Amelogenesis imperfecta and six children showed hypomineralised second primary molars. Enamel defects were associated with preterm birth (p = 0.024; OR = 4.9) and hospitalisation in the first year of life (p = 0.013; OR = 4.6). CONCLUSION: A relatively small proportion of 3-year-old Thuringian children suffered from DDE, with second primary molars as the most affected teeth and demarcated opacities as the most prevalent type of defect. Preterm birth and hospitalisation in first year of life can be considered as risk factors for DDE in the primary dentition. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00003438.

Was molar incisor hypomineralisation (MIH) present in archaeological case series?

OBJECTIVE: With respect to the unknown aetiology of molar incisor hypomineralisation (MIH), it is unclear whether this phenomenon was overlooked in the last century as a result of a high number of caries in children or if this developmental disorder was not present until then. Therefore, this study determined the presence of MIH in historical dentitions and teeth. MATERIALS AND METHODS: Dental remains from late medieval (n = 191, twelfth-sixteenth century, Regensburg, Germany), post-medieval (n = 33, sixteenth-eighteenth century, Passau, Germany) and modern age archaeological skeletal series (n = 99, nineteenth-twentieth century, Altdorf, Germany) were examined for MIH. In addition, linear enamel hypoplasia (LEH), diffuse opacities, hypoplasia and Turner's teeth were documented. RESULTS: MIH-related demarcated opacities or enamel breakdowns were found in only 15 (0.4 %) of the 3891 examined permanent teeth. Ten cases (3.1 %) from a total of 323 dentitions were classified as having MIH. In contrast, 98 individuals (30.3 %) showed LEH. Other enamel disorders were recorded in 64 individuals (19.8 %). CONCLUSION: With respect to the low number of affected dentitions and teeth, MIH most likely did not exist or was at least rarely present in the investigated archaeological case series. CLINICAL RELEVANCE: This study supports the hypothesis that MIH may be linked to contemporary living conditions or other health-related factors.

Hypomineralised second primary molars: prevalence, defect characteristics and possible association with Molar Incisor Hypomineralisation in Indian children.

AIM: To report on the prevalence, defect characteristics, and distribution of hypomineralised second primary molars (HSPM) in Gautam Budh Nagar, Uttar Pradesh, India and to report on possible association, if any, between HSPM and molar-incisor-hypomineralisation (MIH). METHODS: A cross-sectional survey included a random sample of 978, 6-8-year-old school children. EAPD diagnostic criteria for scoring MIH defects on first permanent molars (FPM) were adapted and used to score hypomineralisation defects in both FPM and second primary molars (SPM) by a single calibrated examiner. Comparative statistics for HSPM versus hypomineralised FPM were computed using a Chi square test. An odds ratio (OR) at 95 % confidence interval (CI) was used to test and any association between HSPM and MIH. RESULTS: An overall prevalence of 5.6 % (55/978) was reported for HSPM in the study population. Prevalence of MIH as hypomineralised FPM was 7.4 % (72/978). Concomitant presence of HSPM and MIH was observed in 32.73 % (18/55) of affected subjects. The presence of HSPM had significantly higher odds ratio for development of MIH (OR 7.82; 95 % CI = 4.18-14.65; p < 0.001). A greater severity of defects was observed in HSPM compared with affected FPM as greater number of affected surfaces presented with post-eruptive breakdown (PEB) in former compared to latter (p < 0.001). CONCLUSION: The prevalence of HSPM in 6-8-year-old Indian children was 5.6 %. The severity of hypomineralisation was milder in FPM compared to SPM. The presence of HSPM was reported to have significantly higher odds for development of MIH in future.