Rita Pangjaj

5th year, group 14

Knowledge and awareness toward MIH among dental students at LSMU

Master’s Thesis

Supervisor

Doctor, Sandra Petrauskienė

Kaunas, 2020

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY

FACULTY OF ODONTOLOGY

CLINIC PREVENTIVE AND PAEDIATRIC DENTISTRY

Knowledge and awareness toward MIH among dental students at LSMU

Master’s Thesis

The thesis was done

by student ................................................ Supervisor ............................................... (signature) (signature)

..................................................... ............................................................................. (name surname, year, group) (degree, name surname)

.............................. 20…. .............................. 20…. (day/month) (day/month)

Kaunas, year 2020

CONTENTS

ABBREVATION ....................................................................................................................................... 4

SUMMARY ............................................................................................................................................... 5

INTRODUCTION ..................................................................................................................................... 6

1. REVIEW OF LITTERATURE ........................................................................................................... 9

2. MATERIAL AND METHODS ........................................................................................................ 11

3. RESULTS ......................................................................................................................................... 13

4. DISCUSSION .................................................................................................................................. 19

5. CONCLUSIONS .............................................................................................................................. 21

6. ACKNOWLEDGEMENT ............................................................................................................... 21

7. ENSURING OF CONFIDENTIALITY .......................................................................................... 21

8. PRACTICAL RECOMMENDATIONS........................................................................................... 21

9. REFERENCES ................................................................................................................................. 22

10. ANNEXES ....................................................................................................................................... 26

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ABBREVATION

LSMU – Lithuanian University of Health Sciences

MIH- Molar-incisor hypominseralisation

CI - Confidence interval

GDPs – General dental practitioners

PDs – Paediatric dental specialists

FPMs – First permanent molars

EAPD – European Academy of Paediatric Dentistry

GIC – Glass ionomer cement

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Knowledge and awareness toward MIH among dental students at LSMU

SUMMARY

The aim of study: To evaluate the knowledge and awareness toward MIH among dental students at

Lithuanian University of Health Sciences.

The material and methods: A cross-sectional study enrolled dental students at LSMU during the

academic year of 2019/2020. 187 students participated with a response rate of 81.7%. A self-

administrated questionnaire covered information about definition, etiology and treatment of MIH.

Statistical analysis was performed with SPSS 19. To establish the correlation between variables, the

chi-squared test was applied. The level of significance was set at p<0.05 with a CI of 95 %. The study

was approved by LSMU Bioethics Center (No BEC-OF-59).

Results: 45.6% of undergraduates knew a correct definition of MIH. Considering the etiology factors,

final year participants showed better knowledge regarding to period of MIH development than 4th

academic year students (88.8 % vs. 67.1 %) (P<0.001). 68.7% of participants reported knowing clinical

MIH features. More Lithuanian students knew clinical MIH features than international ones (75.5 % vs.

39.5 %) (P<0.001). Only 18.5 % of undergraduates reported knowing the MIH diagnosis criteria. The

most common challenge in treating patients with MIH (41.1 %) was insufficient training among

participants.

Conclusion:

The overall knowledge and awareness toward MIH among dental students at LSMU was insufficient.

Knowledge of MIH aetiological risk factors was low among dental students at LSMU. More senior

dental students reported that they are able to implement MIH diagnosis criteria and they have

experience in treatment of MIH than younger ones.

Keywords: MIH definition, MIH aetiology, MIH clinical criteria, MIH diagnosis, knowledge of dental

students, awareness of dentists

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INTRODUCTION

Molar-incisors hypomineralisation (MIH) remains an ongoing concern in paediatric dentistry [1-4].

The term was introduced for the first time in 2001 at the congress of the European Academy of

Paediatric Dentistry as 'hypomineralisation of systemic origin, presenting as demarcated, qualitative

defects of enamel of one to four first permanent molars (FPMs) frequently associated with affected

incisors' [5]. Although MIH is a relatively new condition, it is more common than we may think.

Studies show that worldwide prevalence of MIH ranges from 2.8 % to 44 % [6-8].

The etiology of MIH remains uncertain [4,6,9]. However, researchers suggest that MIH originates due

to systemic cause and affects ameloblasts in early stage of maturation – or even earlier at the late

secretory phase [10]. Any temporary or permanent interruption of the ameloblast function may result in

enamel hypomineralisation. Defects occurring in infancy can be detected when teeth have erupted years

later, as the enamel does not undergo remodeling [11].

Studies show that predisposing factors may be such as prenatal, perinatal complications, environmental

conditions or any form of paediatric respiratory tract problem at early childhood period [12,13].

Additionally, MIH may be a consequence of use of antibiotics, oxygen starvation and low birth weight

[14].

Clinical features, diagnosis and challenges in treatment

The clinical features of MIH are influenced by its level of severity and may include clinical features

such as opacities ranging from cream-white to yellow-brown in color. The lesions are usually larger

than 1 mm and post eruptive enamel breakdown to atypical caries is located on minimum one first

permanent molar (regardless involvement of incisors). FPMs show rapid caries progress in teeth with

MIH shortly after eruption – in majority of patients – resulting in serious complications to patients as

well challenges in treatment management by dentists [15].

Early studies classified the severity levels of MIH as following [16] mild, moderate and severe.

Clinical characteristics of MIH vary from the demarcated opacities located at non-stress bearing areas

to post-eruptive enamel breakdown and crown destruction, while patients with MIH affected teeth may

report dental sensitivity and aesthetic concerns [16].

Examination for early diagnosis is recommended to begin around the age of eight, as all PFMs and

most of incisors will be present. Early diagnosis of MIH prevents further post eruptive breakdown to

happen. During examination dentist should check for the presence of changes in enamel color, opacities

and areas of enamel loss in places where commonly affects the posterior teeth [17].

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To confirm diagnosis, dentist should ask parents if they are aware of any illness that occurred during

prenatal, perinatal or postnatal period that may have resulted in this condition [15].

Treatment of teeth with MIH can be based on non-operative and operative dental treatment approaches

[18-20]. For instance, usage of an arginine paste reduces dental sensitivity due to sealing of dentinal

tubules and decreasing the number of exposed sensory afferents – achieving block of hydrodynamic

pain mechanism [18,21]. Moreover, fluoride varnish is another suggested therapeutic option [19].

Considering the success rate of operative restorative treatment, significantly greater success rate at 12

months was found after treating tooth with glass ionomer restorations compared to resin composite

restorations [20]. In contrary, studies revealed controversial results, several studies showed that resin

composite was used often as a restorative material for teeth with MIH [22,23].

However, other studies indicate high variety in choice of dental material in treating MIH-affected tooth.

One study picked the main preferred choice of filling as resin-modified glass ionomer cement [23] and

other study chose glass ionomer cement [24].

Management of young patients with severe hypomineralized molars, requires stainless steel crowns to

prevent further tooth loss [20,25].

On the other hand, tooth bleaching, micro-abrasion or composite fillings may be required because of

the aesthetical defect of the anterior teeth. In addition, the application of hydrogen-peroxide-based gels

on enamel of MIH-affected teeth can result the decreased hardness of tooth structure and

morphological alterations causing mineral loss [26].

Management of young patients with severe hypomineralized molars, requires stainless steel crowns to

prevent further tooth loss [20].

Due to its high prevalence [6-8] MIH-affected patients are frequently encountered in the dental practice

worldwide [15,22]. However, dental practitioners and undergraduates [2,27-29,30] show low

knowledge, awareness and perception regarding prevalence, aetiology and treatment management for

MIH-affected teeth. Therefore, dental practitioners and undergraduates must stay up to date and should

be provided new information on MIH – thus increasing the quality of life for the patients through

effective early preventative care.

Hypothesis

We expect that 5th year dental students have a greater knowledge and awareness than 4th year students

regarding molar-incisors hypomineralisation.

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The aim of study: To evaluate the knowledge and awareness toward molar-incisors

hypomineralisation among dental students at Lithuanian University of Health Sciences.

Objectives:

1. To collect and analyze the data related to the knowledge and awareness toward MIH among

4th and 5th year dental students of English and Lithuanian program.

2. To compare dental students’ knowledge and awareness towards MIH based on academic year.

3. To compare dental students’ knowledge and awareness towards MIH based on program of

Dentistry at LSMU.

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1. REVIEW OF LITTERATURE

1.1 The prevalence of MIH in Lithuania

Study performed by Jasulaitytė et al. revealed that 9.6% of children aged 7-9 years had moderate MIH

[31] in comparison to worldwide studies which showed a variation ranging from 2.4%–40.2% [32,33].

1.2 Worldwide studies conducted to evaluate dentists’ perception and knowledge of MIH

Numerous studies were conducted to measure perception and knowledge of MIH among dental care

workers.

Study carried out in In Hong Kong revealed that majority (71.4 %) of pediatric dentists and general

practice dentists MIH-affected cases during their dental practice, while pediatric dentists showed

significantly higher level of knowledge of MIH. However, majority of participants claimed requiring

continuing education on MIH [2].

Furthermore, Irish general dentists working in private practice or from the age 36 (or above) claimed

having less experience in MIH-related cases. Subsequently, a half of participants encountered MIH at

least weekly. Thus, dental education for dental practitioners might be recommended for effective

treatment planning for MIH [22].

Study performed in Kuwait showed a high awareness of MIH due to frequent MIH cases in their

practice. Moreover, dental specialists indicated higher confidence in diagnosis of MIH-affected teeth

than general practice dentists [25].

1.2.1 Worldwide studies conducted among undergraduates in regard of MIH

Study carried out in Saudi Arabia compared dentist (general and specialists) and dental students and

found, that majority of undergraduates (64%) had never heard of MIH and required more training in

diagnosis, while dentist required more training in treatment [30].

Equally many undergraduates (11.4 %) chose composite resin and glass ionomer cement as the most

used dental material in treating MIH-affected teeth. However, only 2 % claimed using preformed

crowns [30].

1.3 Challenges in managing treatment of MIH-affected teeth

Recent study suggested the biggest challenge in managing treatment was the child's behavior. The

second biggest challenge was achievement of successful local anesthesia [22].

Another study conducted on dentists undergoing specialist training in paediatric dentistry in UK

indicated that the biggest challenge in managing MIH was distinguishing it from other conditions. The

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trainees’ main concern was the pain of children and the clinical appearance of the condition. Both

GDPs and undergoing specialists claimed parental anxiety appeared in mainly all of the cases. Due to

the presence of challenges, both groups claimed it having a negative influence on the quality of life of

the affected paediatrics patients [34].

1.4 New treatment index to establish clear treatment guidelines

In 2007 a new treatment index was assessed and called the “The Würzburg MIH concept: the MIH

treatment need index” (MIH TNI). It was made to establish guidelines in treatment management of

MIH-affected teeth, and it is based on examination and evaluation of primary or permanent dentition.

All typical present MIH symptoms are recorded as “MIH yes” and no presence of teeth

hypersensitivity, atypical restorations or other typical clinical features of MIH as “MIH no”.

The MIH-TNI can be used in diagnosis of individual cases of MIH as well as treatment planning

depending severity [35].

1.5 Preferred treatment management of MIH among dentists worldwide

Multiple therapeutic approaches (fluoride varnish, fissure sealant, filling with composite, stainless steel

crown, and extraction) can be used to establish impact on oral hygiene and hypersensitivity in MIH-

affected children [35]. Study showed, that patients with mild symptoms, or class I usually are treated

with fluoride varnish. However, teeth on the characteristic edge between class I or class II, were treated

with fissure sealants or fillings. In severe MIH, or class III, required treatment was stainless steel crown

preparation [36].

Study carried out in Norway revealed that 53.5 % of the dentist would prefer application of fluoride

varnish for newly erupted first permanent molar with moderate MIH. Consequently, sealing the fissure

with GIC material would be the second choice. Moreover, majority of dentists would treat severe MIH

through a conventional glass ionomer restoration and only minority would treat it with stainless steel

crown [37].

Another study showed a high survival rate in managing MIH class I, II and II defects with sealants,

composite resin and stainless steel after 1-year follow-up period. The highest survival rate was for

sealants, while the lowest survival rate was seen in treatment management with composite resin and

glass ionomer cement [38].

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2. MATERIAL AND METHODS

A cross-sectional study was conducted to assess the knowledge and awareness toward MIH among

dental students at LSMU during the academic year of 2019/2020. Request application to conduct the

study was approved by Head of LSMU Bioethics Center Dr. E Peičius (No BEC-OF-59).

Participation was voluntary and anonymous; thus, the return of a completed questionnaire and the

consent signed by subjects was considered as acceptance to participate.

2.1 Subjects

A self-administrated English and Lithuanian questionnaire was distributed among 4th and 5th year

dental students (programs: Dentistry in Lithuanian and Dentistry in English) at Lithuanian University

of Health Sciences.

A total of 46 students of Dentistry in English program (4th and 5th academic year) and 183 students of

Dentistry in Lithuanian program (4th and 5th academic year) study at LSMU during the 2019/2020

study year. All dental students (4th and 5th academic year) were invited to participate in this study.

Overall, 187 students participated in the study. Response rate was 81.7%.

The inclusion criteria of subjects were dental students of the 4th and 5th academic year and willingness

to participate, while the exclusion criteria were students of other faculties and dental students of other

academic year at LSMU. Exclusions were made as following participants had lack of knowledge

regarding research topic. Meanwhile fourth year students were used as a control group, to assess level

of academic knowledge related to MIH – in comparison to final year students.

2.2 Questionnaire

An anonymous self-administrated questionnaire was developed by researcher (P.R.) and supervisor

(P.S.). Two versions of questionnaire (Lithuanian and English) were prepared to distribute.

The questionnaire composed of 16 questions covering general information (gender, program of study

and academic year) of the participants, their knowledge and awareness toward MIH, personal attitude

and experience in treatment of teeth with MIH and necessity of additional literature sources.

The knowledge and awareness toward MIH was assessed by asking to select a correct definition of

MIH (options were: MIH, dental caries, fluorosis and dental erosion), a correct period of MIH

development (options were: prenatal or postnatal until 3rd year of life and any period in life).

Question about knowing of clinical MIH features had two options (yes or no). Question about risk

factors of MIH had the following options genetic factors, environmental contaminants, medical

conditions that affect mother during pregnancy and/or the child, antibiotics/medications taken by the

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mother during pregnancy and/or the child and fluoride exposure. Later, answers of this questions were

regrouped as know the risk factors “yes” (environmental contaminants, medical conditions and

medications that affect mother during pregnancy and/or the child as options), do not know the risk

factors “no” genetic factors and fluoride exposure) and “partially know” (selected several correct

options).

Considering the personal attitude and experience in treatment of teeth with MIH, questions inquired

about knowing the clinical criteria to diagnose MIH (options were “yes, and know how to implement”,

“yes, but do not know to implement them” and “ no”), about personal lack of self confidence in

different stage of treatment of MIH (assessing diagnosis, defining risk factors of MIH and choosing the

proper treatment), about challenges while treating patient with MIH (dental treatment needs long time

to be accomplished, child’s behavior, difficulty in achieving local anesthesia or insufficient training to

treat children with MIH), about the most proper restorations for MIH (amalgam, composite resin, glass

ionomer cement, compomer or pre-formed crowns) and about the most important characteristics of

filling choice for tooth with MIH ( adhesion, aesthetics, patient/parent preference, durability,

remineralization potential abilities, sensitivity reducing or personal experience).

Questions regarding to necessity of deepening the knowledge asked if students needed additional

information or courses (yes or no), and which type of literature sources are used to improve knowledge

(dental journals, lecture notes, brochures or pamphlets, internet or textbooks).

2.3 Statistical analysis

Statistical data analysis was made through the use of SPSS Statistics version 19. To establish the

correlation between variables, the chi-squared test was applied. The level of significance was set at

p<0.05 with a confidence interval of 95 %.

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3. RESULTS

In this study females (76.9%) dominated over males (23.1%). Considering the academic year of

studies, 55.8 % of 5th year and 44.2 % of 4th year dental students were enrolled in this study. In

addition, dental students of Dentistry program in Lithuanian (78.8%) prevailed in this study (Table 1).

Table 1. Characteristics of participants by gender, academic year of studies and program of Dentistry

(N=187).

Variables N (%)

Gender (Missing N=5) Male 42 (23.1)

Female 140 (76.9) Total N (%) 182 (100.0)

Academic year of studies (Missing N=6) 4th 80 (44.2) 5th 101 (55.8)

Total N (%) 181 (100.0) Program of Dentistry (Missing N=8)

Lithuanian 141 (78.8) English 38 (21.2)

Total N (%) 179 (100.0)

Chi-square test; comparison between participants by gender, academic year and program of Dentistry

(p>0.05).

Table 2 presents participants’ knowledge and awareness toward MIH. Overall, only 45.6% of under

graduates knew a correct definition of MIH. More dental students of 4th academic year knew a correct

definition than senior ones (48.0% vs. 43.8%) (P=0.58) (Table 2).

A majority (79.2%) of dental students knew a correct period of MIH development. Moreover,

significantly more final year dental students showed better knowledge regarding to period of MIH

development than 4th academic year students significantly greater awareness regarding development

period of MIH (88.8 % vs. 67.1 %) (P<0.001). Overall, 68.7% of participants reported knowing clinical

MIH features, while senior students were self-confident than younger ones (86.9% vs. 46.2%)

(P<0.001) (Table 2). Furthermore, significantly more Lithuanian students knew clinical MIH features

than international dental students (75.5 % vs. 39.5 %) (P<0.001) (Table 3).

Considering the risk factors of MIH, a majority (91.7%) of dental students answered partially correctly.

Consequently, only 9% of final year students and 1.3 % of 4th year students knew all risk factors of

MIH correctly (P=0.002) (Table 2).

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Table 2. Participants’ knowledge and awareness toward MIH by academic year (N=187).

Variables Academic year N (%) Total N (%) p- value

4th year 5th year Knowing of MIH definition (Missing N=16)

Yes 36 (48.0) 42 (43.8) 78 (45.6) 0.58 No 39 (52.0) 54 (56.2) 93 (54.4) Total N (%) 75 (100.0) 96 (100.0) 171 (100.0)

Knowing of MIH development period (Missing N=9) Prenatal and postnatal (until 3 years old) 53 (67.1) 88 (88.8) 141 (79.2) <0.001 Anytime in life 26 (32.9) 11 (11.1) 37 (20.8) Total N (%) 79 (100.0) 99 (100.0) 178 (100.0)

Knowing of clinical MIH features (Missing N=8) Yes 37 (46.2) 86 (86.9) 123 (68.7) <0.001 No 43 (53.8) 13 (13.1) 56 (31.3) Total N (%) 80 (100.0) 99 (100.0) 179 (100.0)

Knowing of risk factors of MIH (Missing N=7) Yes 1 (1.3) 9 (9.0) 10 (5.5) 0.002 No 3 (3.7) 2 (2.0) 5 (2.8) Partially knowing 76 (95.0) 89 (89.0) 165 (91.7) Total N (%) 80 (100.0) 100 (100.0) 180 (100.0)

Chi-square test; comparison between participants by academic year.

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Table 3. Participants’ knowledge and awareness toward MIH by Dentistry program (N=187).

Variables Program of study Total N (%) p-

value

Lithuanian International Knowing of clinical MIH features (Missing N=10)

Yes 105 (75.5) 15 (39.5) 120 (67.8) <0.001

No 34 (24.5) 23 (60.5) 57 (32.2) Total N (%) 139 (100) 38 (100) 177 (100)

Personal lack of self confidence in different stage of treatment of MIH (Missing N=11) Assessing diagnosis 25 (17.9) 6 (16.2) 31 (17.6) 0.048 Defining risk factors of MIH 19 (13.7) 2 (5.4) 21 (12) Choosing the proper treatment 46 (33.1) 7 (18.9) 53 (30.1) Several reasons 49 (35.3) 22 (59.5) 71 (40.3) Total N (%) 139 (100) 37 (100) 176 (100)

Challenges in treating patients with MIH (Missing N=14) Treatment takes more time 6 (4.4) 6 (16.7) 12 (7) 0.001 Child's improper behavior 10 (7.3) 7 (19.4) 17 (9.8) Difficulty in local anesthesia 11 (8) 2 (5.5) 13 (7.5) Insufficient training 66 (48.2) 6 (16.7) 72 (41.6) Several reasons 44 (32.1) 15 (41.7) 59 (34.1) Total N (%) 137 (100) 36 (100) 173 (100)

The need of additional information (Missing N=10) Yes 122 (87.8) 34 (89.4) 156 (88.1) <0.001 No 17 (12.2) 4 (10.5) 21 (11.9) Total N (%) 139 (100) 38 (100) 177 (100)

Chi-square test; comparison between participants by Dentistry program.

Table 4 presents knowledge, personal attitude and experience in treatment of MIH among the

participants. Overall, only 18.5 % of undergraduates reported that they knew the MIH diagnosis

criteria. Subsequently, significantly more dental students of 5th academic year would be able to

implement MIH diagnosis criteria than 4th academic year ones (27.3 % vs. 7.6 %) (P<0.001). 40.4 % of

dental students stated having personal lack of self confidence in different stages of treatment of MIH

such as assessing diagnosis, defining risk factors of MIH or choosing the proper treatment (Table 4).

Moreover, significantly more international dental students reported several reasons than Lithuanian

dental students (69.5% vs. 35.3%) (P=0.0048) (Table 3).

Furthermore, a minority (6.1%) of participants had experience in treatment of MIH. In addition,

significantly more senior year dental students reported having experience in treatment of MIH than the

4th academic year ones (10.0% vs. 1.3%) (P=0.015) (Table 4).

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The most common challenge in treating patients with MIH (41.1 %) was insufficient training among

participants in both 4th and 5th academic year groups (P=0.003) (Table 4). Subsequently, significantly

more international dental students chose several reasons, while Lithuanian dental students reported

insufficient training (41.7% vs. 48.2%) (P=0.001) (Table 3).

Regarding question of the most proper restoration for MIH, a half (52.2 %) of dental students

mentioned several proper restorations. Additionally, composite resin (31.2 %) was the most popular

option among 4th year students, while several options (70.4%) were the most common among senior

dental students (P<0.001) (Table 4). A majority (78.3 %) of students reported several characteristics of

filling for tooth with MIH. In addition, significantly more 5th year dental students chose more than one

characteristic of filling for tooth with MIH than 4th year dental students (86.0% vs. 68.7%) (P=0.016).

Overall, 88.3 % of all students claimed they needed additional information regarding MIH (Table 4).

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Table 4. Participants’ knowledge, personal attitude and experience in treatment of MIH by their

academic year (N=187).

Variables Academic year N (%) Total N (%)

4th year 5th year Knowing of MIH diagnosis criteria (Missing N=9)

Would implement in practice 6 (7.6) 27 (27.3) 33 (18.5) Would not implement in practice 30 (38) 51 (51.5) 81 (45.5) Would not know how to diagnose MIH 43 (54.4) 21 (21.2) 64 (36.0) Total N (%) 79 (100.0) 99 (100.0) 178 (100.0)

Personal lack of self confidence in different stage of treatment of MIH (Missing N=11) Assessing diagnosis 10 (12.5) 21 (21.4) 31 (17.4) Defining risk factors of MIH 14 (17.5) 7 (7) 21 (11.9) Choosing the proper treatment 24 (30.0) 30 (30.6) 54 (30.3) Several reasons 32 (40.0) 40 (41.0) 72 (40.4) Total N (%) 80 (100.0) 98 (100.0) 178 (100.0)

Having of experience in MIH treatment (Missing N=7) Yes 1 (1.3) 10 (10.0) 11 (6.1) No 79 (98.7) 90 (90.0) 169 (93.9) Total N (%) 80 (100.0) 100 (100.0) 180 (100.0)

Challenges in treating patient with MIH (Missing N=12) Treatment takes more time 8 (10.4) 4 (4.1) 12 (6.9) Child's improper behavior 12 (15.6) 5 (5.1) 17 (9.7) Difficulties in local anesthesia 10 (12.9) 4 (4.1) 14 (8) Insufficient training 24 (31.2) 48 (48.9) 72 (41.1) Several reasons 23 (29.9) 37 (37.8) 60 (34.3) Total N (%) 77 (100.0) 98 (100.0) 175 (100.0)

The most proper restorations for MIH (Missing N=9) Amalgam 1 (1.3) 0 (0.0) 1 (0.5) Composite Resin 25 (31.2) 11 (11.2) 36 (20.2) GIC 17 (21.2) 13 (13.3) 30 (16.8) Compomer 5 (6.3) 1 (1.0) 6 (3.4) Pre-formed Crowns 8 (10.0) 4 (4.1) 12 (6.9) Several 24 (30.0) 69 (70.4) 93 (52.2) Total N (%) 80 (100.0) 98 (100.0) 178 (100.0)

The most important characteristics of filling choice for tooth with MIH (Missing N=7) Adhesion 1 (1.3) 0 (0.0) 1 (0.6) Aesthetics 4 (5.0) 3 (3.0) 7 (3.9) Durability 4 (5.0) 6 (6.0) 10 (5.6) Abilities to remineralise, sensitivity reducing 12 (15.0) 5 (5.0) 17 (9.4) Personal experience 4 (5.0) 0 (0.0) 4 (2.2) Several reasons 55 (68.7) 86 (86.0) 141 (78.3) Total N (%) 80 (100.0) 100 (100.0) 180 (100.0)

The need of additional information (Missing N=8) Yes 70 (87.5) 88 (88.9) 158 (88.3) No 10 (12.5) 11 (11.1) 21 (11.7) Total N (%) 80 (100.0) 99 (100.0) 179 (100.0)

Chi-square test; comparison of dental students by academic year.

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Figure 1 presents participants’ commonly used literature sources to study about MIH. Overall, majority

(55 %) of 4th year dental students reported that they do not need any additional literature sources to

study about MIH, while most (55.5%) of the 5th year dental students explained using several sources of

literature to deepen the knowledge toward MIH (P>0.05).

Chi-square test; comparison between participants by academic year (P>0.05)

Figure 1. Variety of literature sources about MIH used by dental students at LSMU.

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4. DISCUSSION

Overall, less than a half of 4th and 5th year dental students of English and Lithuanian program knew a

correct definition of MIH, thus knowledge toward MIH dental students was low insufficient in this

study. Moreover, a minority of dental students chose aetiological risk factors of MIH correctly.

Dental students are introduced and taught about developmental defects of enamel in various specialty

subjects during the Dentistry studies at LSMU. Consequently, results revealed that knowledge and

awareness toward MIH among dental students should be improved.

This study showed that a high share (88.3%) of participants are interested to study additional literature

sources regarding to MIH. Moreover, study performed in Australia and Chile highlighted the

importance of up-to-date guidelines regarding MIH in order to increase awareness and understanding

about MIH among general practitioners [29].

Considering the most proper restorative materials for MIH-affected teeth, in this study most senior

students preferred using several dental materials when managing MIH-affected teeth. Furthermore, the

same line of findings was noticed in the other studies as well [22,23]. In addition, composite filling was

common choice among dental students at LSMU. Subsequently, recently carried out another study

reported a high success rate for composite in MIH-affected teeth and it was recommended in the EAPD

guidelines [22].

On the other hand, dentists' poor knowledge and improper treatment of MIH can have consequences in

the MIH-affected children throughout adolescents. If defect of MIH becomes too severe, it may result

in tooth loss. Later, esthetical complication can have a huge impact on the self-esteem among the

patients suffering this condition [39]. Thus, improving of curriculum of pediatric dentistry and other

subjects may improve knowledge and raise awareness among dental students and general practitioners

later.

Furthermore, a majority (79.2 %) of the undergraduates was able to identify correct time of insult of

MIH such as “prenatal or postnatal until 3rd year of life”. Hence, other study discussed the possibility

of an aetiological agent causing the diseases to express itself until the age of 5 or even 6 years of age

[7].

20

Overall, knowledge regarding diagnosis criteria of MIH was low and most students experienced

challenges in managing MIH due to insufficient training. Another study comparing general dental

practitioners and dental specialists, showed that GDPs had significantly lower confidence in diagnosing

MIH – and claimed that one of the barriers to treat MIH patients was insufficient training.

Consequently, their request for further clinical training was significantly high [28]. Furthermore, a

similar request for a training course regarding MIH was reported among Saudi dentists [30].

Our study reported low confidence among the dental students in different stages of treatment of MIH

such as assessing diagnosis, defining risk factors of MIH or choosing the proper treatment.

On contrary, a study showed that over 90 % of the paediatric dentist were confident in terms of

diagnosis in MIH – in comparison to 55.7% of GDPs [2]. Furthermore, while more than half of

pediatric dentists claimed receiving information on MIH, only 8.8% of the GDPs reported receiving

some information on MIH. The reason behind the high confidence among PDs is the essential training

they get on MIH during their training course. However, it implemented the need for continuing

education seminars and guidelines in Hong Kong – so more GPDs can recognize and diagnose MIH

and manage treatment of simple cases for secondary care [2].

This is a condition with high prevalence [6-8] and frequently encountered in the dental clinics

[15, 22] therefore, the awareness must increase regardless of level of profession among dentists.

Overall, final year students showed better knowledge regarding clinical MIH features (68.7%).

Furthermore, significantly more Lithuanian students knew clinical MIH features than international

dental students (75.5 % vs. 39.5 %). However, these results may be misleading due to such unequal

distribution among dental students of Lithuanian and English program. For a more concrete result,

equal number of students from respectively program of Dentistry, should have conducted in the study.

Our results confirm our hypothesis as dental students of 5th academic year had significantly greater

awareness, in comparison to undergraduates, in majority of aspects.

21

5. CONCLUSIONS

1. The overall knowledge and awareness toward MIH among dental students at Lithuanian University

of Health Sciences was insufficient.

2. More dental students of 4th academic year knew a correct definition than senior ones. Knowledge of

MIH aetiological risk factors was low among both 4th and 5th academic year students. More senior

dental students reported that they would be able to implement MIH diagnosis criteria than 4th academic

year ones. Significantly more senior year dental students reported having experience in treatment of

MIH than the 4th academic year ones.

3. Significantly more Lithuanian dental students knew clinical MIH features than international dental

students. Meanwhile, international dental students tended to sort out several reasons of challenges in

treatment of MIH affected teeth, while Lithuanian dental students reported mainly insufficient training.

6. ACKNOWLEDGEMENT

I would like to thank my supervisor Dr. Sandra Petrauskienė for her invaluable assistance and guidance

through this period of time. In addition, the author would also like to acknowledge all the odontology

students who were willing to participate in the survey and make this study possible.

7. ENSURING OF CONFIDENTIALITY

Confidentiality of participants was ensured as no personal data needed to be shared. The name,

surname and address were not included in this survey.

8. PRACTICAL RECOMMENDATIONS

Proper knowledge of dental students in regards of MIH can influence better prevention and treatment

management of MIH in the future. Therefore, I believe it is necessary to raise awareness about MIH

among dental students, and dental practitioners, early in their practice. This can be achieved through

adding MIH-related cases in the curriculum of paediatric dentistry.

22

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26

10. ANNEXES

10.1 Questionnaire in English

KNOWLEDGE AND AWARENESS TOWARD MIH (MOLAR-INCISOR

HYPOMINERALIZATION) AMONG DENTAL STUDENTS AT LSMU

ABOUT YOU:

Gender: Male/Female

I am a student of the following program of Odontology: Lithuanian/ English

Academic year of studies: 4 / 5

Please choose the most suitable answer of the following questions (please circle):

What is the correct definition of MIH?

□ It is a common disorder, characterized by

hypomineralization of tooth enamel caused by

ingestion of excessive fluoride during enamel

formation.

□ It is a deficit in the mineralisation process of

permanent first molars and, less frequently,

incisors, resulting from a lack of calcium and

phosphate fixing on the matrix formed by the

ameloblasts.

□ It is a heritable disorder, which manifests as

hypoplasia, hypocalcification or

hypomaturation of enamel.

□ It is a localized chemical dissolution of the

tooth surface caused by metabolic events taking

place in the biofilm (dental plaque) covering

the affected area.

What time/period do you think the insult

occurs?

□ Prenatal or postnatal until 3rd year of life

□ Period of life does not play a role.

Do you know the clinical features of MIH?

□ Yes.

□ No.

Do you know if there are clinical criteria to

diagnose MIH?

□ Yes, and know how to implement them.

□ Yes, but do not know how to implement

them.

□ No.

Which factors are involved in the aetiology

of MIH?

□ Genetic factors.

□ Environmental contaminants.

□ Medical conditions that affect mother during

pregnancy and/or the child.

□ Antibiotics/Medications taken by the mother

during pregnancy and/or the child.

□ Fluoride exposure.

What type of material do you often use in

treating MIH tooth?

□ Amalgam.

□ Composite Resin.

□ Glass Ionomer Cement.

□ Compomer.

□ Pre-formed Crowns.

27

Which factors/factor do/does influence your

choice of restorative material?

□ Adhesion.

□ Aesthetics.

□ Patient/parent preference.

□ Durability.

□ Remineralization potential abilities.

□ Sensitivity reducing.

□ Personal experience.

Which of following would represent a

barrier performing MIH management?

□ Dental treatment that needs long time to be

accomplished.

□ Child's behavior (uncooperative child).

□ Difficulty in achieving local anesthesia.

□ Insufficient training to treat children with

MIH.

Have you ever treated a patient with MIH

during your dental school training?

□ Yes.

□ No.

Would you suggest including more MIH-

associated cases in the curriculum of the

”Paediatric dentistry”?

□ Yes.

□ No.

What are the areas do you think you need to

know/be taught about the most?

□ Diagnosis.

□ Aetiology.

□ Treatment.

Are you receiving any information on MIH?

□ Yes.

□ No.

If YES, through which source?

□ Dental journals.

□ Lecture notes.

□ Brochures or pamphlets.

□ Internet.

□ Textbooks.

28

10.2 Questionnaire in Lithuanian

LSMU ODONTOLOGIJOS STUDENTŲ ŽINIOS IR SUVOKIMAS APIE KANDŽIŲ-

MOLIARŲ HIPOMINERALIZACIJĄ.

APIE JUS:

Lytis: Vyras /Moteris

Aš studijuoju Odontologiją LSMU: Lietuvių kalba / Anglų kalba

Studijų kursas : 4 / 5

Pažymėkite jums tinkamiausią atsakymą:

Kuris iš šių teiginių yra moliarų-kandžių

hipomineralizacijos apibrėžimas?

□ Tai sisteminė liga, kuri atsiranda dėl

ilgalaikio lėtinio per didelio fluoro kiekio

poveikio ameloblastams danties formavimosi ir

mineralizacijos metu.

□ Tai liga, kuri atsiranda dėl kalcio ir fosfatų

jonų trūkumo kandžių ir pirmųjų nuolatinių

krūminių dantų užuomazgų vystymosi

laikotarpiu.

□ Tai susirgimas, kuris išsivysto dėl anomalijos

tam tikruose genuose ir pasireiškia sistemine

emalio hipoplazija, bei nėra lydimas jokios

kitos bendrinės patologijos.

□ Tai daugiapriežastinė lėtinė kietųjų danties

audinių liga, sukelianti emalio ir dentino

demineralizaciją.

Kaip manote, kuriuo gyvenimo periodu

įvyksta šis danties audinių pažeidimas?

□ Prenataliniu ar postnataliniu periodu iki 3

metų.

□ Bet kuriuo gyvenimo periodu.

Ar žinote kandžių-moliarų

hipomineralizacijos klinikinius požymius?

□ Taip.

□ Ne.

Ar žinote kokiais klinikiniais kriterijais

remiantis diagnozuojama kandžių-moliarų

hipomineralizacija?

□ Taip, žinau ir moku pritaikyti praktikoje.

□ Taip, žinau, bet nemoku pritaikyti praktikoje.

□ Nežinau.

Kuris/Kurie iš šių veiksnių gali sukelti

kandžių-emalio hipomineralizaciją?

□ Genetiniai faktoriai.

□ Aplinkos tarša.

□ Mamos ligos bei būklės nėštumo periodu.

□ Antibiotikų ar kitų medikamentų vartojimas

nėštumo periodu ar ankstyvosios vaikystės

metu.

□ Per didelis fluoridų kiekis.

Kuri/Kurios restauracinė/ės medžiaga/os

tinkamiausios plombuojant dantis, pažeistus

moliarų-kandžių hipomineralizaciją?

□ Amalgama.

□ Kompozicinė restauracija.

□ Stiklo jonomerinis cementas.

□ Kompomeras.

□ Standartiniai plieno vainikėliai.

29

Kuris/Kurie iš šių veiksnių labiausiai lemia

restauracinės medžiagos pasirinkimą?

□ Resauracijos adhezijos ypatumai.

□ Restauracijos estetika.

□ Paciento ar jo tėvų įgeidžiai.

□ Restauracijos ilgaamžiškumas (laikomumas).

□ Remineralizacinės plombos savybės.

□ Dantų jautrumo mažinimas.

□ Asmeninė patirtis.

Su kokiais sunkumais susiduriat gydydami

kandžių-moliarų hipomineralizacijos

pažeistus dantis?

□ Dantų gydymas ilgiaus trunka nei įprastai.

□ Neigiama vaiko reakcija į dantų gydymą.

□ Silpniau veikiantis vietinis nuskausminimas.

□ Patirties stoka gydant vaikus su kandžių

moliarų hipomineralizaciją.

Ar savo praktikoje jau pasitaikė pacientų su

kandžių-moliarų hipomineralizacija?

□ Taip.

□ Ne.

Ar norėtųsi, jog daugiau dėmesio būtų

skiriama kandžių-moliarhipomineralizacijai

”Vaikų odontologijos” studijų programoje?

□ Taip.

□ Ne.

Kurioje iš šių sričių labiausiai trūksta žinių?

□ Nustatant diagnozę.

□ Įvardijant etiologija.

□ Pasirenkant gydymo taktiką.

Ar randate informacijos apie kandžių-

moliarų hipomineralizaciją?

□ Taip.

□ Ne.

Jei atsakėte TAIP, kokiais informacijos

šaltiniais naudojatės?

□ Žurnalais apie odontologiją.

□ Paskaitų medžiaga.

□ Lankstinukais.

□ Internetu.

□ Vadovėliais.

30

10.3 Bioethics approval