Knowledge, perceptions, attitudes, and clinical experiences on molar incisor hypomineralization among Syrian pediatric dentists and general dental practitioners: a cross-sectional study

Ethical approval was obtained from the institutional review board of Damascus University (N 223/2022) prior to data collection, and the study was performed in accordance with the Declaration of Helsinki. Participants were pediatric dentists (PDs) and general dental practitioners (GDPs) who were members of the Syrian Dental Syndicate of Damascus. Google Forms software survey was used to create an online Arabic questionnaire. A questionnaire was designed based on existing validated questionnaires [10‐13]. The questionnaire was first piloted by a group of PDs and GDPs to ensure that the questions were easy to understand and took no longer than 5 min to complete. “Not sure” choice was added for questions regarding restorative material selection. In addition, “fluoride” and “sealant” options were added for the second question in the clinical problems section.

An Arabic version of the questionnaire was distributed to Damascus Dental Syndicate members (n = 1936) via email in March 2022. The email declared that participation was anonymous and optional, and the researchers had no access to the participants’ personal data. It was also distributed via social networks (Facebook, Twitter, Whatsapp, etc.). The questionnaire was online for 2 months. The inclusion criteria for questionnaire participants were: (1) members of Damascus Dental Syndicate, (2) GDPs, (3) PDs.

Data were entered into an excel spreadsheet (Microsoft Excel, Microsoft Corp, WA, USA) by Google Forms. Statistical analysis was performed using IBM SPSS software v. 23 (IBM Corp., Armonk, USA). Descriptive analysis (simple frequency distribution, and percentage) was determined. Significant differences between the two study groups (GDPs, and PDs) were checked using Pearson’s chi-square test. The level of statistical significance was set at 0.05 (p < 0.05). Multivariate regression models were used to assess the relationship between independent variables (years of practice, and the frequency of encountering MIH patients) and restorative material selection as a parameter. For the multivariate model, the statistical significance level was set as 0.25 as the 0.05 level of significance can fail in identifying important variables [14].

Table 1 shows the demographic characteristics. Of the participants, 82.21% were GDPs, 17.78% were PDs, 54.20% were male, and 45.80% were female. Most GDPs (36.51%), and PDs (43.20%) were 26–30 year old. Similarly, most GDPs (67.65%), and PDs (44.00%) had fewer than 5 years of practice. More than half of the GDPs (59.86%), and PDs (45.60%) worked in the private sector, while the remaining participants were distributed across public (GDPs: 15.57% vs. PDs: 25.60%) and combined sectors (GDPs: 24.57% vs. PDs: 28.80%).

Participants’ knowledge regarding MIH is listed in Table 2. PDs were significantly more familiar with MIH (p < 0.001), more confident when diagnosing MIH (p < 0.001), and implemented clinical criteria to diagnose MIH (p < 0.001) compared to GDPs. A good proportion of participants (52.22%) reported that amelogenesis imperfecta was difficult to distinguish from MIH. However, enamel hypoplasia was the only defect that showed a significant difference between the groups (p = 0.003). Regarding the etiological factors of MIH, most participants believed that genetic factors (GDPs: 64.90% vs. PDs: 45.53%) and acute medical conditions during pregnancy (GDPs: 48.74% vs. PDs: 54.46%) were involved in the etiology of MIH.

Perceptions of responding participants of MIH are presented in Table 3. 39.83% of GDPs had noticed hypomineralized teeth annually, while most of PDs (36.61%) had made diagnosis of MIH weekly (p < 0.001). In addition, 67.97% of GDPs, and 58.93% of PDs reported that < 10% of their patients presented MIH (p = 0.001). Yellow–brown demarcated opacities were the most clinical defects noticed by participants (p = 0.006), followed by white demarcated opacities and post-eruptive enamel breakdown. In terms of prevalence, 64.29% of PDs claimed that MIH prevalence had been increasing in Syria in recent years, with a significant difference to GDPs (p < 0.001). Regarding patients’ quality of life, there were significant differences between the two groups for the problem of pain (p = 0.043), appearance (p = 0.040), anxiety (p = 0.005), and missing school (p = 0.023). PDS were more concerned than GDPs about the pain experienced and missing school, while GDPs were more concerned about the anxiety experienced and the appearance of the defect. Furthermore, 22.29% of the participants perceive parents’ anxiety toward dental treatment under general anesthesia.

Table 4 shows participants’ practices and clinical experiences on MIH. Stainless steel crowns were the material of choice for molars with post-eruptive fractures (GDPs: 51.81% vs PDs: 50.00%). However, there were significant differences to GDPs in the use of flowable composite resin (p = 0.001), and Silver diamine fluoride (p = 0.006). In contrast, there was a significant difference to PDs in the use of resin modified glass ionomer cement (RMGIC) (p = 0.022). As for molars with opacities, composite resin was the material of choice (GDPs: 44.01% vs PDs: 34.82%), with significant differences to GDPs in the use of compomer (p < 0.001). Similarly, composite resin was the material of choice for incisors with opacities (GDPs: 67.40% vs PDs: 67.85%). However, there were significant differences to GDPs in the use of flowable composite resin (p = 0.024). Durability was the main factor when deciding which material to use among participants (GDPs: 77.43% vs. PDs: 73.21%), with significant differences to PDs in adhesion (p < 0.001), and esthetics (p = 0.005) factors. In contrast, there was a significant difference to GDPs in experience in choosing restorative materials (p = 0.021). The multivariate regression model demonstrated that composite resin, stainless steel crown, and glass ionomer cement (GIC) were significantly preferred by participants with more than 15 years of practice for molars with opacities. Moreover, RMGIC was significantly less preferred by participants who have more than 15 years of practice for molars and incisors with opacities. In addition, composite resin was significantly less preferred by participants with less than 5 years of practice for incisors with opacities. For molars with post-eruptive eruption, years of practice was not a predictor for restorative material selection. However, the frequency of encountering MIH patients was a predictor for the latter parameter and flowable composite resin was significantly the most preferable material for dentists who encounter MIH patients weekly. In addition, they prefered stainless steel crowns and composite resin restorations for molars with post-eruptive breakdown and incisors with opacities. Regarding MIH referral considerations, approximately half of GDPs (53.20%) would refer a child with MIH signs to a dental specialist, while most of PDs preferred treating MIH-affected children themselves (p < 0.001). More than half of PDs (58.93%) used a specific diagnosis index, compared to only 8.64% of the GDPs (p < 0.001). Regarding clinical management difficulties, more than the third of the participants said that esthetics (GDPs: 33.15% vs. PDs: 41.96%) and long-term success of restoration (GDPs: 38.16% vs. PDs: 42.86%) were often challenging issues (Table 4).

Table 5 shows dentists’ attitudes toward MIH. The majority of GDPs (89.14%) did not receive any information on MIH, while 62.50% of PDs did (p < 0.001). Among those who received information on MIH, continuous education (GDPs: 58.97% vs. PDs: 70.00%) was the main source of knowledge, followed by the internet (GDPs: 58.97% vs. PDs: 42.85%) and journals (GDPs: 48.71% vs. PDs: 48.57%). Almost three-quarters of the participants agreed on the necessity of information in the field of diagnosis (GDPs: 78.55% vs. PDs: 72.32%) and treatment (GDPs: 81.05% vs. PDs: 62.50%) of MIH.

As presented in the first clinical case (Fig. 1), most of the participants (GDPs: 36.77% vs. PDs: 46.43%) suggested placing a GIC restoration (Table 6). However, the multivariate regression model demonstrated that composite resin was significantly the most relevant restorative material among participants who have more than 15 years of experience. For the second clinical case (Fig. 2), the majority of the participants supported the removal of all the affected MIH tissue until a healthy margin is reached. Moreover, composite resin was the material of choice for most GDPs (23.96%), while 35.71% of PDs preferred GIC restoration (Table 6). Moreover, the same treatment approach was preferred by dentists with more than 15 years of practice. However, dentists who encountered MIH patients on a weekly basis selected GIC restoration as the material of choice.