Objective: This pilot studywas to investigate correlations between molar incisor hypomineralization (MIH) and dental fear.
Materials and Methods: Data were compiled from the dental records of 90 8-12-years-old children with mild/severeMIH. Dental examinations were performed by one calibrated examiner (BS) in university dental clinic, after the children had brushed their teeth, using an intraoral mirror. All the children completed the children’s fear survey schedule—dental subscale (CFSS-DS)Turkish version questionnaire. MIH scores were recorded using EAPD criteria. Data were analysed with SPSS®.
Outcomes: The total number of children in the sample was 90 with 40 boys and 50 girls. The mean age of MIH patients was 8.93±1.33. CFSS-DS scores of children with mild/severe MIH were found as 31.4±10.67. CFSS-DS mean scores were 31.57±11.93 and 31.26±9.65 for boys and girls, respectively, the difference not being statistically significant.Regarding the individual items in the questionnaire, the item ‘injections’ seemed to evoke most stress in children with MIH in both gender. (3.21±1.41)
Conclusions: Children with MIHof their first molars had undergone a considerable amount of dental treatment. Experience of pain and repeated treatment process may be responsible for dental fear in these patients. Altough, a lack of association found between MIH and dental fear in Turkish childrenin this pilot study.
Keywords: Molar-incisor hypomineralization (MIH), behaviour management, dental fear
Despite the decrease in caries prevelance in the last 30 years, there is a group of lesions that increase the caries susceptibility of the first permanent and second decidous molars and ac-celerate the progression of the existing caries. Individuals affected by this condition, especially during and after eruption; refer to dentists due to rapid structural destruciton. Clinically, defects of enamel affected by MIH range from mild or severe demarcated opacities to posteruptive enamel breakdown or atypical caries. The prevalance of MIH is known to range from 2,8 to 44%.[3,4]
Teeth affected by MIH can cause problems to a patient as a result of hypersensitivity to mechanical and thermal stimuli. Children often import shooting pains when they are eating cold or hot foods or drinks or even breathing cold air shortly after the eruption of these teeth has started.  It is known that in non-carious teeth affected by MIH, microorganisms had penetrated into enamel and dentine. Mechan-ical, thermal or bacterial irritants can effect the dentine through the enamel with defects and cause inflammatory reactions in the pulp.  This inflammation can lead to insufficient anaesthetization, making therapy more painful.  At clinical examination, when the children open their mouths, they react intensely to air blowing.  In addition, first permanent molars or incisors affected by MIH are more impres-sionable to restoration failure and repeated treatments because of the prismatic morphol-ogy in the defective enamel is altered making bonding risky. [5, 8–10]
Dental behaviour management problems and dental fear and anxiety are common when treating child patients.  Several risk factors for developing behaviour management and anxiety problems have been identified, e.g. low age, parents’ dental fear, general anxiety, or painful treatments. The difficulties in lay-ing in sufficient anaesthesia and the frequent treatments, children with MIH can be at risk for behaviour management and dental anxiety problems. Two studies in Sweden [5,11] that investigated relationship between enamel hypomineraliza-tion and dental fear and behaviour management problems showed that behaviour management problems were common in children with severe MIH, although their dental fear did not differ significantly at either age. An another study in Greece that explored these relationship showed that the difference of anxiety scores between children with and without MIH were not being statistically significant. 
One of the most commonly used psycho-metric measures for dental anxiety is the Chil-dren Fear Survey Schedule–Dental Subscale (CFSS-DS), that was developed by Cuthbert and Malamed  to evaluate the level of dental anxiety between pediatric patients and this subscale has been translated to several languages and is informed to have high va-lidity and consistency. [13, 14] The Turkish version of the CFSS-DS is a valid and reliable instrument and may be included in assessments design to evaluate dental anxiety and fear in children. These version was validated in 2006 by Seydaoglu et al. The aim of this pilot study was to investigate the dental fear among children with MIH using by Turkish version of CFSS-DS.
Materials and methods
Study Design and Sample Selection
This pilot study was a part of a larger project, also researching MIH prevelance, severity, treatment need, caries experience and poste-rior and anterior teeth treatment options. The study was approved by the Ethics Committee of the Marmara University, Dental School in Istanbul. Participants were chosen among the children who referred Marmara University, Dental School, Department of Paediatric Den-tistry Clinic. Each patient’s parents was given an informed consent form and the children included in this study were those present at clinic on the day of the examination with signed parental consent. 90 children had at least one first permanent molar with MIH. The children were 8–12 years-old when the questionnaire was answered.
Examiation and Data Collection
After brushing with routine oral hygiene procedures, all children were examined by one trained and calibrated examiner (BS) in pediatric dentistry clinic with a dental mirror and artificial room and unit light. MIH was recorded on teeth according to the EAPD criteria.Every child completed the Turkish version of CFSS-DS. CFSS-DS’s Turkish version has been found to have adequate validity and reliability.15 This 15-item psychometric scale includes a kind of dental stimuli, such as injec-tions, drilling, having someone’s teeth cleaned and more general aspects. Children rank their fear on each of these items on a 1-5 scale with 1 meaning ‘not afraid at all’ and 5 meaning ‘very afraid’.[14, 15]
Input and descriptive analyses of the data were performed using Microsoft Excel® software, and statistical analyses with SPSS® procedures.
The total number of children in the sample was 90 with 40 boys and 50 girls. The mean age of MIH patients was 8.93±1.33. CFSS-DS scores of children with mild/severe MIH were found as 31.4±10.67. CFSS-DS mean scores were 31.57±11.93 and 31.26±9.65 for boys and girls, respectively, the difference not being sta-tistically significant. These data at both gender are summarised in Table 1.
Regarding the individual items in the questi-onnaire, the item ‘injections’ seemed to evoke most stress in children with MIH in both gender. (3.21±1.41) The items ‘the dentist drilling’, ‘the sight of the dentist drilling’ and ‘the noise of the dentist drilling’ followed by ‘injections’ were the ones scoring highest. (2.66±1.19; 2.62±1.19; 2.54±1.24 respectively) In both gender groups, there were no statistically significant differences between children with MIH for any of the indi-vidual items. Items that create the least stress; ‘people in white uniform’, ‘having to open your mouth’ and ‘having to go to the hospital’, respectively. (1.54±0.86; 1.61±0.94; 1.67±1.04 respectively). Table 2 shows items of CFSS-DS mean scores.
The CFSS-DS mean score for the total sam-ple of this study (31.4) was higher than the 21.9 reported in two studies in Sweden that included 73 children with enamel hypoplasia and 41 ones for control concerning MIH and its correlation with dental fear.5,11 Likewise, the CFSS-DS mean score that found in this study was higher than the 26.3 and 24.8, respectively, reported in two another studies in Greece.8,17 Differences in cul-tural, enviromental and health care systems and entire population strategies carried out in Sweden and Greece may be responsible for these discre-pancy. Additionally, no statistically significant difference was found between anxiety scores in children with and without MIH with the above these Swedish and Greek studies.
Gender may be a factor in dental fear and anxiety. Generally, girls are informed to import more dental fear than boys but influence of gender on dental anxiety remains controversial.  Although, in this study, we found that the dental fear in boys with MIH was higher than girls; between the difference was not statistically significant. Controversially, in Kosma’s study showed that the girls expressed higher levels of dental fear and this difference was reflected in all sample. This results agrees with previous studies. [5, 11]Scores of 38 or more have been associated with dental fear or anxiety.  If applied to this research, 15 children with MIH should present dental fear or anxiety.Dental fear and anxiety problems are not ne-cessarily associated. In the present clinical study, data were collected on self-reported child dental anxiety only. Mixed data on dental fear and an-xiety could add to understanding the impact of MIH on children and to designing best treatment and management.
Children with molar-incisor hypominerali-zation had undergone a considerable amount of dental treatment. Experience of pain and repeated treatment process may be responsible for dental fear or anxiety in children with MIH. Various pain-reducing procedures (local anaesthesia or sedation eg.) should be used in treatment of these teeth. In cases of severe disintegration of the first permanent molars’ crowns, in cases of repeated treatments or irreversible pulpitis; extraction should be recommended.
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