Oral Epidemiology

Epidemiologie study of idiopathie Goran Koch, Anna-Lena Hallonsten,

Nils Ludvigsson, Bengt Olof Hansson,
Annalena Hoist and Christer Ullbro

enamel hypomineralization in Department of Pedodontics, The Institute for

Postgraduate Dental Education, Jonkoping,
Sweden

permanent teeth of Swedish children

K o c h G, Hallonsten A-L, Ludvigsson N, Hansson BO, Hoist A, Ullbro C: Epidemio-
logie study of idiopathie enamel hypomineralization in permanent teeth of Swedish
children. Community Dent Oral Epidemiol 1987; 15: 279-85.

Abstract - In the late seventies an increasing number of children showing extensive

a n d severe idiopathie hypomineralization of the enamel of incisors and perrnanent
first molars was reported within the Public Dental Services in Sweden. An epidemio-
Key words: dental enamel hypoplasia; dental
logie study was initiated to analyze the prevalence, extension and severity in Swedish hypomineralization; developmental dental
children born in 1970 and in the years before and after. 2252 children born in defects
1966-74 were examined according to well defined criteria on enamel hypomineraliz- G. Koch, Department of Pedodontics, The
ation. It was found that 15.4% ofthe children born in 1970 showed such changes. Institute for Postgraduate Dental Education,
T h e corresponding figures for children born in 1966, 1969, 1971, 1972 and 1974 were Box 1030, S-551 11 Jonkoping, Sweden
6.3, 7-3, 7.1, 5.2 and 4.4, respectively. Accepted for publication 7 March 1987

; Developmental enamel defects are basi- enamel can be genetic (e.g. amelogenesis found around 1970 (14). However, these
cally classified under hypoplasia and/or impeifecta), acquired (e.g. high fluoride data gave no information about the
hypomineralization. There is a large intake, hypocalcemia, local trauma and prevalence. EKLUND (13) reported a
number of known etiologic factors re- infection) and idiopathie. prevalence of 4.5-7.4% for extensive
' sponsible for the development of enamel In the literature enamel opacities in idiopathie hypomineralization in Swed-
disturbatices (1). If amelogenesis imper- permanent teeth have been reported to ish children born in 1967 and 1970.
fecta of the hypomineralized type and occur in 22-80% of the population In view of the reported increased
fluorosis are excluded, hypomineral- (5-13). All these studies were performed prevalence of idiopathie hypominerali-
ization is often referred to in the litera- in low fluoride areas. The variation in zed permanent teeth in children born
• t u r e as non-fluoride enamel opacities, prevalence in the studies cited can, to during the seventies it was seemed im-
internal enamel hypoplasia, non-endemic great extent, be explained by differences portant to perform an epidemiologie
niottling of enamel, opaque spots, idio- in diagnostic criteria. Data on the exten- study on the prevalence, extension and
' pathic enamel opacities and enamel sion and the severity of opacities in indi- severity of idiopathie enamel hypo-
opacities (2). In the FDf Technical Re- viduals are sparsely reported in the litera- mineralization in children born in 1970
; p o r t No. 15, 1982 (3), on developmental ture, except for the distribution of dental and before and after that year.
defects in dental enamel, opacity is de- fluorosis.
; fined as; "a qualitative defect of enamel In the late seventies, a number of
identified visually as an abnormality in Material and methods
Swedish dentists in the Public Dental Material
; the translucency of enamel. It is charac- Services (PDS) reported an increasing
fterized by a white or discolored (cream, number of children showing extensive All children born in 1966, 1969, 1970,
I. brown, yellow) area but in all cases the and severe hypomineralization of the
i enamel surface is smooth and the thick- enamel of incisors and pennanent first
I ness of enamel is normal, except in some Table 1. Number of children examined in dif-
molars (Fig. 1) of unknown etiology ferent age groups
: instances when associated with hypopla- (idiopathie hypomineralization). The
I sia." It should be observed, however, that disturbances represented a considerable Year of No. of ehildren
' "hypoplasia" found in connection with clinical treatment problem. Most of the
birth examined
; hypomineralization can be of two types; children affected were born around 1970. 1966 365
true hypoplasia, meaning that the enamel The Swedish Board of Health and Wel- 1969 370
has never been formed, and hypoplasia fare in 1978 asked the PDS to report 1970 358
(missing enamel) resulting from loss of cases showing these enamel disturbances. 1971 423
hypomineralized enamel after trauma to 1972 367
The distribution of the reported children 1974 343
the soft enamel (4, 5). according to year of birth showed that
The etiology behind hypomineralized highest number of reported cases was Total 2226
280 KOCII CT AL,

Eig. I. Idiopalhic enamel hypomineralizations in incisors (A) and molars (IB).

 Idiopathie etiamel hypommeralization 281

1971, 1972 and 1974 attending compul-

sory school within three school districts
in the municipality of Jonkoping compri-
sed the patient material. All children in- BUCCAL -
cluded in the study were born in Sweden.
I n all, 2252 children were examined for
enamel disturbances (Table 1). Twenty-
six children did not have all permanent
first molars erupted and therefore were
excluded from the study. MESIAL

Study design and clinical examination

After the school authorities, the parents

a n d the children had been informed
a b o u t the project, the children were ex-
amined in their classrooms by a dental
team. Three calibrated dental teams were
in operation and examined a random or-
der of school class units. The examina-
tions were performed with the use of
portable lighting and disposable mirrors.
If a child showed any sign of hypo- LINGUAL \
mineralized enamel according to the cri-
teria described below, the child was
called for a thorough clinical examin-
ation at a nearby school dental clinic.
All these examinations were performed
by the same dentist who had been well
trained in using the clinical diagnosis and
the case report form mentioned below.
In addition to the clinical examination,
all the children were documented photo- BUCCAL
graphically.
Children born in 1966, 1969, 1970 and
1971 were examined in 1979, children
b o r n in 1972, in 1980 and children born
in 1974, in 1983.
All photographs were reviewed by the MESiAL DiSTAL
group of authors to decide upon ques-
tionable exclusions according to defini-
tions stated below.

Criteria and recording of idiopathic enantjei

hypomineraiization
In order to classify the characteristics
and extent of the hypomineraiization of
permanent first molars and incisors a
special mapping and scoring system was
developed. It was based on tooth surface
units which were all examined for enamel
disturbances. The surface units for each
tooth is presented in Fig, 2, Occlusal
surface/incisal edge represented one unit.
D u e to differential diagnostic difficulties Eig. 2. System for examination showing teeth subdivided into units.

Fig. 3. Different clinical appearance of enamel hypomineralizations in permanent first molars. A, yellow color. B, brown color. C, yellow color,
abraded. D, white color, disintegrated. E, yellow color, abraded and disintegrated. F, atypical restoration.
282 KOCH ET AL.

PER CENT
the fissure systems were omitted. Smooth CHILDREN
tooth surfaces were divided into three
units, an incisal/occlusal, an intermediate HVPOMINERALIZATION A •
and a gingival unit. B B

Each unit was examined according to . cm

color and surface changes and the ob-
servations were entered in a specially de-
signed case report form. The following
changes were noted;
Color ehanges:
white
yellow
brown
Surface changes:
rough
abraded
disintegrated
I 1966
365
1969
370
1970
358
1971
423
1972
367
1974
343
VEAR OF
BIRTH
N
atypieal restoration (extensive and ir-
Eig. 4. Pereentage of children horn in 1966, 1969, 1970, 1971, 1972 and 1974 respectively
regular restorations replacing broken distrihuted according to hypomineraiization definitions A, B, C or D in permanent first molars
down hypomineralized enamel) and/or ineisors.
The different situations are exemplified
in Fig, 3 A-R higher in the group born in 1970 than manent first molars, maxillary incisors
To be reeognized as an enamel hypo- in the other age groups (Fig. 4). This mandibular incisors, both permanent
mineraiization, the change in either color difference was true for all the above stat- first molars and incisors. In general
or structure must involve more than one ed definitions of hypomitieralization there was a higher frequency of ehildren,
third of the area of a tooth unit. It was (A-D). The pereentage of children show- born in 1970, with idiopathic enamel
thus possible to describe the hypominera- ing hypomineraiization A was 15.4% for hypomineraiization compared with the
iization concerning tooth surface, site, children born in 1970 and 7.3% for chil- other age groups. Figs, 5-7 reveal that, in
color and structure. dren born in 1969 and 7.1 % for 1971, For the affected children, at least one molar
In this recording of idiopathic enamel children born in 1966, 1972 and 1974, always showed idiopathic enamel hypo-
hypomineraiization all enamel changes the percentages were 3.6, 5.2 and 4,4, mineraiization. The incisors were affect-
diagnosed as amelogenesis imperfecta, respectively. ed to a lesser degree than the molars
dental fluorosis or hypomineralizations Figs. 5-7 show the percentage of chil- and the mandibular incisors less than the
caused by local trauma, local infection dren with idiopathic enamel hypo- maxillary ones. From Figs. 5-7 it is also
or major disturbances in general health mineraiization according to definitions evident that if a mandibular incisor was
were excluded. A, B and D, respectively, when the fol- affected, the maxillary incisors and any
lowing groups of teeth were affected: per- molar usually showed hypomineraliz-
Treatment of data
PER CENT
CHILDREN
The data from the case report forms were
entered into a computer and a frequency
distribution was performed aeeording to PERMANENT FIRST MOLARS
the following descriptive definitions of MAXILLARY PERMANENT INCISORS g]
hypomineraiization: MANDIBULAR PERMANENT INCISORS
PERMANENT FIRST MOLARS
A. All enamel changes observed accord- AND INCISORS
ing to definition stated, including
atypieal restorations
B, Yellowish or brownish color of
enamel, including atypical restor-
ations
C. Yellowish or brownish color of
enamel
D, Disintegrated enamel surface

Resuits

The frequency of children showing idio-

I il
1966
365
1969
370
1970
358
ll
1971
423
1972
367
I ll
1974
343
VEAR OF
BIRTH
N

/^/g. 5. Percentage of children horn in 1966, 1969, 1970, 1971, 1972 and 1974 with hypomiiieraliz-
pathic enamel hypomineraiization of per- ation aeeording to definition A (all enamel ehanges ohserved according to definilion stated,
manent first molars and/or ineisors was ineluding atypical restorations) in different groups of teeth.
 Idiopathic enamel hypomineraiization 283

PER CENT
ation also. Idiopathic enamel hypo- CHILDREN
mineralization characterized as disin-
tegrated tooth surfaces affecting the PERMANENT FIRST MOLARS
MAXILLARV PERMANENT INCISORS
1 maxillary incisors was only found in chil-
MANDIBULAR PERMANENT INCISORS
' d r e n born in 1970 (Figs. 1, 7). PERMANENT FIRST MOLARS
The percentage of children in the dif- AND INCISORS

ferent age groups showing idiopathic

enamel hypomineraiization according to
definition A in 1, 2, 3 and 4 permanent
first molars is presented in Fig. 8. A
higher percentage of children born in
1970 were suffering from affected molars

I
t h a n children in other age groups. This
: difference was most obvious when the
frequency of children showing four af- MJ IJU \mm.
fected molars was compared: 6.1% of 1966 1969 1970 1971 1972 1974 VEAR OF
BIRTH
365 370 358 423 343
i children born in 1970 had four affected 367
rnolars compared with 0.5-2.0% in the Eig. 6. Percentage of children born in 1966, 1969, 1970, 1971, 1972 and 1974 with hypomineraiiz-
ation according to definition B (yellowish or brownish color of enamel, ineluding atypical
-, other age groups. restorations) in different groups of teeth.
: The individual mean numbers of tooth
' units affected according to idiopathic PER CENT
CHILDREN
• enamel hypomineraiization definitions
A , B and D in the different age groups 15- PERMANENT FIRST MOLARS •
i axe presented in Fig. 9. With the excep- MAXILLARV PERMANENT INCISORS Qj]

''. tion of children born in 1971, all age MANDIBULAR PERMANENT INCISORS ^
PERMANENT FIRST MOLARS ^
groups show a similar pattern. Thus, it AND INCISORS
\ is evident that the affected ehildren in 10-
f e a c h group seem to have more or less the
': same number of hypomineralized tooth
units,
I In order to further analyze the extent 5-
to which each child was affected, the
frequency distribution of the ehildren
within each age group according to
number of affected units is presented in
Fig, 10. Thefigurereveals that there are
1 1966
1 1969
i
1970
1 1971
1 1972
1 1974 VEAR OF
343 BIRTH
great similarities between the different 365 370 358 423 367 N

age groups. Eig. 7, Percentage of children born iu 1966, 1969, 1970, 1971, 1972 and 1974 with hypomineraiiz-
ation aeeording to definition D (disintegrated enamel surlaee) in different groups of teeth.

Discussion
T h e findings ofthis study clearly indieate PER CENT AFFECTED FIRST
CHILDREN PERMANENT MOLARS
t h a t severely hypomineralized enamel of ONE •
permanent incisors and permanent first TWO H
5 •
molars was found in a higher percentage THREE g
of children born in 1970 than in children FOUR ^

b o r n during the years before and after.

* The denomination "idiopathic" has
been used in this study. However, it
should be remembered that the material
might include some individuals with
hypomineralized enamel where the etio-

I I
logical factor described as "excluded
from the study" has been overlooked.
These individuals must be few in number
and will have no effect on the interpre- IJ VEAR OF
tation of the differences between the age 1966 1969 1970 1971 1972 1974 BIRTH
365 370 358 423 367 343 N
groups. Eig. S. Percentage of children horn in 1966, 1969, 1970, 1971, 1972 and 1974 having one, two,
The prevalence of hypomineraiization three or four molars with hypomineialization aeeording to definition A (all enamel changes
/ o u n d in this study, 3.6-15.4%, is lower observed aeeording to definitions stated, ineluding atypical restorations).
284 KOCH ET AL.

HYPOMINERALIZATION were restricted to pennanent incisors and

NUMBER OF first molars.
UNITS
When the study was initiated in 1977
the DDE Index (3) was not available.
t5 Therefore a special system for regis-
tration of hypomineraiization was deve-
loped. Up to a certain level, the system
used here provides more detailed analy-
ses of the extent and character of the
10- hypomineraiization.
It can be argued that the earlier high
caries activity might have concealed the
true prevalence of hypomineraiization.
Therefore, atypical restorations were in-
5- cluded in the criteria since, at that time,
such enamel defects were often treated
with excessive and irregular amalgam re-
storations. An analysis of the results of
this study shows that there were few such
M. YEAR OF restorations (Fig. 4 characteristics B-C)
1966 1969 1970 1971 1972 1974 BIRTH
365 370 423 367 343 N in all age groups and these could not
358
influence the prevalence figures.
Eig. 9. Mean number of hypomineralized tooth units in individuals affected in different age Extensive idiopathic hypomineraiiz-
groups, , , ation was found in all age groups. How-
ever, the remarkable increase in preval-
PER CENT enee, up to 15.4%, found in children
CHILDREN
1969
born in 1970 clearly indicates some spe-
1966 cifie influenee on the development of
enamel during a limited period of time.
This supports the results presented by
FoRSMAN (14) and SUNDELL & Kocit (5),
The finding that all children affected
showed about the same level of hypomi-
neraiization (Fig, 10) irrespective of age
1970 group is also worth emphasizing. This
means that in the 1970 age group the
number of affected children was higher
than in other age groups, although the
distribution of the extension and severity
of hypomineraiization was the same
among the children of each age group.
1972
The results of this study reveal a need
for further research on the etiology of
enamel hypornineralization.

-5|6-10|11-15|16-20|21-25|26-30|UNITS | 1 - 5 | 6 -lolii • 1 5 | I 6 ^ O | 21 25 | 2 6 3 0 |UNITS

Pig. 10. Percentage distrihution of children in different age groups according to number of tooth
units with hypomineraiization.

than in most earlier studies (6-13). How-

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