Evaluation of the Virtual Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) For Dental Therapists in Malaysia

Evaluation of the Virtual Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) For Dental Therapists in Malaysia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the Virtual Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) For Dental Therapists in Malaysia Sarah Wan-Lin Lim, Tengku Nurfarhana Nadirah Tengku Hamzah, Nabihah Dziaruddin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7283561/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose/ Objectives: Molar incisor hypomineralisation (MIH) is a common developmental defect of enamel (DDE) seen in children. In Malaysia, dental therapists (DTs) are well-positioned to support early detection through the school dental service. However, most DTs lack adequate training and confidence in managing MIH. This study aimed to evaluate the outcomes of the virtual Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) by comparing the DTs’ knowledge scores (KS) and photographic assessment scores (PS) before (T0), immediately after (T1) and two weeks after (T2) training. Methods A before-and-after study was conducted among DTs in Sarawak, Malaysia. Participants received a one-day virtual MIH training and completed a self-administered questionnaire and photographic assessment of MIH at T0, T1 and T2. Data were analysed using descriptive statistics and repeated measures ANOVA. Results In total, 187 DTs completed this virtual MIH training. There was a significant increase (p < 0.001) in the mean KS from T0 (31.95 ± 11.68) - T1 (49.76 ± 3.76) and T0 - T2 (48.18 ± 4.83), but not from T1 - T2 (p = 0.098). There was a significant increase (p < 0.001) in the mean PS from T0 (13.94 ± 4.52) - T1 (21.41 ± 5.04) and T0 - T2 (20.14 ± 5.50), while a small but significant decrease (p < 0.001) was observed from T1 - T2. Conclusion Within study limitations, the MIH-EDIT improved DTs knowledge on MIH and their ability to detect MIH over the short-term. This virtual MIH training has the potential for nationwide adoption into DT training and continuing professional development programmes, enhancing MIH early detection and intervention in clinical practice. molar incisor hypomineralisation dental therapists training early detection early intervention evaluation Figures Figure 1 1 Introduction Molar incisor hypomineralisation (MIH) is the most common enamel developmental defect seen in children (Patel et al. 2019), and with a pooled global prevalence of 13.5% (Lopes et al. 2021), is increasingly recognised as a significant public health concern (Bussaneli et al. 2021). 3 Although data on Malaysian children are limited, local studies have reported a comparable prevalence of 14.7–16.9% (Ardini et al. 2019; Hussein et al. 2015). The complexity of MIH, arising from its highly varied clinical presentation (Weerheijm 2004), not only poses diagnostic and management challenges but also has profound impacts on affected children (Bussaneli et al. 2021). These include tooth hypersensitivity, post-eruptive enamel breakdown (PEB), rapid caries development and progression along with its sequelae, aesthetic concerns (Shields et al. 2024), as well as heightened dental fear, anxiety and behavior management challenges (Jälevik and Klingberg 2002), resulting in increased treatment needs throughout childhood and adolescence (Jälevik and Klingberg 2012), which can significantly impair the affected child’s oral health-related quality of life (OHRQoL) (Reissenberger et al. 2022). Considering that late detection exacerbates all the aforementioned consequences, early detection and timely intervention of MIH, particularly at the primary care level, are of critical importance. In Malaysia, dental therapists (DTs) are the primary providers of paediatric oral healthcare services within the public sector (Nor et al. 2013; Abu Bakar et al. 2015), particularly through their involvement in the School Dental Service (SDS), which focuses on prevention, early detection and control of oral diseases (Oral Health Division, Ministry of Health Malaysia [MOH], 2006). Given their direct and regular contact with preschool and primary school children, DTs are uniquely positioned to contribute significantly to the early detection and intervention of MIH. Despite this strategic role, a local study reported that 76.5% of Malaysian DTs indicated they had not received sufficient information about MIH. Notably, 100% of DTs cited inadequate training as the main barrier, and 88.2% requested a training program on MIH (Hussein et al. 2014). Unlike in several countries such as Australia, New Zealand and the United Kingdom, where DTs, oral health therapists (OHTs) and dental hygienists (DHs) are trained alongside dental students in university-based programs (Australian Dental Council 2022; Ministry of Health New Zealand 2010; General Dental Council 2015), Malaysian DTs are trained separately at a dedicated national training institute. Based on information supplied by the Training Division, Ministry of Health (MOH) Malaysia, existing DT training places strong emphasis on dental caries, while developmental defects of enamel (DDEs) including MIH are not currently covered in-depth within the curriculum. Given the clear gaps in MIH-related training among Malaysian DTs, there is a pressing need for educational resources that specifically address this area. The widespread distribution of DTs across the country, including in rural areas, presents logistical and geographical barriers to the delivery of conventional in-person training. This underscores the need for a virtual training solution that is designed to be low-tech, mobile-compatible and accessible with limited internet bandwidth. To meet this need, the Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) was developed. This study aimed to evaluate the outcomes of the MIH-EDIT among a group of Malaysian DTs. The specific objectives were to compare the DTs’ mean knowledge scores (KS) and photographic assessment scores (PS) at three time points: before the intervention (T0), immediately after (T1) and two weeks post-intervention (T2). 2 Materials and methods 2.1 Ethical considerations This study was registered on the National Medical Research Register (NMRR) and ethical approval obtained from the Medical Research & Ethics Committee (MREC), Ministry of Health (MOH), Malaysia (NMRR ID-22-01154-AZF (IIR) and the Medical Ethics Committee, Faculty of Dentistry (DF CD2212/0036 (P)). Permission was also granted by the Oral Health Program and Sarawak Oral Health Division, MOH, Malaysia. The participants’ information sheet (PIS) and electronic informed consent were embedded in the questionnaire (Google Form) and participants had the option to agree or disagree to participate. 2.2 Study design, population, setting and sample size This study was reported with reference to the STROBE guidelines (von Elm et al. 2007). 18 A before-after study design with quota sampling was employed. The study population comprised of DTs in Malaysia, with the state of Sarawak selected as the study area due to its having the highest number of DTs nationwide (Health Informatics Centre, MOH, Malaysia 2019). DTs from the three largest divisions in the state of Sarawak: Kuching, Sibu and Miri were invited to participate. These divisions were selected due to logistical reasons, particularly internet accessibility, as the MIH-EDIT was delivered online. All DTs from these three divisions were eligible to participate, with no specific inclusion or exclusion applied. The sample size was calculated based on an estimated standard deviation of 10, an alpha of 0.05 (z = 1.96), and a margin of error of 2 units, yielding a minimum of 97 participants. This was increased to 108 to account for a 10% non-response rate. To enhance representativeness and ensure the study was not underpowered, the final sample was inflated to 208 to include all DTs from the Kuching, Sibu, and Miri divisions (Bujang 2021). 2.3 Summary of the development and implementation of the MIH-EDIT The MIH-EDIT was developed, validated, translated, piloted and finalised prior to implementation. The module content comprised five parts covering basic knowledge (Part 1), clinical features, classification and challenges (Part 2), dilemmas in diagnosis (Part 3), management (Part 4) and referral for further management (Part 5). The module materials included an e-booklet, pre-recorded PowerPoint presentation slides and live interactive Q&A (Mentimeter). The MIH-EDIT was delivered virtually and synchronously as a one-day program. At the end of the program, the e-booklet was shared asynchronously as a supplementary educational material and remained accessible for two weeks. 2.4 Study instruments 2.4.1 Questionnaire: adaptation, validation and translation A self-administered questionnaire, adapted from previous literature and mapped with the module content, was used to assess the DTs’ knowledge about MIH. Section A collected sociodemographic characteristics, while Section B, adapted with permission from Gambetta-Tessini et al. (2016), included 10 questions covering awareness, prevalence, etiology, time of insult, and the caries pattern seen in MIH. Minor rewording and rephrasing were done to fit the local context (Hussein et al. 2015). Individual questions were created for each etiological factor with answer options of “yes”, “no” and “not sure”. “Not sure” responses were scored equivalently to the lowest score for that question to maintain the original knowledge score (KS) range of 20 to 60, with higher KS indicating higher knowledge about MIH. Content validity was quantitatively assessed by three paediatric dental specialists – one from MOH, Malaysia and two from local universities, using a 4-point scale to evaluate relevance and clarity. The I-CVI ranged from 0.67 to 1 (S-CVI = 0.96). Following feedback from content validators, minor wording and phrasing changes were made. The pre-final questionnaire was translated into Malay through two independent forward translations by a linguistic expert and a paediatric dental specialist. A panel comprising two pediatric dental specialists and two dental public health specialists reviewed both translations and agreed on a consensus Malay version. This version was then back-translated by a different linguistic expert and paediatric dental specialist. These English back-translations were compared with the original to ensure conceptual and semantic equivalence. Following re-evaluation by the panel, the Malay version of the questionnaire was finalised. 2.4.2 Photographic assessment: screening, scoring and finalisation of clinical photographs Photographic assessment was used to evaluate participants’ ability to detect and distinguish MIH from sound teeth, caries and other developmental defects of enamel (DDEs) – a key intended learning outcome of the MIH-EDIT. Clinical photographs (n = 125) of sound teeth, caries, mild MIH, severe MIH and other DDEs such as amelogenesis imperfecta (AI), fluorosis and enamel hypoplasia were contributed by the post-graduate students and specialists from the Paediatric Dentistry Unit of a public university. These were compiled into a PowerPoint presentation. assigned unique numerical codes for identification and screened by the panel for image clarity, visibility of the site of interest and adjacent teeth. After screening, 49 clinical photographs were included for scoring by three pediatric dental specialists: two from the MOH, Malaysia and one from a public university. Each photograph was scored based on the observed condition: sound (0), caries (1), mild MIH (2M), severe MIH (2S), and other DDEs (3). The photographs were scored independently in two rounds, one week apart, using Google Forms with a 30-minute timer and randomized order. A consensus scoring session was then conducted via Google Meet, during which all photographs were reviewed, disagreements resolved through discussion, and final consensus scores established. A total of 43 photographs were initially retained following modifications and exclusions. Subsequently, 11 were excluded due to lack of agreement (Fig. 1 ). Concurrently, inter- and intra-examiner reliability were assessed using Cohen’s kappa analysis (Landis and Koch 1977). Inter-examiner reliability ranged from substantial to near-perfect (κ = 0.75–0.87), while each examiner’s scoring showed near perfect agreement with the consensus (κ = 0.83–0.96). Intra-examiner reliability was near perfect for Examiners 1 and 3 (κ = 0.96), and substantial for Examiner 2 (κ = 0.71). All kappa values were statistically significant (p < 0.001). After reliability analysis, the panel reviewed the outcomes and through consensus, selected the final 32 clinical photographs. The consensus score for each of these clinical photographs was used as the gold standard. Each correct answer was awarded 1 point, while incorrect answers received 0 points. PS ranged from 0 to 32 and were converted into percentages to reflect the DTs’ marks out of 100. Higher PS indicated better ability to detect MIH and distinguish it from other conditions. 2.5 Data collection Participants completed the same questionnaire and photographic assessment independently at three time points: before (T0), immediately after (T1) and two weeks after the implementation of the MIH-EDIT (T2). The same set of clinical photographs was used in all sessions, with the sequence reshuffled each time. Each session took approximately 60 minutes. The self-administered bilingual questionnaire (English and Malay) and the scoring form were shared via Google Forms, allowing participants to choose their preferred language. On the day of implementation, the Google Forms links/ QR codes were shared through the Zoom platform. For the two-week follow up, the designated links were shared with the DTs through the district liaison officers, who also sent daily reminders to encourage responses. The forms remained open for five days before being closed. A two-week wash out period was used to minimise potential contamination from other training/ courses. 2.6 Data entry and analysis Participants’ responses from Google Forms were transferred to Microsoft Excel for data entry. To ensure anonymity and confidentiality, direct identifiers (such as participant names) were removed, and each participant was assigned a unique identification code. A data dictionary was created to guide the data entry process. Data were cleaned to minimize errors before being imported into SPSS software version 25.0 for further analysis. Descriptive statistics were used to compare participants’ KS and PS at T0, T1 and T2. Data normality was assessed using skewness, kurtosis, histogram inspection and Kolmogorov-Smirnov test. Repeated measures ANOVA was used to assess if there were statistically significant differences (p < 0.05) in the mean KS and PS across the three time points followed by post hoc pairwise comparisons to identify specific time points with significant differences. 3 Results Table 1 shows the number of responses for both the questionnaire and photographic assessment at T0, T1 and T2. Overall, the response rates exceeded 94% with the exception of the photographic assessment at T2, where the response rate declined to approximately 85%. Table 2 shows the respondents’ sociodemographic characteristics at baseline. All participating DTs were female, with a mean age of 40 years and an average of 15 years in service. Approximately half were based in Kuching, with the remainder from Sibu and Miri divisions. Over 90% held a diploma, and approximately 2% had post-basic training in paediatric dentistry. Approximately 75% had clinical roles whilst the remaining 25% were involved in management and administrative duties. Table 1 Number of responses for the questionnaire and photographic assessment at each time point Study instruments Response rate (N = 187) Before (T0) n (%) Immediately after (T1) n(%) Two weeks later (T2) n(%) Questionnaire (knowledge): Respondents 176 (94.1) 178(95.2) 177(94.7) Declined to respond/ did not answer 11(5.9) 9(4.8) 10(5.3) Photographic assessment: Respondents 185(98.9) 178(95.2) 158(84.5) Declined to respond/ did not answer 2(1.1) 9(4.8) 29(15.5) Table 3 shows the percentage distribution of DTs’ responses for each question on MIH knowledge at T0, T1 and T2. At T0, 27.3% of DTs were unsure that MIH is a DDE distinct from fluorosis and hypoplasia whereas this dropped to zero post-intervention. Over 75% were initially unsure of MIH prevalence in Malaysia, but 86.5% correctly identified it as 10–20% at T1, decreasing to 66.3% at T2. Post-intervention, there was a decrease in the percentage of DTs who answered unsure with regards to the possible etiological factors of MIH. The percentage of DTs who considered genetic factors, environmental pollutants, acute and chronic medical conditions as well as antibiotics or medications to be involved in MIH etiology increased whereas those who excluded fluoride exposure as a cause rose from 16% to approximately 50%. Regarding the timing of enamel disturbance, 25% were unsure at T0, and 48.9% linked it to pregnancy. At T1, 55.1% correctly indicated the critical period as pregnancy to age three. The percentage of DTs who agreed that MIH-related caries patterns differed from classical caries increased from 60.2% to approximately 90% post-intervention. As shown in Table 4 , repeated measures ANOVA revealed statistically significant differences in mean KS and PS across the three time points. Post hoc analysis with Bonferroni adjustment showed a significant increase in the mean KS from T0 to T1 (12.28 (95% CI, 10.86 to 13.70), p < 0.001, η p 2 = 0.7) and from T0 to T2 (11.68 (95% CI, 10.19 to 13.18), p < 0.001, η p 2 = 0.7). However, the difference between T1 and T2 was not statistically significant (-0.60 (95% CI, -1.46 to 0.26), p = 0.284, η p 2 = 0.5). Similarly, for PS, post hoc analysis indicated significant increases from T0 to T1 (7.47 (95% CI, 6.36 to 8.58), p < 0.001, ηp2 = 0.6) and from T0 to T2 (6.19 (95% CI, 5.02 to 7.36), p < 0.001, ηp2 = 0.5). Meanwhile, a small but statistically significant decrease was observed between T1-T2 (-1.28 (95% CI, -2.01 to -0.54), p < 0.001, ηp2 = 0.1). Table 4 Comparison of DTs’ knowledge scores and photographic assessment scores before, immediately after and two weeks after implementing the MIH-EDIT Study instrument Mean±SD p-value* Effect size Questionnaire (knowledge) : Knowledge Score (KS) (N = 164) Before (T0) 37.61±6.97 < 0.001 0.7 Immediately after (T1) 49.89±3.63 Two weeks after (T2) 49.29±4.45 Photographic assessment : Photographic Assessment Score (PS) (N = 145) Baseline (T0) 13.94±4.52 < 0.001 0.6 Immediately after (T1) 21.41±5.04 Two weeks after (T2) 20.14±5.50 *Repeated measures ANOVA; p < 0.05 is considered statistically significant 4 Discussion In the present study, 62.4% of DTs recognized MIH as a DDE distinct from fluorosis and hypoplasia, which was notably lower than figures reported in similar studies (81.1–92.4%) (Gambetta-Tessini et al. 2016; Skaare et al. 2021). Over 75% of DTs were unsure about MIH prevalence in Malaysia, in contrast to just 12–19% in other countries (Gambetta-Tessini et al. 2016; Skaare et al. 2021). This uncertainty likely stemmed from a lack of local data, with very few published studies to date on MIH distribution among Malaysian children (Ardini et al. 2019; Hussein et al. 2015). Accordingly, the MIH-EDIT included local prevalence data to begin addressing this gap. However, more comprehensive national prevalence studies are still needed. Despite growing research into the possible causes of MIH (Bussaneli et al. 2021; Garot et al. 2022), its exact etiology remains unclear. However, it is well established that fluoride exposure is not a contributing factor (Koch 2003). Yet, only 15.9% of DTs were aware of this before the intervention, while 61.9% incorrectly attributed MIH to fluoride exposure, which was substantially higher than in other studies (7.7–13.5%) (Gambetta-Tessini et al. 2016; Skaare et al. 2021). This confusion may be due to frequent misidentification of MIH as fluorosis (Crombie et al. 2008). Additionally, 60.2% of DTs thought that the caries pattern seen in MIH was different from the classical pattern, which was lower compared to 87.9% and 73% in earlier research (Gambetta-Tessini et al. 2016; Skaare et al. 2021). Correspondingly, the mean baseline knowledge score (37.43 ± 7.05) was significantly lower compared to that of Australian OHTs (50.0 ± 5.30) (Gambetta-Tessini et al. 2016). These findings highlight the limited baseline knowledge of MIH among Malaysian DTs compared to their international counterparts, reinforcing the need for targeted training to strengthen their foundational understanding of the condition. The results of the present study showed a statistically significant improvement in DTs’ KS following the implementation of the MIH-EDIT, indicating a clear increase in MIH-related knowledge attributable to the intervention. Interestingly, the post-intervention KS in the present study was comparable to the baseline KS reported among OHTs in Australia (50.0 ± 5.3) (Gambetta-Tessini et al. 2016), suggesting that the MIH-EDIT helped elevate DTs’ knowledge to a similar standard. A similar trend was reported by Aguilar Galvez and colleagues (2022), who observed significant improvements in post-test scores following the implementation of a virtual learning object (VLO). Unlike the single-group design used in the present study, their study included a control group and targeted undergraduate dental students. While the control group received a synchronous virtual theoretical lecture and the intervention group used a more technologically advanced VLO comprising videos, narrations and images, both groups showed similar improvements (Aguilar Gálvez et al. 2022). This suggests that the while enhanced digital tools may offer added value, simpler formats can still be effective for knowledge acquisition. This finding was reassuring, as the MIH-EDIT, though less high-tech, employed a comparable delivery approach and demonstrated similarly positive outcomes. The lack of a statistically significant difference between mean KS at T1 and T2 further suggests that the knowledge gained was retained over the two-week period. This sustained improvement, alongside a medium-to-large effect size, underscores the educational impact of the MIH-EDIT. Based on the limited published studies on MIH training, the use of clinical photographs as a tool for assessment or calibration is consistently supported by researchers (Amarante et al. 2022; Restrepo et al. 2024; Vieira et al. 2023). However, due to differences in the study designs and analytical approaches, direct comparison with the present study was not feasible. In terms of the outcome patterns, previous studies reported improvements with each subsequent calibration or when comparing pre-test and post-test results, aligning with the findings of the present study (Amarante et al. 2022; Restrepo et al. 2024; Vieira et al. 2023). In those studies, the digital clinical photographs were administered under more controlled and standardised conditions such as in a shared physical space with group image projection (Amarante et al. 2022; Vieira et al. 2023), or in a computer lab-like setting where participants accessed images individually via a digital learning platform (Restrepo et al. 2024). In contrast, participants in the present study completed the photographic assessment individually via Google Forms using their own devices, primarily smartphones and tablets. While this decentralized format reflects real-world conditions and enhances the ecological validity of the photographic assessment, it may have introduced variability in viewing conditions due to differences in screen size, resolution and lighting. To mitigate this, efforts to standardize the clinical photographs used in the assessment were made through a rigorous, systematic and consensus-based process. The results of the present study indicate a substantial improvement in the DTs ability to detect MIH and distinguish it from sound teeth, caries as well as other DDEs immediately after implementation of the MIH-EDIT. Although the decrease in mean PS between T1 and T2 was statistically significant, the small effect size suggests that the magnitude of change was minimal, indicating overall stability in the DTs’ performance and that the detection skills acquired were largely retained over the two-week period. To the best of the authors’ knowledge, this study is the first in Malaysia to develop and implement a tailored training module for DTs focused on MIH and translated into the national language, addressing a recognized gap in knowledge and practice. The present study employed a single group, before-after design without a control group and used quota sampling - a non-randomised method chosen for its feasibility at this stage. However, considering all DTs in Malaysia are trained at the same national training institute and constitute a homogeneous group, the present sample likely offers reasonable representativeness and generalisability of findings. Data collection relied on a self-administered, self-reported questionnaire, introducing the possibility of response and social desirability biases, as well as memory bias from repeated testing. Similar concerns applied to the photographic assessment. However, bias was minimized through the randomized presentation of the clinical photographs and the use of a two-week washout period following the intervention. This study was primarily quantitative in nature, focusing only on the short-term outcomes post implementation of the MIH-EDIT. This approach inherently limited the scope of the findings to immediate impacts, without an exploration of long-term effects or qualitative aspects. Thus, future research should explore qualitative feedback to better understand DTs’ experiences and incorporate long-term follow-up to assess knowledge retention, clinical application and patient outcomes to fully establish the impact of the training module. The findings of the present study highlight the need for more coordinated efforts between universities and the MOH, Malaysia to ensure that updated information on MIH is made accessible to DTs through well-structured training. Following further refinement, there is potential for the MIH-EDIT to be implemented nationally, either through integration into pre-service training curriculum for future DTs or as part of continuing professional development (CPD) programs for in-service DTs especially in settings where access to in-person training is limited. Its alignment with CPD objectives is especially relevant given that it is mandatory for DTs to obtain a minimum number of CPD points for Annual Practicing Certificate (APC) renewal. Given its scalability and minimal resource requirements, the MIH-EDIT represents a cost-effective strategy for ongoing workforce development. It could also be adapted for other learner groups such as undergraduate students and general dental practitioners and may serve as a valuable model for similar educational initiatives in other countries where DTs play a key role in pediatric oral healthcare delivery. 5 Conclusion Within the limitations of the study, the MIH-EDIT improved the DTs knowledge of MIH and their ability to distinguish MIH from sound teeth, caries and other DDEs over the short term. With further refinement, the MIH-EDIT holds potential for nationwide adoption into pre-service training and continuing professional development (CPD) programs for DTs, enhancing MIH early detection and intervention in clinical practice. Declarations Disclosure: The authors declare that they have no conflict of interest. Author Contribution SL conceived the idea, collected and analysed the data, supervised by TNF, ND, NAM and THM. TNF, ND, NAM and THM formed the panel during consensus discussions. The initial draft of the manuscript was prepared by SL and was revised by TNF, ND, NAM and THM. All authors read and approved the final manuscript. Acknowledgements: This study was funded by the Dental Postgraduate Research Grant (DPRG), Faculty of Dentistry, Universiti Malaya (UMG032E-2022). Honorarium (food voucher worth RM10) was given to all the participants for their participation in the MIH-EDIT. The authors wish to thank all individuals who were involved in the content validation and translation process of the questionnaire, compilation, screening, and scoring of clinical photographs as well as the dental therapists who participated in the study. References Abu Bakar A, Mohd Nor NA, Ab-Murat N, Jaafar N. Job satisfaction and perceived future roles of Malaysian dental therapists: findings from a national survey. Int J Dent Hyg. 2015;13(3):199–205. https://doi.org/10.1111/idh.12095 Aguilar Gálvez D, Noal FC, Arriola-Guillén LE, Hugo FN, Leal SC, Borba de Araujo F. 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J Clin Pediatr Dent. 2015;39(3):219–23. https://doi.org/10.17796/1053-4628-39.3.219 Hussein AS, Ghanim AM, Abu-Hassan MI, Manton DJ. Knowledge, management and perceived barriers to treatment of molar-incisor hypomineralisation in general dental practitioners and dental nurses in Malaysia. Eur Arch Paediatr Dent. 2014;15(5):301–7. https://doi.org/10.1007/s40368-014-0115-2 Health Informatics Centre, Ministry of Health Malaysia. Health indicators 2019: Indicators for monitoring and evaluation of strategy health for all [Internet]. Ministry of Health Malaysia; 2019 [cited 2025 Aug 3]. Available from: https://www.moh.gov.my/moh/resources/Penerbitan/Penerbitan%20Utama/HEALTH%20INDICATOR/Health%20Indicator%202019.pdf Jälevik B, Klingberg GA. Dental treatment, dental fear and behaviour management problems in children with severe enamel hypomineralization of their permanent first molars. Int J Paediatr Dent. 2002;12(1):24–32. Jälevik B, Klingberg G. Treatment outcomes and dental anxiety in 18-year-olds with MIH, comparisons with healthy controls - a longitudinal study. Int J Paediatr Dent. 2012;22(2):85–91. https://doi.org/10.1111/j.1365-263X.2011.01161.x Koch G. Prevalence of enamel mineralisation disturbances in an area with 1-1.2 ppm F in drinking water. Eur J Paediatr Dent. 2003;4(3):127–8. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74. Lopes LB, Machado V, Mascarenhas P, Mendes JJ, Botelho J. The prevalence of molar-incisor hypomineralization: a systematic review and meta-analysis. Sci Rep. 2021;11(1):22405. https://doi.org/10.1038/s41598-021-01541-7 Ministry of Health, New Zealand. Oral health workforce review. Ministry of Health; 2010. Nor NA, Murat NA, Yusof ZY, Gamboa AB. Senior dentists' perceptions of dental therapists' roles and education needs in Malaysia. Int J Dent Hyg. 2013;11(4):280–6. https://doi.org/10.1111/idh.12038 Oral Health Division, Ministry of Health Malaysia. Malaysia oral healthcare for school children in Malaysia. Ministry of Health Malaysia; 2006. Patel A, Aghababaie S, Parekh S. Hypomineralisation or hypoplasia? Br Dent J. 2019;227(8):683–6. https://doi.org/10.1038/s41415-019-0782-9 Reissenberger T, Ebel M, Klode C, Hirsch C, Bekes K. Hypomineralized teeth and their impact on oral-health-related quality of life in primary school children. Int J Environ Res Public Health. 2022;19(16):10409. https://doi.org/10.3390/ijerph191610409 Restrepo M, Rojas-Gualdrón DF, de Farias AL, Escobar A, Vélez LF, Bussaneli DG, Santos-Pinto L. Development of undergraduate students' diagnostic accuracy for the classification of molar incisor hypomineralization. Eur J Dent Educ. 2024;28(1):154–60. https://doi.org/10.1111/eje.12932 Shields S, Chen T, Crombie F, Manton DJ, Silva M. The impact of molar incisor hypomineralisation on children and adolescents: a narrative review. Healthcare (Basel). 2024;12(3):370. https://doi.org/10.3390/healthcare12030370 Skaare AB, Houlihan C, Nybø CJ, Brusevold IJ. Knowledge, experience and perception regarding molar incisor hypomineralisation (MIH) among dentists and dental hygienists in Oslo, Norway. Eur Arch Paediatr Dent. 2021;22(5):851–60. https://doi.org/10.1007/s40368-021-00649-8 Vieira HAO, Araújo LDC, Carvalho FK, Queiroz AM, Paula-Silva FWG. Use of images and clinical experience to calibrate dental surgeons for the diagnosis of molar incisor hypomineralization. Pesqui Bras Odontopediatria Clín Integr. 2023;23:e220157. https://doi.org/10.1590/pboci.2023.026 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573–7. https://doi.org/10.7326/0003-4819-147-8-200710160-00010 Weerheijm KL. Molar incisor hypomineralization (MIH): clinical presentation, aetiology and management. Dent Update. 2004;31(1):9–12. https://doi.org/10.12968/denu.2004.31.1.9 Tables Tables 2 and 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7283561","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":496638731,"identity":"c0c20075-527b-4047-ae1b-55cb2cd6c61b","order_by":0,"name":"Sarah Wan-Lin Lim","email":"","orcid":"","institution":"University of Malaya","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"Wan-Lin","lastName":"Lim","suffix":""},{"id":496638732,"identity":"e4854585-1548-4db2-a844-96e36ba21622","order_by":1,"name":"Tengku Nurfarhana Nadirah Tengku Hamzah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYJACxgYQyXyAgRlE84PF2HAr54FrYUuAaJFsIFmLwQECWuzZew+/nNl2J3F7G/OzzwU1d+SNb2QnMHwoO8ygOyMBuy0859IsN7Y9S5xzjM149oxjzwy33cjdwDjj3GEGsxs4tEjkmBk+bDucOEO+wZiZh+0wI0gLM28bHi3yb6Ba2Ng/M/P8O2y/eQZQy198WiR4jB9uBGvhMQYZnrhBAqiFEZ+WMzlmIJcbA7UUM/P2HU6ecebthoM959J5zM48wKqFvf2M8ceessOyQIdtZub5dti2vz1344MfZdZyZsex2wIEbBIYQgdA9jMI4NTC/AGHBP8BXFpGwSgYBaNgZAEAkJFl5LuGacYAAAAASUVORK5CYII=","orcid":"","institution":"University of Malaya","correspondingAuthor":true,"prefix":"","firstName":"Tengku","middleName":"Nurfarhana Nadirah Tengku","lastName":"Hamzah","suffix":""},{"id":496638733,"identity":"2ce885d0-01b4-4b5f-80b6-92aca969a179","order_by":2,"name":"Nabihah Dziaruddin","email":"","orcid":"","institution":"University of Malaya","correspondingAuthor":false,"prefix":"","firstName":"Nabihah","middleName":"","lastName":"Dziaruddin","suffix":""},{"id":496638734,"identity":"9fe7556e-125a-43e9-a185-660aea6b222c","order_by":3,"name":"Thaddius Herman Maling","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Thaddius","middleName":"Herman","lastName":"Maling","suffix":""},{"id":496638735,"identity":"9f368101-e27d-451b-86ed-08af426c97fb","order_by":4,"name":"Nor Azlida Mohd Nor","email":"","orcid":"","institution":"University of Malaya","correspondingAuthor":false,"prefix":"","firstName":"Nor","middleName":"Azlida Mohd","lastName":"Nor","suffix":""}],"badges":[],"createdAt":"2025-08-03 13:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7283561/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7283561/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88837645,"identity":"e6c2d6b6-5b9b-475d-b8cd-a3cf3be40167","added_by":"auto","created_at":"2025-08-12 01:23:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32449,"visible":true,"origin":"","legend":"\u003cp\u003eConduct of the study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7283561/v1/1278a9aa3e2d4c2691db3e28.png"},{"id":88838398,"identity":"2103fa1b-eca9-4a03-b6ad-30c731f8d781","added_by":"auto","created_at":"2025-08-12 01:39:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":702898,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7283561/v1/ec9d3c0e-d191-4007-81fb-baa98121a07c.pdf"},{"id":88837647,"identity":"28998190-7172-4225-83f8-aa88519be98a","added_by":"auto","created_at":"2025-08-12 01:23:48","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25470,"visible":true,"origin":"","legend":"","description":"","filename":"Table2and3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7283561/v1/37bd9ac6bca563626e004aa9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEvaluation of the Virtual Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) For Dental Therapists in Malaysia\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eMolar incisor hypomineralisation (MIH) is the most common enamel developmental defect seen in children (Patel et al. 2019), and with a pooled global prevalence of 13.5% (Lopes et al. 2021), is increasingly recognised as a significant public health concern (Bussaneli et al. 2021).\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Although data on Malaysian children are limited, local studies have reported a comparable prevalence of 14.7\u0026ndash;16.9% (Ardini et al. 2019; Hussein et al. 2015). The complexity of MIH, arising from its highly varied clinical presentation (Weerheijm 2004), not only poses diagnostic and management challenges but also has profound impacts on affected children (Bussaneli et al. 2021). These include tooth hypersensitivity, post-eruptive enamel breakdown (PEB), rapid caries development and progression along with its sequelae, aesthetic concerns (Shields et al. 2024), as well as heightened dental fear, anxiety and behavior management challenges (J\u0026auml;levik and Klingberg 2002), resulting in increased treatment needs throughout childhood and adolescence (J\u0026auml;levik and Klingberg 2012), which can significantly impair the affected child\u0026rsquo;s oral health-related quality of life (OHRQoL) (Reissenberger et al. 2022). Considering that late detection exacerbates all the aforementioned consequences, early detection and timely intervention of MIH, particularly at the primary care level, are of critical importance.\u003c/p\u003e\u003cp\u003eIn Malaysia, dental therapists (DTs) are the primary providers of paediatric oral healthcare services within the public sector (Nor et al. 2013; Abu Bakar et al. 2015), particularly through their involvement in the School Dental Service (SDS), which focuses on prevention, early detection and control of oral diseases (Oral Health Division, Ministry of Health Malaysia [MOH], 2006). Given their direct and regular contact with preschool and primary school children, DTs are uniquely positioned to contribute significantly to the early detection and intervention of MIH. Despite this strategic role, a local study reported that 76.5% of Malaysian DTs indicated they had not received sufficient information about MIH. Notably, 100% of DTs cited inadequate training as the main barrier, and 88.2% requested a training program on MIH (Hussein et al. 2014). Unlike in several countries such as Australia, New Zealand and the United Kingdom, where DTs, oral health therapists (OHTs) and dental hygienists (DHs) are trained alongside dental students in university-based programs (Australian Dental Council 2022; Ministry of Health New Zealand 2010; General Dental Council 2015), Malaysian DTs are trained separately at a dedicated national training institute. Based on information supplied by the Training Division, Ministry of Health (MOH) Malaysia, existing DT training places strong emphasis on dental caries, while developmental defects of enamel (DDEs) including MIH are not currently covered in-depth within the curriculum.\u003c/p\u003e\u003cp\u003eGiven the clear gaps in MIH-related training among Malaysian DTs, there is a pressing need for educational resources that specifically address this area. The widespread distribution of DTs across the country, including in rural areas, presents logistical and geographical barriers to the delivery of conventional in-person training. This underscores the need for a virtual training solution that is designed to be low-tech, mobile-compatible and accessible with limited internet bandwidth. To meet this need, the Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) was developed. This study aimed to evaluate the outcomes of the MIH-EDIT among a group of Malaysian DTs. The specific objectives were to compare the DTs\u0026rsquo; mean knowledge scores (KS) and photographic assessment scores (PS) at three time points: before the intervention (T0), immediately after (T1) and two weeks post-intervention (T2).\u003c/p\u003e"},{"header":"2 Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Ethical considerations\u003c/h2\u003e\u003cp\u003eThis study was registered on the National Medical Research Register (NMRR) and ethical approval obtained from the Medical Research \u0026amp; Ethics Committee (MREC), Ministry of Health (MOH), Malaysia (NMRR ID-22-01154-AZF (IIR) and the Medical Ethics Committee, Faculty of Dentistry (DF CD2212/0036 (P)). Permission was also granted by the Oral Health Program and Sarawak Oral Health Division, MOH, Malaysia. The participants\u0026rsquo; information sheet (PIS) and electronic informed consent were embedded in the questionnaire (Google Form) and participants had the option to agree or disagree to participate.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study design, population, setting and sample size\u003c/h2\u003e\u003cp\u003e This study was reported with reference to the STROBE guidelines (von Elm et al. 2007).\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e A before-after study design with quota sampling was employed. The study population comprised of DTs in Malaysia, with the state of Sarawak selected as the study area due to its having the highest number of DTs nationwide (Health Informatics Centre, MOH, Malaysia 2019). DTs from the three largest divisions in the state of Sarawak: Kuching, Sibu and Miri were invited to participate. These divisions were selected due to logistical reasons, particularly internet accessibility, as the MIH-EDIT was delivered online. All DTs from these three divisions were eligible to participate, with no specific inclusion or exclusion applied. The sample size was calculated based on an estimated standard deviation of 10, an alpha of 0.05 (z\u0026thinsp;=\u0026thinsp;1.96), and a margin of error of 2 units, yielding a minimum of 97 participants. This was increased to 108 to account for a 10% non-response rate. To enhance representativeness and ensure the study was not underpowered, the final sample was inflated to 208 to include all DTs from the Kuching, Sibu, and Miri divisions (Bujang 2021).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Summary of the development and implementation of the MIH-EDIT\u003c/h2\u003e\u003cp\u003eThe MIH-EDIT was developed, validated, translated, piloted and finalised prior to implementation. The module content comprised five parts covering basic knowledge (Part 1), clinical features, classification and challenges (Part 2), dilemmas in diagnosis (Part 3), management (Part 4) and referral for further management (Part 5). The module materials included an e-booklet, pre-recorded PowerPoint presentation slides and live interactive Q\u0026amp;A (Mentimeter). The MIH-EDIT was delivered virtually and synchronously as a one-day program. At the end of the program, the e-booklet was shared asynchronously as a supplementary educational material and remained accessible for two weeks.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Study instruments\u003c/h2\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1 Questionnaire: adaptation, validation and translation\u003c/h2\u003e\u003cp\u003eA self-administered questionnaire, adapted from previous literature and mapped with the module content, was used to assess the DTs\u0026rsquo; knowledge about MIH. Section A collected sociodemographic characteristics, while Section B, adapted with permission from Gambetta-Tessini et al. (2016), included 10 questions covering awareness, prevalence, etiology, time of insult, and the caries pattern seen in MIH. Minor rewording and rephrasing were done to fit the local context (Hussein et al. 2015). Individual questions were created for each etiological factor with answer options of \u0026ldquo;yes\u0026rdquo;, \u0026ldquo;no\u0026rdquo; and \u0026ldquo;not sure\u0026rdquo;. \u0026ldquo;Not sure\u0026rdquo; responses were scored equivalently to the lowest score for that question to maintain the original knowledge score (KS) range of 20 to 60, with higher KS indicating higher knowledge about MIH.\u003c/p\u003e\u003cp\u003eContent validity was quantitatively assessed by three paediatric dental specialists \u0026ndash; one from MOH, Malaysia and two from local universities, using a 4-point scale to evaluate relevance and clarity. The I-CVI ranged from 0.67 to 1 (S-CVI\u0026thinsp;=\u0026thinsp;0.96). Following feedback from content validators, minor wording and phrasing changes were made. The pre-final questionnaire was translated into Malay through two independent forward translations by a linguistic expert and a paediatric dental specialist. A panel comprising two pediatric dental specialists and two dental public health specialists reviewed both translations and agreed on a consensus Malay version. This version was then back-translated by a different linguistic expert and paediatric dental specialist. These English back-translations were compared with the original to ensure conceptual and semantic equivalence. Following re-evaluation by the panel, the Malay version of the questionnaire was finalised.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2 Photographic assessment: screening, scoring and finalisation of clinical photographs\u003c/h2\u003e\u003cp\u003ePhotographic assessment was used to evaluate participants\u0026rsquo; ability to detect and distinguish MIH from sound teeth, caries and other developmental defects of enamel (DDEs) \u0026ndash; a key intended learning outcome of the MIH-EDIT. Clinical photographs (n\u0026thinsp;=\u0026thinsp;125) of sound teeth, caries, mild MIH, severe MIH and other DDEs such as amelogenesis imperfecta (AI), fluorosis and enamel hypoplasia were contributed by the post-graduate students and specialists from the Paediatric Dentistry Unit of a public university. These were compiled into a PowerPoint presentation. assigned unique numerical codes for identification and screened by the panel for image clarity, visibility of the site of interest and adjacent teeth.\u003c/p\u003e\u003cp\u003eAfter screening, 49 clinical photographs were included for scoring by three pediatric dental specialists: two from the MOH, Malaysia and one from a public university. Each photograph was scored based on the observed condition: sound (0), caries (1), mild MIH (2M), severe MIH (2S), and other DDEs (3). The photographs were scored independently in two rounds, one week apart, using Google Forms with a 30-minute timer and randomized order. A consensus scoring session was then conducted via Google Meet, during which all photographs were reviewed, disagreements resolved through discussion, and final consensus scores established. A total of 43 photographs were initially retained following modifications and exclusions. Subsequently, 11 were excluded due to lack of agreement (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConcurrently, inter- and intra-examiner reliability were assessed using Cohen\u0026rsquo;s kappa analysis (Landis and Koch 1977). Inter-examiner reliability ranged from substantial to near-perfect (κ\u0026thinsp;=\u0026thinsp;0.75\u0026ndash;0.87), while each examiner\u0026rsquo;s scoring showed near perfect agreement with the consensus (κ\u0026thinsp;=\u0026thinsp;0.83\u0026ndash;0.96). Intra-examiner reliability was near perfect for Examiners 1 and 3 (κ\u0026thinsp;=\u0026thinsp;0.96), and substantial for Examiner 2 (κ\u0026thinsp;=\u0026thinsp;0.71). All kappa values were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After reliability analysis, the panel reviewed the outcomes and through consensus, selected the final 32 clinical photographs. The consensus score for each of these clinical photographs was used as the gold standard. Each correct answer was awarded 1 point, while incorrect answers received 0 points. PS ranged from 0 to 32 and were converted into percentages to reflect the DTs\u0026rsquo; marks out of 100. Higher PS indicated better ability to detect MIH and distinguish it from other conditions.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Data collection\u003c/h2\u003e\u003cp\u003eParticipants completed the same questionnaire and photographic assessment independently at three time points: before (T0), immediately after (T1) and two weeks after the implementation of the MIH-EDIT (T2). The same set of clinical photographs was used in all sessions, with the sequence reshuffled each time. Each session took approximately 60 minutes. The self-administered bilingual questionnaire (English and Malay) and the scoring form were shared via Google Forms, allowing participants to choose their preferred language. On the day of implementation, the Google Forms links/ QR codes were shared through the Zoom platform. For the two-week follow up, the designated links were shared with the DTs through the district liaison officers, who also sent daily reminders to encourage responses. The forms remained open for five days before being closed. A two-week wash out period was used to minimise potential contamination from other training/ courses.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Data entry and analysis\u003c/h2\u003e\u003cp\u003eParticipants\u0026rsquo; responses from Google Forms were transferred to Microsoft Excel for data entry. To ensure anonymity and confidentiality, direct identifiers (such as participant names) were removed, and each participant was assigned a unique identification code. A data dictionary was created to guide the data entry process. Data were cleaned to minimize errors before being imported into SPSS software version 25.0 for further analysis. Descriptive statistics were used to compare participants\u0026rsquo; KS and PS at T0, T1 and T2. Data normality was assessed using skewness, kurtosis, histogram inspection and Kolmogorov-Smirnov test. Repeated measures ANOVA was used to assess if there were statistically significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in the mean KS and PS across the three time points followed by post hoc pairwise comparisons to identify specific time points with significant differences.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the number of responses for both the questionnaire and photographic assessment at T0, T1 and T2. Overall, the response rates exceeded 94% with the exception of the photographic assessment at T2, where the response rate declined to approximately 85%. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the respondents\u0026rsquo; sociodemographic characteristics at baseline. All participating DTs were female, with a mean age of 40 years and an average of 15 years in service. Approximately half were based in Kuching, with the remainder from Sibu and Miri divisions. Over 90% held a diploma, and approximately 2% had post-basic training in paediatric dentistry. Approximately 75% had clinical roles whilst the remaining 25% were involved in management and administrative duties.\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNumber of responses for the questionnaire and photographic assessment at each time point\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eStudy instruments\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eResponse rate (N\u0026thinsp;=\u0026thinsp;187)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003cp\u003e(T0)\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eImmediately after (T1)\u003c/p\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTwo weeks later (T2)\u003c/p\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuestionnaire (knowledge):\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRespondents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e176 (94.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e178(95.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e177(94.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeclined to respond/ did not\u003c/p\u003e\n \u003cp\u003eanswer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11(5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10(5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhotographic assessment:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRespondents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e185(98.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e178(95.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e158(84.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeclined to respond/ did not\u003c/p\u003e\n \u003cp\u003eanswer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2(1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29(15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows the percentage distribution of DTs\u0026rsquo; responses for each question on MIH knowledge at T0, T1 and T2. At T0, 27.3% of DTs were unsure that MIH is a DDE distinct from fluorosis and hypoplasia whereas this dropped to zero post-intervention. Over 75% were initially unsure of MIH prevalence in Malaysia, but 86.5% correctly identified it as 10\u0026ndash;20% at T1, decreasing to 66.3% at T2. Post-intervention, there was a decrease in the percentage of DTs who answered unsure with regards to the possible etiological factors of MIH. The percentage of DTs who considered genetic factors, environmental pollutants, acute and chronic medical conditions as well as antibiotics or medications to be involved in MIH etiology increased whereas those who excluded fluoride exposure as a cause rose from 16% to approximately 50%. Regarding the timing of enamel disturbance, 25% were unsure at T0, and 48.9% linked it to pregnancy. At T1, 55.1% correctly indicated the critical period as pregnancy to age three. The percentage of DTs who agreed that MIH-related caries patterns differed from classical caries increased from 60.2% to approximately 90% post-intervention.\u003c/p\u003e\n\u003cp\u003eAs shown in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, repeated measures ANOVA revealed statistically significant differences in mean KS and PS across the three time points. Post hoc analysis with Bonferroni adjustment showed a significant increase in the mean KS from T0 to T1 (12.28 (95% CI, 10.86 to 13.70), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u0026eta;\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.7) and from T0 to T2 (11.68 (95% CI, 10.19 to 13.18), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u0026eta;\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.7). However, the difference between T1 and T2 was not statistically significant (-0.60 (95% CI, -1.46 to 0.26), p\u0026thinsp;=\u0026thinsp;0.284, \u0026eta;\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.5). Similarly, for PS, post hoc analysis indicated significant increases from T0 to T1 (7.47 (95% CI, 6.36 to 8.58), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u0026eta;p2\u0026thinsp;=\u0026thinsp;0.6) and from T0 to T2 (6.19 (95% CI, 5.02 to 7.36), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u0026eta;p2\u0026thinsp;=\u0026thinsp;0.5). Meanwhile, a small but statistically significant decrease was observed between T1-T2 (-1.28 (95% CI, -2.01 to -0.54), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u0026eta;p2\u0026thinsp;=\u0026thinsp;0.1).\u003c/p\u003e\n\u003ctable id=\"Tab4\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of DTs\u0026rsquo; knowledge scores and photographic assessment scores before, immediately after and two weeks after implementing the MIH-EDIT\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy instrument\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026plusmn;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value*\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEffect size\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestionnaire (knowledge)\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eKnowledge Score (KS) (N\u0026thinsp;=\u0026thinsp;164)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBefore (T0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.61\u0026plusmn;6.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImmediately after (T1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.89\u0026plusmn;3.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo weeks after (T2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.29\u0026plusmn;4.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhotographic assessment\u003c/strong\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhotographic Assessment Score (PS) (N\u0026thinsp;=\u0026thinsp;145)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline (T0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.94\u0026plusmn;4.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImmediately after (T1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.41\u0026plusmn;5.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo weeks after (T2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.14\u0026plusmn;5.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*Repeated measures ANOVA; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is considered statistically significant\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eIn the present study, 62.4% of DTs recognized MIH as a DDE distinct from fluorosis and hypoplasia, which was notably lower than figures reported in similar studies (81.1\u0026ndash;92.4%) (Gambetta-Tessini et al. 2016; Skaare et al. 2021). Over 75% of DTs were unsure about MIH prevalence in Malaysia, in contrast to just 12\u0026ndash;19% in other countries (Gambetta-Tessini et al. 2016; Skaare et al. 2021). This uncertainty likely stemmed from a lack of local data, with very few published studies to date on MIH distribution among Malaysian children (Ardini et al. 2019; Hussein et al. 2015). Accordingly, the MIH-EDIT included local prevalence data to begin addressing this gap. However, more comprehensive national prevalence studies are still needed. Despite growing research into the possible causes of MIH (Bussaneli et al. 2021; Garot et al. 2022), its exact etiology remains unclear. However, it is well established that fluoride exposure is not a contributing factor (Koch 2003). Yet, only 15.9% of DTs were aware of this before the intervention, while 61.9% incorrectly attributed MIH to fluoride exposure, which was substantially higher than in other studies (7.7\u0026ndash;13.5%) (Gambetta-Tessini et al. 2016; Skaare et al. 2021). This confusion may be due to frequent misidentification of MIH as fluorosis (Crombie et al. 2008). Additionally, 60.2% of DTs thought that the caries pattern seen in MIH was different from the classical pattern, which was lower compared to 87.9% and 73% in earlier research (Gambetta-Tessini et al. 2016; Skaare et al. 2021). Correspondingly, the mean baseline knowledge score (37.43\u0026thinsp;\u0026plusmn;\u0026thinsp;7.05) was significantly lower compared to that of Australian OHTs (50.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.30) (Gambetta-Tessini et al. 2016). These findings highlight the limited baseline knowledge of MIH among Malaysian DTs compared to their international counterparts, reinforcing the need for targeted training to strengthen their foundational understanding of the condition.\u003c/p\u003e\u003cp\u003eThe results of the present study showed a statistically significant improvement in DTs\u0026rsquo; KS following the implementation of the MIH-EDIT, indicating a clear increase in MIH-related knowledge attributable to the intervention. Interestingly, the post-intervention KS in the present study was comparable to the baseline KS reported among OHTs in Australia (50.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3) (Gambetta-Tessini et al. 2016), suggesting that the MIH-EDIT helped elevate DTs\u0026rsquo; knowledge to a similar standard. A similar trend was reported by Aguilar Galvez and colleagues (2022), who observed significant improvements in post-test scores following the implementation of a virtual learning object (VLO). Unlike the single-group design used in the present study, their study included a control group and targeted undergraduate dental students. While the control group received a synchronous virtual theoretical lecture and the intervention group used a more technologically advanced VLO comprising videos, narrations and images, both groups showed similar improvements (Aguilar G\u0026aacute;lvez et al. 2022). This suggests that the while enhanced digital tools may offer added value, simpler formats can still be effective for knowledge acquisition. This finding was reassuring, as the MIH-EDIT, though less high-tech, employed a comparable delivery approach and demonstrated similarly positive outcomes. The lack of a statistically significant difference between mean KS at T1 and T2 further suggests that the knowledge gained was retained over the two-week period. This sustained improvement, alongside a medium-to-large effect size, underscores the educational impact of the MIH-EDIT.\u003c/p\u003e\u003cp\u003eBased on the limited published studies on MIH training, the use of clinical photographs as a tool for assessment or calibration is consistently supported by researchers (Amarante et al. 2022; Restrepo et al. 2024; Vieira et al. 2023). However, due to differences in the study designs and analytical approaches, direct comparison with the present study was not feasible. In terms of the outcome patterns, previous studies reported improvements with each subsequent calibration or when comparing pre-test and post-test results, aligning with the findings of the present study (Amarante et al. 2022; Restrepo et al. 2024; Vieira et al. 2023). In those studies, the digital clinical photographs were administered under more controlled and standardised conditions such as in a shared physical space with group image projection (Amarante et al. 2022; Vieira et al. 2023), or in a computer lab-like setting where participants accessed images individually via a digital learning platform (Restrepo et al. 2024). In contrast, participants in the present study completed the photographic assessment individually via Google Forms using their own devices, primarily smartphones and tablets. While this decentralized format reflects real-world conditions and enhances the ecological validity of the photographic assessment, it may have introduced variability in viewing conditions due to differences in screen size, resolution and lighting. To mitigate this, efforts to standardize the clinical photographs used in the assessment were made through a rigorous, systematic and consensus-based process. The results of the present study indicate a substantial improvement in the DTs ability to detect MIH and distinguish it from sound teeth, caries as well as other DDEs immediately after implementation of the MIH-EDIT. Although the decrease in mean PS between T1 and T2 was statistically significant, the small effect size suggests that the magnitude of change was minimal, indicating overall stability in the DTs\u0026rsquo; performance and that the detection skills acquired were largely retained over the two-week period.\u003c/p\u003e\u003cp\u003eTo the best of the authors\u0026rsquo; knowledge, this study is the first in Malaysia to develop and implement a tailored training module for DTs focused on MIH and translated into the national language, addressing a recognized gap in knowledge and practice. The present study employed a single group, before-after design without a control group and used quota sampling - a non-randomised method chosen for its feasibility at this stage. However, considering all DTs in Malaysia are trained at the same national training institute and constitute a homogeneous group, the present sample likely offers reasonable representativeness and generalisability of findings. Data collection relied on a self-administered, self-reported questionnaire, introducing the possibility of response and social desirability biases, as well as memory bias from repeated testing. Similar concerns applied to the photographic assessment. However, bias was minimized through the randomized presentation of the clinical photographs and the use of a two-week washout period following the intervention. This study was primarily quantitative in nature, focusing only on the short-term outcomes post implementation of the MIH-EDIT. This approach inherently limited the scope of the findings to immediate impacts, without an exploration of long-term effects or qualitative aspects. Thus, future research should explore qualitative feedback to better understand DTs\u0026rsquo; experiences and incorporate long-term follow-up to assess knowledge retention, clinical application and patient outcomes to fully establish the impact of the training module.\u003c/p\u003e\u003cp\u003eThe findings of the present study highlight the need for more coordinated efforts between universities and the MOH, Malaysia to ensure that updated information on MIH is made accessible to DTs through well-structured training. Following further refinement, there is potential for the MIH-EDIT to be implemented nationally, either through integration into pre-service training curriculum for future DTs or as part of continuing professional development (CPD) programs for in-service DTs especially in settings where access to in-person training is limited. Its alignment with CPD objectives is especially relevant given that it is mandatory for DTs to obtain a minimum number of CPD points for Annual Practicing Certificate (APC) renewal. Given its scalability and minimal resource requirements, the MIH-EDIT represents a cost-effective strategy for ongoing workforce development. It could also be adapted for other learner groups such as undergraduate students and general dental practitioners and may serve as a valuable model for similar educational initiatives in other countries where DTs play a key role in pediatric oral healthcare delivery.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eWithin the limitations of the study, the MIH-EDIT improved the DTs knowledge of MIH and their ability to distinguish MIH from sound teeth, caries and other DDEs over the short term. With further refinement, the MIH-EDIT holds potential for nationwide adoption into pre-service training and continuing professional development (CPD) programs for DTs, enhancing MIH early detection and intervention in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDisclosure:\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSL conceived the idea, collected and analysed the data, supervised by TNF, ND, NAM and THM. TNF, ND, NAM and THM formed the panel during consensus discussions. The initial draft of the manuscript was prepared by SL and was revised by TNF, ND, NAM and THM. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003eThis study was funded by the Dental Postgraduate Research Grant (DPRG), Faculty of Dentistry, Universiti Malaya (UMG032E-2022). Honorarium (food voucher worth RM10) was given to all the participants for their participation in the MIH-EDIT. The authors wish to thank all individuals who were involved in the content validation and translation process of the questionnaire, compilation, screening, and scoring of clinical photographs as well as the dental therapists who participated in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbu Bakar A, Mohd Nor NA, Ab-Murat N, Jaafar N. Job satisfaction and perceived future roles of Malaysian dental therapists: findings from a national survey. 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Dent Update. 2004;31(1):9\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12968/denu.2004.31.1.9\u003c/span\u003e\u003cspan address=\"10.12968/denu.2004.31.1.9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 2 and 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-archives-of-paediatric-dentistry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EAPD","sideBox":"Learn more about [European Archives of Paediatric Dentistry](https://link.springer.com/journal/40368)","snPcode":"40368","submissionUrl":"https://submission.springernature.com/new-submission/40368/3","title":"European Archives of Paediatric Dentistry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"molar incisor hypomineralisation, dental therapists, training, early detection, early intervention, evaluation","lastPublishedDoi":"10.21203/rs.3.rs-7283561/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7283561/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose/ Objectives:\u003c/h2\u003e\u003cp\u003eMolar incisor hypomineralisation (MIH) is a common developmental defect of enamel (DDE) seen in children. In Malaysia, dental therapists (DTs) are well-positioned to support early detection through the school dental service. However, most DTs lack adequate training and confidence in managing MIH. This study aimed to evaluate the outcomes of the virtual Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) by comparing the DTs\u0026rsquo; knowledge scores (KS) and photographic assessment scores (PS) before (T0), immediately after (T1) and two weeks after (T2) training.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA before-and-after study was conducted among DTs in Sarawak, Malaysia. Participants received a one-day virtual MIH training and completed a self-administered questionnaire and photographic assessment of MIH at T0, T1 and T2. Data were analysed using descriptive statistics and repeated measures ANOVA.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eIn total, 187 DTs completed this virtual MIH training. There was a significant increase (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the mean KS from T0 (31.95\u0026thinsp;\u0026plusmn;\u0026thinsp;11.68) - T1 (49.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.76) and T0 - T2 (48.18\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83), but not from T1 - T2 (p\u0026thinsp;=\u0026thinsp;0.098). There was a significant increase (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the mean PS from T0 (13.94\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52) - T1 (21.41\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04) and T0 - T2 (20.14\u0026thinsp;\u0026plusmn;\u0026thinsp;5.50), while a small but significant decrease (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was observed from T1 - T2.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWithin study limitations, the MIH-EDIT improved DTs knowledge on MIH and their ability to detect MIH over the short-term. This virtual MIH training has the potential for nationwide adoption into DT training and continuing professional development programmes, enhancing MIH early detection and intervention in clinical practice.\u003c/p\u003e","manuscriptTitle":"Evaluation of the Virtual Molar Incisor Hypomineralisation Early Detection and Intervention Training Module (MIH-EDIT) For Dental Therapists in Malaysia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 01:23:43","doi":"10.21203/rs.3.rs-7283561/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-14T04:31:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-07T17:10:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T14:11:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116780752911926377190402294575921901434","date":"2025-08-30T16:09:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207205649318495672913974329815126796820","date":"2025-08-19T12:06:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-06T13:40:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-04T10:01:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-04T10:00:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Archives of Paediatric Dentistry","date":"2025-08-03T13:15:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-archives-of-paediatric-dentistry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EAPD","sideBox":"Learn more about [European Archives of Paediatric Dentistry](https://link.springer.com/journal/40368)","snPcode":"40368","submissionUrl":"https://submission.springernature.com/new-submission/40368/3","title":"European Archives of Paediatric Dentistry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"875067b4-1c7c-4c14-b3e6-b5ff3ceadb93","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-21T04:08:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 01:23:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7283561","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7283561","identity":"rs-7283561","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}