Unilateral Molar Incisor Hypomineralization influences the chewing side? An observational study in children

Unilateral Molar Incisor Hypomineralization influences the chewing side? 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An observational study in children Lana Cardoso-Silva, Bianca Caroline Gomes, Roberta Paula de Faria Melo, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4249292/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Nov, 2024 Read the published version in Clinical Oral Investigations → Version 1 posted 10 You are reading this latest preprint version Abstract Objective: This observational study aims to compare the chewing patterns of children with Unilateral Mild and Severe MIH to those without MIH, based on the hypothesis that children with unilateral MIH may prefer to chew on the side opposite to the defect. Methods: A total of 121 children were included in the study and evaluated for their Preferred Chewing Side (PCS). This comprised 45 children with Unilateral Mild MIH (G1), 42 with Unilateral Severe MIH (G2), and 34 children in the control group (CG) who lacked MIH but had unilateral chewing complaints. Results: The PCS pattern differed among the groups, with 31% of children with MIH and 55.9% of the CG showing bilateral chewing. Chewing deviation prevalence was 24% in the CG and 52% in G2 (χ2 test; p = 0.03). Binomial logistic regression analysis revealed that both severities of MIH influenced the likelihood of chewing deviation (χ2 = 7.33, p = 0.026). Children with Unilateral Severe MIH were found to have 3.57 times higher odds of experiencing chewing deviation than those without MIH. Conclusions: Unilateral MIH affects children's masticatory patterns, increasing the risk of chewing deviation. Clinical Relevance: Unilateral chewing may be associated with various health issues, such as temporomandibular disorders (DTM), decreased hearing, and vision problems. Unilateral MIH could be considered a potential risk factor for unilateral chewing. Molar incisor hypomineralization mastication masticatory muscles pediatric dentistry Figures Figure 1 Figure 2 Figure 3 Introduction Molar incisor Hypomineralization (MIH) is a qualitative developmental enamel defect characterized by demarcated opacities on one to four first permanent molars, also often affecting the permanent incisors, and similar lesions can be found on all other teeth, both primary and permanent. MIH is putatively caused by multiple etiological factors [1,2]. MIH is a significant concern in modern Pediatric Dentistry due to its high prevalence, impact on the quality of life of affected children and challenges in treatment, particularly in severe cases with dental hypersensitivity, post-eruptive enamel breakdown and/or atypical caries lesions [3,4] The evaluation of mastication difficulties and food intake problems in children with MIH have been conducted in a few studies. Ebel et al. used specific questions related to dietary/functional domains from the CPQ 8-10 questionnaire and found that children with severe MIH experienced greater difficulty with cold and hard foods [5]. In another study conducted by the same researchers, restorative treatment improved these symptoms [6]. Our group, evaluating children with and without MIH using surface electromyography, observed higher activity in mastication muscles amongst MIH children, indicating poorer muscle efficacy [7]. Ideally, children exhibit balanced and alternating bilateral chewing patterns, leading to typical anteroposterior and vertical mandibular development [8]. Persistent unilateral chewing may result in various consequences, including facial disharmony, headaches, tooth wear, and even hearing loss [9-13]. No studies have specifically investigated chewing patterns in individuals affected by MIH. Other dental problems, such as dental caries and malocclusion, for instance unilateral crossbite and posterior scissor-bite, can cause chewing alterations [14, 8, 9,15]. Children with carious lesions present changes in chewing ability, masticatory performance, occlusal bite forces and chewing behavior [16, 14]. Dental caries is also weakly correlated with a preferred chewing side (PCS) in children [17]. Anatomical restoration of the carious teeth can lead to occlusal equilibration, and mastication normalization [18,19]. Correction of crossbite may also lead to normalization of mastication cycles [8]. Considering the asymmetry and heterogeneity of clinical manifestations in MIH (e.g., MIH may affect only one first permanent molar or multiple teeth with PC varying severities), it is plausible to hypothesize that affected children may attempt to shift their chewing to the unaffected side. The objective of this observational study is to assess the chewing patterns of MIH and No-MIH children, comparing them in terms of factors related to deviations in the mastication process. Methods Study Design This cross-sectional observational study, following the guidelines outlined in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), was conducted in a public school situated in the West Zone of Ribeirão Preto, São Paulo, Brazil, from August to December 2022. The study enrolled a total of 605 students, ranging in age from 6 to 11 years, comprising both genders. The study was approved by the Research Ethics Committee of the School of Dentistry of Ribeirão Preto, University of São Paulo, under registration number CAAE: 12161019.2.0000.5419. Study Participants and Sample Size Calculation Sample size calculation was performed using the online platform: http://estatistica.bauru.usp.br/calculoamostral/index.php (Lauris; Honório, 2010), with a significance level of 5% (alpha error) and test power of 80% (beta error of 20%), based on the results of a pilot study. This pilot study was conducted in the same school, involving 42 children with or without MIH, considering the deviation of mastication side (estimated standard deviation of 0.35 and minimum detectable difference of 0.15), with a 20% estimated sample loss, resulting in an estimation of 33 children per group. Examiner Calibration Two examiners (LCS and BMS) underwent training and calibration under the supervision of an experienced reference examiner in MIH research (FKC). Calibration followed the criteria established by Ghanim et al., with the calibration protocol outlined in Vieira et al., as summarized below [20, 21]. Initially, detailed explanations were provided regarding concepts, clinical characteristics, and utilized indices. Following the theoretical discussions, each examiner completed two practical calibration sessions, evaluating approximately 30 images sourced from the professorial archives for educational purposes. These images encompassed a range of enamel defects, including MIH as well as various severity levels of other enamel anomalies such as fluorosis, hypoplasia, amelogenesis imperfecta, carious lesions, and sound teeth. Subsequently, calibration was further refined through the assessment of children undergoing treatment. Inter- and intra-examiner agreement yielded a Kappa coefficient exceeding 0.8. Clinical Evaluation Protocol and Sample Selection Initially, a visual screening examination was conducted on all 605 students using a wooden spatula and a head-mounted LED flashlight (Head-mounted 9 LED Flashlight, NOLL-AMATOOLS – model 3510003, Piracicaba-SP, Brazil) to identify suspected cases of MIH. Pre-selected children underwent thorough examination in a mobile dental unit (Dental Case – Portable dental equipment KDL200, São Paulo, Brazil) equipped with a suction device, high and low-speed handpieces, triple syringe, and a compressor capable of producing 5 pcm of air, along with a head-mounted LED flashlight. Prior to the clinical examination, prophylaxis with pumice and water was performed using the slow speed handpiece, followed by drying of the teeth with the triplex syringe. The diagnosis of MIH was made by one clinical examiner (LCS), following the criteria of Ghanim et al. [20]. The severity of MIH was determined using the criteria of Lygidakis et al., with children classified as having Mild MIH (at least one permanent first molar with demarcated white or yellow opacities) or Severe MIH (at least one permanent first molar with post-eruptive enamel fracture, atypical restoration, or atypical caries lesion) [2]. At this stage, only children with unilateral MIH were selected for the study, meaning they presented MIH in only one side of the oral cavity, or in only one first permanent molar, or in two opposing teeth. For the Control Group (without MIH), children were selected who did not have any teeth with enamel developmental defects, but who reported chewing complaints, such as pain and difficulty chewing on one side, in the chewing assessment questionnaires. Children in the control group could have dentin carious lesions (ICDAS 4 or 5) and/or satisfactory and unsatisfactory restorations on the first permanent molars and/or gingivitis. The following exclusion criteria were followed: children with bilateral MIH; recent use of medications that could affect the musculature such as anxiolytics, muscle relaxants, and/or immunosuppressants; and recent oro-facial surgery. Assessment of Preferred Chewing Side and Determination of Chewing Deviation Children from the three groups (Mild MIH, Severe MIH and Control Group) were randomized and evaluated by a second examiner (BMS) to determine the Preferred Chewing Side (PCS), following the protocol of McDonnel et al., as summarized below. Participants were given half a piece of sugar-free Trident™ gum (approximately 1.5 g) to chew (Adams Brasil, Bauru, São Paulo, Brazil) [22]. After a 15 second interval, the evaluators asked the participants to stop chewing and open their mouths to observe on which side the gum had been chewed. This procedure was repeated seven times, with 5 second intervals between each repetition, resulting in seven chewing instances recorded as right or left. If there were four instances recorded on one side and three on the other, the child was classified as "bilateral chewing"; if there were five to seven instances on one side, the PCS was determined. Additionally, children also answered a questionnaire regarding their preferred chewing side, as well as whether they experienced any pain or difficulty on one side of chewing, with the data being tabulated. The evaluator reviewed and piloted the protocol with 30 students who were not included in the study prior to the examination. A third evaluator (IRA) determined using spreadsheets, without knowing the groups to which the children belonged, whether there was a chewing deviation or not, as follows: - Children without chewing deviation: children with bilateral chewing or those with PCS coinciding with the problem (unilateral MIH on the same side or same side of chewing complaint in the control group); - Children with chewing deviation: children with PCS opposite to the side of the problem (unilateral MIH or opposite side of the chewing complaint to the PCS). Statistical Analysis Descriptive analysis was performed with demographic data. Data for the dependent variables of the main outcomes were of nominal qualitative nature (preferred chewing side and chewing deviation). Therefore, for comparison of the data amongst the three groups, the association x 2 test was implemented. Additionally, to assess the influence of the presence and severity of MIH on chewing deviation, a binomial logistic regression analysis was performed using the study grouping variables as predictors, with the outcome being chewing deviation or not. The analyses were conducted by another examiner (FKC), using Jamovi software (The jamovi project, 2022, jamovi, version 2.3), with a significance level of 5%. Results Of the 605 children evaluated, 110 presented with MIH (18.2%), with 87 selected for the study with unilateral MIH (Mild MIH – 45 children (25 girls and 20 boys; mean age 8.7 y (SD 1.6); Severe MIH – 42 children; 19 girls and 23 boys; mean age 8.9 y (SD 1.5), while the control group consisted of 34 children without MIH (19 girls and 15 boys; mean age 8.6 y (SD 1.5) (Figure 1). The groups did not have statistical differences regarding age (Anova; p = 0.715) and sex (x 2 test; p = 0.548). The Mild MIH group consisted of children with demarcated opacities (white and/or yellow), whilst in the Severe MIH Group there were 20 with post-eruptive breakdown, 7 with atypical restoration and 15 with atypical caries lesions. The distribution of affected teeth were: Mild MIH – 17 right side (37.8%) and 28 left side (62.2%); Severe MIH – 27 right side (64.3%) and 15 left side (35.7%); Control Group (pain or complaint chewing side) – 13 right side (38.2%) and 21 left side (61.8%). (Figure 1) A different distribution of PCS was observed among the three groups, with a predominance of bilateral chewing (55.9%) in children in the Control Group, without statistical significance (χ 2 ; p = 0.05). In the groups with MIH, there was a more dispersed distribution among the three possibilities of PCS, with bilateral chewing observed in 31.1% of children in the mild MIH group and 31% of children in the severe MIH group. There was also a lower prevalence of left PCS in the control group (8.8%), compared to the Mild MIH (24.4%) and Severe MIH (33.3%) groups. (Figure 2) Figure 3 shows the comparison of chewing deviation by group. The control group showed a lower proportion of children with chewing deviation on the side where complaints were reported (24%), while in the Severe MIH group, the number increased to 52%, with this difference being statistically significant (x 2 test; p = 0.03). The binomial logistic regression analysis yielded the following results: [χ 2 = 7.33, p = 0.026; R2N = 0.079]. Odds Ratio (95% CI): 3.57 (1.32 - 9.69) [Severe MIH - Control] and 2.844 (1.06 - 7.62) [Mild MIH - Control]. Simple logistic regression showed that having unilateral Mild or Severe MIH significantly influences the likelihood of chewing deviation. The calculated odds ratio indicates that children with unilateral Mild MIH have a 2.84 times higher chance of chewing deviation compared to children without MIH with unilateral complaints, and that children with Severe MIH have 3.57 times higher odds of presenting chewing deviation (children with PCS opposite to the side of the MIH-affected tooth) than children without MIH. Discussion Serious clinical implications are linked to MIH due to its enamel lesion characteristics. The MIH demarcated opacities, particularly the darker lesions (yellow-brownish), tend to exhibit lower mineral density values, disorganized enamel prisms, and higher porosity, resulting in reduced fracture resistance [23]. When combined with a cariogenic diet, this increases the risk of caries development [24]. Enamel porosity is also associated with dental hypersensitivity, challenges in resin adhesion, and dental anesthesia difficulties, rendering MIH one of the greatest clinical challenges in pediatric dentistry [25- 27, 2]. The impact of MIH on Oral Health-Related Quality of Life (OHRQoL) is evident, particularly in domains related to dental pain and food intake [5, 6, 28]. The present study demonstrated that children with unilateral MIH may experience alterations in mastication and are more likely to deviate chewing from the affected side, leading to unilateral mastication. To the best of our knowledge, direct investigation of the masticatory process in the MIH literature is lacking. Some authors have indicated that MIH-affected children encounter difficulties with food intake, as assessed through the food intake domain questions of an OHRQoL-related questionnaire (CPQ 8-10) [5, 6]. They observed that MIH-affected children experienced challenges with consuming cold and/or solid foods, potentially related to enamel porosity or post-eruptive breakdown exposing dentine and subsequent tooth sensitivity. The current study offers novel perspectives on these findings. One potential limitation of our study is the utilization of a single method for assessing the mastication process, coupled with the use of only one food consistency. Chewing gum was selected due to its consistent texture during mastication, facilitating comparison of chewing cycles [22, 9]. Our research team recently discovered that MIH children exhibited heightened activity in masticatory muscles and consequently lower muscle efficacy compared to control children, as determined through surface electromyography [7]. If children adopt unilateral mastication or altered chewing patterns to avoid a permanent first molar affected by MIH, it may lead to difficulties in achieving balance and exerting forces during chewing, potentially resulting in muscular alterations. Conversely, attempting to chew on the affected tooth may exacerbate pain. Another related factor is that if an MIH-affected tooth undergoes post-eruptive breakdown or develops an atypical carious lesion, in addition to the impact of chewed food on dental hypersensitivity, another challenge arises as the food may lodge in the lesion, leading to issues such as halitosis and difficulty in eating [5, 2]. Other dental conditions also contribute to changes in the mastication process. Dental caries, whether affecting anterior or posterior teeth, may induce alterations in chewing, which are often reversible with dental treatment of the affected teeth [29]. No studies were found assessing unilateral carious lesions for comparison with the data from this study; however, Nayak et al. identified a weak association between the presence of caries lesions and PCS [17]. Nevertheless, this study did not evaluate the side affected by dental caries and its correlation with PCS, as conducted in the present study with unilateral MIH. Occlusal and/or orthodontic alterations, such as unilateral missing teeth or unilateral posterior crossbite, significantly affect chewing, including deviations in chewing patterns with adaptation to unilateral chewing on the unaffected side, as observed in the present study [8]. According to the studied population and the methodology used, bilateral chewing is performed by the majority of individuals, ranging from 62.8% to over 80% [30,31]. Bilateral chewing presents functional advantages such as greater chewing efficiency, lower association with temporomandibular disorders, and appropriate facial development [14, 10, 32, 33]. On the other hand, unilateral chewing may be related to various health problems, such as decreased hearing and ophthalmic issues [13, 34]. Severe patterns of MIH often lead to tooth extraction, and recently, the loss of masticatory sensory stimulation related to posterior tooth loss/occlusion pair loss is associated with cognition loss, and even with dementia [35]. Although these more severe repercussions are more common in adults and the elderly, the findings of the present study may serve as a warning to the dental community regarding another focus of attention in the specific care of children with unilateral MIH. Different methods for evaluating chewing patterns have been proposed, some aiming to study functionality and chewing efficiency, while others assess issues related to chewing dynamics. In the first group, studies stand out that use surface electromyography, devices measuring bite force, and technologies allowing evaluation of jaw movements and/or occlusal dynamics [7, 36, 8, 9, 37]. Research related to dynamics include the assessment of chewing performance, quantification of dental functional units, and the PCS [38,13,39-41]. The evaluation of PCS presents advantages such as being easy to perform, reproducible, low in operational cost, as well as being playful and well accepted by children [22, 42, 40]. Conclusions Considering the specific context of this observational study, unilateral MIH leads to alterations in the masticatory pattern of children, resulting in a higher frequency of unilateral chewing and an increased risk of chewing deviation compared to children without MIH who have unilateral chewing complaints. Declarations Ethical Approval The study was approved by the Research Ethics Committee of the School of Dentistry of Ribeirão Preto, University of São Paulo, under registration number CAAE: 12161019.2.0000.5419. Every participant of this study and their legal guardian signed a consent form and/or assent for participation. Funding This research project was financially supported by the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0], Prof. Dr. Fabrício Kitazono de Carvalho Lead Researcher. Availability of data and materials Raw data that support the findings of this study are available in the Repositorio USPt: https://drive.google.com/drive/folders/1ltvQbQYEQSFwYTc-gDX0lxhPXSb80S2R Competing Interest Fabrício Kitazono de Carvalho declares a research funding for this study: the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0]. The authors have no relevant financial or non-financial interests to disclose. The authors have no conflicts of interest to declare that are relevant to the content of this article. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. The authors have no financial or proprietary interests in any material discussed in this article. Funding Declaration Fabrício Kitazono de Carvalho thank the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0] for funding this study. Acknowlegmenents The authors thank Coordination for the Improvement of Higher Education Personnel - (CAPES) [grant number #001] and the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0] for funding this study. 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Regalo IH, Palinkas M, Gonçalves LMN, de Vasconcelos PB, Cappella A, Solazzo R, Ferreira CLP, Dolci C, Regalo SCH, Sforza C, Siessere S. Impact of obesity on the structures and functions of the stomatognathic system: A morphofunctional approach. Arch Oral Biol. 2024 Mar;159:105877. doi: 10.1016/j.archoralbio.2023.105877. Bostancıoğlu SE, Toğay A, Tamam E. Comparison of two different digital occlusal analysis methods. Clin Oral Investig. 2022 Feb;26(2):2095-2109. doi: 10.1007/s00784-021-04191-1 Eberhard L, Rues S, Bach L, Lenz J, Schindler HJ. Biomechanical properties of masticatory balance in cases with RPDs-The influence of preferred and nonpreferred chewing side: A pilot study. Clin Exp Dent Res. 2022 Aug;8(4):912-922. doi: 10.1002/cre2.576. Huang D, Liu L, Zhai X, Wang Y, Hu Y, Xu X, Li H, Jiang H. Association between chewing side preference and MRI characteristics in patients with anterior disc displacement of the temporomandibular joint. J Stomatol Oral Maxillofac Surg. 2023 Oct;124(5):101484. doi: 10.1016/j.jormas.2023.101484. Olivieri Q, Maniewicz S, Chebib N, Mojon P, Müller F. Three tests to determine a preferred chewing side in partially edentulous patients: A pilot study. J Prosthet Dent. 2023 Oct 4:S0022-3913(23)00617-0. doi: 10.1016/j.prosdent.2023.09.003. Zhang, Y.; Liu, K.; Shao, Z.; Lyu, C.; Zou, D. The Effect of Asymmetrical Occlusion on Surface Electromyographic Activity in Subjects with a Chewing Side Preference: A Preliminary Study. Healthcare 2023, 11 , 1718. https://doi.org/10.3390/healthcare11121718 Andrade Ada S, Gavião MB, Gameiro GH, De Rossi M. Characteristics of masticatory muscles in children with unilateral posterior crossbite. Braz Oral Res. 2010 Apr-Jun;24(2):204-10. doi: 10.1590/s1806-83242010000200013. 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-4249292","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292707975,"identity":"989108f7-01b4-4d77-9111-575e0dee62ab","order_by":0,"name":"Lana Cardoso-Silva","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Lana","middleName":"","lastName":"Cardoso-Silva","suffix":""},{"id":292707978,"identity":"c48e719e-51a7-4c20-9412-3cb3b6c78193","order_by":1,"name":"Bianca Caroline Gomes","email":"","orcid":"","institution":"Universidade de São 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MIH\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4249292/v1/2e6bd6293b68f5adf3017233.jpg"},{"id":55319276,"identity":"133db6fa-629f-4da5-b2aa-88e2a6d6aa96","added_by":"auto","created_at":"2024-04-25 15:59:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45424,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4249292/v1/e5d65fb1946fb296c4d33d4b.jpg"},{"id":55319277,"identity":"eebfbc4b-2ca7-4301-8abf-4278a3daa571","added_by":"auto","created_at":"2024-04-25 15:59:32","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":33432,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4249292/v1/69e217a6079ff77dd62b568d.jpg"},{"id":68750070,"identity":"4f9a6934-f35d-476c-bd7a-a8cbf09e5177","added_by":"auto","created_at":"2024-11-11 16:09:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":544440,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4249292/v1/46f49a00-2d70-48a5-b7ad-7a76fa6786db.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Unilateral Molar Incisor Hypomineralization influences the chewing side? An observational study in children","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMolar incisor Hypomineralization (MIH) is a qualitative developmental enamel defect characterized by demarcated opacities on one to four first permanent molars, also often affecting the permanent incisors, and similar lesions can be found on all other teeth, both primary and permanent. MIH is putatively caused by multiple etiological factors [1,2]. MIH is a significant concern in modern Pediatric Dentistry due to its high prevalence, impact on the quality of life of affected children and challenges in treatment, particularly in severe cases with dental hypersensitivity, post-eruptive enamel breakdown and/or atypical caries lesions [3,4]\u003c/p\u003e\n\u003cp\u003eThe evaluation of mastication difficulties and food intake problems in children with MIH have been conducted in a few studies. Ebel et al. used specific questions related to dietary/functional domains from the CPQ 8-10 questionnaire and found that children with severe MIH experienced greater difficulty with cold and hard foods [5]. In another study conducted by the same researchers, restorative treatment improved these symptoms [6]. Our group, evaluating children with and without MIH using surface electromyography, observed higher activity in mastication muscles amongst MIH children, indicating poorer muscle efficacy [7]. Ideally, children exhibit balanced and alternating bilateral chewing patterns, leading to typical anteroposterior and vertical mandibular development [8]. Persistent unilateral chewing may result in various consequences, including facial disharmony, headaches, tooth wear, and even hearing loss [9-13].\u003c/p\u003e\n\u003cp\u003eNo studies have specifically investigated chewing patterns in individuals affected by MIH. Other dental problems, such as dental caries and malocclusion, for instance unilateral crossbite and posterior scissor-bite, can cause chewing alterations [14, 8, 9,15]. Children with carious lesions present changes in chewing ability, masticatory performance, occlusal bite forces and chewing behavior [16, 14]. Dental caries is also weakly correlated with a preferred chewing side (PCS) in children [17]. Anatomical restoration of the carious teeth can lead to occlusal equilibration, and mastication normalization [18,19]. Correction of crossbite may also lead to normalization of mastication cycles [8].\u003c/p\u003e\n\u003cp\u003eConsidering the asymmetry and heterogeneity of clinical manifestations in MIH (e.g., MIH may affect only one first permanent molar or multiple teeth with PC varying severities), it is plausible to hypothesize that affected children may attempt to shift their chewing to the unaffected side. The objective of this observational study is to assess the chewing patterns of MIH and No-MIH children, comparing them in terms of factors related to deviations in the mastication process.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional observational study, following the guidelines outlined in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), was conducted in a public school situated in the West Zone of Ribeir\u0026atilde;o Preto, S\u0026atilde;o Paulo, Brazil, from August to December 2022. The study enrolled a total of 605 students, ranging in age from 6 to 11 years, comprising both genders. The study was approved by the Research Ethics Committee of the School of Dentistry of Ribeir\u0026atilde;o Preto, University of S\u0026atilde;o Paulo, under registration number CAAE: 12161019.2.0000.5419.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Participants and Sample Size Calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSample size calculation was performed using the online platform: http://estatistica.bauru.usp.br/calculoamostral/index.php (Lauris; Hon\u0026oacute;rio, 2010), with a significance level of 5% (alpha error) and test power of 80% (beta error of 20%), based on the results of a pilot study. This pilot study was conducted in the same school, involving 42 children with or without MIH, considering the deviation of mastication side (estimated standard deviation of 0.35 and minimum detectable difference of 0.15), with a 20% estimated sample loss, resulting in an estimation of 33 children per group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExaminer Calibration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo examiners (LCS and BMS) underwent training and calibration under the supervision of an experienced reference examiner in MIH research (FKC). Calibration followed the criteria established by Ghanim et al., with the calibration protocol outlined in Vieira et al., as summarized below [20, 21]. Initially, detailed explanations were provided regarding concepts, clinical characteristics, and utilized indices. Following the theoretical discussions, each examiner completed two practical calibration sessions, evaluating approximately 30 images sourced from the professorial archives for educational purposes. These images encompassed a range of enamel defects, including MIH as well as various severity levels of other enamel anomalies such as fluorosis, hypoplasia, amelogenesis imperfecta, carious lesions, and sound teeth. Subsequently, calibration was further refined through the assessment of children undergoing treatment. Inter- and intra-examiner agreement yielded a Kappa coefficient exceeding 0.8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Evaluation Protocol and Sample Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitially, a visual screening examination was conducted on all 605 students using a wooden spatula and a head-mounted LED flashlight (Head-mounted 9 LED Flashlight, NOLL-AMATOOLS \u0026ndash; model 3510003, Piracicaba-SP, Brazil) to identify suspected cases of MIH. Pre-selected children underwent thorough examination in a mobile dental unit (Dental Case \u0026ndash; Portable dental equipment KDL200, S\u0026atilde;o Paulo, Brazil) equipped with a suction device, high and low-speed handpieces, triple syringe, and a compressor capable of producing 5 pcm of air, along with a head-mounted LED flashlight. Prior to the clinical examination, prophylaxis with pumice and water was performed using the slow speed handpiece, followed by drying of the teeth with the triplex syringe.\u003c/p\u003e\n\u003cp\u003eThe diagnosis of MIH was made by one clinical examiner (LCS), following the criteria of Ghanim et al. [20]. The severity of MIH was determined using the criteria of Lygidakis et al., with children classified as having Mild MIH (at least one permanent first molar with demarcated white or yellow opacities) or Severe MIH (at least one permanent first molar with post-eruptive enamel fracture, atypical restoration, or atypical caries lesion) [2]. At this stage, only children with unilateral MIH were selected for the study, meaning they presented MIH in only one side of the oral cavity, or in only one first permanent molar, or in two opposing teeth. For the Control Group (without MIH), children were selected who did not have any teeth with enamel developmental defects, but who reported chewing complaints, such as pain and difficulty chewing on one side, in the chewing assessment questionnaires. Children in the control group could have dentin carious lesions (ICDAS 4 or 5) and/or satisfactory and unsatisfactory restorations on the first permanent molars and/or gingivitis. The following exclusion criteria were followed: children with bilateral MIH; recent use of medications that could affect the musculature such as anxiolytics, muscle relaxants, and/or immunosuppressants; and recent oro-facial surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Preferred Chewing Side and Determination of Chewing Deviation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChildren from the three groups (Mild MIH, Severe MIH and Control Group) were randomized and evaluated by a second examiner (BMS) to determine the Preferred Chewing Side (PCS), following the protocol of McDonnel et al., as summarized below. Participants were given half a piece of sugar-free Trident\u0026trade; gum (approximately 1.5 g) to chew (Adams Brasil, Bauru, S\u0026atilde;o Paulo, Brazil) [22]. After a 15 second interval, the evaluators asked the participants to stop chewing and open their mouths to observe on which side the gum had been chewed. This procedure was repeated seven times, with 5 second intervals between each repetition, resulting in seven chewing instances recorded as right or left. If there were four instances recorded on one side and three on the other, the child was classified as \u0026quot;bilateral chewing\u0026quot;; if there were five to seven instances on one side, the PCS was determined. Additionally, children also answered a questionnaire regarding their preferred chewing side, as well as whether they experienced any pain or difficulty on one side of chewing, with the data being tabulated. The evaluator reviewed and piloted the protocol with 30 students who were not included in the study prior to the examination.\u003c/p\u003e\n\u003cp\u003eA third evaluator (IRA) determined using spreadsheets, without knowing the groups to which the children belonged, whether there was a chewing deviation or not, as follows:\u003c/p\u003e\n\u003cp\u003e- Children without chewing deviation: children with bilateral chewing or those with PCS coinciding with the problem (unilateral MIH on the same side or same side of chewing complaint in the control group);\u003c/p\u003e\n\u003cp\u003e- Children with chewing deviation: children with PCS opposite to the side of the problem (unilateral MIH or opposite side of the chewing complaint to the PCS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive analysis was performed with demographic data. Data for the dependent variables of the main outcomes were of nominal qualitative nature (preferred chewing side and chewing deviation). Therefore, for comparison of the data amongst the three groups, the association x\u003csup\u003e2\u003c/sup\u003e test was implemented. Additionally, to assess the influence of the presence and severity of MIH on chewing deviation, a binomial logistic regression analysis was performed using the study grouping variables as predictors, with the outcome being chewing deviation or not. The analyses were conducted by another examiner (FKC), using Jamovi software (The jamovi project, 2022, jamovi, version 2.3), with a significance level of 5%.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 605 children evaluated, 110 presented with MIH (18.2%), with 87 selected for the study with unilateral MIH (Mild MIH \u0026ndash; 45 children (25 girls and 20 boys; mean age 8.7 y (SD 1.6); Severe MIH \u0026ndash; 42 children; 19 girls and 23 boys; mean age 8.9 y (SD 1.5), while the control group consisted of 34 children without MIH (19 girls and 15 boys; mean age 8.6 y (SD 1.5) (Figure 1). The groups did not have statistical differences regarding age (Anova; p = 0.715) and sex (x\u003csup\u003e2\u003c/sup\u003e test; p = 0.548). The Mild MIH group consisted of children with demarcated opacities (white and/or yellow), whilst in the Severe MIH Group there were 20 with post-eruptive breakdown, 7 with atypical restoration and 15 with atypical caries lesions. The distribution of affected teeth were: Mild MIH \u0026ndash; 17 right side (37.8%) and 28 left side (62.2%); Severe MIH \u0026ndash; 27 right side (64.3%) and 15 left side (35.7%); Control Group (pain or complaint chewing side) \u0026ndash; 13 right side (38.2%) and 21 left side (61.8%). (Figure 1)\u003c/p\u003e\n\u003cp\u003eA different distribution of PCS was observed among the three groups, with a predominance of bilateral chewing (55.9%) in children in the Control Group, without statistical significance (\u0026chi;\u003csup\u003e2\u003c/sup\u003e; p = 0.05). In the groups with MIH, there was a more dispersed distribution among the three possibilities of PCS, with bilateral chewing observed in 31.1% of children in the mild MIH group and 31% of children in the severe MIH group. There was also a lower prevalence of left PCS in the control group (8.8%), compared to the Mild MIH (24.4%) and Severe MIH (33.3%) groups. (Figure 2)\u003c/p\u003e\n\u003cp\u003eFigure 3 shows the comparison of chewing deviation by group. The control group showed a lower proportion of children with chewing deviation on the side where complaints were reported (24%), while in the Severe MIH group, the number increased to 52%, with this difference being statistically significant (x\u003csup\u003e2\u003c/sup\u003e test; p = 0.03).\u003c/p\u003e\n\u003cp\u003eThe binomial logistic regression analysis yielded the following results: [\u0026chi;\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 7.33, p = 0.026; R2N = 0.079]. Odds Ratio (95% CI): 3.57 (1.32 - 9.69) [Severe MIH - Control] and 2.844 (1.06 - 7.62) [Mild MIH - Control]. Simple logistic regression showed that having unilateral Mild or Severe MIH significantly influences the likelihood of chewing deviation. The calculated odds ratio indicates that children with unilateral Mild MIH have a 2.84 times higher chance of chewing deviation compared to children without MIH with unilateral complaints, and that children with Severe MIH have 3.57 times higher odds of presenting chewing deviation (children with PCS opposite to the side of the MIH-affected tooth) than children without MIH.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSerious clinical implications are linked to MIH due to its enamel lesion characteristics. The MIH demarcated opacities, particularly the darker lesions (yellow-brownish), tend to exhibit lower mineral density values, disorganized enamel prisms, and higher porosity, resulting in reduced fracture resistance [23]. When combined with a cariogenic diet, this increases the risk of caries development [24]. Enamel porosity is also associated with dental hypersensitivity, challenges in resin adhesion, and dental anesthesia difficulties, rendering MIH one of the greatest clinical challenges in pediatric dentistry [25- 27, 2]. The impact of MIH on Oral Health-Related Quality of Life (OHRQoL) is evident, particularly in domains related to dental pain and food intake [5, 6, 28]. The present study demonstrated that children with unilateral MIH may experience alterations in mastication and are more likely to deviate chewing from the affected side, leading to unilateral mastication.\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, direct investigation of the masticatory process in the MIH literature is lacking. Some authors have indicated that MIH-affected children encounter difficulties with food intake, as assessed through the food intake domain questions of an OHRQoL-related questionnaire (CPQ 8-10) [5, 6]. They observed that MIH-affected children experienced challenges with consuming cold and/or solid foods, potentially related to enamel porosity or post-eruptive breakdown exposing dentine and subsequent tooth sensitivity. The current study offers novel perspectives on these findings. One potential limitation of our study is the utilization of a single method for assessing the mastication process, coupled with the use of only one food consistency. Chewing gum was selected due to its consistent texture during mastication, facilitating comparison of chewing cycles [22, 9]. Our research team recently discovered that MIH children exhibited heightened activity in masticatory muscles and consequently lower muscle efficacy compared to control children, as determined through surface electromyography [7]. If children adopt unilateral mastication or altered chewing patterns to avoid a permanent first molar affected by MIH, it may lead to difficulties in achieving balance and exerting forces during chewing, potentially resulting in muscular alterations. Conversely, attempting to chew on the affected tooth may exacerbate pain. Another related factor is that if an MIH-affected tooth undergoes post-eruptive breakdown or develops an atypical carious lesion, in addition to the impact of chewed food on dental hypersensitivity, another challenge arises as the food may lodge in the lesion, leading to issues such as halitosis and difficulty in eating [5, 2].\u003c/p\u003e\n\u003cp\u003eOther dental conditions also contribute to changes in the mastication process. Dental caries, whether affecting anterior or posterior teeth, may induce alterations in chewing, which are often reversible with dental treatment of the affected teeth [29]. No studies were found assessing unilateral carious lesions for comparison with the data from this study; however, Nayak et al. identified a weak association between the presence of caries lesions and PCS [17]. Nevertheless, this study did not evaluate the side affected by dental caries and its correlation with PCS, as conducted in the present study with unilateral MIH. Occlusal and/or orthodontic alterations, such as unilateral missing teeth or unilateral posterior crossbite, significantly affect chewing, including deviations in chewing patterns with adaptation to unilateral chewing on the unaffected side, as observed in the present study [8].\u003c/p\u003e\n\u003cp\u003eAccording to the studied population and the methodology used, bilateral chewing is performed by the majority of individuals, ranging from 62.8% to over 80% [30,31]. Bilateral chewing presents functional advantages such as greater chewing efficiency, lower association with temporomandibular disorders, and appropriate facial development [14, 10, 32, 33]. On the other hand, unilateral chewing may be related to various health problems, such as decreased hearing and ophthalmic issues [13, 34]. Severe patterns of MIH often lead to tooth extraction, and recently, the loss of masticatory sensory stimulation related to posterior tooth loss/occlusion pair loss is associated with cognition loss, and even with dementia [35]. Although these more severe repercussions are more common in adults and the elderly, the findings of the present study may serve as a warning to the dental community regarding another focus of attention in the specific care of children with unilateral MIH.\u003c/p\u003e\n\u003cp\u003eDifferent methods for evaluating chewing patterns have been proposed, some aiming to study functionality and chewing efficiency, while others assess issues related to chewing dynamics. In the first group, studies stand out that use surface electromyography, devices measuring bite force, and technologies allowing evaluation of jaw movements and/or occlusal dynamics [7, 36, 8, 9, 37]. Research related to dynamics include the assessment of chewing performance, quantification of dental functional units, and the PCS [38,13,39-41]. The evaluation of PCS presents advantages such as being easy to perform, reproducible, low in operational cost, as well as being playful and well accepted by children [22, 42, 40].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eConsidering the specific context of this observational study, unilateral MIH leads to alterations in the masticatory pattern of children, resulting in a higher frequency of unilateral chewing and an increased risk of chewing deviation compared to children without MIH who have unilateral chewing complaints.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of the School of Dentistry of Ribeir\u0026atilde;o Preto, University of S\u0026atilde;o Paulo, under registration number CAAE: 12161019.2.0000.5419. Every participant of this study and their legal guardian signed a consent form and/or assent for participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research project was financially supported by the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0], Prof. Dr. Fabr\u0026iacute;cio Kitazono de Carvalho Lead Researcher.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRaw data that support the findings of this study are available in the Repositorio USPt: https://drive.google.com/drive/folders/1ltvQbQYEQSFwYTc-gDX0lxhPXSb80S2R\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFabr\u0026iacute;cio Kitazono de Carvalho declares a research funding for this study: the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0].\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003eAll authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003eThe authors have no financial or proprietary interests in any material discussed in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFabr\u0026iacute;cio Kitazono de Carvalho thank the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0] for funding this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowlegmenents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Coordination for the Improvement of Higher Education Personnel - (CAPES) [grant number #001] and the National Council for Scientific and Technological Development (CNPq) [process: 405914/2021-0] for funding this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGarot E, Rouas P, Somani C, Taylor GD, Wong F, Lygidakis NA. 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Effect of Restoring Carious Teeth on Occlusal Bite Force in Children. J Clin Pediatr Dent. 2016;40(4):297-300. doi: 10.17796/1053-4628-40.4.297\u003c/li\u003e\n\u003cli\u003eCollado V, Pichot H, Delfosse C, Eschevins C, Nicolas E, Hennequin M. Impact of early childhood caries and its treatment under general anesthesia on orofacial function and quality of life : A prospective comparative study. Med Oral Patol Oral Cir Bucal. 2017 May 1;22(3):e333-e341. doi: 10.4317/medoral.21611.\u003c/li\u003e\n\u003cli\u003eGhanim A, Elfrink M, Weerheijm K, Mari\u0026ntilde;o R, Manton D. A practical method for use in epidemiological studies on enamel hypomineralisation. Eur Arch Paediatr Dent. 2015 Jun;16(3):235-46. doi: 10.1007/s40368-015-0178-8.\u003c/li\u003e\n\u003cli\u003eVieira, H. A. O., Ara\u0026uacute;jo, L. D. C., Carvalho, F. K. de ., Queiroz, A. M. de ., \u0026amp; Paula-Silva, F. W. G.. (2023). Use of Images and Clinical Experience to Calibrate Dental Surgeons for the Diagnosis of Molar Incisor Hypomineralization. Pesquisa Brasileira Em Odontopediatria E Cl\u0026iacute;nica Integrada, 23, e220040. https://doi.org/10.1590/pboci.2023.026\u003c/li\u003e\n\u003cli\u003eMc Donnell ST, Hector MP, Hannigan A. Chewing side preferences in children. J Oral Rehabil. 2004 Sep;31(9):855-60. doi: 10.1111/j.1365-2842.2004.01316.x. \u003c/li\u003e\n\u003cli\u003eElhennawy K, Manton DJ, Crombie F, Zaslansky P, Radlanski RJ, Jost-Brinkmann PG, Schwendicke F. Structural, mechanical and chemical evaluation of molar-incisor hypomineralization-affected enamel: A systematic review. Arch Oral Biol. 2017 Nov;83:272-281. doi: 10.1016/j.archoralbio.2017.08.008.\u003c/li\u003e\n\u003cli\u003eNeves AB, Americano GCA, Soares DV, Soviero VM. Breakdown of demarcated opacities related to molar-incisor hypomineralization: a longitudinal study. Clin Oral Investig. 2019 Feb;23(2):611-615. doi: 10.1007/s00784-018-2479-x.\u003c/li\u003e\n\u003cli\u003eRaposo F, de Carvalho Rodrigues AC, Lia \u0026Eacute;N, Leal SC. Prevalence of Hypersensitivity in Teeth Affected by Molar-Incisor Hypomineralization (MIH). Caries Res. 2019;53(4):424-430. doi: 10.1159/000495848. \u003c/li\u003e\n\u003cli\u003eSen Yavuz B, Kaya R, Kodaman Dokumacigil N, Ozgur EG, Bekiroglu N, Kargul B. Clinical performance of short fiber reinforced composite and glass hybrid on hypomineralized molars: A 36-month randomized split-mouth study. J Dent. 2024 Mar 1;144:104919. doi: 10.1016/j.jdent.2024.104919.\u003c/li\u003e\n\u003cli\u003eHaidar M, Raslan N. Comparative study of articaine 4% versus lidocaine 2% in the local anesthesia of permanent mandibular first molars affected by MIH: a randomized controlled trial. Eur Arch Paediatr Dent. 2023 Oct;24(5):621-630. doi: 10.1007/s40368-023-00827-w.\u003c/li\u003e\n\u003cli\u003eShields 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 Feb 1;12(3):370. doi: 10.3390/healthcare12030370.\u003c/li\u003e\n\u003cli\u003eBramantoro T, Irmalia WR, Santoso CMA, Mohd Nor NA, Utomo H, Ramadhani A, Kristanti RA, Nugraha AP. The Effect of Caries on the Chewing Ability of Children: A Scoping Review. Eur J Dent. 2023 Oct;17(4):1012-1019. doi: 10.1055/s-0042-1758066.\u003c/li\u003e\n\u003cli\u003eFarias Gomes SG, Custodio W, Moura Jufer JS, Del Bel Cury AA, Rodrigues Garcia RCM. Correlation of mastication and masticatory movements and effect of chewing side preference. Braz Dent J [Internet]. 2010;21(4):351\u0026ndash;5. Available from: https://doi.org/10.1590/S0103-64402010000400011\u003c/li\u003e\n\u003cli\u003eRamos VF, Silva AF, Picinato-Pirola M. Masticatory function in elderly compared to young adults. Codas. 2021 Oct 25;34(1):e20200364. doi: 10.1590/2317-1782/20212020364.\u003c/li\u003e\n\u003cli\u003eAl Taki A, Ahmed MH, Ghani HA, Al Kaddah F. Impact of different malocclusion types on the vertical mandibular asymmetry in young adult sample. Eur J Dent. 2015 Jul-Sep;9(3):373-377. doi: 10.4103/1305-7456.163233. \u003c/li\u003e\n\u003cli\u003eRodrigues VP, Freitas BV, de Oliveira ICV, Dos Santos PCF, de Melo HVF, Bosio J. Tooth loss and craniofacial factors associated with changes in mandibular condylar morphology. Cranio. 2019 Sep;37(5):310-316. doi: 10.1080/08869634.2018.1431591.\u003c/li\u003e\n\u003cli\u003eZieliński G, Matysik-Woźniak A, Baszczowski M, Rapa M, Ginszt M, Pająk B, Szkutnik J, Rejdak R, Gawda P. Myopia \u0026amp; painful muscle form of temporomandibular disorders: connections between vision, masticatory and cervical muscles activity and sensitivity and sleep quality. Sci Rep. 2023 Nov 19;13(1):20231. doi: 10.1038/s41598-023-47550-6.\u003c/li\u003e\n\u003cli\u003eAsher S, Suominen AL, Stephen R, Ngandu T, Koskinen S, Solomon A. Association of tooth location, occlusal support and chewing ability with cognitive decline and incident dementia. J Clin Periodontol. 2024 Mar 11. doi: 10.1111/jcpe.13970.\u003c/li\u003e\n\u003cli\u003eRegalo IH, Palinkas M, Gon\u0026ccedil;alves LMN, de Vasconcelos PB, Cappella A, Solazzo R, Ferreira CLP, Dolci C, Regalo SCH, Sforza C, Siessere S. Impact of obesity on the structures and functions of the stomatognathic system: A morphofunctional approach. Arch Oral Biol. 2024 Mar;159:105877. doi: 10.1016/j.archoralbio.2023.105877.\u003c/li\u003e\n\u003cli\u003eBostancıoğlu SE, Toğay A, Tamam E. Comparison of two different digital occlusal analysis methods. Clin Oral Investig. 2022 Feb;26(2):2095-2109. doi: 10.1007/s00784-021-04191-1\u003c/li\u003e\n\u003cli\u003eEberhard L, Rues S, Bach L, Lenz J, Schindler HJ. Biomechanical properties of masticatory balance in cases with RPDs-The influence of preferred and nonpreferred chewing side: A pilot study. Clin Exp Dent Res. 2022 Aug;8(4):912-922. doi: 10.1002/cre2.576. \u003c/li\u003e\n\u003cli\u003eHuang D, Liu L, Zhai X, Wang Y, Hu Y, Xu X, Li H, Jiang H. Association between chewing side preference and MRI characteristics in patients with anterior disc displacement of the temporomandibular joint. J Stomatol Oral Maxillofac Surg. 2023 Oct;124(5):101484. doi: 10.1016/j.jormas.2023.101484. \u003c/li\u003e\n\u003cli\u003eOlivieri Q, Maniewicz S, Chebib N, Mojon P, M\u0026uuml;ller F. Three tests to determine a preferred chewing side in partially edentulous patients: A pilot study. J Prosthet Dent. 2023 Oct 4:S0022-3913(23)00617-0. doi: 10.1016/j.prosdent.2023.09.003.\u003c/li\u003e\n\u003cli\u003eZhang, Y.; Liu, K.; Shao, Z.; Lyu, C.; Zou, D. The Effect of Asymmetrical Occlusion on Surface Electromyographic Activity in Subjects with a Chewing Side Preference: A Preliminary Study. \u003cem\u003eHealthcare\u003c/em\u003e 2023, \u003cem\u003e11\u003c/em\u003e, 1718. https://doi.org/10.3390/healthcare11121718\u003c/li\u003e\n\u003cli\u003eAndrade Ada S, Gavi\u0026atilde;o MB, Gameiro GH, De Rossi M. Characteristics of masticatory muscles in children with unilateral posterior crossbite. Braz Oral Res. 2010 Apr-Jun;24(2):204-10. doi: 10.1590/s1806-83242010000200013. \u003c/li\u003e\n\u003c/ol\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":"clinical-oral-investigations","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cloi","sideBox":"Learn more about [Clinical Oral Investigations](http://link.springer.com/journal/784)","snPcode":"784","submissionUrl":"https://submission.nature.com/new-submission/784/3","title":"Clinical Oral Investigations","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Molar incisor hypomineralization, mastication, masticatory muscles, pediatric dentistry","lastPublishedDoi":"10.21203/rs.3.rs-4249292/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4249292/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: This observational study aims to compare the chewing patterns of children with Unilateral Mild and Severe MIH to those without MIH, based on the hypothesis that children with unilateral MIH may prefer to chew on the side opposite to the defect.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: A total of 121 children were included in the study and evaluated for their Preferred Chewing Side (PCS). This comprised 45 children with Unilateral Mild MIH (G1), 42 with Unilateral Severe MIH (G2), and 34 children in the control group (CG) who lacked MIH but had unilateral chewing complaints.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: The PCS pattern differed among the groups, with 31% of children with MIH and 55.9% of the CG showing bilateral chewing. Chewing deviation prevalence was 24% in the CG and 52% in G2 (χ2 test; p = 0.03). Binomial logistic regression analysis revealed that both severities of MIH influenced the likelihood of chewing deviation (χ2 = 7.33, p = 0.026). Children with Unilateral Severe MIH were found to have 3.57 times higher odds of experiencing chewing deviation than those without MIH.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: Unilateral MIH affects children's masticatory patterns, increasing the risk of chewing deviation.\u003c/p\u003e\n\u003cp\u003eClinical Relevance: Unilateral chewing may be associated with various health issues, such as temporomandibular disorders (DTM), decreased hearing, and vision problems. Unilateral MIH could be considered a potential risk factor for unilateral chewing.\u003c/p\u003e","manuscriptTitle":"Unilateral Molar Incisor Hypomineralization influences the chewing side? 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