Impact of Resin Infiltrant Therapy on Bullying and Oral Health-Related Quality of Life in Children with Molar-Incisor Hypomineralization

Impact of Resin Infiltrant Therapy on Bullying and Oral Health-Related Quality of Life in Children with Molar-Incisor Hypomineralization | 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 Impact of Resin Infiltrant Therapy on Bullying and Oral Health-Related Quality of Life in Children with Molar-Incisor Hypomineralization Maria Julia Delsin Gallo, Thalia Carvalho Almeida dos Santos, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7807684/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Objectives This study aimed to evaluate the impact of bullying on children with Molar–Incisor Hypomineralization (MIH) and to investigate whether a minimally invasive resin infiltration treatment of MIH-affected anterior teeth could reduce bullying and improve OHRQoL. Materials and Methods Twenty-one children aged 8–14 years with MIH involving anterior teeth participated in a single-arm clinical trial. Eligibility required affirmative responses to two items of the Child Perceptions Questionnaire (CPQ) specifically addressing bullying related to oral conditions, ensuring that all participants presented both anterior MIH and concomitant bullying experiences. Icon Resin Infiltrant (DMG, Germany) was applied to visible opacities. The CPQ was then administered at baseline and one month after treatment to assess changes in OHRQoL, while bullying experiences were reassessed at baseline and three months post-treatment. Data were analyzed using Jamovi 2.3.28 with the McNemar test, Wilcoxon signed-rank test, Friedman test, and Durbin–Conover post hoc comparisons. Results All participants reported bullying before treatment, whereas none did so at the three-month follow-up (p < 0.001). Significant improvements were observed in the emotional and social domains of OHRQoL one month after treatment (p < 0.001), and these benefits were sustained over time. Conclusions Minimally invasive treatment of anterior MIH lesions effectively eliminated bullying experiences and significantly enhanced OHRQoL. Clinical Relevance : Early esthetic intervention for anterior MIH is of high clinical and psychosocial importance, as it can substantially reduce bullying and promote children’s overall well-being. Molar Incisor Hypomineralization Bullying Quality of Life Child Figures Figure 1 Figure 2 Figure 3 Introduction Molar-Incisor Hypomineralization (MIH) is a qualitative defect in enamel development that necessarily affects one or more first permanent molars and may also involve the incisors of the same dentition. In some cases, other teeth such as canines and premolars may be affected as well [ 1 , 2 ]. Histologically, hypomineralized enamel is characterized by a less dense prismatic structure, increased porosity, and enlarged interprismatic spaces, which compromise its mechanical integrity [ 3 , 4 ]. MIH can manifest as white opacities in mild cases and as yellow to brown opacities in more severe presentations. In advanced stages, the reduced mineral content of the affected enamel increases its porosity and fragility, which can potentiate the occurrence of post-eruptive enamel fractures. [ 5 ]. These visible changes can negatively affect a child’s self-perception of their smile and may lead to serious social consequences, such as teasing from classmates, potentially impacting overall quality of life. [ 6 ]. Bullying is a significant concern in both education and public health, and it is one of the most common expressions of violence [ 7 ]. Studies have shown that experiencing bullying is associated with an increased risk of developing emotional and behavioral problems, such as depressive symptoms, anxiety, and post-traumatic stress disorder [ 8 ]. In addition, children may experience social isolation, low self-esteem, and reduced emotional well-being [ 9 ]. Oral Health-Related Quality of Life (OHRQoL) indicators are tools used to measure the impact of oral conditions on daily life, well-being, expectations, and individual satisfaction [ 10 , 11 ]. A cross-sectional study comparing OHRQoL in children aged 8–10 years with and without MIH using the CPQ8-10 found that children with MIH reported significantly lower quality of life compared to those without the condition [ 12 ]. The performance of resin infiltrants on hypomineralized teeth has been investigated in both in vitro studies and clinical trials [ 13 – 15 ]. A meta-analysis [ 16 ] suggested that resin infiltration significantly improves the aesthetic outcomes of anterior teeth affected by MIH. An in vitro study, which aimed to evaluate the penetrability of resin infiltrant in hypomineralized molars with different-colored opacities, concluded that the material was able to infiltrate the lesions, although with varying patterns and depth of penetration [ 17 ]. Despite promising results in laboratory analyses [ 18 – 23 ], there is still a lack of published clinical studies on the performance of resin infiltrants in hypomineralized teeth [ 13 , 24 – 26 ]. This lack of clinical evidence underscores the need for further research to validate their effectiveness and to better understand their performance, not only in clinical settings but also regarding the social and psychological impacts this condition can have on children, such as bullying. In this context, MIH is a relevant condition that challenges the choice of appropriate treatment approaches due to its variability in severity and associated consequences. Although the psychological effects of bullying, such as anxiety and depression, are well documented [ 27 – 29 ], there is still a lack of clinical trials evaluating whether esthetic management of anterior MIH can effectively reduce bullying and improve Oral Health-Related Quality of Life (OHRQoL). Therefore, the aim of the present study was to assess the impact of a minimally invasive resin infiltrant applied to anterior MIH lesions on bullying experiences and OHRQoL in schoolchildren. Methods Ethical Considerations The research project was submitted to and approved by the Research Ethics Committee of the Ribeirão Preto School of Dentistry, University of São Paulo (FORP-USP), under protocol CAAE 76557423.6.0000.5419. The clinical trial followed the guidelines of the Consolidated Standards of Reporting Trials (CONSORT) and was registered on the Brazilian Clinical Trials Registry Platform (ReBEC). For children's participation in the study, legal guardians signed an Informed Consent Form, and the children, after receiving appropriate information about the study, signed an Assent Form when required. Permission to access the schools was obtained through a meeting held at the city hall of Santa Rita do Passa Quatro, involving members of the research team, the mayor, the Secretary of Education, and the Secretary of Health. Study Design This study was designed as a single-arm clinical trial, conducted in three municipal public schools in Santa Rita do Passa Quatro, São Paulo (SRP4), in 2024. A sample of twenty-one children underwent the intervention, which consisted of applying the Icon Resin Infiltrant (Icon Infiltrant, DMG Dental Materials, Hamburg, Germany) to the demarcated opacities caused by MIH on anterior teeth. Data collection was carried out before and after treatment using the Child Perceptions Questionnaire (CPQ) to assess whether the intervention led to improvements in bullying experiences and oral health-related quality of life. Sample Size Calculation A sample size calculation was conducted using the tool available at ( http://estatistica.bauru.usp.br/calculoamostral/ta_diferenca_media_dependente.php ) , adopting a 5% significance level and 80% statistical power, based on the results reported by [ 30 ]. Assuming an estimated standard deviation of 15 points in ORQoL total scores and a minimum detectable difference of 10 points, and accounting for an anticipated 20% sample loss, a total of 19 children will be required for the paired t-test. Eligibility Criteria Children with at least one permanent first molar (to confirm the MIH diagnosis) and at least one incisor with Molar-Incisor Hypomineralization (white or yellow demarcated opacities affecting the labial surface of anterior teeth) were included in the study. Children were excluded if they presented MIH only in posterior teeth, had severe dental crowding or malocclusions, carious lesions or white spots due to caries, or fractures in anterior teeth. Training and Calibration The examining team, composed of four post graduate students, was calibrated for the diagnosis of MIH based on the criteria described by [ 31 ]. The examiners underwent extensive theoretical and practical training on MIH and its diagnostic variations. The administration of the questionnaires, as well as the application of the Icon resin infiltrant (Icon Infiltrant, DMG Dental Materials, Hamburg, Germany), was performed by a single researcher. Children’s Evaluation Protocol Two specific questions of the Child Perceptions Questionnaire (CPQ), according to age groups, CPQ 8–10 and CPQ 11–14 , was used to assess bullying: “In the past month, how often have other children teased you or called you names because of your teeth or mouth?” (Question 28 from the CPQ 8–10 ) and "In the past 3 months, because of your teeth, lips, mouth, or jaws, how often have other children teased you or called you names?" (Question 15 from the CPQ 11–14 ). These questions were initially used to determine whether the child had experienced bullying previously. The questionnaire covers four distinct domains: oral symptoms, functional limitations, emotional well-being, and social well-being. Higher scores indicate a greater negative impact on quality of life. The social and emotional domains were specifically used to evaluate OHRQoL. Resin Infiltrant Application Children in the study were treated with Icon Resin Infiltrant (DMG, Hamburg, Germany) on anterior teeth presenting demarcated MIH opacities. The defect depth was assessed using white light transillumination (Microlux, Addent, USA) to evaluate lesion depth and margins [ 32 ]. After visual assessment, surfaces were prophylactically cleaned with a low-speed rubber cup, pumice, and water, rinsed, and dried. Microabrasion was then performed with abrasive paste (Opalustre; Ultradent, USA) for 60 seconds following manufacturer instructions, followed by rinsing. A single application was done. Next, aluminum oxide finishing abrasive stone (Dura-White Stones, Shofu, Kyoto, Japan) on a low-speed handpiece was used to gently remove a thin layer of hypermineralized enamel, focusing on lesion margins [ 33 ]. After relative isolation with MiniDam gingival barrier (DMG), the surface was conditioned with 15% hydrochloric acid gel (Icon Etch, DMG) for two minutes, repeated three times with polishing between applications, followed by rinsing and drying. A white light transillumination device was placed on the lingual surface while 99% ethanol (Icon Dry, DMG) was applied to the lesion to monitor penetration, visible as a dark-to-light color change indicating lesion accessibility. After air drying, resin infiltrant (Icon Infiltrant, DMG) was applied and teeth shielded from ambient light to prevent premature curing. After 20 minutes - longer than standard due to MIH’s enamel characteristics - excess resin was removed, interproximal areas cleaned with floss, and light curing performed. A second one-minute application followed with excess removal and final curing. The immediate result shows an effective masking effect of the MIH opacities ( Fig. 1 ). After the intervention phase was completed, a new assessment was conducted to observe the impact of MIH treatment on the child’s life through the application of a follow-up questionnaire. Re-evaluations for OHRQoL were performed after one month, while a second re-evaluation for the primary outcome (bullying) was carried out after three months. Statistical Analysis Statistical analysis was performed using the software Jamovi 2.3.28. Data were tested for normality using the Shapiro-Wilk test and showed a non-normal distribution. Therefore, the McNemar test, the Wilcoxon test and Repeated Measures Analysis of Variance (Friedman Test) were used, followed by the Durbin-Conover post hoc test for multiple comparisons. Results In total, 21 children reported experiencing school bullying due to the anterior teeth opacities and were included in the clinical trial. Among them, 12 (57,14%) were female and 9 (42,85%) male, with a mean age of 10 years. All children reported experiencing bullying prior to treatment, whereas none reported such experiences after the minimally invasive intervention. Analysis using McNemar’s test indicated that this change was statistically significant (p < 0.001). The Shapiro-Wilk normality test showed that the data were not normally distributed, requiring non-parametric analysis. The Wilcoxon paired-sample test revealed statistically significant differences in quality of life scores before and after treatment in the emotional (p < 0.001) and social (p < 0.001) domains. These results demonstrate a considerable improvement in emotional aspects, such as reduced feelings of sadness and shame regarding their teeth. In addition, improvements were observed in social aspects: children felt more confident to smile and speak out loud, were no longer questioned about the appearance of their teeth, and were no longer targeted by peers ( Fig. 2 ) . Furthermore, the analysis of the three time points regarding bullying, Repeated Measures Analysis of Variance (Friedman Test) was used and showed statistically significant differences across the three time points (tb0, tb1, and tb2) concerning bullying (p < 0.001). Multiple comparisons (Durbin-Conover test) indicated significant reductions in perceived bullying from pre-treatment (tb0) to both post-treatment points (tb1 and tb2), with p < 0.001 for both comparisons. No significant difference was observed between tb1 and tb2 (p = 1.000), suggesting a sustained effect over time ( Fig. 3 ) . These findings indicate a general improvement in OHRQoL following treatment with resin infiltrant. In particular, the emotional and social domain - closely linked to self-esteem and peer interactions - showed significant reductions in scores, suggesting that the treatment positively impacted children’s social interactions and mental well-being. Discussion Bullying is an intentional, aggressive, repeated, and prolonged behavior that can significantly compromise the mental health of children and adolescents. Despite wide variations in its prevalence across different contexts, a considerable proportion of individuals are exposed to this form of interpersonal violence [ 34 ]. This phenomenon represents a major public health challenge both nationally and internationally due to its negative impact on children's and adolescents' quality of life. A 10-year cohort study showed a strong association between unfavorable oral conditions - such as untreated dental caries in anterior teeth, malocclusions, and dental trauma - and a higher incidence of school bullying [ 35 ]. These conditions can affect dental aesthetics, making individuals more vulnerable to teasing and social exclusion [ 36 ]. The relationship between dental appearance and social judgments in school settings was explored by [ 37 ], showing that discoloration in anterior teeth drastically altered children's perceptions of one another, negatively influencing interpersonal impressions. Assessing Oral Health-Related Quality of Life (OHRQoL) was essential to measure the overall impact of the study intervention on participants' lives. Given the study sample consisted of children aged 8 to 14, the CPQ questionnaire was selected as the most suitable tool for evaluating OHRQoL, as it is specific to this age group and provides more accurate and sensitive measurements. This study aimed to investigate the prevalence of bullying associated with the presence of Molar-Incisor Hypomineralization (MIH) in anterior teeth and to assess whether applying a resin infiltrant could reduce bullying and improve children’s OHRQoL. Although previous studies have shown that MIH negatively impacts children’s OHRQoL [ 38 – 42 ], this is the first study to specifically examine the relationship between MIH in anterior teeth and school bullying. MIH is a qualitative enamel defect characterized by demarcated opacities. When present in anterior teeth, it can compromise aesthetics and lead to dissatisfaction with one’s smile. It represents a clinical challenge, especially for masking these opacities [ 43 ]. Deep white or yellowish stains often require restorative approaches, which tend to be more invasive due to enamel removal. However, minimally invasive alternatives such as enamel microabrasion and resin infiltration have shown promising results in improving aesthetics while preserving dental structure [ 44 ]. Resin infiltrants work by capillary penetration of resin monomers into the micropores of hypomineralized enamel [ 45 ], altering the optical properties of lesions and improving smile appearance. A recent meta-analysis [ 16 ] suggests that resin infiltration significantly improves the aesthetics of MIH-affected anterior teeth by producing visible color changes. Based on this, Icon (DMG, Hamburg, Germany) was chosen for the study intervention and proved suitable for public health settings. The resin infiltration protocol was based on studies aiming to optimize the technique for deeper stains like those from MIH [ 25 , 33 , 46 ]. However, no standardized protocol exists for masking demarcated opacities from MIH, since these defects vary in depth, porosity, mineral density, and the thickness of the hypermineralized surface layer, requiring individualized clinical approaches [ 26 ]. Transillumination was used to map lesions, assess their extent, and monitor infiltration during treatment. As shown in a recent randomized clinical trial [ 46 ], transillumination-guided resin infiltration increased infiltration rates and masking effects. MIH lesions often have sharply angled borders that hinder resin penetration, potentially causing a non-infiltrated halo and compromising esthetics [ 47 ]. To address this, [ 21 ] proposed a deep infiltration technique involving removal of a thin enamel layer at lesion borders. In our study, we used enamel microabrasion with Opalustre abrasive paste (Ultradent, USA) and a finishing stone (Dura-White Stones, Shofu, Japan) to remove the hypermineralized enamel surface [ 33 ]. [ 25 ] also suggested modifying the 15% hydrochloric acid gel (Icon Etch, DMG) application for better access to MIH lesions. Following their proposal and discussions with DMG’s scientific team, this study used three successive applications of Icon Etch interspersed with abrasive stone used to enhance resin contact with the lesion body. Infiltrant application time also influences infiltration depth and uniformity. [ 25 ] showed that longer application times led to deeper, more effective MIH infiltration. Thus, our study used a 20-minute application time. This study clearly demonstrated the association between visible dental alterations and school bullying. Among children with anterior opacities (41 children), over half (23 children − 56.09%) reported bullying specifically due to MIH stains. This finding highlights CPQ's sensitivity in detecting bullying related to dental aesthetics. Being a tool focused on oral health and its impact on quality of life, the CPQ helped children better identify and report such bullying experiences. Clinically and from a public health perspective, these findings emphasize the importance of early MIH diagnosis and management, especially in anterior teeth due to their high visibility. Aesthetic improvement strategies, combined with educational and psychosocial interventions to prevent bullying, can mitigate this condition’s negative impact on childhood. These results underscore the need to train public health professionals to recognize early anterior dental aesthetic issues and understand their emotional and psychosocial effects. The intervention with resin infiltrant significantly improved OHRQoL, with CPQ median scores dropping from 32 to 4 post-treatment (p < 0.001), especially in emotional and social domains. This indicates a direct impact on self-esteem, aesthetic self-perception, and interpersonal relationships—critical aspects of child development. Longitudinal analysis of "bullying" (pre-treatment, 1 month, and 3 months post-treatment) confirmed the psychosocial relevance of the intervention. The Friedman test showed significant reductions in bullying perception post-treatment (p < 0.001), with sustained improvements over time. Despite promising results, limitations such as the absence of a control group remain. However, the choice is justified by the lack of alternative infiltrants and the minimally invasive nature of the approach, making it most suitable for children. In summary, the findings support early aesthetic intervention in children with anterior MIH, not only for preserving enamel structure but especially for improving quality of life and reducing psychosocial issues such as bullying. Incorporating resin infiltration protocols in pediatric public dental care can be a valuable public health strategy. These results also highlight the need for early MIH diagnosis and comprehensive treatment, including psychosocial assessments in pediatric dental protocols. Accessible interventions in public healthcare may effectively promote oral and overall well-being in vulnerable populations. Conclusions This study showed that MIH in anterior teeth is linked to school bullying and negatively affects children's oral health-related quality of life, particularly in emotional and social aspects. Resin infiltration significantly improved dental appearance, emotional well-being, social confidence, and reduced perceived bullying over time. As a minimally invasive and effective treatment, resin infiltration offers both clinical and psychosocial benefits, supporting its use as a valuable intervention in pediatric dentistry, especially in public health contexts. Declarations Author Declaration This research received no funding. The data supporting the findings of this study are available from the corresponding author upon reasonable request. The authors declare that there are no conflicts of interest regarding the publication of this paper. Author Contribution M.J.D.G. wrote the main manuscript text, participated in the article conceptualization, methology, investigation and data collection T.C.A.S. and A.B.S.R. contributed with methodology and data collection. F.W.G.P.S. contributed with conceptualization and clinical support. L.B.N. and S.E. contributed with methodology and resources. F.K.C. and A.R. contributed with review and editing manuscript, methodology, data curation, statistical analysis and supervision. A.M.Q. contributed with review and editing manuscript project administration, methodology, resources and supervision. Data Availability The data supporting the findings of this study are available from the corresponding author upon reasonable request. References Lygidakis, N.A., Garot, E., Somani, C. et al. Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): an updated European Academy of Paediatric Dentistry policy document. Eur Arch Paediatr Dent 23, 3–21 (2022). https://doi.org/10.1007/s40368-021-00668-5 . Juárez-López MLA, Salazar-Treto LV, Hernández-Monjaraz B, Molina-Frechero N. Etiological Factors of Molar Incisor Hypomineralization: A Systematic Review and Meta-Analysis. Dent J (Basel). 2023;11(5):111. 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In vivo comparison of resin infiltration outcomes under different light conditions: A randomized controlled clinical trial. J Dent. 2025;153:105554. doi: 10.1016/j.jdent.2024.105554 . Denis M, Atlan A, Vennat E, Tirlet G, Attal JP. White defects on enamel: diagnosis and anatomopathology: two essential factors for proper treatment (part 1). Int Orthod. 2013;11(2):139–165. doi: 10.1016/j.ortho.2013.02.014 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Nov, 2025 Reviews received at journal 16 Nov, 2025 Reviews received at journal 15 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviews received at journal 10 Nov, 2025 Reviewers agreed at journal 26 Oct, 2025 Reviewers agreed at journal 13 Oct, 2025 Reviewers invited by journal 10 Oct, 2025 Editor assigned by journal 10 Oct, 2025 Submission checks completed at journal 10 Oct, 2025 First submitted to journal 08 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-7807684","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":532785250,"identity":"1c462c20-080c-4100-9855-65d7bf637f8b","order_by":0,"name":"Maria Julia Delsin 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14:04:40","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118929,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7807684/v1/0112afe808f75fb47ce2c788.html"},{"id":94410531,"identity":"5fb83314-401e-4e51-96b3-1260deb7724e","added_by":"auto","created_at":"2025-10-27 14:04:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":572806,"visible":true,"origin":"","legend":"\u003cp\u003eResin infiltrant treatment. (A) Prophylaxis. (B) MIH opacity. (C) Transillumination. (D) Microabrasion. (E) Surface regularization. (F–H) Icon steps: etch, dry, infiltrant. (I) Final result after light curing and polishing.\u003c/p\u003e","description":"","filename":"Capturadetela20251001102427.png","url":"https://assets-eu.researchsquare.com/files/rs-7807684/v1/1157bd473900b558fe130320.png"},{"id":94409987,"identity":"4e9d5840-1c24-4bb9-a786-c6074c71037c","added_by":"auto","created_at":"2025-10-27 14:04:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24193,"visible":true,"origin":"","legend":"\u003cp\u003eTable with significant improvement in general CPQ scores. Significant reductions in the emotional and social domains of the CPQ.\u003c/p\u003e","description":"","filename":"Capturadetela20250922113406.png","url":"https://assets-eu.researchsquare.com/files/rs-7807684/v1/48938b27e9cf76eaa6f8bfa5.png"},{"id":94410554,"identity":"9d46d304-cfc0-4fc4-a830-954cd0b020d6","added_by":"auto","created_at":"2025-10-27 14:04:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":17989,"visible":true,"origin":"","legend":"\u003cp\u003eGraffic with difference across three bullying assessment time points, with maintenance of the effect over time.\u003c/p\u003e","description":"","filename":"Capturadetela20251001103459.png","url":"https://assets-eu.researchsquare.com/files/rs-7807684/v1/d5ad7b8b6c6a325085a385f5.png"},{"id":94491199,"identity":"4062f507-0cd2-4ea3-a47a-511f68537303","added_by":"auto","created_at":"2025-10-27 17:23:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1498728,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7807684/v1/ef8f32c7-58f2-4e97-9fbc-c40bb3817d64.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eImpact of Resin Infiltrant Therapy on Bullying and Oral Health-Related Quality of Life in Children with Molar-Incisor Hypomineralization\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMolar-Incisor Hypomineralization (MIH) is a qualitative defect in enamel development that necessarily affects one or more first permanent molars and may also involve the incisors of the same dentition. In some cases, other teeth such as canines and premolars may be affected as well [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Histologically, hypomineralized enamel is characterized by a less dense prismatic structure, increased porosity, and enlarged interprismatic spaces, which compromise its mechanical integrity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMIH can manifest as white opacities in mild cases and as yellow to brown opacities in more severe presentations. In advanced stages, the reduced mineral content of the affected enamel increases its porosity and fragility, which can potentiate the occurrence of post-eruptive enamel fractures. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These visible changes can negatively affect a child\u0026rsquo;s self-perception of their smile and may lead to serious social consequences, such as teasing from classmates, potentially impacting overall quality of life. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBullying is a significant concern in both education and public health, and it is one of the most common expressions of violence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Studies have shown that experiencing bullying is associated with an increased risk of developing emotional and behavioral problems, such as depressive symptoms, anxiety, and post-traumatic stress disorder [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition, children may experience social isolation, low self-esteem, and reduced emotional well-being [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOral Health-Related Quality of Life (OHRQoL) indicators are tools used to measure the impact of oral conditions on daily life, well-being, expectations, and individual satisfaction [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A cross-sectional study comparing OHRQoL in children aged 8\u0026ndash;10 years with and without MIH using the CPQ8-10 found that children with MIH reported significantly lower quality of life compared to those without the condition [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe performance of resin infiltrants on hypomineralized teeth has been investigated in both in vitro studies and clinical trials [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A meta-analysis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] suggested that resin infiltration significantly improves the aesthetic outcomes of anterior teeth affected by MIH. An in vitro study, which aimed to evaluate the penetrability of resin infiltrant in hypomineralized molars with different-colored opacities, concluded that the material was able to infiltrate the lesions, although with varying patterns and depth of penetration [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite promising results in laboratory analyses [\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], there is still a lack of published clinical studies on the performance of resin infiltrants in hypomineralized teeth [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This lack of clinical evidence underscores the need for further research to validate their effectiveness and to better understand their performance, not only in clinical settings but also regarding the social and psychological impacts this condition can have on children, such as bullying.\u003c/p\u003e\u003cp\u003eIn this context, MIH is a relevant condition that challenges the choice of appropriate treatment approaches due to its variability in severity and associated consequences. Although the psychological effects of bullying, such as anxiety and depression, are well documented [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], there is still a lack of clinical trials evaluating whether esthetic management of anterior MIH can effectively reduce bullying and improve Oral Health-Related Quality of Life (OHRQoL). Therefore, the aim of the present study was to assess the impact of a minimally invasive resin infiltrant applied to anterior MIH lesions on bullying experiences and OHRQoL in schoolchildren.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003e The research project was submitted to and approved by the Research Ethics Committee of the Ribeir\u0026atilde;o Preto School of Dentistry, University of S\u0026atilde;o Paulo (FORP-USP), under protocol CAAE 76557423.6.0000.5419. The clinical trial followed the guidelines of the Consolidated Standards of Reporting Trials (CONSORT) and was registered on the Brazilian Clinical Trials Registry Platform (ReBEC). For children's participation in the study, legal guardians signed an Informed Consent Form, and the children, after receiving appropriate information about the study, signed an Assent Form when required. Permission to access the schools was obtained through a meeting held at the city hall of Santa Rita do Passa Quatro, involving members of the research team, the mayor, the Secretary of Education, and the Secretary of Health.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eThis study was designed as a single-arm clinical trial, conducted in three municipal public schools in Santa Rita do Passa Quatro, S\u0026atilde;o Paulo (SRP4), in 2024. A sample of twenty-one children underwent the intervention, which consisted of applying the Icon Resin Infiltrant (Icon Infiltrant, DMG Dental Materials, Hamburg, Germany) to the demarcated opacities caused by MIH on anterior teeth. Data collection was carried out before and after treatment using the Child Perceptions Questionnaire (CPQ) to assess whether the intervention led to improvements in bullying experiences and oral health-related quality of life.\u003c/p\u003e\n\u003ch3\u003eSample Size Calculation\u003c/h3\u003e\n\u003cp\u003eA sample size calculation was conducted using the tool available at (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://estatistica.bauru.usp.br/calculoamostral/ta_diferenca_media_dependente.php\u003c/span\u003e\u003cspan address=\"http://estatistica.bauru.usp.br/calculoamostral/ta_diferenca_media_dependente.php\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e, adopting a 5% significance level and 80% statistical power, based on the results reported by [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Assuming an estimated standard deviation of 15 points in ORQoL total scores and a minimum detectable difference of 10 points, and accounting for an anticipated 20% sample loss, a total of 19 children will be required for the paired t-test.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eChildren with at least one permanent first molar (to confirm the MIH diagnosis) and at least one incisor with Molar-Incisor Hypomineralization (white or yellow demarcated opacities affecting the labial surface of anterior teeth) were included in the study. Children were excluded if they presented MIH only in posterior teeth, had severe dental crowding or malocclusions, carious lesions or white spots due to caries, or fractures in anterior teeth.\u003c/p\u003e\n\u003ch3\u003eTraining and Calibration\u003c/h3\u003e\n\u003cp\u003eThe examining team, composed of four post graduate students, was calibrated for the diagnosis of MIH based on the criteria described by [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The examiners underwent extensive theoretical and practical training on MIH and its diagnostic variations. The administration of the questionnaires, as well as the application of the Icon resin infiltrant (Icon Infiltrant, DMG Dental Materials, Hamburg, Germany), was performed by a single researcher.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eChildren\u0026rsquo;s Evaluation Protocol\u003c/h2\u003e\u003cp\u003eTwo specific questions of the Child Perceptions Questionnaire (CPQ), according to age groups, CPQ\u003csup\u003e8\u0026ndash;10\u003c/sup\u003e and CPQ\u003csup\u003e11\u0026ndash;14\u003c/sup\u003e, was used to assess bullying: \u0026ldquo;In the past month, how often have other children teased you or called you names because of your teeth or mouth?\u0026rdquo; (Question 28 from the CPQ\u003csup\u003e8\u0026ndash;10\u003c/sup\u003e) and \"In the past 3 months, because of your teeth, lips, mouth, or jaws, how often have other children teased you or called you names?\" (Question 15 from the CPQ\u003csup\u003e11\u0026ndash;14\u003c/sup\u003e). These questions were initially used to determine whether the child had experienced bullying previously. The questionnaire covers four distinct domains: oral symptoms, functional limitations, emotional well-being, and social well-being. Higher scores indicate a greater negative impact on quality of life. The social and emotional domains were specifically used to evaluate OHRQoL.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResin Infiltrant Application\u003c/h3\u003e\n\u003cp\u003eChildren in the study were treated with Icon Resin Infiltrant (DMG, Hamburg, Germany) on anterior teeth presenting demarcated MIH opacities. The defect depth was assessed using white light transillumination (Microlux, Addent, USA) to evaluate lesion depth and margins [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. After visual assessment, surfaces were prophylactically cleaned with a low-speed rubber cup, pumice, and water, rinsed, and dried. Microabrasion was then performed with abrasive paste (Opalustre; Ultradent, USA) for 60 seconds following manufacturer instructions, followed by rinsing. A single application was done. Next, aluminum oxide finishing abrasive stone (Dura-White Stones, Shofu, Kyoto, Japan) on a low-speed handpiece was used to gently remove a thin layer of hypermineralized enamel, focusing on lesion margins [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. After relative isolation with MiniDam gingival barrier (DMG), the surface was conditioned with 15% hydrochloric acid gel (Icon Etch, DMG) for two minutes, repeated three times with polishing between applications, followed by rinsing and drying. A white light transillumination device was placed on the lingual surface while 99% ethanol (Icon Dry, DMG) was applied to the lesion to monitor penetration, visible as a dark-to-light color change indicating lesion accessibility. After air drying, resin infiltrant (Icon Infiltrant, DMG) was applied and teeth shielded from ambient light to prevent premature curing. After 20 minutes - longer than standard due to MIH\u0026rsquo;s enamel characteristics - excess resin was removed, interproximal areas cleaned with floss, and light curing performed. A second one-minute application followed with excess removal and final curing. The immediate result shows an effective masking effect of the MIH opacities \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter the intervention phase was completed, a new assessment was conducted to observe the impact of MIH treatment on the child\u0026rsquo;s life through the application of a follow-up questionnaire. Re-evaluations for OHRQoL were performed after one month, while a second re-evaluation for the primary outcome (bullying) was carried out after three months.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using the software Jamovi 2.3.28. Data were tested for normality using the Shapiro-Wilk test and showed a non-normal distribution. Therefore, the McNemar test, the Wilcoxon test and Repeated Measures Analysis of Variance (Friedman Test) were used, followed by the Durbin-Conover post hoc test for multiple comparisons.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 21 children reported experiencing school bullying due to the anterior teeth opacities and were included in the clinical trial. Among them, 12 (57,14%) were female and 9 (42,85%) male, with a mean age of 10 years. All children reported experiencing bullying prior to treatment, whereas none reported such experiences after the minimally invasive intervention. Analysis using McNemar\u0026rsquo;s test indicated that this change was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eThe Shapiro-Wilk normality test showed that the data were not normally distributed, requiring non-parametric analysis. The Wilcoxon paired-sample test revealed statistically significant differences in quality of life scores before and after treatment in the emotional (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and social (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) domains. These results demonstrate a considerable improvement in emotional aspects, such as reduced feelings of sadness and shame regarding their teeth. In addition, improvements were observed in social aspects: children felt more confident to smile and speak out loud, were no longer questioned about the appearance of their teeth, and were no longer targeted by peers \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFurthermore, the analysis of the three time points regarding bullying, Repeated Measures Analysis of Variance (Friedman Test) was used and showed statistically significant differences across the three time points (tb0, tb1, and tb2) concerning bullying (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multiple comparisons (Durbin-Conover test) indicated significant reductions in perceived bullying from pre-treatment (tb0) to both post-treatment points (tb1 and tb2), with p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both comparisons. No significant difference was observed between tb1 and tb2 (p\u0026thinsp;=\u0026thinsp;1.000), suggesting a sustained effect over time \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThese findings indicate a general improvement in OHRQoL following treatment with resin infiltrant. In particular, the emotional and social domain - closely linked to self-esteem and peer interactions - showed significant reductions in scores, suggesting that the treatment positively impacted children\u0026rsquo;s social interactions and mental well-being.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBullying is an intentional, aggressive, repeated, and prolonged behavior that can significantly compromise the mental health of children and adolescents. Despite wide variations in its prevalence across different contexts, a considerable proportion of individuals are exposed to this form of interpersonal violence [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This phenomenon represents a major public health challenge both nationally and internationally due to its negative impact on children's and adolescents' quality of life.\u003c/p\u003e\u003cp\u003eA 10-year cohort study showed a strong association between unfavorable oral conditions - such as untreated dental caries in anterior teeth, malocclusions, and dental trauma - and a higher incidence of school bullying [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. These conditions can affect dental aesthetics, making individuals more vulnerable to teasing and social exclusion [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The relationship between dental appearance and social judgments in school settings was explored by [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], showing that discoloration in anterior teeth drastically altered children's perceptions of one another, negatively influencing interpersonal impressions.\u003c/p\u003e\u003cp\u003e Assessing Oral Health-Related Quality of Life (OHRQoL) was essential to measure the overall impact of the study intervention on participants' lives. Given the study sample consisted of children aged 8 to 14, the CPQ questionnaire was selected as the most suitable tool for evaluating OHRQoL, as it is specific to this age group and provides more accurate and sensitive measurements. This study aimed to investigate the prevalence of bullying associated with the presence of Molar-Incisor Hypomineralization (MIH) in anterior teeth and to assess whether applying a resin infiltrant could reduce bullying and improve children\u0026rsquo;s OHRQoL.\u003c/p\u003e\u003cp\u003eAlthough previous studies have shown that MIH negatively impacts children\u0026rsquo;s OHRQoL [\u003cspan additionalcitationids=\"CR39 CR40 CR41\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], this is the first study to specifically examine the relationship between MIH in anterior teeth and school bullying. MIH is a qualitative enamel defect characterized by demarcated opacities. When present in anterior teeth, it can compromise aesthetics and lead to dissatisfaction with one\u0026rsquo;s smile. It represents a clinical challenge, especially for masking these opacities [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Deep white or yellowish stains often require restorative approaches, which tend to be more invasive due to enamel removal. However, minimally invasive alternatives such as enamel microabrasion and resin infiltration have shown promising results in improving aesthetics while preserving dental structure [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eResin infiltrants work by capillary penetration of resin monomers into the micropores of hypomineralized enamel [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], altering the optical properties of lesions and improving smile appearance. A recent meta-analysis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] suggests that resin infiltration significantly improves the aesthetics of MIH-affected anterior teeth by producing visible color changes. Based on this, Icon (DMG, Hamburg, Germany) was chosen for the study intervention and proved suitable for public health settings.\u003c/p\u003e\u003cp\u003eThe resin infiltration protocol was based on studies aiming to optimize the technique for deeper stains like those from MIH [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, no standardized protocol exists for masking demarcated opacities from MIH, since these defects vary in depth, porosity, mineral density, and the thickness of the hypermineralized surface layer, requiring individualized clinical approaches [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Transillumination was used to map lesions, assess their extent, and monitor infiltration during treatment. As shown in a recent randomized clinical trial [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], transillumination-guided resin infiltration increased infiltration rates and masking effects.\u003c/p\u003e\u003cp\u003eMIH lesions often have sharply angled borders that hinder resin penetration, potentially causing a non-infiltrated halo and compromising esthetics [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. To address this, [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] proposed a deep infiltration technique involving removal of a thin enamel layer at lesion borders. In our study, we used enamel microabrasion with Opalustre abrasive paste (Ultradent, USA) and a finishing stone (Dura-White Stones, Shofu, Japan) to remove the hypermineralized enamel surface [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] also suggested modifying the 15% hydrochloric acid gel (Icon Etch, DMG) application for better access to MIH lesions. Following their proposal and discussions with DMG\u0026rsquo;s scientific team, this study used three successive applications of Icon Etch interspersed with abrasive stone used to enhance resin contact with the lesion body. Infiltrant application time also influences infiltration depth and uniformity. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] showed that longer application times led to deeper, more effective MIH infiltration. Thus, our study used a 20-minute application time.\u003c/p\u003e\u003cp\u003eThis study clearly demonstrated the association between visible dental alterations and school bullying. Among children with anterior opacities (41 children), over half (23 children \u0026minus;\u0026thinsp;56.09%) reported bullying specifically due to MIH stains. This finding highlights CPQ's sensitivity in detecting bullying related to dental aesthetics. Being a tool focused on oral health and its impact on quality of life, the CPQ helped children better identify and report such bullying experiences.\u003c/p\u003e\u003cp\u003eClinically and from a public health perspective, these findings emphasize the importance of early MIH diagnosis and management, especially in anterior teeth due to their high visibility. Aesthetic improvement strategies, combined with educational and psychosocial interventions to prevent bullying, can mitigate this condition\u0026rsquo;s negative impact on childhood. These results underscore the need to train public health professionals to recognize early anterior dental aesthetic issues and understand their emotional and psychosocial effects.\u003c/p\u003e\u003cp\u003eThe intervention with resin infiltrant significantly improved OHRQoL, with CPQ median scores dropping from 32 to 4 post-treatment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), especially in emotional and social domains. This indicates a direct impact on self-esteem, aesthetic self-perception, and interpersonal relationships\u0026mdash;critical aspects of child development. Longitudinal analysis of \"bullying\" (pre-treatment, 1 month, and 3 months post-treatment) confirmed the psychosocial relevance of the intervention. The Friedman test showed significant reductions in bullying perception post-treatment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with sustained improvements over time.\u003c/p\u003e\u003cp\u003eDespite promising results, limitations such as the absence of a control group remain. However, the choice is justified by the lack of alternative infiltrants and the minimally invasive nature of the approach, making it most suitable for children.\u003c/p\u003e\u003cp\u003eIn summary, the findings support early aesthetic intervention in children with anterior MIH, not only for preserving enamel structure but especially for improving quality of life and reducing psychosocial issues such as bullying. Incorporating resin infiltration protocols in pediatric public dental care can be a valuable public health strategy. These results also highlight the need for early MIH diagnosis and comprehensive treatment, including psychosocial assessments in pediatric dental protocols. Accessible interventions in public healthcare may effectively promote oral and overall well-being in vulnerable populations.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study showed that MIH in anterior teeth is linked to school bullying and negatively affects children's oral health-related quality of life, particularly in emotional and social aspects. Resin infiltration significantly improved dental appearance, emotional well-being, social confidence, and reduced perceived bullying over time. As a minimally invasive and effective treatment, resin infiltration offers both clinical and psychosocial benefits, supporting its use as a valuable intervention in pediatric dentistry, especially in public health contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eAuthor Declaration\u003c/h2\u003e\u003cp\u003eThis research received no funding.\u003c/p\u003e\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\u003cp\u003eThe authors declare that there are no conflicts of interest regarding the publication of this paper.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.J.D.G. wrote the main manuscript text, participated in the article conceptualization, methology, investigation and data collection T.C.A.S. and A.B.S.R. contributed with methodology and data collection. F.W.G.P.S. contributed with conceptualization and clinical support. L.B.N. and S.E. contributed with methodology and resources. F.K.C. and A.R. contributed with review and editing manuscript, methodology, data curation, statistical analysis and supervision. A.M.Q. contributed with review and editing manuscript project administration, methodology, resources and supervision.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLygidakis, N.A., Garot, E., Somani, C. et al. Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): an updated European Academy of Paediatric Dentistry policy document. 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Oral health-related quality of life and survival analysis after preventive and restorative treatment of molar-incisor hypomineralisation. Sci Rep. 2024;14(1):777. Published 2024 Jan 8. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-024-51223-3\u003c/span\u003e\u003cspan address=\"10.1038/s41598-024-51223-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKisacik S, Ozler CO, Olmez S. Molar incisor hypomineralization and oral health-related quality of life: a sample of 8-12-years-old children. Clin Oral Investig. 2024;28(1):105. Published 2024 Jan 20. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00784-024-05490-z\u003c/span\u003e\u003cspan address=\"10.1007/s00784-024-05490-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShields S, Chen T, Crombie F, Manton DJ, Silva MJ. Causal effect of molar incisor hypomineralisation on oral health-related quality of life of Australian children aged 7\u0026ndash;16 years. Eur Arch Paediatr Dent. Published online April 10, 2025. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40368-025-01028-3\u003c/span\u003e\u003cspan address=\"10.1007/s40368-025-01028-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWarner C, Hasmun NN, Elcock C, Lawson JA, Vettore MV, Rodd HD. Making white spots disappear! 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Microinvasive esthetic approach for deep enamel white spot lesion. Dent Res J (Isfahan). 2022;19:29. Published 2022 Mar 21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarouane O, Manton DJ, Cebula M, Schwendicke F, Effenberger S. In vivo comparison of resin infiltration outcomes under different light conditions: A randomized controlled clinical trial. J Dent. 2025;153:105554. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jdent.2024.105554\u003c/span\u003e\u003cspan address=\"10.1016/j.jdent.2024.105554\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDenis M, Atlan A, Vennat E, Tirlet G, Attal JP. White defects on enamel: diagnosis and anatomopathology: two essential factors for proper treatment (part 1). Int Orthod. 2013;11(2):139\u0026ndash;165. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ortho.2013.02.014\u003c/span\u003e\u003cspan address=\"10.1016/j.ortho.2013.02.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\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":"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 Hypomineralization, Bullying, Quality of Life, Child","lastPublishedDoi":"10.21203/rs.3.rs-7807684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7807684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the impact of bullying on children with Molar–Incisor Hypomineralization (MIH) and to investigate whether a minimally invasive resin infiltration treatment of MIH-affected anterior teeth could reduce bullying and improve OHRQoL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-one children aged 8–14 years with MIH involving anterior teeth participated in a single-arm clinical trial. Eligibility required affirmative responses to two items of the Child Perceptions Questionnaire (CPQ) specifically addressing bullying related to oral conditions, ensuring that all participants presented both anterior MIH and concomitant bullying experiences. Icon Resin Infiltrant (DMG, Germany) was applied to visible opacities. The CPQ was then administered at baseline and one month after treatment to assess changes in OHRQoL, while bullying experiences were reassessed at baseline and three months post-treatment. Data were analyzed using Jamovi 2.3.28 with the McNemar test, Wilcoxon signed-rank test, Friedman test, and Durbin–Conover post hoc comparisons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants reported bullying before treatment, whereas none did so at the three-month follow-up (p \u0026lt; 0.001). Significant improvements were observed in the emotional and social domains of OHRQoL one month after treatment (p \u0026lt; 0.001), and these benefits were sustained over time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMinimally invasive treatment of anterior MIH lesions effectively eliminated bullying experiences and significantly enhanced OHRQoL.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Relevance\u003c/strong\u003e: Early esthetic intervention for anterior MIH is of high clinical and psychosocial importance, as it can substantially reduce bullying and promote children’s overall well-being.\u003c/p\u003e","manuscriptTitle":"Impact of Resin Infiltrant Therapy on Bullying and Oral Health-Related Quality of Life in Children with Molar-Incisor Hypomineralization","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-26 13:25:20","doi":"10.21203/rs.3.rs-7807684/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-17T08:31:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T20:39:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T02:32:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103537407850808611862359229792856580646","date":"2025-11-11T16:34:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T02:01:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238116298017207228038835179903780895767","date":"2025-10-26T13:03:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288764757854277284827726238215829366337","date":"2025-10-13T12:15:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-10T10:51:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-10T06:33:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-10T06:31:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Archives of Paediatric Dentistry","date":"2025-10-08T11:54:33+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":"1ade594b-3520-4670-8f1e-3697a74e22bd","owner":[],"postedDate":"October 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-27T10:28:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-26 13:25:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7807684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7807684","identity":"rs-7807684","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}