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Interview: The D3 Group's translational attack on Molar Hypomineralisation and chalky teeth

Updated: Nov 21

EDSA is excited about partnering with The D3 Group (D3G) to help spread the word about developmental dental defects (D3s) and their impacts on global health. D3G is an innovative "translational network" that aims to get D3 problems recognised, understood, and cared for better through a cross-sector, social-good approach. We caught up with D3G Founder/Director, Professor Mike Hubbard, to discuss how dental students can accelerate "the D3 movement" by contributing to global awareness, educational improvement, and scientific understanding of Molar Hypomineralisation and other “chalky teeth” problems.




Q: What are the origins of D3G? What prompted you to set up the initiative?

D3G was born out of a pioneering "translational research" initiative aiming to bring science, medicine and dentistry together to innovate in healthcare areas that benefit children.

Molar Hypomineralisation ("Molar Hypomin" or MH for short) was a natural fit, realising this dental problem – and allied tooth decay – has medical origins in "sick babies" and so will likely become preventable once we have stronger scientific understanding about causation. D3G's unprecedented "cross-sector" membership – involving all walks of life from scientists through practitioners to industry and policymakers – reflects 3 goals of science translation, namely to (1)identify key questions needing science-based answers (2) do great science to get strong answers, then (3) convert these answers into social good – through practical advances such as better practice, products and policy.



When establishing D3G in 2007, my initial goals were to form a ground-breaking collective across Australia and New Zealand that would harness the relatively few clinicians aware of the MH problem, make plans for cross-sector education and advocacy, and also exploit my rare experiences as a dentally-trained biomedical scientist to get the "medical prevention" ball rolling by doing some key biochemical experiments on "chalky enamel". Our "Chalky Teeth Campaign" (www.chalkyteeth.org) was a natural extension of this translational vision and soon led to development of the public-friendly "translational lingo" being used around the world today and in my answers here.


Q: What is Molar Hypomin and why is it so troublesome?

Despite still being poorly recognised by many dental professionals, MH (or "chalky molars") is actually the commonest type of D3 and – believe it or not – "chalky enamel" has been studied as such for 100 years. Today we know that over 1-in-5 schoolchildren worldwide are affected by MH, putting many at high risk for a rapid type of tooth decay that is essentially unpreventable by standard homecare measures (plaque, sugar, fluoride). D3G refers to MH as a 3-level problem comprising a major global health burden compounded by lack of both recognition and research-based understanding.

Many readers will have heard a similar term – "Molar-Incisor Hypomineralisation" (MIH) – that refers to a common presentation of MH in early adult teeth (first-permanent or "6-year molars", and sometimes incisors) but unfortunately overlooks equivalent problems elsewhere in the primary and permanent dentitions. In defining MH, D3G has implemented a stronger holistic perspective that is scientifically and translationally robust, as needed for early dental intervention and ultimately medical prevention at population level. That is, we recommend that attention initially be paid to primary teeth (particularly hypomineralised baby canines and "2-year molars"), then the 6-year molars, and later the second-adult or "12-year molars" too – all of which can be problematic in the clinic (e.g. decay risk) as well as being informative for investigation of causation (aetiology).

It's important for students to understand that, although "MH" is terminologically useful as a case descriptor, the pathological heart of the problem resides at tooth level – specifically the discoloured (white/cream/yellow/brown) enamel patches termed "demarcated opacities" or "chalky spots". Most MH troubles relate to the porous and soft (hypomineralised) enamel in these sharp-bordered opacities, which must be distinguished from the "diffuse opacities" characteristic of dental fluorosis that usually manifest as low porosity/hard white enamel. Students should also know that clinically-equivalent demarcated opacities may arise from either (1) local causes, namely trauma and infection, or (2) unclear systemic causes such as childhood illness. MH involves the latter "idiopathic" causes only, thereby excluding opacities on adult incisors and premolars attributable to primary teeth issues (trauma or abscess). This in turn necessitates an additional descriptor (Incisor Hypomineralisation; IH) for incisor opacities with local causation, and highlights another weakness of the term MIH.


Q: Can you explain how D3G uses a translational approach to educate and foster better research, treatment and prevention of chalky teeth problems?

Hopefully it's clear by now that D3G generates unprecedented impact and sustainability by adopting a broad translational perspective that addresses stakeholder needs across the sector – from scientists, clinicians and students to policymakers and the at-risk public. Consequently, our education and advocacy is uniquely customised for different audiences while maintaining consistency in messaging and scientific robustness.



We similarly aim to present the need for D3 research as a cross-sector responsibility that will benefit from "end-user pull", rather than relying on traditional "researcher push" to get things done – so the collective voice of students has a big role to play here. Our preventive strategy involves multiple stakeholders across medical and dental arms (10 and 20 prevention, respectively) – that is, (1) the immediately available dental approach comprising early detection/intervention, and (2) the future "holy grail" of preventing MH in the first place through medical intervention.


Q: How does D3G work towards translating research into social good?


The science translation field often talks about fostering "better policy, practice and products" (nicknamed "the 3 Ps") – and naturally for MH we add medical prevention as a fourth P. So in this light, D3G is busily expanding an "international army" to work together and attack these "4 Ps" at global level. We're proud to now have paid-up members (including an EDSA Board Member) in 48 countries, many of whom are career researchers interested in medical prevention and clinical management, plus a growing number of industry directors, publishers, educators, policymakers and other people involved in translating scientific advances out to policy, practice and products.

Recently, huge progress has come via an international event series on MH hosted by D3G and academic partners in Toronto, Canada. This started in 2020 as an online "translational gathering" involving 35 presenters from 16 countries then progressed this year to an innovative "research incubator" addressing research priorities and standardisation. Pandemic permitting, next year's event will be a live symposium in Toronto where our "universal D3 curriculum" project will be one of several discussion topics particularly relevant to students and educators.

Q: What resources does D3G have for dental students interested in learning more about Molar Hypomin and D3s?


D3G not only has multiple resources for students wanting to gain top-notch understanding, but – with generous help from student organisations – is also developing opportunities for the global student community to collaboratively alleviate some current sticking points. To learn about D3G's unique scientific, clinical and translational perspectives, we encourage students to start out by putting themselves in "public shoes" and visit the Chalky Teeth Campaign website to see how we simplify various complexities into public-friendly concepts and language. From there you can click through to the D3G website which provides deeper learning for various audiences – progressing from children and families through to public health and clinical practitioners, and finally the all-important researchers. This pioneering online-education resource is both vast (over 150 pages, plus a children's storybook) and widely consulted, having attracted nearly 10 million hits since launch in 2013 – see the link collection below for a quick tour. Additional education is available through D3G membership, continuing education packages, academic publications and media gigs.

Regards the exciting prospect of students teaming up globally to accelerate the D3 movement, many of you will know from personal experience that much could be done to improve professional learning about D3s, particularly MH and its concerning link to childhood tooth decay. D3G is developing two overlapping projects in this space – the aforementioned "universal D3 curriculum", and an "educate the educators" advocacy initiative – both of which need to be approached respectfully given that many of today's educators/trainers have yet to get fully up to speed on this important topic. I'd be thrilled if EDSA saw fit to not only participate in these student-centric research and development projects, but also to contribute in other areas that will evolve today's students into the D3 saviours of tomorrow.

A quick tour of the Chalky Teeth Campaign and other D3G initiatives:

• The wonderful prospect of healthier babies, stronger teeth and happier societies (here)

• A childrens storybook about "chalky molars" (here)

• D3G's social-good mission and impact (here)

1-in-5 schoolchildren worldwide have chalky molars (here)

Much childhood decay is due to MH not caries (here)

• Learning about the clinical and translational aspects of MH (here and here)

• A breakthrough in understanding the pathogenesis of MH (here)

• An international army of motivated stakeholders (here)

• A world-first translational event series on Molar Hypomineralisation and Chalky Teeth (here)


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