MIH Molar Incisor Hypomineralization

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MIH Molar Incisor Hypomineralization Sanjeev Sood Lecturer in Paediatric Dentistry BDS MFDS RCSEd M.Dent.Ch (Paediatric Dentistry)

Transcript of MIH Molar Incisor Hypomineralization

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MIH Molar Incisor

Hypomineralization

Sanjeev SoodLecturer in Paediatric Dentistry

BDS MFDS RCSEd M.Dent.Ch (Paediatric Dentistry)

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MIH

Introduction Clinical Presentation Prevalence Aetiology Treatment

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MIH

Molar-Incisor hypomineralization is defined as a hypomineralization of systemic origin that affects one to all of the first permanent molars and is often associated with affected permanent incisors (Weerheijm et al., 2001)

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MIH

MIH molars can create serious problems for the dentist as well as for the child affected

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MIH Dentists

rapid caries development

inability to anaesthetize the MIH molar

unpredictable behaviour of apparently intact opacities

restoration difficulties

Child experience pain and

sensitivity (even when the enamel is intact)

Pain during brushing

appearance of their incisor teeth

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Clinical Features

Primary teeth are not affected

one, two, three or four permanent first molars affected

white/yellow/brown opacities

well demarcated compared to normal enamel

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Clinical Features

usually presents on the buccal or occlusal surfaces of the molars and incisors

asymmetrical defects

the risk of defects to the incisors appears to increase when more first permanent molars have been affected

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Clinical Features

the affected molars are sensitive to cold and appear to be more difficult to anaesthetise

the lesions on the incisors are usually not as extensive as those in the molars and present mainly a cosmetic problem

the remaining permanent dentition is usually not affected

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Diagnosis

It is important to diagnose MIH, delineating it from other developmental disturbances of enamel

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Diagnosis Diagnostic criteria to establish the

presence of MIH include:

the presence of a demarcated opacity (defect altering the translucency of the enamel)

posteruptive enamel breakdown (loss of surface enamel after tooth eruption, usually associated with a pre-existing opacity)

atypical restorations (frequently extend to the buccal or palatal smooth surfaces reflecting the distribution of hypoplastic enamel)

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Diagnosis

Mild MIH Demarcated opacities are in nonstress-bearing

areas of the molar No enamel loss from fracturing is present in

opaque areas There is no history of dental hypersensitivity There are no caries associated with the affected

enamel Incisor involvement is usually mild if present

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Diagnosis

Moderate MIH Atypical restorations can be present Demarcated opacities are present on

occlusal/incisal third of teeth without posteruptive enamel breakdown

Posteruptive enamel breakdown/caries are limited to 1 or 2 surfaces without cuspal involvement

Dental sensitivity is generally reported as normal

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Diagnosis

Severe MIH Posteruptive enamel breakdown is present There is a history of dental sensitivity Caries is associated with the affected enamel Crown destruction can advance to pulpal

involvement Defective atypical restoration Aesthetic concerns are expressed by the

patient or parent

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Differential diagnosis

MIH can sometimes be confused with fluorosis or amelogenesis imperfecta

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Differential diagnosis

It can be differentiated from fluorosis as its opacities are demarcated, unlike the diffuse opacities that are typical of fluorosis

fluorosis is caries resistant and MIH is caries prone

fluorosis can be related to a period in which the fluoride intake was too high

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Differential diagnosis

Choosing between amelogenesis imperfecta (AI) and MIH:

only in very severe MIH cases, the molars are equally affected and mimic the appearance of AI

In MIH, the appearance of the defects will be more asymmetrical

In AI, the molars may also appear taurodont on radiograph

There is often a family history

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Prevalence

The prevalence figures range from 3.6–25% and seem to differ between countries

The number of hypomineralized first

permanent molars in an individual can vary from one to four

The frequency of MIH molars was not evenly divided among children

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Aetiology Amelogenesis is a highly regulated process

The asymmetrical occurrence of MIH suggests that the ameloblasts are affected at a very specific stage in their development

Children with poor health during the first 3 years of life are more likely to be at increased risk for MIH

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Aetiology Ameloblast cells

are irreversibly damaged

Clinically these appear as yellow or yellow/brown opacities

These opacities are more porous

Ameloblasts have the potential to recover after the disturbance

These defects appear creamy yellow or whitish cream demarcated opacities

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Aetiology Various causes of MIH have been

implicated:

Environmental conditions Respiratory tract infections Perinatal complications Dioxins Oxygen starvation and low birth weight Calcium and phosphate metabolic disorders Childhood diseases Antibiotics Prolonged breast feeding

the aetiology of MIH still remains unclear

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Restoration

Children with MIH may have extensive treatment needs

By the age of nine, children with MIH were treated ten times as often as children without such molars

MIH children display more dental fear and anxiety

Children with MIH exhibited greater DMFS and dmfs

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Restoration

MIH molars are fragile, and caries may develop easily in these molars

This is aggravated because children tend to avoid the sensitive molars when brushing

In order to minimize the loss of enamel and any damage due to caries, both preventive and interceptive treatment is required

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Restoration Besides normal brushing and education,

prevention also includes fluoride varnish application and application of glass ionomer sealants

Sometimes the sensitivity of the teeth is decreased by these applications

In some cases of hypersensitivity the use of casein phosphopetide-amorphous calcium phosphate (CC-ACP) (Tooth Mousse) products have been advised as they remineralize and desensitize the tooth

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Extraction Extraction combined with

orthodontic treatment, should be considered as an alternative treatment, especially if the molars have a poor longterm prospect.

The optimal time for extraction is indicated by the calcification of the bifurcation of the roots of the lower second permanent molar

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Short-Term Treatment The immediate treatment planning needs of young

children with MIH must reflect:

Behavioural Preventive growth and development restorative requirements

The objective is to:

maintain function preserve tooth structure plan for any required orthodontic care

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Partially Erupted Molars Prone to caries development and highly sensitive

Applying desensitizing agent in combination with fluoride varnish applications could be of some help in decreasing sensitivity

GI to cover the affected surfaces of a partially erupted molar can act as an interim method of: decreasing sensitivity reducing caries susceptibility preserving tooth structure

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Mild MIH: Short-Term Treatment Prevention and maintaining the dentition

Teeth should be carefully monitored applying fluoride varnish and placing sealants on the

occlusal surfaces of molars

where the enamel is intact and the patient does not report any sensitivity, sealants are the current treatment of choice

60-second pretreatment with 5% sodium hypochlorite (NaOCl) to remove intrinsic enamel proteins may be beneficial

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Moderate MIH: Short-Term Treatment preventive measures previously outlined

intervention may be required

Anterior teeth with isolated demarcated opacities that are of aesthetic concern can be treated with NaOCl or other bleaching techniques, microabrasion, or resin restorations

Yellow or yellow/brown spots in incisors or molars can lighten and become less noticeable with bleaching, but whitish opacities may become more prominent after applying the bleach

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Moderate MIH: Short-Term Treatment For posterior teeth with enamel loss or decay

limited to 1 or 2 surfaces that does not involve cuspal tooth structure, resin is the material of choice if the tooth can be adequately isolated

The outline of the restoration should be made in non-hypomineralized enamel, but it can be very difficult to find out where sound enamel begins, resulting in repeated restorations due to disintegration of adjacent enamel or opacities on other spots.

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Moderate MIH: Short-Term Treatment Two approaches have been described in

determining the location of the cavity margin but neither is ideal

Fall the visibly defective enamel is removed Only the very porous enamel is removed until good

resistance is felt between the bur and the sound enamel

Existing, intact restorations on molars should be carefully monitored

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Available adhesive dental materials GI RMGI Compomer RBC

Glass ionomers and resin-modified glass ionomers have poor wear resistance and are not recommended for placement in stress-bearing areas

The enamel-adhesive interface Porous Cracks Decreased bond strength Cohesive failure

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Severe MIH: Short-Term Treatment Treatment of children with severe MIH presents a

tremendous challenge

Early intervention is necessary to prevent PEB

To minimize discomfort and decrease the likelihood of behaviour management problems, profound local analgesia is necessary

Some patients may benefit from the use of nitrous oxide sedation in conjunction with local anaesthesia

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Once the molar has erupted, preformed stainless-steel crowns are the treatment of choice for severely hypoplastic molars

Stainless-steel crowns protect the tooth against masticatory forces protect enamel from acid attack decrease sensitivity increase the child’s OH compliance

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Long-Term Treatment

Once children have a mature dentition and a more stable gingival to clinical crown height, full-coverage cast restorations should be considered to replace the interim stainless-steel crowns on molars

Anterior teeth can be managed with veneers or crowns should they be indicated for severe cases of enamel defects, and where aesthetic concerns continue to be an issue

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Summary

Early Diagnosis

High risk prevention protocol

Make a decision regarding prognosis of the molars Extract if prognosis is poor or if behaviour

management will be an issue

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Summary

Replace missing tooth structure Use best available restorative material SSC ideal

Regular recall

Delay aesthetic treatment of the incisors until the child requests treatment

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Thank You