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MIH Molar Incisor Hypomineralization

MIH Molar Incisor Hypomineralization






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    MIH Molar Incisor Hypomineralization MIH Molar Incisor Hypomineralization Presentation Transcript

    • MIH Molar Incisor Hypomineralization Sanjeev Sood Lecturer in Paediatric Dentistry BDS MFDS RCSEd M.Dent.Ch (Paediatric Dentistry)
    • MIH
      • Introduction
      • Clinical Presentation
      • Prevalence
      • Aetiology
      • Treatment
    • 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)
    • MIH
      • MIH molars can create serious problems for the dentist as well as for the child affected
    • 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
    • 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
    • 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
    • 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
    • Diagnosis
      • It is important to diagnose MIH, delineating it from other developmental disturbances of enamel
    • 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)
    • 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
    • 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
    • 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
    • Differential diagnosis
      • MIH can sometimes be confused with fluorosis or amelogenesis imperfecta
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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.
    • 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
      • 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
    • 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
      • 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
    • 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
    • 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
    • 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
    • Thank You