MIH HSPM.pptx

Management of Molar
Incisor Hypomineralization

Outline Presentation
1. Introduction
2. Prevalence: MIH is a Worldwide Problem
3. Aetiology
4. Clinical Presentation of MIH
5. Association between MIH and other hypomineralised teeth
6. Differential Diagnosis
7. Clinical Management: A Holistic Approach
8. Case Study
9. Conclusion
10. References

Introduction
What is Molar-Incisor Hypominralisation (MIH)?
• The term molar-incisor hypomineralisation (MIH) was first introduced
in 2001 by Weerheijm et al. and it was defined as
‘hypomineralisation of systemic origin, presenting as demarcated,
qualitative defects of enamel of one to four first permanent molars
(FPMs) frequently associated with affected incisors’.
Weerheijm K L, Jalevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res 2001; 35: 390–391

• In 2003, MIH was further described as a developmental, qualitative
enamel defect caused by reduced mineralization and inorganic
enamel components which leads to enamel discoloration and
fractures of the affected teeth.
• In MIH, the FPMs show rapid caries progression starting shortly after
eruption in the majority of cases, which causes serious problems to
patients as well as treatment challenges to dentists to manage such
cases.
© 2020 The Authors. International Dental Journal published by John Wiley & Sons Ltd on behalf of World Dental Federation

Prevalence: MIH is a Worldwide Problem
• Studies from different parts of the world show a wide variation in the prevalence
of MIH which can range between 2.8 to 40.2%, depending on the population and
country studied
• Studies shows in recent meta-analyses suggest that MIH affects around 13%–14%
of the world’s children.
• However, this variation may be due to a lack of standardized tools to record MIH
leading to underestimation of the prevalence.
BRITISH DENTAL JOURNAL | VOLUME 225 NO. 7 | OCTOBER 12 2018

• In response to this finding, Ghanim et al have introduced a standardized scoring
system based on the European Academy of Paediatric Dentistry (EAPD) evaluation
criteria.
• A manual has also been recently published to facilitate and standardize its use in
future epidemiological studies.
• They also suggest that the ideal age to diagnose MIH in a child is around 8 years
because, at this age, all FPMs and incisors have erupted but any ‘destruction’ of
hypomineralised enamel is limited.

Aetiology
• The causative mechanism is still
unclear, but the clinical
presentation of localized and
asymmetrical lesions suggests a
disruption in the amelogenesis.
• The condition seems to be
multifactorial and systemic factors
during the last gestational
trimester and first three years
of life have been suggested as
causative or contributing factors.

PRE-Natal Period
• The last trimester of pregnancy is a critical period during which the amelogenesis
of FPMs and incisors teeth starts.
• A recent meta-analysis found that children whose mothers experienced health
problems during pregnancy showed a 40% greater chance of developing MIH
than children whose mothers remained healthy.

• Presumed causative factors of MIH during last trimester of pregnancy
International Journal of Oral & Maxillofacial Pathology. 2013;4(1):26-33
Maternal high fever
Viral infection
(chicken pox /
rubella)
Prolonged
medication
Maternal
hypertension
Maternal diabetes Malnutrition Prolonged vomiting
Exposure to
pollutants

PERI-Natal Period
• Perinatal complications, such as difficulties during labour and
delivery, delivery by Caesarean section, premature birth and low birth
weight, have also been linked to MIH.
• Hypoxia, hemorrhage and detachment during delivery are also some
more supposed peri-natal causes for defective ameloblast function.

Post-Natal (First 3 Years)
• First 3 years of life, when calcification of FPMs and incisors occurs, episodes of
childhood illnesses, environmental pollutants and medication also appear to
disturb the function of proteolytic enzymes, which are key in the amelogenesis
process and pose an increased risk of MIH.
Prolonged
medication
Kidney failure Prolonged fever Environmental
pollutant

• Condition such as asthma, and other respiratory
diseases, can cause respiratory acidosis and
abnormal oxygen levels.
• Affect the pH of the enamel matrix and lead to
abnormal ameloblastic activity during enamel
mineralization.
• Asthmatic children often require therapy with
corticosteroids – known suppressants of osteoblast
formation and activity – which similarly may be
detrimental to ameloblast function and predispose
to MIH.

Clinical Presentation of MIH
• The ideal time to diagnose MIH is as soon as it is clinically apparent in the
dentition / oral cavity.
• The examination should be performed on clean wet teeth.
• Depends on its severity can range from white-creamy opacities, yellow-brown
opacities.
• The affected First Permanent Molar (FPM) may undergo post-eruptive enamel
breakdown because of occlusal loading, whereas incisors rarely exhibit post-
eruptive enamel breakdown.

• The lesions should be larger than 1 mm to be recorded as MIH.
• The structural defect may lead to early caries involvement and rapid progression.
• Affected molars may at times be hypersensitive. This might lead to poor oral
hygiene and therefore, caries susceptibility increases.
• Local anesthesia problems - Affected teeth usually difficult to anesthetize, which
are possibly related to chronic pulp inflammation.

Mathu-Muju and Wright (2006) had classified MIH into three severity
levels:
1. Mild MIH: the demarcated opacities located at non-stress bearing areas, no
caries associated with the affected enamel, no hypersensitivity and incisor
involvement is usually mild if present.
2. Moderate MIH: the demarcated opacities present on molars and incisors, the
post-eruptive enamel breakdown limited to one or two surfaces without cuspal
involvement, atypical restorations can be needed and normal dental sensitivity.
3. Severe MIH: post-eruptive enamel breakdown, crown destruction, caries
associated with affected enamel, history of dental sensitivity and aesthetic
concerns.

Association between MIH and other
hypomineralised teeth
• The same demarcated defects that present on some molars and incisors in MIH
have also been observed on other teeth such as second primary molars and tips
of permanent canine cusp in some MIH cases.
• A significant association between MIH and hypomineralised permanent canines
has been described in a paper by Schmalfuss et al. where they found
approximately one quarter of MIH-affected individuals had one or more
permanent canines with signs of hypomineralisation.

Hypomineralised Second Primary Molar
(HSPM)
• In the primary dentition, a similar presentation
has been observed in the second primary
molar, which is now termed hypomineralised
second primary molars (HSPM).
• HSPM is currently defined as
hypomineralisation of one to four second
primary molars including the presence of
demarcated opacities, post eruptive breakdown
and atypical caries/restorations
McCarra C, Cristina Olegário I, O’Connell AC, Leith R. Prevalence of hypomineralised second primary molars (HSPM):
A systematic review and meta-analysis. Int J Paediatr Dent. 2021;00:1–16. https://doi. org/10.1111/ipd.12892

• Mittal et al. have investigated the
association between
hypomineralised second primary
molar (HSPM) and MIH and they
found that approximately half of
the FPMs with MIH were
associated with HSPM.
• They evaluated the prevalence of
HSPM and MIH and they reported
that 18 out of 55 children with MIH
(32.73%) were having HSPM.

• Ghanim et al. reported the HSPM and MIH association as 39.6% in their study.
Incidence of HSPM in children affected with MIH is more likely to be seen
compared with children without.
• Negre-Barber et al. stated that HSPM can be considered a predictor for MIH,
indicating the need for monitoring, but the absence of HSPM does not rule out
the appearance of MIH
European Journal of General Dentistry Vol. 10 No. 2/2021 © 2021. European Journal of General Dentistry.

• In this regard, they concluded that HSPM may be a risk factor for MIH
development.
• Hence, children with HSPM whose FPMs were not erupted, should be given extra
attention for early diagnosing of MIH, and these children should be followed up
by paediatric dentists until the eruption of FPMs is completed.
European Journal of General Dentistry Vol. 10 No. 2/2021 © 2021. European Journal of General Dentistry.

Differential Diagnosis
Fluorosis
• This is associated with history of fluoride ingestion during enamel development.
• Clinically, fluorosis presents as diffuse, linear, patchy or confluent white opacities
without a clear boundary.
• The severity can range from barely perceptible striations in the enamel to gross
disfiguration with almost complete loss of the external part of the enamel.
• It affects teeth in a symmetrical, bilateral pattern unlike MIH which is
asymmetrical.
• Moreover, teeth affected by fluorosis are caries-resistant while in MIH they are
caries-prone.

Enamel hypoplasia
• This is a quantitative defect with
reduced enamel thickness.
• The borders of hypoplastic
enamel lesions are mostly
regular and smooth, indicating
developmental and pre-eruptive
lack of enamel.
• The margins in MIH with post-
eruptive enamel breakdown are
sharp and irregular due to post-
eruptive shearing of
weakened enamel.

Amelogenesis imperfecta
• This is a genetic condition
which results in enamel
that is hypoplastic,
hypomatured, or
hypomineralised.
• In this condition, all teeth
in both dentitions are
affected and a familial
history is often present

White spot lesion
• This is the earliest clinical
sign of caries.
• The lesions appear
chalkier, matt or more
opaque than the adjacent
sound enamel.
• They can be distinguished
from MIH because they
occur in areas of plaque
stagnation, such as the
cervical margin of
the tooth.

Traumatic hypomineralisation
• Also known as “Turner Tooth/Turner
Hypoplasia”
• This is associated with a history of
dental trauma to the primary
predecessor tooth.
• Periapical infection of the primary
tooth can disturb mineralization of
the underlying tooth germ.
• It has a wide variety of clinical
presentations differing in shape,
outline, localization and color. It is
often limited to one tooth and
asymmetrical.

Clinical Management: A Holistic Approach
• Identification of patients at risk of MIH and early diagnosis can lead to more
effective and conservative management.
• Based on the available evidence, children at risk of MIH are those with poor
general health during early childhood and/or those with HSPMs.
• Management is further challenged by behavioural factors as younger patients
may demonstrate high levels of dental anxiety, which may be exacerbated by
failure to achieve adequate levels of local analgesia during treatment

1. Caries prevention and desensitisation
• It is very important to commence enhanced prevention as soon as MIH teeth
erupt as they are prone to post-eruptive enamel breakdown and caries
especially in severe MIH lesions.
• Additionally, interventions must also aim to reduce sensitivity of
hypomineralised FPMs, which can be experienced even during normal
toothbrushing.
• They should be encouraged to use fluoridated toothpaste with at least 1450 ppm
F to reduce caries risk and tooth sensitivity

• In an effort to remineralise the MIH teeth, the long-term use of products
containing casein phosphopepetide amorphous calcium phosphate (CPP-ACP) is
recommended especially at early stages where the surface enamel of newly
erupted teeth is not completely matured.
• The CPP-ACP ingredient helps to increase the bio-availability of calcium and
phosphate within saliva and therefore encourages remineralization and
desensitization of MIH teeth.
• Tooth Mousse (GC Corporation, Tokyo, Japan) and MI Paste Plus (GC Corporation,
Tokyo, Japan) are the most commonly used dental products containing CPP-ACP.
• The combined use of fluoride and CPP-ACP has been shown to give enhanced
benefits than using either agent alone.

• Conventional fissure
sealants are reported to
have a high failure rate;
thus, glass ionomer-based
sealants may be preferable
for newly erupted and
sensitive FPMs.

2. Treatment option for Incisors
• Aesthetic concerns are common in patients with MIH with incisor
involvement.
• In young patients, these teeth should be treated in a conservative
approach as they have immature anterior teeth with large and
sensitive pulp.

• The areas of enamel hypomineralisation tend to be limited to the
labial surfaces and are located more towards the incisal third, sparing
the cervical enamel.
• Sensitivity and post-eruptive enamel breakdown are not common
features unless the areas of hypomineralisation have a yellow/brown
appearance and the involvement of incisal edge.

• Involves the removal of small amount of surface enamel (no more
than 0.1mm)
• Using 18% HCl and 37.5% phosphoric acid with pumice and finally the
abraded surface is polished.
• Indicated when discoloration is limited to outer surface of enamel
and effective in eliminating brown mottling.
Microabrasion
• The aim is to camouflage white opacities by increasing the overall
brightness of teeth.
• The possible side-effects are sensitivity, mucosal irritation and
enamel surface alteration.
• For more protection, combine use of CPP-ACP tooth mousse with
bleaching gel.
• The CPP-ACP will protect the tooth structure and mineralize the MIH
without interfering with bleaching effect.
Bleaching

• The affected tooth should be etched first with 37% phosphoric acid for
60 seconds, followed by application of 5% NaOHCl as bleaching agent
for 5-10 minutes.
• Then the tooth should be re-etched and covered with protective layer
such as clear fissure sealant or composite binding agent
• This technique was suggested to remove yellow-brown stain.
Etch-bleach-
seal
• Icon by DMH (Germany) is the only material available for this
procedure.
• The Icon system consists of: Icon-Etch (15% hydrochloric acid), Icon-
Dry (99% ethanol) and Icon-Infiltrant (Methacrylate-based resin).
• The Icon-Etch (acid) is used to eliminate the relatively intact surface
layer of enamel and the Icon-Infiltrant (fluid resin) is infiltrated into
the structure.
• This could protect against acid attack, improve enamel
micromechanical properties and decrease enamel breakdown.
Resin
Infiltration

• Composite restoration involve removal of defective enamel and
composite build up.
• Composite veneer could be more conservative as it can be achieved
without tooth preparation and no removal of defective enamel.
• This options indicated for large enamel defects , exposed dentine or
chipped enamel.
Composite
restoration /
veneer
• Usually indicated for patient aged 18 years and above when the
gingival margin has matured.
• It can be an option when other techniques failed to produce
satisfactory results.
Porcelain
Veneer

3. Treatment option for molars
• When managing these teeth, the first clinical consideration is whether to restore
or extract.
• This depends on factors such as: child’s age; severity of MIH; pulp involvement;
presence of third molar germ(s); restorability of the tooth/teeth; expected long-
term prognosis; and long-term treatment cost.

• Also known as erosion-infiltration.
• This technique uses a very low viscosity resin which capable of penetration
demineralized enamel.
• Icon by DMH (Germany) is the only material available for this procedure.
• The Icon-Etch (acid) is used to eliminate the relatively intact surface layer of enamel and
the Icon-Infiltrant (fluid resin) is infiltrated into the structure.
• This could protect against acid attack, improve enamel micromechanical properties and
decrease post eruptive enamel breakdown.
Resin
Infiltration
• It is recommended that the cavity design should involve removal of all porous but not
necessarily discoloured enamel, until resistance to the bur or to the probe achieved.
• GIC or modified GIC can be considered only as intermediate approach.
• Resin composite is the material of choice and recommended for 1 to 3 surface
restorations.
• Amalgam should be avoided due to atypically shaped cavities in MIH molars, may
promote further breakdown at margin
• It is also non adhesive so does not restore the strength of tooth and poor insulator.
Restoration

• Preformed metal crowns (PMC) can be used successfully in severely damaged molars
with long-term survival rates.
• PMC prevent further post eruptive enamel breakdown, manage sensitivity, not
expensive, establish occlusal contact, require no/little tooth preparation.
• PMC can be done in single visit – good for child
• Tooth-coloured indirect onlays can be used in older children but the procedure is time
consuming, technique sensitive and expensive.
Full or partial
coverage
• Generally, whenever practical, the FPM should be extracted when there Is radiographic
evidence of early dentine calcification within the second permanent molar (SPM) root
bifurcation.
• This usually occurs within a chronological age of 8 – 10 years. This will give the SPM an
opportunity to drift into FPM position.
• Full dental assessment and good quality radiographs are mandatory prior extraction of
FPM to check for the presence, position and normal formation of developing
permanent dentition to ensure favourable orthodontic conditions.
• The spontaneous mesial eruption of SPM is more likely to occur when the SPM follicle
is still entirely within the bone.
Extraction of
severely
affected
molar

A Four-Year Follow-Up Case Report of
Hypomineralized Primary Second Molars
(HSPM) Rehabilitated with Stainless Steel
Crowns
A Case Study

• A four-year-old girl attended the Pediatric Dentistry Department at
Egas Moniz Dental Clinic (Almada, Portugal).
• Informed consent was obtained from her parents so that case records
could be made available for teaching purposes, including scientific
publication.
• The patient presented no relevant medical history, and her mother
reported a high thermal sensitivity to cold on the posterior teeth,
with chewing difficulty, as well as tooth brushing.

• During clinical evaluation, an extraoral examination showed no facial
asymmetry or swelling.
• Intraoral and radiographic examinations showed good oral hygiene
and extensive enamel breakdown with irregular opacities on all
primary second molars, being the differential diagnosis compatible
with HSPM (Figure 1).
• The patient’s parents were instructed to use a GC Tooth Mousse and a
toothpaste with 1500 ppm fluoride as a routine at-home oral hygiene
practice, until the specific treatment appointment.

Intraoral pre-treatment photographs

Treatment options given:
Considering her young age, non-cooperative behavior, the fact that the
severity of the HPSM, and the importance of the second primary
molars, it was advised to place four crowns on all second primary
molars.
• 1. Four zirconia crowns on the four primary molars. However, this was
rejected due to the high economic value, despite the aesthetics, the
mechanical resistance, limited plaque adhesion, wear behavior and
natural appearance.
• 2. Four stainless steel crowns. This will maintain the vertical
dimension, and grants the physiological exfoliation of the primary
second molars at a lower cost.

• The complete treatment was performed under general anesthesia.
• After plaque removal with a prophylactic paste at the beginning of
the procedure and the gently drying of the tooth, a rubber dam was
applied, one tooth at a time, to locally isolate the lesions.
• Then, and after partial carious lesion removal, stainless steel crowns
(3M™ ESPE™ Stainless Steel Crowns, 3 M, St. Paul, MN, USA) were
selected and cemented with Ketac™ Cem Easy Mix (3M™ ESPE™,
Maplewood, MN, USA), according to the manufacturer’s instructions
(Figure 3)

Intraoral post-treatment photograph

• After a three-month period, a panoramic radiograph taken (Figure 4),
and every six months, clinical and radiograph exams were collected.

• At the end of four years of follow-up, clinical evaluation revealed a
good marginal adaptation and gingival health (Figure 5)

• 4 years follow up radiographic exam showed normal occlusion in all
the first permanent molars (Figure 6).

Discussion
• In the present case, we have considered stainless steel crowns in all
second primary molars for restorative therapy of a severe case of
HPSM.
• Even though HPSM is a clinical challenge, the maintenance of second
primary molar is of the upmost importance to avoid functional and
aesthetic negative outcome.

• In severe cases, full coverage with stainless steel or zirconia crown is
the best long-term choice. This may be the treatment of choice,
because it promotes the preservation of pulp vitality, maintains a
proper occlusion, and allows an appropriate eruption of the first
permanent molars.

• The second primary molars are of the utmost importance in the
occlusion, since they have an eruption guide for the eruption of the
first permanent molars.
• Several effects of premature space loss are mentioned, such as dental
crowding, ectopic eruption, impaction of the permanent tooth,
crossbite, center line discrepancies, and, in cases of premature loss of
deciduous second molars, tipping of the first permanent molar can
occur.
• Therefore, it is essential to maintain the second primary molar until
the first permanent molar tooth and the successor erupt successfully.

9. Conclusion
• Children with poor general health in early childhood or with
hypomineralised second primary molars (HSPM) should be
considered at risk of MIH.
• Therefore, they should be monitored more frequently during eruption
of the FPMs.
• Since MIH is considered common, it should be diagnosed and
managed in primary care wherever possible.
• Automatic referral to any specialized dental hospital is a frequent
approach if these patient are in need of more complex treatment.

10. References
• Weerheijm K L, Jalevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res 2001; 35: 390–391
• 2020 The Authors. International Dental Journal published by John Wiley & Sons Ltd on behalf of World Dental Federation; Molar incisor
hypomineralisation: current knowledge and practice
• Shubha AB, Sapna Hegde. Molar-Incisor Hypomineralization: Review of its Prevalence, Etiology, Clinical Appearance and Management.
International Journal of Oral & Maxillofacial Pathology; 2013:4(1):26-33. ©International Journal of Oral and Maxillofacial Pathology
• Best Clinical Practice Guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH) An EAPD Policy
Document
• Negre-Barber, A. et al. Hypomineralized Second Primary Molars as Predictor of Molar
• Incisor Hypomineralization. Sci. Rep. 6, 31929; doi: 10.1038/srep31929 (2016).
• A practical method for use in epidemiological studies on enamel hypomineralisation. European Academy of Paediatric Dentistry 2015
• Molar incisor hypomineralisation: clinical management of the young patient., 55 (2):83-6 J Ir Dent Assoc
• Bandeira Lopes, L.; Machado, V.; Botelho, J. A Four-Year Follow-Up Case Report of Hypomineralized Primary Second Molars Rehabilitated
with Stainless Steel Crowns. Children 2021, 8, 923. https://doi.org/10.3390/children8100923
• Z. Almuallem*1 and A. Busuttil-Naudi2. Molar incisor hypomineralisation (MIH) – an overview. BRITISH DENTAL JOURNAL | VOLUME 225
NO. 7 | OCTOBER 12 2018

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