MOLAR incisor Hypomineralization

1. MOLAR INCISOR HYPOMINERALIZATION
(MIH)
OJUOLA G.T

2. OUTLINE
 Introduction
 Definition
 Epidemiology
 Diagnosis
 Differential diagnosis
 Treatment
 Conclusion
 References.

3. Introduction
 MIH was reported in the past as:
 Hypomineralized permanent first molars(PFMs)
 Idiopathic enamel hypomineralization
 Dysmineralized PFMs
 Nonfluoride hypomineralization
 cheese molars
 This condition was termed MIH in the European
academy of paediatric dentistry 2000.

4. Definition
 MIH is a clinical appearance of enamel
hypomineralization of systemic origin affecting one or
more permanent first molars (PFMs) that are
associated frequently with affected incisors
(Weerheijm 2001)

5. Definition
 Molar incisor hypomineralisation (MIH) is defined as
the developmentally derived dental defect that
involves hypomineralisation of 1 to 4 first permanent
molars (FPM) and frequently associated with similarly
affected permanent incisors (Weerheijm 2003)

6. Definition
 MIH-like defects have also been observed on second
primary molars and permanent cuspids.
 These MIH-like defects in the primary molars are now
described as Deciduous Molar Hypomineralization
(DMH). (Elfrink et al. 2010)

7. Epidemiology
 The prevalence ranges from 2.5-40.2 %
 Prevalence in Nigeria among 8-10 years old in ile -ife
is 17.6% (Oyedele et al. 2015)
 Another study in ile ife, Nigeria among the same age
group puts it at 9.7% (Temilola et al. 2015)
 Some Studies done in other countries are shown in
the next slide.

9. Aetiology
 It is multifactorial
 Children with poor health during the first 3 years of
life are more likely to be at increased risk for
MIH(William et al. 2005)

10. 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

11. Diagnosis
 Weerheijm et al. 2003 developed diagnostic criteria
for MIH:
 demarcated opacities
 posteruption breakdown (PEB)
 atypical restorations
 extracted PFMs due to MIH
 This is best done at 8yrs of age and done on a wet
tooth.

12. Diagnostic criteria for MIH by
(Weerheijm et al. 2003)

13. Diagnosis
 Based on the diagnostic criteria, severity of MIH is
classified into:
 Mild
 Moderate
 severe

14. Diagnosis
 Mild MIH
 Demarcated opacities are in nonstress-bearing areas of the
molar
 No enamel loss from fracturing is present in opaque areas
 occasional sensitivity to external stimuli e.g. air/water but
not brushing
 There are no caries associated with the affected enamel
 Incisor involvement is usually mild if present

15. 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.
 There is sensitivity

16. Diagnosis
 Severe MIH
 Posteruptive enamel breakdown is present
 Persistent/spontaneous hypersensitivity affecting function.
 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

17. Differential diagnosis
 Enamel hypoplasia
 MIH and enamel hypomineralization (EH) can be difficult to
differentiate when affected molars have posteruptive
enamal breakdown (PEB) due to caries or masticatory
trauma
 However, in hypoplasia, the borders of the deficient enamel
are smooth, while in posteruptive enamel breakdown the
borders to normal enamel are irregular

18. Differential diagnosis
 Amelogenesis imperfecta
 Positive family history
 Generalized and can be detected preeruptively on
radiograph
 Fluorosis
 Diffuse area of enamel opacities as opposed to demarcated
area of enamel opacities in MIH.

19. Treatment
 MIH’s clinical management is challenging due to:
 The sensitivity and rapid development of dental caries
in affected PFMs.
 The limited cooperation of a young child.
 The difficulty in achieving anesthesia
 The repeated marginal breakdown of restorations.

20. Treatment
 Six step management approach by William et al. 2006
 Risk identification.
 Early diagnosis.
 Remineralization and desensitization.
 Prevention of caries and posteruption breakdown.
 Restorations and extractions.
 Maintenance.

21. Risk identification, remineralization, and
preventive management
 Identify children at risk by relevant history of putative
aetiological factors in the first 3 years and from
careful study of the unerupted molar on radiographs
 Dietary assessment and necessary modification during
PFMs eruption.
 Commencement of Oral hygiene includint a
desensitizing toothpaste

22. Risk identification, remineralization, and
preventive management
 When the surface of the PFM is accessible,
remineralization therapy should commence.#
 Remineralization and desensitization may be accomplished
with casein phosphopeptide-amorphous calcium phosphate
(CPP-ACP) oral care products. E.g. tooth mousse
 Use of topical fluoride
 Fluoride varnish
 Application of Fluoride gels several times in a week by the
parent.

23. Risk identification, remineralization, and
preventive management
 Use of fissure sealant.
 Use of GIC in partially erupted PFM

24. Restoration of hypomineralized PFMS
 Restoring affected PFMs is complicated frequently by:
 difficulties in achieving anesthesia
 managing the child’s behavior
 determining how much affected enamel to remove
 selecting a suitable restorative material

26. Restoration of the hypomineralized
permanent incisors.
 Microabrasion can be an effective treatment in shallow
defects.
 A conservative approach in managing yellow-brown
hypomineralized enamel involves:
 etching the lesion with 37% phosphoric acid;
 bleaching with 5% sodium hypochlorite; and then
 re-etching the enamel prior to placing a sealant over the
surface to occlude porosities and prevent restaining

27. Restoration of the hypomineralized
permanent incisors.
 Enamel reduction combined with opaque resin
 Porcelain veneer delayed until late adolescence
because of continued eruption exposing the margin.

29. Full coverage restorations
 Cast restorations are rarely indicated for PFMs in
young children due to placement difficulties associated
with:
 short crowns
 large pulps
 long treatment time and high cost
 The child’s limited cooperation

32. Conclusion
 it is not surprising that a MIH child who has had pain,
difficulties with anaesthesia, and retreatment develops
poor behavior and dental anxiety (William et al. 2006).
 Therefore, identification of risk factors, early diagnosis
and institution of preventive measures reduces the
severity of MIH which inturn helps in better
cooperation of the child.

33. References
 Molar Incisor Hypomineralization: Review and
Recommendations for Clinical Management (Vanessa
William et al. 2006)
 Best Clinical Practice Guidance for clinicians dealing
with children presenting with Molar-Incisor-
Hypomineralisation (MIH) An EAPD Policy Document
by N.A. Lygidakis et.al 2010

34. References
 The prevalence and pattern of deciduous molar
hypomineralization and molar-incisor
hypomineralization in children from a suburban
population in Nigeria (Temilola et al. 2015)
 Garg N, Jain AK, Saha S, Singh J. Essentiality of Early
Diagnosis of Molar Incisor Hypomineralization in
Children and Review of its Clinical Presentation,
Etiology and Management. Int J Clin Pediatr Dent
2012;5(3):190-196