**5.2 Clinical management of MIH**

436 Contemporary Approach to Dental Caries

Libya 9% 378 7-8.9 years Fteita et al., 2006

Lithuania 14.9% 1,277 7-9 years Jasulaityte et al.,2007

Norhern England 15.9% 3,233 12 years Balmer et al., 2011

Table 3. Distribution of MIH in some countries in the world. Selected studies were

conducted using only MIH index criteria as suggested by EAPD.

**5. Clinical considerations and management of MIH** 

**5.1 Dentino-pulpal complex considerations and MIH** 

be related with an overexpressed dental sensitive.

**Years age (mean + SD)** 

Children born from1,October-1997 to 1, 1999

Spain 17.8% 505 6-14 years Martinez Gomez et al., 2011

In spite of having still need of further investigation considering population-based samples, with standardization of methodology, it is clearly seen that different countries from different regions of the world are performing epidemiological surveys using MIH index. This is essential to ascertain the occurrence of the MIH and may otherwise be systematized not only strategies to MIH diagnosis, but also treatments and monitoring as well as outlining scientific researches considering this topic. Thus, it is essential to do well design

Patients with MIH affected teeth suffer from dentine sensitivity once often report exacerbated sensitivity to a variety of normally innocuous thermal, mechanical and osmochemical stimuli (Jalevik & Klingberg, 2002) due to the presence of porous enamel and sometimes, the exposed dentine. Based on the immunocytochemical findings in hypomineralised permanent first molars, changes in pulpal innervation, vascularity, and immune cell accumulation were indicative of an inflammatory response.(Rodd et al.,2007a) Besides, the morphological aspects of MIH may favor ingress of bacterial contaminants (Fagrell et al., 2008), thereby resulting in chronic inflammation of the pulp (Rodd et al., 2007b) Following tissue inflammation, a variety of morphological and cytochemical neuronal changes may occur including neuronal branching and altered expression of neuropeptides and ion channels (Rodd et al., 2007b, Rodd & Boissonade, 2002) that seems to

From a clinical perspective, these findings would support early interventions in order to avoid the development of pulpal inflammation and associated hypersensitivity. Thus, toothpastes and/or chewing gums with mineralizing products, such as Casein

**Authors** 

(Fteita et al., 2006)

(Jasulaityte et al., 2007)

(Balmer et al., 2011)

Fagell et al., 2011 (Fagrell et al., 2011)

(Martinez Gomez et al., 2011)

**(n)** 

**Country Prevalence Subjects**

Southeast Sweden 3.5% 17,055

clinical studies considering MIH pathology.

In accordance with the European Academy of Pediatric Dentistry until now there are only a limited number of evidence based research papers on MIH affected teeth. (Lygidakis et al., 2010) Because of this, the guidelines diagram according to Scottish Intercollegiate Guidelines Network (SIGN) methodology (SIGN, 1999) is impossible to be made. However, treatment modalities in children with teeth affected by MIH were systematically reviewed by LYGIDAKIS, 2010. (Lygidakis, 2010) Thus, the clinical management of MIH was resumed by the present authors as seen in Figure 5. These clinical guidelines approach were organized considering the type of MIH affected teeth (permanent first molars or incisors) and the severity of defects. Then, it was also considered, the treatment management of the first permanent molars (FPM) without post eruptive breakdown (PEB) or with post-eruptive breakdown; as well as to the incisors with different levels of opacities (Figure 3). It worthwhile be emphasized the necessity of not only randomized controlled clinical trials but also the laboratory studies to support and better understand the specificities of MIH condition.

Therefore, a detailed study under magnification of the unerupted molar and incisor crowns on any available radiographs should be done. (William et al., 2006a) During teeth eruption, when MIH is confirmed, it should be made a diet counseling for dietary modifications to avoid dental caries, dental erosion and dental sensitivity; It should be recommended a toothpaste with a fluoride or, in cases of dental sensitivity, aiming to produce a nonsensitivity and hypermineralized surface layer which provides a super saturated environment of calcium and phosphate on enamel surface, a desensitizing toothpaste with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) should be indicated. (Baroni & Marchionni, 2011)

Fissure sealants should be applied early after molars eruption and before enamel breakdown. (Kilpatrick, 2009, Lygidakis et al., 2010, Lygidakis, 2010, William et al., 2006a, Crombie et al., 2008) Taking the morphological aspects of MIH affected teeth into account, for first permanent molars, highly viscosity glass ionomer cements can be considered as an alternative material of choice for fissure sealing due to its stable chemical adhesion on the substrate (Welbury et al., 2004) which ensures its clinical longevity even if disappeared macroscopically in the follow-ups. (Frencken &Wolke, 2010)

Molar Incisor Hypomineralization:

**6. Conclusion** 

Morphological, Aetiological, Epidemiological and Clinical Considerations 439

case, the adjunctive use of nitrous oxide-oxygen analgesia may alleviate anxiety and reduce dental pain. In last case, general anesthesia may be required for restorative treatment. (William et al., 2006a) The maintenance of existing tooth structure and pain relief can be achieved with temporary restorations, often in sub-optimal clinical conditions, through the use of glass ionomer cements. In mild and moderate MIH cases composite restorations using self-etching primer adhesive bonding systems is the treatment of choice (William et al., 2006b) and may last for many years until indirect restorations would be placed. (Lygidakis et al., 2010, Lygidakis, 2010) For cavities involving large areas of dentine, glass ionomer cement has been proposed to be used as a sub-layer under the composite restoration (Mathu-Muju & Wright, 2006). A more definitive restorative approach, albeit still temporary solution, is the preformed metal crown (PMC) which placed on first permanent molars provide an excellent medium term restorative solution. (Kilpatrick, 2009) For that, it requires an excellent analgesia and patient cooperation which may not be forthcoming. In severe cases, transitional treatment for function and aesthetics can be provided until adolescence when permanent prosthetic approach with crowns in molars and veneers or crowns in incisors can be indicated. Cast restorations (full coverage crown, tooth-colored crown, porcelains or veneers) have been used. (Lygidakis et al., 2010, Lygidakis, 2010) However, they are not recommended for teeth in early post-eruptive stage because of the continuous eruption exposing the crown margins, the large pulp size, short crown height, and difficulties in obtaining a good impression for subgingival crown margins. (Koch & Garcia-Godoy, 2000) At last case, any extraction of first permanent molars should only be carried

Despite a fall in the prevalence and in the speed of progression of dental caries disease, often, the clinicians and the pedodontics can find first permanent molars and incisors with hypomineralised enamel defected. MIH must be regarded as a public health problem which brings painful consequences, aesthetic and a negative impact on the quality of life of individuals suffering from MIH. A difficult and complex problem resolution, therefore all effort should converge towards the sense of real knowledge of the MIH aetiology to allow more accurate diagnosis and more appropriate treatment. People seized with MIH pathology have made sure that their expectations in relation to intervention proposal is based on high efficiency and effectiveness scientific evidences by ensuring the quality of life not only these people but also of their families. The etiology of MIH as a result of synergistic action of environmental factors and, suddenly genetic expressions leaving disturbances in enamel formation of molars and incisors in the first year of life, is the challenge to be overcome. Ultimately, the discovery of new genes and novel proteins such as amelotin and apin (Nishio, 2008) that they are also produced by ameloblasts, but during the stage of maturation, with important enamel mineralization function in relation to obtaining final hardness of enamel point to a promissory future in relation to knowledge of dental development. Well-being, understanding the genetic sequential and signaling pathways of developmental normal of enamel will provide us with an invaluable tool for understanding the pathways and mechanisms of tissue maintenance, repair and regeneration. It will enable us to manipulate genetic and environmental factors and ultimately, aid in the development

out with consideration of the possible orthodontic implications.

of dental develpomental defects of enamel therapy.

NA – Not applicable

Fig. 5. Flow chart illustrated by the authors of clinical management of MIH Children with a history of putative aetiological factors in the first 3 years should be screening at risk for MIH (Alaluusua, 2010, Crombie et al., 2009, Fagrell et al., 2011)

As suggested by LIGYDIKIS ET AL., 2010 (Lygidakis et al., 2010), when children express their concern on mild discolorations, at late mixed dentition, incisors with whitish-creamy opacities may occasionally respond to bleaching with carbamide peroxide. (Fayle, 2003) Another conservative approach is microabrasion with either 18% hydrochloric acid or 37% phosphoric acid and pumice for 60s. (Lygidakis et al., 2010, Wright, 2002, Gotler & Ratson, 2010, Willmott et al., 2008) More pronounced enamel defects might be dealt with by combining the two methods (Sundfeld et al., 2007a), bleaching and microabrasion. However, bleaching for young children may induce hypersensitivity, mucosal irritation and enamel surface alterations (Joiner, 2006), whilst microabrasion may result in loss of enamel. (Sundfeld et al., 2007b) An etch-bleach-seal technique by involving:


On the other hand, the replacement of micro-abrasion by local enamel thickness reduction, using high-speed headpiece, should be also evaluated by the professional.

The others clinical problems for patients with MIH are attrition, exposed dentin, atypical cavities or complete coronal destruction. (Kilpatrick, 2009, Jalevik & Noren, 2000) Moreover, pain experience during dental treatment has led some MIH children to be significantly less compliant and more dentally anxious than their peers.(Jalevik & Klingberg, 2002) In this out with consideration of the possible orthodontic implications.

case, the adjunctive use of nitrous oxide-oxygen analgesia may alleviate anxiety and reduce dental pain. In last case, general anesthesia may be required for restorative treatment. (William et al., 2006a) The maintenance of existing tooth structure and pain relief can be achieved with temporary restorations, often in sub-optimal clinical conditions, through the use of glass ionomer cements. In mild and moderate MIH cases composite restorations using self-etching primer adhesive bonding systems is the treatment of choice (William et al., 2006b) and may last for many years until indirect restorations would be placed. (Lygidakis et al., 2010, Lygidakis, 2010) For cavities involving large areas of dentine, glass ionomer cement has been proposed to be used as a sub-layer under the composite restoration (Mathu-Muju & Wright, 2006). A more definitive restorative approach, albeit still temporary solution, is the preformed metal crown (PMC) which placed on first permanent molars provide an excellent medium term restorative solution. (Kilpatrick, 2009) For that, it requires an excellent analgesia and patient cooperation which may not be forthcoming. In severe cases, transitional treatment for function and aesthetics can be provided until adolescence when permanent prosthetic approach with crowns in molars and veneers or crowns in incisors can be indicated. Cast restorations (full coverage crown, tooth-colored crown, porcelains or veneers) have been used. (Lygidakis et al., 2010, Lygidakis, 2010) However, they are not recommended for teeth in early post-eruptive stage because of the continuous eruption exposing the crown margins, the large pulp size, short crown height, and difficulties in obtaining a good impression for subgingival crown margins. (Koch & Garcia-Godoy, 2000) At last case, any extraction of first permanent molars should only be carried
