|Year : 2015 | Volume
| Issue : 2 | Page : 152-155
Molar incisor hypomineralization: Considerations about treatment in a controlled longitudinal case
Daniela Cristina de Oliveira1, Carla Oliveira Favretto2, Robson Frederico Cunha2
1 Department of Pediatric Dentistry, School of Dentistry, Funec, Santa Fé do Sul, São Paulo, Brazil
2 Department of Social and Pediatric Dentistry, School of Dentistry, Univ Estadual Paulista - UNESP, Araçatuba, São Paulo, Brazil
|Date of Web Publication||15-Apr-2015|
Prof. Robson Frederico Cunha
Department of Social and Pediatric Dentistry, Univ Estadual Paulista - UNESP, Rua José Bonifácio 1193, Araçatuba, SP - Cep 16015-050
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Molar incisor hypomineralization (MIH) is a defect in the tooth enamel of systemic origin and may affect one or all four first permanent molars frequently associated with the permanent incisors. This case reports a 7-year-old child with severe MIH in the permanent molars associated with tooth decay and intense pain. In the first stage of treatment, therapy was performed with fluoride varnish and restoration with glass ionomer cement (GIC). After 6 years of clinical and radiographic follow-up, the restorations presented wear and fractures on the margins, indicating their replacement with composite resin. Severe cases of MIH in the early permanent molars can be treated with varnish and GIC to restore the patient's comfort and strengthen the hypomineralized dental structures. The clinical and radiographic monitoring frequently indicated when the restoration with composite resin should be performed.
Keywords: Disturbances in dental development, prevention, restorative dentistry
|How to cite this article:|
de Oliveira DC, Favretto CO, Cunha RF. Molar incisor hypomineralization: Considerations about treatment in a controlled longitudinal case. J Indian Soc Pedod Prev Dent 2015;33:152-5
|How to cite this URL:|
de Oliveira DC, Favretto CO, Cunha RF. Molar incisor hypomineralization: Considerations about treatment in a controlled longitudinal case. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Jul 22];33:152-5. Available from: http://www.jisppd.com/text.asp?2015/33/2/152/155133
| Introduction|| |
The phenomenon of hypomineralization in permanent teeth has been described in the literature since the 80s,  but only in 2001, Weerheijm et al.,  suggested the term molar incisor hypomineralization (MIH) to nominate an alteration of systemic origin that affects the enamel in its formative stage, involving the permanent first molars being frequently associated to the incisors.
The etiological factors are not fully elucidated, and evident is the difficulty of identifying the different factors that sensitize the ameloblasts from the prenatal period through the first 3 years of a child's life, the period during which mineralization occurs in the first molars.  The most frequently reported factors in the literature are related to environmental changes, respiratory diseases, childhood diseases with high fever, and frequent use of antibiotics. ,
MIH is clinically identified as an abnormality in the translucency of tooth tissue characterized by areas of white to yellow-brown, smooth surface, and normal enamel thickness.  Because of the masticatory force, this defect in the enamel makes it susceptible to fracture, causing dentinal sensitivity and a higher incidence of dental caries.
The treatment of the tooth with MIH varies with the performance of a simple procedure, such as a controlled clinical eruption until the need for extensive and recurrent treatments in the most severe cases.  In this work, the goal was to present a case of MIH in a severe stage, with an emphasis on treatment.
| Clinical Case|| |
A 7-year-old patient, male and black, attended the Clinic of Pediatric Dentistry, Araӏatuba School of Dentistry (UNESP) reporting high pain sensitivity in the permanent molars. After the clinical and radiographic examination, the occurrence of hypomineralization of the upper and lower incisors and all the first permanent molars characterizing MIH was diagnosed.
In the clinical analysis, the first permanent molars were presented in the eruption phase, large accumulation of bacterial plaque and caries lesion in the enamel and dentin [Figure 1]. The child had difficulty in oral hygiene due to high sensitivity. Radiographic examination revealed deep dental caries near the pulp tissue in teeth 16, 36, and 46 [Figure 2].
|Figure 1: Clinical view of first permanent molars with hypomineralization|
Click here to view
|Figure 2: Radiographic aspects of first permanent molars with hypomineralization|
Click here to view
Fluoride varnish (Duraphat/Colgate) was applied on all the permanent molars for three sessions with 1 week interval, associated with professional prophylaxis sessions. After this period, the patient reported a significant decrease in sensitivity, and the teeth were restored with glass ionomer cement (GIC).
At 13 years of age, 6 years after the first consultation, there was no complaint of pain symptoms in the permanent molars with MIH and the oral hygiene was adequate, but the clinical and radiographic control revealed that all the restored molars showed loss of restorative material for reasons of wear, marginal fractures, and recurrent caries [Figure 3] and [Figure 4]. The restorations were replaced with composite resin [Figure 5] and [Figure 6].
|Figure 3: Clinical aspects of restorations of affected first permanent molars after 6 years|
Click here to view
|Figure 4: Radiographic aspects of the restorations with recurrent caries. Follow-up after 6 years|
Click here to view
|Figure 5: Clinical aspects of the replaced restorations of first permanent molars|
Click here to view
|Figure 6: Radiographic aspects of the permanent molars with molar incisor hypomineralization (MIH) after replaced restorations|
Click here to view
| Discussion|| |
Proposed treatments for teeth with MIH are varied with the stage of eruption of the affected tooth, as well as the severity of hypomineralization; key factors for choosing the right treatment.  As soon as the diagnosis of this dental modification is established, the treatment should be proposed, especially if the tooth is newly erupted. At this stage, preventive therapy may prevent the breakdown of the enamel. The diagnosis at later stages can lead to more radical treatments such as endodontics or extraction. The extraction of the first four molars, combined with orthodontic treatment, has been described in very severe cases. 
In the case reported, the first permanent molars were severely affected by MIH in the initial phase of the eruption, not allowing a definitive restorative treatment.
The poor oral hygiene due to increased sensitivity and fragility of the affected enamel were prevalent for the rapid and extensive tooth destruction. Therapy with varnish was established by the recognized action of the same reduction in sensitivity due to the high fluoride concentrations that this material presents. Reducing sensitivity is fundamental for the sequence of therapy, since this change occurs in young children that do not sanitize the teeth because of the pain. The number of sessions of varnish application is related to obtaining a decrease in sensitivity and enamel remineralization.  In our experience, three applications of fluoride varnish at weekly intervals are sufficient for the desired result.
When the presence of MIH requires a restoration, the GIC should be considered at least as a transitional stage to promote remineralization of the surrounding structures. It is important to stress that the restorative treatments in hypomineralized teeth can be painful due to the difficulties in getting a good anesthetic effect, probably because there is a subclinical inflammation in the pulp cells caused by the porosity of the enamel; thus making the management of the child difficult. 
In young children that are difficult to handle, the GIC can be maintained until the complete tooth eruption occurs and the most appropriate behavior is displayed, allowing the use of more resistant restorative materials.
In the case presented, the GIC was used because it is biocompatible, moisture tolerant, and effective in controlling the sensitivity, enabling a functional recovery of the patient. However, a lower adhesion of these restorative materials can occur because of the changes of the hypoplastic enamel of the affected teeth, early loss, and fractured edges of the restorations and recurrent caries are common.  Repeated treatments of teeth with GIC in small intervals are common and may occur 10 times more than in children who do not present this alteration.
In the clinical evaluation after 6 years, the restorations of the permanent molars were replaced due to wear and tear and recurrent caries. The clinical conditions, favored by the end of the eruption, allowed the teeth to be restored with composite resin. As a final restorative material, the composite resin showed better results than the GIC, and the average duration of these restorations were 5.2 years.
| Conclusion|| |
The clinical and radiographic follow-up is indicated for the appropriate resolution in cases of MIH with severe impairment of the permanent molars.
| References|| |
Koch G, Hallonsten AL, Ludvigsson N, Hanson BO, Holst A, Ullbro C. Epidemiologic study of idiopathic enamel hypomineralization in permanent teeth of Swedish children. CommunityDent Oral Epidemiol 1987;15:279-85.
Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor hypomineralization (MHI). Caries Res 2001;35:390-1.
Jeremias F, Souza JF, Costa Silva CM, Cordeiro Rde C, Zuanon AC, Santos-Pinto L. Dental caries experience and molar-incisor hypomineralization. Acta Odontol Scand 2013;71:870-6.
Laisi S, Ess A, Sahlberg C, Arvio P, Lukinmaa PL, Alaluusua S. Amoxicilin may cause molar incisor hypomineralization. J Dent Res 2009;88:132-6.
Alaluusua S. A etiology of molar-incisor hypomineralisation: A systematic review. Eur Arch Paediatr Dent 2010;11:53-8.
An epidemiological index of developmental defects of dental enamel (DDE Index). Commission on Oral Health, Research and Epidemiology. Int Dent J 1982;32:159-67.
Kotsanos N, kaklamanos EG, Arapostathis K. Treatment management of first permanente molars in children with molar-incisor hypomineralisation. Eur J Paediatr Dent 2005;6:179-84.
Takahashi K, Correia Ade S, Cunha RF. Molar incisor hypomineralization. J Clin Pediatr Dent 2009;33:193-7.
Weerheijm KL. Molar incisor hypomineralization (MIH): Clinical presentation, aetiology and management. Dent Update 2004;31:9-12.
Rodd HD, Boissonade FM, Day PF. Pulpal status of hypomineralized permanent molars. Pediatr Dent 2007;29:514-20.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]