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Molar Incisor Hypomineralisation
BOBBY SHARMA
BSC ORAL HEALTH SCIENCES
15TH OCTOBER 2021
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Aims and
objectives
Aim:
u Define MIH in terms of aetiology, clinical presentation and
management
GDC Learning Outcome(s): 1.1.5
u Describe relevant and appropriate dental, oral
craniofacial and general anatomy and explain their
application to patient management
Learning Outcomes:
u Discuss the aetiology of MIH
u Understand the clinical and radiographic presentation of
MIH
u Understand the influence these defects may have on
clinical treatment options
u Demonstrate knowledge of management approaches
for the child with MIH
GDC development outcomes:
u A, B & D
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WHAT IS MOLAR- INCISOR
HYPOMINERALISATION?
– Weerheijm et al.(2001)
– “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 et al.(2003)
– ”further described as a “developmental, qualitative enamel
defect caused by reduced mineralisation and inorganic
enamel components which leads to enamel discolouration
and fractures of the affected teeth”
– Almuallem & Busuttil-Naudi (2018)
– “more recently it has been noted that these defects could
affect any primary or permanent tooth”
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So why is it
an issue?
u Rapid breakdown of FPMs
u Sensitivity
u Caries
u Difficulty to restore
u Consider early loss of these teeth?
u Anxiety
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Prevalence
u Wide variation
u 2.8 to 40.2%
Why is there so much variation?
u No standardised tool
u Underestimated prevalence
Current thinking is that MIH affects as many as 1 in
every 6 children Ghanim et al
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Aetiology
Uncertain Theory
?Problems with
enamel formation?
Multifactorial
aetiology?
•Chronic illness?
•Environmental
pollutants?
What contributes
to the number of
teeth affected?
Time of systemic
disturbance
Especially
prenatally,
perinatally and
postnatally
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Aetiology
u Causes of MIH
u Respiratory tract infections
u Complications during birth
u Hypoxia
u Low birth weight
u Metabolism disorders relating to Calcium and Phosphate
u Childhood illnesses
u Antibiotic use
u Prolonged breast feeding
u Genetic component to MIH?
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Diagnosis
u When is the ideal time to diagnose MIH?
u As soon as teeth erupt
Ø Clean & wet teeth
v White, creamy opacities
v Yellow- brown opacities
v Post- eruptive enamel breakdown
v Atypical caries on at least one FPM with or without incisor involvement
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Diagnosis
u How large do the lesions have to be to recorded as MIH?
u Lesions must be larger than 1mm
Determine
– childhood illness in the first 3 years of life
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Severity of molar incisor hypomineralisation
Mathu-Muju and Wright
Mild MIH
– demarcated opacities
Moderate MIH
– post- eruptive enamel breakdown limited to 1 or two surfaces
– normal dentine sensitivity
Severe MIH
– post- eruptive enamel breakdown with widespread destruction of crown
– caries in enamel
– heightened sensitivity
– aesthetic issues
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Differential Diagnosis:
Fluorosis
A) Fluorosis
– Fluoride ingestion
u White opacities without a clear boundary
u Varies in severity
u Mild
to
u Severe
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How do you differentiate
between fluorosis and MIH?
Clinical presentation
u Fluorosis
u Symmetrical and bilateral presentation
u MIH
u Asymmetrical presentation
Caries resistance
u Fluorosis
u Caries resistant
u MIH
u Caries prone
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Differential Diagnosis:
Enamel Hypoplasia
B) Enamel Hypoplasia
u ? Quantitative defect
u Reduced enamel
thickness
u Hypoplastic enamel
lesions are smooth
and regular
WHEREAS
u MIH margins with post
eruptive enamel
breakdown are sharp
and irregular due to
post- eruptive
shearing of enamel
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Differential Diagnosis:
Amelogenesis Imperfecta
C) Amelogenesis Imperfecta
– Enamel can be…
– Thinner (hypoplastic)
– Immature (hypomature)
– Undermineralised (hypomineralisation)
– AI is associated with a
u Affects both the primary and secondary dentition
u +ve family history
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Differential Diagnosis:
White spot lesion
D) White spot lesion
u Earliest sign of caries
u CHALKY when dried
u Occur in areas of plaque
stagnation e.g. cervical
margin of tooth
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Differential Diagnosis:
Traumatic Hypomineralisation
E) Trauma to primary tooth
u Why?
u Periapical infection of the
primary tooth can disturb
mineralization of the
underlying tooth germ
Ø variety of clinical presentations
Ø shape, outline and colour
> Is it often limited to one tooth and
is asymmetrical
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How is tooth anatomy affected by MIH?
u Hypomineralisation in MIH -> ADJ
u Whereas in other enamel defects the defects occur at the enamel surface
u Mild MIH
u Hypomineralisation remains limited to the inner enamel (with the outer enamel layer
remaining intact)
u Severe MIH
u the whole layer is hypomineralised
u With the whole enamel layer having 20% less mineral content in an investigation by
Fearne et al.
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What is the clinical
significance of patients
with MIH?
u Post eruptive enamel breakdown leading to
dentine exposure
u Tooth sensitivity
u Problems with Anaesthesia
u Anxiety
u Through pain experienced with multiple
treatment appointments
u Aesthetic problems
u Tooth loss
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Is there a method of measuring MIH?
Treatment need index for MIH
u Index to categorize the degree by which teeth are affected by MIH
u Assesses the extent of destruction to tooth structure and possibility of
hypersensitivity
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Management of MIH
1) Enhanced Prevention as per SDCEP guidelines
u 12+ can be prescribed 2800ppm Fluoride toothpaste
u 16+ can be prescribed 5000ppm Fluoride toothpaste
u Casein phosphospeptide amorphous calcium phosphate (CPP- ACP)
u remineralises and desensitises MIH teeth
u E.g. Tooth Mousse or MI Paste Plus
u Contra- indications?
u Milk protein allergy!
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Management of MIH
2) Fissure sealants to MIH molars
Enamel intact? – > adhesive resin
F/S
Enamel showing signs of
breakdown/ tooth
hypersensitive? – > GI (temporary
measure)
Check F/S, GI at each visit to
ensure they are sound or top
them up if necessary
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LA
u Difficulty to anaesthetise the
MIH molars is well reported
Clinical impact?
u Difficult to anaesthetise a
hypersensitive tooth even with
increasing the local
anaesthetic dose
u If tooth is not anaesthetised
then ANXIETY can result
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How to overcome difficulties in achieving
anaesthesia in patients with MIH?
u Inhalation Sedation
u Anaesthetic adjuncts e.g. intraligamental, intraosseous and palatal anaesthesia
u Moreover, buccal infiltration with articaine as a LA adjunct to inferior alveolar nerve block was
found to be effective
u Using rubber dam can prevent sensitivity
u Saliva ejector
u Desensitising toothpaste before the restorative appointment
u Recommended the application of fluoride varnish at a pre-restorative appointment.
u Glass ionomer cements have sedative properties in cases of hypersensitivity and they help by
soothing the highly sensitive tooth.52 After one to two weeks, the restorative treatment could be
completed. This two-step technique can offer shorter and more comfortable appoint- ments for
young patients.45
u general anaesthesia could be the last option,
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Treatment options for molars
u MIH molars require 10x more treatment than molars without MIH
1) Restorations
u Glass ionomer cement (GIC) or resin modified GIC restorations can be
considered
u Resin composite is the material of choice and recommended for one to three
surface surfaces
u Amalgam should be avoided
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Treatment options for
molars
2) Full or partial coverage crowns
u Preformed metal crowns (PMCs) can be very
successful
u prevent further post-eruptive enamel breakdown
u manage sensitivity
u are not expensive,
u can establish correct interproximal and occlusal
contacts, require no/little tooth preparation
u can be done in single visit.
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Treatment options for molars
3) Accept poor prognosis and extract severely affected
molars
u For severely affected FPMs with poor prognosis,
extraction might be considered at the dental age of
eight to ten years
u This will give the second permanent molars (SPM) an
opportunity to drift into the FPM position.
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Treatment options for incisors
u Aesthetics are compromised
u Options?
1) Microabrasion
u removal of a small amount of
surface enamel (no more than
100 µm (0.1 mm)) through
abrasion and erosion using
u 18% hydrochloric or 37.5%
phosphoric acid with
pumice.59
u The process abrades the
surface enamel while also
polishing it which leads to
changes in optical properties
and this may improve the
aesthetics.60
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Treatment options for incisors
2) Tooth bleaching
u The aim is to camouflage white opacities
by increasing the overall brightness of the
teeth
u This option is indicated for adolescents
u Possible side-effects of bleaching are:
sensitivity, mucosal irritation, and enamel
surface alterations
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Treatment options
for incisors
3) Composite restorations
or veneers
4) Porcelain veneers
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References
u GDC standards
u Almuallem, Z., Busuttil-Naudi, A. Molar incisor hypomineralisation (MIH) – an
overview. Br Dent J 225, 601–609 (2018).
u Mathu- Muju K, Wright J T. Diagnosis and treatment of molar incisor
hypomineralisation. Compend Contin Educ Dent 2006; 27: 604-610
u Weerheijm K L, Jalevik B, Alaluusua S. Molar incisor hypomineralisation.
Caries Res 2001; 35: 390-391
u Steffen R, Van Waes H. Therapy of Molar Incisor Hypomineralisation under
difficult circumstances. A concept for therapy. Quintessenz 2011; 62: 1613-
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Please access this link to provide feedback
from this lecture
u https://s.surveyplanet.com/lml557w5
u Many thanks for your time
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