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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 651-655  

Molar incisor hypomineralization: clinical characteristics with special emphasis on etiological criteria


1 Department of Paedodontics and Preventive Dentistry, Post Graduate Institute of Dental Sciences, Rothak, Haryana, India
2 Department of Pedodontics and Preventive Dentistry, Hitech Dental College and Hospital, Bhubaneswar, Odisha, India
3 Department of Orthodontics and Dentofacial Orthopaedics, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India

Date of Submission03-Dec-2020
Date of Decision28-Dec-2020
Date of Acceptance29-Dec-2020
Date of Web Publication05-Jun-2021

Correspondence Address:
Bhagabati Prasad Dash
Department of Orthodontics and Dentofacial Orthopedics, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Patia, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_801_20

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   Abstract 


Molar incisor hypomineralization (MIH) is an entity to describe the enamel defects of the first permanent molars with the involvement of one or more incisors due to an underlying systemic cause. It is a frequently encountered challenge by dentists in a dental clinic and dental complications affecting patient's quality of life. Early diagnosis is the key to protect and prevent the deterioration of the condition. This article aims to highlight different aspects of etiology to treatment options in young patients related to MIH.

Keywords: Etiology, European Academy of Paediatric Dentistry, first permanent molars, molar incisor hypomineralization, second primary molars


How to cite this article:
Goel N, Jha S, Bhol S, Dash BP, Sarangal H, Namdev R. Molar incisor hypomineralization: clinical characteristics with special emphasis on etiological criteria. J Pharm Bioall Sci 2021;13, Suppl S1:651-5

How to cite this URL:
Goel N, Jha S, Bhol S, Dash BP, Sarangal H, Namdev R. Molar incisor hypomineralization: clinical characteristics with special emphasis on etiological criteria. J Pharm Bioall Sci [serial online] 2021 [cited 2021 Jul 29];13, Suppl S1:651-5. Available from: https://www.jpbsonline.org/text.asp?2021/13/5/651/317695




   Introduction Top


In human body dental enamel is found to be the hardest tissue comprising 98% mineral and <2% organic matrix and water. Dental enamel is sensitive to environmental disturbances during development; because of its nonremodeling nature, it results in permanent variations of tooth enamel. Weerheijm in 2001 described the term molar incisor hypomineralization (MIH). It is defined as hypomineralization of systemic origin, presented as demarcated, qualitative defects of the enamel involving at least one first permanent molar (FPM) and/or incisors.[1] This condition has been previously described by numerous terms such as nonfluoride enamel opacities, internal enamel hypoplasia, nonendemic mottling of enamel, nonendemic-stained enamel, idiopathic hypomineralization of the enamel of the first molars, idiopathic enamel opacities, and cheese molars. The worldwide prevalence of MIH shows a wide range between 2.8% and 40.2%.[2] Hypomineralised second primary molars (HSPM) is the term currently used for the condition previously known as deciduous molar hypomineralization.[3] Incisor hypomineralization that is demarcated defects on incisor with molar sparing.The prevelance of incisor hypomineralisation is 11%.[4] Initially, it was described that it affects only FPMs and incisors; however, recently, it has been noted that it could affect any primary or permanent tooth. Therefore, the aim of this article is to highlight the most important aspect of MIH from its etiology to treatment options.


   Etiology Top


Critical period, between 28th week of in utero life to the first 10 days of life after birth, is very important because amelogenesis of the FPMs, permanent incisors, and second primary molars begins The exact etiology of MIH is unknown. When any risk factor ensues during this intersecting period, hypomineralization will occur in both the deciduous and permanent dentition.[5] If an unbalance occurs during the secretion phase (ENAMEL MATRIX FORMATION), the enamel defect is called hypoplasia.[6] If it occurs during the maturation phase (ENAMEL MINERALIZATION), it is called hypomineralization aetiological criteria shown in [Table 1] and [Table 2].
Table 1: Etiological crtiteria

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Table 2: Etiological crtiteria

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   Relation of Molar Incisor Hypomineralization with Other Conditions Top


Molar incisor hypomineralization and asthma

Asthma medications, mostly applied by metered-dose inhalers (MDIs), are acidic in nature and reduce salivary function; they create a favorable environment for cariogenic bacteria (Mazzoleni et al. 2008). Chuang et al., 2018 confirmed the association between asthma and dental caries and assessed that asthma increased the risk of caries by the factor two. Asthma was regarded as a risk factor for the development of MIH in the first few years of life only (Allazzam et al., 2014). According to Claudia Flexeder et al., 2019,[7] a significant positive association was found for asthmatic adolescents who did not take MDI medication with higher MIH/t values compared to nonasthmatics. According to Wogelius et al., 2020,[8] no association was found between the use of inhaled asthma medication and the prevalence of MIH.


   Molar Incisor Hypomineralization and Antibiotics Top


Positive association was observed between MIH and antibiotics (penicillin use) and ENT disorders. Mulic et al. studied children with MIH and found that the use of penicillin due to adenoid infections in the first 5 years was associated with a higher prevalence of enamel lesions. Furthermore, Laisi et al.[9] stated that an altered pattern of amelogenesis may interfere with the process of enamel mineralization and that the early use of amoxicillin is one of the main causative factors of MIH.


   Molar Incisor Hypomineralization and Cesarean Section Delivery Top


Newborns delivered vaginally had increased risk of respiratory illnesses such as hypoxia than those delivered by elective cesarean section. Further, the commonly used spinal anesthesia for cesarean section has a frequent complication of maternal hypotension that can be associated with severe nausea or vomiting which occasionally produces infant hypoxia. Hypoxia at birth and/or being born by cesarean delivery had a statistically significant association with the presence of MIH.


   Molar Incisor Hypomineralization and Dental Caries Top


Developmental defects of the enamel are due to faulty enamel formation, which makes the enamel more susceptible to attack by acids and therefore to dental caries. The defective enamel provides an ideal environment for plaque adhesion and colonization by cariogenic bacteria, enabling lesions to progress rapidly.[10] Elfrink et al. observed that the mean density of hydroxyapatite in opacities in the yellow to brown color range is 20%–22% lower than in sound enamel. Pitiphat et al., 2020 found that caries is 10 times more frequent in teeth with posteruptive breakdown than teeth having only opacities.


   Molar Incisor Hypomineralization and Vitamin D Top


As ameloblasts and odontoblasts are target cells for Vitamin D or its metabolites, they play key roles in enamel and dentin formation (Berdal et al., 1995; Berdal et al., 2000). Therefore, it is plausible that Vitamin D deficiency is linked to developmental disorders in the enamel (e.g., Vitamin D-dependent rickets). The total Vitamin D serum concentration was determined by Roche's Vitamin D Laboratory Test using the fully automated modular system. Lower Vitamin D serum concentration was associated with a higher probability for MIH and caries and vice versa; it can be argued that elevated serum 25(OH) D concentrations levels were related to better oral health outcomes.[11],[12]

Classification

  1. Mathu-Muju and Wright, 2006 had classified MIH into three severity levels:


    1. Mild MIH: no caries associated with the affected enamel, no hypersensitivity, the demarcated opacities located at nonstress bearing areas, and incisor involvement is usually mild if present
    2. Moderate MIH: The posteruptive enamel breakdown limited to one or two surfaces without cuspal involvement, atypical restorations can be needed, and normal dental sensitivity. The demarcated opacities present on molars and incisors
    3. Severe MIH: Posteruptive enamel breakdown, crown destruction, caries associated with affected enamel, history of dental sensitivity, and esthetic concerns.


  2. Weerheijm et al., 2001 had classified MIH as:


    • Mild – Color change of the smooth surface without enamel defects
    • Moderate – Loss of enamel without dentine involvement
    • Severe – Dentine involvement, atypical restorations, and teeth extracted because of severe lesions.
    • Diagnosis – Should be done as soon as it is clinically apparent either in primary or permanent dentition. the examination should be performed on clean wet teeth.[13]


Clinical features

  • The hypomineralized enamel will be softly porous and has a discolored chalky appearance
  • Demarcated white/yellow/brown opacities usually limited to incisal or cuspal one third, rarely involving cervical one third. Defects that are <1 mm are not reported under MIH
  • In molars, posteruptive enamel breakdown is common due to occlusal loading
  • Rapid caries progression- because of the porous and friable enamel structure[14]
  • Adhesion of restoration material is poor
  • Anesthetic difficulties: A combination of hypersensitivity and rapidly progressing caries causes chronic inflammation of the pulp, preventing effective local anesthesia[14]
  • Dental fear and anxiety can lead to behavioral management problems
  • Esthetic problems in anterior teeth.



   Characteristic Features Top


  • Clear demarcation between the affected and sound enamel
  • Asymmetry of defects present in molars and incisors.[15]



   Sign Top


  • The most important sign is hypersensitivity during brushing and is due to porous enamel which leads to subclinical pulpal inflammation.[6]



   Treatment Options for Molars Top


Resin infiltration

This technique uses a very low viscosity resin which is capable of penetrating demineralized enamel. It is also known as erosion–infiltration. The Icon system consists of Icon-Etch (15% hydrochloric acid), Icon-Dry (99% ethanol), and Icon-Infiltrant (Methacrylate-based resin). The main disadvantages of RC are the following: shrinkage due to the extent of the restoration, reduced strength due to impaired bond strength, microleakage, occlusal wear, and restoration durability.[14]

Restoration

Until definitive restoration is placed, glass ionomer cement (GIC) or resin-modified GIC restorations can be considered only as an intermediate approach [Figure 1].
Figure 1: Treatment management of MIH

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Full or partial coverage

Preformed metal crowns, nonprecious metal, gold or tooth-colored indirect onlays, preformed malleable composite temporary crowns, preformed stainless steel crowns are the treatment of choice in case of posteruptive breakdown in MIH teeth to provide full coverage to defective molars.

Extraction of severely affected molars

Extraction might be considered at the dental age of 8–10 years for severely affected FPMs with poor prognosis. The chance of ideal positioning is 94% for upper Second permanent molars (SPMs) and 66% for lower SPMs after the extraction of FPMs.


   Treatment Options for Anteriors Top


Microabrasion

This involves the removal of a small amount of surface enamel (no more than 100 μm [0.1 mm]) through abrasion and erosion using 18% hydrochloric acid or 37.5% phosphoric acid with pumice.

Tooth bleaching

Bleaching agent alone is not recommended on a hypomineralized tooth because of mineral changes caused by peroxides causing an increase in carbon content and a decrease in calcium and phosphate content. During a bleaching treatment, peroxides initiate oxide–reduction reaction that may lead to dissolution of both organic and inorganic matrices. Stefano mastroberardino et al 2012 combined the use of CPP- ACP Tooth Mousse and bleaching gel.[16] The CPP-ACP tooth mousse will remineralize the MIH opacities during the bleaching process without interfering with bleaching effect and will protect the tooth structure. The combined use of hydrogen peroxide and CPP-ACP could be done with a ratio range from 1:6 to 3:4. The possible side effects of bleaching are sensitivity, mucosal irritation, and enamel surface alterations Home bleaching through daily placement of 10% carbamide peroxide gel into custom fitted trays is the gentlest bleaching option prescribed by the dentist

Composite restorations

Composite veneers

The composite resins are susceptible to discoloration, wear, and marginal fractures; therefore, long-term maintenance is required.

Porcelain veneer

These are indicated for patients aged 18 years and above when the gingival margin has matured. They are seldom used in young children due to (1) short crowns; (2) large pulps; (3) prolonged treatment; (4) high expense; and (5) children's di-culty in cooperating.

Newer treatment

Using digital workflow and computer-aided design/computer-aided manufacturing

Intraoral scanners are important devices that have become an integral component of the dental tool arsenal. This is often particularly advantageous for children and for persons with a robust gag refflex.[17]

Application of photodynamic therapy

In a permanent teeth with severe molar incisor hypomineralization along with painful sensitivity and presence of deeper portion of caries lesion, Papacarie Mblue modified with the addition of methylene blue as a photosensitizer in conjunction with the low - power laser for laser therapy can be used for desensitization and decontamination of the cavities. The idea of chemical-mechanical removal of caries consists of the application of a chemical on the carious tissue that is removed with a noncutting curette. Papacárie is a gel composed of papain and chloramine. Chloramine has properties related to disinfection.[18]


   Conclusion Top


Children with hypomineralized second molar, or with poor general health, should be considered at risk of MIH. It is a frequently encountered problem in dental clinic, so dentists should look for proper etiology and make proper diagnosis with adequate treatment planning. Hence, dentist should consider their long-term prognosis as well as management of presenting feature such as pain while management of these teeth. Hence, further investigation is required for the best technique/protocol in MIH cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Ghanim A, Elfrink M, Weerheijm K, Marin R, Manton D. A practical method for use in epidemiological studies on enamel hypomineralisation. Eur Arch Paediatr Dent 2015;16:235-46.  Back to cited text no. 1
    
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Padavala S, Sukumaran G. Molar incisor hypomineralization and its prevalence. Contemp Clin Dent 2018;9:246-50.  Back to cited text no. 2
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Negre-Barber A, Montiel-Company JM, Boronat-Catalá M, Catalá-Pizarro M, Almerich-Silla JM. Hypomineralized second primary molars as predictor of molar incisor hypomineralization.Sci Rep 2016;6:31929.  Back to cited text no. 3
    
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Balmer R, Toumba KJ, Munyombwe T, Godson J, Duggal MS. The prevalence of incisor hypomineralisation and its relationship with the prevalence of molar incisor hypomineralisation. Eur Arch Paediatr Dent 2015;16:265-9.  Back to cited text no. 4
    
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Cristiane MC, Janice SD, Glaucia MB, Fábio LM. Influence of deciduous molar hypomineralization on the development of molar-incisor hypomineralizarion. Braz J Oral Sci 12:335-8.  Back to cited text no. 5
    
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Narmatha M, Prathima GS, Selvabalaji A. Molar incisor hypomineralisation – An overview. ActaSci Dent Sci2019;3:42-50.  Back to cited text no. 6
    
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Flexeder C, Kabary Hassan L, Standl M, Schulz H, Kühnisch J. Is there an association between asthma and dental caries and molar incisor hypomineralisation? Caries Res 2020;54:87-95.  Back to cited text no. 7
    
8.
Wogelius P, Viuff JH, Haubek D. Use of asthma drugs and prevalence of molar incisor hypomineralization. Int J Paediatr Dent 2020;30:734-40.  Back to cited text no. 8
    
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Laisi S, Ess A, Sahlberg C, Arvio P, Lukinmaa PL, Alaluusua S. Amoxicillin may cause molar incisor hypomineralization. J Dent Res 2009;88:132-6.  Back to cited text no. 9
    
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Negre-Barber A, Montiel-Company JM, Catalá-Pizarro M, Almerich-Silla JM. Degree of severity of molar incisor hypomineralization and its relation to dental caries.Sci Rep 2018;8:1248:1-7.  Back to cited text no. 10
    
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van der Tas JT, Elfrink EC, Heijboer AC, Rivadeneira F, Jaddoe VW, Tiemeier H. Foetal, neonatal and child vitamin D status and enamel hypomineralization. Community Dent Oral Epidemiol 2018;46:343-51.  Back to cited text no. 11
    
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Kühnisch J, Thiering E, Kratzsch J, Heinrich-Weltzien R, Hickel R, Heinrich J. Elevated serum 25(OH)-Vitamin D levels are negatively correlated with molar-incisor hypomineralization. J Dent Res 2015;94:381-7.  Back to cited text no. 12
    
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Almuallem Z, Busuttil-Naudi A. Molar incisor hypomineralisation an overview. Br Dent J.2018:225:601-9.  Back to cited text no. 13
    
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Jairam LS, Dhananjaya G. Molar incisor hypominearlisation: An overview. J Dent Oro Facial Res 2019;15:89-94.  Back to cited text no. 14
    
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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;5:190-6.  Back to cited text no. 15
    
16.
Stefano M, Guglielmo C, Laura S, Alessandro V, Maria GC. An innovative approach to treat incisors hypomineralization (MIH): A combined use of casein phosphopeptide-amorphous calcium phosphate and hydrogen peroxide – A case report. Case Rep Dent 2012:379593:1-5.  Back to cited text no. 16
    
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Davidovich E, Dagon S, Tamari I, Etinger M, Mijiritsky E. An innovative treatment approach using digital workflow and CAD-CAM part 2: The restoration of molar incisor hypomineralization in children. Int J Environ Res Public Health 2020;17:1499.  Back to cited text no. 17
    
18.
Vieira LD, Paschoal MA, Motta PD, Ferri EP, Ribeiro CD, Santos-Pinto LA, et al. Antimicrobial photodynamic therapy on teeth with molar incisor hypomineralization–controlled clinical trial. Medicine 2019;98:e17355  Back to cited text no. 18
    


    Figures

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    Tables

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