|Year : 2022 | Volume
| Issue : 2 | Page : 173-179
Comprehensive management of molar–incisor–hypomineralization by preventive, palliative, and restorative treatment modalities in a pediatric patient: A case report and literature review
Mohammad Kamran Khan
Private Pediatric Dental Practice, Aligarh, Uttar Pradesh, India
|Date of Submission||10-Jan-2022|
|Date of Decision||11-Apr-2022|
|Date of Acceptance||23-Apr-2022|
|Date of Web Publication||22-Aug-2022|
Mohammad Kamran Khan
Hamdard Nagar A, Civil Line, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Molar–incisor–hypomineralization (MIH) is a developmental defect of enamel dental tissue caused by the disturbances in the maturation stage of amelogenesis. It usually affects the permanent first molars and incisors. In children, MIH condition clinically appears as the demarcated discolored hypomineralized defects of affected teeth, post-eruptive breakdown (PEB) of affected enamel, dentine exposure, hypersensitivity, increased susceptibility to dental caries and behavioral management challenges owing to dental anxiety/fear and dental esthetic concerns. This case report describes the comprehensive dental management of MIH in an 8-year-old male pediatric patient by conservative and noninvasive treatment approach with preventive, palliative, and restorative treatment modalities under nonpharmacological behavior management techniques.
Keywords: Casein phosphopeptide–amorphous calcium phosphate, fluoride varnish, GC tooth mousse, minimal invasive dentistry, molar–incisor–hypomineralization, nonpharmacological behavior management techniques, preventive dentistry, restorative dentistry, silver diamine fluoride, SMART, stainless steel crowns
|How to cite this article:|
Khan MK. Comprehensive management of molar–incisor–hypomineralization by preventive, palliative, and restorative treatment modalities in a pediatric patient: A case report and literature review. J Dent Res Rev 2022;9:173-9
|How to cite this URL:|
Khan MK. Comprehensive management of molar–incisor–hypomineralization by preventive, palliative, and restorative treatment modalities in a pediatric patient: A case report and literature review. J Dent Res Rev [serial online] 2022 [cited 2022 Sep 28];9:173-9. Available from: https://www.jdrr.org/text.asp?2022/9/2/173/354211
| Introduction|| |
Oral health is considered pivotal for the overall health and development of the growing children. Morbidity associated with orodental problems influences the children's quality of life along with functions and esthetics. One such dental disease is molar–incisor–hypomineralization (MIH), which is known to affect young permanent teeth in pediatric age group, which has been reported in the dental literature. MIH causes detrimental impact on the oral health-related quality of life along with substantially increased negative self-perception of oral manifestations. The term “MIH” was well described by Weerheijm et al. in 2001 and also defined it as “demarcated, qualitative developmental defects of systemic origin of the enamel of one or more permanent first molar with or without affecting permanent incisors.” The cusp tips of permanent canines and premolars have been reported to be affected with MIH condition.,, Furthermore, it has been reported that when hypomineralized second primary molar is present in an individual, there is 50% probability of occurrence of MIH in the first permanent molar.,
Globally, a wide variation in the prevalence of MIH has been reported, which ranges from 2.8% to 40.2%., The exact etiology of MIH is still unclear but is regarded to be multifactorial.,,, The several etiological factors for MIH have been reported, such as systemic conditions, environmental factors (prenatal, perinatal, and postnatal disturbances), and also the genetic factors.,,, Researches have reported that the causative factors for MIH influence the amelogenesis stage during the third trimester of gestation and the first 3 years of life of affected child.,
MIH condition may result in posteruptive breakdown (PEB) of effected enamel, and thereby, dentine exposure leads to hypersensitivity, increased susceptibility to dental caries, dental unesthetic appearance of deformed teeth, behavioral management challenges for a clinician due to dental anxiety/fear in children, along with psychosocial problems, and affected school's academic performances., Furthermore, the limited/minimal favorable cooperation of young pediatric patients toward dental treatment, difficulty in achieving adequate anesthesia of affected teeth, and repeated or recurrent episodes of the marginal breakdown of dental restorations have been some of the reasons for challenging the management of MIH among children.,
Early recognition, adequate understanding, and appropriate treatment of MIH-affected teeth in children are critical for the long-term favorable prognosis of the delivered dental treatment. Till date, a very limited number of clinical case reports have been published in literature regarding the comprehensive and appropriate dental management of MIH cases without requiring general anesthesia and injected local anesthesia in young children.
The current article describes the dental treatment of the MIH-affected teeth with conservative and minimally invasive dentistry approach by preventive and restorative treatment modalities. In this case report, an 8-year-old male child with MIH was managed successfully with palliative, preventive, and restorative dental treatment modalities by employing the nonpharmacological behavior management techniques (BMTs). The dentinal hypersensitivity was assessed using the Schiff cold air sensitivity scale., The manuscript of this case report has been written as per the CARE checklist case reporting guidelines.
| Case Report|| |
An 8-year-old male patient presented with a chief complaint of sensitivity to cold and hot food and brownish discoloration of the back teeth for 2 years. The patient's dental history revealed that permanent first molar and central incisors had erupted with irregular coronal structure with yellow-brownish discoloration and dentinal sensitivity to hot/cold food. The patient's parents also revealed that their child has difficulty in brushing teeth in affected molars due to sensitivity to strokes of toothbrush's bristles.
Medical history revealed that during 1–1.5 years of age, the patient had suffered illness with frequent episodes of fever and diarrhea and for which took medications (antibiotics). Later, the patient's parents noticed the symptoms of MIH in erupting permanent teeth such as deformed and discolored teeth with sensitivity to thermal stimuli. The patient's family and psychosocial history was not remarkable.
On general physical examination, patient was found apparently healthy. Extra-oral examination findings were normal. On intra-oral examination, localized brownish-discolorations were observed on the labial surface of partially-erupted permanent central incisors i.e 11, 21, 31 and 41 [Figure 1]a and [Figure 1]b. In addition, Localized brownish discoloration and irregular occlusal surface with wearing and post-eruptive breakdown (PEB) of the enamel of permanent first molars i.e 16, 26, 36 and 46 were found [Figure 1]c and [Figure 1]d. Dentinal hypersensitivity was assessed by using Schiff's scale and thus, scores of 03 for the MIH-affected molars while 01 for the incisors were recorded. Patient was in mixed-dentition stage [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Periodontal and oral mucosa examination findings were normal. Patient had poor oral hygiene index (OHI) with higher plaque index (PI) and debris index (DI) scores.
|Figure 1: Pre-operative images showing the Molar-Incisor-Hypomineralization (MIH); (a and b) MIH-affected young erupting maxillary and mandibular permanent incisors i.e. 11,21,31 and 41; (c and d) MIH-affected upper and lower permanent first molars i.e. 16,26,36 and 46|
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Dental radiographic examination demonstrated the reduced radio-opacity of the enamel of the MIH-affected permanent first molars and erupting central incisors [Figure 2] and [Figure 3]. Furthermore, no pulpal or periradicular involvement was present. The patient showed positive and cooperative behavior as per the Frankl's behavior rating scale.
|Figure 2: Pre-operative radiographs (a and b) of MIH-affected young permanent upper and lower central incisor teeth showing reduced radio-density (radio-opacity) of enamel tissue in coronal structure i.e. hypomineralized enamel|
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|Figure 3: Pre-operative radiographs (a-c) of MIH-affected permanent first molars showing reduced radio-opacity of enamel tissue over occlusal surface i.e. hypomineralized enamel|
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The differential diagnosis included MIH, enamel hypoplasia, Turner's hypoplasia, dental fluorosis, and amelogenesis imperfecta. Based on the patient's relevant medical and dental history along with the oral examination and radiographical findings, a clinical diagnosis of MIH was determined (as per the European Academy of Paediatric Dentistry [EAPD] Diagnostic criteria of MIH, 2021). The degree of involvement of the affected molars and central incisors teeth with MIH was described as severe and mild, respectively, in accordance with the EAPD criteria.
The patient's parents were informed about the MIH diagnosis and its treatment options and prognosis. The patient and parents were counseled and educated about the MIH condition and were motivated for proper treatment and longer follow-ups. Considering the patient's age, compliance, cooperation level, behavior management, and early mixed dentition stage with clinical presentation of MIH in newly erupted young permanent first molars with partially erupted incisors, the suitable treatment plan following the minimal invasive and preventive dentistry approach with the nonpharmacological BMT was determined. In addition, the appropriate treatment plan was made in view of GRADE rating system of MIH. Before the commencement of the dental treatment, informed consent was obtained from the parents.
First dental visit
Clinical examination, treatment planning, diet counseling, and oral hygiene advices were given to the patient and parents. Fluoridated toothpaste (Kidodent, Indoco Remedies Ltd., Mumbai, India) was prescribed for brushing. Behavior shaping methods (desensitization and modeling technique) were employed such that the patient was made familiar with the dental clinic environment and dental staff and also was shown other cooperative pediatric patients who were receiving dental treatment comfortably on dental chair.
Second dental visit
Oral prophylaxis with manual scaling was done. 38% silver diamine fluoride (SDF) (FAgamin, 38% SDF, Argentina) was applied over the affected molars 16, 26, 36, and 46 by brush-on technique under rubber dam isolation.,,,, Remineralizing agent casein phosphopeptide–amorphous calcium phosphate (CPP-ACP) (GC tooth mousse, GC, Tokyo, Japan) was advised for self-application at home on the partially erupting teeth 11, 21, 31, and 41. Tell–show–do (TSD) method was employed to keep the patient cooperative and relaxed during the dental procedures performed. Dental operatory room's environment was maintained relaxed with soothing and soft music.
Third and subsequent dental visits
Preformed stainless steel (SS) crowns (3M ESPE) were placed over the severely MIH-affected molars with glass ionomer cement (GIC) (GC Fuji-I) according to the Hall's technique [Figure 4] and [Figure 5]. Partially erupted incisors received professionally applied fluoride varnish (Fluor Protector N, Ivoclar Vivadent) under rubber dam isolation. TSD technique approach and audiovisual distraction (dental-chair-mounted AU audio–video screen device) were employed for having favorable and positive cooperation for performing the appropriate dental treatment procedures.
|Figure 4: Post-operative images (a and b) demonstrating the restorative rehabilitation of MIH-affected first molars by preformed stainless steel crown (3M ESPE) using GIC luting cement after application of SDF solution, Fluoride agent was applied on partially erupted incisors|
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|Figure 5: Post-operative radiographic images (a-d) of the molars after SS crown cementation with GIC luting cement|
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In follow-up visits, the patient reported significant relief from dentinal hypersensitivity after the treatment. The patient and parents were satisfied with the favorable outcomes of dental treatment provided for MIH-affected teeth. The patient has been kept on long-term follow-up of 3-month interval for clinical evaluation of the treated teeth till their complete eruption and for rendering the definitive and esthetic restoration on growth completion and gingival margin stability.
| Discussion|| |
Clinical manifestation of MIH is characterized by well-demarcated discoloration/opacities ranging from creamy/white to yellow/brown, seldom in association with posteruptive enamel breakdown of the affected teeth., Histologically, these MIH-associated defects are highly porous, mainly in the deeper aspect of the enamel tissue., The histopathological researches on MIH have reported that the hypomineralization in MIH-affected teeth begins at the amelodentinal junction and not from the surface of enamel during amelogenesis in contrast to other types of enamel structural defects. It has been reported in literature that the MIH affected enamel has 20% decreased concentration of minerals. Furthermore that the protein concentration in MIH-affected enamel is 3-15 folds (times) greater in comparison to sound enamel.
In the present case, severely MIH-affected molars showed brownish discoloration and wearing with PEB of enamel of occlusal surfaces of the molars.
It has been reported in literature that teeth with MIH demonstrate the porous subsurface enamel, and hence, the dentine in the affected teeth might be exposed by PEB. Consequently, the hypersensitivity to thermal stimulus (cold/hot food), air blow or during tooth brushing is experienced. In the current case also, patient reported dentinal hypersensitivity to cold food and during tooth brushing in the MIH-affected teeth.
Various clinical classifications for the MIH have been described in literature. One of the classification systems (Mathu-Muju and Wright) divides MIH into three categories, i.e., mild, moderate, and severe type based on various clinical factors, for example, the degree/severity of MIH defects, presence or absence of PEB of enamel and hypersensitivity, etc. In the current case, the molars were found affected with severe type of MIH condition whereas, partially erupting young incisors with moderate type of MIH condition. Similarly, severity level of incisors and molars were determined as mild and severe respectively as per the latest EAPD criteria of MIH.
In recent years, a MIH treatment need index has been introduced, which is based on the two factors, hypersensitivity and PEB. The clinical manifestation of MIH was first classified by the EAPD in 2003.
In literature, several etiological factors for MIH development have been described mainly linked to systemic, prenatal, perinatal, and postnatal complications.,, Most commonly reported causative factors for MIH are cyanosis, childhood morbidities/diseases (measles, mumps, and chickenpox), respiratory diseases, ear infections, frequent use of antibiotics, gastrointestinal diseases disease, low birth weight, malnutrition, prematurity (premature birth), calcium phosphate metabolic disorders, and prolonged breastfeeding.,, Furthermore, genetic etiology with MIH (genes involved TUFT1, TUFT11, ENAM, and AMELX) has also been reported in the literature.,, Although the cause of MIH is not clear, the clinical manifestation of localized (demarcated) and asymmetrical lesions indicates the systemic origin with the disturbance in the amelogenesis process that most possibly occurring in the early maturation stage or even earlier at the late secretory phase of enamel development.
Early and accurate diagnosis of MIH is of paramount importance to provide appropriate and prompt dental treatment and that can be accomplished by detecting the characteristic clinical pattern/features of MIH defects in the affected teeth along with significant medical history. In the present case also, the patient had typical clinical features of MIH along with medical history of several episodes of illness (fever/diarrhea) and medications (antibiotics) in the very early childhood and, thus, confirmed the clinical diagnosis of MIH.
The management of the MIH condition has been a challenge for the clinicians due to many reasons, such as difficulty in attaining adequate anesthesia in the MIH-affected teeth, dentinal hypersensitivity and rapid development/progression of carious lesions in hypomineralized tooth surface, frequent marginal breakdown of dental restorations, and the challenge of having favorable cooperative behavior from child patient for delivering dental treatment effectively. It has been reported in some studies that children with MIH display greater dental anxiety and behavior management problems as compared to unaffected children, and consequently, treatment is usually performed in sedation or general anesthesia., In the present case, the dental treatment was provided successfully and effectively by employing the nonpharmacological BMT such as modeling, TSD method (desensitization method), parental presence, and distraction method.
Various dental treatment modalities have been described in literature, such as prevention approach, palliative treatment, restorative treatment, and extraction. Dental treatment approaches for MIH-affected teeth depend on several clinical factors, such as stage of eruption of the MIH-affected tooth, degree of severity of hypomineralization defect, age, and cooperation level of the child.,,
In the present clinical case, restorative treatment of severely affected permanent molars was done with preformed SS crown following the conservative and minimally invasive dentistry approach of Hall's technique, and the preventive treatment was rendered for partially erupted incisors by professionally applied fluoride varnish agent and application of remineralizing agent CPP-ACP (GC tooth mouse) at home along with oral hygiene maintenance with ultrasoft toothbrush, diet chart, and regular follow-up evaluations.
The preventive treatment of hypomineralized teeth in MIH can be done using fluoride varnish, NaF-mouthwash, fluoride tooth-paste, CPP-ACP (casein phosphopepetide-amorphous calcium phosphate). The constituents of CPP ACP agent enhance the bioavailability of tooth minerals (calcium and phosphate and fluoride ions) in the saliva, and thus hypomineralized defects get remineralized. The CPP-ACP agent has been suggested to use in newly erupted MIH-affected tooth. Tooth Mousse contains 10% CPP-ACP. Pasini et al. observed a significant reduction in tooth sensitivity problem after 4-month use of tooth mousse in MIH-affected teeth., In the current case, CPP-ACP remineralizing agent was used on the partially erupting incisors to remineralize and to provide relief in the dentinal sensitivity problem as suggested in the existing literature. Other effective products, such as Enamelon gel (970 ppm fluoride and ACP) and Novamin-containing toothpaste, have been reported to enhance remineralization of the affected enamel and to reduce the sensitivity of hypomineralized teeth.,,
Preformed SS crowns as full-coverage restoration are used in children for MIH affected teeth because these crowns prevent further loss of tooth structure (i.e. maintain the structural integrity), control dentinal hypersensitivity, halt recurrent dental caries, provide proper interproximal contacts and establish harmonious occlusal relationships with antagonist teeth, impart longevity (durability) to restoration, are also comparatively less expensive and require relatively lesser technique sensitive placement procedure.,, SS-crown can preserve MIH-affected teeth in asymptomatic state until definitive final restorations are possible to place appropriately.,
Other treatment options for MIH-affected permanent molars have been described such as resin infiltration, restorations (GIC, resin-modified GIC [RMGIC], resin composite), full or partial coverage crowns (SS-crown, onlays), and extraction of severely MIH-affected molar with orthodontic alignment.
The various treatment options for MIH-affected young permanent incisors have been described in literature, such as microabrasion, bleaching, etch–bleach–seal technique, resin infiltration, composite restorations, and porcelain veneers.
SMART technique is a recent innovation in dentistry that combines the advantages of SDF and GIC. This SMART approach has been used for MIH-affected molars., SDF is known for treating dentinal hypersensitivity, remineralization, and arresting the incipient caries., In the present case also, GIC (GC Fuji I) was placed over SDF before the placement of SS crown on MIH-affected teeth. It helped in reducing dentinal sensitivity problem, inducing remineralization of hypomineralized enamel, and preventing any possible subclinical incipient caries of affected teeth.
GIC or RMGIC restorations can be regarded only as an intermediate (interim) restorative approach until definitive restoration is placed. However, a reduced adhesion of GIC is found due to enamel developmental defects, for example, MIH. Beside the marginal breakdown and early loss/dislodgement of the GIC filling, the recurrent caries are also commonly seen.
Although composite restoration for MIH-teeth is vastly described in literature, significantly reduced bond strength between affected enamel and composite interface has been found due to increased protein content in the affected enamel. Deproteinization of enamel was suggested as a technique to increase the bond strength with composite resin; however, it has weak evidence. In 2013, “The D3 Group” was launched to provide education resources, knowledge, and updates regarding the developmental dental defects, especially MIH.
This article also highlights the importance and acceptability of nonpharmacological methods of behavior management in delivering the optimum dental care to children as reported in previous studies. Pharmacological techniques including sedation and general anesthesia have been reported as lesser acceptable methods for behavior management methods in children. Newer methods such as audiovisual distraction can be used as nonpharmacological ways for having cooperative dental behavior without any anxiety/stress in child patients.,,
| Conclusion|| |
The present case report showed the successful and comprehensive dental management of MIH in a young child patient by preventive and restorative dentistry with conservative and noninvasive dentistry approach following the nonpharmacological BMT. MIH in young children should be detected early and suitable dental treatment should be provided as per the clinical condition of the affected teeth.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for the patient's images and other clinical information to be reported in the journal. The patient's parents understand that the patient's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]