Holistic treatment planning for children with molar incisor hypomineralisation Flashcards
Definition of MIH (2)
A clinical diagnosis to describe: “hypomineralisation of systemic origin of one to four first permanent molars, frequently associated with affected incisors” 'Idiopathic hypomineralisation' 'Cheese molars' 'Popcorn molars'
Hypomineralisation vs hyploplasia
Hypomineralisation: qualitative disturbance in enamel formation
Hypoplasia; quantitative disturbance in enamel formation
Clinical presentation of MIH (6)
Affected molars present with well-demarcated white/yellow or brown/yellow enamel opacities
1-4 FPMs may be affected, conflicting data as to whether maxillary or mandibular teeth more at risk
In severe cases, defective enamel is lost soon after eruption to expose underlying dentine
Affected incisors also present with well-demarcated white/yellow or brown/yellow enamel opacities
Post-eruptive enamel loss is not usually a feature
Increased risk of hypomineralised incisors where molars are more severely affected
World wide prevalence of MIH (2)
Meta-analysis published 2018 found a global prevalence of 13% (Schwendicke et al)
Pre-natal aetiology of MIH (9% of MIH cases) (6)
Maternal pyrexia Medication (antibiotics) Prolonged vomiting Maternal diabetes Vitamin D deficiency In vitro fertilisation
Peri-natal factors in aetiology of MIH (34% of MIH cases) (4)
Caesarean section
Prolonged/complicated delivery
Prematurity/low birth weight
Twins
Post-natal factors in aetiology of MIH (34% of MIH cases) (6)
Ear/nose/throat infections Respiratory problems Pyrexia Seizures Urinary infections Antibiotics
Aetiology of MIH (4)
Most ‘causes’ seem to be associated with hypocalcaemia and hypoxia
May also involve a genetic susceptibility?
No obvious causes in 10-24% of MIH patients (Jalevik & Noren, 2000)
Conflicting findings regarding role of environmental pollutants such as dioxins (Laisi et al., 2008)
MIH: underlying mechanisms (5)
Insult to enamel formation from around 37 weeks to 3 years
Transitional and maturation phase of enamel affected
reversible or irreversible damage to ameloblasts with qualitative disturbance to enamel formation
Protein retention and poor hydroxyapetite crystal formation
Low content of calcium and phosphate ions
MIH lab studies: enamel (3)
Porous
Weak
Poor etch pattern
MIH lab studies: dentine (2)
Sparse reparative dentine and irregular globular dentine
Influx of bacteria in dentine tubules
MIH lab studies: pulp (3)
Underlying chronic pulpal inflammation
Increased immune cells, vascularity and neural density
MIH clinical challenges: pt related factors (4)
Extreme tooth sensitivity
Aesthetic concerns
Anxious about dental treatment (Jalevik and Klingberg, 2002)
Need for long-term interventions (financial burden)
MIH clinical challenges: clinical related factors (4)
Difficulty in achieving adequate level of analgesia for restorative treatment
High failure rate for adhesive restorations and sealants (poor shear bond strength)
Tooth tissue loss
High caries experience
MIH: holistic care for children (4)
I. Prevention, remineralisation, alleviation of symptoms
II. Treatment planning for first permanent molars
III. Improvement of incisor aesthetics
IV. Incorporating a child-centred approach
DDE: prevention is the first principle of care (4)
Aim to remineralise, alleviate symptoms, improve oral hygiene and diet, reduction in caries risk
Tooth mousse (4)
Marketed for re-mineralisation of enamel since 1996
Delivery system for bio-available calcium and phosphate ions
Patient-application daily in trays or locally to affected tooth
May improve sensitivity symptoms, appearance and structure of DDE (Baroni and Marchionni, J Dent Res, 2010)
Fissure sealants, including clinical tips (4)
Fissure sealants are recommended - but have high failure rates in hypomineralised enamel (only 25% survival at 4-years, Lygidakis et al., 2009)
Pre-use of 5% sodium hypochlorite to remove protein content has been recommended (Mathu-Muju & Wright, 2006)
Clinical tips
Use of warm water and cotton pledgets to remove etch and avoid aspirators
Use of light cured glass ionomer sealants (FUJI TRIAGE)
First permanent molars with DDE: options (3)
Review/ prevention -topical fluoride applications -tooth mouse -fissure sealants Restore (short, mid or long term) -adhesive restorations -preformed metal crowns -laboratory formed crowns Extract -LA/ IS/ GA -need for compensating extractions -ortho considerations -ideal age 9.5/ 10
First permanent molar extraction - too early vs too late
Too early - spacing between lower premolars or distal impaction of lower second premolar against lower second molar
Too late - mesial tipping of lower second permanent molars
Definitely seek an ortho opinion for (4)
Class II cases
Class III cases
Hypodontia cases
Severe crowding cases
Restoration of PMCs: choice of materials (5)
Resin-modified glass ionomer Composite resin Amalgam :( Preformed metal crowns Cast onlays/crowns
Adhesive restorations (2)
GICs are useful as a short-term restoration prior to definitive restoration or extraction (e.g Fuji Triage, GC America Inc)
Composite resins – only indicated for mildly affected teeth with no cuspal involvement –margins of restoration should extend beyond visibly affected enamel
Preformed metal crowns: mid-term restorations (2-5 years) - advantages (5)
Prevent further tooth deterioration/caries
Controls tooth sensitivity
Establish correct interproximal contacts and occlusal relationships
Not as technique-sensitive or costly as cast restorations
Quick
-tip - use of elastic separators may obviate need for interproximal tooth preparation
Preformed metal crowns: mid-term restorations (2-5 years) - disadvantages (4)
Adverse reactions in patients with a nickel allergy
Production of anterior open bite if not fitted correctly
Gingival inflammation
Not a permanent restoration
Cast restorations (3)
Indirect gold onlays - are the restoration of choice for moderate or severe hypomineralisation where the maintenance of FPMs is indicated in the long term
Placement is usually considered in the late mixed or early permanent dentition
No significant differences in successful outcome of cast metal crowns vs PMCs in children with enamel defects (Zagdown et al., 2003)
Caution with conventional full crowns! Immature teeth have short crowns, large pulps and the procedure is highly destructive to tooth tissue
What are the options for clinical (aesthetic) management of anterior teeth (4)
Tooth whitening
Micro-abrasion
Composite resin (direct/ indirect)
Resin infiltration (ICON)
