Clinical management of MIH

In accordance with the European Academy of Pediatric Dentistry until now there are only a limited number of evidence based research papers on MIH affected teeth. (Lygidakis et al., 2010) Because of this, the guidelines diagram according to Scottish Intercollegiate Guidelines Network (SIGN) methodology (SIGN, 1999) is impossible to be made. However, treatment modalities in children with teeth affected by MIH were systematically reviewed by LYGIDAKIS, 2010. (Lygidakis, 2010) Thus, the clinical management of MIH was resumed by the present authors as seen in Figure 5. These clinical guidelines approach were organized considering the type of MIH affected teeth (permanent first molars or incisors) and the severity of defects. Then, it was also considered, the treatment management of the first permanent molars (FPM) without post eruptive breakdown (PEB) or with post-eruptive breakdown; as well as to the incisors with different levels of opacities (Figure 3). It worthwhile be emphasized the necessity of not only randomized controlled clinical trials but also the laboratory studies to support and better understand the specificities of MIH condition.

Therefore, a detailed study under magnification of the unerupted molar and incisor crowns on any available radiographs should be done. (William et al., 2006a) During teeth eruption, when MIH is confirmed, it should be made a diet counseling for dietary modifications to avoid dental caries, dental erosion and dental sensitivity; It should be recommended a toothpaste with a fluoride or, in cases of dental sensitivity, aiming to produce a non-sensitivity and hypermineralized surface layer which provides a super saturated environment of calcium and phosphate on enamel surface, a desensitizing toothpaste with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) should be indicated. (Baroni & Marchionni, 2011)

Fissure sealants should be applied early after molars eruption and before enamel breakdown. (Kilpatrick, 2009, Lygidakis et al., 2010, Lygidakis, 2010, William et al., 2006a, Crombie et al., 2008) Taking the morphological aspects of MIH affected teeth into account, for first permanent molars, highly viscosity glass ionomer cements can be considered as an alternative material of choice for fissure sealing due to its stable chemical adhesion on the substrate (Welbury et al., 2004) which ensures its clinical longevity even if disappeared macroscopically in the follow-ups. (Frencken &Wolke, 2010)

NA - Not applicable

Fig. 5. Flow chart illustrated by the authors of clinical management of MIH Children with a history of putative aetiological factors in the first 3 years should be screening at risk for MIH (Alaluusua, 2010, Crombie et al., 2009, Fagrell et al., 2011)

NA - Not applicable

Fig. 5. Flow chart illustrated by the authors of clinical management of MIH Children with a history of putative aetiological factors in the first 3 years should be screening at risk for MIH (Alaluusua, 2010, Crombie et al., 2009, Fagrell et al., 2011)

As suggested by LIGYDIKIS ET AL., 2010 (Lygidakis et al., 2010), when children express their concern on mild discolorations, at late mixed dentition, incisors with whitish-creamy opacities may occasionally respond to bleaching with carbamide peroxide. (Fayle, 2003) Another conservative approach is microabrasion with either 18% hydrochloric acid or 37% phosphoric acid and pumice for 60s. (Lygidakis et al., 2010, Wright, 2002, Gotler & Ratson, 2010, Willmott et al., 2008) More pronounced enamel defects might be dealt with by combining the two methods (Sundfeld et al., 2007a), bleaching and microabrasion. However, bleaching for young children may induce hypersensitivity, mucosal irritation and enamel surface alterations (Joiner, 2006), whilst microabrasion may result in loss of enamel. (Sundfeld et al., 2007b) An etch-bleach-seal technique by involving:

a. 60 seconds etch with 37% phosphoric acid;

b. bleach with 5% sodium hypochlodite for 5-10 min.

c. re-etch and application of fissure sealant over the surface to occlude the porosities appears as another management treatment possibility. (Wright, 2002)

On the other hand, the replacement of micro-abrasion by local enamel thickness reduction, using high-speed headpiece, should be also evaluated by the professional.

The others clinical problems for patients with MIH are attrition, exposed dentin, atypical cavities or complete coronal destruction. (Kilpatrick, 2009, Jalevik & Noren, 2000) Moreover, pain experience during dental treatment has led some MIH children to be significantly less compliant and more dentally anxious than their peers. (Jalevik & Klingberg, 2002) In this case, the adjunctive use of nitrous oxide-oxygen analgesia may alleviate anxiety and reduce dental pain. In last case, general anesthesia may be required for restorative treatment. (William et al., 2006a) The maintenance of existing tooth structure and pain relief can be achieved with temporary restorations, often in sub-optimal clinical conditions, through the use of glass ionomer cements. In mild and moderate MIH cases composite restorations using self-etching primer adhesive bonding systems is the treatment of choice (William et al., 2006b) and may last for many years until indirect restorations would be placed. (Lygidakis et al., 2010, Lygidakis, 2010) For cavities involving large areas of dentine, glass ionomer cement has been proposed to be used as a sub-layer under the composite restoration (Mathu-Muju & Wright, 2006). A more definitive restorative approach, albeit still temporary solution, is the preformed metal crown (PMC) which placed on first permanent molars provide an excellent medium term restorative solution. (Kilpatrick, 2009) For that, it requires an excellent analgesia and patient cooperation which may not be forthcoming. In severe cases, transitional treatment for function and aesthetics can be provided until adolescence when permanent prosthetic approach with crowns in molars and veneers or crowns in incisors can be indicated. Cast restorations (full coverage crown, tooth-colored crown, porcelains or veneers) have been used. (Lygidakis et al., 2010, Lygidakis, 2010) However, they are not recommended for teeth in early post-eruptive stage because of the continuous eruption exposing the crown margins, the large pulp size, short crown height, and difficulties in obtaining a good impression for subgingival crown margins. (Koch & Garcia-Godoy, 2000) At last case, any extraction of first permanent molars should only be carried out with consideration of the possible orthodontic implications.

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