The growing problem of molar incisor hypomineralisation in children
Amanda Gallie talks about the management and treatment of an increasingly common paediatric condition.
Minimal intervention dentistry (MID) is a holistic approach to oral healthcare.
What interests me most about MID is the ethos of respectfully working with the tooth structure; retaining viable and biologically repairable tissue, with the overarching aim of maintaining tooth vitality for as long as possible.
MID is a useful tool in the clinical management of developmental conditions, such as molar incisor hypomineralisation (MIH) in children.
So what is MIH? You might recognise the appearance but not the name (Figure 1).
People used to refer to MIH as ‘chalky’ or ‘hypoplastic’ teeth. It is a condition affecting the enamel of the first permanent molars. Sometimes it affects the central incisors that erupt in children around the age of six. The combined average prevalence of MIH is approximately one in six children globally and one in eight in the UK.
MIH is a developmental condition that may affect one to four of the molars. It causes the tooth enamel to exhibit opacities. These opacities are creamy or yellow/brown in colour with a clear border against the healthy enamel.
Affected teeth are very fragile and are sensitive to extremes of temperature and toothbrushing. This means that decay is up to 10 times as likely and can develop rapidly. Aesthetic issues with the front teeth can also affect self-esteem.
Causes of MIH
No one fully understands the cause of MIH. Many factors contribute to the condition. These include: prenatal, perinatal and postnatal issues, environmental conditions and a variety of diseases occurring in a child’s early life that cause a disturbance in tooth development.
Untreated, MIH can result in:
- Pain and hypersensitivity that makes a child reluctant to brush their teeth, resulting in high plaque biofilm levels and higher risk of decay
- Tooth decay, which is far more prevalent in this group
- Restorative issues in which the condition makes it more difficult to numb the teeth with a local anaesthetic, therefore making dental treatment more challenging
- Aesthetic issues with the anterior teeth, resulting in low self-esteem or a reluctance to smile
- Children will need up to 10 times more intervention than a child without MIH.
Recognising the signs
MIH is recognisable. It is a relatively new disease with classification only given 15 years ago. Therefore, you can easily confuse it with other enamel developmental conditions:
- Dentinogenesis imperfecta (DI) – a genetic disorder of tooth development
- Amelogenesis imperfecta (AI) – a disorder that affects the structure and appearance of enamel
- Enamel hypoplasia (EH) – a condition of underdeveloped or incomplete tooth enamel.
Treatment options for MIH
As a dental therapist, I regularly deal with early presentations of MIH. Therefore, I need to provide an early recognition and codiagnosis with the dentists I work with.
Treatment planning with radiographs is very important. The decisions made at the start of the life of the tooth are key to longevity and quality of life.
I like to start the process of rehabilitation with an education and discussion session where we discuss MIH, what can happen and what to expect. Using a caries risk assessment tool, I look at different domains of risk, such as diet and drinks, and utilise a reliable mineral therapy to protect and strengthen the teeth. I advocate regular professional tooth cleaning as this will help keep the oral environment as neutral and healthy as possible.
There are various treatment options recommended for early, moderate and advanced cases of MIH, which all require different interventions.
Ideally, the treatment should include preventive, regenerative and restorative measures with minimal aerosol generation. These include the use of patented CPP-ACP (Recaldent)-containing products and varnishes, and GIC restorative materials.
There are several topical mineral therapies on the market that are recommended for treating demineralised enamel and early tooth decay, while also alleviating sensitivity. MI Varnish, Tooth Mousse and MI Paste Plus all incorporate Recaldent technology and can be used as part of an effective desensitisation and caries prevention strategy. Recaldent is recommended as a treatment for remineralisation control in the Dental Standard Operating Procedure: Transition to Recovery issued by the OCDO in June 2020 as part of the response to COVID-19.
MI Varnish (GC) is an enhanced fluoride topical treatment applied in practice that is effective for prevention of sensitivity and caries. It penetrates and seals dentinal tubules, minimising tooth sensitivity, and remineralising and strengthening the enamel.
GC’s Fuji Triage is effective as part of MIH treatment as an intermediate fissure sealant for when compliance or moisture control is difficult. You can use this as a stabilisation medium for open cavities, or to help protect the fissure pattern.
The fluoride incorporated in Fuji Triage will help arrest caries and provides a barrier to the diffusion of demineralisation, helping to maintain mineral equilibrium by providing a fluoride reservoir that can be topped up by applying fluoride varnish at each three-monthly visit.
If there is a breakdown of the tooth we can restore the function by using the new nanotechnology bulk fill glass hybrid glass ionomer cements (GIC), such as Equia Forte. The strength of the new glass hybrid products is considerably greater than previous GIC technologies and provides a viable alternative to composite fillings in this group of patients.
Awareness of MIH and how it should be treated is growing. But there are still many challenges ahead for the profession and a team approach will be key.
While dentists and therapists are trained for early detection and referral, there are opportunities for all team members to get involved in the management of MIH. An advanced and proven range of products exist to help manage this challenging condition.
You need to constantly monitor and manage MIH to monitor deterioration and to give relief to children throughout their lives. Taking regular radiographs of the first permanent molars is key. Acclimatisation sessions will make treatment acceptance easier for children. Any member of the dental team can do this.
Make contact with your local paediatric consultant and orthodontist for advice in the long-term management of MIH. Early planning makes for a successful outcome and a happy child.
For references, email [email protected].