J Pharm Bioallied Sci. 2021 Jun; 13(Suppl 1): S651–S655.

PMCID: PMC8375803
Published online 2021 Jun 5. doi: 10.4103/jpbs.JPBS_801_20: 10.4103/jpbs.JPBS_801_20 PMID: 34447173

Molar Incisor Hypomineralization: Clinical Characteristics with Special Emphasis on Etiological Criteria
Nancy Goel,1 Shruti Jha,1 Subhasmita Bhol,2 Bhagabati Prasad Dash,3 Heena Sarangal,1 and Ritu Namdev1

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

Address for correspondence: Dr. Bhagabati Prasad Dash, Department of Orthodontics and Dentofacial Orthopedics, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Patia,
Bhubaneswar, Odisha, India. E-mail: [email protected]

Received 2020 Dec 3; Revised 2020 Dec 28; Accepted 2020 Dec 29.

Copyright : © 2021 Journal of Pharmacy and Bioallied Sciences

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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 in‐
cisors 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
Introduction

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, qualita‐
tive 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 hypomin‐
eralization 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 hy‐
pomineralization.[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

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 in‐
cisors, and second primary molars begins The exact etiology of MIH is unknown. When any risk factor ensues during this intersecting period, hypomineral‐
ization 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 Tables ​1 and ​2.

Relation of Molar Incisor Hypomineralization with Other Conditions

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 environ‐
ment 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 (Al‐
lazzam 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

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

Newborns delivered vaginally had increased risk of respiratory illnesses such as hypoxia than those delivered by elective cesarean section. Further, the com‐
monly used spinal anesthesia for cesarean section has a frequent complication of maternal hypotension that can be associated with severe nausea or vomit‐
ing 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

Developmental defects of the enamel are due to faulty enamel formation, which makes the enamel more susceptible to attack by acids and therefore to den‐
tal 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

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 anesthesia14
Dental fear and anxiety can lead to behavioral management problems
Esthetic problems in anterior teeth.

Characteristic Features

Clear demarcation between the affected and sound enamel

Asymmetry of defects present in molars and incisors.[15]

Sign
 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

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 sys‐
tem 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 restora‐
tion 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].

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

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 con‐
tent and a decrease in calcium and phosphate content. During a bleaching treatment, peroxides initiate oxide–reduction reaction that may lead to dissolu‐
tion 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 chil‐
dren 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 desen‐
sitization and decontamination of the cavities. The idea of chemical-mechanical removal of caries consists of the application of a chemical on the carious tis‐
sue that is removed with a noncutting curette. Papacárie is a gel composed of papain and chloramine. Chloramine has properties related to disinfection.[18]
Conclusion

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.

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Figures and Tables

Table 1

Etiological crtiteria

Prenatal exposures Perinatal exposures Postnatal exposures

Maternal smoking Prematurity Conditions common in first 3 years of life such as asthma, fever, chicken pox, measles and
rubella, and early childhood caries

Maternal illness Low birth weight

Maternal medication Cesarean delivery Prolonged medications (amoxicillin, antiepileptic, antiasthma, chemotherapeutic)

Maternal stress Birth complications Hypomineralization due to prolonged breastfeeding is due to the exposure to
polychlorinated dibenzo-p-dioxins

Table 2

Etiological crtiteria

Environmental Medical Systemic Genetic

Insufficient oxygen supply Chicken pox respiratory diseases cyanosis Severe malnutrition Dementia Autosomal recessive AMBN, TUFTI, TFIPII gene associated

Alteration in calcium phosphate balance Epilepsy

Nutrition Vitamin D deficiency, allergy, tonsillitis otitis media Lead poisoning

GIT problem

GIT: Gastrointestinal tract

Figure 1

Treatment management of MIH