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Editor - Online Haseeb Uddin CLINICAL PRACTICE Clinical Management Approach of Molar Incisor Hypomineralisation. A case report Abstract Molar incisor hypomineralisation (MIH) is a relatively common dental defect that appears in first permanent molars and incisors and varies in clinical severity. The specific etiological factors remain unclear. Inappropriate diagnosis can result in mismanagement of the condition and results in early loss of first permanent molars (FPM) in particular. Therefore, the early identification of such condition will allow early intervention including monitoring and preventive interventions that might help in remineralisation of the hypomineralised tooth structure. These preventive measures can be instituted as soon as affected surfaces are accessible Clinical relevance statement Failure of early diagnosis and dental management in cases of Molar Incisor Hypomineralisation (MIH) leads to rapid development of dental caries, increased pulpal inflammation and continuous enamel as well as restoration breakdown. Objective statement The reader should understand the Molar Incisor Hypomineralisation (MIH) condition and the availability of different management options of this condition. Introduction Molar Incisor hypomineralisation (MIH) is a developmentally derived dental defect that involves hypomineralisation of 1 to 4 first permanent molars (FPM), frequently associated with similarly affected permanent incisors. The pattern of enamel defects consists of asymmetric, well-demarcated defects affecting the enamel of the FPMs and is associated with similar defects in permanent incisors and canines tips.1 ~ Prevalence Available modern clinical prevalence data for MIH, mostly from Northern Europe, ranges from 3.6% to 25% and seems to differ between countries and birth cohorts.2 ~ An etiology An etiology of this condition is poorly understood, with many associated factors (including environmental changes, breast feeding, respiratory diseases, oxygen shortage of ameloblasts and high fever diseases) but few proven causative agents.3 ~ Clinical Features Fairly large demarcated opacities, whitish-yellow or yellowish-brown in colour that may or may not be associated with post eruptive enamel breakdown. Hypomineralised enamel can be soft, porous and look like discoloured chalk or Old Dutch cheese. Subsurface porosity leads to breakdown after eruption, especially under occlusal forces, resulting in exposed dentine and sensitivity.4 ~ Management Permanent molars affected by hypomineralisation are prone to rapid development of dental caries and repeated breakdown of restorations. Therefore, careful planning is required, taking into account patient’s age (behaviour management issues), degree of crowding and co-operation. Sensitivity of affected teeth plays a major role in difficulty of achieving anaesthesia and thus behavioural issues. - Preventive • Diet advice • Higher fluoride toothpaste (at least 1450ppm F) • Topical fluoride varnish • Casein phopshpeptide-amorphous calcium phosphate (CPP-ACP) - Restorative: • A small lesion can be treated with localized composite, where the enamel is soft, or fissure sealants, where the hardness of the enamel appears no different from the unaffected enamel. • GIC is recommended as dentine replacement or as an interim restoration due the ease of placement, fluoride release and chemical bonding. • For extensive lesions with post-eruptive breakdown especially if the cusps are involved, preformed stainless steel crowns (SSCs) are preferred as an effective medium-term restoration. SSCs can preserve the FPM until cast restorations are feasible. 5,6 - To save the tooth or not? • The first decision in the management of the MIH FPM is whether the tooth should be saved or not. The decision to extract or restore will depend upon a number of different factors, some of these being the degree/extent of hypomineralisation, post- eruptive breakdown, sensitivity, age and co-operation of the patient, any developmentally absent teeth. Consultation with an orthodontist is advised. According to the Royal College of Surgeons of England Guidelines for the Extraction of First Permanent Molars in Children, the ideal timing of first permanent molar extraction is between 8-10 years of age after the eruption of the lateral incisors but before the eruption of the second permanent molars and second premolars. Traditionally, for the most optimum mesial movement of the second permanent molar to occupy the place of the extracted FPM and produce the best occlusal position, t it has been suggested that the second permanent molar is demonstrating radiographic evidence of calcification in the root bifurcation.7 Case report A ten-year-old patient (S.S) with no significant medical history or allergies presented to the Department of Paediatric Dentistry at Hamdan Bin Mohammed College of Dental Medicine (HBMCDM) in Dubai Healthcare City, Dubai (UAE). Complaining of slight pain due to a dislodged filling in her upper left region. Presently the tooth is asymptomatic. The pain is described as intermittent during the day, lasts for a while (hour or less), does not stop her playing or affect her sleep. Detailed history was taken from the father. The father reported that (S.S) had a significant number of upper respiratory tract infections and tonsillitis during early years of life. Clinical and radiographic examination of (S.S) revealed yellowish discoloration of the enamel on the occlusal surfaces of 16 and 26. 26 presented with a dislodged filling, 36 and 46 had big composite fillings. The presentation of the FPM is consistent with the diagnosis of molar incisor hypomineralisation (MIH) without incisor Continued on page 14 10 DENTAL TRIBUNE Pakistan Edition May 2016 Fig. 1 (a, b, c, d & e). Showing a dislodged filling of 36. 16 yellowish brown hypomineralised lesions. 36 and46 large composite fillings. Fig. 2 (a, b & c). OPT radiograph showing: normal alveolar bone levels, a normally developing dentition, except lower left third molar, E’s are near physiological exfoliation, more than 2/3 of the roots of 7’s are calcified, 46 RC Fig. 3 (a, b, c, d & e). Immediate post- treatment completion images. All first permanents molar were restored with SSCs. Good gingival health and oral hygiene were noted. Fig. 4 (a & b). Bitewing radiographs taken 6 months post treatment completion .Radiographic finding, fully seated crowns of all first permant molars with no progression of any pathological lesion underneath the SSC. By Dr. Shaikha Alraeesi, UAE & Dr. Manal Al Halabi, UAE