Pediatric dentistry

MOLAR INCISOR HYPOMINERALISATION SYNDROME (MIH)

Carmen SAVIN1, Adriana BĂLAN2, Laura GAVRILĂ3, Eugeniu MIHALAŞ4,

Ana PETCU1, Vasilica TOMA5
1
Lecturer, Paediatric Dentistry Department, Faculty of Dental Medicine, „Grigore T. Popa” U.M.Ph., Iaşi, Romania
2
Professor, Paediatric Dentistry Department, Faculty of Dental Medicine, „Grigore T. Popa” U.M.Ph., Iaşi, Romania
3
Univ. Assistant, Paediatric Dentistry Department, Faculty of Dental Medicine, „Grigore T. Popa” U.M.Ph., Iaşi, Romania
4
DMD, PhD, private practice, Romania
5
Associate Professor, Paediatric Dentistry Department, Faculty of Dental Medicine, „Grigore T. Popa” U.M.Ph., Iaşi, Romania
Corresponding author: Ana Petcu; email: a_ciulei@yahoo.co.uk

Abstract description of this clinical entity was done in

Molar Incisor Hypomineralisation syndrome (MIH) is
a clinical disease that affects permanent molars and/or
permanent incisors and is characterized by the presence of
some demarcated opacities (with white to yellow-brownish
discolorations within the enamel structure) and by reduced
mechanical properties and resistance of the enamel. In the
literature of the field, MIH prevalence in various countries
ranges from 2.8% to 44%. This syndrome has a multifactorial
etiology (including environmental, medical, genetic,
systemic factors). MIH represents a challenging disease
due to the serious problems that it can raise for both
paediatric dentists and child and due to its interdisciplinary
approach (general practitioner, paediatric dentist,
physician, psychologist, etc.).
Keywords: child, MIH, diagnosis.
In paediatric dentistry care, an important role
is played by patients’ illness experience and by
their relation to treatment, being well known
that, over the last years, special stress has been
laid on the relation between children oral health
status and their quality of life, and also on the
one between individual appearance (facial look/
appearance) and the way in which children are
perceived by others (peers, parents, etc.) [1]. In
the last 12 years, a lot of studies have been
analyzed and explored the impact of dental
diseases, malocclusions, dental or cranial
anomalies on the quality of life [2-4].
Molar Incisor Hypomineralisation syndrome
(MIH) is a clinical disease that affects – as its
name suggests – permanent molars and/or
permanent incisors, being characterized by the
presence of some demarcated opacities (with
white to yellow-brownish discolorations within
the enamel structure) and by reduced mechanical
properties and resistance of the enamel. The first
1987, as an “idiopathic enamel
hypomineralisation” and was reported in
Sweden [5]. The term “Molar Incisor
Hypomineralisation”, first cited by Weerkheijm
et al. in 2001, was defined as “a hypomineralisation
of systemic origin of one to four permanent
molars frequently associated with the affected
incisors” [6].
Usually, hypomineralisation is related to
deficiency in the quality of enamel or of the entire
enamel thickness, mostly frequently occurring in
the maturation phase of tooth development.
In the Molar Incisor Hypomineralisation
syndrome, the dental lesions are in most of the
cases rough and plaque retentive, the risk for
rapid caries development is high, as well as the
risk of post-eruptive breakdown of the tooth
structures and the installation of hypersensitivity.
Prevalence of MIH syndrome
In the literature of the field, MIH prevalence
in various countries ranges from 2.8% to 44%
[5-14].
It is difficult to compare the results of different
studies because of the different criteria used,
examination variability, different recording
methods and different age groups involved [15].
The MIH syndrome distribution between
sexes is equal [9,16,17] in most of the studies. It
must be also mentioned that there is no conclusive
evidence concerning the fact that the maxillary
molars are more susceptible to develop MIH
than the mandibular one, or vice-versa. Most of
the studies failed to find any predilection for

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 MOLAR INCISOR HYPOMINERALISATION SYNDROME (MIH)

MIH defects for a specific arch (upper/lower)/ Clinical features in MIH syndrome
hemiarch (right/left) [9,16-19].
Clinical examination should be undertaken on
Etiology of MIH syndrome clean, wet teeth. The optimum age for examination
is 8 years, as the four permanent molars and the
The syndrome has a multifactorial etiology permanent central incisors are erupted at least
(environmental, medical, genetic, systemic by half. At the clinical exam, the paediatric
factors), all etiological elements acting dentist can notice the following elements:
additionally or even synergistically [20-22], with ¾ ¾ limited opacities at permanent molar/
genetic predisposition (due to the fact that tooth molars level and/or incisor level
development is under a strict genetic control). ¾ ¾ variation in enamel color: white à yellow à
Even if no conclusive data concerning a brownish
specific etiology of MIH syndrome are available, ¾ ¾ enamel loss in permanent molars
it seems that the etiological factors may be related ¾ ¾ hypomineralised enamel is soft, porous,
to prenatal, perinatal and postnatal periods of brittle, chalk like, old Dutch cheese-like
child development, as follows: ¾ ¾ post eruptive enamel breakdown (PEB) à
image of hypoplasia, yet the borders to normal
A. Prenatal factorsà maternal disorders and
enamel are irregular
infections, such as [20, 23-25]:
¾ ¾ sharp demarcation between sound and
√√ Hypocalcemia affected enamel
√√ A and D hypovitaminosis ¾ ¾ dental sensitivity or hypersensitivity to
√√ Diabetes mellitus cold food, cold temperature, brushing à pain
√√ Rubella ¾ ¾ poor oral hygiene
√√ Urinary tract infections ¾ ¾ caries
B. Perinatal factors [20,23,25-27]: ¾ ¾ pulp involvement
¾ ¾ aesthetic problems
√√ Caesarian section
According to the European Academy of
√√ Prolonged delivery
Paediatric Dentistry (EAPD) (2010), MIH it can
√√ Premature birth
be classified into the following forms [15]:
√√ Twin delivery
√√ Infant hypoxia ¾ ¾ Mild
√√ Very low birth weight -- isolated opacities
√√ Neonatal hypocalcemia -- discoloration of permanent incisors
√√ Cyanosis, etc. -- demarcated enamel opacities without
C. Postnatal factors [7,20,24-26,28,29]: breakdown of the enamel
-- sensitivity to external stimuli occasionally
√√ Children with a general disease present (e.g. sensitivity to air/water but not to
√√ Prolonged breast feeding (exposure to brushing)
dioxin) -- aesthetic concerns from the part of the
√√ Hypocalcemia parent/child are mild
√√ Nutrition problems
√√ Chicken pox, measles, rubella and other ¾ ¾ Severe
viral infections with high fever development -- demarcated enamel opacities with
√√ Respiratory diseases (asthma, lung breakdown of the enamel
problems) -- hypersensitivity – persistent/spontaneous
√√ Antibiotics administration (e.g., amoxicillin) -- caries
√√ Anti-asthmatic medication -- crown destruction à pulp involvement
√√ Otitis media -- function alteration
√√ Thyroid and parathyroid disturbances -- intense aesthetic concerns from the part of
the parent/child à psycho-social impact

International Journal of Medical Dentistry 285

Carmen SAVIN, Adriana BĂLAN, Laura GAVRILĂ, Eugeniu MIHALAŞ, Ana PETCU, Vasilica TOMA
Diagnosis in MIH syndrome
Diagnostic criteria for MIH, as proposed by
EAPD in 2010, stipulate that at least 1 to all 4
permanents molars must present enamel
hypomineralisation and that the permanent
incisor can be simultaneously affected (the
presence of opacities on permanent central
incisors is not mandatory for MIH diagnosis).
The higher the number of affected molars is, the
higer the risk that incisors will be also affected
[19,30]. Each tooth should be recorded for:
¾ ¾ demarcated opacities
-- at the occlusal and buccal part of the
crown
-- opacities may vary in size (small defect
(more than 1mm) à defect extended to a
major part of tooth) and color (white,
creamy, yellow to brownish)
¾ ¾ enamel disintegration (PEB)
-- due to the hypomineralisation of the
tooth, a varying degree of porosity will
appear in the permanent molars that, in
cases with severe affected enamel, may
lead to enamel breakdown, dentin
exposure and rapid caries progression
¾ ¾ atypical restoration
-- extensions towards buccal or palatal
smooth surfaces at the level of first
permanent molars and central incisors
that may indicate to the clinician a
previous MIH syndrome
-- associated with tendency of opacities at
the margins
¾ ¾ tooth sensitivity
-- mild to spontaneous hypersensitivity
-- difficult to anaesthetize
¾ ¾ extracted tooth due to MI
-- notes in the clinical observation chart/
records
-- other molars present opacities due to
MIH syndrome
Differential diagnosis in MIH syndrome
1. Fluorosis
-- history of fluoride intake
286
-- number of teeth involved depending on
fluoride exposure time
-- diffused opacities
-- caries resistant opacities
2. Amelogenesis Imperfecta (AI)
-- all teeth are involved
-- family history present
-- on radiological investigation àtaurodontia
3. Hypoplasia
-- smooth borders to normal enamel
-- a quantitative enamel defect
MIH syndrome is a dental disease with an
increasing prevalence and a large impact on
treatment needs. Therefore, it is highly
recommended to increase the regular checkup
for children with history of repeated illness in
the first year of life during the eruption of first
permanent molars. In the same time, MIH
represents a challenging disease, due to the
serious problems that it can provoke for both
paediatric dentists (teeth opacities, REB, rapid
caries development, lack of local anesthesia) and
child (pain, hypersensitivity, aesthetic complains,
dental fear, dental anxiety, dental phobia) and
due to its interdisciplinary approach (general
practitioner, paediatric dentist, physician,
psychologist, etc.)
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