Treatment choice for first permanent molars affected with molar-incisor hypomineralization, in patients 7-8 years of age: a questionnaire study among Swedish general dentists, orthodontists, and pediatric dentists.

PURPOSE: The aim of this study was to investigate attitudes and preferred therapy choice for first permanent molars (FPM) with Molar-Incisor Hypomineralization (MIH). METHODS: An online questionnaire was sent out to general dentists (n = 559) working in the Public Dental Service in Region Västra Götaland, orthodontists (n = 293), and pediatric dentists (n = 156) (members from each interest association), in Sweden. The questionnaire contained three parts: general questions regarding the respondents, patient cases, and general questions regarding extraction of FPMs with MIH. Statistics were carried out using Chi-squared tests, with a significance level of 5%. RESULTS: A response rate of 36% was obtained. Orthodontists and pediatric dentists were more prone to extract FPMs with both moderate and severe MIH, compared to general dentists. When restoring FPMs with moderate MIH, resin composite was preferred. Compared to the general dentists, the pediatric dentists were more prone to choose glass-ionomer cement in the FPMs with severe MIH. The most common treatment choice for FPMs with mild MIH was fluoride varnish. "When root furcation is under development of the second permanent molar on radiographs" was chosen as the optimal time for extracting FPMs with severe MIH, and the general dentists based their treatment decisions on recommendations from a pediatric dentist. CONCLUSION: Extraction of FPMs with moderate and severe MIH is considered a therapy of choice among general dentists and specialists, and the preferred time of extraction is before the eruption of the second permanent molar.

Can molar incisor hypomineralization cause dental fear and anxiety or influence the oral health-related quality of life in children and adolescents?-a systematic review.

PURPOSE: Molar Incisor Hypomineralization (MIH) are first molars with developmental enamel defects and are common findings in many child populations. The porous nature of MIH enamel and the presence of post-eruptive enamel breakdown leads to the presence of hypersensitivity and pain, which is often the patient's main complaint and can result in dental fear and affect the quality of life. The present review aims to summarise the evidence for the ability of MIH to cause problems, such as dental fear and anxiety (DFA) and to summarise the evidence for a possibly negative impact on the oral health-related quality of life (OHRQoL) of MIH affected children and adolescents, in a systematic review. METHOD: Two searches, (1) MIH AND dental anxiety and (2) MIH AND Quality of life, were performed in MEDLINE/PubMed and Scopus. Selection demands were fulfilling the MIH diagnosis criteria using validated instruments and questionnaires for assessing DFA and OHRQoL, respectively. RESULTS: After removing duplicates and articles not fulfilling the selection demands, 6 studies concerning MIH and DFA and 8 studies concerning MIH and OHRQoL remained. CONCLUSION: Children and adolescents with diagnosed MIH did not seem to suffer from increased dental fear and anxiety, but indicated an impaired oral health-related quality of life.

Difficulties in identifying developmental defects of the enamel: a BITA study.

AIM: To evaluate the ability to recognise different types of developmental defects of enamel (DDE) by a group of general dental staff, trained prior to the comprehensive prevalence study (the BITA study), and to compare their skills to that of an untrained group. To evaluate the validity and reliability of the DDE registrations and MIH diagnoses, 3 years after the BITA study ended. To evaluate the reliability of an MIH diagnose, 3 years after the study ended. MATERIALS AND METHODS: The dental staff from five clinics (n = 43) was given instructions in identifying different types of DDE, according to the mDDE index (FDI in Int Dent J 42:411-426 1992). A test protocol with 24 digital photos of teeth with different DDE was filled out. The dental staff from five other clinics (n = 60), without preceding instructions, also filled out the protocol. Ninety-one patients with reported DDE were clinically re-examined 3 years later by two dentists with certified experience of DDE. RESULTS: When untrained dental staff filled out the test protocol, only 42% of the affected surfaces were correctly assessed, whereas 85% of the dental staff instructed in recognizing DDE made a correct assessment (p < 0.000). The specialists confirmed 73% of the teeth diagnosed with DDE in the BITA study as affected. The agreement in judging the opacities as diffuse or demarcated was 76%. One-fourth of those being judged to be affected by MIH in the BITA-study also showed to be affected by other enamel disturbances. CONCLUSIONS: The ability of the untrained dental staff to recognize DDE was insufficient. Instructions, using digital photos, raised the ability considerably. To ensure a correct MIH diagnosis, the patients should be followed until all the permanent teeth have erupted.

The prevalence of developmental defects of enamel, a prospective cohort study of adolescents in Western Sweden: a Barn I TAnadvarden (BITA, children in dental care) study.

AIM: To describe the prevalence of different types of developmental defects of the enamel (DDE) in varying age-cohorts and habitations, and to analyse if early trauma to the primary teeth and early subsequent serious health problems were related to DDE in the permanent dentition. Dental fear and anxiety, and aesthetic problems as a consequence of DDE were also investigated. METHODS: DDE was registered over 5 years annually in three age cohorts (796 children). The DDE index (FDI Commision on Oral Health, Research and Epidemiology, Int Dent J 42:411-426, 1992) was used. Information on diseases in early childhood, trauma to the primary teeth, and dental fear and anxiety were collected. RESULTS: The prevalence of DDE was 33.2% (boys 37.1%, girls 29.3%, p = 0.02). Demarcated opacities (DEO), solely, were the most frequent kind of defect, affecting 18%. Five percent (5%) had diffuse opacities (DIO) and 1% had hypoplasias, whereas 7% had teeth with both DEO and DIO. The most frequently affected teeth of DEO, as well as of DIO, were the first permanent molars and maxillary central incisors. Dental injuries to the primary anterior teeth raised the risk for DDE in the permanent teeth, but early serious health problems did not. Generalised DDE was common (8.4%). The paediatric dentists assessed the DDE in the maxillary anterior teeth as more serious than did the affected children and their parents. CONCLUSIONS: Generalised DDE was more frequent than expected, as well as the occurrence of both DEO and DIO in the same individual. The first permanent molars and the upper central incisors were the most affected teeth.

Prevalence and Diagnosis of Molar-Incisor- Hypomineralisation (MIH): A systematic review.

AIM: This was to review the literature published, to point out shortcomings and to suggest areas in need of improvement concerning the diagnosis and prevalence of MIH. METHODS: A broad search of the PubMed database was conducted. Relevant papers published in English were identified after a review of their titles, abstracts or full reading of the papers. Papers were selected if the number of children with at least one first permanent molar affected by demarcated opacities could be deciphered. Targeted publications were critically assessed by the author concerning examination criteria, selection and character of the study groups, examiners' calibration and result presentation. RESULTS: The initial search revealed 414 papers of which 24 met the inclusion criteria. A wide variation in defect prevalence (2.4 - 40.2 %) was reported. Cross comparison of the results of the various studies were difficult because of use of different indices and criteria, examination variability, methods of recording and different age groups. CONCLUSIONS: Further standardization of study design and methods is needed to make the results comparable.

Best Clinical Practice Guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH): An EAPD Policy Document.

BACKGROUND: The European Academy of Paediatric Dentistry (EAPD) has long recognised the necessity of promoting further research and knowledge regarding the dental defect described as molar-incisor-hypomineralisation (MIH). Following the establishment by EAPD of the defect diagnostic criteria in 2003, the publication of various papers and a whole issue assigned to the defect in the European Archives of Paediatric Dentistry (2008), an Interim Seminar and Workshop on MIH was organized in Helsinki in 2009. RESULT: The outcome of this event is the present consensus paper on the prevalence, diagnosis, aetiology and treatment for children and adolescents presenting with MIH. A clear diagnostic proposal and a treatment decision-making guide are presented together with suggestions on aetiology and guidance for future research. CONCLUSION: MIH is an important clinical problem that often concerns both the general dental and specialist paediatric dentists; the present 'best clinical practice guidance' aims to further help clinicians dealing with the condition.

Scanning electron micrograph analysis of hypomineralized enamel in permanent first molars.

UNLABELLED: First molars with cream- to yellow-coloured demarcated opacities of the enamel, often in combination with severe loss of substance, are common in many child populations. The aetiology is obscure. AIM AND METHOD: The aim of this study was to study the ultrastructure of the enamel of 10 affected teeth by means of scanning electron microscopy (SEM) in order to gain a better understanding of the clinical appearance and treatment problems of this condition, and to find some clues to its aetiology. RESULTS: The basic enamel structure with enamel rods and interrod zones was found in porous parts of the enamel, as well as in normal parts, but the packing of the hydroxylapatite crystals seemed to be looser and less well organized in the porous parts. The border between normal and hypomineralized enamel was usually distinct, and followed the direction of the rods. The preserved basic structure indicates normal function of the ameloblasts during their secretion phase, but impaired function during their maturation stage. CONCLUSION: Considering the poor etch profile, it seems reasonable to recommend removal of all affected enamel surrounding the cavity, if possible, and to use a glass ionomer filling with its chemical bonding to tooth substrate, when restoring first molars with remaining affected enamel.

Dental development after successful treatment of infantile osteopetrosis with bone marrow transplantation.

A 3-week-old boy was diagnosed with congenital osteopetrosis. He underwent a bone marrow transplant at 6 weeks of age. At 3 years of age the primary teeth had all erupted, but the canines and the first molars totally lacked root development. The teeth were smaller in size and had evidence of both enamel hypomineralization and hypoplasia. In the permanent dentition, multiple missing teeth were found. The incisors were conical and the mandibular laterals were extremely small. All permanent teeth had normal eruption. This case shows that dental development and eruption of teeth can be reconstituted in a child with congenital osteopetrosis. Bone marrow transplantation induces normalization of osteoclast function, which is a prerequisite for normal dental development and eruption of teeth.

Dental treatment, dental fear and behaviour management problems in children with severe enamel hypomineralization of their permanent first molars.

OBJECTIVES: To assess the demand for restorative treatment, dental anxiety and dental behaviour management problems among children with severe hypomineralization of their first molars (MIH). DESIGN: Case control study. SAMPLE AND METHODS: Data were compiled from the dental records of 32 9-year-old children with severe enamel hypomineralization of their first molars and from 41 controls of the same age group concerning dental health, a number of restorative treatments, use of local anaesthesia and clinical behaviour management problems (BMP). A questionnaire containing specific questions on children's experiences of dental care and the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS), was answered by the parents. RESULTS: The children in the study group had undergone dental treatment of their first molars nearly 10 times as often as the children in the control group. Repeated treatments of these teeth at brief intervals were common. The dental treatment was often undertaken without the use of local anaesthesia, and BMP, and dental fear and anxiety (DFA) were more common than in the controls. CONCLUSIONS: Children with severe enamel hypomineralization of their first molars had had to undergo a considerable amount of dental treatment. It is reasonable to assume that experiences of pain and discomfort on repeated occasions were related to the occurrence of BMP in patients with MIH. An early treatment planning and prognostication based on increased knowledge of hypomineralized first molars is desirable. Local anaesthesia and other pain-reducing techniques, e.g. sedation, should be used when treating these teeth. Extraction should be considered in cases of extensive disintegration of the crown, in cases of frequently repeated treatments or when pulpal symptoms are hard to cure.

Enamel hypomineralization in permanent first molars. A clinical, histo-morphological and biochemical study.

Hypomineralization in the permanent first molars was common in a group of 516 Swedish 8-year-old children. Ninety-five children (18.4%) had at least one molar with demarcated opacity. The incisors frequently displayed opacities concomitantly. The mean number of hypomineralized teeth of the affected children was 3.2 (SD 1.8), of which 2.4 were first molars. Six and a half percent of the children had severe defects, 5% had moderate defects, while 7% had only mildly hypomineralized teeth. Fifteen percent had more than one tooth affected, indicating systemic causation. The affected children, especially the boys, were reported to have had more health problems, asthma in particular (but only 4 cases), during the first year of life. Breast feeding history was similar in children with and without enamel defects. The children with severely defected enamel had undergone dental treatment of their first molars nearly ten times as often as the children in the healthy control group at the age of nine. Behavior management problems and dental fear and anxiety were common compared to the controls. Undemineralized sections from 73 permanent first molars, extracted due to severe hypomineralization of the enamel, were examined in polarized light. The hypomineralized areas extended from the cusps cervically comprising about half of the buccal and lingual sides. The cervical border to normal enamel was well defined and mainly followed the lines of Hunter-Schreger. The hypomineralized zones were covered by thin well-mineralized enamel. The concentration gradients for F, Cl, Na, Mg, K and Sr in hypomineralized enamel were analyzed by means of Secondary Ion Mass Spectrometry (SIMS), and completed with an analysis of the main matrix elements O, P and Ca by means of X-ray microanalysis (XRMA). Hypomineralized enamel had a higher content of C. Ca and P concentration were lower compared with normal enamel. The mean Ca/P ratio in hypomineralized areas was significantly lower (1.4) than the mean Ca/P ratio in the adjacent normal enamel (1.8).

The prevalence of demarcated opacities in permanent first molars in a group of Swedish children.

The permanent teeth of 516 7- and 8-year-old Swedish children from a low-fluoride area were examined for developmental enamel defects. Special attention was paid to demarcated opacities in permanent first molars and permanent incisors (MIH). The examination was done in their schools, using a portable light, a mirror, and a probe. The modified DDE index of 1992 was used for recording the enamel defects, supplemented with a further classification into severe, moderate, and mild defects. Demarcated opacities in permanent first molars were present in 18.4% of the children. The mean number of hypomineralized teeth of the affected children was 3.2 (standard deviation, 1.8), of which 2.4 were first molars. Of the children 6.5% had severe defects, 5% had moderate defects, whereas 7% had only mildly hypomineralized teeth. In conclusion, hypomineralized first molars appeared to be common and require considerable treatment in the Swedish child population.

Etiologic factors influencing the prevalence of demarcated opacities in permanent first molars in a group of Swedish children.

The aim of this study was to determine possible etiological factors for a developmental enamel defect, i.e. demarcated opacities, affecting the permanent first molars. A questionnaire about possible etiological factors of enamel developmental defects was filled in by the parents of 8-yr-old children (n=516) prior to a dental examination of permanent teeth. Demarcated opacities of permanent first molars had been found in 18.4% of the children in a previous study of these children. Fifteen % had more than one tooth affected indicating systemic causation. Questions were asked about mother's health and medication during pregnancy, birth complications, health and medication of the child during the first 3 yr of life, breast-feeding, heredity, and fluoride supplements. The affected children, especially the boys, were reported to have had more health problems, in particular asthma (but only 4 cases), during the first year of life. Use of antibiotics was also more common among the affected children, but owing to a strong co-variance with health problems these factors could not be separated. Breast-feeding history was similar in children with and without enamel defects. The etiology of hypomineralized first molars is not yet fully understood, but based on the results of this retrospective study, health problems in infancy, especially respiratory diseases, seem to be involved.

Secondary ion mass spectrometry and X-ray microanalysis of hypomineralized enamel in human permanent first molars.

A common finding in Swedish children is hypomineralization in first molars of unknown cause. Little is known about the chemical composition of the disturbed enamel. The aim here was to analyse the concentration gradients for F, Cl, Na, Mg, K and Sr in hypomineralized enamel from 17 permanent molars by means of secondary ion mass spectrometry, to complete this analysis with an examination of the main matrix elements O, P and Ca by means of X-ray microanalysis, and to compare them with normal enamel. Hypomineralized enamel had a higher content of carbon and the calcium as well as the phosphorus concentration was lower than in normal enamel. The mean Ca/P ratio in hypomineralized areas was significantly lower (1.4) than in the adjacent normal enamel (1.8). The F content was highly variable in impaired enamel and higher than in normal, but close to the surface there was most often no difference between the two. Contents of Mg and K were slightly higher in hypomineralized areas, especially towards the surface. Also Na had a somewhat higher content toward the surface in defective enamel. Cl and Sr contents had negligible or no diversity in relation to the degree of mineralization.

Enamel hypomineralization of permanent first molars: a morphological study and survey of possible aetiological factors.

OBJECTIVES: The aim of this study was to investigate the morphological appearance of severe hypomineralized enamel of permanent first molars by means of polarized light microscopy, and to estimate the possible time, severity and longevity of the insult. Furthermore, the aim was to survey some commonly implicated aetiological factors in order to gain knowledge about possible pathogenesis of the enamel disturbances which could be compared with future epidemiological studies. SAMPLE AND METHODS: Seventy-three teeth, which had been extracted due to severe hypomineralizations of the enamel, were collected and serially cut longitudinally in a bucco-lingual direction. The sections were examined in polarized light, dry and embedded in water. The children were also examined with respect to the demarcated opacities of other permanent teeth than those that were extracted. The parents were asked about their health during the mother's pregnancy, the time of gestation, birth weight and any complications. They were also asked about the child's health during the first 2 years of its life, the length of time of breast-feeding and also about fluoride supplements. RESULTS: The hypomineralized areas extended cervically from the cusps, comprising about half of the buccal and lingual sides. The cervical borders to normal enamel were well defined and mainly followed the lines of Hunter-Schreger. The hypomineralized zones were covered by thin well-mineralized enamel. The majority of the children had demarcated opacities of all their first molars and also of some permanent incisors. No obvious correlation to the anamnestic data could be found. CONCLUSIONS: The hypomineralized enamel in the investigated teeth demonstrated areas of porosity of varying degrees. The yellow/brown defects were more porous than the white-cream and extended through the whole enamel layer, while the white-cream opacities were situated in the inner parts of the enamel. There had probably been an interacting disturbance of short duration of systemic origin of the activity of the ameloblast during the first 2 years of the child's life, resulting in chronological dispersed hypomineralized demarcated opacities in the developing teeth.

Dental care of young adults in west Sweden.

107 Swedish subjects, all 20 years old, were studied for the first three years (1990-1992) after they had left the organised dental care for children and adolescents (which is free of charge for all youth through the age of 19). They were registered in four different risk-grouping systems in order to estimate the amount of their future dental care. Three of the systems used registrations from the Public Dental Service records and in the fourth one a dentist made a subjective estimation. The follow-up used dental insurance claims to study performed treatments, courses of treatments and cost. The risk group system that used subjective estimations appeared to be the one that most accurately predicted the actual dental care consumption. Approximately 70% of the subjects received some kind of dental care during the three years. The distribution was not confined to any particular risk group. Ten per cent had received complete dental care annually. Twenty-five per cent went to a private dentist and 75% continued to go to the Public Dental Service. Those who went to a private dentist received substantially more treatment and the annual cost was a little more than twice as much as in the Public Dental Service.

Evaluation of three years of dental care of adolescents in the Public Dental Service in west Sweden.

107 individuals, randomly selected from the County of Göteborg and Bohuslän, all born in 1970 were followed regarding the dental care received 1987-1989. The records of each individual from the actual time were collected and information on diagnosis and treatment measures was gathered. Radiographs from the actual time were studied by one of the authors. Sixty-two per cent of the adolescents had been examined and treated all 3 years. Six percent had not been seen at all. The sample was divided into three groups depending on the patient's DFSa value at the examination the first year. This classification appeared to correlate well with caries development in the following years. One-fourth of the sample was responsible for the major part of the non-attendance and late cancellations. The dental health of these subjects was below average, and non-attendance seemed to be a further risk factor. The preventive measures undertaken during the study appeared to correlate poorly with the actual situation of the patient and the presence or absence of potential risk factors.