✅ Abstract
Molar-Incisor Hypomineralization (MIH) is a developmental enamel defect that affects one or more first permanent molars and frequently permanent incisors.
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✅ Introduction
MIH is a qualitative enamel defect caused by disruption during the maturation phase of amelogenesis. The affected enamel appears opacified, soft, and discolored, ranging from white to yellow-brown shades. Children with MIH often experience pain during brushing or eating, leading to poor oral hygiene and anxiety toward dental treatment.
The global prevalence of MIH varies between 13% and 25%, depending on genetic, environmental, and diagnostic factors (Weerheijm, 2023).
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According to the European Academy of Paediatric Dentistry (EAPD, 2022), MIH is defined as:
| “A developmental defect of enamel affecting one to four first permanent molars, frequently associated with permanent incisors, characterized by demarcated opacities due to hypomineralization.”
➤ Key Clinical Features
▪️ Demarcated opacities: White, yellow, or brown patches on enamel.
▪️ Post-eruptive breakdown (PEB): Rapid loss of enamel after eruption due to masticatory forces.
▪️ Hypersensitivity: Strong reaction to temperature or mechanical stimuli.
▪️ Increased caries susceptibility despite adequate oral hygiene.
▪️ Aesthetic concerns when incisors are affected.
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The exact cause of MIH remains multifactorial, involving systemic, genetic, and environmental factors. Research indicates that disturbances during the final stages of amelogenesis—between birth and 3 years—can lead to defective enamel mineralization.
➤ Possible Etiological Factors
▪️ Perinatal complications: Hypoxia, low birth weight, or premature birth.
▪️ Childhood illnesses: High fevers, respiratory infections, or otitis media.
▪️ Environmental toxins: Bisphenol-A exposure and dioxins.
▪️ Genetic predisposition: Variants in AMELX and ENAM genes.
▪️ Nutritional deficiencies: Vitamin D or calcium insufficiency.
Systemic stress during enamel formation alters ameloblast function, resulting in protein retention and hypomineralized enamel.
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Diagnosis of MIH is clinical, based on well-demarcated opacities and post-eruptive enamel loss in the absence of systemic or generalized enamel defects. However, several conditions can mimic MIH, requiring careful differentiation.
📊 Comparative Table: Differential Diagnosis of MIH
| Aspect | Advantages | Limitations |
|---|---|---|
| Fluorosis | Symmetrical distribution; no post-eruptive breakdown | Lacks localized opacities; enamel remains hard |
| Amelogenesis Imperfecta | Generalized involvement of all teeth; family history | Diffuse enamel defect; not limited to molars/incisors |
| Enamel Hypoplasia | Quantitative defect; linear grooves or pits | Not opacified; enamel thickness reduced |
| Caries | Localized lesion; bacterial etiology confirmed | Lesion starts at plaque retention sites, not developmental |
✅ Treatment and Management
Treatment depends on severity, tooth sensitivity, and extent of enamel loss. The main goals are pain control, enamel preservation, and aesthetic improvement.
➤ Mild MIH (Opacities without breakdown)
▪️ Topical fluoride varnishes or casein phosphopeptide–amorphous calcium phosphate (CPP–ACP) for remineralization.
▪️ Desensitizing toothpastes with stannous fluoride or potassium nitrate.
▪️ Infiltration resin (Icon®) for incisor opacities.
➤ Moderate MIH (Limited breakdown)
▪️ Glass ionomer cements (GIC) as interim restorations due to fluoride release.
▪️ Resin composite restorations after removing porous enamel.
▪️ Stainless steel crowns (SSC) for molars with structural loss.
➤ Severe MIH (Extensive breakdown or sensitivity)
▪️ Preformed metal crowns (PMCs) to protect affected molars.
▪️ Extraction of severely compromised molars, ideally coordinated with orthodontic planning.
▪️ Behavioral management and local anesthesia adaptation due to sensitivity.
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The management of MIH requires early detection, preventive care, and multidisciplinary collaboration. Children with MIH often present dental anxiety due to repeated discomfort, making behavioral guidance and desensitization protocols critical. Emerging therapies—such as biomimetic remineralizing agents and bioactive glass materials—offer promising results in reinforcing weakened enamel.
✅ Clinical Recommendations
▪️ Conduct routine examinations at eruption of first permanent molars.
▪️ Apply fluoride varnish every 3–6 months in at-risk patients.
▪️ Educate parents about gentle brushing techniques and sugar limitation.
▪️ Consider stainless steel crowns in molars with extensive breakdown.
▪️ Use CPP–ACP and bioactive glass agents as preventive strategies.
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Molar-Incisor Hypomineralization (MIH) is a common developmental enamel defect that compromises tooth strength, esthetics, and comfort in children. Early diagnosis, preventive remineralization, and appropriate restorative approaches—from fluoride and CPP–ACP to stainless steel crowns—are essential for long-term success. Pediatric dentists play a key role in recognizing MIH early and preventing unnecessary extractions or dental anxiety in children.
📚 References
✔ Almuallem, Z., & Busuttil-Naudi, A. (2018). Molar incisor hypomineralisation (MIH): An overview. British Dental Journal, 225(7), 601–609. https://doi.org/10.1038/sj.bdj.2018.785
✔ Garot, E., Denis, A., Delbos, Y., & Manton, D. J. (2023). Management strategies for molar incisor hypomineralization: A review and current recommendations. International Journal of Paediatric Dentistry, 33(1), 39–52. https://doi.org/10.1111/ipd.13056
✔ Weerheijm, K. L. (2023). Molar incisor hypomineralization: Prevalence, diagnosis, and etiology revisited. European Archives of Paediatric Dentistry, 24(3), 455–467. https://doi.org/10.1007/s40368-022-00704-1
✔ European Academy of Paediatric Dentistry (EAPD). (2022). Policy document on Molar–Incisor Hypomineralization. Retrieved from https://www.eapd.eu
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