MOLAR INCISOR HYPOMINERALIZATION IN MONOZYGOTIC TWINS: A CASE REPORT
Figure 11. Postop upper occlusal, MB.
Figure 12. Postop upper occlusal, SB.
This follows the recommendations made by Weerheijm in 2003, 14 that the diagnosis of MIH is confirmed by clinical examination on clean and wet teeth ideally after the age of 8 years when all permanent incisors and first molars will mostly be erupted and that at least one FPM has to be affected. 8, 14 Weerheijm et al. 15 also proposed that the clinical appearance of the 4 FPMs and 8 incisors should be recorded for the following features which will aid in the correct diagnosis of the condition: presence or absence of demarcated opacities; post eruptive enamel breakdown; atypical restorations; extraction of a FPM; failure of eruption of a FPM or an incisor. Teeth affected by MIH, with or without enamel loss, are often associated with hypersensitivity to air and cold stimuli. This could be explained by the findings of Rodd et al. 16 that there is increased neural innervation in the pulp horn and subodontoblastic areas of the hypomineralized teeth. An increase in immune cells and vascularity, resembling an inflammatory response, was noted in hypomineralized teeth with enamel loss. The post eruptive enamel breakdown often leads to dentinal exposure to external oral stimuli, which may further contribute to hypersensitivity. 16 As a result, sometimes the affected teeth might not be adequately anesthetized due to peripheral sensitization, despite effective local anesthesia techniques. This may lead to poor patient cooperation and difficulty in treating these teeth. In addition, the sensitivity may lead to the avoidance of brushing in the area, which can hasten the post eruptive enamel breakdown. 3, 8 The management of MIH is thus very challenging and depends on various factors such as the extent and severity of the lesion, presence of
Figure 13. Postop lower occlusal, MB.
Figure 14. Postop lower occlusal, SB.
sensitivity, post eruptive enamel breakdown, the patient’ s age and cooperation level and the child and parental expectations. Clinical approaches may vary accordingly, from simple preventive measures such as resin or glass ionomer sealants to more invasive approaches such as extraction in association with orthodontic management. A multidisciplinary approach is therefore mandatory. 3, 8, 13 In a study conducted by Jalevik et al. 17 on Swedish children, it was found that by the age of 9, children with MIH-affected FPMs had undergone dental treatment nearly ten times more frequently than the controls undergone by healthy children, who were the controls, and the affected teeth had each been treated twice, on an average. This underscores the importance of maintaining good oral hygiene and other preventive measures which may help in the prevention of dental caries and post eruptive breakdown. Brushing with a fluoridated toothpaste( 1000-1500ppm F) twice a day and good dietary habits must be reinforced. Remineralizing agents such as fluoride varnish( Duraphat, 22600ppm) and Casein Phosphopepetide Amorphous Calcium Phosphate( CPP-ACP) have been shown to reduce the sensitivity of the enamel. 11 Preventive measures such as fissure sealants are recommended on FPMs with mild MIH with no evident enamel breakdown or sensitivity. These teeth do however require regular follow up to monitor the retention of the sealants. 3 A study by Lygidakis 10 has shown that application of a 5 th generation bonding agent prior to sealant placement improves its retention. Glass ionomer sealants are recommended for partially erupted molars or when adequate
Case Reports
Stomatology Edu Journal
221