P A E D O D O N T OP LAOE G

DYO D O N T O L O G Y

Molar Incisor Hypomineralization

(MIH): Clinical Presentation,
Aetiology and Management
K.L. WEERHEIJM
developmental defect responsible for
Abstract: In this paper, the current knowledge about Molar Incisor initiation of the cavity was probably
Hypomineralization (MIH) is presented. MIH is defined as hypomineralization of
not diagnosed.
systemic origin of one to four permanent first molars frequently associated with
affected incisors and these molars are related to major clinical problems in severe
Clinically, MIH molars can create
cases. At the moment, only limited data are available to describe the magnitude of the serious problems for the dentist as well
phenomenon. The prevalence of MIH in the different studies ranges from 3.6–25% and as for the child affected. For dentists,
seems to differ in certain regions and birth cohorts. Several aetiological factors (for the problems are related to
example, frequent childhood diseases) are mentioned as the cause of the defect. unexpectedly rapid caries development
Children at risk should be monitored very carefully during the period of eruption of in the erupting first permanent molar,
their first permanent molars. Treatment planning should consider the long-term inability to anaesthetize the MIH molar
prognosis of these teeth. when treatment is indicated, and
unpredictable behaviour of apparently
Dent Update 2004; 31: 9–12
intact opacities. The child, on the other
Clinical Relevance: This paper relates the current knowledge of MIH to the hand, will experience pain and
clinical appearance of the phenomenon. At the moment, children with a poor general sensitivity (even when the enamel is
health in the first four years after birth should be considered at risk for MIH. intact) creating, for instance, toothache
during brushing. They may also
complain about the appearance of their
incisor teeth.

CLINICAL FEATURES
D uring the past decades, declining
caries prevalence figures have been
noticed in all age groups. In the past,
defects in first permanent molars
during, or soon after, eruption (Figure
1). In the literature, such molars are
MIH is a hypomineralized defect of the
first permanent molars, frequently
dentists were used to rapid caries referred to as non-fluoride enamel associated with affected incisors. The
progression in the primary as well as opacities, internal enamel hypoplasia, number of affected first permanent
the permanent dentition in high caries non-endemic mottling of enamel,
populations. In those days, first opaque spots, idiopathic enamel
permanent molars became carious opacities, enamel opacities and cheese
shortly after eruption in most cases. molars.1,2 Since these molars can be
Although occlusal caries still accounts extremely painful to the children, such
for the majority of caries experience in molars have become a field of renewed
children, a rapid caries progression in interest to clinical practitioners.
first permanent molars is not common Recently, Weerheijm et al. suggested
any more in contemporary populations. the term Molar Incisor
However, dentists (especially paediatric Hypomineralization (MIH) and defined
dentists) are still confronted with large it as hypomineralization of systemic
origin of one to four permanent first
K.L. Weerheijm, DDS, PhD, Department of molars frequently associated with
Cariology Endodontology Pedodontology, affected incisors.3 MIH does not appear Figure 1. 6/ with cavity due to MIH. Notice the
Academic Centre for Dentistry (ACTA), to be a new phenomenon, but when yellow opacities at the cavity border, buccal
Amsterdam,The Netherlands.
caries prevalence was high, the cusps and at the occlusal mesial part.

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opacities are demarcated, unlike the

diffuse opacities that are typical of
fluorosis and by the structure of the
enamel (fluorosis is caries resistant and
MIH is caries prone). The cause of
fluorosis can, mostly, directly be related
to the period in which the fluoride intake
was too high. Choosing between
amelogenesis imperfecta (AI) and MIH as
a diagnosis seems a matter of definition:
it should be stressed that, only in very
severe MIH cases, the molars are equally
Figure 2. White opacity buccal at /1 and white/ affected and mimic the appearance of AI.
yellow opacity buccal at /l and 2/. Mostly in MIH, the appearance of the
defects will be more asymmetrical in the
molars per patient varies from one to four molars as well as in the incisors. In AI,
and expression of the defects may vary the molars may also appear taurodont on Figure 3. /6 with yellow opacities and a cavity
in the distal part of the occlusal surface.
from molar to molar. Within one patient, radiograph and there is often a history of
intact opacities can be found on one family onset.
molar, while in another molar large parts factors mentioned are oxygen starvation
of the enamel break down soon after of the child combined with a low birth
eruption. When a severe defect is found PREVALENCE weight, calcium and phosphate metabolic
within a subject, it is likely that the In epidemiological studies, children are disorders and frequent childhood
contralateral tooth is also affected.4 normally not screened for the existence of diseases.10-12 Vaccines given during early
In some cases, apart from defects in the MIH molars. At the moment, only limited childhood have also been suggested as a
first permanent molars, opacities may be data of prevalence of MIH are available. possible cause but no data are available
found in the upper and sometimes the The prevalence figures range from 3.6– to substantiate this. The use of
lower incisors (Figure 2). The risk of 25% and seem to differ between countries antibiotics has also been implicated, but
defects to the upper incisors appears to and birth cohorts.1,4-8 In the study by antibiotic use is in most cases related to
increase when more first permanent Weerheijm et al.,5 it was found that the occurrence of diseases, so it is difficult to
molars have been affected.5 The defects frequency of MIH molars was not evenly distinguish whether the association with
of incisors are usually without loss of divided among the children in the studied MIH is caused by the antibiotic or by the
enamel substance. population. Of the children where MIH illness itself.
Clinically, the hypomineralized enamel molars were found, about 80% had two or The results of the different studies are
can be soft, porous and look like more affected molars indicating child- not always in agreement with each other.
discoloured chalk or old Dutch cheese. related factors.5 A high impact on Problems during pregnancy and birth
The enamel defects can vary from white treatment need is reported in low caries have been mentioned, while in other
to yellow or brownish but they always prevalence areas resulting from MIH studies no differences were found
show a sharp demarcation between the molars.7,9 concerning the health of mother and child
affected and sound enamel (Figure 3). during pregnancy and birth of the
The porous, brittle enamel can easily chip children with and without MIH.2,12 The
off under the masticatory forces. AETIOLOGY latter indicates a more child-related cause
Sometimes, the loss of enamel (post- The asymmetrical occurrence of MIH originating after birth. The suggested
eruptive enamel breakdown) can occur so molars within individuals suggests that influence of prolonged breast-feeding
rapidly after eruption that it seems as if the ameloblasts are affected by a could not be demonstrated in all
the enamel was not formed initially. After systemic disorder at a very specific stage studies.6,7,12,13 At this moment, we have to
occurrence of the post-eruptive enamel in their development. At the moment conclude that the aetiology of MIH still
breakdown, the clinical pictures can researchers speculate that, in the case of remains unclear. It is likely that several
resemble hypoplasia. In hypoplasia, MIH, the ameloblasts are affected in the unknown contributing factors are
however, the borders to the normal early maturation stage, or maybe even involved resulting in a number of
enamel are smooth, whilst in post- earlier at the late secretory phase. possible causes.
eruptive enamel breakdown the borders In the literature, various causes for
to the normal enamel are irregular. MIH molars, such as environmental
MIH can sometimes be confused with conditions, respiratory tract problems, TREATMENT
fluorosis or amelogenesis imperfecta. It perinatal complications and dioxins have MIH may lead to extensive treatment
can be differentiated from fluorosis as its been suggested.1,2,4,6 Other causative need.7,9 Although children with and

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be chosen for these restorations. The consider children with a poor general
outline of the restoration should be made health in the first four years after birth at
in non-hypomineralized enamel, but it can risk for MIH.12 These children should be
be very difficult to find out where sound monitored more frequently during
enamel begins, resulting in repeated eruption of the first permanent molars.
restorations due to disintegration of The same applies to children at low risk
adjacent enamel or opacities on other of caries when an opacity is noticed at
spots. The disintegration of the the eruption of one of the first permanent
hypomineralized enamel can be molars. Management of these teeth
Figure 4. Lower arch with stainless steel crowns unpredictable in the first years after should consider their long-term
on first permanent molars in child with MIH. eruption. In hypersensitive cases, or very prognosis, as well as management of the
severely affected teeth, semi-permanent presenting features such as pain.
restorations with stainless steel crowns
without MIH showed similar dental (Figure 4) or adhesive-retained metal
histories concerning their primary castings can be an alternative restoration.
dentition, it was found that, after eruption Extraction of such molars, combined with REFERENCES
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