Treatment management of first permanent

molars in children
with Molar-Incisor Hypomineralisation
N. KOTSANOS*, E.G. KAKLAMANOS**, K. ARAPOSTATHIS*

ABSTRACT. Aim To study the treatment management of first permanent molars in children with Molar-Incisor
Hypomineralisation (MIH). Study design Retrospective analysis. Methods The records of the clientele of a
private paediatric dental practice were scanned. Thirty-six cases of children fulfilling the diagnostic criteria of
MIH were retrieved who had been followed for a mean period of 4.5 years, and 36 children of matching age and
gender, and with similar follow-up period, were randomly selected from the same clientele to serve as controls.
Results Children in the MIH group exhibited greater DMFS and smaller dmfs scores. The frequency of restorative
intervention was greater in children of the MIH group (OREST=11.00, 95% C.I. 2.85-42.45). Stainless-steel
crowns had been placed only on MIH group molars. The follow-up records revealed that only restorations in the
MIH group needed retreatment. Fillings and sealants in the MIH group had a greater probability of needing
retreatment than in the control group (OREST=3.10, 95% C.I. 1.60-6.01). Conclusions Children affected by MIH
may need to undergo a significant amount of restorative treatment at an early age. Moreover, fillings and sealants
in MIH affected children have a greater probability of needing retreatment than in control group children.

KEYWORDS: Molar-Incisor Hypomineralisation, Treatment, Retreatment needs.

Introduction 2000; Beentjes et al., 2002]. The developmental

Weerheijm et al. [2001a] suggested the term Molar-
Incisor Hypomineralisation (MIH) to describe the
clinical finding of hypomineralisation of a systemic
origin of one or more of the four permanent molars, as
well as any associated and affected incisors. Clinically,
the hypomineralisation defects involve altered
translucency in demarcated areas of enamel. The
defective opaque enamel is of normal thickness with a
smooth surface and can be white-yellow or yellow-
brown in colour. Occasionally, depending on the
degree of sub-surface porosity, posteruptive enamel
breakdown may occur under masticatory forces [Koch
et al., 1987; Alaluusua et al., 1996a; 1996b; 1999;
Jlevik and Norn, 2000; Leppniemi et al., 2001;
Weerheijm et al., 2001b; Hllt et al., 2001]. In the
literature, several factors capable of disturbing normal
enamel development have been associated with these
defects [Alaluusua et al., 1996a; 1996b; 1999; Hllt et
al., 2001; Jlevik, 2001; Jlevik et a.l, 2001a; Van
Amerongen and Kreulen, 1995; Jlevik and Norn,
Depts of *Paediatric Dentistry, **Preventive Dentistry, Periodontology
and Implant Biology, Aristotle University of Thessaloniki, Greece.
kotsanos@dent.auth.gr
defects observed in MIH can create considerable
discomfort to the child, concern to the parents and
problems to the clinician regarding the management of
the affected teeth [Fayle, 2003]. The last few years
have seen a series of reports on treating such cases.
Current information suggests that children presenting
with this type of defect require extensive and often
repeated restorative treatment [Leppniemi et al.,
2001; Jlevik and Klingberg, 2002]. There has also
been research focused on evaluating different types of
interventions and restorative materials [Lygidakis et
al., 2003; Zagdwon et al., 2003]. However, more data
is needed to establish improved clinical strategies,
especially for treating severe cases of MIH.
The present report is a retrospective study of the
treatment needs and management of first permanent
molars in children with MIH attending a paediatric
dental practice.
Materials and methods
Participants. At the beginning of 2004 a
retrospective study was initiated. The records of the
clientele of a private paediatric dental practice were

EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2005 179

N. KOTSANOS, E.G. KAKLAMANOS, K. ARAPOSTATHIS

scanned from 1995, when MIH was diagnosed as a
separate hypomineralisation entity. Subsequently,
records of further treatment up to June 2005 were
added to the study. The location of demarcated
opacities and enamel breakdown had been recorded on
a specially designed patient research data sheet. From
a total of 50 cases fulfilling the diagnostic criteria of
MIH [Weerheijm et al., 2003], 36 cases with a follow-
up time exceeding 12 months were retrieved. Their
characteristics are presented in the results section.
Based on these characteristics a control group of 36
children of matching age and gender were randomly
selected by means of two tables of random numbers,
one for the males and one for the females.
In both groups, the status of restorations of the first
permanent molars (hereafter called molars) had been
assessed at follow-up [Ryge, 1980], and new
restorative needs met. Clinical examination, restorative
treatment and follow up had been performed by the
same paediatric dentist (NK). During their last follow-
up 10% of the patients had been seen twice with at
least one week between sessions, allowing intra-
examiner reproducibility to be measured and Kappa
score calculated (kappa score, 0.95).
Details of medical history such as respiratory, ear or
other infections, hospitalisation, fever >39C etc., of
both MIH and control patients had been recorded after
personal interview with patients mother. Where
mothers had been unsure, the patients health data
booklet with all medical information recorded by their
paediatrician had been inspected.
Statistical analysis. The software SPSS version 11.5
was used for the analyses. In every non-parametric test
(Mann & Whitney and Chi-square tests) the observed
significance level was computed either with Fishers
exact test or with Monte Carlo simulation method
[Mehta and Patel, 1996]. Differences were considered
significant when a p-value of 0.05 or less was
observed.
Results
Description of sample characteristics. The
characteristics of the participants at the time of initial
examination are presented in Table 1. Children in the
MIH group exhibited statistically significantly greater
DMFS and dmfs scores. From the 144 molars in the
MIH group, 119 (82.6%) showed signs of
hypomineralisation.
No statistically significant difference was observed
in the number of maxillary or mandibular molars
affected, nor were there any significant associations
between the number of affected molars and the
presence of affected maxillary incisors, mandibular
incisors or both. No statistically significant differences
were observed regarding the medical history of the
children of both groups during the first three years of
life.

Group
MIH Control Significance
Age (2 age SD) 7.7 1.3 7.5 1.2 NS
Gender* males 19 19
NS
females 17 17
DS (2 mean SD) 2.4 3.0 0.8 1.3 p=0.002
MS - - __ __
FS 0.3 1.0 0.1 0.2 NS
DMFS 2.8 3.2 0.8 1.3 p=0.001
ds ( mean SD)
2
3.0 4.5 5.6 7.0 NS
ms - 0.1 0.8 __
fs 0.7 1.6 3.7 7.0 NS
dmfs 3.8 4.9 9.4 8.4 p=0.002
% of caries free children 14% 11% NS

The significance of the differences was analysed with Mann-Whitney test or by the 2 test.
NS: Not significant, NA: Not applicable

TABLE 1 - Characteristics of the participants at the time of initial examination in a study of MIH in Greek children.

180 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2005


The mean follow-up time ( SD) for the MIH
children was 4.5 2.9 years and 4.6 2.2 years for the
control group children (Mann-Whitney test, p=0.431).
Management of first permanent molars. First
treatments. On a child basis and the review of the
records showed that 33 children (91.7%) in the MIH
group and 18 children in the control group (50.0%)
had at least one molar restored (2 test, p=0.000). The
odds ratio for having restorative intervention in at least
one molar for MIH group children (33/3) compared to
the control group children (18/18) was OREST=11.00
(95% C.I. 2.85-42.45).
On an intervention basis. The overall management of
molars at the time of first treatment can be seen in Table
2. In total, 136 interventions were placed in 133 molars
in the MIH group and 130 in 124 molars in the control
group. Altogether, significant differences between the
children of the two groups were observed regarding the
various types of intervention (2 test, p=0.000). In the
MIH group, of the 35 teeth sealed, 18 had signs of
hypomineralisation and of the 101 teeth that received
restorations, 96 had signs of hypomineralisation.
Therefore, the odds ratio for having restorative
intervention vs. sealing in MIH affected molars (96/18)
compared to the control group molars (40/90) is
OREST=12.00 (95% C.I. 6.42-22.45). A qualitative
finding was that more multisurface restorations were
placed in MIH molars, while restorations placed in the
control group were usually small in the form of
preventive resin restorations (PRRs). Stainless steel
crowns had only been placed in the MIH group. No
Intervention
Sealants
Amalgam fillings
Composite resin fillings
Stainless-steels crowns
Restorative intervention
Total interventions
TABLE 2 - Management of first permanent molars at the time of the first treatment (n% of total
interventions) and follow-up time for every type of intervention (mean months SD).
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2005
TREATMENT MANAGEMENT IN MIH
molars had been extracted in the two groups.
Follow-up treatments. On a child basis, the review of
the follow-up records revealed that 17 out of 36
children in the MIH group and 7 out of 36 children in
the control group needed second treatment in the form
of restoration on at least one molar (2 test, p=0.023).
The odds ratio for having a restoration as retreatments
on at least one molar in the children of the MIH group
(17/19) compared with the children of the control
group (7/29) is OREST=3.70 (95% C.I. 1.29-10.63).
Overall, the mean number of restoration treatments (
SD) for each MIH child was 3.7 1.9 compared to 1.5
1.6 for each control group (Mann-Whitney test,
p=0.000).
On an intervention basis, the needs for re-treatment
can be seen in Table 3. Significant differences between
the children of the two groups were observed regarding
the need for re-treatment of each particular type of
initial intervention (2 test, p=0.000). In the control
group, no restoration needed re-treatment, while out of
the 16 sealants retreated, 11 showed signs of caries and
were substituted with small composite resin fillings in
the form of preventive resin restorations (PRR). In the
MIH group, re-treatment was needed in 11/18, i.e.
more than half of amalgams (mean replacement time
being less than 3 years) and in 15/59 i.e. a quarter of
the restorations of composite restorations (mean
replacement time being 4 years). No molar treated
with a stainless-steel crown (SSC) needed second
intervention. The molars restored more than once were
always hypomineralised. Of the 8 sealants retreated,
MIH group Control group
35 90
(25.7%, 52.2 34.0) (69.2%, 53.5 25.1)
18 6
(13.2%, 41.2 32.7) (4.6%, 36.0 20.2)
59 34
(43.4%, 44.7 31.6) (26.2%, 57.1 27.3)
24 -
(17.6%, 50.2 23.3)
101 40
(74.3%) (30.8%)
136 130
181
N. KOTSANOS, E.G. KAKLAMANOS, K. ARAPOSTATHIS
Intervention
Sealants
Amalgam fillings
Composite resin fillings
Stainless-steels crowns
Total
TABLE 3 - Summary of cases of affected molars needing re-treatment (n% of interventions) and time after
first intervention (mean months SD).
five had been placed on molars with hypomineralised
areas. Six, including the previously mentioned five,
had been replaced with a composite resin restoration.
Sealants in the MIH group were retreated after a
shorter period of time than sealants in the control
group (Mann-Whitney test, p=0.039).
In the MIH group, 34 out of 112 interventions,
excluding SSC, as none had been placed in the control
group, were retreated, compared with 16 out of 130 in
the control group (2 test, p=0.001). The odds ratio for
re-treatments, i.e. replacing sealants and filling in the
MIH group (34/78) compared to control group
(16/114) is OREST=3.10 (95% C.I. 1.60-6.01).
Considering only affected molars in the MIH group, 31
out of 90 interventions (sealants and fillings) had been
retreated compared with 16 out of 130 in the control
group (2 test, p=0.000). The odds ratio for retreating
sealants and fillings in MIH affected molars (31/59),
compared to control group molars (16/114) is
OREST=3.74 (95% C.I. 1.89-7.39).
Discussion
According to the findings of the present study,
children exhibiting MIH have 11 times greater
probability of undergoing restorative treatment in
their first permanent molars compared with children
of a control group. Moreover, fillings and sealants in
MIH affected children have over 3 times a greater
probability of needing re-treatment than interventions
on children of the control group. Comparison with a
control group not representative of the general
population is justified because these children resided
182
MIH group Control group
8 out of 35 16 out of 90
(22.9%, 33.0 25.7) (17.7%, 55.6 22.7)
11 out of 18 0 out of 6
(61.1%, 32.3 30.3) (-)
15 out of 59 0 out of 34
(25.4%, 48.3 30.6) (-)
0 out of 24 (-)
(-) (-)
34 out of 136 16 out of 130
(25.0%, 39.53 29.6) (12.3%, 55.6 22.7)
in the same geographical area as the MIH children,
had been treated and re-evaluated by the same
paediatric dentist, received similar hygiene instruction
and could be followed for approximately the same
length of time.
The dmfs scores were much smaller in the study
group than in the control group, as the latter was
representative of the patient population of a private
paediatric dental practice where nearly half of the
practice children were referred by general dental
practitioners. However, after the eruption of the first
permanent molars, the situation was dramatically
reversed and statistically significant greater DMFS
scores were observed in MIH children. The difference
in the caries experience can provide a rough evaluation
of the substantially increased treatment needs in the
permanent teeth of the study population. Moreover,
children in the MIH group had an 11 times greater
probability of receiving actual restorative treatment on
at least one molar, than children in the control group.
The finding that SSCs were only needed in the study
population is indicative of the extensive defects to be
restored in this group. On the other hand, restorations
in the control group involved mainly PRRs. Thus, MIH
has a significant impact on treatment needs, as
previously reported [Leppniemi et al., 2001; Jlevik
and Klingberg, 2002]. The fragility of the defective
areas may account for the increased number of
restorations placed on MIH molars. This problem may
be aggravated, as these molars are often sensitive and
children avoid brushing them. This leads to increased
plaque stagnation and caries development [Weerheijm,
2003].
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2005

The mean number of restoration treatments in the
MIH group was 2.5 times greater than in the control
group. Jlevik and Klingberg [2002] reported similar,
though more pronounced, differences. They observed
that affected children had undergone dental treatment
of their first permanent molars nearly 9 times more
often than the children in a control group, and that
every defective tooth had been on average treated
twice. The extensive defects encountered in MIH
affected teeth lead to extensive fillings, inevitably
increasing the risk of failure. In addition, if clinically
sound but opaque enamel is left during restoration,
then it may disintegrate later, or problems of adhesion
to the hypomineralised tissue may be encountered
[Weerheijm, 2003]. In our study population, no molar
restored with a stainless steel crown needed
retreatment, in agreement with Zagdwon et al., [2003].
Lygidakis et al., [2003] showed that the use of
composite restorations in molars with at least two
sound surfaces produced satisfactory long-term
results. Apart from the restorations placed in MIH
affected molars, sealants were found to need re-
treatment almost two years earlier than sealants in the
control group.
Retreatment of amalgam restorations was more than
twice as frequent compared with composite resin
restorations, which is in agreement with Fayles [2003]
suggestion of preferring composites for MIH affected
molars, and it is further supported by Lygidakis et al.
[2003] results. However, Mejre et al. [2005] reported
similar success rates for composite and amalgam
restorations. The fact that in their study population,
teeth with more extensive and possibly carious defects
where amalgam fillings are conventionally placed,
were extracted, may account for the contradictory
results. In addition, their finding of restoration
longevity similar to the general population may be
attributable to the same treatment strategy. There
seems to be a feeling that, with the increasing
awareness of the carious and attritional deterioration of
these molars, better and longer lasting restorations are
being placed nowadays. Current and future treatment
of such molars is being documented in new cases and
it will be interesting to compare their re-treatment with
results reported here and elsewhere [Jlevik and
Klingberg, 2002; Mejre et al., 2005].
In our study sample, no molars had been extracted,
although extractions of affected molars have also been
proposed as a treatment alternative. Mejre et al.
[2005] compared cases of restored MIH affected teeth
to cases where severely defective teeth had been
extracted, sometimes followed by orthodontic
correction. They observed that at the age of 18 years,
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2005
TREATMENT MANAGEMENT IN MIH
individuals were equally satisfied with their dental
situation, irrespective of the type of treatment they had
undergone, and suggested the option of extracting
severely defective molars. However, the authors of the
present study believe that this subject warrants further
investigation.
Our data did not support other reports [Koch et al.,
1987; Jlevik et al., 2001b; Weerheijm et al. 2001a]
suggesting a relationship between the number of
affected molars and the presence of defective areas in
maxillary incisors, mandibular incisors, or both.
Mejre et al. [2005] also reported a lack of any
statistically significant relationship between the
number of molars with enamel surface breakdown and
the number of incisors with enamel
hypomineralisation. Moreover, no statistically
significant frequency of occurrence was observed in
the number of affected maxillary or mandibular
molars, which is in agreement with Weerheijm et al.
[2001b]. Leppniemi et al. [2001] reported more
maxillary molars affected. Contrary to other reports
[Van Amerongen and Kreulen, 1995; Jalevik and
Noren, 2000; Jalevik, 2001; Jalevik et al., 2001a;
Beentjes et al., 2002] no statistically significant
differences were observed in medical history during
the first three years of life between the two groups.
Conclusion
Based on the available data, the current study
suggests that MIH has a significant impact on
treatment needs.
Moreover, close follow up of all interventions placed
on affected teeth may be indicated, as they seem to
exhibit decreased survival. These findings point to the
need for better clinical strategies in treating MIH
molars.
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