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MOLAR-INCISOR HYPOMINERALIZATION (MIH): FROM

DIAGNOSIS TO TREATMENT - A SYSTEMATIC REVIEW

Anne Caroline Ribeiro Lacerda1

Beatriz Durando Rebouças2

Clarisse Cirqueira Araujo Telles Nouzinho3

Kádja Alves Freitas Cruz4

Laís Cavalcante Carneiro5

Lívia Jordania Lino Figueredo6

Malvina de Souza Pereira7

Thaís da Silva Oliveira8

Abstract: Introduction: Irregular tooth enamel on one or more molars or even permanent incisors

is Incisor Molar Hypomineralization (IMH), a condition that directly aects the experience of the

aected person. Objective: This systematic review aims to list the specicities of MIH based on the

aim of determining its causes and origins so that it can be understood and treated. Methodology: The

databases used were: National Center for Biotechnology Information, U.S. National Library of Me-

1 Graduate in Dentistry by the Sovereign Faculty of Health of Petrolina, 56308-000, Petrolina-

-PE, Brazil.

2 Graduate in Dentistry by the Sovereign Faculty of Health of Petrolina, 56308-000, Petrolina-

-PE, Brazil.

3 Graduate in Dentistry by the Sovereign Faculty of Health of Petrolina, 56308-000, Petrolina-

-PE, Brazil.

4 Graduate in Dentistry by the Sovereign Faculty of Health of Petrolina, 56308-000, Petrolina-

-PE, Brazil.

5 Graduate in Dentistry by the Sovereign Faculty of Health of Petrolina, 56308-000, Petrolina-

-PE, Brazil.

6 Graduate in Dentistry by the Sovereign Faculty of Health of Petrolina, 56308-000, Petrolina-

-PE, Brazil.

7 Master in Pediatric Dentistry from São Leopoldo Mandic– 13045-755, Campinas-SP, Brazil.

8 Graduate in Dentistry by the Sovereign Faculty of Health of Petrolina, 56308-000, Petrolina-

-PE, Brazil.

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dicine (Pubmed), Virtual Health Library (VHL) and Scientic Electronic Library Online (Scielo), in

English, Spanish and Portuguese. Totaling 1,680 articles. Of which 1,592 articles were excluded whe-

re they did not meet the inclusion criteria, resulting in 88 articles, after a complete reading, 45 articles

were selected to compose the study. Results: Treatment modalities for teeth aected by MIH varied

widely, depending on the severity, and the presence of complicating factors, such as hypersensitivity,

oral hygiene and patient cooperation. Conclusion: MIH has an unresolved etiology with multifactorial

characteristics, such as genetic factors, pathologies during pregnancy and even pollution. Incisor mo-

lar hypomineralization has a late diagnosis associated with the unskilled knowledge of professionals

regarding its manifestations.

Keywords: Developmental Defects of Enamel, Pediatric Dentistry and Maternal and Child Health.

INTRODUCTION

Molar-Incisor Hypomineralization (MIH) This is a condition that impacts the mineral

formation of at least one permanent molar, and can also aect the incisors, causing changes in their

color, shape and texture (Weerheijm et al, 2001). This circumstance has a signicant impact on the

oral health of children and young people, as well as aecting their quality of life and self-condence

(Kajihara LYA, 2022).

It is a challenge for dentists to identify the etiology associated with HMI, since there are

several factors that predispose to it, in the literature, there are studies on defects in the development of

enamel that manifest themselves as a consequence of a range of environmental factors that act at the

systemic level. These include factors such as prenatal, perinatal, postnatal and antibiotic use (Garg N.

et al, 2012; Juárez-López MLA et al, 2023). However, to date, it has not yet been completely claried

(Lopes LB, 2021), probably due to its complexity, which involves hereditary, environmental, and local

factors as possible causes of defects in the structure of deciduous and permanent tooth enamel (Vieira

et al, 2016).

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Diagnosing HMI requires a thorough evaluation of the aected teeth and their x-rays. Early

detection of HMI is crucial for successful treatment, as it enables the identication of lesions in their

early stage and the implementation of more uncomplicated preventive and restorative measures (Silva

et al, 2020).

The treatment of HMI ranges from preventive measures, such as the application of uoride,

the use of uoride varnishes, sealants, and oral health education, to interceptive procedures, such

as restorative, endodontic, and tooth extractions (Padavala et al, 2018), depending on the level

of impairment of the aected teeth. The restorative procedure for HMI consists of removing the

demineralized tissue and reconstructing the teeth using restorative materials, such as composite resin

or glass ionomer cement (Silva et al, 2020; Bekes K, 2020).

Based on scientic evidence, there was a need to carry out a systematic review, with the

objective of understanding its etiology, observing its clinical particularities, in order to identify and

diagnose HMI early. Also emphasizing the importance of understanding the types of treatments and

their compatibility with such a condition.

METHODOLOGY

As it is a systematic review, this is more in-depth and thorough, with the objective of

demonstrating that the author searched for several articles in the literature to support his theory. In the

systematic review, we begin by identifying the concept of interest, taking into account the inclusion

and exclusion criteria of the articles to be reviewed and made available, to form the numbers of nal

articles (GUIRAO, G. S. J. Adolf, 2015).

In the present research, data were collected between the months of February, March, and

April 2024. The databases used were: National Center for Biotechnology Information, U.S. National

Library of Medicine (Pubmed), Virtual Health Library (VHL) and Scientic Electronic Library

Online (Scielo), in English, Spanish and Portuguese. For the inclusion criteria, studies were used

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from 2001, when the term HMI was proposed, to 2024, which were related to the theme guided. The

descriptors in Health Sciences (DeSC): “Developmental Defects of Enamel”, “Pediatric Dentistry”

and “Maternal and Child Health”. Theses, monographs, articles not accessible online, articles outside

the period presupposed by the inclusion criterion, and indexed in other databases were excluded.

A total of 1,680 articles were obtained from the databases. Of which 1,592 were articles,

being excluded where they did not meet the inclusion criteria, as they were Theses, Monographs,

articles that did not meet the theme, full text not available. They resulted in 88 articles, after a complete

reading, 45 articles were selected, thus composing the owchart presented below:

Source: developed by the authors.

DISCUSSION

WHAT IS HMI?

Incisor molar hypomineralization (IMH) is due to the abnormal development of enamel in the

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rst or most permanent molars, then associated with the permanent incisors. The term molar-incisor

hypomineralization (HMI) was suggested by Weerheijm et al (2001) to explain dental anomalies.

During tooth formation, the enamel undergoes changes in its mineralization process, with

the compromise or interruption of the process of supplying components, such as hydroxyapatite,

secreted by the ameloblasts, the minerals do not reach the tooth properly, which results in the presence

of enamel areas with fewer minerals than usual, more susceptible to cavities, hypersensitivity and

coloration variations from white to yellow to brown (Alaluusua S, 2010).

Aected patients have variability of complications ranging from tooth wear to psychosocial

impacts (Bekes K, 2020).

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Source: developed by the authors.

AETIOLOGY

The etiology of Molar-Incisor Hypomineralization is in the process of being dened, however,

it is considered systemic and probably has a multifactorial character, not linked only to an isolated

or specic factor (William V et al, 2006). There is also the probability of an association of the action

of genetic and environmental factors, such as pollution, pathologies present during the gestational

period, complications associated with childbirth, such as prolonged or premature birth, and also in the

perinatal period, as well as early childhood interfering with the normal development of the enamel in

its maturation phase, generating dierent types of alterations in this tooth structure (Fernandes AS et

al, 2012; Assunção CM et al, 2014; Jeremias F et al, 2016; Jan J et al, 2007; Portella PD FF et al, 2018;

Koruyucu M, Ozel S, Tuna EB, 2018; Rai A et al, 2018; Jeremias F et al, 2016).

Thus, when linked to modications in genetic factors, which is what directly determines

the process of amelogenesis, especially in the secretory phase, these changes generate a defect in the

shape, thickness, and hardness of the enamel, resulting in hypoplasia (Jeremias F et al, 2016).

In theory, Allazzam et. al (2014) states that pathologies can aect the ameloblastic activity

and pH of the enamel matrix, generating this defect, as they prevent the action of proteolytic enzymes

and the development of crystalline hydroxyapatite. Still following the theory of this study, there is

no relationship between HMI and birth history, from complications during low birth weight to the

durability of breastfeeding. On the other hand, Elfrink et al identied that children born with normal

weight appear to have a lower risk of enamel defects than those born with low weight, as it is possible

that they have connections with other factors associated with maternal health status to generate these

enamel malformations. Also in this study, asthma, high fever and medical infections were considered

correlated with HMI, but low weight, duration of breastfeeding and urinary infections were not

correlated. Therefore, they found no link between Molar-Incisor Hypomineralization during the

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duration of breastfeeding and preterm birth.

On the other hand, RESENDE AND FAVRETTO (2019) allege that complications in the

prenatal period, whether smoking or pathologies during pregnancy, in the perinatal period, such as

neonatal complications, premature birth, and low body weight at birth, and in the postnatal period,

such as malnutrition, respiratory diseases, and frequent childhood diseases with a history of high fever,

seem to strongly inuence the appearance of HMI. Corroborating RESENDE AND FAVRETTO

(2019), among the prenatal complications, maternal diabetes, the use of illicit substances, and lack of

vitamin D stand out are common reports among patients with HMI (Allazzam S.M et al, 2014; Elfrink

M.E et al, 2014; Lygidakis et al, 2009; FRAGELLI, C.M.B. et al, 2013; Da Silva-Júnior et al, 2018).

In relation to the early childhood period, diseases such as respiratory diseases, such as asthma,

otitis, tonsillitis, gastrointestinal diseases, such as malnutrition, chickenpox, rubella and measles,

corresponding to the rst three years of children’s lives, are also related. A period in which there is

simultaneously the development of the incisors and rst molars, with an interrelationship between

both events in this period (Mast P et al, 2013; Vilani PNL et al, 2014). Thus, it was believed that there

was a link between this malformation and the use of antibiotics in children, however, there are some

studies on the non-existence of this interconnection, considering that enamel defects are probably

related to the underlying disease and not to the use of antibiotic therapy. Since this class of drugs is

widely used in cases of respiratory infections and there is a strong association between Molar-Incisor

Hypomineralization and respiratory diseases, there is a greater probability that it is related to these

underlying diseases and not specically to the antibiotic (O.O. Kuscu et al, 2014; Willmott NS et al,

2008; Kusku OO, Caglar E, N. S., 2008).

HOW TO DIAGNOSE HMI?

Molar-incisor hypomineralization is a condition that is still complex to diagnose due to the

lack of knowledge of dental surgeons for the correct diagnosis. In many cases, it is confused with other

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types of enamel defects such as: uorosis, amelogenesis imperfecta and hypoplasia, thus making the

observation of clinical signs fundamental for the correct diagnosis and consequently management of

the patient in relation to the treatment (BORSATTO, T. V. F. S.; FERNANDES, M. L. da M. F., 2022;

Da Silva-Júnior et al, 2018).

Clinically, changes in the enamel are noticed that vary in relation to color, from white to

yellow or brown, with a clear demarcation in the enamel, which can aect 2/3 of the crown, develop

changes in the translucency of the enamel. The terminologies mild, moderate, and severe are used

to distinguish the severity of the injury. In the mild and moderate ones, we observed characteristics

of enamel porosity, demarcated opacity, color change and sensitivity to stimuli. In severe cases, it

has a darker color, there is the presence of fracture in the tooth element, spontaneous sensitivity, the

presence of extensive carious lesions, and coronary involvement of up to 2/3 (Nagata AG et al, 2023;

Silva et al, 2020).

Generally, patients aected by HMI have related clinical problems. Among them, loss of

enamel, increased propensity to caries, rapid tooth wear and dental hypersensitivity (BORSATTO, T.

V. F. S.; FERNANDES, M. L. da M. F., 2022; E Telles et al, 2024).

Hypersensitivity is a frequent complication of HMI, making it dicult for the patient to

perform oral hygiene and feeding. Molars that have been severely damaged show enamel fragmentation

in the occlusals and cusp regions (Carvalho de Souza et al, 2023).

It was found that the best time to obtain the correct diagnosis of HMI is in the eight-year-old

age group, when it is expected that all the rst permanent molars are already erupted, like most of the

permanent incisors (Carvalho de Souza et al, 2023; Zachi et al, 2024).

HMI TREATMENT

There are a variety of treatment options, depending on the stage, the clinical protocol must

take into account factors such as the severity of hypomineralization, the patient’s age, cooperation,

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and also the socioeconomic pattern in which the patient is inserted (ALVES, M. C. DE O. et al,

2021). For this reason, the literature proposes the following techniques, for simpler cases, the use of

some preventive materials is appropriate, such as desensitizers, remineralizers, varnish, and topical

application of uoride, when there is no loss of structure and sensitivity (Lygidakis et al, 2022).

In cases where enamel or dentin fractures develop, resulting in exposure, individuals may

experience sensitivity to hot and cold temperatures. This sensitivity can cause discomfort during

brushing, and it is advisable to use sealants as a preventive measure against cavities caused by

inadequate oral hygiene (Fragelli et al, 2017). Glass ionomer (CIV) sealing has been recommended

as the rst choice, because of its advantages, such as the release of uoride, which contributes to the

prevention of caries and enamel breakage (SCHRAVERUS, M. S. et al., 2021).

For teeth with caries, the treatment must be conservative, with selective removal of

decayed tissue, thus avoiding pulp exposure, that is, the removal of tissue only surrounding walls.

Hypomineralization presents signicant challenges due to the porosity of the enamel, high protein

content and low resistance, in view of the diculty in performing direct restorations, where adhesion is

an essential factor, and the use of indirect restorations (onlay) is recommended as a satisfactory clinical

protocol, and greater resistance to masticatory forces (ROLIM, T. Z. C. et al., 2021; DHAREULA,

A. et al, 2019).

The approaches proposed in the literature range from conservative options to the use of

prefabricated metal crowns (posterior teeth) when the tooth does not have sucient structure to

receive direct and indirect restorations. However, tooth extraction is considered the last option,

indicated only when previous treatments are not feasible, and there is severe structural loss. In these

cases, orthodontic planning is carried out to restore functionality and aesthetics (ELHENNAWY, K.;

SCHWENDICKE, F., 2016).

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FINAL CONSIDERATIONS

Therefore, molar-incisor hypomineralization (HMI) is the abnormal alteration of tooth

enamel due to a modication of its mineralization process. Its etiology has not yet been dened, but

it has multifactorial characteristics, such as genetic factors, pathologies during pregnancy and even

pollution, thus being linked to genetic mutation. In the process of diagnosing the condition, there is

still a lack of preparation on the part of dental surgeons, and it is still very confused with other oral

disorders. Therefore, HMI is characterized by its staining and sensitivity to stimuli, and its diagnosis

is of paramount importance for the correct treatment. Its conduct will depend on some factors, with

the classication of the stage being the most important to ensure the eectiveness of the treatment,

making it less traumatic.

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