Introduction
Materials and methods
Eligibility criteria
Study design
Participants
Interventions
Comparators
Outcomes
Report characteristics
Search strategy
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#1 (molar AND incisor AND hypominerali*ation) OR (demarcated AND opacities) OR (MIH) OR (mottled AND enamel) OR (developmental AND opacit*) OR (idiopathic OR nonfluoride) AND opacit*) OR (white AND opaque AND enamel) OR (Non-endemic AND mottling AND enamel) OR (hypominerali* AND t**th) OR (enamel AND opacit*) OR (enamel AND defect) OR (enamel AND (hypominerali*) OR (developmental AND dental AND defects) OR (calcification AND molar) OR (cheese AND molar) OR (developmental AND hypominerali*) OR (idiopathic AND hypominerali*) OR (enamel dysminerali*ation)
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Medline: Exp DENTAL ENAMEL HYPOPLASIA EMBASE: Exp ENAMEL HYPOPLASIA
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#2 (manage*) OR (treat*) OR (restor*) OR (extract*) OR (bleach*) OR (resin) OR (composite) OR (orthodont*) OR (seal*) OR (microabrasion) OR (crown) OR (veneer) OR (prevent*) OR (fluorid*) OR (SDF) OR (CPP-ACP) OR (casein phosphopeptide-amorphous calcium phosphate) OR (onlay) OR (inlay) OR (root canal) OR (pulp therapy) OR (pulpotomy) OR (pulpectomy) OR (endodontic) OR (infiltration) OR (reminerali*ation)
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Medline: Exp OPERATIVE DENTISTRY, TOOTH REMINERALIZATION, TOOTH PREPARATION, ORAL SURGERY, PREVENTIVE DENTISTRY, ORALSURGICAL PROCEDURES, ORTHODONTICS, DENTAL ESTHETICS, ENDODONTICS, DENTAL POLISHING, DENTAL BONDING, DENTAL ATRAUMATIC RESTORATIVE TREATMENT, DENTAL ANAESTHESIA EMBASE: Exp OPERATIVE DENTISTRY, PREVENTIVE DENTISTRY, ENDODONTICS, ORALSURGICAL PROCEDURES, RESTORATIVE DENTISTRY, ORTHODONTICS, DENTAL ANAESTHESIA, DENTAL BONDING, DENTAL POLISHING, ATRAUMATIC RESTORATIVE TREATMENT
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#1 & #2
Study selection
Data extraction and quality assessment
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Study characteristics (author, publication year, title, publication journal, study design, country, setting, funding)
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Study design
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Number of patients included
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Number of teeth studied
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Patient demographics (age, gender, ethnicity, socio-economic status)
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Patient selection (inclusion, exclusion criteria, controls included, presence of any other pathology such as dental caries)
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Primary and secondary outcome measures
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Severity of MIH (where this was not explicitly stated, an estimation was made using the EAPD criteria)
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Number and experience of clinicians providing treatment
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Intervention provided, including details on use of behaviour management techniques, local or general anaesthesia, use of sedation, technique and materials used
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Success of intervention (as per primary outcome measure used in that study)
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Annual failure rate and longevity (if applicable)
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Adverse events
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Dentist, patient and parent-reported outcomes
Data synthesis
Results
Findings for molars
Study Country | Study design | Severity of MIH | Follow-up in months (range) | Age of participants in years | No. of participants (drop outs) | No. of teeth (drop outs) | Primary outcome measure | Intervention | Success |
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Fissure sealants | |||||||||
Greece | Restrospective case–control | Mild & Severe | Mean 54 | Mean 7.7 | NR | 35 restorations | Number of re-treatments needed | Fissure sealant (FS) | 77.1% did not need retreatment |
Lygidakis et al. (2009) Greece | Randomised trial | Mild | 48 | Mean 6.8 SD ± 0.4 Range 6–7 | 54 (7) | 108 | Success of fissure sealant | G1: resin-based FS applied with adhesive G2: resin-based FS applied without adhesive | G1: 70.2% fully sealed, 29.7% partially sealed and 0% lost G2: 25.5% fully sealed, 44.6% partially sealed and 29.7% lost |
Fragelli et al. (2017) Brazil | Prospective cohort | Mild | 18 | Mean 7 Range 6–8 | 21 (0) | 41 | Success of restoration using USPHS-modified criteria | Resin-based FS G1: teeth affected by MIH G2: teeth unaffected by MIH | G1: 72.0% G2: 62.6% No difference between groups |
Glass ionomer cement (GIC) restorations | |||||||||
Mejare et al. (2005) Sweden | Restrospective cohort | Mild & Severe | NR | At referral: Mean 8.5 SD ± 2.16 Range 6–17 At follow-up: Mean 18.2 | NR | 63 restorations | Success of restoration | GIC restoration | 49.2% acceptable |
Fragelli et al. (2015) Brazil | Prospective cohort | Severe | 12 | Mean 7.7 Range 6.37–9.54 | 21 (0) | 48 | Success of restoration using USPHS-modified criteria | Non-invasive GIC restoration | 78% cumulative survival |
Grossi et al. (2018) Brazil | Prospective cohort | Severe | 12 | Mean 10.55 SD ± 1.25 Range 7–13 | 44 (1 incisor) | 60 (6 restorations) | Success of restorations measured using modified ART criterion | Glass hybrid restoration using ART technique | 98% cumulative survival |
Durmus et al. (2020) Turkey | Prospective cohort | Severe | 24 | Mean 8.94 SD ± 1.41 | 58 (0) | 134 | Success of restoration using USPHS-modified criteria | Invasive high-viscocity GIC restoration | 87.5% cumulative survival |
Linner et al. (2020) Germany | Retrospective cohort | Severe | Mean 42.9 | Mean 11.2 SD ± 2.9 Range 6.6–18.2 | NR | 28 | Success of restoration using FDI criteria | Non-invasive GIC restoration | 7.0% cumulative survival at 36 months |
Polyacid modified resin composite restorations | |||||||||
Mejare et al. (2005) Sweden | Retrospective cohort | Mild & Severe | NR | At referral: Mean 8.5 SD ± 2.16 Range 6–17 At follow-up: Mean 18.2 | NR | 14 restorations | Success of restoration | Polyacid modified resin composite restoration | 64.3% acceptable |
Composite Resin Restorations | |||||||||
Lygidakis et al. (2003) Greece | Severe | 48 | Mean 8.84 SD ± 0.75 Range 8–10 | 46 | 52 (3 restorations) | Survival of restoration, hypersensitivity score using Cvar Ryge criteria | Composite resin restoration | 100% survival and 100% non-sensitive | |
Greece | Retrospective case–control | Mild & Severe | Mean 54 | Mean 7.7 | NR | 59 restorations | Number of re-treatments needed | Composite resin restoration | 74.6% did not need retreatment Overall retreatment higher than control OREST = 3.10 |
Mejare et al. (2005) Sweden | Retrospective cohort | Mild & Severe | NR | At referral: Mean 8.5 SD ± 2.16 Range 6–17 At follow-up: Mean 18.2 | NR | 34 restorations | Success of restoration | Composite resin restoration | 85.3% acceptable |
de Souza et al. (2017) Brazil | Randomised trial | Severe | 18 | Mean 7 Range 6–8 | 18 (0) | 41 | Success of restoration using USPHS-modified criteria | Selective-etch adhesive (SEA) or total etch adhesive (TEA) composite resin restoration | SEA 68%, TEA 54% cumulative survival |
Sonmez and Saat (2017) Turkey | Randomised trial | Severe | 24 | Mean 8.8 Range 8–12 | 30 (0) | 95 | Success of restoration using USPHS-modified criteria | Composite resin restoration G1: Invasive cavity preparation G2: Non-invasive cavity preparation G3: Non-invasive cavity preparation + pretreatment with 5% sodium hypochlorite G4: control, unaffected by MIH | Retention rate: G1: 93.7% G2: 80.7% G3: 93.5% G4: 100% No difference in success rates between G1, G3, and G4. Success rate group 2 significantly lower than other 3 groups |
Gatón-Hernandéz et al. (2020) Spain | Prospective cohort | Severe | 24 | Mean 7.33 Range 6–8 | 326 (45) | 326 | Success of restoration, evidence of radiographic apexogenesis, absence of pulpal pathology | Selective caries removal and placement of GIC restoration. Replacement wtith composite resin restoration at 6 months | 96.8% clinical and radiographic success |
Linner et al. (2020) Germany | Retrospective cohort | Severe | Mean 42.9 | Mean 11.2 SD ± 2.9 Range 6.6–18. 2 | NR | 126 27 | Success of restoration using FDI criteria | Non-invasive composite resin restoration Conventional composite resin restoration | 29.9% cumulative survival at 36 months 76.2% cumulative survival at 36 months |
Rolim et al. (2020) Brazil | Randomised trial | Severe | 12 | Mean 10 Range 7–16 | 35 | 64 (14 teeth) | Success of restoration using USPHS-modified criteria | Bulk-fill composite resin restoration GI: TEA G2: SEA | G1: 80.8%, G2: 62.3% cumulative survival, no difference between groups |
Amalgam restorations | |||||||||
Greece | Retrospective case–control | Mild & Severe | Mean 54 | Mean 7.7 | NR | 18 restorations | Number of re-treatments needed | Amalgam restoration | 38.9% did not need retreatment Overall retreatment higher than control OREST = 3.10 |
Mejare et al. (2005) Sweden | Retrospective cohort | Mild & Severe | NR | At referral: Mean 8.5 SD ± 2.16 Range 6–17 At follow-up: Mean 18.2 | NR | 32 restorations | Success of restoration | Amalgam restoration | 78.1% acceptable |
Preformed Metal Crowns (PMC) | |||||||||
Greece | Retrospective case–control | Mild & Severe | Mean 54 | Mean 7.7 | NR | 24 restorations | Number of re-treatments needed | Placement of PMC | 100% did not need retreatment Overall retreatment higher than control OREST = 3.10 |
Koleventi et al. (2018) Greece | Prospective cohort | Severe | 6 | Mean 10.6 SD ± 4.2 | 14 (0) | 14 | Multiple periodontal and microbiological outcome measures | Placement of PMC | 100% survival. Increase in gingival index, periodontal depth, P. Gingivalis and T. Forsythia counts when compared with untreated teeth |
Oh et al. (2020) South Korea | Retrospective cohort | Severe | 44.3 mean (12–118) | Mean 9.27 Range 6–14 *mixed data | NR | 50 | Success of restoration | Placement of PMC | 86% survival |
Laboratory manufactured restorations | |||||||||
Gaardmand et al. (2013) Denmark | Prospective cohort | Severe | 38.5 mean | Mean 12 Range 8–18 | 33 | 57 (4 restorations) | Success of restoration | Cast adhesive gold coping | 98.2% functioning at mean 38.6 months |
Dhareula et al. (2018) India | Case series | Severe | 34.8 mean, (30–36) | Mean 11.4 Range 8–14 | 10 | 10 | Success of restoration using USPHS criteria | Indirect composite resin onlay | 100% survival |
Dhareula et al. (2019) India | Randomised trial | Severe | 36 | Mean 10.2 Range 8–13 | 30 | 42 (5 restorations) | Success of restoration, radiographics outcomes, Shiff's sensitivity status, gingival health (Loe and Sillness GI) | G1: minimally invasive cast metal onlay G2: indirect resin onlay | G1: 85% G2: 100% No difference between groups |
Linner et al. (2020) Germany | Retrospective cohort | Severe | Mean 42.9 | Mean 11.2 SD ± 2.9 Range 6.6–18.2 | NR | 23 | Success of restorations using FDI criteria | CAD-CAM fabricated ceramic restoration | 100% cumulative survival at 36 months |
Extractions | |||||||||
Mejare et al. (2005) Sweden | Retrospective cohort | Mild & Severe | NR | At referral: Mean 8.5 SD ± 2.16 Range 6–17 At follow-up: Mean 18.2 | NR | 76 | Space closure | Extraction of FPM (between 1–4) | 87% acceptable space closure |
Jalevik and Moller (2007) Sweden | Prospective cohort | Severe | Median 68.4 (45.6–99.6) | Median 8.2 Range 5.6–12.7 | 33 (6) | 77 | Need for further orthodontic treatment | Extraction of FPM (between 1–4) | 45% favourable development of dentition without need for orthodontic intervention |
Oliver et al. (2014) Spain | Retrospective case series | Severe | Mean 44.4 (10–120 months) *mixed data | Mean 10.1 | 18 | 36 | Completed space closure | Extraction of FPM (between 1–4) | 61.2% complete space closure |
Findings for incisors
Study Country | Study Design | Severity of MIH | Follow-up in months (range) | Age of Participants | No. of participants (drop outs) | No. of teeth | Primary outcome measure | Intervention | Success |
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Resin Infiltration | |||||||||
Kim et al. (2011) South Korea | Prospective cohort | Mild | 0.25 | Mean 12.5 | 12 (0) | 20 | Complete masking as detected by colour change using photographic evaluation, CIE L*a*b* scoring method | Resin infiltration | 25% completely masked, 35% partially masked, 40% unchanged |
Elbaz & Mahfouz (2017) Egypt | Prospective cohort | Mild | 1 | Range 9–14 | 10 (0) | 20 | Colour change using photos and image analysing programme, assessment of radiographs | G1: Resin infiltration G2: NaF 6% varnish | G1: Mean color difference between sound and white spots significantly decreased, improvement in radiodensity G2: no change following treatment |
Bhandari et al. (2018) India | Prospective cohort | Mild | 6 | Range 7–16 | NR | 22 | Colour change using photographic evaluation, CIE L*a*b* scoring method | Resin infiltration | Overall colour change following treatment |
Microabrasion | |||||||||
Bhandari et al. (2019) India | Randomised trial | Mild | 6 | Range 7–16 | NR | 43 | Colour change using photographic evaluation, CIE L*a*b* scoring method | G1: microabrasion pumice slurry 37% phosphoric acid G2: microabrasion and CPP-ACP at home for 6 months | Overall colour change following treatment in both groups |
Findings for managing hypersensitivity
Study Country | Study Design | Tooth | Severity of MIH | Follow-up (months) | Age of Participants | No. of participants (drop outs) | No. of teeth | Primary outcome measure | Intervention | Success |
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Ozgul et al. (2013) Turkey | Randomised trial | I | Mild | 3 | Range 7–12 | 33 (0) | 92 | Cold stimulus with VAS pain scale | G1A: 5% NaF varnish G1B: 5% NaF varnish & ozone G2A: 10% CPP-ACP creme G2B: Ozone & CPP-ACP creme G3A: 10% CPP-ACP creme containing 900 ppm fluoride G3B: 10% CPP-ACP containing 900 ppm fluoride & ozone | Reduction in hypersensitivity in all groups. No difference between groups |
Bekes et al. (2017) Germany | Non-randomised trial | M | Mild & Severe | 2 | Mean 8.2 | 19 (4) | 56 | Cold and mechanical stimulus with SCASS and WBFS | 8% arginine & calcium carbonate paste professionally applied | Reduction in hypersensitivity |
Pasini et al. (2018) Italy | Randomised tiral | M | Mild & Severe | 3 | Range 8–13 | 40 (0) | 40 | Cold and mechanical stimulus with SCASS and VAS pain scale | G1: Control (1000 ppm fluoride TP) G2: 10% CPP-ACP creme in custom tray, twice daily for 2 h | Reduction in hypersensitivity in test group |
Muniz et al. (2020) Brazil | Randomised trial | M&I (115 M/99I) | Mild & Severe | 1 | Mean 8.89 SD ± 2.13 Range 8–12 | 66 (6) | 214 | Cold stimulus and PIFS | G1: Laser G2: 5% NaF varnish G3: 5% NaF varnish and laser | Overall reduction in hypersensitivity in all groups. FV with laser better than laser alone but no difference between FV and FV with laser. Laser immediate effect and FV late onset effect |
Findings for increasing mineral content
Study Country | Study Design | Tooth | Severity of MIH | Follow-up (months) | Age of Participants | No. of participants (drop outs) | No. of teeth | Primary outcome measure | Intervention | Success |
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Baroni & Marchionni (2011) Italy | Prospective cohort | M | Severe | 36 | Range 6–9 | 30 (0) | 30 | In vivo replicas, in vitro biopsy with SEM and ESEM-EDX analysis | 10% CPP-ACP creme in disposable trays, 20 min every evening | Improvement in mineralisation, morphology and porosities in enamel. Reduction in carbon and significant increase in calcium and phosphate |
Restrepo et al. (2016) Brazil | Randomised trial | I | Mild & Severe | 1 | Mean 10.25 SD ± 1.14 Range 9–12 | 51 (0) | 51 | Quantitative light fluorescence imaging | G1: control G2: 4 × applications 4% NaF varnish | No difference in fluorescence between groups |
Bakkal et al. (2017) Turkey | Prospective cohort | M&I (155 M/140I) | Mild | 1 | Mean 9.9 SD ± 1.6 Range 7–12 | 38 (0) | 285 | Laser fluorescence | G1: 10% CPP-ACP creme G2: 10% CPP-ACP containing 900 ppm fluoride | Both groups had a reduction in LF readings but no difference between the groups |
Biondi et al. (2017) Argentina | Prospective cohort | M&I (teeth NR) | Mild & Severe | 1.5 | Range 6–17 | 55 (0) | 92 | Laser fluoresence | G1: 5% NaF varnish G2: 10% CPP-ACP creme G3: 5% NaF varnish containing tricalcium phosphate (TCP) | Reduction in LF scores for all three groups in mild lesions only. NaF better at remineralising severe lesions and NaF with TCP bettter at remineralising mild |
Findings for patient-centred outcome measures
Study | Study Design | Severity of MIH | Follow-up in months (range) | Age of participants | No. of participants (drop outs) | No. of teeth | Primary outcome measure | Intervention | Success |
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Jalevik and Klingberg (2012) Sweden | Retrospective case control | Severe | 108 | 18 at time of review | 72 (5) | NR | CFSS-DS to measure dental fear and anxiety, DVSS satisfaction with dental care, dental health and behaviour management problems by reviewing records. Measured at age 9 and 18 and compared with 41 controls | Over 9-year period G1 MIH: restorations 26 (86%), extractions 7 (23%), both restorations and extractions 27 (90%) G2 control: restorations 12 (32%), extractions 1 (3%), both restorations and extractions 12 32(%) | Increased dental fear and anxiety in MIH group at age 9 At age 9, 9 × more treatment in MIH group vs control. Overall 4.2 × more treatment vs control Behaviour management problems higher in MIH group. No difference in satisfaction between groups |
Hasmun et al. (2020) UK | Prospective cohort | NR | 6 | Mean 11 Range 7–16 | 103 (17) | Mean 3.2 per participant | OHRQoL using C-OHIP-SF19, SPCC physical appearance subscale, social acceptance subscale, global self-worth | Microabrasion (4.65%), resin infiltration (4.65%), tooth whitening (4.65%), composite resin restoration (2.32%), microabrasion & resin infiltration (54%), microabrasion & tooth whitening (9.3%), tooth whitening & microabrasion and/or resin infiltration (7%) | Improvement C-OHIP-SF19 score from 47.4 to 59.8 Improvement in SPCC physical subscale appearance. No changes for social acceptance subscale or global self-worth |
Risk of bias assessment
Discussion
Management of posterior teeth
Management of anterior teeth
Management of hypersensitivity
Increasing mineral content
Patient-reported outcomes following treatment
Conclusion
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There is convincing evidence to support the use of resin-based fissure sealants, preformed metal crowns, direct composite resin restorations and laboratory-made restorations for MIH-affected molars in specific clinical scenarios.
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There is little evidence to support any approaches for affected anterior teeth.
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There is some evidence to support the use of products containing CPP-ACP which may be beneficial for MIH-affected teeth.
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An increase in the existing number of studies addressing the management of MIH-affected teeth has been observed, however, the majority have several methodological limitations and are at moderate or high risk of bias, which reduces the external validity of the results.
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There is a need for further high-quality studies with more participants, longer follow up periods and more clinically relevant and appropriate outcome measures in the management of MIH-affected teeth.