Current evidence on the diagnosis and treatment of

Current evidence on the diagnosis and treatment of hypomineralisation Felicity Crombie BDSc (Hons), Ph. D, M Clin Ed Senior Lecturer, Melbourne Dental School

Hypomineralisation What can go wrong before the teeth erupt? What does it mean once the teeth have erupted?

Hypomineralisation

Hypomineralisation What can go wrong before the teeth erupt? Early childhood • Birth to 8 years old (United Nations) Primary & permanent dentition relevant • ~13 weeks in utero to ~ 4 -5 years of age

Hypomineralisation What can go wrong before the teeth erupt? Hypoplasia • Quantity of tissue Hypo-mineralisation/calcification • Quality of tissue Other

• Amelogenesis Imperfecta All teeth affected - primary and permanent dentition • Variety of phenotypes - enamel hypomineralised, hypoplastic or both • Non-enamel abnormalities • Prevalence 1: 700 - 1: 14000 • Aetiology genetic

Amelogenesis Imperfecta Gene Protein and/or Description/Role AMELX Amelogenin: Enamel matrix protein ENAM Enamelin: Enamel matrix protein WDR 72 Intracellular protein - ? vesicle turnover FAM 83 H Intracellular protein - ? keratin interaction MMP 20 Matrix metalloproteinase 20: secretory stage enamel matrix removal KLK 4 Kalikrien 4: maturation stage enamel matrix removal C 4 ORF 26 Extracellular phosphoprotein capable of promoting mineral nucleation DLX 3 Transcription factor LAMB 3 Cell attachment SLC 24 A 4 Calcium transporter Adapted from Wright

Dentinogenesis Imperfecta • All teeth affected - and Dentine Dysplasia primary and permanent dentition often more severe in primary dentition • Discoloured, bulbous crowns • Short roots • Pulpal obliteration • Aetiology genetic

Fluorosis • Hypomineralisation - increased fluoridated apatite? • Hypoplasia and post-eruptive breakdown (PEB) • Primary dentition? • Prevalence highly variable - • Australia ~35% individual, ~40% tooth level mostly very mild or mild Aetiology predominantly environmental Richards et al, 1992 Do, 2007 Arrow, 2008

Molar Incisor Hypomineralisation (MIH) “hypomineralisation of systemic origin of one to four permanent first molars, frequently associated with affected incisors” Weerheijm, 2001

MIH Crombie et al, 2008

MIH • Hypomineralisation +/- PEB of key teeth - Mahoney et al, 2004 Fearne et al, 2004 Crombie et al, 2013 permanent dentition only (? )

MIH • Hypomineralisation +/- PEB of key teeth - Crombie et al, 2013 Xie et al, 2008 Taube et al, 2015 Fraser et al, 2014 permanent dentition only (? ) higher carbonated apatite content

MIH • Hypomineralisation +/- PEB of key teeth - Crombie et al, 2013 Mangum et al, 2010 Farah et al, 2010 permanent dentition only (? ) higher carbonated apatite content increased protein content surface layer Melin et al, 2015

MIH • Hypomineralisation +/- PEB of key teeth • Highly variable Photos courtesy of Karin Weerheijm

MIH • Hypomineralisation +/- PEB of key teeth • Highly variable • Non-enamel abnormalities - dentine Heijs, 2007 Fagrell et al, 2008 Cocker, DCD thesis, 2014

MIH • Hypomineralisation +/- PEB of key teeth • Highly variable • Non-enamel abnormalities - Fagrell et al, 2008 Rodd, 2007 dentine pulp

MIH • Hypomineralisation +/- PEB of key teeth • Highly variable • Non-enamel abnormalities • Prevalence • Aetiology - Australia ~22%; 6% “severe” - uncertain - environmental + epi/genetic? Arrow, 2008 Jeremias et al, 2013 Alaluusua, 2010 Crombie et al, 2009 Kuhnisch et al, 2013

MIH • Expand definition? • Hypomineralised Second Primary Molars (HSPM) - Second Primary Molars especially - Other primary and permanent teeth - Australian prevalence 14% - may be associated with MIH in permanent dentition - similar problems – similar properties? Owen, DCD Thesis, 2015 Leen, DCD Thesis, 2015 Ghamin et al, 2013 Elfrink et al, 2012 Negre-Barber et al, 2016 Mittal & Sharma, 2013 Costa-Silva et al, 2013

Hypomineralisation What does it mean once the teeth have erupted?

• Amelogenesis Imperfecta, Dentinogenesis Diagnosis Imperfecta & Dentine - • all teeth family history genetic investigation other associated conditions e. g. osteogenesis imperfecta Dysplasia Treatment - generally specialist complex and lifelong influenced by type

Fluorosis • Diagnosis - primary teeth spared fluoride history other diagnoses not mutually exclusive Photo courtesy of David Manton

Fluorosis • Treatment - primary prevention may be possible generally aesthetic etching properties Photos courtesy of Fiona Ng and David Manton

Fluorosis • Treatment - primary prevention may be possible generally aesthetic etching properties Al-Sugaur & Akpata 1999 Torres-Gallegos et al

MIH • Diagnosis - Chawla et al, 2008 Ghanim et al, 2015 Fragelli et al, 2015 key teeth non-chronological deterioration can be rapid be alert for atypical observations hypoplasia versus PEB & HSPM?

MIH • Treatment - Crombie et al 2013 Baroni & Marchionni, “Re”-mineralisation & HSPM?

MIH • & HSPM? Treatment - “Re”-mineralisation Restorative issues Intervention Sealants (69. 2%) MIH group Control group 35 (25. 7%) 90 Amalgam fillings (4. 6%) 18 (13. 2%) Composite resin 59 (43. 4%) 34 (26. 2%) SSCs 24 (17. 6%) - Restorative intervention 101 (74. 3%) (30. 8%) Jalevik & Klingberg 2002 Kotsanos et al 2005 Total Mejare et al 2005 6 interventions 40 136 130

MIH • Treatment - William et al 2006 “Re”-mineralisation Restorative issues - etch & HSPM?

MIH • Treatment - “Re”-mineralisation Restorative issues - etch - pre-treatment - recommendations Burrow conference presentation & HSPM?

MIH • Treatment - “Re”-mineralisation Restorative issues - etch - pre-treatment - recommendations - full coverage William et al, 2006 Zagdwon et al, 2003 Ghandi et al, 2012 Sood et al, 2008 Chay et al, 2014 Lygidakis, 2009 Pictures courtesy of Marilyn Owen AAPD website & HSPM?

MIH • Treatment - - Mejare et al 2005 alevik & Moller, 2007 & HSPM? “Re”-mineralisation Restorative issues - etch - pre-treatment - recommendations 7. 7 years - full coverage Extraction - orthodontic considerations 13. 8 years 8. 8 10. 2

MIH • Treatment - - “Re”-mineralisation Restorative issues - etch - pre-treatment - recommendations - full coverage Extraction - orthodontic considerations Anaesthetic - Local - General Cabasse et al 2015 Eidelman et al 2000 Ridell et al 2015 Jalevik & Klingberg 2002 and & HSPM?

MIH • Anterior lesions - Rodd et al, 2011 Mastroberardino 2012 caries and PEB relatively rare aesthetics & HSPM?

MIH • Anterior lesions - Attal et al 2014 Crombie et al 2014 Natarajan et al 2015 caries and PEB relatively rare aesthetics & HSPM?

Thank you