Int J Paed Dentistry - 2019 - Gatón Hernandéz - Minimally Interventive Restorative Care of Teeth With Molar Incisor
Int J Paed Dentistry - 2019 - Gatón Hernandéz - Minimally Interventive Restorative Care of Teeth With Molar Incisor
Int J Paed Dentistry - 2019 - Gatón Hernandéz - Minimally Interventive Restorative Care of Teeth With Molar Incisor
DOI: 10.1111/ipd.12581
ORIGINAL ARTICLE
1
School of Dentistry, University of
Barcelona, Barcelona, Spain
Abstract
2
Instituto Catalão da Saúde, Barcelona, Aim: To assess the efficacy of treatment using a minimally invasive approach (se-
Spain lective removal of carious tissue, restoration and preventive strategies) in immature
3
School of Dentistry of Ribeirão permanent molars with MIH.
Preto, University of São Paulo, Ribeirão
Design: A total of 281 patients, aged 6‐8 years, with carious lesions (ICDAS 5‐6),
Preto, São Paulo, Brazil
4
Mínima Intervenção e Traumatismo Dental
severe MIH, and incomplete root formation (one tooth/patient) were included. After
(MITD), Barcelona, Spain clinical and radiographic examinations, selective carious tissue removal was per-
5
Growth and Development, Melbourne formed, and the teeth received interim restoration for 6 months and were then re-
Dental School, University of Melbourne,
stored with composite resin. Clinical and radiographic follow‐up was undertaken, 6,
Melbourne, Vic., Australia
6 12, 18, and 24 months. A protocol of preventive oral care measures was established
School of Dentistry, University of
Groningen, Groningen, Netherlands and repeated at each follow‐up, including diet counselling, oral hygiene instruction,
dental plaque control, and topical application of fluoride varnish containing CPP‐
Correspondence
Carolina Maschietto Pucinelli, School of
ACP. All clinical procedures and evaluations were done by a single operator.
Dentistry of Ribeirão Preto, University of Results: Clinical and radiographic success was observed 24 months after treatment
São Paulo, Av. do Café s/n, Monte Alegre, in 96.8% of the cases. Failures were due to enamel fracture at restoration margins,
Ribeirão Preto, São Paulo, Brazil.
Email: [email protected] resulting in pulpitis and absence of apex closure.
Conclusion: Selective removal of carious tissue, interim, and subsequently defini-
tive restoration, combined with home and professional preventive measures, main-
tained marginal integrity of restorations in immature permanent molars with severe
MIH, confirmed by pulp vitality and occurrence of apexogenesis.
KEYWORDS
apexogenesis, MIH, molar incisor hypomineralization, open apex, selective removal of carious tissue
4 | © 2019 BSPD, IAPD and John Wiley & Sons A/S. wileyonlinelibrary.com/journal/ipd Int J Paediatr Dent. 2020;30:4–10.
Published by John Wiley & Sons Ltd
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GATÓN‐HERNANDÉZ et al. 5
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6 GATÓN‐HERNANDÉZ et al.
radiographic features (resorption, thickening of the lamina After 24 months of follow‐up the percentage of clin-
dura, and apical radiolucency); and continued apical devel- ical and radiographic success and failure was calculated.
opment. At each time point, if any clinical or radiographic Kaplan‐Meier survival analyses were also performed to eval-
alteration was detected, the tooth was not submitted to fur- uate the survival rate, using GraphPad Prism 5.0a package
ther evaluations and classified as a failure. The outcomes in (GraphPad).
the study included integrity of the restoration and peripheral
enamel, normal response to pulp sensitivity test (refrigerant
spray), absence of sensitivity to percussion, absence of radio- 3 | RESULTS
graphic features (resorption, thickening of the lamina dura,
and periapical lesions), and apical development and apex- A total of 281 patients (86.2%) completed the 24‐month
ogenesis (to apex closure) in immature permanent molars study follow‐up, and 45 patients (13.8%) left the study after
with MIH. the initial visit (Figure 1 and Table 1). The mean age of the
During the 24‐month experimental period, at every clin- children was 7 years and 4 months.
ical follow‐up, different preventive procedures were imple- In 272 teeth (96.8%), clinical and radiographic success
mented in order to stabilize caries activity and favour the (no pain, integrity of the restoration margins, and absence
remineralization process. These procedures included the of pathological radiographic alterations) was observed at
following: diet counselling, oral hygiene instructions, den- all time points up to 24‐month follow‐up after the selective
tal plaque control using a plaque disclosing agent (GC Tri carious tissue removal technique and restoration plus pre-
Plaque ID Gel, GC Corporation) and professional topical ventive measures. Apexogenesis with physiological closure
application of fluoride varnish, and material containing ca- of the root apex was detected in all 272 successful cases
sein phosphopeptide‐amorphous calcium phosphate (CPP‐ (Figure 2).
ACP) (MI Varnish™ with RECALDENT™‐CPP‐ACP; GC The nine cases of failure (3.2%) presented enamel fracture
Corporation). In addition, the patients and/or parents were at the restorative margin with consequent pulpitis and ab-
instructed to routinely use a pea‐sized amount of a fluoride‐ sence of apical closure. Endodontic treatment was performed
containing dentifrice on the surface of the affected teeth at in these cases. Table 2 describes the results obtained after
bedtime, without mouth rinsing. different time points evaluation.
Follow-Up
Analysis
Analysed (n = 272)
-Excluded from analysis (give reason) (n = 0)
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GATÓN‐HERNANDÉZ et al. 7
TABLE 1 Number of failure per time period, failure rate and to plaque accumulation, and subsequent demineralization.7
survival rate at each analysed time period, after selective removal of Carious lesions are frequently observed in very young chil-
carious tissue and restoration plus preventive measures in immature dren with immature teeth affected by MIH, such as those
permanent molars used in the present study.
Number of failure Failure rate Survival rate The intense pain reported by patients with severe MIH,
Months per time period (%) (%) the frequent difficulty in achieving pain control during
2 mo 1 0.071 99.929 treatment, the extensive coronal destruction, and the rapid
carious lesion progression 2 may lead to excessive removal
6 mo 3 0.338 99.662
of dental tissue and misdiagnosis of the actual pathologi-
12 mo 5 0.929 99.071
cal status of the pulp. This may result in unnecessary end-
18 mo 0 0.929 99.071
odontic treatment or extraction.2,13 Therefore, to preserve
24 mo 0 0.929 99.071 as much healthy dental tissue as possible, it is important to
adopt minimally invasive clinical techniques. A systematic
Figure 3 shows the Kaplan‐Meier survival curve of the se- review and meta‐analysis 14 concluded that incomplete car-
lective removal of carious tissue and restoration plus preven- ious tissue removal, particularly when dealing with deep
tive measures in immature permanent molars. The 24‐month carious lesions, reduces the risk of pulp exposure, improv-
survival rate was 99.07%. ing the prognosis of the tooth.14 The results of the present
study demonstrated that after selective carious tissue re-
moval in teeth with MIH and open apex, pulp vitality was
4 | D IS C U SSION maintained, evidenced by continued root development, and
physiological apical closure was observed. To the best of
The presence of MIH and dental caries is known to be closely our knowledge, there are no studies evaluating the mainte-
related,6,7 possibly due to the affected enamel already miss- nance of pulp vitality and the physiological apexogenesis
ing considerable mineral content, predisposing it to post‐cari- in immature permanent molars with MIH as the outcomes
ogenic challenge cavitation; and post‐eruptive breakdown of selective removal of carious tissue and restoration in
related to the lower enamel strength, predisposing the enamel combination with a preventive oral care protocol.
(A) (B)
(C) (D)
F I G U R E 2 A, Initial periapical
radiograph showing caries lesion and
incomplete root formation; B, clinical aspect
showing severe MIH; C, interim restoration
with glass ionomer cement; D, periapical
radiograph after the 24 mo post‐operative
evaluation showing integrity of the lamina
dura and occurrence of physiological apical
closure (apexogenesis)
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8 GATÓN‐HERNANDÉZ et al.
TABLE 2 Causes of failures and periods of occurrence, after selective removal of carious tissue and restoration plus preventive measures in
immature permanent molars
6 12 18 24
Clinical failure n = 4 (Pulpitis with sponta- – – –
neously pain)
Radiographic failure – n=5 – –
(Apical periodontitis)
Failure of Integrity of the restorations n = 4 (Enamel fracture on n=5 – –
and peripheral enamel restoration margins) (Enamel fracture on restoration margins)
Absence of apical closure n=4 n=5 – –
Several treatment approaches have been proposed for cases was the sole clinician. This fact minimized the interfer-
teeth with severe MIH.2,4,15 In the present work, a minimal ence of confounding factors on the results, which may occur
intervention treatment protocol for severe MIH cases was es- in multicenter studies, where various operators perform these
tablished, involving the selective removal of carious tissue, procedures.
filling of cavities using glass ionomer cement for six months According Dhareula et al,23 there is no agreement on the
followed by definitive restoration with resin composite in best restorative treatment options for severe MIH with hy-
combination with preventive home and professional oral care persensitivity and post‐eruptive breakdown. There are many
measures. According to the clinical parameters established restorative options available for these patients, including
for this protocol, a high clinical and radiographic success rate glass ionomer cement and resin composites.4 In the present
(96.8%) was achieved after 24 months, which is a relevant study, glass ionomer cement was used as an interim resto-
result from a clinical standpoint. Materials containing CPP‐ ration material, before the permanent restoration. In com-
ACP, such as used in the present study, provide a supersatu- bination with diet counselling, oral hygiene instruction,
rated environment of minerals such as phosphate and calcium dental plaque control, and professional application of flu-
on the enamel surface, enhancing remineralization.4 These oride, the interim restoration was used in order to improve
have been recommended for MIH cases.2,16 the oral environment conditions, enhance remineralization,
The authors agree with Lygidakis et al,4 who state that and subsequently reduce the caries risk. According to the
the prevention of dental caries is very important, because results obtained, it was observed that the adoption of these
caries and post‐operative breakage are more likely to occur approaches showed a high efficacy, with almost 96.8% suc-
in affected teeth, especially due to its higher porosity, min- cess rate. Also, no pain, integrity of the restoration margins,
eral density, and hardness. If the prevention measures are and absence of pathological radiographic alterations were
efficient, a more favourable oral environment is created for observed.
the occurrence of remineralization, reducing the caries risk.
According to Crombie et al17 caries remineralizing agents in-
crease mineral content and decrease porosity in teeth with
MIH, demonstrating that the mineral content in these teeth
can be improved.
Also, the enamel porosity in MIH could facilitate the
penetration of bacteria through the dentinal tubules, result-
ing in subclinical pulpal inflammation.18 MIH hypersen-
sitivity, however, is not only related to carious lesions, as
Raposo et al reported significant association between MIH
and air blast and tactile stimuli.19 Some treatments have
been suggested in order to improve the hypersensitivity,
such as Nd:YAG Laser,20 CPP‐ACP,21 and desensitizing
products.22
An important factor that certainly increases the reliability
of the obtained results is that, in the present study, a single F I G U R E 3 Kaplan‐Meier survival curve for the selective
researcher with extensive experience in diagnosis, operative/ removal of carious tissue and restoration plus preventive measures in
restorative procedures, and clinical/radiographic follow‐up of immature permanent molars
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GATÓN‐HERNANDÉZ et al. 9
In the present study, resin composite was used as the AUTHOR CONTRIBUTIONS
restorative material in order to minimize removal of dental
PGH, RABS and PNF: conceived the ideas. PGH, CRS, ERC
tissue. Resin composites seem to be the most suitable ma-
and JMUT: collected the data. CRS, LABS, ERC, CMP, DM
terial for direct restorations in MIH cases, and this material
and JMUT analysed the data. LABS, RABS, CMP, DM and
does not need retentive preparations in order to bond to the
PNF contributed to the writing.
enamel,9 requiring only the use of adhesive systems such
as self‐etching or total etch.24 Adhesion of the restorative
material, however, is decreased on the soft, hypomineral- ORCID
ized enamel of teeth with MIH, and therefore, the risk of
Carolina Maschietto Pucinelli https://orcid.
early loss of restorations and development of carious le-
org/0000-0003-4876-6892
sions at the restorative margin is much higher.2 Possibly,
the high success rate obtained in the present study (96.8%) David Manton https://orcid.org/0000-0002-4570-0620
is associated with the improvement of the oral environment Paulo Nelson‐Filho https://orcid.
conditions, which favour remineralization and enhance the org/0000-0002-4007-7833
quality of enamel, as a result of the preventive oral care
measures and periodic evaluation of the resin composite
restorations at follow‐up visits. Additionally, care was R E F E R E NC E S
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