Received: 8 February 2018 Revised: 8 June 2018 Accepted: 5 August 2018

DOI: 10.1111/jerd.12420

REVIEW ARTICLE

Dental hypomineralization treatment: A systematic review

Ana Sofia Estima da Cunha Coelho PhD1,2 | Pedro Carlos Machado Mata DDS3 |
Carolina Alves Lino DDS1 | Viviana Marisa Pereira Macho PhD3 |
Cristina Maria Ferreira Guimarães Pereira Areias PhD3 |
Ana Paula Mendes Alves Peixoto Norton PhD3 | Ana Paula Coelho Macedo Augusto PhD3

1
Dentistry Area, Faculty of Medicine,
University of Coimbra, Coimbra, Portugal
2
iCBR, Coimbra Institute of Clinical and
Biomedical Research, Faculty of Medicine,
University of Coimbra, Coimbra, Portugal
3
Faculty of Dentistry, University of Oporto,
Oporto, Portugal
Correspondence
 Materials and Methods: PubMed, Scopus, Cochrane Library, Web of Science, and Embase were
Dr Ana Sofia Estima da Cunha Coelho, Area de
Medicina Dentária Av. Bissaya Barreto, Bloco
de Celas, 3000-075 Coimbra.
Email: anasofiacoelho@gmail.com
Abstract
Introduction: Defects in the maturation stage of amelogenesis result in a normal volume of
enamel but insufficient mineralization, called hypomineralization. Molar-incisor hypomineraliza-
tion (MIH), amelogenesis imperfecta and dental fluorosis (DF) are examples of such defects.
Objective: To evaluate the effectiveness of the treatments applied to the different forms of
dental hypomineralization.
screened. The research was limited to studies published in English, Spanish, and Portuguese,
until May 30, 2018. The research question was formulated following the Population, Interven-
tion, Comparison, Outcome strategy. The quality of the methodology of each article was evalu-
ated employing the Cochrane Handbook for Systematic Reviews.
Results: From the initial research, 7895 references were obtained, of which 33 were included in
the systematic review. The following treatments were reported: desensitizing and remineralizing
products, resin infiltration, restorations, fissure sealants, tooth bleaching, enamel microabrasion
and calcium, and vitamins supplements.
Conclusions: Although the results are suggestive, there is a clear need for a greater uniformity
of the methodologies, thus allowing for the development of clinical guidelines. Nevertheless, it
was possible to identify several effective treatments for teeth with MIH (arginine pastes or fluo-
ride varnishes) and DF (tooth bleaching and/or enamel microabrasion).
Clinical Significance: Because MIH, amelogenesis imperfecta, and DF are commonly seen in
dental daily practice, it is extremely important to analyze the literature regarding its treatment.

KEYWORDS

amelogenesis imperfecta, dental fluorosis, hypomineralization, molar-incisor

hypomineralization, treatment

1 | I N T RO D UC T I O N of fragile and quantitatively defective enamel (hypoplasia).2,3 Con-

Dental enamel is a tissue composed of hydroxyapatite crystals (98%)
associated to a matrix composed of water and organic matter (2%)
1
arranged in an elongated hexagonal configuration. It is the hardest
tissue of the human body and its formation is controlled by differenti-
ated cells, the ameloblasts.1,2 The life cycle of these cells is comprised
of 5 stages: presecretory, secretory, transition, maturation, and post-
maturation.1 Generally, defects that occur during the secretory phase
result in minor matrix secretion and, consequently, in the production
versely, defects occurring during the maturation stage result in a
normal volume of enamel but with insufficient mineralization
(hypomineralization).3–5 Within the dental hypomineralization defects,
it is possible to include molar-incisor hypomineralization (MIH), amelo-
genesis imperfecta (the hypomaturated type and the hypocalcified
type), and dental fluorosis (DF).6–9
MIH is defined as a demarcated and qualitative enamel defect of
systemic origin that affects one or more permanent molars and may
also affect the permanent incisors.8,10 Less frequently, MIH-like

J Esthet Restor Dent. 2018;1–14. wileyonlinelibrary.com/journal/jerd © 2018 Wiley Periodicals, Inc. 1

2 DA CUNHA COELHO ET AL.

defects have been described in permanent canines and premolars and The aim of this systematic review was to evaluate the effective-
in primary second molars. Although many studies have researched the ness of treatment methodologies applied to dental hypomineraliza-
potential factors involved in the occurrence of MIH, results have been tion: MIH, AI (hypomatured and hypocalcified type), and DF.
inconclusive. The most frequently suggested factors are neonatal
problems (prematurity and/or low birth weight), early childhood ill-
nesses (asthma or bronchitis), fever, hospitalization, oxygenation with-
2 | M A T E R I A L S A N D M ET H O D S
out intubation, and antibiotic therapy. Some authors have suggested a
genetic-based etiology.11–18 The prevalence of MIH in children and
For this systematic review, a database search was performed in
adolescents varies among different studies, with reported values
PubMed (www.ncbi.nlm.nih.gov/pubmed), Scopus (www.scopus.com),
between 2.8% and 40%.19 Clinically, MIH is characterized by variable-
Cochrane Library (www.cochranelibrary.com), Web of Science (www.
sized opacities, with a white to yellow/brownish staining and a
webofscience.com), and Embase (www.embase.com; Table 1). The
defined demarcation between healthy and affected enamel.20,21 Pos-
research was limited to articles in English, Spanish, and Portuguese,
teruptive breakdown may occur because of masticatory forces, either
published until May 30, 2018.
immediately or later, which facilitates the accumulation of bacterial
The research strategy was formulated following the Population,
plaque. These factors lead to a subclinical inflammatory response and
Intervention, Comparison, Outcome form36 (Table 2).
subsequent hypersensitivity.10,22
Only clinical trials on at least 10 human subjects having one or
Amelogenesis imperfecta (AI) represents a set of developmental
more teeth with enamel hypomineralization (because of MIH, AI, or
defects of genetic origin that interfere with the structure and clinical
DF) were included. The affected teeth had to be in need of treatment
appearance of the enamel of all or nearly all teeth.5,6 AI has a reported
and the results of at least 1 treatment method had to be reported.
prevalence up to 0.14%.23,24 Witkop25 recognizes 4 main types of AI
Articles evaluating the success of preventive treatments were also
based on their phenotype: hypoplastic, hypomatured, hypocalcified
included.
(hypomineralized), and hypomatured-hypoplastic. The hypocalcified
As so, during the selection process review articles, cell and animal
and hypomatured forms are the only types that can be classified as
studies, letters to the editor, clinical cases, and comments were
hypomineralization defects.1,25 The hypocalcified type is characterized
by enamel of normal thickness but with incomplete matrix mineraliza- excluded. Articles whose abstracts were unavailable online and stud-

tion, which results in a soft and fragile enamel. 26

In the hypomatura- ies that exclusively measured the participants’ quality of life were also

lized type, the enamel has a normal thickness but it is opaque and excluded.

brittle because of an irregularity that occurs during the hydroxyapatite All titles and abstracts were examined by 2 reviewers in order to

crystals development in the maturation phase. 26,27 select the relevant studies. Selection of the eligible studies was per-

Exposure of the developing enamel organ to excessive amounts
7
of fluoride results in DF. The prevalence of children and adolescents
with DF ranges between 4% and 70%, with the mild forms being the
28–30
most common. Mildly fluorosed enamel is characterized by nar-
row, diffuse, poorly demarcated and bilateral white lines, and by an
31–33
increase in the subsurface porosity. The more severe forms may
gain a yellow/brown coloration and the enamel may present preerup-
tive or posteruptive breakdown, which leads to a greater susceptibility
to dental caries. DF can occur in both the primary and permanent
dentitions.4,30,34,35
formed by 2 reviewers and opinions of a third reviewer were called
upon in more ambiguous cases. Additional studies were selected by
analyzing the references from the included articles. The methodology
applied during the article selection in the systematic review is outlined
in Figure 1.
The quality of each article’s methodology was assessed through
the Cochrane Handbook for Systematic Reviews version 5.1.0.37 Each
of the selected studies was determined as possessing a high risk of
bias (if 3 or more parameters were assessed with high risk of or
unclear bias), medium risk (if 1 or 2 parameters were assessed with

TABLE 1 Databases consulted and their search formulas

Databases Search formulas

PubMed ((((((((((Hypominerali*) OR Hypocalcifi*) OR Hypomatur*) OR mottled enamel) OR ((MIH OR molar-incisor-hypominerali*)))
OR dental fluorosis[MeSH terms]) OR amelogenesis imperfecta[MeSH terms]))) AND ((((((((management) OR treatment)
OR rehabilitation[MeSH terms]) OR prevention) OR reminerali*) OR therapy) OR fluoride[MeSH terms])))
Scopus TITLE-ABS-KEY(hypomineralization OR hypocalcification OR hypomaturation OR “mottled enamel” OR MIH
OR “molar-incisor-hypomineralization” OR “dental fluorosis” OR “amelogenesis imperfecta”) AND
TITLE-ABS-KEY(management OR treatment OR rehabilitation OR prevention OR remineralization OR therapy OR fluoride)
Web of science (((((((Hypominerali*) OR Hypocalcifi*) OR Hypomatur*) OR mottled enamel) OR (MIH OR molar-incisor-hypominerali*))
OR fluorosis) OR amelogenesis imperfecta) AND TOPIC: (((((((management) OR treatment) OR rehabilitation)
OR prevention) OR reminerali*) OR therapy) OR fluoride)
Cochrane Library (((((((Hypomineralization) OR Hypocalcification) OR Hypomaturation) OR mottled enamel) OR fluorosis)
OR “Amelogenesis imperfecta”)) AND (((((((management) OR treatment) OR rehabilitation) OR prevention) OR
remineralization) OR therapy) OR fluoride)
Embase Hypomineralization OR hypocalcification OR hypomaturation OR mih OR “amelogenesis imperfecta”/exp OR “fluorosis”/exp
AND (“management”/exp OR treatment OR “rehabilitation”/exp OR “prevention”/exp OR “dental procedure”/exp
OR “therapy”/exp OR “fluoride”/exp OR remineralization)
DA CUNHA COELHO ET AL. 3

TABLE 2 PICO strategy used in the evaluation of scientific evidence

Parameter Evaluation
Population (P) Patients with enamel hypomineralization because of MIH, AI or DF
Intervention (I) Prevention, treatment of hipersensitivity and/or rehabilitation of affected teeth (through restorative, endodontic,
prosthetic, surgical or orthodontic methods)
Comparison (C) Placebo or without intervention;
Different treatment methods
Outcome (O) Successful prevention (no need for further interventions), improved esthetics and/or successful rehabilitation of affected teeth

high risk of or unclear bias), or low risk (if all the parameters were eval- studied the effect of casein phosphopeptides and amorphous calcium
uated with low risk of bias). phosphate (CPP-ACP) pastes. Grossi et al.43 used the atraumatic restor-
Given the methodological variability present in the studies ative treatment (ART) protocol and a glass hybrid restorative system
included in the systematic review it was not possible to perform a whereas Sönmez and Saat48 restored the affected teeth with a resin
quantitative analysis (meta-analysis). composite and evaluated the effects of deproteinization of the hypomi-
neralized enamel and of different cavity forms. Bekes et al.39,44
employed an arginine paste and Lygidakis et al.44 used fissure sealants.
3 | RESULTS Of the 12 studies, 939,41–46,48,49 only performed a visual assessment,
using different methods and indices, whereas Bakkal et al.38 and Biondi
The initial survey resulted in 7895 references of which 2008 were et al.40 used laser fluorescence, and Restrepo et al.47 analyzed the quan-
deleted because of duplication. After analysis of titles and abstracts, titative light-induced fluorescence.
56 articles were considered for full text analysis. Thirty-three studies Regarding DF, 850,53,57,60,62,65,67,68 of the selected studies
were included in the systematic review. Of these, 12 were related to assessed the bleaching of the affected teeth, 951,52,54–56,63,64,69,70
MIH and 21 to DF. No AI studies met the inclusion criteria. analyzed the effects of enamel microabrasion, 452,54,56,60 evaluated
The results for MIH and DF are presented in Tables 3 and 4, the effect of a combined treatment (tooth bleaching and enamel
respectively. microabrasion) and Gugnani et al.58 used a resin infiltrant. Gupta
40 45
Among the MIH studies, Biondi et al., Ozgul et al., and Restrepo et al.59 and Mehta et al.66 studied the effect of oral administration of
et al.47 applied fluoride varnish, whereas Fragelli et al.41,42 and Souza calcium and vitamins in reducing lesion size whereas Hasanuddin
et al.49 applied fluoride varnish and then restored/sealed the affected et al.61 applied fissure sealants to molars with DF. All authors analyzed
38 40 45 46
teeth. Bakkal et al., Biondi et al., Ozgul et al., and Pasini et al. the effectiveness of the treatments through a visual evaluation. Of

7895 References from the initial search

(Pubmed = 2641; Cochrane Library = 93; Web of Science = 2772; SCOPUS = 1724;
Embase = 665)

7839 Articles excluded for being duplicates or

after analysis of titles and abstracts

56 Articles selected for full text

examination

23 Studies excluded after reviewing the full text:

No group stratification by type of lesion (n=11)
Sample < 10 (n=4)
Case-report (n=4)
Unequal follow-up between groups (n=3)
Not an intervention study (n=1)

33 Articles included in the review

FIGURE 1 Flow diagram of the study selection process for the systematic review
 4

TABLE 3 Studies included in the systematic review for the treatment of incisor-molar hypomineralization

Authors Age
(year) Participants (n) (years) Intervention Measurement Follow-up Results Comments
Bakkal 38 teeth 7-12 I: CPP-ACP LF 30 d I: T0: 3.739  2.911; T1: 1.826  1.775a;
et al.38 II: CPP-ACFP II: T0: 5.267  2.815; T1: 2.667  2.320b
Bekes 12 6-14 2 applications of an arginine SCASS, WBFS 8 wk Air blast sensitivity (SCASS) Each participant was given a toothpaste, a
et al.39 paste T0: 2.1  0.3; T1: 0.8  0.9a toothbrush and a mouthwash
Tactile sensitivity (WBFS)
T0: 2.1  2.6; T1: 0.6  1.1a
Biondi 55 6-17 I: fluoride varnish (3× 1 min); II: LF 45 d Mild lesions All participants received dietary and oral hygiene
et al.40 CPP-ACP; III: fluoride varnish I: T0: 18.57 5.88; T1: 14.59  4.88c; instructions. Open caries lesions were
containing tricalcium II: T0: 17.37  7.22; T1: 15.15  5.19c; inactivated with a reinforced zinc oxide-
phosphate III: T0: 20.04  5.07; T1: 14.18  3.65c; eugenol material
Moderate lesions
I: T0: 56.88  15.71; T1: 31  11.97;
II: T0: 29.53  17.85; T1: 27.31  15.77;
III: T0: 28.85  8.99; T1: 23.1  7.74
Fragelli 21 6-9 1 mo of weekly applications of Photographs + 12 mo Survival rate: All participants received oral hygiene instructions
et al.41 (48 teeth) fluoride varnish + glass impressions T1: 35/45 (78.8%)
ionomer restoration
Fragelli 25 (MIH) + 16 6-8 4 weekly applications of fluoride USPHS 18 mo Success rate:
et al.42 (control) varnish + resin fissure sealant I: 72%; II: 62%
Grossi 44 7-13 Glass hybrid restorative system Clinical 12 mo Success rate: Success: present and satisfactory or with
et al.43 (60 teeth) (ART protocol) evaluation 98.3% deficiency at cavity margin less <0.5 mm
Lygidakis 47 6-7 I: fissure sealants with double Clinical 4y Fully sealed (%): I: 70.2; II: 25.5b All participants received oral hygiene instructions
et al.44 adhesive II: fissure sealants evaluation Partially sealed (%): I: 29.7; II: 44.6b + fluoride varnish every 6 mo
without adhesive Unsealed (%): I: 0; II: 29.7b
Ozgul 33 7-12 Ia: fluoride varnish; Ib: VAS (0, no 3 mo Ia: 3.21 (2.15)c; Ib: 2.93 (3.10)c Participants received toothbrushes, toothpastes
et al.45 ozone + fluoride varnish; IIa: pain after IIa: 4.53 (3.16)c; IIb: 4.87 (2.47)c and oral hygiene instructions
CPP-ACP; IIb: cold stimuli; IIIa: 3.92 (2.43)c; IIIb: 3.62 (2.84)c
ozone + CPP-ACP; IIIa: 10, worst Unit—difference with baseline (sum of squares)
CPP-ACFP; IIIb: pain)
ozone + CPP-ACFP
Protocol repeated after 4 wk
Pasini 40 8-13 I: CCP-ACP SCASS + VAS 120 d SCASS: I: T0: 2.4  0.6; T1: 1.1  0.4a; II: T0: Each patient used a fluoride toothpaste 3 times a
et al.46 II: fluoride toothpaste + fluoride (0, no pain; 2.3  0.5; T1: 2.2  0.4 day
varnish after 120 d or 10, worst VAS: I: T0: 7.8  1; T1: 3.8  0.6a;
composite restoration in pain) II: T0: 7.5  1.5; T1: 7.2  0.8
severely damage teeth
Restrepo 51 9-12 I: 4 weekly applications of QLF 4 wk T0: I: −7.47  0.43; II: −7.22  0.40; T1: Participants received dietary and oral hygiene
et al.47 (I: 26, II: 25) fluoride varnish; II: negative I: −6.32  0.50; II: −6.43  0.64 (ΔF, %) instructions
control
Sönmez 95 teeth 8-12 Composite restoration: USPHS 2y Retention rates:
and (MIH) + 31 I: cavity form Id; II: cavity form I: 81.3%;
Saat48 (control) IIe; III: cavity form IIe + 5% II: 58.1%c;
sodium hypochlorite (60 s) III: 78.1%; IV: 87.1%
after etching; IV: conventional
cavities (non-MIH teeth)
(Continues)
DA CUNHA COELHO ET AL.
 DA CUNHA COELHO ET AL. 5

these, 1451,52,54–58,63–65,67–70 resorted to photographs and 253,62

fluoride phosphate; LF, laser fluorescence; QLF, quantitative light-induced fluorescence; SCASS, Schiff Cold Air Sensitivity Scale; SEA, self-etching adhesive; T0, baseline; T1, follow-up; TEA, total-etch adhesive; USPHS,
Abbreviations: ΔF, deviation of fluorescence; ART, atraumatic restorative treatment; CPP-ACP, casein phosphopeptides and amorphous calcium phosphate; CPP-ACFP, casein phosphopeptides and amorphous calcium
All participants received dietary and oral hygiene
used a chromameter.

instructions + fluoride gel application every

Several studies39,41,43,50,53,55,57,59,63,67,68,70 did not have a
comparative group and were therefore categorized as having a
high risk of bias. The risk of bias for each remaining study was ana-
lyzed and the results are shown in Table 5. Four studies47,49,54,58
were assessed as having a medium risk of bias. The final 17
studies38,40,42,44–46,48,51,52,56,60–62,64–66,69 were evaluated as pos-
sessing a high risk of bias.
Comments

Cavity form II: soft carious tissue and porous enamel surrounding cavity margins were removed until the bur met with significant resistance from the hypomineralized enamel.
4 | DI SCU SSION
6 mo

Bekes et al.39 proposed the application of an arginine paste to MIH-

affected teeth in order to reduce the associated hypersensitivity. Argi-
nine promotes the sealing of the dentinal tubules, decreasing the
number of sensory afferents exposed, thus blocking the hydrodynamic
pain mechanism.71,72 Yang et al.72 performed a meta-analysis on the
application of arginine toothpaste as a desensitizing agent and con-
cluded that an 8-week use decreased dental hypersensitivity. The
results are consistent with Bekes et al.39 who reported a significant
Cavity form I: soft carious tissue and surrounding hypomineralized enamel were removed until cavity margins ended in sound enamel.

decrease in hypersensitivity 8 weeks after 2 applications of an argi-

nine desensitizing paste on teeth with MIH. Such results suggest that
II: 12/22 (54.6%)
I: 13/19 (68.4%)

arginine paste can be recommended as a desensitizing agent for teeth

Survival rate:

affected with MIH.

Results

Restrepo et al.47 and Ozgul et al.45 reported the reduction of

dental hypersensitivity in MIH-affected teeth after application of
fluoride varnish. These results are similar to those found by other
Follow-up

authors73–77 in patients without MIH, who reported a decrease in

18 mo

dental hypersensitivity after the use of fluoride varnishes. Thus, fluo-

ride varnish treatments may be considered a therapeutic option in
Measurement

cases of MIH-related dental hypersensitivity.

Though Biondi et al.40, Ozgul et al.,45 Bakkal et al.,38 and Pasini
USPHS

et al.46 reported positive results after applying CPP-APC pastes, its

effectiveness as desensitizing and remineralizing agent has been
questioned74,78–82 and long-term clinical trials with large samples are
II: resin composite with TEA
I: resin composite with SEA

needed to validate the results before its widespread recommendation.

(1 mo) + glass ionomer
Weekly fluoride varnish

It is of particular importance for patients with MIH the identifica-

restoration (2 mo) +

United States Public Health Service; WBFS, Wong Baker Faces Scale.

tion of effective agents in the treatment of dental hypersensitivity

Comparison with baseline is statistically significant at P < 0.001.
Comparison with baseline is statistically significant at P < 0.01.

Comparison with baseline is statistically significant at P < 0.05.

because of the impact that this condition has on their quality of life. It
Intervention

has further been described that this hypersensitivity weakens the

action of anesthetic agents, which makes pain control difficult and
reduces patient comfort during dental appointments.10,22
Fragelli et al.42 and Lygidakis et al.44 suggested that fissure seal-
ants may be an effective preventive treatment for MIH teeth. Lygida-
(years)

kis et al.44 reported that fissure sealants applied using an adhesive

Age

6-8

system had a higher retention rate than those that were applied with-
out it. However, results regarding the use of an adhesive prior to fis-
Participants (n)

sure sealant application are conflicting.83–86 In 2015 a meta-analysis

II: 22 teeth)
(I: 19 teeth,
(Continued)

carried out by Botton et al.87 concluded that the nonuse of an adhe-

sive resulted in a higher retention rate of fissure sealants in teeth
18

without hypomineralization. As so, further studies are needed in order

et al.49

to confirm the results reported by Lygidakis et al.44

Authors
TABLE 3

Souza
(year)

Fragelli et al.41 evaluated the success of glass ionomer restora-

tions in teeth affected with MIH, reporting a success rate of 78.8% at
b

d
e
a

c
 6

TABLE 4 Studies included in the systematic review for the treatment of DF

Authors (year) Participants (n) Age (years) Intervention Measurement Follow-up Results Comments
50
Bailey et al. 14 20-46 30% hydrogen peroxide +36% Visual – Success rate: Transient increased thermal
hydrochloric acid (4× maximum) 14/14 sensitivity in 1 case
Bezerra et al.51 15 8-13 I: 37% phosphoric acid (6×) Photographs 1 mo Opacity area (%)
II: 18% hydrochloric acid (4×) T0: I: 55.10  19.83; II:
53.74  22.26
T1: I: 8.14  8.28a; II:
5.68  6.17a
Bharath et al.52 30 9-14 I: 36% hydrochloric acid +30% Photographs (VAS: 1, no 6 mo 6 mob: The sensitivity reported after
hydrogen peroxide (5 min improvement; 7— I: 5.77  0.54a; II: 2.83  1.17a both techniques was
maximum) + APF exceptional improvement) transient and decreased up
II: 18% hydrochloric acid (15× to 1 mo after treatment
maximum) + APF
Cardénas 33 8-12 5% sodium hypochlorite + fissure Chromameter – L* parameter—T0: 68.95  5.01;
Flores et al.53 sealant immediately after:
(prior etching with 37% phosphoric 72.30  3.74c
acid) a* parameter—T0: 1.65  2.43;
immediately after:
−0.04  2.14c; b*
parameter—T0: 12.80  3.95;
immediately after:
12.31  2.83;
DE—T0: 70.32  4.61;
immediately after:
73.42  3.70c
Castro et al.54 70 15-39 I: 37% phosphoric acid Photographs 1 mo Fluorosis staining areas (mmd) Participants received a
(I: 35, II: 35) (1-2 sessions of 12 applications) T0: I—32.0  10.1; II— toothbrush and a fluoridated
II: I + 10% carbamide peroxide, 31.4  9.3 non-whitening toothpaste
at-home, 4 h/d, 2 wk) T1: I—20.4  7.8a; II—
19.8  8.0a
Celik et al55 14 19-38 6.6% hydrochloric acid Photographs (VAS: 1, no 24 h Esthetic improvement—I: 3 patients presented mild or
(5-10×) + 5 min of fluoride gel improvement; 7— 5.7  0.7; moderate dental
exceptional improvement) II: 4.1  1.5; III: 3.3  1.4; hypersensitivity
I vs IIc, II vs IIIc; I vs IIId
Changes in opaque areas—I: Severity (DFI):
5.8  1.1; Group I: mild;
II: 3.4  0.9; III: 3.12  0.9; I vs Group II: moderate
IId, I vs IIId Group III: severe
Changes in brown stains—II:
4.9  1.8;
III: 4.1  1.3
Celik et al56 10 18-41 I: 6.6% hydrochloric acid (5 to Photographs (VAS: 1—no I: 24 h Esthetic improvementb: I had less dental sensitivity than
10×) + 5 min fluoride gel improvement; 7— II: 48 h I: 3.4  1.4; II: 5.8  1.4 IIb
II: I + 38% hydrogen exceptional improvement) Changes in opaque areasb:
peroxide + 5 min fluoride gel I: 4.8  1.5; II: 6.5  0.9
Changes in brown stainsb:
I: 4.2  1.4; II: 5.5  1.2.
Chandra et al57 22 <30 36% hydrochloric acid +30% Photographs – Success rate:
hydrogen peroxide + abrasive 22/22
disc
DA CUNHA COELHO ET AL.

(Continues)
TABLE 4 (Continued)

Authors (year) Participants (n) Age (years) Intervention Measurement Follow-up Results Comments
58
Gugnani et al 80 6-12 I: 35% hydrogen peroxide (8 min); II: Photographs VAS Change in esthetics:
resin infiltration (3 + 1 min); (1-7) I: 1.90  0.954; II: 5.50  1.00;
III: resin infiltration (3 + 3 min) III: 5.53  1.97; IV:
IV: I + III 5.35  1.21; I vs IIb; I vs IIIb; I
vs IVb
Improvement in opacities/
DA CUNHA COELHO ET AL.

stainsb:
I: 1.53  0.07; II: 4.98  0.98;
III: 5.18  1.29; IV:
4.40  1.59; I vs IIb; I vs IIIb; I
vs IVb
Gupta et al.59 29 3-12 Vitamin C + calcium + vitamin D3, Visual 59 d Improvement:
(I: 14; II: 15) orally, 1× day. After 44 d, 15 29/29a
participants have the vitamin C
dose increased
Gupta et al.60 90 10-17 I: 35% hydrogen peroxide Photographs 3 mo Color change: Cases in which satisfactory
(3 × 15 min); II: 15% hydrochloric I: 14.03  8.15a results were not obtained,
acid (3 × 60 s maximum) + 44% II: 16.29  7.89a; III: the respective procedure
carbamide peroxide (3 × 20 min 8.83  5.70a was repeated in further
maximum); III: 5% sodium appointments as necessary
hypochlorite (20 min maximum)
Hasanuddin et 80 7-10 Ia: resin composite fissure sealant; Visual 12 mo Retention rate: Ia: 1.55  0.60; All participants received oral
al.61 (I: 40; II: 40) Ib: Ia + enameloplasty; Ib: 1.70  0.56 hygiene instructions
IIa: glass ionomer fissure sealant; IIb: IIa: 0.58  0.68; IIb: 1.25  0.71
IIa + enameloplasty IIa vs IIbc; I vs IIa; Ia vs IIaa; Ib vs
IIba
Mean of retention (0—total loss;
2—total retention)
Knosel et al.62 18 18.4  4.3 I: 30% hydrogen peroxide (1 h, Chromameter 28 d L* parameter—T0: I:
in-office) + 15% carbamide 75.39  5.19;
peroxide (at-home, 1 h per day, II: 78.46  4.30; T1: I:
14 d) 79.77  4.44d;
II: negative control II: 78.60  4.21; a* parameter—
T 0:
I: −0.29  1.07; II:
−0.82  0.98; T1:
I: −1.04  0.89c; II:
−0.58  1.00; b* parameter—
T0: I: 10.59  6.33; II:
11.56  4.49;
T1: I: 4.62  3.43a; II:
10.79  4.92
Limeback et al.63 14 8-21 Microabrasion with diamond bur (VAS) – Esthetics significantly improved
after treatmenta
(Continues)
7
 8

TABLE 4 (Continued)

Authors (year) Participants (n) Age (years) Intervention Measurement Follow-up Results Comments
64 a a
Loguercio et al. 36 10-12 I: 10% hydrochloric acid Photographs (VAS: 0, no 1 wk I: 5.1  0.8 ; II: 5.3  1.1 All participants received oral
(5×) + 4 min of fluoride gel (3 improvement; 7, (77.7% considered the area hygiene instructions
sessions) exceptional improvement) treated with 6.6%
II: 6.6% hydrochloric acid (5×, 3 hydrochloric acid to be
sessions) rougher than that treated with
the concentration of 10%)
Loyola-Rodriguez 114 12-29 7 nights of NVBT: Photographs 1 wk I versus IIIe (I more effective);
et al.65 (I: 38; II: 38; III: I: 10% carbamide peroxide; II versus III5 (II more effective)
38) II: 20% carbamide peroxide;
III: 7.5% hydrogen peroxide
Mehta and Shah66 30 8-17 I: calcium (daily) + vitamin D3 TSIF 3 mo No change in DF lesions was
(I: 10; II: 10; III: (weekly); II: ascorbic acid observed in the 3 groups of
10) (daily) + vitamin D3 (weekly) participants
III: chlorhexidine mouthwash
Seale and Thrash67 20 8-43 35% hydrogen peroxide (maximum Photographs – The results were better the
4× per session) younger the patientsc, the
yellower the lesionsc and the
longer the bleaching sessiond
Shanbhag et al.68 60 14-17 35% hydrogen peroxide + fluoride Photographs (1, the brightest 6 mo T0—I: 5.25  1.8028; II: Severity (DFI):
(I: 20; II: 20; III: varnish spectrum of the vita scale; 4.65  1.4965; Group I: very mild
20) (severe cases were previously 16—the darkest) III: 5.00  1.8064 Group II: mild
etched with 37% phosphoric acid) T1—I: 3.75  0.7864a; II: Group III: moderate
3.35  0.6708a;
III: 3.70  0.6569d
Sinha et al.69 30 7-14 CPP-ACP paste (15 min) after 4 Photographs + impressions 1 mo Improvement in white spots (T1) Severity (DFI):
(I: 10; II: 10; III: applications of 5 s of: and SEM analysis Ia: 61.3%; Ib: 70.9%; IIa: 55.05%; Group I: very mild, mild
10) Ia: 18% hydrochloric acid or IIb: 67.6%; IIIa: 40.34%; IIIb: Group II: moderate
Ib: 37% phosphoric acid or 46.6% Group III: severe
IIa: 18% hydrochloric acid or Improvement in intensity of stain
IIb: 37% phosphoric acid or (T1)
IIIa: 18% hydrochloric acid or Ia: 66.4%; Ib: 62.7%; IIa: 59%;
IIIb: 37% phosphoric acid IIb: 73.4%; IIIa: 49.7%; IIIb:
51.4%
Improvement in area of stain (T1)
Ia: 71.4%; Ib: 81.9%; IIa: 62.8%;
IIb: 72.6%; IIIa: 43%; IIIb:
48.7%
Improvement in affected area
(immediately after)—Ia: 45%;
Ib: 52%; IIa: 50%; IIb: 50%;
IIIa: 46%; IIIb: 56%

(Continues)
DA CUNHA COELHO ET AL.
TABLE 4 (Continued)

Authors (year) Participants (n) Age (years) Intervention Measurement Follow-up Results Comments
70
Train et al. 41 – 15% hydrochloric acid (20× Photographs+ 4d White spot (0-5) Severity (DFI):
(I: 15; II: 15; III: maximum) Impressions and SEM T0—I: 2.47  1.164; II: Group I: very mild, mild
11) analysis 3.63 1.273; III: Grupo II: moderate
4.40  1.231; T1—I: Group III: severe
1.66  0.653d; II:
3.20  1.270d; III:
DA CUNHA COELHO ET AL.

4.05  1.356d
Area of stain (0-3)
T0—I: 0.06  0.246; II:
0.67  0.547; III:
1.60  0.883; T1—I:
0.00  0.000d; II:
0.27  0.521d; III:
1.50  0.875d
Intensity of stain (0-2)
T0—I: 0.06  0.246; II:
0.70  0.596; III:
1.55  0.510; T1—I:
0.00  0.000d; II:
0.23  0.430d; III:
1.20  0.768d
Affected area (1-4)
T0—I: 1.60  1.429; II:
1.39  1.257;
III: 1.06  0.929; 2 treatments
(immediately after)—I:
1.47  1.106; II:
2.29  1.049d;
III: 1.50  1.3171; 4 treatments
(immediately after)—I:
1.37  1.159; II:
2.11  1.166d; III:
1.63  1.088c

Abbreviation: APF, acidulated phosphate fluoride; CPP-ACP, casein phosphopeptides and amorphous calcium phosphate; DE, delta equation; DFI, Dean’s Fluorosis Index; NVBT, Nightguard Vital Bleaching Technique;
SEM, scanning electron microscope; SCASS, Schiff Cold Air Sensitivity Scale; T0, baseline; T1, follow-up; TFI, Thylstrup–Fejerskov Index; TSIF, Tooth Surface Index of Fluorosis; IU, international units; VAS, visual analog
scale.
a
Comparison with baseline is statistically significant at P < 0.001.
b
Comparison between groups is statistically significant at P < 0.001.
c
Comparison with baseline is statistically significant at P < 0.05.
d
Comparison with baseline is statistically significant at P < 0.01.
e
Comparison between groups is statistically significant at P < 0.05.
9
10 DA CUNHA COELHO ET AL.

TABLE 5 Risk of bias assessment for the studies included in the systematic review

Random sequence Allocation Blinding of participants Blinding of outcome Incomplete Selective Other Risk
Author generation concealment and personnel assessment outcome data reporting bias of bias
Bakkal et al.38 High High High Low Unclear Low Low High
Bezerra et al.51 Unclear Unclear Unclear Low Low Low Low High
Bharath et al.52 Unclear Unclear Unclear Low Low Low Low High
40
Biondi et al. High High High Unclear Unclear Low Low High
Castro et al.54 Low Low High Low Low Low Low Medium
Celik et al.56 High Unclear High High Low Low Unclear High
Fragelli et al.42 Unclear Unclear Low Low Unclear Low Low High
58
Gugnani et al. Low Low Low Low Low Low Unclear Medium
Gupta et al.60 Unclear Unclear Low Unclear Low Low Low High
Hasanuddin et al.61 Unclear Unclear Unclear Unclear Low Low Low High
Knosel et al.62 Unclear Unclear High Low Low Low Low High
64
Loguercio et al. Unclear Unclear High High Unclear Low Unclear High
Loyola-Rodriguez et al.65 Unclear Unclear Low Low Low High Low High
Lygidakis et al.44 Unclear Unclear Unclear Low High Low Low High
Mehta et al.66 Unclear Unclear High High High High Unclear High
Ozgul et al.45 High High Unclear Unclear Low Low Low High
Pasini et al.46 Unclear Unclear Unclear Low Unclear Low Low High
Restrepo et al.47 Low Unclear High Low Low Low Low Medium
Sinha et al.69 Unclear Unclear High Low Low Low Low High
48
Sönmez and Saat Unclear Unclear Low Unclear Low Low Low High
Souza et al.49 Low High Unclear Low Low Low Low Medium

12 months. Using the ART protocol and a glass hybrid restorative sys-
43
tem Grossi et al. reported a higher success rate (98.3%) at
12 months. Though the authors reported positive results there is a
clear need for the patients to be controlled because there is a lack of
information regarding the effectiveness of the ART protocol in perma-
88
nent teeth, especially those affected with MIH.
Souza et al.49 evaluated the success of resin composite restora-
tions and reported a lower success rate at 18 months: 68.4% when
restorations were performed with a self-etch adhesive and 54.6%
when performed with a total-etch adhesive. Such results may be justi-
fied by the hypomineralization of the affected teeth, which compro-
89,90
mises the resin adhesion to the dental surface. In fact, Sönmez
and Saat48 restored hypomineralized teeth with a resin composite and
reported that the removal of whole affected enamel (group I) signifi-
cantly increased the success of the treatment compared with noninva-
sive techniques without removal of all clinically defective tissue
(group II). These results corroborate those of William et al.90 who
reported a lower marginal adhesion of the resin composite to hypomi-
neralized enamel in an in vitro study.
Sönmez and Saat48 suggested deproteinization using 5% sodium
hypochlorite postacid conditioning (group III). The authors reported a
statistically significant difference between group II (restoration with-
out deproteinization) and group III, which suggests that in cavities
without removal of all hypomineralized enamel sodium hypochlorite
may help in achieving better bond strength although preventing major
tissue loss. However, further research is required in order to evaluate
the clinical efficacy of this technique because just a few studies on
this topic have been conducted.91–93
Several authors50,57,60,62,67,68 used dental bleaching in order to
improve the esthetics of DF lesions. Seale and Thrash67 and Bailey
and Christen50 applied hydrogen peroxide, whereas Gupta et al.60,
Loyola-Rodriguez et al.,65 and Knosel et al.62 also employed a carbam-
ide peroxide solution. Although the authors used different product
concentrations, all of them reported an esthetic improvement.
Shanbhag et al.68 also reported an esthetic improvement in DF
lesions 6 months after bleaching with 35% hydrogen peroxide with a
prior etching with 37% phosphoric acid. The combination of these
2 techniques is described in the literature as prior etching allows a
greater diffusion of hydrogen peroxide.94,95
Gupta et al.60 used 5% sodium hypochlorite to remove fluorosis
stains but it was only effective in removing mild stains and better
results were reported when using hydrogen peroxide or hydrochloric
acid. The use of sodium hypochlorite to remove fluorosis stains has
been described in the literature.60,96–98 However, care must be exer-
cised when using sodium hypochlorite because it oxidizes the tissues
that it comes in contact with resulting in hemolysis, ulceration, inhibi-
tion of neutrophil migration, and destruction of endothelial cells and
fibroblasts.99,100
Microabrasion consists of the removal of defects, through an
abrasion and a chemical erosion of the superficial layer of the enamel,
being considered a safe and minimally invasive technique.101 The loca-
tion and depth of the stain or spot are the most important factors for
a successful treatment. As so, this procedure should be restricted to
more superficial enamel and deeper lesions may require additional
treatment.101–103
Although hydrochloric acid is presently used as a component of
microabrasion pastes in concentrations up to 18%, its use at 36% as
suggested by Chandra and Chawla57 is not currently advocated given
the loss of tooth structure caused by high concentrations of hydro-
chloric acid.102,104,105
DA CUNHA COELHO ET AL.
Loguercio et al.64 resorted to enamel microabrasion with 10%
hydrochloric acid, comparing it with the application of the same prod-
uct at 6.6%. Although the authors did not find differences between
the groups, esthetic improvement was reported. Similarly, Train
et al.70 and Gupta et al.60 reported an esthetic improvement after
microabrasion with 15% hydrochloric acid. In addition, Bezerra et al.
and Sinha et al.69 reported a reduction of the total area and of the
intensity of DF stains after the application of 18% hydrochloric acid
or 37% phosphoric acid. However, Sinha et al.69 did not perform a sta-
tistical analysis of the results, which would be imperative for a correct
interpretation of the data.
Celik et al.55 reported that the esthetic improvement because of
microabrasion with 6.6% hydrochloric acid were significantly lower in
teeth presenting severe lesions than in mild or moderate lesions.
These results are similar to those of Sinha et al.69 and Train et al.,70
who reported that the need for additional treatment was higher in
teeth with more severe DF lesions. The enamel microabrasion tech-
nique can be combined with dental bleaching in order to attain higher
esthetic results. In fact, prior etching allows the opening of the den-
95,101
tinal tubules, favoring the diffusion of the bleaching solution.
Enamel microabrasion is a viable treatment to be applied to teeth
with mild DF lesions but may be insufficient in moderate or severe
fluorosis lesions. As such, there is a clear need for a correct diagnosis
so treatments can be performed with foreseeable results and a good
prognosis.
Limeback et al.63 reported an esthetic improvement of DF lesions
through physical enamel abrasion with a diamond bur. This mechanical
removal of pigmented enamel has been described in
literature.106–108 The advantage of this technique is in its celerity in
reaching the desired esthetic in cases of mild or moderate
DF. However, these procedures employ a high-speed rotary instrument,
which can lead to excessive removal of the dental structure. 107,109
Gugnani et al.58 suggested the use of a resin infiltrant to estheti-
cally improve DF stains. The efficacy of resin infiltration in arresting
noncavitated caries lesions has been proven.110 Though resin infiltra-
tion may be considered a feasable alternative for blending mild and
moderate fluorosis, there is a need for long-term clinical trials with
large samples so the stability of the esthetic changes can be evaluated.
The use of resin infiltration in different kinds of stains and oppacities
should also be studied.
Gupta et al.59 reported an esthetic improvement of DF lesions
after daily oral administrations of a vitamin C, vitamin D3, and calcium
solution. However, this study presents a high risk of bias, given the
lack of randomness in sequence generation, the absence of blinding of
outcome assessment and professionals and the nonexistence of a con-
trol group. Mehta et al.66 developed a similar study but did not find
statistical significant differences in the DF lesions. In fact, the irrevers-
ibility of DF lesions has been described in the literature. 7,111,112
Hasanuddin et al.61 evaluated the retention of fissure sealants in
DF permanent molars, reporting significantly higher sealant retention
when applying resin composite than when using glass ionomer seal-
ants. These results are similar to those reported by Kuhnisch et al.113
in a meta-analysis on the longevity of different fissure sealants mate-
rials in teeth without hypomineralization. However, such results are
controversial because several studies have demonstrated a reduction
11
in the resin composites adhesion to hypomineralized enamel affected
with DF.114–117
Even though only some treatments were analyzed in this review
(considering the inclusion and exclusion criteria), there are some
guidelines and case reports that suggest different approaches.118–122
51
Regarding young patients with severe hypomineralized molars, stain-
less steel crowns may be used to prevent further tooth loss whereas
controlling hypersensitivity and establishing interproximal and occlusal
contacts and often provide an effective medium-term solu-
tion.118,123,124 Glass-ionomer cement is also commonly used in situa-
tions where a moisture control is inadequate (because of an
incomplete tooth eruption) as an intermediate restoration.119,122 In
severe MIH situations the extraction of the first 4 molars associated
with orthodontic treatment has also been reported.103,121,125
Although the evolution of the techniques and materials used to
manage hypomineralized teeth has been able to improve patients’ qual-
ity of life, the treatment of these teeth remains a challenge for dentists.
Nowadays, the recommended treatments aim to prevent the destruc-
tion and/or loss of the affected teeth, to offer an esthetic and functional
rehabilitation and to treat dental hypersensitivity.132, 134, 136
However,
an early diagnosis combined with the evaluation of the severity of the
condition and the patients’ dental age and expectation is imperative.132
5 | CONC LU SION
Comparison of the reported results provided by the different studies
the
was difficult given the variability of the methodology. Thus, it is
imperative to carry out further intervention studies aimed at compar-
ing the different treatments and based on the existing scientific
evidence.
It is also worth noting the absence of controlled studies on types
II and III of AI, which makes it impossible to develop guidelines for its
treatment.
Nevertheless, it was possible to identify several effective treat-
ments for teeth with MIH (arginine pastes or Fluoride varnishes to
treat hypersensitivity) and for DF (tooth bleaching and/or enamel
microabrasion).
DISC LOSURE
The authors do not have any financial interest in the companies
whose materials are included in this article.
ORCID
Ana Sofia Estima da Cunha Coelho http://orcid.org/0000-0002-
2924-7926
RE FE RE NC ES
1. Berkovitz BKB, Holland GR, Oral Anatomy MBJ. Histology and Embry-
ology. 5th ed. New York: Elsevier; 2017.
2. Wright JT, Carrion IA, Morris C. The molecular basis of hereditary
enamel defects in humans. J Dent Res. 2015;94(1):52-61.
12
3. Jacobsen PE, Haubek D, Henriksen TB, et al. Developmental enamel
defects in children born preterm: a systematic review. Eur J Oral Sci.
2014;122(1):7-14.
4. DenBesten PK. Biological mechanisms of dental fluorosis relevant to
the use of fluoride supplements. Community Dent Oral Epidemiol.
1999;27(1):41-47.
5. Wright JT. The molecular etiologies and associated phenotypes of
amelogenesis imperfecta. Am J Med Genet A. 2006;140(23):
2547-2555.
6. Aldred MJ, Savarirayan R, Crawford PJ. Amelogenesis imperfecta: a
classification and catalogue for the 21st century. Oral Dis. 2003;9(1):
19-23.
7. Den Besten PK. Mechanism and timing of fluoride effects on devel-
oping enamel. J Public Health Dent. 1999;59(4):247-251.
8. Elhennawy K, Schwendicke F. Managing molar-incisor hypominerali-
zation: a systematic review. J Dent. 2016;55:16-24.
9. Silva MJ, Scurrah KJ, Craig JM, Manton DJ, Kilpatrick N. Etiology of
molar incisor hypomineralization—a systematic review. Community
Dent Oral Epidemiol. 2016;44(4):342-353.
10. Americano GC, Jacobsen PE, Soviero VM, Haubek D. A systematic
review on the association between molar incisor hypomineralization
and dental caries. Int J Paediatr Dent. 2017;27(1):11-21.
11. Bhaskar SA, Hegde S. Molar-incisor hypomineralization: prevalence,
severity and clinical characteristics in 8- to 13-year-old children of
Udaipur, India. J Indian Soc Pedod Prev Dent. 2014;32(4):322-329.
12. Elfrink ME, Schuller AA, Weerheijm KL, Veerkamp JS. Hypominera-
lized second primary molars: prevalence data in Dutch 5-year-olds.
Caries Res. 2008;42(4):282-285.
13. Elfrink ME, ten Cate JM, Jaddoe VW, et al. Deciduous molar hypomi-
neralization and molar incisor hypomineralization. J Dent Res. 2012;
91(6):551-555.
14. Ghanim A, Manton D, Marino R, et al. Prevalence of demarcated
hypomineralisation defects in second primary molars in Iraqi children.
Int J Paediatr Dent. 2013;23(1):48-55.
15. Kuhnisch J, Heitmuller D, Thiering E, et al. Proportion and extent of
manifestation of molar-incisor-hypomineralizations according to dif-
ferent phenotypes. J Public Health Dent. 2014;74(1):42-49.
16. Mittal R, Chandak S, Chandwani M, Singh P, Pimpale J. Assessment
of association between molar incisor hypomineralization and hypo-
mineralized second primary molar. J Int Soc Prev Community Dent.
2016;6(1):34-39.
17. Negre-Barber A, Montiel-Company JM, Boronat-Catala M,
et al. Hypomineralized second primary molars as predictor of molar
incisor hypomineralization. Sci Rep. 2016;6:31929.
18. Tourino LF, Correa-Faria P, Ferreira RC, et al. Association between
molar incisor hypomineralization in schoolchildren and both prenatal
and postnatal factors: a population-based study. PLoS ONE. 2016;
11(6):e0156332.
19. Schwendicke F, Elhennawy K, Reda S, Bekes K, Manton DJ, Krois J.
Global burden of molar incisor hypomineralization. J Dent. 2018;68:
10-18.
20. Crombie F, Manton D, Kilpatrick N. Aetiology of molar-incisor hypo-
mineralization: a critical review. Int J Paediatr Dent. 2009;19(2):
73-83.
21. Seow WK. Developmental defects of enamel and dentine: challenges
for basic science research and clinical management. Aust Dent J.
2014;59(Suppl 1):143-154.
22. Weerheijm KL, Mejare I. Molar incisor hypomineralization: a ques-
tionnaire inventory of its occurrence in member countries of the
European Academy of Paediatric Dentistry (EAPD). Int J Paediatr
Dent. 2003;13(6):411-416.
23. Cogulu D, Becerik S, Emingil G, Hart PS, Hart TC. Oral rehabilitation
of a patient with amelogenesis imperfecta. Pediatr Dent. 2009;31(7):
523-527.
24. Pousette Lundgren G, Karsten A, Dahllof G. Oral health-related qual-
ity of life before and after crown therapy in young patients with ame-
logenesis imperfecta. Health Qual Life Outcomes. 2015;13:197.
25. Witkop CJ Jr. Amelogenesis imperfecta, dentinogenesis imperfecta
and dentin dysplasia revisited: problems in classification. J Oral
Pathol. 1988;17(9–10):547-553.
DA CUNHA COELHO ET AL.
26. Smith CEL, Poulter JA, Antanaviciute A, et al. Amelogenesis imper-
fecta; genes, proteins and pathways. Front Physiol. 2017;8:435.
27. Urzua B, Ortega-Pinto A, Morales-Bozo I, et al. Defining a new candi-
date gene for amelogenesis imperfecta: from molecular genetics to
biochemistry. Biochem Genet. 2011;49(1–2):104-121.
28. Cochran JA, Ketley CE, Arnadottir IB, et al. A comparison of the prev-
alence of fluorosis in 8-year-old children from seven European study
sites using a standardized methodology. Community Dent Oral Epide-
miol. 2004;32(Suppl 1):28-33.
29. da Cunha LF, Tomita NE. Dental fluorosis in Brazil: a systematic
review from 1993 to 2004. Cad Saude Publica. 2006;22(9):
1809-1816.
30. Whelton HP, Ketley CE, McSweeney F, O’Mullane DM. A review of
fluorosis in the European Union: prevalence, risk factors and aes-
thetic issues. Community Dent Oral Epidemiol. 2004;32(Suppl 1):9-18.
31. Aoba T, Fejerskov O. Dental fluorosis: chemistry and biology. Crit
Rev Oral Biol Med. 2002;13(2):155-170.
32. Beltran-Aguilar ED, Barker L, Dye BA. Prevalence and severity of
dental fluorosis in the United States, 1999-2004. NCHS Data Brief.
2010;53:1-8.
33. Abanto Alvarez J, Rezende KM, Marocho SM, Alves FB, Celiberti P,
Ciamponi AL. Dental fluorosis: exposure prevention and manage-
ment. Med Oral Patol Oral Cir Bucal. 2009;14(2):E103-E107.
34. Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and severity of
dental fluorosis in the United States, 1999-2004. NCHS Data Brief.
2010;53:1-8.
35. Denbesten P, Li W. Chronic fluoride toxicity: dental fluorosis. Monogr
Oral Sci. 2011;22:81-96.
36. Riva JJ, Malik KMP, Burnie SJ, Endicott AR, Busse JW. What is your
research question? An introduction to the PICOT format for clini-
cians. J Can Chiropr Assoc. 2012;56(3):167-171.
37. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0 [Updated March 2011]: United Kingdom:
The Cochrane Collaboration; 2011. http://handbook.cochrane.org.
38. Bakkal M, Abbasoglu Z, Kargul B. The effect of casein
phosphopeptide-amorphous calcium phosphate on molar-incisor
hypomineralisation: a pilot study. Oral Health Prev Dent. 2017;15(2):
163-167.
39. Bekes K, Heinzelmann K, Lettner S, Schaller HG. Efficacy of desensi-
tizing products containing 8% arginine and calcium carbonate for
hypersensitivity relief in MIH-affected molars: an 8-week clinical
study. Clin Oral Investig. 2017;21(7):2311-2317.
40. Biondi AM, Cortese SG, Babino L, Fridman DE. Comparison of min-
eral density in molar incisor hypomineralization applying fluoride var-
nishes and casein phosphopeptide-amorphous calcium phosphate.
Acta Odontol Latinoam. 2017;30(3):118-123.
41. Fragelli CM, Souza JF, Jeremias F, et al. Molar incisor hypomineraliza-
tion (MIH): conservative treatment management to restore affected
teeth. Braz Oral Res. 2015;29:1-7.
42. Fragelli CMB, Souza JF, Bussaneli DG, et al. Survival of sealants in
molars affected by molar-incisor hypomineralization: 18-month
follow-up. Braz Oral Res. 2017;31:e30.
43. Grossi JA, Cabral RN, Ribeiro APD, Leal SC. Glass hybrid restorations
as an alternative for restoring hypomineralized molars in the ART
model. BMC Oral Health. 2018;18(1):65.
44. Lygidakis NA, Dimou G, Stamataki E. Retention of fissure sealants
using two different methods of application in teeth with hypominera-
lised molars (MIH): a 4 year clinical study. Eur Arch Paediatr Dent.
2009;10(4):223-226.
45. Ozgul BM, Saat S, Sonmez H, Oz FT. Clinical evaluation of desensitiz-
ing treatment for incisor teeth affected by molar-incisor hypominera-
lization. J Clin Pediatr Dent. 2013;38(2):101-105.
46. Pasini M, Giuca MR, Scatena M, Gatto R, Caruso S. Molar incisor
hypomineralization treatment with casein phosphopeptide and amor-
phous calcium phosphate in children. Minerva Stomatol. 2018;67(1):
20-25.
47. Restrepo M, Jeremias F, Santos-Pinto L, Cordeiro RCL, Zuanon ACC.
Effect of fluoride varnish on enamel remineralization in anterior teeth
with molar incisor hypomineralization. J Clin Pediatr Dent. 2016;
40(3):207-210.
DA CUNHA COELHO ET AL.
48. Sönmez H, Saat S. A clinical evaluation of deproteinization and differ-
ent cavity designs on resin restoration performance in MIH-affected
molars: two-year results. J Clin Pediatr Dent. 2017;41(5):336-342.
49. de Souza JF, Fragelli CB, Jeremias F, Paschoal MAB, Santos-Pinto L,
de Cássia Loiola Cordeiro R. Eighteen-month clinical performance of
composite resin restorations with two different adhesive systems for
molars affected by molar incisor hypomineralization. Clin Oral Inves-
tig. 2017;21(5):1725-1733.
50. Bailey RW, Christen AG. Bleaching of vital teeth stained with
endemic dental fluorsis. Oral Surg Oral Med Oral Pathol. 1968;26(6):
871-878.
51. Bezerra AC, Leal SC, Otero SA, et al. Enamel opacities removal using
two different acids: an in vivo comparison. J Clin Pediatr Dent. 2005;
29(2):147-150.
52. Bharath KP, Subba Reddy VV, Poornima P, Revathy V,
Kambalimath HV, Karthik B. Comparison of relative efficacy of two
techniques of enamel stain removal on fluorosed teeth. An in vivo
study. J Clin Pediatr Dent. 2014;38(3):207-213.
53. Cardenas Flores A, Flores Reyes H, Gordillo Moscoso A, et al. Clinical
efficacy of 5% sodium hypochlorite for removal of stains caused by
dental fluorosis. J Clin Pediatr Dent. 2009;33(3):187-191.
54. Castro KS, Ferreira AC, Duarte RM, et al. Acceptability, efficacy and
safety of two treatment protocols for dental fluorosis: a randomized
clinical trial. J Dent. 2014;42(8):938-944.
55. Celik EU, Yildiz G, Yazkan B. Clinical evaluation of enamel microabra-
sion for the aesthetic management of mild-to-severe dental fluorosis.
J Esthet Restor Dent. 2013;25(6):422-430.
56. Celik EU, Yildiz G, Yazkan B. Comparison of enamel microabrasion
with a combined approach to the esthetic management of fluorosed
teeth. Oper Dent. 2013;38(5):E134-E143.
57. Chandra S, Chawla TN. Clinical evaluation of the sandpaper disk
method for removing fluorosis stains from teeth. J Am Dent Assoc.
1975;90(6):1273-1276.
58. Gugnani N, Pandit IK, Gupta M, Gugnani S, Soni S, Goyal V. Compar-
ative evaluation of esthetic changes in nonpitted fluorosis stains
when treated with resin infiltration, in-office bleaching, and combina-
tion therapies. J Esthet Restor Dent. 2017;29(5):317-324.
59. Gupta SK, Gupta RC, Seth AK. Reversal of clinical and dental fluoro-
sis. Indian Pediatr. 1994;31(4):439-443.
60. Gupta A, Dhingra R, Chaudhuri P, Gupta A. A comparison of various
minimally invasive techniques for the removal of dental fluorosis
stains in children. J Indian Soc Pedod Prev Dent. 2017;35(3):260-268.
61. Hasanuddin S, Reddy ER, Manjula M, Srilaxmi N, Rani ST, Rajesh A.
Retention of fissure sealants in young permanent molars affected by
dental fluorosis: a 12-month clinical study. Eur Arch Paediatr Dent.
2014;15(5):309-315.
62. Knosel M, Attin R, Becker K, Attin T. A randomized CIE L*a*b* evalu-
ation of external bleaching therapy effects on fluorotic enamel stains.
Quintessence Int. 2008;39(5):391-399.
63. Limeback H, Vieira AP, Lawrence H. Improving esthetically objection-
able human enamel fluorosis with a simple microabrasion technique.
Eur J Oral Sci 2006; 114 Suppl 1:123–6; discussion 7–9, 380, 126.
64. Loguercio AD, Correia LD, Zago C, et al. Clinical effectiveness of two
microabrasion materials for the removal of enamel fluorosis stains.
Oper Dent. 2007;32(6):531-538.
65. Loyola-Rodriguez JP, Pozos-Guillen Ade J, Hernandez-Hernandez F,
Berumen-Maldonado R, Patiño-Marin N. Effectiveness of treatment
with carbamide peroxide and hydrogen peroxide in subjects affected
by dental fluorosis: a clinical trial. J Clin Pediatr Dent. 2003;28(1):
63-67.
66. Mehta DN, Shah J. Reversal of dental fluorosis: a clinical study. J Nat
Sci Biol Med. 2013;4(1):138-144.
67. Seale NS, Thrash WJ. Systematic assessment of color removal fol-
lowing vital bleaching of intrinsically stained teeth. J Dent Res. 1985;
64(3):457-461.
68. Shanbhag R, Veena R, Nanjannawar G, Patil J, Hugar S, Vagrali H.
Use of clinical bleaching with 35% hydrogen peroxide in esthetic
improvement of fluorotic human incisors in vivo. J Contemp Dent
Pract. 2013;14(2):208-216.
69. Sinha S, Vorse KK, Noorani H, Kumaraswamy SP, Varma S,
Surappaneni H. Microabrasion using 18% hydrochloric acid and 37%
13
phosphoric acid in various degrees of fluorosis—an in vivo compari-
sion. Eur J Esthet Dent. 2013;8(3):454-465.
70. Train TE, McWhorter AG, Seale NS, Wilson CF, Guo IY. Examination
of esthetic improvement and surface alteration following microabra-
sion in fluorotic human incisors in vivo. Pediatr Dent. 1996;18(5):
353-362.
71. Sharif MO, Iram S, Brunton PA. Effectiveness of arginine-containing
toothpastes in treating dentine hypersensitivity: a systematic review.
J Dent. 2013;41(6):483-492.
72. Yang ZY, Wang F, Lu K, et al. Arginine-containing desensitizing
toothpaste for the treatment of dentin hypersensitivity: a
meta-analysis. Clin Cosmet Investig Dent. 2016;8:1-14.
73. Camilotti V, Zilly J, Busato Pdo M, et al. Desensitizing treatments for
dentin hypersensitivity: a randomized, split-mouth clinical trial. Braz
Oral Res. 2012;26(3):263-268.
74. Madhavan S, Nayak M, Shenoy A, Shetty R, Prasad K. Dentinal
hypersensitivity: a comparative clinical evaluation of CPP-ACP F,
sodium fluoride, propolis, and placebo. J Conserv Dent. 2012;15(4):
315-318.
75. Pandit N, Gupta R, Bansal A. Comparative evaluation of two com-
mercially available desensitizing agents for the treatment of dentinal
hypersensitivity. Indian J Dent Res. 2012;23(6):778-783.
76. Petersson LG. The role of fluoride in the preventive management of
dentin hypersensitivity and root caries. Clin Oral Investig 2013; 17
Suppl 1(Suppl 1):S63–71.
77. Ritter AV, de LDW, Miguez P, et al. Treating cervical dentin hyper-
sensitivity with fluoride varnish: a randomized clinical study. J Am
Dent Assoc 2006; 137(7):1013–20; quiz 29.
78. Gandolfi MG, Silvia F, H PD, et al. Calcium silicate coating derived
from Portland cement as treatment for hypersensitive dentine. J
Dent. 2008;36(8):565-578.
79. Kowalczyk A, Botulinski B, Jaworska M, et al. Evaluation of the prod-
uct based on Recaldent technology in the treatment of dentin hyper-
sensitivity. Adv Med Sci. 2006;51(Suppl 1):40-42.
80. Mahesuti A, Duan YL, Wang G, Cheng XR, Matis BA. Short-term effi-
cacy of agents containing KNO3 or CPP-ACP in treatment of dentin
hypersensitivity. Chin J Dent Res. 2014;17(1):43-47.
81. Prabhakar AR, Manojkumar AJ, Basappa N. In vitro remineralization
of enamel subsurface lesions and assessment of dentine tubule
occlusion from NaF dentifrices with and without calcium. J Indian Soc
Pedod Prev Dent. 2013;31(1):29-35.
82. Raphael S, Blinkhorn A. Is there a place for tooth mousse in the pre-
vention and treatment of early dental caries? A systematic review.
BMC Oral Health. 2015;15(1):113.
83. Erbas Unverdi G, Atac SA, Cehreli ZC. Effectiveness of pit and fis-
sure sealants bonded with different adhesive systems: a prospec-
tive randomized controlled trial. Clin Oral Investig. 2017;21(7):
2235-2243.
84. Khare M, Suprabha BS, Shenoy R, Rao A. Evaluation of
pit-and-fissure sealants placed with four different bonding protocols:
a randomized clinical trial. Int J Paediatr Dent. 2017;27(6):444-453.
85. Nazar H, Mascarenhas AK, Al-Mutwa S, et al. Effectiveness of fissure
sealant retention and caries prevention with and without primer and
bond. Med Princ Pract. 2013;22(1):12-17.
86. Stellini E, De Francesco M, Avventi M, et al. In vitro comparison
of the bond strength to the enamel of conventional and
self-etching dental fissure sealants. Eur J Paediatr Dent. 2013;
14(4):319-322.
87. Botton G, Morgental CS, Scherer MM, Lenzi TL, Montagner AF,
Rocha RO. Are self-etch adhesive systems effective in the retention
of occlusal sealants? A systematic review and meta-analysis. Int J
Paediatr Dent. 2016;26(6):402-411.
88. Dorri M, Martinez-Zapata MJ, Walsh T, et al. Atraumatic restorative
treatment versus conventional restorative treatment for managing
dental caries. Cochrane Database Syst Rev. 2017;12:CD008072.
89. Fagrell TG, Dietz W, Jalevik B, Noren JG. Chemical, mechanical and
morphological properties of hypomineralized enamel of permanent
first molars. Acta Odontol Scand. 2010;68(4):215-222.
90. William V, Burrow MF, Palamara JE, Messer LB. Microshear bond
strength of resin composite to teeth affected by molar
14
hypomineralization using 2 adhesive systems. Pediatr Dent. 2006;
28(3):233-241.
91. Gandhi S, Crawford P, Shellis P. The use of a “bleach-etch-seal”
deproteinization technique on MIH affected enamel. Int J Paediatr
Dent. 2012;22(6):427-434.
92. Sonmez IS, Aras S, Tunc ES, Kucukesmen C. Clinical success of
deproteinization in hypocalcified amelogenesis imperfecta. Quintes-
sence Int. 2009;40(2):113-118.
93. Ekambaram MYC. Bonding to hypomineralized enamel—a systematic
review. Int J Adhes Adhes. 2016;69:27-32.
94. Camps J, Pommel L, Aubut V, About I. Influence of acid etching on
hydrogen peroxide diffusion through human dentin. Am J Dent.
2010;23(3):168-170.
95. Cannabrava VP, Fernandes SL, Calabria MP, et al. Bleaching tech-
nique effect on dentin permeability. Am J Dent. 2014;27(3):
145-148.
96. Belkhir MS, Douki N. An new concept for removal of dental fluorosis
stains. J Endod. 1991;17(6):288-292.
97. Carey CM. Tooth whitening: what we now know. J Evid Based Dent
Pract. 2014;14(Suppl):70-76.
98. Wright JT. The etch-bleach-seal technique for managing stained
enamel defects in young permanent incisors. Pediatr Dent. 2002;
24(3):249-252.
99. Guivarc’h M, Ordioni U, Ahmed HM, et al. Sodium hypochlorite acci-
dent: a systematic review. J Endod. 2017;43(1):16-24.
100. Kerbl FM, DeVilliers P, Litaker M, Eleazer PD. Physical effects of
sodium hypochlorite on bone: an ex vivo study. J Endod. 2012;38(3):
357-359.
101. Pini NI, Sundfeld-Neto D, Aguiar FH, et al. Enamel microabrasion: an
overview of clinical and scientific considerations. World J Clin Cases.
2015;3(1):34-41.
102. Bassir MM, Bagheri G. Comparison between phosphoric acid and
hydrochloric acid in microabrasion technique for the treatment of
dental fluorosis. J Conserv Dent. 2013;16(1):41-44.
103. Croll TP. Enamel Microabrasion. Chicago: Quintessence Publishing
Company; 1991.
104. Meireles SS, Andre Dde A, Leida FL, Bocangel JS, Demarco FF. Sur-
face roughness and enamel loss with two microabrasion techniques.
J Contemp Dent Pract. 2009;10(1):58-65.
105. Tong LS, Pang MK, Mok NY, et al. The effects of etching,
micro-abrasion, and bleaching on surface enamel. J Dent Res. 1993;
72(1):67-71.
106. Coll JA, Jackson P, Strassler HE. Comparison of enamel microabra-
sion techniques: Prema compound versus a 12-fluted finishing bur. J
Esthet Dent. 1991;3(5):180-186.
107. Sherwood IA. Fluorosis varied treatment options. J Conserv Dent.
2010;13(1):47-53.
108. Zuanon AC, Santos-Pinto L, Azevedo ER, Lima LM. Primary tooth
enamel loss after manual and mechanical microabrasion. Pediatr
Dent. 2008;30(5):420-423.
109. Farid H, Khan FR. Clinical management of severe fluorosis in an
adult. BMJ Case Rep. 2012;2012:bcr2012007138.
110. Domejean S, Ducamp R, Leger S, Holmgren C. Resin infiltration of
non-cavitated caries lesions: a systematic review. Med Princ Pract.
2015;24(3):216-221.
DA CUNHA COELHO ET AL.
111. Bronckers AL, Jansen LL, Woltgens JH. Long-term (8 days) effects of
exposure to low concentrations of fluoride on enamel formation in
hamster tooth-germs in organ culture in vitro. Arch Oral Biol. 1984;
29(10):811-819.
112. Lyaruu DM, Medina JF, Sarvide S, et al. Barrier formation: potential
molecular mechanism of enamel fluorosis. J Dent Res. 2014;93(1):
96-102.
113. Kuhnisch J, Mansmann U, Heinrich-Weltzien R, Hickel R. Longevity
of materials for pit and fissure sealing—results from a meta-analysis.
Dent Mater. 2012;28(3):298-303.
114. Ermis RB, De Munck J, Cardoso MV, et al. Bonding to ground versus
unground enamel in fluorosed teeth. Dent Mater. 2007;23(10):
1250-1255.
115. Silva-Benitez EL, Zavala-Alonso V, Martinez-Castanon GA,
et al. Shear bond strength evaluation of bonded molar tubes on fluo-
rotic molars. Angle Orthod. 2013;83(1):152-157.
116. Torres-Gallegos I, Martinez-Castanon GA, Loyola-Rodriguez JP,
et al. Effectiveness of bonding resin-based composite to healthy and
fluorotic enamel using total-etch and two self-etch adhesive systems.
Dent Mater J. 2012;31(6):1021-1027.
117. Waidyasekera PG, Nikaido T, Weerasinghe DD, Tagami J. Bonding of
acid-etch and self-etch adhesives to human fluorosed dentine. J
Dent. 2007;35(12):915-922.
118. Lygidakis NA. Treatment modalities in children with teeth affected
by molar-incisor enamel hypomineralisation (MIH): a systematic
review. Eur Arch Paediatr Dent. 2010;11(2):65-74.
119. Garg N, Jain AK, Saha S, Singh J. Essentiality of early diagnosis of molar
incisor hypomineralization in children and review of its clinical presen-
tation, etiology and management. Int J Clin Pediatr Dent. 2012;5(3):
190-196.
120. Daly D, Waldron JM. Molar incisor hypomineralisation: clinical
management of the young patient. J Ir Dent Assoc. 2009;55(2):
83-86.
121. Weerheijm KL. Molar incisor hypomineralization (MIH): clinical pre-
sentation, aetiology and management. Dent Update. 2004;31(1):9-12.
122. Mast P, Rodrigueztapia MT, Daeniker L, Krejci I. Understanding MIH:
definition, epidemiology, differential diagnosis and new treatment
guidelines. Eur J Paediatr Dent. 2013;14(3):204-208.
123. Fayle SA. Molar incisor hypomineralisation: restorative management.
Eur J Paediatr Dent. 2003;4(3):121-126.
124. Croll TP. Preformed posterior stainless steel crowns: an update. Com-
pend Contin Educ Dent. 1999;20(2):89-100.
125. Eichenberger M, Erb J, Zwahlen M, Schatzle M. The timing of extrac-
tion of non-restorable first permanent molars: a systematic review.
Eur J Paediatr Dent. 2015;16(4):272-278.
How to cite this article: da Cunha Coelho ASE, Mata PCM,
Lino CA, et al. Dental hypomineralization treatment: A system-
atic review. J Esthet Restor Dent. 2018;1–14. https://doi.org/
10.1111/jerd.12420