MOLAR INCISOR HYPOMINERALIZATION (MIH) PEDODONTICS MDSCONQUER DR SHREE

yeah hi winners uh hope you're doing good so uh this is Dr Sant from Team MDS conquer so now I'll be discussing one of the most important topic of uh the pedo in integrated with oral path and oral medicine uh which is nowadays very frequently Asked in the examinations uh let it be a national boards or Let It Be Your neat or inic or any sort of uh license exams uh uh this is one of the most commonly asked clinical based question so before jumping into the topic uh so learning is a is a beautiful process it is nowhere related to the age of an individual or a position of an individual if you have the will to learn okay the things around you will change okay so strongly recommend every one of you to inculcate this particular habit of learning from the surroundings or learning from the people around you and start implementing them in your professional as well as in your personal life so the topic of discussion for today is mih that is molar incisor hypom mineralization so you have hypo mineralization which is more of an a uh focused on area specific that is merss and incisors so before going into the content you have a case here okay a 9-year-old Brazilian boy with a chief complaint of yellow colored patches on maxillary mandibular centrals laterals and first merss as shown in the above clinical photograph his mother gives no complications during pregnancy but has a flu with a high favor of 103° fahit for more than a week during the the first year so what is the diagnosis and treatment plan of course the diagnosis is very simple that is mih the most important aspect in this particular question is Brazilian boy why it is being mentioned it's very simple the prevalency of mih is more in these individuals one the second important aspect is area specific okay the this occurs area specific the hypo mineralization is being occurring in area specific that is your maxillary mandibular centrals that is incisors and your first MERS and of course they have a background ethiology that there is high favor at the age of one year for more than a week that can be the ethiology in this particular case so this is all about mih so we'll try to wrap up this mih as fast as possible and we'll try to discuss few other hypo mineralizations within our limitations with in the differential diagnosis is part of this particular disease so first and foremost thing is about enamel because enamel is the most commonly affected structure in this particular mih so anamel e e for ectoderm so anamel is ectodermal in origin and coming to M M for mineralization so anamel is having the highest mineralization among the structure you have anamel Dentin cementum and alular Bone so if you list out the mineral content or mineralization aspect anamel is having the highest mineralization okay and second thing anamel does not have the ability to regenerate after it is lost okay you cannot regenerate anamel and of course anamel is formed from ameloblast and this ameloblast is very sensitive it is very sensitive to the external environment it is very sensitive to the infections it is is very sensitive to every aspect and in which stage they can ask you that is in the formative stage so an anal has different stages of formation which will be discussed in your dental histology so anamel is very sensitive in formative stat and it shows its reactions in the form of hyp metalization or hypocalcification or hypoplasia all these are the abnormalities but that we regularly see in the Anam so jumping into the next aspect definition so basically the definition of hypo mineral definition of this H is the hyp mineralization hypo mineralization plus systemic origin systemic origin plus first permanent molars 1 to four any of these mostly four if not at least 1 2 or three or four plus similar features can be seen in the case of your incisors so this is basically the definition of hyperman relation they can ask you diagram based question race focusing specifically on the incisors as well as your uh molars some cases they are chances that it can be seen in the case of canines it can be seen in the case of premolars tips of canines and premolars can also be affected but most commonly according to the definition and to to the you to the undergraduate level okay so the question will be system origin plus your uh like your first your permanent Ms okay the first Perman molars followed by your the similar features can be seen in the case of your incisors also so this is basically uh mih so the next important aspects are other terms related to mih which are given by the different scientists and which are present in the standard textbooks the first one is of course M incisor hypo mineralization previously used to be termed as an abbrevation called as mih the next important term is about non-endemic stained enamel the next one is idiopathic anamel hypo mineralization and the next important is demineralizing Dem mineralized first permanent MERS because it's most commonly affected in the four first permanent MERS the next important aspect is they can give as it as cheesy MERS the merss in the clinical photograph appears like a cheesy they appears like cheesy so you have other types of merss which are again questions asked very frequently moons MERS malberry MERS or fortuners M are your the merss which are seen in the case of cental cus so cental cus is moons MERS malber merss or your fortuners merss whereas cheese MERS are the term that is very specifically given to Mi and the next important terminology is hyp mineralized first permanent merss okay so these are the other terms and very very frequently nowadays this question was asked in in what is the other term of M they are null fluoride hyper mineralization it is non fluoride hyper mination it's nowhere related to the fluide okay so these are other terms that you have to make a note okay and next one is coming to ethiology so ethiology uh there are different types of ethiology and there are studies which are showing uh the background history particularly the medical problems during the pre uh or per or postnatal periods okay so that can be an infections very frequently uh the case- based questions can be integrated with a respiratory infection to the individual or a viral infection okay they can tell you the patient is having fever they can tell you the patient is having a viral infection with fever or they can tell you the patient is having asthma or any sort of respiratory illness okay so these are the most commonly or frequently Asked uh the medical issues associated with pre Peri and postnatal periods okay of course we'll discuss them in detail but these are the things that you have to focus on uh the next important thing is uh relation to fluoride okay so M chances will be less in the individuals uh who are exposed to more fluoride it's very simple the fluoride content increases uh during the particular uh period of period of growth the amh chances will decrease the next one is antibiotics there are few antibiotics which can lead to mih uh particularly uh the antibiotics uh which are mentioned uh in references are uh your penins particularly amoxin uh and followed by uh your aromy okay so both of these and there are few drugs which are basically associated with uh the hypo mineralization can also uh lead to the uh mih but specifically it is antibiotics which are related to that is amoxin and your aryin okay so next important aspect is breastfeeding prolonged breastfeeding okay so if the individual is having a prolonged breastfeeding okay so there are higher chances of occurrence of of Mah because uh because of the lack of calcium okay so prolonged breastfeeding can uh cause uh like okay so you can add a note about long prolong uh breast feding so then comes the next one is environmental toxins there are few environmental toxins uh which can also cause this okay so environmental toxins particularly uh they were named as poly chlorinated bols or or your dioxins okay so both of these are responsible for occurrence of uh mih so then comes the socio economic background okay the economical background of the individual the economical background of the individual uh can be like if they're originated from low social economic status uh because of lack of nutrition proper nutrition during the growth period there are high chances of occurrence of MH so here you have to focus mainly on the aspects related to respiratory illness or the favor or viral infections as prenatal as fluoride content increases the chances of MH decreases you have two antibiotics and you have two environmental toxins and of course prolonged breastfeeding are the uh primary ethologist for occurrence of this particular abnormality then comes as I said like uh it can be due to uh the poor health or any systemic medications or the mother is having nitrous oxide during the uh pregnancy uh I mean during the uh during the delivery and the birth complications okay so the birth complications can lead to mih that can be your hypocalcemia or asfixia related to the respiratory system or uh the period of Labor prolonged period of Labor uh the patient is having high favor respiratory illness uh that can be uh related to asthma or ear infection that is aitis Media or systemic fibrosis Ral diseases or viral diseases like chicken poox misil all these can be the background history they can give in the uh they can give in the case based description I'm primarily focusing the list of these things uh as a case based aspect okay no need to mug all these things it is more logical they can ask you mostly a case based or a or a treatment based question on this uh they can be like pre-term baby okay pre-term baby is nothing but uh less than 37 weeks very frequently asked what is pre-term baby pre-term baby means less than 37 weeks or low birth weight lowth weight is nothing but less than 2.5 kgs or 2,500 G okay so these are the main uh medical related pre Peri and postnatal uh disorders which can lead to mih they can be considered as an ethiology the most important aspect is respiratory origin diseases like asthma and cystic fibrosis or viral diseases okay or favor prolong favor can be an ethiology for occurrence of Mi so next one is coming to jumping into the clinical presentation anamal hypoplasia are familiar so diagram based very specific to incisors and Ms that can be easily handled and now uh these These are the criterias that are given by the European Association okay so the criteria includes these things okay I I'll be discussing these things in a descriptive part because your questions will move around these areas okay so you'll have opacities clinically visible you have post eruptive anamel breakdown that is very very important so in most of your hypo mineralizations whatever discussed in your oral path and oral medicine uh the anamal breakdown occurs before the eruption or during the process of eruption but here the anamal breakdown will occur post eruptive means after the eruption the anamal breakdown is going to occur and you will have atypical uh Restorations you'll have Restorations which are not normal which are quely abnormal you see the abnormal registrations uh the margins are being extended you'll have patches of registrations here and there so that is very specifically called as atypical Restorations uh and of course the patient may complaint of extractions of merss that can be due to mih again or sometimes there will be eruption failure of molars or incisors so these are the main clinical uh presentations of mih okay or the clinical criteria the presentation of Mi as anamal is lost the patient most commonly complaints complaint of pain or hyper sensitivity dentinal hypers sensitivity is the most common complaint because anamal is lost and Dentin is being exposed so whenever the Dentin is being exposed the patient will have pain and hypers sensitivity so these are the main important aspects in the clinical presentation okay so luckily in the in the in the in the clinical uh case is what we have discussed the patient doesn't have any symptoms the symptoms were not mentioned the patient concent is Aesthetics that is your first point obasi yellow color patches are same so then jumping into this uh this is given by uh European Association of Pediatrics pedod Pediatrics okay so already discussed that is your discriminate obesities okay post erupto anamal breakdown atypical registrations and extractions extracted molars because of this particular leion okay so these areas are very very important I want you to focus on everything is self-explanatory and abnormality in the transiency of anamel identified as creamy white or yellow to brown color opties this these are the particular terms creamy white creamy white or cheesy white that is the reason why these are called as cheesy Ms which with clear and distant borders uh adjacent to the unaffected anamel okay the second one is I told you there will be anamel breakdown that is uh disintegration of anamel followed following the tooth eruption potentially resulting from the masticatory forces because the anamel here it is very thin or very weak that is fral anamel will be there it will be easily break down and coming to the atypical restrictions which I have already explained that is basically the size and shape of the uh restoration is not confined normally if you prepare cavities or if you dig out the enamel and if you start giving the restoration the margins are very distant okay you can clearly tell this is the boundary of this particular restoration but when you're talking about a typical Restorations which are seen in the case of mih you don't have proper boundaries you don't have proper uh I mean the borders the refinement will not be there okay in most of the cases the extensions can be on the Buckle and the palatal smooth surfaces also right normally we don't have the cares lesions or cavities which are extending mostly on the Buckle and palad very rarely we see this Buckle Extinction pallet Extinction cases uh in your clinical scenario in the Departments also okay so that is very important when talking about extractions basically due to to uh extraction of merss or extractions of incisors basically due to this breakdown uh the patient is going to give in the form of a history so these are the very important criterias of mih that you have to make a note because questions were asked on this particular table in in recently so then uh apart from this uh there are few other things which we have to discuss particularly about the thickness uh and other aspects so as already discussed uh most of these are as the areas affected are oclusion surface of molars and can be seen on the Buckle or labial surface of incisors which we can clearly appreciate in the diagram cheesy molars cheesy is mostly on the ocal surface okay so next one the extent of involvement the extent of involvement they can ask you the extent of involvement uh in the enamel can be in the range of uh can be in the range of thickness of 1/3 to 2/3 thickness 1/3 to 2/3 thickness and there are few important the defs less than 2 mm if you see anamel defects less than 2 mm they are not considered as MH uh defects less than 2 mm are not considered as a m i h okay so the next important point that you have to make a note because the questions can be asked because the questions were already repeated in uh in few examinations on this particular area so I want you to make a note about these aspects that is the cpel inclinations you see this is the cusp the cusp this is a cusp tip and these are inclinations okay the the inclinations are affected but not the cpel tips the cpel tips are not affected okay in this particular individuals and of course you know it is more commonly seen in the case of molars compared to incisors that is your first permanent Ms and uh sometimes you can see these extensions on the tips of uh the canines as well as the prolar but it is very very rarely but this type of presentation can be seen in the primary dentation also okay it can be seen in the primary it can be seen in the permanent also more commonly seen in the case of molars compared to the incisors cpel tips are not affected inclinations are affected less than 2 mm are not considered as MH extended defects can be from 1/3 to 2/3 thickness of the enamel most commonly seen on the ocal surface of molars and buckle and labal surfaces of incisors so these are the important things that you have to make a note clinically okay they can to ask you questions on these areas next one there is something called as sority grading of Mah Mah has been divided into two severities that is mild and severe okay mild is discriminate anamal opacity it is without anamel breakdown there's no breakdown of the anamel okay the patient may have uh occasionally sensitivity will be there next one is second category discriminate anamal opacities with the breakdown the patient will have spontaneous hypers sensitivity affecting the function aesthetic problems and everything two categories mild and severe there are different types of index scales uh that are helps in distinguishing this mih but they are not much important from the examination point of view so we can stick onto these areas particularly your clinical criteria what I have discussed according to European Association of uh Pediatrics is very very important from examination point of view so as already said it is more inclined to the permanent dention but can be seen in the case of deciduous teeth also that is your decious molar hyp mineralization that is anamal hyp mineralization is also reported in the primary teeth okay and you can see the clinical photograph where both primary as well as permanent teeth are being affected by hyper mineralization okay in primary in permanent dentation it is the first molars which are most commonly affected whereas in the case of your primary dentation it is the second merss which are most commonly affected your second merss and in second merss are most commonly affected very rarely inors are going to get affected sometimes the primary canines as well as first M the most important area is the teeth MO is most commonly affected by MH is your permanent merss the teeth which is most commonly affected in your primary dentation is your second primary model coming to differential diagnosis this is utmost important aspect according to me because uh questions on MH yes chances are there but questions on other hyp mineralization or other effects of anamel are very very frequently Asked in the examination okay so coming to differential diagnosis apart from mih what are the other areas uh where your anamal is being affected the first and foremost thing is amalen is imperfect okay you can see amalen imperfect the unique property of amalen imperfect is all the teeth are affected you see all the teeth anamal part is being affected you can see in the clinical photograph you can see in the clinical photograph that all the teeth okay you can see all the teeth are being affected okay the first the second thing is the family history will be there because animal imperfecta is basically origin defect from the genes okay so it is carried from Generations so you can ask you whether uh the parent so in this in this question again they're going to give you the mother is having the same uh clinical future or the mother is having the same complaint or they can tell you the siblings are having the same complain so family history will be present and the utmost important thing again you can see the radiographic appearance of amens is imperfecta when compared to MH MH does not have a drastic changes in the radiographic picture except the defects in the anal whereas you see Amen in perfector you will have a tood DA appearance on a radiograph which help helps in differentiating uh the mih from amalen perect important points all teeth affected mih only incisors and MERS are affected next one family history will be there here no family history will be there okay next one is fluorosis okay so fluorosis are basically uh uh is origined from a background or a region where there is high fluoride exposure to the individual so they can give that as a background information okay and the number of teeth affected during the fluorosis in the Flor case depends upon the time of exposure so this we'll be discussing in the pedo uh and integrated with your fuis and all these things the pedo integrated with Community part we can discuss which area which duration if an individual is being exposed to fluorides or individual is exposed to tetracyclin so there will be stains which teeth are affected so this is again a table this table is there very important from examination point of view okay the table is there very important particularly if you're preparing for national boards so this correlationship table is very frequ frequently Asked okay so the number of teeth affected depends upon the time of exposure and the amount of fluoride that is being exposed in these individuals okay that is how you can differentiate fluorosis case and followed by there is something called as anamal hypoplasia so anamal hypoplasia can be partial affecting only few teeth or can be complete complete affecting all teeth or affecting the entire part of anamel so how can you differentiate this uh so this this anamal hyperopia is basically occurred at the time of eruption and what we have discussed about mih mih is post eruption means the individual will have a normal anamel and over a period of time during the mitigation process MH will be detected whereas anamel hypoplasia will be seen at the time of birth time of eruption during the time of eruption at the birth or during the time of eruption you can diagnosis this anamal hypa so the next important aspect uh after anamal hypoplasia is of course your M MH we have discussed a lot about MH MH is basically seen in the case of molars compared to incisors and how you can like a severe form of MH which is affecting all the teeth you may get confused with amalen is imperfecta so Amal imperfecta and a Severe form of mih looks same because I have discussed the sever form of MH can affect all the teeth including the canines as well as the premolars okay so now you can differentiate only with the help of radiograph because radiographic presence are there in the case of your amalen imp perfector and these radiographic appearances will be absent in the case of your tontis sorry absent in the case of your uh mih okay so that is how you can differentiate uh a severe form of mih to that of amens is imperfect so next one more important most frequently seen is white spotle what is White Spot letion White Spot letion is called as insufficient car letion or in initial car letion that is basically occurring due to the drift or change in the rization demalation cycle you have something called as rization demalation cycle so whenever your reation demalation cycle is most commonly shift to demalation side okay then there is high chance of occurrence of white spot leion and White Spot leion can occur anywhere on the lavial surface or anywhere on the teeth but most occurs on the cervical areas why because plaque accumulation and chances of changing this rization demalation cycle will Morely seen in the cervical one okay so white spot lesions can be seen in those areas where the plaque is being accumulated and there will be intact anamal but there will be subsurface demonization so white spot leion is also called as subsurface demineralization it is more often related to the initial steps of the carries but most of the things whatever we are discussed are not related to the Caris they have high chances of Caris occurrence by presence of MH High chance of Caris occurrence will be there okay but this is process of Caris okay so that's about White Spot leion the next comes is turnus hypoplasia or turnus teeth don't get confused with turnus syndrome turnus syndrome I hope like uh you you know the turnus syndrome that is 45 XO okay right 45x is a turnus syndrome this is turnus hypoplasia or turnus teeth okay here you can see a particular teeth is being affected from its shape shape and form basically it is due to the trauma there are few textbooks telling it as traumatic hypomineralization also or traumatic hypoplasia one of the reason is trauma okay and other reasons can be many other things the changes during the primary dentation so this is most commonly seen in the case of permanent premolars uh because primary molars are most commonly affected by Dental cares and the infection from primary merss will reach the per epical area and which is going to affect the fellow we have discussed the fellow that is M blast fellow will get affected and it will lead to turnus hyperia this is localized anamal hypop means only a particular teeth only one teeth or two teeth are going to get affected and preferably most commonly seen in the case of mandibular premolars area specific it is Mand PR M merss permanent merss okay so this is how you can differentiate Turners hyperplasia from uh mih next comes of course questions very frequently as recent neat examination there is a question on this right coming to the syphilis okay so these are the Futures which are seen in the case of cental syphilis and of course you are very familiar with the Triad of cental syphilis so you have incisors as well as MERS are affected similarly coming to area specific syphilis area specific they can ask you uh the combination I mean the common thing that you see in the case of cental cus and mih is area of occurrence so it can be occurred your abnormality of teeth can occur in incisors as well as in the case of your merss in the syphilis also so incisors are called as hutchingson incisors okay so you'll have a notch like this uh and Ms Ms are called as malberry Ms or they can be called as Moon merss Moon MERS or fortuners MERS okay which are seen in the case of your cental syphus okay that diagram based question or they can give you the background history of syphilis to the mother or they can tell you that the mother is regularly having in a uh unprotected sexual contact they can give some futures of syphilis okay you have lots lots of things about syphilis which are discussed in oral pathon oral medicine part you can do that right so these are the important differential diagnosis part uh coming to the clinical problems until now we have discussed the clinical uh uh clinical criteria and everything clinical problems I said like anamel lost what is the problem if anamel is not there anyone like you and me your parents will have a loss of anamel okay what is going to happen the patient is having dentinal hypers sensitivity and of course if severe loss the patient is going to have break breakdown pain will be the pain and uh sensitivity are most common complaints and of course uh these are seen as a post-operative breakdown okay so the patient have difficulty in mastication so there's are some clinical consideration are more prone to cares anamal is weak more prone to cares anamel is weak discolorations more prone to poor Aesthetics and need recurrent uh treatments because all all the teeth will not get affected by the same time okay so destrction will be at different phases so recurrent treatments are required so these are the clinical problems associated with uh the m and coming to the treatment plans okay so treatment plan of M is very very simple okay so don't write heavy heavy notes okay so try to understand the content once you understand the cont it is very easy to answer so MH can affect the permanent merss that is first permanent molars fpm fpm is very commonly used term for M that is first permanent uh molar hypo mineralization okay next one incisors are affected so incisors are mostly concerned with Aesthetics whereas merss are mostly concerned with mitigatory procedure that is your mastication so without uh breakdown okay that is post Arup to breakdown postup so anamel there's no breakdown of the anamel so one category there's no breakdown of the anamel second category with the breakdown of anamel and coming to the incisors part we have discussed one is uh cheesy or creamy white defects are there second one is brown color yellow brown color defects are there different treatment plans uh one is prevention second one is restoration and third one is rehab okay so these exact terms we'll be discussing in the uh Community handicapped rehabs and everything we'll discuss in the community part the first chapter of community okay so prevention basically uh it is preferred to advise the patient to go for high fluoride containing toothpaste that is around 1,00 to 1500 PPM fluoride content has to be given to the kid okay so this is going to help in remineralization process because what is the problem here hyper mination and what you have to do you have to encourage the reation the best source of reation for us is of course the fluorides or you can use cpacp or you can use the other other things which I'll be discussing now okay so that is that is the most important aspect and coming to the uh um fpm that is uh first permanent m hyp mineralization without enamel mown what you are going to do is fluide application you can do okay that is tropical floride application you can do or you can advise pit and fissure sealants this is a preventive aspect because there is no anamel breakdown so don't disturb the anamel until until it is you try to REM mineralize the anamel because anamel can break down because there is lack of mineralization it so what you have to do you have to feed the anamel with the minerals that can be done with tropical fluoride application or any other things like remineralizing agents can be used there is no need of registration there is no need of rehab next one first permanent molar hypo mineralization with post eruptive breakdown there is a break down here so when there is a breakdown what you have to do you have to do a restoration so what restoration GC can be given okay so GIC can be used as interim registration not a permanent in mih GIC can be used as an interim uh and further you can replace it with a nice good adesu composite registration so that is about the registration or sometimes there is a drastic loss breakdown can be minimal or breakdown can be complete so when there is very large breakdown then you you have to plan for the rehab with the porcelain fused crown or you can go for a cast metal restoration okay or you can go for an extraction followed by orthodontic treatment extraction followed by orthodontic treatment is nothing but assuming that the patient take a radiograph patient is having third Ms what you try to do you try to do a balanced extraction okay if it is already affected then you try to drag the second MERS to the first MERS and third MERS to the second MERS position with the help of Ortho treatment that is called as extraction followed by Ortho treatment okay the next important aspect is uh incisors okay so when you're talking about incisors uh incisors again you have two important aspects one is white creamy defect okay so one second one is brown yellow def okay right so we are done with the molars uh now we are talking about incisors so incisors the main concent for any one of us is Aesthetics Aesthetics and incisors so so coming to aesthetic point of view you have two different aspects okay one is uh you have white creamy defects second one is you have brown yellow color defs which I'm going to discuss detailly because they are mainly concerned with Aesthetics and Aesthetics we have different types of treatments okay I'll be discussing in the next few uh uh slides okay and of course we already done with this extraction followed by orthodontic treatment is nothing but uh because of gross destruction or grossly affected uh or severe form of MH okay so you are going to extract these molars or merss particularly so before extraction of merss you have to take a call whether the third Ms are present uh present or not a of individual and everything has to be taken into consideration so OPG has to be taken and third M's existence has to be confirmed so then you extract the first molers uh replace the positions of the first Ms second Ms and third Ms to the position of first and second molars by orthodontic treatment this is what extraction followed by Oro and of course I'm talking about the aesthetic considerations for the anterior teeth creamy white yellow brown color or obesities okay so the the three aspects uh which can be seen as a clinical features in the case of your mih so three different treatment plants the first one is creamy white opacities uh in a in a kid less than 15 years you can do micro aberration micro aberration basically you have to use preferably this has to be used 18 percentage of HCL in very few conditions you can use 37% of phosphoric acid but I want you to stick on 18% HCL there is something called as micro aberation modified crawls technique okay which we have already discussed so modified crawls technique what he has used he has used 11 percentage of HCL so the updated answer is 11 percentage of HCL if you don't have 11 percentage of HCL then you have have to go for 18 percentage of HCL as an answer which is already covered in your operative Endo okay which is already discussed in your operative Endo part also okay so do make a note of it very important question was repeated so many times in the exam so apart from this uh whenever you have a creamy white opacus okay so the technique that you can use resin infiltration okay so this is resin infiltration very very important okay an updated version not at a u level at a pz level it is there so there is resin infiltration whenever you have a defects in anamel whenever you have a minimal defects in the Dentin you can infiltrate the resin into the parasitus so that is called as resin infiltration technique or you can try tropical fluoride application or CPP ACP that is your remineralizing agents okay remen cpacp is also called as tooth mousey as in the form of a tooth Mouse uh in the form of an a paste or recal recal dent in the form of a chewing gum this is chewing gum and tooth Mouse C is a paste that you can use it okay so the next important aspect is yellow brown color opacities in less than 15 years uh since the defects can involve full thickness of anamel uh micro aberation cannot be so so so effective okay white easy outer surface you can do it but uh uh lower part micro abration single micro abration may not be effective so you have to do two to three treatments of micro abberation then you have to go for composite restoration or then you can try try the vur and all these uh keeping the Aesthetics uh into consideration the next one opacity is more than 15 years in these individuals you can try you can really try this bleaching technique that is 10 to 10 to 15% 10 to 15 percentage is the range okay 10 percentage is the best answer that is 10% of carbom peroxidase can be performed as a bleaching as before you start your composite vur or anything okay so these are the important aspects about the treatments okay um right so I hope uh you're clear with this content so uh just a brief outline okay so mih the most important aspect it is area specific it is most commonly seen in the case of permanent first molars and inors okay and mih has a background history that is systemic oration it is okay so you have some ethiology factors the most important ethiology factors that they can give is favor or respiratory illness they can mention it as an asthma they can mention it as a cystic fibrosis respiratory system related origin diseases or a viral favor or a favor of high favor for an individual at at a particular case and followed by there is some criteria for this okay so the criteria four or five important aspects let it be opacities let it be post eruptive anamal brain break down or let it be a typical registrations or let it be extractions uh due to MH are the important criterias that you have to make your note so followed by the criteria the patient have complaint of pain and hypers sensitivity those two lines are very very important very frequently added to your uh questions okay then differential diagnosis so they're very rather important how can you differentiate anal uh amalan is in perfector all the teeth are affected mother or father or siblings are going to have a same complaint okay next followed by the second one uh when you're talking about uh the fluorosis fluorosis it is a Time based means how much amount of fluide exposed what time it is exposed so basing upon you have turnus hyperplasia is at a single particular preferably mandibular prolar okay and followed by anamel hypoplasia you have a different thing white spotl is related to the Caris syphilis same uh same area specific but you have a different origin you have a background history you have a mother suffering from syphilis okay uh uh other features of syphilis can be add added in the Cil based question coming to the treatment uh Ms with breakdown different treatment without breakdown different treatment anteriors you have three different treatment plants uh one is white cheesy second one is brown uh Brown uh yellow to brown color opacities and third one is a normal opacities in an individual more than 15 years okay so I mean like before concluding this from examination point of view maybe in the future uh you may get exposed to this particular case in your clinical uh scenario or where you're working anything so it's always learning is a big process it's not only this topic is not only from entrance point of view or a University exam point of view uh the main consent of this topic is to is to learn is to implement in your clinical practice or Implement to a particular situation in the future okay so this is all from my side okay so as of now signing off Dr Shan from Team MDS conquer Take Care by bye