Developmental enamel defects in the primary dentition: aetiology and clinical management S Salanitri,*† WK Seow* *Centre for Paediatric Dentistry, School of Dentistry, The University of Queensland, Brisbane, Queensland. †Logan–Beaudesert Division, Metro South Health District, Queensland Health. ABSTRACT Developmental enamel defects, presenting as enamel hypoplasia or opacities are caused by damage or disruption to the developing enamel organ as a result of inherited and acquired systemic conditions. The high prevalence of these defects in the primary dentition demonstrates the vulnerability of the teeth to changes in the pre- and postnatal environment. The presence of enamel hypoplasia increases the risk of primary teeth to early childhood caries and tooth wear as the defective enamel is thinner, more plaque retentive and less resistant to dissolution in acid compared to normal enamel. The purpose of this paper was to critically review the aetiology and clinical complications of developmental enamel defects in the primary dentition and propose recommendations for the clinical management of affected teeth. Keywords: Enamel hypoplasia, enamel opacities, early childhood caries, primary dentition. Abbreviations and acronyms: CMV = cytomegalovirus; CPP-ACP = casein phosphopeptide amorphous calcium phosphate; DDE = developmental defects of enamel; EEC = early childhood caries; HAS-ECC = hypoplasia-associated ECC; MIH = molar-incisor hypo- plasia; SEM = scanning electron microscopic. (Accepted for publication 16 January 2013.) INTRODUCTION Developmental defects of enamel (DDE) are com- monly encountered in clinical practice, and may be defined as aberrations in the quality and quantity of dental enamel which are caused by disruption and/or damage to the enamel organ. 1,2 The presentation and severity of the defect are usually dependent on the stage of development during which the insult occurs as well as the extent and duration of the insult. 3 Enamel hypoplasia is a quantitative defect and presents as a deficiency of enamel while enamel hypo- mineralization is a qualitative enamel deficiency pre- senting as alterations in the translucency or opacity of the enamel which may be diffuse or demarcated and coloured white, yellow or brown. 1,4 Diffuse opacities are thought to be associated with the group of teeth which are undergoing enamel maturation at the time when a systemic insult occurs. In contrast, demarcated opacities and hypoplasia are more commonly noted in teeth which had sustained a localized and transient injury. Although there are many indices which have been proposed for specific types of DDE, such as the Dean and Thylstrup and Fejeskov indices of fluoro- sis, 5,6 the Developmental Defects of Enamel (DDE) Index, often used in a simplified form, is one of the most popular. 7 Compared to the permanent dentition, the preva- lence of DDE in the primary dentition has not been well reported. As noted in Table 1, which shows investigations of DDE in the primary dentition pub- lished since 1996, DDE in the primary dentition has been reported to occur at rates ranging between 10% to 49%. In the study of Montero and co-workers on 517 children in the USA, an overall prevalence of 49% was reported, 8 and in the study of Slayton and co-workers, 6% and 27% of healthy children in the USA had at least one tooth with enamel hypoplasia and enamel opacities respectively, giving a total prevalence of DDE of 33%. In contrast, Casanova- Rosado and co-workers found that only 10% of the Mexican children studied exhibited DDE. 9 In Austra- lia, Seow and co-workers reported a prevalence of DDE of 25% in the primary dentition with enamel opacities three times more prevalent than enamel hypoplasia. 10 Although DDE are now increasingly recognized as important risk factors for dental caries and tooth wear, the condition is not well diagnosed and aetiology is still unclear. Furthermore, the clinical © 2013 Australian Dental Association 133 Australian Dental Journal 2013; 58: 133–140 doi: 10.1111/adj.12039 Australian Dental Journal The official journal of the Australian Dental Association
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