Enhancing pediatric comfort: a comprehensive approach to managing molar-incisor hypomineralization with preemptive analgesia and behavioral strategies

Preemptive analgesia is an important strategy used in pediatric dentistry to intercept pain signals in neural pathways early, thus mitigating the perception of pain and enhancing overall patient comfort. Pedodontists often encounter challenges in conducting the therapy and managing uncooperative patients, when addressing enamel defects of the Molar-incisor hypomineralization (MIH) type. The aim of this study is to demonstrate the impact of preemptive analgesia on optimizing behavioral management and restorative treatment strategies for immature permanent molars exhibiting severe MIH and Treatment need index 4 (TNI), through the effective control of pain. This study comprised 27 cases with MIH level 3 Posteruptive breakdown (PEB), indicating post-eruptive enamel breakdown, with initial hypersensitivity scores exceeding 4 on the Wong-Baker Scale, was conducted over 12 months, between January 2023–January 2024. Data on pediatric patients aged between 5 years and 4 months and 7 years and 1 month with varying degrees of sensitivity in their permanent first molars before the completion of the eruption process were collected. Pain intensity was systematically evaluated at six specific time points: before and after the administration of analgesic medication as well as during restorative treatment using the Wong-Baker scale and data from the Face, Legs, Activity, Cry, Consolability index (FLACC). Statistical analysis for Wong-Baker scores and FLACC index indicated statistical significance (p < 0.05) for Mann-Whitney and Wilcoxon tests, respectively t-test. The comparison of mean scores recorded before and after preemptive analgesia during rotary instrumentation moments for the Wong-Baker index (4 > 0.29) and for the FLACC index (8.47 > 1.71) indicates the positive influence of administering ibuprofen. In conclusion, preemptive analgesia, alongside standardized anesthesia, significantly improved intraoperative pain management and behavioral outcomes.

Molar hypomineralization; Pain measurement; Behavior control; Preemptive analgesia; Dental atraumatic restorative treatment; Analgesia; Patient-controlled

[1] Sluke B, Held U, Wegehaupt F, Neuhaus KW, Attin TSahrmann Ph. Is there a rise of prevalence for molar incisor hypomineralization? A meta-analysis of published data. BMC Oral Health. 2024; 24: 127.

[2] Jianu MC, Muntean A, Mihălțan CI, Pacurar M, Munteanu A. Molar incisor hypomineralisation: a review of etiology, diagnosis criteria and patterns considering EAPD criteria. Romanian Journal of Oral Rehabilitation. 2022; 14: 117–124.

[3] Cutress TW, Ainamo J, Sardo-Infirri J. The community periodontal index of treatment needs (CPITN) procedure for population groups and individuals. International Dental Journal. 1987; 37: 222–233.

[4] Steffen R, Krämer N, Bekes K. The Würzburg MIH concept: the MIH treatment need index (MIH TNI): a new index to assess and plan treatment in patients with molar incisior hypomineralisation (MIH). European Archives of Paediatric Dentistry. 2017; 18: 355–361.

[5] Bekes K, Steffen R. Behavior management and pain control in treatment of children with molar incisor hypomineralization. Clinical Dentistry Reviewed. 2021; 5: 20.

[6] Vicioni-Marques F, Paula-Silva FWG, Carvahlo MR, Queiroz AM, Freitas O, Duarte MPF. Preemptive analgesia with ibuprofen increases anesthetic efficacy in children with severe molar hypomineralization: a triple-blind randomized clinical trial. Journal of Applied Oral Science. 2022; 30: e20210538.

[7] Steffen R. Treatment of children with MIH: a challenge in pain control and behaviour management. In Bekes, K (ed). Molar Incisor Hypomineralization (pp. 99-111). Springer Nature: Switzerland. 2020.

[8] Praveen K, Laxmi T. Challenges in pain assessment: pain intensity scales. Indian Journal of Pain. 2014; 28: 61–70.

[9] Shah SG, Kaul B, Kaul S, Mahajan N, Gupta A. Taking the sting out of shots: determination of effect of four different acceptable methods on perception of pain, anxiety and behaviour during local anesthesia administration in pediatric patients aged 5–9 years—a split mouth randomised clinical trial. International Journal of Medical and Pharmaceutical Research. 2023; 4: 726–738.

[10] Wong DL, Baker CM. Smiling face as anchor for pain intensity scales. Pain. 2001; 89: 295–297.

[11] Garra G, Singer AJ, Domingo A, Thode HC. The Wong-Baker pain FACES scale measures pain, not fear. Pediatric Emergency Care. 2013; 29: 17–20.

[12] von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain. 2007; 127: 140–150.

[13] Peng T, Qu S, Du Z, Chen Z, Xiao T, Chen R. A systematic review of the measurement properties of face, legs, activity, cry and Consolability scale for pediatric pain assessment. Journal of Pain Research. 2023; 16: 1185–1196.

[14] Nilsson S, Finnström B, Kokinsky E. The FLACC behavioral scale for procedural pain assessment in children aged 5–16 years. Pediatric Anesthesia. 2008; 18: 767–774.

[15] Uhlen MM, Valen H, Karlsen LS, Skaare AB, Bletsa A, Ansteinsson V, et al. Treatment decisions regarding caries and dental developmental defects in children—a questionnaire-based study among Norwegian dentists. BMC Oral Health. 2019; 19: 80.

[16] He L, Purton DG, Swain MV. A suitable base material for composite resin restorations: zinc oxide eugenol. Journal of Dentistry. 2010; 38: 290–295.

[17] Wada K, Kanazawa H, Kudo M, Kindaichi J, Miyashin M. Management of developmental enamel defects in the primary dentition. Journal of Oral Science. 2017; 59: 457–460.

[18] Pires CW, Lenzi TL, Soares FZM, Rocha RO. Zinc oxide eugenol paste jeopardises the adhesive bonding to primary dentine. European Archives of Paediatric Dentistry. 2018; 19: 163–169.

[19] Lu C, Zhang YY, Xiang B, Peng S, Gu M, Wong HM. Management of fear and anxiety in dental treatments: a systematic review and meta-analysis of randomized controlled trials. Odontology. 2023; 111: 20–32.

[20] Elnaghy AM, Elshazli AH, Elsaka SE. Effectiveness of oral pre-medication of meloxicam, ketorolac, dexamethasone, and ibuprofen on the success rate of inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: a prospective, double-blind, randomized controlled trial. Quintessence International. 2023; 54: 92.

[21] Keles S, Kocaturk O, Demir P. Efficacy of preemptive analgesia on postoperative pain control in children who underwent full-mouth dental rehabilitation under general anesthesia: a randomized controlled clinical trial. Journal of Oral & Facial Pain and Headache. 2021; 34: 297–302.

[22] Heron MJ, Nwokorie NA, O’Connor B, Brown RS, Fugh-Berman A. Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management. The Journal of the American Dental Association. 2022; 153: 110–119.

[23] Mathias FB, Cademartori MG, Goettems ML. Factors associated with children’s perception of pain following dental treatment. European Archives of Paediatric Dentistry. 2020; 21: 137–143.

[24] Brill W. Behavior of pediatric dental patients throughout the course of restorative dental treatment in a private pediatric dental practice. Journal of Clinical Pediatric Dentistry. 2002; 26: 55–60.

[25] Joshi T, Rahman A, Rienhoff S, Rienhoff J, Stamm T, Bekes K. Impact of molar incisor hypomineralization on oral health-related quality of life in 8–10-year-old children. Clinical Oral Investigations. 2022; 26: 1753–1759.

[26] Sharma AA, Jadhav AA, Bhola ND, Gupta AA, Gupta CS. Pre-emptive analgesic efficacy of single-dose transdermal ketoprofen and diclofenac patches in post-operative pain management following open treatment of mandibular fractures: a randomized controlled study. Cureus. 2022; 14: e27982.

[27] Só GB, Silva IA, Weissheimer T, Lenzi TL, Reis MV Só, da Rosa RA. Do NSAIDs used prior to standard inferior alveolar nerve blocks improve the analgesia of mandibular molars with irreversible pulpitis? An umbrella review. Clinical Oral Investigation. 2023; 27: 1885–1897.

[28] Sansone L, Gentile C, Grasso EA, Di Ludovico A, La Bella S, Chiarelli F, et al. Pain evaluation and treatment in children: a practical approach. Children. 2023; 10: 1212.

[29] Malamed SF. Pain management following dental trauma and surgical procedures. Dental Traumatology. 2023; 39: 295–303.

[30] Cetira-Filho EL, Martins-Filho PR, de Barros Silva PG, da Hora Sales PH, Vieira AF, Sindeaux LME, et al. Is coadministration of preemptive medications an effective strategy for reducing inflammatory clinical events and the need for rescue medication after mandibular third molar surgery? A systematic review of randomized clinical trials. Inflammopharmacology. 2023; 31: 1561–1575.

[31] Miroshnychenko A, Azab M, Ibrahim S, Roldan Y, Diaz Martinez JP, Tamilselvan D, et al. Analgesics for the management of acute dental pain in the pediatric population. The Journal of the American Dental Association. 2023; 154: 403–416.e14.

[32] Ezzeldin M, Hanks G, Collard M. United Kingdom pediatric dentistry specialist views on the administration of articaine in children. Journal of Dental Anesthesia and Pain Medicine. 2020; 20: 303–312.

[33] Dhar V, Gosnell E, Jayaraman J, Law C, Majstrovic M, Marghalani AA, et al. Nonpharmacological behavior guidance for the pediatric dental patient. Pediatric Dentistry. 2023; 45: 385–410.

[34] Weber KR, Wierichs RJ, Meyer-Lueckel H, Flury S. Restoration of teeth affected by molar-incisor hypomineralization: a systematic review. Swiss Dental Journal. 2021; 131: 988–997.

[35] Gatón-Hernandéz P, Serrano CR, da Silva LAB, de Castañeda ER, da Silva RAB, Pucinelli CM, et al. Minimally interventive restorative care of teeth with molar incisor hypomineralization and open apex—a 24-month longitudinal study. International Journal of Paediatric Dentistry. 2020; 30: 4–10.

[36] Linner T, Khazaei Y, Bücher K, Pfisterer J, Hickel R, Kuhnisch J. Hypersensitivity in teeth affected by molar-incisor hypomineralization (MIH). Scientific Reports. 2021; 11(1):17922.

[37] Balasubramanian S, Kamki H, Kalaskar RR. Evaluation of effectiveness of graphics interchange format and Wong-Baker FACES pain rating scale as pain assessment tool in children. The Journal of Contemporary Dental Practice. 2022; 23: 634–638.

[38] Nursin R, Harun MH, Mohamad D, Mohd Bakhori SK, Mahmud S. Subcutaneous tissue reaction to a novel nano zinc oxide eugenol dental cement. Bio-Medical Materials and Engineering. 2024; 35: 139–151.

[39] Alzahrani AY, Alamoudi NMH, El Meligy OAES. Contemporary understanding of the etiology and management of molar incisor hypomineralization: a literature review. Dentistry Journal. 2023; 11: 157.

[40] de Lima Navarro MF, Pascotto RC, Borges AFS, Soares CJ, Raggio DP, Rios D, et al. Consensus on glass-ionomer cement thresholds for restorative indications. Journal of Dentistry. 2021; 107: 103609.

[41] Haidar M, Raslan N. Comparative study of articaine 4% versus lidocaine 2% in the local anesthesia of permanent mandibular first molars affected by MIH: a randomized controlled trial. European Archives of Paediatric Dentistry. 2023; 24: 621–630.

[42] Skaare AB, Houlihan C, Nybø CJ, Brusevold IJ. Knowledge, experience and perception regarding molar incisor hypomineralisation (MIH) among dentists and dental hygienists in Oslo, Norway. European Archives of Paediatric Dentistry. 2021; 22: 851–860.

[43] Butera A, Gallo S, Pascadopoli M, Montasser MA, Abd El Latief MH, Modica GG, et al. Home oral care with biomimetic hydroxyapatite vs. conventional fluoridated toothpaste for the remineralization and desensitizing of white spot lesions: randomized clinical trial. International Journal of Environmental Research and Public Health. 2022; 19: 8676.

[44] Sezer B, Çarıkçıoğlu B. Treatment Strategies for Incisors of Children Affected by Molar Incisor Hypomineralization: A Narrative Review. Oral. 2024; 4(1):74-89