Strategies to enhance local anesthesia efficacy in molar-incisor hypomineralization affected teeth: A systematic review

Tulin Tasdemir¹ image, Elif Ballikaya¹ image

Highlights

Teeth affected by molar-incisor
hypomineralization show increased dentin–pulp sensitivity and pulpal inflammation, which reduces the predictability of local anesthesia.

The use of 4% articaine, preemptive analgesia, intraosseous anesthesia, and cryotherapy has been proposed to improve anesthetic efficacy in MIH-affected teeth.

Current findings are based on small, heterogeneous studies; larger, standardized trials are needed for definitive recommendations.

Abstract

Molar-incisor hypomineralization increases dentin–pulp sensitivity and is frequently associated with chronic pulpal inflammation, which may reduce the effectiveness of conventional local anesthesia. This systematic review aimed to evaluate clinical strategies to improve local anesthesia efficacy in teeth affected by molar-incisor hypomineralization and to provide evidence-based recommendations for clinical practice. A PRISMA-guided literature search was conducted in PubMed/MEDLINE, Web of Science, Scopus, and ScienceDirect using terms related to “molar-incisor hypomineralization” and “anesthesia.” Studies evaluating interventions designed to enhance anesthetic efficacy in MIH-affected teeth were included, while reviews, case reports, in vitro studies, and studies conducted outside an MIH context were excluded. Data were synthesized qualitatively. Seven eligible clinical studies were identified. Articaine 4% demonstrated superior anesthetic efficacy compared with lidocaine, particularly in mandibular molars. Intraosseous anesthesia showed high success rates and rapid onset in difficult-to-anesthetize cases. Preemptive administration of ibuprofen was associated with reduced pulpal inflammation and improved anesthetic effectiveness. Cryotherapy applied following nerve block reduced intraoperative pain, especially in anxious patients. Photobiomodulation did not demonstrate a significant benefit in enhancing anesthetic efficacy. The main limitations of the included studies were small sample sizes, heterogeneity in study designs, and reliance on subjective pain assessments, with no large-scale randomized controlled trials available. Current evidence supports the use of articaine 4% as the preferred local anesthetic agent, the administration of preemptive analgesia, the consideration of intraosseous anesthesia for challenging mandibular MIH cases, and the adjunctive use of cryotherapy following nerve block. Photobiomodulation cannot be recommended at present. Future research should prioritize well-designed, adequately powered randomized clinical trials to confirm these findings and establish standardized clinical protocols.

Keywords: Analgesia; Local anesthesia; Pain; Tooth Hypomineralization; Treatment Outcome 

Author Affiliations

  1. DDS, PhD, Department of Pediatric Dentistry, Faculty of Dentistry,  Hacettepe University, Türkiye (Correspondence:dt.tulintasdemir@gmail.com)
  2. Assoc. Prof., Department of Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Türkiye
  1. Weerheijm KL. Molar incisor hypomineralisation (MIH). Eur J Paediatr Dent 2003;4:114-120
  2. Goel N, Jha S, Bhol S, Dash BP, Sarangal H, Namdev R. Molar Incisor Hypomineralization: Clinical Characteristics with Special Emphasis on Etiological Criteria. J Pharm Bioallied Sci 2021;13:S651-s5
  3. Jälevik B, Klingberg GA. Dental treatment, dental fear and behaviour management problems in children with severe enamel hypomineralization of their permanent first molars. Int J Paediatr Dent 2002;12:24-32
  4. Zhao D, Dong B, Yu D, Ren Q, Sun Y. The prevalence of molar incisor hypomineralization: evidence from 70 studies. Int J Paediatr Dent 2018;28:170-179
  5. Afzal SH, Skaare AB, Wigen TI, Brusevold IJ. Molar-Incisor Hypomineralisation: Severity, caries and hypersensitivity. J Dent 2024;142:104881
  6. Lygidakis NA, Garot E, Somani C, Taylor GD, Rouas P, Wong FSL. Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): an updated European Academy of Paediatric Dentistry policy document. Eur Arch Paediatr Dent 2022;23:3-21
  7. Linner T, Khazaei Y, Bücher K, Pfisterer J, Hickel R, Kühnisch J. Hypersensitivity in teeth affected by molar-incisor hypomineralization (MIH). Sci Rep 2021;11:17922
  8. Bonzanini LIL, Arduim ADS, Lenzi TL, Hugo FN, Hilgert JB, Casagrande L. Molar-incisor hypomineralization and dental caries: A hierarchical approach in a populational-based study. Braz Dent J 2021;32:74-82
  9. Farias L, Laureano ICC, Fernandes LHF, Forte FDS, Vargas-Ferreira F, Alencar CRB et al.. Presence of molar-incisor hypomineralization is associated with dental caries in Brazilian school children. Braz Oral Res 2021;35:e13
  10. Fatturi AL, Menoncin BL, Reyes MT, Meger M, Scariot R, Brancher JA, Küchler EC, Feltrin-Souza J. The relationship between molar incisor hypomineralization, dental caries, socioeconomic factors, and polymorphisms in the vitamin D receptor gene: a population-based study. Clin Oral Investig 2020;24:3971-3980
  11. Bekes K, Steffen R, Krämer N. Update of the molar incisor hypomineralization: Würzburg concept. Eur Arch Paediatr Dent 2023;24:807-813
  12. Dias F, Gradella CMF, Ferreira MC, Oliveira LB. Molar-incisor hypomineralization: parent’s and children’s impact perceptions on the oral health-related quality of life. Eur Arch Paediatr Dent 2021;22:273-282
  13. Jälevik B, Sabel N, Robertson A. Can molar incisor hypomineralization cause dental fear and anxiety or influence the oral health-related quality of life in children and adolescents?-a systematic review. Eur Arch Paediatr Dent 2022;23:65-78
  14. 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. Clin Oral Investig 2022;26:1753-1759
  15. Jawdekar AM, Kamath S, Kale S, Mistry L. Assessment of oral health-related quality of life (OHRQoL) in children with molar incisor hypomineralization (MIH) – A systematic review and meta-analysis of observational studies. J Indian Soc Pedod Prev Dent 2022;40:368-376
  16. Fütterer J, Ebel M, Bekes K, Klode C, Hirsch C. Influence of customized therapy for molar incisor hypomineralization on children’s oral hygiene and quality of life. Clin Exp Dent Res 2020;6:33-43
  17. Jälevik B, Norén JG. Enamel hypomineralization of permanent first molars: a morphological study and survey of possible aetiological factors. Int J Paediatr Dent 2000;10:278-89
  18. Rodd HD, Morgan CR, Day PF, Boissonade FM. Pulpal expression of TRPV1 in molar incisor hypomineralisation. Eur Arch Paediatr Dent 2007;8:184-188
  19. Bekes K, Mitulović G, Meißner N, Resch U, Gruber R. Saliva proteomic patterns in patients with molar incisor hypomineralization. Sci Rep 2020;10:7560
  20. Rodd HD, Boissonade FM, Day PF. Pulpal status of hypomineralized permanent molars. Pediatr Dent 2007;29:514-520
  21. Discepolo KE, Baker S. Adjuncts to traditional local anesthesia techniques in instance of hypomineralized teeth. N Y State Dent J 2011;77:22-27
  22. Bilgir BS, Aydınoğlu S, Arslan İ, Atak M, Köse O, Günaçar DN. Analysis of MMP-8, MMP-20, and TGF-β1 in molar-incisor hypomineralization and assessment of periodontal health. BMC Oral Health 2025;25:1189
  23. Pappa E, Vastardis H, Makridakis M, Zoidakis J, Vougas K, Stamatakis G, Samiotaki M, Rahiotis C. Analysis of Human and Microbial Salivary Proteomes in Children Offers Insights on the Molecular Pathogenesis of Molar-Incisor Hypomineralization. Biomedicines 2022;10:2061
  24. Toledo EDS, Rizzardi KF, de Carvalho FG, Nobre-Dos-Santos M, Sciani JM, Parisotto TM. Salivary proteomics as signature for molar incisor hypomineralization stages. Clin Oral Investig 2025;29:10
  25. Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, Ioannidis JP, Straus S, Thorlund K, Jansen JP, Mulrow C, Catalá-López F, Gøtzsche PC, Dickersin K, Boutron I, Altman DG, Moher D. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 2015;162:777-784
  26. Chandler J, Cumpston M, Li T, Page MJ, Welch V. Cochrane handbook for systematic reviews of interventions. Hoboken: Wiley 2019;4:14651858
  27. Thomas AM, George S, Anandaraj S. Anesthetic efficacy of 4% articaine versus 2% lignocaine in root canal treatment of teeth with molar incisor hypomineralization. J Indian Soc Pedod Prev Dent 2023;41:316-321
  28. 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. Eur Arch Paediatr Dent 2023;24:621-630
  29. Ghanim A, Silva MJ, Elfrink MEC, Lygidakis NA, Mariño RJ, Weerheijm KL, Manton DJ. Molar incisor hypomineralisation (MIH) training manual for clinical field surveys and practice. Eur Arch Paediatr Dent 2017; 18:225-242
  30. Dixit UB, Joshi AV. Efficacy of Intraosseous Local Anesthesia for Restorative Procedures in Molar Incisor Hypomineralization-Affected Teeth in Children. Contemp Clin Dent 2018;9:S272-s7
  31. Preusser SE, Ferring V, Wleklinski C, Wetzel WE. Prevalence and severity of molar incisor hypomineralization in a region of Germany — a brief communication. J Public Health Dent 2007;67:148-150
  32. Vicioni-Marques F, Paula-Silva FWG, Carvalho MR, Queiroz AM, Freitas O, Duarte MPF et al. Preemptive analgesia with ibuprofen increases anesthetic efficacy in children with severe molar: a triple-blind randomized clinical trial. J Appl Oral Sci 2022;30:e20210538
  33. Contac LR, Pop SI, Bica CI. Enhancing pediatric comfort: a comprehensive approach to managing molar-incisor hypomineralization with preemptive analgesia and behavioral strategies. J Clin Pediatr Dent 2024;48:123-132
  34. Peedikayil FC, Kottayi S, Aravind A, Sreedharan A, Ramesh A. Efficacy of local anesthesia with cryotherapy on teeth with molar incisal hypomineralization: a randomized control trial. J Dent Anesth Pain Med 2024;24:385-393
  35. Aykanat B, Elbay M. Effect of photobiomodulation on the efficacy of anesthesia in maxillary permanent molar teeth with molar incisor hypomineralization: A randomized clinical trial. Int J Paediatr Dent 2024;34:219-228
  36. Malamed SF. Handbook of local anesthesia, 7e: South Asia Edition-E-Book: Elsevier Health Sciences, 2019
  37. Kambalimath DH, Dolas RS, Kambalimath HV, Agrawal SM: Efficacy of 4 % Articaine and 2 % Lidocaine: A clinical study. J Maxillofac Oral Surg 2013;12:3-10
  38. Farhad A, Razavian H, Shafiee M. Effect of intraosseous injection versus inferior alveolar nerve block as primary pulpal anaesthesia of mandibular posterior teeth with symptomatic irreversible pulpitis: a prospective randomized clinical trial. Acta Odontol Scand 2018;76:442-447
  39. Seltzer S. Endodontology, Biologic considerations in. Endodontic procedures 1988;31-54
  40. Wilcox AJ, Lie RT, Solvoll K, Taylor J, McConnaughey DR, Abyholm F, Vindenes H, Vollset SE, Drevon CA. Folic acid supplements and risk of facial clefts: national population based case-control study. BMJ 2007; 334:464
  41. Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med 2004;32:251-61
  42. Bjordal JM, Johnson MI, Iversen V, Aimbire F, Lopes-Martins RA. Low-level laser therapy in acute pain: a systematic review of possible mechanisms of action and clinical effects in randomized placebo-controlled trials. Photomed Laser Surg 2006;24:158-68

Article Info

Contemp Pediatr Dent 2025:6(3):189-199

Received: 13 August 2025

Accepted: 22 October 2025

Online First: 23 December 2025

DOI: 10.51463/cpd.2025.46

27 views

Full Text

Attachments

Attachments

File Downloads
pdf CPD_2025_46 29

How to Cite 

				
					Tulin Tasdemir, Elif Ballikaya. Strategies to enhance local anesthesia efficacy in molar-incisor hypomineralization affected teeth: A systematic review. Contemp Pediatr Dent 2025:6(3):189-199

Related Articles

Share Article

Under a Creative Commons license
Tagged , ,