Antimicrobial photodynamic therapy and deproteinization in teeth with molar incisor hypomineralization: a case series

Introduction

Molar incisor hypomineralization (MIH) is a complex developmental enamel defect influenced by multiple factors, including genetic predisposition. This condition primarily impacts the first permanent molars and, in some cases, the permanent incisors (1). MIH can be mild or severe, with white, yellow and brown opacities and a greater frequency of post-eruptive enamel fractures, caries, hypersensitivity, atypical restorations, and extractions (2). Individuals with MIH commonly experience dentinal hypersensitivity to thermal and mechanical stimuli. Properties such as insulation and thermal conductivity are altered in the highly porous enamel. Teeth with demarcated opacities and unconventional restorations due to MIH have mild to moderate hypersensitivity, whereas post-eruptive enamel fractures are commonly associated with severe hypersensitivity (3). Although hypersensitivity in MIH has not been fully clarified, the highly porous enamel in such cases is hypothesized to facilitate bacterial infiltration into dentinal tubules, triggering subtle pulp inflammation (4).

Due to hypersensitivity in teeth affected by MIH and difficulty with regards to the behavioral management of children, chemical-mechanical removal is a viable alternative, which involves the use of a proteolytic substance that softens decayed dentinal tissue, making it easier to remove with manual tools (5). Studies have shown the effectiveness of the commercial product Papácarie^TM for the removal of decayed dentinal tissue while preserving healthy tissue without the need for local anesthesia or rotary cutting instruments (5-7). Restoring teeth with MIH and dentin caries lesions is a recommended practice. Traditionally, the complete removal of hypomineralized enamel is justified by the need to prevent fractures at the margins of restorations, which is a common problem. However, this complete removal can compromise the structural integrity of the tooth, increasing the likelihood of subsequent restoration failures (8). Recent studies suggest that enamel deproteinization can improve the adhesion of restorative materials, eliminating the need for total removal of hypomineralized enamel. The literature describes the use of 5% sodium hypochlorite as an effective approach for deproteinization in teeth with MIH, offering significant benefits (9). However, its use must be cautious to avoid damage to the soft tissues and young pulp of hypomineralized teeth (10). Papacarie is a natural gel-based on papain and an alternative to sodium hypochlorite for deproteinization, offering additional advantages due to its antibacterial, proteolytic, and anti-inflammatory properties (10). Moreover, it provides benefits in caries removal and pain control during treatment, eliminating the need for anesthesia in teeth with MIH (11).

Novel caries treatment modalities have been developed, such as antimicrobial photodynamic therapy (aPDT) (12). The photodynamic process consists of a photosensitizing agent that captures photons emitted from a light source, leading its electrons into a singlet excited state S1 (13). The interaction with the underlying tissue promotes a biological response. A chromophore applied to the dentinal tissue absorbs the light, enhancing the light-tissue interaction (13). A side effect of aPDT observed in vivo was the activation of protective mechanisms of dental pulp repair and the biostimulation of tertiary dentin (14).

The use of aPDT for the decontamination of the remaining affected dentinal tissue after the selective removal of carious tissue within the context of minimal intervention is a promising method with a favorable prognosis (15). Considering the clinical challenge of achieving effective hypersensitivity control after restorative treatment, as well as ensuring the longevity of restorations, the search for effective and minimally invasive treatment protocols becomes urgent and necessary.

The aim of the present study was to report the clinical impact of aPDT on teeth with MIH and caries lesions, using minimally invasive procedures for chemomechanical caries removal and deproteinization, with the goal of enhancing the longevity of restorations. To ensure greater transparency and a high research standard, we present this article in accordance with the AME Case Series reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-24-480/rc).

Case presentation

The study was conducted as a prospective, single-center, and consecutive case series.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Ethics Committee of Universidade Nove de Julho (certificate number: 61027522.0.0000.5511; August 23, 2022) and registered on ClinicalTrials.gov (certificate number: NCT05443035, approved on July 5, 2022). The legal guardians of the children provided a written signed informed consent form, and the children signed an assent form.

The teeth were selected from children aged 7 to 10 years who were enrolled for treatment at the pediatric dental clinic of Universidade Nove de Julho. The patients were treated and followed up from October 2022 to June 2023.

The inclusion criteria were individuals 7 to 10 years of age with at least one permanent first molar with hypomineralization and active dentinal caries classified as International Caries Detections and Assessment System (ICDAS) 5 or 6 (according to the ICDAS, indicating extensive decay) (16). Additionally, there must be post-eruptive fracture on one or more surfaces of the affected tooth, with an indication for direct restorative treatment. Direct visibility and access to the area of interest were also required. The exclusion criteria were teeth with clinical signs or symptoms of pulp involvement and those with radiographic evidence of pulp involvement on initial periapical radiographs. Additionally, teeth with extensive MIH affecting multiple surfaces, for which direct restorative treatment was deemed inappropriate, partially erupted teeth with MIH, and teeth that had previously undergone restorative treatment were also excluded from the study.

The clinical procedure was conducted according to the method reported in the literature (17), as detailed below:

• Initially, a periapical radiograph was performed, followed by the assessment of initial hypersensitivity.
• The procedures began with relative isolation using a lip protector, cotton roll, and suction.
• An initial collection of carious dentinal tissue was performed using a Meyhoefer curette to standardize the tissue volume.
• Subsequently, selective chemical-mechanical removal of the carious tissue from the dentin was carried out using Papacárie Duo (Fórmula & Ação, São Paulo, SP, Brazil), which was applied to the cavity for 40 seconds to soften the carious tissue and facilitate its removal.
• After this procedure, a second collection of dentinal tissue was performed.
• Following this, aPDT was applied.
• A third collection of dentinal tissue for subsequent microbial analysis in the laboratory.
• Next, a layer of resin-modified glass ionomer cement (GIC), Riva Light Cure (SDI, Melbourne, Vic, Australia), was applied to the deepest part of the cavity.
• The next step was the deproteinization procedure, aimed at applying a deproteinizing agent to the surface of the hypomineralized enamel to remove trapped proteins, thereby enhancing the adhesion of the restorative material to the compromised enamel surface. Initially, acid etching of the hypomineralized enamel was performed using 35% phosphoric acid Ultra Etch (Ultradent, Indaiatuba, SP, Brazil) for 20 seconds, followed by rinsing for 15 seconds and drying. This step creates micro-porosities on the enamel surface, improving the penetration and effectiveness of the deproteinizing agent. Subsequently, the deproteinizer Papacárie Duo was applied for 60 seconds, not for the chemical-mechanical removal of carious tissue as in the previous step, but specifically to remove proteins from the hypomineralized enamel.
• After washing and drying the cavity, the Ambar universal adhesive (FGM, Joinville, SC, Brazil) was selectively applied to the enamel for 20 seconds with rubbing. Following a brief air-drying, the adhesive application was repeated once more, ensuring thorough coverage of the enamel.
• The restoration was then carried out with bulk-fill composite resin (Tetric N Ceram Bulk Fill, Ivoclar Vivadent, Barueri, SP, Brazil), extending to the adjacent demarcated opacities, and light-cured for 10 seconds in increments of up to 4 mm, with Radii Cal (SDI, Melbourne, VIC, Australia). Assessments were performed 48 hours, as well as at 3 and 6 months, after the procedures.

The detailed process of aPDT, protection of pulpal or axial wall with resin-modified GIC and deproteinization with Papacárie is presented in Figures 1-4.

Figure 1 Antimicrobial photodynamic therapy. (A) Application of 0.005% methylene blue gel; (B) selection of the laser parameter.

Figure 2 Protection of pulpal wall with resin-modified glass ionomer cement.

Figure 3 Deproteinization with Papacárie. (A) Selective etching of adjacent enamel and demarcated opacities with 35% phosphoric acid; (B) application of Papacárie Duo to adjacent enamel and demarcated opacities for deproteinization; allowed to act for 60 seconds.

Figure 4 Final restoration with bulk fill resin, after the deproteinization procedure with Papacárie.

For aPDT, a 0.005% methylene blue gel was used as a photosensitizer, with a pre-irradiation time of three minutes. The light source used was a laser device (Therapy XT; DMC, São Carlos, SP, Brazil) for aPDT application. The irradiation parameters were based on a previous study (11). The application technique was contact mode, with irradiation concentrated on a single point during a single session. The wavelength was 660 nm, with radiance of 3,571 mW/cm². The temporal regime was continuous, with a power of 100 mW and a beam area of 0.028 cm². The exposure time was 60 seconds, resulting in an energy density of 214 J/cm² and a total energy of 6 J.

Pain or discomfort was determined prior to the removal of the carious tissue using the Visual Analog Scale (VAS) (18). This assessment involved isolating adjacent teeth and applying compressed air to the tooth with MIH for one second. Additionally, the dentist utilized the Schiff Cold Air Sensitivity Scale (SCASS) (3) to measure sensitivity. The VAS and SCASS measures were repeated 48 hours post-restorative treatment as well as at the 3- and 6-month follow-up assessments.

Microbiological analysis was performed in accordance with a previous study, with infected dentin collected on three occasions: before and after the selective removal of carious tissue, and after photodynamic therapy (17). To collect samples, carious dentin fragments were extracted from the pulpal wall using a Meyhoefer No. 2 curette (ABC Surgical Instruments; São Paulo, SP, Brazil). These fragments were then placed into vials containing 1 mL of brain-heart infusion (BHI Broth; Himedia, Kelton, PA, USA), a nutrient-rich medium used to support the growth of microorganisms. During transportation to the laboratory, the vials were kept on ice to preserve the samples. In the laboratory, the samples were homogenized with a Vortex mixer (Vortex Q220; Quimis, Diadema, SP, Brazil) for 30 seconds at maximum speed (level 10). Serial dilutions of the original sample were prepared, ranging from 10⁻¹ to 10⁻⁵. Aliquots of 10 µL from each dilution were plated onto BHI Agar (Himedia, Kelton, PA, USA) and incubated under microaerophilic conditions at 37 ℃ for 48 hours in a CO₂ incubator (Revco Elite II; Kendro Laboratory Products, Asheville, NC, USA) to simulate the growth conditions of oral pathogens. Colony-forming units (CFUs) were then counted, and all procedures were performed in duplicate to ensure accuracy.

The focus of the assessment was the retention of the restorative material in the cavity, the status of the enamel surrounding the restoration, and the detection of secondary caries. This assessment was based on the modified criteria of the United States Public Health Service (USPHS) (19). A restoration was deemed a failure if any of the criteria was rated as C.

We present a case series of 7 patients, aged 7 to 10 years, whose first molars were diagnosed with MIH and caries and were subsequently treated with the procedure described above. The case series was predominantly composed of girls, with 5 females accounting for 71% of the total. The mandibular arch was affected more and tooth 36 was the most affected. The most prevalent score on the ICDAS was Code 5 (Table 1).

Severity was recorded per surface using the codification of the European Association of Paediatric Dentistry (EAPD) (20). Three teeth had post-eruptive fractures on the occlusal surface and one tooth had a fracture on the vestibular surface. On all these teeth, cream-white or yellow-brown opacities were found along the margins of the fractures. All four cases had a baseline SCASS score of 1 or 2 and all were asymptomatic after implementation of the proposed treatment protocol.

Three teeth had post-eruptive fractures on the occlusal surface as well as cream-white or yellow-brown opacities on other faces, with an extension of less than 1/3 or between 1/3 and 2/3. Baseline hypersensitivity showed a positive correlation with the extent of hypomineralized areas, being more pronounced in teeth with a greater number of affected surfaces (3 or 4 faces in total). This pattern was observed in teeth with 2 or 3 surfaces affected by demarcated opacities, along with one surface exhibiting post-eruptive fracture. In these teeth, a significant reduction in hypersensitivity was observed up to 3 months, followed by a gradual return of symptoms after 6 months (Table 2).

The microbiological analysis was performed three times—before and after the selective carious tissue removal and after aPDT. The samples were analyzed for the total number of microorganisms and CFUs were counted. During processing, one of the samples became contaminated, and its result was not accounted for, being excluded from the analysis. The average logarithmic reduction of the six samples analyzed ranged from 1 log (1.00E−01) to 2 logs (1.00E−02) (Figure 5). After the aPDT treatment, the average logarithmic reduction in bacterial load across the six samples analyzed ranged from 1 log (indicating a 90% reduction) to 2 logs (indicating a 99% reduction), as shown in Figure 5.

Figure 5 Fraction of survival presented in logarithmic scale. The x-axis represents the tooth numbers treated with aPDT, while the y-axis shows the logarithmic reduction in bacterial load, quantifying the decrease in bacterial count after treatment. aPDT, antimicrobial photodynamic therapy.

The data on the longevity of the restorations are presented in Table 3. No failures in marginal adaptation, material retention, or presence of secondary caries occurred throughout the six-month follow-up period. All treated teeth received an Alpha score, indicating good marginal adaptation of the restorations, no visible gap, no loss of restorative material, and no presence of secondary carious lesions at all follow-up times.

Discussion

Minimally invasive treatment protocols are the first option when working with young teeth with incomplete root development. Patients with MIH may have the early loss of tooth structure associated with carious lesions as well as hypersensitivity and an unfavorable prognosis.

The microbiome has been widely studied as a biomarker for various diseases, and oral dysbiosis has been linked to both oral and systemic conditions. Recent research has shown significant differences in the salivary microbiome of individuals with various oral pathologies, such as dental fluorosis, compared to healthy controls, with implications for diseases like periodontitis and even lung diseases (21). While the microbiome of supragingival dental plaque in patients with MIH has also been analyzed in the literature, the impact of hypomineralized enamel on bacterial colonization is notable. The high protein content in hypomineralized enamel favors an increase in proteolytic bacteria, which break down proteins, facilitating microbial invasion into dentinal tubules and contributing to cavitation and hypersensitivity (22).

Although our study did not directly assess the oral microbiome in teeth with MIH, understanding how specific microorganisms and their reduction might influence symptoms is crucial. The interplay between the microbiome and oral health, particularly in MIH-affected teeth, could provide valuable insights for clinical management and more effective therapeutic approaches. In this regard, our study demonstrated that aPDT resulted in a significant logarithmic reduction of bacterial load in a considerable portion of teeth with MIH and dentinal caries.

Average decontamination of the six samples analyzed ranged from 1 to 2 logs. In a previous study involving permanent molars with deep carious lesions without pulpal involvement, the logarithmic reduction was 0.91 (23). However, the study did not involve teeth with a diagnosis of MIH, the dosimetric parameters were different from those used in our study, and a larger number of samples was analyzed. According to the authors, the photobleaching phenomenon may have occurred due the high concentration of the photosensitizer (23). In our study, a smaller concentration of methylene blue was used in gel form with a shorter pre-irradiation time.

Adequate analgesia during the restorative procedure on teeth with MIH can be challenging. Thus, procedures aimed at greater patient comfort and the management of child behavior are priorities (24). In our treatment protocol, Papacárie Duo^TM was used for the selective chemical-mechanical removal of the carious tissue prior to aPDT, and no anesthesia was required during the procedure. Previous studies have also demonstrated the effectiveness of Papacárie Duo^TM at reducing pain and ensuring greater patient comfort during treatment (6,11,25). Additionally, this product can be used for deproteinization, a process that helps remove organic material from the enamel surface, improving the bonding of restorative materials to hypomineralized tissue. This method serves as an alternative to 5% sodium hypochlorite, offering the advantage of not causing harm to soft tissues or pulp toxicity (10). In our study, all teeth had restorations with an alpha score, indicating good marginal adaptation without visible gaps, no loss of restorative material, and no secondary caries lesions during the six-month follow-up period.

In a recently published study (the first to perform a clinical assessment of the use of Papacarie for deproteinization), no significant differences were found between the groups using resin with or without deproteinization. However, it is important to note that acid etching was not performed prior to the application of the deproteinizing agent, which may have impacted the clinical results. Additionally, the hypomineralized tissue was partially removed (26). As in our study, the follow-up period was short. In the assessment of restoration longevity in teeth with MIH, significant differences were found only after 12 months of follow-up in a study that assessed the longevity of restorations after deproteinization with 5% sodium hypochlorite (9).

With regards to the scales used in this study, general agreement was found between the VAS and SCASS, with small discrepancies attributed to the children’s lack of understanding and subjective assessment. Moreover, illustrations of the face scale are often linked to emotional state of children rather than a genuine perception of pain. To reduce possible confusion, the SCASS scale was used.

A reduction in hypersensitivity was found in all teeth 48 hours after restorative treatment, which may be explained by the immediate sealing of the dentin. This result is compatible with the findings of a previous study, in which a reduction in hypersensitivity occurred after restorative treatment but without a complete reduction in symptoms in severely affected teeth (27). aPDT appears to be effective at controlling long-term pain in teeth with MIH and mild to moderate baseline sensitivity (SCASS 1 and 2), with the control of sensitivity during the six-month follow-up period. In teeth with severe baseline hypersensitivity (SCASS 3), our case series suggests that aPDT may be effective in controlling hypersensitivity for up to three months, with the return of hypersensitivity observed at six months. The most plausible explanation would be a side effect of photobiomodulation, with the modulation of the inflammatory process and remission of symptoms for a period of time. The effect of photobiomodulation on teeth with MIH has been reported in previous studies, with effective results related to analgesia and the modulation of inflammation (28-30).

A possible association was found between the severity of baseline hypersensitivity and the number of hypomineralized tooth surfaces, with teeth affected on 3 or 4 surfaces showing higher severity of hypersensitivity. This encompasses surfaces with post-eruptive fractures as well as other dental surfaces with cream-white and, especially, yellow-brown demarcated opacities. The severity of baseline hypersensitivity seems to be associated with teeth with more than 3 faces involved and may be a predictor of worse pulp prognosis, with difficult control of post-treatment hypersensitivity. After restoration of the surface affected by caries, surfaces with intact demarcated opacities, especially yellow-brown ones, continue to be exposed and permeable to the oral environment, suffering chronic stimuli that are harmful to the pulp, with greater plaque accumulation on these surfaces and the perpetuation of hypersensitivity, causing a repetitive cycle and making an effective pulp response unfeasible. This may be explained by changes in the microstructure of hypomineralized enamel, with less condensed prisms and greater interprismatic space, which would enable bacterial invasion in dentinal tubules resulting in a pulp response with chronic inflammation (4). The unfavorable pulp prognosis in cases of severe MIH has been reported in the literature for procedures such as direct and indirect pulp capping compared to the prognosis of teeth without MIH (31). In another study that assessed the treatment of vital pulp in teeth with severe MIH, deep carious lesions (ICDAS scores 5 and 6), and reversible and irreversible pulpitis, the success rate of indirect pulp treatment was 96%, and the success rate of total or partial pulpotomy was 86% over 24 months of follow-up. A key factor that may have contributed to these high success rates is the use of stainless steel crowns following pulp treatment (32). The crowns likely provided a seal over the hypomineralized areas of the affected teeth, preventing further bacterial contamination and offering a protective barrier to the vulnerable enamel, thus contributing to the treatment’s success (31,33). Vital pulp therapy is consistently advised for pediatric patients due to its minimally invasive nature. When dealing with immature permanent teeth with an inflamed pulp, treatment options include pulp capping as well as partial or total pulpotomy (31). The mechanism of inflammation in teeth with MIH needs further investigation. Without allowing the pulp time free of further injury so that its recovery can take place, as occurs in teeth without MIH, restorative treatment may be ineffective for hypersensitivity control. Moreover, as teeth affected by carious lesions with a greater number of faces involved and severe baseline hypersensitivity can have an unfavorable pulp prognosis, new treatment strategies should be considered. Few studies have evaluated pulp inflammation in teeth with MIH in the context of carious lesions (31,32). These results may provide important information on the need to include hypersensitivity as a severity criterion for MIH, considering the prognosis and targeted treatment approaches.

A limitation of our study is the short follow-up period and the small number of participants. A well-designed study is necessary to confirm these clinical findings.

The treatment protocol used in the present study, employing the concept of minimal intervention with Papacarie combined with photodynamic therapy, appears promising for decontamination, reduction of hypersensitivity, and longevity of restorations. The result justifies more detailed investigations, as hypersensitivity remains a frequent problem even after restorative treatment. Understanding the severity of the signs and symptoms and customizing the treatment are essential for restoring function and improving the quality of life of these patients.

Conclusions

aPDT proved to be promising treatment for decontamination and hypersensitivity control in molars with hypomineralization and dentinal caries. Moreover, deproteinization with Papacárie offers a promising, minimally invasive approach for enhancing restoration longevity.

Acknowledgments

The authors are grateful to Universidade Nove de Julho (UNINOVE) for the availability of laboratories and volunteers.

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-24-480/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-480/prf

Funding: This work was supported by Coordination for the Advancement of Higher Education Staff-CAPES (protocol number 88887.687413/2022-00 to A.R.H.M.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-24-480/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Ethics Committee of Universidade Nove de Julho (certificate number: 61027522.0.0000.5511; August 23, 2022) and registered on ClinicalTrials.gov (certificate number: NCT05443035, approved on July 5, 2022). Legal guardians of children agreed to their participation by signing the written statement of informed consent and the children a term of assent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bussaneli DG, Vieira AR, Santos-Pinto L, et al. Molar-incisor hypomineralisation: an updated view for aetiology 20 years later. Eur Arch Paediatr Dent 2022;23:193-8. [Crossref] [PubMed]
2. Negre-Barber A, Montiel-Company JM, Catalá-Pizarro M, et al. Degree of severity of molar incisor hypomineralization and its relation to dental caries. Sci Rep 2018;8:1248. [Crossref] [PubMed]
3. Linner T, Khazaei Y, Bücher K, et al. Hypersensitivity in teeth affected by molar-incisor hypomineralization (MIH). Sci Rep 2021;11:17922. [Crossref] [PubMed]
4. Fagrell TG, Lingström P, Olsson S, et al. Bacterial invasion of dentinal tubules beneath apparently intact but hypomineralized enamel in molar teeth with molar incisor hypomineralization. Int J Paediatr Dent 2008;18:333-40. [Crossref] [PubMed]
5. Jawa D, Singh S, Somani R, et al. Comparative evaluation of the efficacy of chemomechanical caries removal agent (Papacarie) and conventional method of caries removal: an in vitro study. J Indian Soc Pedod Prev Dent 2010;28:73-7. [Crossref] [PubMed]
6. Bittencourt ST, Pereira JR, Rosa AW, et al. Mineral content removal after Papacarie application in primary teeth: a quantitative analysis. J Clin Pediatr Dent 2010;34:229-31. [Crossref] [PubMed]
7. Beeley JA, Yip HK, Stevenson AG. Chemochemical caries removal: a review of the techniques and latest developments. Br Dent J 2000;188:427-30. [Crossref] [PubMed]
8. William V, Messer LB, Burrow MF. Molar incisor hypomineralization: review and recommendations for clinical management. Pediatr Dent 2006;28:224-32.
9. Sönmez H, Saat S. A Clinical Evaluation of Deproteinization and Different Cavity Designs on Resin Restoration Performance in MIH-Affected Molars: Two-Year Results. J Clin Pediatr Dent 2017;41:336-42. [Crossref] [PubMed]
10. Ekambaram M, Anthonappa RP, Govindool SR, et al. Comparison of deproteinization agents on bonding to developmentally hypomineralized enamel. J Dent 2017;67:94-101. [Crossref] [PubMed]
11. Vieira LDS, Mandetta ARH, Bortoletto CC, et al. A minimal interventive protocol using antimicrobial photodynamic therapy on teeth with molar incisor hypomineralization: A case report. J Biophotonics 2024;17:e202300414. [Crossref] [PubMed]
12. de Oliveira AB, Ferrisse TM, Marques RS, et al. Effect of Photodynamic Therapy on Microorganisms Responsible for Dental Caries: A Systematic Review and Meta-Analysis. Int J Mol Sci 2019;20:3585. [Crossref] [PubMed]
13. Maisch T, Baier J, Franz B, et al. The role of singlet oxygen and oxygen concentration in photodynamic inactivation of bacteria. Proc Natl Acad Sci U S A 2007;104:7223-8. [Crossref] [PubMed]
14. Ferreira LAQ, Anestino TA, Branco NTT, et al. Adjunctive therapies for in vitro carious lesions: Antimicrobial activity, activation of dentin metalloproteinases and effects on dental pulp cells. Photodiagnosis Photodyn Ther 2022;40:103168. [Crossref] [PubMed]
15. Alves LVGL, Curylofo-Zotti FA, Borsatto MC, et al. Influence of antimicrobial photodynamic therapy in carious lesion. Randomized split-mouth clinical trial in primary molars. Photodiagnosis Photodyn Ther 2019;26:124-30. [Crossref] [PubMed]
16. Gugnani N, Pandit IK, Srivastava N, et al. International Caries Detection and Assessment System (ICDAS): A New Concept. Int J Clin Pediatr Dent 2011;4:93-100. [Crossref] [PubMed]
17. Mandetta ARH, Bortoletto CC, Sobral APT, et al. Evaluation of antimicrobial photodynamic therapy and minimal intervention associated with deproteinisation in permanent teeth with molar incisor hypomineralisation: study protocol for a clinical, controlled, blinded trial. BMJ Open 2023;13:e076226. [Crossref] [PubMed]
18. Wong-Baker FC. Wong-Baker FACES® Pain Rating Scale. 2019. Available online: http://www.WongBakerFACES.org
19. Bal C, Sozuoz MA, Sari MBD, et al. 1-year Results of Molar Incisor Hypomineralization-affected Cases Treated with Silver Modified Atraumatic Restorative Treatment: A Retrospective Study. Int J Clin Pediatr Dent 2024;17:683-9. [Crossref] [PubMed]
20. Lygidakis NA, Garot E, Somani C, et al. 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. [Crossref] [PubMed]
21. Liu S, Song Q, Zhang C, et al. Saliva microbiome alterations in dental fluorosis population. J Oral Microbiol 2023;15:2180927. [Crossref] [PubMed]
22. Hernández M, Planells P, Martínez E, et al. Microbiology of molar-incisor hypomineralization lesions. A pilot study. J Oral Microbiol 2020;12:1766166. [Crossref] [PubMed]
23. Guglielmi Cde A, Simionato MR, Ramalho KM, et al. Clinical use of photodynamic antimicrobial chemotherapy for the treatment of deep carious lesions. J Biomed Opt 2011;16:088003. [Crossref] [PubMed]
24. Özgül BM, Sakaryalı D, Tirali RE, et al. Does MIH Affects Preoperative and Intraoperative Hypersensitivity? J Clin Pediatr Dent 2022;46:204-10. [Crossref] [PubMed]
25. Matsumoto SF, Motta LJ, Alfaya TA, et al. Assessment of chemomechanical removal of carious lesions using Papacarie Duo™: randomized longitudinal clinical trial. Indian J Dent Res 2013;24:488-92. [Crossref] [PubMed]
26. Ozsoy M, Erken Gungor O. Management of severity lesions of hypomineralized molars (MIH) with different treatment alternatives: 9-month results of a clinical trial. J Clin Pediatr Dent 2024;48:68-75. [Crossref] [PubMed]
27. Americano GC, Jacobsen PE, Soviero VM, et al. A systematic review on the association between molar incisor hypomineralization and dental caries. Int J Paediatr Dent 2017;27:11-21. [Crossref] [PubMed]
28. Muniz RSC, Carvalho CN, Aranha ACC, et al. Efficacy of low-level laser therapy associated with fluoride therapy for the desensitisation of molar-incisor hypomineralisation: Randomised clinical trial. Int J Paediatr Dent 2020;30:323-33. [Crossref] [PubMed]
29. da Silva FG, de Almeida SB, de Campos PH, et al. Low-Level Laser Therapy for Management of Hypersensitivity in Molar-Incisor Hypomineralization and Oral Health-Related Quality of Life: Case Report. J Clin Pediatr Dent 2022;46:107-11. [Crossref] [PubMed]
30. Bardellini E, Amadori F, Rosselli L, et al. Molar Incisor Hypomineralization: Optimizing Treatment Protocols for Hypersensitivity: A Randomized Clinical Trial. Dent J (Basel) 2024;12:186. [Crossref] [PubMed]
31. Llena C, Hernández M, Melo M, et al. Follow-up of patients subjected to direct and indirect pulp capping of young permanent teeth. A retrospective study. Clin Exp Dent Res 2021;7:429-35. [Crossref] [PubMed]
32. Al-Batayneh OB, Abdelghani IM. Outcome of vital pulp therapy in deeply carious molars affected with molar incisor hypomineralisation (MIH) defects: a randomized clinical trial. Eur Arch Paediatr Dent 2022;23:587-99. [Crossref] [PubMed]
33. Paschoal MAB, Carvalho FK, Lima MDM, et al. Factors Associated with Hypersensitivity, Management, and Treatment Options for Teeth with Molar Incisor Hypomineralisation. Monogr Oral Sci 2024;32:157-65. [Crossref] [PubMed]