DOI: 10.7860/JCDR/2017/28146.

10599
Original Article

Dentistry Section
In vitro Evaluation of Resin Infiltrant
Penetration into White Spot Lesions of
Deciduous Molars

DINESH FRANCIS SWAMY1, ELAINE SAVIA BARRETTO2, SHANTHALA B. MALLIKARJUN3, SAPNA SADA RAUT DESSAI4

ABSTRACT were then evaluated under cross-polarized light microscope.

Introduction: Caries Infiltration is a recent microinvasive Lesion Depth (LD) and Penetration Depth (PD) of the caries-
restorative technique that permits treatment of non-cavitated infiltrant were measured quantitatively and descriptive statistics
demineralized lesions, known as White Spot Lesions (WSL). were calculated.
Aim: To evaluate the extent of penetration of a commercially Results: Mean LD (standard deviation) for all samples (n=50)
available resin caries-infiltrant into natural WSL occurring in was 367(±182) µm. Caries-infiltrant demonstrated varying
deciduous tooth enamel. depths of resin penetration into the natural white spot lesions
of deciduous molars. Mean PD (standard deviation) was 352 (±
Materials and Methods: Deciduous molars with natural WSL
141) µm.
on any smooth surface were selected and sectioned into halves
to yield equal control and experimental groups. Therefore, Conclusion: Resin-infiltrants can deeply and predictably
25 samples in the control group were untreated whereas 25 penetrate enamel porosities in natural WSL in deciduous molars
samples in the experimental group were treated with caries- and impede lesion progression and prevent cavitation.
infiltrant according to the manufacturer’s instructions. Samples

Keywords: Composite resins, Cariostatic agents/therapeutic use, Dental caries/therapy, Dental enamel/drug effects

INTRODUCTION the pores within the lesion body, which otherwise act as diffusion
In modern dentistry, it has been recognised that no cavity design or pathways for acids and dissolves minerals. By impeding the internal
restorative material will cure caries [1]. Therefore there has been a fluid mechanics contributing to lesion progression and preventing
paradigm shift in caries management from surgical intervention to cavitation by strengthening the enamel structure, this approach
minimally invasive dentistry, that is, from “extension for prevention” to bridges the gap between non-invasive and invasive treatment
“prevention of extension” [2]. In this paradigm, surgical interference options and removes the necessity of the restorative intervention or
is required only in that part of the tooth surface that is irreversibly the delay and uncertainty while waiting for an active WSL to stabilize
broken down, while surrounding demineralised tooth surfaces [5,6].
which are amenable are either remineralised or lesion progression Deciduous and permanent teeth differ structurally in the outermost
is halted. surface of enamel vis a vis the presence of an aprismatic layer and
For caries detection, most of the visual changes and radiographic differences in the degree of mineralization [7]. It is unclear whether
the penetration of resin-infiltrant in deciduous teeth would be similar
changes contributing to the diagnosis come from the body of the
to those of permanent teeth. The present study attempted to
lesion. In the incipient lesion, substantial mineral loss occurs in the
evaluate the extent of penetration of resin-infiltrants in natural WSL
underlying lesion body while the pseudo-intact enamel surface
in deciduous molars.
remains relatively unaltered. This is clinically significant as diagnosis
is usually delayed and is typically made only after substantial mineral
loss, necessitating operative intervention with significant hard tissue
MATERIALS AND METHODS
This in vitro evaluation study was conducted between April 2014
removal. Clinically, such active non-cavitated demineralized areas
and June 2014 in the Department of Paedodontics and Preventive
appear chalky and ‘whitish’ and are called “White Spot Lesions”
Dentistry, Coorg Institute of Dental Sciences, Karnataka, India,
(WSL) [3,4]. In theory, WSL can regress and disappear due to
after obtaining the necessary clearance from the Institutional
mechanical removal of the affected enamel or due to remineralisation
Ethical Review Committee. Non carious deciduous molars
procedures. However, as the cycle of demineralization and
extracted for therapeutic reasons such as space management and
remineralization is confined to the surface and does not involve the
serial extraction were used in this study. The teeth were carefully
subsurface body lesion, the WSL typically become less obvious but
cleaned of soft tissues and stored in saline until use. The teeth
scarcely disappear completely [3].
were examined under a stereomicroscope (20x, Stemi SV 11, Carl
A recently developed addition to the gamut of minimally invasive Zeiss, Oberkochen, Germany) to check for an intact superficial layer
operative techniques is the microinvasive technique of caries resin- on the surface of the lesion. Teeth having macroscopic defects
infiltration. It is unique in a way that unlike other minimally-invasive such as cracks, fractures, wear facets and cavitated lesions were
operative techniques, no hard tissue removal is attempted. In this excluded from this study at this stage. From the remaining, teeth
technique, the body of the caries lesion is infiltrated with low- having active WSL {non cavitated dull surface with chalky opacity,
viscosity light-curing resin methyl-methacrylate. The resin occludes scored as ICDAS 2 (International Caries Detection and Assessment

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System)} on any smooth or proximal surface were selected [8]. layer with variable degree of subsurface demineralization were seen
Teeth were sectioned (Band Saw 300cl; Exakt Apparatebau, [Table/Fig-1].
Norderstedt, Germany) across the WSL perpendicular to the tooth All samples of the experimental group showed resin penetration to
surface, providing two halves of each lesion. The cut surfaces were varying degrees. Of these, 72% (n=18) of samples were observed
examined under stereomicroscope and lesions were sorted into to have resin penetrating nearly entire extent of the lesion [Table/
four grades C1–C4 (as given by Marthaler and Germann) [9]: lesion Fig-2].
extension confined to outer half of enamel (C1), lesion extension
confined to inner half of enamel (C2), lesion extension confined to
outer half of dentine (C3), lesion extension confined to inner half of
dentine (C4). Lesions graded as C4 were discarded and only lesions
with C1-C3 grading, with same grading in corresponding lesion
halves were allocated to be treated either with infiltrant or to serve
as untreated controls. A total of 50 lesion halves were allocated
to two equal groups; experimental group or control group (n = 25
for each group), with respect to treatment with caries resin-infiltrant
for the purpose of the study. Thereafter, cut surfaces were covered
with nail varnish (Lakme, India), leaving an exposed half of the WSL
surface in each sample.
In the experimental group, the targeted surfaces were treated
with Icon® caries-infiltrant (DMG, Hamburg, Germany) following
the manufacturer’s instructions, whereas in the control group,
samples were subjected to no treatment [10]. Icon® usage involved
application of Icon®-Etch syringe (15% Hydrochloric acid) for 2
minutes, followed by rinsing with water for 30 seconds and drying [Table/Fig-1]: Representative image of untreated lesion (sorted as C1) showing
with oil-free and water-free air. The lesion was then desiccated pseudointact surface and subsurface demineralization with lesion depth (LD – dot-
ted line).
using the Icon®-Dry syringe (99% ethanol) for 30 seconds followed
by drying with oil-free and water free air. Icon®-Infiltrant syringe
was placed on the targeted surface and caries resin-infiltrant was
dispensed. After three minutes, excess infiltrant was wiped using
a cotton roll and the surface was light-cured (430-490 nm, 600
mW/Cm2, LEDition, Ivoclar Vivadent, Liechtenstein) for 40 seconds.
Lastly, the infiltrant was reapplied for one minute and light cured for
40 seconds.
Nail varnish was carefully removed and the treated samples
were prepared to observe the penetration of resin-infiltration by
fixing on object holders and parallelized (Mikroschleif system
400cs, Abrasive Paper 1200, 2400, 4000; Exakt Apparatebau,
Norderstedt, Germany). Specimens were cut (Exakt 300 CL) and
polished (Exakt Mikroschleifsystem 400 CS) to a uniform thickness
of 100 µm and observed with cross-polarized light microscopy
(Compact Polarizing Microscope CX31-P, Olympus, Tokyo, Japan).
Measurements were made in micrometer using ImageJ software
(National Institutes of Health, Bethesda, Maryland) measured from
the enamel surface to measure LD and PD. LD was defined as the [Table/Fig-2]: Representative image of lesion treated with infiltrant; lesion depth
maximum linear distance from the enamel surface to the deepest (LD – dotted line) and penetration depth (PD – dashed line) showing nearly com-
plete resin penetration.
front of negative birefringence indicative of the advancing front
of WSL demineralization, PD was defined as the maximum linear
distance from the enamel surface to the deepest front of positive
birefringence indicative of reduction in pore volume by occlusion
with resin.

STATISTICAL ANALYSIS
SPSS (SPSS Inc., Released 2009. PASW Statistics for Windows,
Version 18.0. Chicago, IL, USA) was used for computing means
(with standard deviation) of LD and PD.

RESULTS
Images were analysed based on the optical characteristics of the
specimens. Samples displayed varying refringence under cross-
polarized light between infiltrated and un-infiltrated areas due to
differences in refractivity owing to the imbibition of the resin. Mean
LD (± standard deviation) for all samples (n=50) was 367 (±182)
µm. PD varied within the experimental group (n=25) and mean PD
(± standard deviation) was 352 (±141) µm. In the control group
[Table/Fig-3]: Representative image of lesion treated with infiltrant showing lesion
consisting of untreated samples (n=25), no acid-etching or resin depth (LD – dotted line) and penetration depth (PD – dashed line) with scattered
penetration was attempted. WSL with typical pseudointact surface areas of demineralization (Dem – dots and dash).

72 Journal of Clinical and Diagnostic Research. 2017 Sep, Vol-11(9): ZC71-ZC74.

www.jcdr.net Dinesh Francis Swamy et al., In vitro Evaluation of Resin Infiltrant Penetration into White Spot Lesions of Deciduous Molars

Whereas 28% (n=7), revealed resin penetration with scattered areas invasive treatment. It was found to be effective in deciduous teeth,
of demineralization [Table/Fig-3]. in addition to its established use in permanent teeth.

DISCUSSION LIMITATION
A significant proportion of children show increased incidences of The present study is a modest approach examining the performance
proximal decay and also faster progression following lesion initiation of resin-infiltrants in deciduous teeth. An in vitro design utilizing
as these are plaque retentive sites [11,12]. ‘naturally occurring’ WSL was the closest to approximate the
Plaque control, fluorides, pit and fissure sealants and remineralizing intraoral conditions. However, it is prudent to note that the in vitro
agents have been recommended to arrest the caries process design is the major limitation as the material’s performance may
in the non cavitated lesion. However, dental compliance is a vary from actual in vivo performance. This is due to the dynamic
known issue with children and adolescents, often leading to cycle of remineralization and demineralization occurring in vivo
lesion cavitation. Once cavitated, minimal intervention restorative condition continuously at the highly mineralised pseudointact
strategies are recommended but these still may introduce the surface layer, which in turn influences the initial penetration of resin.
tooth to the restorative spiral. Caries infiltration is a novel strategy Also, the pores of WSL in vivo would be continuously contaminated
with organic materials resulting in lower pore-volume hampering
that improves on the minimal intervention concept, since the
resin penetration. Also, we were constrained by the availability
intervention is on the microinvasive scale. The technique delays
of fluorescence imaging techniques which would have enabled
restorative intervention, reduces the risk of postoperative sensitivity
differential staining of areas. Future investigators may beneficially
and pulpal inflammation and improves aesthetic outcomes when
employ such techniques.
used as a masking resin on demineralised labial surfaces such
as those seen in orthodontic patients [1,13,14]. Compared to its
closest predecessor amongst preventive restorative techniques
CONCLUSION
The resin-infiltration system Icon® was found to be effective
i.e. pit and fissure sealing, the resin layer is established on the
under in vitro conditions in deeply and predictably infiltrating the
superficial layer of enamel of the pit and fissures, whereas in
enamel porosities of natural WSL on smooth or proximal surfaces
the infiltration technique a low viscosity resin-infiltrant is soaked
of deciduous molars. Icon® can be useful as a valuable tool for
into the porous lesion body, in the proximal or cervical surfaces,
the restorative dentist to arrest and restore incipient lesions.
replacing the lost mineral with resin [2,15-18]. This technique has
advantages such as the absence of margins on the tooth surface
that could enhance plaque accumulation and cause periodontal
REFERENCES
[1] Kielbassa AM, Muller J, Gernhardt CR. Closing the gap between oral hygiene
inflammation and also strengthens the lesion mechanically thereby and minimally invasive dentistry: a review on the resin infiltration technique of
preventing further destruction [17]. incipient (proximal) enamel lesions. Quintessence Int. 2009;40(8):663-81.
[2] Borges BC, de Souza Borges J, de Araujo LS, Machado CT, Dos Santos AJ,
Our study showed that Icon® infiltrant is capable of penetrating de Assuncao Pinheiro IV. Update on nonsurgical, ultraconservative approaches
several hundred micrometres into natural carious lesions, when to treat effectively non-cavitated caries lesions in permanent teeth. Eur J Dent.
2011;5(2):229-36.
employed as per manufacturer’s instructions on deciduous teeth
[3] Rocha Gomes Torres C, Borges AB, Torres LM, Gomes IS, de Oliveira RS. Effect
making the Icon® system a valuable tool over other non invasive of caries infiltration technique and fluoride therapy on the colour masking of white
modalities to deal with WSL. Such results are in agreement with spot lesions. J Dent. 2011;39(3):202-07.
the literature available utilizing resin-infiltrants in WSL on permanent [4] ten Cate JM, Larsen MJ, Pearce EIF, Fejerskov O. Chemical interactions between
the tooth and oral fluids. In: Fejerskov O, Kidd EAM, editors. Dental Caries: The
teeth, which describe the considerable variation in penetration Disease and Its Clinical Management. Oxford: Wiley; 2003. pp. 49-69.
depths [18]. [5] Meyer-Lueckel H, Paris S, Kielbassa AM. Surface layer erosion of natural caries
lesions with phosphoric and hydrochloric acid gels in preparation for resin
Paris S et al., evaluated the effect of phosphoric acid and hydrochloric infiltration. Caries Res. 2007;41(3):223-30.
acid gels on the surface layer reduction of natural lesions of [6] Paris S, Hopfenmuller W, Meyer-Lueckel H. Resin infiltration of caries lesions: an
deciduous teeth [19]. This step to effectively degrade the highly efficacy randomized trial. J Dent Res. 2010;89(8):823-26.
[7] Ripa LW, Gwinnett AJ, Buonocore MG. The "prismless" outer layer of deciduous
mineralized surface layer was deemed important to achieve high
and permanent enamel. Arch Oral Biol. 1966;11(1):41-48.
penetration depths by the resin-infiltrant. They were of the opinion [8] Pitts N. "ICDAS"--an international system for caries detection and assessment
that the effects of prismless enamel were of subordinate importance being developed to facilitate caries epidemiology, research and appropriate
when pretreating enamel surface with 15% hydrochloric acid gel. clinical management. Community Dent Health. 2004;21(3):193-98.
[9] Marthaler TM, Germann M. Radiographic and visual appearance of small smooth
In our study, all experimental group samples showed penetration, surface caries lesions studied on extracted teeth. Caries Res. 1970;4(3):224-
with PD comparable to those found by other investigators working 42.
with WSL on permanent teeth [5,15,16,20] and deciduous teeth [10] Icon® [package insert]. Hamburg, Germany: DMG; 2009.
[11] Vanderas AP, Gizani S, Papagiannoulis L. Progression of proximal caries in
[19,21-23]. suggesting that etching and penetration is unhampered
children with different caries indices: a 4-year radiographic study. Eur Arch
by structural differences between deciduous and permanent teeth Paediatr Dent. 2006;7(3):148-52.
enamel. [12] Ismail AI, Sohn W, Lim S, Willem JM. Predictors of dental caries progression in
primary teeth. J Dent Res. 2009;88(3):270-75.
Paris et al., in a study comparing the penetration of Icon® infiltrant [13] Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin
into natural WSL of deciduous molars after different infiltrant infiltration-a clinical report. Quintessence Int. 2009;40(9):713-18.
application times concluded that one minute application was [14] Kim S, Kim EY, Jeong TS, Kim JW. The evaluation of resin infiltration for masking
labial enamel white spot lesions. Int J Paediatr Dent. 2011;21(4):241-48.
sufficient but three minute application time should be recommended
[15] Meyer-Lueckel H, Paris S. Improved resin infiltration of natural caries lesions. J
to infiltrate deep proximal WSL in deciduous molars [23]. A similar Dent Res. 2008;87(12):1112-16.
study by Paris et al., with experimental infiltrants found five minute [16] Paris S, Meyer-Lueckel H. Infiltrants inhibit progression of natural caries lesions in
application to infiltrate WSL in deciduous molars nearly completely vitro. J Dent Res. 2010;89(11):1276-80.
[17] Paris S, Meyer-Lueckel H, Kielbassa AM. Resin infiltration of natural caries
[21]. A study by Soviero VM et al., found one minute application lesions. J Dent Res. 2007;86(7):662-66.
to give penetration similar to five minute applications [22]. In the [18] Kantovitz KR, Pascon FM, Nobre-dos-Santos M, Puppin-Rontani RM. Review of
present study, three minute application yielded varying depths of the effects of infiltrants and sealers on non-cavitated enamel lesions. Oral Health
Prev Dent. 2010;8(3):295-305.
penetration which may be due to the variation in the depth of the
[19] Paris S, Dorfer CE, Meyer-Lueckel H. Surface conditioning of natural enamel
lesion in the teeth selected. The resin-infiltration system Icon® thus caries lesions in deciduous teeth in preparation for resin infiltration. J Dent.
provides an effective ‘bridge’ between non LD invasive and minimally 2010;38(1):65-71.

Journal of Clinical and Diagnostic Research. 2017 Sep, Vol-11(9): ZC71-ZC74. 73

 Dinesh Francis Swamy et al., In vitro Evaluation of Resin Infiltrant Penetration into White Spot Lesions of Deciduous Molars www.jcdr.net

[20] Meyer-Lueckel H, Chatzidakis A, Naumann M, Dorfer CE, Paris S. Influence of [22] Soviero VM, Paris S, Leal SC, Azevedo RB, Meyer-Lueckel H. Ex vivo evaluation
application time on penetration of an infiltrant into natural enamel caries. J Dent. of caries infiltration after different application times in primary molars. Caries Res.
2011;39(7):465-69. 2013;47(2):110-16.
[21] Paris S, Soviero VM, Chatzidakis AJ, Meyer-Lueckel H. Penetration of [23] Paris S, Soviero VM, Seddig S, Meyer-Lueckel H. Penetration depths of an
experimental infiltrants with different penetration coefficients and ethanol addition infiltrant into proximal caries lesions in primary molars after different application
into natural caries lesions in primary molars. Caries Res. 2012;46(2):113-17. times in vitro. Int J Paediatr Dent. 2012;22(5):349-55.

PARTICULARS OF CONTRIBUTORS:
1. Lecturer, Department of Paedodontics and Preventive Dentistry, Goa Dental College and Hospital, Bambolim, Goa, India.
2. Lecturer, Department of Paedodontics and Preventive Dentistry, Goa Dental College and Hospital, Bambolim, Goa, India.
3. Professor and Head, Department of Paedodontics and Preventive Dentistry, Coorg Institute of Dental Sciences, Virajpet, Karnataka, India.
4. Lecturer, Department of Oral Medicine and Radiology, Goa Dental College and Hospital, Bambolim, Goa, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Dinesh Francis Swamy,
Lecturer, Department of Paedodontics and Preventive Dentistry, Goa Dental College and Hospital, Bambolim-403202, Goa, India. Date of Submission: Jun 13, 2017
E-mail: [email protected] Date of Peer Review: Jul 04, 2017
Date of Acceptance: Aug 29, 2017
FINANCIAL OR OTHER COMPETING INTERESTS: None. Date of Publishing: Sep 01, 2017

74 Journal of Clinical and Diagnostic Research. 2017 Sep, Vol-11(9): ZC71-ZC74.