Arnold et al.

Head & Face Medicine (2015) 11:32

DOI 10.1186/s13005-015-0089-2
HEAD & FACE MEDICINE

RESEARCH Open Access

Enamel surface alterations after repeated

conditioning with HCl
W H Arnold1*, B. Haddad2, K. Schaper3, K. Hagemann4, C. Lippold5 and Gh. Danesh2

Abstract
Background: The aim of this study was to investigate the influence of etching time with 15 % hydrochloric acid
(HCl) on the enamel surface destruction by studying the resulting roughness and erosion depth.
Methods: The vestibular surfaces of 12 extracted, caries free human incisors were divided into four quadrants, and
each quadrant was etched with 15 % HCl for different numbers of etching cycles (1×2, 2×2, 3×2 and 4×2 min).
Surface roughness and erosion depth were measured quantitatively with optical profilometry, and the surface
morphology was imaged with scanning electron microscopy (SEM).
Results: After two minutes of 15 % HCl application a median enamel substance loss of 34.02 μm was observed.
Lengthening of etching time (2×2, 3×2 and 4×2 min) resulted in significantly increase in erosion depth to each
additionally, between 13.28 -15.16 μm (p < 0.05) ending up in a total median enamel surface loss of 77 μm.
Regarding surface roughness no significant (p > 0.05) difference was found between unetched enamel and the
etched enamel surfaces.
Conclusion: Repeated 15 % HCl conditioning of the enamel surface increases the depth of the etched surface
erosion. However, the total erosion depth is rather shallow and therefore negligible.

Background non-cavitated lesions up to ICIDAS III [6]. It masks white

A common problem in orthodontic treatment with fixed spot lesions and closes lesion pores, thus arresting further
appliance is the development of white spot lesions [1]. demineralization [7, 8].
Orthodontic treatment with brackets creates retention sites A major challenge for resin infiltration is the need to
for plaque, which subsequently promotes the development remove the hypermineralized surface layer of the lesion
of white spot lesions [2]. Subsurface demineralization in- during enamel etching [9–11]. Surface conditioning is
creases the pore volume of enamel, which changes the necessary because this hypermineralized surface layer
optical refraction of enamel and results in the white, hampers resin infiltration into the lesion [9, 10, 12].
opaque color of white spot lesions [3, 4]. Various white Comparative studies showed that for surface condition-
spot lesion treatment strategies exist. The first is prevent- ing of the enamel, 15 % hydrochloric acid (HCl) has to
ive oral hygiene education and motivation of the patient, be used. Other concentrations (5 % HCl) or acids (37 %
followed by fluoridation of the enamel surface [4]. Invasive phosphoric acid) are not effective enough [9, 13].
treatment is the last option in the treatment of white spot According to the manufacturer’s instructions, a 2 min
lesions. During the past decade, a micro-invasive infiltra- etching time is recommended. If the white spot is still
tion technique for white spot lesions using Icon® (DMG, visible, the etching should be repeated no more than 2
Hamburg, Germany) has been developed, which uses a times. However, repeated etching of the enamel surface
complete resin infiltration of initial carious lesions and results in further destruction of the enamel prisms.
hinders further caries progression [5]. Application of this Further studies of repeated HCl application on the en-
micro-invasive infiltration technique is recommended for amel surface are necessary to determine the limitations
of acid etching with 15 % HCl.
* Correspondence: [email protected] The aim of this investigation was to study the surface
1
Department of Biological and Material Sciences in Dentistry, Faculty of morphology of etched enamel with scanning electron
Health, School of Dentistry, Witten/Herdecke University, Witten, Germany
Full list of author information is available at the end of the article

© 2015 Arnold et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Arnold et al. Head & Face Medicine (2015) 11:32 Page 2 of 7

Fig. 1 3D image of the amount of enamel surface dissolution after etching for 2×2 min with 15 % HCl

microscopy (SEM) and quantitative profilometry after specimen holders, and sputtered with gold palladium
repeated applications of 15 % HCl. (Bal-TEC SCD 050 Sputter Coater, Balzer, Lichtenstein).
The etched windows were imaged with a scanning elec-
Methods tron microscope (Zeiss Sigma VP, Carl Zeiss, Oberkochen,
Tooth preparation Germany) using a 20 kV acceleration voltage and an SE
Twelve extracted, caries free human incisors were stored detector.
in 0.9 % NaCl solution containing 0.1 % thymol. Before
storage all teeth were cleaned with a toothbrush under
running tape water. Tooth collection was approved by the Profilometry
ethical committee (116/2013), and verbal consent was Surface roughness measurements were performed with an
obtained from the patients. Teeth used in the present optical profilometer (InfiniteFocus©,G3, Alicona© Imaging
study were extracted due to periodontal reasons. An GmbH, Graz, Austria) using a vertical resolution of
ICDAS score of 0 on the buccal enamel surface was deter- 450 nm and an Lc of 25. The depth of each etched
mined visually. window was measured using the single step height meas-
The teeth were covered with acid resistant nail urement function of the software. In each window, 20
varnish (BIOCURA® BEAUTY, Nailvarnish, Maxim roughness measurements were taken to determine the
Markenprodukte GmbH & Co. KG, Pulheim-Brauweiler, area scale fractal complexity (asfc), which is related to the
Germany) leaving four 2×2 mm windows on the vestibular
surface. Each window was treated with 15 % hydrochloric Table 1 Influence of etching time on the depth of the enamel
acid (HCl, Icon-Etch®, DMG, Hamburg, Germany) for dif- erosion depth [μm]
ferent periods of time. The time periods were 2, 2×2, 3×2 Conditioning time 2 min 2×2 min 2×3 min 2×4 min
and 4×2 min. After each etching cycle, the enamel surface Mean 35.95 49.37 66.46 79.22
was rinsed with tap water for 30 s and air dried before the Standard devation 10.00 11.35 18.06 19.79
next application of HCl. All teeth were then stored in Median 34.11* 49.36* 64.28* 77.56*
NaCl/thymol solution until further examination.
Minimum 17.75 22.52 32.79 39.91
Maximum 71.34 92.47 151.51 150.58
Scanning electron microscopy (SEM)
The roots of the teeth were removed using a diamond 25 % percentile 28.40 41.77 54.94 66.09
saw, and the nail varnish was removed with acetone. All 75 % percentile 41.10 55.42 73.67 90.72
teeth were then dried in graded acetone, mounted on Values with the superscript asterisk were significantly different (p < 0.05)
Arnold et al. Head & Face Medicine (2015) 11:32 Page 3 of 7

Fig. 2 Comparison of the gradient of the enamel lesion depth after different etching duration. The differences are calculated as follows: The
depth of the 2 min etched window was subtracted from the depth of the 2×2, 2×4 and 2×6 min etches windows

fractal dimension of the surface texture [14], and 20 depth 4×2 min) resulted in a significant increase (p < 0.05) in
measurements were taken in the window. erosion depth (13, 28–15, 34 μm) and is shown in Fig. 2.
The roughness data are summarized in Table 2. While
comparing the profilometric measurements for rough-
Statistical analysis
ness, no significant difference (p < 0.05) was found be-
Prior to the experiments a power analysis was carried out
tween the untreated control surfaces and the etched
with an alpha of 0.05 and a power of 0.8 (sigma 1 = 10.00,
surfaces (Table 2).
sigma 2 = 11.35; mean 1 = 35.95, mean 2 = 49.37) which
SEM revealed four different etching patterns, which
resulted in a sample size of 10. Power analysis was calcu-
were found in all windows independent of the etching
lated using Axum 7 (Mathsoft, Cambridge, Massachusetts,
time. Pattern one was homogeneous with dissolution of
USA). The statistical calculations were performed with the
the prism core and relatively intact prism peripheries
SPSS (IBM Corporation, Amronk, NY, USA; Rel. 21)
(Fig. 3a). Pattern two showed more variation in the
statistical software. The non-parametric Wilcoxon
amount of dissolution of the prism core and minor dissol-
sign test for related variables was used with a p < 0.05
ution of the prism periphery (Fig. 3b). Pattern three was
to determine significance. Comparison of the differences
characterized by a deep prism periphery (Fig. 3c), and
between the time intervals was performed with the
Friedman-test.
Table 2 Influence of the etching time on the roughness of the
Results enamel surface
Power analysis resulted in a minimum sample size of 10 Conditioning time controls 2 min 2×2 min 2×3 min 2×4 min
teeth. Therefore, 14 teeth were used for this investigation. Mean 3.26 3.49 2.83 2.99 3.64
Profilometry demonstrated shallow, etched surfaces Standard deviation 0.72 1.41 1.87 1.72 1.42
with steep ledges (Fig. 1). Table 1 displays the depth of Median 3.14 3.22 2.91 3.88 3.46
the etched enamel surfaces after different etching dura- Minimum 2.03 1.37 0.41 1.37 2.18
tions. The depth of the etched superficial defects in-
Maximum 4.49 6.39 6.86 6.81 6.88
creased significantly (p < 0.05) with the etching duration.
The largest substance loss was found after two minutes, 25 % percentile 2.67 2.70 1.10 2.00 2.54
with a median loss of enamel substance of 34.02 μm 75 % percentile 3.68 4.65 4.21 5.31 4.42
(Table 1). Lengthening the etching time (2×2, 3×2 and All numbers are asfc values
Arnold et al. Head & Face Medicine (2015) 11:32 Page 4 of 7

Fig. 3 (a-e) SEM photo of unetched enamel surface showing a relative smooth surface whith prism cores. b SEM photo of the enamel surface
pattern after etching for 2 min with 15 % HCl showing dissolution of the prism core and an intact prism periphery; c) surface pattern after
etching for 2×2 min with 15 % HCl showing little dissolution of the prism core and the periphery; d) surface pattern after etching for 3*2 min
with 15 % HCl showing dissolution of the prism periphery; e) surface pattern after etching for 4*2 min with 15 % HCl showing destruction of the
enamel prisms core and periphery

pattern four showed variable dissolution of the prism core hampers resin infiltration into the underlying subsurface
and prism periphery (Fig. 3d). demineralization of the lesion and has to be removed
Moreover, the samples examined with profilometry before resin infiltration [9–12]. Phosphoric acid does not
showed a greater depth in the periphery than in the cen- adequately remove the surface layer, but it was demon-
tral portion of the conditioned area (Fig. 4). strated that 15 % HCl for 90–120 s sufficiently removes
the hypermineralized surface layer [9] and enables resin
Discussion infiltration into the body of the lesion. Fifteen percent
By definition, initial white spot carious lesions (WSL) that HCl is used as a pre-treatment in the micro-invasive ther-
are stage ICDAS I and ICDAS II are characterized by a apy of WSL by Icon © (DMG, Hamburg, Germany) as an
hypermineralized surface layer and a demineralized sub- alternative option for non-cavitated lesions [9, 11, 12, 16].
surface body [15]. This hypermineralized surface layer HCl is rarely used in dentistry because of its strong acidity
Arnold et al. Head & Face Medicine (2015) 11:32 Page 5 of 7

Fig. 4 3D-reconstruction using Alicona Infinite Focus©. The etched enamel surface is deeper in the periphery than the central area

[17]. HCl quickly destroys the crystalline structure of To clinically improve esthetic results, studies have rec-
hydroxyapatite, and repetitive etching enhances this effect. ommended etching times of more than 120 s [19]. White
This observation is important for the areas of sound en- spot lesions that have been present for a longer period of
amel adjacent to the lesion. Therefore, one aim of this time and deeper lesions with a thicker intact surface layer
in vitro study was to evaluate the erosion depth of etched require more conditioning time [19]. This raises the ques-
enamel after repeated 15 % HCl applications. tion of whether the amount of enamel loss over multiple
Teeth used in the present study were extracted for cycles of conditioning is clinically significant. The average
periodontal reasons. Furthermore, an ICDAS score of 0 thickness of the enamel of the upper central and lateral in-
on the buccal enamel surface was determined visually. It cisors ranges from approximately 0.5 mm in the cervical
is possible that areas with an ICDAS score of 1 were third to more than 1 mm in the incisal third [20, 21].
present in the 12 tooth samples. Regardless, it is unlikely Bailey and Christen found that a 30 % reduction of the
that the results were distorted by this because those enamel layer is clinically acceptable [22]. For 960 measure-
types of lesions do not exceed a depth of 40 microns [9]. ments in the present study, only 11 had a reduction of
An erosion depth of 34 μm was observed in 75 % of more than 120 μm. Seven of those were in the 8 min
tooth samples after conditioning with HCl for 2 min. group. After 4×2 min of etching time with HCl, an etching
In the present study, optical profilometry was used. In depth of approximately 77 μm was achieved in this study,
contrast to tactile profilometry, this method allows for a which is well below the threshold of clinical significance.
zero-contact measurement of the samples in a non- In general, when acid-etching a white spot lesion with
destructive way [18]. The profilometric experiments of phosphoric acid or hydrochloric acid, it is difficult to
this study demonstrated that repeated application of 15 % avoid etching the adjacent sound enamel. An in vitro
HCl removes the surface layer with a median depth of study showed that samples treated with infiltrating
77.56 μm. In this study, a median enamel substance loss resin were protected against acid dissolution (even in
of 34.02 μm occurred after treatment for two minutes sound enamel, which is not a typical substrate for the
with 15 % HCl. This finding is similar to the findings of infiltrate) [23].
Meyer-Lueckel et al. [9]. Lengthening the etching time Some clinical studies reported good results for mask-
(2×2, 3×2 and 4×2 min) resulted in a significant increase ing WSL with infiltrates [7, 19, 24, 25]. In this context,
in the depth of the lesion (13, 28–15, 34 μm). Knoesel et al. [19] reported adequate esthetic outcomes
Arnold et al. Head & Face Medicine (2015) 11:32 Page 6 of 7

regarding the durability of infiltration after 6 months Conclusions

in vivo. Compared to the microabrasion technique, In this study, we showed that the depth of the etched sur-
which can remove up to 360 μm of enamel during the face layer is dependent upon the etching time. Repeated
treatment of WSL [17], the pre-treatment of the surface pretreatment with 15 % HCl resulted in a reduction of
with 15 % HCl prior to infiltration is gentler. surface roughness. Pre-treating with 15 % HCl prior to
Another aim of this study was to evaluate the surface infiltration results in shallow enamel surface erosions. The
roughness after repeated HCl applications. In contrast to long-term effects 15 % HCl etching prior to the infiltration
surface destruction, etching time did not influence the treatment should be followed up with continuous clinical
surface roughness. A significant difference in the surface and scientific research.
roughness was found between the 2 min and 4×2 min
Abbreviations
groups, which decreases the asfc units and reflects a ICDAS: International Caries Detection and Assessment System; SEM: Scanning
smoother surface. In the other groups, no significant electron microscope; Ra: Average roughness of profile; asfc: Area-scale-
difference in roughness was observed. fractal-complexity; SPSS: Statistical package for social sciences.
This finding is in contrast to a previous study [26].
Competing interests
Takeya reported an increase in surface roughness with The authors declare that they have no competing interests.
increased etching times and that the roughness of the
enamel surface significantly increased after increasing Authors’ contributions
the conditioning periods from 15 to 30 and 60 to 120 s. WHA: drafted the manuscript, conceived of the study, participated in its
design and coordination. BH: carried out all experiments. KS: calculated the
The acids used in the study of Takeya, however, were statistics. KH was responsible for tooth collection and logistics. All authors
not hydrochloric acid but phosphoric, citric and pyruvic read and approved the final manuscript.
acid [26]. Furthermore, the reason for the contradictory
Acknowledgements
results may be the different method of measuring rough- The authors would like to thank Mrs. Susanne Haußmann for her technical
ness. Takeya used a tactile roughness measurement support regarding the specimen preparation for SEM. Icon-Etch® was kindly
method, which is somewhat destructive. Thus, those provided by DMG Chemisch-Pharmazeutische Fabrik GmbH, Hamburg,
Germany.
measurements may be influenced by the mechanical re-
sistance of the etched prism surfaces. Author details
1
Other studies showed that after microabrasion with Department of Biological and Material Sciences in Dentistry, Faculty of
Health, School of Dentistry, Witten/Herdecke University, Witten, Germany.
18 % hydrochloric acid (compared to 37 % phosphoric 2
Department of Orthodontics, Faculty of Health, School of Dentistry, Witten/
acid), the roughness of the enamel decreased, and the Herdecke University, Witten, Germany. 3Department of Medical Biometry and
amount of demineralization simultaneously increased Epidemiology, Faculty of Health, School of Medicine, Witten/Herdecke
University, Witten, Germany. 4Private Praxis for Orthodontics, Essen, Germany.
[27]. Conversely, in vitro investigations showed that sur- 5
Department of Orthodontics, University Medical Centre of Muenster,
faces treated with the caries infiltrate appeared deminer- Muenster, Germany.
alized and showed higher surface roughness compared
Received: 8 June 2015 Accepted: 15 September 2015
to surfaces treated with conventional adhesives or a
combination of both [23, 28]. In practice, this should be
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