Minimally invasive resin infiltration of arrested white-spot lesions: a randomized clinical trial

In-vitro and in-vivo comparative studies of treatment effects on enamel demineralization during orthodontic therapy: implications for clinical early-intervention strategy

OBJECTIVES

This study aimed to investigate if CPP-ACP / infiltrating resin was superior in treating enamel demineralization during orthodontic therapy compared with fluoride varnish, in order to provide early-intervention implications for dental professionals.

MATERIALS AND METHODS

In the in-vitro study, premolars were grouped into four: remineralization with fluoride varnish / CPP-ACP, sealing with infiltrating resin, and negative control. Experimental demineralization of enamel surfaces was analyzed using techniques of QLF, SEM, EDS and micro-hardness testing. An in-vivo intervention study was conducted on patients randomly assigned into three groups. At the baseline and every-3-month follow-up, QLF parameters were compared temporally and parallelly to yield potential implications for promotion in clinical practice.

RESULTS

The in-vitro study performed on 48 experimental tooth surfaces demonstrated that sealing with infiltrating resin reduced enamel surface porosity and increased surface micro-hardness significantly. In the in-vivo intervention study on 163 tooth surfaces, it was suggested that for those who meet the criteria of -10 < ΔF < -6 and - 1000 < ΔQ < -20 at the baseline, all these treatment methods could achieve acceptable outcomes; with the rising of absolute values of ΔF and ΔQ, sealing with infiltrating resin showed more evident advantages.

CONCLUSION

For enamel demineralization during orthodontic therapy, all the treatment methods involved in this study showed acceptable effectiveness but had respective characteristics in treatment effects. QLF parameters could be used as indicators for clinical early-intervention strategy with regards to this clinical issue.

CLINICAL RELEVANCE

With QLF parameters, clinical early-intervention strategy for enamel demineralization during orthodontic therapy could be optimized.

White Spot Lesions in Fixed Orthodontics: A Literature Review on Etiology, Prevention, and Treatment

White spot lesions (WSLs) are a common complication after treatment using fixed orthodontic appliances. Decalcification of enamel surrounding fixed orthodontic appliances, known as WSLs, poses a significant aesthetic difficulty during and after treatment, as the purpose of fixed orthodontic therapy is to improve facial and dental appearance. Modern dentistry utilizes remineralization therapies to non-invasively treat WSLs to prevent the progression of disease and enhance the strength, appearance, and functionality of the affected tooth. This review aims to identify and assess the etiology, formation, and risk factors, as well as current treatment approaches used in achieving WSLs remineralization, induced by fixed orthodontic appliances. An electronic search on the PubMed and ScienceDirect databases was performed using a selected keyword. A total of 172 studies (from 2013 to 2023) were retrieved. Their references were also checked to find other relevant studies. Duplicate copies were excluded. After the abstract and full-text screening, only 39 studies were included. Even though numerous studies address the different treatment modalities for managing post-orthodontic WSLs, such as antiseptics; fluorides such as dentifrices, mouthwash, and varnish, and remineralizing agents such as casein phosphopeptides amorphous calcium phosphate, biomimetic self-assembling peptides, lasers, bleaching, microabrasion, and resin infiltration. There is a lack of evidence-based studies that examine the long-term effects of WSL treatment. Further well-performed controlled clinical trials with long-term follow-up are needed to establish best clinical practice.

Resin infiltration versus fluoride varnish for visual improvement of white spot lesions during multibracket treatment. A randomized-controlled clinical trial

AIMS

This study aimed to evaluate the visual improvement of resin infiltration of white spot lesions (WSL) during orthodontic treatment with the multibracket appliance (MBA) compared to fluoride varnish.

METHODS

Patients aged 12-17 years with at least one WSL with an International Caries Detection and Assessment System (ICDAS) score of 1-2 during an active MBA treatment were included and randomized to receive either resin infiltration (Icon) or fluoride application (Flairesse). Standardized digital images were obtained before, one-day, one-week, one-month, three-months and six-months after treatment using a DSLR camera and a matching polarization filter. A grey reference card was used for color standardization. A Matlab routine was used to measure the color difference between adjacent healthy enamel and treated WSL. The independent-samples t-test was used for intergroup and paired-samples t-test for intragroup comparison.

RESULTS

Images of 116 teeth from 36 patients were analyzed. The ΔE for the "Icon" treated WSL was smaller (T1ICON = 5.0 ± 1.4) than in the fluoride group (T1Fluoride = 8.4 ± 3.2). Caries infiltration significantly improved the aesthetic appearance of WSL (p < 0.001), which remained satisfactory at six months (T5ICON = 5.2 ± 1.6).

CONCLUSION

WSL infiltration management during orthodontic treatment was superior to topical fluoridation in not only arresting the enamel lesions but also significantly improving the aesthetic appearance of demineralized regions around the brackets.

CLINICAL RELEVANCE

WSL treatment in orthodontic patients is usually initiated after debonding. Research has shown that the earlier WSL is treated, the better the aesthetic outcome. There is limited data on the efficacy of resin infiltration of WSL during orthodontic treatment.

White spot lesions in fixed orthodontic treatment: Etiology, pathophysiology, diagnosis, treatment, and future research perspectives

White spot lesions (WSLs) refer to localized areas of hypo-mineralization limited to the enamel of the teeth surface, which is noticeable clinically to the naked eye on drying of the teeth. During fixed orthodontic treatment, it is very hard for the patient to maintain excellent oral hygiene as the brackets, bands, wires, elastics, and other appliances and attachments worn intra-orally provide a platform for food retention, plaque formation, and then colonization by acidogenic bacteria like Streptococcus mutans and Lactobacillus. This review aims to elaborate and focus on etiology, pathophysiology, diagnosis, treatment aspect, and future scope for research about the WSLs occurring due to fixed orthodontic treatment.

The effect of combined use of resin infiltration with different bioactive calcium phosphate-based approaches on enamel white spot lesions: An in vitro study

OBJECTIVES

This in vitro study aimed to evaluate the effect of resin infiltration combined with casein phosphopeptide-amorphous calcium phosphate with fluoride (CPP-ACPF) or bioactive glass (BAG) on the stability of enamel white spot lesions (WSLs) treatment.

MATERIALS AND METHODS

Eighty-four enamel blocks were prepared from the buccal surfaces of sound human premolars. All enamel blocks were placed in a demineralisation solution for 3 days to establish the artificial enamel WSLs. Enamel blocks with WSLs were randomly divided into three groups (n = 28 each group): RI/B: one-off resin infiltration followed by twice daily BAG treatment; RI/C: one-off resin infiltration followed by twice daily CPP-ACPF treatment; RI: one-off resin infiltration treatment only (as control) and subjected to pH cycling for 7 days. Surface morphology, elemental analysis, crystal characteristics, surface roughness and microhardness of enamel surfaces were investigated by scanning electron microscopy and energy-dispersive spectrometry observation, X-ray diffraction (XRD), atomic force microscope and Vickers' hardness testing, respectively.

RESULTS

Mean values of the surface roughness (mean±standard deviation (nm)) were 24.52±5.07, 27.39±5.87 and 34.36±4.55 for groups RI/B, RI/C and RI respectively (p = 0.003). The calcium to phosphate ratios were 1.32±0.16, 1.22±0.26 and 0.69±0.24 for groups RI/B, RI/C and RI respectively (p < 0.001). XRD revealed apatite formation in all three groups. The mean enamel surface microhardness (kg/mm2) of the groups were 353.93±28.49, 339.00±27.32 and 330.38±22.55 for groups RI/B, RI/C and RI respectively (p = 0.216).

CONCLUSIONS

Resin infiltration combined with CPP-ACPF or BAG remineralisation appears to improve the surface properties of WSLs.

CLINICAL SIGNIFICANCE

The combination of resin infiltration and CPP-ACPF/BAG remineralisation may be a potential treatment for the management of the WSLs.

White spot lesions: diagnosis and treatment - a systematic review

BACKGROUND

White spot lesions represent the first stage of caries and their prevalence has been increasing in recent years, particularly in patients undergoing orthodontic treatment. DIferential diagnosis and lesion activity are essential to decide on the clinical approaches to treatment. The aim of this study is to understand if the new diagnostic tools such as fluorescence, microradiography and computed microtomography have the potential to change the conventional treatment of white spots".

METHODS

A systematic search of available studies in the literature was carried out, using PRISMA guidelines, in Pubmed and Scopus electronic databases and manually to identify relevant articles to answer the PICO question: "Do the new diagnostic tools have the potential to change the conventional treatment of white spots?". This systematic review included randomized controlled trials (RCT), cross-sectional and longitudinal studies complying with the following inclusion criteria: (i) studies in humans, (ii) studies about white spot lesions, (iii) studies published between 2012 and 2023, (iv) studies having both diagnosis and treatment and (v) studies with full text available. In this review we excluded other systematic reviews of clinical trials and in vitro studies. The RoB tool was used to assess the risk of bias.

RESULTS

The systematic literature search identified 143 potentially relevant references, which after applying the exclusion criteria, resulted in 20 articles. Regarding diagnostic methods, most articles found were based on conventional methods of visual examination (n:10) or fluorescence (n:7). The least referenced diagnostic techniques were based on the use of clinical photographs (n:2), cross-sectional microradiography (n:1) and computed microtomography (n:1). The use of DIAGNOdent was reported by 3 in vitro studies. With regard to therapies, most studies reported the use of infiltrating resin (n:7) and fluoride-based products (n:5). Other studies have reported the use of self-assembling peptide P11-4 (n:1), home care (n:1), casein phosphopeptide-amorphous calcium phosphate (n:2) and hydrochloric acid (n:1). Combination therapies were also considered.

CONCLUSION

Diagnostic tool does not have the potential to change the form of treatment, whether it is a conventional method or a more differentiated one.

Comparative evaluation of four treatments for postorthodontic white spot lesions: a randomized controlled trial

OBJECTIVES

To evaluate the treatment efficacy of fluoride toothpaste alone and those of adjunctive use of resin infiltration, sodium fluoride varnish, and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSLs).

MATERIALS AND METHODS

Seventy-nine patients (356 teeth) with WSLs after orthodontic treatment were randomly allocated into four groups. The WSLs of the participants received resin infiltration only at baseline, and the other groups received fluoride varnish, CPP-ACP mousse, and placebo treatment every 6 months, respectively. A toothpaste containing 1400 ppm fluoride and toothbrushes were distributed to all participants, and oral hygiene instructions were provided. Photos of the teeth with WSL were taken to compare the change between groups which was measured by ImageJ software.

RESULTS

Twelve months later, different degrees of reduction in the area of WSLs were observed in all groups. The percentage of lesion area reduction in WSLs in the resin infiltration group was 46.6%, which was significantly higher than that in fluoride varnish group (26.6%), CPP-ACP group (28.6%), and control group (29.8%), and the differences were statistically significant (p < 0.001).

CONCLUSIONS

This study shows that after 1-year follow-up, the use of fluoride toothpaste, with or without the use of fluoride varnish or CPP-ACP, can reduce the area of WSLs. While resin infiltration can immediately improve dental aesthetics and continuously improved in 12 months, resin infiltration group showed much better results than other groups.

TRIAL REGISTRATION

Clinical Trials Registration Number: ChiCTR2000032516.

CLINICAL SIGNIFICANCE

The use of fluoride toothpaste, with or without adjunctive use of fluoride varnish and CPP-ACP, can reduce the area of WSLs, while resin infiltration treatment has additional effect and can immediately improve dental aesthetics.

Influence of resin infiltration pretreatment on the microleakage under orthodontic bracket (an in vitro study)

OBJECTIVES

In order to assess the changes in tooth orthodontic adhesive interface microleakage after applying a caries resin penetrated to the sound enamel tooth surface in different storage media.

MATERIALS AND METHODS

A total of 60 human maxillary first premolars (orthodontic extraction) were collected by random separation of the teeth into two equal groups. The control group was classified into three subgroups (n = 10) (control in deionized water, control in milk, and control in energy drink), while the experimental one (treated with ICON) was categorized into three subgroups (n = 10) (ICON in deionized water, ICON in milk, and ICON in energy drink) incubation phase lasted three weeks in total.

RESULTS

A one-way analysis of variance (ANOVA) yielded a significant difference between all experimental subgroups (ICON in deionized water, ICON in milk, and ICON in energy drink) and control subgroups (control in deionized water, control in milk, and control in energy drink). The control group in the energy drink subgroup had the highest mean microleakage value when compared to the other subgroups, whereas the resin-infiltrated group in deionized water had the lowest mean value. According to the results of the T-test, ICON pre-treatment tooth samples had significantly lower mean values of microleakage than non-ICON tooth samples.

CONCLUSIONS

The adhesive system (control group) revealed that a resin infiltrate on a sound enamel surface prior to orthodontic bracket bonding reduced bracket tooth interface microleakage in all examined samples. The ICON-infiltrated surface was discovered to provide a secondary preventive strategy against white spot lesion development by reducing microleakage under brackets.

Effectiveness of resin infiltration (ICON) and microabrasion-remineralization technique with two remineralizing agents (Tooth Mousse and Toothmin) on permanent incisor hypoplasia - A randomized clinical trial

Aims

The study aims to compare the effect of resin infiltration and microabrasion-remineralization (MAb-Re) with Tooth Mousse and Toothmin on permanent incisor hypoplasia.

Materials and Methods

The study included children with permanent incisor hypoplasia above 9 years of age, 171 teeth divided randomly into four groups: Group A - ICON, Group B - MAb-Re using Tooth Mousse, Group C - MAb-Re using Toothmin, and Group D - control group. Process involved taking standardized photographs at T1 - before intervention, T2 - immediately after treatment, and T3 - 6-month follow-up. Color evaluation, area calculation, participant and expert opinion using a Likert scale, treatment time, and cost-effectiveness were all taken into consideration during the assessment.

Statistical Analysis Used

Data were collected, entered into a computer, and analyzed; one-way ANOVA was used for intergroup assessment.

Results

Overall color change was evident immediately after treatment in the ICON group compared to other groups (P < 0.05). However, no significant difference in color change was visible between the groups after 6 months. Reduction in hypoplastic area was seen in all the groups. The mean time was similar for all the groups. Toothmin was found to be the most cost-effective in comparison with the other two interventions.

Conclusions

ICON proved to be more effective immediately after treatment for masking incisor hypoplasia. However, at 6-month follow-up interval, all the groups gave similar results.

Esthetic Effects and Color Stability of Resin Infiltration on Demineralized Enamel Lesions: A Systematic Review

Aims and Objectives

The aim of this study was to systematically review the ability of resin infiltration to conceal demineralized enamel lesions to normal enamel translucency and to maintain color stability.

Materials and Methods

A literature search of PubMed, MEDLINE, Web of Science, and Scopus databases and a manual search of articles from 2009 to 2021 for randomized controlled trials (RCTs) and clinical efficacy trials (nonrandomized) were performed. Methodological quality and risk of bias (RoB) of included papers was assessed using Cochrane Collaboration Risk of Bias Tool 2.0 for RCTs and ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool for nonrandomized studies.

Results

A total of 352 titles and abstracts were reviewed. Eight RCTs and three clinical efficiency studies were included in this review. The masking effects of the demineralized enamel lesion were reported immediately after resin infiltration, and the color stability of this material was up to 24 months, with no adverse effects noted. For RCTs, four studies were classified as "some concerns" and four were as "low RoB." For nonrandomized studies, all of the studies presented an overall moderate RoB.

Conclusion

Resin infiltration achieves the best esthetic outcomes compared with microabrasion and remineralization therapy. Color stability was achieved with this material for up to 24 months and no adverse effects were noted. Factors contributing to the esthetic outcomes of the resin include the elimination of the hypermineralized surface layer, the homogeneity of the resin itself, and polishing after resin infiltration. Longitudinal follow-up and improved control of confounding variables should characterize future high-quality systematic reviews.

Patient Satisfaction with Resin Infiltration Treatment for Masking Noncavitated White Spot Lesions on Anterior Maxillary Teeth: Two Case Reports

Aim

We assessed patient satisfaction with resin infiltration treatment outcomes for masking postorthodontic treatment noncavitated white spot lesions on anterior maxillary teeth.

Background

White spot lesions (WSLs) are opaque white areas of demineralization. The lesion may remineralize over time, but the opaque color usually remains, retaining the undesirable tooth color. Case Description: Resin infiltration (RI) was administered to two patients with a total of 10 anterior maxillary teeth diagnosed with noncavitated WSLs. Immediately after treatment, patients were asked about their comfort during the RI treatment and their level of satisfaction with treatment outcomes. Two weeks post-treatment, the two patients were asked again about their level of treatment outcome satisfaction and if they thought they needed a second treatment. Both reported that they were comfortable during the treatment and were extremely satisfied with the achieved treatment outcomes immediately and two weeks after the treatment and did not feel that they would need to seek further treatment to reach the desired outcome.

Conclusion

Resin infiltration is a comfortable, conservative treatment option providing satisfactory outcomes in masking noncavitated WSLs on anterior maxillary teeth after orthodontic treatment. Clinical Significance. Resin infiltration is a conservative treatment option to mask noncavitated WSLs after orthodontic treatment.

Management of white spot lesions induced during orthodontic treatment with multibracket appliance: a national-based survey

OBJECTIVES

The study aimed to survey current strategies against enamel demineralization during multibracket therapy (MBT) and guide a prevention concept based on existing scientific evidence.

MATERIALS AND METHODS

The survey comprised questions on the prevention and management of white spot lesions (WSL). The questionnaire was sent via email to orthodontists working in practices and universities throughout Germany. The analysis involved descriptive statistics using the chi-square test (p < 0.05).

RESULTS

A prevention protocol was used before MBT by 80.6% of the participants. Less than a quarter of the participants regularly applied topical fluoride (gel or varnish) during MBT. According to the respondents' assessment, the prevalence of WSL during MBT is 11.6%, mainly observed in 12- to 15-year-old male patients. Orthodontists graduating after 2000 tended to recommend and apply fluoride-containing materials more often than their senior colleagues (p = 0.039). Participants from private practices applied fluoride varnish or gel more frequently than those from university clinics (p = 0.013). Fluoridation was the most common (70.7%) treatment for WSL after MBT, followed by resin infiltration (21.2%). The majority (80.9%) of the participants favor a guideline for preventing WSL.

CONCLUSIONS

WSL prevention during MBT is challenging. Males in puberty are predominantly affected. Younger orthodontists are more concerned about the prevention of WSL during MBT.

CLINICAL RELEVANCE

The non-negligible prevalence of individuals with WSL emphasizes the need for dental education and health care reform. This would help to implement standardized procedures and establish innovative applications.

Impact of masking hypomineralization opacities in anterior teeth on the esthetic perception of children and parents: A randomized controlled clinical trial

OBJECTIVES

The aim of this study was to evaluate the impact of treating demarcated opacities in anterior teeth on the esthetic perception of children and their parents. Additionally, the masking effect was evaluated quantitively and qualitatively.

METHODS

Thirty-nine patients, 8-18 years-old, presenting white-creamy opacity in permanent incisors were randomly allocated to test or control group. Test received resin infiltration and control received a placebo. The questionnaire Child's and Parent's Questionnaire about Teeth Appearance was used. The masking effect was quantitatively analyzed using the Lab System to calculate the color difference (ΔE) between the opacity and the surrounding enamel in Photoshop. Fisher's, Chi-square, Wilcoxon, Mann-Whitney tests and Spearman's correlation were applied to data analysis.

RESULTS

In the test group, a significant impact on physical and psychological domains in parents' and in social domain in parents' and children's perception was observed (p<0.05). Significant difference in ΔE between test and control groups was seen from 15 min of application onwards (p<0.05). After treatment, the mean ΔE was 4.07 (SD=3.07) in the test and 7.35 (SD=3.54) in the control group (p<0.01). One month later, the mean ΔE was 4.22 (SD=2.96) in the test and 6.06 (SD=2.52) in the control group (p<0.01). Total masking was seen only in the test group (p<0.01).

CONCLUSION

Aesthetic treatment of hypomineralization opacities in anterior teeth with resin infiltration impacted positively on parents and children. Resin infiltration reduced the color difference between opacities and sound enamel significantly after an application time of at least fifteen minutes.

CLINICAL SIGNIFICANCE

Opacities in anterior teeth impact the self-image of children and parents negatively. This study demonstrated that 15 min resin infiltration can mask opacities in permanent incisors and recover social wellbeing. This minimally invasive approach can be offered to MIH children who report dissatisfaction with their incisors.

Assessment of White Spot Lesion and Enamel Demineralization in Orthodontic Patients With Fixed Brackets—A Clinical Appraisal Using Fluoride Mouth Rinse, Fluoride Varnish Containing CPP-ACP, and CPP-ACFP

Purpose:

Efficacy evaluation of casein phosphopeptide amorphous calcium phosphate complex (CPP-ACP), casein phosphopeptide amorphous calcium fluoride phosphate complex (CPP-ACFP), fluoride mouthrinse, and fluoride containing toothpaste as compared to control group for the remineralization of white spot lesions (WSLs) in orthodontic patients with fixed brackets in an in vivo study.

Methods:

Seventy-five subjects with WSL determined by DIAGNOdent were randomly divided into 5 groups. The WSLs DIAGNOdent values for 0, 3, 6, 9, and 12 months were tabulated and subjected to statistical analysis.

Results:

Among the groups, the remineralizing potential of fluoride mouth rinse, fluoride containing toothpaste, and CPP-ACP were similar; however, CPP-ACFP value was superior in comparison to all other groups.

Conclusion:

The CPP-ACFP technique is highly beneficial for the remineralization of WSL in an orthodontic patient when compared to fluoride mouth rinse, fluoride-containing toothpaste, and CPP-ACP paste.

White Spot Lesions: A Serious but Often Ignored Complication of Orthodontic Treatment

Objective:

The objective of this narrative review is to present an overview of the prevalence, clinical manifestation, diagnosis, and latest advances on white spot lesions.

Background:

White spot lesions have been defined as the earliest stage of demineralization on enamel surfaces that are easily discernible to the human eye.

Methods:

Relevant articles on white spot lesions were searched and reviewed from March 1975 till May 2021 in Pubmed, Scopus, Google Scholar, and ScienceDirect and were included in this review.

Results:

Even though the orthodontic field has seen several advances over the last few years, this is one complication that persists. White spot lesions are very commonly seen after completion of fixed orthodontic therapy when brackets are debonded. Previously conducted research has shown that there is a high prevalence rate of white spot lesions, which ranges from 50 to 90%. On intra-oral examination, a white spot can be seen as a matte-textured, opaque white lesion. Since the demineralization process takes place below the enamel surface, the outer layer only demonstrates pores that affect the natural light refractory properties of a tooth. This is what leads to the characteristic appearance of these lesions. One of the goals of modern dentistry is to treat non-cavitated lesions by promoting remineralization without the involvement of any invasive procedures.

Conclusion:

Fixed orthodontic therapy is usually a lengthy process and requires active cooperation between the orthodontist and the patient. However, it is the responsibility of the treating orthodontist to examine the tooth surfaces at each appointment to diagnose a developing white spot lesion as early as possible. With recent advances in diagnostic techniques, it has become much easier to identify these initial lesions and prevent their progression to cavitated lesions.

Effect of topical fluoride application and diode laser-irradiation on white spot lesions of human enamel

Objectives

This study aims to evaluate the effectiveness of topical fluoride application and diode laser-irradiation on the hardness of demineralized enamel and to evaluate the esthetic improvement of the white spot lesions (WSLs) using a visual analog scale (VAS).

Materials and Methods

Artificial WSLs (3x3 mm) were created on the enamel surface of 45 human third molars. The teeth were randomly assigned into three groups (n = 15): group A, fluoride only; group B, combined therapy of fluoride and diode laser; and group C, control. Vicker’s hardness number (VHN) was measured at baseline, after demineralization and after treatment. To evaluate the esthetic improvement after treatment, 14 raters evaluated each group’s photographs using a 100-millimeter VAS. A one-way ANOVA or Brown-Forsythe and Games-Howell post hoc procedure were performed for statistical analysis. The level of significance was set at α = 0.05 for all tests.

Results

Group A mean VHN was significantly higher than groups B and C, and group B was significantly higher than group C (P < 0.05). However, the mean VAS rating for the combined therapy group (B) was significantly higher than that for groups A and C (P < 0.05).

Conclusion

Combination therapy significantly improved the esthetic appearance of WSLs compared to the fluoride only group. However, there was less enamel hardness versus treatment with fluoride only.

Effect of Ageing Process and Brushing on Color Stability and Surface Roughness of Treated White Spot Lesions: An in vitro Analysis

Purpose

To evaluate the effect of ageing process and brushing on the color stability and surface roughness of white spot lesions treated with resin infiltration or remineralization.

Patients and Methods

Artificial white spot lesions were created on the facial surface of extracted bovine teeth. Specimens were divided into three main groups based on treatment received: resin infiltration (Icon), MI Paste Plus (MI) or no treatment (control). Specimens underwent pH cycling for 7 days, followed by brushing with toothbrush simulator. Specimens were then immersed in three different solutions (water, cranberry juice, or coffee) for 7 days. Surface roughness (SR) and color stability (CS) assessments were performed at baseline and after each test. One-way and two-way ANOVA were used to calculate the statistical comparisons between the groups and significance considered at P <0.05.

Results

Icon group had the least color change after pH cycling, while MI showed the least color change after brushing test. Immersion in coffee produced the highest color change in all groups, followed by cranberry juice. Icon group had the best color stability when immersed in cranberry juice or coffee. Control and the MI treated specimens showed gradual increase of SR after pH cycling and brushing test, while Icon group had improved surface properties. Brushing test alone produced less color change in comparison with immersion in cranberry juice and coffee; however, brushing increased SR.

Conclusion

Icon treatment showed superior color stability and surface roughness, compared to the control and the MI treated teeth. Brushing had less influence on color change compared to the immersion in cranberry juice or coffee.

Outcomes used in trials regarding the prevention and treatment of orthodontically induced white spot lesions: A scoping review

INTRODUCTION

The objective was to identify and summarize the outcomes and evaluation methods used in clinical trials regarding the prevention and treatment of orthodontically induced white spot lesions (WSLs).

METHODS

Three electronic databases were searched to identify studies that were (1) clinical trials on prevention and/or treatment of orthodontically induced WSLs, (2) reported in English, and (3) published between January 2010 and October 2019. At least 2 authors assessed the eligibility and extracted the characteristics, outcomes, and evaluation methods from included studies. All disagreements were resolved through discussion.

RESULTS

Among 1328 studies identified, 51 were eligible and included. A total of 48 different outcomes and 11 different evaluation methods were used in these studies. The most frequently used outcomes were WSLs clinical visual examination scores (n = 22, 43.1%), DIAGNOdent values (n = 14; 27.5%), fluorescence loss measured with quantitative light-induced fluorescence (QLF) (n = 10; 19.6%), and lesion area measured with QLF (n = 10; 19.6%). The most frequently used evaluation methods were clinical examination (n = 25; 49.0%), visual inspection by photographs (n = 15; 29.4%), DIAGNOdent (n = 14; 27.5%), and QLF (n = 10; 19.6%). None of the included studies reported data on quality of life.

CONCLUSIONS

Substantial outcome heterogeneity exists among studies regarding the prevention and treatment of orthodontically induced WSLs. Most of the identified outcomes are aimed to assess morphologic changes of WSLs and may not reflect patient perspectives.

REGISTRATION

The Core Outcome Set for trials on the prevention and treatment of enamel White Spot Lesions (COS-WSL) project was registered in the COMET Initiative database (No. 1399).

Efficacy of resin infiltration to mask post-orthodontic or non-post-orthodontic white spot lesions or fluorosis - a systematic review and meta-analysis

OBJECTIVE

The present review systematically analyzed clinical studies investigating the efficacy of resin infiltration on post-orthodontic or non-post-orthodontic, white spot lesions (WSL), or fluorosis.

MATERIALS

Five electronic databases (Central, PubMed, Ovid MEDLINE, Ovid EMBASE, LILACS) were screened. Article selection and data abstraction were done in duplicate. No language or time restrictions were applied. Outcomes were visual-tactile or DIAGNOdent measurements.

RESULTS

Eleven studies with 1834 teeth being affected in 413 patients were included. Nine studies were randomized control trials, one a prospective cohort study, and one had an unclear study design. Meta-analysis could be performed for "resin infiltration vs. untreated control," "resin infiltration vs. fluoride varnish," and "resin infiltration without bleaching vs. resin infiltration with bleaching." WSL being treated with resin infiltration showed a significantly higher optical improvement than WSL without any treatment (standard mean difference (SMD) [95% CI] = 1.24 [0.59, 1.88], moderate level of evidence [visual-tactile assessment]) and with fluoride varnish application (mean difference (MD) [95% CI] = 4.76 [0.74, 8.78], moderate level of evidence [DIAGNOdent reading]). In patients with fluorosis, bleaching prior to resin infiltration showed no difference in the masking effect compared to infiltration alone (MD [95% CI] = - 0.30 [- 0.98, 0.39], moderate level of evidence).

CONCLUSION

Resin infiltration has a significantly higher masking effect than natural remineralization or regular application of fluoride varnishes. However, although the evidence was graded as moderate, this conclusion is based on only very few well-conducted RCTs.

CLINICAL RELEVANCE

Resin infiltration seems to be a viable option to esthetically mask enamel white spot lesions and fluorosis.

A comparison of resin infiltration and microabrasion for postorthodontic white spot lesion

INTRODUCTION

The objective of this research was to evaluate and compare the effectiveness of microabrasion and resin infiltration for white spot lesions (WSLs).

METHODS

Patients with postorthodontic WSLs were enrolled and randomly assigned to the control, microabrasion, and resin-infiltration groups. Intraoral photographs were taken before and after (6 months later) treatment. WSL sizes were determined through ImageJ (Wayne Rasband, Kensington, Md). Integrated optical density (IOD) was determined for a WSL and its surrounding normal enamel through Image-Pro Plus (version 6.0; Media Cybernetics, Rockville, Md), and their differences of IOD were considered as the IOD surrogate for that WSL. The color change of WSL were measured through ΔE.

RESULTS

A total of 27 eligible patients were enrolled; 9 subjects were assigned to each group, resulting in 56 teeth in the control group, 72 in the microabrasion group, and 58 in the resin-infiltration group. The ratios of WSL size (after/before) were similar between the microabrasion and resin-infiltration group (43.94 ± 0.03% vs 45.02 ± 0.03%; P = 0.96 > 0.05), but those of the 2 groups were significantly lower than those of the control group (92.15 ± 0.02%) (P <0.001). Moreover, the ratios of IOD (after/before) were significantly lower in the resin-infiltration group (22.94 ± 0.02%) than in the microabrasion (78.11 ± 0.03%) and control (83.79 ± 0.02%) (P <0.001) groups. The highest ΔE improvement was obtained by infiltration, but there was no significant difference between microabrasion and control group.

CONCLUSIONS

Resin infiltration and microabrasion are comparably effective in reducing the sizes of WSL, but resin infiltration enjoys an esthetic advantage over microabrasion.

Anti-caries effect of resin infiltrant modified by quaternary ammonium monomers

OBJECTIVES

Resin infiltrant is used in early enamel caries. However, commercial resin infiltrant lacks persistent antibacterial activity. Dimethylaminododecyl methacrylate (DMADDM) was added to resin infiltrant to give it sustainable antibacterial properties and inhibit demineralization.

METHODS

After the application of resin infiltrant to bovine enamel, cytotoxicity, surface roughness, and aesthetics were assessed. A multi-species biofilm was incubated on the enamel disk before and one month after microbial-aging. After a 48-h anaerobic incubation, biomass accumulation, metabolic activity, and lactic acid were analyzed using a crystal violet assay, an MTT (3-(4,5-dimethyl-thiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay, and a lactic acid assay. Biofilm structure and composition were determined by live/dead staining, exopolysaccharide (EPS) staining, scanning electron microscopy (SEM), and quantitative polymerase chain reaction (qPCR). The depth and content of demineralization were tested by transverse microradiography (TMR).

RESULTS

Incorporating DMADDM did not increase the cytotoxicity or change the physical properties when the mass fraction of the DMADDM was 2.5-10 %. The modification decreased the amount of bacterial biofilm, metabolic activity, lactic acid production, EPS, and the proportion of Streptococcus mutans in the biofilms. It also provided anti-demineralization effects. The surface roughness and antibacterial ability were not changed after one month of microbial-aging.

CONCLUSION

The incorporation of DMADDM improved the antibacterial and anti-demineralization effects of the material. It demonstrated a sustained antibacterial effect.

CLINICAL SIGNIFICANCE

The antibacterial modification might be a potential choice for future clinical applications to inhibit early enamel caries.

Effect of Two Methods of Remineralization and Resin Infiltration on Surface Hardness of Artificially Induced Enamel Lesions

Statement of the Problem:

The progression of incipient carious lesions may be simply prevented by non-invasive remineralization of lesions, eliminating the need for invasive and high-cost restorative procedures.

Purpose:

This study aimed to assess the effect of two commonly used remineralizing agents and resin infiltration on surface micro hardness of incipient enamel lesions at different time points.

Materials and Method:

In this in vitro study, 45 intact human maxillary central incisors were selected. After disinfection, enamel samples measuring 5x5x2.5 mm were cut out of the labial surface of the teeth. The surface of samples was polished and they were mounted in auto-polymerizing acrylic resin. According to Amaechi’s method, samples were immersed in acidified hydroxyethylcellulose system (pH= 4.5) for 96 hours to induce white spot lesions (WSLs). The baseline value of surface micro hardness of samples was measured using a Vickers hardness tester, then the samples were randomly divided into three groups (n=15) based on different remineralization methods: MI-Paste Plus, Remin Pro and ICON-Infiltrant according to the manufacturer’s instructions. All samples were stored in anti-dry mouth treatment agent during the experiment and their surface hardness was measured at 15 days (T1) and 20 weeks (T2).

Results:

The hardness of samples in MI-Paste Plus and Remin Pro groups significantly increased at both T1 and T2 (p< 0.001) but this increase was not significant in ICON group (p> 0.05).

Conclusion:

MI-Paste Plus and Remin Pro can efficiently increase the hardness of incipient enamel lesions.

Color masking prediction of posterior white spot lesions by resin infiltration in vitro

OBJECTIVE

To investigate parameters that could predict the color masking effect (ME) of white spot lesions (WSLs) after resin infiltration (RI).

METHODS

Sixty extracted human teeth with natural WSLs were selected (28 premolars, 29 molars and 3 incisors). At baseline, the laser fluorescence (LF) of surrounding sound enamel (SE) and the WSLs were analyzed with DIAGNOdent. Standardized photographs were obtained under D65 and UV illuminants, from which the CIE L*a*b* color coordinates and natural fluorescence (NF) of the WSLs and SE were obtained. The color difference (ΔE₀₀) and differences of NF and LF between the SE and WSLs were calculated. The lesion dimensions (area, perimeter, width, and height) were determined. After RI, the assessments were repeated. ME was considered as the reduction of ΔE₀₀ values after RI. One-way ANOVA and the Tukey tests were used to analyze the absolute means of the LF and NF values. The t test was used to compare the ΔE₀₀ values and lesion dimensions before and after infiltration. The correlations between all parameters at baseline and ME were analyzed.

RESULTS

The absolute mean values of LF at the baseline (B) and after infiltration (I) were SE/B-3.98a, WSL/B-13.28c, SE/I-3.36a, WSL/I-7.95b (p = 0.001). The mean values for NF were SE/B-7.93a; WSL/B-6.29b, SE/I-7.93a, WSL/I-7.27a (p = 0.001). The results for ΔE₀₀ were B-11.74a, I-8.66b (p = 0.001). RI significantly reduced lesion dimensions. No correlations were observed between the baseline parameters and the ME.

CONCLUSIONS

The WSLs presented higher LF and smaller NF than SE, which were respectively reduced and increased after RI. Prediction of the masking effect by the parameters evaluated at baseline was not possible, which could be due to the choice of mainly caries lesions in posterior teeth. Nonetheless, infiltration was found suitable to mask most of the WSL.

CLINICAL SIGNIFICANCE

The color masking effect of white spot lesions after resin infiltration cannot be predicted by a previous analysis of fluorescence, color, or dimensions of the lesion.

Underlying Resin Infiltration and Direct Composite Veneers for the Treatment of Severe White Color Alterations of the Enamel: Case Report and 13-Month Follow-Up

Pronounced white color alterations due to structural anomalies of the enamel are often insufficiently masked by bleaching techniques or resin infiltration procedures alone. This frequently leads to the choice of more invasive prosthetic restorations in order to correct tooth color and form. This article describes a minimally invasive treatment option for esthetic and functional rehabilitation in the case of a 13-year-old female patient with suspected severe fluorosis and misalignment of the anterior teeth. The restorations were performed using underlying resin infiltration to homogenize the tooth shade. In a second step, direct composite veneers were applied on top to attain a natural tooth color and adjust tooth alignment and form. By joining the two minimally and noninvasive techniques, this treatment option combines the directive for preservation of hard tooth structure while treating adolescents with the benefits of easy adaptation and repair when the occlusion is still in adjustment.

Resin infiltration of enamel white spot lesions: An ultramorphological analysis

OBJECTIVE

There is not a clear understanding of the ultramorphology of enamel white spot lesions (WSLs). The purpose of this study is to characterize resin infiltration of enamel WSLs using electron microscopy.

MATERIALS AND METHODS

Enamel sections with sound enamel and WSLs were sectioned from extracted teeth and assigned to three groups: (a) left untreated; (b) etched with 15% hydrochloric acid (Icon-Etch); (c) restored with the resin infiltration sequence (Icon-Etch, Icon-Dry, and Icon-Infiltrant). Restored specimens were demineralized to obtain replicas. Observations were carried out under a field-emission scanning electron microscope.

RESULTS

Icon-Etch resulted in an array of pits and funneled holes on the WSL. Replicas of WSLs depicted 0.5-6.0-μm-thick shaggy resin tags up to a depth of 465 μm. Enamel crystallites were enveloped with resin at the bottom of the WSL forming a hybrid layer.

CONCLUSIONS

The resin infiltrant filled the spaces between the crystallites and resulted in an enamel hybrid layer.

CLINICAL SIGNIFICANCE

In addition to masking enamel WSLs, resin infiltration is able envelop residual enamel crystallites forming an enamel hybrid layer. This hybridization makes resin-embedded enamel more resistant to acid attack than sound enamel.

Silicone Additive Manufactured Indices Performed from a Virtual Diagnostic Waxing for Direct Composite Diastema Closure Combined with Resin Infiltration Technique on White Spot Lesions: A Case Report

The present article describes the resin infiltration technique to address white spots lesions presented on anterior and premolar teeth of a young patient after orthodontic treatment and the digital workflow for planning a diastema closure on the maxillary anterior teeth using facial photographs, an intraoral scanner, a facially driven diagnostic waxing using a dental computer-aided design (CAD) software, and 3-piece additive manufactured (AM) clear silicone indices. The virtual design of the silicone indices was completed using an open-source CAD software and included a flexible clear buccal piece, flexible clear lingual piece, and rigid clear custom tray. The unique 3-piece index design allows a horizontal path of insertion, controlled uniform thickness of the indices, flexible and rigid material properties combination, accurate translation of the diagnostic waxing into the patient´s mouth, and digital storage of the designs.

Current treatment modalities of orthodontically induced white spot lesions and their outcome - a literature review

Introduction

White spot lesion is a demineralization of the enamel that appears as a white spot on the surfaces of the tooth. The cause of this spot is determined by the activity of the bacterial plaque and it represents the initial stage of a carious lesion. This lesion is a common side effect for patients with fixed orthodontic appliances mainly because of the brackets' position that favors the accumulation of plaque that ultimately leads to the formation of the white spot.

Methods

We conducted a search on a single database, PubMed. "Orthodontic", "white spot lesions", "enamel demineralization treatment" and "remineralization" were the search terms used. We found 324 articles, but we took in consideration only the ones from the last 10 years, which resulted in 223 articles.

Results

The first step after research was article selection: first by scrutinizing the title and secondly by reviewing the abstracts or full texts. The exclusion criteria were: meta-analysis, reviews, original articles regarding prevention of white spot lesions and their prevalence or incidence. We included the articles that seemed relevant for the treatment of white spot lesions, made either on extracted teeth either on orthodontic patients. We found 75 articles to be eligible for this research and we eliminated 5 because of the lack of an abstract or full text and a further 22 were rejected because they did not fit the aforementioned criteria.

Conclusion

Although some traditional methods for the treatment of white spot lesions seem to have undesirable results, nowadays with new technologies and thorough investigations in nanotechnology, the eradication of the lesion appears to be short term.

Long-term follow-up of camouflage effects following resin infiltration of post orthodontic white-spot lesions in vivo

OBJECTIVES

To reassess the long-term camouflage effects of resin infiltration (Icon, DMG, Hamburg, Germany) of white spot lesions (WSL) and sound adjacent enamel (SAE) achieved in a previous trial. The null hypothesis was tested that there were no significantly different CIE-L*a*b*-ΔE-values between WSL and SAE areas of assessment after at least 24 months (T24) compared to those at baseline (T0).

MATERIALS AND METHODS

Of twenty subjects who received previous resin infiltration treatment of n_teeth = 111 nonrestored, noncavitated postorthodontic WSL after multibracket treatment during a randomized controlled trial and were contacted 20 months after baseline, eight subjects (trial teeth n_teeth = 40; m/f ratio 1/7; age range (mean; SD) 12-17 [15.25; 2.12] years); response rate: 40%) were available for follow-up after at least 24 months (T24). CIE-L*a*b* differences between summarized color and lightness values (ΔE_WSL/SAE) of WSL and SAE were assessed using a spectrophotometer and compared to baseline data assessed prior to infiltration (T0), and those after 6 (T6), and 12 (T12) months using paired t tests at a significance level of α = 5%.

RESULTS

T24 assessments were performed after a mean 33.86 (SD: 8.64; Min: 24; Max: 45) months following T0. Mean (SD) ΔE_WSL/SAE units of available teeth were 8.76 (5.33) at baseline; 5.5 (2.75) at T6; 5.2 (2.41) at T12; and 5.57 (2.6) at T24. Comparisons of T6, T12, and T24 with T0 yielded highly significant differences, whereas T6-T24 and T12-T24 differences were found to be not significant.

CONCLUSIONS

Assimilation of infiltrated WSL to the color of adjacent enamel by resin infiltration is considered to be suitable for the long-term improvement in the esthetic appearance of postorthodontic WSL.

Assessing the Appearance and Fluorescence of Resin-Infiltrated White Spot Lesions With Caries Detection Devices

OBJECTIVE

This in vitro study examined the effectiveness of caries detector devices in assessing the ability of resin infiltration (RI) (Icon, DMG-Hamburg, Hamburg, Germany) to improve the optical properties of enamel white spot lesions (WSLs).

METHODS AND MATERIALS

Ten caries-free third molars were used. Photographs, a subjective visual assessment of the photographs, fluorescent camera (FC) images using the Spectra (Air Techniques, Melville, NY, USA), and laser fluorescent (LF) readings using the DIAGNOdent (KaVo, Biberach, Germany) were obtained from each tooth's buccal surface. Specimens were coated with nail polish leaving a rectangular window on the buccal surface and placed in pH 4.5 lactic acid gel for two weeks to create a WSL. The WSLs were analyzed by the same methods. RI was applied to half of each WSL; final photographs were then taken, and caries detector assessments were conducted. FC images were converted to grayscale, and the fluorescent image's brightness intensity was measured using ImageJ. Data were analyzed with analysis of variance and Tukey-Kramer honestly significant difference test. Significance was set at α=0.05.

RESULTS

Subjective assessment of the photographs showed that RI improved the appearance of the WSLs so that they resembled intact enamel. Mean FC-brightness intensities for intact, demineralized, and demineralized RI-treated areas were 159.6 ± 9.2, 123.4 ± 7.2, and 160.9 ± 11.5, respectively. There were no significant differences in fluorescent intensity between the intact and RI areas ( p=0.58). The demineralized areas had significantly lower fluorescent intensity than both the RI-treated and intact areas ( p<0.001). LF values did not differ significantly between intact, demineralized, or RI-treated areas.

CONCLUSIONS

This study demonstrates the ability of RI to restore artificial WSLs to the esthetics and fluorescence of intact enamel. The FC can be used to assess the optical properties of WSLs and the impact of RI on these properties.

Concealment effect of resin infiltration on incisor of Grade I molar incisor hypomineralization patients: An in vivo study

Context

Molar incisor hypomineralization (MIH) is a commonly occurring esthetic setback among patients. Depending on the graveness of the lesion, esthetics of MIH can be improved by treatments such as enamel microabrasion, bleaching, composite resin bonding, and the combination of some or all of these techniques.

Aim

The aim of this study is to evaluate the esthetic results of resin infiltration treatment on incisors with Grade I molar incisor MIH.

Materials and Methods

A total of 22incisor lesions with MIH were infiltrated with resin. Photographs were captured before infiltration, just after infiltration, and 6 months after infiltration. The photographic evaluation was done by the CIE L*a*b* scoring method. The means of each parameter such as ΔL and ΔE were calculated.

Statistical Analysis

ANOVA in conjunction with Turkey's post hoc test was used to evaluate the means.

Results

The total color change observed was equal just after treatment and 6 months after treatment, with no statistically significant difference (P = 0.87) between these two time points. The mean of difference in total color change (ΔE₃) of white tooth discoloration was 13.2 SD 6.8, showing an overall color change.

Conclusion

Infiltration can conceal the white opaque appearance of Grade I MIH lesions, and also reduction in lesion whiteness is seen with time.

Amelogenesis Imperfecta: A Non-Invasive Approach to Improve Esthetics in Young Patients. Report of Two Cases

Objective-Evaluate esthetic and functional efficacy of infiltrant resin (Icon, DMG, Hamburg, Germany) in Amelogenesis Imperfecta's treatment.

STUDY DESIGN

Two adolescent patients, G.S. (13 years old) and C.M. (15 years old), affected by the hypomaturation type of Amelogenesis Imperfecta, were treated with Icon resin and were followed for twelve months.

RESULTS

Treated teeth show an excellent aesthetical result immediately after the resin application, effect that lasts in the long-term (six and twelve months follow-up examinations); the dental wear's progression seems to be clinically arrested.

CONCLUSIONS

Resin infiltration has proven to be a minimal invasive treatment for dental discoloration, less aggressive than conventional procedures. This approach might be recommended for a stable esthetical improvement in moderate AI's lesions especially in children and adolescents.

Management of post-orthodontic white spot lesions: an updated systematic review

Background/objectives

The management of post-orthodontic white spot lesions is based on remineralization strategies or a minimal-invasive camouflage of the lesions.

Aim

The aim of this systematic review was to identify and assess the quality of evidence for the various clinical technologies.

Search methods

Four databases were searched for relevant literature published in English between 2011 and 31 October 2015 according to a pre-determined PICO. Only controlled clinical studies were considered. Abstract lists and the selected full-text papers were independently examined by two reviewers and any differences were solved in consensus. The Cochrane handbook and the AMSTAR tool were used for grading the risk of bias. The quality of evidence was rated according to GRADE.

Results

Out of 280 identified publications, seven studies on remineralization, micro-abrasion and resin infiltration met the inclusion criteria. Two of them were assessed with low risk of bias. No pooling of results was possible due to study heterogeneity. The quality of evidence for all technologies was graded as very low.

Limitations

Only papers published in English with more than 20 adolescents or young adults were considered. Furthermore, a follow-up period of at least 8 weeks was required. The publication bias could not be assessed due to the paucity of included trials.

Conclusions/clinical implications

There is a lack of reliable scientific evidence to support re-mineralizing or camouflaging strategies to manage post-orthodontic white spot lesions. Further well-performed controlled clinical trials with long-term follow-up are needed to establish best clinical practice.

Masking of Enamel Fluorosis Discolorations and Tooth Misalignment With a Combination of At-Home Whitening, Resin Infiltration, and Direct Composite Restorations

This clinical report illustrates a conservative technique to mask enamel discolorations in maxillary anterior teeth caused by hypomineralization associated with enamel fluorosis and subsequent direct resin composite to improve the anterior esthetics. The treatment consisted of at-home whitening with 10% carbamide peroxide gel with potassium nitrate and sodium fluoride in a custom-fitted tray to mask the brown-stained areas, followed by resin infiltration to mask the white spot areas. An existing resin composite restoration in the maxillary right central incisor was subsequently replaced after completion of the whitening and resin infiltration procedures, whereas the two misaligned and rotated maxillary lateral incisors were built up with direct resin composite restorations to provide the illusion of adequate arch alignment, as the patient was unable to use orthodontic therapy.

Prevention and Treatment of White Spot Lesions in Orthodontic Patients

Decalcification of enamel, appearing as white spot lesions (WSLs), around fixed orthodontic appliances is a major challenge during and after fixed orthodontic treatment by considering the fact that the goal of orthodontic treatment is to enhance facial and dental esthetic appearance. Banded or bonded teeth exhibit a significantly higher rate of WSLs compared to the controls with no braces as fixed appliances and the bonding materials promote retention of biofilms. These lesions are managed in the first step by establishing good oral hygiene habits and prophylaxis with topical fluorides, including high-fluoride toothpastes, fluoride mouthwashes, gels, varnishes, fluoride-containing bonding materials, and elastic ligatures. Recently, other materials and methods have been recommended, including the application of casein phosphopeptides-amorphous calcium phosphate, antiseptics, probiotics, polyols, sealants, laser, tooth bleaching agents, resin infiltration, and microabrasion. This article reviews the currently used methods to manage enamel demineralization during and after orthodontic treatment and the risk factors and preventive measures based on the latest evidence.

Surface Properties and Color Stability of Resin-Infiltrated Enamel Lesions

OBJECTIVES

To examine the surface topographies, microhardness, and color stability of resin-infiltrated enamel lesions before and after aging challenges in vitro using three-dimensional laser scanning profilometry, surface microhardness testing, spectrophotometry, and scanning electron microscopy.

METHODS

Forty human third molars were embedded in epoxy resin, and each tooth was prepared to have two white spot lesions and one sound enamel area. One white spot lesion received resin infiltration and the other was untreated. Ten specimens were subjected to thermocycling for 10,000 cycles, 10 specimens were immersed in coffee solutions, and 10 specimens were placed in water storage. Surface area roughness (Sa), Vickers microhardness (VHN), and CIE L*a*b* color values were measured on sound enamel, resin-infiltrated lesions, and untreated lesions before and after aging. The surface morphology of resin-infiltrated lesions was observed after aging under scanning electron microscopy and compared with 10 specimens that were not subjected to aging challenge.

RESULTS

Resin infiltration increased the surface microhardness of the enamel lesions from 89.3 to 212.0 VHN. The surface microhardness of resin-infiltrated enamel lesions was not significantly affected by aging. The surface roughness of resin-infiltrated lesions (0.32-0.37 μm) was greater than that of sound enamel (0.05-0.06 μm) and untreated lesions (0.12-0.13 μm). Thermocycling and water storage further increased surface roughness of resin-infiltrated surfaces. Resin-infiltrated enamel lesions showed greater discoloration than sound enamel surfaces. Surface microfissures and microcracks were observed on resin-infiltrated enamel lesions after thermocycling.

CONCLUSIONS

Surface hardness of enamel lesions increased significantly after resin infiltration and remained stable following thermocycling. Surface roughness and color stability of resin-infiltrated enamel lesions were less than ideal and might further deteriorate after aging in the oral environment.

When and How to Intervene in the Caries Process

The decrease in caries prevalence in many industrialized countries and the improved knowledge about the etiology and pathogenesis of caries have shifted the focus of caries therapy over the past decades toward less invasive approaches. Studies on caries progression indicate that it is generally quite slow in most patients today which should lead to a reconsideration of the practice of early invasive intervention. Today noninvasive (eg, fluorides) and microinvasive (occlusal sealing, proximal infiltration) therapeutic options that address etiological factors are gaining importance. The goal of these therapies is to heal or at least to slow down the progress of the disease. Noninvasive treatments are mainly related to controlling pathogenic factors (ie, sugar consumption) and enhancing protective factors (mainly oral hygiene and fluorides). Microinvasive treatments do not rely on the compliance of the patient as much, since these treatments include a resinous material that is applied to serve as a diffusion barrier for acids formed by cariogenic bacteria in the overlying plaque. To establish a minimum intervention treatment strategy for caries, the disease must be diagnosed at an early stage. In addition to assessing caries lesions in single teeth, individual risk factors need to be identified so that the underlying causes related to patients' behavioral patterns that led to the disease can be addressed as well. The patient should be informed about the scientific evidence related to the treatment choices in a participative atmosphere. Decision trees may help to make the range of findings comprehensible and the therapeutic shared decision-making process understandable to the patients.

Effectiveness of resin-based materials against erosive and abrasive enamel wear

OBJECTIVE

The objective of this study was to test the effectiveness of resin-based materials against erosive enamel wear under erosive and abrasive challenges by orange juice and tooth brushing.

METHODS

Fifty enamel specimens from third molars were assigned to five groups: ICON resin infiltration with no etching (ICON-NE), ICON resin infiltration with 15 % HCl etching (ICON-AE), Seal & Protect sealant (S&P), Tetric EvoFlow (TEF), and control. Erosive lesions were first created on enamel, then treated with resin-based materials. Erosive and abrasive challenges by orange juice and tooth brushing were repeated after treatments. Erosive wear of the treated areas was measured with 3D scanning microscopy, and data were analyzed using ANOVA and paired t tests.

RESULTS

Treatments with ICON, S&P, and TEF created a protective material coating of 4.5 ± 1.9 μm, 44.3 ± 8.1 μm, and 84.6 ± 15.7 μm in thickness on the lesion surfaces, respectively. After 15 cycles of erosive and abrasive challenges, enamel or material losses were 21.9 ± 2.3 μm for control, 24.5 ± 4.0 μm for ICON-NE, 24.6 ± 7.4 μm for ICON-AE, 11.2 ± 4.1 μm for S&P, and 3.9 ± 1.9 μm for TEF, respectively. The protective coatings were completely lost in the ICON infiltration groups but remained intact in both the S&P and TEF groups after erosive and abrasive challenges.

CONCLUSION

In contrast to a resin sealant and a flowable composite, ICON infiltration resin was not effective in protecting enamel surfaces from erosive and abrasive wear.

CLINICAL RELEVANCE

Sealant and flowable composite resin may create protective coatings on eroded enamel surfaces and prevent further tissue loss.

Camouflage effects following resin infiltration of postorthodontic white-spot lesions in vivo: One-year follow-up

OBJECTIVE

To assess camouflage effects by concealment of postorthodontic white-spot lesions (WSLs) to sound adjacent enamel (SAE) achieved over 12 months with resin infiltration (Icon, DMG, Hamburg, Germany).

METHODS

Twenty subjects (trial teeth nteeth = 111) who had received resin infiltration treatment of noncavitated postorthodontic WSLs were contacted for a 1-year follow-up assessment of CIE-L*a*b* colors (T12). Color and lightness (CIE-L*a*b*) data for WSLs and SAE were compared to baseline data assessed before infiltration (T0) and those assessed after 6 months (T6), using a spectrophotometer. The target parameter was the difference between the summarized color and lightness values (ΔEWSL/SAE). Intergroup (WSL, SAE) and intertime comparisons (T0 vs T6, T12) were performed using paired t-tests at a significance level of α = 5%.

RESULTS

Nine subjects (trial teeth nteeth = 49; male/female ratio 5/4; age range 13-19 years) were available at T12. After the highly significant reduction of ΔEWSL/SAE discrepancies between T0 and T6, analysis of 12-month records revealed color and lightness discrepancy of WSL vs SAE that was significantly decreased compared with baseline, indicating an assimilation of WSL color to SAE appearance after infiltration, while an additional reduction of discrepancies between T6 and T12 was not significant.

CONCLUSION

As color and lightness characteristics of the Icon infiltrant as well as the esthetic camouflage effects achieved by WSL infiltration were not altered significantly or clinically relevant after 12 months, the method of resin infiltration can be recommended for an enduring esthetic improvement of postorthodontic WSL.

Resin infiltration of non-cavitated caries lesions: a systematic review

OBJECTIVE

The aim of this systematic review was to evaluate the in vivo scientific evidence of the ability of resin infiltration (RI) to arrest non-cavitated caries lesions.

MATERIALS AND METHODS

The PubMed database was searched for randomized controlled trials that evaluated the in vivo effect of RI versus placebo or other preventive treatment on the progression of caries lesions. The keywords used were 'resin infiltration, dental caries', 'resin infiltration, carious lesions', 'resin infiltration, caries lesions', 'caries infiltration' and 'Icon DMG' with the 'clinical trial' filter activated. Among the 14 articles originally identified with these keywords, only 4 (related to 3 different in vivo studies) were included for this review.

RESULTS

All 4 articles reported on proximal caries lesions. One study had been conducted on 48 high-caries-risk children while the other 3 (n = 22, 22 and 39, respectively) concerned moderate- and low-caries-risk adolescents and adults. The quality of the studies was assessed to be high with respect to randomization, split-mouth design and blinding. All the included studies showed significant differences in caries progression between test and control/placebo groups, indicating that RI may inhibit the carious process.

CONCLUSION

This systematic review revealed that RI appeared to be an effective method to arrest the progression of non-cavitated caries lesions. Additional, long-term studies are required.

[White spot lesions and orthodontic treatment. Prevention and treatment]

Decalcification of the enamel surface adjacent to fixed orthodontic appliances, in the form of white spot lesions, is a common and frequent well-known side-effect of orthodontic treatment. Fixed appliances and the bonding materials increase the retention of biofilm and encourage the formation of white spot lesions. Management of these lesions begins with a good oral hygiene regime and needs to be associated with use of fluoride agents (fluoridated toothpaste, fluoride containing mouth rinse, gel, varnish, bonding materials, elastic ligature), CPP-ACP, antiseptics, LASER, tooth whitening, resin infiltration, micro-abrasion. The purpose of this review is to access the direct evidence regarding the prevention and management of white spot lesions during and after orthodontic treatment.