Resin Infiltration Technique: Pediatric Applications€¦ · earlier stages of destruction, and...

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Continuing Education

Resin InfiltrationTechnique: Pediatric

ApplicationsAuthored by Carla E. Cohn, DMD

Upon successful completion of this CE activity 1 CE credit hour will be awarded

Volume 33 No. 10 26

ABOUT THE AUTHORDr. Cohn graduated from the Universityof Mani toba in 1991 and went on tocomplete a postgraduate internship inpediatric dentistry at Health Sci enceCentre Children’s Hospital in Winnipeg,Manitoba, Canada. Her private practice

at Kids’ Dental is focused on prevention and the growth anddevelopment of a cavity-free generation. She has also beena part-time clinical instructor of pediatric dentistry at theUniversity of Manitoba for the last 20-plus years. She is amember of several dental organizations, including thefollowing: Manitoba Dental Associ ation, Manitoba DentalAlumni Association, Cana dian Dental Association,Winnipeg Dental Society, Women’s Dental Group, Shapersof Dentistry, Catapult Elite, Dental Team Concepts,American Academy of Pediatric Den tistry, and theCanadian Dental Institute. She has served on the Dean’sFaculty of Dentistry Ad visory Board at the University ofManitoba Faculty of Dentistry since its inception in 2010.She is active as a current board member for the ManitobaDental Associ ation and will be its incoming president in2016. She is active in continuing education, and she haspublished several clinical articles in both American andCanadian dental journals. She can be reached via e-mail atthe following address: [email protected].

Disclosure: Dr. Cohn receives honorarium support fromDMG America for some educational programs, but shereceived no financial compensation for this article.

INTRODUCTIONAs dental practitioners, we have many restorativealternatives available that are changing and improving at arapid pace. For those of us who care for children, theproperties and requirements of theses options are of utmost

importance, given the different stages of development, bothdentally and behaviorally, that present to us on a daily basis.The guidelines on pediatric restorative dentistry that are putforth by the American Academy of Pediatric Dentistry arepublished in order to assist practitioners in the restorativecare of their patients. Many alternative restorative treatments,based upon the most current literature, are discussed inthese guidelines. At the outset of the guideline, it is stressedthat restorative treatment and comprehensive treatmentplans must take the following factors into consideration:developmental age, caries risk assessment, oral hygiene,and patient and parent compliance.1 With knowledge ofthese factors, as well as knowledge of current materialsavailable to us as clinical practitioners, we can then makedecisions on the best available materials and techniques forour individual patients.

Differences in Patients and Dental MaterialsNot all patients are equal, and most certainly not all restorativematerials and techniques are equal. We have a very widerange available to us, from hydrophilic to hydrophobicmaterials, from forgiving materials to more technique sensitiveones, and from temporary to longer-lasting restorative choices.Our clinical decisions must be based upon both an intimateknowledge of our pediatric patients’ requirements andbehavior and, in addition, taking into account their parents’requirements and behavior. Furthermore, our knowledge mustbe as intimate as to the requirements and behaviors of thosematerials and techniques available to us. Finally, in order totake advantage of all that dentistry has to offer our patients, wemust remain both open-minded to new and emergingtechnologies, and equally demanding that these are supportedby sound scientific data.

Conservative Treatment of Incipient Lesions: ResinInfiltrationAs clinicians, we are often presented with patients whohave incipient lesions. These incipiencies can be diagnosedinterproximally radiographically, or with many of our newertechnology caries scanning devices.2 Excellent radio -graphic techniques and emerging technologies allow us theopportunity to diagnose and treat incipiencies in a moreconservative manner. We are able to identify lesions at


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Resin Infiltration Technique:Pediatric ApplicationsEffective Date: 10/1/2014 Expiration Date: 10/1/2017

earlier stages of destruction, and thus, we must be welleducated in methods to treat these lesions in the mosteffective way possible.

A resin infiltration system (Icon [DMG America]) wasrecently introduced for the treatment of incipient lesions,either in the proximal or smooth surface location, using aninfusion of a highly fluid unfilled light-cured resin. It is arestorative method that can be used equally well, with greatsuccess, in both primary and permanent teeth. Successfultreatment of either proximal or smooth surface lesionsresults in the repair of the existing lesion and in haltingfurther progression by stabilizing the surrounding toothstructure.3,4 Recent studies have shown efficacy inprevention of further demineralization.5 In addition,randomized clinical trials in proximal lesions of permanentteeth have demonstrated significant halting of theprogression of lesions after a 3-year period.6 Furtherstudies concluded that treatment with resin infiltration inconjunction with fluoride varnish is promising for controllingproximal lesions.7 In fact, teeth treated with resin infiltrationshowed higher Vickers hardness values than untreatedteeth.8,9 Due to the efficacy of the method of resininfiltration, tooth structure is saved, local anesthesia isavoided, and the patient experience is better with long-termcosts for restoration of the lesion also significantlydecreased.10-12 The method of resin infiltration has beenwell researched, documented, and is clinically proven.

Synopsis of the Procedural StepsThe procedure is simple to follow and all materials andequipment are in cluded in the Icon kit. The steps include:isolation of the tooth, application of an etchant (Icon Etch),application of the drying agent (Icon Dry), 2 applications ofthe infiltrant resin (Icon Infiltrant), and light curing at eachinfiltrant step. Key to success of the technique is strictadherence to manufacturer’s instructions. The amount ofscientific literature behind each step of the technique isvast. For example, composition, timing, and frequency ofrepetition of the Icon Infiltrant step is cited in severalstudies, and the most effective practice is examined indetail.13-15 The same in-depth research has been executedfor the Icon Etch,16,17 Icon Dry, and the light-curing steps.

Factors for SuccessThere are a few points to follow in order to have asuccessful treatment. First and foremost, when treatingproximal lesions, there must be sufficient spaceinterproximally to passively fit the applicators. This iseasily achieved by placing an orthodontic separator for atime period preoperatively. The duration of separatorplacement will depend upon the tightness of theinterproximal contact; in some cases, 15 minutes issufficient, and in other situations, a few days of separationare needed. Remember that the etchant, drying agent,and infiltrant must all be able to flow interproximallyunimpeded.

Also important to success of the resin infiltrationtechnique is the proper isolation of the area to be treated,since the materials are hydrophobic. Contamination withsaliva or blood will result in failure of penetration of thematerials into the lesion, and ultimately failure of theprocedure. Excellent isolation with a rubber dam isoptimal. Since the procedure takes approximately 12 to 14minutes to complete, a precooperative or uncooperativechild is not a candidate for this resin infiltration technique.

One of the challenges with this procedure is that thematerial is radio lucent and, as such, cannot be detectedon traditional radiographic examination. This does notmean that the lesion cannot be evaluated radiographically;rather that the way the clinician monitors the lesion will bedifferent than the current paradigm. Specifically, in termsof radiographic assessment, one would monitor whetherthe lesion is progressing ra dio graphically at subsequentrecalls. Current advancements in diagnostic technologieswould eliminate this difficulty. These include, but are notlimited to, digital subtraction radiography, fluorescence,electronic frequency, and ultrasound.2 However, achallenge still remains for those patients who leave ouroffices and have traditional radiographic examinationscompleted at a new and uninformed office, thus having theinfiltrated lesions mistaken for caries. Cards that indicaterecord of treatment are provided by the company and canbe given to the patient, but the risk of mistaken diagnosisstill remains for those who fail to keep the cards and passthis information on to their new dental office.


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Resin Infiltration Technique: Pediatric Applications

CASE REPORTSCase 1: Resin Infiltration of an Incipient Carious LesionA 5-year-old male patient presented with interproximallesions. Since he was compliant and cooperative, it wasdetermined that he would be a suitable candidate for resininfiltration. In addition, his parents were of a high dental IQand they understood the importance of regular follow-up.

Clinical Protocol: Separation—An orthodontic separatorwas placed 15 minutes prior to treatment to create someseparation of the teeth prior to placement of the separatingwedge (Figure 1). After isolation, the orthodontic separatorwas removed and the green wedge placed interproximally(Figure 2). The wedge should be placed at a straight angle,so as not to cause any harm to the gingival tissues. It isplaced gently until the first resistance is felt. Leave thewedge in place for several seconds before slowly advancingfurther, thereby achieving the maximum separation possible.Your patient will feel this pressure at first; following a few

seconds, pressure anesthesia will overcome the initiallyuncomfortable sensation.

Etchant—Attach the applicator tip to the syringe of theIcon Etch, which is a 15% hydrochloric acid gel. The greenside of the foil is the active side, with perforations to allowfor dispensing the Icon Etch. The syringe is placedinterproximally (Figure 3) and the etchant is dispensed bytwisting the plunger in a screw-like fashion. The Icon Etch isleft in place for 2 full minutes (Figure 4), allowing for someagitation of the acid while it is in contact with the proximalsurface. Next, wash for 30 full seconds and air dry with oil-free air.

Drying—Icon Dry, a 99% ethanol solution, is applied(Figure 5) and left in place for a full 30 seconds. The area isthen dried with oil-free air.

Infiltration—At this point, remove direct overhead lightsource to avoid any premature curing of the infiltrant. Attachan applicator tip to the Icon Infiltrant and apply infiltrant by


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Figure 1. Case 1. Preoperative separatorplacement of a 5-year-old male patient withan incipient carious lesion indicated fortreatment with resin infiltration (Icon kit [DMGAmerica]).

Figure 2. Preoperative wedge placement. Figure 3. Applicator placement.

Figure 4. Icon Etch application. Figure 5. Icon Dry application. Figure 6. Icon Infiltrant application.

twisting the syringe (Figure 6). Leave theinfiltrant undisturbed for 3 minutes. Maintain amoist surface by continuing to add infiltrantperiodically during this time period, ensuringthat an adequate supply of resin to the lesion.Remove any excess material and light cure for40 seconds. Repeat the infiltration processwith a new applicator tip. Leave undisturbedfor one minute, remove excess again, andthen light cure an additional 40 seconds.

Finish—The finishing step is ac complishedby removing any excess infiltrant material withfloss and hand instruments.

Case 2: Treating White Spot LesionsOne extraordinary feature of this infiltrant material is that ithas the same refractive index as enamel. This is a greatbenefit because once ap plied, it will mask out most smoothsurface white spot lesions, making them effectivelydisappear (or at least with much improved aesthetics, insome cases). Although this is an irrelevant point forinterproximal lesions, it is very relevant for smooth surfacelesions. It effectively wipes out the white spot lesion whenplaced on smooth surfaces. This allows us to treat post-orthodontic white spot lesions—and, in fact, any white spotlesions that are a result of demineralization—bothconservatively and effectively.18

A 3-year-old female patient presented with anterior smoothsurface white spot lesions (Figure 7). She was very compliantand cooperative. Resin infiltration was carried out in the exactsame manner as in the case described previously. An excellentresult was obtained for an otherwise very rapidly spreadingsmooth surface white spot lesion (Figure 8). Note: Theprocedures for resin infiltration can be coded as D2990. Thisnew ADA coding was adopted in 2013.

IN SUMMARYThe resin infiltration technique is simple to understand andto master, and is very beneficial to the patient as well asrewarding for the doctor. As demonstrated on the 2 minicases presented herein, it is a very minimally invasivetechnique that gives the clinician a “no anesthesia, nodrilling” option for the patient.

REFERENCES1. American Academy of Pediatric Dentistry. Clin ical

Affairs Committee—Restorative DentistrySubcommittee. Guideline on pediatric restorativedentistry. Pediatr Dent. 2013;35:226-234.

2. Mital P, Mehta N, Saini A, et al. Recent advances indetection and diagnosis of dental caries. Journal ofEvolution of Medical and Dental Sciences.2014;3:177-191.

3. Paris S, Hopfenmuller W, Meyer-Lueckel H. Resininfiltration of caries lesions: an efficacy randomizedtrial. J Dent Res. 2010;89:823-826.

4. Martignon S, Tellez M, Ekstrand K, et al. Pro gression ofactive initial-proximal lesions after infiltration, sealing orflossing-instructions. J Dent Res. 2010;89(special issueA). Abstract 2519.

5. Paris S, Meyer-Lueckel H. Progression of resin-infiltrated artificial enamel lesions in situ. Caries Res.2009;43:228. Abstract 136.

6. Martignon S, Ekstrand KR, Gomez J, et al.Infiltrating/sealing proximal caries lesions: a 3-yearrandomized clinical trial. J Dent Res. 2012;91:288-292.

7. Ekstrand KR, Bakhshandeh A, Martignon S. Treatmentof proximal superficial caries lesions on primary molarteeth with resin infiltration and fluoride varnish versusfluoride varnish only: efficacy after 1 year. Caries Res.2010;44:41-46.

8. Nobrega D, Perry R, Kaminsky E, et al. Uniquetreatment of early caries and white spot lesions. JDent Res. 2010;89(special issue A). Abstract 2522.

9. Palamara JE, Tyas M, Burrow MF. Resin infiltratedartificial caries lesions examined by polarized lightmicroscopy and micro-hardness tests. Ham burg,Germany: DMG; 2010.

10. Mendes Soviero V, Soares de Oliveira B, Aparecida deLima Ferreira M, et al. Aceitabilli dade do tratamento


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Figure 7. Case 2. Pre-op photo of thesmooth surface white spot lesion on thepatient’s left primary central incisor.

Figure 8. Post-op photo. Note the effectivedisappearance of the white spot lesion byusing the Icon resin infiltration technique.

micro-invasivo para lesões proximais não cavitadasem crianças [Accepta bility of micro-invasive treatmentfor non-cavitated proximal lesions in children]. FC 76,ID 6518, FDI, Salvador de Bahia, Brazil; September 6to 10, 2010.

11. Schwendicke F, Meyer-Lueckel H, Stolpe M, et al.Costs and effectiveness of treatment alternatives forproximal caries lesions. PLoS One. 2014;9:e86992.

12. Alkilzy M, Splieth CH. Clinical applicability and safetyof resin infiltration of proximal caries. Caries Res.2010;44:171-248. Abstract 49.

13. Paris S, Soviero VM, Seddig S, et al. Penetrationdepths of an infiltrant into proximal caries lesions inprimary molars after different application times in vitro.Int J Paediatr Dent. 2012;22:349-355.

14. Paris S, Meyer-Lueckel H. Influence of applicationfrequency of an infiltrant on enamel lesions. J DentRes. 2008;87(special is sue B). Abstract 1585.

15. Paris S, Meyer-Lueckel H, Cölfen H, et al. Pene trationcoefficients of commercially available andexperimental composites intended to infiltrate enamelcarious lesions. Dent Mater. 2007;23:742-748.

16. Meyer-Lueckel H, Paris S, Kielbassa AM. Surface layererosion of natural caries lesions with phosphoric andhydrochloric acid gels in preparation for resininfiltration. Caries Res. 2007;41:223-230.

17. Paris S, Dörfer CE, Meyer-Lueckel H. Surfaceconditioning of natural enamel caries lesions indeciduous teeth in preparation for resin infiltration. JDent. 2010;38:65-71.

18. Cohn C. ICON treatment of post orthodontic white spotlesions. Oral Health. 2013;103:48-56.


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POST EXAMINATION QUESTIONS

1. The guidelines on pediatric restorative dentistry thatare put forth by the American Academy of PediatricDentistry are published in order to assistpractitioners in the restorative care of their patients.

a. True b. False

2. Successful treatment of either proximal or smoothsurface lesions results in the repair of the existinglesion and in halting further progression by stab-ilizing the surrounding tooth structure; however,recent studies have not shown efficacy in preventionof further demineralization.

a. True b. False

3. Further studies concluded that treatment with resininfiltration in conjunction with fluoride varnish ispromising for controlling proximal lesions.

a. True b. False

4. The Icon (DMG America) material is radiopaque and,as such, can be easily detected on traditionalradiographic examination.

a. True b. False

5. The infiltrant material (Icon) has the same refractiveindex as enamel and, once applied, it will mask outmost smooth surface white spot lesions.

a. True b. False


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Resin Infiltration Technique: Pediatric Applications€¦ · earlier stages of destruction, and...

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