Potencial da infiltracao

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November 2012 DentalUpdate 623
Cariology
The Potential for Resin Infiltration 
Technique in Dental Practice
Abstract: Caries infiltration is a micro-invasive treatment to arrest non-cavitated caries lesions. The method is based on the penetration of 
low-viscosity light-curing resins, so called infiltrants, into the pores within the enamel lesion. That way, diffusion pathways for cariogenic 
acids are occluded, resulting in a reduction or even arrest of lesion progression. A positive side-effect of caries infiltration is that lesions 
change their optical properties and appear similar to sound enamel. Therefore, caries infiltration can also be used to camouflage 
aesthetically disfiguring white spot lesions on buccal surfaces.
Clinical Relevance: Resin infiltration is a micro-invasive treatment to arrest and to camouflage non-cavitated proximal caries lesions that 
virtually bridges non-invasive and restorative treatment options.
Dent Update 2012; 39: 623–628
The caries decline observed in many nations 
in the past decades has led to the clinical 
observation that today’s adolescents and 
young adults present many fewer open 
cavities compared with the generation of 
their parents or grandparents. However, a 
high number of caries lesions in earlier stages, 
particularly in proximal surfaces, can still 
be observed in these patients. This shift to 
earlier stages should not be misinterpreted 
to suggest that these individuals do not 
need therapeutic (non-invasive) intervention 
anymore, because many of the non-cavitated 
lesions progress to cavitated stages.1,2 Rather, 
these epidemiological changes present a 
challenge not only to diagnose but also to 
manage these lesions to avoid their further 
progression.
The treatments of choice for 
early non-cavitated caries lesions are non-
invasive interventions that support the 
natural repair processes of the oral cavity. 
However, these approaches usually depend 
on good compliance and a sustained change 
of a patient’s habits (eg oral hygiene, diet) 
and therefore seem to have only limited 
effectiveness. Invasive treatment may bring 
the tooth into a ‘death spiral of restorations’ 
in which more and more tooth tissue gets 
lost when restorations are often replaced, 
even resulting in loss of tooth vitality or even 
extraction of the tooth.3 For this reason, 
the first restorative intervention should be 
postponed as long as possible. Particularly for 
proximal lesions, the collateral damage during 
cavity preparation is high because relatively 
large amounts of sound tissue have to be 
removed to get access to the lesion. Therefore, 
for proximal caries lesions radiographically 
extending around the enamel dentine 
junction, the treatment decision is often 
difficult. Similar to caries sealing of occlusal 
surfaces, caries infiltration aims to bridge 
non-invasive and restorative interventions for 
proximal caries lesions, providing a minimum 
of tissue destruction, with the objective of 
arresting the caries process (Figure 1).
Caries infiltration – principle
The aim of caries infiltration is 
to occlude the pores within the lesion body 
within enamel of non-cavitated caries lesions 
with special low-viscosity light-curing resins, 
so-called infiltrants. That way, diffusion 
pathways for cariogenic acids are blocked, 
resulting in a reduction, or even arrest, of 
lesion progression (Figure 2). To enable 
penetration of the infiltrant into the lesion 
body, first the covering pseudo-intact surface 
layer, as a result of the remineralization 
processes, has to be removed.4 This can be 
achieved by etching the lesion for 2 minutes 
with 15% hydrochloric acid gel.5 Subsequently, 
the lesion has to be properly desiccated to 
allow capillary action to soak the resin into 
the lesion body. Finally, the infiltrant must 
be applied for sufficient time to infiltrate the 
lesion deeply and be light-cured.
The limited access to the proximal 
surfaces is a challenge for any therapeutic 
intervention on this caries predilection 
site. Therefore, in contrast to caries sealing 
where a resin coating is created on the lesion 
surface, for caries infiltration all resin excess is 
removed from the surface before light-curing. 
In the narrow and hardly accessible proximal 
area, resin layers on the lesion surface are hard 
to control clinically and might even promote 
plaque stagnation and gingival inflammation. 
Therefore, for caries infiltration the resinous 
diffusion barrier is solely created within the 
Hendrik Meyer-Lueckel
Sebastian Paris
Sebastian Paris, DDS, PhD, Associate 
Professor, Clinic for Conservative 
Dentistry and Periodontology, School 
of Dental Medicine, Christian-Albrechts-
Universität zu Kiel, Germany and 
Hendrik Meyer-Lueckel, DDS, PhD, 
MPH, Head of Department, Department 
of Operative Dentistry, Periodontology 
and Preventive Dentistry, RWTH Aachen 
University, Germany.
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Cariology
624 DentalUpdate November 2012
lesion body, which greatly simplifies clinical 
application.
 
Proximal application
Resin infiltration may be indicated 
for active non-cavitated caries lesions 
extending radiographically into the inner 
half of enamel (E2) up to the outer third of 
dentine (D1). In the commercially available 
treatment kit for proximal infiltration (Icon®, 
DMG, Hamburg, Germany), all necessary 
materials are included, with the exception 
of rubber dam. To allow application without 
temporary tooth separation for some days,6 
special foil applicators have been designed. 
These applicators consist of two thin, welded 
foils. One foil (white side of the applicator; 
Figure 3d) protects the adjacent tooth from 
contamination, whereas the other foil (green 
side) has a perforation and thus allows 
the discharge of the agents in the area of 
the lesion. The treatment steps for caries 
infiltration of proximal lesions are illustrated 
in Figure 3.
The efficacy of caries infiltration 
has been investigated in clinical trials with 
a split-mouth design. In a study on German 
young adults with medium caries risk, 4% of 
infiltrated lesions progressed radiographically 
within the three-year follow-up period, 
whereas in the control group (risk-related 
non-invasive intervention only) 46% of 
lesions progressed.7,8 In a study on children 
with high caries risk in Greenland, 23% of 
infiltrated lesions in primary molars showed 
radiographic lesion progression, whereas 
for the control lesions progression of 62% 
could be observed within one year. In this 
study, fluoride varnish was applied at baseline 
and after six months in both groups.9 These 
results on randomized clinical trials are 
promising, even if further research is needed 
to evaluate the efficacy of resin infiltration 
when performed by dental practitioners 
in daily practice. In clinical studies, more 
Figure 1. The various stages of the caries process of proximal lesions and appropriate local therapeutic 
interventions. Caries infiltration is indicated for proximal lesions radiographically extending into the 
inner half of enamel (E2) up to the outer third of dentine (D1) where non-invasive interventions often 
fail and restorative options would go along with the destruction of high proportions of sound dental 
hard tissues. Modified from Meyer-Lueckel et al14 and Paris et al.15
Figure 2. During caries infiltration the porosities 
of non-cavitated caries lesions (red dots) are 
occluded with resin (green). Hereby, the diffusion 
pathways for cariogenic acids are blocked, 
resulting in a reduction or even arrest of lesion 
progression.15
lesion progressions were observed for caries 
radiographically extending into the outer 
third of dentine compared with lesions 
extending just into enamel. This suggests that 
(at least some) treatment failures might be 
caused by inadvertently infiltratingcavitated 
lesions which are more frequent in deeper 
caries stages, since these caviations can only 
partially be filled with the resin.10
As with all other therapeutic 
interventions that aim to arrest lesion 
progression, such as fluoridation or sealing, 
the only way to assess the success of proximal 
resin infiltration is to monitor the lesion 
radiographically over time. For proximal caries 
lesions, high quality bitewing radiographs 
are the most accurate and reliable method 
to monitor lesion progression. Intervals 
between radiographs should be adjusted to 
the individual caries risk. Special care should 
be taken to align the sequential radiographs 
similarly, since varying alignments between 
two radiographs might result in a misleading 
interpretation of caries progression or 
regression, even when the lesion is stable.
 
Aesthetic effect
A positive side-effect of resin 
infiltration is that fully infiltrated lesions 
change their whitish opaque appearance 
and look similar to sound enamel.11 White 
spot lesions appear chalky due to the high 
difference in the refractive indices (RI) of 
apatite crystals (RI: 1.62) and the medium 
within the lesion pores, which is either a 
watery medium (RI: 1.33) or air (RI: 1.0).12 
The higher the difference of RI, the more 
visible light is scattered between the crystals 
and the more whitish the lesion looks. For 
this reason, desiccated lesions look even 
whiter than wet ones. When the pores are 
infiltrated with resin (RI: 1.52) light scattering 
is significantly reduced because the difference 
in RI compared with the pores of the apatite 
crystals is rather low and thus the lesion 
appears similar to sound enamel.
Buccal white spot lesions are 
frequently observed after treatment with fixed 
orthodontic appliances. After de-bonding 
of the brackets the lesions can be arrested, 
usually with non-invasive interventions 
like biofilm control and local fluoridation. 
However, because remineralization is usually 
limited to superficial layers, only rather 
shallow lesions disappear. Most lesions remain 
as enamel scars even when they are arrested 
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November 2012 DentalUpdate 625
Cariology
and aesthetic improvement can often only be 
achieved using quite invasive interventions, 
like enamel micro-abrasion or composite 
restorations. Resin infiltration can be used 
to camouflage active non-cavitated buccal 
Figure 3. Resin infiltration of a proximal caries lesion.15 (a) The bitewing radiograph indicates a proximal lesion on the mesial surface of tooth UL6. (b) 
Clinically, the lesion is hardly visible but bleeding of the adjacent papilla on gentle probing is a predictor for lesion activity. (c) After tooth cleaning, rubber 
dam is applied to avoid contamination of the lesion with blood, saliva, or crevicular fluid. A cow-horn ended explorer is used to probe the proximal surface 
gently for possible cavitation. (d) After separation of the teeth with a special flattened wedge, a foil applicator is inserted into the proximal area using a 
sawing motion. Although the tooth separation causes a slightly unpleasant feeling of pressure, usually no anaesthesia is necessary. (e) The etching gel 
(Icon®etch) is injected into the applicator and spreads over the lesion surface. (f) After 2 minutes the etching gel is rinsed off properly and the lesion is 
desiccated with compressed air. (g) In order to desiccate the lesion further ethanol (Icon®dry) is applied and (h) subsequently thoroughly evaporated with 
compressed air. (i) The infiltrant is applied with another foil applicator. (j) After 3 minutes excess resin is removed from the lesion surface by air blowing 
and the use of dental floss. (k) The infiltrated resin is hardened with blue light for 40 seconds. In order to infiltrate pores that possibly emerge within the 
infiltrated lesion due to polymerization shrinkage, steps i–k are repeated, but for the second application of the resin 1 min is sufficient. (l) The result after 
removing the rubber dam.
lesions that are perceived as aesthetical 
impairment. The treatment steps are similar to 
the proximal application (Figure 4).
In a South Korean study, 61% 
of post-orthodontic caries lesions could be 
masked completely using caries infiltration 
and a partial masking effect could be 
observed in another 33% of lesions.13
The masking effect can be 
insufficient, if only an incomplete removal 
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Cariology
626 DentalUpdate November 2012
Figure 4. Resin infiltration of post-orthodontic 
white spot lesions.15 (a) Buccal white spot 
lesions some weeks after removal of orthodontic 
appliances. (b) After application of light-curing 
dam (OpalDam; Ultradent) the etching gel 
(Icon®etch) is applied on to the buccal surfaces 
for 2 minutes and subsequently rinsed off. (c) 
After drying the lesions with compressed air, 
ethanol (Icon®dry) is applied. The aesthetic result 
can be estimated by the speed with which lesions 
change their appearance during re-wetting. (d) 
Lesions are properly desiccated with compressed 
air. Most of the brownish discolorations could be 
eroded together with the surface layer. (e) The 
infiltrant (Icon®infiltrant) is applied for 3 minutes. 
(f) Excess resin is removed with cotton rolls and 
(g) the resin is light-cured for 40 seconds. In 
order to infiltrate pores that might have occurred 
due to polymerization shrinkage, steps e–g are 
repeated once with a resin application time of 
1 minute. (h) Polishing disks (Sof-lex™ discs, 3M 
ESPE) are used to remove the oxygen-inhibited 
resin layer and to polish the roughened enamel 
surface. (i) Satisfying aesthetic result after 
treatment.
occurs. Because rather inactive lesions 
exhibit quite thick surface layers, it is often 
necessary to repeat the etching step until 
the surface layer is completely removed. 
During each application, for 2 minutes, an 
approximately 30 µm thick enamel layer is 
eroded by the HCl-gel. To check if the surface 
layer is completely removed, water or ethanol 
should be dropped on the desiccated lesions. 
When the penetration of these liquids into 
the desiccated lesion results in a quick 
change (within the first 3–5 seconds) in 
lesion appearance (rapid change of refractive 
index within the pores), this effect can also 
be expected during the application of the 
infiltrant and the procedure can be continued. 
If this effect fails to appear, the etching 
should be repeated until the masking effect 
can be observed. Of course, the amount of 
enamel erosion should be balanced with the 
aesthetic impairment caused by the lesions 
and alternative therapeutic options such as 
remineralization and restorations should be 
considered.
For the masking of developmental 
defects like molar-incisor-hypomineralization, 
hypomineralization of a permanent tooth 
after apical trauma of the deciduous tooth 
or fluorosis, resin infiltration cannot be 
recommended at present, because these 
lesions cannot be that easily infiltrated.13 
Moreover, in contrast to the resin infiltration 
of caries, the infiltration of developmental 
defects has not been thoroughly scientifically 
investigated.
Caution is also advised with 
cavitated lesions. Nonetheless, infiltration of 
enamel parts of caries lesions can be easily 
combined with composite restorations. Since 
the infiltrant has similar chemical properties 
to bonding agents, composite resins can 
be placed on to and adjacent to infiltrated 
lesions. Cavities extending into dentine, 
however, have to be restored conventionally 
with dentine adhesives, because the infiltrant 
is far too hydrophobic to be used for this 
purpose. 
Summary
Cariesinfiltration follows the 
principle of caries sealing. However, the 
resinous diffusion barrier is created inside the 
lesion but not on the lesion surface, whereby 
clinical application is simplified. Clinical 
studies have shown that caries infiltration in 
combination with non-invasive measures is 
of the pseudo-intact surface layer is 
accomplished. In this case, only incomplete 
infiltration of the underlying lesion body 
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Cariology
628 DentalUpdate November 2012
more efficacious to arrest proximal lesions 
extending radiographically up to the outer 
third of dentine compared with non-invasive 
measures alone. Thus, particularly for proximal 
caries lesions radiographically extending 
around the enamel-dentine junction, caries 
infiltration is efficacious to slow down or even 
arrest caries progression in order to postpone 
or even avoid the first restorative intervention. 
A positive side-effect of caries infiltration 
is that infiltrated lesions lose their whitish 
appearance. Buccal white spot lesions can 
be arrested with non-invasive interventions 
but often remain as whitish or brownish 
enamel scars which are perceived as being 
unaesthetic. Here caries infiltration can be 
used to camouflage these defects, combining 
hard tissue preservation on the one hand 
and a good predictability of the treatment 
outcome on the other hand. 
Disclosure statement
The two authors receive a research 
grant and royalties from DMG, Hamburg. 
This article is partly based on a previous 
publication: Paris, Dörfer, Meyer-Lückel: 
Kariesinfiltration. Zahnärztliche Mitteilungen 
2011; 101: 38–41.
 
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