Microhardness increasing

Prévia do material em texto

The Journal of EVIDENCE-BASED DENTAL PRACTICE
REVIEW ARTICLE
EFFECT OF RESIN INFILTRATION
TECHNIQUE ON IMPROVING SURFACE
HARDNESS OF ENAMEL LESIONS: A
SYSTEMATIC REVIEW ANDMETA-ANALYSIS
MEHRNAZ ZAKIZADE, DDSa, AMIN DAVOUDI, DDSb, ALI AKHAVAN, DDS, MSc, AND
FARINAZ SHIRBAN, DDS, MSd
aDepartment of Orthodontics, Dental School, Isfahan University of Medical Sciences, Isfahan, Iran
bDental Implants Research Center, Department of Prosthodontics, Dental School, Isfahan University of Medical Sciences, Isfahan, Iran
cDental Materials Research Center, Department of Endodontics, Dental School, Isfahan University of Medical Sciences, Isfahan, Iran
dDental Research Center, Department of Orthodontics, Dental School, Isfahan University of Medical Sciences, Isfahan, Iran
CORRESPONDING AUTHOR:
Amin Davoudi, School of Dentistry,
Isfahan University of Medical
Sciences, Hezarjarib St, Isfahan, Iran.
E-mail: Amindvi@yahoo.com
KEYWORDS
Deminarilzation, Microhardness,
Resin infiltration, Surface hardness,
White spot lesion
Conflict of Interest: The authors have
no actual or potential conflicts of
interest.
Received 24 November 2018;
revised 31 July 2019; accepted 5
November 2019
J Evid Base Dent Pract 2020: [101405]
1532-3382/$36.00
ª 2020 Elsevier Inc.
All rights reserved.
doi: https://doi.org/10.1016/
j.jebdp.2020.101405
ABSTRACT:
Objective
White spot lesion (WSL) is recognized as the first clinical sign of enamel caries; it is
a very critical phase because it can be prevented from progression to frank caries
by changing the surrounding destructive environment. The present study was
undertaken to systematically review the effect of resin infiltration (RI) technique on
surface hardness (SH) of WSL.
Methods
Five electronic databases were searched with proper key words. Related titles
and abstracts, up to October 2018, were screened, selected, and subjected to
quality assessments. After collecting data, meta-analyses were carried out to
compare the effect of RI with untreated WSL and sound enamel by using the
STATA software.
Results
A total of 4567 articles were included in the study after initial search. Finally, 10
studies were reliable enough in methodology to be included in the study. Met-
adata analyses, carried out on 7 studies that compared SH of RI group with un-
treated samples, showed a significant increase in SH with 3.66 mean difference
(95% confidence interval 5 2.56‒4.77, Q value 5 36.07, I2 5 83.4%). However,
meta-analysis on 4 studies that compared SH of RI with sound enamel showed a
significant decrease in SH with 22.35 overall mean difference (95% confidence
interval 5 23.91–0.98, P 5 .00, Q value 5 31.75, I2 5 90.6%).
Conclusion
The RI technique can enhance SH of WSL; however, regaining the SH of RI-
treated WSLs similar to sound enamel is doubtful. Application of RI is more
effective than other methods, including application of fluoride, enamel pro-
varnish, adhesive, and colloidal silica infiltration for enhancing SH of WSLs.
INTRODUCTION
Dental caries is a multifactorial disease that is mostly characterized by
structural mineral loss of the enamel beneath an apparently intact surface
June 2020 1
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https://doi.org/10.1016/j.jebdp.2020.101405
https://doi.org/10.1016/j.jebdp.2020.101405
Table 1. Applied Medical Subject Headings and non- Medical
Subject Headings keywords.
Population “Teeth” OR “caries” OR “dental caries” OR
“initial caries” OR “Smooth surface lesion” OR
“subsurface demineralization” OR “white spot
lesion” OR “incipient caries” OR “non cavitated
lesion” OR “incipient lesion” OR
“Developmental Defect” OR “Molar Incisor
Hypomineralization” OR “Tooth
demineralization” OR “enamel caries” OR
“enamel Hypoplasia” OR “dental enamel
Hypoplasia” OR “enamel Hypocalcification” OR
“initial caries lesions” OR “artificial enamel
lesions” OR “natural enamel lesion” OR “caries
like lesion”
Intervention “Resin Infiltration” OR “Icon Resin Infiltration”
OR “Commercially Available Infiltrant” OR
“Microinvasive Dentistry” OR “Minimally
Invasive Dentistry” OR “Minimum Intervention
Dentistry” OR “Resin Infiltrant” OR
“Experimental Resin Infiltrant” OR “Synthetic
Resin Infiltrant” OR “Low Viscosity Resin
Infiltrant” OR “Infiltration” OR “Infiltrant” OR
“Infiltrating”
Comparison “Placebo” OR “Placebos” OR “Microinvasive
Treatment” OR “Therapeutics” OR “Fluoride”
OR “Fluorides” OR “Sodium Fluoride” OR “Tin
Fluoride” OR “Stannous Fluoride” OR “Fluoride
Varnish” OR “Fluoride Gel” OR “Fluoride
Application” OR “Fluoride Therapy” OR
“Fluoride Application” OR “Fissure Sealant” OR
“Pit And Fissure Sealant” OR “Sealing” OR
“Surface Sealing” OR “Control Group” OR
“Control Groups” OR “Cpp-Acp” OR “Casein
Phosphopeptide-Amorphous Calcium
Phosphate Nanocomplex” OR “Mi Paste” OR
“Mi Paste Plus” OR “Colloidal Silica” OR
“Finishing” OR “Polishing” OR “Dental
Polishing” OR “Microabrasion” OR “Enamel
Microabrasion” OR “Preventive Dentistry” OR
“Operating Dentistry” OR “Sound Enamel” OR
“Adhesive System” OR “Nano Hydroxy Apatite
Paste”
Outcome “Surface Texture” OR “Surface Microhardness”
OR “Enamel Surface Properties” OR
“Mechanical Properties” OR “Surface
Characteristics” OR “Surface Properties” OR
“Hardness” OR “Microhardness” OR “Surface
Hardness” OR “Vickers Test” OR “Knoop Test”
The Journal of EVIDENCE-BASED DENTAL PRACTICE
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layer.1 As a result, “white spot lesion” (WSL), which is the
first clinical sign of enamel caries, is produced and
recognized by its whitish appearance because of
increased porosity of the enamel surface.2 This phase of
the lesion is very important because it can be reversed
from the cavitation process if favorable environmental
conditions can be provided.3
Different treatment strategies have been introduced by
researchers to prevent progression of WSL and reestablish
the enamel structure. Chemical treatment protocols are
mainly based on remineralization of the enamel with the
aid of fluoride-derived agents or topical treatment with
amelogenin-derived peptide and calcium-derived prod-
ucts.4,5 Administration of resin-based materials is a me-
chanical treatment strategy for WSL, which has attracted
the attention of clinicians recently. These resin-based
materials mostly consist of triethylene glycol dimethacry-
late (TEGDMA), which has a viable ability to penetrate
into the porous structure of the lesion body, occluding
the interrod spaces of WSLs, limiting ionic diffusion, and
finally slowing the progression of the WSL.6 Hence, the
sealed lesion becomes resistant to cariogenic acid
byproducts because the resin monomers serve as a
barrier and slow down or even arrest the destruction
process of enamel.7 Preservation of sound hard
substance, permanent occlusion maintenance, and
esthetic outcomes are some other advantages of using
this treatment method.8
Evaluating surface hardness (SH) is 1 of the possible
ways to assess improvements in WSL after using resin
infiltration (RI) technique.9 Although this measurement
technique cannot directly present the mineral content
changes of the WSL during treatment with RI, it can
reflect the positive improvements in the treatment of
WSL.9 Neres et al.10 investigated SH of WSL after
using the RI technique and reported that this
technique significantly increased the SH of RI-treated
WSLs, compared to untreated ones. This finding was
consistent with other studies that highlighted the para-
mount effects of RI in increasing the SH of WSLs.11,12
Nevertheless, there is no consensus about the
effectiveness of this technique for increasing resistance
to other oral environmental challenges.9,10,12 Moreover,
surveying different effective aspects of using RI
techniques for treatment of WSL seems to be in
headlines lately.13,14 Therefore, the present study
systematically reviewed the role of RI technique on SH
of demineralized enamel or WSL by answering the
following question: “What are the effects of using RI
treatment on final SH of WSL compared to other
treatmentmethods or untreated WSLs?” The null
Volume 20, Number 2
hypothesis of this study was that using RI technique
does not improve the SH of demineralized enamel or
WSL.
Figure 1. Flowchart of searching strategy.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
MATERIALS AND METHODS
This systematic review was conducted according to the
guidelines of Preferred Reporting Items for Systematic Re-
views and Meta-Analysis (PRISMA) statement.15
Search Strategy
At the beginning, a PICO question was defined to screen
the articles on enamel lesions or WSL (P, population) which
are treated with RI technique (I, intervention), compared
with other treatment methods, or untreated WSL, or sound
enamel (C, comparison), in the improvement of SH (O,
outcome).
The key words were selected based on Medical Subject
Headings and non-Medical Subject Headings terms in
simple or multiple conjunctions (Table 1). Embase,
Scopus, Cochrane, PubMed, and ProQuest databases
were searched thoroughly, up to October 2018, with
no applied filtering or limitations except language
filter (Only studies in the English language were the
targets.) (Figure 1). Moreover, a hand search was
carried out to obtain the articles that were probably
missed.
Selection of Studies
Two authors (M.Z. and A.D.) independently searched the
databases using the mentioned search strategy and studied
the titles and abstracts of the relevant studies based on
defined inclusion and exclusion criteria (Table 2). The full
texts of each study that met the inclusion criteria were
obtained.
June 2020 3
Table 2. Inclusion and exclusion criteria.
Inclusion criteria Exclusion criteria
� English-language studies
that investigated the
effect of resin infiltration
technique on enamel
lesions in improvement
of surface hardness
� Research on at least
5 specimens in each
group
� Case reports
� Editorial letters
� Pilot studies
� Historical reviews
� Studies in languages
other than English
� Studies qualified as
“high risk” based on
adopted critical
appraisal tool
The Journal of EVIDENCE-BASED DENTAL PRACTICE
4
Assessment of the Risk of Bias
Each selected study was evaluated for inner-methodological
risk of bias according to an appraisal tool adopted from a
similar study,16 which analyzes the terms of selection,
performance, blinding of hardness evaluator, and other
sources of bias. The scoring of this scale is as follows: high
risk of bias (2), moderate risk of bias (1), low risk of bias
(0). Then, the final risk of bias of each article was
calculated and classified into 3 categories: low risk (scored
˂4), moderate risk (scored 4‒7), and high risk (scored $8).
If there was any disagreement between the 2 authors, a
third author (F.S.) took part, reviewed the disagreement,
and reported the final opinion.
After the critical appraisal of the selected studies and
excluding the high-risk studies (Figure 2), the remaining
studies were selected for final data collection. The
following data were collected for each study: authors,
publication year, sample size, the method of
demineralization, grouping, the examined tests, mean SH,
and final outcomes.
After gathering information, the data were sent to an in-
dependent statistician and epidemiologist to prepare a
metadata analysis. Two separate meta-analyses were carried
out to compare SH of the resin-infiltrated WSL with that of
untreated WSL (Figure 3) and sound enamel (Figure 4) by
using the STATA software (StataCorp, College Station, TX).
For statistical analysis, a random-effects model with a con-
fidence interval of 95% and meta-analytical method of in-
verse variance was used. This variability model is directly
related to the sample size; the larger the sample size, the
Volume 20, Number 2
lower the variability and, therefore, the greater the weight of
a given study in the meta-analysis measure estimate.
RESULTS AND DISCUSSION
A flow diagram of the search strategy is presented in
Figure 1. The initial search resulted in a total of 4567 articles
(167 on Embase, 20 on Cochrane, 1492 on Scopus, 51 on
MEDLINE [PubMed], and 2837 on ProQuest). After
excluding 2509 duplicate studies, 95 articles were
included in the abstract analysis phase. Then, 20 articles
remained for full-text screening, of which 8 studies were
excluded as they did not conform to PICO13,17–23 (Table 3).
No systematic review or a meta-analysis of this subject area
was found.
After assessing the bias risk of the remaining articles, 2 ar-
ticles were excluded as they were considered high risk
(Table 4).31,32 Finally, 10 articles9–12,25–30 were selected for
quantitative analysis of data and preparation of an
evidence table (Figure 1). The correlation coefficients
between the two authors in the full-text levels were 0.91.
All the articles were in moderate risk state (Figure 2).
The descriptive results and recorded parameters of each
study are presented in Table 5. All the reviewed articles
were in vitro, describing a total of 473 specimens. In 5
articles, artificial WSLs were made on human enamel
specimens and in 5 articles on bovine enamel specimens.
All the articles used Vickers SH test except 2,9,10 which
used Knoop test for measuring the SH. The applied load
for measurement was different between the studies. Three
studies used a 25-g load9,10,27; 2 studies used a 50-g
load12,30; 2 studies applied a 100-g load25,26; and the 3
remaining ones used 200-g11,28 and 300-g29 loads. All the
studies used a 10-s dwell time for applying force except
for 4 studies,11,25,28,29 which applied a 15-s dwell time for
measuring the SH.
In most studies, the initial WSL was produced by a
demineralizing solution, but 1 study28 used demineralize-
remineralize cycling to create WSLs; another 19 used 3
different methods (demineralize/remineralize cycling,
methylcellulose gel, and methyl-ethyl diphosphonate so-
lution). There were some varieties in the RI technique
between the studies. All the studies used HCl as a pre-
treatment technique except for 127 that used phosphoric
acid gel, which has a weaker acidic pH. One of the
studies11 tried an additional pretreatment procedure
before applying RI by staining the specimens with 0.1%
ethanolic solution of tetramethyl rhodamine
isothiocyanate dye (for 12 hours) after etching with HCl
and drying with ethanol.
The forest plots of meta-analysis results of 7 studies11,12,
25–28,30 (comparing RI samples with untreated samples)
Figure 2. Bias risk of included articles.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
and 4 studies11,25–27 (comparing RI samples with sound
enamel) are shown in Figures 3 and 4, respectively. To
decrease the heterogeneity of the collected data as much
as possible, only studies that used Vickers hardness test
were included in metadata analysis. Also, 1 study that
reported only median and interquartile ranges was
Figure 3. Forest plot of studies that compared resin-infiltrat
SMD, standardized mean difference.
excluded as the estimation of mean and standard
deviation did not seem to be precise enough.29 The
accompanying Forest plots and the weight of each study
are also shown. There is no statistically significant
difference in the outcome of each study (ie, no effect)
when its horizontal line, representing the 95% confidence
ed samples with untreated ones. CI, confidence interval;
June 2020 5
Figure 4. Forest plot of studies that compared resin-infiltrated samples with sound enamel. CI, confidence interval;
SMD, standardized mean difference
Table 3. Excluded studies at full-text level with reason.
Study Reason for exclusion
Crombie et al.
201418
Using hypomineralized enamel
Kumar et al.
201624
Using hypomineralized enamel
Elhiny et al.
201623
Treating resin-infiltrated samples with
low-pH solution before measuring
surface hardness
Paris et al. 201320 Measuring transverse microhardness
Tostes et al.
201422
Using nanoindenter
Andrade Neto
et al. 201619
Measuring transverse microhardness
Taher et al. 201221 Not on enamel lesion
Peng et al. 201617 Not on enamel lesion
The Journal of EVIDENCE-BASEDDENTAL PRACTICE
Volume 20, Number 26
interval, touches the zero (vertical) line. There is also no
significant difference when a horizontal vertex of the
diamond, which represents the 95% confidence interval of
the overall mean of difference, touches the zero line. In
spite of significant heterogeneity of the included studies
(Q value 5 36.07, I2 5 83.4%), the overall mean
difference was 3.66 (95% confidence intervals: 2.56 and
4.77), showing a significant increase in SH of RI treatment
compared with untreated samples (P 5 .00) (Figure 3).
Also, the overall mean difference of the RI treatment
compared to sound enamel was 22.35 (95% confidence
interval: 23.91 and 20.98), showing a significant decrease
in SH (P 5 .00, Q value 5 31.75, I2 5 90.6%) (Figure 4).
Five studies measured SH of RI-treated lesions after
exposing them to some environmental challenges to see
whether they became resistant or not.9,10,12,29,27 Results on
the resistance of RI-treated WSLs to acid challenges are
controversial.10,12
Five studies compared the RI technique with other methods
of treating lesions.11,12,28–30 Three studies used a light-
curing, fluoride-releasing, single-component total-etch
adhesive (ExciTE F; Ivoclar Vivadent) for their interven-
tion.28–30 Moreover, some studies used enamel pro-
Table 4. Critical appraisal of the included studies.
Author
Teeth free of
caries or
restoration
Teeth
randomization
Sample
size
calculation
Materials used according
to manufacturers’
instructions
Intervention
performed by a
single operator
Blinding of the
hardness
evaluators Risk
Neres
et al.10
0 1 1 0 1 2 Moderate
Gurdogan
et al.25
0 0 1 0 1 2 Moderate
Prajapati
et al.26
0 2 1 0 1 2 Moderate
Zhoa and
Ren27
1 0 1 1 1 2 Moderate
Arslan
et al.28
0 1 1 0 1 2 Moderate
Mandava
et al.11
0 0 1 2 1 2 Moderate
Torres
et al.12
0 2 1 0 1 2 Moderate
Yazkan and
Ermis29
1 0 1 0 1 2 Moderate
Freitas
et al.9
1 0 1 0 1 2 Moderate
El-
Zankalouny
et al.30
0 0 1 0 1 2 Moderate
Aziznezhad
et al.31
0 1 2 1 2 2 High
Pancu
et al.32
0 2 2 0 2 2 High
The Journal of EVIDENCE-BASED DENTAL PRACTICE
varnish,28 colloidal silica infiltration,11 fluoride,12 and casein
phosphopeptide-amorphous calcium phosphate (CPP-
ACP).30 One study used microabrasion, with or without
polishing, for treating the lesions.29
This systematic review investigated the effects of the RI
technique on promotion of the SH of WSL. According to the
reviewed studies, the presumed null hypothesis was rejec-
ted as most of the studies claimed that RI was able to in-
crease SH of WSL. They observed that the low viscosity of
resin enables it to penetrate deeper into the lesion body, fill
the spaces between the remaining crystals of the porous
lesion, and create a diffusion barrier not only at the surface
but also within the enamel lesion.33 Thus, the weakened
demineralized enamel can be strengthened by replacing
the lost minerals with resin polymers.20,34 It seems that the
infiltrated resin was able to encapsulate the
hydroxyapatite crystals of the lesion and form a relatively
uniform resin-hydroxyapatite complex with high SH.27
In spite of the agreement on the enhancement of SH by RI,
there is still 1 question: Can RI treatment reestablish the
sound enamel SH? TEGDMA is the main organic compo-
nent of RI materials, particularly ICON-Infiltrant.35,36
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Table 5. Detailed information of included studies.
Study Sample
Demineralization
method
Intervention and sample size
Examined test Test detail
Mean hardness (kg/
mm2) ConclusionTest Control
Neres et al.
201710, Brazil
50 permanent
bovine incisors
Demineralization
solution
(pH 5, 1 d)
RI (Icon)
(10)
G0: sound enamel (10)
G1: untreated lesion (10)
G2: RI 1 brushing (10)
G3: RI 1 pH cycling (10)
G4: RI 1 artificial aging (10)
Knoop (Buehler
5114, USA)
5 indentation
25-g load
10-s dwell
time
RI 5 228.3 6 15.4
G0 5 351.2 6 22.6
G1 5 117.8 6 13.4
G2 5 227.2 6 10.9
G3 5 30.9 6 3.8
G4 5 237.3 6 19.0
RI , G0
(P , .05)
RI . G1
(P , .05)
RI 5 G2 5 G4
RI . G3
Gurdogan
et al.
201725, Turkey
60 bovine
incisors
Demineralizing
solution
(pH: 4, 2h)
RI (Icon)
(20)
G0: sound enamel (20)
G1: untreated lesion (20)
Vickers
(Buehler 5114,
USA)
4 indentation
100-g load
15 s
RI 5 347.55 6 24.42
G0 5 359.48 6 10.65
G1 5 257.63 6 11.86
RI 5 G0
(P 5 .073)
RI . G1
(P 5 .001)
Prajapati et al.
201726, India
30 human
premolars
Demineralizing
solution
(pH: 4.3, 21 d)
RI (Icon) (10) G0: sound enamel (10)
G1: untreated enamel (10)
Vickers
(CLEMEX
CMT HD)
5 indentation
100-g load
10 s
RI 5 12.12 6 4.6
G0 5 234.2 6 48.38
G1 5 5.9 6 1.53
RI , G0
RI . G1
(P 5 .001)
Zhoa and Ren
201627, USA
20 human
third molar
Demineralization
solution
(pH: 4.5, 2 d)
RI (Icon) (20) G0: sound enamel (20)
G1: untreated lesion (20)
G2: RI 1 thermocycling (10)
G3: RI 1 water storage (10)
Vickers
(HMV-2T,
Japan)
3 indentation
25-g load
10-s dwell
time
RI 5 212.0 6 45.6
G0 5 315.2 6 31.9
G1 5 89.3 6 24.1
G2 5 202.9 6 55.2
G3 5 209.6 6 35.6
RI , G0
(P , .01)
RI . G1
(P , .01)
RI 5 G2
Arslan et al.
201528, Turkey
60 human
anterior central
incisors
Demineralize/
remineralize
solution
RI (Icon) (15) G1: untreated lesion (15)
G2: enamel pro varnish (15)
G3: Excite F (15)
Vickers
(HMV-700,
Japan)
3 indentation
2-n load
15-s dwell
time
RI 5 318.240 6 43.91
G1 5 30.646 6 25.826
G2 5 109.577 6 47.40
G3 5 36.607 6 23.654
RI . G1
(P , .05)
RI . G2 .
G3 5 G1
(P , .05)
Mandava et al.
201711, India
40 human
maxillary
central
incisors
Demineralizing
solution
(pH 4.4, 96h)
RI (Icon)
(20)
G0: sound enamel (20)
G1: untreated (20)
G2: colloidal silica
infiltration (20)
Vickers
(400 series,
wilson wolpert,
Germany)
3 indentation
300-g load
15-s dwell
time
RI 5 101.77
G1 5 75.63
G2 5 86.76
RI . G1
RI . G2
(P , .001)
Torres et al.
201212, Brazil
30 bovine
incisors (60
specimens)
Demineralizing
solution
(pH: 5.0, 16h)
RI (Icon) (15) G1: untreated (15)
G2: daily use of fluoride
solution (15)
G3: weekly use of
fluoride gel (15)
G4: immersion in
artificial saliva (15)
G5: RI 1 acid challenge (15)
Vickers (FM-700,
future-tech,
Japan)
3 indentation
50-g load
10 s
RI 5 160.83 6 91.11
G1 5 19.67 6 8.43
G2 5 107.75 6 67.38
G3 5 83.25 6 51.17
G4 5 45.18 6 29.17
RI . G1
(P , .001)
RI . G2 .
G3 . G4
(P , .001)
RI . G5
(P , .001)
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Yazkan and
Ermis, 201829,
Turkey
80 bovine
incisors
Demineralization
solution
(pH 5, 10 d)
RI (Icon) (16) G0: sound enamel (16)
G1: untreated enamel (16)
G2: RI 1 further
demineralization (16)
G3: RI with an adhesive
resin (Excite F) (16)
G4: microabrasion without
polish (16)
G5: micro abrasion 1 polish
(16)
G6: immersion in distilled
water (16)
Vickers
(Duroline M,
Turkey)
3 indentation
200-g load
15 s
RI 5 261.9
G0 5 330.8
G1 5 131.7
G2 5 212.6
G3 5 211.6
G4 5 304.5
G5 5 305.6
G6 5 131.7
RI 5 G0
(P . .05)
RI . G1
(P , .05)
RI5 G45 G5 .
G3 . G6
RI 5 G2
(P . .05)
Freitas et al.
20189, Brazil
39 bovine
incisors
A: demineralization/
remineralization
cycling (13)
B: 8%
methylcellulose
gel (13)
C: methyl ethyl
diphosphonate
solution (13)
A, B, and C: RI
(Icon) (39)
G1 (on A, B, and C):
untreated enamel (39)
G2 (on A, B, and C):
RI 1 further
demineralization (39)
Knoop (Wilson
Tukon 1102,
USA)
5 indentation
25-g load
10 s
DSHa:
A:
RI 5 242.81 6 20.67%
G1 5 291.76 6 9.17%
G2 5 258.54 6 8.15%
B:
RI 5 262.80 6 20.52%
G1 5 275.20 6 9.04%
G2 5 292.25 6 15.16%
C:
RI 5 248.46 6 21.28%
G1 5 292.50 6 3.60%
G2 5 266.81 6 8.17%
A&C: RI . G1
A: RI 5 G2
B&C: RI . G2
El-Zankalouny
et al. 201630,
Egypt
28 human
premolars
Demineralizing
solution
(pH 4.4, 4 d)
RI (Icon) (7) G1: untreated enamel (7)
G2: CPP-ACP (7)
G3: Excite F adhesive (7)
Vickers
(NM)
3 indentation
50-g load
10 s
RI 5 188.61 6 10.25
G1 5 149.03 6 8.65
G2 5 176.03 6 6.44
G3 5 167.26 6 8.31
RI . G1
(P 5 .009)
RI . G2 . G3
(P 5 .009)
CPP-ACP, casein phosphopeptide-amorphouscalcium phosphate; G, group; NM, not mentioned; RI, resin infiltration.
aDSH 5 surface hardness loss (%) compared to the sound surface hardness mean.
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The Journal of EVIDENCE-BASED DENTAL PRACTICE
10
Although this monomer has a high degree of conversion,
the formation of the polymeric chain does not always
happen.37 Therefore, disability of forming a strong
intermolecular secondary bond, plus material shrinkage
during polymerization, might result in the detection of
some regions of noninfiltrated demineralized enamel that
has lower SH than sound enamel. Zhoa and Ren27 and
Prajapati et al.26 confirmed these findings too.
Nevertheless, Gurdogan et al.25 reported that although SH
of RI-treated lesions was lower than that of sound enamel,
the difference was not statistically significant. They claimed
that RI can enhance the hardness of the lesion to reach the
sound enamel properties as well.25 The results of our meta-
analysis confirmed that the RI technique cannot return the
SH of WSL to that of sound enamel; however, more studies
are needed to analyze the precise decision.
Before applying resin infiltrates, researchers had to create
WSL artificially. The artificial WSL might be induced by
different methods. Freitas et al.9 used methylcellulose gel,
but because of its high viscosity, the diffusion rate of the
acid was compromised, resulting in a lower degree of
demineralization with fewer pores.38 As a result, resin
monomers might not make a good interaction with
superficial crystals.26 That might be the reason why the RI
technique was not able to improve the SH of enamel in
these specimens as much as other demineralizing
agents.26 Another method of demineralization is to use a
demineralizing-remineralizing cycle, which is a dynamic
process, similar to what actually happens in the oral cavity
by allowing an intensive ion exchange and consequently
with higher demineralization rate than other methods.
However, demineralizing agents were used in most of the
articles for induction of artificial lesions because of their
easy availability.
Compared with RI treatment, some other methods have
been tried to treat the WSL. Colloidal silica infiltration,
enamel pro-varnish, fluoride application, and CPP-ACP are
some of those methods investigated by Mandava et al.,11
Arslan et al.,28 Torres et al.,12 and Zankalouny et al.,30
respectively. Nevertheless, most of them found the RI
technique more effective than these methods in terms of
enhancing lesion’s SH. The colloidal silica infiltration with
8.3-nm particles might have been lodged in the enamel
voids, sealing the porous structures, but they may not be
capable enough to penetrate into the voids with a smaller
diameter than their actual particle size.11 Therefore, some
demineralized enamel regions might remain unsealed with
low SH values, consequently.11 However, resin monomers
with low viscosity are much more flowable and can
penetrate deeper into enamel microporosities by their
capillary action.11 Enamel pro-varnish (with 5% sodium
fluoride) also contained ACP, which enhanced fluoride
Volume 20, Number 2
release from the varnish.39 As discussed before, resin
infiltrates from a diffusion barrier not only on the surface
but also within the lesion body; however, fluoride varnish
creates a shallower coating layer and forms a diffusion
barrier just on the surface with a probable lower SH.33
CPP-ACP is a nano-complex remineralizing agent that
serves as a calcium-phosphate reservoir, prevents deminer-
alization, and promotes remineralization of enamel subsur-
face lesions.40 It needs saliva for deposition of calcium ions
in the WSL.41 That might be the reason for increased SH
values of the treated specimens over a period of
2 weeks,30 which is different from the RI technique as it
improves the SH values immediately after application.
Three studies28-30 examined ExciTE F adhesive to
compare with the RI technique, and all reported that the
RI technique was more effective. This might be attributed
to nonhomogeneous and partially polymerized layer of
ExciTE F adhesive because of its solvent (water).42 “Icon”
resin, which is more formal for the RI technique in
research studies, has a lower viscosity than ExciTE F.42
Lower viscosity, high surface tension, and low contact
angle on the enamel result in high penetration coefficient
for Icon,43 enabling it to fill the spaces between the
remaining crystals of the porous lesion appropriately to
enhance SH (Figure 5).45,46 Microabrasion, with or without
polishing, is another microinvasive treatment for
noncavitated lesions.47,48 During microabrasion technique,
mostly the superior layers of enamel are affected by
repeated application of an acid and abrasive
compounds.48,49 Yazkan and Ermis29 claimed that this
technique can lead to improved SH similar to the RI
technique. Acid components used in this technique might
change the enamel prismatic structure and induce a
compacting effect on the enamel, which can enhance the
SH.44
In addition to improving the SH of WSL, it is important that
treated lesion become resistant to future exposure to
intraoral challenges. Resin-infiltrated lesions are resistant to
mechanical challenges and artificial aging, which is attrib-
uted to the barrier action of resin and occluded pores of
WSL.10 The results of the RI technique to pH cycles and
acidic challenges were different among studies.10,12 Neres
et al.10 showed that the RI technique did not make WSLs
resistant to acid challenges. However, Torres et al.12
reported the opposite results. Although they observed
reduced SH of RI-treated WSL after acid exposure, the SH
was still significantly higher than that of the control samples.
This could be due to partial dissolution of the remaining
minerals in the lesion’s body that were not completely
embedded by the resin matrix, or it can be a result of resin
shrinkage during light-curing and further leakage and
consequently reduction in acid resistance.50 Another reason
Figure 5. Penetration of RI on WSL displayed by polarization microscopy and Scanning Electron Microscope (SEM).
The asterisks show a residual surface layer. Resin (R), carious lesion (C), residual surface layer (*), enamel (E). RI, resin
infiltration; WSL, white spot lesion.
(Adopted with copyright permission No.4537811273507 from Schneider et al.’s study44).
The Journal of EVIDENCE-BASED DENTAL PRACTICE
might be the composition of resin infiltrates in which
TEGDMA is a highly hydrophilic monomer with less
resistance to degeneration in the oral environment.47 In
summary, more documents are needed on the effects of
microabrasion, resistance of RI-treated WSL to aging, me-
chanical challenges, and acid challenges. Researchers are
encouraged to conduct more clinical studies on RI and focus
on the issues mentioned previously in their future studies.
One of the limitations of this study was that all the articles
discussed in this review were in vitro studies, so they were
not able to investigate the role of saliva, curing shrinkage,
and expansion of resin by intraoral thermal cycling. More-
over, the artificial enamel lesions are mostly limited by the
superior layers of enamel; however, in clinical situations, the
lesions might be more extensive.51 As oral health care is a
component of the general health that can affect the
patient’s quality of life, “dental patient-reported outcome”
has been focused lately. Dental patient-reported outcome
suggests what really matters to patients.52 Therefore,
knowing the patient-perceived impact of the RI technique
in the treatment of WSLs seems to be important. In addition,
RI treatment of WSLs seems to have intangible benefits,
which mostly needs to be evaluated objectively by a clini-
cian, and it can indirectly affect the tangible general health
benefits.53 According to Hujoel’s category, the RI technique
is a treatment with “clinical significance of level 3,” which
has a paramount effect on the therapeutichealth care
because it gives researchers a clue to conduct influential
randomized clinical trials.53
CONCLUSION
In general, and within the limitations of this systematic re-
view, it can be concluded that the RI technique has a sig-
nificant advantage for enhancing the SH of WSL; however,
reestablishing the SH of resin-infiltrated WSLs similar to
sound enamel is doubtful. RI was more effective for
enhancing the SH than other methods (such as fluoride
application, enamel pro-varnish, ExciTE F adhesive, and
colloidal silica infiltration); however, more studies are
needed for conclusive statements.
REFERENCES
1. Hicks J, Garcia-Godoy F, Flaitz C. Biological factors in dental
caries enamel structure and the caries process in the dynamic
process of demineralization and remineralization (part 2). J Clin
Pediatr Dent 2004;28(2):119-24.
2. Kidd EA, Fejerskov O. What constitutes dental caries? Histo-
pathology of carious enamel and dentin related to the action of
cariogenic biofilms. J Dent Res 2004;83(Spec No C):C35-8.
3. Featherstone JD. The caries balance: the basis for caries man-
agement by risk assessment. Oral Health Prev Dent
2004;2(suppl 1):259-64.
June 2020 11
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref1
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref1
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref1
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref1
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref2
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref2
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref2
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref3
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref3
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref3
The Journal of EVIDENCE-BASED DENTAL PRACTICE
12
4. Tickle M, O’Neill C, Donaldson M, et al. A randomized
controlled trial of caries prevention in dental practice. J Dent
Res 2017;96(7):741-6.
5. Lv X, Yang Y, Han S, et al. Potential of an amelogenin based
peptide in promoting reminerlization of initial enamel caries.
Arch Oral Biol 2015;60(10):1482-7.
6. Kielbassa AM, Ulrich I, Werth VD, Schuller C, Frank W,
Schmidl R. External and internal resin infiltration of natural
proximal subsurface caries lesions: a valuable enhancement of
the internal tunnel restoration. Quintessence Int 2017;48(5):
357-68.
7. Paris S, Meyer-Lueckel H. Inhibition of caries progression by
resin infiltration in situ. Caries Res 2010;44(1):47-54.
8. Kantovitz KR, Pascon FM, Nobre-dos-Santos M, Puppin-
Rontani RM. Review of the effects of infiltrants and sealers on
non-cavitated enamel lesions. Oral Health Prev Dent 2010;8(3):
295-305.
9. Freitas M, Nunes LV, Comar LP, et al. In vitro effect of a resin
infiltrant on different artificial caries-like enamel lesions. Arch
Oral Biol 2018;95:118-24.
10. Neres EY, Moda MD, Chiba EK, Briso A, Pessan JP,
Fagundes TC. Microhardness and roughness of infiltrated white
spot lesions submitted to different challenges. Oper Dent
2017;42(4):428-35.
11. Mandava J, Reddy YS, Kantheti S, et al. Microhardness and
penetration of artificial white spot lesions treated with resin or
colloidal silica infiltration. J Clin Diagn Res 2017;11(4):
ZC142-Z146.
12. Torres CR, Rosa PC, Ferreira NS, Borges AB. Effect of caries
infiltration technique and fluoride therapy on microhardness of
enamel carious lesions. Oper Dent 2012;37(4):363-369.
13. Faghihian R, Shirani M, Tarrahi MJ, Zakizade M. Efficacy of the
resin infiltration technique in preventing initial caries progres-
sion: a systematic review and meta-analysis. Pediatr Dent
2019;41(2):88-94.
14. Borges AB, Caneppele TM, Masterson D, Maia LC. Is resin
infiltration an effective esthetic treatment for enamel develop-
ment defects and white spot lesions? A systematic review.
J Dent 2017;56:11-18.
15. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred
reporting items for systematic reviews and meta-analyses: the
PRISMA statement. BMJ 2009;339:b2535.
16. Astudillo-Rubio D, Delgado-Gaete A, Bellot-Arcís C, Montiel-
Company JM, Pascual-Moscardó A, Almerich-Silla JM. Me-
chanical properties of provisional dental materials: a systematic
review and meta-analysis. PLoS One 2018;13(2):e0193162.
17. Peng Y, Qian Z, Ting Z, Jie F, Xiaomei X, Li M. The effect of resin
infiltration vs. fluoride varnish in enhancing enamel surface
conditions after interproximal reduction. Dent Mater J
2016;35(5):756-761.
Volume 20, Number 2
18. Crombie F, Manton D, Palamara J, Reynolds E. Resin infiltration
of developmentally hypomineralised enamel. Int J Paediatr
Dent 2014;24(1):51-55.
19. Andrade Neto DM, Carvalho EV, Rodrigues EA, et al. Novel
hydroxyapatite nanorods improve anti-caries efficacy of enamel
infiltrants. Dent Mater 2016;32(6):784-793.
20. Paris S, Schwendicke F, Seddig S, Muller WD, Dorfer C, Meyer-
Lueckel H. Micro-hardness and mineral loss of enamel lesions
after infiltration with various resins: influence of infiltrant
composition and application frequency in vitro. J Dent
2013;41(6):543-548.
21. Taher NM, Alkhamis HA, Dowaidi SM. The influence of resin
infiltration system on enamel microhardness and surface
roughness: an in vitro study. Saudi Dent J 2012;24(2):79-84.
22. Tostes MA, Santos E Jr, Camargo SA Jr. Effect of resin infiltra-
tion on the nanomechanical properties of demineralized bovine
enamel. Indian J Dent 2014;5(3):116-122.
23. Elhiny O, Elattar H, Salem G. The influence of resin infiltration
system on sound enamel microhardness and shear-bond
strength of orthodontic bands: an in-vitro study. Der Pharma
Chemica 2016;8:100-106.
24. Kumar H, Palamara JEA, Burrow MF, Manton DJ. An investi-
gation into the effect of a resin infiltrant on the micromechanical
properties of hypomineralised enamel. Int J Paediatr Dent
2017;27:399-411.
25. Gurdogan EB, Ozdemir-Ozenen D, Sandalli N. Evaluation of
surface roughness characteristics using atomic force micro-
scopy and inspection of microhardness following resin infiltra-
tion with Icon((R)). J Esthet Restor Dent 2017;29(3):201-208.
26. Prajapati D, Nayak R, Pai D, Upadhya N, K Bhaskar V, Kamath P.
Effect of resin infiltration on artificial caries: an in vitro evalua-
tion of resin penetration and microhardness. Int J Clin Pediatr
Dent 2017;10(3):250-256.
27. Zhao X, Ren YF. Surface properties and color stability of resin-
infiltrated enamel lesions. Oper Dent 2016;41(6):617-626.
28. Arslan S, Zorba YO, Atalay MA, et al. Effect of resin infiltration
on enamel surface properties and Streptococcus mutans
adhesion to artificial enamel lesions. Dent Mater J 2015;34(1):
25-30.
29. Yazkan B, Ermis RB. Effect of resin infiltration and microabrasion
on the microhardness, surface roughness and morphology of
incipient carious lesions. Acta Odontol Scand 2018;76(7):
473-481.
30. El-Zankalouny SM, El Fattah WMA, El-Shabrawy SM. Penetra-
tion depth and enamel microhardness of resin infiltrant and
traditional techniques for treatment of artificial enamel lesions.
Alexandria Dent J 2016;41(1):20-25.
31. Aziznezhad M, Alaghemand H, Shahande Z, et al. Comparison
of the effect of resin infiltrant, fluoride varnish, and nano-hy-
droxy apatite paste on surface hardness and streptococcus
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref4
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref4
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref4
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref5
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref5
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref5
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref6
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref6
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref6
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref6
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref6
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref7
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref7
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref8
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref8http://refhub.elsevier.com/S1532-3382(20)30009-9/sref8
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref8
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref9
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref9
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref9
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref10
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref10
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref10
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref10
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref11
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref11
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref11
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref11
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref12
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref12
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref12
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref13
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref13
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref13
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref13
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref14
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref14
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref14
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref14
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref15
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref15
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref15
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref16
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref16
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref16
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref16
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref17
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref17
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref17
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref17
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref18
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref18
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref18
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref19
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref19
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref19
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref20
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref20
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref20
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref20
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref20
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref21
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref21
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref21
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref22
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref22
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref22
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref23
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref23
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref23
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref23
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref53
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref53
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref53
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref53
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref27
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref27
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref27
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref27
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref28
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref28
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref28
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref28
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref31
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref31
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref26
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref26
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref26
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref26
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref30
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref30
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref30
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref30
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref29
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref29
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref29
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref29
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref24
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref24
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref24
The Journal of EVIDENCE-BASED DENTAL PRACTICE
mutans adhesion to artificial enamel lesions. Electron Physician
2017;9(3):3934-42.
32. Pancu G, Andrian S, Iovan G, et al. Study regarding the
assessment of enamel microhardness in incipient carious le-
sions treated by icon method. Rom J Oral Rehabil 2011;3:
94-100.
33. Meyer-Lueckel H, Paris S. Improved resin infiltration of natural
caries lesions. J Dent Res 2008;87(12):1112-6.
34. Askar H, Lausch J, Dorfer CE, Meyer-Lueckel H, Paris S. Pene-
tration of micro-filled infiltrant resins into artificial caries lesions.
J Dent 2015;43(7):832-8.
35. Catelan A, Briso AL, Sundfeld RH, Dos Santos PH. Effect of
artificial aging on the roughness and microhardness of sealed
composites. J Esthet Restor Dent 2010;22(5):324-30.
36. Paris S, Lausch J, Selje T, Dorfer CE, Meyer-Lueckel H. Com-
parison of sealant and infiltrant penetration into pit and fissure
caries lesions in vitro. J Dent 2014;42(4):432-8.
37. Gajewski VE, Pfeifer CS, Froes-Salgado NR, Boaro LC,
Braga RR. Monomers used in resin composites: degree of
conversion, mechanical properties and water sorption/solubil-
ity. Braz Dent J 2012;23(5):508-14.
38. Damato FA, Strang R, Stephen KW. Comparison of solution-
and gel-prepared enamel lesions–and in vitro pH-cycling study.
J Dent Res 1988;67(8):1122-5.
39. Jablonowski BL, Bartoloni JA, Hensley DM, Vandewalle KS.
Fluoride release from newly marketed fluoride varnishes.
Quintessence Int 2012;43(3):221-8.
40. Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Reminerali-
zation of enamel subsurface lesions by sugar-free chewing gum
containing casein phosphopeptide-amorphous calcium phos-
phate. J Dent Res 2001;80(12):2066-70.
41. Bailey DL, Adams GG, Tsao CE, et al. Regression of post-or-
thodontic lesions by a remineralizing cream. J Dent Res
2009;88(12):1148-53.
42. Meyer-Lueckel H, Paris S, Mueller J, Colfen H, Kielbassa AM.
Influence of the application time on the penetration of different
dental adhesives and a fissure sealant into artificial subsurface
lesions in bovine enamel. Dent Mater 2006;22(1):22-8.
43. Gugnani N, Pandit IK, Gupta M, Josan R. Caries infiltration of
noncavitated white spot lesions: a novel approach for imme-
diate esthetic improvement. Contemp Clin Dent 2012;3(suppl
2):S199-202.
44. Schneider H, Park KJ, Rueger C, Ziebolz D, Krause F, Haak R.
Imaging resin infiltration into non-cavitated carious lesions by
optical coherence tomography. J Dent 2017;60:94-8.
45. Meyer-Lueckel H, Paris S. Progression of artificial enamel caries
lesions after infiltration with experimental light curing resins.
Caries Res 2008;42(2):117-24.
46. Ardu S, Castioni NV, Benbachir N, Krejci I. Minimally invasive
treatment of white spot enamel lesions. Quintessence Int
2007;38(8):633-6.
47. Murphy TC, Willmot DR, Rodd HD. Management of post-
orthodontic demineralized white lesions with microabrasion: a
quantitative assessment. Am J Orthod Dentofacial Orthop
2007;131(1):27-33.
48. Lynch CD, McConnell RJ. The use of microabrasion to remove
discolored enamel: a clinical report. J Prosthet Dent 2003;90(5):
417-9.
49. Fragoso LS, Lima DA, de Alexandre RS, Bertoldo CE,
Aguiar FH, Lovadino JR. Evaluation of physical properties of
enamel after microabrasion, polishing, and storagein artificial
saliva. Biomed Mater 2011;6(3):035001.
50. Paris S, Meyer-Lueckel H, Colfen H, Kielbassa AM. Resin infil-
tration of artificial enamel caries lesions with experimental light
curing resins. Dent Mater J 2007;26(4):582-8.
51. Park J, Eslick J, Ye Q, Misra A, Spencer P. The influence of
chemical structure on the properties in methacrylate-based
dentin adhesives. Dent Mater 2011;27(11):1086-93.
52. John MT. Health outcomes reported by dental patients. J Evid
Based Dent Pract 2018;18(4):332-5.
53. Hujoel PP. Levels of clinical significance. J Evid Base Dent Pract
2004;4:32-6.
June 2020 13
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref24
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref24
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref25
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref25
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref25
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref25
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref32
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref32
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref33
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref33
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref33
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref34
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref34
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref34
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref35
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref35
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref35
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref36
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref36
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref36
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref36
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref37
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref37
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref37
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref38
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref38
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref38
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref39
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http://refhub.elsevier.com/S1532-3382(20)30009-9/sref40
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http://refhub.elsevier.com/S1532-3382(20)30009-9/sref41
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref41
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref41
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref42
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref42
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref42
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref42
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref48
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref48
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref48
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref43
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref43
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref43
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref44
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http://refhub.elsevier.com/S1532-3382(20)30009-9/sref45
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref45
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref45
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref45
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref46
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref46
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref46
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref47
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref47
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref47
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref47
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref49
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref49
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref49
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref50
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref50
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http://refhub.elsevier.com/S1532-3382(20)30009-9/sref51
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref52
http://refhub.elsevier.com/S1532-3382(20)30009-9/sref52
	Effect of Resin Infiltration Technique on Improving Surface Hardness of Enamel Lesions: A Systematic Review and Meta-analysis
	Introduction
	Materials and Methods
	Search Strategy
	Selection of Studies
	Assessment of the Risk of Bias
	Results and Discussion
	Conclusion
	References