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ORIGINAL RESEARCH ARTICLE  
Year : 2018  |  Volume : 21  |  Issue : 4  |  Page : 450-454
Concealment effect of resin infiltration on incisor of Grade I molar incisor hypomineralization patients: An in vivo study


1 Department of Pedodontics, H. P. Government Dental College, Shimla, Himachal Pradesh, India
2 DDS (ISP-1), School of Dental Medicine, University of Colorado, Denver, USA

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Date of Submission09-Mar-2018
Date of Decision02-Mar-2018
Date of Acceptance22-May-2018
Date of Web Publication27-Jul-2018
 

   Abstract 

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.

Keywords: Esthetic dentistry; conservative dentistry; minimally invasive treatment

How to cite this article:
Bhandari R, Thakur S, Singhal P, Chauhan D, Jayam C, Jain T. Concealment effect of resin infiltration on incisor of Grade I molar incisor hypomineralization patients: An in vivo study. J Conserv Dent 2018;21:450-4

How to cite this URL:
Bhandari R, Thakur S, Singhal P, Chauhan D, Jayam C, Jain T. Concealment effect of resin infiltration on incisor of Grade I molar incisor hypomineralization patients: An in vivo study. J Conserv Dent [serial online] 2018 [cited 2019 Jul 18];21:450-4. Available from: http://www.jcd.org.in/text.asp?2018/21/4/450/237745

   Introduction Top


White discolorations of enamel can be classified as enamel demarcated opacities, diffuse opacities enamel fluorosis, or postorthodontic white spot lesions (POD).[1] Molar incisor hypomineralization (MIH) is a specific form of developmental defect of enamel (DDE) delineated recently in 2001. It involves mostly incisors and one or more of the first permanent molars.[2]

These nonfluoride hypomineralized lesions are frequently found in esthetic setback. Various treatment options are available to improve esthetics.[3] Treatment of MIH can be brought through a process involving remineralization of subsurface enamel, prevention of any further progression, and amelioration esthetics.

Various authors have studied the color change of white spot lesions (WSLs) after resin infiltration treatment.[4] However, few authors have studied the stability of resin infiltration. Moreover, they have infiltrated only demineralized WSL developed in postorthodontic patients in their study.[4]

Hence, the purpose of this in vivo research is to evaluate the esthetic results of resin infiltration treatment on Grade 1 MIH white lesion.


   Materials and Methods Top


The present in vivo study is a controlled trial done in the Department of Pedodontics and Preventive Dentistry. The ethical approval was obtained from the College Ethical Committee Board with registration number NO. HFW(GDC) B(12)50/2015. This study consists of patients, in the age strata of 7–16 years, attending the outpatient department. Written consent was obtained from the parents after explaining the treatment procedure. A total of 22 lesions on incisors in MIH patients with equal distribution in gender as per inclusion criteria were treated with infiltration. Grade I (mild) lesions were taken in the study. Criteria of selection were established according to the European Academy of Pediatric Dentistry (EAPD) criteria's given in 2010.[5] Any lesion with isolated opacities, demarcated enamel opacities without a breakdown of the enamel, and sensitivity to external stimuli occasionally present were included in the study. Patients having mental disabilities or systemic diseases, active caries lesion, previously restored tooth in question, loss of the enamel, or dentin structure, clinical symptoms of irreversible pulpitis, and previous use of bleaching agent were excluded from the study.

For resin infiltration procedure, isolation was carried out with a rubber dam. The enamel surface was cleansed with prophylaxis paste rubbed using a rubber cup at slow speed. Then, 15% hydrochloric acid gel was applied (ICON-Etch; DMG; Hamburg, Germany ®) for 120s. Afterward, the etchant was cleansed away thoroughly for 30s. Ethanol desiccation of the lesions was done (ICON-Dry; DMG ®) for 30 s which was followed by drying. Infiltrant resin (ICON-Infiltrant; DMG ®) was applied to the lesion and was made to infiltrate for 3 min. The excessive material was rubbed away using a cotton swab before curing. Following the 40 s of light curing, the infiltration step was repeated again. Finally, the surface of the lesion was polished using polishing discs for composites. Standardized clinical photographs [6] were taken before infiltration (T1), immediately after infiltration (T2), and 6 months after infiltration (T3) [Figure 1]. For standardizing the photographic conditions, the camera was placed at the same distance from the tooth surface every time. Photographs were captured using a digital camera (EOS 700D camera; Canon, Tokyo, Japan), macrolens, and flash.
Figure 1: (a and d) Photographs of before infiltration (T1); (b and e) immediately after infiltration (T2); and (c and f) 6 months after infiltration (T3) (top to bottom)

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Evaluation of color changes

The photographic evaluation was done by two trained examiners; photographs were randomly designated to circumvent measuring bias. Subsequently, the white tooth discolorations were outlined on the screen, and the colors of white tooth discolorations at three points were taken to obtain an average scoring and it was measured using the Commission Internationale de l'E' clairage (CIE) L*a*b* scoring method.[7]

Commission Internationale de l'E'000000000000 clairage laboratory color space

The CIE laboratory color space resembles a uniform color space. The three axes are L*; a*; and b*.[8] Data were extracted from photographs. From T1 photograph for every group, three readings were obtained as L 1, a 1, and b 1. Similarly, from T2 photograph for every group, three readings were obtained as L 2, a 2, and b 2; and from T3 photograph for every group, three readings were obtained as L 3, a 3, and b 3. Changes in the reading of L*; a*; and b* were calculated between every time point, to obtain ΔL, Δa, and Δb. The difference in total color, ΔE, given by the Euclidean distance in CIELAB space, can be obtained by the following equation.[7] ΔE = (ΔL*2+ Δa*2+ Δb*2)½. Means of each parameter such as ΔL, Δa, Δb, and ΔE values taken from photographs at every time points in a given group were calculated, and ANOVA in conjunction with Tukey's post hoc test was used to calculate the means, which are significantly different from each other. Statistical analysis was performed using SPSS 21.0 for Mac (SPSS Inc., Chicago, IL, USA).


   Results Top


After evaluation of photographs for CIE laboratory scoring, 20 pictures were reevaluated by same observer at 1-week interval to access the intra observer consistency and Cohen's K score, that came out be 0.90, indicating an almost perfect agreement. Furthermore, the photographs were evaluated by two different examiners to remove the bias; hence, interobserver consistency was maintained, and Cohen's K score came out be 867, indicating a substantial level of agreement.

Means of difference in lightness (ΔL), red-green color (Δa), yellow-blue color change (Δb), and in total color change (ΔE) with a confidence interval of 95 percentage of WSL were obtained. One-way ANOVA was performed to statistically analyze parameters such as ΔL, Δa, Δb, and ΔE values between time points. Tukey's post hoc test was performed to statistically analyze and provide the specific probability of significance between each and every time points for parameters such as ΔL, Δa, Δb, and ΔE values. Level of significance was kept below 0.05 (P< 0.05) for ANOVA and for Tukey's post hoc test.

Mean of difference in lightness (ΔL1) of white tooth discoloration shows a decrease in the lightness of WSL only after the procedure [Table 1]. The mean difference in lightness (ΔL2) of white tooth discoloration shows further decrease in the lightness of the same in 6 months of time period following treatment with the highly statistically significant difference between these two time points [Table 2]. The mean of difference in lightness (ΔL3) of WSL shows an overall decrease in the lightness of white tooth discoloration.
Table 1: Mean of difference in ΔL, Δa, Δb, and ΔE of white spot discoloration between different time points and the statistical difference between these time points using one-way ANOVA and Tukey's post hoc test

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Table 2: Specific probability of significance between different parameters at the specific time points using Tukey's post hoc test

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Mean of difference in red-green color (Δa1) of white tooth discoloration signifies change toward green color just after treatment. Mean of difference in red-green color (Δa2) of white tooth discoloration signifies change toward red color 6 months following the treatment. Mean of difference in red-green color (Δa3) of WSL shows an overall change toward the red color of white tooth discoloration [Table 1]. No statistically significant difference between groups is observed [Table 2].

Mean of difference in yellow-blue color change (Δb1) of white tooth discoloration signifies the highest change toward the yellow color of white tooth discoloration just after treatment. Mean of difference in yellow-blue color change (Δb2) of WSL shows further change toward the yellow color of white tooth discoloration in 6 months of time period following treatment [Table 1] with the statistically significant difference between these two time points [Table 2]. Mean of difference in yellow-blue color change (Δb3) of WSL shows an overall change toward the yellow color.

Mean of difference in total color change (ΔE1) of white tooth discoloration signifies total color change just after the procedure, and mean of difference in total color change (ΔE2) of white tooth discoloration shows further change in color of white tooth discoloration in 6 months of time period following treatment. The change observed was equal just after treatment and in the following 6 months with no statistically significant difference between these two time points [Table 2]. Mean of difference in total color change (ΔE3) of white tooth discoloration shows an overall color change of white tooth discoloration [Table 1].


   Discussion Top


The major dilemma among dentists is how to differentiate white tooth discoloration among themselves. Russell had developed principles for differentiating fluorosis and opacities.[9] His criterion described white-yellowish lesions which are not well defined as fluorosis, with blending with adjacent normal enamel, and also a symmetrical distribution in arches. On the other hand, nonfluoridated opacities acquire more delineated shape, are well demarcated from the surrounding normal enamel, are commonly situated in the middle of the tooth, and are random in distribution.[10]

Resin infiltration is one of a kind treatment option which is minimally invasive technique, yet nonpatient compliance based.[2] It is made possible by eroding the hypermineralized surface layer and then infiltrating resin through capillary action into the hypocalcified void of enamel. Meyer-Lueckel et al. in 2010 revealed that the infiltrant was able to penetrate 600 mm into enamel lesions clinically.[11] The infiltration of the resin owing to its low viscosity into the voids of enamel has been shown in many in vitro studies. In addition, color masking effects have been also published using artificial caries samples.[12],[13],[14]

Nonetheless, there is a paucity of clinical confirmation about the efficacy of the resin infiltration treatment for masking enamel whitish discolorations in MIH patients.

Eckstein et al.[4] in their study showed that infiltrant material's concealment effect on WSL had no statistically significant or clinically relevant additional color or lightness alterations between 6 and 12 months after infiltration. Hence, in this study, 6-month follow-up was done.

In the present study, a reduction in the whiteness of white spot and also change in total color were noted only after treatment and 6 months after treatment, following resin infiltration. This study shows that resin infiltration shows immediate results and also it shows further improvement overtime.

Similar results were observed by Cohen-Carneiro et al.,[15] who showed that lesions infiltrated with icon underwent higher color change. Furthermore, Borges [16]et al., in 2013, concluded the same with their study. Higher staining was observed when the infiltrated enamel was disclosed to colored solutions. Similarly, Araújo et al.[17] in their clinical study summarized that staining was apparent in infiltrated enamel as there was a significant alteration in color. However, bleaching reversed the staining of infiltrated lesion successfully.

Notwithstanding, results were observed by Yetkiner et al.,[18] who evaluated the color improvement of WSL after resin infiltration treatment, and its stability after discoloration insults. In his study, conclusion was made that resin infiltration treated lesions were stable after discoloration challenges. Furthermore, Senestraro et al.[19] concluded that resin infiltration shows stable results up to 8 weeks after treatment. Moreover, Knösel et al.,[20] in 2013, concluded that esthetics of infiltrated lesions with resin were constant for 6 months. Paris et al.[13] hypothesized that the increase in the resistance against discoloration might be due to resin plugging up the voids of enamel deep within.

However, the reason for the further change in color of the infiltrated lesion in the present study can be explained in a similar way as it can be done for other dental resins. Disregarding their chemical makeup, dental resins favor absorbing liquids.[21] Therefore, discoloration of resin may be inevitable over time.

Limitations of the study

  1. As the changes observed following resin infiltration on MIH lesions were not stable for 6 months, further studies are required with a longer time duration
  2. Esthetic results obtained from resin infiltration could also have been examined by visual assessment scale, as the resin infiltration does not camouflage the whole lesion. In this study, the maximum resin was infiltrated into the center of some lesions only [Figure 2], similar to a study by Kim et al.[3]
Figure 2: Resin was infiltrated in center of some developmental defect of enamel lesion giving a “halo appearance”

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   Conclusion Top


In the present study, a marked reduction in the whiteness of Grade I MIH white spot just after infiltration was seen with a decrease in value of 4.8 with standard deviation (SD) 1.9. Furthermore, change in total color was appreciated only after infiltration with a change in the value of 8.8 SD 5.9. Moreover, a reduction in the whiteness of white spot with a decrease in value of 7.9 SD 7.4 and a change in total color with a change in the value of 13.2 SD 6.8 were appreciated 6 months after treatment.

  1. Resin infiltration shows immediate esthetic results in Grade I MIH-affected incisors
  2. Infiltration of white tooth discoloration brings about a reduction in whiteness with the advancement of time
  3. It can be recommended that mild MIH lesions can be treated with minimally invasive treatment such as resin infiltration before trying any invasive approach such as veneering.


Acknowledgment

It is an immense pleasure for me on this occasion to convey my regards to Dr. Seema Thakur for her constant moral support and help during research. My special acknowledgment to Dr. Tripti Chauhan for helping me in statistical interpretations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Bishara SE, Denehy GE, Goepferd SJ. A conservative postorthodontic treatment of enamel stains. Am J Orthod Dentofacial Orthop 1987;92:2-7.  Back to cited text no. 1
    
2.
Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res 2001;35:390-1.  Back to cited text no. 2
    
3.
Kim S, Kim EY, Jeong TS, Kim JW. The evaluation of resin infiltration for masking labial enamel white spot lesions. Int J Paediatr Dent 2011;21:241-8.  Back to cited text no. 3
    
4.
Eckstein A, Helms HJ, Knösel M. Camouflage effects following resin infiltration of postorthodontic white-spot lesions in vivo: One-year follow-up. Angle Orthod 2015;85:374-80.  Back to cited text no. 4
    
5.
Lygidakis NA, Wong F, Jälevik B, Vierrou AM, Alaluusua S, Espelid I, et al. Best Clinical Practice Guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH): An EAPD Policy Document. Eur Arch Paediatr Dent 2010;11:75-81.  Back to cited text no. 5
    
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Arends J, Christoffersen J. The nature of early caries lesions in enamel. J Dent Res 1986;65:2-11.  Back to cited text no. 6
    
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Joiner A, Hopkinson I, Deng Y, Westland S. A review of tooth colour and whiteness. J Dent 2008;36 Suppl 1:S2-7.  Back to cited text no. 7
    
8.
O'Brien WJ, Hemmendinger H, Boenke KM, Linger JB, Groh CL. Color distribution of three regions of extracted human teeth. Dent Mater 1997;13:179-85.  Back to cited text no. 8
    
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Russell AL. The differential diagnosis of fluoride and nonfluoride opacities. Public Health Dent 1963;21:6.  Back to cited text no. 9
    
10.
Zabokova-Bilbilova E, Popovska L, Kapusevska B, Stefanovska E. White spot lesions: Prevention and management during the orthodontic treatment. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2014;35:161-8.  Back to cited text no. 10
    
11.
Meyer-Lueckel H, Paris S. Infiltration of natural caries lesions with experimental resins differing in penetration coefficients and ethanol addition. Caries Res 2010;44:408-14.  Back to cited text no. 11
    
12.
Meyer-Lueckel H, Paris S, Kielbassa AM. Surface layer erosion of natural caries lesions with phosphoric and hydrochloric acid gels in preparation for resin infiltration. Caries Res 2007;41:223-30.  Back to cited text no. 12
    
13.
Paris S, Schwendicke F, Keltsch J, Dörfer C, Meyer-Lueckel H. Masking of white spot lesions by resin infiltration in vitro. J Dent 2013;41 Suppl 5:e28-34.  Back to cited text no. 13
    
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Crombie F, Manton D, Palamara J, Reynolds E. Resin infiltration of developmentally hypomineralised enamel. Int J Paediatr Dent 2014;24:51-5.  Back to cited text no. 14
    
15.
Cohen-Carneiro F, Pascareli AM, Christino MR, Vale HF, Pontes DG. Color stability of carious incipient lesions located in enamel and treated with resin infiltration or remineralization. Int J Paediatr Dent 2014;24:277-85.  Back to cited text no. 15
    
16.
Borges A, Caneppele T, Luz M, Pucci C, Torres C. Color stability of resin used for caries infiltration after exposure to different staining solutions. Oper Dent 2013;39:433-40.  Back to cited text no. 16
    
17.
Araújo GS, Naufel FS, Alonso RC, Lima DA, Puppin-Rontani RM. Influence of staining solution and bleaching on color stability of resin used for caries infiltration. Oper Dent 2015;40:E250-6.  Back to cited text no. 17
    
18.
Yetkiner E, Wegehaupt F, Wiegand A, Attin R, Attin T. Colour improvement and stability of white spot lesions following infiltration, micro-abrasion, or fluoride treatments in vitro. Eur J Orthod 2014;36:595-602.  Back to cited text no. 18
    
19.
Senestraro SV, Crowe JJ, Wang M, Vo A, Huang G, Ferracane J, et al. Minimally invasive resin infiltration of arrested white-spot lesions: A randomized clinical trial. J Am Dent Assoc 2013;144:997-1005.  Back to cited text no. 19
    
20.
Knösel M, Eckstein A, Helms HJ. Durability of esthetic improvement following icon resin infiltration of multibracket-induced white spot lesions compared with no therapy over 6 months: A single-center, split-mouth, randomized clinical trial. Am J Orthod Dentofacial Orthop 2013;144:86-96.  Back to cited text no. 20
    
21.
Della Bona A, Anusavice KJ, Mecholsky JJ Jr. Failure analysis of resin composite bonded to ceramic. Dent Mater 2003;19:693-9.  Back to cited text no. 21
    

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Correspondence Address:
Dr. Ranu Bhandari
Room No 301, Department of Pedodontics, H. P. Government Dental College, Shimla - 171 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCD.JCD_61_18

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