|Year : 2014 | Volume
| Issue : 2 | Page : 176-180
Esthetic improvement of white spot lesions and non-pitted fluorosis using resin infiltration technique: Series of four clinical cases
Neeraj Gugnani1, IK Pandit1, Virinder Goyal2, Shalini Gugnani3, Jyoti Sharma4, Shikha Dogra2
1 Department of Pedodontics and PCD, D.A.V. (C)Dental College, Yamuna Nagar, Haryana, India
2 Department of Pedodontics, D.I.D.R.S., Faridkot, Punjab, India
3 Department of Periodontology and Oral Implantology, D.A.V. (C)Dental College, Yamuna Nagar, Haryana, India
4 Department of Pedodontics, D.A.V. (C)Dental College, Yamuna Nagar, Haryana, India
|Date of Web Publication||17-Apr-2014|
Department of Pedodontics and PCD, DAV (C)Dental College, Yamuna Nagar - 135 001, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
White opacities have always been a major concern of esthetics for patients and can have varying etiology. In general, white discolorations of enamel might be due to dental fluorosis, early caries (white spot lesions), developmental defects etc. Conventional treatment options available for such opacities include non-invasive and invasive approaches. Recently, a new "micro-invasive" technique has been introduced as an alternative therapeutic approach that improves such opacities esthetically, in a single sitting, is painless and exhibits no complications. This case series illustrates the use of resin infiltration to treat fluorosis stains and WSLs, exhibiting significant improvement in esthetics.
Keywords: Brown stains, dental caries, dental fluorosis, minimally invasive technique, non-pitted fluorosis, resin infiltration, white spot lesions
|How to cite this article:|
Gugnani N, Pandit I K, Goyal V, Gugnani S, Sharma J, Dogra S. Esthetic improvement of white spot lesions and non-pitted fluorosis using resin infiltration technique: Series of four clinical cases. J Indian Soc Pedod Prev Dent 2014;32:176-80
|How to cite this URL:|
Gugnani N, Pandit I K, Goyal V, Gugnani S, Sharma J, Dogra S. Esthetic improvement of white spot lesions and non-pitted fluorosis using resin infiltration technique: Series of four clinical cases. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Nov 22];32:176-80. Available from: http://www.jisppd.com/text.asp?2014/32/2/176/130996
| Introduction|| |
White tooth discoloration can result from a number of factors and are usually a concern of esthetics for patients. In general, white discolorations of enamel might be due to dental fluorosis, opacities due to early caries called as white spot lesions (WSL's) and other opacities for example-developmental defects.
WSLs are the manifestation of demineralization of smooth enamel surface of crown. 
Enamel demineralization leads to enamel crystal dissolution, which creates pores between the enamel rods. This results in alteration of the refractive index in the affected area, that leads to loss of surface shine and alteration in the internal reflection resulting in greater visual enamel opacity. 
Such lesions frequently get formed in patients who have undergone fixed orthodontic treatment, as the fixed orthodontic appliance complicates daily oral hygiene maintenance and increases the risk of subsequent enamel demineralization. 
These lesions may or mayn't represent the cariological problem but are always a concern of esthetics and are frequently called as orthodontic scars. 
Other factors like poor oral hygiene, xerostomia, high caries index etc. also lead to the formation of white spot lesions. These lesions are generally the precursors of frank enamel caries and hence the treatment of such lesions should aim upon both improving the esthetics and prevention of caries progression. 
The other main cause of white opacities is dental fluorosis. Fluorosis is a clinical manifestation of chronic exposure to high intakes of fluoride during tooth development. Although fluoride from any source can cause fluorosis, high concentration of naturally occurring fluorides in drinking water has been reported as the main cause. 
The sign of dental fluorosis ranges from opaque white flecks to unsightly dark brown spots to pitting. This difference in the severity of dental fluorosis depends on when and for how long the exposure to high fluoride levels has occurred, patient's age, weight, nutritional factors, and individual response.
Regarding the white spot lesions and fluorosis, prevention is the best way to control them. Guided tooth brushing, use of both professional and home care topical fluorides have been documented to play a pivotal role in the prevention of white spot lesion formation  while for fluorosis, controlling the fluoride intake is the best preventive measure. However, when WSLs/fluorosis has already occurred and is causing esthetic problems to the patient, some form of treatment has to be imparted. For white spot lesions, conventionally, the same measures that are used for prevention are also used for reversal of the lesions, that is, improved oral hygiene practices, use of topical fluorides, remineralization agents like ACP-CPP.  While the more aggressive approaches include micro abrasion, which includes application of acidic and abrasive compounds to enamel surfaces and, if these lesions don't get reversed and lead to frank cavitations, the only possible treatment option left is invasive treatment that primarily includes composite restoration or veneers.
For fluorosis, tooth bleaching and micro abrasion are recommended procedures for non-pitted fluorosis while composites and veneers are recommended for pitted and severe fluorosis. Thus, there's a range of treatment strategies available that are either non-invasive or invasive in nature. Recently, a new "micro-invasive" technique has been introduced as an alternative therapeutic approach that not only improves such opacities esthetically but also prevents further progression of early carious lesions (WSL's). The purpose of this case series is to assess the masking effects of resin infiltration technique in post-orthodontic white spot enamel lesions and non-pitted fluorosis stains and to discuss the mechanism of action and limitations of this new minimally invasive therapy.
| Case Reports|| |
Four patients who presented in the out-patient Department of Pedodontics and Preventive dentistry, DAV(C) Dental College, Yamuna Nagar, with the chief complaint of unesthetic appearance due to the presence of white/rown stains in the maxillary incisors were clinically examined in their first visit and were differentiated as fluorosis or non-fluoride opacities using Russell's criteria.
Further, the history of the patients also helped us to make the differential diagnosis, and the patients were classified as follows:
Clinical cases - I- III
Two of these were male patients aged 10 and 12 years, respectively, and both reported with the chief complaint of unesthetic appearance due to the presence of white stains in upper front tooth while third patient, 12-year-old male, complained of brown stains on upper front teeth. On oral examination, all the three patients were diagnosed to have non-pitted fluorosis opacities on the labial aspect of tooth 11 in first two patients and brown-stained non-pitted fluorosis in tooth 12 in the third patient.
Post-orthodontic white spot lesion.
Fourth patient was a 14-year-old male, who had recently undergone fixed orthodontic therapy and complained of unesthetic white-colored stains on upper front teeth. He was diagnosed to have post-orthodontic white spot lesions, also called as white scars.
For the treatment decision making, we considered the importance of shiny teeth and smile and subsequent implication for self-esteem in these ages. Ethical approval was sought from Institutional Review Board, DAV(C) Dental College and Hospital, Yamuna nagar, and informed written consent was obtained from patients and their parents.
For all these lesions, we planned to use the novel resin infiltration technique. The resin infiltration kit (ICON, DMG, Germany) contains 3 syringes, that is acid gel (ICON Etch), drying agent (ICON Dry), and resin infiltrant (ICON Infiltrant) [Figure 1].
The etching gel is composed of 15% HCl, water, silica and additives, the drying agent is ethanol, and the resin infiltrant is composed of tetra ethylene glycol dimethacrylates, additives, and initiators.
For the purpose of resin infiltration of the lesions, rubber dam was initially applied to protect the soft tissues and achieve clean and dry working conditions [Figure 2]a. The teeth were cleaned using prophylaxis paste, which was followed by steps of infiltration.
First step included the application of 15% HCl gel (ICON Etchant) [Figure 2]b for two minutes. The etchant gel was applied using the special applicator tip provided in the kit and was stirred with a micro brush to achieve a homogenous "etchy" pattern. Subsequently, the etching gel was washed away with water spray for 30 seconds.
Second step involved the application of ethanol (ICONDry) supplied with the kit [Figure 2]c. The ethanol desiccates the lesion body and removes the water retained in the microporosity of enamel lesion. This is followed by air drying of the tooth surface and leads to accentuated picture of white porosity.
Last step involved the application of low viscosity resin infiltrant (ICON Infiltrant), which was left for 3 minutes to allow its penetration deep into the lesion [Figure 2]d.
After 3 minutes, the excess resin on the tooth surface was wiped away with cotton rolls and dental floss. This was followed by light cure polymerization for 40 seconds [Figure 2]e.
Clinically, changes were remarkably evident, and immediate improvement in esthetics was observed [Figure 2]f. Same treatment was imparted for all the cases. The resin infiltration technique was able to provide immediate esthetic improvement in teeth affected with post-orthodontic WSL [Figure 3]a and b] and in mild to moderate white chalky fluorosis, [Figure 2] and [Figure 4]a,b, and significant improvement was also obtained in brown fluorosis stains [Figure 4]c and d.
| Discussio|| |
The ultimate goal of treatment of tooth discoloration is to produce an acceptable esthetic result as conservatively as possible. 
Conventionally, for WSLs, re-mineralization is done, but usually such lesions take a long time, and sometimes, the superficial lesion body becomes mineralized while the underlying lesion body is still porous and thus, the whitish appearance often persists.  Moreover, sometimes during remineralization, exogenous stains get incorporated into the lesion causing formation of brown spots, which are of even more esthetic concern than WSL. 
Treatment of fluorosis is conventionally done using office/home bleaching with different concentrations of hydrogen peroxide or carbamide peroxide. However, the most frequent limitation of these agents is gingival irritation, tooth sensitivity, and sometimes even reversible pulpitis.
Resin infiltration involves etching of the lesion with 15% hydrochloric gel. This is done to remove the pseudo intact surface layer covering the deep lesion body in a WSL.  Alcohol is applied to allow proper desiccation for resin to soak in the lesion body. Thus, the low viscosity resin-infiltrant enters the porous enamel,  and now the pores, which were early filled with water (refractive-index = 1.33), are filled with infiltrant (Refractive-index of 1.46) whose refractive index matches more closely as that of enamel (1.62-1.65).
Hence, the improvement in esthetics in all the four cases can be attributed to blending of enamel lesions, with the surrounding sound enamel, based on changes in the refractive index. The infiltration of the lesion by low-viscosity resin makes this a promising procedure in improving the esthetics of non-pitted fluorosis and white spot lesions, with an added advantage of stopping the caries progression in WSLs.
Though various studies have demonstrated the efficacy of RI technique in arresting the lesion  and have shown improvement in esthetics of WSLs,  fluorosed teeth,  MIH affected teeth, and other hypoplasia stains  but with varying degrees of success. One of the limitations of the technique is the need to follow the strict diagnostic criteria to distinguish between the developmental and non-developmental opacities as RI shows limited effects in cases of developmental defects. Further, it is a radiolucent material, which may be of concern for some dentists. Lastly, long-term clinical studies are still required to study the stability, the esthetic changes, and to discern its suitability to be used for different types of white-brown opacities.
Conclusively, RI is a micro invasive, single sitting, painless technique that remarkably improves the esthetics in non-pitted fluorosis and WSLs.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]