Abstract
Objectives
To determine if resin infiltration is an effective treatment for improving the esthetic appearance of tooth discoloration resulting from development defects of enamel (EDD) and white spot lesions (WSL) by means of a systematic review.
Data sources
A comprehensive search was performed in PubMed, Scopus, Web of Science, LILACS, BBO Library, Cochrane Library, and SIGLE, as well as in the abstracts of IADR conference, and in the clinical trials registry.
Study selection
Clinical studies in patients with whitish tooth discoloration, in which the resin infiltration technique was applied, were included. Color masking was the primary outcome. The methodological quality and risk of biases of included papers was assessed using MINORS criteria for non-randomized (NRS) comparative studies and Cochrane Collaboration for randomized clinical trials (RCT).
Results
From a total of 2930 articles, 17 were assessed for eligibility and 11 remained in the qualitative synthesis. Four NRS and seven RCT studies were selected, the latter consisting of four full-text studies and three conference abstracts. Two studies were excluded from the quality assessment, due to overlapping results. The number of participants (treated teeth) ranged from 18 to 21 (38–74) in the NRS, and 20–83 (20–231) in the RCT studies. Post-orthodontic WSL were the most frequent treated lesions. Initial condition was used as control in the NR studies. In the RCT, resin infiltration was compared to non treatment, remineralization, or bleaching. Overall, partial or complete color masking of affected teeth was reported immediately after resin infiltration. Only two studies followed original outcomes up to one year and reported maintenance of original color masking. Two NR studies were assessed as “moderate” and one as “high” quality. Two RCT were classified as “low” risk of bias in the chosen key domains. The remaining four studies were considered “unclear” or “high” risk of bias.
Conclusion
Although the partial or total masking effect of enamel whitish discoloration has been shown with resin infiltration, there is no strong evidence to support this technique based on the present clinical studies.
Clinical significance
Enamel whitish discolorations in esthetically compromised areas are clinically undesirable. Minimally invasive approaches used as attempts to minimize the discoloration include the resin infiltration technique. The evidence for clinical recommendation of this technique is not strong, thus, further RCT studies with long-term follow-ups should be conducted.
1
Introduction
Whitish enamel discolorations can occur as a consequence of pre- or post-eruptive damage. Fluorosis, traumatic hypocalcification and molar-incisive hypomineralization (MIH) are conditions caused by disturbances during enamel development. The post-eruptive discoloration resulting from caries are called white spot lesions (WSL). All these conditions are associated with a reduction of the enamel mineral phase, altering its chemical composition and, consequently, its optical characteristics .
When these discolorations occur in anterior teeth, compromising the esthetical appearance, minimally invasive color-masking treatments can be used. Topical application of remineralizing agents , microabrasion , and bleaching represent attempts to reverse enamel demineralization and/or to improve tooth appearance. The resin infiltration technique was also found to be useful in these cases .
Resin infiltration is based on the hydrochloric acid erosion of the lesion surface and posterior infiltration of a low-viscosity resin into the intercristaline spaces of hypocalcified or demineralized enamel. This alters the refractive index (RI) of the porous enamel, formerly filled with air (RI = 1.00) or water (RI = 1.33), since the infiltrated resinous material shows a RI (1.52) closer to hydroxyapatite (1.62). As a consequence, the optical characteristics of the affected enamel are altered and it seems like the surrounding sound enamel .
The penetration of the low-viscosity resin into porous enamel with caries or hypomineralization has been shown in in vitro studies. Additionally, color masking efficacy with resin infiltration has been demonstrated using artificial caries models . Some clinical reports also showed favorable esthetic results . Nevertheless, there is a lack of evidence concerning the clinical efficacy of the technique for camouflaging enamel whitish discolorations.
The present study reports the findings of a systematic review focused on the following question: is resin infiltration an effective esthetic treatment for discolorations resulting from enamel development defects and/or white spot lesions?
2
Materials and methods
2.1
Protocol and registration
The study protocol was registered at the PROSPERO database ( www.crd.york.ac.uk/PROSPERO ) under the number CRD42015023862. The recommendations of the PRISMA statement for the report of this systematic review were followed .
2.2
Eligibility criteria
The search strategy was defined based on the elements of the PICO question:
Population: patients with enamel presenting color alterations arising from developmental defects (hypocalcification, hypoplasia, fluorosis, and hypoplasic molar-incisive syndrome) or white spot lesions, with no age restrictions.
Intervention: resin infiltration technique treatment.
Comparison: initial condition, no treatment or any minimally invasive treatment that aims to mask the discolorations (remineralization, bleaching, and microabrasion).
Outcome: esthetical results in terms of color masking.
Non-randomized study designs (before and after clinical condition comparison) and randomized clinical trials (RCT) that evaluated the masking effect of discolored enamel using resin infiltration were eligible. In vitro or in situ studies, editorial letters, pilot studies, historical reviews, case reports, and case series were excluded. When overlapping outcomes were identified, both the studies were included for data extraction, but only the study with the most complete data was assessed for risk of bias.
2.3
Sources and search strategy
An electronic search was performed in MEDLINE via PubMed ( Table 1 ), Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature database (LILACS), Brazilian Library in Dentistry (BBO), and Cochrane Library. An expert librarian (D.M.) supervised the search strategy. No restrictions were placed on the publication date or languages.
| PubMed Search Strategy |
|---|
| (((((((((((((((((((((((((((Dental Enamel[MeSH Terms]) OR Dental Enamel[Title/Abstract]) OR Enamel[Title/Abstract]) OR Fluorosis, Dental[MeSH Terms]) OR Dental Fluorosis[Title/Abstract]) OR Enamel Fluorosis[Title/Abstract]) OR Dental Enamel Hypoplasia[MeSH Terms]) OR Enamel Hypoplasia*[Title/Abstract]) OR MIH[Title/Abstract]) OR Amelogenesis Imperfecta[MeSH Terms]) OR Amelogenesis Imperfecta[Title/Abstract]) OR Tooth Calcification[MeSH Terms]) OR Enamel Defect*[Title/Abstract]) OR Enamel Maturation[Title/Abstract]) OR Tooth Discoloration[MeSH Terms]) OR Tooth Discoloration*[Title/Abstract]) OR Enamel Stain[Title/Abstract]) OR Teeth Discolorations[Title/Abstract]) OR Discoloration* Defect*[Title/Abstract]) OR Dental Caries[MeSH Terms]) OR Dental Caries[Title/Abstract]) OR Dental Decay[Title/Abstract]) OR White Spot*[Title/Abstract]) OR WSL*[Title/Abstract]) OR Tooth Demineralization[MeSH Terms]) OR Enamel Demineralization[Title/Abstract])) AND (((((Resins, Synthetic[MeSH Terms]) OR Synthetic Resin*[Title/Abstract]) OR Dental Resin*[Title/Abstract]) OR Resin infiltration[Title/Abstract]) OR Low viscosity resin[Title/Abstract]) |
The grey literature was consulted using the database System for Information on Grey literature in Europe (SIGLE). The abstracts of International Association for Dental Research (IADR) were consulted (1990–2015) and authors from relevant studies were contacted for additional information. The registered clinical trials site (clinicaltrials.gov) was also accessed. Dissertations and theses were searched using the ProQuest Dissertations and Theses Fulltext database as well as the Periodicos Capes Theses database.
2.4
Study selection and data collection
The studies were initially selected by title and abstracts according to the previously described search strategy. Full texts were obtained for articles identified and judged as potentially eligible. The following data were extracted by two independent authors (A.B.B. and T.M.F.C) and recorded for each included study: study design, age of subjects, number of participants, number of treated teeth, type of lesion, type of treatment, outcome report, follow-up time, and final outcome details. The authors were contacted when data not described in the articles were necessary.
2.5
Risk of bias
Two independent reviewers (A.B.B. and T.M.F.C.) performed quality assessments of the included studies. The evaluation of non-randomized studies was based on a methodological index for non-randomized studies (MINORS) . The MINORS items were classified as: 0- non-reported; 1- reported, but inadequate; 2- reported and adequate. The MINORS scale includes 12 items, the first eight being specifically for non-randomized studies. Since this tool was used only for non-randomized studies, with no distinct comparative groups, only the first eight items were considered. Scores were considered as: 0–4 “very low quality”, 5–8 “low quality”, 9–12 “moderate quality”, and 13–16 “high quality” .
Randomized clinical trials were assessed according to Cochrane Collaboration’s Risk of Bias tool. The criteria for judging risk of bias covers six domains: selection bias (sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), reporting bias (selective reporting), and other sources of bias . These domains were assessed at the study level. The risk of bias of each domain was classified following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 ( ). Since it was not possible to blind participants and personnel due to the nature of intervention, and no other source of bias was assessed, these two sources of bias were not included in the assessment method. The items random sequence generation, blinding of outcome assessment, and selective reporting were considered the key domains for the assessment of the risk of bias. The studies were classified as having a “low”, “high”, or “unclear” risk of bias .
2.6
Meta-analysis
As shown in Table 2 , the selected studies showed a large variability due to different evaluation methods, such as spectrophotometry, digital camera combined with software analysis, and visual scale analysis. Thus, the outcome data were not comparable, since some studies presented CIE L*a*b* data, others exhibited histograms of gray scale, or percentage of reduction of white affected area. Additionally, the control groups in RCT studies also varied, with no treatment, fluoride varnish or dentifrice (remineralization), and bleaching used as the control. Therefore, a meta-analysis was not performed. Nonetheless, a comprehensive extraction of the study data was presented.
| Study ID | Study Design | Subjects’ age mean ± SD [range] (yrs) | Number of subjects (% male) | Number of teeth | Type of Lesion | Treatment | Outcome Report (parameter analyzed) |
Follow-up time | Final Outcome |
|---|---|---|---|---|---|---|---|---|---|
| Kim et al. 2011 | Clinical Efficacy (non-randomized) | 12.5 (DDE) 15.1 (WSL/PO) [n.r.] |
21 (n.r.) | 38 | DDE (MIH and hypocalcification) and WSL/PO | Resin Infiltration | Digital camera/image processing software (CIE L * a * b * ) |
1w | % color changes: Completely masked (DDE = 25%, WSL/PO = 61%) Partially masked (DDE = 35%, WSL/PO = 33%) Unchanged (DDE = 40%, WSL/PO = 6%) Significant differences (p < 0.05) before and after treatment |
| Hammad et al. 2012 | Clinical Efficacy (non-randomized) | 15.3(1.7) [n.r.] |
18 (n.r.) | n.r. | WSL/PO1 Without surface disruption WSL/PO2 With roughened surface |
Resin Infiltration | Digital camera/image processing software (Histograms of gray scale from 0 to 225) |
Immediate | WSL/PO1 Before = 126.09 After = 221.26 WSL/PO2 Before = 95.58 After = 155.61 Significant differences (p < 0.05) for both groups before and after treatment |
| Feng et al. 2013 a | Clinical efficacy (non-randomized) | n.r. [14–28] | 20 | 74 | WSL/PO | Resin Infiltration | Digital camera/image processing software (Histograms of gray scale from 0 to 225) |
1w | % color changes: Completely masked 27% Partially masked 73% Unchanged 0 Significant differences (p < 0.05) before and after treatment (1w) |
| Feng & Chu 2013 a | Clinical efficacy (non-randomized) | n.r. [14–18] | 8 (n.r.) | 48 | WSL/PO | Resin Infiltration | Digital camera/image processing software (Histograms of gray scale from 0 to 225) |
1y | % color changes: Completely masked 22.9% Partially masked 77.1% Unchanged 0 Significant differences (p < 0.05) before and after treatment (1y) |
| Banava & Safaie Yazdi 2011 | RCT | n.r. [n.r.] |
n.r. | 20 | DDE (Fluorosis) | No treatment × resin infiltration | Visual analysis of photographs (Visual analog scale – VAS) |
Immediate | Numerical data (n.r.) Significant differences (p < 0.05) between the groups |
| Wang et al. 2013 | RCT | 15 (n.r.) [12–27] |
29 (48.27) | 70 | WSL/PO | Resin infiltration (RI) × remineralization (fluoride varnish- F) | Intraoral photo/visual analysis performed by dentists (reduction of the white affected area: 0% no reduction; 50% reduction of the half area, 100% complete masking) | 6 m | RI = 53.5 x F = 49.2 Significant differences (p < 0.05) for both groups after treatment. |
| Knösel et al. 2013 b | RCT | 15.5(n.r.) [12–19] |
21 (47.61) | 231 | WSL/PO | Control (no treatment) × Resin infiltration (RI) |
Spectrophotometer (CIE L*a*b*) |
6 m | ΔE baseline vs 6 months (RI = 2.55 × Control = 0.29). Significant differences (p < 0.05) between the groups |
| Senestraro et al. 2013 | RCT | 16.6 (1.8) [14–21] |
20 (n.r.) | 66 | WSL/PO | Control (no treatment) × Short abrasion + Resin infiltration (RI) |
Digital camera/Visual analysis (Visual analog scale − VAS: 0 = no change; 100 = complete masking and area measurement in square mm). | 8 w | VAS (RI = 65.9 x Control = 5.7) Area reduction (RI = 60.9% × Control = 1%). Significant differences (p < 0.05) between the groups |
| Haddad et al. 2014 | RCT | n.r. | 83 (57.83) | n.r. | WSL/PO | Remineralization (Dentifrice with 5000 ppm F + Novamin) × resin infiltration | Laser fluorescence and visual analysis (Gorelick index) | 3 m | Numerical data (n.r.) Significant decrease in the severity of WSL for both treatments (p < 0.05). |
| Eckstein et al., 2015 b | RCT | n.r. (n.r.) [13–19] |
9 (55.5) | 49 | WSL/PO | Control (no treatment) × Resin infiltration (RI) |
Spectrophotometer (CIE L*a*b*) |
12 m | Significant differences achieved by infiltration after 6 months persisted after 12 months (p < 0.05). |
| Gugnani et al 2015 | RCT | [6–14] | 48 (n.r.) | 80 | DDE (Fluorosis) | Bleaching (B) × Resin infiltration (RI) × 2 applications RI (2RI) × Bl + RI | Digital camera/image processing software (CIE L * a * b * ) |
6 m | ΔE baseline vs post-operative (2RI = 6.08 × B + RI = 5.95 × RI = 5.53 × B = 2.53). Significant differences: RI and 2RI > B (p = 0.01). No differences RI = 2RI = B + RI (p > 0.05). No significant differences for post-operative and after 6 m results. |
2
Materials and methods
2.1
Protocol and registration
The study protocol was registered at the PROSPERO database ( www.crd.york.ac.uk/PROSPERO ) under the number CRD42015023862. The recommendations of the PRISMA statement for the report of this systematic review were followed .
2.2
Eligibility criteria
The search strategy was defined based on the elements of the PICO question:
Population: patients with enamel presenting color alterations arising from developmental defects (hypocalcification, hypoplasia, fluorosis, and hypoplasic molar-incisive syndrome) or white spot lesions, with no age restrictions.
Intervention: resin infiltration technique treatment.
Comparison: initial condition, no treatment or any minimally invasive treatment that aims to mask the discolorations (remineralization, bleaching, and microabrasion).
Outcome: esthetical results in terms of color masking.
Non-randomized study designs (before and after clinical condition comparison) and randomized clinical trials (RCT) that evaluated the masking effect of discolored enamel using resin infiltration were eligible. In vitro or in situ studies, editorial letters, pilot studies, historical reviews, case reports, and case series were excluded. When overlapping outcomes were identified, both the studies were included for data extraction, but only the study with the most complete data was assessed for risk of bias.
2.3
Sources and search strategy
An electronic search was performed in MEDLINE via PubMed ( Table 1 ), Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature database (LILACS), Brazilian Library in Dentistry (BBO), and Cochrane Library. An expert librarian (D.M.) supervised the search strategy. No restrictions were placed on the publication date or languages.
| PubMed Search Strategy |
|---|
| (((((((((((((((((((((((((((Dental Enamel[MeSH Terms]) OR Dental Enamel[Title/Abstract]) OR Enamel[Title/Abstract]) OR Fluorosis, Dental[MeSH Terms]) OR Dental Fluorosis[Title/Abstract]) OR Enamel Fluorosis[Title/Abstract]) OR Dental Enamel Hypoplasia[MeSH Terms]) OR Enamel Hypoplasia*[Title/Abstract]) OR MIH[Title/Abstract]) OR Amelogenesis Imperfecta[MeSH Terms]) OR Amelogenesis Imperfecta[Title/Abstract]) OR Tooth Calcification[MeSH Terms]) OR Enamel Defect*[Title/Abstract]) OR Enamel Maturation[Title/Abstract]) OR Tooth Discoloration[MeSH Terms]) OR Tooth Discoloration*[Title/Abstract]) OR Enamel Stain[Title/Abstract]) OR Teeth Discolorations[Title/Abstract]) OR Discoloration* Defect*[Title/Abstract]) OR Dental Caries[MeSH Terms]) OR Dental Caries[Title/Abstract]) OR Dental Decay[Title/Abstract]) OR White Spot*[Title/Abstract]) OR WSL*[Title/Abstract]) OR Tooth Demineralization[MeSH Terms]) OR Enamel Demineralization[Title/Abstract])) AND (((((Resins, Synthetic[MeSH Terms]) OR Synthetic Resin*[Title/Abstract]) OR Dental Resin*[Title/Abstract]) OR Resin infiltration[Title/Abstract]) OR Low viscosity resin[Title/Abstract]) |
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