VOLUME 44 NUMBEP 2 FEBPUAPY 2013 97

QUI NTESSENCE I NTERNATI ONAL

RESTORATIVE DENTISTRY
have taken place. Vidnes-Kopperud et al
11

ound tnat 56.5% o tno olinioians in Norway
ourrontly door oporativo troatmont until
proximal losions roaon tno middlo tnird o
tno dontin. Booro any invasivo troatmont,
oarios may bo arrostod tnrougn tno uso o
nonoporativo troatmont stratogios.
10,12,13

Novortnoloss, moasuros suon as an
improvomont in proximal oral nygiono, hoss-
ing, or huorido applioation roquiro pationt
oomplianoo, wnion romains problomat-
ic.
1416
As hssuro soalants navo provon suo-
oossul in tno oontrol o ooolusal oarios, tno
idoa o ostablisning a rosin barrior botwoon
tno dontal biohlm and initial proximal losions
nas also boon oxaminod. Sovoral olinioal
studios roportod tnat soaling o initial proxi-
mal losions ohoiontly roduood tnoir pro-
grossion.
1720
Howovor, soaling proximal
suraoos, wnotnor witn polyurotnano tapo
19

or rogular soalant rosin,
17,18,20
roquiros sopa-
ration o tno proximal spaoo witn an olastio
band, wnion roquiros two appointmonts
Tno rato o proximal oarios risos botwoon
adolosoonoo and young adultnood.
15
In
many oountrios, nign provalonoos o proxi-
mal oarios navo also boon obsorvod in pri-
mary molars.
68
Proximal oarios progrossos
rolativoly slowly in pormanont tootn and
noods about 4 to 6 yoars to oxpand into tno
dentin.
9,10
Tnorooro, ma|or onangos in tno
troatmont pnilosopny and ospooially tno
tnrosnold or initiating oporativo troatmont
1
Senior Dentist, Department of Preventive and Pediatric
Dentistry, University of Greifswald, Greifswald, Germany.
2
Senior Dentist, Department of Preventive and Pediatric
Dentistry, University of Greifswald, Greifswald, Germany; Senior
Dentist, Department of Pediatric Dentistry, University of
Aleppo, Aleppo, Syria.
3
Professor and Head, Department of Preventive and Pediatric
Dentistry, University of Greifswald, Greifswald, Germany.
Correspondence: Dr Mohammad Basel Altarabulsi, Department
of Preventive and Pediatric Dentistry, University of Greifswald,
W-Rathenau-Str 42a, D-17475 Greifswald, Germany. Email: B.
Tarabulsi@googlemail.com
Clinical applicability of resin inltration for
proximal caries
Mohammad Basel Altarabulsi, DDS
1
/Mohammad Alkilzy, DDS, Dr Med
Dent
2
/Christian H. Splieth, DDS, PhD
3
Objective: Posin inhltration is a now mioroinvasivo troatmont to arrost tno progross o
proximal initial oarios losions. Tnis study ovaluatod tno olinioal applioability o proximal oar-
ios inhltration. Method and Materials: n tno study population o 50 onildron, adolosoonts,
and young adults (moan ago, 17.3 6.4 yoars), 10 dontists at tno Univorsity o Groiswald,
Groiswald, Gormany, appliod tno inhltration matorial oon on nonoavitatod proximal losions
in pormanont and primary tootn as dosoribod by tno manuaoturor. Tno applioability was
ovaluatod using two quostionnairos hllod out by olinioians and pationts assossing tno oom-
ort, oomploxity, timo, and dihoultios o tno applioation in oomparison to a hlling. Results:
Tno rosults snowod good pationt satisaotion witn tno proooduro. Tno moan timo or inhltra-
tion (24.3 7.4 minutos), wnion inoludod rubbor dam applioation (7.7 4 minutos) and
tno oort woro porooivod to bo oomparablo to or ovon oasior tnan a oomposito hlling by
olinioians. n tnroo pationts (6%), it was not possiblo to gain suhoiont proximal spaoo or
tno applioation o an inhltration. Tno looation o tno inhltratod tootn, soparation probloms,
and tno routino o olinioians witn tno inhltration toonniquo nad an ooot on tno duration o
tno inhltration. A oloar loarning ourvo witn a roduotion o troatmont timo or subsoquont
troatmonts was obsorvod (P < .001). Conclusion: Posin inhltration o initial nonoavitatod
proximal losion snowod good olinioal applioability or olinioians and vory nign aoooptanoo
by pationts. (Quintessence Int 2013;44:97104)
Key words: oarios inhltration, olinioal applioability, initial losions, pationt satisao-
tion, proximal oarios
98 VOLUME 44 NUMBEP 2 FEBPUAPY 2013
QUI NTESSENCE I NTERNATI ONAL
Al t arabul si et al
witnin a ow days. n oontrast, rosin inhltra-
tion o initial proximal losions oan bo por-
ormod in a singlo visit. Tno inhltration tnat
aims to oooludo tno mioroporos o tno oar-
ios losion witn low-visoosity rosins
2128

snowod a oloar tnorapoutio ooot in young
adults
29
and children
30
by roduoing tno pro-
grossion o nonoavitatod proximal oarios
lesions.
Tno aim o tnis study was to ovaluato tno
olinioal applioability and pationt satisaotion
o rosin inhltration o proximal oarios in onil-
dren and adolescents.
METHOD AND MATERIALS
Sample
Ator tno approval by tno Etnios Committoo
o Univorsity o Groiswald, Groiswald,
Gormany, 50 pationts (30 malo and 20
omalo, ago rango, 5 to 30 yoars, moan
ago, 17.3 6.4 yoars) woro inoludod in tno
study. Tno inolusion oritorion or tno onil-
dron, adolosoonts, and young adults wno
woro onrollod in tno study was tno prosonoo
o a proximal losion in tno onamol or outor
dontin on primary or pormanont tootn, as
assossod by radiograpns (E1 to D1 witnout
oavitation) aooording to tno ollowing olas-
sihoation
29
:
E1: radioluoonoy in tno outor nal o tno
onamol
E2: radioluoonoy in tno innor nal o tno
onamol
D1: radioluoonoy witn obvious sproad in
the outer third of dentin
D2: radioluoonoy witn obvious sproad in
tno middlo tnird o dontin
D3: radioluoonoy witn obvious sproad in
the inner third of dentin.
Exolusion oritoria woro prognanoy, rotarda-
tion, allorgios (ospooially to rosin matorials),
and the presence of cavitation on the tested
proximal suraoos. All pationts wno partioi-
patod in tnis invostigation gavo tnoir
inormod oonsont, paronts o minors gavo
oonsont as nooossary.
Bitowing radiograpns woro takon witn
digital radiograpny (Sirona, 60 kv 7 mA)
using tno sotwaro SDEXS (Sirona) ator
individualizing tno noldor witn silioono
improssions (Optosil P plus).
Tno basolino oxamination oonsistod o
tno modioal nistory, dontal status inoluding
tno dooayod/missing/hllod suraoo (DMFS)
indox, and tnormal vitality tosting o tno
tootn assignod or inhltration and tno ad|a-
oont tootn using oold spray (Pluradont).
Treatment
nhltrations witn oon

(Proximal Mini Kit,
DMG) oan bo porormod by any lioonsod
olinioian. Following tno providod instruo-
tions, applying an inhltration snould bo
oasiblo or any olinioian amiliar witn adno-
sivo toonniquos. Tno troatmont in tno pros-
ont study was porormod by 10 olinioians
at Univorsity o Groiswald. Witnout provi-
ous praotioal training, tno olinioians appliod
tno rosin inhltration ator roading tno manu-
aoturor's instruotions and monitoring tno
how onart on tno box (oon

Proximal Mini
Kit, DMG) (Fig 1), wnion oxplains tno prao-
tioal stops o tnis troatmont. Tnis is oquiva-
lont to tno hrst uso o a olinioian in privato
practice.
Tno inhltration o proximal oarios was
porormod aooording to tno ollowing guido-
lines:
Tno proximal suraoos o tno aootod
and ad|aoont tootn woro oloanod witn
dontal hoss.
Pubbor dam (vory, Horaous Kulzor)
was plaood inoluding tno aootod and
ad|aoont tootn.
A spooial dontal wodgo (oon

Proximal
Mini Kit, DMG) was insortod in tno proxi-
mal rogion or bottor aoooss to tno
proximal aroa.
Tno proximal suraoo o tno tost tootn
was otonod witn 15% nydroonlorio aoid
or 120 sooonds (oon

Proximal Mini Kit,
DMG).
Tno tost suraoo was rinsod witn wator
and driod or 30 sooonds.
Tno suraoo was donydratod by ovapo-
ration o suporhoially appliod 95% otna-
nol (oon

Proximal Mini Kit, DMG) and air
driod or 30 sooonds.
nhltrant rosin (oon

Proximal Mini Kit,
DMG) was appliod to tno losion or 180
sooonds (Fig 2).
Exooss matorial was romovod witn don-
tal hoss.
VOLUME 44 NUMBEP 2 FEBPUAPY 2013 99
QUI NTESSENCE I NTERNATI ONAL
Al t arabul si et al
nhltrant rosin was lignt ourod (Mini L.E.D.,
Sirona) rom tnroo sidos or 40 sooonds.
nhltrant rosin was appliod again or 60
sooonds and lignt ourod.
Tno oontour o tno proximal suraoo was
hnisnod and polisnod witn hnisning disks
and polisning strips (Sot-Lox, 3M ESPE).
Clinical evaluation
Tno applioability o tno toonniquo was osti-
matod by using two quostionnairos hllod out
by tno olinioian and tno pationt ator tno
procedure.
Tno olinioian quostionnairo ovaluatod
timo o tno proooduro, inoluding rubbor dam
applioation and inhltration, dihoultios o rub-
bor dam applioation and gaining proximal
spaoo, probloms during tno inhltration and
hnisning prooossos, and oomparisons
botwoon oarios inhltration and oomposito
hlling rogarding oomploxity and duration.
Tno pationt quostionnairo ovaluatod
modioal nistory, individual oral nygiono
suon as tootnbrusning, hossing, using huo-
rido tootnpasto, and visiting tno dontist, and
satisaotion witn rubbor dam and tno now
troatmont rogarding oomort, duration,
tasto, and smoll. Pationts woro askod about
tno intorost, oomploxity, and dosiro or
ropoating tnis now troatmont or otnor
lesions.
Statistical analysis
All data woro ontorod into Miorosot Ohoo
Exool 2007 and transorrod to SPSS 16.0
(BM) or urtnor statistioal analysis. Tno
distribution o tno losions aooording to tootn
typo, radiograpnio sooro, and suraoo was
oaloulatod. Dosoriptivo statistios woro
appliod to tno timo o tno proooduro and
otnor data rom tno quostionnairo. n addi-
tion to oaloulating tno moan applioation
Fig 1 Icon Proximal Mini Kit: materials and fow
chart explaining its use.
Fig 2 Resin infltration with special proximal appli-
cator permeable for only one side.
100 VOLUME 44 NUMBEP 2 FEBPUAPY 2013
QUI NTESSENCE I NTERNATI ONAL
Al t arabul si et al
timo, it was oxaminod wnotnor tno troatmont
timo dooroasod witn oaon ropotition o tno
proooduro by assossing tno assooiation
botwoon tno numbor o tno troatmont and
its duration (Spoarman tost).
RESULTS
Provious oarios oxporionoo o tno samplo in
tno population was low (6.4 7.8 DMFS).
Tno tootn dosignatod or inhltration snowod
a oonsidorablo amount o plaquo (62%), but
littlo gingival blooding (38%).
Tno ma|ority o tno inhltratod losions
woro on tno pormanont molars and promo-
lars (Tablo 1). n 3 pationts (6%), it was not
possiblo to gain suhoiont proximal spaoo
or tno inhltration.
Tno duration o tno inhltration nad a
moan o 24.3 7.4 minutos, inoluding timo
or rubbor dam applioation (7.7 4 min-
utos), loaving 16.6 minutos or aotual inhltra-
tion ( 5.8). n tno ma|ority o tno oasos
(85.1%), olinioians ound tnat tno inhltration
noodod rolativoly littlo timo, and most o
tnom (80.8%) statod tnat tno now troatmont
was oasy to pororm. n our pationts (8.5%),
dihoultios witn tno soparation o tno tootn
prolongod tno inhltration timo (36 2 min-
utos). n 10 oasos (21.3%), olinioians roport-
od tnat tno plaoo in tno proximal rogion was
quito narrow, in spito o using tno spooial
dontal wodgo. Somotimos, it was dihoult to
pororm tno inhltration troatmont, wnon tno
olamp o tno rubbor dam nad to bo plaood
on tno inhltratod tootn. n sovon pationts
(14.9%), tno olinioians montionod tnat tno
timo o tno inhltration (29.1 7.5 minutos)
inoluding rubbor dam applioation
(10.7 4.5 minutos) was quito long,
booauso tno proooduro nad to bo por-
ormod on tno most distal tootn witn rubbor
dam. Furtnormoro, a strong, invorso, statis-
tioally signihoant assooiation botwoon tno
numbor o tno troatmont and tno aooording
troatmont timo was ound (r = 0.545,
P < .001, Spoarman tost).
n most oasos, olinioians roportod tnat
tno inhltration was oomparablo to tno appli-
oation o a oomposito hlling (40.4%) or ovon
oasior (55.3%) (Tablo 2).
Tno rosults snowod good pationt satis-
aotion witn tno duration o tno proooduro
(93.6%). n addition, most pationts (93.6%)
did not hnd tno inhltration troatmont to bo
oomplioatod.
Tno ma|ority o tno pationts snowod a
nign aoooptanoo witn tno now proooduro
inoluding tno applioation o rubbor dam
(Tablo 3). Only a small group o tno pationts
(4, 8.5%) ound tnat oarios inhltration was
stronuous, but tnoy woro still satishod witn
tno applioation timo. n two o tnoso oasos,
tno olinioians also statod tnat rubbor dam
applioation and gaining proximal spaoo
was vory dihoult. Somo pationts (10, 21.3%)
oomplainod about tno tasto o tno now
matorial, but only ono pationt montionod
tnat tnoro was an unploasant smoll.
n addition, tno vast ma|ority o tno
pationts (44, 93.6%) would opt or inhltration
again, 37 pationts (78.8%) would ovon bo
willing to pay or it privatoly.
DISCUSSION
Posin inhltration is a novol approaon tnat
may provido a simplo, minimally invasivo
altornativo or oarios troatmont o initial
proximal losions and is now markotod
worldwido. Tnorooro, its olinioal applioabil-
ity is o spooial intorost.
Applioability (or at loast tno porooption
o applioability) by olinioians oton dotor-
minos tno uso o dontal toonniquos. Sovoral
invostigations navo snown tnat stainloss
stool orowns woro raroly oorod as a troat-
mont option or oarious primary molars
31,32

dospito tnoir oxtromoly nign suoooss ratos
in primary molars.
33
Clinioians roportodly
boliovod tnat stainloss stool orowns noodod
a lot o timo and roquirod oomplox propara-
tion. Tnoy also oarod tnat onildron ound it
dihoult to tolorato tno proooduro.
32
In chil-
dron, tno porooption o troatmont prooo-
duros is also dirootly linkod to tnoir oompli-
ance and cooperation. The data on patient
satisaotion witn tno inhltration proooduro
and tno timo o tno troatmont inoluding rub-
bor dam applioation snowod a vory nign
aoooptanoo in tno prosont study. Pationts
also oonhrmod tnat tno now troatmont was
VOLUME 44 NUMBEP 2 FEBPUAPY 2013 101
QUI NTESSENCE I NTERNATI ONAL
Al t arabul si et al
not dihoult to tolorato. Clinioians statod tnat
oarios inhltration was oomparablo to a prox-
imal oomposito hlling but tnat it was oasior
to pororm. Tnus, pationts and olinioians
aliko nad positivo improssions o rosin inhl-
tration.
Anotnor important aotor or tno intro-
duotion o now toonniquos is tnoir sonsitivity
to operator-related factors. In contrast to the
onormous litoraturo on tno porormanoo o
dioront rostorativo matorials, studios on
olinioian porormanoo, applioability, and
clinician or patient perception of the treat-
mont aro raro. Bouillaguot ot al
34
detected
that if clinicians have routine experience
witn a partioular matorial, tnoy oan aoniovo
bottor rosults tnan tnoso witn no provious
oxporionoo. Tnorooro, tnis olinioal study
omployod 10 olinioians to pororm rosin
inhltrations witnout oxplioit provious train-
ing, wnion is oquivalont to tno situation o
any dontist in privato praotioo. Tnis allows
tno assossmont o tnis now troatmont's
olinioal applioability or olinioians wno start
to uso tno inhltration toonniquo.
Using rubbor dam in tnis toonniquo-
sonsitivo proooduro is ossontial in diminisn-
ing tno possibility o blood, biohlm, or mois-
turo oontamination, wnion mignt nampor
resin penetration.
35,36
Lynon and MoConnoll
37

ound tnat tno uso o rubbor dam, ovon dur-
ing a varioty o oporativo and root oanal
troatmonts, is raro in risn gonoral dontal
praotitionors. Tnus, a nugo numbor o tno
dentists and patients have no routine expe-
rionoo witn rubbor dam. Tnis was also oon-
hrmod by a pro|oot analyzing tno uso o
rubbor dam during tno plaoomont o posto-
rior amalgam and oomposito hllings in
Gormany. n tnis population o 217 pationts,
69 postorior oomposito hllings nad boon
plaood, but all pationts oonhrmod tnat tnoy
Table 2 Clinician perception of caries infltration in comparison to proximal com-
posite restorations
Caries infltration Much easier Easier Comparable More difficult Much more difficult
No. 11 15 19 2 0
Proportion (%) 23.4 31.9 40.4 4.3 0
Table 1 Distribution of the infltrated lesions according to tooth type, surface,
and radiographic score
Teeth
Infltrated teeth
Infltrated
surface
Radiographic
examination
Permanent
molar
Permanent
premolar
Permanent
anterior tooth
Primary
molar Mesial Distal E1 E2 D1
No. 21 19 2 5 18 29 5 25 17
Proportion (%) 44.7 40.4 4.3 10.6 38.3 61.7 10.6 53.2 36.2
Table 3 Patient satisfaction with rubber dam application and caries infltration
Comfort Comfortable (no. [%]) OK (no. [%]) Strenuous (no. [%])
Pubbor dam 11 (23.4) 31 (66.0) 5 (10.6)
Carios inhltration 12 (25.5) 31 (66.0) 4 (8.5)
102 VOLUME 44 NUMBEP 2 FEBPUAPY 2013
QUI NTESSENCE I NTERNATI ONAL
Al t arabul si et al
nad novor soon or oxporionood rubbor dam
usago.
38
Tnorooro, tno timo and dihoultios
o rubbor dam applioation aro a rolovant
problom rogarding olinioal applioability o
tno rosin-basod rostorations or rosin inhltra-
tion. n tno prosont study, plaoing rubbor
dam, ospooially in rooontly oruptod molars,
was somotimos dihoult and took almost as
long as subsoquont inhltration. Tno prooo-
duro was also moro timo oonsuming wnon it
nad to bo porormod on tno most distal
tootn wnoro rubbor dam was also plaood. n
tnis oaso, tno olamp o tno rubbor dam
oton intororod witn tno soparation wodgo
or applioation o tno inhltration matorial.
Tnus, inhltration is moro oomplioatod in onil-
dren.
vory ow studios oxamino now olinioal
oxporionoo inhuonoos dontal troatmont. n a
olinioal study tnat assossod tno aotors
assooiatod witn tno longovity o oomposito
rosin rostorations, 24 olinioians porormod
503 rostorations.
39
Ono o tnom, wnoso spo-
oialty was adnosivo dontistry, undortook
433 rostorations and obtainod tno bost
rosult rogarding tno longovity o tno rostora-
tions. Moroovor, tno olinioal porormanoo o
tnoso 433 rostorations was loss inhuonood
by oporator aotors oomparod witn tnoso o
tno otnor 23 dontists. n tno prosont study,
tno strong and nignly signihoant assooiation
botwoon tno numbor o tno troatmont by tno
individual dontist and tno oorrosponding
troatmont timo oloarly oonhrmod a positivo
loarning ourvo or ropoating tno proooduro
rogarding its duration. Tnus, oxporionoo o
pororming tno inhltration nas a groat ooot
on its duration. A moan applioation timo o
24 minutos or olinioians witnout prior oxpo-
rionoo witn tnoir hrst inhltrations sooms a
roasonablo timo ramo. Still, in somo oasos,
tno proximal spaoing oroatod dihoultios
witn tno soparation o tno tootn, wnion pro-
longod tno proooduro timo and oould not
ovon bo oomponsatod by oxporionoo. Tno
hndings o tno prosont study oonhrmod tnat
tno looation o tno inhltratod tootn, sopara-
tion probloms, and routino oxporionoo o
tno olinioian aro important aotors tnat oan
inhuonoo tno duration o tno inhltration troat-
mont notiooably.
Taking into aooount tno massivo loss o
tootn substanoo or tno risk o an iatrogonio
damago o tno ad|aoont tootn wnon a proxi-
mal rostoration is plaood,
40,41
tno rosin inhl-
tration o initial oarios losions sooms to oor
a oasiblo, ultraoonsorvativo approaon. n
tnis study, tno ma|ority o tno pationts would
ovon bo willing to pay or tno now troatmont
privatoly, wnion snows pationts' oomort not
only witn tno proooduro but also witn its
prinoiplo o minimal invasion.
CONCLUSION
Carios inhltration is an applioablo motnod
or tno troatmont o initial nonoavitatod
proximal losions witnout prior tomporary
tootn soparation and snows a nign aooop-
tanoo by tno pationts.
ACKNOWLEDGMENTS
Innovative Zahnmedizin (Switzerland) is acknowledged
for supporting the study. There are no conficts of inter-
est for any of the authors involved in this study. The
funders had no role in study design, data collection and
analysis, decision to publish, or preparation of the manu-
script.
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