Journal of Dental Research

http://jdr.sagepub.com/

Infiltrating/Sealing Proximal Caries Lesions : A 3-year Randomized Clinical Trial

S. Martignon, K.R. Ekstrand, J. Gomez, J.S. Lara and A. Cortes
J DENT RES 2012 91: 288 originally published online 17 January 2012
DOI: 10.1177/0022034511435328

The online version of this article can be found at:

http://jdr.sagepub.com/content/91/3/288

Published by:

http://www.sagepublications.com

On behalf of:
International and American Associations for Dental Research

Additional services and information for Journal of Dental Research can be found at:

Email Alerts: http://jdr.sagepub.com/cgi/alerts

Subscriptions: http://jdr.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Feb 8, 2012

OnlineFirst Version of Record - Jan 17, 2012

What is This?

Downloaded from jdr.sagepub.com at International Association for Dental Research on September 20, 2012 For personal use only. No other uses without permission.

© 2012 International & American Associations for Dental Research

 RESEARCH REPORTS
Clinical

S. Martignon1*, K.R. Ekstrand2,

J. Gomez1, J.S. Lara1,
Infiltrating/Sealing Proximal
and A. Cortes1 Caries Lesions: A 3-year
1
Caries Research Unit UNICA, Dental Faculty, Universidad El
Bosque, Cra. 7B Bis No. 132-11, Bogotá, Colombia; and
Randomized Clinical Trial
2
Section of Cariology, Endodontics, Paediatric Dentistry and
Clinical Genetic, School of Dentistry, Faculty of Health
Sciences, University of Copenhagen, Copenhagen, Denmark;
*corresponding author, martignonstefania@unbosque.edu.co

J Dent Res 91(3):288-292, 2012

Abstract
This randomized split-mouth controlled clinical
trial aimed at assessing the therapeutic effects of
infiltration vs. sealing for controlling caries pro-
gression on proximal surfaces. Out of 90 adult
students/patients assessed at university clinics and
agreeing to participate, 39, each with 3 proximal
lesions identified radiographically around the
enamel-dentin junction to the outer third of the
dentin, were included. Lesions were randomly
allocated for treatment to test-A (Infiltration:
ICON-pre-product; DMG), test-B (Sealing: Prime-
Bond-NT; Dentsply), or control-C (Placebo).
Primary outcome after 1, 2, and 3 yrs of radio-
graphically observed lesion progression was
assessed by an independent examiner blinded to
groups, using pair-wise and digital-subtraction
readings. No adverse events occurred. In 37 par-
ticipants assessed after 3 yrs, 10 lesions (A-4; B-2;
C-4) progressed deep into dentin and needed oper-
ative treatment. The 3-year therapeutic effect,
based on pair-wise radiographic readings between
infiltration and placebo, was 37.8% (95%CI: 20.5-
55.2%) and that between sealing and placebo was
29.7% (95%CI: 20.2-35.0%). One-year follow-up
digital-subtraction readings showed significant
differences in lesion progression between infiltra-
tion and placebo (P = 0.0012) and between sealing
and placebo (P = 0.0269). The study showed that
infiltration and sealing are significantly better than
placebo treatment for controlling caries progres-
sion on proximal lesions. No significant difference
was seen between infiltration and sealing
(ClinicalTrials.gov number CT01417832).
KEY WORDS: caries treatment, clinical studies/
trials, radiography, resin(s), caries detection/diag-
nosis/prevention, preventive dentistry.
DOI: 10.1177/0022034511435328
Received September 28, 2011; Last revision December 06,
2011; Accepted December 12, 2011
© International & American Associations for Dental Research
Introduction
W ith modern dentistry, preservation of the dental structure and avoidance
of surgical treatment have become treatment goals (Ekstrand et al.,
2001, 2009; Kielbassa et al., 2009; Splieth et al., 2009). Consequently, suc-
cessful non-operative treatment initiatives have been developed, such as seal-
ing of proximal early lesions (Martignon et al., 2006, 2010a) and infiltration
with a resin capable of effectively penetrating the lesion pores (Paris et al.,
2007; Meyer-Lueckel and Paris, 2008). Studies in young adults (Paris et al.,
2010) and children (Ekstrand et al., 2010) have shown a significantly higher
efficacy of resin infiltration on early proximal lesions after a short period of
time in comparison with placebo or conventional non-operative measures.
This study was conducted on young adults with the aim of comparing the
therapeutic effects of infiltrating vs. sealing proximal caries lesions and pla-
cebo treatment after 1, 2, and 3 yrs. The outcome (lesion progression) was
evaluated by radiographic techniques.
Materials & Methods
This split-mouth placebo-controlled randomized clinical trial was conducted
on 16- to 35-year-old individuals in Bogotá, Colombia. Sample size calcula-
tion was based on parameters from a previous proximal sealing study
(Martignon et al., 2006): difference of control (84%) vs. test (43%) progres-
sion percentages (41%); and proportion of discordant pairs (56%), α = 0.05,
1–β = 0.8. The calculated sample size was 22 persons. With an expected 30%
drop-out after 3 yrs, at least 29 participants were to be included.
Ethical approval was obtained from the Ethical Board at the Universidad
El Bosque (IRB-089, 2008) (protocol available).
The study population was comprised of students/patients from Universidad
El Bosque who were approached in 2008 for participation in the 3-year study.
Exclusion criteria and study flow are outlined in Fig. 1. The study was
explained to potential participants by two of the authors (JSL, AC), who
informed them that infiltration and sealing are alternative preventive treat-
ments for early proximal lesions, and that 2 initial bitewing radiographs
would be made to search for 3 of these lesions. Of the 680 people approached,
90 agreed to participate (providing written informed consent) in the study and
had the first set of radiographs made.
In all cases, participants were referred for operative treatment if needed.
To be included in the study, participants were required to have at least 3 radio-
graphically observed caries proximal lesions in the posterior teeth, with a
score of 3 or 4 (SM) in the following modified radiographic scoring system
(Martignon et al., 2006): 0, no radiolucency; 1, outer half of enamel; 2, inner

288
Downloaded from jdr.sagepub.com at International Association for Dental Research on September 20, 2012 For personal use only. No other uses without permission.

© 2012 International & American Associations for Dental Research

J Dent Res 91(3) 2012 Infiltrating vs. Sealing Proximal Caries   289

half of enamel; 3, around the enamel-

dentin junction (EDJ); 4, outer third of
dentin; 5, middle third of dentin; 6, inner
third of dentin; and 7, not assessable.
The final population was comprised of
39 individuals (117 lesions) who signed
the consent form. For these participants,
two appointments were planned.
At the first visit, standardized geo-
metrically aligned bitewing radiographs
were obtained, with individual biting
registers made with silicone impression
material. Proximal surfaces of posterior
teeth were radiographically classified by
one trained examiner (SM). If a partici-
pant had more than 3 eligible lesions, 3
were randomly selected (AC). Then, a
clinical examination was conducted to
assess DMF-T/S (D, diagnostic thresh-
old: cavitated level), and individual car-
ies risk assessment was completed with
the Cariogram program 3.0 (Bratthall et
al., 2008), including assessment of all 9
factors with the aid of a salivary test kit
(CRT®, Vivadent, Schaan, Liechtenstein).
Furthermore, the gingival ‘not-bleeding/
bleeding’ status of the papillae relative to
the selected lesions was assessed after
gentle air-probing (Ekstrand et al.,
1998). At that point, orthodontic elastic
bands were placed next to the selected
lesions.
The second appointment was two
days later. Using the ICDAS criteria
(Ismail et al., 2007), the previous exam-
iner conducted a visual-severity scoring
of the selected cleaned proximal-surface
lesions. The lesions’ activity status was Figure 1.  Study flow diagram.
assessed according to the combination of
4 indicators following a modified points system (Ekstrand et al., (Prime Bond NT®; Dentsply, York, PA, USA) (Martignon et al.,
2007): plaque-stagnation area (1-no; 2-yes); visual appearance 2006). The placebo treatment (C) consisted of a micro-brush
(1-brown-spot lesion; 3-white-spot lesion; 4-surface break- passed through the spaces between teeth for 30 sec, with the
down); tactile feeling (2-smooth; 4-rough); and papilla bleeding procedure repeated after 2 min. All individuals received routine
(0-no; 1-yes). The lesion was considered as active if the sum of instructions on flossing.
points was ≥ 8. Participants were clinically examined after 1, 2, and 3 yrs by
The 3 lesions were randomly allocated (in randomly per- one examiner (JSL) blinded to the selected treatment groups. In
muted blocks generated by SPSS) to 1 of 3 groups undisclosed cases of general presence of obvious cavitated lesions, the par-
to the participants (AC): A, Infiltration; B, Sealing; C, Placebo. ticipant was referred for operative treatment. Standardized bite-
Treatments were conducted (by SM, blinded to lesions’ scores), wing radiographs were made annually.
with rubber-dam isolation and plastic wedges. Infiltration (pro-
cedure A) was conducted with the ICON® pre-product (DMG, Radiographic Assessment
Hamburg, Germany), which, instead of the market-available
application kit, came with individual vials and a plastic-strip An independent examiner (JG) assessed the radiographs by reading
teeth separator. The procedure included: plastic-strip isolation of lesions A, B, and C in a randomized order, regardless of the par-
adjacent teeth; selected-surface etching with 15% hydrochloric ticipant number and group. Reading of images was conducted after
acid (120 sec); rinsing and drying; 95% ethanol- and air-drying; 1 yr by digital-subtraction radiography of scanned images (Image
resin infiltration with a syringe (120 sec); polymerization, and Tool®, UTHSCSA, San Antonio, TX, USA) and in terms of pair-
infiltrant re-application (30 sec) plus polymerization. The seal- wise reading of conventional radiographs with the aid of a Mattson’s
ing of the selected lesions (B) was performed with an adhesive magnifying glass (Dental X-ray, Copenhagen, Denmark). After 2

Downloaded from jdr.sagepub.com at International Association for Dental Research on September 20, 2012 For personal use only. No other uses without permission.

© 2012 International & American Associations for Dental Research

290  Martignon et al. J Dent Res 91(3) 2012

Table.  Distribution of the Randomly Selected Lesions (A, B, C) According to Tooth Surface and Radiographic Score

Tooth 14/24 15/25 16/26 17/27 34/44 35/45 36/46 37/47 Total

Surface M D M D M D M D M D M D M D M D  

Infiltration (A)
Score 3 1 1 2 1 1 0 0 0 0 1 1 6 1 1 0 0 16
Score 4 0 1 3 6 4 1 0 0 0 0 1 3 3 1 0 0 23
Sealing (B)
Score 3 0 3 0 0 2 0 0 0 0 0 1 5 2 1 0 0 14
Score 4 0 8 5 3 2 0 0 0 0 0 1 3 1 1 1 0 25
Placebo (C)
Score 3 0 2 2 2 0 2 1 0 0 1 3 2 0 0 0 0 15
Score 4 0 2 4 5 1 2 1 0 0 1 1 4 1 2 0 0 24
Total 1 17 16 17 10 5 2 0 0 3 8 23 8 6 1 0 117

therapeutic effect (difference in the proportions of lesion progres-

sion between test and control groups) and the 95% confidence
intervals (Siegel and Castellan, 2002). In all tests, p-values less than
0.05 were considered significant.

Figure 2.  Radiographic pair-wise reading progression of proximal
lesions after 1, 2, and 3 yrs.
and 3 yrs, only pair-wise radiograph readings were conducted. For
all readings, the examiner was blinded to whether the lesion was an
A, B, or C (placebo) lesion. For the pair-wise readings, the most
recent film was coded and then read against baseline. For reproduc-
ibility assessment, the examiner repeated 20% of radiograph read-
ings by both methods 1 wk after the first reading.
Statistical Analysis
The intra-examiner reliability for the pair-wise and the digital-
subtraction radiographic readings was assessed by unweighted
kappa scores (Landis and Koch, 1977). Caries experience (DMF-
T/S), individual caries risk levels, ICDAS criteria, radiographic
scores, and progression status of selected lesions were reported
descriptively. The outcome variable of lesion progression during
the 1-, 2-, and 3-year study period was assessed by pair-wise radio-
graphic reading. Results of the digital-subtraction radiography were
reported after 1 yr only. The placement of a restoration during the
study period was considered as lesion progression. Differences in
lesion progression between treatments at each follow-up were ini-
tially tested by the Cochran Q test (Siegel and Castellan, 2002). In
case of significant difference between groups, the McNemar
Change test for related groups was conducted, including the
Downloaded from jdr.sagepub.com at International Association for Dental Research on September 20, 2012 For personal use only. No other uses without permission.
Results
Baseline
The sample included 28 women and 11 men, with a mean age of
21 yrs (range, 16-31 yrs). The mean DF-T of the sample was 4.9
± 3.4, and the DF-S corresponded to 7.0 ± 5.9 (D-S, 0.6 ± 1.0;
F-S, 6.4 ± 6.0). No teeth were extracted due to caries (M). More
than half of the participants were classified as ‘moderate-very
high’ caries risk (moderate, 28%; high, 21%; very high, 5%),
and the rest (46%) as low caries risk.
The Table demonstrates that most of the selected lesions
(61.5%) were radiographically classified as score 4; the majority
were located in the upper teeth (58.1%), and, with respect to tooth
type, more than half were in the second premolars (54.7%).
The visual assessment revealed that the majority (88%) of
the selected proximal lesions had an ICDAS score of 2 (A, 90%;
B, 87%; C, 87%), followed by a score of 3 (5%). In 4 cases
(3%), the lesion could not be visually assessed. Activity was
assessed in 80/117 lesions (68.4%); in 37 cases, visual and/or
tactile access of lesions was not possible. Of these, 64.9% were
premolar teeth. Of the 80 lesions, 26/27 in group A, 26/27 in
group B, and 24/26 in group C were assessed as active.
Follow-up
Only two participants (5%), one during the first and one during
the second year, dropped out of the study. No unwanted side-
effects (pain, vitality loss, staining) were observed. During the
study period, 10 cases (A-4; B-2; C-4) showed radiographic
lesion progression reaching the middle third of dentin and were
referred for operative treatment.
Pair-wise Reading of Radiographs
Fig. 2 demonstrates the 1- (n = 38), 2- (n = 37), and 3-year pro-
gression results (n = 37) of the pair-wise readings. Three-year
percentages were: 32% infiltrated, 41% sealed, and 70% placebo

© 2012 International & American Associations for Dental Research

J Dent Res 91(3) 2012 Infiltrating vs. Sealing Proximal Caries   291

cases, with significant progression rate

differences between treatments at the 3
follow-ups (Cochrane Q test p-values <
0.01). Significant differences (McNemar
test) were observed between infiltration
and placebo after 1 (χ2= 8.643; P =
0.0033), 2 (χ2= 10.563; P = 0.0012), and
3 yrs (χ2= 10.563; P = 0.0012), and
between sealing and placebo after 3 yrs
(χ2= 4.762; P = 0.0291).
The therapeutic effects between infil-
tration and placebo were 31.6% (95%CI:
15.1-48.1%) after 1 yr, 37.8% (95%CI:
20.5-55.2%) after 2 yrs, and 37.8%
(95%CI: 20.5-55.2%) after 3 yrs.
Between sealing and placebo, the thera-
peutic effect after 3 yrs was 29.7%
(95%CI: 20.2- 35.0%).
Figure 3.  3-year radiographic behavior of test A, test B, and C (placebo) lesions.
Digital-subtraction Radiography
The 1-year follow-up digital-subtraction readings showed pro- Since only two participants left during the study, leaving 37
gression in 10 (A), 16 (B), and 24 (C) cases (Cochrane Q test; p participants, no drop-out analysis was conducted.
< 0.001), with significant differences in lesion progression The participants represented a higher socio-economic status
between infiltration and placebo (χ2= 10.563; P = 0.0012) and and a lower caries experience than a population from the same
between sealing and placebo (χ2= 4.900; P = 0.0269). age group in Bogotá (Ministerio de Salud – República de
Colombia, 1999). With the split-mouth design, individual par-
Behavior of Lesions ticipant variables (observer and information bias) were
accounted for, eliminating the concern that there would be dif-
Fig. 3 shows the pair-wise radiographic-reading behavior of the
ferences in lesion progression between the lesions selected for
lesions after 3 yrs for each group according to their baseline code
the different treatment modalities.
and their progression status. Overall, the highest lesion progres-
The caries progression protective effect of the infiltration for
sion was observed in group C, with highest progression for base-
proximal lesions is in accordance with recent studies conducted
line lesions into dentin (code 4: 74%) vs. those around the EDJ
in young adults (Paris et al., 2010) and children (Ekstrand et al.,
(code 3: 64%). Fewer lesions with a radiographic code 3 pro-
2010). The higher infiltration efficacy with digital-subtraction
gressed in group A (7%) in comparison with group B (38%),
radiography reported after 18 mos (93%) (Paris et al., 2010), in
while the trend was opposite for code 4 lesions (50% and 46%,
comparison with that of the current study (74%), might be
respectively).
related to the fact that the previous study included several
lesions located in enamel, while this study mostly included den-
Intra-reliability Radiograph Readings tin lesions (scores 3-38% and 4-62%), and it is well-known that
dentin lesions tend to progress faster than enamel lesions
The intra-reliability for the pair-wise and the subtraction radio-
(Mejàre et al., 1999; Martignon et al., 2010b).
graphic methods (kappa values) was 0.74 and 0.78, respectively.
As for the sealing, a 57% efficacy, shown in a previous
18-month study in young adults with the paired-radiograph
Discussion method (Martignon et al., 2006), is similar to that of this study
after 2 (60%) and 3 yrs (60%). Still, in this study, significant
The results of the present study strongly indicate that caries differences were observed with the pair-wise radiograph read-
infiltration is significantly more efficacious, in terms of the ings when compared with the placebo only after 3 yrs, even
capacity for beneficial change or therapeutic effect of a given though, after 1 and 2 yrs, there was a consistently lower caries
intervention, than placebo treatment for controlling the progres- progression of sealing cases in comparison with placebo cases.
sion of proximal caries lesions after 1, 2, and 3 yrs. Caries seal- In this study, all selected surfaces received a 2-day temporary
ing appeared to be significantly more efficacious than placebo separation for diagnosis purposes and to allow for creating a
after 3 yrs. Analysis of the data also showed no significant dif- working space to place either dental material on the lesion sur-
ference in efficacy between infiltration and sealing during the 3 face. These two appointments to conduct the procedure are no
yrs, even though the infiltration showed a consistently higher longer needed for the infiltrant as with the current isolation
therapeutic effect than the sealing. This statement is based on the applicator it can be done in one session.
pair-wise radiographic readings, but the same trend was seen The fact that more infiltrated than sealed lesions of score 4 pro-
from the subtraction evaluation method after 1 yr. gressed could be related to etching and/or insufficient infiltration. A

Downloaded from jdr.sagepub.com at International Association for Dental Research on September 20, 2012 For personal use only. No other uses without permission.

© 2012 International & American Associations for Dental Research

292  Martignon et al. J Dent Res 91(3) 2012
caries lesion’s surface layer is remineralized, but its thickness
becomes significantly reduced after HCl etching compared with
that achieved with phosphoric-acid etching (Paris et al., 2007).
Thus, it could be argued that if the eroded etched surface is not
properly infiltrated, lesion progression could then be facilitated.
In this study, the temporary-elective separation allowed for
the visual/tactile access of the proximal surfaces, facilitating the
ICDAS-severity and activity scoring of the lesions. Most lesions
were classified as ‘Distinct visual change in enamel’, and 5% as
‘Localized enamel breakdown’ (microcavity) (A, 2; B, 3; C, 1),
confirming correlation between visual and radiographic scores
with the ICDAS system on proximal surfaces (Ekstrand et al.,
2011). The majority of the lesions were scored as active, sup-
porting the activity assessment and non-invasive management
of these lesions (Ekstrand et al., 2009).
The progression rates shown in all groups reinforce the man-
agement of early lesions with non-operative interceptive treat-
ment, which highlights the need to select appropriate cases and
requires recalls, as suggested in the ICDAS caries management
flow diagram (Pitts and Richards, 2009). The alternative, a
class-II cavity plus restoration, sacrifices dental structure and
does not guarantee a 100% success rate (Qvist, 2008). The fact
that 70% of placebo lesions progressed after 3 yrs, even after
flossing instruction and within a health system that includes
systemic salt fluoridation and prevention activities, such as fluo-
ride and plaque control (Ministerio de Salud–República de
Colombia, 1999), highlights the low compliance with flossing
(Martignon et al., 2010b) and emphasizes the need to improve
preventive strategies such as the one tested in this study.
Digital-subtraction radiography, a more sensitive technique than
conventional pair-wise reading of radiographs (Ricketts et al.,
2007), was used in this study after one year. This was performed to
allow for a short follow-up period to compare with other studies
(Martignon et al., 2006; Paris et al., 2010) of similar duration. It
was not considered necessary to continue using it subsequently,
since pair-wise reading already showed differences between treat-
ments at that follow-up. In normal clinical settings, dentists would
use pair-wise readings to assess caries progression.
The higher efficacy shown by pair-wise radiographic readings
after 3 yrs for the infiltration (68%) and for the sealing (60%) of
proximal lesions in comparison with a placebo (30%) makes these
approaches modern non-invasive alternatives for active lesions
extending radiographically around the EDJ or in the external third
of the dentin. Careful selection of cases as well as periodical radio-
graphic and clinical examination is encouraged.
Acknowledgments
The author(s) disclose receipt of financial support for the
research, for travel expenses to discuss and/or present the study,
and/or publication of this article from the DMG Dental-Material
GmbH (Hamburg, Germany). The author(s) declared no poten-
tial conflicts of interest with respect to the authorship and/or
publication of this article.
References
Bratthall D, Allander L, Lybegard K-O (2008). Cariogram. Internet version.
Version 3.00. Res. 1024*768. http://www.mah.se/fakulteter-ochomraden/
Odontologiska-fakulteten/Avdelning-och-kansli/Cariologi/Cariogram/.
Downloaded from jdr.sagepub.com at International Association for Dental Research on September 20, 2012 For personal use only. No other uses without permission.
© 2012 International & American Associations for Dental Research
Ekstrand KR, Brunn G, Bruun M (1998). Plaque and gingival status as
indicators for caries progression on proximal surfaces. Caries Res
32:41-45.
Ekstrand KR, Ricketts DN, Kidd EA (2001). Occlusal caries: pathology,
diagnosis and logical management. Dent Update 28:380-387.
Ekstrand KR, Martignon S, Ricketts DJ, Qvist V (2007). Detection and
activity assessment of primary coronal caries lesions: a methodologic
study. Oper Dent 32:225-235.
Ekstrand KR, Zero DT, Martignon S, Pitts NB (2009). Lesion activity
assessment. In: Detection, assessment, diagnosing and monitoring
of caries. Monogr Oral Sci 21. Pitts N, editor. Basel: S. Karger,
pp. 63-90.
Ekstrand KR, Bakhshandeh A, Martignon S (2010). Treatment of proximal
superficial caries lesions on primary molar teeth with resin infiltration
and fluoride varnish versus fluoride varnish only: efficacy after 1 year.
Caries Res 44:41-46.
Ekstrand KR, Luna LE, Promisiero L, Cortes A, Cuevas S, Reyes JF, et al.
(2011). The reliability and accuracy of two methods for proximal caries
detection and depth on directly visible proximal surfaces: an in vitro
study. Caries Res 45:93-99.
Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. (2007). The
International Caries Detection and Assessment System (ICDAS): an
integrated system for measuring dental caries. Community Dent Oral
Epidemiol 35:170-178.
Kielbassa AM, Muller J, Gernhardt CR (2009). Closing the gap between oral
hygiene and minimally invasive dentistry: a review on the resin infiltra-
tion technique of incipient (proximal) enamel lesions. Quintessence Int
40:663-681.
Landis JR, Koch GG (1977). The measurement of observer agreement for
categorical data. Biometrics 33:159-174.
Martignon S, Ekstrand KR, Ellwood R (2006). Efficacy of sealing proximal
early active lesions: an 18-month clinical study evaluated by conven-
tional and subtraction radiography. Caries Res 40:382-388.
Martignon S, Tellez M, Santamaría RM, Gomez J, Ekstrand KR (2010a).
Sealing distal proximal caries lesions in first primary molars: efficacy
after 2.5 years. Caries Res 44:562-570.
Martignon S, Chavarría N, Ekstrand KR (2010). Caries status and proximal
lesion behaviour during a 6-year period in young adult Danes: an epi-
demiological investigation. Clin Oral Investig 14:383-390.
Mejàre I, Källestl C, Stenlund H (1999). Incidence and progression of
approximal caries from 11 to 22 years of age in Sweden: a prospective
radiographic study. Caries Res 33:93-100.
Meyer-Lueckel H, Paris S (2008). Improved resin infiltration of natural car-
ies lesions. J Dent Res 87:1112-1116.
Ministerio de Salud–República de Colombia, Centro Nacional de Consultoría–
CNC (1999). Estudio Nacional de Salud Bucal. In: Ministerio de Salud,
Centro Nacional de Consultoría–República de Colombia: III Estudio
Nacional de Salud Bucal–ENSAB III. Colombia: Lito Servicios Aler.
Tomo VII.
Paris S, Meyer-Lueckel H, Kielbassa AM (2007). Resin infiltration of natu-
ral caries lesions. J Dent Res 86:662-666.
Paris S, Hopfenmuller W, Meyer-Lueckel H (2010). Resin infiltration of
caries lesions: an efficacy randomized trial. J Dent Res 89:823-826.
Pitts NB, Richards D (2009). Personalized treatment planning. In: Detection,
assessment, diagnosing and monitoring of caries. Monogr Oral Sci 21.
Pitts N, editor. Basel: S. Karger, pp. 128-143.
Qvist V (2008). Longevity of restorations: the ‘death spiral’. In: Dental car-
ies. The disease and its clinical management. Fejerskov O, Kidd E,
editors. 2nd ed. Singapore: Blackwell Munksgaard, pp. 443-455.
Ricketts DN, Ekstrand KR, Martignon S, Ellwood R, Alatsaris M, Nugent Z
(2007). Accuracy and reproducibility of conventional radiographic
assessment and subtraction radiography in detecting demineralization
in occlusal surfaces. Caries Res 41:121-128.
Siegel S, Castellan NJ Jr (2002). The case of k related samples. In:
Nonparametric statistics for the behavioral sciences. Siegel S, Castellan
NJ Jr, editors. 2nd ed. Singapore: McGraw-Hill, pp. 168-188.
Splieth CH, Ekstrand KR, Alkilzy M, Clarkson J, Meyer-Lueckel H,
Martignon S, et al. (2009). Sealants in dentistry: outcomes of
the ORCA Saturday Afternoon Symposium 2007. Caries Res 44:
3-13.