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Resin infiltration as treatment for an anterior tooth discoloration of

developmental origin

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AESTHETIC
Resin infiltration as treatment for an anterior
D E N T I S T RY
tooth discoloration of developmental origin
Nathaniel Lawson, DMD, PhD; Celin Arce, DDS, MS, FACP

R
esin infiltration is a technique that has been
available as a commercial product since 2010.
The procedure consists of etching the tooth
with a 15% hydrochloric acid, drying with an etha-
nol solution, and applying a TEGDMA-based resin
infiltrant. The product (ICON, DMG) was initially
developed as a treatment for incipient interproximal
caries and anterior white spot lesions. Clinical expe-
rience with this technique, however, revealed that
it is also effective in masking enamel discoloration
of non-carious origin. This article will summarize
the diagnosis of discolorations that may be treated
with resin infiltration, the mechanism of action of
the resin infiltration product, and a clinical protocol
for the use of resin infiltration to treat an anterior
tooth discoloration of developmental origin.
DIAGNOSIS OF LESIONS TREATABLE WITH RESIN IN-
FILTRATION
Discolorations seen on dental enamel can be attrib-
uted to either a caries-induced and non-carious etiol-
ogy. Discoloration from changes in enamel formation
initiated by caries are known as “white spot lesions” or
“decalcification lesions.” Decalcification lesions typi-
cally are located at the cervical aspect of the tooth or
surrounding orthodontic brackets because these sur-
faces are more likely to accumulate acid-producing
plaque.1 The incidence of decalcification lesions dur-
ing orthodontic treatment have been reported to be as
high as 50%-97%.2,3 Decalcification lesions also may
be suspected based on the patient’s caries risk. Pa-
tients with poor oral hygiene, a diet that lowers intra-
oral pH, a lack of fluoride, or a history of orthodontic
treatment may be more likely to acquire decalcifica-
tion lesions seen as white spots.4
Diagnosing the true etiology of a non-carious
tooth discoloration is often difficult. Some clini-
cians (and patients) will attribute all non-carious
tooth discolorations to fluorosis. Fluorotic lesions
are brown or white discolorations caused by expo-
sure to excess fluoride during the years of amelo-
genesis. According to the Centers for Disease Con-
trol and Prevention, the prevalence of some form of
fluorosis affected about 23% of Americans during
period from 1999 to 2004.5 Severity and mani-
festation of the fluorosis stain vary, and about 7%
of the population were categorized with a form of
fluorosis with visibly apparent lesions (mild, moder-
ate, or severe).2 Many discolorations are not caused
by fluorosis, and some may be idiopathic white or
brown enamel discolorations formed during devel-
opment. Croll has coined the term “dysmineraliza-
tion” to describe these disturbances in the formation
of the inorganic component of enamel.6 A history of
trauma, high fever episodes, or medications taken
during childhood may be responsible for altering
the enamel mineralization process and lead to dis-
coloration.7 Discolorations attributed to systemic
conditions should be present on all teeth mineral-
izing at the same time during development, whereas
those caused by trauma may be limited to a single
tooth. Common components of our diet can be ex-
trinsic causes of stains, such as coffee, tea, soy sauce,
red wine, or an iron supplement in vitamins, as well
as some dental products such as chlorhexidine and
stannous fluoride. The clinician should ask the pa-
tient about the onset of appearance of the discolor-
ation. A discoloration that has developed during the
patient’s span of memory is more likely to be extrin-
sic staining than is one that has to do with tooth de-
velopment. In the author’s experience, treatment of
extrinsic staining from diet or dental products may
be accomplished with a dental cleaning or enamel
microabrasion.
Resin infiltration has been shown to be able to mask
discoloration from both decalcification lesions8-12 and
those of developmental non-carious etiology.8,9,13-16
In the clinical trials examining resin infiltration of
decalcification lesions following orthodontic brack-
ets, lesions were infiltrated at an average time of 5
months,11 12 months,12 or 21 months9 after removal
of orthodontic brackets depending on the trial. One

Nathaniel Lawson is the Director of the Division of Biomaterials at the University of Alabama at Birmingham School of Den-
tistry and the program director of the Biomaterials residency program. He graduated from UAB School of Dentistry in 2011
and obtained his PhD in Biomedical Engineering. He works as a general dentist in the UAB Faculty Practice. Dr. Celin Arce
is a board certified prosthodontist. He received his dental degree from University Latina of Costa Rica and completed resi-
dency in Advanced Prosthodontics at the University of Alabama at Birmingham, and Master of Science in Clinical Dentistry.
He is a Diplomate of the ABP and Fellow of the American College of Prosthodontists. He is currently Assistant Professor of
the Restorative Sciences Department at the University of Alabama at Birmingham School of Dentistry.
oralhealthgroup.com | 75
A ESTH E TI C DE N TI ST RY
of the trials reported that there was no as-
sociation between time from debonding to
infiltration with the improvement in ap-
pearance of the lesion.12
In a clinical trial, 11 out of 18 teeth
(61%) with decalcification lesions were
completely masked, whereas, only five
out of 20 teeth (25%) with non-carious
discolorations were completely masked.9
In a laboratory study, resin infiltration
was shown to have variable results with
different hypomineralized enamel le-
sions of developmental origin.17 Another
clinical trial reported better masking
effects for lesions attributed to fluorosis
than those attributed to hypomineral-
ization.13 A practical consideration for
treating non-carious discolorations is
determining the thickness of the discol-
oration. A thicker discoloration is more
visually apparent18 and will be more dif-
ficult to infiltrate and mask. A method
to help determine the thickness of a stain
is to transilluminate the tooth with a
dental transilluminator or light-curing
unit (with proper eye protection). If the
lesion becomes significantly darker with
transillumination, the lesion is likely
deeper within the enamel.19,20
MECHANISM OF ACTION OF RESIN INFIL-
TRATION
Resin infiltration was developed as a
technique to treat enamel caries. The
histopathology of enamel caries occurs
as acid dissolves inter-crystalline spaces
within enamel.21 Since the outermost
10-30 microns of enamel is more resis-
76 A P R I L 2020 | oralhealth
1. White discolorations present on the labial surfaces of maxillary central incisors.
2. Latex rubber dam placed to protect soft tissue and prevent salivary contamination.
tant to dissolution from the presence of
fluorapatite, a more porous subsurface
forms.22 The principle of resin infiltra-
tion for caries arrest is to occlude the po-
rosity formed during the caries process
and prevent pathways for acid to further
dissolve the tooth structure.23
The two basic steps to achieve this
goal are to remove the less-porous sur-
face layer of enamel and allow resin to
infiltrate the internal enamel porosities
through capillary movement. As the
surface of a carious lesion may act as a
barrier to resin infiltration, several pre-
liminary studies evaluated different acid
solutions for removal of the surface layer.
A solution of 15% hydrochloric acid ap-
plied for 90-120 seconds was shown to
almost completely remove the 45-micron
thick surface layer of the lesion.24 After
removing the surface layer of the carious
lesion, the next step is to infiltrate resin
into the porosities created during dis-
solution of intercrystalline enamel. Un-
filled resin infiltrants have been shown
to penetrate deeper into carious lesions
than dental adhesives25 and a TEGD-
MA resin infiltrant was shown to pen-
etrate deeper than other formulations
of infiltrants.26 When applied for three
minutes, the ICON TEGDMA-based
infiltrant was shown to penetrate 414
microns into non-cavitated interproxi-
mal caries lesions.27
The visual change in enamel that
arises from enamel caries is due to the
air present in the subsurface porosities.
The opaque appearance of the white
1 2
spot lesion occurs because light is scat-
tered within the body of the white spot
lesion. Light scattering is caused when
light interacts with two substances with
different refractive indices. The refrac-
tive index of enamel (1.62-1.65) is differ-
ent than that of air (1.00). Infiltration of
the lesions with an infiltrant that has a
refractive index of 1.52 is able to mask
the lesion.28
Resin infiltration has also been shown
to infiltrate hypomineralized enamel of
non-carious developmental origin.17,29 A
laboratory study reported infiltration to
an average depth of 0.67 +/- 0.39 mm in
hypomineralized enamel lesions.17
CLINICAL PROTOCOL FOR TREATMENT OF
AN ANTERIOR TOOTH DISCOLORATION OF
DEVELOPMENTAL ORIGIN
A patient presented to the UAB faculty
practice with esthetic concerns of white
discoloration on her maxillary central
incisors (Fig. 1). An exam revealed that
the only discolorations on her teeth were
present on her maxillary central incisors.
Based on the location and appearance of
the lesions, they were determined to be
non-carious discolorations caused either
by fluorosis or an idiopathic dysmin-
eralization of developmental origin. A
transilluminator (Microlux, Addent) was
placed on the lingual aspect of the cen-
tral incisors and the lesions were viewed
through transillumination (Fig. 2). The
lesions did not appear to become dark-
er, and therefore were determined to be
Continued on page 79 ➜
 AESTHETIC D ENTISTRY

➜ Continued from page 76

3 4 5

6 7 8

9 10
3. Transillumination of lesion does not show darkening. 4. Application of ICON Etch hydrochloric acid etchant.
5. After first application of etchant. 6. The ICON dry ethanol solvent is used to re-wet lesion however desired effect was not
achieve yet. 7. After second application of etchant. 8. After third application of etchant the surface was re-wet with ICON dry and
desired masking affect was achieved. 9. Lesion was infiltrated with ICON infiltrant. 10. Teeth were light cured for 40 seconds.

relatively shallow lesions capable of treat-
ment with resin infiltration. The patient
was presented with alternative options,
including no treatment, bleaching and
enamel microabrasion. The patient was
given the option to bleach her teeth prior
to infiltration as the use of bleaching pri-
or to infiltration has been reported to im-
prove the masking effect.30 The patient
refused. The patient was also informed
that the chance of complete or partial
masking of the lesion was estimated as
25% and 35% respectively.9
A latex rubber dam was placed on the
patient (Fig. 3). Non-latex rubber dams
may also be used for the latex allergic pa-
tient or clinician, however, prolonged ex-
posure of the infiltrant to non-latex rub-
ber dams may cause partial dissolution of
the dam. The use of isolation is critical as
salivary contamination of the infiltration
process decreased its effectiveness27 and
exposure of hydrochloric acid to soft tis-
sue may cause temporary bleaching and
chemical burn.6
The hydrochloric acid etchant from
the resin infiltration system (ICON-
Etch) was applied for two-minutes with
a gentle scrubbing motion (Fig. 4). Af-
terwards, the etchant was rinsed, the
tooth was dried (Fig. 5) and the ICON-
dry ethanol solvent was placed on the
tooth (Fig. 6). At this point the tooth was
observed to determine if an acceptable
color change had occurred. A clinical
trial reported that re-wetting the etched
lesion with ethanol (after three seconds
of waiting) was able to predict the color
change that would occur once the lesion
was ultimately infiltrated.31 As the de-
sired color change was not achieved, an
additional two minutes of etching was
performed. The lesion was dried and re-
viewed (Fig. 7). Following re-wetting,
the desired color change was still not
achieved. A third 2 minute etching was
performed. Following air drying and re-
wetting, an acceptable color change was
achieved (Fig. 8).
The lesions were infiltrated with the
ICON-infiltrant for three minutes (Fig.
9), air dried, flossed, and light cured for
40 seconds (Fig.10). The lesion was in-
filtrated for an additional 1 minute and
light cured for 40 seconds. The esthetic
masking effect of the treatment was evi-
dent immediately upon completing the

oralhealthgroup.com | 79
A ESTH E TI C DE N TI ST RY

11
12
11. Teeth display improved outcome immediately following treatment. 12. Teeth display similar outcome at
one-week following treatment.

treatment (Fig. 11). Prior to removing
the rubber dam, the patient was shown
her teeth and she accepted the treatment
outcome. In the case of more extensive
staining that would not have been entire-
ly removed, resin infiltration improves
the bond to composite resin of demin-
eralized enamel and has no negative ef-
fect on bonding to sound enamel.32,33 A
clinical trial reported improved masking
at one-week following treatment.9 The
patient returned one-week following
treatment and the masking effect looked
similar to immediately after treatment
(Fig. 12).
CONCLUSION
Resin infiltration may be an effective
method of treatment for anterior tooth
discoloration of developmental origin as-
suming their depth is not too great. Mul-
tiple etching steps may be needed in order
to achieve the desired outcome. Several
clinical trials have reported the masking
effects of resin infiltration have remained
unchanged at follow up times up to 12
months for non-carious lesions16 and 24-
45 months for carious lesions.12
Oral Health welcomes this original article.

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