| Abstract|| |
Context: Aesthetic concerns due to dental fluorosis (DF) considerably impact pyschosocial health in young children and requires aesthetic microinvasive treatment. Aims: The aim of this study was to use quantitative light-induced fluorescence to evaluate two intervention protocols: microabrasion with resin infiltration and microabrasion with remineralization and assess which brings about more fluorescence gain; better colour masking and greater patient satisfaction among subjects with dental fluorosis. Methods and Material: 120 maxillary central incisors with Grade 3 DF (Dean's Fluorosis Index) were randomly distributed into four groups: I-microabrasion + resin infiltration (fluorosis with stains); II-microabrasion + remineralization (fluorosis with stains); III-microabrasion + resin infiltration (fluorosis without stains); IV-microabrasion + remineralization (fluorosis without stains). At baseline, post-microabrasion and post-intervention Quantitative light-induced fluorescent images were captured. Fluorescence gain (ΔF) was analysed from the blue light images. The white light images were used to evaluate post intervention colour difference (ΔE = [(ΔL*) 2+(Δa*) 2+(Δb*) 2]1/2) and child satisfaction was evaluated. Statistical Analysis Used: Collected data was analysed using repeated measures ANOVA and Independent t-test. Results: Intra-group comparison of ΔF values showed statistically significant improvement in ΔF value in all the four groups (P < 0.001, 0.002). Inter-group comparison of ΔF values based on intervention showed statistically significant fluorescence gain (P < 0.004) indicating resin infiltration intervention being better than remineralization in unstained grade III fluorosis. The colour difference was statistically significantly better with resin infiltration in both stained and unstained Grade III DF (P < 0.001). Conclusions: Resin infiltration intervention showed better fluorescence gain and colour masking compared to remineralization intervention.
Keywords: Dental fluorosis, Dental aesthetics, Resin Infiltration, Tooth Remineralization, Quantitative light induced fluorescence
|How to cite this article:|
Singhania S, Nandlal B, Shanbhog R, Veeramani R. Resin infiltration and remineralization interventions in management of moderate dental fluorosis: A quantitative light-induced fluorescence-based randomized controlled trial. Indian J Dent Res 2021;32:362-71
|How to cite this URL:|
Singhania S, Nandlal B, Shanbhog R, Veeramani R. Resin infiltration and remineralization interventions in management of moderate dental fluorosis: A quantitative light-induced fluorescence-based randomized controlled trial. Indian J Dent Res [serial online] 2021 [cited 2022 May 27];32:362-71. Available from: https://www.ijdr.in/text.asp?2021/32/3/362/338138
| Introduction|| |
Dental fluorosis (DF) is a common developmental disorder of enamel resulting from ingestion of excessive fluoride during enamel formation., The prevalence of children and adolescents with DF ranges between 4 and 70% and has been steadily increasing. Fluoride-related alterations in enamel, clinically characterized by white opacities often with secondary brown staining, cause surface hyper-mineralization with hypo-mineralization in subsurface areas. Although DF may have variable clinical presentation ranging from discoloration to pitting, it is aesthetically objectionable and considerably impacts the psyche and social interactions.,
The selection of an appropriate management approach for DF depends on its severity. Microabrasion and bleaching have been advocated for managing mild DF, whereas, in moderate to severe cases, they are both either inefficient or may only lead to temporary improvement. Other restorative treatment options available include composite or ceramic veneers.[8–11]
However, as described by Qvist et al., “the durability of restorations is limited and the initial invasive intervention often brings the tooth into a circle of treatment and re-treatment, known as the death spiral of restorations.” Therefore, restorations requiring tooth preparation accelerate the tooth destruction and are unsuitable especially for young patients. Thus, there is a need to identify micro-invasive, aesthetic and patient-friendly management techniques for moderate to severe DF.,
Enamel microabrasion is one such micro-invasive technique that has the ability to improve the visual appearance in patients with mild and moderate fluorosis (Thylstrup-Fejerskov Index 1-7)[14–16] and it must be advocated as the first line of treatment in such cases., Following microabrasion, the resultant enamel surface appears smoother, but it has been proven to be prone to staining in the long term. Moreover, patients may develop hypersensitivity. Moreover, incipient caries in teeth with DF are more prone to progression but their response to remineralization is stronger than sound teeth.
Previous studies have reported that with the use of CPP-ACP crème, the crystallinity of the enamel structure is improved, the tooth is surrounded by an environment supersaturated with calcium and phosphate ions, which helps in overcoming the hypersensitivity and thus, better long-term results follow.,, Deshpande et al. has employed microabrasion-remineralization (Mab-Re) in the aesthetic management of DF.
Previous literature has also reported the potential of another recently introduced micro-invasive intervention: the resin infiltration technique for management of white opaque lesions that may be acquired or developmental. Resin infiltration involves using 15% hydrochloric acid for mild erosion of the affected surface. Then, a low-viscosity resin is used to infiltrate the exposed body of the lesion and a change in the refractive index after infiltration results in masking.,,
Even though microabrasion-remineralization and resin infiltration were originally developed for initial carious lesions, it can also be used in non-pitted DF. Since fluorosis is an enamel mineralization disturbance, QLF can be used to detect and quantify the mineral content of teeth by comparing it with sound enamel, which is measured as fluorescence loss or ΔF., Previous studies by Pretty et al., Cuevas-Espinosa et al. and Park et al. have reported the use of QLF in diagnosis of enamel fluorosis., Remineralization of artificial carious lesions in fluorotic teeth have been previously evaluated by Alhawij et al. However, literature on evaluation of resin infiltration in DF using QLF is scarce.
Therefore, the present study employed QLF as a modality to evaluate effectiveness of microabrasion with resin infiltration and microabrasion with remineralization in children with moderate DF. The objective of this clinical study is to evaluate which of the two intervention protocols bring about more fluorescence gain, better colour masking and greater patient satisfaction and to compare their performance in the stained and unstained moderate DF groups.
| Materials and Method|| |
Trial design and ethics
This single blinded clinical trial had four parallel arms with an allocation ratio of 1:1. The trial design was approved by the Institutional Ethics Committee (JSSDCH IEC PROTOCOL NO. 80/2019). After giving written information about the research to the participants and their parents, written informed consent (in regional language) was obtained. The study was conducted from a period of September- November 2019 (Reported according to CONSORT Guidelines) [Figure 1].
Based on a previous study by Castro et al. and with a power of 80%, a sample size of 25 was required per treatment group. 20% teeth with DF were added to accommodate for attrition. Thus, a total sample of 120 teeth with moderate DF was determined, both upper central incisors being included for all the 60 participants. 30 teeth were treated in each of the four groups: I-microabrasion + resin infiltration (fluorosis with stains); II-microabrasion + remineralization (fluorosis with stains); III-microabrasion + resin infiltration (fluorosis without stains); IV-microabrasion + remineralization (fluorosis without stains).
Initially, 82 children aged 9-11 years old were assessed for presence of white opacities in the anterior teeth. According to Russell's criteria, these could be classified as 'Fluoride' and 'Non-fluoride' opacities. The children with fluoride opacities were further screened to determine fluorosis severity as per Dean's Fluorosis Index Modified Criteria (1942). Children were screened according to the selection criteria [Table 1] and a total of 60 children that met eligibility criteria were included. Block randomization was used to allocate the children into one of the four different groups. Allocation was done by an individual other than the investigator who carried out the intervention and the operator was unaware about the allocation. Both upper central incisors of each participant were subjected to the same intervention.
Before starting the procedure, the participants were made to brush their teeth under the guidance of a dental professional, following which, standardized preoperative photographs were acquired.
Rubber dam was applied to achieve optimum isolation and protection of the soft tissues. The fluorotic teeth in all four groups were treated with microabrasion using Opalustre (Ultradent Products, South Jordan, UT, USA). As per the manufacturer instructions, the Opalustre [Table 2] slurry was dispensed on the enamel. Bristle cup or “Opal Cup” was used to compress the slurry on the tooth surface for 60 s after which it was washed and dried. The Opalustre slurry was reapplied two more times in the same way [Figure 2].
|Figure 2: Microabrasion: Rubber dam isolation; Dispensing of Opalustre; Stains covered by slurry; Opal Cup used for 60 seconds|
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In groups I and III, the fluorotic teeth were subjected to resin infiltration after microabrasion. Resin infiltration was carried out using the commercially available resin infiltration kit ICON (DMG, Germany). The ICON kit [Table 2] contains 3 syringes: 15% hydrochloric acid gel (ICON Etch), ethanol-drying agent (ICON Dry), and resin infiltrant (ICON Infiltrant).
As instructed by the manufacturer, the first step included application of 15% HCl gel (ICON Etch) for 2 min. using the special applicator tip provided in the kit. Then, water spray was used for 30 s. This was followed by the application of ethanol (ICON Dry). Then, the low viscosity resin infiltrant (ICON Infiltrant) was applied and was left for 3 min, to allow its penetration deep into the lesion [Figure 3]. After 3 min., the excess resin on the tooth surface was wiped away, flossed and finally light cured for 40 s. The infiltrant was again applied for 1 min. followed by light curing for 40 s. [Pre-treatment and Post-treatment results for Group I and Group III can be appreciated in [Figure 4]].
|Figure 3: Resin Infiltration: Application of ICON-Etch; Area covered by ICON-etch; Application of ICON-Dry; Application of ICON-Infiltrant|
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|Figure 4: Pre-treatment and Post- treatment images when treated with microabrasion and resin infiltration (Group I and Group III)|
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In Groups II and IV, the fluorotic teeth were treated with re-mineralizing agent Tooth Mousse (GC, Tokyo, Japan) after microabrasion. A pea sized amount was applied on the surface of the four incisors using an applicator tip and left undisturbed for 4 min. All the participants were instructed to apply tooth mousse on the labial surface of upper incisors every morning after brushing for a period of 3 weeks. [Pre-treatment and post-treatment results for Group II and Group IV can be appreciated in [Figure 5].
|Figure 5: Pre-treatment and Post- treatment images when treated with subjected to microabrasion and remineralization (Group II and Group IV)|
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QLF image acquisition and analysis
The QLF images were captured by a single trained examiner in white light and fluorescent light pre-treatment, post microabrasion, post intervention (resin infiltration/re-mineralization) and post 1 month follow-up by QLF-D Biluminator™ device (Inspektor Research Systems BV, Amsterdam, The Netherlands) attached to a standard digital SLR camera. After placing the cheek retractor, the participants were asked to rest their chin on the chin rest to orient them with respect to the illumination tube of the QLF-D device. The distance between the participant and the QLF-D was 1 cm, a customized jig was used to maintain a 90° between them. The images were obtained from buccal aspects of the upper central incisors of each participant over a period of seconds under class 1 ASA darkroom conditions at the following setting. For white light images shutter speed of 1/30 s, aperture value of 20.0, and ISO speed of 1,600 and at a shutter speed of 1/10 s, aperture value 10.0, and ISO speed of 1,600 for Blue light images. The QLF-D software was used to analyse these QLF-D images taken in the standardized condition. White Spot Lesion Analysis was done for each image by blurring, masking and reconstruction. Mineral loss was automatically calculated as ΔF (%) at 5% fluorescence loss threshold. Blind image analysis was conducted by a single calibrated examiner [Figure 6].
|Figure 6: Quantitative light-induced fluorescence image analysis using software|
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Colorimetric analysis was performed on the white-light images using an image analyzer Image J Software 1.52q (Wayne Armband, National Institute of Health, USA). The colour difference (ΔE value) for white-light images were calculated using the following equation: “Δ E = [(Δ L)2+ (Δ a)2+ (Δ b)2]1/2”, where L, a and b are the components of a CIE L*a*b* colour system. The L* component stands for lightness, which can have a value ranging from 0 (most black) to 100 (most white). The intensity of green or red, and the intensity of blue or yellow is represented by the a* and b* components, respectively. The ΔL, Δa, and Δb components in the equation for colour difference represent the differences between the L*, a*, and b* values of images taken at baseline and post one month follow-up.
For evaluation of patient satisfaction, visual analogue scales were translated in the regional language and were filled out by the participants at end of the trial. The participant was shown his own picture before and after the treatment on a presentation and participant satisfaction with the intervention used ranging from 1 (no improvement) to 7 (exceptional improvement) was recorded. Tooth sensitivity and/or gingival irritation ranging from 1 (none) to 5 (severe) post intervention and at one month follow-up was recorded [Figure 7].
|Figure 7: Visual analog Scale Evaluation form in local language to assess patient satisfaction|
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All statistical analyses were performed using the SPSS Statistics program (version 23.0, SPSS, Chicago, IL, USA) at statistical significance level of P < 0.05. Data was tabulated and they were analysed using SPSS software v 23.0. Arithmetic mean, mean difference and standard deviation (S.D) was used for descriptive statistics and for tests of significance; repeated measures of ANOVA, One-way ANOVA, Independent t-test were used.
| Results|| |
There were 60 individuals who participated in this study, of which 48.33% were male. The mean age of the participants was 10 years (±1 year).
At baseline, mean ΔF value showed higher fluorescence loss among group I and II due to presence of stains compared to group II and IV. After microabrasion and intervention, all the four groups showed fluorescence gain compared to baseline [Table 3].
Intragroup comparison of ΔF values across different time intervals show statistically significant improvement in ΔF value in all the four groups. (P < 0.001, 0.002). Post microabrasion, maximum fluorescence gain is present only in group I (-0.18). Post intervention maximum fluorescence gain is seen in group I (-5.47) followed by group II, III and IV (-0.38), respectively. Post follow-up fluorescence gain values also showed a similar trend [Table 4].
|Table 4: Intra group comparison of ΔF values across different time interval among different test groups|
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Intergroup comparison of ΔF values between Groups III and IV show statistically significant fluorescence gain (P < 0.004) concluding that resin infiltration intervention caused better fluorescence gain in unstained grade III dental fluorosis compared to remineralization intervention. However, in stained Grade III dental fluorosis groups (I and II), the improvement with both the intervention protocols is statistically insignificant [Table 5].
|Table 5: Inter group comparison of ΔF values based on intervention across stained and unstained Grade III dental fluorosis|
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The fluorescence gain caused by resin infiltration was compared between the stained and unstained group (I and III). Inter group comparison of ΔF values show statistically significant fluorescence gain (P < 0.001) meaning it performed better in the stained fluorosis group. Similarly, when ΔF values were compared for remineralization protocol in the stained and unstained group, it was significantly better in the stained group (P < 0.001) [Table 6].
|Table 6: Inter group comparison of ΔF values based on stains in grade III dental fluorosis across type of intervention|
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The colorimetric analysis evaluated L* and ΔE values in relation to materials. It shows that when mean L value is compared between resin infiltrated (62.73 ± 5.52,67.69 ± 2.31) and remineralized (67.58 ± 6.33,70.72 ± 3.62) fluorotic teeth with and without stains, respectively, the results are statistically significant (P < 0.02, 0.005). It also reveals that when mean colour difference value (ΔE) post resin infiltration (11.6 ± 0.24; 9.1 ± 0.18) is compared with mean ΔE value post remineralization (4.55 ± 0.03;5.03 ± 0.03) in both groups of DF, the results are highly statistically significant (P < 0.001; P < 0.001) irrespective of brown staining and in both cases the resin infiltration protocol had a higher mean ΔE value indicating a greater clinically significant change [Table 7].
|Table 7: Colorimetric measurements expressed as L value and ΔE-values post intervention one month follow up compared to baseline|
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Seventy five percent of the participants reported that there was a moderate improvement and the remaining found the improvement to be exceptional when pictures before and after the treatment were shown to them. Participants who reported exceptional improvement belonged to the resin infiltration intervention group having stained DF. None of the participants reported tooth sensitivity or gingival irritation before or after the treatment.
| Discussion|| |
DF, being a condition causing intrinsic staining of teeth, is known to affect facial aesthetic. Individuals with DF may be psychosocially affected, wherein they report to be embarrassed to smile, lack self-esteem and struggle to pursue social relations., Therefore, the treatments should necessarily be able to improve the aesthetics of the patients, helping them rebuild their self-confidence.
Patients with moderately fluorotic anterior teeth were selected for this study. To minimize the confounding factors, the participants were selected according to the inclusion criteria.
Microabrasion has been recommended for the management of fluorosis with scores of 1–4 on the TSIF (Tooth Surface Index of Fluorosis) which corresponds to mild and moderate DF per Dean's Fluorosis Index Modified Criteria (1942)., Microabrasion, a minimally invasive technique, employs abrasion and chemical erosion of the superficial enamel layer resulting in the removal of defects. The determining factors for a successful outcome are the location and depth of the stain or spot. Therefore, this procedure proves more successful for superficial enamel lesions whereas deeper lesions may need additional treatment.[34–36]
Christensen et al. had concluded that when enamel of fluorotic teeth is bathed in a supersaturated remineralizing solution, the mineral uptake in vitro is increased. Our findings also revealed a significant decrease in mean ΔF values over time in the groups where microabrasion-remineralization was performed. This is in accordance with the outcome of a study by Alhawij et al. which concluded that artificial enamel carious lesions in teeth with moderate fluorosis demonstrated better remineralization than those in unaffected teeth.
Celik et al. reported that following microabrasion with 6.6% hydrochloric acid, the aesthetic improvement was significantly lower in severely fluorotic teeth than in mild to moderate lesions. Similarly, Sinha et al. and Train et al. reported that teeth with more severe DF lesions require yet additional treatment. Therefore, enamel microabrasion technique combined with resin infiltration could be employed for such lesions to attain superior aesthetic results.
Previous studies have proven the effectiveness of resin infiltration therapy in management of white spot lesions on facial surfaces.,, Histologically, a white spot lesion is characterized by deep-seated hypo-mineralized porous lesion. However, Munoz proposed that fluorosis stains simulate inactive lesions and unlike carious lesions, have a completely intact surface structure and a significantly greater depth. Hence, to ensure the erosion and subsequent penetration of infiltrant till the deep hypo-mineralized zones, microabrasion of the “inactive” sound surface was done followed by etching using the ICON Etch. Tirlet et al. recommended this procedure as well.
After the resin infiltrates the porous lesion, a change in refractive index causes the opaque area to blend better with the surrounding healthy enamel. This might have resulted in deep and effective penetration of the infiltrant resulting improved aesthetic in this study.
Resin infiltrant does not have a radiopaque component, which makes its evaluation difficult using X-ray imaging. Therefore, QLF was considered as a useful evaluation tool in this study. The basic ideology behind the method adopted in this study was that infiltration of subsurface porous fluorotic area with the resin infiltrant, consisting mainly of triethylene glycol dimethacrylate (TEGDMA), would reduce light scattering from the surface of the tooth, thereby changing the ΔF value.
In this study, the baseline mean ΔF values were higher in the stained groups than the unstained group, which indicates that the severity of fluorosis can be determined using quantitative light-induced fluorescence device. Pretty et al. concluded that the software analysis of QLF images demonstrated significant correlations with the clinical examinations for both Dean's and TF index. The mean baseline values of ΔF in our study ranged from 6.18 ± 0.67 to 12.50 ± 9.46 which was similar to that reported in the case report published by Park et al.
The statistically significant fluorescence gain across different time intervals in all the four groups concludes that combination of microabrasion with either resin infiltration or remineralization can be acceptable treatment options for micro-aesthetic management of moderate dental fluorosis.
Although, the observed change in ΔF values was remarkable in the resin infiltration groups (I and III) immediately after intervention, it was more pronounced after a month's follow-up in the remineralization groups (II and IV). This could be attributed to the fact that remineralization with CPP-ACP (Casein phosphopeptide-amorphous calcium Phosphate) is a time taking process because it is dependent on the slow deposition of calcium ions., As opposed to this, resin infiltration penetrated deep lesions, improving the aesthetic appearance of the fluorotic area immediately after treatment.
As per previous literature, a colour difference or ΔE value of more than 3.7 is considered as clinically acceptable colour difference. In this study, the colour difference was clinically observable as well as statistically significant with both interventions irrespective of presence or absence of stains; resin infiltration being superior than remineralization.
Visual analog scales were used in our study to evaluate the participants' satisfaction with the intervention. Wong and Winter suggested that aesthetics is a subjective perception and indices are incapable of accurately interpreting personal appearance. Therefore, this trial did not attempt to incorporate any aesthetic index.
The outcome of this trial has reaffirmed that resin infiltration, the micro-invasive technique can be effectively used in patients with moderate dental fluorosis. QLF-D may be used as a tool to quantify the extent of the fluorotic lesion, and it may act as a tool for the clinician to employ the treatment of choice. If the young patient is motivated enough and compliant, microabrasion-remineralization is also an effective intervention for the management of moderate dental fluorosis.
The benefit of this study is that it employs a tool for quantification of the lesion extent at baseline and provides a quantified improvement in the fluorescence loss ΔF which is at the structural level of the enamel. Moreover, it also takes into consideration the subjective and quantitative aspects of aesthetics by employing a VAS and measuring colour difference (ΔE). This in vivo study has its limitations that the study participants could have been followed up for a longer period to assess the colour stability of the resin infiltration intervention. Also, bleaching could have been included as another comparable intervention group. Further studies exploring the other techniques with a long follow up period would provide a detailed insight into the success of these micro-invasive interventions for dental fluorosis management.
| Conclusion|| |
Within the limitations of this study, the QLF evaluation suggests that microabrasion with resin infiltration has performed significantly better than microabrasion-remineralization in the unstained group with respect to fluorescence gain (P < 0.004). And even though both interventions were equally effective for stained fluorotic lesions, microabrasion with resin infiltration, a single sitting procedure with significantly better colour masking can be preferred over remineralization.
This is to acknowledge the support from my colleagues and staff that aided in the smooth conduction of this study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Shreepriya Singhania
Department of Pediatric and Preventive Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education, SS Nagar, Mysore, Bangalore Road, Mysuru - 570015, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]