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. REFERENCES 1. 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