Joined: 25 Aug 2005
|Posted: Tue Jul 28, 2009 5:41 am Post subject: Icon -
|Infiltration: A new approach to caries treatment
A new technique that bridges the gap between remineralization and restoration could do away with that age-old dilemma: is it better to wait and watch or drill and fill?
By Kathy Kincade
A new caries treatment technique that bridges the gap between remineralization and restoration could do away with that age-old dilemma: is it better to wait and watch or drill and fill?
Developed by researchers from the University School of Dental Medicine at Charite-Universitatsmedizine Berlin, the technique -- resin infiltration – has been exclusively licensed to DMG, which is commercializing it under the brand name Icon. The company introduced the Icon system to the European dental community at the International Dental Show in Germany earlier this year and plans to launch it in the U.S. this Fall at the ADA meeting, according to Wayne Flavin, director of scientific affairs for DMG America.
"This is a completely new technology and treatment option," Flavin said. "It is not intended to replace remineralization or the attempt to remineralize early lesions. It is intended for when the doctor has decided that remineralization is not working."
Invented by Sebastian Paris, D.D.S, and Hendrik Meyer-Lueckel, D.D.S., resin infiltration utilizes the concept of capillary forces -- "similar to a sugar cube soaking up coffee," Dr. Paris said in an e-mail to DrBicuspid.com. The pseudointact surface layer of the caries is first eroded by etching the lesion for 120 seconds with 15% hydrochloric acid gel (this layer would otherwise hamper penetration, Dr. Paris said). The lesion is then desiccated with ethanol and air blowing and the infiltrant -- an experimental resin comprising tetraethyleneglycol dimethacrylate, ethanol, camphorquinone, and ethyl 4-(dimethylamino)benzoate -- is applied, penetrating into the porous lesion via the capillary forces.
"The secret to Icon and to infiltration is the resin, which has an extremely high penetration coefficient," Flavin said. "The best bonding agents on the market today infiltrate 10 to 12 microns into the tooth structure. Icon infiltrates 600 microns, and it can fully infiltrate a lesion in only 2-3 minutes."
After three minutes, the excess material is removed from the lesion surface and the material is light cured, leaving no resin coat on the lesion surface. Rather, the resin occludes the lesion pores inside the lesion body, thus preventing diffusion of cariogenic acids into the lesion, Dr. Paris explained. In the process, however, the sealing process also eliminates the possibility of remineralization, he said.
"Infiltration is not indicated for lesions where remineralization is the first choice. Of course we aim for remineralization of lesions first, by local fluoridation, oral hygiene education, and dietary control," Dr. Paris noted. "However, if this approach fails, at a certain point lesions have to be restored with fillings. Using caries infiltration, we want to delay or even prevent this first operative intervention."
While remineralization works well on shallow lesions, Flavin noted, "when you get to deeper lesions, such as one that has progressed through the enamel-dentine junction and into the first third of the dentin, you are probably not going to have great success with remineralization. And this is where infiltration comes in. Rather than reaching for a handpiece, this offers the option to treat the lesions using very minimally invasive procedures."
But Douglas Young, D.D.S., M.S., M.B.A., an associate professor at the University of the Pacific School of Dentistry, disagrees that deeper lesions have less success of remineralization.
"Remineralization can happen at any stage, and the important question should be not how deep the demineralization goes, but is the lesion cavitated," he said in an e-mail to DrBicuspid.com. "If the lesion is not cavitated, then bacteria are physically too big to get into the dentin; therefore, remineralization can (and perhaps should) be done first. Remineralization does not fail; it is predictable chemistry. What fails are our attempts to figure out how to correct the patient's chemistry."
Dr. Paris and his colleagues have been publishing on resin infiltration since 2006, addressing various aspects of the infiltration technique, such as evaluating different etching gels for pre-treatment purposes (Journal of Dental Research 2007, 86(7):662-666); comparing the penetration coefficients of a proprietary resin formulation to commercially available adhesives (Journal of Dental Research 2008, 87(12):1112-1116); and validating the ability of fluorescence confocal microsopy to analyze the infiltration of caries lesions with low-viscosity resins (Microscopy Research and Technique July 2009, 72(7):489-494).
More recently, at this year's International Association for Dental Research (IADR) meeting, they presented two additional studies involving resin infiltration: "Progression of resin-infiltrated natural caries lesions in vitro" and "Modern detection, assessment and treatment of initial approximal lesions."
In the first, they applied the infiltration process to extracted teeth, etching the teeth 15% hydrochloric acid gel for 120 seconds and then infiltrating with one of four experimental infiltrants (BisGMA 25%, TEGDMA 75%; BisGMA 20%, TEGDMA 60%, ethanol 20%; TEGDMA 100%; and TEGDMA 80%, ethanol 20%) for five minutes. Specimens of the teeth were then exposed to a demineralizing solution (pH 4.95) for 200 days. After imaging with microradiography, they found that the lesions treated with the latter three infiltrants all showed lower progression rates in a demineralizing environment in vitro than lesions that were untreated with infiltrants.
The second study -- sponsored by DMG -- compared resin infiltration to flossing and sealing of approximal lesions around the enamel-dentin junction as part of an ongoing three-year, split-mouth study on approximal-posterior surfaces and preventive procedures, concluding only that "the infiltration technique has been described as a clinically feasible method for treating approximal enamel-dentin junction lesions."
But because resin infiltration is such a new approach, Dr. Young feels more research needs to be done -- especially on early cavitated lesions -- before dentists begin adopting infiltration into their treatment regimens. Additional studies are under way in the U.S. at the University of Michigan, Case Western Reserve, and the University of Alabama and in Germany, Denmark, and Colombia, according to DMG.
Dr. Young also feels there needs to be a clearer understanding of when it is best to remineralize versus when surgical intervention or resin infiltration are called for.
"Is (infiltration) less invasive than surgical restoration? Yes, but not at the expense of natural remineralization on intact surfaces," he said. "Aggressive marketing, incomplete understanding of remineralization chemistry, and nonstandardized terminology will lead many down the path of irreversible procedures such as infiltration."
copied from an email...
Jason Luchtefeld, DMD, FAGD