Journal of Dentistry 79 (2018) 77–84

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Power bleaching enhances resin infiltration masking effect of dental T

fluorosis. A randomized clinical trial
⁎
Christoph M. Schoppmeier , Sonja H.M. Derman, Michael J. Noack, Michael J. Wicht
Department of Operative Dentistry and Periodontology University Hospital of Cologne, Kerpener Str. 32, 50931, Cologne, Germany

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: Patients with moderate dental fluorosis often feel esthetically compromised. Aim of this RCT was to
Dental fluorosis evaluate the objectively and self-assessed masking effect of resin infiltration alone or in combination with in-
Hydrogen peroxide office bleaching on dental fluorosis in adults.
Resin infiltration Methods: Twenty-seven patients (9 male, 18 female, 24.81 ± 3.7 yrs) with 410 fluorotic teeth (TF 1–4) were
Tooth whitening
randomly assigned to a treatment (BLI) or control group (NBLI). Patients underwent in-office bleaching (25%
Opacities
H2O2) in the BLI or a placebo bleaching (ACP gel) in the NBLI group followed by resin infiltration after two
weeks. Standardized digital photographs were obtained at baseline; after bleaching; before and after resin in-
filtration and after 1, 3, and 6 months. Color differences (ΔE) between sound and fluorotic areas were calculated
and patient satisfaction was evaluated using a VAS (1–10).
Results: Statistical analysis revealed significant differences in the mean ΔE values 6 months after resin in-
filtration between the BLI (ΔE = 1.41) and the NBLI group (ΔE = 4.33) (p = 0.024). VAS values increased after
resin infiltration (p < 0.05) in both groups. After 3 months patients in the BLI group had higher VAS values than
in the NBLI group (p = 0.029).
Conclusions: Findings of this study suggest that resin infiltration alone can effectively mask mild to moderate
dental fluorosis in young adults. In-office bleaching with 25% H2O2 before resin infiltration provides sig-
nificantly better masking effects.
Clinical Significance: Resin infiltration is a safe and efficient treatment option for masking fluorotic opacities. A
priori in-office bleaching with 25% H2O2 enhances the masking effect.
This controlled clinical trial is registered in the German Clinical Trials Register #DRKS00010465.

1. Introduction microporosities and undifferentiated hypomineralization, which can

Over the past 70 years, fluoridation has contributed to a sustained
decrease in the caries prevalence by promoting remineralization and
inhibiting demineralization [1]. However, the use of fluorides has also
been linked to an increase in dental fluorosis [2]. Water fluoridation
and the use of fluoride-containing toothpaste, specific foods/beverages,
and fluoride supplements are considered possible risk factors for the
development of dental fluorosis [3].
Dental fluorosis (ICD-10-GM-2016 K00.3) is the main reason for
intrinsic tooth discoloration and is caused by high fluoride absorption
during tooth development (> 0.05 mg/kg/BW/d) [4–6]. Worldwide,
the prevalence of fluorosis among 6–18 year olds ranges from 7.5% to
18.3% (water fluoride level < 0.7 ppm) [7].
Beneath a sound surface, the enamel structure is characterized by
pathophysiologically lead to air and water inclusions. These inclusions
result in a change in the refractive index, which, in turn, leads to a
change in internal reflection and increased opacity of tooth enamel [8].
Clinically, dental fluorosis is characterized by white opacities that
vary from small spots and lines to extensive areas. More pronounced
fluorosis is characterized by brown stains and superficial pitting. These
changes are evenly distributed throughout the dentition, although their
magnitude varies among the different tooth groups. To characterize the
clinical appearance of dental fluorosis, several indices have already
been used. The Thylstrup and Fejerskov index (TFI) [9] seems to be
more appropriate for use in clinical trials, primarily because teeth are
dried and fluorosis can be identified in its milder forms. The resulting
increased sensitivity provides statistical and practical advantages as-
sociated with the possible detection of effects in smaller samples [10].

⁎
Corresponding author.
E-mail addresses: christoph.schoppmeier@uk-koeln.de (C.M. Schoppmeier), sonja.derman@uk-koeln.de (S.H.M. Derman),
michael.noack@uk-koeln.de (M.J. Noack), michael.wicht@uk-koeln.de (M.J. Wicht).

https://doi.org/10.1016/j.jdent.2018.10.005
Received 28 August 2018; Received in revised form 5 October 2018; Accepted 15 October 2018
0300-5712/ © 2018 Published by Elsevier Ltd.
C.M. Schoppmeier et al.
Table 1
Inclusion and exclusion criteria.
Inclusion criteria
At least one fluorotic lesion (TF 1-4) in teeth 15–25 or 35–45
Majority and legal competence
Written informed consent
Biochemical ameloblastic cell apoptosis plays a major role in the
development of the condition. Fluorides can trigger this effect by dis-
turbing the synthesis, secretion, and intracellular transport of enamel
matrix proteins in ameloblasts [11]. In particular, this leads to the
delayed removal of enamel matrix via an influence on certain protei-
nases such as matrix metalloproteinase (MMP-20) [12]. Fluoride-in-
duced ameloblastic apoptosis is triggered by oxidative stress due to a
decrease in enzymatic antioxidants [13]. Bcl-2, a central antiapoptosis
protein, is of particular importance. It plays a significant role in the
inhibition of apoptosis during embryonic development, including
amelogenesis, via control of the outer mitochondrial membrane per-
meability. It has been shown that fluoride-induced apoptosis is asso-
ciated with Bcl-2 downregulation [14].
Previous studies have shown that mildest forms of fluorosis did not
affect children’s quality of life [15]. However, fluorotic changes in
permanent teeth, particularly in the maxillary anterior region, can lead
to an unappealing appearance. Therefore, the presence of dental
fluorosis has a direct socio-psychological influence [16,17]. Today
several invasive and noninvasive treatment strategies for dental
fluorosis are available. For severe fluorosis, composite restorations and
veneers are optional, whereas tooth bleaching and microabrasion are
the basic therapies for mild to moderate fluorosis [18].
Tooth whitening aims at providing optical adjustment between
fluorotic and healthy enamel areas. Regardless of the chosen bleaching
technique (in-office or at home), inclusions within the fluorotic enamel
cannot be eliminated [19]. Microabrasion is performed using a hydro-
chloric or phosphoric acid suspension containing abrasives; the entire
enamel surface is etched and smoothed. However, the white opacities
are masked at the cost of a large amount of tooth structure, which is lost
during the treatment procedure [20,21].
Resin infiltration has been overcoming the limitations of the above
described strategies [22]. Clinical studies and systematic reviews have
shown the potential of resin infiltration systems to mask acquired or
development-related white opacities [23]. Resin infiltration is based on
gentle erosion of the affected surface with 15% hydrochloric acid. The
exposed lesion body is infiltrated with a low-viscosity resin having
optical properties similar to those of healthy enamel. The masking ef-
fect is based on a change in the refractive index. After successful in-
filtration, the affected area visually appears similar to the surrounding
healthy enamel [8]. Thus, while microabrasion removes hypominer-
alized enamel, resin infiltration stabilizes the hypomineralized areas
and reinforces the weakened prism structure within the lesion.
The performance and masking efficacy of resin infiltration into
hypomineralized or carious enamel have already been demonstrated.
However, the clinical efficacy and precise technique of resin infiltra-
tion, as well as the durability of the masking effect, remain unclear, and
this information is crucial for a patient´s informed choice [23].
Accordingly, we conducted this randomized clinical trial to evaluate
the masking effect of resin infiltration alone or in combination with
preceding in-office power bleaching on non-pitted dental fluorosis in
adults. The null hypothesis was that there is no significant decrease in
the color difference between sound enamel and fluorotic areas at 6
months after either treatment strategy.
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Journal of Dentistry 79 (2018) 77–84
Exclusion criteria
Attendance to other interventional studies
Contraindications according to technical information or the instruction for use
Allergies to one of the ingredients or contact allergies
Serious general diseases (American Society of Anesthesiologists physical status > 1)
History of restorative treatment of fluorotic areas
Bleaching within the last 18 months
Indications of noncompliance with the study protocol (e.g., unwillingness to co-operate)
Staying in a facility as per court or an official order
2. Materials and methods
The ethics review board at the University of Cologne (Dossier 16-
188) approved this trial, which was registered in the German Clinical
Trials Register (DRKS00010465; https://www.germanctr.de). Written
consent was obtained before treatment from every patient. Recruitment
was initiated in August 2016 and completed in January 2017. The last
follow-up examination was in November 2017.
2.1. Trial design
We conducted a monocentric randomized controlled trial with
simple blinding according to §23 b of the Medical Devices Act and a
parallel-group design. Patients who visited the Centre of Dental
Medicine, Department of Operative Dentistry and Periodontology,
University of Cologne, Germany were considered for the study. First, all
patients were examined for opacities on the basis of Russell’s criteria.
Thus, we were able to perform differential diagnoses of different
whitish opacities [24]. Patients exhibiting dental fluorosis grade 1–4
according to the Thylstrup and Fejerskov index were asked whether
they were interested in participating in the study. Inclusion and ex-
clusion criteria are listed in Table 1. According to the current state of
knowledge, no sex-based differences were to be expected. The expected
female/male ratio for consecutive inclusion was 3:2. On the basis of all
criteria, 27 patients (nine men and 18 women; mean age, 24.81 ± 3.7
years) with 410 teeth showing non-pitted fluorosis were recruited and
randomly assigned to the treatment (BLI) or control group (NBLI).
Randomization was based on permuted blocks of variable length, and
the random sequence was generated according to http://www.
randomization.com. The randomization list was generated by a statis-
tician not involved in the study. Access rights to this list (paper and
electronic) were provided to individuals involved in the study only
when required. Fig. 1 shows patients flow during the trial.
2.2. Treatment procedure
In the BLI group fluorotic teeth were subjected to light-activated in-
office bleaching with 25% hydrogen peroxide (ZOOM!; Discus Dental
Europe, Rotterdam, Netherlands) according to the manufacturer’s in-
structions. The patients’ lips were covered with vitamin E oil, and a lip
retractor was placed. A light-curing liquid dam (OpalDam; Ultradent,
South Jordan, USA) and a gauze were used to obtain a clear treatment
field. For eye protection, patients were asked to wear protective goggles
with blue light filters both for bleaching and infiltration. The patients
underwent a total of three bleaching cycles for 15 min each.
In the NBLI Group the fluorotic teeth were first treated with placebo
in-office bleaching with ACP gel (Relief ACP Oral Care Gel; Discus
Dental Europe, Rotterdam, Netherlands) according to the same protocol
used for the BLI group.
In both groups resin infiltration was performed 2 weeks after
bleaching. As a prerequisite for successful infiltration, the teeth were
cleaned with a fine polishing paste (Proxy Rosa RDA 7-fine; Ivoclar
Vivadent, Schaan, Liechtenstein) and polishing cup (Pro-Cup soft, light
C.M. Schoppmeier et al.
Fig. 1. Flowchart.
Patient flow through the trial.
blue; Kerr, Montana, USA) to eliminate any extrinsic discoloration that
could interfere with the treatment.
Subsequently, vitamin E oil (Discus Dental Europe, Rotterdam,
Netherlands) was applied to the lips and a lip retractor was placed to
ensure adequate and fast drainage. A light-curing liquid dam
(OpalDam; Ultradent, South Jordan, USA) or a conventional rubber
dam (Roeko Dental Dam; Colténe Whaledent, Altstaetten, Switzerland /
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Journal of Dentistry 79 (2018) 77–84
for latex allergy: Roeko Dental Dam silicone; Colténe Whaledent,
Altstaetten, Switzerland) was applied in the cervical regions of the
evaluated teeth in order to protect the gingiva from irritation. We fol-
lowed a standardized hydrochloric acid etching protocol comprising
three cycles for 2 min each. The etched enamel was dried for 30 s with
ethanol containing Icon-Dry (Icon; DMG, Hamburg, Germany), fol-
lowed by infiltration with a low-viscosity resin (Icon; DMG, Hamburg,
C.M. Schoppmeier et al.
Germany). The infiltrant was left on the tooth surface for 10 min. Excess
material was removed with cotton roles and dental flossing prior to
light curing for 40 s (1492 mW / cm2, Acteon MiniLED; Financiere
Acteon SAS, Merignac, France). A second layer was allowed to set for
one minute and photopolymerised accordingly. Surfaces were polished
with Super-Snap (Shofu Dental Corporation, San Marcos, USA) with
Diract Dia Polishing Paste (Shofu Dental Corporation, San Marcos, USA)
and an Occlubrush (Kerr, Montana, USA).
2.3. Blinding
The present clinical trial was conducted in a simple-blind manner.
For this purpose, non-distinguishable test and placebo bleaching pro-
ducts provided by the manufacturer were used in both groups. Test
products were numbered according to the randomization list.
2.4. Color measurements
For color analysis, standardized digital photographs were taken
with a SLR camera (Canon EOS 750 D; Canon, Tokyo, Japan) at base-
line (T1); immediately after bleaching/placebo bleaching (T2); before
resin infiltration (T3); immediately after resin infiltration (T4), and 1
(T5), 3 (T6), and 6 (T7) months after resin infiltration (Fig. 2, pre-
operative and postoperative). An image-stabilizing macro lens (Canon
EF 100 mm, 1:2.8; diagonal angle of view, 24°; focusing, ring USM,
internal focusing system, manual focusing at any time; minimum fo-
cusing distance, 0.31 m/foot; 1× magnification; filter size, 67 mm;
Canon, Tokyo, Japan) with a ring flash (Macro Ring Lite MR-14 EX II,
guide number 14, ISO 100; Canon, Tokyo, Japan) was used for this
purpose. The settings on the camera were manually set and auto-
matically adjusted on the flash unit (via E-TTL II: shutter speed, 160,
f22, ISO sensitivity 100; Canon, Tokyo, Japan). All measurements were
performed under standardized ambient conditions to guarantee accu-
racy, stability, and reproducibility. LAB color values were calibrated
with the help of a target (X-Rite ColorChecker Passport Photo; X-Rite,
Grand Rapids, USA) and checked for color fastness using commercially
available software (Photoshop Lightroom 6; Adobe, San Jose, USA).
Before study initiation, training sessions for color evaluation were
performed, first with 60 dental fluorosis pictures (in lux calibration)
Fig. 2. (a)–(d) Representative images of a 26 year old male patient TFI grade 2 (NBLI group) at baseline (a) and after 6 months (b) and a 25 year old female patient
TFI grade 3 (BLI group) at baseline (c) and at the 6 months recall (d).
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Journal of Dentistry 79 (2018) 77–84
and then under actual clinical (in vivo) conditions. The study images
were taken at the same distance under controlled lighting conditions.
The same background, camera, light source, and exposure were used for
all patients. To ensure a white balance, a neutral gray reference (X-Rite
ColorChecker Passport Photo; X-Rite, Grand Rapids, USA) was photo-
graphed under the given light with each shot. The photographer un-
derwent a calibration exercise after training to ensure that images were
always captured at the same camera position and angle. Any deviations
in the brightness values (L*) for the gray map from the default value
were recorded and adjusted to the photos. The patients were made to
recline on a dental chair, with the Frankfort horizontal plane parallel to
the ground. For a freely accessible, well-arranged treatment field and
effective drainage, a lip holder (OptraGate; Ivoclar Vivadent, Schaan,
Liechtenstein) was applied. To minimize the effects of both specular
reflection and lip shadows, a camera flash angle of 45° and the 12
o’clock position were chosen. Before photographs were taken, the tooth
surfaces were air-dried for 60 s. The tooth with the highest fluorosis
grade was chosen as the index tooth in each patient. Photos with light
reflections on the index teeth were excluded. Two examiners performed
the measurements after photographs were randomly labeled to avoid
unwanted measuring bias. Images were re-examined after 1 month to
evaluate the intra- and inter-rater reproducibility using interclass cor-
relation (ICC).
The borders of the fluorotic lesions were outlined on the screen, and
the color values of the sound enamel and fluorotic lesions were mea-
sured using an image analysis software (Photoshop CC; Adobe, San
Jose, USA). The patch analysis and surface contour were copied and
matched for size, orientation, and location on the tooth surface in each
consecutive image to ensure that the same area was analyzed at all
times. RGB values for the sound enamel and lesions were obtained for
each tooth and transformed to the CIELAB color space. Color distribu-
tions were analyzed using the Commission International de l'Eclariage
L*a*b system [25]. We calculated and compared the L*a*b* values for
healthy enamel and fluorotic enamel and determined the total color
difference ΔE (Excel 2016, Microsoft, Redwood, United States) using
the following formula:
ΔE = [(ΔL*)2 + (Δa*)2 + (Δb*)2]1/2
C.M. Schoppmeier et al.
2.5. Patient satisfaction
Patients were administered a questionnaire based on the Oral
Health Impact Profile-14 [26] at the beginning and end of the trial for
evaluation of the oral health-related quality of life. Furthermore, they
received questionnaires that determined and compared the patient sa-
tisfaction levels in terms of the overall appearance and comfort during
treatment at the time of diagnosis (T1), immediately after bleaching/
placebo bleaching (T2), immediately after resin infiltration (T4), and at
the follow-up appointments (T5-T7); a global rating was applied. The
patient assessed the masking effect using a hand mirror.
2.6. Sample size calculation and statistical analysis
To verify the primary outcome (ΔE), a mixed linear model with
measurement repetitions was used for two independent samples. The
required sample size was estimated using PS Version 3.0.43 software
[27]. At a given two-sided significance level of α = 5%, a standardized
effect of 1 with a power of 1 − β = 80% should be demonstrated by the
test. For a solid basis of measurement data, a study population of 20 per
group was considered necessary.
An intermediate evaluation was performed for 26 evaluable patients
according to O'Brien-Fleming barriers [z1 = 2.7965, p1 = 0.002583
(one-sided); z2 = 1.9774, p2 = 0.023996 (one-sided)]. The study de-
sign (in particular, case number adjustment) was adapted according to
the “inverse-normal method” [28].
Improvements in ΔE were analyzed using a mixed linear model for
measurement repetitions (effects output value, group, time, group*-
time; unstructured covariance matrix; corresponding contrast). No
dropouts were expected. When this occurred, the study population was
replenished by the recruitment of new patients.
Intraclass correlations were calculated for intra-rater and inter-rater
reliability of both examiners.
The secondary endpoints were analogously evaluated, using the
generalized estimating equations method. All statistical analyses were
performed using SPSS Statistics 26 (IBM SPSS, Armonk, United States).
3. Results
In total, 26 patients exhibiting 405 fluorotic teeth (BLI group:
n = 13, 213 teeth; NBLI group: n = 13, 192 teeth) completed the trial
up to the 6-month follow-up. One patient missed the resin infiltration
treatment and every follow-up appointment and was therefore excluded
from the study.
Repeated photographs of the grey card and white balance taken at
different dates and subsequent colorimetric analyses revealed highly
reproducible results using an absolute agreement definition (ICC
average measure = 0.77). Baseline TF values of both groups showed no
significant difference (p > 0.42, chi-square test). At every observation
reliability and reproducibility were excellent (p < 0.01) with intra-
rater ICC ranging from 0.99 to 1.00 and inter-rater correlations from
0.996 and 1.00 respectively. Therefore, final calculations are based on a
single observer’s measurements.
Mean NBLI ΔE values were deducted from BLI values at every ob-
servation point and statistically plotted against baseline ΔE values
(Table 2). The mixed linear model revealed significant differences be-
tween estimates group and time (p < 0.01).
Patients in both groups showed significantly increased VAS values
(Table 3) after infiltration and the follow up recalls T5, T6 and T7
(p < 0.05). At T6 significant differences between groups were found
with mean VAS differences T6-T1 of 6.4 in the BLI and 5.7 in the NBLI
group (p = 0.02 mixed linear model). Due to the corrected level of
significance T7 was not statistically significant between groups
(p = 0.039) (Table2).
Lower differences of ΔE values correlated with an increased patient
satisfaction (Pearson, r = −0.42, Fig. 3). Correlation was more
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Journal of Dentistry 79 (2018) 77–84
pronounced in the NBLI (r = 0.56) than in the BLI group (r = 0.28).
4. Discussion
In the present study, we found that resin infiltration alone effec-
tively masks mild to moderate dental fluorosis in young adults. In-office
bleaching with 25% hydrogen peroxide prior to resin infiltration pro-
vides a significantly better masking effect. Therefore, we rejected our
null hypothesis.
In order to prove if treatment (BLI) was particularly beneficial or
harmful compared to the placebo group (NBLI) during the ongoing
study, we were ethically obliged to assess this difference on the basis of
an interim analysis according to O'Brien-Fleming barriers [29]. Iterated
hypothesis testing increases the type I error rate. Therefore, boundary
points are defined that total significance levels do not exceed the value
of α. Due to a significant improvement in the BLI group, the study was
discontinued after 27 instead of 40 patients.
Intrinsic discoloration of teeth in the visible zone might negatively
affect esthetics. A perfect smile has gained popularity in recent decades,
and the presence of healthy teeth without any signs of abnormality has
become very important for many individuals [30]. Previous studies
have shown that fluorosis leads to negative self-perception and feelings
of dissatisfaction [31]. The severity of the disease determines the self-
perception, and the perception of mild and moderate fluorosis has long
been controversial [32]. New findings show that even adolescents can
distinguish different levels of fluorosis [17]. This has led to increased
awareness about the clinical symptoms of the disease and the possible
negative effects on mental health.
To the best of our knowledge, this is the first clinical study that not
only determined the objective masking effect of resin infiltration
combined with prior in-office bleaching but also evaluated patient sa-
tisfaction levels using VAS, which was adapted from previous studies on
fluorosis and applied in an improved form [33]. The scores indicated
that patients were significantly happier after infiltration than at base-
line, with similar satisfaction levels among patients who received resin
infiltration alone (NBLI group) and those who received resin infiltration
combined with prior in-office bleaching (BLI group).
Training session for color evaluation were performed to minimize
intra-examiner errors and ensure uniformity in the diagnosis of dental
fluorosis with different degrees of severity (1–9) according to TFI.
Standard quantifications of color changes were performed using a
spectrophotometer and digital images. Reliability and reproducibility of
measurement methods have already been demonstrated in similar stu-
dies [34].
Tooth whitening was performed with 25% hydrogen peroxide 14
days before resin infiltration in order to ensure color stabilization and
washing out of the oxygen ions, which may hinder infiltration by re-
ducing the adhesion of resin materials to enamel and dentin [35]. The
use of ACP gel (NBLI) did not inhibit subsequent resin infiltration.
Because light itself appears to have a bleaching effect, an orange filter
was adapted to the LED lamp in order to protect the teeth from any blue
light. Although some authors [36] have found that in-office bleaching
does not have any significant effect, our results were different. Tooth
whitening was able to achieve a light adjustment between fluorotic and
healthy enamel. As a consequence, ΔE decreased significantly in the BLI
group, relative to the value in the NBLI group, after resin infiltration.
Tirlet et al. assumed that the dehydration–rehydration effects of
bleaching [37] are the basis of this phenomenon. Our assumption is
based on the fact that the penetrability of enamel increases by the re-
lease of oxygen radicals. Another important observation in this study
was that the full extent of the fluorotic defect became visible to the
dentist only after tooth whitening; this allowed the dentist to infiltrate
the complete defect in the second treatment session. Moreover, stains,
which are usually brownish, could be easily removed. Therefore,
bleaching is considered an effective pretreatment for patients scheduled
for resin infiltration therapy.
C.M. Schoppmeier et al. Journal of Dentistry 79 (2018) 77–84

Table 2
Colorimetric measurements expressed as ΔE-values post bleaching/placebo bleacing (T2) – 6-months recall (T7) compared to baseline.
95% Confidence Interval Mean Difference (NBLI-BLI)

Group Date Mean Std. Error Lower Bound Upper Bound Std. Error Significance

NBLI T2 0.42 0.77 −1.17 2.01 0.92 1.09 0.40

T3 −0.63 0.79 −2.27 1.00 0.95 1.12 0.41
T4 −5.69 0.18 −6.06 −5.31 2.99 0.25 0.00
T5 −5.79 0.15 −6.09 −5.48 2.86 0.21 0.00
T6 −5.81 0.13 −6.09 −5.53 2.87 0.19 0.00
T7 −5.84 0.14 −6.14 −5.54 2.85 0.20 0.00

BLI T2 −0.5 0.77 −2.09 1.09

T3 −1.58 0.79 −3.22 0.06
T4 −8.68 0.18 −9.05 −8.31
T5 −8.65 0.15 −8.95 −8.35
T6 −8.68 0.13 −8.96 −8.40
T7 −8.69 0.14 −8.99 −8.39

ΔE-values T2-T7, mean, standard error, 95% confidence interval, mean difference between groups and standard errors. According to O’Brien Fleming boundaries p
values < 0.024 were statistically significant. Covariates in the mixed linear model were evaluated against T1 (ΔE baseline) = 10.06.

ΔE values in the placebo group increased after placebo bleaching.
However, this condition was only temporary, because the color values
quickly returned to their original levels. The increased tooth brightness
was associated with the use of lip and cheek retractors and the asso-
ciated reversible dehydration of the enamel.
Microinvasive resin infiltration therapy enables gentle and painless
treatment of proximal and vestibular carious lesions [38]. Several sys-
tematic reviews have demonstrated the success of caries infiltration
treatment [39]. In addition to cavity sealing, optical adaptation
(masking) of the lesion area to the surrounding healthy enamel occurs
as an additional effect [23]. Unlike other methods, this technique does
not remove the affected fluorotic areas, thus protecting the tooth
structure and prolonging the life of the tooth [38]. The etching protocol
involving three etching sessions removed approximately 111 ± 24 μm
of enamel [40].
In the present study, the infiltration time was extended to 10 min.
Individual case reports and our own clinical experience have shown
that an extended infiltration time leads to significantly better masking
in cases of hypomineralization. Fluorotic defects, unlike carious lesions,
have a completely intact surface structure and a significantly greater
depth. Because the infiltrant seals these defects by capillary forces, it
requires a longer contact time with the tooth. We also modified the
etching protocol to include three 2-min sessions, because previous
studies have shown that an existing intact surface layer is an actively
limiting factor for successful infiltration [41]. Finally, we repeated in-
filtration for 1 min, as the manufacturer recommends additional in-
filtration for 1 min in cases of carious lesions in order to minimize su-
perficial enamel microporosities, which are also expected to be present
after removal of the surface layer of fluorotic teeth.
Previous studies [42] have shown that infiltrated defects tend to
discolor after light curing when compared with healthy teeth. This can
be attributed to various reasons. The resulting microporosities cannot
be completely filled by the infiltrant [43]. Furthermore, it is assumed
that the chemical composition of the infiltrant can lead to possible
water absorption with color pigments. The remaining oxygen inhibition
layer and insufficient polishing can also lead to increased dye accu-
mulation on the rough resin surface [44]. Surface polishing is essential
for the success of infiltration. This additionally minimizes bacterial
adhesion and, consequently, plaque accumulation. For this reason,
patients should be informed that the discoloration potential after in-
filtration therapy is increased, and that they should limit the con-
sumption of colored foods such as red wine, coffee, tea, saffron, etc. In
case of severe discoloration, both polishing of the infiltrated surfaces
and subsequent tooth whitening can lead to satisfactory results [44].
Although color pigments can be eliminated with all tooth whitening
methods, we personally think tooth whitening after infiltration can be
performed via home bleaching due to diffusion effect.
A notable phenomenon was a further decrease in ΔE values during
follow-up appointments for the BLI group. The difference between va-
lues obtained immediately after infiltration and those measured 1
month after infiltration was particularly noticeable. We assumed that
ethanol drying leads to massive dehydration of the fluorotic tooth
structure during infiltration therapy. This dehydration continues even
after successful infiltration, and infiltrated enamel probably takes
longer for complete rehydration and optical adaptation.
The greatest challenge with this therapy lies in the predictability of

Table 3
Patients’ satisfaction expressed asVAS-values post bleaching / placebo bleaching (T2) – 6-months recall (T7) compared to baseline results.
95% Confidence Interval Mean Difference (NBLI-BLI)

Group Date Mean Std. Error Lower Bound Upper Bound Std. Error Significance

NBLI T2 0.73 0.44 −0.18 1.64 −1.04 0.62 0.11

T4 5.65 0.26 5.11 6.18 −0.49 0.37 0.19
T5 5.78 0.27 5.22 6.34 −0.14 0.38 0.72
T6 5.72 0.18 5.35 6.1 −0.64 0.26 0.02
T7 5.78 0.18 5.40 6.16 −0.57 0.26 0.04

BLI T2 1.77 0.44 0.86 2.68

T4 6.14 0.26 5.60 6.67
T5 5.92 0.27 5.36 6.48
T6 6.36 0.18 5.99 6.74
T7 6.35 0.18 5.97 6.73

VAS-values T2-T7, mean, standard error, 95% confidence interval, mean difference between groups and standard errors. According to O’Brien Fleming boundaries p
values < 0.024 were statistically significant. Covariates in the mixed linear model were evaluated against T1 (VAS baseline) = 3.16.

82
C.M. Schoppmeier et al.
Fig. 3. Correlation ΔE-VAS.
Differences of ΔE and VAS values over time (T2-T7) with reference to baseline (TX-T1), r = −0.42, Pearson.
treatment. Variations in fluorotic defects despite the same TFI are large.
Thus, the practitioner is faced with the challenge of achieving a pre-
dictable treatment outcome with a personalized treatment concept. In
very pronounced cases of fluorosis, the results of infiltration therapy
may be limited and can be satisfactorily enhanced by the use of more
invasive methods. Infiltrated areas allow additional restorative treat-
ments.
5. Conclusion
The findings of this study suggest that resin infiltration alone can
effectively mask mild to moderate dental fluorosis in young adults. In-
office bleaching with 25% hydrogen peroxide before resin infiltration
provides a significantly better masking effect; therefore, it can be re-
commended as a pretreatment regimen for patients with high esthetic
demands.
Declaration of interest
The authors received a research grant from DMG, Hamburg,
Germany. There were no restrictions concerning the publication of the
results. CS received a Köln Fortune scholarship (232/2016) from the
local scientific board.
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