Journal of Dentistry xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

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

Modified resin infiltration of non-, micro- and cavitated proximal caries

lesions in vitro
⁎
H. Askara, , F. Schwendickea, J. Lauschb, H. Meyer-Lueckelc, S. Parisa
a
Department of Operative and Preventive Dentistry, CharitéCentrum 3, Charité – Universitätsmedizin, Berlin, Germany
b
Department of Operative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen University, Germany
c
Department of Restorative, Preventive and Pediatric Dentistry, School of Dental Medicine, University of Bern, Switzerland

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

Keywords: Objective: Infiltrant resin (IR) is currently indicated for non-cavitated caries lesions. However, modifying the
Caries infiltration technique might expand its indication spectrum to micro-cavitated lesions. The present study aimed to evaluate
Infiltrant the penetration/filling ability of a newly developed micro-filled infiltrant resin (MFIR) in non-, micro- and
Cavitation cavitated natural caries lesions.
Enamel lesions
Materials and methods: Proximal lesions in 120 extracted human teeth with ICDAS-2 (n = 30), 3 (n = 45) and 5
ICDAS
(n = 45) lesions were etched with 15% hydrochloric acid gel for 2 min and allocated to one of the following
Micro-filled infiltrant resin
treatments; IR: lesions (ICDAS-2, 3 and 5; each n = 15) were treated with commercial infiltrant resin for 3 min.
MFIR: experimental MFIR [55 wt% IR plus 45 wt% organic fillers] was applied to lesions (ICDAS-2, 3 and 5; each
n = 15) for 3 min. IR + FC: IR was applied for 3 min, light-cured, and cavities (ICDAS-3 and 5; each n = 15)
filled with flowable composite (FC). Percentage infiltration of the demineralized enamel (Inf.%) and percentage
filling of the cavity (Fill.%) were analyzed using dual-fluorescence staining and confocal microscopy.
Results: No significant differences in Inf.% (range of medians: 57%-100%) were observed between different
treatments (p > 0.05; Kruskal-Wallis) within each ICDAS-code. Fill.% of cavities was significantly higher in
groups MFIR (median in ICDAS-3/-5: 100%/100%) and IR + FC (100%/100%) than IR (25%/38%) (p < 0.05).
Conclusion: MFIR showed similar penetration into natural lesions as the commercial infiltrant, but better ability
to fill cavitated areas.
Clinical relevance: MFIR and IR + FC might provide a new micro-invasive treatment for small cavitated proximal
lesions.

1. Introduction placed, the tooth enters a cycle of repeated restorative treatments

In recent years, due to better understanding of the caries process as
well as declining caries prevalence in many countries [1], caries man-
agement shifted towards being preventive and minimally invasive [2].
Proximal lesions are frequently observed in adolescents and young
adults [3,4]. Non-invasive approaches based on fluoride application,
oral hygiene improvement and diet control are highly recommended as
first treatment option for non-cavitated proximal lesions. However,
quite often, due to increased lesion extension or lack of patient co-
operation such measures alone are not effective to arrest the caries
process and subsequent surface breakdown might occur, causing micro-
cavitation[5,6].
For proximal lesions the conventional “drill and fill”-approach re-
quires destruction of substantial amount of sound tooth structures to get
access to the lesion [7]. Furthermore, once the first restoration is
which might negatively affect the integrity and survival of the tooth
[8–10]. Resin infiltration (potentially in combination with non-invasive
measures) has offered a clinically effective micro-invasive treatment for
non-cavitated proximal lesions [11–14], saving healthy tooth structures
from that extensive cutting required for accessibility. The basic prin-
ciple of resin infiltration is to perfuse the demineralized enamel pores
with a low-viscosity light-cured resin (infiltrant) driven by capillary
forces. After photo-polymerization, infiltrant resin (IR) occludes diffu-
sion pathways for cariogenic acids and dissolved minerals leading to
arrest of the lesion progression [15,16].
While clinically proven efficacious for non-cavitated lesions
[12,13,17], the indication spectrum and the therapeutic certainty could
be increased if small cavitated proximal lesions were treatable as well
using this technique. One approach could be to combine the infiltrant
resin with a subsequent application of a flowable composite resin to fill

⁎
Corresponding author at: Department of Operative and Preventive Dentistry, Charité Centrum 3, Charité – Universitätsmedizin, Aßmannshauser Straße 4-6, 14197 Berlin, Germany.
E-mail address: haitham.askar@charite.de (H. Askar).

https://doi.org/10.1016/j.jdent.2018.03.010
Received 13 March 2018; Accepted 21 March 2018
0300-5712/ © 2018 Elsevier Ltd. All rights reserved.

Please cite this article as: Askar, H., Journal of Dentistry (2018), https://doi.org/10.1016/j.jdent.2018.03.010
H. Askar et al. Journal of Dentistry xxx (xxxx) xxx–xxx

the cavitated lesion parts. Another more recent approach is a combi-

nation of the infiltrating properties of infiltrants with the consistency of
flowable composite resins. This could be achieved by adding filler
particles to the low-viscosity resin matrix [18]. Such modified micro-
filled infiltrant resins (MFIRs) have been suggested to overcome the
mentioned problems, allowing both, lesion penetration and cavity
filling. In a previous experiment, MFIRs with organic fillers showed
similar penetration into artificial non-cavitated enamel lesions [19] and
cavitated natural occlusal lesions like commercially available unfilled
IR [19,20].
The International Caries Detection and Assessment System (ICDAS)
was developed to allow the clinicians to diagnose the caries at different
stages [21] and consequently, selecting the appropriate treatment op-
tion. For proximal lesions, visual assessment is not always easy to
perform, therefore radiographic assessment might be necessary for di-
agnosis process.
Modification of the resin infiltration technique by either changing
the properties of the used resin or altering the application procedure
might give the opportunity to use the technique for treatment of small
cavitated proximal lesions. Therefore, it was the aim of the present in
vitro study to evaluate the penetration and filling ability of an MFIR in
natural lesions with different ICDAS-codes. We tested the null hy-
pothesis that neither filling technique/material nor the cavitaiton has
an effect on the penetration and the filling ability of the resin materials
Fig. 1. Representative CLSM image of resin infiltrated ICDAS-3 lesion showing
into the natural caries lesions.
the cavity and demineralized lesion dimensions. In dual fluorescence staining,
non-infiltrated demineralized enamel and dentin appeared in green (NaFluo
2. Materials and methods dye) while the infiltrated parts of the lesion and the filling resin appeared in red
(RITC dye). Sound enamel appeared in black. DEA: demineralized enamel area,
Ethical approval was obtained to collect extracted human teeth Inf.DEA: infiltrated demineralized enamel area, Cav.A: cavity area, Fill.A: filled
(Ethical committee, Charité – Universitätsmedizin Berlin; EA4/102/ area of the cavity, LD: lesion depth, PD: penetration depth, CD: cavity depth,
14), which were then cleaned, rinsed and stored in 0.1% Thymol so- CW: cavity width. (For interpretation of the references to colour in this figure
lution until use. Donors were informed that the teeth were collected for legend, the reader is referred to the web version of this article.)
research purposes and a signed consent was obtained before extraction.
Lesion activity and ICDAS scoring of proximal lesions in extracted Table 1
molars and premolars was assessed by two examiners using 1.75x Median (Q1/Q3) of infiltration variables for IR and MFIR applied to ICDAS-2
magnification lens (HA and SP). Only active proximal lesions (n = 120) lesions.
with ICDAS-2 (distinct visual change in enamel) (n = 30), −3 (loca- ICDAS 2
lized enamel break down) (n = 45) and −5 (distinct cavity with visible
dentin) (n = 45) were selected for this study [21]. All proximal lesions Variable IR MFIR pa
were etched with 15% hydrochloric acid (Icon etch, DMG, Hamburg,
DEA (mm2) 0.864(0.593/1.376) 0.806(0.573/1.402) 0.910
Germany) for 2 min and then rinsed with demineralized water for 30 s. Inf.DEA (mm2) 0.619(0.456/0.833) 0.545(0.315/0.966) 0.571
To examine resin infiltration using dual fluorescence and confocal mi- Inf.% 73(62/80) 69(47/87) 0.701
croscopy, enamel lesions were stained with 0.1% ethanol solution of LD (μm) 792(474/862) 732(492/960) 0.982
Rhodamine B isothiocyanate (RITC, Sigma Aldrich, Steinheim, Ger- PD (μm) 537(361/622) 450(350/699) 0.701
n 15 15
many) for 12 h [22]. Afterwards, teeth were randomly allocated to
three experimental groups: infiltrant resin (IR), micro-filled infiltrant a
No significant differences were observed (p > 0.05; Mann–Whitney U
resin (MFIR) and a combined application of infiltrant resin and flowable test). DEA: demineralized enamel area, Inf.DEA: infiltrated demineralized en-
composite filling (IR + FC). amel area, Inf.%: percentage infiltration of the demineralized enamel, LD: le-
In IR and MFIR groups; non-cavitated lesions (ICDAS-2; n = 15/ sion depth, PD: penetration depth, n: number of specimens.
group) were resin-infiltrated (IR or MFIR) for 3 min and then light
cured for 60 s (400 mW/cm2, Bluephase C8; Ivoclar Vivadent, Schaan, The organic filler particles were specially prepared for this project in
Liechtenstein), while in the cavitated lesions (ICDAS-3 and −5; DMG laboratories from a thermally polymerized mix of aliphatic me-
n = 15/group) resin materials (IR or MFIR) were applied in excess thacrylate monomer and fumed silica particles. After polymerization,
ensuring complete filling of the cavities and allowed to penetrate into the hardened filler mixture was milled and filtered to obtain required
the lesions for 3 min. Subsequently, transparent matrices (SuperMat; particles sizes (mean: 42 μm, range: 0.5–200 μm).
KerrHawa, Bioggio, Switzerland) were used to restore proximal con- One gram of MFIR was freshly prepared for five specimens im-
tours before final polymerization for 60 s. In the IR + FC group; IR was mediately before resin application. For the purpose of exact visualiza-
first applied into cavitated lesions (ICDAS-3 and −5; n = 15/group) for tion of the filled cavity space, resin materials were also labeled with
3 min. The excesses resin was removed from the cavity by gentle air 0.1% RITC.
blowing for 30 s. After light curing of IR for 60 s, cavities were filled After resin application, roots of the teeth were cut and the crowns
with FC (EcuSphere; DMG, Hamburg, Germany). Proximal contours were completely embedded in methacrylate resin (Technovit 4071,
were again formed with transparent matrices before second poly- Heraeus Kulzer, Hanau, Germany). From each lesion a 1 mm thick
merization for 60 s. section was cut perpendicular to the tooth surface (Band Saw EXAKT
Experimental MFIR was prepared by mixing a commercially avail- 300 CL; EXAKT Advanced Technologies, Norderstedt, Germany). The
able IR (Icon, DMG) with an experimental pre-polymerized organic cut sections were fixed to microscopic slides (Plexiglas, patho-service,
filler powder (DMG) in a weight ratio of 55% and 45%, respectively.

2
H. Askar et al. Journal of Dentistry xxx (xxxx) xxx–xxx

Table 2
Median (Q1/Q3) of infiltration variables for IR, MFIR and IF + FC applied to ICDAS-3 and −5 lesions.
ICDAS 3 ICDAS 5

Variable IR MFIR IR + FC p IR MFIR IR + FC p

2
DEA (mm ) 0.330(0.152/0.864) 0.289(0.093/0.370) 0.225(0.119/0.528) 0.584 0.263(0.193/0.294) 0.324(0.197/0.612) 0.191(0.131/0.287) 0.487
Inf.DEA (mm2) 0.330(0.152/0.528) 0.164(0.087/0.272) 0.135(0.101/0.370) 0.184 0.246(0.112/0.268) 0.205(0.136/0.434) 0.191(0.131/0.279) 0.901
Inf.% 100(78/100) 69(53/100) 71(59/79) 0.187 100(100/100) 100(80/100) 100(100/100) 0.639
Cav.A (mm2) 0.362(0.245/0.712) 0.307(0.193/0.486) 0.210(0.147/0.475) 0.381 1.670(1.052/2.197) 0.965(0.767/1.415) 1.025(0.646/1.863) 0.264
Fill.A (mm2) 0.075(0/0.354) 0.305(0.193/0.434) 0.210(0.147/0.415) 0.068 0.512(0.190/0.870) A 0.767(0.433/1.129) B 1.025(0.646/1.863) B 0.020
Fill.% 25(0/54) a 100(100/100) b 100(100/100) b 0.000 38(17/49) A 100(79/100) B 100(100/100) B 0.000
LD (μm) 863(608/1105) 748(551/772) 627(319/1010) 0.440 1018(836/1320) 778(672/1056) 934(629/1216) 0.340
PD (μm) 448(221/503) 639(426/771) 452(332/662) 0.169 428(152/587) A 727(395/808) B 934(629/1216) B 0.002
CD (μm) 447(272/659) 304(203/566) 293(236/407) 0.488 990(836/1320) 778(625/1056) 934(593/1216) 0.347
CW (μm) 1228(838/1463) 1539(1018/1794) 1416(1100/1649) 0.404 2101(1578/2860) 1849(1485/3219) 2157(1667/2528) 0.987
LA (mm2) 0.729(0.479/1.465) 0.638(515/709) 605(291/716) 0.389 1.817(1.244/2.244) 1.062(0.841/1.576) 1.108(0.807/2.028) 0.291
IF% 53(40/59) a 84(65/100) b 82(73/91) b 0.009 39(17/51) A 100(79/100) B 100(100/100) B 0.000
Air.B* 1 2 2 0 5 2
n 15 15 15 15 15 15

P values for the comparisons of the different infiltration techniques within each ICDAS-code lesions are given, the level of significance was set at 0.05 (Kruskal–Wallis
test). Different letters (lowercase; ICDAS-3, uppercase; ICDAS-5) indicate significant difference [p < 0.017(bold); adjusted Mann–Whitney U test for multiple testing
(Bonferroni)]. * Number of specimens showed internal air bubbles. DEA: demineralized enamel area, Inf.DEA: infiltrated demineralized enamel area, Inf.%: per-
centage infiltration of the demineralized enamel, Cav.A: cavity area, Fill.A: filled area of the cavity, Fill.%: percentage filling of the cavity, LD: lesion depth, PD:
penetration depth, CD: cavity depth, CW: cavity width, LA: total lesion area, IF%: percentage of infiltration/filling of the entire lesion; AirB: presence of air bubbles
within the filling, n:number of specimens.

Oststeinbek, Germany) using instant adhesive (LOCTITE 493, Henkel,
Düsseldorf, Germany) and polished (silicon carbide paper 500, 1200,
2500, 4000, Struers, Willich, Germany) parallel to the cut surface
(EXAKT 400 CS, EXAKT Advanced Technologies, Norderstedt,
Germany) till reaching the deepest part of the lesion/cavity. Unbound
RTIC was bleached out from the non-infiltrated porous structures by
immersion of the specimens in 30% hydrogen peroxide (Merck
Millipore, Darmstadt, Germany) for 24 h at 37 °C [22]. Subsequently,
specimens were washed with demineralized water for 30 s. Shortly
before CLSM imaging, non-infiltrated porous structures were labeled
with 50% ethanol solution of 100 M sodium fluorescein (NaFluo, Sigma
Aldrich) for 3 min, followed by washing with demineralized water for
10 s. The specimens were examined with confocal laser scanning mi-
croscope (LSM 510, Zeiss, Jena, Germany) using a 5 × objective in
dual-fluorescence mode [22].
The following dimensions and parameters of the infiltrated lesions
and cavities were measured (Zeiss LSM Image Browser 4.2; Zeiss, Jena,
Germany); demineralized enamel area (DEA), infiltrated demineralized
enamel area (Inf.DEA), cavity area (Cav.A); the outer cavity margin was
determined by using the outer sound enamel surface as a reference to
draw a curved line continuing the cavitated enamel, filled area of the
cavity (Fill.A), lesion depth (LD), penetration depth (PD), cavity depth
(CD), cavity width (CW) and presence of air bubbles within the filling
(AirB) (Fig. 1). From the previously measured parameters, the following
variables were calculated: total lesion area (LA = DEA + Cav.A), per-
centage infiltration of the demineralized enamel (Inf.% = Inf.DEA/
DEA × 100), percentage filling of the cavity (Fill.% = Fill.A/
Cav.A × 100) and percentage of infiltration/filling of the entire lesion
[IF% = (Inf.DEA + Fill.A)/LA × 100].
Statistical analysis was performed with SPSS statistics 22 for win-
dows (IBM SPSS; Armonk, NY, USA). Data were checked for normal
distribution by Shapiro-Wilk test. Differences in Inf.%, Fill.% and IF%
between different resin infiltration techniques were analyzed using
Kruskal-Wallis test and Mann-Whitney test. Bonferroni correction was
performed to adjust for multiple testing. The level of significance was
set at 5%.
3. Results
Median (Q1/Q3) values for the different infiltration variables are
presented in Tables 1 and 2. In non-cavitated lesions, no significant
differences in percentage infiltration (Inf.%) were observed between IR
and MFIR (p > 0.05; Mann–Whitney U test) (Table 1). Within ICDAS-3
and ICDAS-5, no significant differences were observed between dif-
ferent techniques regarding the percentage infiltration of the lesion
body (Inf.%) (p > 0.05; Kruskal–Wallis test). But because the IR did
not fill-up the cavitated lesion parts, this group showed significantly
lower Fill.% and IF% compared with MFIR and IR + FC (p < 0.017;
adjusted Mann–Whitney U test) (Table 2) which were able to com-
pletely fill the cavities of ICDAS-3 and −5 lesions (Fig. 2). No sig-
nificant differences were found between MFIR and IR + FC concerning
their ability to fill cavitated areas of lesions (Fill.% for ICDAS-3 and
−5) (p > 0.05; Kruskal–Wallis test) (Table 2). When comparing dif-
ferent lesion stages, infiltration (Inf.%) was significantly more complete
in ICDAS-5 than ICDAS-2 and −3 (p < 0.05; Mann–Whitney U test). In
some cases, air bubbles were observed within the fillings, with the
highest frequency (33.3%) in ICDAS-5 lesions treated with MFIR
(Table 2).
4. Discussion
The conventional indication for resin infiltration is non-cavitated
caries lesions, while for all cavitated lesions, invasive treatment is still
required. MFIR might be a suitable approach to combine the idea of
lesion infiltration and filling the cavity. This is relevant, as cavitation
cannot always be excluded when assessing lesions radiographically (as
done for most proximal lesions), especially for lesions extending beyond
the enamel-dentin junction (i.e. D1-lesions) [6,23]. Minimal invasive
treatment of the simple proximal caries lesions mostly associated with
destruction of considerable amount sound tooth structure only for ac-
cessibility, therefore, the modified MFIR technique with help of the
innovative proximal applicator might help to avoid substance loss as-
sociated with invasive lesions. Within the present study, MFIR showed
both similar penetration capability as IR and similar filling capability as
FC.
The penetration of IR into non-cavitated natural lesions (ICDAS-2)
observed in this study was similar to results in previous experiments
[15,18]. Interestingly the MFIR showed similar penetration ability like
the IR into natural lesions- a result which had been shown for artificial
caries [19]. The good infiltration/filling ability of the MFIR was due to
the use of relatively large filler particles (42 μm), which provided the
required consistency to the uncured mixture to fill the cavity.

3
H. Askar et al.
Meanwhile; they did not restrict the movement of the IR within the
MFIR mixture, allowing its penetration into the demineralized enamel
pores by capillary force [19]. Although the combined application of the
IR with the FC was used in this experiment as control to MFIR, it
showed good potential in treatment of the cavitated lesions similar to
the MFIR but required multiple applications which could complicate
the clinical implementation of the technique.
It should be noted that demineralized enamel in ICDAS-5 lesions
showed deeper resin infiltration compared to ICDAS-2 and −3 lesions.
The extensive mineral loss of the enamel (i.e. more porous) at the cavity
margins in ICDAS-5 lesions might explain this deep infiltration into the
porous enamel.
In this experiment neither Icon applicator nor proximal contact si-
mulation was used to eliminate any possible effect of the application
method on the infiltration of the tested resins. Biofilm in the proximal
cavitation as well as the method of restoring the proximal contour could
represent a clinical challenge to implement this modified infiltration
technique successfully. Therefore, the application method should be
optimized and validated. Improving the final surface polish of the resin
material is a point of consideration in the development process of the
modified resin infiltration technique [24].
Leakage around restoration is one of the main reasons for secondary
4
Journal of Dentistry xxx (xxxx) xxx–xxx
Fig. 2. Representative CLSM images of resin
infiltrated/filled lesions at various ICDAS
codes. Non-infiltrated demineralized enamel
and dentin appeared in green while the in-
filtrated parts of the lesions and the filling resin
appeared in red. (a and b) ICDAS-3 lesions
treated with MFIR and IR + FC, respectively.
(c and d) ICDAS-5 lesions treated with MFIR
and IR + FC, respectively. Please note that the
penetration of IR/MFIR (red) into dentin is an
artefact which is unlikely in the clinical situa-
tion due to the intrinsic moisture of vital
dentin. (For interpretation of the references to
colour in this figure legend, the reader is re-
ferred to the web version of this article.)
caries. Although the new resin infiltration techniques showed good
filling ability of the cavity, the marginal integrity of this new restora-
tions should be evaluated for clinical application.
The ability of ICDAS to categorize the initial and advanced stages of
the caries process, particularly the cavitated phases, encouraged the use
of the system for this experiment. In this in vitro study, no radiographic
categorization of the lesions was performed, however, to determine the
indication spectrum of the modified resin infiltration techniques
radiographic and visual/tactile assessment are required to evaluate the
lesion extension.
5. Conclusions
Within the limitations of this in vitro study, MFIR showed similar
penetration capacities into the porous enamel of non-, micro- and ca-
vitated natural caries lesion like conventional IR. At the same time,
MFIR filled cavities similar to a flowable composite resin. MFIR might
extend the indication spectrum of resin infiltration.
Conflict of interest
The Charité – Universitätsmedizin Berlin holds US and European
H. Askar et al.
patent for an infiltration technique for dental caries lesions in which
two of authors (HML and SP) are appointed as inventors. HML and SP
receive royalties as well as research funding from DMG, the manu-
facturer of Icon.
Acknowledgments
This study was supported by the Deutsche Forschungsgemeinschaft
(DFG; PA 1508/1-3), which is hereby acknowledged. We would also
like to thank DMG for providing the filler particles.
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