The Journal of EVIDENCE-BASED DENTAL PRACTICE

REVIEW ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS

RESIN INFILTRATION MAY REDUCE

PROXIMAL CARIOUS LESION PROGRESSION
IN PERMANENT TEETH WITH ONGOING
UNCERTAINTY FOR PRIMARY TEETH

REVIEWERS
MARK D. ROBERTSON, MARIANA PINHEIRO ARAUJO, NICOLA P.T. INNES

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

The effect of resin infiltration on proximal caries lesions in primary and permanent SORT SCORE
teeth. A systematic review and meta-analysis of clinical trials. Chatzimarkou S,
A B C N/A
Koletsi D, Kavvadia K. J Dent 2018; 77:8-17. SORT, Strength of Recommendation Taxonomy.

LEVEL OF EVIDENCE
1 2 3
SUMMARY See page 8A for complete details regarding SORT and LEVEL OF
EVIDENCE grading system.

Selection Criteria
This systematic review was reported using the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses1,2; however, it was not registered before QUESTION
being carried out. Trials were eligible if they were randomized control or Is resin infiltration effective at
controlled; compared resin infiltration with other microinvasive or noninvasive arresting the progression of proximal
treatments in primary or permanent dentitions; and evaluated lesion progression. caries lesions?

PICO question:

Population (P) 5 Patients with proximal caries lesions in primary, mixed, and SOURCE OF FUNDING
permanent dentition limited to the outer third of dentin; None.

Intervention (I) 5 Resin infiltration (with or without other methods);

Comparison (C) 5 Other microinvasive or preventive methods, placebo, or no TYPE OF STUDY

treatment; Systematic review and meta-analysis.

Outcome (O) 5 Proximal lesion progression (clinically or radiographically

assessed).
KEYWORDS
Medline, Cochrane CENTRAL, LILACS, OpenGrey, ClinicalTrials.gov, and Na- Resin infiltration, Caries, Proximal
tional Research Register searches yielded 135 articles. Two authors indepen- lesion, Systematic review, Meta-
dently screened results’ titles and abstracts obtaining full texts of potentially analysis
eligible articles (a third author resolved disagreements). Articles’ risk of bias was
assessed using the Cochrane tool3 and study quality of evidence using Grading of
J Evid Base Dent Pract 2019: [177-179]
Recommendations Assessment, Development and Evaluation criteria.4,5 Only
1532-3382/$36.00
studies at low or unclear risk of bias were included in meta-analyses.
Crown Copyright ª 2019
Published by Elsevier Inc. All
Key Study Factor rights reserved.
All 10 articles were split-mouth randomized controlled trials (published doi: https://doi.org/10.1016/
2010-2018) with resin infiltration as their main intervention, although many j.jebdp.2019.05.001

June 2019 177

 The Journal of EVIDENCE-BASED DENTAL PRACTICE
interventions were multicomponent. Eight studies evaluated
lesion progression using conventional and digital subtrac-
tion radiography. Two used visual inspection (International
Caries Detection and Assessment System) with radiographic
supplementation.
Main Results
Ten articles (9 studies) met the inclusion criteria. Four
studies investigated the primary or mixed dentition (mean
age: 5.8-11 years, including 32-84 lesions in 16-42 partici-
pants), and 5 investigated the permanent dentition (mean
age: 21-25 years, including 44-186 lesions in 16-70
participants).
No meta-analyses could be carried out for primary teeth
because of the studies’ statistical heterogeneity. Three
studies were at high risk of bias, but because these all
investigated primary teeth, the number of studies included
in the meta-analyses of permanent teeth, where all 6
studies (all at unclear risk of bias) were included, was not
affected.
Random-effects meta-analyses performed at follow-up visits
from 18 months to 2 years (odds ratio 5 0.14; 95% confi-
dence interval, 0.08 to 0.25) and at 3-year follow-up (odds
ratio 5 0.15; 95% confidence interval, 0.06 to 0.36) both
showed a reduced chance of lesion progression with resin
infiltration in the intervention arm. However, the studies
were of low to moderate quality (Grading of Recommen-
dations Assessment, Development and Evaluation), with
further research being considered likely to have an impor-
tant influence on the effect estimate.
CONCLUSION
Further studies are needed before supporting resin infiltra-
tion for primary teeth because the evidence quality was low
and study heterogeneity precluded data synthesis.
For permanent teeth, the evidence quality was low to
moderate, with evidence supporting resin infiltration com-
bined with preventive approaches to stop progression of
proximal lesions compared with preventive approaches
alone.
Commentary and Analysis
Occlusoproximal caries remains prevalent, and its manage-
ment, particularly in line with contemporary cariology, pre-
sents a challenge for clinicians. It is generally accepted that
restoration failure is ultimately inevitable, which should be a
key consideration before performing surgical dental treat-
ment. With resin composite restoration annual failure rates
of 2% to 15%,6,7 once invasive treatment is initiated, a tooth
becomes condemned to a cycle of progressively larger,
deeper direct restorations and associated pulpal
178 Volume 19, Number 2
inflammatory reactions over the course of a patient’s life-
time. Resin infiltration to arrest proximal caries lesions offers
a microinvasive8 management strategy for noncavitated
approximal lesions extending less than one-third of the
way through dentin that may prevent or at least defer a
tooth’s entrance to the “repeat restoration cycle.”9
This well-conducted systematic review clearly laid out
methodological considerations, inclusion and exclusion
criteria, searching, and screening. However, data presenta-
tion within the meta-analyses would benefit from the inclu-
sion of participant numbers within each study rather than
simply percentage weight, which does not allow readers to
consider the generalizability of the findings. The data
extraction table is comprehensive, but the “results of orig-
inal studies with regard to lesion progression” column is not
intuitive. This makes consideration of the primary data and
the appropriateness of the statistical approaches used
difficult to assess.
A Cochrane review from 201510 considered a similar
question around microinvasive interventions for managing
proximal caries in primary and permanent teeth but is not
discussed or referenced by Chatzimarkou et al. However,
they have included all 3 appropriate studies that were
included in the Cochrane review and have gone on to
include 6 further studies published since 2015, which
affirms the necessity of this review to update the state of
the evidence.
The authors identify a high degree of statistical heteroge-
neity in the primary dentition studies that precluded meta-
analyses. Clinical investigation (reviewing the data table)
justifies this because of interstudy differences in: 1) in-
terventions and comparators; and 2) follow up time points.
These differences are greater than those seen in the per-
manent dentition studies in which meta-analyses were car-
ried out. The lack of comparable evidence for primary teeth
is a gap in the literature; however, 3 out of the 4 studies that
considered the primary dentition showed a benefit in favor
of the resin infiltration arm. The fourth study showed no
difference.
Clinicians need to be vigilant for changes in the evidence
base. This is essential to allow the adoption of new treat-
ments as they become supported by evidence and to move
away from current treatments as their effectiveness be-
comes superseded. The evidence presented in this review
for the use of resin infiltration in permanent teeth to arrest
carious lesions is convincing. However, it should be kept in
mind that the evidence in the review was graded as being of
low to moderate quality using the quality-assessment tools.
This means that there is the potential for the direction and
magnitude of the effect size to change if further clinical
studies are carried out. Having said that, there was

consistency in the direction of the results, with all favoring
that resin infiltration arrests caries despite variations in the
interventions (comparators). This was consistent for both
primary and permanent teeth. So, although higher quality
evidence might increase or decrease the effect size, it would
seem unlikely that the direction of effect (resin infiltration
currently being seen to be more effective than the com-
parators) would be reversed.
In conclusion, this review is warranted and well conducted.
The findings are promising with respect to the permanent
dentition and show that resin infiltration with standard oral
hygiene measures is significantly more effective than stan-
dard oral hygiene delivery alone in stopping the progres-
sion of noncavitated, approximal lesions that extend less
than a third of the way through dentin. Dental care pro-
fessionals should consider this microinvasive technique to
prevent or postpone the entry of permanent teeth into the
repeat restoration cycle but, as for all treatments, should
remain vigilant for changes in the evidence.
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The Journal of EVIDENCE-BASED DENTAL PRACTICE
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REVIEWERS
MARK D. ROBERTSON, BDS, MSC, MFDS, RCS(ED)
Senior Clinical Researcher, School of Dentistry, University of
Dundee, Park Place, Dundee, UK, DD1 4HR, m.r.robertson@
dundee.ac.uk
MARIANA PINHEIRO ARAUJO, BDS, PHD
Student and Visiting Researcher, School of Dentistry, Uni-
versity of São Paulo, Brazil; School of Dentistry, University of
Dundee, Park Place, Dundee, UK, DD1 4HR, m.p.dearaujo@
dundee.ac.uk
NICOLA P.T. INNES, BDS, PHD, BMSC, MFDS, RCSENG,
MFGDP
Professor of Pediatric Dentistry, Associate Dean for Learning
and Teaching, School of Dentistry, University of Dundee,
Park Place, Dundee, UK, DD1 4HR, n.p.innes@dundee.ac.uk
June 2019 179