UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
CASE REPORT DOI: https://doi.org/10.4322/bds.2025.e4549
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Braz Dent Sci 2025 Apr/Jun;28 (2): e4549
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Early enamel affected lesions: benefits and limitations of simplified
resin techniques
Lesões incipientes em esmalte alterado: benefícios e limitações das técnicas resinosas simplificadas
Gabriela Guarda DALLAVILLA1 , Mylena Proença COSTA1 , Sérgio Kiyoshi ISHIKIRIAMA1 , Linda WANG1 ,
Marina Ciccone GIACOMINI1
1 - Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Dentística, Endodontia e Materiais Odontológicos.
Bauru, SP, Brazil.
How to cite: Dallavilla GG, Costa MP, Ishikiriama SK, Wang L, Giacomini MC. Early enamel affected lesions: benets and limitations of
simplied resin techniques. Braz Dent Sci. 2025;28(2):e4549. https://doi.org/10.4322/bds.2025.e4549
ABSTRACT
Objectives: Advances in the early diagnosis and detection of enamel lesions have led to the development of
commercially available adhesive resin-based systems designed to enable smart and minimally invasive treatment
strategies. These systems are particularly valuable when the exclusive management of etiological factors and/or
remineralization is insufcient or no longer effective. In addition to their management, carious lesions invoke
strategies aimed at lling the subsurface porosities, whereas erosive tooth wear (ETW) requires the application
of external protective measures that serve as a mechanical barrier to mitigate the effects of acidic attacks.
Case Report: The present article presents two case reports involving young patients treated with simplied
techniques, either with resin inltration to recover white spot lesions caused by caries or ion-enriched systems to
protect the external surfaces affected by ETW. Effective, reliable, and long-term outcomes depend on a thorough
comprehension of dental surface alterations which guides the appropriate selection and use of simplied and
conservative resin materials. Conclusion: The integration of early diagnosis with minimally invasive procedures,
supported by a person-centered care approach, has demonstrated long-lasting and successful clinical outcomes.
KEYWORDS
Dental caries; Early diagnosis; Resin inltrant; S-PRG particle; Tooth erosion.
RESUMO
Objetivos: Os avanços no diagnóstico precoce e na detecção de lesões de esmalte levaram ao desenvolvimento de
sistemas adesivos à base de resina disponibilizados comercialmente, desenvolvidos para permitir estratégias de
tratamento inteligentes e minimamente invasivas. Esses sistemas são particularmente valiosos quando o controle
exclusivo de fatores etiológicos e/ou remineralização é insuciente ou não é mais ecaz. Além de seu manejo,
as lesões cariosas requerem estratégias destinadas ao preenchimento das porosidades subsuperciais, enquanto
o desgaste dentário erosivo (DDE) requer a aplicação de medidas de proteção externas que servem como uma
barreira mecânica para minimizar os efeitos dos ataques ácidos. Relato de Caso: Este artigo apresenta dois
relatos de caso envolvendo pacientes jovens tratados com técnicas simplicadas, seja com inltração resinosa
para reestabelecer lesões de manchas brancas por cárie ou uso de um sistema enriquecido com íons para proteger
superfícies externas afetadas por DDE. Resultados ecazes, conáveis e de longo prazo dependem de uma
compreensão completa das alterações da superfície dentária, orientando a seleção adequada e o uso de materiais
resinosos simplicados e conservativos. Conclusão: A integração do diagnóstico precoce com procedimentos
minimamente invasivos, apoiados por uma abordagem de cuidado centrada na pessoa, demonstrou resultados
clínicos duradouros e bem-sucedidos.
PALAVRAS-CHAVE
Cárie dentária; Diagnóstico precoce; Inltração resinosa; Partículas S-PRG; Erosão dentária.
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Dallavilla GG et al.
Early enamel affected lesions: benefits and limitations of simplified resin techniques
Dallavilla GG et al. Early enamel affected lesions: benefits and limitations of
simplified resin techniques
INTRODUCTION
The development of innovative materials
and strategies for dental treatments has been
effectively observed in recent years. This
advancement is largely driven by investigations
into the histopathological features of enamel and
dentin alterations that induced major clinical
challenges [1-3]. Simultaneously, the adhesive
resin concept has served as a foundation, enabling
a wide range of solutions for addressing these
challenges [1-4]. To ensure effective approaches,
early diagnosis is crucial for facilitating conservative
interventions, while clear communication with
patients is mandatory for achieving effective and
long-lasting treatments [5-8].
Caries dysbiosis is no longer the sole
primary focused event compromising dental
tissues. Nowadays, other etiologies such as
non-carious lesions, including erosive tooth
wear (ETW), and developmental defects like
uorosis and molar-incisor hypomineralization
(MIH) also demand preventive and minimally
invasive interventions [1-3,9-11]. Differential
and early diagnosis, regardless of the lesion’s
etiology, plays a critical role in minimizing or
halting progression through the combined use
of appropriate materials and the management
of etiological factors.
In this context, alternative treatments
involving materials capable of covering the
external enamel surface garnered increasing
interest. Commercially available options, such
as resin inltrants and barrier coat varnishes,
are being utilized for minimal intervention
procedures or as preventive strategies [10,12,13].
Notably, the expanding application of these
materials beyond their original intended purposes,
supported by evidence-based protocols, highlights
their versatility and growing favorability [11,13].
Furthermore, their cost-effectiveness enhances
their appeal, which remains an important factor
to consider.
Resin infiltrants were first proposed in
the 1960s and became commercially available
after extensive experimental research [14]. A
prominent example of this category of products
is Icon (DMG, Hamburg, Germany), primarily
indicated for treating inactive carious lesions
on free and proximal surfaces [12,13,15]. Its
mechanism of action involves removing the outer
enamel layer to access subsurface porosities,
which are then dried with alcohol and filled
with the inltrant material. This process halts
the progression of demineralization through a
physical-mechanical approach [12,13,15]. As an
additional benet, the resin inltrant relies on its
capacity to improve the esthetic appearance by
reducing the difference in the refractive index
(RI) between enamel lled with water (1.62)
or air (1.00) and the inltrant (1.52), resulting
in a closer approximation to the natural enamel
appearance [11-13].
Another clinical approach involves the
use of resin coatings that release multiple ions,
aiding in remineralization and strengthening of
dental structures. In this context, these systems
are based on monomers as delivery vehicles to
achieve chemical benets [16-18]. Among the
available options, S-PRG/Giomer technology
stands out as a system enriched with multi-ionic
trilaminar glass particles nominated as S-PRG
(surface pre-reacted glass-ionomer) [19,20].
As a xerogel, its external porous layer aids in
the process of releasing multiple ions, including
uoride, aluminum, sodium, silicate, strontium
and boron. Commercially, it is launched as PRG
Barrier Coat (Shofu, Kyoto, Japan), which is
a light-cured varnish applied as an adhesive
coating layer. Once applied onto the enamel
surface, it is primarily indicated as a dentin
hypersensitivity agent and for remineralization
of areas susceptible to dental caries [4,16,21].
For ETW, the PRG Barrier Coat can act as a
mechanical barrier against acid action while
simultaneously promoting remineralization and
controlling pH buffering, likely reducing the
erosive process [18,22].
Despite these benefits, it is essential to
recognize that no material fully satises all clinical
requirements. The effectiveness of these materials
depends on their proper indications and the
management of etiological factors. Professionals
must be aware of the appropriate indications of
these systems and carefully consider their benets
and limitations. The following case reports aim to
discuss clinical considerations by comparing two
promising resin-based strategies for managing
early enamel lesions caused by different prevalent
etiologies.
MATERIALS AND METHODS
The present series of clinical case reports
was approved by the Local Ethical Committee
(Protocol Number: 63544222.0.0000.5417).
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Dallavilla GG et al.
Early enamel affected lesions: benefits and limitations of simplified resin techniques
Dallavilla GG et al. Early enamel affected lesions: benefits and limitations of
simplified resin techniques
Case report 1
An 18-year-old female patient was referred
to the dental school expressing dissatisfaction
with her smile. Through anamnesis and clinical
examination, poor oral health and low motivation
for proper care were observed. She admitted
neglecting good oral hygiene habits despite being
aware of the consequences, as highlighted by
her previous dental history. We emphasized the
importance of oral care and also recommended
some treatment options for her, offering close
support. She expressed a willingness to change.
For a successful management, it was relevant
to consider her reported history of gastric and
dietary issues and the fact that she was recovering
from a depressive disorder, which had affected
her self-esteem.
Clinical examination revealed inflamed
gums (Figure 1) and white lesions on the cervical
areas of the maxillary anterior teeth (#13 - #23).
Proximal restorations resulting from previous
caries lesions were also observed. Additionally,
irregular and worn incisal edges resulting from
a combination of erosive and attrition factors
were noted.
The treatment approach began with the
reinforcement of appropriate hygiene and dietary
habits. Before planning the technical procedures,
person-centered care was emphasized to ensure
the patient’s active involvement, which is essential
for achieving long-term results. In this case, given
the patient’s history of depression, continuous
encouragement and monitoring were critical for
fostering engagement in her treatment. Initial
restorative work involved repairing existing
restorations and treating new cavitated carious
lesions. Oral hygiene was reassessed during all
follow-up visits.
At the subsequent appointment, cleaning
with prophylaxis paste (Herjos, Vigodent, Rio
de Janeiro, Brazil) using a Robinson brush
(Microdont, São Paulo, Brazil) was performed
for a general cleaning, subsequently facilitating
a more accurate evaluation (Figure 2A). The
white lesions were deemed suitable for resin
inltrant treatment, although some limitations
were anticipated. The lesions were considered
active, as evidenced by their notable rough and
opaque surfaces (Figure 2B). While covering these
areas with composite resin restorations were not
discarded, the use of the inltrant was preferred
to minimize the invasiveness of the procedure.
A rubber dam was installed and therefore, the
classical Icon (DMG, Hamburg, Germany) protocol
of application was followed (Figures 3A to 3H).
Icon Etch (15% hydrochloric acid) was applied
for 2 minutes, followed by rinsing for 30 seconds
and drying with air jets. Given the depth of the
porosities, the etching step was repeated to
Figure 1 - Case 1. Initial view of the oral clinical condition presenting
inflamed gums and white lesions on cervical areas of the maxillary
anterior teeth.
Figure 2 - Case 1. (A) Professional cleaning performed with prophylaxis paste; (B) Preoperative view suggesting active lesions.
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Dallavilla GG et al. Early enamel affected lesions: benefits and limitations of
simplified resin techniques
ensure the adequate subsequent penetration
of the inltrant. Icon Dry (99% ethanol) was
applied for 30 seconds, followed by air drying.
The next step involved the application of Icon
infiltrant for 3 minutes. Excess material was
removed using a microbrush, and the area was
light-cured for 40 seconds. A second application
of Icon inltrant was performed for 1 minute,
followed by removal of any excess and additional
40-second light curing. Finally, polishing was
completed using abrasive disks and points. By
the end of the appointment, particularly after
polishing, a signicant reduction in the whitish
appearance was observed.
Two weeks later, the patient returned for a
follow-up. The resin inltrant treatment appeared
to be successful, stable and effective within its
known limitations. The patient reported feeling
motivated to continue treatment, which was
further evidenced by the improved condition of
her gums. Therefore, composite resin restorations
were performed to enhance the buccal surfaces
and correct tooth inclination, cover the worn
incisal edges and repair the proximal restorations.
The outcome reects a successful combination
of esthetic techniques, improving both the
appearance and functionality of the teeth. The
procedure and nal appearance are illustrated
in Figures 4A-C.
Case report 2
In this case, a 14-year-old female patient was
referred to the dental school reporting episodes
of dentin hypersensitivity. Although no structural
dental compromise was observed, anamnesis
revealed the habit of consuming an acid-based
diet. Additionally, the patient had not attended a
professional dental appointment for several years.
As in the previous case, the concept of
person-centered care was applied. The patient
and her parents received guidance regarding
the necessary care and the diagnosis. Clinical
examination revealed early signs of erosive tooth
wear (ETW). Among the possible treatments, it
Figure 3 - Case 1. (A) Rubber dam positioned on the maxillary arch with ligatures performed to allow cervical exposure; (B) Application of
hydrochloric acid (two 2-minute applications on all white lesions in the cervical areas) – Icon Etch; (C) Ethanol application – Icon Dry; (D)
Infiltration with low-viscosity resin – Icon Infiltrant; (E) Removal of excess resin with dental floss, followed by light curing for 40 seconds; (F)
Final aspect after resin infiltration; (G) Polishing procedures; (H) Postoperative view showing a significant reduction in the whitish perception.
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Dallavilla GG et al. Early enamel affected lesions: benefits and limitations of
simplified resin techniques
was decided to perform a professional cleaning
session using prophylaxis paste (PRG Pro-
Care Gel, SHOFU, Kyoto, Japan) in the first
appointment, followed by the application of PRG
Barrier Coat (SHOFU, Kyoto, Japan) in the next
session. This product is based on a self-etching
system combined with S-PRG llers which release
aluminum, uoride and strontium to reinforce
the tooth structure. This combination helps
to alleviate sensitivity while the coating acts
as a temporary barrier against acidic attacks.
Figures 5A-H illustrate the main steps of the
recommended protocol.
First, the tooth surface was thoroughly
cleaned and dried to ensure optimal adhesion.
As a varnish, it is expected to dissolve, however,
its resin component can extend its adhesion to
the tooth surface for several weeks. The area was
then isolated to prevent contamination during the
application process. A thin layer of PRG Barrier
Coat was applied with a disposable applicator
from the cervical to the incisal third, ensuring
uniform coverage. The excess in the proximal
areas was removed using dental floss. After
application, the material was left undisturbed for
at least 3 seconds and light-cured according to the
manufacturer’s instructions (10 seconds). Finally,
the patient was advised on post-application care,
including maintaining good oral hygiene and
avoiding certain foods that could compromise
the coating during the initial phase.
Since this product is also indicated as a
varnish for promoting remineralization and
resistance to demineralization, its application
was extended to other dental surfaces. Due to
the impracticality of using a rubber dam in this
case, moisture control was managed with cotton
rolls and suction.
After one month, the patient reported a
signicant reduction in dentin hypersensitivity,
even though some material detachment from
the teeth was observed. The combination of
dental structure reinforcement using a temporary
physical barrier provided by the material with
the reduction on the intake of acidic diet
consumption contributed to an improvement
in her quality of life several weeks later. The
OHIP-14 questionnaire revealed a decrease in
Figure 4 - Case 1. (A) Two-week follow-up and pre-restoration view; (B, C) Follow-ups at one week and two months, respectively.
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Dallavilla GG et al. Early enamel affected lesions: benefits and limitations of
simplified resin techniques
hypersensitivity frequency, from “4-always” to
“1-rarely”. [23] After four months, the patient
continued to report minimal or no painful
discomfort with no complaints regarding the
esthetic appearance (Figure 5I).
DISCUSSION
Contemporary dentistry focuses on the
primary goal of providing long-term benets to
patients while considering the practical use of smart
materials that facilitate professional handling and
minimize technical errors. Achieving this balance
requires a conservative approach supported by
early diagnoses and patient compliance.
From this perspective, adhesive resin
materials and new functional monomers have
introduced diverse strategies for treating enamel
and dentin [5,16]. The development of resin
inltrants, such as Icon, represents a remarkable
advancement that has achieved optimal
performance beyond the treatment of early white
carious lesions [12,13,15]. The understanding of
its mechanism extended its indication to include
non-cavitated whitish lesions without structural
damage [10,11,13]. While outcomes may vary,
these treatments typically enhance esthetics,
improve patient self-esteem, and promote
treatment adherence. These aspects are critical
for clinical success [10].
Cazzolla et al. [24] observed a successful
four-year follow-up of a post-orthodontic patient
who presented white spot lesions treated with Icon.
Although no signicant alterations were observed,
there was no progression of early carious lesions. In
addition, it is not uncommon to associate different
procedures to enhance the overall performance
towards promoting esthetic and conservative
properties [25]. In particular, when esthetics is
the main complaint of whitish lesions of enamel
mal formation, enhanced improvements have been
investigated [11]. Therefore, combined treatments
Figure 5 - Case 2. (A) Preoperative view after cleaning procedures; (B) Application of a thin layer of PRG Barrier Coat (Shofu) on the dried
buccal surface of the maxillary teeth; (C) Product application on the palatal surface of the maxillary teeth; (D, E) Application of PRG Barrier
Coat on the buccal and lingual surfaces of the mandibular teeth, respectively; (F) Removal of excess material with dental floss, followed by
light curing; (G) Final aspect after applying PRG Barrier Coat (Shofu); (H, I) One and four-month follow-ups, respectively.
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Dallavilla GG et al. Early enamel affected lesions: benefits and limitations of
simplified resin techniques
and/or variation of techniques have consolidated
this material as promissory.
In recent years, bioactive materials have
gained increasing attention among professionals
and researchers. While the concept is not new,
adhesive systems have driven the development
of novel material categories with precise
applications, redefining their purpose [26].
Managing erosive tooth wear has emerged as a
predominant concern [27,28].
Therefore, approaches such as the use of self-
etching systems like PRG Barrier Coat (Shofu)
have experienced expanded indications beyond
treating dentin sensitivity [21]. This product,
based on Giomer technology, releases multiple
ions due to the presence of S-PRG (surface pre-
reacted glass) particles [19,20]. Studies have
shown its efficacy across various scenarios,
demonstrating promising results [18,21,29-32].
Agulhari et al
.
[32] described the successful use
of PRG Barrier Coat combined with a composite
resin restoration for a patient with ETW, reducing
sensitivity and hindering erosive progression.
Both systems – Icon and PRG Barrier Coat
– offer benets in restoring functionality, while
also providing esthetic outcomes depending on
the case. Another important aspect is their easy
application, making them practical for clinical use.
Lately, the literature has been demonstrating
their efcacy and appropriate use. Kalisiri et al. [33]
demonstrated that Icon and PRG Barrier Coat
effectively seal articial white-spot lesions, providing
long-term protection and demonstrating great
defense against microleakage. Mosquim et al. [34]
highlighted the effectiveness of combining polymeric
resin with inorganic ion-releasing llers for managing
dentin hypersensitivity under erosive conditions.
Kaga et al. [18] emphasized that PRG Barrier Coat
plays an important role in protecting against enamel
demineralization.
The development and application of
materials like Icon resin inltrant and PRG Barrier
Coat have expanded treatment possibilities,
providing effective solutions for conditions such
as early carious lesions, non-cavitated whitish
lesions, and erosive tooth wear. In addition,
variations of these materials and protocols cannot
be ignored since they have achieved outstanding
results, particularly when esthetics is a mandatory
complaint [11].
However, clinical success depends not
only on the inherent properties of materials
and the skills of dental professionals, but also
on the active participation and awareness of
patients. Early diagnosis, patient compliance,
and follow-up care remain pivotal in achieving
long-term outcomes [8]. By integrating advanced
materials with person-centered care, dentistry
can meet both the clinical and emotional needs
of patients, fostering improved oral health and
quality of life.
CONCLUSION
Professional skills and the advantages
offered by advanced materials provides signicant
support in managing and minimizing etiological
factors. However, patient compliance remains
essential to ensure effective results. Efficient
and transparent communication with patients
promotes their cooperation by addressing their
needs and expectations. Regular follow-ups are
essential for strengthening this relationship.
Therefore, the integration of early diagnosis
with the appropriate use of advanced materials
is likely to ensure successful outcomes when the
indications and applications are correctly aligned.
Author’s Contributions
GGD: Conceptualization, Methodology,
Investigation, Visualization, Resources,
Data Curation, Writing – Original Draft
Preparation, Writing – Review & Editing. MPC:
Conceptualization, Methodology, Investigation,
Visualization, Resources, Data Curation, Writing
– Original Draft Preparation, Writing – Review
& Editing. SKI: Visualization, Investigation,
Supervision. LW: Conceptualization, Methodology,
Validation, Investigation, Resources, Writing –
Original Draft Preparation, Writing – Review
& Editing, Visualization, Supervision, Project
Administration, Funding Acquisition. MCG:
Validation, Investigation, Resources, Writing –
Original Draft Preparation, Writing – Review
& Editing, Visualization, Supervision, Project
Administration, Funding Acquisition.
Conict of Interest
The authors have no conicts of interest to
declare.
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Early enamel affected lesions: benefits and limitations of simplified resin techniques
Dallavilla GG et al. Early enamel affected lesions: benefits and limitations of
simplified resin techniques
Funding
The present study was nanced in part by
the Coordenação de Aperfeiçoamento de Pessoal
de Nível Superior - Brasil (CAPES) - Finance
Code 001.
Regulatory Statement
The present study was conducted in
accordance with all the provisions of the local
human subjects’ oversight committee guidelines
and policies of the Bauru School of Dentistry
– University of São Paulo, approval number
63544222.0.0000.5417.
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Marina Ciccone Giacomini
(Corresponding address)
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