Document Type


Date of Degree

Summer 2018

Access Restrictions

Access restricted until 08/31/2020

Degree Name

MS (Master of Science)

Degree In

Operative Dentistry

First Advisor

Kolker, Justine L.

First Committee Member

Vargas, Marcos A.

Second Committee Member

Maia, Rodrigo R.

Third Committee Member

Dawson, Deborah V.


Title: The Esthetic Outcome and the Infiltration Capacity of Three Resin Composite Sealers Compared to ICON (DMG, America).

Objective: The aim of these studies, including a randomized control in-vitro study and a survey study was to answer the following question: In treating initial caries lesions, is the esthetic outcome and the infiltration capacity of the three resin composite sealers; BisCover LV (Bisco Dental), Optiguard (Kerr), PermaSeal (Ultradent) similar to that of the gold standard ICON (DMG, America) resin infiltrant.

Methods: A sample of 75 extracted human permanent molars were painted with an acid resistant nail varnish (Revlon, USA) to protect the tooth surface from demineralization leaving only two panels of 1x7 mm of exposed enamel on the buccal and the lingual surfaces of each tooth to be demineralized. Samples were immersed in an acidic gel (500g of Fisher G-8 Gelatin, 275 Bloom, 0.1% thymol, lactic acid, pH 4.30) for a period of 3 months to create artificial initial caries lesions. Seventy-five specimens were randomly assigned to 5 groups: I: ICON (DMG, America), B: BisCover LV (Bisco Dental), O: Optiguard (Kerr), P: PermaSeal (Ultradent) and C: control group. Specimens were hemi sectioned yielding two halves, each with a panel of 1x7 mm of initial caries lesion. One side was used to assess the esthetic following the caries lesion resin infiltration with ICON, BisCover LV, Optiguard and PermaSeal applied according to ICON manufacturer instructions. The control group (C) did not receive any treatment and was only included in the esthetic part of this study. Preoperative and postoperative photographs were taken. Two sets of photographs were taken for the control group. The preoperative, postoperative and control group photographs were installed in a PowerPoint presentation and placed side by side on a black background. A total of 17 operative faculties and residents at the department of operative dentistry at the University of Iowa (UI) participated in the survey. The esthetic improvement was assessed based on a 100-mm visual analogue scale (VAS). A value between 0 and 20 indicated slight esthetic improvement. A value between 20 and 40 indicated mild esthetic improvement. A value between 40 and 60 indicated moderate esthetic improvement. A value between 60 and 80 indicated high esthetic improvement. A value between 80 and 100 indicated outstanding esthetic improvement. A value of 100 indicated full esthetic recovery. Each subject was asked to look at the preoperative and postoperative photographs of a specimen in each slide and place a line on the respective VAS according to her/his opinion of esthetic improvement. The survey was conducted twice in two different sessions to evaluate the inter-rater and intra-rater reliability.

For lesions on the opposite side, the resins: ICON, BisCover™LV, Optiguard and PermaSeal were applied according to the indirect dual fluorescence technique protocol using the red fluorophore rhodamine B isothiocyanate (RITC 0.1%; Sigma Aldrich, Steinheim, Germany) and the green sodium fluorescein (NaFl; Sigma Aldrich). Specimens were sectioned in a mesio-distal direction yielding thin sections of 200 μm and were visualized under the Confocal Laser Scanning Microscope (CLSM, Leica Microsystems, Buffalo Grove, IL.) to assess the infiltration depth percentage (ID%) and the infiltration area percentage (IA%) following the application of the different resins.

Statistical analysis: The effect of treatment type on ID% and IA% was evaluated using the one-way ANOVA. The effect of treatment type on esthetic improvement measures represented by VAS scores was evaluated using the non-parametric analogue of the one-way ANOVA; Kruskal-Wallis test. All pairwise comparisons were performed using the Tukey method with an overall 0.05 level of significance. Spearman rank correlations were used to assess the relationship between esthetic improvement measures and infiltration measures. Validity of assumptions related to normality and variance homogeneity were assessed using the Shapiro-Wilk and Brown-Forsythe tests, respectively. The intra-class correlation and associated 95% confidence interval reflecting the reproducibility of the mean VAS scores and the reliability among the evaluators were obtained using the method of Shrout and Fleiss. The Wilcoxon Signed Rank procedure was used to evaluate differences between sessions for individual evaluators. The paired student’s t-test was used to detect any systematic differences between the mean VAS scores at session 1 and 2. Bonferroni adjustment for multiple testing was made for the 17 tests associated with individual raters, using an overall 0.05 level of significance.

Results: the mean IA% values were significantly higher in the ICON group compared to the other three treatment groups. Optibond and Permaseal groups resulted in intermediate values that did not differ significantly from each other. Biscover group yielded the lowest mean values and were significantly lower than that of the other three treatment groups. The results of the ID% values were consistent with the results of the IA% values. the mean ID% values were significantly higher in the ICON group compared to the other three treatment groups. Optibond and Permaseal groups resulted in intermediate values that did not differ significantly from each other. Biscover group yielded the lowest mean values and were significantly lower than that of the other three treatment groups.

The distribution of esthetic improvement outcomes represented by the average VAS scores for session 1 (AVGVAS1), average VAS scores for session 2 (AVGVAS2), and the combined average VAS scores (AVERAGED_VAS) for each sample obtained from the two sessions were all significantly lower in the control group than in the other four treatment groups. Biscover yielded intermediate average VAS values. ICON, Optiguard and Permaseal yielded significantly greater average VAS values than both the control and Biscover groups and were not significantly different from each other.

According to the Spearman rank correlations which was used to assess the relationships between the esthetic improvement measures; AVGVAS1, AVGVAS2 and AVERAGED_VAS for each sample and the two measures of infiltration; the IA% and the ID%, all results were highly significant (p<0.0001) and indicative of a moderately large positive correlation between each of the infiltration measures and the three esthetic improvement measures. The Spearman coefficients for the six relationships evaluated were quite similar, ranging from about 0.523 to 0.548.

Conclusion: The resin composite sealers BisCover LV, Optiguard and Permaseal can infiltrate artificial initial caries lesions. The esthetic outcome of artificial initial caries lesion following resin infiltration with Optiguard and Permaseal was similar to ICON and thus might be adequately used in caries resin infiltration. BisCover LV showed the least esthetic improvement and thus might not be indicated for the esthetic management of initial caries lesions but might be used for caries prevention purposes. The esthetic improvement is correlated to the resin infiltration depth to a certain extent after which the esthetic outcome will not be visually impacted.


xv, 162 pages


Includes bibliographical references (pages 155-162).


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Copyright © 2018 Tamer George Theodory

Available for download on Monday, August 31, 2020