Dental Policy Bulletins

Number: 038

Subject: Resin Infiltration of Incipient Smooth Surface Lesions

Reviewed: October 29, 2012

Important Note

This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:

• Clinical outcome studies in the peer-reviewed published medical and dental literature
• Regulatory status of the technology
• Evidence-based guidelines of public health and health research agencies
• Evidence-based guidelines and positions of leading national health professional organizations
• Views of physicians and dentists practicing in relevant clinical areas
• Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

The restoration of decay that is present on a smooth surface and extends into the dentin is considered a one-surface resin-based composite. Restoration of an incipient lesion that does not extend into the dentin may be reported as a resin infiltration of incipient smooth surface lesion. Placement of an infiltrating resin restoration is for strengthening, stabilizing and/or limiting the progression of the lesion.

Background

This technique is used to treat smooth surface white spot lesions microinvasively. It is based on the infiltration of an initial enamel caries lesion with low-viscosity light-curing resins called infiltrants. The surface layer is eroded and desiccated, followed by resin infiltrant application. The resin penetrates into the lesion microporosities driven by capillary force and is hardened by light curing. Infiltrated lesions lose their whitish appearance and look similar to sound enamel. Additionally, the treatment prevents lesion progression.

Codes¹

D2990* - Resin infiltration of incipient smooth surface lesions.

Revision Dates

Original policy: October 29, 2012
Updated:
Revised:

The above policy is based on the following references:

¹ American Dental Association. Current Dental Terminology, CDT 2013.*

² Dorothy D. McComb, B.D.S., M.Sc.D., FRCD(C). NIH Consensus Development Conference on Caries. Copyright 2000 Regents of the University of Michigan. 2003.

³ Shivanna, V., Shivakumar B. Novel treatment of white spot lesions: a report of two cases. J Conserv Dent. 2011 Oct-Dec; 14 (4): 423–426. doi: 10.4103/0972-0707.87217

*Effective January 1, 2013.
Copyright 2012 American Dental Association. All rights reserved.

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and, therefore, is subject to change.

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