Gone are the days of managing dental
caries by only surgical and restorative
intervention. With increased understanding
of the caries process, more effective
therapeutic modalities have become available that not only
intervene when lesions are in their earliest stages, but also
contribute to their reversal by promoting remineralization.1
Dental caries is a dynamic, multi-factorial process that
starts in the biofilm. The first goal in caries management is to
prevent disease progression by ending the ongoing process,
followed by prevention and repair through remineralization.
Effective caries management is based on the early detection
of visible changes in tooth tissues, with meticulous documentation
of severity, extent, and activity of the lesion, in
addition to other factors, such as patient history. Documenting
the lesion's activity is crucial to diagnosis. Initial risk
assessment and subsequent recare appointments are part of
an effective continuum of care. Remineralization of active,
noncavitated lesions is the ultimate goal.
Acid-producing bacteria in dental biofilm cause the minerals
in tooth tissues to dissolve. Frequently switching demineralization/remineralization cycles at the tooth surface are
normal physiologic occurrences that occur numerous times
per day. In a healthy mouth, these cycles are in balance,
with saliva providing a constant supply of calcium, phosphate,
and fluoride minerals to assist remineralization of
the partly dissolved apatite crystals.2
In a caries-inducing oral environment, however, this balance
tilts toward demineralization, leading to subsurface porosities.
If these conditions are allowed to continue, the incipient,
noncavitated lesion will progress until the surface collapses and
a cavity is created. The constant battle between mineral dissolution
(demineralization) and mineral uptake (remineralization)
at the tooth-biofilm interface consists of continual ion-exchange
across this interface. This demineralization/remineralization
process takes place both at external tooth surfaces (enamel and
root surface) and internally in the dentin (cavitated lesions,
caries associated with restorations). Bioactive restorative materials
can also induce remineralization.
Generally, carious lesions do not develop
rapidly (other than in erupting teeth or in
the case of hyposalivation). Lesions may
take 3 years to 4 years to become cavitated,
providing clinicians with unique opportunities
for successful intervention during the
initial phase of lesion formation. Remineralization
therapy in this phase leads to uptake
of minerals in the tissues, resulting not only
in repair and strengthening of the porous
tooth structure, but also in increased acidresistance.
The subtle rearrangement of crystals
and redeposition of dissolved minerals in
the subsurface lesion parts make the remineralized
tooth surface less susceptible to
renewed caries attacks. Most of the remineralization
occurs at the surface, leaving a
sealed porous subsurface underneath.3
Contemporary management strategies are
based on interpretation of lesion activity and
future caries risk. Early detection is crucial for
successful, noninvasive lesion management.4 Focused clinical assessment and diagnosis of
early lesions might be time-consuming, but
they are rewarded with positive results.
More recent treatment strategies include
calcium-based technologies. These technologies
need additional study, but the body of
evidence supporting their efficacy continues to
grow. Insufficient evidence does not necessarily
mean that the intervention does not work.
Rather, a lack of evidence may be related to an
insufficient number of well-designed clinical
studies investigating the intervention or, for
example, when efficacy has only been shown
for a specific subset of the population.1
Overtreatment of remineralized, white, or
brown "tissue scars" should be avoided.
These arrested, nonactive lesions do not need
management. Their surface layer is more acidresistant
than sound enamel. Greater awareness
of this phenomenon will help reduce the
perceived need for remineralization intervention
and avoid therapeutic overtreatment.
The dental professional's goal is to assist the
natural, daily demineralization/remineralization
cycles to shift toward remineralization activity
and reverse early carious lesions. Because caries
is an infectious disease, the process can be interrupted and arrested by modifying the
biofilm through changes in local or oral environment.
Basic prevention (Table 1) includes
plaque-removal and plaque-reducing strategies,
and stimulation of salivary flow (sugarfree,
polyol-containing chewing gum). These
cleaning strategies expose the tooth surface to
a healthy amount of saliva, which delivers minerals
to the tooth surface, thus promoting local
Reduction in bacterial acid production will
influence the local dynamics of ion-exchange at
the tooth surface, and encourage remineralization.
Patients should be advised to brush at
least twice per day, regardless of age or health
status. Daily toothbrushing with fluoride toothpaste
keeps plaque build-up under control
while delivering additional fluoride ions to the
exposed clean surface (Table 1). Elevated levels
of fluoride in the oral environment should be
considered active chemical treatment for carious
tissues. Daily cleaning with fluoride toothpaste
will help convert active carious lesions in
enamel and dentin into inactive lesions. The positive effects of simple oral hygiene
measures should be emphasized to
at-risk patients (Table 2).5,6
Little or no exposure to fluoride
constitutes an elevated risk of caries.
The use of fluoride toothpaste is a
cost-effective way to control caries.7 This strategy enhances plaque
removal while facilitating remineralization
of the tooth surface. Frequent
presence of small amounts of fluoride
at the tooth surface promotes effective
remineralization. This prompts the
"Spit, but don't rinse" recommendation.
After excess toothpaste has been
spit, the remainder will continue to
facilitate remineralization, and may
result in up to a 26% reduction in the
incidence of approximal caries.9 This is
particularly important for erupting
teeth. After eruption into the oral cavity,
local conditions, in combination
with saliva, modify the composition of
the enamel surface and lead to
enamel maturation. The matured
tooth surface is then less soluble and
more resistant to caries challenges.10–13
Exposing dentin surfaces to the
oral environment results in a similar maturation
effect. After gingival recession, the
cementum is rapidly worn away, exposing
the dentin surface to similar demineralization/
remineralization cycles. This creates a
root surface augmented with minerals,
which significantly reduces permeability and
caries susceptibility. Rigorous cleaning with
fluoride toothpaste may revert active root
dentin lesions into hard, leathery, inactive
lesions.6 Likewise, caries-affected dentin in
cavitated lesions can arrest and remineralize
when the local cariogenic conditions
change. For example, an open, advanced
lesion that has lost its walls will expose the
dentin to the self-cleansing actions of chewing
and saliva. Because the biofilms are no
longer able to accumulate for significant
amounts of time, the now-exposed dentin
lesions will remineralize and arrest. Another
example is the alternative nonrestorative
caries management strategy of "opening of
contact areas" among patients with rampant
caries in the deciduous dentition.14
A different approach to arrest lesions and
protect tooth surfaces from demineralization is
sealing of the surface through the application
of a resin sealant. Sealants provide an impenetrable
barrier, completely blocking off the
biofilm from the tooth. The effectiveness of
sealants in managing noncavitated and cavitated
caries lesions is overwhelming: sealants
resulted in caries reduction of about 71% up to
5 years after placement.15 Both sealing of the
caries process and sealing of restorations
appear to be highly effective in conserving
sound tooth tissue and providing protection of
hard tooth tissues against caries progression.
A glass ionomer sealant encourages remineralization
and maturation of the underlying
enamel. Among noncompliant patients with
moderate to high caries risk, sealant application
may be the preferred option. Once a resin
sealant is applied to the lesion, however, the protected
tooth surface can no longer be remineralized.
This is also true for resin-infiltrated lesions.
The protective resin film inhibits the ionexchange
with saliva and biofilm fluids in both
directions—not only shielding the enamel from
bacterial acid challenge, but concurrently barring
the potential for remineralization.
Additional caries reduction can be
achieved when fluoride toothpaste
is combined (either at home or
via in-office application) with
other topical fluorides, such as
mouthrinses, gels, and varnish.11 These are essential parts
of any caries control program
High concentration prescription
fluoride toothpaste and fluoride
mouthrinses may benefit
adults with active caries who
have difficulty cleaning their
teeth adequately. For patients
with hyposalivation and/or
burning mouth syndrome,
alcohol-free products should be
Fluoride levels should be
kept elevated as often as possible,
thus the daily addition of a
third fluoride boost through
extra brushing with high-concentration
fluoride toothpaste, fluoride mouthrinse, or other applications (eg,
tablets, gels), may be indicated. Strong evidence13 supports professional application of
topical fluorides as an effective caries control
measure. Fluoride gel and foam should be
applied for 4 minutes to gain the full effect.
Fluoride varnish should be applied two to
four times per year among moderate to high
caries risk patients.16 Complementary preventive
strategies, such as sealants, fluoride varnish,
and toothbrushing, are also indicated.
Currently, the evidence to support fluoride
varnish is strong and mounting. Due to ease
of application and eliminating the need for
at-home compliance, fluoride varnish may
soon be the preferred mode of adjunct fluoride
delivery instead of gels and foams.
Calcium-based products for the remineralization
of caries show considerable promise.
In addition to fluoride, calcium and phosphate
ions are needed to achieve remineralization.
The calcium and phosphates in saliva
are the primary source for recrystallizing minerals
while fluoride facilitates and assists the remineralization process. With hyposalivation,
however, supplementing fluorides with
home applications of bioactive calcium
phosphate complexes may greatly assist
Amorphous calcium phosphates (ACP),
casein phosphopeptides (CPP)-ACP, calcium
sodium phosphosilicate, and tri-calcium
phosphate have shown potential benefits.
They may serve as effective adjuncts to fluoride
treatment in the noninvasive management
of early carious lesions. Many are
currently used to treat dentinal hypersensitivity,
though additional research is needed
to validate their efficacy in caries management.17,18
A recent clinical study reported an
alternative therapy for treating incipient
proximal lesions.19 The study used a simple,
low-cost, noninvasive method to deliver
supplemental minerals. Using orthodontic
elastics to separate and open approximal
contacts, glass ionomer cement (GIC) was
applied directly to carious lesions. The study
demonstrated that the application of GIC to
early noncavitated proximal carious lesions
inhibited the progression and enhanced the
regression of the lesions. Application of GIC
to proximal lesions is a viable method in
cases where home use of remineralizing
products is not feasible, or where poor
patient compliance is anticipated. Further
studies, however, will be necessary to define
the long-term clinical effects of GIC on the
progression of initial proximal caries.
Dental erosion is characterized by the irreversible
loss of tooth structure due to chemical
dissolution by acids not of bacterial origin.
Remineralization requires the presence of partly
demineralized apatite crystals that grow back
to their original size. Entirely new crystals are
rarely formed.20 At eroded surfaces, the enamel
is etched away layer by layer, and crystals are
lost layer by layer. As such, erosion lesions are
not likely to remineralize, even when exposed
to mineral-saturated saliva for long periods of
time. Though fluoride does not contribute to
the remineralization of eroded surfaces, there is
convincing evidence that it can strengthen
teeth against erosive acid damage.
Oral hygiene measures influence the
progress of erosive lesions. When erosion is a
problem, patients should avoid toothbrushing
immediately after an erosive challenge.
Instead, patients should be encouraged to
brush before the acid challenge, using a soft
toothbrush and low abrasive toothpaste. This
procedure does not completely remove the
pellicle, and the pellicle is thus able to continue
its protective function when the erosive
attack follows.21 After acid intake (eg, soft
drinks, wine), patients can stimulate saliva
flow by chewing gum or lozenges and postponing
toothbrushing. Periodic use of fluoride
mouthrinse and concentrated topical
fluoride are advised. Fluoride toothpastes, high-concentration fluoride agents, and/or
frequent fluoride applications are potentially
effective approaches in preventing dental
MINERAL ADDITIONS TO
Over the past decade, tooth whitening
products have become widely available in
the United States, and vital tooth whitening
has become a common procedure in daily
clinical practice. Whitening agents use
active ingredients, such as carbamide peroxide
and hydrogen peroxide, to effectively
whiten teeth. Tooth whitening, however,
may cause side effects, such as dentinal
hypersensitivity and morphological and
chemical alterations of the enamel surface
(eg, decrease in calcium and fluoride content,
reduced microhardness, and increased
Enamel is susceptible to mineral changes
during whitening treatment. The recent
addition of fluoride, calcium, and phosphate
to whitening agents is designed to minimize
mineral loss in the enamel and dentin. The
use of remineralizing gels after whitening
can significantly enhance the naturallyoccurring
remineralization by saliva, rapidly
enhance microhardness, and reduce roughness
of the whitened enamel.27
Patients require individually-tailored management
to effectively prevent and manage
the caries disease process. Patients at high
risk of caries include: children with erupting
teeth and immature enamel; patients
with appliances (fixed and removable
orthodontics, removable partial dentures);
patients with newly exposed root surfaces
after periodontal surgery; older adults with
root caries; and all individuals who suffer
from hyposalivation (due to medication,
xerostomia, radiation, etc).
Among high caries risk patients, the saliva
and thus the biofilm fluids should be saturated
with minerals that will tip the balance toward
remineralization when cariogenic conditions
arise. Both at-home and professional applications
might be advised (Table 4). More frequent
fluoride boosters (eg, applying fluoride
varnish four times per year) will benefit these
Caries activity and risk assessment are
vital to the development of an effective
caries management strategy. Once the
correct strategy has been decided, patient
compliance is key to a successful longterm
outcome. Encouraging communication
and monitoring compliance are integral
parts of effective caries management and
maintenance plan. If compliance or monitoring
is problematic, sealants are strongly
recommended for all at-risk surfaces. Fluoride
remains the most widely used agent
for managing the remineralization process, but adjunct calcium and phosphate
technologies may also help enhance remineralization.
Mathilde C. Peters, DMD, PhD,
is professor of dentistry in the Department of Cariology, Restorative
Sciences and Endodontics at the University of Michigan School of
Dentistry in Ann Arbor. She directs an international clinical research
network focused on cariology and minimum intervention trials. In 2008,
she received the Academy of Operative Dentistry's Hollenback Memorial
Prize for her leadership and research in minimally-invasive dentistry.
Preetha P. Kanjirath, BDS, MDS, MS,
is the preclinical program director and associate professor at
Midwestern University, College of Dental Medicine-Illinois in Downers
Grove. Her research interests include educational, clinical, and
Juliana A. Barros, DDS, MS,
is an assistant professor in the Department of Restorative Dentistry
and Biomaterials at the University of Texas School of Dentistry in
Houston. Her research and teaching interests include restorative
dentistry, cariology, and laser applications.
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From Dimensions of Dental Hygiene. October 2011; 9(10): 42-47.