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Caries of Enamel

Clinical signs. Differential Diagnostics. Treatment and

Prevention. Arrested Caries
Maria K. Makeeva
Senior Teacher of
Operative Dentistry Department,
Russian University of People Friendship
Caries of Enamel
Clinical signs
International Statistical Classification of Diseases and
Related Health Problems 10th Revision WHO Version 2016
Chapter XI Diseases of the digestive system (K00-93)
(K00-K14) Diseases of oral cavity, salivary glands and jaws
K02 Dental Caries
K02.0 Caries of enamel
White spot lesions [initial caries]
K02.1 Caries of dentine
K02.2 Caries of cementum
K02.3 Arrested dental caries
K02.4 Odontoclasia
Infantile melanodontia
K02.5 Caries with pulp exposure
K02.8 Other dental caries
K02.9 Dental caries, unspecified
Caries of Enamel. Clinical signs
Types of lesion:
NON-CAVITATED (white spot) all localizations are possible

CAVITATED (small defect in the cervical area mostly,

enamel, not spreading into dentin) fissures sometimes

Localization: Complaints:
Pits NO complaints (more
Fissures often)
Cervical area Bad esthetic (spots in
SMOOTH cervical area of frontal teeth
Approximal surfaces SURFACES and spots after braces)
(between teeth) Slight sensitivity to sour or
cold or sugar food (not very
A Little Bit about Terminology
1. Caries of enamel:
- white spot (non-cavitated) = initial caries, incipient caries.
- cavitated caries of enamel = superficial caries.

2. Primary / Initial caries is one in which a lesion came up in

this tooth surface first time. No restoration on this very tooth
surface was placed earlier.
Secondary / Recurrent caries - caries is observed around
the edges or under restoration.

Not to be confused - pay attention to the overall meaning of

sentence if see INITIAL CARIES in text!
Caries of Enamel in Pits
Palatal pits of
maxillary molars
Buccal pits of
mandibular molars
Palatal pits of
maxillary incisors
Caries in Pit Cunning Caries

It seems to be not so big,

but after drilling you will
se it is much bigger
(compare tissue colors:
in cusp with pit color is
grayish and white. In
healthy cusp color is
light yellow (normal
tissue color)).
Caries of Enamel in Cervical Area

44, 45, 46, 47 caries of enamel (white spot in cervical area)

46 also filling with stained border in buccal pit
Caries of Enamel in Cervical Area

46, 45, 44, 33 caries of enamel (white spot),

43 caries of dentine (there is a small brown-color cavity in cervical area)
Caries of Enamel in Cervical Area

Deep, narrow, retentive

31, 32, 42 caries of enamel (white spot),

41, 33 caries of dentine (small brown-color cavity in cervical area)
Caries of Enamel around Braces

After removing of braces

Caries of Enamel around Braces
Typical form of lesions
(round or oval area of healthy
enamel in the center of
vestibular surface surrounded
by white or yellowish-brown
demineralized tissues)

Typical localization
(vestibular surfaces of all or
almost all teeth are affected)
Caries of Enamel
Differential Diagnostics
Caries of Enamel. Differential Diagnostics

Carious white spot should be distinguished with:

Mild and very mild forms of fluorosis

Fluorosis and hypoplasia have different forms

and clinical signs (pathological pits, grooves, areas of destruction etc.)
here ONLY spots and spot-like elements
(e.g. thick lines or any irregular white color area) will be discuss. As
only these elements have similar to carious white spot
Carious White Spot VS. Fluorosis and Hypoplasia Spots
Next data should be considered:
1. Anamnesis vitae
1. Person with fluorosis was born and grown-up in
region with high concentration of fluorine ion in
drinking water.
2. Person with hypoplasia had some severe
disease (rickets, nephrosis, dipepsiya, edema
disease etc.) in period of development and
mineralization of teeth (first years of childhood)
2. Spot localization
1. fluorosis spots are localized in smooth surfaces Mild fluorosis
or cover teeth totally
2. Hypoplasia spots localization depends of time of
disease attack. For instance, if disease occurs in
the age of 8-9 months hypoplastic spots will be
on lateral incisors and canines (because
formation of these teeth goes on in this age)
3. Spot smoothness (carious spot is rough
during probing, hypoplasia and fluorosis
spots are smooth)
4. Spot coloring (carious spot is colored by
erythrosine, hypoplasia and fluorosis - no)
Caries of Enamel. Coloring

43 white carious spot After erythrosine After rinsing by water: NO

application colorants on healthy enamel
(because it is smooth).
Demineralized enamel has red
color because of rough
surface and microporosity
which retains erythrosine
Caries of Enamel
Treatment (Remineralization and Infiltration).
Caries of Enamel. Treatment
1. Non-cavitaded lesions on smooth surfaces:

Remineralization therapy (applications of varnishes or gels

with fluorine and calcium, rinsing of fluorine contains solutions

Infiltration therapy (material is called ICON).

2. BOTH non-cavitated and cavitated lesions in pits

and fissures:

Preparation by bur or ultrasound tips and filling by composite,

compomer or glassionomer cement.
To improve oral hygiene in all cases!
Caries of Enamel on Smooth Surfaces.
Demineralized enamel is weak, permeable for
pathogenic agents (facilitate microbial invasion into
dentin) and looks not esthetic.

Aim of treatment:
1. Makes weak demineralized enamel hard again, stop
progression of demineralization and prevent microbial
migration into dentin (aim is actual for vestibular/buccal and
approximal surfaces).
2. Return normal light reflection and refraction for better
esthetic (aim is actual for vestibular/buccal surfaces only).
Caries of Enamel on Smooth Surfaces.
For better understanding of treatment methods
its necessary to remember enamel structure,
histopathology of carious spot and also some
biochemical processes in enamel apatite and
Enamel Structure
Enamel Structure:

Enamel rods (prisms) key-shaped

structures are built from hydroxyapatite
crystals. Has head and tail. Each rod is
covered by enamel rod sheath.
Interrod (interprismatic) spaces
Enamel Structure
1. Enamel rods 2
Degree of
2. Interrod spaces minerlization 3
3. Enamel rod sheath 1

Demineralization goes on in next sequence:

enamel rod interrod enamel
sheath spaces rods

Thus demineralized enamel rod sheath

and interrod spaces is pathways for
microorganisms and acids to move in
subsurface area. transverse SEM
Caries of Enamel on Smooth Surface.

Tooth Structure: Caries spot is NOT only surface BUT

1. Enamel SUBSURFACE demineralization
2. Dentin
Area of
3. Pulp chamber increased
1 spot

3 Solid enamel
Caries of Enamel on Smooth Surfaces.
Area of

Demineralized enamel looks white because of changing of light

reflection and refraction to compare with healthy tissue.
Caries of Enamel on Smooth Surface.

SZ Surface Zone (SZ) - relatively unaffected

area due to greater degree of
TZ mineralization because of contact with
DZ B saliva (total volume of pores 1-2%).

Body of Lesion (B) area

of greatest demineralization (25-50%

Dark Zone (DZ) demineralized zone

contains 5-10% porosity.

Transparent Zone (TZ) - not always

present, slightly more porous than healthy
enamel (1-2%).
Caries of Enamel on Smooth Surfaces.

Healthy solid
White carious spot
enamel (increased subsurface

Surface Zone (SZ) - relatively unaffected area due to greater degree of

mineralization because of contact with saliva (total volume of pores 1-2%).

Body of Lesion (B) area of greatest demineralization (25-50% porosity).

Chemical Composition of Enamel
Transverse section

Inorganic 96 % (mostly calcium

hydroxyapatite (HAP) with some inclusions
of magnesium (magnesium apatite),
strontium (strontium apatite), fluorine
(fluorapatite) etc).
Organic 1.2 %
Water 2.8 %
Longitudinal section

Enamel rod,
longitudinal section,
side view

Chemical Composition of Enamel

Rods consists from hydroxyapatite (HAP) crystals (black dotted lines on

scheme), interrod spaces also contain HAP crystals but oriented in
different direction (compare yellow and red lines on SEM).

Longitudinal section
Hydroxyapatite of Enamel
Calcium hydroxyapatite Ca10(PO4)6(OH)2 has hexagonal lattice, in the middle of
hexagonal axis OH- group is located. In acidic conditions mineral ions come out
from crystal lattice, empty spaces after ions coming out are called vacant places.
Each crystal surrounded by firmly bound water so called hydration shell . Mineral
ions from external source could come into hydration scell and go deeper in
crystal to substitute another ions or to deposit in vacant places.

OH -

P (from PO43-) hydration shell

vacant place

pH = 5.5
Hydroxyapatite of Enamel
If pH is neutral HAP is stable, isomorphic substitution can occurs in the outer
layer of enamel. Ions dont come out and HAP will not be destructed.

If pH < 5.5 destruction of HAP starts, first PO43- come out from HAP, then
- , and after that - Ca2+. Destruction of HAP is not a fast process, after
some ions came out from HAP, vacant places occurs there. These places
could be filled by mineral ions from saliva (physiological process) and from
varnishes, gels etc. (remineralization therapy).

Deposition of 2+, PO43-, F- increases strength of HAP, substitution of PO43-

by 32- decreases strength of HAP. For instance, it is known that
immediately after eruption tooth enamel is immature (there are big percent
of weak carbonated apatite) and mineralization will be finished by ions from
saliva (phosphates will replace carbonates; calcium contents also will be
Hydroxyapatite of Enamel
Some ions could be substituted on another from external source (saliva,
varnish etc.). This is called isomorphous substitution.

Different mineral ions not only substitute

ions in solid HAP but also precipitate (deposit)
in vacant places of partly dissolve (demineralized) HAP.

Next substitution / deposition is possible:

2+ Sr2+, Mg2+
PO43- 42-, 32-
- Cl-, F-
Hydroxyapatite of Enamel
Ions substitution this process is Ions deposition this
a base for all preventive measure process is a base for caries
when we want to enhance healthy spot treatment procedures.
enamel. Most widespread caries Micropores of caries spot
prevention is rinsing and
should be filled by mineral
application of fluorides. Fluorides
ions incorporated in vacant
replace OH- in outer layer of
enamel and form there places of partly dissolved
fluorapatites (FAP) and crystals. And also new
fluorhydroxyapatite (FHAP). It is crystals should be restored
known that fluorapatite and FHAP if some crystals were fully
is more acid-resistant (and caries- dissolve.
resistant) than pure HAP. Thus
caries resistance of teeth
Caries of Enamel on Smooth Surfaces.
Natural Two approaches Artificial
Micropores are filled by micropores are filled
deposition of mineral ions NOT by natural mineral
from external source (gel, ions but by artificial
varnish) - process is substance polymeric
similar to natural income resin.
of minerals into enamel
from saliva.
Remineralization therapy: Infiltration therapy:

1. Weak enamel becomes 1. Weak enamel becomes

harder. harder.
2. Esthetic (natural look of 2. Esthetic (natural look of
enamel) NOT always enamel) ALMOST always
come back. micropores come back.
Caries of Enamel
Remineralization Therapy
Remineralization Therapy
Remineralization is deposition of mineral ions (calcium,
phosphate, fluoride) in micropores of enamel (basically it is
incorporation of ions into vacant places of HAP crystals and
restoration of fully dissolved crystals).

There are many agents used for remineralization therapy:

different compounds of fluorides (sodium fluoride,
aminofluoride, monofluorphosphate)
calcium gluconate
calcium phosphate based products
Remineralization by Fluoride
Fluorides is used as gels, varnishes,
applications of solution.

Fluorides have next advantages:

Inhibition of demineralization
Beginning of remineralization
Fluorapatite formation
CaF2 globules formation
Inhibition of carbohydrate metabolism of oral
Remineralization Therapy by Fluoride
Inhibition of demineralization increasing of F- concentration
in saliva (near the outer surface of enamel) cause mineral ions
(fluorides first) moving in under saturated area (demineralized
area - white spot).

Destructed and Fluoride ions

partly destructed released from gel,
hydroxyapatite cause varnish etc. cause
UNDER saturation SUPER saturation
by mineral ions by mineral ions

Ions move from the

saliva to the enamel
Demineralized Saliva
(locally close to enamel
enamel surface)
Remineralization Therapy by Fluoride
Beginning of remineralization
It is known that low (acidic) pH causes demineralization of enamel. In pH = 5.5 HAP starts
to dissolve BUT NOT rebuilt. It is also known that dissolution of FAP and FHAP starts
at lower pH (about 4.5). So in pH=5.5 (than other apatites dissolve) fluorides
continue to deposit at the enamel and form FAP and FHAP.

So, if imagine that a person ate some sweets, pH decreased a lot and dissolution of HAP
started. Time was running, saliva was secreting, pH started to normalize. During this
normalization formation of FAP and FHAP starts earlier than pure HAP formation.


4.0 4.5 5.0 5.5
Acid Neutral
Remineralization Therapy by Fluoride
Fluorapatite formation

Ca10(PO4)6(OH)2 + 2 F- Ca10(PO4)6F2 + 2 OH-

It is also known that OH- could be replace by F- totally (in that case fluorapatite
(FAP) will be formed) or partly (in that case fluorhydroxyapatite apatite
(FHAP) will be formed). Both apatites have increased acid-resistance (caries-
resistance), demineralization of these crystals starts about pH = 4.5
(compare with pure HAP dissolution about pH=5.5). Thus FAP and FHAP have
increased caries resistance to compare with HAP.
Remineralization Therapy by Fluoride
CaF2 globules formation



Bjorn Ogaard, 1999

After fluorides application on the enamel surface globules of

CaF2 are formed. These are spherical globules different
amount and size there calcium ions are from saliva and
fluorides from any source. CaF2 precipitates on the enamel
surface and serves as calcium and fluorides reservoir in
terms of pH decreasing.
Remineralization by Fluoride
Inhibition of carbohydrate metabolism of oral bacteria
Fluoride is transported as HF into the bacterial cell, where it then
dissociates into H+ and F (Li & Bowden 1994). This process leads to an
accumulation of fluoride inside the cell and simultaneously to an
over-acidification of the cytoplasm. In the cell, fluoride can inhibit
two enzymes: enolase and the protonreleasing adenosine
triphosphatase (Sutton et al. 1987). The over-acidification of the
cytoplasm can also inhibit the mechanism of glucose transport into
the cell.
No 100% proves that these processes really have caries-preventive or
treatment input.
Application of Fluoride Varnish

Concentration of sodium fluoride 50

mg/ml = 2,26 % F- = 22.600 ppm (parts-
Application of Fluoride Varnish
1. Vizualize zone of demineralization
Application of Fluoride Varnish
2. Cleaning of tooth surfaces
Application of Fluoride Varnish
3. Put small amount of varnish on to polypad
Application of Fluoride Varnish
4. To place varnish on dryed teeth surfaces by brush
Application of Fluoride Varnish
5. After hardening yellow varnish turn into translusent
film and becomes almost not visible on the teeth
Remineralization by Calcium Gluconate
1. Cleaning of teeth surfaces.

2. Surface treatment by 1% H202.

3. Drying.

4. Placement of cotton rolls with

calcium gluconate solution on 5
minutes and change it four times
(total exposition 20 min).

5. Not to eat during 2 hours after

Remineralization by Calcium Phosphate
Based Substances
We know that inherently calcium and phosphates are main
components of HAP and it would be good to restore HAP (to carry
out remineralization therapy) by ions which are inherently typical for
enamel (we remember that fluorides often to use for remineralization
inherently are in traces quantity in enamel if no fluorosis). These ions
are Ca2+ and PO43-.

So, first it has been decided to use calcium phosphate remineralization

therapy. But the problem is that pure calcium phosphate is
crystalline substance with very low solubility. But we know that
only free ions (or group of ions) could be incorporated in vacant
places of dissolved crystals. So after contact with saliva in oral
cavity only a few ions can be available for remineralization. Thats
why for delivering Ca2+ and PO43- into enamel it has been decided
to used NOT PURE CRYSTALLINE calcium phosphate BUT so called
calcium phosphate based substances.
Remineralization by Calcium Phosphate
Based Substances

1. Unstabilized Amorphous Calcium Phosphate

calcium salt (e.g. calcium sulfate) and phosphate salt (e.g.
potassium phosphate) are delivered separately intra-orally
or in a product with low water activity as these salts contact
saliva they dissolve, releasing free phosphates and calcium
2. Stabilized Amorphous Calcium Phosphate in
this products for calcium and phosphate ion
stabilization different proteins are used (e.g. casein
from milk). These proteins provide free ions
availability for remineralization.
Caries of Enamel
ICON Infiltration Technique
ICON Caries Infiltration Technique

Infiltration technique was developed for treatment on caries

of enamel (spots) and caries of enamel with minimal
spreading into dentin. Despite it is not a direct indication
but ICON also can be used with some percent of success
for improving of esthetic in cases of hypoplasia and
fluorosis spots.

Why was infiltration technique developed? First, because

remineralization therapy is not always effective neither
for stopping caries process nor for returning esthetic view.
Second, because if we chose restoration by composite as
a method of treatment, during drilling we always will cut
too much healthy tissues.
Drilling of Small Enamel Caries Lesion
Is Too Invasive Procedure
Too big volume of healthy
tissues should be removed
to make an access to
carious tissues.

In case of small caries

drilling is INVASIVE
Infiltration is MINIMAL
INVASIVE approach.
Indication for Infiltration Method

ICON is indicated for caries of enamel without spreading into dentin (E1, E2) or with
minimal spreading into dentine (D1). It is considered that if involving of dentin is
small, after infiltration of demineralized enamel small number of bacteria in dentin
will be entombed and die in absence of nutrition not longer possible to have through
micropores of enamel. The only problem here is how to know is dentin involving is
big or small as far as radiological investigation not always gives ideally correct data.
Some clinicians use additional methods of diagnostics as fluorescence,
transillumination for clarification of clinical situation.
ICON Caries Infiltration Technique
1. 15% HCL acid for pre-treatment
of lesion (Icon-ETCH)
2. Ethanol for drying of lesion
before application of resin
3. Light-cured resin for infiltration
of caries lesion (Icon-
4. Brushes
5. Syringe tips for vestibular
surfaces and for approximal
surfaces 3 2 1
ICON Caries Infiltration Technique

Set (continue): Demonstration of syringe tip for proximal surfaces

6. Brushes.
7. Syringe tips for
surfaces and for
proximal surfaces.

Demonstration of syringe tip for vestibular surfaces

ICON Protocol
Icon technique does NOT NEED anesthesia !
1) Cleaning teeth from soft plaque
2) Isolate tooth/teeth with caries spot with rubber dam
3) Apply Icon-Etch on caries spot with excess (acidic gel should overlap caries spot toward healthy
enamel on 2 mm) and wait 2 minutes. Icon-Etch should be used ONLY on enamel (NEVER on dentin!).
Etching could be carried out twice if caries spot is not white but yellowish or brown (arrested caries)
OR if treatment is carried out more than 1.5-2 months after removing of braces, because in this case
surface layer of enamel which need to be dissolved is thicker than in regular white spot and need
more time for dissolution. If after second etching spot doesnt disappear acid should be applied again
(but no more than three times).
4) Rinse not less than 30 seconds
5) Dry by air
6) Apply Icon-Dry on 30 seconds
7) Dry by air
8) Apply Icon-Infiltrant on etched area with excess and wait 3 minutes (switched off dental light to avoid
early polymerization of resin)
9) Remove excess by dental floss of cotton roll
10) Polymerize 40 seconds
11) Apply Icon-Infiltrant again for 1 minute.
12) Polymerized 40 seconds
13) Polish with rubber cups or polishing discs (for vestibular surface) or strips (for proximal surface).
Why Do We Need Etching in Icon

Surface zone
15 % HCL

2 minutes micropores

In carious spot relatively unaffected surface zone prevent resin flow in

subsurface micropores. So we need to dissolve surface zone to open
access to micropores of carious spot lesion.

Before infiltration After infiltration

After infiltration white spot area is soaked by acid-resistant resin.

Caries Prevention
Good brushing (using toothbrush and flosses, interdental brushes)
Correct diet (increasing of fruits, vegetables and other food requires
active chewing (active chewing provides self-cleaning of teeth
because of increase saliva secretion and mechanical cleansing of
teeth by hard food); decreasing intake of sugar food in the brakes
between main meals)
Increasing of caries-resistance of enamel (application of fluorine-
contains varnishes in dental office once or twice per year
(especially for children))
Caries of Enamel
Arrested Caries
International Statistical Classification of Diseases and
Related Health Problems 10th Revision (ICD-10)-WHO
Version 2016
Chapter XI Diseases of the digestive system (K00-93)
(K00-K14) Diseases of oral cavity, salivary glands and jaws,
K02 Dental Caries
K02.0 Caries of enamel
White spot lesions [initial caries]
K02.1 Caries of dentine
K02.2 Caries of cementum
K02.3 Arrested dental caries
K02.4 Odontoclasia
Infantile melanodontia
K02.5 Caries with pulp exposure
K02.8 Other dental caries
K02.9 Dental caries, unspecified
Arrested Caries
Arrested caries mostly
manifests as brown spot. If it
localizes not in esthetic zone
brown spot doesnt require
treatment but monitoring
(annual dental check-up for
being sure brown spot isnt
progress) and improve oral