Chapter 11.

Oral Biologic Defenses in Tooth Demineralization and Remineralization -

Norman O. Harris John Hicks

Objectives

1. Describe at least five body defense systems that are operational in and-around the oral
cavity.

2. List the names of the major salivary glands in rank order of both their daily output of
unstimulated (resting) saliva and the amount of stimulated output.

3. List three means of stimulating saliva output and three methods of inhibiting saliva output.

4. Define and compare the terms sialorrhea, xerostomia, and ptyalism.

5. Describe the appearance and the implications of the contour of the Stephan Curve.

6. Describe how the fluid viscosity of the plaque affects diffusion within the plaque.

7. Describe the ultramicroscopic morphology of enamel rods, enamel crystals and the unit
cell of hydroxyapatite (HAP).

8. Explain why an extracted tooth immersed in a liquid acid solution (in vitro) will not yield
an incipient lesion, whereas, if it is immersed in a buffered gel of similar pH, the incipient
lesion develops.

9. Explain why a newly erupted tooth is at high risk to develop a carious lesion.

10. Recount the key events that cause and occur in demineralization, and how the reverse
events of remineralization can often repair the damage.

Introduction

[Chapter 11 is a continuation of Chapter 3. Whereas Chapter 3 emphasized the basics of the

caries process, chapter 11 concentrates on the saliva and the ultramicroscopic structure of
the tooth, as they affect de- and remineralization.]

The mouth is the gateway for food and drink destined for the gastrointestinal (GI) tract. To
ensure the safety of the body from the oft-unknown quality of foods being brought into the
mouth, two powerful evolutionary monitoring sensory systems exist to help determine safety
and quality before ingesting the gustatory farevision and smell. Both of these senses allow
the host to reject food deemed to be undesirable. Once within the oral cavity, there is the
protective umbrella of the body's immune systemthe cellular and the secretory immune
systems. The former is cell-mediated and consists of the phagocytic and lymphoid elements
involved in preventing infection. The secretory system mainly protects mucous membranes
with secretions of antibodies, such as sIgA (secretory immunoglobulin A).1 Two other
defense mechanisms are taste2 and tactile sense. As an example, tactile sense allows for
proprioceptiona via nerves in the oral tissues to evaluate morsel size, texture and shape of the
entering food; to segregate foods that need to be chewed from food that needs to be incised;
and to determine when a bolus of food is of the correct size and consistency from chewing to
be safely swallowed.3

The defense functions of the saliva are part of the total body's ability to maintain
homeostasis, i.e., the ability to resist routine daily challenges by chemical and bacterial
agents, and to repair limited amounts of tissue damage typical of the wear and tear of daily
life.4 It is only when the bacterial challenge exceeds the body's defense capabilities and/or
there is a lack of a person's commitment to self-care, that dental caries ensues.

The saliva helps modulate and augment the previously described major body defense systems
in protecting oral tissues. However, in the demineraliztion and remineraliztion process of
tooth structure (caries and repair), the saliva cannot be isolated from an interrelated three
compartment model consisting of saliva, plaque and teeth.5
a
Proprioception = The reception of sensory nerve stimuli that locate the location of position
of parts of the body. Example: While eating, a diner with every bite, provides the brain with
information as to where the opposing teeth are in time to prevent a traumatic occlusion.

The Saliva Compartment

The saliva is derived mainly from the major salivary glandsthe parotid, submandibular, and
sublingual glands. Of these, the parotid elaborates a serous (watery, mucous-poor) fluid
containing eletrolytes, but is relatively low in organic substances. The parotid gland secretes
the majority of the sodium bicarbonate that is essential in neutralizing acids produced by
cariogenic bacteria in the dental plaque,6,7 and the majority of the enzyme amylase that
initiates intraoral digestion of carbohydrates. The submandibular gland secretes a mixed
serous and mucuos fluid, while the sublingual gland has a greater proportion of mucous
output than the other major glands. The minor glandspalatal, lingual, buccal, and labial
salivary glands empty onto the mucus membrane in many locationson the palate, under the
tongue, and on the inner side of the cheeks and lips. These minor glands are mainly mucous
secreting glands that lubricate these surfaces and allows for improved mastication and
passage of food substance into the esophagus.3 The minor salivary glands also contribute
fluoride that bathes the teeth and enhances caries resistance.8,9,10

Pure saliva produced by the oral glands is sterile, until it is discharged into the mouth. When
the fluids from all major and minor glands mix with each other, this secretion becomes
known as whole saliva. Whole saliva is further altered by the presence of particles of food,
tissue fluid, lysed bacteria, and sloughed epithelial cells. It becomes even more complex with
the inclusions of living cells and their metabolic products, for example, bacteria and
leucocytes, the latter derived from the gingival crevices and tonsils.

Functions of saliva

The physical and chemical protective functions of saliva can be divided into five convenient
categories(1) lubrication, (1) flushing/rinsing, (2) chemical, (3) antimicrobial (includes
antibacterial, antifungal and antiviral), and (4) maintenance of supersaturation of calcium and
phosphate level batheing the enamel, helping to stymie demineralization and/or to aid
remineralization of tooth structure.11,12 To reinforce the concept expressed in (4), Peretz aptly
opined that saliva can be considered similar to enamel but in a liquid phase.13

The salivary defensive system functions continuously, but its secretion becomes greatest and
most active during foodstuff ingestion. It has the lowest flow rate during the sleep period of
the daily 24-hour cycle.

Lubrication and Flushing

A very thin microscopic layer of mucus protects the oral hard and soft tissues from the often
harsh and abrasive foods, as they are being chewed and swallowed. It also protects the soft
tissues from dessication and the teeth from abrasion. The moistening of food by saliva
facilitates chewing and swallowing. Speech is enhanced by the reduced friction between the
dry tongue and soft tissues. Coversely, a lack of saliva (xerostomia) results in a greatly
increased risk of caries with its accompaniment of an extremely annoying dry-mouth
sensation. Chewing, swallowing and speaking can all be difficult and uncomfortable with
dry-mouth syndrome and often requires frequent ameliorating sips of water.

Flow Rate

Providing a constant fluid flow is probably the most important defense function of the
salivary glands, because it is the fluid that transports the buffering agents, the antimicrobials,
and the mineral content of saliva to help control the equilibrium between the demineralization
and remineralization of tooth structure. Also, the fluid output of the glands is essential for
diluting acids, flushing food particles embedded around the teeth, clearing refined
carbohydrates (acid-producing sugar substrates) and physically removing any displaced
bacteria12 Oral fluids in contact with food particles results in solubilizing food substances that
interact with the taste buds to provide an accurate assessment of taste.2

The composition of saliva varies, depending on whether it is stimulated or unstimulated

(resting). During the day, submandibular glands secrete the greatest proportion of the
unstimulated saliva, although the flow rate of resting saliva for all three glands is very low,
being about one tenth that during stimulated flow. Approximately 2/3 of the resting saliva is
derived from the submandibular glands, one-quarter is from the parotids, and about 1/20 is
from the sublingual glands. The minor salivary glands secrete almost 1/10 of the total amount
of saliva. The unstimulated flow rate of the salivary glands is subject to a circadian rhythm,
with the highest flow in mid-afternoon and the lowest around 4:00 A.M.

Upon moderate stimulation, the submandibular and parotid glands secrete approximately
equal amounts of saliva, whereas at full stimulation the parotid has the greatest output. When
salivary flow is stimulated by chewing gum or paraffin, 1 to 2 mL of whole saliva per minute
can be expected. The minimum level of stimulated salivary flow necessary to maintain hard-
and soft-tissue health is unknown, but when it is below 1 mL/minute, there is cause for
concern regarding a possible dry mouth and caries formation. Once the flow rate is below 0.7
mL/minute, a diagnosis of xerostomia may be rendered. In the course of a single day, up to 1
liter (1 quart) of saliva is secreted into the oral cavity.

The total amount of saliva secreted varies considerably between and within individuals,
depending on the environmental factors. Seasonal variations occur, with flow being lower in
warm weather and higher in cold. The act of smoking increases flow rates. Flow is greater
while standing than when sitting and greater when recumbent, with these postural changes
paralleling changes in systemic blood pressure.

Saliva flow may be stimulated (1) physiologically, (2) pharmacologically (over the counter
drugs, herbals and prescription medications) and by (3) many different disease states14,15
Examples of physiologic stimulation are the simple acts of chewing food and gum, gustatory
stimuli caused by tasting an enjoyable food, while psychologic stimulation for food can be
evoked by anticipating the first bite of a delicious food via the sense of sight and/or smell.
Saliva can also be stimulated by the use of drugs, such as pilocarpine. Under certain
conditions, saliva flow can be abnormally higha condition termed sialorrhea,(or ptyalism)
which is often manifested by drooling. Under some conditions drug therapy can be used,16, 10
but sialorrhea or ptyalism may be so severe as to require surgical removal (excision)of the
responsible gland or ligation of the gland duct.17

Saliva flow can also be suppressed physiologically, pharmacologically16 and/or by disease.

The dry mouth sensation (xerostomia) that accompanies fear is an example of a physiological
response; pharmacologically it may follow the intake, among others, of antidepressant and
antihypertensive drugs;18,19 it occurs when there are sialoliths (stones) within the gland ducts
resulting in obstruction of saliva flow,19,20 or following radiation exposure of the glands
during cancer therapy.

The concentration of the various saliva components secreted by the glands is closely related
to the flow rate. Stimulation of the rate of flow by stimulation increases the concentration of
some constituents and decreases it for others. Stimulation of the parotid glands causes an
increase in calcium, sodium, chloride, bicarbonate and pH. The same saliva demonstrates a
concomitant decrease in phosphate and potassium.

In addition to the secretion of different proportions of electrolytes, organic molecules are

secreted that can be categorized into five major groups: amylase, mucins, phosphoproteins,
glycoproteins, and immunoglobulins. Two of the families of small salivary
proteinshistadine and statherindeserve specific mention because they help control the
status of calcium and phosphate in the saliva. These proteins prevent fall-out of the calcium
and phosphate that maintain supersaturation in relation to HAP. They prevent a rapid drop in
saliva pH and aid in its quicker recovery. In addition, they both are antifungal and help
prevent mucosal infections.

Question 1

Which of the following statements, if any, is correct?

A. sIgA (secretory immunoglobulin A) is a guardian of moist epithelial surfaces (mucous

membranes).

B. The major salivary glands are the parotid, palatal, and the submandibular.

C. The saliva output of the major salivary glands increases in defense effectiveness at the
time of chewing.

D. In the order of maximum flow rate, the parotid is first, the sublingual second, and the
minor salivary glands third.

E. All the major salivary glands can be both stimulated or retarded in flow rate by
physiological stimulus, drugs, or disease.
Protective Functions of Saliva

The protective functions of saliva are from its physical, chemical, and antimicrobial
properties.10 Saliva is not equally distributed around the oral cavity because of differences in
anatomical and orthodontic features. It also has a tendency to stay on the side it was
secreted.21 These differences mean there is an increased risk for caries formation owing to
retention of refined carbohydrates at difficult-to-reach sites in the mouth.22 Of parallel
importance, a viscid saliva is not as effective in clearing food particles and snacks, as is
normal saliva.

Antibacterial Functions

The most easily understood major antibacterial function is performed by one of the
glycoproteinsthe mucinsthat trap or aggregate bacteria that are eventually swallowed.
The same mucins provide a thin film over the mucous membrane and teeth to serve as
lubricants.

Four important antimicrobial proteins found in saliva are: lysozyme, lactoferrin, salivary
peroxidase and secretory immunoblobulin A (sIgA). In vitro, lactoferrin strongly inhibited
adherence of mutans streptococci to saliva coated hydroxyapatite (HAP) blocks.23 Lactoferrin
combines with iron and copper to deprive bacteria of these essential nutrients. Salivary
peroxidase reacts with saliva to form the antimicrobial compound hypothiocyanate, which in
turn inhibits the capability of the bacteria to fully use glucose. Lactoperoxidase strongly
adsorbs to hydroxyapatite as a component of the acquired pellicle, and can influence the
qualitative and quantitative characteristics of the microbial population of dental plaque. The
role of the body's cellular and immunologic defense systems in moderating the course of the
plaque-induced disease needs clarification. The main access that phagocytic cells and their
antibacterial products, have to the oral cavity is through the gingival crevice and the tonsils. It
is difficult to conceive of the cellular immune system operating in the bacterial plaque, yet
about 500 leukocytes per second are estimated as emigrating from the tissues through the
gingival crevice into the oral cavity. The majority of these soon disintegrate in the saliva, a
phenomenon that may be related to the fact that more intact polymorphonuclear leukocytes
occur in caries-free than in caries-susceptible individuals. On a research basis, there is reason
to believe that a linkage exists between normal humoral and cellular defenses, and both caries
and periodontal disease. How the cells and immunoglobulins exercise this potential is
unclear. The development of a successful vaccine against caries and possibly, against
periodontal disease will ultimately depend on such a clarification.

The Plaque Compartment

The plaque compartment begins with the acquired (salivary) pellicle, which is an acellular
protein layer of saliva components that is adsorbed onto the surface of the enamel (Chapter
2). Upon this pellicle, the bacteria colonize. The pellicle plus the bacteria and the gel they
create, constitutes a biofilm (dental placque). For several hours after a prophylaxis (that
removes biofilm) there is a steady change in the quantity and composition of the pellicle as
new proteins are added from the saliva. Glycoproteins appear to mediate the attachment sites
of the subsequent colonizing plaque bacteria. Even though mucins are a minor component of
the pellicle, they can be very protective against acid diffusion.

To understand the effect that plaque has on teeth, it is neccesary to focus on the action of acid
in demineralizing teeth. To reduce the potential of demineralization, it is necessary to (1)
reduce the number of bacteria producing the acid, (2) reduce the amount of acid produced by
the existing bacteria, and/or (3) negate the effects of the acid produced by plaque.

Physical Character of Plaque

A major consideration in the defense of the tooth is the physical character of plaque itself. In
order for the fluid and chemical components of saliva and plaque to function, they must be
able to diffuse freely (intermix) with the constituents of the plaque. This diffusion requires
time, which is contingent on two important factors. (1) If the fluid content in the plaque is
relatively high, incoming and exiting ions diffuse rapidly. (2) If the colloid and glucan
content of the plaque is high, the diffusion is slow, thus retaining any acid against the tooth
surface longer.

Probably the most unpredictable factor relating to the plaque diffusion is the character of the
microbial population. Variations in bacterial species from one plaque to another or in
different parts of the same plaque result in different diffusion patterns. In other words the
bacteria and their metabolites can act as either a barrier, or as a gateway to the passage of
selected anions, cations and proteins. For example, bacteria use phosphate in their
metabolisma metabolic need that is accentuated during periods of acidogenesis. Thus, the
bacterial need for phosphate from the plaque metabolic pool occurs at the same time that the
same phosphate is required to maintain supersaturation at the plaque tooth interface.

Not all bacteria are bad. Veillonella, when present, metabolizes lactic acid generated by
mutans streptococci, lactobacilli, actinomycetes, and other acidogenic organism. Presumably
this action decreases the amount of acid available to demineralize tooth structure. Several
studies indicate that the presence of Veillonella, indeed, decreases caries risk. Thus the
varieties, metabolic characteristics and interrelationships of the plaque bacteria at any one
time, are important in determining whether caries will occur.

Question 2

Which of the following statements, if any, are correct?

A. All parts of the mouth are equally assessable to the flushing effect of saliva.

B. The following are anti-microbial agents found in saliva: lysozme, lactoferrin, and salivary
peroxidase.

C. If a cross section of a plaque coated crown of a tooth is studied, the following structures
would be seen starting with the tooth surface: the enamel surface, acquired (salivary pellicle),
bacterial plaque, and finally, saliva.

D. The bacteria of the plaque cannot use the phosphate diffusing out of the pores for their
own metbolism.

E. Plaque acidogenesis could probably be reduced to inoculous levels by a major

commitment to sugar discipline as a part of self-care.

Reducing Acid Production

Toothbrushing, flossing and irrigation ("brush, floss and flush") are ideal for personal self-
care. However, there are natural oral defense mechanisms that exist in the body that are not
dependent on the frailities of human motivation, memories or techniques.

1. Great numbers of bacteria in the saliva are eliminated by flushing, aggregation and
swallowing.

2. The bacterial populations in the saliva and plaque are continually exposed to the
antimicrobial elements of saliva.

Reducing the amount of acid produced by the bacteria is mainly a function of limiting the
intake of refined carbohydrates (i.e., sugar discipline). This subject is discussed in detail in
later chapters dealing with sugars, nutrition and clinical preventive dentistry. The ingestion
of refined sugars makes dental caries a self-inflicted disease.

Reducing the Acid Damage

The plaque pH can drop to as low as 4.0 on the Stephan Curve after a glucose mouth rinse.
Damage control from acid in the plaque, is achieved by dilution, chemical buffering, and by
increasing the protective ions (mainly, calcium, phosphate and fluoride) in the environs of the
teeth.24,10 The water content of the saliva and plaque aid greatly in diluting the acid and in
transporting acid into the main flow of saliva where it is further diluted and swallowed. This
dilutional effect is supplemented by the buffering capacity of the plaque which can be 10
times higher than for the fluoride in the saliva. This higher adsorption capacity for fluoride in
the plaque also occurs to differing extents in increasing bicarbonates, phosphates and
ammonia concentrations derived from the saliva. These neutralizing actions serve as a brake
in the rapidity and extent to which the pH can drop during periods of acidogenesis.

Each individul has a different potential for modifying the drop and recovery of the pH
represented by his/her individual Stephan Curve. As an example, if a group of individuals is
given a glucose mouth rinse, each person demonstrates a different, but reproducible pH
pattern. Once the pH has started to fall, the availability of statherin and other salivary buffers
help to shorten the time that the pH is at its lowest and most damaging level.

The Tooth Compartment

Coronal caries involves the enamel capb and the underlying dentin. Enamel is more
mineralized than bone or dentin. It is estimated that enamel is composed of approximately
96% mineral by weight with an average volume of 87%. The enamel contains millions of
enamel rods that run from the dentinoenamel junction (DEJ) to the tooth surface. The rods are
approximately 4 to 7 micrometers, and by 6 to 8 micrometers in cross section for primary and
permanent teeth, respectively. In cross sections they resemble keyholes, more than rods.
Around each rod there is an enveloping protein matrix. During formation of the crown, this
organic matrix forms the template that is involved in determining crystal and rod size and
orientation (Chapter 3).

The inorganic phase of enamel is based on the mineral, hydroxyapatite (HAP), made up
mainly of calcium (Ca), phosphate (PO4) and hydroxyl (OH) ions. It also contains trace
amounts of other elements that happen to be in the bloodstream during enamel formation, in
fact more than 40 elements have been identified in analysis of enamel. Each rod is made up
of millions of crystals each which are shaped much like a carpenters hexagonal lead
pencilone that is slightly flattened on two opposite sides between the submicroscopic
crystals there are also submicroscopic amounts of matrix. These enveloping protein wraps of
both the enamel rods and crystals are the main channels for diffusion for demineralizing acids
and remineralizing electrolytes as explained in Chapter 3.

[In order to better understand the tooth histology at increasing magnifications, this is to invite
you to join the following art and photographic tour featuring the "Anatomy of a Tooth." The
starting point is Figure 11-1. You will need this information throughout your career.

Illustration 11-1a is a cross section of enamel, showing how each of the tails are cradled
between the heads of the adjoining rods. The drawing 11-1b provides a concept of a single
enamel rod.c With these two background schematics, the head and tail positioning becomes
even more understandable when viewed on an electron micrograph, (Figure 11-2) that shows
the rod as a crude keyhole structure. Figure 11-1 c is of a single crystal portrayed as a
carpenter-shaped pencil configuration. Each crystal is composed of Ca, PO4 and (OH) (and
other extraneous contaminants). Each of the crystals making up the enamel rod is considered
as a unit cell.(11-1d) A unit cell is the smallest subdivision of a crystalline substance that is
entirely representative of the structure of the crystal. This means that all rods of any
dimensions can be constructed (or remineralized) by adding additional unit cells, much as a
building can be increased in size by adding additional bricks. It is important to recognize that
unit cells, unlike the bricks, have no physical meaning as such; they are just a convenient
means of conceptualizing the atomic structure and relationship of crystals at the simplest
level.

If one unit cell could be detached along the c-axis, it would resemble a windchimes on a
string, with each successive triangular grouping being comprised of calcium, phosphate and
hydroxl ions equidistant from adjacent groupings (Figure 11-1 e) When looking at the
arrangement from the top of the column, the center position is occupied by hydroxyl ions,
surrounded by a trianglular configuration with a calcium ion at each point of the triangle.
Immediately peripheral to each calcium ion is a phosphate grouping (11-1f). Each successive
triangular grouping grouping along the c-axis is rotated 180-degrees from the ones above and
below, as illustrated by the solid and dotted lines in Figure 11-1 f). Each of the atoms can be
replaced by other atoms. For instance, a hydroxyl group can be substituted by fluoride; a
calcium ion by strontium, and a phosphate by a carbonate.

Next, let us take a more detailed look at how a crystal dissolves starting with Figures 11-1 c,
and then illustrations in Figure 11-3 parts 1, 2, and 3 that show the sequence of dissolution of
a crystal, which starts with a central etch pit. The etch pits on the basal faces are beautifully
illustrated at electron microscope level, as are the images of hallowed out crystals shown in
Figure 11-4, parts 1 and 4, respectively.
b
If an intact tooth is stripped of all dentin and cementum, the remaining portion of the tooth is
the "enamel cap".
c
Enamel rods can be correctly called enamel prisms.

Demineralization
There were a few early interesting experiments by Silverstone who first focused worldwide
attention to the overall subject of de- and remineralization. Several decades ago, researchers
could not understand the reason why a typical cavity did not form when a tooth was directly
placed in acid Instead the outer layers of the tooth would continue to dissolve, but there were
no white spots. There were no incipient (subsurface) lesions. However, when Silverstone
used an acidified pH gel (instead of an acid solution) in which to immerse the tooth, an
incipient lesion did form with the expected four zones of enamel caries.25-27 The surface zone
had sufficient calcium and phosphate exiting from the body of the lesion to the surface zone
to create a supersaturation of calcium and phosphate ions to cause a HAP precipitation
between the gel and the tooth surface. The next study by Silverstone was to grind off the
entire mature surface of the crown and again immerse the tooth in the buffered gel. The entire
surface area of the tooth was recreated, showing that the outward diffusing minerals had
attained sufficient saturation to precipitate and form the exterior of the enamel. This was
interesting, but he carried the study one or two steps further towards practical application.

When a tooth with a carefully preserved pellicle was subjected to the same gel immersion
treatment, there was the same build-up of mature enamel and closing of the pores between the
tooth surface and the pellicle. He reasoned that the pellicle acted as a template to maintain
the contour of the remineralized area. This demonstrated for the first time that the pellicle
served as a protective layer.

When using saliva as the remineralization solution, the ability to remineralize tooth sections
in vitro varies with the saliva from different individuals, but occurs consistently with the
saliva of each individual, indictating that some people have a greater capacity for
remineralization (host resistance) than others.

Fluoride has a major influence on both demineralization and remineralization.28 Fortunately,

only small concentrations of fluoride are needed to inhibit demineralization or to enhance
remineralization. As little as 0.1 ppm fluoride can reduce the amount of enamel dissolution in
vitro. The presence of fluoride at the remineralizing site can accelerate rehardening by a
factor of up to fivefold. In the mouth, the fluoride can come from four sources (1) transitory
contact with fluoridated drinking water; (2) the continual low fluoride ouput of the salivary
glands; (3) the bound fluoride occurring in the plaque which is released when the pH drops to
around 5.5; or, (4) from the fluoride contained in the mature enamel layer following
demineralization.

Figure 11-1 Enamel: From the electron microscope to the molecule. a. An electron
microscope model of the keyhole morphology of enamel. Note that the crystals (dotted
lines) within any single prism are coaxial with the prism in the head region. From
Meckel, A. H., Griebstein, W. J. and Neal. R. J. International Symposium on the
Composition, Properties and Fundamental Structure of Tooth Enamel. April 1964.
Courtesy: Ed. Stack, M. V., and Fearnhead, R. W., Bristol, England: John Write and
Sons, Ltd, 1965. b. Individual enamel rod, showing different crystal orientations in head
and tail. c. Illustration of a crystal with labels a, b, and c axes. d. Theoretic presentation
of unit cells that make up the crystallites. e. Vertical arrangement of hydroxyapatite
along C axis of the unit cell. f. Showing how every other molecular configuration is
rotated 180 as illustrated by the solid and then the dotted lines. (Courtesty of N. O.
Harris, University of Texas Dental School, San Antonio.)
Figure 11-2 Same electron micrograph as 3-2a. Same caption. (A repeat) Electron
micrograph of rod cut perpendicular to long axis, showing head (H) and tail (T)
 relationship.
Figure 11-3 Dissolution of the crystal schematic: Each enamel prism is made up of
parallel crystals of hydroxyapatite that have a slightly flattened hexagonal appearance.
1. The initial etching of the crystal begins at the ends with, 2. the formation of etchpits.
3. These etchpits deepen along the c-axis to eventually produce a hollow core. (From
Arends J. Jangerbloed WL. Ultrastructure studies of synthetic apatite crystals. J Dent
Res, 1979 [Special Issue B]; 58:837-843.)
Figure 11-4 Dissolution of the crystal, photographic. 1. Artificially grown apatite
crystal with etchpit on basal face, original magnifiction  500. 2. A hexagonal etchpit in
fluorapatite, original magnifiction  2500. 3. TEM picture of sound enamel crystallites,
original magnification  100,000; and 4. TEM picture of etched enamel crystallites that
are partially hollowed out, original magnification  100,000. (Courtesy of Dr. W.L.
Jongebloed, I. Molenaar and L. Arends. University of Groningen, The Netherlands and
Joel News, Japan. 1976; 13e(2):14.)

Question 3

Which of the following statements, if any, is correct?

A. The enamel is a solid piece of hydroxyapatite.

B. The crystal of a rod is the first component of the enamel cap to dissolve; it is also the first
to be reconstituted in remineralization.

C. A protein matrix envelops each crystal as well as each rod.

D. The central configuration of the unit cell is made up of calcium and phosphate, the OH is
at the corners of the triangle.

E. It requires more acid of the same pH to dissolve a crystal than to dissolve the rod.

Remineralization

Remineralization is the repair of enamel rod structure following acidogenic episodes. When
teeth erupt, they are anatomically complete, but crystallographically incomplete and
immature. Following eruption, the missing ions are supplied from the saliva, a process termed
post-eruptive maturation, Throughout life, minerals from the saliva are used to repair acid-
damaged tooth structure. This repair process can range from an almost immediate
replacement of daily ion losses from the enamel surface, to a slow repair (under proper
conditions) of more extensive subsurface (white spot) lesions. Without specific knowledge of
the caries process, a lay person is likely to envision the development of a caries lesion as a
continuous process, accompanied by an ever-increasing loss of tooth mineral until the stage is
reached when a clinically discernible cavity is present. Fortunately, this conception is
incorrect. The process of demineralization is not irreversible or inevitably progressive. If
damage has not progressed beyond a still yet to be defined point, lost mineral can be
replaced.

Considerable clinical evidence exists for remineralization. Head, a physician and a dentist,
pointed out in 1912 that teeth underwent cycles of softening and hardening.29 By 1933,
Boedecker30 advocated the use of Andreasen's method of remineralizing "soft" teeth and
"white spots." Andreasen's remineralizing powder consisted of tartaric acid, gelatin, calcium
phosphate, calcium carbonate, magnesium carbonate, sodium bicarbonate and sodium
chloride. Boedecker commented as follows: "The purpose that this powder is to fulfill, is to
go into solution in the saliva and in this state, permeate and recalcify the porous area in the
enamel . . . and after the remineralizing powder has been used for 6 weeks, decay around
fillings will come to a standstill."

Muhler, in several clinical studies of the anticaries effectiveness of stannous fluoride, often
found that the experimental subjects had more sound teeth later in the study than at the initial
examination.31 Invariably, the number of these reversals was greater in the stannous fluoride
treatment groups than in the controls. Von der Fehr and colleagues were able to induce white
spots with sucrose mouth rinses and reversed the process with fluoride rinses.32 Backer-
Dirks,33 in a long-term study, noted that over 50 percent of the interproximal lesions seen at
the initial examination did not progress, indicating an arrestment phenomenon due to
remineralization. Additional support for remineralization is derived from the frequent
observations of teeth that are acid-etched prior to placement of pit-and-fissure sealants. For
those etched areas not covered with the resin, the chalky white appearance disappears over a
period of a few days and the enamel regains its initial translucent, glossy appearance.

Except under unusual circumstances, such as occur following the destruction of the salivary
glands during cancer radiotherapy or diseases of the glands, deviations from remineralizing
conditions in the mouth are transient. For example, the local pH may be lowered to where
enamel demineralization occurs during the ingestion of acid foods or from the production of
acid by the plaque bacteria following the ingestion of refined carbohydrates. If the insults are
brief and widely separated in time, remineralizing conditions can be restored in the
intervening periods and the slight damage repaired. On the other hand, frequent or protracted
periods of acidogenesis, with insufficient time intervals for remineralization, ultimately lead
to the development of overt caries.

Crystal Size in Demineralization and Remineralization

Siverstone, when he published the article, "The significance of remineralization in caries

prevention." opened up a new area of conservative dentistryan era that ten Cate calls
"noninvasive restorative care." In his review of remineralization. Silverstone pointed out that
crystal sizes differ predictably in each of the zones of the incipient lesion and in
remineralized caries areas.34 In the incipient carious lesions, the crystals in the two zones of
demineralizationthe body of the lesion and the translucent zonewere smaller than in
sound enamel. (Figure 11-5). The crystals in the two zones of remineralizationthe dark and
the surface zoneswere equal to, or greater in size than those found in normal enamel.
Predictably, when a remineralizing solution with fluoride is used to remineralize the
subsurface lesion, the crystal sizes are greater than for normal sound enamel.

Figure 11-5 Illustration of the relative crystal diameters in sound enamel (bottom) and
in the four histological zones of the enamel lesions (right). (Courtesy of Silverstone
LM. The significance of remineraliztion in caries prevention. J Can Dent Assn. 1984;
50: 157-184.)

Question 4
Which of the following statements, if any, are correct?

A. The concept of remineralization dates from the last quarter of the 20th century.

B. The crystals of the body of the lesion are larger than those of the dark zone.

C. An incipient lesion with a low pH and a low saliva calcium and phophate concentration is
more likely to remineralize than one with a high saliva pH and is supersaturated with calcium
and phosphate.

D. The anti-caries benefits of saliva during the Stephan Curve both slows demineralization
and accelerates remineralization.

E. A remineralized rod in the presence of fluoride is a more acid resistant rod than one
originally made up of hydroxyapatite.

Summary

It has been emphasized that oral disease, in fact, all disease occurs when the challenge posed
by pathogens exceed the body's capability for defense and repair. In the case of dental caries,
the defense and self-repair mechanisms of the body operate continuously in the saliva, in the
plaque, and in the enamel cap. Aside from the host's usual humoral and cellular defense
functions to destroy pathogens, the oral cavity is protected by the senses of smell and vision,
taste and tactile sensation, the body's immunological defenses, and the saliva.
Demineralization is dependent on two major factorspH of the plaque, and saturation of the
tooth minerals. If the saturation is high and the pH high, demineralization will not occur. If
both the pH and the saturation are low, the risk of caries is high. The output of resting saliva
is moderate to low throughout the day; it is only through the period of the Stephan Curve that
the maximum stimulated saliva protection occurs.

Bacterial acidogenesis in the dental plaque causes the plaque pH to fall and recover is a
manner predicted by the Stephan Curve. If the maximum drop in pH is below the 5.5 to 5.0
range, demineralization occurs with the extent dependent on calcium and phosphate
saturation level as well as the duration and frequency of the acid attacks. The increased
secretions of haptins and statherin slow the drop in pH. An increased amount of salivary
buffering minimizes the affect of the acidogenic end-products of the plaque bacteria. The
increased flow of saliva, with its high fluid content, enhances the removal of cariogenic
residues. As the pH drops, supersaturation of calcium and phosphate ions decline along the
plaque-tooth interface. Ions, such as magnesium and carbonate that are adsorbed onto the
tooth, dissolve preferentially and add to the buffering capacity of the local environment.
When undersaturation occurs, somewhere between pH 5.5 and 5.0, calcium fluoride, HAP
and FHA begin to dissolve in successive order. These dissolving crystals add to the saturation
along the dissolving plaque-tooth interface, thus slowing and eventually arresting tooth
demineralization. At that time, remineralization takes over. Ions necessary for mineral repair
are again available from the inorganic components of the plaque that participate in the
remineralization process and are ready for combating the next acidogenic cycle.

Answers and Explanations

1. A, C, and Ecorrect.
Bincorrect. The palatal glands are minor salivary glands. The correct answer should have
included the submandibular gland, not the palatal gland.

Dincorrect. The order should be: parotid, submaxillary, and sublingual glands.

2. B, C, and Ecorrect.

Aincorrect. There can be teeth that overlap, the palate can be malformed and/or an
abnormally large tongue can block saliva flow to some parts of the oral cavity. This problem
of difficult-to-reach areas is best solved by a counseling session with a dental hygienist.

DBacteria need phosphate for energy; there is no way to tell the PO4 from one source
compared to another.

3. B and Ccorrect.

Aincorrect. The enamel cap is porous with over 10% of the spacing being between the rods
and crystalsalso in areas such as the hypomineralization of the DEJ, stria of Retzius,
spindles and tufts.

Dincorrect. The central core of the HAP crystal is made up of mainly hydroxyl ions, but
can include exchanged elements.

EIt requires much less acid to dissolve an individual crystal than a rod. (Just remember the
rod is made up of crystals, not vice versa.)

4. D and Ecorrect.

Aincorrect. Remineralization is mentioned in Dental Cosmos (an early dental journal) prior
to the turn of the 20th Century and became of interest to researchers in the mid 20th century.
If is rarely used in private or public health practice in the United States. (Now routinely used
in New Zealand and Scandinavia public health school programs).

Bincorrect. The crystals in the two zones of recrystalizationthe surface and the dark
zones are the larger.

Cincorrect. The higher the pH and saturation of the saliva the greater the chance for
remineralization.

Self-evaluation Questions

1. The ability of the brain to continually monitor the location and action of a body part is
known as _________.

2. The parotid gland produces the most amylase (enzyme to break down carbohydrates) and
_________. (neutralizing agent).

3. The ability of the body to balance the factors causing disease, and the events promoting
body health is known as maintaining _________.

4. The quantity and quality associated with Stephan's Curve in (resting)(stimulated) saliva is
usually seen at the time of (eating)(fasting between meals). Circle correct responses.

5. Sialorrhea is best treated with (a saliva stimulant) (an antisialogogue).d Circle correct
response.

6. A desalivated animal (glands removed) or a person with excised glands would have a
problem with _________.

7. A pellicle acts to slow the transit of acid from the plaque to the subsurface ______.

8. The glycoprotein of the saliva that serves to lubricate the oral tissues (to reduce friction
and abrasion) and to aggregate bacteria for swallowing is _________.

9. It was __________ (name of individual) who gave the major impetus to the modern basic
concepts of de- and remineralization.
d
Antisialogogue = an antidote to sialorrhea.