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An Update on Demineralization/Remineralization

Mark E. Jensen, MS, DDS, PhD; Robert V. Faller, BS

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  • Vorige
  • Evaluating the Caries Evidence with Respect to Fluorides - Scientific Support for Clinical Decisions
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The world of dentistry has begun to change to require sound scientific evidence for clinical applications of both treatment and preventive approaches to dental caries. In a nutshell cariology is evolving as a part of evidence-based dentistry. Evidence-based dentistry (EBD) is defined by the American Dental Association as "…an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences."32 (ADA Positions & Statements)


The University of North Carolina has a tutorial (EDM tutorial UNC) in Evidence based-Medicine that helps in the understanding of this approach. Forrest and Miller33 have provided an approach for evidence-based decision making in dentistry and demonstrate the process with clinical examples. The PICO approach – Population (P), Intervention (I), Comparison (C) and Outcome (O) system can easily be applied to remineralization/demineralization.


Ismail and Bader34 have provided a practical clinical approach to evidence–based dentistry and discussed various models for use and stated in their conclusions "In the evidence-based approach to clinical decision making, dentists incorporate the best scientific evidence—evidence that is critically appraised in systematic reviews—with clinical experience and their patients' preferences for treatment outcomes." Clinical practitioners have access to a large amount of scientific literature just as patients do via the Internet. A quick search using PubMed at the time of writing this course revealed 33,040 articles cited using the keywords tooth and demineralization. Twelve hundred twenty-nine (1,229) citations were found when tooth remineralization was used and 913 discovered for enamel remineralization. Another approach to searching the literature is a refinement of the Medline database using "EviDents". When caries was used for the "Problem" and remineralization for the "Outcome," 847 references were found. When the "Problem" is completed with caries and fluoride dentifrice used in the "Intervention" box, 1,262 citations are found. When the search is selected as "focused," there were 389 references for caries and fluoride toothpaste; when the search is refined by indicating "systematic reviews," there were only 42 papers found. In performing searches of the literature, these are easily available methods to begin.


Jeyanthi35 indicates a number of useful databases to be used in evidence-based dentistry when performing searches that include:

  • AMED (Allied and Complementary Medicine Database)

  • ASSIA (Applied Social Sciences Index and Abstracts on the Web)

  • CancerLit by US National Cancer Institute

  • CINAHL (Cumulative Index of Nursing and Allied Health Literature)

  • DAIC (Dissertation Abstracts Online)

  • EMbase (Excerpta Medica) database

  • PsycINFO

  • HTA (Health Technology Assessment) database

  • LILACS (Latin American ACS and Caribbean Health Science Literature)

  • Web of Science


These will not normally be the object of many clinical practitioners' searches for evidence, but one should be aware that they exist and are used in analysis of clinical questions. Evaluation of the evidence is done using strict criteria by such groups as the Cochrane database. When one looks at the current dental topics, the following regarding fluorides are in existence:

A shift toward a "medical model" in the treatment and prevention of dental caries as described by Anderson40 has truly begun in the past decade.  Barber and Wilkins41 discuss the application of an evidence-based approach to caries and indicate a caries risk level must be evaluated at each maintenance appointment.  We have experienced a "paradigm shift" in the approach to caries from surgical to a medical model as described by Steinberg.42 The model includes bacterial control, reduction of risk levels for at-risk patients, reversal of active sites by remineralization, and follow-up and maintenance.  It is hoped the shift in approach and addition of an evidence-based approach will lead many practitioners to a higher quality of care for their patients and much more sound approach in preventive care rather than a "drill and fill" surgical approach that was present in the past.  To quote ten Cate in the 50th Anniversary ORCA Congress43, "The caries-preventive effects of fluoride are beyond any reasonable doubt! Inclusion of fluoride use in caries prevention protocols has resulted in significant reduction in caries prevalence in the majority of the population."

(Images provided by Dr. James Wefel)

(Images provided by Dr. James Wefel)

Polarized-light micrographs (in water) of a single section enamel lesion used in an in vivo human model to observe the remineralization of a lesion through the use of fluoride therapy.  The top micrograph is prior to placement in the appliance and the bottom micrograph is the same section after the experimental period in the patient's mouth while using a fluoride regime.  Note the reversal in the size of the body of the lesion indicating remineralization.

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