Print this page Email this page | Users Online: 805
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2016  |  Volume : 7  |  Issue : 4  |  Page : 231-234

Remineralize early demineralized enamel structure

Department of Pedodontics and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Date of Web Publication13-Dec-2016

Correspondence Address:
Suchetana Goswami
Department of Pedodontics and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, 114, AJC Bose Road, Kolkata - 700 014, West Bengal
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-433X.195633

Rights and Permissions

Dental caries is a multifactorial disease and is the major health concern across the world. The etiology of dental caries includes a combination of fermentable dietary carbohydrate, cariogenic microorganisms, host factor, and time. Caries is preventable until cavitation or breakdown of organic template with the help of different remineralizing agents. This is the noninvasive treatment of incipient carious lesions. The objective of this paper is to review different remineralizing agents that can be used in incipient non cavitated carious lesions to prevent cavitation.

Keywords: Demineralization, enamel, remineralizing agents

How to cite this article:
Goswami S. Remineralize early demineralized enamel structure. SRM J Res Dent Sci 2016;7:231-4

How to cite this URL:
Goswami S. Remineralize early demineralized enamel structure. SRM J Res Dent Sci [serial online] 2016 [cited 2023 Jan 29];7:231-4. Available from:

  Introduction Top

Dental caries is a chronic, dietomicrobial, site specific disease caused by shifts from tooth protective factors favoring tooth remineralization to destructive factors leading to demineralization. [1] Dental caries etiologically is a multifactorial disease results from complex interactions among tooth structure, dental biofilm, dietary, salivary, and genetic influences. Recent knowledge states that about 90% of carious lesions occur in the pit and fissures of primary and permanent posterior teeth and molar teeth are more susceptible to caries. [2]

Enamel mineral is not pure hydroxyapatite (HA) but a mixture of compounds including a number of carbonated apatite of 98% weight and 96% volume. The carbonated apatite crystals are long (possibly up to 1 mm), 50 nm wide, and 25 nm thick extending from the dentinoenamel junction toward surface. [3] Fluoroapatite is less soluble than HA. Ratio of components required for remineralization is 10 Ca 2+ , 6 (PO 4 ) to either 2F or 1 hydroxyl ion and one carbonate ion, a ratio of 5:3:1. Calcium availability is the single most important factor for remineralization. Remineralzation I defined as the process whereby calcium and phosphate ions are supplied from a source external to the tooth to promote ion deposition into crystal voids of demineralized enamel to produce net mineral gain. [4],[5] Demineralization and remineralization of enamel is a dynamic process that occurs when oral microorganisms form a biofilm on the enamel surface and it is exposed to fermentable dietary carbohydrates. [6] For remineralization calcium and phosphate ion usually assisted by fluoride ion is needed to rebuild a new surface on existing crystal remnants. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16] A critically low pH must be maintained for a certain time to promote demineralization but return to physiological values when exposure to sugar ceases. [7] Then, remineralization of enamel occurs when all the conditions are fulfilled. [9],[13]

  • Saliva should be saturated with calcium and phosphate
  • A molecule of carbonic acid must be produced in proximity to a mineral molecule, where it dissolves into its ionic compounds
  • His phenomenon should occur in proximity to a demineralized spot where mineral deposition is needed
  • The tooth region has to be clean so that the mineral deficient spot is accessible
  • The carbonic acid then converts to CO 2 and water before the changes. When all this happens, a mineral ion is precipitated out of solution into enamel structure.

Requirements of an ideal remineralizing agent (Zero 2006): [17]

  • Diffuses into the subsurface or delivers calcium and phosphate into the subsurface
  • It should not deliver an excess of calcium
  • Does not encourage calculus formation
  • It can work at an acidic pH
  • Works in xerostomic patients
  • Boosts the remineralizing properties of saliva
  • For nobel materials shows a benefit over fluoride.

Salivary constituents and therapeutic agents have synergistic effects in the process of remineralization. An example would be the similar role played by salivary statherins and casein phosphopeptides (CPP) in "Recaldent," both of which regulate the behavior of calcium and phosphate and stabilize calcium phosphate compound. The process of remineralization can be largely controlled by calcium concentration in saliva which is low in resting but shows higher amount in stimulated condition. But phosphate levels do not vary markedly in resting and stimulated saliva. [15]

  Action of Fluoride Top

Fluoride works primarily via topical mechanisms that include the inhibition of demineralization from tooth surface, enhancement of remineralization at the crystal surface, inhibition of bacterial enzymes. Low levels of fluoride in plaque and saliva help prevent and reverse caries by inhibiting demineralization and enhancing remineralization. High levels of surface fluoride can increase resistance to carious lesion formation and dental erosion. Remineralization of incipient caries is accelerated by trace amount of fluoride. [9],[10],[15]

Reasons to find alternative to fluoride:

  • The efficiency of fluoride is mainly for smooth surface caries
  • High fluoride exposures should be restricted to avoid fluorosis
  • In certain countries, fluoride exposures has been limited
  • When used properly fluoride is found to be safe in normal individual but among certain conditions the fluoride exposures should be limited as the toxicity of fluoride increases with nutritional deficiency (inadequate vitamin-mineral) and in immune-compromised cases such as diabetes and renal disease
  • The strong antifluoride lobby is claiming that diseases like mental retardation, GI diseases, intestinal disorders, Down's syndrome, thyroid problems are mainly attributed to the over exposure of fluoride. [5],[16]

The different remineralizing agents are:

Beta-tricalcium phosphate

Calcium carbonate and calcium hydrogen phosphate can be combined and heated to over 1000°C for one day to give rise to a stiff flaky powder. Then, it is undergone milling to 0.01-5 micron in size. [17] Beta-tricalcium phosphate (TCP) is less soluble than its alpha counterparts. A major problem of such use of TCP is the formation of calcium phosphate complexes which lowers the bioavailability of calcium and fluoride. An organic coating prevents undesirable interactions with fluoride, but may dissolves away when particles contact saliva. It is used in products such as Cerasorb, Bio-Resorb, and Biovision. [18]


Bioactive glass material containing calcium sodium phosphosilicate and comprises 45% of SiO 2 , 24.5% Na 2 O, 24.5% CaO, and 6% P 2 O 5 . [18] Novamin is mainly used as desensitizing agent. When this bioactive glass comes in contact with saliva, it rapidly releases sodium, calcium, and phosphorous ions into the saliva available for remineralizaton. Nvamin attaches to exposed dentin surface and form a tough, acid resistant mineralized layer. [12] Novamin technology is used in "Oravive" tooth revitalizing paste is a dentrifice which is entirely free from fluoride. Novamin technology was developed by Dr. Len Litkomski and Dr. Gary Hack. [19]

Enamelon TM

Unstabilized calcium and phosphate salts with sodium fluoride are named as Enamelon TM . The both salts are separated from each other and with sodium fluoride by a plastic divider in the center of the toothpaste tube. Clinical trials proved the benefit of Enamelon over conventional stannous fluoride gel in radiation cares over 12-month period. The calcium and phosphate of Enamelon is not stabilized, allowing the two ions to combine into insoluble precipitates before they come into contact with saliva or enamel. The manufacturer of this product claims that its "Liquid Calcium" formula delivers fluoride along with soluble calcium and phosphate. [20],[21]

Pronamel TM

Despite the name it does not contain calcium compound and is not considered as a remineralizing agent. It contains 5% potassium nitrate in a neutral pH and is used mainly to relieve dentin hypersensitivity and tooth erosion. The fluoride content is sodium fluoride, giving 0.15% w/v fluoride ion, 1500 ppm, an increase of 50% above conventional dentrifices. [12],[13],[19],[21],[22],[23]

Dicalcium phosphate dehydrate

Inclusion of dicalcium phosphate dehydrat in fluoride dentifrices to enhance on the remineralizing effects of the fluoride component. It increases biologically active Ca 2+ in plaque fluid and remains elevated for up to 18 h after brushing.

Amorphous calcium phosphate

The amorphous calcium phosphate (ACP) technology was developed by Dr. Ming S. Tung. In 1999, ACP was incorporated into dentifrice called Enamelon and later reintroduced in 2004 in "Enamel Care" toothpaste by Church and Dwight. After topical application ACP hydrolyses at a pH of 7.4 and octacalcium phosphate and intermediate compound released and then surface apatite. The surface action of ACP explains its desensitizing effects and has cosmetic influences on abraded enamel surface by filling surface defects.

Complex of casein phosphopeptides amorphous calcium phosphate

The technology of CPP-ACP technology was first used in dentistry by Prof. Eric Reynolds et al. at the University of Melbourne. It has been incorporated into chewing gums and tooth cream. A formulation with incorporated fluoride with a concentration of 0.2% or 900 ppm. The protein nanotechnology combines specific phosphoproteins from bovine milk with forming nanoparticles of ACP. The precise ratio is 144 calcium ions plus 96 phosphate ions and 6 peptides of CPP. The compounds work effectively as a remineralizing agent at acidic pH levels (down to 4) as well as in the neutral and alkaline range. This complex combination tooth cream in clinical dental practice is used for treating incipient caries, fluorosis, orthodontic decalcification, enamel demineralization and desensitization.

Anticaries action of casein phosphopeptides-amorphous calcium phosphate complex

  • It binds to adhesion molecules on mutans streptococci and prevents their incorporation into dental plaque.
  • Provide protein and phosphate for filling demineralizing defects and buffer pH of the plaque fluid
  • It elevates the plaque calcium levels to inhibit plaque fermentation.

The reversal of incipient caries and hidden caries led to revolutionary changes for caries management. Great efforts and interest is being given in the field of inventing remineralizing agents. Evidence based studies are going on to find out conclusive result in clinical trials.

  Conclusion Top

Enamel remineralization has been studied since many years and is known as non invasive treatment of early carious lesions. This treatment module has a great potential to be the major advance in the clinical management of the disease. This article discusses the different remineralizing technique that is available nowadays to treat incipient carious lesions. In the process of searching articles regarding this matter we find insufficient number of clinical trials conducted with different remineralization technique. More randomized clinical trials are necessary to study remineralization efficacy of different material and systems to treat hypersensitive dentin and early caries.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Head J. A study on saliva and its action on tooth enamel in reference to its hardening and softening. JAMA 1912;59:2118-22.  Back to cited text no. 1
Koulourides T. Remineralization methods. Ann N Y Acad Sci 1968;153:84-101.  Back to cited text no. 2
Koulourides T. Implications of remineralization in the treatment of dental caries. Higashi Nihon Shigaku Zasshi 1986;5:1-20, 87-97.  Back to cited text no. 3
Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC. New approaches to enhanced remineralization of tooth enamel. J Dent Res 2010;89:1187-97.  Back to cited text no. 4
Goswami M, Saha S, Chaitra TR. Latest developments in non-fluoridated remineralizing technologies. J Indian Soc Pedod Prev Dent 2012;30:2-6.  Back to cited text no. 5
  Medknow Journal  
Paes Leme AF, Dalcico R, Tabchoury CP, Del Bel Cury AA, Rosalen PL, Cury JA. In situ effect of frequent sucrose exposure on enamel demineralization and on plaque composition after APF application and F dentifrice use. J Dent Res 2004;83:71-5.  Back to cited text no. 6
Dawes C. What is the critical pH and why does a tooth dissolve in acid? J Can Dent Assoc 2003;69:722-4.  Back to cited text no. 7
Ten Cate JM. In vitro studies on the effects of fluoride on de-and remineralization. J Dent Res 1990;69:614-9.  Back to cited text no. 8
Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC. Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Caries Res 2004;38:551-6.  Back to cited text no. 9
Melberg RJ, Ripa WL, Leske SG. Fluoride in Preventive Dentistry: Theory and Clinical Aspects. Chicago: Quintessence Publishing Co. Inc.; 1983.  Back to cited text no. 10
Fejerskov O, Ekstrand J, Burt AB. Fluoride in Dentistry. 2 nd ed. Copenhagen: Munkegaard; 1996.  Back to cited text no. 11
Walsh LJ. Contemporary technologies for remineralization therapies: A review. Int Dent SA 2009;11:6-16.  Back to cited text no. 12
Pradeep K, Rao PK. Remineralizing agents in the non-invasive treatment of early carious lesions. Int Dent J Case Rep 2011;1:73-84.  Back to cited text no. 13
Zero DT, Fontana M, Martínez-Mier EA, Ferreira-Zandoná A, Ando M, González-Cabezas C, et al. The biology, prevention, diagnosis and treatment of dental caries: Scientific advances in the United States. J Am Dent Assoc 2009;140 Suppl 1:25S-34S.  Back to cited text no. 14
Beltrán-Aguilar ED, Barker LK, Canto MT, Dye BA, Gooch BF, Griffin SO, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis - United States, 1988-1994 and 1999-2002. MMWR Surveill Summ 2005;54:1-43.  Back to cited text no. 15
Johansen E. Comparison of the ultrastructure and chemical composition of sound and carious enamel from human permanent teeth. Bristol: J Wright & Sons; 1965. p. 177-81.  Back to cited text no. 16
Zero DT. Dentifrices, mouthwashes, and remineralization/caries arrestment strategies. BMC Oral Health 2006;6 Suppl 1:S9.  Back to cited text no. 17
Döri F, Arweiler N, Gera I, Sculean A. Clinical evaluation of an enamel matrix protein derivative combined with either a natural bone mineral or beta-tricalcium phosphate. J Periodontol 2005;76:2236-43.  Back to cited text no. 18
Reynolds EC. Calcium phosphate-based remineralization systems: Scientific evidence? Aust Dent J 2008;53:268-73.  Back to cited text no. 19
Featherstone JD. Prevention and reversal of dental caries: Role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31-40.  Back to cited text no. 20
Brown WE. Physicochemical mechanisms of dental caries. J Dent Res 1974;53:204-16.  Back to cited text no. 21
Kontonasaki E, Zorba T, Papadopoulou L, Pavlidou E, Catzistavrou X, Paraskovopolas K, et al. Hydroxy carbonate apatite formation on particulate bioglass in vitro as a function of time. Cryst Res Technol 2002;37:1165-71.  Back to cited text no. 22
Thompson A, Grant LP, Tanzer JM. Model for assessment of carious lesion remineralization, and remineralization by a novel toothpaste. J Clin Dent 1999;10:34-9.  Back to cited text no. 23

This article has been cited by
1 Comparative Evaluation of Two Remineralizing Agents on Artificial Carious Lesion Using DIAGNOdent
Sham S Bhat,Sundeep K Hegde,Vidya S Bhat,Dilip Shirly Arjun,Hejamady Tati Ajay Rao,Shenoy S Ramdas
International Journal of Clinical Pediatric Dentistry. 2021; 14(2): 192
[Pubmed] | [DOI]
2 Effect of hydroxyapatite from waste of tilapia bone (oreochromis niloticus) on the surface hardness of enamel
Siti Prihartini Devitasari,Maya Hudiyati,Danica Anastasia
Journal of Physics: Conference Series. 2019; 1246: 012009
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Action of Fluoride

 Article Access Statistics
    PDF Downloaded347    
    Comments [Add]    
    Cited by others 2    

Recommend this journal