This document discusses remineralization of early dental caries. It explains that caries is a process of demineralization and remineralization, and that remineralization can reverse early caries if the pH rises and calcium, phosphate and fluoride enter the subsurface lesion. Methods for detecting early caries include visual examination, tactile examination using a blunt explorer, radiographs, caries detecting dyes, laser fluorescence and digital imaging. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) can aid in remineralization by localizing amorphous calcium phosphate in dental plaque and inhibiting bacterial adherence. The document presents a clinical case where CPP-ACP paste used twice

1. REMINERALIZATION
OF INCIPIENT
CARIES
Osama AlKhalifa

2. REMINERALIZATION OF INCIPIENT
CARIES
15-year-old male DMFT= 23

3. The Caries Process
Caries is a multifactorial bacterial infection
involving a process of demineralization and
remineralization

4. The Caries Process
The progress of caries depends on the
balance of demineralization and
remineralization.
A lesions develops when the caries balance
shifts toward demineralization

5. Demineralization & Remineralization
Ca10(PO4)6(OH)2 10Ca+6PO4+2OH
PH = 5.5

6. Natural Remineralization
Demineralization is reversed by saliva, which
contains calcium, phosphate and fluoride ions
as well as buffering agents

7. Natural Remineralization
Remineralization occurs when the pH rises
and calcium and phosphate from the saliva,
and fluoride, enter and repair the subsurface
lesion. The resulting layer is more resistant to
dissolution than the original content

8. Natural Remineralization
The higher the level of acid and the longer it is
present at the tooth surface, the more difficult
it is for saliva to buffer the area and for
remineralization to succeed

9. Natural Remineralization
When remineralization is possible in the early
stages of lesion development, no visible
change may be apparent,

10. Detection of early caries
1- Visual Examination
2- Tactile Examination
3- Radiographic Examination
4- Caries Detecting Dyes [CDD]
5- Laser Fluorescence [LF]
6- Digital Imaging Fibero-Optic Transillumination
[DIFOTI]
7- Quantitative Light-induced Fluorescence [QLF]

11. Detection of early caries
Visual Examination
 A white spot lesion that becomes visible only
after thorough air drying indicate that
demineralization will be less than halfway
through enamel.
 A white spot lesion visible on wet surface
indicates that demineralization is over
halfway through enamel, possibly extending
into dentin.

12. Detection of early caries
Tactile Examination
G.V. Black 1924;
[A sharp explorer should be used with some
pressure and if a very slight pull is required to
remove it, the pit should be marked for
restoration even if there are no signs of
decay]

13. Detection of early caries
Tactile Examination
Explorer has been advocated for many
decades as important method to detect
caries, but research has shown this is to be
unwise practice
Summitt 1996

14. Detection of early caries
Tactile Examination
The explorer can damage white spot lesion by
breaking the relatively intact surface zone.
Ekstrand 1987

15. Detection of early caries
Tactile Examination
Graham Mount 2000;
[It is recommended that a blunt explorer
be used, only if necessary. The probe
must be used very lightly on the side
rather than the point. To test the
firmness and texture of tooth surface.]

16. Detection of early caries
Radiographic Examination
Bitewing radiographs are used to detect
proximal and occlusal caries
Enamel lesions will not be visible on
occlusal surface in a radiograph, but it
can be visible on proximal surface.

17. Detection of early caries
Caries Detecting Dyes [CDD]
Caries Detecting Dyes are
used for detection of occlusal
caries

18. Detection of early caries
Laser Fluorescence [LF]
 Diode laser beam is directed
to the tooth then the reflected
fluorescent light is measured
in a numeric value

19. Detection of early caries
Digital Imaging Fibero-Optic Transillumination
[DIFOTI]
High intensity white light is
directed towards teeth through
handpiece and images are
captured and stored in computer.
Incipient caries appear as darker
areas in the resultant images.

20. Detection of early caries
Quantitative Light-induced Fluorescence [QLF]
Teeth are illuminated with high
intensity blue light and images
are captured and stored on the
computer. Caries lesions are
shown as dark lesion

21. Principles of Minimal Intervention
Dentistry [MI] FDI, 2000
1- Control the disease through reduction of
cariogenic flora
2- Remineralize early lesions
3- Perform minimal intervention surgical
procedures
3- Repair rather than replace, defective
restorations

22. Aided Remineralization
1- Topical fluorides
2- Ozone therapy
3- Casein phosphopeptide-amorphous calcium
phosphate (CPP-ACP)

23. Ozone therapy

24. ANTICARIOGENIC ACTIONS OF MILK
 Due to protein buffers, calcium and
phosphate (1940s)
 Due to casein (Reynolds 1987)
 Due to Casein Phosphopeptides (CPP)
(Reynolds 1997)

25. Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
A combination of casein phosphopeptides
(CPP) and amorphous calcium phosphate
(ACP) was manufactured. The casein is
derived from cow’s milk

26. Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
CPP can bind
calcium and
phosphate and keep
them in a soluble,
amorphous state

27. Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
CPP-ACP complexes
localize ACP in dental
plaque

28. Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
CPP-ACP has also been
found to be incorporated
into pellicle and to help
inhibit adherence of
streptococci mutans .

29. Remineralization with fluoride

30. Remineralization with CPP-ACP
and CPP-ACPF

31. Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
CPP-ACP is available for use in two forms:
1- Paste
2- Chewing gum

32. Paste application
Paste is applied with finger or
tray

33. Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
Clinical uses
1- Prevention and treatment of dental caries
2- Prevention and treatment of dental erosion
3- Prevention and treatment of cervical tooth
sensitivity

34. Clinical indications of CPP-ACP
Patients at increased risk for
caries:
1- Xerostomia
2- patients wearing fixed
appliances
3- patients practicing poor oral
hygiene

35. Clinical indications of CPP-ACP
 patients with intermittent
vomiting
 Patients with cervical tooth
sensitivity

36. Clinical case
6 weeks CPP-ACP
Paste 2 x daily

37. Casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
In the future CPP-ACP may also be
contained in:
1- Carbonated drinks
2- Toothpastes
3- glass ionomer cement

38. The best product in the market

39. Conclusion
G.V. Black
‘’The day is surely coming when
we will be engaged in preventive
rather than reparative dentistry’’