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An Update on Demineralization/ Remineralization

Course Number: 73

Microscopic Examination of the Demin/Remin Process

To understand the concept, we can examine this lesion that has been prepared for microscopic examination. We can easily note the outer layer, the surface layer, and the inner demineralized area termed a subsurface lesion.

Image of a polarized-light micrograph of an early enamel subsurface lesion.

Image provided by: Dr. James Wefel

Polarized-light micrograph (in water) of an early enamel subsurface lesion. Blue area is normal enamel and surface zone over lesion. Brown area is the early lesion.

The calcium and phosphate are dissolved from the crystals in a complex environment. The concept of a “critical pH” is the situation under which net mineral loss occurs. Previously this was thought to be a fixed value, but it is now accepted that it is rather a value that is inversely proportional to the calcium and phosphate concentrations in solution in the localized environment.13 Larsen and Pierce14 developed a computer program for examining the solubility of enamel. Small pH changes around a pH of 4 were demonstrated to significantly impact the demineralization potential of enamel.

What has actually happened? Acids diffuse through the interprismatic rod substance and travel along the rod margin to an area of lowered fluoride content (Note: the outer 10 microns of enamel holds a higher concentration of fluoride.)

As the process of demineralization continues, the edges of the enamel crystal demineralize...that is, calcium and phosphate become dissociated in the small subsurface area.

Photo showing partially demineralized enamel crystals

Partially Demineralized Enamel Crystals

This process results in the development of an early lesion (begins 10-15 microns beneath the surface) which has a relatively intact surface layer that cannot be penetrated with a dental explorer during the early stages of formation. If the acid challenge continues, greater amounts of subsurface enamel will be demineralized (or as it is sometimes called “decalcified”) and the lesion will continue to progress deeper under the intact surface layer.

Polarized-light micrograph showing the body of the lesion in brown with its advancing front and a blue surface zone at the enamel surface area

Image provided by: Dr. James Wefel

Polarized-light micrograph (in water) of early enamel lesion (about half way through the enamel) showing the body of the lesion in brown with its advancing front and a blue surface zone at the enamel surface area as shown in the accompanying diagram.

Diagram of an early tooth lesion

Early Lesion

The caries process is a dynamic situation which occurs as a result of substantial pH fluctuations taking place in the biofilm on the tooth surface. Kidd and Fejerskov15 describe this process and its histopathology and indicate the “Regular removal of the biofilm, preferably with a toothpaste containing fluoride, delays or even arrests lesion progression.” The processes of demineralization and remineralization can occur simultaneously or alternately. The high resolution transmission electron microscope has been used to demonstrate how these crystals look in caries lesions.16 In very simple crystallographic terms, demineralization is crystal dissolution and remineralization is the restoration of partially dissolved crystals, growth of surviving crystals and the formation of new crystals within the carious lesion. If net demineralization continues, the outer layer of enamel will eventually become extensively undermined; with the clinical result being an area that is “sticky” or “soft” to the explorer coupled with visual evidence of demineralization. Larsen and Bruun17 describe this process in detail in their textbook chapter on “Caries Chemistry and Fluoride – Mechanisms of Action.” They discuss the theory which claims that when “...fluoride is present in the aqueous phase around the tooth, in saliva and in plaque fluid, enamel solubility is low, which tends to prevent it from dissolving.”

Photo showing an advanced tooth lesion.

Advanced Lesion

Microscopic scans showing tooth enamel remineralization


Remineralization of the subsurface lesion occurs when the dissociated ions of calcium and phosphate recombine to form an even stronger crystal. This reaction is enhanced in the presence of fluoride.