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An Update on Demineralization/ Remineralization

Course Number: 73

The Final Cochrane Review: Fluoride Mouthrinses

This review “included 37 studies in which more than 15,000 children (aged six to 14 years) were treated with fluoride mouthrinse or placebo (a mouthrinse with no active ingredient) or received no treatment."57 Key results from the study “confirmed that supervised regular use of fluoride mouthrinse can reduce tooth decay in children and adolescents. Combined results of 35 trials showed that, on average, there is a 27% reduction in decayed, missing and filled tooth surfaces in permanent teeth with fluoride mouthrinse compared with placebo or no mouthrinse. This benefit is likely to be present even if children use fluoride toothpaste or live in water-fluoridated areas. Combined results of 13 trials found an average 23% reduction in decayed, missing and filled teeth (rather than tooth surfaces) in permanent teeth with fluoride mouthrinse compared with placebo or no mouthrinse. No trials have looked at the effect of fluoride rinse on baby teeth. We found little information about unwanted side effects or about how well children were able to cope with the use of mouthrinses.” The reviewers concluded “Regular use of fluoride mouthrinse under supervision results in a large reduction in tooth decay in children's permanent teeth. We found little information about potential adverse effects and acceptability.” Therefore, fluoride mouthrinses can be effective in caries prevention. In our best clinical judgment it may be that patients using fluoridated toothpastes who are at risk of caries may be candidates for the additional benefits of a fluoridated rinse.

A shift toward a “medical model” in the treatment and prevention of dental caries as described by Anderson58 has been suggested. Barber and Wilkins59 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 Steinberg60 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 Congress,61 “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.”

Over recent times, there have been a number of “models” in use that focus not only on lesion identification and severity, but also on recommendations for appropriate intervention. The International Caries Detection System (ICDAS), the International Caries Classification and Management System (ICCMS), Caries Management by Risk Assessment (CAMBRA), Caries Management System (CMS) and the American Dental Association Caries Classification System are all systems that have been in use. A 2012 meeting held at Kornberg School of Dentistry in Philadelphia brought together a diverse group of experts from academia, research, industry and dental organizations to review all of the available models. One outcome of this meeting was the Caries Management Pathways (CaMPs) model that serves as an umbrella that incorporates all of the various classification systems. At this conference, a new mission for dentistry was defined; “that it is time for all oral health professionals to focus on the promotion of oral health and preservation of sound teeth rather than counting the number of surgical procedures provided.” There was overwhelming agreement that there is a need to preserve dental tissues, and to only perform restorative measures when needed. Focusing on the identification of lesions in the earliest stages enables dental health professionals to implement appropriate interventions, such as fluoride treatment, to remineralize these challenged areas.62

At present, the ICDAS System, an integral aspect of the ICCMS™ approach, is the most favored model. While the ICCMS™ represents a new, enhanced approach to the diagnosis and management of caries, the ICDAS System provides a standardized method for assessing and tracking changes in caries activity.

Polarized-light micrographs of a single section enamel lesion before treatment
Polarized-light micrographs of a single section enamel lesion after treatment

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.