Print this page Email this page Users Online: 512
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 1-7

White spot lesions: A literature review

Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India

Date of Web Publication20-Feb-2015

Correspondence Address:
Dr. Sidhant Pathak
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Pavillion Road, Davangere, Karnataka - 577 004
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-6646.151839

Rights and Permissions

There has been a paradigm shift from Black's "extension for prevention" to a minimal intervention approach in the recent time. To diagnose earliest stages of enamel demineralization, accurate and reliable detection of white spot lesions is very important. The newer diagnostic aids would enable the dentist to detect and diagnose early such lesions and direct appropriate preventive measures to promote remineralization and conservation of the tooth substance. A high level of caries experience necessitates preventive strategies which are more cost-effective than surgical intervention and restorative procedures. The goal of modern dentistry is to manage white lesions non-invasively through remineralization in an attempt to prevent disease progression, and to improve strength, esthetics, and function of teeth.

Keywords: Demineralization, Remineralization, White spot lesions

How to cite this article:
Roopa KB, Pathak S, Poornima P, Neena IE. White spot lesions: A literature review. J Pediatr Dent 2015;3:1-7

How to cite this URL:
Roopa KB, Pathak S, Poornima P, Neena IE. White spot lesions: A literature review. J Pediatr Dent [serial online] 2015 [cited 2019 Oct 20];3:1-7. Available from:

  Introduction Top

The initial carious lesions are the so-called "white spot" lesions, which implies that there is a subsurface area with most of the mineral loss beneath a relatively intact enamel surface. [1]

Clinically, early caries lesion in enamel is initially seen as a white opaque spot and is characterized by being softer than the adjacent sound enamel and is increasingly whiter when dried with air. A cross-section of the white opaque spot reveals the features of carious enamel and suggests that dental caries is essentially an enamel defect with a relatively intact surface layer (SL) and some subsurface damage due to acid formed from plaque on tooth surface. [2] Downer's criteria for detection of caries include: Enamel caries-if there is destruction of the enamel surface or a white area in enamel extending up to, but not including the ADJ, and there is no cavity or discolored area beneath the ADJ. Dentinal caries - if there is destruction of the enamel extending up to and including the ADJ or a cavity or discolored area beneath the ADJ extending into dentine. [3]

The main types of enamel demineralization include incipient lesions and "surface-softened defect" which are the other names used to describe white spot lesions. [4],[5] It is essential to differentiate incipient lesion from arrested lesions. Incipient lesions are active lesions which continue to progress under acid attack whereas an arrested lesions does not progress. In vivo ultrastructural studies done by Thylstrup and Fredebo concluded that there were wide variations between active and arrested lesions. [6] "Micro-scars" were seen on active lesions while micro-cavitation was usually seen on arrested lesions. [2]

Dental caries is now being increasingly considered as a dynamic disease process wherein equilibrium exists between pathological factors causing demineralization and protective factors causing remineralization. The major pathological factors involve frequent ingestion of fermentable carbohydrates, inhibition of salivary function, and acidogenic bacteria while the protective factors include antibacterial agents which are both natural and applied, composition and rate of salivary flow, fluoride from extrinsic sources and diet. Caries intervention can be natural, or by some mode of treatment or procedure. The disease process is believed to be a continuum beginning with the first atomic level of demineralization, and then the early lesions of the enamel are followed by the dentinal involvement and finally cavitation. However, the early lesion is known to remineralize and is, therefore, regarded as reversible. [7]

  Subsurface White Spot Lesion Formation Top

The caries process takes place slowly which requires repeated episodes of prolonged exposure to acidic conditions consistently below the critical pH for enamel dissolution (pH 5.5, demineralization) with intervening periods of return to the resting pH of plaque (pH 7.0, remineralization period). [8],[9],[10],[11] In case of failure to remove plaque from retentive tooth areas, a diet rich in refined carbohydrates, and frequent carbohydrate ingestion, the dynamic equilibrium between demineralization and remineralization will be tipped toward demineralization with the development of clinically detectable white spot lesions. The early enamel lesion is characterized by four distinct histopathologic zones. [12],[13] Two zones of demineralization are present:

  1. The translucent zone (1% pore volume) along the advancing front of the lesion; and
  2. The body of the lesion (>5-25% pore volume) representing the majority of the lesion and situated approximately 15-30 μm beneath the overlying intact enamel surface.

Two zones of remineralization are also present:

  1. The dark zone (2-4% pore volume) situated near the advancing front just superficial to the translucent zone; and
  2. The surface zone (1 to <5% pore volume) forming the intact surface overlying the lesion.

The initial formation of the lesion is due to the dissolution of hydroxyapatite (HAP) from the enamel prisms forming the enamel surface. [8],[12],[13]

The initial dissolution results in the loss of a small amount of mineral within the enamel and would have a similar appearance to the translucent zone (negative birefringence in quinoline). With continuing demineralization without the benefit of remineralization of this initial lesion, a surface zone that resembles the surrounding sound enamel, with respect to its negative birefringence (water imbibition) is formed. With ongoing removal of mineral from the underlying enamel, a positively birefringent body of the lesion (water imbibition) develops and separates the overlying surface zone from the translucent zone at the advancing front. If lesion development occurs over a relatively long period, a zone of remineralization (the dark zone, positive birefringence in quinoline) with reciprocation of mineral phases from the translucent zone will occur. If lesion formation is over a short period of time, the dark zone will not form and there will be rapid advancement of the front with a large, heavily demineralized body of the lesion and a surface zone of minimum thickness. Once a certain degree of demineralization has occurred the lesion will take on a white spot appearance and become clinically detectable. The maintenance of an intact surface during caries formation is quite remarkable. At first, this was considered to be unique to surface enamel. Later, it was proven that an intact surface can be reproduced even when the surface enamel is ground away, and artificial caries is created in the remaining abraded enamel.

The subsurface white spot lesion with an intact surface occurs due to the physicochemical parameters of demineralization of HAP. The mechanistic approach to demineralization of enamel is based upon the primary driving force being hydrogen ion transport from the dental plaque at a pH of 5.0 into the underlying enamel at a pH of 7.0. The concentration gradient for hydrogen is much less in enamel than that in dental plaque, during episodes of acidogenesis by mutans streptococci and lactobacilli. Hydrogen ions are transported to the advancing front of the lesion. Once the hydrogen ions encounter susceptible tooth mineral, dental HAP undergoes dissolution with the resultant dissolved mineral transported from the advancing front to the dental plaque. Of interest is the fact that the fluid phase at the advancing front has a much lower calcium and phosphate concentration (0.1 mmol/L) than that at the enamel surface (5-8 mmol/L). This implies that calcium and phosphate are being transported against their concentration gradient, and this requires energy input to accomplish this. The energy for this active transport of solubilized mineral phase from the advancing caries front is supplied by the influx of the hydrogen ions driven by a 100 fold concentration gradient. In the plaque compared with enamel along the advancing front. Mineral phases may become entrapped in the zones of remineralization if the caries process is a slow process. During the intervening periods of remineralization and return to a resting neutral plaque pH, partially demineralized crystals may be repaired, or new crystals formed from the available dissolved mineral phases within the lesion and dental plaque. Demineralization may be markedly decreased in individuals with high plaque levels of calcium, phosphate, and fluoride. The increased calcium and phosphate in plaque would require a lower pH between plaque and the advancing front to allow for active transport of calcium and phosphate from the advancing caries front into the plaque. This effectively would result in a lower critical pH in order to induce demineralization. The presence of increased levels of fluoride in plaque favors reprecipitation of dissolved mineral and also allows for the incorporation of fluoride into reconstituted HAP. Likewise, increased fluoride content of native enamel in the form of fluoro-hydroxyapatite would lessen the extent of demineralization and favor mineral reprecipitation. [14]

  Detection of White Spot Lesions Top

Over the last two decades, there has been a drastic change in the prevalence and pattern of dental caries with a decrease in smooth surfaces caries and with more lesions being detected on the occlusal surfaces of the tooth. Thus, it is important to identify early and institute preventive measures for the control of dental caries. The traditional methods of detecting early lesions include visual inspection and radiography. In visual observation, reflected light is used to detect changes in color, texture, and translucency of the tooth substance. However, these traditional methods for early caries diagnosis have been found to be inaccurate and insensitive. Unfortunately, radiographs have the added risk of exposure of ionizing radiation to the patient. [3] As the present-day caries lesion progresses slowly, it is advisable to have a method which misses some of the shallow lesions, but yet has a high positive predictive value for deeper lesions. [2] It is hard to diagnose occlusal caries in teeth without a macroscopic breakdown of the outer enamel surface. [15] Enamel approximal caries lesions are poorly detected by radiography since demineralization in excess of 40% must occur for the radiographic detection to be possible although dentinal lesions in occlusal surfaces may be detected with some accuracy. [16],[17] In a study by Yassin on in vitro mechanical damage of early carious lesion (enamel lesion) in artificial U-shaped grooves caused by a sharp dental explorer, it was seen that when a force of 500 g was used there was no damage to the sound enamel grooves. However, the probing by a sharp dental explorer in demineralized enamel grooves resulted in cavitation of white spot lesion with apparently a sound SL. The dentist should, therefore, be cautious while using a sharp dental explorer to examine early carious lesions in pits and fissures. [18] The newer available methods for caries detection include auto-fluorescence (such as quantitative light-induced fluorescence [QLF]) of teeth, electrical resistance (such as ECM), and imaging techniques like conventional and digital bitewing radiography. [19] Transillumination, DIAGNOdent, and DIFOTI devices comprise the other supplemental methods to aid in the diagnosis. [20] QLF which measures enamel autofluorescence can detect differences in remineralization of early enamel caries. [21] A new fiberoptic diagnostic tool enabling dentists to identify early caries lesions with greater sensitivity and specificity is the fibre-optics-based confocal imaging system which can record axial profiles through caries lesions using single-mode optical fibers. [22] A novel technology involving optical coherence tomography (OCT) imaging of tooth which shows greater light backscattering intensity at sites of carious lesions than the sound enamel could be used for screening carious sites and determining lesion depth, in combination with Raman spectroscopy for biochemical confirmation of caries. [23] Polarization-sensitive optical coherence tomography (PSOCT) system has also been used to study the spatially resolved scattering and polarization phenomena of teeth which are known to have strong polarization effect. PSOCT is another tool that has been used for in vitro dental caries assessment of remineralized lesions. [24] Digital Imaging Fiber-Optic Transillumination (DIFOTI) uses images of teeth obtained with a digital CCD camera, which are sent to a computer for analysis with dedicated algorithms for location and diagnosis of carious lesions by the operator in real time, thereby providing a quantitative characterization for monitoring of approximal, occlusal, and smooth-surface caries. [25] Frequency-domain photothermal radiometry (FD-PTR or PTR) and modulated luminescence have also been used to detect early interproximal demineralized lesions. However, PTR provides more accurate diagnosis than the modulated luminescence. [26] Laser fluorescence device DIAGNOdent has been used to detect occlusal caries and has more sensitivity and specificity than radiographic examination. [27] In a study on Digital Imaging Fiber-Optic Trans-Illumination (DIFOTI), F-speed radiographic film, and depth of approximal lesions, it was observed that the histologic lesion depth determined by F-speed radiographic film was identical to that evaluated by polarized light microscopy while DIFOTI did not measure the depth. However, DIFOTI could detect surface changes associated with early demineralization as early as 2 weeks. The investigators of this study suggested that surgical or chemical treatment strategies should take into account cavitation rather than histologic lesion depth. [28] Data evaluating the accuracy of enamel demineralization detection using conventional, digital, and digitized radiographs, and evaluation of radiographs and logarithmically contrast-enhanced subtraction images show that Den-Optix ® system represents the advances in the development of photostimulable phosphor plates and is a plausible alternative to conventional radiographs. It was observed that radiographs taken with InSight ® film were cheap and accurate and that digital subtraction enhanced approximal enamel caries lesion detection. [16] According to Gimenez et al. fluorescence-based methods had similar accuracy in detecting occlusal and approximal caries lesions, on both primary and permanent teeth, and they performed better in detecting more advanced caries lesions. [29] Gomez et al. concluded that electrical conductance (EC) and QLF seemed to be promising for the detection of early lesions. Visual methods remained the goal standard for clinical assessment in dental practice keeping in mind both cost and practicality considerations. [30] Twetman et al. reported in his study that electrical methods and laser fluorescence could be useful adjuncts to visual-tactile and radiographic examinations, especially on occlusal surfaces in permanent and primary molars. [31]

  Characteristics of White Spot Lesions in Enamel Top

The enamel demineralization defect has a lower mineral distribution in the SL in comparison to the adjacent sound enamel and also a lower interprismatic mineral content. The first stage of enamel demineralization is characterized by removal of interprismatic mineral content and in the subsequent stages a well-defined SL formation occurs which constitutes early caries lesion. [2] These studies have demonstrated that a porous and mineral-rich SL covers an enamel lesion and the morphology differs a little from that of sound enamel while body of the lesion which comprises the subsurface area has low mineral content (10-70 vol.%). The early caries lesion in enamel is characterized by a prominent perikymata pattern and focal holes. [32],[33],[34] The main drawback of the numerous experimental techniques is that they are static measurements of caries progression at a particular time period whereas the carious process is time-dependent and is in a constant state of dynamic equilibrium wherein a balance is struck between demineralization and remineralization.

  Surface Layer Covering White Spot Lesions Top

The early investigators who observed the white opaque spots attributed the presence of these lesions to artifacts. They believed that the SL could be due to sound enamel which has a higher mineral content. These explanations were proved false by subsequent investigations by Langdon et al. [35] Their studies on pressed pellets of HAP demonstrated that subsurface lesion could occur in an acidic gel system with 2 ppm fluoride. They also concluded that organic matrix is not important for subsurface lesion formation, and that neither a preferred crystallite orientation in the enamel prisms nor an uneven ion/mineral distribution in enamel were essential for the formation of a subsurface lesion since these are absent in pressed apatites. This is in contrast to earlier reports by Brudevold et al. [36]

  Remineralizing Agents for Treatment of White Spot Lesions Top

Complex of casein phosphopeptides-amorphous calcium phosphate

Complex of casein phosphopeptides-amorphous calcium phosphate (CPP-ACP) is an acronym for a CPPs and ACP. Caseins are a heterogeneous family of proteins predominated by alpha 1 and 2 and b-caseins. CPPs are phosphorylated casein-derived peptides produced by tryptic digestion of casein.

The CPP containing the amino acid cluster sequence - Ser (P)-Ser (P)-Ser (P)-Glu-Glu has the ability to bind and stabilize calcium and phosphate in solution, as well as to bind dental plaque and tooth enamel. Through their multiple phosphoryl residues, the CPPs bind to form clusters of ACP in metastable solution, preventing their growth to the critical size required for nucleation and precipitation. The proposed mechanism of anticariogenicity for the CPP-ACP is that it localizes ACP in dental plaque, which buffers the free calcium and phosphate ion activities, thereby helping to maintain a state of supersaturation with respect to tooth enamel depressing demineralization and enhancing remineralization. The CPPs have been shown to keep fluoride ions in solution, thereby enhancing the efficacy of the fluoride as a remineralizing agent. [37],[38]

Complex of casein phosphopeptides inhibits adherence of oral bacteria to saliva-coated hydroxyapatite beads (S-HA). By selectively inhibiting the streptococcal adhesion to teeth, it can modulate the microbial composition of dental plaque and favor establishment of less cariogenic species such as oral actinomyces. This could also control acid formation (buffering) in dental plaque, in turn reducing HAP dissolution from tooth enamel. [39],[40]

It can be incorporated into the pellicle in exchange for albumin and thus inhibits the adherence of Streptrococcus mutans and Streptococcus sobrinus, causing both neutralization and enhancement of remineralization. [41]

The Recaldent Technology was developed by Prof. Eric Reynolds of the University of Melbourne. CPP-ACP has been trademarked Recaldent and has been launched in sugarless chewing gum and confectionery. More recently, a sugar-free, water-based cream containing RECALDENT (CPP-ACP) (GC Tooth Mousse/Prospec MI Paste) has been made available to dental professionals. [42]

Azarpazhooh and Limeback concluded that the long-term effectiveness of CPP-ACP in preventing caries in vivo is unknown due to lack of clinical trial evidence. [43]

Amorphous calcium phosphate

The ACP technology requires a two-phase delivery system to keep the calcium and phosphorous components from reacting with each other before use. The current sources of calcium and phosphorous are two salts, calcium sulfate and dipotassium phosphate. When the two salts are mixed, they rapidly form ACP that can precipitate onto the tooth surface. This precipitated ACP can then readily dissolve into the saliva and can be available for tooth remineralization. [44]

It can be considered a useful adjuvant for the control of caries in orthodontic applications. Experimental ACP composite has shown to efficiently establish mineral ion transfer throughout the body of the lesion and restore the mineral lost due to acid attack. [45]

The ACP technology was developed by Dr. Ming S. Tung. In 1999, ACP was incorporated into toothpaste called Enamelon and later reintroduced in 2004 in Enamel Care toothpaste by Church and Dwight. It is also available as Discus Dental's Nite White Bleaching Gel and Premier Dental's Enamel Pro Polishing Paste. It is also used in the Aegis product line, such as Aegis Pit and Fissure Sealant, produced by Bosworth. [46]

Sodium calciumphosphosilicate (bioactive glass)

When bioactive glass comes in contact with saliva, it rapidly releases sodium, calcium, and phosphorous ions into the saliva that are available for remineralization of the tooth surface. The ions released form hydroxycarbonate apatite (HCA) directly. They also attach to the tooth surface and continue to release ions and remineralize the tooth surface after the initial application. These particles have been shown to release ions and transform into HCA for up to 2 weeks. Ultimately, these particles will completely transform into HCA. [47]

Novamin adheres to exposed dentin surface and forms a mineralized layer that is mechanically strong and resistant to acid. There is a continuous release of calcium over time, which maintains the protective effects on dentin. [48]

The NovaMin Technology was developed by Dr. Len Litkowski and Dr. Gary Hack. Currently, available products in the market are NovaMin: SootheRx, DenShield, NuCare-Root Conditioner with NovaMin, NuCare-Prophylaxis Paste with NovaMin, and Oravive. [49],[50]

Calcium carbonate carrier-SensiStat

The SensiStat technology is made of arginine bicarbonate, an amino acid complex, and particles of calcium carbonate, a common abrasive in toothpaste. The arginine complex is responsible for adhering the calcium carbonate particles to the dentin or enamel surface and allows the calcium carbonate to dissolve slowly and release calcium that is then available to remineralize the tooth surface. [51]

The SensiStat Technology was developed by Dr. Israel Kleinberg of New York. The technology was first incorporated into Ortek's Proclude desensitizing prophy paste and later in Denclude. [52]

Xylitol carrier

The use of chewing gum carrying xylitol increases salivary flow rate and enhances the protective properties of saliva. This is because the concentration of bicarbonate and phosphate is higher in stimulated saliva, and the resultant increase in plaque pH and salivary buffering capacity prevents the demineralization of tooth structure. Moreover, the higher concentration of calcium, phosphate, and hydroxyl ions in such saliva also enhances remineralization. [53]

Miake et al. observed that xylitol can induce remineralization of deeper layers of demineralized enamel by facilitating Ca 2+ movement and accessibility. [54]


A study was done to determine the effect of nano-HAP concentrations on initial enamel lesions under dynamic pH-cycling conditions. It was concluded that nano-HAP had the potential to remineralize initial enamel lesions. A concentration of 10% nano-HAP may be optimal for remineralization of early enamel caries. [55]

The trimetaphosphate ion

The potential mode of action of trimetaphosphate ion (TMP) is likely to involve in adsorption of the agent to the enamel surface, causing a barrier coating that is effective in preventing or retarding reactions of the crystal surface with its fluid environment, and hence reducing demineralization during acid challenge. [56]

Gu et al. highlighted the role of sodium TMP as a templating analog of dentin matrix phosphoproteins for inducing intrafibrillar remineralization of apatite nanocrystals within the collagen matrix of incompletely resin infiltrated dentin. [57]

Alpha-tricalcium phosphate

It is used in products such as Cerasorb, Bio-Resorb, and Biovision. Tricalcium phosphate (TCP) has also been considered as one possible means for enhancing the levels of calcium in plaque and saliva. Some small effects on free calcium and phosphate levels in plaque fluid and in saliva have been found when an experimental gum with 2.5% alpha-TCP by weight was chewed, when compared to a control gum without added TCP. [58]

Dicalcium phosphate dihydrate

Inclusion of dicalcium phosphate dehydrate (DCPD) in a dentifrice increases the levels of free calcium ions in plaque fluid, and these remain elevated for up to 12 h after brushing, when compared to conventional silica dentifrices. [59]

Calcium from DCPD was incorporated into enamel and detected in plaque 18 h post-treatment after brushing with a DCPD dentifrice which fosters improved remineralization of teeth in combination with fluoride. [60]

The reaction of DCPD and fluoride forming fluorapatite may provide a potentially promising treatment for remineralization of caries lesions in vivo. [61]

  Conclusion Top

The dynamic balance between demineralization and remineralization determines the progression of white spot lesion. The diagnostic armamentarium includes novel technologies and non-invasive techniques like fiber-optic transillumination and electrical resistance methods which are very useful in detecting posterior approximal dentinal caries and occlusal caries. Radiographs and direct digital imaging are still important tools in estimation of caries. A clear understanding of the mechanism of subsurface lesion formation and progression, possibilities, and limitations of newer methods and their clinical applications need to be recognized by the dentist to direct preventive strategies to the high caries risk individuals. The emphasis currently is being given to new technologies for enamel remineralization which suggest the changes in the understanding of dental caries. Recent investigations have primarily focused on various calcium phosphate-based technologies which are designed to supplement and enhance fluoride's ability to restore tooth mineral.

  References Top

Toumba DC. Diagnosis and prevention of dental caries. In: Welbury R, Duggal MS, Hosey MT, editors. Paediatric Dentistry. 3 rd ed. UK: Oxford Univ Press; 2005. p. 109.  Back to cited text no. 1
Arends J, Christoffersen J. The nature of early caries lesions in enamel. J Dent Res 1986;65:2-11.  Back to cited text no. 2
Ashley PF, Blinkhorn AS, Davies RM. Occlusal caries diagnosis: An in vitro histological validation of the Electronic Caries Monitor (ECM) and other methods. J Dent 1998;26:83-8.  Back to cited text no. 3
Koulourides T, Feagin F, Pigman W. Remineralization of dental enamel by saliva in vitro. Ann N Y Acad Sci 1965;131:751-7.  Back to cited text no. 4
Schweizer-Hirt CM, Schait A, Schmid R, Imfeld T, Lutz F, Mühlemann HR. Erosion and abrasion of the dental enamel. Experimental study. SSO Schweiz Monatsschr Zahnheilkd 1978;88:497-529.  Back to cited text no. 5
Thylstrup A, Fredebo L. A method for studying surface coatings and the underlying features in SEM. In: Frank RM, Leach SA, editors. Surface and Colloid Phenomena in the Oral Cavity. Oxford: IRL Press; 1982. p. 169-84.  Back to cited text no. 6
Featherstone JD. The continuum of dental caries - evidence for a dynamic disease process. J Dent Res 2004;83 Spec No C:C39-42.  Back to cited text no. 7
Zero DT. Dental caries process. Dent Clin North Am 1999;43:635-64.  Back to cited text no. 8
Fejerskov O. Concepts of dental caries and their consequences for understanding the disease. Community Dent Oral Epidemiol 1997;25:5-12.  Back to cited text no. 9
Walsh LJ. Preventive dentistry for the general dental practitioner. Aust Dent J 2000;45:76-82.  Back to cited text no. 10
Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc 2000;131:887-99.  Back to cited text no. 11
Silverstone LM, Hicks MJ, Featherstone MJ. Dynamic factors affecting lesion initiation and progression in human dental enamel. II. Surface morphology of sound enamel and carieslike lesions of enamel. Quintessence Int 1988;19:773-85.  Back to cited text no. 12
Silverstone LM, Hicks MJ, Featherstone MJ. Dynamic factors affecting lesion initiation and progression in human dental enamel. Part I. The dynamic nature of enamel caries. Quintessence Int 1988;19:683-711.  Back to cited text no. 13
Hicks J, Garcia-Godoy F, Flaitz C. Biological factors in dental caries: Role of saliva and dental plaque in the dynamic process of demineralization and remineralization (part 1). J Clin Pediatr Dent 2003;28:47-52.  Back to cited text no. 14
Wenzel A, Verdonschot EH, Truin GJ, König KG. Accuracy of visual inspection, fiber-optic transillumination, and various radiographic image modalities for the detection of occlusal caries in extracted non-cavitated teeth. J Dent Res 1992;71:1934-7.  Back to cited text no. 15
Ferreira RI, Haiter-Neto F, Tabchoury CP, de Paiva GA, Bóscolo FN. Assessment of enamel demineralization using conventional, digital, and digitized radiography. Braz Oral Res 2006;20:114-9.  Back to cited text no. 16
Hintze H, Wenzel A, Jones C. In vitro comparison of D-and E-speed film radiography, RVG, and visualix digital radiography for the detection of enamel approximal and dentinal occlusal caries lesions. Caries Res 1994;28:363-7.  Back to cited text no. 17
Yassin OM. In vitro studies of the effect of a dental explorer on the formation of an artificial carious lesion. ASDC J Dent Child 1995;62:111-7.  Back to cited text no. 18
Pretty IA. Caries detection and diagnosis: Novel technologies. J Dent 2006;34:727-39.  Back to cited text no. 19
Yang J, Dutra V. Utility of radiology, laser fluorescence, and transillumination. Dent Clin North Am 2005;49:739-52, vi.  Back to cited text no. 20
Feng Y, Yin W, Hu D, Zhang YP, Ellwood RP, Pretty IA. Assessment of autofluorescence to detect the remineralization capabilities of sodium fluoride, monofluorophosphate and non-fluoride dentifrices. A single-blind cluster randomized trial. Caries Res 2007;41:358-64.  Back to cited text no. 21
Rousseau C, Poland S, Girkin JM, Hall AF, Whitters CJ. Development of fibre-optic confocal microscopy for detection and diagnosis of dental caries. Caries Res 2007;41:245-51.  Back to cited text no. 22
Ko AC, Choo-Smith LP, Hewko M, Leonardi L, Sowa MG, Dong CC, et al. Ex vivo detection and characterization of early dental caries by optical coherence tomography and Raman spectroscopy. J Biomed Opt 2005;10:031118.  Back to cited text no. 23
Jones RS, Darling CL, Featherstone JD, Fried D. Remineralization of in vitro dental caries assessed with polarization-sensitive optical coherence tomography. J Biomed Opt 2006;11:014016.  Back to cited text no. 24
Schneiderman A, Elbaum M, Shultz T, Keem S, Greenebaum M, Driller J. Assessment of dental caries with Digital Imaging Fiber-Optic TransIllumination (DIFOTI): In vitro study. Caries Res 1997;31:103-10.  Back to cited text no. 25
Jeon RJ, Matvienko A, Mandelis A, Abrams SH, Amaechi BT, Kulkarni G. Detection of interproximal demineralized lesions on human teeth in vitro using frequency-domain infrared photothermal radiometry and modulated luminescence. J Biomed Opt 2007;12:034028.  Back to cited text no. 26
Anttonen V, Seppä L, Hausen H. Clinical study of the use of the laser fluorescence device DIAGNOdent for detection of occlusal caries in children. Caries Res 2003;37:17-23.  Back to cited text no. 27
Young DA, Featherstone JD. Digital imaging fiber-optic trans-illumination, F-speed radiographic film and depth of approximal lesions. J Am Dent Assoc 2005;136:1682-7.  Back to cited text no. 28
Gimenez T, Braga MM, Raggio DP, Deery C, Ricketts DN, Mendes FM. Fluorescence-based methods for detecting caries lesions: Systematic review, meta-analysis and sources of heterogeneity. PLoS One 2013;8:e60421.  Back to cited text no. 29
Gomez J, Tellez M, Pretty IA, Ellwood RP, Ismail AI. Non-cavitated carious lesions detection methods: A systematic review. Community Dent Oral Epidemiol 2013;41:54-66.  Back to cited text no. 30
Twetman S, Axelsson S, Dahlén G, Espelid I, Mejàre I, Norlund A, et al. Adjunct methods for caries detection: A systematic review of literature. Acta Odontol Scand 2013;71:388-97.  Back to cited text no. 31
Arends J, Jongebloed WL, Schuthof J. The ultrastructure of surface enamel in relation to de-and remineralization. In: Leach SA, Edgar WM, editors. Demineralization and Remineralization of the Teeth. Oxford: IRL Press; 1983. p. 155-64.  Back to cited text no. 32
Haikel Y, Frank RM, Voegel JC. Scanning electron microscopy of the human enamel surface layer of incipient carious lesions. Caries Res 1983;17:1-13.  Back to cited text no. 33
Thylstrup A, Featherstone JD, Fredebo L. Surface morphology and dynamics of early enamel caries development. In: Leach SA, Edgar WM, editors. Demineralization and Remineralization of Teeth. Oxford: IRL Press; 1983. p. 165-84.  Back to cited text no. 34
Langdon DJ, Elliott JC, Fearnhead RW. Microradiographic observation of acidic subsurface decalcification in synthetic apatite aggregates. Caries Res 1980;14:359-66.  Back to cited text no. 35
Brudevold F, Mccann H, Gron P. In: Wolstenholm GE, editor. Dental Caries in Caries Resistant Teeth as Related to the Chemistry of Enamel. London: Churchill; 1965. p. 121-41.  Back to cited text no. 36
Rose RK. Effects of an anticariogenic casein phosphopeptide on calcium diffusion in streptococcal model dental plaques. Arch Oral Biol 2000;45:569-75.  Back to cited text no. 37
Reynolds EC. Calcium phosphate-based remineralization systems: Scientific evidence? Aust Dent J 2008;53:268-73.  Back to cited text no. 38
Kumar VL, Itthagarun A, King NM. The effect of casein phosphopeptide-amorphous calcium phosphate on remineralization of artificial caries-like lesions: An in vitro study. Aust Dent J 2008;53:34-40.  Back to cited text no. 39
Azarpazhooh A, Limeback H. Clinical efficacy of casein derivatives: A systematic review of the literature. J Am Dent Assoc 2008;139:915-24.  Back to cited text no. 40
Rose RK. Binding characteristics of Streptococcus mutans for calcium and casein phosphopeptide. Caries Res 2000;34:427-31.  Back to cited text no. 41
Schüpbach P, Neeser JR, Golliard M, Rouvet M, Guggenheim B. Incorporation of caseinoglycomacropeptide and caseinophosphopeptide into the salivary pellicle inhibits adherence of mutans streptococci. J Dent Res 1996;75:1779-88.  Back to cited text no. 42
Llena C, Forner L, Baca P. Anticariogenicity of casein phosphopeptide-amorphous calcium phosphate: A review of the literature. J Contemp Dent Pract 2009;10:1-9.  Back to cited text no. 43
Tung MS, Eichmiller FC. Dental applications of amorphous calcium phosphates. J Clin Dent 1999;10:1-6.  Back to cited text no. 44
Langhorst SE, O'Donnell JN, Skrtic D. In vitro remineralization of enamel by polymeric amorphous calcium phosphate composite: Quantitative microradiographic study. Dent Mater 2009;25:884-91.  Back to cited text no. 45
Sullivan RJ, Charig A, Blake-Haskins J, Zhang YP, Miller SM, Strannick M, et al. In vivo detection of calcium from dicalcium phosphate dihydrate dentifrices in demineralized human enamel and plaque. Adv Dent Res 1997;11:380-7.  Back to cited text no. 46
Du M, Tai BJ, Jiang H, Zhong J, Greenspan D, Clark A. Efficacy of dentifrice containing bioactive glass (NovaMin) on dentine hypersensitivity. J Dent Res 2004;83:13-5.  Back to cited text no. 47
Burwell A, Jennings D, Muscle D, Greenspan DC. NovaMin and dentin hypersensitivity - in vitro evidence of efficacy. J Clin Dent 2010;21:66-71.  Back to cited text no. 48
Tai BJ, Bian Z, Jiang H, Greenspan DC, Zhong J, Clark AE, et al. Anti-gingivitis effect of a dentifrice containing bioactive glass (NovaMin) particulate. J Clin Periodontol 2006;33:86-91.  Back to cited text no. 49
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. 50
Nizel AE, Harris RS. The effects of phosphates on experimental dental caries: A literature review. J Dent Res 1964;43:1123-35.  Back to cited text no. 51
McClure MJ. Further studies on the cariostatic effect of organic and inorganic phosphates. J Dent Res 1963;42:693-9.  Back to cited text no. 52
Mäkinen KK. Sugar alcohols, caries incidence, and remineralization of caries lesions: A literature review. Int J Dent 2010;2010:981072.  Back to cited text no. 53
Miake Y, Saeki Y, Takahashi M, Yanagisawa T. Remineralization effects of xylitol on demineralized enamel. J Electron Microsc (Tokyo) 2003;52:471-6.  Back to cited text no. 54
Huang SB, Gao SS, Yu HY. Effect of nano-hydroxyapatite concentration on remineralization of initial enamel lesion in vitro. Biomed Mater 2009;4:034104.  Back to cited text no. 55
Gonzalez M. Effect of Trimetaphosphate Ions on the process of Mineralization. J Dent Res 1971;50:1055-60.  Back to cited text no. 56
Gu LS, Kim J, Kim YK, Liu Y, Dickens SH, Pashley DH, et al. A chemical phosphorylation-inspired design for Type I collagen biomimetic remineralization. Dent Mater 2010;26:1077-89.  Back to cited text no. 57
Vogel GL, Zhang Z, Carey CM, Ly A, Chow LC, Proskin HM. Composition of plaque and saliva following a sucrose challenge and use of an alpha-tricalcium-phosphate-containing chewing gum. J Dent Res 1998;77:518-24.  Back to cited text no. 58
Walsh LJ. Contemporary technologies for remineralization therapies: A review. Int Dent S Afr 2009;11:6-16.  Back to cited text no. 59
Sullivan RJ, Masters J, Cantore R, Roberson A, Petrou I, Stranick M, et al. Development of an enhanced anticaries efficacy dual component dentifrice containing sodium fluoride and dicalcium phosphate dihydrate. Am J Dent 2001;14 Spec No:3A-11A.  Back to cited text no. 60
Wefel JS, Harless JD. The use of saturated DCPD in remineralization of artificial caries lesions in vitro. J Dent Res 1987;66:1640-3.  Back to cited text no. 61

This article has been cited by
1 Second Order Differentiation Analysis of Micro FTIR Method Revealed the Variable Erosion Characteristics of Carbonated Soft Drink for the Individual Human Teeth Enamel
Tetsuro Kono,Arata Watanabe,Takeshi Kanno,Yukari Ootani,Ryo Tamamura,Toshiro Sakae,Hiroyuki Okada
Journal of Hard Tissue Biology. 2019; 28(1): 7
[Pubmed] | [DOI]
2 Oral health and socio-economic status among children during Syrian crisis: a cross-sectional study
Bahaa Aldin Alhaffar,Raeed Alawabdi,Leen Barakat,Chaza Kouchaji
BMC Oral Health. 2019; 19(1)
[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
Subsurface White...
Detection of Whi...
Characteristics ...
Surface Layer Co...
Remineralizing A...

 Article Access Statistics
    PDF Downloaded2820    
    Comments [Add]    
    Cited by others 2    

Recommend this journal