Enamel Remineralization: The Medical Model of Practicing Dentistry

In the medical profession patients are generally treated 2 ways - either medically or surgically. If a patient has some type of small tumor, the surgical way to treat this is physically to access the tumor and then surgically remove it. The medical way may consist of using chemotherapy to treat this tumor without having an invasive procedure.
The question that we have as treating dentists and hygienists is this: how do we want to treat our patients? Certainly right now, we overwhelmingly treat hard and soft dental structures the surgical way. Whether it is teeth, hard bony tissue, soft-tissue structures, or everything in between, we are picking up a high-speed handpiece, a laser, a scalpel, or a scaler, and physically treating the mouth.
Do we have a medical model for treating dentition? The answer is absolutely yes, and we need to agree to a paradigm shift to add a medical regimen for treating teeth. We all now use somewhat of a medical regimen to treat periodontal disease and certainly dental infections with prescription antibiotics and oral hygiene prevention. I would venture to say that very few of us use a medical model to treat carious lesions, but doing so can add tremendous value to your practice of dentistry.

MINIMUM INTERVENTION

Minimum intervention, or MI, is the modern medical approach to management of caries. The principles are really very simple. The first principle is to assess and identify any carious risk factors early on. The second principle is to minimize these risk factors in order to help prevent caries. The third and final principle is conserving as much tooth structure as possible if we need to restore the tooth.
Let me give you a quick primer as to what is happening in your mouth and your patients’ mouths right now. Caries is a bacterial infection and is a multifactorial process that consists of constant demineralization and remineralization. Dental plaque, which is a complex biofilm, sits on the teeth, and when fueled by carbohydrates and a high-sugar diet will go ahead and produce acids. These acids sit right up against the tooth structure, creating a very low pH, which starts demineralizing the enamel rods. Calcium and phosphate ions get sucked out of the enamel rods, and these are some of the building blocks of the enamel. Then, what seems like all of a sudden, the enamel turns white in what you see clinically as a white spot lesion. These white spots on the enamel have not cavitated yet and have not yet created an actual cavity until more of the demineralization process occurs and the enamel rods start to collapse.
Saliva has naturally occurring calcium and phosphate ions in it. The saliva tries to buffer the low pH that the bacterial acids have created, and once the pH is buffered, these calcium and phosphate ions naturally occurring in the saliva try to infuse back into the enamel. This process is happening constantly in everyone’s mouth. When the demineralization wins, you have a white spot lesion that feels rough to the explorer, and sometimes if it’s far enough along and soft enough, you can actually poke through it with the explorer, creating the cavity. When remineralization wins in these cases, you’ve got frosty looking enamel that is hard and smooth to the touch of an explorer.
The medical model to approaching these white spot lesions is to aid the remineralization process so that these will not turn into actual cavities. When do you see these white spots? You and I, as dental clinicians, see these all the time. Certainly you find them in a patient who has not brushed very well during orthodontic treatment. By no means is this the only place that you see them. Look very carefully at your next clinical exam and you will find many patients, if not most  (unless they have a very low caries risk), will have certain white spots all over their mouths as this remineralization/demineralization process keeps occurring.
I know that many dentists and hygienists, when seeing these white spots, may not even note them in their clinical exam or may not even tell the patient about them. If a patient asks about the white spots, we usually tell him or her that there is nothing to worry about, and we will just watch them. Using the medical model here, disease activity is actually going on, especially if the spots feel rough as you drag your explorer over the top of them. We need to treat these areas, not watch them get worse. When I talk about treating these, I am talking about treating them medically, not surgically.

TREATING MEDICALLY

The way to treat white spot lesions medically is to try to get calcium and phosphate ions to these lesions as quickly and as directly as you can. You may have seen the term ACP, which stands for amorphous calcium phosphate, used in the remineralization literature. ACP has been shown to be able to provide the necessary calcium and phosphate ions, which can then aid the remineralization process to rebuild the enamel and work with fluoride to make the enamel strong. ACP has been around for a long time, and an ADA Health Foundation study that is about 30 years old has shown it to be effective. Various toothpastes and even whitening products on the market contain ACP. The challenge with ACP alone is that it increases the calcium and phosphate ions in the mouth, but they aren’t generally directed to the place where you need them the most, which is into the plaque, biofilm, and then into the tooth.
CPP-ACP, which stands for casein phosphopeptides with ACP, actually attaches to the plaque and the bacteria in the plaque, and then releases the ACP right onto the tooth surface where it is needed the most. Recaldent is the trademark name for this, and it can be found in the very innovative product Prospec MI Paste (GC America). Prospec MI Paste has multiple uses that will fit most of the patients in your practice right now. Because of a unique CPP-ACP formulation, it will help remineralize white spot lesions that you see on patients. It will also block dentinal tubules and eliminate sensitivity in teeth, and will help reduce the caries risk factors for your patients.
Let’s talk about dentin hypersensitivity for a few moments. Patients walk in with sensitivity for all kinds of reasons. The most common causes of hypersensitivity are related to dental erosion, receding gingiva, periodontal disease, or post periodontal therapy. Dentin hypersensitivity is also produced by the various treatments given in our office that patients need or want, which include tray or 1-hour whitening as well as scaling and root planing. Going forward, any patient in our office who has scaling and root planing will automatically get a tube of Prospec MI Paste to apply to their sensitive teeth to reduce and eliminate postoperative sensitivity issues quickly and easily.
I know that whitening in this day and age is not supposed to induce any kind of sensitivity, especially if you believe all the manufacturers’ claims. I routinely speak to hundreds of dentists in my lectures, and I often survey the crowd as to which dental offices in the room have had patient complaints of dental sensitivity with any kind of whitening. Nearly every hand goes up, and this is with the whitening desensitizing formulas! Prospec MI Paste is placed into a tray or onto the teeth with the patient’s finger after a whitening treatment. This will quickly and easily eliminate sensitivity.
Prospec MI Paste is a water soluble, sugar-free formulation that comes in 5 different flavors, which will also help stimulate saliva production and help the buffering capacities of the mouth. It is applied in-office with a prophy cup after prophylaxis, root planing, and in-office whitening. The rest of the tube can be given to the patient for at-home use. Prospec MI Paste can be applied with a tray (my method of choice), or the patient can apply it with a finger. It stays in the mouth for 3 to 5 minutes, at which time the patient can expectorate the rest and rinse lightly if needed. Ideally, for white spot lesions and patients with high recurrent decay, I try to have them use it at night and expectorate as much as possible, then go to sleep without rinsing so it can stay on the teeth all night.
The cost of using this CPP-ACP technology can easily be absorbed into many of the procedures that you do already so that your patients can take advantage of this wonderful remineralizing technology that exists for us today. When the Prospec MI Paste is used for caries control and dentin hypersensitivity, we usually make the patient a custom-fitted tray similar to a home-whitening tray to facilitate applying the paste evenly. We then charge the patient for the tray and the material. The tremendous benefits of eliminating dentin hypersensitivity and reducing a patient’s caries risk at a reasonable cost are a wonderful service for our patients.


Dr. Malcmacher is an internationally known lecturer and author, known for his comprehensive and entertaining style. An evaluator for CRA, Dr. Malcmacher has served as a spokesman for the AGD and is a consultant to the Council on Dental Practice of the ADA. He works closely with dental manufacturers as a clinical researcher in developing new products and techniques. He can be reached at (440) 892-1810 or via e-mail to This e-mail address is being protected from spambots. You need JavaScript enabled to view it . His lecture schedule is available at commonsensedentistry.com.

Disclosure: The author has received honoraria for work done for GC America.