Tooth Enamel Demineralization

Dental diagnosis
Overview
Severe enamel demineralization from methamphetamine abuse.

Figure 1a: Severe enamel demineralization secondary to chronic use of methamphetamine (“meth mouth”). These teeth exhibit generalized enamel demineralization that ranges from early to advanced. Areas where it has completely eroded through the enamel into the underlying dentin appear as brown spots.

Enamel demineralization represents a superficial dissolving of the surface enamel—the glassy outer shell — of the tooth. It is the earliest stage of tooth decay (caries), and is most commonly seen on the visible “facial” surfaces of teeth as frosty white areas (so-called “white spot” lesions).

It is caused by a regular exposure of the tooth enamel to acids, such as those produced within accumulations of bacterial plaque. White spot lesions can also be caused by direct exposure to acids found in food and drinks. Commonly, the white spots will darken as their roughened surface easily accumulates stains.

Common sources of acids

Softened tooth enamel removed after severe demineralization from meth abuse.

Figure 1b: The extent of damaged tooth structure became evident after the softened enamel was removed.

  • Bacterial plaques
  • Frequent ingestion of acidic beverages (e.g. phosphoric acid is a common ingredient in soda, sports drinks and flavored water—it’s even found in diet soda!)
  • Frequent exposure of the teeth to citrus fruits, which contain citric acid (particularly lemons)
  • Stomach acids (as in the eating disorder, bulimia and patients with reflux disorders. Cells in the stomach produce hydrochloric acid to help digest food.)
  • Certain drugs such as methamphetamines (meth), whether from the drug itself, poor nutrition, chronic dry mouth caused by the drug, or poor dental hygiene common in drug abusers.
  • Poor dental hygiene while undergoing orthodontic treatment frequently results in white spot lesions or enamel demineralization.
  • Infection/inflammation. This is the cause of the isolated white spot demineralized areas which are commonly seen on permanent incisor teeth, after a primary (baby) incisor is injured. The primary tooth root is positioned very close to the developing crown of the permanent incisor. If the primary tooth is injured and becomes inflamed at its root tip, the inflammation can demineralize the permanent incisor crown (known in such cases as Turner’s hypoplasia). Those white spots typically are not soft and chalky, however.
How is this dental diagnosis established?

Tooth enamel is extremely durable, and is glassy smooth when healthy. Early demineralization usually appears as frosty white spots on the enamel. Demineralized enamel has a chalky surface, which may scrape off in a fine powder with relative ease, and readily picks up brown stains from coffee, tea, smoking, and food / drink colorings.

Clues about the origin of the demineralized enamel can be obtained by studying the pattern of demineralization on the teeth. This includes looking at which teeth are involved, which surfaces of the teeth, the amount of surface area involved, and the location of the demineralization.

For example, patients with the eating disorder, bulimia, typically show acid erosion of the palatal surfaces of the upper front teeth. Patients who maintain poor oral hygiene (especially while in braces) often have demineralization in the gingival one third of the teeth (often, in the tell-tale shape of an orthodontic bracket).

Enamel demineralization can be difficult to discern from enamel hypoplasia (a condition in which the enamel shell is thin, and may be pitted or otherwise irregular; or from enamel hypocalcification, a condition in which the enamel never mineralizes completely to begin with. Generally, however, if it is possible to establish that the enamel was once regular, and that chalky demineralized spots occurred since that time, the diagnosis of enamel demineralization is correct.

Many times, early enamel demineralization won’t be apparent on X-ray images of the teeth, because enough hard enamel remains to stop the penetration of X-rays. However the remaining hard tissue may no longer be durable.

Treatment options

Early demineralization can often be arrested by the application of topical fluoride gels or varnishes. The dentist may recommend using a prescription-strength fluoride toothpaste or mouth rinse until the soft spots can be remineralized. It’s important to understand the cause(s) of the problem, and the cause(s) must be eliminated for treatment to be successful. Diagnostic photographs and radiographs will likely be prescribed to document the progression of enamel demineralization to cavities that need fixing.

If early enamel demineralization is not treated to arrest the damage, and its causes are not eliminated, it may be necessary to cut out the weakened tooth enamel and place some type of dental restoration—which is certainly indicated if the demineralization extends into the dentin layer of the tooth or produces an irregular, plaque-retentive enamel surface (Figure 1a in Overview).

If enamel demineralization is considered unattractive by the patient, treatment options may include tooth bleaching, tooth colored fillings, and/or veneers. For bleaching to be a permanent solution, the tooth enamel must be of normal hardness, and free of bacteria (which will continue to decay the tooth).

Depending on the cause(s), the patient may require nutrition counseling, drug counseling or counseling on eating disorders for the best likelihood of successful dental restoration.

Depending on the extent of damage caused by the enamel demineralization, the patient may require fillings, veneers, onlays and/or crowns to restore the teeth to normal contours, function and esthetics.

Related diagnoses

Tooth decay (caries), enamel demineralization and acid erosion are all caused by acids. Identifying the source of the acids is important if treatment is to be successful. Enamel hypoplasia can produce an enamel surface having a surface similar to these conditions; however, its cause is damage during the formation of the tooth.

Author: Thomas J. Greany, D.D.S.
Editor: Ken Lambrecht
This page was reviewed by members of our review board.

This page was last updated on July 8, 2015.

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Related pages on ToothIQ.com

Caries
Caries
Crowns
Crowns
Enamel Hypoplasia
Enamel Hypoplasia
Fillings and Core Buildups
Fillings and Core Buildups
Fluoride Treatments
Fluoride Treatment
Onlays
Onlay
Photographs
Photographs
Poor Oral Hygiene
Poor Oral Hygiene
Tooth Whitening
Tooth Whitening
Veneers
Veneers
X-rays
X-rays

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Background information

Methamphetamine Use and Dental Disease: Results of a Pilot Study
Cretzmeyer, Margaret, et al.
Journal of Dentistry for Children
2007 74 (2): 85-92

The use of sorbitol- and xylitol-sweetened chewing gum in caries control
Burt, Brian A., BDS, MPH, PhD
The Journal of the American Dental Association
2006 137 (2): 190-196

A Caries Vaccine? The State of the Science of Immunization Against Dental Caries
Russel, Michael W., et al.
Caries Research
2004 38: 230-235

Minimally invasive dentistry
Murdoch-Kinch, Carol Anne, DDS, PhD, and McLean, Mary Ellen, DDS
The Journal of the American Dental Association
2003 134: 87-95

Eating habits that can harm teeth
ADA Division of Communications
The Journal of the American Dental Association
2002 133 (12)

Protective Immunity to Streptococcus mutans Induced by Nasal Vaccination with Surface Protein Antigen and Mutant Cholera Toxin Adjuvant
Saito, Masayuki, et al.
The Journal of Infectious Diseases
2001 183: 823-826

Caries-Detector Dyes — How Accurate and How Useful Are They?
McComb, BDS, M.Sc.D., FRCD( C )
Journal of the Canadian Dental Association
2000 66: 1995-1998

The science and practice of caries prevention
Featherstone, John D.B., MSc, PhD
The Journal of the American Dental Association
2000 131 (7): 887-899

Prevention of colonization of Streptococcus mutans by topical application of monoclonal antibodies in human subjects
Ma, J.K., and Lehner, T.
Archives of Oral Biology
1990 35
Notes: Supplement: 115S-122S. Dept. of Immunology, United Medical School, Guy’s Hospital, London, England.

Topical Fluoride Therapy: Discussion of Some Aspects of Toxicology, Safety, and Efficacy (PDF, 665K)
Newbrun, E.
Journal of Dental Research
1987 66: 1084-1086

Caries Vaccine
Various
HealthMantra web site
Last viewed: 7/15/2016
Editor’s notes: An untitled article summarizing various international research projects aimed at developing a caries vaccine. Summary discusses progress 1990–1999.

Dental Fluorosis (Mottled Teeth)
Meiers, Peter
Fluoride-History web site
Last viewed: 7/15/2016
Editor’s notes: Personal web site cataloging various personalities, milestones, and volatile issues associated with fluoride.

Methamphetamine use and oral health
ADA Division of Communications in cooperation with JADA and the ADA Division of Scientific Affairs
The Journal of the American Dental Association

More U.S. Teeth Susceptible to Silent Enamel Eating Syndrome
Not specified
Medical News Today web site
Last viewed: 7/15/2016

More U.S. Teeth Susceptible to Silent Enamel Eating Syndrome
Not specified
Medical News Today web site
Last viewed: 7/15/2016

Vaccine prevents cavities—ready for tests on tots
Cromie, William J.
Harvard University Gazette
Notes: Published October 4, 2001

Information you may wish to read before making a decision on treatment

Evaluation of a new caries detecting dye for primary and permanent carious dentin
Hosoya, Y., et al.
Journal of Dentistry
2007 35 (2): 137-143

Minimally invasive operative techniques using high tech dentistry (PDF, 148K)
Brostek, Andrew M. Dr., et al.
Dental Practice
2006: 106-106
Editor’s notes: Online publication date September/October 2006.

Porcelain Laminate Veneers. A Retrospective Evaluation After 1 to 10 Years of Service: Part II—Clinical Results
Dumfahrt, Herbert, Dr med and Schaffer, Herbert, Univ-Doz Dr med
International Journal of Prosthodontics
2000 13 (1)
Editor’s notes: Findings in this study were generally positive, and provide evidence in support of porcelain veneers.

Addressing the caries dilemma: detection and intervention with a disclosing agent
Styner, D. et al.
General Dentistry
1996 44 (5): 446-449

The use of caries detector dye in diagnosis of occlusal carious lesions
al-Sahaibany, F., et al.
Journal of Clinical Pediatric Dentistry
1996 20 (4): 293-298

Cranberries contain possible anti-caries/anti-plaque agents
BrightSurf.com web site
Last viewed: 7/15/2016
Editor’s notes: Correspondence with the IADR showed that this research was presented at the annual meeting of the IADR in Brisbane, Australia, June 29, 2006 by Koo, H, et al. Dr. Koo’s group has published two articles on the subject.