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Tooth Enamel Demineralization

What is Tooth Enamel Demineralization?

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 does the dentist diagnose Tooth Enamel Demineralization?

Note: ToothIQ.com contains general information. Only a dentist can properly diagnose your specific condition.

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.

How is Tooth Enamel Demineralization treated?

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 (or causes), 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.

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Author: Thomas J. Greany, D.D.S. / Editor: Ken Lambrecht

This page was last updated on February 9, 2018.

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