Topic 4

Enamel Caries

According to ICD-10, enamel caries is coded as K02.0 - Caries limited to

enamel. This diagnosis has two clinical forms: white spot lesions [initial caries]
and a superficial cavity, limited to enamel.
According to radiological classification enamel caries is coded as E1 (outer
half of enamel) or E2 (inner half of enamel).

Pathogenesis and histological features

After dental plaque maturation cariesogenic microorganisms began to utilize
sugars during anaerobic glycolysis. Lactic acid is produced, ph under the plaque
becomes acidic, hydroxyapatite crystals are dissolved. This process is called
enamel demineralization and it starts every time sugar enters in the mouth. The
best illustration of pH dynamic in dental plaque is so called Stephan curve.

Question: why salivary buffering system does not neutralize a small amount
of acid?
Answer: dental plaque is fixed on the enamel surface and prevents interaction
between enamel and oral fluid.

As a result of repeated acidic attacks white spot develops.

The four regularly zones in a sectioned incipient lesion are observed: (outside
to inside): surface zone, body of the lesion, dark zone, and translucent zone.
- Surface Zone. The surface zone is relatively unaffected by the caries attack.
It has a lower pore volume than the body of the lesion (<5%) and a radiopacity
comparable to unaffected enamel. The surface of normal enamel is hyper-
mineralized by contact with saliva and has a greater concentration of fluoride ion.
This is the first reason for the relative immunity of the enamel surface. The other
reason is remineralization, which occurs on the enamel surface even under the
plaque. The intact surface over incipient caries is a phenomenon of the caries
demineralization process rather than any special characteristics of the superficial
enamel.
- Body of Lesion. The body of the lesion has the largest pore volume, varying
from 5% at the periphery to 25% at the center. The striae of Retzius are well
marked in the body of the lesion, indicating preferential mineral dissolution along
these areas of relatively higher porosity. The first penetration of caries enters the
enamel surface via the striae of Retzius. The interprismatic areas and these cross-
striations provide access to the rod (prism) cores, which are preferentially attacked.
Bacteria may be present in this zone if the pore size is large enough to permit their
entry. Studies using transmission electron microscopy and scanning electron
microscopy show the presence of bacteria invading between the enamel rods
(prisms) in the body zone.
- Dark Zone. This zone is known as the dark zone because it does not
transmit polarized light. This light blockage is caused by the presence of many tiny
pores too small to absorb quinoline. These smaller air-filled or vapor-filled pores
make the region opaque. The total pore volume is 2% to 4%. Experimental
remineralization has shown increases in the size of the dark zone at the expense of
the body of the lesion. There is also a loss of crystalline structure in the dark zone,
suggestive of the process of demineralization and remineralization. The size of the
dark zone is probably an indication of the amount of remineralization that has
recently occurred.
- Translucent Zone. The translucent zone is the deepest zone and represents
the advancing front of the enamel lesion. The name refers to its structureless
appearance when perfused with quinoline solution and examined with polarized
light. In this zone, the pores or voids form along the enamel prism (rod)
boundaries, presumably because of the ease of hydrogen ion penetration during the
carious process. When these boundary area voids are filled with quinoline solution,
which has the same refractive index as enamel, the features of the area disappear.
The pore volume of the translucent zone of enamel caries is 1%, 10 times greater
than normal enamel.

At this stage carious process is reversible. Arresting the caries process at this
stage results in a hard surface, this may at times be rough, although cleanable.

As the enamel lesion progresses, scanning electron microscopy shows

conical-shaped defects in the surface zone. These are probably the first sites where
bacteria can gain entry into a carious lesion. Microorganisms cause further
demineralization and, finally, organic matrix distraction. After cavity formation the
process becomes irreversible.

Initial caries. Clinical features.

On clean, dry teeth, the earliest evidence of caries on the smooth enamel
surface of a crown is a white spot (usually on the facial and lingual surfaces of
teeth). Similar noncavitated lesions occur on the proximal smooth surfaces or in
fissures, but usually are undetectable.
White spots are chalky white, opaque areas that are observed when enamel is
dry. These areas of enamel lose their translucency because of the extensive
subsurface porosity caused by demineralization. The surface texture of a non-
cavitated lesion is unaltered and is undetectable by tactile examination with an
explorer.
A more advanced lesion develops a rough surface that is softer than the
unaffected, normal enamel. Softened chalky enamel that can be chipped away with
an explorer is a sign of active caries. Use of an explorer tip can cause actual
cavitation in a previously noncavitated area, requiring, in most cases, restorative
intervention. Removal of dental deposits with ultrasound scaler or air-flow device
also can cause cavity formation.
 Noncavitated enamel lesions sometimes can be seen on radiographs as a faint
radiolucency that is limited to the superficial enamel. When a proximal lesion is
clearly visible radiographically, the lesion may have advanced significantly, and
histologic alteration of the underlying dentin probably already has occurred,
whether the lesion is cavitated or not.

Cavitated enamel lesions can be initially detected as subtle breakdown of the

enamel surface. These lesions are very sensitive to probing, and can be easily
enlarged by using sharp explorers with excessive probing force. More advanced
cavitated enamel lesions are more obviously detected as enamel breakdown.
Although some cavitated enamel lesions can be arrested and may not progress to
larger lesions, most cavitated caries lesions require restorative treatment.

Non-cavitated caries of enamel can partially remineralize and stay relatively

stable for a long period of time. The supersaturation of saliva with calcium and
phosphate ions serves as the driving force for the remineralization process.
Arrested lesions (K02.3 Arrested dental caries) can be observed clinically as intact,
but discolored, usually brown or black, spots. The change in color is presumably
caused by trapped organic debris and metallic ions within the enamel. These
arrested caries areas should not be restored unless they are esthetically
objectionable. Mind, that arrested caries is not an initial process. The most of
pigmented spots penetrate into dentine.
 The main clinical features of enamel caries are presented in the table 1.
Table 1
White spot Cavitated lesion, limited to
enamel
Chief complaint No complaint / esthetic Short-time tenderness to sweet
complaints or cold meal
Visual White opaque spot Small defect on the enamel
examination surface
Probing Probing is painless Pain on probing
Smooth or rough surface Rough surface
Additional Color test (staining with Transillumination (to detect
diagnostic methylene blue) hidden cavities)
methods Fluorescent diagnostics Radiological examination
Radiological examination (cavity detection, lesion depth
assessment)

Initial caries. Differential diagnosis

White spot lesion should be differed from non-carious lesions: fluorosis and
enamel hypoplasia (see table 2)

Table 2.
Differential diagnosis of the enamel caries (white spot)

Enamel caries Fluorosis Enamel hypoplasia

(nonhereditary)
time of after the eruption of before the eruption before the eruption
development tooth
localization typical for caries vestibular surface a lot of white spots
(often cervical of teeth with the on all tooth
area) same time of surfaces of all teeth
development
probing enamel is opaque, the surface is the surface is
rough smooth, shiny smooth, shiny
Staining with yes no no
methylene blue 2%
 Cavitated lesion, limited to enamel, should be differ from fluorosis, enamel
hypoplasia, wedge defect and enamel erosion (see table 3).

Table 3.
Differential diagnosis of the enamel caries (cavitated lesion)

Enamel caries Fluorosis Enamel Wedge defect Enamel erosion

hypoplasia
time of after eruption before before after eruption after eruption
development of tooth eruption eruption
complaints Short-time Esthetic Esthetic Short-time Short-time
tenderness to complaints complaints tenderness to tenderness to
sweet or cold sweet or cold sweet or cold
meal meal meal
Visual A small Mani small Single or V-shaped Broad rounded
examination enamel defect round defects multiple defects in concavity in
in cervical area on opaque or defects on cervical area equator area of
brown enamel enamel surface incisors
exploration Pain on Probing is Probing is Pain on probing Pain on probing
probing painless painless the surface is the surface is
enamel is the surface is the surface is hard, shiny hard, opaque
opaque, rough hard, shiny hard, shiny