Along these same lines of observation, we more recently have begun to consider the entire caries process and approach the disease differently than in the past. We have long known caries is a complex biological process which involves an infectious agent (acid-forming bacteria), the host or patient, and the diet (fermentable carbohydrates). If the diet is balanced in such a way that the host protective factors (saliva) and fluoride can overcome the bacterial acid challenge, no net demineralization occurs. Increased frequency of foods that are acidogenic can tip this balance in the direction of net demineralization. A human, intraoral, demineralization/remineralization model was used to evaluate various between-meal snack foods. The study demonstrated that certain foods can cause net remineralization while "acidogenic" foods can cause demineralization.9 Duggal et al.10 used a slightly different human model to examine the frequency of carbohydrate consumption with and without fluoride toothpaste. When a fluoride free toothpaste was used and carbohydrate frequency exceeded 3 times per day, significant demineralization occurred. When subjects used a fluoride-containing toothpaste, net demineralization was only seen when carbohydrate consumption exceeded 10-times/day. This study emphasizes the need for use of a fluoride toothpaste by all patients to help balance, prevent, and reverse the caries process on a daily basis. Hicks et al.11-13 have provided a three-part series on the biological factors in the caries process with respect to demineralization and remineralization and also emphasize the role of low levels of fluoride on a daily basis.
In this example a 15-year old male had his orthodontic brackets removed and came directly to the general dentist's office presenting as shown below. This illustrates an imbalance in the demineralization/remineralization process to the extent of developing many frank cavitated lesions which cannot be remineralized. Is there a need for understanding the caries process here and preventing demineralization? Could the lesions have been recognized at an early stage and been reversed through remineralization?