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Does acid etching enhance remineralisation of

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Article in European Archives of Paediatric Dentistry. Official Journal of the European Academy of Paediatric
Dentistry June 2014
DOI: 10.1007/s40368-014-0131-2 Source: PubMed

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Eur Arch Paediatr Dent (2014) 15:413419

DOI 10.1007/s40368-014-0131-2

ORIGINAL SCIENTIFIC ARTICLE

Does acid etching enhance remineralisation of arrested white spot

lesions?
S. N. Al-Khateeb S. J. Tarazi E. F. Al Maaitah
O. B. Al-Batayneh E. S. J. Abu Alhaija

Received: 2 April 2014 / Accepted: 6 May 2014 / Published online: 21 June 2014
European Academy of Paediatric Dentistry 2014

Abstract
Aim To investigate the effect of acid etching procedure
on the remineralisation of white spot lesions (WSL) which
had undergone an initial phase of arrest, and to compare
between the effect of fluoride and/or CPP-ACP on remineralisation before and after acid etching.
Study design In vitro study.
Methods WSL were prepared in vitro on 130 human
enamel slabs which were allocated into four experimental
groups (N = 30) and one control group (N = 10). Changes
in mineral content were registered weekly by Quantitative
Light Induced Fluorescence QLF. When changes had
arrested (after 8 weeks), the enamel surface of 20 slabs in
each group were acid etched. The remineralisation process
was continued until it slowed down again (after 5 weeks).
Results Mean fluorescence gain was 13.7 0.9 % in the
fluoride group, 16.5 1.1 % in the CPP-ACP group, and
11.4 1.2 % in the combination of fluoride and CPP-ACP
group.
Conclusions There was a tendency toward better remineralisation after acid etching but this did not reach a significant level; the effect of etching was more pronounced in
the presence of fluoride. Although CPP-ACP seemed to
give a steadier rate of remineralisation over time when
compared with fluoride, the overall remineralisation in the
regimens was similar. In this model, combined treatment of
fluoride and CPP-ACP did not have an extra benefit over
the fluoride or CPP-ACP alone.

S. N. Al-Khateeb (&)
S. J. Tarazi
E. F. Al Maaitah

O. B. Al-Batayneh
E. S. J. Abu Alhaija
Department of Preventive Dentistry, Faculty of Dentistry, School
of Dentistry, Jordan University of Science and Technology,
P.O. Box 3030, Irbid, Jordan
e-mail: susank@just.edu.jo

Keywords Acid etching
Remineralisation
CPP-ACP

Fluoride
QLF

Introduction
White spots which have arrested present a significant aesthetic challenge when they are present on anterior teeth,
and hence there is interest in how to accelerate the remineralisation process. These areas are known to be relatively impermeable, making further attempts to treat them
problematic. Several attempts have been made to enhance
the remineralisation process of white spot lesions (WSL)
such as the use of topical fluoride in different concentrations and forms (Amaechi et al. 2012; Brighenti et al. 2013;
Danelon et al. 2013), the use of casein phosphopeptide
amorphous calcium phosphate (Rose 2000; Sudjalim et al.
2006) or increasing the porosity of the outermost surface
layer of the WSL (Al-Khateeb et al. 2000). However, only
partial remineralisation of WSL occurred in most cases
where fluoride was used alone (Bishara and Ostby 2008).
This stresses the need for improved protocols to maximise
the rate and amount of remineralisation.
A proposed mechanism to enhance the remineralisation
process is acid etching of enamel surface layer; phosphoric
acid etching would remove the fluoride-rich layer and
expose more reactive crystals without affecting porosity
and mineral content of the underlying tissues of the body of
the lesion (Peariasamy et al. 2001). It would also promote
the removal of deposits from enamel pores and thus give
greater access to the outermost enamel. By first using acid
etching, a more pronounced reduction in lesion depth and
enamel irregularity in WSL has been seen following remineralisation (Flaitz and Hicks 1994; Yamazaki et al. 2007;
Baroni et al. 2013). Al-Khateeb and coworkers (2000)

123

414

reported an increase in the amount of mineral deposition in

the enamel surface and body of the lesion by first acid
etching the WSL surface, however the enhanced rate of
remineralisation seemed to reach a plateau of effect after a
few weeks, suggesting the possible need for further etching
treatments during the remineralisation process.
A concern with acid etching is that when applied injudiciously, it will dissolve the surface layer of enamel to the
point that surface loss is not recovered by the remineralisation process (Hidaka et al. 2011). This finding may discourage any attempt for a second etching of enamel surface
during the remineralisation process. Nevertheless, a repeated etching protocol could be worthwhile when it becomes
apparent clinically that remineralisation rates are slowing.
The effect of a second etching step under such conditions
has not hitherto been examined. Accordingly, the aim of
this in vitro study was to investigate the effect of acid etching
on the remineralisation of WSL after they have been exposed
to a remineralising regimen and the remineralisation process
had slowed down. This was accomplished using either
fluoride and/or CPP-ACP as the remineralising agents.
Changes in mineral content during the remineralisation
process, pre- and post-etching were assessed using quantitative light induced fluorescence (QLF).

Materials and methods

One hundred and thirty sound premolar teeth were selected
from 200 sound human premolars extracted for orthodontic
reasons. All teeth were polished with non-fluoridated prophylaxis paste using a brush on a low speed handpiece. The
buccal surfaces of the polished premolars were removed
using a fissured diamond bur in a high speed hand piece
with water cooling. A diamond disc was then used to flatten
the cut surfaces. The samples were glued to numbered
plastic holders. The enamel surface of each sample was
covered with nail varnish leaving a window of
*2 mm 9 3 mm. Subsurface artificial lesions in the
enamel slabs were produced using the lactic acid-methyl
gel method with an exposure time of 10 days (Al-Khateeb
et al. 2002). Nail varnish was removed from the enamel
surface with acetone. QLF images, using the QLF-D Biluminator 2? (Inspektor Research Systems BV, Amsterdam, The Netherlands), were captured at this stage to
record the amount of fluorescence loss just after the initial
demineralisation stage (T0), to then serve as a baseline.
The QLF system included Canon Camera EOS 550D with
Canon EF-S 60 mm f/2.8 USM macro lens (Canon Inc.,
Tokyo, Japan) and BiluminatorTM Tube, with blue illumination from 12 high performance LEDs, white illumination
from 4 LEDs, and a QLF high-pass yellow filter.

123

Eur Arch Paediatr Dent (2014) 15:413419

To ensure reproducibility of the QLF images, the samples were placed on an xy table so that samples could be
replaced in the same position for successive images. The
QLF tube attached to the camera covered the sample
completely and also kept the distance between the sample
and the lens constant.
The samples were assigned randomly into four experimental groups and a control group; sample #1 was assigned
to group A, sample #2 to group B, sample #3 to Group C
and sample #4 to group D. Every thirteenth sample was
assigned to the control group.
Each experimental group comprised 30 enamel samples
(Sample size calculation revealed that for an 80 % power
and 5 % precision (a = 0.05), the study should include at
least 14 subjects). The control group comprised ten samples. The samples in each group were exposed to one of the
following regimens:
Group A
In this group, enamel slabs were exposed to a remineralising solution containing 1.5 mM CaCl2, 0.9 mM KH2PO4, 130 mM KCl and 20 mM HEPES at pH 7.0 and
37 C.
Group B
In this group, the samples were exposed to the same
remineralising solution used in Group A in addition to
daily fluoride slurry (30 % weight of a 1,000 ppm fluoride
dentifrice (Colgate Max FreshTM, Colgate-Palmolive,
Thailand) mixed with distilled water). The specimens were
kept in the slurry for 5 min, washed with de-ionised water,
gently blotted with tissue paper and then returned to their
remineralising solution.
Group C
In addition to the remineralising solution as used in
group A, this group was exposed to CPP-ACP paste (GC
Tooth MousseTM, GC Corporation, Tokyo, Japan). The
CPP-ACP paste was applied on to the specimens with a
cotton bud once daily for 5 min, after which they were
washed with de-ionised water, gently blotted with tissue
paper and then put back into their remineralising solution.
Group D
In addition to the remineralising solution in group A, the
samples were exposed to a daily combination of fluoride
slurry followed by CPP-ACP paste. The fluoride slurry was
applied as described above in Group B, followed by CPPACP paste as mentioned in Group C.
Group E
The remaining ten samples were kept in normal saline as
a negative control.
All solutions were refreshed weekly.
Quantitative light induced fluorescence images were
taken for all samples each week until the fluorescence
change approached zero, which was reached after 8 weeks.

Eur Arch Paediatr Dent (2014) 15:413419

415

Each group was then further divided into two subgroups;

an experimental group (N = 20) and a positive control
group (N = 10). Samples in the experimental subgroup
were etched with 40 % orthophosphoric acid (S.S. White
Acid Etch Gel, SS White Group, UK). The acid etchant
was applied for 15 s, after which the samples were washed
for another 15 s and then dried with compressed air from a
three-in-one syringe for 15 s. The groups were identified as
follows: A1, B1, C1 and D1 for the etched samples in each
of the corresponding group, and A2, B2, C2 and D2 for the
non-etched samples of the corresponding groups.
After the etching procedure, samples from both etched
and non-etched subgroups were returned to their respective
containers to continue with the same remineralisation
treatment that they were assigned to. QLF images were
captured for the specimens once per week. The remineralisation process was carried out until further minimal
changes were registered by QLF. The solutions were
refreshed every week.
The QLF images of the samples were analysed using
dedicated software (QA2 version 1.18, Inspektor research
B.V., Amsterdam, The Netherlands). Two parameters were
calculated for each specimen; DF, which is defined as a
measure of average lesion fluorescence loss (mineral loss)
in percent, and the surface area in pixels2 (de Josselin de
Jong et al. 1995).
Error of the method
Twenty samples were randomly selected from across all
groups and were re-analysed after a 20-day interval from
the initial analysis to determine the measurement error.
The method error was calculated using Dahlbergs double
determination formula (1940). The Houston coefficient of
reliability (1983) was also calculated. Houstons coefficient of reliability was above 90 %. The values of
Dahlberg error were 0.8 % for DF and 0.9 % (91,000) for
the area.

Statistical analyses
Means and standard deviations for all the measured
parameters at each time point were calculated using the
Statistical Package for the Social Science (SPSS version
19, Chicago, IL, USA). A general linear model for repeated
measures was used to compare between the weekly changes in each group, and between the groups. The Bonferroni
test was used to compare subgroups. The t test for independent samples was employed to investigate differences
between the variables in the etched and non-etched subgroups. A normality test for all data sets confirmed they
followed a Gaussian (normal) distribution. The results were
considered to be significant at P B 0.05.

Results
No statistically significant differences were found in the
mean fluorescence loss of all the groups at T0.
Total change in fluorescence radiance and area
Remineralisation occurred in all the experimental groups to
different degrees. When compared with the control group,
all experimental groups had significant regain in fluorescence and reduction of lesion area (P \ 0.001) as seen in
Table 1.
Changes during Phase I
Table 2 shows the total change in fluorescence and lesion
area after Phase I of remineralisation for the four treatment
groups and the control. All the experimental groups
exhibited significantly better remineralisation than the
control group (P \ 0.001). Significant differences were
found in the measured parameters between group A and the
other three groups (P \ 0.001). Group A showed the least

Table 1 Mean SD of fluorescence radiance loss (DF) and area in each study group at baseline, end of remineralisation and the difference
between them
Area (91,000) (pixel2)

DF (%)
Baseline

Final

Change

Baseline

Final

Change

Control

-25.9 3.6

-29.6 6.2

-3.7 (NS)

5.9 1.4

5.4 1.3

-0.5 (NS)

Group A

-25.9 5.0

-16.1 5.0

9.8***

6.3 2.3

3.4 1.4

-2.9***

Group B
Group C

-27.4 5.6
-26.8 5.4

-13.7 2.6
-10.3 3.9

13.7***
16.5***

6.3 1.7
6.6 2.0

2.8 1.1
1.7 1.9

-3.5***
-4.8***

Group D

-23.4 5.3

-12.0 3.7

11.4***

7.1 1.3

2.7 1.9

-4.4***

NS not significant
* P \ 0.001

123

416
Table 2 Total change
(mean SD) in fluorescence
radiance and area after Phase I

* P \ 0.01
*** P \ 0.001

Eur Arch Paediatr Dent (2014) 15:413419

Group

Area (91,000) (pixel2)

DF (%)
Baseline

Final

Change

Baseline

Final

Change

Control

-25.9 3.6

-30.4 4.2

-4.5*

5.9 1.4

5.4 1.3

-0.5*

Group A

-25.9 5.0

-22.5 3.9

3.4***

6.3 2.3

5.4 1.8

-0.9***

Group B

-27.4 5.6

-17.7 2.6

9.7***

6.3 1.7

4.0 1.1

-2.3***

Group C

-26.8 5.4

-16.9 2.1

9.9***

6.6 2.0

4.7 2.0

-1.9***

Group D

-23.4 5.3

-16.1 1.7

7.3***

7.1 1.3

5.1 1.3

-2.0***

(P \ 0.001) as seen in Table 3. The etched samples

showed better remineralisation than their counter parts in
the non-etched subgroups except Group C (Fig. 2). However, the differences did not reach a significant level.

Discussion

Fig. 1 Mean enamel fluorescence radiance loss measured over time

(weeks) during the remineralisation process (Phase I)

mineralisation. No significant differences were found

between the groups B, C and D.
Figure 1 shows mean DF values for all the groups at
each measured time point during Phase I of the remineralisation process.
Changes during Phase II
After Phase II of remineralisation, the maximum change in
the measured parameters was seen in Groups A and C
Table 3 Mean SD in
fluorescence radiance and area
at the end of Phase I (baseline
for Phase II), at the end of Phase
II of remineralisation and the
difference between them

** P \ 0.01
*** P \ 0.001

123

Factor

Natural remineralisation through saliva involving mineral

gain in the surface layer of WSL offers little if any
improvement in aethetics or in the structural properties of
deeper enamel lesions (Cochrane et al. 2010; Chen et al.
2013). Therefore, it is necessary to apply remineralising
agents to repair the deeper parts of WSL for better enamel
quality and aesthetic results (Chen et al. 2013).
Remineralisation by fluoride is a self-limiting surface
phenomenon that through formation of calcium fluoride
and other aggregates prevents penetration of calcium and
phosphate ions into the depth of the lesion (ten Cate et al.
1981; Peariasamy et al. 2001). To overcome this problem,
additional measures have been suggested such as surface
etching to open the blocked pores or the use of a combination of remineralising agents (Al-Khateeb et al. 2000;
Reynolds et al. 2008). However, repeated etching attacks of
the outer surface layer of enamel may lead to excessive loss
of tooth structure to the point that it cannot be reversed by
the remineralisation process (Al-Khateeb et al. 2000).
Area (91,000) (pixel2)

DF (%)
Baseline

Final

Change

Baseline

Final

Change

Group
A1

-22.2 3.6

-15.6 5.0

6.6***

5.9 1.7

3.3 1.6

2.6***

A2

-23.0 4.8

-17.0 5.1

6.0***

4.7 2.0

3.4 1.8

1.3**

B1

-17.7 2.9

-13.1 2.6

4.6***

4.0 0.8

2.5 1.1

1.5***

B2

-17.7 2.5

-14.8 2.2

2.9***

4.6 0.9

3.3 1.0

1.2***

C1

-17.2 2.1

-10.0 3.6

7.2***

4.0 2.3

1.6 1.7

2.4***
1.9***

C2

-16.5 2.2

-11.0 4.5

5.5***

4.0 2.4

2.1 2.4

D1

-16.3 1.9

-11.3 4.2

5.0***

3.9 1.5

2.2 1.9

1.7***

D2

-16.0 1.5

-13.4 1.9

2.6***

5.3 1.6

3.6 1.5

1.7***

Eur Arch Paediatr Dent (2014) 15:413419

417

weeks

weeks

weeks

weeks

Fig. 2 Mean enamel fluorescence radiance loss (in %) measured over time (weeks) during the remineralisation process (Phase I and Phase II) for
the four experimental groups

Accordingly, the aim of the present study was to delay the

phosphoric acid etching procedure to re-open the pores in
the outermost layer of enamel until after the enamel slabs
had been exposed to remineralising agents and the process
had slowed down.
During the first phase of the remineralisation process,
groups B, C and D gained significantly more fluorescence
than Group A. Group C (CPP-ACP) showed the greatest
fluorescence gain followed by group B then group D.
However, the difference between groups did not reach the
significance level; this may indicate that both fluoride and
CPP-ACP were effective in remineralisation of WSL during the first few weeks of the study. In addition, the
sequential combination of a fluoride slurry and CPP-ACP
in group D had no advantage over their separate treatment
protocols in the other two groups. Similar results were
reported by Lata et al. (2010) and Krithikadatta et al.
(2013). Other studies, on the other hand, reported that
combining fluoride with CPP-ACP did exert a synergistic
effect in boosting remineralisation of WSL (Bhat et al.
2012; Patil et al. 2013). Differences in the results between
these studies and the current study could be attributed to
the nature of WSL, the remineralisation regimens
employed, and the differing methods used to assess mineral
changes (Sudjalim et al. 2007; Reynolds et al. 2008).
Group B (fluoride treatment) showed the highest amount
of fluorescence gain during the first 23 weeks, after which
it slowed down to reach a plateau after a few weeks. This

indicates that while fluoride treatment is effective at the

beginning of remineralisation process, surface hypermineralisation soon occurs due to mineral deposition on the
surface, which then prevents further mineralisation of the
porous body of lesion (Ogaard et al. 1988; ten Cate and
Featherstone 1991; Willmot 2008; Chen et al. 2013). In
group C, on the other hand, remineralisation using CPPACP started slower than group D (fluoride followed by
CPP-ACP) (as measured by fluorescence radiance, DF) but
continued for a longer period, after which it slowed down
and reached the same plateau. This finding suggests that
CPP-ACP may be effective in remineralising surface and
subsurface lesions with optimal levels of calcium and
phosphate (Cai et al. 2003; Garca-Godoy and Hicks 2008).
No significant differences were found between etched
and non-etched samples within each group. The groups A,
B and D showed a tendency toward better remineralisation
in the etched samples while in group C, etched and nonetched samples followed the same curve of remineralisation. Although the groups A, B and D exhibited better
remineralisation in the etched samples than the non-etched
ones, the difference did not reach significance. Several
explanations can be offered. There was a high variance in
the sample groups, which likely reflected differing
responses to the demineralisation phase of the study caused
by variations in mineral composition within the groups.
A further factor could be that minerals gained in the
etched groups were consumed to replace those lost by the

123

418

etching procedure (Hidaka et al. 2011). Although fluoride

and CPP-ACP caused remineralisation of WSL, a substantial lesion remained at the end of the study. This can be
explained by the lack of contact with human saliva, which
not only dilutes the CPP-ACP but helps to activate the
release of calcium and phosphate ions from it.

Conclusion
In conclusion, although CPP-ACP seemed to give a steadier rate of remineralisation over time when compared with
fluoride, the overall remineralisation in the regimens was
similar. Combined treatment of fluoride followed by CPPACP did not have an extra benefit over using fluoride or
CPP-ACP alone. Acid etching was able to boost remineralisation of arrested lesions using fluoride but was not as
beneficial for CPP-ACP. However, acid etching using
3740 % orthophosphoric acid needs to be regarded cautiously since mineral loss may exceed mineral gain. Further
investigation is needed to explore the potential benefits of
lower acid concentrations on remineralisation for arrested
enamel WSL.
Acknowledgments This study was supported by a grant from the
Scientific Research Fund at the Ministry of Higher Education and
Scientific Research of Jordan. The authors are indebted to Professor
Laurence J. Walsh, University of Queensland, Brisbane, for his critical revision of the manuscript.

References
Al-Khateeb S, Exterkate R, Angmar-Mansson B, ten Cate JM. Effect
of acid-etching on remineralization of enamel white spot lesions.
Acta Odontol Scand. 2000;58:316.
Al-Khateeb S, Exterkate RA, de Josselin de Jong E, Angmar-Mansson
B, ten Cate JM. Light-induced fluorescence studies on dehydration of incipient enamel lesions. Caries Res. 2002;36:2530.
Amaechi BT, Ramalingam K, Mensinkai PK, Chedjieu I. In situ
remineralization of early caries by a new high-fluoride dentifrice.
Gen Dent. 2012;60:e18692.
Baroni C, Marchionni S, Bazzocchi MG et al. A SEM and noncontact surface white light profilometry in vivo study of the
effect of a cre`me containing CPP-ACP and fluoride on young
etched enamel. Scanning. 2013. doi:10.1002/sca.21102.
Bhat SS, Hegde SK, Habibullah MA, Bernhardt V. Incipient enamel
lesions remineralization using casein phosphopeptide amorphous
calcium phosphate cream with and without fluoride: a laser
fluorescence study. J Clin Pediatr Dent. 2012;36:3535.
Bishara SE, Ostby AW. White spot lesions: formation, prevention,
and treatment. Semin Orthod. 2008;14:17482.
Brighenti FL, Takeshita EM, Santana Cde O, Buzalaf MA, Delbem
AC. Effect of low fluoride acidic dentifrices on dental remineralization. Braz Dent J. 2013;24:359.
Cai F, Shen P, Morgan MV, Reynolds EC. Remineralization of
enamel subsurface lesions in situ by sugar-free lozenges
containing casein phosphopeptide-amorphous calcium phosphate. Aust Dent J. 2003;48:2403.

123

Eur Arch Paediatr Dent (2014) 15:413419

Chen H, Liu X, Dai J et al. Effect of remineralizing agents on white
spot lesions after orthodontic treatment: a systematic review. Am
J Orthod Dentofacial Orthop. 2013;143:37682.
Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC. New
approaches to enhanced remineralization of tooth enamel. J Dent
Res. 2010;89:118797.
Dahlberg G. Statistical methods for medical and biological students.
New York: Interscience Publications; 1940. p. 12232.
Danelon M, Takeshita EM, Sassaki KT, Delbem AC. In situ
evaluation of a low fluoride concentration gel with sodium
trimetaphosphate in enamel remineralization. Am J Dent.
2013;26:1520.
de Josselin de Jong E, Sundstrom F, Westerling H et al. A new
method for in vivo quantification of changes in initial enamel
caries with laser fluorescence. Caries Res. 1995;29:27.
Flaitz CM, Hicks MJ. Role of acid-etch technique in remineralization
of caries-like lesions of enamel: a polarized light and scanning
electron microscopic study. J Dent Child. 1994;61:218.
Garca-Godoy F, Hicks MJ. Maintaining the integrity of the enamel
surface: the role of dental biofilm, saliva and preventive agents
in enamel demineralization and remineralization. J Am Dent
Assoc. 2008;139(Suppl):25S34S.
Hidaka K, Nishimura K, Miyazawa K, Miwa H, Goto S. Effect of acid
etchants used for bonding orthodontic brackets on remineralization of enamel white spot lesions. Orthod Waves.
2011;70:12535.
Houston WJ. The analysis of errors in orthodontic measurements. Am
J Orthod. 1983;83:38290.
Krithikadatta J, Fredrick C, Abarajithan M, Kandaswamy D. Remineralisation of occlusal white spot lesion with a combination of
10% CPP-ACP and 0.2% sodium fluoride evaluated using
Diagnodent: a pilot study. Oral Health Prev Dent.
2013;11:1916.
Lata S, Varghese NO, Varughese JM. Remineralization potential of
fluoride and amorphous calcium phosphate-casein phospho
peptide on enamel lesions: an in vitro comparative evaluation.
J Conserv Dent. 2010;13:426.
Ogaard B, Rlla G, Arends J, ten Cate JM. Orthodontic appliances
and enamel demineralization. Part 2. Prevention and treatment of
lesions. Am J Orthod Dentofacial Orthop. 1988;94:1238.
Patil N, Choudhari S, Kulkarni S, Joshi SR. Comparative evaluation
of remineralizing potential of three agents on artificially
demineralized human enamel: an in vitro study. J Conserv Dent.
2013;16:11620.
Peariasamy K, Anderson P, Brook AH. A quantitative study of the
effect of pumicing and etching on the remineralisation of enamel
opacities. Int J Paediatr Dent. 2001;11:193200.
Reynolds EC, Cai F, Cochrane NJ et al. Fluoride and casein
phosphopeptide-amorphous calcium phosphate. J Dent Res.
2008;87:3448.
Rose RK. Binding characteristics of Streptococcus mutans for
calcium
and
casein
phosphopeptide.
Caries
Res.
2000;34:42731.
Sudjalim TR, Woods MG, Manton DJ. Prevention of white spot
lesions in orthodontic practice: a contemporary review. Aust
Dent J. 2006;51:2849.
Sudjalim TR, Woods MG, Manton DJ, Reynolds EC. Prevention of
demineralization around orthodontic brackets in vitro. Am J
Orthod Dentofacial Orthop. 2007;131:705.e19.
ten Cate JM, Jongebloed WL, Arends J. Remineralization of artificial
enamel lesions in vitro. IV. Influence of fluorides and diphosphonates on short- and long-term remineralization. Caries Res.
1981;15:609.
ten Cate JM, Featherstone JD. Mechanistic aspects of the interactions
between fluoride and dental enamel. Crit Rev Oral Biol Med.
1991;2:28396.

Eur Arch Paediatr Dent (2014) 15:413419

Willmot D. White spot lesions after orthodontic treatment. Semin
Orthod. 2008;14:2008.
Yamazaki H, Litman A, Margolis HC. Effect of fluoride on artificial
caries lesion progression and repair in human enamel: regulation

419
of mineral deposition and dissolution under in vivo-like conditions. Arch Oral Biol. 2007;52:11020.

123