Methods for Biomimetic Mineralisation of Human Enamel: A Systematic Review

Treatment Approaches to Molar Incisor Hypomineralization: A Systematic Review

AIM

This systematic review aimed to comprehensively evaluate the available literature on treating molar incisor hypomineralization (MIH) or enamel hypomineralization published between 2013 and 2023, focusing on identifying relevant studies and their characteristics.

MATERIALS AND METHODS

The search process encompassed reputable academic databases, including PubMed, Scopus, Cochrane Library, and Web of Science, using a precise keyword strategy ("((molar incisor hypomineralization) OR (enamel hypomineralization)) AND (treatment)"). A total of 637 articles were initially retrieved, followed by a strict selection process adhering to PRISMA guidelines. The inclusion criteria encompassed Randomized Control Trials (RCTs), case series with more than five clinical cases (CSs), studies involving human participants, availability as free full-text or accessible with university credentials, and English-language publications. Exclusion criteria included systematic or literature reviews, editorials, single-case reports, studies conducted in vitro, those involving animals, paid articles, and non-English-language publications.

RESULTS

The search yielded 864 articles, of which 23 met the stringent inclusion criteria after a meticulous selection process. These studies will serve as the basis for a comprehensive analysis of MIH treatment approaches. The systematic review ensures the quality and relevance of the chosen studies for a detailed assessment of MIH treatment strategies.

CONCLUSIONS

This systematic review will provide valuable insights into the characteristics of selected studies, patient profiles, and available treatment options for molar incisor hypomineralization, contributing to a better understanding of this dental condition's management.

Review: Application of chitosan and its derivatives in medical materials

Chitin is a natural polymeric polysaccharide extracted from marine crustaceans, and chitosan is obtained by removing part of the acetyl group (usually more than 60 %) in chitin's structure. Chitosan has attracted wide attention from researchers worldwide due to its good biodegradability, biocompatibility, hypoallergenic and biological activities (antibacterial, immune and antitumor activities). However, research has shown that chitosan does not melt or dissolve in water, alkaline solutions and general organic solvents, which greatly limits its application range. Therefore, researchers have carried out extensive and in-depth chemical modification of chitosan and prepared a variety of chitosan derivatives, which have expanded the application field of chitosan. Among them, the most extensive research has been conducted in the pharmaceutical field. This paper summarizes the application of chitosan and chitosan derivatives in medical materials over the past five years.

Synchrotron X-ray Studies of the Structural and Functional Hierarchies in Mineralised Human Dental Enamel: A State-of-the-Art Review

Hard dental tissues possess a complex hierarchical structure that is particularly evident in enamel, the most mineralised substance in the human body. Its complex and interlinked organisation at the Ångstrom (crystal lattice), nano-, micro-, and macro-scales is the result of evolutionary optimisation for mechanical and functional performance: hardness and stiffness, fracture toughness, thermal, and chemical resistance. Understanding the physical-chemical-structural relationships at each scale requires the application of appropriately sensitive and resolving probes. Synchrotron X-ray techniques offer the possibility to progress significantly beyond the capabilities of conventional laboratory instruments, i.e., X-ray diffractometers, and electron and atomic force microscopes. The last few decades have witnessed the accumulation of results obtained from X-ray scattering (diffraction), spectroscopy (including polarisation analysis), and imaging (including ptychography and tomography). The current article presents a multi-disciplinary review of nearly 40 years of discoveries and advancements, primarily pertaining to the study of enamel and its demineralisation (caries), but also linked to the investigations of other mineralised tissues such as dentine, bone, etc. The modelling approaches informed by these observations are also overviewed. The strategic aim of the present review was to identify and evaluate prospective avenues for analysing dental tissues and developing treatments and prophylaxis for improved dental health.

Impact of Dentistry Materials on Chemical Remineralisation/Infiltration versus Salivary Remineralisation of Enamel-In Vitro Study

The aim of this study is to evaluate salivary remineralisation versus chemical remineralisation/infiltration of enamel, using different dentistry materials. The enamel changes were studied using confocal laser scanning microscopy (CLSM), and the depth of lesions and demineralisation/remineralisation/infiltration percentage were calculated. Additionally, the macro elemental composition of the teeth was performed using atomic absorption spectroscopy (AAS). Two studies were performed: (i) demineralisation of enamel in 3% citric acid and infiltration treatment with infiltration resin (Icon, DMG), remineralisation with Fluor Protector (Ivoclar Vivadent) and artificial saliva pH 8; and (ii) enamel demineralisation in saliva at pH 3 and remineralisation at salivary pH 8. The results showed that, firstly, for the remineralisation of demineralised enamel samples, Fluor Protector (Ivoclar Vivadent) was very effective for medium demineralised lesions followed by saliva remineralisation. In cases of deep demineralisation lesions where fluoride could not penetrate, low viscosity resin (Icon, DMG, Hamburg) effectively infiltrated to stop the demineralisation process. Secondly, remineralisation in salivary conditions needed supplementary study over a longer period, to analyse the habits, diet and nutrition of patients in detail. Finally, demineralisation/remineralisation processes were found to influence the macro elemental composition of enamel demineralisation, with natural saliva proving to be less aggressive in terms of decreasing Ca and Mg content.

Investigation of the Effect of Particle Surface Charge and Dispersion Stability on Latex Behavior in Cement Using Non-Ionic and Traditional Latexes

In this work, a novel total non-ionic polystyrene-polyurethane (PS-PU) composite latex was synthesized with polymerizable polyethylene glycol ether. Contrary to traditional styrene-butyl acrylate latex (St-BA), PS-PU has a smaller size and superior dispersion stability, and it is stable in saturated Ca(OH)₂ even after 72 h. In fresh-mixed mortars, PS-PU showed a little adverse effect on workability and insignificant air entrainment, with little defoamer consumption. The retardation effect of PS-PU is also much milder than traditional St-BA. As for strength, PS-PU showed a less adverse effect on early and late age compressive strength, but its effect on flexural strength is not as pronounced as St-BA at high dosages (4% and 6%). The different behavior in cementitious materials between PS-PU and St-BA can be reasoned from their different adsorption behavior and surface charge properties, as the results from characterizations suggest. The non-ionic nature of PS-PU made it less prone to destabilization and adsorption, which turned out as the aforementioned behavior in cementitious systems. The difference can further be ascribed to the difference in their polymeric structure and properties.

Novel trends, challenges and new perspectives for enamel repair and regeneration to treat dental defects

Dental enamel is the hardest tissue in the human body, providing external protection for the tooth against masticatory forces, temperature changes and chemical stimuli. Once enamel is damaged/altered by genetic defects, dental caries, trauma, and/or dental wear, it cannot repair itself due to the loss of enamel producing cells following the tooth eruption. The current restorative dental materials are unable to replicate physico-mechanical, esthetic features and crystal structures of the native enamel. Thus, development of alternative approaches to repair and regenerate enamel defects is much needed but remains challenging due to the structural and functional complexities involved. This review paper summarizes the clinical aspects to be taken into consideration for the development of optimal therapeutic approaches to tackle dental enamel defects. It also provides a comprehensive overview of the emerging acellular and cellular approaches proposed for enamel remineralization and regeneration. Acellular approaches aim to artificially synthesize or re-mineralize enamel, whereas cell-based strategies aim to mimic the natural process of enamel development given that epithelial cells can be stimulated to produce enamel postnatally during the adult life. The key issues and current challenges are also discussed here, along with new perspectives for future research to advance the field of regenerative dentistry.

Advances in biomineralization-inspired materials for hard tissue repair

Biomineralization is the process by which organisms form mineralized tissues with hierarchical structures and excellent properties, including the bones and teeth in vertebrates. The underlying mechanisms and pathways of biomineralization provide inspiration for designing and constructing materials to repair hard tissues. In particular, the formation processes of minerals can be partly replicated by utilizing bioinspired artificial materials to mimic the functions of biomolecules or stabilize intermediate mineral phases involved in biomineralization. Here, we review recent advances in biomineralization-inspired materials developed for hard tissue repair. Biomineralization-inspired materials are categorized into different types based on their specific applications, which include bone repair, dentin remineralization, and enamel remineralization. Finally, the advantages and limitations of these materials are summarized, and several perspectives on future directions are discussed.

A Chitosan-Agarose Polysaccharide-Based Hydrogel for Biomimetic Remineralization of Dental Enamel

Developing multifunctional systems for the biomimetic remineralization of human enamel is a challenging task, since hydroxyapatite (HAP) rod structures of tooth enamel are difficult to replicate artificially. The paper presents the first report on the simultaneous use of chitosan (CS) and agarose (A) in a biopolymer-based hydrogel for the biomimetic remineralization of an acid-etched native enamel surface during 4–10-day immersion in artificial saliva with or without (control group) fluoride. Scanning electron microscopy coupled with energy-dispersive X-ray spectrometry, Fourier transform infrared and Raman spectroscopies, X-ray diffraction, and microhardness tests were applied to investigate the properties of the acid-etched and remineralized dental enamel layers under A and CS-A hydrogels. The results show that all biomimetic epitaxial reconstructed layers consist mostly of a similar hierarchical HAP structure to the native enamel from nano- to microscale. An analogous Ca/P ratio (1.64) to natural tooth enamel and microhardness recovery of 77.4% of the enamel-like layer are obtained by a 7-day remineralization process in artificial saliva under CS-A hydrogels. The CS component reduced carbonation and moderated the formation of HAP nanorods in addition to providing an extracellular matrix to support growing enamel-like structures. Such activity lacked in samples exposed to A-hydrogel only. These data suggest the potential of the CS-A hydrogel in guiding the formation of hard tissues as dental enamel.

Atomic force microscopy studies of enamel, inner enamel, dentin, and cementum in canine teeth

The main goal of the present work is to explore the three dimensional (3-D) atomic force microscopy (AFM) images of human teeth and investigating their micromorphology. For this purpose, 10 fresh and permanent canine teeth were selected from a group of 40-year-old men who were candidate for the experimental processes. Afterward, they were all applied for studying the morphology of their hard tissues. The tapping mode of AFM was used to characterize the surface micromorphology on the square areas of 1 μm × 1 μm (512 × 512 pts). AFM results and surface stereometric analysis indicate the relationships between the micromorphology of the surface and the structural properties of these tissues across the length scales. As can be seen, the surface of cementum has the most irregular topography (D = 2.87 ± 0.01) while the most regular topography (D = 2.43 ± 0.01) is found in dentin. Furthermore, the more and less regularity of the surface have been found in inner enamel (Sq = 26.26 nm) and dentin (Sq = 41.28 nm), respectively. Stereometric and fractal analyses give valuable information about human canine teeth via 3-D micromorphology.

Applying Pb2+ to probe the dissolution of carbonated hydroxylapatite by Enterobacter sp.: A new insight into the bioerosion of tooth mineral

Dental caries is one of the most common disorders in dentistry. Typically, it is caused by the dissolution of the tooth mineral due to cariogenic organisms. Bioapatite is vulnerable to acid-etching ascribed to a variety of substitutions. This study applied Pb²⁺ cations to probe the dissolution of synthetic carbonated hydroxylapatite (CHAp) in the acidic environment induced by Enterobacter sp. It indicated a decreasing tendency of crystallite size (from ∼400 nm to 10-20 nm) during gradual incorporation of carbonate (from 2.5 to 13.8 wt %). Meanwhile, the shape of CHAp crystals was transformed from elongated to plate-like. Addition of Enterobacter sp. enhanced P release from CHAp (especially for the CHAp with ∼8 wt % CO₃ ) around 10 times. Moreover, the bacterium provided a moderately acidic environment to cause more formation of stable pyromorphite over other Pb-minerals, for example, Pb₃ (PO₄ )₂ , and PbCO₃ . Then, transmission electron microscopy-energy dispersive X-Ray spectroscopy mapping successfully confirmed the Pb labeling on the newly formed phosphate mineral as Pb (with high-atomic weight) has strong signal under electron microscopy. This study therefore elucidated that Pb labeling has a bright future to explore the degradation of tooth mineral by microorganisms, as well as to evaluate the resistance of calcium phosphate dental restorative materials.

Biomimetic Aspects of Restorative Dentistry Biomaterials

Biomimetic has emerged as a multi-disciplinary science in several biomedical subjects in recent decades, including biomaterials and dentistry. In restorative dentistry, biomimetic approaches have been applied for a range of applications, such as restoring tooth defects using bioinspired peptides to achieve remineralization, bioactive and biomimetic biomaterials, and tissue engineering for regeneration. Advancements in the modern adhesive restorative materials, understanding of biomaterial–tissue interaction at the nano and microscale further enhanced the restorative materials’ properties (such as color, morphology, and strength) to mimic natural teeth. In addition, the tissue-engineering approaches resulted in regeneration of lost or damaged dental tissues mimicking their natural counterpart. The aim of the present article is to review various biomimetic approaches used to replace lost or damaged dental tissues using restorative biomaterials and tissue-engineering techniques. In addition, tooth structure, and various biomimetic properties of dental restorative materials and tissue-engineering scaffold materials, are discussed.

Multifractal analysis of human canine teeth at nano scale: atomic force microscopy studies

The aim of the present study is to explore the 3-D micromorphology of human canine teeth materials using multifractal analysis through atomic force microscopy (AFM). The 3-D surfaces of ten extracted canine teeth of a group of 40 year old men were studied (enamel, inter enamel, inter dentin, and cementum) by AFM images in tapping mode and on square areas of 1 μm × 1 μm (512 × 512 points). The AFM images and surface multifractal analysis confirm the dependency of surface micromorphology to their structure–property of these materials across the length scales of the teeth structural architecture. Surface statistical parameters and hence, multifractal approach have been considered as reliable and sensitive tools for quantifying the 3-D surface microtexture changes of human canine teeth materials. The surface of inter dentin had the most irregular topography (the width spectrum Δα = 2.8361, value bigger than all the other Δα sample values), while the most regular topography (the width spectrum Δα = 2.6804, value lower than all the other sample values) was found in cementum. It has been concluded that multifractal analyses can be used as mathematical tools to explore the 3-D micromorphology of human canine teeth materials.

Enhancing Collagen Mineralization with Amelogenin Peptide: Towards the Restoration of Dentin

Mammalian teeth primarily consist of two distinct calcified tissues, enamel and dentin, that are intricately integrated by a complex and critical structure, the dentin-enamel junction (DEJ). Loss of enamel exposes the underlying dentin, increasing the risk of several irreversible dental diseases. This paper highlights the significance of utilizing the functional domains of a major enamel matrix protein, amelogenin, intrinsic to tooth enamel and the DEJ interface, to rationally design smaller bioinspired peptides for regeneration of tooth microstructures. Using this strategy, we designed a synthetic peptide, P26, that demonstrates a remarkable dual mineralization potential to restore incipient enamel decay and mineralization defects localized in peripheral dentin below the DEJ. As a proof of principle, we demonstrate that interaction between P26 and collagen prompts peptide self-assembly, followed by mineralization of collagen fibrils in vitro. P26-mediated nucleation of hydroxyapatite (HAP) crystals on demineralized dentin in situ significantly facilitates the recovery of mineral density and effectively restores the biomechanical properties of dentin to near-native levels, suggesting that P26-based therapy has promising applications for treating diverse mineralized tissue defects in the tooth.

Constructing an Antibiofouling and Mineralizing Bioactive Tooth Surface to Protect against Decay and Promote Self-Healing

Numerous methods have been investigated to manage dental caries, one of the top three diseases threatening human health as reported by the World Health Organization. An innovative strategy was proposed to prevent dental caries and achieve self-healing of the decayed tooth, and a novel bioactive peptide was designed and synthesized to construct an antibiofouling and mineralizing dual-bioactive tooth surface. Compared to its original endogenous peptide, the synthesized bioactive peptide showed statistically significantly higher binding affinity to the tooth surface, stronger suppression of demineralization, and a certain promotion of tooth remineralization. The abilities of the peptide to inhibit Streptococcus mutans (S. mutans) biofilm formation and S. mutans adhesion on the tooth surface were not affected after synthesis. Biocompatibility tests revealed the safety of the synthesized bioactive peptide. Interaction mechanisms between the synthesized bioactive peptide and tooth surface were also explained by molecular dynamic simulation analysis. In summary, the synthesized bioactive peptide could be applied safely to prevent dental caries and effectively induce in situ self-healing remineralization for treatment of the decayed tooth.

The Significance and Utilisation of Biomimetic and Bioinspired Strategies in the Field of Biomedical Material Engineering: The Case of Calcium Phosphat-Protein Template Constructs

This review provides a summary of recent research on biomimetic and bioinspired strategies applied in the field of biomedical material engineering and focusing particularly on calcium phosphate-protein template constructs inspired by biomineralisation. A description of and discussion on the biomineralisation process is followed by a general summary of the application of the biomimetic and bioinspired strategies in the fields of biomedical material engineering and regenerative medicine. Particular attention is devoted to the description of individual peptides and proteins that serve as templates for the biomimetic mineralisation of calcium phosphate. Moreover, the review also presents a description of smart devices including delivery systems and constructs with specific functions. The paper concludes with a summary of and discussion on potential future developments in this field.

Synchrotron IR-microspectroscopy-based visualization of molecular and chemical interactions between dental cement, biomimetic composite and native dental tissue

The low affinity of composite materials for the hard tissue of human teeth poses a challenge to restorative dentists. This study was undertaken to explore molecular and chemical characteristics of the interface between the dental cement, the buffer layer formed from a next generation biomimetic material that mimics the organic mineral composition of human enamel and dentin, and the intact native hard dental tissue. Seven plane-parallel dental slices were analyzed using synchrotron IR microspectroscopy. The obtained absorption spectra of functional molecular groups were organized into cluster maps. This allowed us to identify the intact tissue, the adhesive agent and the biomimetic layer at their interface and to localize and measure concentrations of functional groups involved in the integration of the biomimetic composite into the hard tissue of the human tooth. The proposed biomimetic material is based on nanocrystal carbonate-substituted calcium hydroxyapatite synthesized from a biogenic calcium source and a complex of basic polar amino acids copying the composition of the human tooth and can form a functional bond with hard dental tissue.

The relation between structural, rugometric and fractal characteristics of hard dental tissues at micro and nano levels

Human tooth exhibits a structure of a mixture of inorganic hydroxyapatite nanocrystals and organic phases. The aim of this study is to investigate different tissues of human canine teeth surface along with the micro structure parameters of each tissue. X-ray diffraction (XRD) is used to study the amorphous or crystalline nature of each tissue with different mineral compositions and crystalline structures where the highest crystalline quality is related to enamel. The surfaces are also examined by energy-dispersive X-ray spectrometry. Moreover, crystalline quality factor is carried out to estimate the crystallinity of the tissues. Also, based on the basic Scherrer equation, the Williamson-Hall equation is applied to extend the formula for the XRD. Enamel and cementum tissues of a typical human tooth, which look similar, are composed of a large variety of wide lines with different widths through Raman spectra analysis. In addition, the applied scanning electron microscopy extracts similar morphology for all tissues with round granular structures which are denser in the cementum. Atomic force microscopy is finally used for investigation of micro-morphologies of the different tissues and the results are compared with the fractal analysis which ends to the bifractal and anisotropic nature of enamel and cementum along with monofractal and isotropic nature of dentin.

Emergent functions of proteins in non-stoichiometric supramolecular assemblies

Proteins are the basic functional units of the cell, carrying out myriads of functions essential for life. There are countless reports in molecular cell biology addressing the functioning of proteins under physiological and pathological conditions, aiming to understand life at the atomistic-molecular level and thereby being able to develop remedies against diseases. The central theme in most of these studies is that the functional unit under study is the protein itself. Recent rapid progress has radically challenged and extended this protein-function paradigm, by demonstrating that novel function(s) may emerge when proteins form dynamic and non-stoichiometric supramolecular assemblies. There is an increasing number of cases for such collective functions, such as targeting, localization, protection/shielding and filtering effects, as exemplified by signaling complexes and prions, biominerals and mucus, amphibian adhesions and bacterial biofilms, and a broad range of membraneless organelles (bio-condensates) formed by liquid-liquid phase separation in the cell. In this short review, we show that such non-stoichiometric organization may derive from the heterogeneity of the system, a mismatch in valency and/or geometry of the partners, and/or intrinsic structural disorder and multivalency of the component proteins. Either way, the resulting functional features cannot be simply described by, or predicted from, the properties of the isolated single protein(s), as they belong to the collection of proteins.

Exogenous mineralization of hard tissues using photo-absorptive minerals and femto-second lasers; the case of dental enamel

A radical new methodology for the exogenous mineralization of hard tissues is demonstrated in the context of laser-biomaterials interaction. The proposed approach is based on the use of femtosecond pulsed lasers (fs) and Fe³⁺-doped calcium phosphate minerals (specifically in this work fluorapatite powder containing Fe₂O₃ nanoparticles (NP)). A layer of the synthetic powder is applied to the surface of eroded bovine enamel and is irradiated with a fs laser (1040 nm wavelength, 1 GHz repetition rate, 150 fs pulse duration and 0.4 W average power). The Fe₂O₃ NPs absorb the light and may act as thermal antennae, dissipating energy to the vicinal mineral phase. Such a photothermal process triggers the sintering and densification of the surrounding calcium phosphate crystals thereby forming a new, dense layer of typically ∼20 μm in thickness, which is bonded to the underlying surface of the natural enamel. The dispersed iron oxide NPs, ensure the localization of temperature excursion, minimizing collateral thermal damage to the surrounding natural tissue during laser irradiation. Simulated brushing trials (pH cycle and mechanical force) on the synthetic layer show that the sintered material is more acid resistant than the natural mineral of enamel. Furthermore, nano-indentation confirms that the hardness and Young's modulus of the new layers are significantly more closely matched to enamel than current restorative materials used in clinical dentistry. Although the results presented herein are exemplified in the context of bovine enamel restoration, the methodology may be more widely applicable to human enamel and other hard-tissue regenerative engineering.

STATEMENT OF SIGNIFICANCE

In this work we provide a new methodology for the mineralisation of dental hard tissues using femtosecond lasers and iron doped biomaterials. In particular, we demonstrate selective laser sintering of an iron doped fluorapatite on the surface of eroded enamel under low average power and mid-IR wavelength and the formation of a new layer to substitute the removed material. The new layer is evaluated through simulated brushing trials and nano-indentation. From the results we can conclude that is more acid resistant than natural enamel while, its mechanical properties are superior to that of current restorative materials. To the best of our knowledge this is the first time that someone demonstrated, laser sintering and bonding of calcium phosphate biomaterials on hard tissues. Although we here we discuss the case of dental enamel, similar approach can be adopted for other hard tissues, leading to new strategies for the fixation of bone/tooth defects.

Synthesis of artificial dental enamel by an elastin-like polypeptide assisted biomimetic approach

The synthesized artificial enamel assisted by an elastin-like polypeptide revealed a similar structure and excellent mechanical properties to those of natural enamel.

Biomineralization: From Material Tactics to Biological Strategy

Biomineralization is an important tactic by which biological organisms produce hierarchically structured minerals with marvellous functions. Biomineralization studies typically focus on the mediation function of organic matrices on inorganic minerals, which helps scientists to design and synthesize bioinspired functional materials. However, the presence of inorganic minerals may also alter the native behaviours of organic matrices and even biological organisms. This progress report discusses the latest achievements relating to biomineralization mechanisms, the manufacturing of biomimetic materials and relevant applications in biological and biomedical fields. In particular, biomineralized vaccines and algae with improved thermostability and photosynthesis, respectively, demonstrate that biomineralization is a strategy for organism evolution via the rational design of organism-material complexes. The successful modification of biological systems using materials is based on the regulatory effect of inorganic materials on organic organisms, which is another aspect of biomineralization control. Unlike previous studies, this study integrates materials and biological science to achieve a more comprehensive view of the mechanisms and applications of biomineralization.

Keratins as components of the enamel organic matrix

Dental enamel is the hardest tissue in the human body, and although it starts as a tissue rich in proteins, by the time of eruption of the tooth in the oral cavity only a small fraction of the protein remains. While this organic matrix of enamel represents less than 1% by weight it plays essential roles in improving both toughness and resilience to chemical attacks. Despite the fact that the first studies of the enamel matrix began in the 19th century, its exact composition and mechanisms of its function remain poorly understood. It was proposed that keratin or a keratin-like primitive epithelial component exists in mature enamel, however due to the extreme insolubility of its organic matrix the presence of keratins there was never clearly established. We have recently identified expression of a number of hair keratins in ameloblasts, the enamel secreting cells, and demonstrated their incorporation into mature enamel. Mutation in epithelial hair keratin KRT75 leads to a skin condition called pseudofollicularis barbae. Carriers of this mutation have an altered enamel structure and mechanical properties. Importantly, these individuals have a much higher prevalence of caries. To the best of our knowledge, this is the first study showing a direct link between a mutation in a protein-coding region of a gene and increased caries rates. In this paper we present an overview of the evidence of keratin-like material in enamel that has accumulated over the last 150years. Furthermore, we propose potential mechanisms of action of KTR75 in enamel and highlight the clinical implications of the link between mutations in KRT75 and caries. Finally, we discuss the potential use of keratins for enamel repair.