Dentine Hypersensitivity

Transcription

Dentine Hypersensitivity
Recommendations for the Management
of a Common Oral Health Problem
AUTHORS:
Editorial
Dentine hypersensitivity is a common global oral health
problem affecting many individuals, but despite this only a
small proportion of people suffering with sensitive teeth seek
advice from their dental professional (Zapera 2007).
Irina Laura Chivu-Garip
DDS
Scientific Affairs Manager
Colgate-Palmolive Europe
Lone Lenes
DDS
Scientific Affairs Manager,
Colgate-Palmolive Nordic
Tanja Borch
DDS, PhD
Academic Affairs Advisor
Colgate-Palmolive Nordic
In recent years, dental professionals have grown
increasingly aware that dentine hypersensitivity is an
important issue that needs addressing both from a diagnostic
and a management perspective. However, a survey among
Danish dentists shows that only 23% of them screened their
patients for dentine hypersensitivity as part of the regular dental
check-up (Zapera 2009). It is therefore important that
dental professionals screen their patients for this regularly.
Advances in scientific understa ding have laid foundations
for new approaches to the management of dentine hypersensitivity, which include control of the underlying condition,
as well as management of the discomfort.
This material provides an overview of dentine hypersensitivity
for dental professionals, including an internationally-accepted
definition of the condition, information on its epidemiology
and aetiology, and its relevance for clinical practice to both
patients and dental professionals. It continues by examining
strategies for prevention, management and treatment, by
focusing on the most common underlying conditions
responsible for dentine hypersensitivity. It concludes with a
concise management strategy, offering a valid option aimed
at helping patients suffering (or at high risk of suffering) from
dentine hypersensitivity.
Katerina Solomou
MSc, PhD
Scientific Affairs Manager
Colgate-Palmolive Greece
SCIENTIFIC
CONSULTANTS:
Richard Chesters
BSc
Scientific Consultant
Colgate-Palmolive Europe
Diane Cummins
BSc, MSc, PhD
Worldwide Director
Knowledge Management
Oral Care, R&D
Colgate-Palmolive USA
Cynthia Murphy
BSc, MSc, PhD
Seniot Technical Associate
Knowledge Management
Oral Care, R&D
Colgate-Palmolive USA
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PROFESSIONALKNOWLEDGE
Content
Editorial.............................................................................................................2
Definition of dentine hypersensitivity.............................................................4
Epidemiology....................................................................................................4
Relevance..........................................................................................................4
Aetiology...........................................................................................................6
Treatment principles for dentine hypersensitivity..........................................9
Management of dentine hypersensitivity and underlying conditions.......18
References......................................................................................................29
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About Dentine Hypersensitivity
Definition of dentine hypersensitivity
Dentine hypersensitivity has been defined as a short, sharp pain arising from
exposed dentine in response to stimuli - typically thermal, evaporative, tactile,
osmotic or chemical - and which cannot be ascribed to any other dental defect
or disease (Canadian Advisory Board on Dentine Hypersensitive Teeth, 2003).
Epidemiology
Dentine hypersensitivity is a widespread condition with a reported
prevalence varying from as low as 4.5% to as high as 57% (Cummins 2009),
depending upon the population and the criteria used to assess sensitivity.
A Nordic countries survey of adults (Zapera 2007) shows that 79% suffer from
occasional dentine hypersensitivity, with one in four people suffering from it
at least once a week and 9% being affected every day.
The teeth most frequently affected are the permanent premolars (38%),
followed by incisors (26%) and canines (25%). Least affected are molars (12%).
Premolars
38%
Incisors
26%
Canines
25%
Molars
12%
Premolars are most frequently affected by hypersensitivity
The sites of those teeth most commonly affected are the buccal cervical
regions. Orchardson and Collins (1987) found that in 90% of cases the hypersensitive area was at the cervical margin.
Occlusal/buccal sites are also now becoming more frequently affected in
young adults, probably as a result of dental wearing caused by a combination of erosion and abrasion (Jaeggi and Lussi 2006). Dentine hypersensitivity
can present at any age, but the majority of individuals range in age
between 20 and 50 years with a peak in prevalence in the age range 30-39 year
(Cummins 2009).
Relevance
Dentine hypersensitivity is a painful experience which, for the majority of
sufferers, generates a very unpleasant perception, causing them to adapt by
developing new habits, like protecting the sensitive tooth with the tongue,
drinking on the opposite side of the mouth or even avoiding ice-cold food
and drinks completely. For some people, dentine hypersensitivity can be so
disturbing that it affects their quality of life.
4
40
33,1
36,0
OHIP-G summary score
30
20
14,3
10
0
10,7
< 40 years
40+ years
General population
< 40 years
40+ years
Patients
Comparison between the OHR QoL of patients with hypersensitivity
and the general population in different age groups (Bekes et al. 2009)
Influence on the dental visit
Dentine hypersensitivity can even be provoked by some standard
in-surgery procedures, thereby making a regular dental visit unpleasant
and painful for the patient. The discomfort due specifically to dentine hypersensitivity may add stress to an already stressful experience and environment for
the patient. A conscientious dental professional, may tend to work more slowly,
resulting in delays and an inability to complete the dental procedure within the
duration of the scheduled visit. In the most severe cases, patients may
even require local anaesthesia. However management options are now
available to enable dental professionals to create a calmer environment for
both the patient and the professional, by initiating a dentine hypersensitivity
treatment before any potentially painful, stress-provoking dental procedure is
performed.
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ABOUT DENTINE HYPERSENSISTIVTY
Influence on quality of life
A recent Quality of Life (QoL) study conducted in Germany (Bekes et al. 2009)
shows that hypersensitive teeth affect people’s oral-health-related (OHR)
quality of life as measured by the Oral Health Impact Profile-Germany
(OHIP-G) score. The OHIP-G summary score is almost three times higher for
patients seeking care for hypersensitivity compared with the score for the
general population, and the impact is comparable with that of other oral
diseases and conditions such as craniomandibular dysfunctions.
Aetiology
The most widely accepted theory to explain the aetiology of the pain
caused by dentine hypersensitivity is the Hydrodynamic Theory advanced by
Brannström (1972).
Exposed dentine with open dentine tubules.
Photos:
www.thejcdp.com, 2007
According to the Hydrodynamic Theory, dentine hypersensitivity occurs when
the external stimulus contacts exposed dentine and triggers a change in
the flow of dentinal fluid. The resultant pressure change across the dentine
activates intradental nerve fibres to cause immediate pain.
The Hydrodynamic Theory of dentine hypersensitivity also explains that
dentinal tubules are open at the dentine surface and unobstructed all the
way to the pulp. Scanning electron microscopy has shown that tubules
in exfoliated teeth clinically characterised as "sensitive" are eight times
more numerous, twice larger in diameter and are open, whereas tubules in
"non-sensitive" teeth are less numerous, smaller, and usually blocked.
Non-sensitive dentine
Sensitive dentine
Microscopy images showing difference in structure between sensitive and non-sensitive dentine.
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Poiseuille’s law of fluid dynamics predicts that the flow of fluid in the sensitive
tubules would therefore be 16 times greater than that of non-sensitive teeth
(Absi et al. 1987). Combining the increase in diameter of open tubules with
the greater number of dentine tubules in sensitive teeth, the flow of fluid in
sensitive teeth would therefore be expected to be approximately 100 times
greater than in non-sensitive teeth (Canadian Advisory Board on Dentine
Hypersensitive Teeth, 2003).
Illustration of hydrodynamic theory mechanism - movement of fluid in the dentine tubules
Photo courtesy of Inside Dental Assisting.
Most pain-producing stimuli, especially the most problematic cold and
evaporative stimuli, cause an outflow of dentinal fluid. This results in a
pressure change across the dentine which activates intradental A-beta and
A-delta nerve fibres, via a mechanoreceptor response, to cause pain. In
addition, the fluid movement in the tubules can cause an electrical discharge, known as ”streaming potential”, which may contribute by electrically
stimulating a nerve response.
By contrast, heat causes a relatively slow retreat of dentinal fluid, and the
resultant pressure changes activate the nerve fibres in a less dramatic fashion.
This is consistent with the fact that heat is generally a less painful stimulus
than cold.
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In a study among Australian dentists (Amarasena 2011), cold and air stimuli
were reported as the most frequent triggers for dentine hypersensitivity.
Triggers
Stimuli
%
n
Cold
80,1 %
920
Air
23,2 %
266
Touch
20,7 %
238
Hot
13,0 %
149
Dietary acid
6,9 %
79
Endogenerous acid
0,7 %
8
Other
6,1 %
70
Patient A
Patient B
Clinical apperance is not necesarily corelated with the reported degree of sensitivity
The weight of evidence suggests that this occurs not only because of the
subjective nature of pain, but also because of the natural process of tubule
occlusion which occurs over extended time periods, as a result of precipitation of calcium phosphate complexes triggered by proteins in saliva (Cummins
2010). For many years it has been known that calcium and phosphate ions in
saliva can remineralize tooth defects, such as early carious lesions. Research into
the mechanism of natural desensitisation suggests that calcium and phosphate
ions, associated with salivary glycoproteins, can also facilitate tubule plugging.
Although in periodontal healthy patients dentine hypersensitivity is generally
associated with good oral hygiene, it has been shown that general dental
hygiene may be hampered by the discomfort arising from dentine hypersensitivity with the consequence that persistent accumulation of dental plaque
can increase the risk of caries and periodontal problems (Carranza 1996).
This therefore provides a strong clinical reason for dental professionals to
assess and treat dentine hypersensitivity, as well as for the patient’s comfort and
quality of life.
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Photo courtesy of:
Bo Danielsen,
Head of SKT, Copenhagen
University
Photo courtesy of:
Chief Dentist, Ulla Pallesen,
Copenhagen University
Like any other condition that involves subjective experiences such as pain,
there is a difference in reported hypersensitivity by patients displaying the same
exposure to aetiological factors. Dental practitioners often face the question
of ”why some patients with exposed roots experience dentine hypersensitivity
whilst others do not?” The clinical observations are not necessarily correlated
with the degree of subjective sensitivity reported by the patient.
For example, patient A (below) experiences no pain, despite advanced
tooth wear lesions, while patient B, with minimal gingival recession in the first
premolar reports severe pain.
Treatment Principles
1. Desensitising the nerves.
2. Occlusion of open tubules to block the hydrodynamic mechanism.
Desensitising the nerves
Nerve desensitisation is based on potassium, which can depolarise the
excited nerve, thus ‘numbing’ the pain associated with dentine hypersensitivity
(Orchardson & Gillam 2000). Potassium nitrate (5%), potassium chloride (3.75%)
and potassium citrate (5.5%) have all been used in toothpastes for dentine
hypersensitivity relief with each salt providing 2% potassium ions.
Nerve desensitisation mechanism
Clinical studies have shown that equimolar concentrations of potassium (2%)
delivered from any one of these three potassium salts are effective in reducing
dentine hypersensitivity in comparison with regular fluoride toothpastes.
However using this method to achieve a reduction in dentine hypersensitivity
takes at least two weeks of twice-daily use to yield measurable reductions in
sensitivity, and longer time periods - generally four to eight weeks - to demonstrate significant levels of pain relief (Chesters et al. 1992, Ayad et al. 1994, Schiff
et al. 1994, Hu et al. 2004, Wara-Aswapati et al. 2005).
The addition of fluoride for cavity protection, an antibacterial ingredient for
plaque and gingivitis control, crystal inhibitors and high cleaning abrasives for
tartar control and whitening respectively, to potassium-based toothpaste, do
not seem to have a negative impact on sensitivity relief.
Based upon the available data, it can be concluded that potassium-based
toothpastes do not provide instant relief from dentine hypersensitivity, which
seems an important benefit to those in need to address this condition.
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TREATMENT PRINCIPLES
Different therapeutic approaches have been used for treating dentine hypersensitivity. Today two basic treatment principles are used:
While there is a substantial evidence base for recommending the use of a
potassium-based desensitising toothpaste, some authors have suggested that
support for the efficacy of such toothpastes is equivocal, as some studies also
showed no statistically significant difference, when compared with a regular
fluoride toothpaste (Manochehr-Pour et al. 1984, Gillam et al. 1996, West et al.
1997, Poulsen et al. 2006).
The variations in the clinical results have been attributed to differences among
clinical study parameters, especially population and scoring methods, and to
the well-known Hawthorne effect. The fact that placebo control products can
reduce sensitivity by as much as 40% from baseline has significantly impacted
the ability to differentiate the efficacy of a test product in some studies.
In vitro studies of the mechanism of action of potassium salts have shown
that they can dramatically reduce the excitability of intra-dental nerves.
Specifically, raising the concentration of potassium ion significantly above
the physiological level in the extra-cellular fluid induces depolarization of
the nerve cells, a brief excitatory burst, following which the nerves become
unresponsive to excitatory stimuli.
Nevertheless, for the clinical effect to occur, the potassium ion has to diffuse
from the oral cavity into the dentin tubules, then through the dentin tubules
against the flow of dentin fluid to the site of action at the interface of the
inner dentin surface and the pulp chamber, i.e.,the nerve endings. This
explains the slow time to action, as to achieve significant pain relief, the
concentration of potassium must build up in the fluid surrounding the nerve
ending, which typically takes a period of 4 to 8 weeks, and be maintained at
that level on an ongoing basis. If and when treatment with potassium-based
products is ceased, elevated levels of potassium at the site of action are
diffused, and sensitivity relief is lost (Cummins 2010).
Occluding dentine tubules
The second treatment principle in dentine hypersensitivity aproach is based
on agents that block exposed, open tubules, thereby preventing the external
stimuli from causing fluid movement and triggering pain (Orchardson, Gillam
2006). There are multiple and complex ways in which different technologies
and products could potentially act to occlude tubules, such as:
a.
b.
c.
Deposition of a thin film coating: materials such as restorative resins
and dentin bonding agents can create an “artificial smear layer” on
the exposed dentin and cover the open tubules.
Deposition of a layer of fine particles: materials delivered directly from
a dentifrice, e.g. fine abrasive particles, or formed as precipate in situ,
e.g. strontium, stannous fluoride, and calcium phosphate particles,
have been suggested to form a physical barrier on the exposed
dentin and in the openings of the tubules.
Induction of natural mineral formation in situ: technologies such as the
NovaMin® bioactive glass and the new Pro-ArginTM Technology, have
been proposed to physically adhere to the exposed dentin surface
and the openings of the tubules, to mediate the formation of
calcium-and phosphate-rich mineral.
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Occluding dentine tubules mechanism
In the following different technolgies are reviewed:
Glutaraldehyde and HEMA
Glutaraldehyde is an occluding agent which creates a coagulation plug
inside the dentine tubules, via precipitation of serum albumin (Dijkman
e al. 1994, Bergenholtz et al. 1993, Schüpbach et al. 1997, Qin et al. 2006).
In the presence of hydroxyethyl methacrylate (HEMA), glutaraldehyde
together with serum albumin induces the polymerisation of HEMA (Qin
et al. 2006). Glutaraldehyde +/- HEMA has been used only in-office
products. Some clinical trials have shown a reduction in dentine hypersensitivity (Felton et al. 1991; Dondi dall’Orologio G and Malferrari S, 1993; Kakaboura et al. 2005; Ishihata et al. 2009; Ozen et al. 2010; Yu et al. 2010), but
others have not shown any benefit (Sobral et al. 2005; de Assis et al. 2006).
Strontium salts
Strontium salts are said to work by precipitating strontium and depositing fine
particles of insoluble strontium compounds on dentine surfaces and within
the dentine tubules (Cummins 2010, Earl et al. 2010). Strontium chloride (10%)
was the first strontium salt used in toothpastes, but it was not compatible with
fluoride, and was largely replaced by potassium-containing toothpastes, as the
potassium ion was considered to be a more effective desensitising agent.
Later on, strontium was again introduced in desensitising toothpaste in the
form of strontium acetate, which is compatible with fluoride. Despite the long
history of strontium toothpastes, a review published in 2010 identified that the
clinical data regarding long-lasting relief during routine, twice-daily brushing is
equivocal (Cummins 2010).
More recently, a study suggested that a 8% strontium acetate toothpaste
provided significant relief from dentine hypersensitivity, and that there was
no significant difference between the strontium toothpaste and an argininecalcium carbonate based toothpaste, which has been previously proven to provide significant reduction in dentine hypersensitivity (Hughes et al. 2010).
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In addition, another study suggested that the 8% strontium acetate toothpaste
may be effective in relieving hypersensitivity immediately after direct topical
application, compared with a regular fluoride toothpaste (Mason et al. 2010).
However, it is noteworthy that the first of these studies did not include a negative control and the second did not include a positive control, precluding
meaningful interpretation of their results.
For this reason, the results of three new clinical studies published in 2011
(Docimo et al. 2011, Li et al. 2011, Schiff et al. 2011) are important because
they clearly showed that 1) the 8% strontium acetate toothpaste provides inferior efficacy in dentine hypersensitivity relief compared with an arginine-based
toothpaste, and 2) the 8% strontium acetate toothpaste is no more effective in
providing immediate relief of dentine hypersensitivity than a regular fluoride
toothpaste (Cummins 2011).
Stannous salts
Stannous fluoride has also been used as an occluding agent, and is thought
to work by precipitating insoluble stannous metal compounds on the dentine
surface, thereby occluding the tubules. Stannous fluoride-based products
(either as an anhydrous gel or in toothpaste formulations), have been shown
significantly to reduce dentine hypersensitivity over four to eight weeks of
twice-daily use (Thrash et al. 1994, Schiff et al. 2005, Schiff et al. 2006, Walters
2005).
The review by Cummins (2010) confirmed the effectiveness of properly
formulated dentifrices containing stannous fluoride, when used over a four
to eight week period. It however identified that stannous fluoride does not
provide instant relief. In addition, stannous-based products can result in tooth
staining and poor taste (Cummins 2010).
A more recent clinical trial, however, suggested that a stannous fluoride
toothpaste provided improvement in the negative effects of both tactile
and air-blast stimuli when compared with a fluoride-containing negative
control, after both three days and two weeks of product use (He et al. 2011).
Recent clinical studies on a new variant of the technology, containing stannous
chloride with sodium fluoride (NaF), demonstrated that four to eight weeks
of product use are required for significant improvement in hypersensitivity
compared with fluoride-containing negative control toothpastes (Ni et al.
Abstract 2825 2011, Du et al. Abstract 2826 2011).
In another clinical trial, a stannous chloride, NaF-containing toothpaste
provided reductions in dentine hypersensitivity after four to eight weeks of
use, comparable with a toothpaste with 2% potassium ion (Ni et al. 2010).
Interestingly however, a recent clinical study appears to be the first to
compare these two variants of the technology. This study showed that the
stannous fluoride toothpaste delivered better sensitivity relief than both the
stannous chloride, NaF-containing paste and a sodium fluoride negative
control after four and eight weeks of use (CP data on file), while the stannous
chloride, NaF-containing paste was not significantly different from the
negative control at four and eight weeks.
These studies demonstrate the importance of properly stabilising
stannous salts in formulation, for optimal hypersensitivity relief.
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Fluorides
High-concentration fluorides can reduce dentine hypersensitivity
probably through precipitation of calcium fluoride globules within the
dentine tubules (Orchardson and Gillam 2006; Porto et al. 2009).
Professionally-applied high-fluoride products, such as fluoride varnish
(22,600 ppm fluoride) have been shown significantly to reduce
dentine hypersensitivity following a single application (Gaffar 1998).
Calcium sodium phosphosilicate
Calcium sodium phosphosilicate (CSPS) – also referred to as Bioglass® and sold
commercially as NovaMin® - is an occluding agent used in toothpastes and
in-office products. This technology is thought to work by forming a calcium
phosphate layer that occludes open dentinal tubules (Greenspan 2010).
In more detail - calcium and phosphate ions are first released into the local
environment and then precipitate, resulting in the formation of a calcium
phosphate layer, which in turn crystallises into a hydroxyapatite-like material
(Greenspan 2010). The CSPS particles remain on the dentin surfaces through
interactions with collagen, and serve as a long-term reservoir of calcium and
phosphate ions.
The effectiveness of CSPS in toothpaste formulations containing 5% and 7.5%
NovaMin®, is supported by data showing significant improvement of dentine
hypersensitivity compared with baseline, and superiority in comparison with
control toothpastes (Du et al. 2008, Burwell 2009, Litkowsky and Greenspan
2010, Sharma 2010, Salian et al. 2010, Pradeep et al. 2010, Gendreau et al.
2011). Moreover, a 5% NovaMin® dentifrice showed a statistically significant
greater reduction in dentine hypersensitivity at two and four weeks
compared with both a potassium dentifrice and a regular fluoride dentifrice
(Salian et al. 2010). Similarly, a 7.5% NovaMin® dentifrice provided significant
reductions in dentine hypersensitivity at two and four weeks compared
with a potassium-based and a stannous fluoride toothpaste (Sharma et al.
2010). It should be pointed out that a 5% NovaMin® toothapste is significantly
more effective that a 10% strontium chloride toothpaste at two and six weeks
(Du et al. 2008). However, so far there is no published data showing an instant
reduction of sensitivity.
The characteristics of an ideal desensitising agent?
It is generally recognised that instant relief is a highly motivating factor for
patients, and complete and robust dentine occlusion is the most promising
strategy to achieve this. Unfortunately, most desensitising agents are unable to
provide instant relief.
Since 1935 - when Grossman introduced them - the ideal characteristics of
a desensitising agent have been accepted as being non-irritant to the pulp,
relatively painless on application, easily applied, rapid in action, effective for a
long period, without staining effects and consistently effective.
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Ideal Desensitising Agent
Non-irritant to the pulp
Painless on application
Easy to apply
Rapid in action
Effective for a long period
No staining effects
Consistently effective
Target both underlying causes and symptoms
Characteristics of an ideal desensitising agent according to Grossman, Markowitz and Pashley
Apart from these traditionally stated requirements, a recent review (Markowitz and Pashley 2007), suggested that new desensitising technologies should
target both the underlying causes and the symptoms of dentine hypersensitivity. This could be achieved, firstly, by increasing the mineral density of
the dentine surface itself (improving resistance to wear by both acid erosion and
abrasion) and secondly, by plugging and sealing open tubules with a calciumand phosphate-containing dentine-like substance (to block diffusion through
the tubules into the dentinal sub-surface and increasing acid resistance).
The review also suggested that the ideal dentine hypersensitivity treatment
would mimic the natural desensitising process that leads to spontaneous
occlusion of open dentinal tubules over time. A successful treatment would
render dentine non-sensitive and sclerotic - such a state being more desirable
than open, patent, sensitive dentine.
The authors concluded that any treatment that completely seals dentinal
tubules will restore that surface to a healthy state.
Arginine and Calcium Carbonate
The newly introduced desensitising technology - Pro-ArginTM Technology,
based on 8% arginine and calcium carbonate, pushes scientific research
(Kleinberg 2002) into examining the role saliva plays in the mouth’s natural
tubule occlusion process, to deliver both instant and lasting hypersensitivity
relief in a series of published clinical trials (Ayad et al. 2009, Nathoo et al. 2009,
Docimo et al. 2009, Schiff et al. 2009, Docimo et al. 2009, Schiff et al. 2009,
Hamlin et al. 2009, Fu et al. 2010, Que et al. 2010, Docimo et al. 2011).
Scanning Electron Microscope (SEM)
photograph of untreated dentine surface
with exposed tubules.
SEM photograph of dentin surface showing
occlusion of dentinal tubules after application
of Pro-ArginTM Technology.
14
The technology has been formulated into easy-to-apply delivery vehicles,
like everyday toothpaste or professional prophylaxis paste, without affecting
clinically documented dentine hypersensitivity relief and without detrimental
tooth staining or unpleasant flavor. The technology is also compatible with
fluoride, to provide additional strengthening of dental hard tissues, delivering
virtually all of the attributes of an ideal desensitising agent.
When applied immediately before treatment, the in-office desensitising
paste has been clinically documented to provide better relief of the dentine
hypersensitivity associated with dental prophylaxis than a pumice-based control
paste (Hamlin et al.2009). In a second, double-blind clinical trial, a single
professional application of the 8% arginine and calcium carbonate
desensitising paste after dental scaling provided significant reduction in
dentine hypersensitivity immediately after application that was sustained for 28
days (Schiff et al. 2009).
Clinical studies have documented that a dentifrice with 8% arginine,
calcium carbonate and 1450 ppm fluoride is more effective at reducing dentine
hypersensitivity than a fluoride toothpaste (Docimo et al. 2009, Docimo et al.
2009).
A series of clinical trials has also documented that direct application of the
8% arginine, calcium carbonate, and 1450 ppm fluoride toothpaste to the
sensitive tooth surface delivers immediate improvement in hypersensitivity.
Application directly with patient fingertip or with a cotton applicator swab
provided an immediate improvement that was maintained during seven
days of twice-daily brushing with the arginine-containing dentifrice (Schiff
et al. 2009). Two additional double-blind, placebo-controlled clinical studies
demonstrated that, after a single fingertip application, the 8%
arginine-containing toothpaste provided significant immediate improvement
in sensitivity, compared with both a 2% potassium ion with 1450 ppm fluoride
positive control and a 1450 ppm fluoride negative control. This significant
benefit continued after three days of twice-daily brushing with the
arginine-containing toothpaste (Ayad et al. 2009, Nathoo et al, 2009). The 2%
potassium-ion dentifrice only showed improvement when compared with the
fluoride-only control in one study, and that benefit was only in response to air
blast stimulus after three days of product use (Ayad et al. 2009).
A modification of this 8% arginine, calcium carbonate and 1450 ppm
fluoride dentifrice formulation - including a high-cleaning calcium carbonate
system for enhanced extrinsic stain removal (Yin et al. 2010) - has been clinically
documented to deliver dentine hypersensitivity relief comparable with
the clinically-proven dentifrice containing only the traditional calcium
carbonate system (Ayad et al. v2009, Docimo et al. 2009, Docimo et al. 2009) and
superior sensitivity relief when compared with a 1450 ppm fluoride-only control
dentifrice (Que et al. 2010).
An additional clinical study documented that both the instant and three-day
improvements in hypersensitivity were comparable for the 8% arginine, calcium
carbonate and 1450 ppm fluoride dentifrices, independent of the addition of
the high-cleaning calcium carbonate system (Fu et al.2010).
15
These studies demonstrate the flexibility of this desensitising technology in
incorporating additional patient benefits, such as whitening (Yin et al. 2010).
This clinically documented hypersensitivity relief has been shown to be
primarily a result of tubule occlusion, by physical plugging of the tubule
and formation of a protective surface layer. The amino acid, arginine - which
is found naturally in saliva and carries a positive charge at physiological
pH -attracts calcium carbonate to the negatively-charged dentinal surfaces.
Calcium and phosphate ions are also recruited into dentinal tubules and
induce plugging and the formation of a protective surface layer.
Occluded dentine tubules with
Pro-ArginTM Technology
Calcium indicated by
green via Energy Dispersive X-Ray (EDX)
chemical mapping
Dentine treated with Pro-ArginTM Technology
The use of the 8% arginine and calcium carbonate technology effectively
accelerates this natural mechanism of occlusion. It is documented through
the use of advanced imaging techniques, to visualise tubule occlusion
and protective layer formulation on the dentinal surface. This, paired with
state-of-the-art surface analysis techniques, demonstrates the arginine tubule
plug as well as calcium, phosphorous, and carbonate in the dentinal surface
layer (Petrou et al. 2009, Lavender, 2010).
In addition to demonstrating dentine hypersensitivity relief, two recent
clinical studies have documented benefits for an arginine, calcium
carbonate and 1450 ppm fluoride toothpaste compared with a silica-based,
1450 ppm fluoride control, in preventing and repairing enamel damage by
acid softening. Leveraging an intra-oral erosion model and crossover clinical
study design, the arginine-containing toothpaste provided significantly better protection for enamel samples against erosive acid challenges over five
days compared with the fluoride-only control toothpaste (CP data on file). A
separate intra-oral, clinical study demonstrated better repair of acid-softened
enamel after three days use of the arginine-containing toothpaste compared
with the fluoride control (CP data on file). The proposed mechanism of action
for these clinically-documented enamel benefits is the physical deposition of
a calcium-rich layer on the enamel surface.
16
Dentine tubule plug
Calcium indicated by green
via EDX chemical mapping
Fractured Sample of Dentine treated with Pro-ArginTM Technology
Surface analysis methods demonstrate that both arginine and calcium
carbonate form a surface coating on acid-damaged enamel that acts as a
”reparative” layer – both by filling the microscopic gaps in enamel created by
acid and in helping in the physical protection of enamel during subsequent
acid challenges (CP data on file).
Arginine with PVM/MA copolymer and pyrophosphates
A mouthwash can provide an alternative delivery system for sensitivity
relief, especially in reaching sensitive areas that may be difficult to brush.
A mouthwash composed of 0.8% Arginine with a PVM/MA copolymer
system, pyrophosphate and 0.05% sodium fluoride in an ethanol-free base has
been clinically documented to provide better dentine hypersensitivity relief
than a 0.05% sodium fluoride control rinse after two, four and eight weeks
(CP data on file). In a second clinical trial, the same 0.8% arginine-containing
mouthwash formula provided more effective dentine hypersensitivity relief than both a mouthwash containing 2.4% potassium nitrate and 0.022%
sodium fluoride, and the same 0.05% sodium fluoride negative control after
two, four and six weeks.
The 2.4% potassium nitrate mouthwash required six weeks to deliver
effective sensitivity relief to tactile stimulus, but demonstrated improvement on the air blast stimulus at two, four, and six weeks compared with the
0.05% sodium fluoride negative control (CP data on file). For both clinical
trials, mouthwash was added to a standard, twice-daily brushing protocol,
with a regular, non-hypersensitivity toothpaste and a soft toothbrush.
17
Before Treatment
After treatment
In-vitro Confocal Laser Scanning Microscopy (CLSM) image showing untreated dentine surface
with exposed tubules, and coating of dentine tubules with Arginine with PVM/MA Copolymer
and Pyrophosphates
The proposed mechanism for the clinically documented dentine hyper
sensitivity relief from the arginine-containing mouthwash, is reduction in
fluid flow of exposed tubules, through occlusion by coating. To support this,
in vitro hydraulic conductance studies have shown a 42% reduction in flow
rate for the 0.8% arginine/copolymer/pyrophosphate mouthwash formula
compared with a 0.05% sodium fluoride negative control (CP data on file).
Analytical methods identified the chemical nature of the occlusive coating to
be an arginine-rich layer together with phosphate and copolymer (CP data
on file).
Regimen
In addition to proving the individual benefits of the arginine-based
toothpaste and mouthwash, a clinical study determined the combined effect
of pairing the 8.0% arginine, calcium carbonate and 1450 ppm fluoride
dentifrice (for twice daily brushing with a soft-bristled toothbrush) with the
0.8% arginine, PVM/MA copolymer system, pyrophosphate and 0.05% sodium
fluoride mouthwash (used twice daily after brushing).
This occlusive-technology regimen demonstrated significantly better dentine
hypersensitivity relief than both a potassium-based regimen (comprised of a
2% potassium ion toothpaste with 1450 ppm fluoride, soft bristled brush, and
mouthwash with 0.27% potassium ion and 230 ppm fluoride) and a placebo regimen after two, four, and eight weeks. The potassium-based regimen
demonstrated better dentine hypersensitivity relief than the placebo regimen
at two, four, and eight week measures for air blast stimulus and, at two and
eight weeks, for tactile stimulus (CP data on file).
18
Management of dentine hypersensitivity
and underlying conditions
Before initiating any kind of treatment for dentine hypersensitivity, it is
important to understand that many oral conditions exhibit similar symptoms
and that dentine hypersensitivity therefore is a differential diagnosis reached
by first excluding other diseases and/or defects (Olsson and Lindhe 1991,
Dowell and Addy 1983, Hallmon and Harrel 2004, West 2008).
History
When screening has shown that the patient has a problem with sensitive
teeth, it is essential to let the patient use his/her own words to describe the
symptoms and the pain triggers. Once pain characteristics are described,
closed questions can be used to help to confirm the diagnosis such as: “Does
it persist after stimulus?”
As always, it is important to obtain and record the patient’s dental, medical
and dietary history. It is advisable to check for any history of excessive intake of
acid food and drink (citrus juices and fruits, carbonated drinks, wines or ciders)
in the diet, and to probe for evidence of gastric reflux and eating disorders.
Photos courtesy of Prof. Nicola West
Clinical examination
The clinical examination shall include controlled assessment of the sensitive
teeth, such as mechanical/tactile stimuli (running a sharp explorer over the
area of exposed dentine) and/or thermal and evaporative stimuli (a blast of
cold air from the 3-in-1 syringe).
Cold airblast from triple syringe
Sharp explorer over the area
of exposed dentine
19
EXAMINATION
Screening
As suggested in the recommendations of the Canadian Advisory Board
of Dentine Hypersensitivity (2003), all dental patients shall be actively
screened for dentine hypersensitivity by dental professionals at each dental
check-up, as sensitivity is often unreported by the patient. By actively asking
the patients if they have, or have had, any problems with sensitivity, the vast
majority of dentine hypersensitivity suffers will be detected, enabling the
dental professional to help these suffers.
The application of a controlled stimulus would be expected to result in a
short sharp pain that generally lasts just for the duration of the stimulus, but
may sometimes continue for a short while post stimulation, if the patient has
dentine hypersensitivity.
Differential diagnosis
The combined history and clinical examination are essential to exclude other
factors or conditions like dental caries, pulpitis, cracked tooth syndrome, fractured restorations, gingival inflammation, chipped teeth, lack of care while
contouring restorations, fractured restoration and TMJ disorders.
Differential Diagnosis
Caries
P
Pulpitis
A
IN
Gingivitis
Short, sharp
pain
Cracked tooth syndrome
Fractured restoration
Traumatic occlusion
TMJ disorders
Other pain symptoms - such as dull and throbbing pain, pain that lasts long
after the removal of the stimulus, pain that keeps the patient awake at nights,
the need for pain killers, pain irradiating from original site, pain occur at the
chewing/biting surfaces, pain during air travel or when laying down - may
indicate other dental diseases or defects that require further investigation.
By excluding all other potential causes of the same or similar symptoms, the
diagnosis of dentine hypersensitivity can be confirmed as the most likely
cause of pain. It is then a good idea to measure and record the severity of the
pain in order to allow this to be monitored over time.
20
Measurement and registration of dentine hypersensitivity
Usually, dentine hypersensitivity is measured by (a) tactile (pressure) stimulus
or (b) thermal/evaporative (cold air blast) stimulus.
The air blast measurement is a very simple and often-used technique to
measure dentine hypersensitivity. The sensitive tooth is isolated from the
adjacent teeth. A short blast of air, from a 3-in-1 dental syringe, is directed at
the exposed dentine surface.
The response of the subject to the air blast stimulus is usually scored by the
clinical examiner, based upon the subject’s response, using an analogue scale,
such as the commonly used Schiff scale.
Schiff scale
Value
Response of the patient to the air blast stimuli
3
Responds, requests discontinuation and considered it painful
2
Responds and requests discontinuation
1
Responds
0
Does not respond
Visuel analog scale (VAS)
Another way to determine and record the pain response to the stimulus is for
the subject to rate his/her experience using an open scale, like a visual analog
scale (VAS).
Directions for use
• The patient mark the level of pain on the line.
• The distance from ”No Pain” to the paitients mark is meassured (in mm).
This meassurement is the patient’s VAS-score.
• The VAS-score is registered in the paitient records.
VISUAL ANALOG SCALE (VAS)
AS)
SCALE FOR MEASURING THE LEVEL OF PAIN
Unbearable
pain
No pain
Example of a visual analog scale
21
Treatment Plan
As dentine hypersensitivity is not a disease in itself, but rather a symptom of one
or more of a number of underlying causes, all possible conditions, which could
have led to dentine hypersensitivity need to be identified. The management
of dentine hypersensitivity should first aim to eliminate, or at least minimise, all
the underlying and predisposing factors. These include both those leading to
lesion localisation (exposure of dentine) and those leading to lesion initiation
(opening of tubules). By treating the underlying causes, as well as the dentine
hypersensitivity itself, it is possible to reduce the frequency of dentine hypersensitivity attacks, or even to prevent further dentine hypersensitivity episodes.
SCREENING
Symptoms of DHS ?
Patient describes
pain & triggers
No
NO TREATMENT
required
Yes
CLINICAL EXAMINATION
Examine to exclude other causes such as:
• Caries
• Pulpitis
• Gingival inflammation
• Traumatic occlusion
• Chronic pain syndrome
• Cracked tooth syndrome
• TMJ disorders
• Fractured restoration
• Marginal leakage
• Post-restorative sensitivity
• Refered pain
• Neuropathic pain
CASE HISTORY
Anamnesis
Review medical history
of patient (dental and
general)
CONFIRM DHS Diagnosis
MAINTAIN DHS
TREATMENT PLAN
AND MONITOR
UNDERLYING CONDITION
MEASUREMENT OF DHS
Measure and record level of DHS
IDENTIFY and ADDRESS
UNDERLYING CONDITIONS
Refer to Treatment Strategy
Options further described.
FOLLOW UP
YES
Re-assesment fo DHS and underlying
condition
Does DHS still persist ?
NO
NO FURTHER TREATMENT
OF DHS REQUIRED
Continue to control underlying conditions
22
Dentine can become exposed through gingival recession or through enamel loss. Experts have concluded that gingival recession, rather than cervical
enamel loss, is the key predisposing factor for dentine hypersensitivity.
However, several others conditions also seem to be associated with an elevated
incidence of dentine hypersensitivity. In the following section, the most
common predisposing factors will be reviewed and intuitive flowcharts will be
presented for guidance on how to manage dentine hypersensitivity, and any
related underlying conditions.
Dentine hypersensitivity and gingival recession
due to improper brushing
Gingival recession is a multifactorial condition rendered more complex by anatomical factors. Overzealous and improper tooth brushing techniques have
been associated with gingival damage and loss of gingival tissue through
mechanical forces. Once gingival recession occurs, the cement covering the
dentine surface is easily removed exposing the vulnerable underlying dentine
and increasing the risk of dentine hypersensitivity.
Based on in vitro and in situ studies, it appears that normal tooth brushing
does not cause significant enamel loss. However, erosion from acidic foods and
drinks, in combination with tooth brushing, can result in significant tooth wear
on any part of the tooth surface, especially the cervical area.
Dentine hypersensitivity and lesions resulting from tooth wear
Photo courtesy of
Prof. Roger Elwood
Photo courtesy of
Chief Dentist Ulla Pallesen,
Copenhagen University
Tooth wear in general means loss of tooth substance. It covers four types of
lesions - abrasion, attrition, erosion and abfraction.
Sensitive teeth due to a combination of erosive
and abrasive damages
Sensitive teeth due to erosion
23
TREATMENT PLAN
Exposed dentinal tubules are loosely occluded by a coating, known as the
smear layer, comprised of protein components and calcium phosphate
deposits derived from saliva. On the basis of in vitro studies, it has been
suggested that both chemical and physical forces can remove the smear layer
to open exposed dentinal tubules. While there seems little doubt that acidic
foods and drinks are able to remove the smear layer and soften dentine - rendering the softened dentine tissue susceptible to physical forces such as tooth
brushing - clinical data suggests that physical forces alone are not a key factor
in removing the smear layer and opening exposed dentinal tubules.
In the last few years, basic research has suggested that acid erosion combined
with abrasion can have the potential significantly to accelerate wear on teeth.
Detailed in vitro and in situ studies have shown that the mechanical process
of brushing with a toothbrush alone has no measurable effect on enamel, and
that tooth brushing with toothpaste contributes little, if anything, to the loss
of enamel over a lifetime of use. In contrast, similar studies have shown that
the chemical process of erosion caused by acidic foods and drinks, particularly
when combined with mechanical cleaning, can result in significant tooth wear
and, ultimately, exposure of dentine. Research has suggested that acid erosion
combined with abrasion can have the potential to significantly accelerate tooth
wear.
Patients with abrasion and erosion should, therefore, be considered as predisposed to suffering from sensitive teeth with a need for prevention and
treatment. A desensitising mouthwash may be a valid option for dentine
hypersensitivity sufferers whose condition has resulted from excessive brushing,
used in between the morning and evening brushings.
Dentine hypersensitivity management strategy options for patients with gum recession due
to improper brushing and toothwear lesions
DIAGNOSIS
Identified gum recession and/or tooth wear
lesions caused by excessive brushing or
improper brushing technique, and/or erosion
as primary underlying cause of DHS
PATIENT EDUCATION
FOLLOW-UP
• Show patient the site and what likely
has caused the problem
• Adjust brushing technique
(if appropriate to diagnosis)
• Instruction in modifying frequent
intake of acidic food & drink & avoiding
brushing before and after acidic intake
(if appropriate to diagnosis)
Regular assessment on tooth wear
and dietary habits
AT HOME
ORAL HYGIENE ROUTINE
Brushing with Colgate® Sensitive Pro-ReliefTM
Toothpaste & Toothbrush x 2 daily
Rinsing with Colgate® Sensitive Pro-ReliefTM
Mouthwash 2 x daily ( 20 ml for 30 sec)
In between brushing use of Colgate®
Sensitive Pro-ReliefTM Mouthwash
may be considered for reducing the
risk of gingival and hard tissue trauma
with improper/excessive brushing.
TREATMENT
In-office DHS treatment to
provide instant pain relief
Application of Colgate® Sensitive
Pro-ReliefTM Desensitising Polishing Paste
24
Dentine hypersensitivity and periodontal disease
and treatment
Photo courtesy Prof. M Wolff
Periodontal disease results in periodontal tissue damage and loss of gingival
tissue through biological breakdown processes.
Exposed dentine due to periodontal disease
Once gingival recession occurs, the cementum covering the exposed dentine
surface is easily removed by physical and/or chemical forces, thereby exposing the underlying dentinal tubules and increasing the risk of dentine hypersensitivity.
Patients suffering from dentine hypersensitivity as a result of periodontal
disease, are recommended to receive a two-component treatment and
prevention plan addressing periodontal health and sensitivity. The primary task
must be to focus on the periodontal problem, by initiating both the systemic
phase (general disease and smoking habits control) and the initial phase of the
periodontal therapy including scaling and root planing (SRP) and motivation for
rigorous oral hygiene practices, to control dental plaque effectively.
After these are completed, a re-evaluation will indicate the need to plan
for corrective and maintenance therapies based on the projected desired
outcome of the periodontal treatment (Lindhe et al. 2008).
Several clinical studies have attempted to analyse the contribution of different
clinical variables to the development of dentine hypersensitivity, during both
initial and corrective periodontal therapy phases (Wallace et al. 1990, Fischer
et al. 1991, Tammaro et al. 2000). A meta-analysis showed that periodontal
therapy appears to be a significant cause of dentine hypersensitivity (von Troil
2002). After periodontal therapy, reduction of the gingival protective barrier
may result from excision of tissue that exposes the root surfaces, while SRP may
remove 20 to 50 micrometers of cementum and expose the dentinal tubules to
external stimuli.
Two studies (Fischer et al. 1991 and Tammaro et al. 2000) reported
significant change in dentine hypersensitivity after SRP, with about 55%
of patients experiencing characteristic pain one week after treatment.
A systematic review showed that dentine hypersensitivity occurred in
approximately half of patients after they underwent SRP (von Troil et al. 2002).
Tamminen and colleagues (1998) determined that dentine hypersensitivity
also occurred after periodontal surgery. Clinicians have observed that the
intensity of pain or discomfort differs considerably among patients
(Karadottir et al. 2002).
25
Dentine hypersensitivity needs to be addressed, whenever it occurs during
the periodontal therapy, by using an in-office product that provides instant
relief. Such an approach can not only help to relieve pain, but can also help
ensureproper plaque control following therapy, through effective home
oral hygiene procedures. In patients with a history of discomfort during
periodontal procedures, pre-procedural application of a dentine hypersensitivity treatment may also be considered. At home, management of
dentine hypersensitivity in periodontal patients may be handled through a
range of options, like the use of a desensitising mouthwash, while the daily
brushing with an antimicrobial toothpaste is continued.
Dentine hypersensitivity management strategy options in the context of the periodontal
treatment
DIAGNOSIS
Identified periodontal disease as
primary underlying cause
PATIENT EDUCATION
• Motivation for oral hygiene and
recommendation of at home oral
hygiene routine
• Instruction on ways of reducing
periodental risk factors (local factors,
general diseases, smoking, etc)
TREATMENT
Pro-Relief
INITIAL PHASE
• SRP
• DHS TREATMENT
Apply Colgate® Sensitive Pro-ReliefTM
Desensitising Polishing Paste to reduce
discomfort before/after non-surgical
procedures
Re-evaluation
Follow-up assessment on periodontal
status and DHS
CORRECTIVE PHASE
• Surgical periodontal treatment
Other required therapeutic measures
(implant surgery, endodontic, restorative,
prosthodontic etc.)
• DHS TREATMENT
discomfort before/after surgical
procedures
AT HOME
ORAL HYGIENE ROUTINE
a) Short period, if needed
0.2% CHX mouthwash for plaque control
b) Regularly brushing with Colgate® Total
Toothpaste + 3600 Toothbrush 2 x daily
for plaque control
Colgate® Sensitive Pro-ReliefTM
Mouthwash x 2 daily (20 ml for 30 sec)
for DHS control
FOLLOW UP
MAINTENANCE PHASE
• Supportive periodontal therapy
• Continuous monitoring
• DHS TREATMENT
discomfort before/after supportive
perioodontal therapy procedures
(eg. professional cleaning)
26
Dentine hypersensitivity and restorative treatments
Tooth preparations for restorative treatments on vital teeth inevitably open up
hundreds of dentinal tubules. Hypersensitivity after crown preparation is very
common, especially in young teeth with large pulp and minimum secondary
dentine formation. The resultant smear layer is not able to block the freshly-cut
dentine so a certain degree of fluid movement within the dentinal tubules is still
possible, hence causing dentine hypersensitivity.
It has been shown that the application of a 8% arginine and insoluble calcium
carbonate containing desensitising paste did not have a significant effect on
the shear bond strength of the composites, enabling the safe use of restorative adhesive techniques (Garcia-Godoy 2010), with a proper control of dentine
hypersensitivity, for direct or indirect restorations (Seow Liang Lin 2012).
Dentine hypersensitivity management strategy options for patients with restorative
treatments
DIAGNOSIS
TREATMENT
Decision about
restorative treatment
on vital teeth
RESTORATIVE
PREPARATION
Perform the required
filling and/or crown
preparation
procedure
AT HOME
ORAL HYGIENE
ROUTINE
FOLLOW-UP
Inspect restoration
Brushing with
Colgate® Sensitive
Pro-ReliefTM
Toothpaste &
Toothbrush x 2 daily
Rinsing with
Colgate® Sensitive
Pro-ReliefTM
Mouthwash 2 x daily
( 20 ml for 30 sec)
DHS TREATMENT
Apply Colgate®
Sensitive Pro-ReliefTM
Desensitising
Polishing Paste on
all exposed dentine
FINAL RESTORATION
Filling or crown
cementation
Dentine hypersensitivity and professional tooth whitening
The demand for having white teeth has increased during the last decade
and tooth whitening has become more common. Products that are used for
professional tooth whitening have been found to be linked with tooth
sensitivity (Pohjola 2002, Auschillet al. 2005). Sensitivity often occurs during both
in-office and at-home tooth whitening treatments, and has been considered to
be the most common complication of at-home tray treatments. The problem will
commonly manifest itself as generalised hypersensitivity to cold stimuli, but
often also occurs as a spontaneous sharp pain, sometimes limited to one or a
few teeth (Haywood 1991). Reported incidence is most commonly in the 60%
range and the degree of hypersensitivity in these reports ranges from very mild
to intolerable. The latter can be severe enough for patients to interrupt or even
stop their treatment. (Haywood 2005, Sterrett 1995, Jorgensen 2002). The cause
of the sensitivity experienced during whitening treatments is considered to be
multifactorial - involving acidic pH, dentinal fluid outflow caused by osmotic
stimuli and penetration of peroxides through enamel and dentine. The latter
supposedly results in a reversible pulpal irritation (Hewlett 2007). Pain needs to
be prevented and treated to avoid negative effects on treatment compliance.
Pre-existing dentine hypersensitivity is considered one of the best predictors
of post-whitening hypersensitivity, and the use of classic desensitising agents
applied topically, has proven effective in managing the pain (Haywood 2002,
Seow Liang Lin 2012).
27
Patients undergoing tooth-whitening procedures can be offered an
in-office dentine hypersensitivity treatment, as well as preventive advice and
instruction on the daily use of home dentine hypersensitivity products.
An in-office treatment with a desensitising paste containing 8% arginine
and calcium carbonate, followed by the use of a desensitising toothpaste
containing 8% arginine, calcium carbonate and fluoride, was effective
in achieving immediate and lasting sensitivity relief after professional
tooth-whitening procedures in subjects with pre-existing dentine hypersensitivity. A majority of the subjects noticed a remarkable improvement in
the condition immediately after in-office application of the desensitising paste,
and claimed that twice-daily brushing with the respective toothpaste helped
them to maintain, and even improve, the desensitising effect achieved in the
dental office (Data on file, Colgate-Palmolive 2011).
Dentine hypersensitivity management strategy options for patients in professional
tooth-whitening treatment
DIAGNOSIS
Assessment of
potential for
whitening.
Define whitening
needs and shade
improvement goals.
Assessment of
baseline tooth
sensitivity before
tooth whitening
treatment
FOLLOW-UP
Follow-up
assessment on
DHS and whitening
treatment
PATIENT
EDUCATION
DHS
TREATMENT
Patient counseling
in reducing risk
factors
(acidic drinks & food,
abrasive
toothbrushing)
Apply Colgate®
Desensitising
Polishing Paste to
reduce baseline
hypersensitivity
DAT HOME
ORAL HYGIENE
ROUTINE
If further control of
DHS is needed
Brushing with Colgate®
Toothpaste & Toothbrush x 2 daily
Rinsing with Colgate®
Mouthwash 2 x daily
(20 ml for 30 sec)
WHITENING
TREATMENT
Perform professional
tooth whitening
procedure
Development lesions (Hypomineralized teeth / MIH)
Molar incisor hypomineralisation (MIH) is a type of dental defect which seems
to occur frequently in various populations around the world, raising interest in
further research and understanding of its aethiology and management in the
dental community. Prevalence varies from 6% in Germany to almost 40% in
Denmark (Alalussua 2010). According to a recent EAPD (European Academy
of Paediatric Dentistry) policy document (Ligidakis et al. 2010) the aetiology
of this condition is still not entirely understood. Several existing studies
suggest a multifactorial involvement of medical problems during the prenatal,
neonatal and postnatal periods.
28
Photo courtesy of Dr. J.
Kühnisch, München Universitet, Tyskland
MIH can have several dental consequences for the individual affected, including detine hypersensitivity. In fact, hypersensitivity is
one of the diagnosis criteria for MIH
as established by the EAPD
(Weerheij et al 2003). Hypersensitivity often results in the child avoiing brushing the affected teeth, thus
increasing their risk of developing
caries. In this context adequate
control of pain is part of the initial
management of MIH.
Hypomineralised molar
An in-office treatment may be recommended to try to achieve immediate
relief and increase the ability of the child to maintain proper oral care.
Considering also the mineralisation effect Pro-ArginTM Technology has on
enamel, the recommendation to continue to use a toothpaste with such a
formulation at home seems consistent with proposed approaches for the
management of MIH for partially erupted teeth. This holds true for preventive care, regardless of the severity of the defect or development stage of
the affected teeth. Mineralisation could also be achieved with a high-fluoride
varnish (William et al 2006a, Mathu-Muju and Wright 2006).
Dentine hypersensitivity management options for patients with MIH
DIAGNOSIS
DHS diagnosed in
the context of MIH
FOLLOW-UP
DHS, plaque control
and
caries prevention
PATIENT
EDUCATION
Provide appropriate
dietary and preventive
advice. Involve
parents if needed.
AT HOME
ORAL HYGIENE
ROUTINE
Brushing with
Colgate® Sensitive
Pro-ReliefTM
Toothpaste &
Toothbrush x 2 daily
for further control of
DHS and remineralization.
Brushing with
fluoridated toothpaste
minimum 1000 ppm F
(Smiles Toothpaste
&Toothbrush) for
children under the
age of 6.
Additionally
Colgate® Sensitive
Pro-ReliefTM Mouthwash 2 x daily (20 ml
for 30 sec)
(children 6+)
29
TREATMENT
DESENSITISATION
Apply Colgate®
Desensitising
Polishing Paste to
sensitive MIH teeth.
REMINERALISATION
Apply Duraphat Varnish
RESTORATION
Depending on
severity of
deficiency
30
NO
Yes, with regular
2/daily use of toothpaste
Sr-chloride NO
Sr-acetate YES (with
NaF and MFP)
NO
NO
Yes, with regular
2/daily use of toothpaste
YES (with NaF and
MFP)
Not applicable
Lasting Relief
Compatibility with
Fluoride
Superior efficacy
vs K+ as positive
control
Toothpaste
Instant Relief
Toothpaste
Tubule occlusion
through deposition
of insoluble strontium
compounds on the
dentine surface
Desensitisation of
dental nerve
Mode Of Action
Product Form
Strontium Salts
Potassium Salts (K+)
Depolarising
Agents
No data available
YES
Yes, with 2-3 application in 10 days
YES
In-office varnish
Tubule occlusion
through deposition
of calcium fluoride
globules on the
dentine surface
Fluorides
(high concentration)
No data available
YES
Yes, with regular 2/
daily use of toothpaste
or gel
NO
1)Toothpaste
2)Gel
Tubule occlusion
through deposition
of insoluble stannous
compounds on the
dentine surface
Stannous Salts
YES vs. K+ and Sr2+.
Salts
YES (with MFP)
YES, with regular 2/
or single application of
in-office paste
NO
1)In-office paste
2)Toothpaste
3)RX toothpaste
Tubule occlusion
through formation of
a hydroxy-apatite-like
calcium phosphate
layer on dentine
surface
Calcium Sodium
Phosphosilicate
(NovaMin®)
YES, vs. K+ and Sr2+.
Salts
YES (with MFP)
YES, with regular 2/
or single application of
in-office paste
YES
1)In-office paste
2)Toothpaste
Tubule occlusion
through formation of a
calcium- and phosphate-rich layer on dentine
surface which is triggered by arginine and
calcium carbonate
Arginine-Calcium
Carbonate
Pro-ArginTM
Technology
Overview of different technologies for treatment of dentine hypersensitivity
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