Written by Lou Graham, DDS Wednesday, 30 November 2005 19:00
Dentin hypersensitivity may be greatly impacting your patients, although they may not tell you about it at the time of their dental office visit. Today, safe and effective treatment options are readily available. Especially with the growing demand for and frequency of tooth-whitening procedures, bleaching-induced tooth sensitivity is becoming more and more common. Yet dental professionals still fail to recognize and diagnose this common condition, the impact it can have on their patients’ lives, and how the appropriate clinical management can lead to greater levels of patient satisfaction. To help better educate dental professionals, this article will discuss the etiology, diagnosis, and successful management of dentin hypersensitivity.
DENTIN HYPERSENSITIVITY DEFINED
One of the reasons your patients may not acknowledge that they are suffering from dentin hypersensitivity is because the discomfort can vary from time to time and season to season. Defined as a short, sharp pain arising from exposed dentin, dentin hypersensitivity typically is triggered by a stimulus that is thermal, evaporative, tactile, osmotic, or chemical in nature, and cannot be ascribed to any other defect or pathology.1
Dentin hypersensitivity is most commonly explained by the hydrodynamic theory, which demonstrates that fluid within the dentinal tubules can flow in either an inward or outward direction depending on conditions surrounding the teeth. A stimulus that affects the open tubules of the dentin surface causes a fluid movement, resulting in pain. Common stimuli include foods and beverages that are hot, cold, sweet, or sour. Cold air also is a common stimulus. The buccal cervical zones of canine and premolar teeth are the sites most susceptible to sensitivity.
PREVALENCE OF DENTIN HYPERSENSITIVITY
Dentin hypersensitivity is a condition that affects a wide spectrum of patients. The statistics below demonstrate the pervasiveness of this common condition. Varying data exist regarding the worldwide occurrence of dentin hypersensitivity. Clinical findings demonstrate, however, that approximately 1 in 5 people in the United States suffer from the condition.2 Although sensitivity affects people of all ages, those between the ages of 25 and 50 are more commonly affected,3 and the condition is slightly more prevalent in women.4 In the United States, periodontal patients experience sensitivity at very high rates,5 and patients undergoing professional tooth whitening also are especially prone to tooth sensitivity. In fact, 55% to 75% of patients suffer from whitening-related sensitivity.6
Clearly, dentin hypersensitivity is more prevalent than dental professionals may realize. Data show that 42% of patients do not report consulting their dentist about their condition, and only 27% of those suffering report using a desensitizing dentifrice to help manage the condition.7 Instead, many patients modify everyday behaviors to avoid sensitivity, and may not even be aware they are doing so. For example, some patients avoid hot or cold foods or beverages. Others may avoid brushing sensitive areas, placing them at risk for plaque buildup, calculus formation, and even gingivitis.
DIAGNOSING DENTIN HYPERSENSITIVITY
Making the proper diagnosis is the first step in assisting your patients suffering from dentin hypersensitivity. Identifying patients who are sufferers can be achieved through close examination of existing conditions and by careful analysis of patient behaviors.
In addition to periodontal patients and those undergoing professional tooth-whitening procedures, other groups at risk for dentin hypersensitivity include those who exhibit gingival recession due to aggressive oral hygiene habits, consumers of high-acid food and drink, patients with parafunctional habits, and patients suffering from xerostomia.
In addition to paying special attention to these circumstances, a comprehensive and thorough examination is necessary to diagnose dentin hypersensitivity. Care must be taken to exclude other conditions such as dental caries, pulpitis, cracked tooth syndrome, marginal leakage, fractured restoration, and restoration polymerization shrinkage.
Addressing any underlying causes of dentin hypersensitivity is the first step in successfully managing the condition. Educating patients about proper oral hygiene habits as well as the potential effects that highly acidic foods and beverages can have on their teeth can help them become aware of practices that may be adding to their sensitivity.
Once underlying causes are addressed, the next course of action is to determine the most effective course of treatment. Treatment options include both in-office procedures and at-home care. It is the intent of this article to expand upon the current home therapies available to our patients.
Generally, the least invasive treatment method should be considered first. Anti-hypersensitivity dentifrices that contain 5% potassium nitrate, such as Sensodyne (GlaxoSmithKline), Colgate Sensitive Plus Whitening (Colgate-Palmolive), and Crest Sensitivity Protection (Procter and Gamble), are easy to obtain and use, and have been proven effective in relieving dentin hypersensitivity. Clinical trials demonstrate a reduction in symptoms in 2 weeks when the dentifrice is used twice daily.7 When toothpastes contain potassium nitrate at a concentration of 5%, potassium ions can penetrate the length of the dentinal tubule and block repolarization of the nerve fiber, relieving patients’ pain. Increasing the extracellular potassium ion concentration has been shown to depolarize the nerve fiber membranes, rendering them unable to repolarize because of the remaining high levels of extracellular potassium ions.
The referenced pastes for years have been proven effective in treating the symptoms of dentin sensitivity. Yet new at-home therapies have become quite effective in both decreasing sensitivity and remineralizing the open dentinal tubules. Two such therapies are SoothRx (Omnii Pharmaceuticals) and MI Paste (GC America). These products are delivered via different methods, but their results are based on dentin remineralization.
SoothRx utilizes calcium sodium phosphosilicate as its active ingredient and is distributed from the dental office. Instructions for use are twice-a-day brushing for 2 weeks followed by once-a-week use with routine brushing. MI Paste utilizes Recaldent and is also distributed from the office. A set of custom trays are fabricated, and a variety of treatments can be used with this system. In addition to treating sensitivity, this product has been recommended for use in treating xerostomia, increased caries activity, and enamel and dentin demineralization. Both products work via the route of increasing calcium, phosphate, and fluoride uptake and remineralization.
Should a more immediate approach to treatment be needed, in-office treatments include the application of various desensitizing agents that either occlude the open tubules or inactivate the nerve. In addition, restorations may be placed to cover exposed dentin. In cases of irreversible pulpitis, patients may require removal of the pulp and root canal therapy, or even extraction of the tooth.
BLEACHING-INDUCED TOOTH SENSITIVITY
Tooth sensitivity is the most common side effect of both professionally dispensed and over-the-counter (OTC) tooth-whitening regimens. In many cases, bleaching-induced sensitivity is so severe patients may interrupt or even stop their treatment. As many as 41% of dentists recommend that their patients discontinue bleaching treatment to relieve their pain.2 These considerations may have an impact on overall patient satisfaction.
Dental professionals can address bleaching-induced sensitivity before it becomes a problem by recommending that patients use an anti-hypersensitivity toothpaste for 2 weeks prior to beginning a professional whitening procedure and during the treatment. A recent study of patients using a tray-applied tooth-whitening system demonstrated that patients who brushed with Sensodyne Fresh Mint Toothpaste (GlaxoSmith
Kline) 2 times daily 2 weeks before and 2 weeks during professional whitening treatment experienced significantly more sensitivity-free days as compared to a control group using regular toothpaste.8 In addition, study results showed that the proportion of patients who developed tooth sensitivity during the first 3 days of bleaching while brushing with Sensodyne was significantly less than those using the control toothpaste. From the study data, the desensitizing toothpaste did not adversely affect whitening results.
INCREASING PATIENT SATISFACTION
Patients using the anti-hypersensitivity toothpaste in the above study also reported they were significantly more satisfied with their tooth-whitening treatment and would be much more likely to repeat treatment in the future. Patients also reported no inconvenience in changing toothpastes.
Recommending that patients use an anti-hypersensitivity toothpaste containing 5% potassium nitrate for 2 weeks prior to and 2 weeks during professional bleaching treatment can help make your patients more comfortable and more satisfied with their bleaching treatment. This protocol can help reduce the potential for interruption or discontinuation of treatment due to whitening-induced tooth sensitivity. Patients who complete their treatment comfortably and on time also may be more likely to recommend professional whitening treatment to others,2 further increasing patient referrals.
As discussed in this article, dentin hypersensitivity is more prevalent than both patients and dental professionals may recognize. This common condition affects nearly 20% of adults in the United States. Its complex etiology and symptoms, however, can make diagnosis difficult. A number of factors, including professional whitening treatments, can increase a patient’s potential for tooth sensitivity. Fortunately, anti-hypersensitivity toothpastes are a safe and effective way to treat dentin hypersensitivity, and patients undergoing professional whitening treatment can use them to make the bleaching procedure more comfortable. Addressing whitening-induced sensitivity before patients begin treatment can positively impact patient satisfaction and increase opportunity for profit.
1. Holland GR, Narhi MN, Addy M, et al. Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. J Clin Periodontol. 1997;24:808-813.
2. Data on file, GlaxoSmithKline.
3. Gillam DG, Aris A, Bulman JS, et al. Dentine hypersensitivity in subjects recruited for clinical trials: clinical evaluation, prevalence and intraoral distribution. J Oral Rehabil. 2002;29:226-231.
4. Addy M. Dentine hypersensitivity: new perspectives on an old problem. Int Dent J. 2002;52:367-375.
5. Taani DQ, Awartani F. Prevalence and distribution of dentin hypersensitivity and plaque in a dental hospital population. Quintessence Int. 2001;32:372-376.
6. Haywood VB. Contemporary Esthetics and Restorative Practice. 1993;3(suppl):2-11.
7. Fisher SW, Tavss EA, Gambogi RJ, et al. Anticaries efficacy of a new dentifrice for hypersensitivity. Am J Dent. 2003;16:219-222.
8. Haywood VB, Cordero R, Wright K, et al. Brushing with a potassium nitrate dentifrice to reduce bleaching sensitivity. J Clin Dent. 2005;16:17-22.
Dr. Graham is extensively involved in lecturing and continuing education, focusing on incorporating current clinical advancements through “conservative dentistry.” He is the co-founder of Dental Team Concepts, a continuing education company whose philosophy and programs use contemporary, interactive formats to integrate time-proven conservative dentistry with 21st century materials and techniques. His courses emphasize diagnosis, evidence-based treatment, dental materials, adhesion and cosmetic dentistry, customized approaches to periodontal care, implants, and laser dentistry. He is in private practice in Chicago and holds a part-time faculty position at the University of Chicago. He can be reached at (773) 684-5702 or lgrahamdds@ aol.com.
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