Professional Documents
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PRACTICAL SCIENCE
990
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Background. The objective of this review is to
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inform practitioners about dentin hypersensitivity
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(DH) and its management. This clinical information
A ING ED 3
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is described in the context of the underlying biology.
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Types of Studies Reviewed. The authors used
MEDLINE to find relevant English-language literature published in the
period 1999 to 2005. They used combinations of the search terms
dentin*, tooth, teeth, hypersensit*, desensiti* and desensitiz*.
They read abstracts and then full articles to identify studies describing
etiology, prevalence, clinical features, controlled clinical trials of treatments and relevant laboratory research on mechanisms of action.
Results. The prevalence of DH varies widely, depending on the mode of
investigation. Potassium-containing toothpastes are the most widely used
at-home treatments. Most in-office treatments employ some form of barrier, either a topical solution or gel or an adhesive restorative material.
The reported efficacy of these treatments varies, with some having no
better efficacy than the control treatments. Possible reasons for this variability are discussed. A flowchart summarizes the various treatment
strategies.
Clinical Implications. DH is diagnosed after elimination of other
possible causes of the pain. Desensitizing treatment should be delivered
systematically, beginning with prevention and at-home treatments. The
latter may be supplemented with in-office modalities.
Key Words. At-home treatments; clinical features; desensitizing
treatments; dentin hypersensitivity; etiology; in-office treatments;
prevention; toothpastes.
JADA 2006;137:990-8.
I
ABSTRACT
CON
Dr. Orchardson is a senior lecturer, University of Glasgow Dental School, 378 Sauchiehall St., Glasgow
G2 3JZ, Scotland, e-mail R.Orchardson@dental.gla.ac.uk. Address reprint requests to Dr. Orchardson.
Dr. Gillam is a senior clinician, 4-Front Research, Capenhurst, Cheshire, England, and an honorary
senior lecturer, Department of Restorative Dentistry, Eastman Dental Institute for Oral Health Care Sciences, University College London.
Stimulus:
thermal, mechanical,
evaporative, chemical
Acts on
Exposed dentin; open
tubules
CHARACTERISTICS OF HYPERSENSITIVE
DENTIN
Clinical features. Definition. DH is characterized by short sharp pain arising from exposed
dentin in response to stimulitypically thermal,
evaporative, tactile, osmotic or chemicalthat
cannot be ascribed to any other dental defect or
disease.1 DH usually is diagnosed after other possible conditions have been eliminated. Alternative
causes of pain include chipped or fractured teeth,
cracked cusps, carious lesions, leaky restorations
and palatogingival grooves.2 The clinical features
of DH are well-documented.2-4
Prevalence. The prevalence of DH varies from
45 to 57 percent.6 These variations are likely due
to differences in the populations studied and the
methods of investigation (for example, questionnaires or clinical examinations). The prevalence
of DH is between 60 and 98 percent in patients
with periodontitis.7 A majority of patients, however, do not seek treatment to desensitize their
teeth because they do not perceive DH to be a
severe oral health problem.8 In response to questionnaires, dentists have reported that DH affects
between 109 and 25 percent10 of their patients.
Schuurs and colleagues9 also reported that dentists believe DH presents a severe problem for
only 1 percent of their diagnosed patients.
Distribution. While DH mostly occurs in
patients who are between 30 and 40 years old,2 it
may affect patients of any age. It affects women
more often than men, though the sex difference
rarely is statistically significant. The condition
may affect any tooth, but it most often affects
canines and premolars3,4; the affected teeth tend
to vary among studies and populations, and different distribution patterns have been
described.11
Etiology. Mechanisms of sensitivity. Dentin is
naturally sensitive owing to its close structural
and functional relationship with the dental pulp.12
This inherent sensitivity usually is not a problem
because other tissues cover the dentin. Microscopic examination reveals that patent dentinal
tubules are more numerous and wider in hypersensitive dentin than in nonsensitive dentin.13,14
Generation of action
potentials in intradental
nerves
dentin
pulp
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991
Stimulus:
thermal, mechanical,
evaporative, chemical
b. Increase formation of
intratubular dentin
dentin
c. Induce formation
of tertiary dentin
pulp
3. Decrease intradental
nerve excitability
nerve
Principles. An understanding of the hydrodynamic mechanism of dentin sensitivity provides a basis for developing desensitizing therapies. Desensitizing agents may target various
points in the hydrodynamic sequence, which
can be interrupted by various actions (Figure 2).
Research involves conducting laboratory
studies that screen potential treatments and
identify their mechanisms of action. To evaluate
992
claims made by desensitizing products manufacturers, practitioners should be aware of the limitations and strengths of these research methods.
Dentin disk model. Small dentin disks prepared from extracted teeth can be used to measure the permeability of dentin. Permeability is
derived from the hydraulic conductance or ease of
fluid flow through the dentin.22 Some desensitizing agents such as oxalates reduce dentin permeability, while others such as potassium nitrate
do not. Treated dentin disks can be examined
using a scanning electron microscope to visualize
surface deposits and tubule occlusion.23 By incorporating the dentin disk specimens in intraoral
appliances, experiments can be conducted in situ
under natural conditions in the mouth.24 It also is
possible to replicate the outward flow of dentinal
fluid,25 which can oppose pulpward diffusion of
desensitizing agents.
Recording conduction in isolated nerve
fibers. This model identifies agents (for example,
potassium salts)26,27 or procedures (for example,
use of lasers)28,29 that may block nerve conduction.
Although these in vitro methods allow for rapid
screening of potential desensitizing agents, they
generally do not mimic natural conditions or indicate how the agent will behave when exposed to
saliva and masticatory forces.
Clinical trials. The ultimate test of any treatment is how well it works in the clinic. A randomized, blinded and controlled trial is the gold
standard for determining efficacy.30 In such a clinical trial, the product is compared with the same
formulation minus the active ingredient, which
can be called minus active, negative control or
placebo. A product also can be tested head-tohead against existing products to determine its
effective equivalency or superiority with its
comparators.
CLINICAL MANAGEMENT OF DENTIN
HYPERSENSITIVITY
Pain persists
Pain persists
Eliminate predisposing factors
+ desensitizing toothpaste or mouthwash
Desensitizing toothpastes/dentifrices. Toothpastes are the most widely used dentifrices for
delivering over-the-counter desensitizing agents.
The first desensitizing toothpastes to appear on
the market claimed either to occlude dentinal
tubules (those that contained strontium salts and
fluorides) or destroy vital elements within the
tubules (those that contained formaldehyde).
Now, most desensitizing toothpastes contain a
potassium salt such as potassium nitrate, potassium chloride or potassium citrate, though one
study34 reported that a remineralizing toothpaste
containing sodium fluoride and calcium phosphates reduced DH.
Potassium salts. Toothpastes containing
potassium nitrate have been used since 1980.35
Since then, pastes containing potassium chloride
or potassium citrate have been made available.36
Potassium ions are thought to diffuse along
dentinal tubules and decrease the excitability of
intradental nerves by altering their membrane
potential.26,37 The efficacy of potassium nitrate to
reduce DH, however, is not supported strongly by
the literature, according to Poulsen and col-
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993
mouth and, thus, reduce the efficacy of the cariesreducing effect of fluoride toothpastes.47
Mouthwashes and chewing gums. Studies
have found that mouthwashes containing potassium nitrate and sodium fluoride,48,49 potassium
citrate or sodium fluoride50 or a mixture of fluorides51 can reduce DH. In only one of these
studies,48 however, was the effect of the active
mouthwash significantly greater than that of the
control product. Another study52 concluded that a
chewing gum containing potassium chloride significantly reduced DH, but the study did not
include a control group.
DH severity should be reassessed two to four
weeks after commencement of treatment to determine the effectiveness of the first level of desensitizing treatment (Figure 3). If at-home care fails
to reduce DH compared with baseline levels, the
next level of treatment, an in-office method
(Figure 3), should be started.
IN-OFFICE TREATMENTS
TABLE 1
Some studies indicated that
oxalates significantly reduced
Solutions and products tested in clinical trials.
sensitivity,56-58 while others
TYPE
CHEMICAL/CONCENTRATION
PRODUCT (STUDY)
reported that the effects of
oxalate did not differ signifiSodium fluoride, stannous Dentinbloc, Colgate Oral
Fluoride
fluoride, hydrogen
Pharmaceuticals, Canton,
cantly from those of a
fluoride
Mass. (Morris and
placebo.53,58
colleagues53)
Calcium phosphates. Cal* (Hodosh54)
1-15% solutions
Potassium Nitrate
cium phosphates may reduce
* (Frechoso and colleagues55)
5%, 10% in gel
dentin sensitivity effecProtect, Sunstar Butler,
3% potassium oxalate
Oxalate
tively.59 Calcium phosphates
Chicago (Camps and Pashley56)
Oxa-gel, Art-dent Ltda,
occlude dentinal tubules in
Araraquara, So Paulo, Brazil
vitro62,63 and decrease in vitro
(Pillon and colleagues57)
64
dentin permeability.
Sensodyne Sealant,
6.8% ferric oxalate
Adhesives and resins.
GlaxoSmithKline, Jersey City,
N.J. (Gillam and colleagues58)
Because many topical desensitizing agents do not adhere
* (Geiger and colleagues59)
1.5 molars per liter
Calcium Phosphate
calcium chloride + 1.0
to the dentin surface, their
mol/L potassium oxalate
effects are temporary.
*
Nonmarketed
product.
Stronger and more adhesive
materials offer improved and TABLE 2
longer-lasting desensitization
Adhesives and resins tested in clinical trials.
(Figure 3). In the 1970s,
TYPE
PRODUCT (STUDY)
Brnnstrm and colleagues65
suggested using resin
Fluoride Varnish
Duraphat, Colgate Oral Pharmaceuticals, Canton, Mass.
(Gaffar,66 Corona and colleagues67)
impregnation to desensitize
Fluoline, PD Dental, Altenwalde, Germany (Duran and
dentin. Current DH treatSengun68)
ments involve using adheOxalic Acid and
MS Coat, Sun Medical, Shiga, Japan (Prati and
sives, including varnishes,
Resin
colleagues69)
Pain-Free, Parkell, Farmingale, N.Y. (Morris and
bonding agents and restoracolleagues53)
tive materials. Practitioners
Sealants, Primers
Seal & Protect, Dentsply, Konstanz, Germany (Baysan and
should be aware that clinical
Lynch70)
trials of adhesive desensiDentin Protector, Ivoclar Vivadent, Ellwangen, Germany
(Schwarz and colleagues71)
tizing materials tend to be
Gluma Desensitizer, Heraeus Kulzer, Dormagen, Germany
pragmatic. Many of these
(Duran and Sengun,68 Dondi dallOrologio and colleagues,72
Singal and colleagues73)
trials are single-blind studies
Gluma Alternate, Heraeus Kulzer, Wehrheim, Germany
because true double-blind
(Dondi dallOrologio and colleagues74)
Health-Dent Desensitizer, Healthdent, Oswego, N.Y.
conditions are difficult to
(Duran and Sengun,68 Dondi dallOrologio and colleagues74)
achieve. Table 253,66-77 prePrime & Bond 2.1, Dentsply Caulk, Milford, Del. (Swift
and colleagues75)
sents a list of products tested
Scotchbond, 3M Dental Products, St. Paul, Minn. (Prati
since 1999 that claim to
and colleagues,69 Ferrari and colleagues76)
Single Bond, 3M Dental Products (Duran and Sengun68)
occlude tubules in hypersensitive dentin.
Etch and Primer
Scotchbond, 3M Dental Products (Ferrari and colleagues76)
Systemp.desensitizer, Ivoclar Vivadent, Schaan,
Other procedures. IontoLiechtenstein (Stewardson and colleagues77)
phoresis. This procedure uses
Etch and Primer
Scotchbond Multi-Purpose 3M Dental Products
electricity to enhance diffuand Adhesive
(Dondi dallOrologio and colleagues74)
sion of ions into the tissues.
Primer and
SE Bond, Kuraray, Okayama, Japan (Duran and Sengun68)
Dental iontophoresis is used
Adhesive
most often in conjunction
with fluoride pastes78 or solutions73 and reportedly reduces DH.73,78
the type of laser and the treatment parameters.79
Lasers. The effectiveness of lasers for treating
Studies have reported that the
DH varies from 5 to 100 percent, depending on
neodymium:yttrium-aluminum-garnet (YAG)
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995
START
No
No treatment required
Yes
Yes
No
MANAGEMENT STRATEGY
Confirm diagnosis of DH
Treat with consideration for convenience
and cost-effectiveness (Note 3)
1. Preventive advice
2. At-home treatment (for example,
desensitizing toothpaste)
Review
(2-4 weeks)
(Note 4)
Pain relief
No further treatment;
reinforce preventive
advice; continue to
review
Continue with
preventive advice and
desensitizing toothpaste
In-office treatment:
1. Topical agents (for
example, fluorides, oxalates)
2. Adhesive materials
Review
(Note 4)
Pain relief
Pain persists
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July 2006
997
998
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