Quality Resource Guide l Management of the Patient with Dentin Hypersensitivity 2nd Edition 4 www.metdental.com Management of Dentin Hypersensitivity Prevention of Dentin Hypersensitivity The basic preventive measures for dentin hypersensitivity should be provided at home and/ or in the dental office. At-home measures are basically identical to those tailored for patients with dental erosion. The patient should avoid erosive (highly acidic) drinks and diet and execute gentle but efficient tooth brushing with a soft brush and low abrasive toothpaste. Practice guidelines for specific techniques have not been established as there are no systematic reviews covering nutritional counseling or oral hygiene approaches for dentin hypersensitivity. 1 Dental professionals may reduce the risk of causing tooth sensitivity by avoiding multiple in-office prolonged bleaching sessions with highly concentrated hydrogen peroxide products and by assuring that restorative margins are sealed. Preventive fluoride varnish applications should be a routine practice following periodontal treatment involving root instrumentation. Treatment of Dentin Hypersensitivity “Can you replace tooth enamel?” is a common question asked by patients suffering from dentin hypersensitivity when they learn from their dentist that the reason behind their pain is the exposed dentin due to enamel loss. The answer to this question is “unfortunately no”; tooth enamel has no living cells and cannot repair itself. There are two main approaches reported in the literature to treat hypersensitive teeth: 1) blocking the exposed dentin tubules to prevent fluid movement with currently available desensitizing agents or devices (fluoride varnishes, dentin bonding agents, oxalate gels, laser therapy and protein precipitation) and; 2) inhibition of the neuronal transmission of the stimuli. 17 Potassium nitrate is typically the agent to provide this action. As far back as 1935, Grossman mentioned that the ideal desensitizing agent should be: rapidly acting with long-term effects, non-irritating to the pulp, painless and easy to apply without staining the tooth surface. 18 Initial Steps for Treating Dentin Hypersensitivity Because of the difficulty measuring the pain response, treating dentin hypersensitivity can be challenging for the dental professional. The dentist should initially follow these steps: 1. Complete a comprehensive diagnosis using all the previously mentioned tools. 2. Rule out possible underlying diseases or structural problems. 3. If diagnosis confirms dentinal hypersensitivity due to personal habits, the dentist should: • Educate the patient about dietary acids and good oral care habits. • Recommend different teeth brushing methods, if appropriate. • If the patient is suffering from bruxism, keep teeth grinding in check with an occlusal splint and bring awareness to jaw clenching during the day. 19 • Recommend a desensitizing agent for home use. • Apply topical desensitizing agents. 4. If diagnosis confirms dentinal hypersensitivity after dental treatment, it should be addressed according to the actual dental procedure: • Sensitivity after dental restorations - Inform the patient that it should subside within 1 to 2 weeks. 6 • Sensitivity following periodontal treatment (scaling and root planing) - When calculus is removed from a tooth, the root surface may be exposed - temporary sensitivity may be avoided by the application of a desensitizing agent following the treatment (fluoride varnish is a good option). 15,17 • Sensitivity following crown cementation - Patients usually report sensitivity to cold - occlusion should be checked for premature contacts and occlusion adjustment completed as necessary - the patient should be informed that sensitivity is temporary. Treatment options range from minimally invasive procedures, such as application of a dentin- bonding agent, to more aggressive therapy if dentin hypersensitivity is not resolved. Desensitizing Products Dahnhardt, et al. 20 noted that the two main treatment options for dentin hypersensitivity are desensitization of the nerve and the mechanical occlusion or covering of the dentin tubules. The therapeutic gold-standard treatment that can completely eliminate dentin hypersensitivity has not been discovered and every desensitizing agent currently used has a shortcoming. 21 The classification of dsensitizing agents classification is based on mode of administration (at home treatment or in-office treatment) plus mechanism of action. At Home Treatments Historically, over-the-counter products are the first line of treatment for most patients with dentin sensitivity. The most widely used products are anti-sensitivity dentifrices. They are considered the primary at-home non-invasive treatments because they are simple to use and are cost-effective. Potassium nitrate and stannous fluoride are the most common ingredients in the anti-sensitivity dentifrices. Potassium nitrate interferes with the transmission of the nerve impulse, and stannous fluoride effectively blocks dentinal tubules by forming a smear layer at the surface. 1. Potassium Nitrate Dentifrice Potassium salts (potassium nitrate, potassium chloride or potassium citrate) are known as “nerve- numbing” agents. The literature shows four-week exposure time is needed for 5% potassium nitrate to exert a noticeable desensitizing effect. Dental products that contain potassium nitrate raise the extracellular potassium ion concentration and affect polarization. 22,23 When the concentration is sustained over time, the synapse between nerve cells is blocked, the nerve excitation is reduced and the tooth is less sensitive to the stimuli. 24 While some clinical studies showed that dentifrice containing potassium nitrate effectively reduces dentin hypersensitivity, 22,23 other systematic reviews