BY ANNE NUGENT GUIGNON, RDH, MPH
Some words send chills up the spine of every clinical dental hygienist. Undoubtedly each of you will immediately think of many patients when you read these statements — Hurry up and get done. Don’t touch that spot! Don’t use that darn machine. I hate it when you use the pick on my teeth. It doesn’t hurt until you touch it. Can’t you warm up the cold water? Do you have to blow air on my teeth? I’d rather be anywhere but here. You’ve got to get me numb. Where’s the nitrous?
Every clinical dental hygienist deals with sensitive, anxious patients. Our goal is to create a comfortable appointment. Some patients quit coming, are perennially late, are constant no-shows, or break their appointments at the last minute. Others moan and groan, tense up like a board, or scoot to the other side of the chair. Some are really negative and others won’t schedule appointments. Despite these varied behaviors, the driving force for many is fear of pain and utter frustration that we can’t solve their sensitivity. We secretly label them as difficult, hoping they’ll land in another clinician’s chair. No one wins with this scenario.
For years I’ve joked that I’m “too dumb” to give local anesthesia, but in reality the practice act in Texas does not allow me to give anesthesia. I’m allowed only to monitor nitrous oxide sedation, a service that is not available where I practice. My goal is to figure out how to treat anxious, apprehensive patients without these options.
Actually, I’ve become quite fond of working with patients that no one else wants to treat. It’s a two-stage process, and the first step is to find out what’s causing their anxiety. Can I ask the right questions and listen carefully enough to uncover what’s really bothering a person? Do I have the right tools or skills to eliminate the anxiety trigger? With respect to anxiety, the problem can range from uncontrollable gagging to profound, debilitating dentinal hypersensitivity. Salt on the tip of the tongue is my favorite ploy for gaggers. All that’s needed is a pinch.
But sensitivity is a really interesting puzzle. Two conditions are necessary for sensitivity — exposed dentin and open tubules. People with sensitivity have an average of eight times more open tubules that are twice the mean diameter of a normal tubule. That is a lot of sensitive microscopic real estate. Research indicates that 58% of the population experiences dentinal hypersensitivity. My clinical experience suggests that the prevalence is much higher and will rise as the increasing consumption of acidic beverages accelerates the demineralization process.
Keep in mind that inadequate daily biofilm disruption, GERD, dry mouth issues, frequent carbohydrate consumption, and any condition that involves vomiting also increases the risk for sensitivity. Typically sensitivity issues increase with age, but I’ve treated children as young as six.
A lot of patients have given up because dental professionals often fail to recognize their problem, much less appreciate the severity or recommend effective treatment. Then there are people who don’t even realize they suffer from sensitivity. Here’s a quick trick — ask your patients, “What’s your favorite flavor of ice cream?” Sensitive patients will say they never eat ice cream. A blast of compressed air will confirm the diagnosis, but I’m not fond of putting a sensitive patient through more testing just to confirm my suspicions.
Studies also indicate that those with fair, redhead complexions may carry a gene that makes them very sensitive, and they often require more anesthetic to achieve comfort. If a redhead or fair patient ends up in your chair, ask questions. If they’ve been sensitive since birth, then it is a normal fact of daily living, but it can be reversed. Another tipoff is a patient who says, “Don’t use that machine to clean my teeth. I can’t stand the sound.” About five years ago, I stumbled on the fact that the sound from a power driven scaler is not the issue — dentinal hypersensitivity causes their discomfort. Somehow their brain sends a mixed message.
Despite manufacturers’ promises through the years, few products could be applied to sensitive areas prior to scaling. Sadly, patients were forced to suffer through dental hygiene appointments or receive an injection. If you practice in a state that does not allow hygienists to give anesthetic, precious minutes evaporate when the dentist is not immediately available.
Fluoride varnishes and glass ionomer surface protectants are effective desensitizers, yet clinicians have always wanted a product that’s easy to apply that could eliminate sensitivity prior to scaling. Two different chemistries fit the bill. Colgate’s Sensitive Pro Relief Desensitizing Paste, formerly known as ProClude by Ortek, is an arginine-based bicarbonate/calcium carbonate compound that raises the pH in the oral cavity to seven, which facilitates the deposition of calcium and phosphate into the open dentinal tubules, and the results are immediate, profound, and long-lasting. Products that contain NovaMin, a bioactive glass that contains calcium sodium phosphosilicate, can also be used to treat sensitivity. When activated by water or saliva, NovaMin creates a layer of hydroxyapatite-like material on the tooth surface, which blocks the exposed tubules and raises the pH to 8 to 8.5. Two professionally applied products contain NovaMin — Dentsply’s Nupro Sensodyne Prophy Paste with NovaMin (NSPP), and Sylc, a powder used in air polishing devices.
Colgate’s Sensitive Pro Relief has been the first line of defense in my treatment room for close to a decade. It’s an amazing desensitizer. It is not a prophy paste and will not remove stain, but it does provide immediate and profound relief for the majority of cases. The paste is very creamy and has a propensity to splatter, a problem that can be easily controlled by slowing down the speed of the handpiece and using continuous suction to eliminate excess saliva. Prophy cups that are fashioned with external ridges or flutings, such as Young’s Contra Elite Flex or Total Care’s Perfect Pearl, also reduce splatter. Excess paste and saliva cling to the rotating cup, providing enough time to suction out the excess.
My routine is simple. I apply small amounts of paste to all tooth surfaces with a prophy angle operating at a slow speed, focusing on burnishing the arginine compound into exposed root surfaces, which is the usual location for sensitivity. Typically it takes only three to four prophy cups of paste for an entire mouth. Rather than rinsing the paste off the teeth, the water from the ultrasonic scaler gradually washes away the remaining paste. At the end of the appointment I do another quick application to ensure all areas receive the maximum desensitizing benefit.
CSPR comes in a tube and premeasured cups. There are about 60 full-mouth applications in a tube. In my experience, the unit dose cups have twice as much as needed for a patient. To keep in line with today’s focus on eliminating unnecessary waste, divide the contents in half and store the unused portion in the office refrigerator.
Every patient is different, and sometimes products with NovaMin produce a better result. NuPro Sensodyne prophy paste with NovaMin is my product of choice when the arginine compound does not do the trick. It is available in single dose units, and removes surface stain using traditional paste polishing techniques. Since I don’t have an air polisher, I’ve also made a paste using Sylc powder mixed with a small amount of water that can be applied to the sensitive areas.
It’s a shame if your doctor won’t supply desensitizing products. Don’t let his or her reluctance put the brakes on a great opportunity to take better care of patients. Request samples from companies. With permission from both the patient and doctor, offer to treat really sensitive patients. But before you pat yourself on the back, rule out other sources of sensitivity such as caries, cracked teeth, occlusal trauma, and pulpal pathology. These professionally applied desensitizing products only treat dentinal hypersensitivity. If your patient’s sensitivity goes away completely, then the treatment confirms the diagnosis of dentinal hypersensitivity. If however, there is still lingering sensitivity, re-treat the sensitive areas with the same desensitizer, consider using a different product, or look for another reason for discomfort. Sensitive patients often have multiple etiologies.
Some practices charge for desensitizing and use code 9910. Others consider desensitizing part of the dental hygiene appointment. Either approach has merit, and treating desensitizing therapy as a fee-based service will increase daily production figures. But if a practice does not charge an additional fee, the dental hygiene appointment has another value-added service that has the potential to create a deeper, longer-lasting patient relationship. In my office, the long-term payback from not charging a separate fee has been huge. Patients who come in as emergency patients and receive desensitizing therapy are the only exceptions. They are charged for an office visit when they see the doctor for this treatment.
How long does desensitizing therapy last? The answer to this varies. What is the patient willing to do? Are there lifestyle issues that perpetuate the condition? Are they willing to follow up your amazing treatment and use home-care products that will continue to remineralize their teeth?
So before you reach for anesthetic or nitrous, take time to find out what is really bothering your patient. If the problem is dentinal hypersensitivity, successful treatment will win the patient over. They will be more relaxed, easier to work with, and they will become your most ardent supporters, recommending your practice to all of their friends and colleagues. Comfortable patients keep appointments, show up on time, and get necessary work done. If you solve their sensitivity issues, they will be yours for life. Everyone wins when sensitivity is addressed appropriately and with respect. Their comfort zone will be your comfort zone. RDH
ANNE NUGENT GUIGNON, RDH, MPH, provides popular programs, including topics on biof lms, power driven scaling, ergonomics, hypersensitivity, and remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971.
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