Desensitizing techniques help patients feel more comfortable during appointments
By Jamie Collins, RDH, CDA
Many times throughout the workday we have patients who comment or complain about generalized or localized sensitivity. We've all had patients who cringe as soon as they're seated in the dental chair, sure that their fate is to endure an hour of torture with another uncomfortable cleaning. No matter the cause, if someone is forced to avoid a good scoop of ice cream or cold glass of water, there are things that can be done to alleviate the discomfort of hypersensitivity.
The cause is often due to dentinal hypersensitivity; however, there can be other sources for the discomfort. Hypersensitivity can be the result of cracked-tooth syndrome, pulpitis, or decay. Sometimes it can even be caused by occlusal trauma in addition to bruxism.
Dentinal hypersensitivity generally presents as short, sharp pain caused by a stimulus such as temperature change, or when the area is in contact with a foreign object such as a scaler. Once the sensitivity is determined to be caused by dentinal hypersensitivity, the clinician can evaluate therapies.
Hypersensitivity affects females more often than males and has been noted to be most significant in patients between ages 20 and 50, but it can also affect children. In adults, the buccal aspect of the tooth at the cervical is the most common area to have exposed dentin; thus it is the area most often affected by hypersensitivity. Diet can have an adverse effect on dentinal sensitivity as well. Acidic foods and beverages can increase the rate and process of demineralization, thereby increasing sensitivity.
Children may complain of sensitivity most commonly caused by wear through the enamel on the occlusal aspect of the teeth. Children often brux, which causes wear through enamel on primary teeth into the underlying dentinal layer. This often appears as pitting in the occlusal surface, and the clinician can see the underlying yellowish-colored dentin.
Clinicians should not overlook other causes for hypersensitivity. These include xerostomia, insufficient homecare, or conditions that induce vomiting or GERD, which release acid into the oral cavity. With inadequate salivary flow, the remineralization process and body's ability to wash away biofilm is diminished and sensitivity may increase. If you see evidence of GERD or erosion relevant to vomiting, delve deeper into the risk factors. If warranted, refer the patient to his or her physician for further evaluation. Many people have lived with GERD symptoms for so long they don't realize they have a problem that can be treated.
Xerostomia can have many causes, such as medications, autoimmune disorders, or an array of other pathologies or treatments. Treating xerostomia and providing a customized homecare plan, in addition to oral self-care instructions and demonstration, engages patients in their own methods of prevention and treatment. Engaging patients rather than just providing a bag full of dental products to try at home encourages patients to take an active role in their own prevention and treatment.
A couple of variables must be present for hypersensitivity to occur. The first is that the dentin must be exposed, and secondly, the dentinal tubules must not be occluded. Not all exposed dentin is sensitive to temperature or the touch of a dental instrument. I've been surprised many times when a patient presents with 3-4 mm of exposed root surface but has no hypersensitivity. If there are exposed dentinal tubules that are occluded, the pain sensation cannot travel to the nerve and the patient may not experience sensitivity. For others who experience hypersensitivity and are convinced that a visit to the dentist equals torture, there are pretreatment options to help alleviate some of the symptoms and make time in the dental chair a little more comfortable.
For some individuals, dentinal hypersensitivity is caused by abfraction, abrasion, or erosion at the gingival margin of the tooth. In some cases, the defect may extend a millimeter or more into the tooth, exposing the sensitive dentin layer underneath. After diagnosis by a dentist, placement of a filling in the area of the defect can provide relief of hypersensitivity. Placement of a resin-based filling or a glass ionomer to the root surface of a nondecayed tooth may be billed under the CDT code D9911 and is used on a per-tooth basis. If severe gingival recession is noted, a tissue graft may be indicated to provide root coverage and prevent future damage.
The first line of defense against sensitivity is effective communication with patients. At each dental visit we update the health history and inquire about any dental concerns. We ask about any areas of sensitivity prior to reaching for the ultrasonic scaler. Many patients think a cleaning is synonymous with pain, but this doesn't have to be the case. A patient knows which areas are sensitive and will often tell you where you "can't touch."
For a few patients, the best option for hypersensitivity relief is an anesthetic. Patients with periodontal disease often experience hypersensitivity that in-office sensitivity treatments cannot adequately relieve before hygiene treatment. Local anesthetic can provide pain relief and reduce patient anxiety. I often ask patients to try pretreatment desensitizers first with the understanding that if they're still uncomfortable, local anesthetic can be administered as needed.
Sometimes simply having an option for treatment will relieve a patient's anxiety. When someone experiences discomfort from hypersensitivity during treatment, they're often reluctant to return for continuing care as recommended. Many are pleasantly surprised to learn there are options to help alleviate discomfort in the office as well as at home.
Some dental offices charge for in-office desensitizers, using CDT code D9910. This cites the use of a desensitizing medicament applied to the root surface, and applies to the visit, not per site or quadrant treated. I offer the treatment as part of the service and do not charge unless a patient is scheduled only for an application of desensitizer due to hypersensitivity. I have some patients I see on a six-month basis for whom the desensitizer wears off too soon. So we schedule visits for a reapplication, and for those visits there is a small charge, but the patients are happy to pay due to the proven benefit they enjoy. Providing in-office sensitivity treatment as part of the hygiene visit as needed creates a loyal following. Patients know the dental team considers their comfort and will likely refer others to the practice.
When their sensitivity affects everyday life, patients are often motivated to use the recommended home treatments. There is an array of over-the-counter sensitivity toothpaste, as well as prescription-strength pastes that diminish sensitivity. For best results, I recommend spitting out excess toothpaste but not rinsing immediately.
Encourage patients to try these products and learn which brands work best, as well as avoid highly abrasive pastes. They should consider adding a daily mouth rinse that contains fluoride to occlude the dentinal tubules. When patients complain of new sensitivity, I've often learned that they've started using a different toothpaste, and found it to be the source of the increased hypersensitivity. By looking at the whole picture of habits and routines, we're often able to identify the causes and recommend appropriate changes.
For many people, a combination of in-office treatment and homecare will provide a significant decrease in sensitivity. Dentinal hypersensitivity can alter the lives of individuals and keep them from enjoying ice cream during the summer or laughing out loud during the cold winter months. Taking the time to evaluate and treat the causes and symptoms ensures they'll be able to smile and enjoy the little things in life again. RDH
For many years I've incorporated Colgate Sensitive Pro-Relief desensitizing paste (formerly Proclude) into practice for patients suffering with dentinal hypersensitivity. It is a combination of calcium carbonate and the amino acid arginine (8%), which work together to quickly occlude the dentinal tubules and provide relief. Applying it with a prophy cup before scaling helps reduce discomfort. I often use it before scaling and do not provide an immediate rinse. I allow the flow from the ultrasonic to provide the rinse as I work my way through the dentition.
At the conclusion of treatment, I often reapply the paste, and the effect can last up to four weeks. Colgate's desensitizing paste does not provide a polishing quality to remove stain, but other pastes containing NovaMin work well for polishing as well as desensitizing.
Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at [email protected].