by Anne Nugent Guignon, RDH, MPH
A recent post on the Amy RDH e-mail list posed a provocative two-line request from Donna. "I am in need of some ideas for HEAVY coffee stains on roots. And of course the patient is sensitive."
Every clinician I know shudders at this combination of events. Bruce, the chain-smoking, three pack-a-day, country western radio disc jockey made me nuts in the early years of my career. Even though he came in faithfully every three months, his visits were always a nightmare.
As a radio announcer, Bruce needed his teeth, and I was expected to perform miracles without anesthesia. A thick wall of periodontal splinting was the only thing holding his lower anterior teeth in his head. Every square millimeter of exposed root structure was covered with thick, black, tar-like stain.
Four decades ago there were no chairside desensitizers that worked in minutes, and Bruce did not want to be numb. So this post hit a nerve and I composed a response.
Good morning Donna,
What a nightmare – a sensitive patient who wants all the stain off! While you did not mention anesthesia, my answer is based on the patient not being numb. Texas does not allow hygienists to provide anesthesia, so effective desensitizers are critical in my practice. Anesthesia only addresses sensitivity during treatment.
Donna, your two-sentence, 20-word question requires a thorough knowledge of what is available, as well as how and when to use a variety of products and technologies.
It used to be a tall order to remove stain on sensitive patients, but with today's advances in power driven scaling, and the growing number of effective desensitizing agents, it is now possible to provide comfortable, quality care with minimal damage to teeth.
Patient comfort is the first priority. Clinicians should desensitize a patient with a product specifically designed to accomplish this goal and then deal with the stain. Most desensitizing agents occlude open dentinal tubules. Others are surface protectants, which create a thin layer over an entire area rather than just plugging the tubules.
Most of today's desensitizers are very creamy pastes, which increase the potential for splatter. They should be applied with a prophy cup at slow speed. Use a saliva ejector to control moisture and work with an anti-splatter angle such as the Young Contra Elite or the Total Care Perfect Pearl. The paste can also be applied with a cotton-tipped applicator or rubbed directly on sensitive areas. The paste should be applied preprocedurally, and reapplied after scaling to ensure maximum desensitizing.
In my clinical practice there are products that work really well. The experiences of other clinicians who treat sensitivity regularly mirror my clinical success. There is not one desensitizer that works for all patients. Since results vary between patients, clinicians need several desensitizing options.
Colgate's Sensitive Pro-Relief desensitizing paste contains 8% arginine bicarbonate/calcium carbonate, which occludes open dentinal tubules. Sensitive Pro-Relief comes in unit dose cups or a tube, which eliminates product waste. The paste is quite effective because it provides immediate and long-lasting relief, but it does not remove surface stain.
Dentsply's Nupro Sensodyne prophy paste contains NovaMin, a calcium sodium phosphosilicate compound that creates a hydroxyapatite-like layer on the tooth surface, occluding the tubules. There is a fine polishing grit and an extra coarse stain removal version. Clinicians should use the mildest grit possible to reduce potential damage to delicate root surfaces.
Sylc air-polishing powder also contains NovaMin technology. Because of its particulate nature, Sylc removes stain when used in a device. Those who prefer not to use an air-polisher can make a paste with Sylc powder and a few drops of water. The paste should be applied with a prophy cup or applicator.
3M ESPE's Vanish Varnish XT is a surface protectant made from a modified resin glass ionomer. It is not a traditional varnish formula. A thin coating needs to be applied to a clean surface.
The durable light-cured coating can last six months or more. Glass ionomer materials absorb fluoride over time, which provides additional protection.
Some clinicians use traditional fluoride-based varnish prior to scaling to reduce sensitivity. Ivoclar's chlorhexidine-based varnish, Cervitec Plus, has been available in Europe for over a decade, and it became available three years ago in the U.S. According to research, Cervitec Plus will relieve sensitivity for three months.
Some clinicians have found success with GC America's MI Paste that contains ACP-CPP. However, a single professionally applied dose does not always provide immediate and profound relief for those with severe sensitivity. These types of patients tend to benefit from repeated applications over time.
Once a patient is desensitized, the next task is to remove stain. Studies indicate that a properly used ultrasonic dental scaler is less damaging to root surfaces than a hand-held curette. Hand instruments have the potential to remove nearly 10 times more root structure than a properly used ultrasonic dental scaler, creating a potential for even more sensitivity.
Specially designed ultrasonic tips fashioned like a blade facilitate stain removal even though the edge is not sharp. In the magnetostrictive world, the triple bend design works like magic on stain. In piezo land, bladed triangular-shaped supragingival tips take stain off in record time. The trick is to keep the touch light and let the insert do the work. Regardless of whether or not one is using magnetostrictive or a piezoelectric technology, the more pressure applied, the longer it takes to remove stain and other deposits and the more potential there is to damage a tooth surface.
Sensitive patients are hard to work on. They drive us crazy and we make them nuts, especially if we fail to acknowledge or treat their sensitivity. Once patients are treated successfully, they will never leave your practice and they will become your biggest supporters. Everyone wins when sensitivity is taken seriously and treated successfully.
A parting thought – once a patient is desensitized, the clinician should find out why the patient's teeth became sensitive and should make a plan to prevent sensitivity from recurring. No one today should suffer from dentinal hypersensitivity. There are many ways to treat sensitive patients successfully. Providing long-term, day-in and day-out relief is a complex topic that deserves a comfort zone column of its own.
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