Would you be surprised if someone asked you the above question after ordering coffee? Remember that more patients than you realize cope with dentin hypersensitivity.
You would probably be alarmed if you were asked this question when ordering a latte at your favorite coffee shop. But for some of your patients, everyday pleasures such as hot drinks, iced tea, or a dish of ice cream cause pain.
Dental professionals may be surprised to learn that dentin hypersensitivity affects as many as one in five people in the United States.1 Despite the high number of those who suffer, dentin hypersensitivity is seldom the primary reason for a dental visit. In fact, data shows that up to 42 percent of patients with dentin hypersensitivity don’t tell their dental professional they are suffering.1 Fortunately, dental hygienists can play an important role in identifying and managing this condition by asking about sensitivity at every patient visit.
This article provides dental hygienists with an overview of dentin hypersensitivity, information about likely sufferers and ways to identify them, and information about effective treatment options. This will also explore tooth sensitivity that results from professional bleaching procedures, and new treatments to make tooth-whitening patients more comfortable.
What’s behind the pain?
A clear understanding of why dentin hypersensitivity occurs can help dental hygienists better identify and treat the condition. Dentin hypersensitivity is defined as a short, sharp pain arising from exposed dentin in response to thermal, evaporative, tactile, osmotic, or chemical stimuli.2 The pain-causing stimuli cannot be ascribed to any other form of dental defect or pathology, which is why a thorough examination to rule out other sources of pain is necessary to properly diagnose dentin hypersensitivity.
The most common explanation of dentin hypersensitivity is the hydrodynamic theory, which states that a stimulus at the outer aspect of the dentin can cause either an inward or outward fluid movement within the dentinal tubule, which provokes the nerves in the dental pulp. Being aware of common stimuli, or triggers, that set off pain associated with dentin hypersensitivity can help identify such pain. These stimuli/triggers include foods and beverages that are cold, hot, sweet or sour; cold air; and aggressive brushing or flossing.
Although any tooth can exhibit dentin hypersensitivity, the most commonly affected are the canines and first premolars, followed by incisors, second premolars, and then molars. In addition, dentin hypersensitivity most often affects the buccal area of the tooth.3
Who’s at risk?
Dentin hypersensitivity can affect people of any age; however, according to recent data, those between the ages of 20 and 50 report dentin hypersensitivity more frequently, with those between 20 and 30 reporting the most hypersensitivity.4 Reports of dentin hypersensitivity decline as people age. This may be due to naturally occurring sclerosis, or mineralization, of the dentinal tubules. Increased mineralization may block or interrupt the pain-causing stimulus, thereby decreasing the incidence of dentin hypersensitivity.5
More women than men report dentin hypersensitivity. One study suggests that 42 percent of women in North America suffer from dentin hypersensitivity, compared to just 31 percent of men.3 And periodontal patients, regardless of gender, frequently suffer from the condition.6
As most of you are aware, whitening procedures are becoming increasingly popular. According to the American Academy of Cosmetic Dentistry (AACD), professional tooth whitening has increased by more than 300 percent since 1996.7 Unfortunately, many of these patients may be at temporary risk for dentin hypersensitivity. Tooth sensitivity is the most common side effect for both over-the-counter (OTC) and professionally supervised bleaching treatments, and up to 75 percent of whitening patients who undergo professional treatment experience sensitivity.8
Identifying sensitive patients
Regardless of the cause, to avoid pain, many hypersensitivity sufferers steer clear of their favorite foods and beverages. Some may not even be aware they suffer from the condition, or may not know it is treatable. Others may fear they are suffering from a more serious condition. Dental hygienists are often a patient’s first contact; therefore, they have the opportunity to educate patients about dentin hypersensitivity and oral health conditions. For these reasons, it is important for hygienists to inquire about dentin hypersensitivity at every patient visit. By asking specific questions about what makes patients sensitive and engaging them in a dialogue about the sensitivity, dental hygienists can help identify dentin hypersensitivity sufferers.
If patients indicate a history of tooth sensitivity, a thorough clinical exam is necessary to rule out any underlying causes. It also may be helpful to discuss proper oral hygiene habits with patients. Aggressive flossing and brushing can contribute to dentin hypersensitivity, as can frequent consumption of acidic foods and beverages.
Providing sensitivity relief
Once a diagnosis of dentin hypersensitivity is made, dental hygienists can help plan a course of treatment. Both in-office and OTC options are available for treatment of dentin hypersensitivity; however, in most cases, the least invasive method should be considered first. Anti-hypersensitivity toothpastes that contain 5 percent potassium nitrate are effective and easy to use, and act by depolarizing the nerves located at the dentin-pulpal interface. Potassium ions can penetrate the length of the dentinal tubule and prevent repolarization of the nerve fiber, which relieves pain. Patients should be advised to brush with anti-hypersensitivity toothpaste twice daily. Examples of these are Sensodyne® (GlaxoSmithKline Consumer Healthcare), Colgate® Sensitive Plus Whitening (Colgate-Palmolive), Crest® Sensitivity Protection (Procter & Gamble), and DenClude/ProClude (Ortek Therapeutics). With anti-hypersensitivity toothpaste, protection builds over time and results are noticeable within two weeks. Anti-hypersensitivity toothpastes contain fluoride and are safe to use for an extended period. Sensodyne is available in eight different formulations, including tartar control, gel, and extra whitening.
In cases where more aggressive treatment is necessary, in-office treatments are available. These include topical agents or sealants. Restorations, such as glass ionomer cements or resins, may be placed on the tooth to cover exposed dentin. Dental hygienists can recommend the use of anti-hypersensitivity toothpaste in addition to in-office treatments to provide increased protection against pain.
Bright, white, and sensitive
As previously mentioned, tooth sensitivity is often associated with professional whitening (also known as bleaching) treatment. Data indicates that 41 percent of dental professionals recommend that patients who experience sensitivity discontinue or alter their whitening treatment.1 Patients with whitening-induced sensitivity may need to delay their treatment or discontinue it altogether. Dental hygienists can educate whitening patients so they can avoid sensitivity as a result of bleaching.
Whitening-induced sensitivity may occur due to the chemical byproducts of peroxide compounds passing through enamel and dentin and into the pulp.9 In a recent study, patients who brushed with Sensodyne® Fresh Mint Toothpaste (GlaxoSmithKline Consumer Healthcare) two times daily, two weeks before and two weeks during professional whitening treatment, reported less sensitivity as compared to a control group that used regular toothpaste. Patients brushing with Sensodyne reported fewer sensitive days during the first three days of treatment, which is when patients experience the most sensitivity. Results were based on patient satisfaction surveys and diary entries, and whitening results were not affected by the desensitizing toothpaste.10 The same study also revealed that those who used the anti-hypersensitivity toothpaste two times daily prior to and two weeks during professional whitening treatment were more satisfied with their overall whitening experience, and were more willing to repeat whitening treatment in the future.
To reduce whitening-induced sensitivity, dental professionals should discuss the potential for sensitivity before they begin treatment, and recommend that patients use Sensodyne two times a day, two weeks prior to and two weeks during whitening treatment. This recommendation can help patients be more comfortable during their tooth whitening treatment. It may also help reduce the number of patients who discontinue whitening treatment due to whitening-related sensitivity.
Dental hygienists play an important role in managing dentin hypersensitivity - a condition that often goes unreported. By asking about dentin hypersensitivity at each patient visit, dental hygienists can determine dentin hypersensitivity sufferers and recommend treatment. Anti-hypersensitivity toothpaste containing 5 percent potassium nitrate is effective, easy to obtain, and can be used as a patient’s everyday toothpaste.
Patients undergoing a professional whitening treatment may be among those most likely to suffer from temporary pain such as dentin hypersensitivity. Dental hygienists can help these patients be more comfortable by addressing sensitivity before they begin whitening treatment, and recommending the use of an anti-hypersensitivity toothpaste containing 5 percent potassium nitrate for use two times daily, two weeks before and two weeks during their professional whitening treatment.
1 GlaxoSmithKline: Data on File
2 Addy M. Etiology and clinical implications of dentine hypersensitivity. Arch Oral Biol. 1990; 34:503-514.
3 Addy M. Dentine hypersensitivity: New perspectives on an old problem. Int Dent J. 2002; 52: 375-376.
4 Gillam DG, Aris A, Bulman JS, Newman HN, Ley F. Dentine hypersensitivity in subjects recruited for clinical trials: clinical evaluation, prevalence and intraoral distribution J Oral Rehabil. 2002: 29:226-231.
5 Daniel S, Harfst S. Mosby’s Dental Hygiene: Concepts, Cases and Competencies. (Chapter 25 - Dentinal Sensitivity)
6 Chabanski MB, Gillam DG, Bulman JS, et al. Clinical evaluation of cervical dentine sensitivity in a population of patients referred to a specialist periodontology department: a pilot study. J Oral Rehabil. 1997; 24(9): 666-672.
7 American Academy of Cosmetic Dentistry Membership Poll, 2000. Available at http://www.aacd.com/media/market_research_data.aspx. Accessed: May 9, 2005.
8 Haywood VB. Contemporary Esthetics and Restorative Practice. 1999; 3 (suppl.): 2-11.
9 Haywood VB. Dentine hypersensitivity: bleaching and restorative considerations for successful management. Int Dent J. 2002; 52:376-385.
10 Haywood, VB, Cordero R, Wright K, Gendreau L, Rupp R, Kotler M, Littlejohn S, Fabyanski J, Smith S. Brushing with a potassium nitrate dentifrice to reduce bleaching sensitivity. J Clin Dent 16:17-22, 2005.
Questions to Ask Every Patient at Every Dental Visit
1. Do you avoid specific foods or beverages that cause tooth sensitivity or pain?
2. Do you experience discomfort from cold, hot, sweet or sour foods or beverages?
3. Have you recently undergone a whitening or bleaching treatment?
4. If so, did you discontinue or interrupt treatment because of tooth sensitivity?
5. Are you considering utilizing whitening or bleaching treatments in the future?