Curbing sensitivity

Staying dressed for success with dentin hypersensitivity

by Lynne Slim, RDH, BSDH, MSDH

Loretta Patricia Hollister, age 87, sat in my operatory chair last week, and we discussed the aging process. “There’s one plus to growing old,” my mother whispered to me. “My roots aren’t as sensitive as they used to be, and I don’t have to use that sensitivity toothpaste but twice a week instead of every day. It will save me a little bit on my grocery bill, won’t it?”

I smiled broadly, and I’m lucky to have big lips because they hide my maxillary and mandibular posterior teeth, all of which have some early gingival recession. My personal periodontist told me my recession is from overzealous toothbrushing. Can you imagine that? A dental hygienist who’s too conscientious about brushing her teeth? Unlike my mother, I still suffer from dentin hypersensitivity and use an OTC dentifrice. I’m always excited about new OTC dentifrices and other treatment options when they come to market, and I’m the first one to try them.

In writing about this topic, I found hundreds of articles on this topic and many of them are current. Instead of focusing on the management of dentin hypersensitivity, I’d like to discuss instead the etiology of gingival recession and associated dentin hypersensitivity and give you data you can share with your patients.

Etiology of gingival recession is multifactorial

In reviewing the literature on gingival recession, there seems to be some consensus on a multitude of risk factors, either alone or in combination that contribute to localized and generalized gingival recession.1,2 Surveys have revealed that about 88 percent of adults 65 years of age and older, and 50 percent of people ages 18-64 have one or more sites of recession.² The presence and extent of gingival recession increases with age.² Recession is found more often on buccal surfaces than other surfaces.²

Harrel reports a strong correlation between misaligned teeth and gingival recession, and it is commonly associated with teeth that are tilted in buccal or lingual version.³ Orthodontics is typically recommended for this type of misalignment; however, gingival recession in young adults following orthodontics is a common finding.⁴ The movement of teeth to positions outside the labial or lingual bone plate can lead to dehiscence formation.² A 2008 systematic review suggests that we have only weak evidence linking orthodontics to small detrimental effects of the periodontium including 0.03 mm of gingival recession.5

One etiological factor that is not often discussed with patients with localized gingival recession is a prior lack of alveolar bone at the site, and the bone deficiencies may be developmental (anatomical) or acquired (physiological or pathological).2

According to a Journal of the American Dental Association (JADA) article, “Anatomical factors that have been related to recession include fenestration and dehiscence of the alveolar bone, abnormal tooth position in the arch, aberrant path of eruption of the tooth, and individual tooth shape. All those anatomical factors are interrelated and may result in an alveolar osseous plate that is thinner than normal and that may be more susceptible to resorption.”2

Many patients who present with localized or generalized gingival recession assume they have “gum disease.” In some cases, bone resorption as a sequela to periodontal disease (localized inflammation) occurs; however, the recession may also be due to periodontally infected teeth that extrude, tilt or become mobile.²

The JADA article noted, “A rat study demonstrated a possible mechanism of gingival recession, showing that loss of attachment was the result of localized inflammatory processes in connective tissue with the accumulation of mononuclear cells. It also was suggested that inflammation may persist subclinically and therefore cannot be eliminated as a factor in recession. Similarly, recession has been related to inflammation in periodontal connective tissue in monkeys.”2

Trauma from occlusion may cause a shift in tooth position and resulting gingival recession. The direction of the tooth movement may depend on the occlusal force, and there are case studies that demonstrate this association. Case studies are not a high level of evidence but they should not be discounted. A well-documented case report (with photos) of a 16-year-old male with severe gingival recession is available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2633168.

Besides case reports, there is an absence of reliable evidence to support the association between gingival recession and occlusal trauma, meaning that there is inadequate research to support this assumption.4,5 Case reports, such as the one above, are useful and should not be discounted in clinical decision-making.

Other forms of trauma are thought to play a role in the etiology of gingival recession. Examples include aggressive toothbrushing, aberrant frenal attachment, TMJ disorder, operative procedures, tobacco chewing, and fremitus.2,6,7

Of interest to dental hygienists in particular is research concerning toothbrushing as a risk factor for gingival recession. In reading a systematic review on the influence of toothbrushing on the development and progression of non-inflammatory gingival recession, a range of etiological factors for gingival recession were implicated such as duration and frequency of toothbrushing, hardness of bristles, technique, brushing force, and frequency of changing a toothbrush.⁸ The authors concluded that data to refute the association between toothbrushing and gingival recession is inconclusive. They also mentioned that there was limited evidence from one randomized, controlled, clinical trial to suggest that toothbrushing with either a manual or powered toothbrush with standardized toothbrushing technique may reduce the severity of gingival recession in noninflammatory lesions.8

A 2009 longitudinal, single blind, randomized study evaluated the effects of manual and powered toothbrushes on early (incipient) lesions of gingival recession.⁹ The test group was randomized to use a Philips Sonicare Elite powered toothbrush, and the control group was randomized to use an Oral-B 35 manual toothbrush. Both groups brushed with Colgate Total toothpaste. Subjects using the powered toothbrush received manufacturer’s instructions for use, including brushing twice daily for two minutes. Those subjects using the manual toothbrush were instructed in crevicular (sulcular) toothbrushing technique twice daily for two minutes.9

The research data suggest that for subjects with incipient lesions of gingival recession, changing from a manual to a Philips Sonicare Elite powered toothbrush did not increase the risk of further recession over a 12-month period. The authors also indicated that there are many other aspects of research that should be explored such as using powered toothbrushes of different designs, recruiting subjects with varying degrees of recession, and extending the period of observation beyond 12 months. Additionally, there were no differences between the groups in the width of clinical keratinized gingival attachment level, probing depth, and bleeding on probing.

Van der Weijden et al. reported on the safety of oscillating-rotating powered toothbrushes compared to manual toothbrushes in a systematic review (SR).10 The aim of this SR was to examine the literature concerning the relative soft and/or hard tissue safety outcomes with the use of oscillating-rotating toothbrushes and compare them to manual toothbrushes. Independent screening of 697 PubMed-MEDLINE, 436 Cochrane-CENTRAL, and 664 EMBASE reports resulted in 35 publications that met the eligibility criteria. The authors concluded that oscillating-rotating toothbrushes are safe when compared to manual toothbrushes, and there were few brushing-related adverse events like gingival recession.

The frequency of gingival recession in patients with excellent oral hygiene has been found to be more frequent at buccal rather than proximal or lingual surfaces.² In addition, recession is more common in patients with good rather than poor oral hygiene.²

Creatively discuss gingival recession

Be creative in educating your patients about gingival recession! Customize a special glossy 4x6 postcard for your patients like the example featured, which explains the multifactorial etiology. It’s a great way to open the door to conversation with your patients on this subject and you can ask them if these areas are hypersensitive. Include your favorite Internet links on gingival recession and dentin hypersensitivity and talk to your patients about professional products that reduce sensitivity. I’ve seen glossy cards advertised for as little as $99 for 5,000 cards!

Not all patients with gingival recession have dentin hypersensitivity. Dentin hypersensitivity usually occurs in patients ages 30 to 40 and the incidence declines with age.11 Periodontal patients are at high risk for dentin hypersensitivity and studies report that over 70 percent of periodontal patients experience it.11 Premolars, mandibular incisors, and facial surfaces of teeth are most often affected by dentin hypersensitivity.11

Treating dentin hypersensitivity associated with gingival recession is a no-brainer for dental hygienists today. During routine dental hygiene visits, it’s a good idea to ask patients if they are experiencing it because it can greatly affect quality of life and even limits dietary choices.11 A plethora of effective chairside and OTC treatments are available (see Table 1).

One solution to dentin hypersensitivity that is often overlooked is referral to a periodontist to correct mucogingival deformities. Soft tissue grafts are commonly used to restore and/or improve these deformities and often multiple recession defects are routinely discovered. Periodontal plastic surgical procedures such as grafts help to resolve root hypersensitivity.

According to a 2009 Academy of General Dentistry survey, the two most common causes of dentin hypersensitivity are aggressive toothbrushing and/or drinking too many acidic beverages.11 In that same survey, many patients (according to dentists surveyed) manage sensitivity by avoiding consumption of cold foods or beverages.11

Treatment combined with desensitizing pastes

In my operatory, I am armed with some of the new desensitizing prophy pastes. Before rubber cup polishing (and I sometimes rubber cup polish with one of these products before scaling to reduce dentin hypersensitivity), I tell my patient that I have selected a special paste that will alleviate their symptoms. We also dispense 1.1% neutral sodium fluoride prescription dentifrices on a case-by-case basis and some of these prescription dentifrices are combined with either potassium nitrate or tricalcium phosphate.

Patients who experience dentin hypersensitivity who are also at risk for root caries are perfect candidates for prescription fluoride dentifrices. Samples of some of the new or tried-and-true OTC toothpastes for dentin hypersensitivity are sent home with the patient in a goody bag and it’s a win-win situation. Patients are very appreciative of my efforts and concern for their genuine pain.

As I’ve said before in one of my periodontal therapy columns, being armed with the appropriate information is like being dressed for success.

Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.

References

1. Serino G, Wennström JL, Lindhe J, Eneroth L. The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol. 1994: 21:57–63.
2. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc. 2003:134:220–5.
3. Harrel SK. Oral health begins with tooth alignment. Dimensions of Dent Hyg. 2011: 9(4): 65-71.
4. Slutzkey S, Levin L. Gingival recession in young adults: occurrence, severity, and relationship to past orthodontic treatment and oral piercing. Am J Orthod Dentofacial Orthop 2008: 134(5): 652-6.
5. Bollen AM, Cunha-Cruz J, Bakko DW Huang GJ, Hujoel PP. The effects of orthodontic therapy on periodontal health: a systematic review of controlled evidence. JADA 2008; 139(4): 413-22.
6. Kundapur PP, Bhat KM, Bhat GS. Association of trauma from occlusion with localized gingival recession in mandibular anterior teeth. Dent Res J (Isfahan) 2009; 6(2): 71-4.
7. Douglas CR, Avoglio JL, de Oliveira H. Stomatognathic adaptive motor syndrome is the correct diagnosis for temporomandibular disorders. Med Hypotheses 2010 Apr: 74(4): 710-8. Epub 2009 Nov 11.
8. Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, Guentsch A, Heasman PA. Does tooth brushing influence the development and progression of non-inflammatory gingival recession? A systematic review. J Clin Periodontol 2007; 34: 1046–1061.
9. McCracken GI, Heasman L, Stacey F, Swan M, Steen N, de Jager M, Heasman PA. The impact of powered and manual toothbrushing on incipient gingival recession. J Clin Periodontol 2009; 36: 950–957.
10. Van der Weijden FA, et al. Safety of oscillating-rotating powered toothbrushes compared to manual toothbrushes: a systematic review. J Periodontol. 2011; 82(1):5-24. Epub 2010 Sep 10.
11. Chu CH, et al. Dentin hypersensitivity and its management. Gen Dent 2011: 59(2): 115-122.

Table 1

Common in-office professional treatments for dentin hypersensitivity

Glutaraldehyde and HEMA
5% fluoride varnish and extended fluoride varnish
Arginine/calcium carbonate prophy paste
Prophy paste with NovaMin

Common recommended home management suggestions for dentin hypersensitivity

OTC desensitizing toothpastes containing 5% potassium nitrate
OTC desensitizing toothpastes containing calcium carbonate Pro-Argin technology
Prescription dentifrices containing 1.1% sodium fluoride alone or in combination with potassium nitrate or tricalcium phosphate