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Preventive Dentistry

What type of palliative care can I provide for persistent generalized dentin hypersensitivity?

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This question was submitted to us by a practising dentist: “I had a patient present today with ongoing generalized sensitivity. No clinical evidence of recession; no bruxism or clenching that she is aware of; and no dietary changes. I would like to make trays to better deliver some palliative relief (she is currently using desensitizing toothpaste). What is the best product for the trays? Would Fluoride or relief gel or some other product that I am unaware of be best?”

Dr. Hardy Limeback, former head of preventive dentistry at the University of Toronto provided this initial response:

Persistent generalized dentin hypersensitivity is difficult to manage, if the etiology cannot be determined.

In the absence of gingival recession, bruxism, or acid erosion, one can assume that there are enamel micro fractures or subgingival abfraction lesions forming.

One should be able to determine which teeth are the most sensitive with the usual diagnostic aids, such as a blast of air at the gingival margin of each tooth. However, if pain is generalized, the ultimate goal is to encourage the formation of sclerotic dentin in all teeth.

Topical fluoride agents are the best in this situation since fluoride encourages calcium-phosphate mineral growth in the form of fluorapatite, which is more resistant to acid erosion. Exposed dentin tubules should be permanently closed. Temporary relief can be achieved with toothpastes containing potassium nitrate; however, a review of clinical trials indicates that long-term relief (6 to 8 weeks) cannot be attained (Poulsen S, Errboe M, Lescay Mevil Y, Glenny AM. Potassium containing toothpastes for dentine hypersensitivity. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD001476).

A toothpaste with 5000 ppm fluoride is sometimes recommended and can be more effective than regular toothpaste, especially if applied in a custom tray. However, extreme caution should be used here due to the toxicity of swallowing fluoride in large amounts which can lead to symptoms of joint pain (Eichmiller FC, Eidelman N, Carey CM. Controlling the fluoride dosage in a patient with compromised salivary function. J Am Dent Assoc. 2005 Jan; 136(1):67-70; quiz 91.)

Toothpastes, that are shown to block exposed dentin tubules by scanning electron micrography, include stannous fluoride (GelKam, ProHealth), strontium acetate (Sensodyne), and calcium-phosphate complexes (MI Paste). MI Paste (without fluoride) is safe to swallow and can be worn daily in custom trays.

There are several professional treatments to immediately relieve dentin sensitivity; however, dentists consider professional fluorides to be the most effective (Cunha-Cruz J, Wataha JC, Zhou L, Manning W, Trantow M, Bettendorf MM, Heaton LJ, Berg J. Treating dentin hypersensitivity: therapeutic choices made by dentists of the northwest PRECEDENT network. J Am Dent Assoc. 2010 Sep; 141(9):1097-105.)

Repeated applications of the professional varnishes will eventually lead to sclerotic dentin and relief from chronic dentin sensitivity.

 

Follow-up: What further information would you like on this topic? Email us at jcdaoasis@cda-adc.ca

Readers are invited to comment on this initial response and provide further insights by posting in the comment box which you will find by clicking on “Post a reply” below. You are welcome to remain anonymous and your email address will not be posted.

 

4 Comments

  1. Clive Friedman March 4, 2013

    I am surprised by the reference provided by Dr Limeback for joint pain and use of high dose fl toothpaste. The article is a case report which does not evaluate fl at all and describes the use of high dose fl in a cancer patient. As long as an individual can spit and does not have issues with swallowing high dose fl should not have the consequences that Dr Limeback is referring to.

    Persistant hypersensitivity may also be related to reflux ( GERD) and saliva testing may also show interesting findings. For example if the patient has minimal buffering capacity or has low ph saliva – this in of itself may be contributing to the continued inability of the dentine to scelrose.

    Reply
    1. Dr. Hardy Limeback March 5, 2013

      I thank Dr. Friedman for his response but I don’t understand why he says that the authors of that study (yes it was a case report) did not evaluate fluoride because they actually did. In fact they measured how much the fluoride levels declined in the urine when the patient (who had classic symptoms of chronic fluoride toxicity) stopped using 5000 ppm fluoride gels administered in custom trays. Indeed, the point I was making was that these toothpastes with very high fluoride content should be used with caution. No one knows just how much fluoride is absorbed through the mucosa. When joints start to hurt more than the teeth the obvious solution is to stop using the high concentration toothpastes.

  2. Lenny jung March 4, 2013

    Usually patients that have generalized thermal sensitivity is related to some para functional activity, which the patient may be unaware of. I prefer to prescribe an anterior plane anti boric ism appliance which discludes the posterior teeth. As well, any exposed root surfaces are treated with a gluma product, microprime. The patient is then instructed to use sensodyne toothpaste, avoid acidic foods over the next few weeks, and avoid having the arches contact during waking hours except when food is being consumed.

    Reply
    1. Lenny jung March 4, 2013

      Sorry my iPhone altered my reply. It should have read that the appliance used is an anterior plane anti bruxism type, made on the maxillary six teeth.

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