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