Dentin Hypersensitivity: Consensus-Based Recommendations for the Diagnosis & Management of Dentin Hypersensitivity
The Role of the Dental Hygienist in the Management of Dentin Hypersensitivity
The role of the dental hygienist is pivotally
important in the prevention and management of dentin hypersensitivity.
Prevention of hypersensitivity is the most cost-effective treatment
option for patients. Through promotion of good oral hygiene practices,
nutritional counseling, nonsurgical periodontal therapy, and application of
desensitizing agents, dental hygienists are uniquely placed to be a first
line of defense in the prevention of
dentin hypersensitivity and its major predisposing
Patients may be reluctant to report symptoms of dentin
hypersensitivity to the dentist during the comprehensive or periodic oral
examinations. The first discussion is frequently with the dental hygienist
during the dental prophylaxis, when hypersensitive areas may be stimulated.
When symptoms of hypersensitivity first become
apparent to the dental hygienist, it is important that a thorough health
questionnaire is completed and that the sites of sensitivity are documented, including duration, onset, and the nature
of stimuli (if any) initiating the symptom. All contributory and
predisposing factors and conditions should be explored, such as gingival
recession, tooth wear, oral hygiene, and any
harmful or factitious habits.
Due to the common nature of symptoms of
hypersensitivity, a differential diagnosis
is essential. The dentist, as
diagnostician, should follow the appropriate protocol to ensure that the
most appropriate restorative or surgical treatment is rendered.
Tooth wear may be a result of mechanical (attrition
and abrasion) or chemical (erosion) activity or, quite commonly, both
(chemical softening of the surface prior to its mechanical removal).
Attrition is wear resulting from tooth-to-tooth contact during normal
mastication and abrasion is mechanical wear by forces other than
mastication. Erosion is a loss of tooth substance by chemical processes
unrelated to bacterial action, most commonly, dietary acids. With all three
types of tooth wear, dentin hypersensitivity commonly results when enamel
is lost and dentin is exposed.
An aspect of patient education, within the scope of
dental hygiene practice, is nutritional counseling and referral. The dental
hygienist must thoroughly assess the nutritional habits of patients with
dental history that includes intake of soft
drinks/acidic beverages or eating disorders (bulimia/anorexia nervosa,
GERD) that may lead to dental erosion. With the
rapidly increasing changes in lifestyles and consumption of acidic beverages, chemical tooth wear (erosion) of enamel and
dentin may inevitably result in more tooth
hypersensitivity for many patients.1
Dietary modifications should include limiting foods
and beverages that cause hypersensitivity such as citrus fruits, acidic
beverages, pickled foods, and ciders, as well as incorporation of foods and
beverages into the diet immediately after an acid exposure that encourage
saliva secretion and remineralization (eg, milk, cheese, yogurt). Some
erosive tooth wear is caused by chronic vomiting related to pregnancy or
bulimia. Patients should be instructed not to brush immediately after
vomiting to allow the acidity of the oral cavity to decrease. Patients with
these conditions should be referred for medical and psychological
Mechanical tooth wear from abnormal habits (abrasion)
and wear from normal occlusion (attrition) also can contribute to dental
hypersensitivity.2 The dental hygienist should frequently assess these behaviors
during recare and periodontal maintenance appointments that follow active
ORAL HYGIENE INSTRUCTION
One of the most important roles of dental hygienists
is to effectively communicate individualized oral hygiene instructions to all patients. Patients should demonstrate their routine
brushing technique while the dental hygienist actively observes.
Traditionally, it has been concluded that overzealous
brushing and using a hard-bristled toothbrush could cause or worsen
gingival recession.4 However, in a recent systematic
review of several studies assessing this correlation, Rajapakse et al5 concluded that data to support or refute an association
between toothbrushing and gingival recession are
inconclusive. This is echoed by Drisko.6 Although the evidence is inconclusive, brushing duration
and frequency are the most-cited causes of toothbrush-related gingival
recession. Other factors studied are brushing technique, brushing force,
toothbrush age, and hardness of toothbrush bristles.4
Patients should be advised to brush at least 2
minutes, twice per day.7 Toothbrushes should be discarded and replaced every 3
months or sooner when the patient experiences a transmissible infection or
when bristles begin to fray.7 To reduce brushing force, patients with normal dexterity should be advised to use a finger grip on their
toothbrush handles as opposed to a palm
grip. Brushing with the non-dominant hand may also alleviate destructive
brushing since studies have reported a higher proportion of sensitive teeth
on the left side of the mouth versus the right side in right-handed
patients.7 Because hard bristled toothbrushes may contribute to tooth and
gingival wear, a soft-, sensitive-, or extra-soft bristled brush should be
recommended to all patients, especially those experiencing sensitive teeth.1,4,8
Marginal biofilm can cause gingival recession to
worsen so brushing technique should be routinely emphasized. Manual toothbrush bristles
should be adapted at a 45° angle toward the sulcular area. Then, the patient should be
instructed to gently brush back and forth,
progressing around the arch in small increments. Once the gum line
brushing has been done on the facial and
lingual surfaces of both arches, the patient can be instructed to then brush the teeth surfaces. Redirecting
habits from toothbrushing to sulcular brushing will effectively remove harmful bio-film and promote
firmly attached and resilient marginal gingiva.
The dental hygienist should
be clear in explaining that how the toothbrush is used is more important than the toothbrush design. This
is true whether the toothbrush is powered or manual. In a few studies, the
results obtained using a power toothbrush were superior to manual
toothbrushing.9,10 Since those investigations, power toothbrushes have undergone
much innovation with enhanced features of particular benefit for patients
with hypersensitivity, which include visual timers, brush guide location by
quadrant, and visual pressure indicators to alert patients when they are
brushing too hard.11
Clinicians and patients must realize the importance of
meticulous oral hygiene in suppressing and preventing periodontal disease, regardless of tooth hypersensitivity.
Children and patients with poor manual
dexterity will often benefit from a powered
brush because of the larger handles and it being less technique dependent than manual toothbrushing. The supply
and demand for more convenient and efficient oral care has sparked rapid
advancements in several manual and powered brush designs. Innovation and
product development may possibly eradicate the
factors that were/are thought to link
toothbrushing with gingival recession.
The hydrodynamic theory is widely accepted as the
mechanism of action of dentin hypersensitivity. This theory states that the hyper-sensitivity
or pain is caused by
various stimuli (temperature, pressure, touch, chemical) which can lead to changes
in the movement of fluids in and out of exposed
dentinal tubules leading to changes in pressure
or flow around the mechano-receptors found in the nerve endings
surrounding the odontoblastic processes.12 The mechanism of action for
most desensitizing agents is either to desensitize the nerve so
that the fluid flow and resulting changes in pressure do not cause the
mechanoreceptors to fire; or to block exposed tubules so there can be no fluid movement at all.
Potassium salts (nitrate most commonly, but also
chloride and citrate) are found in desensitizing toothpastes and have been proven safe and effective in several clinical trials. Potassium delivered in the form of toothpaste is the most
clinically evaluated desensitizing agent. Office-prescribed potassium
nitrate has been shown to be effective in patients experiencing
hypersensitivity from vital teeth bleaching. Potassium nitrate is thought
to work by depolarizing the nerve and preventing pain signals from reaching the brain.13 Custom-tray application of potassium
nitrate before bleaching has provided relief for many patients experiencing
Other desensitizing agents work typically as dentinal
tubule blockers. Several professionally applied
agents are available with various levels of
clinical evaluation. These include high-concentration fluorides, various oxalate salts,
protein precipitants, and physical agents such as filled and unfilled
resins and glass ionomers.
Patients should be instructed to use OTC desensitizing
agents exclusively for maximum results. They should be advised that the
full desensitization effect may not occur immediately (2 or more weeks) and
be encouraged to use the dentifrices continually.8 Patients with dentin
hypersensitivity and high caries or erosion risk should select a
desensitizing dentifrice that also has high fluoride availability and
demonstrated fluoride uptake.15
NONSURGICAL PERIODONTAL THERAPY
Traditionally, the objective of mechanical therapy was
to aggressively root plane the tooth surface to achieve a surface that was
glassy smooth to a lightly held dental explorer. This aggressive
debridement with sharp periodontal instruments was found to create or
worsen tooth hypersensitivity. A contemporary objective is to remove all
calculus deposits and cementum contaminated with endotoxins with the least
amount of effective lateral pressure. After hard-deposit removal, a
root-surface debridement technique follows. Root-surface debridement is a
paradigm shift from traditional dental hygiene practice in that light
pressure using fine finishing curettes is advocated to gently debride root
surfaces and remove harmful endotoxins.16
The use of power scalers is another important step in
reducing hypersensitivity caused during dental hygiene therapy. Ultrasonic
and sonic scalers enable dental hygienists to debride hard deposits with
minimal lateral pressure applied to the tooth surface. Additionally, the
lavage action of power scalers assists with removal of endotoxins.
Removal of extrinsic stains is another dental hygiene
treatment that can promote or aggravate tooth hypersensitivity. Tenacious
deposits traditionally have required repeated application of lateral
pressure using periodontal instruments. Advances in air power-polishing
technology have drastically reduced the need for this method of
For patients who do not require extensive power
scaling, prophy pastes are often used to remove
biofilm and light stains from the teeth. When
using abrasive polishing agents, such as coarse-grit prophy paste, damage
in the form of surface scratching and loss of enamel and cementum may
result. Fine-grit prophy paste is recommended to reduce this potential
Recent advances in prophy paste include formulas that
deliver amorphous calcium phosphate (ACP), an agent shown to desensitize
dentin by depositing ACP into the tubules.15
Another innovation is a prophy angle that
embeds the paste within the prophy cup and claims to reduce enamel
abrasiveness by 50% when compared with using a prophy cup and medium-grit
paste separately. As a general rule, when selecting a prophy paste, the
least abrasive will be the paste of choice, and it should be deployed with
the least amount of pressure commensurate with removing the stain and
leaving a smooth and minimally scratched surface.7,16
Innovations in nonsurgical periodontal instrumentation
for the removal of hard deposits, biofilm, and
extrinsic stains are continuously providing
dental hygienists with greater armamentarium
for preventing and managing dentin
The dentist is responsible for the diagnosis and
initial therapy in the treatment of sensitive
teeth. Concurrently, the dental hygienist must
become actively involved in the suppression of symptoms and prevention of
severity as the patient returns for recare
appointments. Based on the patient’s oral health status and oral hygiene habits, appropriate intervals for recare
should be established. Current treatment
modalities in nonsurgical periodontal
instrumentation, in-office and OTC desensitizing medicaments, and oral
hygiene products have provided dental hygienists
with effective means of managing patients with dentin
hypersensitivity. New knowledge and products are rapidly developing. It is critical for dental hygienists to engage in
lifelong learning through continuing education
and review of the published literature regarding advancements in evidence
related to dental hypersensitivity. Contributions by dental hygienists to
the body of knowledge through participation in research, publication, and
presentation are equally vital to the dental profession and to the patients
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