Hannah Beddis Priya Soneji, Susan Welford and Martin Ashley

Making Sense of Sensitivity Abstract: Our professional understanding of the causes and treatment options for dentine hypersensitivity should now allow the dental profession to manage this condition reliably. This paper reviews the aetiology and explains the scientific basis for what has become a confusing number of products and methods available to patients and dental clinicians. Clinical Relevance: Dentine hypersensitivity appears to be an increasing problem for patients and the dental profession alike. Clinicians need to have up-to-date knowledge of this condition and the products available to treat patients presenting with this troublesome complaint. Dent Update 2013; 40: 403–411

Every dentist will be aware of the recent increase in advertising for toothpastes to treat sensitive teeth. There are also a confusing number of products from which patients can choose (Figure 1). The wide range of treatment options available for dentine hypersensitivity indicates that there are many methods for managing this condition. This paper reviews our current knowledge of dentine hypersensitivity (DHS) and describes the most commonly available products and treatment options.

A historical perspective of sensitive teeth Dentine is a naturally sensitive tissue. When an otherwise harmless stimulus

Hannah Beddis, BChD(Hons), MJDF RCS(Eng) Specialty Registrar in Restorative Dentistry, Leeds Dental Institute, Leeds, Priya Soneji, BDS, Foundation Dentist, Susan Welford, BChD, Foundation Dentist and Martin Ashley, BDS(Hons), FDS RCS(Eng), MPhil, FDS(Rest Dent) RCS, Consultant and Honorary Senior Lecturer in Restorative Dentistry, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, UK. June 2013

contacts freshly cut dentine, pain may be experienced. Historically, numerous attempts have been made either to reduce or eliminate this pain, by treating teeth with a wide variety of chemical remedies. These were generally unreliable, therefore operative dentistry continued to be very unpleasant. Fortunately, as local anaesthetic use became more common, the need for a desensitizing agent became less relevant. However, as dental health has improved and more people retain more teeth later in life, there has been an increasing need for a method to desensitize exposed dentine in otherwise healthy teeth. Initially, the two most commonly used and now thoroughly researched ingredients were strontium and potassium. Sensodyne toothpaste was developed in the early 1960s, containing strontium chloride, but without fluoride, as these readily combine together as an insoluble compound with no clinical benefit. Macleans Sensitive was developed in the 1980s, with strontium acetate and fluoride, which were much less reactive. In the 1970s, the desensitizing effect of potassium nitrate was discovered and, soon after, Sensodyne-F was developed as the first desensitizing fluoride toothpaste. An excellent review of the development of strontium and potassium toothpastes was written by Markovitz.1

Figure 1. There are a confusing number of products available.

It is certainly challenging to consider any benefit that humans derive from having sensitive dentine, other than to provide evidence that there is something wrong with the tooth, such as a carious lesion. Yet, in evolutionary terms, the recognition that there was ‘something wrong’ occurred many thousand years before dentistry was performed that could manage these problems. The concepts of dental pain and dentine sensitivity have also been a longstanding curiosity for dentists. In 1959, Robert Cutler wrote a letter, published in the British Medical Journal, entitled ‘Mysterious dentine’.2 This began: ‘To the practising dentist not wholly bogged down with the DentalUpdate 403

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mechanical procedures in the mouth, the symptomatology of tooth pain presents a continued fascination.’ Forty years later, Martin Addy co-authored an excellent review article in the British Dental Journal, the title of which highlighted the curiosity that DHS continued to hold for dentists3 − Dentine hypersensitivity – an enigma?

natural insulator prevents DHS. The smear layer is a tenacious layer of organic and inorganic material, up to 50 µm thick, that adheres to the tooth surface and penetrates into the dentine tubules. In the absence of a smear layer, the dentine tubules may be blocked by calcium phosphate, formed from saliva. Therefore, for DHS to occur, the smear layer and the deposits of calcium phosphate will have been removed, by either mechanical or chemical means. Several mechanisms have been proposed to explain how stimulus at the dentine surface leads to the sensation of DHS. However, the most widely accepted is the Hydrodynamic Theory. This was initially proposed by Alfred Gysi in 190011 and was then investigated and reported by Brännström, whose name is most often associated with this mechanism, in 1963.12−14 This postulates that external stimuli, such as temperature, can alter the flow of fluid within the exposed dentine tubules. This flow leads to a

What is dentine hypersensitivity? Dentine hypersensitivity is characterized by a short sharp pain arising from exposed dentine in response to stimuli, typically thermal, evaporative, tactile, osmotic or chemical and which cannot be ascribed to any other form of dental defect or disease.4 Data regarding the prevalence of DHS are inconsistent but tend to range from 3.8%5 to 35%6 in the general population and self-reported sensitivity ranges from 37% to 52%.7 There is a higher reported prevalence in females, in patients between 20−40 years, patients with recession or undergoing therapy for periodontal disease (up to 98%),8 bulimics, xerostomics and tobacco chewers.9 There are conflicting reports on which teeth are most commonly affected by DHS. It is, however, clear that the buccal-cervical margins of all teeth, as the most prominent surfaces, are most likely to be involved.


pressure change within the tubule which is detected by sensory A-delta fibres within the pulp, resulting in a short, sharp pain.

Management of dentine hypersensitivity Prevention

Patients will have developed DHS by either physically or chemically exposing the patent dentine tubules. Therefore, any management strategy should have a clear preventive message alongside the treatment provided. Gingival recession

As DHS is frequently associated with recession on the prominent buccal and labial tooth surfaces, it is clear that the common ‘scrubbing’ action of toothbrushing is harmful (Figure 3). Patients should be instructed to use a toothbrush with medium bristles, to hold it between the fingers and thumb in a ‘pen-holder grip’, rather than in the usual ‘screwdriver’ grip and to employ a circular action when brushing. Chemical erosion

The role of acidic foods and drinks in tooth erosion is now well

How does dentine hypersensitivity occur? Dentine is normally insulated by enamel, cementum and the periodontium. Enamel can be lost by caries, toothwear, trauma and dental treatment. Dentine becomes exposed either by loss of enamel or gingival recession (Figure 2). If the surface openings of the dentine tubules are patent, the unpleasant sensation of DHS can occur when external stimuli are applied to those areas of the tooth. It is recognized that teeth with more patent tubules per unit area are more likely to be sensitive.10 Exposed dentine is usually covered with a smear layer and this

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Figure 3. Gingival recession and root abrasion by a scrubbing toothbrush action.

Figure 2. Area of dentine exposed by recession, with patent tubules. (Images courtesy of Colgate Palmolive.)

Figure 4. Advanced erosion leading to loss of enamel, exposure of dentine and dentine hypersensitivity.

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understood and dental clinicians will frequently recognize these effects on their patients’ dentitions (Figure 4). As these products soften enamel and enable its removal by attrition and abrasion, along with loss of the dentine smear layer and any calcium phosphate deposits that are occluding the tubules, it is essential that appropriate dietary advice is given. In particular, the frequency of acidic food and drinks and the importance of a delay before toothbrushing should be explained. It is appropriate to encourage the patient to record a diet history that will identify the erosive components in the diet. Tooth whitening

Of patients having bleaching procedures, 70% experience short-term temperature sensitivity, regardless of the method used. It is known that hydrogen peroxide may penetrate through the tooth to the pulp, resulting in an inflammatory reaction. Whitening also removes staining, which can increase the patency of the dentine tubules. Patients commencing toothwhitening procedures should be warned of the likelihood of DHS. If it occurs during home whitening, they should wear their trays less frequently, for example either on alternate nights or for shorter time periods. It can be helpful for patients to use desensitizing toothpaste in the trays, when not using the bleaching agent.

Treatment Most treatments for DHS take one of two forms:  Reducing the pulpal nerve response; or  Providing an artificial smear layer either to occlude or reduce the diameter of the dentine tubules.

pulpal nerve response and lessen the problem of DHS. On the basis of this effect, numerous toothpaste products have been developed, containing one of a variety of potassium compounds (Table 1). However, it is recognized that this method of treatment is not as effective as hoped. Potassium-containing toothpastes can lead to decreases in dentinal hypersensitivity in response to various stimuli but take at least two weeks, of twice daily use, to become effective and the greatest reductions may not be achieved for eight weeks. However, a review of randomized controlled trials in this area, carried out by the Cochrane Collaboration, concluded: ‘….no clear evidence is available for the support of potassium containing toothpastes for dentine hypersensitivity.’15 Yet such toothpastes remain popular with consumers and manufacturers alike, probably as consumers recognize and trust wellknown brand names, almost regardless of the active ingredients. Manufacturers continue to produce these toothpastes, despite significant marketing efforts with their other products, which are clinically proven to be more effective. The toothpastes also have additional patient benefits, as a result of other active ingredients. In the UK, the two main desensitizing toothpaste ranges are made by GlaxoSmithKline GSK (Sensodyne) and Colgate Palmolive. There are currently nine forms of potassium-based Sensodyne toothpastes, including two forms of Sensodyne ProNamel. Colgate Palmolive has three potassium-based toothpastes available. Other well-known brands such as Crest, Macleans, Beverley Hills, Oral-B, Aquafresh and Arm and Hammer also produce potassium-based toothpastes.

Reducing the pulpal nerve response

A nerve cell has more potassium ions inside and more sodium ions outside the cell membrane. If additional potassium ions are flooded around the cell, they are pumped through the cell membrane and the cell is less able to activate in response to stimulus. Therefore, treatments that increase the potassium ion concentration within the tubules and pulp tissues and then maintain the higher concentration can reduce the

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Occluding the dentine tubules

As a natural dentine smear layer is effective at preventing DHS for most patients, it is appropriate that treatments exist to create an artificial smear layer. These can either be used by the patients themselves, again in the form of a toothpaste, or alternatively as a professionally applied product in the dental clinic.

Toothpastes for use at home In recent years, GSK and Colgate Palmolive have separately developed and thoroughly researched new toothpastes that are able to occlude the tubules reliably and create a smear layer. Colgate Palmolive has widely publicized the immediate and lasting benefits of Pro-Relief toothpaste, which uses ‘Pro-Argin technology’. This contains calcium carbonate and the amino acid arginine, which combine together to seal and plug the open dentine tubules. GSK has made similar statements for Sensodyne Rapid Relief, which contains strontium acetate. GSK has also developed Repair and Protect, which uses ‘Novamin technology’. Novamin is a calcium sodium phosphosilicate compound which releases calcium and phosphate ions when it comes into contact with water or saliva. These ions bind to the exposed dentine surface, forming a strong, protective and acid-resistant layer. A series of papers has been published in special editions of the Journal of Clinical Dentistry to explain the development and support the effectiveness of these new products.16−22 As with potassium-based toothpastes, other well-known brands such as Macleans, Crest, Oral-B and Arm and Hammer also produce toothpastes that occlude tubules and create a smear layer (Table 2). Patients with DHS will want a toothpaste product with the following properties:  Instant and lasting pain relief;  Fast and easy application at home;  Inexpensive;  Pleasant taste. They will understandably be confused by the numerous products available and it is likely that most dental professionals would struggle to make an informed choice of product, based on the available evidence. However, it is clear that the tubule occlusion toothpastes often provide instant improvements for patients with DHS. When used continuously, the benefits of these products may be long lasting. There are also some curious matters that deserve mention and have presumably arisen because of the role of June 2013

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Pottasium Ingredient Tooth Product Fluoride 5% potassium nitrate

Sensodyne Total Care Gel 1450 ppm

Sensodyne Total Care F 1400 ppm Sensodyne Total Care Gentle Whitening

1400 ppm

Sensodyne Total Care Extra Fresh

1400 ppm

Sensodyne ProNamel 1450 ppm Sensodyne ProNamel Gentle Whitening

1450 ppm

Sensodyne Multi Action Iso Active

1450 ppm

Sensodyne Whitening Iso Active

1450 ppm

Colgate Sensitive Enamel Protect

1100 ppm

Colgate Sensitive Multiprotection

1500 ppm

3.75% potassium chloride

Sensodyne Gum Protection 1400 ppm

5.5% potassium citrate

Colgate Sensitive Fresh Stripe 1500 ppm

Table 1. Toothpastes based on potassium, to reduce dentine hypersensitivity.

Occluding Ingredient Toothpaste Product Fluoride Strontium chloride Sensodyne Original 0 Strontium acetate Sensodyne Rapid Relief 1040 ppm Calcium sodium phosphosilicate (‘Novamin’)

Sensodyne Repair and Protect 1450 ppm

‘Pro-Argin technology’

Colgate Sensitive Pro-Relief 1450 ppm

Arginine + Calcium carbonate ‘Pro-Argin technology’ Colgate Sensitive Pro-Relief + 1450 ppm Arginine + Calcium carbonate Whitening ‘Pro-Argin technology’ Arginine + Calcium carbonate

Colgate Sensitive Pro-Relief Multi- Protection

1450 ppm

Strontium acetate Macleans Sensitive 1040 ppm Stannous fluoride Crest® PRO-HEALTH® Sensitive + Enamel Shield

1040 ppm

Stannous chloride Oral-B Pro Expert Sensitive + Gentle Whitening

1450 ppm

Soluble Calcium citrate (‘Liquid Calcium’)

Arm and Hammer Enamel Care

1100 ppm

Table 2. Toothpastes designed to occlude dentine tubules and create an artificial smear layer.

marketing within the industry. There are eight different Sensodyne products with the active ingredient 5% potassium nitrate and one with 3.75% potassium chloride as the active ingredient. In the USA, Colgate Sensitive Pro-Relief toothpaste is advertised as using ‘Potassium nitrate technology, gets to the nerve faster’ and yet the UK version of the same toothpaste uses Colgate’s new and widely promoted ‘Pro-Argin technology’.23 The UK version of Colgate Sensitive Pro-Relief is available in three forms: 1. Sensitive Pro-Relief, with Arginine and June 2013

Calcium carbonate. 2. Sensitive Pro-Relief + Whitening, with Arginine and ‘high-cleaning’ Calcium carbonate. 3. Sensitive Pro-Relief Multiprotection, with Arginine, Calcium carbonate and a ‘unique new flavour’. Even a dental professional may struggle to explain scientifically how the same calcium carbonate ingredient will have three actions worthy of three different products. Personal communications between the authors and two of the leading toothpaste manufacturers, GSK and Colgate Palmolive, confirm this.24,25

The wide product ranges are principally driven by consumer feedback, such as the desire for different flavours and a whitening effect. However, no explanation was received for the continued use of products clinically proven to be less effective than others or for the number of products being marketed with the same active ingredients.

Professionally applied products In addition to toothpastes, there are now numerous products and methods available that dental clinicians DentalUpdate 407

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can use to manage their patients’ DHS. Ideally, such methods should have the following properties:  Instant impact on DHS to make patients feel more comfortable during treatment;  Fast and easy application in the dental surgery;  Product suitable for use before or after dental procedures;  Product safe to use with all dental materials;  Inexpensive. In general, these products are either a fluoride varnish, such as Colgate Duraphat, that forms calcium fluoride globules to occlude tubules, or clear resins, such as Seal and Protect from Dentsply, and Gluma from Heraeus Kulzer. Dentine bonding agents, when topically applied to the cervical margin of sensitive teeth, are an effective way of reducing DHS.26 Colgate Palmolive produces a prophylaxis paste using the ‘ProArgin technology’ and GSK produces a Sensodyne prophylaxis paste using the ‘Novamin technology’. Sylc, by OSspray, uses a dry powder of calcium sodium phosphosilicate (‘Novamin’), applied with compressed air pressure, as a prophylaxis cleaning agent. This combines with water and saliva to form hydroxycarbonate apatite, which occludes the tubules and immediately reduces DHS.27 Glass ionomer and composite resin materials will have been used to restore root surface cavities. In some situations, a dentist may provide a treatment such as endodontics, for a persistently sensitive tooth, or a periodontal plastic surgery procedure, to cover an exposed root surface. Whilst these are unlikely to be the first choice of treatment for DHS, they will probably have the additional benefit of an improvement in, or elimination of, the DHS symptoms. Irradiation of exposed dentine with a low-output laser leads to an immediate and prolonged reduction in DHS. This is thought to be via antiinflammatory effects on the pulp28 and increased cellular metabolism promoting production of tertiary dentine by odontoblasts, which leads to tubular obliteration.29

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However, laser treatment is unlikely to become a commonplace first line treatment for DHS. It requires expensive equipment and is not suitable for all cases: it appears that the desensitizing effects are optimal in patients aged 25−35, with reduced effects in older age groups. This may be related to age-related changes in the pulp-dentine complex (eg reduced number and size of odontoblasts and reduced tubular patency).

A strategy for managing dentine hypersensitivity Dental clinicians are taught and develop strategies for managing all aspects of diseases and conditions. For DHS, useful advice and recommendations have previously been provided.30−32 Consider a person who experiences a short, sharp pain when having a cold drink. They are unlikely to do anything about a single occurrence. If this pain becomes a frequent problem, with each cold drink, they may try to find a remedy to resolve it, rather than just avoiding such stimuli. Numerous advertisements on television, the internet and printed media will offer a solution in the form of a toothpaste for sensitive teeth. A visit to the supermarket will offer a similar number of products, all claiming to be the answer to their problem. If the toothpaste is quickly effective and provides long-lasting relief, the problem is resolved and the person is satisfied. However, without such a positive outcome, the person may attend a dental appointment and ask for professional help. It is important for dentist and patient that an appropriate strategy is used to diagnose and manage the condition.

condition. Methods used to examine for DHS include:  Cold air blast from the 3 in 1 syringe;  Metal dental probe rubbed over exposed dentine. These will all give a short, sharp pain for the duration that each stimulus is applied.  An appropriate intra-oral radiograph will help exclude a carious lesion, a common reason for misdiagnosis. Ice crystals using ethyl chloride on a cotton wool pledget is too strong a stimulus for DHS and are likely to give a positive result with any vital tooth. Patient education

If a diagnosis of DHS is made, the patient can be informed about any potential causes for this condition, so that appropriate preventive advice can be given. The intention is that the patient can then make the necessary changes to his/her diet and dental hygiene methods. Advice may be given regarding the following:  Dietary advice to control the intake of acidic foods and drinks and therefore reduce any erosive components of toothwear;  Toothbrushing technique and timing of brushing after eating and drinking;  Selection and appropriate use of a desensitizing toothpaste, especially to apply it directly to the sensitive area. Treatment

The sensitive teeth can be polished with a desensitizing prophy paste, such as those available from Colgate Palmolive and GSK. These are able to provide an instant improvement in symptoms and can then be followed by regular homecare with an appropriate toothpaste.


Patients often suggest that they have sensitive teeth but the presenting condition may be different from that which a dental clinician would diagnose as DHS. It is important to exclude other clinical conditions that can cause similar symptoms. Examination

In addition to the patient’s history, a clinical examination will either confirm a diagnosis of DHS or suggest another

Review and further treatment

For the occasions when the preventive and simple treatments have not been effective, a further history and examination should be undertaken, to ensure that the original diagnosis was correct. If so, a sensitive tooth can be coated with one of the resin sealants such as Seal and Protect or Gluma. Alternatively, other methods can be used in which the dental clinician has confidence. June 2013

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Conclusion The problem of DHS will continue and is likely to increase as people keep more teeth for longer and dietary erosion becomes more prevalent. Fortunately, owing to the considerable efforts of dental research groups and dental industries, clinicians and patients now have a selection of products and methods to overcome the condition.

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of dentinal tubules in sensitive and non-sensitive cervical dentine. J Clin Periodontol 1987; 14: 280−284. 11. Gysi A. An attempt to explain the sensitiveness of dentin. Br J Dent Sci 1900; 43: 865−868. 12. Brännström M. A hydrodynamic mechanism in the transmission of pain-producing stimuli through the dentine. In: Sensory Mechanisms in Dentine. Anderson DJ, ed. London: Pergamon Press, 1963: pp73−79. 13. Brännström M, Linden LA, Aström A. The hydrodynamics of the dental tubule and of pulp fluid. A discussion of its significance in relation to dentinal sensitivity. Caries Res 1967; 1: 310−317. 14. Brännström M, Johnson G. Movements of the dentine and pulp liquids on application of thermal stimuli: an in vitro study. Acta Odontol Scand 1970; 28: 59−70. 15. Poulson S, Errboe M, Lescay Mevil Y, Glenny A-M. Potassium containing toothpastes for dentine hypersensitivity. Cochrane Database Syst Rev 3: CD001476, 2006. 16. Pro-Argin special edition. J Clin Dent 2009; 20: 1. 17. Pro-Argin special edition. J Clin Dent 2009; 20: 4. 18. Perspectives on design and testing of new dentin hypersensitivity formulations. J Clin Dent 2009; 20: 5. 19. Sensodyne Rapid Relief. Evidence for instant and long-lasting relief from dentin hypersensitivity. J Clin Dent 2010; 21: 2. 20. Evidence for the use of NovaMin in providing relief from the pain of dentin hypersensitivity. J Clin Dent 2010; 21: 3. 21. Evidence for a fluoridated NovaMin containing toothpaste in providing relief from dentine hypersensitivity. J Clin Dent 2011; 22: 3. 22. Dentin hypersensitivity. Efficacy of a dentifrice with arginine/calcium carbonate (Pro-Argin technology) versus a dentifrice with strontium acetate. J Clin Dent 2011; 22: 4. 23. http://www. how-to-get-relief 24. Personal communication with Colgate

Palmolive 13th January 2012. 25. Personal communication with GlaxoSmithKline 16th January 2012. 26. Ide M, Morel AD, Wilson RF, Ashley FP. The role of a dentine-bonding agent in reducing cervical dentine sensitivity. J Clin Periodontol 1998; 25: 286−290. 27. Sauro S, Watson T F, Thompson I. Dentine desensitization induced by prophylactic and air-polishing procedures: an in vitro dentine permeability and confocal microscopy study. J Dent 2010; 38: 411−422. 28. Sicilia A, Cuesta-Frechoso S, Suarez A et al. Immediate efficacy of diode leaser application in the treatment of dentine hypersensitivity in periodontal maintenance patients: a randomized clinical trial. J Clin Periodontol 2009; 36: 650−660. 29. Ladalardo TC, Pinheiro A, Campos RA et al. Laser therapy in the treatment of dentine hypersensitivity. Braz Dent J 2004; 15: 144−145. 30. Addy M, Urquhart E. Dentine hypersensitivity: its prevalence, aetiology and clinical management. Dent Update 1992; 19 407−412. 31. Canadian Advisory Board on Dentin Hypersensitivity. Consensus-based recommendations for the diagnosis and management of dentin hypersensitivity. J Can Dent Assoc 2003; 69: 221−226. 32. Orchardson R, Gillam DG. Managing dentin hypersensitivity. J Am Dent Assoc 2006; 137; 990−998.


1. C

6. A, B

2. B

7. C

3. A, B

8. A, C

4. B, D

9. C

5. A, D

10. B, C DentalUpdate 411

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Making sense of sensitivity.

Our professional understanding of the causes and treatment options for dentine hypersensitivity should now allow the dental profession to manage this ...
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