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Mini Review *Corresponding author Ugur Erdemir, Istanbul University, Faculty of Dentistry, Department of Restorative Dentistry (34093) Capa- Hypersensitivity and Istanbul / Turkey, Tel: 0090 212 414 2020; Fax: 0090 212 525 0075; Email: Submitted: 16 September 2016 Recent Developments in Treatment Accepted: 21 October 2016 Published: 24 October 2016 Options: A Mini Review ISSN: 2333-7133 Copyright Ugur Erdemir*, Gunce Saygi, Taner Yucel, and Esra Yildiz © 2016 Erdemir et al. Department of Restorative Dentistry, Faculty of Dentistry, University of Istanbul, Turkey OPEN ACCESS Abstract Keywords is becoming increasingly prevalent. It is mainly caused by an osmotic, • Dentin hypersensitivity tactile, chemical, thermal or evaporative stimulus which causes the movement of dental fluid • Prevention within the tubules, either outwards or inwards. A sharp pain may be induced, and may hamper • Desensitizers the daily activities of patients. The etiology of the sensitive teeth should be considered before • Treatment methods treatment planning; following this, current options for treatment methods and related desensitizers should be tried. If desensitizers cannot relieve the pain, then restorative materials may be used to seal the dentine. therapy should be the last choice of treatment. It should be noted that sufferers may have an acidic diet or parafunctional habits which exacerbate the lesions. Therefore, patients should be encouraged to use products carefully, and preventive management should not be ignored. Various forms of desensitizers (toothpastes, gels, , etc.) have certain advantages, and it is often best to use a combination of different desensitizers with treatment methods such as lasers and iontophoresis. In this mini- review, treatment options described in recent studies are discussed, and the latest products used in sensitivity prevention are compared in detail, in order to facilitate the management of these painful lesions.

INTRODUCTION

Dentin hypersensitivity has recently become increasingly creates a sharper and stronger pain than that of a heat stimulus. widespread. For the majority of patients, a sharp pain appears, flow of the dentinal fluid to the outer edge of the pulpal body, and lasting for a short period and occurring at intervals. This the [7]. This causes a slower and duller response [3]. The generally occurs when drinking cold water, eating icy food or Heat pressure extends the tubules and induces fluid flow towards breathing in frosty weather. In severe cases, the pain last for by many researchers to involve the rapid outward movement of hours and hampers daily activities. Since the pain spectrum is more severe response from a cold stimulus has been confirmed wide, it is essential to address this condition and to apply the oral environment, the dentin tubules are opened to the pulpal optimum treatment. nerves,the dentinal and thisfluids initiates [4,8,9].Irrespective hypersensitivity. of whether A high exposed proportion to the of people have exposed dentin surfaces; however, only a relatively from a chemical, tactile, thermal, osmotic or evaporative stimulus small number of patients suffer from this pain [10]. Dentin hypersensitivity is often defined as the pain arising whereby the dentin surface is exposed to the oral environment Dentin hypersensitivity is usually encountered among people [1,2]. There are many reasons for dentin involvement in the oral aged between 20 and 50 [11,12]. The older population rarely cavity, such as , and erosion, cervical caries, encounters hypersensitivity problems; this can be ascribed to and excessive brushing [3]. Many theories of the etiology of hypersensitivity have been proposed over the sclerosis of the tubules [10,13].The prevalence of these cases is years; however, the most recent and most generally accepted reportedthe reparative as a wide properties spectrum; of dentine, numerous fibrosis clinical within studies the evaluated pulp and of these is the hydrodynamic theory [4]. This theory involves by trained dentists have shown a range of prevalence of between 3%and 57% [10]. A variation of results has been reported due to either the pulpal or enamelodentinal junction in response to the differences in clinical settings [14]. the flow of the dentinal fluids found in the dentinal tubules to and triggers the sensory nerves located either in the dentinal TREATMENT OPTIONS -I tubulesstimulus. (A-nerves) The flow creates or within a pressure the pulpal change body in (C-nerves) each direction [3-6]. Preventive Management The response of the sensory nerves depends on the type and duration of the stimulus. For example, a cold stimulus extends the The most important procedure for overcoming sufferers’

Cite this article: Erdemir U, Saygi G, Yucel T, Yildiz E (2016) Dentin Hypersensitivity and Recent Developments in Treatment Options: A Mini Review. JSM Dent 4(4): 1072. Erdemir et al. (2016) Email: Central existing pain is to eliminate the etiological factors. There are able to initiate a reaction with the calcium ions within teeth. numerous treatment options for hypersensitivity, and the Calcium crystals are able to plug the dentinal tubules, majority of them have been found to heal this condition [3]. It is while the remaining ions can depolarize the nerve therefore essential to use the most appropriate treatment option blocking properties are the reason for using potassium in many develop, there are several preventive strategies available for membranes, blocking the stimulus [11,19]. Although these nerve- considerationfor the specific by underlying dentists. cause.A reduction Before in pain the andrisk severe of etiological lesions results. When used as a topical agent and concentrated between factors is the main goal of preventive management. These 1%desensitizing and 15%, methods,potassium clinical nitrate studies has been have shown reported to remove conflicting the procedures (Figure 1) focus on to prevent the exposure of the sensitivity successfully [20,21]. However, in one study [22], opened tubules to the oral environment and basically aim to the blocking capacity of potassium nitrate was evaluated as prevent the formation of the cervical lesions. Cervical area of teeth being inadequate even within sound teeth. Moreover, Poulsen is the most vulnerable part that existing enamel and can be worn and ruptured during normal forces. Thus, ability of dentifrice containing potassium nitrate to diminish underneath dentin could be exposed to etiologic factors of sensitivityet al.[23], found when that compared there was to placebo insufficient dentifrices. evidence In for other the hypersensitivity. Preventive management has the importance of studies, alternative chemical formulas have shown promising noticing the sensitive areas and having precautions before. results [4,24]. One of these studies found that a solution of

TREATMENT OPTIONS –II decreased hypersensitivity, while 5% potassium nitrate did not [4].10% Otherstrontium formulations chloride, shown2% sodium to reduce fluoride hypersensitivity and 40% formalin are Recent Developments There are many treatment options for eliminating the pain. toothpastes, silver nitrate agents [4], strontium chloride varnish [25],aluminummagnesium sulfate lactate iontophoresis, rinses [26] sodium and Guanethidinemonofluorophosphate [27].The the most common methods used. Among the numerous treatment authors believe that new formulations in different physical forms options,Several previous the most studies frequently [15-17] used have are evaluated nerve the desensitization, efficiency of (such as rinses, solutions and chewing ) would be more covering or plugging of the tubules or a combination of both [10]. The most recently developed materials used in experiments are Fluorides are also used in hypersensitivity problems. The discussed below; a combination of these methods is generally beneficial than the current methods used. recommended. In order to relieve the pain, restorative treatments may be applied, and root canal therapy is a last resort (Figure 2). preventive mechanism of fluoride may arise from The treatment options usually known as desensitizers may appliedof the tubules by dentists or blocking have the of themost transmission successful results of stimuli of these [28]. According to the results of studies [10,29], fluoride varnishes mechanisms [4]. Potassium nitrate is currently the most increased retentiveness of the varnished surfaces compared with preferredbe classified material. in terms Dentifrices of their containing chemical formulae potassium and nitrate physical are fluoride treatment methods. This can be attributed to the common, easy to use and accessible oral health care products. The mechanism of potassium salts (nitrate or chloride) relies on chemicalsother forms such of fluorideas strontium treatment. should If betoothpastes added to arethe involvedtoothpaste. in the relatively small size of the ions, which act quickly enough to treatment modalities, not only fluoride but also or +2 ¯ move into the dentinal tubules and reach the pulp in just minutes hypersensitivity problems to provide Ca and PO4 ions to the toothBioactive surface glass to is block mainly the composed tubules [30-32]. of silica Pradeep and is etutilized al. [24], in

[4,18]. Potassium oxalate is another potassium salt which is

Figure 1 Preventive procedures for dentine hypersensitivity.

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Figure 2 Treatment options for dentine hypersensitivity. showed that a 5% concentrated bioactive glass toothpaste known as calcium-sodium-phosphosilicate had superior results over a toothpaste containing 5% potassium nitrate in reducing use . An 8% arginine in-office paste has been shown to hypersensitivity in 110 patients over 6 weeks. Strontium mouthwashreduce hypersensitivity reduced the more tactile effectively sensitivity than of a patientsfluoride-based more salts have recently been used in toothpastes and have shown prophylaxis paste after 4 weeks [46]. Moreover, a 0.8% arginine promising results. The exact mechanism is not yet known [33], although microscopic evaluations have shown that these salts thussignificantly resulting than in less those dentine using hypersensitivity potassium nitrate [46]. Patients with undergo direct adhesion to the organic content of the dentin [47]. These rinses are thought to reduce the dentinal fluid flow, such as the odontoblastic processes [10]. Several in vitro studies are ineffective, however. With the added challenge of acidity, a highly acidic diet often find that toothpastes and mouthwashes in occluding dentinal tubules [34,35], although some studies Recently, an acid-resistant occluding material has been used in have proven the efficiency of strontium-containing toothpastes the occluded dentinal tubules are re-exposed to the oral flora. Moreover, strontium acetate is currently recommended rather tests, a mouthwash containing 1.4% potassium oxalate (Listerine thanhave strontium reported chloride, no clinical due efficiencyto its improved from characteristics strontium [14,36]. such Advancedmouthwashes Defense with Sensitive; good results Johnson&Johnson, [48]. In hydraulic NJ, USA) conductance reduced

the potential sensitivity elimination rates of Listerine Advanced Various biomolecules are incorporated into newly-designed as stronger linkage with fluoride and potassium nitrate [37,38]. Defensedentine permeabilitySensitive mouthwash by 100% and [49]. Colgate Another Sensitive study comparedPro-Relief toothpastes in order to overcome hypersensitivity problems toothpaste and mouthwash and showed that the toothpaste had increased the mineral/matrix ratio to the greatest extent by adding well-known arginine toothpastes have also been subjected to extra calcium and phosphate. However, Listerine mouthwash numerous[39]. Investigation studies [40-42]. is not limitedRegarded to as strontium a breakthrough toothpastes; invention the occluded the dentinal tubules to the largest extent, even after in nanotechnology [40], arginine has a simple mechanism the acidic challenge [50]. If patients are uncomfortable with the tactile effect of and even sensitive toothpastes, Arginine is an amino acid generally found in human saliva and these very effective mouthwashes may be recommended. worksinvolving in parallelthe creation with ofcalcium precipitates carbonate on the and dentine phosphate surface to form[39]. precipitates [14]. This is the basis for the interaction between Today, lasers are widely used in many areas of dentistry. arginine technology and calcium-, phosphate- and glycoprotein- Although lasers are not extensively used in hypersensitivity containing toothpastes (Colgate Sensitive Pro-Relief, Colgate- cases, many types of lasers have been used in these treatments Palmolive Company, NY, USA). Studies have described the superior results of these toothpastes in reducing dentine treatment of hypersensitivity including neodymium-yttrium- aluminum-garnetsince 1985 [17].There (Nd:YAG), are various erbium types (Er):YAG, of lasers carbon used dioxide in the

[41, 43-45], and electron spectroscopy images have shown a high (CO2), helium-neon (He-Ne) and gallium-aluminum-arsenide proportionhypersensitivity of calcium, as compared oxygen with and potassium phosphate nitrate ions, or indicating fluorides varies between 5.2% and 100% [17]. The basic mechanism of studies, various forms of arginine have been released. In addition lasers(GaAlAs) in the[17,51]. reduction However, of dentin the efficiency hypersensitivity of these is treatments not clear, remineralization [40]. Based on the satisfactory results of these and it is believed that this depends mainly on the type of laser to these toothpastes, in-office pastes and mouthwash also now JSM Dent 4(4): 1072 (2016) 3/6 Erdemir et al. (2016) Email: Central system and parameters chosen [17,51,52]. The basic mechanism CONCLUSION of low-power lasers (He-Ne, GaAlAs)involves the coagulation of the proteinal tissues of dentin, “promoting biomodulatory Dentin hypersensitivity is a common problem within many populations, and preventive management therefore has an essential role. Oral examinations should be carefully carried thus reducing the permeability [51,53]. In addition, medium- out, and the risk of sensitivity should not be ignored. Although powereffects, lasers reducing including inflammatory CO , Nd:YAG processes and Er:YAGlasers and related increase pain”, 2 there are a wide variety of treatment options for dentin surface temperature, which can recrystallize the dentin surface hypersensitivity, agents are likely to diminish the pain for only and result in the complete sealing and closure of tubules [51,52]. Er:YAG lasers have been only recently been used in the treatment varnishes and lasers should be combined with additional products of dentin hypersensitivity, and limited data are available for for3 to home6 months use [11]. to overcome In-office treatments the pain. Thesuch novelas dentin technologies sealants, this treatment [51]. Results reported for the reduction of dentin addressed in this article such as sensitive toothpastes containing lasers [51]. Despite strong theoretical evidence, clinical trials hypersensitivity range from 38.2% to 47% at 6 months for Er:YAG chloride and potassium oxalate mouthwashes should be advised sodium monofluorophosphate, arginine technology, strontium results, it is advisable to combine laser treatment with ion-based products is optimal to achieve successful outcomes in dentin gelshave or shown varnishes. conflicting results [54,55]. Due to these inconsistent hypersensitivity.for patients’ daily use. 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Cite this article Erdemir U, Saygi G, Yucel T, Yildiz E (2016) Dentin Hypersensitivity and Recent Developments in Treatment Options: A Mini Review. JSM Dent 4(4): 1072.

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