Comparison of Two Desensitizing Agents for Decreasing Dentin Hypersensitivity Following Periodontal Surgeries

GENERAL DENTISTRY Comparison of two desensitizing agents for decreasing dentin hypersensitivity following periodontal surgeries: a randomized clinical trial Mitra Askari, DDS, MSD/Reza Yazdani, DDS, PhD

Objective: Dentin hypersensitivity (DH) is a common problem three interventions (groups 1 to 3) effectively decreased DH at with multifactorial etiology. It is characterized by a short, sharp 60 and 90 days. Conclusions: This clinical trial showed all inter- pain due to exposed dentin usually at the cervical margin. This ventions were more effective than the placebo in decreasing randomized clinical trial aimed to evaluate the efficacy of two DH. The tested propolis extracts were equally effective irrespec- desensitizing agents for reduction of dentin hypersensitivity tive of their concentration. Application of Single Bond Universal (DH) following periodontal surgeries. Method and materials: had a fast relieving effect on DH. Propolis extracts and dentin This study evaluated 96 patients who had one or two teeth with bonding agent were equally effective in relieving DH in the DH (120 teeth). The teeth were randomly allocated into four long term. Clinical relevance: DH following periodontal sur- groups for treatment with 10% ethanolic extract of propolis gery causes patient discomfort and hinders everyday activities. (group 1), 30% ethanolic extract of propolis (group 2), Single Propolis is a natural desensitizing agent with antimicrobial and Bond Universal dentin bonding agent (group 3), and distilled anti-inflammatory properties, healing effects, and cariostatic water as placebo (group 4). The degree of DH was determined activity. It also stimulates reparative dentin formation. Flavo- according to the patients’ response to tactile and air blast stimuli noids and cinnamic acid derivatives are the main biologically using a visual analog scale (VAS). The level of pain was also re- active components in the composition of propolis. According to corded before treatment and at 1, 7, 14, 21, 60 and 90 days after the results of this study, application of propolis is recommended the treatment. Results: All interventions (groups 1 to 3) were for patients with mild or moderate pain. Dentin bonding agent significantly effective in decreasing DH, and 10% and 30% eth- could be a better choice when immediate effect is needed. anolic extracts of propolis were equally effective. The dentin (Quintessence Int 2019;50: 320–329; doi: 10.3290/j.qi.a42096) bonding agent was completely effective at all time points. All

Key words: dentin bonding agent, dentin hypersensitivity, desensitizing agent, periodontal surgery, propolis

Dentin hypersensitivity (DH) is a common clinical problem between 20 and 50 years of age. Also, it seems to be more prev- characterized by a short, sharp pain in response to external alent among women.3-6 DH generally involves the buccal sur- stimuli such as thermal, evaporative, tactile, osmotic, or chem- face of the teeth at the cervical margin, and is more common in ical stimuli due to exposed dentin and open dentinal tubules.1,2 canine teeth, premolars, and molars.7 DH causes pain, which affects patients’ everyday activities such Several theories have explained DH8 including the trans- as toothbrushing, eating, drinking, speaking, and even breath- ducer theory, the modulation theory, the “gate” control, vibra- ing, which cannot be ascribed to any other form of dental tion theory, and the hydrodynamic theory, which is the most pathology or defect. It occurs in 10% to 30% of the population widely accepted theory explaining DH. According to the latter

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theory, increased fluid movement within the dentinal tubules effect on reduction of dentin permeability,20,25,26 but no in-vivo or change in its direction due to external stimuli triggers the study has compared the desensitizing effects of propolis and baroreceptors (Aδ fibers) along the pulpal canal of the dentin dentin bonding agents. Considering the properties of propolis, and around the odontoblasts and subsequently causes pain.9 it seems to be beneficial for patients with periodontal prob- Accordingly, there are two principal methods to prevent or lems. Propolis is a safe and inexpensive desensitizing agent, decrease DH. The first one is to obstruct the outer end of open which can be used at home. Thus, the aim of this in-vivo study dentinal tubules by coagulation of dentinal proteins or obstruc- was to evaluate the clinical effects of 10% and 30% ethanolic tion of the pulpal end of tubules by forming a sedimentary extracts of Iranian propolis compared with Single Bond Univer- layer to decrease the movement of dentinal fluid. The second sal dentin bonding agent in patients with DH following peri- method is to decrease the sensitivity of intratubular nerve end- odontal surgery. ings by use of chemical agents such as potassium ions and depolarization of synapses.10-13 DH has a multifactorial etiology. Method and materials Gingival recession is the most important clinical cause of DH, which exposes the root surface. Denuding of root surfaces also This randomized, single-blind clinical trial evaluated DH follow- occurs in periodontal treatment, surgical/dental operative pro- ing periodontal surgeries such as crown lengthening, pocket cedures, periodontal disease, aging, incorrect tooth brushing, reduction, and apically repositioned flaps in patients present- or a combination of these factors.14-16 Other factors include ing to the Department of Periodontology in School of Den- patients’ harmful habits, poor oral hygiene, nutritional habits, tistry, Tehran University of Medical Sciences. exposure of teeth to chemical agents, chewing tobacco, extreme forces of occlusion, and premature contacts of teeth.2,17 Inclusion criteria Various methods and materials are used for treatment of DH such as laser therapy, fluorine, hydroxyapatite, strontium The inclusion criteria were the following: chloride, zinc chloride, potassium oxalate, dental adhesives, ■ patients of any age who had undergone periodontal sur- and glass-ionomer cements.15,18,19 Despite the large number of gery at the Department of Periodontology, School of Den- studies on this topic, a consensus has not been reached regard- tistry, Tehran University of Medical Sciences ing a “gold standard” treatment for DH.2,5 In search for natural ■ patients who had a maximum of two non-adjacent teeth desensitizing agents with long-lasting effects, propolis seems with no cervical caries and any degree of DH at the cervical to be a suitable desensitizing agent due to its assumed positive margin following periodontal surgery effects on DH.20 Propolis or bee glue is a natural, non-toxic resin ■ patients with good oral hygiene that has been widely used for hundreds of years in homeo- ■ patients with complete general health pathic and traditional medicine because of its antimicrobial, ■ patients who agreed to participate in this 3-month study. anti-inflammatory, anesthetic, and healing properties with no major side effects.20,21 Evidence shows that propolis can be Exclusion criteria effective for prevention of dental caries22,23 and reduction of pulp inflammation.24 Propolis can also significantly decrease The exclusion criteria were the following: dentin permeability.25 This natural resin can stimulate the for- ■ patients who had systemic diseases and/or psychologic dis- mation of reparative dentin.21 To date, there have been very few orders, or previous hospitalization studies on desensitizing effects of propolis in vivo, and the ■ teeth with caries, cracks, or fracture at their cervical margin available ones mostly have a small sample size. ■ teeth with extensive or faulty restorations, prostheses, or Bonding agents and dental adhesives seal the dentinal orthodontic appliances tubules and can resolve DH.26 They have a strong, long-lasting ■ substance abusers and patients taking analgesics and/or desensitizing effect on DH. They block the tubules by coagula- anti-inflammatory drugs tion of dentinal fluid proteins and formation of pegs within the ■ patients with a history of using desensitizing agents dentinal tubules, which counteracts the hydrodynamic mecha- ■ patients who had allergy to materials used in the study nism of DH.19,27 ■ patients who did not consent to participation Some in-vitro and in-vivo studies have reported that prop- ■ patients who did not attend the follow-up olis and dentin bonging agents have a clinically significant ■ pregnancy.

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Figs 1a and 1b (a) Application of desensitizing agent. (b) Light curing was performed using a LED light-curing unit 1a 1b with a light intensity of 400–550 mW/cm2 for 15 seconds.

Study design randomized by four opaque envelopes that contained one card stipulating “dentin bonding agent,” one card stipulating “10% The research protocol was approved by the Ethics Committee propolis,” one card stipulating “30% propolis,” and one envelope of Tehran University of Medical Sciences (approval No: IR.TUMS. containing one card stipulating “distilled water.” The examiner REC.1394.1567). It was also registered in the Iranian Registry of was blinded to the group allocation of patients. Prior to the Clinical Trials (IRCT2016102430475N1), available at www.irct.ir. study, all the procedures and instructions were standardized by A total of 108 patients (with 140 teeth) who fulfilled the an expert. Patients were not aware of the type of desensitizing inclusion criteria underwent a preliminary screening. Finally, 96 agent applied. Due to the low concentration of propolis extract patients (with 120 teeth) who completed the follow-up period and also the small amount of the applied material, it did not were evaluated. The purpose of the study, the procedures, and have a distinctive odor or taste. Nutritional counseling was also the safety of the products were thoroughly explained to performed and oral hygiene instructions were given. patients and they signed informed consent forms prior to their ■ Group 1: 10% ethanolic extract of Iranian propolis gel participation in this 3-month study. (Soren Tech Toos) All tooth surfaces were examined at their cervical margin. ■ Group 2: 30% ethanolic extract of Iranian propolis gel Clinical diagnosis was made under the conventional dental (Soren Tech Toos) chair light using a dental mirror, an explorer, and a periodontal ■ Group 3: dentin bonding agent (Single Bond Universal, 3M probe. Radiographs were taken if required. The number of Epse Dental Products) teeth was recorded after confirmation. Participants were ran- ■ Group 4: distilled water. domly divided into four groups (n = 30 in each group). In patients with two hypersensitive teeth, only one desensitizing Application agent was used to prevent false application of desensitizing agents and to simplify the procedure. In order to obtain more In all groups, the procedures were carried out as follows: accuracy, only individuals with a maximum of two hypersensi- ■ removal of debris and calculus, if any, around the respective tive teeth were included in this study. In patients with one teeth by hand scalers hypersensitive tooth, randomization was performed for the ■ precise isolation of the tooth with cotton rolls first 12 patients with 12 opaque envelopes that contained ■ complete drying of tooth surfaces with a cotton pellet three cards stipulating “dentin bonding agent,” three cards stip- ■ application of agents directly on the hypersensitive sites ulating “10% propolis,” three cards stipulating “30% propolis,” using a disposable micro-brush; care was taken not to apply and three envelopes containing three cards stipulating “dis- the products on oral mucosa tilled water” (block randomization). After the first 12 patients, ■ removal of excess material using cotton pellets. the randomization process was repeated until the four groups In order to avoid bias, the same treatment protocol was used were completed. Patients with two hypersensitive teeth were for all patients 2 minutes after the application as follows:

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2 Assessed for eligibility (n = 140 teeth, 108 patients)

Excluded (n = 7) teeth, 5 patients: Declined to participate (n = 3), systemic diseases (n = 2), drug addicted (n = 2)

Dentin bonding agent Propolis 30% Propolis 10% Distilled water (n = 34 teeth, (n = 32 teeth, Allocation (n = 33 teeth, (n = 34 teeth, 26 patients) 25 patients) 26 patients) 26 patients)

• Extraction of tooth because of periodontal • Discomfort patients disease Lost to complete Follow-up Lost to (n = 2) (Discontinued (n = 2 teeth) follow-up (n = 2 teeth) intervention) follow-up (n = 3) • Use other agents • Lost to follow-up (n = 2) (n = 2 teeth)

n = 30 teeth n = 30 teeth Analysis n = 30 teeth n = 30 teeth

Fig 2 Clinical trial follow-up diagram.

■ In group 3, which was treated with the dentin bonding while the adjacent teeth were protected by the examiner’s finger agent, light curing was performed using a LED light-curing or cotton pellets (to avoid desiccation of dentin surface in other unit with a light intensity of 400 to 550 mW/cm2 for 15 sec- teeth). A tactile test was done by moving a dental explorer (17/23) onds. Also, the placebo (distilled water) was applied after mesiodistally with lightly increasing pressure across the cervical drying and isolation of teeth using a disposable micro- margin perpendicular to the long axis of the tooth. This test was brush twice a day for 4 weeks. repeated three times before the final score was recorded.28 ■ In groups 1, 2 (10% and 30% propolis), and 3 (distilled The degree of hypersensitivity reported by the patient fol- water), light curing was imitated using a sham light-curing lowing the use of each stimulus was determined using a visual unit. The teeth were isolated and dried, and 10% or 30% analog scale (VAS) from 0 to 10, where: propolis or distilled water was applied on the tooth surface ■ 0 = no pain twice a day for 4 weeks. ■ 1 to 4 = mild pain ■ 5 to 7 = moderate pain Patients were instructed to refrain from rinsing, eating, and ■ 8 to 10 = severe pain. drinking for 30 minutes after the treatment and requested to The values were recorded before the intervention (baseline val- avoid using any other professional or self-applied desensitizing ues) and after each application on days 1, 7, 14, 21, 60 and 90. agents in the course of the study (Fig 1). Statistical analysis Treatment evaluation procedure All data were entered into Microsoft Excel. Descriptive statisti- Each tooth received two stimuli including air blast and tactile cal analysis was performed using SPSS version 22 (IBM). stimuli. Air blast was applied with an air syringe for 1 second at Repeated measures analysis of variance (ANOVA) was used to 1 mm distance from the tooth and perpendicular to the surface determine the effect of treatment on VAS. Wherever ANOVA

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Table 1 Distribution of patients’ age and gender in each group

Age (y) Gender (n)

Treatment group Minimum Maximum Mean Female Male Total (n)

10% propolis 39 55 47 19 8 27 30% propolis 38 54 46 16 6 22 Dentin bonding agent 45 53 49 15 8 23 Placebo 38 54 46 17 7 24 Mean 40 54 47 67 29 96

Table 2 Distribution (n) of types of teeth with dentin hypersensitivity less than half compared to baseline (47%). At 14 days, 13% of the patients had mild pain. The effect of application of 10% Treatment group Incisors Canines Premolars Molars propolis on DH compared to the placebo was statistically sig- 10% propolis 14 6 8 2 nificant (P = .00). 30% propolis 10 6 12 2 In the 30% propolis group, pain decreased by approxi- Dentin bonding agent 16 2 11 1 mately one-third of the value at baseline (33%) at 7 days. Most Placebo 16 6 8 0 patients (87%) had mild pain at 21 days. Thus, use of 30% prop- Total 56 20 39 5 olis compared to placebo was significantly effective for reduc- tion of DH (P = .00). Dentin bonding agent rapidly decreased DH at one day, as no severe pain was reported. At 90 days, approximately half of yielded significant results, one-way ANOVA was applied for the patients (53%) had mild pain while 47% had no pain. Den- multiple comparisons of the groups. The Tukey’s HSD post-hoc tin bonding agent caused significant reduction of DH com- test was applied for pairwise comparisons of four groups. pared to the placebo (P = .00). In the placebo group (no desensitizing agent), more than half of the patients (57%) had severe pain at 60 days and 27% Results had mild pain at 90 days. A total of 140 hypersensitive teeth of 108 patients following periodontal surgery were evaluated in this study. Since some Air blast stimulus patients were lost to follow-up, data of 120 teeth of 96 patients were statistically analyzed (Fig 2). These included 67 women Table 4 shows the percentage of reduction of DH in each group and 29 men with a mean age of 47 years (Table 1). at different time points in response to air blast stimulus. Table 2 shows the frequency distribution of the type of In the 10% propolis group, most patients had severe pain at hypersensitive tooth. Incisors, followed by premolars and baseline, which decreased to 3% at 14 days. At 90 days, 33% of canine teeth, were the most commonly involved teeth. the patients reported moderate pain. The difference between According to Figs 3 and 4, the results of tactile and air blast the effect of application of 10% propolis and the placebo on stimuli for evaluation of DH matched (P < .05). DH was statistically significant (P = .00). In the 30% propolis group, most patients had moderate pain at baseline; 73% had mild pain after 14 days, and 3% had Tactile stimulus moderate pain. The effect of 30% propolis on reduction of DH Table 3 shows the percentage of reduction of DH in response to was significantly greater than that of the placebo (P = .00). tactile stimulus in each group at different time points. At baseline, In the dentin bonding agent group, half of the patients had most patients showed severe pain in response to tactile stimulus. severe pain while the other half had moderate pain at baseline. In the 10% propolis group, the number of patients express- In the first day of application, 94% of patients had no pain. After ing DH in response to tactile stimulus on day 7 decreased to 90 days, 70% had no pain and 30% had mild pain. Single Bond

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Fig 3 Trend reduction by tactile stimulus 3 (DH, dentin hypersensitivity). 120

100

80 Propolis %10

60

DH% Propolis %30

40

Dentin Bonding Agent 20

0 Distilled Water Baseline 1st Day 7th Day 14th Day 21th Day 60th Day 90th Day

Fig 4 Trend reduction by air blast stimulus 4 (DH, dentin hypersensitivity). 100

90 Propolis %10 Propolis %30 80 Dentin Bonding Agent Distilled Water 70

60

50 DH% 40

30

20

10

0 Baseline 1st Day 7th Day 14th Day 21th Day 60th Day 90th Day

Universal compared to placebo was absolutely effective for res- Discussion olution of DH (P = .00). In the placebo group, 30% of patients had mild pain after Propolis and dentin bonding agents are desensitizing agents 60 days and 57% had moderate pain after 90 days. with some benefits as well as some disadvantages. The aim of The results showed overall reduction of DH in all groups in the present study was to evaluate the efficacy of two concen- response to tactile and air blast stimuli. The effects of applica- trations of Iranian propolis and a dentin bonding agent for tion of 10% and 30% propolis on DH were not significantly dif- reduction of DH following periodontal surgeries. ferent (P > .05). At 60 days, there was no significant difference DH is a common problem after periodontal surgeries.29 between the application of Single Bond Universal and 10% and Several teeth at the site of surgery may be involved, causing 30% propolis (P > .05). However, Single Bond Universal was patient discomfort. The present study was performed on this more effective than 10% and 30% propolis in the short term group of patients. According to the results, DH after peri- (P < .05; Tables 3 and 4). odontal surgeries can cause severe pain. However, Torwane As shown in Table 5, the overall reduction of DH in the 10% et al20 reported higher prevalence of moderate pain due to propolis (77%), 30% propolis (82%), and dentin bonding agent DH. The mean age of the present patients was 47 years, (81.5%) groups was similar, and the greatest difference among which was different from the mean age reported in some the groups was noted on day 1. previous studies (37 years). This difference in the results may

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Table 3 Reduction in severity of DH in response to tactile stimulus

Baseline Day 1, Day 7, Day 14, Day 21, Day 60, Day 90, Treatment group Severity score, n (%) n (%) n (%) n (%) n (%) n (%) n (%)

No pain 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 17 (57%) 17 (57%)

10% propolis Mild 0 (0%) 0 (0%) 0 (0%) 4 (13%) 16 (53%) 13 (43%) 13 (43%) (group 1) Moderate 0 (0%) 9 (30%) 16 (53%) 24 (80%) 14 (47%) 0 (0%) 0 (0%) Severe 30 (100%) 21 (70%) 14 (47%) 2 (7%) 0 (0%) 0 (0%) 0 (0%) No pain 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 15 (50%) 26 (87%)

30% propolis Mild 0 (0%) 0 (0%) 0 (0%) 4 (13%) 26 (87%) 15 (50%) 4 (13%) (group 2) Moderate 1 (3%) 4 (13%) 20 (67%) 20 (67%) 4 (13%) 0 (0%) 0 (0%) Severe 29 (97%) 26 (87%) 10 (33%) 6 (20%) 0 (0%) 0 (0%) 0 (0%) No pain 0 (0%) 24 (80%) 24 (80%) 5 (17%) 2 (7%) 16 (53%) 14 (47%)

Dentin bonding agent Mild 0 (0%) 6 (20%) 6 (20%) 25 (83%) 28 (93%) 14 (47%) 16 (53%) (group 3) Moderate 2 (7%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Severe 28 (93%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) No pain 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Distilled water Mild 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (3%) 8 (27%) (group 4) Moderate 0 (0%) 0 (0%) 0 (0%) 0 (0%) 6 (20%) 12 (40%) 14 (47%) Severe 30 (100%) 30 (100%) 30 (100%) 30 (100%) 24 (80%) 17 (57%) 8 (27%)

Table 4 Reduction in severity of DH in response to air blast stimulus

Baseline Day 1, Day 7, Day 14, Day 21, Day 60, Day 90, Treatment group Severity Score n (%) n (%) n (%) n (%) n (%) n (%) n (%)

No pain 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 16 (53%) 20 (67%)

10% propolis Mild 0 (0%) 0 (0%) 0 (0%) 7 (23%) 20 (67%) 14 (47%) 10 (33%) (group 1) Moderate 5 (17%) 9 (30%) 20 (67%) 22 (73%) 10 (33%) 0 (0%) 0 (0%) Severe 25 (83%) 21 (70%) 10 (33%) 1 (3%) 0 (0%) 0 (0%) 0 (0%) No pain 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 16 (53%) 25 (83%)

30% propolis Mild 5 (17%) 5 (17%) 0 (0%) 8 (27%) 29 (97%) 14 (47%) 5 (17%) (group 2) Moderate 25 (83%) 25 (83%) 11 (37%) 22 (73%) 1 (3%) 0 (0%) 0 (0%) Severe 0 (0%) 0 (0%) 19 (63%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) No pain 0 (0%) 28 (93%) 19 (63%) 19 (63%) 11 (37%) 21 (70%) 21 (70%)

Dentin bonding agent Mild 0 (0%) 2 (7%) 11 (37%) 11 (37%) 19 (63%) 9 (30%) 9 (30%) (group 3) Moderate 15 (50%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Severe 15 (50%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) No pain 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Distilled water Mild 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 9 (30%) 11 (37%) (group 4) Moderate 13 (43%) 12 (40%) 12 (40%) 11 (37%) 14 (47%) 15 (50%) 17 (57%) Severe 17 (57%) 18 (60%) 18 (60%) 19 (63%) 16 (53%) 6 (20%) 2 (7%)

be due to higher prevalence of periodontal disease in older lars were the most commonly involved teeth, irrespective of individuals.6,20 the etiology of DH.7,20 According to the present findings, the prevalence of DH The present study did not determine the prevalence of DH was the highest in incisors, followed by premolars and canine by the type of tooth, age, or gender of participants because all teeth, after periodontal surgeries. In previous studies, premo- patients complained of DH after periodontal surgeries. Also,

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Table 5 Mean reduction of DH

Interval times Treatment group 1 day 7 days 14 days 21 days 2 months 3 months

Treatment 1: 10% propolis 4.5 17.5 38.0 51.5 75.0 77.0 Treatment 2: 30% propolis 4.5 22.5 41.5 56.0 81.0 84.0 Treatment 3: Single Bond Universal 85.5 78.0 78.5 75.5 80.5 80.5 Treatment 4: Distilled water 0.0 0.0 0.0 4.5 22.5 31.0

the site of surgery and the location of teeth with DH in most of and then continued until day 90. In this product, glutaralde- the patients did not allow the study to be conducted with a hyde reacts with the plasma proteins in the dentinal fluid and split-mouth design. decreases hydraulic conductance.19 Although the immediate Generally, it is recommended to use more than one stimu- effect of dentin bonding agent is an advantage compared with lus for DH testing in clinical studies.20 Thus, tactile and air blast propolis, it should be noted that application of dentin bonding stimuli were used. Sowinski et al30 confirmed the accuracy of agent is an in-office treatment and requires a light-curing unit. using these stimuli for evaluation of DH. The degree of DH was In contrast, propolis is an insoluble lipophilic sticky compound, determined using a VAS. Although VAS is a subjective tool, it is which can adhere to tooth structure, increase tooth resistance widely used in human clinical and physiologic studies.31,32 to acidic dissolution,37 and prevent the formation of water-sol- In the present study, both 10% and 30% ethanolic extracts uble glucans, which are required for adhesion of cariogenic of propolis decreased the degree of DH, which was in agree- streptococci to tooth surface.38 Moreover, propolis can be used ment with the results of previous studies.20,33-35 The difference at home, is low-cost, and has no side effects. from using 10% (77%) and 30% (84%) propolis was not signif- Distilled water was used as placebo in the present study icant. An in-vitro study reported no significant difference (negative control). DH reduction in patients in the distilled between these two concentrations of propolis.25 It seems that water group was minimal and gradual (33%). Such minimal the efficacy of propolis for reduction of DH is not dose-depen- reduction may be related to formation of reparative or intra- dent. However, use of higher concentrations of propolis may tubular dentin, which decreases the hydraulic conductance of yield greater relieving effects; this topic is in need of further dentinal fluid. Pashley39 reported that physiologic or patho- investigation. logic formation of intratubular crystals from dentinal fluid or In the present study, the effect of propolis on DH was salivary crystals, bacterial invasion into dentinal tubules, and acceptable but the action of the dentin bonding agent was formation of sclerotic or reparative dentin can all decrease faster. Propolis gel partially occludes the dentinal tubules but DH. Finally, this reduction may be due to the placebo effect or cannot decrease the hydraulic conductance in dentinal participants’ bias.34 In the present study, the site of surgery tubules.25 However, Geiger et al36 postulated that propolis pre- and the location of teeth with DH in most of the patients did cipitates and obstructs the dentinal tubules and decreases not allow a split-mouth design. Despite the positive effects of dentinal permeability by 85% or more. This mechanism may be propolis on periodontal status, this study only assessed its due to the high content of flavonoids in the composition of efficacy for resolution of DH. Future studies are recommended propolis and their reaction with dentin and the subsequent to study DH and periodontal status together in this group of production of crystals that occlude the dentinal tubules.25,33 On patients. the other hand, flavonoids inhibit the formation of free radicals by binding to heavy metal ions, which are known to catalyze Conclusion many reactions leading to generation of free radicals.33 In the present study, application of the dentin bonding Patient discomfort due to DH following periodontal surgeries agent had a significant effect on DH (81.5%); its effect began may hinder everyday activities. Application of propolis as a immediately (after 1 day), then experienced a slight decrease, desensitizing agent is recommended for mild to moderate pain

QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019 327 GENERAL DENTISTRY due to DH since it is cost-effective, safe, and easy to use. It also Acknowledgments has other favorable properties, such as antimicrobial and anti-inflammatory properties and healing effects, which can be This study was a doctorate thesis for a DDS degree and sup- useful in periodontal patients. Use of a dentin bonding agent ported by the Department of Dentistry, Tehran University of could be a better choice when a rapid effect is needed. Consid- Medical Sciences, International Campus, Iran. The authors ering the deficiencies in the methods to evaluate DH, an ideal thank Mrs Melika Zargar, DDS, PhD student, Community Oral method to compare the efficacy of different desensitizing Health Department, Dentistry School, Shahid Beheshti Univer- agents has yet to be determined. Therefore, clinical comparison sity of Medical Sciences, Iran, for her contribution. of these methods can better elucidate this topic. Future studies with higher concentrations of propolis, larger sample sizes, lon- Declaration ger follow-ups, and a split-mouth design will aid interpretation of the results. The authors have no conflicts of interest to declare.

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Mitra Askari Assistant Professor, Oral & Maxillofacial Pathology Department, Dentistry School, Tehran University of Medical Sciences, International Campus, Iran.

Reza Yazdani Associate Professor, Community Oral Health De- partment, Dentistry School, Tehran University of Medical Sciences, Iran.

Mitra Askari Reza Yazdani

Correspondence: Dr Askari Mitra, Department of Oral & Maxillofacial Pathology, Dentistry School, Tehran University of Medical Sciences, International Campus, Iran. Email: [email protected]

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