Original Article Int J Clin Prev Dent 2018;14(1):29-34ㆍhttps://doi.org/10.15236/ijcpd.2018.14.1.29 ISSN (Print) 1738-8546ㆍISSN (Online) 2287-6197

A Clinical Test of Dental Hypersensitivity by Use of the Dentifrice with the Desensitization Agents

Jin-Hee Won1, Su-Ok Lee1, Mi-Ra Lee2, Su-Yeon Park3

1Department of Dental Hygiene, Chungbuk Health & Science University, Cheongju, 2Department of Dental Hygiene, Baekseok Culture University, 3GAON Dental Hospital, Cheonan, Korea

Objective: In order to examine the desensitization effect for the dentifrice with such ingredient as Zinc Chloride and Kalium Phosphate 1 and 2, by the experiment in vitro and in vivo. Methods: Ninety-nine adults volunteers who had a little hyper-sensitive dentin were divided with 3 groups as experimental, negative or positive control group, after in vitro experiment as closing ability for dentinal tubules by use of each dentifrice, and observed them with scanning electro microscope (SEM). Clinical test for desensitization effect was checked by use of electric pulp tester after using each dentifrice contained Zinc Chloride or Kalium Phosphate. Questionnaire method was add- ed in order to check the subject’s response for satisfaction. Results: More closing effect on the dentinal tubules with the precipitation materials through coagulation of protein by were seen in experimental group than in negative or positive control group, observed with SEM in vitro study. The most in ex- perimental group were satisfied to use the dentifrice with desensitization ingredients, examined by questionnaire method (p＜0.05). It revealed more leveled in Electro-Pulp test in experimental group than in negative or positive control group for hypersensitivity check for 6 days use (p＜0.05). Conclusion: Dentifrice with Zinc Chloride and Kalium Phosphate together was recommended to use for hypersensitivity den- tal patient.

Keywords: , dentin desensitizing agents, toothpastes

Introduction eases, occurring in 1 out of 7 adults [1]. Paik et al. [2] study re- ported that dentin hypersensitivity is higher in men than in Dentin hypersensitivity is one of the common dental dis- women and the cervical rate increases with age. It is most commonly seen in the labials of canines and premolars. Dentin hypersensitivity can be defined as a specific sensory Corresponding author Su-Yeon Park reaction or pain response that appears on the root surface ex- GAON Dental Hospital, 129 Dongseo-daero, Seobuk-gu, Cheonan 31109, Korea. Tel: +82-42-552-0005, Fax: +82-2- posed by heat, mechanical, or chemical stimuli that do not cause 6280-2468, E-mail: [email protected] discomfort in normal teeth, it is a complex symptom rather than https://orcid.org/0000-0002-2121-5081 a disease [1]. Dentin hypersensitivity is associated with the in- cidence of exposed dentin, and is the cause of exposed dentin Received March 20, 2018, Revised March 25, 2018, due to abrasion by improper brushing, irregular habits such as Accepted March 25, 2018 , erosion due to dietary habits and

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29 International Journal of Clinical Preventive Dentistry due to periodontal operation and occlusal trauma. Materials and Methods The mechanisms of dentin hypersensitivity are modulation theory, transducer theory, gate control theory, and hydrody- 1. Subjects and materials namic theory. Among them, the use of the hydrodynamic theory is the most widely recognized. The treatment of dentin hyper- Eighty - nine patients aged 27 to 86 years (42 males and 57 sensitivity can be divided into two types based on the hydrody- females) who had at least one natural tooth undergoing dentin namic theory [1]. First, to prevent the flow of dentinal tubule hypersensitivity in their oral cavity were included in the study. fluid in the dentinal tubule, the open dentinal tubule is physi- With a history of hypersensitivity to temperature, mechanical cally closed to inhibit the movement of the dentinal tubule fluid. stimuli, the patients who were not treated in the dentistry within Second, as used chemically, it induces the desensitization effect the last 6 weeks were excluded, as well as patients suffering of the nerve and reduces the sensitivity to stimulation to control from the cervical and occlusal dental caries, without fractures, it with pain. The most common treatment method based on this and with and implants. principle is to use a dentifrice containing dentin hypersensiti- 2. Materials vity mitigating ingredients that are inexpensive, easy to use, and widely available. Lee et al. [3] study reported a 78% dentinal The research material used was an experimental dentifrice tubule rate using a dentifrice containing nano-sized containing zinc chloride, potassium monophosphate, dibasic carbonate apatite and Ahn et al. [4] reported that cervical dentin potassium phosphate, a negative control dentifrice containing with hydroxyapatite and strontium chloride containing denti- fluoride, and a dentin hypersensitivity mitigation dentifrice, frice was closed by dentin tubules of the dentin by scanning elec- which was certified as a commercially available positive con- tron microscopy. In addition, Lim et al. [5] study reported that trol dentifrice (Table 1). dentin hypersensitivity was reduced by 54.72% when dental hy- 3. Methods droxyapatite containing dentifrice was used for 2 weeks. The hydroxyapatite was deposited in the dentinal tubule and pene- 1) Approval of IRB trated into the dentin to reduce dentin hypersensitivity. Nagata This study was conducted after approval of the research and et al. [6] and Tarbet et al. [7] reported that dentin hypersensiti- permission as granted from the Institutional Review Board of vity was significantly reduced by using dentifrice containing the Natural Graduate School of Dankook University (IRB File 5% potassium nitrate, and was noted as more pronounced when No. DKU 2015-03-009-004). used continuously. Jang et al. [8] and Son et al. [9] studies re- ported that a dentifrice containing potassium phosphate showed 2) Classification of study subjects excellent dentinal tubule closure effect and clinical trials, and After examining the dentin hypersensitivity subjects, several dentin hypersensitivity mitigation effect is reviewed with an ex- randomly selected patients were included in the study. The writ- cellent result from the use of a scanning electron microscopy. ten consent by the patient for uniform distribution by the IRB It is noted that dentin hypersensitivity is less frequent in pa- regulations during the four test times except for the abandon- tients with good management after periodontal surgery, whereas dentin hypersensitivity is more frequent in pa- tients not under dental plaque management, and dentin hyper- Table 1. Composition of experimental toothpastes sensitivity is more common in dental plaque-free teeth [10]. Of Group Main ingredient Contents (%) the 34.1% of patients with dentin hypersensitivity, 84.3% had E. Group Zinc chloride 0.09 a gingival recession [11]. The Kakar et al. study [12] reported Potassium phosphate monobasic 2.00 that the zinc chloride-containing dentifrice is effective in con- Dibasic potassium phosphate 3.00 trolling gingival formation and improving gum health com- Tocopherol acetate 0.01 pared to other sodium fluoride dentifrice. Sodium fluorophosphate 0.76 The purpose of this study was to compare the effects of a den- Dental type silica 10.00 Calcium carbonate 10.00 tifrice containing zinc chloride, potassium monophosphate and C1 group-negative Tocopherol acetate 0.01 potassium phosphate, and a commercially available dentifrice Sodium fluorophosphate 0.76 which received certification for the use as a dentin hyper- Dental type silica 10.00 sensitivity mitigation effect on the subjective sensation and Calcium carbonate 10.00 electric pulp test (EPT) of dentin hypersensitivity. C2 group-positive Arginine 8.00 Calcium carbonate

30 Vol. 14, No. 1, March 2018 Jin-Hee Won, et al：Dental Hypersensitivity by Use of the Dentifrice with the Desensitization Agents

ment of the personal circumstances and the experimental group tionnaire results. was 34 people, with 35 people used as a negative control, where- by the total in the positive control group of 30 people were 99 Results people, who participated in the clinical trials as they were conducted. 1. EPT result 3) Measurement and evaluation of dentin hypersensitivity The EPT was performed after an oral examination before us- The EPT was used to check the numerical value, and when ing the dentifrice, and the EPT was performed after 1, 3, and the value was higher than the previous day, the dentin hyper- 6 days after using dentifrice. As a result of the EPT after 1 day, sensitivity was mitigated. The numbers appearing on the device 3 days, and 6 days of using dentifrice, the dentin hypersensiti- are not meaningful, and they are meaningful for the range of vity relaxation effect was the highest in the experimental group change of the numerical value (5→10, 10→15). The noted ef- based on the base (Table 2). fect of the dentifrice before use, showed a low electrical resist- 2. Survey results ance from the teeth, after using the dentifrice, if the participant saw a high electric resistance, that answer was judged that there 1) Evaluation of the degree of dentin hypersensitivity mitigation is a notable dentin hypersensitivity relieving effect. as compared with the condition experienced before the dentifrice use 4) Research course Table 3 show the results of the dentin hypersensitivity miti- Before the use of each dentifrice, an electroplating test (EPT) gation as compared to the experience of the condition before was performed and the dentifrice was used for a total of 4 evalua- dentifrice use. The respondent’s satisfaction with the ques- tions on days 1, 3, and 6. The electrical dimension examination tionnaire on the degree of mitigation of dentin hypersensitivity (EPT) was performed to measure buccal cervical 1/3 site. was highest in the experimental group (85.3%), and the positive Before using each dentifrice, it was noted how the participants control group was 71.0% and the negative control group was in the study selected the target tooth by a comprehensive dental the lowest with 48.6%. Top 2 classified ‘very satisfied’ and examination, and then record the numerical value by conduct- ‘satisfied’ into ‘satisfied’. Others were classified as ‘normal’, ing EPT. Each group was given the same and denti- ‘slightly dissatisfied’, and ‘very dissatisfied’ as ‘dissatisfied’. frice for research and had no other treatment. After the use of dentifrice, the electrodural test (EPT) was carried out on the 1st, 2) The time felt the effects after using the dentifrice 3rd and 6th days. On the 6th day, surveys on the participant sat- Table 4 show the response to the first time point when dentin isfaction were also conducted.

5) Statistical analysis Table 3. Satisfaction for desensitization felling after using each dentifrice (unit: %) A statistical package for the social science SPSS version 21.0 program (IBM Co., Armonk, NY, USA) was used and the sig- Group 1 2 3 4 5 Total Top2 nificance level for statistical significance was recorded at 0.05. E. Group 8.8 76.5 11.8 2.9 0.0 100 85.3 Additionally, a one-way ANOVA was performed to see the sig- C1 Group-N 2.9 45.7 40.0 11.4 0.0 100 48.6 nificant difference between the groups, and a repeated meas- C2 Group-P 3.3 67.7 17.6 5.9 0.0 100 71.0 ured ANOVA was performed to see the significant difference 1: very satisfied, 2: satisfied, 3: normal, 4: slightly dissatisfied, 5: very on a daily basis. The chi-square was used to analyze the ques- dissatisfied, Top2: very satisfied＋satisfied.

Table 2. Result of electric pulp test

Group Number Base After 1day After 1day After 1day E. Group 34 11.06±6.71 12.44±6.51 17.79±8.58**,a 17.65±11.43*,a C1 Group-N 35 13.57±7.13 12.11±6.85** 13.09±6.92b 10.00±0.72**,b C2 Group-P 30 10.17±12.43 12.43±5.51 14.50±7.12**,ab 14.67±8.45**,ab p-valuec 0.061 0.971 0.002 0.002 Values are presented as number only or mean±standard deviation. abThe same letter means no statistical difference. *p＜ 0.05 by paired t-test, **p ＜0.01 by paired t-test. cp-value by one way ANOVA.

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Table 4. The point when felt the desensitization (unit: %) Table 6. Comparing the experience the feeling with the desensitization for the dentifrice which used before (unit: %) Group 0 1 2 3 4 5 6 Total Group 1 2 3 4 5 Total Top2 E. Group 5.8 8.8 20.6 14.7 32.4 11.8 5.9 100 C1 Group-N 22.8 2.9 17.1 5.7 14.3 22.9 14.3 100 E. Group 8.8 52.9 32.4 5.9 0.0 100 61.7 C2 Group-P 26.1 5.9 23.3 17.6 20.6 6.5 0.0 100 C1 Group-N 5.7 20.0 48.6 25.7 0.0 100 25.7 C2 Group-P 9.7 50.0 30.0 2.9 0.0 100 59.7 0: no change, 1: after 1 day, 2: after 2 days, 3: after 3 days, 4: after 4 days, 5: after 5 days, 6: after 6 days. 1: very satisfied, 2: satisfied, 3: normal, 4: slightly dissatisfied, 5: very dissatisfied, Top2: very satisfied＋satisfied. Table 5. Satisfaction degree for desensitization (unit: %)

Group 1 2 3 4 5 Total Top2 were 61.7% in the experimental group and the highest, 59.7% E. Group 8.8 61.8 23.5 5.9 0.0 100 70.6 in the positive control group, whereas the negative control C1 Group-N 8.6 17.1 62.9 11.4 0.0 100 25.7 group was the lowest to 25.7%. The top 2 classified with an- C2 Group-P 6.5 44.1 40.0 2.9 0.0 100 50.6 swers as ‘very satisfied’ and ‘satisfied’ into ‘satisfied’ as noted 1: very satisfied, 2: satisfied, 3: normal, 4: slightly dissatisfied, 5: very with the survey. The others were classified as ‘normal’, ‘slightly dissatisfied, Top2: very satisfied＋satisfied. dissatisfied’, and ‘very dissatisfied’ as ‘dissatisfied’ in this case.

Discussion hypersensitivity was reduced after using the dentifrice. The ex- perimental group was higher by 32.4% on the fourth day after Dentin hypersensitivity is an easily accessible symptom of using dentifrice, and the negative control group was 22.9% at a dental disease, and can be defined as a specific sensory re- the 5th day and the positive control group was higher by 23.3% action or pain that occurs when an exposed dentin is stimulated at the 2nd day. by an action or cause related to eating, or chewing motions of The positive control group showed the effect of the noted the patient. The cause of dentin hypersensitivity is related to the dentin hypersensitivity mitigation at the earliest point, but in the incidence of abnormal brushing habits, abnormal habits such subjects who did not feel the effect of dentin hypersensitivity as , abrasion, bruxism, loss of enamel due to acid or diet- mitigation on the 6th day of the experiment, 5.8% in the ex- ary habits, and may also be noted as a result of gingival re- perimental group, 22.8% in the negative control group and cession, or seen as the side effects caused by tooth whitening 26.1% in the positive control group, which were seen as the low- procedures. It frequently occurs in canines and premolars, and est in the experimental group. is common in the left teeth when right-handed. Among them, 38% of premolars, 26% of incisors, 24% of canines, and 21% 3) Evaluation of satisfaction with improvement of dentin hyper- of molars appear frequently to result in this condition. The cer- sensitivity vical abrasion rate increased in frequency with the noted age of Table 5 show the results of the degree of satisfaction with the the patient, and the highest rate was found in premolar toot loca- improvement of the dentin hypersensitivity of the subjects. The tions (49.2%) [2]. The number of dentinal hypersensitivity teeth subjects who answered as having achieved ‘satisfaction’ with is increased by about eight times the number of open dentinal the procedure were 70.6%, and in the experimental group and tubule entrances per unit area, as compared with normal teeth the highest, 50.6% in the positive control group and the negative and the diameter of the dentinal tubule, which is noted as twice control group was the lowest to 25.7%. Top 2 classified ‘very as large and more filled with fluid [1,13,14]. The number and satisfied’ and ‘satisfied’ into ‘satisfied’. Others were classified diameter of open dentinal tubules is an important factor in re- as ‘normal’, ‘slightly dissatisfied’, and ‘very dissatisfied’ as ducing the incidence of dentin hypersensitivity. Additionally, ‘dissatisfied’. the closure effect of the dentinal tubules can be confirmed by scanning with an electron microscope [4,15]. 4) Satisfaction with the degree of improvement compared with To illustrate, there are various dentin hypersensitivity miti- the dentin hypersensitivity dentifrice as used before gation products that have been introduced for the treatment of Table 6 show the results of the satisfaction with the degree dentin hypersensitivity, and the effects are continuously being of improvement compared to the experience with a dentifrice studied. In 1935, Grossman [16] suggested that there should be that was previously approved by a dentin hypersensitivity miti- no dentin stimulation as a requirement for the product to treat gation dentifrice. The subjects who answered ‘satisfaction’ dentin hypersensitivity, and that there should be no pain when

32 Vol. 14, No. 1, March 2018 Jin-Hee Won, et al：Dental Hypersensitivity by Use of the Dentifrice with the Desensitization Agents

applied, when the product is easy to use, has a permanent and an EPT that does not necessarily coincide. However, in general, rapid effect, and produces no subsequent no discoloration of the the dentin response to electrical stimulation is often used clin- teeth after use of the product. There are special treatments and ically in response to cold stimulation [1]. In addition, the Tarbet self-treatment for these conditions. Among them, a dentifrice et al. [20] study showed that when electrical stimulation and containing effective ingredients and oral solution can be easily cold stimulation were performed to observe the degree of dentin used as a patient home self-treatment for this condition. Of hypersensitivity, the related correlation was significant, and the these, the use of dentifrice is the easiest, cheapest and con- use of an electric stimulation had a greater placebo effect. In this tinuously convenient application to prevent this condition [3]. experiment, to compare the effects of dentin hypersensitivity In the case of dentifrice containing dentin hypersensitivity miti- mitigation before and after dentifrice use, an EPT, which can gation, the smear layer is formed by brushing to close the denti- be recorded numerically, was carried out to evaluate the effect nal tubule component to penetrate within the dentinal tubule in of the dentin hypersensitivity mitigation when the value as re- the dentifrice where the smear layer is formed, thus allowing corded for the mitigation efforts was noted as measuring higher penetration of the effective ingredient into the dentifrice which than the previous day. is further increased [17]. Respectively, Jang et al. [8] and Son In the study, the dentin hypersensitivity mitigation effect was et al. [9] studies reported that a dentifrice containing potassium the highest in the experimental group as a result of the ongoing phosphate showed excellent dentinal tubule closure effect and clinical experiments. On the third day, there was a significant clinical trials, and the dentin hypersensitivity mitigation effect difference between the experimental group and the negative is achieved in an excellent way by scanning using an electron control group, whereas the positive control group and the neg- microscopy procedure. The Kakar et al.’s study [12] reported ative control group showed no difference. The noted base com- that a zinc chloride-containing dentifrice is effective in control- pared to the third day of the study, the experimental group was ling a gingival formation and improving gum health, as com- 1.61 times and the positive control group was able to confirm pared to another sodium fluoride dentifrice. a mitigation of dentin hypersensitivity by recognizing stim- In this study, a dentifrice containing potassium phosphate; ulation of 1.43 times. But the negative control group was 0.96 with a high closure effect on dentinal tubules due to reminerali- times, almost similar to the initial value, indicating no effect on zation of teeth, and zinc chloride; with mitigation effect of den- the improvement of dentin hypersensitivity. In addition, a ques- tin hypersensitivity due to periodontal improvement, was ex- tionnaire survey was conducted on the subject’s satisfaction on pected to have the mitigation effects of dentin hypersensitivity. the 6th day after using the dentifrice, and the degree of miti- Appropriately, the clinical trials were conducted to confirm this gation and satisfaction of the dentin hypersensitivity among the result. subjects were better than the other groups in the experimental There were adults including 99 people with one or more natu- group in 3 items. This study is intended to compare the effects ral teeth with dentin hypersensitivity who were included in this of the use of zinc chloride and a dentifrice containing potassium study. The negative control group was identified using a denti- phosphate monobasic, potassium phosphate dibasic. In addi- frice containing potassium phosphate monobasic, potassium tion, it is noted that the clinical trials were effective in reducing diphosphate, zinc chloride and fluorine, and the positive control dentin hypersensitivity, and there was no discomfort or side ef- group using a dentifrice for dentin hypersensitivity mitigation fects experienced by the subject. Therefore, it may be useful for were compared before and after 1, 3, and 6 days after the use an effective clinical application. However, it is necessary to of the dentifrice. continue the study of how long the maintenance of dentin hyper- Consequently, the Gillam [18] study reported that mechan- sensitivity mitigation effect can be continued for the mitigation ical stimulation, chemical stimulation, electrical stimulation, therapies as applied to the patients to manage dentin hyper- air, and thermal stimulation can be used to measure dentin sensitivity in each case. hypersensitivity. Accordingly, the electrical stimulation was used as a stimulus source in this experiment. Kim et al. [19] Conclusion study showed that if an EPT does not respond to a mechanical and thermal stimuli by treating dentin hypersensitivity, the pa- In this study, to evaluate the mitigation effect of the dentin tient’s teeth show an increased electrical resistance in abrasion, hypersensitivity, the dentifrice containing zinc chloride, potas- which can be used to diagnose a dentin hypersensitivity, which sium phosphate monobasic, potassium phosphate dibasic, and reported that an EPT was useful in an evaluation of the result dentifrice containing fluorine, and dentifrice already used for of a dentin hypersensitivity treatment, as well. But, there are re- the mitigation of dentin hypersensitivity were given to 99 vol- ports that the association between a hypersensitivity score and unteers for 6 days. After that, an EPT was carried out, and the

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