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Tooth sensitivity and whitening

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Edward J Swift at University of North Carolina at Chapel Hill
Edward J Swift
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Abstract

This article presents a review of the basic concepts of tooth sensitivity and how those concepts apply to cervical dentin hypersensitivity and the sensitivity frequently associated with tooth whitening. The etiology and treatment of cervical dentin hypersensitivity are described. The clinical presentation, incidence, and predisposing factors for sensitivity associated with tooth whitening also are discussed.
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ANNALS OF BIOMEDICAL RESEARCH AND EDUCATION 2005 October/December, Volume 5, Issue 4
Tooth sensitivity and whitening
Khatuna Chonishvili, Vasil Chonishvili
Dental Clinic “Face” Tbilisi, Georgia
ABSTRACT
The study purposed to evaluate the basic concepts of tooth sensitivity, the etiology of cervical dentin hypersensitivity and costs
of tooth whitening. The etiology and treatment of cervical dentin hypersensitivity are described. Total of 120 patients (50 men
and 70 women aged 20-45) have been interviewed. Dentin hypersensitivity appeared more prevalent than many dentists
believe. It's the most frequent side effect associated with vital bleaching procedures. Desensitizing dentifrices provide a
convenient, inexpensive, and effective first line of defense for treating cervical dentin hypersensitivity.
KEYWORDS: sensitivity, whitening, hydrodynamic theory, dentinal tubules
he most widely accepted explanation of dentin
hypersensitivity is Brannstom’s “hydrodynamic
theory” [3]. According to this theory, various thermal,
mechanical, evaporative, and osmotic stimuli can cause a
rapid outward flow of fluid in the dentinal tubules.2-5
Rapid fluid flow causes a pressure change across the
dentin, stimulating pulpal A-
δ nerve fibers and resulting in
the perception of pain. Cold is the most common stimulus
for dentin hypersensitivity [2-5].
MATERIALS AND METHODS
Total of 120 patients (50 men and 70 women aged 20-
45) have been interviewed during the period of 2002-
2005. Studies concerning the prevalence of cervical
dentin hypersensitivity have reported that 4% to 57% of
adults experience cervical dentin hypersensitivity in 1 or
more teeth [7-12]. The prevalence of hypersensitivity is
substantially higher (60% to 98%) in periodontal patients
[11-13]. The most common locations for dentin
hypersensitivity are cervical areas on the facial surfaces
of the canines and first premolars, followed by the second
premolars and the incisors [4-14].
This survey also revealed that only half of affected
individuals reported that they had talked to their dentist
about their sensitive teeth and that only half of those
individuals received a treatment recommendation.
Many patients believe that this problem is a minor
annoyance not worthy of the dentist’s attention, and some
dentists might feel the same way. A surprisingly large
proportion of dentists lack knowledge of the problem, its
etiology and treatment alternatives [15]. A better
understanding of dentin hypersensitivity is important for
dental professionals, especially as more people are
experiencing a similar type of sensitivity with tooth
whitening.
Exposure of dentinal tubules – either through gingival
recession and subsequent loss of cementum or through
wear of enamel – is required for cervical dentin
hypersensitivity to occur. However, dentin exposure does
not inevitably result in hypersensitivity. A number of
factors contribute to hypersensitivity with exposed dentin,
including ingestion of acidic beverages and foods, use of
abrasive or tartar-control dentifrices, overzealous or poor
brushing technique, and brushing immediately after
ingesting an acidic beverage or food [4,14,15].
Resin-based dentin adhesives are one of the methods for
sealing dentin surface. These materials impregnate the
dentin, occlude the tubules, and form a polymeric coating
on the surface. The coating tends to be relatively thin
(about a few microns) and therefore is susceptible to
abrasion. In clinical trials, several resin adhesives have
demonstrated significant reductions in cervical dentin
hypersensitivity.
The reported incidence of tooth sensitivity in clinical trials
of whitening varies widely, from as low as 0% to 7% to
as high as 75%.1 Although some studies have reported
occasional subject dropouts because of tooth sensitivity,
nearly all sensitivity (~80% of occurrences) is described
as “mild”. A recent clinical trial and literature review
concluded that mild sensitivity can be expected to occur in
54% of patients, moderate sensitivity in 10% and severe
sensitivity in fewer than 5%. In other words, about two
thirds of patients are likely to experience at least some
tooth sensitivity at some point during the whitening
process. (As a point of reference, this study evaluated a
15% carbamide peroxide gel containing fluoride that
was applied 3 to 4 hours per day over a 4-week period).
Fig.1 Whitening sensitivity is related to the easy
passage of peroxide through the enamel and dentin to the
pulp.
Interestingly, tooth sensitivity rates of up to 20% to 30%
have been reported with placebos, which suggest that the
sensitivity is not related strictly to the peroxide content of
whitening gels. One example of this was reported in a
clinical trial by Matis et al, who compared a 10%
carbamide peroxide gel with a placebo gel. This study
included 5 categories of subject-reported sensitivity –
none, slight, moderate, considerable, and severe. With the
whitening gel, the percentages of subjects in each
category were 45%, 10%, 28%, 7% and 10%,
respectively. For the placebo gel, the percentages were
80%, 10%, 10%, 0% and 0%. In summary, 55% of
subjects in the active group experienced at least some
tooth sensitivity, but so did 20% of subjects in the placebo
group. A similar study by Leonard et al reported tooth
T
Tooth is a semipermeable
membrane
Peroxide/urea penetrates
to the pulp in 5 to 15
minutes
Color change is same at
pulp at dentin-enamel
j
unction
ISSN 1512-0929
269
2005 October/December, Volume 5, Issue 4 TBILISI STATE MEDICAL UNIVERSITY
sensitivity in 58% of subjects in the active group and in
34% of subjects in the placebo group.
CONCLUSION
Dentin hypersensitivity is more prevalent than many
dentists believe. Desensitizing dentifrices provide a
convenient, inexpensive, and effective first line of defense
for treating cervical dentin hypersensitivity. A variety of
professionally applied topical agents also are available,
but no single method has proved to be 100% effective.
Tooth sensitivity is the most frequent side effect associated
with vital bleaching procedures. Although it tends to be
mild and transient, it is also very common and is annoying
to patients. Its presentation is similar to that of cervical
dentin hypersensitivity and may involve a similar
mechanism.
REFERENCES:
1. Haywood VB, Leonard RH, Nelson CF, et al. Effectiveness side effects and long-term status of nightguard vital bleaching.
Jam Dent Assoc. 1994;125:1219-1226.
2. Holland GR, Narhi MN, Addy M, et al. Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. J Clin
Periodontol. 1997;24:808-813.
3. Brannstrom M Sensitivity of dentin. Oral Surg Oral Med Oral Pathol. 1966:21:517-526.
4. Addy M Dentine hypersensitivity: new perspectives on an old problem. Int Dent J. 2002:52(suppl 1):367-375.
5. Walters PA. Dentin hypersensitivity: a review. J Contemp Dent Pract. 2005:6:107-117.
6. Absi EG, Addy M, Adams D. Dentine hypersensitivity. A study of the patency of dental tubules in sensitive and non-sensitive
cervical dentine. J Clin Periodontol. 1987:14:280-284.
7. Murray L,Roberts AJ. The prevalence of self-reported hypersensitive teeth. Arch Oral Biol. 1994:39(suppl 1):S129-S135.
8. Fischer C, Fischer RG, Wennberg A. Prevalence and distribution of cervical dentine hypersensitivity in a population in Rio de
Janeiro, Brazil. J. Dent. 1992;20:272276.
9. Liu HC, Lan WH, Hsieh CC. Prevalence and distribution of cervical dentine hypersensitivity in a population in Taipei, Taiwan.
J Endod. 1998;24:45-47.
10. Irwin CR, McCusker P. Prevalence and distribution of dentine hypersensitivity in a general dental population. J Ir Dent. Assoc.
1997;43:7-9.
11. Rees JS, Addy M. A cross-sectional study of dentine hypersensitivity. J Clin Periodontol. 2002;29:997-1003.
12. Taani S, Awartani F. Clinical evaluation of cervical dentin sensitivity (CDS) in patients attending general dental clinics (GDC)
and periodontal specialty clinics (PSC). J Clin Periodontol. 2002;29:118-122.
13. Chabanski MB, Gillam DG, Bulman JS, et al. Clinical evaluation of cervical dentine sensitivity in a population of patients
referred to a specialist periodontology department: a pilot study. J Oral Rehabil. 1997;24:666-672.
14. Drisko CH. Dentine hypersensitivity – dental hygiene and periodontal considerations. Int. Dent J. 2002;52(suppl 1):385-393.
15. 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.
Чувствительность зубов и отбеливание
Хатуна Чонишвили, Василий Чонишвили
Стоматологическая Клиника "Face", Тбилиси, Грузия
Р Е З Ю М Е
Целью работы являлось изучение этиологии чувствительности зубов, гиперестезии дентина и связь с отбеливанием зубов.
Опрос 120 пациентов (50 мужчин и 70 женщин в возрасте от 20-ти до 45-ти лет) показал, что гиперчувствительность дентина
более распространена, чем было принято считать. Гиперчувствительность зубов - самый частый побочный эффект, связанный
с бытовыми процедурами отбеливания. Зубные пасты обеспечивают удобную
, недорогую, и эффективную первичную защиту
от гиперчувствительности дентина.
Ключевые слова: чувствительность, отбеливание,теория гидродинамики, дентальные тубулы
270 http://www.tsmu.edu/ABRE
... On the other hand, the GPO treated with a 1.5% potassium oxalate desensitizer did not report sensitivity throughout the treatment, rejecting the null hypothesis H01. The most accepted theory for sensitivity to bleaching is that of Markowitz [28], who argues that dentin sensitivity and sensitivity to bleaching have different mechanisms of pain generation, and sensitivity to bleaching is caused through direct activation by penetration of hydrogen peroxide in the intradental nerve [29]. ...
Effect of 1.5% potassium oxalate on sensitivity control, color change, and quality of life after at-home tooth whitening: A randomized, placebo-controlled clinical trial
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Full-text available
Objective This clinical trial evaluated the effect of 1.5% potassium oxalate (PO) in controlling sensitivity and color change after at-home tooth whitening. It also evaluated the influence of PO on health-related quality of life (HRQoL) and the degree of patient satisfaction after bleaching treatment. Materials and methods Fifty volunteers were randomized into two groups (n = 25): At-home bleaching gel with 22% carbamide peroxide for 45 min + placebo gel (GP) or 1.5% PO (GPO) for 10 min. The intensity of tooth sensitivity was assessed daily through the visual analog scale. The color analysis was performed three times: baseline, 21 days, and 1 month after the last application of the whitening gel. The impact of the oral condition on the patient’s quality of life (OIDP) was used to measure the impact caused by the whitening treatment in relation to the individuals’ ability to carry out their daily activities and its influence on HRQOL. Results No difference in tooth sensitivity was observed (p > 0.05). In addition, there was no difference in color change between groups (p > 0.05). However, there was an intragroup statistical difference throughout the evaluation period (p <0.05). The OIDP analysis showed a statistical difference between the groups (p > 0.05) and there was no difference between the groups regarding the degree of satisfaction with the bleaching (p > 0.05). Conclusions The 1.5% PO was effective in preventing sensitivity and did not interfere with tooth whitening. Desensitizing therapy had a positive impact on quality of life and patient satisfaction.
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... 36 Since the hydrodynamic theory of dentin sensitivity enjoys wide acceptance as the explanation of dentinal sensation, many authors view bleaching-related pain as a form of dentin sensitivity. 37 Major differences distinguish bleaching-related pain from dentin hypersensitivity. ...
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Objectives: This study aimed to evaluate the desensitizing effect of a prefilled disposable tray containing potassium nitrate and fluoride on the self-reported tooth sensitivity (TS) and the bleaching efficacy of 40% hydrogen peroxide bleaching agent used for in-office bleaching in comparison with potassium nitrate and fluoride gel applied in a conventional-delivered tray system in an equivalence clinical trial. Methods and materials: Seventy-eight patients, with a right maxillary canine darker than A3, were selected for this single-blind (evaluators), randomized clinical trial. Teeth were bleached in two sessions with a one-week interval in between. Before in-office bleaching, the prefilled disposable tray or conventional tray containing potassium nitrate and fluoride was used for 15 minutes. Subsequently, the bleaching agent was applied in two 20-minute applications (per the manufacturer's directions) in each session. The color change was evaluated by subjective (Vita Classical and Vita Bleachedguide) and objective (Easyshade Advance Spectrophotometer) methods at baseline and 30 days after the first bleaching session. TS was recorded for up to 48 hours using a 0-10 visual analog scale. The absolute risk was evaluated by chi-square test, while the intensity of TS was evaluated by McNemar test (α=0.05). Color change in shade guide units and ΔE was analyzed by Student t-test for independent samples (α=0.05). Results: Significant whitening was observed in both groups after 30 days of clinical evaluation. The use of different methods of desensitizer in a tray did not influence the absolute risk and intensity of TS (p>0.05), although a tendency of lower risk of TS with the prefilled disposable tray containing potassium nitrate and fluoride was observed. Conclusion: The use of a prefilled disposable tray containing potassium nitrate and fluoride before the application of the in-office bleaching product did not affect the whitening degree and decreased self-reported TS when compared with a conventional-delivered tray system.
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... Regarding the tooth sensitivity, the etiology of tooth sensitivity induced by bleaching is not fully understood. Since the hydrodynamic theory of dentin sensitivity has been widely accepted as the explanation of dentinal sensation, some authors have used this theory to explain tooth sensitivity due to bleaching [58]. However, pain during and following bleaching treatment can affect intact teeth lacking dentin exposure and this is in sharp contrast with the hydrodynamic theory [59]. ...
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Article
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Objectives The aim of the study was to compare the color change produced by tray-delivered carbamide peroxide [CP] versus hydrogen peroxide products [HP] for at-home bleaching through a systematic review and meta-analysis. Materials and methods MEDLINE via PubMeb, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature database (LILACS), Brazilian Library in Dentistry (BBO), and Cochrane Library and Grey literature were searched without restrictions. The abstracts of the International Association for Dental Research (IADR) and unpublished and ongoing trial registries were also searched. Dissertations and theses were explored using the ProQuest Dissertations and Periodicos Capes Theses databases. We included randomized clinical trials that compared tray-delivered CP versus HP for at-home dental bleaching. The color change in shade guide units (SGU) and ΔE were the primary outcomes, and tooth sensitivity and gingival irritation were the secondary outcomes. The risk of bias tool of the Cochrane Collaboration was used for quality assessment. Data After duplicate removal, 1379 articles were identified. However, only eight studies were considered to be at “low” risk of bias in the key domains of the risk bias tool and they were included in the analysis. For ΔE, the standardized mean difference was −0.45 (95 % CI −0.69 to −0.21), which favored tray-delivered CP products (p < 0.001). The color change in ΔSGU (p = 0.70), tooth sensitivity (p = 0.83), and gingival irritation (p = 0.62) were not significantly different between groups. Conclusions Tray-delivered CP gels showed a slightly better whitening efficacy than HP-based products in terms of ΔE, but they were similar in terms of ΔSGU. Both whitening systems demonstrated equal level of gingival irritation and tooth sensitivity. Clinical significance Tray-delivered CP gels have a slightly better whitening efficacy than HP-based products in terms of ΔE. This should be interpreted with caution as the data of ΔSGU did not show statistical difference between the products.
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... The etiology of bleaching-induced TS is not fully understood. Since the hydro- dynamic theory of dentin sensitivity has been widely accepted as the explanation of dentinal sensation, some authors have used this theory to explain bleaching-induced TS (Swift 2005 ). However, pain during and following bleaching treatment can affect intact teeth lacking dentin exposure and this is in sharp contrast with the hydrodynamic theory (Markowitz 2010 ). ...
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This book reviews the evidence relating to the mechanisms, clinical efficacy, safety/toxicity, and clinical application of tooth whitening techniques and materials. All clinical techniques are profusely illustrated step by step. The book is divided into four parts, the first of which explains how tooth whitening with peroxides works and examines the overall safety of peroxides and potential complications. The findings of clinical trials with peroxide-based materials for clinical practice are then examined, with discussion of a wide range of issues in at-home whitening and in-office whitening. The third part focuses on the techniques of enamel microabrasion and resin infiltration, which entail removal of a microscopic layer of enamel and may be used to improve tooth color either alone or in combination with peroxides. The concluding part includes a variety of informative clinical cases using combined bleaching and restorative techniques for discolored teeth. Tooth Whitening — An Evidence-Based Perspective will be of interest for dentists, dental hygienists, dental assistants, and others with an interest in the subject
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... 21 Many authors have viewed TWIS as a form of dentin hypersensitivity. 22 However, this condition differs markedly from TWIS. For example, in contrast to dentin hypersensitivity, TWIS can occur in the absence of a provoking stimulus, and it is not necessarily associated with exposed dentinal tubules. ...
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Dentin hypersensitivity: A review
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Full-text available
  • Jun 2010
Dentin hypersensitivity may be defined as brief, sharp pain arising from exposed dentin. It occurs typically in response to chemical, thermal, evaporative or osmotic stimuli and cannot be explained as arising from other dental defects or pathology. The primary cause of dentin hypersensitivity is loss of enamel on the tooth crown and gum recession exposing the tooth root, with subsequent loss of cementum. The exact mechanism of dentin hypersensitivity is still being researched, but many accept the hydrodynamic theory as an explanation of the symptoms. A Hong Kong survey found a prevalence of dentin hypersensitivity greater than 60% among patients attending a dental hospital; lower incisors were the most commonly affected teeth. Studies have found that many dental clinicians have misconceptions about dentin hypersensitivity and lack the confidence to manage this oral health problem. It is important that Hong Kong dentists know how to diagnose dentin hypersensitivity and provide appropriate treatments and recommendations for patients. Many treatments have been proposed but no universally accepted or highly reliable desensitizing agent or treatment has been identified. When a patient presents with symptoms that may be attributed to dentin hypersensitivity, a thorough clinical examination should be carried out to rule out other likely causes before making a diagnosis and embarking on treatment. Depending on the identified cause, a combination of individual oral health behavior instructions, use of self-care products, and professional treatment may be required to manage the problem.
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Dentine hypersensitivity - dental hygiene and periodontal considerations
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  • Jan 2002
Removal of cementum and exposure of dentinal tubules leading to the symptoms of dentine hypersensitivity may occur through incorrect oral hygiene techniques by patients and by instrumentation of the root surface by dental professionals in the management of periodontal diseases. This paper discusses both homecare and professional management of the 'open dentinal tubule' as well as techniques to minimise the onset of hypersensitivity. An assessment of the clinical support for various therapeutic agents is discussed.
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Dentine hypersensitivity - Dental hygiene and periodontal considerations
Article
Removal of cementum and exposure of dentinal tubules leading to the symptoms of dentine hypersensitivity may occur through incorrect oral hygiene techniques by patients and by instrumentation of the root surface by dental professionals in the management of periodontal diseases. This paper discusses both homecare and professional management of the 'open dentinal tubule' as well as techniques to minimise the onset of hypersensitivity. An assessment of the clinical support for various therapeutic agents is discussed.
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Oral hygiene and periodontal considerations in preventing and managing dentine hypersensitivity
Article
The onset of dentine hypersensitivity is almost exclusively associated with exposed den- tine due to tooth wear or to gingival recession, or at times both tooth wear and gingival recession. Recession secondary to periodontal disease is thought to be related to poor oral hygiene, while overzealous, incorrect tooth brushing may be responsible for the recession associated with good oral hygiene. However, the aetiology of gingival reces- sion is multifactorial and is therefore unlikely to be caused by any single factor. Dentine hypersensitivity is preceded by gingival recession and exposure of the root surface. Acidic and erosive foods and drinks combined with vigorous tooth brushing and highly abrasive dentifrices are likely to elicit dentine hypersensitivity. Successful treatment of patients with mild sensitivity and minimal recession can be accomplished in most cases simply by correcting destructive oral hygiene habits in conjunction with use of a desensitising den- tifrice. Moderate to severe dentine hypersensitivity in the presence of gingival recession ≥1 mm usually requires a surgical root coverage procedure with or without daily use of desensitising toothpastes and/or professional application of desensitising agents, dentine bonding materials, or cervical restorations.
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Dentine hypersensitivity: New perspectives on an old problem
Article
  • Oct 2002
Dentine hypersensitivity is a prevalent, painful condition of the teeth. Despite the fact that the accuracy of the terminology is questionable and other terms have been proposed, 'dentine hypersensitivity' has been in long-term use and is, therefore, the preferred term. In dentine hypersensitiv-ity, lesions exhibit patent tubules at the exposed dentine surface and appropriate stimuli trigger pulpal nerves via a hydrodynamic mechanorecep-tor mechanism to produce a typically short, sharp, painful response. This accepted definition of the condition indicates the need to consider a differential diagnosis. This review will consider evidence that dentine hyper-sensitivity is a tooth-wear phenomenon characterised predominantly by erosion, which both exposes dentine and, more importantly, initiates the lesions. Abrasion caused by brushing teeth with toothpaste appears to be a secondary aggravating factor, which may even act in synergy with erosion. Gingival recession probably accounts for most dentine exposure at the gingival margin, but the process is poorly understood. Management strate-gies, which take into account aetiological and predisposing factors, rather than treatment alone, should be considered. There is little clinical research on many aspects of the aetiology and particularly on the management of the condition. In 1982, dentine hypersensitivity was described as an enigma, because it was frequently encountered yet poorly understood 1 . Some 20 years later, it is worthwhile reconsidering the statement, as the title of a recent article seems to suggest 2 . This review will discuss the terminology, definition, epidemiology, mecha-nisms, anatomy, aetiology and management of the condition. It is hoped that it will demonstrate that, although dentine hypersensitivity is not the enigma it once was, there is still much to be discovered about the condition, its prevention and its management.
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Prevalence and distribution of cervical dentine hypersensitivity in a population in Rio de Janeiro, Brazil
Article
The prevalence, distribution and possible causal factors of cervical dentine hypersensitivity were studied in a population from a Marine Dental Clinic in the city of Rio de Janeiro, Brazil. A total of 635 patients were examined for the presence of cervical dentine hypersensitivity by means of a questionnaire and intraoral tests (air and probe stimuli). There were 157 patients (25%) reporting to have hypersensitive teeth, but only 108 patients (17%) were diagnosed as having cervical dentine hypersensitivity. The prevalence of hypersensitivity was higher among females than males, but this difference was not statistically significant. Most females with hypersensitivity were aged 20-49 and most males were aged 40-59. Incisors and premolars had the highest prevalence of dentine hypersensitivity to air and probe stimuli, while molars had the lowest. The presence and history of dentine hypersensitivity were positively correlated with previous exposure to periodontal treatment. Only a few of the patients who claimed to have dentine hypersensitivity had tried treatment with desensitizing toothpastes or sought professional help.
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Dentine hypersensitivity
Article
  • Jun 1987
Based on the hydrodynamic theory for stimulus transmission across dentine, it would be logical to conclude that teeth exhibiting the clinical symptoms referred to as dentine hypersensitivity should have dentinal tubules open at the root surface and patent to the pulp. With the exception of studies on cut dentine, there is little direct evidence to support this conclusion. In this study, caries-free teeth with exposed cervical root areas scheduled for extraction which were classified as non-sensitive or hypersensitive after suitable stimulation were examined by scanning electron microscopy. Hypersensitive teeth showed highly significantly increased numbers of tubules per unit area (approximately 8 X) compared with non-sensitive teeth. Tubule diameters were significantly wider (approximately 2 X) in hypersensitive compared to non-sensitive teeth. The number of teeth showing the penetration of methylene blue through the zone of exposed cervical dentine was larger and the depth of penetration greater in hypersensitive teeth compared to non-sensitive teeth. The results provide further evidence that stimulus transmission across dentine in hypersensitive teeth is mediated by a hydrodynamic mechanism. An understanding of factors which open dentinal tubules would seem important if attempts to prevent or treat dentine hypersensitivity are to be successful.
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