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What You Don't Know May Hurt Them
Woman Dentist Journal
September 2007
by Sarita Arteaga, DMD, FAGD
During the course of a busy day, your patients rarely think about an essential part of daily life — their teeth. Teeth largely function without notice. Only when certain foods, beverages or dental treatments result in tooth sensitivity do your patients become painfully aware of them. According to recent data, Dentin hypersensitivity is a condition that affects 22 percent of American adults — approximately one in five people.1 Your patients may not be aware of the common triggers of tooth sensitivity, and for this reason, cannot take preventive measures to protect their teeth. This can result in unexpected discomfort that makes teeth suddenly and painfully be noticed. Thus, it is essential that dental professionals are aware of common sensitivity triggers, and how discomfort can be lessened or eliminated with many preventive measures.
Common triggers of sensitivity
As explained by the hydrodynamic theory, dentin hypersensitivity occurs when open tubules on the tooth surface are exposed to sensitivity-inducing stimuli. This includes foods and beverages that are cold, hot, sweet or sour. It also includes cold air, and aggressive brushing, or flossing. Coldness is, by far, the most common cause of sensitivity.2 When stimuli make contact with a tooth surface with open tubules, it causes a rapid outward flow of fluid into the dental tubules and a pressure change across the dentin. This is perceived as pain by the patient. The amount of exposed dentin and tubule system is a direct indicator of the degree of sensitivity. This indicates that patients with advanced gingival recession are particularly susceptible.
Gingival recession, or the exposure of the root surface by an atypical shift in the gingiva, results in larger areas of exposed tubules. Overzealous brushing, sometimes called "toothpaste abuse," can cause gingival recession. This leads to greater sensitivity to stimuli.3 In addition, a history of family members with gingival problems may increase the likelihood that patients exhibit the recession. Only circumstantial evidence exists to explain why certain patients have greater gingival recession than others, but at least one study reports that gingival recession predisposes a person to sensitivity.4
Erosion-Induced Sensitivity
Erosion and abrasion are the result of different behaviors, but each can result in tooth wear and hypersensitivity. Erosion, defined as the pathological wear of teeth from a chemical dissolving process, results from the large consumption of acidic fruits and diet soft drinks. It has been suggested that acidic changes in the tooth surface, also known as tooth wear, may be considered a risk factor for dentin hypersensitivity. This may occur when acidic agents start to cause demineralization of the enamel surface. The enamel surface then is more easily brushed away, and leaves dentinal tubules exposed to outside stimuli.5
Causes of erosion
Acidic fruits and juices contribute to erosion and surface loss, particularly if they are consumed to excess or consumed inappropriately (i.e., sipping acidic juices over prolonged periods of time or swishing the juices around the mouth). Oranges, vinegar-based salad dressings, and most fruit juices are high in acid content. Drinking soda or sports drinks can also increase the risk of erosion. Soda can be highly acidic, and may have pH levels as low as 2.4.6 Under normal conditions, the pH level in the mouth is 6.2-7.0. Levels drop rapidly following intake of acidic foods and beverages, thereby increasing the potential of enamel demineralization. Enamel demineralization occurs when pH levels fall less than approximately 5.7 while root surface demineralization occurs when levels are less than 6.0 to 6.7.7 Acidic foods and beverages are likely to cause pH levels in the mouth to drop to these levels.8
Abrasion-induced sensitivity
Abrasion is defined as the pathological wear of teeth from a mechanical or rubbing process. Over time, wear and incessant rubbing diminishes the enamel or cementum surface, resulting in a larger area of exposed tubules and greater tooth sensitivity. The two most common causes of abrasion are toothpaste abuse and bruxism. Bruxism is the habit of grinding the teeth together when not eating. Studies show that all toothpastes can cause abrasion, regardless of the type of brush that is being used.9 Time, speed, and pressure of brushing determine the rate of abrasion. Repeated tooth-on-tooth contact in patients with bruxism erodes the enamel surface Anterior teeth exhibit the greatest wear.
Sensitivity from whitening treatments
In-office whitening procedures comprise a large part of today's general dentistry practice. In addition, the number of patients who whiten their teeth at home using OTC products is growing significantly.10 Patients may not know that dentin hypersensitivity is the primary side effect of any whitening treatment. Some 55 to 75 percent of patients experience sensitivity from the effects of repeated bleach applications.11 Typically, pain begins early in the whitening process, and disappears completely a day or two after the whitening regimen is completed.12 But some patients experience pain throughout the whitening process. While patients may experience whitening-related sensitivity, it appears often to be connected to patients who have a history of dentin hypersensitivity. Thus, dentists should ask patients who are considering an at-home or in-office whitening procedure if their teeth are sensitive to hot or cold stimuli.13
Diagnosing dentin hypersensitivity
Though dentin hypersensitivity is a highly prevalent condition, diagnosis can be difficult because many patients do not complain of discomfort to their dentist. In fact, some patients may consider sensitivity a mild annoyance, and perhaps not worthy of their dentist's attention.14 Patients may also perceive treatment to be more unpleasant or expensive than the condition. Adding to the challenge of diagnosis is the fact that dentin hypersensitivity is — by nature — an intermittent condition, Those suffering may not be experiencing pain at the time of their dental visit. By proactively questioning patients to see if they have experienced unusual tooth sensitivity since their last visit, the dentist can discuss treatment options that may help ease their discomfort. In addition, being aware of the demographics of people who are most likely to experience sensitivity helps to identify at-risk patients. People of all ages suffer from dentin hypersensitivity, but those who are ages 20 to 50 report the condition more frequently. This is particularly true for females, and for people who are ages 20 to 30.15
Treatment options
Once dentin hypersensitivity is diagnosed, a variety of at-home and in-office treatment options are available. Patient-applied products should be recommended as a first line of treatment, and can be used in conjunction with in-office treatments. While effective in providing immediate relief by occluding dental tubules, in-office treatments can be brushed away and may not be effective for long-term relief when used alone. An anti-sensitivity toothpaste containing 5 percent potassium nitrate and fluoride, such as Sensodyne® (GlaxoSmithKline Consumer Healthcare), Colgate® Sensitive Plus Whitening (Colgate-Palmolive), or Crest® Sensitivity Protection (Procter and Gamble), reduces intradental nerve activity and interrupts pain impulses, thereby lessening pain.16 Patients should be advised to brush with an antisensitivity toothpaste twice a day, and can continue use of it daily for long-term relief.
What you know can help them
By becoming aware of diet and lifestyle risk factors, dental professionals can help patients avoid painful tooth sensitivity and suggest effective solutions that have been proven to work. Among these solutions is antisensitivity toothpaste for current sufferers. By identifying the most at-risk patients, and making it a priority to question all patients about potential sensitivity symptoms, you can pinpoint sensitive patients and communicate treatment options soon after they first experience discomfort. Knowledge of the etiology, risk factors, and treatments for dentin hypersensitivity is the first step in helping patients live in comfort and in keeping teeth a comfortable, unnoticed part of daily life — just as they should be.
Dr. Sarita Arteaga, DMD, FAGD, is a three-year high school graduate from St. Catharine Academy in the Bronx, N.Y., and a graduate from New York University with a B.A. degree in biology. After attending the University of Connecticut School of Dental Medicine, she received a D.M.D. degree and then completed a General Practice Residency at Bronx Municipal/Albert Einstein hospitals in the Bronx. In 1990, Dr. Sarita returned to Connecticut and worked as an associate in a private dental practice. In 1995, she became an assistant clinical professor at the University of Connecticut. She has been teaching and treating patients at the UCONN Health Center to date. Sarita attained a Fellowship from the Academy of General Dentistry, and is a member of the Hispanic Dental Association, Academy of General Dentistry, National Dental Association, and American Dental Education Association.
Dr. Sarita has served on the Board of Trustees of the Hispanic Dental Association for two years, and has been a two-year member of the association's Annual Meeting Planning Committee. She has also served on the Silent Auction, and Recruitment and Retention committees. She is a faculty advisor for the combined Student National Dental Association/Hispanic Student Dental Association, and serves on the dental school's Admissions Committee.
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