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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 778-783
Comparative evaluation of two commercially available desensitizing agents for the treatment of dentinal hypersensitivity


Department of Periodontology, D.A.V. (C) Dental College, Yamuna Nagar, Haryana, India

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Date of Submission02-Mar-2009
Date of Decision16-Jun-2010
Date of Acceptance01-Jul-2010
Date of Web Publication3-May-2013
 

   Abstract 

Aims: A randomized clinical trail was designed to compare the efficacy of two commercially available desensitizing agents (fluoride varnish containing 6% sodium fluoride and 6% calcium fluoride and a gel containing 6% potassium nitrate and 0.11% fluoride ions) in the treatment of dentinal hypersensitivity.
Settings and Design: Randomized clinical trial.
Materials and Methods: Twenty-one patients were selected. Subjects were evaluated using three different stimuli, i.e., tactile test, air blast test and cold water test. They were then randomly divided into two groups. Patients in group I were treated with fluoride varnish and group II patients were treated with gel containing 6% potassium nitrate and 0.11% fluoride ions. The patients were examined at baseline, immediately after application of the agent, at 1 week, 1 month and 3 months interval.
Statistical Analysis: Statistical analysis was done using unpaired "t" test, paired "t" test and Chi-square test with Yate's correction.
Results: The results were analyzed; it was seen that patients treated in group I showed significantly better results compared to group II patients at 1 month and 3 months interval. Teeth which required repeat dose and those which did not require repeat dose were comparable in number.
Conclusions: Both the agents showed significant reduction in sensitivity at all time intervals compared to baseline. A comparatively significant reduction in sensitivity score was seen in patients treated with fluoride varnish and it appeared to be more effective in providing long-term relief against all the three test stimuli. Teeth with initial high sensitivity score required repeat doses, which was comparable for both the groups.

Keywords: Clinical trials, dentinal hypersensitivity, desensitizing agents, fluoride varnish, potassium nitrate

How to cite this article:
Pandit N, Gupta R, Bansal A. Comparative evaluation of two commercially available desensitizing agents for the treatment of dentinal hypersensitivity. Indian J Dent Res 2012;23:778-83

How to cite this URL:
Pandit N, Gupta R, Bansal A. Comparative evaluation of two commercially available desensitizing agents for the treatment of dentinal hypersensitivity. Indian J Dent Res [serial online] 2012 [cited 2020 Nov 28];23:778-83. Available from: https://www.ijdr.in/text.asp?2012/23/6/778/111259
The practice of excellent oral physiotherapy is central to the ultimate goal in the prevention of caries and periodontal disease; however, it is very discouraging to the patient and most disheartening to the dentist to insist upon cleanliness when it is painful to perform the necessary procedures. The common cause of pain is dentinal hypersensitivity, which may occur due to loss of enamel, as in attrition, abrasion, and erosion or as a result of recession. [1] Patient is unable to maintain satisfactory plaque control, thus reducing the patient compliance and leading to a vicious cycle which further complicates the condition. [1] Numerous agents have been used to treat dentinal hypersensitivity since thousands of years. These include potassium oxalate, [2] sodium fluoride, [3] potassium nitrate, [4] restorative resins, [5] dentin bonding agents, [3] etc. Use of fluoride as a topical desensitizing agent has been reported since 1941 by Lukomsky. [6] Fluoride application leads to formation of calcium fluoride and, to some extent, formation of fluoroapatite also occurs, thus mechanically blocking the transmission of stimulus to the pulp. [7],[8]

Studies have also shown the beneficial effect of potassium nitrate as a desensitizing agent. Potassium nitrate was accepted as a desensitizing agent by American Dental Association (ADA) in 1986. The mechanism of action of potassium nitrate is controversial; it appears to be neural type [9] or also said to posses occlusive properties. [10] In a study, it was seen that potassium cation which is the active part in the agent, tends to concentrate in the interior of dentinal tubules, causing depolarization of the cellular membrane of the nerve terminal and a refractory period with decreased sensitivity. [9],[10]

This study was done to compare the efficacy of a gel containing 6% potassium nitrate and 0.11% fluoride ions with a solution 6% calcium fluoride and 6% sodium fluoride in alleviating dentinal hypersensitivity.


   Materials and Methods Top


Patients recruited for the study were selected from the out-patient department of periodontics of D.A.V. (C) Dental College and Hospital, Yamuna Nagar, Haryana, India.

Subject eligibility

The candidates were selected irrespective of their sex, age, caste, religion and socioeconomic status. Their age ranged between 20 and 65 years. Participants who gave the history of sensitivity to hot/cold, sweet and sour food were examined using light tactile response along the cervical margin of the teeth. Teeth found to be hypersensitive with dental explorer were then measured using other efficacious measurements. All the participants signed informed consent forms.

Patients reporting with the history of sensitivity to hot/cold, sweet/sour, mechanical stimuli on at least two teeth, with good general health of the patient and no known allergy to test material were included in the study. Exclusion criteria included were the presence of carious tooth, restoration or cracked enamel, patients using desensitizing agent/dentifrices, those having a history of significant chronic systemic disease or taking antibiotics and anti-inflammatory drugs, pregnant and lactating women and patients who had undergone periodontal surgery within the last 6 months.

A total of 294 teeth from 21 patients were included in the study. They were randomly divided into two groups: group I comprised 147 teeth treated using fluoride varnish (containing 6% calcium fluoride and 6% sodium fluoride) and group II comprised 147 teeth treated with a gel containing 6% potassium nitrate and 0.11% fluoride ions.

Clinical examination

Enrolled patients were evaluated using the three test stimuli. The test site was isolated using cotton rolls and the stimuli were applied. The tests used were the following. Tactile test: To test the affected area, a mechanical stimulation was done along the cervical area carefully with help of a sharp dental explorer (17/23). The explorer was passed lightly across the affected area, perpendicular to the long axis of the tooth. The test was repeated thrice before scoring by using discomfort scale and then the reading was noted. [11] Air blast test: A blast of air from the dental syringe at 60-lb/inch [2] pressure was applied onto the affected area of the tooth isolated with cotton rolls, for 1 second from a distance of 10 mm (measured by taping scale to the dental syringe). [11] The score was recorded using the discomfort scale. Cold water test: Ice-cold water was freshly melted within 1-2 minutes and it was then filled in pre-cooled 1 ml disposable syringe. After isolating the specific tooth, 0.2 ml of this ice-cold water was slowly poured from the syringe on to the suspected tooth surface. [11]

All the three tests were applied in the ascending order of discomfort, i.e., tactile test (least disturbing) then air blast test and at last cold water test (most disturbing). [11] The stimuli were applied in the same order, at a time interval of 5 minutes each, at every recall visit. [3]

The patient response was recorded using the following scale:

0 - No significant discomfort or awareness of stimulus;
1 - Discomfort, but no severe pain;
2 - Severe pain during application of stimulus;
3 - Severe pain during and after application of stimulus.

Values of 2 and 3 were regarded as indicating hypersensitivity. [3],[12] Using the sensitivity measure, those teeth were selected which showed a score of ≥2 for at least two test stimuli. The discomfort score was measured and recorded in a tabulated form to maintain a record. Improvement was defined as a change in score from 2 or 3 to 1 or 0, indicating the improvement of the hypersensitive symptoms and disappearance of symptom was indicated when the value changed from 2 or 3 to 0. [3]

Agents and procedures

Group I

The teeth to be treated were isolated with cotton rolls, cleaned and dried with cotton pledges. Fluoride solution (Bifluorid 12, VOCO Company, Germany) must be shaken well before each use. The solution was dropped on the brush or preferably on Pele Tim foam pellets (provided by the manufacturer). The surface should be thinly painted. Adequate dilution should be done, if the solution seems viscous. For 10-20 seconds, the varnish applied should be allowed to dry, using air syringe. For hypersensitive teeth, treatment should be repeated two to three times at an interval of 7 days.

Group II

The teeth selected were isolated. The gel form (Soothe, SDI Company, Australia) was applied with a cotton pellet and rubbed onto the affected area for 2 minutes. The patient was instructed not to rinse for at least 10 minutes after the application.

The teeth were evaluated immediately after treatment (not using the tactile method), at 1 week interval, at 1 month and 3 months, using the three stimuli mentioned above. The use of any desensitizing agent in any form was not allowed during the study period.

In case of failure at 1 week interval, the affected teeth were retreated with the same drug as before and evaluated further. The treatment was considered as a failure, when the recurrence of hypersensitivity at a score of 2 or higher, was noted for any two of the three test stimuli. [3]

Data analysis

The primary efficacy measurements used in this study included the change in the discomfort score, mean change in the discomfort score and the number of teeth which required repeat dose and those which did not require repeat dose. The statistical analysis was performed using paired "t" test, unpaired "t" test and Chi-square test with Yate's correction. The null hypothesis was that there was no treatment group difference. The alternative hypothesis was that a difference existed between the two groups. All the statistical tests were two-tailed, conducted at a significance level of ≤0.05.


   Results Top


The statistical analysis was performed using paired "t" test, unpaired "t" test and Chi-square test with Yate's correction.

The mean discomfort score was compared using unpaired "t" test. It was seen that there was no statistically significant difference between groups I and II at baseline and 1 week interval. Statistically significant difference was seen at 1 month and 3 months interval in all three test stimuli [Table 1], [Figure 1].
Figure 1: Bar graph showing mean discomfort score comparison (Groups 1 and 2)

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Table 1: Comparison of mean discomfort score at different time intervals between groups I and II

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The number of teeth which required repeat dose and which did not require repeat dose was calculated using Chi-square test. The difference between the two groups was found to be statistically nonsignificant. At 3 months, the difference between groups I and II in all the three tests were statistically nonsignificant [Table 2], [Figure 2].
Figure 2: Bar graph showing comparison between group 1 and 2 at 3 months

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Table 2: Comparison between teeth of groups I and II that required repeat dose and that did not require repeat dose

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When mean discomfort baseline scores in each group for teeth requiring and for those not requiring retreatment were compared, the results were highly significant for the entire three test stimuli.


   Discussion Top


Dentinal hypersensitivity is described clinically as an exaggerated response to non-noxious sensory stimuli. It is a painful response of a tooth to different stimuli such as dental brushing, food or thermal changes. Various theories proposed are direct receptor theory, [13] gate control theory, [14] transducer theory, modulation theory and hydrodynamic theory. Currently, hydrodynamic theory is the most widely accepted theory. [15]

Based on the hydrodynamic theory, the use of fluoride as a desensitizing agent was evaluated. In this study, the in office application of agents were done because they may be far more effective and this also allows professional control and monitoring, which enhances patients' satisfaction. The teeth in group I were treated with fluoride varnish applied topically. Fluoride varnish mainly acts by its ability to form calcium fluoride and, to some extent, by formation of fluoroapatite, thus blocking the transmission of stimuli to the pulp. In a study done by Shen and Jaana, [16] it was found that after fluoride application, a significant elevation of fluoride level in whole saliva occurred with Bifluorid 12. Due to the presence of significant amount of fluoride in saliva, high fluoride uptake in the surface and sub surface layer has been reported by Gedalia, et al.[17] Ehrlich, et al.[18]

In group I at baseline measurement (T1), the number of teeth which were not sensitive for tactile test was 6.8%, and it was 0% for air blast test and 0% for the cold water test. This increased to 72.8, 64.6 and 63.9% after 3 months for tactile, air blast and cold water tests, respectively, as shown in [Table 3]. In an earlier study, 70% reduction was reported in the sensitivity over a period of 4 weeks. [8]
Table 3: Discomfort scores at different time intervals in Group I

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The highly significant decrease in the discomfort score indicates the long lasting effect of fluoride varnish in decreasing dentinal hypersensitivity. The results shown in the study were in accordance to the studies done by Tarbet, et al., [12] Clark, et al.[7] and Kishore, et al.[19] There was a significant reduction of sensitivity in the test group in both cold air test and electric stimulus on 3 rd and 7 th days. Kishore, et al.[19] conducted a study to evaluate the efficacy of many desensitizing agents. They concluded that 10% strontium chloride, 2% sodium fluoride and formalin 40% showed significant reduction in dentinal sensitivity, whereas 5% potassium nitrate solution did not.

Clark [8] used 5% sodium fluoride solution (Duraphat) along with a desensitizing agent and concluded that fluoride when applied topically was retained for hours, thereby enhancing fluoride uptake while providing a temporary coating on the affected tooth surfaces. The coating brings an immediate relief and this is primarily responsible for the high level of fluoride uptake that is known to occur. Ehrlich, et al.[18] did an Scanning Electron Microscopic study; after a single topical application of 2% acidulated sodium fluoride, they showed precipitations on the peritubular dentin, indicating a long lasting effect of topical fluoride in reducing dentinal hypersensitivity.

In group II, the agent used was a gel containing 6% potassium nitrate and 0.11% fluoride ions. Gel form was preferred because it allowed maximum adherence to the oral surfaces and provided total precision in its application. The gel form thus allowed gradual liberation of potassium nitrate in the area to be treated. [20] It was found by Kim [21] that high concentration of potassium ions was responsible for the sustained depolarization of the sensory nerve, leading to a phenomenon called as axonal accommodation.

Frechoso, et al.[20] did a randomized study comparing the efficacy of two bioadhesive gels containing 5% and 10% potassium nitrate. They confirmed the efficacy of 10% potassium nitrate gel, as it was more effective in less time. The gel used contained 6% potassium nitrate, which could be more efficacious in reducing dentinal hypersensitivity compared to the use of lower concentration of potassium nitrate.

In group II at baseline measurement (T1), the number of teeth, which were not sensitive for tactile test, was 3.4%, while it was 0% for air blast test and 0% for the cold water test, which increased to 50.3%, 51.7% and 49.66% after 3 months for tactile, air blast and cold water test, respectively, as shown in [Table 4]. The results obtained in a study done by Nagata, et al.[22] showed 70-82% reduction in sensitivity in all the three tests, i.e. tactile test, cold stimulus test and subjective assessment test. The results got in the present study do not coincide with the above mentioned, may be due to the application of the agent twice daily.
Table 4: Discomfort scores at different time intervals in Group II

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When the mean discomfort score was compared at different time intervals, both the groups showed comparable results in all the three tests, except for comparably significant improvement seen in cold test immediately after application in group II compared to group I. It may be due to high concentration of potassium nitrate combined with fluoride ions. In group I, the mean discomfort scores at 1 month for tactile test, air blast test and cold water test were 0.70 ± 0.72, 0.80 ± 0.71, 0.74 ± 0.60, respectively, and after 3 months the values changed to 0.33 ± 0.59, 0.41 ± 0.61 and 0.41 &# 77; 0.58, respectively. While in group II, the improvement seen at 1 month for all the three tests were 0.98 ± 0.75, 1.04 ± 0.73, and 090 ± 0.76, respectively, and after 3 months the values changed to 0.61 ± 0.70, 0.63 ± 0.73, and 0.57 ± 0.66, respectively. The significant difference seen was probably due to the immediate and long-term relief produced by the topical fluoride application [Figure 1].

The teeth, which required repeat dose and which did not require repeat dose for both the groups did not show statistically significant difference. The teeth, which showed more sensitivity scoring at baseline required repeat dose, as shown in [Table 2]. These findings are in accordance to the study done earlier [23] [Figure 2].

Hence, from this study it was observed that the agents used are potentially effective methods of managing the dentinal hypersensitivity. Among the two agents, we found fluoride varnish to be slightly more potent in providing long-term relief from dentinal hypersensitivity against all the three test stimuli.


   Conclusions Top


The conclusions drawn from the study are the following: Both the agents, fluoride varnish and the gel containing 6% potassium nitrate and 0.11% fluoride ions, revealed significant reduction in the sensitivity at different time intervals to all the three test stimuli when compared to the baseline. Hence, they both can be considered as potential desensitizers. From the two desensitizing agents, fluoride varnish appeared to be more effective in providing long-term relief against all the three test stimuli.

 
   References Top

1.Dowell P, Addy M, Dummer P. Dentine hypersensitivity: Aetiology, differential diagnosis and management. Br Dent J 1985;158:92.  Back to cited text no. 1
    
2.Muzzin KB. Effect of potassium oxalate on dentinal hypersensitivity n Vivo. J Periodontol 1989;3:151-8.  Back to cited text no. 2
    
3.Singhal P, Gupta R, Pandit N. 2% sodium fluoride -iontophoresis compared to a commercially available desensitizing agent. J Periodontol 2005;76:351-7.  Back to cited text no. 3
    
4.Hodsoh MA. Superior desensitizer-potassium nitrate. J Am Dent Assoc 1974;38:831-2.  Back to cited text no. 4
    
5.Javid B, Barkhordar RA, Bhinda SV. Cyanoacrylate- a new treatment for hypersensitive dentin and cementum. J Am Dent Assoc 1987;114:486-8.  Back to cited text no. 5
    
6.Lukomsky EH. Fluorine therapy for exposed dentin and alveolar atrophy. J Dent Res 1941;20:649.  Back to cited text no. 6
    
7.Clark DC. A review of fluoride varnish: An alternative topical fluoride treatment. Community Dent Oral Epidemi1982;10:117-23.  Back to cited text no. 7
    
8.Clark DC, Hanlry S, Geoghean S, Vinet D. The effectiveness of fluoride varnish and desensitizing toothpaste in treating dentinal hypersensitivity. J Periodontal Res 1985;20:212-9.  Back to cited text no. 8
    
9.Pashley DH. Dentin permeability, dentin sensitivity, and treatment through tubule occlusion. J Endod 1986;12:465-74.  Back to cited text no. 9
    
10.Markowitz D, Kim S. The role of selected cations in the desensitization of the intradental nerves. Proc Finn Dent Soc 1992;88:39-54.  Back to cited text no. 10
    
11.Clark GE, Troullous ES. Designing hypersensitivity clinical studies. Dent Clin North Am 1990;34:531-44.  Back to cited text no. 11
    
12.Tarbet WJ, Silverman G, Stolman JM, Fratarcangelo PA. An evaluation of two methods for the quantitation of dentinal hypersensitivity. J Am Dent Assoc 1979;98:914-8.  Back to cited text no. 12
    
13.Scott D Jr, Steward GG. Excitation of the dental receptor of cat by heat and chemical agents. Oral Surg Oral Med Oral Pathol 1955;20:784-94.  Back to cited text no. 13
    
14.Seltzer S, Bender IB. The nerve supply of the pulp and pain perception. The dental pulp. Philadelphia: J. B. Lippincot.Co; 1975. p. 131-51.  Back to cited text no. 14
    
15.Parveen C. Comprehensive review article-dentin hypersensitivity. J Indian Dent Assoc 1989;60:85-91.  Back to cited text no. 15
    
16.Shen C, Jaana AG. Assessing fluoride concentration uniformity and fluoride release from three varnishes. J Am Dent Assoc 2002;133:176-82.  Back to cited text no. 16
    
17.Gedalia I, Brayer L, Kalter N. The effect of fluoride and strontium application on dentin: In Vivo and in Vitro studies. J Periodontol 1978;5:269-72.  Back to cited text no. 17
    
18.Ehrlich J, Hochman I, Tal M. Residual fluoride concentrations and scanning electron microscopic examination of root surfaces of human teeth after topical application of fluoride in vivo. J Dent Res 1975;4:897-900.  Back to cited text no. 18
    
19.Kishore A, Mehotra KK, Siambi CG. Effectiveness of desensitizing agents. J Endod 2002;1:34-5.  Back to cited text no. 19
    
20.Frechoso C, Menendez M, Guisasola C, Arregui I, Tejerina JM, Sieilsa A. Evaluation of the efficacy of two potassium nitrate bioadhesive gels (5% and 10%) in the treatment of dentinal hypersensitivity: A randomized clinical trail. J Clin Periodontol 2003;30:315-20.  Back to cited text no. 20
    
21.Kim S. Hypersensitive teeth: Desensitization of pulpal sensory nerves. J Endod 1986;12:482-5.  Back to cited text no. 21
    
22.Nagata T, Ishida H, Shinohara H, Nishikawa S, Kasahara S, Wakano Y, et al. Clinical evaluation of potassium nitrate dentifrices for the treatment of dentinal hypersensitivity. J Clin Periodontol 1994;21:217-21.  Back to cited text no. 22
    
23.Carlo GT, Sebastain GC, Seyrek SK. An evaluation of iontophoresis application of fluoride for tooth desensitization. J Am Dent Assoc 1982;105:452-4.  Back to cited text no. 23
    

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Correspondence Address:
Nymphea Pandit
Department of Periodontology, D.A.V. (C) Dental College, Yamuna Nagar, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111259

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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