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Dentine hypersensitivity - Guidelines for the management of a common oral

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Article  in  Dental update · September 2013

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Generic Heading: Dentine Hypersensitivity or Sensitive teeth

Title: Dentine Hypersensitivity - Guidelines for the Management of a Common

Oral Health Problem

Authors:

David G Gillam BA, BDS, MSc, DDS, FRSPH, FHEA, Clinical Lecturer in Restorative Dentistry,

Centre for Adult Oral Health, Institute of Dentistry, Queen Mary's School of Medicine &

Dentistry, London, UK

Richard K Chesters BSc, Independent Consultant, Parkgate, UK.

David C Attrill BDS, PhD, FDS RCS, FDS RCS(Rest Dent), FHEA, Senior Lecturer and Hon.

Consultant in Restorative Dentistry, University of Birmingham School of Dentistry, UK.

Paul Brunton PhD, MSc, BChD, FDSRCS(Edin), Professor of Restorative Dentistry, University of

Leeds.

Mabel Slater MBE, MEd, RDH, Independent Consultant.

Peter Strand BDS, MSc, MRD, Specialist Periodontist Ashford Kent

Helen Whelton PhD, BDS, MDPH, FFD, FFPH, Director, Oral Health Services Research Centre,

Professor of Dental Public Health and Preventive Dentistry, Dental School and Hospital,

University College Cork, Ireland

David Bartlett BDS, PhD, FDS (restorative) MRD, Head of prosthodontics at Kings College

London Dental Institute, UK

26th Sept. ‘12 1

Dentine Hypersensitivity - Guidelines for the Management of a Common Oral Health Problem

Abstract: Dentine hypersensitivity (DHS) remains an under-reported and under-managed problem in

the UK and Ireland despite making some dental treatments more stressful than necessary and having a

negative impact on the patients’ quality of life. This article is designed to build dental professionals’

confidence and remove any confusion regarding the diagnosis, prevention & treatment of sensitive

teeth caused by dentine hypersensitivity in those patients known to be at risk. There is a need for

simple guidelines, which can be readily applied in general practice. However it is also obvious that one

strategy cannot suit all patients. This review describes a DHS management scheme for dental

professionals that is linked to management strategies targeted at three different groups of patient.

These patient groups are 1) patients with gingival recession, 2) treatment patients with tooth wear

lesions and 3) patients with periodontal disease & those receiving periodontal treatment .

The authors also acknowledge the role of industry as well as dental professionals in a continuing role in

educating the public on the topic of sensitive teeth. It is therefore important that educational activities

and materials for both dental professionals and consumers use common terminology in order to reduce

the possibly for confusion.

Clinical Relevance: This review article provides practical, evidence-based guidance on the management

of dentine hypersensitivity for dental professionals covering diagnosis, prevention and treatment.

Sensitivity associated with gingival recession, tooth wear and periodontal disease & periodontal

treatment are specifically addressed in the article.

Objective Statement: The reader should understand that the active management of sensitive teeth can

reduce stress and in some cases improve patients’ quality of life. Such management requires a diagnosis

by exclusion and prevention as well as the treatment of dentine hypersensitivity.

26th Sept. ‘12 2

INTRODUCTION

Dentine hypersensitivity (DHS) is an oral health problem for 10-20% of adults that can affect

their life style and quality of life (Bekes et al. 2009, Bioko et al 2010.). Recent research in the

USA (Cunha-Cruz et al 2011) has confirmed earlier research by Gillam et al (2002) that DHS is

still inconsistently managed in many dental surgeries possibly because of a lack of confidence to

manage the condition effectively. It is therefore important to recognize that new technologies

(Garcia-Godoy 2009, Cummins 2009 a&b, Greenspan 2010), may offer simple and effective

relief for DHS thereby reducing stress for both patient and dental professional.

A group of 8 Experts from different dental backgrounds were assembled to form the UK and

Ireland Dentine Hypersensitivity Expert Forum. Their primary aim was to recommend simple,

evidence-based guidelines for the active management of DHS taking account of the need for a

differential diagnosis of DHS, its prevention (both lesion localisation & initiation) and its

treatment.

This article summarises the outcome of the Expert Forum discussions on the diagnosis,

prevention and treatment of dentine hypersensitivity. The Forum Experts recognised that no

single management strategy would be suitable for all patients. Thus management strategies for

specific groups of patients have been developed from the discussions of the Forum Group.

These patient groups include patients with patients with gingival recession, patients with tooth

wear lesions and finally periodontal diseases and those receiving periodontal treatments. It is

important to recognize that some other dental treatments, such as crown preparation

(Brännström 1996) and whitening procedures (Jorgensen & Carroll 2002, Hewlett 2007), can

cause sensitivity and that this needs to addressed when providing treatment. However the

26th Sept. ‘12 3

aetiology of the sensitivity may not be the same as for classical DHS, so these procedures have

been excluded from these guidelines.

DEFINITION OF DENTINE HYPERSENSITIVITY

Dentine hypersensitivity has been defined as a short sharp pain arising from exposed dentine in

response to stimuli typically thermal, evaporative, tactile, osmotic or chemical and which

cannot be ascribed to any other dental defect or disease (Canadian Advisory Board on Dentin

Hypersensitive Teeth 2003).

EPIDEMIOLOGY

Dentine hypersensitivity is a commonly occurring condition with a reported prevalence varying

from as little 4% to as high as 57% (Cummins 2009a). This wide range is thought to be because

of differences in the population, the setting and the clinical methodology employed to assess

DHS and also variations in patient perception. Canines and first premolars are most frequently

affected, followed by incisors and second premolars with molars being least affected (Addy

2002). The sites of those teeth most commonly affected are the buccal cervical regions. In

1987 Orchardson and Collins reported that in 90% of cases the hypersensitive area was at the

cervical margin. However occlusal/buccal sites are now becoming more frequently affected in

young adults probably due to the combination of erosive and abrasive tooth wear (Jaeggi and

Lussi 2006). DHS can present at any age, but the majority of individuals range from 20-50 years

with a peak in prevalence in the age range 30-39 years (Cummins 2009a).

Dentine may become exposed through either gingival recession or enamel loss. Experts have

concluded that gingival recession, rather than cervical enamel loss, is the key pre-disposing

factor for exposing the dentine surface. However once the dentine has been exposed it is

26th Sept. ‘12 4

evident that erosion is a key factor in dentine hypersensitivity initiation (Canadian Advisory

Board on Dentin Hypersensitive Teeth 2003). However, it is also clear that some dental

procedures may also be associated with an elevated incidence of tooth sensitivity.

RELEVANCE

DHS is a painful experience that for the majority of sufferers generates a very unpleasant

feeling causing them to adapt and often modify their life style. For example, patients may start

guarding the sensitive tooth with the tongue or drinking in the opposite side of the mouth or

even avoiding ice cold food and drinks completely. However for some people, DHS can be so

disturbing that it affects their quality of life (Bekes 2009, Bioko 2010). Additionally it has been

reported that localised DHS can lead to sensitive areas being avoided during toothbrushing,

which in turn can increase the risk of periodontal diseases and sequelae.(See Aetiology below)

DHS may also be provoked by some routine dental procedures such as scaling and polishing,

thereby making a regular dental visit unpleasant and painful for the patient. This discomfort

may therefore add anxiety to an already stressful experience. Preventive treatment for DHS

before carrying out any potentially painful, stress-provoking dental procedure is recommended

in such cases as it creates a calmer environment in subsequent treatment visits for both the

patient and the professional. In more severe cases, it may be more appropriate to complete the

procedure under a local anaesthetic.

AETIOLOGY

Currently the most widely accepted theory to explain the aetiology of the pain sensation caused

by DHS is the Hydrodynamic Theory advanced by Brannström & Astrom (1972). According to

the hydrodynamic theory, DHS occurs when an external stimulus contacts exposed dentine and

26th Sept. ‘12 5

triggers a change in the rate of flow of dentine fluid within the dentine tubule(s), and the

resultant pressure change across the dentine activates intra-dental nerve fibres to cause

immediate pain. DHS is similar to any other condition involving subjective experiences such as

pain in that there is a difference in reported hypersensitivity of patients displaying the same

exposure to aetiologic factors. Thus the clinical observations are not necessarily correlated

with the degree of sensitivity reported by the patient. Such an apparent mismatch between the

clinical condition and the extent of discomfort experienced by the patient complicates the

management of dentine hypersensitivity. This disparity may also raise the question “Why do

some patients who have exposed roots suffer from dentine hypersensitivity yet others with

exposed roots do not?”.

The weight of evidence suggests that this may occur not only because of the subjective nature

of pain, but also because of the natural process of tubule occlusion. Blocking of the dentine

tubule can occur over extended time periods as a result of precipitation of calcium phosphate

complexes triggered by proteins in saliva (Cummins 2009a). For a number of years it has been

known that both calcium and phosphate ions in saliva can remineralise tooth defects, such as

early carious lesions. Research into the mechanism of natural desensitisation suggests that

calcium and phosphate ions, associated with salivary glycoproteins, can also facilitate tubule

plugging. (Cummings, 2009a)

The role of plaque in the aetiology of DHS is controversial (Addy 2005). Some investigators

(Addy 2000, Gillam & Orchardson 2006) report that plaque is not an significant factor in DHS.

However other investigators (Dababneh, Khouri & Addy 1999) proposed that plaque played an

important role possibly due to the production of acids, which may affect the patency of the

26th Sept. ‘12 6

dentine tubules by the dissolution of the smear layer. It may also be possible that the

importance of plaque as a factor in DHS depends upon the patient type. For example, it is

recognised that DHS is generally associated with good oral hygiene practices in periodontally

healthy patients (Gillam & Orchardson 2006). Regardless of whether plaque is a significant

cause of lesion initiation, the importance of good plaque control is beyond dispute. However

there is also the possibility that a patient’s oral dental hygiene may be affected by the

discomfort arising from DHS and this may in turn increase the risk for both caries and

periodontal diseases. There is therefore a compelling clinical reason for dental professionals to

not only recognise, assess and manage DHS but to address a patient’s comfort and quality of

life during the management of the condition.

MANAGEMENT OF DENTINE HYPERSENSITIVITY AND UNDERLYING CONDITIONS

From the literature it is evident that a number of different therapeutic approaches have been

used for the treatment dentine hypersensitivity. Currently these therapeutic approaches

include:

 Desensitising the nerves.

 Occlusion of open dentine tubules (tubular occlusion)

Monitoring is essential in any management strategy and this may be the most important

component of the management strategy when implemented in dental practices. The Expert

Forum considered a number of published management paradigms including Schuurs et al. 1995,

Addy & Urquhart 2001, Gillam et al. 2002, Drisko 2002, Orchardson & Gillam 2006, Drisko 2007,

West 2007, Porto et al. 2009. It was decided that while there was considerable merit in terms of

content there was a need for a simplified management scheme , which should be easier to

26th Sept. ‘12 7

incorporate into clinical practice for the general dental setting. After careful consideration, the

Forum proposed a simplified management scheme (Figure 1). This scheme is elaborated in the

following sections starting with a section of patient screening.

Screening

As suggested in the recommendations of Canadian Advisory Board of Dentin Hypersensitivity

(2003) all dentate patients should be actively screened for dentine hypersensitivity by dental

professionals at both the initial and subsequent check-ups (dental examinations), because DHS

is frequently unreported by the patient. A simple but effective strategy is to ask patients

whether they have or have had any problems with sensitive teeth (discomfort) recently or since

their last visit. This simple strategy should “capture” the vast majority of dentine

hypersensitivity sufferers, thus enabling the dental professional to manage the problem more

thoroughly.

History

Once the dental professional has identified that the patient has a problem with sensitive teeth,

it is essential to let the patient use his/her own words to describe both the symptoms and

stimuli that trigger pain. At this stage, dental professionals should avoid putting words in the

patient’s mouths (leading the patient to a diagnosis). Once the pain characteristics have been

described by the patient, the dental professional can then use ‘closed questions’ in order to

confirm the diagnosis for example “Does the pain persist when you drink cold drinks?” or “Does

the pain linger once you have stopped drinking your drink?”

It is important therefore to obtain and record the patient’s dental and medical history. It is also

advisable to check for any history of an excessive intake of acid food and drink (e.g. citrus juices

26th Sept. ‘12 8

and fruits, carbonated drinks, wines or ciders) in the diet as well as to consider evidence of

gastric reflux and eating disorders prior to considering a management strategy. This is because

acid erosion can lead to both exposure of dentine (lesion localisation) and removal of the smear

layer opening the dentine tubules (lesion initiation).

Clinical Examination

The clinical examination should ideally include an assessment to identify all sensitive teeth.

This examination could involve triggers such as thermal and evaporative stimuli (e.g. a short

blast of cold air from the 3-in-1 syringe) or mechanical/tactile stimuli (e.g. running a sharp

explorer over the area of exposed dentine). The application of a controlled stimulus would be

expected to result in a short sharp pain that generally lasts just for the duration of the stimulus.

However pain/discomfort may sometimes continue for a short time post stimulation

particularly if the patient has severe dentine hypersensitivity. This assessment can also be used

to assess the severity of the patient’s DHS (see later section on Assessment of DHS Severity).

Differential Diagnosis

DHS can only be diagnosed by exclusion of other potential causes for the patient’s sensitivity.

Hence the information provided by the screening questions, patient history and clinical

examination is essential in order to exclude dental diseases and dental defects such as: dental

caries, pulpitis, cracked tooth syndrome, fractured restorations, gingival inflammation, chipped

teeth, fractured restoration and TMJ disorders.

Other pain symptoms, such as dull and throbbing pain, pain that persists after the stimulus has

been removed, pain that may keep the patient awake at night, the need for pain relief

(medication), pain irradiating from other sites in the mouth (referred pain), pain occurring at

26th Sept. ‘12 9

the chewing/biting surfaces, may indicate that other dental diseases or defects that would

warrant further investigation (for example pulp vitality (sensibility) testing, diagnostic

radiographs etc.).

Once the dental professional has excluded other potential causes of pain symptoms typically

associated with DHS, a more definitive diagnosis of DHS can be reached. This will enable the

dental professional to effectively manage the condition.

Assessment of dentine hypersensitivity severity

It is advisable to record the severity of DHS even though such measurements are notoriously

problematic due the subjective nature of pain. Assessments provide the dental professional

with a way of monitoring the effectiveness of any management plan. They also have the added

advantage of increasing the involvement of the patient in the management of their condition.

Since all assessment methods are likely to cause pain or discomfort, only one measure should

usually be used (for example, an air blast from a triple syringe). If, however the patient’s DHS is

seriously impacting a patient’s Quality of Life, then multiple assessments may be justifiable

provided this provides essential additional information to manage the condition.

In general, the use of a well-controlled stimulus should help obtain a more reproducible

assessment. Whatever approach for monitoring sensitivity is used, this should be addressed

from the patient’s perspective. Such an approach could be as simple as asking the patients,

whether they think that the pain/discomfort has “diminished”, “stayed the same” or “increased

since the last visit”. This can then be broadened to encompass questions aimed at whether any

improvements have allowed them to discontinue any of their avoidance strategies. More

26th Sept. ‘12 10

complex scales and Visual Analogue Scales (VAS) have been extensively used in clinical trials,

however these require the patient to be trained in their use.

Treatment planning

As DHS is not a disease per se, but rather a symptom of one or more underlying causes, it is

essential that all possible conditions potentially mimicking the symptoms of DHS should be

identified and eliminated prior to deciding upon a management strategy. The management of

DHS should identify and aim to eliminate any underlying and predisposing factors, which could

lead to lesion localization (exposure of dentine) and/or to lesion initiation (opening of tubules).

By identifying and treating the underlying causes, it should be possible to reduce both the

frequency and intensity of DHS episodes.

In the following sections, the most common predisposing factors have been reviewed and

management strategies presented as guidance on how to manage dentine hypersensitivity and

any related underlying conditions.

Dentine Hypersensitivity Management Strategies

Gingival recession from mechanical trauma

Gingival recession is a multi-factorial condition rendered more complex by anatomical factors.

Overzealous tooth brushing and improper tooth brushing techniques have been associated with

gingival damage and loss of gingival tissue through mechanical trauma. Once gingival recession

occurs, the cementum covering the dentine surface can be removed easily thereby exposing

the vulnerable underlying dentine, which is at increased risk of DHS.

A treatment strategy for patients where mechanical trauma is primarily responsible for the

gingival recession is summarised in Figure 2 based on the DHS Management Scheme (Fig. 1).

26th Sept. ‘12 11

This group of patients normally exhibit good plaque control with minimal gingivitis and no

evidence of periodontitis.

Initiate the patient’s education by showing him/her the sites with gingival recession and check

what type of toothbrush (soft, medium, hard texture) the patient normally uses. If possible,

assess the patient’s toothbrushing technique to see if this is likely to be responsible for the

gingival recession or whether there are anatomical features, such as prominent canines or

premolars or thin tissue types, which predispose the patient to gingival trauma. An indication

of whether manual or powered toothbrushing techniques should be made and also the role of

supplemental hygiene measures noted (i.e. floss, interdental brushes).

Explain the cause of sensitive teeth and check that the patient understands what can trigger

episodes of DHS. In particular, explain that frequent consumption of acidic food and/or drink

may remove the protective smear layer and hence cause teeth to become more sensitive.

The use of a professional desensitising treatment to provide instant relief for any sensitive site

is recommended, as this may not only reduce the stress associated with the dental check-up

but can also improve overall patient satisfaction. Check the patient’s periodontal health, if this

has not been previously been checked and then work with the patient to agree an effective oral

hygiene regimen. Keep in mind that this group of patients usually exhibit a good standard of

plaque control. However it may be useful to point out to the patient that good brushing

technique rather than use of excessive force is critical to good plaque control. It is often useful

to demonstrate the ideal brushing force (pressure) required. Finally record the essential details

on the patient’s records and check at follow up appointments about DHS & compliance with the

previously agreed oral hygiene regimen.

26th Sept. ‘12 12

Dentine hypersensitivity and tooth wear lesions

Toothwear refers to loss of tooth substance caused by abrasion, attrition, erosion and possibly

abfraction. In recent years, investigators have suggested that acid erosion combined with

either abrasion or attrition can significantly accelerate toothwear. Detailed in vitro and in situ

studies have demonstrated that the mechanical process of brushing with a toothbrush alone

has no measurable effect on enamel, and that tooth brushing with toothpaste contributes little,

if anything, to the loss of enamel over a lifetime of use. However studies have demonstrated

that acidic foods and drinks can soften enamel leading to significant tooth wear, particularly

when combined with mechanical cleaning (Addy 2005). Ultimately toothwear can lead to

exposure of dentine, thus patients showing evidence of erosion/abrasion are at risk of suffering

from dentine hypersensitivity.

The outline treatment strategy of DHS for patients with toothwear lesions is shown in Figure 3

following directly from the DHS Management Scheme (Fig. 1). Patient education plays a critical

part of the management strategy for this group of patients as it is essential to prevent or at

least reduce the rate of toothwear and hence lesion localization. The probable cause of the

toothwear should be explained to the patient as well as the location of any toothwear lesions.

The management strategy should involve pre-emptive treatment with a high fluoride

professional product (e.g. varnish) to remineralise any softened enamel & dentine. However

this alone is unlikely to be effective, so instruction should be given to slow or prevent any

subsequent future toothwear. Clearly the measures to prevent further toothwear depend

upon its probable cause. The main sources of acids are dietary (the frequency of consumption

26th Sept. ‘12 13

of acidic foods or drinks) or gastric (i.e. gastric reflux or excessive vomiting) and very rarely

environmental (enamel loss caused by the patient’s work environment).

Where the patient’s diet is the probable cause, then the patient should be encouraged to

reduce the frequency of consumption of acidic foods and drinks. In some cases it may also be

advisable to change toothbrushing practice (e.g. brushing before rather than after meals [Addy

2005]). The adjunctive use of a clinically proven desensitising mouthwash between twice daily

toothbrushing may be recommended for patients, who report excessive tooth brushing

frequency. Patients should also be advised to seek medical advice, where the primary cause of

toothwear is either environmental or medical.

Dentine hypersensitivity and periodontal disease and treatment

Periodontal disease results in tissue damage, loss of gingival tissue and alveolar bone through

biological breakdown processes and can cause gingival recession. Gingival recession is also a

common side effect of periodontal treatment. Once gingival recession occurs, the cementum

covering the exposed dentine surface may be easily removed by either physical and/or

chemical forces, thereby exposing the underlying dentine tubules and increasing the risk of

DHS.

Patients suffering from DHS as a result of periodontal disease or its treatment should receive a

multi-phase treatment and prevention plan that addresses both periodontal health and DHS.

Patient education is of paramount importance and should cover at least the points shown in

Figure 4. It is vital that the patient understands the absolutely critical role played by at home

oral hygiene as well as the need to reduce periodontal risk factors by maintaining good control

of systemic disease conditions such as diabetes and the need for smoking cessation.

26th Sept. ‘12 14

The initial phase of management should include a periodontal assessment in order to assess

what treatment, usually non-surgical, is required. Where appropriate, the possibility that the

treatment may invoke temporary post-therapeutic sensitivity should be explained to the

patient and consent obtained. The re-evaluation after the initial therapy phase should indicate

whether there is a need to plan for a corrective phase based on the expected outcome of

periodontal treatment (Lindhe et al. 2008). The corrective phase would typically involve the

use of surgical periodontal therapy. Again consideration should again be given to relief of any

pain associated with the treatment therapy.

Any DHS associated with exposed dentine or periodontal treatment should be managed by

using a chair-side desensitising product applied by the dental professional. The application of

desensitising products, such as polishing pastes, prior to, during and after treatment, can be

recommended particularly for patients with a previous history of discomfort during such

treatments. Such pre-emptive desensitisation can improve patient satisfaction by making it less

uncomfortable and stressful. It may also help remove a potential barrier to the patient

achieving effective plaque control measures at home following periodontal treatment.

Experience has shown that an evolutionary approach to improving oral hygiene is more likely to

be successful in the longer term than a revolutionary one.

26th Sept. ‘12 15

Concluding Remarks

After a careful review of the published literature, the DHS Expert Forum concluded that dentine

hypersensitivity remains an under-reported and under-managed problem in the UK & Ireland

despite its potential to negatively impact on a patients’ quality of life. The DHS Forum

members therefore wish to encourage the active management of dentine hypersensitivity in ‘at

risk’ patients. The DHS Expert Forum recognised the need to promote simple guidelines that

can be readily applied in general practice, but also agreed that a one strategy approach would

not suit all patients. This article describes a DHS Management scheme for dental professionals

covering diagnosis, prevention and treatment that is linked to management strategies targeted

at three groups of patient. These patients groups include a) patients with gingival recession

caused by mechanical trauma b) patients with tooth wear lesions & c) patients with periodontal

disease & those receiving periodontal treatment.

The DHS Expert Forum acknowledge the role of industry as well as dental professionals in a continuing

role in educating the public on the topic of sensitive teeth. It is therefore important that any

educational activities and materials use common terminology for both dental professionals and

consumers in order to reduce the possibly for confusion.

26th Sept. ‘12 16

MEMBERSHIP OF DHS EXPERT FORUM & ACKOWLEDGEMENTS

Membership: David Atrill (University of Birmingham), David Bartlett (Kings College, London),

Paul Brunton (University of Leeds), David Gillam (Queen Mary, University of London) , Mabel

Slater (Consultant), Peter Strand (Private Practitioner and lecturer at Kings College Dental

Institute, London), Helen Whelton (University College Cork) & Richard Chesters (Consultant).

The DHS Expert Forum would also like to recognise the financial support provided by Colgate-

Palmolive (UK) Ltd .

26th Sept. ‘12 17

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26th Sept. ‘12 20

 Figure 1: Dentine Hypersensitivity Management Guidelines

SCREENING
Any symptoms of DHS or tooth
sensitivity following last dental No
treatment? Ask patient to describe NO TREATMENT REQUIRED
his/her pain & any associated
triggers

CLINICAL EXAMINATION
Yes Examine dentition to exclude other causes such as:
∙ Cracked tooth syndrome ∙ Post-restorative sensitivity
CASE HISTORY ∙ Fractured restorations ∙ Marginal leakage
∙ Chipped teeth ∙ Pulpitis
History of patient's complaint
∙ Dental caries ∙ Palatogingival grooves
Review patient’s dental & medical ∙ Gingival inflammation
history. Use either evaporative or tactile stimuli to identify sensitive
areas. Record severity of DHS at sites following application
of stimulus or overall sensitivity.

Symptoms & case history consistent with DHS

MANAGEMENT STRATEGY TO IDENTIFY and ADDRESS UNDERLYING CONDITIONS

MAINTAIN DHS TREATMENT PLAN AND See section entitled - Dentine Hypersensitivity
MONITOR UNDERLYING CONDITION Management Strategies

FOLLOW UP VISIT (APPOINTMENT)

Re-assessment of DHS and any relevant underlying
condition. Does patient’s DHS still persist?

Yes No

RESOLUTION OF PATIENT’S COMPLAINT NO FURTHER

TREATMENT OF DHS NECESSARY (at this time)
Continue to monitor any underlying conditions and, if
appropriate to implement a suitable DHS management in
the form of professional or at-home treatments, removal of
any aetiological factors .

26th Sept. ‘12 21

Figure 2 Dentine Hypersensitivity management strategy options for patients with gingival
recession caused by mechanical trauma

DIAGNOSIS
 Primary underlying cause of dentine exposure leading to
DHS identified as mechanical. (
 Patients exhibit good standard of plaque control

PATIENT EDUCATION
 Show patient the affected site(s)
FOLLOW-UP
 Explain probable cause for recesssion.
 Regular assessment of patient’s oral
 Explain factors triggering sensitive teeth episodes
hygiene regimen including brushing
 Encourage patients to modify their oral hygiene regimen
frequency and force
in order to reduce damage to gingivae
 Assess severity & frequency of DHS
 Reduce excessive consumption of acid foods and drinks .

AT HOME
ORAL HYGIENE ROUTINE
 Brushing with a desensitising
toothpaste & an appropriate
MANAGEMENT toothbrush twice daily.
 In-surgery desensitising treatment to provide instant
pain relief.  Use of a clinically proven
 Check patient’s periodontal health. desensitising mouthwash between
twice daily brushing may be
recommended if necessary to reduce
the risk of further gingival tissue
trauma due to over-zealous tooth
brushing.

26th Sept. ‘12 22

Figure 3 Dentine Hypersensitivity management strategy options for patients with toothwear
lesions

DIAGNOSIS
 Tooth wear 1° cause of dentine exposure & subsequent
DHS.
 Identify cause of tooth wear (enamel loss) & record
severity of lesions, if possible, using a recognised index*.

PATIENT EDUCATION
• Show patient the site(s) and explain probable cause of FOLLOW-UP
the toothwear lesion(s)  Regular assessment of toothwear and
• Recommend an oral hygiene regimen to minimise risk of review potential causes for enamel
further toothwear. loss
• Where appropriate recommend reducing frequency of  Assess severity & frequency of DHS
consumption of acidic food & drink.

AT HOME
 ORAL HYGIENE ROUTINE
MANAGEMENT Brushing with a desensitising
 Provide high fluoride remineralising treatment toothpaste & an appropriate
 Provide professional desensitising treatment to relieve toothbrush twice daily
DHS  Recommend use of a clinically proven
• Encourage patient to seek advice from medical densensitising mouthwash between
practitioner, if tooth wear caused by working twice daily toothbrushing in order to
environment or reflux/excesssive vomiting help reduce the risk of toothwear
caused by excessive brushing.

* For example: Basic Erosive Wear Examination (Bartlett et al. 2008) or Smith & Knight (1984)

26th Sept. ‘12 23

 Figure 4 Dentine Hypersensitivity Management Strategy options for periodontal patients

DIAGNOSIS
 Periodontal disease or periodontal treatment primary
cause of exposure of dentine & hence DHS.

PATIENT EDUCATION
 Reinforce need for good oral hygiene
 Show patient the site(s) affected by periodontal disease
and explain probable cause of the exposed dentine
 Guide patient to improve at home oral hygiene
regimen.
 Instruction on ways of reducing periodontal risk factors.

MANAGEMENT

INITIAL PHASE
 Non-surgical periodontal procedure(s).
 DHS Treatment

RE-EVALUATION
 Follow-up assessment on periodontal status and AT HOME
dentine hypersensitivity ORAL HYGIENE ROUTINE
 Regular brushing with an antibacterial
CORRECTIVE PHASE toothpaste to aid plaque control.
 Surgical periodontal procedure(s)  Use of clinically proven desensitising
• DHS Treatment mouthrinse twice daily for dentine
hypersensitivity control.
 Short period, the use of a 0.2%
chlorhexidine solution for plaque control
FOLLOW UP MANAGEMENT 

MAINTENANCE PHASE
 Supportive periodontal therapy
 Ongoing monitoring of periodontal health
 Dentine Hypersensitivity treatment
 Oral Hygiene advice

26th Sept. ‘12 24

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