A New Perspective on Dentine Hypersensitivity - Guidelines for General Dental Practice

David G Gillam BA, BDA, MSc, DDS, FRSPH, FHEA, MICR

Centre for Adult Oral Health, Institute of Dentistry, Barts and the London School of
Medicine and Dentistry, Queen Mary University, London, UK

Running Title: A New Perspective on Dentine Hypersensitivity

Key Words: Dentine Hypersensitivity, Clinical Management Strategies, Desensitizing

products, New Perspective

Address for Correspondence

David Gillam
Clinical Senior Lecturer
Barts and The London School of Medicine & Dentistry
Institute of Dentistry
New Road
London E1 2AD

Tel: +44 (0)20 7882 8665

d.g.gillam@qmul.ac.uk
http://www.dentistry.qmul.ac.uk/

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Title: A New Perspective on Dentine Hypersensitivity - Guidelines for General Dental

Practice

Clinical Relevance: Dentine Hypersensitivity is a persistent and a troublesome clinical

condition which at times is under diagnosed by dental professionals who may struggle to

successfully resolve the problem to their patient’s satisfaction. The recent UK Forum

guidelines on the management of Dentine Hypersensitivity (DH) based on the presenting

features of the condition provide practical recommendations, helping dental professionals to

successfully manage this persistent problem correctly.

Objective of the manuscript: Is to update the dental professional on the recent guidelines

regarding the management of Dentine Hypersensitivity (DH) and to develop a management

strategy based on the presenting features of the condition thereby enabling dental

professionals to both recognise and treat this persistent problem correctly. The importance of

working towards a joint management strategy involving both the dental professional and

patient to understand the potential impact of the condition on the patient’s day to day

activities and the steps to be taken to make changes in the patient’s behaviour will also be

emphasized.

Abstract

The aim of this review is to update dental professionals on the issues and challenges

associated with the clinical management of Dentine Hypersensitivity (DH) and to provide

simple guidelines based on presenting clinical features that may help them successfully

manage the condition in their day-to-day clinical practice. Details on the management of DH

have been previously published in Dental Update which indicated that there was a need for

simple pragmatic guidelines to be recommended to the dental professional in order to

successfully diagnose and manage the condition in the day to day clinical practice. The

Authors of these guidelines also suggested that despite the various published clinical studies

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there does not currently appear to be one ideal desensitizing agent than can be recommended

for treating DH. A joint working relationship between the dental professional and the patient

in changing the patient’s behaviour is therefore essential if the condition is to be successfully

treated.

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Introduction

Although Dentine Hypersensitivity (DH) has been extensively reported on in the published

literature there appears to be unresolved issues regarding its true prevalence. For example, it

is clear from these studies that the patient’s perspective on the condition is different from the

dental professional. According to Orchardson & Gillam (1) patients who complain of the

classic symptoms of DH e.g., rapid in onset, sharp in character and of short duration,

generally have lower prevalence values (15-30%) following a clinical examination compared

to those values based on questionnaire studies which tend to rely on the patients’ perception

of DH, which may in turn, overestimate the extent of the problem (up to 74%)(2). However a

recent review on the burden of DH by Cunha-Cruz & Wataha (3) would appear to

suggest that the best overall estimate of the prevalence of DH in the population was

10%. There may however, be an explanation for this apparent discrepancy for example,

the patient’s difficulty in determining the type of dental pain they may be experiencing

at the time when questioned. Another issue that has been recently addressed in the

published literature was in regard to the extent of the impact of DH on the Quality of Life of

those individuals who suffer with the condition (4), for example, in this study by Gibson et

al. 28.2% of patients were unable to drink cold water without some discomfort, with 26.5%

of patients also unable to eat ice-cream without discomfort. 8.7% of patients also reported

they were unable to brush their teeth without some discomfort. While several studies have

suggested that DH may be a major problem in patients, it would appear that DH may be a

relatively minor problem for the majority of the population since the discomfort experienced

by individuals has been reported to be transient (episodic) in nature (5). This observation may

be one of the reasons why some patients either do not self-treat or fail to report the problem

when seeing a dental professional (6-7). It may also be a reason why the condition is often

under-diagnosed by dental professionals in that unless patients complain of the problem there

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does not appear to be any screening undertaken by dental professionals (7). There are

undoubtedly a number of diagnostic challenges facing the dental professional when

examining patients complaining of dental pain in general, and more specifically with DH. It

is important therefore, to recognise that the diagnosis of DH is essentially a diagnosis of

exclusion (7). Several studies have also reported on the apparent lack of confidence by dental

professionals when treating DH in daily practice particularly with the vast array of

commercially available In-office and over-the-counter (OTC) products that claim to be

effective in reducing DH (8-9). The question that arises is how does the dental professional

effectively screen, prevent, treat and monitor DH in a general dental practice and are there

simple and pragmatic guidelines that can help in the successful treatment or management of

the condition when examining patients. The aim of this review is therefore to update dental

professionals (Dentists, Dental Therapists and Hygienists) on the issues and challenges

associated with the clinical management of Dentine Hypersensitivity (DH) and to provide

simple guidelines based on presenting clinical features that may help them successfully

manage the condition in their day-to-day clinical practice.

1. Terminology and Prevalence

According to Gillam (9) various terms have been used to describe Dentine Hypersensitivity

(DH), for example cervical dentine sensitivity (CDS), or cervical dentine hypersensitivity

(CDH); or dentine sensitivity (DS), and more recently dentine hypersensitivity (DHS).

Traditionally the term “dentine hypersensitivity” (DH) has been preferred due to its historical

significance ”dentine sensitivity” (DS) however, may be a more accurate term for the dental

professional to use. The classic definition of DH is based on ‘pain derived from exposed

dentine in response to chemical, thermal, tactile or osmotic stimuli which cannot be explained

as arising from any other dental defect or disease (7). This definition is important in that DH

is essentially a diagnosis of exclusion and therefore will encourage the use of a thorough

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examination of the patient to determine a correct diagnosis. Historically DH has been

linked to individuals with relatively healthy tissues and good plaque control, although more

recently, the term root sensitivity or root dentine sensitivity (RDS) or root dentine

hypersensitivity (RDH) has been used to describe tooth sensitivity arising from periodontal

disease and its treatment (2). It should however by noted that to date most published studies,

do not appear to distinguish these two groups when undertaking prevalence studies. As

indicated in the Introduction, one of the main problems when evaluating the prevalence of

DH was how the data was collected and whether the studies were questionnaire based surveys

or clinical in nature.

2. Mechanisms involved in Dentine Hypersensitivity

The currently held view on the mechanisms associated with DH is based on the

hydrodynamic theory as proposed by Brännström & Åström (10), although it should be

recognized that not all stimulus transmission across dentine can be explained by this theory,

and as such other mechanisms may be involved (11). Generally speaking DH is differentiated

from other associated tooth pain by A-δ fibers which are mainly stimulated by the application

of a cold stimulus, producing sharp pain, compared to the stimulation of C fibers which

produce dull aching pain (12). For practical purposes, the hydrodynamic theory promotes two

basic approaches for treating hypersensitive dentine namely:

1) By occluding the exposed open dentine tubules thereby reducing any stimulus-evoked

fluid movements and subsequently prevent the transmission of the external stimulus

to the pulp.

2) By potassium ion diffusion from desensitising products such as toothpaste

formulations via the dentine tubule to reduce intra-dental nerve excitability and

prevent any nerve response to the stimulus-evoked fluid movements within the

dentine tubule.

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 3. Aetiology and Predisposing features

A number of aetiological and predisposing factors have been implicated in the initiation of

DH for example, abrasion, abfraction, erosion, gingival recession, quality of the buccal bone,

periodontal disease and its treatment, surgical and restorative procedures and patient

destructive habits (13)(Table 1).

More recently, several investigators have suggested that DH may be a tooth-wear

phenomenon characterized predominantly by erosion, which may subsequently expose the

dentine surface and initiate the tooth wear lesions (14-16). Dababneh et al. (17) also

suggested that there may be two specific biological processes implicated in DH; namely 1)

lesion localization and 2) lesion initiation associated with the above mentioned aetiological

factors. It has been postulated that 1) the dentine has to be exposed as a result of the loss of

enamel and/or soft tissue loss associated with gingival recession (including the loss of

cementum) (lesion localization). Secondly, once the dentine has been exposed, the patent

dentine tubules will be open to the oral environment (lesion initiation) and as a consequence

any subsequent stimuli (e.g. cold) may initiate minute fluid movement within the dentine

tubules, thereby activating the mechano-receptors in the dentine/pulp complex.

A number of investigators have traditionally claimed that DH occurs as a result of ‘zealous’

plaque control in a healthy mouth which affects mainly the buccal surfaces of the teeth (2)

(Fig. 1). Other investigators have however, suggested that the condition may arise as a result

of periodontal disease and or its treatment (2) (Fig 2). Recently the term ‘root sensitivity’

(RS) was introduced by the European Federation of Periodontology (18) to describe tooth

sensitivity associated with periodontal disease and/or periodontal therapy in contrast to the

traditional viewpoint of DH associated with individuals with good plaque control. Currently

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there does not appear to be any substantive evidence from the prevalence data in the

published literature to distinguish between these two conditions.

4. Clinical Features of DH

Evidence from the published literature would suggest that the most commonly associated

teeth with DH are canines, premolars and molars. Generally speaking the buccal aspect of

these teeth are more frequently exposed probably as a result of over-zealous and/or incorrect

toothbrushing in association with other aetiological factors (2,6)(Fig 1). However there may

be different precipitating and predisposing factors associated with DH and these features

should be carefully considered when deciding on a management strategy for treating DH

(Table 2). More recently simple guidelines on the management of DH have been

proposed based on the presenting clinical features of patients with DH (6) that may help

them successfully manage the condition in their day-to-day clinical practice. According

to Gillam et al. (6) patients with DH may be categorized as follows: patients 1) who have

relatively healthy mouths and DH as a result of meticulous and perhaps overzealous oral

hygiene, 2) who complain of DH as a result of periodontal disease and/or its treatment and

may also have aesthetic concerns relating to the loss of gingival tissue (gingival recession), 3)

who complain of DH as a result of toothwear problems (Figures 1-3). The intention of these

proposed guidelines were therefore designed to help the clinician address the different

presenting features associated with DH with a more tailored approach rather than simply

following a non-specific generalized management strategy.

5. Clinical Diagnosis of DH (including differential diagnosis)

The clinical diagnosis of oro-facial pain can be a difficult and time consuming procedure,

particularly in a busy dental practice. Diagnosing patients with DH can be problematic for a

number of reasons; firstly the difficulty in identifying areas of the mouth that may be causing

the problem and secondly the highly subjective nature of pain and its variability between

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patients. According to Gillam (5) it is important for dental professionals to correctly identify

patients with DH by excluding any confounding factors from other oro-facial pain conditions

prior to the successful management of the condition (See Fig.4). Several investigators have

also reported on the difficulties that dental professionals may face when treating the condition

and it is clear from the published literature that there is a need to recommend practical

guidelines which can be implemented into clinical practice (6-7).

It is important to note that the definition of DH is essentially a definition of exclusion and this

will encourage the dental professional to exclude any other potential oro-facial condition in

order to determine a definitive diagnosis of DH. During the appointment it is essential that

the clinician obtains a thorough medical and dental history from the patient to enable them to

take into account all relevant information prior to formulating a treatment plan. For example

the use of the Mnemonic ‘SOCRATES’ as a checklist for the patient’s pain history: Site,

Onset, Character, Radiation, Alleviating factors/ Associated symptoms, Timing (duration,

frequency), Exacerbating factors, Severity (NB Signs and Symptoms may be alternated with

the 'S').

Although a number of methodological measures have been proposed to both qualify and

quantify the pain associated with DH these measures are generally used in clinical trials

designed to evaluate desensitizing products (19). From the dental professional’s perspective

in general dental practice the use of an explorer probe and an air blast from a triple air syringe

together with an indication of the degree of discomfort from the patient following the

application of the stimulus during the clinical examination may be acceptable for the

identification of susceptible sites and the severity of the pain response. The use of a simple

numerical scoring scales (e.g., 0-10) may be more appropriate in clinical practice in order to

record the patient’s perception of DH during the first appointment and when monitoring an

improvement during subsequent visits (19). Sometimes, when there is uncertainty regarding

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whether a particular tooth is responsible for the patient’s discomfort a useful tip would be to

blow cold air from a dental air syringe onto the exposed dentine surface and then ask the

patient to give an indication of the severity of the perceived pain. The dental professional

could then apply a varnish over the exposed dentine and then repeat the cold air test if the

pain response has been eliminated or reduced in terms of severity then this may help the

dental professional to identify the cause of the patient’s pain. More recently Quality of Life

(QoL) measures have been included in some clinical trials in order to determine

whether DH has any effect on the patient’s daily activities (7) and these measures may

also be of benefit in the management of DH (see below).

6. Clinical Management of Dentine Hypersensitivity

There have been a number of treatment paradigms recommended in the literature relating to

the management of DH (1, 7, 20), but there have been concerns as to whether these measures

can be effectively undertaken in a general dental practice. Of these previous suggestions, a

simple less invasive stepwise approach was proposed by Orchardson & Gillam (1) based on

the WHO pain ladder which incorporated a strategy for determining the management of DH

depending on the extent and severity of DH. According to Gillam et al. (6) however, there

was a need to produce guidelines that are relatively simple and pragmatic to be used in

general dental practice (see Fig 4). For example, for patients with localized and

generalized gingival recession it may be prudent to take study casts and clinical

photographs to monitor condition over time as well as check and monitor the

periodontal status of the patient. The use of pain scores (e.g., Visual Analogue Scores or

a simple 0-10 numeral score) may be a useful indicator of the severity of the pain

associated with DH. It is also important to identify and correct any predisposing or

precipitating factors that may be responsible for the development of the gingival

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recession (e.g. patient habits, incorrect toothbrushing technique etc. These factors may

be discussed with the patient in order to prevent any further damage to both hard and

soft tissues that may increase the severity of the pain associated with DH, together with

a recommendation of avoiding the excessive consumption of acidic food and drink

particularly in association with the timing of daily toothbrushing. There a number of

treatment options available to the dental professional in treating patients with gingival

recession and associated DH for example, the use of silicone gingival veneers to improve

the aesthetics, restorative correction of a recession defect (with or without surgical

grafting (root coverage) procedures and sub gingival margins of fillings and crowns as

well as using products that occlude the dentine tubules (see Table 2). Depending on the

severity the dental professional may also recommend the use of desensitizing

toothpaste/mouthrinses for home use (e.g. strontium chloride/strontium acetate,

potassium nitrate/chloride/citrate/oxalate etc.) It is essential to have a monitoring

strategy in place based on the severity of the condition (Fig 1). Patients who have been

diagnosed with DH associated with toothwear problems or from periodontal disease

and/or its treatment may also be managed with a similar strategy specifically based on

their presenting features (see Table 2). It is however, important for the dental professional

to recognize that one of the key components from the UK Guidelines document (6) was that

no one desensitizing product (OTC or professionally applied) can fully resolve the various

presenting features of DH and therefore it may be prudent for the dental professional to

utilize a range of products in order to resolve the patient’s symptoms (Figure 4, Table 2). The

successful management of DH therefore not only involves the correct diagnosis of the

condition by the dental professional but also includes the importance of implementing

prevention strategies that either eliminate or limit any further deterioration of DH by

appropriate treatment choices, dietary advice and monitoring of the condition (1, 6). One of

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the problems in the management of any medical or dental condition is that behavioural

changes may be required in order to minimize or prevent the effects of a patient’s life style on

the condition in question (e.g., poor plaque control, smoking etc.). According to Gillam &

Ramseier (21) there is often a tendency for the dental professional to simply prescribe or

recommend a treatment without determining the aetiological and predisposing factors that

may have been instrumental in initiating the problem in the first place and if these factors are

not correctly managed or monitored they may continue to impact on not only the condition

but also on the patient’s quality of life, for example, being unable to drink cold water or

eating ice-cream or brushing their teeth without some discomfort (4). This approach would

therefore involve not only educating the patient but also the clinician and it is important to

recognize that the clinicians will need to adopt management strategies and goals that will

effectively encourage behavioural changes in the life style of their patients (21). According to

Gillam & Ramseier (21), in order to accomplish these goals the dental professional would

need to motivate and engage the patient in order to affect the recommended changes in

behaviour in order to effectively manage and monitor DH within the constraints of a general

dental practice.

Although there is plethora of both professionally applied and over-the-counter (OTC)

products reported to be effective in reducing DH (1) the question remains as to whether the

clinician has the confidence to successfully utilise these products in order to treat DH (8)(see

below). Generally speaking clinicians may receive information on these products directly or

indirectly from the manufacturing companies. The education and updating of clinicians

through professional meetings and continuing education courses (cpd) provides a very

valuable resource for the clinician. However it should be recognized that unless dental

professionals implement these changes in management and new product development into

daily practice then these proposed changes may not benefit the patient. One of the problems,

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however for the dental professional is which of these in-office and OTC products would be

effective both in the short and long term and while there have been a number of papers

supporting the various claims of efficacy in reducing DH there is still confusion among

clinicians as to which of these products may be of clinical benefit to their patients. For

example, according to Cunha-Cruz et al. (8) the dentists in their survey used a myriad of

products to treat DH, but the diversity of the dentists’ responses suggested that the

respondents were not convinced of the clinical efficacy of any of the treatment options. As

indicated above it is important that the clinician should have confidence in the ability of these

products to treatment successfully DH before prescribing or recommending them to their

patients. Furthermore the management of DH should not involve simply providing treatment

without first removing any aetiological or predisposing factors associated with DH and it is

essential that the clinician initiates behavioural changes in reducing or preventing any future

risk to the hard and soft tissues. The recent UK Expert Forum on the guidelines for the

management of DH (6) recognized that there was a need to promote simple guidelines that

may be readily applied in general dental practice, although the Forum acknowledged that a

‘one shoe fits all’ strategy to the problem may not necessarily satisfy all patients. One of the

key components from the Guidelines document was that the authors linked recommended

management strategies to three specific groups of patients rather than recommend a blanket

management for all patients with DH (Figs 1-3).

7. Discussion

It is evident from both the published literature and anecdotal evidence from colleagues that

there are a number of challenges when identifying patients with DH as well as problems as to

how to treat the condition effectively. As previously mentioned there are a number of

pertinent questions that need to be addressed when considering the extent and severity of the

condition in dental practice. For example, are dental professionals over-diagnosing or under-

13
diagnosing the condition and what is the true extent and severity of the problem in dental

practice and more specifically, what is the true impact of DH on the quality of life (QoL) of

patients in general dental practice? According to Cunhan-Cruz & Wataha (3) the actual

prevalence figure is around 10% based on their overview of the prevalence studies. This

would mean that 1 in 10 patients attending a dental practice may have a problem with DH but

may not actually disclose this to their Dentist unless asked (7). If this observation is correct

then it may be possible that the condition may be under-diagnosed in general dental practice.

There is no doubt that DH is a persistent problem to both patients and dental professionals

alike and it is important to be able to correctly identify the recognised aetiological causes and

pre-disposing factors associated with DH and treat the condition correctly in order to either

reduce or prevent any discomfort arising from the condition. As previously mentioned there

is often a tendency for the dental professional to simply prescribe or recommend a treatment

without determining the aetiological and predisposing factors that may have been

instrumental in initiating the problem in the first place and if these factors are not correctly

managed or monitored they may continue to impact on not only the condition but also on the

patient’s quality of life (21). It is important therefore, for the dental professional to introduce

changes in the patient’s behaviour and potentially habits in order to successfully manage the

condition. This aspect of the management of DH is however, very time consuming and can be

frustrating both to the dental professional and the patient if there appears to be very limited

success in treating the condition. Although there have been a number of management

paradigms recommended in the published literature (1, 7, 20) the issues and challenges

associated with the clinical management of DH in general dental practice can be very

challenging for a number of reasons (e.g., time and financial considerations).

The advantage(s) of the recently proposed guidelines on DH was to introduce simple and

practical measures based on the presenting clinical features of patients with DH and

14
recognising the differing aetiologies and predisposing factors associated with DH (6) (Figs 1-

3). For example, the treatment for toothwear and DH may be more complex in restoring lost

enamel and dentine than patients with DH associated with a well maintained dentition with

relatively little tooth surface loss. It should also be noted that despite the various published

claims of clinical efficacy of both in-office and over-the-counter products there does not

appear to be one ideal desensitizing agent than can be recommended to be used by the dental

professional when treating DH (22). The importance of educating both the dental professional

and the patient in the prevention and management of DH is therefore paramount if the

condition is to be successfully monitored and treated.

8. Conclusions

Recent proposals by a UK Expert Forum on DH would appear to provide practical, evidence-

based guidance on the management of DH for the diagnosis, monitoring, prevention and

treatment of specific presenting features of patients with DH (6). It is also evident from the

published literature that a one strategy management approach cannot fully resolve the

problem for all patients with DH. The importance of educating both the dental professional

and the patient in the identification, prevention and management of DH is paramount if the

condition is to be successfully monitored and treated.

Acknowledgements

This article was based on a lecture presented at the BDA Conference in Manchester (2015)

and the article by Gillam et al. (6) previously published in Dental Update.

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 Legend Figures and Tables

Figures

Figure 1 Clinical photograph illustrating gingival recession with exposed buccal surfaces

(Acknowledgement George Belibasakis)

Figure 2 Clinical photograph illustrating gingival recession following periodontal surgery in a

patient with Dentine Hypersensitivity.

Figure 3 Clinical photograph illustrating toothwear with severe exposed dentine

(Acknowledgement Wendy Turner)

Figure 4: Dentine Hypersensitivity Management Guidelines (Acknowledgement modified

from Gillam et al. [6])

Tables

Table 1 Aetiological and pre-disposing factors associated with DH (Acknowledgement:

adapted from Chabanski & Gillam (13)

Table 2 Overall Management Strategy options for treating Dentine Hypersensitivity

(Acknowledgement Gillam et al. [6] modified)

19
Figure 1 Clinical photograph illustrating gingival recession with exposed buccal surfaces

(Acknowledgement George Belibasakis)

Figure 2 Clinical photograph illustrating gingival recession following periodontal surgery in a

patient with Dentine Hypersensitivity.

Figure 3 Clinical photograph illustrating toothwear with severe exposed dentine

(Acknowledgement Wendy Turner)

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 Figure 4: Dentine Hypersensitivity Management Guidelines (Acknowledgement modified
from Gillam et al. [6])
SCREENING

Any evidence of symptoms associated with

DH, or tooth sensitivity following the last No
dental treatment? Ask the patient to describe NO TREATMENT REQUIRED
his/her pain & any associated triggers

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

Symptoms & case history consistent with DH

MANAGEMENT STRATEGY TO MAINTAIN IDENTIFY and ADDRESS UNDERLYING CONDITIONS See

DH TREATMENT PLAN AND MONITOR Table 1: Management of specific clinical features
UNDERLYING CONDITION

FOLLOW UP VISIT (APPOINTMENT)

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

Yes No

RESOLUTION OF PATIENT’S COMPLAINT: NO

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

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 Loss of enamel

Denudation of cementum

Gingival recession

Attrition

Abrasion

Abfraction

Erosion (intrinsic and extrinsic)

Tooth malposition

Thinning, fenestration, absent buccal alveolar bone plate

Periodontal disease and its treatment

Periodontal surgery, restorative treatment

Patient habits

Table 1 Aetiological and pre-disposing factors associated with DH (Acknowledgement:

adapted from Chabanski & Gillam (13)

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Table 2 Overall Management Strategy options for treating Dentine Hypersensitivity
(Acknowledgement Gillam et al. [6] modified)
Gingival Recession
Clinical evaluation
 Clinical measurement of the
Gingival Recession defect
 Take study casts and clinical
photographs to monitor condition
over time
 Check and Monitor periodontal
health
 Identification and correction of
predisposing or precipitating
factors
 Use of pain scores to assess and
monitor DH (e.g., Visual Analogue
Scores)
Patient Education (Including
Preventive advice)
 Show patient the affected site(s)
 Explain probable cause for
recession.
 Explain factors triggering sensitive
teeth episodes
 Encourage patients to modify their
oral hygiene regimen in order to
reduce damage to gingivae (e.g.,
reducing brushing force,
correction of toothbrush
technique)
 Reduce excessive consumption of
acid foods and drinks
Corrective clinical outcomes
 Reduce excessive consumption of
acid foods and drinks
 Manufacture of silicone gingival
veneers
 Orthodontic treatment
 Restorative correction of recession
defect and sub gingival margins of
fillings and crowns
 Polymers:
Sealants/varnishes/resins/dentin
e bonding agents
 Laser obturation of dentinal
tubules
 Use of Desensitizing polishing
pastes
 Pulpal extirpation (Root Canal
Treatment)
 For local recession defects soft
tissue grafting (root coverage)
surgical procedures can be
considered (see under the
corrective phase of periodontal
treatment)
Toothwear
Clinical evaluation
 Identify cause of tooth wear
(enamel loss)
 Record severity of lesions, if
possible, using a recognized index
(23-24)
 Take study casts and clinical
photographs to monitor condition
over time
 Check and Monitor periodontal
health.
 Use of pain scores to assess and
monitor DH (e.g., Visual Analogue
Scores)
Patient Education (Including
Preventive advice)
 Show patient the site(s) and
explain probable cause of the
tooth wear lesion(s)
 Recommend an oral hygiene
regimen to minimize risk of
further tooth wear.
 Where appropriate recommend
reducing frequency of
consumption of acidic food &
drink.
Corrective clinical outcomes
 Provide high fluoride
remineralizing treatment (pre-
emptive phase)
 Provide professional
desensitizing treatment to relieve
DH
 Encourage patient to seek advice
from medical practitioner, if tooth
wear caused by working
environment or reflux/excessive
vomiting (Psychiatric evaluation
may also be appropriate)
 Restorative correction in the form
of composite build up, crowns
may also be appropriate
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Periodontal Treatment
Clinical evaluation
 Periodontal disease or
periodontal treatment as the
primary cause of exposure of
dentine and associated DH.
 Check and Monitor periodontal
health (6 point pocket charting)
 Use of pain scores to assess and
monitor DH (e.g., Visual Analogue
Scores)
Patient Education (Including
Preventive advice)
 Reinforce the need for good oral
hygiene
 Show patient the site(s) affected
by periodontal disease and
explain probable cause of the
exposed dentine
 Guide the patient to improve ’at
home’ oral hygiene regimen.
 Instruction on measures of
reducing periodontal risk factors
for example diabetes, smoking,
obesity.
Corrective clinical outcomes
INITIAL PHASE
 Non-surgical periodontal
procedure(s).
 DH Treatment (including
desensitising polishing
pastes/Fluoride varnishes)
RE-EVALUATION
Follow-up assessment on periodontal
status and dentine hypersensitivity
CORRECTIVE PHASE
 Surgical periodontal procedure(s)
e.g., Guided Tissue Regeneration,
Coronally Advanced Flap +
Enamel Matrix Derivatives,
Connective Tissue Graft (flap),
Free Gingival Graft (acellular
dermal matrix allograft)
 DH Treatment (including
desensitising polishing
 pastes/Fluoride varnishes)

FOLLOW UP MANAGEMENT

MAINTENANCE PHASE

 Supportive periodontal therapy

 Ongoing monitoring of
periodontal health
 Dentine Hypersensitivity
treatment (including
desensitizing polishing
pastes/Fluoride varnishes)
 Oral Hygiene advice

Recommendations for Home Use

Recommendations for Home Use (including toothpaste/
(including toothpaste / mouthrinses)
mouthrinses)  Oral Hygiene implementation as
 Oral Hygiene implementation as per recommendation
per recommendation  Regular brushing with an anti-
Recommendations for Home Use bacterial toothpaste to aid plaque
(including toothpaste/mouthrinses)  Toothpastes and mouthrinses control.
 Oral Hygiene implementation as (see Recommendations for  Short period, the use of a 0.2%
per recommendation Gingival Recession) chlorhexidine solution for plaque
 Strontium chloride/strontium control
acetate  Use of a desensitising mouthrinse
 Potassium twice daily for DH control (when
Nitrate/Chloride/Citrate/Oxalate appropriate)
 Calcium Compounds:
 Calcium Carbonate and Arginine
and Caesin
Phosphopeptide+Amorphous
Calcium Phosphate
 Bioactive glass
 Nano/Hydroxyapatite
 Fluoride In higher concentration
(2800/5000ppm F[prescription])
Amine/Stannous Fluoride

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