The effectiveness of current dentin desensitizing agents used to treat dental hypersensitivity: a...

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QUINTESSENCE INTERNATIONAL

GENERAL DENTISTRY

The effectiveness of current dentin desensitizing

agents used to treat dental hypersensitivity: A

systematic review

Wellington Luiz de Oliveira da Rosa1/Rafael Guerra Lund, PhD2/Evandro

Piva, PhD2/Adriana Fernandes da Silva, PhD2

Objective: Dentin desensitizing agents are used in the treatment of dentin hypersensitivity,

which is defined as a painful response in the exposed dentin to stimuli that are thermal,

evaporative, tactile, osmotic, or chemical. A systematic review was conducted to analyze

the clinical effectiveness of current desensitizer with at least 3-months follow-up. Method

and Materials: Eight electronic databases were searched: MedLine (PubMed), Embase,

Lilacs, Ibecs, Web of Science, Scopus, Scielo, and The Cochrane Library. Only those clini-

cal trials published from 2000 to 2012 were included. Results: A total of 3,029 relevant

records were identified. After title and abstract examination, 2,645 articles were excluded.

A data extraction form was designed and completed by reviewers from the selected stud-

ies for a retrospective comparison. From the 99 studies retrieved for detailed review, only

17 had an evaluation time of at least 3-months follow-up and fulfilled the selection criteria.

Conclusion: Cervitec Plus, SE Bond & Protect Liner F, laser, and iontophoresis have

shown satisfactory posttreatment results between 3 and 6 months. However, additional

clinical trials are warranted to better compare the different types of treatments and their

effectiveness in the longer term. (Quintessence Int 201#;##:1–12; doi: ##.####/j.qi.a#####)

Key words: dentin desensitizing agents, dental materials, dentin sensitivity,

systematic review

1Undergraduate Student, Faculty of Dentistry, Federal Universi-

ty of Pelotas, Pelotas, Brazil.

2Professor, Department of Restorative Dentistry, Federal Univer-

sity of Pelotas, Pelotas, Brazil.

Correspondence: Professor Adriana Fernandes da Silva, Restor-

ative Dentistry, Department of Restorative Dentistry, College of

Dentistry, Federal University of Pelotas, Gonçalves Chaves St.

457/504, Centro, Pelotas - RS – Brazil 96015-560. Email: adrisil-

[email protected]

Dentin hypersensitivity (DH) is one of the

most common painful conditions affecting

oral comfort and function.1,2 It is also one of

the least successfully resolved problems of

the teeth.3 DH can be defined as temporary

pain or an exaggerated response in

exposed dentin to stimuli that are typically

thermal, evaporative, tactile, osmotic, or

chemical, which cannot be explained as

arising from other forms of dental defect or

pathology.1,3-8 Primary treatment strategies

should undoubtedly aim to eliminate predis-

posing factors, such as abfraction, abra-

sion, or erosive components, thereby

preventing recurrence.1,9,10

Under normal conditions, dentin is cov-

ered by enamel or cement and does not

suffer direct stimulation.11 However, the

exposure of dentinal tubules due to enamel

loss by abrasion, erosion, abfraction, or root

surface exposure caused by gingival reces-

sion, periodontal treatment, or a combina-

tion of both may produce strong dentin sen-

sitivity.4,12 Root area exposures with cervical

lesions may be multifactorial, resulting from

chronic trauma from tooth brushing, tooth

flexure due to abnormal occlusal loading

forces, parafunctional habits, acute and

chronic inflammatory gingivitis, and peri-

odontal diseases.3,9

Although several hypotheses have been

presented to characterize DH, the generally

accepted basis for its physiological cause

is Brännstrom’s hydrodynamic theory.4,13-16

According to its principles, exposed and

open dentinal tubules at the tooth surface

permit fluid movement inside the tubules

that leads to sensorial activation of the

nerve cells in the pulp, thus causing

pain.4,13,17

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QUINTESSENCE INTERNATIONALda Rosa et al

There are many approaches to the treat-

ment and prevention of DH.13 Extensive

research has been conducted regarding its

treatment, although no single treatment is

accepted universally.14 Treatment with a

chemical agent (eg potassium nitrate) that

penetrates into the dentinal tubules and

depolarizes the nerve synapse, thereby

reducing sensitivity by preventing the con-

duction of pain impulses, is a method used

in daily use toothpastes.13 An alternative

approach is to treat the tooth with a chemi-

cal or physical agent that creates a layer

that mechanically occludes the exposed

dentinal tubules, thus reducing sensitivity

by preventing dentinal fluid flow. This

method is used by prophylaxis pastes and

varnishes.13,16

Numerous desensitizing agents also

have been clinically tested over several

decades in an effort to alleviate DH.3,14 Due

to the different methodologies employed,

variability of the subjective responses, and

influence of the placebo effect, results have

been variable and to some extent inconclu-

sive.13,18 For immediate alleviation of mild to

moderate symptoms, occlusion of dentinal

tubules can be noninvasively achieved with

toothpastes containing strontium salts and/

or highly concentrated fluoride lacquers or

varnishes.11,19,20 Another approach is to use

potassium salt formulations that modulate

intradental nerve excitability.21,22 In the case

of pronounced severity, a semi-invasive

treatment can block dentin tubules via the

application of a bonding agent or an adhe-

sive restorative material.23,24 These different

modalities have shown variable results over

time.1,11,21,23-28

Current therapies provide only tempo-

rary effects and require multiple applica-

tions to take effect, which explains the large

number of studies evaluating the reduction

of pain in the short-term as well as the lack

of long-term effects associated with these

materials.28-31 The aim of this study was to

analyze the clinical effectiveness of the

treatments for DH with at least 3-months

follow-up.

METHOD AND MATERIALS

Search strategies

This systematic review was performed

according to the PRISMA (Preferred Report-

ing Items for Systematic Reviews and Meta-

Analyses) Statement.32 The literature search

was carried out by two independent review-

ers (WLOR and AFS) involving publications

between January 2000 and August 2012.

Eight databases – MedLine (Pubmed),

Embase, Lilacs, Ibecs, Web of Science,

Scopus, Scielo, and The Cochrane Library

– were searched using the keywords “den-

tin sensitivity”, “dentine sensitivity”, “dentine

Fig 1 Selection criteria.

Clinical trials with patients that presented dentin hypersensitivityStudies that investigated the effectiveness of dentin desensitizing agents over timeStudies in which it was possible to distinguish case and control groups

Clinical trials with follow-up shorter than 3 monthsUnclear definition of dentin hypersensitivityNo assessment of dentin hypersensitivity using a scale for pain measurementNo definition of selection criteriaStudies published in a language other than English, Portuguese or Spanish

Exclusion criteria

Selection criteria

Inclusion criteria

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hypersensitivity”, “desensitizing dentin”,

“dental sensitivity”, “hypersensitivity teeth”,

“dentin desensitizing agents”, “teeth desen-

sitizer”, and “dental desensitizer”. Only

those clinical trials that evaluated dentin

desensitizing agents over time were

selected. All identified papers were evalu-

ated and chosen based on the following

inclusion criteria (Fig 1): any in vivo study

with a protocol for dentin hypersensitivity

with at least 3 months of follow-up.

Study selection

According to the PRISMA Statement,32 the

abstracts were independently reviewed by

two reviewers (WLOR and AFS). After the

screening and eligibility criteria were indi-

vidually accomplished, the article was

included if a consensus was reached. If

not, a third author was invited to discuss the

article. The studies were analyzed accord-

ing to the selection criteria (Fig 1). Only

those studies that fulfilled all criteria were

admitted.

The authors of selected manuscripts

were contacted by email when it was nec-

essary to retrieve some missing data or

information. If no answer was received by 2

weeks after the first email message was

sent, then a second email was forwarded. If

no answer was provided by the author 1

month after the first contact, the missing

Table 1 Demographics of the included studies

Study Year Country Study design Patients Teeth Posttreatment time

Aranha et al3 2009 Brazil CCT; split-mouth 39 101 1 wk, 1 mo, 3 mo, 6 mo

Birang et al29 2007 Iran RCT; alternate allo-

cation

9 63 1 mo, 3 mo, 6 mo

Brahmbhatt

et al14

2011 India RCT; split-mouth 25 260 15 d, 1 mo, 3 mo

Ciaramicoli

et al43

2003 Brazil CCT; alternate allo-

cation

20 145 6 mo

Clavijo

et al45

2009 Brazil RCT, alternate allo-

cation

10 28 7 d, 14 d, 1 mo, 2 mo, 3 mo

Drebenstedt

et al51

2012 Germany RCT, parallel groups 120 NS 1 d, 7 d, 1 mo, 3 mo

Duran and

Sengun52

2004 Turkey RCT; split-mouth 52 277 10 d, 3 mo

Ipci et al55 2009 Turkey RCT, parallel groups 50 450 1 wk, 1 mo, 6 mo

Kobler et al46 2008 Germany RCT; split-mouth 132 NS 2 wk, 2mo, 3 mo, 6 mo

Lier et al59 2002 Norway RCT; split-mouth 17 34 1 wk, 1 mo, 4 mo

Polderman

and

Frencken26

2007 Netherlands RCT; split-mouth 14 28 1 mo, 3 mo, 19.2 mo, 25.2 mo

Sethna

et al47

2011 India RCT; split-mouth 250 500 1 mo, 3 mo

Singal et al48 2005 India RCT, alternate allo-

cation

50 425 2 wk, 1 mo, 3 mo

Vieira et al28 2009 Brazil RCT; split-mouth 30 164 3 mo

Yilmaz et al31 2011 Turkey RCT; alternate allo-

cation

42 146 1 wk, 1 mo, 3 mo

Yilmaz et al60 2011 Turkey RCT; split-mouth 48 244 1 wk, 1 mo, 3 mo, 6 mo

Yilmaz et al57 2011 Turkey RCT; split-mouth 51 174 1 wk, 1 mo, 3 mo

CCT, controlled clinical trial; NS, not specified; RCT, randomized clinical trial.

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information was not included in this review.

When papers from the same group of

authors were identified, with very similar

databases of patients, materials, methods,

and outcomes, the authors were also con-

tacted to clarify whether the pool of patients

was indeed the same.

Data extraction

A data extraction form was designed ad

hoc and filled by reviewers to register data

from the selected studies. Demographic

data (eg number of patients, country) were

recorded for each of the studies (Table 1).

The number of patients and teeth evaluated

were also recorded. For each study, the

type of materials tested (Table 2) and the

main results (Table 3) were recorded, as

described in the study.

Assessment of methodologic

quality

Due to the high degree of heterogeneity in

terms of the different studies, the materials

tested, the number of treatment sessions,

and the variety of follow-up periods used, a

meta-analysis among the selected studies

was considered inappropriate. Decreases

Table 2 Different materials tested in the groups

Studies Materials tested

Aranha et al3 An aqueous solution of hydroxyethyl-methacrylate and glutaraldehyde (Gluma Desensitizer,

Heraeus Kulzer), an adhesive system Seal&Protect (Dentsply), a 3% potassium oxalate gel

(Oxa-Gel; Art Dent), an acidulated phosphate fluoride (Nuprogel, Dentsply), and low-intensity

laser therapy (LILT) of GaAlAs semiconductor laser diode (660 nm/3.8 J/cm²/15 mW; MMOptics)

Birang et al29 Nd:YAG laser (1 W, 15 Hz, 60 s, two times), Er:YAG laser (100 mJ, 3 Hz, 60 s, two times), and

control group without any treatment

Brahmbhatt

et al14

2% NaF solution (DNS Fine Chemicals), Gluma Desensitizer (Heraeus Kulzer), iontophoresis

with distilled water (placebo), and NaF-iontophoresis (Desensitron II; Parkel)

Ciaramicolli

et al43

Nd:YAG laser treatment and a control group with no treatment

Clavijo et al45 3% potassium oxalate gel (Oxa-Gel; Art Dent), low-level diode laser with 110 mW/cm2 (UltraB-

lue; DMC)

Drebenstedt

et al51

Cervitec Plus (Ivoclar Vivadent), Cervitec (Ivoclar Vivadent), and placebo

Duran and

Sengun52

Single Bond (3M Espe), Health-Dent Desensitizer (Healthdent), Gluma Desensitizer (Heraeus

Kulzer), SE Bond & Protect Liner F (Kuraray), and Fluoline (PD Dental)

Ipci et al55 2% NaF, CO2 laser (MedArt 610; Intros), Er:YAG laser (Versawave; Hoya ConBio), NaF plus

the CO2, and NaF plus the Er:YAG laser

Kobler et al46 Varnish with strontium chloride (Hyposen; Lege Artis Pharma), and placebo.

Lier et al59 Activated and nonactivated (placebo) Nd:YAG laser (MØlsgaard Dental)

Polderman

and Frencken26

Low-viscosity glass ionomer (Fuji VII; GC Europe), and Gluma Desensitizer (Heraeus Kulzer)

Sethna et al47 Cervitec varnish (Ivoclar Vivadent), and Gluma Desensitizer (Heraeus Kulzer)

Singal et al48 NaF-iontophoresis and Gluma Desensitizer (Heraeus Kulzer)

Vieira et al28 Low-level GaAlAs diode laser (Bio Wave LLLT Dual; Kondortech Equip. Odontológicos), 3%

potassium oxalate gel (Oxa-Gel; Kota Imports), and a placebo gel

Yilmaz et al31 Er,Cr:YSGG laser (Waterlase MD; Biolase Technology) at an energy level of 0.25 W, and a

control without laser emission

Yilmaz et al60 GaAlAs laser (LaserSmile; Biolase Technology) at 8.5 J/cm2 energy density, placebo laser,

NaF varnish (Voco), and a placebo NaF varnish

Yilmaz et al57 Diode laser with the GaAlAs laser (LaserSmile; Biolase Technology) at 8.5 J/cm2 energy den-

sity, Er,Cr:YSGG laser ( Waterlase MD; Biolase Technology) at an energy level of 0.25 W, and

a control group with no treatment

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Table 3 Main results of the included studies

Studies Main results

Aranha et al3 After 6 months, all therapies showed lower VAS sensitivity values. Oxa-Gel and low-intensity

laser therapy showed higher scores for sensitivity when compared to Gluma Desentizer and

Seal&Protect after the initial treatment. Acidulated phosphate fluoride presented an intermedi-

ate level of sensitivity.

Birang et al29 Nd:YAG laser was more effective and resulted in a significant reduction in VAS scores at each

follow-up compared to the Er:YAG laser group.

Brahmbhatt

et al14

At all-time intervals, 2% NaF-iontophoresis and Gluma Desensitizer were more effective than

2% NaF local application. However, at 3 months, 2% NaF-iontophoresis was more effective

than Gluma Desensitizer.

Ciaramicolli

et al43

Nd:YAG laser irradiation was effective after 6 months, while the reduction of DH was statisti-

cally greater when there was an association with the removal of etiologic factors.

Clavijo et al45 The application of laser irradiation was effective 6 days after the first session, and 3% potas-

sium oxalate was effective for 30 days. While both were effective, laser irradiation presented

better effectiveness.

Drebenstedt

et al51

While both Cervitec Plus and Cervitec reduced tooth hypersensitivity, the former reduced

hypersensitivity for a longer period of time.

Duran and

Sengun52

At 3 months, the Protect Liner F group continued to show significantly reduced sensitivity lev-

els. At the end of the 3-month evaluation, all desensitizers showed VAS sensitivity values lower

than baseline, with Protect Liner F being the most effective desensitizer in the study period.

Ipci et al55 A significant increase in mean degree of discomfort at 6 months compared with 1 week and 1

month was observed for the NaF group only. No superiority was found for desensitization

among the other materials tested, although lasers in combination with NaF gel appeared to

show better efficacy than either treatment modality alone.

Kobler et al46 Significant positive effect of strontium chloride compared to the placebo. After 24 weeks, pain

relief or painlessness was observed in 72% of patients.

Lier et al59 The effect of treatment with a Nd:YAG laser was not different from the placebo. Changes that

occurred between evaluation times were not statistically significant.

Polderman

and Frencken26

Fuji VII was more effective than Gluma Desensitizer after 3 months. The positive treatment

effect of the glass ionomer continued for 25.2 months.

Sethna et al47 Both varnishes had the therapeutic potential to alleviate DH, although the Cervitec varnish was

more efficacious than the Gluma Desensitizer at 4 and 12 weeks posttreatment.

Singal et al48 NaF had a comparatively greater effect than did Gluma Desensitizer at both the 1- and

3-month intervals. Both agents were effective immediately after application; however, 2% NaF

was comparatively better than the Gluma Desensitizer in providing long-term relief.

Vieira et al28 GaAlAs laser, potassium oxalate gel, and the placebo gel were effective immediately and at 3

months after treatment. No significant differences among the groups were detected regarding

efficacy at either the immediate or 3-month evaluations.

Yilmaz et al31 One application of a Er,Cr:YSGG laser showed immediate DH reduction compared with pla-

cebo, which remained stable over the 3-month examination period.

Yilmaz et al60 GaAlAs laser and NaF varnish treatments resulted in an immediate reduction in VAS scores,

which were sustained throughout the study. However, the NaF group showed a significant

increase in VAS scores at 3 and 6 months compared to at 1 week and 1 month.

Yilmaz et al57 Er,Cr:YSGG and GaAlAs lasers were immediately effective following a single application. No

significant differences were identified between the lasers at any follow-up examination.

VAS, visual analog scale.

in DH were analyzed over time. Addition-

ally, the type of desensitizer used, the num-

ber of patients and teeth, the evaluation

time, and the results over time from each

study were taken into consideration to eval-

uate the effectiveness of the materials.

Table 3 summarizes the main results of the

included studies.

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RESULTS

Study characteristics

The last electronic search was conducted

on August 2012. A total of 3,029 potentially

relevant records were identified from all

databases. Fig 2 is a flowchart that summa-

rizes the article selection process. A total of

285 records were duplicated, and after title

and abstract examination, 2,645 articles

were excluded because they did not meet

the inclusion criteria (Fig 1). From the 99

studies that were retrieved for detailed

review, 82 were excluded because the

evaluation time was shorter than 3 months

and failed to meet the selection criteria

(Fig 2). A total of 17 studies fulfilled all

selection criteria and were included in the

review.

Table 1 shows demographic data from

the studies considered in this study. All

included studies were published between

2002 and 2012. A total of 949 subjects and

3,039 teeth were included in this systematic

review (ie without considering the data that

were not reported in 2 studies). They

reported data from people from different

countries and ethnicities. Table 2 shows the

different types of materials that were tested

in the included studies. Nine of the 17 stud-

ies evaluated the efficacy of lasers in the

treatment of hypersensitive teeth for at least

3 months. Gluma Desensitizer (Heraeus

Kulzer) was evaluated in six different clini-

cal trials, Cervitec (Ivoclar Vivadent) and

Oxa-Gel (Art-Dent) were evaluated in three

studies, and therapy with iontophoresis was

evaluated in two trials.

Some current treatments with common

desensitizers containing arginine 8%, CPP-

ACP (casein phosphopeptide and amor-

phus calcium phosphate) or calcium

sodium phosphosilicate (NovaMin, NovaMin

Technology) have shown satisfactory

results over time.33-36 However these materi-

als require multiple applications or continu-

ous use by patients, which does not guar-

antee their effectiveness. Furthermore, most

studies have evaluated the reduction of

pain of these materials for a period shorter

than 3 months.37-40 Therefore, studies with

these dentin desensitizers were not

included in this review.

Main outcomes

Among 99 records preselected with clinical

trials that evaluated dentin desensitizing

agents since 2002, only 17 were found

among the selected journals that evaluated

the decrease in the DH for at least 3

months. It was possible to note that the

majority of selected studies analyzed the

decrease of pain for up to 3 months (Fig 3).

Only one clinical trial26 evaluated the effec-

tiveness of dentin desensitizing agents after

6 months.

In relation to posttreatment outcome

there was no therapy that could be consid-

ered ideal in the management of this com-

Fig 2 Search flow (as described in the PRISMA statement).32

3,029 potentially rele-vant records identified

from database searches

2,744 records after removal of duplicates

2,744 screened records2,645 records excluded on the

basis of title and/or abstract inclusion and/or exclusion criteria

99 full-text articles assessed for eligibility

82 studies excluded on the basis of inclusion and/or exclusion cri-

teria

17 studies included in the qualitative synthesis

0 studies included in the quantitative synthesis

(meta-analysis)

Iden

tific

atio

nSc

reen

ing

Elig

ibili

tyIn

clud

ed

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plex sensory condition. There was also high

heterogeneity of study design, which made

comparison difficult. The deficiency in post-

treatment efficacy may be because the

substances used in these treatments are

lost in the oral cavity over time.28,41

DISCUSSION

Clinical trials that have evaluated different

desensitizing agents have used different

approaches, making their effective compar-

ison difficult. There are studies prior to the

period analyzed in this review that evalu-

ated the decrease of sensitivity over 6

months. Among them, Kielbassa et al42

evaluated the effectiveness of two fluoride

lacquers, one containing 6% NaF and 6%

CaF2 (Bifluorid 12, Voco) and another con-

taining only 6% NaF (control group). Evalu-

ations after 6- and 12-month intervals

indicated that the use of the two lacquers

resulted in constantly low hypersensitivity

scores compared to before the treatment.

During these times there was alleviation of

pain, however neither lacquer resulted in

complete removal of the painful condition.42

This finding is likely related to the effective-

ness of the desensitizing agents, which is

directly related to their capacity to promote

the sealing of dentinal tubules or blocking

of nerve activity.14,31,43,44 These temporary

effects could occur because of the tempo-

rary action of the desensitizing agents or

the nontreatment of DH etiology. Figure 4

illustrates a case of DH due to gingival

recession. An understanding of the etiology

of this disease is essential for effective pre-

vention and treatment.9

Fig 3 Posttreatment time of the included studies.

Fig 4 Clinical case illustrating a patient with DH due to gingival recession in the teeth 15, 23, 34, 35, 43, and 44 (FDI tooth-numbering system). (a) Ante-rior view. (b) Right lateral view. (c) Left lateral view .

3 months 3 to 6 months Over 6 months

56%38%

6%

a

b c

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Some researchers43,45,46 have included

patients submitted to periodontal therapy

procedures in their studies. Although

defined as short and sharp pain arising

from exposed dentin which cannot be

ascribed to any other form of dental defect

or disease,26,47,48 many authors have consid-

ered the possibility of DH arising after peri-

odontal therapy, which is an obvious out-

come and can be described only as

temporary sensitivity. While there is no con-

sensus on the definition of this disease, the

studies included in this review evaluated

patients who also had DH after periodontal

procedures. On the other hand, clinical

studies which evaluated the sensitivity after

dental bleaching were not included in this

review because this sensitivity seems to be

a transient outcome after the bleaching pro-

cedure. Although many patients undergo-

ing bleaching procedures complain of post-

operative sensitivity, there is a lack of

clinical investigations correlating the altera-

tions of the dentin-pulp complex with tooth

sensitivity.49,50 It is hypothesized that direct

activation of the intradental nerve via the

chemosensitive ion channel TRPA1 triggers

the sensitivity mechanism during bleach-

ing.49

Among the conventional treatments for

DH, two types of varnish designed to treat

exposed root surfaces (Cervitec Plus and

Cervitec; Ivoclar Vivadent) were evaluated

for 3 months.51 Both equally reduced hyper-

sensitivity for a certain period of time. How-

ever, the efficacy of Cervitec Plus was still

observed 90 days after application

because of better adhesion of the varnish.

When Cervitec was compared to Gluma

Desensitizer in another study,47 the first was

more efficacious after 1 and 3 months.

Gluma Desensitizer was also compared to

Single Bond (3M Espe), Health-Dent

Desensitizer (Healthdent), SE Bond & Pro-

tect Liner F (Kuraray), and Fluoline (PD

Dental) in another clinical trial52 included in

the present review. At the end of the

3-month evaluation period, all desensitizers

showed lower sensitivity values compared

to baseline. Only SE Bond & Protect Liner F

contain colloidal silica, which has consider-

able treatment potential, especially in terms

of tubule blockage. It may have been this

different substance that made SE Bond &

Protect Liner F the most effective agents in

the study period.52

Only one study26 included in the present

review evaluated the decrease of hypersen-

sitivity over 6 months. In this study the

hypersensitive teeth were treated with low-

viscosity glass ionomer (Fuji VII, GC) and a

resin-based glutaraldehyde-containing

primer (Gluma Desensitizer). Fuji VII was

more effective than Gluma Desensitizer

after 3 months and its effect continued for

about 25 months. This indicated that the

glass ionomer was retained longer and still

covered dentin tubules after many episodes

of plaque removal using a toothbrush.

In relation to current treatments, ionto-

phoresis is another therapy that has gained

some popularity. It is a technique in which

fluoride can be transferred under electrical

pressure deep into the dentinal

tubules.10,14,53,54 It may cause calcium fluo-

ride precipitation when used with sodium

fluoride (NaF), which may decrease fluid

movement in dentin tubules, thereby reduc-

ing DH.14 The clinical trials14,48 that evalu-

ated for 3 months 2% NaF-iontophoresis

observed that iontophoresis was more

effective than other treatments (Table 2).

These studies were consistent with the

hypothesis that electrically driven fluoride

ions react with calcium in the hydroxyapa-

tite to form fluorapatite, which blocks the

dentinal tubules.10,27,48

Due to the absence of effective success

in the routine treatment for DH, laser ther-

apy was first introduced in the mid-1980s

as a potential treatment modality.29,55,56 Nine

of the studies evaluated in the present

review included laser therapy. With its

growing utilization in dentistry, many

improvements have occurred in both the

quality and quantity of available laser

types.55,56 In the absence of established

protocols for DH treatment using low-level

laser therapy, comparisons between stud-

ies become difficult.45 Furthermore, com-

pared with conventional approaches, in-

office laser treatment has several

disadvantages, including high cost, com-

plexity of use, and decreasing effectiveness

over time, all of which limit its clinical util-

ity.14,23

Various laser types are used, including

neodymium or erbium-doped yttrium alumi-

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num garnet (Nd:YAG or Er:YAG), CO2,

He-Ne, and diode (ie GaAlA) lasers, all of

which can be applied at various energy set-

tings and wavelengths ranging from

632.8 nm (He-Ne) to 10,600 nm (Er:YAG,

CO2).56 Furthermore, Er,Cr:YSGG laser

(wavelength 2,780 nm) has recently been

tested and its use showed a stable effect

for at least 3 months.31,57 It is important to

consider that the clinical effect of low-level

lasers on DH relies not only on an immedi-

ate analgesic effect, but also on changes in

neural transmission networks and delayed

obliteration of dentinal tubules by tertiary

dentin, the latter of which is due to

increased metabolic activity of odonto-

blasts.44,46,58 However, its efficacy and

mechanism of action are controversial

because of the lack of information related to

the irradiation protocol and the subjectivity

of the evaluation of DH.28,56

In another 6-month evaluation3 that com-

pared five different treatment modalities

(Oxa-Gel, Gluma Desensitizer, Seal&Protect

[Dentsply], Nuprogel [Dentsply], and low-

intensity laser therapy [LILT] of GaAlAs), it

was demonstrated that laser did not pro-

vide an immediate reduction of sensitivity.

After 6 months, all desensitizing agents

were capable of reducing DH. Another simi-

lar clinical trial28 showed that after 3 months

GaAlAs and potassium oxalate gel reduced

the degree of sensitivity; however, a pla-

cebo gel also showed similar effectiveness

over time. Further, in a randomized clinical

trial55 CO2 and Er:YAG lasers showed

potential desensitizing effects for 6 months.

In addition, lasers in combination with NaF

gel appeared to show better efficacy than

either treatment modality alone. Although

the decrease in sensitivity has been verified

in these studies, neither treatment resulted

in complete remove of dentin sensitivity.

In a 4-month posttreatment evaluation,59

the effects of activated Nd:YAG laser were

not statistically significant or different from

the placebo group (non-activated laser) in

reducing pain sensation. However, it was

noted in another study43 that after 6 months

there was significant reduction in DH in

patients who received treatment with

Nd:YAG laser and whose etiologic factors

were removed. In another clinical trial29

using the same laser it was demonstrated

that Nd:YAG was more effective than

Er:YAG laser in reducing pain after 6

months. These studies demonstrated the

potential effectiveness of laser therapy for

DH, although more comparative studies

over 6 months must be conducted to con-

firm its effectiveness.

From these studies, it can be under-

stood that although many therapies aim to

treat DH, there is no agent that is able to

effectively obliterate the dentin tubules

because the substances used are lost over

time and require many applications. The

removal of DH etiologic factors is another

important factor that was little reported in all

selected studies and should be taken into

consideration by researchers, since it can

become a bias in the study design if not

observed. Among all studies included in

this review, therapies involving laser and

iontophoresis showed satisfactory results

for 6 and 3 months, respectively, although

they are more expensive than other modali-

ties and they have not been directly com-

pared. Treatments using mechanical barri-

ers such as Cervitec Plus or SE Bond &

Protect Liner F also seem to have efficacy

until 3 months. However, studies with post-

treatment evaluation over 3 months are

required to evaluate the effectiveness of

these treatments for longer periods. Fur-

thermore, the effective treatment for DH

may be achieved when the desensitizing

agent induces the biomineralization of den-

tin tubules and results in a biological

response of the tooth, thereby obliterating

the tubules and directly addressing the

pathology. Research using biological treat-

ments associated with the removal of DH

etiologic factors is required, since current

therapies have led to recurring sensitivity.

CONCLUSION

There is lack of clinical trials that evaluate

different types of dentin desensitizing

agents over 6 months. Some treatments

with Cervitec Plus, SE Bond & Protect Liner

F, laser, and iontophoresis have shown sat-

isfactory posttreatment results between 3

and 6 months. However, additional clinical

trials are warranted to better compare the

10 doi: ##.####/j.qi.a#####


different types of treatments and their effec-

tiveness in the longer term.

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