Effectiveness of Diode Laser 980nm Versus Sodium Fluoride Varnish in the Treatment of Dentinal Hypersensitivity

Mohammed Saleem Alhabeel *¹, Adriano Bartoli², Marco Garrone  DS³, Wayn Salting⁴, Eleyan Abukhalil⁵, Mohammad Sarahneh⁶, Aseel Qasarweh⁷, Emanuele Ruga ⁸

1. BDS; MSc ABLS, Dentist and oral maxillofacial laser specialist, Director of Development in American Board of Laser Surgery, Director of Dental department in Salamaty Polyclinic , Saudi Arabia, international speaker Laser dentistry , Facial Aesthetics medicine and Oral surgery.

2. DDS. Oral Surgery specialist. MSc Aesthetic medicine.

3,8. DDS, Specialist in Oral Surgery; MSc Aesthetic Medicine, Active members of Italian Society of Aesthetic Dental Medicine (SIMEO).

4.Department of Surgical Science and integrated Diagnostics, University of Genoa, Largo R. Benzi 10-16132 GenoaItaly.

5,6,7. B.D.S

*Correspondence to: Mohammed Saleem Alhabeel, BDS; MSc ABLS, Dentist and oral maxillofacial laser specialist, Director of Development in American Board of Laser Surgery, Director of Dental department in Salamaty Polyclinic , Saudi Arabia, international speaker Laser dentistry , Facial Aesthetics medicine and Oral surgery.
 

Copyright

© 2023 Mohammed Saleem Alhabeel. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 23 August 2023

Published: 05 October 2023

Abstract

Background: Dentin hypersensitivity is a problem associated with sharp and short duration pain due to many predisposing factors. Many treatments are important in this aspect which are effective as well, among which laser treatment and chemical agents are well known. But scientific study demands continuous advancement and evaluation in order to make more updated knowledge to the researchers, doctors and professionals. This makes the foundation of this study very significant.

Aim and Objectives: The primary aim of the study is to review the literature to compare the effectiveness of Diode laser 980 nm versus fluoride varnish in the management of hypersensitivity of dentin.

Objective of this research study is:

1. To systematically search, synthesize and critically appraise the available literature for both methods of treatment.
2. To determine the effects of the treatment for dentinal hypersensitivity in clinical practice and research.

Method: Electronic databases were investigated and explored using specific search methods. Hand searches of applicable reviews and literature were carried out to gain maximum yield from them. The veteran opinion and experts advise for extra helping bits and pieces .Keeping all this in mind specifically the studies' inclusion and exclusion criteria, care was taken to include competent and eligible abstracts of  knowledge were added in this review manuscript.

Results: The studies and reviews included were evaluated for methodological outcomes with a proper analysis .Many manuscripts were added in the paper starting from basic knowledge including significant causes, anatomical importance for the occurrence of disease, treatment and classification with a focus on laser treatment along with treatment with sodium fluoride varnish for DH. Both treatments were found very effective but synergistic effect of both protocols proved an enhanced efficacy in treating the DH.

Discussion

The quality research reviews and manuscripts were evaluated for the desired purpose of treatment. It was carefully estimated that continuous study with upgrading technology variation is mandatory in the treatment of cases. It was concluded that all studies were consistent gold standard, however further research is needed in the field of oral dentistry and real benchmarks have to be recorded for enhanced prospects in dentin hypersensitivity treatment protocol.

Abbreviations

• DH   (Dentin Hypersensitivity)
• HD   (Hypersensitive Dentin)
• NaF ( Sodium Flouride ).

Introduction

Dentin hypersensitivity that is abbreviated as DH (Karim and Gillam,2013)or it can also be shortened as DHS and also recognized as sensitive dentin or dentin sensitivity (Miglani et al,2010) or cervical sensitivity (Advisory board,2003) and cervical hypersensitivity is a class of dental pain which is very sharp in character and of very short duration, that arise from exposed dentin surfaces in response to some kind of specific stimuli, normally thermal, evaporative, tangible, osmotic, chemical or electrical and which cannot be credited to any other kind of dental disease (Advisory board,2003).

Dentin sensitivity is usual, but here pain is not generally experienced in everyday activities like drinking a cold drink (Turp and Jens 2012). Therefore the term dentin sensitivity and sensitive dentin are used regularly to refer to dental hypersensitivity (Advisory board, 2003). So such terminologies or definitions are used most frequently in the literature, research papers and books.

Dentine tubules must be patent from the dental pulp to the oral environment to experience pain (Absi etal, 1987) which is widely thought to result from stimulus-induced tubular fluid flow and consequent nocioceptor activation in the pulp or dentine boundary area (Addy, 1987; Addy et al, 2000; Addy et al, 2002). Patients’ value or quality of life is frequently distorted as the pain is linked with tangible frequent discomfort (Bekes et al, 2009).Affected individuals manage by modifying behaviors such as avoiding more from chilled food and drink and seeking self or expert treatment(Nicola, 2013).

Definitions

• Dentinal Hypersensitivity is indicated by a sharp pain, which is of a short duration, which arises from exposed dentin surfaces when it is stimulated by thermal, tactile or osmotic stimuli. This pain cannot be related to any other dental disease or condition.
• De-sensitizing Agents are drugs, which alleviate painful sensations occurring in exposed dentin. Some of desensitizing agents are sodium fluoride, stannous fluoride etc. Cervical Sensitivity is synonymous to dentinal hypersensitivity.
• Diode Laser 980nm is a high-energy laser, which has low cost and maintenance rates and is greatly versatile owing to its small size.
• Erosion of tooth is the wearing of tooth enamel due to acidic reactions and this can be a major reason for Hypersensitive Dentin.
• Gingival Recession is an undesirable condition in which the roots are exposed, leading to caries and hysensitivity.

Signs and Symptoms

Hypersensitivity is a very sharp and sudden pain in response to an external stimulus. (Addy and Dowell 1983). The generally and widespread cause is cold (Nicola, 2013) with set up of 70% - 75% of people with hypersensitivity reporting pain upon application of a cold stimulus (Advisory board,2003).There are also other types of stimuli which can also start pain in dentin hypersensitivity. There are different stimuli which may impact teeth as well.

1.Thermal stimulus is very significant, e.g. hot and cold drinks and foods(Petersson,2006) and electrical

2. Mechanical, for example dental probe during dental examination,(Hargreaves,2010)

3.Tooth brushing (Petersson, 2012).

4.Osmotic stimuli such as sugars. (Hargreaves,2010)

5.Another stimulus is evaporation, for example air blast from a dental instrument (Hargreaves, 2010)

6.Chemical exposure to teeth like acids, dietary, gastric, acid etch during dental treatments. (Hargreaves,2010)

Significant Causes

The main cause of DH (Dentin Hypersensitivity) is gingival slump or recession along with revelation of root surfaces, trouncing of the cementum and smear layer and tooth wear (Hargreaves, 2010).We can see receding gums. Receding gums can be a precursor of long-term trauma from needless or dynamic tooth brushing, or brushing with coarse toothpaste (Hargreaves, 2010).

Other less extensive causes are acid decomposition (this is related to gastroesophageal reflux disease, excessive utilization of acidic foods and drinks etc) and periodontal root planning. (White, 2007). Dental bleaching is another recognized root of “Dentin hypersensitivity “or DH (Hargreaves, 2010).

Dentine is a complex structure to observe .Dentine contains many microscopic tubular structures that branch out outwards from the pulp. These dentinal tubules are typically 0.5–2.5 micrometres in diameter. Plasma-like biological fluid is present in the dentinal tubules that can trigger mechanoreceptors present on nerves that are located at the pulpal facet, thereby giving out a pain reaction. This flow can be augmented by cold, air pressure, drying, sugar, sour or stimuli that are acting onto the tooth. A very hot or cold food or drinks, and solid pressure are most common triggers in these individuals with DH.Most experts and veteran on this topic declare that the pain of Dentin hypersensitivity (DH) is a normal, physiological reaction of the nerves in a healthy, non-inflamed dental pulp in the situation where the insulating layers of gingiva and cementum have been gone (Advisory board, 2003). To disagree with this observation that not all exposed dentin surfaces cause DH (Advisory board,2003), some others suggest that due to the presence of obvious dentinal tubules in areas of oversensitive dentin, there may be increased pain to the pulp, thus causing a state of reversible inflammation (Schmidlin,2012).

Epidemiology

Dentine hypersensitivity (DH) is a general oral pain condition characterized as an intense, transient pain resulting from stimulation of exposed dentine, characteristically in response to chemical, thermal, tactile or osmotic stimuli (Addy, 1983; Ress et al, 2003).

Prevalence with respect to age factor.

Dentin hypersensitivity is a relatively common condition. The reported incidence of DH ranges from 4-74%. Dentists may under-report dentin hypersensitivity due to complexity in diagnosing and overseeing the condition. In common, it is estimated to affect about 10%-15% of the general population to some extent.

Dentine hypersensitivity (DH) manifests as a transitory but stunning oral pain. The incidence is thought to be increasing, mainly in young adults, due to increases in consumption of healthy, however erosive diets. The studies measure a towering prevalence of DH and relative importance of risk factors in 18–35 year old People especially Europeans. (Nicola, 2013).

Prevalence with respect to gender

It may involve people of any age, though those aged 20–50 years are more expected to be affected, with more people affected between ages of 30-40 years of age (Advisory board, 2003 and Flynn, 1985).

Females are slightly more likely to build up dentin hypersensitivity compared to males (Advisory board, 2003).

Prevalence with respect to anatomical position.

The condition is most normally associated with the maxillary and mandibular canine and bicuspid teeth on the facial aspect (Advisory board, 2003).DH has more prevalence with the type and location of teeth involved. (Taani and Awartani, 2001)

Prevalence with respect to type of teeth involved.

Regarding the type of teeth involved, incidence is elevated in canines and premolars the most affected teeth. This is also seen that buccal aspect of cervical area is the normally affected site (Addy, 1987).

Overall, the prevalence of DH was seen high as compared to many available findings, with a well-built, progressive correlation between DH and erosive tooth wear, which is important to differentiate for patient preventive therapies and medical management of DH pain (Nicola, 2013).

Prevalence of the common oral pain condition, dentine hypersensitivity (DH) is high in young adults, however peoples’ insight of their pain is less than that of clinical reporting possibly reflect the transient nature of the pain condition and good coping mechanisms. Erosive tooth wear and loss of attachment were strongly associated with high prevalence of DH. Possible risk factors such as erosion from gastric origin and intake of erosive foods were corroborated in this investigation as they are considerably associated with high prevalence (Boiko et al, 2003) of dentine hypersensitivity (Nicola, 2013).

Pathogenesis

Dental Hypersensitivity has a sharp and painful tract in the oral channel. Lesions develop slowly in steps with sharp mode. It has been stated many times in most of literature that DH develops in numerous phases, usually two phases: lesion localization and lesion initiation (Gillam and Orchardson, 2006). Lesion localization takes place by loss of defensive covering (Orchardson and Cadden, 2001) over the dentin, thus revealing it to external environment. It comprises defeat of a protective layer that is enamel via attrition, abrasion, erosion. Another reason for lesion localization is gingival recession which can be due to toothbrush scratch, tooth preparation for crown, unnecessary flossing (Dababneh et al, 1999).

As it is assured before, not all uncovered dentine is sensitive. For DH to occur, the lesion localization has to be initiated. It occurs after the defensive covering of smear layer is disconnected that leads to revelation and opening of dentinal tubules. (Wilchgers and Emart, 1997).

Mechanism

There are several mechanisms by which dentinal sensitivity operates. (Pashley et al, 1986; 1990; 1992; 2000).Three key mechanisms of dentinal sensitivity have been premeditated.

1. Direct innervations theory
This theory narrates that nerve endings go throughout dentine and extend to the dentino-enamel junction. (Irvine, 1988).Straight mechanical stimulation of these nerves will start an action prospective. There are many insufficiency of this mechanism theory. There is need of substantiation that outer dentin, which is characteristically the mainly sensitive element, is innervated. Developmental studies and researches have exposed that the plexus of Rashkow and intratubular nerves do not set up themselves till the tooth has erupted, however, lately erupted tooth is much sensitive (Orchardson and Cadden, 2001).Additionally, pain inducers such as bradykinin not succeed to encourage pain when relate to dentine, and bathing dentine with local anaesthetic solutions does not stop pain, which does so when applied to skin usually.

Figure 1: Tubule anatomy. When cementum or enamel covering the dentin is removed or breached, the fluid within the exposed dentinal tubule is able to transmit pain-producing stimuli.

Source: http://www.dentistrytoday.com/aesthetics/129

2.   Odontoblast receptor theory
There is another theory of mechanism of action by which DH is observed in teeth. Odontoblast receptor theory observes that Odontoblast act like as receptors by themselves and passes on the signal or signal to a nerve terminal (Rapet al, 1968).But extensively held studies and researches have made known that odontoblasts are medium of forming cells and consequently they are not measured to be emotional cells and no synapses have been established stuck between odontoblasts and nerve terminals. So this speculation also has an excellent weight in determination of the DH.

Figure 2:  Odontoblast

Source: http://biologicalexceptions.blogspot.com/2014_05_01_archive.html

3.   Hydrodynamic theory

Among many theories of dentinal pain and DH, the most pertinent theory is that dentinal pain is due to hydrodynamic mechanism of action i.e., fluid force (Brännströmand Åström, 1964).

Electron microscopic (EM) analysis of “hypersensitive” dentin indicates the existence of widely open dentinal tubules (Absi, 1987).The incidence of wide tubules in oversensitive dentin is constant with the hydrodynamic theory. This theory of action is extensively based on the existence and progress of fluid in the dentinal tubules. This special fluid movement, in turn, activates the nerve endings at the end of dentinal.(Orchardson and Gillam,2006) This is parallel to the commencement of nerve fibers neighbouring the hair by touching and applying pressure to the nearby hairs. The reaction of pulpal nerves depends upon the pressure applied, i.e., strength of stimuli (Orchardson and Gillam,2006).It has been eminent and distinguished that stimuli which tend to move the fluid away from the pulp–dentine complex, formulate additional pain. These stimuli comprise which contribute to this is cooling, drying, evaporation and ultimately application of hypertonic substances (Chidchuangchai et al, 2007).

About more than 70-75%% of patients with DH complain of pain with appliance of cold stimuli allegedly said, a reduced pain in the tooth. (Chidchuangchai et al, 2007). In spite of the fact that fluid progress inside the dentinal tubules induces pain, it must be renowned that not all exposed dentine is sensitive. As said before, the “hypersensitive” dentin has more generally open tubules as compared with “non-sensitive” dentine. The wider tubules increase the fluid movement and thus the pain response become

Figure 3: Vitality and sensitivity of dentines further prominent (Absi, 1987 and Rimondini, 1995)

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