Comparison of the effectiveness of three different desensitizing toothpastes in reducing dentin hypersensitivity: A 4-week clinical study.

AIM: To compare the effectiveness of three different desensitizing toothpastes containing potassium salt, natural ingredients, and 8% arginine in reducing dentin hypersensitivity (DH).
MATERIALS AND METHODS: A 4-week study was conducted on 45 adult patients suffering from hypersensitivity associated with cervical abrasion of two or more teeth anterior to the molars. Patients were divided into three toothpaste groups as follows: Group I: potassium salt, Group II: herbal desensitizing paste containing natural ingredients, and Group III: 8% arginine. Using tactile stimulus and air stimulus, the sensitivity scores were recorded using Visual Analog Scale (VAS) at baseline, immediately after application, after 1 week, after 2 weeks, and after 4 weeks. STATISTICAL ANALYSIS: One-way ANOVA test and post hoc Tukey's test were used, and P ≤ 0.05 was considered statistically significant.
RESULTS: Group III showed significantly better reduction in DH at all time intervals when compared with Group I. Group III was significantly better than Group II at 1, 2, and 4 weeks.
CONCLUSION: Desensitizing toothpaste containing 8% arginine was found to be the most effective in the reduction of DH after a single application up to a period of 4 weeks followed by herbal desensitizing toothpaste and potassium salt-containing toothpaste.

INTRODUCTION

Dentine hypersensitivity (DH) is characterized by short, sharp pain arising from the exposed dentine in response to stimuli, typically thermal, evaporative, tactile, osmotic, or chemical, which cannot be ascribed to any other form of dental defect or pathology.[1]

DH is one of the most commonly encountered clinical problems. It is an uncomfortable and unpleasant condition that affects up to 57% of patients within a dental practice setting.[2] Its diagnosis can be challenging, and the dental professional must perform differential diagnosis to exclude other dental defects and diseases that might give rise to similar presentations such as cracked tooth, dental caries, or periodontal disease. The correct diagnosis always place an important role for treatment to be implemented correctly.[34]

DH is a symptom complex, rather than disease, and a persisting problem, which without proper clinical management can have a significant impact on a sufferer's quality of life.[56] The incidence of DH ranges from 4% to 74%. A slightly higher incidence has been reported in females than in males. The most commonly affected patients are in the age group of 20–50 years, with a peak between 30 and 40 years of age.[78] Canines and premolars are the most commonly affected teeth. Buccal aspect of the cervical area is the commonly affected site.[9]

Gingival recession resulting from abrasion or periodontal disease is considered the primary etiological factor for exposed dentin. Acid erosion is an important factor in opening the exposed dentinal tubules.[1011] Once DH occurs, it gets stimulated on exposure to any external stimulus and causes discomfort to the patient. The discomfort of DH varies from minor (reversible pulpitis) to severe (irreversible pulpitis) discomfort.[1213] As normal hygiene maintenance becomes more difficult, accumulation of dental plaque increases the risk for caries formation, gingival inflammation, and further periodontal problems.[14]

The clinical methods used to diagnose DH include “tactile” method using a blunt probe on the exposed dentin in a mesiodistal direction or “air blast” method on the hypersensitive areas of the tooth. The degree of pain can be quantified either according to categorical scale (i.e., slight, moderate, or severe pain) or using the Visual Analog Scale (VAS).[15]

There are two strategies to control the hydrodynamic mechanism of pain for managing DH. Agents that reduce fluid flow within the dentine tubules by occluding the tubules, thereby blocking the stimuli, and those that interrupt the neural response to the stimuli.[16]

The majority of desensitizing toothpastes contain potassium salt which is believed to work by penetrating the length of the dentin tubule and depolarizing the nerve, interrupting the neural response to pain stimuli.[17]

A novel DH treatment technology (Pro-Argin), consisting of 8% arginine, an aminoacid found in saliva, in combination with calcium carbonate, is now available as a desensitizing paste for in-office application. This desensitizing technology mimics saliva's natural process of plugging and sealing open dentinal tubules.[18]

There has been growing interest among people regarding herbs which have property to influence on the oral health. HiOra-K (Himalaya Drug Company, Bengaluru, Karnataka, India) is a recently marketed herbal desensitizing toothpaste which claimed to give adequate relief of pain due to DH. It is also safer to use with less adverse effects.[1920]

Despite a huge amount of published data, the “gold standard” in the management of DH still lacks. There is insufficient literature which compares the desensitizing efficacy of herbal desensitizing pastes with other commercially available desensitizing pastes. Hence, the objective of this study was to compare the desensitizing efficacy of potassium salt-based paste, 8% arginine-based paste, and herbal desensitizing paste containing natural ingredients in reducing DH instantly after single application and at 1-, 2-, and 4-week follow-up.

MATERIALS AND METHODS

Ethical clearance was obtained for this study from the Institutional Ethics Committee, PMNM Dental College and Hospital, Bagalkot. An in vivo, double-blind study was done among 45 patients who visited the department of our institution. The duration of the study was 4 weeks. The sensitivity scores were recorded at baseline, immediately after application, after 1 week, after 2 weeks, and after 4 weeks.

Inclusion criteria

Patients with good health in the age range of 18–50 years

Patients with minimum of two hypersensitive teeth which are anterior to the molars and demonstrated cervical abrasion or gingival recession

Defects <1 mm loss of dentin in depth which did not require restorative treatment

Patients were required to be available during the duration of study and to sign an informed consent form.

Baseline sensitivity values were recorded before starting the treatment using tactile method and air blast stimuli.

Exclusion criteria

Patients with gross underlying pathologies, patients with existing systemic medical condition, and pregnant and lactating females were excluded from the study.

Tactile sensitivity assessment

Tactile sensitivity was assessed by using a blunt probe used under slight manual pressure in the mesiodistal direction on the hypersensitive areas of the tooth.

Air blast sensitivity assessment

Air blast sensitivity was assessed by directing a 1–2 s blast of air perpendicular to the exposed dentin (40 ± 5 psi) onto the buccal surface of sensitive tooth from a distance of 1 cm using air component of an air–water syringe. Adjacent proximal teeth were shielded from air blast through the placement of two fingers.

The record of hypersensitivity was based on the VAS; the scores were recorded on the 10-cm scale, with stipulated ratings ranging from 0 to 1 with no pain, 2–3 with slight pain, 4–6 with moderate pain, and 7–10 for severe pain. Patients with baseline values ≥4 on VAS were accepted into the study.[21]

The individuals who qualified the tactile as well as the air blast sensitivity assessment were selected and randomly assigned to the three study groups, 15 patients in each group with two teeth per patient to be considered in the study. The randomization process was made using a computer-generated random table (Microsoft Excel):

Group I: Desensitizing paste containing potassium salt (Sensodyne, GlaxoSmithKline Asia Pvt. Ltd., Patiala, Punjab, India) (n = 30 teeth)

Group II: Herbal desensitizing paste containing suryakshara, palakya, lavanga, and triphala (HiOra-K, Himalaya Herbal Healthcare) (n = 30 teeth)

Group III: Desensitizing paste containing 8% arginine (Colgate Sensitive Pro-Relief™, Colgate-Palmolive [India] Ltd., Mumbai, India) (n = 30 teeth).

Method of application

Using a disposable applicator tip, pea-sized amount of the toothpaste was applied over the isolated hypersensitive area of the tooth for 5 s, and a rotary polishing cup at moderate-to-high speed was used to polish the paste over this surface for 1 min.

Scores immediately, post application and after 1 week, after 2 weeks, and 4 weeks were recorded by the same examiner using the same methodology of tactile stimuli and air blast stimuli.

Statistical analysis

Analysis of data was done by SPSS 17.0 software (SPSS, Chicago, IL, USA). Word document and Excel sheet were used to generate tables. Analysis of variance and post hoc Tukey's test were used to determine the significance of reduction in DH of the patients between the three groups at different time intervals. The level of statistical significance was set at 0.05.

RESULTS

All the 45 participants completed the study, and the total number of teeth was 90. There were no adverse effects on hard and soft tissues.

There was a significant difference in mean change in VAS scores between all groups when baseline values were compared with immediate, 1-week, 2-week, and 4-week time intervals [Table 1].

Table 1

Descriptive statistics of the Visual Analog Scale scores difference from baseline to different time intervals

Change in VAS score	Groups	n	Mean	SD	P
Preoperative versus immediate	Group I	30	1.067	0.583	0.035*
	Group II	30	1.267	0.740
	Group III	30	1.533	0.730
Preoperative versus 1 week	Group I	30	1.533	0.629	0.001*
	Group II	30	1.833	0.747
	Group III	30	2.300	0.877
Preoperative versus 2 weeks	Group I	30	2.300	0.750	0.004*
	Group II	30	2.500	0.938
	Group III	30	3.033	0.850
Preoperative versus 4 weeks	Group I	30	2.533	0.730	<0.001*
	Group II	30	2.767	0.935
	Group III	30	3.733	0.907

*Statistically significant using one-way ANOVA. VAS: Visual Analog Scale, ANOVA: Analysis of variance

Group III showed significantly better reduction in DH at all time intervals when compared with Group I. Group III was significantly better than Group II at 1-week, 2-week, and 4-week time intervals [Table 2].

Table 2

Comparison of Visual Analog Scale scores difference from baseline to different time between the groups

Dependent variable	Group (I)	Group (J)	Mean difference (I−J)	SE	P
Preoperative versus immediate	Group I	Group II	−0.200	0.178	0.501
		Group III	−0.467	0.178	0.027
	Group II	Group III	−0.267	0.178	0.296
Preoperative versus 1 week	Group I	Group II	−0.300	0.196	0.280
		Group III	−0.767	0.196	<0.001*
	Group II	Group III	−0.467	0.196	0.050*
Preoperative versus 2 weeks	Group I	Group II	−0.200	0.219	0.634
		Group III	−0.733	0.219	0.003*
	Group II	Group III	−0.533	0.219	0.045*
Preoperative versus 4 weeks	Group I	Group II	−0.233	0.223	0.549
		Group III	−1.200	0.223	<0.001*
	Group II	Group III	−0.967	0.223	<0.001*

*Statistically significant using Tukey’s post hoc test. SE: Standard error

The effectiveness of single application of desensitizing paste over a period of 4 weeks among the individuals was graded as Group III > Group II > Group I.

DISCUSSION

Pain due to DH is largely a subjective symptom, and so effective pain control requires careful assessment and regular review of the patient's experience of dental pain. The satisfactory material for the treatment of DH is required to be nonirritant to the pulp, painless on application, easy to apply, rapidly acting, long-term effective, and consistent.[19] Desensitizing pastes have been used widely in the past for treating DH because of their low cost and ease for the use for the home application.

In this study, the stimuli used were both tactile and evaporative, as it was recommended by Holland et al.,[22] which arose from the fact that different stimuli can elicit different pain sensations of different intensities.

There was a significant difference in mean change in VAS scores between all groups when baseline values were compared with immediate, 1-week, 2-week, and 4-week postoperative scores. This finding is in accordance to the study done by Jena and Shashirekha.[23]

In this study, toothpaste containing 8% arginine (Group III) was found to be most effective in the reduction of DH followed by herbal (Group II) and potassium salt (Group I) toothpastes at all time intervals. This result is in accordance to the study done by Elias Boneta et al. which showed significant desensitizing efficacy of 8% arginine toothpaste over potassium salt-containing toothpaste.[24] This result is also in accordance to the study done by Bansal and Mahajan which showed significant desensitizing efficacy of 8% arginine toothpaste over herbal toothpaste.[19] This finding may be attributed to the presence of arginine and calcium carbonate which interact at physiological pH and bind to negatively charged dentin surface to form a calcium-rich layer that naturally plugs and seals patent dentinal tubules. This plug is resistant to normal pulpal pressure and acid challenge, thereby reducing dentin flow and DH.[25]

In this study, herbal desensitizing paste (Group II) was more effective in reducing DH than potassium nitrate-containing toothpaste (Group I). This finding may be attributed to the presence of natural ingredients such as suryakshara, palakya, lavanga, and triphala. Suryakshara is a naturally derived potassium nitrate which desensitizes dental nerves. Palakya (spinach) contains natural oxalates which help in the formation of phytocomplexes and occlude the exposed dentinal tubules. Lavanga (clove) and triphala control pain due to the obtundant action of eugenol. These herbs altogether could be exhibiting a synergistic effect in reducing pain due to DH.

Other treatment options for DH such as laser therapy and iontophoresis are also used. However, they have many disadvantages such as more expensive, more complex, and questionable long-term effectiveness.[26]

As the goal of the study was to investigate the efficacy of desensitizing pastes to eliminate participants’ acute complaints of DH on a single application, a short-term study (4 weeks) was performed. However, long-term studies should be performed to determine the pain relief efficacy of desensitizing pastes.

CONCLUSION

Under the limitations of the study, 8% arginine-containing toothpaste was found to be most effective followed by herbal and potassium salt-containing toothpastes. There has been growing interest in natural products, especially in dentistry. Herbal desensitizing toothpaste could be a safer and effective alternative to potassium salt-containing toothpaste in reducing DH in future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.