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ORIGINAL ARTICLE
Year : 2013  |  Volume : 4  |  Issue : 4  |  Page : 143-149

Comparative evaluation of acidulated sodium fluoride gel 0.33% (iontophoresis) with hydroxy-ethyl methacrylate with glutaraldehyde as a desensitizing agent in dentinal hypersensitivity patients: A clinical study


Department of Periodontics and Oral Implantology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Wanadongri, Hingna, Nagpur, Maharashtra, India

Date of Web Publication22-Jan-2014

Correspondence Address:
Anurag Ashok Shendre
"Shuklendu", 124, Behind Old Hislop College, Mahal, Nagpur - 440 032, Maharashtra
India
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DOI: 10.4103/0976-433X.125589

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  Abstract 

Background: Iontophoresis is a method of electrically transporting ionic particles into the hard and soft-tissues to achieve therapeutic benefits to manage dentinal hypersensitivity. Aim: The primary aim of the following study is to evaluate and the secondary aim is to compare the efficacy of two different desensitizing agents in moderate and severe dentinal hypersensitivity patients using acidulated sodium fluoride (NaF) gel 0.33% using iontophoretic unit and hydroxyl-ethyl methacrylate with glutaraldehyde (HEMA-G), in reducing the dentinal hypersensitivity. Materials and Methods: The hypersensitive teeth were identified by the patient and verified by the light stroke of dental explorer along the cervical area of all teeth. A total of 40 Subjects fulfilling the inclusion criteria were evaluated using stimuli. Responders were recorded with the verbal rating scale scores and divided into two groups: Group 1 (moderate dentinal hypersensitivity) and Group 2 (severe dentinal hypersensitivity). Each group was further subdivided into Subgroup A (treated with Iontophoresis) and Subgroup B (treated with 35% hydroxy-ethyl methacrylate and 5% glutaraldehyde).The teeth were evaluated after 2 weeks and 1 month from baseline. Results: The results were obtained using analysis variance and Student t-test using Graph Pad Prism 5.0 version and SPSS 17.0 version Software for Windows 7 software for Windows and was not significant, reduction in dentinal hypersensitivity was observed with both HEMA-G and Iontophoresis, with a remarkable reduction with Iontophoresis at the end of 2 weeks and 1 month. Conclusion: Desensitizing agents HEMA-G and 0.33% acidulated NaF gel, were both equally effective in causing immediate relief in dentinal hypersensitivity, but Iontophoresis (0.33% NaF) was found to be comparatively better than HEMA-G desensitizer for long-term relief.

Keywords: Hypersensitivity, Iontophoresis, hydroxy-ethyl methacrylate with glutaraldehyde


How to cite this article:
Shendre AA, Gattani DR, Jayaraman P. Comparative evaluation of acidulated sodium fluoride gel 0.33% (iontophoresis) with hydroxy-ethyl methacrylate with glutaraldehyde as a desensitizing agent in dentinal hypersensitivity patients: A clinical study. SRM J Res Dent Sci 2013;4:143-9

How to cite this URL:
Shendre AA, Gattani DR, Jayaraman P. Comparative evaluation of acidulated sodium fluoride gel 0.33% (iontophoresis) with hydroxy-ethyl methacrylate with glutaraldehyde as a desensitizing agent in dentinal hypersensitivity patients: A clinical study. SRM J Res Dent Sci [serial online] 2013 [cited 2019 Sep 20];4:143-9. Available from: http://www.srmjrds.in/text.asp?2013/4/4/143/125589


  Introduction Top


Dentinal hypersensitivity or "sensitive teeth" is a common dental complaint, which may cause patients much distress. [1] It also makes it difficult for patient to maintain oral hygiene and perform proper plaque control measures. The failure to practice satisfactory plaque control has well-established consequences on gingival and periodontal health. Thus, a cycle of sensitive teeth leading to reduced plaque control, more periodontal disease and more recession may be established. [2]

Three major theories currently exist to explain the mechanism of dentinal hypersensitivity. The hydrodynamic theory, [3] which is the most widely accepted, proposes that the stimuli cause a displacement of the fluid that exists within the dentinal tubules and this mechanical disturbance activates the nerve endings in the dentine or pulp.

Various therapeutic rationales have led to different clinically proven treatment modalities. These include nerve depolarization, [4] as occurs with topical potassium nitrate; protein binding and calcium compound deposition within tubules, as with "tooth mousse" or Casein phosphopeptide-amorphous calcium phosphate; [5] increased peritubular mineral deposition, as with topical glucocorticoid therapy; [6] and photobiomodulation leading to tubular occlusion, that light amplification by stimulated emission of radiation desensitization is based upon. [7] Iontophoresis is another technique in which desensitizing agents can be transferred under electrical pressure into the tooth structure to manage hypersensitivity. [8] Iontophoresis of sodium fluoride (0.33% NaF), in which the fluoride ions are transferred under electrical pressure deep into the dentinal tubules, has been utilized.

In the light of the hydrodynamic theory of dentine hypersensitivity, sealing the dentinal tubules with a bonding agent or resin has also been suggested, [9],[10] to create a long-lasting blockage of dentine hypersensitivity. One such product is an aqueous solution of hydroxyl-ethyl methacrylate and glutaraldehyde (HEMA-G) and a strong desensitizing effect of this system on dentine hypersensitivity has been reported. [11],[12]

The aim of the present study was to evaluate and to compare the efficacy of two different desensitizing agents in moderate and severe dentinal hypersensitivity using Acidulated NaF gel (0.33% NaF) Iontophoresis and HEMA-G in reducing the dentinal hypersensitivity.


  Materials and Methods Top


The patients with a history of tooth hypersensitivity were selected from the Department of Periodontics and Oral Implantology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, India, irrespective of age, gender or socio-economic status.

The inclusion criteria were:

  1. History of tooth hypersensitivity to thermal, mechanical, sweet, or sour stimuli on at least one tooth.
  2. Hypersensitive areas on the facial surfaces of the teeth.
  3. Good physical health and willingness to participate in the study for 1 month period.


The following patients were excluded from the study:

  1. Patients having chipped teeth, defective restorations, cracked tooth syndrome, palate-gingival groove, or deep periodontal pockets.
  2. Patients having bridgework, or wore orthodontic appliances.
  3. Patients having pulpal response to caries or to restorative treatment.
  4. Patients using desensitizing toothpastes or any other desensitizing agent.
  5. Patients on a cardiac pacemaker.
  6. Pregnant women.


The patients fulfilling the inclusion criteria were then evaluated using different stimuli. The teeth were isolated with cotton rolls and the stimuli were applied in the following sequence.

Tactile test

A sharp dental explorer was passed lightly across the affected area of the tooth, perpendicular to the long axis of the tooth. The test was repeated 3 times before a score, using the discomfort scale, was noted.

Air blast test

A blast of air from a 3-way syringe was directed onto the affected area of the tooth for 1 s from a distance of 10 mm; the adjacent teeth were protected using cotton rolls.

Cold water test

A pre-cooled 1 cc disposable syringe was filled with freshly melted ice-cold water. After isolating the specific tooth, 0.2 ml of the water was slowly expelled from the syringe onto the tooth surface.

A minimum 5 min gap was given between the applications of different stimuli. On the basis of the above stimuli tests, the patients' response was recorded on the following verbal rating scale (VRS): [13]

0-No discomfort

1-Mild discomfort

2-Moderate discomfort

3-Severe pain only during application of stimuli

4-Severe pain persisting after removal of stimuli

The patients with a VRS score of 2 or more were further included in the study. A written consent was obtained from all selected patients and verbal information about the study was given to each patient prior to treatment.

Study procedure

A total of 40 patients (425 teeth) were included in the study after the stimuli tests. They were divided into further groups and subgroups in the following manner.

Group 1

A total of 20 patients were included having VRS score = 2 (moderate dentinal hypersensitivity). Further 20 patients were subdivided into:

Subgroup A (10 patients) - Treated with acidulated NaF 0.33% gel using iontophoretic unit.

Subgroup B (10 patients) - Treated with 35% hydroxyl-ethyl methacrylate with 5% glutaraldehyde.

Group 2

A total of 20 patients were selected on the basis of VRS score ≥3 (severe dentinal hypersensitivity). Further these 20 patients were equally subdivided into:

Subgroup A (10 patients) - Treated with using acidulated NaF 0.33% gel iontophoretic unit.

Subgroup B (10 patients) - Treated with 35% hydroxy-ethyl methacrylate with 5% glutaraldehyde.

All the patients underwent scaling and root planning. The respective desensitizing procedures then followed.

Application of 0.33% NaF gel (Iontophoresis) (Subgroup A)

The teeth to be treated were isolated with cotton rolls, cleaned and dried with cotton. The negative polarity of the active electrode was selected, as it propels the negative fluoride ions into the affected area. The tray foam were manipulated and cut into appropriate size of the selected tray and then it was well soaked in distilled water and filled with the 0.33% NaF gel, which was used with the active electrode and applied to the affected area of the tooth. Cotton soaked in normal saline was wrapped around the other (inactive) electrode, which was held firmly between the fingers of the patient's hand. The equipment was then switched on and the current knob was slowly turned clockwise until the ammeter read 1 mA; this current was applied for 1 min/tooth [14],[15],[16] [Figure 1] and [Figure 2].
Figure 1: Iontophoresis unit

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Figure 2: Application of APF (0.33% NaF) gel

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Application of bonding agent HEMA-G (Subgroup B)

The teeth to be treated were isolated with cotton rolls, cleaned and dried with cotton. A drop of 35% hydoxyethyl methacrylate with 5% glutaraldehyde was then applied using a cotton applicator and left for 30 s. The surface was then carefully dried with a stream of air until the fluid film had disappeared and the surface was no longer shiny. The patients then rinsed thoroughly with water. [17]

At baseline - Application of 0.33% NaF gel using Iontophoresis (for Subgroup A) and 35% hydoxy ethyl methacrylate with 5% glutaraldehyde (for Subgroup B) was done. For the severe group (Group 1; Subgroup A), the second application of NaF Iontophoresis was done after 2 days (According to manufacturer instructions).

At 2 weeks - Scores were recorded again. Application of both agents (for the respective subgroups), was done, if required.

At 1 month - Scores were recorded again. Application of the respective agents was done, only for patients who still had persistent hypersensitivity. Intra-group and inter-group comparisons were made.


  Results Top


The statistical analysis was performed using the paired t-test, unpaired t-test and chi square test.

[Table 1] depicts, Comparison of the response of Iontophoresis (Subgroup-A) and HEMA-G (Subgroup B) to three types of stimuli in the moderate dentinal hypersensitivity patients (Group 1)
Table 1: Comparison of the response of Iontophoresis (Subgroup A) and HEMA-G (Subgroup B) to three types of stimuli in the moderate dentinal hypersensitivity patients (Group 1)

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[Table 2] depicts, Comparison of the response of Iontophoresis (Subgroup A) and HEMA-G (Subgroup B) to three types of stimuli in the severe dentinal hypersensitivity patients (Group 2)
Table 2: Comparison of the response of Iontophoresis (Subgroup A) and HEMA-G (Subgroup B) to three types of stimuli in the severe dentinal hypersensitivity patients (Group 2)

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[Table 3] depicts, Comparison of the response of moderate (Group 1) and severe (Group 2) dentinal hypersensitivity patients to three types of stimuli after treatment with Iontophoresis (Subgroup A)
Table 3: Comparison of the response of moderate (Group 1) and severe (Group 2) dentinal hypersensitivity patients to three types of stimuli after treatment with Iontophoresis (Subgroup A)

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[Table 4] depicts, Comparison of the response of moderate (Group 1) and severe (Group 2) dentinal hypersensitivity patients to three types of stimuli after treatment with HEMA-G (Subgroup B)
Table 4: Comparison of the response of moderate (Group 1) and severe (Group 2) dentinal hypersensitivity patients to three types of stimuli after treatment with HEMA-G (Subgroup B)

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The following results were obtained in patients with moderate hypersensitivity (Group 1)

  1. Subgroup A and B showed equal effectiveness at baseline.
  2. Subgroup A showed lower mean discomfort scores at 2 weeks, for the air blast [Figure 3]b and cold water stimuli [Figure 3]c, but the results were in favor of Subgroup B for tactile stimulus [Figure 3]a at 2 weeks.
  3. At the 1 month interval, Subgroup A showed lower discomfort scores than Subgroup B, for the air blast and cold water stimuli. Whereas the effectiveness of both treatment modalities was the same for tactile stimuli.
Figure 3: (a-c) Results of Group 1

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The following were the results obtained in patients with severe hypersensitivity (Group 2)

  1. Subgroup A showed lower mean discomfort scores than Subgroup B, at baseline for all 3 stimuli.
  2. At the 2 week interval, Subgroup A was found to be less effective than Subgroup B, for tactile [Figure 4]a and air blast stimuli [Figure 4]b, where the results were the reverse, in case of cold water stimuli [Figure 4]c.
  3. Iontophoresis (Subgroup A) exhibited lower discomfort scores than Subgroup B, at the 1 month interval, for all 3 stimuli, proving to be more effective on a long-term basis.
Figure 4: (a-c) Results of Group 2

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Hence, although the values were not significant, reduction in dentinal hypersensitivity was observed with both HEMA-G and Iontophoresis, with a remarkable reduction with Iontophoresis at the end of 2 weeks and 1 month.


  Discussion Top


Dentinal hypersensitivity probably affects most individuals at some time and in some instances, the pain may be so severe and so regular as to constitute a psychic problem for the patient, who believes that his/her dentition has been seriously and perhaps irreversibly affected. [18] Over the years, a wide variety of methods have been used for the treatment of dentine sensitivity. Effective and robust dentine occlusion offers the greatest prospect for instant and lasting relief of dentine hypersensitivity. [19] Various desensitizing agents have been used, such as, office or home measures, which include sodium fluoride, stannous fluoride, sodium monofluorophosphate, strontium chloride, sodium citrate, potassium oxalate, resins/adhesives and so on. [20] Iontophoresis is another office procedure that produces rapid and effective relief in hypersensitivity.

The present study compares two treatment modalities (NaF Iontophoresis and bonding agent HEMA-G), in the management of dentinal hypersensitivity. NaF was first proposed as a desensitizing agent by Lukomsky, [21] who suggested that when applied to the exposed dentine, NaF forms an effective barrier and results in desensitization of dentine. A study done by Kern et al. [22] concluded that 2% NaF Iontophoresis reduced sensitivity more than 2% NaF used alone.

Burke et al. [11] suggested sealing the tubules or impregnating them with some bonding resin or adhesive material. It has been reported that topical application of bonding agent (HEMA-G) as a desensitizer led to the creation of a peripheral intrinsic barrier consisting of multiple thin septa within the lumen of dentinal tubules. [12] Dondidall' Orologio et al. also suggested that single topical application of the desensitizer eliminated or significantly reduced dentine sensitivity for at least 6 months. [23]

The following mechanisms have been hypothesized for the desensitizing action produced by fluoride Iontophoresis:

  1. Formation of reparative dentine following the application of electric current to dentine. [24]
  2. The electric current produces paresthesia by altering the sensory mechanism of pain conduction. [24]
  3. The concentration of fluoride ions in the dentinal tubules may be increased due to fluoride Iontophoresis. This could cause the microprecipitation of calcium fluoride which may act to block hydrodynamically mediated pain inducing stimuli. [8],[24]


The other desensitizing agent used (bonding agent) contains 5% glutaraldehyde, 35% HEMA.and purified water. The action was attributed to glutaraldehyde, which is a biologic fixative that may denature the proteins in the dentinal fluid, thereby occluding the dentinal tubules. [25] HEMA-G, being water-soluble, might promote deep penetration of glutaraldehyde into the tubules leading to the formation of the peripheral intrinsic barrier consisting of multiple thin septa within its lumen. [12]

In the present study, reduction in dentinal hypersensitivity was observed with both HEMA-G and Iontophoresis, with a remarkable reduction with Iontophoresis at the end of 2 weeks and 1 month. The findings suggested that NaF Iontophoresis provides both immediate and long-lasting relief from tooth hypersensitivity. The findings of the present study are in accordance with the results reported by Murthy et al., [26] Carlo et al., [27] and Kern et al. [22] Murthy et al. [26] reported a 55% reduction in sensitivity immediately after one application. Carlo et al. [27] reported that 61.6% of all the lesions treated had 100% relief of sensitivity to the air blast stimulus and 73.9% had complete relief of sensitivity over tactile stimulus. Kern et al. [22] reported a significant reduction in sensitivity to both tactile ad air blast stimuli immediately after application, which began to return to baseline levels at 3 and 6 months. HEMA-G treatment also showed an effective reduction in dentinal hypersensitivity, in the findings of the current study. However there was a reduction in the effectiveness of the product at the end of the study, probably as a result of the loss of the occluding layer. Kern et al. [22] also reported a reduction in the effectiveness of the product in 3 months probably as a result of wear or loss of the occluding layers. The findings of the present study were in accordance with those of Davidson and Suzuki, [28] and Dondidall' Orologio et al. [23] Davidson and Suzuki [28] reported that a single topical application significantly reduced the hypersensitivity of the exposed cervical dentine. Dondidall' Orologio et al. [23] also reported that a single topical treatment of hypersensitive abrasion/erosion lesions with the HEMA-G desensitizer eliminated or significantly reduced dentine sensitivity throughout the 6 month observation time.

Carlo et al. [27] found that patients with severe hypersensitivity (score at least 3) required a second application of desensitizing agents, while those with moderate sensitivity (score 2) experienced highly significant relief and did not require any additional therapy. In the present study too, a second application was scheduled for the Group 2 (severe hypersensitivity) patients having VAS score more than 2. Singal et al. [17] reported similar results as the current study, wherein the NaF Iontophoresis had a comparatively greater effect than HEMA-G at both 1-3 month intervals. These findings were also in agreement with those reported by Brahmbhatt et al. [29]

However, Olusile et al. [30] in a short-term study reported better and immediate response to HEMA-G compared with NaF Iontophoresis, but further noted a better response after 7 days with Iontophoresis. Hence, from the findings of the present study, it was observed that both NaF Iontophoresis and HEMA-G desensitizer are reasonably effective methods for the management of dentinal hypersensitivity. Further, both are equally effective as far as immediate relief is concerned, but NaF Iontophoresis provides more long-term relief.


  Conclusion Top


The desensitizing agents HEMA-G and NaF Iontophoresis, were both equally effective in causing immediate relief in dentinal hypersensitivity, but 0.33% NaF Iontophoresis was found to be comparatively better than HEMA-G desensitizer for long-term relief.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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