Comparison of the Effectiveness of Three Different Desensitizing Toothpastes in Reducing Dentinal Hypersensitivity: A Four-Week Clinical Study

Introduction

Dentin 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 It is one of the most prevalent clinical issue, especially in adults and older age group and peak is seen between 30-40 years of age. The incidence of dentin hypersensitivity ranges from 4% - 74% and a slightly higher prevalence is noted in females than in males.^2,3 Gingival recession, abrasion, attrition could be the primary etiological factors for exposed dentin and also acidic diet, improper brushing technique leading to erosion are the other factors attributing to it.⁴ The most frequently affected areas are the buccal surfaces and occlusal surfaces on the cervical side.

Once DH has formed, any form of external stimulation can trigger it to become active and cause harm to the sufferer. With DH, discomfort can range from mild (reversible pulpitis) to severe (irreversible pulpitis).^5,6 When tooth plaque builds up, it becomes harder to maintain proper hygiene, which increases the risk of periodontal disease and the development of caries.⁷

The "tactile" method using a periodontal probe on the exposed dentin in a mesiodistal direction and the "air blast" method using an air blast on the hypersensitive portions of the tooth are clinical techniques for diagnosing DH. The Visual Analogue Scale (VAS) is used to measure the intensity of the pain.⁸

Two management strategies for DH include the use of drugs that interfere with the neurological reaction to stimuli and restrict fluid movement by occluding the tubules within the dentine, thus blocking the stimuli. These medications also block the hydrodynamic pain mechanism.⁹

This condition is also controlled by occluding dentinal tubules and there are various methods to treat this, for example, application of bonding and desensitizing agents, lasers, etc. One among them which is commonly used and easily followed by patients is the use of desensitizing toothpastes containing remineralizing agents like fluoride, potassium nitrate, calcium and few natural ingredients like propolis, guava leaves, bentonite clay, clove oil, etc.

Majority of toothpastes designed to reduce pain sensitivity include potassium salt, which is believed to function by entering the dentin tubule and depolarizing the nerve, stopping the neurological reaction to pain stimuli.¹⁰

In recent times, people are more inclined towards the use of organic or herbal medicaments as an alternative, due to lesser side effects and similar action. To treat various conditions, Bentodent an earthly natural toothpaste containing propolis and guava leaves was used. Bentonite clay along with Propolis and guava extract seals the dentinal tubules. Additionally, it creates a barrier of defense against acidity, brushing, heat, cold, sweet, and sweet-related tooth sensitivity. Guava extract helps to quickly relieve tooth sensitivity pain, making Bentodent natural toothpaste the most reliable and secure choice for daily teeth cleaning.

NovaMin, a bioactive glass, has been used to treat dentin hypersensitivity due to its osteogenic potential. It reacts with saliva-deposited hydroxycarbonate apatite, occluding dental tubules and forming an apatite layer, as shown in SEM analysis as demonstrated by Gillam et al.^11,12

Till date, there have been no studies done using Bentodent desensitizer toothpaste.

This study's goal was to compare the efficacy of a natural toothpaste with two other commonly used desensitizing toothpastes containing potassium nitrate and calcium sodium phosphosilicate (CSPS) against dentin hypersensitivity immediately after first use, and after one week and four weeks.

Materials and Methods

Due clearance was obtained from the Ethical Committee of the Institution, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore. Adult patients presenting with the complaint of sensitivity due to dentine exposure either because of abrasion, attrition, erosion, gingival recession, post scaling and dentine exposure <1 mm that does not require restoration and patients with a VAS score of ≤3 were included in the study. The patients not willing to give informed consent, patients with active periodontal disease, active skin infections, patients with sensitivity due to caries or fractured restorations, patients allergic to any ingredient of toothpaste, pregnant and lactating women and those with VAS score of >3 were excluded. The materials used were three-way syringe, periodontal probe, soft toothbrush, Bentodent desensitizer toothpaste, Sensodyne toothpaste and Shy-NM toothpaste.

Procedure

An in vivo, two arm, randomized controlled clinical trial was conducted including 36 walk-in patients reporting to the outpatient Department of Conservative Dentistry and Endodontics with the chief complaint of sensitivity. The study period extended up to four weeks. This randomized controlled trial was done by following CONSORT (Consolidated Standards of Reporting Trials) guidelines. Informed consent was obtained from each patient and before beginning the treatment, each patient's baseline sensitivity levels were obtained using air blast stimuli and tactile sensitivity testing methods.

Tactile sensitivity assessment was done using a periodontal probe with minimal manual pressure in the mesio-distal direction on the affected teeth.

Air blast sensitivity assessment was determined by utilizing the air component of an air-water syringe to fire a 1-2 second airburst perpendicular to the exposed dentine of the impacted teeth from 1 cm distance.

The observed hypersensitivity was recorded based on Visual Analog Scale. The scores were recorded on the 10 cm scale, with stipulated ratings ranging from, 0-1: no pain, 2-3: slight pain, 4-6: moderate pain, and 7-10: severe pain. Patients were accepted into the research if their VAS baseline values were ≤3.

Those who passed both evaluations were chosen and allotted randomly to one of three following study groups, each with 12 participants.

• Group I: Desensitizing toothpaste comprising natural ingredients like guava leaf, propolis, bentonite clay, clove oil etc. (Bentodent Desensitizer toothpaste, Patiala, Punjab, India) [n=12]

• Group II: Potassium nitrate-based desensitizing paste (Sensodyne by GlaxoSmithKline Asia Pvt. Ltd. Patiala, Punjab, India) [n=12]

• Group III: Calcium sodium phosphosilicate (CSPS) containing paste (Shy-NM, Group Pharmaceuticals Ltd.) [n=12]

Patients were instructed to take the toothpaste in a pea-sized amount, apply it onto the sensitive teeth, keep it for two minutes and brush using a soft toothbrush twice a day for a period of 30 days. Patients were recalled after first use, one week and four weeks. Sensitivity assessment was carried out using the same tactile sensitivity and air blast sensitivity assessment methods. The VAS scores were compared with the initial score measured.

Statistical test

Statistical analysis was performed using SPSS (Statistical Package For Social Sciences) version 20 (IBM SPASS statistics, IBM corp. released 2011) and Excel. Descriptive statistics of the explanatory factors and outcome metrics were calculated by mean, standard deviation, median and IQR (based on data distribution) for quantitative variables, frequency and proportions for qualitative variables. Inferential statistics like Chisquare test was applied for qualitative variables and One-way ANOVA test (Post hoc analysis- Tukey test) was applied for quantitative variables between the groups. The significance level was set at 5%.

Results

All the 36 subjects finished the trial without experiencing any negative effects on their hard or soft tissues. The mean change in VAS scores between all groups was significantly different when pre-operative values were compared with immediate, one-week, and four-week time intervals.

Baseline comparison depicts a comparable result between all the three groups. One week comparison between the three groups showed both Shy-NM and Bentodent to have significantly better effect compared to Sensodyne. Shy-NM showed slightly better results than Bentodent, but there was no significant difference between the two. The results after four weeks were similar to post one week data.

Discussion

Dentinal hypersensitivity is a significant global clinical issue due to dentin exposure elicited by thermal stimulus, often referred to as “mysterious dentin” or an “enigma”. It is most commonly noticed in middle aged individuals, with either cervical abrasion, attrition, erosion or poor periodontal conditions.¹³

It is often a combination of multiple factors, with open dentinal tubules providing a direct link between the external environment and the internal pulp of the tooth. In sensitive dentine, the apertures are patent, allowing more stimuli to contact the pulp. Despite prolonged exposure, dentinal sensitivity may persist, making the pulp irreversibly sensitive. Treatment aims to restore impermeability and control neural elements within the pulp, either through partial or total obliteration or alteration of sensory activity.

Keeping in mind the etiological factors, in this study, the labial surfaces of the teeth were taken into consideration, and tactile, evaporative, and aqueous stimuli were used in that order for sensitivity testing to avoid interpretation error. To reduce two stimuli interactions, a gap of about five minutes was provided between the two.¹⁴

The utilization of natural ingredient to treat dentine hypersensitivity and to evaluate its effectiveness when compared to commonly available over the counter products was the main criteria of this investigation.

The length of relief offered by different desensitizing toothpastes vary greatly. A substance is required to chemically react with the dentin's surface and cling firmly to the tooth structure, greatly decreasing the likelihood that the dentinal tubules would reopen.

One of the groups in the current study was Bentodent desensitizer toothpaste, and its effectiveness was compared to Sensodyne and Shy-NM separately. Propolis, Hemp extract, guava leaves extract, Peppermint extract, tea tree extract, clove oil, glycolipids, Bentonite earth, Grapeseed extract, water, sodium benzoate and bentonite clay, are the ingredients in Bentodent toothpaste.

Oral care can be compromised by poor habits and wear and tear, exposing nerve endings in dentinal tubules. Bentonite clay, Propolis, and guava extract seal dentinal tubules, providing a protective barrier against tooth sensitivity. Guava extract relieves pain from tooth sensitivity. Bentodent natural toothpaste is safe and non-irritating, unlike major toothpastes containing sodium laurel sulfate, preventing allergic reactions and maintaining oral health.

Shy-NM contains Bioglass, also known as NovaMin, an inorganic substance made of calcium sodium phosphosilicate. This bioglass paste is used to treat dentin hypersensitivity and has been shown to create sealing depth in dentinal tubules. In an aquatic environment, NovaMin particles physically occlude and release sodium ions and phosphate ions. These ions release into the saliva within seconds, causing the creation of a calcium-phosphate layer. This layer creates hydroxycarbonate apatite during crystallization, which is physically and chemically identical to biological apatite. According to another study, the physical blocking of dentinal tubules brought on by the interaction of lingering NovaMin particles and the hydroxycarbonate apatite layer enhances hypersensitivity.¹²

Using toothpaste containing NovaMin and Shy-NM, numerous experiments have been conducted. Because of its highest percentage of tubular occlusion.¹²

The mean change in VAS scores was significantly different between the aforementioned two groups when the baseline values for Shy-NM and Sensodyne with immediate, one week, and four week postoperative assessments were compared. This outcome is in line with the studies conducted by Jena and Shashirekha comparing Sensodyne with Shy-NM.¹²

In this study, toothpastes with natural ingredients (Group I) were observed to reduce DH more effectively than toothpastes with Shy-NM (Group III) and Sensodyne (Group II) at all time points.

In this trial, natural desensitizing paste (Group I) was found to be more efficient than toothpaste containing potassium nitrate (Group II) in lowering DH. This result could be explained by the natural components such as Propolis, Hemp extract, guava leaves extract, Peppermint extract, tea tree extract, clove oil, glycolipids, Bentonite earth, Grapeseed extract, water, sodium benzoate and bentonite clay present in the paste. The eugenol's obtundant activity present in clove oil has the ability to reduce pain. The combination of these natural ingredients may have a synergistic impact in easing DH-related discomfort.

Dentinal hypersensitivity related pain is challenging to recognize and reproduce, with tolerance varying based on individual factors. The Hawthorne effect may occur due to non-intervention procedures, such as frequent examinations, improved oral hygiene, or treatment compliance. Patients often improve from trial effects.

As clinicians, we should incessantly look for regimens that are effective, patient friendly and minimally invasive. To validate the findings of this study, further clinical studies using the Bentodent desensitizer toothpaste are required.

Conclusion

This in vivo study findings suggest that natural ingredient containing dentifrice can provide speedier and more effective treatment for dentine hypersensitivity.With the proper usage recommendations, it can be chosen as an alternative to other commercially available and overhyped toothpastes. To corroborate the results of this study, additional research is needed to assess the treatment retention over the long term, changes in surface morphology after chronic usage, and comparisons with other commercially available dentifrices.

Conflict of interest

None