Ever had a hypersensitive patient tell you where you can scale, rinse, and polish? Here's how you can improve the appointment experience, relieve your patient's pain, and show how much you care.
If the thought of a steaming cup of coffee or a scoop of ice cream makes you cringe, hypersensitivity may be to blame. I have had many patients come in and tell me where I can scale, where I can rinse, and where I can polish. Like many of you I wonder how well I can provide therapy if the patient is eliminating half of the mouth. The causes of hypersensitivity may vary but often the treatments can be the same.
Hypersensitivity may be caused by an array of conditions from cracked tooth syndrome, decay, recession, teeth whitening, bruxism, or erosion. The individual will often describe the discomfort as a short, sharp pain associated with external stimuli. This can be caused by temperature changes such as eating, drinking, rinsing with the air-water syringe, or something as uncontrollable as a cold outdoor temperature. Once the cause of sensitivity can be determined, an effective therapy can be recommended both in office and at home.
A cracked tooth will generally cause pain when biting and releasing, and is manifested by a quick pain that a patient may state happens “off and on,” but goes away quickly. With this type of sensitivity, the tooth can be on edge and sensitive to temperature as the crack opens and closes during mastication. If it is determined to be cracked tooth syndrome, it may be resolved by a filling or crown to repair the damaged tooth.
Erosion can be caused by and array of health conditions (e.g., GERD) or may be diet related. Erosion can present as“potholes” in the smooth surfaces of the enamel, often on the lingual surfaces or cusp tips. It is commonly associated with GERD and eating disorders, or can be caused by xerostomia. The acid and fumes from the stomach are released into the oral cavity, altering the pH and causing damage. The nonbacterial acid exposure contributes to erosion, whether it is from stomach acid or an acidic diet. Have a proactive conversation with the patient about symptoms and risk factors. I have often referred the patient to their physician, if warranted, for evaluation. As clinicians we are in the business of overall health in addition to oral health, and for a patient experiencing GERD, the risk of esophageal damage or cancer potential increases if not treated.
Many times in daily practice I will see patients presenting with 2 mm to 4 mm recession. Their symptoms vary, with no sensitivity to extreme hypersensitivity that makes them jump from the chair when you pick up a scaler. Often accompanying the recession are abfractions into the tooth to various degrees. The degree of sensitivity can often depend on how occluded the dentinal tubules are; the more occluded, the less the stimuli can travel toward the nerve causing pain sensations. Proving treatments to occlude the tubules can alleviate sensitivity for a period of time once the patient leaves the office.
Xerostomia can be a result of many factors, either single or combined. Often medications can reduce saliva flow or alter the buffering capacity of saliva. With a reduced saliva flow, the individual is not only susceptible to decay, they are additionally more prone to sensitivity. Education and recommendations for the patient for home use when experiencing xerostomia not only will treat and protect the dentition, but can help prevent further damage.
Reducing sensitivity during the hygiene appointment
No matter the cause of erosion and sensitivity, there are both at-home and in-office treatments that can help alleviate discomfort and calm patient anxiety. I will often apply Colgate Sensitive Pre-Procedural Desensitizing Paste with a prophy cup prior to ultrasonic and hand scaling, and it seems to provide enough relief and diminish the torture of a dental appointment for many patients. The combination of arginine and calcium carbonate quickly provides relief to reduce sensitivity to scaling. Personally, I will apply it with the cup and allow it stay in place while I start with the ultrasonic scaler, which rinses it as I move along the dentition. For many patients, the medicament application in addition to the emotional peace of knowing you are going the extra mile to apply a therapy that can help is enough to provide peace of mind, or at least reduce anxiety.
Application of an in-office desensitizer medicament (CDT code D9910) is an effective way to provide relief for a patient long after they leave the dental office. While this is not a long-term fix, it will often provide relief for a period of weeks or months. If a patient is reluctant to try the desensitizing treatment due to cost, I will occasionally apply it at no additional charge for the first time. Often, the patient will see the value in the hypersensitivity relief and will be more than happy to pay the charge at additional appointments. For some patients, the benefit of the desensitizer may wear off prior to a six-month recall, and they will schedule a separate visit for reapplication. The perception of how willing you are to ensure a pain-free visit and your willingness to listen and provide a solution for their concerns will create a loyal following among patients.
Don’t forget the party bag
When you send a patient out the door at the conclusion of a visit, are you sending them with a standard bag of brush and floss? By taking the time to evaluate the concerns and appearance of the oral cavity and dentition, you have the ability and expertise to make tailored recommendations to each and every patient and send home that party bag full or products that will provide the best results.
I believe that a fluoride rinse can be beneficial to many patients and recommend it often to those with recession and sensitivity. Its caries prevention properties for root surfaces is particularly helpful. I have an array of pastes and flosses, but for my patients who suffer with hypersensitivity due to recession or erosion, I have a cabinet full or products such as Prevident (Booster, Dry Mouth, Enamel Protect and Sensitive formulas) for patients, all of which are prescription strength. I strongly believe in recommending products that I personally have tried and have the science to back the claims. Prevident is one of my personal favorites, as I have some areas of recession myself and it using it daily has allowed me to enjoy my addiction to iced coffee and ice cream without sensitivity. When we give a patient too many steps to follow in a daily routine, they will often become complacent. The benefit for recommending a higher fluoride content product is that it will replace their normal toothpaste without adding additional steps. The only special instructions I will recommend with any sensitive toothpaste is for the patient to spit and not rinse with water directly after brushing to allow the product to be optimally effective.
For many people living with hypersensitivity, no matter the cause, must avoid the pleasures that food or a cold winter outing can provide. With a little education, in-office treatment, and planning for home-care routines, we as clinicians can help our patients avoid further damage to the dentition, and often make the dental visit less painful while keeping smiles bright and dazzling.
Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at [email protected].