Dentin hypersensitivity and gingival recession: How can we break the cycle?

Gingival recession is a significant risk factor for dentin hypersensitivity, which can in turn lead to poor oral hygiene, biofilm accumulation, and further gingival inflammation. Here, we discuss preventative strategies dental students can implement to help patients to break this vicious cycle.

Etiology and connection

Dentin hypersensitivity can be described as “pain derived from exposed dentin in response to chemical, thermal, tactile or osmotic stimuli, which cannot be explained as arising from any other dental defect or disease.”

Gingival recession does not cause dentin hypersensitivity, but it can help to create the conditions necessary for it to develop and often occurs alongside it.

One of the main causes of gingival recession is poor oral hygiene, which can lead to biofilm accumulation, inflammation of the gingiva, and the loss of periodontal tissue. Gingival tissue can also be damaged by aggressive toothbrushing.

When the gingival tissue recedes, it leaves the cementum at the root of the tooth exposed. Cementum is thinner and softer than enamel, so without the protection of the gingival tissue, it’s considerably more vulnerable to dental caries, erosion and abrasion. Should the cementum be lost, the dentin becomes exposed.

Exposed dentin in and of itself does not cause sensitivity. However, the same forces that cause enamel and cementum loss can also affect the protective smear layer that covers the dentinal surface and the “plugs” that occlude the dentin tubules. External stimuli are then able to influence fluid movement within the tubules, affecting the pupal nerve fibers and causing the characteristic short, sharp pain of dentin hypersensitivity.

In turn, the discomfort of dentin hypersensitivity can impede proper oral hygiene. Patients may be reluctant or unable to practice thorough toothbrushing and interdental cleaning, allowing biofilm to thrive. This can worsen gingival inflammation and contribute to the further loss of periodontal tissues, which in turn can increase the risk or severity of dentin hypersensitivity.

Breaking the cycle

There are a number of strategies students can employ to help prevent or manage dentin hypersensitivity and gingival recession.

1. Implement routine screening

Despite an estimated prevalence of up to 85%, and a significant detrimental impact on quality of life, many patients do not raise the problem of dentin hypersensitivity with a dental professional. Many accept it as a fact of life, only asking for help once symptoms become severe. That means it’s up to you to proactively screen for dentin hypersensitivity as part of your routine care. Aside from the presence of gingival recession, there are a number of risk factors to be aware of:

• Active or prior periodontal disease

• Prior periodontal treatment that exposes the root surface

• A diet high in acidic foods and drinks

• Aggressive brushing

• Use of a hard toothbrush

• Use of an abrasive toothpaste

• Smoking or chewing tobacco

• High alcohol consumption

• Xerostomia

• Bulimia

• Reflux disorders, e.g. GERD

2. Optimize oral hygiene

The most important step is to ensure that patients are practicing meticulous oral care. Twice-daily brushing with a fluoride toothpaste and daily interdental cleaning helps to prevent the further loss of tooth structure and periodontal tissue, halting the progression of both conditions. It is also important to advise patients not to brush in the hour after consuming acidic foods or drinks, as enamel and exposed cementum will be more vulnerable to abrasion and loss.

3. Recommend tools and technique

Recommend a suitable fluoride toothpaste made specifically for sensitive teeth. Colgate Sensitive Prevent & Repair contains 5% potassium nitrate to depolarize the pulpal nerves, preventing transmission of pain signals. It also has the American Dental Association (ADA) Seal of Acceptance, and falls within the recommended range of Relative Dentin Abrasivity (RDA).

Advise your patient to switch to a soft toothbrush to help make brushing less painful. The Colgate SlimSoft has softer, thinner bristles than a standard toothbrush, and is designed for a deeper clean without irritating or traumatizing the gingival tissue. Patients should also be advised to adopt a gentle brushing technique; they may not realize they’re applying too much pressure, so consider asking them to demonstrate and help them correct their technique if necessary.

4. Offer dietary counseling

Dietary acids are a key contributor to the development and progression of dentin hypersensitivity, not to mention a trigger for sensitivity attacks. Recommend that your patient keeps the following foods and drinks to a minimum:

• Carbonated drinks, e.g., soda, sports drinks

• Alcoholic drinks

• Juices

• Citrus fruits.

You can also offer the following tips:

• Drink water or milk with or after meals

• Drink acidic drinks with a straw to minimize tooth contact

• Avoid sipping on acidic drinks or snacking on acidic foods throughout the day

• Don’t hold or “swish” acidic drinks in the mouth

• Rinse the mouth with water after eating or drinking anything acidic.

5. Make the necessary referrals

Optimal prevention or management of hypersensitivity and gingival inflammation is often a multidisciplinary effort. As you establish risk factors and causative factors, consider who else may need to be involved. For example, the patient may need to be referred to:

• A periodontist for examination and treatment

• A physician for underlying medical conditions such as eating disorders or GERD

• Cessation or support services for smoking or alcohol abuse.