Desensitizers REALITY S CHOICES. Office. Home

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1 REALITY S CHOICES Desensitizers Office 1. Gluma Desensitizer Heraeus Kulzer 2. Super Seal Phoenix 3a. HurriSeal Beutlich Pharmaceuticals 3b. MicroPrime Danville Materials 4. Hemaseal & Cide Advantage 5. D/Sense 2 Centrix Home 1. UltraEZ Ultradent 2005 REALITY Publishing Co. Vol. 19 The Ratings 359

2 Bond Strength Microleakage Available in Office Cost/ml Unit Dose OptiBond Solo plus Prime & Bond NT OptiBond Solo plus Prime & Bond NT Gluma Desensitizer Heraeus Kulzer $19.37 $21.76 Yes 5% Glutaraldehyde, 35% HEMA, water 1.8 Super Seal Phoenix $10.00 $12.49 Potassium oxalate-based salt, water 1.6 = HurriSeal Beutlich Pharmaceuticals $3.33 Benzalkonium chloride, HEMA, sodium fluoride, 5.5 = water MicroPrime Danville Materials $4.40 5% benzethonium chloride, 35% HEMA, sodium 3.6 = fluoride 10ppm, water Hemaseal & Cide Advantage $8.33 HEMA, 4% chlorhexidine 5.6 digluconate, water D/Sense 2 Centrix $7.14 $11.19 Step 1: Potassium phosphate, potassium carbonate, water Step 2: Calcium chloride, strontium chloride, water Step 1: 6.9 Step 2: 5.3 N/A N/A N/A N/A Home UltraEZ Ultradent $4.16 3% potassium nitrate, 0.11% with fluoride ion 6.8 N/A N/A N/A N/A Less than Control More than Control = Equal to Control 360 The Ratings 2005 REALITY Publishing Co. Vol. 19

3 It seems that every patient who comes into our offices has at least a few sensitive teeth. These sensitive teeth are usually discovered early in the patient s visit, typically when we pick up the air syringe to dry the teeth during the initial exam. The patient s eyes will get real big, prompting a comment (or plea) like You re not going to blow air on my teeth, are you? They re real sensitive to air. If the patient does not actually tell us about the sensitivity, we soon discover it after blasting the teeth with air and then watch as the patient pulls the arms of our dental chair out of their moorings. But, even if the patient is real macho during the exam, the dreaded prophy will break through even the most stubborn defenses and reduce the patient to begging us not to use the torture machine, a.k.a., the ultrasonic/sonic scaler, on those sensitive areas. Treatment Approaches Traditional approach s desensitizing toothpastes and/or topical fluoride treatments. Even today, there is nothing wrong with trying these modalities first, since they are inexpensive and require minimal if any staff time. Seal tubules If the sensitivity does not respond to these simple treatments and since the sensitive areas are usually exposed root surfaces, it makes sense to try to seal these areas using an in-office applied treatment or with potassium nitrate gel in a bleaching-like tray at home. Definitive restoration If the exposed root is accompanied with an actual lesion (carious or abfracted), then a definitive restoration would be indicated. Other s Desensitize Preparations for Indirect Restorations (at the preparation appointment) Sealing your preparations at the preparation appointment prior to or immediately after taking the impression has become popular as a way of keeping patients comfortable during the provisionalization period and possibly negates the need to administer local anesthesia at the seating appointment. Using it before the impression would alleviate the concern that the film thickness of the desensitizing layer could prevent full seating of the definitive restoration if this layer was applied after the impression. However, the film thickness of these materials is very low, minimizing this possible problem. Nevertheless, there are no data on the effect this desensitizing layer may have on the accuracy of the impression and the ability of the lab to read your margins. In addition, if your provisional is fabricated out of a composite material, it may bond with this desensitizer, even if the preparation was lubricated liberally prior to fabricating the provisional. To test the effect on impression materials, we took impressions of a quadrant of preparations with Aquasil and Honigum before and after applying Gluma Desensitizer to the preparations. We were unable to detect any visible differences either in the impressions themselves or on the die stone models between the control and test groups. Effect on the bond strength of the definitive restoration is also a concern with this procedure. In other words, if you actually hybridize the dentin at the preparation appointment, will that make it more difficult to bond the definitive restoration? To investigate this issue, we tested the bond strength of OptiBond Solo plus/nexus2 under the following pretreatment conditions: Preparation was etched, OptiBond Solo plus was applied and cured, Temp-Bond Clear was applied, and the specimen was stored in the T/H chamber for seven days. Then Temp-Bond Clear was removed, the preparation was cleaned, etched, and bonded using OptiBond Solo plus/nexus2. Bond strength of this group = 28.5MPa. Preparation was not etched, OptiBond Solo plus was applied and cured, Temp-Bond Clear was applied, and the specimen was stored in the T/H chamber for seven days. Then Temp- Bond Clear was removed, the preparation was cleaned, etched, and bonded using OptiBond Solo plus/nexus2. Bond strength of this group = 28.5MPa. Preparation was etched, All-Bond DS Primers A&B were mixed, applied, and cured, Temp-Bond Clear was applied, and the specimen was stored in the T/H chamber for seven days. Then Temp-Bond Clear was removed, the preparation was cleaned, etched, and bonded using OptiBond Solo plus/nexus2. Bond strength of this group = 25.7MPa. Control = 34.2MPa These results suggest there is a price to pay for sealing your preparations at the preparation appointment, although the clinical significance of the lower bond strength is questionable. If your patients are not having sensitivity now during the provisional period, then there is probably no reason you should seal your preparations at the preparation appointment. Otherwise, the diminution in bond strength may be worth it to keep your patients comfortable. Desensitize Preparations for Indirect Restorations (at the cementation appointment) We have all experienced calls from patients who have sensitive teeth after their new indirect restorations have been luted. If you are bonding the restorations, proper application of an adhesive should seal the tooth, minimizing or eliminating this problem. But for more conventional cementation, applying a desensitizer prior to seating the restoration should help alleviate the typical post-cementation sensitivity. Desensitize Preparations Prior to Applying an Adhesive Desensitizers are also being applied to preparations after etching, but before the adhesive is applied. This is supposed to enhance bond strength, minimize the chances for sensitivity postoperatively, and to reduce gaps at the margins. We tested the effect of this application on both bond strength and microleakage. The results are listed in the commentary for the products recommended for these functions. The significance of is uncertain in this group. Nevertheless, it would seem that a low would be counterproductive for a desensitizer REALITY Publishing Co. Vol. 19 The Ratings 361

4 Dedicated Product vs. Dental Adhesive Most desensitizers that are professionally applied have their origins in dental adhesives. Indeed, some components of these products are straight out of the adhesive kits. So, the big question is: Do you really need a dedicated product for desensitizing dentin or will the primers, with or without the bonding resin, in your current adhesive system do just fine? The best answer is: depends on the purpose for which you are using the desensitizer. If you want a material to desensitize cervical abfractions, our experience has found an adhesive system with a primer followed by a light-cured bonding resin is the most effective technique. Or, you can use a double application of a single-component adhesive. If you are desensitizing a preparation, there could be two good reasons to use a dedicated product: ease of use and film thickness, the latter of which needs to be minimal to allow complete seating of your restoration. However, most single-component adhesives also have minimal film thicknesses. Sequence for Application on Abfraction Lesion Step 1 Clean the sensitive area. This is usually done with a cavity cleaner/disinfectant, mixed with pumice if the preparation is debris-laden. If you are desensitizing a non-anesthetized patient, this cleaning step may not be the most comfortable procedure. Step 2 Rinse and leave lesion with the amount of moisture specified as optimal for that specific product. Step 3 Apply the desensitizer according to the protocol specific to the product you are using. Office vs. Home We have divided these products into two categories: Office Must be applied professionally. Can be used for a variety of purposes. Home Potassium Nitrate Gel applied by a patient in a modified bleaching tray. Can presumably occlude the dentinal tubules. We have not found them to be as effective as the resin-based products, but they can be of some benefit for general sensitivity or sensitivity caused by bleaching. Office 1 REALITY S CHOICES Gluma Desensitizer Heraeus Kulzer (4.5) Bottle Cost: $96.83/5ml ($19.37/ml) 1 btl (5ml) Single Dose Cost: $65.28/3ml ($21.76/ml)($1.63/unit dose) 40 unit doses (0.075ml ea) Shelf life: 3 years MSDS: Included w/ bottle, not w/unidose 5% glutaraldehyde, 35% HEMA, water. 1.8 Blot dry. Apply with a cotton pellet or applicator tip by rubbing the preparation for 30 seconds and dry thoroughly (except if you are using a wet or moist adhesive protocol). Be careful about getting it on the soft tissue it can irritate the gingiva. One patient actually had an allergic reaction. Only product to decrease leakage with both adhesives Long track record Very expensive Glutaraldehyde use still questioned by some Effect on Bond Strength OptiBond Solo plus Slightly higher than control. Prime & Bond NT Slightly higher than control. Effect on Microleakage OptiBond Solo plus Less than control. Prime & Bond NT Less than control. 362 The Ratings 2005 REALITY Publishing Co. Vol. 19

5 Bottle Simple as it gets. Bottle comes in small, cardboard box. Labels on bottle and the box include expiration date. However, the section of the label on bottle that contains the expiration date is protected by adhesive tape, but the label in general rubs off after a few disinfection procedures. Single Dose Large cardboard box with rear-attached lid. The single dose applicators come in foil pouches that are loose in the box. It is easy to open the foil pouch due Shelf to a life: notched 2 years area at one end. The pouches are well identified, MSDS: have Included the expiration date embossed, and include three line drawings on how to actually use the single dose applicator. This applicator has a gray plastic handle, which inserts into a two-stage black plastic cylinder. Using the handle, you push the smaller stage into the larger one. Then you pull out the applicator to find the head immersed in desensitizer. You then apply the product as you would with any applicator tip. Desensitizers Bottle Typical thin paper. Various procedures explained reasonably well. Instructs you to use a gentle, but firm rubbing motion, but how do you perform both gentle and firm at the same time? Single Dose Small, plain paper booklet in 11 languages plus a large, plastic-coated treatment room card with color illustrations displaying the application steps. While the illustrations are welldone, the lack of words hinders the card s usefulness. There is also a single sheet of plain paper illustrating how to open the single dose unit. (3.9) Super Seal Phoenix 2 Cost: $80.00 ($10.00/ml) 1 btl (8ml) Cost: $49.95 ($12.49/ml) 1 btl (4ml) Oxalic acid, potassium salt, water. Shelf life: 2 years MSDS: Included SAMPLING Very effective clinically on abfraction lesions Easy to apply improvement over controls for leakage Much lower bond strengths than controls 1.6 Apply with cotton pellet for 30 seconds on a clean tooth (we suggest blotting dry before application). Presumably, it will demineralize the smear layer and peritubular dentin and will restructure the demineralized material as a calcium oxalate precipitate within two minutes. Effect on Bond Strength OptiBond Solo plus Much lower than control. Prime & Bond NT Much lower than control. Effect on Microleakage OptiBond Solo plus Same as control. Prime & Bond NT More than control. Typical plastic squeeze bottle shipped in a small box, with expiration date. Label on bottle includes the expiration date and is moisture-resistant. Plain paper, very short and to the point REALITY Publishing Co. Vol. 19 The Ratings 363

6 3a HurriSeal Beutlich Pharmaceuticals (3.8) ENCORE Cost: $39.95/12ml ($3.33ml) 1 btl (12ml) Shelf life: 3 years MSDS: t Included Benzalkonium chloride, HEMA, sodium fluoride, and water. 5.5 Least expensive Less leakage with OptiBond Solo plus More leakage with Prime & Bond NT Slightly lower bond strengths with both adhesives Blot dry. Apply with an applicator tip. There is no stipulated dwell time you are merely supposed to apply and allow the material to air dry for 20 seconds, then repeat two more times. Then, if you are using it as a remoistener prior to applying the adhesive, remove any pooled material by suctioning. If you are treating a cervical lesion, gently dry with an indirect air flow. We tested this technique as well as a more conventional one. Effect on Bond Strength OptiBond Solo plus Same as control (both techniques). Prime & Bond NT More than control (both techniques). Effect on Microleakage OptiBond Solo plus More than control. Prime & Bond NT More than control. Conventional plastic squeeze bottle comes in small, cardboard box. The expiration date is printed directly on the bottom of the bottle and on the box. On the bottle, it cannot be removed through disinfection. Typical thin paper. Procedure explained reasonably well. 3b MicroPrime Danville Materials (3.8) 5% benzethonium chloride, 35% HEMA, sodium fluoride 10ppm, and water. 3.6 Cost: $43.95/10ml ($4.40/ml) 1 btl (10ml) Shelf life: 3 years MSDS: Included Blot dry. Apply Microprime and wait 30 seconds. Dry thoroughly with air (unless you are using a moist or wet adhesive protocol.) Effect on Bond Strength OptiBond Solo plus Same as control. Prime & Bond NT Lower than control. Inexpensive Less leakage with OptiBond Solo plus More leakage with Prime & Bond NT Lower bond strength with Prime & Bond NT Effect on Microleakage OptiBond Solo plus Less than control. Prime & Bond NT More than control. 364 The Ratings 2005 REALITY Publishing Co. Vol. 19

7 Typical plastic squeeze bottle comes in small, cardboard box. Label on bottle includes the expiration date, but it will be rubbed off during disinfection procedures. Coated paper, gives direction for non-bonded and bonded applications. (3.6) Hemaseal & Cide Advantage 4 HEMA and 4% chlorhexidine digluconate and water. 5.6 Cost: $83.30/10ml ($8.33/ml) 1 btl (10ml) Shelf life: 3 years MSDS: t included Blot dry. Apply with an applicator tip, scrub the preparation for seconds. Suction excess and leave dentin moisture level to optimize performance of the adhesive you are using. Effect on Bond Strength OptiBond Solo plus Higher than control. Prime & Bond NT Higher than control. Effect on Microleakage OptiBond Solo plus Slightly more than control. Prime & Bond NT Significantly less than control. Only product with chlorhexidine Enhances bond strength Recommends use with self-etching adhesives single dose Conventional white plastic bottle comes in small, cardboard box. Label on bottle includes expiration date and is moisture-resistant. Plain paper, brief, to the point. However, there is no instruction on use under bonded crowns. In addition, applying it prior to placing a self-etching adhesive is listed as one of the indications. But a desensitizer is rarely if ever used with a self-etcher, since minimizing sensitivity is one of the main reasons self-etchers are used in the first place REALITY Publishing Co. Vol. 19 The Ratings 365

8 Desensitizers 5 D/Sense 2 Centrix (3.5) ENCORE thing toxic Mimics what body does to plug tubules Cannot be used to desensitize preparations Two steps/multiple applications 7ml Kit: Cost: $99.95/14ml ($7.14/ml) 1 btl of Step 1 (7ml) 1 btl of Step 2 (7ml) 72 BendaBrushes 36 BondLogic dispensing wells 2.5ml Kit Cost: $55.95/5ml ($11.19/ml) 1 btl of Step 1 (2.5ml) 1 btl of Step 2 (2.5ml) 40 BendaBrushes 10 BondLogic dispensing wells Shelf life: 3 years MSDS: Included : Step 1 Potassium phosphate, potassium carbonate, water. Step 2 Calcium chloride, strontium chloride, water. Step Step Apply Step 1 to the sensitive area first by rubbing it into the dry tooth surface for 10 seconds. Then apply Step 2 in the same manner. Film thickness is approximately 3µ. Relatively large cardboard box mainly used to house the disposable BondLogic wells and BendaBrushes. Expiration date is on the top of the box and on bottles. Bottles have moisture-resistant, colorcoded labels and caps. Two-sided, plain paper in nine languages. There is a second small paper insert with essential points to remember. Very short, to the point, effective. Effect on Bond Strength and Microleakage It is not recommended for use prior to placing a restoration. Our tests confirm that it does significantly lower bond strengths. Because of these results, we did not test microleakage. Home 1 UltraEZ Ultradent (3.8) Kit Cost: $19.99/4.8ml ($4.16/ml) 4 syringes with dispensing tips (1.2ml ea) 3% potassium nitrate, 0.11% with fluoride ion. Shelf life: 2 years MSDS: Included Less expensive than office-based service Best syringes for convenience Relies on patient compliance Don t use immediately prior to bonding The Ratings 2005 REALITY Publishing Co. Vol. 19

9 Desensitizers Desensitizing gel designed to be used with custom tray. Dispense gel in reservoir of custom tray in the same manner you would for most home bleach systems. Recommended treatment times range from 15 minutes to eight hours depending on the condition. Effect on Bond Strength and Microleakage It is not recommended for use prior to placing a restoration. Our tests confirm that it does significantly lower bond strengths. Shelf life: 2 years Because of these results, we did not test microleakage. MSDS: Included Cardboard box with removable translucent plastic tray securing the contents. The syringes have the tips already attached. Expiration date is on a sticker on the outside of the cardboard box and chiseled into the syringe itself. However, on the translucent plastic, the numbers are hard to read. Plain paper, 11 languages, nine photos, annoying foldout design. Straightforward and easy to follow. Includes instructions on how to make a modified bleaching tray for this purpose. REALITY OFFICE Gluma Desensitizer started the trend of desensitizing crown preparations prior to conventional cementation. It has at least one clinical study that validates its claims and a long track record. Our tests show it was the only product not to have a negative effect on bond strength and to decrease the leakage when used with both test adhesives. However, it also contains glutaraldehyde, which has come under attack due to the potential toxicity, although it has the ability to coagulate plasma proteins in the tubules and thus provides a mechanism for the desensitization effect. Our evaluators found it to be an effective product under restorations and crowns, but not as effective on abfractions. It is available in single dose packaging as well as bottles, but it is quite expensive. Super Seal is recommended for use under restorations as well as on abfractions. Unfortunately, it had negative effects with bond strength and leakage in our tests. On the other hand, it has been very effective at desensitizing abfractions. Furthermore, it is not as expensive as Gluma Desensitizer. HurriSeal has either a positive or neutral effect on bond strength of both test adhesives, using either the manufacturer-mandated application procedure, which is time-consuming and requires multiple coats or our truncated method, in which it is applied for 15 seconds. However, using the manufacturer s technique, both test adhesives exhibited increased levels of microleakage. On the other hand, it is the least expensive product in this group. MicroPrime is designed to be a non-glutaraldehyde, low-cost version of Gluma Desensitizer. While its efficacy has not been as well documented as that of Gluma Desensitizer, anecdotal reports are encouraging. Our evaluators found it to be an effective product under restorations and crowns, but not as effective on abfractions. In addition, it had mixed results with bond strength and microleakage. Hemaseal & Cide Desensitizer is the only product in this group containing chlorhexidine in a concentration usually reserved for hand scrubs. Its ability as a rewetting agent was highly touted, enhancing the bond strength of both test adhesives, but its effectiveness on cervical sensitivity was less stellar and its effect on microleakage was mixed. Nevertheless, there is a 110% guarantee, so that if it doesn t work to your satisfaction, you will get your money back plus 10%. D/Sense 2 is designed to be used on sensitive areas of teeth that are not destined for restorations, although there is some indication that conventional etching will remove it and allow the tooth to be restored. Its two bottle/two step application protocol is presumably necessary to achieve profound desensitization. This type of material desensitizes via the precipitation of calcium phosphate. However, it requires the deposition of these crystals in a particle size that is small enough to enter the dentinal tubules. There is no point simply having lots of calcium phosphate deposits merely on the surface of the intertubular dentin, since these will eventually be rinsed off or dislodged. Our clinical evaluation found it was quite effective, but not in all cases. However, most evaluators found it to be a real hassle to apply one solution, then a second solution, especially when treating hard-to-access and hard-to-isolate molar areas. On the other hand, it has no resin, glutaraldehyde, or anything else that could be considered less than totally safe from a toxicity standpoint just two solutions of inorganic salts REALITY Publishing Co. Vol. 19 The Ratings 367

10 HOME UltraEZ has convenient packaging (smaller unit dose syringes) and is less expensive than an office treatment. This is a good option when a patient has generalized sensitivity, especially after bleaching. OTHER PRODUCTS IN THIS CATEGORY AcquaSeal BENZ AcquaMed AcquaSeal G AcquaMed Admira Protect Voco BisBlock Bisco Desensitize! Den-Mat Desensitizer w/ FL Healthdent l D/Sense Crystal Centrix Gel-Kam Dentin Bloc Colgate Oral Pharmaceuticals Pain-Free Parkell Prep-Eze Pentron Quell Pentron Relief Discus Systemp.desensitizer Ivoclar Vivadent Therma-Trol Desensitizer Gel Premier 368 The Ratings 2005 REALITY Publishing Co. Vol. 19