- Email: [email protected]
DENTIN HYPERSENSITIVITY: Author's response
LETTERS
sealant programs and practices within these programs. Increased awareness and participation among dental professionals is critical to the success of program efforts to refer children who are in need but are without a usual source of care. Margherita Fontana, DDS, PhD Associate Professor Department of Cariology, Restorative Sciences and Endodontics School of Dentistry University of Michigan Ann Arbor 1. Beauchamp J, Caufield PW, Crall JJ, et al.; American Dental Association Council on Scientific Affairs. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. JADA 2008;139(3):257-268. 2. Gooch BF, Griffin SO, Gray SK, et al.; Centers for Disease Control and Prevention. Preventing dental caries through schoolbased sealant programs: updated recommendations and reviews of evidence. JADA 2009;140(11):1356-1365. 3. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Sys Rev 2008;(4) CD001830. “onlinelibrary.wiley.com/o/ cochrane/clsysrev/articles/CD001830/frame. html”. Accessed Sept. 27, 2010 4. Mejàre I, Lingström P, Petersson LG, et al. Caries-preventive effect of fissure sealants: a systematic review. Acta Odontol Scand 2003;61(6):321-330. 5. Griffin SO, Oong E, Kohn W, et al. The effectiveness of sealants in managing caries lesions. J Dent Res 2008;87(2):169-174. 6. Griffin SO, Gray SK, Malvitz DM, Gooch BF. Caries risk in formerly sealed teeth. JADA 2009;140(4):415-423. 7. Kolavic Gray SK, Griffin SO, Malvitz DM, Gooch BF. A comparison of the effects of toothbrushing and handpiece prophylaxis on retention of sealants. JADA 2009;140(1): 38-46.
DENTIN HYPERSENSITIVITY
This letter is in reference to Dr. Tanita Narongdej and colleagues’ August JADA article, “The Effectiveness of a Calcium Sodium Phosphosilicate Desensitizer in Reducing Cervical Dentin Hypersensitivity: A Pilot Study” (JADA 2010; 141[8]:995-999). When conducting a clinical trial to assess the efficiency of dentin desensitizing agents, it 16
JADA 142(1)
http://jada.ada.org
is best that the study adheres to the established guidelines. This is done to create a standard for future testing and evaluation of products for the clinical treatment for dentin hypersensitivity.1 The American Dental Association Council on Scientific Affairs has put forth guidelines for evaluating products for the clinical treatment of dentin hypersensitivity. According to Section IV, Clinical Test Protocol, “materials, instruments and items selected for tests to produce the stimulus must be measurable, reproducible and behaviorally predictable.”2
“The methodology employed to evaluate clinically the effectiveness of a desensitizing agent must be reliable and reproducible.”
In the JADA article, tactile and cold stimuli were employed to elicit tooth hypersensitivity. The degree of hypersensitivity was then assessed with the help of a visual analog scale. The use of an explorer to evaluate the sensitivity has been criticized, as it is said to introduce variability in pressure. The authors could have used a probe like the Yeaple probe, where the pressure applied to the surface being tested can be measured. This helps apply the same tactile pressure on all the teeth tested, at each time during the clinical trial.3 When applying the cold stimuli, the authors could have used syringes with cold water placed in a water bath kept at a temperature of 7˚C. This will help to maintain the constant stimuli throughout the study,
and will also help to avoid falsepositive results.3 In conclusion, the methodology employed to evaluate clinically the effectiveness of a desensitizing agent must be reliable and reproducible. The standardization of the clinical trial methods is needed to establish a yardstick for future testing and assessment of methods for treating dentinal hypersensitivity. Manuel S. Thomas, MDS Assistant Professor Department of Conservative Dentistry and Endodontics Manipal College of Dental Sciences Manipal University Mangalore, Karnataka India 1. Holland GR, Narhi MN, Addy M, Gangarosa L, Orchardson R. Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. J Clin Periodontol 1997;24(11):808-813. 2. American Dental Association Council on Scientific Affairs. Acceptance program guidelines: products for the treatment of dentinal hypersensitivity. “www.ada.org/sections/ scienceAndResearch/pdfs/guide_prod_ hypersensitive.pdf”. Accessed Nov. 30, 2010. 3. Gillam DG, Newman HN. Assessment of pain in cervical dentinal sensitivity studies: a review. J Clin Periodontol 1993;20(6): 383-394.
Author’s response: The use of a Yeaple probe is the best method to evaluate sensitivity. However, we did not have one, so we tried our best to limit the variability in pressure by training the operator to apply pressure to the digital scale before the experiment. For the cold stimuli, the use of a syringe may not be a proper method since it is more difficult to control the area. We found that the sponge kept in the thermometer-controlled water is more controllable. We can apply the sponge to the cervical area without water soaking the whole tooth. Rangsima Sakoolnamarka, DDS, PhD Assistant Professor Department of Operative Dentistry
January 2011
Copyright © 2011 American Dental Association. All rights reserved.
LETTERS Faculty of Dentistry Chulalongkorn University Bangkok
ORTHODONTIC BRACKETS
As an orthodontist who was an early advocate of indirect banding in the 1950s and indirect bonding in the 1970s, I was especially interested in Dr. Mette Kuijpers and colleagues’ August JADA article, “The Effect of Antisialogogues in Dentistry: A Systematic Review With a Focus on Bond Failure in Orthodontics” (Kuijpers MAR, Vissink A, Ren V, Kuijpers-Jagtman AM. JADA 2010;141[8]:954-965). The indirect technique for bracket placement, which I have used since the 1970s, allows easy placement of multiple brackets with the use of antisialagogues. This technique also gives much more accurate placement with much easier cleanup than the direct technique. Other benefits include less stress on the operator and greater comfort for the patient. Bracket placement on a model with tacky glue and tray fabrication with a one-step silicon material allows for simplicity and comfort. W. Bonham Magness, DDS Houston
Authors’ response: We thank Dr. Magness for his reaction to our systematic review about the use of antisialogogues in dentistry with focus on bond failure. In the search strategy for this review, studies applying direct and indirect bonding were included. In our analysis of the studies concerning use of antisialogogues and bonding in dentistry, and on bond failure in orthodontics in particular, we did not find evidence that use of antisialogogues lowers the bond failure in orthodontics, irrespective of whether direct or indirect 18
JADA 142(1)
http://jada.ada.org
bonding was applied. Unfortunately, only one study looked properly at the use of antisialogogues and bonding in orthodontics,1 while no study concerning bonding in dentistry was found. The very good experiencebased results with indirect bonding and use of antisialogogues that Dr. Magness mentions in his letter might also be due to a very good protocol for bonding brackets that he applies, to the use of an indirect bonding technique in which the tray lowers the risk of saliva contamination, and to the shorter duration of the bonding procedure. In other words, from a case series it is difficult to conclude whether the results are particularly based on the use of antisialogogues during the bonding. A double-masked randomized controlled trial in which the patients are randomized in two groups, one group receiving indirect bonding with antisialogogues and one group receiving indirect bonding without, is the only way to get an objective, evidence-based answer on this question. It would be applauded when Dr. Magness would perform such a study. Thus, the current literature provides no evidence for the preferential use of antisialogogues to improve bonding results in orthodontics, and might imply that a good bonding protocol is more important.2-3 The pros and cons for using indirect or direct bonding are beyond the scope of our study. What is relevant is that for neither procedure has the positive effect of antisialogogues been shown. Since the added value of antisialogogues, if present, might be negligible, the negative effects in the form of systemic effects of the medication outweigh the supposed positive effects.
Mette A. Kuijpers, DDS, MSc Postgraduate Orthodontic Resident Division d’Orthodontie Faculté de Médécine Dentaire Université de Genève Geneva 1. Ponduri S, Turnbull N, Birnie D, Ireland AJ, Sandy JR. Does atropine sulphate improve orthodontic bond survival? A randomized clinical trial. Am J Orthod Dentofacial Orthop 2007;132(5):663-670. 2. Maia SR, Cavalli V, Liporoni PC, do Rego MA. Influence of saliva contamination on the shear bond strength of orthodontic brackets bonded with self-etching adhesive systems. Am J Orthod Dentofacial Orthop 2010;138(1):79-83. 3. Campoy MD, Plasencia E, Vicente A, Bravo LA, Cibrián R. Effect of saliva contamination on bracket failure with a self-etching primer: a prospective controlled clinical trial. Am J Orthod Dentofacial Orthop 2010; 137(5):679-683.
CAREER OPTIONS
I read with interest Dr. Roger Levin’s August JADA “Perspectives” article, “A Better Practice: Practice Options for New Dentists” (JADA 2010:141[8]; 1023-1024). The author describes four main career options for the new graduate: become an associate, work for dental service organizations, join the military or open a solo practice. The most compelling argument in favor of the first three of these, at least, is the high student loan debt that many students find themselves facing upon graduation. However, I was disappointed that a fifth option, academic dentistry, was not presented as a viable one for a new dentist. In a report on the 2007 dental school faculty work environment survey, Haden and colleagues1 note that on average over 300 budgeted, vacant faculty positions exist in U.S. dental schools. Currently, less than 1 percent of our graduates nationally enter a career as a dental educator.2 Unless new graduates see dental education as a possible career choice, there is no reason to expect those numbers to improve.
January 2011
Copyright © 2011 American Dental Association. All rights reserved.
sealant programs and practices within these programs. Increased awareness and participation among dental professionals is critical to the success of program efforts to refer children who are in need but are without a usual source of care. Margherita Fontana, DDS, PhD Associate Professor Department of Cariology, Restorative Sciences and Endodontics School of Dentistry University of Michigan Ann Arbor 1. Beauchamp J, Caufield PW, Crall JJ, et al.; American Dental Association Council on Scientific Affairs. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. JADA 2008;139(3):257-268. 2. Gooch BF, Griffin SO, Gray SK, et al.; Centers for Disease Control and Prevention. Preventing dental caries through schoolbased sealant programs: updated recommendations and reviews of evidence. JADA 2009;140(11):1356-1365. 3. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Sys Rev 2008;(4) CD001830. “onlinelibrary.wiley.com/o/ cochrane/clsysrev/articles/CD001830/frame. html”. Accessed Sept. 27, 2010 4. Mejàre I, Lingström P, Petersson LG, et al. Caries-preventive effect of fissure sealants: a systematic review. Acta Odontol Scand 2003;61(6):321-330. 5. Griffin SO, Oong E, Kohn W, et al. The effectiveness of sealants in managing caries lesions. J Dent Res 2008;87(2):169-174. 6. Griffin SO, Gray SK, Malvitz DM, Gooch BF. Caries risk in formerly sealed teeth. JADA 2009;140(4):415-423. 7. Kolavic Gray SK, Griffin SO, Malvitz DM, Gooch BF. A comparison of the effects of toothbrushing and handpiece prophylaxis on retention of sealants. JADA 2009;140(1): 38-46.
DENTIN HYPERSENSITIVITY
This letter is in reference to Dr. Tanita Narongdej and colleagues’ August JADA article, “The Effectiveness of a Calcium Sodium Phosphosilicate Desensitizer in Reducing Cervical Dentin Hypersensitivity: A Pilot Study” (JADA 2010; 141[8]:995-999). When conducting a clinical trial to assess the efficiency of dentin desensitizing agents, it 16
JADA 142(1)
http://jada.ada.org
is best that the study adheres to the established guidelines. This is done to create a standard for future testing and evaluation of products for the clinical treatment for dentin hypersensitivity.1 The American Dental Association Council on Scientific Affairs has put forth guidelines for evaluating products for the clinical treatment of dentin hypersensitivity. According to Section IV, Clinical Test Protocol, “materials, instruments and items selected for tests to produce the stimulus must be measurable, reproducible and behaviorally predictable.”2
“The methodology employed to evaluate clinically the effectiveness of a desensitizing agent must be reliable and reproducible.”
In the JADA article, tactile and cold stimuli were employed to elicit tooth hypersensitivity. The degree of hypersensitivity was then assessed with the help of a visual analog scale. The use of an explorer to evaluate the sensitivity has been criticized, as it is said to introduce variability in pressure. The authors could have used a probe like the Yeaple probe, where the pressure applied to the surface being tested can be measured. This helps apply the same tactile pressure on all the teeth tested, at each time during the clinical trial.3 When applying the cold stimuli, the authors could have used syringes with cold water placed in a water bath kept at a temperature of 7˚C. This will help to maintain the constant stimuli throughout the study,
and will also help to avoid falsepositive results.3 In conclusion, the methodology employed to evaluate clinically the effectiveness of a desensitizing agent must be reliable and reproducible. The standardization of the clinical trial methods is needed to establish a yardstick for future testing and assessment of methods for treating dentinal hypersensitivity. Manuel S. Thomas, MDS Assistant Professor Department of Conservative Dentistry and Endodontics Manipal College of Dental Sciences Manipal University Mangalore, Karnataka India 1. Holland GR, Narhi MN, Addy M, Gangarosa L, Orchardson R. Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. J Clin Periodontol 1997;24(11):808-813. 2. American Dental Association Council on Scientific Affairs. Acceptance program guidelines: products for the treatment of dentinal hypersensitivity. “www.ada.org/sections/ scienceAndResearch/pdfs/guide_prod_ hypersensitive.pdf”. Accessed Nov. 30, 2010. 3. Gillam DG, Newman HN. Assessment of pain in cervical dentinal sensitivity studies: a review. J Clin Periodontol 1993;20(6): 383-394.
Author’s response: The use of a Yeaple probe is the best method to evaluate sensitivity. However, we did not have one, so we tried our best to limit the variability in pressure by training the operator to apply pressure to the digital scale before the experiment. For the cold stimuli, the use of a syringe may not be a proper method since it is more difficult to control the area. We found that the sponge kept in the thermometer-controlled water is more controllable. We can apply the sponge to the cervical area without water soaking the whole tooth. Rangsima Sakoolnamarka, DDS, PhD Assistant Professor Department of Operative Dentistry
January 2011
Copyright © 2011 American Dental Association. All rights reserved.
LETTERS Faculty of Dentistry Chulalongkorn University Bangkok
ORTHODONTIC BRACKETS
As an orthodontist who was an early advocate of indirect banding in the 1950s and indirect bonding in the 1970s, I was especially interested in Dr. Mette Kuijpers and colleagues’ August JADA article, “The Effect of Antisialogogues in Dentistry: A Systematic Review With a Focus on Bond Failure in Orthodontics” (Kuijpers MAR, Vissink A, Ren V, Kuijpers-Jagtman AM. JADA 2010;141[8]:954-965). The indirect technique for bracket placement, which I have used since the 1970s, allows easy placement of multiple brackets with the use of antisialagogues. This technique also gives much more accurate placement with much easier cleanup than the direct technique. Other benefits include less stress on the operator and greater comfort for the patient. Bracket placement on a model with tacky glue and tray fabrication with a one-step silicon material allows for simplicity and comfort. W. Bonham Magness, DDS Houston
Authors’ response: We thank Dr. Magness for his reaction to our systematic review about the use of antisialogogues in dentistry with focus on bond failure. In the search strategy for this review, studies applying direct and indirect bonding were included. In our analysis of the studies concerning use of antisialogogues and bonding in dentistry, and on bond failure in orthodontics in particular, we did not find evidence that use of antisialogogues lowers the bond failure in orthodontics, irrespective of whether direct or indirect 18
JADA 142(1)
http://jada.ada.org
bonding was applied. Unfortunately, only one study looked properly at the use of antisialogogues and bonding in orthodontics,1 while no study concerning bonding in dentistry was found. The very good experiencebased results with indirect bonding and use of antisialogogues that Dr. Magness mentions in his letter might also be due to a very good protocol for bonding brackets that he applies, to the use of an indirect bonding technique in which the tray lowers the risk of saliva contamination, and to the shorter duration of the bonding procedure. In other words, from a case series it is difficult to conclude whether the results are particularly based on the use of antisialogogues during the bonding. A double-masked randomized controlled trial in which the patients are randomized in two groups, one group receiving indirect bonding with antisialogogues and one group receiving indirect bonding without, is the only way to get an objective, evidence-based answer on this question. It would be applauded when Dr. Magness would perform such a study. Thus, the current literature provides no evidence for the preferential use of antisialogogues to improve bonding results in orthodontics, and might imply that a good bonding protocol is more important.2-3 The pros and cons for using indirect or direct bonding are beyond the scope of our study. What is relevant is that for neither procedure has the positive effect of antisialogogues been shown. Since the added value of antisialogogues, if present, might be negligible, the negative effects in the form of systemic effects of the medication outweigh the supposed positive effects.
Mette A. Kuijpers, DDS, MSc Postgraduate Orthodontic Resident Division d’Orthodontie Faculté de Médécine Dentaire Université de Genève Geneva 1. Ponduri S, Turnbull N, Birnie D, Ireland AJ, Sandy JR. Does atropine sulphate improve orthodontic bond survival? A randomized clinical trial. Am J Orthod Dentofacial Orthop 2007;132(5):663-670. 2. Maia SR, Cavalli V, Liporoni PC, do Rego MA. Influence of saliva contamination on the shear bond strength of orthodontic brackets bonded with self-etching adhesive systems. Am J Orthod Dentofacial Orthop 2010;138(1):79-83. 3. Campoy MD, Plasencia E, Vicente A, Bravo LA, Cibrián R. Effect of saliva contamination on bracket failure with a self-etching primer: a prospective controlled clinical trial. Am J Orthod Dentofacial Orthop 2010; 137(5):679-683.
CAREER OPTIONS
I read with interest Dr. Roger Levin’s August JADA “Perspectives” article, “A Better Practice: Practice Options for New Dentists” (JADA 2010:141[8]; 1023-1024). The author describes four main career options for the new graduate: become an associate, work for dental service organizations, join the military or open a solo practice. The most compelling argument in favor of the first three of these, at least, is the high student loan debt that many students find themselves facing upon graduation. However, I was disappointed that a fifth option, academic dentistry, was not presented as a viable one for a new dentist. In a report on the 2007 dental school faculty work environment survey, Haden and colleagues1 note that on average over 300 budgeted, vacant faculty positions exist in U.S. dental schools. Currently, less than 1 percent of our graduates nationally enter a career as a dental educator.2 Unless new graduates see dental education as a possible career choice, there is no reason to expect those numbers to improve.
January 2011
Copyright © 2011 American Dental Association. All rights reserved.