On dentinal hypersensitivity: a randomized clinical trial.

1. SCIENTIFIC ARTICLE
Australian Dental Journal 2012; 57: 1–6
doi: 10.1111/j.1834-7819.2012.01726.x
Comparison of efficacy of three commercially available
dentrifices on dentinal hypersensitivity: a randomized
clinical trial
AR Pradeep,* E Agarwal,* P Bajaj,* NS Rao,* SB Naik,* R Reddy, AK Kumar
*Department of Periodontics, Government Dental College and Research Institute, Fort, Bangalore, Karnataka, India.
Department of Periodontics, CKS Teja Dental College, Tirupati, Andhara Pradesh, India.
ABSTRACT
Background: Dentinal hypersensitivity has been defined as a short, sharp pain arising from exposed dentine as a result of
various stimuli such as heat, cold, chemical, or osmotic, that cannot be ascribed to any other pathology. This study was
conducted to assess the efficacy of three commercially available toothpastes in the reduction of dentinal hypersensitivity.
Methods: A total of 149 subjects (72 males and 77 females; aged 20 to 60 years) were entered into the study and randomly
divided into four groups: Group 1 – toothpaste containing 5% potassium nitrate; Group 2 – toothpaste containing 5%
calcium sodium phosphosilicate with fused silica; Group 3 – toothpaste containing 3.85% amine fluoride; and Group 4 –
a placebo toothpaste. After sensitivity scores for controlled air stimulus and cold water at baseline were recorded, subjects
were given toothpastes and sensitivity scores were measured again at 2 weeks and 6 weeks.
Results: All groups showed a reduction in sensitivity scores at 2 weeks and 6 weeks. The calcium sodium phosphosilicate
group was found to be significantly better compared to the other groups at the end of 6 weeks.
Conclusions: The calcium sodium phosphosilicate group showed a better reduction in the symptoms of dentinal
hypersensitivity.
Keywords: Toothpaste, dentinal hypersensitivity.
Abbreviations and acronyms: ANOVA = analysis of variance; DH = dentinal hypersensitivity.
(Accepted for publication 8 March 2012.)
INTRODUCTION
Dentinal hypersensitivity (DH) has been defined as a
short, sharp pain arising from exposed dentine as a
result of various stimuli such as heat, cold, chemical,
or osmotic, that cannot be ascribed to any other
pathology.1
The incidence of DH may affect patients
of any age and reportedly peaks during the third and
fourth decades of life.2
The condition may affect any
tooth, but it most often affects canines and premolars.3
There is a wide variation in the literature regarding the
distribution patterns of affected teeth.4
DH can
manifest if dentine is exposed by loss of enamel (due
to abrasion, erosion or attrition), keeping the tubules
open on the dentine surface. The constant action of
acids or loss of structure such as cementum denudes
the root surface, which is prone to removal by
brushing or periodontal treatment,5
or more com-
monly, by the association of two or more of these
factors.6
It may also be caused by gingival recession
which physiologically occurs with ageing or patholog-
ically due to chronic periodontal disease or the
patient’s deleterious habits.7
Braennstroem and Astroem in 1964 proposed the
‘hydrodynamic theory’ which is widely accepted as the
explanation of the pain caused by DH.8
According to
this theory, the opening of dentinal tubules due to loss
of enamel and cementum in the cervical areas may
stimulate the pulp nerves due to the movement of
dentinal fluid inside the tubules. This may result in the
sensation of pain. Also, bacteria and their elements may
diffuse from the oral cavity to the pulp through the
open dentinal tubules, resulting in localized inflamma-
tory response.9
Histologically, under transmission elec-
tron microscope, a sensitive tooth shows two times
larger tubules and an increased number per area
compared to a normal tooth without DH.10
Although
macroscopically the dentine of a hypersensitive tooth
does not differ from that of a normal tooth, the
symptoms suggest minor inflammation of pulp.11
ª 2012 Australian Dental Association 1
Australian Dental JournalThe official journal of the Australian Dental Association

2. Currently, two major approaches are commonly
employed in the treatment and prevention of DH:
occlusion of tubules and nerve activity blockage. In the
tubular occlusion approach, the tooth is treated with an
agent that occludes the dentinal tubules, thus resulting
in stoppage of pulpal fluid flow, leading to reduction in
DH.12,13
Treatment strategies such as lasers, dentine
sealers and periodontal soft tissue grafting work on the
same principle. In the blockage of nerve activity,
potassium ions cause a depolarization of the cellular
membrane of the nerve terminal by concentrating on
dentinal tubules and thus giving rise to a refractory
period with decreased sensitivity.14
Desensitizing agents have been classified according to
various criteria such as their reversible or irreversible
characteristics, their mode of action, whether applied
by the patient or professional, or according to their
physical and chemical properties. They may be manu-
factured and delivered in the form of mouthwashes,
gels, dentifrices, or agents to be applied topically, such
as resin composite, varnishes, glass ionomer cement and
periodontal membranes.
The advantage of using products available for home
use is that they are immediately available for treatment
when compared with those applied by the professional.
One disadvantage is that more time is required for
remission of symptoms (2–4 weeks), while those
applied in-office promote immediate relief.
Fluorides such as sodium and stannous fluoride can
reduce DH.15
They precipitate calcium fluoride crystals
in the dentinal tubules inlet, creating a barrier. The
temporary action of the formed barrier may be due to its
slow solubility in saliva. 5
Another fluoride, amine
fluoride, has also been used in dentifrice to alleviate
dentinal hypersensitivity.16
However, there is little data
available on the efficacy of its ability to reduce DH.
Calcium sodium phosphosilicate, a bioactive glass,
provides calcium and phosphate ions that form a
hydroxycarbonate-apatite, a mineral that is chemically
similar to the mineral in enamel and dentine.17
In one
of our recent studies, calcium sodium phosphosilicate
showed a greater reduction in sensitivity compared to
potassium nitrate.18
Considering the aforementioned findings, this study
was conducted to assess and compare the efficacy of
three commercially available toothpastes containing
either 5% potassium nitrate or 5% calcium sodium
phosphosilicate or 3.85% amine fluoride compared to a
placebo in the reduction of DH over a period of
6 weeks.
MATERIALS AND METHODS
The study was a single centre, longitudinal, triple
masked (investigators, subjects and statistician),
randomized parallel-arm design. The study duration
was 6 weeks, in which sensitivity scores were measured
at baseline, at 2 weeks and 6 weeks. The research
protocol was initially submitted to the Ethical Com-
mittee and Review Board of the Government Dental
College and Research Institute, Bangalore, India. After
ethical approval, subjects were selected from the
outpatient section of the Department of Periodontics,
Government Dental College and Research Institute,
Bangalore. The duration of the study was from July to
October 2011.
The four toothpastes studied were: (1) a commer-
cially available toothpaste containing 5% potassium
nitrate (SHY, Group Pharmaceuticals, Mumbai, India);
(2) a commercially available non-aqueous toothpaste
containing 5% calcium sodium phosphosilicate with
fused silica (SHY-NM, Group Pharmaceuticals, Mum-
bai, India); (3) a commercially available toothpaste
containing 3.85% amine fluoride (AMFLOR, Group
Pharmaceuticals, Mumbai, India); and (4) a placebo
toothpaste (Group Pharmaceuticals, Mumbai, India).
Sample size calculations were based on detecting a
difference of 30% reduction in visual analogue scale
(VAS) scores19
between test and control groups using a
two-tailed significance level of 5% with a 90% power.
A total of 160 subjects were included in the study,
randomized and categorized into four groups, each
containing 40 subjects. The randomization was done
using a computer-generated random table, and investi-
gators were neither involved in the randomization
process nor were they aware of the assigned groups.
The toothpastes were dispensed in white tubes by the
investigator (ARP) labelled A, B, C and D, the contents
of which were disclosed to the investigators only after
completion of the statistical analyses.
A total of 149 subjects (72 males and 77 females)
were finally considered because 11 subjects failed to
follow-up or discontinued the treatment.
There were 39 subjects in Group 1, 36 in Group 2, 38
in Group 3 and 37 in Group 4 who finally completed
the study. Subjects participating in the study were aged
20 to 60 years. The mean age was not statistically
different among groups and ranged from 41.7 years for
Group 1, 38.9 years for Group 2, 38.2 years for Group
3 and 40.6 years for Group 4. Subjects who were in
good general health, could fulfill the scheduled appoint-
ment and gave written informed consent to participate
were recruited to the six-week trial. A flow chart of the
study is provided in Fig. 1.
Inclusion and exclusion criteria
Volunteers selected at baseline had a history of DH
caused by gingival recession or cervical erosion. Patients
who had at least two teeth with a VAS score of ‡4 were
included in the study. Teeth with caries, defective
restorations, occlusal restorations, chipped teeth, deep
2 ª 2012 Australian Dental Association
AR Pradeep et al.

3. periodontal pockets (no probing depth >4 mm), peri-
odontal surgery within the previous 6 months, and
subjects with orthodontic appliances or bridge work
that would interfere with evaluation were excluded. In
addition, subjects were also excluded if they were
allergic to ingredients used in the study or exhibited
any gross oral pathology, eating disorders, chronic
disease, pregnancy and lactation, acute myocardial
infarction within the past 6 months, use of pacemaker,
uncontrolled metabolic disease, major psychiatric dis-
order, heavy smoking or alcohol abuse, any systemic
disease or any disease requiring repeated or regular
analgesia, anti-inflammatory drugs, or antihistamines.
Sensitivity assessment
To assess tooth sensitivity, a controlled air stimulus
(evaporative stimulus) and cold water (thermal stimulus)
were used. Sensitivity was measured using a 10 cm VAS
score, with a score of zero being a pain-free response and
a score of 10 being excruciating pain or discomfort.
Scoring of tooth sensitivity was done first by using
controlled air pressure from a standard dental syringe at
40 to 65 psi at ambient temperature, directed perpen-
dicularly and at a distance of 1 to 3 mm from the exposed
dentine surface while adjacent teeth were protected with
gloved fingers to prevent false-positive results.
This was followed by scoring of tooth sensitivity
using 10 ml of ice cold water applied to the exposed
dentine surface while neighbouring teeth were isolated
during testing using the operator’s fingers and cotton
rolls. A period of at least 5 minutes was allowed
between the two stimuli on each tooth. The types of
teeth included in the study are shown in Table 1.
After recording sensitivity scores at baseline (EA),
subjects were randomly given respective toothpastes
and advised to use the toothpaste with soft bristle
toothbrushing twice a day. Subjects were also directed
to refrain from any other dentifrice or mouthrinse
during the trial but were allowed to continue their
normal oral hygiene practice.
Statistical analysis
Mean VAS scores and mean ± SD were calculated from
raw VAS scores from all subjects in a treatment group.
Mean VAS scores were compared among groups at
different time points (baseline, at 2 weeks and 6 weeks)
and among groups at each time point using one-way
analysis of variance (ANOVA). Post hoc pair-wise
Table 1. Types of teeth included in the study
Types of teeth Teeth
selected by the
investigators (%)
Upper central incisor 6.1
Upper lateral incisor 5.7
Upper canine 12.3
Lower central incisor 5.7
Lower lateral incisor 2.5
Lower canine 11.9
Upper premolars 20.9
Lower premolars 17.9
Upper molars 10.7
Lower molars 6.3
Assessed for
eligibility (n = 187)
Minimum of two teeth with
VAS score of ≥4 for air and
water stimuli
Excluded (n = 27), not meeting
inclusion criteria (n = 18), refused to
participate (n = 9)
Randomized (n = 160)
computer generated
number sequence
Allocated to Group 1/
potassium nitrate group
(n = 40)
Allocated to Group
3/amine fluoride
group (n = 40)
Analysed (n = 39)
excluded from analysis
(n = 1)
Allocated to Group 2/
calcium sodium
phosphosilicate group
(n = 40)
Failed to follow-up
(n = 3) discontinued
intervention (n = 1)
Analysed (n = 36)
excluded from analysis
(n = 4)
Allocated to Group
4/placebo group
(n = 40)
Failed to follow-up
(n = 1) discontinued
intervention (n = 1)
Analysed (n = 38)
excluded from analysis
(n = 2)
Failed to follow-up
(n = 2) discontinued
intervention (n = 1)
Analysed (n = 37)
excluded from analysis
(n = 3)
Failed to follow-up (n = 1)
discontinued intervention
(n = 0)
Fig. 1 Consort flow diagram.
ª 2012 Australian Dental Association 3
Dentinal hypersensitivity

4. multiple comparisons were done; p < 0.05 was taken as
significant when detected. Data were statistically anal-
ysed using a software programme (SPSS statistical
package, Version 17.5, SPSS, Chicago, IL, USA).
RESULTS
Mean VAS scores for air stimulus and water stimulus for
all four groups at baseline, and at 2 and 6 weeks are
shown in Table 2. Group 2 resulted in more improve-
ment at 2 weeks and 6 weeks compared to the other
groups (Table 2). Intragroup comparison showed that
all groups recorded a significant improvement from
baseline to 2 weeks, and from baseline to 6 weeks
(Table 3). Table 4 shows the intergroup comparison.
No significant difference between groups at baseline was
found for both air and water stimulus. For air stimulus,
there was a significant difference between Group 1 and
2, Group 2 and 3, and Group 2 and 4 at 2 weeks. Similar
results were found for water stimulus at 2 weeks. The
differences were significant for all the comparisons
between groups except between Group 1 and 3 for both
air and water stimulus at 6 weeks.
DISCUSSION
DH is one of the most common and painful, and least
successfully treated chronic tooth problems. In 1884,
Calvo wrote that ‘there is a great need of a medicament,
which while lessening the sensitivity, will not impair the
vitality of the pulp’. In spite of a considerable amount
of research for more more than 100 years, the clinical
management of DH is largely empirical.3
This study compared three commercially available
dentifrices and a placebo toothpaste. The results
demonstrated a reduction in symptoms for all treatment
groups from baseline to 2 and 6 weeks for both
measures of sensitivity. There was a remarkable pattern
toward reduction of DH with time for all the variables
during the 6 weeks of the active phase of the study
independent of treatment groups. The calcium sodium
phosphosilicate group showed a higher degree of
effectiveness at reducing DH than commercially avail-
able potassium nitrate and amine fluoride dentifrices
and a placebo for both sensitivity measures. There was
no statistically significant difference between the results
of the potassium nitrate toothpaste and the amine
fluoride toothpaste in the reduction of symptoms at the
end of 6 weeks.
Well-designed clinical trials providing evidence for
the formulation containing all potential active ingredi-
ents used in this study can be found in the literature.
The 5% potassium nitrate toothpaste was used as a
positive control in our study because it has proved to be
clinically efficient in the treatment of DH. Some studies
have reported the effectiveness of 5% potassium nitrate
gel as an active ingredient.20–22
Unlike other products,
potassium nitrate does not diminish dentine hydraulic
conductivity, or promote obstruction of dentinal
tubules by the deposition of crystals. According to
Wilchgers and Ermert23
and Kim,24
the desensitizing
effect of potassium nitrate is due to the increase in
concentration of extracellular potassium around the
nerve fibres which cause their depolarization, avoids
repolarization and blocks the axonic action. This
blocks the passage of nerve stimulus, resulting in
inactivation of the action potential.
Table 4. Intergroup comparison of air and water
stimulus at baseline, 2 weeks and 6 weeks
Comparison
between
groups
Baseline
p-value
2 weeks
p-value
6 weeks
p-value
Air stimulus Group 1–Group 2 0.55 <0.001* <0.001*
Group 1–Group 3 0.89 0.37 0.47
Group 1–Group 4 0.17 0.68 <0.001*
Group 2–Group 3 0.46 0.003* <0.05*
Group 2–Group 4 0.53 <0.001* <0.001*
Group 3–Group 4 0.23 0.19 <0.001*
Water stimulus Group 1–Group 2 0.23 <0.001* <0.001*
Group 1–Group 3 0.76 0.27 0.15
Group 1–Group 4 0.27 0.34 <0.001*
Group 2–Group 3 0.37 <0.001* <0.001*
Group 2–Group 4 0.44 <0.001* <0.001*
Group 3–Group 4 0.32 0.87 <0.001*
*Statistically significant.
Table 2. Sensitivity scores to air and water stimulus for
all groups at baseline, 2 weeks and 6 weeks
Toothpaste
groups
Baseline 2 weeks 6 weeks
Air
stimulus
Group 1 5.48 ± 0.44 4.25 ± 0.45 2.35 ± 0.46
Group 2 5.55 ± 0.34 3.78 ± 0.41 1.88 ± 0.44
Group 3 5.46 ± 0.59 4.14 ± 0.59 2.09 ± 0.33
Group 4 5.31 ± 0.46 4.23 ± 0.40 3.55 ± 0.42
Water
stimulus
Group 1 6.82 ± 0.34 5.52 ± 0.34 3.11 ± 0.76
Group 2 6.95 ± 0.42 4.74 ± 0.50 2.12 ± 0.36
Group 3 6.86 ± 0.48 5.37 ± 0.71 2.96 ± 0.42
Group 4 6.29 ± 0.41 5.34 ± 0.40 4.13 ± 0.50
Table 3. Intragroup comparison of air and water
scores between different visits
Groups Visits p-value
Group 1 Baseline – 2 weeks <0.001*
Baseline – 6 weeks <0.001*
Group 2 Baseline – 2 weeks <0.001*
Baseline – 6 weeks <0.001*
Group 3 Baseline – 2 weeks <0.001*
Baseline – 6 weeks <0.001*
Group 4 Baseline – 2 weeks <0.001*
Baseline – 6 weeks <0.001*
*Statistically significant.
4 ª 2012 Australian Dental Association
AR Pradeep et al.

5. Calcium sodium phosphosilicate, originally devel-
oped as a regenerative bone material, has been shown to
be effective at physically occluding dentinal tubules.17,25
Clinical evaluations of calcium sodium phosphosilicate
for the treatment of DH have recorded statistically
significant and clinically positive results.18,26
It has been
shown that the innovative bioactive glass-containing
toothpaste occludes dentinal tubules and resists acid
challenge.27,28
Moreover, it has demonstrated a strong
antimicrobial behaviour in vitro,29
which reduces
symptoms of DH by preventing bacteria to induce
pulpal response.
Fluorides such as sodium and stannous fluoride
reduce DH.15
The application of fluorides seems to
deposit calcium fluoride crystals which form a barrier
at the inlet of dentinal tubules. High level fluoride
products, such as varnishes, form calcium fluoride
which can occlude dentine tubules and provide relief
from sensitivity. However, low fluoride products, such
as dentifrices and mouthwashes, do not provide
significant sensitivity relief. In contrast, stannous
fluoride works by depositing insoluble stannous com-
pounds that also occlude tubules to provide sensitivity
relief. Amine fluoride has also been used in dentifrice
to alleviate dentinal hypersensitivity.16
A mouthrinse
based on fluoride salts (potassium fluoride and amine
fluoride) has been evaluated for the treatment of
dental hypersensitivity and was found to be effec-
tive.30
Like calcium sodium phosphosilicate, amine
fluoride has been shown to have an antimicrobial
affect which may contribute to reducing symptoms of
DH by preventing bacteria from inducing a response
from the pulp.31
Although 8 weeks was considered a suitable dura-
tion for most clinical trials evaluating the efficacy of
desensitizing toothpaste, some studies have stated that
the optimum time course for different agents differs
based on their action. The duration of our study was
6 weeks with sensitivity measured at baseline, at
2 weeks and 6 weeks based on a previous clinical
trial conducted for assessment of calcium sodium
phosphosilicate as a desensitizing agent.32
Dentine
sensitivity may differ for different stimuli,33
and it is
recommended that at least two hydrodynamic stimuli
be used in the clinical trial. We used evaporative air
stimulus and cold water in our study because these are
both physiologic and controllable. Evaporative air
stimulus was first used for sensitivity assessment
followed by water stimuli because the least severe
stimulus should be applied first to prevent interpreta-
tion error. An interval of ‡5 minutes was allowed
between the two stimuli to minimize interactions
between stimuli.
In the present study, the placebo group also reported
greater reduction in mean sensitivity scores over time.
One probable factor may be the environment under
which this study was performed. The patients know-
ingly participated in a clinical trial to determine the
efficacy of desensitizing products. Despite randomiza-
tion and stratification effects to homogenize sample
characteristics and their distribution to different
groups, enrolled volunteers often try to impress the
investigators. Furthermore, positive emotional and
motivational behavioural responses during the clinical
trial can activate the body’s central pain-inhibiting
system.34
The placebo effect, which is the phenomenon
of patients reporting relief without using any active
ingredient varies from 20% to 60% in DH clinical
trials.35,36
The Hawthorne effect can also be responsi-
ble for the same. Subjects may show improved oral
hygiene due to frequent examinations. Improved oral
hygiene would cause more saliva to penetrate dentinal
tubules, increasing the deposition of calcium and
phosphate and thus decreasing the pain sensation. The
influence of the Hawthorne effect is difficult to
calculate.
A study of Australian dentists found that most had a
sound knowledge of the current mechanisms underlying
dentinal hypersensitivity The most common manage-
ment strategy employed was to prescribe desensitizing
agents for home use.37
In agreement with other studies, statistically signif-
icant positive placebo responses can be expected in DH
treatment studies which may mask the positive treat-
ment effects of active ingredients. To prevent the
placebo effect which may mask the treatment affects
of an effective agent, the design of the clinical trials
done for DH should be modified and improved.
CONCLUSIONS
After 6 weeks of clinical evaluation, all treatments
showed lower VAS sensitivity values compared with
baseline, independent of their different modes of
action. Under clinical trial conditions, the calcium
sodium phosphosilicate group showed better results
compared to a fluoride or a potassium nitrate denti-
frice in reducing DH symptoms. Further, well-
designed, multicentre, prospective, long-term clinical
trials with scanning electron microscope evaluations
should be undertaken to find the gold standard
treatment of DH.
ACKNOWLEDGEMENTS
The authors express their gratitude to Mr R Pachei-
yappan, Manager–Sales and Marketing, Group Phar-
maceuticals, Bangalore, India, for his support in
providing SHY-NM (calcium sodium phosphosili-
cate), SHY (potassium nitrate), AMFLOR (amine
fluoride) and the placebo pastes. The authors also
express their thanks to Mr BS Nandakumar and his
ª 2012 Australian Dental Association 5
Dentinal hypersensitivity

6. team for carrying out all the required statistics. The
authors report no conflicts of interest related to this
study.
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Address for correspondence:
Dr AR Pradeep
Professor and Head
Department of Periodontics
Government Dental College and Research Institute
Fort, Bangalore-560002
Karnataka
India
Email: periodontics_gdc@rediffmail.com
6 ª 2012 Australian Dental Association
AR Pradeep et al.