Professor Gianna Maria Nardi presents a case which focused on the patient’s wellbeing as a primary treatment goal.
Clinical case description
Medical history
A 38-year-old female patient complained about various moderate and diffuse discomfort. In combination with this, she had gingivitis and bleeding at certain points in the oral cavity.
She was in apparently good general health and was referred to our clinic. According to the patient, she was not taking any medication and smoked more than 10 cigarettes per day. She also reported a history of periodontitis in the family.
The patient consumes a large quantity of sugary foods and a lot of fruit juice. As well as freshly squeezed lemon juices, preferably refrigerated.
She stated that her last check-up had been two years ago. In her opinion she practised good oral hygiene at home.
However, she also conceded that she had problems with the use of dental floss. I asked whether she experienced any discomfort, pain or sensitivity when consuming hot and cold food and drinks. The patient responded that she experienced moderate and temporary discomfort when consuming hot and cold food and drinks. However, it generally dissipated again once the stimulus was gone.
Findings and diagnosis
Prior to compiling a customised treatment plan, it was necessary to examine and assess the patient’s dental and periodontal status.
To this end, the clinical plaque index, sulcus bleeding index and gingival index were determined. Calculus was also identified in the interdental spaces. No carious lesions were found.
There were white spots present on the surfaces of the tooth enamel. This was a result from debonding following treatment with fixed orthodontic appliances.
The pain was assessed using the air blast test to determine the degree of possible dentine hypersensitivity. The diagnostic procedures revealed a generalised hypersensitivity. There was a score of two on the Schiff scale and five on the visual analogue scale.
After thorough investigation and assessment of the risk factors identified in the medical history, such as inadequate oral hygiene measures at home and a sugar-rich diet, the first step was to document the case photographically.
The patient was shown the initial clinical situation using an intraoral video camera (Acteon Soprocare).
During the patient briefing, the patient was made aware of the presence of bacterial biofilm in the interdental spaces (Figure 2). In addition, the minimally invasive treatment that would be performed and which instruments would be used was explained to her.
Diagnosis
Gingivitis – induced by dental biofilm as well as moderate, diffuse dentine hypersensitivity.
Treatment
To enable the use of the D-Biotech procedure (Dental Biofilm Detection Topographic Technique), a three-phase plaque-disclosing agent was applied to the surfaces of the teeth in order to determine the topography of the existing bacterial biofilm.
A minimally invasive approach with selective polishing, an air flow polisher and scalers was then selected.
The measures outlined in the official requirements were taken so as to reduce the risk of a COVID-19 infection.
First of all, the patient was asked to rinse her mouth out with an antiviral mouthwash. Double suction was employed during the phases of air flow polishing and debridement with the Combi Touch scaler (Mectron). We only used the air flow system to a limited extent. Instead we preferred to perform selective polishing with Cleanjoy tooth cleaning and polishing pastes (Voco GmbH, Cuxhaven, Germany) with different abrasion strengths (Liebermann et al, 2019).
These pastes contain both fluoride (700 ppm) and xylitol, resulting in an effective remineralisation effect.
The selective cleaning alone was sufficient to polish the tooth enamel surfaces to the extent that external stains were removed. The use of a rubber cup in combination with the polishing pastes with different grit sizes and abrasion strengths was successful.
The tooth surfaces were first treated with a three-phase plaque-disclosing agent. This rendered the acidic bacterial plaque, both older and newer plaque, visible.
In this first stage of plaque removal, the coarse paste with the red colour code and an RDA (Relative Dentine Abrasivity) value of 195 was applied with a high cleaning pressure and soft cup. This allowed gentle but effective removal of the stubborn stains and older bacterial biofilm.
Polishing
When using the polishing pastes, the traffic light-based colour-coding system makes it easy to perform the polishing selectively. In the second step, the areas without any bacterial biofilm were treated using the paste with the medium grit size, yellow colour code and an RDA value of 127, which was equivalent to cleaning with moderate abrasion.
The third step of the selective cleaning and polishing procedure was performed using the fine polishing paste with the green colour code and an RDA value of 16. This was followed by the application of a transparent-white fluoride varnish (Voco Profluorid Varnish) for desensitisation.
Voco Profluorid Varnish is able to remineralise areas of the enamel surface where calcium has been lost as a result of erosion.
The fluoride content is 22,600 ppm, corresponding to 5% sodium fluoride (NaF). The VPV is characterised by its high moisture tolerance and excellent adhesion to dental hard tissue, which facilitates the application.
The VPV should be applied to the surface of the tooth in a fine layer. Thick layers are more prone to becoming detached and offer no therapeutic advantage (Ortiz-Ruiz AJ et al, 2021; Poggio C et al, 2016).
Post treatment
After the treatment, the patient reported not having felt any hypersensitivity during the selective cleaning and polishing. The procedure described above results in rapid desensitisation and continuous release of the fluoride contained in the varnish (Ravishankar et al, 2018).
The selective polishing with the fine paste with the green colour code and an RDA value of 16 was repeated at a follow-up appointment two weeks later. The VPV was then also reapplied. The next follow-up was arranged for three months later.
Result
The clinical indices and hypersensitivity values were significantly better following the treatment. The patient kept to the instructions given in the beginning and was motivated with regard to appropriate lifestyle choices, oral hygiene and diet.
In addition, the cleaning and polishing of the tooth surfaces during the treatment also produced an objective improvement in the appearance of the teeth.
Discussion
The selection of effective techniques requires sound knowledge of novel treatment protocols validated by scientific and clinical research. These should benefit both the patient’s oral health and their physical/mental and social wellbeing.
Monitoring of the bacterial biofilm by the patient themselves and in the dental practice ensures the health of the dental hard tissues and periodontal tissues. It should also be mentioned that plaque-disclosing systems are useful in promoting compliance with oral hygiene instructions while simultaneously improving the timing and effectiveness of professional procedures.
The D-Biotech clinical procedure uses a variety of disclosing systems. Single-phase disclosing systems are able to determine the presence or absence of plaque, while dual-phase disclosing systems can identify new and old bacterial plaque, and three-phase disclosing systems allow detection of new and old plaque, based on the presence of acidic bacterial plaque.
Selective cleaning and polishing using the abrasion pastes with different RDA values allows a minimally invasive approach and a treatment adapted to the clinical situation. Cleanjoy (Voco) is available in tubes and the single-dose packaging. The latter proves particularly useful in the current pandemic situation.
Check-ups
Hypersensitivity often results in patients skipping check-ups, although they are important for the maintenance of good oral health. The of the varnish VPV desensitises and remineralises the tooth enamel, and is thus a key component of an ideal clinical strategy with which the dental practice can treat hypersensitivity effectively and maintain the achieved well-being efficiently at the same time.
This motivates patients to attend their check-ups. 1 ml Voco Profluorid Varnish contains 50 mg sodium fluoride, corresponding to a fluoride content of 22 mg. Although the varnish is indicated for the treatment of hypersensitive teeth and sensitive root surfaces, Voco Profluorid Varnish should not be used in cases of known hypersensitivity or allergy to individual components of the varnish.
Like the majority of other fluoride varnishes, Voco Profluorid Varnish also contains colophony and artificial flavours. Similarly, you should not use fluoride varnishes in patients with ulcerative inflammations of the gingiva or oral mucosa. Moreover, the ingredient colophony can affect the curing and bonding adhesion of composites.
Based on clinical experience, the quantity of Voco Profluorid Varnish required to treat all the teeth is between 0.25 ml and 0.40 ml.
Conclusion
The treatment should aim to reduce or eliminate completely the stimuli and risk factors in order to prevent discomfort. The causes should be controlled both with professional desensitisation therapies and with instructions for proper dental hygiene at home.
Provided there are no clinically manifested dentine defects, the goal of the treatment is to seal the tooth surfaces with products in such a way that pain-triggering stimuli can no longer penetrate the tubule system.
This article was first published in Private Dentistry magazine. Read the latest issue of Private Dentistry magazine here.
References
Liebermann A, Spintzyk S, Reymus M, Schweizer E, Stawarczyk B (2019) Nine prophylactic polishing pastes: impact on discoloration, gloss, and surface properties of a CAD/CAM resin composite. Clin Oral Investig Jan 23(1):327-335
Ortiz-Ruiz AJ, Martínez-Marco JF, Pérez-Silva A, Serna-Muñoz C, Cabello I, Banerjee A (2021) Influence of Fluoride Varnish Application on Enamel Adhesion of a Universal Adhesive. J Adhes Dent 23(1):47-56.
Poggio C, Andenna G, Ceci M, Beltrami R, Colombo M, Cucca L (2016) Fluoride release and uptake abilities of different fissure sealants. J Clin Exp Dent Jul 1;8(3):e284-9
Ravishankar P, Viswanath V, Archana D, Keerthi V, Dhanapal S, Lavanya Priya KP (2018) The effect of three desensitizing agents on dentin hypersensitivity: A randomized, split-mouth clinical trial. Indian J Dent Res Jan-Feb;29(1):51-55
