pi is 0300571215000305

JJOD-2418; No. of Pages 10

Effectiveness of various toothpastes on dentinetubule occlusion

W.H. Arnold *, M. Prange, E.A. Naumova

Department of Biological and Material Sciences in Dentistry, Witten/Herdecke University, Witten, Germany

j o u r n a l o f d e n t i s t r y x x x ( 2 0 1 5 ) x x x – x x x

a r t i c l e i n f o

Article history:

Received 22 December 2014

Received in revised form

29 January 2015

Accepted 31 January 2015

Available online xxx

Keywords:

Toothpaste

Dentine

Dentine tubules

Root dentine

Hypersensitivity

a b s t r a c t

Objective: Dentine hypersensitivity is an increasing problem in dentistry. Several products

are available that claim to occlude open dentine tubules and to reduce dentine hypersensi-

tivity. The aim of this study was to investigate the effectiveness of several different products

on dentine tubule occlusion using qualitative and quantitative methods.

Materials and methods: Dentine discs were prepared from extracted human premolars and

molars. The dentine discs were brushed with 6 different experimental toothpastes, 1

positive control toothpaste and 1 negative control without toothpaste; the brushing simu-

lated a total brushing time of 1 year. Half of the discs were etched with lemon juice after

toothpaste application. Standardized scanning electron microphotographs were taken and

converted into binary black and white images. The black pixels, which represented the open

dentine tubules, were counted and statistically evaluated. Then, half of the dentine discs

were broken, and the occlusion of the dentine tubules was investigated using energy

dispersive X-ray spectroscopy (EDS).

Results: The number of open dentine tubules decreased significantly after brushing with 5 of

the 6 tested toothpastes. A significant effect was observed after acid erosion for 3 of the 6

tested toothpastes. EDS revealed partly closed dentine tubules after brushing with 3 tooth-

pastes; however, no partly closed dentine tubules were observed after acid erosion.

Conclusions: Some toothpastes are capable of partial dentine tubule occlusion. This occlu-

sion is unstable and can be removed with acid erosion.

Clinical significance: Desensitizing toothpastes are the most common products that are used

against dentine hypersensitivity, and these toothpastes affect dentine tubule occlusion.

# 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC

BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/jden

1. Introduction

As the demographics of the human population change and as

the human population ages, more teeth remain in the mouths

of elderly people due to effective caries prevention and

periodontal disease management. Thus, dentine hypersensi-

tivity is becoming an increasing problem in dentistry.1,2

* Corresponding author at: Department of Biological and Material SGermany. Tel.: +49 2302926658; fax: +49 2302926661.

E-mail address: [email protected] (W.H. Arnold).

Please cite this article in press as: Arnold WH, et al. Effectiveness of variouhttp://dx.doi.org/10.1016/j.jdent.2015.01.014

http://dx.doi.org/10.1016/j.jdent.2015.01.0140300-5712/# 2015 The Authors. Published by Elsevier Ltd. This is

creativecommons.org/licenses/by-nc-nd/4.0/).

Dentine hypersensitivity and a possible cause for this

condition were described first by Gysi in 1900.3 Since then,

the mechanisms causing this type of pain have remained

controversial. Pulpal nerves from the plexus of Raschkow

extend into approximately 15% of the dentine tubule length.4

These nerves do not innervate the peripheral dentine.

Odontoblast processes may function as sensory receptors;

however, odontoblast destruction does not cause insensitive

ciences in Dentistry, Alfred Herrhausenstrasse 44, 58455 Witten,

s toothpastes on dentine tubule occlusion. Journal of Dentistry (2015),

an open access article under the CC BY-NC-ND license (http://

http://dx.doi.org/10.1016/j.jdent.2015.01.014

http://creativecommons.org/licenses/by-nc-nd/4.0/

mailto:[email protected]


http://www.sciencedirect.com/science/journal/03005712

www.intl.elsevierhealth.com/journals/jden




j o u r n a l o f d e n t i s t r y x x x ( 2 0 1 5 ) x x x – x x x2


dentine.5,6 In addition, no synaptic contacts exist between the

somatic nerves and odontoblasts.7 In 1968, Brannstrom

postulated the hydrodynamic theory, which hypothesizes

that fluid movement from the pulp towards the outer dentine

within the dentine tubules causes dentine sensation.8–10 The

hydrodynamic theory is now widely accepted as the cause of

dentine sensitivity. Open dentine tubules may be the reason

for the increased fluid movement that causes dentine

hypersensitivity.2,11–13 This possibility is supported by the

observation that dentine hypersensitivity directly correlates

with the number of open dentine tubules.14

Numerous home-use desensitizing products for the

treatment of dentine hypersensitivity are currently avail-

able. These products are divided into two categories:

products that block the pulp nerve response and products

that occlude open dentine tubules.1 The first group is

composed of products that contain potassium salts. Potassi-

um is thought to diffuse inside the dentine tubules and lower

the excitability of the pulpal nerve fibres. Several arguments

oppose this theory. One is that the diffusion distance in

human teeth is greater than that in tested animals. Another

argument is that the flow of dentinal fluid is outward from

the pulp towards the tooth surface, which would hinder

diffusion towards the pulp.16 The majority of home-use

desensitizing products belong to the second group and

contain a wide variety of active components. These active

components can be divided into several subgroups, which

are summarized in Table 1.

The effect of strontium salts is thought to be attributable to

their ability to absorb onto the connective tissue of dentine

and to form strontium apatite, which may occlude the dentine

tubules.17–19 However, dentine tubule occlusion by strontium

salts has not been proven. Clinical studies have demonstrated

a reduction of pain perception in patients who used strontium

salts.20–22

Recent investigations have demonstrated that arginine

combined with calcium carbonate occlude dentine tubules

and that this deposit converts to calcium phosphate.13,23

However, many calcium phosphates are soluble in acidic

environments and, therefore, unstable upon dietary acid

challenge. Several randomized controlled clinical trials have

demonstrated clear treatment effects of arginine and calcium

carbonate toothpastes immediately and up to 8 weeks after

treatment.24–28

In vitro studies have shown that stannous fluoride

produces precipitates onto dentine; this precipitate is water-

and acid-resistant.29 These in vitro studies are supported by

Table 1 – Summary of substances that occlude dentinetubules.

Substance Literature

Strontium (chloride, acetate) 18,29,61

Stannous fluoride 30,31

Calcium sodium phosphosilicate 32,33,35,36

Oxalates 41,42,48

Fluorides 41

Arginine and calcium carbonate 2,15,23,24

Nanoparticles with various functionalizing agents 50–52,59,60


randomized controlled clinical trials that demonstrated the

effective treatment of dentine hypersensitivity using stannous

fluoride.30,31

Calcium sodium phosphosilicates precipitate onto dentine

collagen as calcium phosphate and silicate, forming deposits

on the dentine surface and in dentine tubules.32–36 These

precipitates are water- and acid-resistant. Randomized con-

trolled clinical studies of calcium sodium phosphosilicates

have shown the effective treatment of dentine hypersensitiv-

ity compared to controls.37–40

Oxalates form calcium oxalate crystals within the dentine

tubules and act as desensitizing agents.41 This effect is

enhanced when combined with calcium chloride.42 Some

studies have demonstrated decreased hydrodynamic fluid

flow within the dentine tubules upon oxalate treatment, thus

reducing pain sensations.41,43–46 Another study demonstrated

that oxalates block dentinal fluid flow by forming precipitates

within the dentine tubules.47 However, a systematic review

regarding the effectiveness of oxalates in the treatment of

dentine hypersensitivity determined that that single treat-

ments of oxalates had no effect on dentine hypersensitivity

compared to placebos.48

The mechanisms of the action of fluorides in desensitiz-

ing dentine hypersensitivity remain unclear. Although most

toothpastes contain fluorides in some form, the incidence of

dentine hypersensitivity remain high. Fluorides, similar to

other desensitizing agents, may block the dentine tubules.

Fluorides enhance the mineralization of hydroxyapatite49

and may enhance hydroxyapatite formation within the

dentine tubules, which blocks fluid movement and reduces

pain. However, this enhancement has not been demon-

strated.

A novel approach in the development of desensitizing

agents is the use of various combinations of nanoparticles.50–

52 The idea behind this approach is that nanoparticles may

easily penetrate into dentine tubules and that these nano-

particles could act as mineralising agents that block fluid

movement within the dentine tubules when combined with

various agents.

Considering that almost all desensitizing agents claim to

occlude open dentine tubules, the aim of this study was to

investigate quantitatively the effectiveness of various sub-

stances on dentine tubule occlusion.

2. Material and methods

Seventy-eight caries-free extracted human molars were used

for this experimental study. The collection of the teeth was

approved by the ethical committee of Witten/Herdecke

University (116/2013). Informed verbal consent was obtained

from the patients before the use of the teeth. The teeth were

stored in 0.9% NaCl containing 0.1% thymol until use.

2.1. Experimental design

Dentine discs with a thickness of 3 mm were cut from the

teeth using a saw microtome (Leica 1600, Leitz, Wetzlar,

Germany). Twelve dentine discs were used for each brushing

experiment with the different toothpastes. The discs were



Table 2 – Active ingredients of the desensitizing toothpastes used.

Toothpaste # Product name Active ingredient Company

1 Elmex Sensitive Professional Pro-Argin, calcium carbonate GABA

2 Sensodyne Rapid Strontium acetate Glaxo Smith Kline

3 Sensodyne Repair Stannous fluoride Glaxo Smith Kline

4 BioRepair Zinc-carbonate hydroxyapatite Dr. K. Wolff

5 Colgate Total Sensitive New silica Colgate-Palmolive

6 Dontodent Sensitive Tetrapotassium pyrophosphate, hydroxyapatite DM Dogeriemarkt

j o u r n a l o f d e n t i s t r y x x x ( 2 0 1 5 ) x x x – x x x 3


mounted on specimen holders, and the dentine surface was

polished. Before the experiment, the dentine surface was

eroded with lemon juice (Hitchcock, Monchengladbach,

Germany) for 30 s. Then, the discs were placed in a tooth

brushing machine, and a tooth brushing time of six months

was simulated (2 h of continuous brushing, assuming 28 teeth

in an oral cavity and 2� 3 min tooth brushing per day). Slurries

were prepared in a dilution of 1:3 toothpaste/water mixture.

The dentine discs were brushed with the Dr. Best classic

(medium) toothbrush at 120 spm and a slurry flow rate during

tooth brushing of 10 ml per minute. The toothbrush load was

2 N. Six discs were prepared directly for scanning electron

microscopic (SEM) investigation, and the six remaining discs

were eroded with lemon juice for 30 s and then prepared for

SEM investigation.

2.2. Toothpastes

Five different commercially available toothpastes against

hypersensitivity were used. All toothpastes had different

active components, which are summarized in Table 2. The

following toothpastes were used: Elmex toothpaste (CP-

GABA, Hamburg, Germany; toothpaste 0), which served as

the positive control; Elmex Sensitive Professional (CP-GABA,

Hamburg, Germany; toothpaste 1); Sensodyne Rapid (Glaxo

Smith Kline, Brentford, Middlesex, United Kingdom; tooth-

paste 2); Sensodyne Repair (Glaxo Smith Kline, Brentford,

Middlesex, United Kingdom; toothpaste 3); BioRepair Sensi-

tive (Dr. K. Wolff GmbH, Bielefeld, Germany; toothpaste 4);

Colgate Total Sensitive (Colgate-Palmolive, Hamburg,

Germany; toothpaste 5); and Dontodent Sensitive (DM-

Drogerie Markt, Karlsruhe, Germany; toothpaste 6). Six

dentine discs were only brushed with artificial saliva as the

negative controls.7

Fig. 1 – Preparation of microphotographs for the quantitative det

converted binary black and white image.


2.3. SEM investigation

All specimens were dehydrated in graded acetone, critical

point dried and sputter-coated with gold palladium. Then, the

specimens were examined under a scanning electron micro-

scope (Zeiss Sigma VP, Zeiss, Oberkochen, Germany) at 20 kV

acceleration voltage. Standardized images of the dentine discs

were acquired at a magnification of 1000�. Twenty images

were acquired per disc. In addition, energy dispersive X-ray

spectroscopy (EDS, EDAX Ametec; Mahwah, NJ, USA) and

the accompanying product software were used to observe

the penetration of the toothpaste into the dentine tubules.

The X-ray signal for silicon served as evidence for the

toothpaste. Surface scans were made to study the covering

of the discs. Then, the specimens were frozen in liquid N2,

fractured and the penetration of silica from the toothpastes

into the open dentine tubules was studied.

2.4. Quantitative analysis of dentine tubule occlusion

The standardized SEM microphotographs were imported into

ImageJ software (NIH, USA) and converted into binary images.

The black (open dentine tubules) and white (occluded dentine

tubules and dentine) pixels (Fig. 1) were counted, and the

numbers were transferred into a Microsoft Excel worksheet.

2.5. Statistical analysis

The mean of all black pixels of each disc was calculated. These

mean values were compared between the different tooth-

pastes using the Wilcoxon–Mann–Whitney test for indepen-

dent variables and post hoc Bonferroni adjustment, which

resulted in a final p value of 0.0083. Descriptive statistics are

presented as boxplots. All calculations were performed with

ermination of closed dentine tubules. (a) SEM image and (b)





SPSS (IBM Corporation, Armonk, NY, USA; Rel. 21) statistical

software.

3. Results

3.1. Quantitative evaluation

After tooth brushing, significant differences were found

between the brushed only negative control (#7) and tooth-

pastes 2 and 5. No differences were found between the

negative control and toothpastes 1, 3, 4 and 6 (Fig. 2). A

significant difference was found between the positive control

toothpaste (#0) and test toothpastes 2, 3, 4, 5 and 6 (Fig. 3). After

erosion with lemon juice, significant differences were found

between the negative control (#7) and toothpastes 2, 4 and 6

but not between the negative control and toothpastes 1, 3 and

5 (Fig. 4). After erosion with lemon juice, the number of open

dentine tubules was significantly different between the

positive control toothpaste and test toothpastes 3, 5, and 6

(Fig. 5).

3.2. SEM investigation combined with EDS analysis

The surface scans of the discs demonstrated irregular

coverage of the dentine surfaces by silica. No evidence of

silicon was found near the dentine surface within the open

dentine tubules of both controls (Fig. 6/0 and 6/7). A scattered

thin layer of silicon covered the dentine surface after the

Fig. 2 – Boxplot graphics of the quantitative determination of op

the negative control (without toothpaste). Significant difference

and 5.


application of toothpaste 1 (Fig. 6/1). A clear thin layer of

silicon covered the dentine surface and the openings of the

dentine tubules after the application of toothpaste 2 (Fig. 6/2).

No clear silicon layer was observed after the application of

toothpaste 3 (Fig. 6/3). Several occluded dentine tubules were

found after the application of toothpaste 4 (Fig. 6/4). Neither a

silicon layer on the dentine surface nor occluded dentine

tubules were observed after the application of toothpastes 5

and 6 (Fig. 6/5 and 6/6).

4. Discussion

Gingival recession results in exposed dentine, which is the

primary cause of dentine hypersensitivity and which is an

increasing problem in dentistry. Consequently, several differ-

ent strategies have been developed for the treatment of

dentine hypersensitivity. These strategies emphasize the

application of various types of desensitizing dentifrices, which

are recommended as appropriate treatments in most cases.53

In principle, two alternative dentine hypersensitivity treat-

ment methods exist. The first method is the blockage of the

nerve transmission in the pulp, and the second method is

dentine tubule occlusion to block the hydrodynamic mecha-

nism in the dentine tubules. Potassium ions block the nerve

response of the A-beta and A-delta nerve fibres1 and diminish

the pain caused by external stimuli. Several different

potassium-containing toothpastes are available. Potassium-

based toothpastes are often combined with other ingredients

en dentine tubules after tooth brushing. Comparison with

s were observed between the controls and toothpastes 2



Fig. 3 – Boxplot graphics of the quantitative determination of open dentine tubules after tooth brushing. Comparison with

the reference toothpaste (positive control). Significant differences were observed between the controls and toothpastes 2, 3,

4, 5 and 6.

Fig. 4 – Boxplot graphics of the quantitative determination of open dentine tubules after tooth brushing and acid etching.

Comparison with the negative control (without toothpaste). Significant differences were observed between the control and

toothpastes 1, 2, 4, and 6.



Please cite this article in press as: Arnold WH, et al. Effectiveness of various toothpastes on dentine tubule occlusion. Journal of Dentistry (2015),http://dx.doi.org/10.1016/j.jdent.2015.01.014


Fig. 5 – Boxplot graphics of the quantitative determination of open dentine tubules after tooth brushing and acid etching.

Comparison with the reference toothpaste (positive control). Significant differences were observed between the control and

toothpastes 3, 5, and 6.



to increase the benefits, and numerous clinical studies

regarding potassium-based toothpastes have been performed,

with differing results. Some of these studies reported no

difference between potassium-based toothpastes and regular

fluoridated toothpastes,54,55 whereas other studies raised

some doubts regarding the clinical evidence of the effectivity

of potassium-containing toothpastes.11,56–58 One toothpaste

that was used in this study contained potassium and

hydroxyapatite for the occlusion of dentine tubules; however,

occlusion could not be verified.

Dentine tubule occlusion is achieved in two different ways,

by either the deposition of an occluding layer on top of the

dentine or the introduction of occluding material into dentine

tubules. Insoluble salts usually form a thin deposition on the

dentine. Hydroxyapatite; arginine, in combination with calcium

carbonate (Pro-Argin technology)2,15,23,24; or various nanopar-

ticles with different functionalised agents50,59,60 are used for the

induction of intratubular mineralisation. Several different

active ingredients are available and are summarized in Table 2.

In vitro studies have shown that strontium acetate or

strontium chloride (SrCl2) treatment forms small crystalline

deposits on the dentine surface, which can easily be washed

away.29,61 Controversial reports regarding the clinical effects

of strontium exist. Several studies have reported positive

effects of SrCl2 or Sr acetate on dentine hypersensitivity

relief.17,19,28,36,62 One study found that SrCl2 is less effective

than conventional fluoride-containing products.21 Another


study found no significant differences between SnCl2-contain-

ing toothpastes and conventional fluoride-containing tooth-

pastes.55 However, only one study that reported a positive

effect of SrCl2 and that fulfilled the criteria for evidence-based

dentistry has been identified.63,64 Sr acetate was shown to

form a thin occluding layer on the dentine surface in the

present in vitro study; however, no tags could be found in the

tubule openings.

Another active ingredient is SnF2. Several studies regarding

the clinical efficacy of SnF2 have been published, with

controversial results. Some studies reported positive effects

of SnF2,30,31,65 whereas another study was neutral and found

no difference between SnF2-containing toothpastes and

conventional toothpastes.66 No dentinal occlusion of the

cross-sections of dentine could be observed after treatment

with SnF2-containing toothpaste in the present study. The top

view demonstrated single occluded tubules.

Oxalates were introduced for the treatment of dentine

hypersensitivity in the early 1980s. Some studies reported good

effectiveness of oxalates in reducing dentine hypersensitivi-

ty.41,44–46 This effectiveness may be due to the precipitation of

oxalates within the dentine tubules and to their relative

insolubility, which reduces hydraulic conductivity in the

dentine tubules.47,67 However, a meta-analysis of the published

papers regarding oxalates found little evidence regarding a

positive clinical effect of oxalates.48 No oxalate-containing

toothpaste was tested in the present study.



Fig. 6 – Cross-sections of dentine discs with dentine tubule occlusion. The toothpastes are identified by EDS silicon mapping

(pink). Ca is mapped in blue. A weak positive signal for silicon is visible on the surface but not in the tubule openings after

treatment with toothpastes 1, 2 and 7. No signal could be detected after treatment with toothpastes 3, 5, and 6. Several

dentine tubules were occluded after treatment with toothpaste 4.



Please cite this article in press as: Arnold WH, et al. Effectiveness of various toothpastes on dentine tubule occlusion. Journal of Dentistry (2015),http://dx.doi.org/10.1016/j.jdent.2015.01.014




A relatively new method is arginine-calcium carbonate

technology (Pro-Argin technology), which was introduced in

2002.68 Several in vitro studies demonstrated a good occluding

effect of Pro-Argin technology on open dentine tubules.34,69–72

Clinical studies of Pro-Argin technology supported the in vitro

results and showed instant relief of dentine hypersensitivi-

ty.24,73

Currently, no in vitro or in vivo studies regarding the

occluding effects of zinc-carbonate hydroxyapatite on dentine

tubules are available; only reports regarding the effects of

zinc-carbonate hydroxyapatite on enamel have been pub-

lished. Several occluded dentine tubules could be found in the

dentine cross-sections after zinc-carbonate hydroxyapatite

treatment (toothpaste # 4) in the present study. This finding

was supported by the surface scan results, and this occluding

effect was not resistant to acid challenge with lemon juice.

5. Conclusion

Taken together, these results indicate that certain toothpastes

occlude dentine tubules. This occlusion is superficial and may

be dissolved with acids. Dentine tubule occlusion is dependent

on the active ingredient and is not complete in any of the

tested toothpastes.

Acknowledgments

The authors would like to thank Mrs. Susanne Haußman for

her technical assistance preparing the SEM specimens. Elmex

toothpaste was provided by CP Gaba, Hamburg, Germany.

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