• Nenhum resultado encontrado

Teste sensorial quantitativo no estudo da sensibilidade dentária decorrente de tratamentos clareadores

N/A
N/A
Protected

Academic year: 2017

Share "Teste sensorial quantitativo no estudo da sensibilidade dentária decorrente de tratamentos clareadores"

Copied!
98
0
0

Texto

(1)

Vanessa Rahal

ARAÇATUBA-SP

(2)

Vanessa Rahal

Teste Sensorial Quantitativo no Estudo da Sensibilidade Dentária

Decorrente de Tratamentos Clareadores

Tese apresentada à Faculdade de Odontologia do Campus de Araçatuba - Unesp, para a obtenção do Grau de ³'RXWRUHP2GRQWRORJLD´- Programa de Pós-Graduação em Odontologia, Área de concentração em Dentística.

Orientador: Prof. Adj. Dr. André Luiz Fraga Briso

ARAÇATUBA-SP

(3)

 

Catalogação  na  Publicação  (CIP)  

Serviço  Técnico  de  Biblioteca  e  Documentação  ʹ  FOA  /  UNESP    

  Rahal,  Vanessa.  

R147u   Teste  sensorial  quantitativo  no  estudo  da  sensibilida-­‐  

  de   dentária   decorrente   de   tratamentos   clareadores   /   Vanessa   Rahal.  -­‐  

  Araçatuba  :  [s.n.],  2013       96  f.  :  il.  ;  tab.  +  1  CD-­‐ROM    

    Tese  (Doutorado)  ʹ  Universidade  Estadual  Paulista,    

  Faculdade  de  Odontologia  de  Araçatuba  

    Orientador:  Prof.  Dr.  André  Luiz  Fraga  Briso    

    1.  Peróxido  de  hidrogênio  2.  Clareamento  dental     3.  Sensação  4.  Análise  quantitativa  I.  T.  

 

        Black  D2  

        CDD  617.6  

(4)

Dados Curriculares

VANESSA RAHAL

NASCI M ENTO 25/10/1982 - Birigui ± SP

FI LI AÇÃO Ricardo Antonio Rahal

Nilva Garcia Rahal

2001/2004 Graduação

Faculdade de Odontologia de Araçatuba ± UNESP

2007/2009 Curso de Pós-Graduação em Odontologia, área de Dentística, nível de Mestrado

Faculdade de Odontologia de Araçatuba ± UNESP

2010/2012 Obtenção dos créditos referentes ao Curso de Pós-Graduação em Odontologia, área de Dentística, nível de Doutorado

(5)

Dedicatória

Dedico esta Tese aos meus pais Ricardo e Nilva, meus maiores amigos e mestres, que me

incentivam a cada passo com muita sabedoria. Grandes guerreiros, meus maiores espelhos,

exemplos de família, honestidade, trabalho, caráter e muito amor. Deixo aqui registrada toda

minha admiração e todo o orgulho que sinto em ser sua filha! Obrigada por tudo... Nem todos

os segundos dessa vida serão tempo suficiente para que eu possa retribuir todo o cuidado e

amor de vocês!

Ao meu noivo Felipe, pelo amor e cumplicidade que me fazem seguir sempre em frente.

Minha maior certeza! Te amo muito, cada dia mais...

À minha irmã Sabrina e meu cunhado Gustavo por todo o amor e carinho e pelas horas de

lazer, conversa e descontração! Seria mais difícil sem poder contar com vocês nos momentos

difíceis!

Ao meu sobrinho João, já muito amado e esperado com muito carinho!

Aos meus avôs e avós, que de algum lugar zelam por nós e nos guiam e iluminam em cada

passo desta jornada... Amor eterno e infinito!

Muito obrigada por me ajudarem a chegar até aqui! Vocês são meus tesouros, minha base,

meu orgulho, meu porto seguro, sem o qual me perderia e minha vida deixaria de ter o sabor

adocicado que ela tem.

(6)

Agradecimento Especial

Ao meu orientador, Prof. Adj. Dr. André Luiz Fraga Briso, grande amigo e mestre, que

com sua atenção e carinho me ofereceu todo o seu precioso saber e que, de coração aberto, me

acolheu e se tornou indispensável em meu caminho acadêmico. Serei eternamente grata por

tudo o que fez por mim durante todos esses anos, colaborando com meu crescimento como

pessoa e como profissional. Obrigada por sempre estar ao meu lado e por me ajudar a superar

(7)

Agradecimentos

A Deus, que me guia em cada passo de minha vida. A Ele que nas horas difíceis me

acolhe e protege e que me dá forças para alcançar meus objetivos.

À )XQGDFmRGH$PSDURj3HVTXLVDGR(V WDGRGH6DѺR3DXOR - FAPESP, pela

FRQFHVVmRGRDX[tOLRjpesquisa, sem o qual não seria possível a realização destes trabalhos.

À Faculdade de Odontologia do Campus de Araçatuba ± UNESP, na pessoa da Ilma.

Diretora Profa. Adj. Ana M aria Pires Soubhia e Vice-Diretor Prof. Titular Wilson

Roberto Poi, pela oportunidade de realização dos meus estudos.

Ao Programa de Pós-Graduação em Odontologia, na pessoa de sua coordenadora

Profa. Adj. M aria José Hitomi Nagata.

Aos professoresdo Curso de Pós-Graduação Stricto Sensu em Odontologia  da

Faculdade de Odontologia de Araçatuba ± UNESP.

Ao meu inesquecível orientador de mestrado, Prof. Adj. Dr. Renato Herman

Sundfeld, que como um verdadeiro pai me ajudou em meus primeiros passos como

pesquisadora. Sou eternamente grata por todo o seu carinho e seus ensinamentos.

Ao querido professor de Pós-Graduação, Prof. Adj. Dr. Paulo Henrique dos Santos,

(8)

Ao Prof. Ass. Dr. Luciano Tavares Angelo Cintra pela orientação e paciência

infindável na realização da análise estatística deste estudo.

Ao Prof. Dr. Reynaldo Leite M artins Júnior e à Juliana Stuginski Barbosa por

toda a colaboração durante a idealização e realização deste estudo.

À Profa. Ana Karina Bedran Russo (University of Illinois at Chicago) pela

oportunidade de estudo e aprendizado e pela hospitalidade durante o estágio no exterior.

À Profa. Adj. M aria Lúcia M arçal M azza Sundefeld por toda colaboração durante

todos estes anos.

À Profa. Cléa Adas Saliba Garbin pela sua amizade, compreensão e por todas as

suas palavras de carinho.

Ao Prof. Eloi Dezan Júnior pela grande amizade construída sob os pilares da

confiança e do carinho mútuo. Estarei sempre ao seu lado!

Aos meus professores de Dentística: Laumer Pedro Alcântara Silva e Quintella,

M ara Antônio M onteiro de Castro, Renato Herman Sundfeld, Sandra Rahal M estrener, 6LOYLR-RVHғ0DXUR, Ricardo Coelho Okida e André Luiz Fraga Briso por todo o saber que

(9)

A todos os meus queridos professores de graduação, em especial aos professores da

Disciplina deEndodontia do Departamento de Odontologia Restauradora.

A todos os funcionários e ex-funcionários do Departamento de Odontologia

Restauradora da Faculdade de Odontologia de Araçatuba ± UNESP, pelo carinho e momentos

de descontração durante todos esses anos.

Aos queridos amigos de pós-graduação Letícia Cunha Amaral Gonzaga de

Almeida, Ana Paula Albuquerque, Fernanda Garcia de Oliveira e Lucas Silveira

M achado, por todos estes anos de companheirismo e amizade.

Às queridas amigas M arjorie de Oliveira Gallinari e Fernanda Almeida de

Azevedo, por cada dia de ajuda durante a realização deste trabalho e também por todo o

carinho durante esses anos.

Aos estagiários e amigos do Departamento de Odontologia Restauradora Naiara

M ontes, Ana Paula Pereira, Ana Paula Lima, Clícia Ribeiro, Gustavo Arcos, Francine

Benetti, M ariana Campos Hidelbrand, M ariana Fioravante, Fernanda Bernardi e

Laércio Neves M arcon pelos momentos de conversa, risadas e também de estudo.

Aos amigos Rafael Simões Gonçalves, Laura M olinar Franco, André Gustavo de

Lima Godas, Diego Valentim e Aguinaldo Cândido da Silva Facundo pela amizade epor

todos os momentos de estudo e descontraçãodurante a realização deste trabalho e de todos os

(10)

Aos meusqueridos pacientes que tornaram possível a realização deste estudo.

A todos osfuncionários da Seção de Pós-Graduação da Faculdade de Odontologia de

Araçatuba ± UNESP, Valéria, Lilian, Diogo, Cristiane e Joilson pela amizade, atenção e

pela paciência.

Aos bibliotecários da Faculdade de Odontologia de Araçatuba ± UNESP, em especial

à Ana Claudia pela colaboração durante todo o período de redação deste trabalho.

Aos meus familiares, em especial à minha tia M aria Eli (Lili), pelo carinho, amor e

cuidados desde o meu nascimento até os dias de hoje.

À minha segunda família, já tão amada: M aria do Carmo, Claudecir, Guilherme,

Tio Tonho, Tia Lu, Leda, Lara, Júnior, Tio Júnior, Tia M ari e Laura.

À minha querida avó que a vida me deu de presente, Dona Cida, por todo o carinho e

amor.

Às minhas amigas de todos os dias, Camila e Dayana, que não mediram esforços para

me ajudar a chegar até aqui.

A todos os meus amigos e àqueles que direta ou indiretamente contribuíram durante

(11)

RAHAL V. Teste Sensorial Quantitativo no Estudo da Sensibilidade Dentária Decorrente de

Tratamentos Clareadores [tese]. Araçatuba: Faculdade de Odontologia de Araçatuba da

UniveUVLGDGH(VWDGXDO3DXOLVWD³-~OLRGH0HVTXLWD)LOKR´.

Resumo Geral

Depois de reconhecido como uma terapia esteticamente eficaz, o clareamento dental tem sido

comumente procurado pela maioria dos pacientes na busca por um sorriso mais harmonioso e

agradável. No entanto, o surgimento da sensibilidade dentária em decorrência do uso de

peróxidos faz com que muito pacientes tornem-se insatisfeitos com o tratamento clareador.

Neste contexto, estudos relacionados a essa sintomatologia são frequentes, porém, baseados

em metodologias limitadas e imprecisas. Por isso, torna-se necessário empregar um método

recente no campo odontológico a fim de enriquecer cientificamente as análises de

sensibilidade dentária. Objetivos: Assim, o presente estudo objetivou analisar e quantificar a

ocorrência de sensibilidade dentária por meio do Teste Sensorial Quantitativo (QST) com a

utilização de um equipamento de análise neurosensorial em diferentes momentos do

tratamento clareador e mesmo após o uso de dessensibilizantes. Além disso, relacionar o

limiar de sensação dos pacientes com tal ocorrência para que se estabeleça um protocolo de

indicação individual adequado. Materiais e Métodos: Inicialmente, sessenta voluntários foram

divididos em 4 grupos de acordo com o limiar de sensação da pele (baixo - GI e GIII e alto -

GII e GIV), classificado por meio do QST, e o tratamento clareador (peróxido de hidrogênio -

GI e GII e placebo - GIII e GIV). A sensibilidade dental mensurada por meio do QST, em 10

tempos de estudo. Como estudo complementar, foi realizada a segunda etapa desta pesquisa,

onde os dez pacientes restantes receberam o tratamento clareador com peróxido de hidrogênio

(12)

dessensibilizante tópico no hemiarco esquerdo da maxila. No hemiarco direito foi aplicada

uma solução salina a temperatura ambiente (controle). O QST foi realizado antes do

clareamento (AC), imediatamente depois do clareamento (DC) e imediatamente após a

aplicação do dessensibilizante (DD). Resultados: Como resultado da primeira etapa desse

estudo, foram verificadas respostas distintas de sensibilidade nos pacientes de baixo e alto

limiar sensitivo GD SHOHGXUDQWH D SULPHLUD H WHUFHLUD VHVV}HV FODUHDGRUDV S”Por sua

vez, no estudo complementar o tratamento clareador promoveu o aumento da sensibilidade

dental, sendo esta ainda presente mesmo após o uso da solução salina. No entanto, com a

aplicação do dessensibilizante, a sensibilidade dental foi reduzida Conclusões: Com base nos

resultados obtidos em nossos estudos, concluímos que o limiar de sensação em pele pode

representar um fator determinante na ocorrência de sensibilidade dental exacerbada pelo

tratamento clareador. Além disso, o uso do dessensibilizante após o clareamento dental

mostrou-se efetivo ao reverter esta condição.

Palavras-chave: Peróxido de Hidrogênio. Clareamento Dental. Sensação. Análise

Quantitativa.  

(13)

RAHAL V. Dental Sensitivity Assessment During Dental Bleaching Using Quantitative

sensory testing [thesis]. Araçatuba: UNESP ± Univ Estadual Paulista; 2013.

Abstract Geral

After being considered as an esthetically efficient technique, dental bleaching has been

frequently sought by patients that look forward to a harmonious and pleasant smile.

Nevertheless, dental sensitivity due to the use of peroxides makes patients become very

unsatisfied with the bleaching treatment. In this context, studies related to this issue are very

common, but based on limited and inaccurate methodologies. Therefore, we improved a

recent method in dentistry in order to contribute to the enrichment of these scientific analyses.

Objectives: Hence, the present study aimed to perform a Quantitative Sensory Testing (QST),

using a neurosensory analyzer to verify and quantify the occurrence of dental sensitivity, in

different periods of evaluation, during bleaching treatment and after the use of a desensitizer

DJHQW$GGLWLRQDOO\ZHUHODWHGWKHSDWLHQWV¶sensation threshold with this occurrence in order

to establish an appropriate personal protocol statement. Materials and Methods: Seventy

volunteers were criteriously selected and sixty from them were divided into 4 study groups

according to the skin cold sensation threshold (low - GI and GIII and high - GII and GIV),

obtained using QST, and the bleaching treatment (hydrogen peroxide - GI and GII and

placebo - GIII e GIV). After the classification according to the skin cold sensation threshold,

bleaching treatment was performed and dental cold sensation threshold was measured using

QST in 10 different times. As a complementary study, we conducted the second part of this

research. Ten patients underwent bleaching treatment using 35% hydrogen peroxide

(Whiteness HP Maxx). After the bleaching session, a topical desensitizer was applied to the

teeth of the left maxillary hemi-arch. A saline solution at ambient temperature was applied in

(14)

immediately after bleaching (AB), and immediately after the desensitizer (AD). Results: In

the first part of the study, distinct responses of dental sensitivity were found in patients with

high and low sensitive thresholds during the first and WKLUGEOHDFKLQJVHVVLRQS”. On the

other hand, in the complementary study, bleaching treatment promoted dental sensitivity,

which remain the same even before the saline solution application. However, results revealed

a reduction of dental sensitivity after desensitizing application. Conclusions: Based on these

results, we can conclude that skin cold sensation might represent a determining factor in the

occurrence of dental sensitivity enhanced by the bleaching treatment. Furthermore, the use of

a desensitizing agent after this procedure was effective to revert this condition.

(15)

D = nível de significância / significance level

ºC = graus Celsius / degree Celsius

% = porcentagem / percentage

> = maior que / higher than

” = menor ou igual a / lower or equal to

= = igual / equal

1st = first

2nd = second

3rd = third

AB = after bleaching

AC = antes do clareamento

AD = after desensitizer

a.m. = ante meridien (antes do meio-dia)

BB = before bleaching

CST = Cold Sensation Threshold

DC = depois do clareamento

DD = depois do dessensibilizante

DP = Desvio Padrão

et al. = e colaboradores

GI = grupo I

GII = grupo II

GIII = grupo III

GIV = grupo IV

HP = Hydrogen Peroxide

Ltd. = Limited

Ltda. = Limitada

ml = mililitro / mililiter (unidade de medida equivalente a 10-3l) mm = milímetro / milimeter (unidade de medida equivalente a 10-3m) n = tamanho da amostra do grupo / group sample size

NaCl = Sodium Chloride

(16)

P = evaluation period

pH = Potencial Hidrogeniônico / Hydrogen Potential

QST = Quantitative Sensory Testing

SD = Standard Deviation

SCST = Skin Cold Sensation Threshold

UNESP = Universidade Estadual Paulista ³-~OLRGH0HVTXLWD)LOKR´

(17)

CAPÍ TULO 1

Figure 1: Flow chart diagram detaching the enrollment, allocation, follow-up and analysis during the study (CONSORT Statement).

39

Figure 2: Scheme of the skin neurosensory analysis using the equipment TSA II. 40

Figure 3: Individual perforated tray confectioned to standardize the dental region to be measured.

41

Figure 4: Scheme of the tooth neurosensory analysis using the equipment TSA II. 42

CAPÍ TULO 2

Figure 1: Flow chart diagram detaching the enrollment, allocation, follow-up and analysis during the study (CONSORT Statement).

68

Figure 2: Scheme of the neurosensory analysis using the equipment TSA II. 69

Figure 3: Data of cold sensation threshold in the right and left hemi-arches during the periods of evaluation.

(18)

CAPÍ TULO 1

Table 1: Inclusion and exclusion criteria for selection of patients. 43

Table 2: Evaluation periods of the skin and dental cold sensation threshold. 44

Table 3: Study groups and experimental and placebo products composition. 45

Table 4: P. values obtained after dental cold sensation evaluation in different periods.

46

Table 5: Temperature variations for cold sensation (oC) in different evaluation periods, after the beginning of dental bleaching.

47

Table 6: P. values obtained after skin cold sensation threshold evaluation in different periods.

48

Table 7: Temperature variations for dental cold sensation (oC) of experimental groups with low and high threshold.

49

CAPÍ TULO 2

Table 1: Inclusion and exclusion criteria for selection of patients. 71

Table 2: Treatment according to the split-mouth design method. 72

Table 3: Composition of the products used in this study. 73

Table 4: Mean temperatures and standard deviation of cold sensation threshold (oC) in right and left hemi-arches.

(19)

1 Introdução geral 18

2 Capítulo 1 ± I nfluence of cold sensation threshold in the occurrence of dental sensitivity during dental bleaching: a placebo controlled clinical trial

21

2.1 Resumo 21

2.2 Abstract 22

2.3 Introdution and proposition 23

2.4 Materials and Methods 25

2.5 Results 29

2.6 Discussion 30

2.7 Conclusion 33

2.8 Acknowledgements 34

2.9 References 35

3 Capítulo 2 ± Quantitative Sensory Testing of the effect of desensitizing treatment after dental bleaching

50

3.1 Resumo 50

3.2 Abstract 51

3.3 Introduction and proposition 52

3.4 Materials and Methods 55

3.5 Results 59

3.6 Discussion 60

3.7 Conclusion 62

3.8 Acknowledgements 63

3.9 References 64

(20)

1 Introdução Geral

*

A busca por tratamentos estéticos nos consultórios odontológicos é cada vez mais

frequente. Dentre os procedimentos que visam melhorar a aparência e a autoestima dos

pacientes (POLYDOROU et al., 2007) destaca-se o clareamento dental, que se caracteriza por

ser uma técnica conservadora capaz de proporcionar resultados impactantes, satisfazendo os

anseios dos pacientes e também de muitos profissionais (DIETSCHI et al., 2006; MATIS et

al., 2007; PARK et al., 2004).

Desde que proposto, o clareamento caseiro foi considerado uma terapia reconhecida

como tecnicamente simples, biologicamente segura e esteticamente eficaz (DIETSCHI, 2005;

DIETSCHI et al., 2006; HAYWOOD & HEYMANN, 1991; LEONARD et al., 1997; PARK

et al., 2004), quando bem indicada e sob adequada supervisão do profissional em

Odontologia.

Recentemente, novas técnicas foram desenvolvidas, como o tratamento de consultório

(in-office), que emprega produtos à base de peróxidos altamente concentrados diretamente

sobre a superfície de esmalte. A possibilidade de obtenção de resultados rápidos e a não

necessidade do incômodo uso das moldeiras são os principais apelos mercadológicos da

técnica, que tem agradado profissionais e pacientes (DOS SANTOS MEDEIROS et al., 2008;

PARK et al., 2004). Seu mecanismo de ação baseia-se na presença de formas reativas de

oxigênio, que, por serem extremamente instáveis, promovem oxidação dos pigmentos

incorporados nos tecidos dentais, tornando-os mais claros (CALLAN et al., 2008; DELFINO

et al., 2009; DIETSCHI et al., 2006; MYERS et al., 2003; USHIGOME et al., 2009).

Apesar da eficácia clareadora, estudos relatam a presença de sensibilidade dentária em

70% dos pacientes tratados, o que pode prejudicar a continuidade do tratamento ou causar

     

*

(21)

uma redução no sentimento de satisfação (BROWNING et al., 2007; KUGEL et al., 2009;

MONCADA et al., 2013).

Neste contexto, a maioria dos estudos clínicos sobre a ocorrência de sensibilidade

durante o clareamento apresenta dados coletados através de relatos de experiência e

questionários de dor, fazendo com que haja o surgimento de um viés de interpretação

referente aos dados coletados, afetando a confiabilidade dos resultados obtidos e

reprodutibilidade do método (BROWNING et al., 2007; CALLAN et al., 2008; KUGEL et

al., 2009).

Alguns estudos que avaliaram clinicamente a intensidade da sensibilidade dental

(BROWNING et al., 2007; LEONARD et al., 1997; MACHADO et al., 2013), mostram que a

ocorrência da sensação dolorosa varia muito de indivíduo para indivíduo e tende a ser mais

intensa no final do tratamento. Esta variação individual pode estar de alguma forma associada

ao limiar de dor ou de sensação de cada pessoa, que podem apresentar respostas distintas

frente a um estímulo de mesma intensidade, independentemente das características clínicas

bucais que cada pessoa apresenta.

Vale destacar que o limiar de dor pode ser definido como o ponto ou momento em que

um dado estímulo é reconhecido como doloroso. Este ponto que provoca a dor, ou mesmo

inicia um processo de desconforto é mais facilmente detectado em alguns pacientes, podendo

ser classificados como indivíduos com limiar de dor baixo. Do contrário, o limiar de dor alto

seria atingido mais dificilmente. Já o limiar de sensação é definido como o momento em que o

estímulo é percebido ou detectado pelo paciente e pode também ser classificado em alto e

baixo (AFFAITATI et al., 2009; GRANGES et al., 1993; STAUD et al., 2011).

O mercado de produtos relacionados à ciência da dor possui hoje equipamentos

modernos e eficientes que permitem quantificar sintomas dolorosos, por meio de análises

(22)

PAVLAKOVIC et al., 2008; PIGG et al., 2010). Um desses equipamentos, o TSA-II (Medoc

Advanced Medical Systems Ltd., Ramat Yishai, Israel), fornece dados precisos sobre limiar

de dor e limiar de sensação. O maior diferencial desta tecnologia é a possibilidade de

quantificar a resposta neurosensorial de fibras nervosas maiores e menores (LIST et al., 2009;

PAVLAKOVIC et al., 2008; PIGG et al., 2010), enquanto outros equipamentos permitem

apenas a análise baseada em fibras mais grossas (SIAO et al., 2003). Esta informação é de

grande importância, já que as fibras mielínicas sensitivas mais grossas (AE) perfazem apenas

7% da totalidade das fibras mielínicas pulpares (NAIR et al., 1992). As principais fibras de

condução sensitiva encontradas no tecido pulpar são as fibras mielínicas (A˜) e amielínicas

(C) que transmitem a sensação térmica ao sistema nervoso central (SACERDOTE et al.,

2012).

Testes de sensibilidade ao frio e ao calor podem ser realizados com o uso do TSA-II,

por meio do termode, que permite aquecimento e resfriamento em diferentes tempos e

temperaturas (GRANOT et al., 2005; KALANTZIS et al., 2007). Por este motivo, almeja-se

que o estudo simultâneo do limiar de sensação e da sensibilidade dentária frequentemente

presente nos tratamentos clareadores, possibilite aos clínicos um novo parâmetro para a

indicação de terapias prévias e de combate à sensibilidade no caso do tratamento de pacientes

predispostos a tal ocorrência. Além disso, esses novos conhecimentos podem auxiliar o

profissional na indicação da terapia clareadora mais adequada a cada indivíduo.

Diante do exposto, nossos estudos clínicos do tipo cego fatorial randomizado

controlado buscam quantificar a ocorrência de sensibilidade dental antes, durante e após o

tratamento clareador levando em consideração o limiar de sensação em pele de cada paciente

e visando, ainda, a prevenção dessa sensibilidade por meio de tratamentos dessensibilizantes

(23)

2 Capítulo 1

I nfluência do limiar sensitivo na ocorrência de sensibilidade dentária durante o

clareamento: ensaio clínico controlado

QST: Limiar sensitivo e sensibilidade dentária

2.1 Resumo

O presente estudo verificou a ocorrência de sensibilidade dental em pacientes submetidos ao

procedimento clareador realizado com 3 aplicações de 15 minutos do peróxido de hidrogênio

a 35% (Whiteness HP Maxx 35% - FGM), a ocorrência de variação no limiar sensitivo em

pele de cada um e o papel deste limiar na ocorrência da sensibilidade dentária. Para tanto,

sessenta voluntários foram divididos em 4 grupos de estudo (n=15) de acordo com o limiar de

sensação da pele (baixo ± GI e GIII e alto ± GII e IV) e o tratamento clareador (peróxido de

hidrogênio ± GI e GII e placebo ± GIII e GIV). O limiar de sensação da pele foi determinado

no antebraço dos pacientes em 6 diferentes tempos de estudo, por meio de estímulos térmicos

produzidos pelo equipamento de análise neurosensorial, o TSA II. Após a classificação dos

pacientes de acordo com o limiar sensitivo, o tratamento clareador e placebo foram realizados.

A sensibilidade dental foi então mensurada em 10 tempos de estudo por meio de um

dispositivo intraoral acoplado ao TSA II e posicionado na face vestibular do incisivo superior.

Foram verificadas respostas distintas de sensibilidade nos pacientes de baixo e alto limiar

sensitivo GDSHOHGXUDQWHDSULPHLUDHWHUFHLUDVHVV}HVFODUHDGRUDVS”Além disso, os

dentes submetidos ao clareamento se tornaram mais sensíveis ao frio do que os tratados com o

placebo. O limiar de sensação em pele permaneceu inalterado durante todo o experimento.

Concluiu-se que o limiar de sensação da pele pode representar um fator determinante na

ocorrência de sensibilidade dental, já que os pacientes de limiar sensitivo em pele alto e baixo

responderam de maneiras distintas frente ao estímulo térmico em dente. Significância Clínica:

O estudo da sensibilidade durante o clareamento dental relacionada ao limiar sensitivo em

pele pode auxiliar os profissionais a estabelecer um protocolo adequado de clareamento e de

terapias dessensibilizantes prévias e posteriores ao tratamento, considerando a predisposição à

sensibilidade dentária em pacientes de diferentes limiares sensitivos em pele (alto e baixo).

(24)

I nfluence of cold sensation threshold in the occurrence

of dental sensitivity during dental bleaching: a placebo controlled clinical trial

QST: Sensation threshold and dental sensitivity

2.2 Abstract

The present study verified the occurrence of dental sensitivity in patients submitted to 3

15-minute applications of a 35% hydrogen peroxide based product (Whiteness HP Maxx 35% -

FGM), the skin cold sensation threshold (SCST) occurrence and its influence on dental

sensitivity. Sixty volunteers were divided into 4 study groups (n=15), according to the SCST

(low ± GI and GIII and high ± GII and IV) and bleaching treatment (hydrogen peroxide ± GI

and GII and placebo ± GIII and GIV). SCST was determined in the inner forearm in 6

different times using a neurosensory analyzer, the TSA II (Medoc Advanced Medical

Systems, Ramat Yishai, Israel). Dental sensitivity measurements were performed in 10

different times using TSA II attached to an intraoral device, positioned in the buccal surface

of the teeth. Distinct responses of dental sensitivity were found in patients with high and low

SCST GXULQJ WKH ILUVW DQG WKLUG EOHDFKLQJ VHVVLRQ S” DQG WKH WHHWK VXEPLWWHG WR WKH

bleaching treatment became more sensitive to cold than those treated with placebo. SCST

remained the same during bleaching treatment. Bleaching agent increased dental sensitivity

and the skin cold sensation threshold might represent a determining factor in this occurrence,

since low and high SCST patients had different responses to the thermal stimulus in tooth.

Clinical Significance: The study of dental sensitivity during dental bleaching considering skin

cold sensation threshold may enable professionals to establish an adequate dental bleaching

protocol and even adequate prior and posterior desensitizing therapies, considering the

predisposition to dental sensitivity in patients of different skin cold sensation threshold (low

and high).

(25)

2.3 I ntroduction‚

Tooth bleaching is one of the most popular esthetic procedures requested by patients

and a conservative approach with efficient results.1-4 The in-office technique using highly

concentrated hydrogen peroxide products has become an excellent alternative for both

professionals and patients.5-7 Its mechanism of action is similar to the at-home technique,

which is based on unstable reactive oxygen species that lighten tooth pigments through

oxidation.1,8

Despite the whitening efficacy, recent studies showed that patients submitted to dental

bleaching reported different intensities of dental sensitivity.9-12 This symptom is a concern for

dentists and patients as a limitation for treatment evolution and satisfaction.

Some clinical trials about dental sensitivity showed that pain is different between

individuals and it is usually stronger at the final phase of treatment.10,13 This variation may be

associated to the sensation threshold of each patient, which is classified as low when cold

sensation is easily detected and high in the opposite situation.

TSA II (Medoc Advanced Medical Systems, Ramat Yishai, Israel) 8,14-17 represents a

modern technology for quantification of neurosensory response related to major and minor

nervous fibers3 through Quantitative Sensory Testing (QST) using thermal, mechanical, or

electrical stimuli.

Thus, test for cold and heat sensation can be conducted using accurate devices that

transfer temperature changes to several body structures under predetermined speed.18,19 In this

sense, a simultaneous study for skin sensation threshold and dental sensitivity experienced

during whitening would provide clinical safety levels to prevent and treat this side effect.

     

Ώ  Normalização segundo a revista Operative Dentistry (Anexo C).

(26)

The aim of the present study was to verify the influence of the skin cold sensation

threshold in dental sensitivity using the neurosensory analysis to quantify thermal sensitivity

during dental bleaching.

The null hypothesis assumed that:

- there is no difference in dental sensitivity at different periods during bleaching with 35%

hydrogen peroxide products,

- there is no difference in skin cold sensation threshold during bleaching with 35% hydrogen

peroxide products,

- skin cold sensation threshold of each patient does not influence dental sensitivity during

(27)

2.4M aterials and M ethods

Experimental Design

After approval by the Committee of Ethics in Research (00278/2011), 60 male patients

aged from 18 to 25 years were selected according to the criteria shown in Table 1. The

patients were carefully evaluated and submitted to anamnesis and appropriate clinical and

radiographic exams before allocation (Figure1).

This placebo-controlled, blind and factorial clinical trial with equal randomization

included the factors: (1) bleaching treatment in 2 levels (35% hydrogen peroxide and

placebo); (2) skin cold sensation threshold in 2 levels (low and high) and (3) 10 evaluation

periods (Baseline ± 24 hours before treatment; immediately before treatment; immediately

after the 1st treatment session; 24 hours after the 1st treatment session; immediately after the

2nd treatment session; 24 hours after the 2nd treatment session; immediately after the 3rd

treatment session; 24 hours after the 3rd treatment session; 7 and 30 days after the treatment

(Table 2).

It is noteworthy that patients were also instructed no to use analgesic or

anti-inflammatory medications and desensitizing toothpastes during and 30 days after the

bleaching treatment in order to avoid misreading of data.

Quantitative Sensory Testing (QST) ± Skin Cold Sensation Threshold

Skin cold sensation threshold was firstly performed in order to divide the patients

according to experimental or placebo treatment.

The first measurement of skin cold sensation threshold was performed using the

(28)

and its skin probe (30 mm x 30 mm), in a silent environment with a constant temperature of

26º C. The sessions were conducted from 8:00 a.m. to 10:00 a.m..

7KH76$,,ZDVFRQILJXUHGXVLQJWKH³/LPLWV´IXQFWLRQDQGWKHWHVWRIFROGVHQVDWLRQ

thresholds (CST) was used for this purpose. Three descending temperature tests were

performed in the inner forearm. The test began at 32 oC (comfort temperature), and the

thermode cooling speed was 1 ºC per second. After patient perception of temperature

alteration, the patient paused the stimulus, and the measurement was repeated for two times,

30 seconds after the previous one (Figure 2).

The values obtained during the first test were discarded, and the mean of the following

tests was used as the temperature for cold sensation threshold testing in skin.

The mean temperature was considered the skin cold sensation threshold and was used

to classify patients in low or high skin cold sensation threshold.

Measurements were performed in different periods according to Table 2.

Quantitative Sensory Testing (QST) ± Dental Cold Sensation Threshold

For standardization of tooth analysis, a 100% ethylene copolymer and vinyl acetate

tray was fabricated for each patient. The tray had a circular perforation with a diameter

similar to the active tip of the intraoral thermode. The perforation was created on the buccal

surface and 2 mm below the cervical, incisal, and proximal margins of the upper right central

incisor (Figure 3).

Quantitative Sensory Testing (QST) for dental cold sensation thresholds was

conducted using an intraoral device of 6 mm diameter connected to TSA II. It was always

positioned in the same area, within the circular perforation of the tray, in the flattest region of

(29)

Before measurement, the tooth was covered with thermal paste containing silver oxide

(IPT - Pasta Térmica Implastec, Implastec Eletroquímica Ltd., Votorantim, São Paulo, Brazil)

to optimize thermal conduction. The tests were performed in the same conditions previously

reported.

The patients were able to stop cooling of the intraoral thermode at any time using the

device in their hands. The test began at 36 oC, and the thermode cooling speed was 0.5 ºC per

second, resulting in slow temperature variation that allowed transference of the thermal

stimulus to the dentine-SXOS FRPSOH[ 7KH 76$ ,, ZDV FRQILJXUHG XVLQJ WKH ³/LPLWV´

function, and the test of cold sensation thresholds (CST) was used for this purpose. Three

descending temperature tests were performed. After patient perception of temperature

alteration, the patient paused the stimulus, and the measurement was repeated for two times,

30 seconds after the previous one. The values obtained during the first test were discarded,

and the mean of the following tests was used as the temperature for cold sensation threshold

testing in tooth.

Dental cold sensitivity measurement was performed for both study groups in

predetermined evaluation periods (Table 2).

Treatments performed

Once the patients were classified according to the skin cold sensation threshold (low

cold sensation threshold were the ones who detected thermal sensation up to 30 oC and high

cold sensation threshold, the ones who detected thermal sensation below 30 oC), the in-office

bleaching technique using 35% hydrogen peroxide (Whiteness HP Maxx, FGM Produtos

Odontológicos ± Ltda., Joinville, Santa Catarina, Brazil) was performed in patients in groups

(30)

system (one bottle contains the peroxide and the other contains the activator), and the

substances are mixed in a peroxide/activator ratio of 3:1 drops.

After tooth prophylaxis and soft tissue isolation using a light cured resin gingival

barrier (Top Dam ± FGM Produtos Odontológicos Ltda., Joinville, Santa Catarina, Brazil),

the bleaching agent was inserted into a graduated syringe, and 0.06 ml of the bleaching

product was applied on the buccal surface of the teeth for 15 minutes. After the first

application, the teeth were cleaned and dried with gauze, and the procedure was repeated

twice, totalizing 45 minutes of contact between the bleaching product and enamel in each

session. After 7 and 14 days the same procedure was performed.

In groups I I I and I V, a placebo agent, identical to the original bleaching agent

presentation, purchased from the same manufacturer, was applied to the dental surface the

same way as reported for the bleaching agent (Table 3). Patients were not informed of the

group to which they belonged.

Statistical Analysis

Temperature variations (delta) were used to perform the statistical analysis. They were

obtained by subtracting the initial temperatures/baseline from those found in the other periods

of study.

'DWDZDVVXEPLWWHGWR6WXGHQW¶VW-test at a 5% level of significance using Pacotico 5.1

(31)

2.5 Results

The values of dental cold sensation in the bleached groups (Groups I and II) were

statistically different from the initial values (S”In groups treated with placebo (Groups

III and IV), cold sensation remained the same during the study (p>0.05), except for P 02 in

JURXS,,,S”DQGP 03 in group IV (Table 4).

It was also observed that temperature variations for cold sensation in the bleached

JURXSZHUHVWDWLVWLFDOO\GLIIHUHQWLQFRPSDULVRQWRSODFHERLQDOOSHULRGVS”UHJDUGOHVV

the skin cold sensation threshold (Table 5). Data revealed stronger dental sensitivity during

bleaching with 35% hydrogen peroxide compared to placebo.

For the analysis of skin cold sensation threshold during dental bleaching, no statistical

difference was found between the periods (p>0.05) (Table 6).

The influence of skin cold sensation threshold on dental cold sensation was evaluated

through comparison of temperature change (delta) for cold sensation in the maxillary central

incisor of experimental groups with low and high threshold. Statistically significant

(32)

2.6 Discussion

The Quantitative Sensory Testing (QST) used in this study to measure dental cold

sensation during whitening has been used in several fields for pain evaluation.1,20-22 Among

all devices applied for this technique, the neurosensory analyzer (TSA II) provides

reproducible and reliable tests mainly when conducted by a single operator and associated to

SDWLHQW¶VFROODERUDWLRQ5,9,23,24

This analysis allows evaluation of thick and thin myelinated and unmyelinated

fibers,1,19 which is noteworthy in Dentistry since different types of fiber penetrate into the

apical foramen.15

The test ³Limits´DYDLODEOHLQWKHGHYLFHVRIWZDUHZDVXVHGEHFDXVHLWLVUHSURGXFLEOH

and well tolerated by the patient.25 This characteristic is important since a time-consuming

analysis causes stress and data inaccuracy.

Since the influence of repeated testing in the same tooth should be also considered, an

interval between trials must be established to avoid windup. In the present study, a 30-second

interval was waited between the measurements to reestablish a comfortable temperature. Slow

temperature change was conducted to reach the dentine-pulp complex.

Based on the present results, the first null hypothesis was rejected since the

temperature for dental cold sensation was different during treatment. Previous studies

evaluating dental sensitivity through self-reports and questionnaires with Analogue Visual

Scale are in accordance with the present results.10,13,26 However, the dental cold sensation

threshold remained unaltered in the groups treated with placebo (III and IV), which justifies

its use in the study. The alterations in those groups were observed at P 02 (low threshold) and

P 03 (high threshold) and may be associated to stress and to the placebo response associated

(33)

It is noteworthy that its was verified the presence of dental cold sensation even 7 days

after finishing the bleaching treatment. It has been demonstrated that bleaching agents cause

histomorphological alterations in enamel8,28,29 and the present results suggested that some of

those modification persisted over time. The product pH and its action on enamel proteins may

have increased the diffusion channels and tissue permeability, influencing the response to

thermal stimulus.6,12,28,30 In addition, penetration of peroxide into dental pulp may cause

structural damage and inflammation with more inflammatory cells and interruption of

odontoblasts layers as a result of reversible pulpitis.3,12,31,32 On the other hand, 30 days after

finishing the treatment, there was no incidence of dental cold sensation threshold alterations.

The second null hypothesis was accepted since whitening did not change the skin cold

sensation threshold. The skin threshold changes during specific situations, such as systemic

disease and ageing.2 Thus, sample standardization regarding health condition, gender and age

should be established since those factors may influence the results.2,7,33

On the other hand, it plays an essential role in dental sensitivity since those individuals

with high and low skin cold sensation thresholds showed different behavior during the 1st and

3rd sessions of the treatment. In those cases, the skin threshold influenced clinical tooth

response, representing different tolerance levels against thermal stimuli on tooth.2 Thus, the

third null hypothesis was also rejected.

These periods are coincident to the ones in which our patients reported increased

incidence of dental sensitivity and also corroborate with previous studies where, especially at

the beginning and end of the bleaching treatment, cold sensations become exacerbated.13,35

In this context, though the sensitivity has a very negative impact on satisfaction, this

undesirable symptom was not sufficient to cause the discontinuance or interruption of

(34)

In general, the neurosensory analysis with TSA II in tooth is beneficial for

Dentistry since knowledge about bleaching side effects30,34,35 is relevant for development of

safe and comfortable protocols. These data also provide practitioners with a better estimate of

what their patients are likely to experience. Otherwise, further investigations are necessary to

improve this method of quantitative analysis of cold sensation in tooth, which is a hard and

(35)

2.7 Conclusion

Based on the present results, temperature for dental cold sensation did not remain the

same during bleaching treatment; skin cold sensation threshold did not change during

bleaching treatment using 35% hydrogen peroxide; and skin cold sensation threshold might

(36)

2.8 Acknowledgements

This research was supported by Fapesp (10/11627-6). The authors thank FGM

(37)

2.9 ReferencesÁ

1. Chong PS & Cros DP (2004) Technology literature review: Quantitative Sensory

Testing Muscle & Nerve29(5):734-747.

2. Lautenbacher S, Kunz M, Strate P, Nielsen J & Arendt-Nielsen L (2005) Age effects

on pain thresholds, temporal summation and spatial summation of heat and pressure

pain The Journal of the International Association for the Study of Pain 115(3) :410-418.

3. Markowitz K (2010) Pretty painful: why does tooth bleaching hurt? Medical

Hipotheses74(5):835-840.

4. Pfab F, Valet M, Sprenger T, Toelle TR, Athanasiadis GI, Behrendt H, Ring J &

Darsow U (2006) Short-Term alternating temperature enhances histamine-induced

itch: a biphasic stimulus model Journal of Investigative Dermatology126(12) :2673-2678.

5. Chaudhry V, Cornblath DR, Mellits ED, Avila O, Freimer ML, Glass JD, Reim J,

Ronnett GV, Quaskey SA & Kuncl RW (1991) Inter- and intra-examiner reliability of

nerve conduction measurements in normal subjects Annals of Neurology 30(6) :841-843.

6. Dezotti MS, SoX]D-XғQLRU0+-U& Nishiyama CK (2002) Evaluation of pH variation

and cervical dentin permeability in teeth submitted to bleaching treatment Pesquisa

Odontológica Brasileira 16(3):263-268.

7. Edwards RR, Fillingim RB & Ness TJ (2003) Age-related differences in endogenous

pain modulation: a comparison of diffuse noxious inhibitory controls in healthy older

and younger adults The Journal of the International Association for the Study of Pain

101(1-2):155±65.

8. Nour El-din AK, Miller BH, Griggs JA & Wakefield C (2006) Immediate bonding to

bleached enamel Operative Dentistry31(1): 106-114.

9. Chaudhry V, Corse AM, Freimer ML, Glass JD, Mellits ED, Kuncl RW, Quaskey SA

& Cornblath DR (1994) Inter- and intra-examiner reliability of nerve conduction

measurements in patients with diabetic neuropathy Neurology Journal 44(8) :1459-1462.

     

ΐ  Referências identificadas no texto em números arábicos sobrescritos e numeradas

(38)

10.Kugel G, Ferreira S, Sharma S, Barker ML & Gerlach RW (2009) Clinical Trial

assessing light enhancement of in-office tooth whitening Journal of Esthetic and

Restorative Dentistry21(5):336-347.

11.Pigg M, Baad-Hansen L, Svensson P, Drangsholt M & List T (2010) Reliability of

intraoral quantitative sensory testing (QST) The Journal of the International

Association for the Study of Pain148(2):220-226.

12.Reis A, Tay LY, Herrera DR, Kossatz S & Loguercio AD (2011) Clinical effects of

prolonged application time of an in-office bleaching gel Operative Dentistry

36(6):590-596.

13.Browning WD, Blalock JS, Frazier KB, Downey MC & Myers ML (2007) Duration

and timing of sensitivity related to bleaching Journal of Esthetic and Restorative

Dentistry 19(5):256-264.

14.Lang PM, Stoer J, Schober GM, Audette JF & Irnich D (2010) Bilateral acupuncture

analgesia observed by quantitative sensory testing in healthy volunteers Anesthesia &

Analgesia110(5):1448-1456.

15.Nähri M (1990) The neurophysiology of the teeth Dental Clinics of North America

34(3):439- 448.

16.Olaleye D, Perkins BA & Bril V (2001) Evaluation of three screening tests and a risk

assessment model for diagnosing peripheral neuropathy in the diabetes clinic Diabetes

Research and Clinical Practice 54(2):115-128.

17.Pfau DB, Rolke R, Nickel R, Treede RD & Daublaender M (2009) Somatosensory

profiles in subgroups of patients with myogenic temporomandibular disorders and

Fibromyalgia Syndrome The Journal of the International Association for the Study of

Pain147(1-3):72-83.

18.Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B & Riley JL 3rd (2009) Sex, gender and pain: a review of recent clinical and experimental findings The

Journal of Pain10(5):447-485.

19.Kalantzis A, Robinson PP & Loescher AR (2007) Effects of capsaicin and menthol on

oral thermal sensory thresholds Archives of Oral Biology52(2):149-153.

20.List T, Leijon G & Svensson P (2008) Somatosensory abnormalities in atypical

odontalgia: A case-control study The Journal of the International Association for the

(39)

21.Pavlakovic G, Klinke I, Pavlakovic H, Züchner K, Zapf A, Bachmann CG, Graf BM

& Crozier TA (2008) Effect of thermode application pressure on thermal threshold

detection Muscle & Nerve 38:1498-1505.

22.Siao P & Cros DP (2003) Quantitative sensory testing Physical Medicine &

Rehabilitation Clinics of North America 14(2): 261-286.

23.Juhl GI, Jensen TS, Norholt SE & Svensson P (2008) Central sensitization phenomena

after third molar surgery: a quantitative sensory testing study European Journal of

Pain12(1):116-127.

24.Shukla G, Bhatia M & Behari M (2005) Quantitative thermal sensory testing - value of

testing for both cold and warm sensation detection in evaluation of small fiber

neuropathy Clinical Neurology and Neurosurgery107(6):486-490.

25.Yarnitsky D & Sprecher E (1994) Thermal testing: normative data and repeatability

for various test algorithms Journal of the Neurological Sciences125(1):39-45.

26.Charakorn P, Cabanilla LL, Wagner WC, Foong WC, Shaheen J, Pregitzer R &

Schneider D (2009) The effect of preoperative ibuprofen on tooth sensitivity caused

by in-office bleaching Operative Dentistry34(2):131-135.

27.Horin AP, Lee KM & Colloca L (2012) Placebo effects in therapeutic outcomes

Current Clinical Pharmacology³LQSUHVV´

28.Berga Caballero A, Forner Navarro L & Amengual Lorenzo J (2007) In vivo

evaluation of the effects of 10% carbamide peroxide and 3.5% hydrogen peroxide on

the enamel surface Medicina Oral, Patología Oral y Cirurgía Bucal12(5):E404-407. 29.Severcan F, Gokduman K, Dogan A, Bolay S & Gokalp S (2008) Effects of in-office

and at-home bleaching on human enamel and dentin: an in vitro application of fourier

transform infrared study Applied Spectroscopy62(11): 1274-1279.

30.Ushigome T, Takemoto S, Hattori M, Yoshinari M, Kawada E & Oda Y (2009)

Influence of peroxide treatment on bovine enamel surface-cross-sectional analysis

Dental Materials Journal28(3):315-323.

31.Fugaro JO, Nordahl I, Fugaro OJ, Matis BA & Mjör IA (2004) Pulp reaction to vital

bleaching Operative Dentistry29(4):363-368.

32.Kina JF, Huck C, Riehl H, Martinez TC, Sacono NT, Ribeiro APD & Costa CAS

(2010) Response of human pulps after professionally applied vital tooth bleaching

(40)

33.Washington LL, Gibson SJ & Helme RD (2000) Age-related differences in the

endogenous analgesic response to repeated cold water immersion in human volunteers

The Journal of the International Association for the Study of Pain89(1):89-96.

34.Delfino CS, Chinelatti MA, Carrasco-Guerisoli LD, Batista AR, Fröner IC &

Palma-Dibb RG (2009) Effectiveness of home bleaching agents in discolored teeth and

influence on enamel microhardness Journal of Applied Oral Science17(4):284-288. 35.Leonard RH, Haywood VB & Philips C (1997) Risk factors for developing tooth

sensitivity and gingival irritation associated with nightguard vital bleaching

(41)

Figures

Figure 1 - Flow chart diagram detaching the enrollment, allocation, follow-up and analysis during the study (CONSORT Statement).

Analysed (n=30)

i  Excluded from analysis (n=0)   Analysed (n=30)

i  Excluded from analysis (n=0)  

Assessed for eligibility (n=69)

Lost to follow-up (n=0)

Discontinued intervention (n=0)

Allocated to experimental agent (n=30) i  Received allocated intervention (n=30)   i  Did not receive allocated intervention (n=0)   Allocated to placebo agent (n=30)

i  Received allocated intervention (n=30)   i  Did not receive allocated intervention (n=0)  

Excluded (n=9)

i      Not meeting inclusion criteria (n=7) i      Declined to participate (n=2) i      Other reasons (n=0)

Lost to follow-up (n=0)

Discontinued intervention (n=0) Allocation  

Analysis   Follow-­‐Up   Enrollment  

(42)
(43)

Figure 3- Individual perforated tray confectioned to standardize the dental region to

(44)
(45)

Tables

Table 1 - Inclusion and exclusion criteria for selection of patients.

I nclusion Criteria

Healthy and vital maxillary teeth No decayed teeth

No visible enamel defects No orthodontic brackets Overall good systemic health Healthy oral soft tissue Non-smoking

Pacients who have never undergone bleaching treatment

Exclusion Criteria

Direct and indirect restorations in the maxillary anterior region Adverse reaction to peroxide

Use of opioids or medications influencing neurosensory response Use of pacemaker

Presence of dental staining (tetracycline, trauma, fluorosis, and unknown etiology) Neurological diseases

(46)

Table 2 - Evaluation periods of the skin and dental cold sensation threshold.

Evaluation Period Tooth Skin

Period 00 Baseline (24 hours before treatment) Baseline (24 hours before treatment) Period 01 Immediately before treatment Immediately before treatment

Period 02 Immediately after the 1st treatment session Immediately after the 1st treatment session Period 03 24 hours after the 1st treatment session ---

Period 04 Immediately after the 2nd treatment session Immediately after the 2nd treatment session Period 05 24 hours after the 2nd treatment session ---

Period 06 Immediately after the 3rd treatment session Immediately after the 3rd treatment session Period 07 24 hours after the 3rd treatment session ---

Period 08 7 days after treatment 7 days after treatment

(47)

Table 3 - Study groups and experimental and placebo products composition.

* FGM ± Dental Products GROUPS

SKI N COLD

SENSATI ON THRESHOLD

TREATMENT COM POSI TI ON POSOLOGY LOT

I Low Whitennes HP Maxx a 35%* (35% hydrogen peroxide)

30%±35% hydrogen peroxide, thickener, pigments, glycol, inorganic

compound and deionized water

3 applications of 15 minutes every 7

days

260111

II High

III Low

Placebo*

Distilled water, thickener, pigments, glycol, inorganic compound and

deionized water 290910

(48)

Table 4 - P. values obtained after dental cold sensation evaluation in different periods.  

Evaluation Periods

Low Threshold High Threshold

Group I (Bleaching agent)

Group I I I (Placebo)

Group I I (Bleaching agent)

Group I V (Placebo)

P 01 x P 02 0.0000* 0.0152* 0.0000* 0.1062

P 01 x P 03 0.0000* 0.7878 0.0000* 0.0022*

P 01 x P 04 0.0000* 0.9872 0.0000* 0.0900

P 01 x P 05 0.0000* 0.8607 0.0000* 0.0655

P 01 x P 06 0.0000 * 0.8650 0.0000* 0.0760

P 01 x P 07 0.0000* 0.6016 0.0000* 0.1163

P 01 x P 08 0.0000* 0.5941 0.0000* 0.0757

P 01 x P 09 0.0000* 0.5032 0.0000* 0.2216

(49)

Table 5 - Temperature variations for cold sensation (oC) in different evaluation periods, after the beginning of dental bleaching.

Evaluation Periods

Low Threshold

P. value High Threshold P. value Group I Group I I I Group I I Group I V

02 6.732A 0.874B 0.0000* 3.034A 1.700B 0.0445*

03 6.132A 1.545B 0.0000* 3.228A 1.610B 0.0180*

04 6.958A 1.473B 0.0000* 7.371A 1.853B 0.0000*

05 4.781A 1.539B 0.0002* 4.481A 1.776B 0.0005*

06 4.871A 1.424B 0.0000* 6.898A 2.657B 0.0000*

07 8.115A 1.283B 0.0000* 6.008A 1.733B 0.0000*

08 3.078A 1.663B 0.0124* 5.822A 2.187B 0.0006*

09 4.773A 1.636B 0.0000* 4.813A 1.833B 0.0008*

Means followed by different letters in lines represent a statistically significant difference according to the

6WXGHQW¶VW-test, p”

(50)

Table 6 - P. values obtained after skin cold sensation threshold evaluation in different periods.  

Evaluation  Periods   P.  value  

Low  Threshold   High  Threshold  

P  01  X  P  02   0.5488   0.3444  

P  01  X  P  04   0.2866   0.5721  

P  01  X  P  06   0.3173   0.6883  

(51)

Table 7 - Temperature variations for dental cold sensation (oC) of experimental groups with low and high threshold.

Bleaching Session Evaluation Periods

Group I (Low Threshold)

Group I I

(High Threshold) P. value

1st session

01 3.067 4.143 0.7422

02 6.732 3.034 0.0000*

03 6.132 3.228 0.0007*

2nd session 04 6.958 7.371 0.5822

05 4.781 4.481 0.7558

3rd session 06 4.871 6.898 0.0177*

07 8.115 6.008 0.0159*

Post-bleaching control 08 3.078 5.822 0.0042*

09 4.773 4.813 0.9622

(52)

3 Capítulo 2

Teste Sensorial Quantitativo: efeito de um tratamento dessensibilizante após o

clareamento dental.

QST após tratamento dessensibilizante

3.1 Resumo

O objetivo deste estudo clínico randomizado foi quantificar a sensibilidade dentária durante o

tratamento clareador e após a aplicação de um dessensibilizante. Para tanto, o equipamento de

análise neurosensorial, TSA II, foi utilizado para a realização do Teste Sensorial Quantitativo

(QST) por meio de estímulos térmicos. Dez pacientes (n=10) receberam o tratamento

clareador com peróxido de hidrogênio a 35% (Whiteness HP Maxx) e após a sessão

clareadora foi realizada a aplicação de um dessensibilizante tópico a base de nitrato de

potássio a 5% e fluoreto de sódio a 2% (Desensibilize KF 2%) apenas no hemi-arco esquerdo

da maxila, utilizando o método da boca dividida. No hemi-arco direito foi aplicada uma

solução salina a temperatura ambiente (controle). O QST foi realizado antes do clareamento

(AC), imediatamente depois do clareamento (DC) e imediatamente após a aplicação do

dessensibilizante (DD). Para padronizar o local do estímulo, uma moldeira de acetato com

perfurações circulares foi utilizada durante as mensurações. A análise estatística foi realizada

por meio do WHVWH W GH 6WXGHQW Į $V WHPSHUDWXUDV PpGLDV oC) (DP) do limiar de sensação ao frio para o hemi-arco direito (controle) foram: AC-13,898 (4,81), DC-19,241

(3,68), DD-20,646 (3,72) e para o hemi-arco esquerdo foram: AC-14,102 (3,22), DC-19,646

(4,82), DD-13,835 (3,63). Concluiu-se que clareamento dental com peróxidos de alta

concentração exacerbaram a sensibilidade dental ao estímulo térmico e que o uso do

dessensibilizante foi efetivo para reverter esta situação.

Perspectiva: O novo método utilizado neste estudo pode aumentar a confiabilidade dos estudos clínicos sobre sensibilidade dentária ao analisar quantitativamente a eficácia de

tratamentos dessensibilizantes após o clareamento dental. Esta análise neurosensorial pode

ajudar no desenvolvimento de terapias clareadoras mais seguras e confortáveis.

(53)

Quantitative Sensory Testing of the effect of desensitizing treatment after dental

bleaching

QST assessment after desensitizing treatment

3.2 Abstract

The aim of this randomized clinical trial was to quantify dental sensitivity during bleaching

treatment and before a desensitizing treatment using a new device, TSA II, that uses thermal

stimuli to conduct Quantitative Sensory Testing (QST). Ten patients (n=10) underwent

bleaching treatment using 35% hydrogen peroxide (Whiteness HP Maxx). After the bleaching

session, the teeth were cleaned with air/water spray and the split-mouth design was used.

Thus, a topical desensitizer containing 5% potassium nitrate and 2% sodium fluoride

(Desensibilize KF 2%) was applied to the teeth of the left maxillary hemi-arch. A saline

solution at ambient temperature was applied in the right maxillary hemi-arch (control). QST

was performed before bleaching (BB), immediately after bleaching (AB), and immediately

after the desensitizer (AD). For standardization of tooth analysis, an acetate tray, with circular

SHUIRUDWLRQV ZDV XVHG 6WXGHQW¶V W-test was XVHG Į WR DQDO\]H WKH GDWD 0HDQ

temperatures (oC) (SD) of cold sensation threshold for the right hemi-arch (control) were: 13.898 (4.81), AB-19.241 (3.68), AD-20.646 (3.72) and for the left hemi-arch were:

BB-14.102 (3.22), AB-19.646 (4.82), AD-13.835 (3.63). Dental bleaching with highly

concentrated peroxides increased dental cold sensation thresholds, but the topical desensitizer

reversed the immediate cold sensation caused by the cold stimulus.

Perspective: The new method used in this study may increase the reliability of clinical studies regarding dental sensitivity and quantitatively assess the effect of a desensitizing

treatment after dental bleaching. This neurosensory analysis could potentially help to develop

safer and more comfortable bleaching therapies.

(54)

3.3 I ntroduction§

Dental professionals often consider dental bleaching to be a conservative technique

that provides low-cost, effective, and fast results. As many patients request dental bleaching,

it has become a primary marketing and a focus of treatment planning for many dental

professionals.1,16,33,38 When supervised by a dentist, home bleaching can be a simple, safe, and

esthetically pleasant approach.15,16,28,38 However, the in-office technique that uses highly

concentrated hydrogen peroxide has been widely used because results are achieved quickly

without the use of trays.6,12,17

Usually, dental professionals apply products containing 30% to 40% hydrogen

peroxide while protecting soft tissues against deleterious effects.14,16 Bleaching occurs using

an unstable type of reactive oxygen that oxidizes tooth pigments, promoting lightening.16,42

Despite the effectiveness of dental bleaching, current studies reveal that patients exposed to

this whitening strategy report different frequency and intensity of dental sensitivity,28,14 a

negative treatment outcome that UHGXFHVSDWLHQW¶VVDWLVIDFWLRQ

The current literature does not clarify the origin of dental sensitivity, which is crucial

in determining an effective bleaching technique that causes minimum patient discomfort. In

the past, desensitizers have been applied to reduce discomfort with no apparent influence on

bleaching efficacy. 20,33,46,48 Among many different options, 5% potassium nitrate, which may

or may not be incorporated with 2% sodium fluoride, has been used as a desensitizing

agent.25,37,46,48

Clinical studies have evaluated the frequency and intensity of dental sensitivity and

have presented subjective data based on personal reports6,5,28,34 and pain questionnaires5

according to the Visual Analogue Scale (VAS). However, misunderstanding of data may have

     

§

Imagem

Figure 1  -  Flow  chart  diagram  detaching  the  enrollment,  allocation,  follow-up  and  analysis  during the study (CONSORT Statement)
Figure 2 - Scheme of the skin neurosensory analysis using the equipment TSA II.
Figure 3- Individual  perforated  tray  confectioned  to  standardize  the  dental  region  to  be measured
Figure 4- Scheme of the tooth neurosensory analysis using the equipment TSA II.    
+7

Referências

Documentos relacionados

Diante disso, o principal objetivo com este estudo foi definir um sistema de gestão para o Escritório de Proje- tos da Unoesc Chapecó, baseando-se no modelo Cerne. Para isso,

Além de analisar as danças solos de Volúsia e a construção de um “bailado nacional” a partir da mestiça- gem de elementos da cultura européia, negra e indígena, com ecos de

Seria o caso, por exemplo, de hipóteses envolvendo o foro privativo por prerrogativa de função, em que alguns dos réus não ostentassem o mesmo status processual ou que o tivessem

A fim de determinar nas linhagens HEK293 e HEK293T knockdown para p53 e scramble se a morte induzida por DMMB fotoativado também está relacionada à autofagia, avaliou-se, após 24

Both month and year are factors that interfere with total bacterial count, somatic cell count, and protein and fat of milk, and the best patterns are found in the coldest periods

ciências da linguagem e o autor sustenta que a escrita é um dos fatores necessários ao aparecimento das ciências da linguagem, os quais remontam à virada

- Não houve associação significativa entre os níveis de 25(OH)D e o sexo, tipo de cancro, TMO, tratamento com GCs, anos desde o diagnóstico, IMC, suplementação de vitamina

It is clear that, given an union-closed family F such that the average frequency of the elements is greater than half the size of the family, then there is at least one element in