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Associative Protocol for Dentin Hypersensitivity Using Nd:YAG Laser and

Desensitizing Agent in Teeth with Molar-Incisor Hypomineralization

Article  in  Photobiomodulation Photomedicine and Laser Surgery · April 2019

DOI: 10.1089/photob.2018.4575

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 Photobiomodulation, Photomedicine, and Laser Surgery
Volume 37, Number 4, 2019 Case Report
ª Mary Ann Liebert, Inc.
Pp. 262–266
DOI: 10.1089/photob.2018.4575

Associative Protocol for Dentin Hypersensitivity

Using Nd:YAG Laser and Desensitizing Agent
in Teeth with Molar-Incisor Hypomineralization

Alana Cristina Machado, DDS, MSc,1 Vinı́cius Maximiano, DDS, MSc,1,2

Carlos de Paula Eduardo, DDS, MSc, PhD,1,2 Luciane Hiramatsu Azevedo, DDS, MSc, PhD,2
Patricia Moreira de Freitas, DDS, MSc, PhD,1,2 and Ana Cecilia Aranha, DDS, MSc, PhD1,2
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Abstract

Objective: The aim of this article was to describe and discuss a clinical case in which the Nd:YAG laser and a
desensitizing agent were associated in a protocol for dentin hypersensitivity (DH) in teeth with molar-incisor
hypomineralization (MIH).
Background data: DH is a common condition among the population, being one of the main reasons for patients
to seek for a dental treatment. MIH can be considered a condition that induces DH.
Methods: The patient was referred for evaluation, complaining of hypersensitivity during eating or drinking
cold foods. Clinical evaluation revealed the presence of MIH on the first lower molars. Aiming to treat DH, two
strategies for dentin desensitization were associated: the use of a high-power laser (Nd:YAG laser, 1.064 nm;
Lares Research), with a 300 lm quartz optical fiber, 1 W of power, 100 mJ of energy, 10 Hz of repetition rate,
and 85 J/cm2 of energy density, followed by the application of two layers of a desensitizing agent (Gluma
Desensitizer).
Results: DH was evaluated immediately, after 1 week and after 1 month of the treatment. Clinical outcomes
were satisfactory, confirming the efficacy and considerable durability of the protocol used for the reduction of
DH originated from MIH.
Conclusions: The association of Nd:YAG laser and a desensitizing agent for controlling DH was effective,
showing to be an interesting protocol.

Keywords: dentin hypersensitivity, molar-incisor hypomineralization, Nd:YAG laser

Introduction Loss of enamel leading to a coronal or root dentin ex-

posure with opened dentin tubules can be induced by the

D entin hypersensitivity (DH) is a common condition

among the population, being one of the main reasons for
the patients to seek for a dental treatment.1–4 It is defined as a
short, sharp pain from an exposed dentin with dentinal tu-
bules susceptive to external stimuli and that cannot be as-
cribed to any other form of dental defect or pathology.2,5,6
According to Brännström et al., dentin exposure with a
subsequent opening of dentinal tubules allows the fluid to
flow in or out of the tubules, while the incidence of stimuli
(thermal, evaporative, tactile, osmotic, or chemical), acti-
vating baroreceptors in the pulp, results in the generation of
impulses and perception of sensorineural pain.7
combination of various factors, such as inappropriate or
poor oral hygiene, periodontal therapy, nonbacterial acid
exposure, excessive occlusal force, or premature occlusion,
and all them are related to DH.8
Another condition that can induce DH is related with
hypomineralization. Molar incisor hypomineralization
(MIH) refers to enamel hypomineralization of systemic or-
igin, affecting one to four permanent first molars of the
permanent dentition and frequently associated with affected
incisors.9 Teeth with MIH show soft and porous enamel,
with high degree of brittleness, and can be more prone to
breakdown. Lesions may progress and cause dentin

1
Department of Restorative Dentistry, School of Dentistry, University of São Paulo, São Paulo, Brazil.
2
Special Laboratory of Lasers in Dentistry (LELO), Department of Restorative Dentistry, School of Dentistry, University of São Paulo,
São Paulo, Brazil.

262
 ND:YAG LASER IRRADIATION AND DESENSITIZER AGENT IN MIH
exposure, which can be very sensitive to air flow, and cold
and warm and mechanical stimuli.9,10
The literature shows a considerable prevalence of MIH, in
special in Brazilian population, where the highest preva-
lence percentage was found. The prevalence varies from 3%
to 25% in Europe,11 2.9% to 13.5% in Africa,12,13 and 2.8%
in China.14 In Brazil, studies have shown a prevalence
varying from 2.5% to 40%.15,16 The etiology of MIH is
thought to be multi-factorial and has not been totally de-
fined, possibly due to its complexity, involving exposure to
medical and/or environmental conditions during pregnancy
or in the first years of life.17,18 Systemic changes during
odontogenesis during the perinatal period or first years of
life could result in changes on the dental enamel forma-
tion.19,20 Perinatal complications in the last trimester, low
birth weight, lack of oxygen in the birth moment, metabolic
disorders of calcium and phosphate, asthma, respiratory
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tract infections, otitis media, use of antibiotics, high fever
history, tonsillectomy, and exposure to environmental pol-
lutants are mentioned as possible etiological factors for this
alteration.19–22 Therefore, it is extremely important to give
attention to the prevention/treatment of MIH-affected teeth,
including strategies to treat DH presented in this dental
condition.
The use of desensitizer agents to occlude the dentinal
tubules—isolating the tubule contents from the oral envi-
ronment and preventing the flow and movement of the tu-
bular fluid—or the use of chemical agents to desensitize
sensory nerves that are able to block the transmission of
noxious stimuli of dentinal tubules into the central nervous
system can be the strategy to manage DH.6,23,24
In this context, in-office products can be an effective al-
ternative, since the market offers a wide choice of complex
desensitizing agents, with immediate and long-term effects
when compared with at-home products. However, the fre-
quency of application is low and may present certainly
longevity, requiring more frequent visits to the dentist.23,25
One potential method for the treatment of DH, suggested
since 1985, is the use of photobiomodulation therapy with
low-power lasers and/or high-power lasers.26,27 The litera-
ture reports that the laser with the best in vitro and clinical
results for the treatment of DH is the high-power laser, more
specifically the Nd:YAG laser.28,29 Its mechanism of action
consists of the increase in temperature induced on the dental
surface, generating melting and resolidification of the
structures, which results in the obliteration and/or reduction
of the diameter of the dentinal tubules. It can also reduce
DH by leading to the depolarization of the pulp nerve fi-
bers.30
Some authors have evaluated the effectiveness of
Nd:YAG and Er:YAG lasers and concluded that the
Nd:YAG laser is superior in relation to patients’ pain re-
duction and also to dentin tubular occlusion.31,32 Other
studies show that the Nd:YAG laser presented immediate
and long-term results, without adverse effects in the treat-
ment of DH.29
Another widely used in-office treatment option is de-
sensitizing agents, as the Gluma Desensitizer. This product
has been considered the ‘‘gold standard’’ of the treatments
of the office and been used as positive control in some
studies, since it presents satisfactory results for the treat-
ment of DH. Among its components are hydro-
263
xyethylmethacrylate (HEMA) and 5% glutaraldehyde. Its
mechanism of action is based on the coagulation reaction of
plasma proteins of the tubular fluid when in contact with
glutaraldehyde. This reaction causes precipitations that re-
duce tubular diameter and are responsible for the polymer-
ization of HEMA, blocking the dentinal tubules.33 A study
in which this desensitizing agent was used revealed almost a
complete obliteration of dentinal tubules and significant
reduction in pain levels after application, for both air and
probe stimulation.29
Considering the decrease in dentin permeability caused
by the desensitizing agent Gluma desensitizer and the action
of the Nd:YAG laser, the association between them may
present even more favorable and long-lasting results for the
treatment of DH.
In view of the above, the aim of this article was to de-
scribe and discuss a clinical case in which the Nd:YAG laser
and the Gluma Desensitizer agent were associated on a
protocol for DH in teeth with MIH.
Clinical Case
An 8-year-old male patient, accompanied by his parents,
attended the Special Laboratory of Lasers in Dentistry
(LELO) from the School of Dentistry, University of São
Paulo, reporting hypersensitivity in teeth when ingesting
cold food and drinks.
Through a complete medical history questionnaire, the
parents reported that the patient, when around 2 years of
age, presented stomach bacterium infection and was hospi-
talized for 5 days, with a clinical condition of high fever,
diarrhea, dehydration, and weight loss.
Clinical examination revealed that the inferior first molars
presented absence of enamel structure with subsequent
brownish spots in some regions of the occlusal surface,
possibly characterizing MIH (right inferior molar presented
a composite resin restoration at the occlusal-vestibular sur-
faces and left inferior molar was with partially fractured
ionomeric sealant) (Fig. 1A, B). A similar MIH character-
istic was observed on superior molars, although not so ev-
ident (Fig. 1C, D). As no clinical characteristics of
hypomineralization were found on central incisor, the di-
agnosis of MIH is not definite.
Before any treatment, an approval consent was signed by
the child’s parents and all possible questions were answered.
After initial hypersensitivity test on inferior molars using a
gentle air flow from the triple syringe over the surface, the
patient reported pain level of 8 on a numerical scale of 0–10
(Visual Analogue Scale). These data represent a high level
of DH.
A protocol to treat DH was then performed, associating
two techniques/strategies: high-power laser, using the
Nd:YAG laser (Power Laser; Lares Research, San Clem-
ente, CA—1.064 nm), followed by the application of a de-
sensitizing agent (Gluma desensitizer). First, four Nd:YAG
laser irradiations were performed at the hypomineralized
area: two irradiations scanning the surface in the mesiodistal
direction and two in the occlusogingival direction, using a
300 lm quartz optical fiber, with 1 W of power, 100 mJ of
energy, 10 Hz of repetition rate, and 85 J/cm2 of energy
density (Fig. 1E). The detailed description of laser irradia-
tion can be found in Table 1. After irradiating all
 264 MACHADO ET AL.

test using the triple syringe was performed and the patient
reported a pain level of 0 on a numerical scale of 0–10.
A follow-up of 1 week and 1 month after treatment
conclusion was done and the patient reported a pain level
varying between 1 and 3 in 1 week and 2 in 1 month, using a
numerical scale of 0–10.

Discussion
The etiology and mechanism of MIH development remain
relatively unknown and undefined. It is a fairly new con-
dition, but it is known that MIH occurs more frequently in
children with a history of systemic complications in the first
years of life, such as respiratory problems, episodes of high
fever, and the use of antibiotic medication.19–21 The diag-
nosis of this clinical case was made under clinical exami-
nation, assessing the clinical characteristics described in the
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literature and associating it with the medical history re-

ported by the patient’s parents. The period in which the
infectious condition occurred, as well as the signs and
symptoms (high fever) reported, coincided with the matu-
ration period of the organic matrix of the impacted molars.
Management of MIH includes preventive procedures, such
as fluoride varnishes (indicated only in cases where there is
no structural tooth loss), conservative procedures (infiltrant
resin and glass ionomer cements), or invasive restorations,
both with removal of the affected area.34
DH is a common complication in MIH35 and the initial
pain level reported by the patient in this clinical case was
considerably high (pain level of 8), making oral hygiene and
FIG. 1. (A, B) Inferior first molars with MIH, occlusal- feeding a difficult task. If not treated, these teeth can create
vestibular resin and fractured occlusal ionomeric sealant, problems for the patient according to Jälevik and Klingberg.
respectively. (C, D) MIH characteristic observed, although Children with MIH, during dental examination, usually open
not so evident, on superior molars: right and left, respec- their mouths reluctantly and react intensely to air blowing,
tively. (E) Nd:YAG Laser irradiation on MIH areas with the making the treatment not easy. Untreated surfaces will result
aid of a optical fiber. (F) Application of desensitizing agent in possible faster progression of tissue loss and consequently
(Gluma Desensitizer) on MIH areas immediately after laser more DH.36
irradiation. MIH, molar incisor hypomineralization. The treatment for DH in teeth with MIH is generally
performed as palliative, based on the conventional protocol
of topical applications of fluoride or, when considering the
existing loss of dental structure caused by MIH, in combi-
hypomineralized areas, the air sensitivity test using the triple
nation with the crown covering with glass ionomer cements
syringe was performed once again and the patient reported a
or composite resins. However, there is no established pro-
pain level of 2 on a numerical scale of 0–10.
tocol in the literature for the treatment of DH on teeth with
After laser irradiation, two layers of a desensitizing agent
MIH. Therefore, this article proposes the association of two
(Gluma Desensitizer; Kulzer GmbH, Hanau, Germany) were
techniques, Nd:YAG laser irradiation and a desensitizing
applied with the aid of a disposable brush (Microbrush; KG
agent (Gluma Desensitizer), both already reported on the
Sorensen, Cotia-SP, Brazil), according to the manufacturer’s
literature for the treatment of DH in other kind of substrates
recommendations (Fig. 1F). Once again, the air sensitivity
like erosive and abrasive affected teeth.29,31,37,38
In this clinical case, immediately after the Nd:YAG laser
Table 1. Parameters of the Nd:YAG Laser Used irradiation, the pain level decreased significantly (pain level
in the Clinical Case reported as 2), but was not completely eliminated. Perhaps
Laser Nd:YAG this fact can be explained by previous studies that reported a
nonhomogeneous melting formed by the Nd:YAG laser ir-
Wavelength 1064 nm radiation and the possible presence of untreated areas.39,40
Delivery system 300 lm quartz optical fiber Therefore, limitations exist on the clinical protocol for laser
Power 1W irradiation, not guarantying that all dentinal tubules were
Power density 1.4 W/cm2 occluded. This fact may explain why the patient, even after
Energy density y85 J/cm2 irradiation with the Nd:YAG laser, still reported pain (pain
Duration 4 irradiations of 10 sec each level 2). However, when applying the Gluma desensitizing
Frequency 1 session
Repetition rate 10 Hz agent immediately after laser irradiation, pain was reduced
to 0. If tubules were not sealed by means of the
 ND:YAG LASER IRRADIATION AND DESENSITIZER AGENT IN MIH
resolidification process caused by the Nd:YAG laser, this
could be complemented by the desensitizing agent action,
reducing the number of open dentin tubules to the maximum
extent. Farmakis et al. also showed a combined approach for
the treatment of DH with great potential to improve the
success.41 The authors used a bioglass combined with
Nd:YAG laser irradiation and suggested this combined
treatment as an alternative for DH management in other
types of substrate.41
The pain level obtained immediately after the application
of the Gluma desensitizing agent (pain level 0) corroborates
with others clinical studies that showed the potential of this
product to obliterating dentinal tubules, reducing pain levels
immediately after treatment.29,39 Authors have also reported
the maintenance of reduced pain level over the course of
time (6- and 18-month post-treatment).29,39
Some hypothesis can be raised for the increase in pain
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level during the follow-up period. It can be related to the
possible removal of the desensitizer agent due to mechanical
impact during feeding and brushing, even the layer formed
by laser could be no longer term resistant. However, the
interaction of these products with hypomineralized tooth
surface and its maintenance over time have not been ex-
plored and explained by the literature. For another kind of
substrate like erosive and abrasive teeth conditions, the lit-
erature shows positive results; for those, some clinical
studies using the same desensitizing agent (Gluma De-
sensitizer) have shown a decrease in DH immediately after
its application and also when re-evaluated after some
months.29,39
Until now, the interaction of this product with hypomi-
neralized teeth surface and its maintenance over time have
not been clearly explored and explained by the literature.
Regarding laser irradiation, it is reported that Nd:YAG laser
can have an analgesic effect when compared with the other
high-power lasers. This most probably occurs because the
irradiation may temporarily alter the final part of the sensory
axons and block both the C and aA fibers, thereby de-
creasing the levels of pain.42 There are still no reports on
how long this effect remains. This clinical case suggests that
the effect can be transitory, since there was an increase in
pain level during the second and third evaluation periods
(1 week and 1 month).
DH on teeth with MIH can be considered a difficult
condition to be treated in dentistry, because of the difficulty
of measuring pain, choice of material and most suitable
technique, and the uncertain prognosis. It is necessary to
consider the severity of the DH and the MIH before
choosing a treatment, and it is also necessary to use correct
and safe protocols. Conservative approach should be used as
the first line of option before invasive treatments, such as
composite resin restorations or crowns.
Considering the relativity effectiveness and low com-
plexity of the associated technique proposed in this clinical
case, the treatment with high-power laser associated with a
desensitizing agent can be considered a conservative and
appropriate alternative for the treatment of DH on teeth with
MIH, provided that the correct protocols, based on scientific
evidence, are used. However, we should consider the need
of studies evaluating the interaction of the laser with this
kind of substrate, reduction of DH, and maintenance of the
long-term treatment.
265
Conclusions
The use of Nd:YAG laser and a desensitizing agent for
the treatment of DH originating from MIH demonstrated to
be effective in reducing the pain levels immediately and up
to 1 month after treatment, without discomfort or adverse
reactions for the patient.
Acknowledgments
The authors would like to express their gratitude to the
Special Laboratory of Lasers in Dentistry (LELO) from the
Department of Restorative Dentistry, School of Dentistry of
USP and FAPESP (São Paulo Research Foundation).
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ana Cecilia Aranha, DDS, MSc, PhD
Special Laboratory of Lasers in Dentistry (LELO)
Department of Restorative Dentistry
School of Dentistry
University of São Paulo
Av. Prof. Lineu Prestes 2227
São Paulo 05508-000
Brazil
E-mail: acca@usp.br
Received: October 23, 2018.
Accepted after revision: January 13, 2019.
Published online: March 20, 2019.