dentin hypersensitivity educational teaching resource
TRANSCRIPT
DENTIN HYPERSENSITIVITY
Physiology, Etiology, Epidemiology, Diagnosis, and Treatment
Dentin Hypersensitivity
After viewing this lecture, attendees should be able to:
• describe the oral anatomy as it relates to dentin hypersensitivity.• discuss the etiology and physiologic mechanism of dentin hypersensitivity.• describe the prevalence and epidemiology of dentin hypersensitivity.• describe the diagnosis and management of dentin hypersensitivity.
Dentin Hypersensitivity
Dentin hypersensitivity is best defined as a “short, sharp, pain arising from exposed dentin in response to stimuli—typically thermal, evaporative, tactile, osmotic or chemical, and which cannot be ascribed to any other form of defect or pathology.”1
• Enamel• Dentin• Cementum• Dental Pulp
The 4 main dental tissues:
Enamel
Dentin
Cementum
Dental Pulp
Oral Anatomy: Dental Tissues
• Anatomic Crown• Anatomic Root• Pulp Chamber
The 3 parts of a tooth:
Anatomic Crown
Anatomic Root
PulpChamber
Oral Anatomy: Dental Tissues
Oral Anatomy:Dental Tissues
Enamel
Dentin
Cementum
Dental Pulp
Oral Anatomy:Dentinal Tubules
• Presence of tubules renders dentin permeable to fluid movement
• Number of tubules per unit area varies
• Dentinal tubules are conical
Dentin
Pulp
Tubule
Fluid Nerve Fibers
Odontoblast Cell
Dentin Hypersensitivity: Physiology
The dental pulp is richly innervated.
According to conduction velocities, the nerve units can be classified into A group—having the conduction
velocity more than 2 m/s and C group—with conduction velocity less than 2 m/s
The sharp, better localized pain is mediated by A delta
fibers, whereas C fiber activation seems to be connected
with the dull radiating pain sensation.
Myelinated A fiber
seems to be responsible for dentin sensitivity.
Dentin Hypersensitivity: Physiology
The most widely accepted mechanism of action for dentin hypersensitivity is the Hydrodynamic Theory, which was first proposed by Gysi in 1900 and
validated by Brannstrom in 1996.2
Mechanism of Dentin Hypersensitivity
Dentin Hypersensitivity: Physiology
There are two essential elements of the hydrodynamic mechanism:2
• Fluid flow through dentinal tubules• Pulpal sensory nerves
Mechanism of Dentin Hypersensitivity
Dentin Hypersensitivity:
Physiology
Two processes required:3
• dentin must be exposed• dentin tubules must be open to:
– dentin surface– patent to the pulp
Hydrodynamic Theory
Enamel
ExposedDentin
RecedingGingiva
Tubules
Odontoblast
Dentin Hypersensitivity:
Physiology
Trigger stimuli include:3 • Thermal
– Hot– Cold
• Tactile• Evaporative• Osmotic
Hydrodynamic Theory
Dentin Hypersensitivity:
Physiology
The true physiologic stimulus is the inward or outward fluid
shifts, not the actual trigger.4
Hydrodynamic Theory
Fluid-filledTubules
Dentin NerveFibers
Odontoblast Cell
Dentin Hypersensitivity:Physiology
• Mathews et al (1994– stimuli such as cold causes fluid flow away from
the pulp, produces more rapid and greater pulp nerve responses than those such as heat, which causes an inward flow.
• This certainly would explain the rapid and severe response to cold stimuli compared to the slow dull response to heat
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Dentin Hypersensitivity:Physiology
• The dehydration of dentin by air blasts or absorbent paper causes outward fluid movement and stimulates the mechanoreceptor of the odontoblast, causing pain.
• Prolonged air blast causes formation of protein plug into the dentinal tubules, reducing the fluid movement and thus decreasing pain
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Dentin Hypersensitivity:Physiology
Hydrodynamic theory showing pain because of fluid
movement
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Dentin Hypersensitivity:
Etiology
The most important factor in the etiology of dentin hypersensitivity is exposed dentin.5,6
Hydrodynamic Theory
• The result of gingival recession(exposure of root surfaces)
• The result of loss of enamel from tooth wear or trauma
• Loss of cementum • Removal or absence of a smear
layer
RecedingGingiva
ToothWear
Dentin Hypersensitivity: Etiology
Gingival Recession is caused by:7
• Physiologic factors– Hormonal fluctuations– Poor nutrition– Aging
• Periodontal diseases
– Gingivitis– Periodontitis
• Periodontal therapy– Scaling and root planning
– Surgery
• Restoration margins
• Chronic trauma– Oral hygiene (toothbrushing)– Habits (tobacco smoking &
chewing)
• Predisposing anatomic factors– Thin gingiva– Prominent roots – Dehiscences– Fenestrations– Frenum pulls– Roots moved outside alveolar
housing by orthodontics
• Physical Loss– Abrasion—mechanical– Attrition—tooth/tooth– Abfraction—lesions
• Chemical dissolution– Erosion
-Extrinsic acids -Intrinsic acids
• Multifactorial etiology – Erosion, abrasion, attrition,
abfraction
Tooth Wear can occur as a result of:3,8
Dentin Hypersensitivity: Etiology
Dentin Hypersensitivity:
Etiology
• Not all exposed dentin is sensitive3
Dentinal Tubules
• Surface appearance
• Open/patent tubules
• Greater number of tubules
• Tubules larger in diameter
• Absence of smear layer
• Tubules open from tooth wear
Characteristics of Sensitive Dentin:
Dentin
ToothWear
RecedingGingiva
Dentin Hypersensitivity: Etiology
• Dentin becomes exposed through enamel or cementum loss and/or gingival recession
• Opening of tubules by removal of the smear layer initiates the lesion
• Disturbed flow stimulates A-beta (A-β) and some A-delta (A-δ) nerve fibers
Understanding Dentin Hypersensitivity Pain4
Dentin Hypersensitivity: Etiology
• Aggressive toothbrushing• Periodontal diseases• Periodontal therapy• Tooth whitening/bleaching
Understanding Dentin Hypersensitivity Pain
Dentin Hypersensitivity: Etiology
Understanding Dentin Hypersensitivity Pain
Dentin Hypersensitivity:
Etiology
• Erosion—acts alone, or in combination with abrasion to cause enamel loss
• Extrinsic/intrinsic acids cause surface softening of enamel which takes hours to re-harden and results in greater susceptibility to physical insult
Understanding Dentin Hypersensitivity Pain9
3. Strassler HE, Drisko CL, Alexander DC.
• Incidence: 15% (4% to 57%)• Age range: 15 – 70+ years• Peak incidence: 20 – 40 years • Gender: Female > Males
Global Prevalence3
Dentin Hypersensitivity:
Epidemiology
Pain or discomfort caused by cold, hot, sweet, sour, foods/drinks or tooth brushing.
Dentin Hypersensitivity:
Epidemiology
• Teeth: Canines (cuspids) and premolars (bicuspids)
• Sites: Buccal cervical regions
Most Commonly Found3
Canine Premolar
Canine
In: Pashley DH, Tay FR, Haywood VB, et al. Dentin Hypersensitivity: Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity.
Frequency of Dentate Adults who Responded Positively to Having or Ever
Having Sensitive Teeth
Dentin Hypersensitivity: Epidemiology
In a multi-national survey conducted with 11,000 adults in 2002, 48% of participants said at some point they had consulted a dentist due to sensitive teeth.10,11
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Dentin Hypersensitivity: Epidemiology
• Dietary changes – Acidic food/drinks• Periodontal procedures• Cosmetic treatments – Bleaching/whitening12-14
– Restorative• Aging – Retain natural teeth
There are a number of factors that may contribute to an increased prevalence of dentin hypersensitivity:3
Dentin Hypersensitivity: Management
• Differential diagnosis• Exclude or treat other causes
of dentin pain• Identify etiological factors• Prevent, remove or modify
etiological factors• Management/treatment
Management begins with patient education and modification of risk factors15
Dentin Hypersensitivity: Management/Diagnosis
Complete History• Sign and symptoms• Intensity• Frequency and duration• Dietary changes• Other related events
Clinical Examination• Visual assessment• Physical assessment – Dental explorer (probe): tactile stimulus• Periodontal probe
– Depth of periodontal pocket
• Percussion testing• Response to cold air
Dentin Hypersensitivity is a diagnosis of exclusion
Radiographic examination• Rule out periapical lesions
Differential Diagnosis• Cracked tooth syndrome• Fractured restoration• Chipped teeth• Dental caries• Periodontal disease• Post-restorative sensitivity• Marginal leakage• Pulpitis• Palatogingival groove• Bleaching sensitivity
Needs to rule out:15
Non-Odontogenic Origin• Musculoskeletal• Neuropathic• Neurovascular• Inflammatory (sinusitis)• Systemic (cardiac, herpes, zoster, sickle cell anemia, neoplasm)• Psychogenic• Referred pain
Dentin Hypersensitivity: Management/Diagnosis
• Tooth sensitivity is one of the most common forms of dental pain• Usually occurs on the side opposite the dominant hand• The buccal cervical sites on the canine and pre-molars are the most
common sites for tooth sensitivity
Incidences3
Dentin Hypersensitivity: Management/Diagnosis
Dentin Hypersensitivity:Management/Diagnosis
• Root sensitivity is typically a result of gingival recession that may be compounded by tooth wear
• Sensitivity in the crown may be caused by some form or combination of factors attributed to tooth wear
Tooth Wear3
RecedingGingiva
DentinWear
Enamel Wear
• All forms of vital tooth bleaching are associated with some level of sensitivity• Bleaching sensitivity is caused by the easy passage of hydrogen peroxide and
urea through the intact enamel, through the dentin in the interstitial spaces into the pulp within 5 to 15 minutes16
Tooth Whitening/Bleaching16
Dentin Hypersensitivity: Management/Diagnosis
Dentin Hypersensitivity:Management/Diagnosis
Tooth hypersensitivity differs from dentinal or pulpal pain.
In case of dentin hypersensitivity, patient’s ability to locate the source of pain is very good, whereas in
case of pulpal pain, it is very poor
The character of the pain does not outlast the stimulus; the pain is intensified by thermal
changes, sweet and sourThe pain can be duplicated by hot or cold
application or by scratching the dentinInsert Text Here
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Prevention and Treatment of Bleaching Hypersensitivity
16. Pashley DH, Tay FR, Haywood VB, et al.
Dentin Hypersensitivity: Management/Diagnosis
Dentin Hypersensitivity:Management/Diagnosis
• Cold beverages • Eating cold food• Breathing cold air• Toothbrushing• Improper dental floss use• Eating sour/acid food• Eating sweet/sugary liquids
and foods• Bleaching/whitening procedures
Occurrence of pain:3
• Thermal—pain in response to cold or hot• Evaporative—blowing air on the tooth surface• Tactile—pain in response to touch• Osmotic—pain in response to sugar/acid• Dental treatment—this type of sensitivity is transient and will resolve
with removal of treatment or over time
Dentin Hypersensitivity: Management/Diagnosis
Sensitivity may occur in response to various stimuli:3
Dentin Hypersensitivity:Management/Etiological Factors
Tooth Wear/Erosion:• Use fluoride-rich dentifrice • Behavior modification • Decrease abrasive forces• Application of topical fluoride• Enhance the defense mechanisms of the body• Provide nutritional counseling
Management of Pre-disposing Factors17
Dentin Hypersensitivity:Management/Etiological Factors
Gingival Recession:• Correct toothbrushing technique• Plaque control• Avoidance of harmful habits• Periodontal disease management• Replacement of restorations with defective margins• Smoking cessation
Management of Pre-disposing Factors17
Dentin Hypersensitivity:Treatment
• Obturate tubules or alter fluid flow in dentinal tubules
• Modify or block pulpal nerve response
Management of Dentin Hypersensitivity3,4
KNO3
CHEMICAL AGENTS18 Nerve Inactivators
• Potassium salt (nitrate-KNO3)
Tubule Obtundants• Strontium chloride• Calcium hydroxide• Fluorides• Sodium citrate• Potassium oxalate• Iontophoresis with NaF
Management of Dentin Hypersensitivity
Protein Precipitators• Strontium chloride• Silver nitrate• Formaldehyde
Dentin Hypersensitivity: Treatment
Potassium salt (nitrate-KNO3)
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Potassium salt (nitrate-KNO3)
• Potassium ion is a desensitization agent because it diffuses through dentin tubules and increases the extracellular potassium concentration at the
nerve ending, eliminating the potassium ion concentration gradient across the nerve cell membrane. Without this concentration gradient, the nerve cell will not depolarize and will not respond to stimuli; thus the sensation
of pain will not be transmitted. Potassium ion can be delivered in a variety of salt forms (e.g., potassium nitrate, potassium citrate). The most
common potassium salt used in sensitivity dentifrices is potassium nitrate (KNO3)
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Tubule Blocking or Occluding Agents
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Tubule Blocking or Occluding Agents
• Calcium sodium phosphosilicate (Novamin®, Sensodyne® Repair & Protect).
• In saliva, Novamin® releases calcium and phosphate ions and raises the pH. Under these conditions, calcium phosphate salts precipitate from solution to not only block dentin tubules but also to form an insoluble calcium phosphate layer on the surface of enamel
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Tubule Blocking or Occluding Agents
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PHYSICAL AGENTS18
Dentin Hypersensitivity: TreatmentManagement of Dentin Hypersensitivity
• Composite resins• Bonding agents• Sealants• Glass-ionomer cements• Varnishes• Soft tissue grafts• Lasers
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Dentin Hypersensitivity: Treatment
At-home treatments—patient applied• Anti-sensitivity dentifrice• Fluoride-based gels• Rinses
Options for Treatment19
Dentin Hypersensitivity: Treatment
In-office by dental professional• Chemicals (oxalates)• Physical agents• Restorations • Endodontic (root canal)• Tooth extraction
Options for Treatment19 (listed as least invasive to most)
Dentin Hypersensitivity: “the common cold of dentistry.”3
Dentin Hypersensitivity
Dentin Hypersensitivity—References
1. Ajcharanukul O, Kraivaphan P, Wanachantarak S, et al. Effects of potassium ions on dentin sensitivity in man. Arch Oral Biol. 2007;52(7);632-639.2. Matthews B, Vongsavan N. Interaction between neural and hydrodynamic mechanisms in dentine and pulp. Arch Oral Biol. 1994:39(Suppl):87S-95S.3. Strassler HE, Drisko CL, Alexander DC. Dentin hypersensitivity: its inter-relationship to gingival recession and acid erosion. Inside Dentistry. 2008;29(5
Special Issue):3-8.4. Dentin hypersensitivity: current state of the art and science. In: Pashley DH, Tay FR, Haywood VB, et al. Dentin Hypersensitivity: Consensus-Based
Recommendations for the Diagnosis and Management of Dentin Hypersensitivity. Inside Dentistry. 2008;4(9 Special Issue):8-18. 5. Watson PJ. Gingival recession. J Dent. 1984;12(1):29-35. 6. Smith RG. Gingival recession. Reappraisal of an enigmatic condition and a new index for monitoring. J Clin Periodontol. 1997;24(3):201-205. 7. Dentin hypersensitivity and gingival recession. In: Pashley DH, Tay FR, Haywood VB, et al. Dentin Hypersensitivity: Consensus-Based Recommendations
for the Diagnosis and Management of Dentin Hypersensitivity. Inside Dentistry. 2008;4(9 Special Issue):19-24. 8. Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci. 1996;104(2 (Pt 2)):151-155. 9. ten Cate JM, Imfeld T. Dental erosion. Summary. Eur J Oral Sci. 1996;104(2 (Pt 2)):241-244. 10. Addy, Martin, Dentin hypersensitivity: new perspective on an old problem. Int Dent J. 2002;52:367-375.11. Drisko, CH. Dentin hypersensitivity – dental hygiene and periodontal considerations. Int Dent J. 2002;52;385-393.12. Auschill TM, Hellwig E, Schmidate S, et al. Efficacy, side-effects and patient’s acceptance of different bleaching techniques (OTC, in-office, at home). Oper
Dent. 2005;30(2):155-163.13. Broening WD, Blalock JS, Fraizer KB, et al. Duration and timing of sensitivity related to bleaching. J Esthet Restor Dent. 2007; 19(5): 256-264
Dentin Hypersensitivity—References
14. Haywood VB, Leonard R, Nelson CF, et al. Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc. 1994;125(9):1219-1226.
15. Dentin hypersensitivity: consensus-based recommendations for the diagnosis and management of dentin hypersensitivity. In: Pashley DH, Tay FR, Haywood VB, et al. Dentin Hypersensitivity: Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity. Inside Dentistry. 2008;4(9 Special Issue):1-7.
16. Considerations for managing bleaching sensitivity. In: Pashley DH, Tay FR, Haywood VB, et al. Dentin Hypersensitivity: Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity. Inside Dentistry. 2008;4(9 Special Issue):25-31.
17. Lussi A, Hellwig E. Risk assessment and preventative measures. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:190-199. Whitford GM. Monographs in Oral Science; vol 20.
18. Dentin Hypersensitivity: Etiology, Diagnosis and Successful Management. Advancements in Oral Health Educational Module. 19. Canadian Advisory Board on Dentin Hypersensitivity. Consensus-based recommendations for the diagnosis and management of dentin hypersensitivity. J
Can Dent Assoc. 2003;69(4):221-226.