DENTIN HYPERSENSITIVITY

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DENTIN HYPERSENSITIVITY

• Physiology, Etiology, Epidemiology, Diagnosis,
  and Treatment

Reviewed by
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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.

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Dentin Hypersensitivity

• Dentin hypersensitivity is best defined as a
  short, sharp, pain arising from exposed dentin
  in response to stimulitypically thermal,
  evaporative, tactile, osmotic or chemical, and
  which cannot be ascribed to any other form of
  defect or pathology.1

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Oral Anatomy Dental Tissues

• The 4 main dental tissues

• Enamel
• Dentin
• Cementum
• Dental Pulp

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Oral Anatomy Dental Tissues

• The 3 parts of a tooth

• Anatomic Crown
• Anatomic Root
• Pulp Chamber

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Oral AnatomyDental Tissues
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Oral AnatomyDentinal Tubules

• Presence of tubules renders dentin permeable to
  fluid movement
• Number of tubules per unit area varies
• Dentinal tubules are conical

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Dentin Hypersensitivity Physiology

• Mechanism of Dentin Hypersensitivity

• 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

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Dentin Hypersensitivity Physiology

• Mechanism of Dentin Hypersensitivity

• There are two essential elements of the
  hydrodynamic mechanism2
• Fluid flow through dentinal tubules
• Pulpal sensory nerves

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Dentin HypersensitivityPhysiology

• Hydrodynamic Theory

• Two processes required3
• dentin must be exposed
• dentin tubules must be open to
• dentin surface
• patent to the pulp

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Dentin HypersensitivityPhysiology

• Hydrodynamic Theory

• Trigger stimuli include3
• Thermal
• Hot
• Cold
• Tactile
• Evaporative
• Osmotic

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Dentin HypersensitivityPhysiology

• Hydrodynamic Theory

• The true physiologic stimulus is the inward or
  outward fluid shifts, not the actual trigger.4

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Dentin HypersensitivityEtiology

• Hydrodynamic Theory

• The most important factor in the etiology of
  dentin hypersensitivity is exposed dentin.5,6

• 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

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Dentin Hypersensitivity Etiology

• Gingival Recession is caused by7

• 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

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Dentin Hypersensitivity Etiology

• Tooth Wear can occur as a result of3,8

• Physical Loss
• Abrasionmechanical
• Attritiontooth/tooth
• Abfractionlesions
• Chemical dissolution
• Erosion
• -Extrinsic acids
• -Intrinsic acids
• Multifactorial etiology
• Erosion, abrasion, attrition,
  abfraction

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Dentin HypersensitivityEtiology

• Dentinal Tubules

• Not all exposed dentin is sensitive3

• Characteristics of Sensitive Dentin

• Surface appearance
• Open/patent tubules
• Greater number of tubules
• Tubules larger in diameter
• Absence of smear layer
• Tubules open from tooth wear

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Dentin Hypersensitivity Etiology

• Understanding Dentin Hypersensitivity Pain4

• 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-ß) and some
  A-delta (A-d) nerve fibers

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Dentin Hypersensitivity Etiology

• Understanding Dentin Hypersensitivity Pain

• Aggressive toothbrushing
• Periodontal diseases
• Periodontal therapy
• Tooth whitening/bleaching

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Dentin HypersensitivityEtiology

• Understanding Dentin Hypersensitivity Pain9

• Erosionacts 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

3. Strassler HE, Drisko CL, Alexander DC.
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Dentin HypersensitivityEpidemiology

• Global Prevalence3

• Incidence 15 (4 to 57)
• Age range 15 70 years
• Peak incidence 20 40 years
• Gender Female gt Males

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Dentin HypersensitivityEpidemiology

• Most Commonly Found3

• Teeth Canines (cuspids) and premolars
  (bicuspids)
• Sites Buccal cervical regions

Canine Premolar
In Pashley DH, Tay FR, Haywood VB, et al. Dentin
Hypersensitivity Consensus-Based Recommendations
for the Diagnosis and Management of Dentin
Hypersensitivity.
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Dentin Hypersensitivity Epidemiology
Frequency of Dentate Adults who Responded
Positively to Having or Ever Having Sensitive
Teeth

• 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
There are a number of factors that may contribute
to an increased prevalence of dentin
hypersensitivity3

• Dietary changes
• Acidic food/drinks
• Periodontal procedures
• Cosmetic treatments
• Bleaching/whitening12-14
• Restorative
• Aging
• Retain natural teeth

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Dentin Hypersensitivity Management
Management begins with patient education and
modification of risk factors15

• Differential diagnosis
• Exclude or treat other causes of dentin pain
• Identify etiological factors
• Prevent, remove or modify etiological factors
• Management/treatment

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Dentin Hypersensitivity Management/Diagnosis

• Dentin Hypersensitivity is a diagnosis of
  exclusion

• 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

• Radiographic examination
• Rule out periapical lesions

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Dentin Hypersensitivity Management/Diagnosis

• Needs to rule out15

• Differential Diagnosis
• Cracked tooth syndrome
• Fractured restoration
• Chipped teeth
• Dental caries
• Periodontal disease
• Post-restorative sensitivity
• Marginal leakage
• Pulpitis
• Palatogingival groove
• Bleaching sensitivity

• Non-Odontogenic Origin
• Musculoskeletal
• Neuropathic
• Neurovascular
• Inflammatory (sinusitis)
• Systemic (cardiac, herpes, zoster,
  sickle cell anemia, neoplasm)
• Psychogenic
• Referred pain

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Dentin Hypersensitivity Management/Diagnosis

• Incidences3

• 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

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Dentin HypersensitivityManagement/Diagnosis

• Tooth Wear3

• 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

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Dentin Hypersensitivity Management/Diagnosis

• Tooth Whitening/Bleaching16

• 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

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Dentin Hypersensitivity Management/Diagnosis

• Prevention and Treatment of Bleaching
  Hypersensitivity

16. Pashley DH, Tay FR, Haywood VB, et al.
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Dentin HypersensitivityManagement/Diagnosis

• Occurrence of pain3

• 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

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Dentin Hypersensitivity Management/Diagnosis

• Sensitivity may occur in response to various
  stimuli3

• Thermalpain in response to cold or hot
• Evaporativeblowing air on the tooth surface
• Tactilepain in response to touch
• Osmoticpain in response to sugar/acid
• Dental treatmentthis type of sensitivity is
  transient and will resolve with removal of
  treatment or over time

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Dentin HypersensitivityManagement/Etiological
Factors

• Management of Pre-disposing Factors17

• 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

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Dentin HypersensitivityManagement/Etiological
Factors

• Management of Pre-disposing Factors17

• Gingival Recession
• Correct toothbrushing technique
• Plaque control
• Avoidance of harmful habits
• Periodontal disease management
• Replacement of restorations with defective
  margins
• Smoking cessation

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Dentin HypersensitivityTreatment

• Management of Dentin Hypersensitivity3,4

• Obturate tubules or alter fluid flow in dentinal
  tubules
• Modify or block pulpal nerve response

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Dentin Hypersensitivity Treatment

• Management of Dentin Hypersensitivity

CHEMICAL AGENTS18

• Nerve Inactivators
• Potassium salt (nitrate-KNO3)

• Tubule Obtundants
• Strontium chloride
• Calcium hydroxide
• Fluorides
• Sodium citrate
• Potassium oxalate
• Iontophoresis with NaF

• Protein Precipitators
• Strontium chloride
• Silver nitrate
• Formaldehyde

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Dentin Hypersensitivity Treatment

• Management of Dentin Hypersensitivity

PHYSICAL AGENTS18

• Composite resins
• Bonding agents
• Sealants
• Glass-ionomer cements
• Varnishes
• Soft tissue grafts
• Lasers

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Dentin Hypersensitivity Treatment

• Options for Treatment19

• At-home treatmentspatient applied
• Anti-sensitivity dentifrice
• Fluoride-based gels
• Rinses

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Dentin Hypersensitivity Treatment

• Options for Treatment19 (listed as least
  invasive to most)

• In-office by dental professional
• Chemicals (oxalates)
• Physical agents
• Restorations
• Endodontic (root canal)
• Tooth extraction

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Dentin Hypersensitivity

• Dentin Hypersensitivity the common cold of
  dentistry.3

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Dentin HypersensitivityReferences

• 1. Ajcharanukul O, Kraivaphan P, Wanachantarak S,
  et al. Effects of potassium ions on dentin
  sensitivity in man. Arch Oral Biol.
  200752(7)632-639.
• 2. Matthews B, Vongsavan N. Interaction between
  neural and hydrodynamic mechanisms in dentine and
  pulp. Arch Oral Biol. 199439(Suppl)87S-95S.
• 3. Strassler HE, Drisko CL, Alexander DC. Dentin
  hypersensitivity its inter-relationship to
  gingival recession and acid erosion. Inside
  Dentistry. 200829(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. 20084(9 Special Issue)8-18.
• 5. Watson PJ. Gingival recession. J Dent.
  198412(1)29-35.
• 6. Smith RG. Gingival recession. Reappraisal of
  an enigmatic condition and a new index for
  monitoring. J Clin Periodontol.
  199724(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.
  20084(9 Special Issue)19-24.
• 8. Imfeld T. Dental erosion. Definition,
  classification and links. Eur J Oral Sci.
  1996104(2 (Pt 2))151-155.
• 9. ten Cate JM, Imfeld T. Dental erosion.
  Summary. Eur J Oral Sci. 1996104(2 (Pt
  2))241-244.
• 10. Addy, Martin, Dentin hypersensitivity new
  perspective on an old problem. Int Dent J.
  200252367-375.
• 11. Drisko, CH. Dentin hypersensitivity dental
  hygiene and periodontal considerations. Int Dent
  J. 200252385-393.
• 12. Auschill TM, Hellwig E, Schmidate S, et al.
  Efficacy, side-effects and patients acceptance
  of different bleaching techniques (OTC,
  in-office, at home). Oper Dent.
  200530(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

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Dentin HypersensitivityReferences

• 14. Haywood VB, Leonard R, Nelson CF, et al.
  Effectiveness, side effects and long-term status
  of nightguard vital bleaching. J Am Dent Assoc.
  1994125(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. 20084(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.
  20084(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 2006190-199. 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.
  200369(4)221-226.

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Dentin Hypersensitivity

• This IFDEA Educational Teaching Resource was
  underwritten by an unrestricted grant from
•