Chapter 43 Dentin Hypersensitivity

Hypersensitivity
General considerations
Sensitive to dental treatment
Cold water, air, scaling

Definition
Stimulus causes pain but is alleviated upon removal Can be difficult to diagnose, rule out other causes

Stimuli That Elicit Pain Reaction

Tactile or mechanical
Toothbrush, instrument, clasps

Thermal
Hot and cold, beverages, food, air

Evaporative - suction Osmotic

Pressure in dentinal tubules

Chemical citrus, spices, wines, soda

Characteristics of Pain from Hypersensitivity

Pain at onset
Sharp, short, transient pain, rapid onset

Cessation upon removal of stimulus Chronic condition with acute episodes Response to nonnoxious stimulus No dental defect or pathology

Etiology
Anatomy of tooth structures Mechanisms of dentin exposure Hydrodynamic theory Neural theory

Review
Which of the following factors contributes to loss of enamel and cementum and contributes to sensitivity? A) Enamel and cementum overlap at the CEJ B) Attrition and abrasion C) Erosion from high pH drinks D) Brushing with baking soda E) Rinsing with bicarbonate of soda after getting sick

Answer
B) Attrition and abrasion Loss of tooth structure is multifactorial. Wear can occur if the enamel and cementum do not meet at the CEJ, not if they overlap. Low, not high, pH drinks would cause erosion. Brushing with baking soda would not increase erosion as it is not abrasive. Rinsing with bicarbonate of soda would help erase the acidic environment that enhances erosion.

Anatomy of Tooth Structures

Dentin Pulp Nerves

Dentin

Portion of the tooth covered by enamel on the crown and cementum on the root. Composed of fluid-filled dentinal tubules that narrow and branch as they extend from the pulp to the dentinoenamel junction.

Dentin
The only portion of the dentinal tubules that are innervated with nerve fiber endings from the pulp chamber are those closest to the pulp. Tubules in sensitive areas are wider and more numerous

Pulp
Highly innervated with nerve cell fiber endings that extend just beyond the dentinopulpal interface of the dentinal tubules. Body portion of odontoblasts (dentin-producing cells) located adjacent to the pulp extend their processes from the dentinopulpal junction a short way into each dentinal tubule.

Nerves
Nerve fiber endings extend just beyond the dentinopulpal junction and wind around the odontoblastic processes as shown in the next slide. Nerves react via the same neural depolarization mechanism (sodium potassium pump), which characterizes the response of any nerve to a stimulus.

 General considerations Gingival recession and root exposure Loss of enamel and cementum
Once exposed, demineralization of the root surface will occur more rapidly than of the enamel because of the higher mineral content of enamel and the lower critical pH to initiate demineralization.

Mechanisms of Dentin Exposure

Mechanisms of Dentin Exposure

Acute hypersensitivity may occur with sudden dentin exposure since gradual exposure allows for the development of natural desensitization mechanisms such as smear layer or sclerosis. After many years, secondary or reparative dentin may have formed, which also protects the pulp.

Factors Contributing to Gingival Recession and Root Exposure

Improper oral hygiene self-care
Medium/hard toothbrush Aggressive brushing

Anatomy and physiology of area

Narrow zone of attached gingiva
More susceptible

Facial orientation High frenum attachment

Factors Contributing to Gingival Recession and Root Exposure

Subgingival instrumentation
After scaling and root planing
Tissues will shrink

Excessive scaling in shallow sulci

Periodontal disease processes

NUG
Junctional epithelium migrates apically in response to inflammatory factors
Connective tissue breaks down, loss of attachment

Factors Contributing to Gingival Recession and Root Exposure

Surgical procedures
Reducing pocket depth
Removes gingival coverage of root

Restorative procedures
Crown preparation
Can abrade gingival tissues

Factors Contributing to Gingival Recession and Root Exposure

Orthodontic procedures
During toothmovement

Oral habits or piercings

Metal repeatedly traumatizes the adjacent facial or lingual gingival tissue and may lead to gingival recession and bone loss around the involved teeth.

Factors Contributing to Loss of Enamel and Cementum

Anatomy of cervical area
Cementum
Thin, easily abrades Enamel and cementum do not meet at the CEJ in 10% of teeth, leaving exposed area of dentin

Factors Contributing to Loss of Enamel and Cementum

Attrition and abrasion
From mastication, and improper oral hygiene practices.

Erosion
Dietary acids, such as citrus fruits/juices, wine, and carbonated drinks.

Factors Contributing to Loss of Enamel and Cementum

Erosion
Brushing with a dentifrice immediately after consumption of acidic foods and beverages further abrades the already demineralizing tooth surface. Gastric acids from conditions such as gastric reflux, morning sickness, or self-induced vomiting (bulimia) repeatedly expose teeth to a highly acidic environment.

Factors Contributing to Loss of Enamel and Cementum

Abfraction
Cervical lesion caused by occlusal stressed or tooth flexure from bruxing Microscopic portions of the enamel rods chip away from the cervical area of the tooth resulting in loss of tooth structure. Lesion appears as a wedge- or V-shaped cervical notch.

Factors Contributing to Loss of Enamel and Cementum

Restorative procedures
procedures that remove enamel or cementum can expose dentin at the cervical area.

Periodontal instrumentation
SR&P

Improper stain removal techniques

Abrasive materials

Root surface caries

Hydrodynamic Theory
Transmission of stimuli
Fluid movement within tubules
Hydrodynamic Theory
Fluid movement creates pressure on the nerve endings=stimulation=pain

Pain impulse Widened dentin tubules

Seen in sensitive teeth, not present in non-sensitve teeth

Neural Activity
Pain registered by the depolarization/neural discharge mechanism that characterizes all nerve activity Sodium-potassium pump is responsible for depolarizing the nerve as potassium leaves the nerve cell and sodium enters it

Review
The hydrodynamic theory states that a stimulus at the outer aspect of dentin causes fluid movement within the dentinal tubules. Developed by Brannstrom in 1960, the hydrodynamic theory is the currently accepted explanation for transmission of stimuli from the outer surface of dentin and pulp. A) Both statements are true B) Both statements are false C) The first statement is true and the second statement is false D) The first statement is false and the second statement is true

Answer
A) Both statements are true This is the most currently accepted explanation for sensitivity.

Open dentinal tubules. (centered tubule is partially occluded)

Natural Desensitization
Sclerosis of dentin
occurs by mineral deposition within tubules as a result of traumatic stimuli
such as attrition or dental caries.

Creates a thicker, highly mineralized layer of peritubular dentin (deposited within the periphery of the tubules).
Results in a smaller-diameter tubule that is less able to transmit stimuli through the dentinal fluid to the nerve fibers at the dentinopulpal interface.

Natural Desensitization
Secondary dentin
deposited gradually on the floor and roof of the pulp chamber after teeth are fully developed. Secreted more slowly than primary dentin that formed prior to tooth eruption; both types of dentin are created by odontoblasts.

Natural Desensitization
Creates a walling off effect between the dentinal tubules and the pulp
Insulates the pulp from dentin fluid disturbances caused by a stimulus such as dental caries. As aging occurs, secondary dentin accumulates
Results in a smaller pulp chamber with fewer nerve endings and less sensitivity.

Natural Desensitization
Smear layer
consists of organic and inorganic debris that cover the dentinal surface and the tubules. Accumulates following
scaling and root instrumentation use of toothpaste (abrasive particles), cutting with a bur attrition, or abrasion (burnishing with a toothbrush or toothpick, or other device).

Natural Desensitization
Smear Layer (cont)
Occludes the dentinal tubule orifices, forming a smear plug or a natural bandage that blocks stimuli. The nature of the smear layer changes constantly since it is subject to effects such as mechanical disruption from ultrasonic debridement, or dissolution from acid exposure. Smear layer may have a positive or negative effect. It protects from hypersensitivity, but may interfere with reattachment of periodontal tissues.

Natural Desensitization
Calculus
provides a protective coating to shield exposed dentin from stimuli. Postdebridement sensitivity can occur after removal of heavy calculus deposits; dentinal tubules may become exposed as calculus is removed.

Patients and Their Pain

Pain profile
Usually reported at 20-40 yrs of age Prevalence of hypersensitivity Teeth affected

Pain experience
Pain perception Impact of pain

Differential Diagnosis
Differentiation of pain table 43-1 Data collection by interview
Use open-ended questions
Location and degree of pain Source of stimulus Record in patient record

Differential Diagnosis
Diagnostic techniques and tests
Bite on a stick pain = fracture Nasal congestion/sinus = pain Check occlusion for contacts high Radiographs check for caries Transillumination to check for cracks Pulp tests to check vitality

Hypersensitivity Management
Assessment components
Evaluate OH self-care procedures Parafunctional habits bruxism, grinding

Educational consideration

Hypersensitivity Management
Treatment hierarchy
there are two basic treatment goals
pain relief modification or elimination of contributing factors

Address mild to moderate pain with conservative activities or agents More severe pain requires an aggressive approach.

 Sequence treatment approaches

From the most conservative and least invasive measures to more aggressive modalities. Prognosis of pain resolution is difficult to predict A trial-and-error approach may be necessary until a particular treatment option is found to be most effective. Treatment options that include both self-care measures and professional interventions have synergistic effects with the same objective of reducing hypersensitivity.

Reassessment

Oral Hygiene Care and Treatment Interventions

Mechanisms of desensitization Behavioral changes Desensitizing agents and mode of action Self-applied measures Dental professional measures Additional considerations

Behavioral Changes
Dietary modifications Dental biofilm control Toothbrush type and technique Burnishing Eliminate parafunctional habits

Burnishing sensitive root surface. A small amount of a fluoride agent or fluoride dentifrice can be burnished into the sensitive area with a toothpick or wooden point. Moderate pressure with a rubbing or circular stroke is applied. A toothpick holder facilitates effective use of a toothpick to burnish an exposed root surface

Desensitizing Agents and Theorized Mode of Action

Potassium salts
Formulations containing
potassium chloride potassium nitrate potassium citrate, or potassium oxalate

Reduce depolarization of the nerve cell membrane and transmission of the nerve impulse. Potassium nitrate dentifrices containing fluoride are widely used and readily available over the counter.

Desensitizing Agents and Theorized Mode of Action

Fluorides Precipitate calcium fluoride (CaF2) crystals within the dentinal tubule to decrease the lumen diameter Create a barrier by precipitating CaF2 at the exposed dentin surface to block open dental tubules.

Self-Applied Measures
Dentifrices
5% potassium nitrate and fluorides separately or in combination are the active desensitizing agents in OTC sensitivity-reducing dentifrices. Studies have suggested that some of the desensitizing effects of dentifrices may be due to the blocking action of the abrasive particles. Tartar control dentifrices may contribute to increased tooth sensitivity for some individuals, although the mechanism is unclear.

Self-Applied Measures

Dentifrices
Prescription-strength dentifrices are available containing highly concentrated fluoride (5,000 ppm fluoride) combined with an abrasive to facilitate extrinsic stain control. This formulation is also available with the addition of potassium nitrate.

Self-Applied Measures

Gels
5,000 ppm fluoride gels (available by prescription) are brushed on for generalized hypersensitivity or can be burnished into localized areas of sensitivity. Contain no abrasive agents for biofilm and stain control. Can be self-applied with custom or commercially available fluoride trays.

Dental Professional Measures

Fluoride agents
Sodium or stannous fl with a tray delivery system Fluoride varnish 5% sodium f

Glutaraldehydes
5% formulation can be applied to tooth surface with microbrush
Isolate area with cotton roll first

Dental Professional Measures

Oxalates
Oxalate salts such as potassium oxalate and ferric oxalate precipitate calcium oxalate crystals to decrease the lumen diameter Oxalate preparations are applied to a dried tooth surface, or can be burnished. Block open tubules These provide immediate and short-term, rather than long-term, relief.

Calcium Phosphate Technology

Amorphous calcium phosphate (ACP)
Theorized to plug dentinal tubules with calcium and phosphate Enhances fluoride delivery in calcium and phosphate-deficient saliva
Remineralize acid erosion, abrasion, improves enamel luster, reduce hypersensitivity

Calcium sodium phosphosilicate (CSP) (Nova Min)

Contains sodium and silica in addition to calcium and phosphorus

Calcium Phosphate Technology

Calcium sodium phosphosilicate (CSP) (Nova Min)
Delivered in solid bioactive glass particles that react in the presence of saliva and water to release calcium and phosphate ions to create a calcium phosphate layer that crystallizes to hydroxyapatite Reacts with saliva; sodium buffers the acid, and calcium and phosphate saturate saliva to fill demineralized areas with the new hydroxyapatite

Calcium Phosphate Technology

Casein phosphopepetide-amorphous calcium phosphate (CPP-ACP or Recaldent)
CCP is a milk-derived protein that stabilizes ACP and allows it to be released during acidic challenges Benefits are described as remineralization of acid erosion and caries inhibition by promoting fluoride uptake in plaque biofilm

Calcium Phosphate Technology

Arginine and Calcium Carbonate Technology
Occludes the dentinal tubules utilzing arginine
Naturally occurring amino acid, bicarbonate (pH) buffer, and calcium carbonate

Marketed as a prophy paste to apply before instrumentation

Dental Professional Measures

Restorative materials
Resins cover tubules, must etch first - may need anesthesia Dentin sealers obturation of the tubule
Methylmethacrylate polymer

Composite/glass ionomers

Soft tissue grafts Iontophoresis electric current Lasers

Review
Which of the following desensitizing agents requires the use of an acid etch step prior to application? A) Dentin sealers B) Unfilled resins C) Oxalates D) 5% glutaraldehyde E) 5% potassium nitrate

Answer
B) Unfilled resins Unfilled resins cover patent dentinal tubules. This requires an acid etch preparation and drying of the tooth, which may necessitate local anesthetic use.

Additional Considerations
Periodontal debridement New developments Tooth-whitening-induced sensitivity

Factors to Teach the Patient

Etiology of gingival recession Contributing factors to hypersensitivity Natural, self-care, and professional measures to alleviate sensitivity Oral hygiene and dietary relationship to sensitivity