IFDEA Dentin Hypersensitivity Educational Teaching Resource

8/2/2019 IFDEA Dentin Hypersensitivity Educational Teaching Resource

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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 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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Enamel

Dentin

Cementum

Dental Pulp

The 4 main dental tissues:

Enamel

Dentin

Cementum

Dental Pulp

Oral Anatomy:

Dental Tissues


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Anatomic Crown

Anatomic Root

Pulp Chamber

The 3 parts of a tooth:

Anatomic Crown

Anatomic Root

PulpChamber

Oral Anatomy:

Dental Tissues


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Oral Anatomy:

Dental Tissues

Enamel

Dentin

Cementum

Dental Pulp


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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

OdontoblastCell


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Dentin Hypersensitivity: Physiology

The most widely accepted mechanism of action for dentin hypersensitivity isthe Hydrodynamic Theory, which was first proposed by Gysi in 1900 and

validated by Brannstrom in 1996.2

Mechanism of Dentin Hypersensitivity


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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


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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


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Dentin


Trigger stimuli include:3

Thermal

Hot

Cold

Tactile

Evaporative

Osmotic

Hydrodynamic Theory


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Dentin


The true physiologic stimulus isthe inward or outward fluid shifts,

not the actual trigger.4

Hydrodynamic Theory

Fluid-filledTubules

Dentin NerveFibers

OdontoblastCell


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Dentin

Hypersensitivity:Etiology

The most important factor in the

etiology of dentin hypersensitivity isexposed dentin.5,6

Hydrodynamic Theory

The result of gingival recession(exposure of root surfaces)

The result of loss of enamel from toothwear or trauma

Loss of cementum Removal or absence of a smear layer

RecedingGingiva

Tooth

Wear


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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 alveolarhousing by orthodontics


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Physical Loss

Abrasionmechanical

Attritiontooth/tooth

Abfractionlesions

Chemical dissolution

Erosion

-Extrinsic acids

-Intrinsic acids

Multifactorial etiology

Erosion, abrasion, attrition,abfraction

Tooth Wear can occur as a result of:3,8



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Dentin


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

Tooth

Wear

RecedingGingiva


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Dentin becomes exposed through enamel

or cementum loss and/or gingivalrecession

Opening of tubules by removal of the

smear layer initiates the lesion

Disturbed flow stimulates

A-beta (A-) and some A-delta (A-)nerve fibers

Understanding Dentin Hypersensitivity Pain4


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Aggressive toothbrushing

Periodontal diseases

Periodontal therapy

Tooth whitening/bleaching

Understanding Dentin Hypersensitivity Pain


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Dentin


Erosionacts alone, or incombination with abrasion tocause enamel loss

Extrinsic/intrinsic acids causesurface softening of enamel whichtakes hours to re-harden andresults in greater susceptibility tophysical insult

Understanding Dentin Hypersensitivity Pain9

3. Strassler HE, Drisko CL, Alexander DC.


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Incidence: 15% (4% to 57%)

Age range: 1570+ years

Peak incidence: 2040 years

Gender: Female > Males

Global Prevalence3

Dentin

Hypersensitivity:Epidemiology

Pain or discomfort caused by cold, hot, s weet, sour, foods/drinks or tooth brushing.


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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. DentinHypersensitivity: Consensus-Based Recommendationsfor the Diagnosis and Management of DentinHypersensitivity.


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Frequency of Dentate Adults whoResponded 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

22


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Dentin Hypersensitivity: Epidemiology

Dietary changes

Acidic food/drinks

Periodontal procedures

Cosmetic treatments

Bleaching/whitening12-14

Restorative

AgingRetain natural teeth

There are a number of factors that may contribute to an

increased prevalence of dentin hypersensitivity:3


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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


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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


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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



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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



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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

EnamelWear


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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



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Prevention and Treatment of Bleaching Hypersensitivity

16. Pashley DH, Tay FR, Haywood VB, et al.



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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


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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 resolvewith removal of treatment or over time

Dentin Hypersensitivity: Management/DiagnosisSensitivity may occur in response to various stimuli:3


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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


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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


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Dentin Hypersensitivity:Treatment

Obturate tubules or alter fluidflow in dentinal tubules

Modify or block pulpal nerve

response

Management of Dentin Hypersensitivity3,4

KNO3


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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


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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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At-home treatmentspatient applied

Anti-sensitivity dentifrice

Fluoride-based gels

Rinses

Options for Treatment19


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In-office by dental professional

Chemicals (oxalates)

Physical agents

Restorations

Endodontic (root canal)

Tooth extraction

Options for Treatment19

(listed as least invasive to most)


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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. 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


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 hypersensitivitydental hygiene and periodontal considerations.Int Dent J. 2002;52;385-393.

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. 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


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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.

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


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.


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IFDEA Dentin Hypersensitivity Educational Teaching Resource