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Chapter 43Dentin Hypersensitivity
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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
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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
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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
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Etiology
Anatomy of tooth structures
Mechanisms of dentin exposure
Hydrodynamic theory Neural theory
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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 sodaE) Rinsing with bicarbonate of soda after getting sick
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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.
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Anatomy of Tooth Structures
Dentin
Pulp
Nerves
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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.
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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
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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 ashort way into each dentinal tubule.
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Nerves Nerve fiber endings extend just beyond the
dentinopulpal junction and wind around the
odontoblastic processes as shown in the nextslide. Nerves react via the same neural
depolarization mechanism (sodium potassium
pump), which characterizes the response of anynerve to a stimulus.
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Mechanisms of
Dentin Exposure
General considerations Gingival recession and root exposure
Loss of enamel and cementum
Once exposed, demineralization of the root surfacewill occur more rapidly than of the enamel because of
the higher mineral content of enamel and the lower
critical pH to initiate demineralization.
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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.
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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
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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 toinflammatory factors
Connective tissue breaks down, loss of attachment
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Surgical procedures Reducing pocket depth
Removes gingival coverage of root
Restorative procedures Crown preparation
Can abrade gingival tissues
Factors Contributing to GingivalRecession and Root Exposure
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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.
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Factors Contributing to Loss ofEnamel 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
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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.
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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 acidicenvironment.
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Abfraction
Cervical lesion caused by occlusal stressed ortooth 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 ofEnamel and Cementum
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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
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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
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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
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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 fortransmission 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
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Answer
A) Both statements are true
This is the most currently accepted explanation
for sensitivity.
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Open dentinal tubules. (centered tubule is partially occluded)
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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 ofperitubulardentin (deposited within the periphery of the tubules).
Results in a smaller-diameter tubule that is less able to transmitstimuli through the dentinal fluid to the nerve fibers at thedentinopulpal interface.
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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.
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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.
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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).
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Natural Desensitization
Smear Layer (cont)
Occludes the dentinal tubule orifices, forming asmear plug or a natural bandage that blocksstimuli.
The nature of the smear layer changes constantlysince it is subject to effects such as mechanicaldisruption from ultrasonic debridement, ordissolution from acid exposure. Smear layer mayhave a positive or negative effect. It protects fromhypersensitivity, but may interfere withreattachment of periodontal tissues.
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Natural Desensitization
Calculus
provides a protective coating to shield exposeddentin from stimuli. Postdebridement sensitivity can
occur after removal of heavy calculus deposits;
dentinal tubules may become exposed as calculus is
removed.
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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
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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
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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
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Hypersensitivity Management
Assessment components
Evaluate OH self-care procedures
Parafunctional habits bruxism, grinding
Educational consideration
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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.
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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
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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
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Behavioral Changes Dietary modifications
Dental biofilm control
Toothbrush type and technique
Burnishing
Eliminate parafunctional habits
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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
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Potassium salts Formulations containing
potassium chloride
potassium nitrate
potassium citrate, or potassium oxalate Reduce depolarization of the nerve cell
membrane and transmission of the nerveimpulse. Potassium nitrate dentifrices
containing fluoride are widely used and readilyavailable over the counter.
Desensitizing Agents and Theorized
Mode of Action
Desensitizing Agents and Theorized
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Desensitizing Agents and Theorized
Mode of Action
Fluorides
Precipitate calcium fluoride (CaF2) crystals
within the dentinal tubule to decrease thelumen diameter
Create a barrier by precipitating CaF2 at theexposed dentin surface to block open dental
tubules.
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Dentifrices 5% potassium nitrate and fluorides separately or in
combination are the active desensitizing agents inOTC sensitivity-reducing dentifrices.
Studies have suggested that some of thedesensitizing effects of dentifrices may be due to theblocking action of the abrasive particles. Tartarcontrol dentifrices may contribute to increased toothsensitivity for some individuals, although themechanism is unclear.
Self-Applied Measures
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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 alsoavailable with the addition of potassium nitrate.
Self-Applied Measures
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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.
Self-Applied Measures
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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
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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.
Dental Professional Measures
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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
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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 acalcium 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
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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
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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 beforeinstrumentation
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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
Dental Professional Measures
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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
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Answer
B) Unfilled resins
Unfilled resins cover patent dentinal tubules.
This requires an acid etch preparation and
drying of the tooth, which may necessitatelocal anesthetic use.
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Periodontal debridement
New developments Tooth-whitening-induced sensitivity
Additional Considerations
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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