An Analysis of the Etiological and Predisposing Factors ...€¦ · The Journal of Contemporary...

1The Journal of Contemporary Dental Practice, Volume 9, No. 5, July 1, 2008

An Analysis of the Etiological and Predisposing Factors Related to Dentin Hypersensitivity

Aim: To determine the prevalence of different etiological factors of dentin hypersensitivity in patients and toprovide information on their association with dentin hypersensitivity.

Methods and Materials: Twenty-nine patients (17 male, 12 female) suffering from pain of dentinhypersensitivity were recruited to participate in the study. A relevant history was taken and dentin hypersensitivity confirmed by using air-blast and tactile stimuli.

Results: All patients were right-handed. The left side of the mouth showed a preponderance of gingival recession, abrasion, abfraction, and erosion while more teeth on the right side showed attrition. Gingival recession and attrition were common among the molars, abrasions among the molars and premolars, abfraction among the premolars, while erosive lesions were predominantly found among the incisors.

A total of 911 teeth were examined in the 29 subjects presenting with dentin hypersensitivity. The followingconditions were found to be associated with the dentin hypersensitivity: 43 of 117 teeth (36.8%) with gingival recession; 41 of 99 teeth (41.4%) with attrition; 40 of 67 teeth (59.7%) with abrasion; 16 of 25 teeth (64%) withabfraction; and 32 teeth had erosive lesions all associated with hypersensitivity.

Abstract

© Seer Publishing


IntroductionDentin hypersensitivity has been described as a condition in which a sound, exposed dentinalsurface is sensitive to stimuli that would normallycause no discomfort.1 Usually, no obvious cause can be identified for this condition;2 Addy3

described it as a tooth wear phenomenon. By definition two conditions need to be satisfied fordentin hypersensitivity to occur: dentin has tobecome exposed by loss of enamel or periodontaltissues and the dentin tubule system has to be opened and be patent to the pulp.4

The most implicated physical/chemical process causing dentin exposure is dental erosion actingalone or synergistically with other factors such as abrasion and attrition. Enamel erosion ischaracterized by acid-mediated surface softeningprogressing to irreversible loss of surface tissue if left unchecked potentially exposing the underlying dentin.5 It is currently believedto be the major factor involved in tooth wear.6

Traditionally, potential factors causing erosion have been described as originating from the diet,environment, and from regurgitation.7 Erosion

may also be due to either extrinsic or intrinsicacids.8,9 Erosion results in shallow, rounded lesions,10 and it is suggested7 when an erosive factor is present ‘cupping’ or ‘grooves’ form in thedentin with the base of the defect not in contactwith the opposing tooth.

Attrition describes the wear of teeth at sites of direct contact between teeth.11 It is associatedwith flattening of the cusp tips or incisal edgesand localized facets on the occlusal or palatal surfaces.

Abrasion describes the wear of teeth caused by objects other than another tooth.11 Most interestin abrasion has centered around the effects oftooth brushing with toothpaste. Typical toothbrushabrasion lesions are side dependent, for example being greater on the left-side in right-handed people. The buccal cervical areas of the teeth are the sites of predilection. Cervical lesions causedby an abrasive tend to be angular and ‘v’-shaped.

Abfraction or cervical stress lesions have been hypothesized as an etiological factor in toothwear.12,13 The process is thought to involveeccentric occlusal loading leading to cusp flexure.This flexure results in damage to the enamel rodsat the gum line resulting in their loosening and consequent flaking away of the tooth structure.It is difficult to diagnose such lesions properly, but generally, in cases where a deep v-shaped cervical notch is present or when cervical restorations are repeatedly lost, the practitioner should look for wear facets or other signs of occlusal trauma.14

Conclusion: Gingival recessions followed by attrition were the most commonly found etiological factors leadingto dentin hypersensitivity. Erosive lesions were mostly associated with dentin hypersensitivity. A statistically significant relationship exists between dentin hypersensitivity, tooth wear lesions, and gingival recession.

Clinical Significance: This study provides clinical evidence supporting the notion of dentin hypersensitivitybeing a tooth wear phenomenon. Therefore, successful preventive and management strategies for sufferers ofdentin hypersensitivity must take into consideration causal factors for tooth wear and gingival recession.

Keywords: Etiological factors, dentin hypersensitivity, tooth wear, gingival recession

Citation: Bamise CT, Olusile AO, Oginni AO. An Analysis of the Etiological and Predisposing Factors Relatedto Dentin Hypersensitivity. J Contemp Dent Pract 2008 July; (9)5:052-059.


included the consumption of orange juice, carbonated beverages, and chewable vitamin C.The type of toothbrush, toothbrushing technique, and handedness of the patient were noted.

A past medical history was taken to ascertain anyunderlying systemic conditions such as diabetes mellitus, hypertension, blood dyscrasias, allergies, bronchial asthma, hiatus hernia, astroesophagealreflux disease (GERD), pregnancy, and currentmedications.

Intraorally, all remaining teeth were examinedwith their numbers, position, mobility, andocclusal relations noted. Any evidence ofgingival recession, caries, attrition, erosion,abrasion, abfraction, fractures, chipping, anddentin hypersensitivity were also recorded. Teeth having caries, cracks or fractures, extensive andunsatisfactory restorations, and mobility were excluded. The suspected sites on the teeth werestimulated by an air-blast from the air-watersyringe of the dental unit and by scratching the exposed area with a dental probe until the patientreported the exact discomfort that precipitatedtheir initial dental visit. All the teeth with dentin hypersensitivity and surfaces involved were recorded.

Frequencies and proportions were calculated. Associations between discreet variables weretested using the Chi square test. In all cases a p-value of less than 0.05 (p=


hypersensitivity. The upper right quadrant had the highest number of attrited teeth.

Sixty-seven teeth had cervical abrasion with theupper left quadrant having the highest number ofteeth affected, which was statistically significant different from the upper right quadrant. Forty (59.7%) teeth had sensitive abrasive lesions.

Twenty-five teeth with abfractions were seen with the upper left quadrant having the highest number of teeth affected. Sixteen (64%) teeth withabfraction had related dentin hypersensitivity.

Thirty-two teeth had erosive lesions with all of them having associated dentin hypersensitivity.The upper left quadrant had the highest number of teeth with erosion. Erosive lesions had a 45% predilection for buccal/labial surfaces, 37% forocclusal surfaces, and 6% for palatal/lingual surfaces (Figure 1).

There was a statistically significant relationship of dentin hypersensitivity with gingival recession and tooth wear (p=0.05, Chi square test).

teeth with gingival recession and 38 (56.7%) teeth with abrasion.

Sixty-five (97%) teeth showing abrasion were found in patients who cleaned their teeth with a toothbrush and toothpaste. Patients who used atoothbrush and toothpaste plus a chewing stickhad two (3%) teeth with abrasion. None of thepatients used a chewing stick alone.

All patients were right-handed. The left side of the mouth showed a preponderance of gingival recession, abrasion, abfraction, and erosion whilemore teeth on the right side showed attrition(Table 1).

Tables 1 and 2 show 911 teeth from 29 patients who participated in the study. A total of 117 teeth had gingival recession with the upper left quadrant having the highest number of teeth affected. Forty-three (36.8%) teeth had dentinhypersensitivity related to the gingival recession.

Ninety-nine teeth had attrited surfaces out ofwhich 41 (41.4%) had an associated dentin

Table 1. Quadrants and right and left-sided distributions of gingival recession, attrition, abrasion, abfraction, and erosion.


it and for the clinicians providing treatment.Understanding the burden of the variouspredisposing factors and recognizing the degree of their association are an integral part of totalpatient care. The aim of the present study was toprovide more information on these factors.

Since only 29 patients were recruited to participate in the study it suffers a limitation. This

Gingival recession and attrition were predominantly found among molars; abrasive lesions among molars and premolars; abfraction among premolars; while erosive lesions were predominantly found among incisors (Table 2).

DiscussionDentin hypersensitivity is a problem posing a number of challenges for those who suffer from

Table 2. Distribution of gingival recession, attrition, abrasion, abfraction, erosion, and their involvement in dentin hypersensitivity.

Figure 1. Predilection of erosive lesions for tooth surfaces.


with toothpaste has been considered to be a prime etiological agent in both abrasive tooth wear and gingival recession.22 Levitch, et al.23 reported the association of toothbrushing with tooth wear existsin subjects who brush their teeth frequently for alonger period and use a scrubbing technique.

Interaction of these factors might have contributed to the high percentage of cervical abrasion lesions and gingival recessions found in subjects using a hard bristle toothbrush and those who usedtoothbrushes indiscriminately. This agrees withthe findings of Bradley et al.20 and Goutoudi et al.24

where hard toothbrush use has been implicatedin gingival recession and abrasion as is dentinhypersensitivity.

Use of a chewing stick has been mentioned as acause of tooth wear in the dental literature25 andgingival recession.26 Such a correlation could notbe ascertained in this study because none of thesubjects in the study used a chewing stick alone.

The preponderant finding of attrition in molars/premolars can possibly be explained by the high fibrous, coarse, or gritty diet common in the Nigerian environment. This result is alsosimilar to the findings of previous studies amongNigerians. Kumar and Ana,27 in their study ofprevalence of attrition in two Nigerian rural areas, reported attrition is marked in molars. Mandibularmolars and first molars were said to be the mostattrited teeth, and they suggested the differentialdiagnoses of attrition be considered for pain in the mouth. Oginni et al.28 reported attrition to be the most prevalent form of tooth wear occurring mostly on the posterior teeth that bear the brunt ofmasticatory forces.29 Attrition occurs due to tooth-to-tooth contact during function30 and it is said to be commonly seen in the developing countries and in the elderly.31

The premolars and canines were the most affected by abrasion in this study. Addy et al.32 had a similarresult due to the position of these teeth within thedental arch where they receive the most attentionduring cleaning.

Abfractive lesions were predominantly seen amongthe posterior teeth on the left side and in the upper left quadrants. This is consistent with the result ofan earlier study done in the same hospital.28

could probably be explained by the low prevalenceof teeth responding positively to the objective diagnosis of dentin hypersensitivity. This was alsoevident by a significant percentage of tooth wearlesions with exposed dentin surfaces which were not sensitive as observed in the study.

The cause of dentin hypersensitivity is attributed to exposed dentinal tubules found in areas where tooth structure has been lost. There are potentially numerous and varied etiological andpredisposing factors of dentin hypersensitivity, certainly no prime cause has been identified.2

During the diagnosis of dentin hypersensitivity andidentification of associated etiological factors for this study, the dominant factors were identified bytheir characteristic appearance and recorded. The wear of an individual’s teeth rarely results from a single cause although one is likely to predominate.This limitation was envisaged during the diagnosis; hence, there was inter-examiner agreement (thePI and at least one other investigator) in the identification of the dominant cause.

The results indicated patients consuming orangejuice and carbonated cola beverages had the highest number of tooth surface loss. This issimilar to the result of a study by Addy et al.19

where they demonstrated citrus fruit juices were capable of rapidly dissolving the dentin smearlayer within a few minutes and carbonated cola drink was less erosive.

Toothbrush characteristics, i.e., hard toothbrush20

and toothbrushing techniques, are major variables in hard and soft tissue damage.21

Since toothbrushing is usually performed with toothpaste, incorrect or vigorous toothbrushing


that dentin hypersensitivity shows a predilection for certain oral sites that may be of etiologicalrelevance. It is not surprising incisors were mostlyaffected by erosion, canines and premolars were preponderantly involved in gingival recession and abrasion. Molars were observed as the most attrited teeth.

The dental management of patients where suchfactors, i.e., tooth wear and gingival recession are overwhelming has proven difficult for clinicians for many years, and the problem seems to be increasing because the population is retaining more natural teeth into old age.38 An increased understanding of the relationship of these entitieswith dentin hypersensitivity is essential to its prevention and effective management.

ConclusionWithin the limitations of this study, the prevalence and distribution of the different etiological factors of dentin hypersensitivity in patients thatpresented with pain due to dentin hypersensitivitywere obtained. Gingival recession followed by attrition were the most common etiological factorsfound while erosive lesions showed the most frequent association with dentin hypersensitivity. A statistically significant relationship exists betweendentin hypersensitivity, tooth wear lesions, andgingival recession. There is still a need to conduct further studies to know the prevalence of tooth wear lesions and gingival recession in the generalpopulation.

Clinical SignificanceThe etiology of dentin hypersensitivity is poorlyunderstood. This study provides clinical evidence supporting the notion of dentin hypersensitivitybeing a tooth wear phenomenon. Therefore,successful preventive and management strategiesfor sufferers of dentin hypersensitivity must takeinto consideration causal factors for tooth wear and gingival recession.

The incisors and canines were predominantly affected by erosion. Smooth surfaces of anteriorteeth have been shown to be particularly vulnerable to attack by acids during theconsumption of acidic beverages which may cause erosion of tooth tissue.33 Most of the erosive lesions in the present study can be attributed to dietary erosion because none of the patientshad a history of intrinsic acid production oroccupational exposure to acids. Also, a significant relationship was observed between patients with ahistory of dietary acid ingestion and tooth erosion.

Some examined teeth had gingival recession,abrasions, abfractions, and attrited lesions that were not sensitive. Absi et al.34 stated not all exposed dentin is sensitive and in areas of sensitive dentin the number of tubules open at thesurface was approximately eight times that of non-sensitive dentin. Furthermore, they indicated the mean diameter of open tubules in sensitive dentin was twice those as in non-sensitive dentin. Theyconcluded the more open dentinal tubules there are on the surface and the greater the diameter,the greater the propensity for tubular fluid flowwith a given stimulus.

A similar distribution of gingival recession andabrasion was found in the present study. The upper left quadrant had the highest number of teeth with gingival recession and abrasion. Theseconditions along with dentin hypersensitivity havebeen shown to be more common on the left than on the right side of the dental arches.35 Addy4 thensuggested such findings showed toothbrushing is associated with dentin hypersensitivity. This issupported by the fact all the patients in this study were right handed and right handed brushers are known to brush the left buccal surfaces more effectively than on right side.32,36

Generally, low percentages of the etiological and predisposing factors were observed but theirdistributions agree with the summation of Addy37 in


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