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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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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
Hypersensitivity:Physiology
Trigger stimuli include:3
Thermal
Hot
Cold
Tactile
Evaporative
Osmotic
Hydrodynamic Theory
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Dentin
Hypersensitivity:Physiology
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
Dentin Hypersensitivity: Etiology
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Dentin
Hypersensitivity:Etiology
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 Hypersensitivity: Etiology
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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Dentin Hypersensitivity: Etiology
Aggressive toothbrushing
Periodontal diseases
Periodontal therapy
Tooth whitening/bleaching
Understanding Dentin Hypersensitivity Pain
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Dentin
Hypersensitivity:Etiology
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
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
Dentin Hypersensitivity: Management/Diagnosis
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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
Dentin Hypersensitivity: Management/Diagnosis
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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
Dentin Hypersensitivity: Management/Diagnosis
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Prevention and Treatment of Bleaching Hypersensitivity
16. Pashley DH, Tay FR, Haywood VB, et al.
Dentin Hypersensitivity: Management/Diagnosis
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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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Dentin Hypersensitivity: Treatment
At-home treatmentspatient applied
Anti-sensitivity dentifrice
Fluoride-based gels
Rinses
Options for Treatment19
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Dentin Hypersensitivity: Treatment
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
Dentin Hypersensitivity
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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
Recommendations for the Diagnosis and Management of Dentin Hypersensitivity. Inside Dentistry. 2008;4(9 Special Issue):19-24.
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
Recommendations for the Diagnosis and Management of Dentin Hypersensitivity. Inside Dentistry. 2008;4(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; 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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Dentin Hypersensitivity
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