This document discusses dentin hypersensitivity and its management. It defines dentin hypersensitivity and describes the physiology of dentin and theories of sensitivity such as the odontoblast receptor theory and hydrodynamic theory. It covers the incidence, etiology, clinical features, diagnosis, and various management approaches including desensitizing agents like potassium salts, lasers and restorative methods. Prevention involves patient education on proper oral hygiene techniques and dietary modifications.

1. DENTIN HYPERSENSITIVITY
&
MANAGEMENT
KIRTHANA MUTHU
III BDS
DEPARTMENT OF CONSERVATIVE DENTISTRY AND
ENDODONTICS

2. CONTENTS
• INTRODUCTION
• DEFINITION
• PHYSIOLOGY OF DENTIN
• THEORIES OF DENTINAL HYPERSENSITIVITY
 ODONTOBLAST RECEPTOR THEORY
 DIRECT INERVATION THEORY
 HYDRODYNAMIC THEORY
• INCIDENCE AND PREVALENCE
• ETIOLOGY AND PREDISPOSING FACTORS
• CLINICAL FEATURES
• DIFFERENTIAL DIAGNOSIS
• DIAGNOSIS
• MANAGEMENT

3. INTRODUCTION
Dentin hypersensitivity (DH) is a common
clinical condition that is difficult to treat
because the treatment outcome is not
consistenly successful.
It is clinically described as an exaggerated
response to application of a stimulus to
exposed dentin, regardless its location.

4. DEFINITION
• GROSSMAN
Hypersensitive dentin is an uncommonly
sensitive or painful response of exposed dentin
to an irritation.
• HOLLAND et al
Dentin hypersensitivity is characterized by
short, sharp pain arising from exposed dentin in
response to stimuli typically thermal,
evaporative,tactile,osmotic or chemical and
which cannot be ascribed to any other form of
dental defect or pathology.

5. PHYSIOLOGY OF DENTIN
• Dentin ia a mineralized connective tissue component of the tooth
that makes up the bulk of the tooth.
• Located between the pulp and external tissue surface.
• Dentin is covered by enamel in the crown region and by cementum
in root region.
• Dentin + pulp --> is a funtional complex
--> denoted as dentin-pulp complex
• 3 types :- Primary
Secondary
Tertiary

6. DENTINAL TUBULES
- The basic structural and functional units of
dentin.
- These are tubular or canal like branched
structures extending from pulpal end to the
DEJ.
- It contains odontoblast process,
nonmyelinated nerve fibres, and dental
lymph.

7. ODONTOBLAST PROCESSES
- In vital teeth, the odontoblasts are arranged as
a continous layer along the periphery of pulp
adjacent to pulpal surface of dentin.
- Each cell has a protoplasmic process that
extends for varying distance into the dentinal
tubule.
- These extension are referred as odontoblastic
process and are major content of dentinal
tubules.

9. • - The dentinal tubules composed of dentinal
fluids & the processes that respond to noxious
stimuli together constitute the P-D complex.
PULP DENTIN COMPLEX

10. - Nerve supply to pulp is abundant
- Sensory nerve supply from:
- trigeminal nerve
- superior cervical ganglion
- The pulp has:
 myelinated nerve fibers
- A beta and A delta fibres which
transmits sharp pain
 nonmyelinated nerve fibres
- C fibers which transmits dull pain

11. - Nerve enter the pulp through apical
foramen, along the afferent blood vessels,
and together form the neurovascular
bundle.
- Each nerve fibre has been estimated to
provide at least 8 terminal branches.
- The nerve bundle from radicular pulp loose
their myelin sheath and branch into
smaller bundles, finally ramify into plexus
of single nerve axons-PLEXUS OF
RASCHKOW.

12. - The nerve further
extend for a short
distance into the
dentinal tubules,
hence called intra-
tubular nerves.

13. Features of A & C Fibres
- A- beta fibres innervate the dentin and
dentin-pulp border, most sensitive to
hydrodynamic stimulation of dentin.
- 25-50% are A-delta fibers.
They innervate dentin, predentin
concentrated in pulp horn.
- A paracrine signalling mechanism exists
between A-delta fibers and odontoblastic
processes

14. - C fibers are polymodal and respond to
inflammatory mediator like histamine,
bradykinin.

15. THEORIES OF DENTINAL
HYPERSENSITIVITY
• DIRECT INNERVATION THEORY
- Neural theory
- acccording to this theory, direct
mechanical stimulation of exposed
nerve endings at the DEJ is responsible
for dentin hypersensitivity
- There is a clear evidence that some nerve
fibres enter dentinal tubule but it is only
observed in a few dentinal tubules.

16. DIRECT INNERVATION THEORY
- the nerve fibres also travel to a short
distance into dentin ( 50 microns distance
from the pulp)
- Major shortcoming
• There is insufficient evidence to prove that
the outer dentin that is most prone to be
sensitive is well innervated.
• Extreme sensitivity which is not in
proportion to the nerve supply.

17. DIRECT INNERVATION THEORY
• Sensitivity in newly erupted teeth because
the intratubular nerves are often
established only sometimes after eruption.
• Application of LA or protein precipitate
such as AgNO3 does not eliminate
sensitivity indicating the nerve are not
directly involved in sensitivity.

18. DIRECT INNERVATION THEORY

19. ODONTOBLAST RECEPTOR THEORY
- Transduction theory
- It proposes that the odontoblast
themselves act as neural receptors and
relay the signals to the nerve terminal.
- Stimuli-->excites the odontoblast body or
process-->odontoblastic membrane comes
into close contact with nerve endings in
the pulp or in the dentinal tubules-->
odontoblast transmits the excitation of
these associated nerve endings.

20. ODONTOBLAST RECEPTOR THEORY
- Major shortcoming
• No evidence demonstrate synapses
between odontoblasts and nerve terminals
• Odontoblast processes do not extend
whole length of dentinal tubule
• Topical LA & protein pricipitants do not
abolish the sensitivity.

22. HYDRODYNAMIC THEORY
- proposed by Brannstorm
- most accepted theory
- it suggests that dentin hypersensitivity
is due to the hydrodynamic fluid
movements occuring across exposed
dentin with open tubules which in turn
activates the nerves present at the
inner ends of the dentin tubules or in
the outer layer of pulp.

23. HYDRODYNAMIC THEORY
• MECHANISM
Stimulus --> fluid flow in exposed open
dentinal tubules --> Stimulation of intra-
tubular baroreceptors -->PAIN

26. INCIDENCE AND PREVALENCE
• Age : 20 - 40 yrs
- reduced in older individuals as it reflects
age changes in dentin & the dental pulp.
• Sex : female predilection
• Site : Buccal cervical zones
• Dentition : Permanent
• Tooth affected : Frequently canine and
premolars

27. ETIOLOGY & PREDISPOSING FACTORS
• primary underlying cause
EXPOSED DENTINAL TUBULES
which occurs due to
• gingival recession/loss of covering
periodontal structure
• loss of enamel

29. 1. GINGIVAL RECESSION
CAUSES
 Inadequate attached
gingiva
 Prominent roots
 Toothbrush abrasion
 Excessive tooth cleaning
 Excessive flossing
 Crown preparation

30. Oral habits resulting in gingival laceration-
traumatic tooth picking,eating hard food
Gingival recession secondary to specific
diseases, i.e. NUG, periodontitis, herpetic
gingivostomatitis

31. Gingival recession
Removal of cemental layer
Exposure of dentin and thus dentinal tubules
Depolarization of nerve endings of odontoblast
PAIN

32. 2. LOSS OF ENAMEL
Attrition by
exaggerated occlusal
functions like bruxism
Abrasion from dietary
components or
improper brushing
technique
Erosion associated
with environmental or
dietary compnents
particularly acids

33. • Once the dentinal tubules are exposed
there are oral processes which keep them
exposed:
Poor plaque control, i.e. acidic bacterial
products
Excess oral acids, i.e. soda, fruit juice,
bulimia
Cervical decay
Toothbrush abrasion

34. CLINICAL FEATURES
• Pain is the most common c/f associated
with dentin hypersensitivity
Intensity : varies from mild discomfort to
severe sensitivity
Onset : rapid
Character : sharp
Duration : short
Difficult to localize

35. • External stimuli which can elicit the
expression of this condition include:
1. Themal stimuli
-hot/cold food and beverages
-cold blast of air
2. Osmotic stimuli
-sweet food
3.Acidic stimuli
-citrus fruits
-acidic beverages
-medicines
4.Mechanical stimuli-toothbrush
-dental instruments

36. DIAGNOSIS
• A thorough patient history and clicical
examination is mandatory.
• Diagnosis is confirmed by using a jet of air
or by using a diagnostic probe on dentin in
a mesiodistal direction in the area where
the patient complaints of pain.

37. DIFFERENTIAL DIAGNOSIS
• A number of dental conditions are associated with dentin
exposure and therefore, may produce the same
symptoms.
• Such conditions may include:
 chipped teeth
 fractured restorations
 restorative treatments
 dental caries
 cracked tooth syndrome
 other enamel invaginations

38. MANAGEMENT
• Removal of Etiological Factors
-Improper tooth brusing techniques
-Poor oral hygiene
-Premature contacts
-Gingival recession
-Endogenous and exogenous acids

39. • PATIENT
EDUCATION
- It is important to
counsel the patient in
order to modify their
dietary habits.
- Efforts should be
made to teach them a
proper tooth brushing
techniques and
achice plaque control.

40. TREATMENT MODALITIES FOR DH
• Various desensitizing agents have been used &
are currently being used to treat DH.
• IDEAL REQUIREMENT OF
DESENSITIZING AGENT
According to Grossman,
rapidly acting
long-term effects
non-irritant to pulp
painless
easy to apply
should not stain the tooth

41. • CLASSIFICATION OF DESENSITIZING
AGENTS
Mode Of Administration
a.At home desensitizing agent
b.In-office treatment
On the basis of mechanism of action
a.Nerve desensitization
-Potassium nitrate

42. b.Protein precipitation
-Gluteraldehyde
-Silver nitrate
-Zinc chloride
-Strontium chloride hexahydrate
c.Plugging dentinal tubules
-Sodium fluoride
-Stannous fluoride
-Strontium chloride
-Potassium oxalate
-Calcium phosphate
-Calcium carbonate

43. d.Dentine adhesive sealers
-Fluoride varnishers
-Oxalic acid and resin
-GIC
-Composites
-Dentin Bonding Agents
e.Homeopathic medication
-Propolis

44. f.Lasers
-Neodymium;yttrium aluminium garnet (Nd-
YAG) laser
-GaAlAS( galium-aluminium-arsenide laser)
-Erbium- YAG laser

45. • AT HOME DESENSITIZING AGENT
- This includes toothpastes,
mouthwashes,and chewing gums
TOOTHPASTES
- It contains potassium salts, sodium
fluoride, strontium chloride, dibasic sodium
citrate,formaldehyde,sodium
monofluorphosphate and stannous
fluoride.

46. 1. Potassium salts dentrifices
- potassium nitrate,potassium
chloride,potassiun citrate
- MOA - act by diffusion along the dentinal
tubules and by decreasing the excitability
of the intradental nerve fibers by blocking
the axonic action
- 5 % of potassium nitrate for 4 weeks is
commonly used to reduce DH

47. 2. Strontium Chloride
Dentrifices
- Commercial
name:Sensodyne
- 10% is effective in
relieving pain of tooth
hypersensitivity.

48. 3. Fluoride dentrifices
- MOA- mecanically block the tubule or that
labile fluoride in the organic matrix of
dentin could block the transmission of
stimuli
- sodium fluoride is superior to sodium
monoflurophosphates in fluoride
deposition on the teeth.

49. 4. OXALATES
- MOA - tubule
occlussion by oxalate
ions reacting with
calcium ions in the
dentinal fluid to form
insoluble calcium
oxalate crystals.
- However, they are
acid labile and can be
easily washed from
the surface of dentin.

50. 5. SILICA ABRASIVES
- Can also occlude dentinal tubules & can
reduce sensitivity.

51. INSTRUCTIONS
- Use the desensitizing toothpaste with the
help of a toothbrush with soft bristles.
- Minimal amount of water should be
advised as it dilutes the active agents
- Follow-up after 3-4 weeks to know the
results
- If there is no relief in DH , "in-office"
theraphy should be initiated.

52. • IN-OFFICE DESENSITIZING AGENTS
- Should provide an immediate relief from
symptoms of DH
- It includes-
1. Cavity varnishes
2. Corticosteroid
3. Procedures/Chemical agents that can
obturate dentinal tubules
4.Primers & bonding agents
5.Iontophoresis
6.Lasers
7.Restorative methods

53. • CAVITY VARNISHES
- Dentin often becomes
insensitive when open
tubules covered with
thin film of varnish.
- This provides a
temporary relief.
- For sustained relief : A
fluoride containing
varnish can be used
(Duraflor)

54. • CORTICOSTEROIDS
- Steroids cause complete obliteration of
tubules thus decreasing dentin
permeability.

55. • PROCEDURES/CHEMICAL AGENTS
THAT CAN OBTURATE DENTINAL
TUBULES
i. Burnishing of dentin
- This results in the formation a smear layer
that partially occlude the dt.
- Wooden stick are used.

56. ii. Silver Nitrate/Zinc Chloride
- Salt + tooth structure -> forms
crystal on surface of dentin
- Such crystallisation should
occur 1-2 mins & crystal
should be able to enter the dt.
- Silver nitrate precipitates
protein contituents of
odontoblast processes,
thereby partially blocking the
tubules
- ZnCl alone or ZnCl-potassium
ferrocyanide has also been
used.

57. iii. Fluorides
- it decreases the dentinal permeability by
percipitating calcium fluoride crystals
inside the dentinal tubules
- Fluoride is used in the form of 2% sodium
fluoride or 0.4% stannous fluoride.
- Sodium silicofluoride was more effective
than sodim fluoride.

58. • PRIMERS / BONDING AGENTS
- They are used to seal the dentinal tubules
- GIC luting cement has been used to
desensitize dentin because it is
hydrophilic, adheres well & it is esthetically
pleasing.

59. • LASER
- MOA - unclear
- Nd-YAG lasers - occludes the the dentinal
tubules
- GaAIA - affecting the neural transmission
in the dentinal tubules
- lasers coagulate the protein inside the
dentinal tubules and block the movement
of fluid.
ADVANTAGES :
i. analgesic
ii. bio-stimulant
iii. anti-inflammatory effects
iv. painless, safe, fast, conservative treatment,
and it is well accepted by the patients
DIS: Expensive
Not available for routine use

60. • RESTORATIVE
METHODS
- Exposed dentin is
restored with GIC/
Composite resins,
especially in case of
recession.
- A routine conservative
cavity is prepared and
restored with any of
these cements.

61. PREVENTION
• SUGGESTION FOR PATIENTS
- Avoid gingival recession by practicing good
oral hygiene measures.
- Avoid using large amount of dentrifices.
- Avoid toothbrushes with hard bristles.
- Avoid brushing teeth immediately following
ingestion of acidic food or beverages
- Avoid over brushing with excessive pressure
for prolonged periods of time.
- Avoid excessive flossing or incorrect use of
other interproximal cleaning devices
- Avoid frequent use of toothpicks

62. • SUGGESTION FOR PROFESSIONALS
- Avoid over instrumenting the root surfaces
during calculus removal & scaling & root
planning.
- Avoid over polishing the exposed roots
during stain removal.
- Avoid violating the biologic width when
placing crown margins causing
subsequent recession.
- Avoid 'burning' the gingival tissue during
in-office tooth whitening or bleaching
procedures.

63. NEWER TECHNIQUES
• Pro - Argin Technology
- It is estalished that saliva transports
calcium & phosphate into dt
inducing tubule plugging.
- A new "saliva-based composition"
containing arginine, bicarbonate &
calcium carbonate is developed to
massage sensitivity.
- Trade name:ProCLude
- Colgate further improve this
technology by combining arginine &
calcium carbonate with fluoride to
provide a significant advance in
treatment of DH.

64. • n

65. • NovaMin
- It is a bioactive glass
ceramic material that
provides calcium &
phosphate
- The active ingredient is
calcium sodium
phosphosilicate that
reacts when exposed to
aq medium & provide
calcium & phosphate ions
that form hydroxy-
carbonate with time .

66. • CASEIN DERIVATIVES
- is a milk protein
- used to develop casein phosphopeptide
(CPP) that gets attached to amorphous
calcium phosphate(ACP).
CPP-ACP Complex
- it enables early enamel remineralization in
white spot lesions
- also have potential to treat & prevent
dentin hypersensitivity.

67. SUMMARY
• Effective management of DH should
incorporate a detailed clinical history along
with identification of etiological factors.
• Clinicians have used many materials and
techniques to treat DH, including specific
dentrifices, laser irradiation, dentin
adhesives,antibacterial agents,
aldehydes, fluoride varnishes, calcium
phosphate, potassium nitrate, & oxalates
among others.

68. • A combination of patient education &
effective treatment strategy is effective in
alleviating the pain and discomfort
associated with DH.

69. REFERENCES
• The Art & Science of Operative Dentistry,
Sturdevant , a South Asian Edition
• Textbook of Endodontics,Dr. Mithra n.
Hegde
• Textbook of Endodontics, 2nd Edition,
Nisha Garg, Amit Garg
• Essentials of Oral Biology, Maji Jose
• Journal of Conservative Dentistry-Dentin
Hypersensitivity : Recent Trends in
Management, Sanjay Miglani, Vivek
Aggarval,Bhoomika Ahuja (2010)