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Dentin hyper sensitivity 1 /certified fixed orthodontic courses by Indian dental academy


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Dentin hyper sensitivity 1 /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMYLeader in Continuing Dental Education
  2. 2. ContentsIntroductionDefinitionsHistorical perspectiveEtiologyNerve FibersTheories of dentin sensitivityClinical considerationsMethods of measuring HypersensitivityManagement of HypersensitivitySummary & conclusion
  3. 3. Dentin
  4. 4. Introduction
  5. 5. Tooth Hypersensitivity in the Spectrum of Pain
  6. 6. Few Terms…….Definition: “Exaggerated response to a non noxious sensory stimuli”Addy & Urquart (1992) define….Are pain and sensitivity related?? Chronic condition with acute exacerbations. An enigma
  7. 7. Flashback 2000 years or more - Chinese… by the application of ‘Xiao-Shi’ 3 rd century B.C-The Egyptian Medical Papyrus …red and yellow vitriol and alum for “teeth that suffer” 875 A.D - Rhages ….treatment with astringent agents. 1678 Leeuwenhoek … “tooth canals in dentin”
  8. 8. Early years from B.C. toA.D.
  9. 9.  1855 - J.D.White …. movement of fluid in dentinal tubules 1857 - Cartwright …. dentine sensitivity was observed……… that some areas of the tooth were "exquisitely sensitive" and a source of great discomfort.
  10. 10.  1898 - Henry H. Buchard- agents to lower the pain perceptive centers of the brain. destroy or coagulate the dentinal protoplasm local analgesic agents on the dentin. 1899 – George.F.Eames.. caused by erosion 1900 - Alfred Gysi - first to suggest relieving hypersensitivity
  11. 11.  1941-Lukomsky-NaF..desensitizing obtundant. 1962- Brannstorm- Hydrodynamic Theory 1966….. Therapies deposit an insoluble substance on the ends of the fibers or nerves to act as a barrier To stimulate secondary dentin formation. In 1974… Hodosh…superior desensitizer….. Potassium nitrate.
  12. 12. Etiology & Predisposing factors 1. Loss of enamel AbrasionErosion Attrition  Abfraction 2.Gingival Recession
  13. 13.  Scaling, Root planing, Periodontal Surgery…… Question arises whether tooth brushing with or without a dentrifice will expose dentinal tubules Role of plaque – important factor Role of saliva and bacterial contamination.. Loyn et al(1991)..effect of some proprietary mouth rinses on dentin smear layer.
  14. 14. Nerve fibers The dental pulp is richly innervated ….  Myelinated … Non myelinated  A fibers … C fibers  B fibers… A-ά… proprioception, A-β…touch & pressure, A-γ…motor function to spinal nerves and A-δ fibers…pain, temp & touch.
  15. 15.  A-delta and C-fibers sub odontoblastic plexus….. A-δ…. Brief, sharp, well localized pain …. Dentinal hypersensitivity. C fibers… poorly localized pulpal pain.
  16. 16. Theorie s Direct stimulation Odontoblastic transducer mechanism Gate-control theory and vibration Hydrodynamic mechanism
  17. 17. Direct Stimulation theory
  18. 18. Anderson’s explanation No nerve elements…. Receptor mechanisms in dentin that could be stimulated indirectly…no direct stimulation… barrier. This theory is deficient because neural elements have not been shown to extend into the peripheral half of-the dentin. (Forrest et al 1988)
  19. 19. Odontoblastic Transduction theory
  20. 20.  Synaptic like relation b/n the terminal sensory nerve endings & odontoblastic processes. No evidence of acetylcholine Proponents of dentinal receptor mechanism…. Odontoblasts has special sensory function and that a functional complex with the terminal sensory nerve endings … excitatory synapse…neuro sensitive complex
  21. 21. Drawbacks Why dentin continues to be sensitive, despite destruction of odontoblast layer? Also does not explain why protein precipitation does not decrease sensitivity of dentin to osmotic stimuli. Abandoned…. Failure to establish a synaptic relation between the odontoblasts and the pulpal nerves.
  22. 22. Gate control theory and vibration When the dentin is irritated, all of the pulpal nerves become activated from the vibrations. As the low-intensity "pain gates" from the larger fibers are closed, the high-intensity "pain gates" from the smaller fibers are enhanced.
  23. 23. Drawbacks : Little to explain how pain responses from the dentin are transmitted and perceived by the nerve endings of the pulp- only how they may be centrally interpreted.
  24. 24. Hydrodynamic Theory (Brannstrom)This idea of fluid movement within the dentinal tubules is thebasis for the transmission of sensations according to thehydrodynamic theory.
  25. 25. Two mechanismsDiffusion ……Convection, transport or filtration
  26. 26. Hydraulic conductance of dentin………
  27. 27. Alternative mechanism (Modified Hydrodynamic theory)Application of various chemical solutions Raising the intratubular potassium content,Interdental nerves less excitable to further stimuli by depolarizing the nerve fiber membrane.
  28. 28. To summarize….
  29. 29. Clinical considerations
  30. 30. Physiologic & Pathologic pulpal defense mechanisms Formation of secondary dentin Peritubular dentin calcification… Natural occlusion of the dentinal tubules Plaque adhesion and salivary occlusion of the surface of the dentin
  31. 31. Methods of measuring Dental HypersensitivityTactile sensitivityThermal SensitivityElectrical SensitivityOsmotic SensitivityChemical Sensitivity
  32. 32. Subject Assessment
  33. 33. Questions
  34. 34. Tactile Method Tactile-sharp explorer over sensitive area. CEJ Smith & Ash…(1964)
  35. 35. Tactile Method Using a Yeaple probe…. Compact handpiece that contains an explorer tine …electromagnetic field. Scratchometer Courtesy : Kleinberg{1988}
  36. 36. Thermal Sensitivity
  37. 37. Thermal Sensitivity An air thermal device devised by Dr. K.C. Yeh used a temperature controlled stream of air as the stimulus. Air was heated to 1000F close to temperature of the mouth. Its temp was then reduced until the subject felt pain or discomfort.Drawbacks : Moisture content
  38. 38. Thermoelectric deviceDevices…. Electrical cooling or heating of direct contactmetal probes.
  39. 39. Electrical Sensitivity Pain response from both non sensitive and sensitive teeth. Lower organic resistance material to enamel, cementum and dentine. Access of electrical stimulus via open tubules
  40. 40. Stark instrument for electrical stimulationIntensity:0-25 RMS
  41. 41. Osmotic MethodAn osmotic method….. McFall and Hamrick(1987)Fresh saturated solution of sucrose and allowing it toreach room temperatureSolution is then applied to the root surface of the tooth… place for 10 sec
  42. 42.  Popularized by Anderson and his colleagues Effective because the chemical activity of water in these solutions is less than the chemical activity of water in dentinal fluid Calcium chloride excites intra dental nerves owing to osmotic movement of fluid Sodium chloride excite nerves owing to indirect osmotic effects on superficial dentin & direct effects on intra dental nerves in deep dentin.
  43. 43. Chemical sensitivity
  44. 44. Differential Diagnosis Chipped teeth.. Fractured restorations. Cracked tooth syndrome Dental caries. Post-restorative sensitivity. Teeth in acute hyper function Galvanism, marginal leakage, Palatogingival groove
  45. 45. TreatmentModalities
  46. 46. Current approaches to the Management1.Fluid formation of smear layer2.Topical application3.Impregnation of tubules4.Dentin bonding agents
  47. 47.  Most agents that are effective in reducing dentinal hypersensitivity are also effective in partially occluding the dentinal tubules Greenhill and Pashley found potassium nitrate to be ineffective, but it is effective as a desensitizing agent. Most in-office procedures are aimed at obturating the tubules
  48. 48. Mechanism of actions of desensitizing agentsThe methods of tubule occlusion are,1. Formation of calcium over sensitive tubules2. Formation of intra tubular crystals from salivary mineral3. Formation of intra tubular crystals from dentinal fluid.4. Progressive formation of peritubular dentin5. Invasion of tubules by bacteria6. Formation of intratubular collagen plugs
  49. 49. 7. Formation of irritation dentin8. Leakage of large plasma proteins into tubules.9. Formation of smear layer by brushing, use of tooth picks etc10. Resin impregnation or covering11. Topical application of Calcium hydroxide, sodium fluoride and oxalate12. Restorations
  50. 50. Criteria Selecting desensitizing procedures Desensitizing agents Instructions to the patients
  51. 51. Office treatments for dentinal hypersensitivity1. Cavity varnishes2. Anti inflammatory agents3. Treatment that partially obturate dentinal tubules o Burnishing of dentin o Silver nitrate o Zinc chloride - potassium ferro cyanide o Formalin o Calcium compounds  Calcium hydroxide  Dibasic calcium phosphate
  52. 52. Office treatments for dentinal hypersensitivity – Fluoride compounds • Sodium fluoride • Sodium silico fluoride • Stannous fluoride – Iontophoresis – Strontium chloride – Potassium oxalate4. Restorative resins5. Dentin bonding agents
  53. 53. Cavity varnishes Wycoff(1982) advocated the use of a cavity varnish such as Copalite
  54. 54. Corticosteroids Anti-inflammatory effect of glucocorticoids …. decrease dentinal sensitivity Mjor and Furseth ….. Use is based on the assumption that hypersensitivity is linked to pulpal inflammation
  55. 55. Burnishing of dentin Tooth pick or "orange wood stick … Pashley et al(1987)….Reduced fluid movement by 50% to 80%
  56. 56. Formation of insoluble precipitates Calcium oxalate dihydrate Calcium fluoride Silver nitrate. Zinc chloride potassium Ferro cyanide impregnation Formalin
  57. 57. Silver nitrate Powerful protein precipitant Precipitated in solution with formalin or eugenol It may cause pulpal inflammation in shallow cavities.
  58. 58. Calcium hydroxide Block dentinal tubules or promote peritubular dentin formation Brannstrom (1976) … constriction of the dentinal tubules… depth of 0.1mm Following periodontal surgery, Jorkjend and Tronstad(1972)……
  59. 59. Fluoride First proposed …. Lukomsky (1941) Bolden and Hezen et al have indicated that sodium monofluorophosphate dentifrice…. Effective Ranouse and Ash….. 0.76% of sodium monofluorophosphate
  60. 60.  Mechanism of action…. Clement and Hoyt and Bibby found sodium fluoride very effective in reducing dentinal hypersensitivity It may produce severe pulpal inflammation when applied to dentin.
  61. 61. Acidulated sodium fluoride Laufer et al(1981) ……Concentration of fluoride in dentin … greater No difference after samples were washed with synthetic saliva A small fraction of the fluoride initially deposited on the root surfaces was retained in the insoluble apatite form.
  62. 62. Sodium silico fluoride Bhatia …. saturated solution of sodium silico fluoride for 5 min …..potent than 2% solution of NaF in desensitizing painful cervical areas of teeth. Everett et al…. that silicic acid forms a gel with the calcium of the tooth, thus producing an insulating barrier
  63. 63. Stannous fluoride Blank and Charbeneau(1986) advocated burnishing a 10% solution of stannous fluoride Ellingsen and Rolla(1987) examined SnF2 treated dentin surface using S.E.M. and observed a dense layer of tin and fluoride containing globular particles blocking the dentinal tubules. Blong and associates(1985)…0.4% SnF2 gel effective
  64. 64. Fluoride Iontophoresis Iontophoresis … Iontophoresis of fluoride … controversial Induction of Secondary dentin formation by Iontophoresis …. Murthy et al Lefkowitz et al reported on the pulpal response to 1% sodium fluoride Iontophoresis
  65. 65.  Gangarosa recommends that teeth be isolated with plastic strips and cotton rolls rather than a rubber dam Induction of parasthesia on odontoblast process by Iontophoresis …Gangarosa and Park (1978) produce parasthesia by a direct effect on the odontoblastic process or by alteration of the sensory mechanism of pain conduction Singhal(2005)……
  66. 66. Nd-YAG Laser treatment Effective in reducing dentine hypersensitivity to cold stimuli. The mechanism of action has yet to be confirmed Lier et al (2002)…Nd:YAG laser…not significant Shwartz et al (2002)… Er:YAG laser…. Dentin Protector
  67. 67. Kimura et al (2000)…..
  68. 68. Oxalates Calcium ions in the dentinal fluid to form insoluble calcium oxalate crystals Formaldehyde Formalin is an agent … control of dentin hypersensitivity During late 1940s, Emoform tooth paste was introduced.
  69. 69. Resins and Adhesives Brannstrom and Nordenvall ….. impregnating it with resin (the unfilled dentin bonding agent) Bowen & Cobb … composite resin bonded to dentin decreased dentin permeability. Objective-
  70. 70.  Javid & co workers… 6 week study …. Isobutyl cyanoacrylate with 33% of NaF paste…. Immediate desensitization.. Sensitivity slowly returned Glass ionomer cement…. Hydrophilic GLUMA…dentin bonding system …includes 5% glutaraldehyde primer & 35 % HEMA
  71. 71. Strontium chloride
  72. 72. Potassium NitrateWara-swapati(2005)…
  73. 73. To summarize….
  74. 74. References DCNA on Tooth hypersensitivity 1990, 34:3 Text book of Clinical Periodontology –Carranza Clincal Periodontology & Oral Implantology – Jan Lindhe Text book of conservative dentistry – Sturdevent Dentinal Sensation and Hypersensitivity A Review of Mechanisms and Treatment Alternatives (Louis H. Berman) Journal of Periodontology 1985 Apr (216 - 222): Role of dentin bonding agent in reducing cervical dentin hypersensitivity – JCP 1998
  75. 75.  JCP 2002 “desensitizing effects of an Er:YAG laser on hypersensitive dentin” JISP 1997… Comparative evaluation of Gluma primer & 10% pot nitrate in treating cervical dentin hypersensitivity. JCP 2002.. Treatment of dentin hypersensitivity by Nd:YAG laser JP 2001…. Efficacy of 3% pot nitrate desensitizing mouthwash in the treatment of dentin hypersensitivity. Dentine Hypersensitivity: new perspectives on an old problem. International Dental Journal (2002) 52, 367–375