Dentinal hypersensitivity. Includes definition, synonyms, etiology, mechanism of dentin sensitivity, theories associated, predisposing factors, Clinical features, diagnosis, management, and recent advances.

1. DENTINAL
HYPERSENSITIVITY
PRESENTER:
DR. MRINALINI

2. CONTENT
INTRODUCTION
DEFINITION
ETIOLOGY
MECHANISM OF DENTIN
SENSITIVITY
THEORIES ASSOCIATED WITH
HYPERSENSITIVITY
PREDISPOSING FACTORS
METHODS OF MEASURING
HYPERSENSITIVITY
(DIAGNOSIS)
MANAGEMENT OF
HYPERSENSITIVITY
CONCLUSION
REFERENCES

3. INTRODUCTION
1987, Johnson and Coworkers: Dentine Hypersensitivity is an
enigma being frequently encountered yet ill understood
Generally used to describe a common painful condition of teeth
Dowell and Addy,1981: Short sharp pain arising from exposed dentine in response to stimuli,
typically thermal, evaporative, tactile, osmotic, chemical and which cannot be ascribed to any
other dental defect or pathology

4. DENTINAL
HYPERSENSITIVITY
Sharp
transient
pain
Stimulated
pain
Dentin
exposure
Exclusion
of other
dental
defects

5. Prevalance: 15-80%
in general population
72-98% in
periodontal patients
Age incidence: 20-50
yrs( because of
appearance and
progression of
gingival recession)
Gender: Female
Distribution: Buccal
and cervical(Enamel
is thinnest and site of
gingival recession
Teeth: Canine and 1st
Premolar followed by
Incisor and 2nd
Premolar, least often
molars

6. ETIOLOGY
Lesion localisation:
Dentine has to
become exposed
Causes: Enamel
loss
Gingival recession
Lesion initiation
Attrition, Abrasion, Erosion,
Abfraction
Others: Improper
instrumentation, Enamel and
Cementum do not meet at CEJ
Requires opening of dentinal tubules
Tooth paste with abrasives, erosive
agents etc causes removal of dentin
smear layer after few minutes of
exposure and cause bulk loss of
dentin

7. PLUG/ SMEAR LAYER:
Elements of protein and
sediments derived from
salivary calcium
phosphate and seals the
tubule inconsistently and
transiently
Mechanical + Chemical
factor: remove smear layer

8. Sensitive dentin: 8 times more
dentinal tubules, also tubules
are thicker than non sensitive
ones (Orchardson(2006),
Cummins D (2010),
Miglani(2010)
DEJ: Profuse branching of
tubules at DEJ, thus most
sensitive
Rate of fluid flow is directly
proportional to tubule radius to
the power 4
Rate of fluid flow is directly
proportional to tubule radius to
the power 4
Mainly A delta fibers (present
at periphery)
Stimuli that move fluid away
from pulp dentin complex
produce more pain(cold, drying,
evaporation, hypertonic solution)

9. SENSITIVE TO HYPERSENSITIVE
•Dentinal tubules first exposed , become more sensitive to tactile, evaporative and osmotic
stimuli.
•Over time, because of poor plaque control becomes hypersensitive.
•Mechanism: Localised pulpal inflammation, Sprouting of pulpal nerves, Expression of
inflammatory sodium channels.
•Often such hypersensitivity disappears due to protective mechanism.
•Problem: when endogenous protective mechanism fail to correct hypersensitivity.

10. •Normal: outward movement of fluid because of pulpal pressure, prevents ingress of endotoxins
Pulpal inflammation
Release of chemical mediators( Histamine, Bradykinin)
Make pulpal nerves more sensitive than normal and cause surrounding fibroblast to divide more
rapidly
Fibroblasts release more nerve growth factor
Nerve terminals sprout
Increase in nerve density will cause hypersensitivity
•Inflammatory mediators: Upregulate new sodium channels that are easily activated

11. • Neural theory or
Direct nerve
innervation
theory
Theories
• Odontoblastic
transduction
theory
Associated
• Fluid
Hydrodynamic
theory
Dentin
Sensitivity

12. THEORIES

13. OBJECTIVE
ASSESSMENT
Mechanical or Tactile
stimuli: Dental
explorer(No.23): 5-
10gm force
SUBJECTIVE
EVALUATION
VERBAL RATING
SCALE: 0-4(No, mild,
moderate and marked
discomfort)
Visual Analogue Scale
Questionnaire
Hand held scratch
device: Dr. Kleinberg
CLINICAL ASSESSMENT

14. Torsion gauge
Sharp explorer like
probe
Indicator: Records the
force of displacement in
centinewtons
Probed at CEJ
A tooth that fails to
respond at 80 centi
newtons is non sensitive

15. THERMAL
SENSITIVITY
EPT
Dental Pulp Stethoscope: Stark
Osmotic stimulation( least
preffered): NaCl, glucose,
sucrose, CaCl2
Cold water test: Varies temp
of 15ml water
Thermoelectric device:
Provides a continuous
application of heat/ cold
Directing a burst of cold air
from a dental syringe onto the
test tooth( 1sec, 65-70F, 45psi,
1cm distance & perpendicular)
Air thermal device: Dr. K. C.
Yeh: Air was heated to
100F(close to mouth temp.)
,temperature was reduced until
subject felt pain or discmfort

16. DIFFERENTIAL
DIAGNOSIS
Cracked tooth
syndrome
Dental caries
Teeth in acute
hyperfunction
Chipped teeth
Fractured
restoration
Post restorative
sensitivity

17. Overenthusiastic brushers
Chewing smokeless tobacco
or snuff tobacco
Periodontally treated patients
Gingival recession
Bulimics
High acid food intake
Xerostomia
Poor oral hygiene practices
RISK OF
SENSITIVITY

18. Brushing: Avoid
abrasive paste, soft
bristle brush, no
brush after 1 hr of
acid food or drink
Premature occlusal
contact: Splint,
occlusal
adjustment
Gingival
recession:
Periodontist for
graft or flap
surgery
Exogenous acid :
Carbonated drinks,
citrus fruits,
Alcohol, Yoghurt -
Diet counselling
Endogenous acid:
GERD- Doctor
consultation
Poor oral hygiene:
Oral hygiene
practices
PREVENTION OF DENTINAL
HYPERSENSITIVITY

19. MANAGEMENT
Classification(Scherman and Jacobeen,1992)
CHEMICALAGENTS
Corticosteroids
Silver nitrate
Strontium chloride
Formaldehyde
Potassium nitrate or oxalate
Fluorides
Sodium citrate
Iontophoresis with 2% NaF
PHYSICALAGENTS
Composites
Resins
Varnishes
Sealants
Soft tissue grafts
GIC
Lasers

20. At home: Paste,
Mouthwash (F
& K nitrate)
Chewing gums
(KCl)
In office
Mode of
administr
ation Disturb neural
response to
pain stimulus
Block the fluid
flow and
occlude tubule
Mechanis
m of
action

21. “MECHANISM,
•Most likely: Reduction in the diameter of dentinal tubules so as to limit the displacement
of fluid in them.
•Can be attained by:
•Formation of smear layer produced by burnishing the exposed surface.
•Topical application of agents that forms insoluble ppt within tubules.
•Impregnation of tubules with plastic resins.
•Sealing of tubules with plastic resins.
•Act via ppt of crystalline salts on the dentine surface, which blocks tubules.
•Desensitizing agents for a continuous period of atleast 2 weeks.

22. STRONTIUM CHLORIDE
(10%)
•In-vitro studies: Slightly reduces dentinal
fluid flow, the occurrence thought to be
produced by abrasive filler occluding the
tubule orifice
•Skurnick: Decreased sensitivity in 93% cases
•Anderson and Matthews: ineffective
POTASSIUM NITRATE
• Greenhill and Pashley: ineffective in in-vitro
study even at 30% conc.
•Others: 5% effective
•Hodash,1974: effective at 1-15%
concentration
•Tarber: 5% for 1 week was effective in 92%,
histologic examination: did not induce any
pulpal damage
SODIUM MONOFLUOROPHOSPHATE
Arowojolu(2001): Better than strontium
chloride
Effective results after 6 weeks

23. VARNISH: 5% NaF by Clark et al(1985)
HEMA containing primers like GLUMA(5% Gluteraldehyde and 35% HEMA)
CORTICOSTEROID: Antiinflammatory effect decreases sensitivity, causes complete
obliteration of dentin, eg. Prednisolone+ Parachlorophenol+ m-cresyl acetate+ gum camphor
BURNISHING OF DENTIN
Tooth pick or orange wood stick creates partial smear layer
Reduces fluid movement by 50-80%
Pashley: Compared Burnishing NaF, Kaolin, Glycerin, alone and in various combination,
Results indicated that important variable was not any constituents of the paste rather
burnishing process itself

24. SILVER NITRATE
•Powerful protein precipitate
•Greenhill and Pashley: Silver nitrate either
alone or in combination with formalin ppt
silver chloride and elemental silver
•May cause pulpal inflammation
•Most studies: Ineffective and deleterious
CALCIUM HYDROXIDE
Block dentinal tubules, promotes peritubular
dentin formation
Mjor(1967); Increased radiodensity
Grene: Better than potassium nitrate at all time
intervals throughout cold stimulation
HYDROXYAPATITE:
Shetty et al: HPT as in-office agent showed
potential as an effective desensitizing agent
providing quick relief
FLUORIDE:
MOA- Reparative dentin formation and CaF
ppt(insoluble)
Clement and Hoyt and Bibby (33.3% NaF):
Very effective but may produce pulpal
inflammation when applied to dentin

25. FLUORIDE IONTOPHORESIS
A low voltage electric current is used to impregnate the tooth with fluoride ions
2-6 times more fluoride can be impregnated
Carlo (non-controlled study): significant relief from sensitivity in 90% cases

26. OXALATES
Inexpensive, easy to apply, well tolerated
Potassium oxalate and Ferric oxalate solutions:
Calcium ion in dentinal fluid form calcium
oxalate
Short effect, long term use can lead to
digestive problem
LASERS
Example: Nd:YAG, Er:YAG
Expensive and complex technique
Kumar et al: Nd:YAG with 5% NaF better than
when used alone
Yilmaz(2011):Er:Cr:YSGG immediate result
and was effective even after 3 months
Occlude by coagulating protein of fluid inside
tubule
VARNISH
Short duration result
DENTIN BONDING AGENT
Easy, Aesthetic
Brannstorm: Immediate and lasting blocakde
in 20 patients studied for a period of 2-20
months.
Narhi et al( Animal study) : No neural activity
after resin impregnation
COMPOSITE AND GIC
Long lasting, Indicated only if loss of tooth
structure is present

27. GC TOOTH MOUSSE:
Minimum 6 weeks of topical application
NANO STRUCTURE BIOACTIVE GLASS:
Mitchell et al(2011)- Produced an immediate reduction in fluid conductance
maintaining it for a minimum of 7 days
Main constituent is silicate that ppt Ca and PO4, SEM: tubule occlusion
ARGININE:
Cummins D(2009), 8% arginine+ CaCO3+ 1450ppm F: Established alkaline
environment leading to precipitation of salivary calcium and phosphate on the
surface as well as in the tubule
PORTLAND CEMENT:
Porto IC(2009)- Occlusion of tubule through remineralisation

30. Clinical and Dietary
history+ Examination:
Diagnosis
At home
products(3-4
weeks):
CaPO4, F,
Oral hygiene
practice
In office:
APF gel,
Laser,
Varnish etc
LAST RESORT: CONSIDER RCT

31. REFERENCES:
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2006;137:990–998.
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Yardic RL, Madden TE, Reyes SC, Gilbert GH, National Dental PBRN Collaborative Group.

32. 8. Management of Dentin Hypersensitivity by National Dental Practice-Based Research
Network practitioners: results from a questionnaire administered prior to initiation of a
clinical study on this topic. BMC oral health. 2017 Dec 1;17(1):41.
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instant and lasting sensitivity relief. Am J Dent. 2010;23 Spec No A:3A–13A
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dentine hypersensitivity. Cochrane Database Syst Rev. 2006
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