Dentinal Hypersensitivity

Textbook-of-Endodontics-
2nd-Edition

Chapter 32

Ziyad kamal
Spring Semester 2020/21
AAUJ/Faculty of Dentistry
 Definition :
Pain is an unpleasant sensation, which mostly warns
that there is a degree of tissue damage.
Pain is felt whenever a noxious stimulus just exceeds
the pain perception threshold. (C fibers)

Hypersensitivity is an exaggerated sharp transient

or temporary sensation of discomfort due to non ‐
noxious low intensity stimuli. (A delta fibers)
 Sensory fibers in the pulp
C ‐ fibers

Non-Myelinated Deep Throbbing, High, stimulated

aching, with intense
lingering, tissue damage
less bearable

Myelination Location of Pain character Stimulation

terminals threshold
 Sensory fibers in the pulp
A ‐ delta fibers

Myelinated Superficial Sharp, fast, Low, stimulated

momentary, without tissue
bearable damage

Myelination Location of Pain character Stimulation

terminals threshold
Adverse Effects of Hypersensitivity & Post‐Operative Pain

Restoration of health and function is the major goal of

restorative dentistry, dentin hypersensitivity may interfere
with this goal as follows:

1. The patient may become unable to eat, drink and even

sometimes to breath.
2. The patient may avoid using the involved side.

3. The patient may acquire para‐functional adaptive biting

habits which may result in unfavorable TMJ, and periodontal
reactions
 Adverse Effects of Post‐Operative Pain &
Hypersensitivity

4. If left un‐treated it may cause pathological pulp reactions.

5. If miss‐diagnosed as pain may lead to

wrong and complicated treatment.
 Mechanism of Dentin Sensation

(Nerve Endings Theory)

(Odontoblasts
Receptor Theory)

A‐delta nerve endings ,interweave with the Odontoblasts along a distance of

100 micrometer from the pulp surface
Factors Affecting Dentin Sensitivity

1 The rate of tubular fluid flow

2 The nature and rate of change of the stimulus

3 The dentinal permeability or conductance

 The rate of tubular fluid flow

❖ The rate and not the amount of tubular fluid‐

flow is the principle factor in hypersensitivity
response because activation of mechano‐
receptors is affected most by the rate of change
of the stimulus rather than its absolute value

❖The true physiologic

stimulus is the inward or
outward fluid shifts, not the
actual trigger.
 The nature and rate of change of the stimulus

❖ Stimuli that cause outward fluid‐flow cause more

intense response than those producing inward
fluid‐flow.

❖ Suddenly applied or released pressure activates the A‐delta

fibers causing perception of dentinal hypersensitivity while
steadily applied pressure does not cause such characteristic
response..

❖ When a steadily applied stimulus reaches noxious

values, it causes tissue damage and evokes the
C‐fibers with perception of dull pain.
The dentinal permeability or conductance

❖ The greater the dentin conductance, the more intense the

perception of hypersensitivity in response to stimulation by
environmental factors..
 Hydrodynamic Theory

These are sensory receptors that have relatively low stimulation

threshold and are described as mechano‐receptors that
can respond to sudden changes in environmental conditions
whether thermal, tactile, osmotic or evaporative pressure.

Therefore any low intensity non‐noxious stimuli reaching an

exposed virgin dentin surface that can cause sudden inward/
outward movement of tubular fluid will stimulate these receptors
with the perception of dentinal sensitivity.
Factors contribute to the clinical problem of hypersensitivity

1 Presence of Exposed Conducting Dentin

2 Tactile Pressure

3 Osmotic Pressure

4 Thermal Stresses

Evaporative Stimuli
5
Galvanic Stimuli
6
Presence of Exposed Conducting Dentin

❖ Dentin is permeable, and its permeability

increases from the DEJ to the pulp, i.e., with the
increase of cavity depth, as a result of the
increase in diameter and number of dentinal
tubules per surface area and decrease in length
o f t h e t u b u l e s .
 Rapidly progressing caries, fresh cracks or fractures
of teeth or restorations, cavity preparation, and recession
usually exposes virgin, permeable, and conducting dentin.

The deeper the preparation the less the remaining dentin

Thickness(RDT) and the wider and more permeable
is the dentin.

Occlusal forces ??
Food and drinks ??
 acid conditioners

Removal of smear plugs & smear layer from dentinal

tubules eliminates efficient natural protective barriers.
 Tactile Pressure

Deflection of dentin by tactile pressure threshold

of 2‐Kg/cm2 , e.g., as a result of probing, premature
contacts, or by polymerization shrinkage stresses of
resin‐based restorations, causes sudden inward
movement of dentinal fluids and perception of
hypersensitivity
 Osmotic Pressure

- Leakage, and cracked teeth or restorations causes

penetration of osmotic fluids have osmotic pressure
different from that of dentinal fluids.

- The difference in osmotic pressure creates an osmotic

pressure gradient.

- When this gradient reaches the minimum osmotic threshold

of 25 atmospheres, it causes sudden inward or outward
movement of dentinal fluids with hypersensitivity response
 Thermal Stresses

The thermal stresses are conducted to underlying exposed

dentin surfaces through metallic restorations or by leakage
around non‐metallic restorations.

A thermal threshold of 47 C° (heating) or 26C° (cooling) at

the DEJ will evoke hypersensitivity by causing expansion/
contraction of dentinal fluid with respective sudden inward/
outward movement.
 Evaporative Stimuli

Produced by air blasts and cause rapid

outward fluid shift resulting from loss of
dentinal fluids by evaporation.

Evaporative stimuli are usually employed

to identify the tooth involved in
hypersensitivity by blasting air at the
various teeth
 Galvanic Stimuli

Dissimilar metallic restorations, e.g., gold

and amalgam have different electric
potential so that if they are connected in
presence of an electrolyte (saliva), a
galvanic current passes from one
restoration to the other causing a galvanic
shock of hypersensitivity
Expressions in frequent usage for DH
 Dentin Hypersensitivity: Epidemiology

Global Prevalence
❖ Incidence: 15% (4% to 57%)
❖ Age range: 15 – 70+ years
❖ Peak incidence: 20 – 40 years
???
❖ Gender: Female > Males
❖ Cold is the most common
stimulus (74%)
 Dentin Hypersensitivity: Epidemiology

Most Commonly Found

❖ Teeth:
Canines (cuspids) and premolars (bicuspids)

canines > premolars > incisors > molars

❖ Sites:
Buccal cervical regions the most common site

In: Pashley DH, Tay FR, Haywood VB, et al. Dentin

Hypersensitivity: Consensus-Based Recommendations
for the Diagnosis and Management of Dentin
Hypersensitivity.
Generally, sensitive incisors are the most painful, followed by premolars, and then
molars.
Older teeth are generally less sensitive than younger teeth.
 Dentin Hypersensitivity: Diagnosis

Dentin Hypersensitivity is a diagnosis of exclusion

Complete History Clinical Examination Radiographic examination

❖ Sign and symptoms ❖ Visual assessment ❖ Rule out periapical lesions
❖ Intensity ❖ Physical assessment
❖ Frequency and – Dental explorer
duration (probe): tactile stimulus
❖ Dietary changes ❖ Periodontal probe
❖ Other related events ▪ Depth of periodontal
pocket
❖ Percussion testing
❖ Response to cold air

Cervical hypersensitivity may be caused not only by

chemical erosion, but also by mechanical abrasion or even
occlusal stresses.
Treatment & Prevention of
Hyper‐sensitivity
 Dentin Hypersensitivity:
Management/Etiological Factors
Management of Pre-disposing Factors

Tooth Wear/Erosion:
• Application of topical fluoride
• Use fluoride-rich dentifrice
• Decrease abrasive forces
• Behavior modification
• Enhance the defense mechanisms of the body
increase salivary flow
• Provide nutritional counseling
 Dentin Hypersensitivity:
Management/Etiological Factors
Management of Pre-disposing Factors

Gingival Recession:
• Correct tooth brushing technique
• Plaque control
• Replacement of restorations with defective
margins
• Avoidance of harmful habits
• Periodontal disease management
Dentin Hypersensitivity:
Management of Dentin Hypersensitivity
Treatment
Treatment

KNO3
❖ Obturate tubules or alter fluid
flow in dentinal tubules

❖ Modify or block pulpal nerve

response
 Dentin Hypersensitivity: Treatment
Management of Dentin Hypersensitivity

Chemical Agents
Nerve Inactivators Tubule Obtundants Protein Precipitators
❖ Potassium salt ❖ Strontium chloride ❖ Strontium chloride
(nitrate-KNO3) ❖ Calcium hydroxide ❖ Silver nitrate ?
5% ❖ Fluorides ❖ Formaldehyde
fast-acting ❖ Sodium citrate
has some anesthetic fixes the fluid in the
❖ Potassium oxalate- 3 to
properties 10% dentin tubules
forms collagen plugs
.
React with calcium & phosphate ions
crystals with low solubility
Obstruct dentinal tubules
Dentin Hypersensitivity: Treatment
Management of Dentin Hypersensitivity

Physical Agents
❖Varnishes
❖Bonding agents
❖Sealants
❖Glass-ionomer cements
❖Composite resins
❖Lasers
❖Soft tissue grafts
Dentin Hypersensitivity: Treatment
Options for Treatment
(listed as least invasive to most)
In-office by dental professional

❖ Chemicals GLUMA Desensitizer

❖ Adhesives
❖ Restorations
❖ Endodontic (root canal)
❖ Tooth extraction
 Desensitizing agent
(Gluma Desensitizer (Heraeus Kultzer) )

5% glutaraldehyde and 35% HEMA

Gluma is compatible with any restorative

material and does not affect the bonding quality
of adhesive agents (other products ?)
contact with the patient’s soft tissues should
be avoided.!
glutaraldehyde is a strong antibacterial

main method of action is occlusion of the dentinal

tubules by precipitation of serum proteins within it

It produce an immediate long-term effect up to 12 months

 Desensitizing agent
(Gluma Desensitizer (Heraeus Kultzer) )
Application procedure

❖ The anesthetized tooth should be cleaned with

pumice, washed, and the affected area blot dried.
soft tissue should be protected
❖ Gluma Desensitizer (Heraeus Kultzer) is applied
for 30-60 s and then the area dried until the fluid
film has disappeared and the surface is no longer
shiny then rinse .
no light-curing required
penetrates up to 200µm
cannot be used to treat the pain from irreversible
pulpitis

Repeat application if necessary Total etch tech. --- applied after etching
Self etch tech. ---- before bonding
Dentin Hypersensitivity: Treatment
Options for Treatment
At-home treatments—patient applied

❖ Anti-sensitivity dentifrice
❖ Fluoride-based gels
❖ Rinses
Thank You
❖ glutaraldehyde-based desensitizing agent has been suggested as
a rewetting agent on etched dentin to help prevent
postoperative sensitivity under posterior composite restorations

❖ The use of a dentin desensitizer before cementing full-coverage

crowns is supported by studies that showed dentin-desensitizing
solutions do not interfere with crown retention, regardless of the
type of luting cement used
Examples of Post‐Restoration Hyper‐sensitivity

1) Leaky Restoration:

.
Leakage mean penetration of fluids along the
Definition tooth / restoration interface.

1) Improperly adapted restoration due to

Causes improper condensation pressure or improper
packing technique.(condenser, type of restoration? )
2) Difference in coefficient of thermal expansion
and contraction between tooth structure and
the restorative material.
3) Dimensional changes of restorative materials
during setting.(composite?)
4) Dissolution of luting cement under indirect
restorations. (thickness)
Examples of Post‐Restoration Hyper‐sensitivity

1) Leaky Restoration:

. Produce hypersensitivity due to ingressed fluids as :

Effect 1) It contains irritant constituents and oral
microbes.
2) It affects the movement of dentinal fluids.

1) Construction of properly adapted restoration.

Treatment 2) Selection of restorative material of thermal
coefficient near to that of the tooth structure.
3) Compensation of polymerization shrinkage of
resin restorative materials.
4) Beveling of the cavity margins with proper
burnishing of the casted metal to protect the
cement line.
Examples of Post‐Restoration Hyper‐sensitivity

2) Fractured Restoration:

Improper cavity design:

Causes
Too shallow depth → No bulk for material.
Sharp line angles → stress concentration.
Improperly constructed restoration:
Improper condensation.
Moisture contamination.
Excess Hg in amalgam. γ2 phase
Over carving that decrease the bulk of restoration.
Under carving resulting in premature contact (marginal ridge)
Examples of Post‐Restoration Hyper‐sensitivity

2) Fractured Restoration:

Effect
Pain on biting due to opening of the
fracture line that lead to:
1) Displacement of restoration that produce
pressure on the tooth or gingival tissues.
2) Ingress of oral fluids with its irritant
constituents and microbes.
3) Movement of dentinal fluid
Examples of Post‐Restoration Hyper‐sensitivity

2) Fractured Restoration:

Treatment 1) Removal of restoration. Or repair?

2) Evaluation of prepared cavity and correction of

the design.

3) Proper construction of a new restoration

Examples of Post‐Restoration Hyper‐sensitivity

3) Inadequately lined Restoration:

Neglection of use of any liner or base under

Causes . Large metallic restoration.

Effect - Conduction of thermal changes to underlying

dentin and pulp, which often causes pain.
- The pain is usually felt after fading out of
anesthesia and elicited by hot or cold application
and lasts for the period of stimulation or a little
longer, and it often decreased few days later.
- The greater the temperature changes the more the
painful effect and longer lasting stimulus.

Remake of restoration with proper selection

Treatment and application of insulating base.
Examples of Post‐Restoration Hyper‐sensitivity

4) Cracked Tooth:

Weakening of the tooth structure as a result of:

Causes . 1) Caries. 2) Over extended outline.
3) Vibration of the cutting bur. 4) Trauma

Effect Pain due to biting or eating citrus food or

drinks, which disappears upon opening.

Treatment Most properly, full coverage restoration will be

indicated.
Examples of Post‐Restoration Hyper‐sensitivity

5) Galvanism:

1)Two dissimilar metallic restorations.

Causes .
2) Old and new amalgam fillings.
3) Polished and unpolished amalgam
restorations

1) Discoloration of restoration → e.g. discoloration

Effect
of gold restoration due to precipitation of amalgam
ions on the gold surface.

2) Corrosion of amalgam restoration.

3) Pain: → Sudden short sharp pain when the

opposing teeth occlude with each other. This pain
could be disappeared if the patient could retain his
teeth occluding to each other, due to depolarization
of one surface of the opposing metallic restoration.
 Galvanic Shock

AMALGAM FILLING

S A L I V A

ENAMEL
GOLD FILLING DENTINE
PULP
The metal giving up electrons is called anode and the one accepting electrons is
called cathode

The anode is the one which deteriorates (corrode), cathode remain intact
Examples of Post‐Restoration Hyper‐sensitivity

Treatment. 1) Painting of one restoration with varnish

to prevent contact between them .But this is
a temporary treatment as the varnish will be
bealed off during mastication.

2) Replacement of one restoration

Examples of Post‐Restoration Hyper‐sensitivity

6) Faulty Occlusal & Proximal Relationship:

Causes 1) Improper carving of restoration leaving

. premature contact.

2) Improper matricing resulting in open contact.

3) Improper construction of indirect restoration.

A) High occlusal contact will often result in:

Effect
* Tooth sensitivity to biting pressure.
* Mobility may develop, with damage to supporting
structures.
* If the high spot is on the marginal ridge, there is a
great danger of restoration fracture.
Examples of Post‐Restoration Hyper‐sensitivity

Effect - Amalgam restoration may adjust itself in a matter of

days by flow and creep, and a shiny facet will appear.

- Composite restoration may undergo wear, but

differs according to the type of composite and the
technique of construction either direct or indirect.

- Indirect cast gold and ceramic restoration do not

adjust themselves
Creep is the increase in strain under constant stress below elastic limit
Examples of Post‐Restoration Hyper‐sensitivity

B) light or open proximal contact may result in:

Effect - Food impaction with gingival inflammation.

- Continuous pressure may lead to gingival

tissue loss with inter proximal bone loss.

- Pain due to gingival damage

Treatment
1) Occlusal adjustment for premature occlusal
contact.

2) Remake of restoration with open proximal

contact.