DENTINAL HYPERSENSITIVITY.... PPS aceContents. * Introduction Same Loi aera Pee nato lyn] Pam Coca nee Teen ha (a Same D icon * Clinical considerations = Methods of measuring hypersensitivity = Management of hypersensitivity Comesstrn tin ty a carey Cel ets (ol byIntroduction. « The term dentine hypersensitivity has been used for many decades to describe a common painful condition of the teeth. plese cee A eee acc eT Rem anu elcome mT Tcd dentine hypersensitivity. = It is perhaps not surprising therefore that one can still have sympathy with statement made in 1987 by Johnson and Co- workers that dentine hypersensitivity is an Enigma, being frequently encountered yet ill understood.Definition. Dentine hypersensitivity is defined as short, sharp pain arising Fite un soy ete Re COORD ECS ee CRORE Sue Cer Mee evaporative, tactile, osmotic or chemical and which cannot be ascribed to any other dental defect or pathology.cei el ya) Ser Om deol rey eta 72-98% - In periodontal patients Cael aie eee oer OR eer Leen Lee De (Oot ear) nen Cee Lh eK COMM etna a] cee Gender:- Proportionately more females affected than males. Reasons: Related to the better oral hygiene of females compared with male Differences in diet — favoring healthy but often acidic foods and drinks in Sel oeDistribution Buccal cervical area of teeth Reasons ~ site of pre-dilection for gingival recessions and the area SU eee Tn Sea CR RTE Most commonly affected are canines and | premolars, then incisor EY team aunts) CVC ote Con mte)eLe Show a negative co-relation with plaque scores recorded by site. Significantly greater proportions of left side tooth sensitivity ’ wiEtiology Two processes need to occur to arise dentine hypersensitivity. * Lesion localization * Lesion initiation = A. LESION LOCALIZATION: dentine has to become exposed. Causes: = Enamel loss Deere cress)Enamel loss Neowin Perse.Abfraction.Other reasons. Improper instrumentation eT RRC on eee Mem coe (me eaGingival recession Cause: Same Clee tsd * ANUG and ANUP, = Self- inflicted injury, * Periodontal disease, = Periodontal surgical and non-surgical procedures, « Dehiscence / fenestrations,B, LESION INITIATION Require opening of dentinal tubules Menon ces ecco through abrasive and detergent actions Rohr oem Leta Ehret oc la fluids readily expose tubules Abraded inter tubular Dantin Nee ime ln cme orl e) be) ita Penance Tae esata acl yer COLIN y chambres ORO CRUNR Cee MC oe Tee) aa eae ce tte Erosion causes bulk loss of dentine and Tu recto ica R MILER Col susceptible to physical insults.The neural theory, gate control theory The odontoblastic transduction theory The hydrodynamic theoryDirection neural stimulation = According to this theory the dentinal tubules innervated by NaC AICS R OR CMe en eman mec one liye forere cas Pe UCM CeCe Maen eee C eel Ravi camera TT reach the nerve ending in the inner dentine. Cee Urata Clem a vckeclt can gsloaroleh aia ™ Since histological examination shows the dentinal tubules does not contain any nerve endings, this theory is not acceptedGate control theory. (seltzer) . A.k.a. vibration theory + Irritated pulpal nerves get activated & larger myelinated fibres Crete ele Rees UT Lola Ce eur TO eR eR CoM MTeoR eM mn Poem eed oi) oD Causing pain2. Transduction theory Membrane of the odontoblast process is excited by the stimulus PYRO Ua meee emo RCT een dentine i.e. pre-dentine, odontoblast zone and pulp. Nea otic OM eae n tecnica (dat) CONC Paice CEC cca ee acl amon its Ey oeel eas te Cela3. Hydrodynamic theory Ta ke enrecm ey Rene lLee) UU eee een rae) RETR er Mead CCR Teme dentinal tubules, following stimulus Eyelet ee ashen Penance Reman SHC Me LC Corel eyeee OPEN TUBULES COLD, HEAT, TACTILE STIMULI! DENTINAL TUBULES. FLUID MOVEMENT WHICH STIMULATE SENSITIZED NERVE ENDINGS PROSTAGLANDINS AND OTHER MEDIATORS MAY SENSITIZE ee 3 SENSORY a NERVESClinical assessment of dentine LIS] " Subjective EvaluationVerbal rating scale is a simple descriptive pain scale which includes the following: 0 - No discomfort 1- Mild discomfort SUC Reieo ong Pee cceRelee ln Chae imc cece Ro mnteorae nn een ener2. Visual analogue scale isa line 10 cm in length, ieee cone m ante aK scon enema te ETE Cn MCe ium eeu oe sO external stimulus. PwC Buea eee era shown 20 sets of words and asked to select a Boo CoM tueynmesCeln Ms sek y atta MYerimelferu loans" Objective assessmentMechanical or tactile stimuli = Pass asharp dental explorer... grade the response .....scale 0 - 3 © Collins used a no 23 explorer © Simple yet effective © 5-10 gm of force...Tip of the explorer ... 500/nmz2... compression and deformation of dentin. = Incorporating a calibrated strain gauge in the explorer. « Using a Yeaple probe.... Compact handpiece that contains an explorer .., electromagnetic field.Hand held scratch device... Dr Kleinberg ® Torsion gauge © Sharp explorer like probe e Indicator ...Records the force of displacement in centinewtons Ct) Probed at CEJ A tooth that fails to respond at 80 centi-newtons is non Bret e hoScratch deviceThermal Sensitivity « Directing a burst of warm temperature air from a dental syringe feline cs Tacelelan CON Reon eM ce Keene Te aN Meet R eye ETC OM eT ec M cet Re Molen a] DONOR connionia = 1- Mild discomfort, but no severe pain = 2- Severe pain when stimulus is applied * 3- Severe pain occurs and persists even after removal of stimulus= Anair thermal device devised by Dr. K.C. Yeh * Used a temperature controlled stream of air as the stimulus. = Airwas heated to 100°F close to temperature of the mouth. Its temp was then reduced until the subject felt pain or discomfort. = The Yeh device had a disposible plastic tip, and air emitted at 10 PSST EC Uc cod IO COLea aed ATTN(eR M ie oR CH eMC Uke SCBA Ue Com Ce uli Thermo-electric device (Biomat-thermal probe) It provides a continuous application of heat/cold. eevee ese UMvepa ero OR Henman uni Cerw ce ecte atte MON TTS thermistor measures the temperature at the probe tip. Peed BCR RCRD ee MeN cetera mh increasing or decreasing the current flow in range of 12°C- 82°C It is preset at temperature of 37.5°C. It can be used for heat and cold testing by increasing or decreasing the temperature by I°C. b(t CaCold face of th meee Hot face of thermocouple x i . | Brass housing Nylon sieeve — Copper thermode Stimulotor H Lc “Nylon screw Thermisier probe NK electvical lead to: thermocouple Thermister leads nd Ash to apply a hat Smith BA, Ash MM Figure 3, Diagram of the thermo-electric device used by Smit! or cold stimulus to sensitive teeth to elicit a pain response. (Adapted fr Jr: Evaluation of a-desensitizing dentifrice. J Am Dent Assoc 68.639, 1964Electrical stimulation Electrical pulp tester See CEM con me acc ee ane ee mame nee Mens mele the output voltage may be increased by pre-setting various numbered gradations (0-10) on a thumb wheel. Dental Pulp Stethoscope = Developed by Stark et al (1977) * Consisted of a digital readout sensitive voltameter connected to a digital printer teeth was activated by push button control. A conventional battery powered electrical pulp tester was attached to the Voltameter. * The stimulus intensity was measured in volts. = The pulp test lip is placed on the gingival 1/3“ of enamel and tooth stimulated, A electrolytic gel with a pH of 5.4 - 5.6 is used.Stark instrument for electrical stimulationChemical / osmotic stimulation Cae eNotes me emesis Rel eaters eee Cae oe Darel calcium chloride. «The use of chemical solution is complicated, because the solute in solution diffuses into the dentine fluid. On repeated applications, teria Me or one aK at aL Rn LUC UMaine Tema Eve M ech Ml Uee tse ies b emus Lete een are ae mea ae) Lae eC ee TELL toa SPL ol Man aM OL AULT RT clace) alt aletel eve Morac Come applications of the solutions. zDifferential Diagnosis "Cracked tooth syndrome. « Fractured restorations. = Chipped teeth. * Dental caries. * Post-restorative sensitivity.Av Ae aa| Classification = According to Scherman A and Jacobeen - 1992. Sian hee eon eee Oy Nei ec Be ne and eee) len = Chemical agents Physical agents = Corticosteroids Composites Pas Comalis lcd Resins * Strontium chloride Meranatad « Formaldehyde RTS En Led See CCS Bake cles Sto) fase tet ate tie -* Fluorides Glass inomer cementB. IN-OFFICE PRODUCTS EME terete Ong es a. Varnishes / Precipitants SaaS alto Sa Cn Se ee Cn oR eU eu noe enn ed Cae on ee ere EOS ea es Peer eed Seen oe ce Seen ott Perea Maso Rana) Pee eon + 35% HEMA in water TR ee ee Ue cng Conia gece Conventional glass ionomer cement. Resin-modified glass ionomer cement / Compomers Peat)Mechanisms The most likely mechanisms of action is the reduction in the diameter of the dentinal tubules so as to limit the displacement of cat mons eco aCM CERES Cem Cr Renn eer g Formation of a smear layer produced by burnishing the exposed Ettru ected SOE yu ecu on Hare Mee Re tLe cca ccd Tee arene Lt Lorem CR aLGam eC CSC Sealing of the tubules with plastic resins, Pome Mesa) ieee Mem piel toce ec eenn stots enor ad which blocks dental tubules. DoT ene Cece CREO U RUC SEaT UU Ce|| A. Home use products Prats * Home use ‘over the counter’ desensitizing products appear to Pen ere cee eey ae lel Bn cneee Meccan Teen te patients with tooth dentine hypersensitivity and should be the 1* Siro eT Muelea emu TCe Clb Several reasons exit to prescribe these products. CMD area eat Cian ein te (a PRay Urroncerettta cet reneertae sath soa Chesidte ee products an simple to use and non-invasive 5 tay DRESS en erentStrontium chloride Pee eee cntee ent ccc Pre an cca eean rica rote eles CROCE em ene ccna iey Crone niscl nce enec a Pee Gearscreart (ener neat i scecer iene sree el rea reduces dentinal fluid flow, the occurrence thought.to be Preece m SMe PI CShae melee Raney rips Pies) sale Stes nere)|(cee iat teb MeO Mr alae encod Realy sea er ke ec Ps OPAC CMa ASR a ital cece ere Con et eraniyoae ca = Possible‘detrimental pulpal effects of strontium chloride have also been suggested. PR kee eile See Ree eee ONCLUSION UAT Ced eco Cem sh ecloM an Coney iT Pato ter a eLmusr Li md nceen eon COM ar Lats pTLA) engendered. by thermal and tactile stinvuli.Potassium Nitrate Pee ETRE ern em Cmte nan cere t ran dentinal fluid flow in in vitro coated dentin, even at a 30% concentration. Pen CI mi cd ume Cn ecco eee s alate Ronse ane = Hodash (1974) called potassium nitrate'a superior desensitizer and found it to be ie asics see aoc terla ke) aoe Ceca etme ee ene nest ee stacy desensitize the dentin effectively at 1 week and upto 4 weeks compared to the control (paste without potassium nitrate)!in 92% of the subjects. liva follow-up report, which histologically examined the pulpal effects of the previous study, it RCE NU Corsuu ia Tae ee Men ne Coxe h Mstole ate tree ae Tate oT oK arenaSodium monoflurophospate " Inastudy by Arowojolu (2001) , the desensitizing effect of sodium monoflurophosphate was better than srontium chloride. Pee Deneck eclMeNCne keane ero mh) monoflurophospahte as its active ingredient - effective results after 6 weeks.A. Varnish /Precipitants * 5% sodium fluoride in a thick varnish — by Clark et al (1985). HEMA containing primers like GULMA [5% gluteraldehyde and <= ea N|Corticosteroids = Anti-inflammatory effect of glucocorticoids .... decrease dentinal sensitivity = Myjorand Furseth..... application of corticosteroid preparation to dentin caused complete obliteration of tubules . PMCs ee SS eee een oe) On eS L eT eC RUE ei) parachlorophenol, 25% m-cresyl acetate and 50% gum camphor prevented postoperative thermal sensitivity = Mjor showed that steroid application to dentin increased peritubular dentin SILLS * Thus, the tubule lumen would be‘decreased, resulting in less dentin tubule aT eC Clee eats ane CU en eScaa Sieh 6 See eee ee eT eee CRO (Cran ne ina FraCe trem rTM Soe Pz M Me SrateROCLC RSM eS TaNNT ETim COV eLUA Meal oe Lelie with the steroid causing "completely obturated tubules" and calcification SM eee a ore en Ten McC out easBurnishing of dentin = Tooth pick or "orange wood stick ... creates a partial smear layer on dentin Elo Pome eae Ue nett ame eC Oe Payot Roi ee RRC Set an Rene eos MeO Naas enna b reat ee rnc Rr marae Peo ome ee cece eee Tare Te cee ele glycerin, alone and in various combinations, were determined using an in vitro CUM Met eee tRir a ecu Cre RCM re unm maT CoH eM MeN CCT eM T TL eae eee ecoSilver nitrate SMe geOCu it Gus Camere pc Tae SMe on Mame R Cates Mom ic icea tate en kere combination with formalin ppted silver chloride or elemental silver = It may cause pulpal inflammation in shallow cavities. * Naylorand Anderson and Matthews measured dentin sensitivity oro cast omer rece niTeM CMMemrOrs ar irecnts Ci au sratecm tn Thm nay ote bcm Cees U eRe oestectemnryateh tae toa s erent PSS ase onCalcium hydroxide It may block dentinal tubules of promote peritubular dentin formation . eM Cet) Bement RUM Ou ar Ot coaems Coe ee Mjor (1967)...micro radiography... increased radio density Ina study by Greene et al hydroxide wasan effective desensitizing agent over the control to mechanical, hot and cold stimulation .Calcium hydroxide out-performed potassium nitrate Peet en car ites ent cone tere ented eer ee) ce ee ee en ere POL CERO ROUEN ake ein neces marten onc ene See wee Te sd Ecce Mout ie ese rd awn mel em eLcomn ccd Ca icee ave mdr ira reat ron cron Remote eerste teem arent Tie Meee e Tend ined study, Green et al found calcium hydroxide applications consistently Dieter ene ieee 'Hydroxyapatite Pe ae ec Clete Bs heneng rice eel areola ele Tooth Hypersensitivity - showed definite potential as an effective desensitizing agent providing quick relief from symptoms. None Cyaan pert eMC ere nce Mae onde Copeman TeoFluoride Catan Rei aa (e) ae CRB acon ee ene ee mrs ernee hrc en ey Deeg rcer meen ee rtm tore ens eet TT Johnson et al (1981) stannous fluoride with the ionizing brauh provided significantly greater relief than did the stannous fluoride alone. een eMC nace oa a ker C er Mn tert casa? effective in reducing dentinal hypersensitivity in subjective, noncontrolled studies. However, sodium fluoride may produce severe pulpal inflammation when applied oor Te LLFluoride lontophoresis A low voltage electric current is used to impregnate the tooth with fluoride ions. PR CEP at mean ena Coens Benen eT) fever MnMee cesT RSore ULM Le Ce ue(a PaO a eran EUnet n emt te electrophoretically to desensitize dentin. * Using 2% NaF with iontophoresis, Carlo (in a noncontrolled study) found “significant relief from sensitivity" in 90% of cases. = Singal et al- 2% NaF was comparatively better than HEMA-G in providing long- CaneIntra oral fluoride releasing device. = Sodium fuoride in an acrylic polymer releasing fluoride at the rate emer trea = This device is fast , painless and cost effective (marini et al 2010) copolymer membraneOrsini et al (2013) compared - Three dentifrices [1) containing 8% arginine, 1450ppm sodium monofluorophosphate; 2) containing 8% strontium acetate, Peer EC tmeN nC Ce Reeth thie er mttarme trate tn of zinc-carbonate hydroxyapatite nanocrystals] were compared PliKcue Rec \ Mak Leitch ae OU Taltehms Coretta cos Mea cLMe nearest coe Re Conan ny ao) significantly reduced DH after 3-day treatment, supporting their utility in clinical practice. This is the first report documenting the rapid relief from DH of a zinc-carbonate hydroxyapatite relativesOxalates eee cr neta mcrae well tolerated by the patients eres ec mea eet eee Lee CCR E MRR Meno meee cie reac Muzzin et al compared 30% dipotassium Oxalate (DO) and 3% monohydrogen-monopotassiiim Oxalate (MO) onthe reduction of dentin hypersensitivity in vivo. Results suggested - decrease in dentin hypersensitivity following the application of 3% MO alone, and 30% DO Orly evan keA=) 63 Studies have reported that the neodymium:YAG laser, the erbium:YAG laser and galium-aluminium-arsenide, erbium, chromium- doped:yttrium, scandium, gallium, and garnet all reduce DH A more expensive and complex treatment modality. = Kumaretal- The combination of Nd:YAG laser and 5% sodium fluoride varnish seems to show an impressive efficacy, when compared to either treatment alone, in treating dentin hypersensitivity. ° bie oe MEG cltrlea tn reiela an Rome permet ome eros atte a)Dentine bonding agents Bonding agents are applied to the exposed dentine eae a Aesthetically acceptable Brannstrom et al. obtained "immediate and lasting blockage of sensitivity" in 20 patients studied from 2 to 12 months. This is in agreement with Dayton et al. who tested various unfilled resins in 44 ert Narhi et al. recorded nerve activity directly in cat teeth when denti was mechanically stimulated. He found no neural activity after resin impregnation.Composite/ glass ionomer restorations Long lasting, yet more invasive procedure ce Matel ecto am an ie MCI] Aue late o selma corel Cav dlGC tooth mousse = Kowalczyk A etal GC Tooth Mousse for dentine hypersensitivity was evaluated - cold air stream NIRS eee a COT T Te ite tetera eres ee na reresrc eae CPP-ACP: Casein Phosphopeptide — Amorphous Calcium Phosphate).Nano structures bioactive glass. = -Mitchell et al(201) = Nano structured sol gel bioactive glass with carrier fluid showed a significant change in reduction of conductance... * Produced an immediate reduction in Ae Reena DOE T ee eco ete Cems NcConclusion. Ia wre ee octal ang ete Seema rca described as an enigma 20 years ago. MU etic MM aera nme eC M yeah Lg aS arene enero mem eres em CC Aare he CeCe airs prevention can also be included in the treatment planNeuses gOS Peer ene oe Ce een er cea Peeca ane, ent eaog Hypersensitive Root Surfaces, GREEN et al , jop J. Periodontol. October, 1977. * Clinical Evaluation of a New Treatment for Dentinal Hypersensitivity, Tarbet et al , J. Periodontol. September. 1980. = The Effectiveness of an Electro-lonizing Toothbrush in the Control of Dentinal Hypersensitivity, Johnson et al, J. Periodontol: June, 1982. = Dentinal Sensation and Hypersensitivity A Review of Mechanisms and Treatment Alternatives, Berman, Volume 56, Number 4, i. Periodontol. April, 1984. See UO eT Me Ae el ee Ce PML Coc Led Ld OS me eee oe CCDS sy AR COCR UL = Efficacy of Strontium Chloride in Dental Hypersensitivity, Minkof et sl , J. Teer CMe Metra eee teen ta Pee sieetteg re enc CCM CRM Ey rere m ORC cere M Periodontol. March 1989, Volume 6o Number 3. = Intraora fluoride releasing device: a new clinical therapy for dentin sensitivity, merini et al , JOP 2000 vol 71, 90-95.2% Sedium Fluoride-lontophoresis Compared to a Commercially Available Desensitizing Agent. Singal et al , J Periodontol 2005;76:351-357. Short-Term Assessment of the Nd:YAG Laser With and Without Sodium Aen MM Rl ute meL Me Swe Ele h ais mes eh TarD Pn tate eateries me Ac cere ente] 2005;70:1gO-1g7. Hydroxyapatite as.an In-Office Agent for Tooth Hypersensitivity: A Clinical and Scanning Electron Microscopic Study, shetty et al, J Periodontol PURE Pee Le Peo eye eres Mele MIE ACen ora semana Plc eran Properties of Three Dentifrices, Orsini et al, Journal of Periodontology; PC MPOlM CNC eTieRe tc me BIOMIMETIC-DENTIN DESENSITIZER BASED ON NANO-STRUCTURED BIOACTIVE PSS ats eS eau Ue ee) Bee deteThank you