Dental Sensitivity

Junaid Iqbal Aims of the section:

1. Define dental sensitivity 2. Causes 3. Theories 4. Brnnstrms Hydrodynamic theory 5. Diagnosis 6. What advice to give patients and how to treat!

Defining Dental Sensitivity

Dentine sensitivity is common condition of transient tooth pain caused by a variety of exogenous stimuli such as: thermal (cold), tactile (touch) osmotic changes (sweet or drying of the surface).
While extreme stimuli can make all teeth hurt the hyper sensitivity means painful response to stimuli not normally associated with pain.

Causes
Two processes are essential for the development of dentine hypersensitivity: 1. dentine must be exposed (lesion localistaion), through either loss of enamel or gingival recession 2. the dentin tubules must be open to both the oral cavity and the pulp (lesion initiation). NOTE: Not all exposed tubules will give rise to symptoms! The MOST common clinical cause for exposed dentinal tubules is gingival recession Common reasons for gingival recession: - Inadequate attached gingiva - Prominent roots - Toothbrush abrasion - Pocket reduction periodontal surgery - Post RSD - Oral habits resulting in gingival laceration, i.e traumatic tooth picking, eating hard foods - Excessive flossing - Gingival loss secondary to specific disease i.e ANUG, periodontitis, Herpetic gingivostomatitis - Crown preparation

Theories
There are several theories that have been cited to explain the mechanism involved in dentinal hypersensitivity. These are a. The transducer theory b. The modulation theory c. The gate control and vibration theory d. The hydrodynamic theory

Brnnstrms Hydrodynamic theory

The most widely accepted theory is Brannstorms hydrodynamic theory. It postulates that when the fluid in the dentinal tubules is subjected to temperature changes or physical osmotic changes due to the action of various stimuli, pressure is exerted stimulating baroreceptors leading to neural discharge (depolarisation) perceived as a sharp pain. The various stimuli may be heat, cold, osmotic, electrical, chemical and dehydration. According to this theory, tooth sensitivity, is the transient pain due to only exposed dentin and for no other reason, dental-related or others. Therefore, in sensitive teeth exhibiting such pain, the tubules should be open at the dentin surfaces as well as the pulpal surfaces of the teeth. The most important variable affecting fluid flow in dentin is the radius of the tubuli. If the radius is reduced to half, the fluid flow within the tubuli falls to one sixteenth of the original rate. Therefore, any treatment must consider ways to reduce the flow rate in the tubuli or to obliterate the tubuli to reduce the radius. The only hypersensitivity not associated with the above etiology is the transient spontaneously resolving hypersensitivity associated with the dental bleaching process.

Diagnosis
By definition, dentin hypersensitivity is a diagnosis of exclusion. Therefore before proceeding to management and treatment, conditions that present with sympotms mimicking dentin hypersensitivity must be ruled out. These include caries, pulpitis, cracked tooth syndrome, marginal leakage, fractured restorations, and restoration polymerisation shrinkage.

Rx
First and foremost addressing any underlying causes of the dentin hypersensitivity is paramount. This is the first step in successfully managing the condition. Educating patients about proper oral hygiene habits as well as the potential effects that highly acidic foods and beverages can have on their teeth can help them become more aware of practices that may be adding to their sensitivity. Removing any relevant etiological factor may cause resolution of the sensitivity. Secondly you need to decide on the most effective course of treatment. There are two principle treatment options 1- Plug the dentinal tubules preventing fluid flow 2- Desensitize the nerve, making it less responsive to stimulation

All current treatment modalities address both of the above.

1 Desensitize the nerve Potassium Nitrate 2 Cover the dentinal tubules 2.1 Periodontal surgery/grafting 2.2 Composite/GIC restoration 2.3 Crown placement 2.4 Plug (sclerose) the dentinal tubules 2.4.1 Ions/salts

a- stannous fluoride b- NaF & stannous F combination c- Potassium oxalate d-strontium Cl e- Ferrous oxide

2.4.2Percipitates - proteins/AA 2.4.3 Resins

a-Glutaraldehyde a- Dentin sealers b-methyl methacrylate

Toothpastes and topical pastes contain one or more of the above agents that work in combination to plug the tubules and desensitise the nerve. The ADA has given its seal of approval to certain brands of toothpastes, which are listed below. Other toothpastes may also be successful in treating sensitivity. ADA accepted desensitizing toothpastes Crest Sensitivity Protection Fluoride Toothpaste Orajel Sensitive Pain Relieving Toothpaste for Adults Colgate Sensitive maximum Strength Toothpaste Protect Sensitive Tooth Gel Toothpaste

References & Further Reading

Canadian Advisory Board on Dentin Hypersensitivity: Consensus based Recommendtions for the Diagnosis and Management of Dentin Hypersensitivity Journal of the Canadian Dental Association, 2003; 69(4):221-6 Dentinal Hypersensitivity: A review Patricia A. Walters Crest Oral-B at dentalcare.com, Jan 13 2012
The hydrodynamictheory of dentinal pain: Sensation in preparations, caries, and the

dentinal crack syndrome, Martin Brnnstrm, DDS, Dr. Odont, Journal of Endodontics, Volume 12, Issue 10, 1986, Pages 453457

iBook Additions
Glossary ADA American Dental Association QUESTIONS Differentiation of Symptoms A. B. C. D. E. F. Acute periapical abcess Cracked tooth Syndrome Dentine hypersensitivity Irreversible pulpitis Lateral periodontal abcess Reversible Pulpitis

For each of the following scenarios, choose the most likely diagnosis from the list above. You may use each option once, more than once or not at all. 1. Spontaneous pain, which may last for several hours, be worse at night and is often pulsatile in nature. Pain is elicited by hot and cold at first but in later stages heat is more significant. Pain remains after removal of stimulus. 2. Pain is elicited in response to a thermal, tactile or osmotic stimulus 3. Sharp pain on biting short duration 4. Acute pain and tenderness often associated with a bad taste. 5. Sever pain, which will disturb sleep. Tooth is exquisitely tender to touch. 6. Fleeting pain/sensitivity to hot, cold or sweet with immediate onset. Pain is usually sharp and may be difficult to locate. Quickly subsides after removal of the stimulus.