Tooth Hypersensitivity

CHAPTER
I 11

Chapter Outline
• Definition Differential Diagnosis
• Neurophysiology of Teeth Diagnosis
Mechanism of Dentin Sensitivity Treatment Strategies
- :heories of Dentin Sensitivity _ Management of Tooth Hypersensitivity
Incidence an~ D'.stribution of Dentin Hypersensitivity - Home Care with Dentifrices
- lntraoral Distribution - In-office Treatment Procedure
Etiology and Predisposing Factors - Patient Education

INTRODUCTION
The term tooth hypersensitivity, dentinal sensitivity or .. Leeuwenhoek (1678) described "tooth canals in dentin"
hypersensitivity is often used intermittently to describe • JD White (1855) proposed that dentinal pain was caused
clinical condition of an exaggerated response to an exog- by movement of fluid in dentinal tubules
enous stimulus. ,. Lukomsky (1941) advocated sodium fluoride as a desen-
The exogenous stimuli may include thermal, tactile sitizing obtundent
or osmotic changes. While extreme stimuli can make all • Brannstrom (1962) described hydrodynamic theory or
the teeth hurt, the term hypersensitivity means painful dentinal pain
response to stimuli not normally associated with pain. The • Kleinberg (1986) summarized different approaches that
response to a stimulus varies from person to person due are used to treat hypersensitivity.
to difference in pain tolerance, environment factors and
psychology of patient. Tooth hypersensitivity can fit the Tooth hypersensitivity is not associated with actual
criteria of several pain terms described by Merskey ( l 979 ), tissue damage in the acute sense but can involve poten-
for the International Association for the Study of Pain tial tissue damage with constant erosion of the enamel or
(IASP). Pain is described "as an unpleasant sensory and cementum along with the concomitant pulpal response.
emotional experience associated with actual or potential
tissue damage:· NEUROPHYSIOLOGY OF TEETH
The dental pulp is richly innervated. According to conduc
tion velocities, the nerve units can be classified into A
DEFINITION
group-having the conduction velocity more than 2 m s
Dentin hypersensitivity is defined as "sharp, short pain and C group-with conduction velocity less than 2 m/s.
arising from exposed dentin in response to stimuli typi - The sharp, better localized pain is mediated by A delta
cally thermal , chemical, tactile or osmotic and which fibers, whereas C fiber activation seems to be connectl'<l
cannot be ascribed to any other form of dental defect or with the dull radiating pain sensation. Myelinated r\ fiber
pathology (Holland et al, 1997). seems to be responsible for dentin sensitivity.
 ftieCHANISM OF DENTIN SENSHJVffY Hydrodynam ic Theory
·es of Dentin Sensitivity -rh·rs ur'eory
.L h . i.. •. , .,,. u .... r; -"""r,,,..rffr.e:r.:
prn ~ ~ I at a \ltrfiVu>-~ ....,, , ,e:...,. •~~
, heofl
ofthe Ouid rhat erists in 1hf: cterdr,,:l, /1•,.~... Tr.eC-~~-
Neural Tt,eory men t OCCl.J T~ in either an ,_,.; ,A,;;,;d ( )T rn ~.<f d::~fl- ,,,c_G
ural theory attributes to activation of nerve endin g thi s mec.hanical d1~.urb0nc1: 2'_,;-;a ' ,;<, tt'. ~ r;Kr;£: ~,d!;;~
111e ne .
. 1•tbin che dcncmal tubules. These ne rve signal' are present ifl the dentin or pufp. . A
~~" . ~
• conducted along
then .
the parent primary afferent
.
nerve: Brann <;tro m ( 1962} w iyp.It:d crizi 1f,f:' dhpiu:i:Tt.er:1 r.
-bef5 in the pulp, mto the dental nerve branches and then th e tubulf: C(JO (P,TTI.'! 1-, rap:<l en<JU#, tr, df:ir;rrr: t.l!r.f: f=~
n che brain (Fig. 26.1 ). Neural theory considered thar in pulp or pn:demjn or d.cma~ <><lon'"'~ U:,L &.JCJ ,Ji
~w .
~~
. e length of tubule contains free nerve endings . thes.e effec.1.s appear ,..ap,2hfo ()( pr<..d.1r.:in~ iP--'1 rn,;..-2&2:
Currently m c:151 in•;~igaw-.~ 21:el:'p· fh;-.1 derd::i ~ -
Theories of dentin sel\5ifivity 1

ti,.;t)• i5 due w the hydrr.>d171ami.c fruid wt.'"'. ~,t;:<.t r..ca:.~

• Neural theory
• odontoblastic transduction theory
• Hydrodynamic theory.
()dontoblastic Transduction Theory
The theory assumed that odontoblasts extend to the
periphery. The stimuli initiaJJy excite the process or body
of me odontoblast. The membrane of odontoblasts may
come into close apposition with that of nerve endings i~
the pulp or in the dentinal tubule and the odomoblast
rransmits the excitation of these associated nerve endings.
However, in the most recent study; Thomas (1984) indi-
cated that the odontoblastic process is restricted to the
inner third of the dentinal tubules. Accordingly it seems
that the outer part of the dentinal tubules does not contain
any cellular elements but is only filled with· dentinal nuid.
acros<, expo-;,ed dentin ....1th rJpE:;1 mhule<, (FiJ;. 26-1,- Tri~
rapid flu id mm-emem in rum u:t.r,alt:"> che rr.rffi.ano-
receplOr nerves of A group in th~ putp fn:g. 21;..4 ;-
.\la thews et al ( 1994 J noted th~, st.im-JH ~ a-;, ,.nld
ca uses nu id /1 0\v away fro m the putp, prrJdJU::'i rTt£'.i'1~ rapid
and greater pul:p nerve rE:;Sp<,nse<.. than t.ho,;e ~ ~ tJf:::a1..
which caw.es an inward flt:,w. Th~ cert.a.inf:,· woo!d -~
the rapid an d severe r£:Spon.s.e w cfJ!d sumuH cr.,mpared u,
the slow du ll response w h~ l .
The dehydrati on of dentin b;.- ;,ir blzst.-, or aiw.)-rl:len!
paper causes outward fl uid mrr;t m em and srimula--~
the mechanoreceprnr of m~ ooomobtzst. ~ patn_
Prolonged air blast causes fonruilion of prm.em prug h.uo
the deminaJ tubules, red ucing me ftuirl mr.r.remem an6
mus decreasing pain (Hg. 26.5).

1
(1
(
0. 11 I

'-II.,__ _.,,

~ re 26.1 : l hcoric) of denr in hypersensir iv it ~. I I ) .'.'eural theory:

;1 mulu1appl ied 10 Jen tin ca u\t"> din:cLexcira rion of the nerve fi ber~
,, O<lontobla,tic rra n\d ucri/Jn theorv:. St imulu ~i5 rransmit red along
·
:t: odontnbla)! and pas_<.cs to the ¼:n.sory nerve cndinp thro ugh

•t,.ip,e, ( 3 I lvd rodvnamic thcorv: Sr imulu~ cause, di~placement () ( figure 26.2; f l<,drod;mami< theor, w,... ,,~ r1 :l CJeU_"'";,c rx 6::,c
r~,,,prc,.:n, ,~ denti na l tubu les ~ hi ch furth er cxote nerve ftben ITIOli~
 :i:-extbook of Operative Dentistry

Stimulu s ll~n
thornml , machonicol, t - - - - - - ~
cho rnlc,11

---
t
/ osed dentin with
tubul es

t
Increase rate of donllnal
flu id flow

Generation of aclion
potentials In intradental Figure 26.5: Eflc·cl of air bl;,sl on dc:111i11 , p,1in pruducccl hy
nerves di!Tcrrnl slimuli
Pulp

Pain
)
)
)
Figure 26.3: I l)'drod )'11a111ic llic·oq, or dentin hypnsen si 1ivi1 y
'j
~ Heat,
:.i ~ pressure
v
(

• • ---A

•
---B
- - -- - - - c Nerve
plexus
l+-1---- -- D

-+- - -- -- E
l'igurc 26.(,: Dilfnrnt stimul i n:sultin g in fluid 111 uvc·111c111 ,111d
subsc:quc:nl pain
Figure 26.4: I lydrody11a111ic thrnry : A. Odo 11tolila.s1 ; 11. lk111i11 ;
C. A-<'i ner ve fib er; J). Odo111obl;1stic process; I:. S1i11111l.11io11 of A-ti
11crvc lihcr J"ro111 fluid 111ovc111r:11t

INCIDENCE AND DISTRIBUTION OF

The pain produced when sugar or salt solutions are
pl aced in contact with exposed dentin can also be explained
by dentinal fluid movement. Dentinal fluid is of relatively low
osmolarity, which have tendency to flow towards solution of
higher osmolarity, i.e. salt or sugar solution (Fig. 26.6).
DENTIN HYPERSENSITIVITY
The prevalence studies for dentin hypersensitivi ty are
limited in number. The available prevalence data va ries
considerably and dentin hypersensitivity has been sta tetl
to range from 8 to 30 percent of adult population .
 Tooth Hypersensitivity , ,. .:.. --~-

•-'ost sufferers range from 20-40 years of age and k

, in • ' d th a pea
occurrence 1s 1?un at_ e end of the third decade.
In general, a slightly higher incidence of dentin h
• .. . d. , yper
sensitJVlty 1s reporte m 1emales than in males
, 1he reduced . . incidence of dentin hyperse ns1:t.IVIty
. m.
older ind1VIduals reflec_ts age changes in dentin and
the dental pulp: Sclerosis of dentin, the laying down of
secondary dentm and fibrosis of the pulp would inter-
fere with the hydrodynamic
. transmission of sti ID ul'I
through expose dd ennn.
lntraora l Distribution
, Hype rsensitivity is most commonly noted on buccal
cervical zo nes of permanent teeth. Although all tooth
rype ma~• be affected, canines and premolars in either
jaw are rh e most frequently involved.
, Regardiilg the side of mouth, in right handed tooth
brusher,. the dentin hypersensitivity is greater on the
left sided teeth compared "\o\rith the equivalent contrn-
lateral 1eeth.
by two processes; either by loss of covering periodontal
structures (gingival recession), or by loss of enamel.
_
The most common clinical cause for exposed dentinal
tubules is gingival recession (Fig. 26.8). Various factors
which can cause recession are inadequate attached
gingiva, improper brushing technique, periodontal
surgery, overzealous tooth cleansing habits, oral habits,
etc.
Common reasons for gingivol recession
• Inadequate attached gingiva
• Prominent roots
• Toothbrush abrasion
• Oral habits resulting in gingiva laceration, i.e. traumatic
tooth picking, eating hard foods
• Excessive tooth cleaning
• Excessive flossing
• Gingival recession secondary to specific diseases, i. e.
NUG, periodontitis, herpetic gingivostomatitis
• Crown preparation .

ETIOLOGY AN D PREDISPOSING The recession may or may not be associated with bone
FACTORS (F IG. 26.7) loss. If bone loss occurs, more dentinal rubules get exposed.
When gingival recession occurs, the outer protective layer
The primarj' underlying cause for dentin hypersensitivity of root dentin, i.e. cementum gets abraded or eroded away
is exposed
denrinal tubules. Dentin may become exposed (Fig. 26.9).
This leaves the exposed underlying dentin, which
consists of protoplasmic projections of odontoblasts
Aggressive or Extrinsic acids within the pulp chamber (Fig. 26.IO). These cells contain
poor oral hygiene intrinsic acids nerve endings and when disturbed, nerves depolarize and
this Is l111 erprc1ed ns pain (Fig. 26.l I).

Gingival recess ion Erosion

Dentin exposure
lhrough either enamel
loss or gingival recessiion

Opening or
tubules denlinal

Disturbed now = sensitivity

stimulates A-delta nerve fibers

Dentin hypersensitivity

Figure 26.7: Etiology of dentin hypersensitivity Figure 26.8: Recession of gingiva

 -irextbook of Operative Dentistry
Once the dentinal tubules are exposed, there are oral
processes which keep them exposed. These include poor
plaque control, enamel wear, improper oral hygiene tech.
nique, cervical erosions, enamel wear and exposure to acids.
Gingival recession

''
Removal of cementa! layer

Exposure of dentin
and thus dentinal tubules

''
Depolarization of nerve endings of odontoblast

Pain

Reasons for continued dentine! tubular exposure

... Poor plaque control, i.e. acidic bacterial byproducts
- Excess oral acids, i.e. soda, fruit juice, swimming pool
Figure 26.9: Erosion of cementum
chlorine, bulimia
.. Cervical decay
• Toothbrush abrasion
,. Tartar control toothpaste . The other reason for exposure
of dentinal tubules is due to loss of enamel.

Causes of loss of enamel

,.. Attrition by exaggerated occlusal functions like bruxism
• Abrasion from dietary components or improper brushing
technique
.... Erosion associated with environmental or dietary com-
ponents particularly acids.

Sin ce dentinal tubules get sclerosed of their own and

plug th emselves up in the oral environment, treatment
should focus on eliminating factors associated with
continued denlinal exposure.

DIFFERENTIAL DIAGNOSIS (FIG . 2_6.12)

Dentin hypersensitivity is perhaps a symptom complex
Figure 26.10: Exposure of dentin al tubules rather than a true disease and results from stimulus trans-
mission across exposed dentin. A number of dental condi-
tions are associated with dentin exposure and therefore,
Depolarization may produce the same symptoms.
Such conditions include:
• Chipped teeth
• Fractured restoration
• Restorative treatments
• Dental caries
• Cracked tooth syndrome
Figure 26.11: Depolarization of nerve ending causing pain • Other enamel invaginations.

>
 Tooth Hypersensitivity · ;,. ,. "-

Transient dentinal pain in respons e to th ermal, probing,

· osmotic or chemical stlimuli

Differential diagnosis
Cracked tooth syndrome
Fractured restorations
No further Chipped teeth
Any suspected ~
Dental caries
treatment required • etiology ~ •
Periodontal disease
Post-restorative sensitivity
Marginal leakage

Reinforce
preventative advice:
Continue Confirm diagnosis of
and review dentin hypersensitivity

Provide patient education

and over-the-counter
treatment options Treat as appropriate ]

Consider pain of
Re-evaluate after 3 weeks non-odoentogenic origin
to check pain
(i) Musculoslolotal
(ii) Psychogenic
(iii) Referred pain
(iv) Neurovascular
In-office topical treatment (v) Inflammatory
(i) nerve desensitizers*
(ii) tubule obturators*

Review diagnosis of
dentin hypersensitivity

In-office invasive
treatment
periodontal surgery
Restorative treatment
root canal treatment

Re-evaluate
for pain

Figure 26.12: Treatment of dentin hypersensi tivity

 iTektbook\:>f Operative Dentistry
DIAGNOSIS
• A careful history together with a thorough clinical and
radiographic examination is necessary before arriving
at a definitive diagnosis of dentin hypersensitivity.
However, the problem may be made difficult when two
or more conditions coexist.
• Tooth hypersensitivity differs from dentinal or pulpal
pain. In case of dentin hypersensitivity, patient's ability
to locate the source of pain is very good, whereas in case
of pulpal pain, it is very poor.
Desensitization by
• The character of the pain does not outlast the stimulus; the Hypersensitive
Desensitization by altering nerve excitability
pain is intensified by thermal changes, sweet and sour. dentin
with open tubules tubule occlusion
• Intensity of pain is usually mild to moderate.
Figure 26.13: Different treatment modalities for dentin hypersensitivity
• The pain can be duplicated by hot or cold application or by
scratching the dentin. The pulpal pain is explosive, inter-
mittent and tl1.robbing and can be affected by hot or cold.
Management of dentin hypersensitivity
TREATMENT STRATEGIES - Home care with dentifrices:
• Strontium chloride dentifrices
Hypersensitivity can resolve without the treatment or • Potassium nitrate dentifrices
may require several weeks of desensitizing agents before • Fluoride dentifrices .
improvement is seen. Treatment of dentin hypersensi - .,. In office treatment procedure :
tivity is challenging for both patient and the clinician • Varnishes
mainly for two main reasons: • Corticosteroids
1. It is difficult to measure or compare pain among • Treatments that partially obturate dentinal tubules.
different patients. i. Burnishing of dentin
2. It is difficult for patient to change the habits that initially ii. Silver nitrate
caused the problem. iii. Zinc chloride-potassium ferrocyanide
iv. Formalin
Management of Tooth Hypersensitivity v. Calcium compounds .
a. Calcium hydroxide
It is well known that hypersensitivity often resolves without b. Dibasic calcium phosphate.
treatment. This is probably related to the fact that dentin vi. Fluoride compounds
permeability decreases spontaneously because of occur- a. Sodium fluoride
rence of natural processes in the oral cavity. b. Sodium silicofluoride
c. Stannous fluoride .
Natural process contributing to desensitization vii . lontophoresis
• Formation of reparative dentin by the pulp viii. Strontium chloride
• Obturation of tubules by the formation of mineral ix. Potassium oxalate .
deposits (Dental sclerosis) • Tubule sealant
- Calculus formation on the surface of the dentin . i. Restorative resins
ii. Dentin bonding agents .
Two principal treatment options (Fig. 26. 13) • Miscellaneous
i. Laser.
Plug the dentin al tubules preventing the fluid flow
,. Patient education :
• Desensitize the nerve, ma ing it less responsive to stimula-
• Dietary counseling
tion . All the current modalities address these two options.
• Tooth brushing technique
• Plaque control.
Treatment of denttn hypersensitivity can be divided into
• Home care with dentifrices Home Care with Dentifrices (Fig . 26.14)
.. lnoffice treatment procedure
.. Patienteducation. Dentifrice has been defined as a substance used with a
toothbrush to aid in cleaning the accessible surfaces oflhe
 Tooth Hypersensitiv.ity

a m ~

Sealing of the Obfrtera tion of the me-.e xposed

Co,,eri.'lg,

exposed tooth dentinal tubtiles deruinat~D'f

su:rgjcal mea..""15
surface
• r;
Figure26.14: Commonly used home care products for Figures 26.1 SA to C: 1n offiee 1re21mem procedun:s ,or
dentin hypersensitivity dentin hypersensrtivit\·

teeth. Dentifrice components include abrasive, surfactant, obliteration of the tubules or to surgically cover che
humectant, thickener, flavor, sweetener, coloring agent exposed dentinal tubules so as to limit flui d mO\emem
and water. (Figs 26.15A to C).
After professional diagnosis, dentinal hypersensitivity
can be treated simply and inexpensively by home use of Criteria for selecfing desensifizi,ng agent I
desensitizing dentifrices. The habit of toothbrushing with • Provides immediate and lasting re lief from pai n
a dentifrice for cosmetic reasons is well established in the - Easy to apply
population, thus compliance with this regimen can be - Well tolerated by pati ents
easily made. - Not injurious to the pulp
- Does not stain the tooth
Strontium Chloride Dentifrices - Relatively inexpensive.

Ten percent strontium chloride desensitizing dentifrices
have been found to be effective in relieving the pain of
tooth hypersensitivity.
Potassium Nitrate Dentifrices
Five percent potassium nitrate dentifrices have been found
to alleviate pain related to tooth hypersensitivity.
Fluoride Dentifrices
Sodium monofluorophosphates dentifrices are the effec-
tivemode of treating tooth hypersensitivity.
In-office Treatment Procedure
Rationale of Therapy
According to hydrodynamic theory of hyperse~sitivity, a
rapid movement of fluid in the dentinal tubules is capable
of activating intradental sensory nerves. Therefore,
tre atmem of hypersensitive
..
tee th s h 0 uld be directed
towards redu cing the anatomical diameter of th e tubules,
Treatment Options to Reduce the Diameter of
Dentinal Tubules can be
• Formati on of a smear layer by b urnishing the ~l)Osed
root surface (s mear layer consisrs of small amorphous
particles of dentin, min erals and orgaruc rnauix-
denatured collagen).
• Application of agents that form insoluble precipitates
within the tubules .
• Impregnation of tubules ,~ith plastic resins.
• Application of dental bonding agents ro S€.ai off me
tubules.
• Covering the exposed dentinal tubules by surgical
means.
It must be recognized that single procedure may nm
be consistently effective in the treatment of hypersensi-
tivity; therefore, the dentist must be familiar ,,ith aher-
native methods of treatment. Prior ro treating sensitiYe
root surfaces, hard/ soft deposits should be remm·ed
from the teeth. Root planning on se nsitiYe de ntin may
cause considerable discomfo n , in mis case, teeth should
 . . .Te><t.book of Operative Dentistry

be anesthetized prior to treatment and teeth should be
isolated and dried with warm air.
Varnishes
Open tubules can be covered with a thin film of varnish
providing a temporary relief; varnish such as copalite ca1~
be used for this purpose. For more sustained relief a fluo -
ride containing varnish Duraflor can be applied .
Corticosteroids
Corticosteroids containing one percent prednisolone in
combination with 25 percent parachorophenol, 25 percent
methacresylacetate and 50 percent gum camphor was
found to be effective in preventing postoperative thermal
sensitivity.
The use of corticosteroids is based, on the assumption
that hypersensitivity is linked to pulpal inflammation;
hence, more information is needed regarding the relation -
J
ship between these two conditions.
.. )J
Partial Obliteration of Dentinal Tubules
Burni,shing of dentin: Burnishing of dentin with a tooth-
pick or orange wood stick results in the formation of a
smear layer. This layer partially occludes the dentinal
tubules which help in reducing the hypersensitivity.
Formation of insoluble precipitates to block tubules:
Certain soluble salts react with ions in tooth structure to
form crystals on the surface of the dentin. To be effective,
crystallization should occur in 1-2 minutes and the crys-
tals should be small enough to enter the tubules and must
also be large enough to partially obturate the tubules.
• Calcium oxalate dihydrate crystals are formed when
potassium oxalate is applied to dentin; these crystals
are very effective in reducing permeability.
• Silver nitrate (AgNO) has ability to precipitate protein
constituents of odontoblast processes, thereby partially
blocking the tubules.
• Zinc chloride-potassium ferrocyanide : When applied
forms precipitate, which is highly crystalline and covers
the dentin surface.
• Formalin 40 percent is topically applied by means of
cotton pellets or orangewood sticks on teeth. It had
been proposed by Grossman in 1935 as the desensiti -
zing agent of choice in treating anterior tooth because,
unlike AgN0 3, it does not produce stain.
• Calcium compounds have been popular agent for many
years for the treatment of hypersensitivity. The exact
- It may block dentinal tubules
- May promote peritubular dentin formation
On increasing the concentration of calcium ions
around nerve fibers, may result in decreased nerve
excitability. So, calcium hydroxide might be capable
of suppressing nerve activity.
i. A paste of Ca(OH) 2 and sterile distilled water
applied on exposed root surface and allowed to
remain for 3.5 minutes, can give immediate relief
in 75 percent of cases.
ii. Oibasic calcium phosphate when burnished with
round toothpick forms mineral deposits near the
surface of the tubules and found to be effective in
93 percent of patients.
• Recaldent (CPP-ACP)
CPP-ACP (complex of casein phosphopeptides and
amorphous calcium phosphate). CPPs are group of
peptides derived from casein. Casein is the part of protein
which naturally occurs in milk, CPP is responsible for high
availability of Ca2 • from milk. In normal state calcium
phosphate forms a crystalline structure at neutral pH
and thus becomes insoluble. But CPP keeps calcium and
phosphorus in ionic form (amorphous state). In this state,
calcium and phosphate ions can enter the tooth enamel
and thus promote remineralization of tooth. Recently, a
sugar free, water based creme containing RECALDENI'M
(CPP-ACP) has been made available under the name GC
tooth mousse (Fig. 26.16) .
• Fluoride compounds: Lukomsky (1941) was the first
to propose sodium fluoride as desensitizing agent,
because dentinal fluid is saturated with respect to
calcium and phosphate ions. Application of NaF leads
.e ,J

mechanism of action is unknown but evidence suggests

Figure 26.16: GC tooth mousse fo r tooth remineralization, thereby
that:
redu cing hypersensitivi ty
 Tooth Hypersensitivity~ _.

to precipitation of calcium fluoride crystals th

' ' us,
reducing the fu nct10nal radius of the dentinal tubules.
_ Acidulated sodium fluoride: Concentration of fluo -
ride in dentin treated with acidulated sodium fluo -
ride is found to be significantly higher than dentin
created with sodium fluoride .
_ Sodium silicofluoride: Silicic acid forms a gel with
u1e calcium of the tooth and produces an insulating
barrier. Thus application of 0.6 percent sodium sili -
cofluoride is much more potent than 2 percent solu -
tion of sodium fluoride as desensitizing agent.
_ Stannous fluoride: Ten percent solution of stan-
nous fluoride forms dense layer of tin and fluoride
containing globular particles blocking the dentinal
tubules. 0.4 percent stannous fluoride is also an
effective agent, however, requires prolonged use (up Figure 26.17: GLUiv!A desensit izing solu tion
to 4 weeks) to achieve satisfactory results.
• Fluoride iontophoresis: Iontophoresis is a term applied
ro the use of an electrical potential to transfer ions into Lasers
the body for therapeutic purposes. The objective of fluo - Treatment of Dentin Hypersensitivity by Lasers
ride iontophoresis is to drive fluoride ions more deeply Kimura Y et al (2000) reviewed treatment of dentin
into the dentina1 tubules that cannot be achieved with hypersensitivity by lasers. The lasers used for the treatment
topical application offluoride alone. of dentin hypersensitivity are divided into two groups:
• Strontium chloride: Studies have shown that topical l. Low output power (low level) lasers: Helium -neon
application of concentrated strontium chloride on an [He-Ne] and gallium/ aluminum / arsenide (GaAIAs)
abraded dentin surface produces a deposit of strontium [diode] lasers
that penetrates dentin to a depth of approximately 10 to 2. Middle output power lasers: Nd:YAG and CO, lasers.
20 µm and extend into the dentinal tubules. Laser effects are considered to be due to the effects of
• Oxalates: Oxalates are relatively inexpensive, easy to sealing of dentinal tubules, nerve analgesia or placebo
apply and well tolerated by patients. Potassium oxalate effect. The sealing effect is considered to be durable,
and ferric oxalate solution make available oxalate ions whereas nerve analgesia or placebo effects are nor.
that can react with calcium ions in the dentin fluid to
form insoluble calcium oxalate crystals that are depos- Patient Education
ited in the apertures of the dentinal tubules.
Dietary Counseling
Dental Resins and Adhesives Dietary acids are capable of causing erosive loss of tooth
The objective in employing resins and adhesives is t~ sea! structure, thereby removing cementum and resulting in
the dentinal tubules to prevent pain producing sumuli opening of the dentinal rnbules. Consequently, dietary
from reaching the pulp. Several investigators have de~on - counseling should focus on the quantity and frequency
stra1ed immediate and enduring relief of pain for penods of acid intake and intake occurring in relation to tooth
of up to 18 months following treatment. Although n~t brushing. Any treatment may fail if these factors are not
intended for treatment of generalized areas of root sensi - controlled. A written diet history should be obtained on
tiii ty, thi s can be an effective method of treatment when patients with dentinal hypersensitivity in order ro advise
other form s of th erapy have failed. . those concerning eating habits.
GLUMA is a dentin bonding system that includes Because of the presence of a smear layer on dentin,
~utaraldeh yde primer and 35 percent HEMA (hydro~- teeth are not usually sensitive immediately following
tlhyl meth ac rylate). ft provides an anachment to dennn scaling and root planning. However, removal of the smear
1ha1 is imm edi ate and strong. GLUMA has been fou nd to layer may result from exposure ro certain components of
hehighl y cffec rive when other methods of treatment failed the diet. Srudies have shown that citrus frujr juices, apple
10 ProiicJ e relief (Fig. 26.17) . juice and yoghurt are capable of dissolving the smear layer.
 ;r:e xtoook of Operative Dentistry
Because loss of dentin is greatly increased when
brushing is performed immediately after exposure of the
tooth surface to dietary acids, patients should be cautioned
again st brushing their teeth soon after ingestion of citrus
food .
Toothbrushing Technique
Because incorrect toothbrushing appears to be an etio -
logic factor in dentin hypersensitivity, instruction about
proper brushing techniques can prevent further loss of
dentin and the h ypersensitivity.
Plaque Control
Saliva contains calcium and phosphate ions and is there -
fore able to contribute to the formation of mineral deposits
within exposed dentinal tubules. The presence of plaque
may interfere with this process, as plaque bacteria, by
j producing acid, are capable of dissolving any mineral
.J precipitates that form, thus opening tubules.
' .)
. ·7 Professional interest in the cause and treatment of
'i dentinal hypersensitivity has been evident in the dental
..i literature for approximately 150 years or more. Dentinal
1,1 ~ hypersensitivity satisfies all the criteria to be classi-
0 fied as a true pain syndrome. Myelinated A fibers mostly
A-delta type seems to be responsible for the sensitivity
of dentin. Of the various theories proposed, the hydro -
dynamic theory is the most accepted explanation for the
mechanism of dentin hypersensitivity. Management of
the condition requires determination of etiologic factors
and predisposing influences. Desensitizing toothpastes
containing potassium nitrate, strontium chloride and
sodium monofluorophosphate have proven to be effective
in the management of hypersensitivity. Partial obturation
of open tubules the most widely practiced in office treat-
ment of dentinal hypersensitivity.
@ Key Points
• Pain is descri bed "as a n unp leasa nt sensory and emo-
tiona l experi e nce associ ated with actual or potential tis-
sue dama ge ."
• Dentin hy perse nsiti vity is defined as "sharp, short pa in
arising from ex posed dentin in respon se to stimu li typi-
ca lly thermal, chemical, tactil e or osmotic a nd wh ich
cannot be ascribed to a ny othe r form of denta l defect
or pathology.
• The sharp, better localized pain is mediated by A delta
fibers, whereas C fibers activation seems to be connect-
ed with the dull radiating pain sensation . Myel inated A
fiber seems to be responsible for dentin sensitivity.
• The dehydration of dentin by air blasts or absorbent pa-
per cause s outward fluid movement and stimulates the
mechanoreceptor of the odontob last, causing pain . Pro-
longed air blast causes formation of protein plug into
the dentinal tubules, reducing the fluid movem ent and
thus decreasing pain .
• The most common reason for ex posed dentinal tubules
is gingival recession which can be due to inadequate
attached gingiva , improper brushing technique, perio-
dontal surgery, overzealous tooth cleansing habits, oral
habits, etc.
• Tooth hypersensitivity differs from dentinal or pulpal
pa in. In case of dentin hypersen sitivity, pati e nt's abil-
ity to locate the source of pain is very good, whereas in
case of pulpal pain, it is very poor.
• To treat dentin hypersensitivity different ways to reduce
the dia meter of dentinal tubules are formation of a smear
layer by burnish ing the exposed root surface, appl ication
of agents that fo rm insoluble precipitates within the tu-
bul es, appl ication of dental bond ing agents a nd covering
the exposed dentinal tubules by surgical means.
• The objective of fluoride iontophoresis is to drive fluoride
ions mo re dee ply into the dentinal tubu les that cannot be
achieved with topical application of fluoride alone.
• GLUMA is a dentin bond ing system that incl udes gluta-
raldehyde primer and 35 perce nt HEMA (hydroxyethyl
methacrylate) . It provides an imm e diate and strong at-
tachment to dentin .
• La ser causes desen sitization because of se aling of de n-
tinal tubu les, nerve analgesia o r placebo effect.
QUESTIONS
1. Write short notes on:
a . Management of dentin hypersensitivity
b . Theories of dentin hypersensitivity.
BIBLIOGRAPHY
l . Butler WT. Dentin matrix proteins. Eur I Oral Sci.
1998;106:204.
2. Trowbridge HO, Silver DR. A review of current approaches
for in-office management of tooth hypersensitivity. Dent
Clin North Am. 1990;107:65-9 .