IJNIB WMGOG

HYPERSENSITIVITY

Dr. Damtew

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 CONTENTS

• Introduction

• Etiopathogenesis

• Assessment of DHS

• Diagnosis of DHS and Differential Diagnosis

• Management Strategy of DHS

• Conclusion
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 INTRODUCTION

• Dentine hypersensitivity (DHS)

• is one of the most commonly encountered dental
problems
• It is characterized by
• short, sharp pain arising from exposed dentine in
response to stimuli
• Stimulus
• thermal, evaporative, tactile, osmotic or chemical

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• Hypersensitivity may present on
several teeth,, or on one specific
tooth
• DHS should be differentiated from
• dental caries,
• microleakage,
• cracked tooth or
• fractured restorations

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 PRE VA LE NCE A ND E PI DEMI OLOG Y

• Incidence of DHS in most populations

• Ranges between 10-30% of the general population
• Age range varies from 20-50 years
• Peak incidence occurring at the end of the third
decade
• Decreases during the fourth and fifth decades of
life

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• Higher incidence of DHS is reported in
females than in males
• May reflect hormonal influence and dietary
practice
• canines and premolars of both the
arches are the most affected teeth.
• buccal aspect of cervical area is the
commonly affected site

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 THEORIES AND MECHANISM
OF SENSITIVITY

• Odontoblastic transduction theory

• Neural theory
• Hydrodynamic theory

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 O D O N TO B L A S T I C T R A N S D U C T I O N
T H E O RY

• Postulated that odontoblasts act as

receptor cells and causing sensation
• Deficient and unconvincing
• Odontoblasts are matrix forming cells
• They are not considered to be excitable cells
• No synapses have been revealed between
odontoblasts and nerve terminal

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 NEURAL THEORY

• Presence of unmediated nerve fibers in

the outer layer of root dentine
• Thermal, or mechanical stimuli, directly
affect nerve endings within the dentine
tubules
• Theoretical with lack of solid evidences
to support it

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 H Y D R O D Y N A M I C T H E O RY

• The currently accepted mechanism

• Proposed by brännström in1964
• Fluid flow within the dentine tubules will be
increased when exposed to stimuli
• This fluid movement within the dentine tubules
causes an alteration in pressure and excites
pressure-sensitive nerve receptors across the
dentine.

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• Cold stimuli
• Stimulate fluid to flow away from the pulp
creating more rapid and rigorous neural
responses
• Heat stimuli
• Cause somewhat sluggish fluid flow towards
the pulp
• Dentine hypersensitivity patients are
more frequently complain of pain in
response to cold stimuli than to heat

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 PATHOGE NES I S

• DHS develops in two phases

1. Lésion localization
• Dentinal exposure by
• Loss of enamels (attrition, abrasion, erosion )
• Dentinal exposure mostly occurs due to gingival
recession
• Gingival recession..
• Overzealous(much energy) and improper tooth brushing
• Frequently seen on the buccal surfaces of the teeth
• Root surface of canines and premolars
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• Lesion initiation
• Tubular plugs and the smear layer are
removed
• Dentinal tubular and pulp are exposed to the
external environment

• lesions of DHS have many more and wider

open tubules than do non sensitive dentin

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 ASSESSMENT OF DHS

• Commonly, DHS might either be

assessed…
1. Stimulus-based assessment
2. Response-based assessment
• Response
• Verbal rating,
• Visual analogue scales,
• Questionnaires

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• Stimulus-based assessments
• The stimulus is varied with increasing and decreasing
intensities
• Different devices have been used in these methods
such as..
• A calibrated probe
• Tactile pressure applied to the tooth with a dental explorer
tip
• Pressure can be increased in steps of 10 g increments until
the patient experienced discomfort
• Graded thermal or electrical stimuli
• Electrical pulp testers,
• Dental pulp stethoscope 12/22/2022 15
Dr. damtew
• Drawbacks
• Repeated painful stimulation may cause a change
in sensitivity and influence the outcome.
• Time consuming

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• Response-based methods
• Assess pain severity after application of a constant,
standardized, consistent, and reproducible stimulus
• Timed airblast
• The air will be directed for 1 s
• From a distance of approximately 1 cm at the exposed buccal
surface
• Isolation from the adjacent teeth
• Subject response can be quantified by using
• A verbal rating, or visual analog scales or a validated graphic
pain scale

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• Several studies recommended the use of the Schiff
cold air sensitivity scale to assess subject response to
a stimulus like air or evaporative
• This scale is composed of several distinct scores
which are:

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• Reproducibility of assessment methods
of DHS was hard to achieve

• Recommendations
• Use least two different stimuli
• Use both assessment methods

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 VERBAL RATING SCALES

• Used to grade the level of pain experience

• Pain descriptors..
• ‘No pain’, ‘weak’, ‘mild’, ‘moderate, ‘strong’, ‘intense’, and
‘agonizing’
• Numerical scores (0, 1, 2, 3, etc.) Have been attached to these
descriptors
• Mean values are calculated
• Disadvantage
• Scores are often arbitrarily assigned numerical values
• Not offer enough descriptions that can be placed in a continuous
andDr. damtew
ascending or descending order of severity of pain12/22/2022 20
 VISUAL ANALOGUE SCALE

• Utilizes a line of 10 cm length anchored

at the 2 extremes with descriptors
representing the absolute minimum and
the absolute maximum of pain
• The patient is asked to mark off the line
such that it corresponds to the severity of
the perceived pain
• The pain intensity can be shown as an
absolute value or as a percentage of the
maximum

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 OBJECTIVE EVALUATION

• Thermal and evaporative stimuli

• A short blast of cold air
• Mechanical or tactile stimuli
• Running a sharp explorer over the area of exposed dentine
• Chemical stimuli
• Using hypertonic solutions
• The applied stimulus is expected to yield a short
sharp pain

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 DIAGNOSIS OF DHS AND DIFFERENTIAL DIAGNOSIS

• Based on a diagnosis of exclusion

• Identification of etiologic and predisposing factors
• Dietary and oral hygiene habits associated with erosion and
abrasion
• Extrinsic and intrinsic acids
• Overzealous dental hygiene
• A verbal screening, patient is asked about
• The time of the start of the disease,
• The site, the intensity
• Factors that reduce or increase the pain
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• Moreover, the patients should be
asked if the symptoms are present
• During oral hygiene procedures
• Following previous…
• professional tooth cleaning,
• vital tooth bleaching
• restorative procedures

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 DIFFERENTIAL DIAGNOSIS

• Pulpal inflammation,
• Periodontal pain,
• Cracked tooth syndrome,
• Insufficient margins of restorations,
• Atypical odontalgia(also termed phantom tooth pain
or non-odontogenic tooth pain , is a disease characterized by
continuous pain affecting the teeth or tooth sockets after
extraction in the absence of any identifiable cause on clinical or
radiographic examination)

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 CLINICAL SIGNS

• Dental erosion,
• Gingival recession, and
• Exposed cervical dentin

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 M A N A G E M E N T S T R AT E G Y O F D H S

• Depends mainly on identification and elimination of the

causative and predisposing factors
i. Avoid faulty tooth brushing to lower the risk of gingival
recession and abrasion of exposed cementum and dentin
• Not to use a hard tooth brush use only a
toothbrush with soft filaments.
• Avoid using of an excessive pressure or force
during brushing.
• Brushing time should not be extended for
prolonged period of time.

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• Excessive scrubbing at the cervical part of the
tooth that damages to the supporting structures
and causes gingival recession should be avoided

• Not to use large amounts of dentifrice or

reapplying it during brushing

• Avoid using a highly abrasive tooth powder or

paste

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• Desensitizing dentifrices containing an active agent
potassium Salts such as
• Potassium nitrate, potassium chloride or potassium citrate
• The potassium ions can decrease the excitability of A fibers,
which surround the odontoblasts resulting in a significant
reduction tooth sensitivity.
• Remineralizing toothpastes containing
• Sodium fluoride and calcium phosphates.
• Mouth rinses and chewing gums that contain
• Potassium or sodium salts

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• Avoid excessive flossing or improper use
interproximal cleaning devices or toothpicks
• Reduce the quantity and the frequency of
taking foods containing acids
• Avoid brushing for at least 30 minutes after
taking acidic food or drinks
• Wear occlusal splints to minimize tooth
wear associated with parafunctional habits
like bruxism
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 P R O F E S S I O N A L I N T E RV E N T I O N S

• Professional application of desensitizing agents

based on either
• Occlusive therapies or
• Nerve desensitization strategies

• The mechanism of occlusive therapies depends on

• plugging of the open dentine tubules
• formation of a protective layer on the dentin
surface

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• Occlusion of dentine tubules through:
I. The use of varnish, calcium compounds, fluoride
compounds
• leads to precipitation of a dentin-like mineral
II. The application of strontium chloride, formaldehyde
or glutaraldehyde
• leads to formation of salivary protein precipitants in
dentine tubule
III.use of anti-inflammatory agents such as
corticosteroids
• presumed to induce mineralization leading to tubule
occlusion
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IV.application of adhesive resin materials
• seal the dentine tubules by forming a hybrid layer and
resinous tags

• A new generation of dentin bonding agent

contains desensitizers are introduced with only
purpose of treating DHS
• cause coagulation and precipitation of serum proteins
inside dentine tubules

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V. use of bioactive glass
• form an appetite layer that occludes the
dentine tubules

• due to the presence of silica in its composition

• acts as site for precipitation of calcium and

phosphates

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IV. Laser application
• Recrystallization of dentin
• producing a glazed, nonporous surface that
partially or totally obliterate dentine tubules
• Affect the neural transmission
• coagulation of proteins in the dentine fluid

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VII. Heal ozone treatment
• Ozone penetrates the exposed tubules
• Eliminate bacterial contamination
• Allow mineral ingress
• Subsequent sealing of the dentine
tubules

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• Nerve desensitization strategy by potassium
salts depends on
• blocking of the synapse between the nerve cells
• potassium ions, will reduce the nerve excitation
• A last options for a tooth which does not
respond to other desensitizing protocols are:
1.Use of restorative material such as
• glass ionomer, and composite resins restorations
• for situations where there has been significant loss
of cervical tooth structure

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• Periodontal surgery , to cover exposed root
surface
• free gingival grafts,
• lateral sliding grafts,
• connective tissue and coronally
repositioned flaps
• If the symptoms still persists,
• the offending tooth is either root canal treated or
extracted

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 CONCLUSION

• Clinically, DHS is a relatively common and significant dental

problem for which patients look for treatment and visit dental
clinics.
• There are many treatment modalities for DHS which the clinician
may find successful in relieving the pain of DHS.
• The dental practitioner should first identify the causative or
predisposing factor after taking a thorough history before the
treatment plan is designed.
• The treatment strategy of the DHS should be begun with
prevention, self care management and later may be supplemented
with professional interventions depending on the severity of the
case

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 THANK YOU
MY
JESUS
CHRIST

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