DENTIN

PART II
PRESENTED BY A SRAVYANJALI
MDS 1ST YEAR
DEPT OF CONSERVATIVE AND ENDODONTICS

1
CONTENTS
INNERVATION OF DENTIN
PERMEABILITY OF DENTIN
AGE CHANGES OF DENTIN
DEVELOPMENT OF DENTIN
DENTINOGENESIS
CLINICAL SIGNIFICANCE
THEORIES OF DENTIN HYPERSENSITIVITY
DENTIN HYPERSENSITIVITY
MANAGEMENT OF DENTIN HYPERSENSITIVITY
REFERENCES 2
Innervation
of dentin

3
 Nerve fibers were shown to accompany 30%-
70% of the odontoblastic process and these
are referred to as intratubular nerves.

Intratubular Dentinal tubules contain numerous nerve

nerves endings in the predentin and inner dentin no
farther than 100-150 um from the pulp.

Most of these small vesiculated endings are

located in tubules in the coronal zone,
specifically in the pulp horns.

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• The nerves and their terminals
are found in close association
with the odontoblast process
within the tubule.
• There may be single terminals or
several dilated and constricted
portions.

5
• In any case, they interdigitate with the
odontoblast process, indicating an
intimate relationship to this cell.
• Synapse-like relation between the
process and nerve fibers were
demonstrated.
• It is believed that most of these are
terminal processes of the myelinated
nerve fibers of the dental pulp.

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PERMEABILITY OF
DENTIN

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 DENTINAL TUBULES EXPOSED DENTINAL DENTIN PERMEABILITY
BECOME OCCLUDED BY SURFACE BECOMES DEPENDS UPON THE
GROWTH OF PERITUBULAR HYPERMINERALIZED. PATENCY OF DENTINAL
DENTIN OR BY TUBULES.
REPRECIPITATION OF
MINERALS FROM
DEMINERALIZED AREAS OF
DENTAL CARIES.

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Reduction in dentin permeability would lessen the sensitivity of
dentin.

Dentin permeability increases rapidly as the pulp chamber is

approached because the number and diameter of the tubules are more
per unit area toward pulp than toward periphery.

The outward flow of dentinal fluid, probably due to pulpal pressure,

and the odontoblasts act as barriers for entry of bacteria or their
toxins.

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10
 AGE AND
FUNCTIONAL
CHANGES
Age changes

Dentin is laid down throughout life.

This dentin is termed secondary dentin. If dentin forms as a result of

pathological process, like caries, it is termed tertiary dentin.

Tertiary dentin shows irregularity in size, shape, number, and

arrangement of dentinal tubules.

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 Dentinal tubules degenerate
due to injury resulting in the
formation of dead tracts.

Mineralization of dentinal
Functional tubules results in the
changes formation of sclerotic dentin.

This makes the tooth to

appear transparent in these
areas

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 TYPES OF DENTINE AND THEIR DISTRIBUTION

DENTINE

Secondary Tertiary dentin/reparative

Primary physiologic physiologic dentin/reactionary
dentin dentin dentin/irregular
secondary dentin

Mantle
dentin

Circumpulpal
dentin

Peritubular
dentin
Intertubular
dentin
PRIMARY DENTIN
• referred to as circumpulpal dentin
• The outer layer is called mantle dentin
SECONDARY DENTIN
• develops after root formation
• much slower, deposition of dentin
by
• tubular structure
• continuous with that of the primary
dentin.
• The ratio of mineral to organic
material is the same as for primary
dentin.
TERTIARY DENTIN
• produced in reaction to various stimuli,
such as attrition, caries, or a restorative
dental procedure.
• The quality (or architecture) and the
quantity depends on the intensity and
duration of the stimulus.
• may have tubules continuous with those
of secondary dentin, tubules sparse in
number and irregularly arranged, or no
tubules at all
• Subclassified as reactionary or reparative
dentin, the former deposited by
preexisting odontoblasts and the latter
by newly differentiated odontoblast-like
cells.
REACTION OF DENTIN TO EXTERNAL
STIMULI

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DEVELOPMENT
OF DENTIN
Dentinogenesis

Dentinogenesis begins at the cusp tips after the odontoblasts have differentiated and begin collagen
production.

In odontoblast differentiation, fibronectin, decorin, laminin, and chondroitin sulfate may be

involved.

Recent studies showed that laminin a2, a subunit of laminin, is essential for odontoblastic
differentiation and to regulate the e expression of dentin matrix proteins.
⚫ Dentinogenesis is the process of dentine formation
⚫ Starts after tooth germ has reached the
bell stage

EARLY BELL STAGE LATE BELL STAGE

MORPHO HISTO
DIFFERENTIATIO DIFFERENTIATION
N 19
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 Odontoblast and its differentiation…
⚫ Dentin forming cell
⚫ Origin- ectomesenchymal LIFE CYCLE OF
ODONTOBLAST

TGF, DIFFERENTIATION STAGE

BMP
, Form Preodontoblast Attached to BM
IGF

FORMATIVE STAGE

Odontoblast process Increase length

MAP 1B STAGE
QUIESCENT

Decreased in size Decreased dentin 20

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DEPOSITION OF ORGANIC MATRIX

GROUND SUBSTANC
E MATRIX
ORGANIC

PREDENTIN

Ca ,Po4

DENTIN
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PREDENTINE
DEFINITION

• The first deposited layer of unmineralized matrix is called predentin

THICKNESS

• 10 to 50 mm
• lines its innermost (pulpal) portion.
• remains constant because the amount that calcifies is balanced by the addition of new unmineralized matrix.
• thickest at times when active dentinogenesis is occurring
• diminishes in thickness with age.

COMPOSITION

• principally of collagen
• stains less intensely than mineralized dentin

MINERLIZATION

• Predentin gradually mineralizes into dentin

• various noncollagenous matrix proteins are incorporated at the mineralization front.
In histologic sections, predentin stains distinctively
from dentin.
COLLAGEN MATRIX FORMATION…….
MANTLE & CIRCUMPULPAL DENTIN

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Mineralization
Sequence
The earliest crystal deposition is in the form of very fine plates of hydroxyapatite on the surfaces of the collagen fibrils and in the ground
substance.

Subsequently, crystals are laid down within the fibrils themselves.

The crystals associated with the collagen fibrils are arranged in an orderly fashion, with their long axes paralleling the fibril long axes, and
in rows conforming to the 64 nm (640 Å) striation pattern.

Within the globular islands of mineralization, crystal deposition appears to take place radially from common centers, in a so-called
spherulite form.

These are seen as the first sites of calcification of dentin

 MICROBIOLOGY
ORBAN’S ORAL HISTOLOGY AND
Mineralization
First-formed dentin, showing cytoplasm of apical zone of
ameloblast, above, and first-formed enamel matrix at the
dentinoenamel junction.

Below, the junction collagen fibers of dentin matrix are seen

with calcification sites appearing near the first-formed enamel.

Predentin zone is seen below these sites with the odontoblast

process extending from the odontoblasts at bottom of field.

(B) Predentin and dentin as visualized in a later developing

tooth. Observe calcified (black) dentin above, predentin
composed of collagen fibers below, odontoblast processes, and
the cell body (transmission electronmicrographs).

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ORBAN’S ORAL HISTOLOGY AND
MICROBIOLOGY
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Rate of
mineralization The general calcification process is
gradual,

the peritubular region becomes

highly mineralized at a very early
stage.
The ultimate crystal size remains
very small, about 3 nm (30 Å) in
thickness and 1001 nm (1000 Å) in
length.
30
 PATTERN OF MINERALIZATION

LINEAR MIXED GLOBULAR

 SLOW RATE  RAPID

 UNIFORM NON UNIFORM
(CIRCUMPULPAL DENTIN) MANTLE DENTIN

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FACTORS EFFECTING
MINERALIZATION
CACLIUM • INITIATION

• INHIBIT GROWTH OF HYDROXY APPETITE

OSTEONECTIN • PROMOT BINDING OF Ca2 &Po4

OSTEOPECTIN • MINERALIZATION

PROTEOGYCAN • PREVENT PREMATURE CALCIFICATION

• Transport of ca,
DPP • Aggregation of fiber,stabilization of crysytal

GLA PRTOEIN • ATTRACT AND CONCENTRATE CALCIUM

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GENETIC FACTORS
• REGULATE
Wnt10a SIALOPHOSPHOPROTEIN mRNA.

• REGULATE DENTIN MATRIX

M06-G3 PROTEIN

HEPARAN • REGULATE SIGNALING AND

SULPHAT DEVELOPMENT
E
TGF,BS • MINERALIZATION
P 33
COLLAGEN MATRIX

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MINERALIZATION PROCESS

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 Ca
BSP 2,6
OPN DIFFERENTIATION OF
ODONTOBLAST

TGF ß 1

DEPOSITION OF
FIBRONECTIN RICH
MATRIX

EXPRESS DSP

REPARATIVE DENTIN
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Recap ……… ODONTOBLAST

1- PRIMARY PREDENTIN
2-SECONDARY 1-MANTLE
3- TERTIARY 2-CIRCUMPULPAL
Metadentin

DENTIN

1-PERITUBULAR 1- INTERGLOBULAR
2- INTERTUBULAR 2-TOMES GRANULAR
LAYER

1-VON EBNER 1-DEAD TRACT

2-OWEN 2-SCLEROTIC
3-NEO NATAL DENTIN 37
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 38
3
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CLINICAL
SIGNIFICANCE
DENTIN HYPERSENSITIVITY
DENTINAL CARIES

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DENTINAL CARIES

The rapid penetration and spread of caries in the dentin is the result of the
tubule system in the dentin.

The enamel may be undermined at the dentinoenamel junction, even when

caries in the enamel is confined to a small surface area.

This is due in part to the spaces created at the dentinoenamel junction by

enamel tufts, spindles, and open and branched dentinal tubules.

The dentinal tubules provide a passage for invading bacteria and their products
through either a thin or thick dentinal layer.

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Electron micrographs of carious The tubules are enlarged by the
dentin show regions of massive destructive action of the
bacterial invasion of dentinal tubules. microorganisms.

Dentin sensitivity of pain,

unfortunately, may not be a
Thus patients are surprised at the
symptom of caries until the pulp is
extent of damage to their teeth with
infected and responds by the process
little or no warning from pain.
of inflammation, leading to
toothache.

Undue trauma from operative

instruments also may damage the
pulp.

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Air-driven cutting instruments cause
dislodgement of the odontoblasts from the This could be an important factor in survival
periphery of the pulp and their “aspiration” of the pulp if the pulp is already inflamed.
within the dentinal tubule.

Repair requires the mobilization of the

macrophage system as healing takes place;
as this progresses,
there is the contribution of deeper pulpal
cells, through cytodifferentiation into
odontoblasts, which will be active in
formation of reparative dentin.

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DENTIN
HYPERSENSITIVITY
 THEORIES OF
DENTIN
HYPERSENSITIVIT
Y

T H E R E A R E T H R E E T H E O R I E S

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 D I R E C T N E U R A L S T I M U L AT I O N

THE NERVES IN THE THE NERVES IN THE TOPICAL APPLICATION HENCE THIS THEORY IS
DENTIN GET DENTINAL TUBULES ARE OF LOCAL NOT ACCEPTED.
STIMULATED. NOT COMMONLY SEEN AND
EVEN IF THEY ARE ANESTHETICS DOES
PRESENT, THEY DO NOT NOT ABOLISH
EXTEND BEYOND THE SENSITIVITY.
INNER DENTIN.

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46
 HYDRODYNAMIC
THEORY

Various stimuli such as heat, cold, air blast desiccation, or mechanical or

osmotic pressure affect fluid movement in the dentinal tubules.

This fluid movement, either inward (due to cold stimuli) or outward.

Stimulates the pain mechanism in the tubules by mechanical disturbance

of the nerves closely associated with the odontoblast and its process.

Thus these endings may act as mechanoreceptors as they are affected by

mechanical displacement of the tubular fluid.

MOST ACCEPTED THEORY

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48
 Which presumes that the odontoblast process
is the primary structure excited by the stimulus
and that the impulse is transmitted to the nerve
endings in the inner dentin.

TRANSDUCTION
This is not a popular theory.
THEORY

However, odontoblasts, by modifying the local

ionic environment, alter the threshold of
intradentinal nerves.

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DIAGRAMATIC EXPLAINATION
OF THREE MAIN THEORIES

On the left is shown the transduction theory in which the

membrane of the odontoblast process conducts an impulse to the
nerve endings in the predentin, odontoblast zone, and pulp.

In the center is the hydrodynamic theory.

Stimuli cause an inward or outward movement of fluid in the

tubule, which in turn produces movement of the odontoblast and
its process.

This in turn stimulates the nerve endings.

On the right is the direct conduction theory in which stimuli directly

affect the nerve endings in the tubules.

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The sensitivity of the dentin has been explained
by the hydrodynamic theory.

Most pain-inducing stimuli increase centrifugal

fluid flow within the dentinal tubules, giving
rise to a pressure change throughout the entire Sensitivity
dentin.

This, in turn, activates the Ao intradentinal

nerves at the pulp-dentinal interface, or within
the dentinal tubules thereby generating pain.
 Erosion of peritubular dentin and smear plug removal
accounts for dentin hypersensitivity

Causes Caused by agents like

acidic soft drinks.

Brushing after acidic drink consumption induces smear

layer formation, thus reducing sensitivity.
PRINCIPLES OF TREATMENT OF
HYPERSENSITIVITY
1
To block the patent tubules or to modify or block pulpal nerve
response.

The most inexpensive and first line of treatment is to block the

patent tubules with dentifrice-containing potassium nitrate
and/or stannous fluoride.

Lasers have been used in the treatment of hypersensitivity with

varying success, ranging from 5.2% to 100%.
2
The permeability radicular dentin near the pulp is only about
20% that of coronal dentin

The permeability of outer radicular dentin is about 2% of

coronal dentin.

This suggests that the outer dentin of the root acts a barrier to
fluid movement across dentin in normal circumstances and
recalls the correlation between root planing and
hypersensitivity.
3

Smear layer consists of cut dentin surface along

with the embedded bacteria and the debris.

Though the smear layer occludes the tubules and

reduces the permeability, it also prevents the
adhesion of restorative materials to dentin.

Therefore, this layer has to be removed by

etching and a rough porous surface should be
created for bonding agent to penetrate.
4
Recent studies on tertiary dentin show that the patients treated
with transforming growth factor beta 1 (TGF-1) and to a lesser
extent with osteogenic protein-1 (OP-1) showed significantly
greater tertiary dentin formation and intratubular
mineralization, over an 8-week perio when compared with
control. Group.
  Incidence range 4-74%
 Female>>> male
 Age prevalence 20-50yrs
LESION
LOCALIZATION Mostly involved
premolar and
canine
 Mostly left side

LESION
INITIATION

59
CLINICAL TEST DIFFERENTIAL
HISTORY DIAGNOSIS

DENTIN
HYPERSENSITIVE

HOME
DESENSITIZING

IN OFFICE
DESENSITIZING

PREVENTION

ENDODONTIC
THERAPY
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 DESENSITIZING AGENT
MECHANISM
OF
ACTION

NERVE PROTEIN PLUGGING

DESENSITIZATIO PRECIPITATIO DENTINAL TUBULES
N N
 POTASSIUM
 Sodium fluoride
NITRATE
 Silver nitrate  Stannous fluoride
 Zinc chloride  Potassium oxalate
 Calcium hydroxide
Sodium monofluoro
phosphate

61
 SOME COMMERCIALLY
AVAILABLE
COMMERCIAL NAME
toothpaste
COMPOSITION

Senquel, Potassiun nitrate 5%

sensodent k
Sensodyne
Senquel f Potassium nitrate 5%
Sensodent kf Sodium monofluoro
Nitra phosphate.7%
Thermoseal RA F-917 ppm
Thermokind f

Sensoform Strontium chloride 10%

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27
 Desensitizing Mouth rinse
COMMERCIAL NAME COMPOSITION

SENQUEL –AD Potassium nitrate 3%

NITRA OR Sodium fluoride 0.2%
SENSOWASH

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 OTHER METHOD
DENTIN ADHESIVE

Dentin bonding agent are used

Micro mechanical bonding through
formation of an interdiffusion hybrid layer
 Fluoride varnishes
 Oxalic acid and resin
 Glass ionomer cements
 Composites
 Dentin bonding agents
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 NOVAMIN in DH

⚫It is Bio active glass ceramic

MOA
⚫ Calcium sodium
phosphosilicate
Aqueous medium
Release calcium and phosphate
ion

Form hydroxy-
carbonate appetite
SEAL DT

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 Recaldent
Is a complex of Casein Phosphopeptide (CPP) and Amorphous
Calcium Phosphate (ACP)
MAO
 Binds readily to surfaces within the oral cavity
Delivers calcium and phosphate ions to the enamel and into
the oral environment
 Works with fluoride in toothpaste (for MI Paste & MI Paste
Plus
users)

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 Laser in DH

Example- Nd:YAG laser, CO2 LASER

MOA- 1-Coagulation and precipitation of plasma

protein in dentinal tubules(Goodies et al 1994)
2-thermal energy liberated alter intra-dental nerve
activity (Orcharelous et al 1998)

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 IONTOPHORESIS…
Electrical potential is used to transfer the ion into body
for therapeutic purpose
Used sodium fluoride.
MOA-
Method… Current may
Place a negative electrode on produce reparative
the dentin & positive dentin or nerve
Electrode on the patients arm
Chemical is applied to tooth paresthesia.
surface & current is  Fluoride ion
passed through –ve precipitation may
electrode using 0.5mA occlude by
current calcium formation.
fluoride 68
33
 Advanced THERAPY FOR
DH
The PILP system-
The polymer-induced liquid precursor
(PILP) system created by Laurie Gower, PhD, an
associate professor in the department of materials
science and engineering at the University of Florida
in Gainesville.(June 2, 2011)

(study performed at the University

of California, San Francisco (UCSF))

69
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 MOA…

Poly- L-aspartic acid delivers calcium phosphate to the

fibrils and releases it inside the collagen fibril so
minerals form within them.
Its occurs too shortly
Full recovery will
occurs.

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 ICON DMG…..
Features and Benefits
 Micro invasive technique
 No drilling or anesthesia required
 Prevents lesion progression
 Treated lesions lose whitish appearance and look like
healthy enamel
 Easy treatment
 only one visit

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 FUTURE THERAPY FOR
DH
Gene therapy……
Blocking the nerve
growth factor (NGF) by
pulpal fibroblast near
the lesion .

72
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HERBAL THERAPY FOR DH

73
73
to get rid
of
Crush l g:o Add ,a few drops of

ENSITIVITY dic dove. wafer.

Add some table Apply it on the affected

sal.i. tooth. Rinse oH
REPEAT TWICE DAILY FOR A after □II
sever 74
 leaves
, To ,GET RI,D
QF
T00TH
Put 4 - 5 guava
SENSITIV ITY
Strain & let it cool
-
leaves in FAST AT HOME down,
1 cup of water.

Add some salt & use this

Boil it for 5 solution
minutes. as o mouthwash. 75
 ALTto Get Rid of TH
WATET
R SENSITIVITY

a Rinse your mouth .w1th. this s. a. lt-water solution.

Mix ½ tsp sa1It ·rn l cup.· .o. · fi w· . rm Do this fw 11ce 76
 REFERENCE
⚫ JOURNA F CONSERVATIVE Orban’s Oral histology and
DENTISTRY 2010 OCT-DEC Embryology
Dentin hypersensitivity: Recent  Ten cate’s oral histology
trends in management Shafer’s Text book of
Sanjay Miglani, Vivek oral pathology
Aggarwal, and Bhoomika Ahuja
⚫ International Journal of Dentistry
Volume 2009 (2009), Article
ID 464280, 12 pages
http://dx.doi.org/10.1155/2009/4642
80Review Article Reparative
Dentinogenesis Induced by Mineral
Trioxide Aggregate: A Review from
the Biological and Physicochemical
Points of View
Takashi Okiji and Kunihiko Yoshiba

77
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 REFERENCE…….
1.Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Remineralization of
enamel subsurface lesions by sugar–free chewing gum containing
casein phosphopeptideamorphous calcium phosphate. J Dent Res.
2001 Dec;80(12):2066–70.
2.Morgan MV, Adams GG, Bailey DL, Tsao CE, Reynolds EC. CPP–ACP
gum slows progression and enhances regression of dental caries. J
Dent Res 2006; 85 (Sp. Iss. B): 2445.
3.Walsh LJ. Tooth Mousse: Anthology of Applications. GC Asia Dental,
2007. 4.Cochrane NJ, Cai F, Reynolds EC. QLF and TMR analysis of CPP–
ACFP remineralized enamel in vitro. J Dent Res 2006; 85 (Sp. Iss. B):
0192.

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“I will apply, for the benefit of the sick, all measures [that] are required,
avoiding those twin traps of overtreatment and therapeutic nihilism”.
(Hippocratic Oath)

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