DENTINAL

HYPERSENSITIVITY.

Contents.
Introduction
Definitions
Etiology
Mechanism of dentin sensitivity
Theories
Clinical considerations
Methods of measuring hypersensitivity
Management of hypersensitivity
Summary & conclusion

Introduction.
The term dentine hypersensitivity has been used for

many decades to describe a common painful condition

of the teeth. Despite this there are many gaps in our
knowledge concerning 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 from exposed dentine in response to
stimuli, typically thermal, evaporative, tactile, osmotic
or chemical and which cannot be ascribed to any other
dental defect or pathology.
Dowell and Addy 1983

Prevalence
15-18% of the general populations;
72-98% - In periodontal patients

Age incidence: 20-40 yrs peak; range 20-50 yrs.

(Reasons appearance and progression of gingival recession.)

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 females.

Either periodontal disease and / or periodontal treatment

predisposed to dentine hypersensitivity, presumably through

both having effects on dentine and gingival recession.

Distribution
Buccal cervical area of teeth
Reasons site of pre-dilection for gingival recessions and

the area where enamel is the thinnest.

Most commonly affected are canines and Ist premolars,

then incisor and 2nd premolars, least often molars.

Show a negative co-relation with plaque scores recorded

by site.
Significantly greater proportions of left side tooth

sensitivity compared with their right contralateral tooth

types.

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

Gingival recession

Enamel loss

Attrition.

Abrasio
n.

Erosion.

Abfraction.

Other reasons.
Improper instrumentation
Enamel and cementum do not meet at the CEJ

Gingival recession
Cause:

Tooth brushing

ANUG and ANUP,

Self- inflicted injury,

Periodontal disease,
Periodontal surgical and non-

surgical procedures,
Dehiscence / fenestrations.

B. LESION INITIATION
Require opening of dentinal

tubules
Tooth paste remove the smear

layer through abrasive and

detergent actions
Erosive agents, particularly acid

dietary fluids readily expose

tubules
Most soft drinks, some alcoholic

beverages and yoghurt all readily

remove the dentine smear layer
after a few minutes of exposure.
Erosion causes bulk loss of

dentine and surface softening,

which is very susceptible to
physical insults.

Mechanism of action

Direction neural stimulation

According to this theory the dentinal tubules innervated

by nerves, which extend upto 100 microns along the

dentinal tubules.

Whenever there is injury to these dentinal tubules, the

stimuli reach the nerve ending in the inner dentine.
The stimulated nerve causes hypersensitivity.
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 accommodate these sensations.

But smaller C fibres tend to be maintained hence

high intensity gates remain open

Causing pain

2. Transduction theory
Membrane of the odontoblast process is excited by the

stimulus and the impulse is conduct to the nerve ending

in the inner dentine i.e. pre-dentine, odontoblast zone
and pulp.
Not popular theory since there is no neurotransmitter

vesicles in the odontoblast process to facilitate the

synapse or synaptic specialization.

3. Hydrodynamic theory
Ist proposed Gysi 1900,)

(Brannstrous 1963,67.)
Rapid shifts of the fluids within
the dentinal tubules, following
stimulus application, result in
activation of sensory nerves in
the inner dentin region of the
tooth

Clinical assessment of
dentine hypersensitivity

Subjective Evaluation

1.

Verbal rating scale is a simple descriptive pain scale

which includes the following:

0 No discomfort

1 Mild discomfort

2 Marked discomfort

3 Marked discomfort that lasted for more than 10

seconds

2.

Visual analogue scale is a line 10 cm in length,

the extremes of the line representing the limits
of pain, a patient might experience from an
external stimulus.

3.

McGill pain questionnaire the patient is

shown 20 sets of words and asked to select a
word from each set which best describes the
present pain experience.

 Objective assessment

Mechanical or tactile stimuli

Pass a sharp dental explorer grade the response

..scale 0 3
Collins used a no 23 explorer
Simple yet effective
5 10 gm of forceTip of the explorer 500/nm2
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
Indicator Records the force of displacement in

centinewtons
Probed at CEJ
A tooth that fails to respond at 80 centi-newtons is non

sensitive.

Scratch device

Thermal Sensitivity
Directing a burst of warm temperature air from a dental

syringe onto the test tooth

One second blast from the air syringe . temperature

is b/n 650 and 700F and at a pressure of 60 psi

0 - No discomfort
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

 An air thermal device devised by Dr. K.C. Yeh

Used a temperature controlled stream of air as the stimulus.

Air was heated to 1000F 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 psi could be adjusted to between 100 0 and 700F

within about 2 minutes.

 Cold water testing: varied temperature of 15 ml of water is

rinsed.
Thermo-electric device (Biomat-thermal probe)

It provides a continuous application of heat/cold.

Consists of small probe tip to which thermistor is attached.

This thermistor measures the temperature at the probe tip.

A current flow is used to regulation air temperature either by

increasing or decreasing the current flow in range of 12 oC- 82oC

It is preset at temperature of 37.5 oC. It can be used for heat

and cold testing by increasing or decreasing the temperature

by IoC.
Ice stick.
Heat or cold air.
Ethyl chloride.

Electrical stimulation
Electrical pulp tester
Is a battery operated, producing pulses of direct current. The

intensity of the output voltage may be increased by presetting 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 1/3rd of enamel and

tooth stimulated. A electrolytic gel with a pH of 5.4 5.6 is

used.
When patients feel tingling warm sensation, it is switched off

Stark instrument for electrical

stimulation

Chemical / osmotic
stimulation
Hypertonic solutions. Eg. Sodium chloride glucose, sucrose

and calcium chloride.

The use of chemical solution is complicated, because the

solute in solution diffuses into the dentine fluid. On repeated

applications, the osmotic pressure difference between the
tubular fluid and the applied fluid will decrease and reduce
the effect of the solution as our osmotic stimulus.
To avoid this, long time intervals must be allowed between

the applications of the solutions.

Practically least preferred.

Differential Diagnosis

Cracked tooth syndrome.

Fractured restorations.

Chipped teeth.

Dental caries.

Post-restorative sensitivity.

Teeth in acute hyper function.


MANAGEMENT

Classification
According to Scherman A and Jacobeen 1992.
Based on chemical and physical properties as follows.
Chemical agents

Physical agents

Corticosteroids
Silver nitrate

Composites
Resins

Strontium chloride

Varnishes

Formaldehyde

Sealants

Potassium nitrate or oxalate

Soft tissue

grafts
Fluorides
Sodium citrate
Iontophoresis with 2% NaF

Glass inomer cement

Lasers

B. IN-OFFICE PRODUCTS
1.

Treatment agents that do not polymerize.

a. Varnishes / Precipitants
Shellacs
5% NaF varnish
1% sodium fluoride, 0.4% stannous fluorides
3% mono-potassium-monohydrogen oxalate
6% acidic ferric oxalate
Calcium phosphate preparations.
Calcium hydroxide.
b. Primes containing HEMA (Hydroxy ethyl methacrlate)
5% glutaradehyde
35% HEMA in water

II. Treatment agents that undergo setting or polymerization reactions.

Conventional glass ionomer cement.
Resin-modified glass ionomer cement / Compomers
Adhesive resin primers
Adhesive resin bonding system.

III. Use of mouth guards.

IV. Iontophoresis.
V. Lasers.

Mechanisms
The most likely mechanisms of action is the reduction

in the diameter of the dentinal tubules so as to limit the

displacement of fluid in them.
According to Trowbridge and Silver (1990) this can be
attained by
Formation of a smear layer produced by burnishing the

exposed surface.
Topical application of agents that forms insoluble

precipitates with in the tubules.

Impregnation of tubules with plastic resins.
Sealing of the tubules with plastic resins.
Act via precipitates of crystalline salts on the dentine

surface, which blocks dental tubules.

Desensitizing agents are effective when used

continuously for a period of at least 2 weeks.

A. Home use products

Rationale.
Home use over the counter desensitizing products appear

to be the most realistic and practical means of treating most

patients with tooth dentine hypersensitivity and should be
the 1st step in routine management.

Several reasons exit to prescribe these

products.
They are readily and widely available in pharmacies
The products are cost effective.
The over the counter products an simple to use and non-

invasive
The habit of tooth brushing is almost universal the patients

are not required to do anything.

Strontium chloride

Dentifrice containing 10% strontium chloride

hexahydrate as the desensitizing agent

Sensodyne tooth paste was formulated with

strontium chloride hexahydrate in 1961

In vitro studies report that strontium chloride only

slightly reduces dentinal fluid flow, the
occurrence thought to be produced by the
abrasive filler occluding the tubule orifices.

Skurnick in an uncontrolled study, found that it

decreased dentinal sensitivity short term in 93%
of cases.

However, Anderson and Matthews found it

ineffective as a densitizing agent.

Possible detrimental pulpal effects of strontium

chloride have also been suggested.

Minkoo et al regular at-home use of a dentifrice

containing 10% strontium chloride hexahydrate is
an effective means for reducing the discomfort
and pain engendered by thermal and tactile

Potassium Nitrate

Greenhill and Pashleyfound potassium nitrate - ineffective in

decreasing any dentinal fluid flow in in vitro coated dentin, even at a
30% concentration.

But many investigators have found 5% potassium nitrate an excellent

dentinal desensitizing agent.

Hodash (1974) called potassium nitrate a superior desensitizer and

found it to be highly effective at concentrations of 1 to 15 %

In a controlled study, Tarbet et al found 5% potassium nitrate-paste

able to desensitize the dentin effectively at 1 week and up to 4 weeks
compared to the control (paste without potassium nitrate) in 92% of
the subjects. In a follow-up report, which histologically examined the
pulpal effects of the previous study, it was determined that
"potassium nitrate did not induce any pulpal tissue change

Sodium monoflurophospate
In a study by Arowojolu (2001) , the desensitizing effect

of sodium monoflurophosphate was better than

srontium chloride.
In conclusion a commercially available dentrifice of Na

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 35% HEMA]

Corticosteroids

Anti-inflammatory effect of glucocorticoids . decrease dentinal

sensitivity

Mjor and Furseth .. application of corticosteroid preparation to

dentin caused complete obliteration of tubules .

Mosteller . liner consisting of 1% prednisolone in combination

with 25% parachlorophenol, 25% m-cresyl acetate and 50% gum
camphor prevented postoperative thermal sensitivity

Mjor showed that steroid application to dentin increased

peritubular dentin mineralization.

Thus, the tubule lumen would be decreased, resulting in less

dentin tubule fluid movement, reducing the dentinal sensitivity.

Green et al compared steroid application to Ca(OH)2 in their

ability to induce mineralization. The results were very similar for
both compounds, with the steroid causing "completely obturated
tubules" and calcification "in an area of the dentine where no
highly mineralized peritubular matrix is normally found."

Burnishing of dentin

Tooth pick or "orange wood stick creates a partial smear layer on

dentin surface .

Reduced fluid movement by 50% to 80% .

More effective in reducing dentin permeability than burnishing with

glycerin alone or glycerin in combination with sodium flouride.

Pashley et al - The effects on dentin permeability of burnishing NaF,

kaolin, or glycerin, alone and in various combinations, were
determined using an in vitro system. The results indicate that the
important variable was not any of the constituents of the paste but
the burnishing process itself.

Silver nitrate
Powerful protein precipitant .
Greenhill and Pashley found that the silver nitrate either

alone or in combination with formalin ppted silver chloride

or elemental silver
It may cause pulpal inflammation in shallow cavities.
Naylor and Anderson and Matthews measured dentin

sensitivity before and after silver nitrate application and

found no significant difference in pain response.
Thus, silver nitrate may be ineffective and is possibly

deleterious in the management of dentin sensitivity.

Calcium hydroxide

It may block dentinal tubules or promote peritubular dentin formation .

Brannstrom (1976) construction of the dentinal tubules depth of 0.1mm .

Mjor (1967)micro radiography increased radio density

In a study by Greene et al hydroxide was an effective desensitizing agent over

the control to mechanical, hot and cold stimulation .Calcium hydroxide outperformed potassium nitrate at all time intervals throughout cold stimulation
and therefore is especially recommended as a desensitizing agent for those
patients who are sensitive only to cold.

Jorkjend and Tronstad applied calcium hydroxide to sensitive teeth following

periodontal surgery, sealing it in with polymethacrylate and a periodontal
pack. They found best results were obtained after 7 days, with the teeth no
longer sensitive to cold, air, carbohydrates, toothbrushing, toothpicks, scaling
or ultrasonic devices

In a 3-month clinical study, Green et al found calcium hydroxide applications

consistently effective in relieving cervical hypersensitivity

Hydroxyapatite
Shetty et al evaluated Hydroxyapatite as an In-Office

Agent for Tooth Hypersensitivity - showed definite

potential as an effective desensitizing agent providing
quick relief from symptoms. None of the patients
reported any adverse responses to the agent

Fluoride

Mechanism of action.
increasing the amount of reparative dentin, or
by precipitating calcium fluoride in the tubules

Johnson et al (1981) stannous fluoride with the ionizing brauh

provided significantly greater relief than did the stannous fluoride
alone.

Clement and Hoyt and Bibby (using 33.3% NaF) found sodium fluoride
very effective in reducing dentinal hypersensitivity in subjective,
noncontrolled studies. However, sodium fluoride may produce severe
pulpal inflammation when applied to dentin.

Fluoride Iontophoresis
A low voltage electric current is used to impregnate the tooth with

fluoride ions.
Two to six times more fluoride can be impregnated into dentine than

when treated with topical sodium fluoride.

Manning described an iontophoretic device which would work

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-term relief

Intra oral fluoride releasing

device.
Sodium fuoride in an acrylic polymer releasing fluoride

at the rate of 0.04mg/day,

This device is fast , painless and cost effective (marini

et al 2010)

 Orsini et al (2013) compared

Three dentifrices [1) containing 8% arginine, 1450ppm

sodium monofluorophosphate; 2) containing 8%
strontium acetate, 1040ppm sodium fluoride; 3)
containing 30% micro-aggregation of zinc-carbonate
hydroxyapatite nanocrystals] were compared after 3day treatment .

This study documented that the three tested

dentifrices 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 dentifrice.

Oxalates

used popularly as desensitizing agent

inexpensive

easy to apply and

well tolerated by the patients

Potassium oxalate and ferric oxalate solutions -calcium ions in

the dentinal fluid to form insoluble calcium oxalate crystals.

Muzzin et al compared 30% dipotassium Oxalate (DO) and 3%

monohydrogen-monopotassium Oxalate (MO) on the reduction
of dentin hypersensitivity in vivo. Results suggested - decrease
in dentin hypersensitivity following the application of 3% MO
alone, and 30% DO followed by 3% MO.

Lasers
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.

Kumar et al - 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.
Yilmaz et al (2011) evaluate the efficacy of er cr ysgg laser on

reduction in dh. Immediately after treatment the er cr ysgg

laser had a significant higher desensitizing effect and the

Dentine bonding agents

Bonding agents are applied to the exposed dentine

Easy to apply

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 teeth.

Narhi et al. recorded nerve activity directly in cat teeth

when dentin was mechanically stimulated. He found no
neural activity after resin impregnation.

Composite/ glass ionomer

restorations
Long lasting, yet more invasive procedure
Is indicated when there is significant loss of tooth

structure

GC tooth mousse
Kowalczyk A et al
GC Tooth Mousse for dentine hypersensitivity was

evaluated - cold air stream

Min. 6 weeks of topical application would reduce

hypersensitivity.

CPP-ACP: Casein Phosphopeptide

Amorphous Calcium Phosphate).

Nano structures bioactive

glass.
-Mitchell et al(2011)
Nano structured sol gel bioactive glass with carrier fluid

showed a significant change in reduction of

conductance
Produced an immediate reduction in

fluid conductance, and maintaining it for at least 7 days

Conclusion.
Much has been learnt about hypersensitivity since it
has been described as an enigma 20 years ago.
The ultimate goal in the treatment of dentine
hypersensitivity is the immediate and permanent relief
of pain
Professionals should identify the causative factors
so that prevention can also be included in the
treatment plan

References.

Calcium Hydroxide and Potassium Nitrate as Desensitizing Agents for

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-Ionizing 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.

The Effects of Burnishing NaF/Kaolin/Glycerin Paste on Dentin

Permeability, Pashley et al, J Periodontol. January, 1987. Volume 58
Number 1

Efficacy of Strontium Chloride in Dental Hypersensitivity, Minkof et sl ,

J. Periodontol. July, 1987 Volume 58 Number 7.

Effects of Potassium Oxalate on Dentin Hypersensitivity in Vivo,

Muzzin et al, J. Periodontol. March 1989, Volume 60 Number 3.

Intraora fluoride releasing device: a new clinical therapy for dentin

sensitivity, merini et al , JOP 2000 vol 71, 90-95.

2% Sodium Fluoride-Iontophoresis Compared to a Commercially

Available Desensitizing Agent. Singal et al , J Periodontol 2005;76:351357.

Short-Term Assessment of the Nd:YAG Laser With and Without Sodium

Fluoride Varnish in the Treatment of Dentin Hypersensitivity A Clinical
and Scanning Electron Microscopy Study, Kumar et al , J Periodontol
2005;76:1140-1147.

Hydroxyapatite as an In-Office Agent for Tooth Hypersensitivity: A

Clinical and Scanning Electron Microscopic Study, shetty et al, J
Periodontol 2010;81:1781-1789.

A 3-Day Randomized Clinical Trial to Investigate the Desensitizing

Properties of Three Dentifrices, Orsini et al, Journal of Periodontology;
2013 , DOI: 10.1902/jop.2013.120697 .

BIOMIMETIC DENTIN DESENSITIZER BASED ON NANO-STRUCTURED

BIOACTIVE GLASS, Mitchell et al J Dental materials 2011;27:386393.

Yilmaz HG,Cengiz E,Kurtulmus-Yilmaz S,Leblebicioglu B. Effectiveness

of Er,Cr:YSGG laser on dentine hypersensitivity: a controlled clinical trial.
J Clin Periodontol.2011 Apr;38(4):341-6.

Thank you