Dentin Hypersensitivity

Dentinal Hypersensitivity
Textbook-of-Endodontics-
2nd-Edition
Chapter 32
Ziyad kamal
Spring Semester 2019/20
AAUP/Faculty of Dentistry
Definition :
Pain is an unpleasant sensation, which mostly warns
that there is a degree of tissue damage.
Pain is felt whenever a noxious stimulus just exceeds
the pain perception threshold. (C fibers)
Hypersensitivity is an exaggerated sharp transient

or temporary sensation of discomfort due to non ‐
noxious low intensity stimuli. (A delta fibers)
Sensory fibers in the pulp
C ‐ fibers
Non-Myelinated Deep Throbbing, High, stimulated

aching, with intense
lingering, tissue damage
less bearable
Myelination Location of Pain character Stimulation

terminals threshold
Sensory fibers in the pulp
A ‐ delta fibers
Myelinated Superficial Sharp, fast, Low, stimulated

momentary, without tissue
bearable damage
Myelination Location of Pain character Stimulation

terminals threshold
Adverse Effects of Post‐Operative Pain &
Hypersensitivity
Restoration of health and function is the major goal of

restorative dentistry, dentin hypersensitivity may interfere
with this goal as follows:
1. The patient may become unable to eat, drink and even

sometimes to breath.
2. The patient may avoid using the involved side.
3. The patient may acquire para‐functional adaptive biting

habits which may result in unfavorable TMJ, and periodontal
reactions
Adverse Effects of Post‐Operative Pain &
Hypersensitivity
4. If left un‐treated it may cause pathological pulp reactions.
5. If miss‐diagnosed as pain may lead to

wrong and complicated treatment.
Mechanism of Dentin Sensation
(Nerve Endings Theory)
(Odontoblasts
Receptor Theory)
A‐delta nerve endings ,interweave with the Odontoblasts along a distance of

100 micrometer from the pulp surface
Factors Affecting Dentin Sensitivity
1 The rate of tubular fluid flow
2 The nature and rate of change of the stimulus
3 The dentinal permeability or conductance

The rate of tubular fluid flow
 The rate and not the amount of tubular fluid‐

flow is the principle factor in hypersensitivity
response because activation of mechano‐
receptors is affected most by the rate of change
of the stimulus rather than its absolute value
The true physiologic stimulus

is the inward or outward fluid
shifts, not the actual trigger.
The nature and rate of change of the stimulus
 Stimuli that cause outward fluid‐flow cause more

intense response than those producing inward
fluid‐flow.
 Suddenly applied or released pressure activates the A‐delta

fibers causing perception of dentinal hypersensitivity while
steadily applied pressure does not cause such characteristic
response..
 When a steadily applied stimulus reaches noxious

values, it causes tissue damage and evokes the
C‐fibers with perception of dull pain.
The dentinal permeability or conductance
 The greater the dentin conductance, the more intense the

perception of hypersensitivity in response to stimulation by
environmental factors..
Hydrodynamic Theory
These are sensory receptors that have relatively low stimulation

threshold and are described as mechano‐receptors that
can respond to sudden changes in environmental conditions
whether thermal, tactile, osmotic or evaporative pressure.
Therefore any low intensity non‐noxious stimuli reaching an

exposed virgin dentin surface that can cause sudden inward/
outward movement of tubular fluid will stimulate these receptors
with the perception of dentinal pain.
Factors contribute to the clinical problem of hypersensitivity
1 Presence of Exposed Conducting Dentin
2 Tactile Pressure
3 Osmotic Pressure
4 Thermal Stresses
Evaporative Stimuli
5
6 Galvanic Stimuli
Presence of Exposed Conducting Dentin
 Dentin is permeable, and its permeability

increases from the DEJ to the pulp, i.e., with the
increase of cavity depth, as a result of the
increase in diameter and number of dentinal
tubules per surface area and decrease in length
o f t h e t u b u l e s .
Rapidly progressing caries, fresh cracks or fractures
of teeth or restorations, cavity preparation, and recession
usually exposes virgin, permeable, and conducting dentin.
The deeper the preparation the less the remaining dentin

Thickness(RDT) and the wider and more permeable
is the dentin.
Occlusal forces ??
Food and drinks ??
acid conditioners
Removal of smear plugs & smear layer from dentinal

tubules eliminates efficient natural protective barriers.
Tactile Pressure
Deflection of dentin by tactile pressure threshold

of 2‐Kg/cm2 , e.g., as a result of probing, premature
contacts, or by polymerization shrinkage stresses of
resin‐based restorations, causes sudden inward
movement of dentinal fluids and perception of
hypersensitivity
Osmotic Pressure
- Leakage, and cracked teeth or restorations causes

penetration of osmotic fluids have osmotic pressure
different from that of dentinal fluids.
- The difference in osmotic pressure creates an osmotic

pressure gradient.
- When this gradient reaches the minimum osmotic threshold

of 25 atmospheres, it causes sudden inward or outward
movement of dentinal fluids with hypersensitivity response
Thermal Stresses
The thermal stresses are conducted to underlying exposed

dentin surfaces through metallic restorations or by leakage
around non‐metallic restorations.
A thermal threshold of 47 C° (heating) or 26C° (cooling) at

the DEJ will evoke hypersensitivity by causing expansion/
contraction of dentinal fluid with respective sudden inward/
outward movement.
Evaporative Stimuli
Produced by air blasts and cause rapid

outward fluid shift resulting from loss of
dentinal fluids by evaporation.
Evaporative stimuli are usually employed

to identify the tooth involved in
hypersensitivity by blasting air at the
various teeth
Galvanic Stimuli
Dissimilar metallic restorations, e.g., gold

and amalgam have different electric
potential so that if they are connected in
presence of an electrolyte (saliva), a
galvanic current passes from one
restoration to the other causing a galvanic
shock of hypersensitivity
Expressions in frequent usage for DH
Dentin Hypersensitivity: Epidemiology
Global Prevalence
 Incidence: 15% (4% to 57%)
 Age range: 15 – 70+ years
 Peak incidence: 20 – 40 years
???
 Gender: Female > Males ?
 Cold is the most common
stimulus (74%)
Dentin Hypersensitivity: Epidemiology
Most Commonly Found
 Teeth:
Canines (cuspids) and premolars (bicuspids)
canines > premolars > incisors > molars
 Sites:
Buccal cervical regions the most common site
followed by labial, occlusal, distal and lingual
surfaces with the incisal and palatal surfaces
which were the least affected (Amarasena et al. In: Pashley DH, Tay FR, Haywood VB, et al. Dentin
Hypersensitivity: Consensus-Based Recommendations
2010 ; Splieth and Tachou 2012 ) for the Diagnosis and Management of Dentin
Hypersensitivity.
Generally, sensitive incisors are the most painful, followed by premolars, and then
molars.
Older teeth are generally less sensitive than younger teeth.
Dentin Hypersensitivity: Diagnosis
Dentin Hypersensitivity is a diagnosis of exclusion
Complete History Clinical Examination Radiographic examination

 Sign and symptoms  Visual assessment  Rule out periapical lesions
 Intensity  Physical assessment
– Dental explorer
 Frequency and duration
(probe): tactile stimulus
 Dietary changes
 Periodontal probe
 Other related events
 Depth of periodontal
pocket
 Percussion testing
 Response to cold air
Cervical hypersensitivity may be caused not only by

chemical erosion, but also by mechanical abrasion or even
occlusal stresses.
Treatment & Prevention of
Hyper‐sensitivity
Dentin Hypersensitivity:
Management/Etiological Factors
Management of Pre-disposing Factors
Tooth Wear/Erosion:
• Application of topical fluoride
• Use fluoride-rich dentifrice
• Decrease abrasive forces
• Behavior modification
• Enhance the defense mechanisms of the body
increase salivary flow
• Provide nutritional counseling
Management/Etiological Factors
Management of Pre-disposing Factors
Gingival Recession:
• Correct tooth brushing technique
• Plaque control
• Replacement of restorations with defective
margins
• Avoidance of harmful habits
• Periodontal disease management
Management of Dentin Hypersensitivity
Treatment
Treatment
KNO3
 Obturate tubules or alter fluid
flow in dentinal tubules
 Modify or block pulpal nerve

response
Dentin Hypersensitivity: Treatment
Chemical Agents
Nerve Inactivators Tubule Obtundants Protein Precipitators
 Potassium salt  Strontium chloride  Strontium chloride
(nitrate-KNO3)  Calcium hydroxide  Silver nitrate
5%  Fluorides  Formaldehyde
 Sodium citrate
 Potassium oxalate
the tubular occlusion was not permanent in nature, particularly

following the impact of an acid challenge to the surface deposit
Physical Agents
Varnishes
Bonding agents
Sealants
Glass-ionomer cements
Composite resins
Lasers
Soft tissue grafts
Options for Treatment
1ST line : At-home treatments—patient applied
 Anti-sensitivity dentifrice
 Fluoride-based gels
 Rinses
2–4 weeks is required for the remission of symptoms

Options for Treatment
2nd line : In-office by dental professional
(listed as least invasive to most)
 Chemicals GLUMA Desensitizer
 Adhesives
 Restorations
 Endodontic (root canal)
 Tooth extraction
There is a tendency however to apply an in-office treatment

following several attempts to resolve the patient’s pain following
the unsuccessful use of an OTC/at-home product
Desensitizing agent
(Gluma Desensitizer (Heraeus Kultzer) )
5% glutaraldehyde and 35% HEMA
Gluma is compatible with any restorative

material and does not affect the bonding quality
of adhesive agents (other products ?)
contact with the patient’s soft tissues should
be avoided.!
glutaraldehyde is a strong antibacterial
main method of action is occlusion of the dentinal

tubules by precipitation of serum proteins within it &
HEMA polymerization
It produce an immediate long-term effect up to 12 months

Desensitizing agent
(Gluma Desensitizer (Heraeus Kultzer) )
Application procedure
 The anesthetized tooth should be cleaned with

pumice, washed, and the affected area blot dried.
soft tissue should be protected
 Gluma Desensitizer (Heraeus Kultzer) is applied
for 30-60 s and then the area dried until the fluid
film has disappeared and the surface is no longer
shiny then rinse .
no light-curing required
penetrates up to 200µm
cannot be used to treat the pain from irreversible
pulpitis
Glutaraldehyde containing adhesives, provide immediate
and long- term relief of pain associated with DH
 In general, in-office treatments are successful in treating DH in patients with a
localized severe problem in one or more teeth
 OTC products which are recommended for mild to moderate generalized DH
 No ideal desensitizing product or clinical approach that can fully address the impact
of DH on the quality of life of patients
 Clinical management of DH continues to be very challenging to the clinician

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Dentinal Hypersensitivity

Hypersensitivity is an exaggerated sharp transient

Non-Myelinated Deep Throbbing, High, stimulated

Myelination Location of Pain character Stimulation

Myelinated Superficial Sharp, fast, Low, stimulated

Myelination Location of Pain character Stimulation

Restoration of health and function is the major goal of

1. The patient may become unable to eat, drink and even

3. The patient may acquire para‐functional adaptive biting

4. If left un‐treated it may cause pathological pulp reactions.

5. If miss‐diagnosed as pain may lead to

(Nerve Endings Theory)

A‐delta nerve endings ,interweave with the Odontoblasts along a distance of

1 The rate of tubular fluid flow

2 The nature and rate of change of the stimulus

3 The dentinal permeability or conductance

 The rate and not the amount of tubular fluid‐

The true physiologic stimulus

 Stimuli that cause outward fluid‐flow cause more

 Suddenly applied or released pressure activates the A‐delta

 When a steadily applied stimulus reaches noxious

 The greater the dentin conductance, the more intense the

These are sensory receptors that have relatively low stimulation

Therefore any low intensity non‐noxious stimuli reaching an

1 Presence of Exposed Conducting Dentin

 Dentin is permeable, and its permeability

The deeper the preparation the less the remaining dentin

Removal of smear plugs & smear layer from dentinal

Deflection of dentin by tactile pressure threshold

- Leakage, and cracked teeth or restorations causes

- The difference in osmotic pressure creates an osmotic

- When this gradient reaches the minimum osmotic threshold

The thermal stresses are conducted to underlying exposed

A thermal threshold of 47 C° (heating) or 26C° (cooling) at

Produced by air blasts and cause rapid

Evaporative stimuli are usually employed

Dissimilar metallic restorations, e.g., gold

Most Commonly Found

canines > premolars > incisors > molars

Dentin Hypersensitivity is a diagnosis of exclusion

Complete History Clinical Examination Radiographic examination

Cervical hypersensitivity may be caused not only by

 Modify or block pulpal nerve

the tubular occlusion was not permanent in nature, particularly

2–4 weeks is required for the remission of symptoms

There is a tendency however to apply an in-office treatment

5% glutaraldehyde and 35% HEMA

Gluma is compatible with any restorative

main method of action is occlusion of the dentinal

It produce an immediate long-term effect up to 12 months

 The anesthetized tooth should be cleaned with

 OTC products which are recommended for mild to moderate generalized DH

 Clinical management of DH continues to be very challenging to the clinician

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