BELARUSIAN STATE MEDICAL UNIVERSITY 3RD DEPARTMENT OF THERAPEUTIC

GUIDE MANUAL FOR THE PRACTICAL LESSON №11

1. Topic. Dentine sensitivity: clinical features, diagnosis, treatment methods 2. Total Time of the Lesson ─ 240 minutes. 3. Motivational Characteristics. In Belarus, dentine sensitivity is diagnosed in 9.1–67.3 % of patients of different age groups. Dentine sensitivity diagnosis and treatment are rather difficult because the methodological basis for the application of medicines, physical factors is not well enough studied and developed. This dictates the necessity to systematize the knowledge on the development mechanisms, clinical features and diagnosis that will contribute to the selection of the adequate tactics in planning the treatment of patients, the development of measures to prevent dentine sensitivity. 4. Aims of the Lesson Didactic: to motivate the students to understand the importance of the correct diagnosis and the choice of treatment tactics for dentine sensitivity. Methodological: to teach the students to maintain conventional principles of diagnosis, treatment and prevention of dentine sensitivity. Scientific: to teach the students science-based clinical thinking in the diagnosis, treatment and prevention of dentine sensitivity. 5. Goals of the Lesson: On completing the lesson On completing the lesson the students MUST KNOW the students MUST BE ABLE 1. Definition, prevalence rate and intensity 1. To examine patients with dentine of dentine sensitivity. Classifications of sensitivity (assisted by the instructor). dentine sensitivity. 2. To calculate and interpret CIDTS 2. Development of dentine sensitivity. (L. N. Dedova, 2004) in a patient with 3. Diagnosis of dentine sensitivity. dentine sensitivity (without assistance).* Complex index of differentiated tooth 3. To use classification signs and CIDTS sensitivity — CIDTS data (L. N. Dedova, 2004) for making the (L. N. Dedova, 2004). diagnosis of dentine sensitivity (without 4. Treatment of dentine sensitivity. assistance). Complex treatment of patients with dentine 4. To develop a treatment plan for a patient sensitivity. with dentine sensitivity (assisted by the 5. Measures to prevent dentine sensitivity. instructor).

* Manipulation 2 in the column «MUST BE ABLE» is included into the list of practical skills performed without assistance.

6. Requirements for the Initial Level of Knowledge: 6.1 Morphological structure of the dentoalveolar system. 6.2 Specific features of innervation and blood supply of the maxillofacial area. 6.3 Diagnosis and treatment planning for dental patients. 6.4 Pharmacokinetics and pharmacodynamics of local anesthetics. 7. Control Questions from the Related Disciplines: 7.1 Specific features of the morphological structure of the teeth and . 7.2 Biochemical and physiological peculiarities of the dental tissues and oral cavity. 7.3 Subjective and objective methods of examining a dental patient. 7.4 Hydrodynamic theory of dentine sensitivity.

8. Control Questions on the Topic of the Lesson: 8.1 Definition, prevalence of dentine sensitivity. 8.2 Development mechanism of dentine sensitivity. 8.3 Diagnosis of dentine sensitivity. Classifications of dentine sensitivity (Y.A. Fedorov, 1970; WHO, 1994; L.N. Dedova, A.S. Solomevich, 2006). 8.4 Complex index of differentiated tooth sensitivity CIDTS (L. N. Dedova, 2004): methodology, interpretation. 8.5 Methods of treating dentine sensitivity. Complex treatment method for patients with dentine sensitivity, developed at the 3rd department of therapeutic dentistry. 8.6 Prevention of dentine sensitivity. 8.7 Discussion of publications on the topic of the lesson in dental journals, including «The Stomatologist».

9. Educational Materials. Basic chart Diagnosis and the choice of treatment method for patients with dentine sensitivity Components Means of Actions Self-Control Criteria and Sequence of Actions Examination Friendly atmosphere Patients trust to doctor, complaints, favorable for medical and oral history. Clinical conversation, doctor’s picture typical for the dental hard attention to the patient, tissues or periodontal diseases. dental armamentarium Making the preliminary diagnosis Differential diagnosis Dental armamentarium Making the final diagnosis, treatment planning Treatment of dentine Dental armamentarium, Absence of complaints, normal sensitivity dental materials parameters of the objective tests Recommendations for Information about dental Absence of complaints home treatment pastes, mouth washes, etc.

10. Tasks for the Students’ Individual Work. To learn the material of this lesson the student must study the lecture material on the topic and the recommended literature. Practical skills on the topic are acquired under the guidance of the instructor. A student examines a patient, makes the differential diagnosis, makes the final diagnosis and develops a treatment plan. Particular attention is drawn to substantiation of the treatment method of the patient with dentine sensitivity. All the actions must be coordinated with the instructor in advance. At first the teacher demonstrates the method and then the students practice treating dentine sensitivity without assistance. At the end of the practical part the instructor evaluates the students’ work.

11. Self-Testing of the Topic Consolidation Case-studies Case-study No 1. Patient K., 34 years old, came to the dentist complaining of intermittent pain from thermal, chemical and mechanical stimuli in teeth #2.4, #2.6, #3.3, #3.4, #3.5, #4.3. On examination of these teeth superficial defects on the vestibular surface of the hard tissues exposing to the dentine were revealed. Dentine probing and a directed stream of cold air caused sensitivity over 3 points according to CIDTS (L. N. Dedova, 2004). What is your tactics in this situation?

Case-study No 2. Patient M., 25 years old, came to the dentist complaining of transient pain from thermal and mechanical stimuli in tooth #1.3. On examination a 4 mm root exposure from the vestibular surface of tooth #1.3 was revealed. Dentine probing and a directed stream of cold air caused sensitivity over 6 points according to CIDTS (L. N. Dedova, 2004). What is your tactics in this situation?

Case-study No 3. Patient R., 52 years old, came to the periodontologist complaining of , bleeding and pain in the , pain in the teeth when eating and toothbrushing. She was not motivated, hadn’t come for preventive examinations, smoked, suffered from coronary heart disease. On examination the dentist revealed OHI-S = 2.9; gingiva condition GI = 2.4; periodontal status CPI = 4.5. Dentine caries was diagnosed in teeth #2.4, #2.6, #3.7, #3.4, #4.5, #4.8. Poor quality restorations were noted in teeth #1.1, #2.2, #2.5, #3.5. Teeth #1.8, #1.7, #1.6, #1.5, #2.7, #3.8, #3.6, #4.6, #4.7 were extracted. Chronic apical periodontitis was diagnosed in teeth #1.4, #2.3. All the teeth had degree I–III tooth mobility. There was generalized gum recession, abrasion of teeth #1.3, #1.2, #1.1, #2.1, #2.6, #3.5, #3.4, #3.3, #3.2, #3.1, #4.1, #4.2, #4.3, #4.5. Dentine probing and a directed stream of cold air caused sensitivity over 6 points according to CIDTS (L.N. Dedova, 2004). What is your tactics in this situation?

TEST QUESTIONS 1. Which hypothesis explains the most complete mechanism of dentine sensitivity? (1 correct answer) a) odontoblasts receptors; b) direct stimulation of the nerve endings; c) hydrodynamic; d) chemical and parasitogenic. 2. Which term corresponds to 1994 WHO classification? (1 correct answer) a) teeth hypersensitization; b) dental hyperesthesia; c) dental hard tissues hypersensitization; d) sensitive dentine. 3. In what series does the prevalence of dentine sensitivity in different teeth groups increase? (1 correct answer) 1) incisors; 2) canines; 3) premolars; 4) molars; a) 4, 1, 3, 2; b) 1, 3, 2, 4; c) 2, 1, 4, 3; d) 4, 3, 2, 1.

4. Who suffers from dentine sensitivity more frequently? (1 correct answer) a) men; b) women; c) children; d) elderly people. 5. Where is dentine sensitivity clinically determined more frequently? (1 correct answer) ) a) in the tooth crown; b) in the cervical part of the tooth; c) in the tooth root; d) in the dental cusps. 6. What factors predispose to the occurrence of dentine sensitivity? (1 correct answer) a) adolescence; b) smoking; c) chronic stress; d) teeth whitening. 7. What degree of tooth sensitivity corresponds to 7.0 points of the complex index of differentiated tooth sensitivity (L. N. Dedova, 2004)? (1 correct answer) a) degree I; b) degree II; с) degree III; d) degree IV. 8. What is used for the assessment of pain intensity in case of dentine sensitivity? (2 or more correct answers) a) the visual analogue scale; b) the digital rating scale; c) the verbal rating scale; d) the sound rating scale. 9. What is the most efficient treatment for patients with dentine sensitivity? (1 correct answer) a) dentine adhesive system; b) fluoride varnish; c) vacuum darsonvalization and desensitizers; d) vacuum darsonvalization, desensitizers and calcium medicines (eg. DentoVitus) 10. What happens to the dentinal fluid during stimulation of exposed dentine with a weak citric acid solution? (1 correct answer) a) it moves out; b) it moves in; c) it can move both in and out; d) it does not move. 11. What are the main methods of diagnosing dentine sensitivity? (1 correct answer) a) clinical examination; b) pulp test vitality; c) probing; d) biopsy of dental hard tissues. 12. What are additional methods of diagnosing dentine sensitivity? (2 or more correct answers) a) thermometry; b) pulp test vitality; c) probing; d) staining.

13. What are the physical methods of dentine sensitivity treatment? (2 or more correct answers) a) laser puncture; b) electroanesthesia; c) vacuum therapy; d) home treatment. 14. What probing force is used to determine the intensity of dentine sensitivity to tactile stimuli? (1 correct answer) a) 0.25 g; b) 2.5 g; c) 25 g; d) 250 g. 15. What are initial measures to eliminate dentine sensitivity? (1 correct answer) a) primary preventive measures and a special toothbrushing technique; b) the use of calcium medicines locally and internally; c) application of fluoride varnish and other medical interventions (by indication); d) physiotherapy. 16. What is the first level of the complex treatment of dentine sensitivity? (1 correct answer) a) emergency care; b) preparatory stage; c) preliminary stage; g) preventive stage. 17. What is the second level of the complex treatment of dentine sensitivity? (1 correct answer) a) re-assessment of the dental hard tissues; b) consolidation of the obtained results; c) dynamic observation; d) supportive therapy. 18. What does the complex therapy of dentine sensitivity include? (2 or more correct answers) a) local and systemic treatment of the patient; b) home and proffesional measures; c) effect on teeth, nervous system and mineral metabolism in the organism; d) maxillofacial surgery. 19. Match the measures carried out during the complex treatment of dentine sensitivity with their mechanism of action: Medical measures Mechanism of action 1. Physiotherapy a) influences the vegetative nervous system and dental tissues 2. Systemic therapy using calcium b) influences the dental hard tissues and neuro- medicines receptor apparatus of the dental pulp 3. The use of special toothpastes c) normalizes the mineral metabolism in the body 4. The use of resin-containing d) influences the dental hard tissues desensitizers 20. Match the toothpaste used to treat dentine sensitivity with the mechanism of its action: Toothpaste Mechanism of action 1. Toothpaste containing potassium a) obturation of dentinal tubules with insoluble nitrate precipitates 2. Toothpaste containing b) resistant membrane depolarization of sensory hydroxyapatite nerves of the pulp-dentine complex 3. Toothpaste containing fluorides c) stimulation of reparative dentine generation 4. Toothpaste containing calcium d) mechanical filling of open dentinal tubules glycerophosphate 21. Match the method of dentine sensitivity physical treatment with the mechanism of its action: Physical treatment method Mechanism of action 1. Medical electrophoresis a) influences the vegetative nervous system causing changes in the irritation threshold of dental pulp 2. Electroanesthesia b) leads to the melting and sealing of dentinal tubules 3. Vacuum darsonvalization c) stimulates the generation of reparative dentine 4. Carbon laser d) causes changes in the electric potential generation of the tooth pulp nervous apparatus 22. Match the resin-containing desensitizer with the mechanism of its action: Resin-containing desensitizer Mechanism of action 1. Unfilled desensitizer, containing a) obturates dentinal tubules with precipitated HEMA proteins of dentinal fluid 2. Unfilled desensitizer, containing b) seals inputs, obturates dentinal tubules glutaraldehyde and HEMA 3. Filled desensitizer containing HEMA c) forms a highly adhesive resin layer, slows plaque formation 4. Dentine adhesive system d) narrows the dentinal tubules 23. Match the desensitizer and the mechanism of its action: Desensitizer Mechanism of action 1. Desensitizer, containing oxalic a) forms a highly adhesive sealed resin layer on the acid or oxalate dentine surface 2. Unfilled desensitizer, containing b) obturates dentinal tubules with precipitated crystals glutaraldehyde and HEMA 3. Desensitizer, containing tin c) obturates dentinal tubules with precipitated proteins of dentinal fluid 4. Filled desensitizer, containing d) is deposited in the surface and subsurface dentine HEMA layers

LITERATURE 1. Carranza, F. A. Carranza’s Clinical / F. A. Carranza. 11th ed. Saunders Elsevier, 2012. 825 p. 2. Aesthetic Periodontology / J. L. Denisova [et al.]. Minsk : BSMU, 2015. 20 p. 3. Egelberg, J. Periodontal examination / J. Egelberg, A. Badersten. Copenhagen : Munksgaard, 1994. 85 p. 4. Lindhe, J. Clinical Periodontology and Implant Dentistry / J. Lindhe. 4th ed. Black-well Munksgaard, 2003. 1044 p. 5. Mueller, H. P. Periodontology. The Essentials / H. P. Mueller. Thieme, 2004. 188 p. 6. Perry, D. A. Periodontology for the dental hygienist / D. A. Perry, P. Beemsterboer. 3rd ed. St. Louis, Mo. : Saunders Elsevier, 2007. 484 p. 7. Schluger, S. Periodontal diseases : basic phenomena, clinical management and occlusal and restorative interrelationships / S. Schluger, R. Yuodelis, R. C. Page. 2nd ed. Philadelphia : Lea & Febiger, 1990. 759 p. 8. Publications on the topic of the lesson in dental journals, including «The Stomatologist».