Earn 4 CE credits This course was written for , dental hygienists, and assistants.

A Demographic Dilemma: Dentinal Hypersensitivity and Its Treatment A Peer-Reviewed Publication Written by Howard E. Strassler, DMD, FADM, FAGD, FACD

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This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives Figure 1. U.S. Population Aged 65 and Older Upon completion of this course, the clinician will be able to do the following: 80 80 1. Understand the changing demographics of patients and Aging Baby Boomers’ 70 their growing needs for dental care—be it treatment Longevity of caries and periodontal diseases, failures of existing 60

restorations, sensitivity, or other conditions. 50 2. Understand the causes and effects of dentinal hypersensitivity as it relates to the physiology of teeth 40 36 and patient discomfort 30 3. List the steps of protocol when assessing a treatment People of Millions 20 plan for a patient with dentinal hypersensitivity, and understand how the treatment effectively resolves the 10 patient’s pain 0 4. Be able to prescribe the best form of treatment for a 2006 2050 particular patient—in the office or at home According to a recent report, over 70 percent of adults Abstract aged 65 and older currently have some or most of their For the dental community, the increasing life span of the natural teeth.1 It is expected that the number of edentulous average person means patients who require more dental patients will remain stable at nine million adults until health care for a longer period of time. As gingival recession 2020.2 Adults currently over age 60 have an average of is a condition that only worsens with age, its contribution 19 teeth.3 Over 90 percent of these individuals will have to dentinal hypersensitivity cannot be ignored. Statistics at least one coronal carious lesion. Among this group in show that approximately one-third of the nearly 78 mil- 2002, almost 32 percent had root caries or a restored root lion American adults, the baby boomers, over age 60 are at surface. Since root caries is an indication of recession, this risk for recession in one or more teeth. With the impend- means that at least 30 percent of adults over age 60 are at ing flood of dentinal hypersensitivity cases that are likely risk for recession plus root caries in one or more teeth and to result from this demographic, the treatment of dental highlights the risk of root caries in addition to the risk of hypersensitivity is more important than ever. This course dentinal hypersensitivity in the presence of gingival reces- will discuss factors contributing to and treatment methods sion. Another study concluded that at least 22 percent of for dentinal sensitivity. the adult population between 30 and 90 years of age will have evidence of recession of 3 mm or greater in one or Introduction more teeth.4 When a patient presents with dentinal hypersensitivity, den- Gingival recession is a common condition that increases tal professionals have an obligation to provide well-consid- as we age.5 When gingival recession is present, patients are ered recommendations for treatment, whether in the office, at at risk for pain due to the exposed root surface and root car- home, or both. We will see an increase in the need to provide ies, and they may also have aesthetic concerns.5 Clinically, our patients with recommendations for all levels of dental patients are concerned whenever there is dental pain.6 One treatment based upon the changing demographics. aspect of routine dental treatment that has been on the rise is the reported presence of dentinal hypersensitivity Demographics and Oral Health (Figure 2). Perhaps of most importance demographically, U.S. census Dentinal hypersensitivity refers to a sharp, sudden data shows that in the U.S. alone there were 78.2 million pain when teeth are exposed to a stimulus.7 Stimuli can be baby boomers in July 2005. This group represents a large tactile sensations (such as those that occur during brush- aging population with particular oral health needs. The old- ing or flossing, or when an explorer is rubbed over the root est baby boomers are turning 60 in 2006. Currently there are dentin) or changes in temperature (such as those that oc- over 36 million adults 65 years or older.1 By 2050 this number cur with hot or cold food, beverages, or even air). No vital will grow to over 80 million (Figure 1). This translates into tooth in the mouth is immune to dentinal hypersensitivity. an increase in the number of patients who will need dental Root sensitivity has been reported on incisors, canines, services for the treatment of caries and . premolars, and molars. The prevalence of dentinal hyper- These same patients will require additional care for pain and sensitivity in the general population has been reported at trauma, tooth hypersensitivity, and failures of existing dental up to 57 percent.8,9,10,11,12,13,14 Among periodontal patients, restorations, along with a greater demand for replacement of the frequency of tooth hypersensitivity is considerably missing teeth. higher (60 percent to 98 percent).15,16

2 www.ineedce.com Figure 2. Schematic of tooth sensitivity (Figure 3). In normal function, the tubules sclerose Stimulus (tactile, and become plugged. However, when dentin is cut or abraded, cold or hot, sweets, the mineralized matrix produces debris that spreads over the or breathing in cold air) Root surface dentin surface to form a smear layer.22,23 This phenomenon being stimulated occurs to both enamel and dentin, but the loss of this smear Fluid flow due layer (the unplugging of the dentinal tubules) contributes to to stimulus dentinal hypersensitivity.23 When the root surface is exposed, Dentinal tubules the physical action of brushing with toothpaste can be a pre- disposing factor in removing the smear layer, leaving a tooth hypersensitive.24 The opening of dentinal tubules can also result from poor techniques, leaving bacterial plaque on root surfaces. The acidic by-products of the plaque can open the dentinal tubules. Also, otherwise excellent oral hygiene techniques but with highly abrasive dentifrices can Pulp of tooth cause continued dentinal tubule exposure. Another at-risk Odontoblast occurrence is the exposure of the oral cavity to acids, such as occurs with consumption of acidic foods and beverages, ex- posure to chlorinated pool water, or physiological conditions Nerve in pulp including bulimia and gastrointestinal refl ux disease.25,26,27

Physiology and the Etiology of Figure 3. SEM showing open dentinal tubules Dentinal Hypersensitivity Dentinal hypersensitivity has been a recurring issue in clini- cal dentistry. In 1884 Calvo wrote: “There is great need of a medicament, which while lessening the sensitivity of dentin, will not impair the vitality of the pulp.”17 The most widely accepted mechanism of dentinal hypersensitivity was fi rst de- scribed by Brännström in 1963.18 According to his hydrody- namic theory, the aspiration of odontoblasts into the dentinal tubules as an immediate effect of physical stimuli applied to exposed dentin results in the outward fl ow of the tubular contents (dentinal fl uids) through capillary action (Figure 2). The changes to the dentinal surface lead to stimulation of the A-type nerve fi bers surrounding the odontoblasts. Within the dentinal tubules there are two types of nerve fi bers, myelin- Exposed root surfaces due to gingival recession are the ated (A-fi bers) and unmyelinated (C-fi bers).19 The A-fi bers most signifi cant contributor to dentinal root hypersensitivity are responsible for the sensation of dentinal hypersensitivity. (Figure 4).27 Common causes of gingival recession include Another theory that has been proposed is an alteration in inadequate attached gingiva, prominent roots, toothbrush pulpal sensory nerve activity.20 abrasion, periodontal surgery, oral parafunctional habits Why are some root surfaces hypersensitive while others (picking at cervical of tooth with fi ngernail), excessive tooth are not? Absi and his coworkers reported that nonsensitive cleaning, excessive fl ossing, loss of gingival attachment due to teeth were not responsive to any type of physical stimulus specifi c pathologies, and iatrogenic loss of attachment during and had few exposed dentinal tubules.21 Conversely, sensitive restorative procedures.27 Once the root surfaces are exposed, teeth had as many as eight times the number of open dentinal the cementum/dentin is more susceptible to caries and loss tubules per surface area when compared to the nonresponsive of tooth substance due to erosion, abrasion, and teeth. Dentin is a mineralized connective tissue composed (Figure 5).28,29,30,31 of hydroxyapatite, an inorganic component, and an organic Root caries progresses more rapidly than coronal car- matrix of collagenous proteins. These canals have different ies even in the absence of any predisposing factors such as confi gurations and diameters in different teeth. For human xerostomia. The organic matrix in cementum comprises a dentin, one square millimeter of dentin can contain 30,000 larger proportion of its structure than in dentin and even tubules depending on depth. more so compared to enamel, and the inorganic component With the root surfaces exposed to the oral environment, is less, making the cementum more susceptible. From a tooth the dentinal tubules must be opened at both ends, to the pulp morphology perspective, once gingival recession has occurred and to the oral cavity, for a patient to develop dentinal hyper- and the root is exposed, some roots will have an area with no www.ineedce.com 3 Figure 4. Examples of gingival recession; exposed root surfaces are Table 1. Flow chart showing treatment flow and options susceptible to dentinal hypersensitivity Dentinal Hypersensitivity

STEP 1: PATIENT COUNSELING Counsel patient on good oral hygiene practices, dietary factors. Counsel patient on risk factors for hypersensitivity and root caries.

STEP 2: INTERVENTIONAL TREATMENT

IN-OFFICE TREATMENT OPTIONS • In-Office Surface Applications • Fluorides • Oxalates • Hema/Glutaraldehyde FACTORS TO CONSIDER • Resins Effectiveness Figure 5. Root caries on an exposed root surface • Other Caries Risk • Class V Restorations Oral Hygiene • Laser Therapy Aesthetics APPLY • Gingival Graft Tooth Structure DESENSITIZING • Iontophoresis Convenience TREATMENT Patient Acceptance AT-HOME TREATMENT OPTIONS Patient Compliance • OTC Potassium Nitrate Desen- sitizing Dentifrices • OTC Stannous Fluoride Gels and Dentifrices • Prescription-Level (5,000ppm) Fluoride Dentifrices Containing Potassium Nitrate Image courtesy of Jeffrey C. Hoos, DMD cementum covering dentin, and for the majority that do have mendations to the patient to avoid or minimize acid damage a continuous cementum layer, it is very thin in cross-section can be made, as acid attack on tooth surfaces combined with compared to the harder and thicker layer of enamel coronally brushing with toothpaste can lead to further tooth loss and protecting dentin. Furthermore, baby boomers are an at risk opening of the distal ends of the dentinal tubules as well as group for xerostomia (drug induced, immuno-suppressed, increasing the patient’s caries risk due to demineralization. radiation induced, and other)—further increasing the risk of a combination of dentinal hypersensitivity and root caries. Desensitizing Treatment Desensitizing treatment of dentin on root surfaces can be Treatment of Dentinal Hypersensitivity accomplished in the office with professional treatments or at Over the years, dentinal hypersensitivity on root surfaces of home with the use of desensitizing dentifrices. At the time teeth caused by external stimuli has been treated to control the of treatment recommendation, consideration should also be pain. Before treatment of dentinal hypersensitivity is initiated, given to the individual patient’s caries experience and risk. a diagnosis must be made. As stated earlier, the diagnosis of It is well accepted that exposed root surfaces are one of the dentinal hypersensitivity is one of exclusion. Questioning the risk factors for future caries experience. As the baby boomers patient for the cause of pain and physical and radiographic age, the overall incidence and risk of both sensitivity and root evaluation of the site(s) for pain must exclude all symptoms caries will increase. A carefully considered treatment plan that might relate to other causes.6 Once all other causes can be should include such evaluation and consider the use of pre- eliminated, the diagnosis of dentinal hypersensitivity can be scription-level fluoride as a caries preventive in combination made. With the correct diagnosis a plan can be developed and with desensitizing treatment. implemented for treatment (Table 1). A definitive diagnosis of dentinal hypersensitivity should Mechanisms of Action for Desensitizing Agents lead the dental professional to provide both patient counsel- The mechanism for desensitizing teeth can be a blockage of ing and one or more prescribed treatment courses. nerve response in the pulp, a reduction in dentinal tubule flow, or both. Blockage of nerve activity and the transmission Patient Counseling of pain have been reported with the use of potassium nitrate Since acidic substances can contribute to the opening of or potassium chloride, both of which have been active ingre- dentinal tubules, a dietary analysis, history of bulimia, diet- dients in toothpastes for at-home application. In one clinical ing, consumption of acidic drinks and foods, or history of trial, the direct application of potassium nitrate solution to gastrointestinal reflux must be taken into account. Recom- hypersensitive dentin demonstrated a reduction in dentinal

4 www.ineedce.com pain.32 Reduction in tubule fluid flow can be accomplished dentinal tubules using a combined bioglass paste with an Nd: with surface blockers or agents that create a new smear YAP laser has also been demonstrated.41 layer. Over the years, tubule blocking agents have included Another treatment method—iontophoresis—utilizes a precipitates on the dentinal surface with potassium and ferric low galvanic current to accelerate ionic exchanges and pre- oxalates, aluminum, fluorides, hema (with and without glu- cipitation of insoluble calcium with fluoride gels to occlude taraldehyde), and sealants ranging from restorative materials open tubules.37 and dental resins to glass ionomers.33,34,35,36 More recently, lasers have been introduced as an additional in-office profes- In-Office Surface Treatments sional treatment option. A popular and noninvasive approach to treating root hyper- sensitivity is the use of in-office paint-on surface treatments. Professional In-Office Treatment of A variety of products has been used to reduce dentinal Dentinal Hypersensitivity hypersensitivity, including resin-based materials.34,35 Use Where in-office treatment is selected either alone or in com- of five percent neutral sodium fluoride varnish ®(Colgate bination with home therapy, the choice of in-office treatment Duraphat®, Colgate Oral Pharmaceuticals, Inc.) applied to should consider the following factors: effectiveness, invasive- exposed root surfaces has been clinically proven to be an ef- ness, caries risk, loss of tooth structure and tooth contour, pa- fective treatment of dentinal hypersensitivity, treating hyper- tient tolerance/acceptance, cost, aesthetics, and oral hygiene. sensitivity for up to six months.42 This product has the benefit of providing a rich source of fluoride to the root surface during In-Office Operative Treatments desensitization. Other fluoride varnishes have also been used, including Fluor Protector (Ivoclar Vivadent®). DentinBloc®, Loss of tooth structure and contour which blocks tubules using a combination of three fluorides When the exposed sensitive root surface has surface loss due (sodium, stannous, and hydrogen), is an option for rapid, to abrasion, erosion, and/or abfraction, leaving a notching of temporary preprocedural relief. An aqueous solution of five the root, consideration should be given to using either an ad- percent glutaraldehyde and 35 percent HEMA (hydroxyeth- hesive composite resin or glass ionomer restoration.36 These ylmethacrylate), Gluma® Desensitizer (Heraeus-Kulzer) has will restore the tooth to full contour and seal the exposed and been reported to be an effective desensitizing agent for up open dentinal tubules (Figure 6). to nine months.34,38 The mechanism for tubule occlusion by Gluma Desensitizer appears to be due to the glutaraldehyde Figure 6. Loss of periodontium with subsequent loss of tooth effects.43 The use of oxalates for the treatment of dentinal hy- structure and contour persensitivity has been shown to be effective as well.44,45 The oxalate precipitates on the open dentinal tubules, occluding them. A dual-action oxalate desensitizer with potassium nitrate (D/Sense® 2, Centrix) has demonstrated effective desensitizing properties.44 This product combines occlu- sion of open dentinal tubules with the desensitizing effect of potassium nitrate. Recently, bioactive glasses containing hydroxycarbonate apatite in a prophylaxis paste (NuCare™, Butler Sunstar) have been introduced that have the capacity to seal dentinal Loss of periodontium over the exposed root area tubule surfaces. The basis for this use comes from a clinical Depending on the area of loss and the individual patient’s trial using the same active ingredient that is used in tooth- acceptance and desire, periodontal treatment with gingival pastes for the treatment of dentinal hypersensitivity.46 grafts should be considered as part of a treatment plan.37,38 The recommendations for and techniques of use are More recently, lasers have been used successfully to seal product-specific. The clinician needs to understand open dentinal tubules either by themselves or in concert with which in-office desensitizing agents are appropriate to surface treatments.39,40,41 The use of an Er:YAG laser has been use, giving careful consideration to his or her patients’ shown to be effective for desensitizing hypersensitive dentin risk factors. In some cases, the placement of a restoration for up to six months.39 The desensitizing effect was attributed may be indicated. to the deposition of insoluble salts into the exposed dentinal tubules. Another study investigated the use of an He:Ne laser At-Home Treatment of Dentinal Hypersensitivity and a combined He:Ne—Nd:YAG laser for the treatment of Over-the-counter desensitizing dentifrices, usually in the dentinal hypersensitivity.40 This study indicated that both form of toothpastes, are a major category of dentifrice. In treatments reduced dentinal hypersensitivity by more than the United States, the change in demographics for people 60 percent for up to three months. Surface sealing of patient over age 50, the fastest-growing segment of our popula- www.ineedce.com 5 Table 2. At-Home Desensitizers—ppm Fluoride experience dentinal hypersensitivity have varying degrees 5,000 of risk for root caries due to their exposed root surfaces. 5,000 While such patients can benefit from additional fluoride protection, it is unrealistic to expect that many patients will 4,000 be compliant in the use of more than one dentifrice—one for hypersensitivity and another containing a high, prescription 3,000 level of fluoride. More recently, desensitizing dentifrices have become 2,000 1,100 1,100 available with prescription-level 5,000 ppm neutral sodium fluoride and potassium nitrate, providing a high level of fluo-

1,000 ride for additional caries protection for patients at risk for root caries. For these to be considered effective desensitizers by 0 OTC Dentifrice Potassium OTC Gel/Dentifrice Rx 1.1% Neutral Sodium the FDA, they must contain the FDA-monographed level of Nitrate 0.4% Stannous Fluoride Fluoride, Potassium Nitrate Dentifrice five percent potassium nitrate. With a combined five percent ppm Fluoride potassium nitrate and 5,000 ppm prescription-level fluoride, such dentifrices provide a clinically appropriate desensitiz- tion, will lead to many more people needing and using ing treatment and provide the best possible level of fluoride desensitizing toothpastes. protection against root caries on exposed roots with at-home What are desensitizing toothpastes, and do they work? use. The 5,000 ppm fluoride dentifrice Colgate® Prevident® Dentifrices claiming a desensitization effect come under scru- has been clinically proven to remineralize root caries by up to tiny by the U.S. Food and Drug Administration. The claim 57 percent over a six-month period.52 must be substantiated by either clinical trials or the addition Clearly the least invasive treatment option the dental pro- to the toothpaste of an ingredient recognized as being an ef- fessional has available is the recommendation of a dentifrice fective, active agent for the treatment of the condition listed, product for home use, whether an over-the-counter or pre- at the FDA-accepted therapeutic concentration. Because the scription dentifrice. Many desensitizing toothpastes contain addition of fluorides to toothpastes has been shown to reduce fluoride for an anticaries effect and may contain antitartar, an- caries, a claim can be made that the presence of different types tigingivitis, and/or whitening ingredients. There is no doubt of fluoride additives to toothpastes reduces caries. that toothpastes containing 5 percent potassium nitrate are Two potassium compounds, potassium chloride and effective in reducing hypersensitivity of the dentin and root. potassium nitrate, have been added to toothpastes to reduce Many clinical trials have provided evidence of a reduction in dentinal hypersensitivity. While both have been shown to tooth sensitivity with potassium nitrate.53,54,55,56,57,58 In most reduce sensitivity, potassium nitrate is the more effective (and cases the dentifrice needs to be used for at least two weeks to popular) of the two.47,48 According to the FDA monograph, see an effect, and continued use is required to avoid relapse. for a toothpaste to be desensitizing it must contain 5 percent potassium nitrate as an active ingredient. Potassium nitrate’s Conclusion mode of action has been described as a penetration of the po- The diagnosis of dentinal hypersensitivity is one of exclusion. tassium ions through the tubules to the A-fibers of the nerves One of the questions that dental professionals should ask of the pulp, where repolarization of these fibers is prevented patients during every recall appointment is whether there are after initial depolarization.49,50,51 The potassium levels act to any sensitive teeth. Based upon evaluation and the discovery block the potential for action generated in intradental nerves. that dentinal hypersensitivity is the diagnosis, the dental If elevated levels of potassium nitrate are maintained, the de- professional can make recommendations for treatment. For polarized state decreases the perception of pain. It can almost individual teeth that are hypersensitive, in-office treatment be described as a numbing effect on dentinal hypersensitivity. can provide the patient with pain relief. Once teeth are pre- A second type of desensitizing toothpaste that has been disposed to dentinal hypersensitivity, they will need to be popular for the treatment of dentinal hypersensitivity is a gel evaluated for at-home treatment.The least invasive treatment that contains 0.4 percent stannous fluoride (Gel-Kam® gel) is a desensitizing toothpaste. The combination of five percent and acts by blocking the tubules. A third type is a dentifrice potassium nitrate and 1.1 percent neutral sodium fluoride containing 0.4 percent stannous fluoride and 5 percent (5,000 ppm fluoride) provides clinicians with the possibil- potassium nitrate for desensitization. This has been found ity of providing ongoing treatment for desensitization and a in clinical studies to be an effective desensitizer.44 The cur- high-level fluoride toothpaste for at-home preventive care of rently available popular over-the-counter desensitizing den- exposed root surfaces. Consideration needs to be given to the tifrices contain 1,000–1,100 ppm fluoride, which is the same patient’s status, including his or her caries and hypersensitiv- level of fluoride contained in regular fluoride dentifrices and ity experience and risk, in the dental professional’s choice of provides the same level of caries protection. Patients who treatment to recommend.

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Gillam DG, Tang JY, Mordan NJ, Newman HN. The in the Departments of Endodontics, Prosthodontics, effects of a novel Bioglass dentifrice on dentine sensitivity: a scanning electron microscopy investigation. J Oral Rehabil and Operative Dentistry. He has lectured nationally and 2002; 29:305–313. internationally on techniques and a selection of dental 47. Silverman G, Gingold J, Curro FA. Desensitizing effect of a materials in clinical use and aesthetic restorative dentistry. potassium chloride dentifrice. Am J Dent 1994; 7:9–12. He is a fellow in the Academy of Dental Materials and the 48. Sowinski J, Ayad F, Petrone M, DeVizio W, et al. Academy of General Dentistry, a member of the American Comparative investigations of the desensitizing efficacy of Dental Association, the Academy of Operative Dentistry, a new dentifrice. J Clin Periodontol 2001; 28:1032–36. and the International Association of Dental Research. He 49. Markowitz K, Bilotto G, Kim S. Decreasing intradental is on the editorial board of numerous publications. He is nerve activity in the cat with potassium and divalent cations. Archives of Oral Biology 1991; 36:1–7. a consultant and clinical evaluator to more than 15 dental 50. Peacock JM, Orchardson R. Effects of potassium ions on manufacturers. Dr. Strassler has published more than 400 action potential conduction in A- and C- fibers of rat spinal articles in the field of restorative dentistry and innovations nerves. J Dent Res 1995; 74:634–641. in dental practice, and he has coauthored seven chapters in 51. Markowitz K, Kim S. The role of selected cations in the texts. He has presented more than 425 programs, including desensitization of intradental nerves. Proc Finn Dent Soc most of the major programs throughout the United States, 1992; 88(Suppl) 1:39–54. Canada, and Europe. Dr. Strassler has a general practice 52. Baysan, A et al. Reversal of primary root caries using dentifrices containing 5,000 ppm and 1,100 ppm fluoride. in Baltimore, Maryland, that is limited to restorative den- Caries Res. 2001; 35: 41–46. tistry and aesthetics. 53. Wara-aswapati N, Krongnawakul D, Jiraviboon D, Adulyanon S, et al. The effect of a new toothpaste containing Disclaimer potassium nitrate and triclosan on gingival health, plaque The author of this course has no commercial ties with the formation and dentine hypersensitivity. J Clin Periodontol sponsors or the providers of the unrestricted educational 2005; 32:53–58. grant for this course. 54. Sowinski JA, Battista GW, Petrone ME, Chaknis P, et al. A new desensitizing dentifrice—an 8 week clinical investigation. Compend Contin Educ Dent Suppl 2000; 27:11–16. Reader Feedback 55. Schiff T, Bonta Y, Proskin HM, DeVizio W, et al. We encourage your comments on this or any PennWell course. Desensitizing efficacy of a new dentifrice containing 5.0% For your convenience, an online feedback form is available at potassium nitrate and 0.454% stannous fluoride. Am J Dent www.ineedce.com.

8 www.ineedce.com Questions

1. According to the U.S. census, in the 12. One square millimeter of dentin can 22. In a clinical trial, the direct applica- U.S. alone there were 78.2 million baby contain as many as _____ tubules. tion of ______to hypersensitive boomers in July 2005. a. 30,000 dentin demonstrated a reduction in a. True b. 15,000 dentinal pain. b. False c. 40,000 a. Aluminum 2. What percentage of adults aged 65 and d. 20,000 b. Potassium nitrate older currently have some or most of their 13. What are the two types of fibers within c. Ferric oxalate natural teeth? dentinal tubules? d. Potassium chloride a. 50 percent a. A-fibers and C-fibers 23. When the exposed root surface has been b. 60 percent b. Enamel and dentin c. 70 percent eroded, abraded, or abfracted, the author c. Myelinated and unmyelinated d. 80 percent suggests using: d. a and c a. Glass ionomers 3. According to a recent report, adults over 14. The most significant contributor to b. Potassium chloride age 60 have ____ teeth on average. c. Ferric oxalate a. 32 dentinal root hypersensitivity is exposed d. Aluminum b. 29 root surfaces due to: c. 23 a. Toothbrush abrasion 24. Which kind of laser has been shown to be d. 19 b. Gingival recession effective for desensitizing hypersensitive 4. What percentage of adults over age 60 are c. Demyelinization dentin for up to six months? at risk for recession and root caries in one d. Capillary action a. Er:Ne or more teeth? 15. Once the root surfaces are exposed, the b. Er:YAG a. 30 percent cementum/dentin is more susceptible to c. Nd:YAG b. 50 percent caries due to which of the following? d. Er:YAP c. 70 percent a. Erosion, abrasion, and refraction 25. The dentinal hypersensitivity treat- d. None of the above b. Erosion, recession, and abfraction ment that utilizes a low galvanic cur- 5. According to the author, which of these is c. Erosion, abfraction, and abrasion rent and the precipitation of insoluble NOT true of gingival recession? d. Erosion, aphasia, and abfraction calcium is called: a. It is a common condition. a. Ionophoris b. The risk of developing it increases with age. 16. For a patient to develop dentinal hyper- c. Over 60 percent of adults over age 60 have it. sensitivity, the dentin tubules must be: b. Electrodensisitization d. It greatly increases the risk of pain due to exposed a. Exposed to the pulp c. Iontophoresis root surfaces. b. Exposed to the oral cavity d. Calcification c. a and b 6. Dentinal hypersensitivity as defined in the 26. Where dentinal hypersensitivity is d. None of these article refers to: concerned, in-office paint-on surface a. A condition in which the patient experiences 17. What is a smear layer? treatments are more popular than irrational anxiety over dental treatment a. Mineralized debris spread over the dentin surface laser treatments. b. A sudden change in temperature on the root surface b. Plaque spread over the surface of the enamel a. True or dentin c. Acidic by-products of plaque inside the b. False c. A sharp, sudden pain when teeth are exposed to dentinal tubules a stimulus d. A protective coating of potassium nitrate on the 27. According to FDA standards, desensitiz- d. An indication of recession exposed root dentin ing toothpastes are those that contain 7. Some teeth in the mouth are immune ____ as an active ingredient. 18. Which of these can be a significant a. five percent potassium chloride to hypersensitivity. contributor to the development of a. True b. three percent potassium nitrate b. False dentinal hypersensitivity? c. Either five percent potassium chloride or five a. Bulimia percent potassium nitrate 8. Among periodontal patients, the b. Acidic foods and beverages d. five percent potassium nitrate frequency of tooth hypersensitivity has c. Gastrointestinal reflux disease been reported at up to: d. All of the above 28. How do elevated levels of potassium on a. 57 percent the dentin reduce the perception of pain? b. 32 percent 19. and malocclusion have been a. They prevent depolarization of the pulp’s c. 98 percent positively identified as major causes of myelinated fibers. d. 90 percent dentinal hypersensitivity. b. They promote repolarization of the pulp’s 9. The most widely accepted mechanism of a. True demyelinated fibers after depolarization. dentinal sensitivity is: b. False c. They prevent repolarization of the pulp’s myelin- a. Brännström’s hydrodynamic theory 20. According to Table 1, if the patient’s ated fibers after depolarization. b. Calvo’s medicament hypersensitivity issues have improved, d. They promote and maintain depolarization of the c. Pulpal sensory nerve induction which of these is NOT involved in the pulp’s demyelinated fibers. d. Strassler’s dictum of hydrodynamics next phase of treatment? 29. When a patient presents with dentinal 10. Which of these is true of the correct a. Regular reviews hypersensitivity, the least invasive treat- answer to Question 9, above? b. Maintenance of current treatment ment option available is: a. It involves capillary action. c. Recommendations for removal of excess a. Laser treatment b. Aspiration of odontoblasts figures prominently. dietary acids b. Desensitizing toothpaste c. It centers around pulpal sensory nerve activity. d. Consideration of predisposing factors c. Paint-on surface treatments d. a and b d. Pulpal treatment 11. When compared to nonsensitive teeth, 21. Which of these substances has been sensitive teeth have been shown to have as shown to reduce dentinal pain AND 30. Desensitizing toothpastes need to be many as ____ times as many open dentinal has also been included in commercially used for at least _____ before an effect can tubules per surface area. available toothpastes? be observed. a. Two a. Glass ionomers a. One week b. Four b. Potassium chloride b. Three days c. Eight c. Ferric oxalate c. One month d. Sixteen d. Potassium oxalate d. Two weeks www.ineedce.com 9 ANSWER SHEET A Demographic Dilemma: Dentinal Hypersensitivity and Its Treatment

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Understand the changing demographics of patients and their growing needs for dental care—be it treatment of caries A Division of PennWell Corp. and periodontal diseases, failures of existing restorations, tooth sensitivity, or other conditions. P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 2. Understand the causes and effects of dentinal hypersensitivity as it relates to the physiology of teeth and patient discomfort For immediate results, go to www.ineedce.com 3. List the steps of protocol when assessing a treatment plan for a patient with dentinal hypersensitivity, and understand and click on the button “Take Tests Online.” Answer how the treatment effectively resolves the patient’s pain sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. 4. Be able to prescribe the best form of treatment for a particular patient—in the office or at home Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Course Evaluation If paying by credit card, please complete the following: MC Visa AmEx Discover Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. Number: ______1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Exp. Date: ______Objective #2: Yes No Objective #4: Yes No Charges on your statement will show up as PennWell 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them. ______

11. Was there any subject matter you found confusing? Please describe. ______

12. What additional continuing dental education topics would you like to see? ______AGD Code 010

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The author of this course has no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% (answering 21 or more questions correctly) on the PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification examination will receive a verification form verifying 4 CE credits. The formal continuing offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. education program of this sponsor is accepted by the AGD for Fellowship/Mastership all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER credit. Please contact PennWell for current term of acceptance. Participants are urged to of receipt. This course was made possible through an unrestricted educational grant. No EDUCATIONAL DISCLAIMER contact their state dental boards for continuing education requirements. PennWell is a manufacturer or third party has had any input into the development of course content. The opinions of efficacy or perceived value of any products or companies mentioned California Provider. The California Provider number is 3274. The cost for courses ranges CANCELLATION/REFUND POLICY All content has been derived from references listed, and or the opinions of clinicians. in this course and expressed herein are those of the author(s) of the course and do not from $49.00 to $110.00. Any participant who is not 100% satisfied with this course can request a full refund by Please direct all questions pertaining to PennWell or the administration of this course to necessarily reflect those of PennWell. contacting PennWell in writing. Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. Many PennWell self-study courses have been approved by the Dental Assisting National Completing a single continuing education course does not provide enough information Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet © 2008 by the Academy of Dental Therapeutics and Stomatology, a division COURSE EVALUATION and PARTICIPANT FEEDBACK to give the participant the feeling that s/he is an expert in the field related to the course DANB’s annual continuing education requirements. To find out if this course or any other of PennWell We encourage participant feedback pertaining to all courses. Please be sure to complete the topic. It is a combination of many educational courses and clinical experience that PennWell course has been approved by DANB, please contact DANB’s Recertification survey included with the course. Please e-mail all questions to: [email protected]. allows the participant to develop skills and expertise. Department at 1-800-FOR-DANB, ext. 445.

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