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Dentinal Hypersensitivity: Etiology, Diagnosis and Management a Peer-Reviewed Publication Written by Howard E

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Dentinal Hypersensitivity: Etiology, Diagnosis and Management a Peer-Reviewed Publication Written by Howard E Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants. Dentinal Hypersensitivity: Etiology, Diagnosis and Management A Peer-Reviewed Publication Written by Howard E. Strassler, DMD, FADM, FAGD, FACD and Francis G. Serio, DMD, MS, MBA, FICD, FACD, FADI This course has been made possible through an unrestricted educational grant from Colgate-Palmolive Company. 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 fects incisors, canines, premolars and molars, with canines The overall goal of this course is to provide dental profes- and premolars reported to be affected most often.15,16 sionals with information on the etiology, diagnosis and Patients with dentinal hypersensitivity may not spe- treatment of dentinal hypersensitivity. Upon completion of cifically seek treatment, because they do not view it as a this course, the participant will be able to do the following: significant dental health problem, but will mention it at a 1. Know the incidence of dentinal hypersensitivity and routine dental appointment.17 At other times, patients will risk factors for this condition seek treatment recommendations from their dental profes- 2. Know the anatomical and physiological features, and sionals. Some patients are concerned whenever there is the accepted theory, associated with dentinal hypersen- dental pain,18 and for some the first time they experience sitivity dentinal hypersensitivity creates fear that there is some- 3. Understand the need for screening and diagnosis by thing more serious occurring. The authors of this course exclusion for dentinal hypersensitivity have had patients report sensitivity who believe that it may 4. Know the treatment options available for dentinal be a toothache that requires immediate attention so that the hypersensitivity and considerations in selecting these. pain does not get worse. Patients can identify areas of den- tinal hypersensitivity before a clinical exam is performed. Abstract This may be chronic, or unpredictable and cause intermit- Dentinal hypersensitivity has been referred to as one of the tent discomfort that is difficult to pinpoint.19,20 Other pa- most painful and chronic dental conditions, with a reported tients cannot distinguish between dentinal sensitivity and prevalence of between 4% and 57% in the general population gingival sensitivity. Patients may also experience dentinal and a higher prevalence in periodontal patients. It may also hypersensitivity as a result of treatment such as scaling and occur as a result of, or during, dental treatment. Clinicians root planing or during routine and normal actions associ- must screen for dentinal hypersensitivity and diagnose by ated with treatment, such as when a tooth is dried using an exclusion, determine appropriate treatment, and provide air spray or scratched with the tip of an explorer. Dental treatment and preventive recommendations. Consideration treatment can also exacerbate pre-existing sensitivity. should also be given to treating dentinal hypersensitivity Dentinal hypersensitivity has all the criteria to be associated with dental treatment. Traditional treatments considered a true pain syndrome.21 It is important to dis- have included adhesive resins, fluoride varnishes, HEMA, tinguish sensitivity pain, that of short duration, from pain iontophoresis, gingival grafts and desensitizing dentifrices. of longer duration not treatable with desensitizing agents. Other technologies include the use of bioglass particles, A painful response that lingers or that wakens the person ACP, as well as 8% arginine and calcium carbonate paste. from a sound sleep may be the result of pulpal inflamma- tion. A diagnosis by the dentist is necessary to establish Introduction a cause and effect, and a diagnosis by exclusion must be During routine dental examinations, our patients frequent- made for dentinal hypersensitivity, ruling out other condi- ly inquire about dentinal hypersensitivity that was one tions requiring different treatment. After the diagnosis episode or is chronic and recurring due to a given action, of dentinal hypersensitivity has been made, depending e.g., drinking cold beverages, eating hot foods, breathing on the etiology, recommendations can be made for effec- in and out. This common complaint is defined as dentinal tive treatment. Calvo noted in 1884: “There is great need hypersensitivity, but it is also known as root sensitivity, of a medicament, which while lessening the sensitivity of or just sensitivity. Patients describe this phenomenon as dentin, will not impair the vitality of the pulp.”22 Recom- sharp, short-lasting tooth pain, irrespective of the stimu- mendations can include in-office, at-home professionally lus.1 Holland et al. described dentinal hypersensitivity as dispensed or over-the counter treatments.23-26 Regardless of “characterized by short, sharp pain arising from exposed which treatment recommendations are made and provided, dentin in response to stimuli typically thermal, evaporative, it is important to follow up with the patient to evaluate the tactile, osmotic or chemical and which cannot be ascribed therapeutic results. to any other form of dental defect or pathology.”2 The prevalence of dentinal hypersensitivity has been Etiology and Physiology of Dentinal reported to be between 4% and 57% in the general popula- Hypersensitivity tion.3-10 Among periodontal patients, its frequency is con- Dentinal hypersensitivity can have multiple etiologies. It siderably higher (60%–98%).11,12 This hypersensitivity may is important that the patient’s medical and social history, be due to cementum removal during root instrumentation. lifestyle, medications and supplements being taken, diet Dentinal hypersensitivity has been described as generally and food habits, and oral hygiene be thoroughly reviewed. occurring in patients 30 to 40 years old,13 but it can occur in Before making a diagnosis of dentinal hypersensitivity, patients significantly younger or older. Women may be af- other oral conditions must be ruled out, including occlusal fected more often than men.14 Dentinal hypersensitivity af- trauma, caries, defective restorations, fractured or cracked 2 www.ineedce.com teeth, potential reversible or irreversible pulpal pathology, Location of Dentinal Hypersensitivity – or gingival conditions.14,24 For instance, pain during chew- Patients at Risk ing may be due to a fractured and mobile restoration that Why are some root surfaces hypersensitive and others is rubbing against the dentin or diagnostic for a cracked are not? tooth.27 Exposed root surfaces due to gingival recession are a Dentin is sensitive due to its anatomy and physiology. It major predisposing factor to dentinal root hypersensitiv- is a porous, mineralized connective tissue with an organic ity (Figure 2).33 According to a recent report of adults over matrix of collagenous proteins and an inorganic compo- the age of 60, almost 32% had root caries or a restored root nent, hydroxyapatite. Dentinal tubules are micro-canals surface.34 Since root caries are an indication of periodontal that radiate outward through the dentin from the pulp attachment loss and subsequent recession, this defines the cavity to the dentinal surface, with different configurations population of adults over 60 with an at-risk of recession in and diameters in different teeth. For human dentin, one at least one or more teeth as at least 30%. Another study square millimeter can contain 30,000 tubules, depending concluded that at least 22% of the adult population between on depth. Each tubule contains a Tomes fiber (cytoplastic 30 and 90 years of age will have evidence of recession in cell process) and an odontoblast that communicates with one or more teeth of 3 mm or more.35 Gingival recession the pulp. Within the dentinal tubules there are two types is more common as patients age and in patients with better of nerve fibers, myelinated (A-fibers) and unmyelinated oral hygiene.14,36 Common causes include inadequate at- (C-fibers).28 The A-fibers are responsible for the sensation tached gingiva, prominent roots with a thin alveolar hous- of dentinal hypersensitivity, perceived as pain in response ing or bony dehiscence, toothbrush abrasion, periodontal to all stimuli. surgery, factitial habits (e.g., picking at cervical area of the The most widely accepted mechanism of dentinal tooth with a fingernail), excessive tooth cleaning, excessive sensitivity is the hydrodynamic theory, first described by flossing, loss of gingival attachment due to specific patholo- Brännström.29,30 In this model, the aspiration of odonto- gies, and iatrogenic loss of attachment during restorative blasts into the dentinal tubules, as an immediate effect procedures.33,37 of physical stimuli applied to exposed dentin, results in Figure 2. Gingival recession with exposed root surfaces the outward flow of the tubular contents (dentinal fluids) through capillary action (Figure 1). The changes to the Exposed lingual root surfaces dentinal surface lead to stimulation of the A-type nerve fibers surrounding the odontoblasts. For there to be a stimulus response, the tubules must be open at both the dentinal interface and within the pulp. Absi and coworkers reported that nonsensitive teeth were not responsive to any physical stimuli; sensitive teeth had up to eight times the number of open dentinal tubules
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