Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants.

Hypersensitive Updates (2nd edition) A Peer-Reviewed Publication Written by Catherine D. Saylor BSDH, MS and Pamela R. Overman BSDH, MS, EdD Recertified by Ian Shuman, DDS, MAGD, AFAAID

Abstract Educational Objectives: Author Profiles Dentinal hypersensitivity is characterized by a short, Upon completion of this educational Catherine D. Saylor BSDH, MS, earned her Bachelor’s Degree in Dental Hygiene and sharp pain in response to stimuli. Dentinal hypersensitiv- activity the participant will be able to: MS degree in Dental Hygiene Education from UMKC – School of . Ms. Saylor is a ity, which is more commonly seen in adults in the 20-40 1. List and describe the anatomical clinical assistant professor at the University of Missouri-Kansas City, School of Dentistry year old age group, has several etiological factors. features of dentin that predispose in the Department of Periodontics. She is a member of the American Dental Hygienists’ and enamel loss both contribute to the it to dentinal hypersensitivity; Association, Sigma Phi Alpha, and the American Dental Education Association. prevalence of this condition, resulting in the exposure 2. List and describe the etiological Pamela R. Overman BSDH, MS, EdD, earned her Bachelor’s Degree in Dental Hygiene of dentin. Dentinal hypersensitivity is believed to occur factors in dentinal hypersensitivity; from UMKC – School of Dentistry, an MS Degree from UMKC School of Graduate Studies, due to the movement of fluid within the dentinal tubules 3. List and describe the prevalence and a doctoral degree in educational policy and leadership at the University of Kansas. occuring in response to thermal, chemical, tactile and and most common sites for Dr. Overman is a Professor and the Associate Dean of Academic Affairs at the University of evaporative stimuli, in accordance with Brännström’s dentinal hypersensitivity; Missouri-Kansas City, School of Dentistry. She is a member of the American Dental Hygien- Hydrodynamic Theory. Treatment options include in- 4. List and describe the home and ists’ Association, Sigma Phi Alpha, and the American Dental Education Association. office procedures and home use products that are aimed in-office options for the treatment at occluding the dentinal tubules or preventing neural of dentinal hypersensitivity. Author Disclosures transmission, thereby blocking the pain response. Catherine D. Saylor and Pamela R. Overman have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. INSTANT EXAM CODE 15163 Go Green, Go Online to take your course

Publication date: Feb. 2011 Supplement to PennWell Publications Review Date: May 2014, June 2017 This educational activity was made possible through an unrestricted educational grant by Dentsply. Expiration date: May 2020 This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products PennWell designates this activity for 3 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 03-4527-15163 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Registration: The cost of this CE course is $59.00 for 3 CE credits. (10/31/2019) Provider ID# 320452. 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 within the dentin. Hypersensitive dentin typically consists of Upon completion of this educational activity, the participant will large, numerous dentinal tubules open to the oral cavity and be able to: a thin, poorly calcified (or absent) smear layer. This smear 1. List and describe the anatomical features of dentin that layer is composed of a deposit of salivary proteins, debris from predispose it to dentinal hypersensitivity; dentifrices, and other calcified matter that helps protect the ce- 2. List and describe the etiological factors in dentinal hypersen- mentum and dentin.4 In normal dentin, the smear layer covers sitivity; the openings of the dentinal tubules and reduces the risk that a 3. List and describe the prevalence and most common sites for stimulus for hypersensitivity reaches the dentinal tubules.4 dentinal hypersensitivity; 4. List and describe the home and in-office options for the Figure 1. SEM showing open dentinal tubules treatment of dentinal hypersensitivity.

Abstract Dentinal hypersensitivity is characterized by a short, sharp pain in response to stimuli. Dentinal hypersensitivity, which is more commonly seen in adults in the 20- to 40-year-old age group, has several etiological factors. Gingival recession and enamel loss both contribute to the prevalence of this condition, resulting in the ex- posure of dentin. Dentinal hypersensitivity is believed to occur due to the movement of fluid within the dentinal tubules occurring in response to thermal, chemical, tactile, and evaporative stimuli, in accordance with Brännström’s hydrodynamic theory. Treatment options include in-office procedures and home-use products that are aimed at occluding the dentinal tubules or preventing neural transmission, thereby blocking the pain response. Courtesy of Dr. Charles Cobb Introduction Dentinal hypersensitivity can be a challenging condition for Figure 2. Brännström’s Hydrodynamic Theory patients to describe and dental professionals to accurately diag- nose. It consists of short, sharp pain that occurs when a stimu- lus reaches exposed dentin. This stimulus is most commonly thermal (hot and/or cold), but can also be tactile, chemical, or evaporative. Typically, no other pathology can be found for the pain associated with dentinal hypersensitivity.1,2,3,4 Patients may or may not report this painful and often chronic condition to their dentist or dental hygienist, and when they do, they re- port experiencing short, sharp pain after a variety of stimuli.4,5 A definitive diagnosis of dentinal hypersensitivity can be chal- lenging, and practitioners must rule out other problems, such as caries, fractured or cracked teeth, defective restorations, oc- clusal trauma, or gingival conditions that could be the underly- ing cause of the dental pain a patient experiences.6,7 Dentin consists of an organic component containing colla- gen fibers in a matrix of collagenous proteins and an inorganic component containing crystals. Dentinal tu- bules run from the to the outer dentinal surface and are easily identifiable on scanning electron microscopic images of cross-sections of dentin as either open or plugged dentinal tubules. The number of tubules varies and can be as many as 30,000 in a square millimeter of dentin. The dentinal tubules contain Tomes’ fibers, first described by Sir John Tomes in 1850, that extend into the dentinal tubules from the odonto- blasts that communicate with the pulp.8,9 Three types of nerve Note the outward flow of fluid in response to stimuli, represented by fibers (A-delta fibers, A-beta fibers, and C-fibers) are found the black arrows.

2 www.DentalAcademyOfCE.com The mechanism by which the pain associated with den- Figure 3. Localized gingival recession tinal hypersensitivity is currently believed to occur is de- scribed by Brännström’s hydrodynamic theory. This theory states that stimuli (thermal, chemical, tactile, or evaporative) are transmitted to the pulp surface due to movement of fluid or semifluid within open dentinal tubules. Anatomically, the areas of the tubules closer to the pulp chamber are wider and the fluid movement away from the pulp activates the nerves associated with the at the end of the tubule, re- sulting in a pain response.10 The fluid movement stimulates the small, myelinated A-delta fibers, which then transmit to the brain and result in the sensation of well-localized, sharp pain that is associated with dentinal hypersensitivity.4,10

Etiology of dentinal hypersensitivity

Gingival recession and enamel loss Gingival recession and enamel loss have multiple causes that result in and/or dentin exposure. Exposed Figure 4. Generalized attachment loss cementum due to gingival recession tends to be thin and thus easily abraded or eroded contributing to sensitivity.11 Gingival recession is more common as patients age.1 Some common causes of gingival recession include the anatomy of the labial plate of the alveolar bone, toothbrush , and surgery, poor , acute or chronic trauma, frenal attachments, and .4

Gingival recession is more common as we age and has multiple etiologies that can cause cementum and/or dentin to become exposed.

Courtesy of Dr. Mabel Salas With respect to the anatomy of the labial plate, the alveolar bone may be thin, fenestrated, or even absent, and is a large fac- Occlusal trauma and improper frenal attachments are tor in causing recession. Tooth anatomy and tooth position may two other factors that may contribute to recession and hy- also affect the thickness of this labial plate of alveolar bone.4 persensitivity. A frenal pull that results in the tissue moving Poor oral hygiene is another contributing factor for gingival more toward the cementoenamel junction (CEJ) may result recession. Plaque-induced may progress to recession in recession. Occlusal trauma appears to be a risk factor for and attachment loss if inadequate plaque control continues. attachment loss in individuals with active periodontal disease Toothbrushing techniques causing repeated gingival trauma since the occlusal forces may lead to further recession of can be a significant factor for gingival recession. The frequency, the periodontally involved apparatus.12 Other less common duration, and force of brushing all contribute to recession. causes of gingival recession include inadequate attached Excessive force and improper technique may lead to gingival gingiva, periodontal surgery, aggressive scaling and root irritation that, over time, can also lead to recession. planing, excessive tooth cleaning and flossing, loss of gingival attachment due to specific pathologies, and loss of attachment during restorative procedures. These potential etiologies may Toothbrushing techniques causing repeated lead to exposed root surfaces which are predisposed to den- gingival trauma can be a significant tinal hypersensitivity.13,14 (Table 1) factor for gingival recession.

www.DentalAcademyOfCE.com 3 Figure 5. Advanced frenal involvement Figure 7. Abrasion

Figure 8. Extensive loss of dentin, visible pulp chambers Courtesy of Dr. Mabel Salas

Table 1. Causes of gingival recession and attachment loss Anatomy of the labial plate of the alveolar bone Periodontal disease Frenum involvement Toothbrush abrasion Poor oral hygiene Inadequate attached gingiva Periodontal surgery Iatrogenic loss during restorative procedures Aggressive Acute or chronic trauma Occlusal trauma Loss of enamel results in exposed dentin and therefore is Excessive oral hygiene associated with dentinal hypersensitivity. , abra- sion, erosion, and are conditions that affect tooth structure. (Table 2) Abrasion is the “loss of tooth structure by Figure 6. Advanced frenal involvement mechanical forces from a foreign element.”15 Once enamel is lost and/or recession is present, the exposed cementum and/ or dentin are abraded, worn, and eroded more quickly than enamel due to their lower inorganic mineral content. Dentin abrades 25 times faster than enamel, and cementum abrades 35 times faster.4

Exposed cementum and/or dentin are readily abraded, compared to enamel. Dentin abrades 25 times faster than enamel and cementum abrades 35 times faster.

Courtesy of Dr. Mabel Salas

4 www.DentalAcademyOfCE.com Table 2. Risk factors for enamel loss Hypersensitivity occurs most commonly in periodontal Abrasion patients with a reported frequency of 60-98%, while 57% of the general population experiences hypersensitivity.20,24,25 Attrition The higher prevalence for this group of individuals may be Erosion attributed to root surface exposure from the periodontal dis- ease process and treatment. Between 9% and 23% of patients Abfraction have reported root sensitivity before root planing, while after root planing approximately 55% of patients have re- Erosion is the loss of tooth structure caused by acid ported experiencing dentinal hypersensitivity. This increase based chemical dissolution of non-bacterial origin. It is in sensitivity occurred for a one-to-three week period after one of the more common chronic conditions in children the procedure and then gradually decreased over time.14,25 and adolescents and is common in adults of all ages. Only Over and above the removal of the superficial smear layer recently has this condition been recognized as a dental during scaling and root planing that can result in sensitiv- health problem.16,17,18 Erosion can be of intrinsic or extrinsic ity, aggressive scaling and root planing can remove layers origin. Gastric acid regurgitation associated with medical of protective cementum and dentin, causing sensitivity.26,27 conditions such as acid reflux disease and disorders such as When cementum or dentin is exposed, these areas are more bulimia results in intrinsic erosion. By far the most common susceptible to caries, erosion, abrasion, and abfraction.28,29,30 causes of extrinsic erosion are dietary factors that contribute Women are more prone to hypersensitivity, potentially due to a more acidic oral environment. Frequent consumption of to a higher frequency of dental visits and more extensive carbonated, acidic drinks, fruit drinks, and fruit are the pri- oral hygiene than men.6,31 mary causes. (Table 3) In general, the dissolution of enamel Hypersensitivity tends to be most prevalent on the buc- occurs at a pH below 5.0–5.7.19,20 Highly acidic foods and cal and cervical areas of the teeth.5,32,33 The most common drinks remove enamel over time, exposing the dentin. They sites are the cervical margins of the buccal and labial surfaces also have the ability to remove the smear layer, exposing of teeth, with these sites accounting for 90% of sensitive sur- dentinal tubules, thereby causing sensitivity and pain.20 faces.34 These areas of normally thin enamel are a common site for recession. Canines and first , followed by Table 3. Common risk factors for erosion incisors, second premolars and molars are commonly affect- Acid reflux disease ed by recession. Patients with moderate to severe sensitivity tend to have gingival recession predominantly on one side of Bulimia their mouth compared to the contralateral side.4 Frequent consumption of acidic drinks Frequent consumption of acidic foods Ninety percent of sensitive surfaces are found at the cervical margins of the buccal and Erosion may be a more important factor than abrasion in removing the smear layer or dentinal plugs, thereby causing labial surfaces of teeth. dentinal hypersensitivity.21 In addition, once erosion has oc- curred, patients are more susceptible to subsequent abrasion, further exacerbating the loss of tooth structure and risk of den- Diagnosis tinal hypersensitivity. A diagnosis of dentinal hypersensitivity can be a challenge for dental professionals since patients may not report it and it may not be obvious. A majority of patients do not deem it Erosion may be a more important factor than to be a severe oral health condition and may not seek treat- abrasion in removing the smear layer ment or even report this condition to their practitioner.35 or dentinal plugs. Conversely, patients with exposed dentin may or may not experience sensitivity. Exposed dentin may also be present but inconspicuous. One study used scanning electron mi- croscopy (SEM) of dental impressions to study the micro- Prevalence of dentinal hypersensitivity morphology of the bucco-cervical area of bicuspid teeth in Dentinal hypersensitivity presents as early as the teen years dentally healthy young adults. Half the sites with gingival and through old age, with higher incidences occurring in recession observed on the SEM were not evident clinically. the 20- to 40-year-old age group. 22,23 There is a wide range The SEM also showed areas of gingival with in the reported prevalence of dentinal hypersensitivity, root exposure and an absence of cementum without clinical ranging from 4-98%, depending on the population group. evidence of abrasion.11 www.DentalAcademyOfCE.com 5 behavior modifications focus on dietary choices—avoiding Patients with exposed dentin carbonated beverages and acidic foods and drinks to reduce may or may not experience sensitivity. the risk of erosion, and avoiding excessively hot/cold bever- ages and food. Routine screening for this condition does not readily oc- cur and many other oral conditions may present with similar Table 5. Patient education 4,26 symptoms. Definitively excluding these oral conditions Causes of dentinal hypersensitivity first will then lead to the diagnosis of dentinal hypersensi- tivity.36 Fractured teeth, dental caries, pulpal pathologies, or Instructions on toothbrushing technique and when to brush leaking, fractured, or failing restorations are conditions that Advice on toothbrush type—avoid medium and hard bristles present with similar signs and symptoms but require differ- Advice on appropriate use of toothpaste ent treatment.4,5 Through the use of radiographs, conversa- tions with the patient, and a thorough clinical exam, the Advice on technique for interdental cleaning dental practitioner must first exclude these conditions and Dietary advice then establish a diagnosis of hypersensitivity. Clinical signs Hypersensitivity associated with and symptoms include sensitivity or pain when a stimulus is applied (such as hot/cold/sweet/sour/touch), exposed dentin at the site of sensitivity, and in the absence of dental Patients should also be educated on when to brush, i.e., caries, fracture lines, or failing restorations.4,26 Reaching a to avoid brushing immediately after ingesting acidic foods diagnosis is a process of exclusion. and drinks (or immediately after exposure to gastric acid). Patients may exhibit a variety of behaviors when receiv- Instead, it is better to rinse with water and wait at least two ing dental care if they have experienced hypersensitivity to three hours before brushing.20 Patients may also need over the years. They may have anxiety with a routine dental education on the effect of tooth whitening on the occurrence cleaning, and can be so anxious about pain that they avoid and severity of dentinal hypersensitivity. Tooth whitening examinations and routine dental care in general.36,37 Dental can contribute to dentinal hypersensitivity by opening up professionals may need to provide patients with desensitiz- the dentinal tubules during tooth whitening treatments. ers during treatment and postoperatively. Local anesthesia Patients who have sensitive teeth should have the sensitiv- may be required for routine prophylaxis.22,36,38,39 ity addressed prior to tooth whitening and should also be given specific instructions regarding tooth whitening and Table 4. Differential diagnoses the management of associated hypersensitivity.27 Dental caries Fractured teeth Patients should be educated to avoid brushing immediately after ingesting acidic foods and drinks. Cracked teeth Fractured restorations Treatment options Leaking restorations Treatment options for hypersensitivity include self-applied, at- Pulpal pathology home desensitizing agents and professional, in-office desensitizing procedures. These treatment options can be categorized into two groups by their modes of action.4,27,40,41 Agents used to occlude the Management and treatment dentinal tubules include compounds, strontium chloride, Educating the patient on the causes and management of den- hydroxyethyl methacrylate (HEMA), and fluorides (including sil- tinal hypersensitivity is a primary goal for dental profession- ver diamine fluoride). Precipitates other than fluoride compounds als when creating a treatment plan for this condition. The first that have been used to treat sensitivity include calcium phosphate step is to identify the cause of the dentinal hypersensitivity. compounds, calcium hydroxide, amorphous calcium phosphate, (Table 4) As listed above, there are multiple etiologies and casein phosphopeptide amorphous calcium phosphate (CPP- once the main cause has been identified, education is the next ACP), and calcium sodium phosphosilicate. Recent approaches step. (Table 5) This may entail behavior modifications, such have focused on remineralizing tooth structure by increasing as instructions on toothbrushing technique, using the correct salivary calcium and phosphate levels as well an increasing the type of bristled toothbrush, and avoid using excess toothpaste salivary pH, stimulating the formation of calcium phosphate or or repeated applications of toothpaste during brushing.27 Ed- hydoxyapatite.42,43,44 Calcium phosphate compounds occlude the ucation on the appropriate way to brush, floss, and use other tubules by forming a calcium phosphate precipitate, while calcium interdental devices is necessary to avoid further loss of tooth hydroxide occludes the tubules and promotes peritubular dentin structure and dentinal hypersensitivity. Other suggestions for formation.45,46

6 www.DentalAcademyOfCE.com Figure 9. Tubule occlusion In-office treatments for tubule occlusion Professional treatments include varnishes and precipitates, primers containing glutaraldehyde and hydroxyethylmethacry- late (HEMA), and polymerizing agents.4,48 In severe cases where there is a loss of cervical tooth structure, restorations such as composite resin-based materials or restorations with glass iono- mer may be used and have been reported to effectively reduce dentinal hypersensitivity.4,47,48,49,50 There are several direct appli- cation products that work by occluding and sealing the dentinal tubules. Glutaraldehyde/HEMA-based agents have been found to significantly relieve hypersensitivity immediately after treat- ment, and reduce dentin permeability.51,52,53 Oxalate-based treat- ment is also effective and found to reduce dentin permeability.54 A third option, 5% varnish (with optional use of diode lasers), is applied topically to occlude the dentinal tubules. Initially, this forms a barrier over the exposed dentin, and once the varnish has been removed, relief from hypersensitivity is obtained by calcium fluoride deposits that occlude the dentinal tubules. This is effective for up to six months.40,55 Laser therapy is now also used for the treatment of dentinal hypersensitivity.55 Note the occlusion of the dentinal tubules, preventing the outward Severe cases may require the use of resin or glass ionomer res- flow of fluid and subsequent stimulation of nerve fibers. torations for deeper abrasive lesions. Grafting may be necessary to treat some cases of gingival recession. The World Health Or- Products that interfere with the transmission of the nerve ganization recommends that mild dentinal hypersensitivity be impulse work by raising the extracellular ion con- managed by less complex treatments, i.e., use of at home desen- centrations and affecting polarization. When this is sustained sitizers, and that in-office treatment (and follow-up home care) for a period of time, nerve excitation is reduced and the nerve be provided for more severe, recalcitrant cases and for patients becomes less sensitive to the stimuli. Potassium nitrate is the who have ongoing moderate dentinal hypersensitivity.20 most common agent used for this method. Periodontal patients without sensitivity prior to treatment may experience hypersensitivity following treatment due to scal- Figure 10. Blocking neural transmission ing and root planing or other periodontal procedures that result in exposure of open dentinal tubules.14,26 Prophylaxis can also result in hypersensitive dentin. In these situations, it is ideal if the patient can receive in-office treatment, especially those with localized hypersensitivity. There are several in-office products available for treating hy- persensitivity. The amino acid, , a bicarbonate pH buffer and a calcium source in the form of calcium carbonate can be ap- plied with a low-speed handpiece. The relief of hypersensitivity may last for up to four weeks when used as the final polishing step during a professional cleaning.39,56,57,58 A prophylaxis paste con- taining is available that is indicated for immediate desensitization. It is used to desensitize exposed dentin during prophylaxis or to prevent hypersensitivity associated with pro- phylaxis and the removal of the smear layer, or post-procedurally following scaling and root planing. This bioactive glass contains calcium sodium phosphosilicate, marketed under the name No- vaMin®, and has been investigated for hypersensitivity relief.59,60 Calcium sodium phosphosilicate (CSPS) is an inorganic, amor- phous melt-derived glass compound that contains only calcium, sodium, phosphate, and silica. This ingredient has been incorpo- Note the outward flow of fluid is still present in response to a stimu- rated into oral healthcare products for the alleviation of dentinal lus; however, neural transmission in response to this is prevented by hypersensitivity for nearly 10 years and can be found in a range of the presence of extracellular potassium. products including dentifrice and prophylaxis paste.60.61 www.DentalAcademyOfCE.com 7 In recent studies, NovaMin® has been shown to rapidly regular application is needed. These dentifrices have dem- release calcium, sodium, and phosphorous ions which form onstrated a significant reduction in hypersensitivity within a hydroxy apatite-like layer that is similar in composition to a two-week time frame when used twice daily to maintain a the minerals found in teeth and bones. These particles have high level of extracellular potassium.4,69 There are a number the ability to adhere to the dentin surface and continue re- of dentifrices containing 5% potassium nitrate, as well as leasing calcium and phosphate ions once they are deposited fluoride ions for protection against caries. Potassium nitrate onto the tooth surface.62 The crystalline hydroxycarbonate has also been used in whitening trays to relieve hypersensi- apatite-like layer that is precipitated relieves hypersensitivity tivity between whitening treatments.70 through occlusion of the dentinal tubules63 and is also resis- tant to acid challenges. A 2013 study64 evaluated the ability Home-use treatments for tubule occlusion of NovaMin® to reduce dentin hypersensitivity immediately Home-use, over-the-counter desensitizing agents that oc- after a single application following scaling and root planing clude the dentinal tubules are found in toothpastes, gels, and 28 days post-application. In this study, 2 NovaMin® con- and mouth rinses. One of the primary active ingredients taining prophy pastes were used, one containing fluoride, one used in this manner is fluoride. Stannous fluoride (0.4%) in without fluoride. The control prophy paste contained neither particular has a long history of use for relief of dentinal hy- NovaMin® nor fluoride. Following scaling and root planing persensitivity,71 and is found in dentifrices and gels, as well both NovaMin® containing prophy pastes resulted in signifi- as at other concentrations in mouth rinses. When fluoride cantly better dentinal hypersensitivity reduction compared is applied to exposed dentin, precipitates form, which block to the control immediately and 28 days post-application. the dentinal tubules. Long-term relief requires continued Furthermore, there was no statistical difference between use of the product. Stannous fluoride dentifrices have been the NovaMin® containing pastes with and without fluoride, shown to relieve dentinal hypersensitivity in clinical tri- demonstrating that fluoride was not the primary agent re- als.72 It has been reported that other fluoride dentifrices sponsible for the reduction in hypersensitivity. Prophy paste effectively relieve dentinal hypersensitivity by occluding with NovaMin® is indicated for polishing procedures before the dentinal tubules, including prescription level 5,000ppm and after scaling and root planing. Given that prophylaxis is sodium fluoride dentifrice. Calcium and phosphate precipi- typically the last step in a scaling and root planing procedure, tates formed following use of dentifrices containing calcium and a routine treatment at recall, incorporating the desensitiz- and phosphate technologies have also been found to relieve ing agent into the prophylaxis paste saves an extra step and hypersensitivity, including CPP-ACP, ACP, and calcium makes relief of hypersensitivity a simultaneous event, while sodium phosphosilicate. Studies have been conducted on still ensuring that stain is removed. dentifrice formulations containing 5% and 7.5% calcium sodium phosphosilicate.62 The research has indicated that Home-use treatments using calcium sodium phosphosilicate delivered by brushing Mild, generalized dentinal hypersensitivity can usually be twice daily with a dentifrice has a beneficial effect, reducing managed well with at-home treatment.65 Home-use treat- the sensitivity caused by exposed cervical dentin surfaces.73 ments for dentinal hypersensitivity fall into two categories Both concentrations of calcium sodium phosphosilicate (5% defined by their mechanism of action. At-home treatments and 7.5%) demonstrated effective relief, and the 7.5% con- for sensitivity relief are cost effective, safe, noninvasive, and centration was even more favorable for relief compared to the simple to use. These at-home treatments come in a variety 5% concentration.73 of applications including dentifrices, gels, or rinses, and are incorporated into the daily oral home-care regimen. Figure 11. Patient with hypersensitive dentin and root caries

Home-use treatments interfering with neural transmission The most popular agent in over-the-counter dentifrices that affect neural transmission is 5% potassium nitrate, the concentration recognized by the FDA for this ingredient. Potassium ions work by penetrating the length of the den- tinal tubule and block the repolarization of the myelinated A-fibers. This increase in extracellular potassium allows for a sufficient concentration to depolarize the nerve fibers and does not allow repolarization to occur. As a result, neu- ral transmission will not occur following exposure to the stimulus and the patient will have no sensation of sensitivity or pain.4,66,67,68 For these dentifrices to work, frequent and Courtesy of Dr. Keerthana Satheesh

8 www.DentalAcademyOfCE.com Conclusion 13. Canakci CF, Canakci V. Pain experience by patients Dentinal hypersensitivity can be a challenging condition for undergoing different periodontal therapies. J Am Dent dental practitioners to diagnose and treat effectively. With Assoc. 2007;138:1563-73. the advancement in dental products, options for providing 14. Gillam DG. Current diagnosis of dentin hypersensitivity relief from pain and sensitivity are great and vary according in the dental office: an overview. Clin Oral Investig. 2013 to the severity of the condition. Dental practitioners should Mar;17 Suppl 1:S21-9. be more aware and proactively ask patients about sensitivity. 15. Summit’s Fundamentals of Operative Dentistry: A With practitioners being more proactive with this condition, Contemporary Approach. 4th edition. Quintessence patients may not need to experience the pain associated with Publishing Co. Inc. 2013. hypersensitivity and can receive treatment that provides relief 16. 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Chabanski MB, Gillam DG, Bulman IS, Newman hypersensitivity? An overview. Clin Oral Investig. 2013 HN. Clinical evaluation of cervical dentine sensitivity Mar;17 Suppl 1:S31-40. in a population of patients referred to a specialist 7. Pashley DH, Tay FR, Haywood VB, Collins MC, periodontology department: a pilot study. J Oral Drisko CL. Dentin hypersensitivity; Consensus-based Rehabil. 1997;24:666-72. recommendations for the diagnosis and management of 25. Von Troil B, Needleman E, Sanz M. A systematic dentin hypersensitivity. Inside Dentistry. 2008; 4(Special review of the prevalence of root sensitivity following Issue):I-35. periodontal therapy. J Clin Periodontol. 2002;29 (Suppl 8. Johnson DC. Innervation of the dentin, predentin and 3):173-7. pulp. J Dent Res. 1985; 64(Spec Issue):555-63. 26. Canadian Advisory Board on Dentin Hypersensitivity. 9. Available at: http://www.merriam-webster.com/ Consensus-based recommendation for the diagnosis medical/tomes’%20fiber and management of dentin hypersensitivity. J Can Dent 10. Chung G, Jung SJ, Oh SB. Cellular and molecular Assoc. 2003;69:221-6. mechanisms of dental nociception. J Dent Res. 2013 27. Drisko CH. Dentine hypersensitivity—dental hygiene Nov;92(11):948-55. and periodontal considerations. Int Dent J. 2002;52:385- 11. Bevenius J, Lindskog S, Hultenby K. The 93. micromorphology in vivo of the buccocervical region 28. Piotrowski BT, Gillette WB, Hancock EB. Examining of teeth in young adults: a replica study by the prevalence and characteristics of abfraction-like scanning electron microscopy. Acta Odontol Scand. cervical lesions in a population of I.S. veterans. J Am 1994;52:323-34. Dent Assoc. 2001;132:1694-701. 12. Davies SJ, Gray RJM, Linden GJ, James JA. Occlusal 29. Braem M, Lambrechts P, Vanderle G. Stress induced considerations in periodontics. Br Dent J. 2001;191:597-607. cervical lesions. J Prosthet Dent. 1992; 67:718-22. www.DentalAcademyOfCE.com 9 30. Smith GBN, Knight JK. A comparison of patterns phosphate-based solutions promote dentin tubule of with the etiologic factors. Br Dent J. occlusions less susceptible to acid dissolution. Am J 1984;157:16-9. Dent. 2011 Jun;24(3):169-75. 31. Brännström M. Dentin sensitivity and aspiration of 46. Geiger S, Matalon S, Blasbalg J, Tung M, Eichmiller FC. odontoblasts. J Am Dent Assoc. 1963; 66:366-70. The clinical effect of amorphous calcium phosphate 32. Jensen AI. Hypersensitivity controlled by iontophoresis: (ACP) on root surface sensitivity. Oper Dent. double blind clinical investigation. J Am Dent Assoc. 2003;28:496-500. 1964; 68:216-5. 47. Kakaboura A, Rahiotis C, Thomaidis S, Doukoudakis S. 33. Graf HE, Galasse R. Morbidity, prevalence and intra- Clinical effectiveness of two agents on the treatment of oral distribution of hypersensitive teeth. J Dent Res. tooth cervical hypersensitivity. Am J Dent. 2005; 18:291- 1997; 56(Suppl):162. 5. 34. Yoshizaki KT, Francisconi-Dos-Rios LF, Sobral MA, 48. Freitas Sda S, Sousa LL, Moita Neto JM, Mendes RF, Aranha AC, Mendes FM, Scaramucci T. Clinical Prado RR. Dentin hypersensitivity treatment of non- features and factors associated with non-carious cervical carious cervical lesions—a single-blind, split-mouth lesions and dentin hypersensitivity. J Oral Rehabil. 2016 study. Braz Oral Res. 2015;29:45. Dec 14. 49. Schmalz G, Hellwig F, Mausberg RF, Schneider H, 35. Gillam DG, Seo HS, Bulman JS, Newman HN. Krause F, Haak R, Ziebolz D. Dentin protection Perceptions of dentine hypersensitivity in a general of different desensitizing varnishes during stress practice population. J Oral Rehabil. 1999; 26:710-4. simulation: an in vitro study. Oper Dent. 2017 Jan/ 36. Panagakos F, Schiff T, Guignon A. Dentin Feb;42(1):E35-E43. hypersensitivity: Effective treatment with an in-office 50. Pamir T, Dalgar H, Onal B. Clinical evaluation of three desensitizing paste containing 8% arginine and calcium desensitizing agents in relieving dentin sensitivity. Oper carbonate. Am J Dent. 2009;22(Spec Issue):3A-7A. Dent. 2007; 32:544-8. 37. Kumar PS, Leblebicioglu B. Pain control during 51. Yu X, Liang B, Jin X, Fu B, Hannig M. Comparative nonsurgical periodontal therapy. Compend Contin in vivo study on the desensitizing efficacy of dentin Educ Dent. 2007;28:666-70. desensitizers and one-bottle self-etching adhesives. 38. Kleinberg I. Sensistat: a new saliva-based composition Oper Dent. 2010 May-Jun;35(3):279-86. for simple and effective treatment of dentinal sensitivity 52. Aranha AC, Pimenta LA, Marchi GM. Clinical pain. Dent Today. 2002;21:42-7. evaluation of desensitizing treatments for cervical 39. Schiff T, Delgado E, Zhang YP, Cummins D, DeVizio dentin hypersensitivity. Braz Oral Res. 2009 Jul- W, Mateo LR. Clinical evaluation of the efficacy of an Sep;23(3):333-9. in-office desensitizing paste containing 8% arginine and 53. Ishihata H, Kanehira M, Nagai T, Finger WJ, Shimauchi calcium carbonate in providing instant and lasting relief H, Komatsu M. Effect of desensitizing agents on dentin of dentin hypersensitivity. Am J Dent. 2009;22 (Spec permeability. Am J Dent. 2009 Jun;22(3):143-6. Issue):8A-15A. 54. Corral C, Grez PV, Letelier M, Dos Campos EA, 40. Petersson LG. The role of fluoride in the preventive Dourado AL, Fernández GE. Effect of oxalic acid- management of dentin hypersensitivity and root caries. based desensitizing agent on cervical restorations Clin Oral Investig. 2013 Mar;17 Suppl 1:S63-71. on hypersensitive teeth: a triple-blind randomized 41. Al-Sabbagh M, Brown A, Thomas MV. In-office controlled clinical trial. J Oral Facial Pain Headache. treatment of dentinal hypersensitivity. Dent Clin North 2016 Fall;30(4):330-337. Am. 2009; 53(1): 47-60. 55. Suri I, Singh P, Shakir QJ, Shetty A, Bapat R, Thakur 42. LaTorre G, Greenspan DC. The role of ionic release R. A comparative evaluation to assess the efficacy from NovaMin® (calcium sodium phosphosilicate) in of 5% sodium and diode laser and tubule occlusion: an exploratory in vitro study using their combined application in the treatment of dentin radio-labeled isotopes. J Clin Dent. 2010; 21(Spec hypersensitivity. J Indian Soc Periodontol. 2016 May- Iss):72-6. Jun;20(3):307-14. 43. Wefel JS. NovaMin: likely clinical success. Adv Dent 56. Kleinberg I. Sensistat: a new saliva-based composition Res. 2009; 21:83-6. for simple and effective treatment of dentinal sensitivity 44. de Oliveira da Rosa WL, da Silva TM, Demarco FF, pain. Dent Today. 2002; 21:42-7. Piva E, da Silva AF. Could the application of bioactive 57. Hamlin D, Phelan Williams E, Delgado E, et al. Clinical molecules improve vital pulp therapy success? A evaluation of the efficacy of a desensitizing paste systematic review. J Biomed Mater Res A. 2016 Dec 20. containing 8% arginine and calcium carbonate for the 45. Gu H, Ling J, LeGeros JP, LeGeros RZ. Calcium in-office relief of dentin hypersensitivity associated with

10 www.DentalAcademyOfCE.com dental prophylaxis. Am J Dent. 2009; 22:16A-20A. 72. Schiff T, He T, Sagel L, Baker R. Efficacy and 58. Chen CL, Parolia A, Pau A, Celerino de Moraes Porto safety of a novel stabilized stannous fluoride and IC. Comparative evaluation of the effectiveness of sodium hexametaphosphate dentifrice for dentinal desensitizing agents in dentine tubule occlusion using hypersensitivity. J Contemp Dent Pract. 2006 May scanning electron microscopy. Aust Dent J. 2015 1;7(2):1-8. Mar;60(1):65-72. 73. Litkowski L, Greenspan DC. A clinical study of the 59. Kulal R, Jayanti I, Sambashivaiah S, Bilchodmath S. An effect of calcium sodium phosphosilicate on dentin in-vitro comparison of nano hydroxyapatite, NovaMin hypersensitivity—proof of principle. J Clin Dent. 2010; and Proargin desensitizing toothpastes - A SEM Study. J 21(Spec Iss):77-81. Clin Diagn Res. 2016 Oct;10(10):ZC51-ZC54. 60. Scott, R. NovaMin® Technology. J Clin Dent. 2010; Author Profiles 21(Spec Iss):59-60. Catherine D. Saylor, BSDH, MS, earned 61. Greenspan, DC. NovaMin® and tooth sensitivity—an her bachelor’s degree in dental hygiene and overview. J Clin Dent. 2010;21(Spec Iss):61-5. MS degree in dental hygiene education 62. Jennings DT, McKenzie KM, Greenspan DC, Clark from UMKC—School of Dentistry. Ms. AE. Quantitative analysis of tubule occlusion using Saylor is a clinical assistant professor at NovaMin (sodium calcium phosphosilicate). J Dent the University of Missouri-Kansas City, Res. 2004; 83(Spec Iss A):2416. School of Dentistry in the Department of 63. Litkowski L et al. Pilot clinical and in vitro studies Periodontics. She is a member of the American Dental Hy- evaluating NovaMin® in desensitizing dentifrices. gienists’ Association, Sigma Phi Alpha, and the American IADR. 1998;Abstract #747. Dental Education Association. 64. Neuhaus KW, Milleman JL, Milleman KR, Mongiello KA, Simonton TC, Clark CE, Proskin HM, Seemann Pamela R. Overman, BSDH, MS, EdD, R. Effectiveness of a calcium sodium phosphosilicate earned her bachelor’s degree in dental hy- containing prophylaxis paste in reducing dentine giene from UMKC—School of Dentistry, an hypersensitivity immediately and 4 weeks after a single MS degree from UMKC School of Graduate application: a double-blind randomized controlled trial. Studies, and a doctoral degree in educational J Clin Periodontol 2013; .doi:10.1111/jcpe.12057. policy and leadership at the University of 65. Rajesh KS, Hedge S, Arun Kumar MS, Shetty DG. Kansas. Dr. Overman is a professor and Evaluation of the efficacy of a 5% calcium sodium the associate dean of academic affairs at the University of phosphosilicate (Novamin) containing dentifrice for the Missouri-Kansas City, School of Dentistry. She is a member relief of dentinal hypersensitivity: a clinical study. Indian of the American Dental Hygienists’ Association, Sigma Phi Alpha, and the American Dental Education Association. J Dent Res. 2012 May-Jun;23(3):363-7. 66. Markowitz K, Bilotto G, Kim S. Decreasing intradental Author Disclosures nerve activity in the cat with potassium and divalent Catherine D. Saylor and Pamela R. Overman have no cations. Arch Oral Biol. 1991;36:1-7. commercial ties with the sponsors or the providers of the unre- 67. Peacock JM, Orchardson R. Effects of potassium ions stricted educational grant for this course. on action potential conduction in A- and C-fibers of rat spinal nerves. J Dent Res. 1995;74:634-41. 68. Markowitz K, Kim S. The role of selected cations in the desensitization of intradental nerves Proc Fin Dent Soc. 1992; 88(Suppl 1):39-42. 69. Tavss EA, Fisher SW, Campbell S, Bonta Y, Darcy- Siegel J, et al. The scientific rationale and development of an optimized dentifrice for the treatment of dentin hypersensitivity. Am J Dent. 2004 Feb;17(1):61-70. 70. Haywood VB, Caughman WF, Frazier KB, Myers ML. Tray delivery of potassium nitrate-fluoride to reduce bleaching sensitivity. Quintessence Int. 2001;32(2):105- 9. 71. Thrash WJ, Dodds MW, Jones DL. The effect of stannous fluoride on dentinal hypersensitivity. Int Dent J. 1994 Feb;44(1 Suppl 1):107-18.

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Questions

1. Dentinal hypersensitivity: 12. Which of the following is correct regarding a. Educating the patient on the causes of dentinal a. Consists of short, sharp pain in response to a stimulus the rate of dentin and cementum abrasion hypersensitivity b. May or may not be reported respectively compared to enamel? b. Educating the patient on the management of dentinal c. Occurs when a stimulus reaches exposed dentin a. 35 times; 25 times hypersensitivity d. All of the above b. 25 times; 45 times c. Covering exposed dentin 2. Dentin contains: c. 25 times; 35 times d. a and b d. None of the above a. Collagen fibers 22. Behavior modification can include: b. An inorganic component 13. Which of the following can result in erosion a. Using proper oral hygiene techniques c. Hydroxyapatite crystals of intrinsic origin? b. Making sound dietary choices d. All of the above a. Acid reflux disease c. Avoiding brushing after intake of acidic foods and 3. Which of the following is the correct b. Swimming drinks c. Bulimia number of tubules there may be in a square d. All of the above millimeter of dentin? d. a and c 23. Strontium chloride: a. 10,000 14. Enamel demineralization occurs below a b. 20,000 pH of: a. Prevents neural transmission of a stimulus c. 30,000 a. 3.0–3.7 b. Occludes the dentinal tubules d. 40,000 b. 4.0–4.7 c. Is part of the normal smear layer d. a and c 4. Which of the following communicate with c. 5.0–5.7 the pulp? d. 6.0–6.7 24. Which of the following has been used to a. Odontoblasts 15. Higher incidence of dentinal hypersensitiv- treat dentinal hypersensitivity? b. Tomes’ fibers ity occurs in which of the following age a. Fluoride c. Dentinal tubules groups? b. Amorphous calcium phosphate d. None of the above a. 20- to 40-year-old c. Calcium sodium phosphosilicate 5. Which of the following is a characteristic of b. 30- to 40-year-old d. All of the above hypersensitive dentin? c. 10- to 20-year-old 25. Calcium hydroxide: d. 40- to 60-year-old a. Dentinal tubules open to the oral cavity a. Occludes the tubules b. Large and numerous dentinal tubules 16. Which of the following is correct regarding b. Precipitates calcium phosphate c. A thin, poorly calcified (or absent) smear layer the prevalence of dentinal hypersensitivity c. Promotes peritubular dentin formation d. All of the above cited in publications? d. a and c a. Up to 78% 6. The smear layer: 26. Products that interfere with the transmis- a. Helps protect the cementum and dentin b. Up to 88% sion of the nerve impulse work by raising: b. Covers the openings of the dentinal tubules c. Up to 98% c. Reduces the risk that a stimulus for hypersensitivity d. None of the above a. Extracellular sodium ion concentrations b. Intracellular sodium ion concentrations reaches the dentinal tubules 17. Which of the following is correct regarding c. Intracellular potassium ion concentrations d. All of the above the number of patient reports of dentinal d. Extracellular potassium ion concentrations 7. The A-delta fibers: hypersensitivity after scaling and root plan- a. Are stimulated by fluid movement in the dentinal ing compared to before? 27. Glutaraldehyde/HEMA-based agents tubules a. Fewer have been found to: b. Transmit to the brain b. The same number of a. Significantly relieve hypersensitivity immediately after c. Are myelinated c. More treatment d. All of the above d. None of the above b. Significantly relieve hypersensitivity after six months 8. Which of the following is a common cause of 18. Which of the following is correct regarding c. Reduce dentin permeability gingival recession? the most common sites for dentinal d. All of the above a. Occlusal trauma hypersensitivity on the buccal and labial 28. Restorations such as composite resins are b. Frenum attachment surfaces of teeth? used for which type of dentinal hypersensi- c. Periodontal disease a. Incisal margins tivity cases? b. Cervical margins d. All of the above a. Mild cases c. Midfacial 9. Gingival recession can be the result of the b. All cases d. a and b alveolar bone being: c. Severe cases a. Fenestrated 19. Which of the following can present with d. None of the above b. Thin signs and symptoms similar to those of c. Absent dentinal hypersensitivity? 29. 5% sodium fluoride varnish: d. All of the above a. Fractured teeth or restorations a. Initially forms a barrier over exposed dentin b. Occludes the dentinal tubules with calcium fluoride 10. Which of the following is a less common b. Pulpal pathologies c. Leaking or failing restorations deposits cause of gingival recession? c. Is effective in treating dentinal hypersensitivity a. Aggressive scaling and root planing d. All of the above d. All of the above b. Inadequate attached gingiva 20. Patients who have dentinal hypersensitivity c. Iatrogenic loss during restorative procedures may: 30. Based on a hierarchical model from the d. All of the above a. Have anxiety with a routine dental cleaning World Health Organization, it has been 11. Which of the following is one of the condi- b. Be so anxious about pain that they avoid examinations recommended that mild and responsive tions that can result in enamel loss? and routine dental care in general dentinal hypersensitivity be managed by: a. Abrasion c. Request local anesthesia even for routine prophylaxis a. Less complex treatments b. Attrition d. All of the above b. More complex treatments c. Erosion 21. Which of the following is a primary goal for c. In-office treatments only d. All of the above dental professionals? d. None of the above

12 www.DentalAcademyOfCE.com Notes

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14 www.DentalAcademyOfCE.com INSTANT EXAM CODE 15163 ANSWER SHEET Hypersensitive Dentin Updates (2nd edition)

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8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 1. 16.

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 2. 17. 3. 18. 10. Do you feel that the references were adequate? Yes No 4. 19. 11. Would you participate in a similar program on a different topic? Yes No 5. 20. 12. If any of the continuing education questions were unclear or ambiguous, please list them. 6. 21. ______7. 22. 13. Was there any subject matter you found confusing? Please describe. 8. 23. ______9. 24. ______10. 25. 14. How long did it take you to complete this course? 11. 26. ______12. 27. ______13. 28. 15. What additional continuing dental education topics would you like to see? 14. 29. ______15. 30. ______AGD Code 010

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