Cervical . Part i: The air indexing method

Thomas A. Coleman, DDSVKeith E. Kinderknecht,

The purpose ot this article is to introduce an objective method for quantitying cervical dentin hypersensi- tivity. Air emissions trom a standard air-water syringe or a syringe with a Fluid Control Block are directed toward the cervices of teeth at a 45-degree angle to the long axis of test teeth trom a distance of 0.5 cm for 0.5 to 1.0 second. An air indexing method has been deveioped to quantify threshold patient response values for individual teeth to this detined air stimulus. The air indexing method, using the Fluid Control Block, otters the olinician objective information to compare cervical denlin hypersensitivity betöre and after treatment tor this common, painful condition. (Quintessence int 2000,31:481^65)

Key words: abfractive lesion (abtraction), air index mapping, air indexing method, cervical dentin hypersenshivify. Fluid Conlrol Block, hydrodynamic theory, threshold patient response

umerous patients experietice acitte or chronic may lead to eervical hypersensitivity for teeth with Nsensitivity and pain in the cervical regions of vital pulp tissues.''"'^ teeth. An estimated 40 million Americans a year suffer Open dentinal tubules on root surfaces may result from cervical (dentin) hypersensitivity. aniä 10 miliion from multiple etiologies. One popuiar explanation is of this group experience chronic symptoms.' - Cervicai that exeessive force or time during toothbrushing may pairt is a pulpai response resuiting from exposure of result in and root , leading open dentinai tubules to coid, air, eieetrieal stimuia- to cervical hypersensitivity.'""^^ Other authors have tion, acid exposure, tactile stimulation, or combina- inversely attributed this sensitivity to plaque accumu- tions of these stimuii.^-'- lation.^•'•^= The erosive effects of environmental or This pulpal response appears to resuit from changes dietary acids on the dentin surlace have been sug- in osmotic pressure within open tubuies, as suggested gested as contributory etiologies.^^"-* Gastric régurgita- by Gysi.^ The hydrodynamic theory, further developed tion, such as occurs with bulimia or esophageal reflitx, by Brännström'" and Anderson et al," proposes that is a potential source of dentin erosion from exposure pulpal meehanoreeeptors are stimuiated by evapora- to a systemic acidic agent.-•'•^"•'' tion of dentin fluids from open tubules on root sur- The mechanical effects of exeessive occiusai ioad- faces. Teeth witii a history of cervical hypersensitivity ing stresses in the development of eervical abfractive have been found to iiave many more open tubules lesions have not been verified in controlled clinical with larger diameters than teeth with no history oí studies but rnay also result in open dentinal hypersensitivity.*'^" Modern techniques to treat symp- tubules.""'*^ Xhonga et aF' found that the rate of for- toms of cervical hypersensitivity inciude the use of mation of iesions in the presence of brtix- resin composites, strontium chloride, fluoride, ism does not decrease following appiication of topieai oxalates, or other materials that occlude these denti- Ilitorides. Excessive functional or parafunctional hori- nal tubules.'•'^•^•'^ Thus, treatment mimics the physio- zontal loading forces seem to have a greater potential logic presence of the salivary glycoprotein pellicie to lead to the deveiopment of abfractive lesions than layer that occludes tubular root dentin.^-^ Oral condi- do vertical or compressive forces.^'"" Studies are tions that interrupt the integrity of this pellicle layer needed to clarify the roles that these theoretical etiolo- gies play in the development of cervical dentin hyper- sensitivity. ' Private Practice, Stiattsbury, Vermont. Methodology for assessing cervical dentin hypersen- ^Department of Oral Healtli Practice, University of Kentucky. Coliege of sitivity of individual teeth is based on pulpal response Denlistry, Lexington, Kentucky. to cold, air, osmotic, tactile, or electrical stimula- Reprint requests: Dr Thomas A. Coleman. Shaftsbury Medical Building, Box ¿30. Shaftsbury, Vermont 05262. Fax 802-442-2072. t¡Q¡^ 5.11,12.40-69 Pashley' has deseribed available methods

Quintessence internationai 461 • Colema n/Kinderknecht —

Fig 1 Fiuid Control Biock (prototype 1): Reguiates air and water Fig 2 Fiuid Controi Block (prototype 2). Reguiates air by disk by disk rotation. rotation, water ¡low is nol interrupted. and discussed the advantages and disadvantages of pufis of air in an attempt to differentiate hypersensitive these methods in significant detail. The use of a Yeaple from nonhypersensitive teeth. This method of air deliv- probe and a calibrated strain gauge ¡n an explorer ery lacked specificity in exchanging objective informa- have been used for tactile stimulation studies,-"''''' Cold tion between operators and required a significant water has been found tnore useful than warm water for learning cui^ve to standardize attenuated air emission, assessment of thermal response.""^" A standard air-water syringe (eg, A-Dee) was modi- Air blasts applied to the cervical regions have been fied in 1994 by insertion of a Fluid Control Block™" used for study of the hydrodynamic theory and the between the wand attachment and syringe head {Fig effectiveness of desensitizing agents,^"'"''''''^ The dis- 1). This device offered 5 metered choices for ambient tance from the tooth, duration, and volume of air have air emission at approximately 40 psi from an air-water never been standardized by previous stitdies,''^"^' The syringe (Fig 2), Ambient air was defined at room tem- effects of evaporation arising from prolonged exposure peratures of lS-C to 25°C, The color-coded Fluid or increased/decreased distance from air source to the Control Block dial was rotated by finger pressure to tooth may alter pulpal responses.^ Osmotic stimula- any of 5 air selections: 2 to 3 psi, 4 to 6 psi, 11 to 17 tion produces a pulpal response when dentin is psi, 25 to 30 psi, or 35 to 40 psi. Calibrations were exposed to solutions with high solute concentra- determined by the use of an air gauge following 12 tri- tions,^°"" Neither osmotie nor electrical stimuli offer als with each aperture of the installed Fluid Control practical methods for the dctcetion of dentin hyper- Block at ineoming pressures of 20 to 40 psi. sensitivity,^ The purpose of this article is to introduce a stan- Air indexing method dardized technique for quantifying ccrvieal dentin hypersensitivity. The method uses defined gradients of The "air indexing" method was designed to detect sen- air, applied from a defined distance and for a defined sitivity of dentin to air within an acceptable range of period of time. The intent is to provide the clinician patient comfort, A restricted air stream was directed with a means to document a "threshold patient toward the cementoenamel junction at approximately response" for detecting this hypersensitivity. a 45-degree angle to the long axis of a tooth for a duration of 0,5 to 1,0 second, A short duration of air exposure avoids the potential release of neurotrans- TECHNIQUE mitters in pulpal tissue ("neurogenic inflammation") or evaporative phenomena, as discussed by Pashiey,' Fiuid Control Biock The distance from the wand tip to the tooth cervix was approximately 0,5 cm. From 1979 until 1994, "minor puffs" of air from a stan- Cervical dentin found sensitive to low volumes of dard air-water syringe were used for the detection of air was termed hypersensitive. The most posterior sensitive root dentin. The amount of air delivered dur- tooth of a test zone was evaluated first, by application ing hypersensitivity testing was selected by the audible of air from Fluid Control Block hoie 1 (2 to 3 psi) on sound of air released from the syringe. The clinician the facial surface. If the air stream did not elicit a had to become acquainted with the sound of minor response from the patient, then the next more anterior

462 Voiume 31, Number 7, • Coleman/Kinderknectit • tooth was evaluated for sensitivity, and so on, to CONCLUSION ohtain an air index mapping for this test zone of teeth. If no sensitivity was found with air from hole 1, the The Fluid Control Block, developed in 1994, provides dial was rotated to hole 2 (4 to 6 psi). The same a controlled and quantifiable amount of air in the method for detecting cervical dentin sensitivity was determination of the threshold patient response to cer- repeated, beginnitig with the most distal tooth of this vical dentin hypersensitivity. The air indexing method test zone. If all teeth were reported not sensitive by provides the foundation for future studies investigating the patient to the stimulus, the dial was rotated to the efiologic factors and treatment modalities related holes 3 (11 to 17 psi), 4 {25 to 30 psi), or 5 (35 to 40 to this eommon dental complaint. psi) until a subject tooth or teeth were quantified as sensitive to the air stimulus. The least air pressure neeessary for patient detec- ACKNOWLEDGMENTS tion of a sensitive tooth was termed the threshold patient response. These threshold response values The authors wish to express gratitude to the American Denial were determined hy the patient and reeorded as none Aîsociation Research Library fnr their literature search. The authors (0), slight (1), moderate (2), or severe (3), The same uko acknowledge Gordon Christenscn, DDS, MSD, PhD: Sebastian Ciancio. DDS. PhD: Peter Da\vson, DDS; Davis Garlapo, DDS; John method was then applied to lingual cervical regions of 0. Grippo, DDS; Robeti Kerstdn. DMD; Kenneth Malament, DDS. teeth for this test zone. Resultant threshold patient MSt-D; Norman Mohl. DDS, PhD; Jeffrey Okeson. DMD; and David responses were then available to track changes in cer- H. Pashky, DMD, PhD, for their assistance, guidance, and encour- vical dentin sensitivity over time and in response to treatment. A diagnosis of cervical dentin hypersensitivity was not made, nor was treatment rendered, unless a veri- REFERENCES fied positive threshold patient response value was 1. Jianapka JA. Over tht'-tounter dí;ntifiii;es in the treatment found 7 to 10 days after the inifial detection. of tooth hypi;rsensilivity. Dent Clin North Am 1990;34: 545-560. 2. Martin EJ. Tending to tenderness: GPs get hip to new DISCUSSION hypersensitivity products. AGD Impact J997:25(ll): 19-20, 3. Gurro FA. Tooth hypersensitivity in the spectrum of pain. The air indexing method provides a practical way for Dent Clin North Am 1990;34:429-437. the clinician to objectively compare pretreatment den- 4. Addy M. Etiology and clinical implications of dentine tin hypersensitivity with posttreatment results. It gen- hypersensitivity. Dent Clin North Am 199O;34:5O3-5I4. 5. Pashiey DH. Mechanisms of dentin sensitivity. Dent Clin erates a quantified threshold patient response for North Am 199Ü;34;450-473. dentin sensitivity to air emission hy using a Fluid 6. Pashley DH. Dentin sensitivity: Theory and treatment. Control Block on a standard air-water syringe while Adult Oral Health 1993;l(2):l-7 allowing maximal patient comfort. The air stimulus 7. Tavares M, Depaoia PF, Soparhar P, Using a fluoride-releas- necessary to elicit a detectahle pafient response is reg- ing resin to reduce cervicai sensitivity. ] Am Dent Assoc ulated by the Fluid Control Block, allowing compar- 1994;125:1337-1342. isons of dentin sensitivity with minimized stimulation 8. Absi EG, Addy M, Adams D. Dentine hypersensitivity; A of pulpal mechanoreceptors hy evaporation. Initial study of the patency oí dentinai tubules in sensitivity and nonsensitive cervical dentine. J Clin Periodontol 1987;14: and follow-up threshold patient responses offer a 280-284. method of assessing treatment modalities for dentin 9. Gysi A. An attempt to explain the sensitiveness of dentin. Br hypersensitivity. ) Dent Res 1900;43:865-868. Informafion associating ahfractive lesions and cer- 10. Brânnstrom M. Dentin sensitivity and aspiration of odonto- vical denfin hypersensitivity, determined with the air blasts. ] Am Dent Assoc 1963;66:366-370. indexing method, will be presented in part II of this 11. Anderson DJ, Hannam AG, Matthews B. Sensory mecha- article. Part III will contain data from a retrospective nisms in mammalian teeth and their supporting structures. study disclosing resolution of cervical dentin hyper- Physiol Rev 1970:59171-195. sensitivity following occlusal therapy. 12. Brânnstrom M. Dentinai and puipai response. III. Appli- cation of an air stream to exposed dentine; long observation periods, Aeta Odontol Scand 1960;18;235-252.

Quintessence International 463 • Coleman/Kinderi

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464 Volume 31, Number 7, 2000 • Coleman/Kinderknechi Electroforming ¡n 60, Trowbridge HO, Franks M, Korostaff E, Emling R, Sensory response to thermal stimulation in human teelh. J Endod Restorative 1980:6:405-412, 61, Brännström M, Linden L, Astrom A, The hydrodynamics of New Dimensions in dental tubule and of pulp fluid: Its significance in relation to dental pain. Caries Res 1967;l:310-317 Biologically Based Prostheses 62, Van Hassel HJ, Brown AC, Effect of temperature changes on intrapulpal pressure and hydraulic pertncability in dogs. Jakob Wirz and Andreas Haffmann Arch Oral Biol 1969;14:301-315. 63, Orchardson R, Collins WJN. Clinical features of hypersensi- tive teeth, Br Dent J 1987:162:253-256. rpJiis clinical atlas describes the use of elec- 64, Pashley DH, Stewart FP Galloway SE. Effects of air-diying 1 troforming technology to achieve estheti- in vitro on human dentine permeability. Arch Oral Biol cally superior restorations that are also 19S4;29.379-J83, biologically compatible, Electroforming is a 65, PolhagL'n L, Brännström M, The liquid movement in desic- process that involves the deposition of layers eated and rebydrated dentine in vitro. Acta Odont Scand of goid to form esthetic support structures 1971:29:95-102, featuring highly adaptable margins For a pre- 66, Johnson G, Brännström M. The sensitivity of dentin: cise fit; when veneered with ceramic, these Changes in relation to conditions at exposed tubule aper- restorations also offer superb durability and tures. Acta Odontol Scand )974;32:29-38, functionality. Since electroforming can be 67 Matthews B, Hughes SHS, The ultra structure and receptor transduction mechanism of dentine. In: Hamann W, Iggo A used with titanium as well as with gold, this (eds], Transduction and Cellular Mechanisms in Sensory technology has Receptors. Progress in Brain Research, vol, 74. New York: broad potential Elsevier, 1988:69 for use with 68. Bender IB, Landau MA, Porlsecca S, Trüwbridge HO, The implant-support- optimum placement-site of tbe electrode in eleetrie puip ed prostheses. testing of the 12 anterior teeth J Am Dent Assoc 1989;118:305-309. 69. Karlsson UL, Penney DA, Natural desensitization af exposed tooth roots in dogs. | Dent Res 1975:54:982-986, 70. Coleman TA, Rate controlled fluid delivery in dental appli- eations. US patent 5,547374, August 20, 1996,

71. Coleman TA. Rate controlled delivery in dental applica- ¿29 pp. 751 illus: tions. US patent 5,807,105, September 15, 1998. ISBN0-BÖ715-37Ö-8: US 5189

1. Biological Dentül Prosihetics 2, Development of Electroiorming Technology "i, Electroforming—Dental Laboratory Technology 4, Electroforming—Clinical Aspects 5, Material and Technological Aspects 6, Tips and Tricks for the Dental Technician

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