Dentin Hypersensitivity

Dentin hypersensitivity is defined as

a short, sharp pain arising from exposed dentin in response to stimuli, typically thermal, evaporative, tactile, osmotic or chemical and which can not be ascribed to any other form of dental defect or pathology

Cold stimulus Hot stimulus Air blast Tactile stimulus

inward flow outward flow outward flow inward flow

Intra tubular fluid shift receptor in superficial pulp

acivate mechano pain

Etiology

Etilogy

Abrasion

Attrition

Abfraction

erosion

57% and peaks between 20 to 40 years of age the facial surfaces of canines > premolars > incisors > molars.

Do all teeth with exposed dentin develop sensitivity? No

The number and size of exposed (patent) tubules determines if a tooth is sensitive

Addy et al.1987, Yoshiyama et al. 1989

Understanding Dentinal Sensitivity

To understand and treat hypersensitive teeth it is necessary to understand the structure and nature of the dentinal tubule transduction system.

Understanding Dentinal Sensitivity

Note that enamel is a highly crystalline mineralized tissue with minimal organic material. It covers the dentin coronally. Cementum is a less crystalline tissue than enamel with much more organic material. 55% organic, relatively soft, high permiability, 10-100m. It covers the root dentin. Dentin is much less crystalline than enamel and is much more organic but it is traversed by tubules filled with serum-like dentinal fluid . The dentinal fluid movement stimulates movement of the odontoblastic processes that fill the pulpal ends of the dentinal tubules evoking a pain response from the Nerve around the odontoblast

Hydrodynamic Theory of Dentinal Pain

In 1963 Brannstrom proposed that fluid movement within the tubule occurred in response to pain producing stimuli. He demonstrated that cold water or evaporative air resulted in outward movement of fluid from the tubule and warm stimuli resulted in the inward Movement

Transmission of pain requires rapid movement of fluid through patent tubules.

What is the Etiology of Dentin Hypersensitivity? First there is a need for exposed dentin

Second, the tubules need to be exposed and should remain patent

Why do some patients who have exposed roots have dentinal sensitivity yet others with exposed roots do not? Major reason is differences in their saliva. Saliva contains calcium and phosphate ions that can remineralize tooth defects. When combined with salivary glycoproteins, calcium and phosphate ions can facilitate tubule plugging.

In alkaline mouths, this complex can form calculus. While calculus may be harmful to the periodontium it can prevent sensitivity if it is covering dentinal tubules. When removed, it can produce dentinal sensitivity but usually this is temporary.

Treatment strategies for dentinal hypersensitivity

1.Nerve desensitization 2. Anti-inflammatory agents 3. Cover or plugging dentinal tubules

Treatment strategies for dentinal hypersensitivity 1. Nerve desensitization

Potassium nitrate

Treatment strategies for dentinal hypersensitivity

2. Anti-inflammatory agents

Corticosteroids

Treatment strategies for dentinal hypersensitivity

3. Cover or plugging dentinal tubules a. Plugging (sclerosing) dentinal tubules Ions/salts Potassium oxalate Sodium monofluorophosphate Sodium fluoride Sodium fluoride/stannous fluoride combination Stannous fluoride Strontium chloride Protein precipitants Strontium chloride hexahydrate Casein phosphopeptides Fluoride iontophoresis b. Dentine sealers Glass ionomer cements Composites Resins Varnishes Sealants Methyl methacrylate c. Periodontal soft tissue grafting d. Crown placement/restorative material

Dentine Hypersensitivity treatment options

Desensitising the nerves

Occluding the dentine tubules

Rationale for Using Potassium Ion

The active ingredient is usually potassium ions as potassium nitrate. Potassium ions are believed to reduce the ability of the pulpal nerve fibers to repolarize because of a hyperpotassium environment in the tubules and around the odontoblasts. Requires continuous use of the product and indefinite depolarization of the nerve fiber is not physiological.

Mode of Action of Potassium

Ions must establish a concentration gradient and move against fluid flow to depolarize nerve requires Time

K ions

Fluid

Relieves Hypersensitivity by Depolarizing Nerve

Desensitising of nerves mechanism and clinical evidence*

Buffering of membrane potential with potassium (K+) ions Potassium salts delivered in at home products (toothpastes)

Potassium nitrate (5%) Potassium citrate (5,5%) Potassium chloride (3,75%)

Pain relief - 4-8 weeks of 2/day use

Usage of corticosteroids have been proposed ,however clinical trials have not found them to be successful. May induce mineralization leading to tubule occlusion

PM Barrold ADJ,2006:51(3),212-218

Rationale for Plugging Dentinal Tubules

If the movement of fluid causes dentinal pain then the occlusion of tubules should block the sensation of pain.

Dentine tubule occlusion mechanism and clinical evidence*

At home use (Toothpaste) - precipitation of insoluble metal compounds. Strontium chloride reported less effective than potassium salts** Stannous fluoride secondary effects (staining)** In office use Established desensitisers with HEMA or oxalate seal Desensitising pastes with calcium sodium phosphosilicate or CPPACP technologies High fluoride containing products with sensitivity relief as secondary benefit only (varnishes, toothpastes and gel)
*Literature review in Orchardson, JADA, 2006; ** Cummins, J Clin Dent 2009

Rationale for Use of Fluoride iontophoresis

Fluoride is applied as varnishes, toothpastes and gels.

The intended use of fluoride is to facilitate demineralization of the tooth surface by forming fluoroapatite.
Fluoride is a negatively charged ion. In the presence of a negative electrical potential, the fluoride is forced into the tubules. When combined with the tubular fluid, calcium phosphate is precipitated in the tubule as calcium fluoride. (Gangarosa) Tubules are sealed with varying degrees of success

Rationale for Use of Strontium Chloride Toothpaste

Scanning electron microscopy revealed filling of dentinal tubules but no tubule plugging Clinical studies failed to result in short or long term pain relief beyond a placebo effect.

Rationale for Use of Potassium Oxalate

30% and 3% solutions of potassium oxalate. When contacting calcium, a calcium oxalate precipitate is formed. High concentrations can create boulders over the tubule and the 3% fills in the minor voids. (Pashley & Galloway 1985)

Rationale for Use of Varnish Varnishes cover the tubules Only 1/3 of the tubules are covered

Water soluble in most cases

Recent advances.

Arginine
An arginine bicarbonate/calcium carbonate is the highly soluble arginine bicarbonate component surrounds, or is surrounded by, particles of poorly soluble calcium carbonate component, and because of the adhesive qualities of the composition forms a paste-like plug that not only fills but also adheres to the dentinal tubule walls. Because of its alkalinity, also reacts with the calcium and phosphate ions of the dentinal fluid to make the plug chemically contiguous with the dentinal walls (Kleinberg 2002)

What is Arginine?

Arginine is a natural amino acid and is an essential element in many biological processes

Arginine is naturally found in saliva Arginine is compatible with fluoride

US Food and Drug Administration has categorised arginine as safe in food.

Arginine

Novamin Non-structural biactive glass that becomes highly active after exposure to water contains calcium, phosphorus, sodium and silicon Rise in pH precipitation of calcium phosphate -Occluded tubules, resists acid (Burwell 2006) Clinical trials demonstrated reduction in dentin hypersensitivity (Litkowski et al. 1998)

CPP_ACP
Stabilized amorphous calcium phosphate under neutral or alkaline conditions allows an increase in the biofilms content of calcium and phosphate by the incorporation of a casein phospho-peptide with amorphous calcium phosphate (CPPACP) (Reynolds et. al. 1995) Incorporated in multiple delivery systems though paste utilized to desensitize

Clinical trials demonstrated reduction in dentin hypersensitivity (Walsh et al. 2006)

Rationale for Use of Bonding

Resin

Dentin bonding agents irreversibly bond to dentin, plugging the tubules thereby stopping fluid flow.
Problem: excess resin creates periodontal problems. Problem: resin frequently requires acid treatment which opens more tubules.

Seal and Protect

Light cured material applied as a thin Solution Penetrates dentin and cured in situ

Functions to: Seals tubules reducing sensitivity Improve wear and reduce abrasion Antimicrobial effect
7 nm NanoFiller particles, well dispersed, clear Triclosan (2,4,4-trichloro-2hydroxy diphenyl ether) antimicrobial against strep M and lactobacilli- works on bacterial cell membrane by inhibiting amino acid uptake