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Dentin Hypersensitivity DH102: Clinic II Lisa Mayo, RDH, BSDH Concorde Career College.

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Presentation on theme: "Dentin Hypersensitivity DH102: Clinic II Lisa Mayo, RDH, BSDH Concorde Career College."— Presentation transcript:

1 Dentin Hypersensitivity DH102: Clinic II Lisa Mayo, RDH, BSDH Concorde Career College

2 Reference Wilkins CH43

3 Outline 1. Define dentinal hypersensitivity 2. Review Anatomy of Tooth Structures 3. What can cause dentin exposure 4. Hydrodynamic Theory 5. Natural Desentization 6. Desentization Products

4 Objective #1: Define Dentinal Hypersensitivity

5 Dentin Hypersensitivity Short, sharp painful reaction that occurs when some areas of exposed dentin are subjected to certain stimuli:  Mechanical  Thermal  Chemical

6 Hypersensitivity Patient Concerns  Hot/cold sensitivity to foods/drinks  Pain during dental appointments: metal instruments can elicit pain  Will ask RDH why they have pain Dentinal Hypersensitivity  Difficult to diagnose: their pain could be caused by many factors. May not be dentinal sensitivity.  Numerous tx approaches  Pain elicited by a stimulus and alleviated upon its removal

7 Stimuli That Elicit Pain Reaction Tactile or mechanical  Toothbrushing  Eating utensils  Dental instruments  Friction from prosthetic devises such as denture clasps  Evaporative  Dehydration of oral fluids as from high-volume suction or applying air to dry teeth during intraoral procedures Thermal  Cold more common than hot

8 Stimuli That Elicit Pain Reaction Chemical  Acids in foods and beverages such as citrus fruits, condiments, spices, wine, and carbonated beverages  Acids produced by acidogenic bacteria following carbohydrate exposure  Acids from gastric regurgitation  Osmotic  Alteration of osmotic pressure in dentinal tubules due to isotonic solutions of sugar & salt

9 Characteristics of Pain from Hypersensitivity Pain at onset  Sharp, short, transient pain and rapid onset Cessation  From pain upon removal of stimulus Chronic condition w/ acute episodes Response to non-noxious stimulus (one that would not normally cause pain or discomfort) Discomfort that cannot be ascribed by another dental defect or pathology

10 Objective #2: Review Tooth Anatomy

11 Anatomy of Tooth Structures Dentin  Portion of the tooth covered by enamel on the crown and cementum on the root  Composed of fluid-filled dentinal tubules that narrow and branch as they extend from the pulp to the dentinoenamel junction  The only portion of the dentinal tubules that are innervated with nerve fiber endings from the pulp chamber are those closest to the pulp  10% of all teeth have dentin exposure

12 Anatomy of Tooth Structures Dentin  Tubules in sensitive areas are wider and more numerous  Dentinal tubule closest to the pulp contains an odontoblastic process: thin tail of cytoplasm from a cell in the tooth pulp called an odontoblast  Fluid movement w/in open dentinal tubules can stimulate certain nerve endings that are associated w/ the odontoblastic processes, resulting in a short, sharp pain in the tooth

13 Odontoblastic Process

14 DENTIN PULP DENTIN ENAMEL Odontoblastic Process Nerves

15 Anatomy of Tooth Structures Pulp  Highly innervated with nerve cell fiber endings that extend just beyond the dentinopulpal interface of the dentinal tubules  Body portions of odontoblasts (dentin-producing cells) located adjacent to the pulp extend their processes from the dentinopulpal junction a short way into each dentinal tubule

16 Anatomy of Tooth Structures Nerves  Nerve fiber endings extend just beyond the dentinopulpal junction and wind around the odontoblastic processes as shown in the next slide  Nerves react via the same neural depolarization mechanism (sodium potassium pump), which characterizes the response of any nerve to a stimulus

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20 Objective #3: What Can Cause Dentin Exposure

21 Mechanisms of Dentin Exposure General considerations  Once dentin exposed: demineralization of the root surface will occur more rapidly than of the enamel  Lower mineral content  Higher critical pH to initiate demineralization  Acute hypersensitivity may occur with sudden dentin exposure since gradual exposure allows for the development of natural desensitization mechanisms such as smear layer or sclerosis  After many years, secondary & reparative dentin may have formed, which also protects the pulp

22 RECESSION

23 Factors Contributing to Gingival Recession & Root Exposure Improper oral hygiene self-care  Medium or hard toothbrushes  Aggressive brushing  Improper brushing motion Anatomy and physiology of area  Anatomically narrow zone of attached gingiva is more susceptible to abrasion that can lead to recession and subsequent cemental exposure  Malocclusion  Tight, short labial frena that pulls on gingival tissues Subgingival instrumentation  Large amts of sub-g calculus can pull gums away from tooth and create recession  May heal after removal

24 Frenum Pull

25 Factors Contributing to Gingival Recession and Root Exposure Periodontal disease processes  Junctional epithelium migrates apically in response to inflammatory factors leading to connective tissue breakdown and loss of periodontal attachment Surgical procedures  Dr’s reduce pocket depths  Gums repositioned  Tooth extraction

26 Factors Contributing to Gingival Recession and Root Exposure Orthodontic procedures & appliances Oral habits or piercings  Lip, tongue

27 Factors Contributing to Loss of Enamel & Cementum Anatomy of cervical area  Thin and easily abraded when exposed  Enamel and cementum do not meet at CEJ in about 10% of teeth Occlusion  Constant trauma to teeth  When recession present & pt grinds – can cause abfractions Attrition and abrasion  Mechanical wear  Clenching / Grinding Erosion  Chemical wear of teeth  From diet such as high acids, citric acids, wine, sodas  Bulimics

28 EROSION

29 ATTRITION

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31 ABFRACTION

32 =TLiKey6xaSc-mx7C8gTGYWtcmG7kG3C0o8

33 Objective #4: Hydrodynamic Theory

34 Hydrodynamic Theory Currently accepted explanation for transmission of stimuli from the outer surface of the dentin to the pulp Developed by Brannstrom (1960s): theorized that a stimulus at the outer aspect of dentin will cause fluid movement within the dentinal tubules  Fluid movement creates a pressure on the nerve endings within the tubule  Transmits pain impulses by stimulating the nerves in the pulp

35 Open Dentinal Tubules

36 Hydrodynamic Theory Explains the following  Dentinal tubules exposed  Pain-producing stimuli are present  Pain-producing stimuli initiate the flow of lymphatic fluid within dental tubules  Odontoblasts and their processes act as receptors and transmitters of sensory stimuli  Movement of tubular fluids causes nerve endings in the pupal wall to be stimulated & produce pain

37 Objective #5: Natural Desentization 1. Sclerosis of dentin (your oral embry book p.101 refers to this as tertiary dentin, reactionary/response, reparative dentin) 2. Secondary Dentin 3. Smear layer 4. Calculus

38 Natural Desensitization 1. Sclerosis of dentin (tertiary dentin)  Occurs by mineral deposition within tubules as a result of traumatic stimuli, such as attrition or dental caries  Creates a thicker, highly mineralized layer of peritubular dentin (deposited within the periphery of the tubules)  Results in a smaller-diameter tubule that is less able to transmit stimuli through the dentinal fluid to the nerve fibers at the dentinopulpal interface

39 Natural Desensitization 2. Secondary Dentin  Deposited gradually on the floor and roof of the pulp chamber after teeth are fully developed  Secreted more slowly than primary dentin that formed prior to tooth eruption: both types created by odontoblast  Creates a “walling off” effect between the dentinal tubules and the pulp to insulate the pulp from dentin fluid disturbances caused by a stimulus such as dental caries  As aging occurs, secondary dentin accumulates, resulting in a smaller pulp chamber with fewer nerve endings and less sensitivity

40 Natural Desensitization 3. Smear layer  Consists of organic and inorganic debris that covers the dentinal surface and the tubule  Accumulates following scaling and root instrumentation, use of toothpaste (abrasive particles), cutting with a bur, attrition, or abrasion  Occludes the dentinal tubule orifices forming a “smear plug” or “bandage” that blocks stimuli  May have a positive or negative effect  It protects from hypersensitivity, but may interfere with reattachment of periodontal tissues

41 Natural Desensitization 4. Calculus  Provides protective coating to shield exposed dentin from stimuli  Post debridement sensitivity can occur after removal of heavy calculus deposits  Dentinal tubules may become exposed as calculus is removed

42 Patients and Their Pain Dentinal Hypersensitivity Statistics  Prevalence of hypersensitivity 8-30% of adults  Greatest age to be affected = 20-40yrs  Incidence decreases with increasing age = secondary dentin, sclerosis of dentin  Higher incidence in perio patients

43 Differential Diagnosis Diagnostic techniques and tests  Visual assessment of the tissues and teeth  Palpitation both extra and intraoral  Ask about sinus issues  Occlusal exam: articulating paper  Radiographic assessment: pulpal pathology? Vertical root fracture?  Percussion: use handle to tap on tooth to see if pain elicited  Mobility?  Pain from biting: Bite Stick, cracked tooth  Transillumination: cracked tooth  Thermal/Electric tests on the pulp: Cold-Test

44 Question After many years of root exposure, what structure can form that protects the root and pulp? a. Primary dentin b. Secondary dentin c. Reparative dentin

45 Question After many years of root exposure, what structure can form that protects the root and pulp? a. Primary dentin b. Secondary dentin c. Reparative dentin

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47 Objective: Desentization Products

48 Desensitizing Agents and Theorized Mode of Action: Mosby’s Potassium salts  Formulations containing potassium chloride/nitrate/citrate/oxalate  Reduce depolarization of the nerve cell membrane and transmission of the nerve impulse by occluding dentinal tubules  OTC Fluorides  Decrease the lumen diameter, block/occlude open dental tubules Calcium phosphate technology  Caries control to reduce demin and to remineralize by releasing Ca, Phosphate ions for deposition of new tooth mineral (hydroxyapatite)  May occlude dentinal tubule openings

49 Desensitizing Agents and Theorized Mode of Action: Mosby’s Oxalates  Block open dental tubules  Oxalate salts (potassium & ferric oxalate) decrease the lumen diameter Glutaraldehyde  Can be combined with HEMA, a hydrophylic resin which seals tubules  Creates Ca-crystals w/in dentinal tubule to decrease the lumen diameter Arginine and calcium carbonate  Occlusal tubules using arginine (amino acid), bicarbonate, Ca- carbonate  Marketed as a px paste to be applied before instrumentation

50 Types of Desentizing Tx No single agent or form of tx is effective for all persons Numerous agents have varying degrees of success  Solutions, gels, pastes of fluoride in varying compounds and %  Adhesive, varnish, bonding materials  Polymerizing agents 1. Glass ionomer cements (GIC) 2. Adhesive resin primers 3. Iontophorectic devises 4. Laser therapy 5. Restorations

51 Glass Ionomer Cements Used in cervical abrasion and abfractions Sensitive area etched with 50% citric acid Rinse with water Dry Glass ionomer placed

52 Adhesive Resin Primers Reduce dentin permeability by occluding open tubules Material rubbed on sensitive area for approximately 30 sec and air-dried

53 Iontophoretic Devises Application of an electric current to impregnate tissues with ions from dissolved salts Fluoride iontophoresis is thought to result in the increased uptake & penetration of fluoride ions into dentin Devises are technique sensitive

54 Laser Therapy One-time tx that reduces or eliminates dentin sensitivity Seals tubules Sensitive dentin treated with laser is found to be harder compared with untreated dentin

55 Restorations Placed on surface where dentin is exposed to help reduce sensitivity  Unfilled or partially filled resins  Covers patent dentinal tubules  Dentin-bonding agents  Obturation of the tubule opening  Composite/glass ionomer

56 Soft Tissue Grafting  Surgical placement of soft tissue grafts can cover a sensitive dentinal surface  Results are somewhat unpredictable  Done with a specialist  High cost to patient

57 Behavioral Changes Dietary modifications  Limit acidic foods and beverages  Evaluate use of dental products: no acid formulations – can contribute to erosion  Avoid hot/cold extremes in the mouth: no ice, coffee not too hot… Excellent dental biofilm control Eval toothbrush type and technique Eliminate parafunctional habits: mouthguard, ortho, occlusal adjustments Medical referral for acid-reflux / GERD issues, Bulimia suspected At home fluoride tx

58 FLUORIDE TRAY

59 Dental Professional Measures Fluoride varnishes  Does not require a dry tooth surface: advantageous since this drying the tooth can be a painful procedure for a patient with dentin hypersensitivity

60 Novamin Ca and Phosphate ions in ACP will seek out areas of demin and enhance enamel remin., occlude dentinal tubules, increase F uptake, prevent caries progression High risk caries groups should use People w/ sensitivity should use Should be used in combo with F Toothpaste, polish paste, sealant

61 Recaldent / Casein Phosphopeptides Enhance the effects of Fluoride & provides a supersaturated environment of Ca and P for remin. Not a Fluoride substitute High caries risk, sensitivity issues Caries prevention Gum, pastes, professional application

62 Additional Considerations Tooth-whitening-induced sensitivity  Commonly associated with carbamide peroxide  A reversible pulpitis is caused from the dentin fluid flow and pulpal contact of the material, which changes the osmolarity, without apparent harm to the pulp  Hypersensitivity = few days to several months  Exposed dentin and pre-existing dentin hypersensitivity increase risk for hypersensitivity secondary to whitening  Reduce tooth-whitening-induced sensitivity: Potassium nitrate, fluoride, or other desensitization product prior to & concurrently while whitening

63 Question Novamin is made of which two ions: a. Calcium, phosphate b. Calcium, fluoride c. Phosphate, fluoride d. Phosphate, Potassium

64 Question Novamin is made of which two ions: a. Calcium, phosphate b. Calcium, fluoride c. Phosphate, fluoride d. Phosphate, Potassium


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