2. Dr. Liya Alice Thomas
First year MDS

3. CONTENTS
• INTRODUCTION
• HISTORICAL REVIEW
• ETIOLOGY/PREDISPOSING FACTORS
• PREVALENCE
• THEORIES
• CLINICAL FEATURES
• METHODS OF EVALUATION
• MANAGEMENT
• RECENT ADVANCES

4. INTRODUCTION
• Common global oral health problem
• Most frequently encountered clinical
problem
• One of the oldest recorded complaints of
discomfort
• Response to a stimuli varies from person
to person

5. DEFINITION
• “Dentine hypersensitivity is characterized
by short, sharp pain arising from
exposed dentin in response to stimuli
typically thermal, evaporative, tactile,
osmotic or chemical and which
cannot be ascribed to any other form of
dental defect or pathology”.
[HOLLAND ET AL,1997]

6. SO WHAT IS ROOT SENSITIVITY
• PERIODONTAL PERIODONTAL
DISEASE TREATMENT
• Different etiology BUT similar pain
symptoms

7. HISTORIC REVIEW
YEAR PERSON DISCOVERY
1855 JD WHITE Dentinal pain was caused by
movement of fluid in dentinal
tubules
1941 LUKOMSKY Advocated sodium fluoride as
desensitising agent
1963 BRANNSTROM Hydrodynamic theory of
dentinal pain
1986 KLEINBERG Summarised different
approaches that are used to
treat hypersensitivity
1915 ALFRED GYSI Fluid in the tubule is
incompressible

8. INCIDENCE AND PREVALENCE
• AGE: all age groups
peak incidence : 30-39 yrs
old age : sensitivity because of-
1)secondary & tertiary dentin
2)pulp fibrosis
3)sclerosis of tubules

9. • SEX : women more frequently affected
(15%)
• INTRAORAL DISTRIBUTION: buccal
cervical zones of permanent teeth

10. ETIOLOGY &
PREDISPOSING FACTORS

12. GINGIVAL RECESSION
PRE-DISPOSING FACTORS :-
1)Alveolar bone
2)Tooth anatomy & tooth position
3)Oral hygiene
4)Gingival diseases
5)Trauma
6)Other factors

13. (1)ANATOMY OF ALVEOLAR
BONE :
• Most frequently cited predisposing factor
• Thin, fenestrated or absent LABIAL
BONE(Aldritt 1968,Bernimoulan and Curilovie
1977,Lost 1984)

14. (2)TOOTH ANATOMY & POSITION
:
• Tooth anatomy (Olsson and Lindhe 1991) & tooth
position (Gorman 1967,Modheer and Odenrick 1980)
can influence alveolar bone thickness
• Orthodontic tooth movement

15. (3) ORAL HYGIENE :

16. (4) GINGIVAL DISEASES :
• ANUG
• ANUP
• Chronic periodontitis with associated
bone loss can cause recession although
the BUCCAL area does not appear to be a
site of predilection for periodontal
lesions

17. (5) TRAUMA :
• Non-surgical(scaling & root planing)
• Impaction of foreign objects in the
gingiva(Jenkins and Allen 1994)
• Factitious injury(Glenwright and Stranhan 1994)
• Toothbrushing (Sandholm et al 1982 , Bergstrom
and Eliasson 1988 , Knocht et al 1993)

18. (6) OTHER FACTORS :
• Frenal pull at the gingival margin
(Mazdyasma and stoner 1980,Powell and McEniery
1981)
• Occlusal trauma (Parfitt and Mjor 1964, Trott and
Love 1966)
• Emotional stress (Stone 1948)

19. NEUROPHYSIOLOGY OF
TEETH
• Teeth are supplied by the alveolar
branches of the fifth cranial nerve,
namely the trigeminal nerve (the
maxillary branch in the upper jaw and
the mandibular in the lower jaw).
• Pulp is a highly innervated tissue that
contains sensory trigeminal afferent
axons.
• Sympathetic efferent fibers control the
blood flow

20. • The cell bodies of the sensory neurons of
the pulp are located in the trigeminal
ganglion. Hundreds, perhaps thousands,
of axons enter the pulp through the
apical foramen where they branch
following the distribution of the blood
supply all over the pulp.
• The majority of the nerve bundles reach
the coronal dentin where they fan out to
form the nerve plexus of Raschkow.
• These then synapse into the
odontoblastic cell layer

21. • Two types of sensory nerve fibres are
seen :
Myelinated fibres (A delta{90%} & A
beta)
Unmyelinated fibres
A delta fibres – pulp dentin borderin the
coronal portion of the pulp & pulp horns
C fibres – core of the pulp

22. THEORIES OF DENTIN
HYPERSENSITIVITY

23. A number of theories have been proposed
over the years to explain the pain
mechanism of dentinal hypersensitivity - :
Direct Neural Stimulation
Odontoblast Deformation
Theory/Tranducer theory
Hydrodynamic theory

24. (1)DIRECT NEURAL
STIMULATION
• One of the first theories put forth

25. Drawbacks :
• Nerves are present only in the predentine
& inner dentinal zones but donot extend
upto the DEJ which is the most sensitive
part of the dentine
• Nerves absent in root dentin

26. (2)Odontoblast Deformation
Theory/Tranducer theory
• Rapp et al

27. Drawbacks :
• Odontoblastic processes extend only
partly through the dentin and not upto
the DEJ
• No demonstrable neurotransmitters like
acetylcholine in the neural transmission
of the pulp

28. (3) Hydrodynamic theory
• Brannstrom
• Dentin has over 300,000 tubules/mm2
which is filled with dentinal fluid.
• In a vital tooth there is constant slow
outward movement of the fluid through
the tubules.

30. • WIDTH of the tubule is important as the
rate of fluid flow is dependent on the
fourth power of the radius.
• If tubule diameter doubles a 16 fold
increase in fluid flow occurs
• Sensitive teeth have many more(8 times)
& wider(2 times)tubules at the buccal
cervical area compared to non-sensitive
teeth.

31. • Higher velocity of fluid flow also occurs in
tubules with smaller dimeter
• Dentin will only be sensitive if the tubules
are patent from pulp to the oral
environment & this patency will change
with production and removal of the
smear layer hence resulting in an
episodic condition.

32. CLINICAL FEATURES
–Patients generally complain that pain
arising from dentine hypersensitivity is
usually rapid in onset, sharp in
character, and short in duration.
–Pain is considered to be an
exaggerated response of normal pulp-
dentin complex and is only felt on
application of external stimulus.
–No lingering discomfort once the
stimulus is removed .

33. DIAGNOSIS
(A) CASE HISTORY :
• History & nature of pain
• Number & location of the sensitive teeth
• Intensity of the pain
• Stimuli which initiates the pain
• Frequency & duration of sensitivity
• Treatment history

34. (B) CLINICAL EXAMINATION :
• SUbjECTIvE
EvALUATION
1. Verbal rating scales
2. Visual analogue
scales
3. Verbal descriptor
checklists
4. McGill word
descriptors
• ObjECTIvE
ASSESSmENT
1. Mechanical stimuli
2. Chemical stimulation
3. Electrical stimulation
4. Dehydrating
stimulation
5. Thermal stimulation
6. Hydrostatic pressure

35. SUbjECTIvE EvALUATION
(1)VERBAL RATING
SCALES :
• Keele 1948
• Four point scale grading pain as SLIGHT ,
MODERATE , SEVERE & AGONIZING
• Restrictive choice of words that may not
be very precise with all patients.

36. (2)VISUAL ANALOGUE
SCALES :
• 10cm line.extremes of the line represent
limits of pain
• More sensitive in discriminating betwen
various treatments and changes in pain
intensity
• Best available method

37. (3)VERBAL DESCRIPTOR
CHECKLISTS :
• Allows quantitative assessment of both
the sensory and affective dimensions of
pain using a continuum across different
pain conditions instead of words
intended to distinguish conditions (Gracely
et al 1978)

39. (4)McGILL WORD
DESCRIPTORS :
• It is used to determine the nature of the
discomfort & to monitor response to
treatment.
DISADV:reliance on the ability of the
subject to understand the words
presented to them

41. ObjECTIvE EvALUATION
(1)MECHANICAL
STIMULATION :

42. (2) CHEMICAL(OSMOTIC)
STIMULATION :
• Hypertonic solution of sucrose or calcium
chloride (Anderson & Matthews 1967,Clark et al
1987)
• Solute in solution diffuses into the
dentinal fluid so on repeated application
the osmotic pressure difference between
the tubular fluid & applied fluid will
decrease & reduce the effect of the
solution as an osmotic stimulus(Pashley
1986)
• Long time intervals should be allowed

43. (3) THERMAL
STIMULATION:

44. (4)DEHYDRATING/EVAP
ORATIVE STIMULI :
• Combined thermal & evaporative
stimulus
• Short air blasts have been recommended
to avoid excess evaporation &
consequent changes in hypersensitivity
(Brannstrom 1963,Pashley et al 1984) &
undesirable pulpal effects
• Affects wider area-more intense pain
response

45. (5)ELECTRICAL
STIMULATION :
• Quantification of electric current can be
used to measure sensitivity
• Determine a condition called PRE-PAIN
• Attributed to larger,more rapidly
conducting nerve fibres
• Current applied should be less than 1
milliampere

46. DIFFERENTIAL DIAGNOSIS
• Cracked tooth syndrome(in heavily restored teeth)
• Incorrect placement of dentin adhesives
(nanoleakage)
• Fractured restorations
• Pulpal response to caries & restorative
treatment
• Improperly contoured restorations (traumatic
occlusion)
• Chipped teeth
• Vital bleaching

47. PREVENTION
(1) DIETARY
COUNSELLING :
• Reduce dietary acids

48. (2)TOOTHBRUSHING
TECHNIQUES :

49. (3) PLAQUE CONTROL :

50. (4)REDUCE OR
ELIMINATE
PARAFUNCTIONAL
HABITS• Professionally fabricated occlusal
night guards
• Re-positioning splints
• Stress management

52. TREATMENT

53. DESENSITIZATION BY OCCLUDING
DENTINAL TUBULES
A)Formation of smear layer
B)Topical agents C)Restorations
1.calcium hydroxide paste D)Lasers
2.calcium phosphate paste
3.silver nitrate
4.strontium chloride
5.fluorides
6.potassium oxalates
7.varnishes
8.dentin adhesives

54. A) Formation of smear layer :
• Isolating the affected tooth &
burnishing the dentin with an
orangewood stick.
• Results in the formation of a
smear layer which occludes the
tubules
• Temporary relief

55. B) Topical Agents :
i)CALCIUM HYDROXIDE –
Mixed with distilled water to
form a thick paste
Applied for a few minutes on
exposed dentin
Increases remineralization
Temporary relief

56. ii)CALCIUM PHOSPHATE PASTES –
Amorphous calcium phosphate (ACP)
Blocks tubules & reduces permeability by 85%
Can also be used to remineralize incipient
enamel caries
Commercially available product:GC Tooth
Mousse contains ACP & caesin
phosphopeptide

57. iii)SILVER NITRATE –
It reduces fluid movement by
precipitating protein or silver
chloride within the dentinal
tubules.
But it stains dentin and is also
damaging to the pulp and
gingiva.
Not used anymore

58. iv)STRONTIUM CHLORIDE –
SrCl2 was the first tubule blocking agent to be
introduced into toothpastes
3 MOA :
a)nerve depolarization
b)because it is chemically similar to calcium it can
replace lost calcium in hydroxyapatite lattice
c)deposit a layer of fine particles which can
occlude the tubules
Commercially available – Sensodyne
Tooth wear & sensitivity – Martin Addy, Graham Embery, W Miachael Edgar & Robin
Orchardson - 1st
edition

59. V)FLUORIDES –
Agents like sodium fluoride , stannous
fluoride or acidulated phosphate fluoride
may be used for few minutes as
mouthrinse, toothpaste or as topical
application over exposed dentin.
Act by forming fluoroapatite within
tubules which blocks fluid movement
within dentin.

60. STANNOUS FLUORIDE
Research has shown Stannous fluoride to be
effective against dentinal hypersensitivity –
2 to 4 weeks – 0.4% gel
MOA– tin rich surface deposit (in vitro) –
nearly complete surface coverage and
occlusion of tubules
Topical stannous fluoride – reduces
sensitivity on exposed cervical root surfaces
Patricia A. Walters - J Contemp Dent Prac, May 15, 2005, Vol 6, No 2, 107-117

61. Limitation – potential for temporary extrinsic
tooth staining associated with long-term use
Open tubules following treatment After use of SnF2 dentrifice
with non-sensitivity fluoride toothpaste

62. SODIUM FLUORIDE
Increase in resistance of dentin to acid
decalcification as well as precipitations in
exposed dentinal tubules
MOA– precipitated fluoride compounds
mechanically blocking exposed dentinal tubules
or fluoride within tubules blocking transmission
of stimuli

63. vi)IONOTOPHORESIS -
Electrical potential is used to transfer the ions
into the body for therapeutic purposes
METHOD :-
Place a negative electrode on the dentin &
positive electrode on the patient’s face/arm
Isolate teeth with plastic strips or cotton rolls
Chemical is applied to tooth surface & current is
passed through –ive electrode using 0.5mA
current.

64. Commonly used solutions –
a)30% potassium oxalate
b)6% ferric oxalate
ADV:long term relief
DISADV:1) uses expensive equipment
2)requires more than one
application

65. vii)POTASSIUM OXALATE –
Oxalate ions + calcium ions =
calcium oxalate crystals
Very effective method

66. viii)VARNISHES –
Forms a barrier over exposed dentin
& reduces the permeability
Temporary relief
Eg:duraflor,duraphat

67. ix)DENTIN ADHESIVES-
Dentin bonding agents are used
Micromechanical bonding through
formation of an interdiffusion hybrid
layer
Eg:Gluma desensitizer(Heraeus Kulzer)
Amalgambond(Parkell)
Single Bond(3M)

68. GLUMA DESENSITIZER
• 5% gluteraldehyde and 35%HEMA
in water
• Control DH & decrease post
operative sensitvity in restorative
procedures
• No mixing & no curing.No repetitive
steps.
• No drip formula, so it stays where
you place it,minimising contact with
soft tissues.

69. INDICATIONS :
• Cervical erosions
• Exposed dentin surface
• Gingival recession
• Under crowns
• Bridges
• Inlays & onlays
• Veneer & temporaries
• Margins around temporary crowns
• Under all direct restorations.

70. C)Restorations :
• Glass Ionomer Cement or a
Composite Resin Restoration is
used
• Long lasting relief

71. D) Lasers :
a.CO2 laser
b.Nd:YAG laser
c. Er:YAG laser
d.He:Ne Laser
• MOA- Coagulation & precipitaion of
plasma proteins in the dentinal fluid without
altering the surface of dentin.
• A meta-analysis study done by Sgolastra F
et al in 2013 proved the efficacy of Nd:YAG
over Er:YAG in the treatment of dentinal
hypersensitivity.

72.  ADVANTAGES :
i. analgesic
ii.bio-stimulant
iii.anti-inflammatory effects
iv.painless, safe, fast, conservative
treatment, and it is well accepted by
the patients

73.  DISADVANTAGES
i. High cost
ii. Professional expertise
iii. Thermal side effects
Lasers as a treatment modality for dentinal hypersensitivity-Teresa Mao,
Dr. Julie Toby
IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume9, Issue2 (Jul.- Aug. 2013),
PP 29-32
www.iosrjournals.org

74. DESENSITIZATION BY BLOCKING
PULPAL SENSORY NERVES
POTASSIUM SALTS :
• Excitability of intradental nerves
• MOA : raise concentration of potassium ions
in the extracellular fluid
Depolarization of nerve cells
Brief excitatory burst

75. • DISADV : works slowly over a period of time
HOW TO USE???
Brushing mouthguard type soft tray

76. RECENT ADVANCES
A. Pro-Argin technology
B. NovaMin
C. Casein Derivatives

77. A) PRO-ARGIN
TECHNOLOGY
• “Saliva based composition”
i>Arginine (an aminoacid which is positively
charged at physiological pH)
ii>Bicarbonate (pH buffer)
iii>Calcium carbonate (source of calcium)
• Commercially available as ProClude (instant
relief which lasts upto 28days)

78. • COLGATE has combined ARGININE ,
CALCIUM CARBONATE & FLUORIDE and
this has been clinically proven to provide
lasting relief

80. B) NOVAMIN
• Bioactive glass ceramic material that
provides calcium and phosphate
• Calcium sodium phosphosilicate
reacts when exposed to aqueous
medium to release calcium &
phosphate ions which form
hydroxy-carbonate apatite

81. D) CASEIN DERIVATIVES
• Predominant phosphoprotein in BOVINE
milk
• In alkaline conditions calcium phosphate
is prsent as an alkaline amorphous phase
along with casein referred to as casein
phosphopeptide-amorphous calcium
phosphate
• CPP-ACP : cariostatic agent

82. USES :
• Preventive therapy in high caries risk
patients
• Reduce dental erosion
• Repair enamel involving white spot
lesions
• Orthodontic decalcification
• Desensitizing agent

84. F)CALM-IT DESENSITIZER
• Calm-it™ Desensitizer is
glutaraldehyde-based desensitizer
that functions by reacting/cross-
linking with plasma proteins in
dentinal fluid

85. • Protection for upto 6-months-This
simple & effective technique
reduces hypersensitivity &
eliminates discomfort from cervical
erosion.
• Tubule penetration in seconds
• Compatibility with adhesives,
cements, restoratives, amalgams,
core build-up & temporary materials

86. G) GLU-SENSE
• The no-drip HEMA/Glutaraldehyde
desensitizer that goes where you
place it.
• 35%HEMA/5%Glutaraldehyde gel
formulation
• acts in seconds to seal dentinal
tubules, preventing the fluid shift in
them.

87. • Rub on sensitive area for 30 seconds &
allow to dry. Tooth does not need to
be completely dry before application.
No etching or light curing necessary.
Avoid contact with soft tissue.
• Effect lasts 6 months or longer
depending on patient. Permanent
under restorations.
• Does not interfere with cements or
bonding agents

88. H)GEL-KAM DENTIN
BLOCK
• Consists of 0.9% sodium fluoride,0.4%
stannous fluoride & 0.14% hydrogen
fluoride that can be applied in a tray.

89. CONCLUSION
Screen patients (does the patient suffer
from stabs of pain or sensitivity)
Obtain patient history
Examine patients to exclude :
•Cracked tooth syndrome
•Fractured restorations
•Caries
•Post operative sensitivity
•Vital bleaching
•Traumatic occlusion
No treatment
YES
NO

90. Is your patient’s history consistent with
dentin hypersensitivity
Confirm the diagnosis
Initiate management
Follow up
Seek and treat other causes

91. REFERANCES
 Textbook of operative dentistry-Vimal K Sikri III edition
 Clinical Operative Dentistry-Ramya Raghu,Raghu Srinivasan
 Tooth wear & sensitivity- Martin Addy,Graham Embery,W.
Michael Edgar, Robin Orchardson.
 Treatment of dentin hypersensitivity-DCNA 2011
 Dentin hypersensitivity: Recent Trends in Management- J
CONS DENT, oct-dec 2010
 Clinical Dentin Hypersensitivity: Understanding the causes &
prescribing the treatment- Journal of Contemporary Dental
Practice.
 Dentin hypersensitivity : Etiology,diagnosis and management –
A peer-reviewed publication.Howard E Strassler
DMD,FADM,FACD and Francis G Serio DMD,MS,MBA,FACD