Dentinal Hypersensitivity: Dr. Nitin Maitin

DENTINAL
HYPERSENSITIVITY
Prepared and presented by :
Dr. Nitin Maitin

Post graduate
Dept. of Conservative Dentistry and Endodontics
Kothiwal Dental college and Research Centre, Moradabad
1
Dentinal Hypersensitivity
Debt of gratitude owed to,
Prof. Dr. Shashi Prabha Tyagi

Prof. Dr. Rajat Jain
Dr. U. P. Singh
Dr. Rajni Nagpal
Dr. Dexter Brave
Dr. Lalit C. Boruah
Dr. Chandrakar Chaman Mishra
Dr. Gagan
2
Introduction
Dentinal hypersensitivity is one of the most common
symptomatic conditions which cause complaints of
discomfort in patients that has long been a problem in
dentistry having a multifactorial etiology.
It is reasonable to presume that, with the increasing life

expectancy with a functional natural dentition prone to
tooth wear, dentine hypersensitivity is likely to become
a more frequent dental complaint and an increase in
requests for treatment.
3
Introduction (contd.)
Management of dentinal hypersensitivity should be

based on a correct diagnosis of the condition to
differentiate it from the other clinical conditions that are
similar in their presenting features as well as on the
severity of the condition
Yet, conclusive evidence of successful treatment

regimens still eludes us despite a multitude of
products available for treatment! The explanation is
due to the complexity of pain assessment and the
nature of the episodic disease process.
4
Definition
Dentine hypersensitivity is characterised by short,

sharp, pain arising from exposed dentine in
response to stimuli, typically thermal, evaporative,
tactile, osmotic or chemical, which cannot be
ascribed to any other form of dental defect or
pathology.
(Holland et al. 1997).
5
DENTINAL SENSITIVITY Vs
DENTINAL HYPERSENSITIVITY
Dentinal sensitivity is also sometime

misunderstood as hypersensitivity.
Dentinal sensitivity is a normal response to

stimulation of freshly exposed dentin while
hypersensitivity have pathological basis for its
occurrence like erosion abrasion, attrition, caries,
defective restoration, etc.
6
EPIDEMIOLOGY
Dentinal hypersensitivity appears to be a

common problem with various reports
indicating an incidence of between 4 to 74 % of
the population.
The incidence can vary considerably between

the cohort being studied and periodontal
patients, patients with gingival recession and
smokers with periodontitis showing the highest
incidence of diagnosed dentinal
hypersensitivity. 7
Epidemiology (contd.)
Teeth more commonly affected are upper premolars

followed by upper first molars and incisors being the
lease sensitive. The condition generally involves the
facial surfaces of teeth near the cervical aspect
Female predilection is greater than male.
It has been suggested as the life span of the general

patient increases, prevalence of hypersensitivity
increases as loss of enamel and cementum and
gingival recession is more prevalent in older adults.
8
Epidemiology (contd.)
Most sufferers range from ages from 20 to 40

years with peak incidence occurring at the end
of third decade and decreases during the
fourth and fifth decades of life.
In addition periodontal disease and improper

brushing habits can also result in gingival
recession accompanied by sensitive teeth.
Australian Dental Journal 2006; 51 :( 3):212-218.

J Contemp Dent Pract 2005 May;(6)2:107-117.
9
PULPODENTIN COMPLEX
Dentin
It is a porous biologic composite made up of

apatite crystal filler particles in a collagen
matrix.
Three types :
a. Primary dentin
b. Secondary dentin
c. Tertiary dentin
10
Pulpodentin complex (contd.)
Primary dentin : it is the original tubular

dentin largely formed prior to eruption of
the tooth.
Secondary dentin : same circumpulpal

dentin as primary dentin but formed after
root completion, secreted more slowly than
primary dentin.
11
Tertiary dentin : also known as irritation

dentin, irregular secondary dentin,
reactionary dentin or reparative dentin.
Found only in dentin that has been

subjected to trauma or irritation
12
Odontoblastic Processes
•These are the cytoplasmic extensions of the

odontoblasts
•Reside at the peripheral pulp at the pulp-

predentin border and their processes extend
into the dentinal tubules.
13
Odontoblasts
•Reside adjacent to the predentin

(odontogenic zone of pulp) with cell bodies in
the pulp and cell processes in the dentinal
tubules .
14
Neurophysiology
•Teeth are supplied by the alveolar branches

of the fifth cranial nerve.
•Dental pulp contains sensory trigeminal

afferent axons, cell bodies of the sensory
neurons of the pulp are located in the
trigeminal ganglion.
15
•The majority of nerve bundles reach the

coronal dentin where they fan out to form
the “Nerve plexus of Raschkow”. There they
anastomose and terminate as free nerve
endings that synapse onto and into the
odontoblast cell layer and odontoblastic cell
processes.
16
Sensory nerve fibres of the pulp
1. Myelinated A fibres ( A-delta and A-Beta

fibres) – mainly located at the pulp dentin border
in the coronal portion of the pulp and
concentrated at the pulp horns.
2. Unmyelinated C fibres – located in the core of

the pulp or pulp proper and extend into the cell-
free zone underneath the odontoblastic layer
17
A - fibres –
•Have a smaller diameter (larger than C-fibres).
•Slower conduction velocity ( faster than C-fibres).
•Transmit pain directly to the Thalamus

generating a fast, sharp, easily localized pain.
•Contain neuropeptide calcitonin gene-related

peptide (CGRP).
18
A - fibres (contd.) –
•They respond to various stimuli through the

hydrodynamic effect.
•A delta fibres are stimulated during the electric

pulp testing (larger diameter and conduction speed
and presence of myelin sheath).
19
•A-beta fibres innervate mainly dentin and

dentin-pulp border near the pulp horn tip and
lack the receptors for the low affinity NGF
receptors.
•A-beta fibres are some of the large endings

that make close appositions with odontoblasts.
20
•They are more affected by the reduction of

pulpal blood flow ( inability to function during
anorexia ).
•Dental hypersensitivity is treated by blocking

the tubules, which directly affects A fibres
(hydrodynamic cessation).
21
C-fibres –
The majority of nerve fibres in teeth are

unmyelinated, slowly conducting C-fibres.
Most are regulated by Nerve Growth Factor
(NGF) in adults, and half require NGF during
development, while others utilize Brain-derived
neurotrophic factor (BDNF) or Glial-derived
Neurotrophic factor (GDNF).
22
C-fibres (Contd.) –
They are polymodal and responsive to

capsaicin and to inflammatory mediators such
as histamine and bradykinin. C-fibres express
NGF-receptors and neuropeptides such as
substance P, Calcitonin gene related peptide
or neurokinin.
23
C-fibres (Contd.) –
•The location of C –fibres within the nerve

bundles in the core or central region of the
pulp may explain the diffuse pain (referred pain).
•May survive in the presence of hypoxia.
•C-fibres do not respond to electric pulp

testing (high threshold).
24
Transmission of Nociceptive information to the

CNS
Activation of C and A delta fibres
via 5th nerve
Signals transmitted to Trigeminal Spinal tract nuclear complex

(nucleus oralis, nucleus interpolaris and nucleus caudalis/
medullary dorsal horn) and other regions ( cervical dorsal spinal
cord, reticular formation and Solitary tract nucleus ).
Medullary dorsal horn (relay station) processes nociceptive

signals and output them to higher brain regions.
25
MDH has five major components:
1. Central terminals of afferent fibres

2. Local circuit interneurons,
3. Projection neurons,
4. Glia
5. Terminals from descending neurons
26
Central terminals of afferent fibres:
C and A-delta nociceptors enter the MDH

via the trigeminal tract, the central
terminals of these C and A-delta fibres end
primarily in the outer layers of MDH, these
sensory fibres transmit information by
releasing amino acids such as glutamate or
neuropeptides (substance P or Calcitonin
gene-related peptide).
27
Local circuit interneurons
Local circuit interneurons regulate

transmission of nociceptive signals from
primary afferent to Projection neurons. They
can enhance or suppress nociceptive
processing.
28
Projection Neurons
The cell bodies of Projection neurons are

within the medullary dorsal horn, and their
axons comprise the output system for
sending orofacial pain to more higher brain
regions.
29
Projection Neurons (contd.)
Three major classes

1. Nociceptive-specific projection neurons –
receive sensory inputs from nociceptive
afferent fibres.
2. Low threshold mechanoreceptive projection
neurons – receive inputs from non-
nociceptors.
3. Wide Dynamic Range projection neurons
(WDR) – receive inputs from both
30
nociceptors and non-nociceptors.
Glia
This constitute the fourth component of the
MDH. In the Dorsal horn they respond to
nociceptive input and facilitate the activity
of Projection neurons by releasing of
cytokines (interleukin 1 B or TNF).
Terminals from descending neurons.
The fifth component modulates the

transmission of nociceptive information.
31
32
THEORIES OF DENTINAL
HYPERSENSITIVITY
1. Odontoblastic transduction theory

2. Neural theory
3. Hydrodynamic theory
4. Modulation theory
33
ODONTOBLASTIC TRANSDUCTION
THEORY
This hypothesis states that functional

connection between the Odontoblastic
processes and the terminal sensory nerve
endings and impulse propagation down the
odontoblasts are essential requirements.
34
ODONTOBLASTIC TRANSDUCTION THEORY ( contd..)
The presence of neural transmitting

substances such as acetyl cholinesterase in
the dentine with the nerve endings
suggested an affinity between odontoblasts
and terminal nerve endings.
35
Since odontoblasts are neural crest in origin,

it is reasonable that they might retain
potentiality of neural cells to propagate
impulses.
Exclusive anastomosis of Odontoblastic

branches at the dentinoenamel junction
could explain the dentinal hypersensitivity.
36
Flaws
Method of accessing acetyl cholinesterase has

failed to demonstrate its presence in dentine.
Membrane potential of odontoblasts measured
in tissue culture was too less to take part in
excitable process.
SEM studies indicate that the inter-tubular

processes present in the dentinal tubules were
seen as collagen fibres and not Odontoblastic
processes. 37
NEURAL THEORY
As an extension of the Odontoblastic theory,

this concept advocates that thermal, or
mechanical stimuli directly affect the nerve
endings within the dentinal tubules through
direct communication with Pulpal nerve fibres.
38
NEURAL THEORY ( Contd…)
Histological studies show that nerve fibres

leave the plexus of Raschkow, pass to the
predentine as loops and pass out again to the
plexus. Some may even enter the dentinal
tubules. The endings within the tubules get
activated. The nerve signals are conducted
along the parent primary afferent nerve fibres
in the pulp and into the nerve branches.
39
40
Flaws
The presence of nerve fibres in predentine

is insignificant.
The formation of plexus of Raschkow takes

place after the completion of root formation.
41
Flaws (contd..)
While this theory has been supported by the

observation of the presence of unmylinated
nerve fibres in the outer layer of root
dentine and the presence of putative
neurogenic polypeptides, this theory is still
considered theoretical with little solid
evidence to support it.
42
HYDRODYNAMIC THEORY
Most widely accepted theory for dentinal

hypersensitivity proposed by Brannstrom and co-
workers.
It postulates that, fluids within the dentinal tubules are

disturbed either by temperature, physical or osmotic
changes or movements stimulate a baroreceptor which
leads to neural discharge. The basis of this theory is
that the fluid filled dentinal tubules are open to the
oral cavity at the dentine surface as well as within the
pulp.
43
Hydrodynamic Theory ( Contd…)
44
45
Dehydration associated with desiccation

following air movement over the exposed
dentine surface results in outward
movement of dentinal fluids towards the
dehydrated surface.
Thermal changes result in expansion or

contraction of dentinal tubules resulting in
changes in dentinal fluid flow and
associated excitation of nerve fibre.
46
47
High osmotic stimuli such as sugar, acid and salt

can also result in fluid flow within the dentinal
tubules and induce nerve stimulation and
painful sensations.
JCDA February 2009, Vol. 75, No. 1

JADA, Vol. 137 July 2006
ADJ 2006; 51: (3):212-218
48
The hydrodynamic theory of dentine

hypersensitivity proposes that external stimuli
cause dentinal fluid movement within dentinal
tubules thereby triggering mechanosensitive
nerves and eliciting a pain response.
49
A study employing X-ray microtomography (XMT)

was conducted to monitor the diffusion of
caesium acetate through dentine to investigate the
extent to which transport occurs within the primary
tubules compared to that through branched
microtubules believed to run perpendicular to the
direction of the primary dentinal tubules.
50
There was clearly considerable ingress of caesium

acetate into the dentine lying below the exposed
surface, but considerably less beneath the sealed
surface, suggesting that diffusive transport occurs
predominantly in the direction of the primary
dentinal tubules, with no significant lateral
transport. Primary tubules are clearly the
dominant transmission route for triggering the
mechanosensitive nerves present at the dentine–
pulp interface, and for delivery of nerve
desensitising agents.
51
Archives of Oral Biology 53 ( 20 0 8 ) 7 3 6 – 7 4 3
ETIOLOGY AND
PREDISPOSING FACTORS
1. Loss of enamel
2. Denudation of cementum
3. Gingival recession
4. Attrition, Abrasion, Erosion
5. Abfraction
6. Tooth malpositioning
7. Thinning, fenestration, absent buccal alveolar
bone plate
8. Periodontal disease and its treatment
9. Periodontal surgery
10. Patient habits
52
MECHANISM OF
Two mechanisms are responsible for the
permeation of substances across the dentin like
Diffusion and Convection (transmission of heat in
liquid/gases by circulation carried on by the heated
particles).
Phases of development for DH
1. Lesion Localisation
2. Lesion Initiation
53
MECHANISM OF
DENTINAL HYPERSENSITIVITY (contd..)
Lesion Localization : Occurs by the exposure

of dentin.
Lesion Initiation : Dentin is thought to be

covered by a salivary pellicle or the tubules
occluded by calcium phosphate deposits
derived from saliva, available evidence
suggest that lesion initiation in DH can be
induced by erosive and abrasive agents,
erosion being more dominant.
54
International Dental Journal (2002) Vol.52/ No.5 (Sup.1)
CLINICAL FEATURES
Rapid, sharp and short duration pain
Factors such as individual pain

tolerance, emotional state, and
environment can contribute to the
variety of responses between and
among patients.
55
DIFFERENTIAL DIAGNOSIS
1. Cracked tooth syndrome.

2. Fractured restorations/ Fractured teeth.
3. Dental caries.
4. Post-operative sensitivity.
5. Acute hyperfunction of teeth.
6. Atypical facial odontalgia.
7. Palatal-gingival groove.
8. Hypoplastic enamel.
9. Congenitally open CEJ.
10.Improperly insulated metallic restorations.
56
METHODOLOGY FOR
OBJECTIVE EVALUATION
The evaluation of DH is based on the stimuli
applied to the exposed dentine producing
pain.
Methods for inducing DH

1. Mechanical (tactile) stimuli
2. Chemical (osmotic) stimuli
3. Cold air currents
4. Cold water stimulation
5. Thermoelectric systems
6. Electric stimulations 57
Methodology for
Objective evaluation (contd..)
1. Mechanical (tactile) stimuli : includes the

following
• Scratching of the dentin surface with sharp-

tipped probe or mechanical pressure
stimulators (YEAPLE PROBE)
• If a force equivalent to 70g is reached without

eliciting pain sensation, the tooth is classified
as non-sensitive.
58
Methodology for
2. Chemical (osmotic) stimuli :
• Hypertonic solutions such as glucose and

sucrose are used.
• These solutions exert their effects through
osmotic pressures that induce intratubular fluid
movement.
• This method has become less popular
because low pH values produce tubular
demineralisation therefore worsening the
symptoms and controlling the response is
difficult. 59
Methodology for
3. Cold air currents :
• Air current of 45 psi and environmental

temperature of 19-24oC is applied for 1 sec at
a distance of 1 cm, perpendicular to the
surface of the tooth.
• Procedure usually used for the screening and

initial selection of subjects destined for study.
60
Methodology for
4. Cold water stimulation
• Water at a temperature of 7oC is ideal for the

identification of DH and for minimizing the
incidence of false positive results.
• The temperature of water is lowered in steps of

5oC and testing is stopped when a painful
response is recorded, or when 0oC is reached
( non-sensitive teeth ).
61
Methodology for
5. Thermoelectric systems:
• Technique involves continuous heat or cold

application.
• Instrument used is fine tipped thermal probe

placed on the surface of the tooth.
• Testing begins at a temperature of 25oC,

followed by stepwise 5oC decrements until the
pain is reported.
62
Methodology for
6. Electric stimulation.
• Measured in Volts.
• Applied gradually to the dentinal surface.
• Risk posed is the possibility of extending the

stimulus to neighboring zones, due to current
loss to the periodontium and subsequent
stimulation of periodontal nerves – generating
false-positive results.
63
METHODS FOR EVALUATING

RESPONSE AFTER STIMULATION
1. Verbal rating scale (VRS)

2. Visual analog scale (VAS)
3. Global evaluation of DH
Verbal rating scale (VRS) : The patient uses a

numerical code from 0 to 3 to rate perceived
sensation.
• 0 = no discomfort
• 1 = mild discomfort
• 2 = important discomfort
• 3 = Important discomfort lasting more than 10
seconds. 64
Methods for evaluating response after stimulation

(contd..)
Visual analog scale (VAS) : The Patient

scores pain intensity on a 10 cm straight
line scale traced on a piece of paper.
• 0 = no pain
• 10 = extreme, unbearable pain
65
Methods for evaluating response after stimulation

(contd..)
Global evaluation of DH: DH can be evaluated

in terms of both “the intensity of pain
needed to produce pain (stimulus based
technique)” and “subjective evaluation
of pain induced by a stimulus (response
based technique)”. In the first case pain
threshold is the measurement used, in second
case intensity of pain is assessed.
Med Oral Patol Oral Cir Bucal, 2008 Marl; 13(3); E201-6.
66
PREVENTION OF
Suggested tips for the patient
1. Practicing good oral hygiene techniques

2. Avoid using large amounts of dentifrice, or
reapplying additional dentifrice during brushing
3. Avoid hard bristled toothbrushes without end
rounded bristles
4. Avoid over brushing with excessive pressure for
prolonged periods of time
5. Avoid excessive flossing or incorrect use of other
interproximal cleaning devices
6. Avoid `picking’ at the gums or using toothpicks
67
inappropriately
Prevention ( Contd…)
Suggested tips for professionals
1. Avoid over instrumenting the root surfaces during

calculus removal and scaling and root planing.
2. Avoid over polishing the exposed roots during stain
removal.
3. Avoid violating the biologic width when placing
crown margins causing subsequent recession.
4. Avoid `burning’ the gingival tissue during in-office
tooth whitening or bleaching procedures.
5. Review patient regularly for signs of erosion,
abrasion and abfraction. 68
69
yes
70
J Can Dent Assoc 2003; 69(4):221–6
SPECIFIC
TREATMENT MODALITIES
1. Dentin Sealers –
I. GIC
II. Composites
III. Dentinal adhesives
IV. Resinous dentinal desensitizers
V. Varnishes
VI. Sealers
VII.Methyl Methacrylate
71
Specific Treatment modalities (contd..)
2. Cover or Plugging dentinal tubules
a. Plugging dentinal tubules
IONS/ SALTS
i. Aluminum
ii. Ammonium hexafluorosilicate
iii. Calcium hydroxide
iv. Calcium carbonate
v. Calcium phosphate
vi. Calcium silicate
72

Plugging dentinal tubules
IONS / SALTS
vii. Dibasic sodium citrate
viii. Fluorosilicate
ix. Potassium oxalate
x. Silicate
xi. Sodium monofluorosilicate
xii. Sodium fluoride
xiii. Sodiun flouride/ Stannous fluoride
scombination
xiv. Stannous fluoride
xv. Strontium acetate with fluoride
xvi. Strontium chloride
73

Plugging dentinal tubules
PROTEIN PRECIPITANTS
i. Formaldehyde
ii. Glutaraldehyde
iii. Silver nitrate
iv. Strontium chloride hexahydrate
v. Zinc chloride
PHYTOCOMPLEXES
i. Rhubarb rhaponicum
ii. Spinacia oleracia
FLUORIDE IONTOPHORESIS
74
b. Periodontal soft tissue grafting

c. Lasers
d. Homeophatic medication
i. Plantago maior
ii. Propolis
3. Local Alodynes
4. Dietary counselling
Journal of Oral Sciences, Vol.51, No.3, 323-332, 2009
75
1. Dentin Sealers
Resin composites and glass ionomer

cements, as well as varnishes and dentinal
adhesives work as fillings, sealing the
entrances of the open dentinal tubules and
blocking sensitivity by the formation of a
sealing covering. Nevertheless, a restorative
material must only be used when there is a
loss of dental structure.
76
Dentin Sealers (contd..)
Resinous dentinal desensitizers The

application of resin to reduce dentin hypersensitivity
was initially proposed by Dayton et al.(1974).
Products such as Gluma Desensitizer can effectively

seal dentinal tubule openings.
Constituents: Hydroxyethyl methacrylate (HEMA),

Benzalkonium chloride,
Glutaraldehyde and Fluoride.
77
SPECIFIC
TREATMENT MODALITIES (Contd..)
Resinous dentinal desensitizers GLUMA (contd..)
HEMA – Physically blocks dentinal tubules.
Glutaraldehyde - Coagulation of plasma proteins
of the tubule fluid, resulting in the reduction of
dentinal permeability
Gluma acts as a desensitizer by means of two

reactions ( Qin et al.)
1. Glutaraldehyde reacts with part of the serum
albumin in the dentinal fluid which induces
albumin precipitation.
2. second reaction, glutaraldehyde with albumin

induces HEMA polymerization. 78
SPECIFIC
TREATMENT MODALITIES (Contd..)
Resinous dentinal desensitizers(contd..)
Various other available resinous desensitizers
Seal&Protect (Methacrylate resins, PENTA

(dipentaerythritol penta acrylate monophosphate), nanofillers,
Triclosan and acetone. Photoinitiators and stabilizers are also
present).
MicroPrime (Benzethonium chloride and HEMA)
Sultan Desensitizer (Sodium fluoride, Kaolin, Glycerine)
Cavity Shealth (Unit-dosed 5% NaF Varnish)
UltraEZ (Potassium Nitrate, Fluoride ions)
All Bond (N-tolyglycin-glycidyl methacrylate and biphenyl
dimethacrylate)
79
European Journal of Dent. 2008 January; 2: 43–47
2. Cover or plugging dentinal tubules
Ions / salts
Ammonium hexafluorosilicate [(NH4)2SiF6]

Induces precipitation of Calcium phosphate
from saliva, presenting a continuous effect of
dentin tubular occlusion. Treatment with
fluorosilicate could play an important role in
obtaining durable occlusion because some
silica composites induce apatite formation. 80

IONS / SALTS
Calcium Hydroxide
Topical application of Calcium hydroxide

reduces dentinal permeability.
Mechanisms involved :
•Physical blockage of the openings of the tubules by

calcium hydroxide.
•Production of intratubular mineralization or
precipitates.
•Production of reparative dentin.
81

IONS / SALTS
Calcium Carbonate
Desensitizing dentifrices containing active

ingredients such as Calcium Carbonate, Calcium
Phosphate, Strontium Chloride (SrCl2), Silica and
Potassium have therapeutic potential for partially or
completely occluding the dentinal tubules.
These products are aimed at reducing the

hypersensitivity symptoms through daily tooth-
brushing at home.
82

IONS / SALTS
Calcium Carbonate (contd..)
Kleinberg et al (2002) at the State University of New

York developed a new anti-sensitive technology. The
essential components being arginine, an amino acid
which is positively charged at physiological pH, i.e.,
pH 6.5-7.5, bicarbonate, a pH buffer, and calcium
carbonate, a source of calcium.
This technology, called Pro- Argin, has been shown

to physically plug and seal exposed dentin tubules
and to effectively relieve dentin hypersensitivity.
American Jr. of Dent, Vol. 22, Spl. Issue A, March, 2009 83


IONS / SALTS
Dibasic Sodium Citrate
2% dibasic sodium citrate gel, reports suggests

that the polyglycol might decrease
hypersensitivity by intratubule protein
precipitation or aid precipitation of salivary
mucin decreasing the tubule size. Thus aiding
the tubular blocking.
Dental Traumatology 1991; 7: 145 - 152

84

IONS / SALTS
Fluorosilicate
Ammonium hexafluorosilicate [(NH4)2SiF6]

induces precipitation of calcium phosphate
from saliva thereby causing dentinal tubular
occlusion.
Treatment with Fluorosilicate (SiF) plays an

important role in the treatment of DH as
silica composites may induce apatite
formation.
85

IONS / SALTS
Potassium oxalate
Reduces the fluid flow across dentine.
2% Potassium oxalate was found to reduce

DH by 95.71%.
Two mechanisms,
Tubule occluding property and
Inhibitory effect of potassium.
86

IONS / SALTS
Sodium monofluorophosphate
Clinical effectiveness of Sodium

monofluorophosphate was reported in
combination with 1.3% formalin, with
strontium acetate and with potassium nitrate.
Dental Traumatology 1991; 7: 145 - 152 87


IONS / SALTS
Sodium fluoride
Professionally applied in 2 forms, 2%

aquous solution and a 33% paste, both in
the form of kaolin/ glycerin paste and
varnishes.
It was proposed that precipated fluoride

compounds might block dentinal tubules
mechanically and thereby prevent hydraulic
fluid transmission of pain producing stimuli.
88

IONS / SALTS
Stannous fluoride
Incorporated in dentinal tubules and used in gel

form.
Reported to be less effective than
monofluorophosphate.
Forms calcified barrier blocking dentinal tubular
opening. SEM studies show layers of Tin and
Fluoride sloution providing mechanical and chemical
protection.
Stannous fluoride applied with Ionizing brush was
more effective than stannous fluoride with the same
brush without current.
89

IONS / SALTS
Stannous fluoride (contd…)

IONIC BRUSH
The tooth is normally negatively charged and the
plaque is positively charged. Opposite charges
attract and bond to each other. The plaque,
therefore, is attached to the tooth surface by "ionic
bonding".
The toothbrush bristles are negatively charged

through the metal rod with the brush head. When
holding the metal band on the toothbrush handle
with moistened fingers, the positively charged ions
are transferred to the teeth. 90

IONS / SALTS
Stannous fluoride (contd…)

IONIC BRUSH
The tooth polarity changes

from negative to positive. The
positively charged tooth ions
repel the positively charged
plaque ions. The positively
charged plaque ions are then
attracted to the negatively charged bristles of the ionic
toothbrush for removal from the oral cavity.
91

IONS / SALTS
Strontium chloride
Penetration of Strontium chloride ions into

dentin was observed, suggesting that
strontium ions may interfere with internal
components of dentin regardless of the
desensitizing effect.
When used in toothpaste, the desensitizing

effect of the strontium chloride is attributed to
the abrasive filler of the tooth paste rather
than to the proposed active ingredient. 92

IONS / SALTS
Potassium nitrate
Used in form of solution, gel, paste or

incorporated into dentifrices.
The desensitizing effect is thought to be due

to penetration of potassium ions into the pulp
where the sensory nerves are prevented to
repolarize after an initial depolarization. The
depolarized state would decrease the pain
perception.
93
PROTEIN PRECIPITANTS
Glutaraldehyde
Component of various Resinous dentinal

desensitizers like Gluma which also contains
Hydroxyethyl methacrylate (HEMA)
94

Protein precipitants
Glutaraldehyde (Contd..)
Glutaraldehyde reacts with part of the serum

albumin in dentinal fluid, which induces a
precipitation of serum albumin, then, second,
a reaction of glutaraldehyde with serum
albumin induces polymerization of
HEMA (component of resinous desensitizing
agent).
95

Silver Nitrate
Topical application of silver nitrate solution of

varying strength and ammonium silver
nitrate of 28% were various measured used
in the past.
Silver and Nitrate ions diffuse through

opened dentinal tubules and cause a slow
denaturation of proteins of odontoblastic
fibrils
96

Silver Nitrate (contd…)
Howe’s ammonical silver nitrate is deposited

on the surface by addition of Eugenol or
10% solution of formaldehyde.
Its use is limited to posterior teeth as it

causes black discoloration.
97

Strontium chloride hexahydrate
Acts both as a tubule precipitant and a

tubule occluding agent.
Cohen A. postulated that the effect of

strontium chloride was related to its ability to
combine with the bio-colloids in the dentinal
tubules and deposition of an insoluble barrier
at the tubule orifice.
98

Strontium chloride hexahydrate (contd…)
Desensitizing action is by blockage of the

outer organic matrix of the root surface due
to its penetration in the calcified tissue.
It also accelerates calcification, thus causes

eventual obliteration of dentinal tubules.
99

Zinc chloride
•40% solution of Zinc chloride is found to be

effective.
•Can be applied to the affected teeth using

to methods
1. Heating with warm air for several minutes
2. Using chloroform
100
PHYTOCOMPLEXES
Rhubarb rhaponicum
Spinacia oleracia
Oxalate-containing phytocomplexes
many vegetables, such as rhubarb,

spinach and mint, contain oxalates either as
soluble or insoluble salts or as oxalic acid.
101
PHYTOCOMPLEXES (contd…)
Oxalic acid forms soluble salts with sodium,

potassium or ammonium ions, and insoluble
salts with calcium, magnesium and iron ions.
In neutral and alkaline environments,
calcium and oxalate may bind together
forming different shaped crystals of calcium
oxalate.
Archives of Oral Biology (2006) 51, 655—664
102
Iontophoresis is a method of electrically transporting

ionic particles into hard or soft tissue (Sausen 1955;
Harris 1967; and Zadok et al. 1976).
Fluoride, an ionic particle is negatively-charged.

Therefore, when an electrical potential is applied,
fluoride ion would be repelled from the negative
electrode (cathode) and attracted to the positive
(anode).
103
According to Gangerosa (1983), the ion movements

in iontophoresis follow some physical laws,
Ohm's Law [V = I.R]

That is electromotive force (V, in volts) equals
current (I, in amps) times resistence (R, in ohms).
Therefore, the current level, which quantifies the
electron movement in an electric conductor or
electrolytic solution is directly proportional to
electromotive force and inversely proportional to
electrical resistance.
104
Coloumb's Law [ Q = I.T ]

the quantity of electricity (Q) delivered is obtained by
multiplying amperage (milliamps) times time (T, min)
Faraday's Law
which states the amount of fluoride ions delivered in
the incipient caries decay is directly proportional to
the quantity of energy (Q), which means, to time
and current.
105
When sodium fluoride dissolves in an aqueous

solution, negatively charged fluoride ions are
formed.
When a DC circuit is established in a patient's mouth

in the presence of such a fluoride solution, such that
a cathode is placed in electrical contact with the
hypersensitive tissue, the cathode will electrically
repel the fluoride ions into the tooth surface.
106
LASERS
Light Amplification by the Stimulated Emission of

Radiation.
Stern & Sognnaes (1964) and Goldman et al. (1964)

were the first to investigate the potential uses of the
ruby laser in dentistry and found a reduction in
permeability to acid demineralization of enamel after
laser irradiation.
Other lasers used - argon (Ar), carbon dioxide

(CO2),neodymium:yttrium-aluminum-garnet (Nd:YAG),
and erbium (Er):YAG lasers 107
LASERS (contd…)
The first laser use for the treatment of dentine

hypersensitivity was reported by Matsumoto et al.
(1985) using Nd:YAG laser.
The lasers used for the treatment of dentine

hypersensitivity are divided into two groups.
I. Low output power (low level) lasers - Helium-
neon (He-Ne) and gallium/aluminum/arsenide
(GaAlAs) diode lasers
II. Middle output power lasers - Nd:YAG and CO2

lasers. 108
Low Output Power (Low-level) Lasers

•First used in 1970s
•Initially was used to support wound healing
( Kimura et al. 1991).
Helium-Neon (He-Ne) Laser

The first use of He-Ne laser for the treatment of
dentine hypersensitivity was reported by Senda et
al. In 1985.
He-Ne laser irradiation does not affect peripheral A-

delta or C fiber nociceptors but does affect electric
activity (action potential). 109

Gallium/aluminum/arsenide (diode ) GaAlAs Laser
Initially GaAs system were difficult to run for long

periods in a CW mode because of the propensity of
the chip to over heat.
In 1929, new diode was used. This new chip that

used water-thin crystals of GaAlAs could produce
variety of wavelengths ranging from 720 – 904 nm,
all within the infrared spectrum. Three wavelengths
of GaALAs have been used for the treatment of
dentinal hypersensitivity (780, 830 and 900 nm). 110

GaAlAs Laser (Contd…)
It is postulated that this type of low output power

lasers mediated an analgesic effect related to
depressed nerve transmission.
According to physiologic experiments using the

GaALAs laser at 830 nm, this effect is caused by
blocking the depolarisation of C-fibres.
111
.

GaAlAs Laser (Contd…)
Immediate relief from DH is observed when using

810 nm Diode laser (DL) and 10% potassium nitrate
bioadhesive gel (NK 10%)
J Clin Periodontol 2009; 36: 650–660. 112

Middle output power lasers
Nd:YAG lasers
First used for managing DH by Matsumoto et

al. (1985).
Use of Black ink as absorption enhancer in

recommended to prevent deep penetration
of laser beam through enamel and dentin.
113
Nd:YAG lasers
Reports recommend the use of black ink for

enhancing the effects of Nd:YAG laser to
treat DH.
Mechanism of action is supposed to be the

laser induced occlusion or narrowing of
dentinal tubules as well as direct nerve
analgesia. 114
Nd:YAG lasers
Nd:YAG and CO2 lasers effectively cause

occlusion of dentinal tubules.
It has been hypothesized that laser energy

interferes with the sodium pump mechanism,
changes the cell membrane permeability and
temporarily alters the endings of the nerve
axons. 115
Nd:YAG lasers
Dentine surfaces are modified by laser radiation

produced by a pulsed Nd:YAG laser that leads to
sealing of open dentinal tubules under suitable
conditions that are reached after covering dentine
surfaces with dye agents.
Erythrosin solution in water has been found the most

suitable and the lower and upper limits of pulse
energies for sealing of dentinal tubules 116
Journal of molecular recognition, 2007; 20: 476–482
CO2 lasers
Moritz et al. first used this laser in the

treatment of DH in 1996.
Effects are due to the occlusion or narrowing

of dentinal tubules. Using CO2 lasers at
moderate energy densities, mainly sealing of
dentinal tubules is achieved as well as
reduction of permeability. 117
Combination of lasers with fluorides
The combined use of GaALAs laser at 830

nm with fluoridation enhances treatment
effectiveness by more than 20% over that of
laser treatment alone.
Lan et al. 1999 reported that most dentinal

tubules were occluded after treatment by
Nd:YAG laser irradiation followed by topical
sodium fluoride.
J. Clin. Periodontal; 27; 715 - 721 118
CO2 lasers
Moritz et al. first used this laser in the

treatment of DH in 1996.
Effects are due to the occlusion or narrowing

of dentinal tubules. Using CO2 lasers at
moderate energy densities, mainly sealing of
dentinal tubules is achieved as well as
reduction of permeability. 119
LOCAL ANODYNES
Cocain hydrochloride
Procaine hydrochloride
Menthol
Clove oil
Eugenol
Phenol
Used alone or in combination have been

used in managing DH.
120
GENERAL ANESTHETICS
Administration of Potassium, sodium or

ammonium bromide, chloral hydrate,
barbiturates and morphine sulphate may be
resorted in extreme cases.
121
OTHER AGENTS
Hartman’s Solution : 1.25 parts thymol, 1 part

ethyl alcohol, 2 parts sulphuric ether by weight used
to treat DH. However they are considered
protoplasmic poisons
Buckley’s Solution : consists of 1.3 grams of

cocaine hydrochloride, 8.0 cc chloroform, 30.0 cc
ether.
122
Homeophatic medication
Propolis
Propolis, a resinous substance collected by

honeybees from the buds of living plants, has been
used for several purposes because of its wide range
of suggested activities (antibacterial, antiviral,
antifungal, anti-inflammatory, antioxidant and
chemopreventive actions).
It is believed to cause the occlusion of dentinal

tubules thereby reducing DH 123
Drug Safety 2008; 31 (5): 419-423.
Patient Counseling
Since acidic substances can contribute to the

opening of dentinal tubules, a dietary analysis,
history of bulimia, dieting, consumption of acidic
drinks and foods, or history of gastrointestinal reflux
must be taken into account and managed
accordingly.
Patient should be advised to decrease the intake of

acidic food and citrus fruits as acid attack on tooth
surfaces combined with brushing with toothpaste
can lead to further tooth loss and opening of the
dentinal tubule. 124
The natural mineral dietary supplement

(NMDS)
3.6 mg/l of fluoride and silica, bicarbonate, sodium,

chloride, potassium, calcium and various other
minerals in trace amounts (pH 9.6)
This product was the first to be classified as a

NMDS under the US Dietary Supplement Health and
Education Act of 1997.
125
The natural mineral dietary supplement

(NMDS)
The product is claimed to be beneficial in reducing

oral pain, alleviating tooth sensitivity and diminishing
bleeding of oral soft tissues as well as improving
overall oral health.
Int J Dent Hygiene 4, 2006; 122–128

126
Recent Advances
Intraoral fluoride releasing devices

Bioadhesive potassium nitrate 5 /10%
gels.
Application of 3% potassium oxalate or 6%
ferric oxalate.
Remineralisation toothpastes.
Novel silica formulations.
Combination of Casein Phosphopeptide
and Amorphous Calcium Phosphate (CPP-
ACP). 127
Recent Advances
Products developed from bioactive and

biocompatible glasses that are known to
induce osteogenesis and occlude dentinal
tubules. (Novamin)
Chewing gums containing Potassium
chloride.
Mouth rinses containing potassium citrate
and potassium nitrate solutions.
128
Recent Advances
Calcium silicate coating derived from

Portland cement –
Gandolfi et al. (2008) proposed the application
of Calcium Silicate paste derived from Portland
cement. It has shown to be effective in tubular
occlusion and reduction of dentinal
hypersensitivity.
Journal of Dentistry 36(2008); 565 - 578

129
CONCLUSION
In spite of various treatment modalities available,

treatment of DH still remains one of the most
perplexing challenges faced by the clinicians.
In light of the recent advances in the management of

DH, a wide array of options are made available based
on a better understanding of its process and
presenting clinical features. Dental practitioners should
be aware of the preventive and management
strategies and use their clinical judgment in
determining the appropriate agent and monitor the
progress over time. 130
REFERENCES
1. Pathways of the Pulp (9th Edi)– Cohen; Hargreaves.
2. Seltzer and Bender’s Dental Pulp – Hargreaves; Goodies.
3. Dental Erosion from diagnosis to treatment – A. Lucci.
4. Australian Dental Journal 2006; 51 :( 3):212-218.
5. J Contemp Dent Pract 2005 May;(6)2:107-117.
6. JCDA February 2009, Vol. 75, No. 1
7. JADA, Vol. 137 July 2006
8. Archives of Oral Biology 53 ( 2008 ) 7 3 6 – 7 4 3
9. Med Oral Patol Oral Cir Bucal, 2008 Marl; 13(3); E201-6.
10. J Can Dent Assoc 2003; 69(4):221–6
11. International Dental Journal (2002) Vol.52/ No.5 (Sup.1)
12. Journal of Oral Sciences, Vol.51, No.3, 323-332, 2009
13. European Journal of Dent. 2008 January; 2: 43–47
14. American Jr. of Dent, Vol. 22, Spl. Issue A, March, 2009
15. Dental Traumatology 1991; 7: 145 – 152
16. Archives of Oral Biology (2006) 51, 655—664
17. J. Clin. Periodontal; 27; 715 – 721
131
18. Journal of molecular recognition 2007; 20: 476–482
REFERENCES
19. J Clin Periodontol 2009; 36: 650–660
20. Drug Safety 2008; 31 (5): 419-423
21. Int J Dent Hygiene 4, 2006; 122–128
22. Journal of Dentistry 36(2008); 565 - 578
132
THANK YOU
133

Dentinal Hypersensitivity: Dr. Nitin Maitin

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Dentinal Hypersensitivity: Dr. Nitin Maitin

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DENTINAL

Prepared and presented by :

Dr. Nitin Maitin

Debt of gratitude owed to,

Prof. Dr. Shashi Prabha Tyagi

It is reasonable to presume that, with the increasing life

Management of dentinal hypersensitivity should be

Yet, conclusive evidence of successful treatment

Dentine hypersensitivity is characterised by short,

(Holland et al. 1997).

Dentinal sensitivity is also sometime

Dentinal sensitivity is a normal response to

Dentinal hypersensitivity appears to be a

The incidence can vary considerably between

Teeth more commonly affected are upper premolars

Female predilection is greater than male.

It has been suggested as the life span of the general

Most sufferers range from ages from 20 to 40

In addition periodontal disease and improper

Australian Dental Journal 2006; 51 :( 3):212-218.

It is a porous biologic composite made up of

Pulpodentin complex (contd.)

Primary dentin : it is the original tubular

Secondary dentin : same circumpulpal

Pulpodentin complex (contd.)

Tertiary dentin : also known as irritation

Found only in dentin that has been

Pulpodentin complex (contd.)

•These are the cytoplasmic extensions of the

•Reside at the peripheral pulp at the pulp-

Pulpodentin complex (contd.)

•Reside adjacent to the predentin

Pulpodentin complex (contd.)

•Teeth are supplied by the alveolar branches

•Dental pulp contains sensory trigeminal

Pulpodentin complex (contd.)

•The majority of nerve bundles reach the

Pulpodentin complex (contd.)

Sensory nerve fibres of the pulp

1. Myelinated A fibres ( A-delta and A-Beta

2. Unmyelinated C fibres – located in the core of

Pulpodentin complex (contd.)

•Have a smaller diameter (larger than C-fibres).

•Slower conduction velocity ( faster than C-fibres).

•Transmit pain directly to the Thalamus

•Contain neuropeptide calcitonin gene-related

Pulpodentin complex (contd.)

•They respond to various stimuli through the

•A delta fibres are stimulated during the electric

Pulpodentin complex (contd.)

•A-beta fibres innervate mainly dentin and

•A-beta fibres are some of the large endings

Pulpodentin complex (contd.)

•They are more affected by the reduction of

•Dental hypersensitivity is treated by blocking

Pulpodentin complex (contd.)

The majority of nerve fibres in teeth are

Pulpodentin complex (contd.)

They are polymodal and responsive to

Pulpodentin complex (contd.)

•The location of C –fibres within the nerve

•May survive in the presence of hypoxia.

•C-fibres do not respond to electric pulp