HYPERSENSITIVITY

DONE BY:
NABA KHALDOON, 201310127
NOOR ALHUDA, 201311432

 Hypersensitivity is dental pain which is sharp in character

and of short duration, arising from exposed dentin surfaces in
response to stimuli, typically thermal, evaporative, tactile,
osmotic, chemical or electrical; and which cannot be ascribed
to any other dental disease.

 Its a very common condition, considered as the common cold of dentistry

(which means it has implications in the clinic because of people present with
this condition).

Its usually affects the age group from 20-50 years with the peak being 30-40
years.

Its more common in females than males.

Teeth most commonly affected are the canines, first and second premolars.
Less commonly it affects the incisors and molars.

Most common location is on the buccal or cervical areas, and the left side is
more likely to be affected rather than the right side.

CAUSES
Dietary Factors: it can be due to the type of food (acidic foods particularly)
loss of enamel or cementum: due to attrition, abfraction, abrasion, erosion, caries,
trauma, developmental disturbances (like amelogenesis imperfecta), environmental
factors (like turners hypoplasia)

Aging: people are living for longer periods and so their teeth are maintained for
longer periods (as a result of better health, better living conditions)

Restorations and cosmetic treatment: replacement of restorations results in the

removal of sound tooth structure as well. Also bleaching/tooth whitening increases
the chances of developing hypersensitivity on the long run.

Loss of periodontal tissue: due to periodontitis (associated with gingival recession

and periodontal pockets), periodontal treatment (such as subgingival scaling
(because we are removing part of the cementum), periodontal surgery(flap surgery)
and traumatic occlusion).

STIMULI
Thermal: hot and cold drinks and foods, cold air, coolant water jet from a
dental instrument.

Electrical: electric pulp tester.

Mechanicaltactile dental probe during dental examination, periodontal
scaling and root planning, tooth-brushing, friction from dental clasps.

Osmotic hypertonic solutions such as sugars.

Evaporation air blast from a dental instrument.
Chemical acids, e.g. dietary (citrus fruits/juices, carbonated drinks), gastric
( as a result of eating disorders), acid etch during dental treatments.

ANATOMY OF DENTIN PULP COMPLEX

Dentine is covered and protected by hard tissues such as enamel or cementum. Dentin itself is a vital tissue, consisting
of dentinal tubules, and is naturally sensitive because of extensions of odontoblasts and formation of dentinepulp
complex.

Pulp is integrally connected to dentine, i.e., physiologic and/or pathologic reactions in one of the tissues will also affect
the other.

Dentin consists of small canal like spaces, dentinal tubules. These tubules occupied by odontoblastic processes. The
odontoblastic processes may extend through the entire thickness of dentin from pulp to dentino-enamel junction.

The odontoblastic processes are actually the extensions of odontoblasts, which are the major cells of pulpdentin
complex.

The odontoblastic processes are surrounded by dentinal fluid inside the tubules. The dentinal fluid forms around 22% of
total volume of dentin. It is an ultrafiltrate of blood from the pulp via dentinal tubules and forms a communication
medium between the pulp (via the odontoblastic layer) and outer regions of the dentin.

The thickness/diameter and the number of tubules differs at the dentino-enamel junction and at the pulpal side, with the
pulpal end having a larger diameter (2.5 micrometers) and number of tubules ( 59,000 76,000/ Sq mm ) than the DEJ
that has a diameter of 900 nanometers and almost half the number of tubules of the pulpal end.

Root dentin is usually more sensitive than crown dentin because the terminal branching of dentinal tubules is more in the
root dentin than the crown dentin, therefore exposure of the root dentin can cause more intense pain compared to
exposure of crown dentin.

THEORIES OF HYPERSENSITIVITY
There are two main theories considered to describe the
mechanism of action of hypersensitivity:

Hydrodynamic theory
Neural activity theory

HYDRODYNAMIC THEORY
Its widely used and most accepted theory.
The theory states that since dentinal tubules are filled with a
fluid, any external stimuli (such as heat, cold, air blast) has
the ability to displace/move the fluid rapidly within the
tubules inducing pressure changes across the dentin leading
to the activation of the interdental nerves within the tubules
or at the pulp-dentin interface which causes the pain
sensation.

NEURAL ACTIVITY THEORY

Its less commonly used.
This theory states that the nerve membrane itself in normal conditions
has a negatively charged inner surface (lots of positively charged
potassium ions) and a positively charged outer surface (high
concentration of positively charged sodium ions) and is impermeable
(does not allow any ion to get in or get out) but once a stimuli arrives,
the membrane becomes permeable which increases the influx of sodium
ions and efflux of potassium ions and this is known as sodium-potassium
pumping or depolarization leading to the development/induction of pain.

DIAGNOSIS
The diagnosis of dentin hypersensitivity may be challenging.
It is a diagnosis of exclusion, reached once all other possible
explanations for the pain have been ruled out.

A thorough patient history and clinical examination are

required.

The nature, intensity and duration of pain as well as the

number and location of sensitive teeth must be identified.

Identify and remove any etiological or pre-disposing factors.

To confirm hypersensitivity clinically, we expose the
sensitive tooth surface to a blast of air which will dry any
fluid in the dentinal tubules provoking pain or by gentle
scratching of the tooth surface with a dental probe.

If a negative result for the pain provocation test occurs, no

treatment for dentinal hypersensitivity is indicated and
another diagnosis should be sought, such as fractured
restorations, chipped teeth, non-vital teeth, dental caries,
marginal leakage, proximal or cemental caries etc.

 To confirm hypersensitivity
clinically, we expose the
sensitive tooth surface to a
blast of air which will dry any
fluid in the dentinal tubules
provoking pain or by gentle
scratching of the tooth
surface with a dental probe.

TREATMENT
1. Blocking or sealing the dentinal tubules:

Formation of a smear layer OR Application of agents

that form insoluble material within the tubules

2. Reducing nerve excitability

3. Dietary modification
4. Home treatment
5. Physical agents (Impregnation and sealing off the tubules)
6. Endodontic treatment or extraction

BLOCKING OR SEALING THE DENTINAL

TUBULES
Formation of a smear layer:
Cutting/ burnishing the tooth surface with a rotary instrument or a hand instrument
which will result in the formation debris on the mineralized tooth surface that can
occlude the dentinal tubules.

Application of agents that form insoluble material within the tubules:

In this method mainly potassium oxalate agent is used, where its applied to the
exposed tooth surface (dentin) and following the application, the oxalate ion will react
with the calcium ions in the dentin forming calcium oxalate crystals that will block the
dentinal tubules. High levels of potassium can also increase its concentration around
the nerves deep in the dentin which can lead to depolarization of the nerves.

REDUCING NERVE EXCITABILITY

5% Potassium Nitrate is used,
where potassium salts release
potassium ions which move
down the dentinal tubules and
surround the sensory nerve
endings near the junction of
dentin and pulp, causing a
decrease in the nerve
excitability.

K
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DIETARY MODIFICATION AND HOME

TREATMENT
Dietary modification: Reducing acidic foods as well as any abrasive foods (limit
them).

Home treatment:
Use smaller and extra soft tooth brush (start with the least sensitive area to
the most sensitive area and use the non-dominant hand to exert less pressure.

Desensitizing agent in the form of toothpaste or gel such as sensodyne tooth

paste (because contains potassium nitrate) or fluoridated tooth paste. Also
fluoridated mouth wash can be used (because it results in the formation of
reparative dentin and precipitation of calcium fluoride).

PHYSICAL AGENTS (IMPREGNATION AND

SEALING OFF THE TUBULES)
This is usually indicated if chemical agents are not effective and can be
done through the use of restorative agents such as:

Fluoridated varnish
Bonding agent
Fissure sealant
Composite
Glass ionomer
Crown placement
Mucogingival surgery (grafting in order to treat the recession)

ENDODONTIC TREATMENT OR
EXTRACTION
These two modalities are usually indicated for patients with
extreme hypersensitivity.

Extraction is always considered as an end-line treatment if

nothing else can be done to save the tooth or reduce the
discomfort associated with severe hypersensitivity.