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.
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• It is viewed as originating from the underlying

exposed dentin after the enamel or the cementum of
the tooth surface has been lost.
• Its occurence in canines and premolars is more than
other teeth.
• The disease is prevalent in the patient with the age
range of 20-50 years. However, it is more prevalent
in the patient with the age range of 30- 40 and
more prevalentin female
 To be hypersensitive, three conditions must be met in
the dentin itself:
1. Dentin exposure to the oral cavity;
2. Open ends of dentin tubules of the exposed dentin;
3. and entire path to be open from the exposed dentin
surface to the pulp.
 Clinical features
 The pain arising from DH is extremely variable in character,
ranging in intensity from mild discomfort to extreme severity.

 The degree of pain varies in different teeth and in different

persons. It is related to the patient’s pain tolerance.

 It may emanate from one tooth or several teeth and it is

sometimes felt in all quadrants of the jaws.
 The external stimuli eliciting dentinal pain can be thermal,
osmotic, chemical, physical, or mechanical in nature.
 The thermal stimuli include hot and cold food and beverages
and warm or cold blasts of air.
 Osmotic stimuli include sweet food and beverages. Acid stimuli
include grapefruit, lemon, acid beverages.
 Common mechanical stimuli are toothbrushes, and dental
instruments.
 The use of cold air blasts from a dental air syringe, cold
water, and suction from a dental aspirator tip (physical) may
also cause discomfort.
THEORIES OF DENTINAL
HYPERSENSITIVITY

1. ODONTOBLAST TRANSDUCTION THEORY

2. NEURAL THEORY

3. HYDRODYNAMIC THEORY
ODONTOBLAST 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.
FLAWS:
 Processes are limited to inner third of dentin

 Membrane potential of odontoblasts measured in

tissue culture was too less to take part in excitable

process.
 NEURAL THEORY
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 According to this theory, nerve

endings penetrate dentine and
extend to the dentino-enamel
junction.

 Hence direct mechanical

stimulation of these nerves will
initiate an action potential,
which cause pain.
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 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.
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NEURAL THEORY
FLAWS
1. There is lack of evidence that outer dentin, which is
usually the most sensitive part, is innervated.

2. Moreover, pain inducers such as bradykinin fail to

induce pain when applied to dentine.
 HYDRODYNAMIC THEORY
13

Most widely accepted theory

for dentinal hypersensitivity
proposed by Brannstrom
(1964)
The basis of this theory is that
the movement of fluid in
dentinal tubules is basic event
in arousal of dentinal pain.
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 It postulates that, fluids within the dentinal tubules are

disturbed due to temperature, physical or osmotic changes
which in turn, activates the nerve endings in the dentinal
tubules or at the pulp–dentine complex.
External stimuli cause fluid Which leads to activation of
movement A fibers.
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 There is a positive correlation between rate of fluid

flow in the tubules and discharge evoked in
intradental nerves, with outward fluid movements
producing a much stronger nerve response than
inward movements.
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 Presumably, heat expands the fluid within the

tubules faster than it expands dentin, causing the
fluid to flow toward the pulp, whereas cold causes
the fluid to contract more rapidly than dentin,
producing an outward flow.
 It is speculated that the rapid movement of fluid
across the cell membrane of the axon terminal
activates a mechanosensitive receptor.
Thermal changes result in expansion or contraction of
dentinal tubules resulting in changes in dentinal fluid
flow and associated excitation of nerve fibre.
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 Dessication of dentin can theoretically cause

dentinal fluid to flow outward at a rate of 2 to 3
mm/sec.
 In addition to air blasts, 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.
• Stimuli which tend to move the fluid away from the pulp–dentin
complex produce more pain.
• These stimuli include cooling, evaporation and application of
hypertonic chemical substances.
• Approximately, 75% of patients with dentinal hypersensitivity
complain of pain with application of cold stimuli.
• The wider tubules increase the fluid movement and thus leads to
more pain. Therefore, treatment regimens aim to narrow or
occlude the tubules
 Understanding the mechanism described in the
hydrodynamic theory provides two strategic
approaches to manage dentin hypersensitivity,
including:
 reduce or stop the fluid movement in the tubules, or
 interfere with the neural transmission to the brain.
ETIOLOGY AND
PREDISPOSING FACTORS
1. Loss of enamel
2. Loss of cementum
3. Gingival recession
4. Attrition
5. Abrasion
6. Erosion
7. Tooth malpositioning
8. Periodontal disease and its treatment
9. Patient habits
 DIFFERENTIAL DIAGNOSIS
• As like any other clinical condition, an accurate
diagnosis is important before starting the management
of DH.
• DH has features which are similar to other conditions
like caries, fractured or chipped enamel/dentine, pain
due to reversible pulpitis, and post dental bleaching
sensitivity.
• Diagnosis of DH starts with a thorough clinical history
and examination.
• The other causes of dental pain should be excluded
before a definite diagnosis of DH is made.

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 A simple clinical method of diagnosing DH includes a jet of air or
using an exploratory probe on the exposed dentin, in a mesio-
distal direction, examining all the teeth in the area in which the
patient complains of pain. The severity or degree of pain can be
quantified either according to categorical scale (i.e., slight,
moderate or severe pain) or using a visual analogue scale.

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 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. Thermal stimuli
3. Chemical (osmotic) stimuli
4. Electric stimulations

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 Mechanical (tactile) stimuli : includes the following

 Scratching of the dentin surface with sharp-tipped
probe .
 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.
 THERMAL TEST
• The specific tooth is isolated and subjected to air
blast and cold water tests:

• Air blast test : The nozzle tip of an air syringe is

kept about 1 - 2 cm away from the isolated tooth
and then a blast of air is directed on the tooth for
one second.

• Cold water test : A disposable syringe is filled

with ice-cold water and the water is poured on the
suspected isolated tooth surface drop by drop.

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 EVALUATION OF RESPONSE AFTER
STIMULATION

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 = moderate discomfort.
• 3 = severe discomfort.

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 MANAGEMENT STRATEGY
29

 Take a detailed clinical and dietary history.

 Identify and manage etiological and

predisposing factors.

 In case of mild-to-moderate sensitivity, advice

at-home desensitizing therapy.
 Removal of etiological factors
30

 The etiological factors include faulty tooth brushing,

poor oral hygiene and exogenous/endogenous
non-bacterial acids.

 The patient should be taught the correct method of tooth

brushing with the help of a model. Highly abrasive tooth
powder or pastes should be avoided.
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 Also, the patients should be instructed to avoid brushing

for at least 2 hours after acidic drinks to prevent agonist
effect of acidic erosion on tooth brush abrasion.
 Erosive agents are also important agents in initiation and
progression of DH. They tend to remove the enamel or
open up the dentinal tubules.
 The erosive agents can be either exogenous dietary acids
or endogenous acids. The exogenous dietary acids
include carbonated drinks, citrus fruits, wines etc.
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 A detailed dietary history should be taken. The quantity

and frequency of the foods containing acids should be
reduced.
 Patient should be advised to take something alkaline
(milk) or at least neutral (water) after acidic drinks and
to use a straw to sip the drink and avoid swishing it
around the teeth.
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 The endogenous acid comes

from gastroesophageal reflux
or regurgitation. It is also
common in patients with
eating disorders. The condition
is characterized by generalized
erosion of the palatal surfaces
of maxillary anterior teeth.
 An occlusal splint can be fabricated to cover the affected
areas, to prevent further contact with the acids.
Desensitizing therapy
 Treatment Modality
35

 In-Office desensitizing
• FLOURIDES
• IONTOPHORESIS
• OXALATES
• ADHESIVE MATERIALS
• BIOGLASS
• LASER
• CPP-ACP
 At Home Desensitizing:- Toothpastes, mouthrinses and
other local applications.
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At home desensitizing therapy

 Patients are often prescribed “at home”
desensitizing agents include toothpastes and
mouthwashes which primarily aimed at occluding the
dentinal tubules.
 Majority of the toothpastes contain potassium
nitrate, sodium fluoride, strontium chloride, sodium
monofluorphosphate and stannous fluoride.
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Nowadays, most of the desensitizing toothpastes

contain potassium salts such as potassium chloride,
potassium citrate, and potassium nitrate. Potassium
salts move along the dentinal tubules and through
blocking the axonic action of the intra-dental nerve
fibers decrease the excitability of the tooth.
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Strontium chloride
 Acts both as a tubule precipitant and a tubule

occluding agent.
 the effect of strontium chloride is related to its
ability to combine with the bio-colloids in the
dentinal tubules and deposition of an insoluble
barrier at the tubule orifice.
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Recently, some tooth pastes and powders contain

arginine and are proved to be effective. They contain
8% arginine, calcium carbonate, and 1450 ppm
fluoride and by establishing an alkaline environment,
lead to the precipitation of more salivary calcium and
phosphate on the surface and within the dentinal
tubules.
 Formaldehyde or glutaraldehyde
40

 The application of formaldehyde or glutaraldehyde leads to

formation of salivary protein precipitants in dentine tubule.
These agents are very strong tissue fixatives; they should be
used with extreme caution to ensure they do not come in
contact with the vital gingival tissues.
 FLUORIDES
41

• Traditionally, fluorides have been used as a caries preventive

material which can help in remineralization of tooth. Also,
various clinical trials have shown that application of fluoride
solution can decrease the DH.
• Various fluoride formulations are used to treat DH :-
• sodium fluoride,
• stannous fluoride,
• sodium monofluorophosphate
• and fluoride combined with iontophoresis.
 Sodium fluoride
42

• Sodium fluoride is professionally applied in a

concentration of 2%.
• Fluorides precipitates calcium fluoride crystals inside the
dentinal tubules, and thus decrease dentinal permeability.
But these precipitates formed by sodium fluoride can be
removed by the action of saliva.
• Therefore, an addition of acid formulation is
recommended. The acidulated sodium fluoride can form
insoluble precipitates deep inside the tubules.
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 Some authors have recommended the use of iontophoresis along

with 2% sodium fluoride as the electric current is supposed to
increase the ion diffusion.

 IONTOPHORESIS is a technique which uses electric current to

deliver a medicine or other chemical through the tissue surface.

 Iontophoresis utilizes a low-amperage direct electrical current to

introduce ions or ionized drugs into tissue.
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 This procedure allows a concentrated application of the drug

in a desired localized area. A much higher dose of drug can
be introduced into the area to be treated without the systemic
effects of conventional oral or parenteral drug therapy.
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 By applying the appropriately charged direct electrical current,

ionized drugs can be driven into tooth based on the principle
that like charges repel and opposite charges attract.
 For example, fluoride exists as a negative ion. By applying
fluoride under a negatively charged electrode, the fluoride can
be driven with a direct electrical current into the tooth structure.
 Oxalates
46

 Oxalates can reduce dentinal permeability by

occluding dentinal tubules.
 30% potassium oxalate had shown reduction in
dentinal permeability.
 The oxalate reacts with the calcium ions of dentine
and forms calcium oxalate crystals inside the
dentinal tubules as well as on the dentinal surface.
 Dentin Sealers
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 Glass ionomer cements

 Composites
 Dentinal adhesives
 Resinous dentinal desensitizers
 Varnishes
 Adhesive materials
48

 Resin-based dental adhesive systems can provide a

more durable and long lasting dentine desensitizing
effect. The adhesive resins can seal the dentinal
tubules effectively by forming a hybrid layer.
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 Gluma Desensitizer (Heraeus Kulzer) contains

o hydroxyethyl methacrylate (HEMA)
o gluteraldehyde
o and fluoride.
 Gluteraldehyde causes coagulation of the proteins inside
the dentinal tubules. It reacts with the serum albumin in the
dentinal fluid, causing its precipitation.
 HEMA forms deep resinous tags and occludes the dentinal
tubules.
 Bioglass
50

 Bioglass was developed to stimulate the

formation of new bone.
 It has been used in dentistry to fill up the
osseous defects during periodontal surgery.
 Also it has been reported that a formulation of
bioglass can promote infiltration and
remineralization of dentinal tubules.
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 The basic component in bioglass is silica, which

acts as a nucleation site for precipitation of
calcium and phosphate. Bioglass application forms
an apatite layer, which occludes the dentinal
tubules.
 The use of bioglass in management of DH has been
shown by some products such as NovaMin (calcium
sodium phosphosilicate bioactive glass)
Lasers
 Laser is an acronym for light amplification by
stimulated emission of radiations.
 Use of Lasers is based on basis of two different
mechanisms :-
1. Lasers implies direct effect on electric activity of
nerve fibers.
2. Lasers modify the tubular structure of dentin by
melting and fusing of hard tissue or smear layer
and subsequently sealing the dentinal tubules.
 Lasers used for treatment of hypersenstivity can be divided
into two groups:-

 Low power lasers (GaAlAs diode laser)

 Medium power lasers ( Nd:YAG and CO2 )

 Casein phosphopeptide–amorphous calcium
phosphate
54

 Recently, milk protein casein has been used to

develop a remineralizing agent (GC Tooth Mousse).
 By virtue of its remineralizing capacity, it has also
been proposed that it can also help in prevention
and treatment of DH.
 The casein phosphopeptide (CPP) contains
phosphoseryl sequences which get attached and
stabilized with amorphous calcium phosphate (ACP).
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 The stabilized CPP–ACP prevents the dissolution of

calcium and phosphate ions and maintains a
supersaturated solution of bioavailable calcium
and phosphates.

 Various studies have shown that CPP–ACP can

effectively remineralize the enamel subsurface
lesions, which ultimately cures the DH.
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