“Post operative hypersensitivity”

Prepared by:
Dr: Kareem Hamdi
BDS, MDS, PhD Operative dentistry, Mansoura University
Lecturer of operative dentistry, Faculty of Dentistry, Zagazig
University

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Despite great progress, restorative techniques still present a certain rate of failures.
Discoloration, marginal leakage, recurrent caries and loss of the restoration are the
main problems related to restoration failures. Class I and II resin composite
restorations are the most predisposed to failure. Perhaps the most intriguing and
challenging problem is post-operative dentin sensitivity, one of the disadvantages
of using direct resin composites in
posterior teeth

After restorations with resin composite, especially in posterior teeth, clinical

observation has shown that patients complain of dentinal sensitivity at different
levels and in different situations. This is a common problem, even with no visible
failures in the restoration. Pain is always a warning signal of possible aggression,
and although it does not have a direct relationship with the pathological processes,
it is one of the most common reasons for seeking dental treatment, either in public
service or private clinics

Post-operative sensitivity in resin composite restorations is a common occurrence

that causes discomfort in the patient and inconvenience to the professional,
because it has various causes. Although frequent, it has still not been fully
explained. Therefore, it is important to study the problem to establish a work
routine to avoid it

Dentinal sensitivity

The main morphological characteristic of dentin is that it is a tubular structure, filled

with fluid, connecting the pulp to the enamel–dentine junction. The lumen of
dentinal tubules is surrounded by thin cuffs of mineralized tissue, called peritubular

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dentin. The matrix interposed between this cylindrical structure, the intertubular
dentin, contains around 30% by volume of mineralized collagen type I fibrils
perpendicular to the long axis of the tubules. Much smaller quantities of collagen
(10% by volume) are present in peritubular dentin. Dentinal permeability is,
therefore, a direct consequence of this structural pattern. The closer one gets to the
pulp, the greater is the value of this porosity (45,000–65,000; 29,500– 35,000;
15,000–20,000/mm2 ) and the diameter of the tubules (2.5 µm close to the pulp; 1.2
µm in the intermediate region; 0.5 µm at the enamel–dentine junction). This explains
the increase in dentin permeability in the area close to the pulp chamber.

The widely accepted hydrodynamic theory seeks to explain the painful phenomenon
that occurs in dentin by the movement of fluid within the dentinal tubules after
certain stimuli, which causes intratubular pressure changes, thus leading to
excitation of the pulp nerve terminals, producing a sensation of pain.

Pre-operative causes

It is extremely important to establish a precise diagnosis before any restorative

procedure, in order to be certain that the pain reported by the patient does not
originate from pre-existing causes, such as cracks, tooth fractures, dentinal
sensitivity resulting from dentin exposure in the cervical region, or reversible or
irreversible inflammatory processes in the pulp.

1- Cracks and fractures

Cracked tooth syndrome is an entity characterized by the presence of incomplete

cracks or fractures of the enamel or enamel and dentin in a tooth, with symptoms of

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pain when chewing and inexplicable sensitivity to cold. The difficulty in visualizing
the crack and the patient’s report of symptoms, which are not always well explained,
sometimes make it a complex diagnosis, and the symptoms may be confused with
post-operative sensitivity.

2- Cervical dentinal exposure

Areas of cervical dentinal exposure may present as insensitive before the restoration,
and may be stimulated during the operative procedure due to prolonged contact with
the clip, or inadvertently, by the prolonged presence of phosphoric acid during cavity
etching, which could lead to difficulties in diagnosing the pain, and may lead to re-
intervention in the restoration. Thus, a meticulous examination should be performed
to identify the presence of exposed dentin, whether there is a record of painful
symptoms or not, and avoid possible procedures that may trigger or exacerbate
existing pain.

3- Pulp condition

A determinant factor before restoring the tooth is to establish the condition of the
pulp. Radiographic examination should be done, previous procedures should be
observed, the presence or absence of symptoms reported by the patient should be
recorded and pulp vitality tests should be performed. All these procedures are
essential to minimize the risks of sensitivity.

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 Operative causes

Pain of dentinal origin is intimately related to restorative procedures, and may occur
by cutting and exposing healthy dentin due to dentin dehydration and the release of
toxic substances from the restorative material, among other causes.

1- Abusive dental structure wear

The use of burs and diamond tips with excessive cutting or wearing pressure,
without the use of adequate cooling, may generate frictional heat and dentin
dehydration. Even if this happens for only a short time, it causes displacement of the
tubular fluid and a painful pulp response. Blunt burs and diamond tips demand
greater pressure during cavity preparation, inducing a rise in temperature. Diamond
tips are subject to increasing degrees of wear and diamond particle loss, as they are
submitted to a larger number of cavity preparations, and must be replaced.

2- Dentin desiccation

Excessive dentin dehydration may also occur by repetitive cavity drying during
preparation of the tooth and/or while performing the restoration, causing pain due to
pulp fluid displacement.

3- Incomplete carious tissue removal

The environment found under restorations presents favorable conditions for

microbial growth between the restorative material and the cavity wall. Incomplete
carious tissue removal leads to the possibility of bacteria remaining between the

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restoration and the cavity wall, increasing the susceptibility of the pulp to leakage of
the bacteria themselves and their toxins. Bacterial activity results in pulp infection
or inflammatory reactions resulting from bacterial products. Consequently, post-
operative sensitivity results from pulp aggression caused by the presence of carious
dentin and the low quality of the adhesive bond to dentin. The deficient bond causes
marginal gaps and consequently, microleakage, recurrent caries and pulp
inflammation. The presence of bacteria and their products may be detected at any
stage of the restorative procedure. Contamination of the cavity may occur during
cavity preparation with the presence of carious dentin, by saliva penetration during
cavity preparation, while performing the restoration, with the use of contaminated
instruments, or in the post-operative stage due to the presence of marginal leakage.

4- Negligence in protecting the dentin–pulp complex

Undoubtedly, dentin is the best pulp protection material. At the time of deciding
about protecting the dentin–pulp complex during a resin composite restoration,
dentinal permeability and the type and quality of remaining dentin should be
assessed. Whether dentin is removed by pathological or professional means, if its
thickness is reduced the dentinal tubule openings are increased, making it more
permeable and consequently, more susceptible to irritation by chemical or bacterial
agents. Another very important factor is cavity depth, which varies from shallow to
medium and deep, and it is fundamental to know how to act in each case. Shallow
and medium cavities present a larger quantity of dentin, which favors the
maintenance of the number of odontoblasts. The larger the number of odontoblasts,
the greater the repair capacity of the pulp. In deep cavities, there is a smaller quantity
of odontoblasts remaining, which may be diminished even further during the
restorative procedure, drastically reducing the chances of pulp recovery. The
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increase in cavity depth is proportional to the dentinal permeability and significantly
predisposes the dentin to post-operative sensitivity. Restorations in deep cavities
present four times greater risk of failure, whereas cavities with pulp exposure have
a 14 times higher risk of failure, compared with restorations in cavities with a greater
dentin thickness. The quality of remaining dentin found between the cavity floor and
the pulp is of important in preventing pulp complications caused by operative
procedures. The patient’s age must also be considered. A young tooth has a larger
pulp cavity than an adult tooth, which has received more physiological stimuli or
injuries during the course of life, and in which more reparative dentin has formed,
and consequently, the pulp chamber is reduced in size. The use of resin composite
materials during restorations is a controversial but important topic. It has been
questioned whether it is really necessary to use a lining material under a composite
restoration?

Several studies stated that perfect seal is very difficult to achieve clinically,
therefore, under the condition of a not so perfect seal, a cavity floor lining may still
be of great value. Liners, when used, must support (and continue to support) the
restorations superimposed upon them, otherwise any decomposition will result in a
defective base, causing a pumping action and marginal percolation during chewing,
resulting in sensitivity. The indiscriminate use of calcium hydroxide linings to
stimulate secondary dentin formation continues to be controversial. On the one hand,
it is argued that secondary dentin will form in any case, as a response to the repair
process. Generally, it became widely accepted that the use of calcium hydroxide is
recommended in very deep cavities in which the remaining dentin thickness <0.5-
1mm.

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 5- Inadequate isolation of the operative field

Absolute isolation is indicated to reduce two issues that cause post-operative

sensitivity generated by penetration of saliva into the operative field: contamination
of the cavity by microorganisms that cause pulp inflammation and contamination by
humidity, which harms the bond and facilitates marginal leakage.

6- Failure in dental tissue hybridization

Hybridized dentin is prepared at the interface of the surface demineralized by

previous acid etching to expose the collagen fibers in the dentin matrix and allow
infiltration of adhesive monomer into the exposed fiber network. Therefore, dentin
hybridization is a process that creates a mixed layer of resin monomers and collagen
fibrils, altering the physical and chemical properties of this tissue. Previous acid
etching transforms the tooth surface, making it more receptive to bonding with the
adhesive system and resin composite, and facilitating the formation of resin tags
within the dentinal tubules, which gives the restoration greater resistance and
durability. Acid etching for a longer time than that recommended by the
manufacturer leads to many conditions that result in sensitivity. Most acids are
hypertonic and cause pulp fluid displacement, leading to movement of the
odontoblasts as a pulp response. Acid solutions used in excess of the recommended
time (15 s) denature the collagen fibers, increase dentin permeability and humidity,
facilitate chemical aggression by the adhesive system and bacterial infiltration, and
for all these reasons, harm the bond and may cause pain (4). Dentin demineralization
of over 5 µm is not of much value to the clinical procedure, and may result from
longer exposure of dentin to the acid. An increase in the demineralized dentin layer
will not guarantee the formation of a thicker hybrid layer and a better bond, as the

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primer/adhesive may not have the capacity to infiltrate throughout its entire
thickness, causing exposure of the collagen within and at the base of the hybrid layer,
which could lead to degradation and leakage. The greater the flow of adhesive
between the collagen fibrils and through the complex of demineralized channels, the
better will be the quality of the hybrid layer, giving it a higher degree of resistance
to hydrolysis and offering greater protection against microleakage. An increased
dentin etching time is a clinical error responsible for the occurrence of postoperative
sensitivity.

Therefore, Self-etching adhesives have an advantage over adhesives that require acid
etching. As the primer is acidified, acid etching is performed without the need for
washing. Although the hybrid layer formed is thinner, the entire etched area is
occupied by adhesive, thus diminishing the chances of hydrolysis occurring in the
area.

7- Handling restorative material

Resin composites are having a broad range of indications in clinical dentistry. They
consist of an organic matrix permeated with inorganic particles surrounded by a
bonding agent that makes them adhesive to the resin matrix. The organic base of
contemporary resin composites is composed of the monomer bisphenol A-glycidyl
dimethacrylate (bisGMA) in combination with other di-methacrylates such as
triethylene glycol dimethacrylate (TEGDMA), urethane dimethacrylate (UDMA)
and bisphenol A-glycidyl dimethacrylate ethoxylate (BisEMA). Despite the
differences in their formulations, all the methacrylate-based composite are
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polymerized by the generation of free radicals. In this process, the approximation of
the methacrylate monomers to establish covalent bonds with one another during the
polymerization reaction causes a significant reduction in the volume of resin after
polymerization, thereby leading to what is called polymerization/ volumetric
shrinkage. Such a shrinkage has an adverse effect on the tooth structure causing
cuspal deflection, postoperative sensitivity, and finally secondary caries.

Several attempts have been performed to reduce/ control polymerization shrinkage:

At material level: silorane composite has been introduced, bulk fill composite with
stress breakers has been introduced

At operator level: layering technique (oblique wedge shape layering) is highly

recommended

Incomplete resin composite polymerization is also responsible for post-operative

sensitivity. Problems associated with inadequate polymerization include inferior
physical properties, diminished retention, greater degradation in the oral
environment and adverse pulp responses. In clinical practice, only one light curing
device is bought and used to polymerize all the materials available in the dental
office with inadequate power due to degradation of the components (bulbs,
reflectors, filters and light conducting tips), which occurs with use over time,
contributes to difficulties in polymerizing these materials.

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 Post-operative causes
1- Restoration finishing and polishing

Finishing and polishing are commonly performed by dentists. Restorations must be

done in such a way that the finishing and polishing stages are restricted to small
adjustments in the shape and superficial smoothness of the restoration. Purposely
inserting a large excess of material and then performing finishing is extremely
unfavourable to the tooth and the restoration. Immediate and excessive superficial
wear of a recently placed resin composite generates alterations in the resin matrix by
the heat produced, disturbs the post-irradiation phase of polymerization, and
removes the superficial layer, which theoretically obtains the highest degree of
conversion. The possibility of pulp injury due to the exaggerated frictional heat
generated by the high-speed bur is increased. The careful use of burs and abrasive
instruments at this stage avoids possible damage to the restoration margins and
adjacent dental tissue, avoiding failures at the tooth/restoration interface.

2- Occlusal interference

During mastication of solid foods, or when the restoration is in occlusion with the
antagonist tooth, deformation of the margins and interfaces occurs, and this may lead
to a dimensional change that could cause fluid movement within the dentinal tubules
and cause pain.

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