DENTIN HYPERSENSITIVITY
Harlan J. Shiau, DDS, DMSc
ABSTRACT
Context: In dental practice, dentin hypersensitivity is a commonly presenting condition, which consists of sharp pain arising from exposed dentin in response to a
varied assortment of stimuli; for example, dietary factors, such as an ice-cold beverage, to even environmental considerations, such as the exposure to atmospheric air
on a cold winters day. The heterogeneity of this presentation, ranging from minor
inconvenience to the patient, to a near incapacitating quality-of-life disturbance, as
well as the wide range of treatment strategies, as is discussed in this article, certainly
pose a challenge to the clinician.
Evidence Acquisition: A search was performed on the MEDLINE database (2002
to present) by way of OVID. Search terms, such as dentin hypersensitivity and variants (eg, dentinal hypersensitivity, cervical dentin hypersensitivity) were used. Select
references of review-type articles from the original search were sought.
Evidence Synthesis: Efforts were made to identify multiple comparative clinical
treatment studies that were of highest quality study designspecifically, randomized control trials. Efforts also were made to identify rigorous meta-analysis in the
literature on the subject of dentin hypersensitivity treatment.
Department of Periodontics,
University of Maryland Dental School,
Baltimore, MD 21201.
Introduction
220
Epidemiology of DH
Despite common empirical presentation in the office, a wide
range of DH prevalence is reported in the literature. For
example, estimates as to the prevalence of dentine hypersensitivity range from 3% to 73% of the adult population of
Western Europe and the United States.7,9,10 Again, the heterogeneity of prevalence may likely be related to assessment
methods, ranging from questionnaires to clinical detection,
and possibly related to study location, ranging from private
practice to institutional settings. Reviews of available studies
conclude that the incidence of hypersensitivity in most populations ranges from 10% to 30% of the general population.8,11
Some studies indicate there is a higher female incidence in
DH compared with males.12,13 The literature reports that DH
most commonly affects premolars and incisor teeth. Some
studies indicate that the molar teeth are least likely to be
affected by DH.13 The role of age in the distribution or incidence of DH is unclear. On one hand, the severity of the
condition increasing with age has been attributed to the increased prevalence of periodontal disease, periodontal treatment, gingival recession, and erosive toothwear on exposing
dentine to external stimuli.4,13 All of the aforementioned scenarios would presumably act to increase the susceptibility to
classic DH stimulus. At the same time, some reports indicate
the occurrence of DH to be at peak presentation at the
between the third and fourth decades, followed by a gradual
decline thereafter.4
Mechanism of DH
Theories for the mechanism of DH are intimately related
to the anatomy and histology of the dentin-pulpal complex.
Recall that odontoblast cells synthesize the dentins collagen
matrix (majority Type I) and are instrumental in the mineralization process; odontoblasts are crucially involved in dentin
formation and repair.14 The macrostructure of dentin consists
of tubule units, surrounded by hypermineralized tissue: peritubular dentin (Fig.1, A and B). The dentin tubule contains
serum-like fluid and an odontoblast cell process. Ultrastructural studies have confirmed the close physical proximity of
sensory nerves to the odontoblast (process and cell body).15
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Figure 2. (A) A simplified diagram of the dentinopulpal complex. A, Dentin tubule; B, odontoblast
cell and extending process, note proximally
associated nerves (yellow); C, nerve/nerve plexus
in pulp region. (Source: Illustrated by H.J. Shiau.)
(B)Upon challenge by a stimulus (thermal,
mechanical, evaporative, chemical), the exposed
dentin and open tubules permit a change in rate of
fluid flow in the dentin tubule. An action potential
is generated involving the trigeminal sensory
nerves (yellow). (Source: Illustrated by H.J. Shiau.)
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Clinical Diagnosis
An imperative component of any clinical treatment is to
ascertain a proper diagnosis and to address predisposing
factors of the condition; this is most appropriate in management of DH. A careful differential diagnosis must be developed considering other clinical conditions that may mimic
DH: postoperative restorations, cracked tooth syndrome,
sensitivity from bleaching, fractured restorations, and dental
caries and related pulpitis are some worthy entities to rule
out. Also relevant may be a thorough dietary history and
information on oral hygiene practices. Again, a proper history of the nature of pain, clinical evaluation, radiographic
examination, and use of diagnostic tests, such as percussion,
palpation, and pulp vitality testing will aid in confirming DH
by excluding other conditions. A clinical technique of diagnosing DH may involve the use of air from a triple-syringe
or use of an exploratory probe on the exposed dentin.
The severity or degree of pain can be quantified according
to either a categorical scale (ie, slight, moderate, or severe
pain) or using a visual analogue scale (VAS).21 Such structured data collection will best allow the clinician to track
a patients DH symptoms during the course of treatment.
Potassium nitrate
Potassium nitrate is the most common therapeutic agent
taking the strategy of nerve desensitization. Potassium
nitrate is an effective treatment modality that is currently
used in most over-the-counter desensitization toothpastes
and a variety of at-home and in-office gels. The mechanism
of potassium nitrate is likely related to its ability to increase
the extracellular potassium ion concentration, consequently
depolarizing the nerve and preventing it from re-polarizing.
In general, patients report favorable outcomes in the use of
potassium nitrate in managing their DH symptoms.26 In one
of the earliest studies, potassium nitratecontaining dentifrices (5% potassium nitrate) have been demonstrated to
be safe on the pulp, and, with daily use, to be effective in
desensitizing affected teeth for up to 4weeks.27 However,
a recent Cochrane review of potassium nitratecontaining
toothpastes, factoring in a meta-analysis of 6 studies, was
unable to offer strong support for the use of potassium salts
in the management of DH.28
Management of DH
Strontiumsalts
223
Fluorides
Fluoride products, such as sodium fluoride and stannous
fluoride, have demonstrated positive effects in occluding
dentin tubules and offering clinical sensitivity relief. Topically
applied fluoride creates a barrier by precipitating CaF2 on
the dentin surface.37 One randomized control study indicates effectiveness of 2 separate 5% sodium fluoride varnish products in sensitizing efficacy, as measured by VAS response to air and cold tests, over a 24-week period.38 Topical
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Oxalates
Oxalates are used to manage DH by leveraging their ability to form precipitates within dentin tubules, consequently blocking dentinal fluid flow.43 The oxalates, such as 3%
monohydrogen-monopotassium oxalate, have the added
benefit of relative insolubility in acid, rendering them very
resistant to dissolution on treatment.44 A recent systematic review found only 3% monohydrogen-monopotassium
oxalate as effective in decreasing DH, but recommended
more stringent studies.44
Glutaraldehyde
Arginine
Arginine and calcium carbonate formulations have been
developed to manage DH symptoms based on naturally
occurring biological process of tubule occlusion by salivary
glycoproteins. Saliva transports calcium and phosphate in
proximity to dentin tubules to induce occlusion and formation of a protective salivary glycoprotein with calcium
and phosphatea process favored under alkaline pH conditions. These observations underpinned the commercial
research and development of a formulation containing arginine, an amino acid positively charged at physiological pH;
bicarbonate, functioning as a pH buffer; and calcium carbonate, functioning as a source of calcium. The mechanism
Bioactive glass
As a biomaterial, bioactive glass has been used in dentistry
over the past 4 decades. This class of glass-ceramic compounds was developed as a bone repair and regeneration material in orthopedic, maxillofacial, and periodontal
224
Periodontal surgery
I. PREVENTIVE
ORAL HYGIENE:
(Proper brushing technique; Proper type of toothbrush;
Timing of toothbrushing related to acidic intake)
DIET INVENTORY & HISTORY: (Acidic foods/drinks;
Identify eating disorders)
MEDICAL CONSULTATION:
(e.g. Erosion related to regurgitation and vomiting related
to a medical condition?)
Lasers
Low-output devices, such as the He-Ne laser or diode-type
laser, have been investigated as a prospective treatment for
DH. Original publications of He-Ne lasers applied to treat
dentin hypersensitivity used low-output power at 6 mW
in both continuous wave and pulsed modes. Effectiveness
varied considerably from 5% to 100%.62 The mechanism
involved in laser treatment of dentine hypersensitivity remains to be fully elucidated. Some experiments suggest that
low-output lasers of the diode type may operate by mediating an analgesic effect controlled by decreasing nerve
transmission.63
OTHER:
Address para-function related to attrition?
Combination
Office applied desensitizing agents
Resins/adhesives
Periodontal surgery/Endodontic Tx
In-Office
of arginine-calcium carbonate formulations in addressing DH have been established via confocal laser scanning
225
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Practical Considerations in DH
Management
9.
First, the clinician should develop a preventive strategy toward DH, focusing on predisposing factors (see Fig. 4).These
measures, for example, might be aimed at reducing the risk
of exposing dentin by identifying the cause of enamel removal (erosion or zealous toothbrush use). Another example would be the counseling of a patient to reduce or eliminate intake of acidic foods deemed contributory to erosion
of enamel. Only with predisposing factors addressed should
the clinician begin to formulate directed therapy toward the
hypersensitivity, aimed at interfering with the mechanism
of DH. At-home strategies in the form of dentifrices and
rinses, using the active ingredients and materials described
previously, are generally safe, cost-effective, and reversible.
More-invasive in-office treatments form the next component of directed therapy; a suggested working algorithm is
presented based on the currently available and reviewed
DH treatments discussed in this article (Fig. 4)
The literature presents many clinically successful approaches at managing DH. Products, including at-home strategies
containing fluorides, strontium chlorides, and more contemporary materials, such as bioactive glass and arginine, have
been broadly studied and are shown to be safe and beneficial to patients with DH. The reviews of individual strategies
correctly point out that, in many instances, there does not
exist a large body of systematic and rigorous controlled
studies to demonstrate efficacy clinically. As such, clinical research cannot currently proclaim one technique to be vastly
superior to another in DH management.
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