Dentine Hypersensitivity - PDF

Dentine Hypersensitivity Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to prevention, diagnosis and treatment 1.1.4 Explain the aetiology and pathogenesis of oral disease 1.2.2 Recognise the importance of and record a comprehensive an...

Dentine Hypersensitivity Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to prevention, diagnosis and treatment 1.1.4 Explain the aetiology and pathogenesis of oral disease 1.2.2 Recognise the importance of and record a comprehensive and contemporaneous patient history 1.2.3 Recognise the significance of changes in the patients reported oral health status and take appropriate action 1.5.5 Discuss the role of the dental therapist and other members of the dental team in the treatment plan Pre-reading ‘Histology of enamel and dentine’ Lectures Learning Objectives Objectives, by the end of this session you will be able to.. Define dentine hypersensitivity using its typical presentation Explain the mechanism of dentine hypersensitivity Describe and recognise the aetiological factors that lead to dentine hypersensitivity Outline the role you will play in the management of such patients including provision of preventative treatments and advice So what is dentine hypersensitivity?  DENTINE HYPER- SENSITIVITY Only affecting this “Having too much of “Having a strong tooth surface (will aid a quality” reaction to something in diagnosis later on) by being able to identify small changes” PAIN How does this pain present? Short Rapid Sharp pain Quickly resolves duration onset ***In the absence of other symptoms*** So why does this pain occur? Stimul + Susceptible us Tooth = Dentine Hypersensiti vity What makes a tooth susceptible? (anatomy revision) Enamel Exposed Dentine Cementu and Cementum m Dentine  Dentinal Tubules Pulp Blood vessels and nerves Dentine Surface Theories on how pain is registered A = Direct Innervation Theory Nerves extend through dentinal tubules to the tooth surface and directly transmit pain B = Odontoblast Receptor Theory Odontoblast processes extend to the tooth surface through dentinal tubules and directly register stimuli C = Hydrodynamic Theory To be discussed…  HYDRO-DYNAMIC THEORY “Denoting a water, “Force that produces “Something liquid or fluid” movement - suggested as a energetic” reasonable explanation of fact but not confirmed”  Osmosis Fluid moving from an area of high concentration to an area of low concentration through a semi- permeable membrane Approximately 22% of the dentine volume is water What can stimulate this? Thermal Hot and cold (expansion and contraction) Chemical Acid (removes smear layer) Whitening gel can travel down tubules and irritate the nerve Mechanical Tooth brushing, eating, breathing (removes smear layer and changes thermal Understanding the aetiology leads to the definition… “Pain derived from exposed dentine in response to chemical, thermal tactile or osmotic stimuli which cannot be explained as arising from any other dental defect or Canadian Advisory Board on Dentin Hypersensitivity disease” Consensus Statement 2003 How does dentine become exposed? 1. Natural Morphology Localised gingival recession followed by cementum removal Tooth Nail biting Opening items Piercings Brushing Lack of Periodontal High fraenum keratinised Orthodontics disease tissue 3. Generalised gingival recession post periodontal treatment 4. Tooth surface loss (erosion, abrasion, abfraction and attrition) If TSL is identified, it is managed as per TSL lecture both with prevention and active treatment. How do I know it is not arising from another dental defect or disease?  Examination History Taking Verbal History Taking  What: Do you have sensitivity/pain? Yes No Where: Generalised Localised Trigger e.g. Other? Stimulus/Habit? When: STOPs CONTINUES when After stimulus stimulus How long: removed removed Always with Rarely with a stimulus a stimulus How often: Manage dentine Refer to No action Action: hypersensitivity GDP required Courtesy or Ms Stockholm Clinical Examination Remember tooth morphology and assess for any dentine exposure that may be source of pain Try to illicit pain (3 in 1) to confirm symptoms and identify areas of interest The diagnosis is definitely dentine hypersensitivity. Now what do I do? Dental Hygiene and Therapists Role Your role is to.. 2. Identify 1. Identify if 3. Educate aetiological this is the the patient factors (e.g. cause of a about the diet history, patient’s pain problem OH demo) 4. Provide 5. Refer to preventative GDP as management needed and advice What can patients do at home? Mechanisms of Action Remove Desensitise Stimulus Nerves Prevent Occlude Tubule Tubules Exposure How do these agents work?  Dentinal Tubules How do these agents work?  Calcium Phosphosilicate  Calcium triphosphate  Bioactive Glass  Strontium Chloride/Acetate  Fluoride  Dentinal Tubules How do these agents work? Occluding Dentinal Tubules Challen ge Chemical ions readily Chemical ions can be Chemical ions need to form a dissolve away from the mechanically removed from precipitate to occlude surface surface Therefore all of these agents are temporary! Solutions How can we solve these problems? Use proteins to allow chemical ion to stick to tooth surface (e.g. arginine) Use chemicals that precipitate in an acidic environment (e.g. bioactive glass) Use higher concentrations of fluoride (e.g. duraphat toothpaste or varnish) Continual daily use to allow benefits to be long lived Spit don’t rinse to keep chemicals close to the tooth surface Agents for use at home Colgate: Sensitive instant relief - Arginine Sensodyne : apid – Contains stannous fluoride to occlude R tubules Repair and protect – Contains Stannous Fluoride to occlude tubules Fluoride: Fluoride reduces dentine hypersensitivity as it can block tubules through formation of calcium- phosphorous precipitates as well as calcium fluoride and fluoroapetite  Pulp Dentine K+ K+ K+ K+ K+ K+ Potassium Nitrate in  Pulp Dentine K+ K+ K+ K+ K+ K+  Pulp K+ concentration immediately surrounding the intradental nerves increases which K+ presumably depolarizes the nerve fibre membrane and K+ elicits an initial firing of action potentials. Because of the K+ persisting high levels of K+ extracellular potassium a K+ sustained depolarized state occurs that results in an inactivation of the action K+ potential. K+ concentration immediately surrounding the intradental nerves increases which presumably depolarizes the nerve fibre membrane and elicits an initial firing of action potentials. Because of the persisting high levels of extracellular potassium a sustained depolarized state occurs that results in an inactivation of the action potential. Professional Treatment Straightforward Extreme Summary Recommended Reading Dentine hypersensitivity — an enigma? a review of terminology, epidemiology, mechanisms, aetiology and management R. H. Dababneh, A. T. Khouri and M. Addy (1999) A new perspective on Dentine Hypersensitivity – Guidelines for General Dental Practice. DG Gilam (2017). Dental Update