Dentine Hypersensitivity PDF

Den$ne Hypersensi$vity Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to preven5on, diagnosis and treatment 1.1.4 Explain the ae5ology and pathogenesis of oral disease 1.2.2 Recognise the importance of and record a comprehensive and co...

Den$ne Hypersensi$vity Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.2 Describe oral diseases and their relevance to preven5on, diagnosis and treatment 1.1.4 Explain the ae5ology and pathogenesis of oral disease 1.2.2 Recognise the importance of and record a comprehensive and contemporaneous pa5ent history 1.2.3 Recognise the signiAcance of changes in the pa5ents reported oral health status and take appropriate ac5on 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 den5ne’ Lectures Learning Objec$ves Objec5ves, by the end of this session you will be able to.. DeAne den5ne hypersensi5vity using its typical presenta5on Explain the mechanism of den5ne hypersensi5vity Describe and recognise the ae5ological factors that lead to den5ne hypersensi5vity Outline the role you will play in the management of such pa5ents including provision of preventa5ve treatments and advice So what is den$ne hypersensi$vity?  DENTINE HYPER-SENSITIVITY Only a'ecting this “Having too much of “Having a strong tooth surface (will aid a quality” reaction to something in diagnosis later on) by being able to identify small changes” PAIN How does this pain present? Short dura$on Rapid onset Sharp pain Quickly resolves ***In the absence of other symptoms*** So why does this pain occur?  Tooth surface covered in dentine S$mulus + Suscep$ble Tooth = Den$ne Hypersensi$vity What makes a tooth suscep$ble? (anatomy revision) Healthy tooth Bone loss and recession of gingiva exposing dentine Enamel Exposed Den5ne and Cementum Cementum Den5ne  Den5nal Tubules Extend from outside of tooth to pulp Pulp Blood vessels and nerves Den$ne Surface Holes present are the dentine Tubules · Theories on how pain is registered A = Direct Innerva5on Theory Nerves extend through den5nal tubules to the tooth surface and directly transmit pain B = Odontoblast Receptor Theory Odontoblast processes extend to the tooth surface through den5nal tubules and directly register s5muli C = Hydrodynamic Theory To be discussed…  Fluid movement theory to explain dentine hypersensitivity HYDRO-DYNAMIC THEORY “Denoting a water, “Force that produces “Something liquid or @uid” movement - suggested as a energetic” reasonable explanation of fact but not conFrmed”  Osmosis Fluid moving from an area of high concentra5on to an area of low concentra5on through a semi- permeable membrane Approximately 22% of the den5ne volume is water What can s$mulate this? Movement of water through dentine tubules that sensitises the nerves within the pulp. This can be caused by thermal , chemical and mechanical. Thermal Hot and cold (expansion and contrac5on) Chemical Acid (removes smear layer) Whitening gel can travel down tubules and irritate the nerve Mechanical Tooth brushing, ea5ng, breathing (removes smear layer and changes thermal condi5ons) Understanding the ae$ology leads to the deSni$on… “Pain derived from exposed den5ne in response to chemical, thermal tac5le or osmo5c s5muli which cannot be explained as arising from any other dental defect or disease” Canadian Advisory Board on Den5n Hypersensi5vity Consensus Statement 2003 How does den$ne become exposed? 1. Natural Morphology Everyone’s morphology is different. The junction between between crown and root surface (cemto-enamel junction) is supposed to overlap to stop dentine being exposed. However sometimes this doesn’t occur and dentine is exposed naturally. Localised gingival recession followed by cementum removal Causes of gingival recession Tooth Brushing Nail bi$ng Opening items Piercings Lack of kera$nised High fraenum Periodontal disease Orthodon$cs $ssue 3. Generalised gingival recession post periodontal treatment 4. Tooth surface loss (erosion, abrasion, abfrac$on and a\ri$on)  Tooth surface loss If TSL is iden$Sed, it is managed as per TSL lecture both with preven$on and ac$ve treatment. How do I know it is not arising from another dental defect or disease?  Examination History Taking Verbal History Taking What is the problem Location of pain What causes it What they are doing Duration How often it occurs  What: Do you have sensi5vity/pain? Yes No Where: Generalised Localised Trigger e.g. Other? S5mulus/Habit? When: STOPs CONTINUES when s5mulus Aeer s5mulus removed removed How long: Always with Rarely with a a s5mulus s5mulus How o^en: Manage den5ne Refer to GDP No ac5on required Ac$on: hypersensi5vity Courtesy or Ms Stockholm Clinical Examina$on Remember tooth morphology and assess for any den5ne exposure that may be source of pain Try to illicit pain (3 in 1) to conArm symptoms and iden5fy areas of interest The diagnosis is deSnitely den$ne hypersensi$vity. Now what do I do? Dental Hygiene and Therapists Role High acid diet Your role is to.. 2. Iden$fy 1. Iden$fy if this is 3. Educate the ae$ological factors the cause of a pa$ent about the (e.g. diet history, pa$ent’s pain problem OH demo) Tooth surface loss Over brushing If more tx is required 4. Provide 5. Refer to GDP as preventa$ve needed management and advice What can pa$ents do at home? Correct brushing technique Correct amount of sensitive toothpaste Sensitive toothpaste Remove stimuli Limit acidic drinks if erosion is present Mechanisms of Ac$on Remove Desensi$se S$mulus Nerves Block surface of tubules Prevent Tubule Occlude Exposure Tubules How do these agents work?  Dentinal Tubules How do these agents work? Calcium Phosphosilicate Calcium triphosphate Bioactive Glass Strontium Chloride/Acetate Fluoride Arginine Theses agents work by blocking dentine tubules preventing dentine hypersensitivity  Calcium Phosphosilicate  Calcium triphosphate  Bioac5ve Glass  Stron5um Chloride/Acetate  Fluoride  Arginine Occluding Den$nal Tubules Topical agent has been applied and now blocked the dentine tubules. Challenge Chemical ions readily dissolve Chemical ions can be mechanically Chemical ions need to form a precipitate away from the surface removed from surface to occlude Therefore all of these agents are temporary! Sensitive toothpaste needs to be uses regular Solu$ons How can we solve these problems? Use proteins to allow chemical ion to s5ck to tooth surface (e.g. arginine) Use chemicals that precipitate in an acidic environment (e.g. bioac5ve glass) Use higher concentra5ons of guoride (e.g. duraphat toothpaste or varnish) Con5nual daily use to allow beneAts to be long lived Spit don’t rinse to keep chemicals close to the tooth surface Agents for use at home Colgate: Sensi5ve instant relief - Arginine Sensodyne: Rapid – Contains stannous guoride to occlude tubules Repair and protect – Contains Stannous Fluoride to occlude tubules Fluoride: Fluoride reduces den5ne hypersensi5vity as it can block tubules through forma5on of calcium-phosphorous precipitates as well as calcium guoride and guoroape5te  Pulp Den$ne K+ K+ K+ K+ K+ Reducing action potential within the nerves. This is done by potassium nitrate (this can be present in toothpaste). Potassium ions are able to diffuse through dentine K+ tubules and into the pulp surrounding the nerve. Potassium Nitrate in Toothpaste  Pulp Dentine K+ K+ K+ K+ K+ K+  Pulp K+ concentra5on immediately surrounding the intradental nerves increases which presumably depolarizes K+ the nerve Abre membrane and elicits an ini5al Aring of ac5on poten5als. K+ Because of the persis5ng high levels of extracellular potassium a sustained K+ depolarized state occurs that results in K+ an inac5va5on of the ac5on poten5al. K+ K+ K+ concentra5on immediately surrounding the intradental nerves increases which presumably depolarizes the nerve Abre membrane and elicits an ini5al Aring of ac5on poten5als. Because of the persis5ng high levels of extracellular potassium a sustained depolarized state occurs that results in an inac5va5on of the ac5on poten5al. Professional Treatment Gingival graph Placing fluoride varnish Resin based Root canal Straighlorward Extreme Covering recession Summary Recommended Reading Den5ne hypersensi5vity — an enigma? a review of terminology, epidemiology, mechanisms, ae5ology and management R. H. Dababneh, A. T. Khouri and M. Addy (1999) A new perspec5ve on Den5ne Hypersensi5vity – Guidelines for General Dental Prac5ce. DG Gilam (2017). Dental Update