Dentine Hypersensitivity GN 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$vity?  DENTINE HYPER-SENSITIVITY Only a'ecting this “Having too much of “Having a strong tooth surface (will aid a quality” reaction to something in diagnosis later on) by being able to identify small changes” “Dentine having a big reaction to small changes” Normally presents as pain for patients PAIN How does this pain present? Short, sharp pain Short dura$on Rapid onset Sharp pain Quickly resolves It goes away as quick as it comes Comes and goes quickly Comes very quickly, sharp pain ***In the absence of other symptoms*** Might have these symptoms with other dental problems but if experiencing these symptoms alone, it is likely to be Dentine hypersensitivty So why does this pain occur? S$mulus + Suscep$ble Tooth Cold/hot/sweet Exposed Dentine tubules = Den$ne Hypersensi$vity What makes a tooth suscep$ble? (anatomy revision) Enamel Exposed Den5ne and Cementum Cementum Due to periodontal disease and destruction of periodontal tissues has exposed Dentine and cementum on tooth surface — susceptible surface Not just through peridodontal disease will the Dentine and cementum become exposed Den5ne  Extend from outside all the way through to pulp Den5nal Tubules Pulp Blood vessels and nerves Den$ne Surface 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…  (Theory thinking about the force of movement of water) 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  Removal of smear layer that covers Dentine tubules from acid or mechanical allowing water to move more easily What can s$mulate this? Water is moving within tubules, movement of water is what stimulates nerves inside tooth The water moving up and down tubules is what sensitises the nerves inside the tooth Thermal Hot and cold (expansion and contrac5on) Of the water within tooth surface and leads to fluid movement and nerve sensitisation and feeling of pain for patient Chemical Acid (removes smear layer) Acidic drinks Whitening gel can travel down tubules and irritate the nerve Chemical within gel can move down tubules and irritate nerve Mechanical Tooth brushing, ea5ng, breathing (removes smear layer and changes thermal condi5ons) Cause movement of water within tubules due to physical movement Breathing in cold air can change thermal conditions also Understanding the ae$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 Less commonly but does occur Naturally has exposed Dentine Majority of patients Localised gingival recession followed by cementum Exposed Dentine removal Tooth Brushing Nail bi$ng Opening items Piercings Lack of kera$nised High fraenum Periodontal disease Orthodon$cs $ssue 3. Generalised gingival recession post Most likely have Dentine hypersensitivty due to amount of Dentine exposed periodontal treatment 4. Tooth surface loss (erosion, abrasion, abfrac$on and a\ri$on) If we are wearing away enamel on crown of tooth this can remove surface layer of enamel and expose underlying Dentine and cause sensitivity If TSL is iden$Sed, it is managed as per TSL lecture both with preven$on and ac$ve treatment. May need to provide Dentine sensitivity management as part of treatment  Dentine hypersensitivity is presence of these symptoms in absence of other disease How do I know it is not arising from another dental defect or disease?  Look in mouth and see is symptoms correlate with mouth Examination Detailed history taking to use this to reach diagnosis History Taking Verbal History Taking When something specific happens? Is the problem? Certain areas of mouth or generalised pain? Or Happens randomly with no obvious cause? Minutes, hours, days What are they doing about it? Daily, monthly?  What: Do you have sensi5vity/pain? Yes No Where: Generalised Localised Trigger e.g. Other? If not triggered by stimuli unlikely to be S5mulus/Habit? Dentine hypersensitivty and refer to dentist for When: further assessment 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 Tooth surface loss or gingival recession 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? Exposed Dentine present Short, sharp pain on stimulus with no other symptoms associated with pain Dental Hygiene and Therapists Role Your role is to.. Tell them what’s happening Explain what Dentine hypersensitivty is Explain reasons why they have it 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$ent’s pain problem OH demo) What is leading to this problem happening High acidic diet? Tooth brushing? TSL? Unlikely to be happening naturally 4. Provide First stage preventative management and advice 5. Refer to GDP as preventa$ve needed management and advice What can pa$ents do at home? Advice for patients: Check toothbrushing technique to ensure brushing effectively and good technique not causing damage Good oral hygiene to prevent periodontal disease Limit causes — acidic drugs, whitening (reduce frequency or using topical agents), ice lollies Topical applications of desensitising toothpastes. Mechanisms of Ac$on Fluid movement within tubules but not able to activate nerves in tooth due to being desensitised Remove Desensi$se Do what we can to prevent tubules becoming exposed S$mulus Nerves Prevent Tubule Occlude Exposure Tubules Block surface of tubule to prevent movement of fluid How do these agents work?  Dentinal Tubules How do these agents work? Some topical agents (think of them as plugs that plug tubules to prevent fluid movement) Agents: calcium phosphosilliate Calcium triphosphate Bioactive glass Strontium chloride/acetate Fluoride Arginine ALL work by blocking dentine tubules by getting patient to apply to tooth surface,  Calcium Phosphosilicate  Calcium triphosphate  Bioac5ve Glass  Stron5um Chloride/Acetate  Fluoride  Arginine  Dentinal Tubules How do these agents work? Occluding Den$nal Tubules Challenge Blockages can be removed from tubules over time Chemical ions readily dissolve Chemical ions can be mechanically Chemical ions need to form a precipitate away from the surface removed from surface to occlude Over time they become unblocked again and topical agents will need to be reapplied to prevent dentine hypersensitivty — needs to be regularly Therefore all of these agents are temporary! Solu$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 DESENSITISING NERVES Pulp Potassium ions Den$ne K+ K+ K+ POTASSIUM IONS IN THE TOOTHPASTE OR TOPICAL PREVENT ACTION POTENTIALS BEING FIRED BY NERVE INSIDE TOOTH K+ K+ K+ Desensitise nerves inside teeth through Potassium Nitrate in Toothpaste  Pulp Dentine Potassium ions within toothpaste are able to diffuse K+ through dentine tubules into tooth. Within theory the potassium goes through dentine tubules and surrounds nerve inside the pulp. This increase in potassium depolarises the nerve fibre membrane to elicit initial firing of action potential. K+ Because of persistent high levels of potassium ions, the nerve remains depolarised and not able to fire another action potential to stimulate pain to nervous system. K+ K+ Postassium increase prevents firing anymore action potentials and prevents message getting to brain and experiencing pain. K+ POTASSIUM IONS IN THE TOOTHPASTE OR TOPICAL PREVENT ACTION POTENTIALS BEING FIRED BY NERVE INSIDE TOOTH 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 Within dental surgery Covering exposed dentine — Topical applications we apply; fluoride varnish, resin based products composite restoration to prevent dentine sensitivity Root canal if nerve becomes infected or severe sensitivity that isn’t being managed by anything else Straighlorward Extreme 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