Transcript of An Analysis of the Etiological and Predisposing Factors ...
Bamise1 The Journal of Contemporary Dental Practice, Volume 9, No.
5, July 1, 2008
An Analysis of the Etiological and Predisposing Factors Related to
Dentin Hypersensitivity
Aim: To determine the prevalence of different etiological factors
of dentin hypersensitivity in patients and to provide information
on their association with dentin hypersensitivity.
Methods and Materials: Twenty-nine patients (17 male, 12 female)
suffering from pain of dentin hypersensitivity were recruited to
participate in the study. A relevant history was taken and dentin
hypersensitivity confirmed by using air-blast and tactile
stimuli.
Results: All patients were right-handed. The left side of the mouth
showed a preponderance of gingival recession, abrasion, abfraction,
and erosion while more teeth on the right side showed attrition.
Gingival recession and attrition were common among the molars,
abrasions among the molars and premolars, abfraction among the
premolars, while erosive lesions were predominantly found among the
incisors.
A total of 911 teeth were examined in the 29 subjects presenting
with dentin hypersensitivity. The following conditions were found
to be associated with the dentin hypersensitivity: 43 of 117 teeth
(36.8%) with gingival recession; 41 of 99 teeth (41.4%) with
attrition; 40 of 67 teeth (59.7%) with abrasion; 16 of 25 teeth
(64%) with abfraction; and 32 teeth had erosive lesions all
associated with hypersensitivity.
Abstract
© Seer Publishing
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July 1, 2008
Introduction Dentin hypersensitivity has been described as a
condition in which a sound, exposed dentinal surface is sensitive
to stimuli that would normally cause no discomfort.1 Usually, no
obvious cause can be identified for this condition;2 Addy3
described it as a tooth wear phenomenon. By definition two
conditions need to be satisfied for dentin hypersensitivity to
occur: dentin has to become exposed by loss of enamel or
periodontal tissues and the dentin tubule system has to be opened
and be patent to the pulp.4
The most implicated physical/chemical process causing dentin
exposure is dental erosion acting alone or synergistically with
other factors such as abrasion and attrition. Enamel erosion is
characterized by acid-mediated surface softening progressing to
irreversible loss of surface tissue if left unchecked potentially
exposing the underlying dentin.5 It is currently believed to be the
major factor involved in tooth wear.6
Traditionally, potential factors causing erosion have been
described as originating from the diet, environment, and from
regurgitation.7 Erosion
may also be due to either extrinsic or intrinsic acids.8,9 Erosion
results in shallow, rounded lesions,10 and it is suggested7 when an
erosive factor is present ‘cupping’ or ‘grooves’ form in the dentin
with the base of the defect not in contact with the opposing
tooth.
Attrition describes the wear of teeth at sites of direct contact
between teeth.11 It is associated with flattening of the cusp tips
or incisal edges and localized facets on the occlusal or palatal
surfaces.
Abrasion describes the wear of teeth caused by objects other than
another tooth.11 Most interest in abrasion has centered around the
effects of tooth brushing with toothpaste. Typical toothbrush
abrasion lesions are side dependent, for example being greater on
the left-side in right-handed people. The buccal cervical areas of
the teeth are the sites of predilection. Cervical lesions caused by
an abrasive tend to be angular and ‘v’-shaped.
Abfraction or cervical stress lesions have been hypothesized as an
etiological factor in tooth wear.12,13 The process is thought to
involve eccentric occlusal loading leading to cusp flexure. This
flexure results in damage to the enamel rods at the gum line
resulting in their loosening and consequent flaking away of the
tooth structure. It is difficult to diagnose such lesions properly,
but generally, in cases where a deep v-shaped cervical notch is
present or when cervical restorations are repeatedly lost, the
practitioner should look for wear facets or other signs of occlusal
trauma.14
Conclusion: Gingival recessions followed by attrition were the most
commonly found etiological factors leading to dentin
hypersensitivity. Erosive lesions were mostly associated with
dentin hypersensitivity. A statistically significant relationship
exists between dentin hypersensitivity, tooth wear lesions, and
gingival recession.
Clinical Significance: This study provides clinical evidence
supporting the notion of dentin hypersensitivity being a tooth wear
phenomenon. Therefore, successful preventive and management
strategies for sufferers of dentin hypersensitivity must take into
consideration causal factors for tooth wear and gingival
recession.
Keywords: Etiological factors, dentin hypersensitivity, tooth wear,
gingival recession
Citation: Bamise CT, Olusile AO, Oginni AO. An Analysis of the
Etiological and Predisposing Factors Related to Dentin
Hypersensitivity. J Contemp Dent Pract 2008 July;
(9)5:052-059.
3 The Journal of Contemporary Dental Practice, Volume 9, No. 5,
July 1, 2008
included the consumption of orange juice, carbonated beverages, and
chewable vitamin C. The type of toothbrush, toothbrushing
technique, and handedness of the patient were noted.
A past medical history was taken to ascertain any underlying
systemic conditions such as diabetes mellitus, hypertension, blood
dyscrasias, allergies, bronchial asthma, hiatus hernia,
astroesophageal reflux disease (GERD), pregnancy, and current
medications.
Intraorally, all remaining teeth were examined with their numbers,
position, mobility, and occlusal relations noted. Any evidence of
gingival recession, caries, attrition, erosion, abrasion,
abfraction, fractures, chipping, and dentin hypersensitivity were
also recorded. Teeth having caries, cracks or fractures, extensive
and unsatisfactory restorations, and mobility were excluded. The
suspected sites on the teeth were stimulated by an air-blast from
the air-water syringe of the dental unit and by scratching the
exposed area with a dental probe until the patient reported the
exact discomfort that precipitated their initial dental visit. All
the teeth with dentin hypersensitivity and surfaces involved were
recorded.
Frequencies and proportions were calculated. Associations between
discreet variables were tested using the Chi square test. In all
cases a p-value of less than 0.05 (p=<.05) was taken as
significant.
Results Patients who consumed orange juice either daily or at least
once a week had 29 (90.6%) teeth with erosive lesions. Patients who
consumed carbonated cola drinks daily or at least once a week had
16 (50%) teeth with erosive lesions. In patients who took chewable
vitamin C daily or at least once a week had 13 (40.6%) teeth with
erosive lesions.
Patients who claimed to use a hard bristle toothbrush had 45
(38.5%) teeth with gingival recession and 27 (40.3%) teeth with
abrasion. Patients who used a soft bristle toothbrush had six
(5.1%) teeth with gingival recession and two (3%) teeth with
abrasion. Patients who used toothbrushes indiscriminately had 66
(56.4%)
Gingival recession and subsequent root surface exposure allow more
rapid and extensive exposure of dentinal tubules because the
cementum layer overlying the root surface is thin and can be easily
removed.15
Dentin hypersensitivity has also been described as the most common
side effect of tooth whitening.16,17 Other causative factors which
seldom act in isolation include bruxing, side effects of
medication, aging, genetic conditions, and periodontal disease or
procedures.18
There is very little direct clinical evidence of the association of
these suggested etiological factors with dentin hypersensitivity.
The purpose of this study was to determine the prevalence of the
etiological and predisposing factors of hypersensitivity and their
associations with sufferers of this condition.
Methods and Materials This study was conducted in the Conservative
Dentistry unit of the Obafemi Awolowo University Teaching Hospital
complex in Ile Ife, Nigeria over a 12 month period. A total of 29
patients (17 males, 12 females) suffering from dentin
hypersensitivity referred from the Oral Diagnosis department were
recruited to participate in the study. The study protocol was
approved by the Ethics Committee of the Hospital and informed
consent from all the patients was obtained prior to data
collection.
Dentin hypersensitivity was diagnosed by intraoral testing done by
the principal investigator (PI) and confirmed by at least one other
investigator. A detailed relevant history was taken, which
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hypersensitivity. The upper right quadrant had the highest number
of attrited teeth.
Sixty-seven teeth had cervical abrasion with the upper left
quadrant having the highest number of teeth affected, which was
statistically significant different from the upper right quadrant.
Forty (59.7%) teeth had sensitive abrasive lesions.
Twenty-five teeth with abfractions were seen with the upper left
quadrant having the highest number of teeth affected. Sixteen (64%)
teeth with abfraction had related dentin hypersensitivity.
Thirty-two teeth had erosive lesions with all of them having
associated dentin hypersensitivity. The upper left quadrant had the
highest number of teeth with erosion. Erosive lesions had a 45%
predilection for buccal/labial surfaces, 37% for occlusal surfaces,
and 6% for palatal/lingual surfaces (Figure 1).
There was a statistically significant relationship of dentin
hypersensitivity with gingival recession and tooth wear (p=0.05,
Chi square test).
teeth with gingival recession and 38 (56.7%) teeth with
abrasion.
Sixty-five (97%) teeth showing abrasion were found in patients who
cleaned their teeth with a toothbrush and toothpaste. Patients who
used a toothbrush and toothpaste plus a chewing stick had two (3%)
teeth with abrasion. None of the patients used a chewing stick
alone.
All patients were right-handed. The left side of the mouth showed a
preponderance of gingival recession, abrasion, abfraction, and
erosion while more teeth on the right side showed attrition (Table
1).
Tables 1 and 2 show 911 teeth from 29 patients who participated in
the study. A total of 117 teeth had gingival recession with the
upper left quadrant having the highest number of teeth affected.
Forty-three (36.8%) teeth had dentin hypersensitivity related to
the gingival recession.
Ninety-nine teeth had attrited surfaces out of which 41 (41.4%) had
an associated dentin
Table 1. Quadrants and right and left-sided distributions of
gingival recession, attrition, abrasion, abfraction, and
erosion.
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July 1, 2008
it and for the clinicians providing treatment. Understanding the
burden of the various predisposing factors and recognizing the
degree of their association are an integral part of total patient
care. The aim of the present study was to provide more information
on these factors.
Since only 29 patients were recruited to participate in the study
it suffers a limitation. This
Gingival recession and attrition were predominantly found among
molars; abrasive lesions among molars and premolars; abfraction
among premolars; while erosive lesions were predominantly found
among incisors (Table 2).
Discussion Dentin hypersensitivity is a problem posing a number of
challenges for those who suffer from
Table 2. Distribution of gingival recession, attrition, abrasion,
abfraction, erosion, and their involvement in dentin
hypersensitivity.
Figure 1. Predilection of erosive lesions for tooth surfaces.
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with toothpaste has been considered to be a prime etiological agent
in both abrasive tooth wear and gingival recession.22 Levitch, et
al.23 reported the association of toothbrushing with tooth wear
exists in subjects who brush their teeth frequently for a longer
period and use a scrubbing technique.
Interaction of these factors might have contributed to the high
percentage of cervical abrasion lesions and gingival recessions
found in subjects using a hard bristle toothbrush and those who
used toothbrushes indiscriminately. This agrees with the findings
of Bradley et al.20 and Goutoudi et al.24
where hard toothbrush use has been implicated in gingival recession
and abrasion as is dentin hypersensitivity.
Use of a chewing stick has been mentioned as a cause of tooth wear
in the dental literature25 and gingival recession.26 Such a
correlation could not be ascertained in this study because none of
the subjects in the study used a chewing stick alone.
The preponderant finding of attrition in molars/ premolars can
possibly be explained by the high fibrous, coarse, or gritty diet
common in the Nigerian environment. This result is also similar to
the findings of previous studies among Nigerians. Kumar and Ana,27
in their study of prevalence of attrition in two Nigerian rural
areas, reported attrition is marked in molars. Mandibular molars
and first molars were said to be the most attrited teeth, and they
suggested the differential diagnoses of attrition be considered for
pain in the mouth. Oginni et al.28 reported attrition to be the
most prevalent form of tooth wear occurring mostly on the posterior
teeth that bear the brunt of masticatory forces.29 Attrition occurs
due to tooth- to-tooth contact during function30 and it is said to
be commonly seen in the developing countries and in the
elderly.31
The premolars and canines were the most affected by abrasion in
this study. Addy et al.32 had a similar result due to the position
of these teeth within the dental arch where they receive the most
attention during cleaning.
Abfractive lesions were predominantly seen among the posterior
teeth on the left side and in the upper left quadrants. This is
consistent with the result of an earlier study done in the same
hospital.28
could probably be explained by the low prevalence of teeth
responding positively to the objective diagnosis of dentin
hypersensitivity. This was also evident by a significant percentage
of tooth wear lesions with exposed dentin surfaces which were not
sensitive as observed in the study.
The cause of dentin hypersensitivity is attributed to exposed
dentinal tubules found in areas where tooth structure has been
lost. There are potentially numerous and varied etiological and
predisposing factors of dentin hypersensitivity, certainly no prime
cause has been identified.2
During the diagnosis of dentin hypersensitivity and identification
of associated etiological factors for this study, the dominant
factors were identified by their characteristic appearance and
recorded. The wear of an individual’s teeth rarely results from a
single cause although one is likely to predominate. This limitation
was envisaged during the diagnosis; hence, there was inter-examiner
agreement (the PI and at least one other investigator) in the
identification of the dominant cause.
The results indicated patients consuming orange juice and
carbonated cola beverages had the highest number of tooth surface
loss. This is similar to the result of a study by Addy et
al.19
where they demonstrated citrus fruit juices were capable of rapidly
dissolving the dentin smear layer within a few minutes and
carbonated cola drink was less erosive.
Toothbrush characteristics, i.e., hard toothbrush20
and toothbrushing techniques, are major variables in hard and soft
tissue damage.21
Since toothbrushing is usually performed with toothpaste, incorrect
or vigorous toothbrushing
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July 1, 2008
that dentin hypersensitivity shows a predilection for certain oral
sites that may be of etiological relevance. It is not surprising
incisors were mostly affected by erosion, canines and premolars
were preponderantly involved in gingival recession and abrasion.
Molars were observed as the most attrited teeth.
The dental management of patients where such factors, i.e., tooth
wear and gingival recession are overwhelming has proven difficult
for clinicians for many years, and the problem seems to be
increasing because the population is retaining more natural teeth
into old age.38 An increased understanding of the relationship of
these entities with dentin hypersensitivity is essential to its
prevention and effective management.
Conclusion Within the limitations of this study, the prevalence and
distribution of the different etiological factors of dentin
hypersensitivity in patients that presented with pain due to dentin
hypersensitivity were obtained. Gingival recession followed by
attrition were the most common etiological factors found while
erosive lesions showed the most frequent association with dentin
hypersensitivity. A statistically significant relationship exists
between dentin hypersensitivity, tooth wear lesions, and gingival
recession. There is still a need to conduct further studies to know
the prevalence of tooth wear lesions and gingival recession in the
general population.
Clinical Significance The etiology of dentin hypersensitivity is
poorly understood. This study provides clinical evidence supporting
the notion of dentin hypersensitivity being a tooth wear
phenomenon. Therefore, successful preventive and management
strategies for sufferers of dentin hypersensitivity must take into
consideration causal factors for tooth wear and gingival
recession.
The incisors and canines were predominantly affected by erosion.
Smooth surfaces of anterior teeth have been shown to be
particularly vulnerable to attack by acids during the consumption
of acidic beverages which may cause erosion of tooth tissue.33 Most
of the erosive lesions in the present study can be attributed to
dietary erosion because none of the patients had a history of
intrinsic acid production or occupational exposure to acids. Also,
a significant relationship was observed between patients with a
history of dietary acid ingestion and tooth erosion.
Some examined teeth had gingival recession, abrasions, abfractions,
and attrited lesions that were not sensitive. Absi et al.34 stated
not all exposed dentin is sensitive and in areas of sensitive
dentin the number of tubules open at the surface was approximately
eight times that of non- sensitive dentin. Furthermore, they
indicated the mean diameter of open tubules in sensitive dentin was
twice those as in non-sensitive dentin. They concluded the more
open dentinal tubules there are on the surface and the greater the
diameter, the greater the propensity for tubular fluid flow with a
given stimulus.
A similar distribution of gingival recession and abrasion was found
in the present study. The upper left quadrant had the highest
number of teeth with gingival recession and abrasion. These
conditions along with dentin hypersensitivity have been shown to be
more common on the left than on the right side of the dental
arches.35 Addy4 then suggested such findings showed toothbrushing
is associated with dentin hypersensitivity. This is supported by
the fact all the patients in this study were right handed and right
handed brushers are known to brush the left buccal surfaces more
effectively than on right side.32,36
Generally, low percentages of the etiological and predisposing
factors were observed but their distributions agree with the
summation of Addy37 in
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