14/10/2015 22:23 © Author / Presentation ReferenceSlide 1 Dentine Hypersensitivity.
Transcript of 14/10/2015 22:23 © Author / Presentation ReferenceSlide 1 Dentine Hypersensitivity.
21/04/23 06:09 © Author / Presentation ReferenceSlide 1
Dentine Hypersensitivity
21/04/23 06:09 © Author / Presentation ReferenceSlide 2
Introduction
Besides being an extremely uncomfortable disturbance for the patient, dentine hypersensitivity is difficult for the dentist to diagnose and solve as it is a physiological phenomenon of high complexity.
21/04/23 06:09 © Author / Presentation ReferenceSlide 3
Definition
“a short, sharp transient pain, arising from exposed dentine in response to thermal, chemical or osmotic stimuli”
21/04/23 06:09 © Author / Presentation ReferenceSlide 4
Dentine exposed by either
• Loss of enamel covering crown (attrition, erosion)
• Gingival recession with exposure of root surface and loss of cementum
21/04/23 06:09 © Author / Presentation ReferenceSlide 5
Causes: Attrition - excessive tooth contact
Erosion - acidic drinks
Loss of tooth enamel with exposure of underlying dentine
21/04/23 06:09 © Author / Presentation ReferenceSlide 6
Etiology – Loss of enamel with exposure of underlying dentin
• Abrasion
• Attrition
• Abfraction
• Erosion
• Fracture
• Enamel is resistant to tooth-brushing, but acid softened enamel is highly susceptible to brushing abrasion*
• “Abrasive” toothpastes may produce a smear layer, thereby reducing sensitivity**
*Davis and Winter, Br. Dent J, 1980, **Adams et al, Oxford U. Press, 1992
21/04/23 06:09 © Author / Presentation ReferenceSlide 7
Localised Generalised
Gingival recession with exposure of root surface and loss of cementum
21/04/23 06:09 © Author / Presentation ReferenceSlide 8
Etiology – Gingival recession with exposure of root surface and loss of cementum
• Incorrect tooth-brushing or flossing• Secondary to specific diseases – periodontitis, necrotising-ulcerative gingivitis (NUG)• Periodontal procedures• Age• Gingival trauma (picking, hard foods)• Crown preparation
Localised
Generalised
21/04/23 06:09 © Author / Presentation ReferenceSlide 9
In 93% of instances pain involves root surfaces exposed as result of gingival recession
The focus of this presentation will be dentine hypersensitivity associated with gingival recession (exposure of the neck of
tooth)
21/04/23 06:09 © Author / Presentation ReferenceSlide 10
Enamel
Dentine
Pulp
Root cementum
Healthy tooth
21/04/23 06:09 © Author / Presentation ReferenceSlide 11
Gingival recession
21/04/23 06:09 © Author / Presentation ReferenceSlide 12
Teeth most commonly affected by recession and hypersensitivity
• Incisors 26%
• Canines 25%
• Premolars 38%
• Molars 12%
21/04/23 06:09 © Author / Presentation ReferenceSlide 13
Patients report sensitivity to:
• Thermal stimulus (cold) 75%
• Tactile stimulus 25%
• Osmotic stimulus (sweet) 16%
21/04/23 06:09 © Author / Presentation ReferenceSlide 14
cold
Heat
Movement of fluid in the
tubules
Movement of fluid in the
tubules
Odontoblasts
Exposed root dentine
Hydrodynamic theory
Tubules exposed at
dentine surface
21/04/23 06:09 © Author / Presentation ReferenceSlide 15
Brain
Fluid movement
Nerve receptors
Hydrodynamic theory
21/04/23 06:09 © Author / Presentation ReferenceSlide 16
Non-sensitive SensitiveNo of open tubules x 8 xDiameter of tubules 0.43 0.83Fluid Flow (Poisseuille’s law) y 16 y
*Absi et al, J Clin Periodont 1987; pictures from http://www.thejcdp.com, Sept 2006
Structural differences between sensitive and non-sensitive dentin*
21/04/23 06:09 © Author / Presentation ReferenceSlide 17
Exposure of root surface and root dentine can occur as a result of:
• Abrasion - toothbrushing
• Periodontal disease
• Periodontal treatment
21/04/23 06:09 © Author / Presentation ReferenceSlide 18
Abrasion
21/04/23 06:09 © Author / Presentation ReferenceSlide 19
Abrasion
21/04/23 06:09 © Author / Presentation ReferenceSlide 20
Abrasion and acid erosion
21/04/23 06:09 © Author / Presentation ReferenceSlide 21
Exposure of root surface and root dentine can occur as a result of:
• Abrasion - toothbrushing
• Periodontal disease
• Periodontal treatment
21/04/23 06:09 © Author / Presentation ReferenceSlide 22
Peridontal disease
21/04/23 06:09 © Author / Presentation ReferenceSlide 23
Exposure of root surface and root dentine can occur as a result of:
• Abrasion - toothbrushing
• Periodontal disease
• Periodontal treatment
21/04/23 06:09 © Author / Presentation ReferenceSlide 24
Root sensitivity following periodontal therapy
Fischer et al. (1991)
9% patients sensitive before treatment
55% patients sensitive 1 week after
Tammaro et al. (2000)
23% sensitive before treatment
54% sensitive 1 week after treatment
21/04/23 06:09 © Author / Presentation ReferenceSlide 25
Periodontal treatment
21/04/23 06:09 © Author / Presentation ReferenceSlide 26
Treatment Principles:Two Mechanisms
• Tubule occlusion
• Inhibition of sensory nerve activity
21/04/23 06:09 © Author / Presentation ReferenceSlide 27
Treatment principles:two mechanisms
• Tubule occlusion
• Inhibition of sensory nerve activity
21/04/23 06:09 © Author / Presentation ReferenceSlide 28
Stimulation ofnerve endingsPAIN
Stimulus
Fluid movement
Dentinal tubule
Hydrodynamic theory
Odontoblast
21/04/23 06:09 © Author / Presentation ReferenceSlide 29
Occlusion
Tubule OcclusionOpen Tubule
21/04/23 06:09 © Author / Presentation ReferenceSlide 30
Tubule occlusion
Measures type of productStannous Fluoride Toothpaste, Gel
RinseHigh fluoride Varnish, Gels
Precipitating salts Calcium phosphateSilicatesHydroxyapatite
Restorative materials AdhesivesResins
Laser Softlaser
21/04/23 06:09 © Author / Presentation ReferenceSlide 31
Home care treatment: SnF2 Gel (Gel-Kam)
Abstract:
• 18 subjects
• Eight weeks, double blind, placebo controlled clinical study
• Treatment of dentinal hypersensitivity
• Thermal stimulus
Blong MA et al. Dental Hygiene, November 1985; 489-92
21/04/23 06:09 © Author / Presentation ReferenceSlide 32
Home care treatment: SnF2 Gel (Gel-Kam)
Results:
• After 4 and 8 weeks treatment subjects in the Gel-Kam group experience a significant higher resistance against low temperatures than the placebo group.
Blong MA et al. Dental Hygiene, November 1985; 489-92
Thermal Threshold Measures
60
65
70
75
80
Baseline 2 weeks 4 weeks 8 weeks
Assessment intervals
Deg
rees
Fah
ren
hei
tGel-Kam Control
21/04/23 06:09 © Author / Presentation ReferenceSlide 33
In office treatment: High fluoride varnish (Duraphat)
Abstract:
• 59 subjects
• Two / four weeks, examiner blind, positive controlled clinical study
• Treatment of dentinal hypersensitivity
• Heat, cold, touch and air-blast stimuli
Papas AS et al. J Dent Res 71 (Special Issue); 28, 1992
21/04/23 06:09 © Author / Presentation ReferenceSlide 34
In office treatment: High fluoride varnish (Duraphat)
Results:
• Pain relief after a single varnish treatment
• Almost no pain felt (air-blast stimulus) after 3 treatments
• For positive control 1.500 ppm MFP Gel 1 month of treatment needed for some relief
Papas AS et al. J Dent Res 71 (Special Issue); 28, 1992
21/04/23 06:09 © Author / Presentation ReferenceSlide 35
Duraphat varnish
21/04/23 06:09 © Author / Presentation ReferenceSlide 36
Treatment
• Tubule occlusion
• Inhibition of sensory nerve activity
21/04/23 06:09 © Author / Presentation ReferenceSlide 37
Inhibition of sensory nerve activity
• Potassium salts
21/04/23 06:09 © Author / Presentation ReferenceSlide 38
Typical structure of a neuron
nucleusMyelin sheath
Ranvier‘s node
Schwann‘s cell
Desensitizing of nerves
21/04/23 06:09 © Author / Presentation ReferenceSlide 39
Resting potential at neuronal membranes
• K+ gradient from inside to outside
• K+ diffuses from inside to outside along the gradient
21/04/23 06:09 © Author / Presentation ReferenceSlide 40
Action potential
• Changes in the membrane lead to an influx of Na+ and an increased efflux of K+ which leads to a depolarisation of the membrane realized as pain
++
++
++
Number of open Na+ channels
Number of open Na+ channels
DepolarisationDepolarisation
Influx of Na+ ionsInflux of Na+ ions
21/04/23 06:09 © Author / Presentation ReferenceSlide 41
Desensitization through buffering the membrane potential with K+
K+
K+
K+ K+
K+ K+
K+K+
K+
Potassium ions
Pain receptor
Pain receptor
Reduced nerve stimulation
Reduced nerve stimulation
• Increased K+ concentration at the outside of membranes decrease the diffusion of K+, thus stabilizing the membrane potential
21/04/23 06:09 © Author / Presentation ReferenceSlide 42
Desensitising efficacy of dentifrices containing potassium nitrate
Abstract:
• 68 subjects
• 12-week, double-blind, three-way parallel comparative study
• Treatment of dental hypersensitivity
• Cold air and tactile stimuli
Silverman G et al. 1985
21/04/23 06:09 © Author / Presentation ReferenceSlide 43
Desensitising efficacy of dentifrices containing potassium nitrate
Results:
• Dentifrices containing potassium nitrate were significantly more effective in reducing discomfort caused by tactile and thermal stimuli than placebo
Silverman G et al. 1985
0
0.5
1
1.5
2
2.5
Baseline 4 weeks 12weeks
Mea
n c
old
air
sco
res
Potassium Nitrate Control
21/04/23 06:09 © Author / Presentation ReferenceSlide 44
Desensitising efficacy of dentifrices containing potassium salts
Abstract:
• 80 subjects
• Examinations at 4 and 8 weeks
• Tactile and air-blast stimuli
Hu et al. 2004
21/04/23 06:09 © Author / Presentation ReferenceSlide 45
Desensitising efficacy of dentifrices containing potassium salts
Double-blind design, 80 participants
Results: Tactile stimulus
Hu et al. 2004
Groups BL 4W 8W
Sensodyne F 19.75 29.92* 35.13*
Colgate Sensitive 19.19 29.29* 34.88*
21/04/23 06:09 © Author / Presentation ReferenceSlide 46
Desensitising Efficacy of Dentifrices containing potassium salts
Double-blind design, 80 participants
Results: Air Blast
Hu et al. 2004
Groups BL 4W 8W
Sensodyne F 2.50 1.74 1.31
Colgate Sensitive 2.53 1.80 1.33
21/04/23 06:09 © Author / Presentation ReferenceSlide 47
Desensitising therapies – treatment options
At Home Treatments In Office TreatmentsPreventive Measures
21/04/23 06:09 © Author / Presentation ReferenceSlide 48
Treatment options
1. Eliminate aetiological and predisposing factors, such as acid foods and traumatic toothbrushing
2. Advise the use of a toothpaste that either occludes the tubules or reduces the responsiveness of the nerves together with a soft toothbrush
3. In severe cases: additional professional application of fluoride varnish and / or at home application of stannous fluoride or high fluoride gels
21/04/23 06:09 © Author / Presentation ReferenceSlide 49
Preventive Measures
• Often underestimated by dental professionals*:
• Use proper brushing and flossing technique
• Avoid brushing of acid eroded enamel (brush no earlier than 2-3 hours after consuming acidic foods or drinks)
• Diet hygiene, avoiding exogenous acids (fruits, fruit juice, soft drinks, wine)
• Treatment of diseases that associate regurgitation, or severe vomiting (gastric acid reflux, nervous bulimia)
*Rees et al, J Dent 2003
21/04/23 06:09 © Author / Presentation ReferenceSlide 50
CONCLUSIONS
• Dentinal hypersensitivity is a common condition.
• Professional diagnosis is essential to eliminate other possible causes of pain
• Treatment possibilities are based on – Tubule occlusion
– Desensitizing of nerves
• Treatment options should be based on the severity – Mild and medium : Home maintenance
(Sensitive toothpaste plus soft toothbrush) Home treatment (Fluoride Gels)
– Medium to severe: Acute in-office treatment (Varnish) plus additional at home treatment (fluoride gels) and
maintenance
21/04/23 06:09 © Author / Presentation ReferenceSlide 51
Back-up
21/04/23 06:09 © Author / Presentation ReferenceSlide 52
Acknowledgements
This lecture has been prepared by Prof. Robin Davies (DHU Manchester, UK) Irina Tarba (Professional Relations Manager, Colgate Romania) and Michael Warncke, (Professional Relations Manager, Colgate Germany)
© Scientific Affairs, Colgate Europe / South Pacific, Geneva, Switzerland