Republic of Iraq

Ministry of Higher
Education

and Scientific Research

University of Baghdad

College of Dentistry

Tooth Hypersensitivity
A Project Submitted to

The College of Dentistry, University of Baghdad, Department of Operative

Dentistry

in Partial Fulfillment for the Bachelor of Dental Surgery

By

Nabaa Abdul Rida Hammood

Supervised by
Dr. Bashair Abdul Sahib

March, 2023

I
 Certification of the Supervisor

I certify that this project entitled " Tooth Hypersensitivity"

was prepared by the fifth-year student Nabaa Abdul Rida Hammood under
my supervision

at the College of Dentistry/University of Baghdad in partial fulfilment of the

graduation

requirements for the Bachelor Degree in Dentistry.

Supervisor‟s name

Dr. Bashair Abdul Sahib

Date

II
Dedication

This review is dedicated to my supporting family and loving friends who

were with me through thick and thin.

III
Acknowledgement

This review was not possible if it weren‟t for the support and guidance of
my supervisor Dr. Bashair Abdul Sahib.

IV
Table of Contents
Number Name Page
List of Figures VI

List of Abbreviations VII

Introduction 1
Aims of Review 2

1.1. Etiology 4-8

1.2. Chapter One: Pathogenesis 8-10

Review of
1.3. Epidemiology 11
Literature
1.4. Effects 11-12
1.5. Diagnosis 12
1.6. Management 13-18

Chapter Two: Conclusion and

2 19-20
Suggestions

V
List of Figures
Number Name Page
Patient with exposed cervical dentin
1.1 surfaces and signs of erosion. 5
(Abuzinadah et al, 2021)

The schematic picture of the propped

theories on DH
A. Direct Innervation (DI) Theory
1.2 7
B. Odontoblast Receptor (OR) Theory
C. Fluid Movement/Hydrodynamic
Theory (Davari et al, 2013)

VI
List of Abbreviations

Abbreviations Meaning
dentin
DH
hypersensitivity
scanning electron
SEM
microscope
DI direct innervation
odontoblast
OR
receptor
dentinoenamel
DEJ
junction
cervical dentinal
CDS
sensitivity
relative dentin
RDA
abrasivity
OTC over-the-counter
Casein
phosphopeptide-
CPP-ACP
amorphous calcium
phosphate
CO2 carbon dioxide

VII
Introduction

Different terms have been used to describe dentin hypersensitivity.

These terms are used based on the place of occurrence of hypersensitivity
and include: cervical, root, dentine, cemental, and the terms sensitivity, and
hypersensitivity. All of these terms convey the same clinical conception and
can be used interchangeably. (Davari et al, 2013)

Dentin hypersensitivity can be defined as a short, sharp pain that

arises from exposed dentin in response to stimuli (typically thermal,
evaporative, tactile, osmotic or chemical) and that cannot be ascribed to any
other form of dental defect or pathology.

Conditions that should be ruled out include dental caries, pulpitis,

fractured teeth, fractured restorations, post-restorative sensitivity, marginal
leakage, chipped teeth and gingival inflammation. Dentin hypersensitivity is,
therefore, a diagnosis of exclusion.

The problem appeared to be intermittent, affecting most participants

“occasionally” and few participants “always”. (Cunha-Cruz et al, 2013)

1
Aims of Review

 to provide a brief overview of the diagnosis, etiology and clinical

management of dentin hypersensitivity
 to discuss technical approaches to relieve sensitivity

2
Chapter One:
Review of
Literature

3
Chapter One: Review of Literature

1.1. Etiology

Patients have reported that pain was initiated mainly by cold drinks
but also by hot drinks, toothbrushing and sweet foods.

Dentin tubules may become exposed as a result of enamel loss from

attrition, abrasion, erosion (acid dissolution) or abfraction (cervical stress
lesion), but dentin exposure often may be a result of gingival recession and
cementum loss from root surfaces, most frequently in canines and
premolars. The enamel and cementum loss may be visible clinically as non-
carious cervical lesions. A diet rich in acidic liquids and foods, occupational
exposure to acids, use of tooth-whitening agents and gastric reflux have been
implicated as causes of dental erosion. Aggressive or frequent
toothbrushing and periodontal treatment (such as scaling and root planing)
may contribute to gingival recession, cementum loss and subsequent dentin
exposure. (Cunha-Cruz et al, 2013)

DH is multifactorial, wherein more than one causative factor always

plays a role, either directly or indirectly. (Haneet et al, 2016)

Investigators in studies conducted in general dental practices have

reported that the prevalence were 52 percent, 42.4 percent, 40.3 percent, 15
percent, 25 percent, 4.1 percent, 3.8 percent and 1.3 percent. The reason for
this wide range of prevalence might be explained by how dentin
hypersensitivity was estimated, by means of self-reports or questionnaires,
which can provide a higher prevalence than that estimated by means of a
specific clinical examination.

4
 Patients tried at-home treatments for dentin hypersensitivity, but most
reported that the treatment had no effect or that relief lasted less than six
weeks.

At-home and in-office treatments are more often than not ineffective
in eliminating pain caused by this condition in the long term. (Cunha-Cruz
et al, 2013)

Periodontal disease can be considered as a risk factor or a cause of

dentinal hypersensitivity as it involves gingival recession and therefore is
associated with dentin exposure. A study performed on an adult and elderly
population in Brazil stated that a reduction in the prevalence of tooth
sensitivity may be accomplished by periodontal health improvements.
(Costa et al, 2014)

Improper tooth brushing includes using hard- or thick-bristle tooth

brushes, brushing teeth with excessive pressure, excessive scrubbing at
cervical areas or even missing to brush cervical areas. (Davari et al, 2013)

Traumatic toothbrushing in an otherwise healthy dentition is often

undiagnosed in adolescents and young adults. Subclinical soft- and hard-
tissue abrasion lesions are probably a precursor of gingival recession and
tooth wear, and thus DH. (Pashley, 2008)

Chrysanthakopoulos reported that the horizontal brushing method,

performed once daily with a toothbrush with medium-hardness bristles, is
associated with gingival recession, one of the etiological factors for DH.
(Chrysanthakopoulos, 2011)

5
 The most brushed teeth with the lowest plaque scores exhibit the most
gingival recession. This has led to the description of gingival recession/DH
as „toothbrush disease‟. (Pashley, 2008)

In a study published by Fukumoto et al., teeth devoid of plaque were

more hypersensitive than teeth with plaque accumulation. This statement
was disputed by another work that found a significant association between
high plaque accumulation and gingival recession. (Fukumoto et al, 2014)
(Toker et al, 2009)

Plaque accumulation on tooth surfaces may lead to demineralization

of tooth structures, which could be associated with patency of dentinal
tubule orifices. (Kawasaki et al, 2001)

Facial piercings are strongly correlated with the prevalence of

recession. (Clark et al, 2016)

Individuals who may be at risk for dentin hypersensitivity such as:

(Davari et al, 2013)

 Overenthusiastic brushers

 Periodontal treated patients

 Bulimics

 People with xerostomia

 High-acid food/drink consumers

 Older people exhibiting gingival recession

6
  Chewing „smokeless‟ or „snuff‟ tobacco

Figure 1.1 Patient with exposed cervical dentin surfaces and signs of
erosion. (Abuzinadah et al, 2021)

Periodontal surgery is not a risk-free procedure and should not serve

as the first line of treatment for tooth hypersensitivity. Periodontal surgery
should be the last resort for the resolution of tooth hypersensitivity and used
only when other, less invasive, methods were unsuccessful as long as there
is no other indication for tooth coverage. Only after all the above non-
invasive and less-invasive methods have failed to reduce the symptoms
should the root-coverage option be considered. (Clark et al, 2016)

There is insufficient research to establish whether scaling and root

planing procedures had any impact on tooth hypersensitivity and, as a result,
more research needs to be performed before making recommendations

7
specific to the correlation of periodontal disease and dentinal
hypersensitivity. (Draenert et al, 2013)

1.2. Pathogenesis

As it is known, dentin is covered by enamel in the crown surface and

by a thin layer of cementum in the root surface of the tooth. Dentin is
sensitive to stimuli due to the lesion extension of odontoblastic process and
formation of dentin-pulp complex. (Davari et al, 2013)

Dentin and pulp are histologically different. However, they have the
same embryonic origin; ecto-mesenchymal origin. The formation of dentin-
pulp causes dentin to be affected by pulp and vice versa. Dentin has very
minute tubules which are filled with odontoblastic process. The processes
are also surrounded by dentinal fluid which forms about 22% of the total
volume of dentin. The fluid is completely filtrated and originates from the
blood vessels of the pulp.

Dentin‟s sensitivity to stimuli does not lead to any problem while it is

covered with protective tissues; enamel and cementum. The results of
scanning electron microscope (SEM) indicate that the number of tubules in
sensitive dentin is eight times more than the number of tubules in non-
sensitive dentin. Furthermore, tubules of sensitive dentin are thicker than
those in non-sensitive dentin.

It is worth noticing that not all the exposed dentins are sensitive.
However, their calcified smear layer, as compared to non-sensitive dentin, is
thin and this leads to an increase in the fluid movement and consequently the
pain response.

8
 For the exposed dentin to be sensitized, the tubular plugs and the
smear layer are removed and consequently, dentinal tubular and pulp are
exposed to the external environment. Plug and smear layer on the surface of
exposed dentine are composed of elements of protein and sediments which
are derived from salivary calcium phosphates and seal the dentinal tubules
inconsistently and transiently.

It seems that Microbial plaque is not a significant factor in triggering

DH. First, as mentioned previously, the canines and first premolars have the
greatest recession and sensitivity. The same teeth also reveal the lowest
buccal plaque scores. Secondly, teeth with DH are cleaned extremely by
patients suffering from the condition. This would suggest that plaque does
not produce dentin hypersensitivity itself nor does it act as a stimulus for

pain. (Davari et al, 2013)

Figure 2 The schematic picture of the propped theories on DH

A. Direct Innervation (DI) Theory

B. Odontoblast Receptor (OR) Theory

9
 C. Fluid Movement/Hydrodynamic Theory (Davari et al, 2013)

Regarding the first theory; DI, it has been reported that the nerve‟s
endings enter dentin through pulp and extends to DEJ and the mechanical
stimuli directly transmit the pain. However, there is little evidence to prove
this theory; firstly, because there is little evidence that can support the
existence of nerve in the superficial dentin; where dentin has the most
sensitivity; and secondly because the plexus of Rashkov do not become
mature until complete tooth eruption. However, the newly developed teeth
can be sensitive too.

In the OR theory, odontoblasts act as receptors of pain and transmit

signals to the pulpal nerves. But this theory has also been rejected since the
cellular matrix of odontoblasts is not capable of exciting and producing
neural impulses. Furthermore, no synopsis has been found between
odontoblasts and pulpal nerves.

Hydrodynamic Theory for sensitive dentine is the most widely

accepted theory for DH & has proposed based on the movement of the fluid
inside the dentinal tubules. The movement of fluid stimulates a baroreceptor
and leads to neural discharge. This process is similar to activating the neural
fibers around the hair by touching or pressing the hair. The movement of
fluid can be toward the inside of the pulp or the outside of dentin. Cooling,
drying, evaporation, and hypertonic chemical stimuli cause the dentinal fluid
to flow away from the dentin-pulp complex and lead to an increase in pain.
Heating causes the fluid to flow toward the pulp. (Davari et al, 2013)

10
1.3. Epidemiology

Patients with hypersensitivity were more likely to be younger, to be

female and to have a high prevalence of gingival recession and at-home
tooth whitening. (Cunha-Cruz et al, 2013)

Higher prevalence in females would probably be related to their dental

hygiene and dietary habits. (Davari et al, 2013)

The decrease in dentin hypersensitivity with increased age might be

explained by the continued deposition of dentin and subsequent pulp atrophy
of the teeth during the lifetime or even by tooth loss in people in the older
age group. The average participant had multiple teeth that were sensitive,
with sensitivity occurring more frequently in molars, premolars and incisors
than in canines. (Cunha-Cruz et al, 2013)

Other studies reported that the occurrence of DH in canines and

premolars is more than other teeth.

The buccal surface of the teeth has been reported to be more involved
with the disease than other places. (Davari et al, 2013)

he quality of life and enjoyment of daily activities are both impacted

by dentin hypersensitivity, and many patients are unaware that it is a
treatable illness. (Salam et al, 2023)

1.4. Effects

Dentin hypersensitivity can lead to both physical and psychological

problems for the patient. Furthermore, it can have a negative effect on the
11
quality of a person‟s life, especially with regards to dietary selection,
maintaining optimal dental hygiene, and beauty aspects.

It has been observed that some people with DH do not pursue

treatment of the disease. However, they may report it in a clinical visit to the
dentist. This is perhaps due to the fact that they do not consider DH as a
(specific) disease. (Davari et al, 2013)

1.5. Diagnosis

The often forgotten or neglected phase in the treatment of DH is the

diagnosis and eliminating or treating the main routs of DH.

There are two common methods to determine the intensity of DH.

One of them is through asking some questions from the patient and the other
is through clinical examination. The prevalence distribution of DH in the
first method is usually estimated higher than that of the second method.

The diagnosis of the disease starts through investigating the medical

history of the patient and examination. In investigating the medical history
some questions are asked about the time of the start of DH, the intensity of
the pain, the stability of the pain and the factors that reduce or increase the
intensification of the disease.

Some techniques such as pure air, pure water, and sounds are used in
order to reconstruct the stimulating factors and to determine the degree of
pain of the patient. Other diagnostic tests are as follows: palpitation for
diagnosing pulpitis or periodontal involvement, pushing a wood stick or
transillumination for diagnosing a fracture or cracked tooth. (Davari et al,
2013)

12
1.6. Management
Although DH is a prevalent disorder and one of the most annoying
diseases, the treatments which have been suggested for it are not sufficient
and very successful. (Davari et al, 2013)

Until recently, two approaches were used to cure cervical dentinal

sensitivity (CDS). The first is blocking the dentinal tubules, and the second
is intervening in the response of the mechanoreceptors. (Lin et al, 2013)

The patient should be taught the correct method of tooth brushing,

avoid the use of abrasive tooth pastes and avoid brushing at least for one
hour after consuming acid drinks or foods (due to agonist effect of acidic
erosion on tooth brush abrasion). (Davari et al, 2013)

Aggressive toothbrushing is considered to be the use of excessive

force with a hard-bristled toothbrush. A study published in 2013 indicated
that most cases of dentinal hypersensitivity studied involved patients who
were currently using a hard toothbrush. (Vijaya et al, 2013)

Sometimes through correction of occlusion or the use of an occlusal

splint, the problem can be easily resolved.

For gingival recession, the patient should see a periodontist for

consultation. Moreover, treatments such as graft or positioning flap might be
adopted.

The patient‟s diet should be monitored for a while, concerning the

quality and the frequency of consumption of acidic foods so that the
necessary recommendations can be offered to the patient.

13
 Patients with gastro-esophageal regurgitation and eating disorders are
recommended to be referred to their doctors for the underlying diseases.
(Davari et al, 2013)

Relative dentin abrasivity (RDA) is a method for measuring the

abrasiveness of certain ingredients in toothpastes on the dentin surface.
An in situ randomised trial published in 2012 determined that RDA was
directly related to dentin loss and concluded that patients with dentin
hypersensitivity should opt for a toothpaste with lower RDA. (West et al,
2012)

Classification of desensitizing agents:

1. At home: this mode is simple and reasonable and can be used in

treatment of many teeth. (Davari et al, 2013)

a. Tooth dentifrice and tooth pastes: tooth pastes are amongst the
most common over-the-counter (OTC) materials in
desensitizing. Potassium salts, present in toothpaste, move
along the dentinal tubules and through blocking the axonic
action of the intra-dental nerve fibers decrease the excitability
of the tooth. These tooth pastes should be used with soft-
bristled tooth brushes and the minimum amount of water so that
the tooth pastes would have their maximum positive effects.
Remineralizing tooth pastes which contained sodium fluoride
and calcium phosphates could reduce DH dramatically.
b. Mouthwashes and chewing gums

2. In office: This is a complicated and expensive mode which can be

used in treatment of a limited number of teeth. Theoretically, in-office
14
therapy of DH should lead to immediate relief of the pain. However,
practically, this might not be the case.

a. Potassium nitrate is available in two forms of aqueous solution

and adhesive gel. The number of potassium ions decrease when
they enter dentinal tubules and decrease the excitability of
nerves that transmit pain.
b. Fluorides precipitate calcium fluoride crystals inside dentinal
tubules, and thus decrease dentinal permeability. These crystals
are almost insoluble. Sodium fluoride with a 2 % concentration
is used in the office. The precipitate which is formed by sodium
fluoride can be removed by the saliva or mechanical scrubbing.
Therefore, acid has been added to the formula so that the
resultant acidulated sodium fluoride can form precipitates deep
in the tubules.
c. Oxalates can occlude dentinal tubules and reduce permeability
of dentine. The application of 28% potassium oxalate can lead
to the formation of calcium oxalate in the depth of dentinal
tubules. However, findings have indicated that the reduction of
dentin hypersensitivity induced by oxalate, remains for a short
time. To increase the effectiveness of oxalate, the surface of the
tooth can be etched. Potassium oxalate can lead to some
digestive disorders so it should not be used for a long term.
d. The composites can effectively seal dentinal tubules through
forming a hybrid layer. The old adhesives formed the hybrid
layer through removing the smear layer and etching the dentinal
surface so that deep resin tags could be formed. The new

15
 adhesives, however, act in a way that the smear layer will be
modified and incorporated into the hybrid layer.
e. Bioglass has been produced to stimulate bone formation. It is
employed to fill the osseous defects during periodontal
surgery. The application of bioglass causes the formation of an
apatite layer which further leads to the occlusion of dentinal
tubules.
f. CPP-ACP remineralizes the early lesions of enamel subsurface.
The manufacturing factory has claimed that the product can be
effective in prevention and treatment of DH.
g. The effect of laser on the treatment of DH is different and is
based on the type of laser and therapeutic parameters such as
the laser‟s length of beam; the amount of time spent on the use
of laser; and the intensity of laser. Mechanisms of action
include: occlusion through coagulation of the proteins of the
fluid inside the dentinal tubules, occlusion of tubules through
partial sub-melting, and discharging of internal tubular nerve.
This type of therapy is highly acceptable to patients because its
proper usage has no negative impacts. (Davari et al,
2013)Middle-output lasers, such as Nd:YAG, CO2 and
Er:YAG, work by occluding dentinal tubules (Sgolastra et al,
2011) and lower level output lasers, such as He-Ne and
GaAlAs, affect nerve activity.
h. Calcium Sodium Phospho-silicate is designed to stimulate the
remineralization of enamel and simultaneously it occludes
dentinal tubules. (Clark et al, 2016) When in the oral cavity,
sodium ions exchange with hydrogen ions, allowing the release
16
 of calcium and phosphate from the dentifrice. These minerals
deposit within the dentinal tubules until occlusion occurs.
(Chen et al, 2015)
i. Bonding agents are used for a variety of dental applications,
one of which is restorative dentistry. Bonding agents etch tooth
surfaces in order to provide an adhesive layer for the
application of a desired material. Another use for dentin
bonding agents, however, can be to treat hypersensitivity. Self-
etch bonding systems typically contain acidic ingredients that
condition the dentin, as well as monomers that combine on the
dentin, forming a hybrid layer. This layer provides a coating
over the dentin and significantly reduces hypersensitivity over a
4-week period. Two-step systems are thought to be even more
effective as they are proven to be less permeable and more
durable. (Pashley et al, 1978)

Other methods of management include

A. Cervical restorations: Covering exposed dentin seals tubules, thus

eliminating hypersensitivity symptoms. A study performed by
Laybovich et al. compared the treatment of a tissue graft versus a
Class V restoration in treating dentin hypersensitivity. Their results
indicated no significant difference in the reduction of sensitivity;
however, they found that patients preferred the tissue graft for
aesthetic reasons. (Leybovich et al, 2014) Glass ionomer material is
commonly used for cervical restorations as a result of its ability to
bond with the dentin and enamel whilst simultaneously releasing
fluoride. A study focusing on the longevity of glass ionomer

17
 restorations over a period of 13 years revealed that the restorations
sustained satisfactory qualities. Therefore, and because of its well-
known advantages, glass ionomer might be the restorative material
preferred for this treatment option for tooth hypersensitivity. (Gordan
et al, 2014)
B. Root canal treatment: endodontic treatment that involves the removal
of pulp and its replacement with gutta percha eliminates all sensory
feeling associated with that tooth. Dentinal hypersensitivity is not, and
should not be a reason or indication for, root canal treatment. More
often this procedure is performed to treat irreversible pulpitis and pulp
necrosis. (Veitz-Keenan et al, 2013) Although root canal therapy
would not be a first-line treatment, it is an option that might be
considered in extreme cases when no other option can relieve the
hypersensitivity. (Clark et al, 2016)
C. Tissue graft: Regarding sensitivity caused by exposed root surfaces, a
gingival graft may be desired to cover the exposed dentinal tubules. A
study performed in 2013 demonstrated a statistically significant
reduction of cervical dentinal hypersensitivity after treatment with a
coronally positioned flap and connective tissue graft. (Douglas de
Oliveira et al, 2013)

18
 Chapter
Two:
Conclusion
and
Suggestions

19
Chapter Two: Conclusion and Suggestions

A question specifically about sensitive teeth may generate more

positive responses than may a general question about ill effects of daily
activities such as drinking cold water.

With vague prevalence comes uncertainty in diagnosis, the

appropriate time to treat and how aggressive the treatment should be.

The treatment of dental hypersensitivity should be on a regular basis

and initiate with at-home therapy and then continue with complementary
therapies. It is recommended that follow-up visits should be organized for all
the patients after undergoing periodic treatments.

A systematic review focusing on the effectiveness of lasers in

treating dentinal hypersensitivity concluded that although lasers are
effective, the evidence is considered weak because of the strong placebo
effect.

To treat the condition properly, consider the patient‟s risk factors and
the initial cause of the sensitivity. When all the factors are considered, the
dental professional and patient can agree on a treatment plan based on the
desired outcome. As in any condition, begin by eliminating the causes and
then select the least invasive option that is believed to provide the desired
result.

20
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