ETIOLOGY AND CLINICAL IMPLICATION OF DENTINE HYPERSENSITIVITY Introduction : Relatively common cause of pain associated with teeth.

. An enigma, frequently encountered but ill understood : Suitability of term questionable. n most cases pain is initiated and persists only during the application of a suitable stimulus to the e!posed dentin surface, associated with many conditions including dental caries. "here is no evidence to indicate that #ypersensitive dentin differs in anyway from normal dentin or that specific pulpal changes occur. "erm $entine sensitivity may be more appropriate. Definition : $entin hypersensitivity may be defined as pain arising from e!posed dentine, typically in response to chemical, thermal, tactile or osmotic stimuli that cannot be e!plained as arising from any other form of dental defect or pathology. t is perhaps a symptom comple! rather than a true disease and results from stimulus transmission across e!posed dentine. %ther conditions which may produce some symptoms include: &hipped teeth 'ractured restorations Restorative treatments $ental caries (ndisplaced crac)ed cusps. *alatogingival grooves + other enamel invaginations. Histor :
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"ooth + dentin hypersensitivity is one of the oldest recorded complaints of discomfort to people. nspite of a considerable amount of research over the last -. years clinical management of dentin hypersensitivity still remains largely empirical because the physiologic mechanism remains ill defined and to some e!tent poorly understood. Mid !"t# Centur : $r. /ohn 0eill of *hiladelphia, postulated that $entin consists of hallow tubules filled with a fluid secreted by the pulp, and pressure applied without, by compressing the enamel and fluid of the tubules, affects the nervous pulp within, by sub1ecting the letter to a species of hydrostatic pressure, the amount of which can be measured. 2hatever reduces the thic)ness of the enamel or uncovers any portion of the dentin, increases the painful impression caused by e!ternal pressure. ,.. years later 3ramer proposed the #ydrodynamic theory as "he dentinal tubules contain fluid or semifluid materials and their walls are relatively rigid. *eripheral stimuli are transmitted to the pulp surface by movements of this column of semifluid material within the tubules. 2or) by 4raunstrom resulted in widespread and current acceptance of the hydrodynamic theory. T#e e$r% e$rs fro& 'C to ()t# centur : *ain in the teeth 5a6"ong treated by &hinese some 7... years ago by application of 8iao 9Shi believed to be 0iter or potassium nitrate. :gyptian papyous :bers, ;<=.. 4& to ,--. 4&>, described gingivitis, the pain associated with tooth erosion and tooth ache. Rhages an Arabian physician ?=- A$, first recogni@ed the pain associated with gum recession, which occurred mostly in older people, and observed that it may be a difficult ailment in some and simple in others. Suggested treatment with astringent salts.
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Aeeuwenhoc), shortly, after his invention of microscope described tooth canals in dentin. n ,B=?, he reported t is asserted that the tooth is formed from very narrow, transparent tubes si! or seven hundred of these pipes put together e!ceed not the thic)ness of one hair of a manCs beard. Did ,?B.Cs 'rancis presented view of fluid movement impinging on pulpal nerves and causing pain and supported the practice of using cavity liners to promote the development of secondary dentin for 4etter self protection. 'or serious sensitivity problems, he recommended a paste of arsenous acid, tannin and creosote. Aate ,??.Cs use of carboli@ed potash ;RobinsonCs Remedy> ;trituation of equal proportion of carbolic acid and potassium hydro!ide> came into widespread use for treating sensitivity of dentin. ;0o one had yet ascribed the effect to potassium ions until quite recently i.e. n ,E.. issue of 4ritish /ournal of $ental Sciences, a published report appeared by Alfred Fysi, stated that dental conaliculi are devoid of nervous substances, but that at inner boundary of dentine around the odontoblasts there is an abundant networ) of finest nerve fibers. #e proposed that movement of fluid in dental canuliculi in either direction results in a sensation of pain in the nerves interwoven with the odontoblasts. $rawing or movement of fluid away from pulp can be induced by salt, sugar, alcohol etc. #e also stated that when however the e!ternalportion of the contents of the tubuli is caused to coagulate albumen, such as by carbolic acid or formed of sublimate and thereby loses its mobility, then also the great sensibility disappears. Although Fysi was not the first to describe fluid movement in dentinal tubules, he was among the first to suggest relieving dentin sensitivity by coagulating its protein content.

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,st edition of a te!tboo) of dental pathology and therapeutics including pharmacology by #enry #. 4urchard in ,?E? provides a categori@ation of < approaches for controlling pain of hypersensitivity of dentin. ,. Administration of agents to lower the pain perceptive centers of the brain ;anesthetic and analgesic agents> 7. (se of agents to destroy or coagulate the dentinal protoplasm ;@inc chloride, silver nitrate, carbolic acid, mineral acids, concentrated al)alies and others>. <. (se of local anesthetic agents on the dentin ;essential oils, sedative al)aloids, morphine, atrophine, cocaine etc.> Suggestion was made for the use of an electric current to deliver medicaments more effectively. First #$%f of t*entiet# centur : "e!tboo) dental pathology and therapeutics, #enry 4urchard states "he e!posure of dentine to e!ternal agencies is so commonly followed by an increase in sensitivity that the condition requires description in itself. t is a general condition attendant upon abrasion, erosion and caries, and has a therapeutics of its own. "he nitrate of silver powerfully coagulates fibrillar protoplasm, forming albuminate of silver, which turns blac) upon e!posure to light. Subsequent use of sodium chloride reduces staining. *otassium carbonate in glycerin may be given to the patient for self treatment at home. Did ,E<.Cs, 7 important publications appeared that include &harles ' 4odec)er and :dward ApplebaumCs and second by Aouis . Frossman. 'irst was regarding active metabolism in the dentin. "heir conclusions were that there is an active e!change between the fluids of the dental pulp and the structure of the teeth. n young teeth, fluid flows readily
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from the pulp and provides the necessary calcium phosphorus and carbonate to carry on minerali@ation process. "he odontoblasts that line the pulp chamber and pulp canal are probably secretory cells. Residual fluid, depleted of salts, passes bac) through 0eumannCs sheath into the circumtubular space. 2hen caries threatens the tooth structure, a defensive mechanism occurs to put down a layer of secondary dentin to help protect the pulp. n young teeth, this process is not yet well developed, and the carious process proceeds rapidly to involve the pulp. 7nd publication by Aouis . Frossman ,E<- gave a comprehensive summary of causes of hypersensitive dentin and the methods used to treat it. According to him, hypersensitiveness in dentin describes an uncommonly sensitive or painful response of the e!posed dentin to an irritation. "his includes dentin e!posed by caries, attrition, abrasion or erosion, by failure of the enamel to meet the cementum and by mar)ed atrophy of the alveolar process, e!posing both dentin and cementum. &hemical stimuli that affect hypersensitive dentine include citrus fruits, berries, acid food stuffs such as tomatoes or rhubarb, vinegar, candy, sugar, salt and other condiments and many raw and coo)ed foods. *hysical stimuli include temperature below ,..& or above G..& or tactile pressure. #e pointed to FysiCs e!planation that because fluid in tubules is incompressible, a stimulus induces a wave li)e motion transmitted to the pulp. Frossman listed the requirements for an ideal therapy : ,. t should not usually irritate or in any way endanger the integrity of the pulp. 7. t should be relatively painless on application or shortly afterward. <. t should be easily applied.
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G. t should be rapid in its action -. t should be permanently effective B. t should not discolor tooth structure. ,E<B, $r. #artmann proposed application of a balanced micture of ether chloroform and thymol based on the theory that lipoids present in dentin play an important role in transmission of sensation. Semite! a commercial densiti@ing agent in solution form was a chloride of metals : sodium, magnesium, @inc, potassium, aluminium, calcium, aluminium o!ide, and triple distilled water. n ,EG,, Au)oms)y advocated sodium fluoride as a desensiti@ing obtundent. #oyt H 4obby ;,EG<> reported an effectiveness of a paste made of equal parts of sodium fluoride, white clay and glycerin. Since this report, it has probably been the most e!tensively used dental office therapy to treat hypersensitivity. (nd #$%f of ()t# centur : :moform toothpaste was introduced in Swit@erland by $r. 2ild in late ,EG.Cs. t contained : 6 'ormaldehyde ,.GIJ 6 &alcium carbonate ,GI 6 Dagnesium carbonate ,-I 6 Dinerali@ing salt mi!ture of Sodium bicarbonate <.GI Sodium chloride ,.G-I *otassium sulfate ....=-I Sodium sulfate ....=-I ntroduced in (.S. as "hermodent. *awlows)a ,E-B published a report stating that strontium chloride combined with biocolloids of teeth e!erted a favourable effect on

hypersensitivity, based on this report sensodyne toothpaste was developed with strontium chloride he!ohydrate. A possible e!planation for mechanism of strontium ion was advanced by Futentag. #e proposed that since calcium has been shown to stabili@e e!citable neural membranes by modifying their permeability to sodium and potassium, the effect is more pronounced and longer lasting with strontium. n ,EB7, 4romstrom summari@ed the #ydrodynamic theory of dentinal pain e!citation. :verett and colleagues summari@ed in ,EBB therapies popular for treatment. ,. A paste containing 7I formaldehyde in a vehicle of calcium carbonate, magnesium carbonate, sodium bicarbonate and soap powder. 7. A formaldehyde containing mouthwash. <. 'luorides in various forms and their vehicles, applied either alone or by a sequential treatment with calcium hydro!ide. G. Strontium chloride -. 7?I Ammoniacal silver nitrate. B. Kinc chloride 9 potassium ferrocyanide impregnation ;FottliebCs solution> in which the active ingredients are applied sequentially. =. &orticosteroids ?. Sontophoresis with fluoride n ,E=G, #odosh proposed a superior densensities, potassium nitrate. *resumably, the mechanism depends on the ability of 3 L to permeate through the dental tubules to nerve endings at the dentin6pulpal 1unction and there to modify the usual e!change of sodium and potassium in nerves ;0a L 3L *ump>

4erman proposed the term dentinalgia to differentiate sensitivity from *ulpalgia. "he gate control therapy and the hydrodynamic theory were proposed as most probable mechanisms. %rchardson and cowor)er published reports on some characteristics of tooth hypersensitivity. n one report, ,.E patients in Scotland were e!amined for hypersensitive dentin ?.I were sensitive to cold alone or to cold and some other stimuli. Aower ,st molars and upper canines were most frequently affected, and B?I of hypersensitive teeth had significant recession but only 7percent had evidence of abrasion, attrition or erosion. (se of iontophoresis with sodium fluoride has been reevaluated in recent years. &arla &iancio and Seyre) reported that over E.I of patients thus treated had a significant reduction in sensitivity. 3leinberg ;,E?B> summari@ed the different approaches that have been used to treat hypersensitive dentin. ,> Reminerali@ation by saliva deposits of calcium phosphate comple! within dentinal tubules. 7> 'ormation of secondary dentin, which may occur naturally or can be stimulated by daily burnishing. <> &alcium hydro!ide facilitates calcium phosphate deposition from dentinal fluid and saliva. G> *otassium o!alate forms calcium o!alate within dentinal tubules. -> Sodium fluoride promotes the deposition of less soluble fluoropatite B> Sliver nitrate precipitates proteins within dentinal tubules => Strontium chloride forms strontium hydro!yapatite and strontium phosphate within dentinal tubules. ?> Resins seal the outer ends of dentinal tubules. E> *otassium nitrate appears to be effective.

,.> $entrifices may provide one of the active ingredients above or function by occluding tubular orifices. 3rawer pointed out that severe cases of sensitivity can be so problematic as to cause an emotional change among sufferers that can alter lifestyle. S+MMARY : 'or well over a century, there has been cogni@ance that sensitivity is a serious problem, that is arises when the dentin and cementum are e!posed, that fluid movement within the dentinal tubules acts as a provocative stimulus, that tubules can be sealed off ;apparently in most instances> without damage to the tooth or the dental pulp, and that the problem can also be at least partially resolved by suppressing nerve firing within the pulp. Sealing off the dentinal tubules or dampening neural impulses, although admittedly none meet all of the hypothetic requirements proposed by Frossman over -. years ago. 'luorides, strontium chloride, potassium nitrate, potassium o!alate, sodium citrate, surface sealing agents ;varnishes, resins, cyanoacrylate>, calcium hydro!ide, and others. Toot# # ,ersensiti-it in t#e s,ectru& of ,$in : As an e!aggerated response to a non6no!ious sensory stimulus. "he sensory stimuli usually considered are thermal by the application of a burst of air to the tooth and tactile by running a metal instrument across the hypersensitive region of the tooth. "ooth hypersensitivity is viewed as originating from the underlying e!posed dentin. Ders)ey for the international association for the study of pain ; AS*>. *ain is described as an unpleasant sensory and emotional e!perience associated with actual or potential tissue damage or described in terms of such damage. "ooth hypersensitivity is not associated with actual tissue damage in the acute

sense but can involve potential tissue damage with constant erosion of the enamel or cementum along with the concomitant *ulpal response. Allodynia pain resulting from a non6 no!ious stimulus to normal s)in. Allodontia to describe appropriately tooth hypersensitivity is a chronic condition with acute e!acerbations. &hronicity ends when the enamel or cementum defect is restoredM however, differs from dentinal and *ulpal pain in that the patientCs ability to locate the source of pain is very good. Aside from that characteristic "ooth hypersensitivity is similar in its description to dentinal pain 9 i.e., in terms of its differential diagnosis. "he character of the pain does not outlast the stimulus, the pain in intensified by thermal change, and sweet and sour. *ain intensity is usually mild to moderateM both can be associated with caries, defective restorations, and e!posed dentin. "he pain can be duplicated by hot or cold application or by scratching the dentin, and both tooth hypersensitivity and dentinal pain usually show a normal radiographic architecture of the peripheral region. $entinal hypersensitivity is a response from a non6no!ious stimulus and a chronic condition with acute episodesM whereas dentinal pain is a response from a no!ious stimulus and usually an acute condition. A clear understanding of tooth sensory conduction still needs further elucidation to aid the clinical investigator in choosing the most appropriate clinical model. "he fact that local anesthetics applied topically to dentin are not affective and that one can still elicit a pain response from a root6canaled tooth ;from e!teroceptors from the periodontal ligament> present challenging in vitro and in vivo hurdles to overcome in the future by dental scientists in deciphering the mechanism of action. DENTAL HYPERSENSITIVITY : Pu%,$% consider$tions : "he tooth pulp and dentin are now )nown to be innervated by A6delta and &6fibers that form an interlacing networ), the subodontoblastic ple!us.
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'rom this ple!us, nerve fibers e!tend to the odontoblastic layer, predentin, and dentin and terminate as free nerve endings. "he sensory receptors respond to chemical, thermal and mechanical stimuli and are thus termed polymodal. t has been proposed that A6delta fibers are responsible for dentinal pain, and &6fiber nociceptors ;receptors preferentially sensitive to a no!ious or potentially no!ious stimulus account for the pain from e!ternal irritants that reach the pulp. Dorphologically, nerve fibers may penetrate into the dentin as far as ,-. to 7.. m only. :!cept possibly for serotonin, many vasoactive substances implicated in pain ;such as substance *, brady)inin, and histamine> appear to have no direct effect on A6delta *ulpal afferent but may activate &6fiber *ulpal afferents. Sympathetic nerve simulation and changes in blood flow can alter *ulpal afferent activity, and it now seems li)ely that these substances may have indirect effects by altering blood flow. "he neural theory attributes activation to an initial e!citation of those nerves ending within the dentinal tubules. "hese nerve signals are then conducted along the parent primary afferent nerve fibers in the pulp into the dental nerve branches and then into the brain. "he hydrodynamic theory proposes that the stimuli cause a displacement of the fluid that e!ists within the dentinal tubules. "his mechanical disturbance activates the nerve endings in the dentin or pulp. "he odontoblastic transduction theory proposes that the stimuli initially e!cite the process or body of the odontoblast, the membrane of which may come into close apposition with that of nerve endings in the pulp or in the dentinal tubule, and that the odontoblast transmits the e!citation to these associated nerve endings. "echnically, enamel and cementum erosion of a tooth would satisfy the definition of inflammation ;i.e., a locali@ed protective response elicited by in1ury or destruction of tissue>, which serves to destroy, dilute, or wall off both the in1urious agent and the in1ured tissue. "he tooth can mas) the
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classical signs of acute inflammation including heat, redness, and swelling to some e!tent, but not pain and loss of function ;sensitivity to chewing, percussion and air>. t is interesting to speculate the role, if nay that the process of inflammation plays in the chronic conditions of dentinal hypersensitivity. "he biochemical cascade involved would allow a wide range of clinical and *harmacologic approaches for its treatment. &urrently the treatment of choice for the chronic management of dentinal hypersensitivity. "he active agent that has the widest data base of in vivo as well as in vitro studies is strontium. ,> cariostatic effects, especially in the pre6eruptive phase of tooth formation, 7> strontium can be ta)en up at e!tra6vascular site and the retention is by surface adsorptionM <> strontium can be sued to differentiate two different forms of acetylcholine ;A&h> secretion and is effective in supporting asynchronous, neurally evo)ed A&h release asynchronous A&h secretion is the delayed, residual increase in miniature end6plate potential frequency evo)ed by repetitive nerve impulses that can be analogous to dentinal hypersensitivityM G> in many secretory processes, strontium can substitute for calcium in activating the secretory mechanism, and can possibly affect or modulate the *ulpal cholinergic and adrenergic mechanisms involved in dentinal hypersensitivityM and -> strontium can increase the time of the rat trial6flic) response suggesting analgesia and may possess central analgesic potency similar to narcotic drugs by possibly altering the calcium disposition including binding or transport. Strontium chloride dentifrices have been suggested to wor) by occluding dentinal tubules by binding to the tubules matri! and + or stimulating reparative dentin formation. "he simplest conclusion to be drawn is that in vitro models do not provide a good model to e!trapolate data to e!plain human dentinal sensitivity. n humans stimuli are applied to outer dentin, whereas in animal models the stimuli are applied to deep cavities, where the length and width
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of the tubules would facilitate a direct action on nerves in the inner dentin or pulp. Additionally, dentin electrodes can record from only a limited sample of the total intradentinal nerve population, not ta)ing into account neural convergence or summation. Dore than twenty peptides have been identified in the nervous systemM some ;such as brady)inin, serotonin, and substance *> have been identified or associated with sensiti@ation of the tooth. Sensiti@ation of tooth neciceptors after repeated e!posure to no!ious stimuli can lower the nociceptor threshold, allowing for increased sensitivity to what was normal and is now a suprathreshold stimuli ;hypersensitivity> and if persistent to spontaneous activity ;odontalagia>. Su./ecti-e consider$tions : "o evaluate the sub1ective responses of pain, many pain6word questionnaires, visual analog scales, and lists of worlds are currently available and have been used to assess various pain syndromes with controversy as to which are the most appropriate. "o assess a patient completely an evaluation of the physical determinants of pain should be supplemented by an assessment of at least two other components 9 one observable, the other more sub1ective. Fracely has listed five properties for an ideal pain measure to both optimi@e the information gained on the sub1ective component, and to relate the clinical and e!perimental assessment of pain. "hey are ,> sensitive measurement free of biases inherent in different assessment methodsM 7> provision of immediate information about the accuracy and reliability of the sub1ectCs performance in the tas)M <> separation of the sensory 9 discriminative aspects of the pain e!perience from its hedonic qualitiesM G> usefulness for clinical as well a e!perimental pain measurement, allowing reliable comparisons between these fundamentally different types of painM -> absolute measures that increase the validity of pain comparisons between and the within groups over time.
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&hronic pain is a learned behavior, and the chronic pain patient is a person who acts li)e a chronic pain patient. t is immaterial whether the pain is somatogenic, neurogenic, or psychogenic ;or for that matter, whether there really is any sub1ectively e!perienced pain>. &hronic dentinal hypersensitivity patients acquire learned behavior characteristics such as avoiding cold drin)s and certain foods, not opening their mouths, on cold days, and avoiding tooth brushing in sensitive areas 9 possibly ma)ing them susceptible to gingival and periodontal problems. Recently, 2oolf described a distinction that should be made between two forms of organic pain: physiologic and pathologic. "he distinction between the two depends on the premise that physiologic pain is a normal sensation, whereas pathologic pain is the consequence of an abnormal state. $ynamic sensations perceived as a result of stimuli of sufficient intensity to threaten to damage tissue or produced small locali@ed areas of in1ury, but which neither provo)e an e!tensive inflammatory response nor damage the nervous system as physiologic pain. t can be manifested in response to mechanical, thermal, or chemical stimulation. t is characteri@ed by quantifiable stimulus6response relationships, yet it is particularly susceptible to interference from psychologic factors. "his definition aptly describes dentinal hypersensitivity, ta)es into account the polymodal nature of the nerve fibers, and considers the psychological component. S+MMARY : t is estimated that the frequency of dentinal hypersensitivity affects one of si! people, and one or more teeth can be affected. "he incidence of dentinal hypersensitivity appears to pea) around the third decade of life and may appear as root sensitivity in the fifth decade of life as root sensitivity particularly in patients undergoing periodontal surgery. T#e neuro,# sio%o0 of t#e teet# :

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t is well )nown that even the most peripheral part of dentin can be sensitive. Recent neuroanatomic studies have shown that only the inner ,.. to 7.. m of dentin is innervated, odontoblasts would act as receptor cells and mediate the effects of e!ternal stimuli to the nerve ending located in the pulp 9 dentin border. #owever, there are few e!perimental data supporting this theory. Doreover, combined electrophysiolgic and histologic studies have shown that dentin can be sensitive despite irritation 9 induced odontoblasts aspiration and other tissue in1ury in the pulp6dentin border area. Also, the nerve endings in dentin were found to be in1ured in these studies. #uman dentin can be sensitive despite considerable tissue trauma in the pulp6dentin border. INNERVATION OF THE P+LP AND DENTIN : As already mentioned, the dental pulp is enormously richly innervated. "he mean number of a!ons entering one human premolar tooth is E7B. a great ma1ority of the a!ons are unmyleinated. "o 4yers, one a!on may innervate more than a hundred dentinal tubules. "he density of the innervation in the pulp6dentin border is enormous. #owever, most of the recent studies indicate that only the inner ,.. to 7.. m, of dentin is innervated. "his has been confirmed with electron microscopic techniques as well as with light microscopic studies employing autordiographic and immunohistochemical nerve labeling methods. "he density of the innervated tubules is highest in the area of pulp horns. Although close contacts have been shown to e!ist between the nerve fibers and the odontoblasts synapses or other 1unctions that would allow nerve impulse transduction between the cells do not seem to e!ist. Although the results of many histologic studies are conflicting, the most recent results indicate that the odontoblast process is restricted to the inner third of the dentinal tubule. Accordingly, it seems probable that the
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outer part of the dentinal tubules does not contain any cellular elements but is only filled with dentinal fluid.

THE F+NCTION OF INTRADENTAL NERVES : Duch of the information concerning the function of intradental nerves, especially that of &6fibers, originates from single unit recordings performed on e!perimental animals. "he recent electrophysiologic recordings indicate that intradental nerves in cats, dogs, and mon)eys function in the same way as those in human teeth. Also the structure of intradental innervation is similar in all these species. As already mentioned, the dental pulp is innervated by both myelinated and unmyelinated a!ons. &orrespondingly, according to conduction velocities ;c.v.>, the nerve units can be classified into A6 ;c.v N7 m+s> and &6groups ;c.v. 7 m+s>. Dost of the A6fibers have their conduction velocities 9 velocities within the A range ;O<. m+s>. "his functional organi@ation of intradental innervation is significant because in other parts of the body the first, sharp, better locali@ed pain is mediated by A 6fibers, whereas &6fiber activation seems to be connected with the second, dull, radiation pain sensations. Some intradental nerve a!ons have conduction velocities higher than <. m pre second and thus they can be classified as A 6fibers. "hey have bee suggested to mediate non6painful sensations induced by low6intensity electrical stimulation of human teeth. #owever, their responses to other stimuli applied to the tooth indicate that they belong to the same functional group as the intradental A6fibers. "here is little evidence that stimuli other

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than electrical can induce non6painful sensation when applied to human teeth. ntradental A6fibers respond to drilling of dentin. "hey also respond to probing and air drying of dentin and hyperosomotic solutions applied to the e!posed dentin surface as well as to direct mechanical irritations of the pulp. "he &6fibers of the pulp do not respond to the same type of dentinal stimulation. A fibers also respond to rapid heating of the tooth. "he nerve firing starts within a few seconds few the beginning of stimulation. n this stage, no considerable change in the temperature of the pulp6dentin border has occurred. Accordingly, the nerve responses cannot be due to a direct effect of heat on nerve terminals. f heating of the tooth crown is slow, A6 fibers do not respond, even if the pulp temperature is elevated up to -. to B..&. "emperature changes are able to induced fluid flow in dentinal tubules. 2ith intense heating, the fluid flow is strong enough to induce activation of intradental A6fibers ;see *ashleyCs article, Dechanisms of $entin Sensitivity>. A common effect of the stimuli activating A6fibers is that they can induce fluid flow in dentinal tubules, as studied in vitro. "he &6fibers of the pulp are polymodal and respond to several different stimuli when they reach the pulp proper. n heat stimulation their mean threshold temperature is G<.? <.G.&. &onsidering the function of both intradental nerve fiber groups, rapid heating induces A6fiber activation within a few seconds followed by a delayed &6fibers firing. Sharp pain is induced within a few seconds, and if stimulation is continued, a dull, aching, and radiating pain sensation is evo)ed. ntradental &6fibers also respond to direct mechanical irritation of the pulp tissue and to such chemicals as brady)inin and histamine. A6fibers are not activated by these chemicals. 'rom this point to view, it is interesting that brady)inin applied on the e!posed human pulp induces dull pain.
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n general, unmyelinated a!ons are more resistant to the effects of pressure and hypo!ia than myelinated fibers. 4oth pressure elevation and hypo!ia may occur in the pulp during inflammation. Accordingly, the function of intradental A6fibers may be loc)ed. %n the other hand, such inflammatory mediators as histamine and brady)inin are released and are able to activate intradental &6fibers. :!plain why the pain connected with advanced pulpitis is dull, aching, and poorly locali@ed. THE MECHANISMS OF DENTIN SENSITIVITY : Dyelinated A6fibers seem to be responsible for dentin sensitivity. "he sensitivity of the nerve units is very dependent on the condition of the dentin surface, with either open or bloc)ed dentinal tubules. Acid etching of the drilled dentin surface removes the smear layer and pen the dentinal tubules, and the sensitivity of the nerve fibers to dentinal stimulation is increased to a great e!tent. 4loc)ing of the tubules with resin impregnation or potassium o!alate treatment prevents the nerve activation. 4ecause pain in general is evo)ed by intense stimuli that induce tissue damage ;no!ious stimuli>, a clinically relevant problem is whether stimulation of dentin, for e!ample with air blasts, is no!ious to the pulp. %n the other hand, if tissue damage is induced in connection with dentinal stimulation and pulp nerve activation, it would be important to )now how the nerve function might be affected by the in1ury. Air drying of human dentin induces odontoblast aspiration into dentinal tubules. Doreover, chronic dentin e!posure may result in considerable tissue damage and inflammation in the pulp6dentin border area. t seems that thee morphologic change do not affect dentin sensitivity that much. n dog teeth, dentinal stimulation causes tissue damage in the pulp dentin border area, and the dentinal innervation is in1ured. "he responsiveness of the units seems to be more dependent on the openness of the dentinal tubules than the tissue in1ury in the pulp 9 dentin border. "hese
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results from human and animal e!periments support the view that the activation of intradental nerves by dentinal stimulation must be induced by an indirect effect. "hese result also indicate that sensitive dentin does not necessarily mean that the dental pulp is healthy. 0either does insensitive dentin mean that the pulp is dead. Sometimes patients may have wide areas e!posed dentin without feeling any discomfort or pain. n these the dentinal tubules may be bloc)ed by dentinal sclerosis or irritation dentin formation in the pulp 9dentin border area. &ertain inflammatory mediators, such as prostaglandins, histamine, serotonin ;-6#">, and neuropeptides, such of the nerve endings. Accordingly, their thresholds to e!ternal irritation may change. 'or e!ample, after local application of serotonin on dentin close to the pulp, the responses, of the intradental nerve fibers to dentinal stimulation are much enhanced. MECHANISMS OF DENTIN SENSITIVITY : HISTORIC CONSIDERATIONS : &linician )new that freshly e!posed dentin was e!tremely sensitive and concluded ;erroneously> that nerve fibers in teeth must e!tend to the $:/ to be responsible for such pain. 2hen histologists began loo)ing for nerve fibers in peripheral dentin using light microscopy and special heavy6 metal stains, they found that branches of *ulpal nerves did not e!tend more than ,.. m into peripheral dentin. Rapp and his colleagues, proposed that odontoblasts could serve as receptors. Stimulation of odontoblast processes in peripheral dentin was proposed to cause change in the membrane potential of odontoblasts via synaptic 1unctions with nerves, thereby causing pain. #owever, careful electron microscopy failed to demonstrate any synaptic comple!es between *ulpal nerves and odontoblasts. *erhaps the most damaging blow to that
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hypothesis was the observation that odontoblast processes may not e!tend peripherally beyond one third to one half of the length of dentinal tubules. Anderson and colleagues and 4rannstrom, wor)ing independently, found that peripheral dentin, although very sensitive to a variety of physical stimuli ;tactile, thermal, evaporative> was uncreative to 3& and local anesthetics, which normally modified nerve activity. 4rannstrom reintroduced FysiCs concept that sensitivity may be due to the movement of tubule contents, the so called hydrodynamtic theory of sensitivity. (nli)e Fysi, 4rannstrom accumulated a great deal of laboratory and clinical evidence to support the concept that, although the peripheral one half of dentin is devoid of nerve or odontoblastic processes, movement of fluid within dentin transduces surface stimuli by deformation of *ulpal mechanoreceptors, which in turn, cause pain. "his hypothesis, which is currently the most popular theory. P+LPAL INNERVATION : Ner-e t ,e : "he dental pulp is richly innervated with a variety of nerve fibers. %nly a few of the ,... to 7... nerves found in each tooth reach the dentin. %f these nerves, appro!imately =- per cent are nonmyelinated and 7- per cent are myelnated. "he myelinated nerves are classified as A6 , , or 6 fibers, depending upon their a!on diameter and their conduction velocity. Dost of the myelinated nerve fibers in teeth are A6 nerves, which are thought to be responsible for the brief, sharp, well6locali@ed pain associated with dentin sensitivity. "hese fibers have a relatively low stimulation threshold. As they are relatively large, their depolari@ation causes much more current flow than smaller nerves, and their activity can be recorded e!tracellular from cavities cut into dentin. 2hen investigators measure intradental nerve activity, the implication is that it is A6 nerve activity. "he
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unmyelinated nerve of the pulp are composed of small c6fibers and sympathetic nerves. "he c6fibers contain peptides that may contribute to both pain sensation and local inflammation. "he poorly locali@ed, dull, burning ache of *ulpal pain is thought to be due to c6fiber. "hey are too their fibers from the mandibular nerve as single units, which are then placed on recording electrodes. "he stimulation threshold of c6fibers is relatively high. "he proportion of sympathetic nerves in the total number of unmyelinated nerves has been reported to vary from ,. pre cent to a ma1ority of the fibers. 0ormal electric pulp testing stimulates the lowest threshold nerves first which are A6 fibers. #igher currents are required to activate c6fibers. 'ew electric pulp testers used in clinical practice can stimulate c6fibers, although the development of such devices may be useful in future clinical research. Ner-e Re$ctions : Pasoactive peptides such as substance *, calcitonin gene 9 related peptide ;&FR*>, and neuro)inins A and 4 ;03A, 034> are found in c6 fibers often in close association with blood vessels. "hey can be released by tissue destruction ;pulp e!posure, elevated cutting temperature, antigen6 antibody reactions, complement activation> or by antidromic stimulation of the inferior alveolar nerve. "hese peptides all promote vasodilation and plasma e!travasation. "hese agents contribute to the phenomenon called neurogenic inflammation and they have been demonstrated in the dental pulp. "he utility of neurogenic inflammation was developed in AewisCs nocifensor system, which consisted of a peripheral neurogenic defense mechanism by which e!ogenous or endogenous to!ic material was removed by local increases in tissue blood flow, interstitial fluid production, and lymph drainage. "he dental pulp contains for more unmyelinted than myelinated
7,

neurons. "hese nerves proliferated in response to bacterial challenge. n the low6compliance environment of the pulp, neurogenic inflammation may, under some conditions, promote and sustain dentin sensitivity rather than leading to its resolution. "he wave of depolari@ation traveling along the nerve which depolari@e bac) toward the periphery. Recent modifications to the original concept suggest that the nerve can act as both receptors and effectors. n this way, painful impulses may perpetuate *ulpal inflammation and perhaps aggravate it. 0erves that contain these neurogenic peptides are capsaicin6sensitive. "he most interesting effect of capsaicin is its ability to desensiti@e tissues to the effects of S*, &FR*, and 03A. &apsaicin itself can cause pain when applied to dentin, presumably by causing the release of substance *. A6 fibers can be stimulated repeatedly for hours with no apparent change in their sensitivity. "hey are polymodal ;sensitive to changes in temperature, osmotic pressure, or tactile stimuli> fibers that are not sensitive to brady)inin or histamine. "hey mediate the sharp, transient pain that is typical of dentinal sensitivity. n contrast, c6fibers are activated by chemical mediators of inflammation. "hey produce a dull, aching pain when brady)inin or histamine is placed in deep cavities cut into human teeth. A brief application of hot gutta6percha on crown enamel can produce a transient burst of A6 nerve active. f a tooth is heated continuously but very slowly, no nerve activity is produced until tissue damage results, causing c6 fibers to fire. 4ased on indirect evidence, 3im has suggested that vasodilating agents may actually decrease *ulpal blood flow following a transient increase in blood flow. As the pulp is a low6compliance environment, any increase in its volume, whether due to dilation of vessels or filtration of fluid across capillaries following dilation, would increase tissue pressure,
77

which would compress local venules, thereby increasing postcapillary resistance and decreasing blood flow. DENTIN CONSIDERATIONS : 2hen the *ulpal terminations of the tubules are sealed by reparative dentin, the dentin is generally insensitive for two reasons. 'irst, reparative dentin generally has fewer tubules than primary dentin. Second, reparative dentin generally has few nerves innervating the dentin. "here are two mechanisms responsible for the permeation of substances across dentin: diffusion and convection. $iffusion is the process by which substances are transported from an area of high concentration to an area of low concentration. n pure diffusion, there is no bul) fluid movement but only molecular translocation. n convective transport or filtration, bul) fluid movement occurs from an areas of high hydrostatic pressure to an area of low hydrostatic pressure. "his type of fluid movement can be quantitated by measuring the hydraulic conductance of dentin. #ydraulic conductance is the reciprocal of resistance. "hat, is dentin with a high conductance has a low resistance. "he important variables regulating hydraulic conductance of dentin are the length of the tubules ;that is, dentin thic)ness>, the number of tubules per unit surface area, the applied pressure, the viscosity of the fluid, and the radius of the tubules raised to the fourth power. "hese are e!pressed in the *oiseuille6#agen equation. QR 2here: Q R 'luid flow * R applied pressure ;hydrostatic or osmotic> rG R radius of tubules ;that is, smear layer> 0 R tubules density ;depth 9 dependent> n R viscosity of fluid ;temperature 9dependent>
7<

*rG0 ?nA

A R length of tubule ;remaining dentin thic)ness> "he amount of fluid that can shift across a full preparation is much larger than the amount that can shift across a buccal pit preparation. "he most important variable is the radius of the tubule because it is raised to the fourth power. "he creation or dissolution of smear layers and smear plugs from dentinal tubules can have a profound influence on the hydraulic conductance of that dentin and hence its sensitivity. #owever, the hydraulic conductance of dentin is not uniform but is highest over pulp horns, high on a!ial walls, and relatively low on root surfaces. "his is due in part to regional differences in tubules density and diameter and in part or regional differences in the amount of intratubular material. "he surface resistance of dentin is variable owing to the presence or absence of the smear layer or the growth calculus or other surface deposits. *atients with sensitive dentin generally lac) smear layers and have open tubules orifices. Several therapies bases on tubule occlusion have been proposed that were designed to decrease fluid flow by decreasing the hydraulic conductance of dentin. :!posed dentin free of a smear layer should have a high hydraulic conductance. f these tubules are open all the way to the pulp, *ulpal fluid should slowly filter down its hydrostatic pressure gradient to the surface. "his has actually been demonstrated by Ainden and 4rannstrom and by *ashely and associates in vivo. Apparently, the spontaneous rate of fluid filtration across open, sensitive dentin is too slow to activate the mechanoreceptors. 2hen an additional stimulus is superimposed on it, however, then the receptors are activated. Steadily applied pressures do not cause as much pain as when the pressure is suddenly applied or released. MECHANISTIC EVAL+ATION OF ADE1+ATE STIM+LI : T$cti%e : All clinicians use a dental e!plorer to identify regions of sensitive dentin. t is simple yet effective. Although the use of a gently force of - to
7G

,. mg on the e!plorer ;measured by performing such maneuvers on an analytical balance> seems as though it would be a trivial stimulus, that force is locali@ed on the tip of the e!plorer, which is only about -.. m7 ;*ashley, unpublished observation>. f - gm of force is applied over -.. m7, the resulting pressure is gm+- 8 ,.6B cm7 R ,... )g+ cm7 R ,.7 Dpa. "his is sufficient to overcome the elastic limit of dentin, leading not only to compression of dentin and smear layer creation under the e!plorer tip but also to permanent ;yet incroscopic> deformation of dentin, ;scratch development>. "his compression of dentin can presumably cause displacement of fluid inwardly at a rapid rate, which activates mechanoreceptors. "actile stimuli can be made quantitative by incorporating a calibrated strain gauge in the e!plorer or by using a 5eaple probe. A 5eaple probe is a compact handpiece that contains an e!plorer tine in an ad1ustable electromagnetic fluid. "he probe is calibrated such that one can apply forces sequentially to sensitive dentin in a graded manner. "he force should be applied to the same area at E. . to the surface in a static inwardly directly manner. "he patient is as)ed to respond whether there is either pain or no pain at each test. "he instrument is ad1usted in - to ,.6gm increments from ,. to =. gm. :ach increasing force compresses more and more dentin. "his is a variable stimulus + constant response type of test. f different laboratories wish to compare testing data, they should all use the same type of e!plorer tine ;that, is identical surface area, sharpness and so on>. Os&otic sti&u%i : "he use of osmotic stimuli for evaluation of dentin sensitivity was populari@ed by Anderson and his colleagues. At the time they developed this methodology, the smear layer had not yet been discovered and the hydraulic conductance of the dentin that they studied was probably very low. "his required them to use very large osmotic stimuli ;very concentrated
7-

solutions of various solutes> in order to induced enough fluid movement to cause, pain. "he same concentrations of different solutes amounts of fluid movement. "his was due to differences in the reflection coefficients of these solutes for dentin. Reflection coefficients are values that correct the theoretical osmotic pressure of a solution for the relative permeabilities of the solute versus the solvent. AndersonCs group found that repeated applications of the same hypertonic solutions to cavity preparations in the teeth of unanestheti@ed sub1ects evo)ed fewer and fewer reports of pain. "hey also demonstrated that repeated applications of these solutions induced successively smaller amounts of fluid movement across dentin in vitro. "his was due to the diffusion of the solute into the dentinal fluid, which loaded them so that subsequent applications of the solution produced smaller and smaller osmotic gradients. %smotic stimuli are effective because the chemical activity of water in these solutions is les than that of the chemical activity of water in dentinal fluid. 2ater flows from the area of higher activity to the area of lower activity, which is, by definition, osmosis. #oriuchi and Datthews reported that than were osmotic pressure. #owever, osmotic stimulation continues to be a convenient, popular method of evo)ing pain in neurophysiologic studies in cat teeth, where it is technically difficult to produce hydrostatic stimulation. &alcium chloride, has multiple effects. when applied to superficial dentin, it e!cites intradental nerve owing to osmotic movement of fluid. n deep dentin, it may depress nerve activity owing to the direct effect of calcium at stabili@ing e!citable membranes. Solutions of sodium chloride tend to e!cite nerves owing to indirect osmotic effects on superficial dentin and direct effects on intradental nerves in deep dentin. "hus, for a variety of reasons, osmotic stimuli are not generally used clinically to quantitate dentin sensitivity although some have tried. 'or a review of this topic see pashely. Saturated solutions of calcium chloride
7B

may be useful for e!ploring the integrity of margins of drowns or other restorations. A cotton pellet saturated with the solution is place on a suspect margin. "here is usually a delay of - to <. seconds as the osmotic stimulus diffuses into any defects. "he lac) of a painful response in an unanestheti@ed patient indicates either that the margin is tight or that the dentin in insensitive. Dargins should be tested individually to limit identification to a specific lea)y margin. T#er&$% sti&u%i : "hermal stimuli have been used ever since endodontists began using hot gutta percha to elicit *ulpal nerve responses. "hermoelectric devices are useful for delivering cold or warm stimuli in a controlled quantitative manner. 4ecause patients are generally more sensitive to cold than to hot stimuli, the use of cold water ;,.,,-,7.,7-, <. .&> as a simple, quantitative stimulus is gaining in popularity. n using cold water, each tooth tested is isolated with a rubber dam and water at a )nown temperature is slowly flowed on the e!posed dentin surface for a ma!imum of < seconds from a disposable plastic syringe. "he patient is forced to decide if that temperature causes pain or not and then the ne!t lower temperature is tried until the patient responds unequivocally. "hermal stimuli are effective hydrodynamic stimuli because of the differences in thermal conductivity and coefficients of e!pansion or contraction of pula+dentinal fluids and their containers, enamel and dentin. "his is, application of cold causes a more rapid volumetric contraction of dentinal fluid than occurs in dentin. "his mismatch of volumetric changes produces negative ntrapulpal ;and presumably intradental> pressures that displace mechanoreceptors and cause pain. 4ecause many thermal stimuli require that the tooth be touched with a device, they are actually both tactile and thermal. Application of a water stream is almost purely thermal, as there is no pressure application. "he use
7=

of a thermally 9 ad1usted air stream provides a no6touch thermal stimulation. (nfortunately, it provides both thermal and evaporative stimuli simultaneously. "hermal stimuli to vital dentin cause sharp, well6locali@ed pain ;that is, activation of A6 fibers> before there is a change in dentin temperature near the pulp where the nerves are located. Dany seconds later, the thermal wave or pulse arrives at the pulp and may activate other nerves. however. "he thermal stimuli that the used in testing dentin sensitivity should be regarded as hydrodynamic stimuli rather than thermal stimuli pr se. "hat is, they induce fluid movement or pressure changes indirectly rather than directly stimulating temperature 9sensitive receptors. "hus, the term thermal stimuli actually a misnomer. *rolonged application of hot or cold stimuli to dentin eventually cause changes in the temperature of *ulpal nerves. Although this is useful in endodontics it is not used in testing dentin sensitivity. &linically, cold stimuli are more useful than hot stimuli for testing dentinal sensitivity. *atients tolerate cold stimuli better than hot stimuli, and there is less danger of causing *ulpal damage. E-$,or$ti-e Sti&u%i : "he use of an air blast as a no!ious stimulus in testing for dentin sensitivity has been widely used since 4rannstrom, Aonden, and Astrom first demonstrated that air blasts to cut dentin caused evaporative fluid movement across dentin. "here are two mechanisms operating to cause pain under these conditions. "he first is the evaporation of fluid from the dentin by relatively dry 7-.& air directed at a <7.& toot. "his occurs very quic)ly ;within , second>. f longer blasts of air are used, one begins to cool the tooth, and the stimulus becomes comple! owing to the addition of a thermal stimulus with an evaporative stimulus. A thermal testing device has been developed that blows air of progressively lower temperature on sensitive
7?

teeth. Although it is regarded as primarily a thermal stimulus, it includes an evaporative component. Air blasts are useful stimuli during patient screening. "hey quic)ly identify individual sensitive teeth but they are not useful at identifying sensitive tooth surfaces. "hat is, an air syringe does not identify e!actly where, on a tooth, the sensitive dentin is located. "he e!act location of dentin sensitivity often dictates the type of therapy that might be employed. 2henever permeable dentin is e!posed to an environment in which the relative humidity is less than ,.. percent, water in dentinal fluid will change from the liquid state to the gaseous state, which, by definition, is evaporation. "he important variables in evaporation are the tooth or dentin temperature, the ambient relative humidity, and the presence or absence of convective air movement. Spontaneous evaporation of water from e!posed dentin is the same regardless of the presence or absence of a smear layer. #owever, the accelerated evaporative water loss seen during an air blast is much higher in the absence of a smear layer ;Foodis, "ao, *ashley>. "he direction of the air blast should be E.. to the dentin surface to obtain ma!imal rates of water evaporation. "here is no standard air blast, although perhaps there should be clinicians direct air at teeth at varying distances for varying periods of time. t would be desirable to standardi@e to a ,6second air blast, , cm from the tooth, directed at E.. using room temperature air. %rchardson and &ollins 6 an air syringe that uses a prolonged air blast. "he patient holds a cut6off switch that they activate when pain is perceived. A timer begins when the clinician activates the air syringe. "he time in milliseconds between the onset of the stimulus and the patients cancellation of the stimulus was found to be proportional to dentin sensitivity. %ne criticism of the use of prolonged evaporative stimuli is that
7E

sufficient water can evaporate from the dentin to cause partial tubule occlusion by the salts and proteins left behind. *rolonged air blasts also tend to decrease dentin sensitivity until the dentin becomes rehydrated. 'inally prolonged air blasts cause temperature changes on and in the dentin that can be avoided by using ,6second air blasts. f prolonged air blasts are directed at e!posed dentin, the rate of evaporative water loss may occur faster than dentinal fluid can flow into the dentin, causing negative intradental pressures. "his may be responsible for the displacement of nerves and odontoblasts nuclei from the cell body into the cytoplasmic processes inside dentinal tubules. Although this phenomenon has been called SaspirationC of odontoblasts, the preferred term is SdisplacementC. "hese cells die and are generally replaced by underlying mesenchymal cells. Fi%tr$tion of f%uid : "he most physiologic stimulus for evo)ing dentin sensitivity should be the graded, quantitative movement fluid across dentin. Ahlquist and colleagues, by preparing circular cavities on the facial surface of incisors and cementing conical plastic chambers into the preparation with cyanoacrylate. "he chamber was connected to a fluid reservoir with polyethylene tubing. (anestheti@ed sub1ects reported the quality and magnitude of their sensation of pain by means of an intermodal matching technique, finger6span potentiometer, and verbal descriptors. n the presence of the smear layer, no pain could be evo)ed. After using ..-D :$"A ;p# =.G> for 7 minutes, fluid flow in either direction elicited sensations of sharp pain. Rapid changes evo)ed higher pain intensities than slow changes in flow. 2hen the dentin was treated topicaly with < percent o!alic acid ;7 minutes> to occlude the tubules with calcium o!alate crystals, the same stimuli were prevented from producing sufficient fluid flow to evo)e pain. "his effect could be reversed by :$"A treatment, which restored both
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dentin permeability and its sensitivity. "hese results tend to support the hydrodynamic theory of dentin sensitivity. "here is a linear relationship between applied pressure and the flow of fluid through dentinal tubules. "he hydraulic conductance of dentin is the slope of the linear relationship between fluid flow and the applied hydrostatic pressure gradient. "he presence or absence of smear layers has a profound influence on the magnitude of the hydraulic conductance, which also varies inversely with dentin thic)ness. "he histologic appearance of the odontoblast process in dentinal tubules would suggest that it should have an enormous effect on the hydraulic conductance of dentin. #owever, if one removes the smear layer of dog dentin in vivo and measures the hydraulic conductance of the dentin before and after filtration of water ;which should osmotically swell odontoblast processes in tubules> across dentin, there are no statistically significant changes. Similarly hypertonic ;<D> 0a&l across dentin ;which should osmotically shrin) the odontoblast process>, one sees no change. A prolonged ;,. minute> air blast to dentin to cause displacement of odontoblast nuclei up into the tubules, there is not change in Ap even though subsequent histologic e!amination revealed that more than -. percent of the tubules contained displaced nuclei. *resence of irregularities in the walls of the tubules, the presence of organic partitions, minerali@ed and unminerali@ed collagen fibers, and so on. "heir summed effects are apparently much more important in modifying fluid movement across dentin than is the presence of the odontoblast process. E%ectric$% sti&u%i : &ritici@ed on several grounds as being nonphysiologic, rather than testing the pulpodentin comple! via hydrodynamic stimuli, it has been argued that electrical stimulation of teeth directly stimulates pulpal nerves
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and hence is of little value in evaluation of dentin sensitivity. "hat is, it only evaluates the presence or absence of nerve vitality rather than the degree of sensitivity. 'urther, most clinical devices that are used to test pulp vitality pass different currents through teeth because of the different resistances offered by varying enamel and dentin thic)nesses. &onstant6current stimulators are used in neurophysiology to deliver an e!act current flow regardless of the resistance of the tooth. 4ecause current flow is the critical variable in stimulating nerves, constant current stimulators, as they are called, are absolutely necessary in studies of nerve thresholds and sensitivity. "here are regional differences in nerve distribution within teeth. %ne might e!pect to obtain differences in nerve responses if the electrode was placed on the incisal versus the middle third of coronal enamel. 4ender and associates demonstrated that the incisal third of the crown was more sensitive to electric pulp testers than the cervical third. 3arlsson and *enney study, the root surfaces became more sensitive after periodontal treatment, whereas coronal sensitivity remained unchanged. t is theoretically possible for electrical stimuli to induce hydrodynamic fluid movements through open dentinal tubules via a phenomenon called electro6osmosis. :lectro6osmosis is the bul) movement of an electrolyte solution through a porous substance in response to the impression of an electrical potential. (ntil we )now much more about electro6osmosis in dentin, we cannot dismiss electrical stimulation of teeth as being unphysiologic. '$cteri$% contri.utions to dentin sensiti-it : *eriodontists have long thought that patients who )eep their root surfaces free of plaque will e!hibit less dentin sensitivity. %ver@ealous tooth brushing by some patient may abrade radicular dentin and remove surface
<7

salivary mineral deposits, thereby creating dentin sensitivity rather than preventing it. ndeed, Addy and colleagues reported a higher amount of gingival recession and dentin sensitivity on the left side of right6handed individuals than on the teeth on the right side of their mouth. "hey found an inverse correlation between plaque scores and dentin sensitivity. "hat is, low plaque scores were associated with high levels of sensitivity. Adrians and cowor)ers found far more microorganisms in the dentin ad1acent to periodontal poc)ets than in normal radicular dentin. 'urther, more bacteria were found in superficial root dentin than in middle dentin. #owever, they found a significant number of bacteria in the pulps of periodontally involved teeth even though these teeth were asymptomatic. A relatively common histologic observation of bacterial penetration into dentin is that it is e!tremely locali@ed. A few tubules may be filled with bacteria while most of the ad1acent tubules remain bacteria free. 4ergenholt@ clearly demonstrated that bacterial products placed on dentin can induce pulpal inflammation. Some bacterial substances can activate complement, whereas others are strongly chemotactic for *D0s. Still others may activate macrophages to release tumor necrosis factor. bacterial products may have direct vasoactive properties on pulpal vascular smooth muscle. Alternatively, they may have indirect effects on the vasculature through their direct effects on the release of neuropeptides from pulpal nerves. 4acterial products may have cytoto!ic effects on pulpal fibroblasts that may modify areas of the pulp during inflammation. "hey may damage or )ill the odontoblast and their mesenchymal stem cells. f there had been multiple episodes of acute pulpal inflammation immediately beneath open sensitive entinaltubules followed by healing, one result might be a local accumulation of fibrous tissue ;that is, scarring> and a reduction in capillary density. Such relatively avascular regions would not clear bacterial products
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diffusing into the pulp from open tubules, thereby permitting their local concentrations to rise to levels that were cytoto!ic. "he relative lac) of capillaries would tend to interfere with or retard the transport of fibrinogen and globulins that might reduce the rate of entry of bacterial products through dentin to the pulp.

Dentin # ,ersensiti-it : Some authors use the term hypersensitivity dentin or dentin hypersensitivity, whereas others simply refer to it as dentin sensitivity. &an dentin become hypersensitivity and if so, how T "he hydrodynamic theory of dentin sensitivity implicates both dentin and nerves as important elements. it follows, then, that one could have dentin hypersensitivity or nerve hypersensitivity or both. As dentin becomes thinner ;from multiple root planings or tooth abrasion>, its hydraulic conductance increases. "he most important variable is the condition of the tubule apertures. "ubule orifices plugged with smear plugs have a much lower hydraulic conductance than those same tubules devoid of smear plugs and smear layers. As dentin loses its smear layer, it becomes hyperconductive and hence hypersensitivity relative to what it was when it was covered with a smear layer, especially from the patientCs perspective. Alternatively, changes may occur in nerve sensitivity. "he ionic concentration of sodium and potassium of predentin fluid, in none!posed dentin determined by micropuncture technique, has been reported to be G?.. and E.. m:q per A, respectively. "he concentrations of the same ions in e!posed dentin have been reported to be ,-. and < m:q per A, respectively. 4ecause resting membrane potentials of nerves are more sensitivity to changes in e!tracellular potassium than sodium, one would e!pect the
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membrane potential of intradental nerves to be more negative ;and less e!citable> in open, e!posed dentinal tubules ;owing to the lower, more plasma li)e potassium concentration> than the same nerves in none!posed dentin. #ypersensitive states may also develop during inflammation via several mechanisms. "he small unmyelinated c6fibers that are normally thought of as nociceptors may release small but important quantities of neuropeptides without firing. "hey increase local blood flow and increase capillary permeability. :!travasation of plasma tends to cause local elevations in pulpal tissue pressure that may lower the e!citatory threshold of mechanoreceptor nerves, thereby contributing to a true hypersensitivity of that dentin. "he supporting of nerves may increase the innervation density of dentin or the subodontoblastic regions, further increasing dentin sensitivity. C%inic$% consider$tions : Fenerally, patients who have had e!tensive root planning will have lost all of the cementum on the cervical third of the root as well as variable amounts of root dentin. "hese patients seldom complain of dentin sensitivity until their periodontal pac)s are removed. Although the subsequent events vary considerably among individuals, many patients complain of increases in dentin sensitivity of the planed teeth over the ne!t =to ,. days. "his is generally followed by a gradual decline in sensitivity over the following = to ,. days. As saliva is saturated in calcium and phosphate with respect to most forms of insoluble calcium phosphate at normal salivary flow rates and p#, there are numerous physiochemical mechanisms tending to occlude dentinal tubules with a wide variety of crystal types. "his may lower the hydraulic conductance of the e!posed dentin below levels that permit activation of mechanoreceptors hydrodynamically. "he transudation of plasma and the
<-

macromolecules that it contains may tend to fill tissue spaces and perhaps even the pulpal ends of the tubules with fibrin, thereby decreasing the si@e of diffusion channels, decreasing dentin permeability. "he pulp may then have an opportunity to heal and the thresholds and distribution of sensory fibers should return to normal leaving the patient relatively comfortable.

DENTINAL PERMEA'ILITY IN ASSESSING THERAPE+TIC AGENTS sotonic potassium chloride does not elicit pain when applied to dentin but does when in direct contact with the pulp M and acetic acid buffer ;p# -.=>, reported to induce pain in subcutaneous in1ections, had no effect on the dentin or the pulp. 4rannstrom observed that dentin e!posed by drilling was less sensitive than dentin e!posed by fracture, which he attributed to the bloc)age of tubule openings caused by the debris produced during drillings. "hese observations together with the observations that pain could be produced from air blasts, application of sugar solution, and dry absorbent paper led to the conclusion that a central vital part of the tooth pulp acts as a mechanoreceptor, and any stimulating agent causing mechanical disruption or movement of fluid flow through the tubules is a potential cause of pain. 'urthermore, 4rannstrom reasoned that the geometry, that is, the conical shape, of the dentinal tubules combined with capillary action could ma)e instaneous minute amounts of fluid flow possible, and could e!plain the acute pain reported in the clinical operatory. &iting three natural defense mechanisms for reducing dentin permeability as formation of irregular atubular dentin at the pulpal wall, obturation of dentinal tubules by sclerosis, and minerali@ation of a
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superficial layer of pellicle or plaque, 4rannstrom proposed a clinical technique for sealing dentin using a resin material. 4rannstrom later suggested the application of cavity lining and varnishes under restorations, the retention of smear plugs in restorative procedures, and use of calcium hydro!ide and non6abrasive fluoride gels for treatment of e!posed sensitive dentin. 'ollowing 4rannstrom, the greatest protagonist of the hydrodynamic theory and the role of dentin permeability has been $.#. *ashley who has presented numerous reports in the field of evaluating agents for the treatment of hypersensitivity. ,> #ydraulic conductance ;Ap> measures the ease with which fluid movement occurs across a membrane in a hydraulic gradient. 7> *ermeability coefficients ;*> are a property of solutes for a particular membrane. n the absence of bul) fluid movement, * is a measure of the ability of solute to diffuse across a membrane because of a concentration gradient. n an analysis of factors influencing *, molecular si@e, configuration, polarity, Pan der 2aals forces, Aondon forces, and interaction potentials need be considered. <> Reflection coefficient ;> is a factor that reports the relative ability of a solute and a solvent to diffuse through a membrane. 4y definition, R , when the membrane is impermeable to the solute but completely permeable to the solvent, and when R . the membrane cannot distinguish between the solvent and solute. n ,E=G, *ashley published the first e!perimental wor) utili@ing a laboratory method to measure dentin permeability by hydraulic conductance. n this wor), a split chamber device was described wherein thin slices ;..EEmm> of coronal dentin from e!tracted human third molars were placed between fi!ed surface area ple!iglass reservoirs, one end of
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which could be connected to a source of hydrostatic pressure or treatment solution and the other end to a means of measuring flow rate or to collect diffused fluid. Dovement through a micropipette was found to be an accurate flow meter. 'luid movement through dentin was nil with no hydrostatic pressure, flow was a linear function of hydrostatic pressure, acid6etched discs had flow rates nearly <7 times greater than unetched discs, permeability was inversely proportional to dentin thic)ness, and permeability was directly proportional to surface area. ?B percent of the resistance to dentinal fluid flow was due to the surface characteristics of dentin, strongly suggesting that the alteration of permeability by surface agents could be a useful clinical treatment modality. 'low was greater in the direction from the enamel to the pulp. n ,E?<, *ashley measured the effect of temperature on the flow rate of saline solutions, through etched and unetched dentin. Fenerally, permeability increased with temperature, however, the increases were greater with etched dentin. n ,E?7, *ashley measured the influence of saliva, bacterial suspensions, and plasma proteins on fluid movement across dentin. *ashley speculated that after in1ury, a natural defense mechanism originating from the pulp could be the formation or release of plasma proteins, lea)ed into the dentinal fluid in an attempt to occlude tubular passageways and reduce hydrodynamic transmission to the mechanoreceptors in the pulp. (sing a modification of the split chamber deice wherein the enamel side was acid etched and then brushed with slurries of a series of dentifrices, *ashley determined fluid flow through dentin in the direction pulp to enamel, and interpreted the reduction in flow as a measure of the dentifrices ability to occlude dentin. n the series of products tested, no significant differences were reported among Sensodyne, &rest, $enquel, *romise, and
<?

"hermodent, but an e!perimental o!alate dentifrice developed by *ashley was significantly more able to reduce hydraulic conductance ;Ap>. *ashley also applied iontophoretic currents in the range . to ,.. mA to dentin discs in a further modification of the split chamber device. (sing 0a and & lidocaine as test materials, iontophoresis was reported to significantly increase the permeability of dentin, and it was concluded that iontophoresis may be useful for enhancing dentin permeability to deliver therapeutic agents to the pulp. *ashely and colleagues in ,E?- evaluated a series of commercial cavity varnishes and bases for their ability to reduce dentin permeability. "he split chamber device was employed in two ways. ,> to measure permeability by a radiotracer applied to the top reservoir of a split chamber device, collecting the perfusion in the bottom portion with a fraction collector and 7> to measure hydraulic conductance by fluid filtration through dentin as driven by <. cm of hydrostatic pressure. the products tested were &opalite, "ubulitec, $ropsin, (niversal &avity Parnish, $urelon, $ycal, Kn*%G cement, and Kn%+ eugenol cement. All cavity varnishes decreased dentin permeability by 7. to -. percent. n the filtration method, only "ubulitec produced a statistical reduction in Ap. 'urthermore, the effect of varnishes was found proportional to their solid content, but cavity bases and liners produced larger reductions in dentin permeability. 4urnishing dentin with orangewood and a paste composed of sodium fluoride, )aolin and glycerin. Act of burnishing with orangewood alone was the most effective part of the therapy, reducing permeability by ?. percent. 0a' had no appreciable positive contribution, and )aolin and glycerin slightly diminished the reduction in flow rates. %!alic acid reduced flow by E- percent.

<E

Smear layers produced by burnishing were found to be more resistant to acid than those produced by a bur. 4urnishing may force more debris deeper into the tubule openings than bur cutting could. Dultistep dentin bonding procedure containing ferric o!alate, 0"F6 FDA ;06tolyl glycine6glycidlymethacrylate>, and *D$D ;pyromellitic dianhydride L 76hydro!yehtylmethacrylate> developed by 4owen and associates. 'erric o!alate 9 reducing dentin permeability by B- percent. 'erric o!alate at p# ..E may dissolve the smear layer and then re6precipitate as calcium o!alate and ferric phosphate salts, occluding the patent and e!posed tubules. "a)ahashi 6 the lactate, tartarate, citrate, maleate, and chlorides of Al, Kn, &a, Sn and Dg were evaluated, with Saforide ;diamine silver fluoride>, silver nitrate, calcium hydro!ide, #yperband 3imura ;paraformaldehyde>, and FottliebCs recipe ;@inc chloride and potassium ferrocyanate solutions> serving as positive controls. 7.,? percent aluminum lactate ;p# ,=> emerged as the agent of choice for further clinical investigation. Addy and his cowor)ers 6 the sensitive teeth were found to have an average number of -E.E open tubules per unit area versus =.G= for the nonsensitive e!amples. "he average tubule diameter was estimated as ..?< microns for the sensitive teeth and ..G< microns for the non6sensitive e!posed dentin areas. Addy and associates also reported the effects of acids and acidic dietary substances on root6planed and bur6cut dentin. (sing S:D, the authors observed that the strong mineral acids such as nitric, sulfuric, citric and lactic removed the smear layer, as did red wines, citrus fruit 1uices, apple 1uice and yogurt. 'inally, the recent wor) by Absi and colleagues, which involved the development of a replica technique to study sensitive and non6sensitive
G.

cervical dentin, is a rather novel approach. Silicone impressions were ta)en of e!tracted human teeth that had been root planed to e!pose dentin and then acid etched to e!pose dentinal tubules. "hese replica S:Ds were compared with S:Ds of the original dentin surfaces. :!cellent correlation between the original and replica S:Ds in terms of tubule cunts was reported as well as e!cellent resolution of surface details such as tubule diameters as low as , micron, illustrating patent tubules. 3im used a refined electrophysiologic method on the vital teeth of cats, dogs, and humans to measure baseline pulpal sensory nerve activity ;S0A> or electric potential and the effects of therapeutic agents on their activity. 3im reported for the first time that potassium ion is the active portion of potassium nitrate and any other potassium compound. 2hen potassium ions reached the pulpal sensory nerve, after passage through dentinal tubules in 3imCs deep6cut cavities, the e!ternal part of the nerve membranes became regions of greatly increased potassium concentration. "his locali@ed increase in potassium caused rapid firing of the sensory nerve that ceased quic)ly because the e!tracellular potassium ions subsequently inhibited hyperpolari@ation of the pulpal sensory nerve, that is, they raised the nerve action potential and produced a desensiti@ing effect. HYPERSENSITIVE TEETH : E2,eri&ent$% studies of dentin$% desensiti3in0 $0ents : 0ot all teeth with e!posed dentine are sensitive. "eeth with toothbrush or other forms of abrasion and erosion may have e!tensive loss of tooth structure without sensitivity. ,> "he dentinal smear layer consists of small amorphous particles of dentin, minerals, and organic matri!, which cover the cut surface of dentine, obstructing the orifices of the tubules.

G,

7> Salivary proteins adhere to the outer dentine surface and, in addition, plasma proteins can adhere to the inner dentine surface, bloc)ing the tubules. <> Reparative dentine forms in response to chronic irritation. "his type of dentine is less permeable than primary dentine and serves to insulate the pulp from irritating stimuli. Anatomic study of pulpal nerves shows that in the coronal area of the tooth there is e!tensive peripheral branching of a!ons and many a!ons entering the dentine. "his is in sharp contrast to the cervical and radicular areas, where most of the a!ons are found in central bundles and very little branching occurs. #ow then can the roots becomes so sensitive T %ne possible e!planation is provided by 4yers and cowor)ers. 'ollowing grinding of the roots f rat molars they found sprouting of new a!ons branches in the area of in1ury. "hus, the dentine in the area of in1ury may be more richly innervated than intact sites. ,> t can reduce fluid flow through the dentine by clogging the tubules. 7> t can decrease the activity of the dentinal sensory nerves, preventing the pain signal from being transmitted to the central nervous system. "oothpastes containing Sr&l7 and 30%< have gained wide popularity. 4oth agents have been hypothesi@ed to cause bloc)age of dentinal tubules. #istorically, 30%< was preceded by silver nitrate, and this substance was reported to be effective but permeability stained teeth blac) and was never popular in our cosmetically conscious society. Met#od for &e$surin0 sensor ner-e $cti-it : n order to study the effects of desensiti@ing agents, the multi6unit intradental recording method developed by Scott and modified by others was used. n the canine teeth of anestheti@ed cats and dogs, two dentinal cavities were prepared, one deep cavity over the incisal pulp horn and a
G7

second less deep cavity near the gingival margin. "he incisal cavity an active low impedance platinum or silver + silver chloride electrode was placed. "he incisal cavity was also used to apply various stimulating and desensiti@ing solutions. "he gingival cavity held a reference electrode and was always filled with saline. "he electrodes were connected to standard pre6amplifier and recording equipment. (sing this method, many intradental nerve units can be recorded simultaneously. n order to study the effect of desensiti@ing agents, some means of stimulating neuronal firing had to be used. 'irst the e!citatory solution <D 0a&l was applied to the cavity for 7 minutes. "he nerve activity during this time constitutes the control sensory nerve activity. "hen, following a 76minute saline rinse, the test desensiti@ing agent was placed in the cavity for 7 minutes. mmediately following removal of the test desensiti@ing agent, the <D 0a&l was reapplied. 30%<, the active ingredient in Sensodyne ' and $enquel, significantly reduced the sensory nerve activity. Strontium chloride, which is the active ingredients in Sensodyne toothpaste, was shown to be effective only at the higher concentration. ,> "he 0%<9 anion is not effective as a desensiti@ing agent. 7> 3L is an effective desensiti@ing agent regardless of the anion with which it is combined. <> $ivalent cation solutions were effective in reducing sensory nerve activity but less effective then 3L. 4oth 3L and divalent cation solutions had a reversible effect, that is, they did not appear to damage the dentinal sensory apparatus. Mode of $ction of effecti-e $0ents : "he e!tracellular potassium ion concentration is the principal determinant of the nerve resting electrical potential. "he normal resting potential for nerve fibers is appro!imately 9 E. mv measured from the
G<

inside of the cell. 2hen the concentration of 3L is increased above the normal physiologic level the cell depolari@es, that is, the inside becomes less negative. %nce a certain critical ;threshold> potential level is reached, action potentials begin to occur. %wing to the properties of the membrane gates that mediate the action potential, the burst of spi)es in response to increase 3L does not last long. After ,- to 7. seconds of prolonged depolari@ation, the action potentials cease as a result of the closing of the action potential membrane gates. $ivalent cations such as &aLL, DgLL, and SrLL can act to stabili@e the nerve membrane by raising the membrane threshold without actually changing the resting potential. Recent evidence also suggests that divalent cations may bloc) the membrane channel that mediates the action potential. *atients who brush with 30%<9 containing toothpastes do not complain of pain when applying these agents. Also, in our e!periments, desensiti@ation occurs immediately and is of short duration in contrast to the clinical situation, in which all desensiti@ing agents require time and repeated application of the agent of order to have ma!imal benefit. Future directions : *ain and inflammation are interconnected phenomena. "he presence of inflammation in hypersensitive teeth has yet to demonstration. nflammation is mar)ed by an increase in blood flow. "he laser $opper flowmeter 9 allows continuous monitoring of pulpal blood flow. 2hen the effect of agents that stimulate sensory nerve activity such as hypertonic 0a&l and 3&l solutions are tested, these solutions cause an increase in pulpal blood flow. 2hen lidocaine is applied to bloc) nerve activity, the blood flow changes evo)ed by 3&l are greatly attenuated. ETIOLOGY AND CLINICAL IMPLICATIONS OF DENTINE HYPERSENSITIVITY :

GG

$entine hypersensitivity may be defined as : pain arising from e!posed dentine, typeically in response to chemical. A number of other dental conditions are associated with dentine e!posure and therefore may produce the same symptoms. Such conditions include chipped teeth, fractured restorations, restorative treatments, dental caries, undisplaced crac)ed cusps ;the crac)ed tooth syndrome>, and palato6gingival grooves or other enamel invaginations. "hus, a careful history, together with a thorough clinical and radiographic e!amination, is necessary before arriving at a definitive diagnosis of dentine hypersensitivity. #owever, the problem may be made difficult when two or more conditions co6e!ist. "here can be few other conditions or diseases in man besides dentine hypersensitivity that are treated apparently successfully by so many compounds. Some authors have commented that because of their sub1ective nature many of the earlier reports on desensiti@ation have little scientific basis and belong in the realms of testimonials. T#e %esion : $irect evidence has been gathered of tubule patency associated with dentine hypersensitivity. "hus, teeth diagnosed as e!hibiting dentine hypersensitivity, when e!tracted and studied by scanning electron microscopy, e!hibited in e!cess of seven times the mean surface tubule count at buccal cervical dentine sites compared with teeth classified as non6 sensitive. Incidence $nd distri.ution : &ross6sectional prevalence studies for dentine hypersensitivity have been limited in number and there are no longitudinal incidence figures for the condition. "he available prevalence data vary considerably, and dentine hypersensitivity has been stated to range from ? to <. per cent of adult dentate populations. Dost sufferers range in age from 7. to G. years a pea) occurrence is found at the end of the third decade. "he reduced incidence of
G-

dentine hypersensitivity in older individuals despite increasing dentine e!posure with age, particularly through gingival recession, presumably reflects age changes in dentine and the dental pulp. Sclerosis of dentine, the laying down of secondary dentine, and fibrosis of the pulp would all interfere with the hydrodynamic transmission of stimuli through e!posed dentine and the response of pulpal nerves. A slightly higher incidence of dentine hypersensitivity is reported in females than in males, however, the differences are not usually statistically significant. Dost surveys do not conform to standard epidemiologic methods, and therefore a gender difference may or may not e!ist. $entine hypersensitivity is most commonly reported from the buccal cervical @ones of permanent teeth. $entine e!posure may occur occlusally and at lingual cervical sites, but in many populations this is less frequently found and sensitivity only rarely reported. &anines and premolars in either 1aw are the most frequently involved. Additionally, in a group of patients characteri@ed as moderate to severe sufferers, the dominant factor influencing the distribution of recession and dentine hypersensitivity was the side of the mouth. Etio%o0 $nd ,redis,osin0 f$ctors : $entine may become e!posed by two processes either loss of enamel or loss of covering periodontal structures, usually termed gingival recession. Aoss of enamel occurs by attrition associated with occlusal function and may be e!aggerated by habits or *arafunctional activity such as bru!ismM by abrasion from dietary components or habits such as toothbrushingM or by erosion associated with environmental or dietary components, particularly acids. *robably rarely, if ever, is enamel loss due to a single agent. :!posure of root dentine by gingival recession similarly is multifactorial, but acute and chronic periodontal diseases, toothbrushing, or

GB

chronic trauma from other habits and some forms of periodontal surgery are important causal factors. ndirect and direct evidence indicates that for dentine to be sensitive, not only must it be e!posed to the oral environment but dentinal tubules have to be patent at the surface. &learly not all factors that e!pose dentine necessarily open dentinal tubules. ndeed, most mechanical influences applied to dentine, including abrasion and attrition, cause this plastic tissue to flow, producing the so6called smear layer. "his very thin layer thus will cover the dentine surface and obturate the tubules. "he buccal cervical site predilection for dentine e!posure and sensitivity is consistent with toothbrushing practices, with lingual sites receiving little attention during the brushing cycle of most individuals. "he particular involvement of canines and premolars is therefore not surprising, because epidemiologic evidence and data from dentine hypersensitivity sufferers indicate these are the most well cleaned teeth. nterestingly, the finding that females are more commonly affected by dentine hypersensitivity than males, if actually correct, would also relate in part to oral hygiene practices. 'emales have increased grooming behavior compared with males, and this is associated with better oral hygiene. n vitro studies suggest that brushing with water will remove the dentine smear layer to e!pose tubules only after protracted periods of continuous brushing. 4rushing with a toothpaste may produce occlusion of tubules both by a smearing effect on the dentine and by the deposition of toothpaste ingredients on the dentine and into the tubule orifices. Some artificial silicas readily adhere to dentine, occlude open dentinal tubules, and are resistant to removal by washing or dietary acids. 2or)ers e!posed to fumes of hydrochloric, sulfuric, nitric, picric and tartaric acids e!hibit e!tensive tooth decalcification as do individuals with a high dietary acid inta)e or suffering gastric regurgitation. %rganic hydro!y
G=

acids, in particular citric acid, appear more erosive than inorganic acids, and clearly activity is not directly p# dependent. "he rate of erosion is rapid, and buffering by saliva is probably too slow to prevent the initial decalcification. Aoss of enamel or dentine due to toothbrushing is very mar)edly increased with prior e!posure to dietary acids. "he role of plaque as an etiologic factor in dentine hypersensitivity would appear to be an area of controversy. "hrough, even over6enthusiastic, toothbrushing has long been associated with gingival recession and sensitivity, yet other authors have suggested that plaque causes dentine hypersensitivity. Darginal lea)age around restorations leading to bacterial activity may be responsible for pulpal pathology and sensitivity beneath restorations. "he possible role of saliva and bacterial contamination of e!posed dentine in dentine hypersensitivity has been proposed but not proved. 4acteria do penetrate into tubules of dentine left open to the oral environment and therefore to!ins may diffuse to the pulp. "his diffusion would have to occur over relatively large distances and against the outward flow of dentinal fluid. Additionally, the concentration gradient would be 1ust as great if not greater in an outward direction. *laque6induced dentine sensitivity is considered in the differential diagnosis, in which the emphasis of management would be quite different from that of dentine hypersensitivity. C%inic$% i&,%ic$tions : "he possible consequence of dentine hypersensitivity could be reduced oral hygiene. "hus, the scenario has been proposed of pain on toothbrushing leading to a vicious circle of reduced plaque control, more gingival disease, more recession, and more sensitivity. "he dental surgeon will have to choose the treatment to provide from an e!tensive range of possibilities. ndeed, different treatments may be chosen for different teeth in the same mouth. 2hatever is decided, all
G?

treatments are designed either to bloc) the dentine sensitivity mechanisms or to interrupt nerve transmission. "hese treatment modalities encompass e!tremes, from the use of toothpaste and applications of restorative materials to dentine, to endodontia or even e!odontias. "here is a need for greater public awareness, through education, of the effects of e!posure to acids on the teeth, particularly dietary acids. Accepting the nutritional and health value of many acidic foods and beverages, as with any item in the diet, e!cessive quantities or frequency of inta)e rarely produce proportional increase in benefits and may have deleterious effects on certain systems, including the teeth. "he need to determine etiologic factors in dentine hypersensitivity is essential if management is to be successful, and this should include the ta)ing of a diet history or evaluating the less common possibilities of e!ogenous erosive elements in an individualCs living or occupational environment. n the light of the aggravating effect of toothbrushing, advice on method and frequency would appear sensible. :!cessive force should be avoided, as should the use of very abrasive toothpastes. Aittle benefit to periodontal health is obtained with frequencies of toothbrushing in e!cess of twice a day. ndeed, advice to brush before meals should be provided, and because there are clear benefits from such a regimen derived not only from mechanical cleaning but also from the properties of toothpaste, before6meal brushing should be the norm for all individuals. Su&&$r : Danagement requires the determination of etiologic factors and predisposing influences, and where possible, their control or modification. METHODS OF MEAS+RING TOOTH HYPERSENSITIVITY : :lectrical stimulation differs from the other stimuli in that the stimulus is not transmitted by the movement of the dentinal fluid. Rather, it is transmitted by the passage of electrical charge via the moisture associated
GE

with the organic material in enamel, cementum, and dentine as well as that in dentinal tubules, especially if they are open. F$ctors $ffectin0 &e$sure&ent of # ,ersensiti-it : (sing a silicone rubber impression method to obtain replicas of root dentine surfaces in vivo, Absi, Addy and Adams showed that non6sensitive teeth have closed dentinal tubules, whereas tubules of sensitive teeth are open. 4ecause enamel is thic)er than cementum, it generally provides greater protection of the underlying coronal dentinal tubules e!cept perhaps near the cemento6enamel 1unction where the enamel is thin. :namel, because of its thic)ness, also provides greater electrical resistance. A greater electrical stimulus is required to produce a sensation in molars because of their thic)er enamel coverings than in premolars and cuspids and in turn, incisors. Aoss of the thin protective cementum easily occurs with use of a hard toothbrush and+or an abrasive toothpaste, or by root scaling and planning during oral hygiene and periodontal therapy. Another factor that may affect hypersensitivity values is the state of the pulp. nflamed pulpal tissue could result in a reading of greater sensitivity than normal, whereas necrotic pulp tissue generally results in readings of lower sensitivity or non6sensitivity. Still another factor is the fact that stimuli for some sensitivity measurements persist. "his means that more time is required for the tooth and pulp tissues to return to baseline values before another or a repeat stimulus can be applied. A placebo effect occurs remar)ably frequently in clinical studies on tooth hypersensitivity. Dc'all and #amric) and Addy and his cowor)ers suggest that toothpaste components may also contribute to this frequently observed placebo effect. Met#ods used to &e$sure toot# # ,ersensiti-it :
-.

T$cti%e : "he simplest tactile method used to test fro hypersensitivity is to lightly pass a sharp dental e!plorer over the sensitive area of a tooth ;usually along the cemento6enamel 1unction> and to grade the response of the patient on a severity scale, generally . to <. a score of . is assigned if no pain is felt, , if there is slight pain or discomfort, 7 if there is severe pain, and < if there is severe pain that lasts. Smith and Ash a device with a ,-mm ;..7B gauge> stainless steel wire with a tip ground to a fine point and moveable across the highest arc of curvature of the facial surface of the sensitive tooth under test. "he scratching force could be increased with a small screw that moves the tip closer to or away from the totoh surface. As the wire is passed across the surface of the test tooth it bends, and the amount of bending of the wire and therefore the force applied can be measured from a scale on the device. "o start the measurement, the screw for ad1ustment of the wire tip is set so that the tip 1ust barely touches the root surface being tested. "hen the wire is moved laterally in an arc across the area of sensitivity. "his procedure is repeated after the pressure is increased with the ad1ustment screw. "his is continued, usually in steps of ,+G or ,+< of a millimeter, until the sub1ect is able to feel a pain sensation. At that point, the scratching force, e!pressed in millimeters, is ta)en as the threshold value. "o permit accurate repositioning for a subsequent re6e!amination, a matri! of dental compound is fitted over the lingual and occlusal surfaces of two or three teeth near the tooth being measured. 2hile the compound material is still soft, the frame of the device is impressed in the compound material. Another tactile device that has been used is the force6sensitive electronic probe devised by 5eaple for measurement of the depth of periodontal poc)ets at fi!ed pressures. Such a pressure sensitive probe has
-,

been modified to accept the tine of a dental e!plorer tip. "he operator can vary the force applied to the tip of this device by regulating the amount of current to an electromagnet controlling the tip position. "he probing force is set, and when reached, the probe tip is retracted by an electromagnetM a red light on a control panel goes on, and the applied force is released. "he handle of the probe is about the si@e of a fountain pen and is connected by a fle!ible electrical lead to the control panel. "he probe force is controlled within , gram. &alibration is carried out by using a top loading balance to relate probe meter readings in microamperes with probe force in grams. n a dentinal sensitivity test, the probe force can be increased in steps of - grams until the sub1ect e!periences discomfort. "hat point is ta)en as the pain threshold. f a ma!imum force of =. grams is reached with no discomfort, the tooth is scored as non6sensitive. "he probe emits a bu@@ing sound when a predetermined pressure is applied. T#er&$% : A simple thermal method for testing for tooth sensitivity is directing a burst of room temperature air from a dental syringe onto the test tooth. Room air is cooler than the teeth, and cooling by this means can be easily detected as pain if the teeth are sensitive. 4lowing air on a tooth also involves drying, which as pointed out above could also be stimulatory. Air stimulation has been standardi@ed in a number of studies as a ,6 second blast from the air syringe of a dental unit, where its temperature is set generally between B-. and =.. ' and at a pressure of B. psi. usually, the air is directed at right angles to the test surface near the cemento6enamel 1unction and+or e!posed root surface, with ad1acent teeth usually isolated by the operatorCs fingers. Responses are assessed on a severity scale such as . where there is no discomfort, , if there is some discomfort but no severe

-7

pain, 7 if severe pain is felt during application of the stimulus, and < if severe pain occurs during and persists after stimulus application. "he temperature of room air is about 7. .& and when gently blown over a hypersensitive site at about <7.&, the temperature of the site decreases. 4y using a miniature thermistor connected to a multi6channel recorder, "hrash and associates found that the temperature could be easily measured. Deasurement of the drop in temperature is usually repeated three times and the average ta)en. "actile stimuli are applied before thermal stimuli if the two are being used in the same sub1ect. Ash, the temperature of the probe tip was measured with a thermistor embedded in the tip. A flow of current in one direction was used to cool the probe tip from room temperature to ,7 .&M current flow in the other direction heated the tip to ?7.&. the temperature was controlled by regulating the intensity of the current to the probe from a power supply. "he initial temperature for thermal sensitivity testing was set at <=.-.&. 'or cold stimulation, the temperature was reduced in decrements of appro!imately ,.&. at each lower decrement, the instrument was shut off and the stimulator tip was then placed in contact with the root surface. "he sub1ect raised his or her hand when pain was first detectable. "esting with heat was carried out in e!actly the same way e!cept that the temperature of the stimulating tip was increased from the initial temperature of <=.-.& in increments of ,.& to the point at which pain could be felt. Os&otic : "he sub1ective pain response to a sweet stimulus was used by Dc'all and #amric) to measure the effect of several test dentifrices on dentinal sensitivity. "his was done by preparing fresh a saturated solution of sucrose and allowing it to reach room temperature. After isolation of the test tooth with cotton rolls, a cotton applicator was saturated with the sucrose solution
-<

and then applied to the root surface of the tooth and allowed to remain in place for ,. seconds or until discomfort was perceived. "he sub1ect rated the sensation as no pain or pain, which was recorded as . or ,, respectively. "he osmotic challenge was stopped by rinsing with warm water. E%ectric$% : :lectrical measurements differ from the others in that a pain response can be obtained from non6sensitive as well as from sensitive teeth and with either an enamel6covered crown or a cementum6covered root site of stimulation. (ntil recently, instruments for applying electrical stimuli of increasing intensity, generally referred to as pulp testers, were used mainly to determine whether a pulp is vital or not. "he answer determined the treatment that would be carried out. nstrument improvement led to better quantification of the electrical stimulus and discovery that a condition of pre6pain consisting of a tingling or warm sensation is observed before real pain and discomfort are felt by the sub1ect as the magnitude of a stimulus is increased. "he pre6pain sensation has been attributed to the larger, more rapidly conducting, nerve fibers located at or in the pulp reacting sooner, than the smaller diameter nerve fibers that are also present. "he presence of a pre6pain @one of stimulation ma)es it possible to obtain threshold stimulation levels without hurting the patient. "his results in less or no apprehensionM such apprehension can have an adverse effect on readings. nstruments for stimulating a tooth electrically have as their basic constituents an electrode or probe to apply the electrical stimulus to the test tooth, a power source, a means of varying the electrical stimulus so that its magnitude can be progressively increased, an a means of completing the electrical circuit. 4ecause of the high resistivity of teeth, toothpaste or a similar material with high electrical conductivity is necessary to facilitate transmission of the electrical stimulus to the tooth. n some cases, the
-G

operator serves as a means of completing the circuit, with the finger of one hand in contract with the patientCs mouth and the other hand in contract with the casing of the probe. 2ith the present need of the operator to wear protective gloves, this method is not satisfactory. Also, alternate pathways of current flow are more li)ely to occur if the operator is part of the electrical circuit. :limination of the operator from the circuit was accomplished by Star), who used as a reference electrode a saliva e1ector connecting the patient to a pulp6stimulating instrument that he called the pulp stethoscope. As an alternative, the reference electrode can be applied to the s)in as in :&F measurements. "he electrical resistance of the s)in can vary from ,... ohms for damp s)in to , million ohms for dry s)in. 4y using a conducting gel, this difference largely disappears. "his method is better than the saliva e1ector method of Star) because there is less li)elihood of interruption of the electrical circuit during a measurement. Alternate pathways of current flow that are of some concern are those that can occur via the gingival ad1acent to the site of electrode placement on the tooth, via other oralM soft tissues such as the chee) or tongue, or via saliva. All of these can be eliminated by carefully isolating and thoroughly drying the tooth being tested and by having the insulation of the stimulating probe e!tend right up to its tip. 'ortunately, the sensation felt by a patient when the gingival, tongue, or chee) is inadvertently touched with the probe tip is very different and easy to distinguish from the sensation felt when only the tooth is controlled and the pulp is stimulated. 4y trial and error, an electrical stimulus consisting of a direct current pulsed voltage between . and ,-. ;$igilog *ulp "ester> or between . and <.. volts ;Analytic "echnology *ulp "esterM Redmond, 2A> has been found suitable for eliciting a pulp response. f an alternating current supply is used to power the unit generating the electrical stimulus, then for safety reasons, it must provide for patient isolation. Although alternating current6
--

powered units are bul)ier and less portable than direct current6powered instruments, they do allow for easier addition of printers and other recording devices, which are e!tremely useful for recording such information as the tooth stimulated and the magnitude of the electrical stimulus that elicited a pulpal response. 'or safety reasons, any electrical current that is applied should be limited to less than , milliampere, preferably ..- milliampere or less, which is in the appro!imate range of the human bodyCs threshold of current perception for , second hand6to6hand contact. "he voltage of an electrical stimulus should be in the from of pulses to avoid summation and a chance of reaching voltage levels that might result in pain rather than pre6pain. *ulses with a width of ...- to ..7. millisecond each and spaced at - to ,. millisecond intervals will provide a stimulus of pre6pain instead of pain. 2ith a commercial digital pulp tester that contains this feature of automatic ramping ;Analytical "echnology *ulp "ester>, an indicator light comes on when the probe tip contacting the surface of a tooth encounters a circuit resistance below - million ohms. Met#od use in studies : t seems from the numerous studies that have been carried out on tooth hypersensitivity that different types of teeth in the human dentition and teeth of different ages and history will vary considerably in their response to pain6producing stimuli so that testing of homologous pairs of teeth would be prudent. "o assess effects of an agent on dentinal sensitivity, there need to be relatively large numbers of sub1ects with sensitive and non6 sensitive teeth in a cell. n general, we have found this number to be a minimum of 7- but preferably <-. Conc%usion : #ypersensitivity apparently affects one in seven dental patients. t is a problem that should not be ignored because many of such teeth may become
-B

non6vital with time. 0ow that such measurements are becoming possible, practitioners should be able to monitor teeth that are sensitive to determine whether they are getting better or worse following treatment. A chronically sensitive tooth should be a warning sign that a pulp is under continual trauma. 2ith the aging of the population, greater retention of teeth, and greater root surface e!posure because of gingival recession and periodontal surgery, one can e!pect the number of sensitive teeth to rise.

DESIGNING HYPERSENSITIVITY CLINICAL ST+DIES :

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A clinical dentinal tooth hypersensitivity study is first and foremost a clinical pain study. &ritical design factors include proper selection of investigator, sub1ects, hypersensitivity test measurement devices, agents to be tested, and statistical analysis. In-esti0$tor : "he central aspect of hypersensitivity studies is the investigator. "he investigator must )now and understand the neurophysiologic e!planations for cause and effect of dentinal hypersensitivity. "he design and implementation of a research protocol require comprehension of the proposed mechanism. "he investigator should be capable of designing a thorough and efficient hypersensitivity study protocol. Sufficient time must be allocated to manage every aspect of a hypersensitivity study. "he test site must be adequately staffed with trained au!iliary personnel. "he best plans have little chance to translate into a well e!ecuted study when crammed into a busy schedule. "he investigator must understand that the sensitive region of the tooth can be very specific. 0ot every e!posed cervical dentin area not all points within a )nown sensitive area will be hypersensitive. "he investigator must be thoroughly trained and e!perienced in the use of the test devices. n becoming proficient, the investigator will develop an intuitive feel for the sensitivity of the measuring device and when it is being correctly applied to suspected sensitive areas.

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"he investigator should be adept in evaluating prospective study sub1ects fro their genuine interest in participating in the study. #e or she should be able to determine that each sub1ect is properly relating when sensitivity is first perceived, or when a sub1ect is 1ust giving answers to get through the study for one reason or another. Dost importantly, the investigator must be capable of developing rapport with sub1ects so they will be able to rela! during hypersensitivity test e!aminations. A rela!ed, professional atmosphere will give sub1ects a chance to provide accurate and reliable responses during the hypersensitivity testing procedures. O-er$%% desi0n : *rinciples of good clinical design must be followed in order to attain reliable conclusions. 2hen performing a dentinal hypersensitivity study this usually means double6blind, parallel, randomi@ed or stratified, and comparative study designs. n a double6blind study, neither the investigator ;including research personnel> nor the sub1ect )nows the identity of the test product assigned to the sub1ect. n a parallel study, all test materials+products should be assigned to separate sub1ect groups+ cells and used by the respective sub1ect cells. "hus, each sub1ect group tests only one product. n a cross6over design, each sub1ect uses one of the study products for a specified use6time. At the end of the product use6time, the sub1ects use no study product for a brief period to wash out the effect of the first study product. "his wash6out period is then followed by use of a second study product by each sub1ect. "he product6use and wash6out period sequence is followed by the sub1ects until they have used all study products. &ross6over designs are contraindicated because the wash6out period is not usually )nown for most desensiti@ing agents.
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A comparative study compares one product to another. "he simplest study design tests an active product to a placebo control. Dore complicated studies might compare two or more active products with each other and with the placebo. Sub1ect recruitment, e!perimental design and statistical analysis become more difficult as the number of cells is increased.

Test &$teri$%s : "he dentifrice with the active agent ;active dentifrice> should be compared with the same dentifrice without the active agent ;placebo or negative control>. t must be emphasi@ed that the placebo dentifrice should possess the same color, taste, consistency and ingredients as the active dentifrice e!cept for the active agent. "he clinical dentinal hypersensitivity literature is replete with reports demonstrating efficacy for the placebo dentifrice. "his is common referred to as the placebo effect. "he use of a placebo control dentifrice will not only enable demonstration of desensiti@ing efficacy by the active agent aloneM it will also rule out an additional potential placebo effect within the active product itself. &omparison of two or more desensiti@ing dentifrices is a frequent ob1ective of clinical hypersensitivity studies. %ne of the dentifrices might be a well )nown and documented desensiti@ing product. "his dentifrice could be referred to as a positive control and lead the investigator to rationali@e that negative or placebo control is not necessary. A placebo control ;negative> should be included in studies comparing two active products to verify that the design and conditions of the study will allow active agents to overcome a placebo effect and demonstrate their potential efficacy.
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Su./ect se%ection : Sub1ect selection is the most demanding part of a clinical hypersensitivity study. Specific sub1ect selection criteria should be written into the protocol and strictly adhered to. "he study should be designed to answer a question with regard to an identified population. "he study sub1ects should be a representative sample of that population. (sually, the study sub1ect population represents the general population of those bothered with dentinal hypersensitivity. %ccasionally, the primary ob1ective of the study is subset of the population, such as post6periodontal surgery patients. *eople troubled by hypersensitivity were found to range from ,- to BE years of age. "he greatest concentration were in their 7.s and <.s. sensitivity has also been reported to be evenly distributed in males and females. deal sub1ects should be : ,. &ooperative and relatively rela!ed in the dental chair 7. :!perienced in interacting with dentists as dental patients <. Reliable in their responses to test measurements, use of assigned product, and attendance at appointed e!aminations. *rospective sub1ects should not be troubled with active periodontal disease in the areas of their hypersensitivity teeth. *rospective sub1ects should not have undergone periodontal surgery within B months prior to the initiation of the study. $ental hypersensitivity is a particular problem in the post6periodontal surgery patient. A study designed specifically to investigate hypersensitivity in post6periodontal surgery patients would be appropriate. "eeth with crac)ed tooth structure, large carious lesions, or restorations should not be acceptable study teeth.

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*rospective sub1ects should be in good general health. "hey should not be suffering from a chronic debilitating disease or a chronic disease that is associated with daily episodes of pain, such as arthritis. Such conditions would most probably interfere with obtaining representative hypersensitivity pain data. An important final consideration for sub1ect selection would be the level of hypersensitivity appropriate for inclusion in the study. 'or e!ample, the tactile sensitivity of a prospective study tooth should not be too close to the tactile sensitivity of a prospective study tooth should not be too close to the low end of tactile sensitivity, which precludes the opportunity to demonstrate potential improvement, that is, non6responsive. %n the other end of the sensitivity range, it might not be appropriate to include a tooth that is on the high end of tactile sensitivity. t might be difficult to distinguish between pulpal and dentinal pain for those sub1ects. t is also infinitely more difficult to reliably measure hypersensitivity pain at this end of the range of pain. H ,ersensiti-it &e$sure&ent : 2hatever stimulus is used, the stimulus should be quantifiable and reproducible. "he stimulus should also elicit dentinal pain and not pulpal pain. $entinal pain is usually rapid in onset, sharp in nature, and of short duration. $entinal pain is produced by stimuli such as tactile, cold, heat, and osmotic, which are applied to e!posed dentin. A general principle for all studies, clinical or laboratory, is to use accepted methods. (nfortunately, acceptable devices+techniques have not yet been established for measuring hypersensitivity. "hus, a large share of the underta)ing of a clinical hypersensitivity study is transformed from a science to an art. T$cti%e sensiti-it :

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A dental e!plorer is passed over e!posed dentin on the labial cervical areas of suspected sensitive teeth. Sub1ects will then report their sensitivity or lac) of sensitivity to the e!aminer. %nce sensitive teeth have been designated and sub1ects enrolled in a clinical study, the dental e!plorer is frequently used to measure tactile sensitivity levels throughout the study. Sub1ects will then evaluate their level of tactile sensitivity to the e!plorer using a verbal rating scale ;PRS>. A typical PRS might appear li)e this to the sub1ect: . R 0o discomfort, but aware of stimulus , R Dild discomfort 7 R Dar)ed discomfort < R Dar)ed discomfort that lasted more than ,. seconds Deasurement of tactile sensitivity by this method has two limitations. 'irst, the investigator should test all sensitive areas on all teeth of all sub1ects during all e!aminations with the same tactile pressure. "his would be an almost impossible tas). Second, the PRS offers a restrictive choice of words that may not represent pain e!perience with sufficient precision for all sub1ects. An electronic pressure6sensitive probe ;5eaple probe> has been used to measure levels of tactile sensitivity. "he primary advantage of the probe is that tactile sensitivity can be reported in terms of a quantified reproducible grams force. "he probe tip ;dental e!plorer> can also reach all tooth surfaces in all areas of the mouth. &are must be e!ercised that the force is applied gradually so that the applied force will not go beyond the point at which the sub1ect actually perceives sensitivity. "he investigator may sweep a suspected sensitive area with a tactile probe several times before finding 1ust one spot within the area that elicits sensitivity by the sub1ect. *atience is a virtue in these situations.
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T#er&$% sensiti-it : "he cold stimulus appears to be the strongest and causes the greatest problems to those troubled by dentinal hypersensitivity. A method often reported in the literature for measurement of cold sensitivity is the ,6second air blast at about =..' from a dental unit air syringe. "here are several problems associated with this apparently simple quantifiable technique that render it difficult to reproduce accurately. 'irst, there always e!ists the problems of proper control f the temperature of the air emanating from the syringe. "he usual practice is to report a temperature range of B?. to =<. '. such a relatively wide range has the danger of crossing bac) and forth over the threshold temperature of cold air sensitivity for each sub1ect. "he intensity of the stimulus could also vary in accordance with variances in pressure ;usually reported at B. psi>, the distance of the syringe tip from the tooth being tested, and the actual duration of the ,6second air blast. "he latter of these two intensity factors are investigator controlled and could easily vary from one test to another. "he question of an air drying effect on the e!posed dentin area from the air blast has not been resolved. mmediately after the cold air blast, the sub1ect usually reports the level of sensitivity via a PRS as discussed for tactile sensitivity.

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"he pain threshold approach has also been used test sensitivity to cool+cold air. A temperature6controlled stream of air was directed to the e!posed dentin of a sensitive tooth via a disposable plastic tip. "he initial air temperature of ,...' was reduced until the sub1ect first e!perienced sensitivity or until a lower limit of =..' was reached. "he air stream was generated by a compressor at ,. psi. the air temperature was controlled by an intricate device and was monitored at all times by a temperature probe 1ust prior to the e!isting of the air through the tip. "his technique would appear to be quantifiable and reproducible, but it may have the advantage of drying and sensiti@ing a test tooth as the investigator proceeds down through a temperature range. "he thermocouple device used to test thermal sensitive provides a continuous application of heat or cold via a probe tip to a point on the tooth. "he device has the advantage of precise control of temperature, but it suffers from a lag between probe and tooth surface temperature. changes in temperature must be made slowly so that a temperature threshold of sensitivity is not bypassed. n addition, sensitivity measurement by this device may not be representative of real world thermal sensitivity e!perienced by sub1ects. Sub1ects usually complain of cold air or cold liquids and not cold ob1ects. &old air or cold liquids produce sudden changes in dentin temperature and thereby, sudden shifts in dentinal fluid in the tubules result in hypersensitivity pain as described by the hydrodynamic theory. "he thermocouple would most li)ely produce more gradual changes in dentinal temperature and dentinal tubule fluid movement.

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A cold water testing technique was developed and later modified to include the use of different temperatures of water placed directly on the e!posed dentin. *lastic impression syringes were filled with water from thermal insulated containers with temperatures equilibrated to 7. ., ,.. and ..&. the investigators used the syringes to flow water over the e!posed root surface fro < seconds or until a positive response was noted by the sub1ect. "esting began with water at 7. .& and proceeded to ,.. and .. or until a positive response was obtained. "he intensity of pain perceived by the sub1ect at the temperature that first produced a positive response was not evaluated. "his method is, in effect, a threshold technique and should include several more temperatures of water between 7.. and ..&. to add more temperatures would require more thermal insulated water containers. "he requirement of numerous water baths would ma)e the technique considerably more equipment intensive. Another concern about this technique would be controlling the amount of water flowed over the e!posed dentin during each challenge. C#e&ic$% sensiti-it : &hemical stimuli have been used in clinical hypersensitivity studies. "he stimulus is not conductive to threshold measurement because repeated applications of the chemical stimulus reduce the sensitivity of the e!posed dentin. *roblems such as inconvenience, difficulty in administering and controlling the stimulus, and possible in1ury to the ad1acent soft tissue de6emphasi@e the chemical stimulus as a practical measurement of hypersensitivity in clinical studies.

E%ectric$% sensiti-it :

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Application of electrical stimuli to either enamel or e!posed dentin has not been shown to result in any noticeable effect on tubule fluid movements. "he electrical stimulus would appear to be more appropriate for measuring pulp vitality than dentinal sensitivity. Su./ect $ssess&ent : 2ord descriptors that patients use to describe their hypersensitivity pain have not been documented. &linical hypersensitivity studies should provide an opportunity to indicate the )ey words that best describe hypersensitivity pain throughout the use of an assigned product. "he sub1ects quantitative assessment of their own overall perception of hypersensitivity pain has been used in clinical studies. 2hen this method of evaluating the level of hypersensitivity is used, sub1ects are as)ed to rate the severity of sensitivity that they have been e!periencing during their everyday routine. "hey are to include stimuli from cold air, hot+cold foods or drin), sweet and sour food, toothbrushing and so on in their overall sensitivity evaluation. 2hen provided a suitable method for evaluation of perceived sensitivity, sub1ect assessment of hypersensitivity during a clinical study provides meaningful information. "he visual analogue scale is an acceptable method for providing this assessment. Visu$% $n$%o0ue sc$%e : A visual analogue scale ;PAS> is a line, usually ,. cm in length. "he e!tremes of the line represent the limits of pain a sub1ect might e!perience during a dentinal hypersensitivity episode. %ne end could be labeled no discomfort or no pain, whereas the other end could be labeled severe discomfort or severe pain. Sub1ects are as)ed to place a mar) on the ,.cm line at a location between the no pain and sever pain ends that best indicates their current level of hypersensitivity. 2hen the PAS is properly e!plained to sub1ects, they can easily understand its use and successfully use it to indicate their level of pain response to a hypersensitive stimuli. "he
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Pas offers a continuum between what the sub1ects would perceive as the e!tremes of pain ;none to severe>. "he PAS also offers a greater capacity to change in response to a hypersensitive stimulus. %n the other hand, the verbal rating scale ;PRS> is restrictive in that it does not offer enough descriptions that can be placed in a continuous and ascending ;or descending> order of severity of pain. (se of the PAS has been found to be reproducible because a very high correlation between successive measurements of pain severity has been noted. A,,%ic$tion of sti&u%i : 2hen more than one stimulus is used, the application order of the stimulus is very important. &are should be ta)en to insure, as much as possible, that each stimulus does not interfere with other stimuli used in the measuring procedure. "he least disturbing stimulus should be used first, with the most disturbing stimulus used last. $epending on which stimuli are used, testing should begin with sub1ect assessment and then followed by tactile, heart and cold stimuli. &ontrol of e!traneous factors that could potentially influence sub1ect response is important. Standardi@ed instructions and stimulus demonstration should be given. "he e!amination room should be free of distractions caused by noise, music, lights, temperature and so on. Avoid fear6generating procedures. "he sub1ect should be allowed to ad1ust to the e!amination room environment. Test ,roduct $ssi0n&ent : Su./ect $ssi0n&ent : "he first consideration in sub1ect assignment should be the establishment of two sub1ect groups ;cells> with equivalent level of dentinal hypersensitivity. "reatment of equivalent levels of hypersensitivity is very important for a meaningful comparison of the active dentifrice with the

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control dentifrice and the establishment of a desensiti@ing efficacy by the active dentifrice. Random assignment of sub1ects to treatment groups is the simplest scheme to implement. 4y this method, however, an investigator is always at ris) of ending up with groups of different levels of hypersensitivity by this method. "he ris) becomes greater as the group si@e is decreased, whereas the ris) is lessened as the group si@e is increased. %ne easy method of stratification involves maintaining a cumulative sum of the cold sensitivity measurements from the baseline e!amination of sub1ects. Sub1ects are assigned to the two groups with the guideline of maintaining equivalent sums of cold sensitivity data between the two groups. "he stratification process can be made more intricate by also maintaining equivalent tactile sensitivity sums between the two groups in addition to maintaining equivalent cold sensitivity sums. "he second consideration is sub1ect group assignment based on real world population variables. Fenerally, the sub1ects within each group should be in the age range of 7. to -.. "his age range should also be equally represented between the two groups. 2henever possible, males and females should be equally represented in each group. Achieving the ideal representation of these population variables is often very difficult because of the usual limited availability of hypersensitivity sub1ects. Product $ssi0n&ent : "he active and control dentifrices should be assigned to the sub1ects so that the investigator, sub1ect, and any other office staff do not )now which product each sub1ect is using ;double blind>. "he active and control dentifrices should be pac)aged in plain dentifrice tubes and properly coded for identity. A third person who has no investigator or sub1ect contact should be the only one who )nows the code.
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Stud %en0t#4e2$&in$tion ,eriods : "he length of time sub1ects brush with their assigned dentifrice can be a critical factor of dentinal hypersensitivity studies. Sub1ects should use their assigned dentifrice over a sufficient time period to : ,. $emonstrate clinical efficacy on the part of the active desensiti@ing dentifrice as compared to the control or placebo dentifrice. 7. Rule out a placebo effect on efficiency as compared with the active dentifrice. t has been the e!perience of the authors that a placebo effect by the control dentifrice usually runs its course in about B wee)s of treatment. n order to confirm the course of the placebo effect, hypersensitivity measurement should be obtained after ? and ,7 wee)s of use of the study dentifrices. "hus, a suggested e!amination+length of study format would be two baseline hypersensitivity e!aminations , wee) apart, begin use of study dentifrice immediately upon completion of the second baseline e!amination, and hypersensitivity e!aminations obtained upon completion of 7, G, ? and ,7 wee)s of dentifrice use. St$tistic$% $n$% sis : Sound statistical principles of study design and analysis must be considered at the outset of the trial, not at the conclusion. 'ailure to do so could wea)en the scientific validity of the study and lead to inaccurate conclusions. mportant factors to consider include representativeness of the sub1ect sample, number of sub1ects needed, treatment group allocation methods, and selection of appropriate analytic methods. "he clinical investigator should not turn to the statistician after a study has, been completed without prior consultation and e!pect the statistician to derive statistical meaning from the data.

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$esigning hypersensitivity study is in effect a clinical e!periment of testing the null hypothesis that the active desensiti@ing dentifrice is no different than the control dentifrice in reducing hypersensitivity. "he ability to separate treatments in a statistical analysis is partly a function of the statistical tests used. A desirable statistical test has a small probability of re1ecting the null hypothesis when it is true and a large probability or re1ecting it when it is false. *arametric tests usually have higher probabilities of re1ecting the null hypothesis when it is false than non6parametric tests. 2hen appropriately used, both parametric and non6 parametric tests have low probabilities of re1ecting the null hypothesis when it is true. "he choice of which of these two statistical techniques and which specific tests should be used depends on several factors and assumptions. A good study should include enough sub1ects to have adequate power. "hat is , the study should be able to identify, with high confidence, when there is a meaningful difference between the treatment groups. "his is especially important when interpreting studies that show no statistically significant difference between the treatment groups. 'or studies with an adequate number of sub1ects, this result can be interpreted to mean that the treatments are unli)ely to differ by a meaningful amount. n studies with too few sub1ects, the failure to differentiate treatments may simply be due to insufficient power. OVER5THE CO+NTER DENTIFRICES IN THE TREATMENT OF TOOTH HYPERSENSITIVITY : "raditionally, a dentifrice has been defined as a substance used with a toothbrush to aid in cleaning the accessible surfaces of the teeth. *ader has e!panded this definition to recogni@e the pharmacologic role of anticaries therapeutic dentifrices by defining a dentifrice that falls into this category as an abrasive6containing dosage from for delivering anticaries agents to the teeth. A dentifrice formulated to alleviate or treat the symptoms of tooth
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hypersensitivity can be defined as an abrasive6containing dosage form for delivering desensiti@ing agents to the affected teeth. t is important to note that in the (nited Stages and many other countries, dentifrices that claim to treat the symptoms of tooth hypersensitivity are regulated as drugs and thus must meet strict standards of safety and effectiveness. Dentifrice $s $ de%i-er -e#ic%e : "oothpaste, by far the commonest form of dentifrice, is apparently a simple product but is actually quite comple! in formulation terms. %n the one hand, consumers e!pect a toothpaste to e!trude from its container easily, spread onto and stic) to the toothbrush, but then brea) apart and foam almost instantly when brushing starts. (sers also e!pect a pleasant and refreshing flavor, a certain level of foam, and a lac) of stringiness and grittiness. &onversely, manufacturers must provide a product that is stable and retains its rheologic characteristics for 7 or ideally < years and more important, retains effective drug availability and delivery potential for this length of time, often under less than ideal storage conditions. $entifrice components include abrasive, surfactant ;foamer>, humectant, thic)ener, flavor, sweetener, coloring, and water. "herapeutic dentifrices contain drug agents in addition to the other items. $esensiti@ing dentrifices are, for the most part, standard in formulation e!cept that a concern for abrasivity e!ists because the condition is associated with e!posed cementum or dentin, structures that are much softer than enamel. Abrasives are solid particles that clean or polish the tooth surface. compounds used for this purpose include various insoluble calcium salts ;e.g., phosphate, pyrophosphate, and carbonate>, sodium metaphosphate, and alumina. n recent years, a shift toward silicas has occurred because of their compatibility with fluoride, and their utility in formulating clear or opacified gel dentifrices. n the (nited States the abrasiveness ;abrasivity> of a dentifrice is commonly determined by an in vitro procedure in which
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radioactive dentin is mechanically brushed with a standardi@ed slurry of dentifrice under a standard protocol developed by the American $ental Association ;A$A>. "he amount of radioactive material removed is compared with that removed by a standard abrasive, which is given a value of ,..M hence, this scale is commonly referred to as the R$A ,.. ;radioactive dentin abrasivity> scale. Dost toothpastes that are available today, including desensiti@ing pastes, have R$A values from about -. to ,-.. this is well within the estimate of a safe and effective level of abrasiveness, -. to 7.. R$A, provided by *ader after e!tensive review. $entifrice abrasives are essential to prevent tooth staining. 4ecause clinical studies have shown that the degree of stain formation is inversely proportional to the abrasivity level, a certain degree of abrasiveness in a dentifrice is cosmetically essential. &linicians, however, have sometimes noted wedge6shaped lesions or defects at the cementoenamel 1unction, and the question has arisen as to the role of dentifrice abrasives in the etiology of this condition. "he results of a clinical study designed to answer this question showed that the action of brushing contributed substantially to the amount of dentin removed, whereas the contribution of dentifrice abrasivity was not a ma1or factor in the progression of cervical lesions. A second cosmetic attribute of dentifrices that is essential to successful treatment of tooth hypersensitivity is flavor. n fact, the taste of a dentifrice is one of the most important factors related to the continuous use of a particular dentifrice, and, perhaps somewhat surprisingly, mar)et research has shown that most consumers will not continue to use a particular dentifrice solely for its therapeutic benefit. Dost desensiti@ing toothpastes have a taste that is different from that of conventional toothpastes because they incorporate therapeutic agents. 2hen recommending or prescribing a product, clinicians should e!plain this to the patient. "he fact that a taste is different does not mean that it is unacceptable. "he pleasantness of a taste is
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a cultural, sub1ective, and personal phenomenon, and adaptation can rapidly occur. f a patient reports that the flavor of a particular brand is unacceptable for continued use, then the dentist should recommend another brand that incorporates a different active system. (sing an in vitro dentin disc system, *ashley and co6wor)ers found that dentifrice components could occlude tubules, and that products differed in their ability to produce this effect. &linically, Addy and &o6wor)ers related decreased tooth sensitivity to an in vitro observation that the fine silica abrasive particles in some toothpastes readily occluded open dentinal tubules. nteractions among several potential dentifrice components affect their upta)e by dentin, and these interactions may have advantageous or negative consequences for treatment. RATIONALE FOR OTC TREATMENT OF TOOTH HYPERSENSITIVITY (p to one in seven adults screened in an office practice in Swit@erland had tooth hypersensitivity. n view of this incidence, home6use %"&6desensiti@ing products appear to be the most realistic and practical means of treating most patients with tooth hypersensitivity and should be the first step in routine management. "his presupposes that the diagnosis of hypersensitivity has been made and the patient educated as to the proper preventive measures to adopt. 'irst, they are readily and widely available, especially in pharmacies. Second, the products are cost6effective. Repeated dental office visits for desensiti@ation treatments are costly in terms of time and money. "hird, the %"& products are simple to use and noninvasive. 'ourth, the habit of tooth brushing is almost universal in economically developed societies, the patient is not required to do anything he or she would not normally do, thus easing problems with regimen compliance. n ,E?,, the &ouncil on $ental "herapeutics of the American $ental Association established a category for
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acceptance of desensiti@ings agents. *roducts that meet the associationCs criteria for safety and effectiveness are allowed to display the A$A seal of acceptance on the product and pac)aging, provided the manufacturer also agrees to adhere to the associationCs standards in promotion and advertising. &urrently, the council has accepted formulations containing three active ingredients for %"& dentifrice use : potassium nitrate, strontium chloride he!ahydrate, and dibasic sodium citrate in a pluronic gel. C%inic$% &et#ods of effic$c $ssess&ent : t is important to note that the ultimate criterion of success for a hypersensitivity treatment is, in fact, the sub1ective opinion of the clinician and patient : the former will not use a procedure or recommend a treatment that is perceived to be ineffective, whereas the latter will not allow a treatment regimen that does not alleviate the pain encountered in everyday situations. 0evertheless, the unreliability of sub1ective opinions alone necessitates that well6designed, double6blind, controlled clinical trials be conducted to establish scientifically the effectiveness of hypersensitivity treatment procedures before dissemination to the dental profession and the public at large. *ain perception, however, depends on several variables including among other factors the significance of the pain, individual personality, psychological factors, cultural attitudes, anticipation of pain, and the degree of apprehension. "hat fact, along with other negative study design factors including lac) of stimulus standardi@ation among investigators, led to inconclusive or contradictory results in many studies in which the intensity of pain perceived was the primary measurement criterion. An ad hoc advisory committee on dentinal hypersensitivity appointed by the A$A recommended the following study design features M ,> the test data should be quantifiable and reproducible M 7> the threshold of response should be established, preferably quantified, and correlated to a clinically
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definable intensity M <> the relationship between the e!perimental stimulus and the defined area of hypersensitivity must be established by controlled clinical research M G> if more than one stimulus is used, then these stimuli should be reproducible, and interference between them must be minimi@ed M and -> appropriate statistics should be used, and these should be 1ustified according to the e!perimental design. "he committee recommended, in addition to sound clinical and statistical design, the use of variable stimulus level6fi!ed threshold response as opposed to the earlier method of fi!ed stimulus level6variable response for the evaluation of tooth hypersensitivity. n evaluating the results of clinical desensiti@ation studies, the clinician should carefully determine how close the methodology used is in conformance with the preceding guidelines and give greater credence to results obtained with newer methods. 0ote that the terms old methods and new methods are used for convenienceM many studies conducted decades ago essentially confirm to the guideline, whereas some studies conducted recently do not. CLINICAL RES+LTS Strontiu& c#%oride Dentifrices $entifrices containing ,.I strontium chloride he!ahydrate as the desensiti@ing agent have been widely available for three decades. Sensodyne tooth paste for Sensitive "eeth was the product testedM at least one other brand ;"hermodent Sensitive "eeth "oothpaste, Dentholatum &ompany, 4uffalo, 0ew 5or)> incorporating strontium chloride he!ahydrate is available commercially. Ross in ,EB, reported the results of a monadic study conducted among =? office patients who were instructed to use this dentifrice at home. Sub1ectively, =<I of the sub1ects reported complete relief of the condition, and this was confirmed by the clinician who observed the sub1ectsC involuntary response to artificially induced tactile and thermal stimuli.
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Alleviation of symptoms usually occurred within , month of use. Similar results were reported in other monadic studies by &ohen, S)urni), Deffert and #os)ins, Kelman. Although these early monadic studies showed that the use of a strontium chloride dentifrice had a potential benefit, they did not establish the efficacy of the drug agent itself because a placebo control was not used. Subsequently, as clinical methodology evolved, several double6blind, placebo6controlled clinical studies, were conducted two double6blind, placebo6controlled clinical studies were conducted two double6blind studies comparing the effectiveness of a strontium chloride dentifrice against that of a placebo control, or placebo and monofluorophosphate6containing controls. n the study against placebo, after G wee)s of use, B?I of the sensitive teeth in <? sub1ects had improved in the active group as compared with -<I in the <? sub1ects using the placebo. "his difference was significant at the E-I confidence level. After ? wee)s of use, however, although the percentage of improved teeth in both the active and placebo groups continued to increase ;=B vs. =,I respectively> the differences were no longer significant. Sub1ects using the monofluorophosphate dentifrice e!perienced the same degree of benefit in comparison with the placebo as did sub1ects using the strontium chloride product. 4lit@er conducted a double6blind ,6month study in which the patients sub1ectively rated their response to either an active ;7. sub1ects> or placebo ;,= sub1ects> dentifrice into the categories of complete disappearance of hypersensitivity, partial relief, or no improvement. n the active group, =-I of the sub1ects rated their improvement as complete in comparison with 7GI in the placebo group. "he intergroup difference was significant at the EEI confidence level. Smith and Ash conducted a double6blind, placebo6controlled study over B. days in 7. sub1ects using qualitatively applied thermal and
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mechanical stimuli to elicit a response. Sub1ects also self6rated their hypersensitivity condition. "he results showed that no improvement occurred in either group regarding any of the parameters tested. /ohnson and co6wor)ers found that after ,7 wee)s of unsupervised twice daily use, 7? sub1ects using the strontium chloride dentifrice demonstrated an increase in the ability to tolerate a cold water stimulus of -.<< .&, whereas an identical number of sub1ects using a conventional stannous fluoride dentifrice showed a smaller increase of <..G.&. "he intergroup difference was significant at the EEI confidence level. Addy and cowor)ers found that a strontium chloride dentifrice was significantly superior to a placebo dentifrice when measured by the graded responses using the classical cold air method, but was inferior to the placebo in terms of the number of sensitive teeth responding to a thermoelectric probe set at ..& and -.&. Min6off $nd A2e%rod : (chida and co6wor)ers studied the effectiveness of a strontium chloride dentifrice in treating hypersensitivity following periodontal surgery. n the active group, the pain score ;a summary of pain responses to mechanical, cold water, and cold air stimuli> increased from ,.7 to 7.B, , wee) postoperatively, and then decreased to ..B ;=BI>, ? wee)s postoperatively or = wee)s after the start of treatment. n the placebo group, the pain score also increased from ,.. to 7.7, , wee) postoperatively, but at the end of treatment the value was still ,.G, a <GI reduction. "he significance of the (chida study lies in the fact that the results quantitatively confirmed the clinical impression that periodontal procedures often induce tooth hypersensitivity, and, additionally, that a strontium chloride dentifirce is effective in relieving the condition.

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Pot$ssiu& Nitr$te Dentifrices : n ,E=G, a potassium nitrate6containing dentifirce was reported as providing effective desensiti@ation for <- dental office patients who e!perienced slight to severe tooth hypersensitivity. "he positive results for the agent provided by this type of quantifiable stimulation in double6blind controlled studies led to the acceptance by the A$A of several commercial products, $enquel Sensitive "eeth "oothpaste ;Richardson6Pic)s, 2ilton, &onnecticut>, Sensodyne6', and promise with 'luoride. "arbet and co6wor)ers compared the relative abilities of four active ingredients present in %"& dentifrices to desensiti@e hypersensitive teeth. "hey reported that -I potassium nitrate was the most effective agent tested and ran) ordered the relative effectiveness of the other agents tested as follows: strontium chloride, dibasic sodium citrate, formaldehyde. %n an overall basis, the clinical evidence supports the efficacy of a -I potassium nitrate dentifrice for the alleviation of the pain of tooth hypersensitivity. Di.$sic Sodiu& Citr$te Dentifrices $ibasic sodium citrate, formulated into a pluronic '6,7G containing dentifrice ;*rotect> is the final ingredient currently recorgni@ed by the A$A as being safe and effective for the treatment of dentinal hypersensitivity. For&$%de# de Dentifrices : 0o longer sold in the united States, %ne brand, :moform is available in the (nited 3ingdom. Actually, dentifrices that contain ,.7 to ,.GI formaldehyde were the first widely available, commercially successful desensiti@ing dentifrices. &linically, however, the results have been decidedly mi!ed. n early monadically designed studies, some investigators reported a favorable effect. "he results for formaldehyde dentifrice have been generally negative. Dc'all and Dorgan confirmed the negative tactile

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finding but also found a significantly increased ability to tolerate a quantifiable cold stimulus. "he A$A has not evaluated this agent to date. F%uoride $nd ot#er dentifrices : %ne of the more popular early in6office treatments for treatment of hypersensitivity was burnishing the affected sites with fluoride6containing medicaments. "he results of several studies, especially, those conducted with sodium monofluorophosphate in comparison with nonfluoride control, indicate a certain degree of effectivness. 3anouse and Ash found that after < months of use, sub1ects using the monofluorophosphate dentifrice had an increased tolerance to cold and hot of ,.=.& and ,.<.&, respectively, whereas sub1ects using a placebo showed increases of ..- .& for both stimuli. "he intergroup differences were significant at the E-I confidence level. RECOMMENDATIONS FOR F+T+RE ST+DY DESIGN After reviewing the clinical desensiti@ation literature of the last <. years, one can conclude that a ma1or obstacle impeding the development of more efficacious products to treat tooth hypersensitivity is the lac) of standardi@ation in study design. &linical studies have been of varying duration, from G to ,7 wee)sM numbers of sub1ects per e!perimental cell vary widelyM and the unit of data analysis has been the hypersensitive surface, hypersensitive tooth, and the individual. 'leiss and 3ingman state that it is a mista)e to employ statistical procedures that ta)e individual sites as the units of analysisM the patient must be the unit of analysis. Although intrastudy comparisons are possible, and overall assessments of drug efficacy are possible on the basis of the number of studies and their overall quality, interstudy comparisons cannot be made. #ence, questions such as the relative effectiveness of agents or the comparative times required to observe an effect cannot be answered reliably on the basis of published data.
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&ontrast this situation with that in anticaries clinical research. n this area, the units of measurements are well defined: decayed6missing6filled teeth or surfaces. Deasurements are usually made at yearly intervals. :ven the usual test population, school children, is well6defined because this age group is both prone to the disease and is readily accessible to clinical investigators. n earlier studies, the active products were compared with true placebosM currently, new products are compared with clinically verified positive controls. "he net result of this has been the establishment of a large data base suitable for interstudy comparisons, which will allow for future advances in this area. &hoice of stimulus will remain a difficult issue because different investigators have different opinions on this instrumentation. 0evertheless, some have adopted tactile stimulation because at least one instrument is widely available ;5eaple *robe, Pine Palley Research, Diddlese!, 05>. A re-ie* of Current A,,ro$c#es to In5Office &$n$0e&ent of toot# H ,ersensiti-it : CLINICAL CHARACTERISTICS OF DENTAL HYPERSENSITIVITY "he terms dentin sensitivity and dentin hypersensitivity are often used interchangeably, although the prefi! hyper6denotes e!cessive sensitivity. 2hereas dentin sensitivity is a normal response to stimulation of freshly e!posed dentin, hypersensitivity may have a more pathologic basis. n virtually all cases of hypersensitivity, it is the vestibular surfaces of the teeth that are sensitive. %rchardson and &ollins found that in different tooth types the relative frequency of hypersensitivity was: premolars, <? percentM incisors, 7B per centM canines, 7G per centM and molars, ,7 per cent. $entinal hypersensitivity is sub1ective evidence that dentin has lost its investiture of cementum. #owever, about ,. per cent of teeth have no cementum covering the cervical portion of the root, and in these teeth
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gingival recession alone may lead to hypersensitivity. Dost hypersensitive teeth have associated gingival recession in e!cess of ,mm, and about <. percent have cervical lesions. Fingival recession can be caused by periodontal disease, periodontal therapy ;including oral prophyla!is>, and improper tooth6brushing habits. "ypically, the chief symptom of dentinal hypersensitivity is a sharp, sudden pain of short duration, although some patients complain of a dull, lingering sensitiveness. "he most frequent complaint is sensitivity to cold, but pain may also be elicited by the use of a toothpic) and +or brushing. n some cases, hot liquids and sweet or sour foods may evo)e a response. Although most teeth are sensitive to more than one stimulus, not all hypersensitive teeth respond to the same stimulus. DIFFERENTIAL DIAGNOSIS : n attempting to determine the cause of discomfort, teeth should be e!amined for the presence of carious lesions, restorations, fractures, discoloration, periodontal disease, occlusal trauma, and e!posed dentin that might be sensitive. %nce the diagnosis of hypersensitivity has been established, it may be advisable to obtain a written dietary history in order to gather information regarding the possible etiologic role of acidic foods. ncomplete tooth fracture can be associated with a number of symptoms ranging from mild discomfort to severe pain. "he most common complaint is pain to pressure. "apping the teeth or having the patient bite down on an orangewood stic) almost invariably evo)es a sharp pain in the affected tooth. Application of a dye such as methylene blue to suspected tooth may aid in the diagnosis by disclosing the line of fracture. :!posure of dentin due to chipped enamel is usually obvious. 'ractured restorations may be more difficult to visuali@e. 0evertheless, careful e!amination of the restoration will usually reveal the fracture.

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$ifferentiating dentinal hypersensitivity from caries is realatively easy, particularly in the case of a deep carious lesion. #owever, it must be recogni@ed that caries and dentinal hypersensitivity can coe!ist in the same tooth. "ooth sensitivity following a restorative procedure may resemble hypersensitivity in that the tooth is particularly sensitive to heat and cold and the evo)ed pain is generally of short duration and moderate intensity. Acute hyperfunction. A common e!ample is the new amalgam or crown that has been placed without proper ad1ustment of the occlusion. Although the recent operative procedure may be partially at fault, hyperfunction alone can produce symptoms of pulpitis, %cclusal equilibration has been reported as a treatment modality for hypersensitive roots that did not successfully respond to accepted desensiti@ing methods. "eeth in acute hyperfunction are typically responsive to temperature changes and may mimic hypersensitive dentin, even though the investiture of these teeth ay be intact. Application of a saturated solution of &a&l 7 ;?.?m> on a cotton pellet may be useful in identifying areas of hypersensitive dentin ;$r. $avid *ashley, personal communication>. Saturated &a&l7, a highly soluble salt, is capable of evo)ing a sharp sensation by creating a strong osmotic pressure across dentin, thus producing fluid movement in the tubules. $iagnosis of pulpitis must be based on sub1ective and ob1ective findings. $iagnostic aids include history of pain, percussion and palpation tests, inspection of the teeth and surrounding tissues, thermal and electric pulp tests, and radiographic e!amination. "he dental history should cover the chronology, nature, location, radiation, and aggravating and alleviating factors that influence the pain. $entinal hypersensitivity resembles reversible pulpitis in that pain is generally mild to moderate and fairly well locali@ed to the tooth in question.
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SPONTANEO+S REMISSION OF HYPERSENSITIVITY t is well )nown that hypersensitivity often abates without treatment. "his is probably related to the fact that dentin permeability can decrease spontaneously. 0atural processes contributing to desensiti@ation include the formation of reparative dentin by the pulp, obturation of tubules by the formation of mineral deposits ;dentinal sclerosis>, and calculus formation on the surface of the dentin. t has been estimated that appro!imately 7. to G- per cent of patients who receive no treatment or sham treatment e!perience relief. PLACE'O EFFECT A ma1or factor in the establishment of a placebo response is the doctor6patient relationship. ndividuals afflicted with real or imagined illness must have complete confidence in their doctor because patient e!pectations are critical for the induction of the placebo response. llness and discomfort are perceived by the patient as threatening, and it is assumed that practitioners are able to decrease the peril. A positive doctor6patient relationship can motivate a patient to obtain relief. 'urthermore, positive emotional and motivational behavioral responses can activate the bodyCs central pain6inhibiting system. this system modulates painful stimuli from the periphery through the release of endorphins centrally. PATIENT MANAGEMET nforming a patient in advance regarding the possibility of a potentially painful event can greatly strengthen the doctor6patient relationship, alleviate an!iety, reduce unnecessary emergency calls, lower the ris) of litigation, and enhance the placebo effect. *roper patient management relies heavily on good communication s)ills. :very patient must be informed of the potential treatment ris)s, and post6treatment dentinal hypersensitivity is no e!ception.

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IN5OFFICE TREATMETN PROCED+RES : RATIONALE OF THERAPY "reatment of hypersensitive teeth should be directed toward reducing the functional diameter of the tubules so as to limit fluid movement. n order to accomplish this ob1ective there are several possible approaches : ,. 'ormation of a smear layer by brushing the e!posed root surface. 7. "opical application of agents that form insoluble precipitates within the tubules. <. mpregnation of tubules with plastic resins. G. Application of dental bonding agents to seal off the tubules. Although most agents that are effective in reducing dentinal hypersensitivity are also effective in partially occluding the dentinal tubules, potassium nitrate ;30%<> is an e!ception. S*:& ' & "R:A"D:0" D%$AA " :S : *rior to treating sensitive root surfaces, hard or soft deposits should be removed from the teeth. Root planning with curettes or otherwise manipulating sensitive dentin may cause considerable discomfort, in which case teeth should be anestheti@ed prior to treatment. "he teeth should be isolated and dried with warm air. 2hen using desensiti@ing agents that have a caustic effect on sot tissue, care must be e!ercised to prevent them from contacting the alveolar mucosa. C$-it V$rnis#es : $entin often becomes insensitive when open tubules are covered with a thin film of varnish. "his may be an effective means of providing temporary relief. 2ycoff advocates the use of a cavity varnish such as &opalite. 'or more sustained relief, a fluoride6containing varnish, $uraflor. &an be applied

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Corticosteroids : Dosteller reported that when a liner consisting of , per cent prednisolone in combination with 7- per cent para6chlorophenol, 7- per cent m6cresyl acetate, and -. per cent gum camphor was applied to the walls of cavities, it was completely effective in preventing postoperative thermal sensitivity. t has also been reported that burnishing an ophthalmic corticosteroids solution into sensitive root areas achieved some success. Studies involving the use of corticosteroids have provided little evidence that desensiti@ation was due to the hormone, particularly when it was claimed that sensitivity was promptly relieved. &orticosteroids are not fast6acting drugs. Effects of 'urnis#in0 Dentin :

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4urnishing of dentin with a toothpic) or orangewood stic) results in the formation of a smear layer that partially occludes the dentinal tubules. *ashley and cowor)ers employed an in vitro method to study the effects of burnishing 0a', )aolin, and glycerin, alone or in various combinations, on dentin permeability. "hey observed that burnishing created a partial smear layer that reduce fluid movement across dentin by -. to ?. per cent. 4urnishing dentin with a dray orangewood stic) was more effective in reducing dentin permeability than burnishing with glycerin alone. For&$tion of inso%u.%e ,reci,it$nts to .%oc6 tu.u%es : &ertain soluble salts react with ions in tooth structure to form crystals on the surface of the dentin. n order to be effective, crystalli@ation should occur within , to 7 minutes, and the crystals should be small enough to enter the tubules. "he crystals must also be large enough to partially obturate the tubules. Although relatively large crystals such as calcium o!alate dihydrate ;which form when potassium o!alate is applied to dentin> are very effective in reducing permeability smaller crystals such as &a' 7 are les apt to be effective. Although it is used infrequently today, Ag0%< is time6honored desensiti@ing agent. 0umerous authors have attributed the effectiveness of Ag0%< to its ability to precipitate protein constituents of odontoblast processes ;"omesC fibers>, thereby partially bloc)ing the tubules. #owever, there are reasons to doubt this e!planation.

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Fottlieb developed the @inc chloride 9 potassium ferrocyanide impregnation method for desensiti@ing root surfaces and cavities. n this procedure a G. per cent solution of aqueous @inc chloride was rubbed into the surface per cent aqueous solution of potassium ferrocyanide was vigorously rubbed onto the dentin surface until an orange, curdy precipitate formed. Scanning electron micrographs of this precipitate have revealed a highly crystalline deposit covering the dentin surface. As most of the crystals were too large to enter the tubules, it is doubtful whether this method would provide a more efficient means of desensiti@ing dentin than burnishing alone. Frossman proposed formalin as the desensiti@ing agent of choice in treating anterior teeth because, unli)e Ag0% <, it does not produce an unsightly stain. 'ormalin has been used in the dental office in a concentration of G. per cent ;full strength> for topical application by means of cotton pellets or orangewood stic)s. CALCI+M COMPO+NDS : C$%ciu& # dro2ide : &alcium hydro!ide ;&a;%#7> has been a popular agent for the treatment of dentin hypersensitivity for many years, particularly after root planning. "he e!act mechanism of action is un)nown, but evidence suggests that it may bloc) dentinal tubules or promote peritubular dentin formation. (sing S:D, 4rannstrom observed a variable constriction of the dentinal tubules in the ma1ority of teeth treated with &a;%#> 7, but only to a depth of .., mm D1or employed microradiograph to compare &a;%#>7 9 covered dentin with normal dentin and demonstrated increased radiodensity in the &a;%#>76covered dentin.

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4ecause increasing the concentration of calcium ions around nerve fibers can results in decreased nerve e!citability &a;%#>7 might be capable of suppressing nerve activity. #owever, "rowbridge and cowor)ers found that application of &a;%#>7 to the walls of deep cavities in cat canine teeth had no effect on the e!citability of nerve fibers in the underlying pulp. Aevin and associates applied &a;%#>7 paste to the nec)s of ,,? teeth in -. patients and found it to be immediately effective in reducing sensitivity in E? per cent of the teeth. 'irst, sensitive teeth were isolated and dried with cotton rolls. 0e!t, a paste of &a;%#> 7 and sterile distilled water was applied to the e!posed root surfaces with a sable brush. "he paste was allowed to remain on the tooth for < to - minutes. After removal of the paste, the tooth was tested sensitivity. f the dentin was still sensitive, the paste was re6applied. *ashely and cowor)ers found that &a;%#>7 was effective in reducing the permeability of acid6etched dentin as well as smear layers. #owever, when B per cent citric acid was applied to the &a;%#> 76treated smear layer, dentin permeability returned to the initial acid6etched value. "his would suggest that ingestion of acidic foods and beverages might result in removal of &a;%#>7 from the dentin. Di.$sic C$%ciu& P#os,#$te : #iatt and /ohansen studied the effectiveness of burnishing &a#*% G into sensitive areas of roots with a round toothpic) and found that E< per cent to patient reported significant relief of discomfort, as compared with 7per cent of the control group, which received burnishing only. FL+ORIDE COMPO+NDS :

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Au)oms)y was the first to propose sodium for fluoride ;0a'> as a desensiti@ing agent. Aater, #oyt and 4ibby developed a paste consisting of equal parts of 0a', )aolin, and glycerin. "he paste was burnished into the e!posed root surfaces with a porte polisher, an orangewood stic) or a rubber cup for , to - minutes. Although this procedure was considered to be a success in decreasing sensitivity, at least part of the effect can be attributed to burnishing. Dore recently, fluoride gels have been developed for in6 office treatment of hypersensitivity. 4ecause dentinal fluid is saturated with respect to calcium and phosphate ions, application of 0a' to dentin leads to precipitation of &a' 7 crystals, thus reducing the functional radius of the dentinal tubules. "he crystal si@e of &a'7 is very small ;appro!imately ..- m>, and therefore as single application of 0a' has less effect on dentin permeability than agents such as potassium o!alate that give rise to larger crystals. 'urthermore, it has been shown that fluoride is lost fairly rapidly following application of 0a' to dentin. "his may e!plain why topical application of fluoride solutions is of limited effectiveness in reducing sensitivity on a long6term basis. :vidence suggests that a small fraction of the fluoride initially applied to dentin is retained in the insoluble apatitic form, thus ma)ing the lattice more stable and less soluble in acid. "his could protect the dentin from dietary acids, which tend to open the tubules. Acidu%$ted Sodiu& F%uoride : Aaufer and colleagues observed that the concentration of fluoride in dentin treated with acidulated 0a' was significantly higher than dentin treated with 0a'. #owever, there was no difference after samples were washed with synthetic saliva. Sodiu& si%icof%uoride:
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4hatia claimed that application of saturated solution ;..B per cent> of sodium silicofluoride for - minutes was much more potent than a 7 per cent solution of 0a' in desensiti@ing painful cervical areas of teeth. :verett and associates postulated that silicic acid forms a gel with the calcium of the tooth, thus producing an insulating barrier. St$nnous F%uoride : 4lan) and &harbeneau advocate burnishing a ,. per cent solution of stannous fluoride ;Sn'7> into sensitive root areas. :llingsen and R lla. "his observed a dense layer of tin6 and fluoride6containing globular particles bloc)ing the dentinal tubules. "he dentinal tubules were totally covered even after treatment with relatively low concentrations of Sn'7. 4long and associates found that a ..G per cent Sn' 7 gel was an effective agent in the control of pain associated with hypersensitive dentin. #owever, prolonged use of the gel ;up to G wee)s> was necessary to achieve satisfactory results. F%uoride 7 Inoto,#orises : ontophresis is a term applied to the use of an electrical to transfer ions into the body for therapeutic pusposes. "he ob1ect of fluoride iontophoresis is to drive fluoride ions more deeply of fluoride alone. n a histologic study, lefl)owit@ observed secondary ;reparative> dentin in the pulps of teeth e!tracted soon after iontophoresis and concluded that iontophoresis stimulates dentin formation. "his inference is highly suspect, as it ta)es several wee)s for reparative dentin to form in human teeth. ontophoresis is not a simple procedure. t involves the placement of a negative electrode to dentin and a positive electrode to the patientCs face or arm. f the negative electrode ma)es contact with salvia, gingival tissue or a metallic restoration, the flow of current will follow the path of least resistance and stream around the dentin rather than through. t for this,
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reason, Fangarosa recommended that teeth be isolated with plastic strips and cotton rolls rather, than a rubber dam. #e cautions that moisture can accumulate between the tooth and the rubber dam, thus providing a low resistance pathway for the current. Although a number of authors have reported a significant reduction in sensitivity with the use of iontophresis with 7 per cent 0a', Freenhill and *ashely6 found that the use of Ag0%< or potassium o!alate produced significantly grater reductions in hydraulic conductance than fluoride iontophoresis. Although iontophoresis has gained some popularity, its effectiveness needs to be demonstrated in well6controlled clinical studies. ontophoresis devices are e!pensive, somewhat difficult to use, and generally less cost6 effective than other treatment procedures. Strontiu& c#%oride : 3un found that ;topical application of concentrated strontium chloride ;Sr&l7> on an abraded dentin surface produced a deposit of strontium that penetrated dentin to a depth of appro!imately 7. and e!tended into the dentinal tubules. t has been suggested that strontium deposits are produced by an e!change with calcium in the dentin resulting in recrystalli@ation in the form of a strontium apatite comple!. Fedalia and associates reported that topical application of ,. per cent Sr&l7 prior to application of 7 pre cent 0a' was more effective in decreasing sensitivity than 0a' alone, as assessed < months following treatment. O2$%$tes : Since their initial development as a desensiti@ing agent, the o!alates have gained great popularity, particularly among periodontitis. "hey are relatively ine!pensive, easy to apply, and well tolerated by patients.
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*otassium o!alate and forric o!alate solutions ma)e available o!alate ions that can react with calcium ions in the dentinal fluid to form insoluble calcium o!alate crystals that are deposited in the apertures of the dentinal tubules. S:D revealed a high degree of tubule occlusion by crystals that almost completely covered the orifices of the tubules. Subsequent application of B per cent citric acid to the o!alate6treated dentin did not increase dentin permeability, indicating that calcium o!alate should be resistant to dietary acids. n the development of an effective desensiti@ing system, there o!alate compounds have been developed, B per cent ferric o!alate, <. per cent dipotassium o!alate, and < per cent monohydrogen6monopatssium o!alate. *ashley and Falloway found that when reacting with ioni@ed calcium, <. per cent dipotassium o!alate produced fewer but significantly layer calcium o!alate crystals than those produced by < per cent monohydrogen6 monopotasium o!alate. "hese investigators suggested that the larger crystals are only effective in obturating wide open tubules, whereas the smaller crystals are capable of obturating open as well as partially close tubules. Application of 3#%! to the etched dentin reduced sensory nerve e!citability to the level of unetched dentin. 3#%! is commercially available under the name of *rotect. t comes in a convenient unit6dose applicator tubules with a cotton tip that delivers 3#%! to the dentin surface. 'erric o!alate is currently mar)eted under the Sensdodyne Sealant name. t is available as a professional desensiti@ing treatment for unit6dose application with a disposable contra6angled instrument. DENTAL RESINS AND ADHESIVES : "he ob1ective in employing resins and adhesives is to seal the dentinal tubules to prevent pain6producing stimuli form reaching the pulp. Several investigators have demonstrated immediate and enduring relief of
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pain for periods of up to ,? months following treatment. although not intended for treatment of generali@ed areas of root sensitivity, this can be an effective method of treatment when other forms of therapy have failed. 4rnnstrm and colleagues achieved e!cellent results by impregnating the dentinal tubules with a restorative resin material. in this procedure, the area of sensitive dentin was cleansed and etched with an acid conditioner for - seconds. "he dentin was them dehydrated with a continuous blast of air for a at least ,- to 7. seconds in order to dry the outer part of the dentinal tubules. A drop of a &oncise :namelbond was then applied to the dentin. 4efore the resin on the surface hardened into a thin film it carefully removed to allow resin tags to occlude the outer part of the tubules without covering the dentin between the tubules with resin. "he use of 0"&6FDA and *D$D following ferric o!alate treatment of the dentin smear layer led to a sustained decrease in dentin permeability. "his system spears to hold promise as a future treatment for dentinal hypersensitivity. *ashley and associates have shown that contamination of dentin with blood or salvia lowers the bond strength of composite resin. #owever, they found that contaminated surface could be removed with a high6speed bur. $uring a B6wee)s study, /avid and cowor)ers compared the effects of a single application of isobutyl cyanoacrylate with wee)ly applications of a << per cent 0a' paste. "he material is gradually lost, so that repeated cyanoacrylate applications may be necessary. 2ycoff advocates the use of adhesives for severe cases of hypersensitivity that do not respond to other therapy. #e prefers a glass6 ionomer cement because it is hydrophilic acid conditioning is not required, the material adheres well, and it is esthetically pleasing. &opeland found that application of Scotchbond produced immediate and lasting relief from hypersensitivity. &linically superior results were
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obtained by covering the resin with a drop of dilute restorative material. :ighteen months following treatment, ?E per cent of <B? hypersensitive teeth remained free of pain. FA(DA6 includes a - per cent gluteraldehyde primer and <- per cent #:DA. t provides an attachment to dentin that is immediate and strong. FA(DA has been found to be highly effective when other methods of treatment failed to provide relief. t has been reported that the sequential use of FA((OA followed by Scotchbond produced impressive bond strength. 4ecause. FA(OA has e!cellent wetting characteristics, it should enhance bond strength of a resin when the dentin has been contaminated with blood or saliva. Recently 'elton and cowor)ers have reported that FA(DA seems to prevent bacterial growth in tooth+restoration interfaces. "his could have a beneficial effect in inhibiting plaque accumulation on sensitive root surfaces. PATIENT ED+CATION : Diet$r counse%in0 : $ietary counseling should focus on the quantity and frequency of acid inta)e and inta)e occurring in relation to tooth brushing. Any treatment may fail if these factors are not controlled. A written diet history should be obtained on patients with dentinal hypersensitivity in order to advise them concerning eating habits. Addy and associates found that red and white wine, citrus fruit 1uices, apple 1uice, and yogurt were capable of dissolving the smear layer in vitro. "hey also found that formic and tannic acids, low6p# carbonated drin), &oca6&ola and blac) currant cordial had no effect on smear layers. "ooth brushing in combination with decalcification of superficial dentin is capable of accelerating the loss of tooth structure. because loss of dentin is greatly increased when brushing is performed immediately after
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e!posure of the tooth surface to dietary acids, patients should be cautioned against brushing their teeth soon after ingestion of citrus foods. Toot# 'rus#in0 Tec#ni8ues : 4ecause incorrect tooth brushing appears to be an etiologic factor in dentin hypersensitivity, instruction in proper brushing techniques can prevent further loss of dentin and the resulting hypersensitivity. PLA1+E CONTROL : Saliva contains calcium and phosphate ions and is therefore able to contribute to the formation of mineral deposits within e!posed dentinal tubules. "he presence of plaque may interfere with this process, as plaque bacteria, by producing acid, are capable of dissolving any mineral precipitates that form, thus opening tubules. *eriodontitis generally feel that patient who maintain effective plaque control complain less about hypersensitivity. Recurrent of root sensitivity has been noted in specific areas that were missed in home care. t is difficult for patients of underta)e desensiti@ing procedures such as plaque control if the procedures cause pain. "he goal of treatment is to reduce sensitivity so that the patient is able to burnish sensitive dentin surfaces with a toothpic), Stim6(6$ent, or abrasive6containing dentifrice. "his )eeps the dentin surfaces clean and at the same time forms a smear layer.

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