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June 2013 Issue:2, Vol.:5
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Review Article
Indian Journal
of Dental Sciences
E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1
Suchetha A
Dentinal Hypersensitivity - A Review 2
B S Keshava Prasad
3
Abstract Apoorva SM
4
Dentinal hypersensitivity is defined as pain arising from exposed dentine typically in response to Lakshmi P
1
thermal, chemical, tactile or osmotic stimuli. It is associated with exposure of dentine due to loss Prof and Head, Dept of Periodontics
2
of enamel by processes such as abrasion, erosion or denudation of the root surface by gingival Prof., Dept of Conservative Dentistry & Endodontics
3
recession or periodontal treatment. The pain arising from dentinal hypersensitivity is extremely Senior Lecturer
4
variable in character, ranging in intensity from mild discomfort to extreme severity. There are a PG Student, Dept of Periodontics
DAPM RV Dental College, Bangalore-560078
number of clinical conditions that may provide clinical features similar to that of dentinal
Address For Correspondence:
hypersensitivity and it is important to distinguish between these in order to provide a correct Dr. Lakshmi P PG Student, Dept of Periodontics
diagnosis and successful management of the problem. Review of literature on Dentinal DAPM RV Dental College, CA 37, 24th main
hypersensitivity provides with a general guideline to be followed in the management of dentinal JP Nagar 1st Phase, Bangalore-560078
hypersensitivity. The goal of treatment of dentinal hypersensitivity ideally should be the Email: [email protected]
restoration of the original impermeability of the dentinal tubules and the relief of dentinal Contact Number: +91-8095988505
hypersensitivity experienced by the patient or at least to reduce the level of discomfort to enable Submission : 1st September 2012
the patient's quality of life to be maintained. This review aims at building a better understanding of Accepted : 4th March 2013
the condition and thereby, providing a more comprehensive care to the patient.
Quick Response Code
Key Words
dentinal hypersensitivity, pain, dentinal tubules, diagnosis
Introduction chemical, tactile or osmotic stimuli.[2]
Dentinal hypersensitivity is a common Dentine may become exposed via several
painful condition of the teeth. It is means:
associated with exposure of dentine due The most common clinical cause for
to loss of enamel by processes such as exposed dentinal tubules is gingival
abrasion, erosion or denudation of the recession[3], which in turn may be caused
root surface by gingival recession or by: concentrations of peroxide results in a
periodontal treatment. 1. Inadequate attached gingiva greater degree of sensitivity.
Dentinal hypersensitivity has been 2. Prominent roots 9. Scaling and rootplaning[5]: Removes
shown to peak in 20 to 30 year olds and 3. Toothbrush abrasion 20-50µm of cementum and expose
rise again when in their 50s. The 4. Pocket reduction periodontal surgery the dentinal tubules to a variety of
condition generally involves facial 5. Oral habits resulting in gingival stimuli. Von Troil et al found 50% of
surfaces of teeth near the cervical aspect. laceration, i.e., traumatic tooth patients undergoing scaling and root
Patients undergoing periodontal picking, eating hard foods planing had dentine hypersensitivity
treatment are particularly susceptible to
6. Excessive tooth cleaning after treatment.
this condition because of recession 7. Excessive flossing Once dentinal tubules become exposed,
following periodontal surgery or loss of8. Gingival loss secondary to specific there are often oral processes or habits
cementum following non-surgical diseases, i.e., NUG, periodontitis that keep them exposed[3]:
periodontal therapy.[1] 9. Crown preparation 1. Poor plaque control, i.e., acidic
Other causes include[4]:
It has become essential that the clinicians bacterial byproducts
understand the cause, the diagnosis and 1. Loss of enamel 2. Excess oral acids, i.e., sodas, fruit
the management of the condition. 2. Denudation of cementum juice, swimming pool chlorine,
Dentinal hypersensitivity has been 3. Attrition bulimia
extensively researched through the years4. Abrasion 3. Cervical decay
and many authors express an agreement 5. Abfraction 4. Toothbrush abrasion
that dentinal hypersensitivity is either6. Erosion (intrinsic and extrinsic) Theories For Dentinal Hyper
under-reported by the dental patient 7. Thinning, fenestration, absent buccal sensitivity [2]
population or misdiagnosed. This review alveolar bone plate Odontoblastic transduction theory
aims at building a better understanding of
8. Bleaching[5]: occurs as a result of a According to this theory, odontoblastic
the condition and thereby, providing a reversible pulpitis that is caused by processes are exposed on the dentine
more comprehensive care to the patient. the flow of dentinal fluid from surface and can be excited by a variety of
osmolarity changes in the pulp. These chemical and mechanical stimuli. This
Definition And Etiology changes occur when the bleaching causes the release of neurotransmitters
Dentinal hypersensitivity is defined as material rapidly penetrates enamel and impulses are transmitted towards the
pain arising from exposed dentine and dentin to the pulp. Usually higher nerve endings. However, no such
typically in response to thermal,

©Indian Journal of Dental Sciences. (June 2013 Issue:2, Vol.:5) All rights are reserved. 112
neurotransmitters have been found to be instruments.[14],[15] hypertonic solutions of glucose and
produced or released by odontoblastic Diagnosis sucrose are used, which creates osmotic
processes. Following are the important points that pressure that induces intratubular fluid
Neural theory : This concept advocates have to be evaluated during the diagnosis movement. A chemical stimulus for
that thermal, or mechanical stimuli, of dentine sensitivity: assessing dental hypersensitivity is not
directly affect nerve endings within the 1. History and nature of the pain preferred, as the response obtained by
dentinal tubules through direct 2. Number and location of the sensitive this method is difficult to control. [17]
communication with pulpal nerve fibres. teeth Electrical Stimulation: This is more
Although observations like the presence 3. Area of origin of sensitivity from complex and usually consists of
of unmyelinated nerve fibres in the outer tooth progressive elevation of the magnitude of
layer of root dentine and the presence of 4. Intensity of pain, frequency and the stimulus until a slight sense of pain is
putative neurogenic polypeptides duration of each episode felt. However, due to current loss through
support this theory, it is still considered 5. Triggering factor or stimulus for the periodontium and the subsequent
theoretical with little solid evidence to dentinal hypersensitivity stimulation of the periodontium, false
support it. Differential Diagnosis positive results can occur. [17]
Hydrodynamic theory : Hydrodynamic There are also a number of clinical Cold air blast from a dental air
theory proposed by Brannstrom and co- conditions that may provide clinical syringe: An air current is applied for 1
workers is the most widely accepted features similar to that of dentinal second at a pressure of 45psi and at a
theory for dentinal hypersensitivity. This hypersensitivity and it is important to temperature of 19-240C through dental
theory postulates that fluids within the distinguish between these in order to chair. Air current technique is generally
dentinal tubules are disturbed either by provide a correct diagnosis and used for screening. [17]
temperature, physical or osmotic changes successful management of the problem.[4] Cold water testing: It is suggested to use
and that these fluid changes or Clinical and radiographic examination is a series of syringes containing water at
movements stimulate a baroreceptor necessary to elucidate the cause. different temperatures (between 0 and
which leads to neural discharge. The These include: 200C), starting with the warmest water
basis of this theory is that the fluid filled Cracked tooth syndrome and gradually lowering the temperature.
dentinal tubules are open to the oral Fractured restorations A gap of three minutes should be
cavity at the dentine surface as well as Fractured teeth maintained before performing the next
within the pulp. Dental caries test at a lower temperature. The
Clinical Features : The teeth most Post-operative sensitivity temperature of the water is decreased by
commonly affected by dentinal Acute hyperfunction of teeth 50C and the test is terminated when a
hypersensitivity are the upper premolars Atypical facial odontalgia painful response is recorded or when 00C
followed by the upper first molars with Palatal-gingival groove is reached. [17]
the incisors being the least sensitive Hypoplastic enamel Thermo-electric devices: A fine-tipped
teeth.[6], [7], [8], [9], [10], [11], [12], [13] Congenitally open cementum-enamel thermal probe is used in this method. It is
It has been reported that there is a slightly junction placed on the surface of the tooth wherein
higher incidence of dentine Improperly insulated metallic heat or cold is continuously applied that
hypersensitivity in females compared to restorations allows quantification of the applied
males.[6],[8],[9] This difference is, however, Assessment Of Dentinal Hyper stimulus. The test is performed when
not statistically significant.[10] sensitivity temperature is 250C; subsequently the
The pain arising from dentinal Recommendations by Holland et al. [16] temperature is reduced by every 50C until
hypersensitivity is extremely variable in suggest that dentinal hypersensitivity the patient experiences the pain.
character, ranging in intensity from mild may be evaluated either in terms of the
discomfort to extreme severity. It may stimulus intensity required to evoke pain The other stimuli include:
emanate from one tooth or several teeth (stimulus-based assessment), or as the Mechanical pressure stimulators
and it is sometimes felt in all quadrants of subjective evaluation of the pain Scaling procedures
the jaws.[14] Most patients describe the produced by a stimulus (response-based Single-tufted brush
pain arising from dentinal assessment). Electrical pulp testers
hypersensitivity as being rapid in onset, Stimuli used to assess dentine Dental pulp stethoscope
sharp in character, and of short duration. hypersensitivity/ root dentine sensitivity Evaporative stimuli
The external stimuli eliciting dentinal in the clinical setting: Air jet stimulator
pain can be thermal, osmotic, chemical, Temptronic device (microprocessor
physical, or mechanical in nature. The Mechanical (tactile) stimuli: In this, the temperature-controlled air delivery
thermal stimuli include hot and cold food dentinal surface is rubbed with either system)
and beverages and warm or cold blasts of sharp tipped probe, mechanical pressure Thermal stimuli
air entering the oral cavity. Osmotic stimulators or Yeaple probe. In Yeaple Electronic threshold measurement
stimuli include sweet food and probe, force variation is controlled by an device
beverages. Acid stimuli include electromagnetic device. Generally, a Heat
grapefruit, lemon, acid beverages, and tooth is said to be non- sensitive when a
medicines. Common mechanical stimuli force equivalent to 70g is reached Management Of Dentinal Hyper
are toothbrushes, utensils used for without eliciting pain sensation.[17] sensitivity
consuming food, and dental Chemical (osmotic) stimuli: In this, Review of literature on Dentinal

©Indian Journal of Dental Sciences. (June 2013 Issue:2, Vol.:5) All rights are reserved. 113
hypersensitivity provides with a general secondary dentine formation, or obstruct hypersensitivity. Once the cause is
guideline to be followed in the pulpal neural response. It takes 2 weeks determined, treatment options can be
management of dentinal hypersensitivity. with twice a day usage to get a reduction considered.
The various steps to be followed in dentine sensitivity while using Options can be reversible or non-
includes[4]: desensitizing toothpaste. Instead of reversible or a combination of both
? History and examination to establish having patients brush with the toothpaste, depending upon the severity and extent of
diagnosis the paste could be placed in a soft tray to the condition[19][Table 2]
? Identification of cause increase the contact time. Haywood et al
? Treatment based on severity of recommended placing 5% potassium Different conditions and their
problem nitrate in bleaching trays to minimize treatment options
? Incorporation of preventive sensitivity that may occur as a result of Abscessed teeth, cracked teeth or dental
measures- remove etiological and bleaching. The desensitizing toothpaste caries: Removing the cause can involve
predisposing factors Review the should not have sodium lauryl sulfate endodontic therapy, extraction, root
patient regularly for signs of attrition, because a large amount of this ingredient resection or apical surgery, or replacing
abrasion, erosion, and abfraction may cause tissue irritation.[5] the restoration and broken cusp.
? Give dietary advice in line with
current thinking particularly in view The various methods for management of Restoration: Preventing sensitivity can
of the potential effect of erosive dentinal hypersensitivity include (Table- take the form of base placement ( such as
materials (food and fizzy drinks) and 1) vitrebond for thermal sensitivity) or
brushing immediately after meals. 1. Nerve desensitization sealing dentine tubules with a prime and
? Give oral hygiene instruction and Potassium nitrate bond system. Sensitivity can be reduced
recommend an atraumatic 2. Anti-inflammatory agents by cleaning the cavity preparation with a
toothbrushing technique to avoid Corticosteroids chlorhexidine solution to reduce
potential damage to both hard and 3. Cover or plugging dentinal tubules bacterial insult, sealing tubules with a
soft tissues a) Plugging (sclerosing) dentinal HEMA and gluteraldehyde material (eg.
? Mild generalized sensitivity-use of tubules Gluma) or selecting materials that have
OTC desensitizing products Ions/salts no history of inducing this condition.[19]
(toothpastes, gels, etc) Calcium hydroxide
? Localized moderate to severe Ferrous oxide Crown Cementation: Techniques which
sensitivity-use of In-office products Potassium oxalate preclude over drying of the tooth where
(primers, varnishes, sealants, etc) Sodium monofluorophosphate glass ionomer cements are employed
? Av o i d p l a c i n g s u b g i n g i v a l Sodium fluoride may be helpful in avoiding sensitivity.
restorations that may retain plaque Sodium fluoride/stannous Depending on the cement used, dentine
? Avoid violating the biological width fluoride combination tubules can be sealed under crowns with
when placing crown margins Stannous fluoride prime and bond, HEMA/ gluteraldehyde
? Use of periodontal flap surgery Strontium chloride or simple copal varnish.
(including GTR) in the treatment of Protein precipitants
exposed root dentin Formaldehyde Occlusal trauma: Adjusting the
? In severe cases, pulpal extirpation and Glutaraldehyde occlusion or inserting a splint may be
extraction may be the treatment of Silver nitrate beneficial.
choice Strontium chloride hexahydrate
? Review on an appropriate basis and Casein phosphopeptides Cervical lesions from abrasion or
reassess if pain persists Burnishing abfraction : May require restorations for
Fluoride iontophoresis thermal protection
Treatment Strategies For Dentinal b) Dentine sealers
Hypersensitivity Glass ionomer cements Composite restorations: Sensitivity is
Current techniques for treatment may be Composites due to placement techniques and bulk
only transient in nature and results are not Resins cure of high polymerization shrinkage
always predictable.[5] There are two main Varnishes materials. The 'C' factor can help
approaches for the treatment of dentinal Sealants determine the potential for sensitivity and
hypersensititvity, namely, Methyl methacrylate suggest a possible change in placement
(a) Tubule occlusion, c) Periodontal soft tissue grafting techniques to minimize the effects of
(b) Blocking nerve activity through d) C r o w n p l a c e m e n t / r e s t o r a t i v e
polymerization shrinkage. Techniques
direct ionic diffusion materials that can minimize the chance for post
The most common form of management e) Lasers operative sensitivity include; avoid bulk
is the placement of a topically applied filling, placement of a stress breaker liner
agent applied either by a dental Dentine Hypersensitivity: Restorative such as Optibond II or Vitrabond and soft
professional or by the patient at home.[2] Considerations For Successful start curing lights.
Self- applied treatments to reduce Management
sensitivity consist of materials that A diagnosis of the cause of tooth Abfraction lesions: May require
occlude dentinal tubules, coagulate or sensitivity can be an abscessed or cracked adjustment of the occlusion followed by
precipitate tubular fluids, encourage tooth, dental decay or some form of placement of a microfilled composite,

©Indian Journal of Dental Sciences. (June 2013 Issue:2, Vol.:5) All rights are reserved. 114
 Table 1 Table 2
Treatment Modality Material used Mechanism of action Reversible Non-reversible
Nerve desensitization Potassium Nitrate Largely unknown Desensitising toothpastes Glass ionomer cements
Oxidizing effect or blocking of tubules by crystallization has been proposed[2].
Fluoride gels, rinses, and varnishes Resins, filled or unfilled
Another explanation is that potassium nitrate reduces dentinal sensory nerve activity due to the
depolarizing activity of the K+ ion, Oxalates of ferric, aluminium and Pulp extirpation and root canal filling
Anti-inflammatory Corticosteroids potassium Protein precipitants
Presumed to induce mineralization leading to tubule occlusion.
agents
Calcium hydroxide Occlusion of dentinal tubules through the binding of loose protein radicals by calcium ions and Prevention Of Dentine
increasing mineralization of the exposed dentine. Hypersensitivity [18]
Covering or plugging Sodium fluoride Increase in the resistance of dentine to acid decalcification as well as to precipitation of fluoride
Suggestions for Patients
compounds in the exposed dentinal tubules. ? Avoid gingival recession due to poor
dentinal tubules
plaque removal by practicing good
The mode of action: oral hygiene techniques
Stannous Fluoride 1)Induction of a high mineral content which creates a calcific barrier blocking the tubular openings on
the dentine surface.
? Avoid using large amounts of
2)Alternatively, stannous fluoride may precipitate on the dentine surface leading to occlusion of the dentifrice, or reapplying additional
exposed dentinal tubules. dentifrice during brushing
Fluoride Iontophoresis Iontophoresis is the process of influencing ionic motion by an electric current and has been used as a ? Avoid hard bristled toothbrushes
desensitizing procedure in conjunction with sodium fluoride. without end rounded bristles
? Avoid brushing teeth immediately
Gluteraldehyde Desensitizers such as Calm-it(Dentsply Caulk), Gluma desensitizer, are based on aqueous
gluteraldehyde, which occludes the tubules by cross linking of dentinal tubules.[5] following ingestion of acidic food or
beverages
Resins or adhesives ? Avoid over brushing with excessive
Sealing of dentinal tubules with resins and adhesives can be used for managing dentinal hypersensitivity
(Seal & Protect (Dentsply Caulk) pressure for prolonged periods of
Varnish In Varnish XT Extended contact Varnish, the resin modified glass ionomer infiltrated the smear layer with time
(Varnish XT Extended resin, penetrated the dentin tubules, and created the resin tags, thereby demonstrating the potential to ? Avoid excessive flossing or incorrect
reduce sensitivity on exposed root dentine.5 Other examples of varnish include Vanish 5% Sodium
contact Varnish) Fluroide White Varnish, Profluorid L (Voco), Duraphat.
use of other interproximal cleaning
devices
? Avoid 'picking' at the gums or using
Oxalate Pashley and Galloway felt that using potassium oxalate resulted in calcium oxalate crystals.[5]
Example: BisBlock: contains calcium oxalate crystals, and etching before placement allows crystals to
toothpicks inappropriately
form deep in the tubules.
Suggestions for Professionals
Pro-Argin In 2002, Kleinberg developed a material consisting of arginine, an amino acid with a positive charge at Avoid over instrumenting the root
?
physiologic pH; bicarbonate ; and calcium carbonate, which provides a source of calcium. This material surfaces during calculus removal and
plugs and seals exposed dentinal tubules to decrease sensitivity.[5]
scaling and root planing
Casein Phosphopeptide-
Avoid over polishing the exposed
?
The peptide present in Recaldent become bound to dentine surface and this causes a mineral deposit roots during stain removal
Amorphous calcium phosphate formation in the dentine surface resulting in decreased opening of the dentinal tubules.
Avoid violating the biologic width
?
(CPP-ACP) (Recaldent) when placing crown margins causing
Laser treatment reduces sensitivity by coagulation of protein and without altering the surface of the subsequent recession
dentine.[5]Dicalcium phosphate- bioglass in combination with Nd: YAG laser treatment has sealed dentin
Lasers
tubules to a depth of 10µm.Dicalcium phosphate-bioglass plus 30% phophoric acid occluded exposed
Avoid 'burning' the gingival tissue
?
tubules up to 60µm.[5] The Nd:YAG laser has been used in conjunction with sodium fluoride varnish with during in-office tooth whitening or
encouraging results showing up to 90 per cent of the dentinal tubules being occluded. bleaching procedures
Periodontal soft tissue grafting[18] Surgical correction of dentinal hypersensitivity can include root coverage with connective tissue graft or in
some cases guided tissue regeneration for treatment of localized gingival recession Desensitizing Toothpaste
In clinical trials, the desensitizing effect
which offers some flexibility with the arch can result in fenestrations and of anti- sensitivity toothpaste generally
tooth movement. dehiscence. Over time, this will result in takes about two weeks of application
areas that are more vulnerable to twice per day to show reduction in
Dental Hygiene And Periodontal destruction of soft and hard tissues, sensitivity, and greater effect develops
C o n s i d e r a t i o n s I n D e n t i n e which in turn result in hypersensitivity. with continued use.[19] Applying the
Hypersensitivity Other causes of gingival recession desensitizing toothpaste in a tray for 10-
include a past history of periodontal 30 minutes prior to the prophylaxis
Gingival recession resulting in exposure therapy including scaling and root appointment has been reported to reduce
of dentinal tubules is the most common planing and pocket elimination discomfort during and after the
cause of dentine hypersensitivity. In surgery[18]. Literature shows that dentine procedure.[19]
p e r i o d o n t a l p a t i e n t s , d e n t i n e sensitivity following scaling and root
hypersensititvity has been reported to be planing lasts for days to weeks . Discussion
between 72.5-98.0 percent. Sensitivity following periodontal Evaluation of treatment is hampered by
Genetic influence can play an important surgery, particularly crown lengthening the lack of knowledge of the mechanism
role in dentinal hypersensitivity since the or pocket elimination surgery results in of dentine hypersensitivity, including its
presence of thin peridodontium and teeth prolonged sensitivity that may last for natural history and apparent tendency to
that erupt outside the bony housing of the months and require definitive treatment.

©Indian Journal of Dental Sciences. (June 2013 Issue:2, Vol.:5) All rights are reserved. 115
natural desensitization by, as yet, diagnosis, then, implement management 9) Orchardson R, Collins WJN. Clinical
hypothetical processes, the absence of strategies that will help reduce or features of hypersensitive teeth. Br
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requirements suggested by Grossman thought to contribute to tooth of cervical dentine sensitivity in a
(1935).[15] hypersensitivity after restorative population of patients referred to a
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There are many causes of and treatment
for tooth sensitivity. The dentist must
Source of Support : Nill, Conflict of Interest : None declared
explore all possibilities, form a definitive

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