Sensitivity of dentin to chemical stimuli

Current Concepts of Dentinal Hypersensitivity

INTRODUCTION

Although many clinical studies have reported on the prevalence of dental pain, far fewer studies have focused on the mechanisms of dental pain. This is an important gap because increased understanding of dental pain mechanisms may lead to improved diagnostic tests or therapeutic interventions. The aim of this study was to comprehensively review the literature on the mechanisms of dentinal sensitivity.

METHODS

PubMed and Ovid were searched for articles that addressed dentinal pain and or pulpal sensitivity. Because of the breadth of research ranging from cellular/molecular studies to clinical trials, a narrative review on the mechanisms of dentinal sensitivity was constructed based on the literature.

RESULTS

Five various mechanisms for dentinal sensitivity have been proposed: (1) the classic hydrodynamic theory, (2) direct innervation of dentinal tubules, (3) neuroplasticity and sensitization of nociceptors, (4) odontoblasts serving as sensory receptors, and (5) algoneurons.

CONCLUSIONS

These theories are not mutually exclusive, and it is possible that several of them contribute to dentinal sensitivity. Moreover, pulpal responses to tissue injury may alter the relative contribution of these mechanisms. For example, pulpal inflammation may lead to neuronal sprouting and peripheral sensitization. Knowledge of these mechanisms may prompt the development of therapeutic drugs that aim to disrupt these mechanisms, leading to more effective treatments for pulpal pain.

The Role of Transient Receptor Potential (TRP) Channels in the Transduction of Dental Pain

Dental pain is a common health problem that negatively impacts the activities of daily living. Dentine hypersensitivity and pulpitis-associated pain are among the most common types of dental pain. Patients with these conditions feel pain upon exposure of the affected tooth to various external stimuli. However, the molecular mechanisms underlying dental pain, especially the transduction of external stimuli to electrical signals in the nerve, remain unclear. Numerous ion channels and receptors localized in the dental primary afferent neurons (DPAs) and odontoblasts have been implicated in the transduction of dental pain, and functional expression of various polymodal transient receptor potential (TRP) channels has been detected in DPAs and odontoblasts. External stimuli-induced dentinal tubular fluid movement can activate TRP channels on DPAs and odontoblasts. The odontoblasts can in turn activate the DPAs by paracrine signaling through ATP and glutamate release. In pulpitis, inflammatory mediators may sensitize the DPAs. They could also induce post-translational modifications of TRP channels, increase trafficking of these channels to nerve terminals, and increase the sensitivity of these channels to stimuli. Additionally, in caries-induced pulpitis, bacterial products can directly activate TRP channels on DPAs. In this review, we provide an overview of the TRP channels expressed in the various tooth structures, and we discuss their involvement in the development of dental pain.

Dentine sensitivity: past, present and future

OBJECTIVE

This review defines dentine sensitivity (DS), its prevalence, its aetiology, the mechanism(s) responsible for DS, its diagnosis and its treatment. The review then examines the modes of action of various treatments for DS including potassium salts, strontium salts, bioglasses, arginine/calcium carbonate and professional treatments such as adhesives and oxalates. The methods used to evaluate the various treatment modalities are discussed, including laboratory studies and randomised controlled clinical trials.

DATA SOURCES AND STUDY SELECTION

A literature search was conducted using PubMed, Ovid Medline and Cochrane reviews for information on DS and its treatments, as well as laboratory and clinical studies used to evaluate the efficacy of various DS treatments. With regard to efficacy of treatments for DS only reports of clinical studies that were randomised, controlled and blinded were reviewed. The authors offer new insights into the shortcomings of the recent systematic review of the use of oxalates for DS.

CONCLUSION

The authors introduce the concept of a novel desensitising mouthrinse containing 1.4% potassium oxalate: Listerine® Advanced Defence Sensitive mouthrinse. Readers of this supplement issue of the Journal of Dentistry are invited to review the significance of managing the clinical problem of DS. They are also invited to assess data from laboratory and randomised controlled clinical studies in order to understand the advantages offered by regular use of 1.4% potassium oxalate-containing mouthrinse, Listerine Advanced Defence Sensitive, in particular its resistance to daily erosive and/or abrasive challenges.

Physical properties of root cementum: part 2. Effect of different storage methods

This study examined the effect of 5 disinfection and storage protocols over different time periods on the hardness and elastic modulus of human premolar cementum. The sample consisted of 20 first premolars, which were divided into 5 groups of 4 teeth and stored in 1 of the following ways: (1) Miltons solution (1% sodium hypochlorite) for 10 minutes, (2) Miltons solution for 24 hours, (3) 70% alcohol, (4) desiccation, or (5) Milli Q (deionized water, Millipore, Bedford, Mass). Teeth in groups 1 and 2 were initially stored in Milli Q, tested within 6 hours, placed in their respective media, and retested. Groups 3, 4, and 5 were tested within 6 hours, then at 1 month, 2 months, and 3 months after extraction. Group 5 was further studied at 9 months, and 2 teeth in Group 4 were tested at 4 months. The hardness and elastic modulus of cementum was tested with the Ultra-Micro Indentation System (UMIS-2000, Commonwealth Scientific Industrial Research Organization, Australia) on unprepared specimens mounted on a 3-dimensional jig assembly. The results showed that storage in Miltons solution for 10 minutes had no significant effect on the hardness or elastic modulus, whereas storage for 24 hours caused a significant decrease in the hardness of cementum (P =.03). Storage in 70% alcohol for up to 4 months and in Milli Q for up to 9 months had no significant effects. Desiccation caused a significant increase in both the hardness and the elastic modulus from baseline to 3 months (P =.02 and P =.04, respectively), with most changes occurring within the first month. It was concluded that Miltons solution for 10 minutes could be considered an appropriate method for disinfection and removal of periodontal ligament fragments; however, its use for 24 hours should be avoided. Seventy percent alcohol and Milli Q are better storage methods, and desiccation should be avoided.

Effects of hexafluorosilicate on the precipitate composition and dentine tubule occlusion by calcium phosphate

OBJECTIVES

To improve the calcium phosphate precipitation (CPP) method for the occlusion of dentine tubules with calcium phosphate, the addition of calcium hexafluorosilicate (CaSiF6) to CPP solution was evaluated in vitro with respect to its occluding capacity and the composition of the precipitate.

METHODS

The occlusion of dentine tubules was evaluated by SEM observations and by measurements of dentine permeability. The composition of the precipitate was determined by measuring the calcium to phosphorus (Ca/P) ratio of the precipitate in dentine tubules by energy dispersive X-ray spectroscopy (EDS).

RESULTS

The addition of CaSiF6 to the CPP solution resulted in an increase of the Ca/P ratio in the precipitate not only on the dentine surface but also inside the dentine tubules; indicating that the precipitate became more apatitic in nature. The addition of CaSiF6 had no effect on occluding capacity in terms of measurements of dentine permeability or SEM observations. Dentine permeability decreased to approximately 4% of pretreatment values and the dentine tubules were occluded for approximately 10-15 microns from the dentine surface.

CONCLUSION

It is concluded that the addition of CaSiF6 to CPP solution was desirable, since it provided a more apatitic precipitate in the dentine tubules, not only on the dentine surface but also inside the tubules, and there were no drawbacks with respect to its occluding capacity.

The enigma of potassium ion in the management of dentine hypersensitivity: is nitric oxide the elusive second messenger?

We report the development of a 'second-messenger' model in an attempt to re-evaluate the role of K+ as a desensitising agent. Despite unequivocal validation of the effectiveness of potassium-based dentifrices in the management of dentine hypersensitivity, the mechanism(s) of action of K+ remains unclear. Although experimental paradigms of the Nernst equation demonstrate a direct inhibitory effect of K+ ion upon nerve conduction, in vivo considerable constraints can be argued to preclude this mechanism of action. Indeed, measurements of solution velocity within individual dentinal tubules obtained by scanning electrochemical microscopy indicate that outward movement of tubular fluid may represent a far greater barrier to the inward diffusion of K+ ions than previously estimated from measurements of hydraulic conductance across bulk dentine. Despite such probable limited penetration of dentine tubules, K+ ions may desensitise deeply-located nerve terminals through activation of a second-messenger transduction pathway that is capable of controlling the gain of K+-evoked effects which remain physically restricted to the more superficial aspects of the tubule. In addition to a direct effect upon transmembrane potential K+ can also indirectly attenuate neural activity through effects upon levels of the endogenously-synthesised free radical, nitric oxide (NO). Stimulation of the release of NO by K+ has been observed using a variety of cell preparations, which include endothelium, smooth muscle, adrenal medulla, hypothalamus and cerebellum. Importantly, a growing number of studies now report that an increase in the production of NO is associated with analgesia through a modulation of nociceptive input and a downregulation of sensitised nociceptors, most likely achieved through an increase in intraneural content of cGMP. The clinical role of a K+-evoked liberation of NO as a principal mechanism in the management of dentine hypersensitivity is supported by recent findings which include: (1) the localisation of NADPH-diaphorase activity and inducible nitric oxide synthase (iNOS) immunoreactivity within odontoblasts, their processes in dentine, and the subodontoblast layer of the pulp; (2) iNOS causes a sustained release of large (nanomolar) amounts of NO; (3) NO is freely diffusible and capable of displaying remarkably potent effector actions at distant target cells; (4) the actions of NO may be enhanced by endogenous carrier molecules such as S-nitrosothiols; (5) the synthesis of NO can be evoked by concentrations of K+ ion far less (i.e. <1 mM) than those required for direct inhibitory effects upon neural activity.

Occlusion of dentinal tubules with calcium phosphate using acidic calcium phosphate solution followed by neutralization

The occlusion of dentinal tubules with calcium phosphate, by a calcium phosphate precipitation method (CPP method), was investigated in vitro for evaluation of the potential value of this method for the treatment of dentin hypersensitivity. The method consists of treating the dentinal surface with a CPP solution, i.e., an acidic solution that contains both calcium and phosphate, followed by neutralization with basic post-treatment solution. The CPP solutions used in this study ([Ca] = 0.2 - 1.0 mol/L, [PO4] = 0.2 - 4.0 mol/L) were prepared by dissolving Ca(OH)2 or CaHPO4 x 2H2O in H3PO4 or HCl, and 1 mol/L NaOH solution was used for the post-treatment solution. Sections of human dentin disks treated by the CPP method were observed by scanning electron microscopy, and the precipitate in the dentinal tubules was subjected to x-ray micro-analysis. After treatment by the CPP method, dentinal tubules were occluded to a distance of approximately 15 microns from the surface, and the precipitate showed a Ca/P molar ratio of 1.03 +/- 0.01 To obtain a larger amount of precipitated mineral for further analysis, we used the same procedure with glass tubes (inside diameter, 1 mm). Powder x-ray diffraction analysis and FT-IR measurement revealed that the precipitate was dicalcium phosphate dihydrate (CaHPO4 x 2H2O). The instant precipitation of calcium phosphate mineral in the dentinal tubules demonstrated the potential value of the CPP method for the occlusion of dentinal tubules, this occlusion may be useful for the treatment of dentin hypersensitivity.

Assessment of pain in cervical dentinal sensitivity studies. A review

Traditionally cervical dentinal sensitivity (CDS) has been evaluated mainly subjectively on the basis of the individual patient's subjective response, e.g., in the form of verbal rating and visual analogue scales and questionnaires. The stimuli used for evaluating this response can be grouped into 4 main categories: mechanical, chemical, electrical and thermal. This review of the literature, however, indicates that there are problems in evaluating patient subjective response to these various test stimuli used in the assessment and treatment of CDS. Opinions also vary as to the reliability of some of these methods of assessment, although recently, efforts have been made to develop controlled reproducible stimuli more suited to the evaluation of CDS. Currently no single method of eliciting and assessing CDS may be considered ideal. Further research is required to evaluate suitable methodology for the quantification of realistic test stimuli under controlled clinical conditions, whereby the subjective response may be objectively measured by the investigator.

Hypersensitive dentin: testing of procedures for mechanical and chemical obliteration of dentinal tubuli

This study examined by scanning electron microscopy the effect of various mechanical and chemical procedures in obliterating dentinal tubuli. Dentin blocks containing open, cross-sectioned dentinal tubuli were separated into one experimental and one control area. The mechanical treatments consisted of 20 seconds of continuous instrumentation with sharp and dull curets, finely textured inserts for the EVA reciprocating handpiece, metal and plastic inserts for a sonic scaler, and metal inserts for an ultrasonic scaler. Chemical treatments included a light-cured dental resin and active obliterating agents including sodium, stannous and hydrogen fluorides, potassium oxalate, glycerin, ferric oxalate, and potassium nitrate. These substances were applied to the test surfaces for 2 minutes and allowed to dry. One half of the chemically treated specimens were then sprayed with water in order to evaluate the retention of the obliterating agents. The results revealed that among the mechanical treatments, the sharp curet gave the most consistent and complete obliteration of the tubuli. The plastic inserts had no tubular occluding effects. Among the chemical procedures, the light-cured resin resulted in the most complete obliteration of the tubuli, while the fluoride agents and glycerin had no effect. It can be hypothesized that combining instrumentation with a sharp curet causing a heavy smear layer and occlusion of tubuli apertures, followed by application of a light body resin, may prove to be a rational method of desensitizing hypersensitive dentin surfaces. However, this combined treatment should be evaluated in clinical trials.

An in vivo study of dentin sensitivity: the relation of dentin sensitivity and the patency of dentin tubules

Dentin hypersensitivity can be a major problem for periodontal patients. The relationship between dentin hypersensitivity and the patency of dentin tubules in vivo has been established. Thirteen adult patients with teeth scheduled for extraction were selected and a stent fabricated to confirm location of the root surface being examined. Response to a constant air blast was recorded on a numeric pain rating scale (from 0 to 4) during the course of treatment. The tooth surface was initially treated with 0.5 molar EDTA (pH = 7.4), to remove the smear layer and expose tubules. The region was then treated with either a 3% monopotassium-monohydrogen oxalate solution or a 3% sodium chloride solution, both at pH = 2.4. Solutions were prepared to be indistinguishable to the examiner. Response to air was evaluated before and after EDTA treatment and after treatment with a desensitizing agent. The patient was anesthetized and the treated tooth extracted. Specimens were sectioned, critical point dried, sputter coated with gold, and examined under the scanning electron microscope. Photomicrographs were analyzed by computer assisted digital analysis to evaluate the degree of tubule occlusion. Statistical analysis by repeated measures ANOVA for univariate tests of hypothesis for within subject effects showed the sodium chloride solution was more effective in reducing dentin sensitivity than the potassium oxalate solution. Scanning electron micrographic analysis revealed a mean dentin tubule aperture size of 1.720 square microns following EDTA treatment alone, 0.564 square micron following potassium oxalate treatment, and 0.386 square micron following sodium chloride treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Dentinal tubule occlusion and root hypersensitivity

Previous studies have established that root sensitivity is due in part to open dentinal tubules at the root surface. The purpose of this study was to longitudinally evaluate the occlusion of dentinal tubules by various clinical procedures including scaling and root planing and the application of potassium oxalate. A model was developed to evaluate dentinal surfaces in vivo. Six 2 mm x 3 mm sections were taken from the roots of extracted teeth immediately below the CEJ. One half of the treated dentin samples from each donor was incorporated into the removable denture worn by the donor and the other half served as baseline. The dentin samples were evaluated at 1 week by scanning electron microscopy. At day zero no open tubules were observed in any of the samples due to the presence of a smear layer or oxalate crystals. Evaluation of root planed samples revealed that by 7 days the tubules had re-opened. The samples which had been treated with potassium oxalate showed few oxalate crystals by 7 days revealing open tubules. Control samples were etched with EDTA and evaluated in the same manner. Although the number of tubules did not significantly change in the EDTA etched control samples, the diameter of the tubules dramatically decreased by 4 weeks. It can be concluded that the creation of a smear layer or application of oxalates to occlude dentinal tubules to reduce sensitivity are relatively short-lived. These procedures may provide patient comfort prior to natural occlusion of the tubules.

Dentin bonding: overview of the substrate with respect to adhesive material

The current challenge in adhesive dentistry is to develop dentin bonding systems that will reproducibly achieve high bond strengths similar to those obtained between resins and acid-etched enamel. Some of the limitations of dentin as a bonding substrate are that it changes its structure as it is prepared deeper, it is difficult to dry, and its smear layer is weak. Further, it is difficult to avoid contaminating proximal boxes with blood. Such contamination lowers dentin bond strengths to very low values. Decontamination of such dentin must be done prior to resin placement. The forces of polymerization contraction depend, in part, on the shape of cavities and how they are filled. Bulk filling of class I cavities can lead to conditions in which the forces of polymerization contraction exceed dentin bond strength with some materials and locations. The future development of resin systems that do not shrink on polymerization would eliminate many current problems in adhesive dentistry.

The effects of storage after extraction of the teeth on human dentine permeability in vitro

Freshly extracted third molars were stored for one week in one of four solutions: 70% ethanol, 10% formalin, distilled water with thymol and phosphate-buffered saline with thymol. Crown segments were prepared and initial permeability measurements taken. Each specimen was placed in a fresh preparation of its original solution, and permeability was measured over two periods: 1, 4, 6 and 8 days or 1, 8, 15 and 22 days. Ten crown segments were used for each solution for each time sequence. Permeabilities were lower for those specimens stored in ethanol and formalin than in water/thymol and saline/thymol, but most specimens showed increased permeability with time. Both storage solution and storage time had statistically significant effects (p less than 0.05), with significant differences between specimens stored in water/thymol and saline/thymol and those stored in ethanol and formalin. Thus, type of storage solution effects dentine permeability over time.

Effect of a desensitizing dentifrice on dentinal hypersensitivity

The objective of this study was to assess the effectiveness of a dentifrice with 2% dibasic sodium citrate in poloxamer 407 in decreasing dentinal hypersensitivity. The test toothpaste was compared with a control toothpaste containing 0.76% sodium monofluorophosphate in a 6-week double-blind clinical trial. A total of 75 hypersensitive teeth were examined in the test group, while 100 hypersensitive teeth were in the control group. Changes in hypersensitivity levels were monitored after 6 weeks, using thermal, chemical and mechanical stimuli. At the end of 6 weeks, the test dentifrice was not significantly more effective than the control in decreasing dentinal hypersensitivity. Of the stimuli used, cold was the most effective in eliciting a hypersensitive response, followed by chemical stimulation and air. Heat and toothbrushing caused the least discomfort.