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ADH - Shared Teaching Dental Surgery > Recession And Hypersensitivity > Flashcards

Recession And Hypersensitivity Flashcards

1
Q

Gingival recession - what is it?

A

When the gingival margin is positioned apical to the CEJ - that’s when you have gingival recession (exposed root surface)

Gingival margin moves down the tooth exposing more crown and root

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2
Q

What does the image show?

A

Pocket depth: base of pocket to gingival margin (4.5 mm)

Attachment level (clinical attachment loss): CEJ to base of pocket (7.5 mm)

Gingival recession: CEJ to gingival margin (3 mm)

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3
Q

What does pocket depth measure

A

base of pocket to gingival margin

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4
Q

What does attachment level (clinical attachment loss) measure?

A

CEJ to base of pocket

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5
Q

What does Gingival recession measure

A

CEJ to gingival margin

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6
Q

Prevalence of recession

A

Recession of 1mm or more in 58% of adults age 30+

Increased prevalence and extent with age
- 37.8% and extent of 8.6% of teeth in 30-39 year olds
- 90.4% and extent of 56.3% in 80-90 year olds

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7
Q

Distribution of recession

A

Some studies have found it more common in…

  • Maxillary 1st molars and mandibular central incisors
  • upper and lower canine, 1st premolar and incisor teeth - dentine hypersensitivity
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8
Q

Greater gingival recession found in who?

A
  • left side of jaw
  • males more than female
  • more in afrocarribeans rather than caucasians
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9
Q

Causes of recession

A
  • good OHI - buccal
  • poor OHI - lingual lower

Trauma
- foreign bodies eg piercing
- finger nail picking
- tooth brushing
- poorly designed / partial denture / OH
- chemical trauma eg cocaine

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10
Q

Aetiology of recession

A

Normal sulcus and undiseased interdental crestal bone
– Anatomical position of tooth
– Extent of cortical bone
– Tooth position in arch

Orthodontic tooth movement
– Creation of dehiscence
– Volume of soft tissue
– Greater risk of recession with excessive proclination of lower incisors and arch expansion

Periodontal disease

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11
Q

Recession and keratinised tissue

A

Width and Thickness
– Believed that a certain apico-coronal width of keratinised tissue required
– No minimum width
– Thickness and texture of attached gingiva
• thin, fragile tissue pre-disposed to recession in presence of plaque-induced inflammation or trauma

Gingival biotype
– Height of keratinised tissue not important
– Thickness of tissue is key
– Recession more likely where gingivae are thin

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12
Q

Local plaque retention factors - how do they affect recession?

A
  • high muscle attachment and frenal pull
  • calculus
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13
Q

Local plaque retention factors - caused by restorative dentistry how?

A

– subgingival margins increase plaque retention
– more pronounced inflammation seen in thin gingiva
– ? Does increase in thickness decrease risk of recession

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14
Q

Recession commonly associated with…

A

periodontal disease

  • as bone is lost there is apical migration of the soft tissues, exposing root
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15
Q

What treatment can cause recession

A

Periodontal treatment

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16
Q

What bad habit can cause recession

A

Smoking

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17
Q

Consequences to gingival recession

A

Fear of tooth loss
Plaque accumulation and bleeding gingiva
Aesthetics
Root caries
Abrasion
Pain from dentine hypersensitivity

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18
Q

Dentine hypersensitivity - what is it

A

Dentine hypersensitivity is characterised by short, sharp pain arising from exposed dentine in response to certain stimuli, which cannot be explained as arising from any other dental defect or disease

It may go on to manifest as a dull ache beyond the duration of the stimulus, possibly as an altered (irreversible) pulpal response

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19
Q

Epidemiology of dentine hypersensitivity

A

The prevalence distribution and appearance of the disease have been reported differently in different studies.

These differences are due to the differences in populations, habits, diets, and methods of investigation

  • Peak incidence is 20-40 years of age
  • Perceived by patient/self-reported 8-30% of population
  • Diagnosed by clinicians 15-18%

Gender bias to sensitivity, F>M
– And at an earlier age
– Could be due to better OH, F>M (females see dentists more so more cases reported)

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20
Q

Distribution of dentine hypersensitivity

A

Most frequently affects the buccal/labial and cervical areas of teeth

Most often affected teeth in order are:
• First premolars
• Canines
• Incisors
• Second premolars
• Molars

• Correspond to areas of gingival recession
• Correspond to areas of thinning enamel
• Correspond to areas of cementum loss

21
Q

Aetiology of dentine hypersensitivity - inception of hypersensitive lesion

A

Dentine exposure (lesions localisation) + Tubules made patent ‘open’ (lesion initiation) + Stimulus

Pulp must be vital in order to experience dentine hypersensitivity

22
Q

Stimuli that trigger dentine hypersensitivity

A

Thermal
- hot
- cold

Osmotic
- sweet / spicy
- acidic
- micro organisms / metabolites may penetrate tubules

Desiccation
- drying of lesion (eg, 3 in 1)
- evaporation of fluid - thermal element

Electrical
- galvanic reaction
- electrical pulp testing

Tactile
- touching / probing
- tooth brushing

23
Q

Mechanisms of sensitive conduction
What are the possible mechanisms that are unlikely?

A

• Odontoblasts as receptors– Inconclusive

• Nerves in dentine– Only seen in 1% of tubules in the cervical margin, however electrical current and cold stimulate nerves directly

• Hydrodynamic mechanism– Currently accepted hypothesis (Brännström, 1963)

24
Q

What is the accepted mechanisms of sensitive conduction

A

Brännström hydrodynamic hypothesis

• Dentine hypersensitivity caused by themovement of dentinal tubule contents
• Increased outward fluid flow causes apressure change across the dentine
• Distortion of A-delta fibre causes pain

(A fibres conduct pain quickly hence sharp pain)

25
Q

The hydrodynamic mechanism of pulp nerve activation

A

Stimulus affects dentinal tubules

Odontoblats with odontoblast tubules extend part way into the tubules

Fluid flow causes the pain to be set off

A beta and delta fibres conduct impulse for pain to be felt by the pulp

26
Q

Is an electrical process involved?

A

Possibly an electrical process involved

• Fluid flow changes also result in an electrical discharge
• This may be able to stimulate nerveselectricallyWidth

27
Q

What about the tubules is important?

A

Width of tubules important

• Rate of fluid flow depends on 4th power of the radius
• So if a tubule is twice the width, the fluid flow is 16 times greater

Width of tubule changes throughout life
Wider tubules are more prone to sensitivity

28
Q

The sensitive lesion in focus

Sensitive dentine shows?

A

• A disrupted smear layer
• Many more dentinal tubules at the surface
• Tubules not occluded by deposits
• Tubule diameter wider

29
Q

Current debate about the pulp

A

• What degree, if any?

• Does the pulp react to modifysensitivity over time?

• With resolution of inflammation,is there regression of sensitivity?

30
Q

Root sensitivity

A

• Term proposed for dentine hypersensitivity from gingival recession due to periodontal disease and treatment

• Potentially microorganisms invading root dentinal tubules. Maybe different aetiology

31
Q

How does the dentine become exposed - resulting from loss of enamel?

A

Resulting from loss of enamel

– Removal of enamel by restorative procedures
– Attrition (not in cervical buccal lesions)
– Abrasion
– Erosion
– Combined

32
Q

Erosion

A

• Intrinsic or extrinsic source of acids
• enamel and dentine loss and surface softening
• more tooth surface loss by toothpaste abrasion if intra-oral environment acid
• pH of the acid is not the only factor in erosion
• Type, chemical strength,temperature, exposure timeare other variables
• Think of fruits other than citrus, health supplements, mouthwashes, fruit teas, alcopops, wine etc

33
Q

How does the dentine become exposed?

A

• Gingival recession occurs exposing root surface covered with cementum
• Cementum a relatively weak structure in thin layer
• Cementum not designed to be exposed in the oral environment
• Wear and tear including toothbrushing readily remove cementum and expose the dentine beneath

34
Q

The role of tooth brushing and toothpaste

A

• Tooth brushing alone has no significant effect on hard tissues
• Plus toothpaste, has potential to abrade dentine and cementum considerably
• Toothbrush design/bristles may contribute indirectly
• Abrasive particles might remove the smear layer and open dentinal tubules
• Detergents might help to remove the smear layer
• Tubules could be occluded with particulate matter from the paste

35
Q

Management and Efficacy of Treatments for Dentine Hypersensitivity and Gingival Recession

Managing hypersensitivity - how?

A
  • tubule occlusion
  • blocking pulpal nerve response
36
Q

Tubule occlusion

A

• promotes formation of new tissue eg: smear layer, intratubular dentine, tertiary dentine in response tostimulus or trauma

• application of an artificial barrier e.g.: varnish, dentinebonding agents, composite resins, GIC and toothpaste

37
Q

Blocking pulpal nerve response

A

• Potassium ions diffuse along tubules and raise extracellular K+ conc, reducing nerve excitability

• Unproven in humans

• Clinically unlikely that ions will diffuse into tubulesagainst flow of dentinal flu

38
Q

Ideal qualities of barrier materials

A

• Retentive
• Insoluble
• Penetrate tubules
• Form mechanical tags into tubules
• Seal the end of tubules

39
Q

Managing hypersensitivity at home - what can be used?

A

• Toothpastes, gels and mouthwashes
• Contain potassium, strontium,oxalate and fluoride salts
• Potassium nitrate: Cochranereview (2005) no clear evidence
• Novamin: releases of calcium and phosphate ions from saliva to give a hydroxyapatite-like layer
• Long term use needed

40
Q

Evaluation of efficacy of home products - what are the problems?

A

• Inherent problems of clinical trials
- Pain perception is subjective, qualitative, and open toindividual interpretation
• Psychological, medical, gender and cultural issues abound• Stimulus variable or fixed
• Response is often complex
• Unable to examine effects on subject’s tissue \

The placebo effect
• All products achieved a modestreduction in hypersensitivity
• This was irrespective ofpresence of active ingredients

41
Q

Managing hypersensitivity: in-surgery products

A

• Varnish eg. Duraphat (5% NaF), Clinpro (5% NaF & Tricalciumphosphate) (high fluoride agents that can be applied directly onto the root surface)

• 1-3 layers of adhesive resin bonding systems eg. Seal and Protect, Optibond Solo, Scotchbond 1 (+etchant?)

• Desensitising polishing paste (calcium carbonate and arginine)

• Reinforced GIC where there is abrasion cavity progression
- watch for overhangs at the gingival margin

42
Q

Comparison of efficacy

A

• Fluoride varnish
– Reasonable efficacy but dissolution over time

• Resins
– Good if film thickness adequate. Products which do not require etching

• GIC
– Good at occluding tubules where indicated for use

43
Q

Preventative patient advice - for recession and hypersensitivity

A

Oral hygiene advice

• Change from damaging brushing techniques to:
– Modified Bass technique
– Roll technique
- electric toothbrush

Eliminate traumatic habit
Smoking cessation
Reduce risk factors
- diet history
- limit acidic drinks / don’t brush immediately after
- night time splints - bruxism

44
Q

Orthodontic therapy
Partial dentures / restorations

  • how should this be maintained to a high standard?
A

Orthodontic therapy
• High standard of maintenance during ortho
• Possible grafting if anticipate creation of bony dehiscence and in presence of thin gingiva

Partial Dentures and Restorations•
Careful design, techniques,placement and maintenance
• Supragingival margins prefer

45
Q

Treatment of disease - root caries - how do we address

A

Root caries
– Radiographs to detect root caries interproximally
– Prevention: diet, OHI
– Prevention: fluoride: mouth rinses, gels, use of custom made trays, topical professional application
– Recontouring of shallow lesions
– Conventional restoration - glass ionomer

46
Q

Treatment of disease - periodontal disease - how do we address

A
  • initial therapy
  • corrective therapy
  • supportive therapy
47
Q

Restoration of aesthetics from gingival recession

A

• Reassure re further progression
• Removable gingival veneer: silicone or acrylic
• mask to cover the black triangles of interdental spaces
• Crowns and veneers
• Root coverage

48
Q

Surgical Management of Gingival Recession:Root Coverage

A

Coverage• Indications• Aesthetics• Hypersensitivity• Shallow root caries andabrasions• Contraindications• Poor OH• Usual medical contra-indications for perio surgery• Smoking

ADH - Shared Teaching Dental Surgery (8 decks)

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