Diagnostic tool in treatment planning of dentinal hypersensitivity: T-scan the unheeded newer dimension

Shivani Sachdeva; Sanket Shinde; Harish Saluja; Vipin Dehane

doi:10.4103/jhnps.jhnps_38_22

CASE REPORT

Year : 2022 | Volume : 10 | Issue : 2 | Page : 183-187

Diagnostic tool in treatment planning of dentinal hypersensitivity: T-scan the unheeded newer dimension

Shivani Sachdeva¹, Sanket Shinde², Harish Saluja³, Vipin Dehane⁴
¹ Department of Periodontology, Rural Dental College, PIMS, Ahmednagar, Maharashtra, India
² Department of Periodontology, Government Dental College and Hospital, Mumbai, Maharashtra, India
³ Department of Oral and Maxillofacial Surgery, Rural Dental College, PIMS, Ahmednagar, Maharashtra, India
⁴ Department of Oral Surgery, Fortis Hospital, Mumbai, Maharashtra, India

Date of Submission	24-Jun-2022
Date of Decision	26-Sep-2022
Date of Acceptance	18-Oct-2022
Date of Web Publication	15-Dec-2022

Correspondence Address:
Shivani Sachdeva
Department of Periodontology, Rural Dental College, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jhnps.jhnps_38_22

Abstract

Background: Occlusion is dynamic and plays an important role in the functioning of the stomatognathic system. Disturbance in one of the components of the stomatognathic system may result in hypersensitivity of teeth, orofacial pain, migraine, and temporomandibular joint (TMJ) disorders. Coronoplasty performed using articulating paper is the conventional method for occlusal corrections. T-scan is a computerized occlusal analysis system that overcomes the limitations of articulating paper. Methods: Patients with Myofascial Pain Dysfunction Syndrome (MPDS) having dentinal hypersensitivity were taken into consideration. The joint vibratory analysis is performed using JVA device to rule out any TMJ disorders. T-scan-assisted coronoplasty is performed. The patient is asked to score for dentinal hypersensitivity on a visual analog scale pre- and postoperative. Results: Occlusion and disocclusion time are reduced along with hyperactivity of the muscles after T-scan-assisted coronoplasty. There is a reduction in dentinal hypersensitivity postoperative. Conclusion: T-scan quantifies the forces and hence proved a boon in the field of dentistry. The present case report highlights coronoplasty assisted with T-scan for diagnosis and treatment planning of hypersensitivity of teeth and hence it is the future of dentistry.

Keywords: Coronoplasty, occlusion, T-scan

How to cite this article:
Sachdeva S, Shinde S, Saluja H, Dehane V. Diagnostic tool in treatment planning of dentinal hypersensitivity: T-scan the unheeded newer dimension. J Head Neck Physicians Surg 2022;10:183-7

How to cite this URL:
Sachdeva S, Shinde S, Saluja H, Dehane V. Diagnostic tool in treatment planning of dentinal hypersensitivity: T-scan the unheeded newer dimension. J Head Neck Physicians Surg [serial online] 2022 [cited 2023 Jun 4];10:183-7. Available from: https://www.jhnps.org/text.asp?2022/10/2/183/363924

Introduction

Occlusion is dynamic and plays an important role in the functioning of the stomatognathic system. The temporomandibular joint (TMJ), muscles, and teeth are components of the stomatognathic system which maintain a harmonious relationship with each another. Disturbance in one of the components of the stomatognathic system may result in hypersensitivity of teeth, orofacial pain, migraine, and TMJ disorders.

Dentinal hypersensitivity is described in the literature as a sharp, acute pain of short duration, arising from open dentinal tubules in vital teeth which are diagnosed through a process of exclusion with thorough dental screening, examination, and history. Among dental conditions that can cause dentinal hypersensitivity is hyperocclusion and acute traumatic occlusion. Coronoplasty is the mechanical elimination of occlusal supra contacts that may be present during functional movements.^[1] It is the selective reduction of occlusal areas to establish functional relationships favorably reshaping the teeth (grinding), restorative procedures, intraocclusal appliance therapy, and orthodontic movement and orthognathic surgery.

T-scan is a computerized occlusal analysis system that overcomes the known limitations of articulating paper. It quantifies and displays relative occlusal force information, so the clinician can minimize repeated errors of incorrect occlusal contact selection that often occur from relying solely on the combination of dental articulating paper. Studies repeatedly show that it can be very difficult for a clinician to predictably identify which occlusal contact has more force than the others nearby when using articulating paper alone. By enabling us to identify previously unobtainable occlusal force characteristics, the T-scan can help to ensure high quality and complete occlusal end results predictably obtained from the clinical occlusal treatment. Occlusion's role in dentinal hypersensitivity is not clearly documented in the literature; however, West^[2],[3] argued that the likely etiology is traumatic occlusion or occlusal microtrauma when no exposed dentin exists. It is based on the concept of disocclusion time-reduction therapy.

Concept of disocclusion time-reduction therapy

According to Robert Kerstein, the occlusal time should be <0.3 s and disocclusion time should be <0.5 s. Occlusion time is defined as the time from the first contact of occluding teeth to maximum intercuspation and disocclusion time is defined as the time from maximum intercuspation to complete disocclusion during lateral movements.

Mechanism of hypersensitivity

Different mechanisms of hypersensitivity have been described in the literature as follows:

Frictional hypersensitivity theory: Prolonged periodontal ligament (PDL) compressions resulting from prolonged opposing excessive occlusal surface frictional engagements lead to muscle hyperactivity, whereby the PDL compressions stimulate excessive contractions of the muscle of mastication above their baseline required to move the mandible during function.^[4],[5] The increased contraction levels lead to excessive parafunctional loads. Intricate feedback mechanism between PDL and pulp through mechanical stimulation of intradental A-beta mechanoreceptors from tooth deformation and central nervous system leads to neurogenic inflammatory response due to torsional flexure within pulp which may manifest clinically as frictional dentinal hypersensitivity (FDH).^[6],[7]

Other mechanisms associated with it are:

The stiletto heel effect: The physical compressions of the occlusal surface are thought to compress the subocclusal surface tissues causing tubule expansion and hence increased outward fluid flow. The effect means a small surface area contact point will apply great pressure to the occlusal surface of a tooth, flexing the tooth in pain.
Strain deformation mechanism: It was shown using extracted bovine incisors that a relationship existed between temperature distribution and tooth surface deformation (Linsuwanont et al. 2008).^[8] Thermal stimuli applied to the labial surface resulted in the rapid development of strain at the pulpal–dentin interface before any temperature change was detected at dentinoenamel junction. Hence, deformation of tooth structure may trigger nerve impulses directly or exert mechanically induced fluid flow that triggers nerve activity. Armamentarium used for the procedure is mentioned in [Figure 1].
Joint vibration analysis: It is a TMJ screening tool that assesses the health of the cartilaginous TMJ discs while in function. It records vibrations within the TMJ, which are displayed in proprietary software for analysis. Vibration-laden readings indicate changes in cartilage and can be correlated with known stages of TMJ damage and Piper's classification.

Figure 1: Armamentarium displayed in the picture includes (a) A: T-scan sensor, (b) JVA device and T-scan handset, (c) Bausch Arti-Check articulating paper, (d) electrodes, (e) TheraBite, (f) Miller's forceps, and (g) JVA headset: Joint vibratory analysis headset

Click here to view

The following tests are used to determine hypersensitive response.

“Air indexing” method: It is used to determine individual patient DH threshold responsiveness. Regulated “puffs” of room temperature air, directed at the root from a distance of 0.5 cm, sprayed at 45° to the long axis of the tooth, for 0.5 to 1 s.^[9]
Swish water test: The patient is given ice water and swishes it for 5 s and the response of the patient is recorded.^[10]
Visual analog scale: It is reliable pain assessment method for the clinical setting.^[11] A visual analog scale is a psychometric scale that is generally used in pain scale surveys to understand varying degrees of pain experienced by a patient. Alternatively, it is also used in surveys to measure characteristics and attitudes across a range of continuous values.

Case Presentation

A 36-year-old female reported to the department of periodontology with the chief complaint of sensitivity in the lower right and left back teeth for 6 months. A detailed history was recorded which revealed no significant medical history along with no previous history of dental treatment. Informed written consent was taken. Preoperative photographs and maxillary and mandibular arch were taken. Intraoral examination revealed tenderness of the right lateral pterygoid with intermittent TMJ clicking and headache. Periodontal tissues were healthy with no evidence of dental caries. The air indexing technique was used for detecting and quantifying dentinal hypersensitivity^[9] pre- and posttreatment to obtain a “threshold patient response” to air stimulus along with cold water swish assessment pre- and posttreatment. A numerical scale with a response score of 7 out of 10 was marked by the patient preoperatively. Clinical photographs of the patient are shown in [Figure 2].

Figure 2: Intraoral photographs of the patient show (a) frontal view, (b) mandibular occlusal view, (c) maxillary occlusal view, (d) model showing frontal view, (e) model showing the right lateral view, and (f) model showing left lateral view

Click here to view

The mouth opening of the patient was checked using TheraBite which was 42 mm. Four-millimeter overbite was added. Joint vibratory analysis (JVA) was performed to rule out any TMJ disorders.

Values obtained with JVA [Figure 3] were used for analyzing TMJ disorders with Piper's classification.^[12],[13] The patient was classified as Piper Stage II (intermittent click). T-scan was performed along with electromyography. Occlusal forces were determined. The patient was asked to perform lateral excessive movements on the right and left sides. Occlusal and disocclusion time were determined using T-scan [Figure 4].

Figure 3: Joint vibratory analysis readings displayed on the computer screen which is to diagnose whether the patient has any TMJ problems. TMJ: Tempromandibular joint

Click here to view

Figure 4: (a) Joint vibratory analysis (JVA) performed on patient. (b) JVA & Electromyography Device which provides attachment for JVA headset muscle electrodes. (c) JVA performed along with electromyography

Click here to view

Occlusion time was 1.41 s and disocclusion time was 0.85 s [Figure 5]. Articulating paper was used to get the markings. Interferences were eliminated with coronoplasty assisted with T-scan occlusion time below 0.3 s and disocclusion time below 0.5 s was achieved. Following occlusal adjustments, occlusion and disocclusion time achieved was 0.17 s and 0.33 s, respectively [Figure 6]. Hyperactivity of the temporalis and masseter had reduced. The patient was evaluated after 15 days, 1, and 3 months. A swish water test^[14] was performed along with air indexing. The scoring performed by the patient was 1 out of 10 on a 0 to 10 scale postoperatively.

Figure 5: T-scan readings displayed on the computer screen precoronoplasty being performed for occlusal discrepancies

Click here to view

Figure 6: T-scan readings displayed on the computer screen postcoronoplasty being performed for corrections of occlusal discrepancies

Click here to view

Discussion

In the present case report, the patient was treated with coronoplasty assisted with T-scan. It is based on the concept of disocclusion time reduction therapy (DTR). According to Robert Kerstein, occlusal time should be <0.3 s and disocclusion time should be <0.5 s. Muscle activity of the temporalis and masseter was assessed, the values were recorded, and using DTR principle, coronoplasty was performed. There is a reduction in muscular hyperactivity. When the patient was evaluated after 3 months, there was a resolution of hypersensitivity. In a 17 years retrospective study of 250 patients, it was found that occlusal adjustments resolved dentinal hypersensitivity for >6 teeth diagnosed with positive air indices.^[6]

The key factor in dentinal hypersensitivity appears to be excess occlusal surface friction which leads to excessive PDL compression, which directly increases muscle contractions that increase the lateroflexion of tooth structure. FDH is due to strain and deformation. This leads to physical deformation of the dentin, which triggers nerve impulses biomechanically, even without patent dentinal tubules. It is possible that this biomechanical trigger involves the activation of intrapulpal and omnidirectional A-beta myelinated nerve fibers. According to Kerstein and Wrightand Kerstein and Radke, reducing occlusal force reduces masticatory muscle hyperactivity through decreased PDL compressions. Decreased muscle hyperactivity leads to lessened lateroflexion of the teeth because the mastication loads the teeth with less muscle force when there is rapid excursive movement separation of the posterior teeth. Less lateroflexion of the teeth leads to less tooth strain and deformation. Fewer compressions lead to less physical compression of both the periodontal and pulpal vasculature, leading to a decreased nociceptive response to stimuli that triggers DH.^[5],[15]

In the conventional method where occlusal adjustments are performed using articulating paper, it is difficult to quantify the occlusal force. Hence, coronoplasty assisted with T-scan is better as the markings of the articulating paper can be correlated; hence, it is a valuable diagnostic tool.

Limitation

The pterygoid muscles are the first muscles to get involved in occlusal discrepancy. In the present series, hyperactivity of the pterygoid muscle is not measured as it requires needle electrodes which are uncomfortable for the patient and hence only surface electrodes are used for electromyography in the present case series.

Conclusion

Dentinal hypersensitivity is the most common cause with which patients report to the dental office. For proper diagnosis of hypersensitivity, identifying the etiology is most important. FDH is the diagnosis of exclusion. After assessment of TMJ, muscles, and occlusion, DTR can be performed in selected cases. Hence, T-scan can be a valuable tool in diagnosis and treatment planning.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was taken from the institutional ethics committee before starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Singh M.Unravelling coronoplasty in periodontics. Journal of Oral Research and Review. 2021;13:60-5.
2.	West NX. Dentine hypersensitivity. Monogr Oral Sci 2006;20:173-89.
3.	West NX. Dentine hypersensitivity: Preventive and therapeutic approaches to treatment. Periodontol 2000 2008;48:31-41.
4.	Dawson PE. Functional Occlusion from TMJ to Smile Design. 1^st ed. Philadelphia PA: Elsevier Health Sciences; 2006. p. 14,18,23,26,42,146,394.
5.	Kerstein RB, Wright NR. Electromyographic and computer analyses of patients suffering from chronic myofascial pain-dysfunction syndrome: Pre and post treatment with immediate complete anterior guidance development. J Prosthet Dent 1991;66:677-86.
6.	Coleman TA, Grippo JO, Kinderknecht KE. Cervical dentin hypersensitivity. Part III: Resolution following occlusal equilibration. Quintessence Int 2003;34:427-34.
7.	Pashley DH. Mechanisms of dentin sensitivity. Dent Clin North Am 1990;34:449-73.
8.	Linsuwanont J, Palamara ,Messer. An investigation of thermal simulation in intact teeth. Archives of Oral Biology 2007;52:218-27: DOI: 10.1016/j.archoralbio.2006.10.009.
9.	Coleman TA, Kinderknecht KE. Cervical dentin hypersensitivity. Part I: The air indexing method. Quintessence Int 2000;31:461-5.
10.	Brännström M. Sensitivity of dentine. Oral Surg Oral Med Oral Pathol 1966;21:517-26.
11.	Baños JE, Bosch F, Cañellas M, Bassols A, Ortega F, Bigorra J. Acceptability of visual analogue scales in the clinical setting: A comparison with verbal rating scales in postoperative pain. Methods Find Exp Clin Pharmacol 1989;11:123-7.
12.	Ishigaki S, Bessette RW, Maruyama T. A clinical study of temporomandibular joint (TMJ) vibrations in TMJ dysfunction patients. Cranio 1993;11:7-13.
13.	Droter JR. An orthopaedic approach to the diagnosis and treatment of disorders of the temporomandibular joint. Dent Today 2005;24:82, 84-8.
14.	Yiannios N, Kerstein RB, Radke J. Treatment of frictional dental hypersensitivity (FDH) with computer-guided occlusal adjustments. Cranio 2017;35:347-57.
15.	Kerstein RB, Radke J. Masseter and temporalis excursive hyperactivity decreased by measured anterior guidance development. Cranio 2012;30:243-54.