POST OPERATIVE PAIN AND

SENSITIVITY

DR.WEBOKO .I.F BDS (UoN), MScD

ENDODONTICS (UE)
 Introduction

• After restorations with resin composite, especially in

posterior teeth, clinical observation has shown that
patients complain of dentinal sensitivity at different
levels and in different situations (Jung LA et.al. 2003)
• This is a common problem, even with no visible failures
in the restoration

Jung LA, Barbosa NA, Reston EG, Wolwacz VF(2003) Sensibilidade pós-operatória em restaurações de resina composta. Rev ABO Nac
https://www.yourdentistryguide.com/tooth-sensitivity/)
 Main objective
• To identify the causes of post-op sensitivity in resin
composite restorations and how it can be avoided
 Dentinal sensitivity

• Dentin is a tubular structure, • The matrix interposed between

filled with fluid this cylindrical structure, the
• The lumen of dentinal intertubular dentin, contains
tubules are surrounded by around 30% by volume of
thin cuffs of mineralized mineralized collagen type I fibrils
tissue, called peritubular
dentin
• Much smaller quantities of collagen (10% by volume) are
present in peritubular dentin
• Dentinal permeability is, therefore, a direct consequence
of this structural pattern
• The closer one gets to the pulp, the greater is the value of
this porosity and diameter of the tubules (2.5 µm close to
the pulp; 1.2 µm intermediate region; 0.5 µm at the DEJ)
• This explains the increase in dentin permeability in the
area close to the pulp chamber
 Hydrodynamic theory

Movement of fluid within

the dentinal tubules after
certain stimuli, which
causes intratubular pressure
changes leading to
excitation of the pulp nerve
terminals, producing a
sensation of pain
Hydrodynamic theory
• Due to the disposition, size and pattern of dentinal
tubules, the type of dentin has a direct relationship with
dentinal sensitivity
• Reduction in fluid movements and propagation of
molecules through dentin occur due to reduction in the
tubular openings with the deposition of peritubular
dentin or the formation of other intratubular material
• Reparative dentin, in contrast to secondary dentin, does
not have continuous tubules, thus leading to diminished
permeability and fluid movement, and this results in a
reduction in sensitivity
• Teeth with recently cut secondary dentin have a greater
propensity to develop sensitivity after direct restorations
Post-operative sensitivity in resin
composite restorations

Pre- Post-
Operative
operative operative
• Sensitivity is a response given by the body originated
by an aggressive stimulus or in a spontaneous manner
• The sensory potential of the pulp makes it capable of
reaction with an immediate painful response, even
when the stimulus is applied at a distance from the
pulp tissue, eg. the superficial layers of dentin
 • Studies on sensitivity after resin composite restorations have
reported a frequent and very variable prevalence of between
0 and 50% with predominance in posterior teeth and Class II
restorations (Casertani RSA et. al. (2007), Yamazaki PCV et.
al. (2006)
• As the patient can have considerable discomfort,
professionals are sometimes obliged to change restorations
because of the inability to eliminate the problem
Casertani RSA, Pfeifer CSC, Braga RR (2007) Influência da técnica de inserção e do modo de fotoativação na microinfiltração de restauração de CIV em compósito. ScientifcA 1, 54–59
Yamazaki PCV, Bedran-Russo AVB, Pereira PNR, Swift-Junior ED (2006) Microleakage evaluation on a new low-shrinkage composite restorative material. Oper Dent 31, 670–676 .
• Described as a moderate pain, of short duration, that
appears when chewing, with hot and cold foods and on rare
occasions with sweet and acid foods, and disappears when
the stimulus is removed
• Restorative procedures may generate stimuli that result in
pain or potentiate already existing sensitivity
• A resin composite restoration is not: simply removing
carious tissue and inserting restorative material in small
increments
• It comprises various steps that must be carefully
performed so that the restoration will be successful
• IE. A perfectly sealed restoration that restores shape and
function of the tooth, and is comfortable for the patient
 Clinical
Restorative condition of Restorative
technique tooth(Pulp & material
hard tissues)

Post-op sensitivity can be caused by multiple factors

Other factors related to the cause
of post-op sensitivity

Cavity shape & Pulp dentin

Patient profile
extension protection
Pre-operative causes

Cracks &
fractures

Cervical
Pulp
dentin
condition
exposure
 Cracks & fractures
• Incomplete cracks
Cracked tooth and factures of
syndrome enamel and dentin

Pain on chewing • Symptoms

Sensitivity to not well
cold explained
• Difficult to
visualize
Complex • Confused
diagnosis with post-op
sensitivity
 Cervical dentin exposure

Areas of cervical dentinal

exposure may present as
insensitive before the restoration

Prolonged contact with clip

Phosphoric acid

Sensitivity stimulated
 Pulp condition

• Before restoring teeth establish condition

of the pulp
• Radiographic examination
• Previous procedures should be observed
• Presence or absence of symptoms
recorded
• Pulp vitality tests performed
• Inadequate instrumentation during cavity prep, without a
detailed analysis of the pulp condition, may cause irreversible
pulp damage due to the increase in harmful stimulus on pulp
• In the presence of pulp inflammation, it is necessary to make a
meticulous evaluation of the condition of the pulp to consider
whether endodontic treatment should be done
 Operative causes
Abusive Failure in
• Pain of dentinal origin dental dental tissue
structure wear hybridization
may occur due to cutting
and exposing healthy
Inadequate
dentin, dentin dehydration Incomplete
isolation of
caries removal
and release of toxic operative field
substances from
restorative material and Negligence in Handling
protecting restorative
bacteria pulp-dentin material
 Abusive dental structure wear
• Use of burs and diamond tips with excessive cutting or
wearing pressure, without adequate cooling, may generate
frictional heat and dentin dehydration
• Even if it happens for only a short time, it causes
displacement of the tubular fluid and a painful pulp
response
• Increase in temperature of 5.6 ºC may trigger various
degrees of inflammation or even pulp necrosis
• Blunt burs and diamond tips demand greater pressure
during cavity preparation, inducing temperature rise
• Excessive dentin dehydration may occur by repetitive
cavity drying causing pain due to fluid displacement
• Dehydration is limited by smear layer
• Prolonged exposure especially after acid etching, may
induce a more severe pulp trauma due to dehydration
• Use of new burs and diamond tips, adequate cooling
and intermittent cutting recommended
 Incomplete carious tissue removal

• Environment found under restorations presents favorable

conditions for microbial growth
• Incomplete caries removal leads to the possibility of bacteria
remaining
• Bacterial products result in pulp infection/ inflammation
• Sensitivity results from pulp aggression caused carious dentin
and low quality adhesive bond to dentin
Negligence in protecting dentin–pulp
complex
With reduced DT, tubule
Dentinal permeability, type and openings increase, making it
quality of remaining dentin more permeable and susceptible
should be assessed t irritation (chemicals, bacteria)

Dentin-best pulp
protection
material

Deep cavities have smaller Shallow and medium cavities

quantity of odontoblasts, have larger quantity of dentin
diminished further during and odontoblasts, thus greater
restorative procedure, reducing repair capacity of the pulp
chances of pulp recovery
 Handling restorative material

• Polymerization shrinkage of resin composites may develop

forces that cause rupture of the bond between the adhesive
system and cavity walls, reducing the life of restorations
because of the existence of microscopic gaps at the
tooth/restoration interface
• These gaps allow entry of bacteria, and may lead to the
formation of caries, staining and post-op sensitivity
• The use of gradual and careful light activation techniques and
care with maintaining the wavelength emitted by the light
source, inserting the resin in small increments and the use of a
base of materials with a low modulus of elasticity are some of
the suggestions
• Incomplete resin composite polymerization is also responsible
for post-op sensitivity
 Failure in dental hard tissue hybridization

• Hybridized dentin is prepared • Formation of a bond that is

at the interface of the surface as perfect as possible and
demineralized by acid etching minimizes/prevents entry of
• Dentin hybridization creates a bacterial fluids is key
mixed layer of resin • Inadequate formation
monomers and collagen results in marginal leakage,
fibrils, altering the physical resin discoloration and post-
and chemical properties op sensitivity
dentin
• Acid etching for a longer time than recommended leads to many
conditions that result in sensitivity
• Most acids are hypertonic and cause pulp fluid displacement,
leading to movement of the odontoblasts as a pulp response
• Acid solutions used in excess of the recommended time denature
the collagen fibers, increase dentin permeability, facilitate
chemical aggression by the adhesive system and bacterial
infiltration, harm the bond and may cause pain
• Dentin demineralization of over 5 µm is not of much value to the
clinical procedure, and may result from longer exposure of dentin
to the acid
• An increase in the demineralized dentin layer will not guarantee
formation of a thicker hybrid layer and a better bond
• The primer/adhesive may not have the capacity to infiltrate
throughout its entire thickness which could lead to degradation
and leakage
• Acetone in contact with moist dentin rapidly reduces dentin
permeability, making it difficult for the resin monomers to
penetrate and form the hybrid layer
• Use of adhesives with acetone as solvent may increase the
possibility of developing dentinal sensitivity
Inadequate isolation of the operative field

Contamination
by
microorganisms Contamination
by humidity

Pulp Bond affected

inflammation thus marginal
Post-op leakage
sensitivit
y
 Post-operative

Restoration
finishing
Cervical and
dentin polishing
Occlusal exposure
interference
 Occlusal interference

Mastication Deformation of
Dimensional
margins &
Restoration in change
interfaces
contact with
antagonist tooth
Fluid movement
within dentinal
Pain tubules
 Restoration finishing & polishing
• Finishing and polishing should be restricted to small
adjustments
• Immediate and excessive superficial wear of a recently
placed composite
-Heat produced alters the resin matrix
-Disturbs the post-irradiation phase of polymerization,
and removes superficial layer(which obtains highest degree
of conversion)
• Possibility of pulp injury due to the exaggerated frictional
heat generated by the high speed bur is increased
• Careful use of burs and abrasive instrument avoids damage
to the restoration margins and adjacent dental tissue,
avoiding failures at the tooth/restoration interface
 Final considerations
• Resin composite restorations in posterior teeth can be
maintained satisfactorily and post-op sensitivity
avoided/maintained at minimal levels
• Possible when restorations are placed strictly in accordance
with technical recommendations
• Several causes of sensitivity result from errors in technique
before, during and after placement of the restoration
• The dynamics of a poorly conducted restoration may also
trigger post-op dentinal sensitivity
• The material must offer properties that justify their choice
• Clinicians must be familiar with these properties, understand
their indications, and know how to apply them with the
necessary skill
• Procedures performed using same restorative materials,
same technique and under similar clinical conditions
generate sensitivity in some cases and not in others
• Knowledge and command of technique and material applied
ensures placement of adequate restorations and patient’s
physical and psychological well-being
 Failure in
diagnosis &
indication

Occlusal
Causes of post-op adjustment
Cavity prep

sensitivity in direct
resin composite
restorations
Finishing & Placement of
polishing material
Conclusion
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