Dentin Hypersensitivity Related to Apical Fenestration

Case Report

Austin J Dent. 2016; 3(4): 1043.

Dentin Hypersensitivity Related to Apical Fenestration

Gonzalez R¹, Zeng Q², Nissan R², Yesilsoy C¹ and Yang MB¹*

¹Department of Endodontology, Temple University, USA

²Department of Operative Dentistry and Endodontics, Sun Yat-sen, University, China

*Corresponding author: Maobin Yang, Department of Endodontology, Kornberg School of Dentistry, Temple University, 3223 North Broad Street, Philadelphia, PA 19140, USA

Received: July 20, 2016; Accepted: August 31, 2016; Published: September 02, 2016


Dentinal hypersensitivity is a common clinical symptom which is caused by multiple factors. Apical anatomic abnormality including apical fenestration could contribute to dentin exposure, thus may lead to tooth sensation. The purpose of the present case report was to describe a case with initial diagnosis of “dentinal hypersensitivity” caused by apical fenestration and confirmed by cone beam computed tomography, suggesting that apical anatomical morphology should be considered after excluding all other obvious possible etiologies in patients with dentinal hypersensitivity.

Keywords: Dentinal hypersensitivity; Apical fenestration; Cone beam computed tomography


Dentinal hypersensitivity (DH) is a pulp related painful condition when dentin is exposed to various stimuli that cause activation of nerve fibers. American Association of Endodontists (AAE) defines DH as “A short, exaggerated, sharp painful response elicited when exposed dentin is subjected to thermal, mechanical or chemical stimuli” [1] (AAE Glossary of Endodontic Terms). Clinically, Tooth hypersensitivity, or more precisely dentinal hypersensitivity is described as an exaggerated response to non-noxious sensory stimuli [2]. The prevalence of DH in the adult population has been reported ranging from 4-74% depending on the types of study designs that vary from patient questionnaires to clinical examinations [3-6].

The exposure of dentinal tubules can be caused by multiple predisposing factors, including: 1) Cemento-enamel junction anatomic profiles with a gap between enamel and cementum that transmit temperature and induce dentin sensation. 2) Tooth wear, abrasion, erosion, attrition, or other mechanical etiologies cause the loss of enamel or cementum structures and exposure of dentin [7]. 3) Loss of periodontal attachment due to the gingival recession or periodontal disease may result in the exposure of root surface, which is the most common etiology of exposed radicular dentin [5,8]. In addition, thin alveolar cortex, fenestration of alveolar bone, trauma, orthodontic therapy or periodontal surgery can contribute to the loss of periodontal attachment and denudation of the root [7]. 4) Even in an intact tooth, nerve fibers can be sensitized to stimuli in the presence of inflammatory mediators [9].

The etiology of DH is multifactorial. To date, the majority of studies support the hydrodynamic theory that stimuli cause a rapid movement of fluid in the dentinal tubules, which mechanically distorts the nerve fibers at the pulp-dentin junction, and activates neuronal fibers located in or near the dentinal tubules [10]. The density and size of dentinal tubules are also the contributing factors and have positive correlation with the pain responses induced from exposed dentin surfaces [11].

A fenestration is defined as “window-like opening or defect in the alveolar plate of bone”, which frequently exposes a portion of the root and usually locates on the facial aspect of the alveolar process [12]. Apical fenestration of a root is usually asymptomatic, but it can become symptomatic after the root canal treatment when the obturation materials are overfilled [12,13]. The diagnosis of apical fenestration can be challenging. In some cases, it may be misdiagnosed as persistent apical periodontitis [14]. Here we report a challenging diagnostic case of a tooth with temperature hypersensitivity. A correct diagnosis and appropriate treatment plan were achieved by using a combination of clinical exam, radiography and cone beam computed tomography (CBCT).

Case Presentation

A 50-year-old female was referred to the Department of Endodontology at Kornberg School of Dentistry, Temple University. The patient reported sharp pain from the maxillary left area provoked by cold liquids during the past one year and a half. Routine oral hygiene instructions, root scaling and root planning were performed 6 months ago, and there was no improvement concerning her chief complaint. Medical History was non-contributory for diagnosis.

Intraoral examination revealed adequate oral mucosal appearance and normal gingival condition. Tooth #11 had a wear-off on the cusp and was absent of any restorations or caries. It had a slightly increased response to cold test compared with the control teeth (#10, #13), but was not lingering. Tooth #12 was devoid of any restorations, caries or attrition, and the cold test showed more intense response than #11 but still not lingering. A probing depth of 4.5mm was found in the mesial-palatal area of #12, and the patient felt very sensitive upon probing in this area. Both #11 and #12 had a normal response to palpation and percussion. Other teeth from this same quadrant were normal in the examination (Figure 1).