Keywords
dentine hypersensitivity - dentists - knowledge - diagnosis - management
Introduction
Dentine hypersensitivity (DH) is a common oral condition that is characterized by
sharp and transient pain frequently arising from thermal, chemical, tactile stimuli
in exposed dentine.[1] Stimulation resulting from cold food or drink is the most common cause of pain;
however, the use of citrus fruits, sweets, and salty food can also lead to DH.[2] Discomfort associated with DH negatively affects the quality of life of patients.[3]
[4] Patients with DH avoid eating, drinking and brushing, and consult dentist or use
self-medication to relive the pain.[5] Gingival recession, excessive tooth brushing, scaling and root planning, and attrition
are some of the common predisposing factors of DH.[6] Previous studies reported the prevalence of DH in different parts of the world that
ranged from 20.6 to 41.9%.[5]
[6]
[7]
[8]
[9]
[10] However, a study of patients attending a teaching dental hospital documented a prevalence
of 1.34%.[11]
It was reported that the majority of dentists were aware of the etiological factors
of DH in United Kingdom.[12] Most of Australian dentists reported understanding of DH and prescribed desensitizing
agents to treat the condition.[13] According to dental practitioners in the United States, the use of desensitizing
potassium nitrate toothpaste was the most common treatment modality for the management
of DH.[14] Similarly, dentists in the United States identified gingival recession, abrasion,
erosion, and attrition as the most common predisposing factors of DH and employed
a variety of diagnostic methods.[2] The most common theories of DH include direct innervation theory, odontoblast receptor
theory, and fluid movement/hydrodynamic theory.[15] About half the Nigerian dentists correctly identified “hydrodynamic theory” as the
most common theory of DH[15] and had inadequate knowledge and skills to diagnose and manage the condition.[16]
DH is highly prevalent and underdiagnosed condition that can be treated with a wide
variety of inexpensive medications.[1] Hence, adequate understanding of DH among dentists is critical for the successful
treatment of the condition to improve the standard of care and quality of life of
patients. There is a lack of reliable data about DH among dentists in Pakistan. The
objective of the study was to assess dentists’ knowledge and practice of DH in Lahore,
Pakistan.
Materials and Methods
This is a cross-sectional observation study. The target population was practicing
dentist from private and public sectors in Lahore, Pakistan. The dentists with more
than one year of clinical experience, practicing in Lahore, and those who showed voluntary
participation met eligibility criteria for the selection in the present study. The
study was conducted from October 2017 to December 2017 with a calculated sample of
588 eligible dentists. A 95% confidence interval, anticipated percentage frequency,
and estimated population size were used for sample size calculation.[17] The power of study was 80% assuming β equal to 0.20 (power = 1–β).
A questionnaire was developed based on previous similar studies.[2]
[12]
[13]
[14]
[15]
[16] The self-administered structured questionnaire had closed ended questions about
sociodemographic data/knowledge and diagnosis/management of DH. The instrument was
piloted over 30 participants to evaluate its applicability and practicality in the
field. Modifications were made based on the results of the pilot study. For example,
there were seven options against the question about the number of patients complaining
of DH. These options were reduced to four after dentists’ feedback. Finally, approved
questionnaire was administered among dentists in their clinics. For the purpose of
obtaining satisfactory response rate, research assistants made maximum of three visits
to dental clinics to accommodate the busy schedule of the dentists.
Ethical approval was obtained from the Institutional Review Board at the Fatima Jinnah
Medical and Dental College, Lahore. The study participants provided their consents
by filling out the questionnaire. The researchers briefed participants through one-on-one
discussion about the details of study including the objective and purpose of study.
Identification of study participants remained concealed because of anonymous questionnaire.
The study was conducted in full accordance with the World Medical Association Declaration
of Helsinki.
Descriptive statistics were expressed using frequency distribution, mean, and standard
deviation. Pearson’s chi-squared tests were performed to evaluate the relationship
of independent variables with knowledge, diagnosis, and management of DH. In addition,
examination of number of patients with DH per week was used as the dependent variable
and was dichotomized in to those who examined 0 to 10 patients (lesser number of patients)
and 11 to ≥ 20 patients (greater number of patients) per week. Gender, type of job,
monthly income, year since graduation, and basic dental qualifications were used as
covariates to evaluate their influence on examining greater number of patients with
DH per week and crude and adjusted odds ratio [OR]: were calculated with 95% confidence
interval. For statistical tests, p-value was set at <0.05. Statistical analyses were performed using SPSS software (IBM
SPSS Statistics for Windows, Version 22.0. Armonk, New York, United States).
Results
The study had a good response rate (89.6%, 527/588 dentists). The study sample comprised
of 41.6% of male and 58.4% of female dentists. The mean age of the participants was
29.46 ± 3.04 years. Almost half the participants (46.1%) were from private dental
practice and 47.1% obtained their basic dental qualification from a private dental
institution. Similarly, about half the participants (56%) had ≤ 5 years since graduation.
The majority (64.3%) reported examining one to five patients with DH per week in their
dental clinics ([Table 1]).
Table 1
Distribution of responses of dentists
|
Variables
|
n (%)
|
|
Abbreviation: DH, dentine hypersensitivity.
|
|
Gender
|
|
|
Male
|
219 (41.6)
|
|
Female
|
308 (58.4)
|
|
Type of job
|
|
|
Private
|
243 (46.1)
|
|
Public
|
284 (53.9)
|
|
Basic dental qualification obtained from
|
|
|
Private institution
|
248 (47.1)
|
|
Public institution
|
279 (52.9)
|
|
Year since graduation
|
|
|
≤Five years
|
295 (56)
|
|
>Five years
|
232 (44)
|
|
Monthly income
|
|
|
<500 $US
|
219 (41.6)
|
|
≥500 $US
|
308 (58.4)
|
|
Number of patients with DH per week
|
|
|
1–5 patients per week
|
339 (64.3)
|
|
6–10 patients per week
|
81 (15.4)
|
|
11–15 patients per week
|
89 (16.9)
|
|
16- ≥20 patients per week
|
18 (3.4)
|
|
Age
|
Mean ± SD
29.46 ± 3.04
|
Regarding the type of pain in DH, stimulated short pain from a tooth was the most
common (85.4%) and it significantly differed between male (49.8%) and female dentists
(50.2%) (p < 0.001). Recession of gums (96.6%), aggressive brushing (88.2%), and frequent use
of tooth whitening procedures (83.1%) were the most common predisposing factors of
DH. Significantly greater percentage of male (55.6%) than female (44.4%) dentists
considered recession of gums as a predisposing factor of DH (p < 0.001). Similarly, more male (55.7%) than female participants (44.3%) believed
that DH is caused by aggressive brushing (p < 0.012). In contrast, more female (55.7%) than male dentists (44.3%) identified
frequent use of teeth whitening procedures as a predisposing factor of DH (p < 0.001) ([Table 2]).
Table 2
Knowledge of male and female dentists about dentine hypersensitivity
|
Response
|
Sample n/%
|
Male n/%
|
Female n/%
|
p-Value
|
|
Abbreviation: DH, dentine hypersensitivity.
|
|
Types of pain in DH
|
|
Spontaneous throbbing pain from a tooth
|
2 (0.4)
|
0 (0)
|
2 (100)
|
0.127
|
|
Intermittent short sharp pain from a tooth
|
149 (28.3)
|
137 (91.9)
|
12 (8.1)
|
< 0.001
|
|
Stimulated short sharp pain from a tooth
|
450 (85.4)
|
224 (49.8)
|
226 (50.2)
|
< 0.001
|
|
Chronic dull pain from a tooth
|
56 (10.6)
|
0 (0)
|
56 (100)
|
< 0.001
|
|
Predisposing factors of DH
|
|
Aggressive brushing /over brushing
|
465 (88.2)
|
259 (55.7)
|
206 (44.3)
|
0.012
|
|
Frequent use of teeth whitening procedures
|
438 (83.1)
|
194 (44.3)
|
244 (55.7)
|
< 0.001
|
|
Excessive dental flossing
|
35 (6.6)
|
35 (100)
|
0 (0)
|
< 0.001
|
|
Recession of gingiva
|
509 (96.6)
|
283 (55.6)
|
226 (44.4)
|
< 0.001
|
|
Periodontal surgery
|
96 (18.2)
|
44 (45.8)
|
52 (54.2)
|
0.087
|
|
Scaling and root planning
|
398 (75.5)
|
257 (64.6)
|
141 (35.4)
|
< 0.001
|
|
Periodontal pocket
|
192 (36.4)
|
89 (46.4)
|
103 (53.6)
|
0.010
|
|
Bruxism
|
218 (41.4)
|
160 (73.4)
|
58 (26.6)
|
< 0.001
|
|
Smoking
|
2 (0.4)
|
2
|
0
|
0.188
|
|
Abrasion, erosion, abfraction and/or attrition
|
403 (76.5)
|
224 (55.6)
|
179 (44.4)
|
0.118
|
|
Excessive use of citrus juices, and/or carbonated drinks
|
337 (63.9)
|
196 (58.2)
|
141 (41.8)
|
0.006
|
|
Gastric reflux and/or excessive vomiting
|
287 (54.5)
|
196 (68.3)
|
91 (31.7)
|
< 0.001
|
|
Trauma during tooth preparation
|
383 (72.7)
|
256 (66.8)
|
127 (33.2)
|
< 0.001
|
|
Loss of cementum
|
394 (74.8)
|
246 (62.4)
|
148 (37.6)
|
< 0.001
|
Among diagnostic methods, the participants most frequently reported evaluating spontaneous
pain after the application of air blast (74.8%), followed by spontaneous patient report
confirmed by dental examination (57.7%) and spontaneous pain after the application
of cold water (43.3%). The electric pulp tester was used by only two dental practitioners
in the study. Significantly, higher percent of female versus male dentists preferred
diagnosing DH by spontaneous pain after the application of air blast and cold water
(p < 0.001) ([Table 3]). The use of fluoride products was the most frequently (96.2%) reported management
approach of DH followed by potassium nitrate toothpastes (75%) and dentine bonding
agents (56.2%). Significantly higher percentage of male dentists preferred using these
products compared with female dentists (p < 0.001). Glutaraldehyde/HEMA products (8.2%) and oxalates (8.7%) were the least
commonly employed methods for the management of DH ([Table 3]).
Table 3
Practice of male and female dentists about the diagnosis of dentine hypersensitivity
|
Diagnostic methods of DH
|
Sample n/%
|
Male n/%
|
Female n/%
|
p-Value
|
|
Abbreviation: DH, dentine hypersensitivity.
|
|
Spontaneous patient report confirmed by dental exam
|
304 (57.7)
|
105 (53.8)
|
90 (46.2)
|
0.959
|
|
Patient report after dentist’s query
|
195 (37)
|
206 (52.3)
|
188 (47.7)
|
0.262
|
|
Spontaneous pain after the application of air blast
|
394 (74.8)
|
99 (43.4)
|
129 (56.6)
|
< 0.001
|
|
Spontaneous pain after the application of cold water
|
228 (43.3)
|
99 (43.4)
|
129 (56.6)
|
< 0.001
|
|
Spontaneous pain after scratching dentine with dental explorer
|
181 (34.3)
|
106 (58.6)
|
75 (41.4)
|
0.105
|
|
Use of electric pulp tester
|
2 (0.4)
|
2
|
0
|
0.188
|
|
Asking patient to numerically rate pain
|
97 (18.4)
|
41 (42.3)
|
56 (57.7)
|
0.012
|
|
Asking patient to rate pain using visual analogue scale
|
79 (15)
|
0
|
75
|
< 0.001
|
|
Management preferences of DH
|
|
Use of fluoride products (e.g., gels, varnishes, pastes, rinses)
|
507 (96.2)
|
283 (55.8)
|
224 (44.2)
|
< 0.001
|
|
Use of desensitizing potassium nitrate toothpastes
|
395 (75)
|
247 (62.5)
|
148 (37.5)
|
< 0.001
|
|
Application of glutaraldehyde/HEMA products
|
43 (8.2)
|
43 (100)
|
0 (0)
|
< 0.001
|
|
Application of dentine bonding agents
|
296 (56.2)
|
180 (60.8)
|
116 (39.2)
|
< 0.001
|
|
Application of sealants
|
120 (22.8)
|
4 (3.3)
|
116 (96.7)
|
< 0.001
|
|
Provision of restorative treatments
|
180 (34.2)
|
128 (71.1)
|
52 (28.9)
|
< 0.001
|
|
Use of lasers
|
56 (10.6)
|
2 (3.6)
|
54 (96.4)
|
< 0.001
|
|
Use of oxalates
|
46 (8.7)
|
28 (60.9)
|
18 (39.1)
|
0.307
|
|
Diet counseling
|
290 (55)
|
165 (56.9)
|
125 (43.1)
|
0.104
|
[Table 4] summarizes data about the comparison between private and public dentists, and dentists
with ≤ 5 year since graduation and those with > 5 years since graduation with regard
to their preferences for diagnosis and management of DH. The use of air blast and
cold water was more frequently employed by public dentists and dentists with more
experience (>5 years) than private dentists and dentists with less experience (≤ 5
year) since graduation (p < 0.001). Significantly higher proportion of public dentists (56%) used fluoride
products than private practitioners (44%) (p < 0.001). However, no significant differences were observed regarding the use of
potassium nitrate toothpaste between private and public dentists (p = 0.667). The dentist with ≤ 5 years of experience (58.2%) used fluoride products,
dentine bonding agents, and diet counseling more commonly than those with > 5 years
of experience (41.8%) p < 0.001) ([Table 4]. Multivariate logistic regression analysis demonstrated that female dentists (OR:
7.79, p < 0.001), private practitioners (OR: 7.34, p < 0.001), and dentists with monthly income of ≥ 500 $US per month (OR: 9.41, p < 0.001) were more likely to examine greater number of patients with DH. Similarly,
the odds of examining greater number of patients with DH per week were significantly
higher for dentists with ≥ 5 years since graduation (OR: 2.75, p = 0.002) and those who obtained basic dental qualification from private dental institution
(OR: 2.04, p = 0.026) ([Table 5]).
Table 4
Practice of private and public dentists and dentists with ≤ 5 and > 5 years of experience
about the management of dentine hypersensitivity
|
Diagnostic methods of DH
|
Private practitioners
|
Public dentist
|
p-Value
|
Dentist with ≤ 5 years since graduation
|
Dentist with > 5 years since graduation
|
p-Value
|
|
Abbreviation: DH, dentine hypersensitivity.
aFisher’s exact test.
|
|
Spontaneous patient report confirmed by dental exam
|
141 (46.4)
|
163 (53.6)
|
0.884
|
179 (58.9)
|
125 (41.1)
|
0.117
|
|
Patient report after dentist’s query
|
80 (41)
|
115 (59)
|
0.073
|
157 (80.5)
|
38 (19.5)
|
< 0.001
|
|
Spontaneous pain after the application of air blast
|
147 (37.3)
|
247 (62.7)
|
< 0.001
|
182 (46.2)
|
212 (53.8)
|
< 0.001
|
|
Spontaneous pain after the application of cold water
|
58 (25.4)
|
170 (74.6)
|
< 0.001
|
74 (32.5)
|
154 (67.5)
|
< 0.001
|
|
Spontaneous pain after scratching dentine with dental explorer
|
82 (45.3)
|
99 (54.7)
|
0.788
|
76 (42)
|
105 (58)
|
< 0.001
|
|
Use of electric pulp tester
|
2 (100)
|
0 (0.0)
|
0.212a
|
2 (100)
|
0 (0.0)
|
0.506a
|
|
Asking patient to numerically rate pain
|
95 (97.9)
|
2 (2.1)
|
< 0.001
|
36 (37.1)
|
61 (62.9)
|
< 0.001
|
|
Asking patient to rate pain using visual analogue scale
|
41 (51.9)
|
38 (48.1)
|
0.263
|
61 (77.2)
|
18 (22.8)
|
< 0.001
|
|
Management preferences of DH
|
|
Use of fluoride products (e.g., gels, varnishes, pastes, rinses)
|
223 (44)
|
284 (56)
|
< 0.001
|
295 (58.2)
|
212 (41.8)
|
< 0.001
|
|
Use of desensitizing potassium nitrate toothpastes
|
180 (45.6)
|
215 (54.4)
|
0.667
|
232 (58.7)
|
163 (41.3)
|
0.027
|
|
Application of glutaraldehyde/HEMA products
|
43 (100)
|
0 (0)
|
< 0.001
|
2 (4.7)
|
41 (95.3)
|
< 0.001
|
|
Application of dentine bonding agents
|
166 (56.1)
|
130 (43.9)
|
< 0.001
|
140 (47.3)
|
156 (52.7)
|
< 0.001
|
|
Application of sealants
|
85 (70.8)
|
35 (29.2)
|
< 0.001
|
65 (54.2)
|
55 (45.8)
|
0.649
|
|
Provision of restorative treatments
|
5 (2.8)
|
175 (97.2)
|
< 0.001
|
77 (42.8)
|
103 (57.2)
|
< 0.001
|
|
Use of lasers
|
56 (100)
|
0 (0)
|
< 0.001
|
38 (67.9)
|
18 (32.1)
|
0.058
|
|
Use of oxalates
|
20 (43.5)
|
26 (56.5)
|
0.708
|
2 (4.3)
|
44 (95.7)
|
< 0.001
|
|
Diet counseling
|
97 (33.4)
|
193 (66.6)
|
< 0.001
|
151 (52.1)
|
139 (47.9)
|
0.046
|
Table 5
Bivariate and multivariate logistic regression: Factors associated with the examining
of greater number of patients with dentin hypersensitivity
|
Variables
|
Examining greater number of patients with DH
|
|
Crude OR (95% CI)
|
p-Value
|
Adjusted OR (95% CI)
|
p-Value
|
|
Abbreviations: CI, confidence interval; DH, dentine hypersensitivity; OR, odds ratio.
aReference categories.
|
|
Gender
Femalea
Male
|
4.91 (3.03, 7.96)
|
< 0.001
|
7.79 (3.87, 15.66)
|
< 0.001
|
|
Type of job
Privatea
Public
|
4.96 (3.06, 8.05)
|
< 0.001
|
7.34 (3.78, 14.25)
|
< 0.001
|
|
Monthly income
<500 $USa
≥500 $US
|
4.54 (2.64, 7.8)
|
< 0.001
|
9.41 (4.67, 18.93)
|
< 0.001
|
|
Year since graduation
> Five yearsa
≤ Five years
|
0.86 (0 0.56, 1.32)
|
0.498
|
2.75 (1.46, 5.19)
|
0.002
|
|
Basic dental qualification (BDS or equivalent) obtained from
Private dental collegea
Public dental college
|
4.72 (2.91, 7.65)
|
< 0.001
|
2.04 (1.09, 3.82)
|
0.026
|
Discussion
This study evaluated dentists’ preferences about the diagnosis and management of DH
in addition to their understanding about the type of pain and its predisposing factors.
In line with the results of a previous study (92.8%) in Nigeria,[16] a vast majority of participants (85.4%) in this study described DH as a stimulated
short sharp pain. It is known that DH is a multifactorial condition.[10]
[18] The present study showed that dental practitioners identified different etiological
factors leading to DH; however, gingival recession was the most frequently reported
factor. This finding is in accordance with similar questionnaire-based studies of
dental practitioners in the United.States and Australia.[2]
[13] On the other hand, Indian dentists indicated dental caries as the main etiological
agent of DH.[19] The finding of gingival recession as the most common etiological factor is supported
by one of the most widely accepted theories of DH, hydrodynamic theory.[5] Clinical studies from China, India, and Brazil had also reported an association
between gingival recession and DH.[7]
[8]
[10]
Dental practitioners in our study used diverse diagnostic methods; however, they most
frequently used air blast to evaluate the spontaneous pain of DH, followed by spontaneous
patient report confirmed by dental exam. Similarly, dentists in the United States
most frequently diagnosed DH by confirming patient report coupled with clinical examination,
while air blast was the second most commonly used method of diagnosis.[2] Another study in the United States also reported that most dental practitioners
relied on patients’ report for the diagnosis of DH.[20] In Senegal, 68% of dentists used mechanical stimuli to diagnose the DH pain.[21] Scratching of tooth was the most commonly used diagnostic method reported by dentists
in Nigeria.[16]
The current study found that many different diagnostic techniques of DH differed significantly
between male and female dentists, private and public dentists, and dentists with lesser
and greater clinical experience. However, consistent patterns regarding the use of
diagnostic methods among these dentists were not identified in the study. The present
study demonstrated that the use of fluoride formulations and potassium nitrate toothpaste
was the most common preferences for the management of DH. These findings are in agreement
with the results of previous studies in Canada, United Kingdom, Australia, and the
United States.[2]
[12]
[13]
[20] A recent study of private practitioners in India reported the prescription of desensitizing
agents for home use as the most common management option.[19] Recently, dentists used sensitivity toothpastes and desensitizers as the most frequently
recommended first line of treatment of DH in United Kingdom.[22] It was also found that the application of fluoride toothpaste resulted in improved
satisfaction of patients with the treatment of DH.[23] In addition, striking similarities were observed between dentists’ preferences for
the treatment of DH and actual recommendations for patients with DH.[2]
[14]
The use of dentine bonding agent (56.2%) and diet counseling (55%) were the third
most common treatment modalities in this study. These findings are consistent with
the results of a previous study.[20] It is known that dietary acids can cause erosion of enamel, leading to the exposure
of dentine and dentinal tubules that results in increased flow of fluids upon stimulation.[6] The use of bonding agent can significantly reduce symptoms of DH.[24] This might explain why almost half the dentists in our study reported using bonding
agent and providing dietary counseling for the treatment of DH.
The application of glutaraldehyde/HEMA products (8.2%) and use of oxalates (8.7%)
were the least frequently reported treatment modalities in the present study. This
is in contrast to the findings of a previous study which found that 58% and 46% of
participating dentists used glutaraldehyde/HEMA products and oxalates, respectively.[20] The effectiveness of laser for the treatment of DH has been demonstrated in many
clinical studies.[25]
[26]
[27] Despite, only 10.6% of dentists preferred lasers for the management of DH in the
current study, possibly because most dentists might not afford laser apparatus in
their clinics.
The results of this study showed inconsistent trends regarding treatment modalities
among dentists. It was found that significantly higher percent of male than female
dentists used fluorides products, desensitizing potassium nitrates toothpastes, and
application of bonding agents to manage DH. On the contrary, male and female dentists
showed no significant differences about providing diet counseling. Similarly, more
public dentists used fluoride products and provided diet counseling than private practitioners.
However, no significant differences were observed regarding the use of potassium nitrate
toothpaste between private and public dentists.
This is the first study that provided valuable data about the current trends of diagnosis
and management of DH in dental practice in Pakistan. The analysis of a large data
in the study provided robust and valid findings that can be used by the organizers
of continuing education activities and dental institutions to enhance knowledge and
skills of dental professionals related to DH. Although data collection included a
large sample of dentists from a cosmopolitan city of 11.1 million people, the generalizability
of the results to other geographical locations or regions should be done with caution.
In addition, the dentists conveniently participated in the study. Hence, the study
may not comprehensively represent the dentists’ population in the city. Moreover,
there can be over- and under-reporting of some responses by male and female dentists,
private and public dentists, and dentists with less or more clinical experience, etc.
In future, a nation-wide study should be conducted to evaluate practices of dentists
about DH.
Conclusion
In conclusion, DH is a highly prevalent condition in dental practice. The majority
of dentists identified recession of gums, aggressive brushing, and frequent use of
tooth whitening procedures as the predisposing factors. Diagnostic techniques and
management preferences varied among participating dentists. The application of air
blast and spontaneous patient report confirmed by dental examination were the most
frequently used diagnostic methods. Preferred management approaches included the use
of fluoride products, desensitizing toothpastes, and bonding agents. Dental practitioners
should continuously update their knowledge and skills to effectively manage DH and
improve quality of life of patients.
Conflict of Interest
None declared.
