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Dentin hypersensitivity is defined as a short, sharp pain arising when dentin is exposed to evaporative, thermal, tactile, osmotic or chemical stimuli, and the pain cannot be ascribed to any other dental defect or pathology.1,2 These stimuli induce fluid flow within dental tubules, which triggers baroreceptors near the pulp, leading to pain.3 This so-called hydrodynamic theory of pain generation assumes an exposed dentin surface and patent tubules that allow fluid flow to reach the pulp where the baroreceptors reside.4 Patients report pain being triggered principally by cold drinks, but also by hot drinks, toothbrushing and sweet foods.5
Prevalence of Dentin Hypersensitivity
Up to 40 million American adults report dentin hypersensitivity symptoms each year,6 but reported prevalence rates range widely. Some research has placed the incidence as high as 74%, but it appears to range between 10% and 30%, depending on the population studied, study setting and design.7
In a systematic review of prevalence studies of dentin hypersensitivity,8 56 cross-sectional studies were identified. On average, the prevalence of dentin hypersensitivity was 61% for patients attending specialty practices such as periodontics and 27% for patients attending general practices. Overall, the average prevalence of dentin hypersensitivity of the studies included in the review was 33% and the best estimate for the prevalence was 10%. This translates to 1 in 10 individuals presenting with dentin hypersensitivity in the general population, and increasing to approximately 1 in 4 in general practices and 1 in 2 in specialty practices.
Dentin hypersensitivity is primarily a chronic condition producing intermittent but not severe pain, and affects multiple teeth.9 This condition is associated most commonly with gingival recession, use of tooth-whitening products and scaling and root planing; and less often with aggressive toothbrushing, non-carious cervical lesions or occlusal trauma.
Diagnosing Dentin Hypersensitivity
In a survey, general dentists in the northwest United States indicated that no less than a dozen methods are currently being used to diagnose dentin hypersensitivity.10 This panoply of diagnosis strategies for dentin hypersensitivity suggests considerable uncertainty among clinicians and researchers about how to diagnose this condition.10
To fully understand the burden of dentin hypersensitivity on patients and clinicians, a detailed diagnosis of this condition, excluding other causes of pain is necessary, but most importantly, the impact of dentin hypersensitivity in daily life should be more often assessed because the mere response to stimulation during a clinical exam may not warrant a need for treatment if it is not a significant problem or concern to the patient. Dentin hypersensitivity should then be diagnosed by the patient’s self-report of pain through querying, by clinical exam to exclude other dental and periodontal conditions and by tests for the evaluation of the patient’s response to a stimulus and for the evaluation of the impact of the sensitivity on daily life.
Querying the Patient
If the patient does not spontaneously report sensitive teeth, the clinician can start by querying the patient about pain in the mouth, preferably with a nonspecific question such as “Have you recently had any pain, sensitivity or discomfort in your teeth or gums?”. The clinician can rely on the patient’s own pain threshold as a trigger for a positive response. Upon a negative response, there is no need for further examinations because even if the patient reports pain during stimulation, the negative response to the nonspecific question indicates that the patient does not perceive it as a significant problem.
Clinical Examination
Upon a positive response to the self-report of sensitivity, the clinician performs a clinical exam. As dentin hypersensitivity is a diagnosis of exclusion,11 during the clinical examination other conditions that could also cause pain or discomfort must be ruled out. These conditions include dental caries, pulpitis, fractured teeth, fractured restorations, post-restorative sensitivity, marginal leakage, chipped teeth, and gingival inflammation.12
Clinical Test: Thermo-evaporative Test and Pain Ratings
By definition, dentin hypersensitivity should be elicited by a stimulus. Upon a positive response to the self-report of sensitivity and after excluding other conditions as the source of the pain, a clinical test generally follows to identify the sensitive teeth.
The clinician stimulates suspected teeth using a thermo-evaporative stimulus to try to trigger pain and record the patient's reaction. The clinician applies a 1-second cold air blast from an air-water syringe to the sensitive tooth from a distance of 1 cm away from the vestibular or buccal surface while covering the adjacent teeth with gloved fingers.
Other stimuli could be used such as tactile stimulus using an explorer or curette or more appropriately a force sensitive probe (eg, Jay sensitivity sensor probe and the Yeaple electronic force sensing probe).13-15 The clinician places the force sensitive probe on each tooth perpendicular to the vestibular or buccal surface and the pressure is gradually increased until the pain threshold is reached or a pre-established maximum force is applied.
After application of the thermo-evaporative or tactile stimulus, the patient is asked to rate the pain felt during the application. Visual analog scales (VAS), numerical rating scales, verbal description scales, face pain scales, and labeled magnitude scales can be used.16 Preference can be given to labeled magnitude scales that have been developed specifically for dentin hypersensitivity such as the Seattle scales.17 The Seattle scales are semantically labeled scales consisting of a bar or line labeled with verbal descriptors of pain spaced according to their semantic magnitude (eg, “no pain,” “dim,” “dull,” “sharp,” “stabbing”). The distance measured in millimeters from the “no pain” end to the patient’s mark is the pain score. The Seattle scales are composed of four scales that measure different dimensions of pain: intensity, duration, tolerability, and description.
The main disadvantage of using Visual Analog Scales (VAS) is that many patients with low- to moderate-level pain conditions, such as dentin hypersensitivity, compress their responses to the lower third of the VAS scale.18 When comparing VAS to the Seattle scales, patients report a broader range of the Seattle scales than the VAS scale.9,18 The Seattle scales seem more appropriate to quantify a low-to-moderate-level, chronic, intermittent pain condition such as dentin hypersensitivity. It appears that this scale can help providers obtain a more thorough understanding of a patient’s pain.
Quality of Life Test: Dentin Hypersensitivity Experience Questionnaire
The assessment of dentin hypersensitivity may also consider the impact of pain on daily life. The clinician can ask the patient to complete the questionnaire after confirming the diagnosis with the clinical examination and testing.
The Dentin Hypersensitivity Experience Questionnaire (DHEQ) has been developed specifically to capture the daily experiences of people with dentin hypersensitivity and its impacts on different dimensions of life such as eating, drinking, talking, toothbrushing, and social interaction.19 The short form of the DHEQ contains 15 questions (Table 2). The response options are on a 7-point Likert scale labeled and scored Strongly Agree (7), Agree (6), Agree a Little (5), Neither Agree nor Disagree (4), Disagree a Little (3), Disagree (2) or Strongly Disagree (1). The patient response to each item should be summed up using the item codes to obtain the effect on life overall known as the total DHEQ score.
The dentin hypersensitivity experience questionnaire will help the clinician understand the burden of the condition in the patient’s life. Understanding dentin hypersensitivity from the patient’s perspective is an important part of the diagnosis of dentin hypersensitivity and should be more widely used.
Conclusion
Dentin hypersensitivity is primarily a chronic condition producing intermittent but not severe pain and clinicians in general practices can expect that approximately 1 in 4 patients may have the condition. Patient spontaneous report of this low-to-moderate chronic pain condition will depend on how well the patient has developed coping mechanisms to adjust and integrate dentin hypersensitivity to everyday life.
By definition, dentin hypersensitivity does not have unique clinical signs that can help clinicians make a definitive diagnosis. The clinician needs to rely on the patient's subjective experience for a proper diagnosis. We proposed in this article a systematic, holistic, and evidence-based method for the diagnosis of dentin hypersensitivity. It uses methods specifically developed to diagnose dentin hypersensitivity taking into account the patient’s subjective experience. This approach goes beyond the clinical aspects of dentin hypersensitivity, to understand the impact of this condition on everyday life that are important to patients and of sufficient magnitude to affect their perception. The proper diagnosis of dentin hypersensitivity can guide clinicians and patients to reach the best initial treatment decision to meet the patient's expectations and also measure the impact of the selected treatments over time.
References
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