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Understanding the Burden and Diagnosis of Dentin Hypersensitivity

Joana Cunha-Cruz, DDS, MPH, PhD

June 2014 Course - Expires June 30th, 2017

Updates in Clinical Dentistry

Abstract

Dentin hypersensitivity is a significant problem for patients and practitioners and understanding its diagnosis and prevalence can inform the burden of this condition and guide treatment decisions. In this article, we describe the prevalence of dentin hypersensitivity and the current evidence base for the use of different methods of diagnosis of this condition.

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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

1. Consensus-based recommendations for the diagnosis and management of dentin hypersensitivity. J Can Dent Assoc. 2003;69(4):221-226.

2. Chabanski MB, Gillam DG. Aetiology, prevalence and clinical features of cervical dentine sensitivity. J Oral Rehabil. 1997;24(1):15-19.

3. Pashley DH. Dentine permeability and its role in the pathobiology of dentine sensitivity. Arch Oral Biol. 1994;39(Suppl):73S-80S.

4. Brannstrom M, Linden LA, Astrom A. The hydrodynamics of the dental tubule and of pulp fluid. A discussion of its significance in relation to dentinal sensitivity. Caries Res. 1967;1(4):310-317.

5. Rees JS, Addy M. A cross-sectional study of dentine hypersensitivity. J Clin Periodontol. 2002;29(11):997-1003.

6. Addy M. Etiology and clinical implications of dentine hypersensitivity. Dent Clin North Am. 1990;34(3):503-514.

7. Rees JS, Addy M. A cross-sectional study of buccal cervical sensitivity in UK general dental practice and a summary review of prevalence studies. Int J Dent Hyg. 2004;2(2):64-69.

8. Cunha-Cruz J, Wataha JC. The burden of dentine hypersensitivity. In: PR, ed. Dentine Hypersensitivity: Developing a Person-Centred Approach to Oral Health. 1st ed. Elsevier. August 2014. 

9. Cunha-Cruz J, Wataha JC, Heaton LJ, et al. The prevalence of dentin hypersensitivity in general dental practices in the northwest United States. J Amer Dent Assoc. 2013;144(3):288-296.

10. Cunha-Cruz J, Wataha JC, Zhou L, et al. Treating dentin hypersensitivity: therapeutic choices made by dentists of the northwest PRECEDENT network. J Amer Dent Assoc. 2010;141(9):1097-1105.

11. Holland GR, Narhi MN, Addy M, Gangarosa L, Orchardson R. Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. J Clin Periodontol. 1997;24(11):808-813.

12. Splieth CH, Tachou A. Epidemiology of dentin hypersensitivity. Clin Oral Investig. 2013;17(Suppl 1):S3-S8.

13. Gillam DG, Bulman JS, Newman HN. A pilot assessment of alternative methods of quantifying dental pain with particular reference to dentine hypersensitivity. Community Dent Health. 1997;14(2):92-96.

14. Kakar A, Kakar K. Measurement of dentin hypersensitivity with the Jay Sensitivity Sensor Probe and the Yeaple probe to compare relief from dentin hypersensitivity by dentifrices. Am J Dent. 2013;26(Spec No B):21B-28B.

15. Sowinski JA, Kakar A, Kakar K. Clinical evaluation of the Jay Sensitivity Sensor Probe: a new microprocessor-controlled instrument to evaluate dentin hypersensitivity. Am J Dent. 2013;26(Spec No B):5B-12B.

16. Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41(6):1073-1093.

17. Heaton LJ, Barlow AP, Coldwell SE. Development of labeled magnitude scales for the assessment of pain of dentin hypersensitivity. J Orofac Pain. 2013;27(1):72-81.

18. Heaton LJ, Barlow AP, Coldwell SE. Development of Labeled Magnitude Scales for Dentine Hypersensitivity. J Dent Res 2009;88(A):10.

19. Boiko OV, Baker SR, Gibson BJ, et al. Construction and validation of the quality of life measure for dentine hypersensitivity (DHEQ). J Clin Periodontol. 2010;37(11):973-980.

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PROVIDER: Dental Learning Systems, LLC
SOURCE: Updates in Clinical Dentistry | June 2014
COMMERCIAL SUPPORTER: Kuraray

Learning Objectives:

  • Define dentin hypersensitivity.
  • Report the prevalence of dentin hypersensitivity.
  • List the methods of diagnosis of dentin hypersensitivity.

Disclosures:

The author reports no conflicts of interest associated with this work.

Queries for the author may be directed to jromano@aegiscomm.com.