CC BY-NC-ND 4.0 · Eur J Dent 2019; 13(04): 540-546
DOI: 10.1055/s-0039-1697110
Original Article
Dental Investigation Society

# A Study of Dentists about Their Knowledge and Practice of Dentine Hypersensitivity

› Author Affiliations
Further Information

### Address for correspondence

Muhammad Ashraf Nazir, BSc, BDS, MPH, FRSPH
Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam
P. O. Box 1982, Dammam 31441
Saudi Arabia

### Publication History

Publication Date:
16 October 2019 (online)

### Abstract

Objective The aim of this study was to evaluate the knowledge and practice about dentine hypersensitivity (DH) among dental practitioners.

Materials and Methods A pilot-tested questionnaire was sent to practicing dentists (n = 588) working in private and public sectors in Lahore, Pakistan. The questions assessed dentists’ knowledge about type of pain and predisposing factors of DH. The dentists were asked about their preferred methods of diagnosing and managing the condition.

Statistical Analysis Basic statistics, chi-squared test, and multivariate logistic regression were performed.

Results Most dentists (64.3%) reported examining one to five patients with DH per week in their dental clinics. A large majority (85.4%) indicated DH as a stimulated short pain from a tooth. Recession of gums (96.6%), aggressive brushing (88.2%), and frequent use of teeth whitening procedures (83.1%) were most frequently reported predisposing factors of DH. Among most commonly used methods of diagnosis, spontaneous pain after the application of air blast was reported by 74.8% of the participants and followed by spontaneous patient report confirmed by dental examination (57.7%). Most widely used management approaches of DH included the use of fluoride products (96.2%), use of desensitizing potassium nitrate toothpastes (75%), and application of bonding agents (56.2%). Female versus male dentists (odds ratio [OR]: 7.79, p < 0.001) and private practitioners versus public dentists (OR: 7.34, p < 0.001) were more likely to examine greater number of patients with DH.

Conclusion Dentists used various methods for diagnosing and managing patients with DH. Application of air blast to evaluate spontaneous pain and use of fluoride products were most widely used diagnostic and management preferences, respectively.

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### 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.

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### 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).

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### 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)

≤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

> 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

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### 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.

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### 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.

None declared.

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None declared.

### Address for correspondence

Muhammad Ashraf Nazir, BSc, BDS, MPH, FRSPH
Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam
P. O. Box 1982, Dammam 31441
Saudi Arabia