272
J. Dent. 1992;
20: 272-276
Prevalence and distribution of cervical dentine hypersensitivity in a population in Rio de Janeiro, Brazil C. Fischer, R. G. Fischer* Departments
of Endodontics
and A. Wennberg and* Periodontology,
School of Dentistry,
Lund University,
Ma/m&
Sweden
ABSTRACT The prevalence, distribution and possible causal factors of cervical dentine hypersensitivity were studied in a population from a Marine Dental Clinic in the city of Rio de Janeiro, Brazil. A total of 635 patients were examined for the presence of cervical dentine hypersensitivity by means of a questionnaire and intraoral tests (air and probe stimuli). There were 157 patients (25%) reporting to have hypersensitive teeth, but only 108 patients (17%) were diagnosed as having cervical dentine hypersensitivity. The prevalence of hypersensitivity was higher among females than males, but this difference was not statistically significant. Most females with hypersensitivity were aged 20-49 and most males were aged 40-59. Incisors and premolars had the highest prevalence of dentine hypersensitivity to air and probe stimuli, while molars had the lowest. The presence and history of dentine hypersensitivity were positively correlated with previous exposure to periodontal treatment. Only a few of the patients who claimed to have dentine hypersensitivity had tried treatment with desensitizing toothpastes or sought professional help. KEY WORDS:
Dentine hypersensitivity,
./. Dent. 1992;
20: 272-276
Prevalence,
(Received 29 November
Distribution, 1991;
Factors
reviewed 7 January 1992;
accepted 3 March
1992) Correspondence should be addressed to: Dr C. Fischer, Department University
of Lund, S 214
21, MaIma,
of Endodontics,
School of Dentistry,
Sweden.
INTRODUCTION Dentine hypersensitivity has been described as a condition in which a sound exposed dentinal surface is sensitive to stimuli that would normally cause no discomfort (Flynn et al., 1985). Patients may experience sensations ranging from mild to extreme pain. Dowel1 and Addy (1983) reviewed the factors involved in the exposure of dentinal surfaces. They have classified them into those causing loss of enamel and those causing denudation of the root surface by loss of cementum and overlying periodontal structures. It is interesting to note that not all patients with exposed dentinal surfaces experience hypersensitivity, and that among those who do, some exhibit spontaneous recovery, while others need the help of a desensitizing treatment (Fischer ef al., 1992). A wide variety of agents has been proposed as desensitizers for hypersensitive teeth, but none has proved to be completely effective (Collaert and Fischer, 1991). These intriguing aspects Q 1992 Butterworth-Heinemann 0300-5712/92/050272-05
Ltd.
seem to be related to the multifactorial aetiology of dentine hypersensitivity and its physiological mechanism, which has not yet been clearly understood. Studies on the prevalence of dentine hypersensitivity have shown that this condition is not an uncommon problem among the adult population (Graf and Galasse, 1977; Flynn et al., 1985; Collaert et al.. 1990). However, the amount of epidemiological data on dentine hypersensitivity is still scarce. Epidemiological studies contribute to a knowledge about the distribution of a disease and to an explanation of the observed distribution in terms of causal factors, which in turn may offer possibilities for prevention. Therefore, the aim of the present study was to investigate the prevalence and distribution of dentine hypersensitivity and its possible causal factors among patients attending a dental clinic in the city of Rio de Janeiro, Brazil.
Fischer et al.: Epidemiology
MATERIALS
Presence
Males Females Total
273 362 635
59 98 157
%
22 27 25
History No. 96 29 37 66
The results of the questionnaire are summarized in Tables I and II. Twenty-five per cent of the patients (59 males and 98 females) reported having hypersensitive teeth and 10% reported a history of hypersensitivity (Table Z). Females presented a higher prevalence of hypersensitive teeth than males, but this difference was not statistically significant (P > 0.05). The age distribution of males and females with hypersensitive teeth according to the questionnaire is shown in Fig. 1. Fifty-two per cent of the patients claiming to have hypersensitive teeth experienced discomfort in daily life caused by more than two stimuli. The most common reported stimulus was cold food and/or drinks (82%),
362)
Males
100
i
60
60
9 E 5
40
40
(n = 273)
20
20
h
50-59 40-49
70-79 60-69
10-19 80-89
Age
68 63 64
Questionnaire
F
30-39
185 227 412
A total of 638 patients was examined. Three edentulous patients were excluded, leaving 635 subjects for the study. Their ages ranged from 13 to 87 years. There were 273 males with a mean age of 39 f 17.7 years and 362 females with a mean age of 33 f 12.9 years. The age distribution among males and females is shown in Fig. 1. There was a statistically significant difference in age distribution between males and females (P < 0.01).
80
20-29
10 10 10
Absence No. %
RESULTS
All teeth with exposed buccal root areas free of caries or restorations were first tested with an air-jet derived from the dental chair unit during 3 s and then scratched three times with a new sharp probe. Any sensation ofpain to the (n=
NO.
air and/or probe stimuli was recorded. The presence of large carious lesions and restorations outside the testing area were noted. The chi square test was used for statistical analysis.
tests
Females
n
Sex
Questions about hypersensitive teeth were read to the patients and the answer recorded. Before the questions were formulated, further information about the condition (cervical dentine hypersensitivity) was always given. The patients were first asked about previous dental treatment and then about the presence or history of hypersensitive teeth. Those reporting present or past hypersensitivity were further asked about its probable cause and duration, stimuli causing pain in daily life and any treatment attempts.
10-19
273
history and absence of hypersensitive teeth according to the questionnaire
Questionnaire
100
hypersensitivity
Table 1. Number and percentage of patients with presence,
AND METHODS
The patients selected for this study were from a Marine Dental Clinic (Odontoclinica da Marinha), located in the city of Rio de Janeiro. At this clinic, new and recall patients are first examined in the Department of ‘Semiologia’ and then referred to the various specialized departments for treatment. During 8 consecutive working days, all patients attending the Department of ‘Semiologia’ were examined for the presence of cervical dentine hypersensitivity. The patients were given a questionnaire and submitted to an intraoral examination, including two intraoral tests, to evaluate the presence of cervical dentine hypersensitivity. Patients who reported having hypersensitive teeth in the questionnaire were diagnosed as having cervical dentine hypersensitivity only when the hypersensitivity was verified by one or both of the intraoral tests. The patients were interviewed and examined by one of two investigators (C.F. or R.F.). Each clinical examination (including the questionnaire) lasted 5-10 min.
Intraoral
of cervical dentine
groups
30-39 20-29
so-59 40-49
70-79 60-69
80-89
(yr)
Fig. 1. Age distribution among males and females. hypersensitive teeth according to the questionnaire.
, Number
of patients with
274
J. Dent.
1992;
20:
No. 5
Table 111. Number atId percentage of patients previously
Table II. Responses to the questionnaire Question/response
exposed to periodontal treatment
Males * Females t Totals CW @I I%)
Cause for hypersensitivity5 Toothbrushing Periodontal disease New restorations, crowns or bridges Professional cleaning Periodontal surgery Orthodontic treatment Don’t know Stimuli causing pain1 Cold drink/foods Hot drink/foods Sweets Toothbrushing Fruit Interproximal cleaning
22 14
18 20
8
7
7.6
7 3 3 42
5.7 2 2 46
80 57 47 43 29 26
82 55 45 37 36 18 20 10 48 21 1
: 5: 85 :; 27 46 5
20 17
Duration of hypersensitivity < 0.5 yr 0.5-I yr I-5yr > 5yr Don’t know
4; 24 2
21 12 47 19 1
Use of desensitizing toothpaste Yes No
27 73
35 65
32 68
Professional treatment Yes No
19 81
21 79
20 80
18
Hypersensitivity according to the questionnaire Presence History Absence
n 157 66 412
Exposed to periodontal treatment No. 96 63 38 107
40** 58*** 26
Intraoral
tests
The results of the intraoral tests are summarized in Table IV. Teeth sensitive to intraoral tests were found in 132 of the 157 patients who reported hypersensitive teeth according to the questionnaire. However, 24 of these patients were excluded, since their sensitivity seemed to be related to carious lesions or large or fractured restorations. Among the remaining 108 patients diagnosed as having cervical dentine hypersensitivity, 95% were sensitive to the air test and 72% to the probe test. Teeth sensitive to intraoral tests were also found in 47% (3 1) of the patients with a history of hypersensitivity and in 14% (57) of those reporting no hypersensitivity to daily life stimuli. The intraoral distribution of teeth sensitive to air and probe stimuli was similar (Fig. 2). The incisors and premolars showed the highest proportion of sensitive teeth, while the molars showed the lowest one.
§Three females reported pregnancy as the cause of their hypersensitivity. IThree patients reported pain on touch.
while discomfort caused by toothbrushing was reported by 37% (Table II). The hypersensitivity was reported to have lasted between 1 and 5 years by 48% of the patients, while 21% reported a duration of more than 5 years and 20% a duration of less than half a year. Desensitizing toothpaste had been used by 32% of the patients and 20% had received professional treatment for their hypersensitivity
DISCUSSION The prevalence of dentine hypersensitivity has been studied ic the West of Scotland (Flynn et al., 1985) and in Sweden (Collaert et al., 1990). In these studies 28% and 22% of the patients reported discomfort to daily life stimuli, which agrees well with our results of 25%. It is interesting to note the great similarity between the prevalence in the three populations from Scotland, Sweden and Brazil. However, when the presence of dentine hypersensitivity was evaluated by means of
(Table IZ).
Forty-six per cent of the patients who reported having hypersensitive teeth did not know of any possible cause for their hypersensitivity. Twenty per cent blamed it on toothbrushing procedures, and 7.7% on periodontal treatment (professional cleaning and periodontal surgery) (Table Ir). Table IV. Results of the intraoral tests
Presence History Absence
108* 31 57
Patients sensitive to Air only Probe only Probe and air No. 96 No. % No. % 30 12 18
28 39 31
60 42 74
A significantly higher proportion of patients who had received periodontal treatment was found in the groups of patients reporting presence (P < 0.01) and history (P < 0.001) of hypersensitivity than in the group reporting no hypersensitivity (Table III).
$n = 157.
n
94 28 304
**P < 0.01 and ***P < 0.001 when compared with the number of Patients with absence of hypersensitiveteeth.
*rl = 59. tn = 98.
H ypersensirivity according to rhe questionnaire
Not exposed to periodontal treatment No. %
8” 265 13
23
73 11 26
*Patients with diagnosed cervicaldentine hypersensitivity.
67 35 46
Mean no. of sensitive teeth per patient 6.1 4.3 2.9
Fischer et al. : Epidemiology
1
3OOd
zood 5 c z c
loo-
M
C
PM Tooth
I
type
Fig. 2. Intraoral distribution of teeth sensitive to air (0, n = 627) and probe ( , n = 327) stimuli.
tests, lower prevalence figures were found. Graf and Galasse (1977), by means of a dental explorer, found hypersensitive teeth in 14.5% of the patients. Prevalences of 18% (Flynn et al., 1985) and 15% (Collaert et al., 1990) were reported when sensitivity was evaluated by means of cold water rinsing. In our study, after intraoral testing with air and probe stimuli, 17% of the population were diagnosed as having cervical dentine hypersensitivity. Considering that these results are from different populations and that different methods to evaluate the presence of dentine hypersensitivity were used, the similarity seen between the results is striking. The difference between the prevalence of dentine hypersensitivity based on patient’s testimonials and the prevalence based on intraoral tests might raise the question about the reliability of both methods of evaluation. Flynn et al. (1985) did not consider the patient’s own evaluation a reliable index, since they found that some patients tended to blame other forms of dental pain on hypersensitive teeth. This tendency was also noted in our study. However, the reliability of the results based on intraoral tests could also be questioned. The air and probe stimuli used in our study, for instance, are not exact reproductions of daily life stimuli. Accordingly, they might fail to cause pain sensations in patients with teeth sensitive to daily life stimuli, and, on the other hand, might elicit pain in patients with no hypersensitivity to daily life stimuli. Thus, it seems that both methods of evaluation, the patient’s subjective evaluation and the intraoral tests, have shortcomings that must be considered when analysing the results. Almost all patients (95%) with diagnosed dentine hypersensitivity were sensitive to the air test, while a lower percentage (72%) were sensitive to the probe test. This difference could be attributed to the fact that the air test was applied before the probe test, since it has been shown that a stream of air of 1 min duration decreases dentine intraoral
of cervical dentine
hypersensitivity
275
sensitivity (Johnson and Brannstrom, 1974). However, in the present study an air-jet of only 3 s was used, and it seems less likely that the air test would have interfered with the dentine sensitivity. Absi et al. (1987) have noticed that usually only a limited area of the exposed dentine is actually sensitive. It is possible that the probe did not touchy the sensitive spots of some of the hypersensitive teeth and, therefore, some patients sensitive to the air-jet did not respond to the probe test. In view of the finding of Absi et al. (1987) and according to the present results, it seems that the air test was more reliable than the probe test to evaluate the presence of dentine hypersensitivity. The common finding that the prevalence of hypersensitive teeth is higher among females than among males (Graf and Galasse, 1977; Flynn et al., 1985; Collaert et al., 1990) was also found in our study. However, in none of these reports and in this one was this difference statistically significant. When considering the number of patients in each age group, the highest proportion of males and females with hypersensitivity occurred in the age group 40-49 years. When considering the total number of patients, most males were aged 40-59 and most females 20-49. In other studies (Graf and Galasse, 1977; Flynn et al., 1985) a high prevalence of hypersensitivity was found in a younger population. The intraoral distribution of hypersensitivity showed that incisors and premolars were the most common teeth sensitive to the air and probe stimuli, while molars were the least sensitive ones. Other studies have shown similar findings (Flynn et al., 1985; Addy et al., 1987; Orchardson and Collins, 1987) but canines were also highly affected by hypersensitivity (Addy et al., 1987; Orchardson and Collins, 1987). Addy et al. (1987) have studied the distribution of plaque and recession in hypersensitive teeth and they found that teeth with the most pronounced sensitivity presented the largest gingival recessions, but also the lowest buccal plaque scores. On the basis of these findings, they concluded that toothbrushing rarely causes pain in patients with dentine hypersensitivity. Our results showed that 37% of the patients claiming to have hypersensitive teeth reported pain on toothbrushing. This should be compared with the fact that 82% of the patients reported pain to cold stimuli. Similar results have been reported in other studies, where pain on toothbrushing varied from 29% (Collaertet al., 1990) to 17% (Orchardson and Collins, 1987). These findings do not seem to support the general belief that patients with hypersensitivity may have impaired oral hygiene because toothbrushing is painful. The results from the questionnaire revealed that only 8% of the patients who reported having hypersensitive teeth blamed periodontal treatment (professional cleaning and periodontal surgery). However, both presence and history of hypersensitivity were positively correlated to previous exposure to periodontal treatment. This is in agreement with findings reported by Fisher et al. (1992), who evaluated the sensitivity of exposed dentine after
276
J. Dent.
1992;
20:
No. 5
periodontal treatment. They found that six of 11 patients experienced a significant increase in dentine sensitivity after subgingival scaling. These results seem to support the hypothesis that periodontal therapy plays a role in the development of dentine hypersensitivity. The number of patients with hypersensitive teeth according to their own evaluation (25%) may seem high. However, the condition did not seem to be a problem for many of these patients, since only 32% of them had tried treatment with a desensitizing toothpaste and 20% had sought professional help. Similar findings were reported by Flynn et al. (1985) who also found that only 25% of the patients who reported having hypersensitive teeth had received desensitizing treatment.
Acknowledgements The authors da Marinha Dr Murillo perform the
wish to thank the staff at the Odontoclinica for their valuable contribution and especially de Luca who provided all the facilities to study.
References
Absi E. G., Addy M. and Adams D. (1987) Dentine hypersensitivity. A study of the patency of dentinal tubules in sensitive and non-sensitive cervical dentine. J. Clin. Periodontal. 14, 280-284. Addy M., Mostafa P. and Newcombe R. G. (1987) Dentine hypersensitivity. The distribution of recession, sensitivity and plaque. J. Dent. 15, 242-248. Collaert B. and Fischer C. (1991) Dentine hypersensitivitya review. Endod. Dent. Traumatol. 7, 145-152. Collaert B., Sbderholm G., Linden U. et al. (1990) The Prevalence of Dentine Hypersensitivity in a Swedish Population Attending Public, Private and Specialist Clinics. Thesis, Lund University, Malmd. Dowel1 P. and Addy M. (1983) Dentine hypersensitivity-a review. Aetiology, symptoms and theories of pain production. .I Clin. Periodontol. 10, 341-350. Fischer C., Wennberg A., Fischer R. G. et al. (1991) Clinical evaluation of pulp and dentine after supragingival and subgingival scaling. Endod. Dent. Traumalol. 7, 259-265. Flynn J., Galloway R. and Orchardson R. (1985) The incidence of ‘hypersensitive’ teeth in the West of Scotland. J. Dent. 13, 230-236. Graf H. and Galasse R. (1977) Morbidity, prevalence and intraoral distribution of hypersensitive teeth. J. Dent. Res. 56, (spec. issue A), A162. Johnson G. and Brannstriim M. (1974) The sensitivity of dentin. Changes in relation to conditions at exposed tubule apertures. Acta Odontol. Stand. 32, 29-38. Orchardson R. and Collins W. J. N. (1987) Clinical features of hypersensitive teeth. Br. Dent. .I 162, 253-256.
Book Review Aspects of Oral Molecular Biology. Edited by D. B. Ferguson. Pp. 144. 1991. Hardback, SFr 155.00.
Karger, Basel.
However admirable the individual contributions may be, combining reviews by different authors into a single volume is not easy. All too often the result is a motley collection with little directional thrust. This volume comprises eight chapters on topics as diverse as the control of dental development and the genetics of oral bacteria, yet three chapters are devoted to genetic variation in salivary constituents. The book thus falls between the two stools of broad overview and specialist monograph. Much of the first chapter (H. Lesot) is taken up by a general consideration of genetic influences on dental development. More specific consideration of cell-matrix and cell-cell interactions is included but it is difficult to grasp the essential molecular message. Two chapters on enamel proteins follow, one (J. D. Termine and M. F. Young) concentrating on the differences and homologies between enamelin and amelogenin, and the other (R. Herold and J. Rosenbloom) on enamel proteins in different species. The use of the salamander, where cells derived from the same progenitor population produce only enamelin in larval teeth but both enamelin and amelogenin in adult teeth, is an ingenious approach to investigating the expression of enamel protein genes. The more general developmental theme is then resumed
with changes in dental mesenchyme that lead to its differentiation into distinct tooth-germ components (I. Thesleff et a/.). The chapter on genetics of oral bacteria (R. R. B. Russell) is a lucid account of how recombinant DNA technology is being used to identify oral microorganisms and investigate their pathogenicity. However, pathogens only produce disease through interaction with the host. A chapter on the molecular biology of the host response to these organisms would therefore have provided a useful balance. The next two contributions deal with salivary mucin (L. A. Tabak) anqi proline-rich proteins (D. B. Ferguson). The startling degree of genetic variation found for mucin and the complex post-translational modification of mucin gene products are shown to present a formidable challenge. The proline-rich proteins are far better understood, being controlled by a series of neighbouring loci on the short arm of chromosome 12 known as the salivary protein complex. The final chapter (R. C. Karn) considers other enzymic and non-enzymic salivary proteins and includes an account of the amylase multigene family. The book does give a flavour of new approaches to oral problems using rapidly advancing technologies and, although only a handful of references are dated after 1988, is to be commended on this account. But, it is also likely to be of value only to those with a particular interest in the specialist areas selected for inclusion. J. A. Sofaer
J. Dent. 1992;
20: 272-276
Prevalence and distribution of cervical dentine hypersensitivity in a population in Rio de Janeiro, Brazil C. Fischer, R. G. Fischer* Departments
of Endodontics
and A. Wennberg and* Periodontology,
School of Dentistry,
Lund University,
Ma/m&
Sweden
ABSTRACT The prevalence, distribution and possible causal factors of cervical dentine hypersensitivity were studied in a population from a Marine Dental Clinic in the city of Rio de Janeiro, Brazil. A total of 635 patients were examined for the presence of cervical dentine hypersensitivity by means of a questionnaire and intraoral tests (air and probe stimuli). There were 157 patients (25%) reporting to have hypersensitive teeth, but only 108 patients (17%) were diagnosed as having cervical dentine hypersensitivity. The prevalence of hypersensitivity was higher among females than males, but this difference was not statistically significant. Most females with hypersensitivity were aged 20-49 and most males were aged 40-59. Incisors and premolars had the highest prevalence of dentine hypersensitivity to air and probe stimuli, while molars had the lowest. The presence and history of dentine hypersensitivity were positively correlated with previous exposure to periodontal treatment. Only a few of the patients who claimed to have dentine hypersensitivity had tried treatment with desensitizing toothpastes or sought professional help. KEY WORDS:
Dentine hypersensitivity,
./. Dent. 1992;
20: 272-276
Prevalence,
(Received 29 November
Distribution, 1991;
Factors
reviewed 7 January 1992;
accepted 3 March
1992) Correspondence should be addressed to: Dr C. Fischer, Department University
of Lund, S 214
21, MaIma,
of Endodontics,
School of Dentistry,
Sweden.
INTRODUCTION Dentine hypersensitivity has been described as a condition in which a sound exposed dentinal surface is sensitive to stimuli that would normally cause no discomfort (Flynn et al., 1985). Patients may experience sensations ranging from mild to extreme pain. Dowel1 and Addy (1983) reviewed the factors involved in the exposure of dentinal surfaces. They have classified them into those causing loss of enamel and those causing denudation of the root surface by loss of cementum and overlying periodontal structures. It is interesting to note that not all patients with exposed dentinal surfaces experience hypersensitivity, and that among those who do, some exhibit spontaneous recovery, while others need the help of a desensitizing treatment (Fischer ef al., 1992). A wide variety of agents has been proposed as desensitizers for hypersensitive teeth, but none has proved to be completely effective (Collaert and Fischer, 1991). These intriguing aspects Q 1992 Butterworth-Heinemann 0300-5712/92/050272-05
Ltd.
seem to be related to the multifactorial aetiology of dentine hypersensitivity and its physiological mechanism, which has not yet been clearly understood. Studies on the prevalence of dentine hypersensitivity have shown that this condition is not an uncommon problem among the adult population (Graf and Galasse, 1977; Flynn et al., 1985; Collaert et al.. 1990). However, the amount of epidemiological data on dentine hypersensitivity is still scarce. Epidemiological studies contribute to a knowledge about the distribution of a disease and to an explanation of the observed distribution in terms of causal factors, which in turn may offer possibilities for prevention. Therefore, the aim of the present study was to investigate the prevalence and distribution of dentine hypersensitivity and its possible causal factors among patients attending a dental clinic in the city of Rio de Janeiro, Brazil.
Fischer et al.: Epidemiology
MATERIALS
Presence
Males Females Total
273 362 635
59 98 157
%
22 27 25
History No. 96 29 37 66
The results of the questionnaire are summarized in Tables I and II. Twenty-five per cent of the patients (59 males and 98 females) reported having hypersensitive teeth and 10% reported a history of hypersensitivity (Table Z). Females presented a higher prevalence of hypersensitive teeth than males, but this difference was not statistically significant (P > 0.05). The age distribution of males and females with hypersensitive teeth according to the questionnaire is shown in Fig. 1. Fifty-two per cent of the patients claiming to have hypersensitive teeth experienced discomfort in daily life caused by more than two stimuli. The most common reported stimulus was cold food and/or drinks (82%),
362)
Males
100
i
60
60
9 E 5
40
40
(n = 273)
20
20
h
50-59 40-49
70-79 60-69
10-19 80-89
Age
68 63 64
Questionnaire
F
30-39
185 227 412
A total of 638 patients was examined. Three edentulous patients were excluded, leaving 635 subjects for the study. Their ages ranged from 13 to 87 years. There were 273 males with a mean age of 39 f 17.7 years and 362 females with a mean age of 33 f 12.9 years. The age distribution among males and females is shown in Fig. 1. There was a statistically significant difference in age distribution between males and females (P < 0.01).
80
20-29
10 10 10
Absence No. %
RESULTS
All teeth with exposed buccal root areas free of caries or restorations were first tested with an air-jet derived from the dental chair unit during 3 s and then scratched three times with a new sharp probe. Any sensation ofpain to the (n=
NO.
air and/or probe stimuli was recorded. The presence of large carious lesions and restorations outside the testing area were noted. The chi square test was used for statistical analysis.
tests
Females
n
Sex
Questions about hypersensitive teeth were read to the patients and the answer recorded. Before the questions were formulated, further information about the condition (cervical dentine hypersensitivity) was always given. The patients were first asked about previous dental treatment and then about the presence or history of hypersensitive teeth. Those reporting present or past hypersensitivity were further asked about its probable cause and duration, stimuli causing pain in daily life and any treatment attempts.
10-19
273
history and absence of hypersensitive teeth according to the questionnaire
Questionnaire
100
hypersensitivity
Table 1. Number and percentage of patients with presence,
AND METHODS
The patients selected for this study were from a Marine Dental Clinic (Odontoclinica da Marinha), located in the city of Rio de Janeiro. At this clinic, new and recall patients are first examined in the Department of ‘Semiologia’ and then referred to the various specialized departments for treatment. During 8 consecutive working days, all patients attending the Department of ‘Semiologia’ were examined for the presence of cervical dentine hypersensitivity. The patients were given a questionnaire and submitted to an intraoral examination, including two intraoral tests, to evaluate the presence of cervical dentine hypersensitivity. Patients who reported having hypersensitive teeth in the questionnaire were diagnosed as having cervical dentine hypersensitivity only when the hypersensitivity was verified by one or both of the intraoral tests. The patients were interviewed and examined by one of two investigators (C.F. or R.F.). Each clinical examination (including the questionnaire) lasted 5-10 min.
Intraoral
of cervical dentine
groups
30-39 20-29
so-59 40-49
70-79 60-69
80-89
(yr)
Fig. 1. Age distribution among males and females. hypersensitive teeth according to the questionnaire.
, Number
of patients with
274
J. Dent.
1992;
20:
No. 5
Table 111. Number atId percentage of patients previously
Table II. Responses to the questionnaire Question/response
exposed to periodontal treatment
Males * Females t Totals CW @I I%)
Cause for hypersensitivity5 Toothbrushing Periodontal disease New restorations, crowns or bridges Professional cleaning Periodontal surgery Orthodontic treatment Don’t know Stimuli causing pain1 Cold drink/foods Hot drink/foods Sweets Toothbrushing Fruit Interproximal cleaning
22 14
18 20
8
7
7.6
7 3 3 42
5.7 2 2 46
80 57 47 43 29 26
82 55 45 37 36 18 20 10 48 21 1
: 5: 85 :; 27 46 5
20 17
Duration of hypersensitivity < 0.5 yr 0.5-I yr I-5yr > 5yr Don’t know
4; 24 2
21 12 47 19 1
Use of desensitizing toothpaste Yes No
27 73
35 65
32 68
Professional treatment Yes No
19 81
21 79
20 80
18
Hypersensitivity according to the questionnaire Presence History Absence
n 157 66 412
Exposed to periodontal treatment No. 96 63 38 107
40** 58*** 26
Intraoral
tests
The results of the intraoral tests are summarized in Table IV. Teeth sensitive to intraoral tests were found in 132 of the 157 patients who reported hypersensitive teeth according to the questionnaire. However, 24 of these patients were excluded, since their sensitivity seemed to be related to carious lesions or large or fractured restorations. Among the remaining 108 patients diagnosed as having cervical dentine hypersensitivity, 95% were sensitive to the air test and 72% to the probe test. Teeth sensitive to intraoral tests were also found in 47% (3 1) of the patients with a history of hypersensitivity and in 14% (57) of those reporting no hypersensitivity to daily life stimuli. The intraoral distribution of teeth sensitive to air and probe stimuli was similar (Fig. 2). The incisors and premolars showed the highest proportion of sensitive teeth, while the molars showed the lowest one.
§Three females reported pregnancy as the cause of their hypersensitivity. IThree patients reported pain on touch.
while discomfort caused by toothbrushing was reported by 37% (Table II). The hypersensitivity was reported to have lasted between 1 and 5 years by 48% of the patients, while 21% reported a duration of more than 5 years and 20% a duration of less than half a year. Desensitizing toothpaste had been used by 32% of the patients and 20% had received professional treatment for their hypersensitivity
DISCUSSION The prevalence of dentine hypersensitivity has been studied ic the West of Scotland (Flynn et al., 1985) and in Sweden (Collaert et al., 1990). In these studies 28% and 22% of the patients reported discomfort to daily life stimuli, which agrees well with our results of 25%. It is interesting to note the great similarity between the prevalence in the three populations from Scotland, Sweden and Brazil. However, when the presence of dentine hypersensitivity was evaluated by means of
(Table IZ).
Forty-six per cent of the patients who reported having hypersensitive teeth did not know of any possible cause for their hypersensitivity. Twenty per cent blamed it on toothbrushing procedures, and 7.7% on periodontal treatment (professional cleaning and periodontal surgery) (Table Ir). Table IV. Results of the intraoral tests
Presence History Absence
108* 31 57
Patients sensitive to Air only Probe only Probe and air No. 96 No. % No. % 30 12 18
28 39 31
60 42 74
A significantly higher proportion of patients who had received periodontal treatment was found in the groups of patients reporting presence (P < 0.01) and history (P < 0.001) of hypersensitivity than in the group reporting no hypersensitivity (Table III).
$n = 157.
n
94 28 304
**P < 0.01 and ***P < 0.001 when compared with the number of Patients with absence of hypersensitiveteeth.
*rl = 59. tn = 98.
H ypersensirivity according to rhe questionnaire
Not exposed to periodontal treatment No. %
8” 265 13
23
73 11 26
*Patients with diagnosed cervicaldentine hypersensitivity.
67 35 46
Mean no. of sensitive teeth per patient 6.1 4.3 2.9
Fischer et al. : Epidemiology
1
3OOd
zood 5 c z c
loo-
M
C
PM Tooth
I
type
Fig. 2. Intraoral distribution of teeth sensitive to air (0, n = 627) and probe ( , n = 327) stimuli.
tests, lower prevalence figures were found. Graf and Galasse (1977), by means of a dental explorer, found hypersensitive teeth in 14.5% of the patients. Prevalences of 18% (Flynn et al., 1985) and 15% (Collaert et al., 1990) were reported when sensitivity was evaluated by means of cold water rinsing. In our study, after intraoral testing with air and probe stimuli, 17% of the population were diagnosed as having cervical dentine hypersensitivity. Considering that these results are from different populations and that different methods to evaluate the presence of dentine hypersensitivity were used, the similarity seen between the results is striking. The difference between the prevalence of dentine hypersensitivity based on patient’s testimonials and the prevalence based on intraoral tests might raise the question about the reliability of both methods of evaluation. Flynn et al. (1985) did not consider the patient’s own evaluation a reliable index, since they found that some patients tended to blame other forms of dental pain on hypersensitive teeth. This tendency was also noted in our study. However, the reliability of the results based on intraoral tests could also be questioned. The air and probe stimuli used in our study, for instance, are not exact reproductions of daily life stimuli. Accordingly, they might fail to cause pain sensations in patients with teeth sensitive to daily life stimuli, and, on the other hand, might elicit pain in patients with no hypersensitivity to daily life stimuli. Thus, it seems that both methods of evaluation, the patient’s subjective evaluation and the intraoral tests, have shortcomings that must be considered when analysing the results. Almost all patients (95%) with diagnosed dentine hypersensitivity were sensitive to the air test, while a lower percentage (72%) were sensitive to the probe test. This difference could be attributed to the fact that the air test was applied before the probe test, since it has been shown that a stream of air of 1 min duration decreases dentine intraoral
of cervical dentine
hypersensitivity
275
sensitivity (Johnson and Brannstrom, 1974). However, in the present study an air-jet of only 3 s was used, and it seems less likely that the air test would have interfered with the dentine sensitivity. Absi et al. (1987) have noticed that usually only a limited area of the exposed dentine is actually sensitive. It is possible that the probe did not touchy the sensitive spots of some of the hypersensitive teeth and, therefore, some patients sensitive to the air-jet did not respond to the probe test. In view of the finding of Absi et al. (1987) and according to the present results, it seems that the air test was more reliable than the probe test to evaluate the presence of dentine hypersensitivity. The common finding that the prevalence of hypersensitive teeth is higher among females than among males (Graf and Galasse, 1977; Flynn et al., 1985; Collaert et al., 1990) was also found in our study. However, in none of these reports and in this one was this difference statistically significant. When considering the number of patients in each age group, the highest proportion of males and females with hypersensitivity occurred in the age group 40-49 years. When considering the total number of patients, most males were aged 40-59 and most females 20-49. In other studies (Graf and Galasse, 1977; Flynn et al., 1985) a high prevalence of hypersensitivity was found in a younger population. The intraoral distribution of hypersensitivity showed that incisors and premolars were the most common teeth sensitive to the air and probe stimuli, while molars were the least sensitive ones. Other studies have shown similar findings (Flynn et al., 1985; Addy et al., 1987; Orchardson and Collins, 1987) but canines were also highly affected by hypersensitivity (Addy et al., 1987; Orchardson and Collins, 1987). Addy et al. (1987) have studied the distribution of plaque and recession in hypersensitive teeth and they found that teeth with the most pronounced sensitivity presented the largest gingival recessions, but also the lowest buccal plaque scores. On the basis of these findings, they concluded that toothbrushing rarely causes pain in patients with dentine hypersensitivity. Our results showed that 37% of the patients claiming to have hypersensitive teeth reported pain on toothbrushing. This should be compared with the fact that 82% of the patients reported pain to cold stimuli. Similar results have been reported in other studies, where pain on toothbrushing varied from 29% (Collaertet al., 1990) to 17% (Orchardson and Collins, 1987). These findings do not seem to support the general belief that patients with hypersensitivity may have impaired oral hygiene because toothbrushing is painful. The results from the questionnaire revealed that only 8% of the patients who reported having hypersensitive teeth blamed periodontal treatment (professional cleaning and periodontal surgery). However, both presence and history of hypersensitivity were positively correlated to previous exposure to periodontal treatment. This is in agreement with findings reported by Fisher et al. (1992), who evaluated the sensitivity of exposed dentine after
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periodontal treatment. They found that six of 11 patients experienced a significant increase in dentine sensitivity after subgingival scaling. These results seem to support the hypothesis that periodontal therapy plays a role in the development of dentine hypersensitivity. The number of patients with hypersensitive teeth according to their own evaluation (25%) may seem high. However, the condition did not seem to be a problem for many of these patients, since only 32% of them had tried treatment with a desensitizing toothpaste and 20% had sought professional help. Similar findings were reported by Flynn et al. (1985) who also found that only 25% of the patients who reported having hypersensitive teeth had received desensitizing treatment.
Acknowledgements The authors da Marinha Dr Murillo perform the
wish to thank the staff at the Odontoclinica for their valuable contribution and especially de Luca who provided all the facilities to study.
References
Absi E. G., Addy M. and Adams D. (1987) Dentine hypersensitivity. A study of the patency of dentinal tubules in sensitive and non-sensitive cervical dentine. J. Clin. Periodontal. 14, 280-284. Addy M., Mostafa P. and Newcombe R. G. (1987) Dentine hypersensitivity. The distribution of recession, sensitivity and plaque. J. Dent. 15, 242-248. Collaert B. and Fischer C. (1991) Dentine hypersensitivitya review. Endod. Dent. Traumatol. 7, 145-152. Collaert B., Sbderholm G., Linden U. et al. (1990) The Prevalence of Dentine Hypersensitivity in a Swedish Population Attending Public, Private and Specialist Clinics. Thesis, Lund University, Malmd. Dowel1 P. and Addy M. (1983) Dentine hypersensitivity-a review. Aetiology, symptoms and theories of pain production. .I Clin. Periodontol. 10, 341-350. Fischer C., Wennberg A., Fischer R. G. et al. (1991) Clinical evaluation of pulp and dentine after supragingival and subgingival scaling. Endod. Dent. Traumalol. 7, 259-265. Flynn J., Galloway R. and Orchardson R. (1985) The incidence of ‘hypersensitive’ teeth in the West of Scotland. J. Dent. 13, 230-236. Graf H. and Galasse R. (1977) Morbidity, prevalence and intraoral distribution of hypersensitive teeth. J. Dent. Res. 56, (spec. issue A), A162. Johnson G. and Brannstriim M. (1974) The sensitivity of dentin. Changes in relation to conditions at exposed tubule apertures. Acta Odontol. Stand. 32, 29-38. Orchardson R. and Collins W. J. N. (1987) Clinical features of hypersensitive teeth. Br. Dent. .I 162, 253-256.
Book Review Aspects of Oral Molecular Biology. Edited by D. B. Ferguson. Pp. 144. 1991. Hardback, SFr 155.00.
Karger, Basel.
However admirable the individual contributions may be, combining reviews by different authors into a single volume is not easy. All too often the result is a motley collection with little directional thrust. This volume comprises eight chapters on topics as diverse as the control of dental development and the genetics of oral bacteria, yet three chapters are devoted to genetic variation in salivary constituents. The book thus falls between the two stools of broad overview and specialist monograph. Much of the first chapter (H. Lesot) is taken up by a general consideration of genetic influences on dental development. More specific consideration of cell-matrix and cell-cell interactions is included but it is difficult to grasp the essential molecular message. Two chapters on enamel proteins follow, one (J. D. Termine and M. F. Young) concentrating on the differences and homologies between enamelin and amelogenin, and the other (R. Herold and J. Rosenbloom) on enamel proteins in different species. The use of the salamander, where cells derived from the same progenitor population produce only enamelin in larval teeth but both enamelin and amelogenin in adult teeth, is an ingenious approach to investigating the expression of enamel protein genes. The more general developmental theme is then resumed
with changes in dental mesenchyme that lead to its differentiation into distinct tooth-germ components (I. Thesleff et a/.). The chapter on genetics of oral bacteria (R. R. B. Russell) is a lucid account of how recombinant DNA technology is being used to identify oral microorganisms and investigate their pathogenicity. However, pathogens only produce disease through interaction with the host. A chapter on the molecular biology of the host response to these organisms would therefore have provided a useful balance. The next two contributions deal with salivary mucin (L. A. Tabak) anqi proline-rich proteins (D. B. Ferguson). The startling degree of genetic variation found for mucin and the complex post-translational modification of mucin gene products are shown to present a formidable challenge. The proline-rich proteins are far better understood, being controlled by a series of neighbouring loci on the short arm of chromosome 12 known as the salivary protein complex. The final chapter (R. C. Karn) considers other enzymic and non-enzymic salivary proteins and includes an account of the amylase multigene family. The book does give a flavour of new approaches to oral problems using rapidly advancing technologies and, although only a handful of references are dated after 1988, is to be commended on this account. But, it is also likely to be of value only to those with a particular interest in the specialist areas selected for inclusion. J. A. Sofaer
