Abstract
Aim: To assess the knowledge of Nigerian dentists regarding dentine hypersensitivity (DH) and their methods of diagnosis and management. Methods: A cross-sectional questionnaire-based study of dentists practicing in all six geopolitical zones of Nigeria was conducted. The questionnaire focussed on participant's demography, exposure to patients with DH, knowledge-based questions, diagnosis and management of DH. Data analysis using EPI Info statistical software determined frequencies and proportions. Associations between discrete variables were assessed using the chi-square test (P ≤ 0.05). Results: A total of 1,057 dentists responded; the majority (83.8%) had practiced for up to 15 years, and 92.0% reported that, on average, between one and 10 of their patients each week complained of DH. The majority (92.8%) of dentists described DH as stimulated brief pain from the tooth; 24.2% expressed that DH can be treated by altering the number of dentinal tubules. A diagnosis of DH is made by tapping (20.6%) or scratching (73.4%) the tooth. Although radical treatments, such as extraction (24.7%) and root canal therapy (34.5%), were mentioned by some, the majority identified aetiological and predisposing factors (98.8%) and provided diet (95.1%) and oral hygiene (95%) counselling as part of the management of DH. Evaluation of 36 knowledge-based questions revealed that only 1.8% of the respondents provided at least 25 correct answers. Knowledge was significantly associated with respondent age and number of years in practice (P ≤ 0.05) but was not associated with the number of patients with DH seen per week (P = 0.46). Conclusion: Dentists practicing in Nigeria exhibited knowledge gaps concerning DH and its diagnosis and management.
Key words: Dentine hypersensitivity, knowledge, diagnosis, management
Introduction
Dentine hypersensitivity (DH) is a dental condition characterised by brief, sharp pain that often manifests in response to thermal, tactile or chemical stimuli1., 2., 3.. The condition is diagnosed in teeth with exposed dentine that have no other dental defects or pathology that can explain the pain symptoms4. The pathology of DH involves the exposure of dentine, the subsequent opening of the dentinal tubules to the external oral environment and the transmission of a hydrodynamic stimulus across the dentinal tubules. Predisposition to this condition is multifactorial, and chronic trauma from physical and chemical factors is the most significant aetiological factor5.
More than 40% of the global population is believed to be affected by DH, with its prevalence reaching 90% in some populations6., 7., 8., 9., 10., 11., 12.. Self-reported prevalences of DH, of 33.8% and 68.4%, have been reported in different Nigerian populations13., 14.. High prevalence of DH has been reported in both younger15., 16. and older17 age groups, and there are varying reports regarding DH prevalence in both male subjects and female12., 18., 19..
Sensitive teeth can affect one's quality of life, specifically by affecting eating and drinking and the ability to remove plaque20, thus compromising oral health. Severe hypersensitivity may result in emotional changes that alter one's lifestyle21. DH is therefore a condition that needs to be well understood by dentists to ensure that it is diagnosed and managed appropriately. Surveys among dental professionals worldwide suggest that many lack adequate knowledge about this condition and its management22., 23., 24.. A study conducted among 331 dentists and 211 dental hygienists, by the Canadian Advisory Board on DH, recognised 14 key knowledge gaps related to the aetiology, diagnosis and management of DH23. To improve the understanding of DH among dental professionals, guidelines have been developed to aid dentists in its diagnosis and management23., 25., 26.. This survey assessed dentists' knowledge regarding the diagnosis and management of DH in Nigeria. The findings from this study will guide the planning of continuing professional educational opportunities and undergraduate curricula and improve the management of DH.
Methodology
A cross-sectional questionnaire-based study of dentists practicing in Nigeria was conducted. Ethical approval to conduct this survey was granted by the Lagos University Teaching Hospital Health Research Ethics Committee, a registered member of the National Health Research Ethics Committee. The study was conducted in full accordance with the World Medical Association Declaration of Helsinki (2008). Informed consent was obtained from participants by including information concerning the purpose of the study, the promise of confidentiality and the voluntary nature of the study on the first page of the questionnaire. Also included was a statement informing participants that completion of the questionnaire served as consent to participate in the study. A signature was not required to maintain confidentiality. The consent procedure for this questionnaire-based survey was approved by the aforementioned Ethics Committee.
The questionnaire sought participant's demographic information, such as location of practice, age, gender, number of years in practice and current job description. Other sections of the questionnaire focussed on participant's exposure to patients with DH and knowledge about the condition. Thirty-six questions on DH were used to assess knowledge of the participants, whereas other questions sought information on the diagnosis and management of DH. The questionnaire was developed by a DH research group that comprised specialists with diverse clinical and academic backgrounds. The instrument was pretested for ambiguity and clarity by administering it to 15 dentists who were not included in the study.
The participants were accessed at their practices, which were located in both the public and the private sectors. The locations of participants' dental practices represented the six geopolitical zones of Nigeria; thus, the participants were representative of dentists practicing throughout Nigeria.
Data analysis was conducted using EPI Info version 3.4.5 statistical software (Center for Disease Control, Atlanta, GA, USA). Frequencies and proportions were calculated. Associations between discrete variables were assessed using a chi-square test. Statistical significance was determined at P ≤ 0.05.
Results
A total of 1,057 dentists participated in the study. Analysis was based on the total number of respondents who answered each of the questions.
Slightly over half (59.3%) of the respondents were 31–50 years of age, with a mean age of 37.26 ± 5.70 years. More than half (61%) of the participants were male, and 83.8% had been practicing for 1–15 years. Additionally, 40.4% of the dentists were general dental practitioners (GDPs), and 83.7% worked in the public sector (Table 1). Table 2 shows exposure of the respondents to patients with sensitive teeth. Most (92.0%) of the respondents reported that an average of one to 10 of their patients per week complained of DH. Almost three-quarters (74%) also reported that the average age range of patients with DH encompassed the third to sixth decades of life.
Table 1.
Sociodemographic characteristics of the respondents
| Variables | Frequency (n) | Percentage (%) |
|---|---|---|
| Age (years) | ||
| 21–30 | 349 | 33.2 |
| 31–50 | 623 | 59.3 |
| >50 | 78 | 7.4 |
| Total | 1,050 | |
| Mean = 37.26 ± 5.701 | ||
| Gender | ||
| Male | 642 | 61 |
| Female | 410 | 39 |
| Total | 1,052 | |
| Number of years in practice | ||
| 1–15 | 836 | 83.8 |
| 16–30 | 148 | 14.8 |
| >30 | 14 | 1.4 |
| Total | 998 | |
| Mean = 8.72 ± 7.79 | ||
| Current job designation | ||
| House Officer | 157 | 15 |
| GDP | 423 | 40.4 |
| Resident doctor | 247 | 23.6 |
| Consultant | 108 | 10.3 |
| Others | 113 | 10.7 |
| Total | 1,048 | |
| Sector of practice | ||
| Private | 164 | 16.3 |
| Public | 844 | 83.7 |
| Total | 1,008 | |
GDP, general dental practitioner.
Table 2.
Respondents' exposure to patients with sensitive teeth
| Variable | n | % |
|---|---|---|
| Number of patients complaining of DH per week (n = 932) | ||
| 1–5 | 707 | 75.9 |
| 6–10 | 150 | 16.1 |
| 11–15 | 47 | 5 |
| 16–20 | 14 | 1.5 |
| 21–25 | 7 | 0.7 |
| 26–30 | 2 | 0.2 |
| >30 | 5 | 0.5 |
| Average age range (years) of patients with DH per week (n = 945) | ||
| 2–5 | 24 | 2.5 |
| 6–11 | 11 | 1.2 |
| 12–14 | 17 | 1.8 |
| 15–19 | 15 | 1.6 |
| 20–34 | 164 | 17.4 |
| 35–44 | 341 | 36.1 |
| 45–64 | 358 | 37.9 |
| 65–74 | 15 | 1.6 |
Tables 3–5 represent analysis of responses to the knowledge-based questions on DH. Almost all (92.8%) of the dentists who responded to the question on the description of DH pain correctly indicated that it is a stimulated brief, sharp pain from a tooth, whereas 62.8% also indicated that it is an intermittent brief sharp pain from a tooth. Two-thirds (n = 917, 66.7%) of the respondents accept that the hydrodynamic theory is the most commonly accepted explanation for the pain associated with DH. Others cited dentinal receptor (18.9%) and odontoblastic transducer (14.4%) mechanisms (data not shown). Most of the respondents expressed that the aetiologic factors for DH include enamel loss (97.0%), gingival recession (89.8%) and toothbrushing (83.7%), although over 90% correctly stated that attrition, abrasion and erosion are its causative factors. Toothwear lesions, attrition, abrasion and erosion were also identified as predisposing factors by over 80% of the respondents. In terms of modalities employed in the treatment of DH, only 24.2% of the respondents incorrectly stated that altering the number of dentinal tubules is a modality. Overall, on a scale of 36 knowledge-based questions on DH, only 1.8% of the respondents provided at least 25 correct answers. Knowledge was significantly associated with respondent age (P = 0.000) and number of years in practice (P = 0.019) but was not related to the number of patients with DH seen per week by the respondents (P = 0.46).
Table 4.
Respondents' knowledge grade
| Knowledge grade | Knowledge score | Frequency (n) | Percentage (%) | Cumulative percentage (%) |
|---|---|---|---|---|
| Poor | 0–15 | 367 | 34.7 | 34.7 |
| Fair | 16–25 | 671 | 63.5 | 98.2 |
| Good | 26–36 | 19 | 1.8 | 100.0 |
| Total | 1,057 | 100.0 |
Table 3.
Responses to dentine hypersensitivity (DH) knowledge-based questions
| Variable | Yes | No | Do not know | Total (n) |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
| Description of DH pain type | ||||
| Spontaneous throbbing pain from a tooth | 143 (19.8) | 552 (76.6) | 26 (3.6) | 721 |
| Intermittent short sharp pain from a tooth | 490 (62.8) | 273 (35.0) | 17 (2.2) | 780 |
| Stimulated short sharp pain from a tooth | 887 (92.8) | 55 (5.8) | 14 (1.5) | 956 |
| Chronic dull pain from a tooth | 87 (12.6) | 562 (81.6) | 40 (5.8) | 689 |
| Aetiological factors | ||||
| Enamel loss | 994 (97.0) | 22 (2.1) | 9 (0.9) | 1,025 |
| Gingival recession | 910 (89.8) | 92 (9.1) | 11 (1.1) | 1,013 |
| Toothbrushing | 829 (83.7) | 147 (14.8) | 14 (1.4) | 990 |
| Acidic diets | 919 (90.6) | 81 (8.0) | 14 (1.4) | 1,014 |
| Bruxism | 908 (90.4) | 75 (7.5) | 21 ((2.1) | 1,004 |
| Cemental loss | 868 (89.2) | 76 (7.8) | 29 (3.0) | 973 |
| Tooth bleaching | 773 (80.3) | 127 (13.2) | 63 (6.5) | 963 |
| Attrition | 908 (95.9) | 37 (3.9) | 2 (0.2) | 947 |
| Abrasion | 882 (95.6) | 34 (3.7) | 7 0.8) | 923 |
| Alcoholism | 254 (31.0) | 378 (46.1) | 188 (22.9) | 820 |
| Vomiting | 631 (71.8) | 191 (21.7) | 57 (6.5) | 879 |
| Erosion | 866 (93.1) | 54 (5.8) | 10 (1.1) | 930 |
| Periodontal pocket | 432 (51.7) | 306 (36.6) | 97 (11.6) | 835 |
| Medications | 290 (36.6) | 284 (35.8) | 219 (27.6) | 793 |
| Predisposing factors | ||||
| Enamel loss | 881 (91.8) | 71 (7.4) | 8 (0.8) | 960 |
| Gingival recession | 919 (95.3) | 38 (3.9) | 7 (0.7) | 964 |
| Toothbrushing | 863 (90.5) | 80 (8.4) | 11 (1.2) | 954 |
| Acidic diets | 921 (95.4) | 27 (2.8) | 17 (1.8) | 965 |
| Bruxism | 869 (91.5) | 62 (6.5) | 19 (2.0) | 950 |
| Cemental loss | 785 (85.1) | 110 (11.9) | 27 (2.9) | 922 |
| Tooth bleaching | 749 (84.1) | 88 (9.9) | 54 (6.1) | 891 |
| Attrition | 776 (88.4) | 92 (10.5) | 10 (1.1) | 878 |
| Abrasion | 765 (88.1) | 90 (10.4) | 13 (1.5) | 868 |
| Alcoholism | 368 (45.9) | 279 (34.8) | 154 (19.2) | 801 |
| Vomiting | 644 (76.9) | 132 (15.8) | 61 (7.3) | 837 |
| Erosion | 750 (87.6) | 90 (10.5) | 16 (1.9) | 856 |
| Periodontal pocket | 491 (63.7) | 207 (26.8) | 73 (9.5) | 771 |
| Medications | 338 (45.7) | 220 (29.8) | 181 (24.5) | 739 |
| Mechanisms for treatment of DH | ||||
| Blocking dentinal tubules | 991 (97.1) | 10 (1.0) | 20 (2.0) | 1,021 |
| Altering number of dentinal tubules | 202 (24.2) | 368 (44.2) | 263 (31.6) | 833 |
| Modification or blocking of the pulpal nerve response | 678 (74.3) | 122 (13.4) | 112 (12.3) | 912 |
Table 5.
Association between respondents' demographics and graded knowledge
| Variables | Knowledge grade | Total | χ2 | d.f. | P-value | ||
|---|---|---|---|---|---|---|---|
| Poor | Fair | Good | |||||
| n (%) | n (%) | n (%) | |||||
| Gender | |||||||
| Male | 212 (33.0) | 419 (65.3) | 11 (1.7) | 642 | 2.22 | 2 | 0.330 |
| Female | 153 (37.3) | 249 (60.7) | 8 (2.0) | 410 | |||
| Total | 365 (34.7) | 668 (63.5) | 19 (1.8) | 1,052 | |||
| Age (years) | |||||||
| 21–30 | 120 (34.4) | 229 (65.6) | 0 (0.0) | 349 | 22.47 | 4 | 0.000* |
| 31–50 | 207 (33.2) | 397 (63.7) | 19 (3.0) | 623 | |||
| 50 | 40 (51.3) | 38 (48.7) | 0 (0.0) | 78 | |||
| Total | 367 (35.0) | 664 (63.2) | 19 (1.8) | 1,050 | |||
| Years of practice | |||||||
| 1–15 | 276 (33.0) | 546 (65.3) | 14 (1.7) | 836 | 11.79 | 4 | 0.019* |
| 16–30 | 58 (39.2) | 86 (58.1) | 4 (2.7) | 148 | |||
| 30 | 10 (71.4) | 4 (28.6) | 0 (0.0) | 14 | |||
| Total | 344 (34.5) | 636 (63.7) | 18 (1.8) | 998 | |||
| Sector | |||||||
| Private | 54 (32.9) | 106 (64.6) | 4 (2.4) | 164 | 0.69 | 2 | 0.708 |
| Public | 296 (35.1) | 534 (63.2) | 14 (1.7) | 844 | |||
| Total | 350 (34.7) | 640 (63.5) | 18 (1.8) | 1,008 | |||
| No. of patients per week | |||||||
| 1–10 | 121 (36.4) | 208 (62.7) | 3 (0.9) | 332 | 9.08 | 4 | 0.060 |
| 11–20 | 116 (32.9) | 233 (66.0) | 4 (1.1) | 353 | |||
| 20 | 110 (32.5) | 216 (63.9) | 12 (3.6) | 338 | |||
| Total | 347 (33.9) | 657 (64.2) | 19 (1.9) | 1,023 | |||
| Dentine hypersensitivity patients per week | |||||||
| 1–10 | 296 (34.5) | 548 (63.9) | 13 (1.5) | 857 | 3.62 | 4 | 0.460 |
| 11–20 | 20 (32.8) | 39 (63.9) | 2 (3.3) | 61 | |||
| 20 | 5 (35.7) | 8 (57.1) | 1 (7.1) | 14 | |||
| Total | 321 (34.4) | 595 (63.8) | 16 (1.7) | 932 | |||
P-value significant at ≤0.05.d.f., degrees of freedom.
Table 6 shows the responses of the dentists regarding how they diagnose DH. Most elicit a pain response from the tooth by scratching the tooth (73.4%), applying an air blast to the tooth (93.3%) or spraying water onto the surface of the tooth (73%), while also excluding other pathological conditions (70.9%).
Table 6.
Methods of diagnosis of dentine hypersensitivity (DH)
| Diagnosis of DH | Yes | No | Do not know |
|---|---|---|---|
| n (%) | n (%) | n (%) | |
| Elicit pain response by tapping tooth | 188 (20.6) | 713 (78.1) | 12 (1.3) |
| Elicit pain response by scratching tooth surface | 698 (73.4) | 238 (25.0) | 15 (1.6) |
| Elicit pain response by air blast onto tooth surface | 934 (93.3) | 62 (6.2) | 5 (0.5) |
| Excluding other pathological conditions | 648 (70.9) | 220 (24.1) | 46 (5.0) |
| Elicit pain response by spraying water onto tooth surface | 690 (73.0) | 220 (23.3) | 35 (3.7) |
Responses to various management options for DH, which are shown in Figure 1, indicated that over 80% of the dentists employed an accepted line of management, including identification of aetiological and predisposing factors, diet and oral-hygiene counselling and desensitisation; however, one-third of the respondents (34.5%) indicated that they would perform a root-canal treatment on a hypersensitive tooth. Almost all of the dentists (95.4%) use home care products in the management of DH. Enquiry about the type of home care desensitising products prescribed by the dentists for relief of pain of DH revealed an array of products and brands.
Figure 1.
Management options used by respondents for their patients with dentine hypersensitivity (DH).
Discussion
There is growing awareness that DH is an increasingly important issue that needs to be addressed from both a diagnostic and a problem-management perspective27. DH is a common oral health problem affecting one or more teeth of many adult individuals on a global basis28. In Nigeria, DH appears to be common, even with recent national prevalence data (yet unpublished) corroborating previous data13., 14., among different population groups. Hence, dentists will encounter increased numbers of patients with this condition and must be equipped to manage these patients appropriately. This study was conducted to determine the knowledge of dentists practicing in Nigeria regarding DH. Additionally, their practices regarding the diagnosis and management of DH were assessed.
In this study, most of the dentists claimed that they encounter up to 10 patients per week in their practice who complain of having sensitive teeth, which confirms the findings of previous reports13., 14., 29. that DH is a common dental complaint in this environment. The prevalence of DH in this population may be connected to the observation that the availability and intake of carbonated drinks, especially those with high erosive potential, are increasing30. Other aetiological factors may also be contributory and this should be a focus for further research. The dentists reported that the third to sixth decade of life was the age range for patients with sensitive teeth, which is in accordance with current observations regarding the peak prevalence of this condition in younger adults, as well as adults in their fourth to sixth decades of life15., 16., 17..
The pain of DH is stimulated and is sharp and brief, in contrast to the spontaneous throbbing pain caused by an inflamed pulp. This description of DH pain was acknowledged by the vast majority (92.8%) of the dentists who participated in this study. This high percentage response to the description of DH pain by the dentists was similar to that recorded (83%) in the study by Benoist et al.24 involving dentists in Senegal, West Africa. However, in this study, we also observed that although most of the dentists provided the correct description of this condition, over half also described its symptoms as the pain of pulpal inflammation. This overlap indicates that their understanding of the character of the pain of DH is not consistent. If this is true, then their ability to diagnose the condition will be affected because the diagnosis is centred on the ability to stimulate the pain clinically using tactile (scratch test) or thermal (water spray) stimuli. In terms of the aetiology of DH, some of the dentists indicated that the odontoblastic transducer (14.4%) or the dentinal receptor mechanism (18.9%) is the most commonly accepted mechanism underlying DH. Similarly, 17% of dentists in a Canadian study23 failed to identify the hydrodynamic theory as the accepted pain mechanism for DH. This is in contrast to the widely documented view5., 31. that the hydrodynamic theory of Brännström2 probably explains the mechanism underlying DH. The hydrodynamic theory proposes that dentinal fluid flow is altered either by an increase in the flow or a change in its direction as a result of thermal, tactile or chemical stimulation near the exposed surface of the tubules. This alteration in dentinal tubule fluid leads to stimulation of A-δ fibres surrounding the odontoblasts, but only if the individual tubules are patent throughout to the pulp. This mechanism of pain transmission in dentine is supported by microscopic findings revealing that patent dentinal tubules are more numerous and wider in sensitive dentine than in non-sensitive dentine32.
With respect to the aetiology of DH, the results from the dentists in this study indicated conflicting understanding of the condition. Although the majority identified abrasion, erosion and attrition as the major etiologic factors that have been attributed to the development of DH, a high percentage of dentists also believed that toothbrushing (83.7%), bruxism (90.4%), enamel loss (97.0%) and gingival recession (89.8%) are major causative factors. These results were similar to the responses of dentists in a Canadian study22, where toothbrushing (85%), bruxism (64%) and gingival recession (60%) were identified as the primary causative factors in dentinal tubule exposure. These findings suggest that the etiology of DH is not fully understood. DH develops in two phases31. The first phase, lesion localisation, occurs when the dentine becomes exposed, either by loss of enamel or by gingival recession. In this phase, the tooth is not sensitive, and clinically, it has been noted that not all of the exposed dentine is sensitive. Hence, factors such as enamel loss or gingival recession cannot be implicated as primary etiologic factors; rather, they are factors that predispose to the eventual development of DH. Symptoms of hypersensitivity occur only after lesion initiation (tubular exposure), which is the second phase in the development of DH. The localised lesion of exposed dentine must be initiated, which occurs when the smear layer or tubular plugs are removed, opening the dentinal tubules to the oral environment. Erosion and abrasion have been implicated as causes of tubular exposure. Absi et al.33 reported the erosive effect of acidic drinks in the removal of the smear layer and the exposure of the dentinal tubules. However, toothbrushing with abrasive toothpaste may abrade the tooth surface and expose dentinal tubules, especially when combined with erosive agents34. Overall, the analysis of the dentists' responses to 36 knowledge-based questions on DH showed that only 1.8% of the respondents provided at least 25 correct answers. It was also shown that this knowledge was significantly associated with respondent age and number of years of practice but was not related to the number of patients with DH seen per week by the respondents.
In this study, inquiry regarding how dentists diagnose DH revealed that most employed acknowledged methods. Importantly, 70.9% of the dentists excluded other pathological conditions before making a diagnosis of DH. Additionally, over 80% of the dentists employed an accepted line of management, including identification of etiological and predisposing factors, diet and oral hygiene counselling and desensitisation. This management practice is recommended because failure to eliminate or modify predisposing agents before the treatment of sensitive teeth provides only short-term success23. It was noted that approximately one-third of the respondents (34.5%) in this study perform root canal treatments for hypersensitive teeth. This calls for continuous training and more vigilance regarding the diagnosis of DH by dentists. It can be argued that a tooth requiring a root canal treatment to eliminate pain may not have been correctly diagnosed as DH. If pain symptoms cannot be eliminated or considerably reduced during the course of treatment for DH, then a review of the diagnosis to exclude other causes of dental pain is indicated. This view is supported by various management guidelines for DH23., 25..
In this study, almost all of the dentists adopted the use of home care desensitising products in the management of DH. The use of this treatment option is convenient and cost-effective for patients, and the choice of product should be based on the identification of active desensitising agents in these products. However, the list of products mentioned by the dentists suggests arbitrary use of the products, without regard for their active ingredients. We did not pursue the reasons for their choices or their knowledge of the active ingredients in the products they mentioned.
Conclusion
Dentists' responses in this study indicate that there are knowledge gaps concerning DH and its diagnosis and management. In view of the documented increasing prevalence of DH, it is recommended that the knowledge, diagnosis and management of this clinical condition should be included in continuing professional education programmes and undergraduate curricula.
Acknowledgements
The authors acknowledge GlaxoSmithKline Consumer Nigeria PLC for supporting this study with a grant. The funders had no role in the study design, data collection and analysis, or preparation of the manuscript.
Conflict of interests
The authors disclose a financial relationship with GlaxoSmithKline Consumer Nigeria PLC. The authors have received honoraria for making presentations on oral health topics at conferences and events. None of the authors have ever been in paid employment with GlaxoSmithKline Consumer Nigeria PLC.
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