From Volume 44, Issue 1, January 2017 | Pages 33-42
The aim of this review is to update dental professionals on the issues and challenges associated with the clinical management of dentine hypersensitivity (DH) and to provide simple guidelines based on presenting clinical features that may help them successfully manage the condition in their day-to-day clinical practice. Details on the management of DH have been previously published in
Although dentine hypersensitivity (DH) has been extensively reported on in the published literature, there appear to be unresolved issues regarding its true prevalence. For example, it is clear from these studies that the patient's perspective on the condition is different from the clinician's perspective. According to Orchardson and Gillam,1 patients who complain of the classic symptoms of DH, which are rapid in onset, sharp in character and of short duration, generally have lower prevalence values (15-30%) following a clinical examination compared to those values based on questionnaire studies, which tend to rely on the patients' perception of DH and which may, in turn, overestimate the extent of the problem (up to 74%).2 However, a recent review on the burden of DH, by Cunha-Cruz and Wataha,3 would appear to suggest that the best overall estimate of the prevalence of DH in the population was 10%. There may, however, be an explanation for this apparent discrepancy, for example, the patient's difficulty in determining the type of dental pain they may be experiencing at the time when questioned. Another issue that has been recently addressed in the published literature was in regard to the extent of the impact of DH on the Quality of Life of those individuals who suffer with the condition.4 In this study, by Gibson et al, 28.2% of patients were unable to drink cold water without some discomfort, with 26.5% of patients also unable to eat ice-cream without discomfort; 8.7% of patients also reported that they were unable to brush their teeth without some discomfort.4 While several studies have suggested that DH may be a major problem in some patients, it would appear that it may be a relatively minor problem for the majority of the population, since the discomfort experienced by individuals has been reported to be transient (episodic) in nature.5 This observation may be one of the reasons why some patients either do not self-treat or fail to report the problem when seeing a dental professional.6,7 It may also be a reason why the condition is often under-diagnosed by dental professionals in that, unless patients complain of the problem, there does not appear to be any screening undertaken by clinicians.7 There are undoubtedly a number of diagnostic challenges facing the dental professional when examining patients complaining of dental pain in general, and more specifically with DH. It is important, therefore, to recognize that the diagnosis of DH is essentially a diagnosis of exclusion.7 Several studies have also reported on the apparent lack of confidence by dental professionals when treating DH in daily practice, particularly with the vast array of commercially available In-office and over-the-counter (OTC) products that claim to be effective in reducing DH.8,9 The question that arises is how does the clinician effectively screen, prevent, treat and monitor DH in a general dental practice, and are there simple and pragmatic guidelines that can help in the successful treatment or management of the condition when examining patients? The aim of this review is therefore to update dental professionals (dentists, dental therapists and hygienists) on the issues and challenges associated with the clinical management of DH and to provide simple guidelines based on the presenting clinical features that may help them successfully manage the condition in their day-to-day clinical practice.
According to Gillam,9 various terms have been used to describe dentine hypersensitivity (DH), for example, cervical dentine sensitivity (CDS), cervical dentine hypersensitivity (CDH), or dentine sensitivity (DS) and, more recently, dentine hypersensitivity (DHS). Traditionally, the term ‘dentine hypersensitivity’ (DH) has been preferred owing to its historical significance, despite the fact that ‘dentine sensitivity’ (DS) may be a more accurate term for the dental professional to use. The classic definition of DH is based on ‘pain derived from exposed dentine in response to chemical, thermal, tactile or osmotic stimuli which cannot be explained as arising from any other dental defect or disease.7 This definition is important in that DH is essentially a diagnosis of exclusion and therefore will encourage the use of a thorough examination of the patient to determine a correct diagnosis. Historically, DH has been linked to individuals with relatively healthy tissues and good plaque control although, more recently, the term root sensitivity or root dentine sensitivity (RDS) or root dentine hypersensitivity (RDH) has been used to describe tooth sensitivity arising from periodontal disease and its treatment.2 It should, however, be noted that, to date, most published studies do not appear to distinguish between these two groups when undertaking prevalence studies. As indicated in the introduction, one of the main problems when evaluating the prevalence of DH was how the data were collected and whether the studies were questionnaire-based surveys or clinical in nature.
The currently held view on the mechanisms associated with DH is based on the hydrodynamic theory, as proposed by Brännström and Åström,10 although it should be recognized that not all stimulus transmission across dentine can be explained by this theory and, as such, other mechanisms may be involved.11 Generally speaking, DH is differentiated from other associated tooth pain by Aδ fibres, which are mainly stimulated by the application of a cold stimulus, producing sharp pain, compared to the stimulation of C fibres, which produce dull aching pain.12 For practical purposes, the hydrodynamic theory promotes two basic approaches for treating hypersensitive dentine namely:
A number of aetiological and predisposing factors have been implicated in the initiation of DH, for example, abrasion, abfraction, erosion, gingival recession, quality of the buccal bone, periodontal disease and its treatment, surgical and restorative procedures and patient destructive habits13 (Table 1).
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More recently, several investigators have suggested that DH may be a toothwear phenomenon characterized predominantly by erosion, which may subsequently expose the dentine surface and initiate the toothwear lesions.14,15,16 Dababneh et al also suggested that there may be two specific biological processes associated with the abovementioned aetiological factors implicated in DH:17
It has been postulated that firstly, the dentine has to be exposed as a result of the loss of enamel and/or soft tissue loss associated with gingival recession (including the loss of cementum) (lesion localization). Secondly, once the dentine has been exposed, the patent dentine tubules will be open to the oral environment (lesion initiation) and, as a consequence, any subsequent stimuli (eg cold) may initiate minute fluid movement within the dentine tubules, thereby activating the mechano-receptors in the dentine/pulp complex.
A number of investigators have traditionally claimed that DH occurs as a result of ‘zealous’ plaque control in a healthy mouth which affects mainly the buccal surfaces of the teeth2 (Figure 1). Other investigators have, however, suggested that the condition may arise as a result of periodontal disease and/or its treatment2 (Figure 2). Recently, the term ‘root sensitivity’ (RS) was introduced by the European Federation of Periodontology18 to describe tooth sensitivity associated with periodontal disease and/or periodontal therapy, in contrast to the traditional viewpoint of DH associated with individuals with good plaque control. Currently, there does not appear to be any substantive evidence from the prevalence data in the published literature to distinguish between these two conditions.
Evidence from the published literature would suggest that the most commonly associated teeth with DH are canines, premolars and molars. Generally speaking the buccal aspect of these teeth are more frequently exposed, probably as a result of over-zealous and/or incorrect toothbrushing in association with other aetiological factors2,6 (Figure 1). However, there may be different precipitating and predisposing factors associated with DH and these features should be carefully considered when deciding on a management strategy for treating DH (Table 2). More recently, simple guidelines on the management of DH have been proposed, based on the presenting clinical features of patients with DH6 that may help them successfully manage the condition in their day-to-day clinical practice. According to Gillam et al,6 patients with DH may be categorized as follows:
| Gingival Recession | Toothwear | Periodontal Treatment |
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Clinical evaluation
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Clinical evaluation |
Clinical evaluation
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Patient education (including preventive advice)
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Patient education (including preventive advice)
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Patient education (including preventive advice)
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Corrective clinical outcomes
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Corrective clinical outcomes
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Corrective clinical outcomes
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The intention of these proposed guidelines are therefore designed to help the dental professional address the different presenting features associated with DH with a more tailored approach rather than simply following a non-specific generalized management strategy.
The clinical diagnosis of orofacial pain can be a difficult and time consuming procedure, particularly in a busy dental practice. Diagnosing patients with DH can be problematic for a number of reasons; firstly, the difficulty in identifying areas of the mouth that may be causing the problem and secondly, the highly subjective nature of pain and its variability between patients. According to Gillam,5 it is important for dental professionals to identify patients with DH correctly by excluding any confounding factors from other orofacial pain conditions prior to the successful management of the condition (Figure 4). Several investigators have also reported on the difficulties that dental professionals may face when treating the condition and it is clear from the published literature that there is a need to recommend practical guidelines which can be implemented in clinical practice.6,7
It is important to note that the definition of DH is essentially a definition of exclusion and this will encourage the dental professional to exclude any other potential orofacial condition in order to determine a definitive diagnosis of DH. During the appointment, it is therefore essential that clinicians obtain a thorough medical and dental history from patients to enable them to take into account all relevant information prior to formulating a treatment plan. For example, the use of the Mnemonic ‘SOCRATES’ as a checklist for the patient's pain history:
Although a number of methodological measures have been proposed both to qualify and quantify the pain associated with DH, these measures are generally used in clinical trials designed to evaluate desensitizing products.19 From the dental professional's perspective, in general dental practice the use of an explorer probe and an air blast from a triple air syringe, together with an indication of the degree of discomfort from the patient following the application of the stimulus during the clinical examination, may be acceptable for the identification of susceptible sites and the severity of the pain response. The use of a simple numerical scoring scale (eg 0–10) may be more appropriate in clinical practice in order to record the patient's perception of DH during the first appointment and when monitoring an improvement during subsequent visits.19 Sometimes, when there is uncertainty regarding whether a particular tooth is responsible for the patient's discomfort, a useful tip would be to blow cold air from a dental air syringe onto the exposed dentine surface and then ask the patient to give an indication of the severity of the perceived pain. The dental professional could then apply a varnish over the exposed dentine and repeat the cold air test to determine whether or not the pain response has been eliminated or reduced in terms of severity. This may help the dental professional to identify the cause of the patient's pain. More recently, Quality of Life (QoL) measures have been included in some clinical trials in order to determine whether DH has any effect on the patient's daily activities4 and these measures may also be of benefit in the management of DH (see below).
There have been a number of treatment paradigms recommended in the literature relating to the management of DH,1,7,20 but there have been concerns as to whether these measures can be effectively undertaken in a general dental practice. Of these previous suggestions, a simple, less invasive stepwise approach was proposed by Orchardson and Gillam1 based on the WHO pain ladder, which incorporated a strategy for determining the management of DH depending on the extent and severity of DH. According to Gillam et al,6 however, there was a need to produce guidelines that are relatively simple and pragmatic to be used in general dental practice (Figure 4). For example, for patients with localized and generalized gingival recession, it may be prudent to take study casts and clinical photographs to monitor condition over time, as well as check and monitor the periodontal status of the patient. The use of pain scores (eg visual analogue scores or a simple 0–10 numeral score) may be a useful indicator of the severity of the pain associated with DH. It is also important to identify and correct any predisposing or precipitating factors that may be responsible for the development of the gingival recession (eg patient habits, incorrect toothbrushing technique etc). These factors may be discussed with the patient in order to prevent any further damage to both hard and soft tissues that may increase the severity of the pain associated with DH, together with a recommendation of avoiding the excessive consumption of acidic foods and drinks, particularly in association with the timing of daily toothbrushing. There are a number of treatment options available to the dental professional in treating patients with gingival recession and associated DH, for example, the use of silicone gingival veneers to improve the aesthetics, restorative correction of a recession defect with or without surgical grafting (root coverage) procedures and subgingival margins of fillings and crowns, as well as using products that occlude the dentine tubules (Table 2). Depending on the severity, the dental professional may also recommend the use of desensitizing toothpaste/mouthrinses for home use (eg strontium chloride/strontium acetate, potassium nitrate/chloride/citrate/oxalate, etc). It is also essential to have a monitoring strategy in place based on the severity of the condition (Figure 1). Patients who have been diagnosed with DH associated with toothwear problems or from periodontal disease and/or its treatment may also be managed with a similar strategy specifically based on their presenting features (Table 2). It is, however, important for the clinician to recognize that one of the key components from the UK Guidelines document6 was that no one desensitizing product (OTC or professionally applied) can fully resolve the various presenting features of DH and therefore it may be prudent for the dental professional to utilize a range of products in order to resolve the patient's symptoms (Figure 4, Table 2). The successful management of DH therefore not only involves the correct diagnosis of the condition by the clinician, but also includes the importance of implementing prevention strategies that either eliminate or limit any further deterioration of DH by appropriate treatment choices, dietary advice and monitoring of the condition.1,6 One of the problems in the management of any medical or dental condition is that behavioural changes may be required in order to minimize or prevent the effects of a patient's life style on the condition in question (eg poor plaque control, smoking, etc). According to Gillam and Ramseier,21 there is often a tendency for the clinician simply to prescribe or recommend a treatment without determining the aetiological and predisposing factors that may have been instrumental in initiating the problem in the first place and, if these factors are not correctly managed or monitored, they may continue to impact on not only the condition but also on patients' quality of life, for example, being unable to drink cold water or eating ice-cream or brushing their teeth without some discomfort.4 This approach would therefore involve not only educating the patient but also the dental professional and it is important to recognize that the clinicians will need to adopt management strategies and goals that will effectively encourage behavioural changes in the life style of their patients.21 According to Gillam and Ramseier,21 in order to accomplish these goals the dental professional would need to motivate and engage the patient to effect the recommended changes in behaviour in order to manage and monitor DH effectively within the constraints of a general dental practice.
Although there is a plethora of both professionally applied and over-the-counter (OTC) products reported to be effective in reducing DH,1 the question remains as to whether the clinician has the confidence to utilize these products successfully in order to treat DH8 (see below). Generally speaking, dental professionals may receive information on these products directly or indirectly from the manufacturing companies. The education and updating of dental professionals through professional meetings and continuing education courses (CPD) provides a very valuable resource for the dental professional. However, it should be recognized that, unless clinicians implement these changes in management and new product development into daily practice, then these proposed changes may not benefit the patient. One of the problems, however, for the dental professional is which of these in-office and OTC products would be effective both in the short and long term and, while there have been a number of papers supporting the various claims of efficacy in reducing DH, there is still confusion among clinicians as to which of these products may be of clinical benefit to their patients. For example, according to Cunha-Cruz et al,8 the dentists in their survey used a myriad of products to treat DH, but the diversity of the dentists' responses suggested that the respondents were not convinced of the clinical efficacy of any of the treatment options. As indicated above, it is important that the clinician should have confidence in the ability of these products to treat DH successfully before prescribing or recommending them to their patients. Furthermore, the management of DH should not involve simply providing treatment without first removing any aetiological or predisposing factors associated with DH, and it is essential that the clinician initiates behavioural changes in reducing or preventing any future risk to the hard and soft tissues. The recent UK Expert Forum on the guidelines for the management of DH6 recognized that there was a need to promote simple guidelines that may be readily applied in general dental practice, although the Forum acknowledged that a ‘one size fits all’ strategy to the problem may not necessarily satisfy all patients. One of the key components from the Guidelines document was that the authors linked recommended management strategies to three specific groups of patients rather than recommending a blanket management for all patients with DH (Figures 1–3).
It is evident from both the published literature and anecdotal evidence from colleagues that there are a number of challenges when identifying patients with DH, as well as problems as to how to treat the condition effectively. As previously mentioned, there are a number of pertinent questions that need to be addressed when considering the extent and severity of the condition in dental practice. For example, are clinicians over-diagnosing or under-diagnosing the condition and what is the true extent and severity of the problem in dental practice and, more specifically, what is the true impact of DH on the quality of life (QoL) of patients in general dental practice? According to Cunha-Cruz and Wataha,3 the actual prevalence figure is around 10% based on their overview of the prevalence studies. This would mean that 1 in 10 patients attending a dental practice may have a problem with DH but may not actually disclose this to their dentist unless asked.7 If this observation is correct, then it may be possible that the condition may be under-diagnosed in general dental practice. There is no doubt that DH is a persistent problem to both patients and dental professionals alike, and it is important to be able to identify the recognized aetiological causes and predisposing factors associated with DH and treat the condition correctly in order either to reduce or prevent any discomfort arising from the condition. As previously mentioned, there is often a tendency for the clinician simply to prescribe or recommend a treatment without determining the aetiological and predisposing factors that may have been instrumental in initiating the problem in the first place and, if these factors are not correctly managed or monitored, they may continue to impact on not only the condition, but also on the patient's quality of life.21 It is important, therefore, for dental professionals to introduce changes in patients' behaviour and habits in order to manage the condition successfully. This aspect of the management of DH is, however, very time consuming and can be frustrating both to the clinician and the patient if there appears to be very limited success in treating the condition. Although there have been a number of management paradigms recommended in the published literature,1,7,20 the issues associated with the clinical management of DH in general dental practice can be very challenging for a number of reasons (eg time and financial considerations).
The advantage(s) of the recently proposed guidelines on DH was to introduce simple and practical measures based on the presenting clinical features of patients with DH and to recognize the differing aetiologies and predisposing factors associated with DH6 (Figures 1–3). For example, the treatment for toothwear and DH may be more complex in restoring lost enamel and dentine than patients with DH associated with a well maintained dentition with relatively little tooth surface loss. It should also be noted that, despite the various published claims of clinical efficacy of both in-office and over-the-counter products, there does not appear to be one ideal desensitizing agent than can be recommended to be used by the dental professional when treating DH.22
Recent proposals by a UK Expert Forum on DH would appear to provide practical, evidence-based guidance on the management of DH for the diagnosis, monitoring, prevention and treatment of specific presenting features of patients with DH.6 It is also evident from the published literature that a one strategy management approach cannot fully resolve the problem for all patients with DH. The importance of educating both the dental professional and the patient in the identification, prevention and management of DH is paramount if the condition is to be successfully monitored and treated.
