J Periodontol • September 2014
Prevalence and Risk Indicators of Dentin Hypersensitivity in Adult and Elderly Populations From Porto Alegre, Brazil Ricardo S.A. Costa,* Fernando S. Rios,* Mauricio S. Moura,† Juliana J. Jardim,† Marisa Maltz,† and Alex N. Haas*
Background: Dentin hypersensitivity (DH) is a clinical condition with potential implications for patients. However, little is known about its occurrence and determinants in the general population. The aim of this study is to assess the prevalence and risk indicators of DH in Porto Alegre, Brazil. Methods: A representative multistage probability sample of 1,023 adults aged ‡35 years was obtained. Individuals were interviewed and clinically examined in their homes. DH was assessed dichotomously in all present teeth by a blast of air and a manual probe. Teeth restored with crowns and presenting with carious cavitation were excluded. Survey logistic regression using sampling weights was applied to assess demographics and behavioral and clinical determinants. Results: Overall prevalence estimates for DH diagnosed by air and probe were 33.4% and 34.2%. DH affected 1 tooth per individual, and approximately 10% of teeth with gingival recession (GR) had DH. In a multivariable model for DH diagnosed with air, females had increased chance of DH (odds ratio [OR] = 2.14; 95% confidence interval [CI] = 1.57 to 2.91). Smoking, periodontal treatment, and GR were also associated with increased DH risk. The chance of DH was lower (OR = 0.47, 95% CI = 0.29 to 0.76) among individuals ‡60 than among those aged 35 to 49 years. Oral hygiene practices, socioeconomic and education status, dental visits, and gingival inflammation were not associated with DH. Conclusions: DH may be considered a concern in a Brazilian general population. Reduction of DH may be achieved by smoking cessation and periodontal health improvements. J Periodontol 2014;85:1247-1258. KEY WORDS Aged; Brazil; dentin sensitivity; epidemiology; gingival recession; risk factors. * Periodontology, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. † Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grande do Sul.
D
entin hypersensitivity (DH) is defined as short and acute dental pain in response to thermal, evaporative, tactile, or osmotic stimuli that cannot be explained by any other dental pathology.1-3 The hydrodynamic theory4 states that DH arises from stimulation of the dental pulp neural fibers due to fluid movement inside the dentinal tubules after external stimuli on the exposed root surface. The prevalence of DH is highly heterogeneous,5-21 with estimates varying from 1.3% to 52.6%.8,9 Although many studies have assessed the occurrence of DH, some have used representative samples, with most findings being provided from university teaching hospitals,8,9,17 dental schools,18,21 and dental practice settings.5-7,12,16,20 Population-based studies of DH have been performed only in China10,11,13,19 and India.15 To the best of the authors’ knowledge, there are no studies evaluating DH in representative samples from other parts of the world. In this context, it is not possible to determine if the observed variability in prevalence estimates of DH is a true picture of the condition or a result of methodologic variations in sampling strategies, target populations, and diagnostic methods. A variety of factors have been related to the occurrence of DH. Middle-aged individuals consistently have a higher prevalence of DH compared with elderly doi: 10.1902/jop.2014.130728
1247
Epidemiology of Dentin Hypersensitivity
individuals. 5-7,12,14,17,21 Similarly, DH is more common among females than males in most studies.8,10-16,18-21 Socioeconomic status,6,7,19 education level,5-7,10,11,19 oral hygiene practices,18,19 smoking,6,7,22 periodontal treatment,23,24 and severity of gingival recession (GR)5,10-15,17,19,20 have also been investigated. Nevertheless, most studies have applied only univariable comparisons,5-10,12-19,21,22 and only two studies19,20 have used multivariable risk assessment models for DH. Therefore, the aim of this study is to assess the prevalence and risk indicators of DH in an urban population of adults and elderly individuals living in Porto Alegre, Brazil. MATERIALS AND METHODS Study Design and Target Population This cross-sectional observational population-based study was designed by the Caries-Perio Collaboration Group from the Federal University of Rio Grande do Sul, Porto Alegre, Brazil. Various oral outcomes were evaluated, including dental caries (coronal and root), dental erosion, DH, gingivitis, GR, and tooth loss. The target population included male and female individuals aged >34 years living in the city of Porto Alegre, Brazil. The last updated census data in 2003 identified 591,297 individuals >34 years old in the total population. Fieldwork for the study was conducted from June 2011 to June 2012. Ethical Aspects The study protocol was reviewed and approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul. Before the interview, all participants read and signed an informed consent form. After the clinical examination, participants were provided with a written report detailing their oral status. Patients diagnosed with pathologic conditions were advised to seek dental care. Sample Size The sample size was estimated using the worst-case scenario considering a prevalence of 50% for any of the outcomes assessed in the study. It was also estimated that the multistage sampling used in the present study would yield approximately 50% inefficiency compared with simple random sample designs, taking into consideration the design effect observed for a series of outcomes. Prevalence was estimated with a standard formula that adjusted the sample size for the design effect. Considering a precision of 4% and a 95% confidence interval (CI), the required sample size was estimated as 940 individuals. Sampling Strategy This study used a multistage probability sampling strategy (Fig. 1) based on information provided by 1248
Volume 85 • Number 9
governmental agencies.25 In the first stage, the city was divided into 86 neighborhoods that comprised the primary sampling units (PSUs), which were stratified into high- and low-income strata. Lowincome PSUs were those in which most (>35%) of the heads of families had a monthly income of < 5 standard Brazilian salaries.25 The PSUs were randomly selected in a proportionate manner relative to the number of PSUs in each stratum. In the second stage, sectors were randomly selected in a proportionate manner relative to the total number of sectors in each PSU. Sectors were defined by the Brazilian Institute of Geography and Economy as map areas comprising 300 households each. All 373 sectors were eligible, and 48 (12.8%) of them were selected, 34 and 14 from low (stratum A)- and high (stratum B)-income strata, respectively. In seven sectors from the high-income stratum, the research team was not allowed to conduct the study as determined by local, religious, or governmental authorities. The third stage consisted of selecting households within each sector. Households were approached consecutively according to the sector starting point until the sector sample size was reached. The number of individuals selected within each sector was estimated based on the proportional distribution of the sample size according to the number of individuals aged >34 years living in each sector. All household members aged >34 years were considered eligible for the study. Individuals were excluded if they presented with any mental or systemic health condition that did not allow them to perform the interview or clinical examination. Places such as nursing homes and commercial establishments were excluded. Study Sample A total of 1,600 individuals were eligible for the study (Fig. 1). Of them, 375 (23.4%) did not participate in the study (non-respondents). Therefore, the whole sample of the study included 1,225 individuals (398 males and 827 females, aged 35 to 95 years; mean age: 52.6 – 11.8 years), of whom 1,023 (83.5%) were dentate and included in the study sample. Table 1 displays the characteristics of the study sample. Fieldwork Procedures A research team of two examiners (RC and FR) and one assistant (Renan Prado, Federal University of Rio Grande do Sul) conducted the fieldwork for this study. One researcher visited each selected sector 1 day before the start of data collection to invite residents to participate. Residents were not included after a third failed attempt of invitation. Interviews and clinical examinations were conducted inside the participants’ homes.
J Periodontol • September 2014
Costa, Rios, Moura, Jardim, Maltz, Haas
Figure 1.
Flowchart of sampling strategy and response rate. PSU = primary sampling unit.
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Epidemiology of Dentin Hypersensitivity
Volume 85 • Number 9
Table 1.
Table 1. (continued )
Demographic and Clinical Characteristics of Participants in the Study
Demographic and Clinical Characteristics of Participants in the Study
Sociodemographic and Clinical Variables
n
%
Sex Males Females
398 625
38.9 61.1
Age (years) 35 to 39 40 to 49 50 to 59 60 to 69 ‡70
148 306 304 174 91
14.5 29.9 29.7 17.0 8.9
Education Low Middle/high
198 825
19.4 80.6
Socioeconomic status Low Middle/high
505 518
49.4 50.6
Gingivitis Low (£22%) High (>22%)
510 513
49.9 50.1
Calculus (%) 0 to 19 20 to 39 ‡40
147 261 615
14.4 25.5 60.1
Behavioral Variables
n
%
Brushing £1 time/day 2 times/day ‡3 times/day
118 344 561
11.5 33.6 54.9
Brush type Soft Medium/hard Unknown
397 580 46
38.8 56.7 4.5
Brushing movement Horizontal Vertical Circular All
565 251 126 81
55.2 24.5 12.3 7.9
Smoking Never smoker Moderate smoker Heavy smoker
463 299 261
45.3 29.2 25.5
1250
Dental visits None Irregular Regular
290 498 235
28.4 48.7 23.0
Periodontal treatment No Yes
830 193
81.1 18.9
1,023
100.0
Total
Interview Three trained and calibrated researchers interviewed participants. The interview was conducted using a structured questionnaire containing questions regarding sociodemographic variables, oral hygiene habits, access to dental services, and behavioral factors, as described below. Demographics included age and sex. The education level was assessed by asking how many years of education and was defined into low (£4 years) and middle/high (‡5 years). Socioeconomic status was assessed using the Brazilian Economy Classification System from the Brazilian Association of Research Companies that attributes points according to the amount of consumer goods of the family and the education level of the head of the family.26 Socioeconomic status was then categorized using cutoff points adapted from those defined by the Brazilian Association of Research Companies into low (£20 points), and middle/high (‡21 points). Toothbrushing frequency, movement, and type were oral hygiene practices assessed in the interview. Toothbrushing frequency was categorized as less than or equal to once, twice, and ‡3 times daily. Toothbrushing movement was divided into horizontal, vertical, circular, and all three movements. Toothbrush types were categorized into soft, medium/hard, and unknown. The amount of cigarettes smoked daily and years of smoking was recorded for each individual to evaluate smoking habits. Exposure to cigarette smoking was evaluated using the combination of current and former smokers. The total number of packs of cigarettes consumed in a lifetime (packyears) was calculated by multiplying the number of cigarettes consumed daily by the years of habit and dividing by 20. Smoking exposure was categorized into never-smokers (0 pack-years), moderate smokers (
Prevalence and Risk Indicators of Dentin Hypersensitivity in Adult and Elderly Populations From Porto Alegre, Brazil Ricardo S.A. Costa,* Fernando S. Rios,* Mauricio S. Moura,† Juliana J. Jardim,† Marisa Maltz,† and Alex N. Haas*
Background: Dentin hypersensitivity (DH) is a clinical condition with potential implications for patients. However, little is known about its occurrence and determinants in the general population. The aim of this study is to assess the prevalence and risk indicators of DH in Porto Alegre, Brazil. Methods: A representative multistage probability sample of 1,023 adults aged ‡35 years was obtained. Individuals were interviewed and clinically examined in their homes. DH was assessed dichotomously in all present teeth by a blast of air and a manual probe. Teeth restored with crowns and presenting with carious cavitation were excluded. Survey logistic regression using sampling weights was applied to assess demographics and behavioral and clinical determinants. Results: Overall prevalence estimates for DH diagnosed by air and probe were 33.4% and 34.2%. DH affected 1 tooth per individual, and approximately 10% of teeth with gingival recession (GR) had DH. In a multivariable model for DH diagnosed with air, females had increased chance of DH (odds ratio [OR] = 2.14; 95% confidence interval [CI] = 1.57 to 2.91). Smoking, periodontal treatment, and GR were also associated with increased DH risk. The chance of DH was lower (OR = 0.47, 95% CI = 0.29 to 0.76) among individuals ‡60 than among those aged 35 to 49 years. Oral hygiene practices, socioeconomic and education status, dental visits, and gingival inflammation were not associated with DH. Conclusions: DH may be considered a concern in a Brazilian general population. Reduction of DH may be achieved by smoking cessation and periodontal health improvements. J Periodontol 2014;85:1247-1258. KEY WORDS Aged; Brazil; dentin sensitivity; epidemiology; gingival recession; risk factors. * Periodontology, Faculty of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. † Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grande do Sul.
D
entin hypersensitivity (DH) is defined as short and acute dental pain in response to thermal, evaporative, tactile, or osmotic stimuli that cannot be explained by any other dental pathology.1-3 The hydrodynamic theory4 states that DH arises from stimulation of the dental pulp neural fibers due to fluid movement inside the dentinal tubules after external stimuli on the exposed root surface. The prevalence of DH is highly heterogeneous,5-21 with estimates varying from 1.3% to 52.6%.8,9 Although many studies have assessed the occurrence of DH, some have used representative samples, with most findings being provided from university teaching hospitals,8,9,17 dental schools,18,21 and dental practice settings.5-7,12,16,20 Population-based studies of DH have been performed only in China10,11,13,19 and India.15 To the best of the authors’ knowledge, there are no studies evaluating DH in representative samples from other parts of the world. In this context, it is not possible to determine if the observed variability in prevalence estimates of DH is a true picture of the condition or a result of methodologic variations in sampling strategies, target populations, and diagnostic methods. A variety of factors have been related to the occurrence of DH. Middle-aged individuals consistently have a higher prevalence of DH compared with elderly doi: 10.1902/jop.2014.130728
1247
Epidemiology of Dentin Hypersensitivity
individuals. 5-7,12,14,17,21 Similarly, DH is more common among females than males in most studies.8,10-16,18-21 Socioeconomic status,6,7,19 education level,5-7,10,11,19 oral hygiene practices,18,19 smoking,6,7,22 periodontal treatment,23,24 and severity of gingival recession (GR)5,10-15,17,19,20 have also been investigated. Nevertheless, most studies have applied only univariable comparisons,5-10,12-19,21,22 and only two studies19,20 have used multivariable risk assessment models for DH. Therefore, the aim of this study is to assess the prevalence and risk indicators of DH in an urban population of adults and elderly individuals living in Porto Alegre, Brazil. MATERIALS AND METHODS Study Design and Target Population This cross-sectional observational population-based study was designed by the Caries-Perio Collaboration Group from the Federal University of Rio Grande do Sul, Porto Alegre, Brazil. Various oral outcomes were evaluated, including dental caries (coronal and root), dental erosion, DH, gingivitis, GR, and tooth loss. The target population included male and female individuals aged >34 years living in the city of Porto Alegre, Brazil. The last updated census data in 2003 identified 591,297 individuals >34 years old in the total population. Fieldwork for the study was conducted from June 2011 to June 2012. Ethical Aspects The study protocol was reviewed and approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul. Before the interview, all participants read and signed an informed consent form. After the clinical examination, participants were provided with a written report detailing their oral status. Patients diagnosed with pathologic conditions were advised to seek dental care. Sample Size The sample size was estimated using the worst-case scenario considering a prevalence of 50% for any of the outcomes assessed in the study. It was also estimated that the multistage sampling used in the present study would yield approximately 50% inefficiency compared with simple random sample designs, taking into consideration the design effect observed for a series of outcomes. Prevalence was estimated with a standard formula that adjusted the sample size for the design effect. Considering a precision of 4% and a 95% confidence interval (CI), the required sample size was estimated as 940 individuals. Sampling Strategy This study used a multistage probability sampling strategy (Fig. 1) based on information provided by 1248
Volume 85 • Number 9
governmental agencies.25 In the first stage, the city was divided into 86 neighborhoods that comprised the primary sampling units (PSUs), which were stratified into high- and low-income strata. Lowincome PSUs were those in which most (>35%) of the heads of families had a monthly income of < 5 standard Brazilian salaries.25 The PSUs were randomly selected in a proportionate manner relative to the number of PSUs in each stratum. In the second stage, sectors were randomly selected in a proportionate manner relative to the total number of sectors in each PSU. Sectors were defined by the Brazilian Institute of Geography and Economy as map areas comprising 300 households each. All 373 sectors were eligible, and 48 (12.8%) of them were selected, 34 and 14 from low (stratum A)- and high (stratum B)-income strata, respectively. In seven sectors from the high-income stratum, the research team was not allowed to conduct the study as determined by local, religious, or governmental authorities. The third stage consisted of selecting households within each sector. Households were approached consecutively according to the sector starting point until the sector sample size was reached. The number of individuals selected within each sector was estimated based on the proportional distribution of the sample size according to the number of individuals aged >34 years living in each sector. All household members aged >34 years were considered eligible for the study. Individuals were excluded if they presented with any mental or systemic health condition that did not allow them to perform the interview or clinical examination. Places such as nursing homes and commercial establishments were excluded. Study Sample A total of 1,600 individuals were eligible for the study (Fig. 1). Of them, 375 (23.4%) did not participate in the study (non-respondents). Therefore, the whole sample of the study included 1,225 individuals (398 males and 827 females, aged 35 to 95 years; mean age: 52.6 – 11.8 years), of whom 1,023 (83.5%) were dentate and included in the study sample. Table 1 displays the characteristics of the study sample. Fieldwork Procedures A research team of two examiners (RC and FR) and one assistant (Renan Prado, Federal University of Rio Grande do Sul) conducted the fieldwork for this study. One researcher visited each selected sector 1 day before the start of data collection to invite residents to participate. Residents were not included after a third failed attempt of invitation. Interviews and clinical examinations were conducted inside the participants’ homes.
J Periodontol • September 2014
Costa, Rios, Moura, Jardim, Maltz, Haas
Figure 1.
Flowchart of sampling strategy and response rate. PSU = primary sampling unit.
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Epidemiology of Dentin Hypersensitivity
Volume 85 • Number 9
Table 1.
Table 1. (continued )
Demographic and Clinical Characteristics of Participants in the Study
Demographic and Clinical Characteristics of Participants in the Study
Sociodemographic and Clinical Variables
n
%
Sex Males Females
398 625
38.9 61.1
Age (years) 35 to 39 40 to 49 50 to 59 60 to 69 ‡70
148 306 304 174 91
14.5 29.9 29.7 17.0 8.9
Education Low Middle/high
198 825
19.4 80.6
Socioeconomic status Low Middle/high
505 518
49.4 50.6
Gingivitis Low (£22%) High (>22%)
510 513
49.9 50.1
Calculus (%) 0 to 19 20 to 39 ‡40
147 261 615
14.4 25.5 60.1
Behavioral Variables
n
%
Brushing £1 time/day 2 times/day ‡3 times/day
118 344 561
11.5 33.6 54.9
Brush type Soft Medium/hard Unknown
397 580 46
38.8 56.7 4.5
Brushing movement Horizontal Vertical Circular All
565 251 126 81
55.2 24.5 12.3 7.9
Smoking Never smoker Moderate smoker Heavy smoker
463 299 261
45.3 29.2 25.5
1250
Dental visits None Irregular Regular
290 498 235
28.4 48.7 23.0
Periodontal treatment No Yes
830 193
81.1 18.9
1,023
100.0
Total
Interview Three trained and calibrated researchers interviewed participants. The interview was conducted using a structured questionnaire containing questions regarding sociodemographic variables, oral hygiene habits, access to dental services, and behavioral factors, as described below. Demographics included age and sex. The education level was assessed by asking how many years of education and was defined into low (£4 years) and middle/high (‡5 years). Socioeconomic status was assessed using the Brazilian Economy Classification System from the Brazilian Association of Research Companies that attributes points according to the amount of consumer goods of the family and the education level of the head of the family.26 Socioeconomic status was then categorized using cutoff points adapted from those defined by the Brazilian Association of Research Companies into low (£20 points), and middle/high (‡21 points). Toothbrushing frequency, movement, and type were oral hygiene practices assessed in the interview. Toothbrushing frequency was categorized as less than or equal to once, twice, and ‡3 times daily. Toothbrushing movement was divided into horizontal, vertical, circular, and all three movements. Toothbrush types were categorized into soft, medium/hard, and unknown. The amount of cigarettes smoked daily and years of smoking was recorded for each individual to evaluate smoking habits. Exposure to cigarette smoking was evaluated using the combination of current and former smokers. The total number of packs of cigarettes consumed in a lifetime (packyears) was calculated by multiplying the number of cigarettes consumed daily by the years of habit and dividing by 20. Smoking exposure was categorized into never-smokers (0 pack-years), moderate smokers (
