Prevalence of sensitive teeth and associated factors: a multicentre, cross-sectional questionnaire survey in France

Dentin hypersensitivity (DH) is a frequently recurring finding and a challenging condition to treat in clinical practice [1‐3]. DH is characterized by an acute, transient pain from an area of exposed dentin, in response to stimuli that cannot be attributed to any other form of defect or disease. The stimulus is usually thermal, chemical, tactile, osmotic, or even related to evaporation (air jet) [2, 4].

Theories concerning the mechanisms of pain conduction inside the dentin are various and controversial. The hydrodynamic theory, developed in 1962 by Brännström, proposes the most commonly accepted explanation for this painful phenomenon [4, 5]. The activation of intra-pulp nerve fibres is thought to result from the displacement of the content of dentinal tubules following a mechanical, thermal or osmotic stimulus [5‐7]. Two conditions need to be met for this to occur: the dentin has to be exposed and the dentin tubular system has to be open so as to allow the release of a neural response in the pulp through the fluid movement [7, 8]. The dentin tubule could be exposed by multifactorial interactions including erosion, abrasion, saliva, and biofilm/pellicle/plaque, all of which influence whether demineralization occurs or not [7]. Cervical enamel may be lost by a combination of erosion and abrasion, and recession of periodontal tissue may result in exposure of the root surface dentin [7]. Loss of periodontal tissue may also be the result of abrasion, as with tooth brushing, or periodontal treatment [7].

Symptoms of DH can sometimes resemble those of other painful oral diseases and diagnosis is mainly based on a search for predisposing factors, the identification of wear lesions and the elimination of other dental diseases such as caries or periodontal diseases [1, 8]. DH may affect the quality of life. It can influence what and how the subject eats and drinks, can hinder tooth brushing, and can even have severe emotional impacts and modify lifestyles [3, 9].

Different data syntheses on DH have shown prevalence ranging from 4 to 74% depending on the sample studied [10]. There may be several explanations for these variations. Some studies used self-administered questionnaires to ask subjects about sensitive teeth (ST) while others diagnosed DH after a professional clinical examination [10]. Persons declaring that they suffer from ST could be suffering not only from DH but also from other oral diseases such as caries or periodontal problems, which would explain the higher prevalence [10]. Nevertheless, even if studies are separated into two groups - self-questionnaires versus clinical records - the range of the estimate remains high (13–57% or 4–74% respectively) [10]. Other arguments have been put forward to explain these differences, such as sample characteristics (ethnic origin, study location, periodontal status, dental care regime, oral hygiene habits, socio-economic status) [10]. The clinical criteria used to define the presence or absence of DH could be based on two opposing approaches: a passive approach using the statement of the subject’s pain experience and an active approach applying different mechanical and thermal stimulations [11, 12]. Another complicating factor is the episodic nature of the condition, which may evoke or subdue the pain symptoms [3].

In France, published data on the prevalence of ST or DH are rare. In 1994, Murray and Roberts reported a prevalence of ST of 14% using a face-to-face questionnaire [13]. The objectives of the present work were to estimate ST prevalence and characteristics, and to explore the associated factors, in a general French population.

The questionnaire was answered by 2413 persons, with well-balanced sample distributions among centres (Bordeaux: n = 399, Lille: n = 400, Montpellier: n = 417, Nice: n = 385, Rennes: n = 404, Strasbourg: n = 408). The total sample included 1255 women (52.0% of the sample) and the average age was 38.2 ± 15.3 years (median = 35.0, minimum = 18, maximum = 92).

The prevalence of ST during the previous 12 months reported in the sample was 42.2% [95% CI: 40.2–44.1%]. Prevalence of reported ST according to the investigation centre ranged from 31.2% in Rennes to 55.8% in Nice (with 34.8% in Montpellier, 42.3% in Lille, 43.6% in Bordeaux and 46.3% in Strasbourg). ST mean pain intensity assessed by a visual analogue scale was 3.8 ± 2.3 (median = 3.2, minimum = 0.1, maximum = 10, n = 1018). Pain characteristics, oral habits, quality of life affected by ST and solutions found to relieve pain are described in Table 1.

Results from the bivariate analyses according to the presence of ST are presented in Tables 2 and 3. Presence of reported ST was statistically associated with occupation (p = 0.01) and use of tobacco (p < 0.001) but not with gender, age group, marital status or a period of frequent vomiting (with respectively p = 0.14, p = 0.09, p = 0.69 and p = 0.32). The consumption of soft drinks and chewing gums were significantly associated with ST (with respectively p < 0.001 and p = 0.008). Regarding access to oral care, there was a significant association between ST and shorter time since last visit to the dentist, and between ST and awareness of untreated oral problems (with p = 0.005 and p < 0.001, respectively). Frequencies of tooth brushing and mouth washing, and type of toothbrush were also associated with ST (with, respectively, p = 0.02, p = 0.01 and p = 0.01).

In the final logistic regression model, gender, use of tobacco, frequency of soft drinks consumption, access to oral care (time since last visit to the dentist and awareness of untreated oral problems) and oral hygiene habits (mouth washing frequency and type of toothbrush used) showed significant statistical associations with ST (Table 4). ST was significantly more frequent among females and smokers (with respectively aOR = 1.27 [95% CI: 1.07–1.52] in women compared to men and aOR = 1.29 [95% CI: 1.08–1.54] in smokers compared to non-smokers). The higher the consumption frequency of soft drinks was, the greater was the risk of ST increase, with aOR = 1.45 [95% CI: 1.17–1.79] for those who consumed them occasionally to often and aOR = 1.72 [95% CI: 1.30–2.26] for those who consumed them at least once per day, compared to those who never consumed them. Time since last visit to the dentist was associated with ST when subjects had consulted less than 6 months previously compared to those who had consulted more than a year ago (aOR = 1.63 [95% CI: 1.30–2.03]). The use of a manual hard brush or an unknown type of brush were significantly associated with ST compared to other types of toothbrush (manual medium or manual soft or electric brush) with aOR = 1.42 [95% CI: 1.06–1.91] and aOR = 1.36 [95% CI: 1.04–1.80], respectively.

The objectives of this study were to estimate the prevalence of ST in a general population in France and to explore associated factors. Nearly half of respondents in a large sample of French people had perceived ST during the previous year.

Many studies have explored DH around the world but data are rare in France. When this study began, only Murray and Roberts had published such data, which dated from 1994. They found a prevalence of 14% of ST evaluated using a face-to-face questionnaire in a French sample of 1000 randomly selected people [13]. They repeated the study in France during the next spring and found a lower prevalence, at 9% [13]. More recently, and concomitantly with our study, West et al. studied DH in 3187 adults in Europe, including 700 subjects from France, according to 3 methods (ST evaluation with a self-administered questionnaire, DH evaluated after cold air stimulation with the Schiff ordinal scale and the response to pain from the patient) [16]. They found a prevalence of 39.6% if DH was defined as reported DH on any tooth in response to cold air stimulation, 11.6% if DH was defined as patient’s response discreetly recorded by a clinical examiner to cold air stimulation at level 2 or 3 of the Schiff score, and 21.0% of declared ST using a self-administered questionnaire [16]. The last result is quite different from that obtained in this study. It may be explained by different selection criteria. In particular, West et al. recruited patients aged 15 to 35 from a routine dental examination in general dental practice and excluded patients if they had 5 teeth or less, were currently wearing orthodontic appliances or had cervical restorations [16]. In 2019, a meta-analysis by Favaro Zeola et al. indicated an estimate of DH of 11.5% [95% CI: 11.3%11.7%] for the fixed-effects model (which could be regarded as the “best estimate” in absence of heterogeneity) and 33.5% [95% CI: 30.2–36.7%] for the random-effects model (which could be regarded as the “average prevalence” from all studies) [17]. They also found that the type of participants included in the studies had a modifying effect, whereas the method of diagnosis, frequently suggested by the literature as an influential factor, did not explain the variability of the prevalence estimate [17].

About 18 and 27% of the sample reported having changed their eating habits for food and drinks, respectively. Drinks appeared to be the most often modified because of ST; it could be thought that subjects reduced, for example, very cold and/or acid drinks in order to limit discomfort/pain caused by this type of drinks or because they had discussed the impact of these elements with their dentist. Although a majority of people with DH noted little impact on their overall quality of life, some reported a significant impact. Bekes et al. also found that patients with DH reported considerably more impaired OHRQoL than subjects in the general population [9, 15]. It would have been interesting to further investigate behavioural changes due to ST and their links with OHRQoL perceived by subjects, using a new, specific and validated instrument: DHEQ (for quality of life measure for dentin hypersensitivity) or its short version, the 15-item DHEQ [18, 19]. It can be noted that, among people with ST, a little more than half had raised the issue with a healthcare professional and preferably a dentist. The treatment proposed for this problem was deemed beneficial by almost 90% of the subjects who used it. Fewer subjects with ST admitted having used self-medication (27%) and 77% were satisfied. The answers to these questions may be biased because those who presented the questionnaires were dental students, so subjects might have tended to under-report their self-medication and overestimate their recourse to the dentist. However, these results are encouraging from the point of view of the decision of people with ST to visit a dentist.

Studies usually evoke a higher prevalence of DH in women than in men, because women are usually more attentive to their overall health and particularly their oral health [11, 20]. In the present study, a higher risk of ST was also found in women, with aOR = 1.27 [95% CI: 1.07–1.52]. There is, nevertheless, conflicting evidence for the gender distribution of DH [21]. Splieth and Tachou argued that women tend to brush more intensively than men, and that they eat more healthy fruity food items, which are also erosive [21]. According to these authors, this combination of erosion and abrasion presents an ideal mixture of etiological risk factors for DH. Some studies report a higher prevalence of DH in smokers than in non-smokers, a prevalence that should be modulated according to the periodontal status [10, 16]. In this study, a significant association between ST and use of tobacco was also found (aOR = 1.29 [95% CI: 1.08–1.54]). The presence of ST is independently associated with a more recent visit to the dentist. The links between ST and access to oral care are difficult to interpret, since subjects with ST might have been to the dentist more recently because of ST. However, health is both a cause and consequence of the use of care. Time since last visit or awareness of untreated oral problems would, therefore, not be relevant to the analysis of the use of health care. It would have been appropriate to include the reason for the consultation.

It is reported in the literature that the prevalence of DH is currently increasing, probably because of changes in lifestyle and increasing risk factors [22]. DH is linked to enamel erosion, which is the main factor in tooth surface wear. It is characterized by a chemical dissolution of the tooth surface after acid attack of non-bacterial origin, extrinsic or intrinsic [23]. Several authors have shown that repeated acid action, such as a frequent consumption of fruit juices or sodas could ultimately lead to tooth erosion by extrinsic attack of the tooth surfaces and opening of dentinal tubules [24, 25]. The multiple analysis did not show a statistically significant association between the presence of ST and consumption of fruit juices. Conversely, a significant association was found between ST and consumption of soft drinks, and the higher the consumption frequency of soft drinks was, the greater was the risk of having ST compared to no consumption: aOR = 1.72 [95% CI: 1.30–2.26] for a daily consumption, aOR = 1.45 [95% CI: 1.17–1.79] if the consumption was occasional to often. Discussion in the literature points out that the daily consumption frequency, the time the soft drink remains in the mouth and the moment the acid drink is taken (during meals or between meals) have an effect on dental erosion [26‐28]. Some general conditions inducing gastric reflux, such as stomach problems, or eating disorders like anorexia or bulimia, are intrinsic factors predisposing to dental erosion processes [29]. Finally, no association was found with a declared period of frequent vomiting and ST (p = 0.32) in this study, whereas West et al. found a significant association between DH reported on any tooth in response to cold air stimulation and reflux or repeated vomiting (p < 0.0001, [16]).

The exposure of the root level dentin follows, in turn, the occurrence of gingival recession, since the thin layer of supra-dentinal cement above this level is easily removed [30]. Thus, factors predisposing to DH at root level are the same as those that indirectly trigger gingival recessions. The links between ST and attitudes towards oral hygiene habits are complex and often discussed in the literature. Thus, improper tooth brushing not only in terms of technique but also in terms of duration or equipment used, or even periodontal treatment (such as scaling and root planing or surgery) could reveal DH by exposing the root dentin [1, 7]. The multivariate analysis showed that the use of a manual hard toothbrush for brushing was significantly associated with ST (aOR = 1.42 [95% CI: 1.06–1.91]), unlike other types of toothbrush. Conversely, a vicious circle between DH and changes in oral hygiene frequency, because of the pain, could result in the emergence of other oral problems and amplification of DH. In the present study, 23.1% of sufferers reported having changed their oral hygiene habits because of ST. A significant association was found between the frequency of tooth brushing and ST in the bivariate analysis, an effect that disappeared when other factors were taken into account in the multivariate analysis. Other determinants, such as tooth brushing technique or type of toothpaste, were not recorded, so it was not possible to verify if an inadequate technique or an excessively abrasive toothpaste could be associated with DH through progressive abrasion of the teeth [1, 31]. West et al. did not find an association between DH and brushing movement in the bivariate analysis [16] but these issues will probably need more exploration when new studies are designed.

A longstanding debate exists on the most appropriate term to use to describe DH. Though the correct term can be questioned, current usage and the accepted definition now suggest a consensus on the use of the term DH [2]. Nevertheless, the data collected in this work did not report DH but ST since a declarative questionnaire was used. Moreover, subjects reporting ST may have been suffering from oral diseases other than DH, such as untreated caries or periodontal diseases, which could not be confirmed by a clinical examination. This may have led to an overestimation of the true prevalence of DH. All data interpretation must necessarily take this limitation into consideration. Even when considering only DH, current methods employ non-gradable mechanical and cold metal/air/water/ice stimuli and use response scales that often rely on subject-investigator interaction that lacks validation [32]. A novel approach, dental quantitative sensory testing, based on controlled graded cold air stimuli, looks promising for obtaining reliable measurements of DH [32]. This could suggest a direction for further studies. Recent research has also focused on the role of illness beliefs and coping in the adjustment to DH [33], which could constitute a promising area of research for better understanding and effective management of people suffering from DH.

Another limit of this study was the sampling strategy. The study recruited the number of subjects indicated by the calculation of the number required. A geographically balanced sample was established in six geographic regions spread throughout France. Nevertheless, representativeness cannot be guaranteed since no random sampling was performed. In particular, the people recruited were passers-by, which could explain why the proportion of unemployed people was above the national average (25% versus about 10% [34]). This, in turn, could have had consequences on the estimation of the prevalence because of the complex links between oral health (in particular ST / DH) and socioeconomic status. Some authors have found a tendency for patients with DH to come from higher social groups [9].

To conclude, this study provides prevalence data on ST and associated factors in multivariate analysis in a general population in France. It seems that prevalence of ST still remains high in the general French population despite the existence of many therapies. The information collected in this study, and more generally, about DH should alert new generations of professionals to a clinical manifestation that is becoming increasingly prevalent and that they will have to take into consideration to help reduce the discomfort arising from it.