C L I N I C A L

P R A C T I C EConsensus-Based Recommendations
for the Diagnosis and Managementof Dentin Hypersensitivity• Canadian Advisory Board on Dentin Hypersensitivity •A b s t r a c t
These consensus recommendations for the diagnosis and management of dentin hypersensitivity were developedby a broadly constituted board of dentists and dental hygienists drawn from general dental practice, specialist practice, academia and research from across Canada, joined by 2 international dentists with subject matter expertise.
The need for consensus recommendations was made evident by the lack of clear and robust evidence in the dental
literature, as well as confusion about diagnosis and management demonstrated by an educational needs assessment
survey. High prevalence of the condition, underdiagnosis and widespread availability of noninvasive, efficacious
and inexpensive preventive treatment further underscored the need for direction. This paper outlines the key
elements of the scientiﬁc basis for the causes, diagnosis and management of dentin hypersensitivity; where such
evidence is deﬁcient, the document relies on the compound experience of the board. A simple algorithm was developed to guide clinicians through the diagnostic process and assist them in determining appropriate case management. Finally, the board makes a series of recommendations to raise awareness, to improve dental education, todevelop symbols for charting, to develop an index for case assessment and for further research.
MeSH Key Words: algorithms; consensus; dentin sensitivity/etiology; dentin sensitivity/therapy© J Can Dent Assoc 2003; 69(4):221–6
This article has been peer reviewed.

D

entin hypersensitivity has been defined as a “short,sharp pain arising from exposed dentin in
response to stimuli typically thermal, evaporative,
tactile, osmotic or chemical and which cannot be ascribedto any other form of dental defect or pathology.”1 Several
reviews2–4 reported that the prevalence of dentin hypersensitivity ranged from 8% to 57% in the general populationand that strategies for managing the condition wereremarkably varied. Furthermore, scientific support for various therapies was variable, so it could be a challenge for apractitioner to select appropriate therapy. Recognizingthese issues, the Canadian Advisory Board on Dentin
Hypersensitivity met in Toronto, Ont., in June 2002 todevelop consensus-based recommendations on the management and treatment of dentin hypersensitivity.

Methods
The board considered data from 2 sources: an extensive
literature search and a survey of knowledge and practices ofdentists and hygienists across Canada. Where scientific defiJournal of the Canadian Dental Association

ciencies were identified, the board developed consensus positions drawn from members’ own diverse clinical and academic backgrounds. Gaps in knowledge were identified
through an educational needs assessment survey. The board
brought together all its considerations into a set of consensus
recommendations, including an algorithm (Fig. 1) to guidepractitioners through diagnosis and case management.

Data Collection — Literature Search
An extensive computer (MEDLINE) and hand search of
the literature identified original articles and reviews for theperiod 1966 to 2002 (see Table 1 for search terms). Becauseof space limitations, only critical findings are presented
here.

Definition
After full consideration of the literature the board
accepted the definition proposed by Holland and others,1
with one minor change. The agreed definition was a “short,sharp pain arising from exposed dentin in response to
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SCREEN PATIENT: Does your patient suffer from twinges or stabsof pain or sensitivity?

No

No treatment
requiredYes
OBTAIN PATIENT HISTORY• Ask patient to describe pain (look for description of pain as short,sharp)• Ask patient to identify pain-inciting stimuli (look for thermal, tactile,
evaporative, osmotic, chemical)• Determine patient’s desire for treatment• Probe for intrinsic and extrinsic acids• Obtain detailed dietary history (look for excessive dietary acids:e.g., citrus juices and fruits, carbonated drinks, wines, ciders)• Probe for gastric acid reﬂux and excessive vomiting
EXAMINE PATIENT TO EXCLUDEa• Cracked tooth syndrome• Fractured restorations• Chipped teeth• Dental caries• Gingival inﬂammation• Post-restorative sensitivity• Marginal leakage• Pulpitis• Palatogingival grooves

Is your patient’s examination/history consistent with dentin
hypersensitivity?b

No

Yes

Diagnosis inconsistent with dentin
hypersensitivity

Seek other causes

CONFIRM YOUR PATIENT’S DIAGNOSISc
Treat other causes
INITIATE MANAGEMENT FOR DENTIN HYPERSENSITIVITY• Educate patient to remove risk factors• Recommend removal of excessive dietary acids• Recommend tooth-brushing remote from mealtime (preferably before)• Advise against overly frequent or aggressive tooth-brushing/hygiene
FOLLOW-UP: Does your patient’s dentin hypersensitivity persist?

NoNo further treatment

Yes
INITIATE TREATMENT FOR DENTIN HYPERSENSITIVITY
Apply desensitizing techniques with consideration for convenience andcost-effectiveness

NONINVASIVE• Desensitizing toothpaste usedcorrectlyd• Topical agents

INVASIVE• Mucogingival surgery• Resins• Pulpectomy

FOLLOW-UP: Does your patient’s dentin hypersensitivity still persist?
(i.e., does your patient report improvement but still have pain and if so,does your patient still desire further treatment?)

No

Maintain current
therapy long-termand review regularly.
Reconsider
predisposing factors.

Yes
REVIEW DIAGNOSIS TO EXCLUDE• Periodontal pain
• Referred pain

No further treatment• Neuropathic pain
• Chronic pain syndrome

Should you continue dentin hypersensitivity treatment and patient
education?

No

YesContinue dentin hypersensitivity treatment and patient education, withongoing reminders to alter predisposing factors

Refer patient toappropriate
specialist (dental or
medical)a. Potentially useful diagnostic
tools• Air jet• Cold water jet• Other thermal tests• Dental explorer• Periodontal probe• Radiographs (if needed)• Percussion testing• Assessment of occlusion• Bite stress tests
b. Deﬁnition of dentin
hypersensitivity
Dentin hypersensitivity is characterized by short, sharp pain
arising from exposed dentin in
response to stimuli typicallythermal, evaporative, tactile,
osmotic or chemical and whichcannot be ascribed to any otherform of dental defect or disease.1
c. Other potential diagnostic
aids• Selective anesthesia• Transilluminationd. The best results are achieved
if desensitizing toothpaste isapplied via twice-daily brushing,performed on an ongoing basis
according to a regular schedule(not applied topically, as in“dabbing”).

Figure 1: Algorithm for diagnosis and management of dentin hypersensitivity

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Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity

Table 1

Key words and search terms used in
the literature search

Search 1(clinical trial OR randomized clinical trial OR clinical evaluation)
AND (dentinal OR dental OR tooth OR intra-dental nerves) AND(toothpaste OR dentifrice OR mouthwash) AND (hypersensitivity
OR sensitivity OR desensitization) AND treatment AND (potassium nitrate OR potassium citrate OR potassium chloride OR
ferrous oxide OR sodium ﬂuoride OR sodium monoﬂuorophosphate OR glutaraldehyde OR strontium chloride), limited tohumansSearch 2(dentinal hypersensitivity) OR (dental hygienists) AND (treatment
AND (conservative OR operative OR restorative OR varnishes OR
resins OR silver nitrate OR glutaraldehyde OR formaldehyde))
NOT potassium NOT toothpaste NOT dentifrice, limited tohumansstimuli typically thermal, evaporative, tactile, osmotic or
chemical and which cannot be ascribed to any other formof dental defect or disease” (where “disease” replaces theoriginal “pathology” of Holland and others1). This definition challenges clinicians to consider other potential causes
for pain associated with tooth sensitivity. Many conditions
share the symptoms of tooth sensitivity, so a differential
diagnosis is essential.

Mechanisms of Dentin Hypersensitivity
The most widely accepted mechanism of dentin hypersensitivity is the hydrodynamic theory proposed by
Brännström,5 whereby fluid flow within dentinal tubules isaltered (increased or changed directionally) by thermal,
tactile or chemical stimuli near the exposed surface of thetubules. This alteration would lead to stimulation of the
A-δ fibres surrounding the odontoblasts. This putative
mechanism requires that individual tubules be open at thedentin surface, as well as within the pulp.

Dentin Morphology
In a study to determine differences between sensitive
and nonsensitive teeth, Absi and others6 reported that
nonsensitive teeth were unresponsive to any stimuli andhad very few exposed tubules. In contrast, sensitive teeth
had much greater numbers of open tubules per unit area
(8 times as many tubules at the root surface than nonsensitive teeth). Similarly, the average diameter of tubules insensitive teeth was almost 2 times greater than that of
tubules in nonsensitive teeth (0.83 µm vs. 0.4 µm).
According to Poiseuille’s law, which states that fluid flow is
proportional to the fourth power of the radius, diameter
differences alone would indicate that the fluid flow intubules of hypersensitive teeth should be 16 (i.e, 24) times
greater than that of fluid in nonsensitive teeth. Combining
the increased number of open tubules with the increased
diameter of the tubules in sensitive teeth, it can be postuJournal of the Canadian Dental Association

lated that the fluid flow in sensitive teeth is approximately
100 times greater than in nonsensitive teeth. The number oftubules increases toward the pulp, and this may not only
increase the probability of dentin hypersensitivity but also
help explain any increase in symptoms as tooth wear advances
toward the pulp.

CausesTwo processes are essential for the development ofdentin hypersensitivity: dentin must become exposed(lesion localization), through either loss of enamel or gingival recession, and the dentin tubules must be open to boththe oral cavity and the pulp (lesion initiation).
Erosion,7 abrasion (or their co-effects), attrition8 andpossibly abfraction9 lead to exposure of tubules. Both clinical and laboratory evidence suggests that enamel at the
buccal cervical region is lost through a combination oferosion and abrasion.7,10 Enamel is resistant to abrasion by
tooth-brushing, with or without toothpaste, but is particularly sensitive to the effects of acid; thus, brushing of acidsoftened (eroded) enamel has a marked abrasive effect.10
As indicated in the survey results (see below), many
practitioners assume that “abrasive” toothpastes are responsible for lesion development. While it is possible that toothpaste may erode dentin to some extent, the abrasivity mightalso produce a smear layer, thereby reducing sensitivity.11
Interestingly, toothpaste abrasives in combination withdetergents may remove the smear layer and open the
tubules. Indeed, if predisposing factors (see below) are noteradicated, brushing with nearly any toothpaste may open
the tubules.3 Occasionally, some deposits of the abrasivefrom toothpastes do adhere to the tubules, but they detacheasily later.
Gingival recession, another factor in exposure of dentin,
has recently been described as an enigma,12 and its causes
are not well understood. However, overzealous brushing,acute necrotizing ulcerative gingivitis, self-inflicted injury
and periodontal procedures are the major predisposing
factors.

Data Collection — Educational Needs
Assessment
A 66-item questionnaire was developed to determine
practitioners’ understanding and clinical management ofdentin hypersensitivity. Key elements included practiceprofile, experience with patients suffering hypersensitivity,
perceptions of causes and diagnosis, and clinical management. The questionnaire was mailed to a random sample of
5,000 dentists and 3,000 hygienists across Canada. The
7% response rate (331 dentists and 211 hygienists) was
reasonable considering the many items on the questionnaire and the method of distribution. An independent
research group (The Chapman Group Limited, Unionville,
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Canadian Advisory Board on Dentin Hypersensitivity

Ont., unpublished data) compiled the results and convened
focus groups to examine knowledge gaps more closely.
A total of 14 key knowledge gaps were identified, whichwere classified as relating to either the causes and diagnosisor the management of the condition.

Causes and Diagnosis of Dentin Hypersensitivity
1. Prevalence was underestimated, particularly for young
adult patients. Approximately 70% of respondents indicated that most of their patients with dentin hypersensitivity were between 35 and 50 years old. Yet an independent
research study (by The Chapman Group Limited) of 683
adults drawn from a nationally representative sample of theCanadian population found that the prevalence of sensitive
teeth was about 30% in adults throughout the 18- to 64year age band (28% for those 18–24 years of age, 22% for
those 25–34 years of age, 30% for those 36–49 years of age
and 30% for those 50–64 years of age).
2. Screening is not routinely conducted, except when
prompted by patients.
3. Fewer than half of the respondents considered a differential diagnosis, even though dentin hypersensitivity is bydefinition1 a diagnosis of exclusion.
4. Many respondents (64% of the dentists and 77% of
the hygienists) identified bruxism and malocclusion as triggers of dentin hypersensitivity, even though neither has
been identified as a major causative factor.
5. Only 7% of dentists and 5% of hygienists correctly
identified erosion as a primary cause of dentin hypersensitivity.13 Sixty percent of respondents overall incorrectly
identified gingival recession (rather than a predisposing
factor) as the most common cause of dentin hypersensitivity.
6. Seventeen percent of dentists and 48% of hygienists
failed to identify the accepted theory of dentin hypersensitivity (the hydrodynamic theory5).
7. Eighty-five percent of dentists and 94% of hygienists
incorrectly cited toothbrush abrasion as a reason for continued tubule exposure, even though toothbrushes with orwithout toothpaste have no significant effect on tubule
exposure.14,15

Management of Dentin Hypersensitivity
8. About 50% of respondents reported that they lacked
confidence in managing their patients’ pain.
9. Only 50% of respondents reported that they try tomodify predisposing factors.
10. Fifty percent of dentists and 73% of hygienists
reported, incorrectly, that the most popular desensitizing
ingredients in desensitizing toothpastes are fluoride
compounds; in fact, the most widely available desensitizing
ingredient is potassium nitrate.
11. Only 10% of respondents correctly thought that
desensitizing toothpastes disrupt pain transmission by
preventing repolarization within the nerve. The remaining
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90% responded incorrectly that the principal action ofdesensitizing toothpastes is tubule occlusion. Potassium
nitrate is thought to act by interfering with the transmissionof pain, whereas strontium chloride, which is much lesswidely available, acts by occluding tubules.
12. Although many desensitizing toothpastes offer
substantial secondary benefits and are suitable for daily use,
misunderstanding exists. For example, 49% of dentists and
40% of hygienists did not believe that desensitizing toothpastes were effective in preventing caries, even though mostcontain fluoride.
13. Thirty-nine percent of respondents recommended
topical application (dabbing) of desensitizing toothpaste,
despite a lack of published evidence of the effectiveness of
this method.
14. Although most dentists (56%) and hygienists (68%)
believed that desensitizing toothpastes were effective inpreventing dentin hypersensitivity, 31% of dentists and
16% of hygienists did not believe that desensitizing toothpastes relieved dentin hypersensitivity.

Developing Consensus
Screening
The advisory board concluded that screening of alldentate patients was essential to avoid underdiagnosis andundertreatment of the condition.

Diagnosis
By definition,1 dentin hypersensitivity is a diagnosis of
exclusion. Therefore, before proceeding to management andtreatment, conditions that present with symptoms mimicking dentin hypersensitivity must be ruled out16 (Fig. 1).
Patients with dentin hypersensitivity usually experience a
short, sharp pain in response to cold (the most common
trigger), touch, evaporation, osmosis or chemical stimuli.17
It is difficult to quantify dentin hypersensitivity in a clinical setting, and hence clinicians must rely on patientreported history. In this regard, a patient might indicatethat she or he experiences pain but that it does not affecther or his quality of life (and that she or he is not seeking
treatment). Others might request intervention to obtainsome relief from the pain they experience. Given the many
variations in presentation, the board members agreed that
objective measures of pain from air blast or thermal stimuli,
as are commonly employed in clinical trials, might not becapable of replicating all types of dentin hypersensitivity,
which would reduce the reliability of evaluating theoutcomes of therapeutic interventions. Given these issues,
the board concluded that it would be most appropriate torely on patients’ perception of pain following treatment; theboard also agreed that there was a need for a universal pain
index. Such an index would constitute a judgement of
global transition, meaning that the patient would indicate
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Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity

that she or he feels an improvement, feels the same or feels
even worse after the intervention. In addition, the patient
might indicate that she or he desires no further treatment;in this situation and if the problem has been reduced or
resolved, further treatment would be inappropriate.

Management: Removal of Predisposing Factors
and Causes
Whenever possible, the predisposing factors should firstbe removed or modified. Otherwise, treatment is likely toprovide only short-term success. In their review, Dababneh
and others2 cited reports of dentin erosion caused by many
acidic substances derived either from the diet or from thestomach. A detailed, written dietary history (and investigation into bulimia and other dietary problems, if suspected)
can help to identify possible predisposing factors. Contrary
to the popular opinion demonstrated in the survey, normal
brushing of the teeth with or without toothpaste has relatively little effect on erosion unless the environment has
recently been acidified. The results of an in vitro study18
suggested that the timing of tooth-brushing should beremote from meals or ingestion of acidic drinks. The board
considered that brushing before meals would be moreadvantageous.
Patients who brush excessively or use undue pressure
while brushing should be instructed on proper toothbrushing techniques to avoid gingival recession, the latterbeing a predisposing factor for both dental erosion anddentin hypersensitivity that is difficult to correct. Althoughdebates continue on the correct method for brushing teeth,
technique has little effect on dentin hypersensitivity (apartfrom the effects on gingival root coverage), unless thepredisposing factors for erosion are still in place.

Treatment
Treatment can be designed to reduce fluid flow in the
tubules, block the nerve response in the pulp or possibly
both. An extensive analysis of review papers that focused on
the use of desensitizing agents indicated a wide array ofpotential treatments for dentin hypersensitivity, mostinvolving attempts to interrupt neural activation and paintransmission with either potassium nitrate or potassium
chloride. Fluid flow can be reduced by a variety of physicaland chemical agents that induce a smear layer or block the
tubules. Tubule-blocking agents include resins, glassionomer cements and bonding agents; strontium chloride
or acetate; aluminium, potassium or ferric oxalates; silicaor calcium-containing materials; and protein precipitants.
Although there is little evidence to determine thesuperiority of one desensitizing agent over another, thereis evidence that desensitizing toothpastes do provide
benefit.4,19–21
The board, in considering the use of desensitizing toothpastes, echoed the conclusion of Dababneh and others2 that
Journal of the Canadian Dental Association“improvement for a majority of cases will be obtained by
the recommendation of a desensitizing agent.”

Follow-up
The members of the board endorsed the concept that
follow-up was necessary. If pain persists, a review of thediagnosis is mandatory to rule out other causes (Fig. 1).
More invasive techniques, such as mucogingival surgery forroot coverage, application of resins (to seal exposed tubules)
or even pulpectomy may be necessary. In some cases thepain may be refractory and should be referred to a specialist (ideally before pulpectomy).
If the pain abates after treatment but recurs thereafter,
and a review of the patient’s medical history is still consistent with a diagnosis of dentin hypersensitivity, thenfurther counselling regarding the removal of predisposing
factors, combined with continuous long-term desensitization treatment, should be considered.

Educational Issues
Academic members of the advisory board (both dentists
and dental hygienists) indicated that little time is allotted todentin hypersensitivity in the curriculum. School curricula
should offer greater focus on the diagnosis and management of pain in general, and give increased emphasis todentin hypersensitivity. Resources for and approaches toteaching dentin hypersensitivity are highly variable andshould be reviewed to ensure greater effectiveness.

Development of a Diagnostic Algorithm
Given the knowledge gaps identified by the educational
needs assessment survey and practitioners’ expressed lack ofconfidence in management, a systematic, structured
approach to the problem of dentin hypersensitivity wasdeveloped and incorporated into an easy-reference algorithm (Fig. 1).
The algorithm reflects the published science on this
topic and, where such evidence is lacking, the clinical experience of the board members. Its framework includes thefundamental elements and critical steps required to increase
the likelihood of correct differential diagnosis and successful management of dentin hypersensitivity, and, whereappropriate, it directs the clinician to other causes, nofurther treatment or referral. This algorithm can be used to
guide the practitioner in making correct diagnostic decisions and then in acting upon the findings in a systematicmanner.

Consensus Recommendations
Screening and Diagnosis• Screening is critical for identifying dentin hypersensitivity.
• Conditions that have symptoms in common with dentin
hypersensitivity must be excluded.
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Canadian Advisory Board on Dentin Hypersensitivity• Universal symbols should be devised to indicate theseverity and extent of condition.
• A universal index combining an analogue pain measurewith the patient’s own rating of the effect of pain on
their quality of life should be developed.
• A detailed dietary history assessing erosive influences isessential.

Management• Predisposing factors and causes of dentin hypersensitivity should be removed or modified.
• Everyday use of desensitizing toothpastes should beconsidered and recommended as a noninvasive, inexpensive, efficacious first line of treatment, without necessarily sacrificing other benefits that patients seek (e.g.,cavity prevention, whitening).
• Brushing with desensitizing toothpaste (at least twice
daily) is the only clinically supported method of
application of such agents. There is no publishedevidence to support topical application (dabbing).
• Depending upon the severity and extent of the condition, reversible procedures should be employed before
nonreversible procedures.
• Follow-up is essential.

Research Needs• Long-term follow-up studies are required. Ideally, studies
would be randomized, placebo-controlled and doubleblinded.
• The mechanisms underlying dentin hypersensitivity
should be explored further; it is then conceivable that
more effective therapies can be developed.

Education• Clinical education should provide greater focus on thepredisposing factors, diagnosis and management of dentin
hypersensitivity and other forms of chronic pain. C
Acknowledgments: The Canadian Advisory Board on Dentin
Hypersensitivity was funded by an educational grant from
GlaxoSmithKline Consumer Healthcare Inc.
The Canadian Advisory Board on Dentin Hypersensitivity
comprises Dr. James R. Brookfield, Dr. Martin Addy, Dr. David C.
Alexander, Dr. Véronique Benhamou, Dr. Barry Dolman, Dr.
Véronique Gagnon, Dr. K. Tony S. Gill, Ms. Marilyn J. Goulding,
Ms. Stacy Mackie, Dr. Wayne A. Maillet, Dr. Gordon Schwartz and
Dr. Howard C. Tenenbaum.
Correspondence to: Dr. James R. Brookfield, 58 Government Rd. W,
Kirkland Lake, ON P2N 2E5. E-mail: brookie@nt.net.

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