Prevalence and Risk Indicators of DentinHypersensitivity in Adult and ElderlyPopulations From Porto Alegre, BrazilRicardo S.A. Costa,* Fernando S. Rios,* Mauricio S. Moura,† Juliana J. Jardim,† Marisa Maltz,†

and Alex N. Haas*

Background: Dentin hypersensitivity (DH) is a clinicalcondition with potential implications for patients. However,little is known about its occurrence and determinants inthe general population. The aim of this study is to assessthe prevalence and risk indicators of DH in Porto Alegre,Brazil.

Methods: A representative multistage probability sampleof 1,023 adults aged ‡35 years was obtained. Individualswere interviewed and clinically examined in their homes.DH was assessed dichotomously in all present teeth bya blast of air and a manual probe. Teeth restored withcrowns and presenting with carious cavitation wereexcluded. Survey logistic regression using samplingweights was applied to assess demographics and behav-ioral and clinical determinants.

Results: Overall prevalence estimates for DH diagnosedby air and probe were 33.4% and 34.2%. DH affected �1tooth per individual, and approximately 10% of teeth withgingival recession (GR) had DH. In a multivariable modelfor DH diagnosed with air, females had increased chanceof DH (odds ratio [OR] = 2.14; 95% confidence interval[CI] = 1.57 to 2.91). Smoking, periodontal treatment, andGR were also associated with increased DH risk. The chanceof DH was lower (OR = 0.47, 95% CI = 0.29 to 0.76) amongindividuals ‡60 than among those aged 35 to 49 years. Oralhygiene practices, socioeconomic and education status,dental visits, and gingival inflammation were not associatedwith DH.

Conclusions:DH may be considered a concern in a Brazil-ian general population. Reduction of DH may be achievedby smoking cessation and periodontal health improvements.J Periodontol 2014;85:1247-1258.

KEY WORDS

Aged; Brazil; dentin sensitivity; epidemiology; gingivalrecession; risk factors.

Dentin hypersensitivity (DH) isdefined as short and acute den-tal pain in response to thermal,

evaporative, tactile, or osmotic stimulithat cannot be explained by any otherdental pathology.1-3 The hydrodynamictheory4 states that DH arises fromstimulation of the dental pulp neuralfibers due to fluid movement inside thedentinal tubules after external stimuli onthe exposed root surface. The preva-lence of DH is highly heterogeneous,5-21

with estimates varying from 1.3% to52.6%.8,9 Although many studies haveassessed the occurrence of DH, somehave used representative samples, withmost findings being provided from uni-versity teaching hospitals,8,9,17 dentalschools,18,21 and dental practice set-tings.5-7,12,16,20 Population-based stud-ies of DH have been performed only inChina10,11,13,19 and India.15 To the bestof the authors’ knowledge, there are nostudies evaluating DH in representativesamples from other parts of the world.In this context, it is not possible to de-termine if the observed variability inprevalence estimates of DH is a truepicture of the condition or a result ofmethodologic variations in samplingstrategies, target populations, and di-agnostic methods.

A variety of factors have been relatedto the occurrence of DH. Middle-agedindividuals consistently have a higherprevalence of DH compared with elderly

* Periodontology, Faculty of Dentistry, Federal University of Rio Grande do Sul, PortoAlegre, Brazil.

† Preventive and Social Dentistry, Faculty of Dentistry, Federal University of Rio Grandedo Sul.

doi: 10.1902/jop.2014.130728

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individuals.5-7,12,14,17,21 Similarly, DH is morecommon among females than males in most stud-ies.8,10-16,18-21 Socioeconomic status,6,7,19 educationlevel,5-7,10,11,19 oral hygiene practices,18,19 smok-ing,6,7,22 periodontal treatment,23,24 and severity ofgingival recession (GR)5,10-15,17,19,20 have also beeninvestigated. Nevertheless, most studies have appliedonly univariable comparisons,5-10,12-19,21,22 and onlytwo studies19,20 have used multivariable risk as-sessment models for DH. Therefore, the aim of thisstudy is to assess the prevalence and risk indicatorsof DH in an urban population of adults and elderlyindividuals living in Porto Alegre, Brazil.

MATERIALS AND METHODS

Study Design and Target PopulationThis cross-sectional observational population-basedstudy was designed by the Caries-Perio Collabora-tion Group from the Federal University of Rio Grandedo Sul, Porto Alegre, Brazil. Various oral outcomeswere evaluated, including dental caries (coronal androot), dental erosion, DH, gingivitis, GR, and toothloss. The target population included male and femaleindividuals aged >34 years living in the city of PortoAlegre, Brazil. The last updated census data in 2003identified 591,297 individuals >34 years old in thetotal population. Fieldwork for the study was con-ducted from June 2011 to June 2012.

Ethical AspectsThe study protocol was reviewed and approved bythe Research Ethics Committee of the Federal Uni-versity of Rio Grande do Sul. Before the interview, allparticipants read and signed an informed consentform. After the clinical examination, participants wereprovided with a written report detailing their oralstatus. Patients diagnosed with pathologic conditionswere advised to seek dental care.

Sample SizeThe sample size was estimated using the worst-casescenario considering a prevalence of 50% for any ofthe outcomes assessed in the study. It was alsoestimated that the multistage sampling used in thepresent study would yield approximately 50% in-efficiency compared with simple random sampledesigns, taking into consideration the design effectobserved for a series of outcomes. Prevalence wasestimated with a standard formula that adjustedthe sample size for the design effect. Consideringa precision of 4% and a 95% confidence interval(CI), the required sample size was estimated as 940individuals.

Sampling StrategyThis study used a multistage probability samplingstrategy (Fig. 1) based on information provided by

governmental agencies.25 In the first stage, the citywas divided into 86 neighborhoods that comprisedthe primary sampling units (PSUs), which werestratified into high- and low-income strata. Low-income PSUs were those in which most (>35%) ofthe heads of families had a monthly income of < 5standard Brazilian salaries.25 The PSUs were ran-domly selected in a proportionate manner relative tothe number of PSUs in each stratum.

In the second stage, sectors were randomly se-lected in a proportionate manner relative to the totalnumber of sectors in each PSU. Sectors were definedby the Brazilian Institute of Geography and Economyas map areas comprising �300 households each. All373 sectors were eligible, and 48 (12.8%) of themwere selected, 34 and 14 from low (stratum A)- andhigh (stratum B)-income strata, respectively. In sevensectors from the high-income stratum, the researchteam was not allowed to conduct the study as de-termined by local, religious, or governmental authorities.

The third stage consisted of selecting householdswithin each sector. Households were approachedconsecutively according to the sector starting pointuntil the sector sample size was reached. Thenumber of individuals selected within each sectorwas estimated based on the proportional distributionof the sample size according to the number of in-dividuals aged >34 years living in each sector. Allhousehold members aged >34 years were consid-ered eligible for the study. Individuals were excludedif they presented with any mental or systemic healthcondition that did not allow them to perform theinterview or clinical examination. Places such asnursing homes and commercial establishments wereexcluded.

Study SampleA total of 1,600 individuals were eligible for thestudy (Fig. 1). Of them, 375 (23.4%) did not par-ticipate in the study (non-respondents). Therefore,the whole sample of the study included 1,225 in-dividuals (398 males and 827 females, aged 35 to95 years; mean age: 52.6 – 11.8 years), of whom1,023 (83.5%) were dentate and included in thestudy sample. Table 1 displays the characteristics ofthe study sample.

Fieldwork ProceduresA research team of two examiners (RC and FR) andone assistant (Renan Prado, Federal University of RioGrande do Sul) conducted the fieldwork for thisstudy. One researcher visited each selected sector 1day before the start of data collection to inviteresidents to participate. Residents were not includedafter a third failed attempt of invitation. Interviewsand clinical examinations were conducted inside theparticipants’ homes.

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Figure 1.Flowchart of sampling strategy and response rate. PSU = primary sampling unit.

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InterviewThree trained and calibrated researchers interviewedparticipants. The interview was conducted usinga structured questionnaire containing questions re-garding sociodemographic variables, oral hygienehabits, access to dental services, and behavioralfactors, as described below.

Demographics included age and sex. The edu-cation level was assessed by asking how manyyears of education and was defined into low (£4years) and middle/high (‡5 years). Socioeconomicstatus was assessed using the Brazilian EconomyClassification System from the Brazilian Associa-tion of Research Companies that attributes pointsaccording to the amount of consumer goods of thefamily and the education level of the head of thefamily.26 Socioeconomic status was then cate-gorized using cutoff points adapted from thosedefined by the Brazilian Association of ResearchCompanies into low (£20 points), and middle/high(‡21 points).

Toothbrushing frequency, movement, and typewere oral hygiene practices assessed in the in-terview. Toothbrushing frequency was categorizedas less than or equal to once, twice, and ‡3 timesdaily. Toothbrushing movement was divided intohorizontal, vertical, circular, and all three move-ments. Toothbrush types were categorized intosoft, medium/hard, and unknown.

The amount of cigarettes smoked daily andyears of smoking was recorded for each individualto evaluate smoking habits. Exposure to cigarettesmoking was evaluated using the combination ofcurrent and former smokers. The total number ofpacks of cigarettes consumed in a lifetime (pack-years) was calculated by multiplying the number ofcigarettes consumed daily by the years of habitand dividing by 20. Smoking exposure was cate-gorized into never-smokers (0 pack-years), mod-erate smokers (<20 pack-years), and heavy smokers(‡20 pack-years).

Table 1.

Demographic and Clinical Characteristicsof Participants in the Study

Sociodemographic and

Clinical Variables n %

SexMales 398 38.9Females 625 61.1

Age (years)35 to 39 148 14.540 to 49 306 29.950 to 59 304 29.760 to 69 174 17.0‡70 91 8.9

EducationLow 198 19.4Middle/high 825 80.6

Socioeconomic statusLow 505 49.4Middle/high 518 50.6

GingivitisLow (£22%) 510 49.9High (>22%) 513 50.1

Calculus (%)0 to 19 147 14.420 to 39 261 25.5‡40 615 60.1

Behavioral Variables n %

Brushing£1 time/day 118 11.52 times/day 344 33.6‡3 times/day 561 54.9

Brush typeSoft 397 38.8Medium/hard 580 56.7Unknown 46 4.5

Brushing movementHorizontal 565 55.2Vertical 251 24.5Circular 126 12.3All 81 7.9

SmokingNever smoker 463 45.3Moderate smoker 299 29.2Heavy smoker 261 25.5

Table 1. (continued)

Demographic and Clinical Characteristicsof Participants in the Study

Dental visitsNone 290 28.4Irregular 498 48.7Regular 235 23.0

Periodontal treatmentNo 830 81.1Yes 193 18.9

Total 1,023 100.0

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Dental care was assessed by asking individualsabout their reasons for and frequency of visits to thedentist during the last 3 years. Individuals werecategorized as having regular dental visits if theyreported going to the dentist for prevention witha frequency of one or more times per year. In-dividuals who reported going to the dentist only foremergencies were classified as having irregulardental visits. Individuals were classified as having nodental care if they reported no dental visits duringthe last 3 years. Self-reported history of periodontaltreatment was assessed dichotomously.

Clinical ExaminationsClinical examinations were conducted using threeportable devices: 1) a medical headlight, 2) an aircompressor (adapted ultrasonic medical nebulizer‡),and 3) a bendable chair. Two examiners (RSAC andFSR) performed the examinations. All permanentfully erupted teeth were examined with a manualcolor-coded periodontal probe§ to assess gingivitis,supragingival calculus, and GR at four sites per toothon the mesio-buccal, mid-buccal, disto-buccal, andmid-lingual surfaces. DH was assessed at the buccalsurface. Additionally, dental caries was assessedusing the International Caries Detection and As-sessment System.

Gingivitis was assessed using the gingival bleed-ing index by inserting the periodontal probe 0.5 to1.0 mm into the gingival sulcus and running it fromone interproximal area to the other. Gingivitis wasdichotomized into low and high gingival inflamma-tion using the median (22%) for the percentage ofbleeding sites as the cutoff point.

GR was defined as the distance from the cemento-enamel junction (CEJ) to the free gingival margin. Ifthe CEJ was located apical to the gingival margin,the GR was given a negative sign. Measurementswere made in millimeters and were rounded to thelowest whole millimeter. The number of teeth withGR ‡1 mm at the mid-buccal site was used toassociate this condition with the occurrence of DHand was entered as a continuous variable in themodel.

DH was assessed in teeth presenting with GR (‡1mm); however, teeth with carious cavitation in dentinand prosthetic crowns were excluded. DH has beenassessed using tactile or cold stimuli, and to allowcomparisons with a higher number of studies fromthe literature, DH was recorded using two stimuli inthe present study. First, the tactile stimulus wasrecorded using the periodontal probe applied with aslight pressure perpendicular to the buccal cervicalregion in a mesiodistal direction. For the air stimulus,a blast of air was applied in a direction perpendicularto the cervical region of the tooth, at a distance of

�1 cm. The air blast was applied for 3 seconds whileprotecting the adjacent teeth with the fingers. Teethdiagnosed with or without DH were scored as 0, or 1,respectively.

Non-ResponseReasons for non-participation are described in Figure1. A total of 375 did not participate in the study. Keyquestions of the interview were answered by 219(58.4%) of these non-respondents and were com-pared with individuals included in the sample. Non-respondents were slightly older (55.5 – 11.8 years,P = 0.001) and had significantly higher educationand socioeconomic status compared with respon-dents. There were no significant differences betweenrespondents and non-respondents with regard to sexand self-reported mean number of lost teeth.

Statistical analyses accounted for non-responseby using the inverse probability weighting strategy.27

A non-response weight variable was generated foreach sector, considering the eligible and actual num-bers of included individuals and the distributions ofage, sex, and education.

ReliabilityReliability of the questionnaire was assessed duringthe fieldwork by using the test-retest approach, with3 to 4 days between each interview, in 50 partici-pants. A set of key questions was used to assess thereproducibility of the questionnaire using k statistics.k coefficients varied from 0.91 to 0.99.

Examiners were trained to conduct the clinicalexamination using standardized methods. An expe-rienced examiner (ANH) trained the two examiners ofthis study to assess gingivitis and calculus. Intra- andinterexaminer reproducibility of GR were assessedbefore the start of the study and during fieldwork.Duplicate measurements of GR were conducted withat least 1 hour between examinations. Before thestart of the study, 16 patients (1,231 sites) from thePeriodontal Department were examined in groups ofthree to four patients. During fieldwork, duplicate mea-surements were performed in 42 participants (2,896sites). Initial intra-examiner reliability revealed weightedk (–1 mm) values of 0.97 and 0.98, and the inter-examiner value was 0.84. During the fieldwork,weighted k values were 0.98 and 0.99 (intra-examiner)and 0.91 (interexaminer).

Statistical AnalysesSeparate analyses were performed for DH diagnosedby air and probe. Prevalence of DH was defined asthe percentage of individuals having at least onetooth with DH. Extent of DH was described by the

‡ Inalar Compact, NS Medical Equipment, Sao Paulo, SP, Brazil.§ PCP10-SE, Hu-Friedy, Chicago, IL.

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total number of teeth within an individual having DH.The percentage of teeth with DH among teeth thathad GR at the buccal site was calculated.

Sampling weights were computed in a separatevariable for each individual using census informa-tion provided by the Brazilian Institute of Geographyand Economy. Complex survey commands wereused to account for cluster correlations expectedfor the multistage sampling strategy used in thestudy. Pairwise comparisons of crude estimates werecarried out using the Wald test. The significancelevel was set at 5%. Data analyses were performedusing a statistical package.i Survey binary logisticregression models were fitted to assess risk indicatorsfor DH. Univariate models were fitted for each in-dependent variable, and variables with P values<0.25 were entered in the multivariable model.Maintenance of variables in the final model wasdetermined by a combination of P values <0.05 andanalyses of confounders and interactions.28 No in-teractions were found.

RESULTS

Overall prevalence values for DH diagnosed by airand probe were 33.4% and 34.2%, respectively(Table 2). Statistically higher rates of DH by eitherstimulus were observed among heavy smokers andthose reporting periodontal treatment. DH di-agnosed by probe was more prevalent among in-dividuals with middle/high levels of education,whereas DH diagnosed by air was significantly lessprevalent in the elderly. No significant differences inDH prevalence were observed among categories ofsex, socioeconomic status, brushing frequency andmovement, toothbrush type, dental visits, andgingivitis.

The overall mean numbers of teeth diagnosedwith DH by air and probe were 1.0 and 0.8, re-spectively. Among individuals with DH diagnosed byair and probe, the mean numbers of teeth with DH(extent of DH) were 3.0 and 1.9, respectively (seesupplementary Table 1 in online Journal of Peri-odontology). The extent of DH diagnosed by air wassignificantly higher among moderate/heavy smokerscompared with never-smokers. DH diagnosed byprobe was significantly less extensive in individualswith older age, higher socioeconomic status, andlower education. No additional significant differenceswere observed for other variables.

Among teeth with GR, the percentages of teethwith DH diagnosed by air and probe were 10.1% –1.1% and 8.3% – 0.7%, respectively, which de-creased significantly with increasing age. Females(12.1% – 1.3%) and heavy smokers (13.2% – 1.9%)had higher percentages of teeth with DH diagnosedby air compared with males (7.8% – 1.3%) and

never-smokers (8.2% – 0.9%), respectively. No ad-ditional significant differences were observed forother variables or DH diagnosed by probe.

Figure 2 illustrates the oral distribution of DH byage. A similar pattern of distribution was observedfor DH diagnosed by air and probe. Overall, pre-molars and first molars were the most frequent teethwith DH among younger individuals, whereas theincisors and canines had higher frequencies of DH inolder individuals. In individuals <60 years of age,18% of the maxillary second premolars and firstmolars were diagnosed with DH by air, representingthe highest frequency of DH among all tooth types.

Tables 3 and 4 show the univariable and multi-variable logistic regression models, respectively, ofrisk indicators for DH diagnosed by air and probe.In the multivariable model for DH diagnosed by air,the chance of DH was 2.14 times higher in femalescompared with males. The chance of DH was sig-nificantly lower among individuals aged ‡60 yearscompared with those aged 35 to 49 years. Thechances of DH were elevated in heavy smokers(59%) and in individuals with a history of periodontaltreatment (53%). The association between GR andDH was significant, with an odds ratio equal to 1.11.When DH was diagnosed by probe, the major dif-ference in the model was that sex was no longerassociated with DH.

DISCUSSION

The epidemiology of DH reveals high variabilitybetween studies, perhaps due to the different di-agnostic methods used to detect DH. A blast of airand tactile sensitivity after probing are the mostfrequently used methods for diagnosis.29-31 Althougheasily assessed, self-reported DH has been demon-strated to overestimate the occurrence of clinicalDH.13,32 In the present study, the authors use bothair and probe to broadly assess the prevalence andrisk indicators of DH, and it is observed that the twoapproaches generally provide similar prevalenceestimates, although specific and deeper analyses areneeded to clarify the accuracy of each method at thesite and individual levels.

With the exception of three studies,8,18,22 as-sessments of dental patients in different settingshave revealed very low estimates of DH prevalence(e.g., 1.3% in Nigeria,9 2.8% to 4.1% in the U.K.,5-7

and 12.3% in the United States).20 Population-basedstudies conducted in China found DH prevalenceestimates of 25.5%10 to 34.5%,13 similar to thepresent estimates for a southern Brazilian popula-tion (�30%). To the authors’ knowledge, this is thefirst population-based study to assess DH in the

i Stata 10 for Macintosh, STATA, College Station, TX.

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Table 2.

Prevalence (% of participants) of DH Diagnosed by Air or by Probe According toDemographic and Behavioral Variables

Variable

Air Probe

Prevalence SE P* Prevalence SE P*

SexMales 29.5 3.5 Ref. 35.3 3.2 Ref.Females 36.6 3.3 0.06 33.3 3.6 0.7

Age (years)35 to 49 36.2 3.9 Ref. 40.2 3.9 Ref.50 to 59 36.3 4.2 0.97 30.6 2.6 0.12‡60 24.0 2.9 0.01 24.7 5.8 0.12

EducationLow 29.9 4.3 Ref. 23.8 4.2 Ref.Middle/high 34.0 3.2 0.38 36.1 2.3 0.004

Socioeconomic statusLow 34.0 0.03 Ref. 35.9 0.03 Ref.Middle 31.9 0.06 0.70 33.2 0.03 0.47High 34.3 0.04 0.95 32.2 0.06 0.59

Brushing£1 time/day 27.1 5.6 Ref. 25.4 4.9 Ref.2 times/day 35.2 4.3 0.24 35.9 4.3 0.06‡3 times/day 33.7 2.9 0.26 35.3 4.0 0.25

Brush typeSoft 35.6 3.0 Ref. 34.2 3.5 Ref.Medium/hard 32.7 4.2 0.52 34.7 3.0 0.9

Brushing movementHorizontal 32.2 3.7 Ref. 33.8 3.3 Ref.Vertical 34.1 5.3 0.74 38.2 4.8 0.48Circular 35.6 4.0 0.46 27.0 4.6 0.29All 35.4 5.4 0.65 36.1 6.0 0.72

SmokingNever smoker 30.0 3.3 Ref. 26.2 3.3 Ref.Moderate smoker 33.1 5.0 0.61 40.0 3.0 0.002Heavy smoker 40.5 3.8 0.01 42.7 3.1 0.001

Dental visitsNone 35.6 3.3 Ref. 33.0 3.1 Ref.Irregular 34.0 3.5 0.70 33.5 2.8 0.9Regular 26.6 4.6 0.21 37.0 5.3 0.45

Periodontal treatmentNo 31.3 3.0 Ref. 31.7 2.5 Ref.Yes 42.5 3.6 0.001 45.5 5.0 0.02

GingivitisLow (£22%) 33.1 3.6 Ref. 32.8 2.5 Ref.High (>22%) 33.6 3.0 0.87 35.7 4.1 0.56

Total 33.4 2.9 34.2 2.4

* Wald test.

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Americas. Only two previous studies have assessedthe occurrence of DH in Brazil, in patients attendinga dental clinic of the Brazilian Navy (17%)23 anda dental school (46%).18 However, it is noteworthythat prevalence estimates in a general populationcannot be directly compared with estimates fromdental patients because of the different source ofstudied individuals.

DHmost frequently affects the premolars,5-7,10,11,13,14,19

followed by the maxillary first molars.5-7 Similarfindings were observed in the present study in in-dividuals <60 years of age. In older individuals, themandibular incisors and canines were also fre-quently affected, probably because molars arecommonly lost in elderly individuals.33 The authorswere unable to find other studies in the literature thathave performed this stratification to make com-parisons.

In the present study, DH affected �1 tooth perindividual on average. Similarly, the mean numberof sensitive teeth was 1.5 in a national study inChina.13 In a dental practice study in the UnitedStates, 3.5 teeth were diagnosed with DH amongthose reporting DH.20 A Chinese study found meannumbers of sensitive teeth per individual with DHranging from 3.4 to 4.1 in different age groups.10

Herein, the extent of air-diagnosed DH was 3.0 inindividuals with DH. Although prevalence estimates

may vary considerably in the literature, the extent ofDH seems to be relatively low and consistent acrossstudies.

Although various factors have been associatedwith DH in previous studies, very few reports haveused multivariable models.19,20 Most data on riskindicators for DH refer to point-by-point comparisonsof crude estimates. For instance, several previousstudies have demonstrated that estimates of DH arehigher among females than males.5-8,10-22 Althoughno significant differences between males and femalesin the univariable comparisons were found in thisstudy, females had two times higher chances ofhaving DH diagnosed by air compared with males inthe final multivariable model. This finding may beexplained by the confounding effect of other vari-ables on the association between DH and sex in thisstudy. Corroborating the present findings, Cunha-Cruz et al.20 found an odds ratio of 1.8 for femalescompared with males using multivariable models ina North American convenience sample, and Queet al.19 observed more than two times higherchances of DH for females compared with malesin China.

In regard to age, previous studies have dem-onstrated that dentin is higher in individuals be-tween 30 and 50 years compared with olderindividuals.5-8,10-22 In the present study, it was

Figure 2.Intraoral distribution of DH according to tooth type and age group. A) DH diagnosed by blast of air. B) DH diagnosed with probe. Numbers 1 to 8represent teeth from central incisors to third molars.

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Table 3.

Univariable Logistic Regression Models of Risk Indicators for DH Diagnosed by Airand by Probe

Potential Risk Indicator

Air Probe

Odds Ratio 95% CI Odds Ratio 95% CI

SexMales 1 1Females 1.38 0.97 to 1.97 0.92 0.57 to 1.49

Age (years)35 to 49 1 150 to 59 1.01 0.61 to 1.67 0.66* 0.44 to 0.98‡60 0.56† 0.37 to 0.86 0.49 0.21 to 1.15

EducationLow 1 1Middle/high 1.21 0.76 to 1.91 1.81† 1.20 to 2.75

Socioeconomic statusLow 1 1Middle 0.91 0.52 to 1.59 0.89 0.62 to 1.26High 1.01 0.66 to 1.54 0.85 0.43 to 1.68

Brushing£1 time/day 1 12 times/day 1.46 0.73 to 2.94 1.64 0.94 to 2.86‡3 times/day 1.37 0.74 to 2.55 1.60 0.67 to 3.87

Brush typeSoft 1 1Medium/hard 0.88 0.57 to 1.35 1.02 0.67 to 1.55

Brushing movementHorizontal 1 1Vertical 1.09 0.63 to 1.88 1.21 0.69 to 2.11Circular 1.16 0.75 to 1.81 0.72 0.38 to 1.39All 1.15 0.58 to 2.29 1.10 0.60 to 2.02

SmokingNever smoker 1 1Moderate smoker 1.15 0.64 to 2.09 1.88† 1.29 to 2.76Heavy smoker 1.58† 1.17 to 2.15 2.10† 1.40 to 3.16

Dental visitsNone 1 1Irregular 0.93 0.62 to 1.40 1.02 0.72 to 1.45Regular 0.76 0.47 to 1.22 1.19 0.73 to 1.95

Periodontal treatmentNo 1 1Yes 1.62† 1.24 to 2.11 1.80* 1.11 to 2.92

GingivitisLow (£22%) 1 1High (>22%) 1.02 0.75 to 1.40 1.14 0.71 to 1.80

Number of teeth with GR 1.09† 1.06 to 1.12 1.09† 1.06 to 1.13

* P <0.05.† P <0.01.

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observed that individuals >60 years old had lowerprevalence and chances of DH compared with in-dividuals 35 to 49 years old, corroborating previousstudies. The decrease of DH with aging may beexplained by the obliteration of dentinal tubules anddeposition of tertiary dentin over a lifetime, resultingin a thick and protective layer of dentin between thepulp and the external environment.2,3

Smoking was a significant risk indicator for DH inthe present study. This finding is relatively new, asvery few studies have assessed the effect of smokingon DH, providing only descriptive statistics.6,7 Thenumber of teeth with DH was higher among smokersfrom two convenience samples in the U.K.6,7 Theincrease of DH in smokers may be explained, inpart, by the negative effect of tobacco on the peri-odontal tissues, which can lead to greater GR andexposure of the root surface.

Among all the risk indicators, GR had the strongestassociation with DH. For instance, it was estimatedthat approximately 10% of teeth with GR showed DHin this study. Of note, this is the first population-basedstudy to assess the effect of GR on DH using mul-tivariable models. Another non-representative studyin the United States observed that individuals with GRhad a 5.5 times higher chance of having DH thanthose without GR.20 Results of other studies re-porting the frequency distribution of teeth with DHand GR5-7,12 also corroborate the present results.

The present population-based study providesadditional evidence supporting previous clinicalfindings that periodontal treatment is related to theoccurrence of DH. A recent systematic review ofinterventional studies34 observed that differentperiodontal therapeutic strategies resulted in ele-vated dental sensitivity, although variations in du-ration and intensity may exist. Another Brazilianobservational study conducted with dental patientsfound similar results.23 In contrast, two other studiesdid not find significant differences in the occur-rence of DH according to history of periodontaltreatment.10,20

Low socioeconomic and education status hasbeen consistently associated with higher occurrenceof destructive periodontal disease.35-38 The impact ofthese variables on DH has been assessed in previousobservational studies, with conflicting results. Threestudies in Asian populations found that low educa-tion level was associated with a higher occurrenceof DH,10,11,15 whereas two studies from the U.K.observed that DH was more prevalent among in-dividuals from higher social groups.6,7 Using thesame classification system, Que et al.19 observedsimilar findings in a representative Chinese sample.In the present study, no associations were foundamong socioeconomic status, education, and DH.

Considering the hydrodynamic theory of DH,4

a positive association between better oral hygiene

Table 4.

Multivariable Logistic Regression Models of Risk Indicators for DH With Air and Probe

Risk Indicator

Air Probe

Odds Ratio 95% CI Odds Ratio 95% CI

SexMales 1 –Females 2.14* 1.57 to 2.91

Age (years)35 to 49 1 150 to 59 0.81 0.47 to 1.40 0.49* 0.31 to 0.79‡60 0.47* 0.29 to 0.76 0.42† 0.19 to 0.94

SmokingNever smoker 1 1Moderate smoker 1.01 0.55 to 1.85 1.66† 1.12 to 2.46Heavy smoker 1.59† 1.07 to 2.35 2.11* 1.35 to 3.31

Periodontal treatmentNo 1 1Yes 1.53† 1.13 to 2.07 1.80† 1.06 to 3.03

Number of teeth with GR 1.11* 1.09 to 1.13 1.09* 1.06 to 1.12

–, removed from the final model.* P <0.01† P <0.05.

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practices and DH would be expected. However, inthe present study no associations were found amongDH and variables related to oral hygiene (e.g.,toothbrushing frequency and movement, toothbrushtype, and extent of gingivitis). Cunha-Cruz et al.20

also did not find association between DH and ag-gressive toothbrushing habits. However, Que et al.19

found higher odds for DH in individuals reportingtoothbrushing more than twice daily. In view of thefew epidemiologic studies assessing this association,no major conclusions may be drawn.

CONCLUSIONS

In conclusion, DH affected a significant proportion ofindividuals, reaching more than one third of the adultpopulation in Porto Alegre, Brazil. Premolars werethe teeth most affected by DH. Age, sex, smoking,periodontal treatment, and GR were risk indicatorsfor DH and may be targeted in preventive strategieson individual and population levels.

ACKNOWLEDGMENTS

This study was funded by the National Coordinationof Post-Graduate Education (CAPES) and the Fed-eral University of Rio Grande do Sul (PROPESQ).The authors thank Drs. Renan Prado and GabrielaGoldenfum (residents of PROPESQ) for their helpduring data collection. The authors report no con-flicts of interest related to this study.

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Correspondence: Alex Nogueira Haas, Rua RamiroBarcelos, 2492, Porto Alegre, RS, 90030-035 Brazil.Fax: 55 51 33085318; e-mail: alexnhaas@gmail.com.

Submitted December 6, 2013; accepted for publicationJanuary 24, 2014.

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