Emilia Bologa1a , Simona Stoleriu1b* , Angela Cristina Ghiorghe1c , Galina Pancu1d , Irina Nica1e , Sorin Andrian1f
1Department of Odontology, Periodontology and Fixed Prosthodontics, Faculty of Dental Medicine, Grigore T. Popa University of Medicine and Pharmacy
of Jassy, Jassy, Romania
aDDS, PhD Student; e-mail: email@example.com; ORCIDiD: https://orcid.org/0000-0002-0091-8765
bDDS, PhD, Associate Professor; e-mail: firstname.lastname@example.org; ORCIDiD: https://orcid.org/0000-0001-5427-6027
cDDS, PhD, Lecturer; e-mail: email@example.com; ORCIDiD: https://orcid.org0000-0002-1636-6686
dDDS, PhD, Lecturer; e-mail: firstname.lastname@example.org; ORCIDiD: https://orcid.org/0000-0001-9593-1884
eDDS, PhD, Assistant Professor; e-mail: email@example.com; ORCIDiD: https://orcid.org/0000-0003-1189-0785
fDDS, PhD, Professor; e-mail: firstname.lastname@example.org; ORCIDiD: https://orcid.org/0000-0002-9271-6123
Introduction Continued education is a fundamental characteristic of one’s working life, especially in the medical field. Keeping up to date should be a mandatory element of dental practice. Dentin hypersensitivity (DH) has been a long-term significant challenge for practitioners due to the uncertainties around its diagnosis and treatment. The aim of this study is to assess the knowledge of senior dental students and young doctors with respect to this dental pathology.
Methodology A total of 632 self-administered questionnaire were distributed to dental students and doctors for data collection. The 10 questions investigated the knowledge about the description of pain in DH, triggering and predisposing factors, treatment strategies, preventive and treatment measures, remineralization products, etiological factors of dental wear, and main characteristics of DH. The data were analyzed using SPSS 20.0. Standard descriptive statistics were computed and analytical statistical analysis was performed using Pearson’s chi-square test.
Results The response rate for dental students was 87.87% and 10.2% for young doctors. Most respondents revealed a good level of knowledge regarding pain characterization, triggering factors, and predisposing factors of dentin hypersensitivity, and a satisfactory level for the disease management strategies. The average score of the questionnaire recorded at group level was 42.253.
Conclusion Young dentists had better knowledge of DH compared to 6th-year dental students. The information obtained from this study revealed that there is a need to provide better theoretical but also clinical teaching opportunities to students, as well as continued educational programs to young doctors.
Dentin Hypersensitivity; Knowledge; Dental Students; Dentists; Questionnaire.
Dentin hypersensitivity (DH) is a condition that has often been encountered in dental practice in recent decades [1–3], however, the historical reporting of this symptomatology goes as far back as the 16th century [4,5]. Holland et al.  described this pathology as a short, sharp pain arising when dentin is exposed to different stimuli (typically thermal, evaporative, tactile, osmotic or chemical) and the pain cannot be ascribed to any other form of dental defect or disease. The prevalence of DH ranges from 1.34% to 92.1% in the adult population [1–4,7–11]. This discrepancy occurs due to the differences in the methods used for diagnosis and in the selection criteria of the subjects. Patients with sensitive teeth experience discomfort while eating, drinking, and brushing their teeth, all of them being considered activities that affect the quality of life [2,12]. The academic curricula include clinical training for students to diagnose and to treat patients with different dental diseases under supervision, and therefore they are expected to have adequate knowledge about these conditions. Dental students and beginner young dentists that no longer have a supervisor to check their work quality must be acquainted with DH and must have the skills to correctly manage the disease [3,9].
There are limited data available regarding dental students’ and young dentists’ understanding of DH, especially in Romania, where no studies have been conducted on this topic. Questionnaires are objective tools that researchers can use to collect information about people’s knowledge, beliefs, attitudes, and behavior . Cross-sectional studies can be based on questionnaires, providing descriptive data on the entire population being studied. In scientific literature, several self-reported questionnaire studies assess students’ or dentists’ knowledge about dentin hypersensitivity [1–4,8,9,14,15]. Those surveys evaluated the clinical practice of the subjects in patients with DH and did not assess the theoretical knowledge that they possess about this disease. The theoretical educational processes represent the base for developing clinical skills. For this reason, we conducted a study to evaluate the knowledge of dental students and young dentists about dentin hypersensitivity regarding pain description, triggering factors, predisposing factors, diagnosis, preventive and treatment measures. The null hypothesis of the present study is that there are no differences in the evaluation of the level of knowledge between young dentists and dental students.
2. Material and Methods
This cross-sectional study was conducted since November 2018 till May 2019. A total of 632 questionnaires were distributed among senior dental students (6th year of study) at the Faculty of Dental Medicine – “Grigore T. Popa” University of Medicine and Pharmacy Iași, Romania, and among alumni who graduated in the last five years.
All participants were informed about the purpose and the objective of this study and signed a consent form of agreement. One hundred thirty-two dental students were asked to respond to the self-administered questionnaire at the end of their Cariology classes. Also, 500 young dentists were randomly chosen from the alumni database and received the questionnaire online. No reminder was given to those participants who did not return the questionnaire.
A literature search was performed on readily available questionnaires that measure the knowledge of dental students and young dentists about dentin hypersensitivity. None of them met the criteria to be followed in this study, so a new questionnaire was developed. The process of developing the new questionnaire followed the recommendations of Tsang et al. . The first step was to establish the expert committee, that was comprised of cariology professors, and then identify the dimensionality of the construct. It was decided that the questionnaire will be self-administered because in this way the respondents will answer more truthfully. The items used specific medical terminology because all the participants were trained in the dentistry field, hence being familiar with such terms. The questio-nnaire was constructed based on nine close-ended questions (seven multiple choice questions, one true/false question, one matrix question) and one open-ended item (Fig. 1). no.9 each correct association scored 2 points, and for question no.10 each correct answer scored 1.2 points. The maximum overall score of the questionnaire was 60 points. For the qualitative assessment, each response was evaluated as follows:
– from 0-2 points = Insufficient,
– 3-4 points = Satisfactory,
– 5-6 points = Good.
The participants’ overall knowledge was categorized using modified Bloom’s cut-off point, as good if the score was between 80 and 100% (48–60 points), satisfactory if the score was between 50 and 79% (30–47 points), and insufficient if the score was less than 50% (< 30 points).
2.1 Statistical Analysis
The data obtained were fed into Microsoft Excel (Microsoft Inc., USA). The statistical software SPSS 20.0 (IBM Inc., USA) was used for data analysis. The standard descriptive methods were applied to determine the characteristics of the sample. Pearson’s Chi-square test was applied to compare categorical variables between the groups.
We used nonparametric Mann-Whitney U and One-Sample Kolmogorov-Smirnov tests to evaluate the differences in the distribution of the age data set and data from the true/false question.
The confidence interval was set to 95% and p-values less than 0.05 were considered statistically significant.
The response rate for dental students was 87.87% (116 questionnaires returned from 132), and for young doctors this was 10.2% (51 questionnaires returned from 500). The mean age of the participants was 26.34 ± 3.635 years. Most participants were students (69.5%) and 30.5% were doctors. The re-sults showed that 61.1% were female participants and 38.9% males.
The qualitative assessment for the seven multiple choice questions is presented in Table 1. The percen-tage of young doctors having a good level of knowledge was statistically significantly higher than the one of dental students (Pearson’s Chi-square Test, p<0.05).
Regarding the characterization of dentin hyper-sensitivity, 27 out of all subjects (16.2%) did not know the correct answer, while the majority of subjects (105 subjects – 62.9%) obtained the maximum score. The comparative study of the results obtained by students and doctors revealed statistically significant differences (Pearson’s Chi-square Test, p = 0.001).
The percentage of students who did not know how to characterize dentin hypersensitivity was significantly higher than the doctors’ percentage as seen in Figure 2.
For the question regarding the triggering factors of DH, 31.7% of all respondents obtained the maxi-mum score. There was a statistically significant diff-erence (Fig. 3) between the percentage of doctors (45.1%) and that of students (25.9%) who obtained a maximum score of 6 (Pearson’s Chi-square Test, p = 0.032).
The third question analyzed the knowledge of the predisposing factors that determine the appearance of DH. Figure 4 shows that a significantly higher percentage of doctors (37.7%) than of students (16.4%) scored a maximum of 6 points, while a significantly higher percentage of students (12.1%) than of doctors scored 4 points.
Table 2 shows the scores obtained by students and dentists for question no.4 regarding the therapeutic strategies.
The fifth item looked into the knowledge regarding the preventive measures for DH. The comparative evaluation of doctors and students showed statistically significant differences (Pearson’s Chi-square Test, p = 0.001 – Fig. 5).
Analyzing the results of the sixth question regarding the treatment measures of DH we identified statistically significant differences (Pearson’s chi-square Test, p = 0.040) between the 5.9% of the young doctors that obtained the maximum score compared with none of the students (Fig. 6).
The results obtained for the seventh question about remineralization strategies are shown in Table 3.
On the open-ended question, namely question eight, 160 participants (95.8%) were able to give examples of desensitizing toothpastes. There were no statistically significant differences (Pearson’s Chi-square Test, p = 0.340) between the answers given by the students compared with the doctors.
Item number nine analyzed the knowledge about the etiology of different types of dental wear (abrasion, abfraction, and erosion). Most participants (63.5%) obtained the maximum score, and 7.8% of the subjects failed to make any correct association. There were no statistically significant differences (Pearson’s Chi-square Test, p = 0.052) between the answers given by the students compared with the doctors.
The last question evaluated the knowledge of some of the main characteristics of the DH. The average score recorded was 3.959 ± 1.2037, and no statistically significant differences (One-Sample Kolmogorov-Smirnov Test p = .000*, Mann-Whitney U = 2689.500, p = 0.328) were obtained between students and doctors.
The subjects’ answers to the questionnaire were also quantified using an overall score, with values between 8 and 54.6. The average score recorded at the level of the whole group was 42.253 ± 8.0697 – a value that proved subjects had average knowledge of dentin hypersensitivity, as seen in Table 4. There were statistically significant differences between the performances of doctors and students in this questionnaire, indicating that doctors had a higher level of knowledge than students on the investigated subject.
The current research is one of the first studies that aimed to establish whether the knowledge of young doctors differs from the knowledge of senior dental students regarding their theoretical information about the dentin hypersensitivity. The high students’ response rate can be due to the setting in which the questionnaires were collected, as soon as they were filled. We observe a similar response rate (75.7 -78.7%) to the one reported in other studies that analyzed dental students [3, 9]. The doctors’ response rate was lower, mainly because the interaction with the participants was on-line. Additionally, the lack of knowledge and understanding of the subject might have prevented them from filling in and returning the questionnaire . These data (response rate of 10.2% in the current study) are also in line with the low response rate (7%) reported by the Canadian Advisory Board on Dentin Hypersensitivity in a similar study regarding the practitioners’ understanding and clinical management of DH .
Our study revealed that most participants knew that the short and sharp pain is characteristic for DH, which is an important step in correctly diagnosing this disease. The first clinical data that a practitioner must collect cover the history of the patient’s pain [8,18].
In the present study, most participants had a good performance on the evaluation of all triggering factors (thermal, tactile, evaporative, chemical stimuli) of DH, but young doctors had a significantly better performance than students. In other studies, 92% of the surveyed dentist identified chemical and thermal stimuli as the main triggering factors for DH . Amarasena et al.  observed that cold stimuli were the most frequently cited trigger of DH (67.5%). An earlier study reported the participants’ lack of knowledge because the doctors had identified bruxism and malocclusion as triggers of DH even though neither has been recognized as a major causative factor .
Most participants had a good performance when asked to identify multiple predisposing factors (tooth erosion, dentin exposure, gingival recession) of DH. Comparatively, young doctors performed better than the senior dental students on this specific item. The data are consistent with other studies that have reported abrasion and gingival recession as the most important predisposing factor for DH [1,19]. The dental professional should identify and remove predisposing factors as a first step approach when treating patients with DH . Less than half of the respondents knew the therapeutic strategies for DH. One-third of the dental students and four doctors obtained a null score on this question, which means an insufficient level of knowledge. This question did not appear in other questionnaire-based studies that we found in our scientific literature search.
The preventive measures were identified by two-thirds of the young doctors and more than one-third of the students, and half of all respondents performed well on this item. This is in agreement with the studies of Benoist et al.  (where 78% of the dentists recognized the preventive measures) and Nazir et al.  where the most common preventive strategy (74.1%) used by dental students and interns was the proper education on tooth-brushing technique.
As to identifying the correct treatment of DH, the data revealed that less than one-third of all participants obtained a good performance score, most of them having only satisfactory results. The mostly recognized treatment strategies were the correction of toothbrushing technique and the use of desensitizing toothpastes, which is consistent with other studies [2,3,9,19]. Less than ten percent of all respondents failed to answer this item correctly. This is in agreement with the result obtained by Cunha-Cruz et al. . Half of all participants had satisfactory knowledge about the remineralization strategies used in the treatment of DH, but one-third of them did not know the answer.
Almost all of the participants had knowledge of and could mention at least one brand of desensitizing toothpaste. That is in conformity with the findings of Benoist et al. , but as different from another study which has shown that fifty percent of the dentists reported incorrectly that the most popular desensitizing ingredients in desensitizing toothpastes are fluoride compounds .
Almost two-thirds of the participants in our study were able to recognize the etiology of different types of dental wear (as abrasion, abfraction, and erosion). Less than half of the young dentists and almost half of the dental students obtained a good result in identifying some of the main characteristics of DH.
The mean global score of the questionnaire proved that subjects had an overall average level of knowledge of dentin hypersensitivity. No participant obtained the maximum score or a score zero. The null-hypothesis was rejected. There were multiple results with statistically significant differences (p < 0.05) between the two groups. This demonstrates that young dentists have a higher level of knowledge of DH when comparing to the students. We believe that the differences between groups are explained by the higher practical experience that doctors accumulate in time, although dental students studied DH more recently. This demonstrates that theoretical knowledge needs to be completed by practice and vice-versa.
Given the high prevalence of DH and its complexity, the results of this study point to the stringent need to provide better theoretical, but also clinical teaching opportunities to students and good access to continued educational programs to young doctors. These will contribute to a better quality of care for patients having this pathology. To date, there is no evidence of such an observational study being undertaken in dentistry, but it is our belief that such a design would lead to interesting and significant insights for the field. The limitations of the study are the decreased overall response rate obtained and the restricted population of undergraduate students belonging to the same university. Further multicenter studies are required in order to allow for these results to be confidently generalized into a wider population of general dental practitioners and senior dental students.
The findings of this study indicate that dentists under five-years’ working experience have significantly better knowledge as compared to 6th-year dental students. Both groups of participants were far better informed regarding DH pain characterization, triggering factors, and predisposing factors of this condition, and less about its treatment.
Conflict of Interest
The authors declare no conflict of interest.
EB: conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article, final approval of the version to be submitted. SS: drafting the article, revising the article critically for important intellectual content.
AG: acquisition of data, analysis and interpretation of data.
IN: acquisition of data, analysis and interpretation of data.
GP: acquisition of data, analysis and interpretation of data.
SA: conception and design of the study, revising the article critically for important intellectual content, final approval of the version to be submitted.
The authors would like to thank all participants in the study who provided their fullest cooperation.
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