**3.4 History taking and clinical evaluation**

It is important to recognize that two broad categories of patients attend a dental clinic: (1) patients who are regular attenders and have an established relationship with the clinician, and (2) patients who have not been previously attending a dental practice but may have decided to attend due to a dental problem such as toothache, esthetic concerns, or other dental problems which have arisen. In the first category of patients, the clinician will be aware of their personal medical and treatment history and to some extent, the consultation period including the examination may be straightforward. For example, a patient who has recently received dental treatment such as restoration

#### **Figure 1.**

*Clinical features of a patient with gingival recession and dentine hypersensitivity (Acknowledgement N. Pandya [17]).*

#### *Management and Prevention Strategies for Treating Dentine Hypersensitivity DOI: http://dx.doi.org/10.5772/intechopen.101495*

of a tooth or had their teeth professionally cleaned may be experiencing discomfort from these procedures and such a problem can be swiftly identified and treated [16]. Patients who have not previously attended a dental practice, however, may require a more prolonged consultation to obtain the relevant medical, dental, and social history prior to the clinical examination and subsequent diagnosis of DH.

For patients with a more obscure orofacial problem, a persistent idiopathic facial pain (PIFP) may require a more extensive examination and it is advisable for the clinician to refer these patients to a Specialist Oral Medicine/Pain clinic [16].

Prior to a clinical examination, the clinician should obtain medical, dental, social, and dietary histories to supplement the information collected during the clinical examination and any subsequent tests such as radiographs. During the initial consultation, it is important to ask the patient why they have arranged the appointment. Toothache is one of the most common of oro-facial pains that prompts a patient to visit a dentist and where possible the clinician should determine the nature of the problem, the location of the pain (if the patient is able to pinpoint the exact location), duration, intensity, and any factors that may intensify or relieve the pain. For example, the clinician can ask if the patient is able to continue their daily activities such as eating, drinking, brushing their teeth without any discomfort. One suggestion would be to use visual analogue scale (VAS) scores (0-10), verbal descriptors, or Quality of Life Questionnaires (QoL) to determine the severity of the discomfort the patient is experiencing, and any impact DH/RS may have the patient's QoL [5]. The clinical examination will involve a thorough evaluation of the patient's oral status including a Basic Periodontal Examination (BSP) and a Basic Erosive Wear Assessment (BEWE) to determine the degree of tooth surface loss [10].

During the clinical examination, clinicians will use a dental explorer probe and air from a triple air syringe to screen any sensitive areas on the exposed cervical/root region. If the patient is prone to DH, then this mechanical or evaporative/thermal stimulus will elicit a response from the patient [1]. The response to these stimuli will be varied depending on the individual's pain threshold and subjective perception of pain. This pain should be transient in nature, in that once the stimulus has been removed, the pain will be resolved. If the pain, however, is continuous in nature, then this may indicate that the problem is related to other dental problems such as dental caries, which will require more extensive testing using an ice stick, ethyl chloride, pulp testers, and so on to evaluate the status of the dental pulp (pulp vitality testing). A simple test at this stage of the initial evaluation for DH is to (1) ask the patient to indicate their perception of the pain they are experiencing with DH following blowing cold air on the tooth (or teeth) in question using a VAS score, (2) apply a varnish to the affected site of the identified tooth (or teeth), and (3) retest the tooth (or teeth) in question using cold air from a dental air syringe and ask the patient to indicate their pain perception using a VAS score. If there is an improvement in the VAS scores, then this may indicate that the initial diagnosis of the patient's problem was DH (see management section).

#### **3.5 Diagnosis and differential diagnosis of Dentine hypersensitivity**

#### *3.5.1 Diagnostic evaluation including special investigations*

According to Gillam [7], there are a variety of methodological approaches used in the dental clinic to identify (diagnose) DH such as tactile, evaporative, and thermal

stimulation using cold air from a dental triple syringe as well as the patient's selfreporting (VAS, patient history, etc.). An example of the range of methodological approaches recommended or used by clinicians can be observed in **Figure 2** [18]. The use of these methodological approaches may, however, be difficult to justify [19].

A useful device to aid clinicians in determining both a provision and definitive is the use of mnemonics such as 'LOCATE' or 'SOCRATES'. This will help to ascertain the relevant information to identify the patient's problem by asking the following questions:


#### *Management and Prevention Strategies for Treating Dentine Hypersensitivity DOI: http://dx.doi.org/10.5772/intechopen.101495*

The clinician, however, should be aware that depending on the longevity and severity of the patient's pain, and particularly from severe toothache, they may have difficulties recalling some of these features due to being unable to cope with pain before attending the clinic [2].

#### *3.5.2 Diagnosis of dentine hypersensitivity*

The classic definition of DH was based on specific wording as 'pain derived from exposed dentine in response to chemical, thermal tactile or osmotic stimuli which cannot be explained as arising from any other dental defect or disease' [6]. In other words, DH is in essence a diagnosis of exclusion based on both the history of the problem and a clinical examination to exclude other forms of oro-facial pain and as such a thorough clinical examination together with a medical and dental history of the patient should enable the clinician to come to a correct diagnosis [1, 20].

There are, however, several problems facing the clinician when investigating oro-facial pain, for example, the time taken to identify the areas in the mouth causing the discomfort as well as the highly subjective nature of the pain response [20]. The clinician is, therefore, reliant not only on the patient's self-reporting of the history of DH but also on the information that they have accumulated through their own analysis of the problem (medical, dental, and social history together with a thorough clinical examination, which may require further evaluation). For example, patients who have recently received restorative, bleaching, and periodontal procedures within the last few weeks before attending the clinic may in fact be suffering from post-operative sensitivity and this should be relatively easy to identify and reassure the patient that the pain should resolve within 4-6 weeks and if not to return for further investigation. For new patients or those with a recent complaint of DH, the clinician will spend more time discussing the problem with the patient, trying to determine the history of the problem using some of the diagnostic tests indicated in **Figure 2**. The clinician should be aware that as DH is an exaggerated response of the normal pulp-dentine, the patient may only be aware of the problem once an external stimulus such as a cold stimulus (cold air from a dental triple syringe, suction from a high-volume suction, etc.). The evidence identified during this process may enable to provide a provisional diagnosis of DH.

#### *3.5.3 Differential diagnosis of dentine hypersensitivity*

According to the Canadian Advisory Board on Dentin Hypersensitivity [6], there is a major problem in the diagnosis of DH where ≤50% of the clinicians participating in the survey considered using a differential diagnosis to eliminate other dental conditions with similar pain characteristics to those of DH. Other studies have also reported on the apparent reluctance by clinicians to consider in this aspect of the management of DH [7].

One of the reasons for this reluctance in making a definitive diagnosis of DH may be the complexity and time required to eliminate the other dental conditions that have similar pain characteristics to DH such as reversible and irreversible pulpitis, dental abscess, cracked tooth syndrome, periodontal disease, pericoronitis, idiopathic oral facial pain, and post-operative sensitivity [18] (**Figure 2**). It is, therefore, important for the clinician to make a definitive diagnosis of DH before undertaking any treatment of the patient's problem. A useful summary of selected oro-facial conditions with their pain characteristics and presenting features is shown in **Table 1** [20].


