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jcpe12011

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In-office treatment for dentinhypersensitivity: a systematicreview and network meta-analysis
Lin P-Y, Cheng Y-W, Chu C-Y, Chien K-L, Lin C-P, Tu Y-K. In-office treatment for dentin hypersensitivity: a systematic review and network meta-analysis. J ClinPeriodontol 2013; 40: 53–64. doi: 10.1111/jcpe.12011.
Abstract
Aim:
Dentin hypersensitivity, caused by the exposure and patency of dentinaltubules, can affect patients’ quality of life. The aim of this study was to undertakea systematic review and a network meta-analysis, comparing the effectivenessin resolving dentin hypersensitivity among different in-office desensitizingtreatments.
Materials and Methods:
A literature search was performed with electronic data-bases and by hand until December 2011. The included trials were divided into sixtreatment groups as placebo, physical occlusion, chemical occlusion, nerve desen-sitization, laser therapy and combined treatments. The treatment effects betweengroups were estimated with standardized mean differences by using a Bayesiannetwork meta-analysis.
Results:
Forty studies were included. The standardized mean difference betweenplacebo and physical occlusion was
À
2.57 [95% credible interval (CI):
À
4.24 to
À
0.94]; placebo
versus
chemical occlusion was
À
2.33 (95% CI:
À
3.65 to
À
1.04);placebo
versus
nerve desensitization was
À
1.72 (95% CI:
À
4.00 to 0.52); placebo
versus
laser therapy was
À
2.81 (95% CI:
À
4.41 to
À
1.24); placebo
versus
com-bined treatment was
À
3.47 (95% CI:
À
5.99 to
À
0.96). The comparisons of thefive active treatments showed no significant differences.
Conclusions:
The results from network meta-analysis showed that most activetreatment options had significantly better treatment outcome than placebo.
Po-Yen Lin
1,3
, Ya-Wen Cheng
1
,Chia-Yi Chu
1,3
, Kuo-Liong Chien
2
,Chun-Pin Lin
1
and Yu-Kang Tu
2
1
Department of Dentistry, School of Dentistry,National Taiwan University and NationalTaiwan University Hospital, Taipei, Taiwan;
2
Institute of Epidemiology and PreventiveMedicine, College of Public Health, NationalTaiwan University, Taipei, Taiwan;
3
Department of Dentistry, Shin Kong WuHo-Su Memorial Hospital, Taipei, TaiwanKey words: dentin hypersensitivity; in-officetreatment; network meta-analysis;randomized controlled trials; systematicreviewAccepted for publication 21 August 2012
Dentin hypersensitivity (DH) isdefined as “short, sharp pain arisingfrom exposed dentin in response tostimuli typically thermal, evapora-tive, tactile, osmotic or chemical andwhich cannot be ascribed to anyother form of dental defect orpathology” (Holland et al. 1997).Clinical surveys showed the preva-lence of DH ranged from 2.8% to74%, depending on the populationstudied, study setting and studydesign (Orchardson & Collins 1987,Liu et al. 1998, Taani & Awartani2002, Rees et al. 2003, Rees & Addy2004, Shen et al. 2009, Que et al.2010). It mostly affects individuals attheir fourth and fifth decade of life(Liu et al. 1998, Rees et al. 2003,Que et al. 2010), causing patient dis-comforts during eating or evenbreathing. The mechanism of dentinhypersensitivity had not been fullyelucidated. The most acceptedhypothesis is the hydrodynamic the-ory proposed by Brannstrom (1963).According to this theory, most pain-
Conflict of interest and source offunding statement
No external funding, apart from thesupport of the authors’ institution,was available for this study. Theauthors declare that there are noconflicts of interest in this study.
©
2012 John Wiley & Sons A/S
53
J Clin Periodontol 2013; 40: 53–64 doi: 10.1111/jcpe.12011
 
inducing stimuli increase centrifugaluid ow within the dentinaltubules, giving rise to a pressurechange throughout the entire dentin.Based on this mechanism, twophases must coincide to produceDH, the exposure of dentin and theopening of the dentinal tubular sys-tem. Therefore, the ideal treatmentof DH should be able to reduce fluidflow in dentinal tubules or block pul-pal nerve response or both (Hollandet al. 1997, Canadian AdvisoryBoard on Dentin Hypersensitivity2003).A large number of desensitizingmethods such as dentifrices contain-ing potassium salts and in-office top-ical desensitizing agents have beenoffered to the market to solve theproblem. It has been suggested thatthe treatment of DH is to begin withan at-home method, such as a desen-sitizing dentifrice (Sowinski et al.2001, Poulsen et al. 2006, Orsiniet al. 2010); this alone may alleviatethe condition. If at-home methodsdo not satisfactorily resolve theproblem, an in-office treatment maybe indicated. When DH is localizedto one or two teeth, an in-officemethod may be the first choice of treatment (Orchardson & Gillam2006). There is a wide range of in-office treatments for DH, includ-ing dentin adhesives (Ide et al. 1998,Schwarz et al. 2002, Kakabouraet al. 2005, Tengrungsun & Sangkla2008), resin emulsions (Prati et al.2001, Erdemir et al. 2010), copalvarnishes (Olusile et al. 2008), glu-taraldehyde-based adhesives (Duran& Sengun 2004, Kakaboura et al.2005, Polderman & Frencken 2007,Ishihata et al. 2012), oxalates(Gillam et al. 2004, Merika et al.2006, Assis et al. 2011), fluorides(Tarbet et al. 1979, McBride et al.1991, Merika et al. 2006, Ritteret al. 2006, Fiocchi et al. 2007),potassium nitrates (Frechoso et al.2003, Sicilia et al. 2009) and lasertherapies (Gerschman et al. 1994,Lier et al. 2002, Schwarz et al. 2002,Tengrungsun & Sangkla 2008), so itcan be a challenge for selecting themost appropriate treatment forpatients, and the relative effective-ness of those treatments remainsuncertain. Traditional meta-analysisundertakes pair-wise comparisonsbetween treatments, but when thenumber of available treatments islarge, pair-wise comparisons may beinefficient or not feasible (Tu et al.2010, 2012, Hoaglin et al. 2011,Jansen et al. 2011). Network meta-analysis is a methodology for thestatistical synthesis of direct andindirect comparisons of differenttreatments and had been used indental research (Tu et al. 2010,2012). The aim of this study wastherefore to undertake a systematicreview and a network meta-analysis,comparing the effectiveness inresolving dentin hypersensitivityamong different in-office desensitiz-ing treatments.
Material and Methods
Literature search
The literature search within MED-LINE (via PubMed), ScienceDirect,ISI web of science, Ovid and Coch-rane Central Register of ControlledTrials (CENTRAL) databases up toDecember 2011 was undertaken. Toidentify relevant studies, we used thefollowing term “(dentin
*
OR toothOR teeth) AND (hypersensit
*
ORdesensiti
*
OR desensitize
*
) NOT(toothpaste OR dentifrice)”, limitedto “clinical trials” and “humans”; nolanguage restrictions were imposed.The reference lists of previously pub-lished reviews (Canadian AdvisoryBoard on Dentin Hypersensitivity2003, Orchardson & Gillam 2006,West 2008, Al-Sabbagh et al. 2009,Porto et al. 2009, Cunha-Cruz et al.2011, He et al. 2011, Sgolastra et al.2011) were crosschecked. The litera-ture search and data extractions(Fig. 1) were undertaken in dupli-cate, and quality assessment of included studies, such as randomiza-tion, allocation concealment, blind-ing, intention to treat and samplesize calculation, was carried outindependently by three authors (PYLin, YW Cheng, CY Chu). Dis-agreements on study inclusions andquality assessment were resolved bydiscussions among the three authors.Tactile, cold and evaporative airstimuli were commonly used inoutcome assessment for DH. In thissystematic review, we chose articleswhich used evaporative air test forfurther meta-analysis to minimizethe heterogeneity of methods used toassess DH. Air test is a more accu-rate method for evaluating DHbecause it involves a wider area of dentin, and it was used most oftenthan tactile test or cold stimuli testin clinical trials on DH. Moreover,air test was usually recorded byresponse-based methods, which canbe used to calculate mean differencesfor our meta-analysis. Trials usingtactile test or cold stimuli test onlywould therefore be excluded in thisreview.
Treatment group classification
Treatments used by the included tri-als were divided into six groupsaccording to the underlying mecha-nisms proposed by a recent review(Porto et al. 2009): group I: placebo;group II: physical occlusion of den-tinal tubules; group III: chemicalocclusion of dentinal tubules; groupIV: nerve desensitization; group V:photobiomodulating action (Lasertherapy); and group VI: combinedtreatment (any combination of groups II
 – 
V) (Table 1).
Data extraction and statistical analysis
Three authors (PY Lin, YW Cheng,CY Chu) performed data extraction.Most of the literatures used visualanalogue scales (VAS) or verbal rat-ing scales (VRS) for pain assessmentof DH (Holland et al. 1997). Thenumber of participants, means andstandard deviations of treatmenteffects were extracted from thereports or using a pooled estimationformula which assumed a correlationcoefficient of baseline and outcomemeasurement equal to 0.5 (Tu et al.2005). When multiple teeth weretreated within one patient, the stan-dard error of means for treatmenteffects were derived from the stan-dard deviation by using the numberof patients as the unit of analysis. If the number of patients in each groupwas not available, we contacted thecorresponding authors by email forrequesting more detailed informa-tion, or assumed that the numbersof participants were equal for alltreatment groups.Both VAS and VRS were usedfor evaluating treatment effects of DH products in clinical trials, butthe scales of them differed. VASconsists of a straight line that is10 cm in length, the ends of whichare defined with the words: “no
©
2012 John Wiley & Sons A/S
54
Lin et al.
 
painand “severe pain(Scott &Huskisson 1976). The scale of VASis usually 0
 – 
10 or 0
 – 
100. VRS usesword descriptors as a scaling tech-nique to describe variations of pain.The scale is usually 0
 – 
3 as follows:0, no discomfort; 1, discomfort ormild pain; 2, severe pain duringstimulation; 3, severe pain whichpersisted for some time after stimula-tion (Holland et al. 1997). If thestudy had more than one follow-upperiod, we would use the final assess-ment for data extraction.To combine data from differentscales, it has been suggested thatdividing the mean difference in eachstudy by that study’s standard devia-tion to create a standardized meandifference which would be compara-ble across studies (Glass 1976). Thestandardized mean difference can beviewed as the mean difference thatwould have been obtained if all datawere transformed into a scale wherethe standard deviation within-groupwas equal to 1.0.Twelve articles were excluded(Kielbassa et al. 1997, Prati et al.2001, Marsilio et al. 2003, Singalet al. 2005, Merika et al. 2006, Ritteret al. 2006, Fiocchi et al. 2007, Azar-pazhooh et al. 2009, Dilsiz et al. 2009,Banerjee et al. 2010, Jalali & Lindh2010, Sethna et al. 2011) because theytested the treatments classified as thesame group. For example, Dilsiz et al.(2009) compared two types of lasers,the Nd:YAG laser and the 685-nmdiode laser, for treating DH.Network meta-analysis, for multi-ple treatments comparisons by incor-porating direct and indirect evidence,was undertaken using the Bayesianhierarchical random-effects model-ling. Because the included studiesreported treatment outcomes with dif-ferent lengthsoffollow-ups, thelengthof follow-up was stratified into twocategories using 1 month as the cut-off value. The study design was dividedinto parallel group and split-mouthdesign to account for the heterogene-ity in treatment effects. The authorsassumed a within-patient correlationcoefficient equal to 0.25 for split-mouth trials. Standard pair-wisemeta-analyses of direct comparisonsamong each group were carried outand compared to results from thenetwork meta-analysis. Meta-regres-sions with covariates such as studydesign, length of follow-ups, multipletreatment courses and interactionterms among them were also con-ducted to explore if they could explaintheheterogeneity.In addition, the number of timesthe same desensitizing treatment
Fig. 1.
Flowchart for literature search and identifications of articles for review.
Table 1.
Grouping of the included articles for network meta-analysisGroup Group IPlaceboGroup IIPhysical occlusion of dentinal tubulesGroup IIIChemical occlusion of dentinal tubulesGroup IVNervedesensitizationGroup VPhotobiomodulatingactionGroup VICombinedtreatmentTreatmentoptionNo treatmentWaterNot specifiedplaceboDesensitizingtoothpastePumice pasteSodium bicarbonateHydroxyapatitesBioglassesGlass ionomersDentin bonding agentsResinsFluoridesOxalatesGlutaraldehyde-basedagentsCalcium compoundsPotassium nitratesGuanethidineLaser therapy Any combinationof Groups II
 – 
V
©
2012 John Wiley & Sons A/S
DH network meta-analysis
55

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