inducing stimuli increase centrifugalﬂuid ﬂow 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
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
) 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
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Lin et al.