J Clin Periodontol 2013; 40: 53–64 doi: 10.1111/jcpe.
In-ofﬁce treatment for dentin hypersensitivity: a systematic review 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 Clin Periodontol 2013; 40: 53–64. doi: 10.1111/jcpe.12011.
Po-Yen Lin1,3, Ya-Wen Cheng1, Chia-Yi Chu1,3, Kuo-Liong Chien2, Chun-Pin Lin1 and Yu-Kang Tu2
Department of Dentistry, School of Dentistry, National Taiwan University and National Taiwan University Hospital, Taipei, Taiwan; 2 Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; 3 Department of Dentistry, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Abstract Aim: Dentin hypersensitivity, caused by the exposure and patency of dentinal tubules, can affect patients’ quality of life. The aim of this study was to undertake a systematic review and a network meta-analysis, comparing the effectiveness in resolving dentin hypersensitivity among different in-ofﬁce desensitizing treatments. Materials and Methods: A literature search was performed with electronic databases and by hand until December 2011. The included trials were divided into six treatment groups as placebo, physical occlusion, chemical occlusion, nerve desensitization, laser therapy and combined treatments. The treatment effects between groups were estimated with standardized mean differences by using a Bayesian network meta-analysis. Results: Forty studies were included. The standardized mean difference between placebo and physical occlusion was À2.57 [95% credible interval (CI): À4.24 to À0.94]; placebo versus chemical occlusion was À2.33 (95% CI: À3.65 to À1.04); placebo versus nerve desensitization was À1.72 (95% CI: À4.00 to 0.52); placebo versus laser therapy was À2.81 (95% CI: À4.41 to À1.24); placebo versus combined treatment was À3.47 (95% CI: À5.99 to À0.96). The comparisons of the ﬁve active treatments showed no signiﬁcant differences. Conclusions: The results from network meta-analysis showed that most active treatment options had signiﬁcantly better treatment outcome than placebo.
Key words: dentin hypersensitivity; in-ofﬁce treatment; network meta-analysis; randomized controlled trials; systematic review Accepted for publication 21 August 2012
Dentin hypersensitivity (DH) is deﬁned as “short, sharp pain arising from exposed dentin in response to
Conﬂict of interest and source of funding statement No external funding, apart from the support of the authors’ institution, was available for this study. The authors declare that there are no conﬂicts of interest in this study.
© 2012 John Wiley & Sons A/S
stimuli typically thermal, evaporative, tactile, osmotic or chemical and which cannot be ascribed to any other form of dental defect or pathology” (Holland et al. 1997). Clinical surveys showed the prevalence of DH ranged from 2.8% to 74%, depending on the population studied, study setting and study design (Orchardson & Collins 1987, Liu et al. 1998, Taani & Awartani 2002, Rees et al. 2003, Rees & Addy
2004, Shen et al. 2009, Que et al. 2010). It mostly affects individuals at their fourth and ﬁfth decade of life (Liu et al. 1998, Rees et al. 2003, Que et al. 2010), causing patient discomforts during eating or even breathing. The mechanism of dentin hypersensitivity had not been fully elucidated. The most accepted hypothesis is the hydrodynamic theory proposed by Brannstrom (1963). According to this theory, most pain-
Lin et al.
large, pair-wise comparisons may be inefﬁcient or not feasible (Tu et al. 2010, 2012, Hoaglin et al. 2011, Jansen et al. 2011). Network metaanalysis is a methodology for the statistical synthesis of direct and indirect comparisons of different treatments and had been used in dental research (Tu et al. 2010, 2012). The aim of this study was therefore to undertake a systematic review and a network meta-analysis, comparing the effectiveness in resolving dentin hypersensitivity among different in-ofﬁce desensitizing treatments.
Material and Methods
inducing stimuli increase centrifugal ﬂuid ﬂow within the dentinal tubules, giving rise to a pressure change throughout the entire dentin. Based on this mechanism, two phases must coincide to produce DH, the exposure of dentin and the opening of the dentinal tubular system. Therefore, the ideal treatment of DH should be able to reduce ﬂuid ﬂow in dentinal tubules or block pulpal nerve response or both (Holland et al. 1997, Canadian Advisory Board on Dentin Hypersensitivity 2003). A large number of desensitizing methods such as dentifrices containing potassium salts and in-ofﬁce topical desensitizing agents have been offered to the market to solve the problem. It has been suggested that the treatment of DH is to begin with an at-home method, such as a desensitizing dentifrice (Sowinski et al. 2001, Poulsen et al. 2006, Orsini et al. 2010); this alone may alleviate the condition. If at-home methods do not satisfactorily resolve the problem, an in-ofﬁce treatment may be indicated. When DH is localized to one or two teeth, an in-ofﬁce method may be the ﬁrst choice of treatment (Orchardson & Gillam 2006). There is a wide range of in-ofﬁce treatments for DH, including dentin adhesives (Ide et al. 1998, Schwarz et al. 2002, Kakaboura et al. 2005, Tengrungsun & Sangkla 2008), resin emulsions (Prati et al. 2001, Erdemir et al. 2010), copal varnishes (Olusile et al. 2008), glutaraldehyde-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, Ritter et al. 2006, Fiocchi et al. 2007), potassium nitrates (Frechoso et al. 2003, Sicilia et al. 2009) and laser therapies (Gerschman et al. 1994, Lier et al. 2002, Schwarz et al. 2002, Tengrungsun & Sangkla 2008), so it can be a challenge for selecting the most appropriate treatment for patients, and the relative effectiveness of those treatments remains uncertain. Traditional meta-analysis undertakes pair-wise comparisons between treatments, but when the number of available treatments is
because it involves a wider area of dentin, and it was used most often than tactile test or cold stimuli test in clinical trials on DH. Moreover, air test was usually recorded by response-based methods, which can be used to calculate mean differences for our meta-analysis. Trials using tactile test or cold stimuli test only would therefore be excluded in this review.
Treatment group classiﬁcation
The literature search within MEDLINE (via PubMed), ScienceDirect, ISI web of science, Ovid and Cochrane Central Register of Controlled Trials (CENTRAL) databases up to December 2011 was undertaken. To identify relevant studies, we used the following term “(dentin* OR tooth OR teeth) AND (hypersensit* OR desensiti* OR desensitize*) NOT (toothpaste OR dentifrice)”, limited to “clinical trials” and “humans”; no language restrictions were imposed. The reference lists of previously published reviews (Canadian Advisory Board on Dentin Hypersensitivity 2003, 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 literature search and data extractions (Fig. 1) were undertaken in duplicate, and quality assessment of included studies, such as randomization, allocation concealment, blinding, intention to treat and sample size calculation, was carried out independently by three authors (PY Lin, YW Cheng, CY Chu). Disagreements on study inclusions and quality assessment were resolved by discussions among the three authors. Tactile, cold and evaporative air stimuli were commonly used in outcome assessment for DH. In this systematic review, we chose articles which used evaporative air test for further meta-analysis to minimize the heterogeneity of methods used to assess DH. Air test is a more accurate method for evaluating DH
Treatments used by the included trials were divided into six groups according to the underlying mechanisms proposed by a recent review (Porto et al. 2009): group I: placebo; group II: physical occlusion of dentinal tubules; group III: chemical occlusion of dentinal tubules; group IV: nerve desensitization; group V: photobiomodulating action (Laser therapy); and group VI: combined treatment (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 visual analogue scales (VAS) or verbal rating scales (VRS) for pain assessment of DH (Holland et al. 1997). The number of participants, means and standard deviations of treatment effects were extracted from the reports or using a pooled estimation formula which assumed a correlation coefﬁcient of baseline and outcome measurement equal to 0.5 (Tu et al. 2005). When multiple teeth were treated within one patient, the standard error of means for treatment effects were derived from the standard deviation by using the number of patients as the unit of analysis. If the number of patients in each group was not available, we contacted the corresponding authors by email for requesting more detailed information, or assumed that the numbers of participants were equal for all treatment groups. Both VAS and VRS were used for evaluating treatment effects of DH products in clinical trials, but the scales of them differed. VAS consists of a straight line that is 10 cm in length, the ends of which are deﬁned with the words: “no
© 2012 John Wiley & Sons A/S
DH network meta-analysis
Fig. 1. Flowchart for literature search and identiﬁcations of articles for review.
Table 1. Grouping of the included articles for network meta-analysis Group Group I Placebo No treatment Water Not speciﬁed placebo Desensitizing toothpaste Group II Physical occlusion of dentinal tubules Pumice paste Sodium bicarbonate Hydroxyapatites Bioglasses Glass ionomers Dentin bonding agents Resins Group III Chemical occlusion of dentinal tubules Fluorides Oxalates Glutaraldehyde-based agents Calcium compounds Group IV Nerve desensitization Potassium nitrates Guanethidine Group V Photobiomodulating action Laser therapy Group VI Combined treatment Any combination of Groups II–V
pain” and “severe pain” (Scott & Huskisson 1976). The scale of VAS is usually 0–10 or 0–100. VRS uses word descriptors as a scaling technique to describe variations of pain. The scale is usually 0–3 as follows: 0, no discomfort; 1, discomfort or mild pain; 2, severe pain during stimulation; 3, severe pain which persisted for some time after stimulation (Holland et al. 1997). If the study had more than one follow-up period, we would use the ﬁnal assessment for data extraction. To combine data from different scales, it has been suggested that dividing the mean difference in each study by that study’s standard deviation to create a standardized mean difference which would be comparable across studies (Glass 1976). The standardized mean difference can be viewed as the mean difference that
© 2012 John Wiley & Sons A/S
would have been obtained if all data were transformed into a scale where the standard deviation within-group was equal to 1.0. Twelve articles were excluded (Kielbassa et al. 1997, Prati et al. 2001, Marsilio et al. 2003, Singal et al. 2005, Merika et al. 2006, Ritter et al. 2006, Fiocchi et al. 2007, Azarpazhooh et al. 2009, Dilsiz et al. 2009, Banerjee et al. 2010, Jalali & Lindh 2010, Sethna et al. 2011) because they tested the treatments classiﬁed as the same group. For example, Dilsiz et al. (2009) compared two types of lasers, the Nd:YAG laser and the 685-nm diode laser, for treating DH. Network meta-analysis, for multiple treatments comparisons by incorporating direct and indirect evidence, was undertaken using the Bayesian hierarchical random-effects modelling. Because the included studies
reported treatment outcomes with different lengths of follow-ups, the length of follow-up was stratiﬁed into two categories using 1 month as the cut-off value. The study design was divided into parallel group and split-mouth design to account for the heterogeneity in treatment effects. The authors assumed a within-patient correlation coefﬁcient equal to 0.25 for splitmouth trials. Standard pair-wise meta-analyses of direct comparisons among each group were carried out and compared to results from the network meta-analysis. Meta-regressions with covariates such as study design, length of follow-ups, multiple treatment courses and interaction terms among them were also conducted to explore if they could explain the heterogeneity. In addition, the number of times the same desensitizing treatment
Table 2. Summary of studies included in the network meta-analysis Treatment agent VRS (0–3) Parallel Parallel Split mouth Parallel Parallel Split mouth Split mouth Split mouth 6 months Immediate 8 weeks 1 week 84 days 3 months Immediate 1 1 1 4 1 3 1 14 days 1 VRS (0–4) VRS (0–3) VAS (0–10) VAS (0.100) VAS (0.100) VAS (0–10) VAS (0–100) Subject number Treatment effect SD Pain score type Study design Follow-up period Treatment courses OHI No N/A N/A N/A Yes No N/A N/A
Lin et al.
Study, year, country
Tarbet et al. (1979), NY
McBride et al. (1991), UK
I III I III
20 20 48 47
patients patients patients patients
À0.11 À0.01 À0.31 À2.11 1.08 1.43 0.83 0.61
Dondi dall’Orologio & Malferrari (1993), Italy
Dunne & Hannington-Kiff (1993), UK Gerschman et al. (1994), Denmark Ide et al. (1998), UK
Yates et al. (1998), UK 16 teeth 16 teeth À32.00 À33.40 19.30 21.90 VAS (0–10) VRS (1–4) VRS (0–3) VRS (0–3) VRS (0–3)
I III III I IV I V I II I III
34 40 42 20 19 28 21 16 16 36 36
teeth teeth teeth patients patients patients patients patients patients patients patients
À2.16 À2.26 À0.29 À1.20 À3.80 À0.80 À3.90 À8.10 À25.30 À3.88 À3.91 0.60 0.53 0.42 2.10 2.60 1.65 1.85 27.91 27.89 1.99 1.73
Morris et al. (1999), USA
Lier et al. (2002), Norway
Split mouth Split mouth Split mouth Parallel Split mouth
16 weeks 6 months 30 days 14 days 3 months
1 1 5 1 1
No Yes N/A Yes N/A
Schwarz et al. (2002), Germany
Corona et al. (2003), Brazil
Frechoso et al. (2003), Spain
Zhang (2003), China
III I V I II V III V I IV IV II II II II II II III 12 patients 10 patients À0.92 À0.67 0.83 0.82
18 teeth 17 patients 17 patients 30 patients 30 patients 30 patients 12 patients 12 patients 15 patients 15 patients 15 patients 10 patients 11 patients 11 patients 9 patients 8 patients 12 patients 10 patients
À36.20 À2.99 À2.72 0.20 À0.30 À1.90 À1.17 À1.37 À1.46 À1.40 À1.66 À1.67 À1.00 À1.75 À1.08 À1.25 À0.58 À1.00 28.80 2.33 2.15 0.36 0.40 0.44 0.80 0.70 0.74 0.98 1.11 0.74 0.80 0.74 0.83 0.74 0.83 0.96
© 2012 John Wiley & Sons A/S
No treatment NaF Deionized water Iontophoresis with 2% NaF No treatment Gluma three Primer Gluma 2000 Conditioner Distil water Guanethidine No treatment GaAlAs laser No treatment Dentin bonding agent Water Amorphous calcium phosphate Distil water Oxalate-containing resin solution 0.7% ﬂuoride solution Placebo Nd:YAG laser No treatment Resin adhesives Er:YAG laser Fluoride varnish GaAlAs laser Placebo 5% NK 10% NK Dentin bonding (occlusal) Enamel bonding (occlusal) Dentin bonding (cervical) Enamel bonding (cervical) Dentin bonding (root) Enamel bonding (root) 75% of NaF glycerine paste (occlusal) 75% of NaF glycerine paste (cervical) 75% of NaF glycerine paste (root)
Table 2. (Continued) Treatment agent SD 2.61 2.05 2.21 VAS (0–10) Split mouth 3 months 1 Pain score type Study design Follow-up period Treatment courses 44 teeth 59 teeth 76 teeth À1.71 À1.97 À3.12 Subject number Treatment effect OHI N/A
Study, year, country
Duran & Sengun (2004), Turkey
II III VI
© 2012 John Wiley & Sons A/S VAS (0–10) Parallel Split mouth Split mouth 4 weeks 9 months 6 weeks VAS (0–10) VRS (0–3) 6 1 1 Yes N/A Yes 42 56 16 16 13 13 40 40 40 16 teeth 28 teeth 30 teeth 32 teeth VAS (0–100) VRS (0–3) VRS (0–3) VRS (0–3) VRS (1–4) À4.20 0.27 Split mouth Split mouth Split mouth Parallel Parallel 1 week 3 months 30 days Immediate 6 months 1 1 1 1 1 N/A N/A N/A N/A Yes 26.50 24.90 0.91 1.26 0.46 0.76 0.51 0.51 À27.40 À26.90 À2.78 À1.36 À1.85 À0.71 À0.35 À1.19 À3.10 À3.30 0.30 0.30 À0.50 0.36 VAS (0–10) Split mouth 8 weeks teeth teeth patients patients patients patients teeth teeth teeth À1.38 À1.29 À4.42 À3.91 À0.72 À0.30 À0.24 À0.63 À0.99 4.96 1.37 2.68 2.69 0.75 0.72 0.14 0.15 0.14 I 1 No 72 72 14 14 70 70 23 22 patients patients patients patients patients patients patients patients VAS (0–10) VAS (0–100) Parallel Parallel 4 weeks 7 days 1 1 Yes Yes 10 10 10 10 10 10 10 13 13 patients patients patients patients patients patients patients patients patients À0.75 À1.94 À1.87 À1.99 À1.98 À5.05 À4.62 À1.62 À48.10 0.59 0.47 0.64 0.55 0.50 0.90 0.92 8.40 6.14 13 13 36 32 patients patients patients patients 15 patients 15 patients 15 patients À51.50 À57.40 À2.70 À2.73 À0.67 À0.73 À1.53 8.85 6.07 0.34 0.34 0.82 1.10 0.74 VRS (0–3) VRS (0–3) Parallel Parallel 12 weeks 60 days 1 1 Yes Yes Dentin bonding agent HEMA + NaF Dentin bonding agent + Fluoride Liner Glutaraldehyde-based agent Sodium & calcium ﬂuoride Curing light GaAlas laser Placebo Ferric oxalate Water Dentin bonding agent Glutaraldehyde-based agent Desensitizer-free bio-adhesive gel Prompt L-pop 2% NaF bio-adhesive gel 5% Potassium nitrate bio-adhesive gel Placebo Potassium ﬂuoride varnish Glass ionomer Glutaraldehyde-based agent Dentin bonding agent GaAlAs laser Pumice paste 8% arginine and calcium carbonate 2% NaF 2% NaF + CO2 laser 2% NaF + Er:YAG laser CO2 laser Er:YAG laser Fluoride varnish Nd:YAG laser Water Glutaraldehyde-based agent Fluoride varnish NK gel Pumice paste 8% arginine and calcium carbonate Placebo 10% NK Diode laser
Gentile & Greghi (2004), Brazil Gillam et al. (2004), UK
Kakaboura et al. (2005), Greece
III III I V I III I II III
Pamir et al. (2005), Turkey
Zantner et al. (2006), Germany Polderman & Frencken (2007), the Netherlands Tengrungsun & Sangkla (2008), Thailand Hamlin et al. (2009), USA
I III II III II V II III
Ipci et al. (2009), Turkey
Kara & Orbak (2009), Turkey Ozen et al. (2009), Turkey
III VI VI V V III V I III
Schiff et al. (2009), USA
III IV II III
DH network meta-analysis
Sicilia et al. (2009), Spain
I IV V
Table 2. (Continued) Treatment agent SD VAS (0–10) Parallel Split mouth Parallel 60 days 60 days 1 3 3 months 4 VAS (0–10) VAS (0–10) N/A Yes N/A Pain score type Study design Follow-up period Treatment courses Subject number Treatment effect OHI
Study, year, country
Lin et al.
Vieira et al. (2009), Brazil
Dilsiz et al. (2010b), Turkey
I III V I V
8 patients 8 patients 8 patients 26 teeth 26 teeth
À3.84 À3.88 À4.09 À3.89 À6.00 2.72 2.78 2.59 1.01 0.68
Dilsiz et al. (2010a), Turkey
Eitner et al. (2010), Germany VAS (0–10) Split mouth
VAS (0–10) Parallel
1 month 4 weeks
Erdemir et al. (2010), Turkey 44 patient 45 patients 45 patients 45 patients 45 patients À24.12 0.54 VAS (0–10) Parallel À23.79 À24.12 À23.12 0.51 0.68 0.57 VAS (0–10) + VRS(0–3) À4.34 2.65
I V V V I III III II VI
24 24 24 24 21 20 21 44 43
teeth teeth teeth teeth patients patients patients patients patients
À0.25 À5.37 À7.25 À4.04 À1.60 À2.86 À2.27 À2.16 À3.37 1.12 1.51 0.97 0.91 1.31 1.90 1.79 2.31 2.77
Shetty et al. (2010), India
I I II
Aranha & De Paula Eduardo (2012), Brazil
Assis et al. (2011), Brazil
I V V V I III III
7 patients 7 patients 7 patients 7 patients 13 patients 13 patients 13 patients
À2.46 À3.16 À2.26 À1.67 À0.70 À0.80 À0.70 2.36 2.30 0.85 1.27 1.00 1.00 1.00
VAS (0–100) VAS (0–100) VAS (0–100)
Parallel Parallel Parallel
7 days 7 days 7 days
1 1 6 (laser)
N/A N/A Yes
Castillo et al. (2011), Lima, Peru Castillo et al. (2011), Cusco, Peru Orhan et al. (2011), Turkey
Yilmaz et al. (2011a), Turkey
VAS (0–10) VAS (0–10) VAS (0–10)
Split mouth Split mouth Split mouth
3 months 3 months 6 months 1
Yes Yes Yes
Yilmaz et al. (2011c), Turkey
© 2012 John Wiley & Sons A/S
Yilmaz et al. (2011b), Turkey
I III I III I I III V I V I V V I I III V
Placebo 3% potassium oxalate GaAlAs laser Desensitizing toothpaste Desensitizing toothpaste + diode laser No treatment Er:YAG laser Nd:YAG laser Diode laser No treatment Gluma Fluoride Resin emulsion Oxalic acid + dentin bonding agent Fluoride containing adhesives Water No treatment Duraphat + Hydroxyapatite-dry powder Duraphat + Hydroxyapatite precipitate No treatment Er:YAG laser 0.25W Er,Cr:YSGG laser 0.5W Er,Cr: YSGG laser Placebo 3% potassium oxalate Calcium and ﬂuoride compounds Water Diammine silver ﬂuoride Water Diammine silver ﬂuoride No treatment Water Glutaraldehyde-based agent GaAlAs laser No treatment Er,Cr:YSGG laser No treatment Er,Cr:YSGG laser GaAlAs laser Saline (NaF control) No treatment (Laser control) NaF GaAlAs laser 34 patients 37 patients 29 patients 26 patients 4 patients 4 patients 4 patients 4 patients 42 patients 42 patients 51 patients 51 patients 51 patients 48 patients 48 patients 48 patients 48 patients 0.40 À35.80 À5.50 À23.40 À2.25 À0.00 À55.30 À59.00 À0.79 À5.67 À0.50 À6.20 À6.00 À0.06 À0.17 À3.35 À5.16 16.20 27.70 18.10 21.00 11.99 4.02 8.89 11.68 1.84 1.58 1.40 1.28 1.21 1.13 1.40 1.77 1.45
SD, standard deviation; OHI, oral hygiene instruction; VRS, verbal rating scales; VAS, visual analogue scales; N/A, not available.
DH network meta-analysis
being given to each patient in the study and any oral hygiene instruction given to patients after treatments were also recorded. If the patients were instructed to maintain the same habits during the trial, it was recorded as no oral hygiene instruction being given. The oral hygiene instruction included toothbrush types, brushing methods and frequency, and eating habits. The Bayesian random-effects network meta-analysis was performed using the statistical software WinBUGS (version 14.3, MRC Biostatistics Unit, Cambridge, UK) with 50,000 simulations. Non-informative priors were used throughout the analysis. The standard pair-wise random-effects meta-analysis, heterogeneity between studies and metaregressions were performed using statistical software STATA (version 11.2, StataCorp LP, College Station, TX, USA). The statistical signiﬁcance level was set at 5%.
Yilmaz et al. 2011b). Seven studies (Dondi dall’Orologio & Malferrari 1993, Morris et al. 1999, Duran & Sengun 2004, Kakaboura et al. 2005, Pamir et al. 2005, Dilsiz et al. 2010a, b) reported their treatment effects by the number of teeth as the unit, so we estimated the numbers of participants were equal in each group of these trials. Adverse events were not observed during these studies.
Quality of studies
Figure 1 summarized the details of the study selection process and the reasons for exclusion. A total of 290 potential relevant titles, abstracts and articles were found electronically, plus reference lists of reviews and related articles, of which 194 were screened for further evaluation by retrieving full texts. Finally, we identiﬁed 40 trials that met all inclusion criteria. The characteristics of these included trials were listed in Table 2.
Appendix S1 shows the quality of the included trials. Thirty-seven studies described as randomized; of them, 21 studies clearly described the allocation process. Triple blinding (patient, caregiver and examiner blinding) was performed in ﬁve of the 44 trials (Frechoso et al. 2003, Zantner et al. 2006, Sicilia et al. 2009, Castillo et al. 2011, Orhan et al. 2011). The masking system used was clearly described in nine trials (Dunne & Hannington-Kiff 1993, Ide et al. 1998, Ozen et al. 2009, Sicilia et al. 2009, Castillo et al. 2011, Orhan et al. 2011, Yilmaz et al. 2011a, b, c), and the remaining were unclear about it. Seven of the included trials reported sample size and statistical power calculations (Morris et al. 1999, Zantner et al. 2006, Sicilia et al. 2009, Castillo et al. 2011, Yilmaz et al. 2011a, b, c).
The overall results from network meta-analysis showed that most active treatment options including physical occlusion group, chemical occlusion group, laser therapy group and combined treatment group had signiﬁcantly better treatment outcome than placebo group except nerve desensitization group (Appendix S2). The standardized mean difference between placebo group versus physical occlusion group was À2.57 [95% credible interval (CI): À4.24, À0.94]; placebo group versus chemical occlusion group was À2.33 (95% CI: À3.65, À1.04); placebo group versus nerve desensitization group was À1.72 (95% CI: À4.00, 0.52); placebo group versus laser therapy group was À2.81 (95% CI: À4.41, À1.24); placebo group versus combined treatment group was À3.47 (95% CI: À5.99, À0.96). However, comparisons of the ﬁve active treatment groups showed no signiﬁcant differences. The combined treatment group had better outcomes than the other groups (À0.90 compared with physical occlusion group, À1.14 compared with chemical occlusion group, À1.75 compared with nerve desensitization group, À0.65 compared with laser therapy group) although the differences were not signiﬁcant either. The study designs including split-mouth-designed trials versus parallel-designed trials, followup periods, and multiple treatment courses versus single treatment showed no signiﬁcant differences.
Pair-wise meta-analysis, heterogeneity and meta-regression
Forty studies were grouped into six different kinds of treatments in the network meta-analysis, yielding 15 possible pairs of comparisons (Fig. 2). Evidence of direct comparisons was only available in 9 of 15 pairs (Figs 2 and 3).
Results from standard pair-wise meta-analysis of overall studies showed that physical occlusion group, chemical occlusion group,
The 40 trials included in the ﬁnal meta-analysis were full reports published between 1979 and 2011, and 36 of them were published after 2000. Table 2 showed the summary of grouping and intervention. Of all 40 studies, 22 were split-mouth trials and the others were parallel trials. Follow-up periods were somewhat diverse in these studies, ranged from immediate (McBride et al. 1991, Dunne & Hannington-Kiff 1993, Hamlin et al. 2009) to 6–9 months (Dondi dall’Orologio & Malferrari 1993, Schwarz et al. 2002, Kakaboura et al. 2005, Ipci et al. 2009,
© 2012 John Wiley & Sons A/S
Figure 2. Network for the comparisons among different in-ofﬁce treatments for dentin hypersensitivity. Dotted lines refer to those comparisons that have not been tested directly in clinical trials. The width of the solid lines is in proportion to the amount of evidence available in the literatures.
Lin et al.
Fig. 3. Forest plot of the standard pair-wise meta-analysis for different in-ofﬁce treatments for dentin hypersensitivity.
© 2012 John Wiley & Sons A/S
DH network meta-analysis
laser therapy group and combined treatment group had signiﬁcantly better treatment outcomes than placebo group (Appendix S2 and Fig. 3), which was similar to the result of network meta-analysis. The comparisons of active treatment groups showed that laser therapy group had signiﬁcant better treatment outcome than physical occlusion group; however, only one study provided the data (Tengrungsun & Sangkla 2008). It also showed that combined treatment group had signiﬁcant better outcome than physical occlusion group and chemical occlusion group, with three trials providing the data (Duran & Sengun 2004, Ipci et al. 2009, Erdemir et al. 2010). The statistical heterogeneity of these comparisons was high (I-squared = 88.6% ~96.7%, Fig. 3) except the comparison between physical occlusion group and combined treatment group (I-squared = 0.0%, p = 0.71). Meta-regressions with covariates including the length of follow-ups, study design, multiple treatment courses and interaction terms among them were tested and none of the results was signiﬁcant (p > 0.05).
The current systematic review attempted to analyse all published clinical trials to assess evidence for different in-ofﬁce desensitizing agents of DH treatments. After review and critiques, 40 studies were included into the ﬁnal analysis (Fig. 1). With network meta-analysis, the result could provide clinical researchers some useful information. The results from network metaanalysis and standard pair-wise metaanalysis were in general consistent: physical occlusion group, chemical occlusion group, laser therapy group and combined treatment group had signiﬁcantly better treatment outcomes than placebo group (Appendix S2). Among the comparisons of active treatments, the pair-wise meta-analysis showed that laser therapy group achieved better treatment outcome than physical occlusion group while the network meta-analysis showed little differences. Although ﬁve studies directly compared placebo and physical occlusion group and 13 directly compared placebo and laser therapy group, only one study
© 2012 John Wiley & Sons A/S
directly compared physical occlusion and laser (Tengrungsun & Sangkla 2008) (Fig. 3). In Tengrungsun’s study, they directly compared the clinical efﬁcacy of the 30-mW GaAlAs laser for 1 min and dentin bonding agent in treating DH and concluded that the GaAlAs laser had less desensitizing efﬁcacy then the dentin bonding agent. The network meta-analysis incorporated both direct and indirect evidence within the whole network and also included all different types of lasers as one group. The inconsistency in results between direct and indirect evidence may be due to chance alone, as only one study provided direct evidence, but it may also indicate the treatment effects of different types of lasers are not the same. In this study, the network metaanalysis showed that regarding the treatment efﬁcacy of dentin hypersensitivity, in-ofﬁce products was more effective than the placebo, which indicated that the active in-ofﬁce agent could overcome the “placebo effect” and demonstrated their efﬁcacy. Although the current study did not show any preference for the ﬁve groups of active agents included, both network and standard meta-analyses indicated that these active treatments achieved better outcomes to relieve patients’ DH symptoms than the placebo group (Appendix S2 and Fig. 3), demonstrating that the treatments were more helpful than placebo effect or the Hawthorne effect. So far, there was not enough evidence to show that toothpastes containing potassium is effective in relieving symptoms of DH (Poulsen et al. 2006), but after considering patient’s costeffectiveness, Orchardson & Gillam (2006) and the Canadian Advisory Board on Dentin Hypersensitivity (Canadian Advisory Board on Dentin Hypersensitivity 2003) suggested the treatment protocol of DH is to begin with home-care method, such as a desensitizing dentifrice. If the symptom persists, an in-ofﬁce treatment is then indicated. This strategy was much more conservative and logical. Grossman suggested that the ideal desensitizing agent should not irritate or endanger the integrity of the pulp, should be relatively painless on application or shortly after-
wards, should be easily applied, rapid in action, permanently effective and ﬁnally should not discolour tooth structure (Grossman 1935). Unfortunately, no such treatment has been identiﬁed to date. However, in the current study, we found that none of the included trials reported any adverse effects or pulp damages during the study periods, so these in-ofﬁce treatment options are relatively safe and met the ﬁrst criteria of the ideal desensitizing agent, and some authors still regard laser therapies as relatively invasive considering their potential damage to pulp, though (Launay et al. 1987, Schwarz et al. 2008). Erosion is currently believed to be the major factor involved in tooth wear and subsequent dentinal tubules exposure (Dababneh et al. 1999). Therefore, reducing dietary acids intake and oral hygiene instruction to patients with DH should be included as part of standard management of dentin hypersensitivity (Canadian Advisory Board on Dentin Hypersensitivity 2003). Among the included trials in the present study, only three of them mentioned the instruction of avoiding excessive dietary acids or providing dietary counselling (Ipci et al. 2009, Shetty et al. 2010, Aranha & De Paula Eduardo 2012). If this predisposing factor was not removed or modiﬁed, the treatment may provide only shortterm success (Canadian Advisory Board on Dentin Hypersensitivity 2003), which may partly contribute to limited efﬁcacy of currently available desensitizing therapies. The objectives of the desensitizing therapy are to alleviate the symptoms of pain or discomfort and to improve the life quality of the patients with DH, while evaluating patients’ response to clinical stimuli may be viewed as a surrogate endpoint (Holland et al. 1997). In the current study, we reviewed 40 clinical trials using in-ofﬁce desensitizing agents, and these trials used controlled clinical stimuli, such as evaporative air, tactile and thermal, to evaluate the baseline and posttreatment response of the patients; only two evaluated how the efﬁcacy of treatment affects the patients’ everyday life (Frechoso et al. 2003, Sicilia et al. 2009), which should be
Lin et al.
Al-Sabbagh, M., Brown, A. & Thomas, M. V. (2009) In-ofﬁce treatment of dentinal hypersensitivity. Dental Clinics of North America 53, 47–60, viii. Aranha, A. C. & De Paula Eduardo, C. (2012) Effects of Er:YAG and Er,Cr:YSGG lasers on dentine hypersensitivity short-term clinical evaluation. Lasers in Medical Science 27, 813–818. Assis, J. S., Rodrigues, L. K., Fonteles, C. S., Colares, R. C., Souza, A. M. & Santiago, S. L. (2011) Dentin hypersensitivity after treatment with desensitizing agents: a randomized, double-blind, split-mouth clinical trial. Braz Dent J 22, 157–161. Azarpazhooh, A., Limeback, H., Lawrence, H. P. & Fillery, E. D. (2009) Evaluating the effect of an ozone delivery system on the reversal of dentin hypersensitivity: a randomized, doubleblinded clinical trial. Journal of Endodontics 35, 1–9. Banerjee, A., Hajatdoost-Sani, M., Farrell, S. & Thompson, I. (2010) A clinical evaluation and comparison of bioactive glass and sodium bicarbonate air-polishing powders. Journal of Dentistry 38, 475–479. Brannstrom, M. (1963) Dentin sensitivity and aspiration of odontoblasts. Journal of the American Dental Association 66, 366–370. Canadian Advisory Board on Dentin Hypersensitivity (2003) Consensus-based recommendations for the diagnosis and management of dentin hypersensitivity. Journal/Canadian Dental Association 69, 221–226. Castillo, J. L., Rivera, S., Aparicio, T., Lazo, R., Aw, T. C., Mancl, L. L. & Milgrom, P. (2011) The short-term effects of diammine silver ﬂuoride on tooth sensitivity: a randomized controlled trial. Journal of Dental Research 90, 203–208. Corona, S. A., Nascimento, T. N., Catirse, A. B., Lizarelli, R. F., Dinelli, W. & Palma-Dibb, R. G. (2003) Clinical evaluation of low-level laser therapy and ﬂuoride varnish for treating cervical dentinal hypersensitivity. Journal of Oral Rehabilitation 30, 1183–1189. Cunha-Cruz, J., Stout, J. R., Heaton, L. J. & Wataha, J. C. (2011) Dentin hypersensitivity and oxalates: a systematic review. Journal of Dental Research 90, 304–310. Dababneh, R. H., Khouri, A. T. & Addy, M. (1999) Dentine hypersensitivity – an enigma? A review of terminology, mechanisms, aetiology and management British Dental Journal 187, 606–611; discussion 603. Dilsiz, A., Aydin, T., Canakci, V. & Gungormus, M. (2010a) Clinical evaluation of Er:YAG, Nd:YAG, and diode laser therapy for desensitization of teeth with gingival recession. Photomedicine and Laser Surgery 28(Suppl. 2), S11–S17. Dilsiz, A., Aydin, T. & Emrem, G. (2010b) Effects of the combined desensitizing dentifrice and diode laser therapy in the treatment of desensitization of teeth with gingival recession. Photomedicine and Laser Surgery 28(Suppl. 2), S69–S74. Dilsiz, A., Canakci, V., Ozdemir, A. & Kaya, Y. (2009) Clinical evaluation of Nd:YAG and 685-nm diode laser therapy for desensitization of teeth with gingival recession. Photomedicine and Laser Surgery 27, 843–848. Dondi dall’Orologio, G. & Malferrari, S. (1993) Desensitizing effects of Gluma and Gluma 2000 on hypersensitive dentin. American Journal of Dentistry 6, 283–286. Dunne, S. M. & Hannington-Kiff, J. G. (1993) The use of topical guanethidine in the relief of dentine hypersensitivity: a controlled study. Pain 54, 165–168. Duran, I. & Sengun, A. (2004) The long-term effectiveness of ﬁve current desensitizing products on cervical dentine sensitivity. Journal of Oral Rehabilitation 31, 351–356. Eitner, S., Bittner, C., Wichmann, M., Nickenig, H. J. & Sokol, B. (2010) Comparison of conventional therapies for dentin hypersensitivity versus medical hypnosis. International Journal of Clinical and Experimental Hypnosis 58, 457– 475. Erdemir, U., Yildiz, E., Kilic, I., Yucel, T. & Ozel, S. (2010) The efﬁcacy of three desensitizing agents used to treat dentin hypersensitivity. Journal of the American Dental Association 141, 285–296. Fiocchi, M. F., Moretti, A. J., Powers, J. M. & Rives, T. (2007) Treatment of root sensitivity after periodontal therapy. American Journal of Dentistry 20, 217–220. Frechoso, S. C., Menendez, M., Guisasola, C., Arregui, I., Tejerina, J. M. & Sicilia, A. (2003) Evaluation of the efﬁcacy of two potassium nitrate bioadhesive gels (5% and 10%) in the treatment of dentine hypersensitivity. A randomised clinical trial. Journal of Clinical Periodontology 30, 315–320. Gentile, L. C. & Greghi, S. L. (2004) Clinical evaluation of dentin hypersensitivity treatment with the low intensity Gallium-AluminumArsenide laser – AsGaAl. Journal of Applied Oral Science 12, 267–272. Gerschman, J. A., Ruben, J. & Gebart-Eaglemont, J. (1994) Low level laser therapy for dentinal tooth hypersensitivity. Australian Dental Journal 39, 353–357. Gillam, D. G., Newman, H. N., Davies, E. H., Bulman, J. S., Troullos, E. S. & Curro, F. A. (2004) Clinical evaluation of ferric oxalate in relieving dentine hypersensitivity. Journal of Oral Rehabilitation 31, 245–250. Glass, G. V. (1976) Primary, secondary, and meta-analysis of research. Educational Researcher 5, 3–8. Grossman, L. I. (1935) A systematic method for the treatment of hypersensitive dentin. Journal of American Dental Association 22, 11. Hamlin, D., Williams, K. P., Delgado, E., Zhang, Y. P., Devizio, W. & Mateo, L. R. (2009) Clinical evaluation of the efﬁcacy of a desensitizing paste containing 8% arginine and calcium carbonate for the in-ofﬁce relief of dentin hypersensitivity associated with dental prophylaxis. American Journal of Dentistry 22(Spec No A), 16A–20A. He, S., Wang, Y., Li, X. & Hu, D. (2011) Effectiveness of laser therapy and topical desensitising agents in treating dentine hypersensitivity: a systematic review. Journal of Oral Rehabilitation 38, 348–358. Hoaglin, D. C., Hawkins, N., Jansen, J. P., Scott, D. A., Itzler, R., Cappelleri, J. C., Boersma, C., Thompson, D., Larholt, K. M., Diaz, M. & Barrett, A. (2011) Conducting indirect-treatment-comparison and network-meta-analysis studies: report of the ISPOR Task Force on Indirect Treatment Comparisons Good Research Practices: part 2. Value Health 14, 429–437. Holland, G. R., Narhi, M. N., Addy, M., Gangarosa, L. & Orchardson, R. (1997) Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. Journal of Clinical Periodontology 24, 808–813.
the most important clinical outcome but was often neglected. To minimize the differences between the trials, we used standardized mean difference and only included trials with evaporative air test. However, the result of pairwise meta-analysis still showed relatively high statistical heterogeneity, with I-squared = 88.6% ~ 96.7% (Fig. 3). We explored the heterogeneity by undertaking meta-regression with covariates such as length of follow-ups, study design and multiple treatment courses, but both network and standard metaregressions showed no signiﬁcant impact of these covariates. Finally, this systematic review has several limitations. Firstly, most trials did not report how randomization was undertaken and whether treatment allocations were unknown to caregivers, although treatment allocations sometimes become recognizable owing to materials and devices used. Secondly, due to insufﬁcient reporting of the results in the included studies, some assumptions such like the number of participants in each group were made in the data extraction procedure. Thirdly, the trials that did not use evaporative air test to evaluate DH or the treatments categorized within the same group were excluded, and this might lose some important information. Finally, although we divided the studies into six groups in the network meta-analysis, we did not conduct any test for further within treatment group comparisons.
In conclusion, the results from network meta-analysis showed that most active treatment options including physical occlusion, chemical occlusion, laser therapy and combined therapy had signiﬁcantly better treatment outcome than placebo. The comparisons of the ﬁve active treatment groups showed no signiﬁcant differences.
The authors thank Renee Tseng (Medical library of Taiwan Adventist Hospital) for her contribution to the literature search.
© 2012 John Wiley & Sons A/S
DH network meta-analysis
Ide, M., Morel, A. D., Wilson, R. F. & Ashley, F. P. (1998) The role of a dentine-bonding agent in reducing cervical dentine sensitivity. Journal of Clinical Periodontology 25, 286–290. Ipci, S. D., Cakar, G., Kuru, B. & Yilmaz, S. (2009) Clinical evaluation of lasers and sodium ﬂuoride gel in the treatment of dentine hypersensitivity. Photomedicine and Laser Surgery 27, 85–91. Ishihata, H., Kanehira, M., Finger, W. J., Shimauchi, H. & Komatsu, M. (2012) Effects of applying glutaraldehyde-containing desensitizer formulations on reducing dentin permeability. Journal of Dental Sciences 7, 105–110. Jalali, Y. & Lindh, L. (2010) A randomized prospective clinical evaluation of two desensitizing agents on cervical dentine sensitivity. A pilot study. Swedish Dental Journal 34, 79–86. Jansen, J. P., Fleurence, R., Devine, B., Itzler, R., Barrett, A., Hawkins, N., Lee, K., Boersma, C., Annemans, L. & Cappelleri, J. C. (2011) Interpreting indirect treatment comparisons and network meta-analysis for health-care decision making: report of the ISPOR Task Force on Indirect Treatment Comparisons Good Research Practices: part 1. Value Health 14, 417–428. Kakaboura, A., Rahiotis, C., Thomaidis, S. & Doukoudakis, S. (2005) Clinical effectiveness of two agents on the treatment of tooth cervical hypersensitivity. American Journal of Dentistry 18, 291–295. Kara, C. & Orbak, R. (2009) Comparative evaluation of Nd:YAG laser and ﬂuoride varnish for the treatment of dentinal hypersensitivity. Journal of Endodontics 35, 971–974. Kielbassa, A. M., Attin, T., Hellwig, E. & SchadeBrittinger, C. (1997) In vivo study on the effectiveness of a lacquer containing CaF2/NaF in treating dentine hypersensitivity. Clinical Oral Investigations 1, 95–99. Launay, Y., Mordon, S., Cornil, A., Brunetaud, J. M. & Moschetto, Y. (1987) Thermal effects of lasers on dental tissues. Lasers in Surgery and Medicine 7, 473–477. Lier, B. B., Rosing, C. K., Aass, A. M. & Gjermo, P. (2002) Treatment of dentin hypersensitivity by Nd:YAG laser. Journal of Clinical Periodontology 29, 501–506. Liu, H. C., Lan, W. H. & Hsieh, C. C. (1998) Prevalence and distribution of cervical dentin hypersensitivity in a population in Taipei, Taiwan. Journal of Endodontics 24, 45–47. Marsilio, A. L., Rodrigues, J. R. & Borges, A. B. (2003) Effect of the clinical application of the GaAlAs laser in the treatment of dentine hypersensitivity. Journal of Clinical Laser Medicine and Surgery 21, 291–296. McBride, M. A., Gilpatrick, R. O. & Fowler, W. L. (1991) The effectiveness of sodium ﬂuoride iontophoresis in patients with sensitive teeth. Quintessence International 22, 637–640. Merika, K., Heftitarthur, F. & Preshaw, P. M. (2006) Comparison of two topical treatments for dentine sensitivity. The European Journal of Prosthodontics and Restorative Dentistry 14, 38–41. Morris, M. F., Davis, R. D. & Richardson, B. W. (1999) Clinical efﬁcacy of two dentin desensitizing agents. American Journal of Dentistry 12, 72–76. Olusile, A. O., Bamise, C. T., Oginni, A. O. & Dosumu, O. O. (2008) Short-term clinical evaluation of four desensitizing agents. Journal of Contemporary Dental Practice 9, 22–29. Orchardson, R. & Collins, W. J. (1987) Clinical features of hypersensitive teeth. British Dental Journal 162, 253–256. Orchardson, R. & Gillam, D. G. (2006) Managing dentin hypersensitivity. Journal of the American Dental Association 137, 990–998; quiz 1028– 1029. Orhan, K., Aksoy, U., Can-Karabulut, D. C. & Kalender, A. (2011) Low-level laser therapy of dentin hypersensitivity: a short-term clinical trial. Lasers in Medical Science 26, 591–598. Orsini, G., Procaccini, M., Manzoli, L., Giuliodori, F., Lorenzini, A. & Putignano, A. (2010) A double-blind randomized-controlled trial comparing the desensitizing efﬁcacy of a new dentifrice containing carbonate/hydroxyapatite nanocrystals and a sodium ﬂuoride/potassium nitrate dentifrice. Journal of Clinical Periodontology 37, 510–517. Ozen, T., Orhan, K., Avsever, H., Tunca, Y. M., Ulker, A. E. & Akyol, M. (2009) Dentin hypersensitivity: a randomized clinical comparison of three different agents in a short-term treatment period. Operative Dentistry 34, 392–398. Pamir, T., Ozyazici, M., Baloglu, E. & Onal, B. (2005) The efﬁcacy of three desensitizing agents in treatment of dentine hypersensitivity. Journal of Clinical Pharmacy and Therapeutics 30, 73–76. Polderman, R. N. & Frencken, J. E. (2007) Comparison between effectiveness of a low-viscosity glass ionomer and a resin-based glutaraldehyde containing primer in treating dentine hypersensitivity–a 25.2-month evaluation. Journal of Dentistry 35, 144–149. Porto, I. C., Andrade, A. K. & Montes, M. A. (2009) Diagnosis and treatment of dentinal hypersensitivity. Journal of Oral Science 51, 323–332. Poulsen, S., Errboe, M., Lescay Mevil, Y. & Glenny, A. M. (2006) Potassium containing toothpastes for dentine hypersensitivity. Cochrane Database Systematic Review 3, CD001476. Prati, C., Cervellati, F., Sanasi, V. & Montebugnoli, L. (2001) Treatment of cervical dentin hypersensitivity with resin adhesives: 4-week evaluation. American Journal of Dentistry 14, 378–382. Que, K., Ruan, J., Fan, X., Liang, X. & Hu, D. (2010) A multi-centre and cross-sectional study of dentine hypersensitivity in China. Journal of Clinical Periodontology 37, 631–637. Rees, J. S. & Addy, M. (2004) A cross-sectional study of buccal cervical sensitivity in UK general dental practice and a summary review of prevalence studies. International Journal of Dental Hygiene 2, 64–69. Rees, J. S., Jin, L. J., Lam, S., Kudanowska, I. & Vowles, R. (2003) The prevalence of dentine hypersensitivity in a hospital clinic population in Hong Kong. Journal of Dentistry 31, 453– 461. Ritter, A. V., De, L. D. W., Miguez, P., Caplan, D. J. & Swift, E. J. Jr (2006) Treating cervical dentin hypersensitivity with ﬂuoride varnish: a randomized clinical study. Journal of the American Dental Association 137, 1013.1020; quiz 1029. Schiff, T., Delgado, E., Zhang, Y. P., Cummins, D., Devizio, W. & Mateo, L. R. (2009) Clinical evaluation of the efﬁcacy of an in-ofﬁce desensitizing paste containing 8% arginine and calcium carbonate in providing instant and lasting relief of dentin hypersensitivity. American Journal of Dentistry 22(Spec No A), 8A–15A. Schwarz, F., Aoki, A., Becker, J. & Sculean, A. (2008) Laser application in non-surgical periodontal therapy: a systematic review. Journal of Clinical Periodontology 35, 29–44.
Schwarz, F., Arweiler, N., Georg, T. & Reich, E. (2002) Desensitizing effects of an Er:YAG laser on hypersensitive dentine. Journal of Clinical Periodontology 29, 211–215. Scott, J. & Huskisson, E. C. (1976) Graphic representation of pain. Pain 2, 175–184. Sethna, G. D., Prabhuji, M. L. & Karthikeyan, B. V. (2011) Comparison of two different forms of varnishes in the treatment of dentine hypersensitivity: a subject-blind randomised clinical study. Oral Health & Preventive Dentistry 9, 143–150. Sgolastra, F., Petrucci, A., Gatto, R. & Monaco, A. (2011) Effectiveness of laser in dentinal hypersensitivity treatment: a systematic review. Journal of Endodontics 37, 297–303. Shen, S. Y., Tsai, C. H., Yang, L. C. & Chang, Y. C. (2009) Clinical efﬁcacy of toothpaste containing potassium citrate in treating dentin hypersensitivity. Journal of Dental Sciences 4, 173–177. Shetty, S., Kohad, R. & Yeltiwar, R. (2010) Hydroxyapatite as an in-ofﬁce agent for tooth hypersensitivity: a clinical and scanning electron microscopic study. Journal of Periodontology 81, 1781–1789. Sicilia, A., Cuesta-Frechoso, S., Suarez, A., Angulo, J., Pordomingo, A. & De Juan, P. (2009) Immediate efﬁcacy of diode laser application in the treatment of dentine hypersensitivity in periodontal maintenance patients: a randomized clinical trial. Journal of Clinical Periodontology 36, 650–660. Singal, P., Gupta, R. & Pandit, N. (2005) Two percent sodium ﬂuoride-iontophoresis compared to a commercially available desensitizing agent. Journal of Periodontology 76, 351–357. Sowinski, J., Ayad, F., Petrone, M., Devizio, W., Volpe, A., Ellwood, R. & Davies, R. (2001) Comparative investigations of the desensitising efﬁcacy of a new dentifrice. Journal of Clinical Periodontology 28, 1032–1036. Taani, S. D. & Awartani, F. (2002) Clinical evaluation of cervical dentin sensitivity (CDS) in patients attending general dental clinics (GDC) and periodontal specialty clinics (PSC). Journal of Clinical Periodontology 29, 118–122. Tarbet, W. J., Silverman, G., Stolman, J. M. & Fratarcangelo, P. A. (1979) An evaluation of two methods for the quantitation of dentinal hypersensitivity. Journal of the American Dental Association 98, 914–918. Tengrungsun, T. & Sangkla, W. (2008) Comparative study in desensitizing efﬁcacy using the GaAlAs laser and dentin bonding agent. Journal of Dentistry 36, 392–395. Tu, Y. K., Baelum, V. & Gilthorpe, M. S. (2005) The problem of analysing the relationship between change and initial value in oral health research. European Journal of Oral Sciences 113, 271–278. Tu, Y. K., Needleman, I., Chambrone, L., LU, H. K. & Faggion, C. M. Jr (2012) A bayesian network meta-analysis on comparisons of enamel matrix derivatives, guided tissue regeneration and their combination therapies. Journal of Clinical Periodontology 39, 303–14. Tu, Y. K., Woolston, A. & Faggion, C. M. Jr (2010) Do bone grafts or barrier membranes provide additional treatment effects for infrabony lesions treated with enamel matrix derivatives? A network meta-analysis of randomized-controlled trials. Journal of Clinical Periodontology 37, 59–79. Vieira, A. H., Passos, V. F., De Assis, J. S., Mendonca, J. S. & Santiago, S. L. (2009) Clinical evaluation of a 3% potassium oxalate gel and a GaAlAs laser for the treatment of dentinal
© 2012 John Wiley & Sons A/S
Lin et al.
Yilmaz, H. G., Kurtulmus-Yilmaz, S., Cengiz, E., Bayindir, H. & Aykac, Y. (2011c) Clinical evaluation of Er,Cr:YSGG and GaAlAs laser therapy for treating dentine hypersensitivity: A randomized controlled clinical trial. Journal of Dentistry 39, 249–254. Zantner, C., Popescu, O., Martus, P. & Kielbassa, A. M. (2006) Randomized clinical study on the efﬁcacy of a new lacquer for dentine hypersensitivity. Schweizer Monatsschrift fur Zahnmedizin 116, 1232–1237. Zhang, D. (2003) Clinical study on primer and sealer on different position to treat dentin hypersensitiveness. Acta Academiae Medicinae Wannan 22, 53–55.
hypersensitivity. Photomedicine and Laser Surgery 27, 807–812. West, N. X. (2008) Dentine hypersensitivity: preventive and therapeutic approaches to treatment. Periodontology 2000 48, 31–41. Yates, R., Owens, J., Jackson, R., Newcombe, R. G. & Addy, M. (1998) A split-mouth placebocontrolled study to determine the effect of amorphous calcium phosphate in the treatment of dentine hypersensitivity. Journal of Clinical Periodontology 25, 687–692. Yilmaz, H. G., Cengiz, E., Kurtulmus-Yilmaz, S. & Leblebicioglu, B. (2011a) Effectiveness of Er, Cr:YSGG laser on dentine hypersensitivity: a controlled clinical trial. Journal of Clinical Periodontology 38, 341–346. Yilmaz, H. G., Kurtulmus-Yilmaz, S. & Cengiz, E. (2011b) Long-term effect of diode laser irradiation compared to sodium ﬂuoride varnish in the treatment of dentine hypersensitivity in periodontal maintenance patients: a randomized controlled clinical study. Photomedicine and Laser Surgery 29, 721–725.
Appendix S1. Quality assessment of the included articles for network meta-analysis. Appendix S2. Results of network and standard meta-analysis.
Additional Supporting Information may be found in the online version of this article:
Address: Yu-Kang Tu Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University Room 539, 17 Xu-Zhou Road Taipei Taiwan E-mail: email@example.com
Scientiﬁc rationale for the study: A large number of in-ofﬁce desensitizing agents are available for treating dentin hypersensitivity (DH), and this study used the network metaanalysis to compare the relative
effectiveness among those agents in resolving DH. Principal ﬁndings: Most active agents achieved better treatment outcome than placebo group, but there was no substantial difference between active agents.
Practical implications: Although currently there is no gold-standard treatment for DH, commonly used in-ofﬁce desensitizing agents for DH seemed to be effective.
© 2012 John Wiley & Sons A/S