E2 HYGIENE TRIBUNE Hygiene Tribune Middle East & Africa Edition | 03/2022 Understanding the psychology of the dentine hypersensitvity patient By GSK Do patients and dentists think dentine hypersensitivity is a minor oral health issue or a chronic con- dition? Insight from wider socio- logical and psychological work suggests changing the perception of dentine hypersensitivity could help patients manage this com- mon oral complaint and also help strengthen the dentist-patient re- lationship. Is it time to think differently about dentine hypersensitivity? Dentine hypersensitivity (DH) is estimated to affect 1 in 3 people.1 Its ubiquity as a condition can mean that it is regarded, by both patients and dental practitioners, as a minor oral health concern. Yet, even among those with mild symp- toms, coping measures to manage DH can affect their daily activities. “We know that the impact of this condition can, for some peo- ple, result in really significant im- pacts on oral health related quality of life,” says Dr. Barry Gibson, pro- fessor of medical sociology, School of Clinical Dentistry at the Univer- sity of Sheffield. He added that how DH affects people can range from being very mild to becoming pre- dictable and forming part of an “illness career.” Does this provide dentists with an opportunity to reappraise DH? “Seeing it as a chronic condition means that the dentist can see that this may well have progression. This could be something that could be long term and that needs man- agement,” adds Professor Gibson. interaction Understanding this health and illness journey is vital and can have longer-term benefits for the dentist-patient that goes beyond the time they spend in the dentist’s chair. Recognising the impact a simple dental condi- tion can have on patients’ real lives outside the surgery can help change the interaction between them and their dentist, believes Dr. Koula Asimakopoulou, reader in health psychology at King’s Col- lege London: “It’s about building a relationship, using the easy, the simple and the mild - and fixing these - to actually engender trust and confidence in the relationship with the patient.” It’s not major – but it matters Research from Prof. Gibson’s team suggests that DH has over the years been “displaced, trivialised and transformed into a non-prob- lem problem”.2 Although this has been the necessary consequence of an essential public health focus on caries, he points out that now we are seeing conditions arising as a direct consequence of improved oral care, such as dentine hyper- sensitivity from over brushing. From the dentists’ perspective, DH is a commonly seen condition. In GSK research among dentists worldwide, 45% make a DH diagno- sis at least once daily.3 Patients who are less concerned about their DH are, unsurprisingly, less likely to seek dental advice: 42% versus 82% of those that are highly bothered.4 Yet, even among those patients who are less bothered about DH, nearly half will experience symp- toms at least once a month, while over a third suffer weekly.5 Although this DH experience is broadly similar to those that are highly bothered, these ‘mild’ suf- ferers tend not to categorise them- selves as being someone with sen- sitivity or having ‘a condition’, they simply experience sensitivity oc- casionally and have found ways to cope with it by making lifestyle ad- justments.6,7 But why should they? Prof. Gibson believes dentists could be missing an opportunity to en- gage with a significant sector of their patient population: “Many participants [in our research] indi- cated that they felt dentine hyper- sensitivity was actually part of their life”. It’s a chronic complaint but… This emphasises the fact that DH is a chronic complaint. “I can tell you from the classic sociologi- cal literature on this, dentine hy- persensitivity certainly fits the pic- ture as a chronic condition,” confirms Prof. Gibson. DH can alter the way patients act, restrict their eating habits, cause them to make adaptations to daily life and affect their social in- teractions, as well as having an emotional impact and affecting their personal identity.8 Prof. Gibson acknowledges that one of the issues is a lack of under- standing around DH progression. “But it can and for many people it definitely has done. And when it does, it has really significant im- pacts on everyday life.” …why don’t people complain? Put simply, people with DH have already learned to cope, even those that say they are less con- cerned have changed their lifestyle to manage the condition.9 “One of the fundamental indi- cators that you have a chronic con- dition is restrictions, limitations to the performance of daily tasks. Dentists and patients who don't take the condition very seriously, it's because they've adapted so quickly because pain forces you to adapt,” explains Prof. Gibson. Capturing the nuances of DH’s impact on quality of life has re- sulted in the development of the Dentine Hypersensitivity Experi- Figure: COM-B module of behaviour change (adapted from Michie, et al, 2011)13 ence Questionnaire (DHEQ), which is a validated, condition-specific measure used to evaluate respon- siveness to change in oral health-re- lated quality of life measures in DH patients.10,11 Research utilising the DHEQ has found that among patients with DH, these adaptive be- haviours fall into four catego- ries:10,12 • • • • Avoid: 77% avoid cold drinks or foods (90% say they have problems eating ice cream); 38% have avoided hot drinks/foods Adapt: 81% change the way they eat or drink cer- tain things, 79% say they make sure food doesn’t touch certain teeth, 56% make sure they bite their food into small pieces Compromise: 41% cool foods/drinks down before eating; 73% leave cold drinks to warm up before having them Tolerate: 67% are careful how they breathe on a cold day; 45% wear a scarf over their mouths on cold days. The condition also has an emo- tional impact. In research, 89% found DH annoying, while a simi- lar proportion found it irritat- ing.10,12 “Dentine hypersensitivity re- quires a range of adaptive be- haviours to avoid pain and sensi- tivity,” explains Prof. Gibson. I’m fine – I can live without a hot cup of tea It’s the fact that DH patients have already made these changes that makes them so interesting, be- lieves Dr Asimakopoulou. Gener- ally changing behaviour is the hard part, but she warns DH pa- tients could be settng up lon- ger-term issues. “We use the COM-B model of behaviour change to talk about ca- pability, opportunity and motiva- tion. These people will be ticking all three boxes for behaviour change. Only in this case, their ap- parent success in the short-term in solving the problem will probably mean they are less likely to want to engage with the dentist to deal with the problem in the long-term, unless the dentist brings it up and if the dentist offers a really easy solution.” Who raises the issue could be a factor. Recent GSK research among dentists worldwide found 53% be- lieved it was their role to raise DH with their patients.3 However, once raised the “easy solution” that Dr Asimakopoulou refers to could simply be met by recommending a dentine hyper- sensitivity toothpaste. Daily use of a sensitivity toothpaste can signifi- cantly improve the quality of life impact of DH after eight weeks, in particular the emotional impact, the restrictions around their eat- ing habits and how they change their habits.10-12 Let’s talk about the ‘S’ word For the dental practitioner, being more DH-aware can make a significant difference to their pa- tients. Dr Asimakopoulou believes DH offers dentists a chance to en- gage with the patient on a simple behaviour change model. “DH is a brilliant opportunity to do that. So, there is a problem, there is a solu- tion in the toothpaste you are sug- gesting to the patient and that will make the problem more manage- able. I think DH provides an oppor- tunity for dentists to be associated with success in behaviour change.” research suggests that time may be a factor for den- tists in raising issues, such as DH: 31% of dentists say they don’t spend enough time understanding pa- tients’ oral health behaviours and around one in four say they have not spent sufficient time offering advice on these behaviours.3 However, Failing to engage with DH, however, sends a clear message to the patient. “A dentist who is dis- missive about a mild condition es- sentially gives the patient the mes- sage that the condition is not im- portant, it’s not worth their time and attention and the patient shouldn’t be concerned with it. We know that, in that case, the condi- tion will go on in the background and it won’t just disappear over- night, and it will remain a niggle rather than a huge major health concern,” says Dr Asimakopoulou. Prof. Gibson agrees and raises the issue of progression, where DH becomes more bothersome for pa- tients: “What's going to happen when that patient later has pro- gression and the illness career re- ally takes hold? They're going to look back at that dentist, who didn't hold that conversation, very unfa- vourably.” Sensitivity means success Changing the way DH is per- ceived, from an inconsequential, mild condition, to a chronic com- plaint that can have a significant impact on patients’ quality of life, presents the dentist with an oppor- tunity to engage with the patient and be associated with an easy be- haviour change success. Not only can this help patients manage the problem better but can also enhance the dentist-patient relationship in both the immedi- ate and long-term. 1. 2. 3. References Addy M. Int Dent J, 2002; 52:367-375. Gibson BJ, Paul NR. Social The- ory Health, 2014;1-24. GSK Data on File. Survey of 172 den²sts in China, Germany, Turkey, India, UK and USA. June 2020. 4. GSK Data on File. U&A Study 5. France 2018. GSK Data on File. Omnibus re- search in US, Germany, China, Turkey and India. July 2019. 6. GSK Data on File. Be er under- standing the less bothered persona. US. 2020. Davari AR, et al. J Dent Shiraz Univ Med Sci, 2013; 14(3):136- 145. 7. 8. Gibson B, et al. The everyday impact of den²ne sensi²vity: personal and func²onal as- pects. In: Robinson PG, editors. Den²ne hypersensi²vity: De- veloping a person-centred approach to oral health. Lon- don: Elsevier Inc, 2015, Chap- ter 6. 9. GSK Data on File. RDSi Project Fit. July 2019. 10. Mason S, et al. BMC Oral He- alth, 2019;19:226. 11. Baker SR, et al. Clin Periodon- tol 2014; 41: 52–59. 12. GSK Data on File. Study 204930 (2017). 13. Michie S, et al. Implementa- tion Sci, 2011;6:42.