Clinical Evaluation of the Use of Desensitizing Agents in the Management of Dentinal Hypersensitivity
Round 1
Reviewer 1 Report
Suggestions
Methodology and Study design
• The study is also of type longitudinal
Why are descriptive data of the study population and the type of agent chosen not reported?
• Why was the free choice type of desensitizing agent? Could this influence your final results? Why wasn't a study group made for each desensitizing agent?
• How the type of paste used by the study patients influenced the results?
• Can the time it takes the patient to present dental hypersensitivity and how it is triggered influence the results?
• Were patients with missing teeth and without rehabilitation included? Since this can alter your results derived from bone loss of the adjacent tooth.
• Why were individuals who were not residents of the territory excluded? Does this influence your results?
• Why were patients with dental erosion and/or bruxism not ruled out?
• It is suggested to add oral health in inclusion criteria
• It is suggested to add in exclusion criteria patients who did not attend any dental visit during the study.
• Mention how the examiner of the patients was calibrated to perform each of the tests
• Why weren't specific evaluation teeth chosen for each patient? The fact of assigning the results to the dental elements with greater sensitivity can cause bias.
• Has the dental unit syringe atmospheric pressure been calibrated?
• Mention what was the pH value of the acid solution, as well as the characteristics saline solution.
• How was it controlled that the patients followed the instructions as recommended? The fact of not using dental floss, not brushing at some point in the day, the application of the desensitizer wet or dry, the amount and time or the type of diet of each individual, how did it influence your results?
• In the second and third evaluations, were only the most sensitive teeth taken into account, or was it performed again on all the patient's teeth?
• Describe in more detail how the tactile test is performed and it is suggested to add citation.
Results
• It is suggested to show a table or graph of descriptive data of the study population.
• Title the axes of the graphs
• Add the 4 values of the SCASS scale in the graph of figure 3, since only 0, 1 and 2 are presented.
• In figure 3, where the SCASS scale graph is shown, mean values are shown, explain how they were obtained, since the methodology does not mention how many teeth were taken into account from each patient, if they were finally added up and obtained an average per test, it is suggested to mention it.
• Why are values less than 1 reported in figures 4 and 6, if the VAS scale goes from 0 to 10?
• It is suggested to report all the values of the scale in the results of the graphs, since it was the applied measurement instrument.
• All figures show fractional values on the scale, when the codes are not the same. It is suggested to reformulate because it is confusing for the reader or, failing that, explain why they are reported in that way.
Discussion
The discussion presented is ambiguous, it is suggested to reanalyze it based on the theories of dental hypersensitivity, as well as the factors that could influence its triggering and inhibition (age, diet, time of presentation, etc.).
Author Response
Suggestions
Thanks for the comments and suggestions. Please see the attachment to read the new manuscript, complete with the changes that we conducted following your advices and suggestions.
Methodology and Study design
The study is also of type longitudinal
longitudinal was added in the abstract, in the aim of the study (at the end of Introduction) and at the beginning of Materials and Methods.
Why are descriptive data of the study population and the type of agent chosen not reported?
We added descriptive data of the study population: “32 females and 20 males, mean age: 53 ± 9.4 and the type of agent chosen in this section (....sodium monofluorophosphate (1450 ppm) and arginine 8% product (product A... toothpaste containing n-HAp (nano-hydroxyapatite) in effective dose 2,25% and 0,15% fluoride (1500 ppm) (product B).
Why was the free choice type of desensitizing agent? Could this influence your final results? Why wasn't a study group made for each desensitizing agent?
- desensitizing agents were not assigned by the operators but a free choice was adopted in order to increase patient compliance to use the paste that they prefer most. It was added in the text “In this observational study the desensitizing product choice was made independently by each patient to help patient’s compliance”.
- However, results should not be influenced as the two groups were similar and with the same demographic and clinical features. Moreover, the samples of the two groups, were similar (27 in group A and 25 patients in group B); therefore, we decided to perform a comparison between the two groups. If the patients were randomly divided in two study groups the final results should not be influenced by patients group allocation.
In the new manuscript it was specified that “At T0, patients were instructed to use a desensitizing toothpaste and, at T1, 27 patients reported to use sodium monofluorophosphate (1450 ppm) and arginine 8% product (product A), while 25 patients reported to use a toothpaste containing n-HAp (nano-hydroxyapatite) in effective dose 2,25% and 0,15% fluoride (1500 ppm) (product B).”.
How the type of paste used by the study patients influenced the results?
Final results were influenced by both toothpastes that were desensitizing pastes; these agents determined a remineralization of tooth enamel and a dentinal tubules occlusion leading to a reduction of dental hypersensitivity.
It was added a line in this section explaining this mechanism.
Can the time it takes the patient to present dental hypersensitivity and how it is triggered influence the results?
only immediate dental hypersensitivity was evaluated.
Were patients with missing teeth and without rehabilitation included? Since this can alter your results derived from bone loss of the adjacent tooth.
Patients with missing teeth and without rehabilitation were exluded from the study. It was clarified in the line “Patients with total or partial removable prostheses or with extensive fixed prostheses (more than 1/3 of the teeth) and patients with missing teeth and without rehabilitation”.
Why were individuals who were not residents of the territory excluded? Does this influence your results?
it was specified in the new manuscript that individuals not residents of the territory were not included as this factor may affect their compliance of attending regular visits at the follow-up because of the long distances.
Why were patients with dental erosion and/or bruxism not ruled out?
We have specified in the new manuscript that patients with oral pathologies including bruxism were not included: “Patients suffering from oral pathologies and patients with bruxism” and: “Patients presenting at least one of the following conditions: teeth with suspicion of pulpitis, caries, and/or teeth with cracked enamel, dental erosion”.
It is suggested to add oral health in inclusion criteria
oral health was added in the inclusion criteria
It is suggested to add in exclusion criteria patients who did not attend any dental visit during the study.
It was added that patients who did not attend any dental visit during the study were excluded from the study
Mention how the examiner of the patients was calibrated to perform each of the tests
Operator calibration was written in the new text “All subjects were evaluated by a single dental hygienist healthcare practitioner who had received extensive training on clinical procedures before the beginning of the study” . Moreover, Cohen0s kappa coefficient was described in the Statistical analysis and at the beginning of the results.
Why weren't specific evaluation teeth chosen for each patient? The fact of assigning the results to the dental elements with greater sensitivity can cause bias.
- it was specified in the new manuscript that molar teeth with dental sensitivity were evaluated for clinical analysis.
Has the dental unit syringe atmospheric pressure been calibrated?
It was written that “ The same dental unit syringe atmospheric pressure, calibrated at 4 bar, was used for all patients”.
Mention what was the pH value of the acid solution, as well as the characteristics saline solution.
pH value (3) was added in the text as well as the characteristics of saline solution (390 grams dissolved in 1 liter of water, 28%).
How was it controlled that the patients followed the instructions as recommended? The fact of not using dental floss, not brushing at some point in the day, the application of the desensitizer wet or dry, the amount and time or the type of diet of each individual, how did it influence your results?
-It was written at the end of Material and Methods that: “patients were instructed to the same oral hygiene habits that included: the use of dental floss 1 time/day, tooth brushing 3 times/day after the meals: in the morn-ing, afternoon and evening. Finally, a similar type of diet (3 meals/day with a small consumption of acidic foods 1 time/day was suggested to the patients.
-Daily application of toothpaste for 2 minutes was reported in a daily diary by each patient in order to check if the instructions were correctly followed at home.
-Moreover, the patients recorded their oral and dietary habits on a daily diary and the operator checked it at every time point.
In the second and third evaluations, were only the most sensitive teeth taken into account, or was it performed again on all the patient's teeth?
Molar teeth that showed dental hypersensitivity at T0 were taken into account in the second and third evaluations.
Describe in more detail how the tactile test is performed and it is suggested to add citation.
Tactile test was described in more detail: “scratching a light pressure (10 grams) along the cementoenamel junction for three seconds”. Furthermore, a citation was added in the text: Heft et al. 2018 (citation number 40)
Results
It is suggested to show a table or graph of descriptive data of the study population.
Table 1 with descriptive data was added in the new manuscript
Title the axes of the graphs
Title of the axes were written in the graphs.
Add the 4 values of the SCASS scale in the graph of figure 3, since only 0, 1 and 2 are presented.
graphs were modified including the mean value for each time point and including a description of the SCASS Scale from 0 to 3 into the graph.
In figure 3, where the SCASS scale graph is shown, mean values are shown, explain how they were obtained, since the methodology does not mention how many teeth were taken into account from each patient, if they were finally added up and obtained an average per test, it is suggested to mention it
we have written in figure 3 caption that an average value of the teeth was considered in the analysis: “Mean values of air sensitivity test from T0 to T2 for all molar teeth with hypersensitivity considered for each patient”.
Why are values less than 1 reported in figures 4 and 6, if the VAS scale goes from 0 to 10?
We have reported the mean values for each graph that show that alla values are greater than 0.
It is suggested to report all the values of the scale in the results of the graphs, since it was the applied measurement instrument.
values of the scale were reported for each time point: T0, T1 and T2 in each graphs.
All figures show fractional values on the scale, when the codes are not the same. It is suggested to reformulate because it is confusing for the reader or, failing that, explain why they are reported in that way.
it was explained in the figure caption that mean values of the scores were evaluated. Fractional values were obtained from the mean values of the score for all patients examined divided for the number of patients.
Discussion
The discussion presented is ambiguous, it is suggested to reanalyze it based on the theories of dental hypersensitivity, as well as the factors that could influence its triggering and inhibition (age, diet, time of presentation, etc.).
- Discussion was modified. We included theories of dentinal hypersensitivity as well as the factors that could influence its triggering and inhibition: i.e. “aging determines an accumulation of secondary and tertiary dentin with a partial obliteration of dentinal tubules. Furthermore, diet play an important role on the onset and development of dentinal hypersensitivity because of the acidic properties of foods and it is renowned that young people consume high quantities of soft drinks that are one of the main causes of hypersensitivity along with nocturnal or diurnal bruxism, wrong brushing tecniques, use of hard bristles toothbrushes and periodontal diseases with gingival recessions.”
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Dear Authors,
According to the title, the manuscript aimed to evaluate the use of desensitizing agents in the management of dentinal hypersensitivity clinically, but the aim of the study and the objectives are not clearly stated in the manuscript. The methodology section, including inclusion, exclusion criteria is not clear. The study design is not well structured and explained. The results and discussion are confusing. In addition, the study does not present novelty in the field. Most of the references are inappropriate and old as only 12 references are after 2015 out of 43 references.
Author Response
Dear Authors,
According to the title, the manuscript aimed to evaluate the use of desensitizing agents in the management of dentinal hypersensitivity clinically, but the aim of the study and the objectives are not clearly stated in the manuscript. The methodology section, including inclusion, exclusion criteria is not clear. The study design is not well structured and explained. The results and discussion are confusing. In addition, the study does not present novelty in the field. Most of the references are inappropriate and old as only 12 references are after 2015 out of 43 references.
Thanks for the comments and suggestions.
Extensive editing of English language and style was performed. The aim was clearly stated in the new manuscript. The metodology was modified and we modified the discussion. Moreover, more appropriate and recent reference were included.
Please see the attachment to read the new manuscript, complete with the changes that we conducted following your advices and suggestions.
Author Response File: Author Response.pdf
Round 2
Reviewer 2 Report
Dear Authors,
I would like to express my appreciation for your efforts to improve the quality of the manuscript. You did great job trying to clarify the objectives of the study, but one of the objectives is not identified in the title or at the end of the introduction,"analysis of different stimuli for dentine hypersensitivity".
Abstract:
The purpose of the study is still not clear. In addition, I am not sure if this sentence referred to another objective of the study or what?“The secondary outcome was to examine the entire spectrum of stimuli in 18 dentinal hypersensitivity clinical ….”
Add sentences regarding the results and conclusion.
Clarify the abbreviation T0 as it is the first time to be mentioned in the manuscript.
Introduction:
The objective of the study should be stated clearly at the end of the introduction, and still it is not.
Introduction needs to be divided into shorter paragraphs.
Materials and methods:
You added more details to the methodology section but still it is not organized. I recommend to divide the methodology into subtitles that might make the study design more clear.
Inclusion and exclusion criteria still need to be more organized and correlated to the study objectives.
Some items in the inclusion criteria are not representing any criteria, it is just a title; “Systemic health and oral health”.
Signature of the consent is not considered one of the inclusion criteria.
Also, inability to sign the consent is not an exclusion criterion!
Sometimes the authors refer to patient by using the term “subject”. It needs to be unified along the study.
The results and discussion are confusing. Both should be more organized, and the discussion should discuss the methodology and all results gained from the study in ordered separate paragraphs.
Conclusion should be more specific, and not only stating the results again.
Still the Manuscript needs huge English language revision in both linguistic and grammar aspects.
Author Response
Dear Doctor,
thank you for your precious suggestions, please see the attachment to read the new revised manuscript. Down here, you can find specific answers on your comments.
Kind Regards
I would like to express my appreciation for your efforts to improve the quality of the manuscript. You did great job trying to clarify the objectives of the study, but one of the objectives is not identified in the title or at the end of the introduction, "analysis of different stimuli for dentine hypersensitivity"
- thanks for comments and suggestions that improved our manuscript. We have modified the aim of the study, in particular in the abstract. We have written that “This longitudinal study aims to measure dentinal hypersensitivity in adult patients after the use of domiciliary desensitizing devices”, while the analysis of different stimuli was removed, as it describes the procedures performed in materials and methods.
Abstract:
The purpose of the study is still not clear. In addition, I am not sure if this sentence referred to another objective of the study or what?“The secondary outcome was to examine the entire spectrum of stimuli in 18 dentinal hypersensitivity clinical ….”
-We have modified the objectives of the study and we removed the line “The secondary outcome was to examine the entire spectrum of stimuli in 18 dentinal hypersensitivity clinical….”
Add sentences regarding the results and conclusion.
-sentences regarding results and conclusion were added in the abstract
- the purpose of the study was modified and the other objective was removed from the text as it was not clear.
Clarify the abbreviation T0 as it is the first time to be mentioned in the manuscript.
- It was written in the abstract. (Time point 0: baseline)
Introduction:
The objective of the study should be stated clearly at the end of the introduction, and still it is not.
.- at the end of the introduction we wrote that “The objective of the present study was to evaluate the effects of desensitizing agents on DH using different tests: air, tactile, cold thermical, osmotic and acid.”
Introduction needs to be divided into shorter paragraphs.
- introduction was divided in shorter paragraphs.
Materials and methods:
You added more details to the methodology section but still it is not organized. I recommend to divide the methodology into subtitles that might make the study design more clear.
- subtitle were added in materials and methods
Inclusion and exclusion criteria still need to be more organized and correlated to the study objectives.
- inclusion and exclusion criteria were modified. Sentences not stictly correlated to the study objective were removed.
- Some items in the inclusion criteria are not representing any criteria, it is just a title “Systemic health and oral health”.
- the line “Systemic health and oral health”was removed and in the exclusion criteria a more specific line was written :” Patients with periodontal diseases and patients with bruxism” - Signature of the consent is not considered one of the inclusion criteria.
- the line was removed from the criteria - Also, inability to sign the consent is not an exclusion criterion!
- the line was removed from criteria - Sometimes the authors refer to patient by using the term “subject”. It needs to be unified along the study.
- we have used in the new manuscript the term “patients” instead of subjects. - The results and discussion are confusing. Both should be more organized, and the discussion should discuss the methodology and all results gained from the study in ordered separate paragraphs.
-Results were modified and sentences were written in a more organized way.
Moreover, discussion was modified discussing methodology. - Conclusion should be more specific, and not only stating the results again.
- conclusions were modified in order to be more specific. - Still the Manuscript needs huge English language revision in both linguistic and grammar aspects.
- linguistic and grammar aspects were revised.
Author Response File: Author Response.pdf
Round 3
Reviewer 2 Report
Dear Authors,
I really appreciate your efforts to adjust the manuscript from all aspects.
I do not have any other comments.
Best regards.
