Authors: Thibault Colloc1, Bruno Pereira2, Christopher Holmgren3, Peter Robinson4 and Sophie Domejean5
1 OMFS, Aberdeen Royal Infirmary, United Kingdom
2 Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, France
3 AOI, Aide Odontologie Internationale (AOI), France
4 Bristol Dental School, Bristol Dental School, United Kingdom
5 Operative dentistry and endodontics, UFR d’Odontologie de Clermont-Ferrand – Université Clermont Auvergne, France
Corresponding author: Professor Sophie Domejean, Operative dentistry and endodontics, UFR d’Odontologie de Clermont-Ferrand – Université Clermont Auvergne, France. sophie.domejean@uca.fr
ABSTRACT:
Introduction: Patient-reported outcomes are increasingly used to capture the subjective experience of health-conditions and to evaluate treatment. The Dentine Hypersensitivity Experience Questionnaire (DHEQ) was designed to measure impacts of dentine hypersensitivity on daily life. DHEQ was developed in English and as yet, no French version is available. The aim of this study was to translate the DHEQ into French (DHEQ-Fr) and propose a pilot study assessing of the psychometric properties of the DHEQ-Fr. The purpose of the present manuscript is to propose a French version of the DHEQ (DHEQ-Fr) and the results of a pilot study for a preliminary evaluation of the psychometric properties of the DHEQ-Fr.
Materials and methods: DHEQ was translated into French using forward-backward translation. Iterative panel-testing by a convenience sample of 22 dental students (11 with self-reported dentine hypersensitivity and 11 not) continued until there were no concerns.
Results: Despite the small number of participants included in this pilot-study, DHEQ-Fr showed acceptable face validity with an effect size of 1.22 and a Cronbach alpha coefficient >0.95 for each item if item removed.
Conclusion: Further investigations are needed to validate the DHEQ-Fr in terms of internal reliability, test–retest reliability and criterion validity.
INTRODUCTION
Dentine Hypersensitivity (DH) has been defined as a “short sharp pain arising from exposed dentine in response to stimuli typically thermal, evaporative, tactile, osmotic or chemical and which cannot be ascribed to any other form of dental defect or pathology”.1 Prevalence of the pathology is very heterogenous depending on the literature because of a myriad of factors that can be related to the condition like ethnic origin or periodontal status.2 A European study in 2013 looking at patients aged between 18 and 35 years reports DH prevalence from 7.5% up to 19.4% with European average prevalence of 13.5%.3 This condition not only affects patients’ physical health but also their social function and psychological wellbeing also defined as Quality of Life (QoL) and more specifically Oral health related quality of Life (OHrQoL).4,5
OHrQoL questionnaires have been designed to assess the subjective experience of health-conditions and their impacts on daily life as well as to evaluate treatment. The Fédération Dentaire Internationale (FDI) recently developed a policy statement about the need for assessing patient-reported outcomes used to capture the subjective experience of health-conditions and to evaluate treatment.6
The most popular OHrQoL are the Geriatric/General Oral health Assessment Index (GOHAI)7,8 and the Oral Health Index Profile (OHIP).9 If these questionnaires show very good abilities to assess generic measures, they do present limits in assessing specific oral conditions such as DH.4 Thus, to remedy this gap, Boiko et al. developed a questionnaire specific to HD, the Dentine Hypersensitivity Experience Questionnaire (DHEQ) (Table 1).10,11 The DHEQ was developed to evaluate the impact of DH on patients’ quality of life. DHEQ shows excellent reliability and satisfactory psychometric properties and allows identifying negative emotions related to DH but also differential efficacity of DH treatments.10,11 Plain and shortened DHEQ have been translated and validated in Chinese,12 Turkish13 and Brazilian-Portuguese14 but no French version was available. The purpose of the present manuscript is to propose a French version of the DHEQ (DHEQ-Fr) and present the results of a pilot study for a preliminary evaluation of the psychometric properties of the DHEQ-Fr.
MATERIAL AND METHODS
Questionnaire structure (Table 1)
The 50 items constituting the original questionnaire can be divided in the following sections:
- Items #1-6: description of the sensations related to the pathology;
- Items #7-9: scoring, using a visual analogue scale (VAS), of the intensity, the bothersomeness and the tolerability related to DH;
- Items #10-45: scoring, using a seven-point Likert scale, of the impact of DH on QoL. Five domains or impact subscales can be identified: functional restriction (five items), adaptation (12 items), social impact (five items), emotional impact (eight items) and identity (six items).
- Item #46: A global oral health rating, with responses on a five-point Likert scale (from “excellent” to “very poor”).
- Items #47-50: The questionnaire also contains four items recording the impact of the sensations on life overall, with responses on a five-point Likert scale (from “not at all” to “very much”).
Questionnaire translation
A forward-backward translation process was used to translate the original DHEQ (50 items as described in Table 1) into French. The original English version was translated from English to French by CT and DS. This preliminary French version was back-translated to English by two English native dentists (HC and FD) who are fluent in French. The two English independent versions were compared and merged into one by CT and SD. The English original and back-translated versions were compared by two of the authors of the DHEQ (SB and PR) and the preliminary DHEQ-Fr was slightly modified (Supplementary material).
Pilot study
DHEQ-Fr was auto-administrated in spring 2018 to a convenience sample of 22 dental students, 11 with self-reported DH (DH group) and 11 not (non-DH group) (Table 2). The data were entered onto an Excel spreadsheet; the statistical analysis was performed using Stata software. For each participant, a ‘total score’ was calculated as the sum of the item #10-45 scores. A mean score using weight percentiles [p25; p75] was then calculated for both groups (DH and non-DH) (possible range: 36-252; a higher total score indicates negative impact on OHRQoL). ‘Subscale scores’ were also calculated for each of the five domains and for each participant (possible ranges: Functional Restriction 5-35; Adaptation 12-84; Social Impact 5-35; Emotional Impact 8-56; Identity 6-42; a higher total score indicates negative impact on OHRQoL). The mean scores (total scores and subscale scores) were compared between groups with the significance placed at 0.05. Internal consistency reliability was assessed using item-rest correlations and Cronbach’s alpha. Item-rest correlations of >0.2 and Cronbach’s alpha of >0.70 were considered acceptable for comparisons between groups.15,16
RESULTS
Were included 22 participants (nine males and 13 females; age range: 22-25 years); 11 self-reported HD whereas the 11 others considered themselves not suffering from HD (Table 2).
Table 3 shows the total score and the subscale scores for the both study groups.
The total scores were respectively 124 [66; 155] and 50 [36; 105] for DH and non-DH groups with a statistically significant difference between the two groups (p=0.008). A higher DHEQ-Fr total score showed a poorer OHrQoL due to DH. Moreover, all of the subscale scores were statically higher in DH group compared to non-DH group with p-values <0.05. The effect size of >0.8 shows a strong relation for the total score (1.22) and for 4 of 5 subscale scores as described in Figure 1 and Table 3 which confirms the significance of the results.17,18
Figure 2 shows mean score for each item (items #10-45) as well as item rest correlation for each item. This figure shows great internal consistency apart for item 13 (0.18) and item 39 (0.14) which are not showing significant consistency compared to the rest of the questionnaire.
Figure 3 shows the Cronbach alpha coefficient for each item if item removed. These results allow us to confirm that all the items present in the questionnaire are relevant to the subject since Cronbach alpha coefficient is >0.70. Cronbach’s alpha for the total score of the DH group was 0.96.
TABLES
Table 1: Original DHEQ description
Table 2: Patients’ characteristics
Table 3: Total and subscale scores for DH and no-DH groups
FIGURES
Figure 1: Effect size for total score and subscale scores
Figure 2: Mean item scores (+/-SD) among DH participants and item-rest correlation
Figure 3: Cronbach’s alpha coefficient if item removed
QUESTIONNAIRE
DISCUSSION
DH pathognomonic clinical sign is a short sharp pain arising from exposed dentine (gingival recession; erosion) in response to stimuli typically thermal, evaporative, tactile, osmotic or chemical and, which cannot be ascribed to any other form of dental defect or pathology.19,20 The impacts of DH on patient’s daily life has been reported as it deteriorates physical health, social functions and psychological wellbeing.10 Assessing OHrQoL related to DH allows the description of the impact of DH on patients’ everyday lives but also to assess and compare the effectiveness of various DH relief strategies. OHrQoL questionnaires are thus fundamental tools in clinical practice and research. OHIP and GOHAI are the most popular OHrQoL questionnaires but they are not specific to DH. Indeed, only three items, and one item, are potentially related to DH respectively in OHIP and GOHAI. The development and the validation of a DH specific OHrQoL questionnaire is thus of importance to identify people with DH or to evaluate DH treatments.
The DHEQ was originally developed in English language in the United Kingdom.10 Considering that a DH prevalence of about 12% has been reported in France by West et al.,3 developing a DHEQ-Fr seems relevant for research purposes in order to assess comparative effectiveness of DH treatment strategies. Therefore, in order to be able to use this instrument in France, a translation and cross-cultural adaptation process was required.21
To our knowledge the DHEQ-Fr here presented is the first of its kind. It can be reproached that the pilot study only included a limited number of patients. Nevertheless, despite this limitation, the present results show that DHEQ-Fr seems to have acceptable face validity.
Indeed, the total scores between subjects with and without DH (116.4 ± 44 versus 66.4 ± 34.6) shows a statistically significant difference (p = 0.008) meaning that subjects suffering from DH had a poorer QoL. The effect size confirms the strong relation for each subscale with a score >0.8 except for the social subscale (effect size 0.78) which is showing a moderate relation. This could be the cause of a limited number of participants for a pilot study and the fact that the participants were chosen on a subjective self-diagnosis of DH.
The item-rest correlation allows us to compare each item before the rest of them and to evaluate if each item is a good contributor for the questionnaire. Results show acceptable correlation (>0.2) except from items #13 (0.18) and #39 (0.14) (Figure 2). It is interesting to notice that the item (#13) obtaining one of the lowest inter-rest correlation score is one which has been removed in the modified version of the DHEQ.10 Further research is needed in order to confirm if those items will need to be removed in the final French version of the questionnaire. Moreover, in the original questionnaire, item #41 was removed at a later stage because of its weak statistical significance. In the present study, this can’t be confirmed but a study on a larger cohort would allow more reliable statistical analysis for the final version of DHEQ-Fr. Finally, reliability analyses were restricted to internal consistency. Cronbach alphas were high for the total impact score (0.96) and subscale scores (0.70-0.94). The present results confirm consistency, validity and stability of the present DHEQ-Fr questionnaire. Nevertheless, further investigations are needed to validate it in terms of internal reliability, test-retest reliability and criterion validity, and to widespread its use in further research related to DH and OHRQoL.
CONCLUSION
Based on the above results, we can conclude that the preliminary version of DHEQ-Fr used in the pilot study confirmed the consistency, stability and validity of the questionnaire. The next step is to start a large clinical study with an objective assessment of DH in order to confirm the validity and reliability of the DHEQ-Fr.
DECLARATIONS
Ethics approval and consent to participate
All methods were carried out in accordance with relevant guidelines and regulations.
Consent for publication
Not applicable
Declaration of interests
The authors declare that they have no competing interests.
Funding
The study was funded by the authors and their institutions.
LIST OF ABBREVIATIONS
DHEQ – Dentine Hypersensitivity Experience Questionnaire
DH – Dentine Hypersensitivity
DHEQ-Fr – Dentine Hypersensitivity Experience Questionnaire – French
QoL – Quality of Life
OHrQoL – Oral Health related Quality of Life
FDI – Fédération Dentaire Internationale
GOHAI – Geriatric/General Oral Health Assessment Index
OHIP – Oral Health Index Profile
VAS – Visual Analogue Scale
REFERENCES
1. Holland GR, Narhi MN, Addy M et al. Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. J Clin Periodontol 1997; 24: 808-813.
2. Favaro Zeola L, Soares PV, Cunha-Cruz J. Prevalence of dentin hypersensitivity: Systematic review and meta-analysis. J Dent 2019; 81: 1-6.
3. West N X, Sanz M, Lussi A et al. Prevalence of dentine hypersensitivity and study of associated factors: a European population-based cross-sectional study. J Dent 2013; 41: 841-851.
4. Bekes K, John MT, Schaller HG et al. Oral health-related quality of life in patients seeking care for dentin hypersensitivity. J Oral Rehabil 2009; 36: 45-51.
5. Idon PI, Sotunde OA, Ogundare TO. Beyond the relief of pain: Dentin hypersensitivity and oral health-related quality of life. Front Dent 2019; 16: 325-334.
6. Fédération Dentaire Internationale. FDI policy statement on oral health and quality of life: Adopted by the FDI General Assembly: 24 September 2015, Bangkok, Thailand. Int Dent J 2016; 66: 11-12.
7. Atchison KA. The General Oral Health Assessment Index (GOHAI), in Measuring oral health and quality of life, S. GD, Editor. 1997: Chapel Hill : Univeristy of North Carolina, Department of Dental Ecology.
8. Atchison KA, Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dent Educ 1990; 54: 680-687.
9. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health 1994; 11: 3-11.
10. Boiko OV, Baker SR, Gibson BJ et al. Construction and validation of the quality of life measure for dentine hypersensitivity (DHEQ). J Clin Periodontol 2010; 37: 973-980.
11. Baker SR, Gibson BJ, Sufi F et al. The Dentine Hypersensitivity Experience Questionnaire: a longitudinal validation study. J Clin Periodontol 2014; 41: 52-59.
12. He SL, Wang JH. Reliability and validity of the Chinese version of the short form of the Dentine Hypersensitivity Experience Questionnaire (DHEQ-15). Qual Life Res 2015; 24: 1465-1469.
13. Basaran S, Celik C. Turkish Adaptation of Dentine Hypersensitivity Experience Questionnaire (DHEQ). Community Dent Health 2018; 35: 47-51.
14. Douglas-De-Oliveira DW, Lages FS, Paiva SM et al., Cross-cultural adaptation of the Brazilian version of the Dentine Hypersensitivity Experience Questionnaire (DHEQ-15). Braz Oral Res 2018; 32: p. e37.
15. Kline P. The handbook of psychological testing. Second Edition ed. 2000, London; New York: Routledge.
16. Bland JM, Altman DG. Cronbach’s alpha. BMJ 1997; 314: 572.
17. Frit CO, Morris PE, Richler JJ. Effect size estimates: current use, calculations, and interpretation. J Exp Psychol Gen 2012; 141: 2-18.
18. Cohen J. Statistical power analysis for the behavioral sciences. Vol. 1. 1988: Hillsdale, NJ: Lawrence Earlbaum Associates.
19. Brannstrom M. The hydrodynamic theory of dentinal pain: sensation in preparations, caries, and the dentinal crack syndrome. J Endod 1986; 12: 453-457.
20. Bissada NF. Symptomatology and clinical features of hypersensitive teeth. Arch Oral Biol 1994; 39 Suppl: 31S-32S.
21. Del Greco L, Walop W, McCarthy RH. Questionnaire developement: 2. Validity and reliability. CMAJ 1987; 136: 699-700.
ABOUT THIS PAPER
Manuscript submitted: 6 January 2021
Manuscript accepted: 18 March 2021
DOI: https://doi.org/10.36161/FJDM.0009
