|Year : 2014 | Volume
| Issue : 4 | Page : 472-477
Assessment of subjective intensity of pain during ultrasonic supragingival calculus removal: A comparative study
Sachin Malagi1, Kirti Pattanshetti2, Radhika Bharmappa1, Annaji Sreedhara Reddy1, Jagadish Pai1, Rosemary Joseph1
1 Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet, Karnataka, India
2 Padmashree Dr. D Y Patil Dental College, Nerul, Maharashtra, India
|Date of Submission||07-May-2012|
|Date of Acceptance||01-Dec-2013|
|Date of Web Publication||14-Aug-2014|
Department of periodonics, Coorg institute of Dental Sciences, Maggula Post, Virajpet - 571 218, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The background of the following study is to measure the subjective intensity of pain using the verbal rating scale (VRS) during supragingival scaling in relation to mandibular anteriors, with an ultrasonic scaler, with 2 different inserts (Slimline and Focus spray)- split mouth study. Materials and Methods: A total of 30 subjects with a combination of 17 males and 13 females with the chronic generalized gingivitis with a minimum calculus score of 1 (CSSI - Ennever J 1961) who reported to Department of Periodontics, Yenepoya Dental College, Mangalore were chosen for the study. Ultrasonic magnetostrictive scaler unit CAVITRON BOBCAT PRO ® - (DENTSPLY) with maximum power setting at 130A and 25kHZ frequency with 2 different inserts i.e., Slim line insert and Focus spray (DENTSPLY) were used for supragingival scaling in the study. A VRS was used to assess the subjective intensity of pain. Results: There was no statistically significant difference in pain perception when the scores were compared using Wilcoxon signed rank test. VRS rating scores with slimline inserts showed a pain intensity of 2 in 43.3%, 1 in 53.3% and 0 in 3.3%, whereas the focus spray insert showed a pain intensity of 1 in 23.3% and 0 in 76.7%. Statistical analysis showed a P = 0.251 and a z - 1.147 a . Conclusions: The use of both Slim line insert and Focus spray inserts when used at same settings of the scaling unit, showed no statistical significant difference in the intensity of pain perceived and it showed no correlation between patient acceptance and their pain perception.
Keywords: Focus spray, slim line, verbal rating scale
|How to cite this article:|
Malagi S, Pattanshetti K, Bharmappa R, Reddy AS, Pai J, Joseph R. Assessment of subjective intensity of pain during ultrasonic supragingival calculus removal: A comparative study. J Indian Soc Periodontol 2014;18:472-7
|How to cite this URL:|
Malagi S, Pattanshetti K, Bharmappa R, Reddy AS, Pai J, Joseph R. Assessment of subjective intensity of pain during ultrasonic supragingival calculus removal: A comparative study. J Indian Soc Periodontol [serial online] 2014 [cited 2019 Dec 16];18:472-7. Available from: http://www.jisponline.com/text.asp?2014/18/4/472/138698
| Introduction|| |
Pain is a subjective sensation which can be described according to several relevant features or attributes (quality, location, intensity, aversiveness, emotional impact, frequency, etc.) Among these attributes, intensity is recognized as one of the most relevant clinical dimension of the pain experience. Being a subjective experience, there is no objective method to measure pain. However, pain intensity can be measured in patients in a reliable and valid way by recording the self-rating of the sensation on different types of scales. 
Reducing supra and subgingival plaque and calculus as well as preventing recolonization of periodontal pockets by pathogenic bacteria are fundamental aspects of periodontal therapy. Therefore, dental plaque, an adherent, bacterial biofilm that forms on soft and hard tissues and calcified deposits should be removed from the tooth surface.  Calculus can be removed employing hand scalers, ultrasonic instruments, air-powder abrasive scalers, diamond burs and lasers. A beneficial effect of ultrasonic instrumentation in creating a smooth surface without extensive removal of hard tissues could be demonstrated.  Moreover, adjustments in working parameters, shapes and sizes shall allow the adaption of an ultrasonic scaler's efficacy to various clinical needs and may influence efficacy and aggressiveness of the respective device. 
Scaling and root planing is one of the most commonly performed procedures in a dental clinic.
Most patients consider the procedure annoying and some experience pain.  Dental pain, anxiety and fear are important factors that prevent patients from seeking dental care.  Although the available literature is limited, there is sufficient evidence to document that some patients may find both the non-surgical and the surgical treatments painful. Scaling is associated with discomfort if not pain. Many methods are employed to reduce the pain associated, including use of anesthetics and relaxation techniques. 
Patient's compliance with dental treatment procedures is affected by many reasons, including self-destructive behavior, fear, economic factors, health beliefs, stressful events in their lives and perceived dentist indifference.  Supragingival calculus removal procedures are reported to cause painful sensations in the patient.  Thus, the ability to deliver dental care with a minimum of patient discomfort should be an essential part of a clinician's skills to avoid a decline of compliance. 
The aim of the present study was to measure the subjective intensity of pain on a verbal rating scale (VRS) during supragingival scaling in relation to mandibular anteriors, with an ultrasonic magnetostrictive scaler, with 2 different inserts (Slimline and Focus spray).
| Materials and methods|| |
A total of 30 patients with a combination of 13 females and 17 males with a mean age of 36 ± 2 years, who presented with the chronic generalized gingivitis and a minimum calculus score of 1 were selected for the study and informed consent was obtained.  Patients who exhibited signs of wasting diseases such as abrasion, attrition and erosion, patients with underlying systemic diseases and patients with orthodontic appliance and removable partial dentures were excluded from the study.
An ultrasonic magnetostrictive scaler unit-CAVITRON BOBCAT PRO ® - (DENTSPLY) [Figure 1] with maximum power setting at 130A and 25kHZ frequency was used in the study and 2 different inserts, i.e., Slim line insert and Focus spray (DENTSPLY) were used for supragingival scaling in the study [Figure 2]. Both scaler tips showed a predominantly linear oscillation pattern and were operated at the 100% setting of the ultrasonic device.
|Figure 1: Ultrasonic magnetostrictive scaler unit-CAVITRON BOBCAT PRO® - (DENTSPLY)|
Click here to view
Patients received professional dental care and tooth cleaning procedures regularly, but no surgical periodontal treatment before. All treatment procedures were performed by one operator. Using a split-mouth study design, the sequence of the different treatments was randomly assigned. Only Mandibular anteriors were selected for the study. Selected sites were divided into left front and right front teeth (split mouth design study). Selected sites were randomly subjected to instrumentation using 2 different scaler inserts.
All patients had been informed about the study and had given their informed consent. The study was conducted in full accordance with the declared ethical principles (World Medical Association Declaration of Helsinki, Version VI, 2002) and had been approved by the local Ethics Committee.
Supragingival scaling was performed in relation to lower left front teeth or right front teeth randomly, by using 2 different scaler inserts [Figure 3]and [Figure 4] An interval of 2 min was given after the use of each scaler insert. Distilled water was used as a coolant. The coolant was used at room temperature and the irrigation volume was adjusted to 15 ml/min. Saliva ejector was used during the procedure. The end point of treatment was a clinically judged clean tooth surface. The study design comprised only the removal of supragingival calculus. After supragingival scaling of selected sites, patient was requested to fill the VRS sheet. If subgingival calculus was detected during the treatment procedure, it was removed without pain assessment after the supragingival cleaning.
- '0' - no pain or discomfort
- '1' - mild pain or discomfort or sensitivity
- '2' - moderate pain or discomfort or sensitivity
- '3' - severe pain, discomfort or sensitivity which subsides after 5 min of scaling
- '4' - severe persistent pain or radiating pain, discomfort or sensitivity after scaling procedure.
After the treatment the subjective intensities of pain were assessed with a visual analogue scale (VAS). Filled VAS sheets, were then subjected to statistical analysis by using Wilcoxon signed rank test.
| Results|| |
The results of the present study showed that the slimline insert showed that 3.3% of the study population did not perceive pain. Around 53.3% of the study population perceived pain of value 1 and 43.3% of the study population perceived pain of value 2 on the verbal rating scale. On the contrary all the individuals perceived pain in Focal Spray insert group. The verbal rating scale for focal spray insets showed that 76.7% of the population perceived pain value of 1 & 23.3% of the population had a value of 2 on the verbal rating scale [Figure 5].
Wilcoxon signed rank test was applied to the values and it showed a P value of 0.251 and a z value of - 1.147a. Hence, there were no statistically significant differences between the intensities of pain perceived during supragingival scaling using these two different inserts.
| Discussion|| |
Dental plaque formation in a healthy subject first occurs supragingivally, which then often progresses subgingivally. Plaque can mineralize and form calculus deposits. Thus, during periodontal maintenance care or after calculus formation on periodontally healthy teeth, the primary need of dental therapy might be supragingival calculus removal. Supragingival calculus removal procedures are reported to cause painful sensations in the patient. Thus, the ability to deliver dental care with a minimum of patient discomfort should be an essential part of a clinician's skills to avoid a decline of compliance.
By assessing pain associated with periodontal maintenance therapy using VRS, no difference could be demonstrated, comparing the slimline inserts and focus spray inserts at same power setting. Once again, only a VRS was used to assess pain perception in this study. This scale allows only a retrospective assessment of previous painful sensations.
The more common method of evaluating pain scores with a VAS assesses painful sensations only retrospectively and hence that possible high peaks of pain may be recorded imprecisely. Moreover, the depth of penetration of the two inserts and the pressure applied by the operator on the tips for the removal of supragingival calculus has not been standardized and hence could have resulted in a varied pain experience by the patient. 
In the present study, supragingival calculus was assessed only at the mandibular front teeth. The reason for limiting to these teeth was that calculus formation is most commonly seen on the lingual aspects of the lower incisors and canines and on the buccal aspects of the upper first and second molars. These sites of predilection coincide with the openings of the major salivary glands.  The amount of individual calculus accumulation was not assessed before treatment as in the present study both evaluated treatment procedures were used in a split-mouth design, allowing an intra-experimental comparison of the two ultrasonic scaler tips under study.
To minimize inter patient variability in the present study medically healthy patients were included, because systemic factors were shown to modify an individual's response to noxious stimuli.  Pain perceptions with regard to gender variation was not measure in the study because previous results with regard to the relationship between gender and pain perception are inconsistent. 
In the present study, all ultrasonic scalers were used with a tip angulation close to 0°. Investigating working parameters of a sonic and piezoelectric ultrasonic scaler on root substance removal, it could be shown that this angulation might prevent severe root damage.  Instruments were always used with the same power settings and instrumentation of all teeth was undertaken by one investigator, allowing an inter-instrumentation comparison within the experimental set-up. Regarding the oscillation at the used power setting, there was no major difference in the frequency of the used tips.
The drawbacks in the present study include that there was no standardization for the depth of the penetration of the scaler tip and the pressure applied by the operator during supragingival calculus removal. The variability in pain perception depending on gender variation and socio economic factors was also not assessed. In addition, the intensity of pain was not assessed using any other more objective methods available.
| Conclusion|| |
The present study indicates that the use of slim-line inserts of ultrasonic units used for supragingival calculus removal may result in reduction in pain sensations compared with conventional ultrasonic scalers. Considering the overall aim to deliver dental care with a minimum of patient discomfort, it thus might be possible to increase the patient's compliance during dental treatment.
| References|| |
|1.||Caraceni A, Cherny N, Fainsinger R, Kaasa S, Poulain P, Radbruch L, et al. Pain measurement tools and methods in clinical research in palliative care: Recommendations of an Expert Working Group of the European Association of Palliative Care. J Pain Symptom Manage 2002;23:239-55. |
|2.||Bernimoulin JP. Recent concepts in plaque formation. J Clin Periodontol 2003;30 Suppl 5:7-9. |
|3.||Jacobson L, Blomlöf J, Lindskog S. Root surface texture after different scaling modalities. Scand J Dent Res 1994;102:156-60. |
|4.||Braun A, Jepsen S, Krause F. Subjective intensity of pain during ultrasonic supragingival calculus removal. J Clin Periodontol 2007;34:668-72. |
|5.||Shaju JP, Amirishetty R, Zade RM. Factors influencing pain experienced during scaling and root planing: A correlative pilot trial. J Periodontol Implant Dent 2011;3:8-12. |
|6.||Sanikop S, Agrawal P, Patil S. Relationship between dental anxiety and pain perception during scaling. J Oral Sci 2011;53:341-8. |
|7.||Wilson TG Jr. How patient compliance to suggested oral hygiene and maintenance affect periodontal therapy. Dent Clin North Am 1998;42:389-403. |
|8.||Kocher T, Rodemerk B, Fanghänel J, Meissner G. Pain during prophylaxis treatment elicited by two power-driven instruments. J Clin Periodontol 2005;32:535-8. |
|9.||Soben P. Text Book of Essentials of Preventive and Community Dentistry. 3 rd ed. Reprint 2007. New Delhi: Arya Publications; 2006. p . 145. |
|10.||Addy M, Koltai R. Control of supragingival calculus. Scaling and polishing and anticalculus toothpastes: An opinion. J Clin Periodontol 1994;21:342-6. |
|11.||Heins PJ, Karpinia KA, Maruniak JW, Moorhead JE, Gibbs CH. Pain threshold values during periodontal probing: Assessment of maxillary incisor and molar sites. J Periodontol 1998;69:812-8. |
|12.||Guzeldemir E, Toygar HU, Cilasun U. Pain perception and anxiety during scaling in periodontally healthy subjects. J Periodontol 2008;79:2247-55. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]