Injection pain varies with anesthetic agents

Dental injections reduce the pain of procedures, but are themselves considered painful. Puncture of the mucosa, tissue distension from the agent, and low pH of the anesthetic all contribute to the pain experienced with dental injections.

General dentists in Delaware together with a researcher from Temple University in Pennsylvania compared injections on nearly 1,400 patients. One of four local anesthetic agents was randomly assigned to each patient: prilocaine plain, mepivacaine plain, articaine with 1:100,000 epinephrine, and lidocaine with 1:100,000 epinephrine. Benzo-Jel topical anesthetic was used for all injections. Slow, careful injections were administered. Patients rated the pain associated with the injection on a scale of 1 to 10, with 1 being no pain and 10 being unbearable pain.

Less pain was reported when prilocaine plain was used, compared to the other three agents. The pH of this anesthetic solution was closer to neutral than the others.

Differences in technique between clinicians exist as well. In this study, a male and female clinician participated. Differences were noted between clinicians and between clinician to patient – male to female and female to male. More than the pH of an anesthetic agent contributes to the patient’s experience of pain with injections.

Clinical Implications: Since injection technique varies between clinicians these findings cannot be generalized to all clinicians. It is interesting that the prilocaine plain was perceived as less painful when used by these two clinicians.

Wahl, M., Schmitt, M., Overton, D.: Injection Pain of Prilocaine Plain, Mepivacaine Plain, Articaine with Epinephrine, and Lidocaine with Epinephrine. General Dentistry: 54: 168-171, 2006.

Chlorhexidine toothpaste reduces gingivitis

Until now, chlorhexidine (CHX) toothpaste formulations have been ineffective due to the inactivation of the CHX by the detergents. New formulations are being developed to overcome this problem. Researchers in Brazil tested two new formulations: one combining CHX with fluoride and one with only CHX. These two test toothpastes were compared to a commercially available fluoride toothpaste in a group of 83 patients undergoing orthodontic treatment at the University of São Paulo, Brazil. Subjects ranged in age from 13 to 32 years.

Subjects were monitored in the clinic at six, 12 and 24 weeks, and phoned every 15 days by the department receptionist to reinforce motivation and answer questions. Subjects were instructed to brush three times per day for two minutes each time. Compliance with this request was reported by 71% of the group.

All subjects showed improved oral health, due in part to the Hawthorne Effect – participation in a study motivates people to improve, in this case their oral hygiene. Bleeding was reduced from 33% to approximately 7% in all three groups. Plaque and gingivitis levels were reduced more in the CHX toothpaste groups. No differences were observed between the two CHX toothpaste groups. The fluoride did not interfere with the actions of the CHX.

Staining was observed in both CHX groups, despite surprising reports of whiter teeth by 17% of the CHX/Fl toothpaste group and 40% of the CHX only group. During the six-month study, only 6% of subjects reported their teeth yellow or dark. Only 4% reported experiencing a bad taste.

Clinical Implications: We may see CHX toothpaste in the future, now that a formulation has been developed that does not inactivate the CHX.

Olympio, K., Bardal, P., Bastos, J., Buzalaf, M.: Effectiveness of a Chlorhexidine Dentifrice in Orthodontic Patients: A Ramdomized-Controlled Trial. J Clin Perio 33:421-426, 2006.

Full-mouth and quadrant approaches equivalent

Researches at the University of Bonn in Germany compared traditional quadrant instrumentation to the relatively new, full-mouth approach over a six-month period. In 1995, researchers in Belgium reported better healing following full-mouth instrumentation than following the traditional quadrant approach. Research teams since then have not been able to replicate those results for full-mouth instrumentation.

A total of 20 patients participated, half receiving full-mouth instrumentation and the other 10 receiving traditional quadrant instrumentation. Probing was done with the Florida Probe, measuring pocket depth, recession, attachment level and bleeding upon probing. Instrumentation was provided in a clock-wise manner, beginning with the maxillary right quadrant and ending with the mandibular right quadrant. Instrumentation was done with Sonicflex sonic scaler from KaVo and Gracey curettes from Hu-Friedy.

No statistically significant differences were observed between groups. Baseline probing depths were 5.3 mm for those receiving full-mouth instrumentation and 5.5 mm in the quadrant group. At six months, probing depths were reduced 1.6 mm in the full-mouth group and 1.5 mm in the quadrant group. Probing depth reductions reported in previous studies for full-mouth instrumentation ranged from 1 mm to 3 mm. Some researchers evaluated only single rooted teeth while others included multirooted teeth, thus explaining variations in results.

Clinical Implications: Full-mouth instrumentation is an alternative that most often provides results similar to quadrant instrumentation.

Jervøø-Storm, P., Demaan, E., AlAhdab, H., Engel, S., Fimmers, R., Jepsen, S.: Clinical Outcomes of Quadrant Root Planing Versus Full-Mouth Root Planing. J Clin Perio 33: 209-215, 2006.

The value of communication

Hygienists and dentists recommend treatment, but patients don’t always comply. Researchers at the University of Michigan evaluated the patient/clinician relationship, fear, anxiety, education and income to determine a connection between acceptance and rejection of treatment. The study included 74 adult patients scheduled in the graduate periodontal clinic during the summer of 2004. Graduate students told these patients that surgery was needed; however, due to an oversite, the type of surgery recommended was not recorded. Surgical treatment was accepted by 51 patients, non-surgical treatment by 22 patients and one patient declined any treatment. Baseline demographic information was collected at the initial visit and follow-up information was collected two weeks after treatment, either in person or over the phone.

Demographics were similar between those selecting surgical versus non-surgical treatment. However, those accepting surgery had more years of education and a higher monthly income. Those accepting surgery had less dental fear and in general, less anxiety. Monthly income was not associated with dental fear; however, those with higher anxiety earned less per month. Both groups felt they received adequate information from their clinicians. Both groups agreed on the financial value placed on their treatments.

Those who agreed to treatment had a higher trust level for their clinician. The authors concluded that these findings “clearly support the recommendations of the Institute of Medicine’s report on the future of dental education to educate future dental health care providers to be more patient centered.”

Clinical Implications: Good communication between clinician and patient contribute to patient compliance with recommended treatment.

Patel, A., Richards, P., Wang, H., Inglehart, M.: Surgical or Non-Surgical Periodontal Treatment: Factors Affecting Patient Decision Making. J Perio 77: 678-683, 2006.

Atridox enhances healing

According to the research, healing in smokers is compromised following both surgical and non-surgical periodontal treatment. For that reason, adjunctive locally delivered antibiotics are recommended.

Researchers at the State University of Campinas in Brazil compared scaling and root planing with and without Atridox in anterior sites only. Control sites received scaling and root planing followed by saline irrigation. Treatment was performed at baseline and repeated at 12 months for pockets 5 mm or deeper. At all visits (two weeks, 24 days, two months and six months) subjects received full-mouth ultrasonic debridement and oral hygiene instructions. Additional scaling and root planing were done for any site exhibiting 2 mm or more of attachment loss.

The study began with 48 patients; however, 18 were excluded during the two-year test period for several reasons: not completing all visits, quitting smoking or health problems. A total of 236 sites were monitored for two years. Greater healing was noted in deeper sites for both the test and control groups. Deeper sites responded better with the two applications of Atridox, showing probing depth reductions of 3 to 4 mm compared to 2 to 3 mm for the scaling and root planing only group. Attachment level gains were also greater in the Atridox group, 1.5 to 2.8 mm compared to 0.5 to 1.4 mm.

Clinical Implications: Atridox may be helpful when treating anterior sites with severe periodontal disease in smokers.

Machion, L., Andia, D., Lecio, G., Nociti, Jr., F., Casati, M., Sallum, A., Sallum, E.: Locally Delivered Doxycyclnie as an Adjunctive Therapy to Scaling and Root Planing in the Treatment of Smokers: A 2-Year Follow-Up. J Perio 77: 606-6-13, 2006.

Inconclusive laser findings

Occasionally the American Academy of Periodontology (AAP) commissions a review of the literature on a topic of interest. The latest is on lasers by Dr. Charles Cobb. The first report in the literature describing lasers for dental procedures used an ophthalmic laser for caries removal. Four years later the laser was suggested for soft-tissue procedures. Today, the use of lasers for periodontal therapy is common, yet many research questions on the subject are still unanswered.

Dr. Cobb narrowed down a list of over 1,000 articles to 278 that he considered scientific rather than opinion or commercial in nature. These studies covered seven different lasers and also similar lasers used at different settings. Rarely did the researchers follow the same study design, making comparisons difficult, if not impossible. Study conclusions are conflicting, with some demonstrating an advantage with the laser, while others show no advantage and some show potential for damage. Of the 278 studies considered for the review, only 23 were human trials.

Considering the number of periodontal lasers on the market and the increase in scientific reports, the trend is toward laser use in periodontics. The Nd:YAG and the Er:YAG lasers may be equivalent to traditional scaling and root planing, based on reduction in probing depths. However, when attachment levels are considered, minimal evidence exists supporting a superiority of lasers over traditional therapy. Based on the studies to date, no conclusion can be reached concerning the superiority of a specific laser over traditional therapy. More research is needed that follows the randomized, controlled trial design to allow comparison of studies.

Clinical Implications: More research is needed to determine if lasers are superior to scaling and root planing and if so, which type of laser and what wavelength is best.

Cobb, C.: AAP Commissioned Review. Lasers in Periodontics: A Review of the Literature. 77: 545-564, 2006.