Subjective intensity of pain duringultrasonic supragingival calculusremovalBraun A, Jepsen S, Krause F. Subjective intensity of pain during ultrasonicsupragingival calculus removal. J Clin Periodontol 2007; 34: 668–672. doi: 10.1111/j.1600-051X.2007.01100.x.

AbstractObjective: To assess subjective intensities of pain during supragingival calculusremoval employing ultrasonic scaler tips of two different shapes.

Material and Methods: Twenty patients were treated using a piezoelectric ultrasonicdevice (Sirosonic L) and two different scaler tips representing a conventional(Instrument No. 3) and a slim-line style (Perio Pro Line Instrument SI-11) in asplit-mouth design. Pain was recorded during calculus removal at intervals of 0.5 semploying an inter-modal intensity comparison. Additionally, a visual analogue scalewas used for evaluation directly after the treatment procedure. Treatment time wasrecorded to assess the efficiency of calculus removal.

Results: Pain assessment during treatment showed that the slim-line scaler tip(median pain score: 1.4 [U], maximum: 3.5 [U], minimum: 0 [U]) caused less painthan the conventional device (median pain score: 7.8 [U], maximum: 14.7 [U],minimum: 0 [U]) (po0.05). These results could be confirmed by the visual analoguescale. Treatment with the slim-line tip took significantly longer than treatment with theconventional tip (po0.05).

Conclusions: Using slim-line-styled ultrasonic scaler tips for supragingival calculusremoval, painful sensations can be reduced compared with conventional ultrasonicdevices. Thus, it might be possible to increase the patient’s compliance during dentaltreatment with oscillating instruments.

Key words: calculus removal; inter-modalintensity comparison; pain assessment;ultrasonic instrumentation; visual analoguescale

Accepted for publication 4 April 2007

Reducing supra and subgingival plaqueand calculus as well as preventing reco-lonization of periodontal pockets bypathogenic bacteria are fundamentalaspects of periodontal therapy (Westfelt1996). Therefore, dental plaque, anadherent, bacterial biofilm that formson soft and hard tissues (Bernimoulin2003) and calcified deposits should beremoved from the tooth surface. Calcu-

lus can be removed employing handscalers, ultrasonic instruments, air-pow-der abrasive scalers, diamond burs andlasers. A beneficial effect of ultrasonicinstrumentation in creating a smoothsurface without extensive removal ofhard tissues could be demonstrated(Jacobson et al. 1994). Moreover,adjustments in working parameters,shapes and sizes shall allow the adaptionof an ultrasonic scaler’s efficacy tovarious clinical needs (Flemmig et al.1997, 1998b, Braun et al. 2005a, b) andmay influence efficacy and aggressive-ness of the respective device (Jepsenet al. 2004). Additional cavitationaland acoustic microstreaming patterns(Walmsley et al. 1990, Khambay &Walmsley 1999) are supposed to facil-

itate instrumentation of less-accessibleareas and reduce the proportion ofGram-negative bacteria (Leon &Vogel1987). Dental plaque formation in ahealthy subject first occurs supragingiv-ally, which then often progresses sub-gingivally (Bernimoulin 2003). Leavingthis biofilm on the tooth surface in caseof inadequate oral hygiene, plaque canmineralize and form calculus deposits.Thus, especially during periodontalmaintenance care or after calculus for-mation on not periodontally invol-ved teeth, the primary need of dentaltherapy might be supragingival calculusremoval. Moreover, carefully performedsupragingival cleaning procedures canchange the composition and the quantityof subgingival microbiota with a possi-

Andreas Braun, Søren Jepsen andFelix Krause

Department of Periodontology, Operative and

Preventive Dentistry, University of Bonn,

Bonn, Germany

Conflict of interest and source offunding statement

The authors declare that they have noconflict of interests.

The study was self-funded by the authorsand their institution. Sirona Dental sys-tems are acknowledged for providing theultrasonic insert tips.

J Clin Periodontol 2007; 34: 668–672 doi: 10.1111/j.1600-051X.2007.01100.x

668 r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard

ble decrease in the number of period-ontopathogens (Dahlen et al. 1992, Hell-strom et al. 1996). However, exclusivesupragingival plaque control fails toprevent further periodontal tissuedestruction in subjects with advancedperiodontal disease (Westfelt et al.1998).

Patient’s compliance with dental treat-ment procedures is affected by manyreasons, including self-destructive beha-viour, fear, economic factors, healthbeliefs, stressful events in their lives andperceived dentist indifference (Wilson1998). Supragingival calculus removalprocedures are reported to cause painfulsensations in the patient (Kocher et al.2005b). Thus, the ability to deliver dentalcare with a minimum of patient discom-fort should be an essential part of aclinician’s skills to avoid a decline ofcompliance. Recent research could de-monstrate the possibility to affect thesesensations employing different ultrasonicdevices, scaler tip styles or treatment pro-cedures for subgingival treatment (Braunet al. 2003, Hoffman et al. 2005). Parti-cularly with regard to fearful and sensitivepatients, a device inducing only minorpainful sensations during supragingivaltreatment procedures would be desirable,thus enhancing the patient’s complianceand possibly improving the prognosis ofperiodontal care.

Testing the hypothesis of pain beingcorrelated with the shape of differentscaler tips of the same ultrasonic device,the aim of this study was to comparesubjective pain sensations during supra-gingival calculus removal. Both thepatient’s current sensations during thewhole treatment procedure and a sum-marized judgment after the treatmentwere evaluated. The patient’s accep-tance of the different modificationsof the ultrasonic device was classied,

as it strongly correlates with theirpainfulness.

Material and Methods

Twenty patients (11 females, ninemales, mean age: 43.6 � 11.5 years),each of whom presented with supragin-gival calculus on the respective mandib-ular front teeth and with comparableperiodontal pocket depths of 4 mm orless, were treated using a piezoelectricultrasonic handpiece (Sirosonic L,Sirona, Bensheim, Germany) and twodifferent scaler tips representing aconventional (Instrument No. 3, Sirona,Benshelm, Germany) and a slim-linestyle (Perio Pro Line Instrument SI-11,Sirona) (Fig. 1). According to the man-ufacturer, the maximum amplitude ofoscillation was 160mm at 29.4 kHz and120mm at 30.5 kHz, respectively, for the100% power setting (DIN EN ISO22374). Both scaler tips showed a pre-dominantly linear oscillation pattern andwere operated at the 100% setting of theultrasonic device. The same diameter of0.6 mm could be measured at a distanceof 1 mm to the end of the inserts. Owingto different conicities, at a distance of5 mm the diameter of the slim-line-shaped tip (0.7 mm) was smaller thanthe value for the conventional device(1.2 mm). Patients received professionaldental care and tooth cleaning proce-dures regularly but no surgical perio-dontal treatment before. All treatmentprocedures were performed by oneoperator. Using a split-mouth studydesign, the sequence of the differenttreatments was randomly assigned byuse of a computer-generated randomnumber table: either the lower right orleft front teeth were treated with onetype of scaler, leaving the remaining

front teeth to be treated with the otherscaler tip. All patients had beeninformed about the study and had giventheir informed consent. The study wasconducted in full accordance with thedeclared ethical principles (World Med-ical Association Declaration of Helsin-ki, Version VI, 2002) and had beenapproved by the local Ethic’s Commit-tee (reference number: 134/06). Painwas recorded during calculus removalat intervals of 0.5 s employing an inter-modal intensity comparison accordingto a previously published study design(Braun et al. 2003): the patient held thebulb of a manometer (Speidel and Kel-ler, Jungingen, Germany) in his lefthand with the output monitored by acomputer. The patient was asked to setthe pressure of his hand in proportion tothe perceived intensities of pain. Addi-tionally, after the treatment the subjec-tive intensities of pain were assessedwith a visual analogue scale (VAS)ranging from 0, representing no pain ordiscomfort, to 10, representing maxi-mum pain and discomfort. After eachtreatment, a new paper-bow with theprinted interval scale was given to thepatient, so that he could not be influ-enced by the previous results. Treatmenttime was recorded to assess the effi-ciency of calculus removal. The end-point of treatment was a clinicallyjudged clean tooth surface. The studydesign comprised only the removal ofsupragingival calculus. If subgingivalcalculus was detected during the treat-ment procedure, it was removed withoutpain assessment after supragingivalcleaning of all front teeth.

For statistical analysis normal distri-bution of the values was assessed withthe Shapiro–Wilk test. As not alldata were normally distributed, valueswere analysed with a nonparametric test(Wilcoxon). Evaluating the correlationbetween the two different methods forpain assessment, cross tabulation tablesof the VAS readings and both overallmean and median values of hand pres-sure over time and the respective Pear-son’ correlation coefficients werecomputed. Differences were consideredas statistically signicant at po0.05.

Results

Pain scores could be shown to be depen-dent on the used ultrasonic scaler tips.The inter-modal intensity comparisonduring treatment showed that the

Fig. 1. Slim-line-styled (a) and conventional ultrasonic scaler tip (b) used in the study, bothoperated with the same handpiece and power settings.

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slim-line-styled scaler tip (median painscore: 1.4 [U], maximum: 3.5 [U], mini-mum: 0 [U]) caused less pain than theconventional ultrasonic scaler (medianpain score: 7.8 [U], maximum: 14.7 [U],minimum: 0 [U]) (po0.05). Assessingthe occurrence of pain sensations overtime, it could be demonstrated that paindid not occur constantly but treatmentwith the slim-line-styled scaler tip was

never assessed to be as painful as thetreatment with the conventional ultra-sonic tip (Fig. 2). These results could beconfirmed by VAS measurements aftertherapy (Fig. 3). Evaluating the readingsof the two different methods for painassessment, no correlation could befound between the VAS and the overallmean and median pain values of handpressure over time (p40.05). Treatment

with the slim-line-styled scaler (median:95.5 s, maximum: 164 s, minimum: 64 s)took significantly longer time than withthe conventional tip (median: 77.5 s,maximum: 127 s, minimum: 54 s)(po0.05).

Discussion

Regarding scores of both the VAS andthe inter-modal intensity comparisonduring the treatment procedure, therewas a significant difference in painsensations between the two evaluatedscaler tips. This difference cannot beexplained by different periodontal con-ditions as all included teeth had compar-able periodontal pocket depths, allowingan intra-experimental split-mouth com-parison. Another study compared asonic and an ultrasonic scaler regardingpain during prophylaxis treatment(Kocher et al. 2005b). By means of aVAS, no difference could be observedbetween these two treatment devices.Assessing pain associated with perio-dontal maintenance therapy, no differ-ence could be demonstrated, comparingthe Vectort device (Duerr Dental, Bie-tigheim-Bissingen, Germany) and aconventional ultrasonic device at areduced power setting (Kocher et al.2005a). Once again, only a VAS wasused to assess pain perception in thisstudy. This scale allows only a retro-spective assessment of previous painfulsensations. In contrast, in the presentstudy it was possible to record painsimultaneously with the treatment pro-cedure and thus extend the precision ofpain assessment. Recording intensitiesof pain during the whole treatmentprocedure employing a manometergives the opportunity to assess anypain sensations correlated with the exacttreatment time (Braun et al. 2003). Themore common method of evaluatingpain scores with a VAS assesses painfulsensations only retrospectively, so thatpossible high peaks of pain may berecorded imprecisely (Huskisson 1983,Tammaro et al. 2000). Thus, an inter-modal intensity comparison, measuringpainful sensations at intervals of 0.5 s, isnot limited to one recapitulating VASvalue recorded after the treatment pro-cedure but gives time-dependent read-ings. As a consequence, an inter-modalintensity comparison can be consideredmore precise concerning pain assess-ment, as a VAS does not include timeas a variable. The different qualities ofthe two methods are reflected in the

Fig. 2. Pain scores during ultrasonic treatment with the Sirosonic tip and the slim-line styledPerio Pro Line instrument. Pain values [U] show mean values of inter-modal intensitycomparisons for the 20 patients under study. Start of treatment at 12 o’clock position, runningclockwise to the end. Lowest pain scores during calculus removal with the Perio Pro Line tip.

10 175

150

125

100

trea

tmen

t tim

es [s

]

pain

ass

essm

ent [

U]

75

50

8

6

4

2

0

Perio Pro Line Sirosonic Perio Pro Line Sirosonic

Fig. 3. Pain assessment employing the visual analogue scale and treatment time for the twodifferent ultrasonic tips evaluated in the present study. Significantly lower pain scores aftertreatment with the slim-line-styled instrument (po0.05) but shorter treatment time forcalculus removal with the conventional device (po0.05). Box plots show median, first andthird quartiles, minimum and maximum values (whiskers). Outliers are marked as data pointsand asterisks.

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finding of no correlation between therespective outcomes. Unfortunately,there are no further studies availablecomparing the outcomes of a VAS toan inter-modal intensity comparison byhand pressure. However, evaluatingonly short-time pain sensations, e.g.correlated with periodontal probing(Hassan et al. 2005), the use of a VASappears to be appropriate for painrecording as the probing procedure com-prised a temporally defined pain sensa-tion. Another possibility for detectingtooth-related painful sensations inhumans is the recording of evokedpotentials (Braun et al. 2000). In thepresent study, this method was notapplicable as the ultrasonic vibrationdoes not represent an exact temporallydefined and reproducible peripheral sti-mulus, so that characteristic dentalpotentials are not distinguishable fromthe spontaneous activity of the cortex.Thus, VASs and inter-modal intensitycomparisons with a manometer weresuitable to estimate the pain intensitiesin the present study. A manometer likethe one used in the present study is atool previously described for inter-mod-al intensity comparisons (Stevens 1970,Braun et al. 2003). Stevens used amanometer to set the pressure of asubject’s hand in proportion to the inten-sity of light (Stevens 1970). In furtherstudies the intensities of heat, weight,cold, vibration and sound were evalu-ated using a manometer (Stevens 1975).A comparable inter-modal matchingdevice is the so-called ‘‘finger span’’(Franzen & Berkley 1975): two metalarms were taped to the thumb and indexnger of the subject. The distance ofthese two arms was measured with apotentiometer and set in relation to thesubjective intensities of pain.

In the present study, supragingivalcalculus was assessed only at the man-dibular front teeth. The reason for limit-ing to these teeth was that calculusformation is most commonly seen onthe lingual aspects of the lower incisorsand canines and on the buccal aspects ofthe upper first and second molars. Thesesites of predilection coincide with theopenings of the major salivary glands(Addy & Koltai 1994). The amount ofindividual calculus accumulation wasnot assessed before treatment as in thepresent study both evaluated treatmentprocedures were used in a split-mouthdesign, allowing an intra-experimentalcomparison of the two ultrasonic scalertips under study. In the present study, all

ultrasonic scalers were used with a tipangulation close to 01. Investigatingworking parameters of a sonic andpiezoelectric ultrasonic scaler on rootsubstance removal, it could be shownthat this angulation might prevent severeroot damage (Flemmig et al. 1998a, b,1997). Instruments were always usedwith the same power settings and instru-mentation of all teeth was undertaken byone investigator, allowing an inter-instrumentation comparison within theexperimental set-up. Regarding theoscillation at the used power setting,there was no major difference in thefrequency of the used tips but the max-imum amplitude of 160mm for the con-ventional scaler and 120mm for theslim-line-styled tip could have influ-enced pain perception. According tothe manufacturer, this difference inamplitude is due to the design of thescaler tips. The occurrence of differentamplitudes may therefore explain thehigher efficiency of the conventionalultrasonic tip: treatment with the slim-line-styled insert took significantly long-er than calculus removal with theconventional tip. This result is in accor-dance with previous studies evaluatingsubgingival calculus removal employingvarious insert tips of the piezoelectricultrasonic Vectort device (Braun et al.2005a, 2006).

The present study indicates that theuse of slim-line-styled ultrasonic scalertips for supragingival calculus removalmay result in reducing pain sensationscompared with conventional ultrasonicdevices. Considering the overall aim todeliver dental care with a minimum ofpatient discomfort, it thus might bepossible to increase the patient’s com-pliance during dental treatment withoscillating instruments.

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Address:

Priv-Doz Dr Andreas Braun

Department of Periodontology

Operative and Preventive Dentistry

University of Bonn

Welschnonnenstrasse 17

53111 Bonn Germany

E-mail: andreas.braun@uni-bonn.de

Clinical Relevance

Scientific rationale of the study: Par-ticularly with regard to fearful andsensitive patients, a treatment deviceinducing only minor painful sensa-tions would be desirable, thus enhan-cing the patient’s compliance andpossibly improving the prognosis of

periodontal care. Pain assessmentduring supragingival calculusremoval is poorly evaluated andmight lead to reducing patient dis-comfort.Principal findings: Using slim-line-styled ultrasonic scaler tips for supra-gingival calculus removal, painful

sensations can be reduced but treat-ment is more time consuming.Practical implications: Clinicianscan perform pain-reduced supragin-gival debridement procedures withslim-line-styled ultrasonic tips buthave to expect a longer treatmenttime than with conventional devices.

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