ABSTRACT To evaluate the pain experience of the patient during and after scaling and root planing (SRP) using local or topical anesthetic agents. A total of 30 Chronic Periodontitis patients participated in this study. Three quadrants in each patient were randomly allotted to receive non-surgical periodontal therapy i.e. scaling &amp; root planing (SRP) with 2% lidocaine injection (Group 1) or topical application of 8% Lidocaine + 0.8% Dibucaine (Group 2) or 2% lidocaine gel (Group 3). Pain was assessed midway through the treatment and immediately after treatment (post-operatively) using Visual Analogue Scale (VAS). The patients were asked about pain /discomfort following treatment after one day and their preference for the anesthetic if any. ANOVA followed by Bonferroni&apos;s post hoc Analysis was used to compare the mean pain score in all the three study groups. Paired t-tests were used to analyse pain scores during and after treatment in each groups. The inter-group comparisons of mean pain score in all the 3 study groups during procedure and post-operatively among the groups were statistically significant(&lt; 0.05) but pain scores during the procedure between group 2 and group 3 were not statistically significant (0.061). The experience of pain or discomfort one day post operatively was significantly higher in Group1 (2% Lidocaine Injection) 70% compared to Group 2 (8% Lidocaine + 0.8% Dibucaine) 36.70% and group 3 (2% Lidocaine Topical) 46.70%. Though 56.70% of the patients in the study preferred (8% Lidocaine + 0.8% Dibucaine) anesthetic gel for procedure over 2% Lidocaine anesthetic Injection and 2% Lidocaine Topical. Lidocaine Injection 2% was more effective in controlling pain during scaling and root planing than 8% Lidocaine + 0.8% Dibucaine and 2% Lidocaine Topical, but 8% Lidocaine + 0.8% Dibucaine anesthetic gel had less pain/discomfort one day post-operatively and most preferred anesthetic when compared with other two as it avoided postoperative numbness, fear from needle prick and favourable taste of the anesthetic gel

Rithesh K

Sachidananda Chungkham

Savita S

Syed Sirajuddin

CiteSeerX

ISSN: 0975-8585 
 
July– August  2015  RJPBCS   6(4)  Page No. 627 
Research Journal of Pharmaceutical, Biological and Chemical 
Sciences 
 
Evaluation of Pain Experience During and After Scaling and Root Planing 
(SRP) Using Local / Topical Anesthetic Agents: A Comparative Study. 
 
Savita S, Sachidananda Chungkham*, Rithesh K, and Syed Sirajuddin. 
 
Department of Periodontology, Rajarajeswari Dental College and Hospital, Bangalore, Karnataka, India. 
 
 
ABSTRACT 
 
To evaluate the pain experience of the patient during and after scaling and root planing (SRP) using 
local or topical anesthetic agents. A total of 30 Chronic Periodontitis patients participated in this study. Three 
quadrants in each patient were randomly allotted to receive non-surgical periodontal therapy i.e. scaling & 
root planing (SRP) with 2% lidocaine injection (Group 1) or  topical application of 8% Lidocaine + 0.8% 
Dibucaine (Group 2) or 2% lidocaine gel (Group 3). Pain was assessed midway through the treatment and 
immediately after treatment (post-operatively) using Visual Analogue Scale (VAS). The patients were asked 
about pain /discomfort following treatment after one day and their preference for the anesthetic if any. 
ANOVA followed by Bonferroni's post hoc Analysis was used to compare the mean pain score in all the three 
study groups. Paired t-tests were used to analyse pain scores during and after treatment in each groups. The 
inter-group comparisons of mean pain score in all the 3 study groups during procedure and post-operatively 
among the groups were statistically significant(< 0.05) but pain scores during the procedure between group 2 
and group 3 were not statistically significant (0.061). The experience of pain or discomfort one day post 
operatively was significantly higher in Group1 (2% Lidocaine Injection) 70% compared to Group 2 (8% 
Lidocaine + 0.8% Dibucaine) 36.70% and group 3 (2% Lidocaine Topical) 46.70%. Though 56.70% of the patients 
in the study preferred (8% Lidocaine + 0.8% Dibucaine) anesthetic gel for procedure over 2% Lidocaine 
anesthetic Injection and 2% Lidocaine Topical. Lidocaine Injection 2% was more effective in controlling pain 
during scaling and root planing than 8% Lidocaine + 0.8% Dibucaine and 2% Lidocaine Topical, but 8% 
Lidocaine + 0.8% Dibucaine anesthetic gel had less pain/discomfort one day post-operatively and most 
preferred anesthetic when compared with other two as it avoided postoperative numbness, fear from needle 
prick and favourable taste of the anesthetic gel.  
Keywords: Anesthetic gel; Dibucaine; Discomfort; Lidocaine; Pain; Scaling and root planning (SRP). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Corresponding author 
 
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INRODUCTION 
 
Periodontal disease is a chronic inflammatory disease that causes destruction of the periodontal 
tissues that surround and support the teeth. Mechanical debridement i.e. scaling and root planing is 
mandatory to eliminate and to arrest the further progression of periodontal tissue destruction. 
 
Painful experiences often accompany diagnostic and therapeutic procedures involving periodontal 
tissues (Pihlstrom et al. 1999).[1] Patients vary in their ability to tolerate painful or stressful dental procedures 
(Klages et al. 2004).[2]
 
 
Scaling is often associated with discomfort if not pain; sub-gingival scaling and root planing appear to 
be more painful than supragingival scaling that differs in its severity from one person to another. It is often 
necessary to use local anaesthesia during subgingival scaling and root planing (SRP) to control pain and 
discomfort.[3]
 
 
Injectable anesthetics are effective in controlling pain even though patients avoid due to fear of the 
needle, as well as for the prolonged numbness of adjacent tissues, such as the lips and tongue. Topical 
anaesthetics have been used in dentistry to reduce or eliminate discomfort associated with needle penetration 
(Hutchins et al. 1997, Alqareer et al. 2006) and control pain during periodontal procedures.[4, 5]
 
 
When compared with placebo, topically applied lidocaine-containing bioadhesive patches (Carr & 
Horton 2001) significantly reduce pain.6 Anaesthetic in a thermosetting agent (Donaldson et al. 2003; Jeffcoat 
et al. 2001) was also shown to be effective in controlling pain during scaling and root planing.[7, 8] Topical 
anaesthetics may also be preferred because they produce less post-procedure numbness (van Steenberghe et 
al. 2004).[9] Precaine® is a topical anesthetic containing (8% lidocaine + 0.8% dibucaine) that is commercially 
available. This product has proved to be reliable in reducing pain during intraoral procedures like palatal 
injections, inferior alveolar nerve block and gingival depigmentation using laser. 
 
Local anesthetic injection is considered as a gold standard for controlling the pain during dental 
procedure, although various topical anesthetic gels have been used to controlled pain during various dental 
procedures. So, this study was carried out to evaluate the pain and discomfort experience during and after 
scaling and root planing (SRP) using local and topical anesthetic agents. 
 
MATERIALS AND METHODS 
 
A total of 30 patients with chronic periodontitis (21 males and 9 females; age range: 25 to 50 years) 
were included in the study. The study was conducted in Department of Periodontology, Rajarajeswari Dental 
College and Hospital, Bangalore. The treatment procedure was explained to the patient and written consent 
was obtained. Ethical clearance was obtained from Institutional Ethical Committee Review Board. Patients 
with minimum age 25 years who were systemically healthy, able to comprehend the visual analogue scale and 
had at least three dental quadrants each with two or more non-adjacent pockets > 5mm were included in the 
study. Exclusion criteria included patients with abscess and endodontic infections, patients requiring antibiotic 
prophylaxis before root planing, patients allergic to lidocaine or currently under medication such as analgesics. 
In each patient, three sites (each in different quadrants) were randomly allotted to one of the following 
groups. Group 1 included the sites that received scaling & root planing (SRP) with LA injection. Group 2 
included the sites that received scaling & root planing (SRP) with topical application of 8% lidocaine gel+0.8% 
Dibucaine gel (Figure 1). Group 3 included the sites that received i.e. scaling & root planing (SRP) with 2% 
lidocaine gel (Figure 2). 
 
Before scaling and root planning, each subject completed a medical and dental history questionnaire 
and underwent periodontal examination. Participants were individually instructed about the Visual Analogue 
scale (VAS). VAS is usually a horizontal line, 100 millimetres in length anchored by word descriptors at each 
end, as illustrated in Figure 3.[10] The patient marks a point on the horizontal line according to his or her 
perception of the current state of pain. The VAS score is determined by measuring in millimetres from the left 
hand end of the line to the point that the patient mark. Pain was assessed during the treatment i.e. 
approximately midway through treatment (intra-operatively) and immediately after treatment (post-
operatively). 
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July– August  2015  RJPBCS   6(4)  Page No. 629 
 
 
Figure 1: 8% Lidocaine + 0.8% Dibucaine anesthetic gel 
 
Figure 2: 2% Lidocaine anesthetic gel 
 
Single operator performed the subgingival scaling & root planing (SRP) and assessed the main 
outcome. SRP was performed after administration or application of the anesthetic for the selected three 
groups in the same appointment. The patients were asked to indicate the intensity of pain experience during 
the treatment with the aid of the Visual Analogue Scale (VAS) [10] five minutes after the onset of the 
procedure i.e. mid-way during the procedure (intra-operative) & immediately after the completion of 
treatment. The day following the completion of treatment; patients were asked about the pain /discomfort 
from the treatment and their preference of the anesthetic (as per their comfort) were recorded.  
 
 
 
No Pain                                                                                      Very Severe Pain 
 
Figure 3: Visual Analogue scale (VAS). Horizontal line,100 millimetres in length. 
 
Statistical Analysis 
 
The statistical analysis was done using SPSS version 15.0 statistical analysis software. ANOVA followed 
by Bonferroni's post hoc Analysis were used to compare the mean pain score in all the three study groups. 
Paired t-tests were used to analyse pain scores during and after treatment in each groups. Chi-square test was 
done to compare the pain/discomfort following treatment and preferred anesthetic method by patients. In 
this study p < 0.05 was considered to be significant. 
 
 
 
 
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RESULTS 
 
Thirty patients (21 males and 9 females) in the age range of 25 to 50 years (mean35.07±6.44) 
participated in the study and they were equally allocated to the groups. Table 1.shows the inter-group 
comparisons of mean pain score in all the 3 study groups using ANOVA followed by Bonferroni's post hoc 
analysis during and after treatment. As the table shows, the pain scores during the procedure and after 
treatment (post-operatively) among groups were statistically significant (p < 0.05).  However, the comparison 
of pain scores during the procedure between group 2 and group 3 were found to be not statistically significant. 
 
Table 1: Comparison of mean pain perception in all the three study groups using ANOVA followed by Bonferroni's post 
hoc Analysis 
 
Time Period Groups N Pain Score 
Mean 
SD p-value Sig. diff p-value 
During treatment  G1 
(2% Lidocaine 
Injection) 
30 6.6 12.47  
 
 
 
 
<0.001* 
G1 Vs G2 0.015
* 
G2  
(8% Lidocaine + 
0.8%  Dibucaine) 
Topical Gel 
30 14.53 9.508 G1Vs G3 <0.001
* 
G3 
(2% Lidocaine) 
Topical Gel 
30 19.33 9.654 G2 Vs G3 0.061
** 
After  
Treatment 
(postoperative) 
G1 
(2% Lidocaine 
Injection) 
30 3.87 8.308  
 
 
 
 
<0.001* 
G1 Vs G2 <0.001
* 
G2 
 (8% Lidocaine + 
0.8%  Dibucaine) 
Topical Gel 
30 8.77 6.632 G1 Vs G3 0.05
* 
G3 
(2% Lidocaine) 
Topical Gel 
30 12.83 8.424 G2 Vs G3 0.042
* 
   
*-significant        ** - not significant 
 
The mean pain scores for Group1 (2% Lidocaine Injection), Group 2 (8% Lidocaine + 0.8% Dibucaine) 
and group 3 (2% Lidocaine Topical) were statistically significant during the procedure as well as post-
operatively with p < 0.05 for all the three groups (Table 2, 3, 4). 
 
Table 2: Comparison of pain perception in Group 1 (2% Lidocaine Injection) using Paired‘t’ test 
 
 
 
Table 3: Comparison of pain perception in Group 2 (8% Lidocaine + 0.8% Dibucaine) Topical Gel using Paired’t’ test 
 
 
 
 
 
 
 
 
 
Time Period N Pain Score Mean SD SE p-value 
During treatment  30 6.60 12.47 2.28   
 
0.004* 
After  
Treatment 
(postoperative) 
 
30 
 
3.87 
 
8.31 
 
1.52 
 
Time Period N Pain Score Mean SD SE p-value 
During treatment  30 14.53 9.51 1.74  
<0.001* After  
Treatment 
(postoperative) 
 
30 
 
8.77 
 
6.63 
 
1.21 
 
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July– August  2015  RJPBCS   6(4)  Page No. 631 
Table 4: Comparison of pain perception in Group 3 (2% Lidocaine) Topical Gel using Paired‘t’ test 
 
 
 
 
 
 
 
 
*-significant         
 
The experience of pain or discomfort one day after procedure was significantly higher in Group1 (2% 
Lidocaine Injection) 70% compared to Group 2 (8% Lidocaine + 0.8% Dibucaine) 36.7% and group 3 (2% 
Lidocaine Topical) 46.70% (Table .5). 
 
Table 5: Comparison of Pain / Discomfort one day after the completion of treatment, by different study groups 
 
 
Study Groups 
 
Distribution 
Pain / Discomfort  
Chi-Square 
 
P-Value Present Absent 
 
G1 
(2% Lidocaine 
Injection) 
N 21 9  
 
 
 
 
7.026 
 
 
 
 
 
0.03* 
% 70.00 30.00 
G2  
(8% Lidocaine + 0.8%  
Dibucaine) Topical Gel 
N 11 19 
% 36.70 63.30 
G3  
(2% Lidocaine) Topical 
Gel 
N 14 16 
% 46.70 53.30 
*-significant         
 
Of the total patients, 56.7% preferred (8% Lidocaine + 0.8% Dibucaine) anesthetic gel for procedure, 
33% preferred 2% Lidocaine anesthetic Injection and only 10% preferred 2% Lidocaine Topical (Table .6).  
 
Figure 4: Mean pain score during and after treatment 
 
 
 
 
 
 
Time Period N Pain Score Mean SD SE p-value 
During treatment  30 19.33 9.65 1.76   
 
<0.001* 
After  
Treatment 
(postoperative) 
 
30 
 
12.83 
 
8.42 
 
1.54 
 
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July– August  2015  RJPBCS   6(4)  Page No. 632 
Table 6: Comparison of preference to the type of Anaesthesia by different study groups 
 
 
Study Groups 
 
Distribution 
Preference  
Chi-Square 
 
P-Value Preferred Not Preferred 
G1(2% Lidocaine 
Injection) 
N 10 20  
 
 
 
 
14.7 
 
 
 
 
 
0.001* 
% 33.30 66.70 
G2 (8% Lidocaine + 
0.8%  Dibucaine) 
Topical Gel 
N 17 13 
% 56.70 43.30 
G3 (2% Lidocaine) 
Topical Gel 
N 3 27 
% 10.00 90.00 
*-significant         
 
 
 
Figure 5: Amount Pain / Discomfort one day after the completion of treatment 
 
 
 
Figure 6: Preference of Anaesthesia by different study groups 
 
DISCUSSION 
 
It is widely accepted that injectable anesthesia is the first choice for routine SRP procedures. 
However, needles are associated with pain, anxiety and fear. As a result; some patients prefer to bear mild or 
moderate pain during SRP rather than receiving an injection. In the present study, among the three anesthetic 
agents, 2% Lidocaine Injection shows less mean pain score of 6.6 during procedure and 3.87 post operatively; 
compared to 8% Lidocaine + 0.8%  Dibucaine(14.53 and 8.77) and  2%  Lidocaine Topical (19.33 and 12.83) 
[Figure .4]. 
 
However, the experience of pain or discomfort one day after the procedure was found to be more 
pronounced with 2% Lidocaine Injection (70%) as compared to 8% Lidocaine + 0.8% Dibucaine (36.70%) topical 
ISSN: 0975-8585 
 
July– August  2015  RJPBCS   6(4)  Page No. 633 
and 2% Lidocaine topical (46.70%) [Figure .5]. This finding may be due to the needle prick pain during injection 
and the post-anesthetic discomfort such as numbness.  
 
In a study by Hassan et al, pain or discomfort during and after non-surgical periodontal therapy is 
more with 2% Xylocaine when compared to local anesthetic gel (Benzocaine 18.0% and Tetracaine 
hydrochloride 2.0%).
11
 In another study by Nayak R et al., evaluation of three topical anesthetic agents against 
pain was done wherein 18% Benzocaine, 5% Lignocaine and 5% EMLA were used. Results suggested that 
benzocaine had the rapidest onset of action followed by lignocaine and EMLA cream.
12
 Although some study 
shows that benzocaine gel is less effective than injected lidocaine in controlling pain during scaling and planing 
(Stoltenberg et al, 2007).[13]
 
 
On the other hand, results of the present study indicated that among all the patient in the study 
groups 56.70% preferred (8% Lidocaine + 0.8%  Dibucaine) anesthetic gel for procedure compared to 33% for 
2% Lidocaine anesthetic  Injection and only 10% for 2% Lidocaine Topical gel [Figure.6]. Despite significantly 
lower analgesic efficacy of (8% Lidocaine + 0.8% Dibucaine) anesthetic gel over 2% Lidocaine anesthetic 
injection, (8% Lidocaine + 0.8% Dibucaine) anesthetic gel was preferred by more than half of the study 
population. Topical anaesthetics may be preferred over injected anaesthetics for various reasons such as   
painless application of anaesthetics and minimum post-operative discomfort like numbness. Fear of pain is 
common reason patients avoid professional dental care (Milgrom et al. 1997), and for some the sight of an 
anaesthetic needle may be the most fearful experience in dentistry (Kleinknecht et al. 1973).[14, 15] 
 
In this study we have found 2 % Lidocaine injection anaesthesia controlled pain more effectively than 
the (8% Lidocaine + 0.8% Dibucaine) anesthetic gel and 2% Lidocaine anesthetic gel, but more than half of the 
study population preferred (8% Lidocaine + 0.8% Dibucaine) because 2 % Lidocaine injection resulted in 
prolonged postoperative numbness and they are willing to tolerate mild to moderate pain to avoid anesthetic 
injection. Another reason for preference (8% Lidocaine + 0.8% Dibucaine) is the taste of the gel which is more 
acceptable than the other anesthetic agent. The limitation of the present study is that the longevity of the 
effectiveness of the topical anesthetic gel could not be determined. 
 
This study was probably the first which evaluate the pain and discomfort experience during and after 
scaling and root planing (SRP) using 2 % Lidocaine injection anaesthesia, 8% Lidocaine + 0.8% Dibucaine 
anesthetic gel and 2% Lidocaine anesthetic gel. Further studies are needed to determine the efficacy of topical 
anesthetic gel over injected anesthesia. 
 
CONCLUSION 
 
From the present study it can be concluded that 8% Lidocaine + 0.8% Dibucaine anesthetic gel is more 
efficacious as a topical anesthetic agent. Eventhough injectable anesthetic is more effective in controlling pain; 
patient’s preferred 8% Lidocaine + 0.8% Dibucaine anesthetic gel during SRP rather than receiving an injection, 
main reason being the pain, anxiety and fear associated with needle prick. 8% Lidocaine + 0.8% Dibucaine 
anesthetic gel is viable anesthetic option during scaling and root planning. 
 
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[2] Klages U, Ulusoy O, Kianifard S, Wehrbein H. European J Oral Sci 2004;112:477-483. 
[3] Matthews DC, McCulloch CA. J Periodontol 1993;64:990-997. 
[4] Hutchins HS, Young FA, Lackland DT, Fishburne CP. Anesthesia Progress 1997;44:87-89. 
[5] Alqareer A, Alyahya A, Andersson, L. J Dent 2006;34: 747-750. 
[6] Carr MP, Horton JE. J Periodontol 2001;72:479-484. 
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[9] Van Steenberghe D, Garmyn P, Geers L, Hendrickx E, Maré-chal M, Huizar K. J Periodontol 
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[10] Wewers ME, Lowe NK. Res Nurs Health 1990;13:227-236. 
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[11] Akram Hassan, Thanaletchumy Chelvam, Erry Mochamed Arief, Mohammad Khursheed Alam. Int Med 
J 2013;20(5):597-600. 
[12] Nayak R, Sudha P. Indian J Dent Res 2006;17:155-160. 
[13] Stoltenberg JL, Osborn JB, Carlson JF, Hodges JS, Michalowicz BS. J Clin Periodontol 2007;34:892-896. 
[14] Milgrom P, Coldwell S, Getz T, Weinstein P, Ramsey D. J Am Dent Assoc 1997;128:756-762. 
[15] Kleinknecht RA, Klepac RK, Alexander LD. J Am Dent Assoc 1973;86:842-848. 
 
 
 
 
 
 
 


Evaluation of Pain Experience During and After Scaling and Root Planing (SRP) Using Local / Topical Anesthetic Agents: A Comparative Study

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Evaluation of Pain Experience During and After Scaling and Root Planing (SRP) Using Local / Topical Anesthetic Agents: A Comparative Study

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