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J Am Dent Assoc, Vol 138, No 12, 1563-1573.
© 2007 American Dental Association
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CLINICAL PRACTICE

Pain Experienced by Patients Undergoing Different Periodontal Therapies

Cenk Fatih Canakçi, DDS, PhD and Varol Canakçi, DDS, PhD


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The authors assessed the levels of postoperative pain, postoperative dentin hypersensitivity and discomfort patients experienced during various periodontal treatments by using a visual analog scale (VAS). They aimed to determine whether VAS scores could be predicted by patient’s age and sex and to evaluate the factors associated with the pain.

Subjects and Methods. The study was carried out with 56 patients who had chronic periodontitis. Using a split-mouth design, the authors selected one quadrant in each patient and treated it with scaling and root planing (SRP). They treated other quadrants with the surgical therapies of modified Widman flap (MWF), flap with osseous resection (OF) and gingivectomy (GV), depending on the patient’s diagnosis and treatment needs. They measured patients’ discomfort during periodontal treatments, postoperative pain and postoperative dentin hypersensitivity by asking patients to mark a VAS.

Results. The authors’ analysis showed no statistically significant differences between the patients’ discomfort levels associated with the four therapy types during periodontal treatment. However, postoperative pain was significantly higher for OF (P < .01) and GV (P < .05) procedures than for SRP and MWF procedures. All surgical procedures produced significantly more dentin hypersensitivity than did nonsurgical therapy. The analysis showed no statistically significant differences between male and female patients’ discomfort during periodontal treatments. For all periodontal treatments, VAS scores decreased with increasing age.

Conclusions. Discomfort during periodontal treatments, postoperative pain and postoperative dentin hypersensitivity were associated significantly with age, type of therapy and higher scores on Corah’s Dental Anxiety Scale.

Clinical Implications. Periodontal treatment is experienced as painful by substantial numbers of patients. Therefore, the dentist should count the pain responses during and after treatment and estimate the degree of pain according to sex, age and therapy type.

Key Words: Pain, periodontal therapy; periodontitis; postoperative dentin hypersensitivity; postoperative pain

Abbreviations: BOP: Bleeding on probing • CAL: Clinical attachment level • CP: Chronic periodontitis • DAS: Dental Anxiety Scale • GV: Gingivectomy • OF: Flap with osseous resection • PD: Probing depth • MWF: Modified Widman flap • SRP: Scaling and root planing • VAS: Visual analog scale

Chronic periodontitis (CP) a progressive disease that affects the gingiva, periodontal ligament and bone around the teeth.1,2 It is characterized by the development of the inflammation in the gingiva that subsequently extends, resulting in the resorption of the alveolar bone.1–5

According to American Academy of Periodontology, CP affects a majority of adults in the world.6 Researchers have reported that progression of CP in untreated populations can vary from 2 to 35.3 percent.7–9 A meta-analysis of studies has showed that an approximate mean annual tooth loss in untreated patients of 0.28 teeth per patient per year, whereas the mean annual tooth loss in treated patients was 0.08 teeth per patient per year—a difference of x 3.5.3 This difference in mean annual tooth loss strongly suggests that periodontal treatment is a positive factor in providing long-term benefits for patients.

The main purpose of periodontal treatment is to preserve the dentition. Ideally, therapy should resolve inflammation, arrest disease progression, maintain esthetics, maximize patient comfort, regenerate lost periodontium and create an environment that deters recurrent disease.10,11 To accomplish these goals, both nonsurgical and surgical procedures are used.

Nonsurgical therapy—scaling and root planing (SRP)—is the most commonly used procedure for treating periodontitis.2,5,12,13 SRP is designed to free the root surface from dental deposits (calculus and dental plaque) and necrotic cementum.5,12

Surgical therapies increase access to the root surface, making it possible to remove all irritants.5 Various surgical therapy techniques have been used, including subgival curettage, gingivectomy (GV), modified Widman flap (MWF), and full- or split-thickness flap procedures with or without osseous recontouring.5,10 There still is controversy about which therapeutic approach is the best, although the results of longitudinal clinical trials have highlighted the advantages and disadvantages of each technique.5,10

However, patient discomfort during periodontal treatments, postoperative pain and postoperative dentin hypersensitivity are common clinical events.14 Periodontal disease is not necessarily painful. Conversely, periodontal treatment is experienced as painful by substantial numbers of patients.15,16 SRP can be quite painful for patients with CP.13–15,17,18 The intensity of pain or discomfort has been perceived by clinicians to differ dramatically between patients.14

Although the available literature is limited, there is sufficient evidence to document that some patients may find both the nonsurgical and the surgical treatments painful.14,17–19 Therefore, the clinician should count the pain responses during both surgical therapy and SRP and estimate the degree of pain according to sex, age and therapy type.

We conducted a study to assess the levels of postoperative pain, postoperative dentin hypersensitivity and discomfort during various periodontal treatments by using a visual analog scale (VAS). We hoped to determine whether these VAS scores could be predicted by patients’ age and sex and to evaluate factors associated with the pain.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Study population. The patient population consisted of 56 patients (28 female and 28 male) with a mean age of 39.6 years (range: 18–67 years) who had visited the Department of Periodontology, School of Dentistry, Atatürk University, Erzurum, Turkey, for the treatment of CP. One of the authors (C.F.C.), a periodontist, judged the criteria for CP from standard measurements of clinical probing depths (PDs) and, via radiograph, bone loss, according to accepted criteria.1 The patients had moderate periodontitis as evidenced by multiple sites that had a PD of 4 mm or more and horizontal bone loss as established by means of radiographs. The same clinician measured systolic blood pressure and diastolic blood pressure of each patient before each therapy procedure.

We conducted the study between January and October 2006. The criteria we used in selecting patients were generally good health, ability to understand oral or written instructions, presence of a minimum of six teeth in all four maxillary/mandibular quadrants, no use of systemic medications (that is, sedative, muscle relaxant or narcotic analgesic) within the past three months, no record of allergies and no dentin sensitivity to air stimulation. We excluded patients if they had received periodontal therapy up to 12 months earlier, had potentially contributory dental conditions (such as active orthodontic treatment, a restoration, partial dentures, pulpal pathology) or were known to be pregnant. We obtained smoking and alcohol use status from patients’ self-reported data. We gave each patient a detailed description of the procedure and obtained informed consent. This study was reviewed and approved by the ethics committee of Atatürk University.

Clinical examination and study design. A trained and calibrated examiner (C.F.C.) determined each patient’s clinical PD, probing clinical attachment level (CAL), dental plaque and bleeding on probing (BOP). He measured PD as the distance from the free gingival margin to the base of the pocket. He determined CAL by measuring the distance from the base of the pocket to the cementoenamel junction. He scored dental plaque as being present or absent at the four points (mesial, facial, lingual and distal) on each tooth. The clinician also recorded BOP, expressing it as the percentage of sites showing bleeding. The examiner measured PD and CAL using a Florida probe (FP 32, version 4, Florida Probe, Gainesville, Fla.) exerting a constant force of 20 grams at the same six sites on each tooth (mesiofacial, mesiolingual, distofacial, mesiolingual, midlingual and distolingual).

Examiner variability in using the dental examination criteria was tested by performing duplicate examinations on seven randomly selected patients on consecutive days. Corresponding percentages of agreement were 94 percent for PD and BOP and 92 percent for CAL. We used these clinical measurements to determine suitable treatment. After the clinical examination, the clinician gave each patient instruction on toothbrushing and flossing. All patients underwent the initial phase of therapy and full-mouth scaling. The other author (V.C.) carried out indicated extractions during this initial phase of therapy. Patients were recalled and received the intructions repeatedly until their plaque control record reached a level below 20 percent (as recommended by O’Leary and colleagues20).

All surgical procedures produced significantly more postoperative dentin hypersensitivity than did scaling and root planing.

Treatment. Approximately three months after completion of the initial phase, the periodontist performed a clinical reexamination. For each patient, he randomly assigned each of the patients’ four quadrants to receive one of four periodontal treatment types. Using a split-mouth design, he selected one quadrant in each patient and treated it with SRP. Other quadrants underwent surgical treatments—MWF, GV and flap with osseous resection (OF)—depending on their diagnosis and treatment needs.

The clinician treated all root surfaces with a standardized curette pack that consisted of Gracey 1–2, 3–4, 5–6, 7–8, 9–10, 10–11 and 13–14 curettes (Hu-Friedy, Chicago), which were sharpened before use. Treatment continued until the periodontist felt that the root surfaces were hard and smooth. The curettes also were sharpened during use. There were no time limits for treatment. Each quadrant’s treatment was carried out during a period of two weeks. All periodontal therapies were performed by an experienced clinician (V.C.).

Pain and dentin hypersensitivity assessment. We measured any pain or discomfort patients experienced during periodontal treatment as well as postoperative pain and postoperative dentin hypersensitivity by using a VAS. The VAS was administered in a standard manner, with the initial explanation given by the same clinician (V.C.). All patients were asked to define their level of postoperative pain, postoperative dentin hypersensitivity and discomfort during periodontal treatment by using a VAS consisting of equal units from 0 to 100 (a line of 100 mm). On this scale, 0 and 100 represented "no pain/discomfort" and "worst pain/discomfort imaginable," respectively. All pain assessments were performed in the morning in the same clinic, free of extraneous noise, music or conversation. At the termination of treatment, we asked patients to mark the degree of pain they experienced during their periodontal therapy procedure. After each treatment, we gave the patient a separate sheet of paper containing the printed interval scale (a line of 100 millmeters) so that he or she could not be influenced by the previous results. Data from the VAS were recorded by measuring in millimeters the distance between zero point and the sign marked by the patient on the 100-mm line.

We tested the reproducibility of the VAS by having 10 patients complete the scale on two separate occasions. There was strong correlation between the two responses in both procedures (Spearman’s {rho} > 0.84, P < .001).

We also asked patients to complete Corah’s Dental Anxiety Scale (DAS),21 a four-item measure giving rise to scores ranging from four to 20. Postoperative pain was determined as commencing 24 hours after periodontal treatments. We assessed dentin hypersensitivity by means of air stimulus. The clinician directed an air-blast (60 pounds per square inch, 22°C) derived from a dental syringe to the root surface for 1 second. He held the syringe perpendicularly 2 to 3 mm from the root surface. After this stimulation, the patient again scored the pain by using the VAS.

Data analysis. We examined the normality of the data’s distribution using the Shapiro-Wilk test. We assessed the difference of the four groups of normally distributed variables using one-way analysis of variance and Tukey multiple comparisons tests. To evaluate the differences among the groups in other variables (nonnormal distribution), we used the Kruskal-Wallis one-way analysis of variance, followed by the Mann-Whitney U test employing the Bonferroni correction.

We performed multivariate logistic regression model analysis to examine possible factors. The regression model used the dependent variable of pain dichotomized into no (pain score reported = 0) or yes (pain score reported ≥ 1) in patients during periodontal therapy and postoperatively in terms of pain and dentin hypersensitivity. Variables entered in the model were age (18–44 versus 45–67 years), sex (male or female), educational level (high school versus university), smoking status (yes versus no), alcohol use (yes versus no), jaw site (maxilla versus mandible), site of procedure (anterior versus posterior), systolic blood pressure (normal versus higher), diastolic blood pressure (normal versus higher), type of procedure (SRP versus surgery), PD sites of 4 mm or more (yes versus no), CAL of 3 mm or more (yes versus no) and DAS score (< 10 versus ≥ 10). We generated adjusted odds ratios (OR) and corresponding 95 percent confidence intervals (CI) for all significant variables. The significance level we used was P < .05.

We determined correlations between variables by means of a Spearman rank correlation test. We considered a value of P < .05 to be significant. All values are expressed as mean ± standard deviation. For these procedures, we used SPSS for Windows, Version 11.0 (SPSS, Chicago).


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Table 1Go shows the patients’ demographic characteristics and clinical dental variables. There were no significant differences in mean age, age groups and education levels between female and male patients (P > .05). Table 1Go also displays the clinical dental and periodontal variables by sex. The numbers of teeth present and of carious teeth in female and male patients were similar (P > .05). Similarly, we found no significant differences between female and male patients in any periodontal variable (P > .05). Smoking status, alcohol use, localization of procedures and blood pressure also were similar in the two groups (P > .05).


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  		TABLE 1 Demographic characteristics and clinical dental variables in patient populations.*

 
Comparisons of the mean VAS scores concerning the levels of postoperative pain, postoperative dentin hypersensitivity and discomfort during various periodontal treatments are given in Table 2Go. Analysis showed no statistically significant differences in the patients’ discomfort between the four treatment types during periodontal treatment (P > .05). However, postoperative pain scores were significantly higher for OF (P < .01) and GV (P < .05) procedures than for SRP and MWF procedures. There was no significant difference between SRP and MWF in terms of postoperative pain scores (P > .05). All surgical procedures produced significantly more postoperative dentin hypersensitivity than did SRP (P < .05). But we found no statistically significant differences in postoperative dentin hypersensitivity between the three surgery treatments (P > .05). Table 2Go also presents the VAS score (discomfort and pain score) summary for all patients. For example, in examining the distribution of postoperative pain scores, we found that 23.2 percent of patients (13 patients) reported no pain (VAS = 0) during SRP and 76.8 percent of patients (43 patients) reported pain. These values for MWF were 21.4 percent and 78.6 percent, respectively.


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  		TABLE 2 Comparisons of the mean VAS* scores concerning the levels of discomfort during various periodontal treatments, postoperative pain and postoperative dentin hypersensitivity (n = 56 each).

 
Figure 1Go offers comparisons of the mean VAS scores concerning the levels of postoperative pain and postoperative dentin hypersensitivity and discomfort during various periodontal treatments, according to sex. The analysis showed no statistically significant differences between male and female patients’ discomfort during periodontal treatments. For example, the mean VAS score concerning the levels of discomfort during SRP was 17.1 in women and 15.8 in men. Corresponding scores for MWF were 17.5 and 18.0, respectively. The mean VAS scores during OF for female and male patients were 21.2 and 20.4, respectively. These values were not statistically different. Similarly, we found no statistically significant differences between men’s and women’s scores for postoperative pain and postoperative dentin hypersensitivity (P > .05).


Figure 1
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  		Figure 1. Comparisons of the mean visual analog scale (VAS) scores concerning the level of (A) discomfort during various periodontal procedures, (B) postoperative pain and (C) postoperative dentin hypersensitivity. mm: Millimeters. SRP: Scaling and root planing. MWF: Modified Widman flap. OF: Flap with osseous resection. GV: Gingivectomy.

 
Table 3Go (page 1569) presents a multivariate logistic regression model analysis. Of all the examined variables entered in the model, discomfort during therapy, postoperative pain and postoperative dentin hypersensitivity were associated significantly with age, type of therapy and DAS score. Postoperative dentin hypersensitivity was associated significantly with smoking (OR = 1.7, P < .001) and CAL of 3 mm or more (OR = 2.2, P < .001), and discomfort during therapy was associated significantly with systolic and diastolic blood pressure (OR = 1.6 and 1.5, respectively P < .01). During therapy, patients aged 18 to 34 years were 1.7 (range, 1.5–8.9) times more likely to experience pain than were patients aged 45 or more years. Periodontal surgery was 1.7 (range, 1.4–8.1) times more likely to induce pain than was SRP. Patients with high DAS scores were 2.5 (discomfort during treatment), 2.1 (postoperative pain) and 2.3 (dentin hypersensitivity) times more likely to demonstrate a high pain response than were patients with low DAS scores. Patients aged 18 to 34 years were more likely to report pain after therapy. Periodontal surgery was 2.4 times more likely to be associated with pain than was SRP. We had similar findings for postoperative dentin hypersensitivity.


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  		TABLE 3 Multivariate logistic regression analysis of factors associated with pain perception during various periodontal treatments, postoperative pain and postoperative dentin hypersensitivity.*

 
We calculated the Spearman rank correlation coefficient for discomfort during periodontal treatments, postoperative pain and postoperative dentin hypersensitivity between age and VAS scores (Table 4Go, page 1570). The VAS scores decreased with increasing age for all periodontal treatments; for example, in nonsurgical treatment, the Spearman {rho} was 0.319 during treatment (P < .01), 0.329 for postoperative pain (P < .01) and 0.251 for dentin hypersensitivity (P < .05) (Figure 2Go, page 1571).


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  		TABLE 4 Association between age and visual analog scale responses.

 

Figure 2
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  		Figure 2. Association between age and visual analog scale (VAS) responses regarding (A) discomfort during various periodontal procedures, (B) postoperative pain and (C) postoperative dentin hypersensitivity. mm: Millimeters. R2: Spearman rank correlation coefficient. SRP: Scaling and root planing. MWF: Modified Widman flap. OF: Flap with osseous resection. GV: Gingivectomy.

 

   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
This study provides information about postoperative pain, postoperative dentin hypersensitivity and the level of discomfort experienced during various periodontal treatments of patients with CP.

Measurement of pain and discomfort is inherently difficult, as it has both physical and psychological aspects. Subjectively, the true character of the pain experience is not directly accessible to the examiner. Therefore, the examiner must rely on the patient’s ability to communicate his or her perception and interpretation of the pain. Additionally, physiological variables may differ widely among individual subjects.15 Reassurance and psychological support are important to increase patients’ confidence and might play a role in their attitudes toward pain anticipation. As anxiety is thought to influence the effective component of pain,22 we asked patients in this study to complete the DAS.21

Standardized and controlled laboratory conditions are essential components of studies involving subjective pain evaluation. Environmental factors such as temperature, noise and extraneous activity potentially influence pain perception.23,24 In our study, we scheduled test-day visits at the same time of the day. Pain measurements were performed within the same closed operatory with distraction-free surroundings. The controlled environment guaranteed an atmosphere conducive to total concentration. Patients were seated in a dental chair and allowed an uninterrupted period of five minutes to relax before beginning pain response testing.

We used the VAS in this study to evaluate pain of the patients. This scale has been shown to be simple to administer, reliable and valid,25,26 and it has been used to evaluate dental pain.27,28 The VAS also has been used in previous studies evaluating pain arising from periodontal therapies.17–19

In this study, we evaluated postoperative dentin hypersensitivity by means of an air stimulus. Researchers have reported that dentin hypersensitivity may be determined by an air stimulus, a cold stimulus and an electric stimulus.29–31 Since the electric stimulus reflects pulpal rather than dentin hypersensitivity, it is assumed that the pulp is not affected by periodontal treatment.29,31 Wallace and Bissada29 have shown that the air stimulus measures dentin hypersensitivity and not pulpal sensitivity. Because of this, we selected air stimulus as our method of evaluating dentin hypersensitivity.

Several studies have shown that periodontal treatment frequently is associated with pain.14–19 Our study, in agreement with these studies, showed that periodontal treatments were experienced as painful by patients with CP.

Analysis showed no statistically significant differences in the patients’ discomfort/pain between the four treatment types during periodontal treatment. Matthews and McCulloch18 used a VAS and found that patients reported more discomfort for surgical therapies than for SRP. On the contrary, Fardal and colleagues32 reported that SRP was associated with more discomfort than was periodontal surgery. Although not directly comparable, the findings reported in the above-mentioned two studies were considerably more different than ours in this study. The differences between our findings and those of Matthews and McCulloch18 may be explained by operator experience and study design. Treatment in the Matthews and McCulloch study was performed by graduate students in a dental school; in our study, it was carried out by an operator with several years of experience. Also, our study evaluated VAS scores for four periodontal treatment types in the same patients by using a split-mouth design, while in the studies by Matthews and McCulloch18 and Fardal and colleagues32 the researchers obtained a VAS score for one treatment type in each patient. In our study, pain during therapy was associated significantly with systolic and diastolic blood pressure. It has been reported that heart rate is inversely proportional to the pain threshold and that this correlates with anxiety before the dental procedure.33 Additionally, another study reported that visual indexes of pain response correlated positively with heart rate as the autonomic indicator of pain sensitivity.34 Heart rate will further reflect pain perception in similar fashion for normotensive and hypertensive people.35 These findings are in agreement with those in our study.

Postoperative pain was significantly higher with certain surgical procedures than with SRP and MWF. OF produced significantly more postoperative pain than did other treatments. These differences among therapy types may be explained by duration of the surgical procedure and exposure of bone. Curtis and colleagues36 reported that increased duration of the surgical procedure was significantly associated with increased postoperative pain. OF often is more time-consuming, and it requires exposure of the underlying bone, which may contribute to resorptive phenomena. This bone exposure may tend to exaggerate the inadvertent postoperative inflammatory response and increase postoperative pain. In contrast, MWF routinely results in approximation of tissue surfaces with minimal connective tissue and osseous exposure. This exposure does not occur in SRP. These technical differences may account for the differences in postoperative pain experience among therapies.

Several clinical studies have attempted to analyze the contribution of various clinical variables to the development of dentin hypersensitivity after both nonsurgical and surgical periodontal therapy.29–31,37–39 It has been reported that periodontal therapy appears to be a significant cause of dentin hypersensitivity.30,40–42 After periodontal therapy, reduction of the gingival protective barrier may result from excision of tissue that exposes the root surfaces, while SRP may remove 20 to 50 micrometers of cementum and expose the dentinal tubules to external stimuli.29,38 Tammaro and colleagues30 observed significant change in dentin hypersensitivity after SRP. von Troil and colleagues41 found that dentin hypersensitivity occurred in approximately one-half of patients after they underwent SRP. Tamminen and colleagues39 determined that dentin hypersensitivity occurred after periodontal surgery using MWF. On the other hand, Wallace and Bissada29 reported that SRP did not produce dentin hypersensitivity and that periodontal surgery in which extensive root surface area was exposed did produce dentin hypersensitivity.

All surgical procedures in this study produced significantly more dentin hypersensitivity than did SRP. Multivariate logistic regression analysis showed that both patients and all patients in the CAL of 3 mm or more group were 1.3 and 1.4 times more likely, respectively, to experience dentin hypersensitivity after surgery compared with those in the SRP. This may be due to increased surface exposure of root dentin to the oral environment and more gingival recession after periodontal surgery.43,44 The analysis also determined that smokers had a higher pain level in dentin hypersensitivity, which accords with previous studies.43,45 One interesting finding was that a patient with a high DAS score was 2.5 (during treatments), 2.1 (postoperative pain) and 2.3 (dentin hypersensitivity) times more likely to present a high pain response than was a patient with a lower DAS score. This is consistent with a study by Sullivan and Neish,46 who found that people with higher scores on scales measuring dental anxiety and pain reported more pain after dental hygiene treatment.47

Our study showed that there was no difference between the sexes during both nonsurgical and surgical periodontal therapies. This is not in agreement with reports showing that women have greater dentin hypersensitivity and lower tolerance of pain than do men.24 This difference between the sexes has been reported in periodontal probing,15 experimental dental pain48 and postoperative dental pain.49 However, Strahan and Glenwright50 could not find a statistically significant difference in pain between sexes after periodontal surgery. Similar results also were obtained in response to instrumentation for periodontal treatments.15,32 The reasons for the lack of difference between sexes in our study are not clear, but it is possible that the low levels of discomfort reported indicate that no significant differences exist within the patients studied.

Our results demonstrated that the VAS scores decreased with increasing age for both nonsurgical and surgical periodontal therapies. In other words, the reported level of discomfort decreased with age in the patients studied. A general clinical impression is that elderly people usually are more tolerant to pain. Age is one of the biological factors that has been discussed as important in pain experience.32 A higher pain threshold in elderly subjects may be a consequence of tissue changes such as reduced vascularity, fatty degeneration of bone tissue51 and secondary dentin formation.52 Our finding is in accord with those of other studies.32,51,52


   CONCLUSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Our study indicated that periodontal treatments were experienced as painful by patients with CP. Discomfort during therapy, postoperative pain and postoperative dentin hypersensitivity were associated significantly with age, type of therapy and DAS score. The results of our study also showed that although there is no difference between sexes, the VAS scores in all periodontal therapies decreased as age increased. Further studies are needed to clarify the pain experience for all therapy types.

In future research, we plan to identify patients with elevated pain response in nonsurgical and surgical therapy by using the Periodontal Pain Indicator, which was suggested by Karadottir and colleagues15 for use in periodontal maintenance treatment. It will be important to interpret the findings of our study in comparison with those from other studies of periodontal pain linked with therapeutic methods such as laser surgery.


   FOOTNOTES
 

Dr. Cenk Fatih Canakçi is an assistant professor, Department of Periodontology, School of Dentistry, Atatürk University, 25240, Erzurum, Turkey, e-mail "cfcanakci{at}yahoo.com". Address reprint requests to Dr. Çanaki.


Dr. Varol Canakçi is a professor and the vice dean, Department of Periodontology, School of Dentistry, Atatürk University, Erzurum, Turkey.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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