Treatment Experiences of Fear, Anxiety, and Pain Among Chronic

J Clin Periodontol 2015; 42: 1024–1031 doi: 10.1111/jcpe.12472

Camila Carvalho Santuchi1, Sheila Pre- and post-treatment Cavalca Cortelli2, Jose Roberto Cortelli2,Luıs Otavio Miranda Cota1, Camila Oliveira Alencar2 and experiences of fear, anxiety, and Fernando Oliveira Costa1 1Department of Dental Clinics, Oral Pathology, and Dental Surgery, Dentistry pain among chronic periodontitis School, Federal University of Minas Gerais, Belo Horizonte, Brazil; 2Periodontics Research Division, Department of Dentistry, patients treated by scaling and University of Taubate, Taubate, Sao~ Paulo, Brazil root planing per quadrant versus one-stage full-mouth disinfection: a 6-month randomized controlled clinical trial

Santuchi CC, Cortelli SC, Cortelli JR, Cota LOM, Alencar CO, Costa FO. Pre- and post-treatment experiences of fear, anxiety, and pain among chronic periodontitis patients treated by scaling and root planing per quadrant versus one- stage full-mouth disinfection: a 6-month randomized controlled clinical trial. J Clin Periodontol 2015; 42: 1024–1031. doi: 10.1111/jcpe.12472.

Abstract Aim: To relate the clinical effects of two different forms of non-surgical periodontal therapy – scaling and root planing per quadrant (SRP-Q) and one-stage full-mouth disinfection (FMD) – to patient-based outcomes such as fear, anxiety, and pain of moderate chronic periodontitis patients. Methods: Dental Fear Survey (DFS) and Dental Anxiety Scale (DAS) questionnaires and Visual Analogue Scale (VAS) were applied to 78 patients randomized into two groups: SRP-Q (n = 37) and FMD (n = 41). Periodontal clinical parameters: probing pocket depth (PD), clinical attachment level (CAL), plaque index (PI), and gingival index (GI) were monitored at baseline and 6 months after treatment. Data were statistically analysed by chi-square, Fisher’s exact, Mann–Whit- ney, Wilcoxon tests, Pearson’s correlation, and Cluster analysis. Results: All periodontal clinical parameters improved from baseline to 6 months. Patients with higher fear and anxiety showed a worse clinical periodontal status before and after treatment (mean CAL, PI, and GI). After both types of treatment, fear and anxiety decreased (FMD: p = 0.019; SRP-Q: p = 0.043) with no Key words: anxiety; dental fear; pain; differences between the groups. Pain did not differ between groups (FMD: periodontal treatment Æ Æ = 20.6 19.0 and SRP: 20.7 20.0; p 0.930). Accepted for publication 7 October 2015

Conflict of interest and source of funding statement The authors declare that there are no conflicts of interest. This study was supported by grants from the Conselho Nacional de Desenvolvimento Cientıfico e Tecnologico – CNPq Brazil (CNPq 552264/2011–3).

Conclusions: In moderate chronic periodontitis patients, SRP-Q and FMD pro- vided periodontal clinical improvements and similar experiences of fear, anxiety, and pain.

The non-surgical periodontal treat- The periodontal therapy includes and the University of Taubate, ment consists of scaling and root probing procedures and supra- and Brazil, during the years 2011/2012, planing procedures and it is conven- subgingival scaling that can be par- were invited to participate. The fol- tionally done in weekly sessions, per- ticularly painful and cause anxiety lowing inclusion criteria were formed by quadrants (SRP-Q) or and fear (Guzeldemir et al. 2008). adopted: (1) diagnosis of mild to sextants. This treatment strategy Furthermore, these subjective aspects moderate chronic periodontitis requires 4–6 weeks for completion, may be accompanied by some unde- (American Academy of Periodontol- while the approach of one-stage full- sirable effects of periodontal ther- ogy 2000); (2) aged 35–60 years old; mouth disinfection (FMD) performs apy, such as dentine sensitivity, (3) at least 18 natural teeth. Exclu- scaling and root planing procedures gingival recession, and aesthetic sion criteria were: (1) those who over a period of 24 h, combined impairment (Koshy et al. 2005). were in a regular use of antibiotics with the use of chlorhexidine for up In order to recognize the suscepti- or anti-inflammatory drugs, or had to 2 weeks (Quirynen et al. 1995, ble individuals and introduce preven- done so within 3 months preceding Teughels et al. 2009). tive and corrective measures to the start of the study; (2) those who The FMD approach aims to pre- reduce anxiety and pain experience were making regular use (twice a vent re-infection of already treated during dental treatment (Corah day) of mouthwashes, or had made periodontal sites by pathogens that 1969, Karadottir et al. 2002, Fardal regular use within 3 months prior reside on other sites and thus & McCulloch 2012), instruments like to study entry; (3) patients with a improve the effectiveness of non-sur- Dental Fear Assessment Scale history of sensitivity to chlorhexi- gical periodontal treatment (Cionca (DFAS; Armfield 2010), Dental Fear dine; (4) patients undergoing peri- et al. 2009). In a review article, Survey (DFS; Kleinknecht 1973), odontal therapy including dental Teughels et al. (2009) point out that, Dental Anxiety Scale (DAS; Corah scaling and root planing procedures primarily based on the lack of disad- 1969), and Visual Analogue Scale in the 12 months preceding the start vantages, both clinicians and (VAS; Karadottir et al. 2002) have of the study; (5) subjects with bifur- patients tend to gain with FMD due been developed. cation or trifurcation class III; (6) to a lower cost, more efficient treat- It was hypothesized that individu- those who required antibiotic pro- ment, and time management, with als treated by FMD have higher phylaxis for periodontal clinical less travelling or absence from work scores of pain, fear, and anxiety due examination; (7) those with remov- for the patient. However, adverse to procedures be made in a short able partial dentures, fixed, or effects have been reported as major period of time. In this sense, the pre- removable orthodontic devices; (8) postoperative pain compared to sent study aimed to verify the effect those presenting any medical or SRP-Q and increase in body temper- of two different forms of non-surgi- psychological disorder that could ature (Quirynen et al. 2000, Eber- cal periodontal therapy, SRP-Q and affect the ability of the question- hard et al. 2015). FMD, on dental fear, anxiety, and naires’ understanding. Although previous studies and pain experience among patients with The sample size was calculated reviews have shown that SRP-Q or chronic periodontitis. Additionally, with a power of 80% and 5% signifi- FMD led to similar clinical results it aimed to determine the correlation cance level, considering the following (Bollen et al. 1998, Eberhard et al. between periodontal clinical parame- outcomes: (1) primary – the impact 2008, Lang et al. 2008, Swierkot ters and DFS, DAS, and VAS of periodontal treatment in pain, et al. 2009), based on the above- scores. fear, and anxiety scores and (2) sec- mentioned advantages FMD seems ondary – PD reduction and CAL to increase patients’ adherence when gain after non-surgical periodontal Material and Methods there is a need for less time con- treatment from previous studies sumption (Mongardini et al. 1999). (Karadottir et al. 2002, Koshy et al. Anxiety, fear, and pain experi- Study design and study population 2005, Guzeldemir et al. 2008, Jowett ence represent significant problems This study was a randomized con- et al. 2009). Thus, a minimum of 36 in dental practice and are significant trolled trial, registered at clinicaltri- patients per group was determined factors that discourage the demand als.gov (NCT02409966). It was to detect a significant between- for treatment. It negatively interferes approved by the Ethics Committee groups effect ranging from 12% to in the management of patients dur- on Human Research of the Federal 18% (a = 95%). Considering up to ing dental treatment, thereby jeopar- University of Minas Gerais (CAAE 20% of dropouts during 6 months dizing their oral health (Kvale et al. 07172212.3.0000.5149) and of the of follow-up the initial sample size 2004). The level of anxiety increases University of Taubate (521-10). was defined as at least 45 patients in proportion to the severity of the Patients enrolled in the screening per group. A pilot study for training, oral condition, thus creating a service of the Dental School of the calibration, and agreement of exam- vicious cycle (Armfield 2010). Federal University of Minas Gerais iners for clinical examinations and

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1026 Santuchi et al. questionnaires was performed in Periodontal evaluation and treatment Measurements of PD and CAL advance in 20 patients. Clinical examination was per- were obtained at six sites per tooth Ninety patients were randomly formed to collect the periodontal in all present teeth, except third allocated to two treatment groups by clinical parameters: probing pocket molars, with manual periodontal a closed envelope system: (1) scaling depth (PD), clinical attachment probe North Carolina model and root planing per quadrant level (CAL), blending on probing (PCPUNC 15; Hu-Friedy, Chicago, = (SRP-Q, n 45); and (2) one-stage (BOP), plaque index (PI, proposed IL, USA). Scaling and root planing full-mouth disinfection (FMD, by Silness & Loe€ 1964), gingival were performed with Gracey and = n 45). Opaque envelopes contain- index (GI, proposed by Silness & McCall curettes, and the interven- ing identifications for treatment were Loe€ 1966), and percentage of dis- tion phase in both groups were mixed and then numbered. Each eased periodontal sites [%PDS started only after patients received participant took a single envelope (sites with PD ≥ 4mm and oral hygiene instruction and < and was assigned to a specific group CAL ≥ 3 mm)] at T0 and T2. achieved PI 30% (selected peri- by a researcher (LOMC). They Examinations were performed by odontitis patients were enrolled in a attended to clinical appointments in two blinded examiners who were 1-month oral hygiene normalization selected days according to type of trained and calibrated (FOC and period). SRQ-Q and FMD proce- treatment (FMD or SRP-Q). JRC). Kappa tests were performed dures were performed by four expe- After initial examination and dur- for the periodontal clinical param- rienced periodontists (CCS, COA, ing the intervention phase, there was eters (PD and CAL) and intra- DCF, and SCC). After the evalua- a sample loss of 12 individuals by and inter-examiner agreement tion at T2, individuals presenting > incomplete adherence to treatment revealed k values > 92%. sites with PD 4 mm, BOP, and/or (n = 8) or inadequate responsiveness to the questionnaires (n = 4). FMD group lost four individuals (two non-adherence and two inadequate response) and SRP-Q group lost eight individuals (five non-adherence and three inadequate response). Thus, the final sample consisted of: Group 1 – SRP-Q (n = 37), scaling and root planing per quadrant (30 min. each), with weekly intervals between sessions; Group 2 – FMD (n = 41), full-mouth scaling and root planing procedures within 24 h in two sessions, 60 min. each session, for two consecutive days, including subgingival irrigation with 1% CHX gel after scaling, tongue brushing with 1% CHX gel for 1 min., and mouthwashes with 0.12% CHX for 30 s at the beginning and at the end of each session, with the last 10 s involving gargling. Furthermore, a daily 0.12% CHX mouthwash (twice a day) was performed for 2 weeks (Quirynen et al. 1995). This study involved assessments in three times: T0 = periodontal examination and initial application of DFS and DAS questionnaires at the beginning of the interventions (baseline); T1 = VAS scale application at the end of scaling procedures: in the FMD group at 24 h, and in the SRP-Q group at 30 days (orien- tation not to use analgesics previous to procedures); T2 = periodontal clinical examination and application of DFS and DAS questionnaires after 6 months of completion of interventions on FMD and SRP-Q Fig. 1. Study design from screening to completion of the study according to Consoli- groups. dated Standards of Reporting Trials (CONSORT). © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Anxiety, pain, and periodontal treatment 1027 suppuration received additional peri- dental treatment. It was validated after finishing the FMD procedures odontal treatment as indicated. for the Brazilian population (Cesar (24 h). et al. 1993). The score for each ques- A flow chart of data collection tion can range from 1 (little fear) to and interventions of the study, Data collection regarding fear, anxiety, and pain experience 5 (very afraid) (Kleinknecht 1973). according to Consolidated Standards of Reporting Trials (CONSORT), is Questionnaires were applied by three shown in Fig. 1. trained examiners (CCS, COA, and Visual Analogue Scale SCC). To increase the results’ relia- A VAS was used to measure pain. bility, the questionnaires were This type of scale is a simple use Statistical analysis repeated after 7 days in 20 subjects and validated tool (Karadottir et al. Initially, data were presented of the pilot study, and the test–retest 2002, Chung et al. 2003, Hassan descriptively and compared between reliability was assessed using Spear- et al. 2005, Canakcßi & Canakcßi the two treatment groups regarding man’s correlation coefficient (0.87, 2007, Guzeldemir et al. 2008). It the variables of interest in each p < 0.001) and Cronbach’s a (0.92). consists of a defined rule on a sheet phase of the study. Normality of of paper with horizontal markings data was tested through the Kol- Questionnaires DAS and DFS from 0 to 10 mm at the horizontal, mogorov–Smirnov test. Since data where individuals mark their level of distribution was too asymmetric and The DAS (Corah’s Dental Anxiety pain. It was applied in a standard deviations from normal distribution Scale proposed by Corah 1969) ques- manner with an initial explanation were too high, non-parametric tests tionnaire, composed by a self- clarifying that 0 mean no pain and were used. Thus, for statistical anal- reported anxiety scale with four discomfort, while 10 mean a very ysis, the chi-square, Fisher’s exact, items, and DFS-modified question- intense pain and very discomfort. Mann–Whitney, and Wilcoxon tests naire, composed by three questions, This scale was applied in all patients were used. Comparative analysis was proposed by Kleinknecht (1973) participating in the study at T1, used to evaluate the effect of treat- were applied in T0 and T2. immediately after finishing the scal- ment protocols in the mean values These instruments were applied in ing procedures (SRP-Q: at 30 days; of the clinical parameters of interest the compact and validated version considering the four sessions) and (PD, CAL, PI, and GI), as well as in for use in patients undergoing periodontal treatment with root instru- mentation (Karadottir et al. 2002, Table 1. Comparative analysis between SRP-Q and FMD groups, and between T0 and T2 Chung et al. 2003, Guzeldemir et al. in relation to periodontal clinical parameters 2008), with presenting only three of Periodontal clinical Group: FMD Time p the 20 original questions from DFS parameters (N = 41); and four from DAS. Thus, the total SRP-Q T0 T2 score of the anxiety questionnaire (N = 37) could vary from 7 to 35 points. The DAS (proposed by Corah Periodontal probing FMD 2.14 Æ 0.53 1.88 Æ 0.55 <0.001* 1969) is a questionnaire with four depth SRP-Q 2.35 Æ 0.61 2.09 Æ 0.63 <0.001* questions directly related to dental p 0.188 0.160 = = anxiety, which are: (1) “If you were FMD SRP-Q FMD SRP-Q Clinical attachment FMD 2.63 Æ 0.97 2.43 Æ 0.91 <0.001* to go to the dentist tomorrow, how level SRP-Q 2.57 Æ 1.14 2.41 Æ 1.11 <0.001* would you feel?”; (2) “While you p 0.928 0.861 wait in the office, how do you feel?”; FMD = SRP-Q FMD = SRP-Q (3) “While you are in the dentist’s Plaque index FMD 26.72 Æ 17.8 29.09 Æ 21.22 <0.031* chair waiting for him to take the SRP-Q 24.11 Æ 15.6 25.77 Æ 12.02 <0.041* drill to start work on your teeth, p 0.750 0.707 how do you feel?”; and (4) “You are FMD = SRP-Q FMD = SRP-Q in the dentist’s chair to clean your Gingival index FMD 35.22 Æ 28.21 11.83 Æ 21.52 <0.001* Æ Æ < teeth. How do you feel while the SRP-Q 29.17 19.12 6.79 16.52 0.001* dentist takes the instruments to clean p 0.509 0.247 FMD = SRP-Q FMD = SRP-Q your teeth?”. Each question has five Percentage of sites with FMD 8.79 Æ 9.22 6.31 Æ 8.33 <0.001* answer choices, and the final score PD ≥ 4 mm and SRP-Q 11.54 Æ 11.52 8.03 Æ 10.79 <0.001* can range from 4 to 20. CAL ≥ 3 mm (%PDS) p 0.300 0.474 The DFS (proposed by Klein- FMD = SRP-Q FMD = SRP-Q knecht 1973) is an instrument to FMD 5.09 Æ 7.52 3.28 Æ 5.71 <0.001* assess dental fear and attempts to Percentage of sites with SRP-Q 7.17 Æ 9.70 5.05 Æ 8.89 <0.001* avoid treatment. The Likert-like PD (5–6 mm) p 0.466 0.427 questionnaire consists of 20 items Mean Æ SD; the probability of significance (p) refers to the Mann–Whitney test for compar- that assess issues related to the isons between groups and the Wilcoxon test for the comparison between T0 and T2; avoidance of treatment, somatic–vis- *T0 > T2. ceral excitement, and how much fear CAL, clinical attachment level; FMD, full-mouth disinfection; PD, pocket depth; SRP-Q, cause the stimuli associated with scaling and root planing per quadrant.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1028 Santuchi et al. the %PD 4–5 mm and %PDS. Indi- Table 2. Correlation between periodontal clinical parameters and DFS and DAS question- viduals were the unit of analysis. naires (T0 and T2), and VAS scale (T1) Additionally, a Cluster analysis was Periodontal clinical parameters Questionnaires/ Time performed in order to identify simi- scale lar patients’ profiles in relation to T0 T2 DFS and DAS scores simultane- ously, i.e., sum of the scores trans- Periodontal probing depth DFS 0.02 (0.887) 0.12 (0.277) formed into a single variable, DAS 0.01 (0.972) 0.03 (0.785) + according to the data collected at T0 DFS DAS 0.01 (0.928) 0.08 (0.481) VAS T1 NA and T2, as well in relation the peri- 0.05 (0.651) odontal condition. For this purpose, Clinical attachment level DFS 0.01 (0.986) À0.05 (0.644) two clusters were established: cluster DAS À0.06 (0.582) À0.07 (0.545) A(n = 33) – greater fear and anxi- DFS + DAS À0.04 (0.754) À0.07 (0.566) ety; and cluster B (n = 42) – lower VAS T1 NA fear and anxiety. Analyses were per- 0.01 (0.972) formed using statistical software Plaque index DFS À0.03 (0.789) À0.09 (0.448) (Version 14.0 for Windows; SPSS DAS À0.07 (0.555) À0.11 (0.354) + À À Inc., Chicago, IL, USA). DFS DAS 0.05 (0.633) 0.10 (0.365) VAS T1 NA À0.06 (0.624) Results Gingival index DFS À0.04 (0.746) À0.09 (0.423) DAS À0.03 (0.762) À0.01 (0.904) Sample comprised 54 women and 24 DFS + DAS À0.04 (0.736) À0.05 (0.635) men, mean age 44.6 years. There VAS T1 NA were no significant differences À0.05 (0.679) between treatment groups with Percentage of sites with DFS 0.07 (0.528) 0.06 (0.608) respect to gender, educational level, PD ≥ 4 mm and DAS 0.04 (0.702) 0.03 (0.762) household income, age, and smoking CAL ≥ 3 mm (%PDS) DFS + DAS 0.06 (0.594) 0.05 (0.666) (p > 0.05). VAS T1 NA 0.11 (0.344) All clinical parameters signifi- À < Percentage of sites with DFS 0.02 (0.851) 0.12 (0.309) cantly improved (p 0.001) over the PD (5–6 mm) DAS 0.08 (0.463) 0.06 (0.633) 6-month period of the study, without DFS + DAS 0.04 (0.716) 0.09 (0.450) differences between SRP-Q and VAS T1 FMD (Table 1). À0.11 (0.328) There was a negative, but not significant, correlation between Spearman’s correlation (p-value). CAL, clinical attachment level; DAS, Dental Anxiety Scale; DFS, Dental Fear Survey; PD, fear and anxiety with the same pocket depth; VAS, Visual Analogue Scale. parameters (CAL, PI, and GI), when analysing the two questionnaires separately or together. At T2, the Table 3. Comparisons between clusters in was observed between T0 and T2 in results were similar, namely no relation to treatment modalities (SRP-Q both SRP-Q (p = 0.019) and FMD significant correlation between and FMD) (p = 0.043) groups. However, this periodontal condition and question- Group Clusters p* difference was not observed when naires. In relation to the VAS scale individual scores for each question- (T1), it was also not observed A(n = 33) B (n = 42) naire were evaluated between the significant correlations with clinical groups, at the two examination time periodontal parameters (Table 2). FMD 19 (57.6%) 21 (50.0%) 0.514 points of the study (T0 and T2). The cluster analysis detected two SRP-Q 14 (42.4%) 21 (50.0%) Pain scores (VAS) at T1 were similar clusters: A (n = 33) greater fear and Total 33 42 between FMD (20.6 Æ 19.0) and anxiety, and B (n = 42) less fear and *Chi-square test. SRP-Q (20.7 Æ 20.0) groups anxiety. In the cluster A, the Cluster A = greater fear and anxiety; Clus- (p = 0.930) (Table 5). DFS + DAS scores were 17.64 ter B = lower fear and anxiety; FMD, full- No post-treatment adverse (Æ7.39) and in the cluster B were mouth disinfection; SRP-Q, scaling and effects such as increase in body 13.9 (Æ5.01) (p = 0.036). There was root planing per quadrant. temperature and occurrence of no significant differences between abscess have been reported in the clusters in the proportion of individ- present study. uals in each treatment modality A presented significant worse peri- (p = 0.514; Table 3). odontal clinical status when com- Discussion Table 4 shows the comparison of pared to cluster B. the two clusters with respect to clini- When evaluated separately, DAS The results of this randomized con- cal periodontal parameters at T0 significantly changed over time in trolled clinical trial showed FMD and T2. Significant differences were the SRP-Q group (p = 0.021). When and SRP-Q protocols were equally observed in PD, CAL, %PDS, and DAS and DFS were analysed effective on improving clinical peri- % of sites with PD 5–6 mm. Cluster together, a decrease in the scores odontal conditions and did not show © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Anxiety, pain, and periodontal treatment 1029

Table 4. Comparisons between clusters A and B in relation to periodontal clinical parame- rience by individuals, few and con- ters flicting epidemiological investigations ß Periodontal clinical parameters Clusters Time p (Fardal et al. 2002, Canakci& Canakcßi 2007, Aslund et al. 2008, T0 T2 Guzeldemir et al. 2008) were con- ducted specifically in relation to peri- Periodontal probing depth A (n = 33) 2.39 Æ 0.57 2.13 Æ 0.63 <0.001* odontal treatment (Vettore et al. B(n = 42) 2.12 Æ 0.53 1.86 Æ 0.53 <0.001* 2003, Ng & Leung 2008, Armfield 0.024 p 0.056 et al. 2009). Clinical attachment level A (n = 33) 2.88 Æ 1.11 2.71 Æ 1.07 <0.001* B(n = 42) 2.31 Æ 0.90 2.14 Æ 0.87 <0.001* Studies have shown that, due to p 0.039 0.026 the behaviour of avoiding dental vis- Plaque index A (n = 33) 29.49 Æ 14.33 34.10 Æ 15.94 <0.001** its, individuals remain reluctant even B(n = 42) 29.78 Æ 16.69 26.58 Æ 19.12 <0.001* in the presence of an uncomfortable p 0.120 0.488 situation or pain. This behaviour, Gingival index A (n = 33) 36.95 Æ 26.62 13.06 Æ 24.04 <0.001* which includes emotional, cognitive, B(n = 42) 28.71 Æ 22.78 6.46 Æ 15.02 <0.001* and social aspects, can result in a p 0.145 0.313 vicious circle, which in turn can Percentage of sites with A(n = 33) 12.22 Æ 10.59 9.37 Æ 10.03 <0.001* ≥ = Æ Æ <0.001 cause the deterioration of the indi- PD 4 mm and B(n 42) 7.86 9.18 4.88 8.19 * vidual’s oral, interfere with daily CAL ≥ 3 mm (%PDS) p 0.036 0.015 Percentage of sites with A(n = 33) 7.63 Æ 9.25 5.54 Æ 8.28 <0.001* routine and social activities, and also PD (5–6 mm) B(n = 42) 4.14 Æ 6.58 2.57 Æ 5.84 <0.001* cause the maintenance or even p 0.028 0.016 increase anxiety and dental fear over time (Kent et al. 1996, Ng & Leung Mean Æ SD; the probability of significance (p) refers to the Mann–Whitney test for compar- 2008, Armfield 2013). isons between groups and the Wilcoxon test for the comparison between T0 and T2; It is important to emphasize that, * > ** < P T0 T2; T0 T2. Significant values are shown in bold. since the literature indicated that CAL, clinical attachment level; PD, pocket depth. non-surgical periodontal therapy, either by SRP-Q or FMD, produced Table 5. Comparisons between FMD and SRP-Q groups and evaluation times in relation similar clinical results (Bollen et al. to DFS, DAS, DFS + DAS, and VAS scores 1998, Eberhard et al. 2008, Swierkot Group Time p et al. 2009). We hypothesized that the FMD protocol could generate T0 T2 greater anxiety, fear, and pain, resulting from the fact that all proce- DFS FMD 7.1 Æ 3.1 6.4 Æ 3.5 0.055 = dures are carried out in 24 h. Sec- T0 T2 ond, it was hypothesized that the SRP-Q 6.4 Æ 3.2 5.6 Æ 2.9 0.179 T0 = T2 severity of periodontitis increases p 0.276 0.334 pain, fear, and anxiety scores. How- FMD = SRP-Q FMD = SRP-Q ever, these hypotheses were rejected DAS FMD 9.2 Æ 3.7 8.6 Æ 3.7 0.141 because both non-surgical periodon- T0 = T2 tal treatment protocols were similar SRP-Q 8.3 Æ 3.7 7.2 Æ 3.4 0.021 in relation to anxiety, fear, and pain. T0 > T2 Furthermore, the severity of peri- p 0.284 0.075 odontal clinical parameters did not = = FMD SRP-Q FMD SRP-Q influence the DAS and DFS scores. DFS + DAS FMD 16.2 Æ 6.2 15.0 Æ 6.6 0.019 T0 > T2 Our results showed that FMD or SRP-Q 14.6 Æ 6.5 12.8 Æ 6.1 0.043 SRP-Q protocols were equally effec- T0 > T2 tive on improving clinical periodon- p 0.182 0.128 tal conditions, corroborated by FMD = SRP-Q FMD = SRP-Q findings of previous studies of the T1 effectiveness of non-surgical peri- VAS (910) FMD 20.6 (Æ19.0) NA 0.930 odontal therapy (Bollen et al. 1998, SRP-Q 20.7 (Æ20.0) NA Eberhard et al. 2008, Swierkot et al. Mean Æ SD; the probability of significance (p) refers to the Mann–Whitney test for compar- 2009). When the results of the over- isons between groups and the Wilcoxon test for the comparison between T0 and T2. Signifi- all reduction in mean CAL and PD cant P values are shown in bold. measures for both groups were anal- DAS, Dental Anxiety Scale; DFS, Dental Fear Survey; FMD, full-mouth disinfection; SRP- ysed, they could be interpreted as Q, scaling and root planing per quadrant. clinically insignificant. However, it should be emphasized that individu- differences in fear, anxiety, and pain and fear in relation to dental treat- als in the present study had moder- experience. ment (Johannsen et al. 2005, Erten ate periodontitis, and that the results Although there are several studies et al. 2006, Armfield et al. 2009, were diluted by the mean values of that evaluated the degree of anxiety Armfield 2013), as well as pain expe- healthy sites. However, in the %PDS © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1030 Santuchi et al. and %PD 4–5 mm, an expressive and treatment comparing FMD and Fardal, Ø. & Hansen, B. F. (2007) Interviewing significant reduction for FMD and SRP-Q protocols. self-reported highly anxious patients during periodontal treatment. Journal of Periodontol- SRP-Q groups was reported. Therefore, it was concluded that ogy 78, 1037–1042. Both analyses of DAS and DFS, FMD or SRP-Q protocols were Fardal, Ø., Johannessen, A. C. & Linden, G. J. in isolate or combined forms, equally effective on improving clini- (2002) Patients perceptions of periodontal ther- revealed that the scores of fear and cal periodontal conditions and did apy completed in a periodontal practice. Jour- nal of Periodontology 73, 1060–1066. anxiety in FMD group were superior not show differences in fear, anxiety, Fardal, Ø. & McCulloch, C. A. (2012) Impact of to the SRP-Q group. 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Journal Clinical of Periodontology found that subjects with moderate 80 – of Periodontology , 364 371. 35,8–21. and advanced periodontitis had Corah, N. L. (1969) Development of a Dental Anx- Mongardini, C., Van Steenbergher, D., Dekeyser, 48 higher fear scores, although with no iety Scale. Journal of Dental Research , 596. C. & Quirynen, M. (1999) One stage full- versus Eberhard, J., Jepsen, S., Jervøe-Storm, P. M., partial-mouth disinfection in the treatment of differences in the severity of peri- Needleman, I. & Worthington, H. V. (2015) odontitis. chronic. Journal of Periodontology 70, 632–645. Full-mouth treatment modalities (within Ng, S. K. S. & Leung, W. K. 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Quirynen, M., Mongardin, I. C., De Soete, M., Swierkot, K., Nonnenmacher, C. I., Mutters, R., Pauwels, M., Coucke, W., Eldere, J. & van Flores-de-Jacoby, L. & Mengel, R. (2009) One- Address: Steenberghe, D. (2000) The role of chlorhexi- stage full-mouth disinfection versus quadrant Fernando Oliveira Costa dine in the treatment of patients with advanced and full-mouth root planing. Journal Clinical of School of Dentistry adult periodontitis. Journal Clinical of Peri- Periodontology 36, 240–249. Department of Periodontology odontology 27, 578–589. Teughels, W., Dekeyser, C., van Essche, M. & Federal University of Minas Gerais Silness, J. & Loe,€ H. (1964) Periodontal disease in Quirynen, M. (2009) One stage, full mouth dis- Antonio^ Carlos Avenue pregnancy. II. Correlation between oral hygiene infection: ﬁction or reality? Periodontology 6627, Pampulha, PO Box 359 and periodontal condition. Acta Odontologica 2000 50,39–51. Zip Code 31270-901 Scandinavia 22, 112–135. Vettore, M. V., Leao,~ A. T. T., Silva, A. M. M., Silness, J. & Loe,€ H. (1966) Periodontal disease Quintanilha, R. S. & Lamarca, G. A. (2003) Belo Horizonte, Minas Gerais in pregnancy. 3. Response to local The relationship of stress and anxiety with Brazil treatment. Acta Odontologica Scandinavia 24, chronic periodontitis. Journal Clinical of Peri- E-mail: [email protected] 747–759. odontology 30, 394–402.

Clinical Relevance (FMD) versus conventional quad- decreased, with no differences Scientiﬁc rationale for the study: rant scaling (SRP-Q). between groups. Pain did not differ There are few clinical trials Principal ﬁndings: Patients with between groups. regarding the effects of non-sur- higher fear and anxiety showed a Practical implications: FMD and gical periodontal treatment on worse periodontal status before and SRP-Q were equally effective on fear, anxiety, and pain, particu- after treatment. After both types of improving periodontal status and larly when performed by one- treatment, periodontal status did not show differences in fear, stage full-mouth disinfection improved, fear and anxiety anxiety, and pain experience.