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International Journal of Dentistry

Volume 2014, Article ID 472926, 5 pages
http://dx.doi.org/10.1155/2014/472926

Clinical Study
Pain Perception and Anxiety Levels during Menstrual Cycle
Associated with Periodontal Therapy
Nikhat Fatima,1 P. Raja Babu,2 Vidya Sagar Sisinty,2 and Bassel Tarakji3
1

Department of Periodontics, Al-Farabi College, Riyadh, Saudi Arabia

Department of Periodontics, Kamineni Institute of Dental Sciences, Narketpally, India
3
Department of Oral and Maxillofacial Sciences, Faculty of Dentistry, Al-Farabi College, Riyadh, Saudi Arabia
2

Correspondence should be addressed to Nikhat Fatima; [email protected]

Received 10 July 2014; Accepted 25 September 2014; Published 12 October 2014
Academic Editor: Timo Sorsa
Copyright 2014 Nikhat Fatima et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objectives. To compare the pain perception and anxiety levels of female patients undergoing scaling and root planing during
menstrual (perimenstrual) period with those observed during postmenstrual period. Materials and Methods. This was a single
blind study, with a split-mouth design. Forty-four women with chronic periodontitis with regular menstrual cycles were subjected
to complete Corahs Dental Anxiety Scale (DAS) during their first debridement visit. Patients were randomly selected to undergo
their first debridement visit during either their menstrual or postmenstrual period. Scaling was performed under local anesthesia in
bilateral quadrants of patients during the periods. Visual Analogue Scale (VAS) was used to score pain levels for each quadrant after
performing scaling and root planing. Results. Increase in pain perception among females during their menstrual or perimenstrual
period was significantly greater than their postmenstrual period (P < 0.05). It is observed that women whose first appointment
was given in perimenstrual period had more pain (VAS) (P = 0.0000) when compared to those women whose first appointment
was given in postmenstrual period. Conclusion. Females in their menstrual period demonstrated higher pain responses and high
anxiety levels to supra- and subgingival debridement. This increase in the pain levels of women during their menstrual period was
statistically significant. If the appointments are given in postmenstrual period, women feel less pain.

1. Introduction
It is estimated that some 5% to 20% of any population suffers
from severe generalized periodontitis [1]. Periodontitis is
defined as an inflammatory disease of the supporting tissues
of the teeth caused by specific microorganisms resulting in
progressive destruction of the periodontal ligament and bone
loss [2]. If untreated, this chronic inflammatory disease can
lead to tooth loss affecting the oral health related quality of
life (QOL) [3].
When we consider the gender basis of periodontal diseases, there is evidence to support the higher prevalence of
destructive periodontal disease in men than women. The
important factor to be considered is that women still have
varied periodontal conditions due to hormonal fluctuations
in their various phases of life [4].
During the treatment phases of periodontitis (this
includes mechanically removing bacterial biofilm), scaling

and root planing patients feel that the procedure is more

painful [5, 6]. There is increased evidence in literature that
indicates males and females perceive pain differently when
they were subjected to experimental or clinical pain. Several
factors have been suggested to explain the differences with
the most common difference being the sex hormones. The
fluctuating hormones affect womens perception of pain as
well as increase in anxiety [7, 8].
From oral health point of view, there have been studies
which have been conducted to demonstrate degree of pain
and anxiety experienced by patients during probing and
scaling and their perception of pain was directly proportional
to anxiety levels [9].
aka et al. [9] in their pilot study with the small
Ozc
sample size of 20 Turkish women demonstrated the effect
of menstrual cycle on pain experience during periodontal
therapy. Since then no study has been done, especially in
a developing country, so we decided to conduct a study in

International Journal of Dentistry

Indian women in 44 patients to determine the effect of the

menstrual cycle and role of anxiety which plays any effect on
pain perception.

2. Materials and Methods

A total of forty-four (44) female subjects between the ages of
20 and 38 (mean 27 years) were recruited from the nursing,
medical, and dental college and also the female patients
visiting Department of Periodontics, Kamineni Institute of
Dental Sciences, Narketpally, Nalgonda District. This study
was approved by Ethical Committee of Kamineni Institute of
Medical Sciences and Dental Sciences.
2.1. Objectives. The objective of this study is to compare the
pain perception of female patients and their anxiety levels
when undergoing periodontal debridement during
(1) menstrual phases,
(2) postmenstrual phase.
2.1.1. Patient Selection Criteria
(a) Inclusion criteria:
(1) patients should have chronic periodontitis, with
at least five teeth in each quadrant;
(2) at least 3 teeth in each quadrant were required to
have a probing pocket depth of 4 mm or greater;
(3) none of the subjects had received periodontal
debridement within the preceding 12 months;
(4) patients should have regular menstrual cycle.
(b) Exclusion criteria:
(1) patients on oral contraceptives;
(2) patients on antidepressants and analgesics;
(3) patients with systemic disease.
2.2. Design of the Study. The total of forty-four patients was
selected for the study. This study was a single blind study,
with a split-mouth design, where patients were aware of their
menstrual status but supporting examiner was not aware of
the patients menstrual status.
Based on clinical findings, patients who exhibited
moderate-to-advanced chronic periodontitis were included
in the study. Orthopantogram (OPG), probing pocket depth
(PPD), clinical attachment loss (CAL), gingival index (GI)
[10], periodontal index (PI) [10], and bleeding on probing
(BOP) [10] were recorded. Patients menstrual history is taken
and those who reported having regular menstrual cycles (i.e.,
the length of their cycle varied by no more than 3 days) for the
last 12 months were eligible for the study. A menstrual cycle
is conventionally defined as the time from the beginning of
one menstrual flow (day 1) to the beginning of the next [11].
Although there is a great deal of variability in menstrual cycle
length between women and within individual women over
time [12] the prototypical menstrual cycle is usually described

for heuristic purposes as 28 days in length. Patients who

exhibited probing pocket depth 4 mm or greater, and who had
at least 5 teeth in each quadrant, and severity of periodontal
disease was similar were included in the study. At least three
teeth in each quadrant were required to have a probing pocket
depth of 4 mm or greater.
The patients who are on antidepressants and analgesics
were excluded from the study because antidepressants and
analgesics may have an effect on pain threshold [5]. And it was
made sure that none of the subjects had received periodontal
debridement within the preceding 12 months. Corahs Dental
Anxiety Scale (DAS) [13] and Visual Analog Scale (VAS)
[14] numerical were used to assess the anxiety and pain
perception, respectively. Corahs Dental Anxiety Scale was
translated into local language (Telugu) for those subjects who
were comfortable in their local language.
2.3. Clinical Procedures. The scheduling of the first treatment
appointment was done randomly. Patients took their first
appointment during their first 3 days of menstrual period
or in perimenstrual period between 3 and 4 days before the
menstrual period. Some patients took their first appointment
one week after the menstruation, that is, in postmenstruation.
Supragingival and subgingival scaling was performed under
local anesthesia. All patients received infiltrative anesthesia
containing lidocaine 2% with adrenaline 1 : 80000 [15].
This study was performed with a split-mouth design, and
another debridement took place according to the menstrual
phase of the patient.
The treatment was standardized by noting the time taken
for debridement, the amount of local anesthesia used, the
number and type of teeth to be debrided at each visit were
equalized.
Before the start of treatment, in their first debridement
visit, patients were asked to complete Corahs Dental Anxiety
Scale (DAS) that was translated in Telugu.
This was a single-blinded study. The supporting investigator was not informed about the menstrual status of the
subjects. However, the patients were aware of the study.
Supragingival and subgingival debridement was carried out
by the same investigator.
After applying local anesthesia, supragingival and subgingival scaling was performed. When the effect of local
anesthesia wore off after 2 hours, patients started to perceive
pain; they were asked to complete Visual Analogue Scale
(VAS) numerical. The scale starts from 0 to 100; the
starting point indicates no pain and the end point indicates
intolerable pain. Some patients left the clinic taking VAS
form and returned it in their second visit; the rest of the
patients completed the procedure within the clinic.
2.4. Data Analysis. A total of 44 female patients participated
in the study aging between 20 and 38 years. (mean age
27). Perimenstrual and Postmenstrual Dental Anxiety Scale
(DAS) and Visual Analogue Scale (VAS) scores of females
were collected and analysed by the Wilcoxon signed rank test
(see Tables 1 and 2). Comparison of the possible effects of
the order of treatment time (perimenstrual or postmenstrual)
was evaluated by Wilcoxons signed rank test.

International Journal of Dentistry

Table 1: Comparison of perimenstrual and postmenstrual DAS scores by Wilcoxon matched pairs test by ranks.
Menstrual
Perimenstrual
Postmenstrual

Mean
9.5455
8.3409

Std.Dv.
3.0534
3.5955

Mean Diff.

SD Diff.

% of change

value

value

1.2045

3.4071

12.6190

2.3258

0.0200

Significant at 5% level of significance ( < 0.05).

Table 2: Comparison of perimenstrual and postmenstrual VAS scores by Wilcoxon matched pairs test by ranks.
Menstrual
Perimenstrual
Postmenstrual

Mean
57.9318
40.1136

Std.Dv.
11.7263
10.7297

Mean Diff.

SD Diff.

% of change

value

value

17.8182

7.8066

30.7572

5.7592

0.0000

Significant at 5% level of significance ( < 0.05).

Comparison of age groups (2029 years, 30+ years) with

respect to perimenstrual, postmenstrual, and
difference of peri- and postmenstrual DAS scores

10.16

12.0

8.45

Mean value

10.0

8.08

8.08

8.0
6.0
4.0
2.0
0.0

30+

2029
Years

Perimenstrual
Postmenstrual

Figure 1: Comparison of age groups (2029 years, 30+ years) with

respect to perimenstrual, postmenstrual, and difference of peri- and
postmenstrual DAS scores.

Comparison of perimenstrual and postmenstrual PPD

(%) scores was done by students paired -test. Comparison
of age groups (2029 years, 30+ years) with respect to
perimenstrual, postmenstrual, and difference of pre- and
postmenstrual DAS and VAS scores was done by MannWhitney test (see Figure 1).
Frequency distribution of patients Dental Anxiety Scale
and VAS pain responses to periodontal treatment was analyzed.

3. Results
It has been observed that the increase in anxiety among
females in their perimenstrual period was significantly
greater than their postmenstrual period (Wilcoxons signed
rank test) (DAS) ( < 0.0200).
The increase in pain perception among females in their
perimenstrual period was significantly greater than their
postmenstrual period (Wilcoxons signed rank test) (VAS)
( < 0.05).
Perimenstrual PPD% was (mean scores) 53.50 and postmenstrual PPD% was (mean score) 52.88 ( > 0.0461)

significant showing increase in pocket depth during perimenstrual period. And students paired -test was (2.0537) which
is highly significant. It has been observed in the study that
perimenstrual bleeding on probing was more (mean score
50.72) than postmenstrual bleeding on probing (mean score
49.57).
In this study women showed appreciable oral symptoms
during menstruation. In perimenstruation, the mean GI
score was 0.8091 compared to postmenstruation GI score
(mean score 0.7977).
Statistically significant associations were observed
between age and anxiety. Women who are aged 30 and above
have demonstrated more anxiety in their perimenstruation
phase compared to women who are below 30 ( < 0.01). No
statistically significant associations were observed between
age and pain perception.
Comparison of order of treatment time, perimenstrual
to postmenstrual, with respect to DAS is analyzed by using
Mann-Whitney test. It is observed that women whose first
appointment was given in perimenstrual period had more
anxiety (DAS) ( < 0.0041) compared to those women whose
first appointment was given in postmenstrual period.
Comparison of order of treatment time, perimenstrual
to postmenstrual, with respect to VAS is analyzed by using
Mann-Whitney test. It is observed that women whose first
appointment was given in perimenstrual period had more
pain (VAS) ( < 0.0000) compared to those women whose
first appointment was given in postmenstrual period.

4. Discussion
A womans life is continuously affected by reproductive
hormones, in puberty, pregnancy, and menopause. Womans
oral health needs can also change at these times, thus affecting
their dental treatment plans. In the past, research on womens
health has been unfairly neglected and only recently research
and health agencies decided to change this [16]. Therefore,
recent research has identified many interesting and important
differences between genders in terms of oral health and pain
perception.
Female reproductive hormones play important role in
pain perception and response. A menstrual cycle is conventionally defined as the time from the beginning of one
menstrual flow (day 1) to the beginning of the next [11].

4
Although there is a great deal of variability in menstrual
cycle length between women and within individual women
over time [12], the prototypical menstrual cycle is usually
described for heuristic purposes as 28 days in length. Gynecologists divide the menstrual cycle into phases based on
physiological events. The monthly reproductive cycle has two
phases. The first phase is referred to as the follicular phase.
Levels of follicle-stimulating hormone (FSH) are elevated and
estradiol (2 ) the major form of estrogen is synthesized by
the developing follicle and peaks approximately 2 days before
ovulation.
In the second phase which is called luteal phase, the
developing corpus luteum synthesizes both estradiol and progesterone. The corpus luteum involutes, ovarian hormones
level drops, and menstruation ensue. It has been postulated
that ovarian hormones may increase inflammation in gingival
tissues and exaggerate the response to local irritants and
increase in oral symptoms during menses [17]. Miyagi et al.
found that the chemotaxis of polymorphonuclear leucocytes
was enhanced by progesterone but reduced by estradiol.
Testosterone did not have measurable effect on polymorphonuclear leucocytes chemotaxis [18].
It is now generally accepted that males and females exhibit
important differences in their pain experiences [1820].
For example, epidemiological studies indicate that females
report more pain experiences and more negative responses
to pain compared to males [7]. Furthermore, clinically based
research suggests that there are important gender differences
in susceptibility to pain-related diseases, analgesic effectiveness, and recovery from anaesthesia [21, 22].
Finally, experimental pain induction studies reveal that
females consistently exhibit lower thresholds and tolerance
to a wide range of noxious stimuli [23, 24]. A number of
psychological factors, including anxiety, may be sources of
variance in how men and women perceive pain. Women are
often found to experience more transitory and dispositional
anxiety than men [2528].
Anxiety is believed to disrupt the interpretation of
stimuli, resulting in altered perception. It is thought that
anxiety disrupts the experience of pain by influencing the
cognitive processing of nociceptive information [29]. Laboratory induced general anxiety [30] and pain-specific anxiety
[31] have both been found to correspond with increased
sensitivity to painful stimulation.
The patients who are on antidepressants and analgesics
were excluded from the study because antidepressants and
analgesics may have an effect on pain threshold [5]. It
is concluded that tricyclic antidepressants have differential
hypoalgesic effect on different human experimental pain tests
[32].
The purpose of this study was to determine differences
between females pain levels during their perimenstrual
versus their postmenstrual phase by performing debridement
under local anesthesia.
During this study it has been observed that in campus
nursing, dental, and medical students were more cooperative
and followed scheduled appointments regularly. The general
female patients who visited our department did not keep
the track of their menstrual cycle and did not fulfill the

International Journal of Dentistry

study requirement. Six female patients did not complete their
second visit.
Corahs Dental Anxiety Scale (DAS) was translated into
Telugu for those who are comfortable with expressing their
feelings in their local language. We preferred the VAS which
requires minimal linguistic skills and is therefore easier for
patients to use in describing their pain. VAS can be quantified
and allows for comparison of patients on a scale of 0100.
In this study the increase in pain perception among
females in their perimenstrual period was significantly
greater than their postmenstrual period (Wilcoxons signed
rank test) (VAS) ( = 0.0000) and also anxiety was greater
in perimenstrual period (DAS) ( < 0.0200). It is also
observed that women whose first appointment was given in
perimenstrual period had more anxiety (DAS) ( < 0.0041)
and more pain (VAS) ( = 0.0000) compared to those women
whose first appointment was given in postmenstrual period.
With respect to this result, we found that patients in their
perimenstrual period demonstrated higher pain responses
to supra- and subgingival debridement than they did in
their postmenstrual period. This increase in the pain levels
of women during their menstrual period was statistically
significant. There was no statistically significant correlation
between the DAS and the VAS. Spearmans was 0.2429.
Statistically significant associations were observed between
age and anxiety. Women who are aged 30 and above have
demonstrated more anxiety in their perimenstruation phase
compared to women who are below 30. No statistically
significant associations were observed between age and pain
perception.
This study also confirms results of the other study by
Ozgun Ozcaka and collegues.
Gender based medicine and gender based treatment are
going to become the norm of the day. By knowing the
menstrual cycles of their female patients, periodontists may
wish to schedule mechanical periodontal therapy; this will
instill positive attitude in female patients regarding dentistry
in general and periodontal therapy in particular and improves
the comfort level and cooperation from female patients.

5. Conclusion
This study addressed the specific problem of female patients
undergoing periodontal therapy in their perimenstrual and
postmenstrual period. It has been observed that women
perceive more pain during perimenstrual period than in their
postmenstruation period. Periodontists can make women
more comfortable and cooperative by scheduling their
appointment according to their cycle.

Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.

Acknowledgment
The authors would like to thank Ozgun Ozcaka for her
support and encouragement during the study.

International Journal of Dentistry

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