Discussion: Elusion of dental treatment can be attributed to excessive dental anxiety which in

turn has its effect on the overall health. As stated by Erten et al the sight of dental injection
needle along with the feeling of being injected is the most fear producing stimuli. The present
study evaluates the comparative efficacy of an EMLA cream on pain perception during non
surgical periodontal therapy. The EMLA cream, a 5% eutectic mixture of prilocaine and
lignocaine, has been used to anesthetize skin before venepuncture and minor operations in
dermatologic practice. In dentistry, the EMLA cream has been used on skin before venepuncture
for sedation and temporomandibular joint arthrocentesis7. Although EMLA cream was not
originally designed for intraoral use, it was shown to have effective properties in needlepenetration studies and injection studies8. Other studies reported that EMLA cream was more
effective in increasing sensory and pain thresholds than a 2% lidocaine gel, 5% lidocaine gel, and
1% dyclonine, 10% cocaine, 20% benzocaine, and 10% lidocaine. The fear of pain still being a
common reason for avoidance of dental treatments Pain control is considered to be an extremely
important outcome measure for successful periodontal therapy because sustained periodontal
maintenance and patient recall depend on pain perception. Assessment of pain is not easy as it
encompass both physical and physiologic aspects. This present study involved only one
periodontist which included a particular dental chair and all the subjects were treated in the same
chair and in the same position ensuring a perfectly controlled environment. Pain assessment was
done using VAS (Visual analog scale) VRS (verbal rating scale). Visual analogue scale (VAS)
consists of a 10 cm horizontal line whose extreme ends were marked as no pain on the left side
and worst pain on the right side. The patients were asked to place a mark on the line which
represents the level of their pain. Verbal rating scale (VRS), in this scale, four perpendicular lines
was marked on a horizontal line. Lines from left to right side were denoted with the words no
pain, mild pain, moderate pain and severe pain respectively. Patients have to mark the pain which
they are feeling. A score of 0 was given to no pain while 3, 6 and 10 scores were allotted to mild,
moderate and severe pain respectively. Consistent with previous research, most patients enrolled
in the present study experienced limited pain during root planning. Although pain was limited,
the present study showed that EMLA-cream application was significantly (P <0.05) effective in
reducing pain .The VAS mean ranks of EMLA is lower than lignocaine that is 36.97 to 58.03,
likewise the VRS scores are also lower for EMLA than lignocaine that is 38.17 to 56.83.
Svensson et al.10 investigated the analgesic efficacy and duration of effect of lignocaine and

EMLA on tongue and gingiva labial to the lower incisor teeth using argon laser stimulation. They
measured pain and sensory thresholds following a 2 min application of lignocaine and 2, 5, and
15 min applications of EMLA. The greatest increase in pain threshold for all treatments was
noted immediately after removal of the topical anaesthetic. The increase in sensory and pain
threshold was related to the agent applied; EMLA being significantly more effective than
lignocaine. The duration of EMLA application was positively related to the intensity of the effect
on tongue (both sensory and pain perception being more elevated after 15 min compared to 2
min) although such an effect was not apparent on the gingiva. Sensory and pain thresholds were
elevated for all treatments up to 25 min after removal. These authors concluded that a 5 min
application of EMLA on the tongue gives clinical analgesia for 5 min and that a 2 min
application on the gingiva produces analgesia for 10 min. Pere et al. 11 investigated the use of 4 g
EMLA applied over 4 min to the gingiva by a toothbrush as a means of pain control for the
removal of arch bars used in intermaxillary fixation in a double-blind placebo-controlled trial in
dentate patients. They found that pin-prick sensation was significantly less in the EMLA group 5
min after tooth brushing with the topical compared to the placebo before removal of the archbars. However, following removal of the arch bars (mean time 19 min after tooth brushing) there
was no difference between treatments in response to pinpricking of the gingiva. They recorded
significantly more patients with EMLA reported no pain (7/14) compared to those who received
placebo (2/15). They concluded that EMLA produced significant analgesia for the removal of
arch bar
Haasio et al.12 compared the analgesic effects of EMLA and 10% lignocaine spray on buccal
gingival mucosa on the upper jaw in 10 volunteers. They tested loss of sensation by electrical
stimulation and recorded both sensory and pain thresholds. The treatments did not differ in the
amount of analgesia they produced. The use of a customized intraoral splint as a delivery vehicle
of the EMLA cream allowed the local anesthetic to stay in the location where the local anesthetic
was first applied, which prevented dilution and dispersion by saliva. This may be a useful
method to apply local anesthetics intraorally because conventional methods using cotton-tip
applicators or toothbrushes were constantly met with dilution problems.

The use of EMLA cream on each quadrant for 5 minutes in the present study produced an
effective anesthesia. This is in agreement with a number of studies where the duration and
amount of EMLA cream application fell within the categories of 2 to 5 minutes

to produce

analgesic effects. However, careful interpretation of the results is recommended because a splint
instead of cotton tip or toothbrush was used in the present study as the delivery measure. A study
directly comparing the effectiveness, onset, duration, and amount of EMLA needed between the
two delivery means is necessary for a definitive comparison. Also, Svensson and Petersen 14and
Nayak and Sudha15 reported a mean onset time of 2 minutes and 138 seconds of EMLA
application to achieve an analgesic effect, the exact onset time is still unclear, and more efforts to
find the exact onset time to prevent an unnecessary prolonged application time seems to be
needed. In terms of adverse effects of the EMLA cream on the oral mucosa, no evidence of
damage to the oral mucosa was observed or reported by subjects after a 1-day follow-up. This is
in accordance with the results from previous studies. On the contrary, Franz-Montan et al.
reported four cases of mucosa ulceration after 0.3 g EMLA-cream application intraorally. The
patients returned the next day with white ulceration and desquamation on applicated areas. This
phenomenon was not observed in the present study, and a possible explanation of the local
complication might be the long duration (30 minutes) of application. Therefore, it may be
suggested that EMLA cream should not be applied to the oral mucosa for 30 minutes. Reports of
damage to mucosa are rare any problems appear to be reversible and symptomless 13.
The findings suggest that Emla is a more effective topical anesthetic agent than lignocaine alone.
Its duration of action, although relatively short, is sufficient for Root Planings and also in various
minor operations on the gingival tissues such as excision of discrete lesions such as epulides that
involve the free gingival mucosa and papillae.