This study provided information about pain perception and dental anxiety during periodontal probing. Oral examination was conducted in oral health outreach programmes, on a chair in a sitting position under natural light. The findings revealed, 72% of the participants had pathological gingival conditions but very few had periodontal pocket (12%).
Pain perception of the patient cannot be directly assessed by the dentists as communication skills, individual psychological status and, social and cultural backgrounds of the patient affect the expression of pain experienced. In this study, the participants experienced very less pain (6.75 ± 10.65) during periodontal probing but the VAS scores were highly variable (0 to 59.5). Similar results were obtained in other studies [1, 2, 7]. This might be attributed to the reason that pain measurement is subjective and individual, and the assessment and screening are more difficult because of its physical and psychological properties . Additionally, pain perception is influenced by the patients’ systemic conditions, oral pathological status, and patients reporting with the complaint of pain [6, 15].
Pain perception of female participants was similar to the male participants (6.46 ± 9.48 and 6.97 ± 11.53 respectively), and the difference was not statistically significant (p = 0.780). This was similar to the study conducted by Canakci and Canakci  but different than the results of Faisal et al. . In general, the clinical impression is that elderly people are usually more tolerant of pain. Nociceptors are lost due to aging . In contrast, this study showed a higher VAS score in the elderly (11.05 ± 15.41) compared to young participants (6.00 ± 9.50). This might be due to the reason that pain varies subjectively and is also dependent upon many underlying causes that might be unnoticed clinically. There was a significantly significant correlation between the VAS score of maxilla and mandible. The correlation between bleeding and VAS score was also significant (p < 0.001). Bleeding on probing indicated the inflammatory condition of the gingiva that raises the possibility of increased pain perception .
Female patients are more anxious than male patients. It may be due to the difference in pain threshold between genders. In contrast, this study revealed that the dental anxiety was also similar in both males (13.60 ± 2.03) and females (13.30 ± 1.48) with overall anxiety score 13.37 ± 1.81. The anxiety of female participants was less compared to the male participants (13.30 ± 1.48 and 13.60 ± 2.03 respectively), but the difference was not statistically significant (p = 0.408). The insignificant higher anxiety score in male participants might be attributed to difference in sample participants (male = 57; female = 43). The higher mean age of the female participants (31.9 ± 10.6) might have also attributed to insignificant less anxiety score among female. It has been seen that older individuals experience lesser anxiety than their younger counterparts due to general decline in anxiety and many more exposure to diseases and their treatments . This was similar to a study conducted by Shaikh and Kamal  and Ghazaleh et al.  but different than the results of Faisal et al. .
Anxiety is thought to increase pain perception and vice versa . Female is supposed to have more fear compared to the male . In contrast, in this study the anxiety scores for males and females were comparable. There was a very weak correlation between anxiety score and bleeding on probing and anxiety and pain perception. This might be due to the fact that anxiety has an influence on expected pain, but not on the experienced pain .
The sampling covered a large population area including four districts of eastern Nepal. This study is the first of its kind done in the population. Hence, it is an added asset for the dentist to have an insight into the pain perception and dental anxiety during periodontal probing and further plan the approach for patient management.
The sampling technique used was convenience sampling that limits the generalizability of the study and gives a scope for selection bias. Moreover, the probing was performed by the WHO probe that increases the chance for subjective variation of force applied during probing. A digital probe would have been better to maintain the constant force of probing. The other limitation being chances of variation in pain response by the patients as full mouth probing was done and there were partially edentulous patients. Measuring anxiety accurately is extremely difficult and therefore it may alter research outcomes. As pain and anxiety are subjective measures, it is difficult to quantify them. A participant may express pain and anxiety to one aspect of examination but not in another. Hence, experimental studies with digital monitoring of the probing force will further elaborate regarding the correlation between pain and anxiety.