Pre- and postoperative

management techniques.
Before and after.
Part 1: medical morbidities

IN BRIEF

Provides an overview of evidence related

J. Mansoor1

This article provides readers with an overview of available evidence in relation to providing care to patients in different
medical circumstances within oral surgery. There is evidence available to support discussions with patients taking particular medications (such as bisphosphonates, anticoagulants and corticosteroids) and also to try to prevent certain complications (such as dry socket). In order to reduce the risks of potential morbidities, either perioperatively or postoperatively,
operators must use high-quality, reliable and informed protocols, management techniques, advice and interventions to
provide patients with the best care. These are used both preoperatively and postoperatively and patients should be consented appropriately, in a manner tailored to their own individual circumstances, but also using available evidence to
explain the benefits and harms of any given procedure. In this short series we will outline and discuss common pre- and
postoperative management techniques, protocols and instructions, and the evidence available to support these.

INTRODUCTION
POIG (Postoperative instructions given) is a
term that will be familiar to many operators,
clinicians and support staff. There is an array
of advice, instruction and guidance delivered
by healthcare professionals on a daily basis
and this may vary on what is delivered and
the method by which it is conveyed. Oral
surgery still remains one of the most invasive areas within dentistry for the operator to
carry out treatments with potentially serious
morbidities. This short series of articles will
assess discussed risks, advice, management
techniques and interventions commonly
issued to patients across the profession
within minor oral surgery (MOS), both preoperatively and postoperatively.

WHAT IS EVIDENCE?
Evidence-based practice can be defined as
the explicit and judicious use of current best
clinical research evidence to guide healthcare decisions. It integrates this best research
evidence with clinical expertise and patient
values. The aim of evidence-based practice
is to optimise clinical outcomes and the
patients quality of life.1
Ravat and Ray Dental Care, 1 Bateman Street, Bradford,
BD8 7DH
Correspondence to: Dr Jamshaid Mansoor
Email: jamshaid_manzoor@yahoo.co.uk
1

Refereed Paper
Accepted 18 February 2015
DOI: 10.1038/sj.bdj.2015.144
British Dental Journal 2015; 218: 273-278

Systematic review
and meta-analysis

Fig.1 The
hierarchy of
evidence

Randomised-controlled
trials
Cohort studies

Case-control studies

Case series/Case reports

Expert opinion

Within dentistry, the amount of credible,

recent, strong evidence is lacking, especially
when mirrored with the literature available
within medicine.2 This continues to be the
case when assessing the use of guidelines
available in dentistry, which have been
questioned by some authors.3 One example of this would be the 15-year-old NICE
guidelines for the removal of impacted
wisdom teeth,4 which were discussed in
an article in 2013: 1 the authors alluded
to the fact that these particular guidelines
were produced by a working group of
individuals, none of which had any form
of dental qualification; these guidelines
have not been reviewed or updated since
2000. Nevertheless, dentistry follows the
same model in relation to the hierarchy of

BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015

evidence (Fig. 1). Systemic reviews with

incorporated meta-analysis remain the
strongest and best forms of evidence.
Research methods differ in methodology,
time, design, cost and ultimately strength.
Table 1 very briefly outlines the various
research methods available. In order to
be in the best position, it is the authors
belief that healthcare professionals must
not only be aware of the latest research,
but able to critically appraise the literature
to assist a decision-making process, which
should already be supplemented by sound
clinical skills including taking a good history, carrying out a thorough high-quality
examination and also individual patient
risk assessments. Various risk assessment
tools exist for general dental practitioners
273

2015 Macmillan Publishers Limited. All rights reserved

PRACTICE

to minor oral surgery patients who are

taking specific medication.
Defines and summarises the role of
evidence-based practice.
Gives brief descriptions of the importance
and legalities of the consent process in
minor oral surgery.

PRACTICE
already, and some of these have been
incorporated physically into daily treatment plans (for example, certain NHS pilot
contracts have incorporated a RAG system to aid categorisation of patient risk to
dental disease5). The methodology and the
evidence used to formulate such pilots is
largely unclear; however, evidence-based
resources to aid risk assessment do exist;
one such resource is the preventative toolkit
produced by the Department of Health,
Delivering better oral health.6 Unlike the
NICE guidelines mentioned earlier, this
toolkit has been regularly updated and
consists of current evidence-based advice.
The skill of critical appraisal is as any other
in dentistry and requires knowledge, experience and practice; therefore, interested
readers are encouraged to engage in further reading and are directed to other texts
regarding this wide-ranging topic.717
One organisation that aids clinicians,
investigators, researchers, patients and
members of the public make such appraisals
is the Cochrane Collaboration.18 Systematic,
up-to-date reviews (with meta-analysis
where possible) are prepared, maintained
and available, providing an integral resource
to be able to make evidence-based clinical
decisions.

Table1 Research methods

Systematic review
and meta-analysis

Statistical methods are used to combine the results of a collection of randomised-controlled trials that have been systematically identified, appraised and
summarised to provide a summary answer for a particular topic

Randomised controlled
trials

Strategically designed and organised studies with participants that have been
randomly allocated to a specific group, which may be exposed to a particular
intervention, test or treatment. A comparison is then made between the groups

Cohort studies

Two or more groups are followed-up after exposure to a particular agent and
outcomes for each of the groups is observed in order to assess how many in
each group develop a particular condition, pathology or disease

Case-control studies

Patients with a particular condition, pathology or disease are paired with controls in the general population and data is collected from participants regarding
a particular aetiological agent or past-exposure

Case series/case reports

Describes in detail the history of a single patient to demonstrate or highlight a

rare condition, treatment, outcome, complication or other event relating to the
individual

Expert opinion

The views of specialists and particular experts on a particular subject topic are
gathered. The consensus is analysed and used to form a conclusion to a particular healthcare conundrum

Table2 Risk categories for patients taking bisphosphonates

Low

High

Prior to bisphosphonate therapy for any condition

Previous diagnosis of BRONJ

Taking bisphosphonates for the prevention/management of osteoporosis

Taking bisphosphonates as part of the management

for a malignant condition
Other non-malignant systemic condition affecting
bone (eg Ricketts disease)
Under the care of a specialist for a rare medical
condition (eg osteogenesis imperfecta)

PRE-/POSTOPERATIVE PROTOCOLS
Generations of healthcare professionals have delivered important preoperative
intervention and aftercare messages to
patients across many different specialities.
Within dentistry, nearly all procedures are
followed by some form of advice or instruction and some of these also require management before any treatment is carried out.
For some procedures there is clear and concise guidance, for example the prescription
of antimicrobials in primary dental care19,20
(see below). The advice delivered following
other common procedures is a little more
conspicuous an example of this would
be explaining to patients to avoid biting
on their lip/chin following treatment under
local anaesthetic. Both the experienced and
inexperienced clinician will be all too aware
of the potential consequences of litigation
and complaints if effective communication
has not been delivered preoperatively, or
if there are complications within the treatment carried out even if this has previously been explained and included within
the consent (see later).

PREOPERATIVE
Protocols for managing patients before any
particular surgery may involve instructions,
procedures or particular investigations.
Several of these have been discussed (mainly

Taking systemic steroids/immunosuppressants

(eg methotrexate)
Radiotherapy, chemotherapy and/or coagulopathy

within the medical context) by NICE21 and

some of their guidance is likely to be used
within the dental profession.4,22 Perhaps one
of the most well-renown preoperative recommendations is regarding Antimicrobial
prophylaxis against infective endocarditis.22
This particular document is evidence-based
and advises against the use of either antimicrobials or chlorhexidine gluconate mouthwash for prophylactic medicaments for
patients undergoing dental procedures. The
clinical implications of this document have
been evaluated as recently as a few months
ago. Dayer et al. analysed prescription versus
non-prescription for the antibiotic prophylaxis in relation to infective endocarditis, in
England, over a period of just over 12years.
Their findings were a reduced number of
prescriptions since the guidelines were introduced in 2008, but also an increase in the
incidence of cases of infective endocarditis.23
The results are statistically significant for
both low and high-risk patients.23 Another
example of an infamous but perhaps more
under-used regimen is the use of diazepam for anxious patients, before attending

274

appointments. The use of oral sedatives for

nervous, fearful and anxious patients has
been well-documented.19,24
Within oral surgery procedures, clinicians
are now likely to be aware of patients that
are at a greater risk of complications. Some
examples of these risk-groups would be
patients taking certain medications such
as anticoagulants, antiplatelets, bisphosphonates, steroids or the oral contraceptive pill
(OCP). Although we will briefly discuss some
of the guiding evidence for the management
of these patients; there are many other medications and medical conditions that affect
the dental patient, and for this the reader is
referred elsewhere.25

BISPHOSPHONATES AND ANTIBONE-RESORPTIVE MEDICATIONS

Recent research text and articles have discussed the existence of bisphosphonaterelated osteonecrosis of the jaw (BRONJ),
including the condition, the effects of
these powerful drugs, and the management
of patients.2637 The topic of BRONJ has
become so publicised that UK guidance in
BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015

2015 Macmillan Publishers Limited. All rights reserved

PRACTICE
this area is now readily available for clinicians,38,39 although this guidance originates
mainly from expert-opinion or clinical-led
questionnaires/surveys.
One of the more recent articles mentions
that a similar necrotic process within the jaws
exists with some non-bisphosphonate antiresorptive drugs (for example, denosumab),
which has prompted the term ARONJ (antiresorptive-related osteonecrosis of the jaw).37
Advocacy for a preventive dental regimen
is well documented.32,40,41 For those patients
on oral bisphosphonates, and in circumstances in which there is no option but to
proceed with dentoalveolar surgery, drug
holidays have been proposed.28,42,43
The past, present and possible future use
of bisphosphonates should be enquired about
when taking the patients medical history.
Patients must be categorised according to
their risk (Table2), which will consequently
determine management, although the type
of procedure and the experience of the clinicianalthough not currently well-researched
or discussed will also be important factors.
In relation to oral surgery procedures: lowrisk patients may be treated in the primary
care setting simple extractions must be as
atraumatic as possible, mucoperiosteal flaps
should be avoided and good haemostasis
should be achieved. For high-risk patients,
the best option is to contact the local oral
surgery or oral/maxillofacial surgery specialist for advice in relation to whether oral
surgery treatment and/or any treatment that
will impact bone should be continued within
primary care, or whether a referral will be
necessary.32,39 (High-risk includes dentoalveolar surgery, dental implants, periapical
procedures, periodontal surgery and deep
root-planing.) Although it is clear that the
type of procedure proposed may help aid a
decision during risk assessment26,28,29,3135,38,39
little evidence exists regarding the relationship between clinical experience and risk
assessment. There is currently no evidence
supporting the use of antibiotic therapy or
antiseptic oral rinse in reducing the risk
of BRONJ.39
The common theme for the guidance produced within the UK is to emphasise the
importance of the preventative approach
(that is, reducing periodontal disease and
dental infection) and to try to avoid future
extractions and trauma to bone, hence minimising the risk of BRONJ developing.32,38,39
The legal implications related to BRONJ have
been discussed in a thorough article that
readers may find helpful in both primary
and secondary care settings.44 This article
seems to suggest a thorough scrutiny of
events including diagnosis, prescriptions,
management, treatments and referral from

the onset of a patient being prescribed bisphosphonates to immediately after developing BRONJ.44

BLEEDING DISORDERS
AND ANTICOAGULANTS
A recently published article provides guidance on patients with haemophilia and
congenital bleeding disorders.45 The authors
suggest that treatment planning once again
involves an assessment of risk (in this case
bleeding-risk), which is dependent on the
bleeding disorder, the area and invasiveness of the surgery and the experience of
the clinician.59 It is also suggested that any
therapeutic agent should ideally be delivered
preoperatively, ranging from a period of two
hours prior, up to at the point of the procedure (depending on which agent is chosen).
The British Committee for Standards in
Haematology published reviewed guidance in
2011, making recommendations for patients
having dental surgical procedures.46 One of
these recommendations was that oral anticoagulants should not be discontinued for the
majority of patients requiring out-patient
dental surgery, including dental extractions. This may be dependent on the stability and range of the patients International
Normalised Ratio (INR).47 Further guidance
from other resources has emerged.48 These
recommendations are similar to those that
exist for patients on other agents that increase
bleeding tendency: reduction of trauma, limiting dental extractions to four teeth in a single visit and advocating the thorough use of
local haemostasis (that is, suturing, packs and
pressure). Patients using vitamin-K antagonists (such as warfarin) should have the INR
checked within 24hours of the procedure (INR
should be below 4and demonstrate stability).
No preoperative dose-testing or adjustment is
currently recommended for the more recently
developed oral anticoagulants (for example,
dabigatran etexilate and rivaroxaban). In
patients who have a recently placed cardiac
stent, those with alcohol dependency and in
patients with liver/kidney impairments, clinicians are advised to seek the advice of a
senior medical colleague.48

STEROID THERAPY
In 2004, Gibson and Ferguson published
proposed guidelines for clinicians following
a critical review of the literature in relation
to steroid cover.50 Their conclusions for primary care were that supplementary steroid
cover is not required for general dental
procedures, including MOS treatment under
local anaesthetic. This may not be the case
under general anaesthesia, where the dose
of the steroid and the duration of treatment
are factors. This may warrant the use of

BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015

perioperative administration of glucocorticoid supplementation.50

Patients with systemic signs of disease (for
example, a spreading dental abcess) are recommended to have a prophylactic increase
in steroid dose. For those with Addisons
disease the dose must be doubled before
significant dental treatment under local
anaesthetic and this must be continued for
24hours postoperatively.50

POSTOPERATIVE
Similar methods may be used postoperatively as can be employed preoperatively;
that is: instructions, procedures and welldelivered, specific advice can be used in isolation or in conjunction when managing the
postoperative patient.
From a dental perspective, as mentioned
above, the defence organisations have made
general resources available electronically
with immediate and easy access.51
Perhaps one of the most essential components for the patient and operator following surgery is analgesia. In particular for
the patient, it is the authors view that this
is a significant priority. The World Health
Organisation confirms that pain management is the responsibility of healthcare
professionals and has published guidance
to assist clinicians.52 This has been supplemented by other relevant texts.53,54 Analgesic
control will be further discussed in following
articles in this short series.
One of the commonest complications
encountered by clinicians in both primary
and secondary care providing oral surgery
procedures is alveolar osteitis (dry socket).
We can now briefly discuss some of the
postoperative care, advice and management
techniques to avoid this familiar oral surgery
complication, although a detailed account is
available elsewhere.55

DRY SOCKET
Most preventative approaches used to avoid
the development of dry socket have focused
on the use of chlorhexidine gluconate
(0.12% and 0.2%)56. A recent Cochrane systematic review reports some randomisedcontrolled trials do provide evidence of
the benefits in the use of chlorhexidine
gluconate oral rinse both preoperatively
and postoperatively.54 Chlorhexidine gels
have also demonstrated some benefits.58,59
Systemic prophylactic modalities are also
available: there is vast evidence supporting
the use of antibiotics both preoperatively
and postoperatively to reduce the risk of
developing dry socket59,70. However, the
majority of this evidence relates to third
molar removal, rather than extraction of
other teeth56.
275

2015 Macmillan Publishers Limited. All rights reserved

PRACTICE
As well as the interventions available, practitioners will be familiar with the advice given
to patients to minimise the risk of developing
this painful condition. The OCP is the only
known medication that is associated with
developing dry socket. Sweet and Butler60
found a positive correlation between the use
of the OCP and development of dry socket
and one author has even suggested consideration of hormonal cycles to correspond with
an appropriate time for any exodontia.61
Smoking is a habit that has been implicated as
an aetiological factor in too many conditions
to be able to list in this text, but is another
risk factor in the development of dry socket.
Patients are reminded to avoid smoking
post-surgery. One study found the incidence
of dry socket increased by 40% in patients
who smoked on the day of tooth removal.62
Another part of the postoperative instructions
to patients is to avoid physical dislodgement
of the clot often communicated as instruction to avoid spitting or rinsing. No current
evidence exists in the literature to verify this
theory in support of developing dry socket.
Postoperatively, effective communication
remains as essential as it was preoperatively.
In order to avoid patient dissatisfaction and
confusion, as well as preventing unwanted
complaints and litigation, the clear, concise
and well-delivered nature of ongoing communication (even beyond completion of any
procedure) cannot be emphasised enough.
Some dental defence organisations have
produced documentation available to all
operators, clinicians and support staff free
of charge. The author would encourage all
dental healthcare professionals to extend
their attentions to these valuable resources.51

CONSENT
Consent is an ongoing process (Fig.2) and
it is vital for clinicians to remember that a
patient may withdraw this at any time.63,64
This topic is a large but logical one, which
requires rigorous and thorough study to
ensure the safety, quality and satisfaction
(to both patients and operators) of treatment
delivered. Various resources are available
to professionals relating to this particular subject and the author would direct
interested readers to the readily available
documents.6366
At the forefront of the majority of patient
consenting seems to be an explanation of
benefits and risks of treatment, but it is
essential to include preoperative and postoperative information with regards to the
procedure. Within the consent form there are
designated areas to encourage clinicians to
provide these.
In relation to evidence, a knowledge base
that expands deep within the literature of

Fig.2 A
simplified
flow-chart to
represent the
consent process

Patient enters the surgery

enquiring about a treatment
offered at the practice

Full description of the

treatment (and its
alternatives) verbally including nature, risks,
costs and prognosis

Before and treatment,

a review of relevant
information provided, and
opportunity to opt for
alternatives

PERFORM
TREATMENT
Patient returns for
consultation or
treatment visit

Explanation and advice

of key points given in
written form (eg specially
constructed patient leaflets)

Patient has provided verbal

and written consent
willingly, is competent and
adequately informed

Patient leaves the surgery

with verbal and written
information

Provide consent form

or provide a written
coherent treatment plan
for signature

Adequate time to
consider, comprehend
and understand the
information fully

Patient returns to surgery with

decision to proceed or opts for
alternative treatment-assess
patients competence to give
informed consent

a specific procedure may perhaps be more

beneficial to colleagues and fellow clinicians but care and consideration needs to
be exercised when presenting this information to the patient sometimes this information may even be considered irrelevant,
or, especially for the anxious patient, may
form an exaggerated opinion of the nature
of a particular risk.64 This is, however, not
always the case. The prudent patient test
has been performed by courts to decide
whether the patient has been given adequate
information. This will vary from patient to
patient for example, a netizen may want
each material risk of a given procedure, even
if this is an exhaustive list. The individual
nature of each patient makes this test a difficult one to perform.72 Courts may also seek
to use the Bolam test, in which a medical
professional should not be found guilty if a
reasonably competent colleague in a similar
position would have acted in the same way
and the actions would be supported by a
responsible medical body.64 In 1985, this was
further affirmed in the Sidaway vs. Board
of Governors of Bethlem Royal and the
Maudsley Hospital case. The House of Lords
concluded that the degree of risk disclosure is

276

a matter of clinical judgement on part of the

clinician, and the patient must be informed
of any danger that is special in character or
magnitude (or important to that particular
patient) and supply sufficient information
to enable the patient to make a balanced
judgement.64 From a legal perspective, there
is now increasing expectation that clinicians
explain and advise patients of all the material risks that relate to a specific treatment/
procedure and not only those material risks
that a responsible body of medical professionals would provide. One example of this
would be the Bolitho vs. City and Hackney
Health Authority case.64
Before any consent process begins, clinicians must make the assessment of whether
the individual providing it is competent.6062
Perhaps the most common situation when
this assessment is tested is the patients
age, and the existence of Gillick competence,63,64 which is particularly relevant
for children. However, many situations
and circumstances exist where the topic of
consent is more complicated. For example,
those patients in care, unable to demonstrate competence, in events where consent
is unobtainable and disputes regarding care,
BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015

2015 Macmillan Publishers Limited. All rights reserved

PRACTICE
Table3 Basic consent protocols
Scenario

Action

Children in care

The clinician is able to obtain informed consent from an authorised

representative from the local authority

Incompetent patients/patients
without mental capacity

Informed consent should be sought from the patients legal guardian/

deputy from the Court of Protection

Where consent is not obtainable

Consultation with the next of kin is advisable. The clinician should

continue to act in the best interests of the patient, taking a second
opinion when possible

Independent adults lacking external

support with no attorney or deputy

The clinician should call upon the services of the Independent Mental
Capacity Advocate

treatments or procedures. In these cases

it is always wise and ideal to contact an
appropriate body to assist (for example,
dental defence organisations and/or clinical bodies). This may not always be possible or practical in clinical practice, so it is
essential that basic principles are followed
(Table 3). For further reading and understanding of this large and complex topic,
readers are referred to other resources.6366
Whether or not profound and highquality evidence has been used in explanation to patients, it is absolutely essential to
remember the circumstances of each individual patient and undoubtedly these will
never completely be the same (for example,
nerve damage in relation to wisdom teeth
removal6771). Following the initial communication regarding consent, the signing of the
appropriate and accurately presented consent form does not signal the conclusion of
the process, but it is an ongoing process.

SUMMARY
At undergraduate level, it is likely that
most clinicians were taught the principles
of evidence-based dentistry and the fundamentals that constitute the hierarchy
of evidence. Perhaps some of the most
invasive procedures the dentist will perform lie within oral surgery. The use of
the literature to deliver high-quality preoperative and postoperative management,
instructions, advice and protocols, which
have sound evidence-base is the desirable
goal for the provider, especially with treatments carrying such potential morbidities
for patients. This is not always possible, but
in some cases within dentistry, guidelines,
advice sheets and toolkits may exist to aid
decision-making for patient treatments and
treatment plans. Some of the evidence used
to produce such resources has been briefly
discussed above and the author has chosen
select topics within MOS. These brief examples highlight that although the qualities
of clinical guidelines within dentistry have
been criticised, other research and evidence
does exist. When the clinician assesses this,

the strength of such literature should be

appraised including the methodology in
which they were constructed.
A vast amount of information is available
to patients via a range of different resources
in the modern day, but it is still vitally important for operators to realise that the responsibility to deliver this information must still
be their own. In addition to this information, the modalities available to reduce the
morbidities to patients are also plentiful
and it remains imperative to communicate
clearly and effectively, and to be satisfied
that patients understand what information
is being provided. The consent process is a
crucial, mandatory opportunity to explain,
describe and advise patients of the risks and
benefits of accepting/not accepting a particular intervention or treatment. These risks
would often include pre- and postoperative
morbidities. Further discussion of common
pre- and postoperative protocols, management techniques and instructions in relation
to the removal of impacted wisdom teeth
and endodontic surgery will be discussed in
following articles.
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soNICE. Br Dent J 2013; 215: 209212.
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3. Glenny AM, Worthington HV, Clarkson JE, Esposito
M. The appraisal of clinical guidelines in dentistry.
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