Proceedings of the Closed Round Table and Italian Consensus on Clinical Appropriateness in Oral Medicine and Oral Surgery – Part II
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1
University of Palermo, Italy
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2
University of Messina, Italy
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3
Study group for SIPMO (http://www.sipmo.it/) (L. Lo Muzio, G. Campisi, S. Abati, V. Panzarella, M. Pentenero, U. Romeo), Italy
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4
Italian Society of Odontostomatological Surgery (SIdCO), Italy
Practices at risk of inappropriateness in Oral Surgery (SIdCO group) for the following issues:
1. Prescription of radiodiagnostic examinations
2. Prescription of antibiotics
3. Dental care delay during pregnancy
4. Prophylactic extractions of the third lower molars
5. Discontinuation of antiplatelet agents in oral surgery procedures
1. Prescription of radiodiagnostic examinations
Radiographic investigations are a valuable tool for diagnostic formulation in the dental field. However, panoramic radiography should not be considered a screening tool.
In order to provide a correct prescription of dental arch radiographs, a careful physical examination, a complete medical history and the possible acquisition of previous radiographic examinations should always precede the prescription of instrumental investigations. the type of examination (intraoral, OPT, CT) must always be justified by the diagnostic question but also aimed at minimizing the patient's exposure to unnecessary radiant doses.
The prescription of radiodiagnostic investigations in oral surgery is always preceded by anamnestic collection, by the objective examination and by the possible evaluation of previous radiological examinations. These must be an appropriate tool for completing diagnosis and therapeutic planning.
When he decides to perform a radiodiagnostic examination, the dentist must follow the principles of justification, optimization and dose limits.
Practice at risk of inappropriateness
PRESCRIBING radiodiagnostic examinations (RX OPT) as screening tool before oral examination.
Good practice
PRESCRIBE radiographic examinations (intraoral, OPT, CT) only with a valid diagnostic question.
2. Prescription of antibiotics
Although it has been shown that antibiotic prophylaxis may play a role in the prevention of infectious complications, such as bacterial endocarditis or dry alveolitis, its impact appears controversial on post-extraction socket healing, pain and functional limitation.
Therefore, it is more appropriate to limit the antibiotic prescriptions to patients in whom transient bacteraemia exposes to a more severe risk of bacterial endocarditis or local infectious complications, such as glycemic decompensation from diabetes mellitus, valvular or other prostheses and immunodeficiency syndromes.
In non-invasive extractive and oral surgery interventions and especially in the absence of specific local and/or systemic risk conditions, antibiotics should not be indiscriminately administered. In any case it is recommended to adopt local peri-operative antiseptic measures. Adequate antibiotic prescription is required in cases of more invasive oral surgery. Moreover the prescription of appropriate antimicrobial agents for the treatment of odontogenic infections is recommended, respecting the indications of the active principle.
Practice at risk of inappropriateness
PRESCRIBING antibiotic prophylaxis indiscriminately as a routine prescription in patients undergoing dental procedures.
Good practice
LIMIT antibiotic prophylaxis prescription to patients whose transient bacteraemia exposes to a severe risk of bacterial endocarditis or local infectious complications and to cases of more invasive oral surgery.
3. Dental care delay during pregnancy
Pregnancy is not a contraindication to dental treatment. According to the recommendations for the promotion of oral health in perinatal age of the Ministry of Health, it is possible to adopt specific protocols based on the gestation period and obstetric risk conditions.
Diagnostic procedures (including radiography), oral prophylaxis, root planing, endodontic treatments and dental extractions can be performed safely throughout the gestation period. Use exclusively intraoral radiographs, with a low exposure rate and using the long cone technique and the use of Rinn centerers, use collar and protection for the abdomen.
Measures to prevent dental and periodontal diseases are strongly indicated. The ideal period for carrying out routine dental care is indicated between the 14th and 20th week of pregnancy, nevertheless pregnancy is not an absolute contraindication to surgical treatments that have urgent criteria. Emergency treatments should not be delayed but carried out promptly. Only elective surgery procedures should be procrastinated at the end of pregnancy. In accordance with the indications from the gynecological doctor, it is appropriate to adopt specific protocols based on the gestation period and any obstetric risk conditions.
Practice at risk of inappropriateness
TO DELAY dental care during pregnancy.
Good practice
PROVIDE dental care throughout the gestational period as needed and according to the recommendations of the gynecologist.
4. Prophylactic extractions of the third lower molars
Third lower molars extraction for prophylactic purposes, ie in the absence of signs and symptoms, is not supported by concrete scientific evidence and can unnecessarily expose the patient to risks related to the surgical procedure.
Extraction represents an appropriate intervention in the presence of: inflammatory-infectious, caries and periodontal diseases typical of the third molar and/or of the adjacent element; algico-dysfunctional pathologies related to dental inclusion; orthodontic and prosthetic therapeutic needs.
Anyway, a careful evaluation of the clinical indications for the surgical extraction of the third lower molars and of the possible complications of the procedure is recommended.
In cases of lower molars without immediate indication for surgical extraction, monitoring of clinical conditions with regular control visits is recommended.
Practice at risk of inappropriateness
TO routinely EXTRACT the third lower molars.
Good practice
EXTRACT the third lower molars in the presence of inflammatory-infectious diseases, caries and periodontal diseases typical of the third molar and / or of the adjacent element, algico-dysfunctional pathologies correlated with dental inclusion, orthodontic and prosthetic therapeutic needs.
5. Discontinuation of antiplatelet agents in oral surgery procedures
The intra/postoperative hemorrhagic risk in patients treated with oral antiplatelet agents is much lower than the potential cardiac and vascular complications resulting from treatment discontinuation. In accordance with the recommendations of the European Society of Cardiology, the discontinuation of antiplatelet therapy is contraindicated, especially in patients at high cardiovascular risk, and it is therefore considered more appropriate to manage bleeding with anti-hemorrhagic drugs for local use.
Practice at risk of inappropriateness
TO routinely DISCONTINUE antiplatelet agents in oral surgery procedures.
Good practice
DO NOT routinely DISCONTINUE antiplatelet agents including dual antiplatelet therapy in minor oral surgery procedures, APPLY anti-hemorrhagic drugs for local use. CONSULT the prescriber in all cases of more invasive oral surgery.
References
1. American Dental association. Dental radiographic examinations: recommendations for patient selection and limiting radiation exposure, revised: 2012. Council on Scientific Affairs, U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration
2. Smith NJ. Selection criteria for dental radiography. Br Dent J. 1992;173:120-1.
3. Hintze H. Screening with conventional and digital bite-wing radiography compared to clinical examination alone for caries detection in low-risk children. Caries Res. 1993;27:499-504.
4. Hintze H, Wenzel A. Clinically undetected dental caries assessed by bitewing screening in children with little caries experience. Dentomaxillofac Radiol 1994;23:19-23.
5. Ferguson F, Festa SA. Radiography for children and adolescents. N Y State Dent J. 1993;59:25-9.
6. Lawler B, et al. Antibiotic prophylaxis for dentoalveolar surgery: is it indicated? Aust Dent J. 2005;50(4 Suppl 2):S54-9.
7. Poeschl PW, et al. Postoperative prophylactic antibiotic treatment in third molar surgery--a necessity? J Oral Maxillofac Surg. 2004;62:3-8.
8. Tong DC, Rothwell BR. Antibiotic prophylaxis in dentistry: a review and practice recommendations. J Am Dent Assoc. 2000;131:366-74.
9. Hill M. No benefit from prophylactic antibiotics in third molar surgery. Evid Based Dent. 2005;6:10.
10. Habib G, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075-128.
11. Raccomandazioni per la promozione della salute orale in età perinatale 2014, Ministero della Salute
12. Kurien S, et al. Management of Pregnant Patient in Dentistry. Journal of International Oral Health: JIOH. 2013;5:88-97.
13. Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the pregnant patient. J Periodontol. 2004;75:495.
14. Turner MD, et al. Dental management of the gravid patient. N Y State Dent J. 2006;72:22-7.
15. Robinson BJ, Boyce RA. Why is dental treatment of the gravid patient regarded with caution? When is the appropriate time for care--be it emergent or routine--in the gravid patient? J N J Dent Assoc. 2014;85:11-4.
16. Friedman JW. The Prophylactic Extraction of Third Molars: A Public Health Hazard. American Journal of Public Health. 2007;97:1554-9.
17. Costa MG, et al. Is there justification for prophylactic extraction of third molars? A systematic review. Braz Oral Res. 2013;27:183-8.
18. Fuster Torres MA, et al. Evaluation of the indication for surgical extraction of third molars according to the oral surgeon and the primary care dentist. Experience in the Master of Oral Surgery and Implantology at Barcelona University Dental School. Med Oral Patol Oral Cir Bucal. 2008;13:E499-504.
19. Bataineh AB, et al. The surgical removal of mandibular third molars: a study in decision making. Quintessence Int. 2002;33:613-7.
20. Lysell L, Rohlin M. A study of indications used for removal of the mandibular third molar. Int J Oral Maxillofac Surg. 1988;17:161-4.
21. Steen Dalby Kristensen et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. European Heart Journal. 2014;35:2383-431.
22. Napeñas JJ, et al. The frequency of bleeding complications after invasive dental treatment in patients receiving single and dual antiplatelet therapy. J Am Dent Assoc. 2009;140:690-5.
23. Sadeghi-Ghahrody M, et al. Bleeding after tooth extraction in patients taking aspirin and clopidogrel (Plavix®) compared with healthy controls. Br J Oral Maxillofac Surg. 2016;54:568-72.
24. Halley D, et al. No evidence for stopping long-term aspirin therapy before tooth extraction. Evid Based Dent. 2015;16:118-9.
25. Zhao B, et al. Should aspirin be stopped before tooth extraction? A meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:522-30.
Keywords:
Dental radiograph,
Antibiotics in oral surgery,
Dental treatment in pregnant patient,
Lower molar teeth surgery,
Antiplatelet therapy (AT),
SIPMO,
SIdCO
Conference:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine., Ancona, Italy, 19 Oct - 20 Oct, 2018.
Presentation Type:
oral presentation
Topic:
Oral Diseases
Citation:
Campisi
G,
Oteri
G,
Study Group
S and
Study Group
S
(2019). Proceedings of the Closed Round Table and Italian Consensus on Clinical Appropriateness in Oral Medicine and Oral Surgery – Part II.
Front. Physiol.
Conference Abstract:
5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine..
doi: 10.3389/conf.fphys.2019.27.00043
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Received:
12 Dec 2018;
Published Online:
09 Dec 2019.
*
Correspondence:
Prof. Giuseppina Campisi, University of Palermo, Palermo, Sicily, 90127, Italy, campisi@odonto.unipa.it