Surgical Extraction of Impacted Molars: Comparing Postoperative Instruction Delivery

A total of 90 patients with an impacted lower third molar that required surgical removal for the first time were selected. The patients chosen for the study were healthy (ASA I) or had mild systemic disease without functional limitation (ASA II). All patients underwent surgical extraction of impacted lower third molar. Patients excluded from the study were those who could not attend the scheduled appointments, had a limited intelligence quotient, some psychological disorder or mental condition and had difficulties in language comprehension. The exclusion criteria ensured that only the patients that had no difficulties in understanding and following through with the study were selected.
The study was designed according to CONSORT guidelines for randomized clinical trials and was approved by the Research Ethics Committee (CEIC) of the Dental Clinic of the University of Barcelona, Spain (8 (link)). All patients were treated in the Hospital Odontològic de Bellvitge, University of Barcelona, Spain. The incorporation of each subject in the study was decided before knowing the assigned group. Patients were randomly assigned to one of the following three study groups (sequence generated by www.randomization.com).
• Verbal: postoperative instructions were given verbally together with a prescription sheet of the postoperative medication.
• Written: the usual postoperative instructions were given verbally and written, as well as the postoperative medication.
• Additional information: instructions and postoperative medication were given both verbally and written, and additional written information about the postoperative period was also provided ( Table 1, Table 2).
Table 1Table 2Patients were interviewed about their adherence to the instructions one week after the surgery, at the time of suture removal. They were requested about the compliment of the instructions given, number of days that medication and recommendations were followed and the reason of abandon ( Table 3).
Table 3Before surgery, patients completed the Corah Dental Anxiety Scale (9 (link)) and data about age, gender and educational level (Basic, High School / Vocational Training, University) was also collected. Postoperative instructions were given by one resident previously instructed to provide similar instructions according to the study group to which the patient belonged. All surgical interventions were carried out by second year residents of the Master of Oral Surgery and Implantology (Barcelona University) with a similar surgical technique. Patients did not receive any financial compensation for their participation in the study.
The extraction of the impacted lower third molars was performed under local anaesthesia with articaine 4% and epinephrine 1:100.000 (Artinibsa, Inibsa, Lliça de Vall, Spain). The surgical area and all materials were steriles. The surgeon lifted a full-thickness flap that was protected by a cheek retractor. Lingual flap retraction with a Freer periostotom was performed only when deemed necessary by the surgeon. A sterile hand piece at low speed (20,000 rpm) and irrigation with sterile distilled water was used to do the ostectomy and the dental sectioning of the third molar, if needed. The wound was sutured with silk 3-0 (Silkam®, Braun, Tuttlingen, Germany). The surgical technique was similar to that described by Leonard (10 (link)). The following postoperative medication was prescribed.
• Antibiotic (750 mg Amoxicilin. Clamoxyl® -GlaxoSmithKline, Madrid, Spain) orally one tablet every 8 hours for 7 days).
• A NSAID (600mg Ibuprofeno. Espidifen® - Zambon, Barcelona, Spain) orally every 8 hours for 5 days).
• An analgesic (575 mg Metamizol. Nolotil® (Boehringer Ingelheim, Barcelona, Spain) orally, every 8 hours as relief medication).
• Mouthwash (Chlorhexidine Lacer® to 0.12 % (Lacer, Barcelona, Spain), the mouthwash twice daily for 15 days).
All surgeons involved in the study were blinded for which group each patient belonged. Statistical analysis was done using SPSS 15.0 for Windows (SPSS v15.0, SPSS Inc. Chicago, USA, licensed from the University of Barcelona). Demographic data was analysed using Chi-square test and ANOVA test. Chi-square test was used to compare the compliance according to preoperative anxiety level, sociocultural level and how the postoperative instructions were provided. The significance level was set at p <0.05.