11 myths of dentoalveolar surgery

虽然这篇1998年的“专家意见”¹中提到的一些myth已经通过足够的证据得到了解决。但是还有一些仍然在教科书以及日常教学中出现，所以不妨再回顾一下我们的“来时路”：

Here is a summary of the 11 myths discussed in the article, along with the author’s opinions and reasons for challenging each one:

1. MYTH NO. 1: PEOPLE WHO USE ASPIRIN WON’T STOP BLEEDING AFTER SURGERY

   • Author’s Opinion/Reason: This is considered a myth. The author states that long-term use of aspirin and non-steroidal drugs rarely causes any clinically significant bleeding problems, even in major general surgery cases. There is no evidence in the literature that dental surgery must be delayed to discontinue aspirin therapy. While aspirin inhibits platelet aggregation, a literature search over the past three decades failed to discover a single article in which clinically significant bleeding after tooth extraction was directly and primarily attributable to aspirin or other platelet-inhibiting drug therapy. The Ivy bleeding time, a clinical screening test for platelet activity, can be prolonged by aspirin, but a prolonged skin bleeding time does not necessarily correlate with prolonged bleeding in other areas of the body. The decision to perform oral surgery should be made on a case-by-case basis, balancing potential bleeding risk with the urgency, type, and extent of the procedure. Minor procedures are unlikely to cause clinically significant bleeding in patients taking aspirin.

2. MYTH NO. 2: PATIENTS SHOULD USE SALT-WATER MOUTHRINSES AFTER SURGERY

   • Author’s Opinion/Reason: This is a myth. The author found no evidence that intermittent use of salt water has any advantage over plain tap water in immunocompetent patients. A search of the literature revealed no article proving salt water (as a transient mouthrinse) has any advantage over plain tap water in treating or preventing infection or maintaining oral hygiene. Furthermore, studies showed that patients are incapable of accurately mixing a physiologic saline solution from a doctor’s recipe, often resulting in hypotonic or significantly hypertonic solutions. The author concludes that warm tap water mouth soaks or rinses should be considered therapeutically equivalent to homemade saline rinses, until scientific evidence demonstrates otherwise. Clinicians who believe patients require saline rinses should provide premixed solutions, especially for immunocompromised patients.

3. MYTH NO. 3: DRINKING THROUGH A STRAW OR SUCKING WILL DISLODGE THE BLOOD CLOT FROM THE ALVEOLUS

   • Author’s Opinion/Reason: This is a myth. A search of the scientific literature from the past 30 years failed to discover a single article that provides statistically valid evidence that this premise has merit or documents clinically significant postsurgical dental problems scientifically attributable to such activities. The blood clot is mechanically secured within the first 24 to 48 hours after tooth removal, and its security increases over the next 48 hours, suggesting it has internal resistance to low-suction vacuum. The alleged problem should not be confused with localized alveolitis (dry socket), which generally occurs three to five days or more after surgery and involves fibrinolytic (not mechanical) activities within the clot. The author states it seems unlikely that a patient-induced oral vacuum would dislodge a viable clot.

4. MYTH NO. 4: DRINKING CARBONATED BEVERAGES WILL CAUSE DRY SOCKETS OR OTHER PROBLEMS

   • Author’s Opinion/Reason: This is a myth. The author’s review of the literature failed to yield a single study that documents increased morbidity after oral surgery when patients drink carbonated beverages. The belief may have originated from the bubbling action of hydrogen peroxide mouthwash. The author concludes that there is no published clinical data that prove a relationship between drinking carbonated, nonalcoholic beverages and postsurgical morbidity or wound healing problems.

5. MYTH NO. 5: DRINKING ALCOHOL-CONTAINING BEVERAGES WILL CAUSE DRY SOCKETS

   • Author’s Opinion/Reason: This is a myth, at least in terms of causing dry sockets or loss of the blood clot. While alcohol is a direct platelet toxin and affects bleeding, the author found no evidence in the literature that once a blood clot has formed, occasional alcohol use can cause hemorrhage to recur. Furthermore, chlorhexidine-based mouthrinses, often prescribed post-surgery, contain alcohol comparable to that found in wines and light beers. Dentists should counsel patients to refrain from drinking alcohol after surgery, but this advice should be based on the adverse effects of alcohol on healing and potential interactions with medications, not to prevent dry sockets or loss of the blood clot. Long-term excessive alcohol use can lead to bleeding problems due to liver damage, bone marrow depression, and interference with healing, but the literature does not suggest occasional alcoholic beverages dissolve established blood clots.

6. MYTH NO. 6: MENSTRUATING WOMEN WHO UNDERGO SURGERY WILL HAVE SIGNIFICANT POST-OPERATIVE BLEEDING

   • Author’s Opinion/Reason: This is a myth. The author states there is no scientific evidence that female patients will experience any significantly prolonged hemorrhaging after dentoalveolar surgical procedures, regardless of whether they are having their menstrual period. While estrogens can result in greater clinical bleeding of cut surfaces, it is not clinically significant or a contraindication for surgery. Pregnancy, in fact, is considered a state of hypercoagulability, which would logically decrease the possibility of untoward bleeding after an extraction.

7. MYTH NO. 7: PATIENTS SHOULD NEVER RECEIVE BILATERAL THIRD-DIVISION (MANDIBULAR) ANESTHETIC BLOCKS

   • Author’s Opinion/Reason: This is a myth. This belief is not found in any contemporary textbook on dental local anesthesia. Surgeons routinely administer bilateral local anesthetic blocks when removing four third molars at one appointment, demonstrating that the precautionary pediatric principle (avoiding bilateral blocks in children to prevent lip chewing) does not logically extend to adults. The belief that bilateral blocks could create airway problems is not rational or based in science. The author’s review of the literature did not reveal a single case of an older child’s or adult’s experiencing a significant complication that was attributable to bilateral mandibular anesthesia alone. The author concludes that bilateral mandibular anesthetic blocks are appropriate procedures, especially in adult patients, when dictated by the treatment plan and doctor’s judgment.

8. MYTH NO. 8: ORAL POST-OPERATIVE INSTRUCTIONS ARE SUFFICIENT

   • Author’s Opinion/Reason: This is a myth. The author states that patients who receive both written and oral instructions after surgery experience less postoperative morbidity, have less pain and are more compliant. Conversely, patients who receive only oral instructions often do not remember them. It is medicolegally and clinically prudent to provide written instructions. Studies show that a significant portion of the U.S. population (20-48%) lacks the literacy skills necessary to understand healthcare instructions, and patients often mask their inability to comprehend common terms. An unpublished study found even high-school graduates remembered only 67-83% of orally provided information within an hour after surgery. The preponderance of medical literature suggests it is important that written instructions be provided, coupled with oral reinforcement. These written instructions should be clear, using short sentences, drawings, brief paragraphs, and simple words, while avoiding unfamiliar medical jargon.

9. MYTH NO. 9: TEETH SHOULD NEVER BE EXTRACTED IN THE PRESENCE OF ACTIVE INFECTION

   • Author’s Opinion/Reason: This is a myth. In the era of antibiotic availability, it is possible to combine medical and surgical treatment to bring about a rapid resolution of most odontogenic infections. The primary goals of infection management—draining pus and removing the cause—can often be accomplished most expeditiously by removing the offending tooth. Studies as early as 1951 (Krogh) showed that teeth could be safely extracted in the presence of acute infection, often resulting in faster resolution and rarely causing complications, even without prior antibiotic use in many cases. The author concludes that extraction need not be deferred in healthy patients until the acute infection has completely resolved; in fact, deferral might worsen the infection if pus is not evacuated.

10. MYTH NO. 10: DENTISTS SHOULD NOT PERFORM SURGERY ON A PREGNANT PATIENT IN THE FIRST OR THIRD TRIMESTER

    • Author’s Opinion/Reason: This is a myth. The author states there is no valid reason for deferring or withholding essential, emergency surgery from a patient who has an uncomplicated pregnancy, solely due to concerns for the fetus or the mother. Concerns about potential fetal damage are markedly reduced after the first trimester. The author found no statistically significant incidence of spontaneous abortions or miscarriages associated with dental treatment in the literature over the past 30 years. Concerns over dental chair delivery in the third trimester are theoretical, with no reported cases found, and emergency medical services are widely available. While elective surgery is ideally confined to the middle trimester, emergency surgery for pain or infection can be performed at any time during pregnancy with appropriate precautions and risk management steps.

11. MYTH NO. 11: PATIENTS SHOULD NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT BEFORE RECEIVING INHALATION OR INTRAVENOUS SEDATION

    • Author’s Opinion/Reason: This is a myth. The author states that data from the last three to five years suggest that even relaxed advisories (5-6 hours fasting) are of doubtful scientific validity. Prolonged fasting and restriction of fluid intake have been proven to be of no value and of some possible harm in patients about to receive conscious sedation or general anesthetic. Studies refute the need for prolonged preoperative fasting to prevent aspiration. Clear fluids need only be restricted for two to three hours, and solid foods for four to five hours before administration of any conscious sedation. Even for general anesthetic, the risk of aspiration is extremely small to nonexistent with these guidelines. The author notes that American anesthesiologists are considering new guidelines that allow ingestion of clear liquids up to two hours before surgery and solid foods or dairy products up to five hours.

1. Alexander RE. Eleven myths of dentoalveolar surgery. J Am Dent Assoc. 1998 Sep;129(9):1271-9. doi: 10.14219/jada.archive.1998.0424. PMID: 9766108. ↩