CLINICAL
PRACTICE
A B S T R A C T
Through the years, dentists who
perform dentoalveolar surgery
have perpetuated many myths
and other unproven beliefs from
one generation to another.
Sometimes, these beliefs originat-
ed in older textbooks, while oth-
ers were given birth by mentors
sharing anecdotal experiences
with their students. Even today,
many of these scientifically un-
supported statements are perpet-
uated in surgical textbooks and in
continuing education forums and
are passed on to students in den-
tal schools. In todays evolving en-
vironment of evidence-based
medicine and dentistry, these
anecdotal observations do not
withstand scrutiny. The purpose
of this article is to review the
more common surgical myths and
to test their validity against
scientific evidence.
Copyright 1998-2001 American Dental Association. All rights reserved.
ELEVEN MYTHS OF DENTOALVEOLAR SURGERY
ROGER E. ALEXANDER, D.D.S.
Paul Broca (1824 to 1880) once stated, The least questioned as-
sumptions are often the most questionable. This is certainly true of
some surgical beliefs that have been passed orally and in writing
from one generation of dentists to another through the years. These
so-called facts sometimes began as statements in textbooks that are
now outdated, while others originated from mentors sharing anec-
dotal experiences with students. These pseudoscientific statements
are accepted without question by many general dentists and spe-
cialists performing surgical procedures.
Physicians and dentists alike are becoming increasingly interest-
ed in teaching and practicing evidence-based medicine. This has
been defined as the conscientious, explicit and judicious use of cur-
rent best evidence in making decisions about patient care, rather
than relying solely on intuition and experiences.1,2 This has been
shown to be a desirable approach to integrating clinical expertise
with the best available evidence obtained from systematic research.
In this article, I will examine 11 myths that are commonly encoun-
tered in the field of dentoalveolar surgery and show that each lacks
clinical importance or is based on anecdotal beliefs without support-
ing scientific evidence.
MYTH NO. 1: PEOPLE WHO USE ASPIRIN WONT STOP
BLEEDING AFTER SURGERY
Aspirin (that is, acetylsalicylic acid) was first marketed by Bayer in
1899 and became a popular analgesic in the United States after
World War I. With the market emergence of acetaminophen in the
early 1950s and subsequently other analgesics, the use of aspirin
for postsurgical pain relief dramatically declined, partially because
aspirins undesirable effects on platelets were absent or diminished
with the newer drugs. However, aspirin has enjoyed a resurgence
recently, being used as a prophylactic clotting inhibitor.
Other drugs have also emerged in the marketplace because they
induce an aspirinlike platelet inhibition and reduce the risks of un-
wanted clotting. With increasing frequency, patients needing surgi-
cal procedures are being seen in dental offices and their drug regi-
mens include aspirin or other platelet-inhibiting drugs. Dentists
JADA, Vol. 129, September 1998 1271
CLINICAL PRACTICE
have been warned of dire conse-
quences when performing
surgery on such patients, so
they may deny needed treat-
ment or expose the patient to
unnecessary additional medical
expenses.
One dental pharmacology
text and at least one oral
surgery text advise discontinu-
ing aspirin therapy one week be-
fore extensive surgery, without
providing any scientific justifica-
tion for the recommendation or
precautionary comments on the
potential legal risks and impli-
cations of discontinuing medica-
tion prescribed by a physician
for medical purposes without
consulting with the physician.3,4
Effects of aspirin and
platelet-inhibiting drugs on
hemostasis. After injury,
platelets attach to a damaged
vessel wall by a release reaction
mediated by the binding of von
Willebrand factor to receptors
on a monolayer of endothelial
cells lining the blood vessels.5
These cells are normally throm-
boresistant. Factors in this re-
lease reaction include the cy-
clooxygenase metabolites
thromboxane A2 in platelets
and prostaglandin I2, as well as
prostacyclin and nitric oxide in
the endothelial cells. Platelet-
derived thromboxane A2 and
endothelium-derived prostacy-
clin (and nitric acid) have oppo-
site effects, and the balance of
their production is an important
determinant in blood fluidity
and hemostasis.5
Individual platelets are sen-
sitive to aspirin inactivation of
cyclooxygenase and are affected
for the duration of their seven-
to-10-day circulation lifetime.
In contrast, the endothelial cells
recover rapidly after exposure
because they can continuously
synthesize new, unacetylated
1272 JADA, Vol. 129, September 1998
Copyright 1998-2001 American Dental Association. All rights reserved.
cyclooxygenase.6 A single dose
of aspirin will inhibit platelet
aggregation within two hours of
administration, and blood sali-
cylate levels can persist for four
to seven days, long after the lev-
els are clinically undetectable.5
Platelet adhesion function
will be compromised until a suf-
ficient number of affected
platelets are replaced by new,
uninhibited platelets that have
not been exposed to the drug.
Aspirin has been
implicated with
clinically significant
bleeding, but the
results have not with-
stood the scrutiny of
meta-analysis.
Ingestion of alcohol can further
prolong the bleeding time pro-
duced by aspirin and non-
steroidal drugs. An American
Medical Association pharmacol-
ogy reference book notes that
large doses of aspirin taken for
several days can also cause
hypoprothrombinemia, but it is
usually not clinically significant
unless the patient is taking an-
other anticoagulant.7
By contrast, nonsteroidal
analgesics, such as ibuprofen,
produce a weaker, transient ef-
fect that normalizes within 12
hours after exposure.5 Long-
term use of nonsteroidal anti-
inflammatory drugs produces
less-predictable changes, how-
ever. One study involving
ibuprofen demonstrated an
atypical, significantly prolonged
bleeding time two hours after a
single 600-mg dose was taken.5
The Ivy bleeding time is gen-
erally considered the best clini-
cal screening test for platelet ac-
tivity. Interestingly, it has been
shown that the effect is dose-de-
pendent and longer bleeding
times, paradoxically, can occur
with lower doses of aspirin.8 The
bleeding time can be prolonged
because of other factors, howev-
er, including technical artifacts
in the laboratory. Furthermore,
it cannot be extrapolated that a
prolonged bleeding time will re-
sult in a clinical bleeding prob-
lem elsewhere in the body. For
example, a prolonged skin
bleeding time may not be associ-
ated with prolonged bleeding
from an endoscopic stomach
biopsy procedure.9 Bleeding
times can also be prolonged
owing to defects of platelet func-
tion other than adhesion.
Aspirin has been implicated
with clinically significant bleed-
ing, but the results have not
withstood the scrutiny of meta-
analysis.5 Schafer noted that
the clinical relevance of one
study that demonstrated
increased perioperative blood
loss during hip arthroplasty has
been questioned, and studies of
patients receiving aspirin thera-
py who underwent cholecystec-
tomy and coronary artery by-
pass procedures have shown
highly variable results.5
Although cases of spontaneous
gastrointestinal hemorrhage
have been reported, the pre-
dominant conclusion of the lit-
erature, as reviewed by Schafer,
is that aspirin-induced exces-
sive bleeding is of marginal
clinical significance in most pa-
tients.5 A search of the litera-
ture for the past three decades
failed to discover a single article
in which clinically significant
bleeding after tooth extraction
was directly and primarily at-
tributable to a patients receiv-
ing aspirin or other platelet-in-
hibiting drug therapy.

The bottom line. The long-
term use of aspirin and non-
steroidal drugs appears rarely
to cause any clinically signifi-
cant bleeding problems, even in
major general surgery cases.
There is no evidence in the lit-
erature that dental surgery
must be delayed to discontinue
aspirin therapy. The decision to
perform oral surgery should be
made on a case-by-case basis,
with dental professionals bal-
ancing the potential risk of
bleeding with the urgency, type
and extent of the planned proce-
dure(s). It is unlikely that a pa-
tient taking aspirin or other
platelet-inhibiting drugs will
have a clinically significant
bleeding problem after removal
of one or two teeth, placement
of implants or other minor pro-
cedures. With more extensive
surgery, such as full-mouth ex-
tractions, extensive deep scal-
ing or periodontal surgery, an
increased emphasis on local
hemostatic procedures, such as
use of sutures, superficial laser
and/or products such as oxi-
dized cellulose or absorbable
gelatin sponge, may be prudent.
MYTH NO. 2: PATIENTS
SHOULD USE SALT-
WATER MOUTHRINSES
AFTER SURGERY
For more than 50 years, numer-
ous textbooks have advocated
the use of salt water (saline) for
surgical mouthrinses, apparent-
ly on the premise that it is the
most physiologic irrigant avail-
able and will not adversely af-
fect healing tissues. Interest-
ingly, nearly every textbook has
had a different recipe for what
constitutes saline, and the guid-
ance has ranged from no guide-
lines at all to explicit formulas
for mixing ingredients (general-
ly 1/4 to 1 teaspoon table salt
added to tap water in amounts
Copyright 1998-2001 American Dental Association. All rights reserved.
ranging from 8 to 12 fluid
ounces to a glass or cup). None
of the guidelines have rested on
any type of scientific foundation.
They were anecdotal formulas
passed from one doctor to anoth-
er, and perpetuated without
question. These unfounded rec-
ommendations persist in arti-
cles and books today.
A search of the literature
failed to reveal a single article
that proves that salt water (as a
transient mouthrinse) has any
advantage over plain tap water
There is no evidence
that intermittent use
of salt water has any
advantage over plain
tap water in immuno-
competent patients.
in treating or preventing infec-
tion, or in maintaining oral hy-
giene. Further, I could find no
article that proves in a scientifi-
cally valid manner that inter-
mittent clinical use of regular
(tap) water has any adverse ef-
fect on healing tissues or in the
resolution of infections.
I also could find no evidence
that patients are able to mix a
physiologic saline solution from
a recipe provided by a doctor.
Almost a decade ago, Whinery
questioned the viability of using
saline as a mouthwash.10 In a
two-part study, Verser and
Alexander studied exactly which
formula of table salt and water
most closely resulted in a physio-
logic saline solution.11 They dis-
covered that several combina-
tions of the two ingredients
would result in near-normal
saline, including 1/4 tsp salt in 6
fluid ounces of water, 1/2 tsp salt
in 10 oz of water or 3/4 tsp salt in
CLINICAL PRACTICE
14 oz of water. Using the second
formula, they then asked volun-
teer patients to mix the solution
from a written recipe, and found
that patients could not follow the
instructions. They could not even
select the proper container size,
and wound up with hypotonic or
hypertonic solutions, some signif-
icantly hypertonic. The authors
recommended that doctors who
are convinced that warm saline
solutions are superior to warm
water should provide bottled
saline to their patients to heat
up.11
The bottom line. There is
no evidence that intermittent
use of salt water has any ad-
vantage over plain tap water in
immunocompetent patients,
and patients have been shown
to be incapable of mixing accu-
rate solutions from provided in-
structions. Warm tap water
mouth soaks or rinses should be
considered therapeutically
equivalent to homemade saline
rinses, until scientific evidence
demonstrates otherwise.
As a matter of prudence, im-
munocompromised patients
might be advised to use bottled
sterile solutions of water or
saline because of potential mi-
crobial contamination (for ex-
ample, Cryptosporidium) in
community water supplies,
until the precise degree of risk
can be determined in future
studies. Clinicians who believe
that patients require saline
rinses should provide premixed
solutions.
MYTH NO. 3: DRINKING
THROUGH A STRAW OR
SUCKING WILL DISLODGE
THE BLOOD CLOT FROM
THE ALVEOLUS
Through the decades, virtually
every doctors postsurgical in-
struction sheet has carried an
admonition to patients to re-
JADA, Vol. 129, September 1998 1273
CLINICAL PRACTICE
frain from drinking (or sucking)
through a soda straw or sucking
on the extraction site, apparent-
ly on the premise that the in-
traoral vacuum created will
draw the blood clot from the
alveolus, causing localized alve-
olitis (dry socket), infection or
healing problems. Again, a
search of the scientific litera-
ture from the past 30 years
failed to discover a single article
that provides statistically valid
evidence that this premise has
merit. Likewise, the literature
is devoid of any studies that
document clinically significant
postsurgical dental problems
that could be scientifically at-
tributed to such activities.
When a tooth is removed, a
sequence of inflammation, ep-
ithelialization, fibroplasia and
remodeling is initiated.12,13
Within the first day, the fibrin-
covered clot is held in position
by gingival tissue. Unsupported
gingival tissues collapse into
the clot-filled alveolus, which
helps keep the clot in position.
Within 48 hours, there is an in-
growth of fibroblasts and capil-
laries, and epithelium migrates
down the socket wall until it
contacts epithelium or granula-
tion tissue. By the third day,
fibroblasts have proliferated
and grown into the peripheral
portions of the clot.
Therefore, the blood clot is
mechanically secured within
the first 24 to 48 hours after
tooth removal, and the security
of the clot increases over the
next 48 hours. It is logical to be-
lieve that the clot has some in-
ternal resistance to any me-
chanical dislodgement by
low-suction vacuum or sucking
on a straw, even within the first
few hours after surgery. It
seems unlikely that a patient-
induced oral vacuum would be
1274 JADA, Vol. 129, September 1998
Copyright 1998-2001 American Dental Association. All rights reserved.
instrumental in causing a viable
clot to be dislodged from an ex-
traction site, but reliable scien-
tific data are lacking to conclu-
sively prove or disprove this
rationalization. Furthermore,
this alleged problem should not
be confused with the pathophys-
iology of localized alveolitis (dry
socket), which generally occurs
three to five days (or more) after
surgery and involves fibrinolytic
(not mechanical) activities with-
in the clot.14
It seems unlikely that
a patient-induced oral
vacuum would be in-
strumental in causing
a viable clot to be
dislodged from an ex-
traction site.
The bottom line. I could
find no scientific evidence that
sucking through a soda straw
has any relationship to postsur-
gical sequelae, and when one
logically considers the process of
intra-alveolar extraction-site
healing, such events seem im-
probable. However, a valid, dou-
ble-blinded study of this topic
would be beneficial.
MYTH NO. 4: DRINKING
CARBONATED BEVER-
AGES WILL CAUSE DRY
SOCKETS OR OTHER
PROBLEMS
For several decades, many dental
professionals have believed that
drinking carbonated beverages
will bubble the blood clot out of
an alveolus. As noted in the dis-
cussion of drinking through soda
straws, this belief also has no ap-
parent scientific foundation. My
review of the literature failed to
yield a single study that docu-
ments increased morbidity after
oral surgery when patients drink
carbonated beverages. Perhaps
the belief arose from use of hy-
drogen peroxide as a mouth-
wash, which results in the re-
lease of oxygen and creates a
bubbling action. A prospective,
double-blinded clinical study that
compares the postsurgical use of
carbonated beverages with
nonuse would be a welcome addi-
tion to the literature.
The bottom line. I could
find no published clinical data
that prove a relationship be-
tween drinking carbonated,
nonalcoholic beverages and
postsurgical morbidity or
wound healing problems. Until
such evidence is presented, the
belief appears to be a myth
based on anecdotal clinical advi-
sories.
MYTH NO. 5: DRINKING
ALCOHOL-CONTAINING
BEVERAGES WILL CAUSE
DRY SOCKETS
This common admonishment to
patients appears to be grounded
more in pharmacology than in
clinical sequelae. Alling and as-
sociates15 pointed out that alco-
hol is a direct platelet toxin
and, therefore, will affect bleed-
ing. However, I could find no ev-
idence in the literature that
once a blood clot has formed, oc-
casional alcohol use can cause
hemorrhage to recur. In fact,
many clinicians instruct their
patients to use chlorhexidine-
based mouthrinses before
and/or after surgery, and these
products contain 11.6 percent
alcohol. By comparison, most
wines contain 8 to 14 percent
alcohol, and most light beers
contain only 2.5 percent alcohol.
Alcohol has many deleterious
effects on virtually every body
tissue, especially when con-
sumed daily.16 Bleeding prob-
lems can arise secondary to

liver damage from long-term,
preoperative alcohol use, as a
result of impaired synthesis of
several coagulation factors.
Ethyl alcohol is also a direct
bone marrow depressant, so
long-term use can lead to
thrombocytopenia and defective
red and white blood cells.
Alcohol can prolong the bleed-
ing time through its interac-
tions with platelets that have
been compromised by aspirin
and nonsteroidal drug use.
Excessive, long-term alcohol use
can interfere with healing, com-
promise inflammatory respons-
es such as leukocyte migration,
and damage cells, but the liter-
ature does not provide evidence
that an occasional alcoholic bev-
erage can dissolve established
intra-alveolar blood clots.
The bottom line. Dentists
should counsel all patients to
refrain from drinking alcoholic
beverages after surgery, but
not to prevent dry sockets or
loss of the blood clot. Such ad-
vice should be based on the ad-
verse effects of alcohol on heal-
ing and the potential for
interactions with medications
that are likely to be prescribed
during the immediate postoper-
ative period.
MYTH NO. 6: MENSTRU-
ATING WOMEN WHO UN-
DERGO SURGERY WILL
HAVE SIGNIFICANT POST-
OPERATIVE BLEEDING
Although this myth seems final-
ly to be falling into oblivion, for
decades clinicians have believed
that women should wait until
menstrual bleeding has finished
before undergoing dental
surgery because they were at
risk of postoperative hemor-
rhaging. There is only a touch
of scientific reality behind this
myth, and very little clinical
impact.
Copyright 1998-2001 American Dental Association. All rights reserved.
There is little agreement in
the literature on how long a
patient should be expected to
hemorrhage after an extrac-
tion, with estimates ranging
from 30 minutes to 24 hours.
Presumably, prolonged bleed-
ing exceeds one hour and can
last up to 24 hours, making
comparisons difficult and de-
terminations of normal subjec-
tive.
I could find no published
studies that demonstrated clini-
cally significant prolonged
bleeding in women who undergo
oral surgical procedures during
their menstrual periods.
A review of the
literature did not
reveal a single case
of an older childs or
adults experiencing
a significant compli-
cation that was
attributable to
bilateral mandibular
anesthesia alone.
Estrogens can result in greater
clinical bleeding of cut surfaces,
but it is not clinically signifi-
cant or a contraindication for
surgery.17
The bottom line. There is
no scientific evidence that fe-
male patients will experience
any significantly prolonged
hemorrhaging after dentoalveo-
lar surgical procedures, regard-
less of whether they are having
their menstrual period.
MYTH NO. 7: PATIENTS
SHOULD NEVER RECEIVE
BILATERAL THIRD-DIVI-
SION (MANDIBULAR)
ANESTHETIC BLOCKS
I have observed a perplexing be-
CLINICAL PRACTICE
lief among some practicing den-
tists that patients should not
receive bilateral third-division
(inferior alveolar) nerve blocks.
Some faculty members in excel-
lent dental schools even present
the philosophy to dental stu-
dents. It is hard to imagine
where this myth arose, since it
is not found in any contempo-
rary textbook on dental local
anesthesia. It might be an un-
conscious extension to adults of
the conventional wisdom to
avoid bilateral mandibular
nerve anesthetic blocks in
young children whenever possi-
ble, to minimize the risk of the
childs chewing on the lower lip
while anesthetized.
However, any surgeon who
removes four third molars at
one appointment routinely ad-
ministers bilateral local anes-
thetic blocks, so the precau-
tionary pediatric principle does
not extend logically to adults.
The myth might also have
been perpetuated under the
premise that bilateral blocks
could somehow create a poten-
tial airway problem for pa-
tients. This belief also is not
rational or based in science.
My review of the literature did
not reveal a single case of an
older childs or adults experi-
encing a significant complica-
tion that was attributable to
bilateral mandibular anesthe-
sia alone.
The bottom line. Admin-
istration of local anesthetic
should be dictated by the needs
of the patient and the proce-
dures planned, with full knowl-
edge of all known risks.
Bilateral mandibular anesthetic
blocks are appropriate proce-
dures, especially in adult pa-
tients, whenever the treatment
plan and doctors judgment dic-
tate a need for them.
JADA, Vol. 129, September 1998 1275
CLINICAL PRACTICE
MYTH NO. 8: ORAL POST-
OPERATIVE INSTRUC-
TIONS ARE SUFFICIENT
Patients who receive both writ-
ten and oral instructions after
surgery experience less postop-
erative morbidity, have less
pain and are more compliant.18,19
Patients who receive only oral
instructions do not remember
them.20 It is medicolegally and
clinically prudent to provide
such instructions in writing,
but many dentists do not go to
the trouble of preparing written
instructions. They counsel pa-
tients orally after surgery, or
perhaps use a generic, commer-
cially produced information
sheet, which may or may not be
correct and/or useful. Even if
written information is provided,
professionals rarely determine
if the instructions can be under-
stood by patients with limited
literacy and comprehension
abilities.
Adequate postoperative coun-
seling has been shown to mini-
mize complications and have
positive clinical results. In a
study by Vallerand and associ-
ates,18 postoperative pain con-
trol and satisfaction were found
to be greater in patients who re-
ceived extensive written
preparatory information.
There is growing concern
among health care professionals
about the inability of a signifi-
cant portion of the U.S. popula-
tion to read and function in our
health care system.21 Studies
have estimated that as many as
20 to 48 percent of adults do not
have the literacy skills neces-
sary to function in modern soci-
ety.21,22 Patients abilities to
function well socially often
mask their inability to under-
stand instructions from health
care professionals, and vocabu-
lary is a particular problem
1276 JADA, Vol. 129, September 1998
Copyright 1998-2001 American Dental Association. All rights reserved.
area.20 Many patients will not
admit that they do not under-
stand common terms such as
three-fourths, hemorrhage, con-
sume, discard, teaspoon or re-
frain. This has significant im-
plications regarding their
abilities to follow directions,
comply with medication direc-
tives, and read and understand
postoperative instruction sheets
after oral surgery, if such sheets
are provided.
In one small, unpublished
clinical research project,
patients, all of whom were
high-school graduates, could re-
member only 67 to 83 percent of
Patients abilities to
function well socially
often mask their
inability to under-
stand instructions
from health care
professionals.
the significant information pro-
vided to them orally, when
questioned less than one hour
after oral surgery via a ques-
tionnaire (R. Alexander, unpub-
lished data, 1989). It is logical
to assume that in many less-ed-
ucated patients, the oral reten-
tion rate could be significantly
worse. Without written rein-
forcement, the understanding
and retention of oral instruc-
tions over a lengthy recovery
period cannot be ensured, even
among literate patients.
The bottom line. Although
no published studies have ex-
amined the importance of writ-
ten reinforcement of oral post-
operative instructions in
dentistry, nor examined how
well they are understood by pa-
tients, the preponderance of
medical literature suggests it is
important that written instruc-
tions be provided, coupled with
oral reinforcement. Written in-
structions should contain short
sentences, drawings, brief para-
graphs and words with few syl-
lables. Unfamiliar medical jar-
gon should be avoided.20,22,23
MYTH NO. 9: TEETH
SHOULD NEVER BE
EXTRACTED IN THE
PRESENCE OF ACTIVE
INFECTION
The primary goals of infection
management are to drain pus
and necrotic debris and to re-
move the cause of the infection.
Often, these goals can be accom-
plished most expeditiously by
removing the offending tooth or
teeth as soon as possible, if all
options for salvage have been
eliminated. This often requires
establishment of an antibiotic
blood level before the extraction
is carried out. It is no longer
necessary to wait for resolution
of the infection, however.
Although the philosophy of
waiting to extract a tooth ap-
pears to be a carryover from the
preantibiotic era of infection
management, Hall and associ-
ates24 long ago reminded us that
early removal actually existed
before antibiotic use became
widespread.
In 1951, Krogh25 studied
3,000 patients and showed that
teeth could be safely extracted
in the presence of acute infec-
tion, which probably resulted in
faster resolution of the infection
and rarely caused complica-
tions. In the majority of Kroghs
cases, antibiotics were not used
before surgery. These findings
were reproduced in three later
studies involving 350, 720 and
1,376 patients.26-28 Martis and
Karakasis26 concluded that im-
mediate extraction results in a

faster resolution of the infection
and that it is a safe procedure
without serious complications.
Rud28 pointed out that the argu-
ments against immediate ex-
traction generally arise out of
concern over potential litigation
and anecdotal experiences in-
volving a case or two in which
serious complications did occur.
Such complications might have
occurred even if the extraction
had been deferred, and should
not provide a foundation for ac-
ceptable management practices.
This philosophy of early ex-
traction does not imply a cava-
lier approach to surgery in an
infected patient, however. The
risks of anesthetic injection and
tooth extraction must always be
weighed against the anticipated
benefits of early removal, and
the clinician must take into con-
sideration the systemic medical
condition of the patient, the an-
ticipated degree of patient com-
pliance with the drug regimen,
surgical access to the tooth and
the clinicians skill and experi-
ence. Difficult or potentially
traumatic surgical extractions
might be better managed by
specialists who have extensive
experience in such cases.
The bottom line. In this
era of antibiotic availability, it
is possible to combine medical
and surgical treatment to bring
about a rapid resolution of
most odontogenic infections.
That is not to say that clini-
cians should be casual about
extracting teeth in the pres-
ence of an acute infection, but,
rather, that extraction need
not be deferred in healthy pa-
tients until the acute infection
has completely resolved.
Indeed, deferral might result
in a worsening of the infection,
if pus is not evacuated through
an incision for drainage.
Copyright 1998-2001 American Dental Association. All rights reserved.
Patients who are severely in-
fected, are immunologically
compromised or suppressed, or
have uncontrolled metabolic
diseases should begin an appro-
priate antibiotic regimen and
immediately be referred to an
experienced surgeon. This is
also true if the anticipated pro-
cedure is potentially traumatic
or otherwise difficult.
MYTH NO. 10: DENTISTS
SHOULD NOT PERFORM
SURGERY ON A PREG-
NANT PATIENT IN THE
FIRST OR THIRD
TRIMESTER
Many dentists are extremely re-
luctant to perform dentoalveo-
lar surgery on a pregnant
woman at any time, but espe-
cially during the first and third
trimesters, even when the pa-
tient has acute, severe symp-
toms and no other treatment al-
The arguments
against immediate
extraction generally
arise out of concern
over potential litiga-
tion and anecdotal
experiences involving
a case or two in
which serious compli-
cations did occur.
ternatives exist. A variety of
reasons have been expressed for
this reluctance, including the
fear of litigation if the fetus suf-
fers any birth defect; the fear of
spontaneous delivery in the of-
fice; concerns about radiation,
anesthesia and patient manage-
ment; and postoperative medi-
cation concerns. These concerns
have no more clinical signifi-
CLINICAL PRACTICE
cance than they would for any
patient receiving treatment.
Ideally, elective surgery
should be confined to the mid-
dle trimester, because that is
usually the patients most sta-
ble time. Emergency surgery for
the relief of infection, pain or
suffering can be performed at
any time during pregnancy,
however, provided appropriate
precautions and risk manage-
ment steps are followed. These
include the following:
dexposure to radiation for es-
sential films only (with proper
shielding);
dadequate and documented
patient counseling and in-
formed consent;
dobstetric consultation when
and where indicated;
dmedical consultation when
indicated for possible anemia
(about 20 percent of pregnan-
cies)30;
duse of appropriate medica-
tions intraoperatively and post-
operatively.
Concerns about potential
fetal damage are markedly re-
duced after the first trimester.
Guyton and Hall17 pointed out
that the highest risk period of
fetal development is largely
completed by the fifth month,
and the details of all major
organ systems have been
blocked out. During the next
four months, cellular refine-
ments occur in each organ sys-
tem. After the 12th week, the
risks of fetal compromise do not
change dramatically, although
development is not fully fin-
ished until the final month.
Statistically, the risks are low
but necessary when balanced
against a needed procedure to
relieve acute pain or infection.
Also, I found no statistically sig-
nificant incidence of sponta-
neous abortions or miscarriages
JADA, Vol. 129, September 1998 1277
CLINICAL PRACTICE
associated with dental treat-
ment in the literature over the
past 30 years.
Clinically, I occasionally hear
the belief expressed that preg-
nant women will have pro-
longed bleeding after surgery.
In fact, pregnancy is considered
a state of hypercoagulability,
with increased platelet aggrega-
tion, increases in coagulation
factors and decreased fibrinoly-
sis.17 This would logically de-
crease the possibility of unto-
ward bleeding after an
extraction.
Concerns over dental chair
delivery in the third trimester
also appear to be theoretical.
My review of the literature in
the past 30 years revealed no
case reports of serendipitous
dental office deliveries. Even if
a patient goes into labor, the
widespread availability of emer-
gency medical services means
that assistance would be provid-
ed very quickly.
A more realistic concern in
the final trimester is pregnancy
hypotension, induced by the
fetus pressing on the vena cava
when the patient is in a pro-
longed supine or semireclining
position, thus reducing the re-
turn of blood flow to the heart.
This can be alleviated by turn-
ing the patient slightly to the
left, which takes the weight of
the fetus off the liver and vena
cava. Aspirin and nonsteroidal
analgesics should be avoided in
the last trimester. About 10 to
20 percent of all pregnant
women are mildly anemic, but
this would not place them at
any risk during a minor surgi-
cal procedure.29,30
The bottom line. Although
elective procedures are per-
formed with the least risk dur-
ing the middle trimester, there
is no valid reason for deferring
1278 JADA, Vol. 129, September 1998
Copyright 1998-2001 American Dental Association. All rights reserved.
or withholding essential, emer-
gency surgery from a patient
who has an uncomplicated preg-
nancy, solely because of con-
cerns for the fetus or the moth-
er. Dentists should consult with
the patients obstetrician or
other physician whenever man-
agement questions exist, and it
is incumbent on every dentist to
understand the risks related to
surgical management. This in-
formation is readily available in
numerous dental textbooks.29
MYTH NO. 11: PATIENTS
SHOULD NOT EAT OR
DRINK ANYTHING AFTER
MIDNIGHT BEFORE RE-
CEIVING INHALATION OR
INTRAVENOUS SEDATION
For decades, patients who have
been scheduled to undergo in-
halation or receive oral or intra-
venous conscious sedation or
general anesthetic have been
admonished to eat or drink
nothing after midnight the night
before the procedure. Over the
years, this directive has been re-
In the past decade,
studies have been
published that refute
the need for pro-
longed preoperative
fasting in patients to
prevent aspiration.
laxed somewhat, and doctors
now typically counsel their pa-
tients to eat or drink nothing for
five to six hours before dental
procedures. Data in the last
three to five years suggest that
even these relaxed advisories
are of doubtful scientific validi-
ty, and the American Society of
Anesthesiology reportedly is on
the verge of releasing new
guidelines that will further
modify these recommendations.
In the past decade, studies
have been published that refute
the need for prolonged preoper-
ative fasting in patients to pre-
vent aspiration; this includes
patients undergoing inhalation
and intravenous conscious seda-
tion procedures. In a 1993
study, Warner and colleagues30
found only 67 cases of aspira-
tion out of more than 215,000
cases involving general anes-
thetics, and 15 of the 67 were
emergency cases involving pa-
tients who were known to have
full stomachs.
As early as 1833, researchers
showed that fluids pass through
the stomach fairly quickly and
solid foods require three to five
hours to empty (Roger Maltby,
M.D., oral communication,
American Association of Oral
and Maxillofacial Surgeons
Annual Meeting, Seattle, Sept.
21, 1997). Since about 1970,
however, the empiric nothing
by mouth past midnight direc-
tive has been with us in one
form or another.
Several physiology studies
since the 1970s showed that
solid foods are normally emp-
tied from the gut within four
hours and 99 percent of water is
gone after two hours.31,32 Studies
have also shown that patients
who drink fluids before surgery
have smaller residual gastric
volumes at surgery than pa-
tients who drink no fluids for
eight to 12 hours before
surgery. Researchers have
shown that even in cases of ob-
served aspiration, patients who
do not develop symptoms within
two hours rarely have respirato-
ry sequelae.29 American anes-
thesiologists are considering
new guidelines that allow inges-
tion of clear liquids (water,
pulpless fruit juice, plain tea or

coffee, or soda pop) up to two
hours before surgery and solid
foods or dairy products up to
five hours before surgery.
Numerous studies within the
past decade have shown that
the routine use of antacids, acid
blockers, gastrointestinal stim-
ulants or antiemetics are of no
benefit before conscious seda-
tion or general anesthetic is ad-
ministered (Roger Maltby,
M.D., oral communication,
AAOMS Annual Meeting,
Seattle, Sept. 21, 1997).
The bottom line. Prolonged
fasting and restriction of fluid
intake have been proven to be of
no value and of some possible
harm in patients about to re-
ceive conscious sedation or gen-
eral anesthetic. Clear fluids need
be restricted for only two to
three hours, and solid foods for
four to five hours before admin-
istration of any conscious seda-
tion. Even when a general anes-
thetic is to be administered, the
risk of aspiration is extremely
small to nonexistent with these
guidelines in place.
CONCLUSIONS
J. Chalmers Da Costa (1863 to
1933) once said, A man who
has a theory which he tries to fit
to facts is like a drunkard who
tries his key haphazardly in
door after door, hoping to find
one it fits. Many oft-cited be-
liefs, including those reviewed
above, are seemingly innocent.
They have, however, been per-
petuated for decades in our liter-
ature, our schools and our con-
tinuing education courses as
facts, despite the lack of valid,
scientific, statistically verifiable
Copyright 1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE
and unbiased data to support Saunders; 1996:1024-
47.
them. In this evolving era of evi- 18. Vallerand WP,
dence-based practice, it is time Vallerand AH, Heft
M. The effects of
for these surgical myths to be postoperative
subjected to unbiased scientific preparatory informa-
tion on the clinical
scrutiny. Until then, they should course following third
be set aside as anecdotal fiction, Dr. Alexander is an molar extraction. J
associate professor Oral Maxillofac Surg
and not be perpetuated as scien- of oral and maxillofa- 1994;52:1165-70.
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JADA, Vol. 129, September 1998 1279