CLINICAL

PRACTICE

ELEVEN MYTHS OF DENTOALVEOLAR SURGERY

ROGER E. ALEXANDER, D.D.S.

Through the years, dentists who perform dentoalveolar surgery have perpetuated many myths and other unproven beliefs from one generation to another. Sometimes, these beliefs originated in older textbooks, while others were given birth by mentors sharing anecdotal experiences with their students. Even today, many of these scientifically unsupported statements are perpetuated in surgical textbooks and in continuing education forums and are passed on to students in dental schools. In todays evolving environment 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.

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 These so-called facts sometimes began as statements in textbooks that are now outdated, while others originated from mentors sharing anecdotal experiences with students. These pseudoscientific statements are accepted without question by many general dentists and specialists performing surgical procedures. Physicians and dentists alike are becoming increasingly interested in teaching and practicing evidence-based medicine. This has been defined as the conscientious, explicit and judicious use of current 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 encountered in the field of dentoalveolar surgery and show that each lacks clinical importance or is based on anecdotal beliefs without supporting scientific evidence.
MYTH NO. 1: PEOPLE WHO USE ASPIRIN WONT STOP BLEEDING AFTER SURGERY

Paul Broca (1824 to 1880) once stated, The least questioned as-

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 unwanted clotting. With increasing frequency, patients needing surgical procedures are being seen in dental offices and their drug regimens include aspirin or other platelet-inhibiting drugs. Dentists
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have been warned of dire consequences when performing surgery on such patients, so they may deny needed treatment or expose the patient to unnecessary additional medical expenses. One dental pharmacology text and at least one oral surgery text advise discontinuing aspirin therapy one week before extensive surgery, without providing any scientific justification for the recommendation or precautionary comments on the potential legal risks and implications of discontinuing medication 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 thromboresistant. Factors in this release reaction include the cyclooxygenase metabolites thromboxane A2 in platelets and prostaglandin I2, as well as prostacyclin and nitric oxide in the endothelial cells. Plateletderived thromboxane A2 and endothelium-derived prostacyclin (and nitric acid) have opposite effects, and the balance of their production is an important determinant in blood fluidity and hemostasis.5 Individual platelets are sensitive to aspirin inactivation of cyclooxygenase and are affected for the duration of their sevento-10-day circulation lifetime. In contrast, the endothelial cells recover rapidly after exposure because they can continuously synthesize new, unacetylated
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cyclooxygenase.6 A single dose of aspirin will inhibit platelet aggregation within two hours of administration, and blood salicylate levels can persist for four to seven days, long after the levels are clinically undetectable.5 Platelet adhesion function will be compromised until a sufficient 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 withstood the scrutiny of meta-analysis.
Ingestion of alcohol can further prolong the bleeding time produced by aspirin and nonsteroidal drugs. An American Medical Association pharmacology 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 another anticoagulant.7 By contrast, nonsteroidal analgesics, such as ibuprofen, produce a weaker, transient effect that normalizes within 12 hours after exposure.5 Longterm use of nonsteroidal antiinflammatory drugs produces less-predictable changes, however. 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 generally considered the best clinical screening test for platelet ac-

tivity. Interestingly, it has been shown that the effect is dose-dependent and longer bleeding times, paradoxically, can occur with lower doses of aspirin.8 The bleeding time can be prolonged because of other factors, however, including technical artifacts in the laboratory. Furthermore, it cannot be extrapolated that a prolonged bleeding time will result in a clinical bleeding problem elsewhere in the body. For example, a prolonged skin bleeding time may not be associated with prolonged bleeding from an endoscopic stomach biopsy procedure.9 Bleeding times can also be prolonged owing to defects of platelet function other than adhesion. Aspirin has been implicated with clinically significant bleeding, but the results have not withstood the scrutiny of metaanalysis.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 therapy who underwent cholecystectomy and coronary artery bypass procedures have shown highly variable results.5 Although cases of spontaneous gastrointestinal hemorrhage have been reported, the predominant conclusion of the literature, as reviewed by Schafer, is that aspirin-induced excessive bleeding is of marginal clinical significance in most patients.5 A search of the literature for the past three decades failed to discover a single article in which clinically significant bleeding after tooth extraction was directly and primarily attributable to a patients receiving aspirin or other platelet-inhibiting drug therapy.

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The bottom line. The longterm use of aspirin and nonsteroidal drugs appears rarely to cause 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. The decision to perform oral surgery should be made on a case-by-case basis, with dental professionals balancing the potential risk of bleeding with the urgency, type and extent of the planned procedure(s). It is unlikely that a patient 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 procedures. With more extensive surgery, such as full-mouth extractions, extensive deep scaling or periodontal surgery, an increased emphasis on local hemostatic procedures, such as use of sutures, superficial laser and/or products such as oxidized cellulose or absorbable gelatin sponge, may be prudent.
MYTH NO. 2: PATIENTS SHOULD USE SALTWATER MOUTHRINSES AFTER SURGERY

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 another, and perpetuated without question. These unfounded recommendations persist in articles 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 immunocompetent patients.
in treating or preventing infection, or in maintaining oral hygiene. Further, I could find no article that proves in a scientifically valid manner that intermittent clinical use of regular (tap) water has any adverse effect 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 physiologic saline solution.11 They discovered that several combinations 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

For more than 50 years, numerous textbooks have advocated the use of salt water (saline) for surgical mouthrinses, apparently on the premise that it is the most physiologic irrigant available and will not adversely affect healing tissues. Interestingly, nearly every textbook has had a different recipe for what constitutes saline, and the guidance has ranged from no guidelines at all to explicit formulas for mixing ingredients (generally 1/4 to 1 teaspoon table salt added to tap water in amounts

14 oz of water. Using the second formula, they then asked volunteer 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 significantly 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 advantage over plain tap water in immunocompetent patients, and patients have been shown to be incapable of mixing accurate solutions from provided instructions. 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, immunocompromised patients might be advised to use bottled sterile solutions of water or saline because of potential microbial contamination (for example, 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 instruction sheet has carried an admonition to patients to re1273

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frain from drinking (or sucking) through a soda straw or sucking on the extraction site, apparently on the premise that the intraoral vacuum created will draw the blood clot from the alveolus, causing localized alveolitis (dry socket), infection or healing problems. Again, 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. Likewise, the literature is devoid of any studies that document clinically significant postsurgical dental problems that could be scientifically attributed to such activities. When a tooth is removed, a sequence of inflammation, epithelialization, fibroplasia and remodeling is initiated.12,13 Within the first day, the fibrincovered 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 ingrowth of fibroblasts and capillaries, and epithelium migrates down the socket wall until it contacts epithelium or granulation 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 believe that the clot has some internal resistance to any mechanical dislodgement by low-suction vacuum or sucking on a straw, even within the first few hours after surgery. It seems unlikely that a patientinduced oral vacuum would be
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instrumental in causing a viable clot to be dislodged from an extraction site, but reliable scientific data are lacking to conclusively prove or disprove this rationalization. Furthermore, this alleged problem should not be confused with the pathophysiology of localized alveolitis (dry socket), which generally occurs three to five days (or more) after surgery and involves fibrinolytic (not mechanical) activities within the clot.14

It seems unlikely that a patient-induced oral vacuum would be instrumental in causing a viable clot to be dislodged from an extraction site.
The bottom line. I could find no scientific evidence that sucking through a soda straw has any relationship to postsurgical sequelae, and when one logically considers the process of intra-alveolar extraction-site healing, such events seem improbable. However, a valid, double-blinded study of this topic would be beneficial.
MYTH NO. 4: DRINKING CARBONATED BEVERAGES WILL CAUSE DRY SOCKETS OR OTHER PROBLEMS

oral surgery when patients drink carbonated beverages. Perhaps the belief arose from use of hydrogen peroxide as a mouthwash, which results in the release 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 addition to the literature. The bottom line. I could find no published clinical data that prove a relationship between 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 advisories.
MYTH NO. 5: DRINKING ALCOHOL-CONTAINING BEVERAGES WILL CAUSE DRY SOCKETS

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 discussion of drinking through soda straws, this belief also has no apparent scientific foundation. My review of the literature failed to yield a single study that documents increased morbidity after

This common admonishment to patients appears to be grounded more in pharmacology than in clinical sequelae. Alling and associates15 pointed out that alcohol is a direct platelet toxin and, therefore, will affect bleeding. However, I could find no evidence in the literature that once a blood clot has formed, occasional alcohol use can cause hemorrhage to recur. In fact, many clinicians instruct their patients to use chlorhexidinebased 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 consumed daily.16 Bleeding problems can arise secondary to

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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 bleeding time through its interactions with platelets that have been compromised by aspirin and nonsteroidal drug use. Excessive, long-term alcohol use can interfere with healing, compromise inflammatory responses such as leukocyte migration, and damage cells, but the literature does not provide evidence that an occasional alcoholic beverage 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 advice should be based on the adverse effects of alcohol on healing and the potential for interactions with medications that are likely to be prescribed during the immediate postoperative period.
MYTH NO. 6: MENSTRUATING WOMEN WHO UNDERGO SURGERY WILL HAVE SIGNIFICANT POSTOPERATIVE BLEEDING

There is little agreement in the literature on how long a patient should be expected to hemorrhage after an extraction, with estimates ranging from 30 minutes to 24 hours. Presumably, prolonged bleeding exceeds one hour and can last up to 24 hours, making comparisons difficult and determinations of normal subjective. I could find no published studies that demonstrated clinically 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 complication that was attributable to bilateral mandibular anesthesia alone.
Estrogens can result in greater clinical bleeding of cut surfaces, but it is not clinically significant or a contraindication for surgery.17 The bottom line. 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.
MYTH NO. 7: PATIENTS SHOULD NEVER RECEIVE BILATERAL THIRD-DIVISION (MANDIBULAR) ANESTHETIC BLOCKS

Although this myth seems finally 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 hemorrhaging. There is only a touch of scientific reality behind this myth, and very little clinical impact.

I have observed a perplexing be-

lief among some practicing dentists that patients should not receive bilateral third-division (inferior alveolar) nerve blocks. Some faculty members in excellent dental schools even present the philosophy to dental students. It is hard to imagine where this myth arose, since it is not found in any contemporary textbook on dental local anesthesia. It might be an unconscious extension to adults of the conventional wisdom to avoid bilateral mandibular nerve anesthetic blocks in young children whenever possible, 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 administers bilateral local anesthetic blocks, so the precautionary 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 potential airway problem for patients. 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 experiencing a significant complication that was attributable to bilateral mandibular anesthesia alone. The bottom line. Administration of local anesthetic should be dictated by the needs of the patient and the procedures planned, with full knowledge of all known risks. Bilateral mandibular anesthetic blocks are appropriate procedures, especially in adult patients, whenever the treatment plan and doctors judgment dictate a need for them.
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MYTH NO. 8: ORAL POSTOPERATIVE INSTRUCTIONS ARE SUFFICIENT

Patients who receive both written and oral instructions after surgery experience less postoperative 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 patients orally after surgery, or perhaps use a generic, commercially 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 understood by patients with limited literacy and comprehension abilities. Adequate postoperative counseling has been shown to minimize complications and have positive clinical results. In a study by Vallerand and associates,18 postoperative pain control and satisfaction were found to be greater in patients who received extensive written preparatory information. There is growing concern among health care professionals about the inability of a significant portion of the U.S. population 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 necessary to function in modern society.21,22 Patients abilities to function well socially often mask their inability to understand instructions from health care professionals, and vocabulary is a particular problem
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area.20 Many patients will not admit that they do not understand common terms such as three-fourths, hemorrhage, consume, discard, teaspoon or refrain. This has significant implications regarding their abilities to follow directions, comply with medication directives, 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 remember only 67 to 83 percent of

medical literature suggests it is important that written instructions be provided, coupled with oral reinforcement. Written instructions should contain short sentences, drawings, brief paragraphs and words with few syllables. Unfamiliar medical jargon should be avoided.20,22,23
MYTH NO. 9: TEETH SHOULD NEVER BE EXTRACTED IN THE PRESENCE OF ACTIVE INFECTION

Patients abilities to function well socially often mask their inability to understand instructions from health care professionals.
the significant information provided to them orally, when questioned less than one hour after oral surgery via a questionnaire (R. Alexander, unpublished data, 1989). It is logical to assume that in many less-educated patients, the oral retention rate could be significantly worse. Without written reinforcement, the understanding and retention of oral instructions over a lengthy recovery period cannot be ensured, even among literate patients. The bottom line. Although no published studies have examined the importance of written reinforcement of oral postoperative instructions in dentistry, nor examined how well they are understood by patients, the preponderance of

The primary goals of infection management are to drain pus and necrotic debris and to remove the cause of the infection. Often, these goals can be accomplished 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 appears to be a carryover from the preantibiotic era of infection management, Hall and associates24 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 infection, which probably resulted in faster resolution of the infection and rarely caused complications. 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 immediate extraction results in a

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faster resolution of the infection and that it is a safe procedure without serious complications. Rud28 pointed out that the arguments against immediate extraction generally arise out of concern over potential litigation and anecdotal experiences involving 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 acceptable management practices. This philosophy of early extraction does not imply a cavalier 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 consideration the systemic medical condition of the patient, the anticipated degree of patient compliance with the drug regimen, surgical access to the tooth and the clinicians skill and experience. 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 clinicians should be casual about extracting teeth in the presence of an acute infection, but, rather, that extraction need not be deferred in healthy patients 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. Patients who are severely infected, are immunologically compromised or suppressed, or have uncontrolled metabolic diseases should begin an appropriate antibiotic regimen and immediately be referred to an experienced surgeon. This is also true if the anticipated procedure is potentially traumatic or otherwise difficult.
MYTH NO. 10: DENTISTS SHOULD NOT PERFORM SURGERY ON A PREGNANT PATIENT IN THE FIRST OR THIRD TRIMESTER

Many dentists are extremely reluctant to perform dentoalveolar surgery on a pregnant woman at any time, but especially during the first and third trimesters, even when the patient has acute, severe symptoms and no other treatment al-

The arguments against immediate extraction generally arise out of concern over potential litigation and anecdotal experiences involving a case or two in which serious complications did occur.
ternatives exist. A variety of reasons have been expressed for this reluctance, including the fear of litigation if the fetus suffers any birth defect; the fear of spontaneous delivery in the office; concerns about radiation, anesthesia and patient management; and postoperative medication concerns. These concerns have no more clinical signifi-

cance than they would for any patient receiving treatment. Ideally, elective surgery should be confined to the middle trimester, because that is usually the patients most stable 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 management steps are followed. These include the following: dexposure to radiation for essential films only (with proper shielding); dadequate and documented patient counseling and informed consent; dobstetric consultation when and where indicated; dmedical consultation when indicated for possible anemia (about 20 percent of pregnancies)30; duse of appropriate medications intraoperatively and postoperatively. Concerns about potential fetal damage are markedly reduced 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 refinements occur in each organ system. After the 12th week, the risks of fetal compromise do not change dramatically, although development is not fully finished 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 significant incidence of spontaneous abortions or miscarriages
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associated with dental treatment in the literature over the past 30 years. Clinically, I occasionally hear the belief expressed that pregnant women will have prolonged bleeding after surgery. In fact, pregnancy is considered a state of hypercoagulability, with increased platelet aggregation, increases in coagulation factors and decreased fibrinolysis.17 This would logically decrease the possibility of untoward 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 emergency medical services means that assistance would be provided 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 prolonged supine or semireclining position, thus reducing the return of blood flow to the heart. This can be alleviated by turning 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 surgical procedure.29,30 The bottom line. Although elective procedures are performed with the least risk during the middle trimester, there is no valid reason for deferring
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or withholding essential, emergency surgery from a patient who has an uncomplicated pregnancy, solely because of concerns for the fetus or the mother. Dentists should consult with the patients obstetrician or other physician whenever management questions exist, and it is incumbent on every dentist to understand the risks related to surgical management. This information is readily available in numerous dental textbooks.29
MYTH NO. 11: PATIENTS SHOULD NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT BEFORE RECEIVING INHALATION OR INTRAVENOUS SEDATION

For decades, patients who have been scheduled to undergo inhalation or receive oral or intravenous 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 prolonged preoperative fasting in patients to prevent aspiration.
laxed somewhat, and doctors now typically counsel their patients 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 validity, 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 preoperative fasting in patients to prevent aspiration; this includes patients undergoing inhalation and intravenous conscious sedation procedures. In a 1993 study, Warner and colleagues30 found only 67 cases of aspiration out of more than 215,000 cases involving general anesthetics, and 15 of the 67 were emergency cases involving patients 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 directive has been with us in one form or another. Several physiology studies since the 1970s showed that solid foods are normally emptied 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 patients who drink no fluids for eight to 12 hours before surgery. Researchers have shown that even in cases of observed aspiration, patients who do not develop symptoms within two hours rarely have respiratory sequelae.29 American anesthesiologists are considering new guidelines that allow ingestion of clear liquids (water, pulpless fruit juice, plain tea or

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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 stimulants or antiemetics are of no benefit before conscious sedation or general anesthetic is administered (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 receive conscious sedation or general anesthetic. Clear fluids need be restricted for only two to three hours, and solid foods for four to five hours before administration of any conscious sedation. Even when a general anesthetic is to be administered, the risk of aspiration is extremely small to nonexistent with these guidelines in place.
CONCLUSIONS

and unbiased data to support them. In this evolving era of evidence-based practice, it is time for these surgical myths to be subjected to unbiased scientific scrutiny. Until then, they should be set aside as anecdotal fiction, and not be perpetuated as scientific gospel. s
1. Evidence-based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992;268:2420-5. 2. Sackett DL, Rosenberg WM, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isnt. BMJ 1996;312:71-2. 3. Holroyd SV, Wynn RL, Requa-Clark B. Clinical pharmacology in dental practice. 4th ed. St. Louis: MosbyYear Book; 1988:135. 4. Kwon PH, Laskin DM. Clinicians manual of oral and maxillofacial surgery. Chicago: Quintessence; 1991:114. 5. Schafer AI. Effects of nonsteroidal antiinflammatory drugs on platelet function and systemic hemostasis. J Clin Pharmacol 1995;35:209-19. 6. Jaffe EA, Weksler BB. Recovery of endothelial cell prostacyclin production after inhibition by low doses of aspirin. J Clin Invest 1979;63:532-5. 7. Division of Drugs and Toxicology, American Medical Association. Drug evaluation annual 1995. Chicago: American Medical Association; 1995:788. 8. OGrady J, Moncada S. Aspirin: a paradoxical effect on bleeding-time (letter). Lancet 1978;2:780. 9. OLaughlin JC, Hoftiezer JW, Mahoney JP, Ivey KJ. Does aspirin prolong bleeding from gastric biopsies in man? Gastrointest Endosc 1981;27:1-5. 10. Whinery JG. Destroying some old myths (letter). J Oral Maxillofac Surg 1988;46:94. 11. Verser SJ, Alexander RE. Use of saline as a postsurgical rinse (letter). Oral Surg Oral Med Oral Pathol 1994;77:438-9. 12. Hupp JR. Wound repair. In: Peterson LJ, Ellis E, Hupp JR, Tucker MR. Contemporary oral and maxillofacial surgery. 2nd ed. St. Louis: MosbyYear Book; 1993:66. 13. Shafer WE, Hine MK, Levy BM. Textbook of oral pathology. 4th ed. Philadelphia: Saunders; 1983:602. 14. Swanson AE. Prevention of dry socket: an overview. Oral Surg Oral Med Oral Pathol 1990;70:131-6. 15. Alling CC, Helfrick JF, Alling RD. Impacted teeth. Philadelphia: Saunders; 1993:83. 16. Leonard RH. Alcohol, alcoholism, and dental treatment. Compend Contin Educ Dent 1991;12:274-83. 17. Guyton AC, Hall JE. Textbook of medical physiology. 9th ed. Philadelphia:

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 beliefs, including those reviewed above, are seemingly innocent. They have, however, been perpetuated for decades in our literature, our schools and our continuing education courses as facts, despite the lack of valid, scientific, statistically verifiable

Saunders; 1996:102447. 18. Vallerand WP, Vallerand AH, Heft M. The effects of postoperative preparatory information on the clinical course following third Dr. Alexander is an molar extraction. J associate professor Oral Maxillofac Surg of oral and maxillofa1994;52:1165-70. 19. Culbertson VL, cial surgery, Arthur TG, Rhodes Department of Oral PJ, et al. Consumer and Maxillofacial preferences for verbal Surgery and and written medicaPharmacology, tion information. Baylor College of Drug Intell Clin DentistryTAMUS, Pharmacol P.O. Box 660677, 1988;22:390-6. Dallas, Texas 7526620. Weiner MF, 0677. Address Lovitt R. An examinareprint requests to tion of patients unDr. Alexander. derstanding of information from health care providers. Hosp Community Psych 1984;35:619-20. 21. Miles S, Davis T. Patients who cant read: implications for the health care system. JAMA 1995;274:1719-20. 22. Levoy B. Communicating with low-literacy patients. Dent Economics 1995;85:14. 23. Baker GC, Newton DE, Bergstresser PR. Increased readability improves the comprehension of written information for patients with skin disease. J Am Acad Dermatol 1988;19:1135-41. 24. Hall HD, Gunter JW, Jamison HC, McCallum CA. Effect of time of extraction on resolution of odontogenic cellulitis. JADA 1968;77:626-31. 25. Krogh HW. Extraction of teeth in the presence of acute infections. J Oral Surg 1951;9:136-51. 26. Martis CS, Karakasis DT. Extractions in the presence of acute infections. J Dent Res 1975;54:59-61. 27. Martis C, Karabouta I, Lazaridis N. Extractions of impacted mandibular wisdom teeth in the presence of acute infection. Int J Oral Surg 1978;7:541-8. 28. Rud J. Removal of impacted lower third molars with acute pericoronitis and necrotising gingivitis. Br J Oral Surg 1970;7:153-60. 29. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 5th ed. St. Louis: MosbyYear Book; 1997:434-5. 30. Warner MA, Warner EW, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993;78:56-62. 31. Hinder RA, Kelly KA. Canine gastric emptying of solids and liquids. Am J Physiol 1977;233:E335-40. 32. Miller M, Wisehart HY, Nimmo WS. Gastric contents at induction of anesthesia: is a 4-hour fast necessary? Br J Anaesth 1983;55:1185-8.

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