| Abstract|| |
Introduction: The way postoperative care instructions are presented by the professional (verbal and/or written) is the key element that influences quality of treatment. Hence, the aim of the present study was planned to assess the patient's compliance with postoperative care instructions given in different forms following the surgical removal of impacted lower third molars. Materials and Methods: Forty patients scheduled to undergo surgical extraction of impacted lower third molars under local anesthetic were randomly assigned to one of two groups. Before surgery, basic demographic data about age, gender, deleterious habits were recorded. Group A (verbal postoperative care instructions) and Group B (verbal + pictorial postoperative care instructions) were given with a prescription of medication after the surgical removal of impacted lower third molars. Patient were recalled on 7th postoperative day for suture removal and asked to fill the closed-ended questionnaire. Results: Out of 20 patients in each group, one patient from Group A was eliminated as the patient did not turn for the follow-up visit. Therefore, result was based on 39 patients (19 males and 20 females) of age 28–41 years with a mean of 33.2 years (SD ± 3.3). The significance level was set at P < 0.05. The compliance of patients regarding gargling with lukewarm water and mouth opening exercises was seen more significantly in Group B (Pictorial + Verbal). Conclusion: Verbal instructions are inadequate due to difficulty in retention. Hence, a pictorial form of delivering postoperative instructions increases information retention which significantly increases pain relief without extending the analgesic consumption.
Keywords: Compliance, impacted lower third molar, post-operative care instructions, verbal and pictorial forms
|How to cite this article:|
Shenoi RS, Rajguru JG, Parate SR, Ingole PD, Khandaitkar SR, Karmarkar JS. Compliance of postoperative instructions following the surgical extraction of impacted lower third molars. Indian J Dent Res 2021;32:87-91
|How to cite this URL:|
Shenoi RS, Rajguru JG, Parate SR, Ingole PD, Khandaitkar SR, Karmarkar JS. Compliance of postoperative instructions following the surgical extraction of impacted lower third molars. Indian J Dent Res [serial online] 2021 [cited 2021 Aug 3];32:87-91. Available from: https://www.ijdr.in/text.asp?2021/32/1/87/321371
| Introduction|| |
One of the most common oral surgical procedures is the removal of impacted lower third molars. These procedures could be considered extensive because it involves bone guttering with the help of rotary cutting instruments. The postoperative complications include edema, inflammation, bleeding, dry socket, and infection which alter the chronology of healing. The degree of difficulty as well as the impact of the surgical procedure on the quality of life of patients during the postoperative care is well documented in the literature.,,,
The level of understanding and delivering healthcare services is directly proportional to the effective communication between the doctor and the patient. The way the postoperative care instructions are presented by the professional (verbal and/or written) is the key element that influences the understanding of the same. Educating the patient includes the prediction of postoperative complications, instructions regarding the medications and advice on home care of surgical wounds.
The different forms to deliver the postoperative care instructions such as verbal and/or written are well documented in the literature but pictorial forms of postoperative instructions are rare. Hence, the present study was planned to assess the patient's compliance with postoperative care instructions given in different forms following the surgical removal of impacted lower third molars.
| Material and Methods|| |
The study was conducted in the outpatient department of Oral and Maxillofacial Surgery, Dental College and Research Centre, Nagpur from December 2019 to March 2020 after approval from the Institutional Ethics Committee. Reference no. IEC/VSPMDCRC/77/2019. The study was approved by the Institutional Ethics Committee on 28-12-2019. Reference number IEC/VSPMDCRC/77/2019.
The patients included in the study were 18–60 years of age, were healthy (ASA I) or had mild systemic disease without functional limitation (ASA II), who gave consent and had no difficulties in understanding and following through the postoperative care instructions. However, the patients below 18 and above 60 years, ASA III or more, with any psychological disorder, who didn't report for their scheduled appointments for follow-up and had difficulty in comprehension of these postoperative care instructions were excluded from the study.
A sample size of 40 patients was determined using previous literature These patients scheduled to undergo surgical extraction of impacted lower third molars under local anesthetic were randomly assigned using computer generated random numbers to one of two groups. The allocation concealment was done by another investigator by using sealed envelope with case papers of the respective patients within it following which patients were allotted according to sequence generated to overcome selection bias. Before surgery, basic demographic data about age, gender, deleterious habits were recorded. The surgical removal of third molars was done using the same technique by second year junior residents of the department of Oral and Maxillofacial Surgery. Patients did not receive any financial compensation for their participation in the study. The patients were blinded by keeping the same time duration for the instructions to be provided whether verbal alone or verbal with pictures.
Group A comprised of patients who were given verbal postoperative care instructions with a prescription sheet of medications [Table 1], while Group B comprised of patients who received both verbal and pictorial postoperative care instructions with a prescription sheet of medications after the surgical removal of impacted lower third molars [Figure 1].
|Table 1: Postoperative instructions given after the surgical removal of impacted third molar|
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The extraction of the impacted lower third molars was performed under local anesthesia with lidocaine 2% and epinephrine 1:2,00,000. A full thickness mucoperiosteal flap was raised and well protected with a cheek retractor. A hand piece at low speed and continuous irrigation with distilled water was used for osteotomy and sectioning of the third molar was done whenever required. The flap was sutured with Vicryl 3-0. The postoperative medication was prescribed as following –
- Antibiotic (500 mg Amoxicilin + 125 mg Clavulanic acid) orally one tablet every 12 h for 5 days.
- NSAID (Diclofenac sodium + Paracetamol) orally every 12 h for 5 days.
- An antacid (Pantoprazole) orally every 24 h for 5 days.
- Mouthwash (Betadine) four times daily after 24 h of extraction for 7 days.
Patient were recalled on 7th postoperative day for suture removal and asked to fill the closed-ended questionnaire. A score of 1 was given to every question that was marked as YES while a score of 0 was given to every question that was marked as NO.
Statistical analysis was done using IBM SPSS version 21. The blinding of the investigators was not possible while the statistician was blinded with respect to allotment of the intervention in two groups.
| Results|| |
Out of 20 patients in each group, one patient from Group A was eliminated as the patient didn't turn for the follow-up visit [Graph 1]. The results therefore are based on 39 patients (19 males and 20 females) of age 28–41 years with a mean of 33.2 years (SD ± 3.3). Demographic data was analyzed using Chi-square test. Unpaired t-test and Chi-square test were used to compare the compliance according to method of the postoperative instructions. The significance level was set at P < 0.05.
A significant difference was observed in the compliance of patients with the method of postoperative instructions delivered to them. The mean of Group A and Group B are 10.28 and 14.50 respectively, with a t-value of 6.39. The compliance was found significantly more among patients receiving Pictorial + Verbal instructions (Group B) compared to patients receiving verbal instructions alone (Group A) as shown in [Table 2].
The instructions regarding application of ice was followed by 7 and 17 patients in Group A and B respectively while 10 and 18 patients pressed the folded gauze piece over the extraction socket in group A and B, respectively as shown in [Table 3]. The instruction to avoid strenuous exercises was followed by nine patients in Group A while 19 patients followed in Group B. Gargles with lukewarm water and practicing moth opening exercised after 48 h of surgical removal of third molars were followed significantly more by patients in Pictorial + Verbal group as compared to Verbal group as shown in [Graph 2].
| Discussion|| |
The factors that influence recovery from any surgical procedure are understanding and its subsequent implementation of postoperative guidelines. The instructions given to the patient about postoperative care not only improves quality of life but also reduces postoperative morbidity. The way the information is presented by the operator, to provide additional information and levels of preoperative anxiety are a few variables that may interfere with the extent and quality of life.
Compliance is the generally accepted term for patient cooperation with clinical prescriptions which is vital for therapeutic success as stated by Bunzel and Lederach-Hofmann. As documented in the literature, poor compliance is one of the drawbacks in healthcare resulting in waste of resources and funds.
We have very few studies of patient compliance in dentistry. The lack of reports on the effectiveness of postoperative instructions was noted by Alexander. Later, Alexander reported the prescriptions written are usually at higher than the intellectual level of understanding of many patients and excessive jargon makes it difficult to comprehend.
Postoperative instructions delivered in verbal and written forms are common. However, the literature lacks knowledge regarding the pictorial form of delivering these instructions which was done in the present study. The pictorial memory of brain influences the retention of postoperative instructions which is not seen with verbal and written forms.
In the present study, the compliance was found significantly more among patients receiving Pictorial + Verbal instructions compared to patients receiving verbal instructions alone with the instructions regarding application of ice packs. The compliance of patients regarding the removal of gauze after 45 min post-surgical removal of impacted lower third molars, avoiding strenuous exercises like swimming, lifting heavy weights, gargling with lukewarm water, and mouth opening exercises was seen more significantly in the Group B (Pictorial + Verbal).
Vallerand et al. reported that the compliance of patients after removal of third molar improved with both oral and written postoperative instructions. Houts et al. stated that patients remembered only 14% of the verbally given instructions compared to 80% when verbal instructions were combined with pictograms. The verbal instructions when given alone were ineffective.
The limitation of the present study is the number of patients in each group. Despite promising results of postoperative instructions when given in pictorial with verbal form of delivery, the educational status, preoperative anxiety may play a role in compliance of patient which was not evaluated in the present study. A study with larger sample size should be conducted in the future to evaluate the difference in compliance of patients with the various methods of delivering the postoperative instructions.
| Conclusion|| |
Patient compliance of postoperative care instructions is indirectly proportional to complications. Well delivered postoperative period instructions decrease stress, increase satisfaction, and reduce complications. Verbal instructions are inadequate as they may not be retained entirely. In addition, India has a plethora of languages and could lead to miscommunication between the surgeon and the patient; hence a written form of instructions is necessary along with it.
Pictorial form of delivering postoperative instructions increases the quality of information being delivered which significantly increases pain relief and controls pain without increasing analgesic consumption. The present study was planned to assess the compliance of patients to various methods of postoperative instructions and we concluded that there are promising results in pictorial with verbal form of method of delivering post-operative instructions as compared to verbal form of instructions alone.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Phillips C, White RP, Shugars DA, Zhou X. Risk factors associated with prolonged recovery and delayed healing after third molar surgery. J Oral Maxillofac Surg 2003;61:1436-48.
Susarla SM, Dodson TB. Estimating third molar extraction difficulty: A comparison of subjective and objective factors. J Oral Maxillofac Surg 2005;63:427-34.
Yuasa H, Kawai T, Sugiura M. Classification of surgical difficulty in extracting impacted third molars. Br J Oral Maxillofac Surg 2002;40:26-31.
Colorado-Bonnin M, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Quality of life following lower third molar removal. Int J Oral Maxillofac Surg 2006;35:343-7.
Vallerand WP, Vallerand AH, Heft M. The effects of postoperative preparatory information on the clinical course following third molar extraction. J Oral Maxillofac Surg 1994;52:1165-70.
Adebayo ET, Dairo M. Patient's compliance with instructions after oral surgery in Nigeria. J Comm Med Prim Health Care 2005;17:38-44.
Prasad Chundi H, Sujatha B, Mallineni SK, Nuvvula S. Parents' Compliance With Post-Operative Instructions Following The Extraction of Primary Teeth In Children. 2019;18:5-10.
Alvira-González J, Gay-Escoda C. Compliance of postoperative instructions following the surgical extraction of impacted lower third molars: A randomized clinical trial. Med Oral Patol Oral Cir Bucal 2015;20:e224-30.
Ferrús-Torres E, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Informed consent in oral surgery: The value of written information. J Oral Maxillofac Surg 2011;69:54-8.
Bunzel B, Laederach-Hofman K. Solid organ transplantation: Are there predictors for post-transplant non-compliance? A literature overview. Transplantation 2000;70:711-6.
Alexander RE. Readability of published dental educational materials. J Am Dent Assoc 2000;131:937-42.
Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns 1998;35:83-8.
Dr. Jignesh G Rajguru
Department of Oral and Maxillofacial Surgery, VSPM Dental College and Research Centre, F1-04/A-Wing, Vindychal PG Hostel, Lata Mangeshkar Hospital Campus, Hingna, Nagpur - 440 019, Maharashtra
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]