The Need for Improved Surgical Site Management
Scott D. Benjamin, DDS
Wound care is an important part of patient care in almost every discipline of medicine. Oral procedures performed with scalpels, curettes, periotomes, osteotomes, lasers, and various other instruments create surgical wounds. Appropriately dressing surgical site wounds is considered a basic principle of proper surgical procedure,1 allowing for better healing, greater patient comfort, and fewer complications. Surgical dressings comprise various materials, such as bandages, packs, and other ointment, cream, oil, and spray products applied directly to the treatment site.2-4
Historically, surgical and lesion dressings had one role: protect the area from further damage and contamination. Today, research focuses on modalities with bioactive components to provide antimicrobial activity and pain relief. Thus, modern treatments and dressings should perform three major functions: provide pain relief, prevent contamination, and maintain an optimal healing environment.1
Although tremendous progress has been made in the care of external surgical sites and lesions, the care of intraoral sites has been lacking, primarily because the oral environment poses significant challenges. The oral cavity is moist and continually bathed in saliva. It is constantly functioning through speaking, eating, drinking liquids, and tongue activity. Also, toxicity is a consideration when introducing any wound care material into the mouth because of ingestion.
Most current oral wound treatment modalities have inadequacies. Pain medication, including opioid drugs, does not always provide adequate pain relief, particularly after oral surgical procedures, and this has contributed to the current opioid epidemic.5 Agents used to address microbial contamination, such as prescription and popular nonprescription mouthrinses, while offering effective antimicrobial properties, can be harsh to oral tissues and hinder the healing process. Many also possess unwanted side effects that can range from being merely irritating to life-threatening.
The Need Is Great
The need to provide safe, effective, and improved intraoral care of treatment sites and lesions is enormous. According to the latest American Dental Association survey of dental procedures rendered in the United States during a single year, published in 2007,6 more than 60 million oral surgeries were being performed per year. That number has no doubt grown significantly since 2005-2006, when the data was collected. Most dental surgeries, including implant placements, bone grafts, osseous recontouring, dental extractions, and various periodontal procedures, involve both soft tissue and bone; thus, both need healing.
The lack of adequate intraoral wound treatment modalities has long been accepted as a normal aspect of dentistry, such that many practitioners are not even conscious of it being an issue. Dental patients expect the same optimal wound care from the dentist that they receive from their physicians and surgeons. Until oral healthcare clinicians provide truly effective post-treatment extraction and surgical care, their fundamental obligation to patients to provide excellent care, not only during treatment but also after treatment, will go unmet. To improve post-treatment intraoral care, two major issues need to be addressed: bioburden and pain.
Bioburden and Pain
Bioburden refers to the microbial load, or the number of microbial cells on the surface of the treatment site.7 This is important because the microbial load can affect the healing process. Unfortunately, the oral cavity is an ideal site for increased bioburden, with almost 1,000 species of bacteria having been identified in the mouth.8 Several species of fungi and viruses are also present. Non-intact tissue and surgical sites in this environment are obviously at risk for the complications associated with bioburden.
Infection is one such complication, and infection hinders healing. When infection is present, the body's immune system focuses on the infection rather than on healing the tissue. Signs of infection include inflammation, pain, and suppuration with concurrent lack of healing.9,10
Another aspect of bioburden is a condition known as "critical colonization," ie, the presence of microbes in a site to the extent that healing is adversely affected.11 An example of critical colonization in dentistry is alveolar osteitis (dry socket). Although multifactorial, the single most important component of development of dry socket is bioburden. These wounds are not actually infected but show signs of critical colonization, including pain, foul odor, and delayed or lack of healing. Prophylactic use of antibiotics or antimicrobial agents, such as rinses and gels, significantly reduces the incidence of alveolar osteitis.12,13
In addition to adversely affecting healing, high bioburden increases pain due to the activity of the metabolic by-products produced by microbes.14 Reducing bioburden can thus help alleviate pain, which helps explain why patients often report some moderation in pain after use of antimicrobial products.
Unfortunately, the dental profession has never been able to provide excellent pain relief to patients. Moreover, the measures used to address pain come with their own inherent negative aspects.
Issues With Common Wound Care
Issues with current wound care include inadequate pain relief, toxicity, cytotoxicity, and miscellaneous side effects.1 In both medicine and dentistry, opioid drugs have been the traditional choice for pain relief after surgery. Opioids are relatively nontoxic, but they present the risk of abuse.
Today, dentists often recommend over-the-counter (OTC) medications instead of opioids because their efficacy is equivalent to that of opioids, but they do not result in dependence. The use of OTC medications in lieu of opioids, thus, may be considered a step in the right direction. The two most common are acetaminophen and ibuprofen; however, these OTC medications, too, have issues.
Acetaminophen is a non-opioid analgesic for mild to moderate pain. It provides some pain relief and is an antipyretic (fever reducer). It is believed to elevate the pain threshold5 and is thought to reduce fever by affecting the heat-regulating center of the brain (hypothalamus).15
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs block the action of cyclooxygenases (COX) enzymes that are necessary for the formation of prostaglandins.5 Prostaglandins cause swelling of injured tissues, which contributes to pain; they also amplify the pain impulse. The blockade of prostaglandins thus reduces a major contributor to pain (swelling), as well as the magnitude of the pain impulse itself.
Studies have shown that the combination of acetaminophen with ibuprofen provides equivalent pain relief to that of opioids after tooth extraction.5 OTC medications still do not produce excellent pain relief and come with potential although rare adverse effects, such as rash, headache, anemia, liver or kidney damage, and others. Acetaminophen is toxic to the liver; in fact, its toxicity is the foremost cause of acute liver failure in the Western world and accounts for a large percentage of drug overdoses in the United States.16
21st Century Solutions
Clearly, dentistry needs better solutions to address many of the surgical wound issues oral healthcare providers face. Among the concepts for future discussion are all-natural, nontoxic, drug-free, ingestible wound dressings, rinses, and techniques; light energy for decontamination of the surgical site; and photobiomodulation therapy to enhance the healing process at subcellular levels. One thing is clear: A patient's dental treatment is not complete until healing is complete.
1. Obagi Z, Damiani G, Grada A, Falanga V. Principles of wound dressings: a review. Surg Technol Int. 2019;35:50-57.
2. Broussard KC, Powers JG. Wound dressings: selecting the most appropriate type. Am J Clin Dermatol. 2013;14(6):449-459.
3. Dai LG, Fu KY, Hsieh PS, et al. Evaluation of wound healing efficacy of an antimicrobial spray dressing at skin donor sites. Wounds. 2015;27(8):224-228.
4. Gholami H, Yeganeh H. Vegetable oil-based polyurethanes as antimicrobial wound dressings: in vitro and in vivo evaluation. Biomed Mater. 2020;15(4):045001.
5. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental practice. J Am Dent Assoc. 2013;144(8):898-908.
6. ADA Survey Center. 2005-2006 Survey of Dental Services Rendered. Chicago, IL: American Dental Association; 2007.
7. Salcido R. What is bioburden? The link to chronic wounds. Adv Skin Wound Care. 2007;20(7):368.
8. Wade WG. The oral microbiome in health and disease. Pharmacol Res. 2013;69(1):137-143.
9. Haesler E, Swanson T, Ousey K, Carville K. Clinical indicators of wound infection and biofilm: reaching international consensus. J Wound Care. 2019;28(suppl 3b):s4-s12.
10. Gardner SE, Franz RA, Troia C, et al. A tool to assess clinical signs and symptoms of localized infections in chronic wounds: development and reliability. Ostomy Wound Manage. 2001;47(1):40-47.
11. Davis E. Don't deny the chance to heal. Presented at: 2nd Joint Meeting of the Wound Healing Society and the European Tissue Repair Society; May 15-19, 1996; Boston, MA.
12. Lodi G, Figini L, Sardella A, et al. Antibiotics to prevent complications following tooth extractions [update in Cochrane Database Syst Rev. 2021;2(2): CD003811]. Cochrane Database Syst Rev. 2012;11:CD003811.
13. Daly B, Sharif MO, Newton T, et al. Local interventions for the management of alveolar osteitis (dry socket). Cochrane Database Syst Rev. 2012;12:CD006968.
14. Chiu, IM, Heesters BA, Ghasemlou N, et al. Bacteria activate sensory neurons that modulate pain and inflammation. Nature. 2013;501(7465):52-57.
15. Aronoff DM, Neilson EG. Antipyretics: mechanisms of action and clinical use in fever suppression. Am J Med. 2001;111(4):304-315.
16. Lee WM. Acetaminophen (APAP) hepatotoxicity - isn't it time for APAP to go away? J Hepatol. 2017;67(6):1324-1331.