Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 18  |  Issue : 1  |  Page : 33-37

Warm saline mouth rinse instructions after dental extractions: How well do patients comply?


Department of Dental Surgery, Oral and Maxillofacial Unit, University of Calabar Teaching Hospital, Calabar, Nigeria

Date of Web Publication1-Mar-2016

Correspondence Address:
O D Osunde
Department of Dental Surgery, Oral and Maxillofacial Unit, University of Calabar Teaching Hospital, Calabar
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2276-7096.172104

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  Abstract 

Background: The study evaluated compliance with warm saline rinse instruction, the factors militating against it and its association with postoperative complications after dental extractions.
Materials and Methods: A prospective study of all consecutive patients 16 years and above who had dental extraction at the dental clinic of our institution over a 1-year period was undertaken. The patients were reviewed at day 3, 7, 11, 15, and 30 postextractions to evaluate for compliance with warm saline rinse instructions. The information obtained included sociodemographics, compliance, reasons for noncompliance, and complications. The collected data were analyzed using Statistical Package for Social Sciences (SPSS) version 13. The results were presented as frequencies, percentages, mean and standard deviations (SD), and cross tabulations as appropriate. Statistical significance was set at P < 0.05.
Results: Of the 220 patients who met the inclusion criteria, male accounted for 127 (57.7%) while female were represented by 93 (42.3%) giving a male to female ratio of 1.4:1. The ages ranged from 18 to 73 years, mean (SD) 32.2 (9.84) years. Less than half (n = 103; 46.8%) of them complied fully with the instructions. The majority of the noncompliant subjects were able to gargle twice daily (n = 84; 71.8%) and the most frequent number days gargled was 5 days (n = 48; 41%). The most commonly observed reason for noncompliance was the participants' nature of work (n = 36; 30.8%). A total of 17 (7.7%) subjects developed alveolar osteitis and this was significantly more in the noncompliant subjects (χ2 = 9.09; P = 0.003). Those who gargled twice or thrice daily had significantly less alveolar osteitis compared to those that gargled at lower frequencies (χ2 = 23.88; P = 0.0001).
Conclusion: Patients' nature of the occupation, educational activities, and too high a dosing frequency are some of the factors militating against compliance with warm saline rinse instructions.

Keywords: Compliance, warm saline rinse, instructions


How to cite this article:
Osunde O D, Bassey G O, Anyanechi C E. Warm saline mouth rinse instructions after dental extractions: How well do patients comply?. J Med Trop 2016;18:33-7

How to cite this URL:
Osunde O D, Bassey G O, Anyanechi C E. Warm saline mouth rinse instructions after dental extractions: How well do patients comply?. J Med Trop [serial online] 2016 [cited 2019 Aug 20];18:33-7. Available from: http://www.jmedtropics.org/text.asp?2016/18/1/33/172104


  Introduction Top


Warm saline rinse is commonly recommended by dentists to patients after dental extractions. The patients are usually instructed to gargle before and after every meal with frequencies ranging from 6 to 10 times daily.[1],[2] The beneficial effect of warm saline rinse instructions has been reported to include smooth postextraction healing, as well as having a soothing effect, on the extraction sockets. In spite of the acclaimed benefits, anecdotal evidence has shown that compliance, defined as an act of adhering to a prescribed treatment regimen [3] could be difficult for some patients due to the recommended high daily frequency of warm saline rinse instructions. A recent evidenced-based study on the beneficial effect of warm saline mouth gargle in patients who had dental extractions has suggested better compliance with a twice daily regimen than the conventional 6–10 times regimen.[2] This randomized study was however from the surgeon's perspective and did not reflect the patients' opinion about the use of warm saline rinse.

Recently, there has been a paradigm shift in measurements of treatment outcome, from the doctors' perspective to those of the patients and this is gradually creeping into the practice of dentistry as evidenced by the several oral health-related quality of life studies.[4],[5],[6] Some reports have found a strong association between compliance with recommended therapy and quality of life of affected patients.[7],[8] Although the medical literature is replete with published reports on compliance to therapeutic regimen,[3],[8],[9],[10] the dental literature is sparse on this subject. In Nigeria, the few studies that evaluated the level of compliance with warm saline rinse instructions after dental extractions only focused on the outcome of noncompliance, especially as it affects postextraction alveolar osteitis.[1],[2],[11] The authors neither considered the reasons for noncompliance nor factors that encourage compliance.

The present study examines patients' perception about the use of warm saline rinse as a postextraction medicament, the level of compliance and factors militating against compliance among patients undergoing dental extractions in a Nigerian teaching hospital.


  Materials and Methods Top


This was a prospective study of all consecutive patients who had a routine dental extraction, using extraction forceps, at the Dental and Maxillofacial Clinic of University of Calabar Teaching Hospital, Calabar over a 12-month period. The selected subjects were nonsmokers and had no previous history of oral contraceptive use. The extractions were done by the same Surgeon and in the same operating environment. At the end of the procedure, the patients were prescribed the same antibiotics and analgesic. They were also given instructions on warm saline rinse by the same dental surgery assistant. All patients were asked to gargle before and after every meal up to a frequency of 8 times daily for 1-week. The patients were recalled on day 3, 7, 11, 15, and 30 postextractions to evaluate for compliance with the warm saline rinse instructions and postoperative complaints. The information obtained included age, gender, occupation, educational level, marital status, whether or not the patient complied with the instruction, as well as reasons unable to comply, in case of noncompliance. The level of compliance was measured by strict adherence to the warm saline instructions both in the required daily frequencies and for the prescribed number of days. A default in either of the instruction or both was recorded as noncompliant. All the collected information was recorded in a self-administered questionnaire.

The collected data were analyzed using Statistical Package for Statistical Package for Social Sciences (SPSS) Version 13, Chicago, IL, USA. The results were presented as frequencies, percentages, mean and standard deviations (SD), and cross tabulations as appropriate. Statistical significance was set at P < 0.05.


  Results Top


Over the study period, 232 patients had extractions done but only 220 patients who met the inclusion criteria and kept up with the postextractions follow-up visits at the clinic completed the questionnaire. Of these, male accounted for 127 (57.7%) while the female was represented by 93 (42.3%) giving a male to female ratio of 1.4:1. The ages ranged from 18 to 73 years, mean (SD) 32.2 (9.84) years. The occupational distribution of the participants according to gender is shown in [Table 1]. The bulk of the participants was students (n = 79; 35.9%) and civil servants (n = 76; 34.5%). Of the 220 participants, 103 (46.8%) of them complied fully with the instructions. The remaining 117 (53.2%) were not compliant with the instructions. Among the noncompliant, majority of the subjects were able to gargle twice daily (n = 84; 71.8%) and the most frequent number days gargled were 5 days (n = 48; 41%) followed by 4 days (n = 38; 32.5%) [Table 2]. The most commonly observed reason for noncompliance was the participants' nature of work (n = 36; 30.8%) followed by “embarking on a journey” at any day within 1-week postextraction (n = 30; 25.6%) [Table 3]. Other reasons for noncompliance are shown in [Table 3]. A total of 17 (7.7%) cases developed alveolar osteitis within the review period, and the sockets were fully healed with no other observed complications after the last review at 1-month postextraction.
Table 1: Distribution of the participants according to gender and occupation

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Table 2: Highest daily frequency and maximum number of days gargled with warm saline by noncompliant subjects (n=117)

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Table 3: Reasons for noncompliance with warm saline rinse instructions (n=117)

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Overall, the noncompliant subjects had significantly more alveolar osteitis than those who complied fully with the warm saline instructions (15 vs. 2; χ2 = 9.09; P = 0.003). Among the noncompliant subjects, those who gargled twice or thrice daily had significantly less alveolar osteitis compared to those that gargled at lower frequencies (χ2 = 23.88; P = 0.0001) [Table 4]. Similarly, those who gargled for a duration of 3 days or more had significantly fewer number of alveolar ostetitis than those that gargle below 3 days (χ2 = 41.77; P = 0.0001) [Table 4].
Table 4: Distribution of postextraction alveolar osteitis according to the highest frequency gargled daily and the maximum number days gargled

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  Discussion Top


There is yet no universally agreed daily dosing frequency and optimal duration of use of warm saline mouth rinse instructions for maximal benefit.[2],[12],[13] In the present study, the patients were instructed to gargle 8 times daily for 1-week. Less than half (46.8%) of the patients who received instructions on warm saline rinse after dental extractions actually complied with the instructions both in terms of the recommended frequency and for the required number of days. This was much lower than the level of compliance obtained by Adebayo and Dairo [11] and the result of Akpata et al.[1] in a recent study. The present study however differs slightly from the ones cited above with regard to the methodology. While the focus of this study was on compliance to warm saline rinse instructions alone, the other authors evaluated compliance to postoperative follow-up, prescribed medications, as well as to warm saline rinse instructions.

Among the reasons adduced for noncompliance were the patients' nature of work, educational activities, and “having to embark on a journey a day or so after the procedures.” In formulating the instructions on warm saline mouth rinse, the daily activities of the recipients of such instructions were never considered and the practicability of such instructions was similarly overlooked. Asking patients to gargle before and after every meal and for a frequency as high as 6–10 times every day may be difficult to achieve. This was corroborated by the observation that about 13.7% of the respondents could not comply because they felt that the warm saline instructions were too cumbersome. About 89% of the cases gargled for a duration of 3–5 days out of the required minimum of 7 days. Studies have shown that inflammatory changes following surgical extraction of impacted lower third molar peaks at a variable period of 48–72 h postoperatively.[14],[15] This may result in less postoperative pain after about 3 days postoperation. This was supported by the finding that about 9.4% of the participants in the present study discontinued with the gargling instructions when they perceived there was no more pain from the postextraction sockets.

A critical analysis of the results of this study revealed that among the defaulters, majority of them (over 70%) resorted to a twice daily regimen, even though none of the subjects were instructed to gargle twice daily. This was probably a matter of convenience, as it may be easier for a subject, irrespective of its work schedule or other routine daily activity, to gargle first thing before leaving home in the morning, and then later in the evening when he or she returns. This observation supports the earlier report of a randomized trial that found a twice daily regimen of warm saline rinse comparable to the conventionally recommended higher frequencies with regard to the prevention of alveolar osteitis.[2]

In general, factors affecting noncompliance to therapeutic regimen has been categorized into patient-centered factors, therapy-related factors, social and economic factors, healthcare system factors, and disease factors.[16] Although not all of these factors may be implicated in patients' noncompliance to warm saline rinse instructions, patient-centered factors such as age and therapy-related factors may certainly play a role in patients' compliance to postextraction warm saline instruction. Compliance has been reported to increase with age,[17],[18] although few studies found a lower compliance among elderly patients because of decreased psychomotor functions and memory loss.[19],[20] It has been estimated that compliance rate for long-term therapy lies between 40% and 50%, and between 70% and 80% for short-term therapy.[21] Although the result of Akpata et al.,[1] who observed 82.9% compliance with postextraction instructions, supports the assertion, our result was well below the observed compliance rate for short-term therapies. Although warm saline rinse is a short-term therapy, too frequent rate of dosing may increase the complexity and thus may be too cumbersome for some patients. Too high a daily dosing frequency of medications has been reported to decrease patients' compliance to such prescriptions.[10] Thus, the prescribed frequency of gargling for warm saline rinse instructions, which may be up to 10 times daily may hinder compliance to the therapy among some patients.

The use of warm rinse following dental extractions has been shown to reduce the incidence of alveolar osteitis which sometimes occurs as a complication of exodontia.[1],[2] In the present study, alveolar osteitis was observed in 17 cases, with a greater proportion occurring among the noncompliant patients. This supports the result obtained by Akpata et al.[1] who found less frequency of alveolar osteitis in patients who comply with postextraction instructions compared to those that defaulted. Gargling twice or 3 times daily for a minimum period of 3 days confers protection against the development of postextraction alveolar osteitis. The findings of the present study have again demonstrated the superfluity in asking a patient to gargle before and after every meal at a frequency as high as 6–14 times a day following dental extractions.


  Conclusion Top


Patients' daily activities such as nature of occupation and educational activities are some of the factors militating against compliance with warm saline rinse instructions which are often cumbersome because of the very high and unrealistic “dosing” frequency. A twice daily regimen for a period of 3 days or more enhances smooth and uncomplicated postextraction healing and is a more convenient regimen.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Akpata O, Omoregie OF, Owotade F. Alveolar osteitis: Patients' compliance to post-extraction instructions following extraction of molar teeth. Niger Med J 2013;54:335-8.  Back to cited text no. 1
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Adebayo ET, Dairo M. Patients' compliance with instructions after oral surgery in Nigeria. J Community Med Prim Health Care 2005;38:38-44.  Back to cited text no. 11
    
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Caso A, Hung LK, Beirne OR. Prevention of alveolar osteitis with chlorhexidine: A meta-analytic review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:155-9.  Back to cited text no. 13
    
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Osunde OD, Saheeb BD, Adebola RA. Comparative study of effect of single and multiple suture techniques on inflammatory complications after third molar surgery. J Oral Maxillofac Surg 2011;69:971-6.  Back to cited text no. 14
    
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Pasqualini D, Cocero N, Castella A, Mela L, Bracco P. Primary and secondary closure of the surgical wound after removal of impacted mandibular third molars: A comparative study. Int J Oral Maxillofac Surg 2005;34:52-7.  Back to cited text no. 15
    
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Jin J, Sklar GE, Min Sen Oh V, Chuen Li S. Factors affecting therapeutic compliance: A review from the patient's perspective. Ther Clin Risk Manag 2008;4:269-86.  Back to cited text no. 16
    
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Senior V, Marteau TM, Weinman J. Genetic Risk Assessment for FH Trial (GRAFT) Study Group. Self-reported adherence to cholesterol-lowering medication in patients with familial hypercholesterolaemia: The role of illness perceptions. Cardiovasc Drugs Ther 2004;18:475-81.  Back to cited text no. 17
    
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Kim YS, Sunwoo S, Lee HR, Lee KM, Park YW, Shin HC, et al. Determinants of non-compliance with lipid-lowering therapy in hyperlipidemic patients. Pharmacoepidemiol Drug Saf 2002;11:593-600.  Back to cited text no. 18
    
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Balbay O, Annakkaya AN, Arbak P, Bilgin C, Erbas M. Which patients are able to adhere to tuberculosis treatment? A study in a rural area in the northwest part of Turkey. Jpn J Infect Dis 2005;58:152-8.  Back to cited text no. 19
    
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Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA 2002;288:455-61.  Back to cited text no. 20
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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