Proceedings of the closed round table and Italian Consensus on clinical appropriateness in oral medicine and oral surgery – Part II

Giuseppina Campisi1*, Giacomo Oteri2, SIPMO study group3, SIdCO study group4 1Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy 2Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy 3Study group for SIPMO, Foggia, Italy 4Italian Society of Odontostomatological Surgery (SIdCO), Rome, Italy *campisi@odonto.unipa.it

Radiographic investigations are a valuable tool for diagnostic formulation in the dental field. However, panoramic radiography should not be considered a screening tool.
In order to provide a correct prescription of dental arch radiographs, a careful physical examination, a complete medical history and the possible acquisition of previous radiographic examinations should always precede the prescription of instrumental investigations. The type of examination (intraoral, OPT, CT) must always be justified by the diagnostic question but also aimed at minimizing the patient's exposure to unnecessary radiant doses.

Oral presentations
The prescription of radiodiagnostic investigations in oral surgery is always preceded by anamnestic collection, by the objective examination and by the possible evaluation of previous radiological examinations. These must be an appropriate tool for completing diagnosis and therapeutic planning.
When he decides to perform a radiodiagnostic examination, the dentist must follow the principles of justification, optimization and dose limits.
Practice at risk of inappropriateness PRESCRIBING radiodiagnostic examinations (RX OPT) as screening tool before oral examination.
Good practice PRESCRIBE radiographic examinations (intraoral, OPT, CT) only with a valid diagnostic question.

PRESCRIPTION OF ANTIBIOTICS
Although it has been shown that antibiotic prophylaxis may play a role in the prevention of infectious complications, such as bacterial endocarditis or dry alveolitis, its impact appears controversial on post-extraction socket healing, pain and functional limitation.
Therefore, it is more appropriate to limit the antibiotic prescriptions to patients in whom transient bacteraemia exposes to a more severe risk of bacterial endocarditis or local infectious complications, such as glycemic decompensation from diabetes mellitus, valvular or other prostheses and immunodeficiency syndromes.
In non-invasive extractive and oral surgery interventions and especially in the absence of specific local and/or systemic risk conditions, antibiotics should not be indiscriminately administered. In any case it is recommended to adopt local peri-operative antiseptic measures. Adequate antibiotic prescription is required in cases of more invasive oral surgery. Moreover the prescription of appropriate antimicrobial agents for the treatment of odontogenic infections is recommended, respecting the indications of the active principle.
5th National and 1st International Symposium

Oral presentations
Practice at risk of inappropriateness PRESCRIBING antibiotic prophylaxis indiscriminately as a routine prescription in patients undergoing dental procedures.
Good practice LIMIT antibiotic prophylaxis prescription to patients whose transient bacteraemia exposes to a severe risk of bacterial endocarditis or local infectious complications and to cases of more invasive oral surgery.

DENTAL CARE DELAY DURING PREGNANCY
Pregnancy is not a contraindication to dental treatment. According to the recommendations for the promotion of oral health in perinatal age of the Ministry of Health, it is possible to adopt specific protocols based on the gestation period and obstetric risk conditions. Diagnostic procedures (including radiography), oral prophylaxis, root planing, endodontic treatments and dental extractions can be performed safely throughout the gestation period. Use exclusively intraoral radiographs, with a low exposure rate and using the long cone technique and the use of Rinn centerers, use collar and protection for the abdomen.
Measures to prevent dental and periodontal diseases are strongly indicated. The ideal period for carrying out routine dental care is indicated between the 14th and 20th week of pregnancy, nevertheless pregnancy is not an absolute contraindication to surgical treatments that have urgent criteria. Emergency treatments should not be delayed but carried out promptly. Only elective surgery procedures should be procrastinated at the end of pregnancy. In accordance with the indications from the gynecological doctor, it is appropriate to adopt specific protocols based on the gestation period and any obstetric risk conditions. Practice at risk of inappropriateness TO DELAY dental care during pregnancy.

Oral presentations
Good practice PROVIDE dental care throughout the gestational period as needed and according to the recommendations of the gynecologist.

PROPHYLACTIC EXTRACTIONS OF THE THIRD LOWER MOLARS
Third lower molars extraction for prophylactic purposes, ie in the absence of signs and symptoms, is not supported by concrete scientific evidence and can unnecessarily expose the patient to risks related to the surgical procedure.
Extraction represents an appropriate intervention in the presence of: inflammatory-infectious, caries and periodontal diseases typical of the third molar and/or of the adjacent element; algico-dysfunctional pathologies related to dental inclusion; orthodontic and prosthetic therapeutic needs.
Anyway, a careful evaluation of the clinical indications for the surgical extraction of the third lower molars and of the possible complications of the procedure is recommended.
In cases of lower molars without immediate indication for surgical extraction, monitoring of clinical conditions with regular control visits is recommended.
Practice at risk of inappropriateness TO routinely EXTRACT the third lower molars.
Good practice EXTRACT the third lower molars in the presence of inflammatory-infectious diseases, caries and periodontal diseases typical of the third molar and / or of the adjacent element, algico-dysfunctional pathologies correlated with dental inclusion, orthodontic and prosthetic therapeutic needs.

DISCONTINUATION OF ANTIPLATELET AGENTS IN ORAL SURGERY PROCEDURES
The intra/postoperative hemorrhagic risk in patients treated with oral antiplatelet agents is much lower than the potential cardiac and vascular complications resulting from treatment discontinuation. In accordance with the recommendations of the European Society of Cardiology, the discontinuation of antiplatelet therapy is contraindicated, especially in patients at high cardiovascular risk, and it is therefore considered more appropriate to manage bleeding with anti-hemorrhagic drugs for local use.
Practice at risk of inappropriateness TO routinely DISCONTINUE antiplatelet agents in oral surgery procedures.
Good practice DO NOT routinely DISCONTINUE antiplatelet agents including dual antiplatelet therapy in minor oral surgery procedures, APPLY anti-hemorrhagic drugs for local use. CONSULT the prescriber in all cases of more invasive oral surgery.