Risks versus Benefits Analysis: A Useful Patient Education Tool for the Oral Surgeon

Decision makers in the business world often are faced with multiple alternatives that require the use of information to assist in reducing the uncertainty inherent in the decision-making process and to facilitate the application of professional judgment. Indeed, information is said to be decision useful when it aids in reducing the uncertainty facing the decision maker.

A cost–benefit analysis often is used in making business decisions. Such an analysis involves identification and quantification of the costs associated with a decision alternative, as well as identification and quantification of the benefits associated with a decision alternative, and then a calculation of the net benefit (benefits minus costs) of the alternative. The final step in the decision making process is to apply a decision rule of selection to that decision alternative with the greatest net benefit.

This cost–benefit approach to decision-making is a standard subject of study taught in managerial accounting and managerial economics courses in business schools. In such analyses, the decision-maker identifies the costs and benefits that are relevant to the decision-making process, where relevant costs and benefits are defined as those that differ between/among decision alternatives.

The objective of this article is to demonstrate how the oral and maxillofacial surgeon (OMS) may apply this cost–benefit analysis approach to surgical procedures that she or he is considering for the patient and to use this approach as a patient education tool in facilitating the proper treatment for the patient. In this setting, we refer to costs using the more clinical term “risks” that the patient faces with a particular surgical procedure. Furthermore, unlike the business decision setting, where the costs and benefits are most frequently subject to financial quantification, the risks and benefits associated with surgical procedures contemplated by the OMS are not subject to such quantification and, therefore, must be framed in qualitative terms and contexts. However, despite such a limitation, this tool of analysis still facilitates patient education by providing a written analysis in understandable terms that enable the patient and the OMS to determine the proper course of action.

For our study, we determined the most frequently performed oral surgery procedures at our institution. We then attempted to make an exhaustive listing of the risks and benefits associated with each of these procedures with the goal of providing OMSs with a helpful patient education tool for their practice and equipping them with an analytical method that will enable them to apply it to other surgical procedures not included here.

Objective

Our objective was to develop risk–benefit profiles for the most common procedures performed by the OMS. This information can then be used in brochures and on OMS department websites to facilitate patient decision-making and educate patients, helping to relieve anxiety associated with unknown outcomes.

Patient education has a high level of importance when preparing the oral and maxillofacial surgery patient preoperatively, both for addressing expectations and avoiding litigation in the future if unexpected complications arise.(1) The literature supports the idea that patient education programs can lower recalled pain and anxiety for the patient undergoing dental extraction patient, with a possible result of savings in the cost of healthcare for the patients, insurance providers, and healthcare providers because fewer appointments, medications, and diagnostic tools are required.(2) The cost–benefit analysis has applications in the health sciences (e.g., medicine, dentistry) for educating patients about the risk–benefit tradeoffs inherent in different medical and surgical procedures, as well as medications. The tool is specifically helpful to the OMS as a method of patient education when the patient must decide about having a specific procedure performed or choosing among alternative treatment procedures.

Discussion of Risks and Benefits

The OMS’ surgical repertoire is widely varied, depending on the individual’s education, demeanor, and market demand. However, certain procedures are more commonly provided by this branch of surgery. The services most often provided by our institution in recent years can be categorized into four groups: nonsurgical dental extractions; surgical dental extractions; dental implants; and outpatient sedation. This set of procedures appears to be common across a large number of oral surgery practices.

All invasive procedures have inherent risks and benefits. These risks are not independent, but, rather, are influenced by multiple factors, including systemic disease, age, environment, and more. The provider’s objective is to assess all pertinent data and provide options and information to the patient for better decision-making regarding her or his surgical choices.

Risks and Benefits of Dental Extractions

Extraction of teeth is necessary for a variety of reasons, including, but not limited to, infections, neoplasms, and facilitation of orthodontic treatment. Patient needs drive the choice to perform this procedure.

One of the benefits of tooth extraction is the ability to remove diseased teeth from the oral cavity. In a study by Sen et al.,(3) the prevalence of untreated dental caries in one population was 64.6%. The prevalence of clinical complications of dental caries in the same study was 17.9 %. The objective of dentistry is to prolong the life of the dentition and to provide care that creates the best oral and systemic health. There are also aesthetic considerations. In some cases, for example, dental extractions are required for orthodontic treatment. The ability to provide dental arch space for the orthodontist to align and adjust both the occlusion and the appearance of the dentition can be imperative in creating adequate dental health, aesthetics, and function.

Complications of dental extractions include postoperative bleeding (0–1.7%)(4); postoperative infection (8.48–16.55%)(5); alveolar osteitis (0.5–37.5%)(6); oroantral communication (3.1%)(7); osteonecrosis (13.1% for high-risk patients)(8); and inadvertent selection of the wrong site (0.025%–0.046%)(9). Multiple factors play a role in evaluating these risks. For example, postoperative bleeding is directly influenced by the choice of single versus dual antiplatelet therapy. A study by Bajkin and colleagues(4) of 160 dental extraction patients showed that 1.7% of patients experienced postoperative bleeding complications when on dual antiplatelet therapy. Oroantral communication has been demonstrated to be influenced by tooth position. Hasegawa et al.(7) demonstrated that performance of an incision, mesioangular tooth position, and significant superimposition of the maxillary posterior teeth with the sinus floor are identifiable as risk factors with significant association with oroantral perforation.

Surgical tooth extractions typically involve impacted teeth. Although most asymptomatic third molar extractions are for prophylactic reasons related to pathology, physiologic space maintenance, and possible trauma to other teeth, removal of impacted teeth also may have orthodontic indications, including molar distalization(10) and preparation for orthognathic surgery.(11)

All of the aforementioned dental extraction complications have to be considered with regard to impacted teeth as well, and many of these complications increase in incidence when the teeth are impacted. Extraction of impacted teeth further increases the potential risk profile. Obvious anatomic limitations, bone removal, and the necessity for development of a soft tissue flap (5%–35% dehiscence)(12) increase the likelihood of complications. One must now give much more consideration to the possibility of nerve damage, with a paresthesia or anesthesia rate of 0.1% to 23% for the lingual nerve and 0.4% to 13.4 % for the inferior alveolar nerve.(13-15) Bataineh et al.(13) demonstrated a relationship of increased paresthesia of the lingual and inferior alveolar nerves associated with the elevation of lingual flaps and the experience of the operator, respectively.

Risks and Benefits of Dental Implants

Endosseous dental implants have provided the dental community with a reliable way to provide a foundation for prosthetic restorations in the absence of an existing dentition. Implants are used for single restorations as well as attachments for removal prosthetics. Radvar et al.(16) studied the bone loss of patients with and without endosseous dental implants. They found noted improvement in bone retention in all vectors in the implant-placement group. This can be attributed to microstresses placed on the alveolar bone that mimic those of the natural dentition.

Placement of dental implants provides similar risks to dental extractions, with a few notable differences. Unique risks of placing dental implants include hardware failure (5%)(17), sinusitis (4.3%)(18), and peri-implantitis (4.5%)(7). Poli et al.(17) studied 103 patients who underwent implant placement: of those, 41.1% showed signs of peri-implant mucositis, and 4.5% showed signs of peri-implantitis. Occurrence of complications correlated with age over 65, patient adherence to hygiene recalls, and the presence of plaque. Other risk factors that increase the incidence of complications include diabetes mellitus, tobacco use, malnutrition, and poor oral hygiene.(17)

Risks and Benefits of General Anesthesia

One of the greatest tools available to the OMS is the ability to provide anesthesia for outpatient surgical procedures. Anesthesia allows the anxious patient to avoid stress, and it allows the surgeon to provide a better-controlled surgical environment. Risks of anesthesia are diverse and can be fatal if not addressed appropriately. Risks include vomiting, with or without aspiration (<0.3%); prolonged emergence (0.2%); onset of cardiac dysrhythmias (<0.1%); syncope; seizure (0.1%); laryngospasm (<0.1%); bronchospasm (<0.1%); and peripheral vascular injury (0.1%).(19) Inverso et al.(19) reviewed 29,548 cases and found that the incidence of all anesthesia complications was 0.5% for moderate sedation and 0.9% for deep/general sedation. These risks also are closely associated with patient age, duration of sedation, and the patient’s physical condition.

Other Applications

Other potential applications of risk–benefit analysis profiles are possible. We suggest the use of these and other comparisons as an online patient education tool in other departments in dental and medical schools for assessment of different procedures and medications, especially when multiple choices are available.

References

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4. Bajkin B, Urosevic I, Stankov K, Petrovic B, Bajkin IA. Dental extractions and risk of bleeding in patients taking single and dual antiplatelet treatment. Br J Oral Maxillofac Surg. 2015;53(1):39-43.

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8. Bodem J, Kargus S, Eckstein S, et al. Incidence of bisphosphonate-related osteonecrosis of the jaw in high-risk patients undergoing surgical tooth extraction. J Cranio-Maxillofac Surg. 2015;43:510-514.

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13. Bataineh A. Sensory nerve impairment following mandibular third molar surgery. J Oral Maxillofac Surg. 2001;59:1012-1017.

14. Miura K, Kino K, Shibuya T, Hirata Y, et al. Nerve paralysis after third molar extraction [in Japanese]. Kokubyo Gakkai Zasshi. 1998;65(1):1-5.

15. Brann C, Brickley M, Shapherd J. Factors influencing nerve damage during lower third molar surgery. Br Dent J. 1999;186:514-516.

16. Radvar M, Fatemi K, Abrishamchi R, Moeintaghavi A, Mohammadzade S. Dimensional changes of hard and soft tissue after immediate implantation in comparison with conventional tooth extraction. Bangladesh Journal of Medical Science. 2016;15:335-342.

17. Poli P, Beretta M, Battista Grossi G, Maiorana C. Risk indicators related to peri-implant disease: an observational retrospective cohort study. J Periodontal Implant Sci. 2016;46:266-276.

18. Chirila L, Rotaru C, Filipov I, Sandulescu M. Management of acute maxillary sinusitis after sinus bone grafting procedures with simultaneous dental implants placement- a retrospective study. BMC Infect Dis. 2016;16:94.

19. Inverso G, Dodson T, Gonzalez M, Chuang S. Complications of moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction. J Oral Maxillofac Surg. 2016;74:474-479.