Introduction to Pre-Surgical Preparation

Comprehensive pre-operative evaluation and patient preparation significantly influence surgical outcomes, complication rates, and patient satisfaction. Pre-surgical assessment identifies medical comorbidities, current medications, and patient risk factors that may require modification or special perioperative management. Patient education regarding pre-operative instructions, expected sensations during surgery, and realistic recovery expectations reduces anxiety and improves compliance with post-operative instructions.

This guide addresses evidence-based pre-surgical evaluation and preparation protocols for oral and maxillofacial surgical procedures.

Timing of Pre-Surgical Evaluation

Initial Consultation

Pre-operative evaluation should occur sufficiently before the scheduled surgical date to allow time for:
  • Comprehensive medical history review
  • Identification of medical conditions requiring management
  • Consultation with patient's primary care physician or medical specialists if indicated
  • Lab work or diagnostic studies if needed
  • Medication adjustments or clarifications
Recommended Timeline: 1-2 weeks before elective surgery for healthy patients; earlier evaluation for medically compromised patients or complex surgical procedures.

Pre-Operative Appointment

Scheduling a dedicated pre-operative visit (distinct from surgical procedure day) allows thorough preparation, patient education, and discussion of any remaining concerns.

Medical History Assessment

Comprehensive Medical Review

Critical Medical Conditions Requiring Special Attention: Cardiovascular:
  • Hypertension (increases perioperative bleeding and hemodynamic complications)
  • Coronary artery disease (increased MI risk perioperatively)
  • Atrial fibrillation (stroke risk; anticoagulation management essential)
  • Heart failure (decompensation risk with fluid overload)
  • Recent cardiac events or interventions (<6 months: increased perioperative risk)
Pulmonary:
  • Asthma (perioperative bronchospasm risk)
  • Chronic obstructive pulmonary disease (respiratory depression risk, difficulty managing airways)
  • Sleep apnea (respiratory depression risk with sedation/anesthesia)
  • Recent respiratory infections (avoid elective procedures until resolution)
Endocrine:
  • Diabetes mellitus (impaired healing, infection risk, perioperative glucose management)
  • Thyroid disorder (medication interactions, hypothermia/hyperthermia risk)
Renal/Hepatic:
  • Chronic kidney disease (medication dosing adjustments needed)
  • Cirrhosis (coagulopathy, poor healing)
  • Hepatitis C (infection control precautions)
Hematologic:
  • Bleeding disorders (increased perioperative bleeding)
  • Sickle cell disease (tissue necrosis risk, special precautions)
  • Thrombophilia (clotting risk)
Infectious:
  • Hepatitis B or C (infection control precautions)
  • HIV/AIDS (immunosuppression affects healing and infection risk)
  • Tuberculosis (respiratory precautions if active disease)

Allergy Documentation

Drug Allergies: Document specific allergic reactions (rash, anaphylaxis, etc.), not just "allergy." This distinguishes true allergies from adverse effects or intolerances. Clarify:
  • Is penicillin allergy true IgE-mediated reaction or rash?
  • Are NSAIDs contraindicated or just previously ineffective?
Material Allergies:
  • Latex (requires latex-free operatory)
  • Nickel (affects implant selection if applicable)
  • Adhesive materials

Medication Management

Anticoagulation Management

Warfarin (Coumadin): Warfarin inhibits vitamin K-dependent clotting factors. Pre-operative management depends on surgical extent and bleeding risk. Management Strategy:
  • Continue warfarin as prescribed in most cases
  • Check INR within 24 hours of surgery (target 2-3 for most procedures)
  • If INR >4, consider dose adjustment before surgery
  • For minor extractions (minimal bleeding expected): Continue warfarin; use topical hemostatic agents
  • For complex surgical procedures: Consult with prescribing physician regarding perioperative management
Antiplatelet Agents (Aspirin, Clopidogrel, Ticagrelor): Platelet aggregation inhibitors increase bleeding risk. Management varies by indication and surgical complexity. Aspirin:
  • Continue aspirin before and after surgery for most oral procedures
  • Risk of bleeding is minimal with aspirin monotherapy; benefit of continued antiplatelet effect usually outweighs bleeding risk
Clopidogrel (Plavix), Ticagrelor (Brilinta):
  • Continuation usually recommended unless otherwise directed by cardiologist
  • Abrupt discontinuation increases thrombotic event risk (stent thrombosis, MI)
  • Most oral surgeries manageable with continued antiplatelet therapy
  • Use topical hemostatic agents liberally
Direct Oral Anticoagulants (DOAC: Apixaban, Dabigatran, Edoxaban, Rivaroxaban): These newer agents have rapid onset and offset compared to warfarin. Management:
  • For minor surgical procedures: Continue DOAC; use topical hemostatic agents
  • For complex procedures: Timing of dose omission should be coordinated with prescribing physician
  • Document pharmacist or physician consultation regarding perioperative management

Bisphosphonate Management

Oral Bisphosphonates (Alendronate, Risedronate, Ibandronate): Bisphosphonates inhibit osteoclast function. Prolonged use may impair bone healing and increase osteonecrosis risk. Management:
  • Medication history should document duration of bisphosphonate therapy
  • Most oral procedures (simple extractions) carry minimal osteonecrosis risk
  • For complex surgical procedures with extensive bone manipulation, consider brief drug holiday (typically 2-3 months) if clinically appropriateโ€”coordinate with prescribing physician
  • No specific pre-operative intervention required for most patients
Intravenous Bisphosphonates (Zoledronic Acid, Pamidronate): Used for cancer patients and severe osteoporosis. Higher osteonecrosis risk than oral formulations. Management:
  • Obtain detailed history of IV bisphosphonate therapy
  • Consider deferring elective oral surgery in patients receiving active IV bisphosphonate therapy
  • Coordinate with oncologist if patient receiving IV bisphosphonate
  • Dental health optimization before beginning IV therapy reduces surgical necessity

Other Critical Medications

Corticosteroids: Prolonged corticosteroid use impairs healing and immune function. Document dose and duration of therapy. Immunosuppressants: Organ transplant recipients on immunosuppression require prophylactic antibiotics and increased infection precautions. Coordinate with transplant physician. Antibiotics: If patient currently taking antibiotics, note whether prophylactic additional antibiotics are needed or if current therapy provides adequate coverage.

Pre-Operative Instructions

NPO (Nothing by Mouth) Guidelines

Fasting Requirements: Based on anesthetic requirements and planned procedure complexity. For Local Anesthesia Only:
  • No fasting required
  • Light meal acceptable morning of procedure
For IV Sedation:
  • No food for 6 hours before procedure
  • Clear liquids acceptable up to 2-3 hours before procedure
  • Includes chewing gum and cough drops
For General Anesthesia:
  • No food for 8 hours before procedure
  • Clear liquids acceptable up to 2-3 hours before procedure
  • Preoperative medications (with sip of water) acceptable
Rationale: Fasting reduces aspiration risk by decreasing gastric contents. However, excessive fasting causes dehydration and hypoglycemia, particularly problematic in elderly or diabetic patients.

Medication Instructions

Day Before Surgery:
  • Continue all chronic medications as prescribed
  • Diabetes medications: Consult with anesthesia provider regarding morning-of dosing
  • Hypertension medications: Usually continued with small sip of water morning of surgery
Morning of Surgery:
  • Continue essential medications (cardiac, respiratory, seizure) with small sip of water
  • Skip or defer non-essential medications
  • Special consideration for diabetics (may require reduced insulin dose given NPO status)

Pre-Operative Preparation

Clothing:
  • Wear loose, comfortable clothing
  • Avoid tight necklines that restrict access to IV lines or anesthesia equipment
  • Wear low-heeled shoes for procedures involving IV sedation
Hygiene:
  • Brush teeth gently morning of surgery (minimal water swallowing acceptable)
  • Do not wear makeup, nail polish, or jewelry
  • Remove contact lenses, dentures, and hearing aids (provide case for safekeeping)
Transportation:
  • Arrange transportation for procedures involving IV sedation or general anesthesia
  • Patient cannot drive for remainder of day after sedation
  • Plan for responsible adult supervision for 24 hours post-operatively if general anesthesia used

Pre-Operative Checklist

24 Hours Before Surgery:
  • Confirm surgical appointment date/time
  • Review NPO instructions and fasting requirements
  • Arrange transportation
  • Take evening doses of chronic medications as directed
  • Avoid strenuous activity
Morning of Surgery:
  • Shower/bathe
  • Brush teeth gently
  • Dress in comfortable, loose clothing
  • Take pre-operative medications as directed
  • Arrive 15 minutes early for IV placement and final pre-operative assessment

Antibiotic Prophylaxis

Indications for Prophylactic Antibiotics

Patients Requiring Prophylaxis:
  • Cardiac prosthesis or previous endocarditis
  • Complex cyanotic congenital heart disease
  • Cardiac transplantation recipients with valve regurgitation
  • Certain orthopedic implants (typically implants placed <2 years prior)
  • Immunocompromised patients
  • Recent cardiac surgery (<6 months)
Antibiotic Selection: For most oral surgery patients requiring prophylaxis:
  • Amoxicillin 2 g orally 30-60 minutes before procedure (preferred agent)
  • Cephalexin 2 g orally (if non-severe penicillin allergy)
  • Azithromycin 500 mg orally (for penicillin allergy; contraindicated if penicillin anaphylaxis)
  • Clindamycin 600 mg orally (alternative for severe allergy)
Timing:
  • Optimal timing: 30-60 minutes before procedure
  • Can be administered up to 2 hours before procedure if scheduling issues

Anxiety Management and Patient Education

Pre-Operative Anxiety Assessment

Anxiety Risk Factors:
  • Previous negative dental experiences
  • Fear of needles or injections
  • Fear of pain during procedure
  • Claustrophobia or sense of loss of control
  • Distrust of healthcare providers
  • Younger age (teenagers often more anxious than adults)

Anxiety Reduction Strategies

Communication:
  • Detailed discussion of surgical procedure and expected sensations
  • Honest discussion of potential discomfort (pressure vs. pain sensation)
  • Explanation of monitoring equipment and sounds
  • Opportunity for patient questions without time pressure
Familiarization:
  • Tour of operatory for first-time surgical patients
  • Introduction to surgical team members
  • Explanation of anesthetic procedure and onset timeline
Pharmacologic Anxiolysis: For patients with significant anxiety:
  • Pre-operative sedation (oral sedative 30-60 minutes before appointment)
  • Nitrous oxide/oxygen inhalation sedation
  • IV sedation for moderate-to-severe anxiety
  • General anesthesia reserved for extremely anxious patients or those unable to tolerate local anesthesia
Non-Pharmacologic Anxiety Reduction:
  • Deep breathing techniques instruction
  • Relaxation training
  • Music or headphones during procedure
  • Hand signal for "pause" if patient needs brief break
Required Discussion:
  • Nature of surgical procedure
  • Expected benefits and realistic outcomes
  • Material risks and their incidence
  • Alternative treatment options
  • Consequences of no treatment
  • Opportunity for questions
Documentation: Informed consent should be documented in patient record. Written consent forms provide legal protection but require genuine discussion, not merely form-signing.

Setting Realistic Expectations

Expected Outcomes:
  • Recovery timeline with specifics for pain, swelling, and return to normal function
  • Sensations during surgery (pressure, vibration, water spray, suction sounds)
  • Common post-operative symptoms and their expected duration
  • Activity restrictions and timeline for activity progression
Potential Complications:
  • Bleeding and hemostasis timeline
  • Swelling patterns (expected increase days 2-3, then improvement)
  • Dry socket risk factors
  • Infection symptoms and prevention
  • Sensory alterations (temporary or persistent numbness)

Medical Clearance Coordination

When to Consult with Physicians

Uncontrolled Hypertension: Blood pressure >180 systolic or >110 diastolic significantly increases perioperative bleeding and cardiovascular events. Consult with primary care physician for preoperative optimization. Recent Cardiac Events: Recent MI, cardiac intervention, or unstable angina requires cardiology consultation. Most surgeons defer elective oral surgery for 6 months post-MI or intervention to allow healing. Poorly Controlled Diabetes: HbA1c >8% suggests hyperglycemia and increased infection/healing impairment risk. Consult with endocrinologist regarding perioperative glucose management. Chronic Kidney Disease: Medication dosing adjustments may be necessary. Coordinate with nephrologist regarding perioperative management. Active Infection: Defer elective procedures until infection resolves. Prophylactic antibiotics do not treat active infection adequately.

Pre-Operative Lab Work

Routine Assessment

Most healthy patients undergoing minor oral surgery require no laboratory studies. However, consider pre-operative labs for:

Age >65 Years:
  • Complete blood count (CBC)
  • Basic metabolic panel (BMP)
  • Coagulation studies (PT/INR, PTT) if on anticoagulation
Significant Medical History:
  • Cardiac disease: EKG, BNP as indicated by cardiologist
  • Diabetes: Fasting glucose, HbA1c if not recently checked
  • Renal disease: Creatinine, BUN, electrolytes
  • Liver disease: Liver function tests
  • Bleeding history: CBC with differential, PT/INR, PTT
Current Medications:
  • Anticoagulation: PT/INR or other clotting studies
  • Corticosteroids: May check glucose if concern for steroid-induced hyperglycemia

Day-Before Preparation

Phone Call to Patient: Call or send message 24 hours before surgery reminding patient of:
  • NPO requirements and fasting start time
  • Medication instructions
  • Time to arrive for appointment
  • What to bring (insurance card, photo ID)
  • Contact number if questions arise
  • Parking and check-in information
This Contact: Improves compliance, reduces anxiety, and provides opportunity to identify last-minute concerns or schedule changes.

Conclusion

Comprehensive pre-operative evaluation and patient preparation optimize surgical outcomes and patient satisfaction. Detailed medical history assessment identifies comorbidities and medications requiring special perioperative management. Clear pre-operative instructions regarding fasting, medication management, and transportation ensure patient safety. Appropriate antibiotic prophylaxis prevents infective endocarditis in high-risk patients. Patient education regarding the surgical procedure, expected sensations, realistic recovery expectations, and anxiety management reduces fear and improves compliance. Coordination with the patient's primary care physician and medical specialists ensures optimal management of complex medical conditions. Thorough pre-operative preparation establishes the foundation for successful surgical outcomes.