Adequate postoperative instructions and good patient compliance are important to achieve positive clinical results and minimize complications

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227 PATIENT COMPLIANCE TOWARDS POSTOPERATIVE CARE FOLLOWING

SURGICAL EXTRACTION OF MANDIBULAR THIRD MOLAR: A PILOT STUDY John Chong Keat Hon (Corresponding author)

Faculty of Dentistry, Universiti Sains Islam Malaysia, 55100 Pandan Indah, Kuala Lumpur,

Malaysia.

Tel: 0108837158 E-Mail: drjohn@usim.edu.my Aimi Fathonah Binti Muhammad Sufian

Malaysia.

Tel: 0134649455 E-Mail: aimifathonah2019@gmail.com Noor Aina Basirah Binti Abd Rahman

Malaysia.

Tel: 0148127671 E-Mail: noorainabasirah@gmail.com Nadia Binti Halib

Malaysia.

Tel: 0129891281 E-Mail: nadia.halib@usim.edu.my Noor Izyan Mohamad Adnan

Faculty of Computer and Mathematical Sciences, Universiti Teknologi MARA Pahang, 26400 Jengka, Pahang, Malaysia.

Tel: 0193430220 E-Mail: noorizyan@uitm.edu.my

Abstract

Surgical extraction of the mandibular third molar is the most common surgical procedure in oral surgery clinic. Adequate postoperative instructions and good patient compliance are important to achieve positive clinical results and minimize complications. The objectives of the study were to determine the percentage of patient compliance towards postoperative care (POC) given by dental clinicians at USIM polyclinic and to identify the association between factors influencing patient compliance towards POC following the surgical extraction of mandibular third molar at USIM polyclinic and patient’s demographic characteristics. A set of questionnaires was disseminated to 16 patients which assessed the patients’ perception on swelling, bleeding, pain, diet, oral hygiene care, medication compliance, clinician’s factors, and patient’s level of understanding and their attitude towards POC. The percentages of patient compliance were represented by descriptive statistics, while the

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228 identification of possible factors influencing patient compliance were obtained by performing a Fisher Exact test. All factors give a high percentage of compliance which is more than 60% for all demographic characteristics. There is no association between all factors and demographic characteristics (p-value>0.05). Patient’s compliance is good and demographic characteristics do not appear to be key factors that ensure patient compliance towards POC following surgical extraction of the mandibular third molar.

Keywords: Patient Compliance, Post-Operative Care, Surgical Extraction, Mandibular Third Molar

Introduction

Extraction of mandibular third molar is the most common oral surgical procedure in dental clinic.⁵⁹ The patient satisfaction experience following surgical removal of third molar procedure is becoming a wellbeing concern.⁶⁰ Postoperatively experiences that developed after surgical removal of third molar can be categorised as immediate postoperatively tissue reactions and complication. General immediate postoperative tissue reactions are referred to swelling, pain, limited mouth (trismus) and difficulty on swallowing (dysphagia).⁶¹ Other common complications of surgical extraction of impacted lower third molar reported by other authors were lingual or inferior alveolar nerve paraesthesia, haemorrhage (bleeding), infection and dry socket (alveolar osteitis).^62,63 These immediate complications usually occur on the first three days after surgical procedure and can normally affect the patient quality of life because surgery can induce tissue trauma that produce inflammatory response.⁶⁴ Therefore, it is recommended to provide patient with a clear postoperative instructions to minimize the complications that could potentially affect the patient comfort and quality of life.⁶⁵

59 Alvira-Gonzalez, J., Gay-Escoda, C. (2014). Compliance of Post-Operative Instructions Following the Surgical Extraction of Impacted Lower Third Molars: A Randomized Clinical Trial. Medicina Oral Patología Oral Y Cirugia Bucal, 20(2):E224–E230. https://doi.org/10.4317/medoral.20121.

60 Ruta, D. A., Bissias, E., Ogston, S., Ogden, G. R. (2000). Assessing Health Outcomes After Extraction of Third Molars: The Postoperative Symptom Severity (Posse) Scale. British Journal of Oral and

Maxillofacial Surgery, 38(5):480–487.https://doi.org/10.1054/bjom.2000.0339.

61 Bello, S. A., Adeyemo, W. L., Bamgbose, B. O., Obi, E. V., & Adeyinka, A. A. (2011). Effect of Age, Impaction Types and Operative Time On Inflammatory Tissue Reactions Following Lower Third Molar Surgery. Head & Face Medicine, 7(1). https://doi.org/10.1186/1746-160x-7-8

62 Deliverska, E. G., Petkova, M. (2016). Complications After Extraction of Impacted Third Molars - Literature Review. Journal of IMAB - Annual Proceeding (Scientific Papers), 22(3):1202–1211.

https://doi.org/10.5272/jimab.2016223.1202.

63 Bui, C. H., Seldin, E. B., Dodson, T. B. (2003). Types, Frequencies, And Risk Factors for Complications After Third Molar Extraction. Journal of Oral and Maxillofacial Surgery, 61(12):1379–1389.

https://doi.org/10.1016/j.joms.2003.04.001

64 McGrath, C., Comfort, M. B., Lo, E. C. M., Luo, Y. (2003). Changes in Life Quality Following Third Molar Surgery – The Immediate Postoperative Period. British Dental Journal, 194(5):265–268.

https://doi.org/10.1038/sj.bdj.4809930.

65 Matijević, M., Uzarević, Z., Gvozdić, V., Mikelić, V. M., Leović, D., Macan, D. (2013). The Influence of Surgical Experience, Type of Instructions Given to Patients and Patient Sex on Postoperative Pain Intensity Following Lower Wisdom Tooth Surgery. Acta Clinica Croatica, 52(1):23–28.

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229 Postoperative instruction is the instruction given to patients after surgical procedures.⁶⁶ The manner of postoperative instruction presented to patient in either verbal and/ or written form could influence the patient understanding and compliance to postoperative instructions.⁶⁷ Verbal postoperative instruction delivered in oral form is considered the most common and also the traditional mode of postoperative instruction presentation to patient.⁶⁸ The advantage of verbal postoperative instruction is it being direct and cost-effective. However, verbal postoperative instructions to patient were reported to be neither perceived well nor difficulty to recall after surgery and it was related to clinician factor.⁸ Therefore, it is very important to choose an appropriate mode of postoperative instructions presentation. Failure to do so might affect the patient’s understanding, satisfaction, compliance and increase postoperative complications/ morbidity and in certain cases, patient complaints and even allegation.^7,8

Patient compliance is defined as patient cooperation and adherence to clinical prescriptions that lead to a patient wellbeing and successful treatment.⁶⁹ Several research studies conducted in clinical, drug and nursing fields report that noncompliance or poor compliance patient is recognised as a trouble to healthcare system because their actions were greatly associated with funds and resources wasting.¹¹

The term “compliance” by World Health Organization definition is the “extend of which the patient will take a medication, follow proposals on lifestyles or nutrition as well as adhere to the doctor’s advices or instructions”.⁷⁰ Patients that fully cooperative and compliant to the doctor’s instructions will likely to present with satisfactory healing socket during follow up.⁷¹

Active patient cooperation and appropriateness of treatment option by the clinicians are both equally essential to determine the effectiveness of the treatment outcome.¹¹

66 Ekaniyere, E. B., Ifeoma, A. N. (2020). Influence of Post-Operative Instructions on Wound Healing. A Randomized, Single-Blinded Clinical Trial. Iraqi Dental Journal42(1):1-9.

https://doi:10.46466/idj.v42i1.259.

67 Aloy-Prósper, A., Pellicer-Chover, H., Balaguer-Martínez, J., Llamas-Monteagudo, O., Peñarrocha- Diago, M. (2020). Patient Compliance to Postoperative Instructions After Third Molar Surgery Comparing Traditional Verbally and Written Form Versus the Effect of a Postoperative Phone Call Follow-Up A: A Randomized Clinical Study. Journal of Clinical and Experimental Dentistry. 12(10):E909–E915. https://doi.org/10.4317/jced.56680.

68 Johnson, A., Sandford, J. (2005). Written and Verbal Information Versus Verbal Information Only for Patients Being Discharged from Acute Hospital Settings to Home: Systematic Review. Health Education Research, 20(4):423–429. https://doi.org/10.1093/her/cyg141.

69 Bunzel, B., Laederach-Hofmann, K. (2000). Noncompliance in Organ Transplant Recipients: A Review. Weiner Klinische Wochenschrift, 112(10):423-440.

70 Tachalov, V. V., Orekhova, L. Y., Isaeva, E. R., Kudryavtseva, T. V., Loboda, E. S., Sitkina, E. V. (2018).

Characteristics of Dental Patients Determining Their Compliance Level in Dentistry: Relevance for Predictive, Preventive, And Personalized Medicine. EPMA Journal, 9(4):379–385.

https://doi.org/10.1007/s13167-018-0152-8

71 Alsaleh, M. K., Alajlan, S. S., Alateeq, N. F., Alamer, N. S., Alshammary, F., Alhobeira, H. A., Khan, S., Siddiqui, A. A. (2018). Alveolar Osteitis: Patient’s Compliance with Post-Extraction Instructions Following Permanent Teeth Extraction. The Journal of Contemporary Dental Practice, 19(12):1517–

1524.

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230 There are several factors that affect the patient compliance to doctor’s recommendations and prescriptions includes socioeconomic factors (sociocultural level, financial status, age), disease factors (severity of the illness, disease staging, general body debilitating status), treatment factors (therapy complexity, therapy duration, therapy choices, other prescription therapy), healthcare system factors (doctor-patient rapport, doctor’s qualification status, effectiveness of healthcare system, clinical consultation duration, manner of postoperative presentation), and patient factors (dread of undesirable effects, defaulted treatment, unwarranted expectations, carelessness, illnesses information).^1,72,73,74

Till date, there are not much focus in the literature that consider patients’

demographic characteristic including age, gender and educational level influencing the compliance to postoperative instructions or its possible correlation to factors that influence patient compliance. The findings could be able to identify the potential group of patients that might be showing poor postoperative compliance and solutions can be undertaken to overcome the patient poor or non-compliance. Hence, this study was conducted to determine the percentage of patient compliance towards postoperative care given by dental clinicians based on the demographic characteristics and to identify the association between the factors that influence patient compliance towards postoperative care following surgical extraction of mandibular third molar at USIM polyclinic and patient’s demographic characteristics.

Methodology

Study Design and Population

A prospective study of purposive sampling was carried out from August 2020 to January 2021 at Faculty of Dentistry, Universiti Sains Islam Malaysia (USIM). The study population consists of consecutive patients undergone minor oral surgical procedures that is surgical removal of mandibular third molar at the USIM polyclinic between August 2020 to January 2021. Only formal verbal instruction will be given to the patients after treatment. The inclusion criteria are: (1) Patient with American Society of Anaesthesiologists (ASA) classification 1 or 2; (2) Patient that underwent surgical extraction of impacted mandibular third molar (SEIMTM); (3) Malaysian with aged 18 and above; (4) Patient understands either Malay or English languages and able to answer the questionnaires; (5) Patient has electronic devices and internet access to retrieve the questionnaires.

Those who do not meet any of those criteria as well as patients that has mental retardation and psychological disorder, patient that has language barrier or illiterate

72 Isaeva, E. R., Sitkina, E. V., Kudryavtseva, T. V., Loboda, E. S. (2017). Age-Specific Attitudes Regarding Dental Health. EPMA Journal, 8(1):48-49.

73 Volskaya, E. A. (2013). Patient Compliance. Overview of Research Trends. Remedium. Journal About the Russian Market of Medicines and Medical Equipment, 11:6–15.

74 Faheem, Samra. (2017). Patients Compliance and Follow-Up Rate after Tooth Extraction. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), 16(5):115-120.

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231 and repeated patient for removal of other mandibular tooth in the same year will be excluded from the study. Ethics approval was applied and obtained from the Research Ethical Committee, USIM (USIM/JKEP/2020-102).

Sample Selection

All patients undergone surgical removal of third molar at USIM polyclinic between August 2020 to January 2021 will be selected to participate in this study based on the inclusion and exclusion criteria. The sample size in our study was 16 patients with confidence interval 95% and precision set at 5%. Sample size calculation was calculated with Sample Size Calculator Raosoft by using estimation total amount of patients (137) that referred from outpatients to oral surgery specialist clinic and student minor oral surgery clinic from August 2020 to January 2021.

Development of questionnaire to assess the compliance of patient

The questionnaire was distributed to all patients via Google form. The questionnaires consist of three sections which include the demographic items of patients, patient’s compliance towards postoperative care after surgery and factors that affect the patient’s compliance towards post-operative care after surgery. The questionnaire was adopted and modified from a study by Alvira-González and Gay-Escod.¹

Patients were asked to answer the questionnaire in a form of Likert scale questions based on swelling, bleeding, pain, diet, oral hygiene care, others, medication compliance, clinician’s factors, patient’s level of understanding and also patient’s attitude towards postoperative care.

The Likert scale mean ranks for understanding and reviewing of instructions were comparable between the two groups. Patients answered the 46 questions using a Likert scale from 1 to 4, with 4 indicating strongly agree and 1 indicating strongly disagree.

Statistical Analysis

The statistical analysis was carried out using SPSS 20 software (SPSS 20, IBM, Armonk, NY, USA). The distributions and frequencies were examined, and the data was analyzed using descriptive statistics and Fisher Exact Test. For all statistical analysis, a 5% significance level was adopted.

Results

The result section will be discussing on two parts, which are descriptive statistics and Fisher exact test. The descriptive part signifies the demographic characteristics of the patients and their percentage of postoperative instructions compliance to reduce

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232 swelling, reduce bleeding, reduce pain, proper diet, oral hygiene, others and medication categories in bar chart (Figure 1) and frequency table. The Fisher exact test section represents the association between the factors of compliance and demographic characteristics.

Figure 1. Percentage of Demographic Characteristics

The percentage of compliance for seven categories of postoperative instructions by demographic characteristics are represented in Table 1 to 7. This study found that the range of compliance for postoperative instructions to reduce swelling, bleeding and others is between 66% and 100%, and the range of compliance for postoperative instructions to reduce pain, proper diet and oral hygiene is between 80% and 100%.

Nevertheless, there is a low range of compliance for medication category, which is between 33% and 100%. Overall, most items in all categories show satisfying results with the high percentage range of patient compliance that is between 80% and 100%.

According to the results obtained, each category has certain patients from different demographic characteristics that fully complied to all items. Table 1 shows patients who aged from 41 to 50 years old and diploma holders are fully complied with all items in reducing swelling. Based on Table 2, there are 100% compliances for all items in reducing bleeding among female patients, diploma holder patients, and patients aged between 41 to 50 years old give. Table 3 shows that female patients and patients aged from 31 to 50 years old are 100% complied towards all items in reducing pain. Compared to female patients, Table 4 and 5 exhibits that male patients give 100% compliance towards all items in proper diet and oral hygiene categories.

The 100% compliance of all items in proper diet category also can be seen among the degree holder patients. However, the diploma holder patients give 100% compliance

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233 towards all items in oral category. The result of demographic characteristics for 100% compliance towards all items in ‘others’ category is not available in Table 6.

The table also shows that patients aged from 41 to 50 years old gives 0% compliance to one of the items in the category. Moreover, Table 7 shows that the medication category has 100% compliance for all items which is only among patients aged from 41 to 50 years old. It also shows that patients aged from 31 to 40 years old give a low percentage of compliance, which is 33% for one of the items in the category.

Table 1. Percentage of Postoperative Compliance to Swelling by Demographic Characteristics

Table 2. Percentage of Postoperative Compliance to Bleeding by Demographic Characteristics

Table 3. Percentage of Postoperative Compliance to Pain by Demographic Characteristics

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234 Table 4. Percentage of Postoperative Compliance to Diet by Demographic

Characteristics

Table 5. Percentage of Postoperative Compliance to Oral Hygiene Care by Demographic Characteristics

Table 6. Percentage of Postoperative Compliance to Others by Demographic Characteristics

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235 Table 7. Percentage of Postoperative Compliance to Medication by Demographic

Characteristics

Tables 8 to 10 depict the findings for the association between demographic characteristics and factors of the compliance which are clinician, patient’s level of understanding and patients’ attitudes. It can be seen that the p-values for all factors of the compliance are greater than 0.05. This can be deduced that there are no associations between the demographic characteristics and all factors of the compliance.

Table 8. Association between the Clinician Factor Affecting the Patient Compliance and the Demographic Characteristics

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236 Table 9. Association between the Patient Understanding Factor Affecting the Patient

Compliance and the Demographic Characteristics

Table 10. Association between the Patients’ Attitudes Factor Affecting the Patient Compliance and the Demographic Characteristics

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237 Discussion

Factors that influence the speedy recovery of any surgical procedure lies in the patient understanding and compliance to the postoperative instructions. Adequate postoperative instructions have been shown to minimize complications and to have positive clinical results. It was reported that satisfactory patient education on postoperative instructions could increase patient knowledge and subsequently enhance patient satisfaction and minimise the postoperative morbidity.⁷⁵ This patient education incorporates explanation on possible postoperative complications, medications instructions and postoperative wound management.

Several authors suggested that educating patients on postoperative care could minimise the postoperative complications and morbidity, and also expeditated the patient recovery to restore the patient function.⁷⁶ The postoperative instructions for all seven categories in our study give a good and high percentage of compliance with most of the items in each category recorded 80% to 100%.

75 Atchison, K. A., Black, E. E., Leathers, R., Belin, T. R., Abrego, M., Gironda, M. W., Wong, D., Shetty, V., Dermartirosian, C. (2005). A Qualitative Report of Patient Problems and Postoperative Instructions. Journal of Oral and Maxillofacial Surgery, 63(4):449–

456. https://doi.org/10.1016/j.joms.2004.07.019.

76 Ferrús-Torres, E., Valmaseda-Castellón, E., Berini-Aytés, L., Gay-Escoda, C. (2011). Informed Consent in Oral Surgery: The Value of Written Information. Journal of Oral and Maxillofacial Surgery, 69(1):54–

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238 Weiner and Lovitt reported that there was a direct association between educational level and intelligence.⁷⁷ Intuitively, it could be anticipated that patients that received higher education ought to have better information and knowledge in regards to disease and treatment, hence more compliant on postoperative instructions. Other studies supported this statement that patients were more likely to comply to postoperative instructions if they received a higher education level.^78,79,80 However, our study contradicts with the previous studies where patients holding a diploma have more compliance than patients holding a degree in postoperative instructions to all six categories except for proper diet category. This could be possibility due to the hectic work life among these white-collar degree holder patients causing them to ignore or paying less attention on the postoperative care but to focus more on their urgent administration work to meet the dateline.

A study by Kessels reported that most patients have short-term memory and they can even forget instantly up to 80% of the total information given by their doctors in the short period of time. This study also showed that certain factors such as sociocultural level and age-related could affect the patient understanding and compliance to the postoperative instructions.⁸¹ Patients aged 41 to 50 years old are more compliant to postoperative instructions to all seven categories compared to younger age group.

This is expected from the patients at this age group, as they are more likely to be semi-retired or retired, and probably have more time to follow the instructions given by the dentists about the choice of foods, application of ice packs and compliance to medication given. However, in our study there is only one patient from this age group compared to other age groups that have more than one patient, hence this might affect the result.

In our study, we found that female patients reported a higher compliance compared to male in postoperative instructions to reduce swelling, bleeding and pain compliance. This could be due to most female patients generally have lower pain threshold and were more likely to compliance to analgesics for pain relief.⁸² A study conducted by Blinder et al. have shown that

77 Weiner, M. F., Lovitt, R. (1984). An Examination of Patients’ Understanding of Information from Health Care Providers. Psychiatric Services, 35(6):619–620. https://doi.org/10.1176/ps.35.6.619.

78 Yavuz, A., Tuncer, M., Erdoğan, O., Gürkan, A., Çetinkaya, R., Akbaş, S. H., … Yakupoğlu, G. (2004). Is There Any Effect of Compliance on Clinical Parameters of Renal Transplant

Recipients? Transplantation Proceedings, 36(1):120–121.

https://doi.org/10.1016/j.transproceed.2003.11.052.

79 Ghods, A. J., Nasrollahzadeh, D. (2003). Noncompliance with immunosuppressive medications after renal transplantation. Experimental and Clinical Transplantation: Official Journal of the Middle East Society for Organ Transplantation, 1(1):39–47.

80 Okuno, J., Yanagi, H., Tomura, S. (2001). Is Cognitive Impairment a Risk Factor for Poor Compliance Among Japanese Elderly in The Community? European Journal of Clinical Pharmacology, 57(8):589–

594. https://doi.org/10.1007/s002280100347

81 Kessels, R. P. C. (2003). Patients’ Memory for Medical Information. Journal of The Royal Society of Medicine, 96(5):219–222. https://doi.org/10.1258/jrsm.96.5.219.

82 Baig Q.A., Muzaffar D., Afaq A., Bilal S., Iqbal N. (2012). Prevalence of Self Medication among Dental Patients. Pakistan Oral & Dental Journal. 32(2), 34-38.

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239 female patients are very likely complying to postoperative analgesics regimen because of phobia of pain.⁸³ It is possible that compliance to analgesics is better because of the fear of pain. Another recent paper reported that dental anxiety was found to be more in females in the general population and female was very likely to recall the pain after the completion of the dental treatment.⁸⁴ This reason explains why the increased of the compliance following the surgery.²⁶ Besides, ensuring adequate pain relief can expedite the postoperative recovery and increase patient satisfaction after surgery. Some authors supported the findings that female patients have better compliance.^85,86,87 This is however inconsistent with another literature review on compliance in seniors which reported that gender is not a factor affecting patient compliance.⁸⁸ A clinical trial published by Alvira-González and Gay-Escod, also supported this finding that generally patient non-compliance to postoperative instructions is not associated with gender factor. However, they did agree that male patients are likely not obey to instructions to refrain from taking any beverages that contain alcohol or carbonated in a week after surgery.¹

In contrast, male patients in this study were reported to be more compliance for the proper diet, oral hygiene and other categories than female. High daily consumption of carbohydrates and frequent sugary snacks in females compared to males could be the possible cause of less compliance for proper diet but it was believed to be another method used to reduce stress and depression.^89,90 Meanwhile, we believed that male patients nowadays are getting more aware of overall wellbeing and mostly are enthusiasm for fitness workouts that observe closely on their dietary intake, therefore postoperative compliance to dietary advice is easily undertaken by male patients. Besides, the indicators of dental care might be varied for female and male,

83 Blinder, D., Rotenberg, L., Peleg, M., Taicher, S. (2001). Patient Compliance to Instructions After Oral Surgical Procedures. International Journal of Oral and Maxillofacial Surgery, 30(3):216–

219. https://doi.org/10.1054/ijom.2000.0045.

84 Sivarajan M., Lakkoji K., Venkatesh., Ezhilarasan D. (2021). A Review on Gender Differences in Dental Anxiety. Journal of Contemporary Issues in Business and Government,27(2):2378-2384.

https://doi.org/10.47750/cibg.2021.27.02.249

85 Balbay, O., Annakkaya, A. N., Arbak, P., Bilgin, C., Erbas, M. (2005). Which Patients Are Able to Adhere to Tuberculosis Treatment? A Study in A Rural Area in The Northwest Part of Turkey. Japanese Journal of Infectious Diseases, 58(3):152–158.

86 Choi-Kwon, S., Kwon, S. U., Kim, J. S. (2005). Compliance with Risk Factor Modification: Early-Onset versus Late-Onset Stroke Patients. European Neurology, 54(4):204–211.

https://doi.org/10.1159/000090710.

87 Lindberg, M. (2001). Asthma Care and Factors Affecting Medication Compliance: The Patient’s Point of View. International Journal for Quality in Health Care, 13(5):375–383.

https://doi.org/10.1093/intqhc/13.5.375

88 Vik, S. A., Maxwell, C. J., Hogan, D. B. (2004). Measurement, Correlates, and Health Outcomes of Medication Adherence Among Seniors. Annals of Pharmacotherapy, 38(2):303–312.

https://doi.org/10.1345/aph.1d252

89 Bica, I., Cunha, M., Reis, M., Costa, J., Costa, P., Bica, A. (2014). Food consumption, body mass index and risk for oral health in adolescents. Atención Primaria, 46(Suppl 5):154–159.

https://doi.org/10.1016/s0212-6567(14)70084-8

90 Nishizawa, S., Benkelfat, C., Young, S. N., Leyton, M., Mzengeza, S., de Montigny, C., … Diksic, M.

(1997). Differences between males and females in rates of serotonin synthesis in human brain. Proceedings of the National Academy of Sciences, 94(10):5308–5313.

https://doi.org/10.1073/pnas.94.10.5308

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240 with male's behaviour being more likely to be affected by their attitudes towards oral care and dental health. Male patients avoid dental treatment because they are phobia of pain they will experience, their negative experience and worriedness about the cost of a dental treatment.²⁶ Dental phobic patients would try not to visit dentist at any circumstances but only forced themselves to do so when they presented with unbearable pain or severe acute infection that often necessitate for more complex and traumatic dental management.²⁶ Thus, males are more comply to the postoperative instructions to oral hygiene and “other” to avoid unnecessary dental visits again. This, in turn reinforces them to have better compliance for smoking consumption, dietary intake and oral hygiene care that may disturb the healing of the surgery. However, our study contradicts with study conducted by Alvira-González and Gay-Escod that reported male compliance was the least for temporary smoking cessation within seven days postoperatively.¹

A clear detailed education on postoperative instructions can improve the patient understanding and subsequently encourage patient to conduct proper wound care to avoid unnecessary postoperative complications and ensure the patient wellbeing.¹ It was proven that an effective two ways communication between patient and healthcare worker can improve patient attitude and wellbeing status.⁹¹ Several authors reported that patient that inability to read or write and obliviousness of the language as a result of lacking of education, could affect the patient understanding and impede them to follow the postoperative instructions.^23,92 Another authors also reported factors such as being ability to read and understand the language spoken as well as the number of years in school could affect the patient understanding and compliance to postoperative instructions.¹⁷

Alexander recommended dental surgeons after performing oral surgery procedure should focus closely on their expressing by using simple words and shorter phrasing in the postoperative instruction forms because an effective communication serves as a crucial role in ensuring the patient understanding on postoperative management care.⁹³ Most patient especially from the lower education status, would prefer the mode of postoperatively delivery in the combination form of verbal and written instructions or at least in the verbal form.²⁵ However, other authors concluded that even though verbal postoperative instruction is very cost-effective and less hassle, patient may not possibly understand as they were under surgical related stress that might distract their minds and hinder the efficient doctor-patient communication during verbal postoperative instructions.¹⁷ Therefore, a written reinforcement should be used as an adjunct to the usual verbal instructions to improve patient understanding and further increase their compliance.³⁵Ekaniyere et al. supported

91 Van Osch, M., Van Dulmen, S., Van Vliet, L., Bensing, J. (2017). Specifying The Effects of Physician’s Communication On Patients’ Outcomes: A Randomised Controlled Trial. Patient Education and Counseling, 100(8):1482–1489. https://doi.org/10.1016/j.pec.2017.03.009

92 Alexander, R. E. (2000). Readability of Published Dental Educational Materials. The Journal of the American Dental Association, 131(7):937–942. https://doi.org/10.14219/jada.archive.2000.0312.

93 Alexander, R. E. (1999). Patient Understanding of Postsurgical Instruction Forms. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 87(2):153–158.

https://doi.org/10.1016/s1079-2104(99)70265-9.

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241 this statement and they related it to clinician factor on the manner of postoperative instructions presentation.⁸Clinicians that lacking of communicative skill are more likely unable to explain and deliver postoperative instructions clearly and concisely to patient. Hence, it reduces patient satisfaction and compliance.⁹⁴

Studies have also shown that patients in developing countries tend to self-medicate themselves over-the-counter at pharmacy with oral analgesics and/ or in combination with antibiotics especially for female patients.²⁴These types of patients will normally purchase medicine over-the-counter to treat similar dental illnesses from their past experience.⁹⁵ However, our study showed that female patients are generally more compliance than male patients on medications prescribed by dental clinicians on postoperatively.

In this study, we summarised that female patient is generally better compliance in postoperative instructions to reduce pain, swelling, and bleeding compared to male patients. Nevertheless, male patients appeared to be more compliance in oral hygiene, proper diet, and other categories than in female patients. Patients who aged from 41 to 50 years old show higher compliance towards all categories of postoperative instructions compared to the younger age groups. Not including the proper diet category, diploma holder patients are more complied towards all postoperative instructions for all six categories compared to degree holder patients.

P-values for all factors of the compliance were greater than 0.05. This can be deduced that there are no associations between the demographic characteristics and all factors of the compliance such as clinicians, patient’s understanding and patients’

attitudes.

Limitation and Recommendation

Two main limitations were lacking of clinical sessions and patients. Owing to pandemic COVID-19, most of the clinical sessions were postponed or cancelled and only patients with emergencies treatment were treated. This leads to fewer patients recruited in the study. Thus, the sample size was relatively smaller, and the result of this study might not entirely represent the inference employed. Hence, larger number of samples is suggested to be used in future study to extrapolate the result.

Conclusion

Most patients manifested a satisfying result for the postoperative care compliance for mandibular third molar extraction with high percentage range for all seven categories, which is between 80% and 100%. In addition, the compliance factors including clinicians, patient’s understanding, and patients’ attitudes are not affected

94 Schouten, B. C., Eijkman, M. A. J., Hoogstraten, J. (2003). Dentists’ and Patients’ Communicative Behaviour and Their Satisfaction with the Dental Encounter. Community Dental Health, 20(1):11–15.

95 Bhattarai R., Khanai S., Shrestha S. (2020). Prevalence of Self-medication Practices for Oral Health Problems among Dental Patients in a dental college: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc, 58(224):209-213. https://doi.org/10.31729/jnma.4866.

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242 by demographic characteristics namely different genders, group of ages and educational levels. Despite of no association were reported between the three factors affecting patient compliance regarding the clinicians, patient’s understanding and patients’ attitudes with the demographic characteristics, it is importance to make sure that patient is always following the advice on the postoperative instructions by telephone follow-up with patients postoperatively to address their concerns or problems. In addition to telephone follow-up, postoperative instructions in both written and verbal forms should be delivered to patients in a simpler way to enable patient better understanding and compliance.

Acknowledgement

This paper presents a work under Research Grant University Sains Islam Malaysia (USIM), USIM/JKEP/2020-102. We would like to thank Faculty of Dentistry, Universiti Sains Islam Malaysia in support of funding this research. This research would not have been possible without the exceptional support especially in accessing patient’s dental records. A big thank you to our dental surgery assistant, Mrs. Justina from Faculty of Dentistry, Universiti Sains Islam Malaysia for her assistance. Her contributions are sincerely appreciated and gratefully acknowledged.

References

Alexander, R. E. (2000). Readability of Published Dental Educational Materials. The Journal of the American Dental Association, 131(7):937–942.

https://doi.org/10.14219/jada.archive.2000.0312.

Alexander, R. E. (1999). Patient Understanding of Postsurgical Instruction Forms. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 87(2):153–158. https://doi.org/10.1016/s1079- 2104(99)70265-9.

Alsaleh, M. K., Alajlan, S. S., Alateeq, N. F., Alamer, N. S., Alshammary, F., Alhobeira, H.

A., Khan, S., Siddiqui, A. A. (2018). Alveolar Osteitis: Patient’s Compliance with Post-Extraction Instructions Following Permanent Teeth Extraction. The Journal of Contemporary Dental Practice, 19(12):1517–1524.

Aloy-Prósper, A., Pellicer-Chover, H., Balaguer-Martínez, J., Llamas-Monteagudo, O., Peñarrocha-Diago, M. (2020). Patient Compliance to Postoperative Instructions After Third Molar Surgery Comparing Traditional Verbally and Written Form Versus the Effect of a Postoperative Phone Call Follow-Up A: A Randomized Clinical Study. Journal of Clinical and Experimental Dentistry, 12(10): E909–E915. https://doi.org/10.4317/jced.56680.

Alvira-Gonzalez, J., & Gay-Escoda, C. (2014). Compliance of Post-Operative Instructions Following the Surgical Extraction of Impacted Lower Third Molars: A Randomized Clinical Trial. Medicina Oral Patología Oral Y Cirugia Bucal, 20(2): E224–E230. https://doi.org/10.4317/medoral.20121.

(17)

243 Atchison, K. A., Black, E. E., Leathers, R., Belin, T. R., Abrego, M., Gironda, M. W., Wong, D., Shetty, V., Dermartirosian, C. (2005). A Qualitative Report of Patient Problems and Postoperative Instructions. Journal of Oral and Maxillofacial Surgery, 63(4):449–456. https://doi.org/10.1016/j.joms.2004.07.019.

Baig Q.A., Muzaffar D., Afaq A., Bilal S., Iqbal N. (2012). Prevalence of Self Medication among Dental Patients. Pakistan Oral & Dental Journal, 32(2):34-38.

Balbay, O., Annakkaya, A. N., Arbak, P., Bilgin, C., Erbas, M. (2005). Which Patients Are Able to Adhere to Tuberculosis Treatment? A Study in A Rural Area in The Northwest Part of Turkey. Japanese Journal of Infectious Diseases, 58(3):152–

158.

Bello, S. A., Adeyemo, W. L., Bamgbose, B. O., Obi, E. V., Adeyinka, A. A. (2011). Effect of Age, Impaction Types and Operative Time On Inflammatory Tissue Reactions Following Lower Third Molar Surgery. Head & Face Medicine, 7(1).

https://doi.org/10.1186/1746-160x-7-8

Bhattarai R., Khanai S., Shrestha S. (2020). Prevalence of Self-medication Practices for Oral Health Problems among Dental Patients in a dental college: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc, 58(224):209-213.

https://doi.org/10.31729/jnma.4866.

Bica, I., Cunha, M., Reis, M., Costa, J., Costa, P., Bica, A. (2014). Food consumption, body mass index and risk for oral health in adolescents. Atención Primaria, 46(Suppl 5), 154–159. https://doi.org/10.1016/s0212- 6567(14)70084-8

Blinder, D., Rotenberg, L., Peleg, M., Taicher, S. (2001). Patient Compliance to Instructions After Oral Surgical Procedures. International Journal of Oral and

Maxillofacial Surgery, 30(3):216–

219. https://doi.org/10.1054/ijom.2000.0045.

Bui, C. H., Seldin, E. B., & Dodson, T. B. (2003). Types, Frequencies, And Risk Factors for Complications After Third Molar Extraction. Journal of Oral and

Maxillofacial Surgery, 61(12):1379–1389.

https://doi.org/10.1016/j.joms.2003.04.001.

Bunzel, B., & Laederach-Hofmann, K. (2000). Noncompliance in Organ Transplant Recipients: A Review. Weiner Klinische Wochenschrift, 112(10):423-440.

Choi-Kwon, S., Kwon, S. U., Kim, J. S. (2005). Compliance with Risk Factor Modification: Early-Onset versus Late-Onset Stroke Patients. European Neurology, 54(4):204–211. https://doi.org/10.1159/000090710.

Deliverska, E. G., Petkova, M. (2016). Complications After Extraction of Impacted Third Molars - Literature Review. Journal of IMAB - Annual Proceeding

(18)

244

(Scientific Papers), 22(3):1202–1211.

https://doi.org/10.5272/jimab.2016223.1202.

Ekaniyere, E. B., Ifeoma. A.N. (2020). Influence of Post-Operative Instructions on Wound Healing. A Randomized, Single-Blinded Clinical Trial. Iraqi Dental Journal, 42(1):1-9. https://doi:10.46466/idj.v42i1.259.

Faheem, Samra. (2017). Patients Compliance and Follow-Up Rate after Tooth Extraction. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), 16(5):115-120.

Ferrús-Torres, E., Valmaseda-Castellón, E., Berini-Aytés, L., & Gay-Escoda, C. (2011).

Informed Consent in Oral Surgery: The Value of Written Information. Journal

of Oral and Maxillofacial Surgery, 69(1):54–

Ghods, A. J., Nasrollahzadeh, D. (2003). Noncompliance with immunosuppressive medications after renal transplantation. Experimental and Clinical Transplantation: Official Journal of the Middle East Society for Organ Transplantation, 1(1):39–47.

Isaeva, E. R., Sitkina, E. V., Kudryavtseva, T. V., Loboda, E. S. (2017). Age-Specific Attitudes Regarding Dental Health. EPMA Journal, 8(1):48-49.

Johnson, A., Sandford, J. (2005). Written and Verbal Information Versus Verbal Information Only for Patients Being Discharged from Acute Hospital Settings to Home: Systematic Review. Health Education Research, 20(4):423–429.

https://doi.org/10.1093/her/cyg141.

Kessels, R. P. C. (2003). Patients’ Memory for Medical Information. Journal of The

Royal Society of Medicine, 96(5):219–222.

https://doi.org/10.1258/jrsm.96.5.219.

Lindberg, M. (2001). Asthma Care and Factors Affecting Medication Compliance: The Patient’s Point of View. International Journal for Quality in Health Care, 13(5):375–383. https://doi.org/10.1093/intqhc/13.5.375.

Matijević, M., Uzarević, Z., Gvozdić, V., Mikelić, V. M., Leović, D., & Macan, D. (2013).

The Influence of Surgical Experience, Type of Instructions Given to Patients and Patient Sex on Postoperative Pain Intensity Following Lower Wisdom Tooth Surgery. Acta Clinica Croatica, 52(1):23–28.

McGrath, C., Comfort, M. B., Lo, E. C. M., Luo, Y. (2003). Changes in Life Quality Following Third Molar Surgery – The Immediate Postoperative Period. British Dental Journal, 194(5):265–268. https://doi.org/10.1038/sj.bdj.4809930.

Nishizawa, S., Benkelfat, C., Young, S. N., Leyton, M., Mzengeza, S., de Montigny, C., … Diksic, M. (1997). Differences between males and females in rates of serotonin

(19)

245 synthesis in human brain. Proceedings of the National Academy of Sciences, 94(10):5308–5313. https://doi.org/10.1073/pnas.94.10.5308.

Okuno, J., Yanagi, H., Tomura, S. (2001). Is Cognitive Impairment a Risk Factor for Poor Compliance Among Japanese Elderly in The Community? European

Journal of Clinical Pharmacology, 57(8):589–

594. https://doi.org/10.1007/s002280100347.

Ruta, D. A., Bissias, E., Ogston, S., Ogden, G. R. (2000). Assessing Health Outcomes After Extraction of Third Molars: The Postoperative Symptom Severity (Posse) Scale. British Journal of Oral and Maxillofacial Surgery, 38(5):480–

487.https://doi.org/10.1054/bjom.2000.0339.

Schouten, B. C., Eijkman, M. A. J., Hoogstraten, J. (2003). Dentists’ and Patients’

Communicative Behaviour and Their Satisfaction with the Dental Encounter. Community Dental Health, 20(1):11–15.

Sivarajan M., Lakkoji K., Venkatesh., Ezhilarasan D. (2021). A Review on Gender Differences in Dental Anxiety. Journal of Contemporary Issues in Business and Government, 27(2):2378-2384.

https://doi.org/10.47750/cibg.2021.27.02.249.

Tachalov, V. V., Orekhova, L. Y., Isaeva, E. R., Kudryavtseva, T. V., Loboda, E. S., Sitkina, E. V. (2018). Characteristics of Dental Patients Determining Their Compliance Level in Dentistry: Relevance for Predictive, Preventive, And Personalized Medicine. EPMA Journal, 9(4):379–385. https://doi.org/10.1007/s13167- 018-0152-8.

Van Osch, M., Van Dulmen, S., Van Vliet, L., Bensing, J. (2017). Specifying The Effects of Physician’s Communication On Patients’ Outcomes: A Randomised Controlled Trial. Patient Education and Counseling, 100(8):1482–1489.

https://doi.org/10.1016/j.pec.2017.03.009.

Vik, S. A., Maxwell, C. J., Hogan, D. B. (2004). Measurement, Correlates, and Health Outcomes of Medication Adherence Among Seniors. Annals of Pharmacotherapy, 38(2):303–312. https://doi.org/10.1345/aph.1d252.

Volskaya, E. A. (2013). Patient Compliance. Overview of Research Trends. Remedium.

Journal About the Russian Market of Medicines and Medical Equipment, 11:6–

15.

Weiner, M. F., Lovitt, R. (1984). An Examination of Patients’ Understanding of Information from Health Care Providers. Psychiatric Services, 35(6):619–620.

https://doi.org/10.1176/ps.35.6.619.

Yavuz, A., Tuncer, M., Erdoğan, O., Gürkan, A., Çetinkaya, R., Akbaş, S. H., … Yakupoğlu, G. (2004). Is There Any Effect of Compliance on Clinical Parameters of Renal

(20)

246 Transplant Recipients? Transplantation Proceedings, 36(1):120–121.

https://doi.org/10.1016/j.transproceed.2003.11.052.