Implant Surgery: Do I Completely Cover or Drape the Patient?

Many surgeons maintain a (relatively) sterile environment, that is, the entire surgical suite is sterile. So it is no big deal to administer IV sedation and to drape the patient. If you don't have a sterile surgical suite I don't think there is a reason to drape the patient as you describe. Just be "clean" about it. I am assuming that this is a straightforward implant placement only.

The previous post is exactly right. Sterile environments for simply implants are not necessary. 'Clean' is fine. You will of course use sterile saline, burs, instruments, etc. Protocols may have been like that at one time, but not anymore. Implant dentistry is just like other specialties. Let common sense be your guide.

no

I believe that I would treat the surgery the same as you treat a extraction. Of course I use sterile water and sterile surgical kits but I do not go overboard. I just do not see what benefit booties and a Hat do when you are working in a dirty mouth. I think most people do this because it looks cool. Be clean and goo overboard in the beginning because it is good to show the extent you are going for with the patient. As you get more experience the more you will know what is necessary and what is fluff.

Actually, a study done about 15 years ago concludes that the above 4 comments are correct. So, relax.

Placing a dental implant is NOT like extracting a tooth. There is the potential for placing an innoculum deep into bone and captivating it there with possible serious outcomes including osteomyelitis. While various studies show that the rate of osseointegration is not much different between utilizing a complete sterile field and so-called clean field I believe it is a professional responsibility to take every measure possible so that your technique is not the cause of an infection or even has the perception of being a cause of infection. The small additional cost of establishing a sterile field I believe is a sensible and prudent measure. It is the way that I would want my own surgery to be undertaken.

"placing an innoculum deep into bone and captivating it there " Isn't this potential there also when we place an endodontic file into an infected root canal and get patency. Don't forget that the implant surgery is being done in the mouth, which is full of potential pathogens. Anybody thinking they can maintain a sterile field is in "la la" land. We need to base our treatment decision on the available science and a sensible cost benefit analysis to the patient not on "how I would want my surgery to be done" This is just putting implant dentistry out of the financial reach of more and more people. It would be safer for all of us if we drove cars fitted with 20 airbags but in the end it is cost prohibitive so we make do with 4-6 and take a little risk every time we go for a drive!

look at "Southwood RT, Rice JL, McDonald PJ, Hakendorf PH, Rozenbilds MA. Infection in experimental hip arthroplasties. J Bone Joint Surg Br. 1985;67:229-31." for the evidence for innoculation " for evidence forthe innoculum theory

Agree with most of the above, but will add 1. Pre-Op chlorhexidine rinse 2. If you are giving IV sedation, why not give a dose of IV antibiotics? All of my implant / graft patients get a dose of Clindamycin or Ampicillin depending on their treatment and allergy history. Many may think this is overkill, but when I think about the biology involved, especially with immediate implants and grafts into infected sites, it helps me sleep at night. In hospital OR's most patients get a dose of antibiotics right before the incision. Some people would say just give 7 days worth of PO (by mouth) antibiotics. I have had more complications from PO antibiotics (GI upset, nausea, etc.. ) than infections! My patients really appreciate this. Any good surgeon will have a low infection rate. When you start out, you must expect a higher infection rate. This is because your team is not perfected. Your assistants may not know the equipment well and you may be unfamiliar with instrumentation. In these cases, I don't think that a full patient drape is overkill. You must watch you assistants during implant cases and teach them good sterile protocol. Don't suction the back of your patient's mouth with the same suction you use to clear your osteotomies. However, as your speed and team efficiency increases, you will not need full drapes for minor cases. Remember that the longer your case , i. e. the time from incision to close, the greater the chance of harmfull bacteria getting into some place it shouldn't.

Is anybody aware of any published data, a single case study even, of osteomyelitis following implant placement in a non-irradiated or non-immunocompromised patient?

Would be interested to hear from any 'sterile' surgeons who believe they are operating in a sterile field. It is just bad science to believe that the mouth can be made sterile. The bacterial load can be reduced by Chlorhexidine, but 'sterile', please! The post regarding hip implants. The hip is a closed sterile area, not comparable to the mouth. There are probably more bacteria in one ml of saliva, than in the whole of a dental surgery. I would be interested to hear about reported cases of osteomyelitis also.

the implant would get loose and fall out before a true osteomyelitis could develop.

When I first started placing implants, OR style 'sterile technique' was the generally accepted standard complete with betadine swabs - ewww. Over the years, it has evolved into more of 'clean' technique. We're somewhere in between depending on the procedure. Ask Salvin dental for their DVD on operatory prep and review it. Lots of good stuff there - especially for assistants. Pick what you think is reasonable for the procedure and the patient and you should be good. For a simple placement on a healthy patient we drape from the neck down, chlorhexedine rinse, fitted single package gloves, sanisleeves and covers on everything we touch. Sterile saline - no triplex syringes allowed. Someone mentionned before a very good point - suction tip should not enter the surgical site if it's just been used to suck spit. We use a slow speed to suction the mouth and reserve the high speed for the site we are working. We also have a spare tip on hand in case we forget. Lastly, like many said here, there are millions of bacteria in the mouth - no way to be sterile. Thank god we have such fantastic blood supply that we can do what we do! Good luck on your first case!! Ryan

BTW = in reference to the above; when i first started, we were using machined surfaces and waiting at least six months because "Per Ingvar" said so!! Yikes we've come a long way...

For about $50 extra to the patient I use a Hygitech implant wear sterile kit for EVERY implant I do. Why? Because if I have to explain an infection related failure to my dental board and have not done everything in my power to mitigate risk I know what will happen. I call it insurance.

I agree with Peri. The insurance of having a sterile field from a medical legal standpoint is well worth the $50 sterile kit. Although the mouth may be abundant with bacteria, through a pre operative pharmacological protocol of antibiotics, a Peridex rinse pre operativly and a sterile field you are covered. That is what was taught to me by Carl Misch and is what I have done for the past 12 years.

Yes, the entire drape and full set-up MAY be overkill, but eliminating potential problems or setbacks in any form is not only logical, but good practice for success in any industry or profession. As mentioned previously, prevention or protection in medical-legal issues in todays litigous society seems to be safe. What about patient comfort or peace of mind? Many patients appreciate this, especially if it is briefly explained that everything you do is for their safety and benefit. Although completely unrelated, this technique also adds to referrals. If proper patient education takes place, they do not look upon this practice as overkill or get anxious about it, but builds their confidence in you. The best form of ethical marketing is still word of mouth. Finally, the use of a complete or partial set up does not make you a better surgeon, but perhaps a wiser one.

You most certainly need to advise your patient that this is your first solo and charge accordingly.

isolite + iodine $2 no spit = no bacteria assistants no longer a glorified spit sucker

A partial set-up yes. ie, Chlorhex mouth rinse, sterile instrumentation,sterile gloves, sterile drape over patients chest etc. Full sterility as in hospital operatory is simply not warranted as has been said it is a "dirty" surgical field. There will be no problems with explaining an infection to dental board because the science supports this and the dental board is predominantly scientists. As far as "putting on the kit" to impress patients or staff or because "it's what the hoodoo guru does" as the above posters suggest this is an individual marketing decision. The patient doesn't usely see how good we are with our technique so we can try and demonstrate particular care with our costume- it helps justify the fee etc. Maybe if practicing in some countries a clinician could have an evil spirit purging ceremony with the patient prior to the procedure also.

A $50.00 "sterile kit" would be better termed a $50 celan kit and is sensible. Full fluid impermeable sterile drapes as are used in a hospital operatory are $50 alone. full sterile opertory set-up as seen in many of the live surgery demo's would be approx $200. Not to mention the environmental cost!

With your first solo, I would definitely recommend you have a mentor by your side for both your and the patients piece of mind. Also, what does 100 credits mean? Have you actually observed/assisted a few cases? If not, find a mentor and watch and learn, I assisted/watched about a dozen cases before I attempted my first case. As far as sterile gowns/drapes go, I believe the tendency over the coming years will be to limit their use for the extensive surgical type cases only. As many above have already attested, it really is unnecessary expense and time burden. As far as litigation fears go, a key point in your gaining consent from the patient is to clearly explain that implants can and do fail and outline how such failures are managed.. Of interest I hope to you and other colleagues (as I want to sell this within a few years!!), I have recently begun placing immediate implants using a new type of drilling apparatus I have developed. Except for one case, all have involved the traditional 'sterile' set-up. The one case that did not, was done with a 'clean' set up, as described by Mark Miller above. This case involved a patient who smoked, who was about to have a decoronated upper premolar (with apical lucency) extracted and couldn't afford an implant. Anyway, as she had nothing to lose (and I wanted to see if a worse case scenario would work), I offered her a free implant (not including the abutment,crown), on the understanding that what we were going to do was new (but not necessarily risky). The patient agreed, the root (with granuloma attached) extracted with a benex and the implant inserted after osteotomy prep with my 'apparatus'. Early days still (its only been a month) but the implant appears to be perfect (I'm working on the the patient getting off the smokes though!) Getting back to you though, be patient in gaining your skills and continue to use your mentor as you encounter more and more complex cases. regards John

It is imperative to develop an excellent aseptic technique. Draping is fine, but also decontaminate the oral cavity and the associated areas about the external aspect of the oral cavity. Prepare sterile kits that are wrapped and keep a sterile field.

Are there any papers/research suggesting that 'sterile' technique is imperative? Medico-legally, the lawyers, dental board would need this scientific evidence also. The placing of implants can be a sterile procedure as long as you do not put your hands in the patient's mouth! An almost complete lack of scientific knowledge would suggest that this is a 'sterile field'. Shouldn't we be practising evidence based dentistry? 'Impressing' patients does not fit the criteria.