Infection of Grafted Site: recommendations?
This patient had peri-implantitis of #18 & #19. There was a large defect on the buccal of #18, but good surrounding bone mesial and distal. I flapped the area, degranulated, scaled with ultrasonic using chlorhexidine, hand scaled implant with titanium scaler and treated the surface with EDTA. I also used Nd:YAG laser when I made my initial incision. I grafted the area with Bio-Oss, allograft and autogenous mixed with PRF serum and held in place with titanium-reinforced membrane and placed PRF over the membrane and sutured closed with PTFE sutures. I placed the patient on amoxicillin 500mg. The patient is a well-controlled diabetic and has osteoporosis, but did not report bisphosphonate usage.
The patient called two days later complaining of swelling. On examination she had swelling on the left side of her face and slightly below the jaw and area felt warm. There was no suppuration on palpation and the patient did not report significant pain. Primary closure was still present. I placed the patient on Medrol Dose Pak and switched to clindamycin 150mg qid. I called the patient the next day and she reported swelling decreasing and no longer feeling warm in the area.
Now at one week follow-up, no facial swelling but slight oozing from incision line at site #18 and exposure of cover screw on #19. Exudate was yellow and then became yellowish-clear. The patient experiences no pain on palpation. I see no exposure of the membrane but there is a small communication from the incision line. She reported finishing her Medrol but did not take the clindamycin as prescribed. Do you recommend I open up the site and debride or keep her on a longer course of antibiotics and wait it out? She reports no discomfort and everything feels normal.
15 Comments on Infection of Grafted Site: recommendations?
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TH20
6/7/2017
Never use a Nd-YAG on an implant because of the wavelength. It will heat your implant and damage the bone. I only use an Er-YAG or Diodelaser to use on implants for this reason. You take a huge risk using Nd-YAG on implants and can lead to osteonecrosis.
Gregori Kurtzman, DDS, MA
6/7/2017
I would try to irrigate the area out with a syringe using a capsule of Clindamycin mixed in enough saline to make a solution. then make sure she stays on the oral antibiotic check her in a week and if any discharge then you need to open it and clean it out start over. if it has no discharge then radiograph at 2 months to see if the graft took if not then again start over. i would also increase the dosage to 300mg q6h as the 150 I think is too low a dose
Merlin Ohmer
6/7/2017
I would only use a CO2 laser on an implant body.
Why mix cow bone and human bone together. Cow bone takes forever to turn over.
150mg of clindamycin is too low a dose. I would recommend 300mg or add Flagyl to the Amox.
Will be interesting to hear how this resolves.
DrG
6/7/2017
Bio-oss + bacteria = 🔥
The vast majority of peri-implantitis case involve necrotic areas of bio-oss.
My best advice. Open the site up again. Clean out every last particle of bovine, equine, HA graft material and replace it with a fully resorbable material that acts as a space maintainer.
Dr.j
6/8/2017
Is there any literature to support this statement? I'd be interested in seeing it.
There is no golden rule to treat peri-implantitis. We don't fully understand it yet.
Busier has been combining ABB & autogenous bone for over 20 years. He has published 12+ year implant survival rates with his contour augmentation technique.
I'm curious as to why allograft and autogenous mix.
There are so many factors in this case where problems can arise (diabetic, osteoporatic, titanium membrane and prof plus 3 types of graft material) its impossible to say narrow it down to 1 thing.
DrG
6/9/2017
I wasn't suggesting mixing any type of graft material with DFDBA. I'm sorry if I didn't convey that clearly.
After 25 years of placing and replacing and regenerating implants I can convincingly say peri-implantitis is most often seen in association with Bio-oss.
I'll try and post a case I just opened last week for everyone to see.
The most progressive thought leaders in our Field who are not beholden to a corporation are advocating no bone in association with immediate implant placement. In case where ridge augmentation is needed using a fully resorbable material such as Augma (CaSO4) is the ideal treatment.
The next time you have the opportunity listen to Dennis Tarnow speak about immediate molar implant placement. It will confuse your mind and make you question everything you have been doing. But when you follow his directions and think about his explanation of the biology involved you change.
Dr.j
6/9/2017
I was referring to the case posted above. Mixing ABB, allo & autogenous. (Seems overkill)
The use of ABB has been documented for over 20 years.
I will be seeing Dr. Tarnow in Florida in a couple of weeks.
Ive met with hm before. I know he uses ABB successfully and has over the years.
Ill be sure to ask him.
Khanh
6/10/2017
I should clarify that the autogenous portion was very minimal. I had to do slight osseous reduction in another area and I decided to reuse the bone instead of wasting it but the bulk of the graft is really a mixture of bio-oss and allograft.
CRS
6/8/2017
Overtreated. Post operative swelling at two days is normal, steroid at that point not indicated will actually prevent body from walling off infection and not great for diabetics raises blood sugar. You most likely jumped in too soon changing antibiotics at two days. A lot of surgical trauma and overkill. Then overtreating the post op sequela which may have contributed to the post op wound infection at one week not two days, biology of wound healing. I would have done LAPIP with a small Bio oss graft conservatively, these have a 50% success rate. Bone doesn't grow well over inert titanium. What is that big overcontoured white thing on the implant and how long have the implants been placed. If you open this again take out the implants, allow healing and refer to an experienced surgeon. A magic formula or recipe of antibiotics, graft materials or technique does not replace knowledge of wound healing. There is so much foreign material in there the body will have difficulty healing this in a medically compromised patient. By the way did you charge the patient for all this treatment and materials just curious?
Khanh
6/8/2017
I would have liked to have done LAPIP but unfortunately the dentist removed the crown and placed a cover screw. The patient did not come in right away since the area felt better to her so by the time she did come in, tissue had overgrown and there was underlying infection. I felt it was best to get full access to assess. Since there appeared to be good surrounding bone, I attempted to regraft the area and bury the implant for healing.
Yes, I did charge for this procedure since I did not place the implants and the patient was never under my care. She was referred because of the peri-implantitis.
Your comment about referring to an experienced surgeon is very discouraging. In order to have experience, one must be able to perform cases and perhaps run into some complications. I am asking for advise from experienced surgeons who may have come across this and hoping to learn from their experience.
Thank you.
Vladimir Reznikov
6/9/2017
Dr. Khanh,
1. Could you describe you closing technique?
2. The PA that you posted was a pre-op or post-op?
3. Did you tack the membrane?
Khanh
6/10/2017
I released the flap with periosteal score and blunt dissection then tacked the membrane in place on the buccal and placed bone graft underneath and tucked the membrane underneath the lingual flap. Then coronally positioned the buccal flap and sutured with horizontal mattress and figure 8 sutures.
The radiographs are pre-op and actually the crown on #19 was removed the day before surgery.
CRS
6/11/2017
I actually gave you good advice,
overtreated, not understanding wound healing and post op sequela. Don't take it personally, if you want to be a surgeon it is part of the territory. Kinda like scubbing an oak table with a Brillo pad to clean it. By the way placing a healing cap would have allowed you to do LAPIP. This case most likely failed to the restoration causing a food trap. I treat a lot of these.
DrG
6/11/2017
I couldn't agree more. The vast number of cases I've treated all start with either 2 problems.
Lack of KG
Or
Open contacts creating food impaction.
It's a big lesson for the restorative dentist who read this.
Oliver Scheiter
6/14/2017
Well said Khan. Thank you for posting!
It seems to have become customary for some to discourage posters by disparaging remarks. Why do people feel so threatened that they feel the need to lash out?
In terms of treatment concepts I would listen to DrG. Very sound advice. Xenografts around implants result in very poor vitality of the delicate crestal implant-bone interface thus resulting in higher risk for infection. And once infected it's impossible to decontaminate the dead foreign particles...So when you go in and fill it up with more material prone to contamination, your are doing your case no favour.
CaSO4 is a wonderful material, stable volume, hard setting, antibacterial, can be exposed, so no need for anything but maybe your prf to accelerate wound healing and stabilise soft tissues.
That's by the way the thing I'd look out for: Soft tissue stability. I'd bet these implants suffer from insufficient width and thickness of attached gingiva. That's where the trouble started...
Sunny regards from Mallorca
