Pain After Placing Nu-Oss Bone Graft: Source?

Dr P What does the extraction site look like now? Have you had a change to see the patient? Are there any signs of infection? What type of membrane was used? collagen/ PTFE? Is the wound open? Is the bone exposed? The cause of the pain could be anything from mishandling of the tissues during surgery to loss of graft and exposed bone. First bring the patient in and assess the situation.

I agree with colleague Carlos Boudet.Call your patient and have a look at the place of operation.The condition you have described looks like as a dry socket.In this case you have to rinse the socket with saline to remove the debris without disturb the inflammatory soft tissue of the place.Leave the nature to works! The placement of a sterilized gauze sponge immersed in eugenol could be calm the symptoms. Good luck.

Do you have a periapical film of the second molar? From the films you have included, there is a potential lesion on the distal root. If that is not the source, then how did you debride the extraction site? Leaving inflammatory tissue in the apical areas will surely contribute to this type of sequelae. If you are not going to debride the area with a laser, then mix your graft material with metronidazole. Is your membrane still intact, or is there leakage into the grafted area? Try doubling the membrane over next time to slow down resorption or place an autologous PRF membrane over the collagen to dramatically speed up soft tissue closure. RJM

Strikes me this was a recipe for complications in the first place - shovelling a lot of foreign material into the socket and then failing to get soft tissue coverage over the top. It's bound to become infected, just as it would in any other part of the body. Next time I suggest you just take the roots out, leave the socket to heal for 6-8 weeks, then place your implant. Forget about laser debridement, mixing your Nu-Oss (aka minced up dead bone) with an antibiotic, and an autologous PRF membrane. Your best bet is a combination of a blood clot and Mother Nature - and it's cheaper!

Tissue trauma from the extraction is unlikely because the pain developed a week after extraction. Necrosis of the socket wall is a given and is the most likely cause of pain. At this point the porous Nu-Oss granules are simulating osteonecrosis as they are filled with bacteria that the body has no way to kill. Keep the patient on systemic antibiotics, debride the socket but do not graft with porous granules as they will also become infected. It is our experience that grafting with Socket Graft provides rapid pain relief and healing. If you just leave it open pain relief will likely be very slow. If you want to know what is happening in the socket remove the graft material and put it in a biopsy vial and send it to us and we will provide you with histology at no charge. If you want send us a sample email me at ggsteiner@steinerlabs.com

Maybe you would like us to go back to the Dark Ages as well. It's clinicians who don't use these modalities who are the first to denigrate them. Decontamination, debridement, bleeding bone, and occlusion of epthelial cells is as 'mother nature" as you can get. Re-engineering the biology of the osteotomy is the paradigm I have chosen, with success rates identical to healed sites. Compression of the wound response with newer biologics can best "mother nature" as well. RJM

Have seen the effects of an infected site exacerbated by Xenografts , as have others hence the protocol of mixing Abs with the graft .Best to stick to Bacterio-static synthetic materials in these type of sites . Peter

From the films of this case,there is a chronic hardning ostitis around the socket. So the circulation of the blood is very wrong in this site. If you put the NuOss into the socket firmly,the circulation of the blood in the socket is shut down. You had better rinse this socket perfectly and do the decortication by the round diamond bur. Then put into PRF Clot only(not membrane)into the socket and close the socket by the cross matress suture gently. The primary closure of soft tissue is not neccessary.

If you allow mother nature to take her course after trauma or disease you will always get scar tissue with decreased vitality and function. If re-engineering the osteotomy gives you results equal to healing sites why do anything? Compression of the wound response just gets you there quicker. The goal is to skip the normal healing response(mother nature) and regenerate tissue equal to ideal form, function and vitality and maybe even better.

Thanks everyone for their input. I saw the patient for follow up. Patient had lost RCM6 membrane covering the graft. Portion of graft was missing with open bone area I cleaned out the graft creating new clot and patient reports feeling lot better. Appreciate everyone's help.

You should take biopsies for a histological result.