Pus exudate after an open sinus lift operation?

Open the flap, peer into the window you created, try to remove the infected graft material as gently as possible, gently rinse with Peridex, and cover the opening with a PRF membrane followed by a collagen membrane and close the soft tissue. The patient should be on antibiotics for several days.

Yes.

Definitely YES

The consensus of the comments agree with Dr. Rudick , including myself. I prefer to place the PRF membrane on top of and underneath the collagen membrane, for the enhanced soft tissue healing. If you prescribed Amoxicillin post-operatively, consider adding metronidazole to the new regime of antibiotics (amox + metro). Good luck!

When I took my oral board for ABP in 2007 they presented me a similar situation. The discussion concluded with the the warning of such things are bound to happen if you choose to perform the procedures. When you go to correct the unfortunate circumstance avoid introducing and foreign material such as a membrane. Remove, let it heal, re-treat if necessary and chalk it up to the cost of doing business.

Sorry, I disagree with the first 4 contributors. Raise a buccal flap and clean out all the graft material, granulation tissue and general debris (enlarging the bony window to gain access if necessary) then close up with non-resorbable sutures. Remove the sutures at 7-10 days. Prescribe an appropriate antibiotic e.g. co-amoxiclav (3 days). DO NOT put collagen membrane, PRF or any other foreign material back into the wound. Ask any ENT surgeon - do they put resorbable membranes, etc across the antrostomy window after a Caldwell-Luc or any other transoral antral surgery? The answer is "No". The only value of a membrane when performing a sinus lift in the first place is to stop the particulate graft falling out of the hole and you've just gone back in and removed the graft anyway.

I think your question has been answered but clearly there are some conflicting views. However here is my concern. You have performed a sinus operation and now have an infection flare up. So you need to remove the graft material and do the necessary. That is understandable. However you apparently do not know the protocol and process to reasonably do this procedure (if you do, why ask the question?). I do not want to discourage people asking questions or learning. However it truly worries me that some operators think that this site is a training site for beginners. It is not. The site can be used for Hints and Tips, transfer of information on new materials and techniques. I do not think any clinician would expect to get their dental training “by YouTube” or on line (“by Google”). All undergraduate dental training requires a “hands on” training component. Implantology is no different – indeed is could be said that it is more important there is hands on training required. It has been said numerous times on this site; in many cases it is most appropriate that dentists refer to a specialist. Patients are not experimental or training dummies; they deserve the best possible care. It has also been mentioned many times that most specialists would be delighted if the referring dentist observed the operating procedure or even more likely, assist during surgery. You cannot get better hands on experience than that. I am sure we all think that any registered dentist should (must?) know how to conduct a particular procedure before operating on a patient. However I am also sure that we all think that, before an operator starts, they should know how to deal with any problems that may arise. Sometimes a problem can or should be dealt with by the operator. However most of us also know (particularly if we have some experience) that sometimes it is better to stop and refer to a specialist. All clinicians make mistakes or have complications. Some are accepted risks and hopefully the patient was initially informed about these before consent was given. However once problems are identified, clinicians have a moral and legal responsibility to mitigate the damage. Sometimes this can be done by the original operator, but many times it is better handled by referral to a specialist because we have a duty of care to provide the best option once a complication arises. Given your question and the obvious diversity of opinions provided by readers, I suspect you would better serve the patient by referring to a specialist.

Was there a perforation? Is the osteum blocked? If not the graft should be easily removed from the lateral window with gentle suction and curettes. I like the addition of Flagyl. Rare that a graft would produce exudate if there is neither a blocked osteum or perforation. Hope you have an ENT colleague riding shot gun, use of a membrane is the least of your concerns.

Dr. Gerke, In your answer to this posting , you have convinced me that you are the almighty of implant dentistry, therefore I would like for you to enlighten us with an answer to the question posted by the none educated GP .

Forgive me for asking, where is the pus exudate from?

No one claimed gps can’t beautifully perform advanced surgical procedures. Rather, it was reasonably stated providers should be knowledgeable about complications resulting from procedures they perform. No harm or insult in suggesting a referral when in the best interest of a patient. When I receive a referral for a procedure beyond the knowledge or skill of my provider, I am not critical, I am thankful.

In dental education beside oral surgeons nobody is exposed to a surgical protocol that is observed in operating rooms in each hospital. Dentists are used to ignoring strict protocol because they could get away with very little. It comes from the nature of dentistry. Watching periodontists, endodontists work is enough to come to the conclusion that dentist have very little respect for surgical protocol. A dental assistant has no clue how to prepare the area for surgery. Perhaps the problem in the subject case was inadequate asepsis. Decontaminating the wound without any adjuncts would be the way to go. First one needs to establish good tissue health before proceeding further. Just because we started in a barber shop does not mean that we need to return there.

Before giving any antibiotics pus should be given for culture and sensitivity. wait for 72 hours and chose the correct antibiotic. try to get a injectalbe one. keep the patient on the specific drug for 48 hours and call for lavage.Throu the discharging sinus open a window and remove the remaining graft and also the membrane.Flush the area with metrogyl solution multiple times. pack the area with suitable antibiotic gauze and leave it for 24 hours. remove the gauze and flush the sinus and take another culture swab.if it is negetive proceed with your plan. second culture is necessary to rule out fungal growth infection.

The treatment regime is what I follow. You can modify according to your patients general condition and concern.

Well I've been there and treated similar problems. (Perspective; have been placing and restoring implants in Europe since the late eighties). The position of the discharge point was not disclosed. If that tissue was weak, and unsupported, and broke down further during clean-out and lavage, I'd be inclined to be prepared to provide extra support for the soft tissue so that the risk of making the problem worse with an oro-antral fistula is reduced. I think you might want have extra options for closure in those circumstances, including flap advancement. There's also the issue of the granulation tissue, mentioned above. You want to curette out all that stuff and leave the region clean. It can bleed a lot so maybe review any large NVB tracks seen on radiography. A colleague in Denmark treated in this in a very different way for reasons related to the patient's history. He flushed out the drainage point regularly ( hydrogen peroxide rinse and chlorhexidine) while maintaining the patient on antibiotics for several months. In this case they'd done an open lateral wall and placed 2 implants that intruded into the BioOss mass. It all survived. And my other issue is that I feel that it's important that people should feel able to ask a question, and expect patient supportive gestures, even if (and this is not such a case) the practitioner is a complete spanner. Somebody who is prepared to ask for comments and discussion should be encouraged.

One very, very short leash: IF the patient is not febrile. and IF the drainage is minimal, add metronidazole to the antibiotic regimen. Thread an IV catheter into the fistula and GENTLY irrigate with CHX, 10cc total -think 1 cc/minute, there need to be ready drainage for the CHX, and do not force it. Daily for 3 days. If exudate does not resolve or patient becomes febrile, don’t hesitate to proceed with removal. I did this for one patient, and it was successfull in quelling the infection. The patient was me ?. Don’t turn your back on this for a second. That said: Leaving any portion of a contaminated particulate graft in situ is risky, antibiotic regimens aside. Any graft without blood supply will serve as as seed for continuing infection, and this is no area to play the odds. As an aside, I personally use an antibiotic in all grafts including PRF (IV metronidazole 1cc/tube before spin). Who performs this requires an honest reflection on whether your skills are sufficient. Again, the antrum is not to be treated lightly, and between oral and antral microbes, whatever is growing has a virulent potential. Flap it. Take it all out, irrigate liberally w/CHX. I might place PRF but not collagen (infected/compromised site). Consider a drain the patient can orrigate w/ CHX daily for a week. Augmentin and Metronidazole if patient can tolerate. While the patient prefers a quicker approach, impress on them first it is necessary to preserve their health; only after all has healed, especially soft tissue for flap management, should re-entry be attempted. As an aside, large antral tears can be managed with a “Pikos Rosette”, a meeting of origami and guided tissue membranes, which can be used to form the body of an antral graft. Stabilized PRF/particulate graft reduces chances of migration. Subantral procedures can and will become infected. It’s disappointing to patient and surgeon alike, but needs to be treated aggressively to prevent serious sepsis. Prayers and best outcomes for you and your patient.