Adding Antiobiotics to Bone Grafts: What Are Using and What is Your Rationale?

Tetracyclin is in combination with unresorbable Bio-Oss including pathogenic proteins from cows perhaps a result for some months or a few years. But your patient will never have human bone what should be the aim.

As a general rule, the use of systemic antibiotics used topically is contra-indicated and poses many potential problems. If the augmentation material introduced is sterile and an aseptic surgical protocol is used, there should be no indication for routine use of antibiotics, systemically or topically.

In the orthopaedic sector bone substitutes and antibiotics are combined. The practice is "off label" but widely undertaken. The chosen bone substitute is one that can be prepared into beads/pellets and which resporbs completely in a short time scale ie Calcium Sulphate. A porous non or slow resorbing material such as HA (bovine or synthetic) would not be a sensible option in an infected site as it could form a nidus for infection over the long term. Robert

I have found that tetracycline can have multiple benefits. First, use it in a "socket" as it stains soft tissue which should be degranulated. Second, small amounts have been used in osseous grafts although I do not do this unless it is a retreatment. Third, some still use it PO, I prefer Amox. Fourth, mix with your periodontal dressing as my periodontist suggests. Fifth, it can be used in conjunction with citric acid to scrub roots for periodontal/osseous/reattachment surgery. I have used doxycycline sucessfully as Atridox in peri-implantitis with purulence (placed by dental student). I prefer to have a sterile field but that is a goal that may not be 100% "real world" attainable. Oh, lastly, it is inexpensive. That's a benefit right?

What about metronidazole (flagyl*) intraveinus serum ?

Have you ever heard something about Bio-Oss and trigeminal neuralgias and chronical sinus infections?

Dr.A, trigeminal neuralgia is an intracranial disorder and is not related to BioOss or sinus infections. It is caused by irritation of the trigeminal nerve intracranially, i.e. it is a central disorder and therefore not mitigated by peripheral factors.

Sorry, I know cases caused by Bio-Oss. Think about scares!

we can mix bone graft material with antibiotic eye drops, to get a working consistency same antibiotic is administered orally , so that locally and systemically same antibiotic is present.

Antibiotic eye drops? Patients have human bone. Then we have unresorbable xenografts as HA. No human bone at all. You cannot call it bone. Why suffer patients with chronical sinusitis infections after grafting with unresorbable xenografts? Alternatives for example: resorbable Betatricalciumphosphat, resorbable allografts, resorbable autologous bone, blood or no grafting.

I USE A SMALL AMOUNT (4 DROPS) OF CLINDAMYCIN FROM THE MEDICAL MULTIDOSE VIAL. IT WORKS GREAT, ESP FOR SINUS GRAFTS. NEVER USE A PILL FORM OF ANTIBIOTIC AS IT CONTAINS MANY OTHER AGENTS SUCH AS TALC., ETC.

Adding antibiotics to bone grafts has been standard practice in the neurosurgical , orthopedic and maxillofacial arena for decades. There have been only a few studies that have been relatively inconclusive. With that being said, in cases where a sterile field can't be maintained, I mix clindamycin with autogenous grafts,prp and/ or bmp. I don't believe it can hurt anything and unfortunately even though the science doesn't strongly support the utilization of parenteral abx , I still use them in big cases. B. Vinci

Dr c. , one thing that I have started doing ,based on suggestion from a single JOMS article, and personal knowledge of the helpful effects of steroids; is start my sinus lift patients on a week of steroids and pre op abx.. On a large sinus lifts, I add clinda. With prp to my bone grafts, with good results. Some may suggest this as overkill, but the stabilizing effect of steroids has to make help keep the membrane in tact. You are not going to induce an addisons event with one week of pre op low dose steroids. Bv

Has to help keep the membrane intact bv

The main factor you need to consider is the effects of the antibiotic on the regenerative process. At concentrations prescribed orally they are non toxic. But locally applied antibiotics can apply huge doses to the local tissues. The pH is another factor. I understand tetracycline produces a low pH. From our experience a pH below 6 will cause postoperative pain and osteoblast cell death. The most common buffer for pH is sodium bicarbonate. So, figure out an appropriate dose and correct the pH to around 7.2 if needed and you will be the expert. Personally I never do a bone graft without oral antibiotics but I never apply antibiotics locally but I have no criticism of those who do. Greg Steiner Steiner Laboratories

Can't believe what I am reading in this blog. All of the empirical statements about adding chemotherapeudic agents to bone grafts are astounding to me. This question seems to come up regularly. If you want some legitimate answers, place keywords in the search section of this website and peruse the blogs from previous years. The only legitimate studies on adding antibiotics in grafts comes from Choukroun, et al, and Simonpieri, et al in the journal Implant Dentistry. They did split mouth studies on adding metronidazole to sinus grafts and followed up with CT scans to look at bone volume and density. Metronidazole is the clear winner with regard to preventing anaerobic contamination in sinus grafts. Oral antibiotics will have virtually no effect as the graft has no blood supply. Empirical cocktails have no place in clinical practice without histology or a biologically based paradigm. RJM

Dr. Miller I lived through the years when oral antibiotics were questioned as having more serious side effects than the possibility of a post op infection. After a few facial cellulitis cases when not using oral antibiotics I decided that was crazy so I always use antibiotics to prevent infections not in the bone graft site but from spreading into the patiens face. You mention preventing sinus graft infections with local antibiotics. The sinus is sterile so the best way to prevent infection is to use a technique that does not intoduce bacteria. I do sinus augmentations regularly, never use local antibiotics, and have not had a sinus graft infection in years. Greg Steiner Steiner Laboratories

Dr Steiner, the sinus is sterile? How could that be if the ostium is in tact? An intact, functioning sinus is open to the nose below the middle meatus,and if it's obstucted,it is most likely at least colonized with aneorobes and soon to be infected. Dont tell me you think all urine is sterile , as well. The standard u/a has some bacteria in every study I see. Please don't suggest to us now, that sucking through a straw leads to alveolitis. Why do we as dentist, need to continue to forgo evidenced based medicine, and tx patients with wive's tale medicine. I just couldn't resist. Bv

To suggest that the graft in your sinus has no blood supply is a little off as well. If you have ever witnessed an osteotomy of the maxilla you would appreciate just how much blood is in this area , hence the reason we ask the anesthesia doctor to signicantlt lower the patients blood pressure when we proceed with the down fracture. This is the same reason( or one of them) we perforate the host sight and cortical blocks. In reallity ,none of us really knows what goes on at that level, so everything is empirical . There are several good studies that support utilization of preop abx, and there are several that don't . To suggest that it is "stupid" to use abx or steroids, when reward outweighs the risk is........... Well, U get my drift. Practice safe, evidence based dentistry, bottom line. Good day, bv

Why in the world are you using tetracycline? Bv

I was not questioning the use of oral antibiotics as a preventive measure postsurgically. I do, however, take exception to the myriad protocols expressed here without studies to back them up. Whether the graft is in a sinus or extraction site, the possibility of achieving a pathogen free graft is virtually non-existant. The bacterial load intraorally is as high as anywhere in the human body. Salivary contamination, the use of intruments that come in contact with oral fluids and mucosa, remnants of apical pathology, periodontal infections, small sinus perforations, and the simple act of the patient breathing will seed the surgical site with pathogens. Oral antiobiotics may prevent events such as cellulitis, but they have virtually no effect on large particulate grafts. How many times have clinicians on this site reported infections that do NOT clear up with oral antibiotics? Most of these untoward clinical manifestations can be completely avoided by the judicious use of antiobiotics mixed with the graft material. My choice, and the the growing choice of many surgeons , is aqueous metronidazole. RJM

Which are large particulate grafts that lead to infections? Please tell the names of those products.

It would appear to be relevant as to what particulates are used , prevention of bacterial entry to the site is impossible . Thus the use of bacterio-static synthetic graft materials can be of great benefit as Greg Steiner knows . We have also had no infection issues as a result of these materials even when the the lining is torn or even destroyed when removing an object from the sinus. The body wants to heal LETS HELP IT .

I have to comment on the response,that some one" knows of a case of trigeminal neuralgia caused by bioss". This sounds like something straight out of a deposition with an "expert witness". I know I'm a new member on the site,but that can't go unattested . Tic doleureax is a serious condition and half of the neurosurgical world believes that it is intracranial and the other half believes it occurs distal to the foramin ovale . But no one really knows for sure .More than half of patients I know that have been stamped with this dx., typically have an atypical neuralgia ,which is vastly different from tn.. I don't use bioss,but we really need to have some merit ,when we make such "wild" accusations. Bv

Or rotundum(sp) bv