Post-Operative Infections from Bone Grafting?

Dr. M. asks:
One of my patients is a nurse. She requires bone grafting to augment her deficient ridges. She has asked me about prion infections from various bone grafting products. Is anybody aware of any patients developing prion or other bacterial infections following bone grafting procedures? I cannot find any information on this subject. What is the safest bone grafting material that will have the least chance of causing an infection, prion or otherwise? This is the first time I have had a patient question the chance of post-operative infection from grafting and I want to be honest and truthful. I also would like to know myself if this is a reasonable concern. Any thoughts?

36 thoughts on “Post-Operative Infections from Bone Grafting?

  1. Autogenous or a Beta Tri-Ca product (alloplast) should ease her worries, but risk of infection (prion) with others is negligable

  2. The best bone grafting and the one with least chance of infection is the Autogenous bone, her bone is the best for her… if you get my meaning. Synthetics like cerasorb or other similar are also good , not as good but they work.
    The chance of getting mad cow dissease is real, but awfully low if the graft is from a reputed company that grafts in a country where the infection does not exist.
    best of luck

  3. Dear Dr M

    CJD is caused by a prion which is a protein not a bracterium. Bacteria can be killed by the usual sterilization techniques and one would not expect to find bacteria in any commercial artificial bone what ever its source. A prion however is simply a protein and therefore cannot be ‘killed’ in the usual sense of the term, but must be destroyed. This is why bone of bovine origin is heated for lengthy periods of time to remove all proteins and leave just the inorganic salts for grafting. Perfectly safe. Read the patient leaflet for Bio-osse

    Peter

  4. Post Op infections from the invasion of any oral surgery is always a possibility, but I am not aware of a greater risk from “Bottled” bone than there is from autogenous bone.

  5. The chances of infection are really minimal, but there. So the safest bet is to use synthetic bone graft (like DentoGen). They are synthetic, hence do not transmit pyrogens, equally effective (if not more) and less expensive.

  6. Anything is possable. The infection rate is higher in smokers etc. prion infection is a possability with Xenografts of Bovine orgin. Autogenous is best, but you have the morbidity issue. I like to use Osteogen. I have been using osteogen since 1992, without any problems. The cost of osteogen is low and it is easy to manipulate. Protect your graft and make sure you follow the 12 principles of bone grafting (ck Micsh’s new text) You can autoclave Osteogen up to five times and it will still work well. Give Impladent a call, they are a reliable company.

  7. Everyone’s talking about disease transmission. What about the safety measures through sterilization and donor screening, possibility of 1 in over 3 billion of disease transmission. What about the research of spiking bone with HIV viruses and still bone processing was able to keep is clean. Has any one every heard of such a case?

  8. FYI-not all bone products are sterilized in the same manner. Be aware some are disinfected only while others use radiation to sterilize
    Wishing you success
    amy

  9. This is an interesting question and one that I have considered for many years. The incubation period for prion diseases is measured in decades so if grafting material is contaminated it would not manifest itself for an awfully long time. As someone else stated, prions are not “living” organisms so regular sterilization techniques are ineffective. The manufacturing companies each have a proprietory method for purifying their product but it is not at all clear if prions are inactivated by this. I would ask the nurse/patient if she eats burgers at McDonalds or pork at a Chinese restaurant. These products come from animals that probably were not inspected for prion diseases and they were certainly not sterilized like BioOss or Puros. It sounds like she is making a big deal about nothing.

  10. For Dr. I: CDJ is Creutzfeldt-Jacob disease
    http://www.ninds.nih.gov/disorders/cjd/cjd.htm
    There are variants–I think the bovine equivalent is scrapie. Any way you cut it, it’s bad news.
    I’ve heard that at one time a history of bovine bone transplant was a disqualifier for blood donated–but I haven’t been able to confirm this. I’m guessing this is NOT true, since my wife has donated after getting a mixed bone graft containing bovine-sourced material and was allowed to donate.
    Can anyone clarify this issue (if there is one) or is this an urban legend?
    Thanks,
    Steve Bornfeld

  11. Thanks Sharon. According to the Red Cross page you link to, the delay includes all human transplant materials as well. Since the incubation period for prion disease is so long, one year wouldn’t be meaningful if this were the concern.

  12. I hope one day all dentists will do blood tests for bacteria and prions before any surgery. Lyme disease bacterias can complicate everything. It is tough to test for these insideous tiny cwd bacteria but it can be done. Intracellular bacteria (L form) can be easily formed by giving the wrong abx with folks that have Lyme and Lyme-like diseases. Everyday we find more and more evidence of these types of bacterias and prions.

  13. Lyme disease is caused by the bacterium Borrelia burgdorferi. Deer ticks, which feed on the blood of animals and humans, can harbor the disease and spread it. People are more prone to Lyme disease if they live in the grassy or forest areas, which are the normal habitat for ticks. Borrelia burgdorferi from a tick bite can enter patients’ bloodstream only if the tick stays attached to their skin for more than 48 hours.There are some paraclinical tests (Enzyme-linked immunosorbent assay, Western blot test and Polymerase chain reaction) that can help to diagnose the disease. Oral antibiotics are the definitive treatment for this disease. They include doxycycline for adults and children older than eight, or amoxicillin or cefuroxime axetil for adults, younger children, and pregnant or breast-feeding women. These antibiotics clear the infection very well and prevent its complications.It does not seem that Lyme disease is caused by any kind of bone grafting or specifically related to, or any causative factor of infections pertaining to bone graft substituting materials.

  14. I have never heard of contracting a Lyme infection from a medical/dental procedure. I guess anything is possable! When I was a microbiologist, we thought what is now Lyme, was juvenile rheumatoid arthritis (jra).

  15. There are many good articles out there on this subject. I particularly like the Sogal article. They did a nice review that looked at the risks. They quantified it and determined that the risks of contracting spongiform encephalopathy was equal to the risk of being hit by lightning. That being said people do get hit by lightning so the risks are there. Although the risk is small, there is still risk, and the risks should be reviewed with your patient as part of informed consent. There are articles that review risks for both bovine as well as human bone grafts. Below are some articles that are good to read for anyone placing bovine bone, I can list the articles for human bone if anyone is interested.

    Risk assessment of bovine spongiform encephalopathy transmission through bone graft material derived from bovine bone used for dental applications.

    Sogal A, Tofe AJ. J Periodontol. 1999
    BACKGROUND: Several commercial products are currently available for clinical application as bone graft substitutes. These products can be broadly classified into two categories: synthetic and natural. Bovine bone is a popular source for several of the natural bone substitutes. The availability of bovine derived xenogenic bone substitutes has made it possible to avoid traumatic and expensive secondary surgery to obtain autogenous bone once thought essential for effective bone replacement. While autogenous bone still remains the undisputed “gold standard” in bone grafting, the realization that bone requirement in several clinical applications is as effectively met by xenografts has lead to their widespread use. But the convenience of using xenografts is tempered by the possibility of disease transmission from cattle to humans. The recent incidents of bovine spongiform encephalopathies (BSE) in humans have underscored this likelihood. In this paper, we report a risk analysis performed to assess the possibility of such disease transmission from a commercially available bone graft substitute (BGS) that is popularly used in clinical dentistry. METHODS: An extensive review of current literature on the status of risk assessment of BSE transmission was conducted, and two risk assessment models were identified as applicable to the present study. Risk assessment models developed by the German Federal Ministry of Health and by the Pharmaceutical Research and Manufacturers Association of America were applied to BGS. RESULTS: Results from the analyses conducted using both models showed that the risk of disease (BSE) transmission from BGS was negligible and could be attributed to the stringent protocols followed in sourcing and processing of the raw bovine bone used in the commercial product. CONCLUSIONS: Based on the risk analysis, it is evident that the risk of BSE infection from BGS is several orders of magnitude less than that posed by the risk of death related to, lightning, tornadoes, or similar remote events. However, this low risk can only be maintained as long as an effective and active risk management program is implemented in operations that involve processing xenogenic tissue for human use.

    Creutzfeldt-Jakob disease from allogeneic dura: a review of risks and safety.

    Marx RE, Carlson ER. J Oral Maxillofac Surg. 1993
    Division of Oral and Maxillofacial Surgery, University of Miami School of Medicine, FL 33136.
    Surgeons and the lay public have recently expressed concern over the safety of allogeneic dura as it relates to the transmission of Creutzfeldt-Jakob Disease. Indeed, two cases have resulted from use of tissue procured from a commercial agency that did not adhere to criteria accepted by the American Association of Tissue Banks or the Southeast Organ Procurement Foundation. This review discusses the risks and safety of allogeneic dura. The findings should reassure the surgeon of the safety of allogeneic dura when it is properly processed and catalogued by a bona fide, reputable tissue bank. To date, there have been no documented cases reported to the Center for Disease Control in which Creutzfeldt-Jakob Disease was transmitted from allogeneic dura obtained from a registered tissue bank.

    Tissue banking safety: caveats and precautions for the oral and maxillofacial surgeon.
    Marx RE, Carlson ER. J Oral Maxillofac Surg. 1993
    Department of Surgery, University of Miami School of Medicine, FL.
    Oral and maxillofacial reconstructive surgeons using allogeneic tissues have expressed justifiable concern over the safety of these tissues as they relate to the transmission of infectious disease. This report reviews cases of infectious disease transmission from inadequately screened donors of allogeneic tissues, as well as those related to improper sterilization and cataloging of these tissues. It is concluded that good judgment and attention to good science on the part of the tissue bank as well as the surgeon can maximize the ability to place contamination-free specimens, thereby avoiding complications similar to those described.

    Implications for Creutzfeldt-Jakob disease (CJD) in dentistry: a review of current knowledge.
    Walker JT, Dickinson J, Sutton JM, Marsh PD, Raven ND. J Dent Res. 2008 Jun
    TSE Research Group, Centre for Emergency Preparedness and Response, HPA, Porton Down, Salisbury, UK. jimmy.walker@hpa.org.uk
    This review explores our current understanding of the risks of (variant) Creutzfeldt-Jakob disease transmission via dental practice, and whether they merit the rigorous enforcement of improved standards of instrument cleaning and decontamination. The recognition of prions as novel infectious agents in humans has caused significant concern among the public and medical professionals alike. Creutzfeldt-Jakob disease (CJD) in humans has been shown to be transmissible via several routes, including transplantation, contaminated medical products, and via neurosurgery. While the likelihood of transmission via dentistry is undoubtedly very low, this may be amplified considerably by unknown risk factors, such as disease prevalence (particularly in the UK), altered tissue distribution of vCJD, and the failure of decontamination processes to address the inactivation of prions adequately. Since current diagnostic techniques are unable to detect PrP(Sc) in human dental tissues, there is limited evidence for the presence of infectivity. Given these uncertainties, the control of risk by reinforced and improved decontamination practices seems the most appropriate response.

  16. Post-op infections are caused by the body not being able to control the pathogens. If a GOOD blood supply is maintain the infection rates are very low. Therefore, a good technique is the solution and understanding the wound healing principles is a must.
    Look at Sept 2008 issue of JADA about the safety of allografts by Holtzclaw, Toscano, Eisenlohr, Callan.

  17. Dr.’s , what are you able to comment about this situation. I was admitted to the hospital and diagnosed with osteomyelitis of the jaw after failed implant surgery. I am on pick line with antibiotics. #6 and #7 were placed June 30th 2008. #6 removed July 28th and #7 removed August 13th. My internist admitted me August 15th after his concern of infection and extreme pain. It is now September 19th, 2008 and the pain continues (pain started right after initial surgery). It seems to be radiating from #6 area, pin prickly feeling up side of nostril and into cheek area, with extreme tenderness, pain in gum tissue, and noticeable swelling/pain of cheek area. Any insight into the diagnosis and/or treatment of what is going on would be so appreciated for my physical and mental well being. Thank you.

  18. It’s obvious the areas are infected. It’s not always the implant surgeons fault. What is the condition of the bone and teeth prior to implant placement? IF THE BONE HAD AN OLD om THIS COULD BE AN ISSUE, iF THE SITES WERE NOT DETOXIFIED THIS COULD BE AN ISSUE, YOUR GENERAL STATE OF HEALTH AND YOUR PERSONAL HYGEINE AND HABITS ARE ALSO A HUGE FACTOR.

  19. Dr. Hughes, it seems your attitude matches the attitude of the surgeon who placed the implants. He ignored my pain and requests for help. My habits and hygiene have always been complemented by my Dr’s. Isn’t it the surgeon’s job to evaluate the condition of the bone and teeth? I am a patient who is asking for help from professionals, who may have some insight. Thank you.

  20. As Dr. Callan stated,primary cause of any infection is body’s inability to fight organisms.
    Let me give you my own example. I was born and raised in India.In my childhood and early adulthood including my college days I was very care free and ate at every corner vendors which were obviously very unhygienic, I would called them dirty.And drank drinks like sugar cane juice and sodas,tea-cofee in dirty cups.
    But nothing happened.
    But after living in USA for so many years, When ever I visit India- even after taking many precautions including avoiding uncooked food and drinking only bottled water from reputed co.,dining only in very good restaurants,some times I still get sick with dysentry or amaebiasis or hepatitis A.
    The point is my body is same but I have lost immnuity of my Indian days.
    Secondary cause of post-op infectio is dirty instruments,unhygienic condition of clinic or products being used or deficient surgical technique, but again it is human body who responds to those evil orgamisms.
    I have seen many heavy smokers with plenty of plaque and calculus without any trace of perio pockets at the same time very meticuolosly clean mouths with perio problems.
    Prion is a non-orgamism infection and any bovine product which is free of protien SHOULD be of less concern.

  21. lISA, IT’S NOT AN ATTITUDE ISSUE. IT IS WHAT IT IS! THE MOUTH IS NOT STERILE. BELIEVE ME, I FEEL SORRY FOR YOU. GO BACK AND READ WHAT I STATED ABOUT THE PREPERATION OF THE SITE AND ABOUT BONE NECROSIS. SOMETIMES BIOLOGY IS NOT KIND TO US, IT IS NOT A PERFECT WORLD. THE TERM OM REFERS TO A BONE INFECTION. THERE IS NOT ALOT IN THE LITERATURE, BUT THIS MAY BE THE ISSUE.

  22. Is anyone aware of any medical condition that will absolutely preclude a patient from getting dental implants?

  23. Dr. Hughes, Your CAPS seem as though you are yelling at me. I know what OM is. I have it, I am on a pick line. Thankfully, my blood work is coming back showing infection is being decreased. I just wanted to know if any of the Dr’s have any experience with patients like me who developed this ongoing pain after having infected implants removed and what it may be. As described earlier, radiating pain up side of nostril from what it seems #6 site, into cheek area. Soreness, throbbing, and some swelling (surgery was 6/30/08, almost 3 months ago). The M.D. does not think that the infection is the cause of this ongoing pain as it is clearing up, but the pain is not. M.D. does not know why it continues. I would just like feedback on any possible reasons of this continued pain.

  24. I am not yelling at you. You stressed out and I understand that. It is possable that you have a neuralgia from the extraction and or implant placement. This is a still misunderstood and rare event. Unfortunately you are the one with the problem. Iremember I had a neuralgia post sinus infection and it was most painful. It did resolve with time! You may want to see a pain management physician or a neurosurgeon. We do not always have all the answers.

  25. The throbbing and swelling w/o current infection sounds like a reflex sympathetic dystrophy. See a good pain management doc or neurosurgeon. First run the course with antibiotics.

  26. I would highly recommend taking into consideration what Peter Fairbairn said on the initial post. Autogenous or a Beta TCP products will ease many of these issues. Cerasorb has worked very well in my hands plus I like that fact that my patients nor myself have to worry about the issues being discussed here.

  27. i am looking into implants now and i remember being told that there was a risk of touching on or aggravating the sinus nerve. could that be the problem? and Lisa i wouldnt place too much stock in the advise of a dentist who cannot even spell the word preparation. good luck!

  28. I studied prions research for over 15 years now.

    It is highly possible to transmit via any host/graft

    recipient. As there is no known way to eliminate.

    As for the lyme caused by borrelia which is the cousin

    to syphilis, it should be considered highly infective

    in bone as the number one site on autopsy for finding

    them is marrow. Bone and joint necrosis should lead

    doctor to first question if the patient has this,

    which is being estimated cases to be over 200,000. .

    Especially in jaw, shoulders and knees. It is up to

    the doctors to do the research on the latest medical

    research to determine cause of illness and injuries,

    and determine the best treatment for patient.

  29. Silverman, Good points about prions and Borrelia sp. I am glad your thinking, prior to dental school I was a microbiologist for several years. I think Lyme is a big sleeper, that will be a huge public health issue. Where I live and practice in Virginia is known to have some of the highest rates of Lyme in the country. I have had countless patients with all sorts of symptoms due to Lyme disease. From arthritis to heart block and neurologic issues. As for the prions, I am still trying to understand them. I am dating myself but the prion infections uesd to be classified as slow viruses.

  30. I just had an implant removed due to severe health issues and infection. My symptoms are better but the two areas where I had bone grafting (one never had an implant just the graft) are stinging and sore after 5 months. I am also still on antibiotics. My dr used Peros Allograft and since I rejected the implant I am wondering if I am also reacting to the bone graft. Can the graft also be removed?

  31. Dr. Hughes……..you need to wake up and challenge the secret society of the ADA. You will never appreciate the horror of 5 years of research and knowledge I have accumalated after a disaster of bone graft surgery. If you want to implode like the rest of your fellow dental ignorant …..stay the course, but you will regret not questoning the true Dental Experts for your readers.

  32. Karen: First of all, I am not a member of the ADA. And second I usually use a synthetic bone graft material (Osteogen). Why Osteogen-well it works without any infection etc and with the advent of prp or prgf, it’s great. It is too bad that you have these problems. I usually treat with modalities that do not require block or onlay grafting and this is where me and alot of my colleagues part ways.

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