Dental Implants:  An Overview of Infection Control & Healing: Part I
by Mark R. Mortiere, MS DDS, FAGD

The practice of implantology is a complex part of dentistry that requires specific knowledge and training. A discussion on the control of infection and healing around surgically placed implants is addressed. Key points for the surgeon range from the simple to the esoteric. A MEDLINE 1995-98 computer search in the National Library of Medicine retrieved over 1300 articles on dental implants and more than 10,000 citations on infection control. However, only 11 abstracts on a combination of dental implants and infection control were noted and none regarding practice guidelines. Still, as is true of most any endeavor, if common sense prevails, success will follow.

The standard of care for implant dentistry is vague. The standard of care generally describes the level of care given in a particular procedure by a typically trained practitioner in a given geographic region. However, paying attention to detail is of paramount importance in all areas of medicine and dentistry, including implantology.

Controlling Infection

The control of infection around an implant actually begins with the pre-operative screening of the patient. The American Society of Anesthesiology has devised a classification scheme that categorizes the physical status (P.S.) of a patient. Classification is determined by a history and physical examination. Age alone is not enough of an indicator for classifying someone into a P.S. status. The P.S.l classification is a healthy patient, while the P.S. II patient has mild systemic disease, but no functional limitation. Treating patients in these two categories will lead to predictable healing and enhance the clinician's ability to control infection. Table 1 shows the ASA Classification system.

The key to the prime dental implant candidate lies in patient selection. The surgical patient must be chosen carefully; the patient's past medical history must be thoroughly reviewed to rule-out anything that may contra indicate surgery. The personality of the patient is also important; the patient must be emotionally prepared for the various surgical and prosthetic steps involved as well as the time needed to complete the procedures. A carefully chosen implant patient will facilitate the management of problems that arise.

Infection Risk

The risk of infection with dental implants is low. However, Topazian has discussed certain risk factors that are associated with infection around implants. Such factors may either predispose or initiate infection; some risks can be changed by the surgeon, some by the patient. The risk factors for infection may be placed into four groups: host, microbial, implant and surgical.

Host Infection Factors

Intact mucosal tissue in the host patient is an important barrier to resisting infection. This barrier is broken with incisions and placement of implants. James and McKinney, Jr. note the importance of the tissue-implant biologic seal in healing. The gingival epithelium forms the seal around the implant as it emerges from the underlying bone and submucosa into the oral cavity. This is the weakest area of the healing implant; it is where tissue breakdown initially begins in an infection. The biologic seal must be a barrier to plaque, oral debris and other toxins if the implant is to succeed. Healing can be affected by cigarette smoking, which impedes vascularity around oral wounds. Ischemia induced by smoking may cause the implant to fail.

Common systemic host factors are diabetes mellitus and underlying established chronic situations, such as dental caries, bronchial problems and urinary tract infections. These patients are at a greater risk for infection with dental implants. It is important for the clinician to be aware of these problems and to help the patient in the management of these factors before considering and after the placement of implants.

Table 1 ? American Society of Anesthesiologists Physical Status Classification:

1) Normal healthy individual.
2) Patient with mild to moderate systematic disease.
3) Patient with severe systemic disease that limits activity but is not incapacitating.
4) Patient with severe systemic disease that limits activity and is a constant threat to life.
5) Moribund patient not expecting to survive 24 with or without an operation.
6) Clinically dead patient being maintained for harvesting of organs.

Article reprinted with permission from Dental Surgery Products, Vol. 3, No. 2.

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