J Clin Periodontol 2007 doi: 10.1111/j.1600-051X.2007.01162.x

Mahmoud Abu-Ta’a1, Asepsis during periodontal Marc Quirynen1, Wim Teughels1 and Daniel van Steenberghe1,2 1Department of Periodontology, School of involving oral Dentistry, Oral Pathology and Maxillofacial Surgery, Faculty of ; 2Holder of P-I Bra˚nemark Chair in Osseointegration, implants and the usefulness Catholic University of Leuven, Leuven, Belgium of peri-operative antibiotics: a prospective, randomized, controlled clinical trial

Abu-Ta’a M, Quirynen M, Teughels W, van Steenberghe D. Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: a prospective, randomized, controlled clinical trial. J Clin Periodontol 2007; doi: 10.1111/j.1600-051X.2007.01162.x.

Abstract Objectives: This randomized clinical trial compares the usefulness of pre- and post- operative antibiotics while strict asepsis was followed during periodontal surgery. Material and Methods: Two groups of 40 consecutive patients each with fully or partially edentulous jaws were enrolled. Antibiotics group (GrAB1): 23 men, mean age 60, 128 implants, received oral amoxicillin 1 g, 1 h pre-operatively and 2 g for 2 days post-operatively. Non-antibiotics group (GrAB À ): 20 men, mean age 57, 119 implants, received no antibiotics. Bacterial samples were taken from the peri-oral skin before and at the end of surgery. In 12 patients in each group, samples were also taken from the nares. A VAS questionnaire evaluated symptoms of / inflammation by both the patient and the periodontologist at suture removal. Results: There were no significant differences between both groups, neither for the clinical parameters nor for the microbiota. Staphylococcus aureus was detected in the nares of one patient only. The patients’ subjective perception of post-operative discomfort was significantly smaller in the group receiving antibiotics. Three patients lost one or two implants. Key words: ; implant surgery; nose cap; periodontology; post- Conclusions: Antibiotics do not provide significant advantages concerning post- operative infection; Staphylococcus aureus operative in case of proper asepsis. It also does not reduce peri-oral microbial contamination. It does on the other hand reduce post-operative discomfort. Accepted for publication 18 September 2007

Clinical disinfection appeared in surgery suggested that it was the medical per- Periodontal surgical procedures carry in the 19th century when Semmelweiss sonnel who infected patients by with them an inherent risk of developing moving from the autopsy to the delivery complications such as infections. rooms without performing proper It is especially important to avoid Conflict of interests and source of clinical aseptic measures. Around the peri-operative infection of the wound funding statement same time Lister, influenced by the during surgery, when foreign bodies The authors declare that they have no work of , believed it are implanted (Haanaes 1990). Indeed, conflict of interests. was possible to reduce post-operative biofilm-shielded microbial colonization No external funding, apart from the sup- infections by using carbolic acid to on the surface of the latter is much more port of the authors’ institution, was avail- purify the air during surgery (Salvi resistant to antimicrobials than their able for this study. et al. 2006). planctonic form (Gristina et al. 1989). r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard 1 2 Abu-Ta’a et al.

Even though periodontologists and oral viduals are the nares and 20–30% of years. In patients of GrAB1, 128 surgeons often prescribe antibiotics rou- normal people are nasal carriers (Ayliffe endosseous implants were installed. tinely following gingivectomy (Stahl & Lowbury 1982). It has been reported The non-antibiotics group (GrAB À ) et al. 1969), osseous resective (Kidd & that S. aureus carriers have a two- to consisted of 40 patients: 20 men and 20 Wade 1974), regenerative (Cortellini & nine-fold increased risk of development women, mean age 57 years, range 26–88 Bowers 1995), and implant-related sur- of surgical-site infections (Wenzel & years. In this group, 119 endosseous gery (Dent et al. 1997), the validity of Perl 1995) and that S. aureus causes implants were placed. such tradition remains unsubstantiated. 25% of health care-related infections The exclusion criteria for the study The side-effects of antibiotic therapy are and contributes substantially to the mor- were allergy to penicillin, need for well documented and can be serious, bidity and costs of hospitalizations endocarditis prophylaxis, any systemic including anaphylaxis and the possibi- (Engemann et al. 2003). or local immunodeficiency, uncon- lity for development of resistant micro- The aim of this randomized, con- trolled diabetes mellitus, or previous bial strains (Dent et al. 1997). Health trolled clinical trial was to compare the radiation therapy in the head and neck authorities tried to convince doctors to usefulness of pre- and post-operative area. Such patients would systematically limit the use of antibiotics as much as antibiotics while strict asepsis was fol- receive prophylactic antibiotics and possible because of possible side effects lowed during periodontal surgery. were not considered for randomization. and budget implications. Further aims were to investigate the Patients in the GrAB1 group re- Some reports have shown that antibio- effect of peri-operative antibiotics on ceived amoxicillin 1 g per os, 1 h pre- tic prophylaxis offers no advantage in the peri-oral skin microbial flora and to operatively and 500 mg four times per preventing post-operative infections or detect its impact on S. aureus from the day, 2 days post-operatively. Patients affecting the outcomes of periodontal nares of the patients involved. in the other group received no anti- surgery involving gingivectomy (Pack biotics. All patients were instructed to & Haber 1983), mucogingival procedures rinse with chlorhexidine digluconate, (Checchi et al. 1992), osseous grafts PerioAid (0.12 solution without alcohol) (Pack & Haber 1983), or the insertion Material and Methods for 1 min. just before surgery. Post- of endosseous implants (Gynther et al. This prospective, randomized, con- operatively they all rinsed with the 1998). The rate of infections following trolled clinical trial involved 80 conse- same agent twice a day for 1 min. up periodontal surgery, when no antibiotics cutive patients (fully or partially to the follow-up visit (stitch removal), were used, ranges from less than 1% edentulous maxillas or mandibles or which was 7–10 days later. Further- (Pack & Haber 1983) to 4.4% (Checchi both) treated by means of endosseous more, the peri-oral skin of all patients et al. 1992) for routine periodontal sur- oral implants in the OR of the Depart- was disinfected for 30 s using cetrimo- gery and 4.5% when endosseous implants ment of Periodontology of the Univer- niumbromide 0.5 and chlorhexidine are installed (Gynther et al. 1998). sity Hospital of the Catholic University 0.05 in water (UZ Leuven pharmacy, Several sources of infection during Leuven. These patients were randomly Leuven, Belgium). Both the surgical surgery in the oral cavity have been assigned into one of two groups (with team and the patients were blinded to identified: instruments, the hands of and without antibiotics 5 AB) of 40 the groups. surgeon and assistants, the air of the patients each using random sampling Measures of asepsis and prevention operatory room (OR), patients’ nostrils with masking of the person performing against infection from the oral cavity and saliva, and the peri-oral skin (van the randomization. The study was included the use of sterile drapes around Steenberghe et al. 1997). In orthopaedic approved by the Ethics Committee of the patient’s mouth, head, and a large surgery, on the other hand, the air and the University Hospital of the Catholic sterile drape over the supine body of the the skin, that of both the patient and the University Leuven. patient as usually done during perio- surgeon, are the prime vehicles of infec- The antibiotics group (GrAB1) con- dontal surgery in addition to the use of tion (Altemeier 1983, Garner & Favero sisted of 40 patients: 23 men and 17 a meshed nose guard (van Steenberghe 1985). During intra-oral surgery, reduc- women, mean age 60 years, range 27–82 et al. 1997) to prevent contact with the tion of salivary flow can be achieved by atropine and of the microbial flora by pre-operative rinsing with chlorhexidine (Altonen et al. 1976, Veksler et al. 1991). The supine position of the patient and the use of two independent suction tips (one for the mouth and one only for the wound) can further decrease the chances of wound contamination (van Steenberghe et al. 1997). The use of a meshed nose guard prevents contact with the highly contaminated nares while it was demonstrated that the expired air does not contain more bac- teria than the surrounding air of the OR (van Steenberghe et al. 1997). Indeed the main carriage sites of Staphylococcus aureus in healthy indi- Fig. 1. Patient with nose mesh (cap) during surgery. r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard Asepsis during periodontal surgery 3 highly contaminated nasal skin (Fig. 1) erythema, swelling and pus. A score of Statistical analysis in addition to the use of two suction tips 10 meant no pain, no swelling, etc. (one for the mouth and one only for the Data were statistically analysed by wound). The team of periodontologists means of STATISTICA software ver- sion 7 for windows (StatSofts Inc., and nurses are all thoroughly trained in Criteria of infection high-end asepsis. Tulsa, OK, USA). To evaluate the dif- Bacterial samples were taken using A post-operative infection was defined ferences in means between both groups, t dry sterile plain swabs (COPAN innova- as the presence of purulent drainage a test for independent unpaired vari- p tion, Copan Italia S.P.A.); by (pus) or fistula in the operated region, ables was used. The value was set at the peri-oral skin and the sterile drapes together with pain or tenderness, loca- the 0.05 level to detect significance. The 15 times; just before and at the end of lized swelling, redness and heat or fever null hypothesis was the absence of sig- surgery; from every patient, i.e. two (4381C) (Sawyer & Pruett 1994). nificant differences between groups. bacterial samples from every patient. These signs were observed and reported Moreover, bacterial samples were taken by patients by looking into a mirror. A from the nares of the last 12 patients failed implant was defined as the pre- Results from each group, i.e. a total of 24 sence of signs of infection and/or radio- All 80 patients randomly allocated to samples. The swabs were transferred graphic peri-implant radiolucencies that one of the groups completed the study into a conical tube containing 2 ml of could not respond to a course of anti- and all of them were controlled at the RTF and were delivered to the micro- biotics and/or judged a failure after follow-up visit by a post-graduate resi- biological laboratory. performing an explorative flap surgery dent in periodontology (Fig. 2). Table 1 The dilutions 1/10 to 1/1000 were by an experienced periodontologist. shows the distribution of implants in plated in duplicate by means of a spiral This incidence was checked up to the GrAB1 while Table 2 shows the dis- plater (Spiral Systems Inc. Cincinnati, finalization of this study where the time tribution of implants in GrAB À . OH, USA) onto a non-selective blood lapse of evaluation for all implants was All participants were included in the (Blood Agar Base II, Oxford, 5 months. statistical analyses (GrAB1, n 5 40; Basingstoke, UK) and a selective man- itol salt agar plate. After 7 days of anaerobic (80% N2, 10% CO2, and 10% H2) and aerobic incubation at 371C, the total number of CFU/ml of Randomisation (n=80) aerobic and anaerobic bacteria was counted and S. aureus was identified (after of mannitol); once identified (S. aureus, which is coagu- − Allocated to GrAB+ (n=40) Allocated to GrAB (n=40) lase-positive), the test, which Received antibiotics (n=40) Received antibiotics (n=0) is regarded as the gold standard for the Did not receive antibiotics Did not receive antibiotics detection of S. aureus, was additionally (n=0) (n=40) used to confirm its presence and to differentiate it from other coagulase- negative staphylococci. In order to cal- culate the CFU/ml, every counted CFU Pre-operative swab (n=40) Pre-operative swab (n=40) Post-operative swab (n=40) Post-operative swab (n=40) number was multiplied by the corre- + − sponding dilution factor, then the total GrAB nares swab (n=12) GrAB nares swab (n=12) was multiplied by the volume in milli- litre of the conical tube (2 ml), and the result was then divided by the volume plated on the agar plate. Additionally, some of the periopatho- Swab cultured (n=40 +12) Swab cultured (n=40 +12) genic species namely Porphyromonas gingivalis, P. intermedia, and black pig- mented species were identified, primar- ily based on colony morphology. All 80 patients were seen at a follow- Lost to follow up (n=0) Lost to follow up (n=0) up visit (stitch removal appointment) 7–10 days after fixture installation. At the end of this appointment both the periodontologist, who removed the stitches, and the patient were asked to Analysed (n=40) Analysed (n=40) fill in a 10-cm visual analogue score Excluded from analysis Excluded from analysis (10 cm VAS score) consisting of five (n=0) (n=0) questions, in Dutch, to evaluate symp- Analysis Follow-up Allocation toms of infection/inflammation, which were spontaneous and/or evoked pain, Fig. 2. Flow chart of patients’ flow throughout the phases of the study. r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard 4 Abu-Ta’a et al.

Table 1. Distribution of 128 implants in the Table 3. Results from microbiological tests of peri-oral samples upper and lower jaws in the prophylaxis group 1 À (GrAB1) GrAB n GrAB np-value With prophylaxis Case No. of No. of mean CFU/ml SD CFU/ml mean CFU/ml SD CFU/ml (n 5 40) patients implants An Pr 2.3 Â 104 3.5 Â 104 40 1.6 Â 104 2.1 Â 104 40 0.3 Sol UJ 11 19 An Po 6.2 Â 104 1.1 Â 105 40 3.6 Â 104 5.2 Â 104 40 0.2 Sol LJ 6 8 Ae Pr 5.0 Â 103 6.5 Â 103 40 4.6 Â 103 4.5 Â 103 40 0.7 Od UJ 6 24 Ae Po 8.5 Â 103 9.7 Â 103 40 1.1 Â 104 1.3 Â 104 40 0.6 Od LJ 4 8 Full UJ 8 44 Level of significance po0.05. n, number of patients; CFU/ml, colony forming units/ml; An, anaerobic bacteria; Ae, aerobic Full LJ 5 25 1 Total 40 128 bacteria; Pr, pre-operative peri-oral sample; Po, postoperative peri-oral sample; GrAB , group with antibiotic; GrAB À , group without antibiotic; SD, standard deviation. UJ, upper jaw; LJ, lower jaw; Sol, solitary implant; Od, overdenture; Full, edentulous. Table 4. Results from microbiological tests for nasal samples Table 2. Distribution of 119 implants in the GrAB1 n GrAB À np-value upper and lower jaws in the non-prophylaxis À group (GrAB ) mean CFU/ml SD CFU/ml mean CFU/ml SD CFU/ml Without Case No. of No. of An 3.7 Â 103 7.4 Â 103 12 3.4 Â 103 5.6 Â 103 12 0.9 prophylaxis patients implants 3 3 3 3 (n 5 40) Ae 7.8 Â 10 9.6 Â 10 12 8.6 Â 10 7.6 Â 10 12 0.8 Level of significance po0.05. Sol UJ 14 34 n, number of patients; CFU/ml, colony forming units/ml; An, anaerobic bacteria; Ae, aerobic Sol LJ 8 16 bacteria; GrAB1, group with antibiotic; GrAB À , group without antibiotic; SD, standard deviation. Od UJ 6 24 Od LJ 6 12 Full UJ 3 18 1 Full LJ 3 15 Table 5. Infection and failure rates after fixture installation with (GrAB ) or without (GrAB À ) Total 40 119 peri-operative antibiotics

UJ, upper jaw; LJ, lower jaw; Sol, solitary No. patients with Survival rate Position of failed Confounding implant; Od, overdenture; Full, edentulous. post-operative of implants (%) implant(s) factors infection

1 GrAB À , n 5 40; GrAB1 nares, n 5 12; GrAB (n 5 40) 1/40 128/128 (100) None Blood-clotting À problems GrAB nares, n 5 12). Analysis of the À data showed no significant differences GrAB (n 5 40) 4/40 114/119 (96) Four in posterior Parafunctions or 1 À mandible, one in heavy smoking between GrAB and GrAB with anterior mandible respect to aerobic and anaerobic peri- oral bacteria from the peri-oral skin and GrAB1, group with antibiotic; GrAB À , group without antibiotic. the sterile drapes (Table 3). Further- more, there was no significant differ- female patients. One of them, in whom graduate resident at the time of suture ence between both groups with respect placement of short implants together removal with respect to spontaneous to aerobic and anaerobic bacteria taken with immediate placement of the abut- pain (Spont) (p 5 0.1), evoked pain from the nares (Table 4). No side effects ments was performed, demonstrated by pressure (Evok) (p 5 0.3), swelling of the antibiotic were reported. extensive clenching habits. No signs of (Swel) (p 5 0.1), redness (Red) S. aureus was detected in one patient infection could be observed. But there (p 5 0.5), and pus (Pus) (p 5 0.6) (nares) only. He belonged to the no- was noticeable marginal bone loss and (Fig. 3). On the other hand there were antibiotics group. Finally, none of the apical radiolucency just before rehabili- significant differences regarding the well-known periopathogens (P. interme- tation by the final prosthetic work assessment of symptoms of infection/ dia, P. gingivalis, and black pigmented (2 months after fixture installation). inflammation by the patient at the time species) were detected. The fifth failed implant in this group of suture removal with respect to Spont Following the criteria of infection for was installed in the anterior mandible of (p 5 0.01), Evok (p 5 0.02), Swel this study, one patient from GrAB1 a female patient who smokes more than (p 5 0.02), Red (p 5 0.01) but no sig- group and four patients from the 40 cigarettes/day. Two months after fix- nificant difference with regard to Pus GrAB À group developed post-operative ture installation the patient presented (p 5 0.08) (Fig. 4). Standard deviations infections. Survival rate of implants in mobility of the implant together with and the presence of any outliers are the GrAB1 group was 100% while in an abscess, a fistula and suppuration included in the box and whisker plots. the GrAB À group it was 96%. Three around the implant site. A radiograph patients in GrAB À lost a total of five demonstrated a radiolucency surround- implants (Table 5). ing the implant. Four out of the five lost implants in There were no significant differences Discussion the GrAB À group were installed in the regarding the assessment of symptoms Although the use of peri-operative pro- posterior mandibular region of two of infection/inflammation by the post- phylactic antibiotics is inconsistent and r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard Asepsis during periodontal surgery 5

anaerobic bacteria.The patients who reported adverse reactions such as swelling, pain, etc. have mainly experienced this during the first 1 or 2 days. This may explain the contrast between the questionnaires they answered and the VAS scores of the clinician at suture removal.

In the no-antibiotics (GrAB À )group three patients lost a total of five implants, while no implants were lost in the anti- biotics (GrAB1) group. There were con- founding factors in two of them, namely, heavy smoking (440 cigarettes/day) or parafunctions. Four of the five failed implants were placed in the posterior mandible while the fifth was in placed Fig. 3. Box and whisker plot of the assistants’ visual analogue scores for the antibiotics group in the anterior mandible. 1 À (GrAB ) and the non-antibiotics group (GrAB ). Ten means no pain, no swelling etc., According to the results of this clinical 0 means severe pain, severe swelling, etc. trial we suggest that thorough and careful evaluation of the benefits and risks of the use of peri-operative antibiotics should be considered before deciding to pre- scribe them for routine intra-oral surgery even when foreign materials are implanted. The administration of antibio- tics carries the risk of adverse effects reaching from hypersensitivity to ana- phylaxis; and from unwanted pregnancy complications to interactions with some medications. In addition to increased costs, it raises the risk of emergence of resistant microbial strains. Antibiotics should not be used as a cover-up for inappropriate asepsis techniques.

Conclusions Fig. 4. Box and whisker plot of the patients’ visual analogue scores for the antibiotics group This paper reveals that when high-end (GrAB1) and the non-antibiotics group (GrAB À ). Ten means no pain, no swelling etc., asepsis is applied, the use of peri-opera- 0 means severe pain, severe swelling, etc. tive antibiotic prophylaxis does not pro- vide significant benefits concerning post-operative infections. The tendency varies widely among periodontologists relatively atraumatic bone surgery asso- for more implant failures in the group and oral surgeons, the present study ciated with the insertion of oral implants receiving no antibiotics did not reach demonstrated that peri-operative anti- is very low, the differences are difficult significance and could be explained by biotic prophylaxis does not provide to assess. confounding factors. The present find- any significant advantages concerning Although the same surgical protocol ings also show that pre-operative anti- post-operative infections. It should be was used consistently during this study, biotics do not reduce peri-oral microbial pointed out that a high-end policy of several surgeons, with different levels of contamination. asepsis was followed during this study. experience, performed the . One must admit that the post- Indeed, often the use of sterile drapes is The results of the present study also operative discomfort as assessed by the rendered futile because of improper illustrate the following important points: patients themselves during the first days behaviour of the operators and assistants was more limited when peri-operative because they did not have a proper 1. There is no correlation between peri- antibiotics were given. training in the basics of surgery. This oral microbiology and post-operative may explain why some papers report infections. that the use of pre-operative antibiotics 2. There is no noticeable influence of References decreases the risk of implant failure pre-operative antibiotics on the peri- Altemeier, W. A. (1983) Surgical . two to three times (Dent et al. 1997). oral aerobic and anaerobic flora. In: Block, S. S. (ed). Disinfection, Steriliza- One should point out that because the 3. There is no effect for the prophylac- tion and Preservation, pp. 493–504. Phila- incidence of infections following the tic antibiotics on nasal aerobic and delphia: Lea & Febiger. r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard 6 Abu-Ta’a et al.

Altonen, M., Saxen, L., Kosunen, T. & Ainamo, washing and hospital environmental control, Sawyer, R. G. & Pruett, T. L. (1994) Wound J. (1976) Effect of two antimicrobial rinses 1985. Supersedes guideline for hospital infections. The Surgical Clinics of North and oral prophylaxis on preoperative degerm- environmental control published in 1981. America 74, 519–536. ing of saliva. International Journal of Oral American Journal of Infection Control 14, Stahl, S. S., Soberman, A. & de Cesare, A. Surgery 5, 276–284. 110–129. (1969) Gingival healing. V. The effects of Ayliffe, G. A. & Lowbury, E. J. (1982) Air- Gristina, A. G., Naylor, P. T. & Myrvik, Q. (1989) antibiotics administered during the early borne infection in hospital. The Journal of The race for the surface: microbes, tissue cells stages of repair. Journal of Periodontology Hospital Infection 3, 217–240. 40, 521–523. and biomaterials. In: Switalski, L., Hock., M. Checchi, L., Trombelli, L. & Nonato, M. (1992) van Steenberghe, D., Yoshida, K., Papaioannou, & Beachey., E. H. (eds). Molecular Mechan- Postoperative infections and tetracycline pro- W., Bollen, C. M., Reybrouck, G. & Quir- isms of Microbial Adhesion phylaxis in periodontal surgery: a retrospec- , pp. 177–209. ynen, M. (1997) Complete nose coverage to tive study. Quintessence International 23, New York: Springer Verlag. prevent airborne contamination via nostrils is 191–195. Gynther, G. W., Kondell, P. A., Moberg, L. E. unnecessary. Clinical Oral Implants Cortellini, P. & Bowers, G. M. (1995) Perio- & Heimdahl, A. (1998) Dental implant instal- Research 8, 512–516. dontal regeneration of intrabony defects: an lation without antibiotic prophylaxis. Oral Veksler, A. E., Kayrouz, G. A. & Newman, M. evidence-based treatment approach. Interna- Surgery, Oral Medicine, Oral Pathology, G. (1991) Reduction of salivary bacteria by tional Journal of Periodontics and Restora- Oral Radiology and Endodontics 85, pre-procedural rinses with chlorhexidine tive Dentistry 15, 128–145. 509–511. 0.12%. Journal of Periodontology 62, Dent, C. D., Olson, J. W., Farish, S. E., Bel- Haanaes, H. R. (1990) Implants and infections 649–651. lome, J., Casino, A. J., Morris, H. F. & Ochi, with special reference to oral bacteria. Jour- Wenzel, R. P. & Perl, T. M. (1995) The S. (1997) The influence of preoperative anti- nal of Clinical Periodontology 17, 516–524. significance of nasal carriage of Staphylococ- biotics on success of endosseous implants up Kidd, E. A. & Wade, A. B. (1974) Penicillin cus aureus and the incidence of postoperative to and including stage II surgery: a study of control of swelling and pain after periodontal wound infection. The Journal of Hospital 2,641 implants. Journal of Oral and Max- osseous surgery. Journal of Clinical Perio- Infection 31, 13–24. illofacial Surgery 55, 19–24. dontology 1, 52–57. Engemann, J. J., Carmeli, Y., Cosgrove, S. E., Pack, P. D. & Haber, J. (1983) The incidence of Fowler, V. G., Bronstein, M. Z., Trivette, S. clinical infection after periodontal surgery. A L., Briggs, J. P., Sexton, D. J. & Kaye, K. S. retrospective study. Journal of Perio- (2003) Adverse clinical and economic out- Address: comes attributable to methicillin resistance dontology 54, 441–443. Prof. Marc Quirynen among patients with Staphylococcus aureus Salvi, M., Chelo, C., Caputo, F., Conte, M., Department of Periodontology surgical site infection. Clinical Infectious Fontana, C., Peddis, G. & Velluti, C. (2006) Faculty of Medicine Diseases 36, 592–598. Are surgical scrubbing and pre-operative K.U.Leuven Kapucijnenvoer 7 Garner, J. S. & Favero, M. S. (1985) CDC disinfection of the skin in orthopaedic sur- B-3000 Leuven guidelines for the prevention and control of gery reliable? Knee Surgery, Sports Trauma- Belgium nosocomial infections. Guideline for hand- tology, Arthroscopy 14, 27–31. E-mail: [email protected]

Clinical Relevance nificant benefits concerning post- implants. One should rather provide Scientific rationale for the study: The operative infections in case of strict a proper training of the entire surgi- present study is the first prospec- asepsis. It also does not reduce peri- cal team in asepsis. This should not tive randomized controlled study oral microbial contamination. be limited to the symbolic use of examining the eventual benefit of Practical implications: Except when sterile gowns and drapes but in peri-operative antibiotics when per- specific systemic or local conditions well-thought-of gestures. This will forming intra-oral surgery involving render it beneficial, prophylactic allow avoiding in most instances the insertion of endosseous implants. antibiotics should not be routinely the unavoidable liabilities of antibio- Principal findings: The data indicate prescribed during elective surgery, tic use. that antibiotics do not provide sig- such as the intra-oral placement of

r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard