REVIEW S113 Analia Veitz-Keenan, Debra M Ferraiolo, James R Keenan Impact of asepsis technique on implant success. A review Analia Veitz-Keenan DDS, Clinical Professor, Key words antibiotics, antimicrobials, asepsis, clean, dental implants, gloves, hygiene, infection, NYU College of Dentistry sterilization Debra M Ferraiolo DMD, FAGD, Asepsis is described as a state free from microorganisms. In medicine, an aseptic environment is ne- Clinical Assistant Professor, NYU College of Dentistry cessary and expected to avoid the spread of infection through contact between persons, sprays and James R Keenan DDS, splashes, inhalation, and sharps. Most dental procedures are performed in a “clean “environment MAGD with the common use of personal protective equipment (PPE) such as disposable gloves, masks and Clinical Assistant Professor, protective eyewear with disinfection of surfaces and sterilization of instruments. For surgical pro- NYU College of Dentistry cedure such as the insertion of endosseous implants, the recommendations are not clear. The use of Correspondence to: Dr Analia Veitz-Keenan antimicrobials and antibiotics before and after the procedure remains a controversial issue The pur- Email: [email protected] pose of this literature review is to evaluate the current evidence as to what is generally expected and widely accepted in the use of aseptic techniques for the surgical placement of endosseous implants, and the impact on implant survival and overall success. Introduction Good hand hygiene is one of the most important mechanisms to limit the spread of healthcare-asso- Implants have been accepted and embraced world- ciated infections and increase the success of surgical wide by the medical and dental profession, as well procedures. In surgery the recommendations are as by patients, due to their predictable long-term clear as to the difference in when and how to apply success1,2,3. Today, this surgical technique is per- an aseptic versus a clean technique5. The applica- formed by specialists and general practitioners, tion of an aseptic technique is necessary to prevent usually in ambulatory settings, and even in general contamination of a surgical site with microorganisms dental practices under local anesthesia3. The success and includes methods such as sterile gloves, gowns, of implants in oral rehabilitation is dependent upon drapes and masks. Some people recommend this, variables4. Among the variables are the operatory in particular for intraoral implant surgery, as a criti- setting, aseptic technique, the intraoral environment cal component to proper healing and success6. The and systemic management of bacteria. purpose of a clean technique is rather to reduce the The late 1800s saw the introduction of the number of microorganisms in order to minimise the principles of antisepsis in medicine. The principles risk of transmission from the environment or health- of antisepsis, advanced infection control practice, care personnel7. The clean technique is routinely sterilisation, barriers and antimicrobial prophy- practiced in today’s dental practices for ordinary laxis, changed healthcare practice and dramatically dental care. The asepsis technique is more complex reduced the number of postoperative complica- and expensive and includes environmental controls tions5. such as a clean environment and minimising traffic Eur J Oral Implantol 2018;11(Suppl1):S113–S121 S114 Veitz-Keenan et al Impact of asepsis technique on implant success during the procedure to prevent airborne particles • Water quality concerns – flushing waterlines; that can cause infections. • Aseptic technique for parenteral medications; The recommendations for the practice of one or • Pre-procedural mouth rinsing before surgical the other techniques, especially for chronic wound procedures. care, depends on patient factors, immune status, acute versus chronic wound, type and location of Hands are the greatest source of pathogen transmis- the wound, invasiveness of the procedure, if de- sion. Hand washing refers to washing hands with bridement is needed, the type of setting, who is per- soap and water, while antiseptic hand washing refers forming the procedure, maintenance of instruments to washing hands with water and soap plus another and the likelihood of exposure to organisms in the detergent and antiseptic agent, such as triclosan or healthcare setting8. The same recommendations are chlorhexidine. Waterless, alcohol-based agents are not clear for the insertion of endosseous implants. now used in addition to hand washing. Alcohol- The use of personal protective equipment (PPE) based hand sanitisers claim to be the most effective is dependent upon the procedure being carried products for reducing the number of germs on the out. Standard infection control precautions call for hands of healthcare providers10. the use of gloves, gowns, masks and goggles for Spaulding presented a popular approach to cat- any procedures that involve direct contact with the egorising disinfection and sterilisation protocols for patient’s body fluids. instruments and pieces of equipment in health care In oral surgery, hand hygiene, PPE, safety work- in 196811. ing with sharp instruments, sterilisation and disinfec- The classification includes three categories: tion of dental instruments, surgery design, surface • Critical objects, such as scalpels, blades and peri- disinfection, use of plastic barriers and cleaning of odontal probes, which penetrate mucous mem- dental water line units all have the purpose of redu- branes and skin. Sterilisation is crucial. cing the risk of cross-infection. Disposable gloves and • Semi-critical objects, such as mirrors or objects protective eye and mouth wear is recommended to that do not penetrate mucous membranes, also be worn for all dental procedures. Single-use gloves require sterilisation. and masks should be changed in between patients. • Non-critical objects that do not contact mucous Operatories should be designed for easy clean- membrane, such as the operating table or dental ing. Operating tables or dental chairs, floors and fur- chair and other furniture, require intermediate or niture should allow easy cleaning and disinfection. low-level disinfection. The same is expected for local work surfaces such as hand controls, lights and computer keyboards. Another issue is the prevention of postoperative Recommendations exist worldwide and are infection at the site of the surgery. In hospital set- designed to prevent or reduce potential for disease tings, despite all efforts to prevent them, surgical site transmission from all potential areas: patient to infections (SSIs) remain a significant cause of mor- healthcare provider, healthcare provider to patient, bidity and mortality among hospitalised patients12. and from patient to patient in order to prevent post- There are several factors that may contribute to operative infections. postoperative infections and intra-operative con- Although these guidelines focus mainly on out- tamination. Airborne particles carrying microorgan- patient, ambulatory health-care settings, the recom- isms may be a possibility. In order to prevent bacterial mended infection-control practices are applicable to contamination, surgical staff should avoid actions all settings in which dental treatment is provided. such as removing gloves, putting arms through the sleeves of the gown, and unfolding the surgical gowns, as reported by a study observing surgeons What do guidelines recommend9: and nurses mimicking intraoperative actions prior to • Hand hygiene; total knee arthroplasty13. • Gloves; We know and expect a clean operating envi- • Sterilization of unwrapped instruments; ronment during medical and dental treatment and Eur J Oral Implantol 2018;11(Suppl1):S113–S121 Veitz-Keenan et al Impact of asepsis technique on implant success S115 expect a sterile environment when a procedure chlorhexidine and 1% povidone-iodine. A ran- involves an open wound to avoid surgical complica- domised clinical trial published in 2009 compared tions. Surgical site infections for surveillance classifi- the use of three different antiseptic solutions of pov- cation purposes are divided into incisional SSIs and idone-iodine, chlorhexidine-gluconate and cetrim- organ/space SSIs. ide and sterilised physiological solution as a control Incisional SSIs are further classified into superfi- group. All three antiseptic solutions produced a stat- cial and deep incisional. istically significant reduction in aerobic and anaero- Organ/space SSI involves any part of the anatomy bic bacteria, with chlorhexidine having a prolonged other than the incision that is open and manipulated bactericidal effect. The group with 1% povidone- during the surgical procedure. Oral cavity infections iodine had no local postoperative infections17. belong to the organ/space SSI classification14. But what is the impact specifically for the inser- In intraoral implant surgery, the variables for sur- tion of endosseous oral implants? gical success and the recommendations for operating conditions have changed over the years. Manufactur- Use of antimicrobials or antibiotics ers have different recommendations for sterilisation of reusable products and disposal of their products. The empirical use of antibiotics to prevent any kind A publication from 201215 studied asepsis in of infection is still controversial. implant dentistry. In the conclusions of this review, Widespread use of antibiotics by people who do the highest standards of surgical asepsis were pro- not have an