Postoperative contamination of mandibular osteotomy sites with saliva

Transcription

1 - Postoperatve Int. J. Oral Maxllofac. Surg. 1987: 16: (Key words: ; contamnaton, by salva; salva; amylase; surgery, orthognathc) Postoperatve contamnaton of mandbular stes wth salva R. KOOLE AND E EGYEDI Department of Oral Surgery, State Unversty of Utrecht, The Netherlands and Department of Oral Surgery, Faculty of Dentstry, Natonal Unversty of Sngapore, Sngapore ABSTRACT - salvary contamnaton of surgcal wounds around the mandble was found n several types of and bone graftng procedure. Ths problem was nvestgated by determnng the amylase content of wound secretons n redon bottles every 24 h. The mplcatons for antbotc prophylaxs are dscussed. (Accepted for publcaton 30 November 1986) Contnuous sucton s practced frequently after osteotomes and other oral surgcal procedures n order to elmnate accumulaton of secretons. It may have the dsadvantage that salva s drawn nto the feld of surgery as long as the seal towards the oral cavty s not "water-tght". In ths paper, we report on an nvestgaton nto ths problem. The amylase content of the secretons obtaned from surgcal wounds, prmarly open towards the oral cavty, was determned n several types of and bone graft procedure. The results of osteotomes and rdge augmentaton of the vsor-sandwch type wll be reported n ths paper. It was assumed that the amylase content of the secretons n the sucton redon bottles was an ndcaton of salva leakage nto the feld of surgery, f elevated values (as compared to the plasma level) were obtaned. Materal and methods The several types of and bone graft procedure n 34 patents are depcted n Fg. 1. Drans of the redon-type were nserted and bottles were examned daly untl the drans could be removed, as secreton was reduced to an nsgnfcant level. Because of the contnuous sucton dranage, extra efforts to prevent leakage were taken, ncludng strappng of the lower lp (Fg. 2), gastrc tube feedng n some cases, and careful handlng of the surgcal ste durng cleanng of the mouth. Measurements of the amylase content were performed wth the Phadebas method*. Normal serum amylase values are between Ld, ndependent of factors such as food ntake, det, muscle actvty and haemolyss 13. It was assumed that an amylase content between 350 UA Ld after the 2nd day was probably due to mnor salvary leakage nto the wound. A content between was lkely to be caused by a *Pharmaca Dagnostcs AB, Uppsala, Sweden.

2 OSTEOTOMY CONTAMINATION BY A SALIVA 555 number U/L Amylase I K 4 5 Vsor Fg. 1. Patent materal. Obwegeser Robnson anteror segment consderable leakage and amounts larger than 5000, pont to a major dehscence of the wound, vz, 2 upper dots n Fg. 3 at days 2 and 3. o 1000 Results The frst 3 days values are depcted n Fg. 3. The drawn and nterrupted lnes represent averages. The separate marks (29 est Days - - Anteror segment x..... ~ Vsor o Obwegeser/Robnson ncson., Fg. 3. Amylase content of secretons; for explanaton see text. Fg. 2. Strappng and dran n a patent wth an anteror segmental. matons out of a total of 106) represent the above average values. After post-operatve day 3, the secretons as a rule dmnshed such that the drans were removed. Elevated contents were found n 2 out of 4 vsor cases, n 5 out of 18 oblque subcondylar /Obwegeser-Dal Pont cases and n 8 out of 12 anteror segmental cases. As can be seen, t s especally n the anteror segment type of that an elevaton of the amylase content was found after the frst postoperatve day. From Fg. 3, t also becomes clear that even the hgher levels of amylase content

3 556 KOOLE AND EGYEDI Table 1. Some publshed results from the Utrecht clnc for Maxllo-facal Surgery Type of surgery No. of patents % nfecton oblque subcondylar segmental anteror (Hofer)" 18 0 segmental anteror (Krle) ~z major mandbular reconstructons 7 (free bone grafts) * *Total graft loss n 3 patents (7.9%). tend to decrease, but they may reach serum levels only after a perod beyond 3 days, f sucton were contnued. Dscusson Our fndngs may have some mplcatons wth regard to the duraton of antbotc prophylaxs. They may ndcate that contamnaton of the surgcal feld wth salva occurs at least up to the 3rd postoperatve day. It s assumed that the amylase content of the frst sample s caused by salva ntroduced nto the wound durng surgery. Sgnfcance can therefore only be attached to the amylase content of the secretons after the frst day, provded the parotd or other gland(s) have not been damaged secretng salva nto the feld of surgery. Especally where a bone graft s at rsk of beng lost, one should therefore consder antbotc prophylaxs well beyond ths tme. Whether one could manage patents by takng daly samples of flud collected n the redon-systern and havng them examned on ther amylase content seems stll debatable to us. A more ratonal approach seems to be to "defend" the ste routnely aganst nfecton for at least a week. Ths statement s not n accordance wth modern trends n general surgery where short-term prophylaxs seems to preval nowadays 3,~7. The wound nfecton rates n maxllo-facal surgery, beng much hgher than n other surgcal specaltes (see below), seem, however, to warrant such a bascally dfferent approach. It s, however, clear that n vew of our fndngs, the use of sucton dranage should be questoned. Is t necessary4jseful to dran stes? The object of course s to elmnate dead space and obtan a rapd adaptaton of the coverng soft tssues to the underlyng bone, especally n cases where bone grafts have been used. Snce up to 200 ml of secretons can be found occasonally n a vacuum bottle after 24 h (even n anteror segmental osteotomes), the argument n favour of contnuous sucton dranage seems to have a certan logc. It seems unlkely that such large amounts of secretons, blood can be resorbed n a few days. However, we have never conducted a comparatve study on 2 groups (one wth, one wthout contnuous sucton) wth regard to wound nfecton. We can therefore only pont to the general surgcal prncple as outlned above n favour of our practce and also to common practce n orthopaedc bone surgery*, especally where free bone grafts are nserted. Fnally, as already ndcated above we can also pont to the hgh nfecton rate of mandbular osteotomes (up to 21.7%) reported by some la,2, not to speak of the hgh nfecton rate n mandbular reconstructon as reported by others 7, Our own results for wound nfectons are presented n Table 1. *Smth~8: "The use of sucton dranage should be routne for most wounds nvolvng medullary bone n whch complete haemostass cannot be obtaned by ordnary methods, wounds n whch there s a dead space, and after most major operatons on the hp or spne".

4 OSTEOTOMY CONTAMINATION BY A SALIVA 557 As to the queston of whether leakage of salva can be equated wth the ncreased lkelhood of nfecton, the followng consderatons seem relevant. Salva s sterle as t s secreted, but n the oral cavty, the bacteral count n 1 ml of whole salva s 107 aerobc mcro-organsms plus anaerobc ones ~. Many speces found n salva are also found n nfectons after head and neck surgery TM. Clearly, salva enterng a wound through a dehscence n the suture lne may be assumed to contamnate the /bone graft ste producng nfecton f the local and general crcumstances for ts development are favourable. Are there other ways n whch salva could be operatve nsde a wound? In addton to bactera, salva contans several consttuents whch mght n theory be of mportance n oral nfectons. We wll dscuss 2 of them. Lysozyme n combnaton wth complement has bactercdal actvty. However, t s nactve aganst the normal oral flora z~. It could theoretcally be actve aganst contamnant germs, whch crculates n hosptals, and as such be of some value n preventng nfecton wth, say, one or another gram-negatve rods. Ths, however, s purely speculatve. Fbrnolysns and ther nhbtors are found n salva. Fbrnolyss can destruct a blood clot, and also the clot n or around an ste. These substances are thought to play a r61e n post-extracton alveolts 5,~ but local plasmnogen actvators seem to be more mportant than salvary fbrnolytc agents 4, and fbrnolytc nhbtors n normal whole salva seem to have no physologcal mportance at alp. Moreover, t has not been possble to reduce the ncdence of alveolts by applyng a local fbrnolytc nhbtor 9, and therefore, all n all, t seems doubtful whether leakage of salva nto an or bone graft ste has any other sgnfcance than of beng a vehculum for oral bactera. The fnal answer to the problems n- volved seems to be the conducton of a comparatve clncal study. For ethcal reasons, such a study can hardly be set up by such "belevers" as the authors of ths paper. References 1. BALAN, E. H.: Entzfndlche Komplkatonen be der chrurgschen Dysgnathebehandlung nach sagttaler, retromolarer Osteotome m aufstegenden Unterkeferast. In: PFEIFER G. & SCHVgENZER, N. (eds.): Fortschr. Kefer- Gesehtschrurge 1984: 29: Stuttgart: Theme. 2. BECKERS H., KOHNLE T. & DIETRICH H. G.: Enfluss prophylaktscher Antbose auf nfekt6se Komplkatonen nach Dysgnatheoperaton. In: PFEL~R, G., SCHWENZER, N. (eds.): Fortsehr. Kefer-Gesehtschrurge 1984: 29: Stuttgart: Theme. 3. BERGMAN, B. R.: Antbotc prophylaxs n open and closed factures. Acta Orthop. Seand. 1982: 53: 57~2. 4. BIRN, H.: Fbrnolytc actvty n "dry socket". Aeta Odontol. Seand. 1970: 28: BIRN, H.: Etology and pathogeness of fbrnolytc alveolts ("dry socket"). Int. J. Oral Surg. 1973: 2: EGYEDI, P., HOUWING, M & JUTEN E.: The oblque subcondylar : report of resuts of 100 cases. J. Oral Surg. 1981: 39: EGYEDI, P.: Wound nfecton after mandbular reconstructon wth autogenous graft. Ann. Aead. Med. Sngapore 1986: 15: GERSEL-PEDERSEN, N.: Inhbtors of fbrnolyss n salva after oral surgery measured by enzymc and mmunologcal methods. Int. J. Oral Surg. 1979: 8: GERSEL PEDERSEN, N.: Tranexamc acd n alveolar sockets n the preventon of alveolts scca dolorosa, Int. J. Oral Surg. 1979; 8: HOOGKAMP-KORSTANJE, J. J. A.: De normale Flora. In: MOUTON R. P., WINKLER K. C. & KOSTER J. F. (ed.): Medsche Mcrobologe. Bohn, Scheltema, Holkema, Utrecht 1980, p Jatav, S. L.: The use of homologous lyophlzed bone grafts n Hofer's. J. Max. -fac. Surg. 1983: 11: KLOOSTERMAN, J.: K61e's, a followup study. J. Max. -Fac. Surg. 1985: 13:59 63.

5 558 OSTEOTOMY CONTAMINATION BY A SALIVA 13. KREUTZER, H. H. & RAYMAKERS, J. A.: Interpretate van utkomsten van laboratorumonderzoek n de geneeskunde. Bohn Scheltema en Holkema, Utrecht 1982, p KRIZEK T. J. & ARIYAN S.: Infecton. In: CONLEY, J. J. (ed.): Complcatons of head and neck surgery. Georg Therne, Stuttgart 1979, p MEGQUIER, R. J.: Fbrnolytc actvty n human dental sockets after extractons. J. Oral Surg. 1971: 29: OBWEGESER, H. L., H.~.USSLER F. & IBARRA E.: Behandlung des nfzerten Knochentransplantates be der Unterkeferrekonstrukton. In: Pfefer, G., Schwenzer, N. (eds.): Fortschr. Kefer-Geschtschruge 1984: 29: Stuttgart: Theme. 17. SANDUSKY, W. R.: Use of prophylactc antbotcs n surgcal patents. Surg. Cln. N. Am. 1980: 60: SMITH, H.: Surgcal technque. In: Crenshaw A. H. (ed.): Campbell's operatve orthopaedcs. Mosby, St Lous 1971, p STOLL P. SCHILLI, W.: Long-term follow-up of donor and recpent stes after autologous bone grafts for reconstructon of the facal skeletal. J. Oral Surg. 1981: 39: 676~ WEGENER, A.: Ene klnsche und r6ntgencephalometrsche Nachuntersuchung der Ergebnsse der chrurgschen Knnvorverschebeplastk nach Obwegeser. Thess, Zrch. Jurs-Verlag, Zfrch 1971, p WXNKLEP,, K. C.: Algemene Besmettngsleer. In: Mouton, R. E, Wnkler, K. C. & Coster, J. E (eds.): Medsche Mcrobologe. Bohn, Scheltema, Holkerna, Utrecht 1980 p. 67. Address: R. Koole Department of Oral Surgery Academsch Zekenhus Utrecht Catharjnesngel GV Utrecht Holland