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“Sterile” Dental/Bone Graft Implant Surgery… Is It Possible?

UPDATE: This 2014 post is especially important in the age of COVID-19!!! READ THIS

Dental implant surgery should be done in an “aseptic technique” which is a close modification of sterile technique.  This means that your dental implant or bone graft surgery is not just being done with the typical dental bib held by the alligator clip chain!!!

Implant Surgery Needs To Be Clean

Dental implants and bone grafts can be contaminated very easily which can lead to infection, implant failure and bigger things such as osteomyelitis.  Some people are more prone to infection than others so you really have to be careful.

I treat patients with complex medical histories and patient’s that are 90 years old.  Safety comes first!  Besides some patients being more prone to infections, some procedures are more prone to infections.  This is just another reason to keep the surgery as sterile as possible.

A dental bib is not enough for dental implant/bone graft surgery.

sterile/aseptic dental implant surgery in the office of Dr. Ramsey Amin
sterile/aseptic dental implant surgery in the office of Dr. Ramsey Amin
Ramsey Amin DDS in surgery
Ramsey Amin DDS in surgery
Our Sterilization Center
Our Sterilization Center

Your jawbone is essentially sterile (pending no pre-existing infection) until the gums are opened and it becomes exposed to the bacteria of your mouth and other bacteria of the environment.

Aseptic technique is used in medical procedures and microbiology to keep processes and procedures free of cross-contamination.

The mouth is naturally full of bacteria, so sterility is impossible.  The goal is to reduce the bacteria in your mouth from contaminating the implant or bone graft as it is being placed.

Even though we all take showers every morning, our skin has certain bacteria called Staphylococcus, which is sometimes just called Staph.  You may be wearing clothes to your dental implant surgery appointment that you didn’t realize you wore the other day when you were gardening.  Bacteria on your clothes and/or skin can be inadvertently brought into your mouth.  The point is not to allow cross-contamination into your bone or bone graft.

Precautionary Measures Against Dental Implant Infection 

In my office these are just some of the things that I do for every procedure whether it be one single implant or 12 dental implants and bilateral sinus bone grafting.

Your mouth will be prerinsed with chlorhexidine for 30 seconds immediately before the dental implant/bone graft procedure.  I also go one step further and will wipe down the immediate surgical site with Betadine/iodine to decontaminate any natural plaque you may have that can be introduced into your bone.  This means that we take a Betadine swab into your mouth and scrub the gums and teeth.

Every dental implant and bone graft procedure in my office is done in an extremely aseptic environment using at least 2 dental assistants per procedure.  There is no way to have a super clean surgery with only one dental assistant.

Textile drapes that have been autoclaved through a sterilizer will cover you to about your thighs and a comfortable head wrap will leave just your face exposed, covering your hair.  Your eyes will not be covered unless you prefer them to be. The photographs on this post show many of these concepts during live procedures.

Your facial skin will be wiped down with either chlorhexidine or Betadine.

To prevent cross-contamination with the dental light, it will be covered with a sterilized foil barrier.
My dental assistants and I will gown in special sterilized gowns and hats.  We also wear sterilized gloves, not just regular gloves out-of-the-box.  These are crucially important in maintaining a 99% success rate.  It helps to prevent you from having infections which will, in turn, reduce pain, swelling, and help you heal up faster.  We do not touch anything that is outside of the sterile area.  We can’t even scratch our head if we get an itch!

“I was trained in a hospital setting in an operating room. This process is second nature to my team and I. Before placing our sterilized gloves we go through a surgical scrub of our hands, also using a special scrubber embedded with chlorhexidine surgical soap.”

One of my dental assistants maintains the field of sterility while the other can hand items to me from outside the field.  When she opens a dental implant package, bone graft material, sutures, membranes, etc. they are in two packages.  She opens the outer non-sterile package and drops the sterile item onto our sterile surgical instrument set up without touching anything.  This way nothing ever touched the item that will be going to your body.

Our suctions and drill tubings are covered in sterilized disposable plastic sleeves.  Even though these items are wiped down thoroughly between each patient, I prefer complete sterility.

Of course dental instruments are placed in a cassette and sterilized after several pre-sterilization cycles.

Yes, I know it sounds and looks like brain surgery, but it is all for your benefit

Many of my patients have IV sedation anesthesia so it also functions to keep them warm while they are sleeping through the procedure.  The wires for the ECG, pulse oximeter, carbon dioxide sensor and blood pressure cuff are also under the surgical drapes.  This prevents cross-contamination between dental equipment.

Sterile/aseptic technique is more of a way of life in my office than it is a procedure… It is just what we do.  It is not clumsy or foreign.

Feel free to ask questions related to this blog post article.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry
Burbank, California

25 thoughts on ““Sterile” Dental/Bone Graft Implant Surgery… Is It Possible?

  1. Hi Dr. Amin –

    We are currently revamping some of our policies and training. Was wondering if you self-glove or if your assistants do the traditional assisted “gloving and gowning” after you’ve scrubbed-in (i.e. plunge gloving technique). Thank you!

    1. A bit of both but certainly a very aseptic method using actual sterile gloves not just regular gloves.

  2. Professor Amin – It must be so gratifying to know that you have always gone the extra mile (even at your own cost) to use the highest level of sterile protocol (including full surgical PPE) to protect your patients and your team. I’ve been talking with a lot of colleagues in the field of periodontics and endodontics and these new PPE standards have them scrambling to procure and teach their surgical teams how to ‘don’ them properly.

    How do you feel about face shields? For assistants, they seem like a good idea. However, for us who are wearing a headlight and loupes the shields can create quite a glare and obscure the surgical field. I’ve been doing it the last few cases and perhaps it will just take time.

    I’ve also added another scrubbed-in assist to all of our major cases (sinus lifts, ridge augmentations, multi-implant placements, etc.) – so now I have two assistants scrubbed-in assisting chairside and one ‘circulating’ and grabbing supplies as needed.

    1. Thanks for your kind words. This is all I know how to do 😉 Face shields are part of the post COVID 19 era. I am using a custom made, 3-d printed shield that allows light to pass through. I agree, that it is another lens to look through that can cause some blurred vision. We will get through this!

  3. Professor Amin –

    Thank you so much for this post. As a new OMFS practitioner about to open my surgical practice, you hit the ‘nail-on-the-head’. I have 2 AAAASF-certified Operating Rooms that will be used for all procedures (from wisdom teeth to implant placements to full jaw reconstructions). Yes, there are costs associated with doing all procedures in a hospital-level fashion (my sterile team of 4 scrubs-in, does assisted gloving-and-gowning, and dons full surgical PPE from head-to-toe); we also have a Dental Anesthesiologist and 2 Circulating RNs in the room. What you gain is ‘peace-of-mind’ and what you can lose is far more…credibility being top-of-mind. I applaud your willingness to share your thoughts on this topic, especially in light of everybody in the OMFS and Periodontics community pointing to one or two studies that say such precautions are irrelevant. They’re irrelevant until you have to explain to a patient why they have a terrible infection that could have been prevented.

    Have a great weekend.

    – Alex

    1. Thank you for chiming in Doctor! It amazes me how unsterile people are during dental implant and bone grafting procedures!

  4. I just had a extraction done and a bone graft. In preparation for an implant. The dental professionals did not drape me, they also contaminated the sterile field. A half used IV bag hung above the sterile field from the last procedure, the girl said to me you can use the same IV bag. I said the blood from the last patient can go up the tubing, you can’t use the same solution on the next patient. That a big no no. Then during the procedure the assistant picked up an instrument with plain gloves off the sterile field and dropped it again onto the field showing the “surgeon” see we use this one to push it in, she said. I watched in disbelief she was suctioning me and was the unsterile person the only other person in the room with the dental surgeon. Never mind telling the Dr. what he’d have to use in the procedure. Being a nurse myself I cannot believe this is the standard used in the field of implants and bone grafts. I also had to ask for antibiotics for after the procedure, as I have titanium implants in my back. I had been on Antibiotics 2 week prior to the procedure and wondered also why I didn’t have antibiotics a few hours before even though I had been on them 2 weeks ago. Anyway I went home with Clindamycin 150mg tid. I just don’t understand why dential specialists aren’t taught sterile techniques. Why not set higher standards when there are so many cases of post procedure infections. Why aren’t they reported to the CDC. Hospitals have infection control nurses and Doctors in charge and infections and the type of bacteria’s that they are infected with are reported and kept an eye on. Hospital acquired infections are reported, why not in Dental offices? Yes people need to be aware and Dental specialists need to be held accountable. I have suffered with this infection for years not knowing what it was until I had a CT scan and it showed a failed root canal and an infection in the bone. Along with the aching and pain it caused every dentist thought it was due to my TMJ and tooth grinding. I had a fractured root also they said although it was hard to see on the tooth itself when it came out.
    I just hope it was extracted with good reason. Anyway I’m praying that the bone graft doesn’t get infected and I can have the implant done in 4 months. I feel I should wait until I know it’s healed well and not going to get infected into the graft and fail or something.
    Any reason not to wait to have the implant implanted in 4 months?? He said the teeth shouldn’t move or anything. Regards,

    1. Wow…that is quite a story. It sounds like the IV fluid was used for irrigation rather than intravenous. Obviously I run a much tighter ship than what you have described. I also believe in aseptic technique. The reality is the mouth is such a different surgical site compared to the rest of the body as it is filled with bacteria. It doesn’t mean you can be sloppy but the workflow is a bit different. I’m sure the tooth was extracted for good reason. I would wait minimum of 4 months before placing the implant may be even up until 6 months to make sure the bone is mineralize properly. Thank you so much for your comment. I have some additional information on antibiotics on this video.

  5. Dear Dr. Amin,
    First, I want to say (as many others have already said) that your website and blog are extraordinary. The fact that you respond so kindly and thoroughly to questions from strangers reflects such incredible decency and generosity. I am half-tempted to try to make an appointment and fly across the country from New York to have my implant done by you.

    I was hoping to ask a couple of questions. First, is there any way to identify and choose an implant specialist who practices the same aseptic techniques that you describe above? For example, is there a particular certification that i can look for, or is it a matter of just asking each practitioner whether they follow these protocols? More generally, do you have any suggestions for how to choose an experienced and skilled specialist? (I am in New York City, if that helps.)

    I also have another, more specific question. I posted a similar question on your blog a month or so ago, but I foolishly did not bookmark the particular page and now cannot locate it. Basically, I’ve recently read a lot of information about serious problems arising with implants years down the road (from peri-implantitis or other causes), and so I’m a little nervous about my chances for long-term success. So I wanted to ask whether you think an implant might be a good option for me given the following facts:

    * A lower molar (#19) had a botched root canal years ago and will likely need to come out and be replaced with an implant. I will be seeing an endodontist shortly to find out for sure.
    * I clench my teeth at night. I wear a nightguard, but I understand that teeth clenching can cause problems with implants — either with the initial osseointegration, or by making peri-implantitis more likely down the road.
    * This molar is next to another tooth with a root canal (#18). I seem to recall reading that implants adjacent to root canaled teeth are more likely to fail.
    * I am very careful about brushing and flossing, and my dentists have always commented that my oral hygiene and oral health are excellent. However, I do have slight issues with dry mouth — nothing severe, but enough that I’m pretty paranoid about the health of my teeth. (I have tested negative for possible autoimmune causes of dry mouth such as Sjogren’s Syndrome, but I understand that it’s possible to have autoimmune issues without positive test results.)

    One final note: the two root canals described above (#18 and 19) were performed about 10 years ago, by an unscrupulous dentist who later lost his practice for performing unnecessary procedures. I later found out these root canals were likely unnecessary, as neither tooth was symptomatic and x-rays showed no serious problems. (I mention this only because I feel a little sheepish about having had 2 root canals despite saying that I am scrupulous about my oral hygiene.)

    Thank you so much for any advice or suggestions.

    1. Thank you for your very kind words. As for locating an implant dentist with bona fide credentials please refer to this post.

      Keep in mind that the vast majority of patients do not have issues long-term with dental implants. This is a very small percentage. The chance of having long-term issues such as peri-implantitis can be reduced by being treated by a high level practitioner. Of course genetics trumps everything and there are times that even the best will have problems.

      About 5% of patients will develop some small issue years down the road… But 95% will not. I have the pleasure to follow up and maintain my implant patients for almost 2 decades now. If this was such a big problem I would’ve stopped doing this long ago! I only see about 1- 2% issues in my own practice.

      As long as your adjacent root canal is healthy then having an implant next door will likely not be an issue. If it is questionable either retreat the root canal so that it is 100% healthy or extracted in place a second dental implant.

      Grinding in clenching do have some long-term issues. It is important that the final crown restoration be designed with this in mind. The bite is relatively flat and needs to take into consideration all of the side to side excursive movements that are jaws make.

      Dry mouth is a big issue for natural teeth. Routine fluoride use, fluoride treatment, gum with xylitol can help reduce long-term issues with your natural teeth and help prevent further tooth loss.

      I hope this helps you~!

  6. I have recently had a dental implant placed in my mouth. I had to return to dentist 6 weeks later as there was an area of my gum that was sore and red – the dentist gave me antibiotics – I have been wondering how this infection could have occurred as I was careful at keeping it clean – then I remembered as the dentist was placing the implant he dropped it into my mouth by mistake – could this be the cause of infection?

    1. Infections can and do occur without any reason whatsoever. Likely it will be just fine. Were you on a course of antibiotic’s during the implant procedure?

      I have a blog post the talks all about antibiotics. Please search for it it will answer a lot of your questions.

  7. thank you for this lovely blog. The attention to details and the cleanliness of the surgery area amazing.
    Thanks for sharing

  8. Great information you got here. I came across this article by Googling Dental Implant Surgical Asepsis. I just had recently had an implant done and there was nothing close to your procedure in terms of aseptic technique. I asked the dentist why he has not instituted sterile technique procedure. He replied that wasn’t neccessary since all equipment are sterilized before hand. Unfortunately it was already done. I demanded however that I be prescribed antibiotics. Which the dentist would not have prescribed until I said something.
    My question is, is this standard of care for all dental implants and is it regulated by the Dental board to provide aseptic technique on all dental implants ?

    1. Hello Francisco,

      Every dentist is different. You did not have treatment below the standard of care nor is there any regulation to provide aseptic technique. Every dentist utilizes there training and judgment to base their decisions.

      Keep in mind that I do large dental reconstructions and huge bone grafts inside people sinuses, the base of the nose, and even reposition nerves. A simple and straightforward dental implant fortunately has a high degree of success as long as the dentist has some experience. Antibiotics are not always a necessity, but are often needed for more advanced procedures.

      Although you did not have full aseptic technique done, it does not mean your dental implant will fail or you will become infected. It is considered best practices to do full draping as I have described in this post. I was trained with surgeons in the hospital so my background is very different.

      Most of the dentist that are heavily involved in implant dentistry with a good reputation, do this aseptic technique whether it be one implant or 16 implants with advanced bone grafting.

      I’m sure you will be fine. Your dentist meant no harm to you.


      Ramsey Amin DDS

  9. Great information here Dr. Amin. I wish more practiced this way. I am curious to know if you double wrap your cassette setups and use the inner wrap as your sterile work field? If not, can you explain what you do? I am an Infection Control and Efficiency Advisor here in the New England area and previously practiced as a Hygienist and a Dental Assistant in the Air Force 20 years ago. We also practiced this same aseptic technique and I believe all Oral Surgeons should as well but many do not. Thanks so much. Would you ever be interested in participating in my podcast series? I think it’s important for your peers and patients to hear the quality and care you provide. You are a fabulous example of exceeding the standard of care.

    1. Hi Claire,

      Thank you for your very kind words. I do believe this is the standard for aseptic surgical techniques.
      Yes, most of our instrumentation and materials are double wrapped. This allows the instrument or products to be “dropped” onto the sterile field by a third or fourth assistant


      Ramsey Amin DDS

  10. I am so impressed with your website with the wealth of information in detail. I thought I was getting an upper full mouth bridge, they called it a one piece Hybrid bridge but after the surgery I had a big bulky Halloween feel like false teeth over denture in my mouth. The plastic was so big it extended towards the back of my throat causing me to gag and with a large bulbous lump under my front teeth making it difficult to form my words and speak. I panicked and they ended up telling me they could add pink to it and it would be fine but they could not do anything for 3 months while the implants healed. long story short, ended up they don’t know how to do it and admitted I would be a test case. I had 5 implants and am wearing a temporary overdenture that they had a different lab create when they tried to make a more bridge like teeth with different material, but after 3 tryons that were horendesly off size and shape They had me come into their office while the lab tech took the original temporary over denture to the lab, for the dimentions, they said, but it ended up being just like the first one they just took a copy of it, even had the same crooked cant to the
    left. They said they would try putting two more implants in and fashion a bridge that may work. I am scared to death at this point and after the research I’ve done i’m worried about my bite, and the quality of the work. I wanted my bridge to be as close to my natural teeth as possible in size and feel and don’t want to live the rest of my life with with a device that I want to pull out of my mouth, like Halloween teeth after a party. I would like to come to Burbank to your office for a second opinion as soon as possible,

    1. Hi Christy,

      Wow…. It sounds like you have quite the issues going on. A full upper fixed implant bridge is by far the most difficult dental restoration to make in all of dentistry. This is one of those particular things where experience really counts.

      I would love to see you as a patient. I hope it can be corrected. The reason why I say “I hope” is because the position of the surgical placement of the implants is going to dictate how your teeth can be made. The implants have to be in an exact spot or at least close to this exact spot to make things feel as natural as possible. Aesthetics, phonetics and function are all worked out during the try-in and prototype phases. This allows test driving of the teeth to make sure that all aspects have been accounted for so that when the Bridges delivered at the last visit there is no surprise. Also, typically the upper jaw requires a minimum of 6 implants to restore properly. 4 or 5 is typically not enough because of the soft bone. Adding the additional implants will help the long-term.

      I do have many patients that travel to see me. I would need you to be able to make it to all the visits that it takes to fabricate a full mouth upper bridge such as the Prettau

      This link should help you:
      The Process of “Permanent” Fixed Dental Implant Teeth -5 Steps to Replacing All Your Teeth

      The Process of “Permanent” Fixed Dental Implant Teeth -5 Steps to Replacing All Your Teeth

      Ramsey A. Amin, D.D.S.
      Diplomate of the American Board of Oral Implantology /Implant Dentistry
      Fellow-American Academy of Implant Dentistry

  11. Thanks a lot for sharing this with all people. I worked for a dentist that had SO MANY FAILURES on his implants. He never thought covering the patient and cleanliness was important!

    1. Hi Nyra,

      Wow…that is too bad. Unfortunately, some dentists do not care as much but fortunately most do. Most of the time it is a lack of training and experience and always doing what you have always done.

      thank you for sharing your comments especially that you are in the dental world.

      Ramsey Amin DDS

  12. I am a dental assistant. I worked for a dentist that did implants with only of bib.

    I always wondered why we had so many infections and failed implants!!!! I work for a much better surgeon now that drapes the patient’s like you do. I like the way you use the patient’s own blood to make them heal better.

    patient’s need to know more information like what you are giving them. Too many patients think that 1 dentist this is good is another and a shop by Price.

    1. Hello Greggi,

      Thank you for your nice comments and voted of confidence. I strongly believe that excellent infection control and a sepsis during surgery is critical to the safety and success of dental implants/bone graft surgery. I always wonder why other dentists do not do this even though most know that they should. I don’t believe this is a corner that should be cut.

      With regards to patients blood concentrates, L-PRF is excellent for rapid healing of bone grafts and dental implants. I have been using a combination of PRP/L-PRF for a long time now and I have found it to be extremely successful. I find these patients to have tremendously less pain and bone graft surgeries to heal faster and with higher-quality, density and volume of bone.

      Here is a link about using your patients own blood. Show your Dr. this video.
      Do I Need PRP/PRF/PDGF/BMP For Dental Implants and Bone grafts?

      Very Respectfully,

      Ramsey A. Amin, D.D.S.
      Diplomate of the American Board of Oral Implantology /Implant Dentistry
      Fellow-American Academy of Implant Dentistry
      Burbank, CA

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About Ramsey Amin, DDS

Dr. Ramsey Amin has extensive experience in surgical and restorative implant dentistry. As one of only less than 400 Diplomates of the American Board of Oral Implantology/ Implant Dentistry (ABOI/ID) he is considered an expert, and board-certified in dental implants. He is a former instructor at the UCLA School of Dentistry.