Localized Use of Metronidazole or Clindamycin in Immediate Implant and Immediate Provisional (new)

It is our routine to place Clindamycin saturated gauze in the extraction socket for 3 times for a few minutes before osteotomy for immediate implant.  It appears that pre-extraction infection does not resolve completely in some cases (1,2).  It is reported that localized use of Metronidazole (Anaerobic antibiotic) reduces post sinus graft infection.  We are going to test whether this antibiotic can reduce post immediate implant infection, as compared to Clindamycin.  Cases are allotted into each category in time sequence.  For example, the 1st control case is the one placed last Monday (WS); the 1st test is the present case (YJ).  The 3rd case will falls into the 2nd case of control group, whereas the 4th will be the 2nd of the text group.  The study will include 20 cases in each group.  Infection control is evaluated 1 week postop, 1-2 times before restoration and 6 months post cementation.   Evaluation includes vision (whether swelling has been decreased) and palpation (press the fistula to determine whether it has been reduced or disappeared).  In fact, an emergency case shifts the distribution of cases as shown below.

A Metronidazole tablet (.2 g) will be ground with a bone grinder or mortar & pestle and dissolved in 2% Xylocaine/1:50,000 Epinephrine.  Three pieces of gauze for a socket will be soaked in the suspension.  Harvested bone will be saved in the dappen dish for antibiotic preparation.

The 74-year-old patient is excited about having 3 implants placed without discomfort (1,2).  He wants to take care of a loose FPD spanning from #8 to 9 (Fig.1).  It appears that #8 is non-salvageable (Fig.2 * with deep pockets).  There is severe bone loss around the affected tooth (Fig.3; Osteotape is expected for buccal and lingual defects).  In addition, the Incisive Canal is abnormally large (arrowheads).  The coronal end of a 4.5x20 mm implant and a 3.5x5 mm abutment will be slightly deviated mesially (Fig.4), since the 3-unit FPD will be converted to 2 single unit crowns.  Surgical guide is ready.  The 1st step is to section between #8 and the pontic (Fig.5; green outline: implant; red: abutment).  If primary stability is low, the immediate provisional (Fig.8 white area) will be bonded the tooth #7 and the pontic as a supplementary measure (blue areas).   Once the implant is osteointegrated, the distal portion of the pontic (Fig.7 *) will be removed.  Acrylic is added to the mesial portion of the provisional (Fig.8 *) so that the papilla (P in Fig.7) will be pushed mesially and incisally (Fig.8 arrowheads).  The step will be repeated a few weeks later (Fig.9).  It could be done bilaterally at the same time by removing #9 crown and converting to the provisional.  Finally the pontic will be removed.  Two relatively wide crowns will be fabricated if the patient is satisfied with the provisional.

In fact, a control group is added to the study.  After extraction, the socket will be packed with gauze saturated with 2% Xylocaine with 1:50,000 Epinephrine.  Hemostasis helps remove infected granulation tissue.  By time sequence, HY will be the first case in the control group.

Return to Upper Incisor Immediate Implant

Xin Wei, DDS, PhD, MS 1st edition 08/02/2015, last revision 03/21/2020

Table: Comparison of Topical Use of Clindamycin and Metronidazole in Reduction of Postop Infection

  Clindamycin Metronidazole Control Aborted   Clindamycin Metronidazole Control Aborted  
  N A S # Result N A S # Result N A S # Result ZC 50 F 29     N A S # Result N A S # Result N A S # Result            
1 WS 52 M 13 Cement YL 68 F 11 R HY 49 M 3 Peri-i WJ 52 F 3 Cx 51 WY 39 F T   SZ 42 M 4   NF 45 M 30   QC 59 M 19    
2 YJ 74 M 8 Cement       15   WQ 45 M 13   PK 75 F  31   52 CH 34 M 5   ZX 53 M 2   GY 47 F 18              
3 TK 50 M 15 R ZF 43 F 19 Cement TX 86 M 27 R RB 45 M 26   53 HD 71 M 29   QJ 45 M 7   ZH 71 M 22              
4 WQ 68 F 30 C YJ 74 M 30 To C       28   TM 43 M 3   54       30   GJ 73 F 13   LT 60 F 7              
5 ZB 53 M 15 Peri-i ZL 40 F 9 To C JT 45 M 20 R JC 55 M 13 SP 55       31   LJ 53 M 20   LS 72 M 31              
6 CC 67 F 13 R TF 70 M 10 1 piece ZG 41 3 Retight         Cx 56 YL 36 F 4   ZY 35 M 18   YP 59 M 24              
7 CY  62 M 15 R MM 63 M 31         4 12/20 ZC 39 M 31 Cx 57 SH 46 M 3   PM 60 F 13   YL 70 F 26              
8 ZY 49 F 2 To C CZ 62 M 22   CM 48 M 13 R           58 HJ 44 F 8   CH 42 F 13   ZS 76 F 22              
9 FY 45 F 31 R       24   YR 84 F 10             59 ZC 44 M 28   CV 70 F 14         24              
10 ML 63 F 3         26   RY 50 M 14   LM 51 F 18 SP 60 LE 71 M 23   ZY 70 M 14   LX 45 M 18              
11       4         27   RL 51 F 18             61 HL 53 F 19 Periim PV 48 M 25   JJ 50 M 29              
12       10   SG 73 M 28   JG 47 M 13   DM 52 M 14 SP 62 LW 65 F 5   YH 58 F 2   LC 43 M 30   KR 51 F 2 Cx  
13 ZC 51 F 15   ZJ 52 F 3   CZ 62 M 4   HJ 42 F 15 OS 63 TY 34 M 30   ZX 57 M 30   ZJ 47 M 15              
14 YW 56 F 19   CM 53 F 13   CK 70 M 5             64 ZC 44 M 3   LN 65 F 20   ZH 40 M 15              
15 CK 70 M 11   CJ 62 M 1         6             65 CD 37 M 14   WP 62 F 26   LS 73 M 23              
16 HH 51 M 8   WR 49 M 7   MP 37 F 19             66 TJ 60 F 2         27         25              
17       9   ZD 17 M A   CZ 62 M 19             67 WM 32 F 18   YS 59 F 13   ZH 72  M 31              
18 GJ 72 F 8   SQ 58 M 2   XK 42 M 14             68 PV 49 M 14   YJ 67 F 29   SD 47 M 30              
19 CG 58 F 3   ZH 70 M 6   FJ 54 M 19             69 GY 37 F 10   YL 36 F 8   FC 64 M 31              
20 YY 42 M 24   JQ 58 M 28 HL 53 F 18             70 NZ 59 M 24         9   SP 50 F 8              
21 ZH 72 M 14       31   ZW 55 M 18 71       2   QJ 45 M 2   KA 64 F 15              
22 CZ 63 M 13   ZX 52 M 7   CM 50  F 8   WG 56 M 19 Pending 72 LC 65 F 4         3   LQ 45 M 24              
23       14         10   YT 78 F 3   WG 56 M 15 Pending 73 XB 35 F 9         5         26              
24 TF 71 M 6   SH 45 M 19         5   ZY 34 M 18 Saved 74 WG 57 M 15   CQ 36 M 23   HD 41 F 4              
25 SD 51 M 18   ZC 69 F 8   ZQ 53 M 8   HJ 48 F 18 Cx 75 XJ 75 M 12         26   HP 37 M 8              
26 HW 43 F 7   ZC 42 F 19   HJ 43 F 15   CK 70 M 10   76 LJ 62 M 4   YC 41 M 14   LC 65 F 14              
27 SG 73 M 25   DC 48 F 9   LY 60 F 8   WJ 61 M 4 31 77 WH 50 M 11   CQ 36 M 3   LL 43 F 30              
28 CS 62 M 3   HV 48 M 29   ZY 53 F 15   TF 56 F 7 Cx 78 HX 67 M 3         5   WH 45 F 3 CQ 36 M 19      
29 XW 36 F 11   SS 78 F 11   LP 52 F 4             79 LL 53 F 3   YF 53 M 14   CB 40 M 4       20      
30 CY 19 M 4   GJ 54 M 15   YT 78 F 6             80 CV 71 F 30   LL 43 F 2   WJ 55 F 30       7      
31 SJ 35 M 9   GJ 72 F 5         8             81 ZC 44 M 15   YF 53  M 31   KA 64 F 20 CY 40 F 18      
32 WM 58 F 19   JA 54 F 15   LX 55 F 20             82 CS 64 M 14   CA 89 M 10   HY 59 M 15              
33 LP  47 F 31   WX 53 F 24   GL 46 F 14             83 LW 66 F 12   TZ 61 M 4   ZL 58 M 2              
34 LC 37 F 30   LM 60 M 15   XP 64 F 9*   YL 35 F 18 SP 84       13   CY 64 M 2   CK 63 M 18              
35 HR 72 M 14   YL 54 F 2   WM 48 M 21   LM 71 M 20 Cx 85 WW 50 M 30         4   ZG 43 M 18              
36 QY 59 M 23   SH 46 M 4   SQ 41 F 18             86 ZW 51 M T   WZ 87 M 19   CF 55 F 8              
37 LK 54 F 14   DT 55 M 4   XB 64 M 30   ZC 52 F 2*   87 WQ 70 F 14   LH 64 M 14    SF 64 M 19              
38 ZC 56 F 15   JQ 58 M 29   ZC 40 M 19         3*   88 MW 54 M 30   TX 88 M 14   WZ 88 M 31 WP 72 M 18 SP    
39 LL 50 F 14   CZ 50 M 19   SH 46 M 14   CC 46 F 2   89       31   HJ 44 F 25   VC 59 F 2              
40 FJ 50 M 19   RY 52 M 2         18             90 JQ 59 M 3   JY 47 F 19   ZX 54 M 19              
41 MM 64 M 12   ZY 49 F 31   CA 88 M 8             91 HW 53 F 31         15   WC 67 M 2              
42 HR 73 M 4   LL 52 F 3         10             92 YB 41 F 9   YP 66 F 30   DW 60 M 10 TT 71 F 22      
43 WS 82 M 17   ZY 40 F 14   LW 47 M 15             93       10   CN 59 F 19   WW 50 M 19       23      
44 DW 59 M 7   CK 71 M 19   LW 47 M 4             94 WP 62 F 20   CH 61 M 30   YL 57 M 9 ZB 63 M 19 SP    
45 ZC 44 M 14   YB 67 F 3   YZ 59 M 18             95       21   YY 58 M 30   WP 40 M 28              
46 NY 43 F 6   ZZ 59 M 13 LS 72 M 21             96 ZQ 38 F 6   CZ 45 M 30   LH 60 M 14              
47 WP 59 M 2   QJ 45 M 9   GS 52 M 7             97 QJ 46 M 22   SH 47 M 29   LM 54 M 9              
48 TY 57 F 27         10   DC 49 F 3             98       27   YY 54 M 21   SH 47 M 9              
49 CS 29 F 4         11         4             99 LY 48 F 9   WY 35 F 6    QJ 46 M 31              
50 LX 48 F 19         15   LJ 34 M 14             100 ZZ 56 M 9   DA 44 F 12   CC 48 F 3              
101 NJ 58 M 19   TB 29 F 9   CC 44 M 15             126 DL 65 M 14   WY 39 M 31   YX 61 F 14              
102 HJ 44 F 22   SJ 55 M 8   FK 79 M 18 CC 51 M 25     127 CC 49 F 4   YP 67 F 13   WY 61 F 11 WX 61 M 19      
103 XK 73 M 22   ZL 46 F 12   YJ 52 F 11       31     128 YS 49 M 3   LA 79 M 7   JW 55 F 12              
104        25   KS 59 F 31   ZC 54 F 2             129 LF 74 M 13   HL 75 F 25         20              
105       26   GJ 58 M 24   LT 47 F 15             130 ZY 51 M 2   WH 32 F 14   CY 36 F 3              
106 SF 64 M 19         25   CB 60 M 31             130 XJ 44 F 13         19         31              
107 HJ 49 M 15   WJ 75 M 13   XH 58 F 15             131 JQ 60 M 12   NL 68 M 19   LC 40 M 31              
108 ZY 77 M 11   SA 51 F 5   EW 79 F 30             132 RL 58 F 15   WC 46 F 18   HJ 46 F 18              
109       14   HD 72 M 19   LS 54 M 31 ZH 29 F 31     133 JD 54 M 15   WM 74 F 5   WL 57 F 19              
110 LY 61 F 9   JW 34 F 18   ST 61 M 12             134 TS 48 M 4   CY 38 F 29   JK 44 F 18              
111 SS 55 F 14   ZS 54 M 2   SB 56 M 31             135 XX 52 F 4   YZ 54 M 15   LS 56 F 7              
8 ZM 82 F 13   PM 79 F 22   HA 59 F 13             136 PK 80 F 15   YG 47 F 30         9              
113 SB 65 F 3   SD 48 M 29   TM 50 F 22             137 ZH 48 M 14   YZ 53 M 15   LF 74 M 24              
114 SF 64 M 10   ZH 60 M 30   LC 59 M 8             138 LW 29 M C   YL 35 M 18   HM 55 M 14              
115 HS 67 F 30   CJ 78 M 6         9 JB 62 F 20     139       H   LQ 45 M 14   PM 63 F 7              
116 YR 87 F 7         11   LJ 54 F 15             140 LL 73 F 14   WY 37 F 18   SY 33 F 18              
117 XK 67 M 10         12   WH 54 M 11             141 YH 63 F 18   HJ 46 F 20         20              
118 YL 72 F 3   LJ 79 F 14   MY 48 F 30             142 ZG 34 M 12   CZ 67 M 20   HS 71 F 31              
119 ZQ 56 M 13   GJ 56 M 31   DW 61 M 22             143       19   JW 56 F 29   SG 77 M 5              
120 GJ 59 M 30   ZK 56 M 26   ZC 46 F 5             144 FJ 58 M 18         30   SF 66 M 12              
121  SH 54 M 4   ST 67 M 19   SS 56 M 19             145 CY 67 F   LJ 47 M 2   TM 47 M 30              
122       12   WJ 63 M 5   WJ 63 F 12             146 XH 42 M 21         31   VS 66 M 4              
123 ZY 82 M 20   WZ 88 M 21   XJ 53 M 4 ZZ 54 M 19     147 LX 58 F 31   DT  59 M 19   JY 49 F 13              
124       22   WZ 88 M 10   JS 58 M 9             148 NT 66 M 2                                  
125       18   LY 66 F 30   CM 57 M 9                                                        
                                                                                     
                                                                                     
                                                                                     
                                                                                     
                                                                                     
                                                                                     
                                                                                     
                                                                                     
                                                                                     
                                                                                     

Abbreviations: N: name (initial); A: age; S: sex (M: male; F: female); Cx: cancel;