Bone cells live in the most protected environment in the body. Bone cells are encased in thick cortical bone that is never exposed to the surrounding environment. Bone cells are protected from thermal shocks, physical trauma, pressure gradients, and are bathed in very closely controlled conditions of pH, salinity, hydration, and nutrients. If this protected environment is breached, the regenerative cells that we work with are easily killed. In a previous article, we talked about the importance of biocompatibility for bone regeneration. We discussed the requirement that for healthy tissue to grow, it must do so in an inflammatory-free environment. Today we will discuss how dentists routinely compromise the health of bone and how to avoid killing regeneration.
We will use socket grafting as an example of what is good and what is bad for bone regeneration.
First, we need to understand that the bone in the socket is not infected. While there are theories about residual quiescent bacteria present in bone, they remain theories and here at SteinerBio, we have never seen histology to support these theories. A tooth is often extracted because it is a nidus of infection and when removed, the infection can be effectively treated. After the tooth is removed, the granulation tissue is likewise infected and needs to be removed. After granulation tissue is removed, the entire infection is now removed. In the presence of infection, the body mounts an inflammatory response. It is this inflammatory response that triggers bone resorption, not the infection.
Bone is resorbed ahead of bacteria. However, there are very rare instances that bacteria reaches the bone, causing osteomyelitis, which is a surprisingly rare occurrence in the jaws. The bone that is exposed after tooth and granulation removal was not infected prior to extraction, but surely after vigorous removal of granulation tissue, the surface bone will become contaminated with bacteria. You have never seen a bacterial plaque on bone in an extraction socket. The bacteria are not colonized and are merely scattered over the surface as a result of debridement. For this reason, it has been shown that simple rinsing of the socket with sterile saline reduces residual bacteria by 60%. The reason a simple rinse is effective is because the bacteria are scattered over the surface and are not present in attached organized colonies. If you want to grow normal healthy bone, the bone should not be tampered with after tooth and granulation tissue removal, nor should medications or antiseptics ever be introduced into the socket other than a gentle sterile saline rinse. This is not taught by professors and lecturers who usually only have experience with cadaver bone grafts and have no experience regenerating normal healthy bone with science-based bone grafts.
Professors and lecturers who only use cadaver bone grafts commonly teach aggressive post-extraction debridement, often combined with the application of local antimicrobial treatment because of the potential of infection of cadaver bone grafts. Not only is infection of cadaver bone graft common, but infection of cadaver grafts can go unnoticed. After a socket has been filled with mineralized cadaver material, the only thing that is seen on a radiograph is the dead bone of the graft that blends in with the existing bone. You cannot see if mineralization is occurring or if infection is present. The following case is an example.
The Application
Killing Regeneration andExtraction Socket Pain
This is an extraction site 6 months post-op on a healthy young woman. The area of sclerosis is defined by a radiolucent border outlined by the blue arrows. The area of sclerosis cannot be caused by the presence of cadaver bone because the area of sclerosis is much larger and outside the confines of the socket that was filled with cadaver bone. This rounded ball shaped area of sclerotic bone is very common, but only found with cadaver bone grafts.
This radiograph is two weeks after extraction and grafted with Socket Graft. You can see that 2/3 of the socket is filled with visible mineralization.
In this case, if you extracted the tooth, drilled and ground the socket, and then soaked with a toxic antiseptic or applied laser therapy to kill bacteria, you would have killed all of the surrounding bone in the socket and none of this bone formation would have occurred in this time frame.
To utilize the advantages of a science-based bone graft like Socket Graft, you must have immediate osteoblast migration into the graft material. How can this happen if you have just killed all of the osteoblasts in the surface of the bone? When you kill the osteoblasts on the surface of the bone, how can your bone graft become successful when there are no cells to turn the graft material into bone? The killing of the surface osteoblasts is the largest reason for bone graft failures when using science-based bone grafts.
Let’s compare. Cadaver bone grafts heal through an inflammatory process and not from normal migrating osteoblasts. Killing the osteoblasts by aggressive treatment of the socket does not impair the production of mineralized sclerotic bone, but does stop the normal bone formation when using science-based bone grafts. The presence of cadaver bone induces mineralization, but also blocks resorption by preventing the formation of osteoclasts.
So far, we have discussed how the aggressive treatment of the extraction sockets facilitates sclerotic mineralization of cadaver bone grafts and blocks normal bone formation using science-based bone grafts. However, there is one crucial factor that we have not discussed because we needed to provide you with the physiology of the healing socket so that you can understand this next concept.
When you aggressively treat an extraction socket and kill the surrounding bone and then graft with a cadaver bone graft, post operative pain gradually fades. However, when you aggressively treat an extraction socket and graft with a science-based bone graft material, it is not uncommon to experience and increase in post-op pain a few days after extraction. Now that you have an in-depth understanding of what is happing in the socket, we can explain why this happens.
Osteoclasts are responsible for the stimulation and growth of sensory nerve fibers in bone. This makes very good sense because osteoclasts are responsible for removing damaged bone and remodeling bone into normal functioning bone. Wherever osteoclasts migrate to, sensory nerve innervation follows. Nerve innervation is required for normal bone to grow and adapt. In sclerotic bone produced by cadaver bone grafts, you have no osteoclasts present in the newly formed bone and therefore when you kill the bone with aggressive socket treatment, the patient does not experience post operative pain because there are no sensory nerves to feel the pain.
However, when bone is killed with aggressive socket treatment and a science-based bone graft is used, osteoclasts become very active in attacking the damaged bone and bring along sensory innervation. The presence of osteoclasts and the sensory nerves that they bring into the site is what is responsible for the delayed post operative pain when bone is damaged with aggressive socket treatment.
Clinicians only get training from lectures who use cadaver bone grafts and when they substitute a science-based bone grafts for a cadaver bone grafts, they often will produce poor bone graft results with post operative pain.
When we speak to clinicians about socket grafting complications with our products, the response is always the same. They are following the advice of prominent lectures who lack the knowledge about using science-based bone grafts and the techniques they recommend kill regeneration and induce post operative pain.
Our website has a simple list of do’s and don’ts when using science-based bone grafts. Science-based bone grafts are a new world for most clinicians, but by following a few simple rules makes it possible for a successful transition from old technology to the new field of regenerative medicine.
