Clinical Oral Investigations

https://doi.org/10.1007/s00784-018-2476-0

ORIGINAL ARTICLE

Microbial accumulation on different suture materials following oral

surgery: a randomized controlled study
Ran Asher 1 & Tali Chacartchi 1 & Moshik Tandlich 1 & Lior Shapira 1 & David Polak 1

Received: 26 December 2017 / Accepted: 25 April 2018

# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Background The aim of the study was to compare bacterial accumulation on different suture materials following oral surgery.
Methods Patients scheduled for implant or periodontal surgery were included in the study. Upon flap closure, four different
sutures were placed in a randomized sequence—silk, coated polyglactin, nylon, and polyester. Ten days following surgery, the
sutures were removed and incubated in aerobic as well as anaerobic conditions for 7 days and colony-forming units (CFUs) were
calculated. Association between bacterial accumulation and periodontal diagnosis, type of surgery, and antibiotic treatment were
also tested.
Results All sutures in all patients were found to contain bacteria. Overall, nylon sutures showed significantly lower CFU levels
compared to silk, coated polyglactin, and polyester sutures. The type of surgery (implant vs. periodontal surgery) did not
significantly influence bacterial accumulation. Also, periodontal diagnosis had little impact on CFU counts. Interestingly,
post-surgical antibiotic treatment also had only a minor effect on bacterial accumulation on the various sutures.
Discussion The results indicate that the monofilamentous nylon sutures showed less microbial accumulation than the other tested
materials that were all braided. This effect may be due to material qualities as well as suture macrostructure. Type of surgery,
periodontal diagnosis, and antibiotic consumption have little effect on bacterial accumulation of sutures.
Clinical relevance The study provides the microbial profile of commonly used sutures and may assist in suture selection during
clinical procedures.

Keywords Nylon suture . Coated polyglactin suture . Silk suture . Polyester suture

Introduction
Most surgical procedures are finalized with sutures, which
enables flap approximation and hemostasis, allowing restora-
tion of function and esthetics [1, 2]. Choosing an appropriate
suture material may influence wound healing, particularly in
the oral cavity due to the various functions of the oral cavity
(i.e., swallowing and eating) and the presence of saliva [2].
In clinical situations, suture selection relies mostly on per-
sonal preference of the surgeon. Factors which are taken into
consideration by the surgeon in suture selection include the
Lior Shapira and David Polak contributed equally to this work.
* David Polak
polak@mail.huji.ac.il
1
Department of Periodontology, Hebrew University-Hadassah
Faculty of Dental Medicine, P.O.Box 12272, 91120 Jerusalem, Israel
surgical site, duration until their removal (or whether to refrain
from suture moval), ease of handling, and tensile strength.
Due to the importance of infection and inflammation in the
healing process following surgery, the biological response to
the suture material, such as tissue reaction and bacterial adhe-
sion, should be included while considering the use of a spe-
cific suture.
A great variety of suture materials are commercially
available. Classification of sutures is based on the chemical
and physical properties of each suture, as well as the bio-
logical processes occurring in the environment and the ad-
jacent tissues [3]. Sutures are usually classified according
to their bioabsorbable properties or mechanical properties
or according to their macrostructure—monofilament vs.
multifilament [1].
Most studies focused on the inflammatory response to the
suture material. Selvig et al. showed that changes in the sur-
rounding tissue occur immediately after placement of the su-
tures which peak after 3 days [4]. The healing was categorized

by areas according to the histological findings: (a) close to the
entry of the stitch canal adjacent to inflammatory cell exudate,
(b) the stitch canal which is associated with tissue fragments
and damaged cells, (c) the connective tissue infiltrated with
inflammatory cells. Acute inflammation occurs due to the ad-
herence of bacteria and their penetration into the stitch canal,
which is mostly evident when using polyfilament threads
[3–6]. Polyfilament sutures also showed higher numbers of
bacteria residing inside the tissue [1].
Limited information is available regarding bacterial adhe-
sion to different suture materials. Therefore, the primary aim
of the study was to compare bacterial accumulation (CFUs)
between different suture materials in humans following oral
surgery. Secondary aims were to compare bacterial adhesion
to sutures according to the type of surgery, periodontal diag-
nosis, and the effect of post-surgical antibiotic treatment.
Material and methods
Study population
Patients attending the periodontal department at Hadassah
Medical Center, Jerusalem, between March 2016 and
July 2016 were included in the study on a consecutive basis.
The study protocol, questionnaires, and informed consent
were in accordance with the institutional ethic committee
(HMO-0079-15).
Inclusion criteria included the following: (a) patients
scheduled for implant or periodontal surgery with a surgical
incision site large enough to include at least four sutures with a
distance of 5 mm between them; (b) patients willing to partic-
ipate in the study and sign an informed consent form; (c)
patients without known systemic illness (diabetes, heart dis-
ease, immune deficiency, thrombocytopenia/coagulation en-
zymes deficiency); (d) patients without chronic alcohol
consumption/drug consumption; (e) not pregnant; (f) non-
smokers.
Recorded data for each subject included age, gender, type
of surgery, and post-operative care, including whether the pa-
tient was instructed to take antibiotics following surgery.
Periodontal diagnosis was also recorded according to the
AAP consensus report 1999 criteria [7].
Experimental design
Four types of synthetic suture materials (Ethicon, Somerville,
NJ, kindly provided by Shvadent, Israel) were used in each
patient: (a) silk suture—a braided non-absorbable, surgical
suture produced from cocoons of the silk worm and dyed
black; (b) coated polyglactin suture composed of a copolymer
made from 90% glycolide and 10% L-lactide (VICRYL); (c)
nylon suture—a monofilament suture composed of the long-
Clin Oral Invest
chain aliphatic polymers (Ethilon); (d) polyester suture—a
braided suture composed of poly(ethylene terephthalate) coat-
ed with polybutilate (Ethibond Excel). All sutures were 4-0,
with a 16-mm reverse cutting 3/8 needle.
Types of surgery included periodontal surgery, implant sur-
gery, guided bone regeneration, and second-stage implant sur-
gery (implant exposure). Allocation concealment for each su-
ture was obtained using sealed coded opaque envelope con-
taining the suturing sequence for the specific surgery/patient
starting from mesial to distal. The sealed envelope containing
the schematic drawing of the sutures was opened at time of the
surgery immediately before flap approximation and suturing.
The surgical area was sutured using simple interrupted su-
tures, with spacing of one tooth or 5 mm from each other in
edentulous areas. All patients were instructed to refrain from
brushing the surgical site, and to use chlorhexidine mouth-
wash (0.2%) twice daily until suture removal. Decision to
include post-operative antibiotic regimen was depended on
the treating surgeon. Only one surgery per patient was includ-
ed in the study.
Suture removal was carried out 10 ± 2 days following sur-
gery by one periodontist (RA). Each suture was collected
using separate sterile forceps and scissors and transferred into
a tube with 1 ml sterile phosphate buffer saline (Sigma,
Rehovot, Israel). The tubes were immediately transferred to
the laboratory for microbiological cultures.
Bacterial culture
Samples were vortexed for 10sand a series of four 10-fold
dilutions of each sample were prepared. Ten milliliters of each
dilution was seeded on two blood agar plates (Hay laborato-
ries, Rehovot, Israel). For each sample, one plate was incubat-
ed in aerobic condition (CO2 5%) while another identical plate
was incubated in anaerobic conditions (N2 85%, H2 5%, CO2
10%) for 7 days. Following the incubation period, numbers of
colony-forming units (CFUs) were counted. The number of
black-pigmented CFUs was counted on plates from the anaer-
obic conditions. CFU was calculated as the number of colo-
nies per 10 μl at the minimum dilution with clear, separate,
and countable colonies. For each suture, a mean and SD were
calculated for all subjects (including quadruplicates measure-
ment/subject).
Data analysis
Results are presented as mean values and standard deviation.
Statistical significance was tested using one-way ANOVA
followed by t test for significance differences between groups.
Adjusted P values were considered significant lower than
0.05. Sample size was determined according to power calcu-
lations with a 5% alpha error level. A minimum of 30 subjects
Clin Oral Invest

were required for statistical significance. All analyses were
performed using the SigmaStat software 2.03 version.
Results
Fifty-eight patients were recruited to the study. Fifty patients
were included, while 8 subjects did not meet the inclusion
criteria and were therefore excluded from the study. Mean
age was 54 years (range 23–76), and 26 of the subjects were
females (62%).
Total CFUs from silk, coated polyglactin, and Ethibond
sutures exhibited similar bacterial levels (≈ 20 × 104CFU/su-
ture; Fig. 1). Nylon sutures showed significantly less CFUs
compared to all the other tested sutures (P < 0.05), with ap-
proximately 50% of adsorbed bacteria (≈ 10 × 104CFU/su-
ture; Fig. 1). Total anaerobic bacteria showed similar pattern
with CFU values of ≈ 13 × 104CFU/suture in all the tested
sutures, except nylon, which showed significantly lower
values of ≈ 7.5 × 104CFU/suture (P < 0.05; Fig. 1). Aerobic
cultures did not reveal any significant differences between
the different sutures, with CFU values of ≈ 9 × 104CFU/suture
(P < 0.05; Fig. 1). Levels of black-pigmented bacteria were
low for all types of sutures (≈ 2 × 104CFU/suture), but with
lower levels in the nylon suture (P > 0.05; Fig. 1).
The results were further stratified according to antibiotic
consumption, type of surgery, or periodontal diagnosis.
Bacterial attachment according to antibiotic
consumption
Fourteen patients received pre-op antibiotics (13 patients
amoxicillin 2 g and 1 patient clindamycin 600 mg as a single
administration). Eleven patients received post-op antibiotics
(9 patients amoxicillin 500 mg × 3 TID for 7 days, 1 patient
clindamycin 300 mg × 3 TID for 7 days, 1 patient Augmentin
875 mg ×2 BID for 7 days).

Fig. 1 CFU values for total

bacteria. At suture removal (one
suture type/patient), all sutures
were eluted in PBS followed by
10-fold dilution, seeded on blood
agar plates, and incubated for
7 days in aerobic and anaerobic
conditions. Results are expressed
as mean CFUs (± standard
deviation) of total bacteria,
anaerobic bacteria, aerobic
bacteria, and black-pigmented
bacteria. *Statistically significant
difference (P < 0.05). S, silk; N,
nylon; V, coated polyglactin
(VICRYL); E, polyester
(Ethibond)
 Clin Oral Invest

No significant differences were observed between antibiot-
ic consumption and antibiotic-free groups for all the tested
parameters.
Total CFU values for patients who consumed post-surgical
antibiotics did not show any statistical difference between
groups. On the other hand, total CFU for patients that did
not consume antibiotic demonstrated significant differences
between nylon suture and coated polyglactin only (≈ 10 ×
104 CFU/suture vs. ≈ 22 × 104 CFU/suture respectively;
Fig. 2). Anaerobic bacteria showed similar results for antibi-
otic and antibiotic-free patients (Fig. 2). However, only in the
antibiotic-free group the difference between nylon (≈ 5 ×
104 CFU/suture) and other sutures (≈ 13 × 104 CFU/suture)
was statistically significant (Fig. 2). Aerobic cultures did not
show any significant differences between the two groups (≈
8 × 104 CFU/suture).
Bacterial attachment according to type of surgery
No significant differences in bacterial adherence to the differ-
ent sutures were observed between periodontal surgery and
implant surgery.
Total bacterial levels on sutures following periodontal sur-
gery demonstrated no significant differences between groups
(Fig. 3). The difference between nylon and coated polyglactin
sutures following implant surgery was statistically significant
(≈ 10 × 104 CFU/suture vs. ≈ 23 × 104 CFU/suture respective-
ly; Fig. 3). Anaerobic bacterial counts after periodontal sur-
gery were significantly higher on silk than on nylon sutures (≈
18 × 104 CFU/suture and ≈ 7 × 104 CFU/suture, respectively,
P < 0.05; Fig. 3). In general, anaerobic bacteria following im-
plant surgery showed lower CFU levels compared to that fol-
lowing periodontal surgery, with lowest CFU’s in nylon suture
(≈ 5 × 104 CFU/suture) compared to the three other tested su-
tures (Fig. 3). Aerobic CFU values were higher for periodontal
surgery compared to implant surgery, but no statistical differ-
ences could be observed (Fig. 3).
Bacterial attachment according to periodontal
diagnosis
No significant differences were observed between periodon-
tally healthy and periodontal subjects (PD) in all tested
parameters.
Periodontally healthy subjects showed non-significant dif-
ferences between the four suture materials (Fig. 4). Gingivitis
and periodontitis subjects (PD) showed significant differences
between the tested groups: while similar values of bacteria
were found for silk, coated polyglactin and polyester (≈ 20 ×
104 CFU/suture; Fig. 4), the difference between nylon and

Fig. 2 CFU values stratified

according to antibiotic
consumption. At suture removal
(one suture type/patient), all
sutures were eluted in PBS
followed by 10-fold dilution,
seeded on blood agar plates, and
incubated for 7 days in aerobic
and anaerobic conditions. Results
are expressed as mean CFUs (±
standard deviation) for total
bacteria, anaerobic bacteria, and
aerobic bacteria, for patients that
took or did not take post-surgical
antibiotics. *Statistically
significant difference (P < 0.05).
S, silk; N, nylon; V, coated
polyglactin (VICRYL); E,
polyester (Ethibond)
Clin Oral Invest

Fig. 3 CFU values stratified

according to type of surgery. At
suture removal (one suture
type/patient), all sutures were
eluted in PBS followed by 10-fold
dilution, seeded on blood agar
plates, and incubated for 7 days in
aerobic and anaerobic conditions.
Results are expressed as mean
CFUs (± standard deviation) for
total bacteria, anaerobic bacteria,
and aerobic bacteria, for
periodontal vs. implant surgery.
*Statistically significant
difference (P < 0.05). S, silk; N,
nylon; V, coated polyglactin
(VICRYL); E, polyester
(Ethibond)

Fig. 4 CFU values stratified

according to periodontal
diagnosis. At suture removal (one
suture type/patient), all sutures
were eluted in PBS followed by
10-fold dilution, seeded on blood
agar plates, and incubated for
7 days in aerobic and anaerobic
conditions. Results are expressed
as mean CFUs (± standard
deviation) for total bacteria,
anaerobic bacteria, and aerobic
bacteria, for periodontal patients
vs. healthy subjects. *Statistically
significant difference (P < 0.05).
S, silk; N, nylon; V, coated
polyglactin (VICRYL); E,
polyester (Ethibond)

coated polyglactin sutures was significant (≈ 10 × 104 CFU/
suture vs. ~ 20 × 104 CFU/suture respectively; Fig. 4). For PD
patients, similar CFU values (≈ 15 × 104 CFU/suture) were
found for all sutures, except nylon which exhibited significant
lower values (5 × 104 CFU/suture; Fig. 4).
Discussion
The current study shows that bacterial adhesion differs be-
tween various suture materials. Overall, adhesion of bacteria
to nylon suture was found to be lower compared to silk, coated
polyglactin, and polyester sutures. The sutures also represent
two macrostructure types (monofilamentous (nylon) and
braided (silk, coated polyglactin, and polyester)) which most
probably affected the superiority of the nylon suture.
However, in order to clearly distinguish between suture mate-
rial and suture structure, a future study with the appropriate
design should be performed.
Using a mouse model with radio-labeled bacteria, Katz
et al. found similar results and reported 5–8-fold lower adhe-
sion of bacteria to nylon sutures in comparison to the other
suture materials [6]. This notion is also in accordance with
other studies, which showed that multifilament absorbable
braided sutures have higher bacterial counts compared to
monofilament non-resorbable sutures [1–3]. Leknes et al. also
showed that ePTFE suture exhibited less adhesive properties
compared to silk suture, both in the surrounding connective
tissue infiltrate and in the presence of bacterial plaque inside
the suture canal [3]. On the other hand, Banche et al. showed
that an absorbable monofilament suture, Monocryl, exhibited
significantly low microbial load [2]. The current study shows
that resorbable sutures accumulate bacteria to similar extent as
the other tested sutures, excluding nylon. This difference may
be due to the fact that we used a multifilament suture vs.
monofilament which was used by Banche et al. [2].
The flow of bacteria along the suture canal from the oral
environment and into the tissues causes an inflammatory re-
sponse [1, 4, 5]. As a consequence, the medical and dental
literature stresses the harmful effect of bacterial adhesion to
suture materials and also states a clear advantage of monofil-
ament non-resorbable suture [8–10]. One very interesting con-
clusion was noted by Edlich et al. [9] that the chemical struc-
ture of the suture appeared to be the most important factor in
the development of surgical infection while the physical con-
figuration of the suture played a relatively minor role [9]. The
current study contradicts these findings: sutures made from
different materials (silk, coated polyglactin, and polyester)
with a multifilament configuration showed similar bacterial
accumulation, while monofilament suture (nylon) was the on-
ly material that exhibited a significantly lower accumulation
of bacteria. These present results suggest that the physical
Clin Oral Invest
configuration of the suture, and not its chemical composition,
plays a major role in bacterial accumulation onto the suture.
The current study is the first to include analysis of bacterial
adhesion to sutures according to the type of surgery, periodon-
tal diagnosis, and post-surgical antibiotic treatment. Type of
surgery and periodontal diagnosis did not lead to a significant
difference in bacterial accumulation on the different sutures.
Interestingly, post-surgical antibiotic treatment also did not
affect bacterial accumulation onto the different tested sutures.
Another important conclusion that may be drawn from the
current data—the fact that all subjects in the study used chlor-
hexidine mouthwash following surgery did not prevent bacte-
rial accumulation on the sutures, indicating that chlorhexidine
does not completely prevent bacterial infection of the surgical
site.
Our results indicate that, whenever possible, the first choice
of suture between the present tested materials should be nylon.
If nylon sutures cannot be used, the selection between the
other tested suture materials has a minor effect on bacterial
adhesion and may be subjected to personal preference of the
surgeon. Furthermore, since all sutures were found to harbor
bacteria, any suture may be considered as a port of entry for
infection, which in turn may compromise healing of the sur-
gical wound. It is advised to minimize the duration of the
presence of sutures, and their removal should be carried out
as early as possible, according to the specific healing
conditions.
Funding The study was self-funded. Shvadent Ltd., Israel, contributed
the sutures to the study.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
References
1. Burkhardt R, Lang NP (2015) Influence of suturing on wound
healing. Periodontology 2000 68 (1):270–281. doi:https://doi.org/
10.1111/prd.12078
2. Banche G, Roana J, Mandras N, Amasio M, Gallesio C, Allizond V,
Angeretti A, Tullio V, Cuffini AM (2007) Microbial adherence on
various intraoral suture materials in patients undergoing dental sur-
gery. J Oral Maxillofacial Surgery : Official J Am Assoc Oral
Maxillofacial Surgeons 65(8):1503–1507. https://doi.org/10.1016/
j.joms.2006.10.066
Clin Oral Invest
3. Leknes KN, Roynstrand IT, Selvig KA (2005) Human gingival
tissue reactions to silk and expanded polytetrafluoroethylene su-
tures. J Periodontol 76(1):34–42. https://doi.org/10.1902/jop.2005.
76.1.34
4. Selvig KA, Biagiotti GR, Leknes KN, Wikesjo UM (1998) Oral
tissue reactions to suture materials. Int J periodontics Restorative
Dentistry 18(5):474–487
5. Grigg TR, Liewehr FR, Patton WR, Buxton TB, McPherson JC
(2004) Effect of the wicking behavior of multifilament sutures. J
Endod 30(9):649–652
6. Katz S, Izhar M, Mirelman D (1981) Bacterial adherence to surgical
sutures. A possible factor in suture induced infection. Ann Surg
194(1):35–41
7. Armitage GC (1999) Development of a classification system for
periodontal diseases and conditions. Annals Periodontology 4(1):
1–6. https://doi.org/10.1902/annals.1999.4.1.1
8. Masini BD, Stinner DJ, Waterman SM, Wenke JC (2011) Bacterial
adherence to suture materials. J Surgical Education 68(2):101–104.
https://doi.org/10.1016/j.jsurg.2010.09.015
9. Edlich RF, Panek PH, Rodeheaver GT, Turnbull VG, Kurtz LD,
Edgerton MT (1973) Physical and chemical configuration of sutures
in the development of surgical infection. Ann Surg 177(6):679–688
10. Justinger C, Moussavian MR, Schlueter C, Kopp B, Kollmar O,
Schilling MK (2009) Antibacterial [corrected] coating of abdominal
closure sutures and wound infection. Surgery 145(3):330–334.
https://doi.org/10.1016/j.surg.2008.11.007