Dental Education

Routine Antibiotics Not Necessary in Dental Implant Procedures

Antibiotic prophylaxis has long been recommended for individuals that are at a high risk of infection such as those with prosthetic instrumentation, immunodeficiency or infectious endocarditis. For those who are regarded as clinically healthy, that is, patients who are at a low to moderate risk of infection, the extent of antibiotic use has long been the topic of dentist's education debate.

When it comes to fairly complicated oral surgeries like dental implants, dentists are usually faced with the dilemma of judgment when it comes to prescribing prophylactic antibiotics. While usually the prescription of antibiotics is made on a case-to-case basis, actual infection would become complicated to treat if antibiotics were prescribed improperly.

A study dating back to 2000 interestingly reveals that about 40% of general dental professionals would haphazardly prescribe antibiotics as an infection contingency for patients without significant medical history. The Canadian Dental Association, or CDA, states that dental procedures such as implants are becoming more commonplace, and the numbers are still growing to date, making the hasty prescription of antibiotics a cause of concern. It is therefore crucial that case-specific guidelines for prophylactic antibiotics use be drafted and implemented.

In a literature review crafted in 2012, 92% of 11,406 implants that were antibiotic-free turned out to be successful. Cases that used antibiotics saw a success rate of 97% while cases that used antibiotics in both pre and post-operations garnered a 96% success rate. This shows that in low to moderate risk type of patients that undergo dental implants, antibiotic prophylaxis gives no benefit.

Antibiotics are used in order to prevent infection following a dental implant, since infections in such procedures entail a high chance of failure. However, even if dental implant failure is not only due to infections but also to a number of other factors, practitioners more often than not turn to prevention by antibiotic prescription. Since the mouth has its natural flora multitude, the level of bacteremia incidence is quite high. This prompts practitioners to prevent surgical wound infection by administering a concentration of antibiotics in the blood in order to prevent the dissemination and proliferation of bacteria.

Certain bacteria strains are associated with early implant failure. The most common ones involved in implant infections include: anaerobic gram positive cocci, anaerobic gram negative rods, and streptococci. Therefore, preventing slow wound healing entails antibiotics that have low toxicity and are bactericidal.

Penicillin and Amoxicillin are the most common antibiotics in the market, as they have been recommended by the American Heart Association due to their prolonged serum levels and ability for absorption. However, there is an increasing population of Penicillin allergy cases, therefore Clindamycin has been widely used as an alternative. This shows that antibiotics may also pose its own threat as adverse side effects are in existence, ranging from a simple case of diarrhea to more life threatening cases such as allergies. There is also the evolution of bacteria in order to resist antibiotics, as well as the danger of surgical techniques becoming lax due to complacency which may arguably increase the probability of complications.

The use of antibiotics during dental procedures has been over looked for decades. However, recent trends have looked into its routine administration, thus turning to clinical research in order to validate its use. The CDA states that, ”all dental procedures where significant oral bleeding and/or exposure to potentially contaminated tissue occurs typically (will) require antibiotic prophylaxis.“ A similar statement was also released in the guidelines of the ADA. The American College of Surgeons as well as the American Heart Association (AHA) put specifics into their guidelines, suggesting that complicated oral surgery, which includes dental implant placement, will find coverage from prophylactic antibiotic beneficial. However, in as recent as 2007, leniency has been seen in the association between antibiotic prophylaxis and dental implants. It was then suggested that only high and isolated moderate risk cases patient categories should render antibiotic administration. Other concerns include extra precaution for patients with existing prosthetics, since they are at a higher risk for bacterial infection development.

To this day, there is very little documentation on the success rate of pre and post-operation uses of antibiotics in dental implant procedures. Drafting a pre-operational guideline that can hold standard for dental practices all over the world is possible; however, post-operational guidelines are more open-ended as they are subjected to the outcome of the procedure, including all outcomes that take place during and after the operation. Many protocol attempts have been made in the form of written articles, however, ethics prevent the trial of double blind controls.

In a paper done recently, alternative methods for decreasing the risk of infection were explored. This included chlorhexidine digluconate (CHX), an antibacterial rinse that has been proven to have its benefits in reducing procedural complications and in general healing in conjunction to dental implants. CHX has also been known to have a capability of being released within an extended period while keeping its efficacy. A study done by Lambert, et al. (1997) reports that complications due to infection, eventually causing failure of dental implants, were more likely to take place during the period of closed healing. The CHX rinse was determined as effective when it comes to reducing infection complications in implant procedures when used routinely before an operation, and is recommended for practitioner use as an adjunct, if not the primary means for infection prevention.

A surgeon’s skill in applying basic surgery principles, sanitary conditions, intra-operative management and the medical status of the patient all contribute as factors that affect the success rate of implants. Post-operative implant infection may also be increased due to lack of the sufficient amount of alveolar bone, premature loading of an implant, and personal factors involving the patient such as alcohol and tobacco use and hygiene condition.

To this day, studies have, more or less, concluded that no sufficient evidence has justified the routine use of antibiotics in dental implant procedures. Out of one million patients who receive a single oral dose of amoxicillin, 0.9, 400 and 2,400 have been found to occur in severe, moderate and mild allergic cases respectively. Careful deliberation by dental professionals must be done in antibiotic administration in order to avoid unnecessary allergic reactions.