Antibiotic prophylaxis during dental implant placement in the UK

Is routine antibiotic prophylaxis warranted in dental implant surgery to prevent early implant failure? - a systematic review

BACKGROUND

The question of whether antibiotic prophylaxis should be administered routinely for dental implant surgery is unresolved. Despite the lack of conclusive supportive evidence, antibiotics are often administered to reduce the risk of infection, which could lead to early implant failure. Increasing antibiotic resistance is a major concern and it is therefore important to reduce the overall use of antibiotics, including in dentistry. The aim of the present systematic review and meta-analysis was to evaluate the efficacy of preoperative antibiotics in preventing early implant failure, in overall healthy patients undergoing dental implant surgery.

METHODS

An electronic search was undertaken of PubMed (Medline), Web of Science and the Cochrane Library up to October 1st, 2023, to identify randomized clinical trials (RCTs). All RCTs comparing antibiotic prophylaxis with no antibiotics/placebo in overall healthy patients receiving dental implants were included. The primary outcome was patients with early implant failure. Risk of bias was assessed, data were extracted, a meta-analysis was done, and GRADE certainty-of-evidence ratings were determined. The risk ratio (RR), the risk difference (RD) and 95% confidence intervals (CI) were estimated.

RESULTS

After removal of duplicates, 1086 abstracts were screened, and 17 articles were reviewed in full text. Seven RCTs with moderate or low risk of bias and with a total of 1859 patients and 3014 implants were included in the meta-analysis. With reference to early implant failure at patient level, the meta-analysis failed to disclose any statistically significant difference (RR: 0.66, 95% CI: 0.30-1.47) between antibiotic prophylaxis and a placebo. The risk difference was -0.007 (95% CI: -0.035-0.020) leading to a number needed to treat (NNT) of 143.

CONCLUSION

Antibiotic prophylaxis for dental implant surgery does not seem to have any substantial effect on early implant failure ( ). The results do not support routine antibiotic prophylaxis for dental implant surgery.

Efficacy and safety of using antibiotics to prevent post-operative complications in oral implant treatment: evidence-based review

AIMS

To identify and critically appraise available evidence on the efficacy and safety of antibiotics in preventing complications following oral implant placement treatment.

METHODS

An electronic search was performed using PubMed, Ovid MEDLINE and Cochrane Library databases up to July/21 for the purpose of answering the research question: In[healthy adults treated with dental implants]the use of[different antibiotics before or immediately after treatment]in comparison to[treatment without antibiotics]is safe and effective in terms of[infection, pain, swelling, wound dehiscence, soft tissue healing, early/late implant failure]? Following the Best Evidence Topic methodology, the included studies were categorised based on the Oxford Centre for Evidence-Based Medicine (OCEBM) ratings. The critical appraisal skills programme CASP checklist was used for the methodological analysis. The risk of bias assessment was performed according to the Cochrane Methodology for Systematic Reviews of Interventions.

RESULTS

26 of the 245 initially identified articles met our inclusion criteria for analysis after applying rigorous filters. The included human studies demonstrated significant methodological heterogeneity, precluding meta-analysis. These studies spanned evidence levels II to IV, as per OCEBM 2011 classifications, with the United States contributing the most studies (19.2%, n = 5), all at level III. The United Kingdom and Spain followed with three studies each (11.5% each), two from the UK and one from Spain classified at level II. Most studies had less than 1 year of follow-up (21%). Our analysis included 26 studies, with 38 antibiotic patient groups totalling 7459 patients. Amoxicillin was the predominant antibiotic, with various dosage regimens. Complications were observed in studies across different amoxicillin regimens at a cumulative incidence of 5%.

CONCLUSION

The evidence on antibiotics to prevent implant failure presents uncertain and heterogeneous findings. High-risk bias and underpowered studies were prevalent. Future research should prioritise multicentre, double-blinded RCTs with larger samples and longer follow-ups. Structured methodologies, antibiotic stewardship, and adherence to guidelines are needed. Amoxicillin (2 g) was commonly prescribed, but guidelines recommend 3 g, which results in relatively low complications yet there is limited evidence to support it. Clindamycin was favoured for penicillin allergies, but caution is advised due to potential implant failure risk. Consistent use of antiseptic mouthwash was observed. Future research should explore alternatives to antibiotics and antibiotic stewardship. Establishing a well-funded research consortium could yield conclusive results for clinical practice.

Antibiotics in Dentistry: A Narrative Review of the Evidence beyond the Myth

Antibiotics have undoubtedly revolutionized medicine and the health and survival of patients with life-threatening infections, being nonetheless free from potential adverse effects, and the risk of intestinal dysbiosis, antimicrobial resistance, and the resulting consequences for the patient's health and the public purse. The present study narratively reviewed the epidemiological data on worldwide antibiotic consumption and administration in dental practice, patients' adherence to prescriptions, the antimicrobial resistance phenomenon in dentistry, and the evidence supporting and recommending appropriate antibiotic use in dental care. Eligible systematic reviews and original studies in humans published in the English language from January 2000 to 26 January 2023 were considered. A total of 78 studies, 47 on the epidemiology of antibiotic use and prescription in dentistry, 6 on antibiotic therapy in dentistry, 12 on antibiotic prophylaxis in dentistry, 0 on adherence of dental patients to antibiotic prescription, and 13 on antimicrobial resistance in dentistry, were presently considered. Retrieved evidence revealed that antibiotics are frequently overused and misused in dental practice, dental patients frequently do not adhere to prescriptions, and antimicrobial resistance in dentistry is a still rising phenomenon also secondary to improper oral antiseptics use. The present findings highlighted the need to establish more evidence-based and accurate antibiotic prescriptions to sensitize dentists and dental patients to minimize and rationalize the use of antibiotics only when it is indicated and necessary, improve patients' adherence, and enhance knowledge and awareness of the antimicrobial resistance in dentistry.

The effect of preoperative clindamycin in reducing early oral implant failure: a randomised placebo-controlled clinical trial

OBJECTIVES

To assess the effect of preoperative oral clindamycin in reducing early implant failure in healthy adults undergoing conventional implant placement.

MATERIALS AND METHODS

We conducted a prospective, randomised, double-blind, placebo-controlled clinical trial in accordance with the ethical principles and Consolidated Standards of Reporting Trials statement. We included healthy adults who underwent a single oral implant without previous infection of the surgical bed or the need for bone grafting. They were randomly treated with a single dose of oral clindamycin (600 mg) 1 h before surgery or a placebo. All surgical procedures were performed by one surgeon. A single trained observer evaluated all patients on postoperative days 1, 7, 14, 28, and 56. Early dental implant failure was defined as the loss or removal of an implant for any reason. We recorded the clinical, radiological, and surgical variables, adverse events, and postoperative complications. The study outcomes were statistically analysed to evaluate differences between the groups. Furthermore, we calculated the number required to treat or harm (NNT/NNH).

RESULTS

Both the control group and clindamycin group had 31 patients each. Two implant failures occurred in the clindamycin group (NNH = 15, p = 0.246). Three patients had postoperative infections, namely two placebo-treated and one clindamycin-treated, which failed (relative risk: 0.5, CI: 0.05-5.23, absolute risk reduction = 0.03, confidence interval: - 0.07-0.13, NNT = 31, CI: 7.2-∞, and p = 0.5). One clindamycin-treated patient experienced gastrointestinal disturbances and diarrhoea.

CONCLUSIONS

Preoperative clindamycin administration during oral implant surgery in healthy adults may not reduce implant failure or post-surgical-complications.

CLINICAL RELEVANCE

Oral clindamycin is not efficacy.

TRIAL REGISTRATION

The present trial was registered (EudraCT number: 2017-002,168-42). It was approved by the Committee for the Ethics of Research with Medicines of Euskadi (CEIm-E) on 31 October 2018 (internal code number: 201862) and the Spanish Agency of Medicines and Medical Devices (AEMPS) on 18 December 2018.

Preoperative administration of amoxicillin is not recommended in healthy patients undergoing implant surgery

Design A multicentre, prospective, randomised, placebo-controlled, double-blinded clinical trial reported the early implant failure and postoperative infections of healthy or relatively healthy patients receiving 2 grams of amoxicillin one hour preoperatively from their scheduled dental implant placement. The registration of the study protocol in EudraCT and Clinical Trials.gov (#NCT03412305) followed the ethical principles of the Declaration of Helsinki and the CONSORT guidelines for clinical trials.Case selection Several trial drugs expired before recruiting the intended 1,000 patients calculated based on previous trials reporting 2% and 5% early implant loss, with and without antibiotic prophylaxis. Thus, the study cohort (age >18 years, not planned for immediate loading, not requiring substantial bone augmentation, with an absence of severe diseases or immunosuppression or immunodeficiency) received 757 implants in total between November 2014 and April 2018, consisting of the prophylactic antibiotic therapy group (patients n = 235) and the placebo group (patients n = 235), with a fair sex distribution and a mean age of 57.4 ± 13.9 years. A computer-generated list of random numbers assisted the randomisation (test or control group) with a block-size six. For the clinical procedures, bone augmentation was limited to autogenous bone chips and bone debris. One- and two-stage surgery protocols were used in maxillary or mandibular single or multiple dental implants. The utilised implant systems were Straumann SLA (Straumann Implants, Switzerland), Astra Tech Dental Implant Systems (Dentsply Sirona, Sweden), Nobel Biocare (Sweden) and Southern Implants (Ltd, South Africa). Chlorhexidine 0.2% was prescribed preoperatively and/or postoperatively. Implant failure was the main measured outcome, whereas postoperative infections and adverse events were the secondary outcomes postoperatively assessed at 7-14-day (first follow-up) and 3-6-month (second follow-up) intervals.Data analysis The sample size calculation (type one error: 0.05; power: 80%) estimated 500 patients in each group. Proportional differences and relative risk (RR) with a 95% confidence interval (CI) were calculated. Implant failure was the dependent variable for the multiple logistic regression (MLR) model examining the indicator variables smoking (yes or no), and age (<50 years; 50-64; and ≥65), as well as the independent variables bone augmentation (yes or no), number of implants (1, 2-3 and ≥4), and treatment group (antibiotic prophylaxis or placebo). P-values <0.05 or 95% CIs for ratios not including one were deemed statistically significant. The analyses were carried out using statistical software for data science (STATA).Results Overall, six (2.5%) and seven patients (3.0%) from the amoxicillin and placebo groups had implant failures, respectively. Thus, the intergroup difference was not significant (RR: 0.85; 95% CI: 0.29-2.48, p = 0.75). Absolute risk reduction was 0.46%, with a number needed to treat (NNT) of 219. In other words, one in every 219 patients will benefit from receiving prophylactic antibiotics. In addition, no variable was associated with implant failure. Two (0.8%) and five patients (2.1%) from the amoxicillin and placebo groups, respectively, had postoperative infections at the first follow-up interval. Thus, the intergroup difference was not significant (RR: 0.29; 95% CI: 0.08-2.01, p = 0.25). Five (2.1%) and seven patients (3.0%) from the amoxicillin and placebo groups, respectively, had postoperative infections at the second follow-up interval. Thus, the intergroup difference was not significant (RR: 0.70; 95% CI: 0.23-2.18, p = 0.54). No adverse events were reported.Conclusion Prophylactic antibiotic treatment for dental implant surgery to prevent implant loss may not be appropriate. Each dose must be prescribed based on evidence-based guidelines to avoid overuse and misuse of antibiotics promoting resistant bacteria.

Is clindamycin effective in preventing infectious complications after oral surgery? Systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effect of clindamycin in the prevention of infection after oral surgery.

MATERIAL AND METHODS

This systematic review and meta-analysis followed the PRISMA statement, the PICO-framework and included only randomized controlled clinical trials. In all studies clindamycin was administered to prevent infections in patients who underwent oral surgery. Two independent researchers conducted the search, data extraction and risk of bias assessment. Included studies were classified by the type of oral surgery. Besides, data of patients, procedures and outcome variables were collected. Risk ratios (RR) and 95% confidence intervals (CI) were calculated by using Mantel-Haenszel model and the number needed to treat (NNT). Finally, any potential sources of heterogeneity were estimated.

RESULTS

Seven trials of 540 articles met the inclusion criteria and were included in the qualitative synthesis. Four articles assessing the effect of oral clindamycin in third molar surgery were quantitatively analyzed. The overall RR was 0.66 (95% CI = 0.38-1.16), being non-statistically significant (p = 0.15). There was no heterogeneity between the studies I² = 0, p = 0.44. The NNT was 29 (95% CI = 12- -57).

CONCLUSIONS

The effectiveness of clindamycin could not be evaluated except in third molar extraction. Oral clindamycin is ineffective in preventing infection in third molar surgery.

CLINICAL RELEVANCE

There is a lack of high-quality evidence supporting the prescription of clindamycin to prevent infections after oral surgery, despite being frequently prescribed as an alternative for penicillin-allergic patients. Oral clindamycin has not been shown to be effective after third molar extractions.