Antibiotics to prevent complications following dental implant treatment



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Antibiotics to prevent complications following dental implant treatment


Esposito M, Coulthard P, Oliver R, Thomsen P, Worthington HV

This review should be cited as: Esposito M, Coulthard P, Oliver R, Thomsen P, Worthington HV. Antibiotics to prevent complications following dental implant treatment (Cochrane Review). In: The Cochrane Library, Issue 1, 2006. Oxford: Update Software.



A substantive amendment to this systematic review was last made on 15 March 2003. Cochrane reviews are regularly checked and updated if necessary.

Abstract


Background: Some dental implant failures may be due to bacterial contamination at implant insertion. Infections around biomaterials are difficult to treat and almost all infected implants have to be removed. In general, antibiotic prophylaxis in surgery is only indicated for patients at risk of infectious endocarditis, for patients with reduced host-response, when surgery is performed in infected sites, in cases of extensive and prolonged surgical interventions and when large foreign materials are implanted. To minimise infections after dental implant placement various prophylactic systemic antibiotic regimens have been suggested. More recent protocols recommended short term prophylaxis, if antibiotics have to be used. With the administration of antibiotics adverse events may occur, ranging from diarrhoea to life-threatening allergic reactions. Another major concern associated with the widespread use of antibiotics is the selection of antibiotic-resistant bacteria. The use of antibiotics in implant dentistry is controversial. It would be useful to know whether prophylactic antibiotics are effective in reducing failures of dental implants.

Objective: To assess the beneficial or harmful effects of the administration of prophylactic antibiotics for dental implant placement versus no antibiotic/placebo administration and if antibiotics are of benefit, to find which type, dosage and duration is the most effective.

Search strategy: We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. We handsearched several dental journals. No language restrictions were applied. Personal contacts and manufacturers of dental implants were contacted to identify unpublished trials. Most recent search: March 2003.

Selection criteria: Randomised controlled clinical trials (RCTs) with a follow up of at least 3 months comparing the administration of various prophylactic antibiotics regimens and no antibiotics/placebo to patients undergoing dental implant placement. Outcome measures were prosthesis failures, implant failures, postoperative infections and adverse events (gastrointestinal, hypersensitivity).

Data collection and analysis: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were to be conducted in duplicate and independently by two reviewers. Results were to be expressed as random effects models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval. Heterogeneity was to be investigated including both clinical and methodological factors.

Main results: No RCTs were identified.

Reviewers' conclusions: There is not appropriate scientific evidence to recommend or discourage the use of prophylactic systemic antibiotics to prevent complications and failures of dental implants. Even though the present review did not assess the effectiveness of prophylactic antibiotics for patients at risk for endocarditis, it seems sensible to recommend the use of prophylactic antibiotics for patients at high and moderate risk for endocarditis, with immunodeficiencies, metabolic diseases, irradiated in the head and neck area and when an extensive or prolonged surgery is anticipated.


Background


Dental implants are widely used for replacing missing teeth. Despite the high success rates published in the literature, implant failures do occur (Esposito 1998a). It is believed that a certain number of early dental implant losses are due to bacterial contamination at implant insertion (Esposito 1998b). It is known that infections around biomaterials are very difficult to treat and almost all infected implants have to be removed sooner or later (Esposito 1998b). The likelihood of an infection around dental implants is influenced by the surgical skill (traumatic and prolonged surgery is more likely to favour infections) and to the degree of asepsis. In general, antibiotic prophylaxis in surgery is only indicated in the following situations: patients at risk of infectious endocarditis, patients with reduced host-response, when surgery is performed in infected sites, in cases of extensive and prolonged surgical interventions and when large foreign materials are implanted.

In order to minimise infections after dental implant placement various prophylactic systemic antibiotic regimens have been suggested. Initially, antibiotics were recommended preoperatively and up to 10 days postoperatively, one of the most commonly followed protocols being the administration of 2 g of phenoxymethylpenicillin (penicillin-V), per os, about 1 hour preoperatively and then 2 g twice a day for 10 days (Adell 1985). More recent protocols (Flemmig 1990) recommended short term prophylaxis: 2 g of penicillin-V (or Amoxicillin or Augmentin) administered per os, 1 hour prior to surgery and 500 mg of penicillin-V four times a day for 1 day. The prolongation of the prophylaxis should not be extended beyond the first three postoperative days since it may not provide additional protection, if antibiotics have to be used.



While on one hand it is important to minimise risk of implant failures, on the other it is sensible to minimise the use of antibiotics since adverse events may occur. Complications most commonly associated with the use of antibiotics range from diarrhoea to life-threatening allergic reactions. Another major concern associated with the widespread use of antibiotics is the selection of antibiotic-resistant bacteria. The use of antibiotics in implant dentistry is controversial and some controlled clinical trials yielded contradictory results (Dent 1997; Gynther 1998; Laskin 2000). It would be useful to know whether prophylactic antibiotics are effective in reducing postoperative infections and failures of dental implants and which is the most effective antibiotic, at what dose and duration.

Objectives


  • PRIMARY OBJECTIVE

  • There is no difference in the proportion of prosthetic failures, implant failures, postoperative infections and adverse events between groups of patients receiving antibiotic treatment, and those receiving a placebo or no antibiotic treatment.

  • SECONDARY OBJECTIVE

  • There is no difference in the proportion of prosthetic failures, implant failures, postoperative infections and adverse events between groups of patients receiving different antibiotic treatments, or different doses/duration of the same antibiotic.

Criteria for considering studies for this review

Types of studies


Randomised controlled clinical trials with a follow up of at least 3 months.

Types of participants


Any group of patients undergoing dental implant placement.

Types of intervention


  • Administration of prophylactic antibiotics versus no antibiotics/placebo.

  • Administration of different antibiotics.

  • Administration of different doses or different duration of the same antibiotic.

Types of outcome measures


  • Prosthesis could not be placed or prosthesis failure if secondary to implant failures.

  • Implant mobility and removal of stable implants dictated by progressive marginal bone loss or infection.

  • Postoperative infections.

  • Adverse events (gastrointestinal, hypersensitivity).

Search strategy for identification of studies


See: Cochrane Oral Health Group search strategy

  • For the identification of studies included or considered for this review detailed search strategies were developed for each database to be searched. These were based on the search strategy developed for MEDLINE (OVID) but revised appropriately for each database. The search strategy combined a sensitive search strategy for randomised controlled clinical trials (RCTs) (as published in Appendix 5c in the Cochrane Reviewers' Handbook). The search strategy used a combination of controlled vocabulary and free text terms based on the following:

  • #1 randomised controlled trial.pt.

  • #2 controlled clinical trial.pt.

  • #3 randomized controlled trials.sh.

  • #4 random allocation.sh.

  • #5 double blind method.sh.

  • #6 single blind method.sh.

  • #7 latin square.ti,ab.

  • #8 crossover.ti,ab.

  • #9 (split adj (mouth or plot)).ti,ab.

  • #10 or/1-9

  • #11 (ANIMAL not HUMAN).sh.

  • #12 10 not 11

  • #13 clinical trial.pt.

  • #14 exp clinical trials/

  • #15 (clin$ adj25 trial$).ti,ab.

  • #16 ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).ti,ab.

  • #17 placebos.sh.

  • #18 placebo$.ti,ab.

  • #19 random$.ti,ab.

  • #20 research design.sh.

  • #21 or/13-20

  • #22 21 not 11

  • #23 22 not 12

  • #24 12 or 22

  • #25 exp Dental Implants/

  • #26 exp Dental Implantation/ or dental implantation.mp.

  • #27 exp Dental Prosthesis, Implant-Supported/

  • #28 ((osseointegrated adj implant$) and (dental or oral)).mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #29 dental implant$.mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #30 (implant$ adj5 dent$).mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #31 dental-implant$.mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #32 (((overdenture$ or crown$ or bridge$ or prosthesis or prostheses or restoration$) adj10 (Dental or oral)) and implant$).mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #33 "implant supported dental prosthesis".mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #34 ("blade implant$" and (dental or oral)).mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #35 ((endosseous adj5 implant$) and (dental or oral)).mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #36 ((dental or oral) adj5 implant$).mp. [mp=title, abstract, registry number word, mesh subject heading]

  • #37 25 or 26 or 27 or 28 or 29 or 30 or 32 or 33 or 34 or 35 or 36

  • #38 24 and 37

  • SEARCHED DATABASES

  • The Cochrane Oral Health Group's Trials Register (to March 2003)

  • The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2003)

  • MEDLINE (1966 to March 2003)

  • EMBASE (1980 to March 2003)

Last electronic search was done on 21 March 2003.

The bibliographies of identified RCTs and review articles were checked for studies outside the handsearched journals. PubMed was independently searched using the 'related articles' feature. Personal references were also searched.



  • LANGUAGE

  • Non-English papers were to be included. The Cochrane Oral Health Group was to attempt to have non-English papers translated.

  • UNPUBLISHED STUDIES

  • Personal contacts were used to identify ongoing or unpublished RCTs. Fifty-five oral implant manufacturers were written to in an attempt to identify unpublished or ongoing studies. We asked for unpublished and ongoing RCTs on a internet discussion group (implantology@yahoogroups.com). Authors of the identified RCTs were to be contacted.

  • HANDSEARCHING

  • Details of the journals being handsearched by the Oral Health Group's ongoing programme are given on the web site: http://www.cochrane-oral.man.ac.uk.

The following journals have been identified as being important to be handsearched for this review: British Journal of Oral and Maxillofacial Surgery, Clinical Implant Dentistry and Related Research, Clinical Oral Implants Research, Implant Dentistry, International Journal of Oral and Maxillofacial Implants, International Journal of Oral and Maxillofacial Surgery, International Journal of Periodontics and Restorative Dentistry, International Journal of Prosthodontics, Journal of the American Dental Association, Journal of Biomedical Materials Research, Journal of Clinical Periodontology, Journal of Cranio-Maxillo-Facial Surgery, Journal of Dental Research, Journal of Oral Implantology, Journal of Oral and Maxillofacial Surgery, Journal of Periodontology, Journal of Prosthetic Dentistry, Plastic and Reconstructive Surgery. Where these have not already been searched as part of the Cochrane Journal Handsearching Programme, the journals were handsearched by one of the reviewers.

Methods of the review


The titles and abstracts (when available) of all reports identified were scanned independently by two reviewers. For studies appearing to meet the inclusion criteria, or for which there were insufficient data in the title and abstract to make a clear decision, the full report was obtained and assessed independently by two reviewers to establish whether the studies met the inclusion criteria or not. Disagreements were to be resolved by discussion. Where resolution was not possible, a third reviewer was to be consulted. All studies meeting the inclusion criteria then were to undergo validity assessment and data were to be extracted. Studies rejected at this or subsequent stages were to be recorded in the table of excluded studies, and reasons for exclusion recorded.

  • QUALITY ASSESSMENT

  • The quality assessment of the included trials was to be undertaken independently and in duplicate by two reviewers based on what was written in the articles.

  • Three main quality criteria were to be examined:

  • 1) Randomisation and allocation concealment, recorded as:

  • (A) Adequate

  • (B) Unclear

  • (C) Inadequate

  • (D) Not used

  • 2) Blindness of participants and assessors, recorded as:

  • (A) Yes

  • (B) No

  • (C) Unclear

  • 3) Completeness of follow up (is there a clear explanation for withdrawals and drop outs in each treatment group?) assessed as:

  • (A) Yes

  • (B) No.

  • After taking into account the additional information provided by the authors of the trials, studies were to be grouped into the following categories:

  • A. Low risk of bias (plausible bias unlikely to seriously alter the results) if all criteria were met.

  • B. Moderate risk of bias (plausible bias that raises some doubt about the results) if one or more criteria were partly met.

  • C. High risk of bias (plausible bias that seriously weakens confidence in the results) if one or more criteria were not met as described in the Cochrane Reviewers' Handbook 6.7.

  • DATA EXTRACTION

  • Data were to be extracted by two reviewers independently using a specially designed data extraction form. Any disagreement was to be discussed and a third reviewer consulted where necessary. Authors were to be contacted for clarification or missing information. Data were to be excluded until further clarification would be available if agreement could not be reached.

  • For each trial the following data were to be recorded:

  • Year of publication, country of origin, setting and source of study funding.

  • Details of the participants including demographic characteristics and criteria for inclusion.

  • Details on the type of intervention.

  • Details of the outcomes reported, including method of assessment and time intervals.

  • DATA SYNTHESIS

  • For each outcome, all of which were binary, the estimate of effect of an intervention was to be expressed as relative risks together with 95% confidence intervals.

Clinical heterogeneity was to be assessed by examining the types of participants, interventions and outcomes in each study with a planned subgroup analysis considering type, dose and duration of antibiotics. Meta-analyses were to be done only with studies of similar comparisons reporting the same outcome measures. Relative risks were to be combined for the binary data using a random effects model. The significance of any discrepancies in the estimates of the treatment effects from the different trials was to be assessed by means of Cochran's test for heterogeneity and any heterogeneity was to be investigated.

Sensitivity analyses were to be undertaken to examine the effect of concealed randomisation and outcome assessor being blind on the assessment of the overall estimates of effect. In addition, the effect of including unpublished literature on the review's findings was to be examined.


Description of studies


No randomised controlled clinical trial was identified.

Methodological quality


No randomised controlled clinical trial was identified.

Results


No randomised controlled clinical trial was identified.

Discussion


No randomised controlled clinical trials were identified so it is not possible to provide any evidence-based indications to patients and clinicians interested in this issue. The only available data on whether it would be beneficial to use preoperative antibiotics undergoing dental implant placement are those from two controlled clinical trials (CCTs) that yielded opposite results. In one prospective trial, described in two follow-up articles (Dent 1997; Laskin 2000), the use of various prophylactic antibiotic regimens (dosages and regimens were not described) versus no antibiotics was tested for 2,973 implants (the number of patients was not reported); the conclusion was that implants in patients who received preoperative antibiotics had significantly higher survival rates. In the other CCT (Gynther 1998), designed as a retrospective study, 1 g of phenoxymethylpenicillin was administered 1 hour preoperatively and every 8 hours for 10 days in 147 patients. The control group comprised 132 patients who did not receive any antibiotics. The two groups were treated in different periods (antibiotics group between 1980 and 1985 and non-antibiotic group between 1991 and 1995). No statistically significant differences with respect to postoperative infections or implant survival were observed. Unfortunately, both studies were highly biased in their methodology, so the validity of their conclusions can be questioned.

The most recent recommendations by the American Heart Association for the prevention of endocarditis (Dajani 1997) suggested the use of 2 g of amoxicillin 1 hour before the intervention in patients at high and moderate risk for endocarditis (prosthetic cardiac valves, any congenital cardiac malformations, surgically constructed systemic pulmonary shunts, acquired valvular dysfunction, hypertrophic cardiomyopathy, mitral valve prolapse with valvular regurgitation and/or thickened leaflets), a second dose being not necessary. For individuals allergic to penicillins, 600 mg of Clindamycin can be administered instead 1 hour prior to the procedure. In addition, it may be of clinical sense to use prophylactic antibiotic therapy for patients with immunodeficiencies, metabolic diseases (diabetes), irradiated in the head and neck area and when extensive and prolonged implant surgery is anticipated.


Reviewers' conclusions

Implications for practice


There is not appropriate scientific evidence to recommend or discourage the use of prophylactic systemic antibiotics to prevent complications and failures of dental implants. Even though the present review did not aim to assess the effectiveness of prophylactic antibiotics for patients at risk for endocarditis, it seems sensible to recommend the use of prophylactic antibiotics for patients at high and moderate risk for endocarditis, in patients with immunodeficiencies, metabolic diseases and irradiated in the head and neck area and when extensive and prolonged surgeries are anticipated for placements of dental implants or abutments.

Implications for research


There is the need for randomised controlled clinical trials on this topic. A large, double-blind, placebo controlled randomised clinical trial assessing whether the use of a single dose of 2 g of amoxicillin 1 hour before implant placement decreases postoperative complications and implant failures could be an appropriate starting point.

Acknowledgements


We wish to thank Sylvia Bickley (Cochrane Oral Health Group) for her assistance with literature searching and Luisa Fernandez (Cochrane Oral Health Group) for her help with the preparation of this review. We would also like to thank the following referees: Ian M Brook, Matteo Chiapasco, Anne-Marie Glenny, Lee Hooper, Ian Needleman.

Potential conflict of interest


None known.

References


Additional references

Adell 1985

Adell R, Lekholm U, Branemark PI. Surgical procedures. In: Branemark PI, Zarb GA, Albrektsson T, editor(s). Tissue-integrated prostheses Chicago: Quintessence Publishing Co., Inc, 1985:211-32.



Dajani 1997

Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Journal of the American Medical Association 1997;227(22):1749-1801.



Dent 1997

Dent CD, Olson JW, Farish SE, Bellome J, Casino AJ, Morris HF et al. The influence of preoperative antibiotics on success of endosseous implants up to and including stage II surgery: a study of 2,641 implants. Journal of Oral and Maxillofacial Surgery 1997;55 (Suppl. 5):19-24.



Esposito 1998a

Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (I) Success criteria and epidemiology. European Journal of Oral Sciences 1998;106:527-51.



Esposito 1998b

Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (II) Etiopathogenesis. European Journal of Oral Sciences 1998;106:721-64.



Flemmig 1990

Flemmig TF, Newman MG. Antimicrobials in implant dentistry. In: Newman MG, Kornman K, editor(s). Antibiotics/antimicrobial use in dental practice Chicago: Quintessence Publishing Co., Inc, 1990:187-200.



Gynther 1998

Gynther GW, Kondell PA, Moberg LE, Heimdahl A. Dental implant installation without antibiotic prophylaxis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1998;85:509-11.



Laskin 2000

Laskin DM, Dent CD, Morris HF, Ochi S, Olson JW. The influence of preoperative antibiotics on success of endosseous implants at 36 months. Annals of Periodontology 2000;5:166-74.


Cover sheet


Antibiotics to prevent complications following dental implant treatment

Reviewer(s)

Esposito M, Coulthard P, Oliver R, Thomsen P, Worthington HV

Contribution of Reviewer(s)

Conceiving, designing and co-ordinating the review (Marco Esposito (ME)).
Developing search strategy and undertaking searches (ME, Paul Coulthard (PC)).
Screening search results and retrieved papers against inclusion criteria (ME, PC).
Writing the review (ME).
Providing general advice on the review (PC, Helen Worthington (HW), Peter Thomsen (PT), Richard Oliver (RO)).
Performing previous work that was the foundation of current study (ME, HW, PC).

Issue protocol first published

2003 issue 2

Issue review first published

2003 issue 3

Date of last minor amendment

17 April 2003

Date of last substantive amendment

15 March 2003

Most recent changes

Information not supplied by reviewer

Date new studies sought but none found

Information not supplied by reviewer

Date new studies found but not yet included/excluded

Information not supplied by reviewer

Date new studies found and included/excluded

Information not supplied by reviewer

Date reviewers' conclusions section amended

Information not supplied by reviewer

Contact address

Dr Marco Esposito
The University of Manchester
Higher Cambridge Street
Manchester
UK
M15 6FH
Telephone: +44 161 275 6714
Facsimile:
E-mail: marco.esposito@manchester.ac.uk

Cochrane Library number

CD004152

Editorial group

Cochrane Oral Health Group

Editorial group code

ORAL

Sources of support

External sources of support


  • Swedish Medical Research Council (9495) SWEDEN

Internal sources of support

Synopsis


No strong evidence to either recommend or discourage the use of antibiotics to prevent infections when having a dental implant inserted.

Missing teeth can sometimes be replaced with dental implants to which a crown, bridge or denture can be attached. Bacteria introduced during placement of implants can lead to infection. No reliable evidence of the effects of preoperative antibiotics for patients receiving implants was found. Some people are prone to infection, including those with immunodeficiencies or metabolic diseases (like diabetes), people at risk of endocarditis (a heart infection) and people who have received radiotherapy to the head and neck area. For these patients, preoperative antibiotics might be beneficial. These recommendations are not based on evidence from the review, but on subjective clinical sense and experience.


Keywords


Humans; *Antibiotic Prophylaxis; Bacterial Infections[*prevention & control]; Dental Implants[*adverse effects]; Dental Restoration Failure


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