Are dental clinicians educated on antibiotics?

Anisha Hall Hoppe, Dental Tribune International

Tue. 24. October 2023

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PORTOVIEJO, Ecuador: The application of the concept of osseointegration revolutionised the treatment of edentulous patients. However, as applications expanded, complications increased, necessitating further research and careful practice. In this context, antibiotic use in implantology is common, often leading to misuse. A recent systematic review by researchers in Ecuador and Brazil has looked at the prophylactic use of antibiotics in dental implantology, in support of evidence-based medicine. It found that perioperative prophylactic antibiotics can reduce surgical site infections (SSIs) in major procedures and in many dental implant cases.

Drug-resistant infections are on the rise and are procedure-dependent

Osseointegration has revolutionised dental treatment for patients with varying degrees of edentulism. However, the increasing prevalence of antibiotic misuse in implant dentistry necessitates research and careful evaluation. Antibiotics are often used prophylactically to prevent SSIs and conditions such as peri-implantitis and maxillary sinusitis. Antibiotic resistance rates are on the rise, directly related to wide antibiotic use and exposure in the population. Certain pathogens, like streptococci, other oral anaerobes and staphylococci, can develop resistance; penicillin alone is no longer effective, but 95% of these organisms are susceptible to metronidazole and co-amoxiclav.

SSI prevalence varies widely with the nature of the procedure. An estimated 50% of SSIs are preventable through evidence-based strategies. Unlike therapeutic antibiotics, prophylactic antibiotics aim to reduce bacterial contamination in the surgical area for the shortest possible time after the procedure. However, SSIs represent a substantial health burden, especially in head and neck surgery and maxillofacial procedures.

The Association of the Scientific Medical Societies in Germany (AWMF) and 25 collaborating medical societies have initiated an ongoing consensus-driven S3 update of the current S1 perioperative antibiotic prophylaxis guideline—S3 is the highest quality level guideline. This update involves a systematic literature review focusing on antibiotic therapy in oral, maxillofacial and dentoalveolar surgery. The consensus aims to balance the potential benefits of antibiotic prophylaxis with the risks, including the fostering of antibiotic resistance.

The present systematic review was based on various guidelines, particularly the AWMF guideline. The review involved an analysis of 80 studies and found that antibiotics like cefazolin proved more effective than penicillin and clindamycin, but the evidence was subject to high bias risk. The number of patients needing treatment was high, causing uncertainty about the optimal antibiotic and prophylaxis range. The review also found that a one-day postoperative course of antibiotics was effective in preventing infectious complications. Furthermore, ampicillin and sulbactam appeared to be superior to clindamycin for certain procedures, but this was subject to bias.

The American Society of Health-System Pharmacists classifies surgery into four categories: clean, clean-contaminated, contaminated and dirty, each of which carries different risks of infection.. Procedure-related risk factors and the type of surgery also alter infection rates. Antibiotic prophylaxis is not beneficial for clean head and neck operations (< 1% postoperative SSI rate), but is crucial in cases of clean facial contamination after surgery. Infections in clean-contaminated head and neck surgery without preoperative antibiotics can be as high as 80%; thus, perioperative antibiotic prophylaxis is fundamental in maxillofacial surgery.

How antibiotics are used has an impact on efficacy

Perioperative antibiotics effectively prevent wound infections in head and neck surgery involving the aerodigestive tract. They also significantly reduce SSIs in orthognathic surgery, but the optimal duration and regimen remain uncertain. In traumatology, a single dose of prophylactic antibiotics can reduce SSIs in mandibular fractures and Le Fort Type I and II procedures.

For dental implants, five studies with low bias risk suggested that single-shot prophylaxis before placement could reduce dental implant failure but not SSIs. However, such prophylaxis might be beneficial in preventing postoperative pain. In contrast, when peri-implantitis occurs, antibiotics adjunctive to surgical treatment have not improved outcomes.

For odontogenic and inflammatory abscesses, moxifloxacin was more effective than clindamycin in pain reduction, but no significant difference in mean length of hospital stay was observed. A retrospective study found a seven-day antibiotic course effective in implant survival, but other studies found no significant difference between single-dose prophylaxis and extended postoperative treatment.

However, the efficacy of antibiotics in dentoalveolar surgery is uncertain, as evidence suggests no significant reduction of SSIs in third molar removal procedures for healthy individuals. Even in complex cases, there is no significant correlation between antibiotic prophylaxis and postoperative complications.

A way forward

There are continual challenges in setting and implementing methodological standards. The planned S3 update (currently in German) of the perioperative antibiotic prophylaxis guideline initiated by the AWMF will summarise current evidence for antibiotic prophylaxis in oral and maxillofacial surgery, emphasising the importance of evidence-based decision-making in antibiotic administration.

The study, titled “Major evidence and guidelines for antibiotic therapy in implant dentistry: A systematic review”, was published on 21 July 2023 in MedNEXT Journal of Medical and Health Sciences.