Kathy Shafer DMD
Limited evidence suggests two grams of amoxicillin given orally one hour preoperatively significantly decreases implant failure in the first three to five months after placement when placed in ordinary conditions.
Meta-analysis of four randomized control trials (1007 subjects), suggests short-term antibiotics administered before implant placement significantly decreases early (3-5 months) implant failure.
In patients receiving dental implants in ordinary conditions, do preoperative antibiotics reduce implant failure compared to those with no pre-operative antibiotic therapy?
The authors conducted a comprehensive search of The Cochrane Oral Health Groups' Trial Register, The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE, 15 journals, bibliographies, and personal contacts to identify any unpublished or ongoing randomized controlled trials (RCT) to June 2, 2010. There were no language restrictions. Specific inclusion criteria included randomized control trials with at least three months follow-up that evaluated: prophylactic antibiotics versus no antibiotics/placebo; the administration of different antibiotics, and the administrations of different doses or different duration of the same antibiotic; and adverse reactions from antibiotic usage. Outcome measures were prosthesis failures, implant failures, postoperative infections and adverse events (e.g., gastrointestinal, hypersensitivity). Two reviewers independently reviewed studies to determine if they met the inclusion criteria. The authors resolved disagreements either by discussion or through consultation with a third review author. All authors were contacted for clarification and/or missing information. The two review authors conducted quality assessment using the Cochrane Handbook for Systematic Reviews of Interventions. This tool has two parts: part one involves describing what was reported to have happened in the study; part two involves assessing the risk of bias for that entry. The authors assessed each study as having a low risk of bias, an unclear risk of bias, and a high risk of bias.
Four randomized control trials (1,007 subjects) evaluated whether pre-operative antibiotics significantly reduce implant failures and complications. More patients experienced implant loss in the groups that did not receive antibiotics, which was statistically significant (risk ratio = 0.40; 95% confidence interval, CI 0.19 to 0.84). The number needed to treat, defined as the number of patients who must receive a treatment (antibiotics) for one patient to benefit (avoid implant failure), was 33 based on a patient implant failure of 5 percent. The analysis of the four trials showed no statistically significant outcomes for prosthesis failures, post-operative infections and adverse events.
A meta-analysis of four randomized clinical trials suggests that two grams of amoxicillin administered one hour pre-operatively significantly reduces early failures of dental implants. This means that one patient will benefit (by avoiding implant failure) for every 33 patients treated with antibiotics prior to implant placement. No significant adverse events were reported.
Source of Funding:
Source of Funding: None listed
Importance and Context:
The clinical decision to treat a patient with dental implants can be considered an invasive procedure for the patient. Some of the dental implant failures may be due to bacterial contamination at the time of implant insertion.(1) To address this one complication modality it may be prudent to take on a preventive practice approach rather than a therapeutic approach and to premedicate patients with antibiotics prior to dental implant surgery.
Strengths and Weaknesses of the Systematic Review:
An extensive search for identification of literature as well as research in progress was conducted using predetermined inclusion and exclusion criteria. Grey literature, lists of included and excluded studies and characteristics of these studies are listed in the parent systematic review. Scientific quality and bias were assessed for all the included studies. Three of the included studies were authored by the primary author of this systematic review.1,2,3
Strengths and Weaknesses of the Evidence:
A total of 1007 patients were treated in the four studies. High risk patients were excluded from the trials. Groups in the included studies appeared comparable at entry. All included studies had outcome measures of prosthesis failure, implant failure, postoperative failure, and adverse events; had follow-up durations that ranged from three to five months; and evaluated various dental implant systems. However, prosthesis failure does not necessarily equate to implant failure. One trial (4) did not list the type of implant used. Of the four included studies, one study was conducted in a hospital setting and the others were conducted in private practice. In all trials, the patient rinsed with chlorhexidine before surgery. The systematic review did not address any effects associated with chlorhexidine usage. Amoxicillin was the drug used preoperatively with dosages from one gram to two gram pre-operatively and one study (4) continued with the antibiotics for two days at 500 mg, four times daily. The systematic review also intended to assess which type, dosage, and duration of antibiotic was most effective. However, the authors could not meet their secondary objective because none of the included trials evaluated these three parameters. One study was assessed as having a high risk of bias. (4) The included trials appeared underpowered to detect clinically significant difference, although three trials showed trends favoring antibiotics. But after meta-analyses were performed, a statistically and clinically significant difference in implant failure was found favoring the use of antibiotics.
Implications for Dental Practice:
The findings of this systematic review suggest that for every 33 patients treated with two grams of amoxicillan pre-operatively, one of these patients will avoid early implant failure. No significant adverse outcomes were noted as a result of this pre-operative preventive approach. Additional studies are needed to determine the magnitude of effect of various antibiotics and use of other antimicrobial agents prior to the placement of dental implants in order to prevent early implant failure.
1. Esposito M, Grusovin MG, Talati M, Coulthard P, Loiver R, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev 2008;3:CD004152 2. Esposito M, Cannizzaro G, Bozzoli P, Consolo U, Felice P, Ferri V et al Efficacy of prophylactic antibiotics for dental implants; a multicenter placebo-controlled randomized clinical trial. Eur J Oral Implantol 2008; 1:23-31. 3. Esposito M, Grusovin MG, Loli V, Coulthard P, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev 2010;5:CD004152. 4. Abu-Ta'a M, Quirynen M, Teughels W, van Steenberg D. Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: a prospective, randomized, controlled clinical trial. J clin Periodontol 2008;35:58-63 5. Anitua E, Aguirre JJ, Gorosabel A, Barrio P, Errazquin JM, Roman P et al. A multicenter placebo-controlled randomized clinical trial of antibiotic prophylaxis for placement of single dental inmplantsw. Eur J Oral Implantol 2009;2:283-292