The literature search performed produced an equal division between studies supporting the use of antibiotic prophylaxis and those negating the use of antibiotics. However, a draw back in the current literature became evident as many studies were excluded from this literature review because they did not include comparisons between no antibiotic, pre-op, post-op and both pre and post-op antibiotic use. However, this was a significant finding on its own in that many more studies are required to help validate and improve current guidelines regarding antibiotic use and oral implants.
One of the only commonalities amongst most of the papers was the feeling that antibiotics are overused and that the authors requested that all practitioners’ assess each patient individually in the hopes of reducing the amount of prescribed antibiotics. Of the papers which met the inclusion criterion, 50% agreed that pre- or post operational antibiotics were of benefit while the remaining 50% believed that antibiotics were not of any benefit. With such contrasting results one wonders how these studies could have differed so significantly. Differences may have been inherent within the patient population; healthier patients with stronger immunity versus patients with lower resistance, the number of times patients in studies had been previously prescribed antibiotics, cross-reactions with other drugs, or concomitant illnesses. Unfortunately, this reveals that much of the research completed to date on this topic is inconsistent and lacking in validity. For instance, no randomized controlled studies have been done. In addition, due to the lack of standardization many studies were difficult to compare and had to be excluded. Thus, until larger studies can be completed it will be difficult to determine a definitive answer.
Some alternative methods of lowering the risk of infection that have been explored include the use of Chlorhexidine digluconate (CHX), a mouthwash rinse which is often used in conjunction with dental implants. CHX, when rinsed preoperatively has been proven to be an effective aid in promoting healing and reducing surgical complications [24
]. CHX also has been shown to have a high substantively, with the capability to be released over an extended period of time without losing its efficacy. Lambert, et al. (1997) also found that the infectious complications which lead to implant failure were more likely to occur during the closed healing period. Thus, CHX rinse has been shown to be an effective alternative in reducing infectious complications from implant surgery when routinely used in the peri-operative period, and should be used by practitioners who are concerned about infection, if not as the primary means of prevention than at least as an adjunct. Other factors affecting success rates of implants that might be of greater importance include intra-operative management, skill of the surgeon in applying the basic principles of surgery and sanitary conditions, and the patient’s medical status. Early loading of the implant, lack of sufficient alveolar bone, and patient factors such as hygiene levels and the use of alcohol and tobacco all increase the risk of post operative infection [25-29
After a thorough analysis of the literature, one can conclude that there is no clear evidence pointing to the need for prophylaxis antibiotics in conjunction with dental implant surgery. Of every million patients receiving just a single dose of oral amoxicillin, mild, moderate, and severe allergic reactions have been estimated to occur in 2400, 400, and 0.9 patients, respectively [20
]. The dental profession should diligently consider its responsibility of administering antibiotics only when needed, thus avoiding unnecessary allergic reactions whenever possible.
The scientific literature supports the limited use of prophylactic antibiotics, yet clinicians are continually over prescribing them [30
]. This non-evidence based practice protocol raises serious ethical concerns. Surgeons and general practitioners alike are routinely placing implants with antibiotics perhaps due to the fact that they are fearful of the legal repercussions of failure. The cost-benefit ratio of any therapy, including all potential adverse effects, must be determined. Studies of this nature with respect to the treatment of infective endocarditis have already been conducted. The ill advised use of antibiotics has proven to be expensive as well as directly responsible for development of resistant microorganisms [7
The most common adverse effects of antibiotics are direct toxicity, hypersensitivity reactions, and the short or long term development of resistant microorganisms. Direct toxicity includes gastrointestinal (nausea, vomiting, diarrhea, and abdominal pain), hematological concerns (neutropenia, thrombocytopenia, and hemolysis), alterations in the body’s normal flora leading to candidal infections or pseudomembranous colitis, nephrotoxicity (proteinuria or renal failure), neuropathy (nerve dysfunction or peripheral neuropathy), alterations in drug interactions, and finally hepatobiliary (jaundice or hepatitis) [14
Hypersensitivity reactions can range form mild to lethal. Mild reactions include cutaneous eruptions such as rashes, exfoliate dermatitis, or uticaria. Another complication with antibiotics is known as serum sickness, which is an immune complex condition. The most severe form is an immediate hypersensitivity including anaphylaxis, brochospasms, or laryngeal edema [31
From a long-term perspective one must be able to appreciate the concerns when a patient develops antibiotic resistant microorganisms. This is a potentially catastrophic concern, which is very difficult to measure. In addition, there is a tremendous financial concern with respect to the development of new drug therapies to treat such patients. The negative effects associated with use of antibiotic therapy must be assessed in comparison to the costs and morbidity related to treating infective endocarditis or infected prosthetic materials. If the risk-benefit and cost-benefit ratios are thoroughly assessed, it becomes clear that if there are specific therapeutic indications based on sound physiologic, anatomic and scientific evidence, then antibiotic prophylactic therapy may be justified [32
]. However, many professional associations, i.e., the Academy of Orthopaedic Surgeons (AAOS) [32
], American Dental Association (ADA) and the American Heart Assoication (AHA) [17
] have written guidelines regarding specific conditions in which it is important to prophylaxe and if these are followed and efforts are made to balance the cost-benefit ratio in patients that fall into the ”grey zone“, then the dental profession can hopefully curb the use of unnecessary antibiotics and keep antibiotic efficacy high for when they are truly necessary.