Orally Administered Amoxicillin Decreases the Risk of Implant Failures
Stacy Geisler, DDS, PhD
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Clinical question.
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What are the effects of preoperative administration of antibiotics on dental implant placement versus the administration of placebo or no antibiotic?
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Review methods.
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The review authors conducted a hand search of four databases of journals in all languages with published data regarding dental implants. The review included only randomized controlled clinical trials involving human participants and a minimum of three months of follow-up; the authors defined specific inclusion and exclusion criteria a priori. The authors performed data extraction and used statistical methods as outlined in the Cochrane Handbook for Systematic Reviews of Interventions 5.0.1.1 They also completed a formal quality assessment of each trial. In addition, they conducted a meta-analysis of the data to estimate whether and to what degree systemic antibiotic administration decreased the risks associated with implant surgery.
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Main results.
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The review authors found that only two clinical trials met all criteria. Investigators in the first reviewed trial involving 80 participants who underwent implant surgery compared the responses of 40 participants who received a single 2-gram dose of amoxicillin administered one hour before surgery followed by a 500-mg dose of amoxicillin administered four times a day for two days with the responses of 40 participants who received no antibiotic. In the second trial, researchers compared the responses of 316 participants who underwent implant placement and who received one of two regimens: 2 g of amoxicillin administered as a single dose one hour before surgery or placebo tablets. All participants in both trials rinsed with chlorhexidine digluconate before undergoing surgery and continued to use this rinse for one week after surgery. The authors reported only two minor adverse effects in the trials: one patient who had received antibiotics complained of diarrhea and somnolence, and one patient who had received placebo complained of itching of one day’s duration. A meta-analysis of both trials showed that the participants who had received antibiotic therapy had a 78 percent lower risk of experiencing implant failure compared with the participants who had received either placebo or no antibiotic (relative risk, 0.22; 95 percent confidence interval, 0.06–0.86).
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Conclusions.
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The results of each trial suggested that preoperative antibiotic therapy reduced the risk of implant failure, and one trial’s results suggested a reduced risk of postoperative infection. However, both trials were underpowered to detect statistically significant differences, and the reviewers determined that one trial had a high risk of bias. In a combined meta-analysis of both trials, the reviewers did find a statistically significant reduction in the risk of implant failure with the pre-operative administration of systemic antibiotics.
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COMMENTARY
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Importance and context.
Antibiotic use in oral health care has received increased scrutiny since the American Heart Association revised its guidelines for the prevention of infective endocarditis in 2007.2 Bacterial resistance to antibiotics has increased in recent years,3 and potential complications of antibiotic use include fatal allergic reactions, diarrhea and, in some cases, pseudomembranous colitis.4 Studies in which investigators examine the need for antibiotics with invasive dental procedures are relevant and important.
Strengths and weaknesses of the systematic review.
The authors applied a thorough inclusion and exclusion methodology. However, the meta-analysis of the two trials weakened the authors’ conclusions because of a lack of adjustment for the different durations of antibiotic use. In addition, the authors excluded 14 participants from the statistical analysis, introducing a potential source of bias.
Strengths and weaknesses of the evidence.
The results of this systematic review support the use of orally administered amoxicillin in reducing the risk of complications associated with placement of dental implants. However, this evidence should be considered limited until findings from further large-scale trials are available to confirm these findings. Among the limitations of the evidence is the inclusion of only two relatively small clinical trials, one of which lacked blinding of participants to their treatment and had an unclear scheme of allocation to the treatment arms. Also, the trials were conducted in different settings (one in a university setting and the other in 11 private practices), a fact that could have had an important effect on surgical outcomes owing to differences in operator experience and asepsis techniques. Finally, the authors of this review did not evaluate which antibiotic might be the most effective in decreasing implant-related complications, nor did they address whether postoperative administration of antibiotics is useful in preventing implant failures.
Implications for dental practice.
Evidence suggests that orally administered amoxicillin may reduce implant failures and is not associated with serious adverse effects. The authors’ findings of only two minor adverse effects suggest that the benefit of short-term use of antibiotics in dental implant surgery outweighs the risks of use for individual patients. Dentists should consider use of amoxicillin as an adjunct to implant surgery.
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FOOTNOTES
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A critical summary of Esposito M, Grusovin MG, Talati M, Coulthard P, Oliver R, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev 2008;(3). doi: CD004152.
Systematic review conclusion. Evidence suggests that 2 grams of amoxicillin administered orally one hour before implant placement surgery significantly reduces the failure of dental implants placed in ordinary conditions.
Critical summary assessment. The authors conducted a meta-analysis of two clinical trials, resulting in a finding that antibiotics had a significant effect in decreasing the risk of implant failure.
Evidence quality rating. Limited.
The systematic review described here was funded by a grant from the School of Dentistry, The University of Manchester, England, and the Scientific Council for Medicine of the Swedish Research Council, Stockholm, Sweden.
Critical Summaries is supported by grant 1 G08 LM008956 from the National Library of Medicine and the National Institute of Dental and Craniofacial Research.
These summaries, published under the auspices of the American Dental Association Center for Evidence-Based Dentistry, are prepared by practitioners trained in critical appraisal of published systematic reviews who work under the mentorship of experts. The summaries are not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs.
For more information on the evidence quality rating provided above and additional critical summaries, please visit "http://ebd.ada.org".
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REFERENCES
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- Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.1. Oxford, England: The Cochrane Collaboration; 2008.
- Wilson W, Taubert KA, Gewitz M, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association—a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group (published correction appears in Circulation 2007;116[15]:e376–e377). Circulation 2007;116(15):1736–1754.[Abstract/Free Full Text]
- Boucher HW, Corey GR. Epidemiology of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2008;46(suppl 5):S344–S349.[Medline]
- Garey KW, Dao-Tran TK, Jiang ZD, Price MP, Gentry LO, Dupont HL. A clinical risk index for Clostridium difficile infection in hospitalized patients receiving broad-spectrum antibiotics. J Hosp Infect 2008;70(2):142–147.[Medline]
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Clinical question.
Review methods.
