Rationale of use of dental implants
The priority of dental fraternity today is to persevere, restore and maintain the health of the stomatognathic system. Teeth are an essential and integral part of the stomatognathic system. Loss of teeth not only impairs the structural and functional aspects of it but also has a deleterious effect on patients’ psychosocial system. Replacement of the avulsed teeth is essential not only to maintain occlusal function but also to maintain aesthetic integrity. Although several methods are being used with varying success and failures to replace the missing teeth, none has caught the attention and imagination as seen with dental implants. Placement of dental implants to replace single or multiple missing teeth has become a common procedure in modern dentistry. These dental implants are made up of biocompatible materials which are inserted surgically into the extracted sockets.
Reasons for failure of dental implant
There can be multiple reasons for the failure of a dental implant which can be either patient-related or operator related. Among the various reasons, one of the reason is the development and progression of bacteraemia around dental implants. Also, literature has reported multiple cases of dental implant failure which are placed in sockets that are infected with microorganisms.
Use of antibiotics in dental implant procedures, a dilemma to clinicians!
Though there is a long history of the use of antibiotic prophylaxis prior or after the surgical procedures involved in dental implant placement, its rationale has come under scrutiny with the increase in the advent of antibiotic resistance. In dental implant placement procedures, the role of antibiotics in surgical prophylaxis has been controversial. Due to this often-dental implantologists and practitioners are confronted with the dilemma of when to and when not to prescribe the antibiotics for patients undergoing dental implant procedures. An experienced and proficient dental implantologists or clinician only prescribe antibiotics following a thorough local (dental examination) and systemic examination to determine the need for it on a case-to-case basis. However, even today a large number of clinicians from most part of the world would prescribe routine antibiotics during implant placement a conventional rule-based approach, rather than viewing each case on its own merits.
Rationale for use of antibiotics in dental implant placement in yesteryears
In the early days of Branemark et al. who performed groundbreaking research with dental implants has seen him usingphenoxy-methyl-penicillin. This was administered preoperatively approximately 60 minutes before implant placement and then continued for another 10 days. The similar regimen was also seen to be followed by many of his counterparts and was considered as a standard norm in placing six implants each in edentulous maxilla and mandible. The same was also endorsed by some dental associations who argued that prophylactic use of pre-operative antibiotics could potentially minimize the severity and duration of bacteraemia’s which might occur during operative procedures involving placement of dental implants. Also, they supported the use of antibiotics in cases where the implanted socket has some pre-existing infection or when microorganism has been introduced into the socket during such procedures, the use of which could minimize the post-operative infections.
The current issues related to antibiotics
In the light of the modern paradigm of antimicrobial use and the potential issues related to its overprescribing in terms of antibiotic resistance has put their use under scrutiny. Instead of being a common prescription now the emphasis lies on the basis of risk versus benefit ratio. Also, the risk of dose-dependent and idiosyncratic adverse reactions ranging from diarrhoea to life-threatening allergic reactions and the development of multidrug-resistant bacteria has been seen to increase by the inappropriate use of antibiotics.
So, when should we consider use of antibiotics during dental implant placement?
In spite of ever-increasing use of oral implants in dentistry, there are still no clear guidelines for the prophylaxis of antibiotics. Studies have shown that antibiotic prophylaxis will have no added benefit in preventing infections after surgery or affecting the results of endosseous implants. To mitigate infections following dental implant placement, numerous systemic prophylactic antibiotics have been suggested. If antibiotics are to be used, some guidelines recommend short-term antibiotic prophylaxis. The conditions where antibiotic prophylaxis is commonly prescribed currently are patients with poor host response, risk of infective endocarditis, when surgery is performed infected sockets, in lengthy and extensive surgeries and when there is lodgement of foreign materials.
The use of mucoperiosteal flap for dental implants does not pose a serious risk of developing bacteraemia and therefore raises concerns as to whether antibiotic prophylaxis is necessary for patients deemed at risk of bacterial endocarditis or other focal infections. A 0.2% rinse of chlorhexidine before treatment can be an effective therapeutic choice with low iatrogenic risk. Chances of implant failure are more if it gets infected. Therefore, prophylactic antibiotics are prescribed to increase the antibiotic concentration in the blood to prevent the onset of infection at the implant placement site to decrease the chance of bacterial proliferation and dissemination.
Also, the American Heart Association recommends the use of prophylactic antibodies before any dental procedure which can induce bleeding. This is contrary to the recommendation by the Canadian Dental Association which advocates the use of prophylactic antibiotics in all surgical cases as they consider all surgical dental procedures including dental implant lead to a considerable amount of bleeding. The commonest antibiotic used are amoxicillin and penicillin. In the case of penicillin sensitivity, clindamycin is the drug of choice. Most of the clinicians also followed Misch protocol which has 5 categories:
- Category 1: Low risk of infection; Grafting not needed; No need for antibiotics prophylaxis. Use of 0.12% chlorhexidine CHX) is recommended
- Category 2: Moderate risk; Traumatic extraction; Pre-surgical antibiotic loading followed by post-surgical single dose is recommended along with the use of 0.12% of CHX twice a day till suture removal
- Category 3: Moderate to high risk of infection; Multiple implants with the extensive reflection of soft tissue with bone grafting; Pre-surgical antibiotic loading followed by post-surgical three-dose is recommended along with use of 0.12% of CHX twice a day till suture removal
- Category 4: High risk; Implant surgeries requiring lifting of sinus floor with the placement of bone grafts; medically compromised. Follow category 3 regimen but post-surgical antibiotics should be used for 5 days
- Category 5: High risk with procedures involving all sinus augmentation. Pre-surgical antibiotics in such case warrant loading dose one day prior to surgery and post-surgical use of beta-lactamase antibiotics for 5 days. Also, 0.12% of CHX twice a day till suture removal
To conclude, in the light of issues related to the irrational use of antibiotics leading to bacterial resistance, prophylactic antibiotics for each implant surgery is not warranted. However, post-placement of implants, antibiotics are useful in preventing post-operative infections. Therefore, it’s the duty of the clinicians to assess patients’ conditions and weigh the anticipated befit and related harm before prescribing the antibiotics which will in turn prevent antibiotics related complications.