Antibiotic Prophylaxis for the Medically Compromised Dental Implant Patient.

Abstract

In the 47(4), August 2021 issue of Journal of Oral Implantology, the editorial asked, “What is the proper antibiotic prophylaxis regimen for dental implant placement?” Considerations were the following:This editorial will examine relevant literature regarding the need for possible additional postoperative antibiotic doses in medically compromised patients. The benefits of administering antibiotic prophylaxis both pre- and postoperatively are often misunderstood and can lead to irrational expectations and unnecessary use. The principles of antibiotic prophylaxis are well-known; however, they are not frequently followed. Pre- and postoperative antibiotic prophylaxis are beneficial only in select clinical scenarios. Proper antibiotic prophylaxis use is beneficial in patients with a compromised immune system, but unnecessary use may cause adverse effects. Implant clinicians must be aware of the indications and contraindications for postoperative antibiotic prophylaxis. Prophylactic antibiotics are indicated to diminish or eliminate surgical site and metastatic bacteremia in high risk patients.2Clinicians take precautionary steps to assure successful implant treatments. However, arbitrary antibiotic use is unacceptable and may not lead to better implant success rates, but rather increase the risk of failure due to the overgrowth of nonsusceptible microorganisms. Binanhmed et al3 found there was no greater efficacy observed with a 7-d postoperative antibiotic therapeutic course vs. a single preoperative dose.Lockhart et al4 performed a systematic literature search addressing antibiotic prophylaxis for invasive dental procedures in patients with 8 controversial medical conditions (or devices) who are traditionally given pre- and postoperative antibiotic prophylactic doses. The conditions and devices were (i) cardiac-native heart valve disease, prosthetic heart valves, and pacemakers; (ii) hip, knee, and shoulder prosthetic joints; (iii) renal dialysis shunts; (iv) cerebral fluid shunts; (v) vascular grafts; (vi) immunosuppression secondary to cancer and chemotherapy; (vii) insulin dependent (type 1) diabetes mellitus; and (viii) systemic lupus erythematosus. The practice of prescribing postoperative antibiotics is driven by long-standing dogma and habit, medicolegal concerns, and the potentially devastating consequences of infection in some patients. The weight of evidence suggests that the practice of routine antibiotic prophylaxis for many of the patients in these groups should be re-evaluated. The focus should be directed towards daily, thorough oral hygiene to purposefully reduce chronic oral bacteremia.4 There is a lack of evidence regarding the benefits of prolonged antibiotic prescribing; however, there is a problem of identifying patients at high risk, and there is no well-defined list of dental procedures that increase the patient's inherent danger. Therefore, prospective, randomized placebo-controlled clinical trials are needed to guide clinicians in making confident antibiotic prescribing recommendations regarding which patients and implant procedures represent a significantly increased risk of distant site infections.4Based on information currently available in the peer-reviewed literature, it would be incorrect to say that all medically compromised patients require postoperative antibiotic coverage for 7–10 d. Understanding the severity of a patient's compromised immune response will guide the need for postoperative antibiotic coverage and thus prevent some distant site infections. It is unreasonable to expect a dental implant clinician to have the ability, skills, or knowledge to evaluate which patients may or may not benefit from postoperative antibiotic coverage. The patient's physician would be the professional most likely able to determine the value in providing additional antibiotics in these cases. Physicians have the responsibility of understanding how to effectively evaluate a patient's immune risk.It would be clinically wrong to provide all medically compromised patients postoperative antibiotic therapy. Overprescribing antibiotics can lead to (i) an increased risk of superinfections, (ii) promotion of antibiotic-resistant microorganisms that could induce damage to hosts and the microbial ecological niche, and (iii) encouragement of careless or inept surgical techniques. When antibiotics are not used prudently, there may be an increased probability of antibiotic-induced allergies and toxic reactions. Remember, if no antibiotic prophylaxis is provided, there are no drug-related adverse effects to be harmful. However, ignoring the use of antibiotics 100% of the time would be negligent and may lead to poor clinical outcomes in some patients due to unnecessary infections.5For the medically compromised patient, a consultation with the patient's physician is necessary to determine whether postoperative antibiotic prophylaxis is required to prevent a systemic infection from the proposed invasive dental implant procedure. The consultation with the physician should begin with the implant clinician explaining what is to be done, how aggressive the intended procedure is, and what the expected procedural or surgical time is. Providing this information is the responsibility of the implantologist. The physician's responsibility is to provide guidance regarding the nature and risks of the patient's medical condition(s), and if the current treatment is optimized. Once the consultation has been completed, a well-informed decision regarding the need for a single preoperative dose or longer postoperative prophylactic antibiotic prescribing can be made.