Is there a consensus on antibiotic usage for dental implant placement in healthy patients?

Abstract

I read the article entitled ‘Is there a consensus on antibiotic usage for dental implant placement in healthy patients?’ by Park et al., published in the Australian Dental Journal in the March 2018 issue.1 Dr Park et al. cited an article of ours2 that was published in 2014 in a different journal (International Journal of Oral and Maxillofacial Surgery). Although we are pleased that the authors included our findings, we would like to specify some important points to clarify the results of our systematic review. Reading a properly conducted systematic review is an efficient way to become familiar with the best available research evidence for a focused clinical question. The review team might also have obtained information from the primary authors, which was not available in the original reports. The potential strength of a systematic review lies in the transparency of each phase of the synthesis process allowing the reader to focus on the merits of each decision made in compiling the information, rather than a simple contrast of one study with another as sometimes occurs in other types of reviews.3 When a systematic review does not analyse the data statistically, it is called qualitative. However, Park et al.1 did not do a statistical study and, according to them ‘due to the significant heterogeneity which was present among the studies the meta-analysis was not possible’. Nevertheless, in the results section they write a section called ‘Quantitative study results’ where at no time is the data collected in the primary studies analysed. It is worth noting that at least six published systematic revisions exist2, 4-8 in relation to this matter which makes clear the possibility of completing a quantitative analysis (meta-analysis) in spite of heterogeneity. In the study published by Park et al.,1 they comment that our study ‘has several limitations, including a retrospective design, and the lack of a placebo group with which to compare the effectiveness of antibiotics as the intervention’. From the present letter to the editor we want to specify that, as is explained in our materials and methods, the criteria of inclusion are: (1) patients subjected to dental implant surgery; (2) randomized controlled trials; (3) the presence of a control group (not receiving antibiotics or receiving placebo); (4) systemic antibiotic treatment, with specification of the type of antibiotic, the administrated dose and the duration of treatment; and (5) specification of the implant failure and postoperative infection rates. For which we have not included any retrospective study, or any study with an absence of a control group as Park et al.1 commented. On the other hand, Park et al.1 specify that their criteria for inclusion ‘were prospective human clinical trials investigating antibiotic usage during implant placement’ and nevertheless as demonstrated in Table 1 included in Park et al.1 of the 15 studies included three are retrospective. In the USA alone, more than 3 million patients have dental implants according to the American Academy of Implant Dentistry.1 In addition, 10% of all US dentists perform implants but this figure is increasing. In our study,2 the number needed to treat (NNT) to prevent one patient from having an implant failure was 48 (95% confidence interval, 31–109). These results conform to those from other studies such as those of Chrcanovic et al. (NNT = 50)7 or Lund et al. (NNT = 50),8 and other studies with lower figures such as those of Esposito et al. in 2013 (NNT = 25 years)4 and in 2010 (NNT = 33).5 Given the large number of dental implants installed each year, we consider it important to prevent implant failure as far as possible. For all of the above, we do not understand how it is possible that Park et al.1 have reached the conclusion that ‘antibiotic use at the time of surgery does not appear to play a major role in influencing the bearly incidence of prosthesis failure, implant failure, adverse events or postoperative complications’ if they have not performed a statistical analysis of the primary studies; and in the six published meta-analyses2, 4-8 they reach the opposite conclusion, specifically recommending the administration of systemic antibiotics to prevent implant failure.