Article

The effect of systemic antibiotics on clinical and patient reported outcome measures of oral implant therapy with simultaneous guided bone regeneration

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Abstract

Objectives: The aim of the present superiority study was to determine the effect of systemic antibiotics primarily on patient reported outcome measures (PROMs) and post-surgical complications in patients undergoing oral implant therapy with simultaneous guided bone regeneration (GBR). Materials & methods: 236 medically and periodontally healthy patients received oral implants with simultaneous GBR at 7 centres. Pre-operative antibiotics of 2 g amoxicillin were prescribed to the test group 1 hour prior to surgery and 500 mg thrice daily on days 1 to 3 after surgery. The control group was given a placebo. Group allocation was performed randomly. Primary outcome variables were PROMs recorded as Visual Analogue Scale (VAS) scores assessed on days 1-7 & 14 on pain, swelling, hematoma and bleeding. Postoperative complications as secondary outcome variables were examined at 1, 2, 4 and 12 weeks from surgery. Chi-square tests and repeated measures of analysis of variance (ANOVA) were performed for statistical evaluation. Results: No statistically significant differences (p>0.05) between the two groups were detected for the evaluated PROMs. The same was noted with respect to post-surgical complications. Four implants were lost - three in the test group and one in the control group. Conclusion: In this trial, systemic antibiotics did not provide additional benefits to (PROMs), nor the prevention of postsurgical complications in medically and periodontally healthy patients undergoing oral implant therapy with simultaneous GBR. However further studies with larger sample sizes are still required to support the clinical outcomes of this study.

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... Two independent reviewers read the titles and abstracts, excluding 10 for not meeting the criteria described. After reading the full text of the remaining 4 articles, two related to preventive antibiotic therapy in bone augmentation procedures were included (one systematic review [13] and one RCT [14]). As an complementary measure, after reviewing the references of these articles and after an ancillary search in Google Scholar, 3 RCTs were included [4,15,16] (Fig. 1 and Table 2). ...
... A recent study by the Antibiotic Study Group of the International Team for Implantology (ITI) led by Payer et al. (2020) [14] studied how the administration of 2 g of amoxicillin one hour before surgery, followed by 500 mg of amoxicillin, every 8 h, during the 3 days following surgery and compared to a placebo, affects the occurrence of post-surgical complications and the patient's perception of morbidity secondary to GBR with simultaneous insertion of implants. Both groups received paracetamol every 8 h during the two postoperative days. ...
... A recent study by the Antibiotic Study Group of the International Team for Implantology (ITI) led by Payer et al. (2020) [14] studied how the administration of 2 g of amoxicillin one hour before surgery, followed by 500 mg of amoxicillin, every 8 h, during the 3 days following surgery and compared to a placebo, affects the occurrence of post-surgical complications and the patient's perception of morbidity secondary to GBR with simultaneous insertion of implants. Both groups received paracetamol every 8 h during the two postoperative days. ...
Article
Introduction Since the beginning of Oral Implantology, preventive antibiotic therapy has been routinely prescribed. However, at present, due to the growing appearance of antimicrobial resistance, its use has been questioned, generating a great debate and an emerging controversy. The present systematic review aims to analyze the scientific literature to determine whether the preventive prescription of antibiotics in augmentation procedures with the insertion of implants in one or two phases decreases the incidence of postoperative infections and/or the survival rate of the implants. Material and methods The MEDLINE database was searched (via PubMed) with the following keywords: (bone grafting OR alveolar ridge augmentation OR bone graft augmentation OR guided bone regeneration OR bone block) AND (dental implants OR dental implant OR oral implantology) AND (antibiotic prophylaxis OR antibiotics). The criteria used were those described by the PRISMA® Statement. The search was limited to systematic reviews and meta-analyses published in the last 15 years (2005-2020). Results After reading the titles and abstracts of the 6 resulting articles, only one systematic review meeting the described criteria and 4 randomized clinical trials were included. Conclusions Prescription of 2 or 3 g of amoxicillin one hour before surgery is recommended to reduce the early failure rate of one-stage implants and to decrease the bacterial load of grafted bone particles in bone augmentation procedures with one or two-stage implants.
... Overall, few studies investigated the effect of PAT on the prevention of postoperative infections after GBR, with or without simultaneous DI placement, and early DI failure. After evaluation of the selected articles, one systematic review [51] and four RCTs were included [52][53][54][55]. ...
... Post-surgery, they prescribed 1 g/8 h/3 days vs. placebo in the test group, with no significant differences. Finally, the multicentre RCT led by Payer et al. [55] (LoE 1++) was the only one to compare perioperative PAT administration (2 g amoxicillin 1 h before surgery, followed by 500 mg/8 h/3 days) vs. placebo, with no significant differences. However, at the clinical level, suppuration was higher in the control group. ...
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Current patterns of preventive antibiotic prescribing are encouraging the spread of an- timicrobial resistance. Recently, the Spanish Society of Implants (SEI) developed the first clinical practice guidelines published to date, providing clear guidelines on how to prescribe responsible and informed preventive antibiotic therapy (PAT) based on the available scientific evidence on dental implant treatments (DIs). The present document aims to summarise and disseminate the recom- mendations established by this expert panel. These were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were analysed using the Scottish Intercollegiate Guidelines Network (SIGN) checklist templates and ranked according to their level of evidence. They were then assigned a level of recommendation using the Grading of Recommendations, Assessment, Development and Evaluation system (GRADE). Guidelines were established on the type of PAT, antibiotic and dosage of administration in the placement of DIs without anatomical constraints, in bone augmentation with the placement of DIs in one or two stages, placement of immediate DIs, sinus elevations, implant prosthetic phase, as well as recommendations in patients allergic to penicillin. Therefore, the PAT must be adapted to the type of implant procedure to be performed.
... Postoperative pain and swelling are the most common sources of discomfort the patients typically report after implant placement. 13 One of the reported advantages of CAIS is to reduce invasiveness of surgical procedures and thus also potentially minimize the discomfort and unpleasant healing events. 9,16 This study aimed to document the Data expressing patient satisfaction are usually difficult to interpret and generalize, as they tend to strongly relate to individual characteristics and also the pretherapeutical expectations of the patients. ...
... , first, second, third, fifth, and seventh day). The postoperative pain intensity was recorded by patients' self-assessment on a continuous visual analogue scale (VAS) 0-10 adapted from Tan and colleagues12 and Payer and colleagues13 and the painkiller consumption. Swelling was self-assessed on four grades adapted from Santana and colleagues 14 ranging from no swelling (grade 1), intraoral swelling in the surgical zone (grade 2), extraoral swelling within surgical zone (grade 3), and extraoral swelling extending beyond the surgical zone (grade 4). 3. The final questionnaire, distributed at the 2-week follow-up visit, consisted of 6 items assessing experiences of postoperative symptoms similar to the expected ones in the preoperative questionnaire and 8 items assessing patient overall satisfaction by means of a 5-point Likert scale, adapted from Pjetursson and colleagues. ...
Article
Objective The purpose of this study was to compare patient-reported outcomes and experiences (PROs and PREs) among three techniques of dental implant placement, including (a) conventional freehand, (b) dynamic, and (c) static computer-aided implant surgery (CAIS). Material and methods Ninety patients were randomly assigned to have dental implant placed with one of the three protocols. Participants were asked to fill in a series of self-administered questionnaires assessing (1) preoperative expectations, (2) postoperative healing events during the first week after surgery, and (3) experiences and overall satisfaction with the procedures at 2 weeks. Differences within the groups were analyzed by Wilcoxson signed-rank test. Kruskal–Wallis test was used for comparisons among the three groups. Results Eighty-eight patients completed the study. Patients' expectations on chewing difficulty, the postoperative experience of duration of pain, speaking limitations, and impact on routine activities were significantly different among groups (p = 0.04, 0.01, 0.038, and 0.046, respectively). Overall, patients appeared to significantly underestimate the duration of postoperative pain (p = 0.035) and swelling (p = 0.001). No significant difference in magnitude of postoperative pain, swelling, and painkiller consumption was found among the groups. The short-term functional limitations after surgery were deemed acceptable by most participants and 89% were satisfied by the overall procedure. Conclusions Surgical placement of dental implant with conventional freehand, static, and dynamic CAIS techniques did not result in any difference in the level of postoperative pain and swelling, and appeared to lead to equal levels of satisfaction as expressed by the patients postoperatively.
... However, the postoperative swelling of perioral soft tissues and the growth of ecchymosis or maxillary cyst still are common and debilitating complications. These postoperative inconveniences lead to difficulty in eating and sleeping [5][6][7], and so compromise the quality of life of patients. ...
Article
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During implant restorative dentistry, common and crippling postoperative complications are pain and swelling of perioral soft tissues which engraving on patient quality of life. Concentrated growth factors (CGF), a novel generation of autologous platelet concentrate, and melatonin, endogenous indoleamine with also bone regenerative properties, may be useful for reconstruction of bony defects as well as in prosthetic and esthetic rehabilitation. We report a clinical case in which guided bone regeneration was performed combining CGF, melatonin and heterologous biomaterial. Great postoperative recovery without any complications was reported. In conclusion, in restorative dentistry the combined use of CGF and melatonin may have important roles in restoring bone defect, in improving implant osteointegration and, not less important, in preventing postoperative complications.
... In a study by Pistilli et al., 2014, 50% of patients still reported moderate pain 10 days after autogenous bone block augmentation [51]. A recent multicenter study on implants inserted with simultaneous guided bone regeneration showed VASpain scores higher than those reported in the present study during the entire week after surgery [52]. ...
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The present study aims to investigate clinical and patient-centered outcomes after the implant-supported rehabilitation of narrow ridges using a novel wedge-shaped implant. Forty-four patients were treated with the insertion of 59 tissue-level wedge implants (1.8 mm bucco-lingual width) in horizontally atrophic ridges (mean bone width 3.8 ± 0.4 mm). The main outcome measures were: implant stability quotient (ISQ), marginal bone loss (MBL) and patient morbidity. Fifty-eight implants were functioning satisfactorily after one year of loading (98.3% survival rate). ISQ values measured in the mesio-distal direction resulted significantly higher than those in the bucco-lingual direction at all time points (p < 0.001). Both mesio-distal and bucco-lingual ISQ values at 6-month follow-up resulted significantly higher than at 4-month follow-up (p < 0.001 for both). Mean MBL was 0.38 ± 0.48 mm at prosthesis delivery (6 months after implant insertion) and 0.60 ± 0.52 mm after one year of functional loading. The majority of patients reported slight discomfort related to the surgical procedure. Postoperative pain score was classified as mild pain on the day of surgery and the first postoperative day and no pain over the following five days. Within the limitations of the present study, the device investigated showed low morbidity and positive short-term clinical results in narrow ridges treatment.
... Chlorhexidine should be used for a short period of time to avoid cross-resistance to antibiotics. By observing preoperative disinfection and postoperative hygiene, the risk of infection and dry socket (DS) is reduced, thus eliminating the need to prescribe antibiotics [39][40][41][42]. Equally important during surgery is to use sterile instruments and irrigate the wound with sterile saline to reduce the bacterial load and to prevent inflammation in the postoperative area [43][44][45]. ...
Article
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(1) Background: Antibiotics are used in every medical field including dentistry, where they are used for the prevention of postoperative complications in routine clinical practice during the third molar extraction. (2) Methods: This study is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The present systematic review aimed to evaluate and systematize the use of antibacterial drugs in order to prevent postoperative complications in outpatient oral surgery for wisdom teeth extraction. We conducted a systematic review using electronic databases such as Medline PubMed, Scopus, and the Cochrane Central Register of Controlled Trials. Considering inclusion and exclusion criteria, we included randomized clinical trials published up to 2021 investigating the antibiotic prescription for third molar extraction. (3) Results: We selected 10 studies after the application of inclusion and exclusion criteria. The results showed that the most widely used antibiotic was amoxicillin both with and without clavulanic acid, in different dosages and duration. There were no statistically significant differences between treatment groups for development of postoperative complications. (4) Conclusions: Based on the analysis of the included studies, penicillin is currently the most widely prescribed group of antibiotics. The widespread use of this antibiotic group can lead to antimicrobial resistance (AMR). Due to increasing prevalence of bacteria resistance to penicillins, clinicians should carefully prescribe these antibiotics and be aware that the widespread use of amoxicillin may do more harm than good for the population.
... In our opinion, 1 µM cisplatin plus 3 min of CAP treatment or 3 µM cisplatin plus 1 min of CAP treatment are the preferred combination options rather than other treatment regimens, because the viability of cancer cells was sufficiently inhibited, while the viability of HGF-1 cells remained higher than 60%. Furthermore, local treatment of disease in the periodontal region is required to improve therapeutic efficacy because it is hard to reach the periodontal region with the systemic delivery of drugs [46]. Thus, the local treatment modality should be developed to maximize drug efficacy against the periodontal and gingival region [47,48]. ...
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Cold atmospheric plasma (CAP) has been extensively investigated in the local treatment of cancer due to its potential of reactive oxygen species (ROS) generation in biological systems. In this study, we examined the synergistic effect of combination of CAP and cisplatin-mediated chemotherapy of oral squamous cell carcinoma (OSCC) in vitro. SCC-15 OSCC cells and human gingival fibroblasts (HGF-1) cells were treated with cisplatin, and then, the cells were irradiated with CAP. Following this, viability and apoptosis behavior of the cells were investigated. The viability of SCC-15 cells was inhibited by cisplatin with a dose-dependent manner and CAP treatment time. HGF-1 cells also showed decreased viability by treatment with cisplatin and CAP. Combination of 1 μM cisplatin plus 3 min of CAP treatment or 3 μM cisplatin plus 1 min of CAP treatment showed a synergistic anticancer effect with appropriate cytotoxicity against normal cells. ROS generation and dead cell staining were also increased by the increase in CAP treatment time. Furthermore, tumor-suppressor proteins and apoptosis-related enzymes also increased according to the treatment time of CAP. We showed the synergistic effect of cisplatin and CAP treatment against SCC-15 cells with low cytotoxicity against normal cells.
... However, a strict asepsis protocol must be followed during periodontal surgery [40]. Similar outcomes were reported when AB use was evaluated with implant and GBR procedures [41][42][43]. ...
Article
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Aim: To examine the patterns of systemic antibiotics prescription by periodontists in Saudi Arabia and to explore the rationale of their use. Materials and methods: An online, self-administered survey distributed to periodontists in Saudi Arabia questioned about antibiotics prescription practice in different periodontal and implant procedures and prescription rationale. Results and discussion: 123 surveys in total. 93% of the respondents performed all clinical procedures. A significantly lower percentage of them would prescribe AB when dealing with traditional periodontal procedures like crown lengthening, compared to bone grafting. Invasive procedures, like sinus grafting or complex implant treatment, evidenced significantly higher AB prescription practices. The most common rationale for the prescription was to prevent infection, followed by the use of non-autogenous materials. 90% agreed on the need to establish an antibiotics stewardship program. Conclusions: Discrepancy in antibiotics prescription patterns among periodontists was noticed, which highlights the importance of developing evidence-based program for perspiration.
... The use of preoperative single-dose antibiotic prophylaxis seems to have the same effect as 3 days of postoperative treatment for bone grafting (Cosyn et al., 2019), though the scientific evidence is limited and very recent. The use of antibiotics at perioperative infective sites is subject to debate (Payer et al., 2020), and few published data are available on sinus membrane perforation or multiple simultaneous implant placement. According to the scientific literature, a single preoperative antibiotic dose of amoxicillin 1 h before surgery could be useful to reduce early dental implant failure. ...
Article
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Background: Systemic antibiotic prophylaxis is frequently prescribed by dentists performing dental implant surgery to avoid premature implant failure and postoperative infections. The scientific literature suggests that a single preoperative dose suffices to reduce the risk of early dental implant failure in healthy patients. Material and Methods: A systematic review was made based on an electronic literature search in the PubMed-Medline, Embase, Web of Science, Scopus and Open Gray databases. The review addressed the question: “which antibiotic prophylaxis regimens are being used in dental implant surgery in healthy patients according to survey-based studies?” The identification, screening, eligibility and inclusion phases were conducted according to the PRISMA statement by two independent reviewers. The following data were collected: country, number of surveyed dentists, number of dentists who responded (n), response rate, routine prescription of antibiotic prophylactic treatment (yes, no, or conditioned prescription), prescription regimen (preoperative, perioperative or postoperative) and antibiotic choice (first and second choice). Cohen’s kappa coefficient (k) evaluated the level of agreement between the two reviewers. The analysis of risk of bias was performed follow the Joanna Briggs Institute checklist for observational studies. A descriptive statistical analysis was performed to calculate total target sample, sample size and total mean. Results: A total of 159 articles were identified, of which 12 were included in the analysis. Two thousand and seventy-seven dentists from nine different countries on three continents were surveyed. The median response rate was low and disparate between studies. About three-quarters of the surveyed dentists claimed to routinely prescribe systemic antibiotic prophylaxis for dental implant surgery. The prescription regimen was perioperative, postoperative and preoperative, in decreasing order of frequency. The most frequent first choice drug was amoxicillin, with amoxicillin-clavulanic acid as second choice. Conclusions: A majority of dentists from different countries do not prescribe systemic antibiotic prophylaxis for dental implant surgery following the available scientific evidence and could be overprescribing. Efforts are needed by dental educators and professionals to reduce the gap between the use of antibiotic prophylaxis for dental implant surgery as supported by the scientific evidence and what is being done by clinicians in actual practice.
Technical Report
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Desde la Sociedad Española de Implantes acabamos de publicar las primeras Guías de Práctica Clínica sobre la prescripción de antibióticos preventivos en Implantología Oral que se han publicado, hasta el momento, a nivel mundial. En los próximos meses se traducirán al portugués y al inglés para darle una mayor difusión. En ella se establecen pautas específicas de prescripción en: (1) Implantes sin condicionantes anatómicos; (2) Implantes inmediatos; (3) Elevaciones sinusales; (4) Regeneraciones óseas; (5) Fase protésica, incluidas 2ª fases; (6) Recomendaciones en pacientes alérgicos a penicilinas. Esta GPC se presenta en un momento en el que las resistencias a antimicrobianos suponen una grave amenaza para la Salud Pública. Los dentistas prescribimos un 10% de todas las prescripciones de antibióticos, por lo que tenemos un papel importante en este problema. El fin es el fomentar un consumo responsable de estos fármacos.
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Lateral Window sinus surgery, also known as Caldwell-Luc antrostomy is an operation aiming to approach structures of the sinus cavity through the anterior wall of the maxilla. It was introduced by George Caldwell (1893) and Henry Luc (1897) as an operation to remove irreversibly damaged mucosa of the maxillary sinus (1). In ENT and Maxillofacial Surgery, this surgical approach has been utilized for Chronic damage of the sinus cavity bone (2), Removal of foreign bodies (3-5) and Malignancies (6), correction of fractures of the maxilla and/or the orbital floor (7), removal neoplastic tissue or polyps (8) and more (9). The introduction of the lateral window in dentoalveolar surgery is much more recent and has utilized within implant dentistry. The purpose of the lateral window surgery in implant dentistry is to allow the safe detachment and isolation of the Schneiderian membrane from the sinus floor so that dental implants of adequate height can be placed with or without simultaneous bone augmentation procedures. As such, the application of the lateral window technique in implant dentistry is much less invasive than the typical ENT and Maxillofacial applications of Caldwel-Luc, it typically involves a minimally invasive osteotomy of under local anesthesia, involving a portion of the sinus floor and the elevation of the Schneiderian membrane typically for about 5-10 mm in order to accommodate the placement of dental implants. The aim of this paper is to discuss the current international benchmarks in the use of Lateral Window Sinus Floor Elevation (LWSFE) in implant dentistry and review the evidence for safety and efficiency, including prevalence of intraoperative and post-surgical complications and Patient Reported Outcomes Measures. Furthermore, the paper aims to investigate the evidence and potential guidelines for the current standards with regards to minimally invasive techniques and protocols, medical devices, facilities and venues for the safe and efficient practice of such surgery, including reviewing of any existing guidelines in other countries and jurisdictions.
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The antimicrobial resistance (AMR) phenomenon is an emerging global problem and is induced by overuse and misuse of antibiotics in medical practice. In total, 10% of antibiotic prescriptions are from dentists, usually to manage oro-dental pains and avoid postsurgical complications. Recent research and clinical evaluations highlight new therapeutical approaches with a reduction in dosages and number of antibiotic prescriptions and recommend focusing on an accurate diagnosis and improvement of oral health before dental treatments and in patients’ daily lives. In this article, the most common clinical and operative situations in dental practice, such as endodontics, management of acute alveolar abscesses, extractive oral surgery, parodontology and implantology, are recognized and summarized, suggesting possible guidelines to reduce antibiotic prescription and consumption, maintaining high success rates and low complications rates. Additionally, the categories of patients requiring antibiotic administration for pre-existing conditions are recapitulated. To reduce AMR threat, it is important to establish protocols for treatment with antibiotics, to be used only in specific situations. Recent reviews demonstrate that, in dentistry, it is possible to minimize the use of antibiotics, thoroughly assessing patient’s conditions and type of intervention, thus improving their efficacy and reducing the adverse effects and enhancing the modern concept of personalized medicine.
Article
Background: The growing resistance of bacteria to antimicrobial medicines is a global issue and a direct threat to human health. Despite this, antibiotic prophylaxis is often still routinely used in dental implant surgery to prevent bacterial infection and early implant failure, despite unclear benefits. There is a lack of sufficient evidence to formulate clear clinical guidelines and therefore there is a need for well-designed, large-scale randomized controlled trials to determine the effect of antibiotic prophylaxis. Purpose: To compare the effect of a presurgical antibiotic regimen with an identical placebo regimen in healthy or relatively healthy patients receiving dental implants. Materials and methods: The 474 patients participating in the study were recruited from seven clinics in southern Sweden. We randomized the patients into a test and a placebo group; the study was conducted double-blinded. Preoperatively, the test group received 2 g of amoxicillin and the control group, identical placebo tablets. The primary outcome was implant failure; secondary outcomes were postoperative infections and adverse events. Patients were evaluated at two follow-ups: at 7-14 days and at 3-6 months. Results: Postoperative evaluations of the antibiotic (n = 238) and the placebo (n = 235) groups noted implant failures (antibiotic group: six patients, 2.5% and placebo group: seven patients, 3.0%) and postoperative infections (antibiotic group: two patients, 0.8% and placebo group: five patients, 2.1%). No patient reported any adverse events. Between-group differences in implant failures and postoperative infections were nonsignificant. Conclusion: Antibiotic prophylaxis in conjunction with implant placement is likely of small benefit and should thus be avoided in most cases, especially given the unabated growth in antibiotic-resistant bacteria. Clinical trial registration number: NCT03412305.
Article
Background and objective: The clinical outcomes of guided tissue regeneration (GTR) or guided bone regeneration (GBR) procedures can be impaired if a bacterial infection develops at the surgical site. Membrane exposure is one of the causes of the onset of bacterial infection. Previously, we have fabricated a poly(lactic acid/caprolactone) (PLCL) bilayer membrane composed of a porous layer and a compact layer. The compact layer acts as a barrier against connective tissue and epithelial cells, and we hypothesized that it could also be an effective barrier against bacterial cells. The objective of this study was to evaluate the ability of the PLCL bilayer membrane to block bacterial cell penetration, which would be useful for preventing postoperative infections. Methods: Porphyromonas gingivalis, Streptococcus mutans, and multispecies bacteria collected from human saliva were used in this study. Bacteria were seeded directly on the compact layer of a PLCL bilayer membrane, and bacterial adhesion to the membrane, as well as penetration into the membrane's structure, were assessed. Bacterial adhesion was evaluated by the number of colonies formed at 6, 24, and 72 h, and penetration was observed using a scanning electron microscope at 24 and 72 h. Commercially available membranes, composed of poly(lactic-co-glycolic acid) or type I collagen, were used as controls. Results: P. gingivalis, S. mutans, and the multispecies bacteria obtained from human saliva adhered onto all the membranes after only 6 h of incubation. However, fewer adherent cells were observed for the PLCL bilayer membrane compared with the controls for all experimental periods. The PLCL membrane was capable of blocking bacterial penetration, and no bacterial cells were observed in the structure. In contrast, bacteria penetrated both the control membranes and were observed at depths of up to 80 µm after 72 h of incubation. Conclusion: Membrane characteristics may influence how bacterial colonization occurs. The PLCL membrane had reduced bacterial adhesion and blocked bacterial penetration, and these characteristics could contribute to a favorable outcome for regenerative treatments. In the event of membrane exposure at GTR/GBR surgical sites, membranes with an efficient barrier function, such as the PLCL bilayer membrane, could simplify the management of GTR/GBR complications.
Article
Design: A multicentre, prospective, randomized, placebo-controlled, double-blinded clinical trial reported the early implant failure and postoperative infections of healthy or relatively healthy patients receiving 2 grams of amoxicillin 1 hour preoperatively from their scheduled dental implant placement. Case selection: Several trial drugs expired before recruiting the intended 1000 patients calculated based on previous trials reporting 2% and 5% early implant loss with and without antibiotic prophylaxis. Thus, the study cohort (age >18 years, not planned for immediate loading, not requiring substantial bone augmentation, with an absence of severe diseases or immunosuppression or immunodeficiency) received 757 implants in total between November 2014 and April 2018, consisting of the prophylactic antibiotic therapy group (patients n = 235) and the placebo group (patients n = 235), with a fair gender distribution, had a mean age of 57.4 ±13.9 years. A computer-generated list of random numbers assisted the randomization (test or control group) with a block-size six. For the clinical procedures, bone augmentation was limited to autogenous bone chips and bone debris, one- and two-stage surgery protocols were used in maxillary or mandibular single or multiple dental implants. The utilized implant systems were Straumann SLA (Straumann Implants, Switzerland), Astra Tech Dental Implant Systems (Dentsply Sirona, Sweden), Nobel Biocare (Sweden), and Southern Implants (Ltd, South Africa). Chlorhexidine 0.2% was prescribed preoperatively and/or postoperatively. Implant failure was the main measured outcome, whereas postoperative infections and adverse events were the secondary outcomes postoperatively assessed at 7- to 14- day (first follow-up) and 3- to 6-month (second follow-up) intervals. Data Analysis: The sample size calculation (Type one error: 0.05; Power: 80%) estimated 500 patients in each group. Proportional differences and relative risk (RR) with a 95% confidence interval (CI) were calculated. Implant failure was the dependent variable for the multiple logistic regression (MLR) model examining the indicator variables smoking (yes or no), and age (<50 years; 50–64; and ≥65), as well as the independent variables bone augmentation (yes or no), number of implants (1, 2–3, and ≥4), and treatment group (antibiotic prophylaxis or placebo). P-values < 0.05 or 95% CIs for ratios not including one were deemed statistically significant. The analyses were carried out using statistical software for data science (STATA). Results: Six (2.5%) and seven patients (3.0%) from the amoxicillin and placebo groups had implant failures, respectively. Thus, the intergroup difference was not significant (RR: 0.85; 95% CI: 0.29–2.48, p = 0.75). Absolute risk reduction was 0.46%, with a number needed to treat (NNT) of 219. In other words, one in every 219 patients will benefit from receiving prophylactic antibiotics. In addition, no variable was associated with implant failure. Two (0.8%) and five patients (2.1%) from the amoxicillin and placebo groups, respectively, had postoperative infections at the first follow-up interval. Thus, the intergroup difference was not significant (RR: 0.29; 95% CI: 0.08–2.01, p = 0.25). Five (2.1%) and seven patients (3.0%) from the amoxicillin and placebo groups, respectively, had postoperative infections at the second follow-up interval. Thus, the intergroup difference was not significant (RR: 0.70; 95% CI: 0.23–2.18, p = 0.54). No adverse events were reported. Conclusion: Prophylactic antibiotic treatment for dental implant surgery to prevent implant loss may not be appropriate. Each dose must be prescribed based on evidence-based guidelines to avoid overuse and misuse of antibiotics promoting resistant bacteria.
Conference Paper
Objectives: To determine the effect of various systemic antibiotic regimes on patient-reported outcome measures (PROMs) and post-surgical complications in patients undergoing implant installation. Methods: 282 healthy adults (131 males, 151 females;19-80 years old), consecutively admitted to 7 study centres for conventional single implant installation were randomly assigned to one of four groups: Oral administration of: 1) 2g amoxicillin 1 hour prior to surgery (Positive Control (PC), n=71), 2) 2g amoxicillin immediately following surgery (Test 1 (T1), n=69), 3) 2g amoxicillin 1 hour prior to and 500mg thrice daily on days 2 and 3 postsurgically (Test 2 (T2),n=71) and 4) 2g of placebo 1 hour presurgically (Negative Control (NC), n=71). Subjects were examined by blinded examiners at Weeks 1, 2 , 4 and 8 for complications. Visual Analogue Scales (VAS) for pain, swelling, bruising and bleeding were obtained from the patients from Day 1 through 7 and Day 14. ANOVA was performed for the VAS. Descriptive statistics was applied to dichotomous data. Results: At Week 1, 97.18% (PC), 95.59% (T1), 97.14% (T2), 94.37% (NC) of flaps were closed. Subjects with pain and swelling were highest for T2 (20.00%, 25.71% respectively). All flaps were closed with absence of pain at Week 8 for all groups. Suppuration was detected in one subject (T2) at Week 8. All implants were stable at Week 8 except one each from PC and NC. Bleeding, swelling, pain and bruising VAS were low for all groups and decreased from Day 1 to Day 14. There were no significant differences (p<0.0001) between various groups at the various time points. Conclusion: For standard single implant placement, prophylactic systemic antibiotic coverage either before , after or before and after surgery yielded no differences in the incidence of postoperative complications and PROMs and hence, is redundant for routine implant surgery.
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Gut microbiota is established during birth and evolves with age, mostly maintaining the commensal relationship with the host. A growing body of clinical evidence suggests an intricate relationship between the gut microbiota and the immune system. With ageing, the gut microbiota develops significant imbalances in the major phyla such as the anaerobic Firmicutes and Bacteroidetes as well as a diverse range of facultative organisms, resulting in impaired immune responses. Antimicrobial therapy is commonly used for the treatment of infections; however, this may also result in the loss of normal gut flora. Advanced age, antibiotic use, underlying diseases, infections, hormonal differences, circadian rhythm, and malnutrition, either alone or in combination, contribute to the problem. This nonbeneficial gastrointestinal modulation may be reversed by judicious and controlled use of antibiotics and the appropriate use of prebiotics and probiotics. In certain persistent, recurrent settings, the option of faecal microbiota transplantation can be explored. The aim of the current review is to focus on the establishment and alteration of gut microbiota, with ageing. The review also discusses the potential role of gut microbiota in regulating the immune system, together with its function in healthy and diseased state.
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Background Guidelines for antibiotics prior to dental procedures for patients with specific cardiac conditions and prosthetic joints have changed, reducing indications for antibiotic prophylaxis. In addition to guidelines focused on patient co-morbidities, systematic reviews specific to dental extractions and implants support pre-procedure antibiotics for all patients. However, data on dentist adherence to these recommendations are scarce. Methods Cross-sectional study of Veterans undergoing tooth extractions, dental implants and periodontal procedures. Patients receiving antibiotics for oral or non-oral infections were excluded. Data was collected through manual review of the health record. Results Of 183 Veterans (mean age=62 years; 94.5% male) undergoing the included procedures, 82.5% received antibiotic prophylaxis (mean duration=7.1+1.6). Amoxicillin (71.3% of antibiotics) and clindamycin (23.8%) were prescribed most frequently; 44.7% of clindamycin was prescribed to patients not labeled as penicillin allergic. Of those that received prophylaxis, 92.1% received post-procedure antibiotics only, 2.6% pre-procedural and 5.3% received pre- and post-procedure antibiotics. When prophylaxis was indicated, 87.3% of patients received an antibiotic. However, 84.9% received post-procedure antibiotics when pre-procedure administration was indicated. Only 8.2% of patients received antibiotics appropriately based on administration time, dental procedure, and co-morbidities. Three months post-procedure, there were no occurrences of Clostridium difficile infection, infective endocarditis, prosthetic joint infections, or post-procedure oral infections. Conclusion The majority of patients undergoing a dental procedure received antibiotic prophylaxis. Although patients for whom antibiotic prophylaxis was indicated should have received a single pre-procedure dose, most antibiotics were prescribed post-procedure. Dental stewardship efforts should ensure appropriate antibiotic timing, indication, and duration.
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Objective Bisphosphonate-associated osteonecrosis of the jaws (BP-ONJ) is triggered by inflammatory processes. Typical trigger factors are periodontal disease, denture pressure sores, and surgical interventions such as tooth extractions. Unfortunately there is only little data on how to proceed with implant therapy in patients with bisphosphonate treatment. This topic is not addressed in the German guidelines on medication-associated osteonecrosis. Therefore a systematic literature review was performed. Methods The PICO design was used: (Patients) For which subclientel of patients with antiresorptive therapy (intervention) do dental implants have a benefit (control) compared to forgoing dental implants (outcome) in regards to oral rehabilitation and quality of life without having a substantial risk of BP-ONJ development? A PubMed search was performed including all studies dealing with this topic. Case reports and studies with less than 5 cases were excluded. Results There is only very little data available, mostly retrospective case series. 50 articles were analyzed in detail. BP-ONJ can be triggered by dental implants and by dentures in patients with benign and malignant primary diseases. In most studies, analyzing osteoporosis patients only, no cases of BP-ONJ were observed in patients with implant therapy in the time span observed. There are no studies about implant therapy in patients with malignant diseases. Many case series analyzing the trigger factors for BP-ONJ describe dentures as one of the main causes. Perioperative antimicrobial prophylaxis has a benefit in the prevention of BP-ONJ development. Conclusion Successful implant therapy is possible in patients receiving antiresorptive therapy. The possibility of osteonecrosis development needs to be explained to the patient. An individual risk assessment is essential, taking the primary disease with the medication and further wound-healing-compromising diseases and medications into account. If possible, bone augmentations should be avoided, and a perioperative antimicrobiological prophylaxis is strongly recommended in these patients.
Article
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Although various prophylactic systemic antibiotic regimens have been suggested to minimize failure after dental implant placement, the role of antibiotics in implant dentistry is still controversial. The purpose of the present survey was to determine the current antibiotic prescribing habits of oral and maxillofacial surgeons in conjunction with routine dental implant placement to determine whether any consensus has been reached among such practitioners. An electronic survey was sent by electronic mail to all members of the American College of Oral and Maxillofacial Surgeons. The questions asked were related to whether antibiotics were routinely prescribed either pre- or postoperatively during routine dental implant placement, and, if so, what antibiotics, dosage, frequency, and duration were used. The survey participants were also asked to specify whether they were in solo private practice, group private practice, academia, military, or "other." The results were tabulated and analyzed using SAS software. Descriptive statistics and χ(2) analyses were used. A total of 217 members responded to the survey. Overall, 112 of 217 (51.6%) prescribed antibiotics preoperatively (95% confidence interval [CI] 50.0 to 58.2%) and 152 of 213 (71.4%) prescribed antibiotics postoperatively (95% CI 65.0 to 77.0%) during routine dental implant placement. Also, 72 (34%) indicated that they prescribed antibiotics both pre- and postoperatively. The most common preoperative regimen used was amoxicillin 2 g given 1 hour before the procedure (32%, n = 36). The most common postoperative regimen used was amoxicillin 500 mg 3 times daily for 5 days (53%, n = 81). We found no consensus among oral and maxillofacial surgeons regarding the use of antibiotics in association with routine dental implant placement, the type of regimen to use, or whether such use is even effective in preventing early implant loss. Furthermore, most of the antibiotic regimens being used are not in accordance with the recommendations current in the published data. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Article
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To evaluate the efficacy of prophylactic antibiotics for dental implant placement. Thirteen dentists working in private practices agreed to participate in this trial, each centre providing 50 patients. One hour prior to implant placement, patients were randomised to take orally 2 g amoxicillin or identical placebo tablets. Patients needing bone augmentation at implant placement were not included. Outcome measures were prosthesis and implant failures, adverse events and post-operative complications. Patients were seen 1 week, 2 weeks and 4 months post-operatively. Two centres did not deliver any data, two centres did not manage to include the agreed quota of patients and three patients had to be excluded. Two-hundred and fifty-two patients were evaluated in the antibiotic group and 254 in the placebo group, and none dropped out at 4 months. Four prostheses and seven implants (in five patients) failed in the antibiotics group versus 10 prostheses and 13 implants (in 12 patients) in the placebo group. Eleven complications were reported in the antibiotic group versus 13 (in 12 patients) in the placebo group. No side effects were reported. There were no statistically significant differences for prosthesis failures, implant losses and complications. Patients receiving immediate post-extractive implants had an increased failure risk compared with patients receiving delayed implants (9% versus 2%). No statistically significant differences were observed, although trends clearly favoured the antibiotic group. Immediate post-extractive implants were more likely to fail.
Article
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To evaluate the efficacy of prophylactic antibiotics for dental implant placement. Twelve Italian private practices agreed to participate in this trial, each centre providing 30 patients. One hour prior to implant placement, patients were randomised, for consumption orally of 2 g amoxicillin or identical placebo tablets. Patients needing bone augmentation procedures were not included. Outcome measures were prosthesis and implant failures, adverse events and post-operative biological complications. Patients were seen 1 week, 2 weeks and 4 months post-operatively. One centre did not deliver any data and 14 patients had to be excluded from the trial for various reasons. One hundred and fifty-eight patients were evaluated in each group and none dropped out at 4 months. Two prostheses and two implants failed in the antibiotics group, compared with four prostheses and nine implants in the placebo group. There were no statistically significant differences for prosthesis failures, implant losses, complications and side effects. No statistically significant differences were observed. However, four times more patients in the placebo group experienced implant failures than in the antibiotic group, and this requires further investigation.
Article
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To compare the efficacy and safety of 2 g amoxicillin orally with identical placebo tablets 1 hour before implant placement when placing single implants in bone types II and III. 12 private dental clinics in Spain agreed to participate in this trial. A total of 105 patients were recruited. Patients were randomised for consumption orally of 2g amoxicillin or identical placebo tablets. Only patients needing single implants were included. Outcome measures were post-operative infections, adverse events and implant failures. Characteristics of the saprophytic flora were also studied in all patients. Patients were seen 3 days, 10 days, 1 month and 3 months postoperatively. Results: A total of 105 patients (n = 52 in the amoxicillin group and n = 53 in the placebo group) were evaluated and none were excluded from the study at 3 months. Six post-operative infections occurred and two implants were lost in each group. There were no statistically significant differences for postoperative infection, adverse events, implant failures and the characteristics of saprophytic flora between groups. The use of amoxicillin did not either alter or modify the characteristics of the saprophytic flora nor provoke remarkable side effects. Antibiotic prophylaxis may not be needed when placing single implants in patients with bone types II and III.
Article
Purpose: To report retro-prospective data on the prevalence of overall implant failure in a large number of edentulous patients treated at one referral clinic over a 30-year period and to analyze possible associations between implant failure and basic clinical variables. Materials and methods: Altogether, 24,781 implants were consecutively placed in 4,585 edentulous arches between 1986 and 2015. All implant failures identified at the clinic during follow-up were consecutively recorded, and a multivariate logistic regression analysis was performed to identify possible associations between implant failure and different clinical factors. Results: Altogether, 1,333, 688, and 249 treated arches were followed up for 15, 20, and 25 years, respectively. Cumulative survival rates (CSR) for the treated arches were 86.2% and 83.8% after 15 and 25 years, respectively. Most patients lost only one implant each (58%). Loss of all implants was reported in 68 arches, with total failure rates of 1.9% and 2.2% after 15 and 25 years, respectively. The strongest associations with increased risk for implant failure were maxilla (hazard ratio [HR] 4.76; 95% confidence interval [CI] 3.70 to 6.25) and implant surface (HR 2.38; 95% CI 1.59 to 3.57). Age at surgery, implant surgeon, calendar year of surgery, and time of follow-up also showed significant associations with risk of implant failure (P < .05). A completely steady-state level in implant survival was not observed, but few implants were lost up to the last years of follow-up. Conclusion: There is a higher risk for implant failure in the maxilla compared to the mandible. Risk is reduced when using implants with a moderately rough surface. The highest risk for failure was observed during the first year. This was followed by a reduced failure rate, which never reached a steady-state level.
Article
The gastrointestinal tract has become a focus of study recently. The crosstalk between microbiota, especially bacteria, and the intestinal mucosa has to be accurately balanced in order to maintain physiological homeostasis in the human body. This dynamic interaction results in different levels of short-chain fatty acids (SCFAs), IgA, and T cell lymphocyte subsets, which could lead the human body towards health or disease. The disruption of this microbiome characterises gut dysbiosis. Antibiotics are usually prescribed to fight against bacterial infection. They can also modulate the human microbiome, since it acts directly over organisational taxonomic units (OTUs) when taken orally. As a result, these pharmaceuticals enable gut dysbiosis and its systemic effects due to microbiome disturbance. Here, current data have been gathered from mice model experiments and epidemiological studies in an antibiotic-centred perspective. The presented data suggest the importance of translational studies in a murine model focusing on GIT homeostasis with bacterial groups since any changes to the GIT-microbiota have systemic repercussions in human health and disease.
Article
This systematic review aimed to determine whether there is consensus for antibiotic prescription in healthy patients undergoing implant placement. A search of PubMed, Embase and Medline databases was conducted in January 2016 to find published journal articles on the use of antibiotics in implant placement, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria were prospective human clinical trials investigating antibiotic usage during implant placement. Fifteen studies were deemed suitable. In 13 studies, no statistical difference was found between antibiotic use and the incidence of prosthetic failure, implant failure and early postoperative infections. These were rated as having low to high risk bias. Contrary results were reported in two studies, both of which were rated as having a high potential for bias. In conclusion, antibiotic use in healthy patients for the prophylaxis of surgical infection associated with dental implant placement does not appear to improve clinical outcomes. Practitioners should apply principles of antimicrobial stewardship and not use antibiotics as a routine measure in healthy patients.
Article
Background The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997. Methods and Results A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) with liaison members representing the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on IE. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization and bacteremia. The reference lists of the identified articles were also searched. The writing group also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The article subsequently was reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee. Conclusions The major changes in the updated recommendations include the following. (1) The committee concluded that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective. (2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. (3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.
Article
ObjectivesA prospective double-blind randomised controlled trial was conducted to test the effect of prophylactic antibiotics on post-operative morbidity and osseointegration of dental implants. Materials and Methods Fifty-five subjects scheduled for implant surgery were enrolled. The patients were randomly assigned to the antibiotic (test group) and placebo (control group). Twenty-seven patients (test group) received 3g amoxicillin one hour pre-operatively, and 28 patients (control group) received placebo capsules 1h pre-operatively. No post-operative antibiotics were prescribed. Pain diaries and interference with daily activities diaries were kept by the patients for 1week post-operatively. Signs of post-operative morbidity (swelling, bruising, suppuration and wound dehiscence) were recorded by the principal investigators at day 2 and day 7 following the operation. Osseointegration was assessed at 2nd stage surgery or 3-4months post-operatively. ResultsThe results of this study suggest that the use of prophylactic pre-operative antibiotics may result in higher dental implant survival rates (100% vs. 82%). Five implant failures, one in each of five patients, were reported in the placebo group and none in the antibiotic group (P=0.0515). No significant differences were found for most of the signs of post-operative morbidity 2 and 7days post-operatively. Only bruising at 2days following the operation appeared to be higher in the placebo group (P=0.0511). Post-operative pain (P=0.01) and interference with daily activities (P=0.01) appeared to be significantly lower for the antibiotic group after 7days. Those patients with implant failure reported higher pain (based on the VAS scores) after 2days (P=0.003) and after 7days (P=0.0005), higher pain (based on the amount of analgesics used) after 7days (P=0.001) and higher interference with daily activities (based on the VAS scores) after 2days (P=0.005). Conclusions The use of for dental implant surgery may be justified, as it appears to improve implant survival in the short term and also results in less post-operative pain and interference with daily activities. From the results of this study, it appears that prophylactic antibiotics may also be beneficial both in terms of implant survival, especially when the surgical procedure is prolonged due to its difficulty, high number of implants placed or operator's inexperience.
Article
Objectives To determine the effect of various systemic antibiotic prophylaxis regimes on patient-reported outcomes and postsurgical complications in patients undergoing conventional implant installation. Material and methodsThree hundred and twenty-nine healthy adults in need of conventional implant installation were randomly assigned to one of four groups: (i) preoperatively 2g of amoxycillin 1h before surgery (positive control, PC), (ii) postoperatively 2g of amoxycillin immediately following surgery (test 1, T1), (iii) preoperatively 2g of amoxycillin 1h before and 500mg thrice daily on days 2 and 3 after surgery (test 2, T2), (iv) preoperatively 2g of placebo 1h before surgery (negative control, NC). Subjects were examined clinically by blinded examiners over 8weeks after implant installation. In addition, Visual Analogue Scales (VAS) for pain, swelling, bruising and bleeding were obtained over 14days. ANOVA was performed for the VAS. Chi-square tests were applied for postsurgical complications. ResultsAll VAS scores were low for all groups and decreased over time (P<0.001). There were no significant differences for the VAS scores between the various groups at any time point (P>0.05). There was only a significant difference in flap closure at week 4, where NC had 5% of the subjects not achieving complete wound closure compared to 0% for the three other groups (P=0.01), with no other significant differences for any postsurgical complications (P>0.05). Conclusion For standard single implant placement, prophylactic systemic antibiotics either before or after, or before and after the surgical procedure do not improve patient-reported outcomes or prevalence of postsurgical complications.
Article
Missing teeth can sometimes be replaced with dental implants to which a crown, bridge or denture can be attached. Bacteria introduced during placement of implants can lead to infection and sometimes implant failure. It appears that the oral administration of 2 grams of amoxicillin 1 hour before placement of dental implants is effective in reducing implant failures. More specifically, giving antibiotics to 25 patients will avoid one patient experiencing early implant losses. It is still unclear whether postoperative antibiotics are of any additional benefits.
Article
CONFLICT-OF-INTEREST STATEMENT: Marco Esposito is the first author of two of the included studies; however, he was not involved in the quality assessment of these trials. This review is based on a Cochrane systematic review entitled 'Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications' published in The Cochrane Library (see http://www.cochrane.org for more information). Cochrane systematic reviews are regularly updated to include new research, and in response to comments and criticisms from readers. If you wish to comment on this review, please send your comments to the Cochrane website or to Marco Esposito. The Cochrane Library should be consulted for the most recent version of the review. The results of a Cochrane Review can be interpreted differently, depending on people's perspectives and circumstances. Please consider the conclusions presented carefully. They are the opinions of the review authors, and are not necessarily shared by the Cochrane Collaboration. To assess the beneficial or harmful effects of systemic prophylactic antibiotics at dental implant placement versus no antibiotic/placebo administration and, if antibiotics are of benefit, to find which type, dosage and duration is the most effective. The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched up to 2 June 2010 for randomised controlled clinical trials (RCTs) with a follow-up of at least 3 months comparing the administration of various prophylactic antibiotic regimens versus no antibiotics to patients undergoing dental implant placement. Outcome measures were prosthesis failures, implant failures, postoperative infections and adverse events (gastrointestinal, hypersensitivity, etc.). Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Meta-analyses were conducted. Four RCTs were identified: three comparing 2 g of preoperative amoxicillin versus placebo (927 patients) and the other comparing 1 g of preoperative amoxicillin plus 500 mg four times a day for 2 days versus no antibiotics (80 patients). The meta-analyses of the four trials showed a statistically significantly higher number of patients experiencing implant failures in the group not receiving antibiotics: risk ratio=0.40 (95% confidence interval (CI) 0.19 to 0.84). The number needed to treat (NNT) to prevent one patient having an implant failure is 33 (95% CI 17-100), based on a patient implant failure rate of 5% in patients not receiving antibiotics. The other outcomes were not statistically significant, and only two minor adverse events were recorded, one in the placebo group. There is some evidence suggesting that 2 g of amoxicillin given orally 1 h preoperatively significantly reduce failures of dental implants placed in ordinary conditions. No significant adverse events were reported. It might be sensible to suggest the use of a single dose of 2 g prophylactic amoxicillin prior to dental implant placement. It is still unknown whether post-operative antibiotics are beneficial, and which is the most effective antibiotic.
Article
Background: Some dental implant failures may be due to bacterial contamination at implant insertion. Infections around biomaterials are difficult to treat, and almost all infected implants have to be removed. In general, antibiotic prophylaxis in surgery is only indicated for patients at risk of infectious endocarditis; with reduced host-response; when surgery is performed in infected sites; in cases of extensive and prolonged surgical interventions; and when large foreign materials are implanted. A variety of prophylactic systemic antibiotic regimens have been suggested to minimise infections after dental implant placement. More recent protocols recommended short-term prophylaxis, if antibiotics have to be used. Adverse events may occur with the administration of antibiotics, and can range from diarrhoea to life-threatening allergic reactions. Another major concern associated with the widespread use of antibiotics is the selection of antibiotic-resistant bacteria. The use of prophylactic antibiotics in implant dentistry is controversial. Objectives: To assess the beneficial or harmful effects of systemic prophylactic antibiotics at dental implant placement versus no antibiotic or placebo administration and, if antibiotics are beneficial, to determine which type, dosage and duration is the most effective. Search methods: We searched the Cochrane Oral Health Group's Trials Register (to 17 June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 5), MEDLINE via OVID (1946 to 17 June 2013) and EMBASE via OVID (1980 to 17 June 2013). There were no language or date restrictions placed on the searches of the electronic databases. Selection criteria: Randomised controlled clinical trials (RCTs) with a follow-up of at least three months, that compared the administration of various prophylactic antibiotic regimens versus no antibiotics to people undergoing dental implant placement. Outcome measures included prosthesis failures, implant failures, postoperative infections and adverse events (gastrointestinal, hypersensitivity, etc). Data collection and analysis: Screening of eligible studies, assessment of the risk of bias of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as risk ratios (RRs) using a random-effects model for dichotomous outcomes with 95% confidence intervals (CIs). Heterogeneity, including both clinical and methodological factors, was to be investigated. Main results: Six RCTs with 1162 participants were included: three trials compared 2 g of preoperative amoxicillin versus placebo (927 participants), one compared 3 g of preoperative amoxicillin versus placebo (55 participants), one compared 1 g of preoperative amoxicillin plus 500 mg four times a day for two days versus no antibiotics (80 participants), and one compared four groups: (1) 2 g of preoperative amoxicillin; (2) 2 g of preoperative amoxicillin plus 1 g twice a day for seven days; (3) 1 g of postoperative amoxicillin twice a day for seven days, and (4) no antibiotics (100 participants). The overall body of evidence was considered to be of moderate quality. The meta-analyses of the six trials showed a statistically significant higher number of participants experiencing implant failures in the group not receiving antibiotics (RR 0.33; 95% CI 0.16 to 0.67, P value 0.002, heterogeneity: Tau(2) 0.00; Chi(2) 2.87, df = 5 (P value 0.57); I(2) 0%). The number needed to treat for one additional beneficial outcome (NNTB) to prevent one person having an implant failure is 25 (95% CI 14 to 100), based on an implant failure rate of 6% in participants not receiving antibiotics. There was borderline statistical significance for prosthesis failures (RR 0.44; 95% CI 0.19 to 1.00), with no statistically significant differences for infections (RR 0.69; 95% CI 0.36 to 1.35), or adverse events (RR 1; 95% CI 0.06 to 15.85) (only two minor adverse events were recorded, one in the placebo group). No conclusive information can be derived from the only trial that compared three different durations of antibiotic prophylaxis since no event (implant/prosthesis failures, infections or adverse events) occurred in any of the 25 participants included in each study group. There were no trials that evaluated different antibiotics or different antibiotic dosages. Authors' conclusions: Scientific evidence suggests that, in general, antibiotics are beneficial for reducing failure of dental implants placed in ordinary conditions. Specifically 2 g or 3 g of amoxicillin given orally, as a single administration, one hour preoperatively significantly reduces failure of dental implants. No significant adverse events were reported. It might be sensible to suggest the use of a single dose of 2 g prophylactic amoxicillin prior to dental implant placement. It is still unknown whether postoperative antibiotics are beneficial, and which antibiotic is the most effective.
Article
The aim of this study was to attempt to determine the minimum effective regimen of amoxicillin antibiotic prophylaxis for dental implant surgery. One hundred patients were randomly allocated to 4 different antibiotic prophylactic treatment groups. At second-stage surgery, only 2 implants failed in the nonantibiotic group. No statistically significant differences were found in the 4 groups, probably because of the limited number of the samples. Until a study with a larger population may definitely rule on the role of antibiotics in oral implant surgery, in may be prudent for the practitioner to adopt the single preoperative antibiotic dose as the minimal effective regimen.
Article
The aim of the present study was to analyze tissue reactions to plaque formation following ligature removal in experimental peri-implantitis at commercially available implants in dogs. Mandibular premolars and the three anterior premolars in both sides of the maxilla were extracted in six Labrador dogs. After 3 months, four implants representing four different implant systems--groups A (turned), B (TiOblast), C (SLA), D (TiUnite)--were placed in a randomized order in the right side of the mandible. Three months after implant installation, experimental peri-implantitis was initiated by placement of ligatures and plaque formation. The ligatures were removed when about 40-50% of the supporting bone was lost. After the subsequent 24-week period of continued plaque accumulation, block biopsies containing implants and their surrounding tissues were obtained and prepared for histological analysis. All types of implants exhibited extensive inflammatory cell infiltrates and large associated crater-formed osseous defects. The lesions were consistently characterized by insufficient encapsulation of pus and biofilm layers and the inflammatory cell infiltrates extended apical of the pocket epithelium. The presence of numerous osteoclasts indicated active tissue destruction. The vertical dimension and the overall surface area of the infiltrated connective tissue (ICT) were larger at implants of group D than at other implant types. It is suggested that spontaneous progression of peri-implantitis is associated with severe inflammation and tissue destruction.
Article
The aim of the present study was to analyze tissue reactions to plaque formation following ligature removal at commercially available implants exposed to experimental peri-implantitis. Six Labrador dogs about 1 year old were used. All mandibular premolars and the three anterior premolars in both sides of the maxilla were extracted. After 3 months four implants representing four different implant systems with different surface characteristics--implant group A (turned), B (TiOblast), C (sandblasted acid-etched; SLA) and D (TiUnite)--were placed in a randomized order in the right side of the mandible. Three months after implant installation experimental peri-implantitis was initiated by placement of ligatures in a submarginal position and plaque accumulation. At week 12, when about 40-50% of the supporting bone was lost, the ligatures were removed. During the subsequent 24-week period plaque accumulation continued. Radiographic and clinical examinations were performed during the 'active breakdown' period (plaque accumulation and ligatures) and the plaque accumulation period after ligature removal. The experiment was terminated at week 36. The bone loss that took place during the 'active breakdown' period varied between 3.5 and 4.6 mm. The additional bone loss that occurred during the plaque accumulation period after ligature removal was 1.84 (A), 1.72 (B), 1.55 (C) and 2.78 mm (D). Spontaneous progression of experimentally induced peri-implantitis occurred at implants with different geometry and surface characteristics. Progression was most pronounced at implants of type D (TiUnite surface).
Article
The aim of the present experiment was to study the location and composition of plaque associated lesions in the mucosa adjacent to implant systems that differed with respect to both geometry and dimension. At day 0 extraction of the mandibular premolars were performed. After a healing period of 3 months, fixtures of the Astra Tech Implants, Dental System, the Brånemark System and the ITI Dental Implant System were installed. In each mandibular quadrant 1 fixture of each implant system was installed in a randomized order. A period of plaque control was initiated. Following another 3 months of healing, abutment connection was performed in the 2-stage systems (the Astra Tech Implants, Dental System and the Brånemark System). After 1 month, the plaque control measures were abandoned and plaque formation was allowed for 5 months. The animals were killed and biopsies representing each implant region obtained. The tissue samples were prepared for light microscopy and exposed to histometric and morphometric measurements. The present study demonstrated that plaque formation resulted in the establishment of an ICT lateral to a pocket epithelium. The lesion was found to be similar regarding extension and composition in the peri-implant mucosa of the 3 implant systems tested. The vertical extension of the ICT was in all systems within 91-99% of the vertical dimension of the junctional epithelium. The marginal bone level, measured from the abutment/fixture (PS) border, did not differ between the three systems.
Article
The aim of the present experiment was to test the effect of a deproteinized bovine bone mineral (Bio-Oss) on guided bone regeneration (GBR) in dehiscence defects around implants. The first 2 molars and all premolars were extracted on both sides of the mandibles of 3 monkeys (Macaca fascicularis). Three months later, 2 titanium plasma-coated cylindrical implants were placed in all quadrants of each monkey. During the surgical procedure, standardized dehiscence defects were produced buccally and lingually, measuring 2.5 mm in width and 3 mm in height. Four different experimental situations were created: 2 sites in each monkey were covered with an ePTFE membrane (M), 2 were filled with the graft material (DBBM), 2 were filled with the graft material and also covered with a membrane (M + DBBM), and 2 control sites were neither grafted nor covered (C). The flaps were sutured to allow for primary healing. Linear measurements of bone height and width were calculated on histological specimens obtained 6 months following surgery. In addition, values for bone density and for surface fraction of graft to new bone contact were measured. Vertical bone growth along the implant surface of 100% (SD 0%) for M + DBBM, 91% (SD 9%) for M, 52% (SD 24%) for DBBM, and 42% (SD 35%) for C was measured. The width of the regenerated bone 1.5 mm above the bottom of the original defect, i.e. at the 50% mark of the vertical extension of the defect, in relation to the width at the bottom of the defect amounted to 97% (SD 2%) for M + DBBM, 85% (SD 9%) for M, 42% (SD 41%) for DBBM, and 23% (SD 31%) for C. Assessment of bone density within the confinement of the regenerated bone resulted in an increase of 30% (SD 11%) for M + DBBM, 45% (SD 20%) for M, 33% (SD 20%) for DBBM, and 22% (SD 23%) for C. The values for graft to new bone contact within this compartment amounted to 80% (SD 15%) for M + DBBM and 89% (SD 14%) for DBBM. In conclusion, Bio-Oss exhibited osteoconductive properties and hence can be recommended for GBR procedures in dehiscence defects with respect to vertical and horizontal growth of bone.
Article
The American Society of Anesthesiologists (ASA) physical status classification system has previously been shown to be inconsistently applied by anaesthetists. One hundred and sixty questionnaires were sent out to all specialist anaesthetists in Hong Kong. Ten hypothetical patients, identical to those of a similar study undertaken 20 years ago, each with different types and degrees of physical disability were described. Respondents were asked about their country of training and type of anaesthetic practice and to assign an ASA classification status for each patient. Ninety-seven questionnaires were returned (61%) after two mailings. Agreement for each patient within groups, between groups and overall comparisons were made. Percentage of agreement was between 31 to 85%. Overall correlation was only fair in all groups (Kappa indices: 0.21–0.4). We found that the current pattern of inter-observer inconsistency of classification was similar to that 20 years ago and exaggerated between locally and overseas trained specialists (P<0.05). The validity of the ASA system, its usefulness and the need for a new, more precise scoring system is discussed.
Article
Of the various adverse outcomes that may be encountered following periodontal surgery, the risk of infection stands at the forefront of concern to the surgeon, since infection can lead to morbidity and poor healing outcomes. This paper describes a large-scale retrospective study of multiple surgical modalities in a diverse periodontal practice undertaken to explore the prevalence of clinical infections post-surgically and the relationship between diverse treatment variables and infection rates. A retrospective review of all available periodontal surgical records of patients treated in the Department of Periodontics at Wilford Hall Medical Center, San Antonio, Texas, was conducted. The sample comprised 395 patients and included 1,053 fully documented surgical procedures. Surgical techniques reviewed included osseous resective surgery, flap curettage, distal wedge procedures, gingivectomy, root resection, guided tissue regeneration, dental implant surgery, epithelialized free soft tissue autografts, subepithelial connective tissue autografts, coronally positioned flaps, sinus augmentations, and ridge preservation or augmentation procedures. Infection was defined as increasing and progressive swelling with the presence of suppuration. The impact of various treatment variables was examined including the use of bone grafts, membranes, soft tissue grafts, post-surgical chlorhexidine rinses, systemic antibiotics, and dressings. Results were analyzed using Fisher's exact test and Pearson's chi-square test. Of the 1,053 surgical procedures evaluated in this study, there were a total of 22 infections for an overall prevalence of 2.09%. Patients who received antibiotics as part of the surgical protocol (pre- and/ or post-surgically) developed eight infections in 281 procedures (2.85%) compared to 14 infections in 772 procedures (1.81%) where antibiotics were not used. Procedures in which chlorhexidine was used during post-surgical care had a lower infection rate (17 infections in 900 procedures, 1.89%) compared to procedures after which chlorhexidine was not used as part of post-surgical care (five infections in 153 procedures, 3.27%). The use of a post-surgical dressing demonstrated a slightly higher rate of infection (eight infections in 300 procedures, 2.67%) than non-use of a dressing (14 infections in 753 procedures, 1.86%). Despite these trends, no statistically significant relationship was found between post-surgical infection and any of the treatment variables examined, including the use of perioperative antibiotics. The results of this study confirm previous research demonstrating a low rate of postoperative infection following periodontal surgical procedures. Although perioperative antibiotics are commonly used when performing certain regenerative and implant surgical procedures, data from this and other studies suggest that there may be no benefit in using antibiotics for the sole purpose of preventing post-surgical infections. Further large-scale, controlled clinical studies are warranted to determine the role of perioperative antibiotics in the prevention of periodontal post-surgical infections.
Article
The aim of this study was to determine the current antimicrobial susceptibility of the principle anaerobic pathogens involved in dentoalveolar infection, to 13 oral antibiotics, and to assess the value of each antibiotic in the management of the infection. A total of 800 isolates from patients with dentoalveolar infection (Prevotella species, Fusobacterium species, Porphyromonas species and Peptostreptococcus micros) were tested for their susceptibility to amoxicillin, amoxicillin/clavulanate, cefaclor, cefuroxime, cefcapene, cefdinir, erythromycin, azithromycin, telithromycin, minocycline, levofloxacin, clindamycin, and metronidazole using an agar dilution method. Although the majority of Fusobacterium strains were resistant to erythromycin, azithromycin, and telithromycin, the remaining antibiotics demonstrated a high level of antimicrobial activity. P. micros and Porphyromonas species exhibited high susceptibility to all antibiotics tested in this study. In the case of Prevotella species, resistance to amoxicillin occurred in 34% of isolates and all of these resistant strains were found to produce beta-lactamase. Susceptibility of Prevotella strains to cefaclor, cefuroxime, cefcapene, cefdinir, erythromycin, azithromycin, and minocycline was found to correlate with amoxicillin susceptibility. Amoxicillin/clavulanate, telithromycin, clindamycin, and metronidazole exhibited high antimicrobial activity even against amoxicillin-resistant strains of Prevotella species. Amoxicillin would still be advocated therefore as being a suitable first-line agent, while reduced susceptibility of Prevotella strains remains a matter of concern with penicillins. Amoxicillin/clavulanate, clindamycin, and metronidazole are useful alternatives in combating the anaerobic bacteria involved in dentoalveolar infection.
Article
This randomized clinical trial compares the usefulness of pre- and post-operative antibiotics while strict asepsis was followed during periodontal surgery. Two groups of 40 consecutive patients each with fully or partially edentulous jaws were enrolled. Antibiotics group (GrAB(+)): 23 men, mean age 60, 128 implants, received oral amoxicillin 1 g, 1 h pre-operatively and 2 g for 2 days post-operatively. Non-antibiotics group (GrAB(-)): 20 men, mean age 57, 119 implants, received no antibiotics. Bacterial samples were taken from the peri-oral skin before and at the end of surgery. In 12 patients in each group, samples were also taken from the nares. A VAS questionnaire evaluated symptoms of infection/inflammation by both the patient and the periodontologist at suture removal. There were no significant differences between both groups, neither for the clinical parameters nor for the microbiota. Staphylococcus aureus was detected in the nares of one patient only. The patients' subjective perception of post-operative discomfort was significantly smaller in the group receiving antibiotics. Three patients lost one or two implants. Antibiotics do not provide significant advantages concerning post-operative infections in case of proper asepsis. It also does not reduce peri-oral microbial contamination. It does on the other hand reduce post-operative discomfort.
Article
The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997. and A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) with liaison members representing the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on IE. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization and bacteremia. The reference lists of the identified articles were also searched. The writing group also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The article subsequently was reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee. The major changes in the updated recommendations include the following. (1) The committee concluded that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective. (2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. (3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.
Article
Limited evidence exists on the significance of residual probing pocket depth (PPD) as a predictive parameter for periodontal disease progression and tooth loss. The aim of this study was to investigate the influence of residual PPD >or=5 mm and bleeding on probing (BOP) after active periodontal therapy (APT) on the progression of periodontitis and tooth loss. In this retrospective cohort, 172 patients were examined after APT and supportive periodontal therapy (SPT) for 3-27 years (mean 11.3 years). Analyses were conducted using information at site, tooth and patient levels. The association of risk factors with tooth loss and progression of periodontitis was investigated using multilevel logistic regression analysis. The number of residual PPD increased during SPT. Compared with PPD<or=3 mm, PPD=5 mm represented a risk factor for tooth loss with odds ratios of 5.8 and 7.7, respectively, at site and tooth levels. The corresponding odds ratios for PPD=6 mm were 9.3 and 11.0 and for PPD>or=7 mm 37.9 and 64.2, respectively. At patient level, heavy smoking, initial diagnosis, duration of SPT and PPD>or=6 mm were risk factors for disease progression, while PPD>or=6 mm and BOP>or=30% represented a risk for tooth loss. Residual PPD>or=6 mm represent an incomplete periodontal treatment outcome and require further therapy.
The SAC classification in implant dentistry
  • A Dawson
  • S Chen
  • D Buser
  • L Cordaro
  • W Martin
  • U Belser
Dawson, A., Chen, S., Buser, D., Cordaro, L., Martin, W., & Belser, U. (2009). The SAC classification in implant dentistry. Editors: Antony Dawson and Stephen Chen. Publisher: New Malden, Surrey, UK: Quintessence Publishing Co. Limited.