The purpose of the present systematic review and meta-analysis is to determine the efficacy of antibiotic prophylaxis and specific antibiotic regimens in dental implant placement for prevention of post-operative infection (POI) in overall healthy patients.
Materials and methods
Electronic database and manual searches were independently conducted to identify randomized controlled trials (RCTs). Publications were selected on basis of eligibility criteria and then assessed for risk-of-bias using the Cochrane Handbook. The primary outcome was POI (total, early, and late). Wound dehiscence, pain, and adverse events were studied as secondary outcomes. Random-effects meta-analysis was conducted for risk ratios of dichotomous data. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.
With duplicates removed, 1022 abstracts were screened and 22 full-text articles assessed; 10 RCTs of 1934 total patients were included. Meta-analysis did not detect statistically significant differences in total (P = 0.82), early (1–2 week post-op) (P = 0.57), or late (3–4 months post-op) (P = 0.66) POIs, wound dehiscence (P = 0.31), and adverse events (P = 0.21), between antibiotic and no-antibiotic groups. Confounding variables identified.
The results of this systematic review suggest that antibiotic prophylaxis may not be indicated for prevention of POIs following dental implant placement in overall healthy patients. These findings and in light of antibiotic-associated risks for individual and public health demand revaluation of routine prescription of antibiotic prophylaxis in dental implant placement procedures.
It is up to the clinicians to evaluate the benefits (or lack thereof) of antibiotic prophylaxis for each patient given medical history and surgical complexity, until new evidence becomes available.
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We are grateful to Mr. Richard McGowan (NYU Health Sciences Library liaison to the NYU Dentistry) for his assistance with the electronic database search process.
Our appreciation extends to Dr. Analia Vietz-Keenan (NYU Dentistry Department of Oral and Maxillofacial Pathology, Radiology, & Medicine) and Dr. Malvin N. Janal (NYU Dentistry Department of Epidemiology and Health Promotion) for sharing with us their expert opinions on evidence based dentistry and statistical analyses of results.
We thank fellow researchers, Dr. Eduardo Anitua, Dr. Alfonso Caiazzo, Dr. Khalid E. El-Kholey, Dr. Marco Esposito, and Dr. Ioannis Polyzois (Nolan 2012 group), for kindly providing clarification with regard to study design and/or results.
This systematic review received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors of this paper declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors. Ethical approval is not required.
For this type of study, formal consent is not required.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Appendix 1. Search protocol used in the systematic review
The following search terms, created by a medical-dental librarian, were used for database searches.
Keywords: endosseous implant OR endosseous implants OR dental implant OR dental implants OR dental implantation OR tooth implant OR tooth implants OR tooth implantation
Subject headings: PubMed and CINAHL: “dental implantation, endosseous”[MeSH Terms] OR “dental implantation”[MeSH Terms] OR “dental implants”[MeSH Terms]
EMBASE: tooth implant/ OR tooth implantation/(EMTREE)
DOSS: uses keywords only
Keywords: antibiotic OR antibiotics OR (antibiotic prophylaxis) OR (prophylactic antibiotic) OR (prophylactic antibiotics) OR (antibiotic regimen) OR (pre-operative antibiotic) OR (post-operative antibiotic) OR (postoperative antibiotic) OR (perioperative antibiotics) OR (systemic antibiotic) OR (infection prevention)
Subject headings: PubMed and CINAHL: “antibiotic prophylaxis”[MeSH Terms] OR “anti-bacterial agents”[MeSH Terms]
EMBASE: antibiotics prophylaxis/ (EMTREE)
DOSS: uses keywords only
Detailed search queries were as follows:
PubMed: (((“antibiotic”[All Fields] OR “antibiotics”[All Fields] OR “antibiotic prophylaxis”[MeSH Terms] OR (“antibiotic”[All Fields] AND “prophylaxis”[All Fields]) OR “antibiotic prophylaxis”[All Fields] OR (prophylactic[All Fields] AND “antibiotic”[All Fields]) OR (prophylactic[All Fields] AND “antibiotics”[All Fields]) OR (“antibiotic”[All Fields] AND “regimen”[All Fields]) OR (pre-operative[All Fields] AND “antibiotic”[All Fields]) OR (pre-operative[All Fields] AND “antibiotics”[All Fields]) OR ((“postoperative period”[MeSH Terms] OR “postoperative”[All Fields] OR “postoperative period”[All Fields] OR “post operative”[All Fields]) AND “antibiotic”[All Fields]) OR ((“postoperative period”[MeSH Terms] OR “postoperative”[All Fields] OR “postoperative period”[All Fields] OR “post operative”[All Fields]) AND “antibiotics”[All Fields]) OR (perioperative[All Fields] AND “antibiotic”[All Fields]) OR (perioperative[All Fields] AND “antibiotics”[All Fields]) OR (systemic[All Fields] AND “antibiotic”[All Fields]) OR (systemic[All Fields] AND “antibiotics”[All Fields]) OR ((“infection”[MeSH Terms] OR “infection”[All Fields]) AND (“prevention and control”[Subheading] OR “prevention and control”[All Fields] OR “prevention”[All Fields]))))) AND ((“dental implants”[MeSH Terms] OR (“dental”[All Fields] AND “implants”[All Fields]) OR “dental implants”[All Fields] OR (“dental”[All Fields] AND “implant”[All Fields]) OR “dental implant”[All Fields] OR “dental implantation”[MeSH Terms] OR (“dental”[All Fields] AND “implantation”[All Fields]) OR “dental implantation”[All Fields] OR ((“tooth”[MeSH Terms] OR “tooth”[All Fields]) AND implant[All Fields]) OR ((“tooth”[MeSH Terms] OR “tooth”[All Fields]) AND implants[All Fields]) OR ((“tooth”[MeSH Terms] OR “tooth”[All Fields]) AND “implantation”[All Fields]) OR (endosseous[All Fields] AND implant[All Fields]) OR “endosseous implant”[All Fields] OR (“endosseous”[All Fields] AND “implants”[All Fields]) OR “endosseous implants”[All Fields] OR “dental implantation, endosseous”[MeSH Terms] OR “endosseous dental implantation”[All Fields]))
CINAHL: ((MH “Antibiotic Prophylaxis” OR MH “Antibiotics” OR Antibiotic OR antibiotics OR (antibiotic prophylaxis) OR (prophylactic antibiotic) OR (prophylactic antibiotics) OR (antibiotic regimen) OR (pre-operative antibiotic) OR (post-operative antibiotic) OR (postoperative antibiotic) OR (perioperative antibiotics) OR (systemic antibiotic) OR (infection prevention)) AND (endosseous implant OR endosseous implants OR dental implant OR dental implants OR dental implantation OR tooth implant OR tooth implants OR Tooth implantation OR MH “Dental Implants” OR MH “Dental Implantation”)
DOSS: (((Antibiotic OR antibiotics OR (antibiotic prophylaxis) OR (prophylactic antibiotic) OR (prophylactic antibiotics) OR (antibiotic regimen) OR (pre-operative antibiotic) OR (post-operative antibiotic) OR (postoperative antibiotic) OR (perioperative antibiotics) OR (systemic antibiotic) OR (infection prevention))) AND ((endosseous implant OR endosseous implants OR dental implant OR dental implants OR dental implantation OR tooth implant OR tooth implants OR Tooth implantation))
EMBASE: (exp antibiotic prophylaxis/ OR (Antibiotic OR antibiotics OR (antibiotic prophylaxis) OR (prophylactic antibiotic) OR (prophylactic antibiotics) OR (antibiotic regimen) OR (pre-operative antibiotic) OR (post-operative antibiotic) OR (postoperative antibiotic) OR (perioperative antibiotics) OR (systemic antibiotic) OR (infection prevention)).mp.)
AND (exp tooth implant/ OR exp. tooth implantation/ OR (endosseous implant or endosseous implants or dental implant or dental implants or dental implantation or tooth implant or tooth implants or Tooth implantation).mp.)
Appendix 2. Journals included in handsearch
The journals included in handsearch were as follows:
International Journal of Oral and Maxillofacial Implants, European Journal of Oral Implantology, Clinical Oral Implants Research, International Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology, International Journal of Oral and Maxillofacial Surgery Clinical Implant Dentistry and Related Research, Dental Clinics of North America, Journal of Prosthetic Dentistry, Journal of Clinical Periodontology, Journal of Oral Implantology, Journal of Craniofacial Surgery, Journal of Periodontology, Journal of Cranio-Maxillofacial Surgery.
Appendix 3. Extracted information on study characteristics
Extracted information on study characteristics included publication details (author(s), year of publication), trial study design/study design, source of funding, conflict of interest, study period, and location. Treatment group characteristics included the study group intervention (prophylactic antibiotic compound, dosage, and duration of treatment), comparative treatment (placebo or another prophylactic antibiotic with specification of regimen), number of patients and implants, mean age/range, number of females and males, and patient dental and medical history (periodontitis, smoking, diabetes). Treatment/surgical protocols specified additional protocol measures (administration of chlorohexidine, dexamethasone, etc.), implant placement stages (one or two stages), bone graft/graft type, implant platform, and healing/loading protocol. Study outcomes included a summary of outcomes assessed, follow-up times, and study conclusions as well as quantitative results for outcomes assessed: post-operative infection (total, early, and late infections), wound dehiscence, pain, and adverse events. All outcomes were reported in terms of patient number or as reported in the publications if patient number could not be obtained (e.g., pain was often recorded as a mean VAS score). Extracted data were categorized on the basis of antibiotic prophylaxis regimens: administration of only pre-operative antibiotics, pre- and post-operative antibiotics, only post-operative antibiotics, and no antibiotics and respective antibiotic dosage for each regimen.
Reported on page no.
Identify the report as a systematic review, meta-analysis, or both.
Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.
Describe the rationale for the review in the context of what is already known.
Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
Protocol and registration
Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.
Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).
Data collection process
Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.
List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
Risk of bias in individual studies
Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.
State the principal summary measures (e.g., risk ratio, difference in means).
Synthesis of results
Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis.
Risk of bias across studies
Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).
Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.
Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
Risk of bias within studies
Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).
Results of individual studies
For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
Synthesis of results
Present results of each meta-analysis done, including confidence intervals and measures of consistency.
Risk of bias across studies
Present results of any assessment of risk of bias across studies (see Item 15).
Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).
Summary of evidence
Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).
Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).
Provide a general interpretation of the results in the context of other evidence, and implications for future research.
Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.
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Khouly, I., Braun, R.S. & Chambrone, L. Antibiotic prophylaxis may not be indicated for prevention of dental implant infections in healthy patients. A systematic review and meta-analysis. Clin Oral Invest 23, 1525–1553 (2019). https://doi.org/10.1007/s00784-018-2762-x
- Antibiotic prophylaxis
- Dental implants
- Post-operative infection