Abstract
Background and Objectives:
Antimicrobial resistance is a grave public health concern, and it is important to optimize the use of antimicrobials in dental surgeries. Antimicrobial prescriptions in dental implant placements are often empiric and not guided by consensus or specific guidelines. The aim of this study was to elucidate antibiotic prescribing patterns among oral implantologists. The objectives were to identify the frequency of antimicrobial usage and preferences regarding the perioperative timing of prescriptions, type of antibiotic, dosage, and duration in different implant placement scenarios.
Subjects and Methods:
An anonymized web-based survey was carried out. Participants were drawn from the lists of oral implantologists from all local branches of the Indian Dental Association in the state of Kerala, India, until the required sample size was met. Responses were recorded using an Internet-based validated questionnaire sent via e-mail to the participants. The questionnaire contained five sections with both open-ended and closed-ended questions.
Results:
Among the 93 participants, 59% of the dental implantologists preferred 0.2% povidone-iodine as a preprocedural mouth rinse in the backdrop of the COVID-19 pandemic, and 68% prescribed 0.12%–0.2% chlorhexidine as the postoperative mouth rinse. The majority of the participants (73%) routinely prescribed systemic antibiotics perioperatively during implant placement surgery. Interestingly, while none of the participants preferred a solely preoperative regimen, 92.4% of the dentists in our survey prescribed both pre- and postoperative antibiotics. Antibiotics of choice as the preoperative agents were amoxicillin and amoxicillin plus clavulanic acid. The most preferred postoperative agent was amoxicillin plus clavulanic acid. The popularly reported rationale behind a preoperative antibiotic was to decrease or eliminate local or systemic infections (79%), and the majority of the participants (60%) prescribed postoperative antibiotics to prevent postoperative infection.
Conclusions:
Systemic antibiotic prescriptions in implant placement surgery are not based on currently available evidence. Most oral implantologists who participated in the survey prescribed systemic antibiotics to prevent perioperative infection, even in simple and straightforward implant placements. Specific guidelines need to be generated in complex implant placement situations and implant placement in medically compromised patients to prevent excessive prescriptions.
KEYWORDS: Antimicrobials, dental implants, prescriptions
INTRODUCTION
The predictability and success of dental implants are sometimes jeopardized by biological complications leading to implant failure. Esposito et al. reported that infections around implants constitute a significant cause of biologic failures and current evidence points out that prophylactic antibiotics can reduce implant failure rates.[1,2,3,4,5] A “prophylactic” antibiotic is prescribed to prevent infection when it is not present in contrast to a “therapeutic” course prescribed to treat an existing infection.[6] A sound biologic rationale necessitating antibiotics perioperatively in dental implant placement is inconclusive, and often, a “prophylactic” perioperative antimicrobial agent is prescribed to prevent infection.[7]
Systemic antibiotics have been prescribed generously/injudiciously in developing countries, often based on one's knowledge and own experience rather than being evidence based. This has led to the emergence of antibiotic resistance that poses a grave public health concern.[8,9] According to the various sources, in India, this resistance is attributed to the combination of features such as uncontrolled access to antibiotics, gaps in infection prevention and control practices, the “to be sure” attitude of both physician and patient,[10] and high rates of communicable diseases.[10,11]
Dental implant situations can vary from direct placements in healed residual ridges to more complex situations necessitating prolonged duration of surgery, extensive tissue reflections, use of regenerative materials, and sinus lift procedures. Furthermore, the implant recipient may range from the systemically healthy young patient to an aged patient with significant medical compromise. Although systematic reviews and consensus reports in this domain advocate the use of a single dose of 3 or 2 g[4,5,6] of amoxicillin, 1 h prior to the procedure to reduce early implant failures in simple and straightforward implant placements in healed ridges, there is a paucity of guidelines/consensus regarding antibiotic protocols in complex situations and the medically compromised.[12]
Several cross-sectional surveys have shed light on the antimicrobial prescription trends among oral implantologists across the globe.[13,14,15,16,17,18,19] However, the overall evidence regarding the current antimicrobial prescription pattern among dentists performing implant surgeries in India is very scanty.[20] Kerala is the southernmost state of India state with the highest literacy rate and health index.[21] The objective of our web-based cross-sectional survey was to identify the prescribing patterns of antimicrobials perioperatively in implant placement surgery with respect to the timing of drug administration, antibiotic type, dosage, and duration among oral implantologists of Kerala.
SUBJECTS AND METHODS
Study design
An observational cross-sectional design was used in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. The study questionnaire was prepared using Google Sheets after ensuring face and content validity by three experts. The survey was carried out after attaining consent from the institutional review board – No: 11/22/2020.
Study tool
The questionnaire was divided into five sections. The first section had questions regarding the age group, gender, years of practice, type of practice (independent practice/consultant/hospital attached/attached to a teaching facility), preference of pre- and postoperative mouth rinse, frequency of antibiotic prescriptions, and preferred route of administration. Four different case scenarios in ascending order of complexity were presented.[7] The first case scenario was simple implant placement in a systemically healthy patient, the second scenario was immediate implant placement and the use of bone grafts/or membranes in a healthy patient, the third scenario described was that of complex implant surgical procedures which extended for more than 3 h and involved extensive tissue reflection and the use of autogenous bone block grafts and sinus lift procedures in a systemically healthy patient, and the fourth case scenario was same as case scenario 3 in a medically compromised patient. In the abovementioned situations, respondents were asked to indicate their preferred antibiotic regimen (no antibiotic/only preoperative antibiotics/only postoperative antibiotic/both pre- and postoperative antibiotics). The last question in section 1 was a section-based response. Based on the questionnaire developed by Deeb et al.,[15] respondents who preferred to prescribe a preoperative antibiotic 1–2 days prior to implant placement surgery went to section 2 to answer questions on their most preferred preoperative agent, its dosage (In milligrams or grams), and duration. Those respondents who preferred to prescribe a single preoperative dose went to section 3, where they gave responses regarding their preferred antibiotics, their dosage, and duration. The rationale for preoperative antibiotics was also sought. Respondents who prescribed postoperative antibiotics only went on to section 4 of the questionnaire to choose their preferred antibiotic type, dosage, and duration. Those respondents who did not prefer to give a postoperative antibiotic were directed to section 5 of the questionnaire, which included questions regarding the incidence of adverse effects to the antibiotics and the most crucial concern of the dentist when prescribing medication.
Sample size calculation
The study sample size was determined using a commercial software (nMaster). The proportion of dentists who prescribed antibiotics in implant surgical procedures was 72% from a previous representative study, and was used as inputs for the formula n = 4pq/d2.[22] The final sample size was fixed at n = 90 after accounting for absolute precision of 10% and a nonresponse rate of 20%.
Data collection
A list of implantologists were obtained from the registry of the 25 local branches of the Indian Dental Association in the state of Kerala. The officiating secretaries of these branches were contacted to obtain this sampling frame. Ensuring equal representation from each local branch across the state, samples were drawn by lottery method until the required sample size was reached (n = 90). The questionnaire was e-mailed to the enlisted participants along with a brief description of the methods and a request for their consent to participate in the study. The responses were automatically recoded into the digital database and were available as spreadsheets.
Statistical analysis
The data were available for download as spreadsheets. Nominal and ordinal variables were coded appropriately and imported to IBM-SPSS Statistics for Windows (IBM-SPSS Version 27.0. IBM Corp., Armonk, NY.). Counts and proportion were used to summarize qualitative variables. A Chi-square test was done to analyze differences in prescription patterns between types of practice and years of experience. P < 0.05 was considered statistically significant.
RESULTS
Sixty percent of the survey participants were male dentists. Thirty-three percent of the respondents were in the 31–40 years' age group and 30% in the 41–50 years' group. While 46% were attached to a teaching facility, 30% were practicing in their own clinics. A smaller fraction was attached to a hospital (15%), and a few of them were visiting consultants. Around one-third of them (33%) had more than 10 years of experience in implant dentistry. Povidone-iodine was the most preferred (59%) preprocedural mouth rinse in the backdrop of the COVID-19 pandemic, and 68% prescribed 0.12%–0.2% chlorhexidine as the postoperative mouth rinse [Figures 1 and 2].
Figure 1.
Preprocedural mouth rinse preferences in implant placement surgery
Figure 2.
Postoperative mouth rinse preferences following implant placement
All the study participants preferred an oral route of administration of perioperative antibiotics in their implant surgeries, and 73% routinely prescribed systemic antibiotics during implant placement surgery [Figure 3]. A combination of pre- and postoperative antibiotics was prevalent among the study participants (92.4%), and 7.5% prescribed only a postoperative agent. Interestingly, none of the participants prescribed only a preoperative antibiotic [Table 1 and Figure 4].
Figure 3.
Frequency of systemic antibiotic prescriptions for implant placement
Table 1.
Perioperative timing of antibiotic prescriptions
| Pre/postoperative | n (%) |
|---|---|
| Pre- and postoperative | 86 (92.4) |
| Postoperative only | 7 (7.5) |
| Preoperative only | 0 |
Figure 4.
Preferences in perioperative timing of antibiotics in implant placement surgery
When antibiotic prescribing practices for the systemically healthy patients were analyzed (case scenarios 1, 2, and 3), 23.7% of the respondents did not prescribe antibiotics in simple implant placement cases. However, 97% prescribed antibiotics in immediate implant placements (case scenario 2), and 99% prescribed antibiotics in complex implant placement situations (case scenario 3) [Table 2].
Table 2.
Antibiotic prescriptions in systemically healthy patients
| Case scenario | Prescribe antibiotics | |
|---|---|---|
|
| ||
| Yes, n (%) | No, n (%) | |
| Simple implant placement | 71 (76.3) | 22 (23.7) |
| Immediate implant placement | 90 (96.77) | 3 (3.23) |
| Complex implant placement | 92 (98.92) | 1 (1.08) |
The most preferred preoperative agent was amoxicillin plus clavulanic acid 625 mg three times daily [Table 3]. For respondents who prescribed a single preoperative dose, the most common prescription pattern was a single preoperative dose of 500 mg of amoxicillin. The most frequent rationale for using a preoperative agent was to decrease or eliminate local or systemic infections.
Table 3.
Dosage preferences of systemic antibiotics
| Drugs | Amoxicillin | Amoxicillin and clavulanic acid | Amoxicillin and metronidazole | ||||
|---|---|---|---|---|---|---|---|
|
|
|
|
|||||
| 500 mg, n (%) | 1 g, n (%) | 2 g, n (%) | 625 mg, n (%) | Others, n (%) | 500 mg and 400 mg, n (%) | 250 mg and 200 mg, n (%) | |
| Preoperative | 19 (51.3) | 15 (40.5) | 3 (8.2) | 31 (86.1) | 5 (13.9) | 23 (88.5) | 3 (11.5) |
| Postoperative | 65 (97) | 2 (3) | 0 | 70 (97.2) | 2 (2.8) | 43 (91.5) | 4 (8.5) |
A large majority of respondents (79%) who prescribed a postoperative antibiotic preferred to prescribe the antibiotic for 5 days postoperatively [Figure 5]. The most preferred postoperative agent was amoxicillin plus clavulanic acid 625 mg [Table 3]. According to the participants, the most common rationale (60%) for postoperative antibiotics was to prevent infection.
Figure 5.
Preferences in duration of postoperative antibiotics following implant placement
The predominant guidance among participants for their antibiotic prescription practices was from previous clinical experience (39%) from faculty who imparted implantology training (34%), and around 25% of the respondents opined that they followed guidelines from the current literature [Figure 6]. A majority (81%) ensured patient adherence/compliance to their prescriptions. Adverse reactions to antimicrobials were very rare/never encountered. The most frequent concern among dentists (46.2%) when prescribing antibiotics was the probable allergic reactions the patient may develop. The development of antibiotic-resistant strains was another worrying concern among the respondents (30%).
Figure 6.
Knowledge guidance underlying antibiotic prescribing practices in implant placement
There was no statistically significant association between years of experience and antibiotic prescription patterns [Table 4a and b]. The survey also did not reveal any significant association between the type of practice and antibiotic prescribing habits.
Table 4a.
Years of experience and antibiotic prescribing patterns
| Experience (years) | Do you prescribe systemic antibiotics for implant placement surgery?, count (% within experience) | Total | ||
|---|---|---|---|---|
|
| ||||
| 1 | 2 | 3 | ||
| <5 | 27 (75.0) | 8 (22.2) | 1 (2.8) | 36 (100.0) |
| >5 | 41 (71.9) | 12 (21.1) | 4 (7.0) | 57 (100.0) |
| Total | 68 (73.1) | 20 (21.5) | 5 (5.4) | 93 (100.0) |
Table 4b.
Chi-square tests
| Value | df | Asymptotic significance (two-sided) | |
|---|---|---|---|
| Pearson χ2 | 0.780a | 2 | 0.677 |
| Likelihood ratio | 0.853 | 2 | 0.653 |
| Linear-by-linear association | 0.358 | 1 | 0.550 |
| Number of valid cases | 93 |
a 2 cells (33.3%) have expected count <5. The minimum expected count is 1.94
DISCUSSION
This anonymized web-based survey was carried out to study the antibiotic prescribing patterns among oral implantologists in the state of Kerala, India. The study stemmed from a deficit in guidelines and consensus in the body of evidence regarding the use of antimicrobials perioperatively in implant placement surgery. The study was conducted in Kerala, the southernmost state of India, much acclaimed for its health care and literacy.[21]
The response rate to the survey was good, and the high response rate was achieved by a second reminder e-mail. The most preferred preoperative and postoperative mouth rinses were 0.2% povidone-iodine and 0.12%–0.2% chlorhexidine, respectively. The choices of antimicrobial mouth rinses of our study participants are in accordance with current recommendations.[6] The choice of 0.2% povidone-iodine as a preoperative mouth rinse has been underlined in the COVID-19 prevention protocols.[23]
Seventy-three percent of the participants in our study routinely prescribed systemic antibiotics in implant surgery. These findings are comparable to those seen in cross-sectional studies done in the United Kingdom (72%) and Sweden (74%).[14,17] Only a much smaller proportion of dentists prescribed antibiotics regularly for implant placement surgeries in survey results reported from Jordan[13] (49.4%) and The Netherlands (43.7%).[19] The proportion of dentists who prescribed antibiotics routinely for implant placement surgery in Spain (88%) was higher when compared to our study results.[16]
The majority of the respondents prescribed both pre- and postoperative antibiotics, while a small fraction prescribed only postoperative antibiotics. It was interesting to observe that none of our participants restricted their prescriptions to a single preoperative dose. Currently available guidelines only recommend a single preoperative dose in straightforward implant placement surgeries performed on an intact and adequate alveolar ridge.[4,5,6] These prescribing patterns point out excessive antibiotic usage, especially in simple straightforward cases in systemically healthy individuals. A small percentage of participants did not prescribe any antibiotics in simple implant placement situations (case scenario 1).
According to the current evidence and literature, penicillin should be the agent of choice, and the same was observed in our survey results.[24] The most prescribed antibiotic types as preoperative agents were amoxicillin plus clavulanic acid 625 mg thrice daily (when administered 1–2 days prior) and amoxicillin 500 mg (as a single preoperative dose). Most of the participants who preferred to prescribe a preoperative agent prescribed a single preoperative dose. The most commonly followed pattern of postoperative prescription was 625 mg of amoxicillin plus clavulanic acid three times daily for 5 days. The rationale behind the addition of clavulanic acid to amoxicillin may have been to combat beta-lactamase-producing strains and broaden the spectrum, but this choice is fraught with criticism.[25]
Prevention of local/systemic infection was the rationale behind antibiotic prescriptions among our respondents. A significant proportion of the dentists had based their prescribing patterns on previous experiences, while currently available guidelines have guided a small percentage of them. Many of our participants had not encountered adverse events, and participants were most concerned about allergic reactions. A smaller proportion was concerned about the emergence of drug-resistant strains. In our survey, participants were presented with four case scenarios in ascending grades of the complexity of implant placement situations. While case scenarios 1, 2, and 3 were in the systemically healthy patient, case scenario 4 was complex implant placement in the medically compromised patient. Our division into case scenarios was partially based on the categorization by Resnik and Misch.[7] According to their recommendation, case scenario 1 needs only a 0.12% chlorhexidine mouth rinse both pre- and postoperatively. In case scenario 2, they have recommended a single preoperative dose of 1-g amoxicillin 1 h prior to the procedure followed by a single postoperative dose of 500 mg amoxicillin 6 h later. Their recommendation for case scenario 3 is the same as in case scenario 2, plus the extension of postoperative antibiotic for 3 days. In the medically compromised patient who needs a complex procedure, the group recommended continuing the postoperative amoxicillin for 5 days.
A recent randomized controlled clinical trial reported that systemic antibiotics in conjunction with guided bone regenerative techniques did not provide any beneficial effects either on patient-reported outcome measures or the prevention of adverse postsurgical sequelae.[26]
Exposure to broad-spectrum antibiotics dramatically alters the composition of the human gut microbiome.[27,28] These changes may persist for years, and there is growing evidence that many chronic diseases may be linked to dysbiosis of the intestinal microbiota.[29] The only previous study available from India[20] in this domain reported that 85.5% of their respondents routinely prescribed perioperative antibiotics in implant placement surgeries in healthy patients and the most preferred agent of choice was amoxicillin plus clavulanic acid. The authors have also reported an overuse of antibiotics among their study participants.
Antibiotic stewardship encompassing the complexity of implant surgical procedures, systemic status of the patient, general health, and ethnic variations will prevent the excessive/inappropriate use of antimicrobials in implant placements. This study highlights the need for a consensus, especially regarding complex implant placement situations and in the medically compromised. Our survey had few limitations. The site of implant insertion was not addressed in our study questionnaire. As this study was a web-based survey, the responses were largely dependent on the attitude of the respondents. Whether the responses attained in the survey actually translate to clinical situations could not be assessed.
Elderly adults with comorbidities are frequently in need of dental implants. COVID-19 pandemic has underlined to the scientific community the paramount importance of maintaining the homeostasis of the human microbiome. Considering the growing global concern of antimicrobial resistance and the importance of being an immunocompetent population, it is vital to make a risk versus benefit analysis before antibiotic prescriptions.[30] Excessive use of antibiotics could also lead to opportunistic infections like mucormycosis.
CONCLUSIONS
Majority of our survey participants routinely prescribed perioperative antimicrobials in implant placement surgery. The prescriptions of antimicrobial mouth rinses are in accordance with current recommendations. Most of the dentists prescribed both pre- and postoperative antibiotics. The most preferred agent was amoxicillin plus clavulanic acid. A tendency to overprescribe antibiotics in order to prevent/reduce postoperative complications was evident in the survey. Lack of adherence to guidelines from the currently available evidence was also observed. Specific guidelines and antibiotic policies need to be laid, especially in complex implant placement situations and in the dental implant recipient with systemic comorbidities.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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