Prophylactic Antibiotic Regimens in Oral

Implantology: Rationale and Protocol

Randolph R. Resnik, DMD, MDS,* and Carl Misch, DDS, MDS
P
ostoperative wound infections
may have a significant impact on
the success of dental implants and
bone grafting procedures. The occur-
rence of surgical wound infection re-
quires local inoculums to overcome host
defenses and allow an environment that
is conducive for bacterial growth. This
process is very complex with interac-
tions of host, local tissue, systemic and
microbial virulence factors. Various
measures attempt to minimize infection
by modifying the host and local tissue
factors. Such measures include control
of the operating room environment, pa-
tient selection, aseptic protocol, and the
surgical technique. The use of antimi-
crobials has also been shown to be sig-
nificant in reducing postoperative
wound infections.
14
The scope of implant treatment
encompasses an increasing older pop-
ulation with more complex cases, so
that a greater understanding of com-
promised wound healing and inade-
quate immune systems is of benefit.
The dental practitioner should have a
thorough understanding of the indica-
tions and protocol for the use of anti-
microbials in implant dentistry. The
morbidity of implant related compli-
cations may be reduced with the ideal
selection and sufficient dosage levels
of medications.
There is no current accepted phar-
macologic protocol for dental im-
plants, based on both the patients
health status and procedure type.
Many practitioners prescribe medica-
tions empirically or generically with
respect to all implant procedures. The
understanding and use of the various
antibiotic regimens is beneficial for
both the success and maintenance of
dental implants. Antibiotic therapy in
implant dentistry may be classified as
either prophylactic (to prevent infec-
tion) or therapeutic (to treat infection).
This article provides the dentist with
an overview of the pharmacokinetics
and pharmacodynamics of various an-
timicrobials and a prophylactic protocol
based on varying patient and proce-
dure characteristics.
ANTIMICROBIALS
One of the most important compli-
cations that requires prevention after im-
plant surgery is infection. Infection can
lead to a multitude of problems ranging
from pain and swelling, bone loss, and
implant failure. Because of the morbid-
ity of infections, antimicrobial therapy is
an essential component of the surgical
protocol. Although adverse effects are
sometimes associated with antimicrobial
therapy, these are usually mild and
rarely life-threatening. The most com-
mon antimicrobials used in implant den-
tistry consist of antibiotics (local and
systemic) and antimicrobial rinses
(0.12% chlorhexidine gluconate).
PROPHYLACTIC ANTIBIOTICS
In general surgery and its subspe-
cialties, the principles of antibiotic
prophylaxis are well established.
These guidelines specifically relate the
procedure, the type of antibiotic, and
the dosage regimen.
5,6
The use of pro-
phylactic antibiotics in dentistry has
been documented to prevent compli-
cations in patients who are at risk of
developing infectious endocarditis and
immunocompromised patients.
7
In
oral implantology, however, there ex-
ists no general consensus on the use
and indications for prophylactic anti-
biotics. Antibiotic selection, dosage
and duration of coverage for this pop-
ulation is variable and some authors
avoid its routine use.
8
The numerous
disadvantages of the use of antibiotics
that have been documented include the
development of resistant bacteria, sec-
ondary infections, toxicity of antibiot-
ics, adverse reactions, and possible
poor surgical technique.
9,10
A number of studies have docu-
mented the benefit of preoperative anti-
*Clinical Professor, Department of Periodontology and Implant
Dentistry, Temple Dental School, Philadelphia, PA.
**Professor and Director Oral Implantology, Department of
Periodontology and Implant Dentistry, Temple Dental School,
Philadelphia, PA.
ISSN 1056-6163/08/01702-142
Implant Dentistry
Volume 17 Number 2
Copyright 2008 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e3181752b09
The use of antimicrobials re-
duces the incidence of surgical
wound infection in oral implantol-
ogy. Antimicrobial prophylaxis is
indicated in all Class 2 (clean-
contaminated) surgical procedures,
which include sufficient blood levels
at the time of bacterial contamina-
tion of dental implant and bone graft
procedures. Timing and dosage are
critical to the efficacy of antibiotics.
Antibiotic selection is determined mainly
by the bacteria which is most likely to
cause an infection fromthe specific pro-
cedure. The authors have developed a
classification and protocol that allows
the dental practitioner to properly pre-
scribe medication based on procedural,
local host and systemic factors. (Implant
Dent 2008;17:142150)
Key Words: dental implants, antibiotic
prophylaxis, surgical wound infection,
pharmacologic protocol, risk factors
142 PROPHYLACTIC ANTIBIOTIC REGIMENS IN ORAL IMPLANTOLOGY
biotics for dental implantology.
3,11,12
The
most comprehensive and controlled
study to date related to antibiotics and
implants is from the Dental Implant
Clinical Research Group.
3,11
Data from
2973 implants were evaluated and cor-
related with integration failure at different
time periods; initial healing, at surgi-
cal uncovering, before loading the
prosthesis, and from prosthesis loading
to 36 months. A significant difference
was found with the use of preoperative
antibiotics (4.6%failure) compared with
no antibiotics (10% failure), both in the
initial healing and surgical uncovery of
the implants.
The main goal of prophylactic an-
tibiotic use is to prevent infection from
the surgical wound site, thus decreasing
the chance of infectious complications
and insufficient integration. Although
there is no conclusive evidence on the
mechanism of how preoperative anti-
biotics work, most likely a greater
aseptic local environment is achieved.
A landmark study by Burke
13
in 1961
defined the scientific basis for the
perioperative use of antibiotics to pre-
vent surgical wound infection. From
this work and others, several impor-
tant and well accepted principles have
been established regarding the prophy-
lactic use of antibiotics.
1
Principle 1: Incidence of Infection
A classification of operative
wounds and risk of infection was de-
veloped by the American College of
Surgeons Committee on Control of
Surgical Infections.
13,14
To evaluate
the risk for postoperative wound infection,
all surgical procedures were classified
according to 4 levels of contamination
and infection rates (Table 1).
Class 1 (clean surgical procedures)
are least likely to have a post operative
infection. Class 4 (dirty/infected surgi-
cal sites) are most at risk for infection.
Class 2 medical and dental surgical pro-
cedures have been shown to have an
infection rate of 10% to 15%. By defi-
nition, elective dental implant surgery
and bone grafting procedures fall within
the Class 2 (clean-contaminated) cate-
gory. However, with proper surgical
technique and prophylactic antibiotics,
the incidence of infection may be re-
duced to 1%.
15,16
In a healthy patient, risk of infec-
tion after dental implant surgery is in-
fluenced by numerous factors includ-
ing the type, location and duration of
surgery, skill of the surgeon, methods
of intraoperative management, patient
factors, and aseptic technique.
16,17
In
addition, patient related (systemic and
local) risk factors are also important
and correlated with increased suscep-
tibility to infection. Therefore, these
factors should also be considered
when developing a protocol for the use
and duration of antibiotic prophylaxis
(Table 2).
Various routes of virulent bacteria
transmission include (1) direct contact
with the patients blood or other body
fluids; (2) indirect contact with contam-
inated objects; (3) contact with infected
nasal, sinus or oral mucosa; and (4) in-
halation of airborne microorganisms.
21
For ideal conditions to prevent infection,
a controlled, well-monitored aseptic sur-
gical setting is beneficial. The aseptic
component includes proper disinfection
and draping procedures of the patient,
hand scrubbing, sterile gowns worn by
all surgical members and sterility of
instrumentation.
22
Another surgical factor related to
postoperative infections is the dura-
tion of the surgical procedure. This
factor may be the second most critical
risk factor (behind wound contamina-
tion) for causing postoperative infec-
tions.
23
Surgical operations lasting less
than 1 hour have been shown to have
an infection rate of 1.3%, whereas
those lasting 3 hours increase the rate
to over 4.0%.
24,25
The rate of infection
may double with every hour of the
procedure.
9,10
The skill and the experience of the
surgeon during the placement of im-
plants have also been shown to be
significant in postoperative infec-
tions and implant failures. Less ex-
perienced dentists (50 implants
placed) have a 7.3% increase in fail-
ure rates, compared with less than
2% for experienced surgeons.
11
A
factor in the less experienced dentist
which may contribute to this higher
failure rate is the longer duration of
the implant surgery.
The insertion of any medical pros-
thetic implant or device increases the
chance of infection at the surgical
site. An implant placed into the hard
or soft tissue may act as a foreign
body and the hosts defenses may be
compromised. In addition, the sur-
face of an implant may facilitate
bacterial adherence and the presence
of an implant may also compromise
blood supply to the region and affect
the hosts defenses. This may result
in normal bacterial flora with low
virulence potential to cause infec-
tions at the implant-host interface,
which are difficult to remedy.
2628
Table 1. Surgical Wound
Classification With Associated
Infection Rates
15,16
Class 1: Clean (2%)
Elective, nontraumatic surgery,
no acute inflammation, respira-
tory, gastrointestinal, and biliary
tracts not entered
Class 2: Clean-Contaminated
(10%15%)
Elective opening of the respira-
tory, gastrointestinal, and biliary
tracts entered
Elective dental implant and bone
graft procedures
Class 3: Contaminated (20%30%)
Inflammation, gross spillage from
gastrointestinal and biliary
tracts along with fresh trau-
matic injuries
Class 4: Dirty/Infected (50%)
Established clinical infection, per-
foration of respiratory, gastroin-
testinal, and biliary tracts
Table 2. Factors Associated With
Increased Risk of Infection
15,1821
Systemic factors
Diabetes
Long term corticosteroid use
Smoking
Immunocompromised systemic
disorders
Malnutrition obesity
Elderly population
ASA3 or ASA4
Local factors
Use/type of grafting material (au-
togenous, allograft, alloplast)
Periodontal disease
Tissue inflammation
Odontogenic infections
Ill-fitting provisional prosthesis
Incision line opening
Inadequate hygiene
Surgical factors
Poor aseptic technique
Skill/experience of the surgeon
Increased duration of surgery
Wound contamination during surgery
Foreign body (implant)
IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 143
Principle 2: Appropriate Antibiotic
The antibiotic chosen should be ef-
fective against the bacteria that are most
likely to cause the infection. In the ma-
jority of cases, infections after surgery
are from organisms that originate from
the site of surgery.
13
For example, most
postoperative infections after transoral
surgery are caused by endogenous bac-
teria including aerobic Gram-positive
cocci (streptococci), anaerobic Gram-
positive cocci (peptococci), and anaero-
bic Gram-negative rods (bacteroides).
1
Although oral infections are mixed in-
fections in which anaerobes out number
aerobes 2:1, it has been shown that
anaerobes need the aerobes to provide
an environment to proliferate.
29
The
early phase of intraoral infections involve
aerobic streptococci which prepare the
environment for subsequent anaerobic
invasion.
30,31
With that in mind, the
ideal antibiotic must be effective
against both of these pathogens.
Another factor in selecting an an-
tibiotic is to use a drug with the least
amount of adverse side effects. These
effects may vary from mild nausea to
the extreme allergic reaction (anaphy-
laxis). In addition, the antibiotic should
be bactericidal. Bacteriostatic antibiotics
work by inhibiting growth and repro-
duction of bacteria, thus allowing the
host defenses to eliminate the resultant
bacteria. However, if the hosts defenses
are compromised in any way, the bacte-
ria and infection may flourish. Bacteri-
cidal antibiotics are advantageous over
bacteriostatic antibiotics in that (1) there
is less reliance on host resistance, (2) the
bacteria may be destroyed by the antibiotic
alone, (3) faster results occur com-
pared with bacteriostatic medications,
and (4) there is greater flexibility with
dosage intervals.
15
Principle 3: Tissue Concentration
The minimum inhibitory concentra-
tion is the lowest antibiotic concentration
needed to destroy a specific bacteria. A
sufficient tissue concentration of antibi-
otic should be present at the time of
bacterial invasion. To accomplish this
goal, the antibiotic must be given in a
dose that will reach plasma levels that
are 3-to-4 times the minimum inhibitory
concentration of the expected bacteria.
32
It has been shown that normal therapeu-
tic blood levels are ineffective to coun-
teract bacterial invasion.
33
Most often, to
achieve this tissue concentration, the an-
tibiotic must be given at twice the ther-
apeutic dose and at least 1 hour before
surgery.
1
If antibiotic administration oc-
curs after bacterial contamination, no
preventive influence occurs and similar
clinical results are reported as compared
with taking no preoperative antibiotic.
13
Principle 4: Antibiotic Exposure
In a healthy patient, a single dose
of antibiotics is usually sufficient for
most Class 1 and 2 surgical proce-
dures. Continuing antibiotics dosing
after surgery does not decrease the
incidence of immediate postoperative
surgical wound infections.
5,3436
How-
ever, for patients or procedures with
increased risk factors (Table 2), a
longer dose of antibiotics is warranted.
37
With the high degree of morbidity as-
sociated with dental implant infec-
tions, the benefits versus risk involved
for the extended use of antibiotics
should be evaluated.
ADVERSE REACTIONS
It is estimated that approximately
6% to 7% of patients taking antibiotics
will have some type of adverse event.
38
Most of these complications of prophy-
lactic antibiotics are minimal, however a
small percentage can be life threatening.
The risks associated with antibiotics in-
clude gastro-intestinal tract complica-
tions, colonization of resistant or fungal
strains, cross reactions with other med-
ication, and allergic reactions. Allergic
reaction is the most serious complica-
tion occurring locally or systemically
and ranges from mild urticaria to ana-
phylaxis and death. Studies have shown
that 1% to 3% of the population receiv-
ing penicillin will exhibit urticaria type
of reactions and 0.04% to 0.011% will
present with true anaphylactic episodes.
Of this small percentage of anaphylactic
reactions, 10% will be fatal.
39
A less serious, but increasing com-
plication in the general population after
antibiotic use is pseudomembranous co-
litis. This condition is caused by the
intestinal flora being altered and colo-
nized by Clostridium difficile. Clinda-
mycin has historically been associated
with pseudomembranous colitis, because
long term use in hospitalized patients
have resulted in death. However, most
antibiotics have been shown as caus-
ative agents for this complication.
The most recent concerns of antibi-
otic use are the development of resistant
bacterial strains and superinfection. It
has been shown that onset of resistant
bacteria overgrowth begins only after
the hosts susceptible bacteria are killed,
which usually takes at least 3 days of
antibiotic administration. Short-term (1
day) antibiotic use has been shown to
have little influence on the growth of
antibiotic-resistant bacteria.
15
PROPHYLACTIC ANTIBIOTICS
Beta-Lactam Antibiotics
The most common drugs used for
prophylaxis in dentistry are the peni-
cillin and cephalosporins in the beta-
lactam category. These antibiotics are
bactericidal and have similar chemical
structures and similar mechanisms of
action. The death of the bacteria oc-
curs by inhibition of bacterial cell wall
synthesis via the interruption of the
cross-linking between peptidoglycan
molecules.
40
Penicillin V. In the past, penicillin
V was one of the more popular antibi-
otics used in dentistry. It is well ab-
sorbed and will achieve peak serum lev-
els within 30 minutes of administration
with detectable levels of the drug for 4
hours.
40
Penicillin V is very effective
against most Streptococcus species and
oral anaerobes.
34
The main disadvantages
of penicillin is the need for frequent dos-
ing to maintain blood levels and the de-
velopment of resistant bacteria.
Amoxicillin. Amoxicillin is a
derivative of ampicillin, with the ad-
vantage over penicillin of superior ab-
sorption and a bioavailability of 70%
to 80% with very low toxicity. It has
excellent diffusion in infected tissues
and adequate tissue concentrations are
easily achieved. Amoxicillin is con-
sidered broad spectrum and is very
effective against Gram-negative cocci
and Gram-negative bacilli. This anti-
biotic has greater activity than Penicil-
lin V against streptococci and oral
anaerobes.
40
As a result of these fea-
tures, it is often the drug of choice
when the patient is not allergic to this
drug category.
Augmentin (Amoxicillin/Clavu-
lanic Acid). Bacteria resistant to
Amoxicillin inactivate the drug with
144 PROPHYLACTIC ANTIBIOTIC REGIMENS IN ORAL IMPLANTOLOGY
an enzyme beta-lactamase, which
breaks apart the beta-lactam ring. A
combination of 2 antibiotics was syn-
thesized to counteract the destructive
activity of beta-lactamase. Clavulanic
acid, also a beta-lactam antibiotic, was
added to amoxicillin to form Augmen-
tin. This combination antibiotic has a
great affinity for bacteria that produce
penicillinases and inactivates the resis-
tant bacteria.
34
This antibiotic is the
drug of choice when penicillinase bac-
teria are suspected and is very practi-
cal as a perioperative antibiotic for
sinus augmentation procedures.
Cephalosporins. First generation
cephalosporin antibiotics (eg, Cepha-
lexin) have an antibacterial spectrum
similar to Amoxicillin. However, they
have the advantage of not being sus-
ceptible to beta lactamase destruction
by Staphylococcus aureus. They are
frequently used in dentistry as an al-
ternative for the penicillin-allergic pa-
tient.
34
Rates of cross-reactivity of first
generation cephalosporins with
penicillin-allergic patients have been
cited to be approximately 8% to 18%.
However, recent studies have shown
only patients who have had anaphylactic
type immediate hypersensitivity reac-
tions should not be administered a ceph-
alosporin. If the patient has a previous
history of a reaction that was of this
nature, (eg, mediated type II, III, IV or
idiopathic reactions), a first generation
cephalosporin may be administered.
41
Newer second and third generation
cephalosporins exhibit a broader spec-
trum, less cross-reactivity, and even a
greater resistance to beta lactamase de-
struction. Cefuroxime axetil (Ceftin), a
second generation cephalosporin, may
be used as an alternative antibiotic for
sinus augmentation procedures. In addi-
tion, the parental form of a cephalospo-
rin, Cephazolin (Ancef), may be used
within the graft material.
Macrolides
The most common macrolide used
in dentistry is Erythromycin. It is active
against most streptococci, staphylo-
cocci, and some anaerobes and is an
alternative for patients allergic to peni-
cillin. Erythromycin has the advantage
of excellent absorption and not being
affected by the presence of food. It is
primarily used by the oral route and has
a relatively low toxicity.
41
However, this
antibiotic has a high incidence of nausea
and is bacteriostatic. Therefore, this
drug is not an ideal first line choice for
infections in the oral cavity.
Clindamycin
Clindamycin is becoming more
popular in the treatment of dental infec-
tions, primarily because of its activity
against anaerobic bacteria. It also has
activity against aerobic bacteria, such as
streptococci and staphylococci, with su-
perior effects against Bacteroides. How-
ever, this drug is bacteriostatic in normal
concentrations and has a rather high tox-
icity.
40
It also has a disadvantage related
to the occurrence of diarrhea in 20% to
30% of patients treated.
35
This antibiotic
also has an accompanying incidence of
antibiotic-associated pseudomembra-
nous colitis, more often when taken over
a longer duration. Clindamycin (cleocin
phosphate) is also supplied in an aque-
ous 300 mg/2 mL solution, which
makes it suitable for incorporation into
graft materials for sinus augmentation
procedures.
Fluoroquinolones
Quinolones are a more recent
classification of bactericidal antibiot-
ics with a broad antibacterial spec-
trum. They may be used either orally
or parenterally. Ciprofloxacin is a first
generation quinolone and is the proto-
type drug for this antibiotic category.
Newer third and fourth generation
quinolones have also been developed
with great activity against resistant
bacteria and anaerobic bacteria (eg,
Levaquin). In implant dentistry, they
are mainly used during the prophylac-
tic and therapeutic treatment of sinus
augmentation procedures
42
(Table 3).
CHLORHEXIDINE GLUCONATE
Another modality for antimicro-
bial prophylaxis for implant surgery is
the use of 0.12% chlorhexidine diglu-
conate (Peridex, Procter & Gamble,
Cincinnati, OH). Chlorhexidine glu-
conate is a potent antibacterial which
causes lysis by binding to bacterial
cell membranes. It has high substan-
tivity, which at high concentrations
exhibits bacteriocidal qualities, by
causing bacterial cytoplasm precipita-
tion and cell death.
43,44
In the oral cav-
ity, chlorhexidine has been shown to
have a slow release from tissue sur-
faces for over a 12 hour period.
45,46
PROPHYLACTIC PROTOCOL
There are many variables (local,
systemic, surgical) that need to be
considered with the prophylactic use
of antimicrobials. Therefore, a pro-
tocol has been developed by the au-
thors that allows the implant surgeon
to determine the most appropriate
antibiotic, dosage, and duration for
the prevention of postoperative com-
plications
47
(Table 3). Five different
categories are proposed, based on the
previous factors presented and the vari-
ety of invasiveness and difficulty of
the procedure. This format has been
used by several hundred doctors
trained at the Misch International Im-
plant Institute over the last 4 years,
with few complications (Table 4).
Category 1
The first category encompasses all
simple extractions (without grafting)
and routine dental implant second
stage surgeries, in patients without
systemic or oral disease states. These
procedures have a low incidence of
bacterial contamination and infection
of the surgical site, and therefore, no
antibiotic is required. Chlorhexidine
0.12% is suggested as a preoperative
and postoperative agent to decrease
postoperative infection risk and pro-
mote soft tissue healing (Fig. 1).
Table 3. Prophylactic Antibiotic
Recommendations (in Order
of Preference)
Dental implant/bone graft procedures
Amoxicillin
Cephalexin (allergic to penicillin,
but no history of anaphylactic
allergy to penicillin)
Clindamycin (history of anaphylac-
tic allergy to penicillin)
Sinus augmentation procedures
Augmentin
Ceftin (allergic to penicillin, but no
history of anaphylaxis)
Levaquin (history of anaphylactic al-
lergy to penicillin, history of recent
antibiotic use or sinus pathology)
Local use of antibiotics
Ancef (1 g)
Clindamycin (300 mg/2 mL)history
of anaphylactic allergy to penicillin
IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 145
Category 2
The second category includes pro-
cedures which have a moderate risk of
bacterial invasion and infection and in-
cludes traumatic extractions, socket
grafting and immediate implant inser-
tion after an extraction. The graft mate-
rial, implant, or extended procedures in-
dicates a preoperative loading dose of
antibiotics and a single postoperative
dose. In addition, chlorhexidine (0.12%)
rinse is recommended twice a day until
suture removal for all category 2 proce-
dures listed. For these procedures, if the
patients systemic status is greater than
an ASA2, a different regimen (category
4) is to be used (Fig. 2).
Category 3
In category 3 procedures, a mod-
erate to high probability of bacterial
invasion is expected. This is due to the
greater amount of tissue reflection and
longer duration of surgery which are
more complex and extensive proce-
dures. These procedures include mem-
brane bone grafts, multiple implants
with extensive soft tissue reflection
and multiple immediate implant inser-
tions after extractions. A preoperative
loading dose of antibiotic, followed by
3 postoperative doses per day for 3
days is recommended. Chlorhexidine
(0.12%) is also recommended twice a
day until the sutures are removed
(Fig. 3).
Category 4
Category 4 procedures are the
same as category 2 or 3, however
these procedures are performed on
medically compromised patients, have
more extensive tissue reflection than
usual, and/or are longer in duration
than typical. Additionally, sinus floor
lift during implant insertion and autog-
enous block bone graft procedures are
included in this category. With these
conditions, higher risk of bacterial
contamination and infection is ex-
pected. A preoperative loading dose of
antibiotics, followed by 3 daily doses
for 5 days of postoperative antibiotics
is warranted. Chlorhexidine (0.12%) is
also recommended twice a day until
the sutures are removed (Fig. 4).
Category 5
Category 5 (Sinus) procedures
encompass all sinus augmentation
procedures. The unique bacterial envi-
Table 4. Misch International Implant Institute Prophylactic Protocol
Type Patient Selection Procedures Antibiotic Antimicrobial
Type 1 ASA1/ASA2 Simple extractions of
uninfected teeth
Single tooth implants
2nd stage surgery
Limited soft tissue
reflection surgery
None Chlorhexidine (intra/extra
oral): 1/2 oz. bid for 2
wk
Type 2 ASA1/ASA2 Multiple simple extractions
Traumatic extractions
Multiple implants/limited
reflection
Socket grafting
Immediate implants/no
pathology
Amoxicillin: 1 g 1
h before surgery
500 mg 6 h later
Chlorhexidine (intra/extra
oral): 1/2 oz. bid for 2
wk
Type 3 ASA1/ASA2 Membrane bone grafting
(allograft/zenograft/
alloplast)
Multiple implants/extensive
reflection
Multiple immediate implants
Amoxicillin: 1 g 1 h
before surgery,
then 500 mg tid
for 3 d
Chlorhexidine (intra/extra
oral): 1/2 oz. bid for 2
wk
Type 4 Any of the following:
ASA2
Long duration
surgery
Less experienced
surgeon
Immuno-
compromised
Active periodontal
disease
Full arch implants/
extensive reflection
Sinus lift (SA2)
Autogenous bone
grafts
Amoxicillin: 1 g 1 h
before surgery,
then 500 mg tid
for 5 d
Chlorhexidine (intra/extra
oral): 1/2 oz. bid for 2
wk
Type 4 Sinus SA3/SA4 sinus
patients
SA3/SA4 sinus patients Augmentin (875
mg/125 mg): 2
tabs starting 1 d
before, then 1
tab bid for 5 d
Chlorhexidine (intra/extra
oral): 1/2 oz. bid for 2
wk
Medication equivalent doses.
Amoxicillin: (1 g) cephalexin (1 g) clindamycin (600 mg).
Augmentin (875 mg/125 mg) ceftin (500 mg) levofloxacin (500 mg).
ASA indicates American Society of Anesthesiologists.
146 PROPHYLACTIC ANTIBIOTIC REGIMENS IN ORAL IMPLANTOLOGY
ronment and delayed blood levels of
antibiotics in sinus mucosa (especially
in the presence of inflammation), in-
dicate a loading dose of antibiotics
initiated 1 day before surgery. With
this protocol, adequate blood levels of
antibiotics will be present within the
sinus tissues before surgery. The anti-
biotic is also continued for 5 days
postoperatively. A beta-lactamase anti-
biotic (Augmentin) is preferred, because
of the high incidence of beta-lactamase
producing pathogens associated with
maxillary sinus infections. Chlorhexi-
dine (0.12%) is also recommended
twice a day until the sutures are
removal (Fig. 5).
CONCLUSION
Antibiotic prophylaxis has been
shown to be effective in reducing post-
operative complications after dental
implant and bone grafting procedures.
Various recommendations on antibi-
otic use have generalized all implant
and bone grafting procedures under
one standardized protocol. The pro-
posed pharmacologic protocol in this
article involves 5 different categories,
which take into account various local,
systemic, surgical, and procedural
factors.
Disclosure
The authors claim to have no finan-
cial interest, directly or indirectly, in any
entity that is commercially related to the
products mentioned in this article.
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Fig. 1. A single tooth implant with minimal
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Fig. 2. Multiple implants with limited tissue
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Fig. 3. Multiple implants with extensive tissue
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Reprint requests and correspondence to:
Randolph R. Resnik, DMD, MDS
1082 Bower Hill Road
Pittsburgh, PA 15243
Phone: 412-279-7744
Fax: 412-279-7904
E-mail: [email protected]
Abstract Translations
GERMAN / DEUTSCH
AUTOR(EN): Bach Le, DDS, MD, Jeffrey Burstein, DDS,
MD. Korrespondenz an: Bach Le, DDS, MD, Gesichts- und
Kieferchirurgie (Oral & Maxillofacial Surgery), USC zahn-
medizinische Fakultat/medizinisches Zentrum des Stadtbezirks
LA (USC School of Dentistry/LA County Medical Center), OPD
1P51, 2010 Zonal Avenue, Los Angeles, CA 90089. Telefon:
(323) 226-5013, Fax: 323-226-5241, eMail: [email protected]
bzw. [email protected]
Asthetischer Transplantationsansatz fur kleinere Defekte in
Hart- und Weichgewebe zumAufbaueiner Implantierungsoption
ZUSAMMENFASSUNG: Defekte in der Leistenkontur im
Bereich um Implantate herum werden durch diesen zu Grunde
liegende Knochendefekte hervorgerufen. Obwohl eventuell en-
tsprechendes Knochengewebe zur Stabilisierung des Implantats
vorhanden sein kann, kann eine von der Norm abweichende
Kochenanatomie dennoch zu einem unnaturlichen Erschei-
nungsbild der abschlieenden U

berkronung fuhren. Eine

Partikel-Onlay-Spanung zur Unterstutzung des das Implantat
umgebenden Gewebes in Verbindung mit Spannungsfreiem
Verschluss bei Verwendung von Techniken zur Regeneration
der Stielpapille kann wenig asthetisch erscheinende Zahnfleis-
chkonturen zu gut geeigneten Implantierungsstellen umformen.
SCHLU

SSELWO

RTER: Zahnimplantate, Onlay-Spanung,

Papillenregeneration
SPANISH / ESPAOL
AUTOR(ES): Bach Le, DDS, MD, Jeffrey Burstein, DDS, MD.
Correspondencia a: Bach Le, DDS, MD, Oral & Maxillofacial
148 PROPHYLACTIC ANTIBIOTIC REGIMENS IN ORAL IMPLANTOLOGY
Surgery, USC School of Dentistry/LA County Medical Center,
OPD 1P51, 2010 Zonal Avenue, Los Angeles, CA 90089. Tele-
fono: (323) 226-5013, Fax: 323-226-5241, Correo electronico:
[email protected] o [email protected]
Injerto estetico en defectos de tejido duro y blando de
pequen o volumen para el desarrollo de lugares de im-
plante
ABSTRACTO: Los defectos del contorno de la cresta alred-
edor de los implantes dentales son causados por defectos
oseos subyacentes. A pesar de que podr a existir un hueso
adecuado para obtener la estabilidad del implante, una anato-
m a irregular del hueso puede resultar en una apariencia
innatural de la corona final. El injerto incrustado de part culas
para apoyar el tejido blando periimplante con un cierre sin
tension mientras se utilizan tecnicas de regeneracion de la
papila pedicular puede convertir los contornos gingivales
poco esteticos en lugares favorables.
PALABRAS CLAVES: Implantes dentales, injertos incrusta-
dos, regeneracion de la papila
PORTUGUESE / PORTUGUS
AUTOR(ES): Bach Le Cirurgiao-Dentista, Medico, Jeffrey
Burstein Cirurgiao-Dentista, Medico. Correspondencia para:
Bach Le, DDS, MD, Oral & Maxillofacial Surgery, USC
School of Dentistry/LA County Medical Center, OPD 1P51,
2010 Zonal Avenue, Los Angeles, CA 90089. Telefone: (323)
226-5013, Fax: 323-226-5241, e-Mail: [email protected] ou
[email protected]
Enxerto Estetico para Defeitos de Tecido Duro e Mole de
Pequeno Volume para Desenvolvimento de Local de Im-
plante
RESUMO: Os defeitos do contorno do rebordo em torno de
implantes dentarios sao causados por defeitos osseos subja-
centes. Embora o osso adequado possa existir para obter a
estabilidade do implante, a anatomia ossea irregular pode
resultar numa aparencia nao-natural da coroa final. O enxerto
particulado onlay para apoiar o tecido mole do periimplante,
junto com o fechamento isento de tensao, enquanto se uti-
lizam tecnicas de regeneracao da papila do ped culo, pode
converter contornos gengivais nao-esteticos em locais fa-
voraveis.
PALAVRAS-CHAVE: Implantes dentarios, enxerto onlay,
regeneracao da papila
RUSSIAN
ABTPM: Kelly Misch, 1p 1xa1nn, Hom-
Lay Wang, 1p 1xa1nn, xan1p
xnppnnen 1xa1nn. Apc n
ppcnucuuu: Hom-Lay Wang., DDS., MSD, Dept. of
Periodontics and Oral Medicine, University of Michigan,
School of Dentistry, 1101 N. University, Ann Arbor, MI
48109-1078. Tccu: 734-763-3383., a: 734-936-
0374, Apc cnpuu nnnm: [email protected]
xnenun, umpeuumuen npu xuppuue
ununmuuu: omuun u euenue
PE3RME. nennx npn xnppnnen nxnan-
1annn xnxn1x na1ix xnennex n
1xa1nnen npa1ne, n:1x neni nan
:na1i xe1i pii 1anxn naxxn. Hei :1
:pa na:a1i 1pn1n enennx xnppnnenx
nennn, nx:annix nanx enennx, ana1xnen
n npnepn, a 1ae n1i :1nnn, xe1i
pii n napnan1i enennx x 1nennx
ne1npn1ein pe:i1a1a.
RHEBME BA: :nie nxnan1a1i;
nennx npn nxnan1annn; neannax nxnan-
1annx.
TURKISH / TU

RKC E
YAZARLAR: Di Hekimi Kelly Misch, Di Hekimi Hom-
Lay Wang. Yazma iin: Hom-Lay Wang., DDS., MSD,
Dept. of Periodontics and Oral Medicine, University of Mich-
igan, School of Dentistry, 1101 N. University, Ann Arbor, MI
48109-1078 ABD. Telefon: 734-763-3383, Faks: 734-936-
0374, eposta: [email protected]
mplant Cerrahisi Komplikasyonlar: Etiyoloji ve Tedavi
ZET: mplant cerrahisi komplikasyonlar di
hekimliinde sk grlen olaylar olup, bu olgularn tedavis-
inde bilgi byk nem tar. Bu incelemenin amac, tedavi
planna, anatomiye ve prosedre bal cerrahi komplikasyon-
larn zorluklarnn vurgulanmas ve bunlarn yan sra tedav-
ide olumlu bir sonu almak iin etiyoloji, ynetim ve tedavi
seeneklerinin tartlmasdr.
ANAHTAR KELMELER: Dental implantlar; implant
komplikasyonlar; implant baarszlklar.
JAPANESE /
IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 149
CHINESE /
KOREAN /
150 PROPHYLACTIC ANTIBIOTIC REGIMENS IN ORAL IMPLANTOLOGY