prophylactic antibiotic trt in implant

Prophylactic Antibiotic Regimens in OralImplantology: Rationale and Protocol

Randolph R. Resnik, DMD, MDS,* and Carl Misch, DDS, MDS†

Postoperative wound infectionsmay have a significant impact onthe success of dental implants and

bone grafting procedures. The occur-rence of surgical wound infection re-quires local inoculums to overcome hostdefenses and allow an environment thatis conducive for bacterial growth. Thisprocess is very complex with interac-tions of host, local tissue, systemic andmicrobial virulence factors. Variousmeasures attempt to minimize infectionby modifying the host and local tissuefactors. Such measures include controlof the operating room environment, pa-tient selection, aseptic protocol, and thesurgical technique. The use of antimi-crobials has also been shown to be sig-nificant in reducing postoperativewound infections.1–4

The scope of implant treatmentencompasses an increasing older pop-ulation with more complex cases, sothat a greater understanding of com-promised wound healing and inade-quate immune systems is of benefit.The dental practitioner should have athorough understanding of the indica-tions and protocol for the use of anti-microbials in implant dentistry. Themorbidity of implant related compli-cations may be reduced with the idealselection and sufficient dosage levelsof medications.

There is no current accepted phar-macologic protocol for dental im-plants, based on both the patient’shealth status and procedure type.

Many practitioners prescribe medica-tions empirically or generically withrespect to all implant procedures. Theunderstanding and use of the variousantibiotic regimens is beneficial forboth the success and maintenance ofdental implants. Antibiotic therapy inimplant dentistry may be classified aseither prophylactic (to prevent infec-tion) or therapeutic (to treat infection).This article provides the dentist withan overview of the pharmacokineticsand pharmacodynamics of various an-timicrobials and a prophylactic protocolbased 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 canlead to a multitude of problems rangingfrom pain and swelling, bone loss, andimplant failure. Because of the morbid-ity of infections, antimicrobial therapy isan essential component of the surgicalprotocol. Although adverse effects aresometimes associated with antimicrobialtherapy, these are usually mild andrarely life-threatening. The most com-mon antimicrobials used in implant den-

tistry consist of antibiotics (local andsystemic) and antimicrobial rinses(0.12% chlorhexidine gluconate).

PROPHYLACTIC ANTIBIOTICS

In general surgery and its subspe-cialties, the principles of antibioticprophylaxis are well established.These guidelines specifically relate theprocedure, the type of antibiotic, andthe dosage regimen.5,6 The use of pro-phylactic antibiotics in dentistry hasbeen documented to prevent compli-cations in patients who are at risk ofdeveloping infectious endocarditis andimmunocompromised patients.7 Inoral implantology, however, there ex-ists no general consensus on the useand indications for prophylactic anti-biotics. Antibiotic selection, dosageand duration of coverage for this pop-ulation is variable and some authorsavoid its routine use.8 The numerousdisadvantages of the use of antibioticsthat have been documented include thedevelopment of resistant bacteria, sec-ondary infections, toxicity of antibiot-ics, adverse reactions, and possiblepoor surgical technique.9,10

A number of studies have docu-mented the benefit of preoperative anti-

*Clinical Professor, Department of Periodontology and ImplantDentistry, Temple Dental School, Philadelphia, PA.**Professor and Director Oral Implantology, Department ofPeriodontology and Implant Dentistry, Temple Dental School,Philadelphia, PA.

ISSN 1056-6163/08/01702-142Implant DentistryVolume 17 • Number 2Copyright © 2008 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3181752b09

The use of antimicrobials re-duces the incidence of surgicalwound infection in oral implantol-ogy. Antimicrobial prophylaxis isindicated in all Class 2 (clean-contaminated) surgical procedures,which include sufficient blood levelsat the time of bacterial contamina-tion of dental implant and bone graftprocedures. Timing and dosage arecritical to the efficacy of antibiotics.

Antibiotic selection is determined mainlyby the bacteria which is most likely tocause an infection from the specific pro-cedure. The authors have developed aclassification and protocol that allowsthe dental practitioner to properly pre-scribe medication based on procedural,local host and systemic factors. (ImplantDent 2008;17:142–150)Key Words: dental implants, antibioticprophylaxis, surgical wound infection,pharmacologic protocol, risk factors

142 PROPHYLACTIC ANTIBIOTIC REGIMENS IN ORAL IMPLANTOLOGY

biotics for dental implantology.3,11,12 Themost comprehensive and controlledstudy to date related to antibiotics andimplants is from the Dental ImplantClinical Research Group.3,11 Data from2973 implants were evaluated and cor-related with integration failure at differenttime periods; initial healing, at surgi-cal uncovering, before loading theprosthesis, and from prosthesis loadingto 36 months. A significant differencewas found with the use of preoperativeantibiotics (4.6% failure) compared withno antibiotics (10% failure), both in theinitial healing and surgical uncovery ofthe implants.

The main goal of prophylactic an-tibiotic use is to prevent infection fromthe surgical wound site, thus decreasingthe chance of infectious complicationsand insufficient integration. Althoughthere is no conclusive evidence on themechanism of how preoperative anti-biotics work, most likely a greateraseptic local environment is achieved.A landmark study by Burke13 in 1961defined the scientific basis for theperioperative use of antibiotics to pre-vent surgical wound infection. Fromthis work and others, several impor-tant and well accepted principles havebeen established regarding the prophy-lactic use of antibiotics.1

Principle 1: Incidence of Infection

A classification of operativewounds and risk of infection was de-veloped by the American College ofSurgeons Committee on Control ofSurgical Infections.13,14 To evaluatethe risk for postoperative wound infection,all surgical procedures were classifiedaccording to 4 levels of contaminationand infection rates (Table 1).

Class 1 (clean surgical procedures)are least likely to have a post operativeinfection. 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 aninfection rate of 10% to 15%. By defi-nition, elective dental implant surgeryand bone grafting procedures fall withinthe Class 2 (clean-contaminated) cate-gory. However, with proper surgicaltechnique 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 ofsurgery, skill of the surgeon, methodsof intraoperative management, patientfactors, and aseptic technique.16,17 Inaddition, patient related (systemic andlocal) risk factors are also importantand correlated with increased suscep-tibility to infection. Therefore, thesefactors should also be consideredwhen developing a protocol for the useand duration of antibiotic prophylaxis(Table 2).

Various routes of virulent bacteriatransmission include (1) direct contactwith the patient’s blood or other bodyfluids; (2) indirect contact with contam-inated objects; (3) contact with infectednasal, 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 asepticcomponent includes proper disinfectionand draping procedures of the patient,hand scrubbing, sterile gowns worn byall surgical members and sterility ofinstrumentation.22

Another surgical factor related topostoperative infections is the dura-tion of the surgical procedure. Thisfactor may be the second most criticalrisk factor (behind wound contamina-tion) for causing postoperative infec-tions.23 Surgical operations lasting lessthan 1 hour have been shown to havean infection rate of 1.3%, whereasthose lasting 3 hours increase the rateto over 4.0%.24,25 The rate of infectionmay double with every hour of theprocedure.9,10

The skill and the experience of thesurgeon during the placement of im-plants have also been shown to besignificant in postoperative infec-tions and implant failures. Less ex-perienced dentists (�50 implantsplaced) have a 7.3% increase in fail-ure rates, compared with less than2% for experienced surgeons.11 Afactor in the less experienced dentistwhich may contribute to this higherfailure rate is the longer duration ofthe implant surgery.

The insertion of any medical pros-thetic implant or device increases thechance of infection at the surgicalsite. An implant placed into the hardor soft tissue may act as a foreignbody and the host’s defenses may be

compromised. In addition, the sur-face of an implant may facilitatebacterial adherence and the presenceof an implant may also compromiseblood supply to the region and affectthe host’s defenses. This may resultin normal bacterial flora with lowvirulence potential to cause infec-tions at the implant-host interface,which are difficult to remedy.26 –28

Table 1. Surgical WoundClassification With AssociatedInfection Rates15,16

Class 1: Clean (�2%)Elective, nontraumatic surgery,

no acute inflammation, respira-tory, gastrointestinal, and biliarytracts not entered

Class 2: Clean-Contaminated(10%–15%)

Elective opening of the respira-tory, gastrointestinal, and biliarytracts entered

Elective dental implant and bonegraft procedures

Class 3: Contaminated (20%–30%)Inflammation, gross spillage from

gastrointestinal and biliarytracts 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 WithIncreased Risk of Infection15,18–21

Systemic factorsDiabetesLong term corticosteroid useSmoking

Immunocompromised systemicdisorders

Malnutrition obesityElderly populationASA3 or ASA4

Local factorsUse/type of grafting material (au-

togenous, allograft, alloplast)Periodontal diseaseTissue inflammationOdontogenic infectionsIll-fitting provisional prosthesisIncision line openingInadequate hygieneSurgical factorsPoor aseptic techniqueSkill/experience of the surgeonIncreased duration of surgeryWound contamination during surgeryForeign 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 mostlikely to cause the infection. In the ma-jority of cases, infections after surgeryare from organisms that originate fromthe site of surgery.13 For example, mostpostoperative infections after transoralsurgery are caused by endogenous bac-teria including aerobic Gram-positivecocci (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 numberaerobes 2:1, it has been shown thatanaerobes need the aerobes to providean environment to proliferate.29 Theearly phase of intraoral infections involveaerobic streptococci which prepare theenvironment for subsequent anaerobicinvasion.30,31 With that in mind, theideal antibiotic must be effectiveagainst both of these pathogens.

Another factor in selecting an an-tibiotic is to use a drug with the leastamount of adverse side effects. Theseeffects may vary from mild nausea tothe extreme allergic reaction (anaphy-laxis). In addition, the antibiotic shouldbe bactericidal. Bacteriostatic antibioticswork by inhibiting growth and repro-duction of bacteria, thus allowing thehost defenses to eliminate the resultantbacteria. However, if the host’s defensesare compromised in any way, the bacte-ria and infection may flourish. Bacteri-cidal antibiotics are advantageous overbacteriostatic antibiotics in that (1) thereis less reliance on host resistance, (2) thebacteria may be destroyed by the antibioticalone, (3) faster results occur com-pared with bacteriostatic medications,and (4) there is greater flexibility withdosage intervals.15

Principle 3: Tissue Concentration

The minimum inhibitory concentra-tion is the lowest antibiotic concentrationneeded to destroy a specific bacteria. Asufficient tissue concentration of antibi-otic should be present at the time ofbacterial invasion. To accomplish thisgoal, the antibiotic must be given in adose that will reach plasma levels thatare 3-to-4 times the minimum inhibitoryconcentration 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, toachieve this tissue concentration, the an-tibiotic must be given at twice the ther-apeutic dose and at least 1 hour beforesurgery.1 If antibiotic administration oc-curs after bacterial contamination, nopreventive influence occurs and similarclinical results are reported as comparedwith taking no preoperative antibiotic.13

Principle 4: Antibiotic Exposure

In a healthy patient, a single doseof antibiotics is usually sufficient formost Class 1 and 2 surgical proce-dures. Continuing antibiotics dosingafter surgery does not decrease theincidence of immediate postoperativesurgical wound infections.5,34–36 How-ever, for patients or procedures withincreased risk factors (Table 2), alonger dose of antibiotics is warranted.37

With the high degree of morbidity as-sociated with dental implant infec-tions, the benefits versus risk involvedfor the extended use of antibioticsshould be evaluated.

ADVERSE REACTIONS

It is estimated that approximately6% to 7% of patients taking antibioticswill have some type of adverse event.38

Most of these complications of prophy-lactic antibiotics are minimal, however asmall percentage can be life threatening.The risks associated with antibiotics in-clude gastro-intestinal tract complica-tions, colonization of resistant or fungalstrains, cross reactions with other med-ication, and allergic reactions. Allergicreaction is the most serious complica-tion occurring locally or systemicallyand ranges from mild urticaria to ana-phylaxis and death. Studies have shownthat 1% to 3% of the population receiv-ing penicillin will exhibit urticaria typeof reactions and 0.04% to 0.011% willpresent with true anaphylactic episodes.Of this small percentage of anaphylacticreactions, 10% will be fatal.39

A less serious, but increasing com-plication in the general population afterantibiotic use is pseudomembranous co-litis. This condition is caused by theintestinal flora being altered and colo-nized by Clostridium difficile. Clinda-mycin has historically been associatedwith pseudomembranous colitis, becauselong term use in hospitalized patientshave 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 resistantbacterial strains and superinfection. Ithas been shown that onset of resistantbacteria overgrowth begins only afterthe host’s susceptible bacteria are killed,which usually takes at least 3 days ofantibiotic administration. Short-term (1day) antibiotic use has been shown tohave little influence on the growth ofantibiotic-resistant bacteria.15

PROPHYLACTIC ANTIBIOTICSBeta-Lactam Antibiotics

The most common drugs used forprophylaxis in dentistry are the peni-cillin and cephalosporins in the beta-lactam category. These antibiotics arebactericidal and have similar chemicalstructures and similar mechanisms ofaction. The death of the bacteria oc-curs by inhibition of bacterial cell wallsynthesis via the interruption of thecross-linking between peptidoglycanmolecules.40

Penicillin V. In the past, penicillinV 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 administrationwith detectable levels of the drug for 4hours.40 Penicillin V is very effectiveagainst most Streptococcus species andoral anaerobes.34 The main disadvantagesof penicillin is the need for frequent dos-ing to maintain blood levels and the de-velopment of resistant bacteria.

Amoxicillin. Amoxicillin is aderivative of ampicillin, with the ad-vantage over penicillin of superior ab-sorption and a bioavailability of 70%to 80% with very low toxicity. It hasexcellent diffusion in infected tissuesand adequate tissue concentrations areeasily achieved. Amoxicillin is con-sidered broad spectrum and is veryeffective against Gram-negative cocciand Gram-negative bacilli. This anti-biotic has greater activity than Penicil-lin V against streptococci and oralanaerobes.40 As a result of these fea-tures, it is often the drug of choicewhen the patient is not allergic to thisdrug category.

Augmentin (Amoxicillin/Clavu-lanic Acid). Bacteria resistant toAmoxicillin inactivate the drug with


an enzyme beta-lactamase, whichbreaks apart the beta-lactam ring. Acombination of 2 antibiotics was syn-thesized to counteract the destructiveactivity of beta-lactamase. Clavulanicacid, also a beta-lactam antibiotic, wasadded to amoxicillin to form Augmen-tin. This combination antibiotic has agreat affinity for bacteria that producepenicillinases and inactivates the resis-tant bacteria.34 This antibiotic is thedrug of choice when penicillinase bac-teria are suspected and is very practi-cal as a perioperative antibiotic forsinus augmentation procedures.

Cephalosporins. First generationcephalosporin antibiotics (eg, Cepha-lexin) have an antibacterial spectrumsimilar to Amoxicillin. However, theyhave the advantage of not being sus-ceptible to beta lactamase destructionby Staphylococcus aureus. They arefrequently used in dentistry as an al-ternative for the penicillin-allergic pa-tient.34 Rates of cross-reactivity of firstgeneration cephalosporins withpenicillin-allergic patients have beencited to be approximately 8% to 18%.However, recent studies have shownonly patients who have had anaphylactictype immediate hypersensitivity reac-tions should not be administered a ceph-alosporin. If the patient has a previoushistory of a reaction that was of thisnature, (eg, mediated type II, III, IV oridiopathic reactions), a first generationcephalosporin may be administered.41

Newer second and third generationcephalosporins exhibit a broader spec-trum, less cross-reactivity, and even agreater resistance to beta lactamase de-struction. Cefuroxime axetil (Ceftin), asecond generation cephalosporin, maybe used as an alternative antibiotic forsinus augmentation procedures. In addi-tion, the parental form of a cephalospo-rin, Cephazolin (Ancef), may be usedwithin the graft material.

Macrolides

The most common macrolide usedin dentistry is Erythromycin. It is activeagainst most streptococci, staphylo-cocci, and some anaerobes and is analternative for patients allergic to peni-cillin. Erythromycin has the advantageof excellent absorption and not beingaffected by the presence of food. It isprimarily used by the oral route and hasa relatively low toxicity.41 However, this

antibiotic has a high incidence of nauseaand is bacteriostatic. Therefore, thisdrug is not an ideal first line choice forinfections in the oral cavity.

Clindamycin

Clindamycin is becoming morepopular in the treatment of dental infec-tions, primarily because of its activityagainst anaerobic bacteria. It also hasactivity against aerobic bacteria, such asstreptococci and staphylococci, with su-perior effects against Bacteroides. How-ever, this drug is bacteriostatic in normalconcentrations and has a rather high tox-icity.40 It also has a disadvantage relatedto the occurrence of diarrhea in 20% to30% of patients treated.35 This antibioticalso has an accompanying incidence ofantibiotic-associated pseudomembra-nous colitis, more often when taken overa longer duration. Clindamycin (cleocinphosphate) is also supplied in an aque-ous 300 mg/2 mL solution, whichmakes it suitable for incorporation intograft materials for sinus augmentationprocedures.

Fluoroquinolones

Quinolones are a more recentclassification of bactericidal antibiot-ics with a broad antibacterial spec-trum. They may be used either orallyor parenterally. Ciprofloxacin is a firstgeneration quinolone and is the proto-type drug for this antibiotic category.Newer third and fourth generationquinolones have also been developedwith great activity against resistantbacteria and anaerobic bacteria (eg,Levaquin). In implant dentistry, theyare mainly used during the prophylac-tic and therapeutic treatment of sinusaugmentation procedures42 (Table 3).

CHLORHEXIDINE GLUCONATE

Another modality for antimicro-bial prophylaxis for implant surgery isthe use of 0.12% chlorhexidine diglu-conate (Peridex, Procter & Gamble,Cincinnati, OH). Chlorhexidine glu-conate is a potent antibacterial whichcauses lysis by binding to bacterialcell membranes. It has high substan-tivity, which at high concentrationsexhibits bacteriocidal qualities, bycausing 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 beconsidered with the prophylactic useof antimicrobials. Therefore, a pro-tocol has been developed by the au-thors that allows the implant surgeonto determine the most appropriateantibiotic, dosage, and duration forthe prevention of postoperative com-plications47 (Table 3). Five differentcategories are proposed, based on theprevious factors presented and the vari-ety of invasiveness and difficulty ofthe procedure. This format has beenused by several hundred doctorstrained at the Misch International Im-plant Institute over the last 4 years,with few complications (Table 4).

Category 1

The first category encompasses allsimple extractions (without grafting)and routine dental implant secondstage surgeries, in patients withoutsystemic or oral disease states. Theseprocedures have a low incidence ofbacterial contamination and infectionof the surgical site, and therefore, noantibiotic is required. Chlorhexidine0.12% is suggested as a preoperativeand postoperative agent to decreasepostoperative infection risk and pro-mote soft tissue healing (Fig. 1).

Table 3. Prophylactic AntibioticRecommendations (in Orderof Preference)

Dental implant/bone graft proceduresAmoxicillinCephalexin (allergic to penicillin,

but no history of anaphylacticallergy to penicillin)

Clindamycin (history of anaphylac-tic allergy to penicillin)

Sinus augmentation proceduresAugmentinCeftin (allergic to penicillin, but no

history of anaphylaxis)Levaquin (history of anaphylactic al-

lergy to penicillin, history of recentantibiotic use or sinus pathology)

Local use of antibioticsAncef (1 g)Clindamycin (300 mg/2 mL)—history

of anaphylactic allergy to penicillin


Category 2

The second category includes pro-cedures which have a moderate risk ofbacterial invasion and infection and in-cludes traumatic extractions, socketgrafting and immediate implant inser-tion after an extraction. The graft mate-rial, implant, or extended procedures in-dicates a preoperative loading dose ofantibiotics and a single postoperativedose. In addition, chlorhexidine (0.12%)rinse is recommended twice a day untilsuture removal for all category 2 proce-dures listed. For these procedures, if thepatient’s systemic status is greater thanan ASA2, a different regimen (category4) 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 thegreater amount of tissue reflection andlonger duration of surgery which aremore complex and extensive proce-dures. These procedures include mem-brane bone grafts, multiple implantswith extensive soft tissue reflectionand multiple immediate implant inser-tions after extractions. A preoperativeloading dose of antibiotic, followed by3 postoperative doses per day for 3days is recommended. Chlorhexidine(0.12%) is also recommended twice aday until the sutures are removed(Fig. 3).

Category 4

Category 4 procedures are thesame as category 2 or 3, howeverthese procedures are performed on

medically compromised patients, havemore extensive tissue reflection thanusual, and/or are longer in durationthan typical. Additionally, sinus floorlift during implant insertion and autog-enous block bone graft procedures areincluded in this category. With theseconditions, higher risk of bacterialcontamination and infection is ex-pected. A preoperative loading dose ofantibiotics, followed by 3 daily dosesfor 5 days of postoperative antibioticsis warranted. Chlorhexidine (0.12%) isalso recommended twice a day untilthe sutures are removed (Fig. 4).

Category 5

Category 5 (Sinus) proceduresencompass all sinus augmentationprocedures. The unique bacterial envi-

Table 4. Misch International Implant Institute Prophylactic Protocol

Type Patient Selection Procedures Antibiotic Antimicrobial

Type 1 ASA1/ASA2 Simple extractions ofuninfected teeth

Single tooth implants2nd stage surgeryLimited soft tissue

reflection surgery

None Chlorhexidine (intra/extraoral): 1/2 oz. bid for 2wk

Type 2 ASA1/ASA2 Multiple simple extractionsTraumatic extractionsMultiple implants/limited

reflectionSocket graftingImmediate implants/no

pathology

Amoxicillin: 1 g 1h before surgery500 mg 6 h later

Chlorhexidine (intra/extraoral): 1/2 oz. bid for 2wk

Type 3 ASA1/ASA2 Membrane bone grafting(allograft/zenograft/alloplast)

Multiple implants/extensivereflection

Multiple immediate implants

Amoxicillin: 1 g 1 hbefore surgery,then 500 mg tidfor 3 d


Type 4 Any of the following:�ASA2Long duration

surgeryLess experienced

surgeonImmuno-

compromisedActive periodontal

disease

Full arch implants/extensive reflection

Sinus lift (SA2)Autogenous bone

grafts

Amoxicillin: 1 g 1 hbefore surgery,then 500 mg tidfor 5 d


Type 4 Sinus SA3/SA4 sinuspatients

SA3/SA4 sinus patients Augmentin (875mg/125 mg): 2tabs starting 1 dbefore, then 1tab bid for 5 d


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.


ronment and delayed blood levels ofantibiotics in sinus mucosa (especiallyin the presence of inflammation), in-dicate a loading dose of antibioticsinitiated 1 day before surgery. Withthis protocol, adequate blood levels ofantibiotics will be present within thesinus tissues before surgery. The anti-biotic is also continued for 5 dayspostoperatively. A beta-lactamase anti-biotic (Augmentin) is preferred, becauseof the high incidence of beta-lactamaseproducing pathogens associated withmaxillary sinus infections. Chlorhexi-dine (0.12%) is also recommendedtwice a day until the sutures areremoval (Fig. 5).

CONCLUSION

Antibiotic prophylaxis has beenshown to be effective in reducing post-operative complications after dentalimplant and bone grafting procedures.Various recommendations on antibi-otic use have generalized all implantand bone grafting procedures underone standardized protocol. The pro-posed pharmacologic protocol in thisarticle involves 5 different categories,which take into account various local,systemic, surgical, and proceduralfactors.

Disclosure

The authors claim to have no finan-cial interest, directly or indirectly, in anyentity that is commercially related to theproducts mentioned in this article.

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Fig. 1. A single tooth implant with minimaltissue reflection and inserted into existingbone volume is a type I procedure for antibi-otic prophylaxis.Fig. 2. Multiple implants with limited tissuereflection is a type II category for antibioticprophylaxis.Fig. 3. Multiple implants with extensive tissuereflection is an example of a type III categoryfor antibiotic prophylaxis.

Fig. 4. Autogenous block bone harvest andplacement is an example of a type IV categoryfor antibiotic coverage before and after theprocedure.Fig. 5. A sinus graft using the lateral wall ap-proach is a unique host site for a bone graftand is in a separate category (type IV sinus)for antibiotic coverage before, during and af-ter the procedure.


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Reprint requests and correspondence to:Randolph R. Resnik, DMD, MDS1082 Bower Hill RoadPittsburgh, PA 15243Phone: 412-279-7744Fax: 412-279-7904E-mail: [email protected]

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Bach Le, DDS, MD, Jeffrey Burstein, DDS,MD. Korrespondenz an: Bach Le, DDS, MD, Gesichts- undKieferchirurgie (Oral & Maxillofacial Surgery), USC zahn-medizinische Fakultat/medizinisches Zentrum des StadtbezirksLA (USC School of Dentistry/LA County Medical Center), OPD1P51, 2010 Zonal Avenue, Los Angeles, CA 90089. Telefon:(323) 226-5013, Fax: 323-226-5241, eMail: [email protected]. [email protected]´Asthetischer Transplantationsansatz fur kleinere Defekte inHart- und Weichgewebe zum Aufbau einer Implantierungsoption

ZUSAMMENFASSUNG: Defekte in der Leistenkontur imBereich um Implantate herum werden durch diesen zu Grundeliegende Knochendefekte hervorgerufen. Obwohl eventuell en-

tsprechendes Knochengewebe zur Stabilisierung des Implantatsvorhanden sein kann, kann eine von der Norm abweichendeKochenanatomie dennoch zu einem unnaturlichen Erschei-nungsbild der abschließenden Uberkronung fuhren. EinePartikel-Onlay-Spanung zur Unterstutzung des das Implantatumgebenden Gewebes in Verbindung mit SpannungsfreiemVerschluss bei Verwendung von Techniken zur Regenerationder Stielpapille kann wenig asthetisch erscheinende Zahnfleis-chkonturen zu gut geeigneten Implantierungsstellen umformen.

SCHLUSSELWORTER: Zahnimplantate, Onlay-Spanung,Papillenregeneration

SPANISH / ESPAÑOLAUTOR(ES): Bach Le, DDS, MD, Jeffrey Burstein, DDS, MD.Correspondencia a: Bach Le, DDS, MD, Oral & Maxillofacial


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] estetico en defectos de tejido duro y blando depequeno 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 defectososeos subyacentes. A pesar de que podrıa existir un huesoadecuado para obtener la estabilidad del implante, una anato-mıa irregular del hueso puede resultar en una aparienciainnatural de la corona final. El injerto incrustado de partıculaspara apoyar el tejido blando periimplante con un cierre sintension mientras se utilizan tecnicas de regeneracion de lapapila pedicular puede convertir los contornos gingivalespoco esteticos en lugares favorables.

PALABRAS CLAVES: Implantes dentales, injertos incrusta-dos, regeneracion de la papila

PORTUGUESE / PORTUGUÊSAUTOR(ES): Bach Le Cirurgiao-Dentista, Medico, JeffreyBurstein Cirurgiao-Dentista, Medico. Correspondencia para:Bach Le, DDS, MD, Oral & Maxillofacial Surgery, USCSchool 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] [email protected] Estetico para Defeitos de Tecido Duro e Mole dePequeno Volume para Desenvolvimento de Local de Im-plante

RESUMO: Os defeitos do contorno do rebordo em torno deimplantes dentarios sao causados por defeitos osseos subja-centes. Embora o osso adequado possa existir para obter aestabilidade do implante, a anatomia ossea irregular poderesultar numa aparencia nao-natural da coroa final. O enxertoparticulado 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 pedıculo, podeconverter contornos gengivais nao-esteticos em locais fa-voraveis.

PALAVRAS-CHAVE: Implantes dentarios, enxerto onlay,regeneracao da papila

RUSSIAN��: Kelly Misch, �� , Hom-Lay Wang, �� , �� . �� : Hom-Lay Wang., DDS., MSD, Dept. ofPeriodontics and Oral Medicine, University of Michigan,School of Dentistry, 1101 N. University, Ann Arbor, MI48109-1078. ��: 734-763-3383., ��: 734-936-0374, �� : [email protected]�� , �� : ��

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TURKISH / TURKCEYAZARLAR: Di Hekimi Kelly Misch, Di Hekimi Hom-Lay Wang. Yazıma için: Hom-Lay Wang., DDS., MSD,Dept. of Periodontics and Oral Medicine, University of Mich-igan, School of Dentistry, 1101 N. University, Ann Arbor, MI48109-1078 ABD. Telefon: 734-763-3383, Faks: 734-936-0374, eposta: [email protected] Cerrahisi Komplikasyonları: Etiyoloji ve Tedavi

ÖZET: mplant cerrahisi komplikasyonları dihekimliinde sık görülen olaylar olup, bu olguların tedavis-inde bilgi büyük önem taır. Bu incelemenin amacı, tedaviplanına, anatomiye ve prosedüre balı cerrahi komplikasyon-ların zorluklarının vurgulanması ve bunların yanı sıra tedav-ide olumlu bir sonuç almak için etiyoloji, yönetim ve tedaviseçeneklerinin tartıılmasıdır.

ANAHTAR KELMELER: Dental implantlar; implantkomplikasyonları; implant baarısızlıkları.

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