There are two main ways that antibiotics have historically been used "preventively" in dentistry.
1. Invasive dental surgery causes bleeding. Antibiotics may be given to prevent oral bacteria getting into the bloodstream and causing an internal infection (like subacute bacterial endocarditis). Antibiotics taken an hour or so before the dental surgery will be at a high concentration in the blood, and will kill any oral bacteria as soon as they enter the blood vessels.
2. They may also be given to prevent a (local) postoperative infection taking hold at the site of the surgery - a "just be to on the safe side" measure.
There is much disagreement around the world about the usefulness of antibiotic prophylaxis, and when it should or shouldn't be used. Most of the evidence says it does more harm than good.
What is the potential harm that can be done with giving prophylactic antibiotics?
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Let's look at when its use is intended to prevent a localised infection occurring at the site of dental surgery, in a healthy patient:
Third molar surgical extraction
Do antibiotics help reduce postoperative complications of a wisdom tooth surgical extraction?
No.
Antibiotic prophylaxis in third molar surgery: A randomized double-blind placebo-controlled trial. Siddiqi et al. Int J Oral Maxillofac Surg. 2010
Results of the study showed that prophylactic antibiotics did not have a statistically significant effect on postoperative infections in third molar surgery and should not be routinely administered when third molars are removed in non-immunocompromised patients.
Do antibiotics help reduce postoperative complications of root apical surgery?
No.
The role of preoperative prophylactic antibiotic administration in periapical endodontic surgery: a double-blind study. Lindeboom et al. Int Endod J. 2005
No statistically significant difference was found between clindamycin prophylaxis and placebo with regard to the prevention of postoperative infection in endodontic surgical procedures.
Do antibiotics help reduce postoperative complications when a tooth is reimplanted?
Probably not.
The Dental Trauma Guide (and others) recommends giving prophylactic antibiotics. However there is a lack of evidence as to whether this makes any positive difference.
Do antibiotics help reduce postoperative complications of implant surgery?
For simple placements, no, although they may reduce discomfort (which is of course better managed with analgesics rather than antibiotics).
Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: Abu-Ta'a et al. J Clin Perio. 2008
Antibiotics do not provide significant advantages concerning post-operative infections in case of proper asepsis. It also does not reduce peri-oral microbial contamination. It does on the other hand reduce post-operative discomfort.
For complex placements, involving wide flap surgery or bone augmentation, there is (low-quality) evidence that they may increase the success rate.
Many implant suppliers include antibiotics in their protocol for correct placement. If a complaint arose because an implant failed through post-op infection, and the dentist hadn't followed the protocol exactly, they may be blamed by the patient's (and the manufacturer's) lawyers. On the other side, if the protocol was followed, and the patient suffered an allergic reaction, again they may be blamed, by their profession for not following the evidence. An ethical dilemma.
Is antibiotic cover needed for patients with damaged hearts who are at risk of developing sub-acute bacterial endocarditis (SBE)?
Not routinely.
There is a (sometimes fatal) condition called sub-acute bacterial endocarditis (SBE), where bacteria from the blood stream can grow on the lining of the walls of the heart, particularly if it has been roughened by pre-existing disease (like rheumatic fever, or valve disease).
Historically, patients at risk were given antibiotics before invasive dental procedures like scaling or extraction, to prevent oral bacteria from entering the blood stream and forming colonies (called "vegetations") on the heart.
When NICE reviewed the evidence in 2008 for and against this practice, they realised that actually normal toothbrushing at home caused more bacteria, and more often, to enter the blood than did dental procedures.
In the 2 years following the NICE advice, antibiotic prophylaxis dropped by 80% in the UK. But there was no corresponding increase in cases of, or deaths from, bacterial endocarditis. (link to paper here)
Following pressure, in 2015 NICE recommended that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing invasive dental procedures.
The patient's cardiologist may well be better placed than the dentist to decide on the level of risk posed to an individual patient. In this situation, the cardiologist should provide a letter outlining their advice and the dentist should confirm with the patient that this reflects their wishes before acting on the recommendation.
Watch this space!
Evidence in 2024 from the University of Sheffiedl suggests that the benefits of antibiotic prophylaxis in preventing Infective Endocarditis (IE) outweigh the risks, with significant reductions in IE cases when antibiotics are used preventively. This has prompted calls for NICE to reconsider its guidelines, aligning them with international standards to better protect high-risk patients.
Is antibiotic cover needed for patients with artificial joints?
No.
A problem for artificial joints is that, as with damaged heart linings, there is a risk of bacteria growing on the surfaces. For this reason dentists used to provide antibiotic prophylaxis. However, the same logic applied as for SBE patients when the advice was reviewed by NICE.
NICE now recommends that there is no need for antibiotic prophylaxis for patients with prosthetic joints.
The same is true for other types of implants, like breast implants or pace makers or indwelling catheters.
Although NICE and most professional specialist bodies agree that antibiotic cover is not needed for these, many dentists and doctors around the world, including specialists, prefer to ignore the advice.
MRONJ - Medication related osteonecrosis of the jaw.
Is antibiotic cover needed for patients taking bisphosphonates, where there is always a risk of MRONJ?
No. This appears to make no difference to the risk of ONJ for either oral or IV Bisphosphonates.
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Drugs and doses for prophylaxis if required
See page 11 onwards of the document below
The vast majority of patients at increased risk of infective endocarditis will not be prescribed prophylaxis. However, for a very small number of patients, it may be prudent to consider antibiotic prophylaxis (non-routine management), in consultation with the patient and their cardiologist or cardiac surgeon.
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Key Points
Please take a moment to review these points, reflect on their significance and consider how they apply to your own experiences.
Tick to confirm (optional):
Antibiotic prophylaxis in dentistry is often used to prevent infections, but its effectiveness and necessity are widely debated.
Overuse of prophylactic antibiotics can lead to resistant pathogens, serious illness, and environmental harm.
Studies show that prophylactic antibiotics do not significantly reduce postoperative complications in various dental surgeries, including third molar extraction and apical surgery.
Prophylactic antibiotics are generally not recommended for patients with damaged hearts, prosthetic joints, or those at risk of MRONJ, though individual cases may vary.
NICE guidelines suggest that antibiotic prophylaxis is not routinely needed for most patients undergoing dental procedures, though recent studies may prompt reevaluation of this stance for high-risk patients.
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