- Area: Health Sciences
- Program: Dental Hygiene
- Type of Writing: Scientific (writing to communicate scientific research results)
- Course Level: 2000
- English Speaking Nativeness: Native
- Year: 2018
- Paper ID: HS.D.H.S.2.N.2.1
Implant Placement and the use of Antibiotic Prophylaxis
The Observation Report of Implant Placement and the use of Antibiotic Prophylaxis
Antibiotic drugs have been effective at resolving bacterial infections for many decades. Although this powerful group of drugs proves to be successful in treating infections, the overuse of such medications can create a tolerance within the human body. This tolerance can make it difficult to heal the body, and creates a dangerous situation. As doctors increase the prevalence of written antibiotic prescriptions it increases the threat of antibiotic tolerance in our society. One may wonder the validity of the frequent antibiotic prescription use with each medical problem one presents with.
Periodontal procedures have used antibiotics for prevention and treatment of infection. Such infection can cause procedure failures. It has been questioned whether or not such antibiotic drugs are really needed in the practice for implant placement in periodontal offices. Is it important for a periodontist to prescribe an antibiotic for a patient undergoing implant surgery? Will the antibiotic play a valid role in preventing implant procedure failures?
Answers to these questions were revealed through the study of an evidence-based experiment in conjunction with an observation of an implant placement at a periodontal office.
On August 31, 2018 an implant procedure was completed at Utah Periodontal Specialists in South Jordan, Utah. The patient receiving the implant had been in previously for other treatment. In February 2018 tooth #15 was deemed not vital so Periodontist, Dr. S, removed the tooth. During the same procedure, a sinus lift was preformed where a bone graft was placed to extend the roof of the sinus. This procedure was done so an implant could be successfully placed in the area once the bone and tissue healed. In April 2018 the bone and gingival tissues were ready for implant placement. The implant was placed and antibiotics were routinely given to the patient, but the implant failed at the 16-week torque check. On that same day Dr. S removed the implant and replaced the void with more bone so a second attempt for an implant could be made.
In August, the clinical and radiographic findings proved that the patient was ready for the implant to be placed again. The sinus lift with bone material showed opaquely on radiographs. The gingival tissues appeared tight, pink, and without inflammation. The patient’s current oral health practices were deemed acceptable for the procedure. No treatment modifications were needed because the patient was in good health. A topical ester anesthetic, 20% benzocaine, was placed followed by 2.7 ml of an injectable amide anesthetic, 4% articaine 1:100,000 epinephrine. Appropriate maxillary injections were performed to achieve profound anesthesia. Articaine was used because the specialist found it to work the best for this particular procedure.
Instruments used for the procedure included a surgical blade, surgical suction, surgical curette, hemostats, and cotton pliers. An implant hand-piece was used to drill into the bone and place the 6.0 noble implant screw of 6 x 10 mm. A torque wrench was used to tighten the implant in place and a healing abutment was placed over top the implant. Dissolvable gut sutures were used to stitch up the open gingival tissues.
Pre procedures included checking health history, taking a periapical radiograph of site #15, bibbing the patient, and applying topical anesthetic and injectable anesthetic.
Intraoral procedures began with performing flap surgery on the distal of tooth #14. Once the bone was exposed, a series of different drill bits drilled into the bone until it was prepped for the implant. Proper angle and depth of the hand-piece drill was crucial in order to properly place the implant. Once the implant was screwed in and torqued with the wrench, the healing abutment was placed. A gingivoplasty was performed in order for the gingiva to adapt around the implant. Gut sutures were then used to stitch up the open tissue site.
Post procedures were accomplished by setting up patient’s next appointment in two weeks, disposing biohazard waste, sterilizing instruments, and disinfecting room.
Verbal and written post-operative instructions were given to the patient. Two prescriptions were printed and signed by the doctor. The first was ibuprofen 800 mg, to be taken as needed or every eight hours. The second was Amoxicillin 500 mg, to be taken three times a day for two weeks. A third prescription, Norco 500 mg, was printed but thrown away upon the patient’s request. Post operative procedures included using medication as directed, icing the area for the first 48 hours, alerting the patient about possible bleeding for three to five days, no smoking or drinking for 48 hours, refraining from electric toothbrush for two weeks, and educating patient about dissolvable sutures.
The patient did exceptionally well due to the fact that this was his second attempt for the procedure. The patient tolerated injections well, had a pleasant attitude, and obeyed the instruction of the specialist during the procedure. The patient did comment on the unpleasant sounds when drilling into the bone but kept a positive attitude during that part of the procedure. Patient accepted post- operative instructions well and planned on following them precisely.
The evidence-based study selected for exploring the importance of antibiotic use was, “The Role of Antibiotic Prophylaxis in Reducing Bacterial Contamination of Autologous Bone Graft Collected from Implant Site,” by Rodolfo Mauceri, Giuseppina Campisi, Domenica Matranga, Nicola Mauceri, Giuseppe Pizzo, and Dario Melilli.
The goal of this study is to assess the custom of administering antibiotic medications prior to bone graph and implant operations. The research attempted to prove that antibiotic prophylaxis lowers bacterial counts in gingival tissues and saliva, a key factor of implant failures (Mauceri, Campisi, Matranga, Mauceri, Pizzo, & Melilli, 2017). Understanding the effects of antibiotic prophylaxis for periodontal surgery will help identify if antibiotic use is essential to decreasing post surgery infection and increasing successful implant operations.
Other researchers have found these assumptions to be controversial and difficult to control (Mauceri et al., 2017).
This peer-reviewed study selected 34 patients eligible for implant placement. This group was recruited from September 2014 to February 2015. Patients had to have no history of antibiotic use in the last six months. Patients had to be healthy with no contraindications to treatment including pregnancy. Each patient had one implant site, totaling 34 implant sites. The group was then randomly divided into two groups: a control group and an experiment group. Sixteen patients made up the control group and did not consume antibiotic prophylaxis prior to the implant procedure. The remaining 18 students made up the test group. “One 1 gr. tablet of amoxicillin + clavulanic acid was given to the test group patients 12 hours and 1 hour before the surgery” (Mauceri et al., 2017, p. 2). Amoxicillin was selected as the antibiotic “because it is better absorbed, following oral administration, than other beta- lactam antibiotics,” (Mauceri et al., 2017, p. 5).
Each procedure was completed by the same periodontist. Proper sterilization and protective wear was followed during the procedures. Bone fragments left in the coils of the operating drill were collected in sterile tubes and sent for testing one hour within completing the procedure. The samples were centrifuged for ten minutes in temperatures of four degrees Celsius. Solutions were added to the samples to test the bacterial count. Test results of each sample were checked twice on three different agars: Trypticase Soy Agar (TSA), Sabouraud Dextrose Agar (SDA), and Mitis Salivarius Agar (MSA). TSA was used to measure total counts of bacteria. MSA was used to measure isolated streptococci bacteria.
At the end of performing the 34 procedures, no major complications or implant failures occurred. All bone samples showed bacterial contamination. The greatest population of bacteria in the samples was from the streptococci group. Several strains of streptococci were recorded. The TSA test showed a substantial difference between the test and control groups; however, the MSA test showed no significant difference in the number of streptococci bacterial species between the test and control group. The amount of bacteria found in the test samples of the experimental group was substantially lower than the amount of bacteria found in the sample belonging to the control group. This outcome suggests that antibiotic prophylaxis lowers the amount of bacteria counts, but does not necessarily lower the types of bacteria present. This study also suggests that amoxicillin doses do, indeed, reach the surgical site and change oral bacteria counts prior to procedures but does not change saliva microflora. The outcome of this study suggests that antibiotic prophylaxis before implant surgery reduces the amount of contamination introduced to the bone, which reduces the number of infections and failed implant procedures.
This research study strengthened the hypothesis of those conducting the research but also taught the researchers new ideas based on the outcomes. Yes, antibiotic prophylaxis lowers bacteria counts in bone samples at an implant site, but it does not lower the types of bacteria present at the site. These results still support the idea that antibiotic prophylaxis lowers chances of infection and implant failure. Even though no failures occurred in the control group, the use of antibiotics throughout dental implant procedures appears to be a worthwhile preventative practice. Additional studies may aid to a more precise understanding on the affects of antibiotic use for preventative implant placement failure.
The majority of components in this experiment would be considered reliable because of the study design and consistency of the experiment. The study design involved a single periodontist who performed each procedure in the study and the same tests were performed on each sample of bone. These components of the study design increased the reliability of the research. However, the findings were weakened by a few components of the research conducted. First, the implant patients were not randomly selected, but they were randomly selected into the control and test groups. Second, although the periodontist and staff followed sterilization and protective practices, there is still room for human error where contamination could have taken place by staff. While removing samples, placing it in the test tube, and transporting it to the proper facility, contamination could have occurred. There were no comments about if the test tubes were covered immediately after adding the samples. Third, the amount of amoxicillin to produce the response desired can vary from patient to patient depending on their size, drug history, and genetics. These components may have biased the study, creating unreliable results if the study was repeated.
This research is considered internally and externally invalid. Internal validity was biased due to the study lacking in random selection of test subjects even though the control and experimental groups were randomly assigned after selecting the qualified patients. In addition, the study may be externally invalid as well. Although patients were randomly assigned to the control and experimental groups, it is unclear if the periodontist was blinded to the subjects throughout the duration of the study. These variables negatively affect whether the study measured what the researchers state it measured.
The internal and external study components may be invalid, but the authors did claim that insights gained in the study were unbiased by outside sources. “The authors declare that there are no conflicts of interest regarding the publication of this article,” (Mauceri et al., 2017, p. 5). Although validity was already altered, this statement proves that there were no outside sources influencing study findings; therefore, the intent was to accomplish the creation of an unbiased, valid study for educational purposes.
The results of this research support Dr. S’s practice of administrating an antibiotic for the implant procedure observed on August 31, 2018. Although it has been proven that antibiotic administration does not lower saliva bacteria, but does lower bacteria counts in gingival tissue, it is suggested that Dr. S’s administration of antibiotics may have helped lower chances of implant failure due to bacterial contamination (Mauceri et al., 2017).
The main difference of Dr. S’s practice and the research’s practice was that Dr. S prescribed two to three weeks of antibiotic use after the procedure and the clinical research study prescribed one antibiotic tablet prior to the implant procedure. Differences in the timing and doses of antibiotics are unclear within the research studied; it may be assumed that any antibiotic use prior to or promptly after implant procedures can help reduce bacteria counts, which may lower incidence of implant failures.
The patient treated by Dr. S in August had one main preference for the procedure. He had hopes the procedure would be successful after the second time and his implant would not fail. Due to his preference, he supported any of Dr. S’s procedures that would help increase chances of implant success. This included adhering to pre and post-operative instructions: practicing good oral hygiene practices before and after the procedure, taking the antibiotic according to instructions, and following all of the written care procedures after the procedure. The patient and doctor shared mutual preferences, so they were naturally integrated into the clinical treatment.
Circumstances for the patient and the office could have impacted the evidence-based decision making of antibiotic use during the implant procedure. If the clinic staff was not trained to follow through meticulous medical procedures, including post-operative antibiotic instructions, antibiotic treatment could have failed to be given to the patient. Also, if the patient did not have the circumstances to pay for the antibiotic prescription or understand the importance of the drug, he could have failed following through with Dr. S’s prescription order.
It is imperative for the clinician to care about their profession and remain current with ongoing continuing education. If the doctor neglected to continue her education as a periodontist, she could have failed knowing the positive effects of antibiotic use lowering chances of implant failure. Also, if the doctor did not care for her patients and the success of her practice, she could have neglected the importance of fully caring for her patients by prescribing the antibiotic prescription. Since she is committed to ongoing education and the comprehensive care of her patients, Dr. S has successfully incorporated the principles of evidence base practice?
Information gathered from the observation and evidence-based study suggest that antibiotic use for implant procedures are legitimate. If an antibiotic is not implemented in an implant operation, the risk of an infection leading to implant failure is increased. These findings may suggest that the risks of abstaining from antibiotic use outweigh the benefits for such periodontal procedures. Dr. S is an example of recognizing the ultimate importance of antibiotic use and applying it to her practices. By doing so, Dr. S is alleviating more chances of threatening infections and implant failure. Taking the antibiotic medication can save health, resources, and time; these are valuable benefits to the patient and professional.
By furthering knowledge about periodontal procedure best practices, dental hygienists elevate their role in the dental office. Dental hygienists gain more in-depth knowledge about such procedures so they can play a more active role in helping meet their patient’s needs. First, the clinician may be able to better recognize when a patient needs to be referred to a periodontist and for what reason. Second, the clinician will be able to perform appropriate treatments and educate the patient prior to periodontal procedures. Next, the clinician is able to provide optimal post-care to patients who have undergone periodontal procedures. Finally, the clinician has the opportunity to become the catalyst for improving the patient’s health by providing better education on the importance of periodontal procedures. It is necessary for dental hygienists to understand all faucets of dental health professions in order to become a highly competent dental hygienist.
Mauceri, R., Campisi, G., Matranga, D., Mauceri, N., Pizzo, G., & Melilli, D. (2017). The Role of Antibiotic Prophylaxis in Reducing Bacterial Contamination of Autologous Bone Graft Collected from Implant Site. BioMed Research International, 2017, 1-6. doi:10.1155/2017/2175019