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Odontogenic infections are the leading cause of consul- documented after dental procedures.4,5 Bacteremia
tation in emergency departments and outpatient dental has been observed in 100% of patients after dental
practices. In addition, they are the reason for approxi- extraction, 70% after root planing, 55% after third
mately 10% of antibiotic prescriptions written in Spain 1 molar surgery, and 20% after endodontic treatment.6
and frequently result from dental caries, dentoalveolar Severe complications of odontogenic infections
alterations, gingivitis, periodontitis, infections of have been reported as a result of bacteremia, induced
aponeurotic spaces, osteitis, and osteomyelitis.2,3 autoimmune response, diffusion through anatomic
Moreover, the incidence of bacteremia has been well planes, and paths of least resistance.7-9 Infections
*Department Head, Department of Dentistry and Oral and Received January 19 2016
Maxillofacial Surgery, Hospital San Juan de Dios, Cali, Colombia. Accepted March 8 2016
yProfessor, University of Valle; Academic Managing Director, Ó 2016 American Association of Oral and Maxillofacial Surgeons
Hospital Universitario del Valle, Cali, Colombia. 0278-2391/16/00340-2
Address correspondence and reprint requests to Ms Moreno-Drada: http://dx.doi.org/10.1016/j.joms.2016.03.006
Hospital de San Juan de Dios, Cali, Colombia; e-mail: johanita1420@
hotmail.com
1313
1314 ANTIMICROBIAL PROPHYLAXIS IN ORAL PROCEDURES
occasionally can disseminate to different parts of the neck, and thorax, which can lead to severe complica-
body and can even lead to serious complications and tions and even death.
death.1,10 However, surgical wounds of the oral The objective of this study was to determine the
cavity have been classified as clean-contaminated effectiveness of prophylactic antibiotics for preventing
wounds.11 Clean-contaminated wounds can be localized infections of the oral cavity, neck, and thoracic
managed with preoperative prophylactic antibiotics cavity in patients undergoing oral procedures.
if there are no other major risk factors.11
Dental procedures are considered high risk. Based
Materials and Methods
on expert opinions, it is recommended that prophy-
laxis be given to patients at high risk before manipula- This study was performed according to Cochrane
tion of the gingiva or periapical region of the teeth and recommendations and Preferred Reporting Items for
before perforation of the oral mucosa during dental Systematic Reviews and Meta-Analyses (PRISMA)
procedures.12 guidelines. The protocol was registered in PROSPERO
The decision of whether to use preoperative pro- (registration number, CRD42016032985), an interna-
phylactic antibiotics is controversial. Some investiga- tional prospective register of systematic reviews.
tors have written that this decision is based on the Clinical trials were included without any restric-
supposition that the patient has no major medical tions on language. Articles included in this study con-
risk factors that could affect the patient’s defense cerned only women and men older than 18 years who
mechanisms. Several risk factors include poorly underwent oral procedures and received a prophylac-
controlled diabetes, kidney disease, severe alcoholism, tic antibiotic (single preoperative dose) or another
immunosuppressive diseases (eg, leukemia, lym- intervention for the prevention of infection. Proce-
phoma, or advanced malignancy), and the use of dures that were emphasized in the selected articles
chemotherapeutic agents or other immunosuppres- were tooth extraction, oral implantation, and end-
sive medications. In these patients, the health profes- odontic surgery. Similarly, interventions (compari-
sional must be concerned about the prevention of sons) emphasized in the selected studies were
initial contamination and the possibility of reinfection antibiotic versus placebo, antibiotic versus antibiotic,
during the postoperative period.11 and antibiotic versus no intervention.
However, in most cases, the antibiotic prescription Studies in which patients underwent procedures
refers to a series of factors that are not always well outside the oral cavity and studies in which the effec-
defined. As a result, treatments might be inappropriate tiveness of antibiotic prophylaxis or adverse events
and promote the development of bacterial resistance.2 was not described were excluded.
The prescription of prophylactic antibiotics in cases in The primary outcome variables selected were infec-
which they might be unnecessary likewise could tion of the oral cavity, infection of the neck, and infec-
result in an increased risk of adverse reactions. It has tion of the thoracic cavity, and the secondary outcome
been reported that approximately 3% of adverse reac- variables were the type of prophylactic antibiotic, anti-
tions to medications are caused by amoxicillin, the biotic adverse effect, and bacteremia.
antibiotic most widely prescribed for prophylaxis.13 A search of clinical trials was performed using the
Thus, the nature of dental procedures that cause Medline database through Ovid, EMBASE, the Co-
bacteremia, the determination of patients at risk, and chrane Central Registry of Controlled Trials (CEN-
the effectiveness of antimicrobial prophylaxis remain TRAL), LILACS, and OpenGrey. A search for
controversial; despite numerous studies, the discus- additional studies was conducted in the reference lists
sion continues.14 of selected articles. The results of the searches were
In the face of bacterial resistance, infections can verified to eliminate duplicates. Study authors, confer-
continue to disseminate through the anatomic planes ences, and topic experts were contacted to include un-
and pathways with lower resistance, leading to com- published literature (Appendix 1).
plications, such as Ludwig angina, thoracic empyema, The studies were selected by blinded and indepen-
mediastinal retinitis, necrotizing fasciitis, cavernous dent researchers. They were collected according to ti-
sinus thrombosis, cerebral abscess, meningitis, septi- tles and abstracts to determine the possible usefulness
cemia, and bacterial endocarditis. Maxillary sinusitis of the articles. The eligibility criteria were applied to
and osteomyelitis, orbital abscess, abscess causing the complete articles in the final selection.
compression of the airway, carotid sheath abscesses The data were collected using a standardized data
and jugular thrombophlebitis, pleurisy, and other pro- collection format that contained the study design, par-
cesses related to bacteremia have been found.7 ticipants, variables, interventions and comparisons,
Therefore, it is very important to learn about antibi- and results. The authors confirmed the data entry
otic prophylaxis in oral procedures and the risk of and checked it by double entry of the data for greater
infectious dissemination, especially in the head, accuracy.
MORENO-DRADA AND GARCıA-PERDOMO 1315
Results
Of 329 articles found, 14 were included in the
qualitative and quantitative analyses (Anitua et al16;
Halpern et al17; Esposito et al18; Lindeboom et al19;
Bezerra et al20; Nolan et al21; Duvall et al22; Diz Dios
et al23; Maharaj et al24; Vergis et al25; Josefsson
et al26; Lockhart et al27; Shanson et al28; Hall et al29)
after excluding duplicates and articles that did not
meet the inclusion criteria (Fig 1).
In total, 2,063 patients were included in the 14
studies; 6 studies evaluated oral infection as the
outcome of interest, and 8 evaluated bacteremia. FIGURE 1. Study selection diagram.
None measured the 2 outcomes. For type of procedure Moreno-Drada and Garcıa-Perdomo. Antimicrobial Prophylaxis
performed, the studies of Anitua et al, Esposito et al, in Oral Procedures. J Oral Maxillofac Surg 2016.
and Nolan et al examined the placement of dental
implants. The study of Lindeboom et al concerned penicillin derivatives as the principal intervention or
endodontic surgery, and the remaining studies investi- comparator (Table 1).
gated tooth extraction. Only 1 study reported on adverse effects,28 and no
For type of antibiotic, 11 studies used oral antibiotics. adverse effects were reported in 6 studies.16-19,25,26
Five studies compared another antibiotic with nonin- Only the studies by Anitua et al and Lindeboom et al
tervention23-26,28 and 8 studies compared antibiotic presented a ‘‘low’’ risk in their articles, whereas Vergis
with placebo. Only the studies by Lindeboom et al et al, Nolan et al, Hall et al, and Diz Dios et al showed
and Hall et al did not use penicillin derivatives, but an ‘‘unclear’’ risk in their articles. High risk of bias was
instead used lincosamide. The remaining studies used observed in the studies by Shanson et al and Josefsson
1316 ANTIMICROBIAL PROPHYLAXIS IN ORAL PROCEDURES
No prophylaxis
No prophylaxis
No prophylaxis
Oral clindamycin Oral moxifloxacin No prophylaxis
No prophylaxis
Comparison
parameters (Fig 2).
The bias with higher evaluation of low risk involved
Placebo
Placebo
Placebo
Placebo
Placebo
Placebo
Placebo
Placebo
data with incomplete results. The bias of allocation
concealment and blinding of randomization presented
the highest proportion of evaluation, and unclear and
selective outcome reporting and other sources of bias
Antibiotic 3
Oral clindamycin
(95% CI, 0.24-0.99; RD, 0.025; 95% CI, 0.043 to
Antibiotic 2
BACTEREMIA
For antibiotic intervention versus placebo, 7 studies
were included,22-28 which showed an RR of 0.603
Oral amoxicillin and placebo rinse
Oral clindamycin
Oral amoxicillin
Oral amoxicillin
Oral amoxicillin
Oral amoxicillin
Oral amoxicillin
Oral amoxicillin
Oral amoxicillin
Oral amoxicillin
Teicoplanin iv
Tooth extraction
Tooth extraction
Tooth extraction
Tooth extraction
Tooth extraction
Tooth extraction
Tooth extraction
Tooth extraction
Tooth extraction
Procedure
TYPE OF ANTIBIOTIC
Implant
Implant
Implant
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Table 1. CHARACTERISTICS OF INCLUDED STUDIES
Yes
Yes
No
No
No
No
No
No
No
No
2008
1987
1985
1996
2005
Lockhart et al
Diz Dios et al
Esposito et al
Maharaj et al
Bezerra et al
Anitua et al
Duvall et al
Vergis et al
Nolan et al
procedures, highlighting clinical and bacteriologic as- phylaxis compared with placebo in patients undergo-
pects, is recommended. Most of the available evidence ing tooth extraction. In contrast, no differences were
regarding oral procedures involves tooth extraction. observed in prophylactic antibiotic use for implant
Few studies on other procedures in the oral cavity and endodontic surgeries compared with placebo.
have been observed. Randomized controlled experi- Localized infections of the neck and thoracic cavity
mental studies in patients at high risk for the dissemina- were not reported with the use of antibiotic
tion of infection (advanced age, immunosuppression, prophylaxis.
diabetes mellitus, and cardiovascular history) are sug- The incidence of bacteremia decreased when using
gested to determine the most effective antibiotic for antibiotic prophylaxis compared with placebo in pa-
preventing this outcome. tients undergoing tooth extraction. Tooth extraction
To conclude, the incidence of localized infections of was the only procedure that was evaluated as having
the oral cavity decreased with the use of antibiotic pro- such an outcome; thus, further studies evaluating
FIGURE 4. Infection in oral cavity and bacteremia. Antibiotic versus placebo: 0, oral infection; 3, bacteremia. CI, confidence interval; RD, risk
difference.
Moreno-Drada and Garcıa-Perdomo. Antimicrobial Prophylaxis in Oral Procedures. J Oral Maxillofac Surg 2016.
MORENO-DRADA AND GARCıA-PERDOMO 1319
FIGURE 5. Antibiotic versus placebo. Type of treatment. CI, confidence interval; RD, risk difference.
Moreno-Drada and Garcıa-Perdomo. Antimicrobial Prophylaxis in Oral Procedures. J Oral Maxillofac Surg 2016.
bacteremia during other procedures in the oral cavity perineal extension in an immunocompetent patient. Med Oral
Patol Oral Cir Bucal 16:772, 2011
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Review of the literature. Acta Odontol Venez 38:37, 2000
[in Spanish].
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MORENO-DRADA AND GARCıA-PERDOMO 1321