**Author details**

It is well known that the administration of antimicrobial agents causes a disturbance in the oropharyngeal and intestinal microflora, which is considered to be important for health maintenance. This disturbance is not only due to the spectrum of agents, but also to their degree of absorption, route of elimination, possible enzymatic inactivation and/or binding to human fluids and intestinal material [112]. Individual variations in normal microflora further determines the ecological outcome of antimicrobial therapy [112]. Selective pressure by the administration of antibiotics will decrease the number of microorganisms in the oral cavity. Consequently, this leads to a disturbance in human microbial ecology as shown in **Figure 2**

Antibiotic resistance has become a global growing health problem. The golden age of antibiotic therapy is now coming to an end as stated in 2014 by WHO [115]. However, some researcher believes that we are already in the pre-antibiotic era. The Global Economic Forum reported that the development of antibiotic resistance has major societal risks and increases both morbidity and mortality of affected individuals [115, 116]. Each year there are thousands of deaths, and millions of dollars spent on healthcare costs due to resistant infections [117]. Therefore, a restrictive approach towards using antibiotics is mandatory in order to limit the development of microbial antibiotic resistance and avoid the risk of unwanted systemic effects

The prescription of antibiotics in medical practice needs to be addressed globally, particularly in the dental field, including dental implant procedures [29]. In fact, there is a decrease in surgical infection rate incidence even without the use of antibiotics, yet there is still an increase in antibiotic prescriptions [118]. There are a lot of factors influencing the prescription of antibiotics by healthcare practitioners including patients request, gap in knowledge and practitioner's education. Indeed, considering the serious situation regarding emerging and quickly disseminating antibiotic resistance there is no justification for prescription antibiotics

Within the literature, there is a lack of scientific evidence showing the additive effect of antibiotics, either prophylactic or therapeutic, in the treatment of dental implant. However, with the demands on restrictive antibiotic policy more studies are needed to assess the benefit of antibiotic prescription and the safety to refrain from its use. In order to restrict antibiotic use to fields where it has unquestioned medical value, it is important to investigate the need for antibiotics. Therefore, additional RCTs with larger sample sizes and longer follow-up period are needed to determine the role of antibiotic prophylaxis during implant insertion to prevent early implant failure in both uncomplicated/straight forward and complicated cases. Furthermore, different type of complicated cases such as immediate insertion into extraction site, bone augmentation procedures, full jaw surgery and implant surgery in the medically compromised patient, may pose a variable risk of postoperative infection and should therefore be studied separately. In the treatment of peri-implantitis, there is a critical need for double-

[112–114].

28 Dental Implantology and Biomaterial

of antibiotics for the treated individual.

without medical indication [29].

**7. Future prospective and knowledge gap**

Dalia Khalil1\*, Bodil Lund2,3 and Margareta Hultin1

\*Address all correspondence to: Dalia.Khalil@ki.se

1 Department of Dental Medicine, Division of Periodontology, Karolinska Institutet, Huddinge, Sweden

2 Department of Dental Medicine, Division of Orofacial Diagnostics and Surgery, Karolin‐ ska Institutet, Huddinge, Sweden

3 Department of Oral and Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden

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