**2. Prophylactic use of antibiotics during surgery**

#### **2.1. Peri-operative antibiotic treatment and extended prophylaxis**

The empirically based tradition of using a peri-operative systemically administered prescrip‐ tion of antibiotics originates from the introduction of the treatment method by PI Brånemark and collaborators [2] during the 1970s. The original implant placement protocol recommended the use of antibiotic treatment during the initial phase of healing, for up to 10 days, to prevent postoperative infection and early implant failure [16, 17]. A two-staged surgical protocol for implant placement was initially introduced to further prevent infection [18]. The rationale for prescribing the extended antibiotic prophylaxis was, at the time of introduction, based on empiric medical/orthopedic considerations. Today, one has to remember that one of the key factors in making the method successful was the addition of a tissue preserving surgical technique. This technique minimized the risk of bacterial contamination during surgery, which at the time included the extended use of systemic antibiotic treatment.

It has been shown that bacterial contamination during implant insertion may be one of the major reasons for early implant failure [19]. Oral implant surgical procedures are often graded as class II surgical procedures (clean-contaminated surgery) [20, 21]. Clean-contaminated surgery has a local infection rate of 10–15% (**Figure 1**). However, the incidence of infection can be reduced to 1% or less with proper surgical technique and the use of prophylactic antibiotics [20, 21]. Conversely, prophylactic antibiotics can never make up for poor surgical technique and hygienic measures. However, during the past decade, due to the emergence of bacterial antibiotic resistance, the recommendation of extended prophylactic antibiotic treatment has been challenged. Scientific evidence from various surgical fields including placement of dental implants shows no benefit of antibiotic prophylaxis beyond the day of surgery in uncompli‐ cated routine cases [22–25]. Therefore, this extended antibiotic treatment is now increasingly being replaced by a single-dose antibiotic prophylaxis.

**Figure 1.** Surgical wound infection classification and the estimated percentage risk for postoperative infections [20, 21].

#### **2.2. Short-term, single-dose antibiotic prophylaxis**

Therefore, original or consensus-based recommendations, such as the use of antibiotics in implant dentistry, are being reevaluated. Previous policies of prescribing antibiotics, until it is proven safe to refrain from their use, are today considered an outdated option in otherwise healthy patients. Currently, the potential risk of using antibiotics must be weighed against

A dental implant is a titanium device anchored and integrated into the jawbone. Osseointe‐ grated dental implants have been an established treatment modality for replacing missing teeth since the beginning of the 1970s [2]. A substantial number of studies using long-term follow-ups have shown successful results for patients with partially and completely edentu‐ lous jaws [3–8]. Survival rates of 90–100% of inserted implants have been reported in several longitudinal studies during follow-ups of up to 20 years later [4, 9–14]. Despite the high success

Biological implant failures may be categorized into early failures, that is, failure to achieve osseointegration due to surgical trauma, infection, lack of primary stability [15], or late failures, that is, failure to maintain the achieved osseointegration, due to occlusal overload, periimplantitis, or both [15]. Implant failure is an outcome that may require implant removal [15].

The empirically based tradition of using a peri-operative systemically administered prescrip‐ tion of antibiotics originates from the introduction of the treatment method by PI Brånemark and collaborators [2] during the 1970s. The original implant placement protocol recommended the use of antibiotic treatment during the initial phase of healing, for up to 10 days, to prevent postoperative infection and early implant failure [16, 17]. A two-staged surgical protocol for implant placement was initially introduced to further prevent infection [18]. The rationale for prescribing the extended antibiotic prophylaxis was, at the time of introduction, based on empiric medical/orthopedic considerations. Today, one has to remember that one of the key factors in making the method successful was the addition of a tissue preserving surgical technique. This technique minimized the risk of bacterial contamination during surgery, which

It has been shown that bacterial contamination during implant insertion may be one of the major reasons for early implant failure [19]. Oral implant surgical procedures are often graded as class II surgical procedures (clean-contaminated surgery) [20, 21]. Clean-contaminated surgery has a local infection rate of 10–15% (**Figure 1**). However, the incidence of infection can be reduced to 1% or less with proper surgical technique and the use of prophylactic antibiotics [20, 21]. Conversely, prophylactic antibiotics can never make up for poor surgical technique and hygienic measures. However, during the past decade, due to the emergence of bacterial antibiotic resistance, the recommendation of extended prophylactic antibiotic treatment has been challenged. Scientific evidence from various surgical fields including placement of dental

possible benefits for individual patients when undergoing dental implant treatment.

rate of dental implants, failures do occur.

20 Dental Implantology and Biomaterial

**2. Prophylactic use of antibiotics during surgery**

**2.1. Peri-operative antibiotic treatment and extended prophylaxis**

at the time included the extended use of systemic antibiotic treatment.

There are several clinical studies [26–36] summarized in systematic reviews showing that the use of prophylactic antibiotics during dental implant insertion reduces the risk of implant failure [22, 37]. However, this finding has recently been questioned [38, 39]. For example, none of the randomized controlled studies included in a recent meta-analysis [38] showed a statistically significant beneficial effect of antibiotic prophylaxis on their own [27, 30, 31, 40, 41], although the beneficial effect could not be excluded in complex or compromised patients [38, 42]. Therefore, this issue remains a controversial subject under constant revision, and recommendations based on sound scientific evidence are still lacking. Despite this, the routine use of antibiotics during implant placement continues to be common among the majority of dentists in most countries [43–45]. These results today have thus left the clinician with inconclusive recommendations. However, it should also be kept in mind that there are several factors in addition to the use of prophylactic antibiotics during implant placement that can affect implant success rates, such as implant systems, duration of surgery, the number of implants placed, as well as surgical skills [29].
