Patients will sometimes ask, "Do I really need antibiotics after implant surgery?" Patients will often ask this due to previous adverse drug reactions, such as GI distress or a superinfection, such as a yeast infection. If the implant surgery is simply placing an implant in an old extraction site, antibiotics are often not needed. Using a mouth rinse such as PeridexTM or Stella LifeTM is all that is required. These rinses inhibit bacterial growth topically. However, as the procedures get more complicated, antibiotics are advisable. It is preferred to have faster tooth replacement options that require fewer surgeries. Examples of faster treatment options include placing implants at the time of tooth extraction and performing bone or soft tissue grafting.

Duration of antibiotics

The next question is, how long do I need to take the antibiotic? In the past, antibiotics were given for seven days. However, this was based on a seven-day week, not scientific evidence. Current research shows that antibiotic regimens can be shortened to as little as 3 days. This can be an advantage because it minimizes the risk for adverse drug reactions such as GI distress as well as decreases the incidence of bacterial resistance. For every day that we do not use antibiotics, we reduce the incidence of bacterial resistance by as much as 7%. Therefore, decreasing post-operative antibiotics from 7 to 3 days can decrease bacterial resistance by 28%. Globally, at least 1.27 million deaths are directly attributable to bacterial antibiotic resistance each year. A 28% reduction in this number would be huge. 

Antibiotic of choice

The most effective antibiotic for implant surgery is amoxicillin or penicillin, as it offers the best coverage against bacteria commonly found in the oral cavity. This antibiotic has few side effects and is inexpensive. Penicillin was discovered in 1928, yet it is still the best antibiotic used for implant surgery. But what can be done if patients state they are allergic to penicillin? For many years, clindamycin has been the drug of choice for a patient who is allergic to penicillin. The problem with clindamycin is that it is bacteriostatic in nature, which means it only inhibits the growth of bacteria.

In comparison, a bactericidal antibiotic is one that kills bacteria. The failure rate of implants is six times higher in a patient who is taking clindamycin after surgery. Clindamycin is also the antibiotic that has the highest incidence of a superinfection in the GI system from C. difficile.  There are approximately 30,000 deaths a year in the United States because of this infection. Because of these issues, clindamycin is no longer recommended.

Alternative antibiotics

The problem then becomes—what antibiotic can we give? The ideal antibiotic is one like penicillin. The first strategy has been to examine patients who report penicillin allergy, which accounts for approximately 10% of the population. However, only 1% of the population is truly allergic.  Many doctors are now testing for allergies or de-labeling these patients so they can be given amoxicillin. Another strategy is to administer an antibiotic in a similar category to penicillin, such as KeflexTM. It has the same bacterial coverage; yet, it was thought that patients who were allergic to penicillin might be allergic to Keflex, and that the cross-over allergy was as high as 24%. However, it's been found to be only 1%. For patients who have not had an anaphylactic reaction to penicillin, Keflex could be given.

What do we do if a patient is allergic to almost everything? A possibility could be to combine two antibiotics that are ineffective by themselves but can work together to have similar bacterial coverage as penicillin. An example of this strategy is the use of doxycycline and FlagylTM. Ongoing research has shown that this combination is very effective.

Other antibiotics, such as Levaquin or a Z-pack, have been used for implant surgery. Still, either the risk of severe side effects or poor bacterial coverage has prevented their widespread use.

In conclusion, antibiotics are typically used for most implant surgeries. If a patient is having implant surgery, they should ask why a particular antibiotic is needed. What is the duration of the antibiotic, and what are the possible side effects?

John Freeman, MD, DDS, is a graduate of the world-renowned Vanderbilt School of Medicine as well as the University of Oklahoma College of Dentistry. He is a board-certified oral and maxillofacial surgeon. He is a fellow of the American Association of Oral and Maxillofacial Surgeons, the International Association of Oral and Maxillofacial Surgeons, and the American College of Surgeons. He is in private practice in the Houston area at 705 South Fry Road, #200, Katy, Texas, and can be contacted through his website, yourfacedoc.com, or his email johnfreemanmd@ymail.com.