Two Swedish research teams from Malm University and Goteborg University

collaborated to perform a meta-review of various research publications: Review: Prophylactic

antibiotic regimen and dental implant failure: a meta-analysis. The research teams posit the
need for such exploratory meta-analysis as dental surgeons counter-intuitively and possibly
overprescribe antibiotics out of concern for possible malpractice claims although many of these
dental professionals do not necessarily view such drug administration as absolutely necessary in
their patients. In fact, growth of antibiotic-resistant strains of bacteria; possible anaphylaxis and
hypersensitivity in certain patients; and inadvertent discouragement of regimented, aseptic
surgical techniques by dental surgeons dissuade widespread pre- and post-operative antibiotic
use. Moreover, antibiotic drug administration is costly to surgery patients who already face large
dental healthcare and surgery expenses. Also, ambiguous recommendations for prophylactic
antibiotics; little to no research evidence available validating drug use in endosseous implant
patients; and the mutability and recursive nature of oral surgery guidelines using retrospective
analyses necessitated the thorough review of any existing studies on such antibiotic use.

The authors of the study implemented principles from Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) in this meta-analysis. In terms of the studys
objectives, the Swedish universities defined the null hypothesis as no difference in the dental
implant failure rates and post-operative infection rates between groups administered with a
prophylactic antibiotic vs. a placebo and formed the alternative hypothesis as a difference in
these two aforementioned patient outcomes in the treatment vs. placebo groups. PubMed, Web of
Science, and Cochrane Oral Health Group Trials Register comprised the three databases in which
an electronic search with both unrestricted language and data parameters was conducted.
Specifically, in the PubMed search, parameters set in the electronic search included the subject
phrase, dental implant OR dental implant failure OR dental implant survival OR dental implant
success, and the adjective phrase, antibiotic prophylaxis [text words]. Then, in the Web of
Science search, the subject and adjective phrases were respectively dental implant failure OR
dental implant survival OR dental implant success and antibiotic prophylaxis. Similarly,
the phrases dental implant OR dental implant failure OR dental implant survival OR dental
implant success and antibiotic prophylaxis were implemented in the Cochrane Oral Health
Group Trials register search. For all three aforementioned databases, the subjective and adjective
operands were used with the and operator. In addition to these databases, the Swedish
researchers conducted a manual search for publications in periodontics, prosthodontics, and oral
surgery journals like British Journal of Oral and Maxillofacial Surgery; Journal of Oral
Rehabilitation; Journal of Periodontology; and the Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology, and Endodontology; a total of nineteen journals were manually searched. In
addition to these sources, websites detailing clinical trial findings were vetted.
Based on this collection of search strategy results and manually chosen journal articles, the
authors further reduced the pool of applicable reports with inclusion criteria of randomized
clinical human studies and nonrandomized clinical human studies that quantified dental implant
failures and successes in a patient treatment group vs. placebo group; furthermore, exclusion
criteria included case reports, technical reports, in vivo studies, in vitro studies, and review
papers.

Once this collection was procured, the researchers whittled down the number of
qualifying reports by initially vetting the titles and abstracts of electronic search reports, of
which full reports were obtained if not readily available. Also, the collection was further
examined for risk of bias potential relating to sequence generation, allocation concealment,
incomplete outcome data, and blinding protocol. Low bias potential met all four aforementioned
criteria; moderate risk bias, three criteria; and high risk bias, two or less criteria. Only relevant
phrases and terms were extracted from the various reports; such extracted data included study
design, pre- and post-operative antibiotics, failed implants, placed implants, grafting procedure
usage, etc.

The two primary patient outcome measures examined included implant failure rates and
post-operative infection rates. Moreover, measure for heterogeneity across all the reports was
conducted on increment levels of 25%, 50%, and 75% corresponding to low, moderate, and high
heterogeneity, respectively. Another statistic method, the inverse variance method, mitigated the
effects of variance on the aggregated weights of two or more variables for several model types.
PRISMA meta-analysis was conducted for low heterogeneity studies. Review Manager was the
software that analyzed the data, and bias measurements were visualized using a funnel plot.
Upon review by all three of the studys authors, 311 reports were selected via the database;
however, only 28 records were qualified after implementing exclusion criteria. Duplicated
research terms further resulted in 15 remaining reports, which yielded the final quantity of 14
reports that included 11 database records that met inclusion criteria and 3 manually searched
studies. All of the qualifying studies were blind in research protocol, and the data comprised of 8
randomized controlled trials (RCTs); 4 controlled clinical trials (CCTs), and two retrospective
studies. Patient ages and quantity of patients were also included. Follow-up times for the
included reports ranged from 4 months to 6 months for post-operative evaluation. Several of the
reports opted out of post-operative prophylaxis use; other studies variegated antibiotic-type in
their patients. Four reports omitted data on anti-microbial mouth rinse usage. Half of the
examined reports implemented amoxicillin for their dental surgery patients. Dosage for pre-
operative antibiotics ranged from 1 to 2 grams for amoxicillin and included 1 gram of
phenoxymethylpenicillin. Post-operative antibiotics for some of the reports also included 1 gram
of phenoxymethylpenicillin, 1 gram of amoxicillin two times a day for 7 days, three doses of 375
mg ampicillin and sulbactam cocktail, and 500 mg of amoxicillin four times a day for two days.
Data for chlorhexidine mouth rinse ranged from single pre-operative use and post-operative use
twice a day for 7 days; pre-operative use and post-operative use twice a day for 15 days; and pre-
operative use and post-operative use for 4 to 5 times a day for 7 days. Moreover, numerical
outcome data on failed and placed implants; implant failure rate; P-value for implant failure rate;
post-operative infection rate; etc. were included. Implant surface modification type (e.g. Acid-
etched- oxidized, sand-blasted) and brand were also included. Grating information was also
included in the initial review, as well as observations on patients smoking habits, diabetes
medical history, etc.
Also, in terms of quality assessment quantified by bias potential, all of the included
studies were tabulated in meeting or not meeting the randomized sequence generation, allocation
concealment, incomplete outcome data, and blinding criteria. Further categorization yielded half
of the reports as having high risk for bias; one report, moderate risk for bias; and six reports, low
risk for bias. Also, two statistical models were used: random-effects model, in which a hierarchy
of data populations yielded a hierarchy in data differences, and a fixed-effects model, in which
all data parameters are non-random. Consequently, a random-effects model was assigned for
implant failure and success rate evaluation, and a fixed effect model was assigned to post-
operative infection rates.