Knowledge and Prescription Habits toward Preoperative Antibiotics in Implant Dentistry: A Survey Analysis in a Subset of Dentists in Saudi Arabia

INTRODUCTION

Dental implants are considered one of the major game changers in dentistry.¹ The popularity of using dental implants among dental practitioners and the increase demand of patients to have fixed tooth replacement is evident in published literature. With the growing utilization of these devices in modern dentistry, a certain number of implants may fail at the early stages of remodeling due to bacterial contamination.² Accordingly, this situation increased the demand for antibacterial coverage to reduce the chances of failure. Thus, it may be argued that preoperative prescription of antibiotics to reduce any potential infections or implant failures is advocated especially when local and/or systemic factors are present.^3,4

The beneficial role of antibiotics had conflicted results in the literature. Laskin et al. reported that high survival rate of implants was found in patients who received preoperative antibiotics.⁴ Alternatively, Gynther et al. reported that antibiotic administration had no effect in reducing postoperative complication and/or failures.⁵ With the controversies in the literature, a recent meta-analysis of randomized clinical trials showed that prophylactic antibiotics administration for low-risk, healthy patients may reduce the potential of implant failure.⁶ However, there were no conclusive findings about what specific antibiotic, dosage, duration, and any confounding variables that may have influenced the outcomes.

Globally, the potential risk of prescribing antibiotics for low-risk dental implant patients arise from the recent reports of bacterial-resistant species that may complicate the future general health of different human populations.⁷ In addition, the required knowledge of different types of antibiotics is crucial for dentists who practice implant dentistry on regular bases.⁸ Although growing evidence from the literature suggest that preoperative administration of antibiotics may decrease the event of failures with minimal postoperative complications,^9,10 it is of utmost importance for dentist to understand and implement prescription habits that have an acceptable level of balance between potential risks and benefits according to patients individual needs.¹¹

Several reports describe the knowledge, habits, and behaviors regarding prescription of antibiotics among populations of health-care providers. In dentistry, the most common themes for prescribing antibiotic medications were evident in conditions related to infected teeth and dental implants.¹² However, a distinctive variation toward type, dose, and frequency for antibiotic administration was noticed.^13,14 Addressing this issue as early as possible in dentist careers is crucial to establish drug management policies and provide medication prescription stewardship programs in dental education. Thus, our primary objective is to investigate the knowledge and practice toward preoperative antibiotics prescription in healthy dental implant patients among dentists in Saudi Arabia. Second, we want to explore and identify prescription habits toward specific clinical and nonclinical situations among sample participants.

MATERIALS AND METHODS

After receiving institution review approval (no. E-19-4278), a subset of dental practitioners was targeted using the database of the Saudi commission for health specialties. An online-based survey was distributed to licensed dental practitioners, of different specialties and education levels, in central region of Saudi Arabia. The survey construction was formulated after reviewing recent publications of the subject in matter.^6,14 About 200 potential participants who currently practice the surgical placement of dental implants were approached to participate. Only those who did not completed the whole survey were excluded from the study sample. The survey questionnaires consisted of 24 items; 8 questions covered the basic demographics of participant. Then, the survey was prepared to address the research objectives in three parts: the first part consisted of six items that targeted the knowledge level of participants toward antibiotics use in implant dentistry (Table 1). The second part involved seven items evaluating the habits and practice of preoperative antibiotics prescription in routine dental implant procedures (Table 2). Finally, three items addressed participants’ background of acquired knowledge in addition to certain habits of prescribing preoperative antibiotics toward specific case scenarios (Table 3). The initial draft of the survey questionnaire was reviewed by two independent specialists for consistency, followed by reliability and validity testing and retesting on five postgraduates and five specialists within 1-week period. The final version was then distributed via web-based forms (Google Forms; Google LLC, Mountain View, CA, USA) and response was recorded and tabulated. Data were analyzed using SPSS 24.0 version (IBM Inc., Chicago USA) statistical software. Descriptive statistics (frequencies and percentages) were used to describe the categorical variables. Pearson’s Chi-square test was used to compare the distribution of the categorical responses across focused survey variables. A p value of ≤ 0.05 was used to report the statistical significance of the responses.

RESULTS

Only 156 completed the whole survey with a response rate of 78% from the original participants. A total of 120 (76.9%) participants were male subjects. Only 21.2% of them were with bachelor’s degree, and the remaining participants were with higher educational qualification. There was approximately a comparable distribution of dental residents and practitioners among the sample study with more than two third of them were periodontics specialty. The experience in surgical implants placement was about 48.1% of them having less than 5 years of practice, while the place of practice was distributed equally across academics, public, and private sectors. One participant did not respond to the question “source of dental education” by leaving a blank statement and was excluded from the analysis for this item. Thus, of 155 participants, more than 60% of them had postgraduate residency as their source of dental implant education followed by implant fellowship programs (23.9%). A summary of sample characteristics is shown in Table 4.

DISCUSSION

Our findings showed that an increased number of participants do not prescribe prophylactic antibiotics in routine dental implant surgery (63.5%). This is conflicting with recently reported similar studies by Al-Kattan, Al-Shibani and El-Kholey et al. where both reports had higher percentage of prescribing habits preoperatively.^14–15 A possible explanation of this might be the lack of adequate sample size between the two investigations and the current work. Also, the variability of sample characteristics might suggest why responses where different, where in this study we included periodontist for both training residents and specialist. Froum and Weinberg reported that periodontists’ prescription was variable for prophylactic antibiotics, and less than 35% would choose to administer preoperatively.¹⁶ This agrees with our findings especially that most of the respondents were periodontists of both groups. Another possible factor that may contribute to our findings is the increased awareness and strict measurements that direct dental practitioner to limit the use of antibiotics for low-risk patients and was evident in the decline of prophylactic antibiotics for routine implant procedures.¹⁷

In this study, we found that an elevated number of participants were aware of guidelines and/or consensus pertaining to prophylactic antibiotics which is similar to previous reports.¹⁴ While most of the respondents suggest the need to establish protocols in this matter, it was found that private practitioners were not in agreement with this issue. In addition, the significance of private practitioners to prescribe more antibiotics in comparison to other working sectors was evident (Table 1). This may be explained by the difference in workplace protocols where non-private sectors mandate strict policies and procedures for antibiotic prescriptions. Erbay et al. found that restrictive policies for antibiotics may aid in the reduction of unnecessary prescription habits.¹⁷ Furthermore, the interventional policies was found to have a positive impact in behavior change among dental practitioners and support the reduction of antibiotic prescription misuse.¹⁸ In a consensus report by the European Association of Osseointegration, one of the main conclusions found that there is no beneficial impact of antibiotic prophylaxis for straightforward dental implant scenarios.¹⁹ Furthermore, the recent meta-analysis done by Braun et al. supports this conclusion.⁶ Accordingly, it is advocated that policies and interventions should be expanded to involve private practitioners too.

The balance between risk and benefit when prescribing prophylactic antibiotics is a crucial step for the overall management in dental implantology. Additionally, choosing between single and multiple prophylactic antibiotics has been reported to be of variable importance. El-Kholey, in a pilot study, found that there is no difference between both modalities of prescriptions regarding implant survival.²⁰ One of the highlights of this study is the increased level of knowledge toward the possible unwanted adverse effects with the use of multidose compared with single-dose prophylactic antibiotics. This is supported by recent studies where increased adverse events were more evident in multidose regimens.^9,10 While it is argued that a highly concentrated antibiotic regimen will provide similar therapeutic outcomes to a multiple dose, but with minimal adverse events in routine implant placement,¹⁰ the importance of consenting the potential risk vs benefits and tailoring decision making with prophylactic antibiotics in accordance with patients’ needs could help in minimizing prescription overdosing and promote a better prescription practice. Although we did not investigate the method of consenting, most of the respondents shared a positive agreement in this matter (Table 5).

Most of the respondents in this study preferred the 1-hour protocol preoperatively, with amoxicillin/augmentin group and a dose of 1000–2000 mg. Along the way, twice and three times daily was the preferred choice for a multidose prescription. This agrees with previous reports done by Al-Kattan and Al-Shibani, where most participants prescribe 1000 mg of amoxicillin.¹⁴ Also, our respondents were similar in the matter of choosing either amoxicillin/augmentin preoperatively and were similar to results obtained by El-Kholey et al.²¹ However, their sample study tends to prescribe more postoperative medication compared with the present investigation (Table 2). Esposito et al. suggested that 2 g of amoxicillin administered 1 hour before the implant procedure led to the reduction of implant infection and failure.²² On the contrary, Park et al. reported that there is no clinical advantage of antibiotic prophylaxis for routine patients receiving dental implants.²³ However, in a recent metal-analysis of randomized clinical trials, Braun et al. found that prescription pattern of either preoperatively and/or postoperatively was significantly different when compared with no prescription and/or placebo.⁶ Although the meta-analysis was concerned with the implant infection/failure as the primary outcome, it is worth mentioning that lowest failure rate was best achieved for the prophylactic prescriptions.⁶ Thus, variable reports among national^14,21 and international^13,24 toward prescription patterns need to addressed by local and global professional and scientific organizations to provide more collaborative work to ultimately educate dental practitioners and trainees about most recent consensus and available evidence.

One of the important aspects of this study is that we tried to explore participants knowledge and habits with the practice of antibiotic prescriptions when challenged by local, environmental, and systemic diseases/conditions in addition to the background of information they acquired. Majority of study samples relied on previous training programs and scientific publications as the primary source of knowledge. This finding was not reported in previous studies. Furthermore, the selected sample reported that the main purpose of antibiotic prescription was to reduce infection of dental implants (Table 3). This can be explained by the fact that dental implant surgery is an invasive procedure which may increase the chance of developing infections and thus requires chemotherapeutic coverage to reduce the chance of bacterial contamination.²⁵ Also, we identified that a moderate percentage of participants prescribe antibiotics for elderly patients or with systematic conditions including rheumatic heart disease, coronary artery bypass graft, mitral valve prolapse, and prosthetic joint replacement (60.4, 48.7, 51.9, and 48.1%, respectively). However, recent consensus does not support prophylactic antibiotics in these situations anymore.^26,27 These findings suggest that traditional ways of acquiring knowledge may need to be revised. Nonetheless, a growing evidence is advocating the necessity of practice stewardship directed to dental practitioners to avoid misuse and needless antibiotic prescriptions.

Despite its exploratory nature of this study, we attempted to address several factors pertaining to the knowledge and behavior of preoperative antibiotics. Also, we carried out further investigations to analyze clinical and nonclinical factors that influence prescription behaviors. We understand that the sample size achieved in our study need to be larger and involve other regions within Saudi Arabia. However, with the extensive variables acquired through the survey items and focusing on one region of the country, we successfully identified a significant factor which was not previously reported and requires more attention. Also, further studies which take these variables into account will need to be undertaken to develop a full picture of this topic. Furthermore, with the diversity of responses and contradictory results regarding similar studies entails the need to have a more revision and contemplation of what we considered before as “reputable” source of knowledge starting from dental schools. Finally, the implementation of recent guidelines and administrative supervision in all dental sectors should be considered by healthcare officials.

CONCLUSION

Despite the study limitations, this work offers valuable insights into knowledge and certain habits of dental implant practitioners toward prophylactic antibiotics. The methods used for this survey may be applied to large-scale analysis to have better understanding of different behaviors and beliefs. Also, the presented diversity and conflicting opinions require more attention by health authorities to develop a standard guideline that is backed up with recent evidence-based research to reduce nonessential antibiotic prescription.

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