Patients who report penicillin allergies see higher dental implant failure rates
Click Here to Manage Email Alerts
Dental implant failures were more common among patients who reported a penicillin allergy and received other antibiotics than those who used amoxicillin, according to a study published in Clinical Implant Dentistry and Related Research.
“More than 100 million people in the U.S. are missing at least one tooth, which may affect their ability to comfortably eat, speak or smile. In some cases, tooth loss may majorly and unfavorably impact the patient's health and lifestyle,” Zahra Bagheri, DDS, CAGS, MsD, clinical assistant professor with the Ashman department of periodontology and implant dentistry at New York University (NYU) College of Dentistry, told Healio.
Patients can take advantage of options such as bridges and dentures based on their missing teeth and their health, Bagheri said. However, bridges may compromise neighboring healthy teeth, and removable dentures can be inconvenient and may even cause bone loss in the jaw, she continued.
“In contrast, dental implants are more convenient and functional, and they are the closest replica to natural teeth compared with alternative options, making them one of the best tooth replacement options recommended to patients,” Bagheri said.
Although they have a success rate of more than 90%, Bagheri said, a small percentage of dental implants consistently fail, posing challenges for both the patient and the treating clinician. Also, she said, these failures are not completely understood.
“Studies have demonstrated multiple factors for implant failure, which are most often due to infection, or instability of the implant at the time of placement,” Bagheri said, adding that some failures may be due to the body rejecting the implant as a foreign material or due to mechanical forces.
“This study was an attempt to look more closely at one factor that could contribute to implant failure,” Bagheri said.
The study’s design and results
Dental providers typically prescribe amoxicillin, which is the most commonly used antibiotic in dentistry, before and after dental implant surgery to reduce the odds for infection. Patients who report a penicillin allergy receive alternative antibiotics, although previous studies have indicated higher failure rates for these patients.
The researchers examined the records of 838 patients (mean age, 61.4 years; women, n = 468) who received titanium implants placed by dentists at NYU College of Dentistry, including 434 patients who reported a penicillin allergy.
The patients who reported a penicillin allergy were prescribed clindamycin, azithromycin, ciprofloxacin or metronidazole at typical dosages before and after surgery.
The researchers considered implants to be failures if they needed to be removed due to a lack of osseointegration as determined by implant mobility. Overall, 12.9% of these implants failed, with a 13.2% rate among men and 12.6% rate among women.
Patients who did not report a penicillin allergy experienced an 8.4% failure rate, whereas those who did report an allergy had a 17.1% failure rate (adjusted OR = 2.22; 95% CI, 1.44-3.44).
The patients who received clindamycin, which was the most common alternative antibiotic, were at higher risk for implant failure as well (failure rate, 19.9%: aOR = 2.9; 95% CI, 1.77-4.74). Other antibiotic treatments had an adjusted OR of 2.77 (95% CI, 1.77-4.32) for failure.
Most of the failures among the patients reporting a penicillin allergy occurred during the first 6 months after the procedure, whereas most of the failures in the group receiving amoxicillin occurred more than 12 months later.
Recommendations for clinicians
The researchers noted the important distinction between reported and true penicillin allergies, as approximately 10% of the U.S. population reports a penicillin allergy though less than 1% actually are allergic.
Also, the researchers cautioned that the 12.9% overall implant failure rate they found is higher than conventionally accepted rates of about 3% to 5% in dentistry. They indicated that this higher rate may be due to the higher rate of patients reporting a penicillin allergy in their population, which was about 50%, or the skill levels of the students performing these procedures.
Bagheri said that a close collaboration between allergists and dentists could improve dental implant outcomes and that allergists should encourage patients who are diagnosed with different allergies to communicate their medical condition to their dentists.
Yet there is still insufficient evidence to provide an explanation for why patients who report a penicillin allergy have an elevated risk for implant failure, Bagheri said, adding that a penicillin allergy test may increase success for those patients.
“A clinical prospective study consisting of a test of both titanium and penicillin allergy should succeed the present study to determine the dental implant failure rate in truly allergic patients and the prevalence of these two concurrent sensitivities. This will also serve to establish a true association between the use of penicillin and successful outcomes of dental implants,” Bagheri said.
For more information:
Zahra Bagheri, DDS, CAGS, MsD, can be reached at zb8@nyu.edu.
Perspective
Back to Top
Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FIADFE, DICOI, DADIA, DIDIA
Unfortunately, many patients who claim allergy to drugs such as penicillin indicate that they had a reaction at the time of the administration of the drug, which could have been a rash or some other minor issue, and they assumed it was drug related. But few of those patients underwent testing to confirm it was an allergy to the drug. We also may have patients who are allergic but have not encountered the drug before, so they have no idea that they are allergic.
As many doctors routinely place patients who are getting implants on penicillin-type drugs, there could be increased implant failure, as this report outlines. There has been a shift in recent years to avoid premedicating patients with antibiotics for these procedures unless infection was noted at the site during the implant placement appointment either clinically or radiographically.
I have not seen results that match the findings of this study, but failure can be a multifactorial event, and the antibiotic may be one factor. Fortunately, we normally see a very low failure rate during the first year. This study found an overall failure rate of 12.9%, which is much higher than other published studies. This study needs to be analyzed to determine what factors could have generated its much higher rate, and it does outline some factors that could have led to this data result.
Clinicians need to update themselves about what medications should and should not be used based on current evidence that can affect hard and soft tissue healing. Increasing evidence has shown that patients on antidepressant medications have a higher failure rate because these drugs affect osseointegration. Chlorhexidine has been shown to affect fibroblasts interfering with healing.
With regard to antibiotics, perhaps clinicians should avoid penicillin-type drugs and clindamycin as an alternative and switch to doxycycline, which has been shown to have no effect on implant integration and is effective on oral bacteria.
In this study, antibiotics were routinely used at implant placement as a precaution, but studies have shown that this practice was not backed by science and evidence but by speculation. Just as antibiotic premedication prior to some dental treatment has changed over time as evidence has emerged, further studies need to be performed to determine under what conditions antibiotic use is needed with implant surgery and which antibiotics have negative effects on osseous healing.
Collapse
Read more about
Click Here to Manage Email Alerts