Dalia Khalil Margareta Hultin Linda Andersson Fred Nina Parkbring Olsson Bodil Lund
Authors’ affiliations: Dalia Khalil, Margareta Hultin, Department of Dental Medicine, Division of Periodontology, Karolinska Institutet, Huddinge, Sweden Linda Andersson Fred, Nina Parkbring Olsson, Swedish Public Dental Service, Stockholm, Sweden Bodil Lund, Department of Dental Medicine, Division of Orofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden and Department of Oral and Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
Antibiotic prescription patterns among Swedish dentists working with dental implant surgery: adherence to recommendations
Key words: antibiotic prophylaxis, implant insertion, prescription behavior Abstract Objectives: To investigate antibiotic prophylaxis prescription behaviors among Swedish dentists working with dental implant surgery and the influence of scientific reviews. Material and methods: An observational questionnaire study was conducted in 2008 and 2012. Dental clinic addresses were found through online search services of Swedish telephone directories. The questionnaires were posted to eligible dentists (120 in 2008, 161 in 2012) in the Stockholm region, Sweden. Absolute frequencies were used to describe the data. Chi-square tests were
Corresponding author: Dalia Khalil, DDS Department of Dental Medicine Division of Periodontology Karolinska Institutet P.O. Box 4064, SE-141 04 Huddinge, Sweden Tel.: +46 768256380 Fax: +46 87118343 e-mail: [email protected]
applied to assess statistically significant differences. Results: The response rate was 75% in 2008 and 88% in 2012. In 2008, 88% of the dentists routinely prescribed antibiotic prophylaxis when performing implant surgery and 74% in 2012 (P = 0.01). There was a significant reduction in the dentists prescription patterns as 65% prescribed a single dose in 2012, compared to 49% in 2008 (P = 0.04). Amoxicillin was the drug of choice for 47% of the respondents in 2012, and 21% in 2008 (P = 0.01). Dentists without postgraduate clinical training were significantly more prone to extend antibiotic administration after surgery (P < 0.009). Conclusions: There is a wide variation in the choice of compound and prescription patterns of prophylactic antibiotic prior to implant insertion. A reduction in antibiotic prescription to a single dose was observed comparing 2008 and 2012, probably influenced by scientific reviews. Dentists with postgraduate education are more likely to limit antibiotic usage.
Date: Accepted 18 March 2014 To cite this article: Khalil D, Hultin M, Fred LA, Olsson NP, Lund B. Antibiotic prescription patterns among Swedish dentists working with dental implant surgery: adherence to recommendations. Clin. Oral Impl. Res. 00, 2014, 1–6 doi: 10.1111/clr.12402
Dental implants insertion is a routine treatment modality for the rehabilitation of partially and completely edentulous jaws. Longterm follow-up has shown successful results in a previous number of studies (Albrektsson et al. 1988; Lekholm et al. 1999; Ekelund et al. 2003; Jemt & Johansson 2006). Moreover, implant survival rates of 90–95% have been reported in longitudinal studies of up to 20 years (Pjetursson et al. 2004; Lekholm et al. 2006; Roos-Jansaker et al. 2006; Astrand et al. 2008). Despite the high success rates, failures do occur and may be categorized as either early failures, occurring prior to prosthetic restoration, or late failures, after placement of the prosthesis. Causes for early implant failures include lack of primary implant stability, surgical trauma, and perioperative contamination (Sakka et al. 2012). Late failures have been suggested to be associated with occlusal overload and peri-implantitis (Klinge et al. 2012; Naert et al. 2012; Sakka et al. 2012; Chang et al. 2013).
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Oral surgical procedures are often graded as class II (clean-contaminated surgery), with a rate of local infection of 10–15%. The incidence of infections is reduced to 1% with proper surgical technique and prophylactic antibiotics (Olson et al. 1984; Peterson 1990). Antibiotics have been used in the last decade to prevent local and systemic bacterial infective complications. However, the harm to the public health and the undesirable effects of antibiotics when used as prophylaxis regimens cannot be neglected (Bidault et al. 2007). The potential benefit of antibiotic regiments during routine dental implant insertion is a controversial subject, and many dentists remain convinced of the positive influence of antibiotics during routine implant surgery while others believe they have no effect. Health authorities have reported on the importance of reducing the total use of antibiotics (Huovinen & Cars 1998), primarily because their overuse can lead to the emergence
1
Khalil et al Antibiotics during dental implant insertion
and development of resistant bacterial strains. Side effects such as interaction with other drugs, gastro-intestinal tract distress, secondary infection, toxicity, and allergic reactions must also be considered (Lawler et al. 2005; Resnik & Misch 2008). The risk of inappropriate use of antibiotics and widespread antibiotic resistance appear to be far more important than possible perceived benefit (Tong & Rothwell 2000). A scenario in which all antibiotics become ineffective for treating even common infections in the near future has been suggested by the Global Economic Forum which ranked the development of antibiotic resistance as one of the 31 global risks for 2014 (weforum 2014). Sweden is a leading country in the field of implant dentistry and the technique first introduced by P.I. Br anemark and collaborators during the 1970s (Branemark et al. 1977). The surgical technique developed for placing dental implants also included antibiotic regimens during surgery and a postoperative healing period of 10 days (Adell et al. 1985). Today, dental implant surgery is routinely performed by general dentists as well as specialists, and the number of dental implants placed has dramatically increased (Narby et al. 2008). Antibiotic prescriptions among dentists in Sweden slowly increased until 2007; however, since then, a small reduction in antibiotic prescription has been noticed (Blomgren et al. 2009). Penicillin V is the most commonly prescribed drug, representing 75% of all antibiotics prescribed by dentists in Sweden (Hellman et al. 2013). The Swedish strategic program against antibiotic resistance (Strama) recently published revised recommendations for antibiotic prescription in conjunction with implant surgery (Blomgren et al. 2009). The Swedish Council on Health Technology Assessment (SBU), which is responsible for assessment of several scientific topics in medical and dental health care, published a literature review in 2010 regarding antibiotic prophylaxis in surgery, including dental implant procedures (Ahlberg et al. 2010). As it is of out-most importance to implement a national guideline on the use of antibiotics, the influence of recommendations and reviews as means in this strategic work needs to be assessed. It is, therefore, of interest to compare the antibiotic prescription patterns before and after these publications. The aim of this study was to investigate the antibiotic prescription patterns among dentists in the Stockholm region who perform dental implant surgery and to assess their adherence to recommendations and
2 |
Clin. Oral Impl. Res. 0, 2014 / 1–6
scientific reviews on antibiotic routines during dental implant surgery.
Material and methods Study design
This study is based on an observational questionnaire survey with two cohorts conducted in 2008 and 2012 to investigate whether the recommendations of Swedish strategic programme against antibiotic resistance (Strama) (Blomgren et al. 2009) and the scientific review from SBU (Ahlberg et al. 2010) influenced the antibiotic regimens prescribed by Swedish dentists, who performed >20 dental implant surgical procedures per year. An anonymous questionnaire was sent to all eligible dentists in Stockholm region, Sweden. Data collection
Dental clinics were identified through online search services of the Swedish telephone directory (www.hitta.se and www.eniro.se) using key words “implant”, “dental clinic,” and “Stockholm region.” Clinics were then contacted via telephone, and the project was explained to the dentists. In 2008, the questionnaires were sent to all eligible dentists who agreed to participate (120 dentists in 76 clinics), and in 2012, they were sent to the same clinics with the additions of new clinics established in the intervening period (161 dentists in 105 clinics). The questionnaire included a prepaid envelope and a cover letter explaining the purpose of the study ensuring confidentiality would be maintained. In both surveys, reminder letters were sent to all included clinics. Questionnaire
The questionnaire included two open and 10 closed questions. The first part included demographic data on gender, age, undergraduate training, number of years of clinical experience, implant surgical experience, and implant education. The second part asked about the presence of local clinical guidelines, routines used at the clinic, and policies regarding antibiotic prescription prior to implant insertion as well as local or systematic factors influencing prescription patterns. Two questions inquired about potential benefits from the establishment of national guidelines and interest in gaining information about antibiotic resistance. The 2012 survey included five additional questions concerning respondents’ knowledge of the recent recommendations and scientific review from Strama and SBU, if these had influenced their prescribing behavior.
Data analysis
Statistical analysis was performed using SPSS for Windows release 21.0 (SPSS Inc., Chicago, IL, USA). Absolute frequencies were used to describe the data and chi-square tests to assess statistically significant differences, and the level of significance was P < 0.05.
Results The response rate in 2008 was 75% (n = 90) and 88% (n = 142) in 2012. Due to missing data, primarily regarding routines in prescribing prophylactic antibiotics prior to implant placement, five and nine questionnaires were excluded in 2008 and 2012, respectively. Therefore, 85 responses from 2008 and 133 from 2012 were included in the analyses. Table 1 shows the demographic data for participating dentists. The majority of dentists were male (79%, 2008; 75%, 2012) and in 55 years or older. With regard to their education in implant dentistry, 46% (n = 39) in 2008 had received clinical postgraduate training while the corresponding figure for 2012 was 40% (n = 53). In 2008, 54% (n = 46) reported they had participated in a single course in implant dentistry and 60% (n = 80) in 2012. Moreover, 53% (n = 45) had over 10 years of experience in implant surgery in 2008 and 64% (n = 83) in 2012. Dentists without postgraduate clinical training were significantly more prone to extend antibiotic prophylactic administration beyond the day of surgery (P < 0.009). There was a significant reduction in the number of the dentists reporting the use of a defined local rationale for antibiotic prescriptions during implant surgical procedures between 2008 and 2012 (P = 0.04). There was a significant reduction in the number of routinely prescribed antibiotics between the cohorts (P = 0.01; Table 2). Figure 1 illustrates the significant change in the antibiotics prescribed (P = 0.006). In 2008, 67% (n = 50) of the dentists prescribed phenoxymethylpenicillin (PcV), while 21% (n = 16) prescribed amoxicillin. In 2012, 43% (n = 42) of dentists prescribed PcV and 47% (n = 46) prescribed amoxicillin. Other antibiotics, such as metronidazole and clindamycin, were less frequently used. There was also a significant reduction in the number of dentists prescribing antibiotic beyond the day of surgery between 2008 and 2012 (P = 0.04). In 2012, 65% (n = 63) of the respondents prescribed a single dose of antibiotics compared to 49% (n = 35) in 2008. In 2012, only 35% (n = 34) of the dentists prescribed an antibiotic course for ≥3 days
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Khalil et al Antibiotics during dental implant insertion
Table 1. Demographic data 2008 n = 85 n (%)
Characteristic
Gender Male 66 (79) Female 18 (21) Age (years) 25–34 6 (7) 35–44 18 (21) 45–54 28 (33) >55 33 (39) Undergraduate training Swedish university 82 (98) Abroad university 2 (2) Implant education Single Course 46 (54) Not specified 46 Clinical postgraduate training 39 (46) Oral and maxillofacial surgery 21 Periodontics 15 Pedodontics 1 Prosthodontics 1 Information about antibiotics in implant education Yes 79 (93) No 6 (7) Clinical experience (years)
Authors’ affiliations: Dalia Khalil, Margareta Hultin, Department of Dental Medicine, Division of Periodontology, Karolinska Institutet, Huddinge, Sweden Linda Andersson Fred, Nina Parkbring Olsson, Swedish Public Dental Service, Stockholm, Sweden Bodil Lund, Department of Dental Medicine, Division of Orofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden and Department of Oral and Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
Antibiotic prescription patterns among Swedish dentists working with dental implant surgery: adherence to recommendations
Key words: antibiotic prophylaxis, implant insertion, prescription behavior Abstract Objectives: To investigate antibiotic prophylaxis prescription behaviors among Swedish dentists working with dental implant surgery and the influence of scientific reviews. Material and methods: An observational questionnaire study was conducted in 2008 and 2012. Dental clinic addresses were found through online search services of Swedish telephone directories. The questionnaires were posted to eligible dentists (120 in 2008, 161 in 2012) in the Stockholm region, Sweden. Absolute frequencies were used to describe the data. Chi-square tests were
Corresponding author: Dalia Khalil, DDS Department of Dental Medicine Division of Periodontology Karolinska Institutet P.O. Box 4064, SE-141 04 Huddinge, Sweden Tel.: +46 768256380 Fax: +46 87118343 e-mail: [email protected]
applied to assess statistically significant differences. Results: The response rate was 75% in 2008 and 88% in 2012. In 2008, 88% of the dentists routinely prescribed antibiotic prophylaxis when performing implant surgery and 74% in 2012 (P = 0.01). There was a significant reduction in the dentists prescription patterns as 65% prescribed a single dose in 2012, compared to 49% in 2008 (P = 0.04). Amoxicillin was the drug of choice for 47% of the respondents in 2012, and 21% in 2008 (P = 0.01). Dentists without postgraduate clinical training were significantly more prone to extend antibiotic administration after surgery (P < 0.009). Conclusions: There is a wide variation in the choice of compound and prescription patterns of prophylactic antibiotic prior to implant insertion. A reduction in antibiotic prescription to a single dose was observed comparing 2008 and 2012, probably influenced by scientific reviews. Dentists with postgraduate education are more likely to limit antibiotic usage.
Date: Accepted 18 March 2014 To cite this article: Khalil D, Hultin M, Fred LA, Olsson NP, Lund B. Antibiotic prescription patterns among Swedish dentists working with dental implant surgery: adherence to recommendations. Clin. Oral Impl. Res. 00, 2014, 1–6 doi: 10.1111/clr.12402
Dental implants insertion is a routine treatment modality for the rehabilitation of partially and completely edentulous jaws. Longterm follow-up has shown successful results in a previous number of studies (Albrektsson et al. 1988; Lekholm et al. 1999; Ekelund et al. 2003; Jemt & Johansson 2006). Moreover, implant survival rates of 90–95% have been reported in longitudinal studies of up to 20 years (Pjetursson et al. 2004; Lekholm et al. 2006; Roos-Jansaker et al. 2006; Astrand et al. 2008). Despite the high success rates, failures do occur and may be categorized as either early failures, occurring prior to prosthetic restoration, or late failures, after placement of the prosthesis. Causes for early implant failures include lack of primary implant stability, surgical trauma, and perioperative contamination (Sakka et al. 2012). Late failures have been suggested to be associated with occlusal overload and peri-implantitis (Klinge et al. 2012; Naert et al. 2012; Sakka et al. 2012; Chang et al. 2013).
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Oral surgical procedures are often graded as class II (clean-contaminated surgery), with a rate of local infection of 10–15%. The incidence of infections is reduced to 1% with proper surgical technique and prophylactic antibiotics (Olson et al. 1984; Peterson 1990). Antibiotics have been used in the last decade to prevent local and systemic bacterial infective complications. However, the harm to the public health and the undesirable effects of antibiotics when used as prophylaxis regimens cannot be neglected (Bidault et al. 2007). The potential benefit of antibiotic regiments during routine dental implant insertion is a controversial subject, and many dentists remain convinced of the positive influence of antibiotics during routine implant surgery while others believe they have no effect. Health authorities have reported on the importance of reducing the total use of antibiotics (Huovinen & Cars 1998), primarily because their overuse can lead to the emergence
1
Khalil et al Antibiotics during dental implant insertion
and development of resistant bacterial strains. Side effects such as interaction with other drugs, gastro-intestinal tract distress, secondary infection, toxicity, and allergic reactions must also be considered (Lawler et al. 2005; Resnik & Misch 2008). The risk of inappropriate use of antibiotics and widespread antibiotic resistance appear to be far more important than possible perceived benefit (Tong & Rothwell 2000). A scenario in which all antibiotics become ineffective for treating even common infections in the near future has been suggested by the Global Economic Forum which ranked the development of antibiotic resistance as one of the 31 global risks for 2014 (weforum 2014). Sweden is a leading country in the field of implant dentistry and the technique first introduced by P.I. Br anemark and collaborators during the 1970s (Branemark et al. 1977). The surgical technique developed for placing dental implants also included antibiotic regimens during surgery and a postoperative healing period of 10 days (Adell et al. 1985). Today, dental implant surgery is routinely performed by general dentists as well as specialists, and the number of dental implants placed has dramatically increased (Narby et al. 2008). Antibiotic prescriptions among dentists in Sweden slowly increased until 2007; however, since then, a small reduction in antibiotic prescription has been noticed (Blomgren et al. 2009). Penicillin V is the most commonly prescribed drug, representing 75% of all antibiotics prescribed by dentists in Sweden (Hellman et al. 2013). The Swedish strategic program against antibiotic resistance (Strama) recently published revised recommendations for antibiotic prescription in conjunction with implant surgery (Blomgren et al. 2009). The Swedish Council on Health Technology Assessment (SBU), which is responsible for assessment of several scientific topics in medical and dental health care, published a literature review in 2010 regarding antibiotic prophylaxis in surgery, including dental implant procedures (Ahlberg et al. 2010). As it is of out-most importance to implement a national guideline on the use of antibiotics, the influence of recommendations and reviews as means in this strategic work needs to be assessed. It is, therefore, of interest to compare the antibiotic prescription patterns before and after these publications. The aim of this study was to investigate the antibiotic prescription patterns among dentists in the Stockholm region who perform dental implant surgery and to assess their adherence to recommendations and
2 |
Clin. Oral Impl. Res. 0, 2014 / 1–6
scientific reviews on antibiotic routines during dental implant surgery.
Material and methods Study design
This study is based on an observational questionnaire survey with two cohorts conducted in 2008 and 2012 to investigate whether the recommendations of Swedish strategic programme against antibiotic resistance (Strama) (Blomgren et al. 2009) and the scientific review from SBU (Ahlberg et al. 2010) influenced the antibiotic regimens prescribed by Swedish dentists, who performed >20 dental implant surgical procedures per year. An anonymous questionnaire was sent to all eligible dentists in Stockholm region, Sweden. Data collection
Dental clinics were identified through online search services of the Swedish telephone directory (www.hitta.se and www.eniro.se) using key words “implant”, “dental clinic,” and “Stockholm region.” Clinics were then contacted via telephone, and the project was explained to the dentists. In 2008, the questionnaires were sent to all eligible dentists who agreed to participate (120 dentists in 76 clinics), and in 2012, they were sent to the same clinics with the additions of new clinics established in the intervening period (161 dentists in 105 clinics). The questionnaire included a prepaid envelope and a cover letter explaining the purpose of the study ensuring confidentiality would be maintained. In both surveys, reminder letters were sent to all included clinics. Questionnaire
The questionnaire included two open and 10 closed questions. The first part included demographic data on gender, age, undergraduate training, number of years of clinical experience, implant surgical experience, and implant education. The second part asked about the presence of local clinical guidelines, routines used at the clinic, and policies regarding antibiotic prescription prior to implant insertion as well as local or systematic factors influencing prescription patterns. Two questions inquired about potential benefits from the establishment of national guidelines and interest in gaining information about antibiotic resistance. The 2012 survey included five additional questions concerning respondents’ knowledge of the recent recommendations and scientific review from Strama and SBU, if these had influenced their prescribing behavior.
Data analysis
Statistical analysis was performed using SPSS for Windows release 21.0 (SPSS Inc., Chicago, IL, USA). Absolute frequencies were used to describe the data and chi-square tests to assess statistically significant differences, and the level of significance was P < 0.05.
Results The response rate in 2008 was 75% (n = 90) and 88% (n = 142) in 2012. Due to missing data, primarily regarding routines in prescribing prophylactic antibiotics prior to implant placement, five and nine questionnaires were excluded in 2008 and 2012, respectively. Therefore, 85 responses from 2008 and 133 from 2012 were included in the analyses. Table 1 shows the demographic data for participating dentists. The majority of dentists were male (79%, 2008; 75%, 2012) and in 55 years or older. With regard to their education in implant dentistry, 46% (n = 39) in 2008 had received clinical postgraduate training while the corresponding figure for 2012 was 40% (n = 53). In 2008, 54% (n = 46) reported they had participated in a single course in implant dentistry and 60% (n = 80) in 2012. Moreover, 53% (n = 45) had over 10 years of experience in implant surgery in 2008 and 64% (n = 83) in 2012. Dentists without postgraduate clinical training were significantly more prone to extend antibiotic prophylactic administration beyond the day of surgery (P < 0.009). There was a significant reduction in the number of the dentists reporting the use of a defined local rationale for antibiotic prescriptions during implant surgical procedures between 2008 and 2012 (P = 0.04). There was a significant reduction in the number of routinely prescribed antibiotics between the cohorts (P = 0.01; Table 2). Figure 1 illustrates the significant change in the antibiotics prescribed (P = 0.006). In 2008, 67% (n = 50) of the dentists prescribed phenoxymethylpenicillin (PcV), while 21% (n = 16) prescribed amoxicillin. In 2012, 43% (n = 42) of dentists prescribed PcV and 47% (n = 46) prescribed amoxicillin. Other antibiotics, such as metronidazole and clindamycin, were less frequently used. There was also a significant reduction in the number of dentists prescribing antibiotic beyond the day of surgery between 2008 and 2012 (P = 0.04). In 2012, 65% (n = 63) of the respondents prescribed a single dose of antibiotics compared to 49% (n = 35) in 2008. In 2012, only 35% (n = 34) of the dentists prescribed an antibiotic course for ≥3 days
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Khalil et al Antibiotics during dental implant insertion
Table 1. Demographic data 2008 n = 85 n (%)
Characteristic
Gender Male 66 (79) Female 18 (21) Age (years) 25–34 6 (7) 35–44 18 (21) 45–54 28 (33) >55 33 (39) Undergraduate training Swedish university 82 (98) Abroad university 2 (2) Implant education Single Course 46 (54) Not specified 46 Clinical postgraduate training 39 (46) Oral and maxillofacial surgery 21 Periodontics 15 Pedodontics 1 Prosthodontics 1 Information about antibiotics in implant education Yes 79 (93) No 6 (7) Clinical experience (years)
