Dental Surgery - Guideline for Antimicrobial Prophylaxis and Prevention of Infection in

Publication: 06/03/2014  
Last review: 01/01/1900  
Next review: 07/07/2020  
Clinical Guideline
CURRENT 
ID: 3729 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2014  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Guideline for Antimicrobial Prophylaxis and Prevention of Infection in Dental Surgery

1. Summary table of routine recommendations
2. Background information
3. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

Procedure

Antimicrobial prophylaxis recommended?

Evidence level

Prophylaxis aims to reduce 

NNT

Antimicrobial dose/route ≤ 1 hour before procedure 

Routine

MRSA risk factors

penicillin allergic 

Endocarditis risk factors

NO

B1

-

-

None

None

None

Periodontal surgery NOT  involving biomaterial grafts

NO

D

-

 

None

None

 

Periodontal surgery involving biomaterial grafts

YES

D

Graft infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 625mg single oral dose plus 1.5g Amoxicillin electronic Medicines Compendium information on Amoxicillin single oral dose

Discuss case by case

Clindamycin electronic Medicines Compendium information on Clindamycin 600mg single oral dose

Dental implant placement without bone augmentation

NO

D

-

-

None

None

None

First stage bone augmentation pre-implant placement

YES

A

Infection of the planned implant site

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 625mg single oral dose plus 1.5g Amoxicillin electronic Medicines Compendium information on Amoxicillin single oral dose

Discuss case by case

Clindamycin electronic Medicines Compendium information on Clindamycin 600mg single oral dose

Single stage augmentation and implant placement

YES

A

Infection of the peri-implant tissues

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 625mg single oral dose plus 1.5g Amoxicillin electronic Medicines Compendium information on Amoxicillin single oral dose

Discuss case by case

Clindamycin electronic Medicines Compendium information on Clindamycin 600mg single oral dose

Second stage dental implant placement after bone augmentation AND additional augmentation required

YES

A

Infection of the peri-implant tissues

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 625mg single oral dose plus 1.5g Amoxicillin electronic Medicines Compendium information on Amoxicillin single oral dose

Discuss case by case

Clindamycin electronic Medicines Compendium information on Clindamycin 600mg single oral dose

Second stage dental implant placement after autogenous bone augmentation and NO additional augmentation required

NO

D

-

-

None

None

None

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2. Background information

Aims of prophylaxis
The aim of antimicrobial prophylaxis in dental surgery is a reduction in surgical site infection (SSI) and complications relating to infection such as loss of an implant.  Prophylactic antibiotic cover has been prescribed for a number of surgical procedures in dentistry. In an era of evidence-based medicine, this is surprising as there is little evidence to support its efficacy.  There has been a move to minimise the use of antibiotics amidst concerns that over-prescription increases the likelihood of antibiotic resistance2 and life threatening anaphylaxis.3

A review of antimicrobial prophylaxis has been undertaken as part of a Trust-wide project to optimise use of antimicrobials and reduce their adverse effects.  The need for this review has been reinforced by the Chief Medical Officers report concerning antimicrobial resistance, Department of Health guidance on antimicrobial stewardship,4 publication of guidance on reducing SSI from NICE and antimicrobial prophylaxis from the Scottish Intercollegiate Guideline Network 5, 6.  In addition, there is an on going need to reduce the risks of Clostridium difficile and Staphylococcus aureus infection in the Trust.  Reducing the risk of acquisition and spread of these pathogens by avoiding unnecessary antimicrobial exposure is a high priority.

Aims of this guideline
Local audit has identified diversity in antimicrobial prescribing practises in dentistry.  The aim of this guideline is to present a review the evidence and a local consensus to standardise the use of antimicrobials.

These guidelines should be applicable to the majority of patients but where the recommendations in these guidelines do not seem appropriate for a particular patient, the dental surgeon is advised to discuss the case with a microbiologist.

Patients with active infection at the time of surgery require treatment not prophylaxis and this guideline does not apply.

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3. Special antimicrobial prophylaxis recommendations

A. Endocarditis prophylaxis
Specific prophylaxis for patients at increased risk of developing endocarditis is no longer recommended.1  However, localised infections in patients at increased risk of endocarditis should be investigated (with microbiological sampling as appropriate) and treated promptly.  If a patient at increased risk of endocarditis has active dental infection they should ideally be commenced on appropriate antimicrobial therapy prior to any dental procedure at the site of infection.1  See summary table.

B. Dental implants
Introduction

Dental implant placement involves the surgical placement of a titanium alloy implant into the maxillary or mandibular bone. A transmucosal abutment is connected to this either at placement or at a separate second stage surgical procedure when the implant is exposed.

Bone augmentation may be required to ensure adequate bone stocks at the osteotomy site to allow placement of the implant in the most optimal position to replace missing teeth and to ensure its longevity.

Bone augmentation and implant placement may be carried out during a single procedure or bone augmentation can be undertaken as an initial procedure with implant placement at a later stage.  Each procedure represents an opportunity to introduce infection.

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1. Dental implant placement without bone augmentation

Dental implants are associated with high survival rates (96.8% at 5 years),7 however, failures do occur.  Implant failure can be classified as early or late.  Early failure describes a lack of osseointegration of the implant following placement, whereas late failure typically results from progressive bone loss around a previously integrated implant, as a result of inflammation of the peri-implant tissues.  Within the NHS implant funding is extremely limited with patient selection based upon modified guidelines from the Royal College of Surgeons.  Failure of an implant has an obvious adverse effect on patient outcome as well as financial implications for the Trust.  Early failure is rare, but aetiological factors include contamination of the implant at placement, poor primary stability and micro-movements in the early stages of healing which prevent osseointegration.  To reduce the risk of early failure due to an infective process, the risk of contamination of the implant at surgery can be lowered with good aseptic techniques.  Additionally, some authors have suggested the use of prophylactic antibiotics.

Dental implant surgery is considered to be complex as it involves the manipulation of soft tissues and the placement of a foreign titanium body, through a mucosa that is colonised by bacteria, into bone. Prevention of peri-implant infection must be given high priority as it can cause patient discomfort, anxiety and even implant failure.8 Once the latter has been established, it is notoriously difficult to treat.9

Factors determining outcome have been classified as endogenous or exogenous.10 Endogenous factors include bone quality and quantity at the implant site, as well as systemic factors and whether the patient smokes. Exogenous factors include operator skill, operator experience and surgical aspects of the procedure, including degree of trauma and asepsis.

A number of issues make investigating the role of antibiotics in implant placement difficult. Firstly, the success rate of dental implants is so high11 that unusually large samples of patients would have to be recruited to detect a statistically significant result.12 Additionally, implant failures appear to cluster in certain individuals, suggesting that factors affecting success may be interrelated and difficult to isolate.12  It is noteworthy that antimicrobial prescriptions did not appear to impact on implant failure in this series.12

Evidence review
The use of antibiotics in implant surgery remains controversial from both a microbiological point of view13, 14 and in terms of implant success rate.  There are currently no national or international guidelines to support clinical decision-making in relation to prophylaxis.  A search of the literature using the PubMed database revealed that four randomised controlled trials (RCTs) have been completed looking at the prophylactic prescription of antibiotics in relation to implant placement.  Prior to these studies, the majority of evidence resulted from longitudinal studies, which were poorly controlled, with a variety of exclusion criteria and outcome measures.  A randomised, placebo controlled trial in 200915 reported that there was no significant difference in outcomes when 2g of Amoxicillin electronic Medicines Compendium information on Amoxicillin was given preoperatively and this finding was also reported in two studies by Esposito et al.16  Abu-Ta’a et al. carried out a non-blinded RCT of no antibiotics compared with a 1g pre-operative dose of Amoxicillin electronic Medicines Compendium information on Amoxicillin followed by a two day post-operative course and also found no significant difference in implant outcomes.14

A Cochrane review16 of the evidence on this subject included the above four studies14-17 as the only ones which satisfied the inclusion criteria. Unsurprisingly, conclusions were limited in that the authors were not able to comment on the most effective dose, type of antibiotics or the efficacy of postoperative antibiotics. None of the studies included could provide evidence that antibiotics positively affected outcome to a level of significance, however three studies14, 16, 17 revealed trends in this direction. When the results of the studies were combined involving over 1000 patients, the meta-analysis led to the conclusion that 2g of Amoxicillin electronic Medicines Compendium information on Amoxicillin administered 1 hour pre-operatively could reduce the rate of implant failure.  The authors also calculated that to prevent implant failure in one patient, 33 would need to be treated with antibiotics.  Although it is generally accepted that a Cochrane review represents the highest level of evidence available, where the number of studies included is so limited the conclusion should be treated with caution.  Furthermore, two of the papers in the meta-analysis were written by the author of the systematic review, and this in itself may have introduced bias.

In a survey, it was reported that 72% of practitioners placing implants prescribe antibiotics routinely and 50% prescribed 3g of Amoxicillin electronic Medicines Compendium information on Amoxicillin 1 hour pre-operatively.18  The authors of the survey concluded that the blanket prescription of antibiotics should not be encouraged as there is no evidence to suggest that antibiotics are required for minor oral surgery procedures to reduce infection risk, post-operative pain or swelling, provided the procedure is carried out in a surgically aseptic environment.  It was their view that this is should also be considered to be true for implant placement.

Recommendation: We conclude from this review that antimicrobial prophylaxis is not indicated for implant procedures without bone augmentation.  See summary table.

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2. Implant Placement with Bone Augmentation

The findings of the Cochrane review relate to “straightforward” implant placement, carried out without the need for bone augmentation.  Bone augmentation can be carried out if there is insufficient bone at the implant site, however this increases the complexity of surgery and has been found to lower implant success rates19, 20 Augmentation can take place at the time of implant placement or prior to this as a separate surgical procedure depending on the size of the defect and the source of the bone.

There is limited evidence to guide clinical practice with regard to antibiotic prescription in these cases but SIGN guidelines do recommend the prescription of antibiotics generally for intraoral grafting procedures.6  The majority of published work investigates autogenous bone grafting performed as a separate procedure prior to implant placement.  A methodologically flawed pilot study involving non-vascularised onlay grafts harvested from local intraoral sites found that infection rates were higher without penicillin prophylaxis, but it would seem unwise to extrapolate from this study of just 20 patients that did not describe the patient selection criteria, among other criticisms.21 Additionally, these studies highlight the importance of prevention of infection as when grafts become infected they are likely to fail completely meaning that implant placement is not possible.

Conclusions from literature review: there is limited evidence that single pre-procedure prophylaxis reduces infection post dental implant with bone grafting.

Recommendation: All patients undergoing implant placement with a history of bone augmentation at the implant site and having bone augmentation at the time of implant placement should be prescribed a single dose of prophylaxis 1 hour pre-procedure. Prophylaxis is not recommended for implant placement into previously grafted sites if no bone augmentation is carried out at the time of placement.

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3. Choice of Antimicrobial

The antimicrobial regimen chosen for prophylaxis should cover the pathogens commonly implicated in dental SSI and ideally should have proven efficacy.  For surgery involving a breach to the oral mucosa, oral streptococci and anaerobes are considered the main potential pathogens.2  Bacteroides spp. were the most prevalent anaerobic pathogens in infection related to orthognathic surgery.22  In the diseased oral cavity and hospitalised patients “coliforms” (Enterobacteriaceae) commonly colonise the mouth.  Staphylococcus aureus remains the most common cause of surgical site infections involving skin incisions but can also cause intraoral infection.  Haemophilus spp. and other fastidious Gram negative members of the oral flora are less common causes of SSI in this setting.

Although penicillins (e.g. Amoxicillin electronic Medicines Compendium information on Amoxicillin) maintain activity against for the majority of oral streptococci, most staphylococci are resistant as are many oral anaerobes and Gram negatives.  Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav (Amoxicillin electronic Medicines Compendium information on Amoxicillin plus clavulanic acid) has good activity against all the above, including meticillin susceptible Staphylococcus aureus, by virtue of the beta-lactamase-inhibiting activity of clavulanic acid.  Macrolides are unreliable against oral streptococci, Gram negatives and anaerobes.  Clindamycin electronic Medicines Compendium information on Clindamycin is a reasonable alternative to penicillins but lacks activity against Gram negatives.  Gentamicin has been added to Clindamycin electronic Medicines Compendium information on Clindamycin and produced superior activity to cefazolin.23  Prophylaxis failures have been noted with cephalosporins in orthognathic surgery.22  For patients who are allergic to penicillin, therefore, the alternative choices are not ideal and include macrolides, Clindamycin electronic Medicines Compendium information on Clindamycin and Metronidazole electronic Medicines Compendium information on Metronidazole.  The latter lacks activity against oral streptococci and Haemophilus spp. making Clindamycin electronic Medicines Compendium information on Clindamycin the preferred choice.  As with all antimicrobials, Clindamycin electronic Medicines Compendium information on Clindamycin is associated with gastro-intestinal symptoms and should be avoided in patients at risk of Clostridium difficile infection.  Metronidazole electronic Medicines Compendium information on Metronidazole may also cause some nausea.

No single agent or even combination can have activity against all potential pathogens and this has been sited as a reason for worse outcomes in some studies of prophylaxis.24

Recommended regimens are summarised in Table 1.

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4. Timing of administration

Ideally oral agents should be given one hour pre-operatively so that peak levels are reached at the time of surgery.  Antimicrobial prophylaxis is most efficacious when given within the hour prior to a procedure.  As it is sometimes not possible to anticipate the need for bone augmentation, in these cases the dose would have to be given immediately post-operatively.  In the context of endocarditis prophylaxis, it has been suggested that if prophylaxis is given within two hours of surgery some prophylactic effect will be maintained.25  A pragmatic recommendation is therefore to give the recommended regimen as soon as possible after surgery, if the need for prophylaxis was not anticipated pre-operatively.

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5. Dose of Antimicrobial

In theory, to be effective for prophylaxis, the minimum inhibitory concentration (MIC) of the chosen antimicrobial must be exceeded in plasma and/or the local tissues where infection may occur.  A single dose of oral Amoxicillin electronic Medicines Compendium information on Amoxicillin 2g provides adequate serum levels to be active against most oral streptococci.26  Although Amoxicillin electronic Medicines Compendium information on Amoxicillin concentrations were undetectable in gingival crevice fluid 1-4 hours after administration of Amoxicillin electronic Medicines Compendium information on Amoxicillin 2g taken orally13, the significance of this to dental implant surgery and periodontal surgery is currently unclear.  The efficacy of various antibiotics and different dosing regimens have been investigated in implant surgery.  A 2g penicillin and 600mg Clindamycin electronic Medicines Compendium information on Clindamycin given an hour prior to surgery were equally as effective in preventing postoperative infection.27  When Clindamycin electronic Medicines Compendium information on Clindamycin was used, a single preoperative dose of 600mg was as effective as the same dose followed by a postoperative course of 300mg 6-hourly for 24 hours.28

The addition of clavulanic acid to Amoxicillin electronic Medicines Compendium information on Amoxicillin (co-amoxiclav) broadens its activity to include many beta-lactamase-producing bacteria (see above) it is therefore the preferred agent as a single dose prophylactic for dental surgery.  By adding 1.5g Amoxicillin electronic Medicines Compendium information on Amoxicillin to a 625mg tablet of  Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav, the standard 2g dose of Amoxicillin electronic Medicines Compendium information on Amoxicillin can be achieved.

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Duration of prophylaxis

NICE and SIGN guidelines recommend single dose antimicrobial prophylaxis for prevention of surgical site infection.5, 6  There is evidence that single dose prophylaxis is as effective as more prolonged prophylaxis regimens for dental implant surgery3 as well as orthognathic surgery, head and neck surgery (clean contaminated) and open reduction and internal fixation of compound mandibular fractures (contaminated).  In head and neck surgery, Clindamycin electronic Medicines Compendium information on Clindamycin and Gentamicin was more effective than cefazolin but five days prophylaxis was not significantly more effective than one day.23  A systematic review of prophylaxis for facial fracture surgery found that one day/”one shot” prophylaxis was more effective than prolonged prophylaxis, though this did not reach statistical significance.29

Procedures in the oral cavity are considered “contaminated” because they occur in an environment with a normal microbial flora.  The effect of prophylaxis on the normal oral flora is an important determinant of the duration of prophylaxis.   Single dose or even prolonged antibiotic prophylaxis does not eradicate the oral flora, it simply alters the microbial composition,30-32 which may be why prolonged prophylaxis does not appear to offer any advantages of single dose regimens.  Modelled dental plaque exposed to single dose of tetracycline showed a small reduction in bacterial numbers but a marked change in resistance profile of the resident bacteria.33  Amoxicillin electronic Medicines Compendium information on Amoxicillin susceptible streptococci in saliva and plaque of healthy volunteers showed a marked reduction after two doses of three grams of Amoxicillin electronic Medicines Compendium information on Amoxicillin.34  It took 13 weeks for resistant streptococci to decline to undetectable levels in all volunteers.34  Three doses of erythromycin resulted in recovery of erythromycin-resistant organisms in the oral flora of 100% of healthy volunteer32, while resistance to Amoxicillin electronic Medicines Compendium information on Amoxicillin increased from 28 to 96% of oral streptococci after seven days treatment with Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav.  Resistance can result from selection of resistant organisms but also by mutation e.g. resistance to penicillins in Streptococcus mitis can results from penicillin binding protein (PBP) mutations.35  Other examples of the selection for resistance in potential oral pathogens includes the observation that production of beta-lactamse in Fusobacterium nucleatum isolates from children increases with age and exposure to antimicrobial.36

In conclusion, once a dental procedure is complete, prolonging antimicrobial prophylaxis only results in the wound being bathed in resistant organisms.  There are numerous examples from dental and contaminated head and neck surgery that prolonging prophylaxis after a procedure does not reduce infection rates.  Single dose (in the hour prior to the procedure) antimicrobial prophylaxis is recommended. 

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6. Other Measures

Sources of infection implicated in surgical site infections include the microflora of the oral tissues and the peri-oral skin, instruments, the hands of the operator and assistant and the air of the surgery.37

The use of pre-operative measures to reduce the risk of surgical site infection at implant placement include the pre-operative use of an antiseptic mouthwash such as chlorhexidine,3, 14 which has been shown to decrease oral microflora load,14, 38 and cleaning of the skin around the mouth and nose with antiseptic solution.14

The standard aseptic technique adopted for all patients undergoing implant placement within the Leeds Dental Institute includes:

  1. 0.2% Chlorhexidine Gluconate mouthwash for one minute pre-operatively
  2. Use of sterile gowns and surgical gloves for operators and assistants
  3. Use of head covers for patient and staff
  4. Use of masks for all staff
  5. Use of sterilised instruments
  6. Sterile drapes to cover the operating surfaces and the patient’s supine body
  7. Cleaning of the peri-oral and peri-nasal tissues with Tisept (Chlorhexidine Gluconate 0.015% w/v and Cetrimide 0.15%)

Operators and assistants are trained in proper aseptic technique.

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Provenance

Record: 3729
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Dental Staff
Adapted from:

Evidence base

  1. NICE. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures.  NICE clinical guideline 64. National Institue for Health and Clinical Excellence, 2008.
  2. Sweeney LC, Dave J, Chambers PA et al. Antibiotic resistance in general dental practice--a cause for concern? J Antimicrob Chemother 2004; 53: 567-76.
  3. Binahmed A, Stoykewych A, Peterson L. Single preoperative dose versus long-term prophylactic antibiotic regimens in dental implant surgery. Int J Oral Maxillofac Implants 2005; 20: 115-7.
  4. Department_of_Health. Antimicrobial stewardship: Start smart - then focus. 2011.
  5. Leaper D, Collier M, Evans D et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, ed: Royal College of Obstetrics and Gynaecology, Press, 2008.
  6. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh, 2008.
  7. Jung RE, Pjetursson BE, Glauser R et al. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res 2008; 19: 119-30.
  8. Resnik RR, Misch C. Prophylactic antibiotic regimens in oral implantology: rationale and protocol. Implant Dent 2008; 17: 142-50.
  9. Haanaes HR. Implants and infections with special reference to oral bacteria. J Clin Periodontol 1990; 17: 516-24.
  10. Esposito M, Hirsch JM, Lekholm U et al. Biological factors contributing to failures of osseointegrated oral implants. (II). Etiopathogenesis. Eur J Oral Sci 1998; 106: 721-64.
  11. Pjetursson BE, Karoussis I, Burgin W et al. Patients' satisfaction following implant therapy. A 10-year prospective cohort study. Clin Oral Implants Res 2005; 16: 185-93.
  12. Alsaadi G, Quirynen M, Michiles K et al. Impact of local and systemic factors on the incidence of failures up to abutment connection with modified surface oral implants. J Clin Periodontol 2008; 35: 51-7.
  13. Khoury SB, Thomas L, Walters JD et al. Early wound healing following one-stage dental implant placement with and without antibiotic prophylaxis: a pilot study. J Periodontol 2008; 79: 1904-12.
  14. Abu-Ta'a M, Quirynen M, Teughels W et al. Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: a prospective, randomized, controlled clinical trial. J Clin Periodontol 2008; 35: 58-63.
  15. Anitua E, Aguirre JJ, Gorosabel A et al. A multicentre placebo-controlled randomised clinical trial of antibiotic prophylaxis for placement of single dental implants. Eur J Oral Implantol 2009; 2: 283-92.
  16. Esposito M, Cannizzaro G, Bozzoli P et al. Effectiveness of prophylactic antibiotics at placement of dental implants: a pragmatic multicentre placebo-controlled randomised clinical trial. Eur J Oral Implantol 2010; 3: 135-43.
  17. Esposito M, Grusovin MG, Talati M et al. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev 2008: CD004152.
  18. Ireland RS, Palmer NO, Lindenmeyer A et al. An investigation of antibiotic prophylaxis in implant practice in the UK. Br Dent J 2012; 213: E14.
  19. Blomqvist JE, Alberius P, Isaksson S et al. Factors in implant integration failure after bone grafting: an osteometric and endocrinologic matched analysis. Int J Oral Maxillofac Surg 1996; 25: 63-8.
  20. Rammelsberg P, Schmitter M, Gabbert O et al. Influence of bone augmentation procedures on the short-term prognosis of simultaneously placed implants. Clin Oral Implants Res 2012; 23: 1232-7.
  21. Lindeboom JA, van den Akker HP. A prospective placebo-controlled double-blind trial of antibiotic prophylaxis in intraoral bone grafting procedures: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 96: 669-72.
  22. Spaey YJ, Bettens RM, Mommaerts MY et al. A prospective study on infectious complications in orthognathic surgery. J Craniomaxillofac Surg 2005; 33: 24-9.
  23. Johnson JT, Myers EN, Thearle PB et al. Antimicrobial prophylaxis for contaminated head and neck surgery. Laryngoscope 1984; 94: 46-51.
  24. Paterson JA, Cardo VA, Jr., Stratigos GT. An examination of antibiotic prophylaxis in oral and maxillofacial surgery. J Oral Surg 1970; 28: 753-9.
  25. Dajani AS, Taubert KA, Wilson W et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. Clinical Infectious Diseases 1997; 25: 1448-58.
  26. Dajani AS, Bawdon RE, Berry MC. Oral amoxicillin as prophylaxis for endocarditis: what is the optimal dose? Clinical Infectious Diseases 1994; 18: 157-60.
  27. Lindeboom JA, Frenken JW, Tuk JG et al. A randomized prospective controlled trial of antibiotic prophylaxis in intraoral bone-grafting procedures: preoperative single-dose penicillin versus preoperative single-dose clindamycin. Int J Oral Maxillofac Surg 2006; 35: 433-6.
  28. Lindeboom JA, Tuk JG, Kroon FH et al. A randomized prospective controlled trial of antibiotic prophylaxis in intraoral bone grafting procedures: single-dose clindamycin versus 24-hour clindamycin prophylaxis. Mund Kiefer Gesichtschir 2005; 9: 384-8.
  29. Andreasen JO, Jensen SS, Schwartz O et al. A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg 2006; 64: 1664-8.
  30. Sefton AM. Macrolides and changes in the oral flora. Int J Antimicrob Agents 1999; 11 Suppl 1: S23-9; discussion S31-2.
  31. Cremieux AC, Muller-Serieys C, Panhard X et al. Emergence of resistance in normal human aerobic commensal flora during telithromycin and amoxicillin-clavulanic acid treatments. Antimicrob Agents Chemother 2003; 47: 2030-5.
  32. Harrison GA, Stross WP, Rubin MP et al. Resistance in oral streptococci after repeated three-dose erythromycin prophylaxis. J Antimicrob Chemother 1985; 15: 471-9.
  33. Ready D, Roberts AP, Pratten J et al. Composition and antibiotic resistance profile of microcosm dental plaques before and after exposure to tetracycline. J Antimicrob Chemother 2002; 49: 769-75.
  34. Southall PJ, Mahy NJ, Davies RM et al. Resistance in oral streptococci after repeated two-dose amoxycillin prophylaxis. J Antimicrob Chemother 1983; 12: 141-6.
  35. Nakayama A, Takao A. Beta-lactam resistance in Streptococcus mitis isolated from saliva of healthy subjects. J Infect Chemother 2003; 9: 321-7.
  36. Nyfors S, Kononen E, Syrjanen R et al. Emergence of penicillin resistance among Fusobacterium nucleatum populations of commensal oral flora during early childhood. J Antimicrob Chemother 2003; 51: 107-12.
  37. van Steenberghe D, Yoshida K, Papaioannou W et al. Complete nose coverage to prevent airborne contamination via nostrils is unnecessary. Clin Oral Implants Res 1997; 8: 512-6.
  38. Veksler AE, Kayrouz GA, Newman MG. Reduction of salivary bacteria by pre-procedural rinses with chlorhexidine 0.12%. J Periodontol 1991; 62: 649-51.

Evidence levels
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies   contradict each other, or no evidence exists)

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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