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News Bulletin : ADA News Bulletin June 2011
41 JUNE 20 11 CLARIFICATION ON THE CORRECT USE OF PROPHYLACTIC ANTIBIOTICS Sir, With regard to the recent correspondence on bisphosphonates, I would seek further clarification on the correct use of prophylactic antibiotics. My limited readings are drawn to the Therapeutic Guidelines: Oral and Dental Version 1 2007 (TG) and the joint statement by Osteoporosis Australia and the Australian Dental Association Guideline summary bisphosphonates and osteonecrosis of the jaw (ONJ) [News Bulletin, No. 392, October 2010]. Under the general title of Antibiotic prophylaxis for dentoalveolar procedures (TG) it states that, "prophylactic antimicrobial therapy must be restricted to situations in which it has been shown to be effective...the low risk of wound infection must be balanced against the risk of adverse effects of the antibiotic." Generally, in "fit immunocompetent patients, antibiotic prophylaxis is not required or recommended" (TG). Accordingly, the earlier empirically-based indications for a loading dose of antibiotics to minimise bacteraemia for patients with endocarditis have now been greatly reduced. "ONJ is not primarily an infection of the bone" (Michael McCullough) but rather "a soft tissue infection" (TG) that may occur until primary healing is complete at 3---4 weeks post-op. If ONJ occurs, then it is treated by "0.12% chlorhexidine mouthwashes and antibiotics for soft tissue pain and swelling" (OA/ADA). I infer that where extractions can be preplanned (and in the absence of infection), then perhaps the regime of CTX, drug holiday, and pre- and post- surgical chlorhexidine mouth washes would be appropriate without the addition of antibiotics. The use of antibiotics runs the risk of causing adverse side-effects, including anaphylaxis, and goes against the evidence-based trends of antimicrobial therapy. Perhaps the addition of a single-dose of prophylactic antibiotics can only be justified where periodontal disease is not controlled (chronic infection), or acute infection where preplanning is not possible. Where there is an acute periapical abscess and the patient does not wish to have an RCT, then the chances of a non-ONJ outcome could be improved by performing an emergency debridement of the canals and Ledermix dressing, followed by the extraction at a later date. I would welcome any comments. Matthew White Campbelltown 2560 RESPONSE Sir, Dr White's letter demonstrates a good understanding of the concept of antibiotic prophylaxis and raises important questions in relation to antibiotic prophylaxis and bisphosphonate related osteonecrosis of the jaws (BRONJ). It also highlights the topical issue of the misuse of antibiotics in dentistry and medicine.1 We confirm that BRONJ is primarily caused by a lack of bone turnover resulting in non-healing of extraction sockets which then become secondarily infected with oral micro-organisms. It is confirmed that the prophylactic use of antibiotics in patients on bisphosphonates is to prevent infection developing. As such, it is important that antibiotics are used in a single high dose which is present in the blood stream prior to the arrival of bacteria into the wound from contaminated saliva. This helps the bone cope with the early wound healing process without the added effects of superficial contamination and increased risk of infection in the surrounding tissues. Given the potential long-term severity of BRONJ, the small risk of an adverse effect from a single dose of antibiotics is considered clinically justified. Dr White is correct that there is currently a lack of evidence-based data to support the use of prophylactic antibiotics for the prevention of BRONJ. However, it should be noted that the Oral and Maxillofacial Surgery Unit at the University of Adelaide has established a case cohort study in which over 600 patients on oral bisphosphonates requiring extractions have been recruited over the last four years. These patients have been managed following the protocol of a single prophylactic antibiotic dose, CTX assessment and a drug holiday as indicated. This study is currently undergoing preliminary data analysis and hopefully the numbers will be of sufficient power to demonstrate both the benefits and the harms of this management protocol. In the meantime, the Australian Dental Association Inc. Dental Therapeutics Committee recommends the protocol as stated in the Therapeutic Guidelines: Oral and Dental Version 1 2007. Alastair Goss Professor and Emeritus Consultant Oral and Maxillofacial Surgery The Royal Adelaide Hospital REFERENCE: 1 Kumar R, Sambrook P, Goss A. Mismanagement of dental infection. Aust Prescriber 2011;34:40-41. Letters to the Letters are published at the Editor's discretion and customary editorial rights are reserved. We request that letters be brief, of interest to the general membership and signed. Letters published are an expression of a personal point of view of the writer and are not necessarily representative of the policies or opinions of the Australian Dental Association Inc. feedback Editor
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