Systemic antibiotics and the risk of superinfection in peri-implantitis

This summary is based on an article published in the Archives of Oral Biology: Systemic antibiotics and the risk of superinfection in peri-implantitis (April 2016)

Fernando Verdugo; Theresia Laksmana; Agurne Uribarri

Context

• Peri-implantitis has emerged in the last few years as a complication difficult to resolve. The etiopathogenesis consensus is mainly attributed to bacteria.
• Controversy exists regarding disease initiation, namely whether specific pathogenic microbiota are indeed the true initiators of bone loss around implants or if they are secondary to a disbalanced foreign body reaction coupled with background factors, such as poorly fabricated implants placed by unqualified clinicians (Albrektsson et al., 2014; Qian, Wennerberg, & Albrektsson, 2012).
• However, there is agreement that the disease process is exacerbated and maintained by specific microbial infection with bacteria and possibly viruses (Rams, Degener, & van Winkelhoff, 2014; Verdugo et al., 2015a; Verdugo, Castillo, Castillo, & Uribarri, 2015; Heitz-Mayfield, Salvi, Mombelli, Faddy, & Lang, 2012).
• Combined surgical and non-surgical, therapies have been proposed, where systemic antibiotics are administered to empirically target specific putative bacteria (Rams et al., 2014a; Heitz-Mayfield et al., 2012).

Purpose of the Review

To review available scientific data on the rationale and to qualitatively assess the potential risk of superinfection after systemic antimicrobials in human periimplant disease.

Key Messages

• There has been little documentation of the potentially deleterious effects of broad-spectrum systemic antibiotics use in peri-implant disease therapy due to the lack of studies with long-term microbiological follow-up.
• The development of chronic peri-implant and periodontal superinfections is a complication that may initially be overlooked but could lead to sustained progressive bone loss compromising dental implant outcomes (Emrani et al., 2009; vanWinkelhoff & Wolf, 2000; Teles et al., 2008; Buchmann et al., 2000;Leonhardt et al., 2003; Botero, González, Mercado, Olave, & Contreras, 2005).
• Patients susceptible to periodontitis appear to be more vulnerable to peri-implantitis than those without a history of the disease (Heitz-Mayfield & Lang, 2010).
• Though systemic antimicrobials have shown to improve therapy outcomes in aggressive periodontitis individuals (Sgolastra, Petrucci, Gatto, & Monaco, 2012), time and indiscriminating empiric regimens have made the risk of antibiotic resistance development a reality (Rams et al., 2014a, 2014b; Poveda Roda, Bagan, Sanchis Bielsa, & Carbonell Pastor, 2007).
• In this study, every clinical study claiming more or less successful therapy outcomes after treating periimplantitis had, at follow-up, a sub-group of implants with either persistent inflammation, residual pockets, suppuration, progressive bone loss or implants that had to be removed.
• To reduce the risks of microbial recontamination in susceptible populations, personalized periodontal supportive therapy might help prevent complications and peri-implantitis relapses. A 3-month recall protocol has shown positive outcomes at five years in a small group of smoker patients with a past history of periodontal disease (Roos-Jansåker et al., 2007).
• Microbiological culture monitoring and antibiotic susceptibility testing could prevent the emergence of implant super- infections in susceptible individuals harboring microorganisms such as E. coli and E. cloacae at baseline (Leonhardt et al., 2003).
• If only antimicrobials that do not alter colonization resistance are used, then the risk of development and spread of resistant strains among patients, and dissemination of resistant elements between pathogens, would be minimized (Rashid et al., 2012).
• Pyrosequencing and Sanger sequencing technology have allowed to identifying large arrays of bacteria infecting peri-implantitis lesions and have shown distinct differences between health and disease. Peri-implantitis seems to be a more microbiologically heterogeneous infection with primarily Gram-negative species and less complex microbiota than periodontitis (Kumar et al., 2012).
• A key aspect in peri-implantitis:
  • Establish precise and personalized maintenance protocols, eliminate reservoirs of pathogenic bacteria, particularly on those with past history of periodontitis (Roos-Jansåker et al., 2014; Van Winkelhoff, 2012),
  • Frequently evaluate individual microbial profiles so that early clinical changes can be monitored and potential risks reduced.
• It is well documented that superinfecting agents, such as, Enterobacter, Candida, or Staphylococcus species, can significantly thrive after the administration of systemic antibiotics (Sullivan et al., 2001; Helovuo et al., 1993; Rashid et al., 2012; Adamsson et al., 1999).
• An effort should be made to monitor and revise patients’ medical history regularly, tracking past antibiotic use, smoking habits and diabetes status, among other conditions, and consider the use of probiotics to protect the normal microflora, in order to help prevent peri-implant superinfection emergence.

List of References (PDF)