“We screwed up, and we ought to say so and apologise. Doctors were handed the wonderful gift of antibiotics but are destroying them through indiscriminate use. We don’t need another committee. We know what to do: we should just use them less.”1
Norman Simmons, emeritus consultant microbiologist at Guy’s Hospital in London, issued this clarion call to fight antibiotic resistance more than two decades ago, and his eloquent words still ring true today.
National medical and dental organizations including the American Heart Association, the ADA, and the American Academy of Orthopaedic Surgeons have heeded the call, as they do not recommend antibiotic prophylaxis for the vast majority of dental patients with heart conditions or artificial joints.
These groups cite both the problems of unwanted side effects such as antibiotic resistance and the lack of efficacy. Antibiotic prophylaxis is now recommended only in very few situations, including artificial heart valves and previous history of endocarditis.
Dental procedures can cause bacteremias, transient bacterial invasions into the bloodstream. Though metastatic infections from bacteremias are rare, there is no doubt that bacteremias can theoretically cause metastatic infections such as endocarditis, artificial joint infections, and breast implant infections.
As a result, some clinicians recommend antibiotic prophylaxis before dental procedures for patients with breast implants.2 However, there are several reasons not to prescribe such antibiotics to otherwise healthy breast implant dental patients.
First, late breast implant infections (more than 7 months after placement) are rare, about 1 in 10,000 (0.01%) cases.3 Although these infections are sometimes blamed on dental procedures, such blame is usually misplaced.
The vast majority of these infections are not caused by dental procedures, as the causative organisms (eg, staphylococci) are not typically found in the mouth. One case of breast implant infection blamed on a dental procedure was an infection caused by Clostridium perfringens, an organism typically found in the intestines.4
Even if all late breast implant infections were caused by dental procedures, giving antibiotic prophylaxis to every dental patient with breast implants would involve exposing 10,000 patients to antibiotics and their potential side effects in the hopes of preventing a single case of breast implant infection.
Second, antibiotic prophylaxis to prevent metastatic infections has never been proven effective. Case control studies of antibiotic prophylaxis have shown low rates of efficacy, even less than 50%.5,6,7
Third, endocarditis is a serious and sometimes fatal heart infection often caused by organisms common in the oral flora. Antibiotic prophylaxis is indicated for dental procedures to prevent endocarditis in patients with artificial heart valves or previous history of endocarditis. In contrast, breast implant infections are almost never caused by organisms found in the mouth, and the most serious complication of breast implant infections usually involves removal of the prosthesis.
Fourth, antibiotic side effects include the emergence of resistant organisms, allergy, anaphylaxis, and even death. To prevent one theoretical case of breast implant infection from a dental procedure, thousands of dental patients would have to be exposed to these potential side effects. Single-dose clindamycin for antibiotic prophylaxis has been shown to lead to fatal reactions in 13 out of a million prescriptions, usually Clostridum difficile infections.8
Fifth, plastic surgeons sometimes recommend antibiotic prophylaxis for dental procedures, but improper prescribing of antibiotics can be a cause of a malpractice suit. The dentist is responsible for the dental treatment, and deferring to a physician’s opinion to prescribe an unnecessary antibiotic for which there is no evidence is not a valid legal defense.9
Finally, of the few cases of breast implant infection caused by organisms found in the mouth, it is impossible to know if the organism entered the bloodstream during the dental procedure, as transient bacteremias occur frequently from other daily activities like toothbrushing, chewing, and flossing.
In fact, it may be much more likely that the offending organism was not from a dental procedure, as the total number of minutes of bacteremia in a six-month period prior to the discovery of a breast implant infection could be a thousand times more from these everyday activities than from a dental procedure during this period.10
The time has come to stop the practice of antibiotic prophylaxis for dental patients with breast implants
References
- Smith R. Action on antimicrobial resistance. Not easy, but Europe can do it. BMJ. 1998;317:764.
- Froum S, Wall B. Antibiotic prophylaxis for patients with breast implants prior to dental procedures. Perio-Implant Advisory. May 1, 2019. https://www.perioimplantadvisory.com/clinical-tips/article/16412203/antibiotic-prophylaxis-for-patients-with-breast-implants-prior-to-dental-procedures Accessed November 21, 2019.
- Brand KG. Infection of mammary prostheses: a survey and the question of prevention. Ann Plast Surg. 1993;30:289-295.
- Hunter JG, Padilla M, Cooper-Vastola S. Late ClostridiumPerfringensbreast implant infection after dental treatment. Ann Plast Surg. 1996;36:(3)309-312.
- van der Meer JTM, Michel MF, Valkenburg HA, et al. Efficacy of antibiotic prophylaxis for prevention of native-valve endocarditis. Lancet. 1992;339:P135-P139.
- Strom BL, Abrutyn E, Berlin JA, et al. Dental and cardiac risk factors for infective endocarditis: a population-based, case-control study. Ann Intern Med.1998;129:761-769.
- Lacassin F, Hoen B, Leport C, et al. Procedures associated with infective endocarditis in adults: a case control study. Eur Heart J.1995;16:1968-1974.
- Thornhill MH, Dayer MJ, Prendergast B, et al. Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. J Antimicrob Chemother. 2015;70:2382-2388.
- Paumier T. No evidence to support the use of antibiotic prophylaxis for patients with breast implants. Perio-Implant Advisory. July 3, 2019. https://www.perioimplantadvisory.com/periodontics/oral-medicine-anesthetics-and-oral-systemic-connection/article/14035767/no-evidence-to-support-the-use-of-antibiotic-prophylaxis-for-patients-with-breast-implants Accessed November 21 2019.
- Guntheroth WG. How important are dental procedures as a cause of infective endocarditis? Am J Cardiol. 1984;54:797-801.
Dr. Wahl practices general dentistry in Wilmington, Delaware, where he is also a part-time assistant attending dentist at Christiana Care Health System. He can be reached at wahldentistry@aol.com.
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