Antibiotics for surgical prophylaxis

Editor, – I would agree that the principles set out in the article 'Antibiotics for surgical prophylaxis' (Aust Prescr 2005;28:38-40) should be applied to dento-alveolar surgery. However, the suggestions set out in the Dental notes (Aust Prescr 2005;28:41) represent a hybrid of traditional dental practice which is not in accord with current evidence-based risk-benefit assessment.

Traditionally in dental practice antibiotics have been given for the prophylaxis of impacted tooth removal after surgery has been completed.¹This is inappropriate and contrary to the principles of surgical prophylaxis. The suggestion of giving antibiotics either orally or intravenously before the procedure is a step in the right direction, but is not widely currently followed in dentistry. It is also weakened by the suggestion that antibiotics should be continued post-extraction as a matter of clinical judgement.

Current evidence-based studies show that the actual risk of infection after third molar removal is low, of the order of 3-5%. This is similar to the risk of adverse reaction to the penicillins, which are the most commonly used antibiotics for this purpose.

In accordance with the literature, the Oral and Maxillofacial Surgery Unit in Adelaide does not give medically fit patients having dento-alveolar surgery antibiotic prophylaxis. Over the last decade, and many thousands of cases, there has been no increased incidence of infection.

This whole issue is currently being reviewed in depth and will shortly be submitted for publication in the Australian Dental Journal and in the new therapeutic guidelines for dental practitioners.

Alastair N. Goss
Professor and Director
Oral and Maxillofacial Surgery Unit
The University of Adelaide

Associate Professor R.G. Woods, author of the Dental notes, comments:

I believe the views I expressed in the Dental notes are essentially consistent with the views expressed in Professor Goss' letter. However, Professor Goss and I see things from different backgrounds, Professor Goss from the Oral and Maxillofacial Surgery Unit in Adelaide and myself from general practice in a rural community.

Most third molars I remove appear to communicate, however slightly, with the oral cavity and often appear infected. The mucosal flap and surrounding soft tissues are often the site of a persistent, possibly anaerobic infection associated with eruption. Other teeth requiring removal usually have evidence of long-term infection, an apical bone lesion or loss of supporting alveolar bone.

In reference to my use of the term 'clinical judgement', essentially I refer to pre-operative assessment of the patient including consideration of the reason for the removal of the tooth, whether there is infection and such factors as immunosuppression or any other general condition which may affect recovery. It is my experience that where infection is present, although drainage is achieved by removal of the tooth, recovery is assisted by appropriate antibiotic therapy.