Dental Extraction Prophylaxis Treatment With Antibiotics Is Controversial
Overview
This study aimed to assess the relationship between antibiotic prophylaxis and adverse outcomes following dental extractions within the Veterans Affairs Healthcare System. Researchers conducted a retrospective cohort analysis of patients who underwent tooth extractions from 2015 to 2019, focusing on antibiotic use and its effect on post-extraction complications, such as alveolar osteitis and surgical site infections, within 7 days. The secondary outcome measured was the need for medical care related to these complications.
Among 385,880 dental extractions, 31.8% of patients received antibiotic prophylaxis. Post-extraction complications occurred in 0.9% of cases, and only 0.09% required subsequent medical intervention. Multivariable regression analysis revealed that diabetes significantly modified the effect of antibiotics on complications. In patients without diabetes, antibiotic prophylaxis was linked to a 25% increase in complication risk. However, in patients with diabetes, no significant effect was observed. Furthermore, antibiotic use did not significantly reduce the need for post-extraction medical care.
The study concludes that in a setting with low complication rates, antibiotic prophylaxis did not provide a clear protective benefit, suggesting that its routine use should be reconsidered to avoid unnecessary antibiotic exposure.
Introduction
Dentists perform tooth extractions primarily due to dental caries and periodontal diseases, both of which are infectious conditions that can compromise tooth structure, supporting tissues, and lead to broader local or systemic issues. While the number of retained teeth over a lifetime has generally increased, certain groups—defined by factors such as race, socioeconomic status, education level, and lifestyle habits like smoking—experience higher rates of tooth loss.
Most extractions take place in outpatient settings, under local anesthesia. The risk of postoperative complications, including infection, tends to increase with the complexity and invasiveness of the procedure. Common complications following tooth removal include pain, swelling, dry socket (alveolar osteitis), and surgical site infections.
Dentists often prescribe antibiotics to prevent these complications, but recent data from the Veterans Health Administration (VHA) shows that only 15% of these prescriptions meet stringent guidelines—limited to patients at high cardiac risk. When the guidelines are expanded to include immunocompromised patients, those undergoing extractions, and those receiving dental implants, the percentage of appropriate antibiotic use rises to 72%. This suggests that while antibiotics are frequently used for post-extraction prevention, there is limited or inconsistent evidence supporting their necessity, particularly for patients with medical vulnerabilities.
A Cochrane review focusing on third molar extractions found low-certainty evidence that antibiotics can reduce the risk of infection by 66% and dry socket by 34%, though their impact on pain and fever was unclear. It’s important to note that third molar extractions, typically more invasive and performed on younger, healthier individuals, may not reflect outcomes for other types of extractions or for medically compromised populations.
Several studies examining routine, nonsurgical extractions in healthy adults have found no significant benefit from systemic antibiotics in preventing complications compared to placebo or no treatment. However, Veterans Affairs (VA) dental patients, who tend to be older and face greater oral and systemic health challenges—including conditions like diabetes and mental health disorders—may experience different post-extraction outcomes due to their higher overall disease burden. Therefore, this study aims to assess the effectiveness of antibiotic prophylaxis in reducing both localized and systemic post-extraction complications in VA dental patients.
Method
This retrospective cohort study analyzed dental extractions performed at Veterans Health Administration (VHA) facilities between January 1, 2015, and December 31, 2019, using data from the VHA Corporate Data Warehouse (CDW). Dental extractions were identified by specific CDT codes (D7140, D7210, D7250, and D7711). Patients who received an implant at the index visit or within 90 days, or had a dental visit between the antibiotic prescription and extraction date, were excluded. Patients undergoing impacted tooth extractions (CDT codes D7220, D7230, D7240, and D7241) were also excluded. Expedited approval for the study was granted by the Edward Hines, Jr. VA Investigational Review Board, and informed consent was exempted.
The primary focus was on antibiotic prophylaxis, defined as antibiotics prescribed within 30 days before the extraction for mail-ordered medications or 7 days prior for those dispensed at outpatient pharmacies. In cases with multiple prescriptions, the closest to the extraction date was considered.
The study’s main outcome was post-extraction complications, which included oral infections, dry socket, or fever within seven days post-extraction, identified through ICD-10-CM codes. Secondary outcomes included the need for follow-up medical care due to complications within the same period.
Covariates considered included patient demographics, comorbidities, medical history, and extraction-specific factors. Comorbidities were identified based on ICD-10-CM codes up to one year prior to extraction. High-risk cardiac conditions were classified according to the guidelines for dental antibiotic prophylaxis. A history of oral infection was noted if diagnosed between 31 and 365 days prior to the extraction, with baseline infections identified within 30 days of the procedure. Immunosuppression and poorly controlled diabetes (HbA1C ≥ 8%) were also assessed as covariates.
Statistical Analysis
Logistic regression models were used to analyze the association between antibiotic prophylaxis and the outcome variables. Variables with a p-value <0.20 were included in the multivariable analysis, and those with a p-value <0.05 were retained in the final model, along with potential confounders. A sensitivity analysis excluded visits where antibiotics were prescribed by a medical provider, and the final regression models were fitted to this restricted cohort.
Result
The study examined 385,880 dental visits involving 269,003 unique patients. The dataset was categorized based on whether patients received antibiotic prophylaxis, as multiple outcomes were analyzed. The distribution of extraction visits was fairly consistent throughout the study period, with 21.1% occurring in 2015 and 18.2% in 2019. The Southern U.S. accounted for 45.5% of visits, while 92.9% of the patients were male, predominantly aged between 65–79 years (47.7%) and 45–64 years (31.9%). White patients made up 66.7% of the cohort, and 26.3% were Black. Half of the patients had diabetes.
Regarding tooth extractions, 61.1% involved the removal of just one tooth, and nonsurgical extractions occurred in 59.4% of cases. Dental practitioners conducted the majority of extractions (91.8%), with oral surgeons and residents performing the rest. The study found a low prevalence of oral infections (2.9%), prior implants (1%), and infections at baseline (1.2%).
Antibiotic prophylaxis was administered in 31.8% of visits (122,810 cases), with amoxicillin being the most commonly prescribed antibiotic (69%), followed by clindamycin (16%). Patients who underwent surgical extractions were more likely to receive antibiotic prophylaxis compared to those who had nonsurgical extractions (37.9% vs. 27.7%). Post-extraction complications occurred in 0.9% of visits, with 1% of complications among those who received antibiotics, compared to 0.8% among those who did not.
In the multivariable analysis, diabetes was found to significantly modify the relationship between antibiotic prophylaxis and post-extraction complications. For patients without diabetes, prophylaxis was associated with a higher risk of complications (OR = 1.25, 95% CI: 1.13–1.38), while no significant association was observed in patients with diabetes (OR = 1.03, 95% CI: 0.92–1.15). Sensitivity analyses confirmed these results.
Only 0.09% of patients sought medical care for post-extraction complications within 7 days, and antibiotic prophylaxis was not significantly associated with this outcome (OR = 1.04, 95% CI: 0.83–1.30). No significant interaction with diabetes was found in this regard, and further analyses excluding patients prescribed antibiotics by non-dental providers yielded similar findings.
Conclusion
In a study examining dental patients from a Veterans Affairs (VA) system over a five-year period, the incidence of 7-day postoperative complications was found to be below 1% for both surgical and nonsurgical extractions, excluding third molar extractions. This complication rate is notably lower compared to rates reported in smaller randomized control trials of healthy adults, where complications ranged from 0% to 14%. Variability in complication rates across studies may reflect differences in measurement methods, procedural protocols, and patient populations.
A review of patients who did not receive antibiotics revealed minimal misclassification in antibiotic use, with very few patients having been missed regarding complication outcomes. The study found no benefit from the use of pre- or peri-procedural antibiotics in preventing postoperative infections or dry socket, aligning with previous research that also found no advantage to antibiotic prophylaxis for nonsurgical extractions.
The study highlights that Veterans, who often have higher rates of dental caries and systemic diseases, present a unique case compared to the general population. Although immunocompromised patients showed higher odds of complications in preliminary analyses, this factor was not a significant predictor of complications in the final model. Notably, patients with diabetes who received antibiotic prophylaxis experienced an increased likelihood of complications, suggesting that antibiotic use might not mitigate risk for these individuals.
Antibiotics were frequently prescribed for cases anticipated to have higher risks, such as surgical extractions or baseline oral infections. The predominant antibiotic prescribed was amoxicillin, with clindamycin used less frequently but discouraged due to adverse effects.
The study acknowledges several limitations, including a male-dominated sample, reliance on medical records for identifying complications, and potential overestimation of localized infections due to coding practices. The findings support the reconsideration of antibiotic prophylaxis for preventing post-extraction complications, particularly given the associated risks and limited benefits. Recommendations for future practice include focusing on evidence-based guidelines and improving antibiotic stewardship to reduce unnecessary prescriptions and mitigate associated risks like antimicrobial resistance and adverse reactions.
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