In December 2012 the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) released a co-developed guideline, “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures,” a systematic review of existing clinical research published in peer-reviewed journals to determine the correlation between dental procedures and prosthetic joint infection (PJI).
The new ADA and AAOS guideline has three recommendations (below) and replaces the previous AAOS Information Statement “Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacement.” The guideline is careful to state that it is “not a stand-alone document”, but rather “an educational tool to guide clinicians through treatment decisions.”
Evidence Insufficient to Recommend Routine Antibiotics for
Joint Replacement Patients Who Undergo Dental Procedures
The following statements from the AAOS press release may be helpful for people in their decision:
- … “in this analysis is that there is no conclusive evidence that demonstrates a need to routinely administer antibiotics to patients with an orthopaedic implant, who undergo dental procedures.”
- “The research showed that invasive dental procedures, with or without antibiotics, did not increase the odds of developing a prosthetic joint infection.”
This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.
The Guideline Recommendations:
1. The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.
Strength of Recommendation: Limited
A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.
Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.
2. We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.
Strength of Recommendation: Inconclusive
An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm.
Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.
3. In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.
Strength of Recommendation: Consensus
A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.
Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.