Dental Antibacterial Prophylaxis Unnecessary for Artificial Joints

The available evidence is insufficient to recommend routine antibiotics for dental procedures in persons with a joint replacement, according to a new clinical practice guideline.

The guideline, titled “Prevention of Orthopedic Implant Infection in Patients Undergoing Dental Procedures,” was developed jointly by the American Academy of Orthopedic Surgeons (AAOS; Rosemont, IL, USA) and the American Dental Association (ADA; Chicago, IL, USA), following a collaborative systematic review of the correlation between dental procedures and prosthetic joint infection (PJI) that found no direct evidence of a causal link.

The clinical practice guideline includes three specific recommendations:

Practitioners should consider changing their customary practice of prescribing prophylactic antibiotics to patients undergoing dental procedures. This recommendation is based on limited evidence that dental procedures are unrelated to PJI.

There is no direct evidence that the use of oral topical antimicrobials before dental procedures will prevent PJI. This is an inconclusive recommendation, in that the guidelines authors were unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopedic implants.

Good oral hygiene should be maintained. This is the only consensus recommendation in the guideline.

Included with the guideline is a shared decision-making tool to facilitate collaborative decision making between patient and clinician and to supplement, but not replace, informed consent procedures. The tool notes that potential adverse effects of routine antibiotic use may include increased bacterial resistance, allergic reactions, diarrhea, and even death. It also notes that immune-compromised patients might be at greater risk for implant infections and that antibiotic use might be considered in this group.

“It has been long debated that patients with orthopedic implants, primarily hip and knee replacements, are prone to implant infections from routine dental procedures,” said David Jevsevar, MD, MBA, chair of the AAOS Evidence Based Practice Committee. “What we found in this analysis is that there is no conclusive evidence that demonstrates a need to routinely administer antibiotics to patients with an orthopedic implant who undergo dental procedures.”

“This guideline was based primarily on clinical research which examined a large group of patients, all having a prosthetic hip or knee and half with an infected prosthetic joint,” said AAOS-ADA work group member Elliot Abt, DDS, a general dentist in Skokie (IL, USA), and a member of the ADA Council on Scientific Affairs. “The research showed that invasive dental procedures, with or without antibiotics, did not increase the odds of developing a prosthetic joint infection.”

In the United States alone, more than 302,000 hip replacements and 658,000 knee replacements were completed in 2010. The mean infection rate is 2%, according to findings from hip and knee replacement studies reviewed by the guideline authors. Infectious organisms may enter the surgical wound during or after the joint replacement procedure, and complications may include surgical drainage or debridement and long courses of antibiotics.

Related Links:
American Academy of Orthopaedic Surgeons
American Dental Association