The Controversy over Antibiotic Prophylaxis for Dental Patients with Prosthetic Joints

The Controversy over Antibiotic Prophylaxis for Dental Patients with Prosthetic Joints

Nelson L. Rhodus, D.M.D., M.P.H., F.I.C.D.*:
 
Introduction
A potential long-term complication of chronic rheumatoid arthritis (also osteoarthritis and other types, including fractures that do not heal and avascular necrosis) is the ultimate  destruction of particular joint structures to the degree that the joint must be replaced with synthetic materials.1 Patients with prosthetic joint replacement (PJR), most commonly  hip and knee replacement (>90 % of all PJR), followed by shoulder, elbow, wrist, and ankle, often are encountered in dental practice. When this occurs, a question arises  concerning the need for antibiotic prophylaxis to prevent infection of the prosthesis. This is a legitimate concern. However, it is whether a transient bacteremia resulting from  dental procedures can cause prosthetic joint infection (PJI) or not that is the primary issue, and the controversy. This issue has been debated for many years, although scientific  evidence for decision making is lacking. 
 
Background
Recommendations to place dental patients on prophylactic antibiotics have been made empirically by orthopedic surgeons, although little evidence exists that dentally induced  bacteremia may cause PJI.2 Although reports in the literature weakly associate PJI with dentally induced bacteremia, authors have questioned the validity of these reports. It  appears that wound contamination or skin infection (with Staph aureus) is the source of the vast majority of infections.2 Oral bacteremias do not typically include much (or any)  Staph aureus. Even the few cases of PJI caused by presumably oral bacteria were more likely to result from physiologically occurring bacteremia or bacteremia caused by acute or  chronic infection than from invasive dental procedures.2



A History of Guidelines
Unfortunately, however, many orthopedic surgeons have persisted in requesting that patients continue to receive antibiotic prophylaxis for all dental procedures.3-5  
 
In an effort  to clarify the issue, initially in 1997 and updated in 2003, an advisory statement made jointly by the American Dental Association and the American Academy of Orthopedic  Surgeons was published.6 The 2003 advisory statement concluded that scientific evidence does not support the need for antibiotic prophylaxis for dental procedures to prevent  LPJI. It further stated that antibiotic prophylaxis is not indicated for dental patients with pins, plates, rods, wires, and screws, nor is it routinely indicated for most patients with  total joint replacement. The statement did indicate, however, that antibiotic prophylaxis can be considered for patients whose joint replacement has been in place  for less than two years, and for “high-risk” immunosuppressed patients who are at increased risk for infection and are undergoing invasive dental procedures (Table I). No  evidence suggests that even these patients are at increased risk for infection from dentally induced bacteremia, and in fact, the microbiology of LPJI in these patients is the same  as for other patients with LPJI.
 
Interpretation and Practice
A more appropriate interpretation is that these patients are at increased risk for LPJI from the usual sources such as wound contamination and acute infection from distant sites.  The advisory statement also is clear that the final decision on whether to provide antibiotic prophylaxis lies with the dentist, who must weigh perceived potential benefits against risks in exercising his or her clinical judgment. Indeed those risks (which include the increase in anaphylactic reactions and antibacterial resistance) may now actually exceed any  benefit of antibiotic prophylaxis and certainly the American Heart Association considered them in their 2007 recommendations for the prevention of infective endocarditis in dental patients. The advisory statement provides suggested antibiotic regimens should the practitioner elect to provide antibiotic prophylaxis (Table II).3 
 
In 2009, the American Association of Oral Surgeons (AAOS) published an information statement that added a great deal of confusion to the dental management of patients with  joint replacements. The AAOS suggested that dentists consider antibiotic prophylaxis for all joint replacement patients for all dental procedures that produced bacteremia. This  statement was made without input from the ADA and appeared to negate the 2003 advisory statement of the ADA and AAOS.3 
 
In 2010, the American Academy of Oral Medicine (AAOM) published a position paper in the JADA.6 It strongly recommended that the ADA, AAOS, and the Infectious Disease  Society of America (IDSA) meet to develop evidence-based recommendations for the dental management of patients with joint replacements. Until this occurs, the AAOM position  paper recommends three options for the dentist dealing with patients with joint replacements regarding antibiotic prophylaxis: 
1. Incorporate informed consent. 
2. Base clinical decisions on the 2003 ADA/AAOS consensus statement. 
3. Contact the patient’s orthopedic surgeon and suggest that they both follow the 2003 guidelines until a new joint consensus statement is approved. If the orthopedist elects to  recommend antibiotic prophylaxis for a patient who would not receive it based on the 2003 guidelines, then have the orthopedist write the prescription for the desired antibiotic.6 
 
In any of the above cases, careful documentation should be made in the patient’s record as to the rationale used for the clinical decision.  



In Development
In November of 2010, the ADA, AAOS, and IDSA began a series of meetings with the goal of developing an evidence-based recommendation for the dental management of  patients with joint replacements. The process was estimated to take about one year. Until this recommendation is available, the dentist should consider one of the options  suggested above in the AAOM position paper. A study that should have a great influence on the future recommendations of the ADA, AAOS, and IDSA was reported from the  Mayo Clinic. In a relatively large case-controlled study, the authors concluded that dental procedure bacteremias were not associated with the onset of LPJIs and that antibiotic prophylaxis did not prevent PJIs.7 
 
Although the ultimate decision as to whether a patient should receive antibiotic prophylaxis prior to dental procedures will be left to the dentist’s clinical judgment and the  patient’s informed consent, at the present time, the University of Minnesota School of Dentistry is continuing primarily to follow the 2003 ADA/AAOS consensus statement. 
 
References
1. Little J. Patients with prosthetic joints: Are they at risk when undergoing dental procedures. Spec Care Dentist 1997;17:153-60. 
2. Surgeons, A.A.O.S. Antibiotic prophylaxis for bacteremia in patients with joint replacements. Amer Acad Orthoped Surg, 2009. http://www.aaos.org(1033).
3. Cutando-Soriano A. and Galindo-Moreno P. Antibiotic prophylaxis in dental patients with body prostheses. Med Oral 2002;7(5):348-59.
4. Bauer T. et al. Dental care and joint prostheses. Rev Chir Orthop Reparatrice Appar Mot 2007;93(6):607-18.
5. ADA/AAOS. Antibiotic prophylaxis for dental patients with prosthetic joints. JADA 2003;134:895-97.
6. Little JW, Jacobson JJ, Lockhart P et al. The dental treatment of patients with joint replacements. JADA 2010;141(6):667-71. 
7. Barberi EF et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospitalbased prospective case-control study. Clin Infect Dis 2010;50(1):8-19. 
 
*Dr. Rhodus is professor and Director, Division of Oral Medicine and adjunct professor, Department of Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, MN  55455.