Antibiotic Prophylaxis for Dental Patients With Prosthetic Joints
Web-based support is now available to dental healthcare providers who are faced with this age-old clinical question: When should we prescribe antibiotic prophylaxis for dental patients with prosthetic joints? A new online tool was adopted by the American Academy of Orthopaedic Surgeons (AAOS) as a result of collaboration with the American Dental Association (ADA) Council on Scientific Affairs (CSA). To appropriately use the new decision-support tool, it is important to first understand the recent clinical practice guideline developments related to the use of prophylactic antibiotics before dental procedures in patients with prosthetic joints.
The 2015 evidence-based clinical practice guideline for dental practitioners is titled, “The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients With Prosthetic Joints.” The guideline states: “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infections.” This panel of experts found no association between dental procedures and prosthetic joint infections. The panel also found no scientifically based efficacy for using antibiotics to prevent prosthetic joint infections.
The clinical practice guideline explains that there may be “special circumstances” in which a clinician may consider antibiotic prophylaxis. And although the clinical practice guideline does not provide a list of these special circumstances, it does recommend that “prophylactic antibiotics should only be considered after consultation with the patient and orthopaedic surgeon” for dental patients with a history of complications associated with joint replacement surgery. Other salient points of the clinical practice guideline include the following:
- A complete medical history is always recommended when making final decisions regarding the need for antibiotic prophylaxis.
- The potential harms of antibiotics include risk for anaphylaxis, antibiotic resistance, and opportunistic infections like Clostridium difficile.
- The benefits of antibiotic prophylaxis may not exceed the harms for most patients.
AAOS Appropriate Use Criteria for 2016-2017
Although dental treatment is not considered a risk factor for prosthetic joint infections, the AAOS and ADA convened a group of multidisciplinary subject matter experts to consider whether antibiotic prophylaxis might be appropriate in certain higher-risk patients. Appropriate-use criteria have been developed with the goal of implementing evidence-based clinical practice guidelines. The development of appropriate-use criteria combines relevant evidence with clinician expertise/experience to rate how appropriate a certain treatment is collectively viewed, given a list of realistic clinical patient scenarios. In developing these criteria, the panel of experts considered the following assumptions and factors:
- The chance of oral bacteremia causing joint infections is extremely low, with no evidence for an association;
- Oral bacteremia frequently occurs secondary to such activities of daily living as tooth brushing and eating;
- Virtually all dental office procedures have the potential to create bacteremia;
- Multiple specific immune-compromised medical patient scenarios (ie, cancer, organ transplantation, rheumatoid arthritis, bone marrow transplantation); and
- Glycemic control in diabetes (ie, glycated hemoglobin (A1C) scores, blood glucose).
The following medically complex patient populations and related issues were used to gain consensus on any potential benefit from antibiotic prophylaxis:
- Planned dental procedures (ie, procedures that do or do not result in the manipulation of gingival or periapical tissues or perforation of the oral mucosa);
- Immunocompromised status (severely or not severely immunocompromised);
- Glycemic control in diabetes (ie, no diabetes diagnosis/activity, active diabetes, and various A1C/blood glucose combinations);
- History of periprosthetic or deep prosthetic joint infection of the hip or knee that required an operation; and
- Time since hip or knee joint replacement procedure (<1 year or ≥1 year).
The voting panel identified relatively few patient subpopulations for whom it might be appropriate to order antibiotic prophylaxis before certain dental procedures. Among the proposed higher-risk patient scenarios, 12% were rated as “appropriate,” 27% as “may be appropriate,” and 61% as “rarely appropriate.” The voting panel results were used to develop the AAOS appropriate-use criteria, available as an online tool for clinicians.
As dental and other healthcare providers become aware of the new appropriate-use criteria decision-support tool and consider using it for patient care, it is critical for them to be familiar with several of the ADA CSA panel’s take-home messages:
- There is no evidence to support an association between dental procedures and risk for prosthetic joint infections.
- The appropriate-use criteria decision-support tool supplements clinicians in making judgments about the need for antibiotic prophylaxis for patients with a prosthetic joint who are undergoing dental procedures. It is not intended as the standard of care or as a substitute for clinical judgment.
- A consensus of ADA-appointed expert panel members and the CSA agreed that this tool could benefit dentists, physicians, and patients by reducing antibiotic prescriptions.
- Discussion of available treatment options applicable to each patient relies on communication between the patient, dentist, and orthopedic surgeon weighing the potential risks and benefits for that patient. Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic use, including:
- Clostridium difficile infection;
- Allergic reaction; and
- The development, selection, and transmission of antimicrobial resistance factors.
- It is appropriate for the dentist to make the final judgment to use antibiotic prophylaxis for patients potentially at higher risk for prosthetic joint infections using the appropriate-use criteria as a guide, without consulting the orthopedic surgeon. However, if the orthopedic surgeon recommends or the patient prefers antibiotic prophylaxis, despite the dentist’s recommendation against premedication, the prescription should be provided by the surgeon.
- The 2015 clinical practice guideline is valid and should continue to inform clinical decisions for dental patients in ambulatory settings. The CSA and ADA-appointed expert panel members encourage dental practitioners to:
- Continue to use the 2015 ADA clinical practice guideline;
- Consult the appropriate-use criteria as needed; and
- Respect the patient’s specific needs and preferences when considering antibiotic prophylaxis before dental treatment.
I strongly encourage dentists to obtain a complete updated medical history for all patients and especially for those with prosthetic joints. It is essential to communicate fully with these patients and the treating orthopedic surgeons in a reasonable attempt to gain interprofessional consensus on theoretical risks for postsurgical prosthetic joint infections. I also suggest that dental practitioners preview the appropriate-use criteria tool and stay current with the relevant publications. These efforts enrich collaboration with our orthopedic surgery colleagues and provide patients with unsurpassed quality of care. Meanwhile, all participants involved should stay tuned for future clinical practice guideline updates on this important clinical topic.