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J Am Dent Assoc, Vol 134, No 7, 895-898.
© 2003 American Dental Association
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ASSOCIATION REPORT

JADA Continuing Education

Antibiotic prophylaxis for dental patients with total joint replacements



AMERICAN DENTAL ASSOCIATION and AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS


   ABSTRACT
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 ABSTRACT
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Background and Overview. In 1997, the American Dental Association and the American Academy of Orthopaedic Surgeons convened an expert panel of dentists, orthopaedic surgeons and infectious disease specialists and published their first Advisory Statement on Antibiotic Prophylaxis for Dental Patients with Prosthetic Joints. This represented the first time that national health organizations had gone on record on this topic. This 2003 advisory statement is the first periodic update of the 1997 statement. In addition, the organizations have created a new patient handout (included at the end of the statement) that dentists may share with their patients. The 1997 Advisory Statement has been well-used by dentists and orthopaedic surgeons. Following their standard protocols for periodic review of existing advisory statements, the ADA and AAOS and their expert consultants recently reviewed the 1997 statement.

Conclusions and Clinical Implications. The 2003 statement includes some modifications of the classification of patients at potential risk and of the incidence stratification of bacteremic dental procedures, but no changes in terms of suggested antibiotics and antibiotic regimens. The statement concludes that antibiotic prophylaxis is not indicated for dental patients with pins, plates or screws, nor is it routinely indicated for most dental patients with total joint replacements. However, it is advisable to consider pre-medication in a small number of patients who may be at potential increased risk of experiencing hematogenous total joint infection.

Approximately 450,000 total joint arthroplasties are performed annually in the United States. Deep infections of these total joint replacements usually result in failure of the initial operation and the need for extensive revision. Owing to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been reduced markedly in the past 20 years.

Patients who are about to have a total joint arthroplasty should be in good dental health prior to surgery and should be encouraged to seek professional dental care if necessary. Patients who already have had a total joint arthroplasty should perform effective daily oral hygiene procedures to remove plaque (for example, by using manual or powered toothbrushes, inter-dental cleaners or oral irrigators) to establish and maintain good oral health. The risk of bacteremia is far more substantial in a mouth with ongoing inflammation than in one that is healthy and employing these home oral hygiene devices.1

Antibiotic prophylaxis is not routinely indicated for most dental patients with total joint replacements.

Bacteremias can cause hematogenous seeding of total joint implants, both in the early postoperative period and for many years following implantation.2 It appears that the most critical period is up to two years after joint placement.3 In addition, bacteremias may occur in the course of normal daily life4–6 and concurrently with dental and medical procedures.6 It is likely that many more oral bacteremias are spontaneously induced by daily events than are dental treatment–induced.6 Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses.1 The risk/benefit7,8 and cost/effectiveness7,9 ratios fail to justify the administration of routine antibiotic prophylaxis. The analogy of late prosthetic joint infections with infective endocarditis is invalid, as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.10

Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity; allergy; and development, selection and transmission of microbial resistance.

It is likely that bacteremias associated with acute infection in the oral cavity,11,12 skin, respiratory, gastrointestinal and urogenital systems and/or other sites can and do cause late implant infection.12 Any patient with a total joint prosthesis with acute orofacial infection should be vigorously treated as any other patient with elimination of the source of the infection (incision and drainage, endodontics, extraction) and appropriate therapeutic antibiotics when indicated.1,12 Practitioners should maintain a high index of suspicion for any unusual signs and symptoms (such as fever, swelling, pain, joint that is warm to touch) in patients with total joint prostheses.

Antibiotic prophylaxis is not indicated for dental patients with pins, plates and screws, nor is it routinely indicated for most dental patients with total joint replacements. This position agrees with that taken by the ADA Council on Dental Therapeutics13 and the American Academy of Oral Medicine14 and is similar to that taken by the British Society for Antimicrobial Chemotherapy.15 There is limited evidence that some immunocompromised patients with total joint replacements (Table 1Go) may be at higher risk of experiencing hematogenous infections.12,16–23 Antibiotic prophylaxis for such patients undergoing dental procedures with a higher bacteremic risk (as defined in Table 2Go) should be considered using an empirical regimen (Table 3Go). In addition, antibiotic prophylaxis may be considered when the higher-risk dental procedures (again, as defined in Table 2Go) are performed on dental patients within two years post–implant surgery,3 on those who have had previous prosthetic joint infections and on those with some other conditions (Table 1Go).


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  		TABLE 1 PATIENTS AT POTENTIAL INCREASED RISK OF EXPERIENCING HEMATOGENOUS TOTAL JOINT INFECTION.*

 

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  		TABLE 2 INCIDENCE STRATIFICATION OF BACTEREMIC DENTAL PROCEDURES.*

 

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  		TABLE 3 SUGGESTED ANTIBIOTIC PROPHYLAXIS REGIMENS.*

 
Occasionally, a patient with a total joint prosthesis may present to the dentist with a recommendation from his or her physician that is not consistent with these guidelines. This could be due to lack of familiarity with the guidelines or to special considerations about the patient’s medical condition that are not known to the dentist. In this situation, the dentist is encouraged to consult with the physician to determine if there are any special considerations that might affect the dentist’s decision on whether or not to premedicate, and may wish to share a copy of these guidelines with the physician if appropriate. After this consultation, the dentist may decide to follow the physician’s recommendation or, if in the dentist’s professional judgment antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic prophylaxis. The dentist is ultimately responsible for making treatment recommendations for his or her patients based on the dentist’s professional judgment. Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity; allergy; and development, selection and transmission of microbial resistance.

This statement provides guidelines to supplement practitioners in their clinical judgment regarding antibiotic prophylaxis for dental patients with a total joint prosthesis. (Editor’s note: The patient handout on page 899 can be duplicated to provide patients with an overview of these guidelines.) It is not intended as the standard of care nor as a substitute for clinical judgment, as it is impossible to make recommendations for all conceivable clinical situations in which bacteremias originating from the oral cavity may occur. Practitioners must exercise their own clinical judgment in determining whether or not antibiotic prophylaxis is appropriate.


   FOOTNOTES
 

Address reprint requests to the ADA Council on Scientific Affairs, 211 E. Chicago Ave., Chicago, Ill. 60611.


The ADA/AAOS Expert Panel that developed the original of this statement consisted of Robert H. Fitzgerald Jr., M.D.; Jed J. Jacobson, D.D.S., M.S., M.P.H.; James V. Luck Jr., M.D.; Carl L. Nelson, M.D.; J. Phillip Nelson, M.D.; Douglas R. Osmon, M.D.; and Thomas J. Pallasch, D.D.S. The staff liaisons were Clifford W. Whall Jr., Ph.D., for the ADA, and William W. Tipton Jr., M.D., for the AAOS. The ADA and the AAOS reviewed and updated this statement in 2003.


Dentists and physicians are encouraged to reproduce the above Advisory Statement for distribution to colleagues. Permission to reprint the Advisory Statement is hereby granted by ADA and AAOS, provided that the Advisory Statement is reprinted in its entirety including citations and that such reprints contain a notice stating "Copyright © 2003 American Dental Association and American Academy of Orthopaedic Surgeons. Reprinted with permission." If you wish to use the Advisory Statement in any other fashion, written permission must be obtained from ADA and AAOS.


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  1. Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontol 2000 1996;10:107–38.

  2. Rubin R, Salvati EA, Lewis R. Infected total hip replacement after dental procedures. Oral Surg Oral Med Oral Pathol 1976;41(1):13–23.

  3. Hansen AD, Osmon DR, Nelson CL. Prevention of deep prosthetic joint infection. Am J Bone Joint Surg 1996;78-A(3):458–71.[Free Full Text]

  4. Bender IB, Naidorf IJ, Garvey GJ. Bacterial endocarditis: a consideration for physicians and dentists. JADA 1984;109:415–20.[Medline]

  5. Everett ED, Hirschmann JV. Transient bacteremia and endocarditis prophylaxis: a review. Medicine (Baltimore) 1977;56:61–77.[Medline]

  6. Guntheroth WG. How important are dental procedures as a cause of infective endocarditis? Am J Cardiol 1984;54:797–801.[Medline]

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  8. Tsevat J, Durand-Zaleski I, Pauker SG. Cost-effectiveness of antibiotic prophylaxis for dental procedures in patients with artificial joints. Am J Public Health 1989;79:739–43.[Abstract/Free Full Text]

  9. Norden CW. Prevention of bone and joint infections. Am J Med 1985;78(6B):229–32.[Medline]

  10. McGowan DA. Dentistry and endocarditis. Br Dent J 1990;169:69.[Medline]

  11. Bartzokas CA, Johnson R, Jane M, Martin MV, Pearce PK, Saw Y. Relation between mouth and haematogenous infections in total joint replacement. Br Med J 1994;309:506–8.[Abstract/Free Full Text]

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  14. Eskinazi D, Rathburn W. Is systematic antimicrobial prophylaxis justified in dental patients with prosthetic joints? Oral Surg Oral Med Oral Pathol 1988;66:430–1.[Medline]

  15. Cawson RA. Antibiotic prophylaxis for dental treatment: for hearts but not for prosthetic joints. Br Dent J 1992;304:933–4.

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  18. Poss R, Thornhill TS, Ewald FC, Thomas WH, Batte NJ, Sledge CB. Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop 1984;182:117–26.[Medline]

  19. Jacobson JJ, Millard HD, Plezia R, Blankenship JR. Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986;61:413–7.[Medline]

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  21. Jacobson JJ, Patel B, Asher G, Wooliscroft JO, Schaberg D. Oral Staphylococcus in elderly subjects with rheumatoid arthritis. J Am Geriatr Soc 1997;45:1–5.[Medline]

  22. Berbari EF, Hanssen AD, Duffy MC, Ilstrup DM, Harmsen WS, Osmon DR. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998;27:1247–54.[Medline]

  23. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young. JAMA 1997;277:1794–801.[Abstract/Free Full Text]




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