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I have read with considerable dismay the ADA Division of Legal Affairs’ September JADA article, "A Legal Perspective on Antibiotic Prophylaxis" and the July JADA update of the July 1997 advisory statement of the ADA and the American Academy of Orthopaedic Surgeons, "Antibiotic Prophylaxis for Dental Patients With Total Joint Replacements." I suggest that the following be provided to the membership.

1. The absolute worst case risk for a dental treatment–associated bacteremia inducing a prosthetic joint infection is 1 in 2.5 million dental treatment procedures (appointments) as documented in the literature.^1–4 The best case scenario is a zero risk, as no purported dental treatment–induced prosthetic joint infections have ever been established via microbial genetic testing to ascertain if the microorganism in the mouth and infected joint is identical. Even then it is not possible to determine if the purported bacteremia occurred before, during or after the dental procedure, as random bacteremias from the oral cavity are very common. Also, a study has indicated that up to 12.8 percent of prosthetic joint implant sites were infected with staphylococci, streptococci and gram-negative rods before the implant was placed.⁵
   
2. With such an extremely low risk rate for dental treatment-induced bacteremic prosthetic joint infections, it is very doubtful that informed consent is legally or medically required, or even advisable.
   
3. The informed consent statement does not advise the patient that there is no evidence that antibiotic prophylaxis can prevent bacteremic joint infections, or that harm may result from such prophylaxis. There is evidence that the risk of death is greater from the prophylaxis than from the infection.^1–4 Therefore, the informed consent statement is erroneous and misleading, as it does not provide full patient informed consent.
   
4. In 33 years of serving as an expert witness in dental and medical malpractice litigation (well over 300 cases), I have yet to experience a situation where the plaintiff’s physician has testified against the treating dentist regarding the standard of care. Tort cases are adjudicated via expert witnesses and, since neither the patient’s dentist nor physician is in this category, such testimony is very unlikely, particularly if the physician’s treatment or recommendations regarding the patient are incorrect. In such situations, cross-examination by attorneys can be brutal.
   
5. Producing these equivocal and confusing statements against antibiotic prophylaxis for dental patients with prosthetic joints does nothing to reduce medicolegal liability, as lawyers thrive upon equivocation. Give them a chance to argue, and they will, for as long as possible.
   
6. The recommendation to send the patient to another dentist (presumably a competitor and a non-ADA member) is hardly good professional advice. We should follow the data, act like doctors and do the right thing.
   
7. If the ADA is concerned about microbial resistance to antibiotics, then it should forthrightly address the data, or lack thereof, and not recommend antibiotics for situations where there is no evidence of efficacy, and minute, if any, evidence of risk and known evidence of harm.
   
8. I would predict that, due to these new, confused, confusing and at times inaccurate "informed consent" recommendations regarding antibiotic prophylaxis for dental patients with prosthetic joints, malpractice cases against dentists will now rise, since we will be sued for not obtaining proper informed consent (the last refuge of a plaintiff’s attorney), even as we correctly follow the scientific data and our best clinical judgment. [I also predict] that many more dental patients will receive antibiotic prophylaxis to prevent lawsuits, again allowing the legal profession to dictate medical treatment for which it bears no medical, legal or ethical responsibility.
   

	REFERENCES

TOP REFERENCES

1. Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontol 2000 1996;10:107–38.
   
   
2. Pallasch TJ, Wahl MJ. Focal infection: new age or ancient history? Endod Top 2003;4(1):32–45.
   
   
3. Pallasch TJ. Antibiotic prophylaxis. Endod Top 2003;4(1):46–59.
   
   
4. Pallasch TJ. Antibiotic prophylaxis: problems in paradise. Dent Clin North Am (in press).
   
   
5. Gill GS, Mills DM. Long-tem follow-up evaluation of 1000 consecutive cemented total knee arthroplasties. Clin Orthop 1991;273:66–76.[Medline]
   
   

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