Antibiotic Prophylaxis for Patients With Prosthetic Joints

The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients With Prosthetic Joints: Evidence-Based Clinical Practice Guideline for Dental Practitioners -- A Report of the American Dental Association Council on Scientific Affairs

Sollecito TP, Abt E, Lockhart PB, et al
J Am Dent Assoc. 2015;146:11-16

Updating the Clinical Practice Guideline

Evidence-based decision-making is currently the primary driver of dental education and clinical practice.^[1] Typically, this process consists of the relevant experts systematically collecting and analyzing the existing evidence on a specific educational and/or clinical issue affecting dentistry and determining whether the quality of the evidence mandates change to the existing pedagogy or clinical recommendations.

Oral healthcare providers carefully weigh the risks and benefits of recommending antibiotic prophylaxis for patients receiving dental care on a daily basis. The 2007 American Heart Association guidelines on antibiotic prophylaxis provide a framework for oral healthcare professionals to determine whether prophylaxis prior to dental treatment for individuals with specific cardiac conditions who may be at increased risk of developing infective endocarditis is warranted.^[2] Patients receiving dental care with prosthetic joints have been thought to be at increased risk of developing prosthetic joint infections, and several clinical practice guidelines have been published by the American Dental Association (ADA) and American Academy of Orthopaedic Surgeons (AAOS) on this issue.^[3,4,5]

The clinical practice guidelines from 2012 on antibiotic prophylaxis for patients receiving dental care with prosthetic joints, endorsed by both the ADA and AAOS, were considered by many to be vague and of equivocal benefit to dentists in the decision-making process for these patients.^[6]

To provide clarification on the 2012 guidelines, a panel of experts was convened by the ADA Council on Scientific Affairs in 2014 to review the current evidence and develop an evidence-based clinical practice guideline on the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures. The 2014 panel chose to use the literature selected by the 2012 panel as the foundation for the new guideline because a comprehensive search of the biomedical literature was previously completed and results of the search were screened according to defined inclusion and exclusion criteria. Furthermore, the 2014 panel updated the literature search and screening process to identify new evidence.

The 2014 panel assessed each identified study according to the Critical Appraisal Skills Programme case-control critical appraisal tool and then summarized the body of evidence to determine the level of certainty in the effect estimate and corresponding strength of the recommendation. Four case-controlled studies evaluating dental procedures as risk factors for prosthetic joint infections were included in the current analysis; one identified by the 2012 panel and three additional studies identified by the 2014 panel through the updated literature search process. Odds ratios and/or hazard ratios for these studies were evaluated for significance by the 2014 panel and were used to guide development of the updated clinical practice guideline.

The 2014 panel judged with moderate certainty that there is no association between dental procedures and the occurrence of prosthetic joint infections. This judgment was based on two considerations:

The results of three of four studies failed to show an association between dental procedures and prosthetic joint infections, and the results of the fourth study demonstrated a protective effect of dental procedures and prosthetic joint infections.
Although the number of studies was limited, it is unlikely that the results of additional studies would have changed the conclusion.

On the basis of these findings and additional parameters, the 2014 panel makes the following clinical recommendations:

In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.
For patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and the orthopedic surgeon.
In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.

Viewpoint

The 2014 panel recommendations are based on a careful analysis of the available evidence to clarify the recommendations of the 2012 panel, which had been a source of concern for oral healthcare professionals.^[6] Additional factors considered against the use of antibiotic prophylaxis are increased risk of developing antibiotic resistance, risk for adverse drug reactions, development of Clostridium difficile infection, and healthcare costs associated with prescriptions for this purpose.

A potential criticism of the updated clinical practice guideline is that it is endorsed by the ADA only, whereas the 2012 guideline was endorsed by both the ADA and AAOS. These updated recommendations could cause conflict between dentists and orthopedic surgeons and potentially produce a deeper quandary for both providers and patients. There is a clear need for additional case-controlled studies to increase the level of certainty on this issue; however, the updated evidence-based clinical practice guideline is intended to provide clarity to oral healthcare professionals when considering antibiotic prophylaxis for patients with prosthetic joints and to improve the quality of patient care.

Abstract

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