Stop premedicating! ADA review examines treatment of patients with prosthetic joints
BY JoAnn R. Gurenlian, RDH, MS, PhD
We have faced this issue in practice too many times to count. Your patient has a hip or knee replacement, and the orthopedic surgeon recommends antibiotic premedication for life. Previous recommendations from the American Heart Association had been to premedicate for a short period of time. Those guidelines were later updated. The dentist you work for follows a practice of premedicating the patient for two years. Another dentist premedicates patients with prosthetic joints for six months only. Patients forget to take their antibiotics prior to their dental hygiene appointment and then you are left with the conundrum of having the patient take a dose five minutes prior to the appointment, not taking the medicine at all, or taking the antibiotic after the appointment.
All of these situations were made worse when, in 2012, a panel of experts representing the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) published a systematic review and clinical practice guidelines that offered no clear recommendations at all. In fact, their report generated more questions than ever even though the report clearly showed no evidence supporting the need for prophylactic antibiotics following joint replacement.
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With the new year, we now have new guidelines concerning prophylactic antibiotics based on the opinions of another panel of experts convened by the ADA Council of Scientific Affairs. This panel considered this question: For patients with prosthetic joints, is there an association between dental procedures and PJI, and therefore, should systemic antibiotics be prescribed before patients with prosthetic joint implants undergo dental procedures?
The expert panel reviewed the previous literature considered by the 2012 group as well as more recent evidence from three additional case-control studies. Upon review of each of the studies, the expert panel judged with moderate certainty that there is no association between dental procedures and the occurrence of prosthetic joint infections.
This determination was based on two considerations. The first was related to consistency of results. Three of four studies reviewed did not show an association between dental procedures and prosthetic joint infections, while the fourth study showed a protective effect of dental procedures on prosthetic joint infections. The second consideration was that the panel felt that additional studies would not change this conclusion. A further consideration was that no other studies have been published addressing the relationship between dental therapy and infections of other types of prosthetic joints.
Given the review by the expert panel, the following clinical recommendation was made: “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use.”(1)
A review of the literature does point to risk factors contributing to post-operative prosthetic joint infections. These include wound drainage after arthroplasty, wound hematoma, and urinary tract infection. Clearly, none of these situations are dental-related. Further, arguments against antibiotic prophylaxis prior to dental and dental hygiene procedures include the risk of antibiotic resistance, adverse drug reactions, and cost of administering antibiotics.
So, now dental professionals have evidence to with which to arm ourselves in making a better decision when our patients present with prosthetic joint implants. We can provide our patients with education so they, too, can make informed decisions. It is understandable that orthopedic surgeons do not want their work marred by infection. However, the evidence does not exist to support that the cause of that infection is related to periodontal debridement or a dental hygiene prophylaxis performed without antibiotic premedication.
Of course, as always, do take the first step of performing a comprehensive medical history to ascertain key health information prior to providing any dental hygiene treatment. Once we are certain there are no other health risks that warrant prophylactic antibiotic coverage, we can move forward with confidence and put this age old question to rest.
JOANN R. GURENLIAN, RDH, MS, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing education programs to health-care providers. She is a professor and dental hygiene graduate program director at Idaho State University, and president of the International Federation of Dental Hygienists. She writes the "Looking Ahead" column in RDH magazine.
Reference
1. Sollecito, TP, Abt, E. Truelove E, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. Evidence-based clinical practice guidelines for dental practitioners—A report of the American Dental Association Council on Scientific Affairs. JADA January 1 2015 146(1):11-16.
