American academy of orthopedic surgeons guidelines for dental prophylaxis

There is no categorical evidence to support the use of prophylactic antibiotics during dental procedures or delaying invasive procedures following primary total joint arthroplasty (TJA), new research finds. The study, presented at the 2019 Annual Meeting of the American Association of Orthopaedic Surgeons (AAOS) in Las Vegas, analyzed studies reporting on the correlation between periprosthetic joint infection (PJI) and antibiotic prophylaxis or the timing of the procedure.

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Current guidelines from the American Association of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) do not recommend prophylactic antibiotic use prior to dental procedures to prevent PJI in all cases. In severely immunocompromised patients, prophylactic antibiotics may be appropriate in dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. Delaying dental procedures may be appropriate in patients with active diabetes and unknown Hemoglobin A1c or blood glucose levels, but only until appropriate test results can be obtained from the patient’s primary care provider.

Controversy surrounds guidelines

These guidelines, however, are based on a body of research that fails to achieve consensus, according to this study. “Controversy remains, and not everyone follows the recommendations from the AAOS and ADA are sometimes contradictory,” states Nicolas Piuzzi, MD, one co-author of the study. “Dentists may think that antibiotics are not necessary, while orthopedists may conservatively recommend prophylaxis.”

In the average adult, the oral microbiome contains roughly 200 predominant bacterial species. Research suggests that the oral microbiome may play a role in human diseases, including diabetes mellitus, cardiovascular disease and bacteremia. In the past, some have wondered if invasive dental procedures might lead to infections in other locations, such as prosthetic joints. However, the role of dental procedures in PJI remains unclear.

This study assessed the quality and evidence level of nine articles related to PJI and dental procedures. The overall infection rate was 0.35% from a total of 279,476 patients. Of this, a mean of 0.6% were confirmed to be associated with a dental procedure. None of the studies suggested that postponing an invasive dental procedure would decrease the risk of PJI.

Of the studies included, the smallest sample size was 399 patients and the largest was 260,000 patients, with the majority sample size being in the 1,000-4,000 patient range. An infecting organism was documented in 56 percent of the studies (n = 5), commonly S. viridans, Peptostreptococcus and S. aureus. When antibiotics were utilized prior to the dental procedures (n=4), it was either a cephalosporin, penicillin or clindamycin.

Dearth of high-quality research

“None of these studies suggest that postponing a dental procedure is warranted and there was no consensus on use, dosage or typing of prophylactic antibiotics,” notes co-author Carlos Higuera-Rueda, MD.  “The level of confusion among physicians is no surprise given such a dearth of high-quality research.”

With questionable clinical benefit, there are concerns that prophylactic antibiotic use may contribute to the rising levels of antibiotic resistance.  According to Dr. Piuzzi, “further research is necessary to determine the appropriateness of these clinical practices.”

The Antibiotic Prophylaxis Guideline for Prosthetic Joints: Trying to Do the Right Thing

From the Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE (Dr. Garvin), the Department of Infectious Diseases, Mayo Medical School, Mayo Clinic, Rochester, MN (Dr. Osmon), the Division of Infectious Disease, University of Nebraska Medical Center, Omaha (Dr. Hewlett), the Department of Orthopedic Surgery, North Shore-Long Island Jewish Health System, Manhasset, NY (Dr. Scuderi), the Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, MN (Dr. Lewallen), and the Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA (Dr. Vail). Dr. Lockhart is in private practice in Charlotte, NC.

Dr. Garvin or an immediate family member has received royalties from Biomet and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and The Knee Society. Dr. Osmon or an immediate family member serves as a board member, owner, officer, or committee member of the Musculoskeletal Infection Society. Dr. Hewlett or an immediate family member serves as a board member, owner, officer, or committee member of the Society for Healthcare Epidemiology of America. Dr. Scuderi or an immediate family member has received royalties from Zimmer; is a member of a speakers' bureau or has made paid presentations on behalf of Zimmer, Medtronics, and Convatec; serves as a paid consultant to Zimmer, Medtronics, and Convatec; and serves as a board member, owner, officer, or committee member of The Knee Society, the International Congress for Joint Reconstruction, and Magnifi Group. Dr. Lewallen or an immediate family member has received royalties from Biomet; serves as a paid consultant and has stock or stock options held in Pipeline Biomedical Holdings; and serves as a board member, owner, officer, or committee member of the American Joint Replacement Registry, The Hip Society, and the Orthopaedic Research and Education Foundation. Dr. Vail or an immediate family member has received royalties from DePuy; serves as a paid consultant to DePuy; has stock or stock options held in Pivot Medical and Biomimedica; and serves as a board member, owner, officer, or committee member of The Knee Society, the American Board of Orthopaedic Surgery, and the American Association of Hip and Knee Surgeons. Neither Dr. Lockhart nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.