Mar 212014

Postoperative Antibiotic Prophylaxis for Dental Patients – Provincial Hip and Knee Committees Weigh In

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In 1997, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) published the first advisory statement on antibiotic prophylaxis (AP) for dental patients with prosthetic joints. This advisory statement was updated in 2003 with new information and concluded that AP is not routinely indicated for most patients with total joint arthroplasty who undergo dental procedures, and that, although bacteremia can cause hematogenous seeding of total joints, there is no evidence linking dental procedures to prosthetic joint infection. These advisory statements were fairly specific concerning which patient populations the clinician might choose to give AP, including the period of time following joint implantation, dental procedures of concern, antibiotic protocols, and alternatives, and there was discussion of the benefits and risks from this practice. In 2009, the AAOS released a new statement: “Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider AP for all total joint replacement patients prior to any invasive procedure that may cause bacteremia.”1-5

 In 2012, the AAOS and ADA again released new clinical practice guidelines recommending that routine AP on all patients was unnecessary, stating: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients…undergoing dental procedures.”  This recommendation is based on limited data and is based largely on the only published case-control study, which found no relationship between dental procedures and prosthetic joint infection.6

To summarize:

APDental

There has been much debate about whether routine antibiotic prophylaxis for dental patients should be recommended for all hip and knee replacement patients in Alberta. The Provincial Hip and Knee Clinical Committee and the Hip and Knee Working Group have agreed that although there are certainly some patients that are appropriate for AP following their surgery, there is not sufficient evidence to recommend this practice be routine.

In Alberta, some patients will receive AP  prior to dental work at the individual surgeon’s discretion. The Provincial Hip and Knee Care Path has been updated to reflect this decision, reading:

Prescription of prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures at surgeon’s discretion. 

Patients will be made aware of the potential need for AP prior to surgery through their teaching book, which will now include the following information:

Once you have had a hip/knee replacement, you may need to take antibiotics before any dental work – including a simple cleaning. Taking an antibiotic will help prevent bacteria, or germs, travelling through the blood stream from you mouth to the area around your new hip/knee where it could cause an infection and lead to serious problems. It is important that you discuss with your surgeon or case manager the use of antibiotics prior to any dental work.

Additionally, appropriate patients will receive a letter at a follow-up visit indicating they should receive AP prior to any dental work, for life.

 References

1. Lockhart, P., et.al. The Antibiotic Prophylaxis Guideline for Prosthesic Joints: Trying to Do the Right Thing. Journal of the American Academy of Orthopaedic Surgeons. March 2013(21): 193-194.

2. American Academy of Orthopaedic Surgeons: Antibiotic prophylaxis for dental patients with total joint replacements: American Dental Association; American Academy of Orthopaedic Surgeons. J Am Dent Assoc 1997;128(7):1004-1008.

3. American Dental Association; American Academy of Orthopedic Surgeons: Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc 2003;134(7):895-899.

4. American Academy of Orthopaedic Surgeons: Information Statement 1033: Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements, February 2009. Revised June 2010. Retired December 17, 2012. Previously available at: http://www.aaos.org/about/ papers/advistmt/1033.asp.

5. Porucznik M: AAOS releases new statement on antibiotics after arthroplasty. AAOS Now May 2009. Available at: http://www.aaos.org/news/aaosnow/may09/cover2.asp.

6. Berbari EF, Osmon DR, Carr A, et al:Dental procedures as risk factors for prosthetic hip or knee infection: A hospital-based prospective case-control study. Clin Infect Dis 2010;50(1):8-16.

 

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