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Antibiotic Prophylaxis for Dental Patients with
Total Joint Replacements
An expert panel of dentists, orthopaedic surgeons and infectious disease
specialists, convened by the American Dental Association (ADA) and the American
Academy of Orthopaedic Surgeons (AAOS) performed a thorough review of all
available data to determine the need for antibiotic prophylaxis to prevent
hematogenous prosthetic joint infections in dental patients who have undergone
total joint arthroplasties. The result is this report, which has been adopted by
both organizations as an advisory statement. The panel's conclusion: Antibiotic
prophylaxis is not indicated for dental patients with pins, plates and screws,
nor is it routinely indicated for most dental patients with total joint
replacements. However, it is advisable to consider premedication in a small
number of patients (Table 1) who may be at potential increased risk of
hematogenous total joint infection.
Approximately 450,000 total joint arthroplasties are performed annually in the
United States. Deep infections of these total joint replacements usually result
in failure of the initial operation and the need for extensive revision. Due to
the use of perioperative antibiotic prophylaxis and other technical advances,
deep infection occurring in the immediate postoperative period resulting from
intraoperative contamination has been markedly reduced in the past 20 years.
Patients who are about to have a total joint arthroplasty should be in good
dental health prior to surgery and should be encouraged to seek professional
dental care if necessary. Patients who already have had a total joint
arthroplasty should perform effective daily oral hygiene procedures to remove
plaque (e.g. manual or powered toothbrushes, interdental cleaners, oral
irrigators) to establish and maintain good oral health. The risk of bacteremia
is far more substantial in a mouth with ongoing inflammation than in one that is
healthy and employing these home-oral hygiene devices.1
Bacteremias can cause hematogenous seeding of total joint implants, both in the
early postoperative period and for many years following implantation.2 It
appears that the most critical period is up to two years after joint placement.3
In addition, bacteremias may occur in the course of normal daily life4-6 and
concurrently with dental and medical procedures.6 It is likely that many more
oral bacteremias are spontaneously induced by daily events than are dental
treatment-induced.6 Presently, no scientific evidence supports the position that
antibiotic prophylaxis to prevent hematogenous infections is required prior to
dental treatment in patients with total joint prostheses.1 The risk/benefit7,8
and cost/effectiveness7,9 ratios fail to justify the administration of routine
antibiotic prophylaxis. The analogy of late prosthetic joint infections with
infective endocarditis is invalid as the anatomy, blood supply, microorganisms
and mechanisms of infection are all different.10
It is likely that bacteremias associated with acute infection in the oral
cavity,11,12 skin, respiratory, gastrointestinal and urogenital systems and/or
other sites can and do cause late implant infection.12 Any patient with a total
joint prosthesis with acute orofacial infection should be vigorously treated as
any other patient with elimination of the source of the infection (incision and
drainage, endodontics, extraction) and appropriate therapeutic antibiotics when
indicated.1,12 Practitioners should maintain a high index of suspicion for any
unusual signs and symptoms (e.g. fever, swelling, pain, joint warm to touch) in
patients with total joint prostheses.
Antibiotic prophylaxis is not indicated for dental patients with pins, plates
and screws, nor is it routinely indicated for most dental patients with total
joint replacements. This position agrees with that taken by the Council on
Dental Therapeutics,13 the American Academy of Oral Medicine,14 and is similar
to that taken by the British Society for Antimicrobial Chemotherapy.15 There is
limited evidence that some immunocompromised patients with total joint
replacements (Table 1) may be at higher risk for hematogenous infections.13,
16-22 Antibiotic prophylaxis for such patients undergoing dental procedures with
a higher bacteremic risk (as defined in Table 2), should be considered using an
empirical regimen (Table 3). In addition, antibiotic prophylaxis may be
considered when the higher risk dental procedures (as defined in Table 2) are
performed on dental patients within two years post implant surgery,3 on those
who have had previous prosthetic joint infections, and on those with some other
conditions (Table 1).
Occasionally, a patient with a total joint prosthesis may present to the dentist
with a recommendation from his/her physician that is not consistent with these
guidelines. This could be due to lack of familiarity with the guidelines or to
special considerations about the patient's medical condition which are not known
to the dentist. In this situation, the dentist is encouraged to consult with the
physician to determine if there are any special considerations that might affect
the dentist's decision on whether or not to premedicate, and may wish to share a
copy of these guidelines with the physician, if appropriate. After this
consultation, the dentist may decide to follow the physician's recommendation,
or, if in the dentist's professional judgment, antibiotic prophylaxis is not
indicated, may decide to proceed without antibiotic prophylaxis. The dentist is
ultimately responsible for making treatment recommendations for his/her patients
based on the dentist's professional judgment. Any perceived potential benefit of
antibiotic prophylaxis must be weighed against the known risks of antibiotic
toxicity, allergy, and development, selection and transmission of microbial
resistance.
This statement provides guidelines to supplement practitioners in their clinical
judgment regarding antibiotic prophylaxis for dental patients with a total joint
prosthesis. It is not intended as the standard of care nor as a substitute for
clinical judgment as it is impossible to make recommendations for all
conceivable clinical situations in which bacteremias originating from the oral
cavity may occur. Practitioners must exercise their own clinical judgment in
determining whether or not antibiotic prophylaxis is appropriate.
The ADA/AAOS Expert Panel consisted of: Robert H. Fitzgerald Jr., MD; Jed J.
Jacobson, DDS, MS, MPH; James V. Luck Jr., MD; Carl L. Nelson, MD; J. Phillip
Nelson, MD; Douglas R. Osmon, MD; and Thomas J. Pallasch, DDS. Staff Liaisons:
ADA-Clifford W. Whall Jr., PhD; AAOS-William W. Tipton Jr., MD.
Table 1. Patients at Potential Increased Risk of Hematogenous Total Joint
Infection12,16-22
All patients during the first two (2) years after prosthetic joint replacement.
Immunocompromised/immunosuppressed patients
Inflammatory arthropathies (e.g.: rheumatoid arthritis, systemic lupus
erythematosus)
Drug - induced immunosuppression
Radiation-induced immunosuppression
Patients with co-morbidities (e.g.)
Previous prosthetic joint infections
Malnourishment
Hemophilia
HIV infection
Insulin-dependent (Type 1) diabetes
Malignancy
Table 2. Incidence Stratification of Bacteremic Dental Procedures*
HIGHER INCIDENCE1
Dental extractions
Periodontal procedures including surgery, subgingival placement of antibiotic
fibers/strips, scaling and root planing, probing, recall maintenance
Dental implant placement and replantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Initial placement of orthodontic bands but not brackets
Intraligamentary and intraosseous local anesthetic injections
Prophylactic cleaning of teeth or implants where bleeding is anticipated
LOWER INCIDENCE2
Clinical judgment may indicate antibiotic use in selected circumstances that may
create significant bleeding.
Restorative dentistry2 (operative and prosthodontic) with/without retraction
cord
Local anesthetic injections (nonintraligamentary and nonintraosseous)
Intracanal endodontic treatment; post-placement and buildup
Placement of rubber dam
Postoperative suture removal
Placement of removable prosthodontic/orthodontic appliances
Taking of oral impressions
Fluoride treatments
Taking of oral radiographs
Orthodontic appliance adjustment
This includes restoration of carious (decayed) or missing teeth.
*Adapted from: Prevention of Bacterial Endocarditis: Recommendations by the
American Heart Association, from the Committee on Rheumatic Fever, Endocarditis,
and Kawasaki Disease, Council on Cardiovascular Disease in the Young. Reprinted
with permission of the Journal of the American Medical Association.23
Table 3. Suggested antibiotic prophylaxis regimens*
Patients not allergic to penicillin: cephalexin, cephradine or amoxicillin: 2
grams orally 1 hour prior to dental procedure.
Patients not allergic to penicillin and unable to take oral medications:
cefazolin 1 gram or ampicillin 2 grams IM/IV 1 hour prior to the procedure.
Patients allergic to penicillin: clindamycin: 600 mg orally 1 hour prior to the
dental procedure.
Patients allergic to penicillin and unable to take oral medications: clindamycin
600 mg IV, 1 hour prior to the procedure.
*No second doses are recommended for any of these dosing regimens.
REFERENCES
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Rubin R, Salvati EA, Lewis R: Infected total hip replacement after dental
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Hanssen AD, Osmon DR, Nelson CL: Prevention of deep prosthetic joint infection.
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physicians and dentists. J Amer Dent Assoc 1984;109:415-420.
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McGowan DA: Dentistry and endocarditis. Br Dent J 1990;169:69.
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Jacobson JJ, Patel B, Asher G, Wooliscroft JO, Schaberg D: Oral Staphyloccus in
elderly subjects with rheumatiod arthritis. J Amer Geriatr Soc 1997;45:1-5.
Berbari EF, Hanssen AD, Duffy MC, Ilstrup DM, Harmsen WS, Osmon DR: Risk factors
for prosthetic joint infection: case-control study. Clin Infectious Dis 1998;
27:1247-1254.
Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH,
Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME,
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American Heart Association. From the Committee on Rheumatic Fever, Endocarditis
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Dentists and physicians are encouraged to reproduce the above Advisory Statement
for distribution to colleagues. Permission to reprint the Advisory Statement is
hereby granted by ADA and AAOS, provided that the Advisory Statement is
reprinted in its entirety including citations and that such reprints contain a
notice stating "Copyright ©2002 American Dental Association and American Academy
of Orthopaedic Surgeons. Reprinted with permission." If you wish to use the
Advisory Statement in any other fashion, written permission must be obtained
from the ADA and AAOS.
Document Number: 1014
Last modified 04/September/2003 by IS
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