Course Overview
It is understandable that there is confusion among dentists and orthopedic surgeons as to whether antibiotic prophylaxis (AP) is necessary for patients who have had a total joint arthroplasty as there have been 6 different Recommendations or Guidelines since 1997. However the most recent ADA Guideline published in JADA in January 2015 has been validated by several studies in recent years that show there is no association between invasive dental procedures (IDPs) and late prosthetic joint infections (LPJIs) and that there is no protection against LPJI by using antibiotic prophylaxis. Therefore, there is NO evidence to support the use of antibiotic prophylaxis prior to invasive dental procedures. Additionally, there is no evidence that co-morbidities such as having multiple prosthetic joints, undergoing cancer chemotherapy, being diabetic or immunosuppressed increases the risk of LPJI from IDPs. Therefore patients with a prosthetic joint and any of the aforementioned co-morbidities would not require AP.
2015 ADA Clinical Practice Guideline
In general, for patients with prosthetic joint implants, prophylactic antibiotics are NOT recommended prior to dental procedures to prevent
prosthetic joint infection.(1)
Studies to Support Guideline
Berbari Study:(2)
339 patients with hip or knee PJI were matched against 339 patients who had a total joint arthroplasty but no joint infection.
CONCLUSIONS:
Found there was no association between having undergone high-risk dental procedures without AP and PJI’s at 6 months or 2 years. Found that taking AP prior to dental work did not decrease likelihood of PJI.
The authors stated:“We believe that reported PJI’s attributed to dental procedures are more likely to have been caused by bacteremia related to
routine daily activities than by bacteremia related to dental procedures.” “It is inconsistent to recommend prophylaxis of prosthetic hip or knee
infection for dental procedures but not to recommend prophylaxis for these same patients during routine daily activities.”
Kao Study: (3)
A 2017 case-control study in Taiwan looked at over 250,000 patients who had a knee or hip arthroplasty, identified 57,000 who had undergone a dental procedure matched against non-dental procedure controls, and 6,500 dental patients who had used AP matched against dental patients
who had not used AP. PJI occurred in 328 patients in the dental subgroup and 348 in the non dental subgroup. 13 PJI occurred in the antibiotic
subgroup and 12 PJI occurred in the non antibiotic subgroup. The authors conclusions were that the risk of PJI is not increased following dental
procedures in patients with hip or knee replacement and is unaffected by antibiotic prophylaxis.
Thornhill JAMA Study: (4)
A 2022 case-crossover study in JAMA looked at nearly 10,000 patients in the UK with late prosthetic joint infection (LPJI) and compared the number of invasive dental procedures (IDPs) in the preceding 3 months vs. the prior 12 months. There was no correlation between having undergone an invasive dental procedure and late PJI.
Thornhill JADA Study: (5)
A January 2023 case-crossover study published in JADA looked at nearly 2500 US patients with LPJI and the number of IDPs in the 3 months
preceding the LPJI vs the prior 12 months and if they had used AP. The results again showed no correlation between IDPs and LPJI as well as no
protective benefit of AP.
Summary
CLINICAL RATIONALE
There is overwhelming evidence that dental procedures are not associated with prosthetic joint infections. There is strong evidence that antibiotics provided before oral care do not prevent prosthetic joint infections. There are potential harms of antibiotics including risk for
anaphylaxis, antibiotic resistance, and opportunistic infections like C. difficile. There is no benefit of antibiotic prophylaxis, and only
potential harm.
(1). Sollecito TP, Abt E, Lockhart PB, et al. 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 ADA Council of Scientific Affairs. JADA 2015;146(1):11-16 doi:10.1016/j.adaj.2014.11.012.
(2). Berbari EF., Hansen AD., et al., Risk Factors for Prosthetic Joint Infection: Case-Control Study. Clinical Infectious Diseases. Vol. 2,7, Issue 5, Nov1998, pages 1247-1254.
(3). Kao FC, Hsu YC, Chen WH, Lin JN, Lo YY, Tu YK. Prosthetic joint infection following invasive dental procedures and antibiotic prophylaxis in patients with hip or knee arthroplasty. Infect Control Hosp Epidemiol. 2017;38(2):154-161. doi:10.1017/ice.2016.248
(4). Thornhill MH, Crum A, Rex S, et al. Analysis of prosthetic joint infections following invasive dental procedures in England. JAMA Netw Open. 2022;5(1):e2142987. doi:10.1001jamanetworkopen.2021.42987.
(5). Thornhill MH, Gibson TB, Pack C, et al. Quantifying the risk of prosthetic joint infections after invasive dental procedures and the effect of antibiotic prophylaxis. J Am Dent Assoc. 2023;154(1):43-52.e12. doi:10.1016/j.adaj.2022.10.001.
Course Instructor
Dr. Tom Paumier
A 1987 cum laude graduate of the Ohio State University College of Dentistry, completed a general practice residency at St. Elizabeth Medical Center in Youngstown, Ohio. He has been in private practice in Canton, Ohio, since 1988. Dr. Paumier is on the faculty of the Mercy Medical Center GPR in Canton and is a fellow in the International College of Dentists and American College of Dentists. He was a member of the American Dental Association Council on Scientific Affairs’ Expert Panel on Prosthetic Joint Prophylaxis and the ADA/American Academy of Orthopaedic Surgeons’ Expert Panel for Prosthetic Joint Prophylaxis Appropriate Use Criteria. He also serves on the ADA Expert Panel for Antibiotic Therapeutics. He is a past president of the Ohio Dental Association.