Providing clarity on evidence-based prophylactic guidelines for prosthetic joint infections
The Journal of the American Dental Association: January 2015 Volume 146, Issue 1, Pages 3–5
Daniel M. Meyer, DDS
The notion of biological plausibility—that is, the likelihood of whether an outcome could occur as a result of a causal association—is frequently a premise for clinical research as well as a basis for clinical decision making. However, what do we as clinicians do when the scientific evidence indicates that a risk factor for a condition, preventive regimen, or treatment is not probable or likely, despite being conceivable? Do we follow precedence, inference, or conflicting professional standards of care, or do we rely on clinical guidelines supported by relevant, scientific evidence from systematic reviews in the peer-reviewed literature? Should we as health care providers discontinue providing conventional care when new scientific evidence from clinical studies indicates a particular therapy or a traditional antibiotic regimen is not necessary, especially if the risk of potential harms outweigh the benefits? Such appears to be the case in regard to the results of systematic reviews in the scientific literature on the use of prophylactic antibiotics to prevent prosthetic joint infections (PJI).
The concept of providing prophylactic antibiotics to prevent PJI has been based on a logical premise and biological plausibility. Dental procedures that involve soft-tissue manipulation or bleeding have the potential to introduce oral bacteria into the blood stream, leading to bacteremia. It has generally been accepted that bacteremia resulting from dental invasive procedures could lead to infection of prosthetic joint implant areas. The common practice, thus far, has been to have patients premedicate with oral antibiotics before dental treatment to prevent bacteremia and postsurgical infections of prosthetic joint implant areas. More recent scientific information published in the peer-reviewed literature is contributing to a greater understanding of the risks versus benefits resulting from the widespread use of antibiotics. Consequently, attitudes regarding the indications and contraindications for antibiotic usage are changing. The overprescribing and overuse of oral antibiotics are now considered to be a significant public health threat. Providers, their patients, and the public need to be aware of widespread antibiotic resistance, adverse drug reactions such as hypersensitivity reactions, anaphylaxis, opportunistic infections, and Clostridium difficile infection.
In 2013, the American Association of Orthopedic Surgeons (AAOS), in collaboration with the American Dental Association (ADA), published the results of a comprehensive evidence-based, systematic review and clinical practice guideline entitled, “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-Based Guideline and Evidence Report.”1, 2, 3 After conducting an extensive review of the published scientific literature, a multidisciplinary expert panel concluded, “There is no evidence to demonstrate a direct link between dental-procedure-associated bacteremia and infection of prosthetic joints or other orthopaedic implants,” noting, “There is no evidence that [dental-related] bacteremias are related to prosthetic joint infections.” The published clinical evidence suggests that there is no association between invasive or noninvasive dental procedures and postsurgical PJIs. Even though the routine practice of prescribing antibiotics may be considered by some providers to be relatively safe, current scientific evidence does not support doing so before performing dental procedures to prevent bacteremia and postsurgical PJIs.
Although the AAOS/ADA systematic review was conducted thoroughly and was supported by robust scientific evidence, the clinical guidance stemming from the review process resulted in considerable confusion among providers and their patients. In addition, the 2013 clinical recommendations were questioned and criticized for their apparent ambiguity. In order to provide more clarity for clinicians, the ADA Council on Scientific Affairs (CSA) convened its own evidence-based expert panel to reevaluate the systematic review and reassess the clinical guidelines. The CSA expert panel reviewed the literature previously conducted by AAOS, ADA, and other professional organizations, as well as additional scientific evidence not included in the 2013 review and publication.
The ADA expert panel identified 3 additional studies and reviewed and evaluated each for its clinical relevance.4, 5, 6 The 3 studies provided additional clinical data that were consistent with the original evidence identified by AAOS and ADA in the 2013 clinical recommendations. The additional studies provided further evidence that invasive dental procedures are not associated with PJIs. The evidence also indicated that prophylactic antibiotics taken before dental treatment do not help prevent PJIs.
The ADA expert panel concluded that the benefits of providing antibiotic prophylaxis to prevent PJIs do not outweigh the potential harm for most patients. In an attempt to provide more accurate clinical guidance and clarity, the expert panel drafted new clinical recommendations that include a chair-side guide, which is published in this issue.7 The chair-side guide was developed to help dentists and orthopedic surgeons communicate with their patients about the potential risks associated with the use of prophylactic antibiotics to help prevent postorthopedic surgery PJIs.
The new CSA guideline clearly states that for most patients, prophylactic antibiotics are not indicated before dental procedures to prevent PJIs. The new guideline also takes into consideration that patients who have previous medical conditions or complications associated with their joint replacement surgery may have specific needs calling for premedication. In medically compromised patients who are undergoing dental procedures that include gingival manipulation or mucosal inclusion, prophylactic antibiotics should be considered only after consultation with the patient and orthopedic surgeon. For patients with serious health conditions, such as immunocompromising diseases, it may be appropriate for the orthopedic surgeon to recommend an antibiotic regimen when medically indicated, as footnoted in the new chair-side guide.
Instituting these new evidence-based changes into clinical practice likely will lead to professional challenges across disciplines for providers and their patients. The new chair-side guide puts at the forefront of multidisciplined, collaborative care the need for dentists and orthopedic surgeons to work more closely together to assess each patient’s medical history, health status, and oral conditions. The chair-side guide is designed to be a useful tool for dentists, orthopedic surgeons, and patients to use in the decision-making process. It is intended to promote supportable, clinically relevant care that is consistent with a systematic assessment of the benefits, risks, needs, and preferences of each patient.
Successful implementation of these clinical guidelines empowers medical and dental providers to use their clinical judgment along with the support from the best available scientific evidence on the potential risks, benefits, and harms. The guidelines enable dentists and orthopedic surgeons to engage in a shared dialogue and decision-making process with each patient to minimize risks while optimizing health outcomes. It is the process of jointly making a systematic, clinical decision, rather than the decision itself, that lends itself to an applicable use of these evidence-based guidelines.
It is time to rely on scientifically sound, interprofessional, and cross-discipline communications to support beneficial evidence-based clinical recommendations. Clinical guidelines that are based on clinically relevant systematic reviews enable medical and dental professionals to provide safe and effective care—comprehensive, multidisciplined care that is based on clinically relevant scientific evidence instead of customary, time-honored principles that are not backed by current research.
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Watters, W., Rethman, M.P., Hanson, N.B. et al. Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg. 2013; 21: 180–189
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Sollecito, T.P., Abt, E., Lockhart, P.B. 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 American Dental Association Council on Scientific Affairs. JADA. 2015; 146: 11–16
Dr. Meyer is chief science officer, American Dental Association, 211 E Chicago Ave, Chicago, IL 60611.
Editorials represent the opinions of the authors and not necessarily those of the American Dental Association.
Disclosure. Dr. Meyer did not report any disclosures.