|Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures
The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.
Moderate strength evidence finds that dental procedures are unrelated to implant infection and that antibiotic prophylaxis prior to dental procedures does not reduce the risk of subsequent implant infection. There is no direct evidence to support otherwise. High strength evidence suggests that antibiotic prophylaxis reduces the incidence of post-dental procedure related bacteremia, but there is no evidence that these bacteremias are related to prosthetic joint infections.
A single well-conducted case-control study provides direct evidence for this recommendation.39 Case-control studies are appropriate to answer questions regarding risk factors or etiology. Study enrollment consisted of 339 patients with prosthetic hip or knee infections (cases) and 339 patients with hip or knee arthroplasties without infection (controls) hospitalized on an orthopaedic service during the same time period. The comparison between these groups was for differences in dental visits (exposure) in terms of high and low-risk dental procedures, with and without antibiotic prophylaxis. Results reported as odds ratios with 95% confidence interval, demonstrate no statistically significant differences between groups. Neither dental procedures nor antibiotic prophylaxis prior to dental procedures were associated with risk of prosthetic hip or knee infections. The authors performed a sample size calculation and withdrawals were low, minimizing attrition bias. The prospective nature of this study minimized recall bias. Additionally, blinding of the treatment group to those assessing outcomes limits detection bias.
Although this one study of direct evidence was of moderate quality, it did have limitations. The authors conducted covariate analysis on some subgroups of higher risk patients. The number of patients in these subgroups, however, was relatively small, and there is insufficient data to suggest that these patients are at higher risk of experiencing hematogenous infections.
There is high quality evidence that demonstrates the occurrence of bacteremia with dental procedures. Historically, there has been a suggestion that bacteremias can cause hematogenous seeding of total joint implants, both in the early postoperative period and for many years following implantation. It was felt that the most critical period was up to two years after joint placement. In addition, bacteremias may occur during normal daily activities such as chewing and tooth brushing. It is likely that these daily activities induce many more bacteremias than dental procedure associated bacteremias. While evidence supports a strong association between certain dental procedures and bacteremia, there is no evidence to demonstrate a direct link between dental procedure associated bacteremia and infection of prosthetic joints or other orthopaedic implants. Multiple studies of moderate and high quality evidence suggest that antibiotic prophylaxis decreases the risk of dental procedure associated bacteremias. However, dental procedure associated bacteremia is a surrogate outcome for prosthetic joint infection. Surrogate outcomes may or may not relate to a clinically relevant patient outcome. Of additional concern is a positive surrogate outcome (e.g. reduced bacteremias) that could mask a negative patient-centered outcome (e.g. implant infection).
This recommendation is limited to patients with hip and knee prostheses because the single study of direct evidence included only patients with these types of orthopaedic implants. There is no direct evidence that met our inclusion criteria for patients with other types of orthopaedic implants.
Topical Oral Antimicrobials
We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.
There is high quality evidence that demonstrates the occurrence of bacteremias with dental procedures. However, there is no evidence to demonstrate a direct link between dental procedure associated bacteremia and infection of prosthetic joints or other orthopaedic implants.
There is conflicting evidence regarding the effect of antimicrobial mouth rinse on the incidence of bacteremia associated dental procedures. One high quality study reports no difference in the incidence of bacteremia following antimicrobial mouth rinsing in patients undergoing dental extractions. Conversely, numerous studies suggest that topical antimicrobial prophylaxis decreases the incidence of dental procedure associated bacteremia. However, there is no evidence that application of antimicrobial mouth rinses before dental procedures prevents infection of prosthetic joints or other orthopaedic implants.
In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.
The lack of evidence relating oral bacteremias to prosthetic joint or other orthopaedic implant infections is the basis for the consensus rationale for this recommendation.
Oral hygiene measures are low cost, provide potential benefit, are consistent with current practice, and are in accordance with good oral health.
There is evidence of the relationship of oral microflora to bacteremia. This bacteremia may be associated with poor oral hygiene. This implies that improvement of oral hygiene (or maintenance of good oral hygiene) may be beneficial in reducing bacteremias.
Guideline Work Group:
William Watters III, MD, Co-Chair, American Academy of Orthopaedic Surgeons (AAOS)
Michael P. Rethman, DDS, MS, Co-Chair, American Dental Association (ADA)
Richard P. Evans, MD, AAOS
Calin Moucha, MD, AAOS
Richard J. O'Donnell, MD, AAOS
Paul A. Anderson, MD, AAOS & Congress of Neurological Surgeons
Elliot Abt, DDS, ADA
Harry C. Futrell, DMD, ADA
Stephen O. Glenn, DDS, ADA
John Hellstein DDS, MS, ADA
David Kolessar, MD, AAHKS
John E. O'Toole, MD, American Association of Neurological Surgeons/Congress of Neurological Surgeons
Mark J. Steinberg, DDS, MD, American Association of Oral and Maxillofacial Surgeons
Karen C. Carroll, MD, FCAP, College of American Pathologist
Kevin Garvin, MD, The Knee Society
Douglas R. Osmon, MD, Musculoskeletal Infection Society
Anthony Rinella, MD, Scoliosis Research Society
Angela Hewlett, MD, MS, Society for Healthcare Epidemiology of America
AAOS Guidelines and Technology Oversight Committee:
Michael J. Goldberg, MD, Chair
Deborah S. Cummins, PhD, Director, Research and Scientific Affairs
Sharon Song, PhD, Manager, Clinical Practice Guidelines
Patrick Sluka, MPH, Former Lead Research Analyst
Kevin Boyer, MPH, Former Appropriate Use Criteria Unit Manager, Former Interim Clinical Practice Guidelines Manager
Anne Woznica, MLIS, Medical Research Librarian
William R. Martin III, MD, Medical Director
Helen Ristic, PhD, Director, Scientific Information
Nicholas B. Hanson, MPH, Lead Research Analyst