Dr. Paumier on Prophylaxis

Conflict between AAOS and ADA guidelines for prophylaxis of orthopedic joint replacement patients: What should I do?

by Dr. Thomas Paumier
ODA Today

There was much confusion among dental practitioners, orthopedic surgeons and patients after the 2012 Joint Recommendations from the AAOS/ADA related to antibiotic prophylaxis for patients with prosthetic joints. While it appeared clear that there was no scientific evidence for a protective benefit of prophylaxis and no association between dental procedure induced bacteremia and prosthetic joint infection (PJI), the guidelines were ambiguous and essentially recommended letting the patient decide. This put dentists in the difficult situation of a potential legal risk regardless of whether he or she recommended for or against prophylaxis should there be an adverse outcome. It also left patients frustrated and confused as to the best choice. So, most often, clinicians relied on the 2003 guidelines recommending prophylaxis in the first two years after surgery, or lifetime prophylaxis for those patients considered high risk. Further complicating the issue was the 2009 opinion for lifetime prophylaxis that was independently issued by the AAOS.

The ADA, inundated by pleas from members to clarify the guidelines, convened a panel in 2013, at the direction of the Council on Scientific Affairs, to re-evaluate the systematic review done by the 2012 joint AAOS/ADA panel and evaluate any additional research. The goal was to provide a guideline with more clarity. I was fortunate to be asked to participate on that panel. While I have heard criticism that the new Clinical Practice Guideline (CPG) would have more impact if it had been developed with input from the orthopedic community, it is unlikely that this would have achieved the goal set for this committee. The ADA understood the predicament its members faced relative to the unclear 2012 guideline and formed the expert panel to provide an evidence based CPG to give guidance to members to provide the most appropriate care for their patients, given the current literature. While it would be better to have a consensus statement to minimize confusion for patients who hear mixed messages from their dentists and orthopedic surgeons, the ADA realized its obligation was to the member dentist. We also wanted to ensure the science would dictate the outcome. I applaud the ADA on living up to its strategic plan of “Members First 2020.”

The 2014 Panel decided that only direct and not surrogate evidence would be considered in shaping the new CPG. The new guideline states “In general, for patients with prosthetic joint implants, prophylactic antibiotics are NOT recommended prior to dental procedures to prevent prosthetic joint infection.” As with all evidence based guidelines, it continues with a qualifier that the clinician and patient should consider all of the patient’s unique medical/health risks in arriving at a decision for or against prophylaxis. To some clinicians this gives them pause and they either consider defaulting to the previous guidelines or abdicating the decision to the orthopedic surgeon, both of which may put them and the patient at risk. I hope to provide you with confidence that in deciding to follow the 2014 CPG, you are not placing the patient at risk of PJI, or yourself at increased legal risk.

Let’s consider the surrogate evidence as well as the direct evidence that NOT providing prophylaxis prior to dental procedures is the right decision. It is reported that there is no clinically significant difference between bacteremia induced from dental procedures such as extraction or scaling, or those induced from chewing or brushing teeth. It also seems clear that antibiotics taken prior to manipulation of mucosal tissue (whether by chewing or dental procedure) will decrease the bacteremia. It is also evident that while the bacteremia is reduced, this may not provide protection against PJI. Why might this be the case? The microbiology of PJI being predominantly staph, and the oral flora being largely strep with very few strains of staph, explains the lack of association between oral-induced bacteremia and PJI. So, if you were to feel prophylaxis were appropriate or beneficial, then it would require daily, if not multiple times daily antibiotics, as normal daily activity-induced bacteremia, if causative for PJI, would put the patient at continual risk. To me the take home lesson for the patient is that good oral health, not antibiotic prophylaxis, reduces bacteremia, and risk for any distant site infection such as PJI.

The incidence of PJI is approximately 2 percent, the majority of which occur in the first two years, with the highest percentage being in the first year and most associated with a smoldering infection from the time of surgery. Studies conducted to explore late PJI and any causal sentinel event, if there was one identifiable, found that they were mostly related to dermatologic infections, seldom dental problems. Again, even if the patient had seen the dentist proximate to the PJI, and oral strep were cultured from the infected joint (rare), you could not determine if the cause was the dental procedure or the chronic bacteremia from normal daily activities.

A common response seems to be: “Well, I’m still concerned that since I have always used prophylaxis and I’ve never encountered a patient who developed a PJI after my care, that I’ll just continue using antibiotics prior to treatment, especially since the majority of orthopedic surgeons still recommend prophylaxis for life. Clearly, as physicians they are more qualified than me to understand how to protect the joint. And what could it hurt?” First, you as the dentist should be well informed and qualified to decide for or against prophylaxis. And consulting the surgeon does not release you from liability should there be an adverse outcome, especially if you write the prescription and the patient has problems related to the antibiotic. If the orthopedic surgeon recommends prophylaxis, and the patient prefers prophylaxis, I would ask the physician to write the prescription. There are over 500,000 infections related to C. diff resulting in 29,000 deaths per year. Recognizing many patients with prosthetic joints are elderly and have other health issues and may have taken antibiotics shortly before dental care, antibiotic prophylaxis may increase their risk for opportunistic infection by C. difficile.

“So, when might I consider prophylaxis with antibiotics for patients with prosthetic joints?” The 2003 joint guidelines identified patients who may be at “high risk” for a PJI following dental treatment. The evidence is clear that any additional risk for PJI is unrelated to dental care. There were identifiable factors that increased a patient’s risk for a PJI, but they were all associated with the joint replacement surgery itself. They included drainage, infection or hematoma at the surgical site, or a post-operative urinary tract infection (UTI). Pre-operative medical conditions such as diabetes, kidney disease, immunosuppression or steroid use were not likely clinically relevant risk factors. So, from a dental perspective no “high risk” patients related to PJI have been identified. It would be the unusual circumstance to recommend prophylaxis for a patient with orthopedic joint replacement(s) in a community practice or other ambulatory dental care setting. Although there is no data to support it, prophylaxis might be prudent with a severely medically compromised patient with a high risk for ANY infection, if the risk of taking the antibiotic were less than any perceived benefit. As with all clinical decisions, weighing the best available science, the individual patient’s medical history and preferences, and all risks and benefits should guide your decision making.

In review, the evidence fails to demonstrate an association between dental procedures and PJI or any protection for PJI from antibiotic prophylaxis. Given this, in conjunction with the potential harm from antibiotic use, prophylaxis with antibiotics prior to dental procedures to prevent PJI is not recommended. It is difficult to change clinical practice models that have been in place for many years and have been generally accepted. But, having been at the table and seeing first-hand the expertise in medicine, microbiology, epidemiology and critical evaluation of the literature demonstrated by our dental colleague experts who composed the 2014 panel, I am confident this CPG is appropriate. I’m hopeful it will be embraced by both the dental and medical community. I’m proud that the ADA took the lead in developing this guideline and hope all dentists see this clarification as a valuable member benefit.

Thomas Paumier, DDS, served on the panel of experts that developed the 2014 guidelines. He is also currently serving as the ODA president.