SIII

ADVISORY STATEAMEVT

ANTIBIOTIC PROPHYLAXIS FOR DENTALPATIENTSaITH TOTAL JOINT REPLACEMENTSAMERICAN DENTAL ASSOCIATION; AMERICAN ACADEMY OFORTHOPAEDIC SURGEONS

An expert panel of dentists, or-

thopaedic surgeons and infectious

disease specialists convened by

the American Dental Association

and the American Academy of

Orthopaedic Surgeons, or 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 advi-

sory statement. The panel's con-

clusion: 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 re-

placements. However, it is advis-

able to consider premedication in

a small number of patients who

may be at potential increased risk

of hematogenous total joint in-

fection.

Qpproximately 450,000 total joint arthroplasties are performedannually in the United States. Deep infections of these total jointreplacements usually result in failure of the initial operation andthe need for extensive revision. Due to the use of perioperative an-tibiotic prophylaxis and other technical advances, deep infection oc-curring in the immediate postoperative period resulting from intra-operative contamination has been markedly reduced in the past 20years.

Patients who are about to have a total joint arthroplasty shouldbe in good dental health prior to surgery and should be encouragedto seek professional dental care if necessary. Patients who alreadyhave had a total joint arthroplasty should perform effective dailyoral hygiene procedures to remove plaque (for example, by usingmanual or powered toothbrushes, interdental cleaners, oral irriga-tors) to establish and maintain good oral health. The risk of bac-teremia is far more substantial in a mouth with ongoing inflamma-tion than in one that is healthy and employing these home oralhygiene devices.'

Bacteremias can cause hematogenous seeding of total joint im-plants, both in the early postoperative period and for many yearsfollowing implantation.2 It appears that the most critical period isup to 2 years after joint placement.3 In addition, bacteremias mayoccur in the course of normal daily life and concurrently with dentaland medical procedures.4-6 It is likely that many more oral bac-teremias are spontaneously induced by daily events than are dentaltreatment-induced.6 Presently, no scientific evidence supports theposition that antibiotic prophylaxis to prevent hematogenous infec-tions is required prior to dental treatment in patients with totaljoint prostheses.' The risk/benefit7'8 and cost/effectiveness79 ratiosfail to justify the administration of routine antibiotic prophylaxis.The analogy of late prosthetic joint infections with infective endo-carditis is invalid, as the anatomy, blood supply, microorganismsand mechanisms of infection are all different.10

It is likely that bacteremias associated with acute infection inthe oral cavity,11'12 skin, respiratory, gastrointestinal and urogenitalsystems and/or other sites can and do cause late implant infection.'2Any patient with a total joint prosthesis with acute orofacial infec-tion should be vigorously treated as any other patient with elimina-tion of the source of the infection (incision and drainage, endodon-

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tics, extraction) and appropriatetherapeutic antibiotics when in-dicated.'12 Practitioners shouldmaintain a high index of suspi-cion for any unusual signs and

symptoms (such as fever,swelling, pain, joint that iswarm to touch) in patients withtotal joint prostheses.

Antibiotic prophylaxis is not

indicated for dental patientswith pins, plates and screws,nor is it routinely indicated formost dental patients with totaljoint replacements. This posi-tion agrees with that taken bythe ADA Council on DentalTherapeutics'3 and theAmerican Academy of OralMedicine,'4 and is similar tothat taken by the BritishSociety for AntimicrobialChemotherapy.'5 There is limit-ed evidence that some immuno-compromised patients withtotal joint replacements (Box,"Patients at Potential IncreasedRisk of Hematogenous TotalJoint Infection") may be athigher risk for hematogenousinfections.lsl&21 Antibiotic pro-

phylaxis for such patients under-going dental procedures with a

higher bacteremic incidence (asdefined in the box "IncidenceStratification ofBacteremic

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"Mm ASSOCIATION REPORT

Dental Procedures") should beconsidered using an empiricalregimen (Box, "Suggested Anti-biotic Prophylaxis Regimens"). Inaddition, antibiotic prophylaxismay be considered when thehigher-bacteremic-incidence den-tal procedures (again, as definedin the box "Incidence Stratifica-tion ...") are performed on dentalpatients within 2 years post-im-plant surgery,3 on those whohave had previous prostheticjoint infections and on those withsome other conditions (Box,"Patients at Potential IncreasedRisk...").

Occasionally, a patient witha total joint prosthesis may pre-sent to the dentist with a rec-ommendation from his or herphysician that is not consistentwith these guidelines. Thiscould be due to lack of familiari-ty with the guidelines or to spe-cial considerations about thepatient's medical condition thatare not known to the dentist. Inthis situation, the dentist is en-couraged to consult with thephysician to determine if thereare any special considerationsthat might affect the dentist'sdecision on whether or not topremedicate, and may wish to

share a copy of these guidelineswith the physician if appropri-ate. After this consultation, thedentist may decide to follow thephysician's recommendation or,if in the dentist's professionaljudgment antibiotic prophylaxis

Any perceived poten-tial benefit of antbi-otic prephylxis mustbe weighd againstthe known deks ofantibiotic texiefty; al-lergy; and development, solection andtransmission of mi-crobial resistances

is not indicated, may decide toproceed without antibiotic pro-phylaxis. The dentist is ulti-mately responsible for makingtreatment recommendations forhis or her patients based on thedentist's professional judgment.Any perceived potential benefitof antibiotic prophylaxis mustbe weighed against the knownrisks of antibiotic toxicity; aller-gy; and development, selection

and transmission of microbialresistance.

This statement providesguidelines to supplement practi-tioners in their clinical judg-ment regarding antibiotic pro-phylaxis for dental patientswith a total joint prosthesis. Itis not intended as the standardof care nor as a substitute forclinical judgment as it is impos-sible to make recommendationsfor all conceivable clinical situa-tions in which bacteremias orig-inating from the oral cavitymay occur. Practitioners mustexercise their own clinical judg-ment in determining whether ornot antibiotic prophylaxis is ap-propriate. -

The ADA/AAOS Expert Panel consisted ofRobert H. Fitzgerald Jr., M.D.; Jed J.Jacobson, D.D.S., M.S., M.P.H.; James V.Luck Jr., M.D.; Carl L. Nelson, M.D.;J. Phillip Nelson, M.D.; Douglas R. Osmon,M.D.; and Thomas J. Pallasch, D.D.S., M.S.The staff liaisons were Clifford W. Whall Jr.,Ph.D., for the ADA, and William W. TiptonJr., M.D., for the AAOS.

Address reprint requests to Clifford W.Whall Jr., Ph.D., Council on Scientific Affairs,American Dental Association, 211 E. ChicagoAve., Chicago, Ill. 60611.

1. Pallasch TJ, Slots J. Antibiotic prophy-laxis and the medically compromised patient.Periodontology 2000 1996;10:107-38.

2. Rubin R, Salvati EA, Lewis R Infected totalhip replacement after dental procedures. OralSurg Oral Med Oral Pathol 1976;41(1):13-23.

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3. Hansen AD, Osmon DR, Nelson CL.Prevention of deep prosthetic joint infection.J Bone Joint Surg[Am] 1996;78-A(3):458-71.

4. Bender TB, NaidorfLJ, Garvey GJ.Bacterial endocarditis: a consideration forphysicians and dentists. JADA 1984;109:415-20.

5. Everett ED, Hirschmann JV. Transientbacteremia and endocarditis prophylaxis: areview. Medicine 1977;56:61-77.

6. Guntheroth WG. How important are den-tal procedures as a cause of infective endo-carditis? Am J Cardiol 1984;54:797-801.

7. Jacobsen JJ, Schweitzer SO, DePorterDJ, Lee JJ. Antibiotic prophylaxis for dentalpatients with joint prostheses? A decisionanalysis. Int J Technol Assess Health Care1990;6:569-87.

8. Tsevat J, Durand-Zaleski I, Pauker SG.Cost-effectiveness of antibiotic prophylaxis fordental procedures in patients with artificialjoints. Am J Public Health 1989;79:739-43.

9. Norden CW. Prevention of bone and jointinfections. Am J Med 1985;78(6B):229-32.

10. McGowan DA. Dentistry and endocardi-tis. Br Dent J 1990;169:69.

11. Bartzokas CA, Johnson R, Jane M, Martin

MV, Pearce PK, Saw Y. Relation betweenmouth and haematogenous infections in totaljoint replacement. Br Med J 1994;309:506-8.

12. Ching DWI, Gould IM, Rennie JAN,Gibson PII. Prevention of late haematogenousinfection in major prosthetic joints. JAntimicrob Chemother 1989;23:676-80.

13. Council on Dental Therapeutics.Management of dental patients with prosthet-ic joints. JADA 1990;121:537-8.

14. Eskinazi D, Rathburn W. Is systematicantimicrobial prophylaxis justified in dentalpatients with prosthetic joints? Oral SurgOral Med Oral Pathol 1988;66:430-1.

15. Cawson RA. Antibiotic prophylaxis fordental treatment: for hearts but not for pros-thetic joints. Br Dent J 1992;304:933-4.

16. Brause BD. Infections associated withprosthetic joints. Clin Rheum Dis1986;12:523-35.

17. Murray RP, Bourne MH, Fitzgerald RHJr. Metachronous infection in patients who havehad more than one total joint arthroplasty. JBone Joint Surg [Am] 1991;73(10):1469-74.

18. Poss R, Thornhill TS, Ewald FC,

Thomas WH, Batte NJ, Sledge CB. Factorsinfluencing the incidence and outcome of in-fection following total joint arthroplasty. ClinOrthop 1984;182:117-26.

19. Jacobson JJ, Millard HD, Plezia R,Blankenship JR. Dental treatment and lateprosthetic joint infections. Oral Surg OralMed Oral Pathol 1986;61:413-17.

20. Johnson DP, Bannister GG. The out-come of infected arthroplasty of the knee. JBone Joint Surg [Br] 1986;68(2):289-91.21. Jacobson JJ, Patel B, Asher G,

Wooliscroft JO, Schaberg D. OralStaphylcoccus in elderly subjects with rheuma-toid arthritis. J Am Geriatr Soc 1997;45:1-5.

22. Dajani AS, Taubert KA, Wilson W, et al.Prevention of bacterial endocarditis:Recommendations by the American HeartAssociation. From the Committee onRheumatic Fever, Endocarditis and KawasakiDisease, Council on Cardiovascular Diseasein the Young. JAMA 1997;277:1794-1801.Also in Circulation. July 1, 1997;96 (in press).Also excerpted in JADA 1997 (in press). Copy-right i' American Medical Association.

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