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Guidelines by the
American Dental Association and Academy of Orthopaedic
Surgeons
Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements
An expert panel of dentists, orthopaedic surgeons and infectious
disease specialists, convened by the American Dental Association
(ADA) and the American Academy of Orthopaedic Surgeons (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 advisory statement. The panel's conclusion:
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 replacements. However, it is
advisable to consider premedication in a small number of patients
who may be at potential increased risk of hematogenous total joint
infection.
Approximately 450,000 total joint arthroplasties are performed
annually in the United States. Deep infections of these total joint
replacements usually result in failure of the initial operation and
the need for extensive revision. Due to the use of perioperative
antibiotic prophylaxis and other technical advances, deep infection
occurring in the immediate postoperative period resulting from
intraoperative contamination has been markedly reduced in the past
20 years.
Patients who are about to have a total joint arthroplasty should be
in good dental health prior to surgery and should be encouraged to
seek professional dental care if necessary. Patients who already
have had a total joint arthroplasty should perform effective daily
oral hygiene procedures to remove plaque (e.g. manual or powered
toothbrushes, interdental cleaners, oral irrigators) to establish
and maintain good oral health. The risk of bacteremia is far more
substantial in a mouth with ongoing inflammation than in one that is
healthy and employing these home-oral hygiene devices.1 Bacteremias
can cause hematogenous seeding of total joint implants, both in the
early postoperative period and for many years following
implantation.2 It appears that the most critical period is up to two
years after joint placement.3 In addition, bacteremias may occur in
the course of normal daily life 4-6 and concurrently with dental and
medical procedures.6 It is likely that many more oral bacteremias
are spontaneously induced by daily events than are dental
treatment-induced.6 Presently, no scientific evidence supports the
position that antibiotic prophylaxis to prevent hematogenous
infections is required prior to dental treatment in patients with
total joint prostheses.1 The risk/benefit7,8 and
cost/effectiveness7,9 ratios fail to justify the administration of
routine antibiotic prophylaxis. The analogy of late prosthetic joint
infections with infective endocarditis is invalid as the anatomy,
blood supply, microorganisms and mechanisms of infection are all
different.10
It is likely that bacteremias associated with acute infection in the
oral cavity,11,12 skin, respiratory, gastrointestinal and urogenital
systems and/or other sites can and do cause late implant
infection.12 Any patient with a total joint prosthesis with acute
orofacial infection should be vigorously treated as any other
patient with elimination of the source of the infection (incision
and drainage, endodontics, extraction) and appropriate therapeutic
antibiotics when indicated.1,12 Practitioners should maintain a high
index of suspicion for any unusual signs and symptoms (e.g. fever,
swelling, pain, joint warm to touch) in patients with total joint
prostheses.
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 replacements. This position agrees
with that taken by the Council on Dental Therapeutics,13 the
American Academy of Oral Medicine,14 and is similar to that taken by
the British Society for Antimicrobial Chemotherapy.15 There is
limited evidence that some immunocompromised patients with total
joint replacements (Table 1) may be at higher risk for hematogenous
infections.13, 16-22 Antibiotic prophylaxis for such patients
undergoing dental procedures with a higher bacteremic risk (as
defined in Table 2), should be considered using an empirical regimen
(Table 3). In addition, antibiotic prophylaxis may be considered
when the higher risk dental procedures (as defined in Table 2) are
performed on dental patients within two years post implant surgery,3
on those who have had previous prosthetic joint infections, and on
those with some other conditions.
Occasionally, a patient with a total joint prosthesis may present to
the dentist with a recommendation from his/her physician that is not
consistent with these guidelines. This could be due to lack of
familiarity with the guidelines or to special considerations about
the patient's medical condition which are not known to the dentist.
In this situation, the dentist is encouraged to consult with the
physician to determine if there are any special considerations that
might affect the dentist's decision on whether or not to premedicate,
and may wish to share a copy of these guidelines with the physician,
if appropriate. After this consultation, the dentist may decide to
follow the physician's recommendation, or, if in the dentist's
professional judgment, antibiotic prophylaxis is not indicated, may
decide to proceed without antibiotic prophylaxis. The dentist is
ultimately responsible for making treatment recommendations for
his/her patients based on the dentist's professional judgment. Any
perceived potential benefit of antibiotic prophylaxis must be
weighed against the known risks of antibiotic toxicity, allergy, and
development, selection and transmission of microbial resistance.
This statement provides guidelines to supplement practitioners in
their clinical judgment regarding antibiotic prophylaxis for dental
patients with a total joint prosthesis. It is not intended as the
standard of care nor as a substitute for clinical judgment as it is
impossible to make recommendations for all conceivable clinical
situations in which bacteremias originating from the oral cavity may
occur. Practitioners must exercise their own clinical judgment in
determining whether or not antibiotic prophylaxis is appropriate.
The ADA/AAOS Expert Panel consisted of: Robert H. Fitzgerald Jr.,
MD; Jed J. Jacobson, DDS, MS, MPH; James V. Luck Jr., MD; Carl L.
Nelson, MD; J. Phillip Nelson, MD; Douglas R. Osmon, MD; and Thomas
J. Pallasch, DDS. Staff Liaisons: ADA-Clifford W. Whall Jr., PhD;
AAOS-William W. Tipton Jr., MD.
Table 1. Patients at Potential Increased Risk of Hematogenous Total
Joint Infection12,16-22
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