by JoAnn R. Gurenlian, RDH, PhD
For the past several years, there has been considerable confusion about the use of prophylactic antibiotics for clients who present with a history of joint replacement. The American Heart Association (AHA) had one perspective about the routine use of premedication prior to dental procedures and the American Academy of Orthopaedic Surgeons (AAOS) had a completely different point of view. In 2009, the AAOS advocated for a lifetime use of prophylactic antibiotics to prevent prosthetic joint infections (PJI).
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When the AAOS first presented this recommendation, many oral health professionals challenged the notion that routine antibiotic therapy before dental and dental hygiene treatment was necessary. They rightly questioned the evidence, or lack thereof, that would lead this professional organization to arrive at that conclusion. Granted, hundreds of thousands of joint replacement surgeries occur yearly. However, the rate of PJI is remarkably low. Attributing these infections to dental treatment appeared unfounded.
Throughout these past 35 years, oral health professionals were confused as to how best to provide care for those individuals with joint replacement. Should every person be exposed to premedication for two years, for life, sometimes, or not at all? Who would bear the responsibility for whichever decision was made -- the practitioner, the employer, or the organization proposing the guidelines and recommendations? Some deferred to their employers, others only used the recommendation of the AHA, and others chose the "CYA" approach and used the AAOS guidelines.
Fast forward a few years and the AAOS, in partnership with the American Dental Association (ADA), agreed to review the existing evidence of clinical research on the subject. Members of the AAOS Evidence-Based Practice Committee reviewed studies of patients with predominantly hip and knee replacements and their propensity to develop infections from routine dental procedures. Findings of their investigation revealed that there is no conclusive evidence that demonstrates a need to use routine prophylactic antibiotics for patients with an orthopedic implant during dental procedures. Their research investigation showed that the odds of developing a PJI were not increased when exposed to invasive dental care, with or without the use of antibiotics.
A new set of guidelines is now available for oral health professionals. "Prevention of Orthopaedic Implant Infections in Patients Undergoing Dental Procedures" is available on the AAOS website at http://www.aaos.org/guidelines. They can also be accessed at the ADA website at http://www.ada.org/contentdocs/dentalexecsumm.pdf. Three recommendations are presented in this document:
- The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic implants undergoing procedures.
- The workgroup was unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopedic implants undergoing dental procedures.
- In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the workgroup that patients with prosthetic joint implants or other orthopedic implants maintain appropriate oral hygiene.
If you were one of the oral health providers who never thought the original AAOS guidelines made sense, you have been vindicated. However, do these recommendations make any sense either? Mind you, these three recommendations are the main gist of a 325-page document that essentially concluded there is no evidence to support prophylactic antibiotics to prevent PJI. And, just to keep things interesting, in all those pages, there are no recommendations for how to handle the person who has undergone finger, elbow, shoulder, ankle, or back joint replacements. What are we supposed to do with those individuals? Even that first recommendation is hedging (i.e., "might consider"). Is this really the best a committee could bring forward in 325 pages? It seems as though a one-page statement indicating that there is no evidence to warrant lifetime or any use of premedication for prosthetic joints could have covered it.
To put another spin on this and help us keep perspective, below are a few thoughts to keep in mind when reviewing these papers:
- Guidelines and recommendations are not laws.
- Guidelines and recommendations can and should change based on regular review of the current scientific literature.
- Guidelines and recommendations should make sense.
- We should keep an open mind, but remain inquisitive when guidelines do not seem to mesh with our understanding of biology, wound healing, pathophysiology, microbiology, and other sciences.
- When we learn something new, we should endeavor to examine the evidence ourselves before making changes to practices and procedures. RDH
JOANN R. GURENLIAN, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing-education programs to health-care providers. She is a professor and interim dental hygiene graduate program director at Idaho State University, and president-elect of the International Federation of Dental Hygienists.