ADA News — January 7, 2013
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Science
Jean Williams


Evidence does not support antibiotics for dental patients with joint replacements

Following a collaborative systematic review of scientific evidence, the ADA and the American Academy of Orthopaedic Surgeons last month released a co-developed guideline that does not support routine prescription of antibiotic prophylaxis for joint replacement patients undergoing dental procedures.

In developing “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures,” an AAOS-ADA work group conducted a systematic review of existing clinical research published in peer-reviewed journals to determine the correlation between dental procedures and prosthetic joint infection (PJI).

“This guideline was based primarily on clinical research which examined a large group of patients, all having a prosthetic hip or knee and half with an infected prosthetic joint. The research showed that invasive dental procedures, with or without antibiotics, did not increase the odds of developing a prosthetic joint infection,” said Dr. Elliot Abt in a Dec. 18 press release. Dr. Abt, a member of the ADA Council on Scientific Affairs, served on the AAOS-ADA work group on behalf of the ADA.

Said David Jevsevar, M.D., M.B.A., chair of the AAOS Evidence Based Practice Committee that oversees the development of clinical practice guidelines, “As clinicians, we want what is in the best interest of our patients, so this clinical practice guideline is not meant to be a stand-alone document. Instead it should be used as an educational tool to guide clinicians through treatment decisions with their patients in an effort to improve quality and effectiveness of care.

“It has been long debated that patients with orthopaedic implants, primarily hip and knee replacements, are prone to implant infections from routine dental procedures,” added Dr. Jevsevar who also is an orthopaedic surgeon in St. George, Utah. “What we found in this analysis is that there is no conclusive evidence that demonstrates a need to routinely administer antibiotics to patients with an orthopaedic implant who undergo dental procedures.”

The new ADA and AAOS guideline has three recommendations and replaces the previous AAOS Information Statement “Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacement.”

The full guideline, supporting documentation and work group disclosures are posted on ADA.org. Supporting documentation includes commentary on the guideline development and results as well as a tool on how to balance clinical information and treatment options with patient preferences. (See below.) (See Page 4 for a commentary on the guideline written by Dr. Abt and Dr. Jevsevar.) ■

ASDA member receives Turner scholarship

Daryn Lu, a student from the University of Oklahoma College of Dentistry, is the recipient of the American Student Dental Association’s 2013 Ryan Turner Memorial Scholarship.

ASDA’s board of trustees selected Mr. Lu for the award. He will receive a $2,500 scholarship with an additional $500 awarded to his school’s ASDA chapter during ASDA’s Annual Session, March 6-9 in Atlanta.

The annual scholarship honors the memory of Ryan Turner, an ASDA national leader and fourth-year dental student at the University of Michigan when he died in 2007.

“The Ryan Turner Memorial scholarship allows its recipients to inspire others and commit themselves to a passionate, lifelong involvement in organized dentistry,” said Mr. Lu. “I’m humbled to be a part of those honored few.”

Mr. Lu currently serves as his ASDA chapter president-elect. He is the founder and president of the University of Central Oklahoma Predental Society, a mentor in the Big Brothers Big Sisters of Oklahoma, a member of the OUHSC Crimson Club, and founder of the Student Professionalism and Ethics Association in Dentistry chapter at the Univeristy of Oklahoma.

Toolkit for discussing antibiotics with patients who have orthopaedic implants

The following is text from the Shared Decision Making Tool: An Aid to Help Balance Clinical Information and Treatment Options with Patient Preferences, authored by David S. Jevsevar, M.D., M.B.A.

More information about this tool is included online and can be viewed at www.ada.org/2157.aspx?currentTab=2#replace.

Shared Decision Making Tool

A Shared Decision Making Tool promotes the collaborative decision making between patient and clinician for best treatment strategy. It is an additional tool to be used and supplements, but does not replace, informed consent procedures.

As a useful aid to the AAOS/ADA Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures clinical practice guideline, the Shared Decision Making Tool would engage patients in a decision making process and provide information to further clarify the risks, benefits and alternatives to treatment. Should I take antibiotics before my dental procedure?

Introduction:

You have an orthopaedic implant (joint replacement, metal plates or rods, etc.) from a previous orthopaedic surgery.

• A potential complication of these implants is bacterial infection, which occurs in approximately 1-3 percent of patients. These infections require more surgery as well as antibiotic usage for an extended period of time. Most infections occur around the time of the procedure (within one year), but some have occurred much later.

• In theory, late implant infections are caused by the spread of the bacteria from the bloodstream to the implant.

Unfortunately, there is no clear scientific evidence to support this theory. We know that many patients with orthopaedic implants frequently have bacteria in their blood that does not spread to their implants.

Dental procedures have long been considered a potential cause of implant infections even after the initial orthopedic postoperative period.

This is because dental procedures can introduce bacteria from the mouth into the bloodstream. However, this fact should be considered in the context that eating and performing oral hygiene at home may also introduce oral bacteria into the blood.

• Traditionally, antibiotics have been provided prior to dental procedures in patients with orthopaedic implants to minimize the bacteria that get into the blood.

• Best evidence, however, does not show that antibiotics provided before oral care help prevent infections of orthopaedic implants.

• The routine use of antibiotics in this manner has potential side effects such as increased bacterial resistance, allergic reactions, diarrhea and may even cause death. Patients who have compromised immune systems might be at greater risk for implant infections.

• Diabetes, rheumatoid arthritis, cancer, chemotherapy and chronic steroid use are examples suggesting immunosuppression. Please discuss your potential for immunosuppression with your physician or dentist.

• Patients who are immune-compromised might wish to consider antibiotics before dental procedures because of their greater risk for infection.

• Decisions with regard to antibiotic premedication should be made by patients, dentists and physicians in a context of open communication and informed consent.

Questions:

1. Patients with orthopaedic implants have which of the following:

a. 0 percent chance of infection

b. 0-1 percent chance of infection

c. 1-3 percent chance of infection

d. >3 percent chance of infection

2. Most implant infections are:

a. Related to dental procedures

b. Occur around the time of surgery

c. Related to skin infections

d. Occur long after surgery

3. Some dental procedures:

a. Routinely cause implant infections

b. Are the primary source of implant infections

c. Never cause implant infections

d. Allow bacteria to enter the bloodstream

4. Routine pre-dental procedure antibiotics are:

a. Not supported by current evidence

b. May be beneficial in certain groups of patients

c. Associated with other unwanted side effects

d. All of the above

Patient Checklist:

1. I have adequate understanding of implant infections associated with dental procedures: __ Yes or __ No

2. My physician/dentist has discussed my specific risk factors with me: Yes or No

3. I need further education and discussion on this issue: __ Yes or __ No

4. I am immunocompromised because I have: (specify condition)________________

5. Based on this educational material and discussion, I will: Not take antibiotics before my dental procedure OR take antibiotics before my dental procedure.
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