Monday, February 13, 2017

ADA Says No Evidence to Support Pre-Med for Joint Prosthetics

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For as long as Ive been in dentistry (even including my training) dentistry has been advocating prescribing antibiotics for patients with prosthetic joints.  At first the rationale was that any procedure that caused the gums to bleed could introduce oral bacteria into the bloodstream and those bacteria could attach to the prosthesis and cause an infection.  That would then lead to a hospital visit with copious doses of IV antibiotics to stop the infection.  It could also potentially lead to failure of the joint which could lead to surgery with all of its potential complications or perhaps even death.

Over time, the opinion of the experts changed.  It was then thought that the risk was only to recently placed prosthetics.  The opinion then shifted again to the point that maybe there was no risk at all or a minimal risk, but no one was quite sure.

To minimize the risk of this infection, the patient was given a dose of antibiotics before blood producing dental procedures so that any bacteria introduced into the bloodstream would be killed.  Now, to lay people this may not seem like a big deal, but to those of us in healthcare, there were potential problems with this.  Namely they were:

  • The cost of the antibiotics.  While this was usually minimal, it was more cost and the “hassle factor” of getting the prescription.
  • Potential allergic reactions.  Anytime a patient takes a medication, there is a chance of them developing an allergy and having a reaction.  While this is fairly rare, it does exist, and when it happens, has the potential to be a serious consequence.
  • The potential to contribute to the development of resistant strains of bacteria.
Now comes word from the ADA as of Friday February 10, 2017, that antibiotics are no longer needed for any patients that have prosthetic joints.  The statement from the ADA is below, published in its entirety.  I’ve got the link if you would like to view the ADA webpage on this subject that includes all of the reference papers and other info.   


Approximately 332,000 primary total hip arthroplasties and 719,000 primary total knee arthroplasties were performed in the United States in 201096% of hip replacement and 98% of knee replacement 1surgeries were performed on patients 45 years and older. Reported infection rates for such operations range from 0.8% to 2.2%.2-Infections can be caused by introduction of microorganisms at the time of surgery, hematogenous seeding, or contiguous spread of infection from an adjacent site.2,Infections of total joint replacements can result in failure of the initial surgical procedure and the need for extensive revision, prolonged antibiotic treatment, functional impairment, considerable cost of care, and even death. 

In 2014, the American Dental Association (ADA) Council on Scien- tific Affairs (CSA) assembled an expert panel to update and clarify the clinical recommendations found in a 2012 joint ADA and American Academy of Orthopaedic Surgeons (AAOS) evidence report and guide- line.4,5 In accord with the 2012 ADA/AAOS evidence report, the updated ADA systematic review (published in the January 2015 issue of The Journal of the American Dental Association) found no statistically sig- nificant association between dental procedures and prosthetic joint in- fections (PJI). On the basis of the review of the evidence, the 2015 ADA Clinical Practice Guideline stated, In general, for patients with pros- thetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.5

The ADA panel found no association between dental procedures and PJIs and no scientifically based efficacy for using antibiotics to prevent PJIs.5 The panel did acknowledge that there may be special circumstances in which a clinician may consider antibiotic prophylaxis despite the lack of scientific evidence. However, the guidelines did not list any special circumstances.

DEVELOPMENT OF APPROPRIATE USE CRITERIA FOR THE MANAGEMENT OF THE CARE OF PATIENTS WITH ORTHOPEDIC IMPLANTS UNDERGOING DENTAL PROCEDURES

Because there is weak evidence that some patients with certain medical conditions, diseases, and disorders may be at higher risk of experi- encing PJI independent of dental procedures, the AAOS contacted the ADA to participate in the develop- ment of appropriate use criteria (AUC) to assist orthopedic surgeons and dentists in managing the care of these patients. (Note: The AAOS began developing AUC in 2011 as a tool to implement evidence-based clinical practice guidelines. AUC are created to inform clinicians for whom a procedure should be per- formed. This involves using clini- cian expertise and experience, in conjunction with the relevant evi- dence, to rate the appropriateness of various treatments in a set of hy- pothetical, but clinically realistic, patient scenarios. For more informa- tion, visit http://www.orthoguidelines. org/go/auc/.) Although dental treat- ment is not considered a risk factor for PJI, the AAOS and ADA convened a group of subject matter experts to consider if antibiotic prophylaxis might be appropriate in any of these higher-risk patients.

To create the AUC, the AAOS used the RAND/University of Cali- fornia Los Angeles Appropriateness Method (RAM).6 The process involved reviewing the available evi- dence, compiling a list of potential clinical indications or scenarios,

and convening an expert panel comprised of representatives from multiple stakeholders to determine the appropriateness of each of the proposed clinical indications for treatment as appropriate,” “may be appropriate,or rarely appropriate.The literature reviewed for the AUC was derived primarily from the sci- entific articles used to develop the 2012 AAOS/ADA guidelines4 and 2015 ADA clinical practice guidelines.5

With the AUC,6 subject matter experts attempted to define clinical situations in which antibiotic pro- phylaxis in defined potentially at-risk patients might reduce the theoretical risk of experiencing post- surgical PJI. A writing panel comprised of AAOS and ADA rep- resentatives developed clinical sce- narios of situations in which dental treatment might theoretically create a higher risk of experiencing PJI. The following medically complex patient populations and related issues were used to develop a matrix to gain consensus on any potential benefit from antibiotic prophylaxis until more definitive scientific data be- comes available:

- planned dental procedure;
- an immunocompromised status; - glycemic control;
- history of periprosthetic or deep PJI of the hip or knee that required an operation;

- time since hip or knee joint replacement procedure.

Once approved by the writing panel, the theoretical risk scenarios were presented to a separate expert voting panel (made up of ADA and AAOS representatives) to determine the appropriateness of antibiotic prophylaxis for each scenario (that is, when antibiotic prophylaxis

is rarely appropriate,” “may be appropriate,or is appropriate). The voting panel identified relatively few patient subpopulations for whom antibiotic prophylaxis might be indicated before certain dental procedures. Of 64 total prophylactic antibiotic voting items, 8 (12%) items were rated as appropriate,17 (27%) items were rated as may be appro- priate,and 39 (61%) were rated as rarely appropriate.A Web-based application of the AUC is available at www.orthoguidelines.org/go/auc.

TAKE-HOME MESSAGES

There is no evidence to support
an association between dental pro- cedures and risk of experiencing PJIs.
The parameters that were used as potential scenarios for the AUC, in which antibiotic prophylaxis may be appropriate, do not indicate an increased risk of experiencing PJI due to hematogenous spread (bacteremia) from dental procedures or possibly other daily, oral healthrelated hygiene behaviors.7 These scenarios may indeed have some added risk of developing PJI in a small number of patients, but they are independent of dental treatment.

The AUC is a decision-support tool to supplement clinicians in their judgment regarding anti- biotic prophylaxis for patients with a prosthetic joint who are under- going dental procedures. It is not intended as the standard of care or as a substitute for clinical judgment. As developed, the AUC could facilitate the treatment of defined high riskand immune compromisedpa- tients. It affects a narrow cohort of patients for whom antibiotic pro- phylaxis might be considered. Although there was not complete consensus on all aspects of the AUC development process or outcomes,

a consensus of ADA-appointed expert panel members and CSA members agreed that this tool could benefit dentists, physicians, and patients by reducing antibiotic prescriptions.

Discussion of available treat- ment options applicable to each patient relies on communication between the patient, dentist, and orthopedic surgeon, weighing the potential risks and benefits for that patient. Prophylactic antibiotics before any clinical procedure that may cause bacteremia are chosen based on the nature and suscepti- bility of microflora at the treatment site, as well as the possible economic and health impact to patients
and populations. Any perceived po- tential bene
fit of antibiotic prophy- laxis must be weighed against the known risks of antibiotic use, including Clostridium difficile infec- tion, allergic reaction, and the development, selection, and trans- mission of antimicrobial resistance factors.8

It is appropriate for the dentist to make the final judgment to use antibiotic prophylaxis for patients potentially at higher risk of expe- riencing PJI (independent of dental treatment) using the AUC as a guide, without consulting the orthopedic surgeon. However, if the orthopedic surgeon recommends antibiotic prophylaxis or the patient prefers it, despite the dentists recommendation against premed- ication, the prescription should be provided by the surgeon.

The 2015 ADA clinical practice guideline is valid and should continue to inform clinical de- cisions for dental patients in ambulatory settings. The guideline

states clearly that the [e]vidence fails to demonstrate an association between dental procedures and PJI or any effectiveness for antibiotic prophylaxis. Given this information in conjunction with the potential harm from antibiotic use, using an- tibiotics before dental procedures is not recommended to prevent PJI.The CSA and ADA-appointed expert panel members encourage dental health care professionals to continue to use the 2015 ADA clinical practice guideline, consult the AUC as needed, and respect the patients specific needs and preferences when considering antibiotic prophylaxis before dental treatment.

CONCLUSIONS

In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.5 n http://dx.doi.org/10.1016/j.adaj.2016.12.002 

In 2014, the American Dental Association (ADA) Council on Scien- tific Affairs (CSA) assembled an expert panel to update and clarify the clinical recommendations found in a 2012 joint ADA and American Academy of Orthopaedic Surgeons (AAOS) evidence report and guide- line.4,5 In accord with the 2012 ADA/AAOS evidence report, the updated ADA systematic review (published in the January 2015 issue of The Journal of the American Dental Association) found no statistically sig- nificant association between dental procedures and prosthetic joint in- fections (PJI). On the basis of the review of the evidence, the 2015 ADA Clinical Practice Guideline stated, In general, for patients with pros- thetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.5

The ADA panel found no association between dental procedures and PJIs and no scientifically based efficacy for using antibiotics to prevent PJIs.5 The panel did acknowledge that there may be special circumstances in which a clinician may consider antibiotic prophylaxis despite the lack 

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