Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1474-4


Antibiotic prophylaxis during dental procedures in patients with in situ lower limb prosthetic joints U. Alao • R. Pydisetty • N. A. Sandiford

Received: 31 January 2014 / Accepted: 23 April 2014 Ó Springer-Verlag France 2014

Abstract The average age of patients presenting for total joint arthroplasty is decreasing. The number of primary and revision arthroplasty procedures performed in the UK, Europe and USA is increasing annually. As number of procedures performed increases, the life expectancy of our patients and therefore the in vivo duration of prosthetic joints increase, and the potential for complications such as infection increases. One potential source for this is bacterial dissemination during dental surgery. Many attempts have been made to address this issue in the form of national guidelines, but there is no clear consensus on antibiotic prophylaxis before these procedures in order to decrease the risk of prosthetic joint infection. This continues to be an area of indecision and uncertainty resulting in patients having delays in their treatment while decisions are made by oral and orthopaedic surgeons about prophylactic antibiotic use. This article reviews the existing national guidelines, highlighting the current views and issues surrounding this subject, and a critical appraisal of current evidence for the use of prophylactic antibiotics in this patient population is presented. We will also review the response in literature to the 2009 American Academy of Orthopaedic Surgeons information statement release on antibiotic prophylaxis in joint arthroplasty patients undergoing dental procedures.

U. Alao  R. Pydisetty Department of Trauma and Orthopaedics, Whiston Hospital, Warrington Road. Prescot, Merseyside L35 5DR, UK N. A. Sandiford Limb Reconstruction Unit, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada N. A. Sandiford (&) Lower Limb Reconstruction and Oncology Fellow, University of British Columbia, Vancouver, BC V5Z 1M9, Canada e-mail: [email protected]

Keywords Antibiotic prophylaxis  Periprosthetic joint infection  Joint replacement  Dental procedures

Introduction Hip and knee arthroplasty are commonly performed procedures. More than 167,000 total joint replacements were performed in England and Wales in 2010 [1], while over 1,000,000 THAs were performed annually in the USA [2]. Increasingly, younger patients are being considered for total joint arthroplasty. As a result, patients may live longer with their implants potentially increasing their lifetime risk of infection. Although the modern era of arthroplasty has seen infection rates decrease, prosthetic joint infection (PJI) remains one of the most commonly reported indications for revision [1] with reported morbidity and mortality rates of up to 10 % [3]. It is estimated that overall one in 75 people will have revision of their prosthesis within 3 years in England, while 7 % of annual procedures in the USA are revision arthroplasties [3, 4]. Management of infection is often expensive, prolonged, demanding on resources and distressing to patients [5]. While it is generally accepted that invasive dental procedures cause transient bacteraemia, it remains a matter of debate whether this leads to prosthetic joint infection.

Existing guidelines UK In 1992, the working party for the British Society for Antimicrobial Chemotherapy recommended against the prophylactic use of antibiotics in patients with joint


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replacements undergoing dental procedures. They found ‘no evidence that such prophylaxis is of any benefit’ [6]. The British Orthopaedic Association and the British Dental Association recommend antibiotic prophylaxis for at risk patients such as those with immunosuppressive disease such as diabetes, rheumatoid arthritis, haemophilia or malignancy, but advised against routine prophylaxis for all patients undergoing dental procedures [7]. In spite of this, up to 78 % of British Orthopaedic Surgeons and 29 % of Maxillofacial surgeons always recommended the use of prophylactic antibiotics before dental procedures [8]. USA The earliest advice by Nelson et al. [9] regarding the use of prophylactic antibiotic to prevent PJI was based on limited evidence. They recommend penicillin V (2 g) before dental treatment and one gram 6 h after the initial dose. They noted that while nearly 60 % of orthopaedic surgeons who were surveyed did not believe there was an established link between transient bacteraemia from dental procedures and prosthetic joint infection; over 90 % surveyed routinely recommended prophylactic antibiotics in patients with prosthetic joints. In 2003, the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) released a joint statement which replaced their 1997 advisory statement on the use of prophylactic antibiotics during invasive dental procedures in patients with in situ prostheses. They recommended the use of prophylactic antibiotics in the first 2 years following joint replacement in high-risk patients. They found that the risk/benefit and cost/effectiveness ratios failed to justify the administration of routine antibiotic prophylaxis [10]. In 2009, this statement was updated. The new message was significantly different, stating ‘given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteraemia’. This latest statement, released by the AAOS patient safety committee, did not meet the AAOS criteria for evidence-based guideline [11]. The ADA responded by saying that there was no evidence for change from the 2003 joint antibiotics prophylaxis recommendations [12]. Australia The Arthroplasty Society of Australia guideline for dental prophylaxis in patients with in situ arthroplasty suggest that elective non-invasive dental procedures should be delayed for 3–6 months following arthroplasty procedures. Routine


administration of prophylactic antibiotics is not recommended in patients [3 months post-operative with wellfunctioning prostheses. Prophylaxis is recommended within the first 3 months for those undergoing high- or medium-risk dental procedures for pain, overt dental infection or those with significant risk factors for periprosthetic joint infection [13].

Method We conducted a literature search using the National Library for Medicine PubMed database for all articles addressing this issue from publication of the AAOS information statement (November 2009) to present. The key search terms used were ‘dental’ ‘prophylaxis’, ‘arthroplasty’ and ‘joint replacement’. We excluded articles that were not in the English language and those that did not specifically address the issue of antibiotic prophylaxis in joint arthroplasty patients undergoing dental procedure.

Results Thirteen articles that met our inclusion criteria were identified. Ten were from dental or maxillofacial journals, two from infectious disease journal and one was from a medical journal. Eight articles were comments or letters in response to the AAOS 2009 statement, three were review articles, and one article was a retrospective study identifying dental-procedure-related periprosthetic joint infection. One article was a prospective case–control study. Of the eight letters or comments, six were against the new advice from the 2009 AAOS information statement citing lack of evidence for the change in advice. One article suggested leaving the decision to prescribe antibiotics to the orthopaedic surgeon or primary care physician [13], while another highlighted the importance of a possible staphylococcus species which may be oral in origin in causing periprosthetic infection [14]. Three review articles cautioned against following the new advice of 2009 AAOS information statement. Among these was a position paper from ADA which recommended that the dentist should choose from three options; inform patients and let them decide about antibiotic use, continue to follow the 2003 guidelines, or suggest to the orthopaedic surgeon that they both follow the 2003 guidelines [15]. The large prospective case–control study by Berbari et al. [16] examined the association between dental procedures with or without antibiotic prophylaxis and periprosthetic hip or knee infection. They found that dental procedures were not a significant risk factor for subsequent

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deep PJI and that the use of antibiotic prophylaxis did not reduce the risk of subsequent periprosthetic infection in patients with in situ hip and knee prostheses. They suggested that the 2009 AAOS statement should be reconsidered. Skaar et al. examined the associations between total joint arthroplasty and patients who developed periprosthetic joint infection over a 10-year period [17]. They found that dental procedures were not significantly associated with subsequent periprosthetic joint infection. They therefore recommended that the 2009 AAOS information statement be reconsidered. Their study lacked the power required to make a firm conclusion however.

Discussion Over 700 bacterial species inhabit the human oral cavity [14]. It is recognised that small amounts of bacteria enters the blood stream with activities such as chewing, flossing, tooth brushing and teeth clenching. The greatest dissemination occurs at the time of extraction of erupted, periodontally infected teeth [13, 15]. Transient bacteraemia may occur for up to 30 min following dental manipulation. Staphylococcal species—consisting of predominantly staphylococcus epidermis and staphylococcus aureus— account for 0.005 % of this natural flora [14, 18]. This is relevant because Staphylococcal species account for the majority of PJI [19]. Staphylococci species may be more readily isolated in groups with impaired immunity such as children, the elderly, those with rheumatoid arthritis and terminally ill patients [20–23]. Several authors have also isolated staphylococci more frequently in patients who wear dentures, diabetics, patients with periodontitis and other dental conditions [24–31]. Some authors believe that these staphylococci are not only part of the normal oral flora but also a potential reservoir for dissemination to other sites [31, 32]. Periprosthetic joint infection Infection accounts for up to 12 and 22 % of revision total hip and knee arthroplasty procedures, respectively [1]. It is associated with significant morbidity and financial cost [3]. The most widely adopted classification for periprosthetic joint infection was first described by Coventry and later expanded by Fitzgerald [32]. Type 1 infection occurs acutely with the first 3 months is often related to intraoperative period. Type 2 infections have a delayed presentation, often occurring 6–24 months following the primary procedure due to the low virulence of the organisms

involved. Type 3 infections are rare and caused by haematogenous spread in a previously asymptomatic hip. There is anecdotal evidence suggesting a link between transient bacteraemia and periprosthetic joint infection but there is little or no clinical or experimental evidence to support this. Few authors have been able to culture oral bacteria from infected prostheses [33]. Uckay et al. reviewed 144 articles in 2008 and found no genetically identical strains of streptococcus in the oral cavity and joints of patients presenting with PJI [34]. Even when historical link of dental procedures and PJI is taken into account, the risk is infection from oral flora remains very low (0.05 %) [35]. AAOS published an information statement in 2009 which recommend antibiotic prophylaxis before any invasive procedure in patients with total joint arthroplasty irrespective of the length of time from implantation of the prosthesis [2]. This statement replaced the 2003 statement made jointly with the ADA. The reason for their change in recommendation is potential for adverse outcomes as well as the financial burden of treating periprosthetic joint infection. This change in guidance is not supported by current evidence nor does it meet the AAOS criteria for evidence-based guideline as described by the authors themselves [11]. A recent consensus statement from the Musculoskeletal Infection Society recommended routine screening of patients having total joint arthroplasty with the use of a questionnaire or directly by a dentist. They did not recommend the routine use of prophylactic antibiotics [36]. Most authors caution against prescription of routine antibiotic prophylaxis before dental procedures in patients without additional risk factors. Some feel this practice is irresponsible and indefensible [37]. Routine use of antibiotics prior to invasive dental procedures could potentially lead to adverse allergic reactions, development of resistance and bacterial superinfection such as with Clostridium difficile. This practice is potentially also not a cost-effective option [8, 34]. If the rationale for avoiding adverse events or financial burden of periprosthetic joint infection is followed to its end, an argument could equally be made for using antibiotic prophylaxis with routine events such as brushing and chewing as they are also associated with bacteraemia [13].

Conclusion There is little evidence to support the 2009 AAOS information statement. The risk of dental-related prosthetic joint infection remains low, and there are no studies proving that antibiotic prophylaxis is effective. The use of antibiotic prophylaxis without risk stratification is expensive and may


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contribute to antibiotic resistance and adverse drug reactions. Most authors support the use of antibiotic prophylaxis in high-risk patients. There is need for consensus regarding antibiotic prophylaxis before dental procedures in patients with in situ lower limb prostheses. Conflict of interest


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Antibiotic prophylaxis during dental procedures in patients with in situ lower limb prosthetic joints.

The average age of patients presenting for total joint arthroplasty is decreasing. The number of primary and revision arthroplasty procedures performe...
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