PERSPECTIVES J Oral Maxillofac Surg 73:1242-1243, 2015
Critique of American Dental Association Council on Scientific Affairs Clinical Practice Guideline: Use of Prophylactic Antibiotics Before Dental Procedures in Patients With Prosthetic Joints Arthur H. Friedlander, DMD,* Tina I. Chang, DMD, MD,y Renna C. Hazboun, DMD,z and Nona Aghazadehsanai, DDSx Oral and maxillofacial surgeons, as dental specialists who plan the treatment of their own elective surgery patients, as well as receive emergency referrals from dentists of patients in the midst of surgery gone awry, need to be keenly aware of the relative strengths of the documentary evidence garnered by the 2014 American Dental Association (ADA) Council on Scientific Affairs in its determination that patients with prosthetic joints do not require antibiotic prophylaxis.1 The panel based its clinical practice guideline on literature search results and direct evidence contained in a comprehensive systematic review initially published by another ADA Panel in conjunction with the American Academy of Orthopaedic Surgeons (AAOS) in 20122 plus the results of an updated literature search that identified 3 additional ‘‘evidence-based’’ documents. Specifically, the 2012 AAOS-ADA Panel noted that a recommendation that the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures was ‘‘limited,’’ ‘‘because the quality of
supporting evidence that exists is unconvincing or that well-conducted studies show little clear advantage to one approach versus another.’’ The Panel also noted that practitioners should be cautioned in deciding whether to follow a recommendation classified as ‘‘limited’’ and should be alert to emerging publications that report evidence. Now let us examine the 3 newly identified studies compiled by the 2014 ADA Panel without AAOS input. In the nested case-control study by Skaar et al3 of 168 participants, 42 case participants who had developed prosthetic joint infections were risk matched to 126 control participants who had not. Skaar et al3 reported that the control participants were more likely to have undergone invasive dental procedures than were the case participants. However, the investigators admitted that the statistical power for their study was low, and the ADA Panel acknowledged that the dental data were based on patient self-report, which is susceptible to recall bias. In the nested case-control study by Swan et al,4 17 patients who had developed joint infection more
*Associate Chief of Staff and Director of Graduate Medical
xResearch Fellow, Oral and Maxillofacial Surgery Section, Dental
Education, Veterans Affairs Greater Los Angeles Healthcare System;
Service, Veterans Affairs Greater Los Angeles Healthcare System, Los
Director of Quality Assurance, Hospital Dental Service, Ronald
Angeles, CA.
Reagan
UCLA
Medical
Center;
and
Professor-in-Residence,
Address correspondence and reprint requests to Dr Friedlander:
Department of Oral and Maxillofacial Surgery, University of
Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wil-
California, Los Angeles, School of Dentistry, Los Angeles, CA.
shire Blvd, Los Angeles, CA 90073; e-mail: [email protected]
yDirector of Research Fellowship and Inpatient Oral and
Received March 24 2015
Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System; and Instructor, Department of Oral and
Published by Elsevier Inc on behalf of the American Association of Oral and Maxil-
Maxillofacial Surgery, University of California, Los Angeles, School
lofacial Surgeons
of Dentistry, Los Angeles, CA.
0278-2391/15/00344-4
zResearch Fellow, Oral and Maxillofacial Surgery Section, Dental
Accepted March 25 2015
http://dx.doi.org/10.1016/j.joms.2015.03.052
Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA.
1242
1243
FRIEDLANDER ET AL
than 3 months postoperatively were compared with 51 control patients who had not. The investigators claimed that their project failed to demonstrate an association between dental procedures and the subsequent development of prosthetic joint infection. The ADA Panel, however, acknowledged that it was unclear whether the case and control participants were demographically similar and denoted that the susceptibility for recall bias was high, because the dental exposure data were collected by telephone interviews. In the nested case-control study by Jacobson et al,5 30 patients who had developed joint infection more than 6 months postoperatively were compared with 100 control patients. The investigators concluded that their statistical analysis demonstrated an association between the performance of dental procedures and the development of prosthetic joint infection.5 The 2014 ADA Panel noted, however, that the investigators did not declare match criteria nor account for confounding factors such as age, gender, smoking status, or medical conditions. Given these contradictory findings among the studies and the admitted specific study weaknesses, it is surprising that the 2014 ADA Panel could declare with ‘‘moderate certainty’’ ‘‘that there is no association between dental procedures and the occurrence of prosthetic joint infections’’ and, by extension, that prophylactic antibiotics are not generally recommended before dental procedures to prevent prosthetic joint infection. It is also surprising that the Panel identified a number of medical conditions (eg, immunocompromised patients and patients with diabetes mellitus)
that are associated with the development of late prosthetic joint infection, but then claimed that the infections were ‘‘independent of dental procedures.’’ One can only surmise that this was why they did not specifically recommend antibiotic prophylaxis for patients with a joint prosthesis and these illnesses. In conclusion, we suggest that the ADA Panel has provided only weak additional information beyond that initially enunciated by the 2012 AAOS/ADA Evidence-Based Guideline and Evidence Report.2 Thus, we believe that clinicians should be very cautious before they alter their historic consenting or prescribing patterns.
References 1. Sollecito TP, Abt E, Lockhart PB, et al: The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners—a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 146:11, 2015 2. American Academy of Orthopaedic Surgeons; American Dental Association. Prevention of Orthpaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-Based Guideline and Evidence Report; 2012. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2012. Available at: www.aaos.org/ research/guidelines/PUDP/PUDP_guideline.pdf. Accessed March 20, 2015. 3. Skaar DD, O’Connor H, Hodges JS, Michalowicz BS: Dental procedures and subsequent prosthetic joint infections: Findings from the Medicare Current Beneficiary Survey. J Am Dent Assoc 142: 1343, 2011 4. Swan J, Dowsey M, Babazadeh S, et al: Significance of sentinel infective events in haematogenous prosthetic knee infections. ANZ J Surg 81:40, 2011 5. Jacobson JJ, Millard HD, Plezia R, Blankenship JR: Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 61:413, 1986
Critique of American Dental Association Council on Scientific Affairs Clinical Practice Guideline: Use of Prophylactic Antibiotics Before Dental Procedures in Patients With Prosthetic Joints Arthur H. Friedlander, DMD,* Tina I. Chang, DMD, MD,y Renna C. Hazboun, DMD,z and Nona Aghazadehsanai, DDSx Oral and maxillofacial surgeons, as dental specialists who plan the treatment of their own elective surgery patients, as well as receive emergency referrals from dentists of patients in the midst of surgery gone awry, need to be keenly aware of the relative strengths of the documentary evidence garnered by the 2014 American Dental Association (ADA) Council on Scientific Affairs in its determination that patients with prosthetic joints do not require antibiotic prophylaxis.1 The panel based its clinical practice guideline on literature search results and direct evidence contained in a comprehensive systematic review initially published by another ADA Panel in conjunction with the American Academy of Orthopaedic Surgeons (AAOS) in 20122 plus the results of an updated literature search that identified 3 additional ‘‘evidence-based’’ documents. Specifically, the 2012 AAOS-ADA Panel noted that a recommendation that the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures was ‘‘limited,’’ ‘‘because the quality of
supporting evidence that exists is unconvincing or that well-conducted studies show little clear advantage to one approach versus another.’’ The Panel also noted that practitioners should be cautioned in deciding whether to follow a recommendation classified as ‘‘limited’’ and should be alert to emerging publications that report evidence. Now let us examine the 3 newly identified studies compiled by the 2014 ADA Panel without AAOS input. In the nested case-control study by Skaar et al3 of 168 participants, 42 case participants who had developed prosthetic joint infections were risk matched to 126 control participants who had not. Skaar et al3 reported that the control participants were more likely to have undergone invasive dental procedures than were the case participants. However, the investigators admitted that the statistical power for their study was low, and the ADA Panel acknowledged that the dental data were based on patient self-report, which is susceptible to recall bias. In the nested case-control study by Swan et al,4 17 patients who had developed joint infection more
*Associate Chief of Staff and Director of Graduate Medical
xResearch Fellow, Oral and Maxillofacial Surgery Section, Dental
Education, Veterans Affairs Greater Los Angeles Healthcare System;
Service, Veterans Affairs Greater Los Angeles Healthcare System, Los
Director of Quality Assurance, Hospital Dental Service, Ronald
Angeles, CA.
Reagan
UCLA
Medical
Center;
and
Professor-in-Residence,
Address correspondence and reprint requests to Dr Friedlander:
Department of Oral and Maxillofacial Surgery, University of
Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wil-
California, Los Angeles, School of Dentistry, Los Angeles, CA.
shire Blvd, Los Angeles, CA 90073; e-mail: [email protected]
yDirector of Research Fellowship and Inpatient Oral and
Received March 24 2015
Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System; and Instructor, Department of Oral and
Published by Elsevier Inc on behalf of the American Association of Oral and Maxil-
Maxillofacial Surgery, University of California, Los Angeles, School
lofacial Surgeons
of Dentistry, Los Angeles, CA.
0278-2391/15/00344-4
zResearch Fellow, Oral and Maxillofacial Surgery Section, Dental
Accepted March 25 2015
http://dx.doi.org/10.1016/j.joms.2015.03.052
Service, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA.
1242
1243
FRIEDLANDER ET AL
than 3 months postoperatively were compared with 51 control patients who had not. The investigators claimed that their project failed to demonstrate an association between dental procedures and the subsequent development of prosthetic joint infection. The ADA Panel, however, acknowledged that it was unclear whether the case and control participants were demographically similar and denoted that the susceptibility for recall bias was high, because the dental exposure data were collected by telephone interviews. In the nested case-control study by Jacobson et al,5 30 patients who had developed joint infection more than 6 months postoperatively were compared with 100 control patients. The investigators concluded that their statistical analysis demonstrated an association between the performance of dental procedures and the development of prosthetic joint infection.5 The 2014 ADA Panel noted, however, that the investigators did not declare match criteria nor account for confounding factors such as age, gender, smoking status, or medical conditions. Given these contradictory findings among the studies and the admitted specific study weaknesses, it is surprising that the 2014 ADA Panel could declare with ‘‘moderate certainty’’ ‘‘that there is no association between dental procedures and the occurrence of prosthetic joint infections’’ and, by extension, that prophylactic antibiotics are not generally recommended before dental procedures to prevent prosthetic joint infection. It is also surprising that the Panel identified a number of medical conditions (eg, immunocompromised patients and patients with diabetes mellitus)
that are associated with the development of late prosthetic joint infection, but then claimed that the infections were ‘‘independent of dental procedures.’’ One can only surmise that this was why they did not specifically recommend antibiotic prophylaxis for patients with a joint prosthesis and these illnesses. In conclusion, we suggest that the ADA Panel has provided only weak additional information beyond that initially enunciated by the 2012 AAOS/ADA Evidence-Based Guideline and Evidence Report.2 Thus, we believe that clinicians should be very cautious before they alter their historic consenting or prescribing patterns.
References 1. Sollecito TP, Abt E, Lockhart PB, et al: The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners—a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 146:11, 2015 2. American Academy of Orthopaedic Surgeons; American Dental Association. Prevention of Orthpaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-Based Guideline and Evidence Report; 2012. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2012. Available at: www.aaos.org/ research/guidelines/PUDP/PUDP_guideline.pdf. Accessed March 20, 2015. 3. Skaar DD, O’Connor H, Hodges JS, Michalowicz BS: Dental procedures and subsequent prosthetic joint infections: Findings from the Medicare Current Beneficiary Survey. J Am Dent Assoc 142: 1343, 2011 4. Swan J, Dowsey M, Babazadeh S, et al: Significance of sentinel infective events in haematogenous prosthetic knee infections. ANZ J Surg 81:40, 2011 5. Jacobson JJ, Millard HD, Plezia R, Blankenship JR: Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 61:413, 1986
