Guest Editorial One Size Does Not Fit All: Involve Orthopaedic Implant Patients in Deciding Whether To Use Prophylactic Antibiotics With Dental Procedures David S. Jevsevar, MD, MBA Chair, AAOS Evidence Based Quality and Value Committee Deborah S. Cummins, PhD Director, AAOS Research and Scientific Affairs Frederick M. Azar, MD President, American Academy of Orthopaedic Surgeons Brian S. Parsley, MD President, American Association of Hip and Knee Surgeons Thomas K. Fehring, MD President, The Knee Society Paul F. Lachiewicz, MD President, The Hip Society William C. Watters III, MMS, MS, MD President, North American Spine Society
From the Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr. Jevsevar), the Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL (Dr. Cummins), Campbell Clinic, Memphis, TN (Dr. Azar), Baylor College of Medicine, Bellaire, TX (Dr. Parlsey), OrthoCarolina, Charlotte, NC (Dr. Fehring), Department of Orthopaedics, Duke University, Durham, NC (Dr. Lachiewicz), and the Bone & Joint Clinic of Houston, Houston, TX (Dr. Watters). http://dx.doi.org/10.5435/ JAAOS-D-15-00045
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA), along with input from the Infectious Disease Society of America (IDSA), American Association of Oral and Maxillofacial Surgeons (AAOMS), American Association of Neurologic Surgeons (AANS), American Society of Plastic Surgeons (ASPS), Musculoskeletal Infection Society (MIS), Scoliosis Research Society (SRS), American Association of Hip and Knee Surgeons (AAHKS), Society for Healthcare Epidemiology of America (SHEA), College of American Pathologists, and The Knee Society, published the collaborative clinical practice guideline (CPG) “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures” on December 7, 2012.1 This AAOS-ADA guideline on dental prophylaxis for patients with orthopaedic implants addressed the weaknesses of previous efforts based on a systematic review of available evidence. The CPG also united the position of these organizations with respect to the necessity of dental prophylaxis in these patient groups, eliminating the contradictory guidelines and statements published by both the AAOS and ADA before 2012. Unfortunately, the halo effect of this unified position was limited, as evidenced by the recent ADA publication “The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints.”2 This new ADA guideline again creates disagreement between
the ADA and AAOS, along with associated specialty societies, including the AAHKS, The Hip Society, and The Knee Society, because the ADA CPG makes a moderate recommendation against routine dental prophylaxis in patients who have undergone hip and/or knee arthroplasty. This recommendation is at odds with the previous recommendation in the 2012 collaborative CPG supported by limited evidence. Our primary concern with the work of the ADA is that it is not supported by evidence and should, in fact, be labeled a consensus statement. The ADA guideline incorrectly includes three lower quality research articles to develop a stronger recommendation, which is not actually supported by evidence. We also object to this 2014 ADA manuscript’s being referred to as an “updated” CPG because it uses different inclusion criteria from those of the 2012 AAOS-ADA CPG. For example, it includes articles (Swan et al,3 Jacobson et al4) that were specifically excluded by the multidisciplinary team that developed the 2012 CPG because these are retrospective studies that do not meet the criteria for inclusion. The third study added by the ADA (Skaar et al5) was published after the last literature search was done for the 2012 CPG, but it also would be excluded in a collaborative update because it is also a retrospective study. No additional higher quality evidence has been published since the 2012 AAOSADA CPG, so no change to the
March 2015, Vol 23, No 3
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
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Guest Editorial: One Size Does Not Fit All
strength or level of recommendation is indicated. The 2012 AAOS-ADA CPG did not include a stronger recommendation because the current evidence base does not support it. Rather, concerns about the lack of subgroup analysis suggested a metered approach to recommending antibiotic prophylaxis for patients with hip or knee arthroplasty undergoing dental work. Clinician assessment of individual patient risk factors was recommended, as well as the use of a shared decision-making approach to determining appropriate care. The work group expressed concern about nuance of care in these patients, and this was supported by the paucity of higher quality evidence available. We are also compelled to express our concern about the unilateral approach taken by the ADA to this issue. Apparently, dentists who were unhappy with the outcome of the original 2012 CPG lobbied for a noninclusive, non–evidence-based methodology rather than stand by the current best-available evidence. By publishing a consensus guideline that contradicts its previous evidencebased position, the ADA further muddies potential liability issues for their members as well as AAOS members. We believe that the patient care benefit of a collaborative position on the issue of dental prophylaxis is considerable and that the new ADA position may actually decrease care
offered to our patients. It also exposes a potential for opposing positions in a litigation scenario. Finally, the purpose of collaboration is to improve care delivery to and education of our patients. The AAOS has a rich history of collaboration with several non-orthopaedic societies as well as affiliate provider groups. When involved in these collaborative efforts, we take at face value a level of trust in supporting the outcome of these interactions. Although the results of evidence-based efforts sometimes disagree with our routine patterns of care, adherence to evidence-based methodology and outcome should not be undermined by political expediency. The new ADA guideline2 appears to lessen the commitment by the ADA to evidence-based care of its members’ patients. Because of the lack of evidence for this topic, derivative products such as appropriate use criteria and shared decision-making resources that use clinical expertise to form treatment recommendations may be better tools. More and better studies are needed to provide clear evidence regarding the correlation between dental procedures and periprosthetic joint infection in patients with orthopaedic implants. Those who may want to criticize these guideline recommendations should take note that the available literature is the basis for these recommendations. Finally, the practice of evidence-based
medicine is based on three pillars: the patient’s preferences and values, the clinician (and the clinician’s experience), and the evidence. Clinicians, both physicians and their dentist counterparts, should work with their individual patients and each other to customize care delivery based on the available evidence. It is hoped that this guideline will stimulate future research in this area.
References 1. American Academy of Orthopaedic Surgeons and American Dental Association: Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-Based Guideline and Evidence Report. http://www.aaos.org/Research/ guidelines/PUDP/dental_guideline.asp. Published December 7, 2012. 2. 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 2015;146(1):11-16.e8. 3. Swan J, Dowsey M, Babazadeh S, Mandaleson A, Choong PF: Significance of sentinel infective events in haematogenous prosthetic knee infections. ANZ J Surg 2011; 81(1-2):40-45. 4. Jacobson JJ, Millard HD, Plezia R, Blankenship JR: Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986;61(4):413-417. 5. 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 2011; 142(12):1343-1351.
Dr. Azar or an immediate family member has stock or stock options held in Pfizer and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Campbell Foundation, and St. Jude Children’s Research Hospital. Dr. Parsley or an immediate family member has received royalties from Conformis; is a member of a speakers’ bureau or has made paid presentations on behalf of Conformis and Nimbic Systems; serves as a paid consultant to or is an employee of, and has stock or stock options held in, Nimbic Systems; has received research or institutional support from Conformis; and serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons. Dr. Fehring or an immediate family member has received royalties from, is a member of a speakers’ bureau or has made paid presentations on behalf of, serves as a paid consultant to, and has received research or institutional support from DePuy, and serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons and The Knee Society. Dr. Lachiewicz or an immediate family member has received royalties from Innomed, is a member of a speakers’ bureau or has made paid presentations on behalf of Mallinkrodt (formerly Cadence), serves as a paid consultant to the Gerson Lehrman Group and Global Guidepoint Advisors, has received research or institutional support from Zimmer, and serves as a board member, owner, officer, or committee member of The Hip Society and the Orthopaedic Surgery and Trauma Society. Dr. Watters or an immediate family member has received royalties from Stryker and serves as a board member, owner, officer, or committee member of the American Board of Spine Surgery and the North American Spine Society. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Jevsevar and Dr. Cummins.
142
Journal of the American Academy of Orthopaedic Surgeons
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
From the Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr. Jevsevar), the Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL (Dr. Cummins), Campbell Clinic, Memphis, TN (Dr. Azar), Baylor College of Medicine, Bellaire, TX (Dr. Parlsey), OrthoCarolina, Charlotte, NC (Dr. Fehring), Department of Orthopaedics, Duke University, Durham, NC (Dr. Lachiewicz), and the Bone & Joint Clinic of Houston, Houston, TX (Dr. Watters). http://dx.doi.org/10.5435/ JAAOS-D-15-00045
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA), along with input from the Infectious Disease Society of America (IDSA), American Association of Oral and Maxillofacial Surgeons (AAOMS), American Association of Neurologic Surgeons (AANS), American Society of Plastic Surgeons (ASPS), Musculoskeletal Infection Society (MIS), Scoliosis Research Society (SRS), American Association of Hip and Knee Surgeons (AAHKS), Society for Healthcare Epidemiology of America (SHEA), College of American Pathologists, and The Knee Society, published the collaborative clinical practice guideline (CPG) “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures” on December 7, 2012.1 This AAOS-ADA guideline on dental prophylaxis for patients with orthopaedic implants addressed the weaknesses of previous efforts based on a systematic review of available evidence. The CPG also united the position of these organizations with respect to the necessity of dental prophylaxis in these patient groups, eliminating the contradictory guidelines and statements published by both the AAOS and ADA before 2012. Unfortunately, the halo effect of this unified position was limited, as evidenced by the recent ADA publication “The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints.”2 This new ADA guideline again creates disagreement between
the ADA and AAOS, along with associated specialty societies, including the AAHKS, The Hip Society, and The Knee Society, because the ADA CPG makes a moderate recommendation against routine dental prophylaxis in patients who have undergone hip and/or knee arthroplasty. This recommendation is at odds with the previous recommendation in the 2012 collaborative CPG supported by limited evidence. Our primary concern with the work of the ADA is that it is not supported by evidence and should, in fact, be labeled a consensus statement. The ADA guideline incorrectly includes three lower quality research articles to develop a stronger recommendation, which is not actually supported by evidence. We also object to this 2014 ADA manuscript’s being referred to as an “updated” CPG because it uses different inclusion criteria from those of the 2012 AAOS-ADA CPG. For example, it includes articles (Swan et al,3 Jacobson et al4) that were specifically excluded by the multidisciplinary team that developed the 2012 CPG because these are retrospective studies that do not meet the criteria for inclusion. The third study added by the ADA (Skaar et al5) was published after the last literature search was done for the 2012 CPG, but it also would be excluded in a collaborative update because it is also a retrospective study. No additional higher quality evidence has been published since the 2012 AAOSADA CPG, so no change to the
March 2015, Vol 23, No 3
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
141
Guest Editorial: One Size Does Not Fit All
strength or level of recommendation is indicated. The 2012 AAOS-ADA CPG did not include a stronger recommendation because the current evidence base does not support it. Rather, concerns about the lack of subgroup analysis suggested a metered approach to recommending antibiotic prophylaxis for patients with hip or knee arthroplasty undergoing dental work. Clinician assessment of individual patient risk factors was recommended, as well as the use of a shared decision-making approach to determining appropriate care. The work group expressed concern about nuance of care in these patients, and this was supported by the paucity of higher quality evidence available. We are also compelled to express our concern about the unilateral approach taken by the ADA to this issue. Apparently, dentists who were unhappy with the outcome of the original 2012 CPG lobbied for a noninclusive, non–evidence-based methodology rather than stand by the current best-available evidence. By publishing a consensus guideline that contradicts its previous evidencebased position, the ADA further muddies potential liability issues for their members as well as AAOS members. We believe that the patient care benefit of a collaborative position on the issue of dental prophylaxis is considerable and that the new ADA position may actually decrease care
offered to our patients. It also exposes a potential for opposing positions in a litigation scenario. Finally, the purpose of collaboration is to improve care delivery to and education of our patients. The AAOS has a rich history of collaboration with several non-orthopaedic societies as well as affiliate provider groups. When involved in these collaborative efforts, we take at face value a level of trust in supporting the outcome of these interactions. Although the results of evidence-based efforts sometimes disagree with our routine patterns of care, adherence to evidence-based methodology and outcome should not be undermined by political expediency. The new ADA guideline2 appears to lessen the commitment by the ADA to evidence-based care of its members’ patients. Because of the lack of evidence for this topic, derivative products such as appropriate use criteria and shared decision-making resources that use clinical expertise to form treatment recommendations may be better tools. More and better studies are needed to provide clear evidence regarding the correlation between dental procedures and periprosthetic joint infection in patients with orthopaedic implants. Those who may want to criticize these guideline recommendations should take note that the available literature is the basis for these recommendations. Finally, the practice of evidence-based
medicine is based on three pillars: the patient’s preferences and values, the clinician (and the clinician’s experience), and the evidence. Clinicians, both physicians and their dentist counterparts, should work with their individual patients and each other to customize care delivery based on the available evidence. It is hoped that this guideline will stimulate future research in this area.
References 1. American Academy of Orthopaedic Surgeons and American Dental Association: Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-Based Guideline and Evidence Report. http://www.aaos.org/Research/ guidelines/PUDP/dental_guideline.asp. Published December 7, 2012. 2. 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 2015;146(1):11-16.e8. 3. Swan J, Dowsey M, Babazadeh S, Mandaleson A, Choong PF: Significance of sentinel infective events in haematogenous prosthetic knee infections. ANZ J Surg 2011; 81(1-2):40-45. 4. Jacobson JJ, Millard HD, Plezia R, Blankenship JR: Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986;61(4):413-417. 5. 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 2011; 142(12):1343-1351.
Dr. Azar or an immediate family member has stock or stock options held in Pfizer and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Campbell Foundation, and St. Jude Children’s Research Hospital. Dr. Parsley or an immediate family member has received royalties from Conformis; is a member of a speakers’ bureau or has made paid presentations on behalf of Conformis and Nimbic Systems; serves as a paid consultant to or is an employee of, and has stock or stock options held in, Nimbic Systems; has received research or institutional support from Conformis; and serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons. Dr. Fehring or an immediate family member has received royalties from, is a member of a speakers’ bureau or has made paid presentations on behalf of, serves as a paid consultant to, and has received research or institutional support from DePuy, and serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons and The Knee Society. Dr. Lachiewicz or an immediate family member has received royalties from Innomed, is a member of a speakers’ bureau or has made paid presentations on behalf of Mallinkrodt (formerly Cadence), serves as a paid consultant to the Gerson Lehrman Group and Global Guidepoint Advisors, has received research or institutional support from Zimmer, and serves as a board member, owner, officer, or committee member of The Hip Society and the Orthopaedic Surgery and Trauma Society. Dr. Watters or an immediate family member has received royalties from Stryker and serves as a board member, owner, officer, or committee member of the American Board of Spine Surgery and the North American Spine Society. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Jevsevar and Dr. Cummins.
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Journal of the American Academy of Orthopaedic Surgeons
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
