COMMENTARIES
LETTERS
J
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that appeared in April JADA usually will be considered for acceptance only until the end of June. You may submit your letter via e-mail to [email protected]; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, Ill. 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
PROPHYLACTIC ANTIBIOTICS
The January 2015 issue of The Journal of the American Dental Association published a cover story and guest editorial on the use of prophylactic antibiotics in patients with prosthetic joints before they undergo dental procedures. The main article was the work of an expert panel convened last year by the American Dental Association (ADA) Council on Scientific Affairs to develop an evidence-based clinical practice guideline (CPG) on “The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients With Prosthetic Joints” (Sollecito TP, Abt E, Lockhart PB. 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. JADA. 2015;146 [1]:11-16). The CPG also was intended to clarify guidelines developed and published in 2012 by the American Academy of Orthopaedic Surgeons and the ADA. The guest editorial that accompanied the main article in the January issue of JADA, “Providing Clarity on Evidence-based Prophylactic Guidelines for Prosthetic Joint Infections,” was authored by Dr. Daniel M. Meyer,
the ADA’s chief science officer, to further clarify the guidelines for the benefit of dentists in clinical practice (JADA. 2015;146[1]:3-5). As of mid-March, these reports resulted in 6 letters to the editor from readers, each letter offering specific questions and observations about the guidelines and their application in dental care. Below are summaries of the 6 letters, followed by a response from the panel of scientists that drafted the guidelines. Dr. Steve McCormack of St. Croix Falls, WI, reports that orthopedic surgeons in his area insist on premedicating patients with prosthetic joints before dental treatment. Dr. McCormack poses 3 related questions: - If the patient’s health is paramount, do I go against their surgeon’s recommendations and state that they no longer need antibiotics? - If this recommendation is not the standard of care and additional case studies are needed to increase the level of certainty, where does that leave me? - What is my liability if I follow the recommendations contrary to the surgeon’s [recommendations] and a patient develops an infection? Dr. Bart Johnson, director of Swedish General Practice Residency in Seattle, WA, said he thought that
one issue not addressed in the guidelines was time. - Is there a certain period of time after hip or knee replacement when antibiotics for dental procedures would not only be reasonable, but perhaps warranted? - For example, a patient gets a hip replacement and within a month, he or she needs some emergent dental care. Does the evidence support not using antibiotics, given the relatively new hip or knee joint? Or if antibiotics are warranted, after what period of time are they considered no longer necessary? Dr. Ralph H. Saunders is a professor at the Eastman Institute for Oral Health, the University of Rochester, Rochester, NY. He notes in his letter that he works with the chronically ill and aging. “An issue we have encountered commonly in our geriatric population, which includes the most PJI [prosthetic joint infection] patients, is naming and locating the orthopedic surgeon,” he writes. - The question is, if the orthopedic surgeon cannot be found, is consultation with a patient’s primary care provider or attending physician regarding the use of antibiotics suggested? In a letter they cosigned, Dr. Peter L. Jacobsen of the University of the Pacific, San Francisco, CA, and Dr. Michael A. Siegel of Nova Southeastern University, Ft. Lauderdale, FL, offer a number of observations and questions related to the guidelines. - The panel’s review of the literature concludes that there is no association between dental procedures and PJIs and no scientifically based efficacy for using antibiotics to prevent PJIs. But the panel also says there may be special circumstances that would make the use of prophylactic antibiotics prudent, though the guidelines do not list those circumstances. - The practice guidelines suggest that to assess a patient’s medical status, a complete health history is recommended when deciding on the
JADA 146(6) http://jada.ada.org
June 2015 357
COMMENTARIES
need for antibiotic prophylaxis. But what information is being sought in that medical history, other than a history of drainage or infection or both after arthroplasty? - Should practitioners continue to use the guidelines released in 2003 and 2009 with recommendations that specified comorbid conditions? - If the clinician decides to provide antibiotic premedication, what is the appropriate antibiotic regimen? No recommendations were included in the guidelines. - Dentists are encouraged to consult an orthopedic surgeon on an appropriate antibiotic regimen. If the dentist and patient lack access to an orthopedic surgeon, they may have to determine the antibiotic regimen on their own. Are there suggestions to help in making those decisions? - The American Heart Association (AHA) guidelines are appropriate for controlling organisms likely to result in a bacteremia of oral flora. But are those the same organisms most likely to cause a PJI, relative to an orally induced bacteremia? Should the antibiotic regimen be directed toward organisms most likely to cause a PJI or toward the organisms most likely to cause a bacteremia of oral flora? - Another question relates to the timing of the prophylactic antibiotic administration. The AHA recommends that antibiotics be administered 30 to 60 minutes before the dental procedure. But bacterial endocarditis and PJI are 2 different infections. Earlier guidelines (2003 and 2009) noted that antibiotic premedication 60 minutes before a dental procedure was likely to result in bacteremia. Dr. Arthur H. Friedlander of the VA Greater Los Angeles Healthcare System, Los Angeles, CA, noted that the guidelines call for the dentist to collect a complete medical history for the patient, including complications associated with joint replacement surgery. - “The article specifically denotes wound drainage and hematoma,” he
358 JADA 146(6) http://jada.ada.org
notes, “but these would not be captured by my medical history nor by those of other dentists.” He says obtaining such information would likely require consultation with the patent’s orthopedic surgeon. - Dr. Friedlander also noted that Dr. Meyer, in his guest editorial, explains that a patient’s previous medical conditions may call for premedication, but that Dr. Meyer does not identify those conditions. - Last, Dr. Friedlander found it “denigrating to the dental profession” to call for the orthopedic surgeon to recommend the antibiotic regimen—and even to write the prescription when possible—rather than the dentist. Dr. Dean M. DeLuke of the Virginia Commonwealth University School of Dentistry and Virginia Commonwealth University Medical Center in Richmond, VA, expressed concern that the 2014 clinical guidelines apparently were developed without input from the American Academy of Orthopaedic Surgeons. - The [2014] panel had some input from infection disease specialists, but only one orthopedic surgeon was involved, he noted. In contrast, the 2012 panel included input from multiple orthopedic and dental groups and other disciplines. - He quoted an American Academy of Orthopaedic Surgeons official who declared the new guidelines to be “at odds with the previous collaborative recommendation” because it uses “different inclusion criteria” from the 2012 guidelines. Dr. DeLuke goes on to ask: - Where does this leave the dental practitioner and the patient with total joint prosthesis? - What are the medicolegal ramifications if a dental practitioner does not consult an orthopedic surgeon and does not prescribe prophylactic antibiotics, and the patient develops a significant joint infection? http://dx.doi.org/10.1016/j.adaj.2015.04.019 Copyright ª 2015 American Dental Association. All rights reserved.
June 2015
Authors’ response: We welcome the opportunity to respond to several letters to the editor regarding the American Dental Association’s (ADA) clinical practice guideline on the use of prophylactic antibiotics before dental procedures in patients with prosthetic joints.1 Because the comments concerned several themes, our answers are grouped accordingly. The theme of the first set of comments concerned the guideline methodology. To best address these questions, a review of the history of statements regarding the use of antibiotic prophylaxis for dental patients with total joint replacement is fitting. Until 2012, the clinical advice that was developed collaboratively between the ADA and the American Academy of Orthopaedic Surgeons (AAOS) (in 19972 and 20033), as well as the “Information Statement” published independently by the AAOS in 2009,4 were not produced using current evidence-based, systematic review methodologies. These clinical advice publications could be considered advisory or consensus statements, which are based on reviews of the published scientific literature and expert opinion. The clinical practice guideline5-7 developed through the collaboration of the ADA and AAOS and published in various forms in 2012 and 2013 was the first attempt at developing an evidence-based clinical practice guideline using a current evidencebased methodology. Because the AAOS evidence-based process requires standardized wording and restrictions on the type of studies to be included, the final main recommendation statement was: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures (Grade of Recommendation: Limited).” This statement was not easily interpretable and elicited many
LETTERS
J
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that appeared in April JADA usually will be considered for acceptance only until the end of June. You may submit your letter via e-mail to [email protected]; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, Ill. 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
PROPHYLACTIC ANTIBIOTICS
The January 2015 issue of The Journal of the American Dental Association published a cover story and guest editorial on the use of prophylactic antibiotics in patients with prosthetic joints before they undergo dental procedures. The main article was the work of an expert panel convened last year by the American Dental Association (ADA) Council on Scientific Affairs to develop an evidence-based clinical practice guideline (CPG) on “The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients With Prosthetic Joints” (Sollecito TP, Abt E, Lockhart PB. 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. JADA. 2015;146 [1]:11-16). The CPG also was intended to clarify guidelines developed and published in 2012 by the American Academy of Orthopaedic Surgeons and the ADA. The guest editorial that accompanied the main article in the January issue of JADA, “Providing Clarity on Evidence-based Prophylactic Guidelines for Prosthetic Joint Infections,” was authored by Dr. Daniel M. Meyer,
the ADA’s chief science officer, to further clarify the guidelines for the benefit of dentists in clinical practice (JADA. 2015;146[1]:3-5). As of mid-March, these reports resulted in 6 letters to the editor from readers, each letter offering specific questions and observations about the guidelines and their application in dental care. Below are summaries of the 6 letters, followed by a response from the panel of scientists that drafted the guidelines. Dr. Steve McCormack of St. Croix Falls, WI, reports that orthopedic surgeons in his area insist on premedicating patients with prosthetic joints before dental treatment. Dr. McCormack poses 3 related questions: - If the patient’s health is paramount, do I go against their surgeon’s recommendations and state that they no longer need antibiotics? - If this recommendation is not the standard of care and additional case studies are needed to increase the level of certainty, where does that leave me? - What is my liability if I follow the recommendations contrary to the surgeon’s [recommendations] and a patient develops an infection? Dr. Bart Johnson, director of Swedish General Practice Residency in Seattle, WA, said he thought that
one issue not addressed in the guidelines was time. - Is there a certain period of time after hip or knee replacement when antibiotics for dental procedures would not only be reasonable, but perhaps warranted? - For example, a patient gets a hip replacement and within a month, he or she needs some emergent dental care. Does the evidence support not using antibiotics, given the relatively new hip or knee joint? Or if antibiotics are warranted, after what period of time are they considered no longer necessary? Dr. Ralph H. Saunders is a professor at the Eastman Institute for Oral Health, the University of Rochester, Rochester, NY. He notes in his letter that he works with the chronically ill and aging. “An issue we have encountered commonly in our geriatric population, which includes the most PJI [prosthetic joint infection] patients, is naming and locating the orthopedic surgeon,” he writes. - The question is, if the orthopedic surgeon cannot be found, is consultation with a patient’s primary care provider or attending physician regarding the use of antibiotics suggested? In a letter they cosigned, Dr. Peter L. Jacobsen of the University of the Pacific, San Francisco, CA, and Dr. Michael A. Siegel of Nova Southeastern University, Ft. Lauderdale, FL, offer a number of observations and questions related to the guidelines. - The panel’s review of the literature concludes that there is no association between dental procedures and PJIs and no scientifically based efficacy for using antibiotics to prevent PJIs. But the panel also says there may be special circumstances that would make the use of prophylactic antibiotics prudent, though the guidelines do not list those circumstances. - The practice guidelines suggest that to assess a patient’s medical status, a complete health history is recommended when deciding on the
JADA 146(6) http://jada.ada.org
June 2015 357
COMMENTARIES
need for antibiotic prophylaxis. But what information is being sought in that medical history, other than a history of drainage or infection or both after arthroplasty? - Should practitioners continue to use the guidelines released in 2003 and 2009 with recommendations that specified comorbid conditions? - If the clinician decides to provide antibiotic premedication, what is the appropriate antibiotic regimen? No recommendations were included in the guidelines. - Dentists are encouraged to consult an orthopedic surgeon on an appropriate antibiotic regimen. If the dentist and patient lack access to an orthopedic surgeon, they may have to determine the antibiotic regimen on their own. Are there suggestions to help in making those decisions? - The American Heart Association (AHA) guidelines are appropriate for controlling organisms likely to result in a bacteremia of oral flora. But are those the same organisms most likely to cause a PJI, relative to an orally induced bacteremia? Should the antibiotic regimen be directed toward organisms most likely to cause a PJI or toward the organisms most likely to cause a bacteremia of oral flora? - Another question relates to the timing of the prophylactic antibiotic administration. The AHA recommends that antibiotics be administered 30 to 60 minutes before the dental procedure. But bacterial endocarditis and PJI are 2 different infections. Earlier guidelines (2003 and 2009) noted that antibiotic premedication 60 minutes before a dental procedure was likely to result in bacteremia. Dr. Arthur H. Friedlander of the VA Greater Los Angeles Healthcare System, Los Angeles, CA, noted that the guidelines call for the dentist to collect a complete medical history for the patient, including complications associated with joint replacement surgery. - “The article specifically denotes wound drainage and hematoma,” he
358 JADA 146(6) http://jada.ada.org
notes, “but these would not be captured by my medical history nor by those of other dentists.” He says obtaining such information would likely require consultation with the patent’s orthopedic surgeon. - Dr. Friedlander also noted that Dr. Meyer, in his guest editorial, explains that a patient’s previous medical conditions may call for premedication, but that Dr. Meyer does not identify those conditions. - Last, Dr. Friedlander found it “denigrating to the dental profession” to call for the orthopedic surgeon to recommend the antibiotic regimen—and even to write the prescription when possible—rather than the dentist. Dr. Dean M. DeLuke of the Virginia Commonwealth University School of Dentistry and Virginia Commonwealth University Medical Center in Richmond, VA, expressed concern that the 2014 clinical guidelines apparently were developed without input from the American Academy of Orthopaedic Surgeons. - The [2014] panel had some input from infection disease specialists, but only one orthopedic surgeon was involved, he noted. In contrast, the 2012 panel included input from multiple orthopedic and dental groups and other disciplines. - He quoted an American Academy of Orthopaedic Surgeons official who declared the new guidelines to be “at odds with the previous collaborative recommendation” because it uses “different inclusion criteria” from the 2012 guidelines. Dr. DeLuke goes on to ask: - Where does this leave the dental practitioner and the patient with total joint prosthesis? - What are the medicolegal ramifications if a dental practitioner does not consult an orthopedic surgeon and does not prescribe prophylactic antibiotics, and the patient develops a significant joint infection? http://dx.doi.org/10.1016/j.adaj.2015.04.019 Copyright ª 2015 American Dental Association. All rights reserved.
June 2015
Authors’ response: We welcome the opportunity to respond to several letters to the editor regarding the American Dental Association’s (ADA) clinical practice guideline on the use of prophylactic antibiotics before dental procedures in patients with prosthetic joints.1 Because the comments concerned several themes, our answers are grouped accordingly. The theme of the first set of comments concerned the guideline methodology. To best address these questions, a review of the history of statements regarding the use of antibiotic prophylaxis for dental patients with total joint replacement is fitting. Until 2012, the clinical advice that was developed collaboratively between the ADA and the American Academy of Orthopaedic Surgeons (AAOS) (in 19972 and 20033), as well as the “Information Statement” published independently by the AAOS in 2009,4 were not produced using current evidence-based, systematic review methodologies. These clinical advice publications could be considered advisory or consensus statements, which are based on reviews of the published scientific literature and expert opinion. The clinical practice guideline5-7 developed through the collaboration of the ADA and AAOS and published in various forms in 2012 and 2013 was the first attempt at developing an evidence-based clinical practice guideline using a current evidencebased methodology. Because the AAOS evidence-based process requires standardized wording and restrictions on the type of studies to be included, the final main recommendation statement was: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures (Grade of Recommendation: Limited).” This statement was not easily interpretable and elicited many
