DENTAL PROPHYLAXIS AFTER TOTAL JOINT ARTHROPLASTY?
Total joint replacement is considered one of the most effective and lifestyle-changing surgical procedures. In contrast, periprosthetic joint infection (PJI) can be a costly and debilitating complication.
Long have surgeons, dentists, and patients worried about the risk of seeding a prosthetic joint with oral bacteria during dental procedures. Traditionally, prophylactic antibiotics have been administered just prior to these procedures with the hope of reducing infection rates. However, this practice was rooted in theory and not well-conducted studies.
HISTORY OF DENTAL PROPHYLAXIS
Numerous studies have demonstrated bacteremia immediately following gingival agitation including invasive dental procedures, professional cleanings, and even tooth brushing. Similar trials also showed a significant decrease in serum bacterial load when oral antibiotics were administered just prior to the dental procedure. Based upon this information and the substantial impact of PJI, surgeons and dentists alike began recommending for prophylactic measures.
2012 CLINICAL PRACTICE GUIDELINES (CPG)
In 2012, the American Academy of Orthopedic Surgeons (AAOS), American Dental Association (ADA), and 10 additional medical associations convened to establish a unifying set of guidelines for administering prophylactic antibiotics. After a thorough review of available literature along with strict inclusion criteria, the group agreed that there was a lack of robust evidence for or against antibiotic prophylaxis prior to dental procedures. As such, they recommended that practitioners reconsider their stance on the routine use of prophylaxis and rely instead on clinical judgment.
2015 JOURNAL OF THE AMERICAN DENTAL ASSOCIATION (JADA) REPORT
In January of 2015, JADA published controversial guidelines recommending against prophylactic measures. Unlike the 2012 CPG, no other medical associations provided input. Additionally, the ADA used less-stringent criteria for excluding low-quality studies. Two studies on which the JADA based its report were omitted by the 2012 CPG work group due to their retrospective nature. A recent additional study cited by the JADA was also retrospective and would likely have been excluded from a collaborative update. Furthermore, many practitioners felt that the wording of the JADA guidelines offered less flexibility for clinical judgment-based exceptions.
RECOMMENDATIONS
If the patient elects to take prophylactic antibiotics, below is a suggested algorithm:
- Patients not allergic to penicillin or cephalosporins: Cephalexin or Amoxicillin 2 grams orally, 1 hour prior to procedure (usually four 500mg tablets are dispensed)
- Patients not allergic to penicillin or cephalosporins and unable to take oral medication: Cefazolin 1 gram or Amoxicillin 2 grams IM or IV, 1 hour prior to procedure
- Patients allergic to penicillin or cephalosporins: Clindamycin 600mg orally, 1 hour prior to procedure (usually two 300mg tablets are dispensed)
- Patients allergic to penicillin or cephalosporins and unable to take oral medication: Clindamycin 600mg IM or IV, 1 hour prior to procedure
AAOS has created a shared decision-making tool which is available online along with a brief patient-oriented article: http://www.aaos.org/research/guidelines/PUDP/DentalSDMTool.pdf
If additional questions or concerns arise, the patient, dentist, or general practitioner should always feel free to contact the treating orthopedist for additional input and collaboration.