Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) have just published their evidence-based guideline and evidence report on prevention of orthopaedic implant infection in patients undergoing dental procedures. The summary of the report concludes,

“(1) 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

Definition: A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.
Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single Moderate quality study recommending for or against the intervention or diagnostic.
Implications: Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

(2) We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.

Grade of Recommendation: Inconclusive

Definition: An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm.
Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention.
Implications: Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.

(3) In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.

Grade of Recommendation: Consensus

Definition: A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.
The supporting evidence is lacking and requires the work group to make a recommendation based on expert opinion by considering the known potential harm and benefits associated with the treatment.
Implications: Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.”

See the full report here. A related editorial by David S. Jevsevar and Elliot Abt, which explains how recommendations have now been based on current evidence, can be found here. As to these authors, in particular the 2009 AAOS information statement,

“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 patients prior to any procedure that may cause bacteremia,”

can only be regarded an “educational tool based on the opinion of the authors” and not an official guideline. As Jevsenar and Abt write, the current clinical practice guideline “meets or exceeds all recommended Institute of Medicine standards for the development of systematic reviews and clinical practice guidelines except for allowing patient input in the selection of topics and questions.”

27 December 2012 @ 4:40 pm.

Last modified December 27, 2012.

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