Could the bacteria released during certain dental procedures result in a periprosthetic joint infection? That question has long plagued patients, their dentists, and their orthopaedists. No one wants to risk an infection, but the medical and monetary impact of the unnecessary use of antibiotics are well-known.

The issue seemed to be settled when, in 2012, the AAOS and the American Dental Association (ADA) published a collaborative clinical practice guideline (CPG) on the “Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.” That guideline, developed with input from 10 other medical associations (including infectious disease, epidemiology, and pathology as well as dental and orthopaedic specialty societies), recommended that “the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics.” It was not a strong recommendation, but the work group found that the evidence did not support a definitive statement on whether patients who had orthopaedic implants should receive antibiotic prophylaxis prior to certain dental procedures.

The issuance of a joint guideline was a stunning show of unity and collaboration. “Unfortunately, the halo effect of this unified position was limited,” notes David S. Jevsevar, MD, MBA, chair of the AAOS Evidence-based Quality and Value Committee (EBQVC). Just last month, the Journal of the ADA (JADA) published a report from the ADA Council on Scientific Affairs, “The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints,” which again reveals disagreement between the orthopaedic and dental communities.

The single clinical recommendation in the report reads: “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” Even in patients who have a history of complications associated with their joint replacement surgery, the guideline does not recommend prophylactic antibiotics, but notes that they “should only be considered after consultation with the patient and orthopaedic surgeon.”

“This recommendation to not use prophylactic antibiotics is at odds with the previous collaborative recommendation, which takes a more tempered approach,” said Dr. Jevsevar.

“This is most unfortunate for patients,” said Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research and Quality. “They will be caught in the middle and have to deal with conflicting opinions.”

What does the evidence say?
Although an association between dental procedures and prosthetic joint infections (PJI) has not been proven, “no evidence supports a definitive recommendation that patients with prosthetic implants should NOT receive prophylactic antibiotics prior to undergoing dental procedures,” noted Paul F. Lachiewicz, MD, president of the Hip Society.

“Our primary concern with the ADA’s work is that it is not supported by evidence and should be labeled as a consensus statement,” agreed Dr. Jevsevar. Although the ADA used the literature supporting the collaborative guideline as a foundation, it also included lower-quality research to develop the stronger recommendation. “This is not an ‘updated’ CPG,” he noted, “because it uses different inclusion criteria from the 2012 AAOS-ADA CPG.”

Dr. Jevsevar points out that two retrospective studies cited in the ADA recommendation were specifically excluded by the 2012 multi-disciplinary team. A third study, published after the 2012 literature search was completed, was also included. Dr. Jevsevar notes that the retrospective nature of that study meant it also would have been excluded in a collaborative update.

“No additional higher quality evidence has been published since the 2012 AAOS-ADA CPG,” said Dr. Jevsevar, “so no change to the strength or level of recommendation is indicated.”

What’s next?
Because no new studies have been published on this topic since the 2012 guideline was released, the AAOS does not believe that a new guideline with different recommendations is needed. Instead, efforts should be made to educate patients on the risks and benefits of antibiotic prophylaxis and to incorporate patients’ preferences and values into treatment decisions. The AAOS has developed a simple, shared decision-making tool to accomplish that goal (Fig. 1).

“The 2012 AAOS-ADA CPG suggests a metered approach to recommending antibiotic prophylaxis for patients with hip or knee arthroplasty undergoing dental work,” said Thomas K. Fehring, MD, Knee Society president. “It recommends clinician assessment of individual patient risk factors as well as a shared decision-making approach to determining appropriate care.

Although disappointed with the ADA’s unilateral approach and use of a non-inclusive, non–evidence-based methodology, the AAOS remains committed to working collaboratively to improve care delivery and education to patients. “The AAOS has a rich history of collaboration with a number of non-orthopaedic societies as well as affiliate provider groups,” noted AAOS President Frederick M. Azar, MD. “When involved in these collaborative efforts, we take at face-value a level of trust in supporting their outcomes—even when the results of evidence-based efforts disagree with our routine patterns of care.”

Although individuals who are unhappy with the outcomes of a CPG may lobby for changes based on studies that do not meet the strict inclusion criteria of evidence-based medicine, the AAOS believes that professional societies should stand firm in their commitment to evidence-based methodologies. Political expediency should not be allowed to undermine the results of evidence-based methodology and outcomes.

“This is the type of situation that appropriate use criteria (AUC) are meant to address,” Dr. Jevsevar said, “and the AAOS has proposed a collaborative effort on this topic, which was well-received by the ADA.” At its meeting last fall, the EBQVC approved the topic and has contacted the ADA about nominating members for the writing panel.

“The practice of evidence-based medicine is based on three pillars: the patient’s preferences and values, the clinician (and his or her experience), and the evidence,” said Brian S. Parsley, MD, president of the American Association of Hip and Knee Surgeons. “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.”

Links to the 2012 AAOS-ADA CPG and the shared decision-making tool can be found here:

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

Guideline Shared Decision Making Tool (pdf)

Mary Ann Porucznik is managing editor, AAOS Now; she can be reached at porucznik@aaos.org