Fig. 1 Appropriate Use Criteria Decision Tree

AAOS Now

Published 3/1/2020
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Kyle Mullen, MPH; Ryan Pezold, MA

First Appropriate Use Criteria Decision Tree Highlights Appropriate Prescription of Dental Prophylaxis in Orthopaedic Patients

The use of antibiotic prophylaxis for dental procedures in patients with joint replacements has long been debated among orthopaedic surgeons and dental professionals. Appropriate use criteria (AUC) developed jointly by AAOS and the American Dental Association (ADA) and published in 2016 have helped bring direction to an area lacking high-quality literature to support clinical decision-making. Although this particular AUC consistently receives the most website visits of any AUC that AAOS has produced, queries persist regarding appropriate antibiotic prophylactic care for patients with joint replacements who are undergoing dental procedures. To increase utilization and ease of use, including an interactive web-based tool, the content from the AUC has been converted to an at-a-glance decision tree highlighting the key takeaways for printable access and ease of reference (Fig. 1).

The clear trends identified by the expert voting panel, in addition to the simplicity of a single treatment option (prophylactic antibiotics), allowed for this unique conversion of the high-impact AUC into a decision tree format. For example, regardless of any other described patient factor, the panel rated it “rarely appropriate” to prescribe prophylactic antibiotics when orthopaedic implant patients are undergoing noninvasive dental procedures (no manipulation of gingival or periapical tissues or perforation of the oral mucosa). In addition, even with invasive dental procedures such as extractions, gum surgery (gingivectomy/periodontal surgery), or dental implants, unless the patient is immunocompromised or has had a prior joint infection, antibiotic prophylaxis was rated by the panel as only maybe or rarely appropriate.

In contrast, the panel most frequently determined dental prophylaxis to be “appropriate” when patients were severely immunocompromised and had uncontrolled diabetes (defined as hemoglobin A1C ≥ 8 or blood glucose ≥ 200 mg/dL) and/or a recent operation with history of prosthetic joint infection. The decision tree format affords users a quick review of the most impactful trends for dental prophylaxis with limited exceptions for complex orthopaedic patients.

The content of the AUC was jointly developed and approved by AAOS and the ADA Council on Scientific Affairs under the standard AAOS AUC methodology. A writing panel of orthopaedic surgeons and dental professionals was assembled to draft the patient indications and clinical assumptions that practitioners should consider when using the AUC tool. A second panel of similar specialty-diverse, financially unconflicted representatives then voted on the appropriateness of prescribing dental prophylaxis for each patient scenario comprised of the varying combinations of clinical indications as described by the writing panel. Following a Delphi process, the voting panel later held an in-person meeting to review the anonymous votes, discuss areas of disagreement, and cast their secondary round of voting. Scenarios of true disagreement defaulted to a “may be appropriate” rating, but that occurred in only about 3 percent of all unique patient scenarios.

AUCs cannot provide the level of evidence used in the development of clinical guidelines. However, the best available evidence, supplemented by expert opinion, was systematically compiled to specify and rate appropriate treatment for common clinical circumstances. The criteria do not encompass all unique cases, but they should be used to complement clinical decision-making between clinician and patient. Clinical decisions should be made by the orthopaedic surgeons, clinicians, and/or dental professionals involved in referral or prescription of antibiotic prophylaxis for orthopaedic implant patients undergoing dental procedures.

The AUC and accompanying visual aid are located on the AAOS website at www.aaos.org/dentalprocedures, where a free PDF can be printed or saved for easy access and sharing in clinical practice. Access the interactive AUC tool and all published quality products through the OrthoGuidelines app on Apple or Android or at www.OrthoGuidelines.org.
See the full AUC methodology at www.aaos.org/methodology.

Kyle Mullen, MPH, and Ryan Pezold, MA, are managers of AAOS Clinical Quality and Value.

Important findings

Important findings from this criteria related to orthopaedic care are:

  1. Routine antibiotic prophylaxis is rarely indicated in orthopaedic implant patients undergoing invasive or noninvasive dental procedures unless they are immunocompromised or have a history of prior joint infection.
  2. Routine dental prophylaxis is rarely indicated for any orthopaedic implant patient undergoing noninvasive routine dental cleaning.