The Use of Antibiotics on Dental Patients with Prosthetic Joint Replacement

Dr. Leslie Fang weighs in on a recent cohort study highlighting the use of antibiotics on dental patients with prosthetic joint implants.

By Genni Burkhart

For decades, dentists in the U.S. have been under pressure from orthopedic surgeons to provide antibiotic prophylaxis to patients with prosthetic joints prior to invasive dental procedures (IDP) in effort to reduce the possibility of late prosthetic joint infection (LPJI). However, given the lack of evidence linking the two procedures together, the risk of adverse reactions, and the potential to further antibiotic resistance – a team of researchers in London looked back at dental records to perform a cohort study1 on associations between IDP and LPJI in patients who didn’t receive antibiotic prophylaxis prior to their IDP.

Dr. Leslie Fang, MD PhD and DOCS Education’s Medical Director, weighs in on this study and further examines the use of antibiotic prophylaxis in dental patients with prosthetic joints.

Research Methods

This cohort study used hospital admission data in England to identify all patients admitted between December 25, 2011 and March 31, 2017 that had a code in their medical records for infection and inflammatory reaction due to internal joint prosthesis.

From this list researchers were able to further narrow down the clinical, diagnostic, and procedural data for the period of January 1, 2000 through March 31, 2017 of patients coded as having any admission for prosthetic joint infection. This allowed them to further identify the time between joint replacement and PJI, and the type of joint replaced.

Comparing this with dental records in England, researchers were then able to create a final data set that linked medical data and dental records for each patient meeting the above criteria.

Were the Results Predetermined?

Leslie Shu-Tung Fang MD PhD , a John R. Gallagher III and Katherine A. Gallagher Endowed Chair in Clinical Excellence at Massachusetts General Hospital and Harvard Medical School as well as DOCS Education’s Medical Director, provides further insight on this study as he’s authored papers on premedication for prosthetic joints, including, “2015 ADA Council on Scientific Affairs Recommendations on Prosthetic Joint Infections.”

Dr. Fang states, “This cohort study has problems with the method, as the researchers had a preconceived notion that they wouldn't find anything, therefore they didn't.”

Dr. Fang goes on to explain that in order to find patients with previous joint infections researchers needed a rather large database to backtrack for any correlations. This made the evaluation subjective, and it was no surprise they came to a “premediated determination.”

This study found no significant temporal association between IDP and subsequent LPJI, and a lower incidence of IDP in the 3 months prior to LPJI (incidence rate ratio, 0.89; 95% CI, 0.82-0.96; P = .002).

“If you are just going to take people that have prosthetic joints in this study, you must also ask how they got infected, and exclude those with infection prior to surgery,” adds Dr. Fang.

Dr. Leslie Fang Weighs In

Regardless of the methods of this study, Dr. Fang does believe, that given the literature on this topic, “It’s difficult to find late prosthetic infection related to a dental procedure with organisms that come from dental floral in an acceptable timeframe.”

Dr. Fang makes the following recommendations with grades, as noted in his paper, “2015 ADA Council on Scientific Affairs Recommendations on Prosthetic Joint Infections.”

RECOMMENDATION 1:  Practitioner might consider changing the longstanding practice of prescribing prophylactic antibiotics for patients who undergo dental procedures.

  • This recommendation is founded on evidence that dental procedures are unrelated to prosthetic joint infection. Antibiotic prophylaxis does not reduce the risk of prosthetic joint infection.

GRADE:  Limited

  • Practitioners should be cautious in deciding whether or not to follow recommendations classified as limited.
  • Practitioners should exercise their judgment and be aware of emerging publications that report evidence.
  • Patient preference should have a substantial influencing role.

“Unfortunately, the Limited Grade of Recommendation leaves it as a free-for-all when it comes to the practical issues of pre-medication.  With the limited grade, the patient,  orthopedic surgeon, primary care physician and dental professional all can decide that the patient’s pre-medication needs. In practice, many orthopedic surgeons continue to insist on pre-medicating all joints forever, despite the total lack of evidence that there is any association between dental source of bacteremia and prosthetic joint infection.” (…Dr. Leslie Fang, “2015 ADA Council on Scientific Affairs Recommendations on Prosthetic Joint Infections.”)

American Dental Association Recommendations

According to the American Dental Association (ADA):

  • When compared with previous recommendations, there’s few patient subpopulations in which antibiotic prophylaxis might currently be indicated prior to specific dental procedures.
  • In patients with prosthetic joint implants, a January 2015 ADA clinical practice guideline, states, “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”
  • According to the ADA Chairside Guide, patients with a history of complications arising from joint replacement surgery who are undergoing dental procedures that include “gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and orthopedic surgeon; in cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.”

In Conclusion

While this particular study does support the theory that dental procedures are not associated with prosthetic joint implant infections, their methods were subjective. However, dentists can use this as an opportunity to further explore the use of antibiotic prophylaxis in patients with joint replacements as their overuse continues to carry the risk of anaphylaxis, antibiotic resistance, and opportunistic infections.

The benefits of antibiotic prophylaxis may not always exceed the harms for certain patients, as individual circumstances and preferences should be considered when deciding whether or not to prescribe antibiotics prior to invasive dental procedures.

  1. Reference: Thornhill MH, Crum A, Rex S, et al. Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England. JAMA Netw Open. 2022;5(1):e2142987. doi:10.1001/jamanetworkopen.2021.42987

 

Author: With over 12 years as a published journalist, editor, and writer Genni Burkhart’s career has spanned politics, healthcare, law, business finance, technology, and news. She resides on the western shores of the idyllic Puget Sound where she works as the Editor in Chief for the Incisor at DOCS Education out of Seattle, WA.

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