Routinely giving patients with joint replacements antibiotics before undergoing dental procedures to prevent possible infection has long been the standard of care. But now, two major medical organizations are suggesting a possible step back from that common practice – for healthy patients. The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) have issued a joint clinical practice guideline that finds insufficient evidence to recommend such routine antibiotic use.
“The theory is, bacteria come through the bloodstream [from the dental work],” says David Jevsevar, MD, chair of the AAOS Evidence Based Practice Committee and an orthopaedic surgeon in St. George, Utah. “Does it increase the risk of infection in joint replacements? The honest answer is, we don’t know. We know that dental work puts bacteria in the bloodstream. What we don’t know is how often bacteria gets into the joints.”
The guideline notes that around a million hip and knee joint replacements were performed in the United States in 2010, and the mean rate of joint infection after the surgery was 2 percent. The clinical research that backs up the guideline finds invasive dental procedures, with or without antibiotics, did not increase the risk of infection in a prosthetic joint.
The guideline – which notes that “no direct evidence” exists that oral or topical antibiotics confer any protection against infection in a replaced joint – therefore recommends oral care professionals reconsider routine use of antibiotics before dental procedures.
But experts say that some joint replacement patients – those with inflammatory joint diseases such as rheumatoid arthritis (RA) and lupus, those on immunosuppressive drugs such as corticosteroids and disease-modifying antirheumatic drugs (DMARDs), and those who’ve had more than one joint replacement – should still get prophylactic antibiotics.
Dr. Jevsevar says the original recommendation to use antibiotics in those who had undergone replacement arthroplasty, or surgery, was basically an extension of what had become traditional practice for patients with heart valve replacements. In both cases, mechanical devices replace natural body structures – and that means they are more vulnerable to bacterial attack. (Although in some heart valve procedures, natural tissues may be used.)
“The joint replacement itself has no means of fighting infection,” Dr. Jevsevar says. He likens the situation to bacteria arriving at a vacation spot, with no white blood cells to spoil the good time.
But what may be the key difference between a mechanical heart valve and an artificial joint is that the former, because of its location, is constantly exposed to whatever bacteria may enter the bloodstream from dental work.
Pre-emptive use of antibiotics may seem like a small step to prevent a bigger problem down the road, but Dr. Jevsevar says there are several good reasons to avoid what may be unnecessary antibiotic use. “The first is an increase in bacterial resistance, which is a huge issue. Second, there are risks associated with taking antibiotics,” he says, noting those risks include common side effects like diarrhea, severe allergic reactions and potentially serious gastrointestinal complications. The third reason is cost.
So, should joint replacement patients now stop being prescribed antibiotics before dental procedures?
Well – not so fast. “What I would suggest is risk-stratifying,” Dr. Jevsevar says. That is, considering antibiotics only for those truly at increased risk of infection.
Other experts agree. “I think the dentist should be up front with the patients about the lack of scientific evidence to support antibiotic prophylaxis for joint prostheses, so patients can make sound decisions for themselves,” says Kanchan Ganda, MD, professor and head of the Division of Medicine, Department of Public Health and Community Services at the Tufts University School of Dental Medicine, Boston. But she says if the patient also has other health problems, “the dentist should confidently indicate the need to support and proceed with [antibiotics].”
Dr. Ganda says she would support continued use of antibiotics before dental work in joint replacement patients with:
– Significant periodontal disease and/or presence of odontogenic (teeth) abscess
– Autoimmune inflammatory joint diseases such as RA or systemic lupus erythematosus (SLE)
– A past history of joint replacement infection
– Multiple joint replacements
– A recent (within 6 months) joint replacement
– Insulin-dependent diabetes and/or uncontrolled diabetes
– Immune deficiencies
– Bleeding disorders, such as Hemophilia A/B or von Willebrand Disease
– A peripheral infection, such as a chronic, open-sore lesion.
Dr. Ganda says there are steps an otherwise healthy patient can take to minimize the risk of infection, aside from taking antibiotics. “The patient should maintain daily optimal flossing, brushing, mouthwash use, along with regular hygiene visits. The dentists should have the patient use a mouth rinse prior to every appointment, to de-germ the oral cavity and aggressively treat any source of oral infection immediately,” she says.
Article from: Arthritis Today