Antibiotic Prophylaxis for Bacteremia in Dentistry (Joints)

Dentist and orthodontist family

Antibiotic Prophylaxis for Bacteremia in Dentistry

2016 AAOS now agrees with ADA to not pre-med except rare medical issues.  They even made a pretty easy to use online questionnaire. 

2015 ADA update Now ADA says no to pre-med

JADA 2015 Update

AAOS I don’t think agrees 2015

Personally I agree with ADA on this as bacteria enters the blood from flossing, brushing, eating so why are people required to take it with dental care it they are daily having the same thing happen?  I tell patients I’m not writing the scripts anymore and if they want the pre-med or their doctor does then have them write the script.

 

Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements

Current recommendation 2012, which seems to change rather often, can be found here.

The jist of it is that for any dental visit where we expect blood and you have had a joint replacement surgery you are required to premeditate with antibiotics for the rest of your life.  It was 2 years post surgery not long ago but has gone back to life.

This is not a consensus statement.  Both the American Dental Association and the American Heart Association disagree with the conclusion the AAOS has drawn form the existing data.  However, at this time I am recommending all my patients follow the AAOS recommendation.

Here is a counter argument.  I have a copy of this in my dental gen info folder

                                                 

Synthetic joints and antibiotic use in the dental setting

So the new joint AAOS-ADA recommendations are out for whether or not someone should pre-medicate prior to dental visits.  To sum up the results, the research to date is unclear as to whether or not there is any benefit to pre-medicating prior to a dental visit.  The recommendations are vague, inconclusive, and of limited strength.  Linked here is the full recommendations and here they are listed.
Based on the following numbers and findings from different studies it appears to me that the main reason to pre-medicate is to cover the dentists liability issues.
“Procedures included tooth extraction (10% to 100%), periodontal surgeries (35% to 88%), scaling and root planing (80% to 98%), teeth cleaning (up to 40%), and endodontic procedures (up to 20%). Transient bacteremia also happens during routine daily activities, including tooth brushing and flossing (20% to 68%), use of wooden toothpicks (20% to 40%), water irrigation (7% to 50%), and chewing food (7% to 51%).10-19 Therefore, occurrence of bacteremia following daily activities is far more frequent than bacteremia following dental visits twice per year.” Source
“The ability of antibiotic therapy to prevent or reduce the frequency, magnitude, or duration of bacteremia associated with a dental procedure is controversial.“7
“Van der Meer and colleagues reported that dental or other procedures probably caused only a small fraction of cases of IE and that prophylaxis would prevent only a small number of cases, even if it were 100%.”
“Roberts et al estimated that tooth brushing twice daily for 1 year had a 154,000 times greater risk of exposure to bacteremia than that resulting from a single tooth extraction.”27,28

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 anti-microbials in patients with prosthetic joint implants or other orthopedic 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.
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 orthopedic implants maintain appropriate oral hygiene.
Grade of Recommendation:Consensus