New CDA Position Statement on Dental Patients with Total Joint Replacement
In June 2013, CDA adopted a new position statement on dental patients with total joint replacement. The Committee on Clinical and Scientific Affairs (CCSA) reviewed clinical evidence, including a thorough systematic review of the literature conducted by the American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) which was conducted in 2011.
The issue of whether patients with orthopedic implants, primarily total hip and knee replacements, are prone to implant infection from routine dental procedures via hematogenous seeding of the implant from dental-procedure-related bacteremia has been a controversial topic for dentists, physicians and patients alike.
In 2003, the American Dental Association (ADA) worked with the American Academy of Orthopaedic Surgeons (AAOS) to issue a joint statement concerning antibiotic prophylaxis for dental patients with total joint replacements which was endorsed by CDA.
Unfortunately, in 2009 the AAOS forced the withdrawal of the joint statement when it issued an Information Statement (revised in 2010) independently of the ADA. After reviewing the AAOS statement, CDA concluded that adhering to its recommendations would result in an over prescription of antibiotics. Therefore, CDA maintained its support for the approach recommended in the withdrawn 2003 statement.
In 2012, the ADA and the AAOS released a co-developed evidence-based guideline on the Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. The clinical practice guideline, with three recommendations, is based on a systematic review of the literature. (The complete review is available at www.aaos.org/guidelines). The systematic review found no direct evidence that dental procedures cause orthopedic implant infections. This finding is consistent with the advice of a Working Party of the British Society for Antimicrobial Chemotherapy that patients with prosthetic joint implants (including total hip replacements) do not require antibiotic prophylaxis for dental treatment.
Based on the current best available evidence, CDA guidance concerning the management of dental patients with orthopedic implants is:
- Patients should not be exposed to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit.
- Routine antibiotic prophylaxis is not indicated for dental patients with total joint replacements, nor for patients with orthopedic pins, plates and screws.
- Patients should be in optimal oral health prior to having total joint replacement and should maintain good oral hygiene and oral health following surgery. Orofacial infections in all patients, including those with total joint prostheses, should be treated to eliminate the source of infection and prevent its spread.
This information should not be used as a replacement for professional dental or medical advice. If you have questions about this position statement, please consult your dentist or contact the Canadian Dental Association.