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New CDA Position Statement on Dental Patients with Total Joint Replacement

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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.

Preamble

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.

Background

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 Therefore, CDA maintained its support for the approach recommended in the withdrawn 2003 statement.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.

Position Statement

Based on the current best available evidence, CDA guidance concerning the management of dental patients with orthopedic implants is:

  1. Patients should not be exposed to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit.
  2. Routine antibiotic prophylaxis is not indicated for dental patients with total joint replacements, nor for patients with orthopedic pins, plates and screws.
  3. 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.

 

2 Comments

  1. Dr Nafisa Ahmad October 24, 2013

    This makes a lot of sense to me, but I still have orthopedic surgeons advising my patients to continue taking antibiotic prophylaxis prior to dental appts. This is not based on science. I would like to know what it will take to change and educate our physician colleagues. Antibiotic overprescribing has led to rampant drug resistance which is only going to worsen with time if all health providers are not on board. I am wondering if the WHO or Health Canada has released any statements on this issue?

    Reply
  2. ADRIAN. LUCKHURST October 26, 2013

    I agree that antibiotics should not be used in joint replacements according to the science.However, when I see recent Dental graduates prescribing 4th generation antibiotics for a routine dental infection rather than local treatment and maybe just plain old Penicillin if the infection is spreading .According to these new graduates this is the information given to them by their instructors.Is this the result of “Better be safe than sorry!” and the fear of litigation -which only compounds our problems for the future of antibiotic resistance .I have been practicing for 40years and very rarely require expensive new drugs ,even after difficult extensive surgical procedures.
    Yes we do need cooperation from our Medical colleagues but we must get our ship in order first!

    Reply

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