Joint Replacement Prophylaxis, American Dental Association 2014
ADA 2014 Expert panel recommendations.#
Adapted from Sollecito TP et al.
The 2014 Panel made the following clinical recommendation:
“In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.”
Which joint(s) have been replaced?#
Total joint replacements that were of concern to dentistry were the major joints, such as the shoulder, elbow, hip, and knee.
Present guidelines DO NOT recommend antibiotic prophylaxis for patients with any type of joint replacement, pins, plates, or screws.
When was the last joint replaced?#
Previous guidelines (from 2003) recommended that antibiotic prophylaxis should be considered within the first 2 years after a total joint replacement, and beyond 2 years under [special circumstances][5] (see below). However, the ADA 2014 guidelines DO NOT RECOMMEND antibiotic prophylaxis prior to dental procedure.
Have you had any complications associated with the joint replacement?#
A history of prosthetic joint infections may still be a consideration for antibiotic prophylaxis before dental procedures.
Do you have any conditions (“special circumstances”) that would put you at a higher risk for hematogenous infections?#
Several comorbid diseases and conditions and special circumstances (see below) were thought to increase the risk for experiencing a hematogenous total joint infection. When these conditions were present, antibiotics was supposed to be considered. The ADA 2014 guidelines do not include any “special circumstances”. Professional judgement should prevail.
Patients at increased risk of developing hematogenous joint infection:#
- All patients during the first two years after joint replacement.
- Immunocompromised/immunosuppressed patients: Inflammatory arthropathies, such as rheumatoid arthritis and systemic lupus erythematosus.
- Patients with comorbidities: Previous prosthetic joint infections, malnourishment, hemophilia, HIV infection, insulin dependent (type 1) diabetes, malignancy.
Do you have any drug allergies?#
Drug allergies may affect the choice of antibiotic used for prophylaxis.
Previous (ADA 2003 Guidelines) antibiotic prophylaxis for dental patients with total joint replacement:#
| Situation | Agent | Adult Regimen |
|---|---|---|
| Standard general prophylaxis | Cephalexin, cephadrine, or amoxicillin | 2 g orally, 1 h before procedure |
| Unable to take oral medication | Cephazolin or ampicillin | Cephazollin 1 g or ampicillin 2g IM or IV, 1 h before procedure |
| Allergic to penicillin | Clindamycin | 600 mg orally, 1 h before procedure |
| Allergic to penicillin and unable to take oral medication | Clindamycin | 600 mg IV, within 30 min of procedure |
Prescription for antibiotic prophylaxis for a patient at risk for infection due to a total joint replacement. 4 visits:#
| Patients with no penicillin or amoxicillin allergies | ||
|---|---|---|
| Name: John Doe DOB: 1/1/50 Address:123 Main Street, Pleasantville, PA Amoxicillin 500 mg tab. Disp. 16 tabs. Sig. 4 tabs. po, 1 hr. prior to dental appointment | ||
| Patients with cephalosporin or amoxicillin allergies | ||
|---|---|---|
| Name: John Doe DOB: 1/1/50 Address:123 Main Street, Pleasantville, PA Clindamycin 300 mg tab. Disp. 8 tabs. Sig. 2 tabs. po, 30-60 min. prior to dental appointment | ||
References/Websites#
- References
- American Dental Association guidance for utilizing appropriate use criteria in the management of the care of patients with orthopedic implants undergoing dental procedures. JADA 2017;148(2):57-59.
- Berbari EF, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study (published correction appears in Clin Infect Dis. 2010;50[6]:944). Clin Infect Dis. 2010;50:8–16..
- Rademacher WMH, et al. Antibiotic prophylaxis is not indicated prior to dental procedures for prevention of periprosthetic joint infections. Acta Orthop. 2017 Oct;88(5):568-574.
- Skaar DD, et al. Dental procedures and subsequent prosthetic joint infections. JADA. 2011;142(12):1343-1351.
- Sollecito TP, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. JADA. 2015;146(1):11-16.