March 2, 2022
By Manie Beheshti, MD
According to studies, more than 90% of orthopedic surgeons in the United States support the use of prophylactic antibiotics for patients with prosthetic joints undergoing invasive dental procedures (IDPs). There is, however, a lack of data to support this practice. Although the American Dental Association did not recommend this practice in its 2014 guidelines, the absence of support from the American Academy of Orthopedic Surgeons has led to ongoing confusion and pressures to prescribe prophylactic antibiotics.
In a recent issue of JAMA Network Open, researchers reported on results of their cohort study to assess a temporal relation between IDPs and late prosthetic joint infections (LPJIs), defined as infections occurring more than 3 months after joint implantation. Using medical and dental records from England, where use of prophylaxis during IDPs is not advocated, the investigators identified 9,427 LPJI hospital admissions. Comparing IDPs — defined as dental extraction, scaling, or endodontic procedure — in the 3 months prior to infection (case period) with the preceding 12 months (control period), they found no association between IDPs and LPJIs. In fact, the incidence of IDPs was lower in the 3 months prior to the LPJI (incidence rate ratio, 0.89; 95% confidence interval, 0.82-0.96; P = .002). In their post hoc analysis, when comparing the effect using a 3-, 4-, or 5-month case period, they also found no difference. Fifty-two percent of the cases were male; 25.3% and 33.6% had prostheses of the hip and knee, respectively. Approximately 9% of LPJIs were caused by oral streptococci. This is similar to prior studies that estimate that less than 10% of LPJIs are caused by oral streptococci.
The researchers conclude that in the absence of an increased incidence of LPJI, the evidence is lacking to support the use of prophylactic antibiotics in patients undergoing IDPs. It is also interesting that the rates of LPJI were indeed lower for those who underwent IDPs in the 3 months prior. The authors suggest that “those few LPJIs caused by oral streptococci were more likely a result of daily oral activities, such as toothbrushing, flossing, and mastication, particularly in patients with poor oral hygiene, rather than from IDP.” Though previous smaller reports have shown mixed results, this study is 30-fold larger than any preceding it. Perhaps this study will lead to revisiting what has seemingly become standard practice in the United States.